Pretibial hematoma as a cause of significant health issue in an elderly traveler.

This paper presents a case of a 77-year-old patient diagnosed with type 2 cardio-renal syndrome, who has undergone a Transcatheter Aortic Valve Implantation surgery due to aortic stenosis associated with permanent atrial fibrillation and type 2 diabetes. This patient, despite their multi-morbidity, undertook family travels to Egypt. Despite disease symptoms and plethora of medication, the patient did not seek medical advice on preventative measures or potential health risks prior to the departure. During the stay in Egypt, the patient sustained a lower limb injury, which resulted in pretibial hematoma requiring a 2-week stay in a local hospital. The patient's condition was systematically deteriorating and after returning to Poland a continued multi-specialist treatment in the field of surgery, nephrology and cardiology was required. The medical history of the described patient and the severity of heart failure and chronic kidney disease were clear contraindications to long-distance travels. Despite those risks, the patient did not seek pre-travel medical advice from specialists and did not undertake any preventative measures. As a result of an accident during travel, an elderly patient with multiple diseases suffered serious health complications that significantly and permanently worsened his general health condition. Due to the aging population and the increasing amounts of elderly patients traveling internationally, proper preparation of seniors before departure is one of the key aspects of modern travel medicine.

Epidemiologic trends and clinical outcomes of imported malaria in a tertiary care hospital, Bangkok, Thailand: A retrospective analysis (2013-2022).

BACKGROUND: Despite a significant declined in malaria incidence in Thailand, the rising global travel has resulted in an increase of imported malaria cases, posing a threat to the goal of malaria elimination. This study aims to understand the epidemiological trends and clinical outcomes of imported malaria cases in Thailand. METHODS: Medical records of all imported malaria cases admitted from 1st January 2013 to 31st December 2022 at the Hospital for Tropical Diseases, Thailand, were retrospectively examined. Demographic data, travel details, severity of illness, and clinical outcomes were described. Logistic regression was performed to identify factors associated with severe disease outcomes. RESULTS: In total, 335 cases of imported malaria were identified, with 33 % classified as transnational malaria and 67 % as border malaria. Transnational malaria cases (79 % P. falciparum) were mostly acquired from Sub-Saharan Africa for business or visiting friends and relatives (VFRs). Border malaria cases (81 % P. vivax) involved unskilled labourers and were acquired from land-border countries. The proportion of imported malaria in business travelers increased from 13 % to 50 % over the ten years. Risk factors for severe imported malaria included male gender, age 40 and older, infection with P. falciparum, and acquired malaria from Africa. CONCLUSIONS: Understanding unique demographic and socioeconomic characteristics in both border and transnational cases is crucial for effective malaria prevention. The increasing imported malaria among business travelers highlight the need for targeted prevention in this high-risk group.

Characteristics and Morbidity Patterns of Last-Minute Travelers in Thailand.

BACKGROUND: Last-minute travelers (LMTs) present significant challenges for travel health services and are considered vulnerable due to their lack of health preparation. However, there is a lack of data to support this assumption. METHODS: The proportion of LMTs was investigated through a cross-sectional study involving all Thai travelers who visited the Thai Travel Clinic before their departure abroad. A prospective study was conducted by enrolling the travelers after the consultation, utilizing two online questionnaires. The first aimed to gather demographic data and categorize participants as either LMTs (if their departure date was ≤ 14 days) or non-LMTs, while the second assessed travel-related illnesses either upon their return or at the one-month point if their trip exceeded a month. RESULTS: A quarter (25.5%) of 310 Thai travelers abroad were classified as LMTs. Both LMTs and non-LMTs showed similar gender distributions with mean ages of 35.8 and 35.7 years old, respectively, but LMTs were more likely to travel for tourism, travel in groups, visit countries within Asia and plan shorter stays abroad. Follow-up studies were conducted from July 2023 to February 2024. 452 departed respondents consisted of 150 LMTs and 302 non-LMTs. Although overall health problems were insignificantly higher in LMTs (32.0% vs 22.0%, AOR = 1.469, p = 0.107), gastrointestinal and neurological symptoms (primarily headache and dizziness) were significantly more common among LMTs. CONCLUSIONS: LMTs represent a significant portion of Thai travelers, posing challenges for travel health specialists in Thailand. Intervention and education efforts may be necessary to address this issue.

Oropouche virus infection: What internal medicine physicians should know.

