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After recreational exposure to river water in Uganda, 12 (17%) of 69 persons had evidence of schistosome infection. Eighteen percent self-medicated with praziquantel prophylaxis immediately after exposure, which was not appropriate. Travelers to schistosomiasis-endemic areas should consult a travel medicine physician. [ABSTRACT FROM AUTHOR]

Summary: We assess risks of communicable diseases that are associated with mass gatherings (MGs), outline approaches to risk assessment and mitigation, and draw attention to some key challenges encountered by organisers and participants. Crowding and lack of sanitation at MGs can lead to the emergence of infectious diseases, and rapid population movement can spread them across the world. Many infections pose huge challenges to planners of MGs; however, these events also provide an opportunity to engage in public health action that will benefit host communities and the countries from which participants originate. [ABSTRACT FROM AUTHOR]

Introduction: When Zika virus (ZIKV) first began its spread from Brazil to other parts of the Americas, national-level travel notices were issued, carrying with them significant economic consequences to affected countries. Although regions of some affected countries were likely unsuitable for mosquito-borne transmission of ZIKV, the absence of high quality, timely surveillance data made it difficult to confidently demarcate infection risk at a sub-national level. In the absence of reliable data on ZIKV activity, a pragmatic approach was needed to identify subnational geographic areas where the risk of ZIKV infection via mosquitoes was expected to be negligible. To address this urgent need, we evaluated elevation as a proxy for mosquito-borne ZIKV transmission. Methods: For sixteen countries with local ZIKV transmission in the Americas, we analyzed (i) modelled occurrence of the primary vector for ZIKV, Aedes aegypti, (ii) human population counts, and (iii) reported historical dengue cases, specifically across 100-meter elevation levels between 1,500m and 2,500m. Specifically, we quantified land area, population size, and the number of observed dengue cases above each elevation level to identify a threshold where the predicted risks of encountering Ae. aegypti become negligible. Results: Above 1,600m, less than 1% of each country’s total land area was predicted to have Ae. aegypti occurrence. Above 1,900m, less than 1% of each country’s resident population lived in areas where Ae. aegypti was predicted to occur. Across all 16 countries, 1.1% of historical dengue cases were reported above 2,000m. Discussion: These results suggest low potential for mosquito-borne ZIKV transmission above 2,000m in the Americas. Although elevation is a crude predictor of environmental suitability for ZIKV transmission, its constancy made it a pragmatic input for policy decision-making during this public health emergency. [ABSTRACT FROM AUTHOR]

During 2013, the Maryland Department of Health and Mental Hygiene in Baltimore, MD, USA, received report of 2 Maryland residents whose surgical sites were infected with rapidly growing mycobacteria after cosmetic procedures at a clinic (clinic A) in the Dominican Republic. A multistate investigation was initiated; a probable case was defined as a surgical site infection unresponsive to therapy in a patient who had undergone cosmetic surgery in the Dominican Republic. We identified 21 case-patients in 6 states who had surgery in 1 of 5 Dominican Republic clinics; 13 (62%) had surgery at clinic A. Isolates from 12 (92%) of those patients were culture-positive for Mycobacterium abscessus complex. Of 9 clinic A case-patients with available data, all required therapeutic surgical intervention, 8 (92%) were hospitalized, and 7 (78%) required ≥3 months of antibacterial drug therapy. Healthcare providers should consider infection with rapidly growing mycobacteria in patients who have surgical site infections unresponsive to standard treatment. [ABSTRACT FROM AUTHOR]

The article reports on the World Health Organization (WHO)-recommended strategy on screening all individuals for Ebola virus disease (Ebola) when entering and exiting airports in West Africa (WA). Topics covered include implementation of the procedure in August 2014 by WA health ministries with global partners such as the U.S. Centers for Disease Control and Prevention (CDC). Also mentioned most Ebola affected WA countries including Guinea, Liberia and Sierra Leone.

