A Machine Learning Model for Evaluating Imported Disease Screening Strategies in Immigrant Populations.

Given the high prevalence of imported diseases in immigrant populations, it has postulated the need to establish screening programs that allow their early diagnosis and treatment. We present a mathematical model based on machine learning methodologies to contribute to the design of screening programs in this population. We conducted a retrospective cross-sectional screening program of imported diseases in all immigrant patients who attended the Tropical Medicine Unit between January 2009 and December 2016. We designed a mathematical model based on machine learning methodologies to establish the set of most discriminatory prognostic variables to predict the onset of the: HIV infection, malaria, chronic hepatitis B and C, schistosomiasis, and Chagas in immigrant population. We analyzed 759 patients. HIV was predicted with an accuracy of 84.9% and the number of screenings to detect the first HIV-infected person was 26, as in the case of Chagas disease (with a predictive accuracy of 92.9%). For the other diseases the averages were 12 screenings to detect the first case of chronic hepatitis B (85.4%), or schistosomiasis (86.9%), 23 for hepatitis C (85.6%) or malaria (93.3%), and eight for syphilis (79.4%) and strongyloidiasis (88.4%). The use of machine learning methodologies allowed the prediction of the expected disease burden and made it possible to pinpoint with greater precision those immigrants who are likely to benefit from screening programs, thus contributing effectively to their development and design.

O viajante como agente ativo na transmissibilidade do SARS-CoV-2: uma revisão sistemática / The traveler as an active agent of SARS-CoV-2 transmission: a systematic review

O objetivo deste trabalho foi evidenciar o papel dos viajantes na transmissão e na disseminação do novo coronavírus. A busca pelos artigos foi realizada nas bases de dados PubMed®, SciELO, MEDLINE®, Cochrane, Center for Disease Control and Prevention e UpToDate. Foram incluídos artigos relacionados à transmissibilidade, principalmente aqueles associados à disseminação realizada por viajantes, do novo coronavírus. Excluíram-se artigos relacionados a outros surtos de coronavírus. Todos os estudos foram lidos e analisados integralmente. Onze artigos foram selecionados e tabulados, dos quais se pôde desenvolver uma fundamentação teórica, que expõe o grande impacto dos viajantes perante o crescimento da pandemia relacionada ao SARS-CoV-2, levando em consideração as diversas formas com que esse vírus pode se propagar, sendo elas por contato com superfícies contaminadas ou pessoa a pessoa, visto que a infecção pode ser decorrente de gotículas, aerossóis, fômites e, possivelmente, contato sexual, estando os indivíduos sintomáticos ou não.

The objective of this study was to highlight the travelers role in the transmission and dissemination of new coronavirus. The search for the articles was carried out in PubMed®, SciELO, MEDLINE®, Cochrane, Centers for Disease Control and Prevention, and UpToDate databases. Articles related with transmissibility of the new coronavirus were included, mainly those linked with the dissemination from travelers. Articles related with other coronavirus outbreaks were excluded. All of the studies were read and analyzed in their entirety. Eleven articles were selected and tabulated, from which a theoretical framework was developed, which exposes the great impact of travelers in the face of the growth of the pandemic related to the SARS-CoV-2, considering the several ways in which this virus can spread, either through contact with contaminated surfaces or person-to-person, since the infection may occur through droplets, aerosols, fomites, and possibly sexual contact, whether individuals are symptomatic or not.

Una consideración sobre el artículo: Brotes, epidemias, eventos y otros términos epidemiológicos de uso cotidiano / Considerations on the article: Outbreaks, epidemics, events and other epidemiological terms of frequent use

Hemos leído con sumo interés el trabajo de Peláez y Más1 publicado recientemente en su revista. A raíz de los datos expuestos en su contenido, quisiéramos, primeramente, puntualizar la importancia de tener en cuenta el marco legal de la Organización Mundial de la Salud (OMS), como lo es el Reglamento Sanitario Internacional (RSI).2 El RSI es un instrumento jurídico internacional de carácter vinculante para 194 países, entre ellos todos los Estados Miembros de la OMS. Tiene el objetivo de ayudar a la comunidad a prevenir y afrontar riesgos agudos de salud pública, susceptibles de atravesar fronteras y amenazar a poblaciones de todo el mundo. Actualmente el RSI vigente tiene el objetivo de ayudar...(AU)

Strategies at points of entry to reduce importation risk of COVID-19 cases and reopen travel.

