Health Problems During and After Travel: A Prospective Observational Study in a Travel Clinic in Portugal.

INTRODUCTION: In order to improve the health of travellers during travel it is important to better understand the health problems faced by travellers in different destinations. The main objective of this study was to characterise the perceived health problems of travellers during and up to six months after travel on a pre-travel clinic in Lisbon, Portugal. MATERIAL AND METHODS: This is a prospective observational study. Participants were recruited among those travellers attending a pretravel clinic between May 2016 and April 2017, meeting the inclusion criteria (age over 18 years old and predicted time of stay from five to 90 days). Structured questionnaires were applied by telephone interviews, three and six months after arrival. Associations and their magnitude were sought between travel and traveller's characteristics with total and specific health problems, using multiple logistic regression models. RESULTS: Out of 364 participants who completed the study, 60% were under 37 years of age, and 87.9% presented a higher educationaldegree. Africa and Asia were travel destinations for 89.1% of travellers. Three months after travel, 39.3% confirmed some travel-acquired health problem, namely diarrhoea (26.6%) and unmeasured fever (12.4%). A malaria case was diagnosed, occurring 3.5 months after return. From a total of 189 travellers to countries with high risk of malaria and chemoprophylaxis recommendation, 65.6% adhered completely and 6.9% of those presenting fever during travel sought healthcare. DISCUSSION: The proportion of travellers that became ill was lower compared to other published studies. Failure to follow a randomsampling method and the characteristics of the travel consultation with a particular profile of travellers in terms of level of education and ability to pay, challenges the external validity of the study. CONCLUSION: Health problems during or after travel occurred in 39.3% of travellers with diarrhoeal disease being the most common (26.6%). From our findings, the need for taking chemoprophylaxis for malaria or seeking health care in the presence of fever is not translated into appropriate action. The reasons are unclear and should be the subject of further research. Furthermore, research is needed with inclusion of other centres practicing travel medicine in Portugal, both in the pre-travel setting and others, in order to better understand the health risks associated with Portuguese traveller's characteristics and destinations.

Introdução: De forma a melhorar a saúde dos viajantes é necessário compreender os principais problemas de saúde enfrentados em diferentes destinos. O principal objetivo deste estudo foi caracterizar os problemas de saúde relatados por pessoas que recorreram a uma consulta do viajante em Lisboa durante e até seis meses após a viagem. Material e Métodos: Este é um estudo observacional e prospetivo. Os participantes foram recrutados entre os viajantes que compareceram na consulta entre maio de 2016 e abril de 2017, de acordo com os critérios de inclusão (idade igual ou superior a 18 anos e o tempo previsto de permanência em viagem de cinco a 90 dias). Os questionários estruturados foram aplicados por entrevistas telefónicas, três e seis meses após a chegada. Usando vários modelos de regressão logística, foram procuradas associações entre as características das viagens e dos viajantes com os problemas de saúde totais e específicos, e determinada a sua relevância. Resultados: Dos 364 participantes que completaram o estudo, 60% tinham menos de 37 anos de idade e 87,9% tinham um curso superior. As regiões de África e da Ásia foram os destinos de viagem para 89,1% dos viajantes. Três meses após a viagem, 39,3% dos viajantes relataram algum problema de saúde nomeadamente diarreia (26,6%) e febre (12,4%). Foi diagnosticado um caso de malária 3,5 meses após o regresso. Num total de 189 viajantes para regiões com indicação para quimioprofilaxia de malária, 65,6% tiveram uma adesão completa e 6,9% procuraram cuidados de saúde, no caso de febre durante a viagem. Discussão: A proporção de viajantes que adoeceu foi menor do que noutros estudos publicados. O não cumprimento de um método de amostragem aleatória e as características desta consulta de viajante, que apresenta um perfil específico de viajantes em termos de nível de escolaridade e capacidade de pagamento, colocam em causa a validade externa do estudo. Conclusão: Os problemas de saúde, durante ou após a viagem, ocorreram em 39,3% dos viajantes, sendo que a diarreia é o problema mais frequente (26,6%). A não adesão a recomendações carece de melhor caracterização. É necessário realizar este tipo de estudo em viajantes que não vão a consultas de aconselhamento antes da viagem e noutros centros de medicina do viajante, de forma a melhor caracterizar os riscos de doença associados a diferentes características e destinos dos viajantes portugueses.

