Travel-related infection in European travelers, EuroTravNet 2011

Intestinal protozoa in returning travellers: a GeoSentinel analysis from 2007 to 2019

BACKGROUND

Prolonged diarrhoea is common amongst returning travellers and is often caused by intestinal protozoa. However, the epidemiology of travel-associated illness caused by protozoal pathogens is not well described.

METHODS

We analysed records of returning international travellers with illness caused by Giardia duodenalis, Cryptosporidium spp., Cyclospora cayetanensis or Cystoisospora belli, reported to the GeoSentinel Network during January 2007-December 2019. We excluded records of travellers migrating, with an unascertainable exposure country, or from GeoSentinel sites that were not located in high-income countries.

RESULTS

There were 2517 cases, 82.3% giardiasis (n = 2072), 11.4% cryptosporidiosis (n = 287), 6.0% cyclosporiasis (n = 150) and 0.3% cystoisosporiasis (n = 8). Overall, most travellers were tourists (64.4%) on long trips (median durations: 18-30 days). Cryptosporidiosis more frequently affected people < 18 years (13.9%) and cyclosporiasis affected people ≥ 40 years (59.4%). Giardiasis was most frequently acquired in South Central Asia (45.8%) and sub-Saharan Africa (22.6%), cryptosporidiosis in sub-Saharan Africa (24.7%) and South-Central Asia (19.5%), cyclosporiasis in South East Asia (31.3%) and Central America (27.3%), and cystoisosporiasis in sub-Saharan Africa (62.5%). Cyclosporiasis cases were reported from countries of uncertain endemicity (e.g. Cambodia) or in countries with no previous evidence of this parasite (e.g. French Guiana). The time from symptom onset to presentation at a GeoSentinel site was the longest amongst travellers with giardiasis (median: 30 days). Over 14% of travellers with cryptosporidiosis were hospitalized.

CONCLUSIONS

This analysis provides new insights into the epidemiology and clinical significance of four intestinal protozoa that can cause morbidity in international travellers. These data might help optimize pretravel advice and post-travel management of patients with travel-associated prolonged gastrointestinal illnesses. This analysis reinforces the importance of international travel-related surveillance to identify sentinel cases and areas where protozoal infections might be undetected or underreported.

Ready for Take-off? – Gestaltung und Wahrnehmung von Reiseimpfberatungschatbots

Der Einsatz von Sprachassistenten (Alltagsbeispiele sind Alexa von Amazon, Siri von Apple oder der Chatbot von Hellofresh) hat auch im Gesundheitswesen Einzug gehalten. Ein aktuelles Beispiel ist der WhatsApp Chatbot der WHO, welcher Nutzer:innen über COVID-19 aufklärt. Sprachassistenten haben die Fähigkeit, Patienten und Patientinnen orts- und zeitunabhängig aufzuklären, wodurch Mitarbeiter:innen entlastet werden. Jedoch gibt es neben den technischen (u. a. Entwicklung und Optimierung der Algorithmen für die Spracherkennung) auch Herausforderungen in der Mensch-Chatbot-Interaktion. In dieser Studie wird untersucht, welche Rolle die menschenähnliche Gestaltung (u. a. menschlicher Name, Begrüßung, menschlicher Avatar) eines Reiseimpfberatungschatbots auf dessen Wahrnehmung durch Nutzer:innen hat. Spezifisch geht es darum zu verstehen, ob und wie sich Anthropomorphismus (die Wahrnehmung von Menschlichkeit und sozialer Präsenz in Objekten, Tieren und Maschinen) auf die wahrgenommene Vertrauenswürdigkeit und letztendliche Zufriedenheit mit dem Service auswirkt. In einem Online-Experiment mit 78 Teilnehmer:innen, wurden zwei Chatbot-Gestaltungen (mit menschenähnlichen Gestaltungselementen vs. ohne diese Elemente) verglichen. Die Ergebnisse zeigen, dass die wahrgenommene soziale Präsenz signifikant die wahrgenommene Vertrauenswürdigkeit und die Zufriedenheit mit dem Service des Chatbots erhöhen. Somit ist die Implikation, dass bei der Reiseimpfberatung und ähnlichen Beratungsprozessen eine menschliche Gestaltung der Sprachassistenten zu empfehlen ist.

Imported malaria definition and minimum data for surveillance

The mobility of malaria-infected individuals poses challenges to elimination campaigns by way of spreading parasite drug resistance, straining country-to-country collaboration, and making routine data collection difficult, especially in resource-poor settings. Nevertheless, no concerted effort has been made to develop a common framework to define the spatial and temporal components of an imported malaria case and recommend the minimum data needed to identify it. We conducted a scoping review of imported malaria literature from 2010 to 2020 which showed that definitions vary widely, and local capabilities of detecting importation are often restricted in low-income countries. Following this, we propose a common definition for imported malaria and the minimum data required to identify a case, depending on the country's capability of conducting an epidemiological investigation. Lastly, we utilize the proposed definition using data from Brazil to demonstrate both the feasibility and the importance of tracking imported cases. The case of Brazil highlights the capabilities of regular surveillance systems to monitor importation, but also the need to regularly use these data for informing local responses. Supporting countries to use regularly collected data and adopt a common definition is paramount to tackling the importation of malaria cases and achieving elimination goals set forth by the World Health Organization.

Bacterial travellers' diarrhoea: A narrative review of literature published over the past 10 years

Travellers' diarrhoea (TD) is the most frequent illness experienced by international travellers to lower-income countries with bacterial agents considered to account for 80-90% of cases. In this review, we summarise evidence published on bacterial TD over the past 10 years, focusing on the epidemiology and aetiology of TD. Diarrhoeagenic Escherichia coli (DEC) continue to be the most commonly implicated bacteria in TD, although Enteropathogenic E. coli (EPEC) and Enteroaggregative E. coli (EAEC) now appear to be predominant where Enterotoxigenic E. coli (ETEC) was previously considered most prevalent globally. Where fluroquinolone resistance had primarily been documented for Campylobacter in Southeast Asia, widespread resistance has been observed in most regions of the world for multiple enteropathogens, including Shigella, Salmonella, ETEC and EAEC. Implementation of novel molecular methods for pathogen detection has led to identification of bacterial pathogens, including Clostridium difficile (with and without the use of prior antibiotics), Arcobacter species and Bacteroides fragilis, as aetiological agents in TD. The widespread resistance to first-line antibiotics in multiple bacterial enteropathogens warrants continued surveillance and re-evaluation of current treatment practices. Further investigations are required to determine the prevalence and geographical distribution of bacterial enteropathogens that have been more recently implicated in TD.

Medical Advice for Travelers

BACKGROUND

In 2019, 1.5 billion international tourist trips were counted worldwide. Germany, with 70.8 million vacations lasting ≥ 5 days, was one of the populations most willing to travel. These days, even elderly and multimorbid persons regularly travel long-distance, which can be associated with significant health risks. By advising travelers and implementing preventive measures, the risk of illness can be reduced significantly.