Recent manufacturing problems resulted in a shortage of the only U.S.-licensed yellow fever vaccine. This shortage is expected to lead to a complete depletion of yellow fever vaccine available for the immunization of U.S. travelers by mid-2017. CDC, the Food and Drug Administration (FDA), and Sanofi Pasteur are collaborating to ensure a continuous yellow fever vaccine supply in the United States. As part of this collaboration, Sanofi Pasteur submitted an expanded access investigational new drug (eIND) application to FDA in September 2016 to allow for the importation and use of an alternative yellow fever vaccine manufactured by Sanofi Pasteur France, with safety and efficacy comparable to the U.S.-licensed vaccine; the eIND was accepted by FDA in October 2016. The implementation of this eIND protocol included developing a systematic process for selecting a limited number of clinic sites to provide the vaccine. CDC and Sanofi Pasteur will continue to communicate with the public and other stakeholders, and CDC will provide a list of locations that will be administering the replacement vaccine at a later date. [ABSTRACT FROM AUTHOR]

We assessed rabies vaccine ( RV) and immune globulin ( RIG) availability on the local market by querying US Embassy medical staff worldwide. Of 112 responses, 23% were from West, Central, and East Africa. RV and RIG availability varied by region. Possible rabies exposures accounted for 2% of all travelers' health inquiries. [ABSTRACT FROM AUTHOR]

Costs and benefits of malaria prevention are provided during domestic pretravel health consultations. Healthcare payers always, and travelers often, save money when travelers adhere to malaria recommendations and prophylactic regimens in West Africa, especially for longer durations of travel.Background. Pretravel health consultations help international travelers manage travel-related illness risks through education, vaccination, and medication. This study evaluated costs and benefits of that portion of the health consultation associated with malaria prevention provided to US travelers bound for West Africa.Methods. The estimated change in disease risk and associated costs and benefits resulting from traveler adherence to malaria chemoprophylaxis were calculated from 2 perspectives: the healthcare payer's and the traveler's. We used data from the Global TravEpiNet network of US travel clinics that collect de-identified pretravel data for international travelers. Disease risk and chemoprophylaxis effectiveness were estimated from published medical reports. Direct medical costs were obtained from the Nationwide Inpatient Sample and published literature.Results. We analyzed 1029 records from January 2009 to January 2011. Assuming full adherence to chemoprophylaxis regimens, consultations saved healthcare payers a per-traveler average of $14 (9-day trip) to $372 (30-day trip). For travelers, consultations resulted in a range of net cost of $20 (9-day trip) to a net savings of $32 (30-day trip). Differences were mostly driven by risk of malaria in the destination country.Conclusions. Our model suggests that healthcare payers save money for short- and longer-term trips, and that travelers save money for longer trips when travelers adhere to malaria recommendations and prophylactic regimens in West Africa. This is a potential incentive to healthcare payers to offer consistent pretravel preventive care to travelers. This financial benefit complements the medical benefit of reducing the risk of malaria. [ABSTRACT FROM PUBLISHER]

Background Children frequently travel internationally. Health-related data on such children are limited. We sought to investigate the demographics, health characteristics, and preventive interventions of outbound US international pediatric travelers. Methods We analyzed data from 32 099 travelers presenting for pre-travel healthcare at the Global TravEpiNet (GTEN), a national consortium of 19 travel clinics, from January 1, 2009 to June 6, 2012. Results A total of 3332 (10%) of all GTEN travelers were children (<18 years of age). These children traveled mostly for leisure (36%) or to visit friends or relatives (VFR) (36%). Most popular destination regions were Africa (41%), Southeast Asia (16%), Central America (16%), and the Caribbean (16%). Compared with children traveling for leisure, VFR children were more likely to present <14 days before departure for pre-travel consultation (44% vs 28%), intended to travel for 28 days or longer (70% vs 22%), and to travel to Africa (62% vs 32%). Nearly half of the pediatric travelers (46%) received at least 1 routine vaccine, and most (83%) received at least 1 travel-related vaccine. Parents or guardians of one third of the children (30%) refused at least 1 recommended travel-related vaccine. Most pediatric travelers visiting a malaria-endemic country (72%) received a prescription for malaria chemoprophylaxis. Conclusions Ten percent of travelers seeking pre-travel healthcare at GTEN sites are children. VFR-travel, pre-travel consultation close to time of departure, and refusal of recommended vaccines may place children at risk for travel-associated illness. Strategies to engage pediatric travelers in timely, pre-travel care and improve acceptance of pre-travel healthcare interventions are needed. [ABSTRACT FROM PUBLISHER]

