Showing papers in "Journal of Travel Medicine in 2011"
TL;DR: This study confirms that foreign travel, especially to the Indian subcontinent and Africa, represents a major risk for rectal colonization with CTX-M-producing E coli and contributed to the Worldwide spread of these bacteria.
Abstract: Background We previously identified foreign travel as a risk factor for acquiring infections due to CTX‐M (active on cefotaxime first isolated in Munich) producing Escherichia coli The objective of this study was to assess the prevalence of extended‐spectrum β‐lactamase (ESBL)‐producing E coli among stool samples submitted from travelers as compared to non‐travelers (a non‐traveler had not been outside of Canada for at least 6 months before submitting a stool specimen)
Methods Once a travel case was identified, the next stool from a non‐traveler (not been outside of Canada for at least 6 months) was included and cultured on the chromID‐ESBL selection media Molecular characterization was done using polymerase chain reaction and sequencing for bla CTX‐Ms, bla TEMs, bla SHVs, plasmid‐mediated quinolone‐resistant determinants, O25‐ST131, phylogenetic groups, pulsed‐field gel electrophoresis (PFGE), and multilocus sequencing typing
Results A total of 226 individuals were included; 195 (86%) were negative, and 31 (14%) were positive for ESBL‐producing E coli Notably, travelers were 52 (95% CI 21–311) times more likely than non‐travelers to have an ESBL‐producing E coli cultured from their stool The highest rates of ESBL positivity were associated with travel to Africa or the Indian subcontinent Among the 31 ESBL‐producing E coli isolated, 22 produced CTX‐M‐15, 8 produced CTX‐M‐14, 1 produced CTX‐M‐8, 12 were positive for aac(6 ′ )‐Ib‐cr , and 8 belonged to clone ST131
Conclusions Our study confirms that foreign travel, especially to the Indian subcontinent and Africa, represents a major risk for rectal colonization with CTX‐M‐producing E coli and contributed to the Worldwide spread of these bacteria
105 citations
TL;DR: These kinds of mycoses are increasingly frequent in non-endemic areas, and newer and faster techniques should be used to reach an early diagnosis.
Abstract: Background. Histoplasmosis and paracoccidioidomycosis (PCM) have increased in Spain in recent years, due firstly to the migration from endemic regions and secondly to travelers returning from these regions. In non-endemic areas, diagnosis of both diseases is hampered by the lack of experience, long silent periods, and the resemblance to other diseases such as tuberculosis and sarcoidosis.
Methods. A total of 39 cases of imported histoplasmosis and 6 cases of PCM diagnosed in the Spanish Mycology Reference Laboratory since 2006 were analyzed. Microbiological diagnosis was performed using classical methods and also a specific real-time polymerase chain reaction (RT-PCR) assay for each microorganism.
Results. We had 9 cases of probable histoplasmosis in travelers and 30 cases in immigrants, 29 of whom were defined as proven. Paracoccidioidomycosis (PCM) cases were either immigrants or people who had lived for a long period of time in endemic regions, all of whom were classified as proven cases. Cultures showed a good sensitivity in detecting Histoplasma capsulatum in immigrants with proven histoplasmosis (73%); however, growth was very slow. The fungus was never recovered in traveler patients. Paracoccidioides brasiliensis was isolated in a culture only in one case of the proven PCM. Serological methods were not very reliable in immunocompromized patients with histoplasmosis (40%). A PCR-based technique for histoplasmosis detected 55.5% of the cases in travelers (probable cases) and 89% of the cases in immigrants (proven). The PCR method for PCM detected 100% of the cases.
Conclusions. These kinds of mycoses are increasingly frequent in non-endemic areas, and newer and faster techniques should be used to reach an early diagnosis. The RT-PCR techniques developed appear to be sensitive, specific, and fast and could be helpful to detect those mycoses. However, it is also essential that physicians perform differential diagnosis in individuals coming from endemic areas.
75 citations
TL;DR: Temperature variations in central Mexico influenced the rate of ETEC but not EAEC-associated diarrhea in the US visitors, and this epidemiological finding could influence seasonal recommendations for the use ofETEC vaccines in Mexico.
Abstract: The frequency of Travelers’ diarrhea (TD) among international travelers to tropical and semitropical regions of the developing world ranges from 10% to 60%. The highest rates of TD are seen in Latin America, Africa and the Indian subcontinent [1].
Worldwide infectious diarrhea rates are influenced by seasonal changes. Striking examples include V. cholerae infection in Asia where the rates of infection double during the warm season [2]. In Mexican children, rates of diarrhea are also influenced by seasonal changes with rotavirus diarrhea predominating in winter months [3]. In the US, pediatric diarrhea rates also vary seasonally, with viral causes of diarrhea predominating during the winter months and enteroaggregative E. coli (EAEC) seen more commonly during spring time [4].
The microbiology of TD in US visitors to Mexico reflects the bacterial enteropathogens identified in Mexican children with diarrhea. Most TD acquired in Mexico is due to enterotoxigenic Escherichia coli (ETEC) and EAEC [5, 6]. Previous studies have shown that the TD overall and TD due to ETEC are more common during summer than during winter months [7–9]. In other regions of the world, investigators have also found seasonal variation in etiology of TD; for instance in a study conducted in Morocco, Campylobacter spp. was associated with TD during winter months and ETEC was seen more commonly identified during the fall months. This is felt to relate to an increase in the ambient temperature and rainfall favoring the growth and spread of bacteria that contaminate food and water. These changes may further evolve in response to current global climate changes. The aim of this study was to characterize seasonal differences in diarrheagenic Escherichia coli pathotypes as causes for TD over a thirteen month period in a popular tourist destination in Mexico.
