A Belgian traveler returning from Laos developed acute schistosomiasis. Feces microscopy and polymerase chain reaction (PCR) followed by sequence analysis revealed Schistosoma mekongi. Schistosome antibody test results and real-time PCR in serum were initially negative or not interpretable. A HRP-2 antigen test for Plasmodium falciparum and an enzyme-linked immunosorbent assay (ELISA) antibody test for Trichinella yielded false-positive results.
]]>We describe a Schistosoma haematobium infection with asymptomatic eosinophilia, persistently negative urine microscopy, and late seroconversion (7.5 months) in a traveler returning from Mali. After initial negative parasitological tests, travel history led to diagnostic cystoscopy, allowing final diagnosis with urine microscopy after the bladder biopsy. The patient was successfully treated with praziquantel. Difficulties in making the diagnosis of schistosomiasis in asymptomatic returning travelers are discussed; we propose a trial treatment in these cases.
]]>We describe a 55-year-old man returning from the Philippines infected with a hookworm, the novel bacterium Laribacter hongkongensis, and a Blastocystis hominis and presenting with both gastrointestinal and neurological symptoms. The high eosinophilia caused by the hookworm infection resulted in both gastrointestinal and neurological symptoms, resembling a hypereosinophilic syndrome.
]]>College freshmen living in dormitories are at increased risk for meningococcal disease. Many students become a high-risk population when they travel to the United States. This study surveyed the knowledge, attitudes toward, and behavior surrounding the disease among Taiwanese college students planning to study in the United States, and to identify factors that may affect willingness to accept meningococcal vaccination.
A cross-sectional survey of college students going to study in the United States was conducted in a medical center-based travel medicine clinic. Background information, attitudes, general knowledge, preventive or postexposure management, and individual preventive practices were collected through a structured questionnaire.
A total of 358 students were included in the final analysis. More than 90% of participants believed that preventing meningococcal disease was important. However, fewer than 50% of students accurately answered six of nine questions exploring knowledge of the disease, and only 17.3% of students knew the correct management strategy after close contact with patients. Logistic regression analysis showed that students who understood the mode of transmission (odds ratio: 3.21, 95% CI = 1.117–9.229), medication management (1.88, 1.045–3.38), and epidemiology (2.735, 1.478–5.061) tended to be vaccinated.
Despite an overall positive attitude toward meningococcal vaccination, there was poor knowledge about meningococcal disease. Promoting education on the mode of transmission, epidemiology, and pharmacological management of the disease could increase vaccination rates. Both the governments and travel medicine specialists should work together on developing an education program for this high-risk group other than just requiring vaccination.
Shewanella algae is an emerging seawater-associated bacterium. In immunocompromised patients, infections may result in bacteremia, osteomyelitis, and necrotizing fasciitis. Our patient, suffering from autoimmune vasculitis and myasthenia gravis, developed typical hemorrhagic bullae and leg ulcers because of S algae. She was treated efficiently with a combination of ciprofloxacin and piperacillin.
]]>Primary care physicians (PCP) are first in line to provide adequate pre-travel medical advice. Little data are available on the content of pre-travel PCP consultations in France. We undertook an observational survey to assess the level of specific knowledge among PCPs on health advice, vaccinations, and malaria prophylaxis.
Standardized questionnaires were sent to a random sample of 400 PCPs practicing in the Franche-Comté regions (eastern France) who were asked to complete and return it on a voluntary and anonymous basis. The questionnaire requested sociodemographic details, practice-related characteristics, and proposed three clinical situations with multiple choice questions (MCQ). To identify factors associated with a higher level of specific knowledge in travel medicine, results were studied by uni- and multivariate analyses. An overall score was calculated based on the MCQ answers and a motivation score was calculated based on parameters such as frequency and developments in pre-travel consulting at the practice, PCPs' personal experience as travelers, and the formal agreement of PCPs to administer yellow fever vaccination.
The response rate was 37.5%, with 150 questionnaires returned completed and suitable for analysis. After multivariate logistic regression, the three variables associated with a higher score were: proximity of a vaccination center (p = 0.001), motivation score (p = 0.004), and absence of request for expert advice on malaria prophylaxis (p = 0.007).