Background Rabies, which is globally endemic, poses a risk to international travelers. To improve recommendations for travelers, we assessed the global availability of rabies vaccine ( RV) and rabies immune globulin ( RIG). Methods We conducted a 20-question online survey, in English, Spanish, and French, distributed via e-mail to travel medicine providers and other clinicians worldwide from February 1 to March 30, 2011. Results were compiled according to the region. Results Among total respondents, only 190 indicated that they provided traveler postexposure care. Most responses came from North America (38%), Western Europe (19%), Australia and South and West Pacific Islands (11%), East and Southeast Asia (8%), and Southern Africa (6%). Approximately one third of 187 respondents stated that patients presented with wounds from an animal exposure that were seldom or never adequately cleansed. RIG was often or always accessible for 100% ( n = 5) of respondents in the Middle East and North Africa; 94% ( n = 17) in Australia and South and West Pacific Islands; 20% ( n = 1) in Tropical South America; and 56% ( n = 5) in Eastern Europe and Northern Asia. Ninety-one percent ( n = 158) of all respondents reported that RV was often or always accessible. For all regions, 35% ( n = 58) and 26% ( n = 43) of respondents felt that the cost was too high for RIG and RV, respectively. Conclusion The availability of RV and RIG varied by geographic region. All travelers should be informed that RIG and RV might not be readily available at their destination and that travel health and medical evacuation insurance should be considered prior to departure. Travelers should be educated to avoid animal exposures; to clean all animal bites, licks, and scratches thoroughly with soap and water; and to seek medical care immediately, even if overseas. [ABSTRACT FROM AUTHOR]

Background. Infectious disease specialists who evaluate international travelers before or after their trips need skills to prevent, recognize, and treat an increasingly broad range of infectious diseases. Wide variation exists in training and percentage effort among providers of this care. In parallel, there may be variations in approach to pre-travel consultation and the types of travel-related illness encountered. Aggregate information from travel-medicine providers may reveal practice patterns and novel trends in infectious illness acquired through travel. Methods. The 1,265 members of the Infectious Disease Society of America's Emerging Infections Network were queried by electronic survey about their training in travel medicine, resources used, pre-travel consultations, and evaluation of ill-returning travelers. The survey also captured information on whether any of 10 particular conditions had been diagnosed among ill-returning travelers, and if these diagnoses were perceived to be changing in frequency. Results. A majority of respondents (69%) provided both pre-travel counseling and post-travel evaluations, with significant variation in the numbers of such consultations. A majority of all respondents (61%) reported inadequate training in travel medicine during their fellowship years. However, a majority of recent graduates (55%) reported adequate preparation. Diagnoses of malaria, traveler's diarrhea, and typhoid fever were reported by the most respondents (84, 71, and 53%, respectively). Conclusions. The percent effort dedicated to pre-travel evaluation and care of the ill-returning traveler vary widely among infectious disease specialists, although a majority participate in these activities. On the basis of respondents' self-assessment, recent fellowship training is reported to equip graduates with better skills in these areas than more remote training. Ongoing monitoring of epidemiologic trends of travel-related illness is warranted. [ABSTRACT FROM AUTHOR]