73 citations
TL;DR: The most common pathogens causing TD in Nepal were Campylobacter, ETEC, and Shigella, and one of these drugs could be used as empiric therapy for TD with the other reserved for treatment failures.
Abstract: Background Diarrhea is the most common illness among travelers and expatriates in Nepal. Published data on the etiology of travelers' diarrhea (TD) in Nepal are over 13 years old and no prior data exist on antibiotic susceptibility for currently used drugs. We investigated the etiology of diarrhea and antimicrobial susceptibility pattern of bacterial pathogens and compared the results to previous work from the same clinical setting.
Methods A total of 381 cases and 176 controls were enrolled between March 2001 and 2003 in a case‐control study. Enrollees were over age 18 years from high socioeconomic countries visiting or living in Nepal. Stool samples were assessed by microbiologic, molecular identification, and enzyme immunoassay (EIA) methods, and antimicrobial susceptibility was determined by disk diffusion. Risk factors were assessed by questionnaires.
Results At least one enteropathogen was identified in 263 of 381 (69%) cases and 47 of 176 (27%) controls ( p ≤ 0.001). Pathogens significantly detected among cases were Campylobacter (17%), enterotoxigenic Escherichia coli (ETEC) (15%), Shigella (13%), and Giardia (11%). Cyclospora was detected only in cases (8%) mainly during monsoon season. Although 71% of Campylobacter isolates were resistant to ciprofloxacin, 80% of bacterial isolates overall were sensitive to either ciprofloxacin or azithromycin while 20% were intermediately sensitive or resistant. No bacterial isolates were resistant to both drugs.
Conclusions The most common pathogens causing TD in Nepal were Campylobacter , ETEC, and Shigella . Because resistance to fluoroquinolone or azithromycin was similar, one of these drugs could be used as empiric therapy for TD with the other reserved for treatment failures.
70 citations
TL;DR: Among a cohort of 274 French pilgrims participating in the 2009 Hajj, 77.4% used hand disinfectant, 89.8% used disposable handkerchiefs, and 79.6% used face masks, and Influenza vaccine and face mask use did not significantly reduce respiratory symptoms.
Abstract: Among a cohort of 274 French pilgrims participating in the 2009 Hajj, 77.4% used hand disinfectant, 89.8% used disposable handkerchiefs, and 79.6% used face masks; 97.4% were vaccinated against seasonal flu, 5.8% against H1N1, and 31.4% against pneumococcus. Influenza vaccine and face mask use did not significantly reduce respiratory symptoms.
61 citations
TL;DR: The repatriation of French patients from foreign hospitals, but also health care provided to foreigners traveling in France, whatever their nationality, then expose the French population to highly resistant bacteria acquired in high resistance prevalent areas.
Abstract: The rapid development of transport and communication, environmental exchanges, and migration of populations creates opportunities for the spread of infectious diseases. The emergence and spread of pathogenic and epidemic pathogens is a major emerging phenomenon of the past 30 years. Some species of bacteria have become resistant to multiple antibiotics and, sometimes, to all antibiotics available: multidrug‐resistant bacteria (MDR), extensively drug‐resistant bacteria (XDR), or pan drug‐resistant bacteria (PDR). 1–3 These terminologies have drawn attention to the evolution of multidrug resistance and the potential difficulties in treating bacterial infections now and in the future. 4
The very high levels of resistance that are currently observed result from massive exposure to antibiotics, to which humans and animals have been subjected over the past 50 years. 5 Resistance to antibiotics concerns not only pathogens but also, and probably even more importantly, the commensally bacteria colonizing individuals (humans and animals). These are less easily detected because the carriage is asymptomatic.
More than 80 million foreign visitors travel in France each year. In the same period, 19.4 million French peoples travel to foreign countries, more often in Europe. 6 In addition, 1.4 million French peoples live in foreign countries (i.e., 48% Europe, 20% America, 15% Africa, 8.5% in Asia‐Oceania, and 6.6% in the Near and Middle East). 7 The repatriation of French patients from foreign hospitals, but also health care provided to foreigners traveling in France, whatever their nationality, then expose the French population to highly resistant bacteria acquired in high resistance prevalent areas.
The risk of the emergence and spread of highly resistant bacteria from migration has been recently evaluated in France because sporadic or limited epidemic situations have occurred in the recent past with pathogens such as Clostridium difficile ribotype 027, 8,9 carbapenemase‐producing Enterobacteriaceae (CPE), 10–12 vancomycin‐resistant Enterococcus (VRE), 13,14 or multidrug‐resistant Acinetobacter …
Corresponding Author: Didier Lepelletier, MD, PhD, Unite de Gestion du Risque Infectieux ‐ Service de Bacteriologie‐Hygiene, Centre Hospitalier Universitaire de Nantes, F‐44093 Nantes Cedex 01, France. E‐mail: didier.lepelletier{at}chu-nantes.fr
57 citations
TL;DR: Rabies is an irreversible, fatal disease most frequently characterized by acute encephalitis that causes approximately 55,000 deaths annually in Africa and Asia and those who travel to areas with high epizootic endemicity are at increased risk of exposure and death.
