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PubMed2005

Neurologic aspects of infections in international travelers.

BACKGROUND: As international travel for business and pleasure becomes part of contemporary lifestyle, the clinician today is confronted with an increasing number of travelers returning ill with unfamiliar syndromes. The physician will encounter a myriad of patients with exotic infections, emerging infectious diseases, or resurgent Old-World infections. REVIEW SUMMARY: This review article will discuss salient points of important infectious diseases associated with overseas travel, provide a syndromic approach to the traveler who returns with neurologic manifestations, and list resources for additional diagnostic, therapeutic, and preventive information. CONCLUSIONS: As many of infections acquired in other countries can directly or indirectly affect the nervous system, the care of the ill traveler often falls into the hands of neurologists. The contemporary neurologist should therefore be knowledgeable of the clinical manifestations, potential complications, and appropriate management of region-specific infections.

Central Nervous System Infections↗
PubMed1995

Association of Aeromonas spp. with travellers' diarrhoea in Finland.

The association of Aeromonas spp. with travellers' diarrhoea was studied among 978 Finnish tourists travelling to Morocco in winter (n = 398) and autumn (n = 580) in 1989. Fifty-five isolates from diarrhoeal patients with (n = 16) or without (n = 39) a recent travelling history in a developing country were also included. In Morocco, Aeromonas spp. were isolated from 8.7% of patients with diarrhoea and from 1.4% of non-diarrhoeal tourists (p < 0.001). Aeromonas spp. were found as the sole pathogen in 5.5% of patients (p < 0.001). Diarrhoea with multiple pathogens, including Aeromonas spp., was found in 3.1% of patients. Species identification by phenotypic and genotypic methods indicated that A. veronii biotype sobria (hybridisation group HG 8/10) and A. caviae (HG 4) were the most common Aeromonas spp. associated with travellers' diarrhoea. A. hydrophila (HG 1) and A. caviae (HG 4) were common in patients acquiring diarrhoea in Finland. Ribotyping of strains within a species showed that all strains had different ribotypes although the tourists were infected during the same trip. This study suggested that only certain Aeromonas spp. were commonly found in travellers' diarrhoea. However, the causative role of those species is unclear.

Aeromonas↗
PubMed1996

Provision of health information by British travel agents.

A study to assess the frequency of health related advice provided by travel consultants to customers planning to travel to the tropics was undertaken. A total of 202 agencies throughout the UK were visited by covert researchers requesting a package holiday for 2 weeks to Kenya or a flight to India. In a face to face consultation, the researchers recorded any health related information provided. If none were forthcoming, the agent was prompted using a standardized prompt. Thirty per cent of the agencies were based in South-east England and London and the remainder in the North, the Midlands and the South-west. No spontaneous health warnings were given in 61% (123) of consultations for malarious destinations. After prompting, 71% of agents gave general health advice, 67% suggested seeking malaria advice from a general practitioner and 37% of agents brought up the need for malaria prophylaxis for the journey. 63% of consultations included a mention of malaria after being prompted. The study reveals that travel agents provide health advice inconsistently and mention health risks only when prompted. For travellers' safety and to meet new consumer regulations, the travel industry needs to draw attention to health risks associated with its products consistently and effectively.

Consumer Advocacy↗
PubMedDate not supplied

Fever in a returned traveller.

An 8-year-old boy, presenting with fever after returning from a visit to Papua New Guinea, was found to have typhoid, despite immunization against this disease prior to travel. This most likely represented vaccine failure, although it is also possible that he acquired the infection from overseas visitors who had stayed with his family prior to his travel, or that he contracted the disease from his father. This case highlights the importance of considering typhoid as a cause of fever in a returned traveller, even if they have been previously immunized against this disease. It also highlights that, in addition to taking the patient's travel history, information should be specifically sought about contact with visitors from overseas and the travel history of other household members.

Anti-Bacterial Agents↗
PubMed2006

Recent air travel and venous thromboembolism resulting in hospital admission.