BACKGROUND: With more countries exiting lockdown, public health safety requires screening measures at international travel entry points that can prevent the reintroduction or importation of the severe acute respiratory syndrome-related coronavirus-2. Here, we estimate the number of cases captured, quarantining days averted and secondary cases expected to occur with screening interventions. METHODS: To estimate active case exportation risk from 153 countries with recorded coronavirus disease-2019 cases and deaths, we created a simple data-driven framework to calculate the number of infectious and upcoming infectious individuals out of 100 000 000 potential travellers from each country, and assessed six importation risk reduction strategies; Strategy 1 (S1) has no screening on entry, S2 tests all travellers and isolates test-positives where those who test negative at 7 days are permitted entry, S3 the equivalent but for a 14 day period, S4 quarantines all travellers for 7 days where all are subsequently permitted entry, S5 the equivalent for 14 days and S6 the testing of all travellers and prevention of entry for those who test positive. RESULTS: The average reduction in case importation across countries relative to S1 is 90.2% for S2, 91.7% for S3, 55.4% for S4, 91.2% for S5 and 77.2% for S6. An average of 79.6% of infected travellers are infectious upon arrival. For the top 100 exporting countries, an 88.2% average reduction in secondary cases is expected through S2 with the 7-day isolation of test-positives, increasing to 92.1% for S3 for 14-day isolation. A substantially smaller reduction of 30.0% is expected for 7-day all traveller quarantining, increasing to 84.3% for 14-day all traveller quarantining. CONCLUSIONS: The testing and isolation of test-positives should be implemented provided good testing practices are in place. If testing is not feasible, quarantining for a minimum of 14 days is recommended with strict adherence measures in place.

Coronavirus-19 disease (COVID-19): A case series of early suspected cases reported and the implications towards the response to the pandemic in Zimbabwe.

Zimbabwe is among the countries that have been identified to be at risk of the COVID-19 pandemic. As of the 15th of March 2020, there was no confirmed case of the virus. Official reports of suspected cases were used to appraise the general screening, case management, and the emergency preparedness and response of the country towards the COVID-19 pandemic. In terms of the surveillance and capacity to screen at the ports of entry, the country seems to be faring well. The country might not be screening optimally, considering the number of COVID-19 tests conducted to date and the suspected cases who missed testing. Three of the suspected cases faced mental, social, and psychological consequences due to them being suspected cases of COVID-19. There is a need to enhance the screening process and infrastructure at all the ports of entry. More COVID-19 diagnostic tests should be procured to increase the testing capacity. Training and awareness on mental, social, and psychological consequences of COVID-19 should be offered to the health care workers and the general public. More financial resources should be sourced to enable the country control the pandemic.

Screening Program for Imported Diseases in Immigrant Women: Analysis and Implications from a Gender-Oriented Perspective.

