Travel Medicine and Infectious Disease

Editorial board

2010-01-01

Avian influenza – A review for doctors in travel medicine

2009-12-02

Summary: First identified in humans in Hong Kong, influenza A/H5N1, known commonly as avian influenza, has caused human disease in 15 countries around the world. Although the current number of confirmed patients is tiny compared to seasonal and the recently emerged H1N1 ‘swine’ influenza, H5N1 remains a candidate for the next highly pathogenic influenza pandemic. Currently, H5N1 has very limited ability to spread from person-to-person but this may change because of mutation or reassortment with other influenza viruses leading to an influenza pandemic with high mortality. If this occurs travellers are likely to be affected and travel medicine doctors will need to consider avian influenza in returning febrile travellers. The early clinical features may be dismissed easily as ‘the flu’ resulting in delayed treatment. Treatment options are limited. Oral oseltamivir alone has been the most commonly used drug but mortality remains substantial, up to 80% in Indonesia. Intravenous peramivir has been filed for registration and IV zanamivir is being developed. This review will focus on the epidemiological and clinical features of influenza A/H5N1 avian influenza and will highlight aspects relevant to travel medicine doctors.

Malaria prevention behaviour and risk awareness in French adult travellers

2009-11-27

Summary: Travellers from Europe to tropical areas risk acquiring malaria against which they have no immunity. The objective of this study was to assess malaria protection measures in European travellers as a function of the risk of infection with malaria.This questionnaire-based, retrospective study evaluated 13,017 French adults. 3066 travellers to malaria-endemic countries were identified and data collected on duration and purpose of stay, knowledge of malaria, use of mechanical protection measures and chemoprophylaxis.Complete data on protection measures were available for 2225 travellers to malaria risk countries. Mechanical protection was used by 1735/2225 of travellers (94.9% of travellers to high-risk areas and 80.4% of travellers to low-risk areas). Appropriate chemoprophylaxis use rates were 47.6% for high-risk areas versus 9.5% for low-risk areas. Chemoprophylaxis compliance was low, even in the case of travellers to high risk areas (18.2%). Many travellers (38%) were unaware that malaria was potentially fatal. The only variables significantly associated with compliant use of appropriate chemoprophylaxis were awareness that malaria was serious (odds-ratio: 2.03; p=0.033) and receiving malaria information from a physician (odds-ratio: 3.01; p=0.042).Use of malaria chemoprophylaxis is very inadequate. Education campaigns are needed to improve the use of chemoprophylaxis and thus minimise the risk of acquiring malaria.

Cough and dyspnoea of an asthmatic patient at Mt. Kilimanjaro: A difficult differential diagnosis

K. Goebbels, U. Gieseler, Volker Schöffl, Thomas Küpper — 2009-12-14

Summary: This case highlights the difficulties associated with the differential diagnosis of pulmonary symptoms in patients with pre-existing diseases in extreme environmental conditions. A 58-year-old man with child-onset allergic asthma developed dyspnoea and an acute non-productive cough during a trekking expedition on Mt. Kilimanjaro (5895m) in Tanzania. The symptoms were believed initially to be linked to the high altitude exposure (high altitude pulmonary oedema (HAPE) or high altitude cough) or his pre-existing asthma. However, he was later diagnosed correctly with a reinfection of Bordetella pertussis. Pertussis is a highly communicable disease with potentially serious medical consequences that could have affected all of the expedition members. The effectiveness of a pertussis vaccine declines 4–12 years after the vaccination. Thus, it is suggested that the status of immunisation against pertussis should be checked along with those of other infections prior to travel.

Tungiasis – A cause of painful feet in a tropical traveller

M.J.M.L. Hakeem, Allen K. Morris, D.N. Bhattacharyya, Christopher Fox — 2009-11-20

Summary: Tungiasis is an ectoparasitosis caused by the impregnated female sand flea Tunga penetrans. It is endemic in certain resource poor areas around the world and imported infestations in travellers can lead to considerable morbidity. With the rise in international travel and immigration, the likelihood of physicians encountering such tropical skin infestations is rising. The ability of physicians to recognise tungiasis early will be immensely beneficial to patients. We describe a case of tungiasis where a traveller presented with painful foot lesions. The patient had returned to the United Kingdom 4 days previously after spending 4 weeks in the Pantanal region in Brazil. A literature review on this subject was undertaken in this article.

Leptospirosis: An emerging disease in travellers

Colleen Lau, Lee Smythe, Philip Weinstein — 2010-01-06

Summary: A recent upsurge in leptospirosis in travellers has prompted the following review of the epidemiology of this infection in humans. The available data from the published literature as well as laboratory surveillance were examined to determine the possible causes of the apparent change in epidemiology.