OBJECTIVE: The objective of the study was to determine the proportion of patients admitted to hospital with a deep vein thrombosis (DVT) or pulmonary embolism (PE) in whom recent air travel was documented in the medical records. METHODS: A retrospective review of the medical records of patients with a primary or secondary discharge diagnosis of DVT or PE in four hospitals in New Zealand was undertaken. From the medical records information was collected on demographic details, documentation of the presence of risk factors and results of radiological investigations. Strict radiological criteria were applied to ensure that the diagnosis of DVT or PE was firmly established. RESULTS: In 60 of 576 (10.4%) patients with a confirmed venous thromboembolism there was documentation of recent air travel; in 31 of these 60 subjects no other risk factors were recorded. In those cases in whom details of the air travel had been recorded, it had been undertaken in the previous 1 week in 65.0%, and in 43.3% the air travel was of at least 10-h duration. CONCLUSION: Long distance air travel is an important risk factor for venous thromboembolism requiring hospital admission and represents a significant public health problem in New Zealand.

Adult↗
PubMed2006

Epidemiological and clinical features of travel-associated cryptosporidiosis.

Data concerning the clinical and epidemiological features of travel-associated cryptosporidiosis are lacking. In order to investigate the impact of this disease on travellers' health, a retrospective study was conducted at the Institute of Tropical Medicine, Berlin. In total, 57 cryptosporidial infections were identified between 2000 and 2004, resulting in a prevalence of 2.9% in patients with travel-associated diarrhoea. Travel to south-central Asia, especially India, was associated with a higher prevalence of infection than was travel to other destinations. Clinically, the disease resembled giardiasis, but fever and arthralgias seemed to occur more frequently.

Animals↗
PubMed2003

Post-traveler's diarrhea irritable bowel syndrome: a prospective study.

OBJECTIVE: Anecdotal evidence suggests that irritable bowel syndrome (IBS) can develop after an episode of traveler's diarrhea (TD). This observation supports a contemporary paradigm proposed for the etiology of IBS and may have important implications for public health strategies aimed at preventing TD. This study aimed to determine the incidence of IBS in people experiencing TD. METHODS: A total of 109 healthy adults traveling outside of Canada or the United States were identified and enrolled in a prospective, cohort field study. GI symptoms before and after travel were assessed using the Rome I criteria. Travel diaries and questionnaires were used to assess for TD. RESULTS: The incidence of TD in the study cohort was 44%. Among those experiencing TD, the incidence of IBS was 4.2%. In those not experiencing TD, the incidence of IBS post-travel was 1.6% (relative risk = 2.5, 95% CI = 0.2-27.2, p = 0.41, ns). There was no significant difference in the incidence of IBS between the exposed and nonexposed groups. CONCLUSIONS: This study does not support a large association between TD and an increased risk of developing IBS. A small increase in relative risk may have been undetected because of the size of the study.

Adult↗
PubMed1998

Campylobacter jejuni as a cause of traveler's diarrhea: clinical features and antimicrobial susceptibility.

Traveler's diarrhea is the most common health problem of international travelers. Although enterotoxigenic Escherichia coli seems to be the most frequent cause of traveler's diarrhea, many other microorganisms, such as Campylobacter jejuni, may cause this infectious disease. Campylobacter jejuni is recognized as a leading cause of enteritis in humans both in developing and in developed countries. However, a few reports on the incidence and antimicrobial resistance of Campylobacter spp. as a cause of traveler's diarrhea have been published. The limited data on the treatment of C. jejuni infections suggest that ciprofloxacin may shorten the duration of symptoms. However, treatment failure associated with the emergence of quinolone-resistant strains of C. jejuni has been documented. The purpose of this study was to determine the prevalence of C. jejuni associated with traveler's diarrhea and to analyze the geographic distribution as well as the clinical features and susceptibility to antibiotics.

Anti-Bacterial Agents↗
PubMed1999

Pretravel advice neglects rabies risk for travelers to tropical countries.

