Zika beyond the Americas: Travelers as sentinels of Zika virus transmission. A GeoSentinel analysis, 2012 to 2016.

BACKGROUND: Zika virus (ZIKV) was first isolated in Africa; decades later, caused large outbreaks in the Pacific, and is considered endemic in Asia. We aim to describe ZIKV disease epidemiology outside the Americas, the importance of travelers as sentinels of disease transmission, and discrepancies in travel advisories from major international health organizations. METHODS AND FINDINGS: This descriptive analysis using GeoSentinel Surveillance Network records involves sixty-four travel and tropical medicine clinics in 29 countries. Ill returned travelers with a confirmed or probable diagnosis of ZIKV disease acquired in Africa, Asia and the Pacific seen between 1 January 2012 and 31 December 2016 are included, and the frequencies of demographic, trip, and diagnostic characteristics described. ZIKV was acquired in Asia (18), the Pacific (10) and Africa (1). For five countries (Indonesia, Philippines, Thailand, Vietnam, Cameroon), GeoSentinel patients were sentinel markers of recent Zika activity. Additionally, the first confirmed ZIKV infection acquired in Kiribati was reported to GeoSentinel (2015), and a probable case was reported from Timor Leste (April 2016), representing the only case known to date. Review of Zika situation updates from major international health authorities for country risk classifications shows heterogeneity in ZIKV country travel advisories. CONCLUSIONS: Travelers are integral to the global spread of ZIKV, serving as sentinel markers of disease activity. Although GeoSentinel data are collected by specialized clinics and do not capture all imported cases, we show that surveillance of imported infections by returned travelers augments local surveillance system data regarding ZIKV epidemiology and can assist with risk categorization by international authorities. However, travel advisories are variable due to risk uncertainties.

Rabies postexposure consultations in New Zealand from 1998 to 2012.

BACKGROUND: Rabies is an invariably fatal zoonotic viral disease. New Zealanders going abroad are largely unaware of the risk of contracting the disease. Prevention is the key to controlling the spread of this disease. METHODS: Data from 363 individuals presenting to New Zealand travel health clinics between 1998 and 2012 for post-travel consultations on potential rabies exposure were collated retrospectively. The data focused on traveler demographics, the country and nature of exposure, the purpose of travel, and pre-travel rabies awareness. RESULTS: The female-to-male ratio of subject travelers presenting was almost equal (1.1 : 1 ratio, respectively); the subjects were typically between 16 and 30 years (44.6%), tourists (64.5%), traveling less than 1 month (55.3%), and likely to have been exposed to animal contact in either Thailand (31.1%), China (13.2%), or Indonesia (12.3%). The animals to which they were exposed were usually dogs (59.5%) or monkeys (28.7%). Most potential exposures were penetrating (69.9%). Injury caused by the animal was more common in the lower limbs (50%) than in the upper limbs (43.4%); 89.4% of exposures were of World Health Organization (WHO) category III. Travelers were more likely to have received pre-travel rabies advice if they had been seen by a travel medicine specialist (96.1%) compared to a general practitioner (GP) (53.3%). Sixteen percent of travelers received rabies preexposure prophylaxis. Of the subjects who were managed following exposure, 79.7% did not receive immunoglobulin when indicated, and 21.5% did not receive any vaccine. Of the travelers that did receive a vaccine, 62.5% did so on the day of exposure. Of the travelers assessed, 16.7% had traveled without insurance. CONCLUSIONS: New Zealanders require better guidance in understanding the need for travel-related rabies vaccination, as they are not managed abroad according to WHO guidelines. Few travelers had had pre-travel immunization, and only 20.3% of them had received WHO-advised postexposure management. Thus, 79.7% of the cohort theoretically remained at risk for contracting rabies because of inappropriate management following possible exposure to the disease.

Illness and injury to students on a school excursion to Peru.

