Travel Medicine and Infectious Disease (Trav Med Infect Dis)

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Benign paroxysmal positional vertigo (BPPV) is a common form of dizziness. The causes of BPPV are not yet known but a relationship between the onset of vertigo and head trauma has been found. Among the causes of head injury related to BPPV, dropping off a camel has not been reported in literature yet. We describe two cases of persons that fell off a camel during a safari in Middle East countries. After the fall they reported vertigo symptoms that were not interpreted as BPPV. When they returned to Italy, due to symptoms persistence, they were referred to our ENT practice: we found evidence of BPPV. In a case it was a bilateral BPPV (bBPPV). Falling off a camel may be a relevant cause of BPPV. We suggest a correct evaluation of the labyrinth for BPPV with the appropriate diagnostic maneuvers and, if necessary, a treatment with repositioning maneuvers.

The 19th Commonwealth Games, conducted once in every four years since 1930, will be held in New Delhi from the 3rd through until the 14th of October, 2010. There will be approximately 17 sports on display and there will also be 15 para-sporting events. This paper focuses on health and safety issues for travellers to India in general, although it provides specific references to advice for visiting Commonwealth Games athletes and team staff, who will be travelling to the games. Whilst it needs be remembered that travel health advice can change, travellers are advised to seek up-to-date travel health advice for India, from their professional providers, closer to their departure.

The public health implications of large crowds gathering at a range of key global events should never be underestimated. This is especially the case with the upcoming 2010 FIFA World Cup South Africa programme where thousands of local and travelling spectators, players and officials from all over the world will be present. Although meningococcal disease contracted whilst actually travelling is relatively rare, any travel health risk assessment should involve consideration of potential exposure to and transmission of this disease where crowding occurs. In South Africa, for reasons not completely understood, the incidence of meningococcal disease is higher than in most European countries. Whilst the currently available polysaccharide vaccines can help protect travellers against meningococcal disease there are some well recognised limitations of such vaccines. These can, however, be overcome with the use of newly developed conjugated quadrivalent meningococcal vaccines. A quadrivalent conjugate vaccine should be the first choice for travellers to areas in which the risk of exposure to meningococcal disease is significant. The conjugated quadrivalent meningococcal vaccine should be recommended for all those attending or playing in the 2010 FIFA World Cup South Africa as well as similar global and regional events.

The Special Olympics is a non-profit organization that was officially founded in 1968. Nowadays, the Special Olympics have evolved to a Global Movement that offers the opportunity to more than 3 million athletes with mental or physical disabilities from 185 countries to participate. The Special Olympics will take place in Greece from June 25 until July 4, 2011, where 7500 athletes from 185 countries will participate in 22 Olympic-type games. Mass gatherings such as Olympic Games represent a significant challenge for public health. This paper focuses on relevant health and safety issues for all travellers travelling to Greece for the summer 2011 Special Olympic Games.

It has been 40 years since David Clyde's landmark induction of sterile immunity against deadly falciparum malaria through immunization by exposure to 1000 irradiated mosquitoes, and the first recombinant Plasmodium falciparum vaccine, RTS,S/AS01, is now in Phase III testing. Interim reports from this largest ever Phase III pediatric trial in Africa show the malaria vaccine decreased clinical and severe disease by 56% and 47% respectively in 5-17 month olds, and by 31% and 26% respectively in infants participating in the Expanded Programme on Immunization. Final data in 2014 will more fully describe the efficacy of RTS,S/AS01 over time against all falciparum malaria cases under a variety of transmission conditions, results essential for decisions on licensure and deployment. Meanwhile, candidate components of a second-generation malaria vaccine are emerging. A field trial of the polymorphic blood stage vaccine AMA-1/AS02 demonstrated no overall efficacy (ve = 17%, P = 0.18), yet a sieve analysis revealed allele-specific efficacy (ve = 64%, P = 0.03) against the vaccine strain, suggesting AMA-1 antigens could be part of a multicomponent vaccine. Initial trials of new antigens include the highly conserved pre-erythrocytic candidate PfCelTOS, a synthetic Plasmodium vivax circumsporozoite antigen VMP-001, and sexual stage vaccines containing antigens from both P. falciparum (Pfs25) and P. vivax (Pvs25) intended to interrupt transmission. Targets for a vaccine to protect against placental malaria, the leading remediable cause of low birth weight infants in Africa, have been identified. Lastly, renewed efforts are underway to develop a practical attenuated-sporozoite vaccine to recapture the promise of David Clyde's experiment.