METHODS

A selective survey of PubMed was performed to identify publications on medical advice for travelers between 2000 and 2020. We included guidelines, studies, and recommendations that mainly deal with the preventive aspects of travel medicine and have a high level of practical relevance and the highest possible level of evidence. Previously published guidelines (based on the GRADE criteria) were adopted, and recommendations not based on the results of scientific studies were characterized as Good Clinical Practice (GCP).

RESULTS

Many medical recommendations for travelers still rely on individualized, experience-based, or consensus-based assessments. Apart from a review of medical history and vaccination status, a risk analysis is performed, travel fitness is evaluated individually, and a prevention plan is designed. Particular attention is devoted to malaria prophylaxis, vector protection, and traveler's diarrhea. Medical advice before travel is especially important for the elderly, children, pregnant women, the chronically ill, long-term and adventure travelers as well as migrants from malaria-endemic areas who are returning home.

CONCLUSION

The health risks associated with travel can be minimized by specialist medical advice. Many recommendations are empirical in nature and require further research.

Diagnostic tools for bacterial infections in travellers: Current and future options

International travel has increased dramatically over the past 50 years, and travel destinations have diversified. Although physicians are more familiar with the panel of aetiological agents responsible for illnesses of returning travellers, thanks to regular epidemiological studies, the spectrum of pathogens potentially encountered in various travel destinations is nevertheless increasing. In addition, the wide array of approaches currently available and addressed in this paper could render the procedures for microbiological analyses increasingly complex. As the time to result is crucial to adequately manage patients, modern approaches have been developed to shorten diagnosis delays. The syndromic approach, which consists of simultaneously testing a wide panel of microorganisms, substantially increases the diagnostic yield with significant time savings, particularly when coupled with point-of-care laboratories. The tools commonly used for this purpose are immunochromatographic tests, mainly targeting bacterial antigens, and multiplex real-time PCR. The emergence of next-generation sequencing technologies, which enable random amplification of genetic material of any microbe present in a clinical specimen, provides further exciting perspectives in the diagnosis of infectious diseases.

Conduite à tenir devant un enfant fébrile au retour de voyage☆

Les pathologies le plus fréquentes au retour de voyage à l’étranger sont les infections gastro-intestinales, les maladies fébriles et les problèmes dermatologiques. L’évaluation d’un enfant fébrile de retour de voyage est clinique : vérification des antécédents et des vaccinations, recherche d’autres cas au contact, signes fonctionnels et physiques, caractéristiques du voyage. Un bilan paraclinique de débrouillage complète souvent l’évaluation pour une orientation syndromique. Si les causes de fièvre sont surtout cosmopolites, la gravité des pathologies exotiques doit les faire rechercher en priorité. Le paludisme doit être évoqué devant toute fièvre en provenance d’Afrique subsaharienne. Le diagnostic repose sur l’association d’un frottis sanguin et d’un test sensible (goutte épaisse, polymerase chain reaction [PCR]) ou d’un test de diagnostic rapide (pour Plasmodium [P ]. falciparum ). Les critères clinicobiologiques de gravité sont essentiels pour orienter et traiter le patient. En cas d’accès non compliqué à P. falciparum , le traitement repose sur une thérapie combinée à base d’artémisinine (ACT), artéméther-luméfantrine ou arténimol-pipéraquine. Les accès graves sont traités par l’artésunate intraveineux, puis un ACT oral. Dengue, chikungunya et infection à virus Zika ont des caractéristiques cliniques communes (association fièvre-éruption-arthralgies, traitement symptomatique). En cas de dengue, il faut surveiller l’apparition de signes d’alerte qui pourraient faire craindre une évolution péjorative. Le chikungunya est grave en cas de transmission per partum, avec un risque d’encéphalite néonatale. Chez l’enfant, le Zika est a- ou peu symptomatique. Mais en cas d’infection pendant une grossesse, le risque est celui d’une embryofœtopathie. Le diagnostic de ces arboviroses repose sur la PCR à la phase aiguë et la sérologie secondairement. La symptomatologie de la typhoïde est peu spécifique, justifiant la pratique d’hémocultures systématiques devant une fièvre du retour. Son traitement repose sur les céphalosporines de troisième génération ou la ciprofloxacine, mais les résistances augmentent. Au total, la diversité des étiologies d’une fièvre de retour et la gravité potentielle des infections importées imposent une réflexion sur le parcours de soins de ces patients, en particulier vis-à-vis du risque de fièvre hémorragique.

Risks Related to Chikungunya Infections among European Union Travelers, 2012-2018

Autochthonous outbreaks of chikungunya have occurred in the European Union (EU) after virus introduction by infected travelers. We reviewed the surveillance data of travel-related cases reported in the EU during 2012–2018 to document factors associated with increased infection rates among travelers and to assess how surveillance data could support preparedness against secondary transmission and timely control of outbreaks. Thirteen EU countries reported 2,616 travel-related chikungunya cases. We observed 3 successive epidemiologic periods; the highest number of cases (75%) occurred during 2014–2015, when most cases were associated with the Caribbean and South America. The highest infection rates among travelers were observed during the same phase. Although surveillance of travel-related cases is relevant for estimating the infection risk for travelers, we could not identify a relationship between the number of infected travelers and a higher likelihood of secondary transmission in the EU.

Adherence to hepatitis A travel health guidelines: A cross-sectional seroprevalence study in Dutch travelling families - The Dutch travel Vaccination Study (DiVeST)

BACKGROUND

This Dutch travel Vaccination Study (DiVeST) aimed to study adherence or compliance to Dutch travel health guidelines in travelling families and to identify risk groups to provide better advice and protection for international travellers.

METHODS

Between 2016 and 2018, family members who travelled to Eastern Europe or outside Europe during the preceding year were recruited via Dutch secondary schools. The vaccination status of the travellers was assessed using questionnaires and vaccination records and hepatitis A virus antibody concentrations in dried blood spot (DBS) eluates. Subgroups of travellers with lower adherence to guidelines were identified.

RESULTS

Of the 246 travellers that participated in this study, 155 (63%) travelled to destinations for which the HAV vaccination was recommended. Of these 155 travellers, 56 (36%) said they visited a pre-travel clinic, and 64 of them (41%) showed a valid HAV vaccination in their vaccination records. Of the 145 travellers with available DBS eluates, anti-HAV antibodies were detected in 98 (68%) of them.

CONCLUSIONS

We found that adherence to travel health guidelines, in terms of HAV vaccination, was suboptimal. According to our results, specific attention should be paid to children, persons visiting friends and relatives and those who travel relatively short distances.

Imported human Schistosoma japonicum: A report on two cases in Filipino migrants present in Italy and a systematic review of literature

BACKGROUND

Schistosoma japonicum is endemic in the Philippines, China, and Indonesia, and is the third-most common schistosoma species. The infection can be asymptomatic for years but, if left untreated, can lead to irreversible complications.

METHOD

We report the results of a systematic review of the literature on imported S. japonicum infection and describe two previously unpublished cases diagnosed in Filipino migrants in Italy.