BACKGROUND: School-organized travels abroad provide an opportunity for students to undertake supervised travel that reinforces scholastic study of various geographical locations under the direction and protection of experienced tour leaders and health professional support. Little is known concerning the nature of illnesses and injuries occurring on overseas school excursions. This study was designed to investigate the prevalence of injury and illness suffered by older teenagers on a school excursion to South America. METHODS: In 2010, the school's tour physician (EH) diagnosed and recorded all illnesses and injuries among 29 school girls and 6 accompanying adults on a school excursion to Peru. Information recorded included age, sex, the nature of the presenting illness, number of days into the tour, the assessment of the condition, and the treatment employed during the excursion's field phase of 21 days. RESULTS: A total of 32 (91%) travelers sought medical advice at least once for a total of 371 consultations, resulting in 153 separate diagnoses. The mean age of the students was 16 years with six adults accompanying the students being significantly older. Primary illnesses diagnosed were related to the following systems and conditions: gastrointestinal (58, 37%), respiratory (25, 16%), altitude sickness (19, 12%), genitourinary (8, 5%), dermatological (10, 7%), trauma (7, 5%), neurological (7, 5%), anxiety or psychological adjustment (7, 5%), adverse drug reactions (4, 3%), and musculoskeletal (5, 3%). The most commonly used medications were antidiarrheal and antiemetic medication. There were six accidents during the journey resulting in minor soft-tissue injuries. There were no deaths or other major accidents requiring emergency evacuation or hospitalization. CONCLUSIONS: On this school excursion, the health problems encountered were consistent with those reported for other specialized tours, including expeditions and premium tours, although altitude illness needs to be carefully planned for in tours to higher elevation destinations as in South America. As well as being part of the service provided to the school students, the inclusion of a physician with appropriate medical supplies for this tour increased the independence of the travel group. A proposed medical kit for such an excursion is presented.

Professional organisation profile: a faculty of expedition and wilderness medicine for Australasia.

A profile of the recent genesis of the Sub-Faculty of Expedition Medicine into a Faculty of Expedition and Wilderness Medicine of The Australasian College of Tropical Medicine is presented. Information is given on aims, structure, professional grades of membership, and the various activities of the Faculty, including publications and scientific meetings.

Plasmodium knowlesi in a traveller returning to New Zealand.

The recent discovery that Plasmodium knowlesi causes malaria in human populations, established it as the fifth species of plasmodium that may do so. A case of P. knowlesi malaria is described in a helicopter pilot from New Zealand, who became ill after returning from recurring visits to Malaysian Borneo in June 2010. His P. knowlesi infection was not detected using microscopic examination and a rapid diagnostic test for malaria, but was confirmed by both PCR (polymerase chain reaction) and sequence analysis showing homology with the ribosomal RNA gene for P. knowlesi. He responded rapidly to treatment with artemether & lumefantrine combination. The evolution of a rapid diagnostic kit to diagnose P. knowlesi is needed, for early identification and appropriate anti-malarial therapy of suspect cases are both critical in the prevention of the potentially life-threatening disease through P. knowlesi. Clinicians need to consider knowlesi infection in the differential diagnosis in recent-onset febrile travellers to areas of forestation in Southeast Asia.

Travelling to India for the Delhi XIX Commonwealth Games 2010.

The 19th Commonwealth Games, conducted once in every four years since 1930, will be held in New Delhi from the 3rd through until the 14th of October, 2010. There will be approximately 17 sports on display and there will also be 15 para-sporting events. This paper focuses on health and safety issues for travellers to India in general, although it provides specific references to advice for visiting Commonwealth Games athletes and team staff, who will be travelling to the games. Whilst it needs be remembered that travel health advice can change, travellers are advised to seek up-to-date travel health advice for India, from their professional providers, closer to their departure.

Professional organisation profile: a sub-Faculty of expedition medicine for Australasia.

A review of the recent foundation by The Australasian College of Tropical Medicine of the Sub-Faculty of Expedition Medicine is presented. Information is given on aims, professional grades of membership, and the various activities of the Sub-Faculty, including publications and scientific meetings.

Illness and injury to travellers on a premium seniors' tour to Indochina.

