Journal of Travel Medicine

Published by Wiley
Online ISSN: 1708-8305
Publications
Article
Until May 2000, bivalent A/C meningococcal vaccine was the only available vaccine in Singapore for hajj travelers to Saudi Arabia. Recent worldwide reports of serogroup W-135 meningococcal meningitis associated with hajj returnees necessitated switching to quadrivalent A/C/Y/W-135 vaccine and crossover vaccination of travelers to Saudi Arabia. No safety data are available for quadrivalent vaccine following recent vaccination with bivalent vaccine. We assessed the safety and side effect profile of bivalent, quadrivalent, and quadrivalent meningococcal vaccine after recent vaccination with bivalent vaccine. A postvaccination telephone questionnaire survey was performed for all travelers who received either bivalent (B), quadrivalent (Q), or quadrivalent with recent (as defined by less than 6 months before) bivalent meningococcal vaccine (BQ) between 22 May and 8 June 2000 in preparation for the umrah (minor pilgrimage). Patients were asked about local reactions (pain, erythema, swelling at injection site graded in mild, moderate, and severe) and systemic reactions (fever, headache, graded in mild and severe). Of 546 persons vaccinated, 323 were interviewed. Median time interval between interview and vaccination was 10 days. Of those interviewed, 64 patients received bivalent (B), 213 quadrivalent (Q), and 46 quadrivalent after recent bivalent vaccine (BQ). The median interval time between previous bivalent and quadrivalent vaccine was 5 weeks. There was no statistically significant difference in the prevalence of side effects between the three groups. Mild pain at injection site was recorded in B as 21.8%, Q as 23%, BQ as 21.7%; low grade fever in B as 7.8%, Q as 9.8%, and BQ as 15.2%. Bivalent and quadrivalent meningococcal vaccine are well tolerated. Crossover vaccination of quadrivalent meningococcal vaccine after recent vaccination with bivalent vaccine does not increase the prevalence of adverse reactions and is therefore safe.
 
Article
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.
 
Article
Hepatitis A vaccination is recommended for travelers from the UK to areas of moderate or high endemicity. Two licensed hepatitis A vaccines are now available in the UK, and this trial was undertaken to determine whether Avaxim can be used as a booster following a primary course of Havrix. One hundred and eighty-five subjects were randomized to receive a booster dose of either Avaxim (n=92) or Havrix (n=93), 6 to 7 months after a primary dose of Havrix. Subjects were observed for 30 minutes for immediate reactions and subsequently completed a diary card for a further 2 weeks. Serology samples for HAV antibody titers were taken at 28 6 7 days later. One month following the booster dose, all subjects in both treatment groups achieved HAV antibody titers >= 20 mIU/mL. In the Avaxim group, geometric mean titer (GMT) values increased from 642 mIU/mL (97.5% CI 330-1250 mIU/mL) to 6669 mIU/mL (4566-9740 miu/mL), compared with 739 mIU/mL (379-1443 mIU/mL) at baseline to 4460 mIU/mL (2880-6908 mIU/mL) following the administration of Havrix. The increase in GMT following the administration of Avaxim was significantly greater than that following Havrix (p=.02). Eight percent of subjects reported pain at the injection site following a booster dose of Havrix, compared with none following Avaxim. This difference in reactogenicity was statistically significant (p=.01). In all other respects, both preparations were safe and equally well tolerated. Either Avaxim or Havrix may be given as a booster dose of hepatitis A vaccine when Havrix has been administered as the primary dose.
 
Article
The increase in international travel and immigration from tropical countries has led to a growing number of imported malaria cases in industrialized countries. We analyzed the charts of every patient hospitalized for malaria from 1970-1992 in Basel, Switzerland. A period lasting from 1970-1986 was compared to 1987-1992. There were 150 malaria-episodes recorded. Over time, the number of immigrants increased from 12 to 27% (p <.05). More patients were admitted with Plasmodium falciparum-infection (49 vs. 75%, p <.005). The number of untypable malaria decreased from 30 to 9% (p <.005). In the more recent period, more diagnosis were done within a week (66 vs. 50%, p <.05). Twenty-three (15%) patients were admitted to the ICU, four (2. 6%) patients died of cerebral malaria. Twenty-seven (18%) patients developed malaria while taking correct prophylaxis. Despite some progress, malaria is still causing considerable morbidity and mortality. Non adherence to chemoprophylaxis was a major risk factor for acquiring malaria in hospitalized patients.
 
Article
Few on-site studies involving local doctors have been published. We conducted a prospective on-site study of health problems occurring among French tourists to Nepal between 1 January 2001 and 31 December 2001, and compared the results with those of an identical study performed in 1984. Of the 21,457 French tourists who visited Nepal in 2001, 276 (1.3%) consulted the French Embassy doctor in Kathmandu with health complaints. The main reasons for seeking medical advice were diarrhea (26.8%), high-altitude illness (15.6%), lower respiratory tract infections (11.6%), dermatoses (8.7%), and fever (8.7%). Fifteen patients (5.4%) required hospitalization, five required medical evacuation (1.8%), and 14 (5%) were rescued by helicopter in the Himalayas. One patient died of cardiovascular disease. Relative to the 1984 cohort, significantly more patients consulted for high-altitude illness (p<.001), lower respiratory tract infections (p=.001), physical trauma (p=.01), and psychiatric disorders (p<.001), and significantly fewer patients consulted for dermatoses (p=.04), sexually transmitted diseases (p=.001), and upper respiratory tract infections (p=.005). These results, obtained 17 years apart, illustrate the changes in the pattern of health disorders causing travelers in Nepal to consult a doctor.
 
