Travel Medicine and Infectious Disease

Published by Elsevier
Online ISSN: 1477-8939
Publications
Article
Basal Cell Carcinoma (BCC) is the most common form of skin malignancy in the UK with 75, 000 new cases per year. It commonly presents as a non-healing lesion in the H zone of the face. The significant risk factors for this condition include UV radiation exposure and a history of sunburn. The gold standard treatment for BCC is Mohs Micrographic Surgery as well a variety of traditional surgical and non-surgical options. A 32 year old white male military helicopter pilot presented with a pea sized lesion which appeared highly vascularised with multiple telangiectasia on the surface. The main risk factors were regular foreign travel to regions of high UV radiation and previous episodes of sunburn. BCC is the commonest form of eye lid malignancy and any form of non-healing lesion on the periocular area should be investigated as a possible neoplasm. The main risk factors are travel to areas of high UV radiation and exposure to UV radiation as a child. There is also a possible risk factor of occupational exposure to ionising radiation from cosmic sources although there is limited research to support this. This is an interesting case of an unusual first presentation of a BCC in a male under 40 years of age and demonstrates the important risk factors in a military population for developing a non-melanoma skin cancer.
 
Article
Australia is a climatically diverse country varying from a tropical climate in the north to arid central desert and grassland regions, and to temperate climates in the south. There are many viral infections found in Australia that are common to developed countries worldwide, but this article will focus on those that pose a special risk for travellers to Australia, especially the mosquito-borne viruses. The commonest are the members of the alphavirus genus, particularly Ross River virus and Barmah Forest virus, which cause predominantly arthralgia with or without fever or rash. Less frequent but more serious illness is seen with the encephalitic flaviviruses, Murray Valley encephalitis virus, and the Kunjin strain of West Nile virus. In addition dengue occurs intermittently on the northern part of Queensland, and in recent years Japanese encephalitis virus has been found in the Torres Strait Islands and the tip of far north Queensland. Also of interest, but with a much lower risk, are the bat-borne viruses, Hendra virus and Australian bat lyssavirus, that have caused a small number of human infections. However, it is important to remember that most tourists pass through other countries in the Asia/Pacific region on their way to and from Australia and may therefore have acquired infections prior to or after leaving Australia.
 
Article
Background: The management of cutaneous leishmaniasis in non-endemic countries is challenging due to the wide variety of clinical manifestations and little information available on treatment modalities for travellers. Methods: Retrospective analysis and follow-up investigation in patients with imported cutaneous leishmaniasis managed at the General Hospital Vienna from 2004 to 2010. Results: In total, 14 patients with cutaneous leishmaniasis were analyzed. The time to diagnosis ranged between weeks and several months and up to four consultations were necessary before diagnosis was accomplished. Histological investigations performed in all patients were diagnostic for CL in 8 (57%) patients. PCR analyses were performed in 12 patients and were positive in 10 (83%) patients. All six patients with negative histological results for CL tested positive in the PCR analysis. Treatment regimens applied included systemic therapy with liposomal amphotericin B, miltefosine, or fluconazole, and local therapy with cryotherapy, paromomycin ointment, photodynamic therapy, surgery, and various combinations. Conclusions: The present analysis strongly suggests that awareness of CL among physicians and travellers remains low and highlights the need to harmonize diagnostic and treatment guidelines for cutaneous and mucosal leishmaniasis in European travellers. Diagnostic outcome can be improved by combining histology and PCR in patients with suspected cutaneous leishmaniasis.
 
Article
The age-specific prevalence of hepatitis A virus (HAV) infection and risk factors were evaluated in a low socioeconomic population in Izmir. Children and adolescents 1-18 years of age admitted to the outpatient clinics for follow-up visits, or healthy children between April-December 2009 were investigated for anti-HAV antibodies by a cross-sectional study. A questionnaire on sociodemographic and hygiene information was obtained from the parents. All unvaccinated children against HAV were grouped according to their age. Seven hundred and twenty-nine children were enrolled in the study. Total HAV IgG seropositivity was 29.5% while age related values were as follows: 1-2 years, 21.4%; 2.1-5 years, 15.1%; 5.1-8 years, 20.1%; 8.1-11 years, 32.6%; 11.1-14 years, 44.3% and 14.1-18 years, 52.4%. The presence of anti-HAV IgG was associated significantly with low family income and lack of education of parents and living in a crowded family. HAV infection was endemic in a population of children living in Izmir. Anti-HAV vaccination should be considered for preschool children because teenagers are at risk of infection in this region.
 
Article
Splenic rupture during acute malaria is rare but underreported. Because splenic rupture occurs mostly in non-immune adults, ongoing malaria elimination efforts may paradoxically increase the proportion of Plasmodium-infected patients suffering from this life-threatening complication. The pathogenesis and optimal patient management are still debated. We collected and analysed reports of pathological rupture of the spleen associated with malaria published over the last 50 years in five languages. Fifty-five cases were reported, due to Plasmodium falciparum (n=26), Plasmodium vivax (n=23), Plasmodium ovale (n=2), Plasmodium malariae (n=2), or P. vivax-falciparum (n=2), and occurred in travellers (n=24), locals (n=21), expatriates (n=6) or migrants (n=4). Median age was 31.5 years and sex ratio M/F 3.2. Splenic rupture was complete with hemoperitoneum (n=50), or partial (n=5). Death occurred in 12 patients (22%), 8 of whom from early irreversible collapse (n=7) or unexpected death (n=1). Death rate was higher among travellers than in other patients (9/24, 38%, versus 3/31, 10%, p=0.01). Clinical features of P. falciparum- or P. vivax-associated splenic rupture were strikingly similar. Treatment included in-hospital medical observation without surgery (conservative management, n=14), immediate splenectomy (n=29), delayed splenectomy (n=4), or none (patients dying at admission, n=8). The type of treatment, conservative or not, had no influence on prognosis. The median duration of malaria symptoms before diagnosis was longer in our review (5-6 days) than in previous reports on imported malaria (3-4 days), suggesting that early diagnosis and therapy of malaria may reduce the incidence of splenic rupture. Abdominal pain, collapse, or fainting is warning symptoms. Fourteen published observations support conservative management in carefully selected patients. Spleen preservation likely reduces the risk of future severe malaria attacks in patients with potential further exposition to Plasmodium sp., and also that of overwhelming sepsis in all.
 