BACKGROUND: Commercial expeditions and upmarket tours provide an opportunity for travellers to undertake various specialised travel to more adventurous and extreme destinations often in the relative security of accompanying medical cover provided by an expedition physician. There is limited knowledge of the nature of illnesses and injuries occurring on premium seniors' tours to Asia. This present study was designed to investigate the prevalence of injury and illness suffered by travellers on a premium tour to Indochina. METHODS: In 2004, the tour expedition physician (MTMS) diagnosed and recorded all illnesses and injuries amongst 23 travellers on a premium seniors' tour to Viet Nam and Cambodia. Information recorded included age, sex, number of days into the tour, the nature of the presenting illness, the assessment of the condition and the treatment employed during the field phase of 14 days. Travel was by air, train and coach, for a total period of 18 days. RESULTS: Nineteen (82%) travellers sought medical advice at least once for a total of 35 consultations. Females presented on 66% of occasions. The mean age of the travellers was 62 years (SD=13) with males being significantly older (p=0.002). Primary illnesses diagnosed related to the following systems: gastrointestinal 29%, respiratory 14%, dermatological 14%, cardiovascular 14%, musculoskeletal 9%, central nervous system 6%, ear/nose/throat 6%, dental 6%, and other problems on 3% of occasions. Of the gastrointestinal problems, diarrhoea was the commonest complaint on 17% of occasions, occurring at any stage throughout the journey. There was a mean of 2.5 presentations per day of the field phase of the tour. Presentations were highest on day 12. More than one third of presentations (37%) were handled conservatively without any further need for therapy, 17% requiring dressings, and 46% requiring specific medications. The commonest medications used were: lozenges/gargles (31%), antiemetic (25%), anti-diarrhoeal or other medications (13%). There were six accidents during the journey resulting in minor soft tissue injuries. There were no deaths or other major accidents requiring emergency evacuation or hospitalisation. CONCLUSIONS: On this premium seniors' tour, the health problems encountered were largely similar to those reported for other specialised tours, including premium expeditions. The most common medical problems included gastrointestinal, respiratory, dermatological, cardiovascular and musculoskeletal conditions in descending order. One aspect requiring further study is the psychological adjustments made by travellers on group tours and expeditions. As well as being part of the service provided to travellers, the inclusion of an expedition physician on this premium seniors' tour increased the independence of the travel group on this journey.

Illness and injury to travelers and access to dental care on a research expedition to Mongolia.

BACKGROUND: Expeditions provide an opportunity for travelers to undertake specialized travel to more extreme destinations in the security of an expeditionary group with medical coverage. Little is known about the illnesses and injuries occurring to expeditioners in Mongolia or access to dental care in the local population. This study was designed to investigate the prevalence of health problems suffered by travelers and managed among the local population on a research expedition to Mongolia. METHODS: In June 2005, the expedition physician (MTMS) and dentist (DD) prospectively diagnosed and recorded all illnesses and injuries among 16 travelers (eight males and eight females) as well as any indigenous people on a 22-day paleontological expedition to the Mongolian Gobi Desert. RESULTS: There were 53 health presentations and 14 dental problems among the indigenous population and the Mongolian escort. Males and females presented in equal proportions with the average age of 49 years (SD = 16). Presentations involved locomotor/accident (32%), dermatological (23%), gastrointestinal (19%), neurological (17%), psychological (6%), and with other systems (11%). Most accidents were due to lacerations (85%). Presentations were highest on days 4 and 5 (10% or 18%). Females were significantly more likely to present later in the expedition (p= 0.013). One quarter (25%) were handled conservatively with 28% requiring topical treatments with others requiring antiemetics (9%) and anti-inflammatory drugs (4%). There were no dental concerns reported among the expeditioners, although there were 14 cases among the indigenous population. While there were no deaths on the expedition, there were two major incidents, one of which required emergency evacuation. CONCLUSIONS: The health problems encountered were largely similar to those reported for other expeditions. The most common problems included trauma as well as dermatological, dental, gastrointestinal, and neurological conditions. It is important that expedition teams are prepared to manage common problems, such as trauma and dental lesions.

Rabies postexposure management of travelers presenting to travel health clinics in Auckland and Hamilton, New Zealand.

BACKGROUND: Rabies is a fatal disease, and travelers going to endemic areas need to take precautions. Little is known about the rabies postexposure management of travelers from New Zealand. METHODS: A total of 459 post-travel records from October 1998 until February 2006 at two travel medicine clinics, in Auckland and Hamilton, were examined for those who reported postexposure management to animals while abroad. RESULTS: Fifty-four patients were included, 48 (88.9%) were New Zealand residents and 52.0% were male. The mean age of exposed travelers was 30.4 years (SD = 15.5). There was an adult to child ratio of 5:1. The highest exposure risk group was those aged 16 to 30 years. South and Southeast Asia were the most prominent geographical regions where exposure occurred, with 45 (83.3%) of subjects being potentially exposed to rabies. Dogs were the commonest animals involved, accounting for two thirds of incidents (36; 66.7%). The commonest sites of animal exposure on the body were the thigh and lower leg (26; 48.1%) and the hand (10; 18.5%). Forty-six (85.2%) of the animal exposures were graded as World Health Organization (WHO) category III. Forty-nine (90.7%) of the travelers had not had preexposure prophylaxis. Once in New Zealand, the correct WHO postexposure prophylaxis regime was applied on 44 of 52 (84.6%) occasions. However, overall, only 25% of the sample received postexposure treatment consistent with WHO guidelines, reflecting inappropriate management abroad. CONCLUSIONS: Post-travel consultations at two New Zealand travel clinics were analyzed for prophylactic rabies postexposure management. The majority were travelers aged 16 to 30 years, who sustained WHO category III exposures to the lower limb in Asia, predominantly from dogs. Few of these travelers had been immunized prior to travel, and only 25% of them received postexposure prophylaxis consistent with WHO guidelines. Thus, 75% of the study sample remains at theoretical risk of contracting rabies due to inappropriate management overseas.