Article
The manners of traveling and travelers' vulnerability to infection are changing: increasing numbers of travelers, travels at the extreme ages of life, "backpacker" tourism in close contact with local populations. What is the epidemiologic situation and what are the trends of imported cholera to Metropolitan France? A descriptive retrospective study was undertaken on all the confirmed cases of cholera imported to France, and notified from January 1, 1973, to December 31, 2005, using compulsory notification data from local health departments and information from the National Reference Centre. A total of 129 imported cases of cholera were notified between 1973 and 2005 (3.9 cases/y on average). The geographical sources of infection have changed with time: in the 1980s, 94% of the patients were infected in Maghreb (Morocco and Algeria) but none were in 2000. On the other hand, Asia and West Africa progressively emerged and now predominate. In spite of certain poorly informed data and possible underdetection, the number of cases of importation appears to be low and falling. The patient profile seems to have evolved and increasingly concerns people at the extreme ages of life, living elsewhere than the principal basins of immigration in France, and diagnosis is increasingly made in nonteaching hospitals. The lessons likely to help clinicians will be discussed.
 
Article
The aim of the study was to retrospectively analyze diving fatalities occurring in Primorje-Gorski Kotar County (northern Croatian littoral), Croatia between 1980 and 2010 in order to identify differences between fatally injured tourist and resident divers, as well as temporal changes in the frequency of diver deaths. Medico-legal and police reports of 47 consecutive fatal diving cases were reviewed to determine the frequency of death among divers in relation to year and month of death, age, sex, nationality, organization of diving, diving type, and health condition. The majority of victims were foreign citizens (59.6%) most of whom fell victim to scuba diving (70.4%). It was found that 79% of resident divers succumbed during free-diving. The number of diving fatalities increased significantly in the last three decades, especially among free-divers. Of the victims, 93% were males, usually belonging to younger age groups with tourist divers being significantly older than local divers. And 31.9% of divers, mostly tourists, showed signs of acute, chronic, or congenital pathological conditions. Fatally injured foreign divers differ from resident diver fatalities in diving method and age. Tourists are the group most at risk while scuba diving according to the Croatian sample. Occupational scuba divers and free-divers are the group most at risk among resident divers. This study is an important tool in uncovering the most common victims of diving and the related risk factors. It also highlights the problems present in the legal and medical monitoring of recreational divers and discusses possible pre-event, event, and post-event preventive actions that could lead to reduced mortality rates in divers.
 
Article
To determine causes of death for Peace Corps Volunteers (PCV) between 1984 and 2003 and compare them with prior Volunteer death rates and with US death rates. We conducted a retrospective cohort study of all PCV between 1984 and 2003 and compared them to published data for prior years and against US death rates. Of the 66 deaths in our study period, the major causes were unintentional injury, homicide, medical illness, and suicide. Comparisons to US mortality data controlled for age, marital status, and educational attainment found equal or lower death rates among Volunteers. When compared to previous study results from 1961 to 1983, the total number of deaths, as well as the death rate per Volunteer-year, decreased. Deaths from unintentional injury, suicide, and medical illness decreased in number and rate; only homicides increased in number during our study period, but this increase did not reach statistical significance. PCV are exposed to unique risks, but these risks have become significantly less fatal over the past 20 years when compared to prior Peace Corps data and matched US population data.
 
Article
The objective of this study was to document the status of malaria infection and effect of preventive measures on the epidemiologic profile of imported malaria cases in Kuwait during 1985-2000. The study included screening of two groups of individuals for malaria infection by microscopy; (1) all migrant workers from malaria-endemic countries on their first entry to Kuwait; and (2) all suspected malaria cases already residing in the country. The study period was divided into pre-war (1985-1990), postwar (1992-1997) and proactive preventive (1998-2000) periods. During the proactive preventive period, the home countries were also involved in screening for malaria infection in all prospective immigrants to Kuwait. The annual incidence of malaria cases detected during the pre-war, postwar and proactive preventive periods ranged between 465 and 1,229, 654 and 1,379, and 248 and 393, respectively. Plasmodium vivax infection was detected in 71% of the cases and P. falciparum in 27%. The number of malaria cases detected increased to >1,300 after the war during 1992-1993. However, the number of malaria cases dropped significantly to less than 400 during 1998-2000 (p80%) of malaria patients were young male adults between 21 and 40 years of age. The data on drug resistance were not well defined, due to limited testing. This study suggests that the proactive preventive program to screen all prospective immigrants for malaria infection in their home countries significantly reduced the numbers of imported infections to <400 cases/year, a drop of 52.6%. In addition, it also identified a group of settled immigrants, the majority of whom were at high risk for acquisition of malaria infection during their visit to home countries. There is an urgent need to target this group for prevention strategies such as education/information and other preventive measures against malaria infection.
 
Article
Dengue fever is an acute, mosquito-transmitted viral disease characterized by fever, headache, arthralgia, myalgia, rash, nausea, and vomiting. Infections are caused by any of four virus serotypes (DEN-1, DEN-2, DEN-3, and DEN-4). The incidence of dengue is increasing in most tropical areas throughout the world (Fig. 1). Although dengue is not endemic in the continental United States, Hawaii, or Alaska, more than 500 laboratory-positive cases of introduced dengue were reported from 1977 through 1994 in U.S. residents who visited dengue-endemic areas throughout the world.1-4 In addition, two competent mosquito vectors (Aedes aegypti and Aedes albopictus) are found in the southeastern United States, and both could possibly transmit an introduced virus. In Hawaii, Ae. albopictus is the dominant mosquito on all islands; Ae. aegypti has only focal distribution on Molokai and the Kona coast of Hawaii. Economic, political, technologic, ecologic, and demographic changes have brought about the emergence of new microbial diseases, as well as an increase in the incidence of previously known infections. The increase in dengue activity in Asia, Africa, and the Americas represents a pandemic that is being facilitated by increased air travel; global urbanization; population growth; greater abundance of disposable, nondegradable containers that can serve as Aedes production sites; and lack of effective mosquito control programs.5,6 This report summarizes information about risk factors for severe disease, recent dengue outbreaks throughout the world, and cases of dengue virus infection in travelers who have been diagnosed on return to the United States.
 