Article
Global coverage with three doses of the diphtheria, tetanus and pertussis vaccine (DTP3) increased from less than 5% in 1974 to 82% in 2009 due to worldwide focus on universal vaccination. Nonetheless, pertussis remains the fifth-leading cause of vaccine-preventable deaths. This study examines DTP3 vaccination from 1980 through 2009 in three countries within Latin America, Bolivia, Brazil and Mexico, selected for their distinct health care systems and vaccination strategies. Similar to global trends, these nations have achieved dramatic improvements in pertussis immunization. In Bolivia, immunization rates increased from 11% to 85%; in Brazil, rates increased from 37% to 97%; and in Mexico, the immunization rates increased from 44% to 72%. Pertussis infections have concomitantly decreased from 1980 to 2009. In Bolivia, cases decreased from 44.4 per 100,000 people to zero reported cases. In Brazil, the incidence decreased from 37.6 to 0.5 cases per 100,000. The incidence in Mexico decreased from 8.2 to 0.5 cases per 100,000. In order to increase vaccination rates further, health systems must continue to raise awareness about disease prevention, expand health surveillance systems, and improve access to health services.
 
Article
Purified rabies vaccine cultured on Vero cells (Verorab, sanofi pasteur) is WHO-approved for pre- and post-exposure prophylaxis by intradermal and intramuscular routes. During 20 years of use, over 40 million doses of Verorab have been administered in more than 100 countries. No serious adverse event due to Verorab has been reported in clinical trials involving 3937 persons, and Verorab is better tolerated than human diploid cell vaccine (HDCV). Pre-exposure prophylaxis is confirmed immunogenic in 1437 subjects by all routes, with prompt responses following boosting; Verorab boosts effectively subjects pre-immunized with HDCV. Unlike HDCV, Verorab is not associated with post-boosting serum sickness. In the absence of data in immunodeficient/HIV-positive individuals, pre-exposure immunization is urged as early as possible. Essen, Zagreb, Thai Red Cross Intradermal (TRC-ID) and other post-exposure intramuscular and intradermal regimens are documented. Two thousand one hundred and eighty-three subjects received post-exposure prophylaxis, including 874 high risk, severe or confirmed rabid attacks. Co-administration of rabies immune globulin (RIG) does not affect neutralizing antibody levels when Essen or TRC-ID regimens are employed; levels are lower with the Zagreb regimen. Verorab has been administered safely and effectively post-exposure to 251 pregnant women, without any increase in congenital malformations or spontaneous abortions. From a pediatric perspective, safety and efficacy have been demonstrated in 759 children (0-15 years). Intradermal post-exposure Verorab is an effective and inexpensive option for developing countries. Inadvertent subcutaneous administration does not reduce immunogenicity. WHO already strongly recommends the replacement of nerve tissue vaccines with modern vaccines. Extensive clinical experience supports the use of Verorab for intramuscular and intradermal pre- and post-exposure prophylaxis, including in special situations.
 
Article
Dengue is the most important human viral disease transmitted by an arthropod vector. The steadily increasing numbers of tourists visiting endemic areas coupled with the present resurgence of dengue, raises the risk of exposure for large numbers of travelers and imported dengue cases are increasingly observed in non-endemic countries. We aimed to study the epidemiology, clinical manifestations and laboratory findings in imported dengue at a City of Vienna hospital. Medical records of 93 patients (age: 17-68 years, 43f, 50m) with imported dengue in Vienna between 1990 and April 2005 were analyzed retrospectively. Forty-eight (52%) were classified as confirmed and 45 (48%) as probable dengue, according to the CDC criteria. The patients acquired the infection in South East Asia (56%), the Indian subcontinent (18%), Africa (10%) and Oceania (3%). The most important symptoms were fever, headache, arthralgia and myalgia, nausea and vomiting, diarrhea, chills, extreme fatigue and dizziness. A rash was observed in 43%, and lymphadenopathy in 22%. Laboratory findings were thrombocytopenia, leukopenia and elevated hepatic enzymes. Eighteen patients showed hemorrhagic manifestations, and 7 fulfilled the criteria of dengue hemorrhagic fever; 1 of them had dengue shock syndrome. Case fatality rate was nil. Dengue has to be considered in all febrile travelers returning from endemic areas. Prompt diagnosis and symptomatic treatment is warranted and should prevent patients from unnecessary and potentially harmful diagnostic and therapeutic procedures.
 
Article
Objectives. To examine fatal and non-fatal incidents involving tourists in Hawaii Volcanoes National Park. Methods. Official press releases from the public relations office at Hawaii Volcanoes National Park were examined for reports of fatal and non-fatal incidents involving tourists. Results. Between 1992 and 2002 there were 65 press releases reporting 40 fatalities, 45 serious injuries, 53 minor injuries, and 25 no injury events. Severity information was unavailable for four additional tourists. Aircraft and backcountry incidents each accounted for 30% of all incidents followed by road incidents (22%) and frontcountry incidents (17%). Aircraft incidents reported 17 fatalities, backcountry incidents accounted for 10 fatalities, frontcountry incidents reported seven fatalities, and road incidents totaled six fatalities. One fatality was classified as a suicide. Backcountry (23) and road (10) incidents had the highest number of serious incidents. Male tourists (62) were more frequently involved in incidents than female tourists (41) and tourists aged 20-29 years and 40-49 years accounted for the highest number of fatalities and total incidents. Conclusions. Helicopter tours, hiking in areas with active lava flows, falls into steam vents and earthcracks, and driving unfamiliar rental cars in unfamiliar locations are the major activities resulting in death and serious injury. Additional factors such as tourists ignoring warning signs, wandering off-trail or hiking at night, tourists misinformed by guidebooks and other tourists, and tourists with pre-existing heart and asthma conditions are contributing causes in many incidents. The findings of this study provide information that allows prospective tourists, tourism managers, and travel health providers make informed decisions that promote safe tourism and can aid future efforts in developing preventative strategies at tourist destinations with similar environments and activities. However, in order for preventative strategies to be most effective, future research using medical or emergency response records and employing an injury epidemiology framework that identifies the cause of fatal and non-fatal injuries is recommended.
 