Not required for Clinical Insight.

Vaccine Literacy and Hesitancy on routine and travelers' vaccines: a preliminary online survey.

Background: The vast amount of conflicting information during the COVID-19 pandemic might have had a detrimental effect on people's opinions about vaccinations, including groups like travelers. This study aimed at assessing Vaccine Literacy in a sample of the general Italian population, together with antecedents of Vaccine Hesitancy, such as confidence, complacency, and convenience, the so-called "3Cs", and their effects on accepting routine and travelers' vaccines. Study Design: A specifically designed anonymous questionnaire was created by using Google forms and validated through a face validity process. Subsequently, it was employed in an online cross-sectional survey. Methods: The assessment Vaccine Literacy scale used in this survey was similar to that employed in earlier surveys. In addition to demographic data and information sources used by participants, the questionnaire was composed, in total, of nine multiple choice questions on Vaccine Literacy, and six questions on the 3Cs. Considered outcomes were self-reported participants' beliefs, attitudes, behaviors and intentions toward recommended routinary adulthoods vaccines and arboviral vaccines for travelers. A section of the questionnaire focused on chikungunya awareness, taken as an example of arboviral disease that has caused outbreaks in Italy, but not yet vaccine-preventable at the time of the investigation. Results: After cleaning the database, 357 responses were suitable for analysis. Vaccine Literacy mean functional score was 2.81 ± 0.74 (lower than in an earlier survey, p = 0.012), while the interactive-critical (score 3.41 ± 0.50) was higher (p<0.001). Vaccine literacy was confirmed to be associated with attitudes and behaviors towards vaccination, with the 3Cs often acting as a mediator. However, interactive Vaccine Literacy was misaligned with respect to functional and critical ones, as if looking for information sources or discussing about vaccination was less relevant than amidst the pandemic. Also, there was an increase in Vaccine Hesitancy, particularly with regard to travel vaccinations, with 10-17% of individuals refusing to be vaccinated if travelling in areas at risk. The main limitation of the study was the unbalance in demographic variables, in particular the education level. Conclusions: The study highlights the risks associated with current travel, including those related to climate change and the spread of vector-borne infections. It underscores the importance of raising awareness about arboviral diseases and the vaccines available to prevent them. As with all online surveys that employ convenience sampling, this study might not have provided a comprehensive representation of the entire population. Nevertheless, a dedicated analysis has been conducted to reduce biases and make data interpretation easier. Despite the need for further research, the findings indicate potential new approaches for assessing Vaccine Literacy and Vaccine Hesitancy, to ease the development of new communication strategies to enhance routine and travel vaccinations.

Imported schistosomiasis in travelers: Experience from a referral tropical medicine unit in Barcelona, Spain.

BACKGROUND: Acute schistosomiasis occurs most often in travelers to endemic regions. The aim of the study is to describe the epidemiological, clinical and parasitological characteristics of patients with schistosomiasis acquired during an international travel. METHODS: Observational retrospective study including all travel-related schistosomiasis cases seen at the International Health Unit Vall d'Hebron-Drassanes (Barcelona, Spain) from 2009 to 2022. Diagnosis of schistosomiasis was defined by the presence of Schistosoma eggs in stools or urine or the positivity of a serological test. We collected demographic, epidemiological, clinical, parasitological, and therapeutic information. RESULTS: 917 cases of schistosomiasis were diagnosed, from whom 96 (10.5 %) were travel-related. Mean age of the patients was 34.9 years, and 53.1 % were women. Median duration of the travel was 72 days, and geographical areas where travelers had contact with fresh water were Africa (82.3 %), Asia (12.5 %), and South America (5.2 %). Twenty (20.8 %) patients reported having had some clinical symptom, being gastrointestinal symptoms the most frequent. Two patients developed the classical Katayama syndrome. In eleven (11.5 %) cases eggs were observed in urine or feces samples, and 85 (88.5 %) cases were diagnosed by a positive serology. Ninety-one (94.8 %) patients received treatment with praziquantel with different therapeutic schemes. The two patients with Katayama syndrome received concomitant treatment with corticosteroids. CONCLUSIONS: Schistosomiasis in travelers represented 10 % of the overall schistosomiasis cases in our center. Increasing the awareness in the pre-travel advice and implementing specific screening in those travelers at risk (long travelers, contact with fresh water) could reduce the incidence and associated morbidity in this group.