Illness and injury to travellers on a premium expedition along the Asian Silk Route.

BACKGROUND: Commercial expeditions provide an opportunity for travellers to undertake various specialised travel to more adventurous and extreme destinations in the relative security of an expeditionary group with medical cover provided by an expedition physician. Little is known about the illnesses and injuries occurring on premium expeditions to Asia. This present study was designed to investigate the prevalence of injury and illness suffered by travellers on a premium expedition along the Asian Silk Route. METHODS: In 2004, the expedition physician (MTMS) diagnosed and recorded all illnesses and injuries amongst 73 travellers on a premium expedition along the Asian Silk Route, a journey from Beijing to St Petersburg travelling through China, Kazakhstan, Uzbekistan and Russia. Information recorded included age, sex, number of days into the expedition, the nature of the presenting illness, the assessment of the condition and the treatment employed. The period of the expedition was for 27 days and travel was primarily by a private train, the China Orient Express. RESULTS: Forty-seven (64%) travellers sought medical advice at least once for a total of 97 consultations. Ninety-seven health presentations were reported and recorded amongst the travellers. Females presented on 54% occasions with the average age of expeditioners presenting being 64 years (SD=12) with males being significantly older (t=3.15, df=95; p=0.002). The types of primary illness diagnosed were largely those related to the following systems: respiratory 36%, gastrointestinal 21%, dermatological 8%, minor trauma 7%, ears, nose and throat 6%, musculoskeletal 5%, central nervous system 5% and other problems 12%. Of the gastrointestinal problems, diarrhoea was the most common single complaint on 19% of occasions, occurring throughout the journey. There was a mean of 3.5 presentations per day of the expedition. In total, the China phase of the trip (days 1-13) accounted for 42 presentations with phases in Kazakhstan (days 14-15), Uzbekistan (days 16-23) and Russia (days 24-28) accounting for 9, 29, and 17 presentations, respectively. Presentations were highest on day 18. More than one third of presentations (37%) were handled conservatively, and the rest required medication: 16% requiring antihistamine medications, 11% requiring antidiarrhoeal medications, 11% requiring antibiotics and 25% requiring other specific medications. There was one major accidental incident but no deaths or other emergencies. CONCLUSIONS: On this premium expedition, the health problems encountered were largely similar to those reported for other expeditions. The most common problems included respiratory, gastrointestinal, dermatological conditions and minor trauma in descending order. As well as being part of the service provided to travellers, the inclusion of an expedition physician on this premium expedition increased the independence of the travellers on this journey and decreased the reliance of the tour on local health services, a source which is often scarce or absent on more remote location expeditions.

Illness and injury to travellers on a premium expedition to Iceland.