Article
This study examines the epidemiology of varicella infection and the impact of vaccination in a population in Eastern Saudi Arabia. All reported cases of varicella infection from 1994 to 2011 were analyzed. A total of 19,577 patients with varicella were reported during the study period, and 8869 were female and 10,248 were male, with a male to female ratio of 1.15:1. Most of the cases were reported in patients between one to four year of age (n = 5625; 29.4%) and five to nine years of age (n = 6614; 34.6%) years of age. The highest numbers of cases were reported in March-May corresponding to the spring time (39.3%) compared with 21.2% in the winter and 25.4% in the summer time. The childhood varicella vaccine was introduced in 1998 and was made mandatory in 2008. The total number of cases decreased from 10,070 in the pre-vaccination period to 1577 cases in the mandatory vaccination period. The incidence rate decreased from 739.8 in 1994 to 355.3 in 1998, to 88.1 in 2011 per 100,000 population (P < 0.0001). Patients less than one year of age constituted 8.3% of cases in 1994-1997 prior to vaccination, 5.4% in 1998-2008 during the initial vaccination phase and 3.4% during the mandatory vaccination period (P < 0.0001). The introduction of varicella vaccine resulted in a significant reduction in the incidence rates between 1994 and 2011.
 
Article
Shigellosis is a global human health problem causing an important morbidity among travellers returning from tropical areas. This study was aimed to describe the evolution of antimicrobial resistance profile in Shigella spp. isolated between the years 1995-2010 in patients with traveller's diarrhoea (TD) returning from tropical areas. The levels of antimicrobial resistance were tested in a total of 191 Shigella spp. isolated during the period from 1995 to 2010. A decrease of cases of diarrhoea caused by Shigella has been observed in recent years. A wide spectrum of antibiotic resistance was observed among Shigella spp. These isolates showed high levels of resistance to tetracycline (84%), co-trimoxazole (75.5%), and ampicillin (45.5%). The resistance was low to ciprofloxacin (2.1%), azithromycin (3.9%) and furazolidone (8.4%). According to the period, in the case of ampicillin, amoxicillin plus clavulanic acid, chloramphenicol, values of resistance were significantly decreasing from 1995-2000 to 2001-2010, (62.5% vs. 28.4%, 19.8% vs. 6.6%, 23.4 vs. 10.4%, respectively). Meanwhile in nalidixic acid and tetracycline the evolution of resistance has increased over time. A decrease in the isolation number of Shigella spp. causing TD has been observed. Differential trends in the evolution of the levels of resistance to the tested antibacterial agents have been observed.
 
Article
Systematic published reviews of national arrests of travellers abroad are rare. The pattern of arrest during international travel has implications for travellers and those involved in providing traveller services. There are also consequences for travellers who are arrested and detained abroad. The Consular Affairs Bureau, Foreign Affairs Canada assists Canadian civilians who are abroad. Beginning in 1995 the Consular Management and Operations System was used to track notifications of Canadian arrests abroad. This database was designed for the demographics, destinations, and reported causes of Canadians arrested abroad for 1996-2004. In this period, there were 6514 notifications of arrested Canadians abroad; 1024 (16%) females and 5490 (84%) males with an average age of 33.3 and 36.4 years, respectively. Recorded reasons for arrest were for females: drugs: 420 (41% of females arrested), violence: 75 (7%), other criminal acts: 198 (19%), immigration: 169 (17%), other minor causes: 20 (2%); and for males: drugs: 1554 (28% of males arrested), violence: 581 (11%), other criminal acts: 1468 (27%), immigration: 1056 (20%), other minor causes: 105 (1.9%); or the cause was not recorded for 142 women and 747 men. The USA was the most common host country for arrested Canadians. Alleged drug offences, other criminal activities, and immigration reasons were the most common cited reasons for arrest. Country of arrest reflected the pattern of Canadian international travel for recreation, business, and ancestral linkages. There are a wide-range of potential physical and mental health outcomes to arrest and imprisonment abroad that may be different in foreign jurisdictions due to language, culture, judicial processes and penalties imposed. The prison environment may also pose significant health risks.
 
Article
The primary objective of this study was to evaluate the prevalence of pathogenic intestinal parasitic infection in primary refugees to Minnesota (MN). Secondary objectives were to determine the association of intestinal parasitic infection with gender, age and continent of origin. A retrospective study was conducted on the first refugee screening visits done between January 1, 1996 and December 31, 2001 on data from the Minnesota Department of Health. Of the 10,358 refugees with screening results, 1969 (19%) had pathogenic intestinal parasites. Parasites were more common in men (OR=1.3; p<0.0001) and were less prevalent with increasing 10 year age intervals (OR=0.79; p<0.001). Asians had the highest proportion of refugees with intestinal parasitic infection (33.6%; p<0.0001). The most common pathogenic intestinal parasites were Trichuris trichiura (7.1%), Giardia lamblia (5.7%), Ascaris lumbricoides (2.1%), and hookworm (2.0%). In this study almost 20% of newly arrived refugees to the state of MN had evidence of intestinal parasitic infection. With very little organized access to health care following arrival of refugees to a new country, risk of transmission of infection, and persistence of infection, the first health visit should be used as a critical opportunity for the screening and treatment of high-risk patients. Future public health work should focus on enhanced screening and surveillance strategies, follow-up for ensuring adequate treatment completion and eradication of parasitosis, as well as research on cost effectiveness of screening versus predeparture anti-helminthic treatment.
 
Article
Objectives. To examine fatal and non-fatal incidents involving tourists in Thailand. Methods. Press records from a major English language newspaper for the period from July 1997 to June 1999 were examined for reports of fatal and non-fatal incidents involving tourists. Results. From July 1997 to June 1999, up to 233 deaths were reported and up to a further 216 were reported injured in incidents involving tourists. One hundred and one deaths and 45 injured were reported following one major domestic jet aircraft crash in southern Thailand, however, it was not stated what proportion of casualties were tourists. Approximately 90 people perished in a single hotel fire in southeast Thailand. Most of the victims were local travellers attending meetings of two Thai companies. Sixteen deaths and 86 injured resulted from five road accidents. The majority of deaths and injuries involved foreigners. Twelve deaths and at least 33 injured resulted from three ferry and tour boat accidents. Most victims were reported to be foreigners. Three deaths and 35 injured resulted from a single cable car accident in northern Thailand. Most of these were Thai tourists, however, four of the injured were foreigners. Eight deaths and six injured resulted from 11 muggings and other violent incidents. All were foreigners. Six deaths were reportedly connected to a scam at the airport in Bangkok involving unlicensed airport taxis. Three deaths and four injured were due to other reported incidents. Conclusions. Newspaper reports of fatal and non-fatal incidents involving tourists in Thailand were probably uncommon, particularly given the volume of tourists entering the Kingdom, although better reporting mechanisms are needed. With the exception of the unusual major incidents, most reported fatal and non-fatal incidents involving tourists were due to road trauma and other transportation accidents, muggings, and occasional water sports and other accidents, which could occur at any major tourist destination. Travel health advisers should include advice concerning personal safety abroad and tourist authorities should endeavour to promote and advocate for tourism safety.
 