The female immigrant population is especially vulnerable to imported diseases. We describe the results of a prospective screening program for imported diseases performed in immigrant female patients. The protocol included tests for HIV, hepatitis B virus (HBV), hepatitis C virus (HCV), Treponema pallidum, Trypanosoma cruzi, Strongyloides stercoralis and Schistosoma spp., intestinal parasites, malaria, and the detection of microfilaremia, according to the patient's origin. Six hundred eleven patients were studied. The most frequent imported diseases were intestinal parasitosis (39.4%), followed by syphilis (14.6%), HIV infection (9%), chronic HCV (5%), and HBV (3.3%). Most of the cases of HIV (78%) and HBV (85%) were diagnosed in patients aged between 16 and 45 years. Hepatitis C virus appeared mostly in patients in the 46- to 65-year range (P = 0.001; odds ratio [OD]: 3.667 [1.741-7.724]) or older than 65 years (P = 0.0001; OR: 26.350 [7.509-92.463]). Syphilis was diagnosed more frequently in patients older than 46 years (P = 0.0001; OR: 4.273 [2.649-6.893]). Multivariate analysis confirmed a greater presence of HCV infection (P = 0.049) and syphilis (P = 0.0001) in patients aged between 46 and 65 years. In 15.4% of patients, screening did not find any pathology. These data show a high prevalence of imported diseases in the female immigrant population, which may have serious consequences in terms of morbimortality and vertical transmission. Our results encourage the establishment of policies of active screening both in women of childbearing age and within the specific pregnancy screening programs.

Update on the major imported helminth infections in travelers and migrants.

Helminth infections cause considerable morbidity worldwide and may be frequently underdiagnosed especially in areas of lower endemicity. Patients may harbor latent infections that may become symptomatic years or decades after the initial exposure and timely diagnosis may be critical to prevent complications and improve outcomes. In this context, disease in special populations, such as immunosuppressed patients, may be of particular concern. Heightened awareness and recent diagnostic developments may contribute to the correct management of helminth infections in nonendemic regions. A review of the main helminth infections in travelers and migrants (strongyloidiasis, taeniasis-neurocysticercosis and schistosomiasis) is presented, focusing on epidemiology, developments in diagnosis, treatment and prevention.

Imported cutaneous leishmaniasis: molecular investigation unveils Leishmania major in Bangladesh.

BACKGROUND: The main clinical forms of leishmaniasis in Bangladesh are visceral leishmaniasis and post-kala-azar dermal leishmaniasis, which are caused by Leishmania donovani. Imported cutaneous leishmaniasis (CL) is emerging globally due mainly to increased human mobility. In recent years, several imported CL cases have also been reported in Bangladesh. Sporadic atypical cases of CL can be challenging for diagnosis and clinical management, while occurrence of infection on a frequent basis can be alarming. We report of a case of a Bangladeshi temporary-migrant worker who, upon return, presented development of skin lesions that are characteristic of CL. METHODS: A serum sample was collected and tested with an rK39 immunochromatographic test. Nucleic acid from skin biopsy derived culture sample was extracted and screened with a real-time PCR assay which targets the conserved REPL repeat region of L. donovani complex. The internal transcribed spacer 2 region of the ribosomal RNA gene cluster was amplified and sequenced. RESULTS: The suspect had a history of travel in both CL and VL endemic areas and had a positive rK39 test result. Based on clinical presentation, travel history and demonstration of the parasite in the skin biopsy, CL was diagnosed and the patient underwent a combination therapy with Miltefosine and liposomal amphotericin B. While typical endemic species were not detected, we identified Leishmania major, a species that, to our knowledge, has never been reported in Bangladesh. CONCLUSIONS: Proper monitoring and reporting of imported cases should be given careful consideration for both clinical and epidemiological reasons. Molecular tests should be performed in diagnosis to avoid dilemma, and identification of causative species should be prioritized.

[Imported schistosomiasis haematobia in Suzhou City: a case report].

OBJECTIVE: To report the diagnosis and treatment of an imported case of schistosomiasis haematobia. METHODS: The patient's medical records were collected, and the clinical features, laboratory diagnosis, epidemiological survey, diagnosis and treatment were analyzed. RESULTS: The patient had arrived to Sudan and Egypt for many times and had a history of contact with the infested water. After returning to China, the patient reported a gross hematuria with unknown causes. Cystoscopy showed neoplasms in the bladder, and pathologic examinations showed chronic granulomatous inflammation with infiltration of plenty of plasma cells, and parasite eggs. Serological test showed positive for the dipstick dye immunoassay, and the microscopic examination of urine sediment revealed Schistosoma haematobium eggs. Following praziquantel treatment for a month, S. haematobium eggs were still detected in the urine. The case was treated with praziquantel again and cured without adverse reactions. CONCLUSIONS: Health education should be strengthened among China-aid-African workers to improve the awareness of self-protection. In addition, the diagnosis and treatment should be improved in medical professionals to achieve a timely definitive diagnosis.