Abstract: Rabies is an irreversible, fatal disease most frequently characterized by acute encephalitis that causes approximately 55,000 deaths annually in Africa and Asia. Disease occurs when rabies virus, a Lyssavirus , is transmitted to a human via the saliva of an infected mammalian carnivore or bat, usually a dog, if it comes in contact with mucous membranes or enters the body via a bite, scratch, or lick on broken skin. Animal reservoirs for rabies exist in all continental areas worldwide. Deaths are presumed to be underreported in areas with poor access to medical facilities. Children are considered to be at a higher risk than adults.1,2 Although the risk of contracting rabies in developed countries is generally low, those who travel to areas with high epizootic endemicity are at increased risk of exposure and death. Steffen and co‐workers evaluated the risk of rabies infection due to animal bites in travelers to developing countries and found an incidence rate per month between 0.1% and 1%.3 An epidemiological study of travelers presenting to GeoSentinel sites worldwide performed by the US Centers for Disease Control and Prevention (CDC) and the International Society of Travel Medicine (ISTM) found that 4.7% of this population required rabies post‐exposure prophylaxis.4
After acquisition of the virus, the incubation period is variable, usually between 20 and 90 d, although occasionally disease develops after only a few days, and, in rare cases, more than a year following exposure. Usually patients develop a furious form of the disease, with episodes of generalized hyperexcitability separated by lucid periods. Encephalitis results from viral replication in the brain. In 20% of cases, a paralytic form of the disease results in progressive immobility. Both forms of rabies, furious and paralytic, are always fatal. One documented case of recovery from symptomatic disease has been reported; …
Corresponding Author: Claudius Malerczyk, MD, Novartis Vaccines and Diagnostics GmbH, Emil‐von‐Behring Strase 76, D‐35041 Marburg, Germany. E‐mail: claudius.malerczyk{at}novartis.com
49 citations
TL;DR: The modified ID schedule used in this case series was highly effective, had similar immunogenicity to the standard ID schedule, and should be considered in travelers who are unable to complete standard IM or standard ID courses of rabies vaccines.
Abstract: Background. Current Australian recommendations for rabies pre-exposure vaccination involve the use of cell-culture-based rabies vaccines, which are administered via intramuscular (IM) or intradermal (ID) routes. ID vaccination is more affordable for travelers, but is only recommended if there is sufficient time to perform serology 2 to 3 weeks post-vaccination and confirm immunity prior to travel. We report the immunogenicity of a modified ID schedule that can be completed in less time than the standard ID schedule, and allow more travelers to be vaccinated prior to departure.
Methods. Travelers were offered a modified schedule if they were unable to afford standard IM vaccinations, and did not have time to complete a standard ID course. The modified schedule consisted of two ID injections of 0.1 mL of human diploid cell rabies vaccine administered on days 0 and 7, and serology was performed to determine immune status at a time between day 21 and 28.
Results. A total of 420 travelers aged between 10 and 65 years were vaccinated using the modified ID course. The overall seroconversion rate was 94.5%, with 397 travelers developing antibody levels of >0.5 IU/mL when tested at approximately 21 days post-vaccination.
Conclusion. The modified ID schedule used in this case series was highly effective, had similar immunogenicity to the standard ID schedule, and should be considered in travelers who are unable to complete standard IM or standard ID courses of rabies vaccines.
47 citations
TL;DR: It is suggested that the frequency and severity of jellyfish stings affecting tourists in Southeast Asia have been significantly underestimated and the application of marine stinger prevention and treatment principles throughout the region may help reduce the incidence and severity.
Abstract: Background: Jellyfish are a common cause of injury throughout the world, with fatalities and severe systemic events not uncommon after tropical stings. The internet is a recent innovation to gain information on real-time health issues of travel destinations, including Southeast Asia.
Methods: We applied the model of internet-based retrospective health data aggregation, through the Divers Alert Network Asia-Pacific (DAN AP), together with more conventional methods of literature and media searches, to document the health significance, and clinical spectrum, of box jellyfish stings in Malaysia for the period January 1, 2000 to July 30, 2010.
Results: Three fatalities, consistent with chirodropid envenomation, were identified for the period—all tourists to Malaysia. Non-fatal chirodropid stings were also documented. During 2010, seven cases consistent with moderately severe Irukandji syndrome were reported to DAN and two representative cases are discussed here. Photographs of chirodropid (multi-tentacled), carybdeid (four-tentacled) box jellyfish, and of severe sting lesions were also submitted to DAN during this period.
Conclusions: This study suggests that the frequency and severity of jellyfish stings affecting tourists in Southeast Asia have been significantly underestimated. Severe and fatal cases of chirodropid-type stings occur in coastal waters off Peninsular Malaysia and Sabah, Borneo. Indeed, the first Malaysian cases consistent with Irukandji-like syndrome are reported here. Reports to DAN, a provider of emergency advice to divers, offer one method to address the historic lack of formalized reporting mechanisms for such events, for photo-documentation of the possible culprit species and treatment advice. The application of marine stinger prevention and treatment principles throughout the region may help reduce the incidence and severity of such stings. Meanwhile travelers and their medical advisors should be aware of the hazards of these stings throughout the Asia-Pacific.
44 citations
TL;DR: A descriptive, cross-sectional design study of cases of malaria, hepatitis A, and typhoid reported to the Quebec registry of notifiable diseases between January 2004 and December 2007 shows that VFR children should be a primary target group for pre-travel preventive measures.
Abstract: Background. Visiting friends and relatives (VFRs), especially young VFRs, are increasingly recognized in the industrialized world as a high-risk group of travelers.
Methods. We performed a descriptive, cross-sectional design study of cases of malaria, hepatitis A, and typhoid reported to the Quebec registry of notifiable diseases between January 2004 and December 2007, occurring in VFRs and non-VFRs travelers.