Article
Tick-borne relapsing fever is an acute febrile and endemic disease in Iran. For many reasons, the incidence of disease is on decrease, however tick-borne relapsing fever is still a health issue in the rural areas for travelers. This study was carried out during 1997-2006 to investigate the tick-borne relapsing fever in Iran. Based on a cross-sectional, retrospective and descriptive study in all the provinces, the residents in the endemic areas who were febrile and suspicious to tick-borne relapsing fever were enrolled in the study. Tick-borne relapsing fever is a notifiable disease in Iran and the national communicable disease surveillance data were used through questionnaires. The infectivity of Ornithodoros species to Borrelia also was studied in two highly endemic areas including Hamadan and Qazvin provinces. During 1997-2006, a total of 1415 cases have been reported from the entire country. The highest prevalence was observed in year 2002 with the incidence rate of 0.41/100,000 population. Ardabil province is the first ranked infected area (625 out of 1415), followed by Hamadan, Zanjan, Kurdestan and Qazvin provinces sequentially. The disease is recorded during the whole year but its peak occurs during summer and autumn. There have been 87.6% of the cases recorded from June to November. Forty five percent of the infected cases were male and one third of the patients were under 5 years of age. Fifty four percent of the patients comprise the children under 10 years. Ninety two percent of the cases were living in rural areas where their dwellings were close to animal shelters. They were involved mainly with farming and animal husbandry activities. All the febrile patients with confirmed spirochetes in their blood samples were treated according to a national guideline for tick-borne relapsing fever treatment. Only 7% of the patients were hospitalized and 0.8% of them exhibited the Jarisch-Herxheimer reaction. The study of infectivity of Ornithodoros species to Borrelia revealed that Ornithodoros tholozani was infected with Borrelia persica and Ornithodoros erraticus with Borrelia microti. Travelers to the rural areas with high prevalence of the disease should be made aware of the risk of tick-borne relapsing fever and use of appropriate control measures. Communicable disease surveillance including tick-borne relapsing fever should be pursued as well.
 
Article
Imported cases of malaria constitute an important public health problem in many countries, even in those with autochthonous cases, where disease could be acquired in these areas and then seen in non-endemic regions. Non-immune populations are susceptible to complications due to malaria infection, particularly in malaria caused by Plasmodium falciparum. However, Plasmodium vivax the predominant Plasmodium spp. in Venezuela can also lead to severe malaria. We reviewed retrospectively cases of malaria to identify the clinical features of those imported cases diagnosed at two institutions in Margarita Island (a non-endemic area), Venezuela, in an 8-year period. We conducted a retrospective observational study to identify the clinical and epidemiological features among hospitalized patients at Hospital Central and Hospital Agustin Hernández with malaria acquired at malaria-endemic locations. We identified eighteen imported cases of malaria confirmed by thin and thick peripheral blood smears at these two institutions over an 8-year period. The mean age of diagnosis was 27 years. P. vivax was responsible for the majority of cases. All patients presented with fever, 89% with malaise, 78% with chills, and 67% with myalgia, among others symptoms. Mean haemoglobin levels on admission were 8.1g/dL (100% <12g/dL); platelets: 79,283cells/mm(3) (89% had platelets below 150,000); and a mean total leukocyte count: 3.4x10(3)cells/mm(3) (78% had leukopenia). Thirty nine percent of patients required blood transfusions. Two fatalities were identified (CFR=11%), one associated to severe malaria due to P. falciparum and the other due to a complicated case of P. vivax malaria. Imported cases of malaria due to P. vivax and P. falciparum in the studied population are associated with significant hematological complications. These findings illustrate the importance of educating non-immune populations about the malaria risk and prevention strategies; and from a pubic health perspective, the need to develop further malaria prevention strategies at a national level.
 
Article
Objective. To review the trends in disruptive passenger behaviour on board UK registered commercial aircraft since the inception of annual reporting from April 1999. Design. Retrospective examination of data made available by the Civil Aviation Authority (CAA) on a common reporting basis. Methods. The CAA requires airlines to submit details of incidents on a standard form. Data has been collected continuously since the start of the reporting system in 1999 and the results are published annually on the Department for Transport website. Results. An annual average of 106 million airline passengers travelled on UK aircraft over the past 4 years and an average of 1040 incidents of disruptive passenger behaviour were recorded for each year. One-fifth of these incidents was deemed to be serious. On average, a serious incident of disruptive passenger behaviour occurs on board in 1 in 30,000 flights or for every 2 million passengers carried. Excessive alcohol use and illegally smoking on board aircraft are implicated in more than 80% of incidents. The typical perpetrator is male and between 30 and 49 years of age. Conclusion. The available data suggests that disruptive passenger behaviour is not a widespread problem on board UK aircraft although there is some evidence of low-level anti-social behaviour. There appears to be a decline in the number of incidents, possibly due to stricter enforcement of air travel rules and regulations, courts handing out custodial sentences to perpetrators and media reports of cases as well as greater self-restraint among airline passengers in the post-September 11, 2001 era.
 
Article
Febrile travelers may pose a diagnostic challenge for Western physicians who are frequently involved in the assessment of these patients but unfamiliar with tropical diseases. Evaluation of this situation requires an understanding of the common etiologies, which are associated with the demographics of travelers and the destinations. We conducted a 5-year prospective observational study on the etiologies of fever in travelers returning from the tropics admitted to the infectious and tropical diseases unit of a university teaching hospital in Marseilles, France. A total of 613 patients were enrolled, including 364 migrants (59.4%), 126 travelers (20.6%), 37 visitors (6%), 24 expatriates (3.9%), and 62 patients (10.1%) who could not be classified. Malaria was the most common diagnosis (75.2%), with most cases (62%) acquired by migrants from the Comoros archipelago and who had traveled to these islands to visit friends and relatives. Agents of food-borne and water-borne infections (3.9%) and respiratory tract infections (3.4%) were also frequently identified as the cause of fever. Other infections included emerging diseases such as gnathostomiasis, hepatitis E infection and rickettsial diseases, as well as common infections or exotic diseases. Although we have identified here various causes of imported fever, 8.2% of the fevers remained unexplained. An improved approach to diagnosis may allow for the discovery of new diseases in travelers in the future.
 