Angola's 2013 dengue outbreak: clinical, laboratory and molecular analyses of cases from four Portuguese institutions.

INTRODUCTION: Dengue virus (DENV) is the arbovirus with the widest impact on human health. In Africa in general, and in Angola in particular, the epidemiology and public health impact of DENV is far from clear. However, rapid population growth, unplanned urbanization, increased international travel, and the presence of virus major vector (Aedes aegypti) in the country suggest that DENV transmission may occur. METHODOLOGY: In parallel to the occurrence of a dengue outbreak affecting the capital of Angola, between March and July 2013 four Portuguese institutions diagnosed dengue infection in 146 individuals returning to Portugal. Clinical presentation, laboratory findings, and molecular analyses of partial viral genomic segments were performed. RESULTS: The mean age of the individuals included in this study was 42 years old, the majority being men of Portuguese nationality, reporting various lengths of stay in Angola. Fever was the most reported clinical sign, being frequently associated (61.0%) with myalgia and headache. Hematological values, including hematocrit, white-blood cell and platelets counts, correlated with the absence of severe or complicated cases, or coagulation disorders. No deaths were observed. Viral NS1 was detected in 56.2% of the samples, and all NS1 negative cases had anti-dengue IgM antibodies. RT-PCR indicated the presence of DENV1, which was confirmed by phylogenetic analysis of 25 partial NS5 viral sequences. CONCLUSION: The DENV cases analyzed conformed to classical and uncomplicated dengue, caused by the suggested exclusive circulation of a genetically homogeneous DENV1 of genotype III, apparently with a single origin.

Contribution of spoligotyping to the characterization of the population structure of Mycobacterium tuberculosis isolates in Portugal.

Tuberculosis is a major health problem in Portugal. To begin characterizing the population structure of Mycobacterium tuberculosis, spoligotyping was used for the systematic typing, through consecutive sampling, of patient isolates from the Amadora-Sintra area of Greater Lisbon. Distribution amongst major spoligotype families, including the Latin American Mediterranean (LAM), T, Haarlem and Beijing, was compared to that of the international spoligotype database SpolDB4 and to the European countries of traditional Portuguese immigration represented in SpolDB4. Spoligotypes from 665 isolates were analyzed and 97 shared international types (SITs) identified. In SpolDB4 Portugal is represented by part of the spoligotypes from this study explaining the reduced number of unidentified patterns. The importance of the LAM family, and especially of LAM1 and LAM9 sub-families that alone represented 38% of all the isolates in this study as compared to 8% relative to the European sub group, led us to believe that at least in this respect the population structure was closer to that of Africa and South America than to Europe. Spoligotypes characteristic of Portugal or Portuguese related settings were identified. These included SIT244 a T1 sub-family predominant in Portugal and Bangladesh, SIT64 a LAM 6 sub-family common to Portugal and Brazil, and SIT1106 a LAM 9 sub-family. These studies were the first in Portugal stressing the importance of monitoring the population structure of M. tuberculosis isolates, an important step towards gaining an understanding of tuberculosis and the dynamics of this disease.

Update on the Spoligotypes of Mycobacterium tuberculosis complex isolates from the Fernando Fonseca Hospital (Amadora-Sintra, Portugal).

The present population study, from 1999 to 2003, has been based on the use of Spoligotyping in the genotyping of 452 isolates of the Mycobacterium tuberculosis complex from tuberculosis patients of the Fernando Fonseca Hospital. Spoligotypes were identified as "shared types" (STs) with the aid of an international database. Eleven rarely found STs, not identified in the database, grouped 8.4% of the isolates. Moreover, particular to Portugal, may be the predominance of STs identified in the database but not previously classified as genotypic families, such as ST244, ST150 and ST389, representing 13.3 % of the total. The identification of clinical isolates of M. africanum genotype Afri1 and of M. tuberculosis genotype CAS1 may confirm import of isolates of African and Asian origin. M. tuberculosis of the Beijing family was first reported by us as of 1999. Since then, the number of isolates at the Hospital has passed from one to five annually, representing 2.2% of the total and the tenth most predominant family in the present study. M. tuberculosis Beijing may correspond to an emerging problem in Portugal due to recent immigration from Eastern Europe and Asia. Other genotypes, ST150 and ST389, have shown increase, the significance of which is not clear. However, the relative frequencies of the predominant families LAM, T1 and Haarlem remained relatively stable. The present study confirms the genetic variability in Portugal of M. tuberculosis complex isolates. These studies may contribute to the definition of priorities in the national tuberculosis control programs.