BACKGROUND: While the risk of acquiring rabies in Europe is low, there have been a number of reports on cases of human rabies "imported" from abroad in recent years. Few studies have been conducted concerning pretravel advice for international travelers about the risk of rabies. METHODS: One-hundred and fifty German and 150 Swiss general practitioners (GPs) who give pretravel advice were interviewed to assess their awareness of the risk of rabies for travelers, and of the relevant preventive measures, using a pretested telephone interview followed by a written questionnaire with a multiple choice list. GPs were asked specifically about pretravel health advice for journeys to Thailand and Kenya. RESULTS: During the telephone interview a majority (76%) of the 300 GPs recommended "nothing" as a preventive measure against rabies for travelers. One or two important preventive measures were mentioned by only a few GPs. No major differences were detected between the German and the Swiss groups concerning their recommendations for rabies prevention. The 119 German and 121 Swiss GPs who returned the completed questionnaire said they would recommend the three important preventive measures in the future significantly more often than they had recommended them to their clients in the past. CONCLUSIONS: The risk of rabies in travelers to tropical countries appears to be neglected in pretravel advice provided by Swiss and German GPs. The recommendations on travel advice published in the Swiss Bulletin of the Federal Office of Public Health (BFOPH) and in the "Deutsches Arzteblatt" should be extended to "other specific health risks." In Switzerland this has now been done.

Attitude of Health Personnel↗
PubMedDate not supplied

Infectious mononucleosis-like syndromes in febrile travelers returning from the tropics.

Infectious mononucleosis (IM), resulting from Epstein-Barr virus (EBV) infection, and IM-like syndromes, mainly due to cytomegalovirus (CMV), Toxoplasma gondii, or human immunodeficiency virus (HIV), have been occasionally reported in travelers returning from the tropics. Our objective was to investigate the prevalence, outcome, and diagnostic predictors of these syndromes in febrile travelers. Between April 2000 and March 2005, all febrile travelers and migrants presenting at our referral centers within 12 months after a tropical stay were prospectively included. We identified all patients serologically diagnosed with IM or IM-like syndrome and compared them with the rest of the cohort. During the 5-year period, 72/1,842 patients (4%) were diagnosed with an IM-like syndrome, including 36 CMV, 16 T gondii, 15 EBV, and 5 HIV primary infections. All patients were western travelers or expatriates. Mean delay before consultation was 2 weeks. Most patients had consulted other practitioners and/or received presumptive treatment. A minority of patients presented with IM clinical features. Lymphocytosis > or =40% of the white blood cells (WBC) and reactive/atypical lymphocyte morphology were observed in 60 and 30% of the patients. The four diseases were indistinguishable. Protracted fever and asthenia were common but complications rarely occurred. IM-like syndromes were independently associated with fever >7 days, lymphadenopathy, elevated liver enzymes, and lymphocytosis > or =40% of WBC. Diagnostic probability increased to >20% if at least three of these predictors were present. Diagnosis of IM and IM-like syndrome is not uncommon in febrile travelers, with a higher proportion of primary CMV, T gondii, and HIV infections than in nonimported series. Consequently, classic IM clinical and laboratory features are often lacking. All four pathogens should be systematically considered because early diagnosis should avoid unnecessary investigations and treatment and allow early intervention in case of primary HIV infection.

Adult↗
PubMed2006

Prevention and self-treatment of traveler's diarrhea.

Of the millions who travel from the industrialized world to developing countries every year, between 20% and 50% will develop at least one episode of diarrhea, making it the most common medical ailment afflicting travelers. Although usually a mild illness, traveler's diarrhea can result in significant morbidity and hardship overseas. Precautions can be taken to minimize the risk of developing traveler's diarrhea, either through avoidance of potentially contaminated food or drink or through various prophylactic measures, including both nonpharmacological and antimicrobial strategies. If diarrhea does develop despite the precautions taken, effective treatment-usually a combination of an antibiotic and an antimotility agent-can be brought by the traveler and initiated as soon as symptoms develop. In the future, vaccines-several of which are in the advanced stages of clinical testing-may be added to the list of prophylactic measures.

Anti-Infective Agents↗
PubMed2006

Association of putative enteroaggregative Escherichia coli virulence genes and biofilm production in isolates from travelers to developing countries.