Article
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
 
Article
Malaria, in particular Falciparum malaria, continues to pose a substantial risk to travelers to endemic areas. In this study we examined 93 case notes of patients with malaria treated in our department between 1990 and 1996. Forty-seven (50.5%) patients had infection with Plasmodium falciparum, 41 (44.1%) had Plasmodium vivax and 5 (5.4%) had Plasmodium ovale. One of these patients had a dual infection with P. falciparum and P. vivax. None of our patients had Plasmodium malariae. Forty-four of the P. falciparum cases (93.6%) were imported from sub-Saharan Africa, 33 of the P. vivax cases (78.5%) were imported from the Indian subcontinent. All the P. ovale cases were imported from sub-Saharan Africa. Fifty-four of our patients (58.1%) did not take any form of chemoprophylaxis. Forty-two out of 93 (45.2%) of the "travelers" were settled immigrants in the UK. Seventy-eight percent of travelers of British caucasian origin took prophylaxis whereas only 13.5% of travelers of ethnic minorities origin took prophylaxis. Greater awareness of the risk of malaria by travelers and medical practitioners in UK must be encouraged and in particular appropriate chemoprophylaxis instituted for travelers to chloroquine-resistant areas.
 
Article
The use of chemoprophylaxis decreases the severity and frequency of death from malaria due to Plasmodium falciparum compared with those who take no prophylaxis. Advice on the prevention of malaria has been deemed as among the most important to give travelers in Australia. Geographic knowledge of the distribution and prevalence of malaria and drug-resistant malaria should be used to base decisions concerning whether or not to give malaria chemoprophlaxis. Therapeutic guidelines, which include guidelines on malaria chemoprophylaxis, assist travel health advisers in their selection of antimalarials. Previous studies have suggested that considerable variation exists in patterns of antimalarials used in relation to the prevailing antimalarial guidelines in Australia.
 
Article
Spain obtained the official certificate of malaria eradication in 1964. However, imported malaria cases have been increasing during the last few decades in this country. This study aims to describe the clinical and epidemiological features of patients diagnosed with malaria on Gran Canaria Island. A retrospective study was conducted based on case review of all patients diagnosed with malaria microbiologically confirmed from 1993 to 2006, at the three referral teaching hospitals on Gran Canaria Island. One hundred eighty-four episodes in 181 patients were diagnosed, 170 of them were analyzed. Most of them (82%) were travelers. Nearly 15% (14.7%) declared having had some chemoprophylaxis, but only half of them completed the treatment. Twenty cases (10.9%) were diagnosed who had just arrived as immigrants, mainly children. Malaria was acquired in Africa by 94.7% of the cases and Plasmodium falciparum was responsible for the majority of the cases (84.1%). Clinical and epidemiological differences were observed among different groups of patients formed by their origin and travel purposes. At least one indicator of severe malaria was established in 22.9% of the cases. However, global mortality was 3.8%. Malaria in Gran Canaria Island is imported from endemic areas, mainly from African countries, observed mostly among young adult males, but clinical and epidemiological features may change among different groups of patients. The number of immigrants diagnosed with malaria is increasing in this area nowadays.
 
Article
In industrialized countries, typhoid fever occurs mainly in returned travelers. To determine the need for preventive strategies, eg, for vaccination, continuous monitoring is needed to assess where the risk for travelers is highest. To investigate where the risk for travelers to acquire typhoid fever is highest, 208 patients with typhoid fever and recent travel were matched with travelers' statistics collected by the Swiss Federal Office of Statistics. At the beginning of the study period, up to 30 infections with Salmonella typhi were recorded per year in Switzerland. Since 2001, less than 15 confirmed cases per year occurred. A majority of the 208 (88.5%) typhoid cases were associated with recent travel. Countries with highest risk were Pakistan (24 per 100,000), Cambodia (20 per 100,000), Nepal (14 per 100,000), India (12 per 100,000), and Sri Lanka (9 per 100,000). We found that over a 12-year period (1993-2004), the travel-associated risk of typhoid fever is highest for destinations in the Indian subcontinent. All other regions showed a decline, most markedly in southern Europe. Our results suggest that typhoid fever vaccination should be recommended for all travelers to countries in South Asia. Otherwise, vaccination of tourists to frequently visited low- and intermediate-risk areas is not necessary, unless there are behavioral risk factors.
 
Article
The World Health Organization estimates that more than 300 million cases of malaria exist worldwide each year, resulting in more than 3 million deaths, with more than 1 million deaths of children in sub-Saharan Africa alone. Malaria is also a reemerging disease in some parts of Africa, including South Africa. Malaria prevention is multi-faceted with no single precaution offering complete protection. Taking chemoprophylaxis decreases the severity and frequency of death from malaria due to Plasmodium falciparum when compared with taking no chemoprophylaxis.
 
Article
Imported measles cases and outbreaks involving Japanese travelers have been reported from the United States and other countries. For the United States, Japan is the top country of origin. The aims of this study were to analyze measles exportation trends from Japan to the United States and to suggest recommendations for improving monitoring and control in both countries. Reviewing all exportation cases reported to the Centers for Disease Control and Prevention and sentinel measles activity data monitored by the Japanese Ministry of Health between January 1994 and December 2006 (observation period). A total of 63 cases were reported (median = 4 cases per year). Cases ranged in age from 9 months to 53 years (median = 17 y). Peaks occurred at 13 to 26 years and 12 to 35 months. Six cases were US citizens and 57 Japanese. Ten cases were reported in July and August, followed by eight in February and March. Twenty-seven cases were reported from Hawaii, followed by 15 from California and 6 from New York. Seven cases developed the secondary spread. Three of the cases had previously received one dose of measles vaccine, compared to 35 who were never immunized (25 cases unknown). During the observation period, measles activity exceeded the warning level in 157 weeks, with measles exportation occurring the subsequent week for 30 of these weeks. In comparison, during the 521 weeks in which measles activity was below the warning level, exportation of measles the following week was observed for 21 of those weeks (OR = 5.62, 95% CI = 3.12-10.2, p < 0.001). Trend of exported measles cases from Japan to the United States has corresponded with the measles activity trend in Japan. Most of the cases were unvaccinated. This international health problem should be solved by strong leadership of Japanese public health professionals.
 