Results. VFRs account for 52.9% of malaria cases, 56.9% of hepatitis A cases, and 94.4% of typhoid cases reported in Quebec travelers. Almost all (91.6%) of the malaria cases among VFRs were acquired in Africa, particularly in sub-Saharan Africa. An important proportion of malaria cases among VFRs (86.4%) were due to Plasmodium falciparum. The vast majority (76.6%) of typhoid fever cases among VFRs were reported by travelers who had visited the Indian subcontinent. Among VFRs, 40% of total cases were under 20 y of age, compared to less than 6% among non-VFRs. Those under 20 years of age also accounted for 16.9% of malaria cases, 50% of typhoid cases, and 65.2% of hepatitis A cases among VFRs.
Conclusion. Our study clearly shows that VFR children should be a primary target group for pre-travel preventive measures.
44 citations
TL;DR: In a large population of European travelers IBS had a lower incidence rate as compared to previous studies, and particular risk groups were identified; those may need to be protected.
Abstract: Travelers' diarrhea (TD) remains a frequent travel-associated infection. Between 4 and 32% of enteric infections were followed by a postinfectious irritable bowel syndrome (pIBS) with long-term sequelae in various settings. Travel-related IBS incidence rates are based on small studies and IBS predictors have not been sufficiently evaluated.
TL;DR: This work demonstrates the convenience of routine application of molecular epidemiology analyses in dengue diagnosis laboratories and the importance of surveillance of imported diseases contributing data for the epidemiological knowledge of infectious diseases in endemic areas has been demonstrated.
Abstract: Background. Dengue viruses (DENV) are the most widespread arthropod-borne viruses, which have shown an unexpected geographic expansion, as well as an increase in number and severity of outbreaks in the last decades. Although the emergence of dengue is considered to be due to a number of complex factors, epidemiological studies have shown that some strains of dengue might be associated with increased severity and higher transmission rates than others. In this context, surveillance and identification of the appearance or introduction of more virulent strains, along with fluctuation of DENV among endemic areas are now considered essential public health activities. Methods. Samples from travelers returning from the tropics with acute dengue infections were analyzed to obtain up-dated information on circulating dengue strains. A short nucleotide fragment located in the carboxyl terminus of the dengue E gene was used for the characterization of DENV strains and the identification of their sero- and genotype. Results. One hundred eighty-six new dengue strains have been classified into 12 distinct genotype groups within the four dengue serotypes. The identification of the emergence of different sero- and genotypes, the appearance of new clades correlating with outbreaks, and the identification of a dengue-4 genotype not previously reported have been achieved. Interestingly, African strains characterized in this study have provided valuable data on dengue circulation on the continent. Conclusions. This work demonstrates the convenience of routine application of molecular epidemiology analyses in dengue diagnosis laboratories. The use of molecular epidemiology tools on the analysis of imported dengue infections strengthens data acquisition on dengue strain movements correlating with epidemiological changes. The importance of surveillance of imported diseases contributing data for the epidemiological knowledge of infectious diseases in endemic areas has been once more demonstrated.
TL;DR: Routine prescription of stand-by antibiotics for these immunocompromised short-term travelers to areas with good health facilities is probably not more useful than for healthy travelers.
Abstract: Background. Immunocompromised travelers to developing countries are thought to have symptomatic infectious diseases more often and longer than non-immunocompromised travelers. Evidence for this is lacking. This study evaluates whether immunocompromised short-term travelers are at increased risk of diseases.
Methods. A prospective study was performed between October 2003 and May 2010 among adult travelers using immunosuppressive agents (ISA) and travelers with inflammatory bowel disease (IBD), with their non-immunocompromised travel companions serving as matched controls with comparable exposure to infection. Data on symptoms of infectious diseases were recorded by using a structured diary.
Results. Among 75 ISA, the incidence of travel-related diarrhea was 0.76 per person-month, and the number of symptomatic days 1.32 per month. For their 75 controls, figures were 0.66 and 1.50, respectively (p > 0.05). Among 71 IBD, the incidence was 1.19, and the number of symptomatic days was 2.48. For their 71 controls, figures were 0.73 and 1.31, respectively (p > 0.05). These differences also existed before travel. ISA had significantly more and longer travel-related signs of skin infection and IBD suffered more and longer from vomiting. As for other symptoms, no significant travel-related differences were found. Only 21% of immunocompromised travelers suffering from diarrhea used their stand-by antibiotics.
Conclusions. ISA and IBD did not have symptomatic infectious diseases more often or longer than non-immunocompromised travelers, except for signs of travel-related skin infection among ISA. Routine prescription of stand-by antibiotics for these immunocompromised travelers to areas with good health facilities is probably not more useful than for healthy travelers.
TL;DR: TRC of diseases caused by enteropathogens that are reportable in Canada represent a significant proportion of the burden of the total diseases, and subgroups of TRC exist and are associated with certain diseases.
Abstract: Background Risk of infections by enteropathogens among individuals traveling outside their country of residence is considered important Such travel‐related cases (TRC) have been poorly estimated and described in Canada
Methods Data from an enhanced, passive surveillance system of diseases caused by enteropathogens within a Canadian community from June 2005 to May 2009 were used to describe TRC in terms of disease (pathogen, symptoms, hospitalization, duration, and timing of sickness relative to return); demographics (age and gender); and travel (destination, length, and accommodation); and to compare them with non‐TRC
Results Among 1,773 reported cases, 446 (25%) were classified as TRC with 9% of them being new immigrants The main TRC diseases were campylobacteriosis, salmonellosis, and giardiasis Disease onset occurred before return in 42% of TRC Main destinations were Latin America/Caribbean and Asia No differences by month and year were observed for onset, departure, and return dates In addition to new immigrants, three subgroups of TRC based on travel destination, length of travel, type of accommodation, and age were identified and some diseases were more frequently observed in these subgroups Generally, TRC did not differ from domestic cases in terms of age, gender, symptoms, hospitalization, and disease duration Campylobacter coli and Salmonella enteritidis were significantly more frequent among TRC
Conclusions TRC of diseases caused by enteropathogens that are reportable in Canada represent a significant proportion of the burden of the total diseases Subgroups of TRC exist and are associated with certain diseases These results help inform the assessment of the actual risk related to travel for each subgroup of travelers and quantify the attribution of traveling abroad to the overall burden of these gastrointestinal diseases
TL;DR: KAP about malaria among exposed Chinese travelers is far from satisfactory and specific educational tools should be developed for those at high risk to make them understand and become compliant with chemoprophylaxis to reduce the rate of imported malaria.