Although malaria can be prevented with prophylaxis, it is diagnosed in over 100 Africa-region Peace Corps Volunteers annually. This suggests that prophylaxis non-adherence is a problem in these non-immune travelers. We investigated Volunteers' knowledge, attitudes, and practices regarding prophylaxis using an internet-based survey during August 19-September 30, 2013. Adherence was defined as taking doxycycline or atovaquone-proguanil daily, or taking mefloquine doses no more than 8 days apart. The survey was sent to 3248 Volunteers. Of 781 whose responses were analyzed, 514 (73%) reported adherence to prophylaxis. The most common reasons for non-adherence were forgetting (n = 530, 90%); fear of long-term adverse effects (LTAEs; n = 316, 54%); and experiencing adverse events that Volunteers attributed to prophylaxis (n = 297, 51%). Two hundred fourteen (27%) Volunteers reported not worrying about malaria. On multivariate analysis controlling for sex and experiencing adverse events Volunteers attributed to prophylaxis, the factor most strongly associated with non-adherence was being prescribed mefloquine (OR 5.4, 95% confidence interval 3.2-9.0). We found moderate adherence and a prevailing fear of LTAEs among Volunteers. Strategies to improve prophylaxis adherence may include medication reminders, increasing education about prophylaxis safety and malaria risk, and promoting prompt management of prophylaxis side effects. Published by Elsevier Ltd.

Schistosomiasis is a tropical parasitic disease caused by blood-dwelling fluke worms of the genus Schistosoma whose infective stages, the cercariae, are amplified through mollusks acting as intermediate hosts. People are infected when exposed to fresh water containing cercariae that penetrate the skin. There are however considerable differences in intensity of infection and morbidity, depending on the pattern of exposure and the infective species. In travellers, schistosomiasis differs substantially from infection in endemic populations in many aspects: geography, morbidity, treatment and prevention. In migrants, schistosomiasis manifests itself in a way more akin to what is seen in endemic populations. In this paper we will review the specific issues associated with schistosomiasis in travellers and migrants, with emphasis on the acute disease manifestations in non-immune persons, and on neuroschistosomiasis as a potential severe complication. We discuss new trends in diagnosis and treatment with respect to the specific disease stage, and summarize precautionary measures and novel ways to prevent Schistosoma infection in travellers.

Schistosomiasis, an infection with the three anthropophilic species of Schistosoma, is endemic throughout wide areas of the tropics and subtropics with an estimated rate of over 200 million people infected worldwide. Whereas symptoms and signs of vesical and gastrointestinal forms of the infection are recognized readily, cutaneous manifestations are still a challenging diagnosis particularly in Western countries. A case is described of a 34-year-old Caucasian pregnant woman who presented to our department and was diagnosed with a cutaneous schistosomiasis involvement of the perianal region. Shistosoma haematobium was shown to be present in the lesion by histopathology and was considered to be the causative organism of the disease. Treatment with a course of oral praziquantel in a dose of 40mg/kg allowed resolution of the symptoms.

Massive haemoglobinuria is encountered rarely during the course of malaria. It is usually considered a diagnostic criterion for severe malaria, together with anaemia, acute renal failure and jaundice. Haemoglobinuria can also present among expatriates travelling to endemic areas following repeated exposure to quinoline or arylaminoalcohol drugs. A case is described of haemoglobinuria developing in a 38-year-old French expatriate diagnosed concurrently with numerous tropical infections, and treated on presumptive basis with an antimalarial regimen containing artemisinin derivatives. Haemoglobinuria resolved spontaneously within a few days. Although this case does not definitely indicate a causal link between haemoglobinuria and artemisinin derivatives, the risk of such infrequent side-effects should be taken into account in pharmacovigilance monitoring. Moreover, the patient illustrates the multifaceted pathology that can be encountered with tropical infections.