Article
Campylobacter sp. is a major cause of bacterial enterocolitis and travelers' diarrhea. Empiric treatment regimens include fluoroquinolones and macrolides. Over the period 1994 to 2006, 724 Campylobacter jejuni/Campylobacter coli isolates recovered from international travelers at the outpatient clinic of the Institute of Tropical Medicine, Antwerp, Belgium, were reviewed for their susceptibility to norfloxacin and erythromycin. Norfloxacin resistance increased significantly over time in isolates from travelers returning from Asia, Africa, and Latin America. For the years 2001 to 2006, norfloxacin resistance rates were 67 (70.5%) of 95 for Asia, 20 (60.6%) of 33 for Latin America, and 36 (30.6%) of 114 for Africa. The sharpest increase was noted for India, with no resistance in 1994, but 41 (78.8%) of 52 resistant isolates found during 2001 to 2006. Erythromycin resistance was demonstrated in 20 (2.7%) isolates, with a mean annual resistance of 3.1% +/- 2.8%; resistance increased over time, with up to 3(7.5%) of 40 and 3 (8.6%) of 35 resistant isolates in 2004 and 2006, respectively (p < 0.05); there was no apparent geographic association. Combined resistance to norfloxacin and erythromycin was observed in five isolates. The high resistance rates to fluoroquinolones warrant reconsideration of their use as drugs of choice in patients with severe gastroenteritis when Campylobacter is the presumed cause. Continued monitoring of the incidence and the spread of resistant Campylobacter isolates is warranted.
 
Article
International migrants represent only 4.5% of the world's population, but they may become a challenge for host countries. The aim of the study was to assess the impact of this population on health parameters in Como county, on the northern border of Italy. A retrospective analysis of migrants' admissions at Sant'Anna Hospital in 1998 was done, and compared to data from 1994. Of 47,378 total admissions at our hospital, 268 involved migrants (0.5%), mostly from the former Yugoslavia, with a slight preponderance of females; 22 out of 268 migrants were admitted in the Infectious Diseases Department (8.2%), mainly from Africa. Most admissions were classified as Drug Related Group (DRG), but an increasing number of miscellaneous DRGs are reported, including obstetric ones. The emergence of a female population among migrant admissions, and the relevance of delivery DRGs in 1998, may suggest that, after a first immigration wave of rather healthy men in search of good job opportunities during the first years of the 90s, we are now observing a second wave of migrants: their families. The increasing number of patients from the former Yugoslavia reported in 1998, could suggest that a third wave is expected in the near future: these will be irregular migrants and refugees.
 
Article
To improve pre-travel advice, we analyzed nationwide population-based surveillance data on malaria cases reported to the National Infectious Disease Register of Finland (population 5.3 million) during 1995 to 2008 and related it to data on traveling and antimalarial drug sales. Surveillance data comprised information on malaria cases reported to the National Infectious Disease Register during 1995 to 2008. Traveling data were obtained from Statistics Finland (SF) and the Association of Finnish Travel Agents (AFTA). SF data included information on overnight leisure trips to malaria-endemic countries during 2000 to 2008. AFTA data included annual number of organized trips during 1999 to 2007. Quarterly numbers of antimalarial drug sales were obtained from the Finnish Medicines Agency. Descriptive and time series analyses were performed. A total of 484 malaria cases (average annual incidence 0.7/100,000 population) were reported; 283 patients were Finnish- and 201 foreign-born. In all, 15% of all cases were children; 72% foreign- and 28% Finnish-born. Malaria infections were mostly acquired in Africa (76%). Among foreign-born cases, 89% of the infections were acquired in the region of birth. The most common species were Plasmodium falciparum (61%) and Plasmodium vivax (22%). Although traveling to malaria-endemic areas increased, no increase occurred in malaria cases, and a decreasing trend was present in antimalarial drug sales. Traveling to malaria-endemic countries and drug sales followed the same seasonal pattern, with peaks in the first and last quarter of the year. More efforts should be focused on disseminating pre-travel advice to immigrants planning to visit friends and relatives and travelers on self-organized trips.
 
Article
Death during international travel concerns several levels of the travel industry. In addition to the immediate effects for the traveler, their family and friends, the nature of travel-related mortality has important implications for pretravel health advisors and providers of medical care services. The Consular Affairs Bureau, Foreign Affairs Canada provides information and assistance to Canadian civilians abroad. Beginning in 1995, the Consular Management and Operations System tracked Canadian deaths abroad notifications. The annual data for 1996 to 2004 was extracted for sex, age, and cause of death by location for all reports received. There were 2,410 reported deaths in Canadians abroad; reported sex was 32% female and 68% male, average age of 61.7 and 60.4 years, respectively. Recorded causes of death: natural (1,762), accidental (450), suicide (92), and murder (106). Country of death reflected the pattern of Canadian international travel for recreation, business, and ancestral linkages. Average age of natural death (66 years) distinguished it from all other causes of death: accidental (45), suicide (41), and murder (43). Natural causes and suicide deaths may be anticipated or planned to occur abroad. The risk of death may be mitigated through personal knowledge and medical assessment and prevention strategies. Deaths due to vaccine-preventable diseases, exotic and infectious diseases were rare in this population. Consular services may be able to provide various types of support. Local laws and customs, as well as international regulations in health and quarantine govern other responsibilities such as funeral services and repatriation of the deceased to Canada.
 