Enteroaggregative Escherichia coli (EAEC) is an emerging enteric pathogen that causes acute and chronic diarrhea among children, human immunodeficiency virus-infected patients, and travelers to developing regions of the world. The pathogenesis of EAEC strains involves the production of biofilm. In this study, we determined the association between presence of putative EAEC virulence genes and biofilm formation in 57 EAEC isolates (as defined by HEp-2 adherence) from travelers with diarrhea and in 18 EAEC isolates from travelers without diarrhea. Twelve nondiarrheagenic E. coli isolates from healthy travelers were used as controls. Biofilm formation was measured by using a microtiter plate assay with the crystal violet staining method, and the presence of the putative EAEC virulence genes aap, aatA, aggR, astA, irp2, pet, set1A, and shf was determined by PCR. EAEC isolates were more likely to produce biofilm than nondiarrheagenic E. coli isolates (P = 0.027), and the production of biofilm was associated with the virulence genes aggR, set1A, aatA, and irp2, which were found in 16 (40%), 17 (43%), 10 (25%), and 27 (68%) of the biofilm producers versus only 4 (11%), 6 (6%), 2 (6%), and 15 (43%) in non-biofilm producers (P = 0.008 for aggR, P = 0.0004 for set1A, P = 0.029 for aatA, and P = 0.04 for irp2). Although the proportion of EAEC isolates producing biofilm in patients with diarrhea (51%) was similar to that in patients without diarrhea (61%), biofilm production was related to the carriage of aggR (P = 0.015), set1A (P = 0.001), and aatA (P = 0.025). Since aggR is a master regulator of EAEC, the presence of aap (P = 0.004), astA (P = 0.001), irp2 (P = 0.0006), pet (P = 0.002), and set1A (P = 0.014) in an aggR versus an aggR-lacking background was investigated and was also found to be associated with biofilm production. This study suggests that biofilm formation is a common phenomenon among EAEC isolates derived from travelers with or without diarrhea and that multiple genes associated with biofilm formation are regulated by aggR.

Biofilms↗
PubMed1986

Malaria prophylaxis: survey of the response of British travellers to prophylactic advice.

A cohort study was conducted to determine the compliance of travellers with chemoprophylactic advice given over the telephone by the malaria reference advisory service. Travellers who visited their general practitioner first for advice about malaria prophylaxis were often advised to consult a specialist service themselves. Compliance fell in travellers who were given complicated information and those who received conflicting advice when they contacted other advisory services. After returning to Britain 48% of the travellers reported that they were fully compliant with prophylactic advice; over a third of the travellers studied did not maintain prophylaxis on their return.

Humans↗
PubMed1997

Influence of changing travel patterns on child death rates from injury: trend analysis.

OBJECTIVES: To examine trends in child mortality from unintentional injury between 1985 and 1992 and to find how changes in modes of travel contributed to these trends. DESIGN: Poisson regression modelling using data from death certificates, censuses, and national travel surveys. SETTING: England and Wales. SUBJECTS: Resident children aged 0-14. MAIN OUTCOME MEASURES: Deaths from unintentional injury and poisoning. RESULTS: Child deaths from injury declined by 34% (95% confidence interval 28% to 40%) per 100,000 population between 1985 and 1992. Substantial decreases in each of the leading causes of death from injury contributed to this overall decline. On average, children walked and cycled less distance and travelled substantially more miles by car in 1992 compared with 1985. Deaths from road traffic accidents declined for pedestrians by 24% per mile walked and for cyclists by 20% per mile cycled, substantially less than the declines per 100,000 population of 37% and 38% respectively. In contrast, deaths of occupants of motor vehicles declined by 42% per mile travelled by car compared with a 21% decline per 100,000 population. CONCLUSIONS: If trends in child mortality from injury continue the government's target to reduce the rate by 33% by the year 2005 will be achieved. A substantial proportion of the decline in pedestrian traffic and pedal cycling deaths, however, seems to have been achieved at the expense of children's walking and cycling activities. Changes in travel patterns may exact a considerable price in terms of future health problems.

Accidents, Traffic↗
PubMed2000

Screening travelers for hepatitis A antibodies: an observational cost-comparison study of vaccine use.