Gideon database

Stephen Toovey — 2009-12-25

Available at www.gideononline.com. Last accessed 5th November 2009. It is not up for debate whether travel medicine practitioners should have access to a travel health database. What is up for discussion though, is ‘which one’? The answer to this will obviously depend upon one's needs, but there is no doubt that travel medicine practitioners, infectious disease physicians and microbiologists in need of a serious database will have to consider Gideon.

Diseases and injuries associated with travel among students, employees and teachers of the Central University of Venezuela during the national summer vacations

2009-11-23

Summary: The objective of this study was to describe the incidence of disease and injuries associated with travel, etiology, risk factors and medical management in a cross-sectional evaluation of university students, employees and teachers of the Central University of Venezuela, Caracas, Venezuela, who returned from domestic travel. A questionnaire completed by 500 individuals was used to evaluate the incidence of disease and injuries associated with travel, the etiology, risk factors and medical management in university students, employees and teachers of Caracas, Venezuela. From the total who accepted and responded to the interview (460, 92%), 50.8% were females. Almost half of them had some vaccination before travel for: measles 78%, rubella 73.6%, hepatitis B 57%, Yellow fever 53.7%. After travel, 53.9% of the individuals reported disease or injury related with travel, including insect bites (22%), which was reported most commonly. Occurrence of disease and injuries was higher for those who traveled to the jungle (OR=5.23, 95% CI 0.62–43.80), followed by those who travel to two areas (OR=1.82, 95% CI 1.06–3.13). Drinking alcohol during travel was identified in 73.8%, was significantly higher in men (p<0.01), and was associated with car accidents. Finally, 14.8% required medical attention during travel. The results indicated the importance of education and training in travel medicine, a relatively new medical discipline in Venezuela. Venezuela has a significant number of people visiting areas at risk for the acquisition of tropical and non-tropical conditions. Occasionally, travelers were without adequate preventive measures and pre-travel advice which is considered of utmost importance.

Quadrivalent meningococcal vaccines: Hyporesponsiveness as an important consideration when choosing between the use of conjugate vaccine or polysaccharide vaccine

Michael Bröker, Keith Veitch — 2010-01-11

Summary: Regional variations in the incidence and the distribution of serogroups which are responsible of meningococcal disease necessitate multivalent vaccines to ensure broad coverage for travelers. For almost 30years, this has been provided by quadrivalent polysaccharide vaccine to protect against serogroups A, C, W-135 and Y, but with the advent of quadrivalent conjugate vaccines is there still a case to use the polysaccharide? The well documented hyporesponsiveness induced by polysaccharide vaccines after repeated administration, most clearly observed against serogroup C, suggest that, where available, conjugate vaccines should always be considered ahead of polysaccharide vaccine.

Attitude and practice of medical students studying in Hungary and India toward health during overseas and domestic travel

2010-01-14

Summary: Background: It is presumed that medical students are travelers who can take care of their health, and thus the present study was conducted to elicit the attitude and practice [AP] of medical students from two different countries toward travel health issues.Objectives: To elicit the attitude and practice of medical students from two different countries toward travel health issues and identify the reasons for any variations.Material and methods: An anonymous pre-tested structured questionnaire consisting of socio-demographic details, travel aspects, travel health issues, and precautions [medicines carried, vaccination history, and pre-travel consultation] adopted was distributed to 250 foreign medical students studying at the University of Debrecen, Hungary [Group I] and another 250 native medical students in India [Group II]. Data were analyzed by simple descriptive statistics and Student t-test.Results: A total of 428 students responded among total eligible population of 500; 228 [90.2%] in group I and 200 [80%] in group II. In 2008, 188 [82%] of the former and 33 [16.5%] of the latter groups traveled to international destinations. Among groups I and II, health problems were experienced by 73 [32%] and 65 [32.5%] students, respectively. During hospitalization, students of group I were admitted for one of the following illnesses such as severe asthma, dehydration, malaria, and tibial fracture, while two other students were admitted to the hospital with deep vein thrombosis [DVT]. During travel, the category of medicines carried by students belonging to group I/II were anti-diarrhoeal [75/19], anti-emetics [53/39], anti-giddiness [49/7], anti-histamines [55/12], anti-pyretics plus analgesics [197/70], anti-spasmodics [55/11], antibiotics [33/10], vitamin pills [84/0], and laxatives [47/6]; supportive items such as adhesive plaster [64/3], and thermometer [37/1]; personal protective materials viz., mineral water [165/88], hygienic food [100/132], insect repellents [86/14], special clothes such as full sleeves and cap [150/0], sun screen [160/14], and items against sexually transmitted diseases [159/0]; health documents such as medical insurance card [161/3], previous health records [40/0], immuno-prophylaxis [127/0], family physician's phone number [43/9] and pre-travel advice [57/2].Comments: Students studying in Hungary were better informed about travel-related issues than native students from Indian medical colleges. The probable reasons for such variations were cultural differences, variation in their pre-medical curricula and teaching, frequent travel, a previous university degree, military training, maturity, and staying away from parents. The overall attitude and practice of medical students toward travel health issues were sub-optimal, since the subjects taught did not focus much on travel and health-related issues. Hence, there is an urgent need to initiate standardized teaching in the field of travel medicine for the students of health sciences for the benefit of the community.