Article
US residents on travel to dengue‐endemic areas 1 should be briefed about the basics of the vector biology of Aedes aegypti and Aedes albopictus . Both breed in fresh water and are mainly indoor mosquitoes. They are active during …
 
Article
As the incidence of dengue increases globally, US travelers to endemic areas may be at an increased risk of travel-associated dengue. Data from the US Centers for Disease Control and Prevention's laboratory-based Passive Dengue Surveillance System (PDSS) were used to describe trends in travel-associated dengue reported from January 1, 1996 to December 31, 2005. The PDSS relies on provider-initiated requests for diagnostic testing of serum samples via state health departments. A case of travel-associated dengue was defined as a laboratory-positive dengue infection in a resident of the 50 US states and the District of Columbia who had been in a dengue-endemic area within 14 days before symptom onset. Dengue infection was confirmed by serologic and virologic techniques. One thousand one hundred and ninety-six suspected travel-associated dengue cases were reported-334 (28%) were laboratory-positive, 597 (50%) were laboratory-negative, and 265 (22%) were laboratory-indeterminate. The incidence of laboratory-positive cases varied from 1996 to 2005, but had an overall increase with no significant trend (53.5 to 121.3 per 10(8) US travelers, p = 0.36). The most commonly visited regions were the Caribbean, Mexico and Central America, and Asia. The median age of laboratory-positive cases was 37 years (range: <1 to 75 y) and 166 (50%) were male. Of the 334 laboratory-positive cases, 41 (12%) were hospitalized, and 2 (1%) died. Residents of the US traveling to dengue-endemic regions are at risk of dengue infection and need to be instructed on appropriate prevention measures prior to travel. Especially in light of the potential transmissibility of dengue virus via blood transfusion, consistent reporting of travel-associated dengue infections is essential.
 
Article
The health of travelers returning home from developing countries has received increased attention in recent years. Much of this attention has centered on immunizations, malaria chemoprophylaxis and treatment of traveler's diarrhea. In contrast, there are very few data on the health problems of international travelers to developed countries such as the United States. We studied the experience of two corporate medical assistance clinics established for both national and international travelers to Atlanta, Georgia during the Centennial Summer Olympic Games in 1996.
 
Article
With the popularity of international travel increasing, more travelers in endemic areas may increase their risk of tuberculosis (TB). We analyzed Peace Corps data to assess the risk of TB in long-term travelers from the United States. We analyzed purified protein derivative (PPD) conversion and acute TB case data from the Peace Corps Epidemiological Surveillance System as well as postservice claims data. We calculated the risk of PPD conversion and active TB in all countries with Peace Corps Volunteers between 1996 and 2005 and compared these risks with other published data. The overall incidence rates for positive PPD conversions and active TB cases are 1.283 and 0.057 per 1,000 Volunteer-months, respectively. The Africa region had the highest PPD conversion rate of 1.467 conversions per 1,000 Volunteer-months as well as the highest active TB rate of 0.089 cases per 1,000 Volunteer-months. Per-country incidence rates for PPD conversions and active TB cases ranged widely from 0.000 to 5.514 cases and 0.000 to 2.126 cases per 1,000 Volunteer-months, respectively. In countries identified as "high risk," there were 1.436 cases of PPD conversions and 0.084 cases of active TB per 1,000 Volunteer-months. Peace Corps Volunteers have significantly higher rates of TB when compared to the average US population but much lower than those reported for travelers to highly endemic countries. Volunteers assigned to highly endemic countries still have a lower risk compared to other travelers to those same countries. Keeping in mind that Peace Corps Volunteers are a unique population, these data may be useful in providing medical advice to long-term travelers.
 
Article
Minnesota (MN) is home to one of the highest number of refugees in the United States. The primary objective of this study was to evaluate the prevalence of latent and active tuberculosis (TB) infection in primary refugee arrivals to MN. Secondary objectives were to determine the association of TB infection with gender, age, and ethnicity of the refugees. A retrospective study of primary refugee arrivals to MN between January 1, 1997, and December 31, 2001, was conducted. Chi-square tests and logistic regression analyses were used to assess the association of TB infection with gender, age, and ethnicity. Of the 9,842 refugees who had Mantoux test results, 4,990 (50.7%) had a positive test. A positive test was more common in men [odds ratio (OR) = 1.6; p < 0.0001], in Africans (OR = 1.6, p = <0.0001), and increased with 10-year age intervals (OR = 1.4; p < 0.0001). A total of 116 (0.8%) refugees received treatment for active TB. Active TB was more common in men (OR = 1.7; p = 0.006), African ethnicity (OR = 4.3; p < 0.0001), and increased with 10-year age intervals (OR = 1.1; p = 0.05). Screening and treatment for latent and active TB should be actively managed among refugees resettling in the United States, as this is common and can have significant public health implications.
 
Article
Influenza is a common vaccine-preventable disease among international travelers, but few data exist to guide use of reciprocal hemisphere or out-of-season vaccines. We analyzed records of ill-returned travelers in the GeoSentinel Surveillance Network to determine latitudinal travel patterns in those who acquired influenza abroad. Among 37,542 ill-returned travelers analyzed, 59 were diagnosed with influenza A and 11 with influenza B. Half of travelers from temperate regions to the tropics departed outside influenza season. Twelve travelers crossed hemispheres from one temperate region to another, five during influenza season. Ten of 12 travelers (83%) with influenza who crossed hemispheres were managed as inpatients. Proportionate morbidity estimates for influenza A acquisition were highest for travel to the East-Southeast Asian influenza circulation network with 6.13 (95% CI 4.5-8.2) cases per 1000 ill-returned travelers, a sevenfold increased proportionate morbidity compared to travel outside the network. Alternate hemisphere and out-of-season influenza vaccine availability may benefit a small proportion of travelers. Proportionate morbidity estimates by region of travel can inform pre-travel consultation and emphasize the ease of acquisition of infections such as influenza during travel.
 