[Laboratory diagnosis of an imported case of visceral leishmaniasis in Henan Province].

OBJECTIVE: To analyze the epidemiological and clinical data of an imported case of visceral leishmaniasis in Henan Province, and explore the method of laboratory diagnosis of kala-azar. METHODS: The epidemiological and clinical data of an imported visceral leishmaniasis patient were analyzed. Leishmania donovani bodies in bone marrow smears were observed microscopically. The antibody was detected by using rK39 dipstick test strips. Two pairs of specific primers, K13A-K13B and LITSR-L5.8S, were used to amplify kinetoplast DNA and internal transcribed spacer of rDNA of the parasite, respectively. RESULTS: The patient had been in the epidemic area of visceral leishmaniasis, and had symptoms such as irregular fever, splenomegaly, pancytopenia, and inversed ratio of albumin and globulin. The amastigotes of L. donovani were found in the bone marrow smears, and rK39 test strip was positive, and the PCR products of K13A-K13B and LITSR-L5.8S were 87 bp and 285 bp respectively. The similarities of the two fragment sequences to the corresponding sequences of L. donovani were 94% and 100%, respectively. CONCLUSIONS: The case is diagnosed as visceral leishmaniasis according to the epidemiological data, clinical manifestations and laboratory test results of the patient, and the pathogen is L. donovani.

Diagnostic algorithm for the confirmation of cases of measles and rubella in Mexico

Due to the successful implementation of measles and rubella elimination strategies, Mexico announced the interruption of endemic transmission of measles in 1996 and that of rubella in 2008. After a verification process, the region of the Americas was declared free of rubella and congenital rubella syndrome in 2015 and of measles in 2016. In order to maintain the elimination status in Mexico, it is essential to continue laboratory surveillance within the framework of the Global Measles and Rubella Laboratory Network. The Institute of Epidemiological Diagnosis and Reference, through the National Network of Public Health Laboratories, guarantees timely and reliable results in view of the possible reintroduction of these and other emerging pathogens.

Prolonged Zika Virus RNA Detection in Semen of Immunosuppressed Patient.

Zika virus RNA has been detected in semen samples collected <370 days after symptom onset. We report unusual persistence of Zika virus RNA in semen, confirmed by sequencing at 515 days after symptom onset and detectable for >900 days, in a patient with immunosuppression.

Case Report: Imported Melioidosis from Goa, India to Israel, 2018.

A previously healthy young man presented with a chronic cavitary pulmonary infection that began while in Goa, India. Burkholderia pseudomallei was cultured from sputum samples. The infection fully resolved after prolonged antibiotic treatment. Other than traveling during the monsoon season, extensive use of well-water for water-pipe smoking of cannabis was identified as a possible risk factor for infection. This is one of the first reports of travel-associated melioidosis from India. Genomic and immunological characterization suggested that the B. pseudomallei isolate collected from the reported case exhibited limited similarity to other B. pseudomallei strains.

Diagnosis of Imported Monkeypox, Israel, 2018.

We report a case of monkeypox in a man who returned from Nigeria to Israel in 2018. Virus was detected in pustule swabs by transmission electron microscopy and PCR and confirmed by immunofluorescence assay, tissue culture, and ELISA. The West Africa monkeypox outbreak calls for increased awareness by public health authorities worldwide.

Migration Medicine.