Spoligotyping and pncA polymorphism: a two step scenario for Mycobacterium bovis diagnosis in Portugal.

The differential diagnosis of Mycobacterium bovis is important in the control of transmission to the human population and also for treatment since M. bovis is naturally resistant to pyrazinamide. Eleven clinical isolates from the Fernando Fonseca Hospital with Spoligotypes indicative of M. bovis, through the absence of spacers 39-43 but that also counted with the absence of spacer 38, were analyzed. For the identification of these strains, the phenotypic analysis of pyrazinamide resistance and study of the polymorphisms of the pncA and gyrB genes were carried out. The study of the pncA polymorphism revealed that the strains analyzed did not contain the M. bovis specific mutation. In relation the gyrB polymorphisms, using the GenoTypeO MTBC kit, the strains were identified as belonging to the group M. tuberculosis, M. africanum subtipo II e M. canetti. The present investigation enabled us to define new genotypes on which future bacteriological studies should be based. Amongst these the study of the pncA polymorphism was considered important due to the immediate practical implications for the clinician. Evaluating transmission and defining groups of risk is an objective for which support from the veterinary services is considered relevant.

[Molecular identification using Spoligotyping of strains from the Mycobacterium tuberculosis complex isolated from the Hospital Fernando Fonseca]. / Identificação molecular pelo método de Spoligotyping de estirpes do complexo Mycobacterium tuberculosis isoladas no Hospital Fernando Fonseca.

Spoligotyping was used in the genotyping of 219 isolates of the Mycobacterium tuberculosis complex, from patients of the Hospital Fernando Fonseca. This technique, based on PCR methodology, analyses a region of the chromosome specific of the Mycobacterium tuberculosis complex, the DR locus (Direct Repeat). With the aid of an international database, we showed that the predominant Spoligotypes belonged to the LAM family (Latino-American Mediterranean), 29.2 %. The LAM 9 family, with 12.3 %, left us attentive to the possible import of the disease through populations from South America, were it has been frequently identified. The genotypic families T1 and Haarlem, with 6.4 % and 8.7 % respectively, represented a frequency typical to Europe. The Beijing family, with 1.4 %, may represent an emerging problem in our country due to recent immigration of Asian and Eastern European populations. Isolates with a Spoligotype of the M. bovis type were found at a high percentage, 3.7 %. In Europe, this infection is extremely rare suggesting the result may not be due to M. bovis infection but to M. bovis BCG (due to vaccination or eventual recombinant BCG based therapies), or M. africanum (due to the proximity of the two species). A high percentage of the Spoligotypes were not identified by the database, 21.4 %. This is the first study of this type amongst us and may be the starting point for the creation of a data base with important consequences on the national program against tuberculosis.

Serological screening for tuberculosis in the community: an evaluation of the Mycodot procedure in an African population with high HIV-2 prevalence (Republic of Guinea-Bissau)

The immuno-dot-blot assay MycoDot, which detects lipoarabinomannan (LAM) antibodies, was evaluated for the serological diagnosis of active pulmonary tuberculosis in patients in a rural community in the Republic of Guinea-Bissau. Sera from 269 adults (age > 15) and 33 children (age < 5) were assayed for antibodies in a blind manner and the results compared to the clinical status of tuberculosis. The assay had a specificity and a sensitivity of 92.4 per cent and 63.0 per cent respectively, when applied to the adult population. In HIV-2 infected individuals (27/269), the specificity and sensitivity of the assay were similar, 94.7 per cent and 62.5 per cent respectively. The assay did not provide high sensitivity for the diagnosis of tuberculosis in children. Sera from patients with leprosy cross-reacted with the antigen of the assay. It is concluded that this easily performed assay may be useful for the presumptive diagnosis of tuberculosis in adult populations in rural areas of developing countries where routine screening is not readily available.