The two-year epidemiological investigation of the COVID-19 pandemic in the nomadic population of Fars province, Southern Iran: An ecological study (February 20, 2020, to February 19, 2022).

Background: The COVID-19 pandemic has highlighted the vulnerability of traveling populations, yet little is known about the health status of nomadic communities. This ecological study aimed to investigate the health status of the nomadic population in Fars Province, Iran, during the first two years of the COVID-19 pandemic. Methods: Nomadic Information Registration System (NIRS) data were used to compare COVID-19 diagnostic tests, confirmed cases, referrals, hospital admissions, deaths, and vaccination coverage between the nomadic and general populations. Non-parametric chi-square test was used for data analysis. Results: In Fars Province, COVID-19 diagnostic tests were performed on 2.73 % of the nomadic population and 40 % of the general population. The test positivity rate was 23.91 % for the nomadic population and 29.3 % for the general population. The case fatality ratio (CFR) for COVID-19 was 9.24 % for the nomadic population and 1.29 % for the general population. Additionally, only 41.83 % and 24.35 % of the nomadic population had received the first and second doses of a COVID-19 vaccine, respectively, which were lower than the general population's rates of 65.65 % and 59.71 %. Conclusion: The nomadic population in Fars Province received suboptimal COVID-19 care compared to the general population.

Tuberculosis Disease Among Nonimmigrant Visa Holders Reported to US Quarantine Stations, January 2011-June 2016.

US-bound immigrants and refugees undergo a mandatory overseas medical examination that includes tuberculosis screening; this exam is not routinely required for temporary visitors applying for non-immigrant visas (NIV) to visit, work, or study in the United States. US health departments and foreign ministries of health report tuberculosis cases in travelers to Centers for Disease Control and Prevention Quarantine Stations. We reviewed cases reported to this passive surveillance system from January 2011 to June 2016. Of 1252 cases of tuberculosis in travelers reported to CDC, 114 occurred in travelers with a long-term NIV. Of these, 83 (73%) were infectious; 18 (16%) with multidrug-resistant tuberculosis (MDR TB) and one with extensively drug-resistant tuberculosis (XDR TB). We found evidence that NIV holders are diagnosed with tuberculosis disease in the United States. Given that long-term NIV holders were over-represented in this data set, despite the small proportion (4%) of overall non-immigrant admissions they represent, expanding the US overseas migration health screening program to this population might be an efficient intervention to further reduce tuberculosis in the United States.

An epidemiological analysis of severe imported malaria infections in Sri Lanka, after malaria elimination.

BACKGROUND: Imported malaria continues to be reported in Sri Lanka after it was eliminated in 2012, and a few progress to life-threatening severe malaria. METHODS: Data on imported malaria cases reported in Sri Lanka from 2013 to 2023 were extracted from the national malaria database maintained by the Anti Malaria Campaign (AMC) of Sri Lanka. Case data of severe malaria as defined by the World Health Organization were analysed with regard to patients' general characteristics and their health-seeking behaviour, and the latter compared with that of uncomplicated malaria patients. Details of the last three cases of severe malaria in 2023 are presented. RESULTS: 532 imported malaria cases were diagnosed over 11 years (2013-2023); 46 (8.6%) were severe malaria, of which 45 were Plasmodium falciparum and one Plasmodium vivax. Most severe malaria infections were acquired in Africa. All but one were males, and a majority (87%) were 26-60 years of age. They were mainly Sri Lankan nationals (82.6%). Just over half (56.5%) were treated at government hospitals. The average time between arrival of the person in Sri Lanka and onset of illness was 4 days. 29 cases of severe malaria were compared with 165 uncomplicated malaria cases reported from 2015 to 2023. On average both severe and uncomplicated malaria patients consulted a physician equally early (mean = 1 day) with 93.3% of severe malaria doing so within 3 days. However, the time from the point of consulting a physician to diagnosis of malaria was significantly longer (median 4 days) in severe malaria patients compared to uncomplicated patients (median 1 day) (p = 0.012) as was the time from onset of illness to diagnosis (p = 0.042). All severe patients recovered without sequelae except for one who died. CONCLUSIONS: The risk of severe malaria among imported cases increases significantly beyond 5 days from the onset of symptoms. Although patients consult a physician early, malaria diagnosis tends to be delayed by physicians because it is now a rare disease. Good access to expert clinical care has maintained case fatality rates of severe malaria at par with those reported elsewhere.