Typhoid fever continues to be an important concern for travelers visiting many parts of the world. This communication provides updated guidance for pre-travel typhoid vaccination from the US Centers for Disease Control and Prevention (CDC) and describes the methodology for assigning country-specific recommendations. [ABSTRACT FROM AUTHOR]

Background: Globally mobile populations are at higher risk of acquiring geographically restricted infections and may play a role in the international spread of infectious diseases. Despite this, data about sources of health information used by international travelers are limited.Methods: We surveyed 1,254 travelers embarking from Boston Logan International Airport regarding sources of health information. We focused our analysis on travelers to low or low-middle income (LLMI) countries, as defined by the World Bank 2009 World Development Report.Results: A total of 476 survey respondents were traveling to LLMI countries. Compared with travelers to upper-middle or high income (UMHI) countries, travelers to LLMI countries were younger, more likely to be foreign-born, and more frequently reported visiting family as the purpose of their trip. Prior to their trips, 46% of these travelers did not pursue health information of any type. In a multivariate analysis, being foreign-born, traveling alone, traveling for less than 14 days, and traveling for vacation each predicted a higher odds of not pursuing health information among travelers to LLMI countries. The most commonly cited reason for not pursuing health information was a lack of concern about health problems related to the trip. Among travelers to LLMI countries who did pursue health information, the internet was the most common source, followed by primary care practitioners. Less than a third of travelers to LLMI countries who sought health information visited a travel medicine specialist.Conclusions: In our study, 46% of travelers to LLMI countries did not seek health advice prior to their trip, largely due to a lack of concern about health issues related to travel. Among travelers who sought medical advice, the internet and primary care providers were the most common sources of information. These results suggest the need for health outreach and education programs targeted at travelers and primary care practitioners. [ABSTRACT FROM AUTHOR]

Globally mobile populations are at higher risk of acquiring geographically restricted infections and may play a role in the international spread of infectious diseases. Despite this, data about sources of health information used by international travelers are limited. We surveyed 1,254 travelers embarking from Boston Logan International Airport regarding sources of health information. We focused our analysis on travelers to low or low-middle income (LLMI) countries, as defined by the World Bank 2009 World Development Report. A total of 476 survey respondents were traveling to LLMI countries. Compared with travelers to upper-middle or high income (UMHI) countries, travelers to LLMI countries were younger, more likely to be foreign-born, and more frequently reported visiting family as the purpose of their trip. Prior to their trips, 46% of these travelers did not pursue health information of any type. In a multivariate analysis, being foreign-born, traveling alone, traveling for less than 14 days, and traveling for vacation each predicted a higher odds of not pursuing health information among travelers to LLMI countries. The most commonly cited reason for not pursuing health information was a lack of concern about health problems related to the trip. Among travelers to LLMI countries who did pursue health information, the internet was the most common source, followed by primary care practitioners. Less than a third of travelers to LLMI countries who sought health information visited a travel medicine specialist. In our study, 46% of travelers to LLMI countries did not seek health advice prior to their trip, largely due to a lack of concern about health issues related to travel. Among travelers who sought medical advice, the internet and primary care providers were the most common sources of information. These results suggest the need for health outreach and education programs targeted at travelers and primary care practitioners. [ABSTRACT FROM AUTHOR]

Abstract: Yellow fever (YF) vaccine has been used for prevention of YF since 1937 with over 500 million doses administered. However, rare reports of severe adverse events following vaccination have raised concerns about the vaccine’s safety. We reviewed reports of adverse events following YF vaccination reported to the U.S. Vaccine Adverse Event Reporting System (VAERS) from 2000 to 2006. We used estimates of age and sex distribution of administered doses obtained from a 2006 survey of authorized vaccine providers to calculate age- and sex-specific reporting rates of all serious adverse events (SAE), anaphylaxis, YF vaccine-associated neurotropic disease, and YF vaccine-associated viscerotropic disease. Reporting rates of SAEs were substantially higher in males and in persons aged ≥60 years. These findings reinforce the generally acceptable safety profile of YF vaccine, but highlight the importance of physician and traveler education regarding the risks and benefits of YF vaccination, particularly for travelers ≥60 years of age. Vaccination should be limited to persons traveling to areas where the risk of YF is expected to exceed the risk of serious adverse events after vaccination, or if not medically contraindicated, where national regulations require proof of vaccination to prevent introduction of YF. [Copyright &y& Elsevier]