RESULTS

Twenty-five imported cases of S. japonicum schistosomiasis were retrieved. All patients but one were migrants. Most subjects acquired the infection in Philippines (n = 18, 72%). Median age at diagnosis was 46 years. Median period of residence in non-endemic countries before diagnosis was 14.5 years. Cases of prevalent hepatosplenic involvement were 10 (40%), those with prevalent intestinal involvement were 10 (40%), whereas five (20%) had overlapping manifestations. Ten patients suffered from cirrhosis; two underwent liver transplantation. Three patients presented with acute abdomen due to intestinal complications, leading to explorative laparotomy. In all cases, but one, the diagnosis was based on a histological examination of biopsy specimen, revealing S. japonicum ova. Seventeen patients were treated with praziquantel, and in three of them, possible treatment failures occurred.

CONCLUSIONS

S. japonicum infection is uncommonly reported in non-endemic areas, but is probably underestimated because of a low threshold awareness of clinicians and unavailability of specific diagnostic tools. Viable S. japonicum adults may persist for decades, indicating that migrants or travellers previously exposed in areas with high-risk areas can harbour viable worms and deserve treatment.

Travel-associated hepatitis A in Europe, 2009 to 2015

Travel to countries with high or intermediate hepatitis A virus (HAV) endemicity is a risk factor for infection in residents of countries with low HAV endemicity. Aim: The objective of this study was to estimate the risk for hepatitis A among European travellers using surveillance and travel denominator data. Methods: We retrieved hepatitis A surveillance data from 13 European Union (EU)/ European Economic Area (EEA) countries with comprehensive surveillance systems and travel denominator data from the Statistical Office of the European Union. A travel-associated case of hepatitis A was defined as any case reported as imported. Results: From 2009 to 2015, the 13 countries reported 18,839 confirmed cases of hepatitis A, of which 5,233 (27.8%) were travel-associated. Of these, 39.8% were among children younger than 15 years. The overall risk associated with travel abroad decreased over the period at an annual rate of 3.7% (95% confidence interval (CI): 0.7–2.7) from 0.70 cases per million nights in 2009 to 0.51 in 2015. The highest risk was observed in travellers to Africa (2.11 cases per million nights). Cases more likely to be reported as travel-associated were male and of younger age (< 25 years). Conclusion: Travel is still a major risk factor for HAV infection in the EU/EEA, although the risk of infection may have slightly decreased in recent years. Children younger than 15 years accounted for a large proportion of cases and should be prioritised for vaccination.

Hepatitis A vaccine immunogenicity in patients using immunosuppressive drugs: A systematic review and meta-analysis

INTRODUCTION

Inactivated hepatitis A (HepA) vaccines are very immunogenic in healthy individuals; however, it remains unclear how different immunosuppressive regimens affect HepA vaccine immunogenicity. Our objective was to summarise the current evidence on immunogenicity of HepA vaccination in patients using immunosuppressive drugs.

METHODS

We systematically searched the literature for studies on immunogenicity of inactivated HepA vaccines in adults using immunosuppressive drugs. Studies reporting seroconversion rates (SCR) 4-8 weeks after 1 and 2 doses of HepA vaccine in organ transplant recipients and patients with chronic inflammatory conditions were included in a meta-analysis.

RESULTS

We included 17 studies, comprising 1,332 individuals. In healthy controls (2 studies), SCRs were 90-94% after the first dose and 100% after the second dose. In organ transplant recipients, SCRs ranged from 0 to 67% after the first dose of vaccine and 0-97% after the second dose. In patients with chronic inflammatory conditions, SCRs ranged from 6% to 100% after the first dose and from 48 to 100% after the second dose of vaccine. Patients using a TNF-alpha inhibitor versus conventional immune-modulators (e.g. methotrexate, azathioprine, corticosteroids) were more likely to seroconvert after the first dose of vaccine (OR12.1 [2.14-68.2]) but not after the second dose of vaccine (OR 0.78 [0.21-2.92]) in a meta-analysis.

CONCLUSION

Studies evaluating HepA vaccine immunogenicity in immunosuppressive agents are heterogeneous. Overall, there is an impaired immune response following HepA vaccination in patients using immunosuppressive drugs, especially after only one dose of vaccine and in organ transplant recipients. HepA vaccination should therefore be considered before immunosuppressive therapy. Future research should focus on alternative vaccination regimens and long-term immunogenicity.

PROSPERO ID

CRD42018102607.

Conducta práctica ante un niño febril al regresar de un viaje

Las enfermedades más frecuentes al regresar de un viaje al extranjero son las infecciones gastrointestinales, las enfermedades febriles y los problemas dermatológicos. La evaluación de un niño febril al regreso de un viaje es clínica: verificación de los antecedentes y las vacunaciones, búsqueda de otros casos en contacto, signos funcionales y físicos, y características del viaje. Unas pruebas complementarias de rutina completan a menudo la evaluación para una orientación sindrómica. Si bien las causas de fiebre son, sobre todo, cosmopolitas, la gravedad de la enfermedad exótica obliga a buscarlas prioritariamente. El paludismo debe sospecharse ante una fiebre procedente de África subsahariana. El diagnóstico se basa en la asociación de un frotis sanguíneo y una prueba sensible (gota gruesa, reacción en cadena de la polimerasa [PCR]) o una prueba de diagnóstico rápido (para Plasmodium falciparum ). Los criterios clínico-biológicos de gravedad son esenciales para orientar y tratar al paciente. En caso de acceso no complicado por P. falciparum, el tratamiento se basa en un tratamiento combinado a base de artemisinina (ACT), arteméter-lumefantrina o artenimol-piperaquina. Los accesos graves se tratan con artesunato intravenoso, seguido de ACT oral. Dengue, chikungunya e infección por virus Zika tienen características clínicas comunes (fiebre-erupción-artralgias, tratamiento sintomático). En caso de dengue, conviene controlar la aparición de signos de alerta, que podrían hacer temer una evolución negativa. El chikungunya es grave en caso de transmisión en el parto, con un riesgo de encefalitis neonatal. En el niño, el Zika es asintomático o poco sintomático. Pero, en caso de infección durante el embarazo, el riesgo es el de una embriofetopatía. El diagnóstico de estas arbovirosis se basa en la PCR en la fase aguda y en la serología secundariamente. La sintomatología de la fiebre tifoidea es poco específica, lo cual justifica la práctica de hemocultivos sistemáticos ante una fiebre tras un viaje. Su tratamiento se basa en las cefalosporinas de tercera generación o el ciprofloxacino, pero las resistencias aumentan. En suma, la diversidad de las etiologías de una fiebre al regreso de un viaje y la potencial gravedad de las infecciones importadas imponen una reflexión sobre el proceso de tratamiento de estos pacientes, en especial en lo referente al riesgo de fiebre hemorrágica.

Estimating the incidence of norovirus acute gastroenteritis among US and European international travelers to areas of moderate to high risk of traveler's diarrhea: a prospective cohort study protocol

Background

Acute gastroenteritis (AGE) is the leading cause of illness among returning travelers seeking medical care. Multiple types of enteric pathogens can cause travel-acquired AGE and, while bacterial pathogens have a predominant role, the importance of viruses, such as norovirus, is increasingly recognized. There is a lack of information on travel-acquired norovirus incidence among symptomatic and asymptomatic individuals irrespective of healthcare-seeking behavior. Our aim is to estimate the incidence of travel-acquired AGE due to norovirus and to characterize the burden of disease among international travelers from the United States and Europe.