PCPs play an important role in travel medicine. This study showed that their high level of knowledge in travel medicine was mostly linked to their motivation to practice in this specialized discipline.
Schistosoma haematobium infection is mainly associated with urinary schistosomiasis. Here, we describe two cases of S haematobium infection in workers returning to China from Tanzania and Angola. They had hematuria and were misdiagnosed as having tuberculosis or tumor of the bladder. The diagnosis was established by discovery of eggs in the urine.
]]>We sought to evaluate and provide better itinerary-specific care to precounseled travelers and to assess diseases occurring while traveling abroad by surveying a community population. An additional quality improvement initiative was to expand our post-travel survey to be a more valuable tool in gathering high-quality quantitative data.
From de-identified data collected via post-travel surveys, we identified a cohort of 525 patients for a retrospective observational analysis. We analyzed illness encountered while abroad, medication use, and whether a physician was consulted. We also examined itinerary variables, including continents and countries visited.
The 525 post-travel surveys collected showed that the majority of respondents traveled to Asia (31%) or Africa (30%). The mean number of travel days was 21.3 (median, 14). Univariate analysis demonstrated a statistically significant increase of risk for general illness when comparing travel duration of less than 14 days to greater than 14 days (11.3% vs 27.7%, p < 0.001). Duration of travel was also significant with regard to development of traveler's diarrhea (TD) (p = 0.0015). Destination of travel and development of traveler's diarrhea trended toward significance. Serious illness requiring a physician visit was infrequent, as were vaccine-related complications.
Despite pre-travel counseling, traveler's diarrhea was the most common illness in our cohort; expanded prevention strategies will be necessary to lower the impact that diarrheal illness has on generally healthy travelers. Overall rates of illness did not vary by destination; however, there was a strong association between duration of travel and likelihood of illness. To further identify specific variables contributing to travel-related disease, including patient co-morbidities, reason for travel, and accommodations, the post-travel survey has been modified and expanded. A limitation of this study was the low survey response rate (18%); to improve the return rate, we plan to implement supplemental modalities including email and a web-based database.
Leptospirosis belongs to the spectrum of travel-related infections.
We retrospectively studied all the consecutive cases of travel-related leptospirosis seen in our department between January 2008 and September 2011. Patients were included with a clinical picture compatible with the disease within 21 days after return, the presence of a thermoresistant antigen or IgM antibodies, Elisa ≥ 1 /400, and a positive microagglutination test (MAT) ≥ 1/100.
Fifteen leptospirosis cases were evaluated. Exposure occurred in Asia (47%), Africa (20%), the Caribbean (20%), and Indian Ocean (13%). Fourteen patients were infected during water-related activities. On admission the most frequent symptoms were fever (100%), headache (80%), and digestive disorders (67%). Relevant laboratory findings included impaired liver function tests (100%), lymphocytopenia (80%), thrombocytopenia (67%), and elevated C-reactive protein (CRP) (67%). Our cases were confirmed by MAT that found antibodies against nine different serovars. Seven patients were cured with amoxicillin, four with doxycycline, two with ceftriaxone, one with ceftriaxone, doxycycline, and spiramycin, whereas one recovered spontaneously (retrospective diagnosis). Eight patients were hospitalized. All patients recovered.
Our cases involved nine different serovars. They were related to travel in Asia, Africa, and the Caribbean. Bathing or other fresh-water leisure activities (canoeing, kayaking, rafting) are the most likely at-risk exposure. Any traveler with fever and at-risk exposure should be investigated for leptospirosis.
Acute hepatitis is a well-described cause of morbidity and sporadic mortality in travelers. Data regarding the epidemiology of hepatitis in travelers are lacking. The aim of this study is to describe the epidemiology of acute viral hepatitis among travelers returning from tropical countries, with particular attention to enterically transmitted hepatitis.
This study is a prospective observational study of ill-returned travelers who presented at two travel medicine clinics in Israel between the years 1997 and 2012. Data of patients with acute hepatitis were summarized. Only travelers were included, immigrants and foreign workers were excluded.