BACKGROUND: Commercial expeditions provide an opportunity for travellers to undertake various specialised travel to more adventurous and extreme destinations in the relative security of an expeditionary group with medical cover provided by an expedition physician. Little is known about the illnesses and injuries occurring on premium expeditions. The present study was designed to investigate the prevalence of health problems suffered by travellers on a premium expedition to Iceland and the Arctic Circle. METHODS: In 2004, the expedition physician diagnosed and recorded all illnesses and injuries amongst 45 travellers on a premium expedition to Iceland. Information recorded included age, sex, number of days into the expedition, the nature of the presenting illness, the assessment of the condition and the treatment employed. The period of the expedition was for 18 days and travel was by chartered aircraft, cruise ship and bus. RESULTS: Thirty-one (69%) travellers sought medical advice at least once for a total of 54 consultations (mean=1.7). Fifty-six health presentations were reported and recorded amongst the travellers. Females presented on 70% occasions, with the average age of expeditioners presenting being 62 years. The types of primary illness diagnosed were largely those related to the following systems: respiratory 34%, gastrointestinal 30%, dermatological 14%, and musculoskeletal 9%, and other problems 13%. Of the gastrointestinal problems, seasickness was the most common single complaint on 27% of occasions, occurring between day 4 and 9, the cruise phase of the journey. In total, the cruise phase accounted for 43 medical presentations with the pre-cruise phase accounting for 11% of them and the post-cruise phase accounting for the remaining 46%. Presentations were highest on day 5. About one third of presentations (34%) were handled conservatively with 23% requiring antiemetics and 6% requiring antibiotics. There were no deaths or other major incidents requiring emergency evacuation or hospitalisation; although 6 accidents were reported. Interestingly, accidents were significantly more likely to occur earlier in the expedition (t-test; t=2.828, df=54, p=0.007). CONCLUSIONS: On this premium expedition, the health problems encountered were largely similar to those reported for other expeditions. The most common problems included respiratory, gastrointestinal, dermatological conditions and musculoskeletal conditions in descending order. As well as being part of the service provided to travellers, the inclusion of an expedition physician on this premium expedition increased the independence of the travellers on this journey, yet decreased the reliance on local health services, a source which is often scarce or absent on more remote location expeditions.

Travelling to china for the beijing 2008 olympic and paralympic games.

The 29th modern Olympic Summer Games, conducted once every 4 years since 1896, will be held in Beijing, China, from 8 to 24 August 2008. There will be approximately 28 major and 302 minor events in 37 venues in the prominent cities of Beijing, Hong Kong and Shanghai, and also in Qingdao (a coastal town in Shandong Province), Qinhuangdao (northeast of Beijing), Shanghai, Shenyang (an industrial city in Liaoning Province) and in Tianjin (on the coast near Beijing). Following the Olympic Games, the Paralympic Games will be conducted from 6 to 17 September 2008 in Beijing and 20 Paralympic Sports will be represented. This paper focuses on health and safety issues for travellers to China in general, although it makes specific references to advice for visiting Olympic and Paralympic athletes and team staff, who will be travelling to the games. It must be remembered that travel health advice can change, and that travellers should be advised to seek up-to-date travel health advice for China closer to their departure.

A case of exposure to Bancroftian filariasis in a traveller to Thailand.

A New Zealander travelling recreationally to Asia became exposed to Bancroftian filariasis. The traveller had presented incidentally with gastrointestinal illness. In addition to diarrhoea, the traveller's symptoms were non-specific and there was no eosinophilia, lymphoedema, lymphangitis, lymphadenitis, or pain. The immunochromatographic test for Wuchereria bancrofti was positive indicating that there was or had been an adult filarial worm. The illness resolved completely following treatment with ivermectin.

Life and death on the Amazon: illness and injury to travelers on a South American expedition.

BACKGROUND: Commercial expeditions provide an opportunity for travelers to undertake various specialized travel to more adventurous destinations in the relative security of an expeditionary group. Little is known about the illnesses and injuries occurring on such expeditions. METHODS: From the commencement of the Blake Expedition in 2001, the expedition physician recorded all illnesses and injuries reported among the crew and also among the indigenous people encountered, while undertaking the expedition. The duration of the expedition was two and a half months, and involved travel by yacht, riverboat and jungle canoe or "bongo". The crew numbered 26 personnel: 24 men, including the expedition physician, and two women. RESULTS: Seventy-eight health problems were reported and recorded among 19 (73.1%) members of the expeditionary team. There was one death, but there were no other major incidents requiring emergency evacuation or hospitalization. Types of illness were largely those related to ear, nose and throat disease (15/78, 19%), injuries (12/87, 15%), bites and stings (12/87, 15%), and respiratory (10/78, 13%), dermatologic (9/78, 12%) and gastroenterologic conditions (7/78, 9%). A further 24 health problems were reported and recorded among 22 indigenous people who approached the expedition physician for treatment. Types of illness were largely related to dermatologic conditions (9/24, 38%), accidents and injuries (4/24, 17%), and malaria (4/24, 17%). CONCLUSIONS: This expedition was both noteworthy and newsworthy because of the death of the team leader, Sir Peter Blake, although the health problems encountered were largely similar to those reported for other expeditions. Tropical disease was uncommon. Adequate pre-trip preparation of expedition teams is considered important, and the inclusion of an expedition physician decreased the reliance on local health services, which are often scarce or absent on more remote-location expeditions. Adequate psychological preparation of expedition teams should also be included, to prepare expedition teams for unexpected outcomes, such as death or severe injury.