OBJECTIVES: To measure the seroprevalence of antibodies to hepatitis A virus (anti-HAV) in a health plan population of travelers and to determine whether prevaccination screening for anti-HAV can reduce unnecessary vaccination and thus promote the most effective, economic use of hepatitis A vaccine. DESIGN: Observational, cost-comparison study. SETTING: Central injection clinic of a health maintenance organization medical center. SUBJECTS: Five hundred twenty-seven adults who denied having previous hepatitis A or vaccination. MAIN OUTCOME MEASURES Subgroups with the greatest prevalence of anti-HAV seen between June 1995 and April 1996 for immunizations before traveling to nonindustrialized countries. Relative costs of their screening and immunization. RESULTS: The presence of anti-HAV precluded the need for vaccination in 148 subjects (28.1%). The highest prevalence of anti-HAV (82.7%) was found in subjects born in nonindustrialized countries (62/75), in subjects who had previously traveled to areas of endemic hepatitis A (32.1% [135/420]), and in subjects born before 1945 (29.2% [92/315]). Costs of screening and vaccinating travelers were cheapest if prevaccination antibody sera testing was limited to subjects born in nonindustrialized countries and those born before 1945. CONCLUSIONS: Prevaccination screening of travelers for hepatitis A can be done selectively on the basis of age and country of origin. This strategy could lead to a more economic use of the vaccine and clinic resources.

Adolescent↗
PubMed1995

Epidemiology of traveler's diarrhea.

Annually, over 75 million international passengers travel to tropical areas, more than 20 million of whom come from industrialized countries. They experience a high rate of traveler's diarrhea (TD), varying from 20 to 56%, which may result in serious limitations to their activities. The cause of TD is considered to be infectious in the overwhelming majority of cases and, apart from differences in relative importance, the list of responsible microbial agents is fairly constant regardless of geographic origin. The ingestion of contaminated food or water is considered to be the principal mode of transmission of the enteric pathogens of TD. Several factors have been proposed as playing a role in the etiogenesis of diarrhea in travelers, including personal (age, socioeconomic status, body weight, preexisting gastrointestinal illnesses), behavioral (mode of travel, standard of accommodation, eating in public places, dietary errors) and travel-related (destination, duration of stay, country of origin, season) factors, which are reviewed in detail.

Animals↗
PubMed1995

Correlation of travel time on roads versus straight line distance.

Studies of hospital demand and choice of hospital have used straight line distance from a patient's home to hospitals as a measure of geographic access, but there is the potential for bias if straight line distance does not accurately reflect travel time. Travel times for unimpeded travel between major intersections in upstate New York were compared with distances between these points. The correlation between distance and travel time was 0.987 for all observations and 0.826 for distances less than 15 miles. These very high correlations indicate that straight line distance is a reasonable proxy for travel time in most hospital demand or choice models, especially those with large numbers of hospitals. The authors' outlier analyses show some exceptions, however, so this relationship may not hold for studies focusing on specific hospitals, very small numbers of hospitals, or studies in dense urban areas with high congestion and reliance on surface streets.

Catchment Area, Health↗
PubMed2004

Emergence of new Salmonella Enteritidis phage types in Europe? Surveillance of infections in returning travellers.

BACKGROUND: Among human Salmonella Enteritidis infections, phage type 4 has been the dominant phage type in most countries in Western Europe during the last years. This is reflected in Salmonella infections among Swedish travellers returning from abroad. However, there are differences in phage type distribution between the countries, and this has also changed over time. METHODS: We used data from the Swedish infectious disease register and the national reference laboratory to describe phage type distribution of Salmonella Enteritidis infections in Swedish travellers from 1997 to 2002, and have compared this with national studies conducted in the countries visited. RESULTS: Infections among Swedish travellers correlate well with national studies conducted in the countries visited. In 2001 a change in phage type distribution in S. Enteritidis infections among Swedish travellers returning from some countries in southern Europe was observed, and a previously rare phage type (PT 14b) became one of the most commonly diagnosed that year, continuing into 2002 and 2003. CONCLUSIONS: Surveillance of infections among returning travellers can be helpful in detecting emerging infections and outbreaks in tourist destinations. The information needs to be communicated rapidly to all affected countries in order to expedite the implementation of appropriate investigations and preventive measures.

Bacteriophage Typing↗