Article
Travel volumes are still increasing resulting in a more interconnected world and fostering the spread of infectious diseases. We aimed to evaluate the relevance of travel-related measles, a highly transmissible and vaccine-preventable disease. Between 2001 and 2013, surveillance and travel-related measles data were systematically reviewed according to the PRISMA guidelines with extraction of relevant articles from Medline, Embase, GoogleScholar and from public health authorities in the Region of the Americas, Europe and Australia. From a total of 960 records 44 articles were included and they comprised 2128 imported measles cases between 2001 and 2011. The proportion of imported cases in Europe was low at 1-2%, which reflects the situation in a measles-endemic region. In contrast, imported and import-related measles accounted for up to 100% of all cases in regions with interrupted endemic measles transmission. Eleven air-travel related reports described 132 measles index cases leading to 47 secondary cases. Secondary transmission was significantly more likely to occur if the index case was younger or when there were multiple infectious cases on board. Further spread to health care settings was found. Measles cases associated with cruise ship travel or mass gatherings were sporadically observed. Within both, endemic and non-endemic home countries, pretravel health advice should assess MMR immunity routinely to avoid measles spread by nonimmune travelers. To identify measles spread as well as to increase and sustain high vaccination coverages joint efforts of public health specialists, health care practitioners and travel medicine providers are needed. Copyright © 2014 Elsevier Ltd. All rights reserved.
 
Article
For two successive years, 2000 and 2001, there was a world-wide outbreak of W135 meningococcal disease amongst pilgrims who attended the Hajj and in their contacts after returning home. Beginning January 2002, we offered meningococcal quadrivalent polysaccharide vaccine (against serogroups A, C, Y and W135) to pilgrims and collected a throat swab for meningococcal W135 carriage before and after their pilgrimage. The overall Neisseria meningitidis carriage pre-Hajj was 8.3% and 6.3% post-Hajj. We found W135 carriage rates of 0.8% before and 0.6% after Hajj, respectively. 21% (36/174) of the pilgrims were treated with antibiotics for respiratory illness. The carriage of meningococcus W135 among UK pilgrims who visited the Hajj in 2002 was low. This contrasts with another study suggesting pilgrims frequently acquired N. meningitidis W135 carriage during 2001 Hajj. The use of the quadrivalent vaccine may account for this difference.
 
Article
The purpose of this study was to assess the epidemiology of malaria in Taiwan between 2002 and 2010. We analyzed data reported as part of surveillance programs run by the Taiwan Centers for Disease Control (Taiwan CDC). Malaria cases were diagnosed by blood films, polymerase chain reaction, or rapid diagnostic tests. The risk of re-establishment of malaria transmission in Taiwan was assessed. A total of 193 malaria cases were included in our analysis. All of the cases were associated with importation. One hundred and fifty-eight cases (82%) were diagnosed within 13 days from the start of symptoms/signs, and 44% of these cases were acquired in Africa and 42% were acquired in Asia. Plasmodium falciparum was responsible for the majority (49%) of these cases. Travel to an endemic area was associated with the acquisition of malaria. The malaria importation rate was 2.77 per 1,000,000 travelers (range, 1.35-5.74). The reproductive number under control (R(c)) was 0. No endemic transmission of malaria in Taiwan was identified. This study suggests that maintaining a vigilant surveillance system, environmental management, vector-control efforts, and case management are needed to prevent outbreaks and sustain the eradication of malaria in Taiwan.
 
Article
In Greece the number of international travellers has increased significantly the past decade. To study the impact of international travels on the epidemiology of hepatitis A and enteric fever in Greece. We studied cases of hepatitis A and enteric fever notified through the National Surveillance System from January 1, 2004 through December 31, 2011. A total of 921 cases of hepatitis A and 106 cases of enteric fever were notified; of them, 88 (9.5%) and 46 (43.4%) were travel-associated, respectively. Travellers returning from Eastern Europe and the Middle East accounted for most imported cases of hepatitis A (37 (43.5%) and 14 (16.5%) cases, respectively). The Indian subcontinent was the prevalent area of acquisition of travel-associated enteric fever, followed by the Middle East (35 (83.3%) and 4 (9.5%) cases, respectively). Foreign-born travellers accounted for 43 (48.8%) and 39 (86.6%) cases of travel-associated hepatitis A and enteric fever, respectively. Children <15 years accounted for 65.1% of hepatitis A cases and 7.7% among foreign-born travellers. Greek Roma accounted for 270 (29.3%) of all hepatitis A cases notified. International travels have a significant impact on the epidemiology of enteric fever in Greece, affecting mainly foreign travellers. Hepatitis A carries a significant burden of morbidity among Greek travellers and children of foreign nationality. There is a need to improve travel medicine services for travellers travelling to developing countries.
 
Article
On 26 December 2004, the Asian tsunami hit countries around the Indian Ocean rim, particularly around its earthquake-associated epicentre off Indonesia. A number of popular tourist destinations for Australian travellers are located in this region. This study was designed to investigate travel insurance claims reported by travellers from Australia following the Asian tsunami and to examine the role of travel insurance and emergency assistance companies. In December 2005, all claims reported, following the Asian tsunami on 26 December 2004, to a major Australian travel insurance company were examined for those claims associated with the Asian tsunami. Twenty-two tsunami-related claims were submitted of which nine travellers (40.9%) used the travel insurance company's emergency assistance service. Four travellers (18.2%) cancelled their trip to Asia, mainly to Thailand. Five travellers (27.3%), who were already abroad, also curtailed their trip as a result of the tsunami. Half of travellers (50.0%) were claiming loss of personal belongings. Of those using the emergency assistance service, five travellers (22.7%) sought policy and claiming advice, two (9.1%) sought assistance with flight rearrangements, and one (4.5%) sought situation advice. There was also assistance provided following the death of one insured traveller as a direct consequence of the tsunami, which included a lump sum payment to the deceased estate. The mean refund, where a travel insurance claim was paid, was Australian dollars (AUD)2234 (SD=AUD5755). This study highlights the importance of travellers taking out appropriate travel insurance, which provides for emergency assistance. Travel insurance agencies do play some role after emergencies, such as the Asian tsunami. This assistance predominantly involves dealing with cancellation of travellers' intended visits to the affected area, but does also involve some assistance to travellers affected by the crisis. Travellers should be advised to seek travel health advice well before departure overseas and to ensure that they are aware of travel advisories for their destination.
 