Article
Previous research in a number of countries has suggested considerable variability in prescribing patterns of antimalarial drugs. The aim of this study was to investigate the trends in prescription of antimalarial drugs recommended for chemoprophylaxis in Australia from 1998 to 2002. In 2005 data was extracted from the online Australian Statistics on Medicines reports published by the Pharmaceutical Benefits Advisory Committee, Drug Utilization Sub-committee, on antimalarials used in Australia from 1998 to 2002. Doxycycline probably remains the malaria chemoprophylaxis of choice prescribed for Australians visiting multiple drug-resistant malarious areas. Over the past 10 years, there has been marked drop in the prescription of less useful antifolate drugs such as pyrimethamine combination antimalarial drugs, especially pyrimethamine plus dapsone, which was withdrawn by 1999. There has also been a reduction in the number of prescriptions for chloroquine, mefloquine, and proguanil. The number of prescriptions for atovaquone and proguanil remain small, although they have increased steadily since its introduction in 2000, in the absence of a recommendation in the prevailing Australian guidelines. The prescription of antimalarials such as proguanil, chloroquine, mefloquine, and the pyrimethamine-containing compounds reduced considerably between 1998 and 2002. This was probably largely influenced by the availability of antimalarials, increasing resistance, the issuing of updated guidelines for malaria chemoprophylaxis, and continuing education. Newer drugs such as atovaquone plus proguanil may displace older antimalarials, particularly in the prevention of Plasmodium falciparum infection.
 
Article
Tourism is important to the Jamaican economy accounting for approximately 25% of the gross domestic product. Health problems in tourists could have significant impact on the health of the local population, the scarce health service resources, and the tourist industry. This study was conducted to identify health problems most commonly occurring in tourists visiting Jamaica and examine how these problems are managed. Records of health problems occurring in tourists who visited principal tourist areas on the north coast from June 1998 to June 2002 were reviewed for the type of illness and how the problem was handled. The data were analyzed using Epi-Info software (Centers for Disease Control and Prevention, Atlanta, GA) and Statistical Analysis System software (SAS Institute, Cary, NC). Accidents were the most common health crises reported by tourists. Gastrointestinal, respiratory, and cardiovascular problems occurred less frequently. Those less than 40 years of age more frequently reported accidents or injury, gastrointestinal problems, and drug abuse, whereas respiratory and cardiovascular problems were more common among those above 40 years of age. Cardiovascular problems, drug abuse, and death were more common in men than in women. Hotel nurses handled most of the cases and were more likely to refer patients to private physicians or hospitals than to public hospitals (p <.05). Factors influencing the way the crisis was handled were age (p =.0441); who handled the crisis (p <.0001); and the method of payment (p =.0072). The factors that influenced hospitalization were gender (p =.0615); who handled the crisis at the onset (p =.0497); how the crisis was dealt with (p =.0336); and previous health problems (p =.0056). Men were more likely to be hospitalized and to be referred to a public hospital than women. Medical insurance covered the costs for 11% of tourists, and 75% paid out of pocket. The information provided by this study can be used to implement changes to reduce health problems in tourists and improve emergency health services in tourist areas.
 
Article
In Austria, being an area of low hepatitis A endemicity, every year, several cases of this infectious disease are reported. The aim of the present study was to provide data on disease and hospitalization of children below the age of 15 for imported and autochthonous hepatitis A in Austria. Nationwide, active, hospital-based surveillance during the period 1998 to 2005. During this 8-year observation period, 413 children below 15 years of age were hospitalized with acute hepatitis due to infection with hepatitis A . The mean annual incidence of hospitalization per 100,000 population was 3.8, with a decreasing trend from 1998 to 2005. The mean length of hospital stay attributable to hepatitis A was 6.5 days. The mean annual number of days of hospitalization attributable to acute hepatitis A infection in children below 15 years of age was 335 days. Information on origin of infection was available in 48% of the reports, the majority of which (69%) were in consequence of infection import. The mean annual incidence of travel-associated, hospitalized hepatitis A cases was 1.3 per 100,000, showing a lesser decrease rate over the observation period than the total hospitalization incidence. In an area of low hepatitis A endemicity such as Austria, hospitalization incidence of children is still at a considerable level. Our findings contribute to an open discussion about universal childhood vaccination.
 
Article
Although the regional approach to malaria control between South Africa, Swaziland, and Mozambique has significantly decreased malaria risk in the Lubombo corridor, many facility owners' and tourists' malaria risk perception has remained unchanged. A large percentage are still unaware of the extensive malaria control efforts in the region and subsequent malaria reductions in the Lubombo corridor. A questionnaire-based follow-up survey was carried out in northern KwaZulu-Natal in the 1999/2000 and 2002/2003 malaria seasons. Tourists and tourist facility owners/managers were interviewed on their perceptions pertaining to malaria risk. In the 1999/2000 malaria season, 18% of tourist facilities in northern KwaZulu-Natal were in areas where 5 to 25 malaria cases per 1,000 population were recorded, and 68% were in areas where <5 malaria cases per 1,000 population were recorded. A major reduction in malaria cases was achieved by the end of the 2002/2003 malaria season. None (0%) of the tourist facilities were in areas where 5 to 25 malaria cases per 1,000 population were recorded, and 98% were in areas where malaria cases were lower than five cases per 1,000 population. The survey of local and international tourists and tourist facility operators in northern KwaZulu-Natal revealed that there was a discrepancy between perceived and actual malaria risk. The perceived malaria risk among both local and international tourists and facility operators needs to be addressed by distributing updated malaria risk information on an annual basis.
 