Among 4,970 Israeli travelers who were seen during this period, 49 (1%) were diagnosed with acute hepatitis. Among them, hepatitis E virus (HEV) was the etiology in 19 (39%) cases and hepatitis A virus (HAV) was the etiology in 13 (27%) cases, demonstrating that 65% of all cases were due to enterically transmitted hepatitis. Acquiring acute hepatitis B (two cases) or acute hepatitis C (one case) was uncommon (6.1%). In 27% of the cases, no diagnosis was determined. Fifty-five percent of cases were imported from the Indian subcontinent, with a predominance of HEV infection (84%). A significant male predominance was seen in all groups regardless of etiology. Pre-travel consultation was documented in only 7% of those with vaccine preventable hepatitis (hepatitis A & B) compared to 89% in those with hepatitis E.
Enterically transmitted hepatitis is the main causes of viral hepatitis among travelers. HEV is an emerging disease and has become the most common hepatitis among Israeli travelers. Although an efficacious vaccine has been developed, no licensed HEV vaccine is yet available. Although hepatitis A vaccine is highly efficacious, safe, and easily available, there is a stable number of HAV cases.
Millions of tourists and climbers visit high altitudes annually. Many unsuspecting and otherwise healthy individuals may get sick when sojourning to these high regions. Acute mountain sickness represents the most common illness, which is usually benign but can rapidly progress to the more severe and potentially fatal forms of high-altitude cerebral edema and high-altitude pulmonary edema.
Data were identified by searches of Medline (1965 to May 2012) and references from relevant articles and books. Studies, reviews, and books specifically pertaining to the epidemiology, prevention, and treatment of high-altitude illnesses in travelers were selected.
This review provides information on geographical aspects, physiology/pathophysiology, clinical features, risk factors, and the prevalence of high-altitude illnesses and also state-of-the art recommendations for prevention and treatment of such illnesses.
Given an increasing number of recreational activities at high and extreme altitudes, the general practitioner and specialist are in higher demand for medical recommendations regarding the prevention and treatment of altitude illness. Despite an ongoing scientific discussion and controversies about the pathophysiological causes of altitude illness, treatment and prevention recommendations are clearer with increased experience over the last two decades.
Surveillance of travel-acquired dengue could improve dengue risk estimation in countries without ability. Surveillance in the French army in 2010 to 2011 highlighted 330 dengue cases, mainly in French West Indies and Guiana: DENV-1 circulated in Guadeloupe, Martinique, French Guiana, New Caledonia, Djibouti; DENV-3 in Mayotte and Djibouti; and DENV-4 in French Guiana.
Rabies, which is globally endemic, poses a risk to international travelers. To improve recommendations for travelers, we assessed the global availability of rabies vaccine (RV) and rabies immune globulin (RIG).
We conducted a 20-question online survey, in English, Spanish, and French, distributed via e-mail to travel medicine providers and other clinicians worldwide from February 1 to March 30, 2011. Results were compiled according to the region.
Among total respondents, only 190 indicated that they provided traveler postexposure care. Most responses came from North America (38%), Western Europe (19%), Australia and South and West Pacific Islands (11%), East and Southeast Asia (8%), and Southern Africa (6%). Approximately one third of 187 respondents stated that patients presented with wounds from an animal exposure that were seldom or never adequately cleansed. RIG was often or always accessible for 100% (n = 5) of respondents in the Middle East and North Africa; 94% (n = 17) in Australia and South and West Pacific Islands; 20% (n = 1) in Tropical South America; and 56% (n = 5) in Eastern Europe and Northern Asia. Ninety-one percent (n = 158) of all respondents reported that RV was often or always accessible. For all regions, 35% (n = 58) and 26% (n = 43) of respondents felt that the cost was too high for RIG and RV, respectively.
The availability of RV and RIG varied by geographic region. All travelers should be informed that RIG and RV might not be readily available at their destination and that travel health and medical evacuation insurance should be considered prior to departure. Travelers should be educated to avoid animal exposures; to clean all animal bites, licks, and scratches thoroughly with soap and water; and to seek medical care immediately, even if overseas.
Travelers to countries where rabies is endemic may be at risk of rabies exposure. We assessed rabies immunization of travelers attending a travel clinic in Thailand.