Article
Malaria and dengue are important problems in Japan particularly since international travel to developing countries has become increasingly popular. To describe the clinical features of malaria and dengue cases in Japan, a retrospective study was conducted on 50 malaria cases and 40 dengue cases presented to the National Centre for Global Health and Medicine of Japan between 2005 and 2010. The most frequent area of acquisition for cases of malaria was Africa (76.0%), and for dengue fever was Asia (90.0%). Although the immigrant population is very small in Japan, patients categorized as visiting friends and relatives were relatively high in proportion, which is similar to Western reports. Confirmed cases of malaria and dengue account for less than 10% of the all travelers returning with any health problems according to the National Centre for Global Health and Medicine. Careful observation of symptoms and signs helps the differential diagnosis of malaria and dengue.
 
Article
Screening of refugees resettled from areas with a high (>8%) or intermediate (2-7%) prevalence of hepatitis B virus infection (HBV) is critical to identify and to provide counseling to those with chronic HBV carriage; and to ensure entry into medical care of those with chronic hepatitis to prevent long-term sequelae. We performed a descriptive retrospective analysis of refugees resettled into the US seen at a US travel clinic over a 3-year period and in whom we have obtained HBV serologies and clinical evaluations to define various clinical stages of HBV infection. During the study period, we evaluated a total of 80 patients categorized as refugees or asylum seekers resettled mostly from African countries. In our clinic, we performed HBV serologic analyses among 74/80 (90%) of them. Of those undergoing testing, 17/74 (23%) patients had evidence of HBsAg-positivity. Among these, one patient died secondary to HBV-associated hepatocellular carcinoma, three had chronic HBV infection, and thirteen were found to be chronic inactive HBV carriers. The average time of their resettlement to their time of HBV-related diagnosis was 3.5 years. All 17 patients with HBV surface antigenemia were counseled and enter into medical care for long-term clinical follow up. Earlier efforts are required to provide counseling for HBV chronic carriers, vaccinate the unexposed, and assure entry into medical care for those with chronic HBV infection among refugee communities resettled in the US.
 
Article
There is limited information about peritoneal tuberculosis in Qatar. This retrospective study aimed to review our experience with peritoneal tuberculosis in patients admitted to Hamad general hospital over a period of 5 years, from 2005 to 2009, with emphasis on presentation, investigation, diagnosis and therapeutic outcome. Fifty-four patients with peritoneal tuberculosis identified during the study period were included. The mean age of them was 31.85 years and 96.3% (52/54) of them were non-Qataris with male predominance. The main symptoms and signs at the time of presentation were abdominal pain and ascites respectively. Underlying diseases were described in 24% (13/54) and history of contact with tuberculous cases was present in 31.5% (17/54) of patients. Tuberculin test was positive in 66.7% (36/54). The ascitic fluid smear showed acid fast bacilli in 2% (1/53), and culture was positive in 39.6% (21/53) of cases. Laparoscopically obtained peritoneal biopsy showed caseating granulomas in 93% (40/43) and mycobacteria were identified by acid fast staining and culture in 58.5% (24/41) and 98% (40/41) of the tested specimens respectively. Most of the patients (84%; 37/44) who had completed their therapy in Qatar improved with antituberculosis therapy, and only one patient died. In conclusion, the clinical features and the imaging findings of the disease were non-specific. A high index of suspicion is essential for early diagnosis. Culture of ascitic fluid delayed the diagnosis in clinically suspected cases, whereas laparoscopically guided peritoneal biopsy provided rapid and correct diagnosis. A Six-month course with antituberculous therapy was effective and improved the outcome.
 
Article
Two elderly people among a group of eight Belgian travellers who had stayed in Turkey for 2 weeks, developed a severe enteritis shortly after their return to Belgium. They had travelled by private bus, and had visited different places during their stay in Turkey from 6 to 17 September 2005. After notification an epidemiological study was conducted by the Public Health authorities in Antwerp to identify the cause of the infection, to detect other cases, and to trace the source in Turkey. Vibrio cholerae was isolated from stools and a slide agglutination test was performed at the reference laboratory for cholera in Belgium. V. cholerae O1, El Tor, Inaba was identified in the stools of two patients. Four other patients, who suffered from a milder form of the disease, met the case definition of probable cases. No secondary infections among their contacts in Belgium were found. In spite of an epidemiological search conducted by the Turkish Public Health authorities, other cases of cholera in Turkey could not be detected. Nor a source for the outbreak could be established. The outbreak of imported cholera in Belgium stresses the risk of contracting cholera in a country not considered as a cholera endemic region. It highlights the need for careful laboratory surveillance of intestinal infections in travellers after their return to their homeland. Early detection and prompt reporting are recommended.
 
Article
A study was conducted to describe the clinical presentation, epidemiology and outcome of imported malaria in patients admitted to Hamad Medical Corporation, Qatar, between 1st January and 31st December 2005. During a one-year study, 81 patients [64 (79%) males and 17 (21%) females] were studied. The median age was 26 years. Most infections were caused by Plasmodium vivax, and Pakistan was the most common area of malaria acquisition. The median times between last arrival in Qatar and the onset of symptoms with Plasmodium falciparum, P. vivax and mixed infections were 14, 28 and 17 days respectively. The median times between onset of symptoms and diagnosis of P. falciparum, P. vivax and mixed infections were 3, 3 and 3.5 days respectively. The predominant symptoms were fever and chill in all patients. High bilirubin and thrombocytopenia were found in 51 (63%) and 47 (58%) of the patients respectively. None had been taking chemoprophylaxis against malaria infection. Six patients had severe falciparum malaria, which was more prevalent among Qatari than non-Qatari patients (p=0.02). No deaths occurred during the study period. The median time of stay in hospital was 3 days; it was longer in patients with P. falciparum infection than in patients with P. vivax (p=0.02). In conclusion, P. vivax is the most common cause of imported malaria, with the majority acquired from the Indian subcontinent. Only a few patients presented with severe malaria. Increased efforts are needed to educate travelers about the need for prophylaxis and other measures.
 