Bismuth subsalicylate, probiotics, rifaximin and vaccines for the prevention of travelers' diarrhea: a systematic review and network meta-analysis.

Background: Bismuth subsalicylate (BSS), probiotics, rifaximin, and vaccines have been proposed as preventive modalities for patients with travelers' diarrhea (TD), but their comparative effectiveness for prevention has rarely been studied. We aimed to perform a systematic review and network meta-analysis to test whether one of these modalities is more effective than the others in reducing the incidence of TD. Methods: We searched Pubmed, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, and clinical registries from inception of the databases through 18 November 2023, without language restriction, for randomized controlled trials (RCTs) evaluating the efficacy of BSS, probiotics, rifaximin, and vaccines in preventing TD. The primary outcome was the incidence of TD and the safety outcome was the incidence of adverse events. The relative ratio (RR) was used to assess the effect of the modalities, and RR estimates between any two of the modalities were calculated and pooled using a frequentist network meta-analysis model. Results: Thirty-one studies (recruiting 10,879 participants) were included in the analysis. Sixteen were judged to have a low risk of bias. In the aggregate analysis, BSS and rifaximin were more effective than placebo and other treatment modalities, which was further confirmed in the individual analysis. The comparison between rifaximin and placebo achieved high confidence, while the comparisons between BSS and placebo, ETEC and probiotics, and rifaximin and vaccines achieved moderate confidence. BSS had a higher rate of adverse events compared with other treatments. Conclusion: Rifaximin had a relative lower TD incidence and lower adverse event rate, and the evidence was with moderate confidence. Systematic Review Registration: https://osf.io/dxab6, identifier.

An assessment of the perceptual elements of urban streets based on the context of urban tourism - The case of Sheffield.

Background: After COVID-19, more and more travelers are more inclined to walk in cities, and the sensory elements of streets can have a significant impact on urban tourism. Local residents and travelers have different perceptions of the street and preferences for its use. The purpose of this study is to evaluate and analyse the streets from the perspective of locals and travelers. Method: In this study, a questionnaire was designed to obtain local residents' and travelers' evaluations of the sensory elements of the street and a quadrant analysis of the street's sensory elements was carried out using the IPA-Kano model. Results: The results of the study show that travelers are particularly concerned about maps and signage guidance, while local residents are more concerned about the green environment of the surroundings and how well it is maintained. Conclusion: There is a difference in the indicators chosen by the two groups in the results of the comparison between locals and travelers, and this study is hoped to provide some data support for future urban managers and designers to learn from and refer to for street improvements and renewal.

Health inequities and marginalized groups: An overview for college student travelers and travel health professionals.

One of the main goals of college- and university-sponsored travel is to broaden the global perspectives of student travelers, thereby enhancing their ability to effectively communicate and work with people from different cultural backgrounds. Pre-travel consultations are important for all students traveling internationally, and especially for those facing current or past health inequities and marginalization. To offer high quality, inclusive services, college travel health clinicians must understand both the student traveler population and cultural norms at the travel destinations, especially those related to health and safety. This article provides an overview of health equity definitions and pre-travel preparation through an equity lens. It also reviews travel health equity-related clinical implications including: helping to prepare student travelers for issues related to gender, sexuality, identity, and sexual assault; assisting travelers with preexisting health conditions and disabilities; and serving older student travelers and travelers with financial limitations.

Overwhelmed by beauty and faith: review on artistic and religious travelers' syndromes.

Traveling with the intention of encountering art or seeking purification of the spirit involves retribution of intangible nature and therefore can be expected to be a positive experience; nevertheless, among susceptible travelers, there is also a possibility of experiencing pathological conditions. Although it is colloquially known that beauty lies in the eyes of the beholder, it is necessary to mention that the appreciation of beauty, immensity, or mysticism contained in masterpieces is not perceived only through the eyes but through other sense organs as well. Additionally, this is understood within a cultural framework and through previous knowledge. The reaction triggers a series of somatosensory responses of diverse nature, with a wide range of responses that together constitute a pathological phenomenon that can be defined as syndromic by eliciting signs and symptoms of a physical, physiological, and psychotic nature. Both Stendhal and Jerusalem syndromes are travelers' syndromes that may occur in response to objectively aesthetic elements saturated with meaning linked to the cultural heritage of contemporary humanity. While Stendhal syndrome evokes physical and psychoemotional symptoms from the contemplation of art, Jerusalem syndrome goes beyond perception, adding delusions of being a religious or prophetic protagonist pursuing individual or collective salvation.