Article
Travel medicine in Spain is provided by a few specialized centers that do not come under the auspices of the main health system. Some kind of reform is required to avoid common summer collapses and postponements of the service. In contrast to other European countries, neither the exact role nor the responsibilities of general practitioners and primary health care in travel medicine are clearly defined. An observational study was performed with retrospective data concerning 2,622 travelers from 1999 to 2004. Although the study was performed at a third-level travel medicine center, continuous contact with and support to general practitioners was maintained throughout the period. International travel was a steadily increasing reality between 1999 and 2004 despite well-known tragic events involving world safety. The number of high-risk travels (53.4%) also increased and even overtook low-risk ones (46.6%). This trend was explained as the result of an increasing number of journeys to sub-Saharan Africa (14.9%) and those made by traveling immigrants (64.1% of those journeys), which represented a significantly higher proportion of high-risk travels compared with those made by autochthonous subjects (52.1%; p < .001). Moreover, traveling immigrants tend to consult more frequently in periods < 15 days prior to travel than do autochthonous travelers (p < .0001). A substantial number of highly vulnerable travelers, such as pregnant women, infants, elderly people, and immunosuppressed subjects, was found (1.8%). Low-risk travelers who could have been advised and vaccinated by general practitioners were 1,139 (43.4%). Given the increasing number of travelers undertaking high-risk travels abroad, any kind of reinforcement of travel medicine provision in Spain should be considered essential. General practitioners could attend to a significant proportion of low-risk travelers.
 
Article
The prevalence and features of travel associated neuropsychiatric problems (NPP) and their relation to previous psychological consultations, antimalarials and recreational drug use have not been adequately studied. A two-phase postal and telephone survey has been conducted among 2,500 young travelers to tropical countries. We measured the rate and duration of NPP, characterized their features, and their association with previous psychological profiles, itinerary, type of travel, consumption of recreational drugs, and malaria prophylaxis. First phase: Out of 1,340 respondents, 151 (11.3%) indicated that they had NPP during travel, in contrast with 2.3% who needed psychological consultation before travel (p<.001). Second phase: 117 of 151 responded to the study questionnaire. The mean age of the respondents was 24.4 years, 54.7% were female, and the mean stay abroad was 5.3 months. The most common NPP were sleeping disturbances (52.1%), fatigue (48.7%) and dizziness (39.3%). Thirty-three travelers (2.5%) had severe symptoms, and 16 (1.2%) had symptoms lasting more than 2 months. Seven travelers had pure or mixed depressive symptoms. Consumption of recreational drugs was admitted by 22.2%. Mefloquine was used significantly more often by those who suffered NPP, than by the entire cohort (98.2% vs. 70.7%; p<.001). Long-term travel to the tropics was associated, in this cohort, with a considerable rate of neuropsychiatric symptoms. The majority of the responding travelers were females, used mefloquine as prophylaxis, and at least one fifth used recreational drugs.
 
Article
The modern Olympic Games, conducted only once every 4 years since 1900, will be held in Sydney, Australia, from September 15 to October 1, 2000. There will be approximately 35 competition venues, 5 villages, 100 training venues, a media center, and sponsor hospitality areas.1 There will be about 300 events for 28 sports, involving 10,300 athletes from 200 countries, 5,100 team officials, 50,000 volunteers, 15,000 media, a world wide audience of around 3.5 billion viewers and listeners, and up to several hundred-thousand spectators at any one time.1 The Paralympic Games will also be held in Sydney, after the Olympic Games, from October 18 to 29, 2000, with more than 4,000 athletes competing.1 This paper focuses on health and safety issues for travelers to Australia in general, although it makes specific references to advice for visiting Olympic and Paralympic athletes and team staff, who will be traveling to the games. It must be remembered that travel health advice can change, and that travelers should be advised to seek up-to-date travel health advice for Australia closer to their departure.
 
Institutions keeping anti-trypanosome drugs
Cases of Rhodesiense sleeping sickness diagnosed in non-endemic countries (2000-2010)
(Continued)
Article
Background. Human African trypanosomiasis (HAT) can affect travelers to sub-Saharan Africa, as well as migrants from disease endemic countries (DECs), posing diagnosis challenges to travel health services in non-disease endemic countries (non-DECs). Methods. Cases reported in journals have been collected through a bibliographic research and complemented by cases reported to the World Health Organization (WHO) during the process to obtain anti-trypanosome drugs. These drugs are distributed to DECs solely by WHO. Drugs are also provided to non-DECs when an HAT case is diagnosed. However, in non-DEC pentamidine can also be purchased in the market due to its indication to treat Pneumocystis and Leishmania infections. Any request for drugs from non-DECs should be accompanied by epidemiological and clinical data on the patient. Results. During the period 2000 to 2010, 94 cases of HAT were reported in 19 non-DECs. Seventy-two percent of them corresponded to the Rhodesiense form, whereas 28% corresponded to the Gambiense. Cases of Rhodesiense HAT were mainly diagnosed in tourists after short visits to DECs, usually within a few days of return. The majority of them were in first stage. Initial misdiagnosis with malaria or tick-borne diseases was frequent. Cases of Gambiense HAT were usually diagnosed several months after initial examination and subsequent to a variety of misdiagnoses. The majority were in second stage. Patients affected were expatriates living in DECs for extended periods and refugees or economic migrants from DECs. Conclusions. The risk of HAT in travelers and migrants, albeit low, cannot be overlooked. In non-DECs, rarity, nonspecific symptoms, and lack of knowledge and awareness in health staff make diagnosis difficult. Misdiagnosis is frequent, thus leading to invasive diagnosis methods, unnecessary treatments, and increased risk of fatality. Centralized distribution of drugs for HAT by WHO enables an HAT surveillance system for non-DECs to be maintained. This system provides valuable information on disease transmission and complements data collected in DECs.
 