Article
Enteric fever seen in the UK has usually been acquired abroad. The cost to the NHS of treating enteric fever cases is not known. Data on the epidemiology of enteric fever, inpatient treatment costs and the public health management is needed to make decisions regarding the cost benefit considerations of introducing targeted prevention strategies. A retrospective study of laboratory confirmed enteric fever cases was conducted to estimate the cost of inpatient treatment and to determine antimicrobial resistance patterns at two hospitals in East London between January 2005 and the end of August 2010. 138 cases of enteric fever were identified during the study period (90 S.ser.Typhi and 48 S. ser. Paratyphi). 92% had a recent history of foreign travel, 57% had travelled to visit friends and relatives (VFRs), 26% sought pre-travel health advice and 26% of patients had received typhoid vaccination. The inpatient treatment cost of 138 cases to the NHS was £272,747. The proportion of isolates with high level ciprofloxacin resistance (MICs>1 mg/L) has increased from 10% in 2006 to 30% in 2010. Our data also shows the emergence of isolates with high azithromycin MICs (>32 mg/L); 60% (six out of ten) isolates tested in July-August 2010. There is a significant direct cost of treating enteric fever cases on the NHS. Cost reduction measures are confined due to the lack of effective oral antibiotics following the emergence of high level resistance to ciprofloxacin and azithromycin. Outpatient parenteral antibiotic therapy service and improved preventative public health measures aimed at VFR travellers in particular may be helpful in reducing costs.
 
Article
In 2007, the World Health Organization's ("WHO") revised International Health Regulations (2005) ("IHR" or "Regulations") entered into force across the globe. The IHR contain a range of binding and advisory provisions for reporting, health measures, capacity-building and further procedures to address the risks of international disease spread in international travel, transport and trade. While the prior versions of the Regulations were limited to a short list of infectious diseases (which did not include tuberculosis), the revised IHR cover virtually all serious internationally transmissible disease risks, whether biological/infectious, chemical or radionuclear in origin, that meet certain criteria. These revised Regulations are now generally applicable to transnational tuberculosis ("TB") transmission, including through air travel. In light of the great numbers of persons undertaking international travel, the worldwide geographical coverage of the IHR, and the emergence of extremely drug resistant TB ("XDR TB"), these Regulations are an important element in addressing these (and other) serious international public health risks. This article describes the relevant provisions in the IHR, and their applicability in this context.
 
Article
Since November 2006, flight-related mumps contact investigations were conducted in the United States only for flights ≥5 h long after an investigation showed minimal risk of mumps transmission on flights <5 h. Because the transmission risk on longer flights had not been evaluated, we investigated whether there was evidence to support the guidelines. We examined data from mumps contact investigations that were initiated by the US Centers for Disease Control and Prevention (CDC) from November 2006 to October 2010. We also cross-referenced passenger-contact data with data on mumps cases in the National Notifiable Diseases Surveillance System (NNDSS). Twenty-seven cases met inclusion criteria. Of 246 passengers identified as contacts, 166 (67%) were distributed to a US health department for contact tracing. Outcomes were reported for 21 (13%) of those 166 passengers. No secondary cases of mumps among passenger contacts were reported or identified by cross-referencing NNDSS data. The findings suggested that in-flight risk of mumps transmission is not high. Furthermore, these investigations have low yield, are resource intensive, there is no post-exposure prophylaxis, and mumps transmission has not been eliminated in the United States. Therefore, CDC discontinued conducting flight-related mumps contact investigations in May 2011.
 
Article
Investigations related to tuberculosis (TB) cases on airline flights have received increased attention in recent years. In Canada, reports of air travel by individuals with active TB are sent to the Public Health Agency of Canada (PHAC) for public health risk assessment and contact follow-up. A descriptive analysis was conducted to examine reporting patterns over time. Reports of air travel by individuals with active TB received by PHAC between January 2006 and December 2008 were reviewed. Descriptive analyses were performed on variables related to reporting patterns, characteristics and actions taken. The number of reports increased each year with 18, 35 and 51 reports received in 2006, 2007 and 2008, respectively. Of the 104 total cases, most were male (63%) and born outside of Canada (87%). Ninety-eight cases (97%) met the criteria for infectiousness and a contact investigation was initiated for 136 flights. Reports of air travel by individuals with active TB have been increasing annually in Canada in recent years. Outcomes of the subsequent contact investigations, including passenger follow-up results and evidence of TB transmission, is necessary to further evaluate the effectiveness of the Canadian guidelines.
 
Article
A case of Plasmodium vivax malaria was diagnosed in Corsica in summer 2006. This is the first case of autochthonous transmission of malaria to be reported in Corsica since 1972. Corsica is a well-known malaria endemic region characterised, for several years now by an anophelism situation without malaria disease, due to the presence of An. labranchiae and An. saccharovi able to transmit P. vivax. The occurring sequence of malaria signs in an imported case on 9 July and in an autochthonous case on 5 August, both in Porto, implies a transmission by local Anopheles. This suspicion is reinforced by the results of entomological investigations. However, from June to September 2006, no other P. vivax malaria case and no other autochthonous case were detected in Corsica. Therefore, it seems that no permanent malaria transmission occurs in this island. Mosquito eradication actions and anti-vectorial measures have been reinforced as well as individual prevention measures against imported diseases while travelling in tropical countries. Obviously, detection of one exceptional autochthonous transmission of one malaria case in Corsica does not justify proposing malaria protection to tourists.
 
Article
Australian Bat Lyssavirus is endemic in Australian bats. More Australians are travelling to rabies (Lyssavirus 1) endemic countries. The nature and frequency of lyssavirus exposures and characteristics of New South Wales (NSW) residents exposed have not previously been described. Access to free rabies post-exposure treatment (PET) can only be arranged through Public Health Units in NSW. Details of people receiving PET after potential exposures to rabies or ABLV from 1 January 2007 to 31 December 2011 were extracted from an NSW Ministry of Health web-based database and analysed to better understand lyssavirus exposure epidemiology. Of 1195 people receiving PET, 415 exposures were in Australia and 780 abroad; 78.3% occurring in Southeast Asia, mainly Indonesia (47.6%) where most were on the island of Bali (95.2%). PET use increased substantially for domestic and international exposures. In Australia, most bat exposures were to members of the public (76.0%), rather than to people who work with bats professionally or as volunteers, with 54.1% due to bat rescue attempts. Injuries abroad were mainly from monkeys (49.4%) and from dogs (35.8%). Only 4.0% of international travellers were vaccinated prior to their exposure. Increasing rates of PET in travelling and non-travelling Australians emphasise the need for more effective communication about appropriate animal avoidance and the measures required if exposed. Opportunities for increasing pre-exposure treatment amongst individuals likely to be exposed should be promoted.
 