Methods

We describe a prospective cohort study implemented in five US and European sites to estimate the role of AGE due to norovirus among adult international travelers. We enrolled individuals aged 18 years and older who are traveling to regions of moderate-high risk of AGE, or via cruise ship with an international port stop, with a trip duration of 3–15 days. The study will generate a wide range of health and travel-related data for pre-, during, and up to 6-months post-travel. We will identify laboratory-confirmed travel-acquired norovirus infections among both symptomatic and asymptomatic individuals from self-collected whole stool samples tested via quantitative RT-PCR. Coinfections will be identified in a subset of travelers with AGE using a multiplex molecular-based assay.

Discussion

This study is unique in design and breadth of data collected. The prospective collection of health and behavioral data, as well as biologic samples from travelers irrespective of symptoms, will provide useful data to better understand the importance of norovirus AGE among international travelers. This study will provide data to estimate the incidence of norovirus infections and AGE and the risk of post-infectious sequelae in the 6-month post-travel period serving as a baseline for future norovirus AGE vaccination studies. This study will contribute valuable information to better understand the role of norovirus in travel-acquired AGE risk and the impact of these infections on a broad set of outcomes.

Hepatitis A in Switzerland: An analysis of 29 years of surveillance data and contemporary challenges

BACKGROUND

Hepatitis A (HA) incidence declined in most European countries in the past decades. We analysed HA notification data for Switzerland of 29 years looking for disease- and notification system-related factors possibly contributing to observed trends.

METHOD

Notification data were descriptively analysed using five time intervals (1988-1993, 1994-1999, 2000-2005, 2006-2011, 2012-2016); and notification rates were calculated.

RESULTS

From 1988 to 2016, the HA notification rate decreased from 9.5 to 0.5 per 100'000 population in Switzerland. Median age and the proportion of hospitalised cases increased over time. In the 1988-1993-time period, intravenous drug use was the most frequently mentioned risk exposure while consumption of contaminated food/beverages was most frequently mentioned in the 2012-2016-time period.

CONCLUSIONS

Notification data does not allow reliably identifying current risk groups (e.g. travellers) due to low case numbers, limited availability and reliability of information. It is important to document changes in the surveillance system for later analyses and interpretation of long-term trends. Population susceptibility likely increases underlining the importance of continued and continuous surveillance and prevention efforts despite decreasing case numbers. Operational research is recommended to further investigate observed trends of HA and to enhance the abilities for decision making from Swiss HA surveillance data.

Risk factors for Burkitt lymphoma: a nested case-control study in the UK Clinical Practice Research Datalink

Burkitt lymphoma (BL) occurs as three subtypes: endemic BL, immunosuppression-related BL and sporadic BL. Descriptive studies of BL age-specific incidence patterns have suggested multimodal peaks near 10, 40 and 70 years of age, but the risk factors for BL at different ages are unknown. We investigated risk factors for BL in the United Kingdom among 156 BL cases and 608 matched BL-free controls identified in the Clinical Practice Research Datalink (CPRD) between 1992 and 2016. Associations with pre-diagnostic body mass index, cigarette smoking, alcohol consumption, hepatitis, Epstein-Barr virus (EBV), human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV/AIDS), malaria, allergic and autoimmune conditions, and prednisone use were evaluated. Overall, we identified inverse associations between smoking and BL risk, and positive associations between prior EBV infection, HIV/AIDS and prescription or use of prednisone with BL risk. In age-group stratified analyses, BL was associated with malaria exposure (vs. no exposure, odds ratio [OR] 8·00, 95% confidence interval [CI] 1·46-43·7) among those aged 20-59 years old and with hepatitis infection (vs. no infection, OR 3·41, 95% CI 1·01-11·5) among those aged 60+ years old. The effects of EBV, malaria, HIV/AIDS, prednisone and hepatitis on BL remained significant in mutually-adjusted age-group-specific analyses. No risk factors were associated with childhood BL. We report novel associations for BL in non-endemic settings.

Epidemiological and clinical features of imported malaria at the three main hospitals of the Friuli-Venezia Giulia Region, Italy

BACKGROUND

Imported malaria cases continue to occur in non-endemic regions among travellers returning from tropical and subtropical countries. At particular risk of acquiring malaria is the group of travellers identified as immigrants who return to their home country with the specific intent of visiting friends or relatives (VFRs) and who commonly believe they are immune to malaria and fail to seek pre-travel advice. Our aim was to review the current trends of imported malaria in the three main hospitals of the Friuli-Venezia Giulia region (FVG), North Eastern Italy, focusing in particular on patient characteristics and laboratory findings.

METHODS

In this retrospective study, we examined all malaria cases among patients admitted from January 2010 through December 2014 to the emergency department of the three main hospitals located in FVG.

RESULTS

During the 5-year study period from 2010 to 2014, there were a total of 140 patients with a diagnosis of suspected malaria and who received microscopic confirmation of malaria. The most common species identified was P. falciparum, in 96 of 140 cases (69%), followed by P. vivax (13%), P. ovale (4%), P. malariae (4%), and mixed infection (4%). The most common reason for travel was VFRs (54%), followed by work (17%), and recent immigration (15%). Moreover, 78% of all patients took no chemoprophylaxis, 80 (79%) of whom were foreigners. Notably, the percentage of Italian travellers who took chemoprophylaxis was only 20% (8 of 39 Italian cases), and the regimen was appropriate in only four cases. Parasitaemia greater than 5% was observed in 11 cases (10%), all due to P. falciparum infection.

CONCLUSIONS

We highlight that VFRs have the highest proportion of malaria morbidity and the importance of improving patient management in this category. These data are useful for establishing appropriate malaria prevention measures and recommendations for international travellers.

Redefining priorities towards graded travel-related infectious disease research

Our knowledge of the health problems and infections encountered by international travellers has evolved considerably in the past decades. The growth of global networks such as the GeoSentinel Surveillance network, TropNet Europe, EuroTravNet and networks based in North America have provided valuable information on the frequency of a wide array of travel-related diseases and accidents, including details on the destination of travel and trends over time. The information gained from these network studies has provided important data for the practice of travel medicine and in some instances for the development of practice guidelines. However, network data due to a lack of denominators usually cannot serve as a basis for a GRADE approach to guideline development. Although epidemiological network studies will continue to serve an important role in travel medicine we encourage an additional strong focus towards translational scientific research questions and towards the broader use of novel techniques to obtain more accurate epidemiological analyses to address the many unanswered questions in our field.