The medical charts of international travelers who came for preexposure (PrEP) or postexposure (PEP) rabies prophylaxis at the Queen Saovabha Memorial Institute (QSMI), Bangkok, Thailand between 2001 and 2011 were retrospectively reviewed.
A total of 782 travelers, including 188 patients who presented with mammal-associated injuries and possible rabies exposures and 594 persons who came requesting PrEP, were studied. Of the travelers who received PEP, only 27 (14.3%) had been previously immunized against rabies and 141 (75.0%) cases experienced high-risk WHO category III exposure. Most of the incidents were unprovoked. Although promptly seeking medical services after the injuries, 114 (60.7%) travelers did not undertake any first-aid care for their wounds. Of these travelers, 19 (10.3%) received intradermal rabies vaccination as they could complete the series here. Rabies immunoglobulin was given to 118 of 121 (97.5%) patients. About one fourth of recipients could accomplish the full schedule at QSMI. Among visitors who requested PrEP, 454 (76.4%) persons had just started their first dose. Among all visitors, 263 (44.3%) were Japanese. The number of Japanese asking for PrEP was higher in 2006, the year when cases of imported human rabies to Japan were reported. This trend has sustained since then. Two (0.3%) travelers were bitten by suspected rabid dogs before they completed their PrEP program.
Rabies prophylaxis is an important decision for each traveler. It should be made before visiting endemic areas.
Japanese encephalitis (JE) vaccine is recommended for travelers to Asia whose itineraries increase their risk of exposure to JE virus. The numbers of travelers with such itineraries and the proportion of those who receive JE vaccine are unknown. We performed a survey to estimate the proportion of US travelers to Asia who receive JE vaccine according to the Advisory Committee on Immunization Practices (ACIP) recommendations.
We surveyed US residents ≥18 years old departing on 38 flights to Asia selected through a stratified random sample of all direct flights to JE-endemic countries from three US airports. We asked participants about planned itineraries and activities, sources of travel health information, JE vaccination status, and potential barriers to vaccination. Participants planning to spend ≥30 days in Asia or at least half of their time in rural areas were defined as “higher JE risk” travelers for whom vaccination should have been considered.
Of 2,341 eligible travelers contacted, 1,691(72%) completed the survey. Among these 1,691 participants, 415 (25%) described itineraries for which JE vaccination should have been considered. Of these 415 higher JE risk travelers, only 47 (11%) reported receiving ≥1 dose of JE vaccine. Of the 164 unvaccinated higher JE risk travelers who visited a health care provider before their trip, 113 (69%) indicated that they had never heard of JE vaccine or their health care provider had not offered or recommended JE vaccine.
A quarter of surveyed US travelers to Asia reported planned itineraries for which JE vaccination should have been considered. However, few of these at-risk travelers received JE vaccine.
The number of people, both adults and children, traveling abroad, is on the rise. Some seek counseling at travel medicine centers before departure.
A prospective study was conducted among children <16 years visiting a travel medicine center in Marseille, France, from February 2010 to February 2011. Parents were contacted by telephone 4 weeks after their return, and asked about compliance with pre-travel advice.
One hundred sixty-seven children were evaluated after their trip. Compliance with immunizations, malaria chemoprophylaxis, and food-borne disease prevention was 71, 66, and 31%, respectively. Compliance with malaria chemoprophylaxis varied significantly with destination, and was higher for African destinations. Significant features associated with poor compliance with chemoprophylaxis were a trip to Asia or the Indian Ocean, age <5 years, and a monoparental family. Compliance with prevention of food- and water-borne diseases was higher in children < 2 years of age.
A ≥80% compliance with pre-travel counseling in children traveling overseas was achieved only for drinking bottled water, using repellents, a routine vaccine update, and yellow fever immunization.
International travelers were at risk of acquiring influenza A(H1N1)pdm09 (H1N1pdm09) virus infection during travel and importing the virus to their home or other countries.
Characteristics of travelers reported to the GeoSentinel Surveillance Network who carried H1N1pdm09 influenza virus across international borders into a receiving country from April 1, 2009, through October 24, 2009, are described. The relationship between the detection of H1N1pdm09 in travelers and the level of H1N1pdm09 transmission in the exposure country as defined by pandemic intervals was examined using analysis of variance (anova).