A letter to the editor is presented on the exposure of U.S. travelers to rabid zebra in Kenya.

Background: The types of place names and the level of geographic detail that patients report to clinicians regarding their intended travel itineraries vary. The reported place names may not match those in published travel health recommendations, making traveler-specific recommendations potentially difficult and time-consuming to identify. Most published recommendations are at the country level; however, subnational recommendations exist when documented disease risk varies within a country, as for malaria and yellow fever. Knowing the types of place names reported during consultations would be valuable for developing more efficient ways of searching and identifying recommendations, hence we inventoried these descriptors and identified patterns in their usage.Methods: The data analyzed were previously collected individual travel itineraries from pretravel consultations performed at Global TravEpiNet (GTEN) travel clinic sites. We selected a clinic-stratified random sample of records from 18 GTEN clinics that contained responses to an open-ended question describing itineraries. We extracted and classified place names into nine types and analyzed patterns relative to common travel-related demographic variables.Results: From the 1756 itineraries sampled, 1570 (89%) included one or more place names, totaling 3366 place names. The frequency of different types of place names varied considerably: 2119 (63%) populated place, 336 (10%) tourist destination, 283 (8%) physical geographic area, 206 (6%) vague subnational area, 163 (5%) state, 153 (5%) country, 48 (1%) county, 12 (1%) undefined.Conclusions: The types of place names used by travelers to describe travel itineraries during pretravel consultations were often different from the ones referenced in travel health recommendations. This discrepancy means that clinicians must use additional maps, atlases or online search tools to cross-reference the place names given to the available recommendations. Developing new clinical tools that use geographic information systems technology would make it easier and faster for clinicians to find applicable recommendations for travelers. [ABSTRACT FROM AUTHOR]

Background: International travel can expose travellers to pathogens not commonly found in their countries of residence, like dengue virus. Travellers and the clinicians who advise and treat them have unique needs for understanding the geographic extent of risk for dengue. Specifically, they should assess the need for prevention measures before travel and ensure appropriate treatment of illness post-travel. Previous dengue-risk maps published in the Centers for Disease Control and Prevention's Yellow Book lacked specificity, as there was a binary (risk, no risk) classification. We developed a process to compile evidence, evaluate it and apply more informative risk classifications.Methods: We collected more than 839 observations from official reports, ProMED reports and published scientific research for the period 2005-2014. We classified each location as frequent/continuous risk if there was evidence of more than 10 dengue cases in at least three of the previous 10 years. For locations that did not fit this criterion, we classified locations as sporadic/uncertain risk if the location had evidence of at least one locally acquired dengue case during the last 10 years. We used expert opinion in limited instances to augment available data in areas where data were sparse.Results: Initial categorizations classified 134 areas as frequent/continuous and 140 areas as sporadic/uncertain. CDC subject matter experts reviewed all initial frequent/continuous and sporadic/uncertain categorizations and the previously uncategorized areas. From this review, most categorizations stayed the same; however, 11 categorizations changed from the initial determinations.Conclusions: These new risk classifications enable detailed consideration of dengue risk, with clearer meaning and a direct link to the evidence that supports the specific classification. Since many infectious diseases have dynamic risk, strong geographical heterogeneities and varying data quality and availability, using this approach for other diseases can improve the accuracy, clarity and transparency of risk communication. [ABSTRACT FROM AUTHOR]