Early diagnosis and appropriate empirical treatment of bacterial meningitis reduce morbidity and mortality. Prevalence rates of different causative pathogens associated with bacterial meningitis can depend on age, the underlying medical condition, way of infection and geographical distribution. Klebsiella pneumoniae represents an infrequent cause of community-acquired meningitis in South-East Asia and North-East Asia, where it accounts for 20% of all bacterial meningitis, frequently associated with septic metastatic complications. We describe a case of K. pneumoniae meningitis, diplopia and chemosis in a recently immigrated patient with impaired glucose tolerance. The reason for the high prevalence of metastatic septic infections caused by K. pneumoniae in Taiwan and South-East Asia remains unclear: high prevalence in this area of serotype K1 and K2 and the expression of a novel locus called magA conferring to bacterium an elevated phagocytosis resistance and an active proliferation ability have been suggested. A high degree of suspicion for this etiology must be taken into account in immigrants from China and Taiwan. Due to a very high lethality, guidelines on empiric treatment should be considered in the management of bacterial meningitis, with the patients geographical origin and the clinical syndrome (meningitis and endophtalmitis) as potential risk factors for K. pneumoniae infection.

Travel health information includes warning on sun exposure, particularly for fair-skinned individuals travelling to tropical countries. A self-completed questionnaire on sun exposure behaviour was sent to the 12,741 French adults enrolled in the SU.VI.MAX cohort. Among the 7822 participants, 196 (110 women and 86 men) declared at least one visit to a high UV-index country over the past year for more than 1 month, subsequently referred to as long-term travellers. The remaining 7626 participants (non-travellers) accounted for 4862 women and 2764 men. Women travellers declared more frequently skin exposure to the sun over the past year, practised tanning in high UV-index areas more than 2h daily, experienced intensive sun exposure than non-travellers. Moreover, they asserted that basking in the sun is very important. Comparable results were found in men. The use of sun protection products was similar in travellers and non-travellers, but women tended to use sunscreen products more often, more regularly and with a higher sun protection factor (SPF) than men. Specific health education campaigns and pre-travel advice aiming to reduce sun exposure and to improve protective measures against ultraviolet (UV) radiation should be addressed to travellers to countries with high UV-index.

To study the usefulness of abdominal ultrasound in the diagnosis of typhoid fever and to determine the common ultrasound findings early in the course of the disease. Abdominal ultrasound examination was performed within the first week of initiation of symptoms in 350 cases with clinical diagnosis of typhoid fever. Subsequent ultrasound follow-up examination was done 15 days later (beginning of the third week). All the patients proved to have positive Widal test and Sallmonella culture. The study was performed in Erbil-Iraq from the period January 1993 to October 2010. The following ultrasound findings were reported: hepatomegaly (31.4%), prominent intrahepatic bile ducts (64.85%), splenomegaly (100%), mesenteric lymphadenopathy (42.85%), bowel wall thickening (35.71%), acalculous cholecystitis (16.28%), perforations (1.14%), and ascites in (3.4%). The current study showed that the findings are typical enough to justify initiation of treatment for typhoid fever when serology is equivocal and culture is negative, and is fairly safe to say that normal ultrasound examination early in the course of febrile illness rules out typhoid fever.