Monoclonal antibody applications in travel medicine.

For decades, immunoglobulin preparations have been used to prevent or treat infectious diseases. Since only a few years, monoclonal antibody applications (mAbs) are taking flight and are increasingly dominating this field. In 2014, only two mAbs were registered; end of October 2023, more than ten mAbs are registered or have been granted emergency use authorization, and many more are in (pre)clinical phases. Especially the COVID-19 pandemic has generated this surge in licensed monoclonal antibodies, although multiple phase 1 studies were already underway in 2019 for other infectious diseases such as malaria and yellow fever. Monoclonal antibodies could function as prophylaxis (i.e., for the prevention of malaria), or could be used to treat (tropical) infections (i.e., rabies, dengue fever, yellow fever). This review focuses on the discussion of the prospects of, and obstacles for, using mAbs in the prevention and treatment of (tropical) infectious diseases seen in the returning traveler; and provides an update on the mAbs currently being developed for infectious diseases, which could potentially be of interest for travelers.

Treatment Failure in a UK Malaria Patient Harboring Genetically Variant Plasmodium falciparum From Uganda With Reduced In Vitro Susceptibility to Artemisinin and Lumefantrine.

BACKGROUND: Recent cases of clinical failure in malaria patients in the United Kingdom (UK) treated with artemether-lumefantrine have implications for malaria chemotherapy worldwide. METHODS: Parasites were isolated from an index case of confirmed Plasmodium falciparum treatment failure after standard treatment, and from comparable travel-acquired UK malaria cases. Drug susceptibility in vitro and genotypes at 6 resistance-associated loci were determined for all parasite isolates and compared with clinical outcomes for each parasite donor. RESULTS: A traveler, who returned to the UK from Uganda in 2022 with Plasmodium falciparum malaria, twice failed treatment with full courses of artemether-lumefantrine. Parasites from the patient exhibited significantly reduced susceptibility to artemisinin (ring-stage survival, 17.3% [95% confidence interval {CI}, 13.6%-21.1%]; P < .0001) and lumefantrine (effective concentration preventing 50% of growth = 259.4 nM [95% CI, 130.6-388.2 nM]; P = .001). Parasite genotyping identified an allele of pfk13 encoding both the A675V variant in the Pfk13 propeller domain and a novel L145V nonpropeller variant. In vitro susceptibility testing of 6 other P. falciparum lines of Ugandan origin identified reduced susceptibility to artemisinin and lumefantrine in 1 additional line, also from a 2022 treatment failure case. These parasites did not harbor a pfk13 propeller domain variant but rather the novel nonpropeller variant T349I. Variant alleles of pfubp1, pfap2mu, and pfcoronin were also identified among the 7 parasite lines. CONCLUSIONS: We confirm, in a documented case of artemether-lumefantrine treatment failure imported from Uganda, the presence of pfk13 mutations encoding L145V and A675V. Parasites with reduced susceptibility to both artemisinin and lumefantrine may be emerging in Uganda.

Gut microbiome and antibiotic resistance effects during travelers' diarrhea treatment and prevention.

IMPORTANCE: The travelers' gut microbiome is potentially assaulted by acute and chronic perturbations (e.g., diarrhea, antibiotic use, and different environments). Prior studies of the impact of travel and travelers' diarrhea (TD) on the microbiome have not directly compared antibiotic regimens, and studies of different antibiotic regimens have not considered travelers' microbiomes. This gap is important to be addressed as the use of antibiotics to treat or prevent TD-even in moderate to severe cases or in regions with high infectious disease burden-is controversial based on the concerns for unintended consequences to the gut microbiome and antimicrobial resistance (AMR) emergence. Our study addresses this by evaluating the impact of defined antibiotic regimens (single-dose treatment or daily prophylaxis) on the gut microbiome and resistomes of deployed servicemembers, using samples collected during clinical trials. Our findings indicate that the antibiotic treatment regimens that were studied generally do not lead to adverse effects on the gut microbiome and resistome and identify the relative risks associated with prophylaxis. These results can be used to inform therapeutic guidelines for the prevention and treatment of TD and make progress toward using microbiome information in personalized medical care.