Abstract: Background. To address the lack of understanding in malaria prevention among Chinese international travelers, we have conducted knowledge, attitudes, and practices (KAP) study in five different Chinese geographic areas. This survey represents one part of the background information needed to analyze imported malaria.
Methods. Standardized questionnaires were distributed to Chinese international travelers in departure lounges at international airports in Guangzhou, Beijing, Shanghai, Qingdao, and Nanjing. The data were entered into the Epidata 3.1 (Jens M. Lauritsen, Odense, Denmark) and analyzed by the SPSS 12.0 statistical package (SPSS Inc., Chicago, IL, USA).
Results. Overall 2,495 completed questionnaires were collected from departing Chinese passengers; 1,573 were contributed by travelers who were going to malaria risk countries. More than half of all travelers spent less than 7 days to organize their trip abroad. Pre-travel medical advice was sought by 998 travelers (40.0%), 65.1% of them did so for 1–7 days before departure. Only 4.0% travelers received their knowledge from travel health providers. Among 389 travelers who were going to high malaria risk countries, only 18.0% realized that there is a high malaria risk in sub-Saharan Africa. Most travelers going to risk areas knew about personal protection measures against mosquito bites, but only 21.4% and 12.1% carried mosquito repellents or insecticides, respectively. Only 18.7% of the 1,573 potentially exposed travelers carried malaria tablets, all of them for self-treatment, none for prophylaxis.
Conclusion. KAP about malaria among exposed Chinese travelers is far from satisfactory. To reduce the rate of imported malaria, specific educational tools should be developed for those at high risk to make them understand and become compliant with chemoprophylaxis.
TL;DR: The majority of travelers seeking PEP at this clinic initiated treatment overseas, and most had not received RIG abroad, when it would have been appropriate, which is a concern to those without preexposure rabies immunization.
Abstract: Background In 2009, 58.6 million UK residents traveled abroad. Of these, 49.5 million (84.5%) visits were to Europe and North America and 9.1 million (15.5%) were to other parts of the world. Rabies is widely distributed and continues to be a major public health issue in many developing countries. The UK is free of rabies in carnivore host species, although cases of rabies in bats have been reported. This study examined the rabies postexposure prophylaxis (PEP) service from 2000 to July 2009 at the Liverpool School of Tropical Medicine.
Methods Medical records of patients who attended the clinic for rabies PEP were reviewed.
Results During the study period, 139 patients were treated for possible rabies exposure. The mean age was 35 years. Thailand and Turkey each accounted for 31 (22.3%) cases. Sixty‐nine (49.6%) of those seen were due to dog bites. Most injuries involved a lower limb ( n = 67, 48.2%) or hands ( n = 26, 18.7%). Eighty‐six (61.9%) cases had initiated rabies PEP overseas, but only 3 of the 78 (3.8%) meeting UK criteria for rabies immunoglobulin (RIG) received it while overseas. Only an additional 11 patients received RIG on return to the UK; most were seen more than 7 days after initiation of PEP. The median time from exposure to receiving rabies PEP was 1 day (range: 0–1,720). Only 14 (10.1%) had received preexposure rabies vaccination.
Conclusions The majority of travelers seeking PEP at this clinic initiated treatment overseas. Most had not received RIG abroad, when it would have been appropriate. Initiation of appropriate treatment is often delayed and is a concern to those without preexposure rabies immunization. In view of the scarcity of RIG, travelers need to be aware of the risks, consider preexposure immunization, and present early for PEP.
TL;DR: A pharmacist-run pretravel health clinic can provide consistent evidence-based care and improve patient compliance compared to PCPs without special training.
Abstract: Background. Pretravel medication and vaccination recommendations and receipt were compared between primary care providers (PCPs) without special training and clinical pharmacists specializing in pretravel health.
Methods. A retrospective chart review of patients seen for pretravel health services in a pharmacist-run travel clinic (PTC) compared to PCPs at a University Student Health Center. Vaccine/medication recommendations were assessed for consistency with national/international guidelines. Medical/pharmacy records were queried to determine the receipt of medications/vaccinations.
Results. The PTC recommended antibiotics for travelers' diarrhea were given more often when indicated (96% vs 50%, p < 0.0001), and patients seen in the PTC received their medications more often (75% vs 63%, p = 0.04). PCPs prescribed more antibiotics for travelers' diarrhea that were inconsistent with guidelines (not ordered when indicated 49% vs 6%, p < 0.0001 and ordered when not indicated 21% vs 3%, p < 0.0001). The PTC prescribed antimalarials more often when indicated (98% vs 81%, p < 0.0001), while PCPs prescribed more antimalarials that were inconsistent with guidelines (not ordered when indicated 15% vs 1%, p < 0.0001 and ordered when not indicated 19% vs 2%, p < 0.0001). The PTC ordered more vaccines per patient when indicated (mean = 2.77 vs 2.31, p = 0.0012). PTC patients were more likely to receive vaccines when ordered (mean = 2.38 vs 1.95, p = 0.0039). PCPs recommended more vaccines per patient that were inconsistent with guidelines (not ordered when indicated: mean = 0.78 vs 0.12, p < 0.0001, ordered when not indicated: mean 0.18 vs 0.025, p < 0.0001).