Self-reported infections during international travel and notifiable infections among returning international travellers, Sweden, 2009-2013

We studied food and water-borne diseases (FWDs), sexually transmitted diseases (STDs), vector-borne diseases (VBDs) and diseases vaccinated against in the Swedish childhood vaccination programme among Swedish international travellers, in order to identify countries associated with a high number of infections. We used the national database for notifiable infections to estimate the number of FWDs (campylobacteriosis, salmonellosis, giardiasis, shigellosis, EHEC, Entamoeba histolytica, yersinosis, hepatitis A, paratyphoid fever, typhoid fever, hepatitis E, listeriosis, cholera), STIs (chlamydia, gonorrhoea and acute hepatitis B), VBDs (dengue fever, malaria, West Nile fever, Japanese encephalitis and yellow fever) and diseases vaccinated against in the Swedish childhood vaccination programme (pertussis, measles, mumps, rubella, diphtheria) acquired abroad 2009–2013. We obtained number and duration of trips to each country from a database that monthly collects travel data from a randomly selected proportion of the Swedish population. We calculated number of infections per country 2009–2013 and incidence/million travel days for the five countries with the highest number of infections. Thailand had the highest number of FWDs (7,697, incidence 191/million travel days), STIs (1,388, incidence 34/million travel days) and VBDs (358, incidence 9/million travel days). France had the highest number of cases of diseases vaccinated against in the Swedish childhood vaccination programme (8, 0.4/million travel days). Swedish travellers contracted most infections in Thailand. Special focus should be placed on giving advice to travellers to this destination.

Non-falciparum malaria imported mainly from Africa: a review from a Portuguese hospital

BACKGROUND

Non-falciparum malaria (NFM) has been reported to be responsible for around 25% of imported malaria cases in Europe but is often neglected due to its less severe clinical course when compared to Plasmodium falciparum. Differentiation between species is however crucial for a correct approach. The objective of this study is to report the cases of this often missed aetiology of malaria in a tertiary hospital in Portugal.

METHODS

Data were retrospectively analysed from patients admitted from January 2006 to August 2016 with a NFM diagnosis based on microscopy, rapid diagnostic tests (RDT) (BinaxNow^®) and/or PCR. Epidemiologic and clinical aspects were reviewed.

RESULTS

A total of 19 NFM cases were diagnosed, corresponding to 8.4% of the total 225 cases of malaria. Seventeen (89%) were male with a median age of 41 years. All but one case were imported from sub-Saharan Africa, with 12 (63%) of the cases returned from Angola. Microscopy was positive for all patients and correctly identified the species in 12 (63%) patients. BinaxNOW^® was performed in all patients and it was positive in 11 cases, showing a sensitivity of 58%. PCR was performed in nine patients and was positive in eight of them, being responsible for the identification of the species in four cases. Plasmodium malariae accounted for 37% (n = 7) of the cases, Plasmodium ovale for 32% (n = 6) and Plasmodium vivax for 17% (n = 3). In three (16%) patients, morphology was suggestive of P. vivax or P. ovale, but precise species identification was not possible. Regarding presentation, fever was the most reported symptom, and the most frequent laboratory finding was thrombocytopaenia. Quinine-doxycycline was prescribed in eleven patients (58%), chloroquine in six cases (32%) and artemether-lumefantrine in two (11%). All of the patients showed clinical improvement.

CONCLUSIONS

NFM remains an important cause of imported malaria in patients from sub-Saharan Africa, alone or as mixed infection with P. falciparum. Access to PCR techniques facilitates diagnosis, as low sensitivity from RDTs and microscopy are to be expected.

Mosquitoes on a plane: Disinsection will not stop the spread of vector-borne pathogens, a simulation study

Mosquito-borne diseases are increasingly being recognized as global threats, with increased air travel accelerating their occurrence in travelers and their spread to new locations. Since the early days of aviation, concern over the possible transportation of infected mosquitoes has led to recommendations to disinsect aircraft. Despite rare reports of mosquitoes, most likely transported on aircraft, infecting people far from endemics areas, it is unclear how important the role of incidentally transported mosquitoes is compared to the role of traveling humans. We used data for Plasmodium falciparum and dengue viruses to estimate the probability of introduction of these pathogens by mosquitoes and by humans via aircraft under ideal conditions. The probability of introduction of either pathogen by mosquitoes is low due to few mosquitoes being found on aircraft, low infection prevalence among mosquitoes, and high mortality. Even without disinsection, introduction via infected human travelers was far more likely than introduction by infected mosquitoes; more than 1000 times more likely for P. falciparum and more than 200 times more likely for dengue viruses. Even in the absence of disinsection and under the most favorable conditions, introduction of mosquito-borne pathogens via air travel is far more likely to occur as a result of an infected human travelling rather than the incidental transportation of infected mosquitoes. Thus, while disinsection may serve a role in preventing the spread of vector species and other invasive insects, it is unlikely to impact the spread of mosquito-borne pathogens.

Spectrum and burden of neglected tropical diseases observed in an infectious and tropical diseases unit in Florence, Italy (2000-2015)

Neglected tropical diseases (NTDs) are a diverse group of acute and chronic conditions with distinct characteristics that thrive mainly among the poorest populations, almost exclusively in tropical countries. To evaluate the relevance and impact of NTDs in a temperate area, the number and features of patients diagnosed with NTDs at the Infectious and Tropical Diseases Unit (ITDU), Azienda Ospedaliero-Universitaria Careggi, Florence, Italy between 2000 and 2015 were retrospectively reviewed. Overall 289 NTD cases were diagnosed in 283 subjects accounting for 2.4% of all patients accessing the center: 96 dengue, 62 schistosomiasis, 36 strongyloidiasis, 22 cystic echinococcosis, 19 Chagas disease, 14 leishmaniasis, 11 chikungunya, 10 cysticercosis, 6 soil-transmitted helminthiasis, 6 lymphatic filariasis, 3 trachoma, 2 onchocerciasis, and 2 leprosy. There was one fatal case of disseminated strongyloidiasis. According to the type of exposure, 145 (50.2%) NTDs were diagnosed in immigrants, 121 (41.9%) in travelers, 18 (6.3%) were autochthonous infections, while in 5 cases (1.7%), the type of exposure was unknown. The number of patients seen at the ITDU with a diagnosis of NTD increased over time (from 29 in 2000-2005 to 81 in 2006-2010, to 173 in 2011-2015). Late diagnosis and mismanagement before coming to the center were common features in several cases. Considering the increasing incidence and possible misdiagnosis of NTDs in non-endemic countries, to raise awareness about NTDs among health care providers seems to be of primary concern.

Migration and infectious diseases

BACKGROUND

Infectious diseases still represent an important cause of morbidity and mortality among foreign-born individuals. The rising migration flows towards Europe throughout the last few years are raising renewed concerns about management issues and the potential associated risk for the native population.

AIMS

To discuss the health implications and challenges related to the four phases of migration, from first arrival to stable resettlement.

SOURCES

Scientific literature and relevant statistical reports.

CONTENT

Although infectious diseases are not a health priority at first arrival, a syndromic screening to identify the most common communicable conditions (pulmonary tuberculosis above all) should be promptly conducted. Reception centres where asylum seekers are gathered after arrival may be crowded, so favouring epidemic outbreaks, sometimes caused by incomplete vaccine coverage for preventable diseases. After resettlement, the prevalence of some chronic infections such as human immunodeficiency virus, viral hepatitis or tuberculosis largely reflects the epidemiological pattern in the country of origin, with poor living conditions being an additional driver. Once resettled, migrants usually travel back to their country of origin without seeking pre-travel advice, which results in a high incidence of malaria and other infections.