Trends in the publication of scientific research in travel medicine from Latin America

Derek R. Smith, Peter A. Leggat — 2009-08-25

We read with interest the recent Letter by Rodriguez-Morales and Palacios describing trends in the publication of scientific research in travel medicine from Latin America. In their Letter, the authors point out that travel medicine has emerged as an important scientific discipline in many parts of the world, including very recently, in Latin America.

Summaries

Michael John Glyn Thomas — 2010-02-18

Norovirus outbreaks (NVOs) are the curse of the cruise industry and many lines make major efforts to prevent them. My personal experience varies at one level from one line where you have to cleanse your hands every time you enter a food area or board the ship after being ashore to another line on which we recently travelled where there were no precautions whatsoever. Carling et al. covertly sent trained health care professionals on 56 cruise ships (approximately 30% of 180 vessels operated by 9 large cruise lines) during the period July 2005 through August 2008. They were tasked to evaluate the thoroughness of disinfection cleaning (TDC) of 6 places in the public lavatories where there was a high potential for faecal contamination. These were the toilet seat, flush handle or button, toilet stall inner handhold, stall inner door handle, lavatory inner door handle, and baby changing table surfaces and they used a previously validated novel targeting method. On average only 37% (Range 4–100%; 95% confidence interval, 29.2–45.4%) were cleaned on a daily basis. There were no major differences between any of the lines but those performing worst were substantially more likely to suffer a NVO within the next 4 months. Over half the vessels had a TDC <30%) They suggest that improving TDC cleaning of public lavatories on cruise ships would have a major impact on reducing NVOs. (Carling PC, Bruno-Murtha LA, Griffiths JK. Cruise Ship Environmental Hygiene and the Risk of Norovirus Infection Outbreaks: An Objective Assessment of 56 Vessels over 3 Years. Clin Infect Dis 2009;49:1312–7, doi:10.1086/606058)

Lecture notes on tropical medicine

Peter A. Leggat — 2009-10-12

Much of the world's population remains at risk of tropical diseases and millions die each year. For those undertaking tropical medicine courses or travelling to developing countries, Lecture Notes on Tropical Medicine is likely to be one of the first choices for a ready reference textbook. This Sixth Edition of the Lecture Notes on Tropical Medicine contains a table of Contents, a list of 21 Contributors, a Preface, a comprehensive List of Abbreviations, New Drug Names, three Parts, 61 chapters, an Index and an abundant use of tables and figures. There is no foreword, bibliography or glossary, although it may be useful for a book of this maturity to incorporate a foreword by an eminent tropical medicine specialist.

Update in Infectious Diseases

Peter A. Leggat — 2009-10-12

In the context of human history, the global conquest of infectious and parasitic diseases has only just begun. Much of the world's population remains at risk of these diseases and millions die each year. Health professionals, who find themselves on the front line of the fight against infectious and parasitic diseases, need ready access to reliable updates. Preferably, these updates should be published on a regional basis, particularly for those working in travel medicine. The first edition of Update in Infectious Diseases is one example of a new era of e-Textbooks designed to help meet this challenge. This first edition of Update in Infectious Diseases contains a Foreword and a Preface by the series editor, a list of Contributors, 12 chapters, and a scant Index. There is no Table of Contents, acknowledgements, list of abbreviations, bibliography or glossary. Infectious Diseases is presented as one of a series of downloadable A4 eBooks in colour and this volume has an attractive cover. The stated primary target audience is the broader health care workforce, especially those with an interest in infectious and parasitic diseases, but it may be attractive to those involved in travel and migrant medicine, as there is a country focus on infectious disease hazards found in Thailand.