Conclusions. A pharmacist-run pretravel health clinic can provide consistent evidence-based care and improve patient compliance compared to PCPs without special training. Pretravel health is a dynamic and specialized field that requires adequate time, resources, and expertise to deliver the best possible care.
TL;DR: The patient was treated successfully with the surgical removal of the cyst and spinal NCC should be considered in the differential diagnosis in high-risk populations with new symptoms suggestive of a spinal mass lesion.
Abstract: Spinal cysticercosis is an uncommon manifestation of neurocysticercosis (NCC). We present a case of isolated lumbar intradural-extramedullary NCC. The patient was treated successfully with the surgical removal of the cyst. Spinal NCC should be considered in the differential diagnosis in high-risk populations with new symptoms suggestive of a spinal mass lesion.
TL;DR: Serum schistosome DNA detection in serum was able to confirm infection in all exposed persons, and clearly outperformed antibody tests and microscopic parasite detection methods as a qualitative diagnostic test.
Abstract: Background. Diagnosis of acute schistosomiasis is often elusive in travelers. Serum schistosome DNA detection is a promising new diagnostic tool. Its performance is compared with current diagnostic procedures in a cluster of travelers recently infected in Rwanda.
Methods. Recent infection with schistosomiasis was suspected in 13 Belgian children and adults, within 2 months after swimming in the Muhazi Lake, Rwanda. All were subjected to clinical examination, eosinophil count, feces parasite detection, schistosome antibody tests [enzyme-linked immunosorbent assay (ELISA) and hemagglutination inhibition assay (HAI)], and schistosome DNA detection in serum by real-time polymerase chain reaction.
Results. All 13 patients, between 6 and 29 years old, had a high eosinophil count (median 2,120 µL−1; range 1,150–14,270). Seven of nine persons exposed for the first time developed symptoms compatible with acute schistosomiasis. Eggs of Schistosoma mansoni were found in a concentrated feces sample of 9/13 (69%), with low egg counts (median 20 eggs per gram; range 10–120). Antischistosome antibodies (ELISA and/or HAI) were present in serum of 10/13 (77%) patients. Combining schistosome antibody tests and fecal microscopy demonstrated schistosomiasis in 11/13 (85%) patients. Schistosome-specific DNA was isolated in all 13 (100%) serum samples.
Conclusion. In this cluster of travelers with acute schistosomiasis, schistosome DNA detection in serum was able to confirm infection in all exposed persons. It clearly outperformed antibody tests and microscopic parasite detection methods as a qualitative diagnostic test.
TL;DR: About one third of the foreign backpackers in Southeast Asia had experienced diarrhea during their trip, and their current practices related to the risk of travelers' diarrhea were inadequate and should be improved.
Abstract: Background. Travelers' diarrhea is the most common disease reported among travelers visiting developing countries, including Southeast Asia, a region visited by large numbers of backpackers each year. Currently, the knowledge of travelers' diarrhea among this group is limited. This study aimed to determine the incidence and impact of travelers' diarrhea in this group.
Method. Foreign backpackers in Khao San road, Bangkok, Thailand, were invited to fill out a study questionnaire, in which they were queried about their demographic background, travel characteristics, pretravel preparations and actual practices related to the risk of travelers' diarrhea. For backpackers who had experienced diarrhea, the details and impact of each diarrheal episode were also assessed.
Results. In the period April to May 2009, 404 completed questionnaires were collected and analyzed. Sixty percent of participants were male; overall, the median age was 26 years. Nearly all backpackers (96.8%) came from developed countries. Their main reason for travel was tourism (88%). The median stay was 30 days. More than half of the backpackers (56%) carried some antidiarrheal medication. Antimotility drugs were the most common medications carried by backpackers, followed by oral rehydration salts (ORS), and antibiotics. Their practices were far from ideal; 93.9% had bought food from street vendors, 92.5% had drunk beverages with ice-cubes, and 33.8% had eaten leftover food from a previous meal. In this study, 30.7% (124/404) of backpackers had experienced diarrhea during their trip. Most diarrhea cases (88%) were mild and recovered spontaneously. However, 8.8% of cases required a visit to a doctor, and 3.2% needed hospitalization. Longer duration of stay and drinking beverages with ice-cubes were associated with higher risk of diarrhea.
Conclusions. About one third of the foreign backpackers in Southeast Asia had experienced diarrhea during their trip. Their current practices related to the risk of travelers' diarrhea were inadequate and should be improved.
TL;DR: Violence and unintentional injury are substantial risks for patrons of international resorts offering a hedonistic nightlife and understanding those characteristics of resorts and their visitors most closely associated with such risks should help inform prevention initiatives that protect both the health of tourists and the economy of resorts marketed as safe and enjoyable places to visit.