IMPLICATIONS

Although infectious diseases among migrants are known to have a negligible impact on European epidemiology, screening programmes need to be implemented and adapted to the different stages of the migratory process to better understand the trends and set priorities for action. Appropriate access to care regardless of the legal status is crucial to improve the health status and prevent the spread of contagious conditions.

Chikungunya virus infections among travellers returning to Spain, 2008 to 2014

Since the first documented autochthonous transmission of chikungunya virus in the Caribbean island of Saint Martin in 2013, the infection has been reported within the Caribbean region as well as North, Central and South America. The risk of autochthonous transmission of chikungunya virus becoming established in Spain may be elevated due to the large numbers of travellers returning to Spain from countries affected by the 2013 epidemic in the Caribbean and South America, as well as the existence of the Aedes albopictus vector in certain parts of Spain. We retrospectively analysed the laboratory diagnostic database of the National Centre for Microbiology, Institute of Health Carlos III (CNM-ISCIII) from 2008 to 2014. During the study period, 264 confirmed cases, of 1,371 suspected cases, were diagnosed at the CNM-ISCIII. In 2014 alone, there were 234 confirmed cases. The highest number of confirmed cases were reported from the Dominican Republic (n = 136), Venezuela (n = 30) and Haiti (n = 11). Six cases were viraemic in areas of Spain where the vector is present. This report highlights the need for integrated active case and vector surveillance in Spain and other parts of Europe where chikungunya virus may be introduced by returning travellers.

Response to fever and utilization of standby emergency treatment (SBET) for malaria in travellers to Southeast Asia: a questionnaire-based cohort study

Background

Guidelines in several European countries recommend standby emergency treatment (SBET) for travellers to regions with low or medium malaria transmission instead of continuous chemoprophylaxis: travellers are advised to seek medical assistance within 24 h in case of fever and to self-administer SBET only if they are not able to consult a doctor within the time period specified. Data on healthcare-seeking behaviour of febrile travellers and utilization of SBET is however scarce as only two studies were performed in the mid-1990s. Since tourism is constantly increasing and malaria epidemiology has dramatically changed in the meantime more knowledge is urgently needed.

Methods

Some 876 travellers to destinations in South and Southeast Asia with low or medium malaria transmission were recruited in the travel clinic of the University Medical Center Hamburg-Eppendorf. Demographic and travel-related data were collected by using questionnaires. Pre-travel advice was carried out and SBET was prescribed in accordance to national guidelines. Post-travel phone interviews were performed to assess health incidents during travel and individual responses of travellers to febrile illness.

Results

Out of 714 patients who were monitored, 130 (18%) reported onset of fever during travel or 14 days after return. Of those travellers who reported fever, 100 (80%) carried SBET during travel. The vast majority of 79 (79%) febrile travellers who carried SBET did not seek medical assistance. Overall, 14 (14%) febrile patients who carried SBET and six (20%) patients who did not carry SBET took the correct measure (doctor visit or timely SBET administration) as a response to febrile illness, respectively. Only two travellers self-administered SBET, but both of them applied the wrong regimen.

Conclusions

In view of declining malaria transmission and improving medical infrastructure in most countries of Southeast Asia and obvious obstacles concerning SBET as shown in this study the current strategy should be re-evaluated. Pre-travel advice concerning malaria in SEA should focus on appropriate mosquito bite protection and clearly emphasize the need to see a doctor within 24 h after onset of fever.

The geography of imported malaria to non-endemic countries: a meta-analysis of nationally reported statistics

BACKGROUND

Malaria remains a problem for many countries classified as malaria free through cases imported from endemic regions. Imported cases to non-endemic countries often result in delays in diagnosis, are expensive to treat, and can sometimes cause secondary local transmission. The movement of malaria in endemic countries has also contributed to the spread of drug resistance and threatens long-term eradication goals. Here we focused on quantifying the international movements of malaria to improve our understanding of these phenomena and facilitate the design of mitigation strategies.

METHODS

In this meta-analysis, we studied the database of publicly available nationally reported statistics on imported malaria in the past 10 years, covering more than 50 000 individual cases. We obtained data from 40 non-endemic countries and recorded the geographical variations.

FINDINGS

Infection movements were strongly skewed towards a small number of high-traffic routes between 2005 and 2015, with the west Africa region accounting for 56% (13 947/24 941) of all imported cases to non-endemic countries with a reported travel destination, and France and the UK receiving the highest number of cases, with more than 4000 reported cases per year on average. Countries strongly linked by movements of imported cases are grouped by historical, language, and travel ties. There is strong spatial clustering of plasmodium species types.

INTERPRETATION

The architecture of the air network, historical ties, demographics of travellers, and malaria endemicity contribute to highly heterogeneous patterns of numbers, routes, and species compositions of parasites transported. With global malaria eradication on the international agenda, malaria control altering local transmission, and the threat of drug resistance, understanding these patterns and their drivers is increasing in importance.

FUNDING

Bill & Melinda Gates Foundation, National Institutes of Health, UK Medical Research Council, UK Department for International Development, Wellcome Trust.

A closer look at travellers' infections abroad: Finnish nationwide data with incidences, 2010 to 2012

BACKGROUND

Although infections represent the most common health problem of travellers abroad, data on morbidity and incidences of various infections are scarce.

METHOD

Data on infections of Finnish travellers during 2010-2012 were retrieved from the database of SOS International, an assistance organization covering 95% of Finns requiring aid abroad. The study included 30,086 cases. For incidence calculation, the data were linked to the numbers of Finns visiting these regions during the same period as recorded by the Official Statistics of Finland.

RESULTS

The incidence of infections was particularly high in Africa, southern Europe plus the eastern Mediterranean, and Asia plus Oceania. The most frequent diagnoses were acute gastroenteritis (38.0%) and respiratory-tract infections (RTI) (34.5%), followed by infections of the ear (12.6%), skin or subcutaneous tissue (5.1%), urogenital tract (4.2%), eye (3.1%), and systemic febrile infections (2.2%). Vaccine-preventable diseases (VPD) accounted for 0.8% of cases, with varicella as most (49%) and influenza as second-most (27%) common.

CONCLUSIONS

Incidence of infections was higher in southern than in eastern and western Europe. Gastroenteritis and RTI proved the most frequent diagnoses, whereas systemic febrile infections were uncommon. Despite pre-travel immunizations, VPDs still occurred; pre-travel consultation should cover both varicella and influenza.