Migration is increasing and practitioners need to be aware of the unique health needs of this population. The prevalence of infectious diseases among migrants varies and generally mirrors that of their countries of origin, but is modified by the circumstance of migration, the presence of pre-arrival screening programs and post arrival access to health care. To optimize the health of migrants practitioners; (1) should take all opportunities to screen migrants at risk for latent infections such as tuberculosis, chronic hepatitis B and C, HIV, strongyloidiasis, schistosomiasis and Chagas disease, (2) update routine vaccines in all age groups and, (3) be aware of "rare and tropical infections" related to migration and return travel.

Effectiveness of passive case detection for imported malaria in a hospital setting in Sri Lanka during the prevention of re-introduction phase of malaria.

Introduction: The effectiveness of the passive case detection (PCD) system for imported malaria was assessed in government hospitals in Sri Lanka post-elimination of malaria. Methods: In 18 medical wards (test wards) in four government hospitals, the referral for malaria testing and the diagnosis of malaria by the ward physicians were monitored. Concurrently, in-ward febrile patients were assessed independently for their eligibility for referral for malaria diagnosis and were tested for malaria. The malaria incidence in 16 other wards (control wards), which the study did not screen, served as controls. Results: Four imported malaria patients were diagnosed within the PCD system among 25 874 febrile patients admitted during the 14-month study period, two of whom were diagnosed in the test wards and two in the control wards. The study's screening programme did not detect any more malaria patients than detected by the routine PCD system of the wards. However, far fewer patients were screened for malaria (1.3%) than were eligible for screening (29.4%), and some infections were detected incidentally, rather than by a request for a malaria test. Conclusion: A continuous effort to maintain awareness of the disease among physicians would be required if the PCD system is to be effective for the detection of imported malaria, post-elimination.

Streptococcal toxic shock syndrome in a returning traveller.

Background: A patient presenting with fever and purpura after a stay in the tropics tempts a physician to make a differential diagnosis mainly focusing on imported diseases. Although the importance of considering a tropical disease is obvious, the fact that cosmopolitan infections account for one third of the cases in a febrile returning traveler must not be overseen. Toxic Shock Syndrome is amongst the most notorious diseases due to the high mortality when inappropriately managed and the association with necrotizing fasciitis. Methods : We present a 60-year old female with fever, shock syndrome and progressive appearance of painful purpura on the lower legs after a 2-week holiday in Zanzibar. Results : The patient was diagnosed with Streptococcal Toxic Shock Syndrome. Treatment focusing on aggressive fluid resuscitation, prompt administration of antibiotics (ceftriaxon, doxycycline and one dose of amikacin) and adjunctive treatment by clindamycin and immunoglobulin was initiated. She was also immediately taken into surgery for a bilateral fasciotomy and surgical exploration of the lower legs. Histology appeared compatible with purpura fulminans, thereby excluding necrotizing fasciitis. No source of infection could be identified.  Conclusion: Toxic Shock Syndrome remains a challenging diagnosis and even more in a returning traveler with an extensive differential diagnosis containing both tropical and cosmopolitan diseases. Cornerstones for the treatment of Streptococcal Toxic Shock Syndrome are abrupt administration of antimicrobial therapy comprising beta-lactam antibiotics and clindamycin and surgical exploration to apply source control when indicated.

A rare case of visceral leishmaniasis in an immunocompetent traveler returning to the United States from Europe.

A young, healthy traveler returning to the United States presented with fever, night sweats, splenomegaly, and pancytopenia. Bone marrow biopsy revealed leishmaniasis (Leishmania infantum), likely acquired in southern France. Although many cases of endemic visceral leishmaniasis (VL) have been reported in Europe, this is a rare case of imported VL in a healthy traveler returning from Europe to the US. Despite successful initial treatment with liposomal amphotericin B (LamB), relapse occurred. Treatments for VL in immunocompetent individuals are highly effective, but relapse can occur. There is more extensive experience in endemic areas with treating relapse that may be lacking in North America. This case alerts physicians in the US that immunocompetent adults can acquire VL during brief visits to endemic areas in Europe. It is important that travelers be counseled on preventive measures. Patients should be monitored after treatment for relapse.