Abstract: Background. Young people's alcohol and drug use increases during holidays. Despite strong associations between substance use and both violence and unintentional injury, little is known about this relationship in young people holidaying abroad. We examine how risks of violence and unintentional injury abroad relate to substance use and the effects of nationality and holiday destination on these relationships. Methods. A cross-sectional comparative survey of 6,502 British and German holidaymakers aged 16 to 35 years was undertaken in airports in Cyprus, Greece, Italy, Portugal, and Spain. Results. Overall, 3.8% of participants reported having been in a physical fight (violence) on holiday and 5.9% reported unintentional injury. Two thirds reported having been drunk on holiday and over 10% using illicit drugs. Levels of drunkenness, drug use, violence, and unintentional injury all varied with nationality and holiday destination. Violence was independently associated with being male, choosing the destination for its nightlife, staying 8 to 14 days, smoking and using drugs on holiday, frequent drunkenness, and visiting Majorca (both nationalities) or Crete (British only). Predictors of unintentional injury were being male, younger, using drugs other than just cannabis on holiday, frequent drunkenness, and visiting Crete (both nationalities). Conclusions. Violence and unintentional injury are substantial risks for patrons of international resorts offering a hedonistic nightlife. Understanding those characteristics of resorts and their visitors most closely associated with such risks should help inform prevention initiatives that protect both the health of tourists and the economy of resorts marketed as safe and enjoyable places to visit. Language: en
TL;DR: The completely revised 2010 edition of Health Information for Overseas Travel is a major update of what is known in the UK as the "Yellow Book."
Abstract: [Extract] Following in the tradition of International Travel and Health1 and Health Information for International Travel,2Health Information for Overseas Travel is the latest addition to the exclusive portfolio of major guidelines in travel health. The completely revised 2010 edition of Health Information for Overseas Travel is a major update of what is known in the UK as the "Yellow Book." It has a table of Contents, a Preface, six main sections, a comprehensive index, and an Acknowledgements and a Disclaimer on the inside back cover. The textbook contains a number of algorithms and 11 maps, as well as numerous tables and figures. The book is usefully spiral bound and in full color on hard wearing gloss paper. The guidebook has an insert that has a "Risk Assessment Form" on one side and a "Risk Management Checklist" on the other, which would be useful templates for the pretravel consultation.
TL;DR: The contextual factors identified reflect the social and geographical context in which these women are operating and how they protect their health using their own means and encourage policymakers and health professionals to redirect their focus and resources to a more holistic approach to sexual health when planning and implementing effective STI/HIV prevention programs.
Abstract: OBJECTIVES: Female sex workers (FSW) have been considered reservoirs and vectors of sexually transmitted infections (STI) in the community. This study estimated the prevalence of STI/human immunodeficiency virus (HIV) among FSW of various migration and residential status in Hong Kong and identified possible risk factors. METHODS: An outreach "Well-women" clinic was set up at Ziteng a non-governmental organization working with FSW. Details of their lifestyle and health risk behavior were gathered before screening tests were performed and the data were analyzed according to their place of origin. RESULTS: A total of 503 FSW were screened for STI/HIV between 2005 and 2007. Syphilis gonorrhea chlamydia and HIV accounted for 1.8 1.8 4.6 and 0.2% respectively. After adjusting for confounders having >/= 2 sexual partners (odds ratio [OR] 8.33 95%CI: 2.17-33.46) residence status (OR 0.38 95%CI: 0.17-0.89) and daily frequency of douching (OR 3.02 95%CI: 1.23-7.35) were identified as significant predictors. CONCLUSIONS: This study provides important insights on the screening and associated risk factors of STI among FSW working in Hong Kong. The contextual factors identified reflect the social and geographical context in which these women are operating and how they protect their health using their own means. These findings encourage policymakers and health professionals to redirect their focus and resources to a more holistic approach to sexual health when planning and implementing effective STI/HIV prevention programs. (c) 2010 International Society of Travel Medicine.
TL;DR: This study investigates physicians' and nurses' knowledge regarding malaria, yellow fever, and dengue fever and reveals significant deficits in travel medicine knowledge among health-care providers.
Abstract: Background. Health-care professionals can help travelers by providing accurate pre-travel counseling for mosquito-transmitted diseases such as malaria, yellow fever, and dengue fever. Governments and international organizations will benefit from knowledge survey among health professionals in this field to promote the development of travel health profession. This study investigates physicians' and nurses' knowledge regarding malaria, yellow fever, and dengue fever.
Methods. A cross-sectional questionnaire survey was distributed to physicians and nurses in Taiwan interested in travel medicine between April and September of 2008. The self-administered, single-choice questionnaire evaluated knowledge regarding epidemiology, prophylactic medication for malaria, yellow fever, and dengue fever, and vaccinations for yellow fever as well as background information of participants.
Results. Complete information was collected from 82 physicians and 203 nurses. (Out of 289, effective response rate = 99.9%). The mean percentage of accurate responses was similar for all three diseases: malaria 67.3% (range, 16.8%–90.5%); yellow fever 65.4% (39.6%–79.3%); and dengue fever 74.4% (14.4%–96.5%). The items with the lowest accuracy were (1) behavior of the dengue fever vector Aedes aegypti mosquito (14.4%) and (2) incubation period of malaria (16.8%). There were 60.4% participants who did not know the current revaccination interval for the yellow fever vaccine. The average knowledge scores for all three diseases were statistically significantly higher in the physician group.
Conclusions. Analysis of the results revealed significant deficits in travel medicine knowledge among health-care providers. Emphasis on continuing medical education for disease vector behavior, prophylactic drug prescription, and preventative vaccination is important to travel safety. Health professionals in Taiwan should actively participate in the International Society of Travel Medicine to follow the international standard of travel medicine practitioners. This type of survey should be adopted in other countries which would be helpful in improving the quality of care for travelers.
TL;DR: NCC in travelers is a rare phenomenon commonly presenting as seizure disorder manifesting months to years post-travel, and antihelminthic therapy followed by 12 to 24 months of antiepileptic therapy resulted in complete resolution of symptoms in patients.
Abstract: Background. Cysticercosis, a human infestation by Taenia solium is endemic in many resource-limited countries. In developed countries it is mostly encountered among immigrant populations. Only few cases are reported in travelers. This report summarizes a nation-wide study of neurocysticercosis (NCC) diagnosed among Israeli travelers to endemic countries, with an estimation of disease incidence among the traveler population.