Multidrug-resistant tuberculosis and migration to Europe

Multidrug-resistant tuberculosis (MDR-TB) in low-incidence countries in Europe is more prevalent among migrants than the native population. The impact of the recent increase in migration to EU and EEA countries with a low incidence of TB (<20 cases per 100 000) on MDR-TB epidemiology is unclear. This narrative review synthesizes evidence on MDR-TB and migration identified through an expert panel and database search. A significant proportion of MDR-TB cases in migrants result from reactivation of latent infection. Refugees and asylum seekers may have a heightened risk of MDR-TB infection and worse outcomes. Although concerns have been raised around 'health tourists' migrating for MDR-TB treatment, numbers are probably small and data are lacking. Migrants experience significant barriers to testing and treatment for MDR-TB, exacerbated by increasingly restrictive health systems. Screening for latent MDR-TB is highly problematic because current tests cannot distinguish drug-resistant latent infection, and evidence-based guidance for treatment of latent infection in contacts of MDR patients is lacking. Although there is evidence that transmission of TB from migrants to the general population is low-it predominantly occurs within migrant communities-there is a human rights obligation to improve the diagnosis, treatment and prevention of MDR-TB in migrants. Further research is needed into MDR-TB and migration, the impact of screening on detection or prevention, and the potential consequences of failing to treat and prevent MDR-TB among migrants in Europe. An evidence-base is urgently needed to inform guidelines for effective approaches for MDR-TB management in migrant populations in Europe.

Prospects for dengue vaccines for travelers

Travel-acquired dengue cases have been increasing as the overall global dengue burden has expanded. In Korea, imported dengue cases have been reported since 2000 when it first became a notifiable disease. During the first four months of 2016, three times more dengue cases were reported in Korea than during the same period the previous year. A safe and efficacious vaccine for travelers would be beneficial to prevent dengue disease in individual travelers and potentially decrease the risk of virus spread to non-endemic areas. Here, we summarize the characteristics of dengue vaccines for travelers and review dengue vaccines currently licensed or in clinical development.

Spectrum of Imported Infectious Diseases: A Comparative Prevalence Study of 16,817 German Travelers and 977 Immigrants from the Tropics and Subtropics

The aim of this study was to assess the spectrum of imported infectious diseases (IDs) among patients consulting the University of Munich, Germany, between 1999 and 2014 after being in the sub-/tropics. The analysis investigated complete data sets of 16,817 diseased German travelers (2,318 business travelers, 4,029 all-inclusive travelers, and 10,470 backpackers) returning from Latin America (3,225), Africa (4,865), or Asia (8,727), and 977 diseased immigrants, originating from the same regions (112, 654 and 211 respectively). The most frequent symptoms assessed were diarrhea (38%), fever (29%), and skin disorder (22%). The most frequent IDs detected were intestinal infections with species of Blastocystis(900),Giardia(730),Campylobacter(556),Shigella(209), and Salmonella(183). Also frequently observed were cutaneous larva migrans (379), dengue (257), and malaria (160). The number of IDs with significantly elevated proportions was higher among backpackers (18) and immigrants (17), especially among those from Africa (18) and Asia (17), whereas it was lower for business travelers (5), all-inclusive travelers (1), and those from Latin America (5). This study demonstrates a large spectrum of imported IDs among returning German travelers and immigrants, which varies greatly based not only on travel destination and origin of immigrants, but also on type of travel.

Malaria in the returning older traveler

BACKGROUND

Increased co-morbidities and physiological changes mean older patients may be at higher risk of adverse outcomes from certain imported illnesses. One of the most commonly diagnosed imported infections in returning travelers is malaria. Increasing age is strongly and independently associated with increasing morbidity and mortality from malaria. Delayed diagnosis leads to higher risks of poor clinical outcomes in older patients presenting with malaria. The objective of this study was to quantify malaria presentations in older patients as a percentage of total malaria presentations, compare length of hospital stay (LOS) between the older and younger cohort, and to describe medical co-morbidities, length of time to diagnosis and factors contributing to delayed diagnosis and increased LOS in the older cohort.

METHODS

A retrospective cohort study was undertaken in two university hospitals of all patients aged 65 years or older presenting with malaria from 2002-2012. A national hospital inpatient database was used to identify patients of all ages with a discharge diagnosis of malaria over this ten year period, and quantify LOS in those aged <65 and those aged 65 years or older. The case-notes for all of the older cohort were reviewed.

RESULTS

There were a total of 203 cases, 12 of whom were aged ≥65 years (5.9 %- total). Median time to diagnosis in this older group was two days (range 0-35), median LOS was eight days (range 1-77), compared to a median LOS of three days in those aged <65 years. All patients aged ≥65 years presented with fever. Travel history was documented in only 6/12 charts, and 11/12 had two or more co-morbid illnesses. Six of the 12 patients were not diagnosed or treated within 48 h of presentation.

CONCLUSIONS

This case series highlights the need for appropriate history-taking and timely diagnosis of the older traveler returning with fever, as delayed diagnosis and treatment can contribute to prolonged hospital stay and increased morbidity. With increasing numbers of older travelers, physicians must remain vigilant to the presence of imported illnesses, particularly malaria, in older patients with unexplained fever.

Has the economic crisis led to a new risk profile for international travellers?

INTRODUCTION

The economic world crisis has led to the migration of European workers to developing countries with a high incidence of infectious diseases. The objective of this study was to assess whether this context has produced an increase in the risks to international travellers for work reasons (TWR).

METHODS

Observational, retrospective study. The study population included TWR who were attended before travelling at an International Health Unit in the year 2007 (the year before the initiation of the European crisis) and in the year 2012 (when the structural crisis was established). A comparative socioeconomic analysis was performed as well as an analysis of the risk factors present in both groups.

RESULTS

In 2007 and 2012 a total of 9,197 travellers were attended. Of these, there were 344 TWR (3.4%); 101 TWR (2.8%) in 2007 and 243 TWR (4.5%) in 2012 (p<0.001). The average age of the travellers was 38.1 years (SD: 10.57). The most common destination was Sub-Saharan Africa, in 164 (47.6%) of the cases. Malaria chemoprophylaxis was prescribed to 152 travellers (44%) and 80 presented comorbidity (23.25%). The TWR from 2012 presented a significantly greater age (p=0.05), more comorbidity (p=0.018) and a greater proportion of stays in rural areas (p=0.0009) for longer time periods (p=0.001).

CONCLUSIONS

At 5 years from the start of the economic crisis, there was a change in the profile of TWR. Their number has increased significantly, as has the proportion who present risk factors for contracting imported diseases. The International Health Units should adapt to these new circumstances and adopt preventive measures for this population.

Vaccine-preventable travel health risks: what is the evidence--what are the gaps?

BACKGROUND

Existing travel health guidelines are based on a variety of data with underpinning evidence ranging from high-quality randomized controlled trials to best estimates from expert opinion. For strategic guidance and to set overall priorities, data about average risk are useful. The World Health Organization (WHO) plans to base future editions of "International Travel and Health" on its new "Handbook for Guideline Development."

METHODS

Based on a systematic search in PubMed, the existing evidence and quality of data on vaccine-preventable disease (VPD) risks in travelers was examined and essentials of vaccine efficacy were briefly reviewed. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework was used to evaluate the quality of the data.

RESULTS

Moderate-quality data to determine the risk of VPD exist on those that are frequently imported, whereas in most others the level of confidence with existing data is low or very low.

CONCLUSIONS

In order for the WHO to produce graded risk statements in the updated version of "International Travel and Health," major investment of time plus additional high-quality, generalizable risk data are needed.