A survey was carried out in five rural communities that enjoy agricultural extension services from the University of Agriculture Abeokuta. Questionnaires and focus group discussions (FGDs) were used to assess perceptions and home management practices of malaria infection. The inhabitants considered malaria (which they refer to as "Iba Otutu") has the least dangerous of other types of common fever such as yellow fever and typhoid fever. A vast majority of the respondents (73%) attributed malaria infection to doing of strenuous jobs in the hot sun, while only 11.7% attributed it to mosquito bites. Hunger, eating or drinking of contaminated food or water were other sources of malaria infection mentioned by the respondent. During the FGDs, another source of infection of malaria identified was excessive exposure to heat of fire used in frying cassava (garri), therefore those frying garri and those spreading cassava flakes in the sun were identified as most vulnerable to malaria infection. During the FGD, high level of malaria infection in children was attributed to children playful activities in the sun. It is believed that malaria infection will occur even without mosquito bites but with exposure to these other factors especially the intense heat of the sun. Respondents showed good knowledge of malaria symptoms even in infants and children. However, in the event of malaria infection consumption of herbal preparations is the first line of treatment. Drug hawkers that sell modern drugs in the communities were mainly consulted for malaria treatment. The antimalarial drugs bought were often wrongly used and none of the respondents were aware of the current trend in malaria management with modern drugs. Hospital visitation is usually after many days of persistent illness without improvement despite all forms of self medication. The main measure used against malaria vectors was insecticide coils (74.6%). None of the respondents used insecticide treated net (ITN). Distance, cost and poor quality of hospital treatment were reasons for refusal to seek proper medical care. Health education and improved health care services are recommended for these farmers in order for them to be able to translate extension services provided into maximum agricultural yields.

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.

The 19th Commonwealth Games, conducted once in every four years since 1930, will be held in New Delhi from the 3rd through until the 14th of October, 2010. There will be approximately 17 sports on display and there will also be 15 para-sporting events. This paper focuses on health and safety issues for travellers to India in general, although it provides specific references to advice for visiting Commonwealth Games athletes and team staff, who will be travelling to the games. Whilst it needs be remembered that travel health advice can change, travellers are advised to seek up-to-date travel health advice for India, from their professional providers, closer to their departure.

The public health implications of large crowds gathering at a range of key global events should never be underestimated. This is especially the case with the upcoming 2010 FIFA World Cup South Africa programme where thousands of local and travelling spectators, players and officials from all over the world will be present. Although meningococcal disease contracted whilst actually travelling is relatively rare, any travel health risk assessment should involve consideration of potential exposure to and transmission of this disease where crowding occurs. In South Africa, for reasons not completely understood, the incidence of meningococcal disease is higher than in most European countries. Whilst the currently available polysaccharide vaccines can help protect travellers against meningococcal disease there are some well recognised limitations of such vaccines. These can, however, be overcome with the use of newly developed conjugated quadrivalent meningococcal vaccines. A quadrivalent conjugate vaccine should be the first choice for travellers to areas in which the risk of exposure to meningococcal disease is significant. The conjugated quadrivalent meningococcal vaccine should be recommended for all those attending or playing in the 2010 FIFA World Cup South Africa as well as similar global and regional events.

Benign paroxysmal positional vertigo (BPPV) is a common form of dizziness. The causes of BPPV are not yet known but a relationship between the onset of vertigo and head trauma has been found. Among the causes of head injury related to BPPV, dropping off a camel has not been reported in literature yet. We describe two cases of persons that fell off a camel during a safari in Middle East countries. After the fall they reported vertigo symptoms that were not interpreted as BPPV. When they returned to Italy, due to symptoms persistence, they were referred to our ENT practice: we found evidence of BPPV. In a case it was a bilateral BPPV (bBPPV). Falling off a camel may be a relevant cause of BPPV. We suggest a correct evaluation of the labyrinth for BPPV with the appropriate diagnostic maneuvers and, if necessary, a treatment with repositioning maneuvers.

The Special Olympics is a non-profit organization that was officially founded in 1968. Nowadays, the Special Olympics have evolved to a Global Movement that offers the opportunity to more than 3 million athletes with mental or physical disabilities from 185 countries to participate. The Special Olympics will take place in Greece from June 25 until July 4, 2011, where 7500 athletes from 185 countries will participate in 22 Olympic-type games. Mass gatherings such as Olympic Games represent a significant challenge for public health. This paper focuses on relevant health and safety issues for all travellers travelling to Greece for the summer 2011 Special Olympic Games.