Methods. We performed a retrospective, nation-wide survey of travel-related NCC in Israel between the years 1994 and 2009.
Results. Nine cases of NCC were diagnosed in Israeli travelers during the study years. Most patients had traveled to South and/or Southeast Asia. The most common symptom at diagnosis was a seizure. The average interval between return from the suspected travel and symptom onset was 3.2 ± 1.8 years. Two patients suffered from multiple lesions, whereas the rest had a single lesion.
Antihelminthic treatment was given to most patients with resolution of symptoms. Median duration of antiepileptic treatment was 16 ± 41 months after albendazole was given. Antiepileptic treatment was discontinued without any complications. The estimated attack rate of clinical disease was 1 : 275,000 per travel episode to an endemic region.
Conclusions. NCC in travelers is a rare phenomenon commonly presenting as seizure disorder manifesting months to years post-travel. Antihelminthic therapy followed by 12 to 24 months of antiepileptic therapy resulted in complete resolution of symptoms in our patients.
TL;DR: A shorter post-travel regimen has a significant impact on adherence to antimalarial prophylaxis, and a reassessment of the risk by travelers on returning home may be a major contributor to this poor adherence.
Abstract: Background. There were 1,370 cases of imported malaria and six fatalities in the UK in 2008, the majority of which were due to chloroquine-resistant Plasmodium falciparum. Poor adherence to prescribed regimens is known to be an important factor in these cases.
Method. An observational study utilizing questionnaires both pre- and post-travel was conducted to assess the adherence behavior of UK travelers undertaking trips of less than 28 days duration, who were prescribed one of three antimalarials recommended to prevent P falciparum malaria (atovaquone plus proguanil, doxycycline, or mefloquine) in travel clinics in England and Scotland. The primary objectives of the study were to assess travelers' perceptions of, and self-reported adherence to antimalarial medication. A secondary objective was to examine the reasons for the choice of antimalarial therapy from the perspective of prescriber and traveler.
Results. For the primary end point of self-reported adherence specified as the proportion of antimalarial tablets prescribed that were actually taken, statistically significantly higher adherence overall and post-travel was seen with atovaquone plus proguanil compared with doxycycline. It was not possible to calculate the statistical significance of comparisons with mefloquine, but adherence to mefloquine appeared similar to or better than doxycycline and similar to atovaquone plus proguanil for categorical adherence. Effectiveness, side effects, previous experience of antimalarials, and dosing convenience were the main determinants of both travelers and practitioner's choice of antimalarial. The practitioner's recommendation was highly important for 63% of travelers.
Conclusion. A shorter post-travel regimen has a significant impact on adherence to antimalarial prophylaxis. A reassessment of the risk by travelers on returning home may be a major contributor to this poor adherence.
TL;DR: Antibiotic prophylaxis of TD in Mexico during the dry season needs to be further studied and its benefits weighed against the benefits of self-treatment.
Abstract: Background. Rifaximin has been shown to be effective in treating and preventing travelers' diarrhea (TD) during the summer season.
Methods. The goal of this double-blinded multicenter trial was to assess the efficacy and safety of rifaximin 550 mg administered once daily for 14 days compared with placebo in the prevention of TD during the dry season in Mexico.
Results. There were 101 participants randomized. Overall, 25 participants developed TD during the 3 weeks of the study: 22% from the rifaximin group and 29% from the placebo group (p = 0.4). Mild diarrhea (defined as only one or two unformed stools during a 24-h period plus at least one abdominal symptoms) developed in only 3 (6%) participants taking rifaximin compared with 10 (21%) taking placebo during the first week of study (p = 0.03). No clinically significant or serious adverse events were reported.
Conclusions. Antibiotic prophylaxis of TD in Mexico during the dry season needs to be further studied and its benefits weighed against the benefits of self-treatment.
TL;DR: This case highlights the importance of obtaining even remote travel histories from ill immigrants and considering occult quartan malaria in patients from endemic locations with nephrotic syndrome.
Abstract: A 34-year-old Nigerian man presented with nephrotic syndrome. Renal biopsy revealed chronic membranous glomerulopathy with focal segmental sclerosis. Blood Giemsa smear contained rare Plasmodium sp. trophozoites and small subunit ribosomal RNA polymerase chain reaction amplification confirmed the presence of Plasmodium malariae. This case highlights the importance of obtaining even remote travel histories from ill immigrants and considering occult quartan malaria in patients from endemic locations with nephrotic syndrome.
TL;DR: There needs to be better awareness and education about travel-related illness and the importance of taking an adequate travel history.
Abstract: Background. Our aim was to document how often travel histories were taken and the quality of their content.
Methods. Patients admitted over 2 months to acute medical units of two hospitals in the Northwest of England with a history of fever, rash, diarrhea, vomiting, jaundice, or presenting as “unwell post-travel” were identified. The initial medical clerking was assessed.
Results. A total of 132 relevant admissions were identified. A travel history was documented in only 26 patients (19.7%). Of the 16 patients who had traveled, there was no documentation of pretravel advice or of sexual/other activities abroad in 15 (93.8%) and 12 (75.0%) patients, respectively.
Conclusions. There needs to be better awareness and education about travel-related illness and the importance of taking an adequate travel history.
TL;DR: An outbreak of severe symptomatic Trichostrongylus spp.
Abstract: We report an outbreak of severe symptomatic Trichostrongylus spp. in travelers visiting a sheep farm in New Zealand. The unusual source of the outbreak was traced as the use of sheep manure as an organic fertilizer on a salad garden.