Parasitic infections in travelers and immigrants: part I protozoa

ABSTRACT 

The growth in international commerce, travel and migration contribute to the global emergence of certain parasitic infections. Importation of vectors and food products may contribute to the emergence of protozoan infections in nonendemic countries. Infections such as malaria are potentially fatal, especially in nonimmune patients, and outcome depends largely on timely diagnosis and treatment. Diagnosis/management of imported parasitic infections may be complex especially as some patients may have underlying immunosuppressive conditions such as HIV infection. Major challenges concern the development of improved diagnostic techniques, safer/more effective drug therapies and identification of biological markers of progression and response to treatment. Imported parasitic diseases which may be transmitted vertically or through blood transfusion/organ donation could become a public health priority in the near future. Climate change may affect arthropod distribution and facilitate the spread of protozoan vector-borne diseases. The first part of this review focuses on protozoan infections in travelers and immigrants.

Jet set pets: examining the zoonosis risk in animal import and travel across the European Union

Ownership of companion animals or pets is popular throughout the world. Unfortunately, such animals are susceptible to and potential reservoirs of zoonotic pathogens. Close proximity to and contact with pets can lead to human infections. The distribution of zoonotic diseases associated with companion animals such as dogs and cats is not uniform around the world, and moving animals between regions, countries, and continents carries with it the risk of relocating the pathogens they might harbor. Critical among these zoonotic diseases are rabies, echinococcosis, and leishmania. In addition, the protozoan parasites, Toxoplasma gondii and Giardia duodenalis, are also significant agents for human disease of pet origin. Considerable effort is applied to controlling movements of companion animals, particularly dogs, into the European Union. However, free movement of people and their pets within the European Union is a risk factor for the translocation of diseases and their vectors. This review considers the current distribution of some of these diseases, the risks associated with pet travel, and the controls implemented within Europe to prevent the free movement of zoonotic pathogens.

Travel-associated infection presenting in Europe (2008-12): an analysis of EuroTravNet longitudinal, surveillance data, and evaluation of the effect of the pre-travel consultation

BACKGROUND

Travel is important in the acquisition and dissemination of infection. We aimed to assess European surveillance data for travel-related illness to profile imported infections, track trends, identify risk groups, and assess the usefulness of pre-travel advice.

METHODS

We analysed travel-associated morbidity in ill travellers presenting at EuroTravNet sites during the 5-year period of 2008-12. We calculated proportionate morbidity per 1000 ill travellers and made comparisons over time and between subgroups. We did 5-year trend analyses (2008-12) by testing differences in proportions between subgroups using Pearson's χ(2) test. We assessed the effect of the pre-travel consultation on infection acquisition and outcome by use of proportionate morbidity ratios.

FINDINGS

The top diagnoses in 32 136 patients, ranked by proportionate morbidity, were malaria and acute diarrhoea, both with high proportionate morbidity (>60). Dengue, giardiasis, and insect bites had high proportionate morbidity (>30) as well. 5-year analyses showed increases in vector borne infections with significant peaks in 2010; examples were increased Plasmodium falciparum malaria (χ(2)=37·57, p<0·001); increased dengue fever (χ(2)=135·9, p<0·001); and a widening geographic range of acquisition of chikungunya fever. The proportionate morbidity of dengue increased from 22 in 2008 to 36 in 2012. Five dengue cases acquired in Europe contributed to this increase. Dermatological diagnoses increased from 851 in 2008 to 1102 in 2012, especially insect bites and animal-related injuries. Respiratory infection trends were dominated by the influenza H1N1 pandemic in 2009. Illness acquired in Europe accounted for 1794 (6%) of all 32 136 cases-mainly, gastrointestinal (634) and respiratory (357) infections. Migration within Europe was associated with more serious infection such as hepatitis C, tuberculosis, hepatitis B, and HIV/AIDS. Pre-travel consultation was associated with significantly lower proportionate morbidity ratios for P falciparum malaria and also for acute hepatitis and HIV/AIDS.

INTERPRETATION

The pattern of travel-related infections presenting in Europe is complex. Trend analyses can inform on emerging infection threats. Pre-travel consultation is associated with reduced malaria proportionate morbidity ratios and less severe illness. These findings support the importance and effectiveness of pre-travel advice on malaria prevention, but cast doubt on the effectiveness of current strategies to prevent travel-related diarrhoea.

FUNDING

European Centre for Disease Prevention and Control, University Hospital Institute Méditerranée Infection, US Centers for Disease Control and Prevention, and the International Society of Travel Medicine.

Efficacy and safety of artemisinin combination therapy (ACT) for non-falciparum malaria: a systematic review

Background

Artemisinin combination therapy (ACT) is recommended as first-line treatment for uncomplicated Plasmodium falciparum malaria, whereas chloroquine is still commonly used for the treatment of non-falciparum species (Plasmodium vivax, Plasmodium ovale and Plasmodium malariae). A more simplified, more uniform treatment approach across all malaria species is worthwhile to be considered both in endemic areas and for malaria as an imported condition alike.

Methods

A PROSPERO-registered systematic review to determine the efficacy and safety of ACT for the treatment of non-falciparum malaria was conducted, following PRISMA guidelines. Without language restrictions, Medline/PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, LILACS, Biosis Previews and the African Index Medicus were searched for studies published up to November 2014.

Results

The literature search identified 986 reports; 40 publications were found eligible for inclusion, all of them on non-falciparum malaria in endemic areas. Most evidence was available for P. vivax (n = 35). Five clinical trials in total were identified evaluating ACT for P. ovale, P. malariae and Plasmodium knowlesi. Most ACT presentations have high efficacy against P. vivax parasites; artemisinin-based combinations have shorter parasite and fever clearance times compared to chloroquine. ACT is as effective as chloroquine in preventing recurrent parasitaemia before day 28. Artemisinin-based combinations with long half-lives show significantly fewer recurrent parasitaemia up to day 63. The limited evidence available supports both the use of chloroquine and an ACT for P. ovale and P. malariae. ACT seems to be preferable for optimal treatment of P. knowlesi.

Conclusion

ACT is at least equivalent to chloroquine in effectively treating non-falciparum malaria. These findings may facilitate development of simplified protocols for treating all forms of malaria with ACT, including returning travellers. Obtaining comprehensive efficacy and safety data on ACT use for non-falciparum species particularly for P. ovale, P. malariae and P. knowlesi should be a research priority.

Trial registration

CRD42014009103

Electronic supplementary material

The online version of this article (doi:10.1186/1475-2875-13-463) contains supplementary material, which is available to authorized users.

Measles associated with international travel in the region of the Americas, Australia and Europe, 2001-2013: a systematic review

BACKGROUND

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.

METHOD

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.

RESULTS

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.

CONCLUSIONS

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.

[Protozoa and protozoan infections of humans in Central Europe]

This article is a condensed review of the medically relevant protozoa in Central Europe and the infections and diseases caused by them. Information is given on modes and sources of infection, organs involved in the disease, prevalence, diagnostics, therapy, and prophylaxis. Moreover, travel-associated infections with protozoa are briefly outlined.