Among the 203 (189 confirmed; 14 probable) H1N1pdm09 case-travelers identified, 56% were male; a majority, 60%, traveled for tourism; and 20% traveled for business. Paralleling age profiles in population-based studies only 13% of H1N1pdm09 case-travelers were older than 45 years. H1N1pdm09 case-travelers sought pre-travel medical advice less often (8%) than travelers with non-H1N1pdm09 unspecified respiratory illnesses (24%), and less often than travelers with nonrespiratory illnesses (43%; p < 0.0001). The number of days from first official H1N1pdm09 case reported by a country to WHO and the first GeoSentinel site report of a H1N1pdm09-exported case in a traveler originated from that country was inversely associated with each country's assigned pandemic interval, or local level of transmission intensity.
Detection of travel-related cases appeared to be a reliable indicator of sustained influenza transmission within the exposure country and may aid planning for targeted surveillance, interventions, and quarantine protocols.
Dengue virus ( DENV) nonstructural protein 1 ( NS1) has been used as a novel diagnostic marker during the early phase of DENV infection.
Presence of NS1 antigen was examined using 336 serum samples obtained from 276 travelers returning to Japan from Asia, Central and South America, Pacific Islands, and Africa with dengue. Assay specificity was evaluated using 148 non-dengue samples.
Positive rates among four DENV serotypes were 68%–89%. NS1 antigen positive rates were at similar levels between primary infection and secondary infection. NS1 antigen positive rates were 88%–96% on days 1–5, 75%–100% on days 6–10, and 36–60% on ≥day 11. Positive rates using real-time polymerase chain reaction (RT-PCR) were over 70% on days 1–5, but decreased thereafter.
The results indicate that NS1 antigen positive rates were higher than those of RT-PCR during longer period of early phase in DENV infection. Thus, NS1 antigen ELISA is a useful tool for confirming DENV infection in international travelers, when it is used in combination with anti-DENV IgM ELISA.
Hepatitis B and C virus (HBV and HCV) cause significant morbidity and mortality worldwide. With the rise in international travel over the last three decades, many travelers are at risk of HBV and HCV infection.
This review focuses on the epidemiology of HBV and HCV in international travelers, the modes of transmission, and the prevention of infection in travelers.
The risk of HBV and HCV infection varies widely and depends on the prevalence of the destination country, the duration of travel, and the activities undertaken while abroad. Travelers commonly undertake high-risk activities that place them at risk of both HBV and HCV infection. Poor uptake of preventative health measures and poor adherence to health recommendations are also common. The monthly incidence of HBV infection for long-term travelers to endemic countries ranges from 25 to 420 per 100,000 travelers. HBV infection can be prevented through timely vaccination of travelers. HBV vaccination is safe and efficacious with protective levels of antibodies achieved in >90% of recipients. Information regarding the risk of HCV acquisition is scarce and until recently was limited to case reports following medical interventions.
This review demonstrates international travelers are at risk of HBV and HCV infection and provides evidence-based information enabling health practitioners to provide more appropriate pre-travel advice. HBV vaccination should be considered in all travelers to countries with a moderate to high HBV prevalence (HBsAg ≥ 2%) and the risk and benefits discussed with the individuals in consultation with the health practitioner. There is no duration of travel without risk of HBV infection. However, it is apparent that those travelers with a longer duration of travel are at greatest risk of HBV infection (ie, expatriates). Travelers should also receive advice regarding the modes of transmission and the activities that place them at risk of both HBV and HCV infection.
We analyzed paired pre- and post-travel sera in a cohort of Australian travelers to Asia and demonstrated the acquisition of hepatitis C virus (HCV) and hepatitis B virus (HBV) infection. The incidence density in nonimmune travelers for HCV infection was calculated as 1.8 infections per 10,000 traveler-days and for HBV infection 2.19 per 10,000 traveler-days.
]]>The risk of Japanese encephalitis (JE) in travelers is unknown. In this prospective study, we investigated the incidence of JE in 387 short-term Australian travelers visiting Asia over a 32-month period from August 2007 to February 2010 by performing pre- and post-travel antibody testing. No travelers were infected with JE virus during travel, indicating a low risk of infection for short-term travelers.
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