Article
The modern Olympic Games have been conducted only once every 4 years since 1900. They were held in Sydney, Australia, from September 15 to October 1, 2000, with approximately 35 competition venues, 5 villages, 100 training venues, a media center, and sponsor hospitality areas. Roughly 300 events for 28 sports involved 10,300 athletes from 200 countries, 5,100 team officials, 50,000 volunteers, 15,000 media, a worldwide audience of around 3.5 billion viewers and listeners, and up to several hundred thousand spectators at any one time. The Paralympic Games were also held in Sydney after the Olympic Games, from October 18 to October 29, 2000, with more than 4,000 athletes competing. A report detailing possible health advice and requirements for travelers attending the games has been published previously. Good systems of public and private health care operate in Australia, but health care is not free. Australian taxpayers contribute to a national public health system, Medicare, and even this does not necessarily cover all the costs of treatment. Section 3.5 of the Medicare Benefit Scheme refers to "Reciprocal Health Care Agreements," which exist for immediately necessary medical care ("emergency care"). Agreements with Australia cover New Zealand, United Kingdom, Netherlands, Sweden, Finland, Italy, Malta, and Ireland. Benefits for Italy and Malta may only be available for the first 6 months of a stay. The Australian government covered much of the costs of medical treatment for most team members competing or involved in the Olympic and Paralympic Games, when the Games Village was open. This did not however extend to other visitors, and public hospitals in Australia are not generally geared and staffed to provide timely general practice services.
 
Article
Prescribing patterns of antimalarial drugs have previously been observed to vary considerably in Australia. The aim of this study was to investigate the trends in prescription of antimalarial drugs recommended for chemoprophylaxis in Australia from 2002 to 2005. In 2007, data were extracted from the online Australian Statistics on Medicines reports published by the Pharmaceutical Benefits Advisory Committee, Drug Utilization Sub-Committee on antimalarials used in Australia for the period 2002 to 2005. Doxycycline probably remains the malaria chemoprophylaxis of choice prescribed for Australians visiting multiple drug-resistant malarious areas. Over the past 15 years, there has been a marked drop in the prescription of less useful antifolate drugs, such as pyrimethamine-containing antimalarial drugs. There has also been a reduction in the number of prescriptions of chloroquine and proguanil, although the downward trend in prescriptions of mefloquine appears to have arrested and has trended upward. The number of prescriptions of atovaquone and proguanil has been increasing dramatically, particularly since inclusion of this combination antimalarial in the prevailing Australian guidelines. Artemether plus lumefantrine combination is now available, but it is used in relatively small quantities. The prescription of the antimalarial drugs, proguanil, chloroquine, and the pyrimethamine-containing compounds, has generally reduced in number. Prescription of mefloquine trended upward during 2002 to 2005, following a period of reducing prescriptions. The atovaquone plus proguanil combination has steadily increased in use and is presumably displacing older antimalarials. The use of quinine has halved, which might be related in part to the uptake of newer antimalarial drugs for treatment. Trends in antimalarial use may be influenced by a number of factors, including the availability of antimalarials, increasing resistance, the issuing of updated guidelines for malaria chemoprophylaxis, and continuing education.
 
Article
Previous studies investigating the travelers' knowledge, attitudes, and practices (KAP) profile indicated an important educational need among those traveling to risk destinations. Initiatives to improve such education should target all groups of travelers, including business travelers, those visiting friends and relatives (VFR), and older adult travelers. In the years 2002 to 2009, a longitudinal questionnaire-based survey was conducted at the Dutch Schiphol Airport with the aim to study trends in KAP of travel risk groups toward prevention of hepatitis A. The risk groups last-minute travelers, solo travelers, business travelers, travelers VFR, and older adult travelers were specifically studied. A total of 3,045 respondents were included in the survey. Travelers to destinations with a high risk for hepatitis A had significantly less accurate risk perceptions (knowledge) than travelers to low-to-intermediate-risk destinations. The relative risk for hepatitis A in travelers to high-risk destinations was probably mitigated by less intended risk-seeking behavior and by higher protection rates against hepatitis A as compared with travelers to low-to-intermediate-risk destinations. Logistic regression analyses showed that an age >60 years was the only significant determinant for improvement of their knowledge. Trend analyses showed a significant change over time in attitude toward more risk-avoiding behavior and toward higher protection rates against hepatitis A in travelers to high-risk destinations. The KAP profile of the risk groups travelers VFR (irrespective of hepatitis A risk of their destination) and solo as well as last-minute travelers to high-risk destinations substantially increased their relative risk for hepatitis A. The results of this longitudinal survey in Dutch travelers suggest an annual 5% increase in protection rates against hepatitis A coinciding with an annual 1% decrease in intended risk-seeking behavior. This improvement may reflect the continuous efforts of travel health advice providers to create awareness and to propagate safe and healthy travel. The KAP profile of travelers visiting friends and relatives (VFR) and solo as well as last-minute travelers to high-risk destinations substantially increased their relative risk for hepatitis A. These risk groups should be candidates for targeted interventions.
 
Article
Cystic echinococcosis (CE) of the liver can be treated with ultrasound-guided puncture, aspiration, injection, and re-aspiration (PAIR), with surgery and with benzimidazole derivatives. The aim of this study was to review available data concerning treatment modality and outcome for patients treated for CE of the liver in a Danish tertiary reference center. A search was made for patients treated for CE infection between January 1, 2002 and January 1, 2010. All relevant patient records and radiology exams were scrutinized and all cysts were re-classified according to the WHO-IWGE, blinded as to which treatment the patient had received. PAIR was performed as a first choice treatment and surgery was reserved for cases where PAIR was impossible. Inactive cyst stages received medical treatment only. The search revealed 26 cases with confirmed CE of the liver. Nine patients underwent PAIR and nine patients surgery as a first choice treatment. Three patients were treated with PAIR secondary to surgery and one patient was treated with surgery secondary to PAIR. For all PAIR treatments, the success rate was 58% regardless of cyst stage and for surgery the success rate was 70%. The difference between the rates was not statistically significant (p = 0.67). CE is a rare disease in Denmark and our study is the first describing clinical management of CE in our institution.
 
Top-cited authors
Annelies Wilder-Smith
  • Universität Heidelberg
Joacim Rocklöv
  • Umeå University
Annelies Wilder-Smith
  • Lee Kong Chian School of Medicine, Singapore
Kamran Khan
Alexander Watts
  • St. Michael's Hospital