Origin a of 131 index cases for which CDC initiated air travel-related tuberculosis contact investigations, January 1, 2007eJune 30, 2008. a ''Asia'' includes SE Asia (Philippines, Myanmar, Thailand, Viet Nam, Cambodia, Indonesia); East Asia (China, Japan, So Korea, Taiwan); and South Asia (India, Pakistan, Afghanistan). ''Africa'' includes Burundi, DR Congo, Ethiopia, Ghana, Kenya, Liberia, Mauritania, Morocco, Somalia, South Africa, Tanzania. ''Others'' include Canada, Italy, France, Bosnia, Macedonia, Russia, Turkey, Ecuador, and Peru.  
Sputum smear and chest radiograph results for 131 index TB cases for which CDC initiated air travel-related contact investigations, January 1, 2007eJune 30, 2008. a DGMQ Z Division of Global Migration and Quarantine; b AFB Z Acid-fast bacilli.  
Dissemination of passenger contact information and TB evaluation and testing results for passenger contacts for air travel-related tuberculosis contact investigations initiated by CDC, January 1, 2007eJune 30, 2008. a DGMQ Z Division of Global Migration and Quarantine; b TB Z tuberculosis; c RFs Z Risk factors for prior TB infection; d LTBI Z Latent TB infection.  
Article
Contact investigations conducted in the United States of persons with tuberculosis (TB) who traveled by air while infectious have increased. However, data about transmission risks of Mycobacterium tuberculosis on aircraft are limited. We analyzed data on index TB cases and passenger contacts from contact investigations initiated by the U.S. Centers for Disease Control and Prevention from January 2007 through June 2008. Contact investigations for 131 index cases met study inclusion criteria, including 4550 passenger contacts. U.S. health departments reported TB screening test results for 758 (22%) of assigned contacts; 182 (24%) had positive results. Of the 142 passenger contacts with positive TB test results with information about risk factors for prior TB infection, 130 (92%) had at least one risk factor and 12 (8%) had no risk factors. Positive TB test results were significantly associated with risk factors for prior TB infection (OR 23; p<0.001). No cases of TB disease among passenger contacts were reported. The risks of M. tuberculosis transmission during air travel remain difficult to quantify. Definitive assessment of transmission risks during flights and determination of the effectiveness of contact-tracing efforts will require comprehensive cohort studies.
 
Seating locations of passengers with their tuberculosis evaluation results for flight A, 2007.
Seating locations of passengers with their tuberculosis evaluation results for flight B, 2007.
Characteristics of passenger contacts of three tuberculosis (TB) contact investigations for four flights, 2007e2008.
Seating locations of passengers with their tuberculosis evaluation results for flights C1 and C2, 2007.  
Article
The potential for transmission of Mycobacterium tuberculosis during air travel has garnered considerable attention in the media and among public health authorities due to high-profile cases of international travelers with infectious tuberculosis (TB). During 2007 and 2008, state and local health officials were asked to locate and conduct diagnostic follow-up for airline passengers considered contacts of three travelers, two with multidrug-resistant (MDR) TB and one considered highly contagious, who undertook air travel while infectious with TB disease. Public health departments in 21 states located and evaluated 79 (60%) of the 131 passenger contacts identified; 52 (40%) were lost to follow-up. Eight (10%) contacts had a history of TB disease or latent TB infection and were not retested. Sixteen (23%) of 71 contacts tested had positive TB test results suggesting latent TB infection, 15 of whom were from countries reporting estimated TB disease rates of greater than 200 cases/100,000 persons. Passenger contacts' positive test results may represent prior TB infection acquired in their countries of residence or may be a result of new TB infection resulting from exposure during air travel.
 
Article
Background: Flight-related measles contact investigations in the United States are coordinated by the Centers for Disease Control and Prevention (CDC). To evaluate the efficiency of CDC's measles protocol, we analyzed data from contact investigations conducted December 2008-December 2011. Methods: Cases were defined as travelers diagnosed with measles that were infectious at the time of the flight. Passengers seated within 2 rows of the case-traveler and all babies-in-arms were defined as contacts. Contact information obtained from airlines was distributed to US health departments; reporting of outcomes was requested. We cross-referenced the National Notifiable Diseases Surveillance System and CDC's National Center for Immunization and Respiratory Diseases to identify unreported cases in passenger-contacts and in passengers not identified as contacts. Results: Our evaluation included 74 case-travelers on 108 flights. Information for 2673 (79%) of 3399 passenger-contacts was provided to health departments; 9 cases of secondary measles were reported. No additional cases were identified. Conclusion: Our evaluation provided evidence of measles transmission related to air travel. CDC's protocol efficiently identifies passengers most at risk of exposure and infection for flights into and within the United States.
 
Article
The 29th modern Olympic Summer Games, conducted once every 4 years since 1896, will be held in Beijing, China, from 8 to 24 August 2008. There will be approximately 28 major and 302 minor events in 37 venues in the prominent cities of Beijing, Hong Kong and Shanghai, and also in Qingdao (a coastal town in Shandong Province), Qinhuangdao (northeast of Beijing), Shanghai, Shenyang (an industrial city in Liaoning Province) and in Tianjin (on the coast near Beijing). Following the Olympic Games, the Paralympic Games will be conducted from 6 to 17 September 2008 in Beijing and 20 Paralympic Sports will be represented. This paper focuses on health and safety issues for travellers to China in general, although it makes specific references to advice for visiting Olympic and Paralympic athletes and team staff, who will be travelling to the games. It must be remembered that travel health advice can change, and that travellers should be advised to seek up-to-date travel health advice for China closer to their departure.
 
Article
The incidence of influenza like illness was evaluated in a cohort of 273 French pilgrims participating to the Hajj 2009 and compared to non-Hajj attending control data from Sentinel System, a nationwide network of French general practitioners who report, in real time, the number of medical visits for influenza like illness. Cases of influenza like illness in pilgrims were observed during weeks 45-50, 2009, with a mean incidence of 1211 cases per 100,000 pilgrims, compared to 520 in controls during the same period. The highest incidence in pilgrims was observed during week 48, corresponding to the Hajj ritual dates.
 
Top-cited authors
Alfonso J. Rodriguez-Morales
  • Fundación Universitaria Autónoma de las Américas
D. Katterine Bonilla-Aldana
  • Fundación Universitaria Autónoma de las Américas
Carlos Franco-Paredes
  • Hospital Infantil de México Federico Gómez
Ranjit Sah
  • Institute of Medicine
José Antonio Suarez
  • The Gorgas Memorial Institute for Health Studies (GMI)