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Rationale for review Chikungunya outbreaks continue to occur, with changing epidemiology. Awareness about chikungunya is low both among the at-risk travellers and healthcare professionals, which can result in underdiagnosis and underreporting. This review aims to improve awareness among healthcare professionals regarding the risks of chikungunya for travellers. Key findings Chikungunya virus transmission to humans occurs mainly via daytime-active mosquitoes, Aedes aegypti and Aedes albopictus. The areas where these mosquitoes live is continuously expanding, partly due to climate changes. Chikungunya is characterized by an acute onset of fever with joint pain. These symptoms generally resolve within 1–3 weeks, but at least one-third of the patients suffer from debilitating rheumatologic symptoms for months to years. Large outbreaks in changing regions of the world since the turn of the 21st century (e.g. Caribbean, La Réunion; currently Brazil, India) have resulted in growing numbers of travellers importing chikungunya, mainly to Europe and North America. Viremic travellers with chikungunya infection have seeded chikungunya clusters (France, United States of America) and outbreaks (Italy in 2007 and 2017) in non-endemic countries where Ae. albopictus mosquitoes are present. Community preventive measures are important to prevent disease transmission by mosquitoes. Individual preventive options are limited to personal protection measures against mosquito bites, particularly the daytime-active mosquitos that transmit the chikungunya virus. Candidate vaccines are on the horizon and regulatory authorities will need to assess environmental and host risk factors for persistent sequelae, such as obesity, age (over 40 years) and history of arthritis or inflammatory rheumatologic disease to determine which populations should be targeted for these chikungunya vaccines. Conclusions/recommendations Travellers planning to visit destinations with active CHIKV circulation should be advised about the risk for chikungunya, prevention strategies, the disease manifestations, possible chronic rheumatologic sequelae and, if symptomatic, seek medical evaluation and report potential exposures.

Background This phase 3b randomized, open‐label study evaluated the immunogenicity and safety of coadministration of a hepatitis A and/or B vaccine with a quadrivalent oligosaccharide meningococcal CRM197‐conjugate vaccine (MenACWY‐CRM), in the context of an accelerated hepatitis A and/or B immunization schedule. Methods A total of 252 healthy adult subjects were randomized to three groups to receive hepatitis A/B only (HepA/B), hepatitis A/B coadministered with MenACWY‐CRM (HepA/B+MenACWY‐CRM), or MenACWY‐CRM only (MenACWY‐CRM). Hepatitis A and/or B vaccination was administered in the form of a single booster dose or a primary three‐dose series, depending on the hepatitis A and/or B vaccination history of subjects. Antibody responses to hepatitis A/B vaccination were assessed 1 month following the last hepatitis A and/or B dose. Serum bactericidal activity with human complement (hSBA) against meningococcal serogroups A, C, W‐135, and Y was assessed 1 month post‐MenACWY‐CRM vaccination. Safety was monitored throughout the study. Results At 1 month following the final hepatitis A and/or B vaccination, concomitant administration of hepatitis A/B and MenACWY‐CRM was non‐inferior to administration of hepatitis A/B alone in terms of geometric mean concentrations of antibodies against the hepatitis A and B antigens. One month post‐MenACWY‐CRM vaccination, the percentages of subjects achieving hSBA titers ≥8 for serogroups A, C, W‐135, and Y in the HepA/B+MenACWY‐CRM group (76, 87, 99, and 94%, respectively) were comparable to those in the MenACWY‐CRM group (67, 82, 96, and 88%, respectively). The percentages of subjects reporting adverse events (AEs) were similar across study groups and a majority of the reported AEs were mild to moderate in nature. There were no study vaccine‐related serious AEs. Conclusions MenACWY‐CRM can be administered concomitantly with a hepatitis A and/or B vaccine in the context of an accelerated hepatitis A and/or B immunization schedule without increasing safety concerns or compromising the immune responses to any of the vaccine antigens. [[NCT01453348][1]] [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT01453348&atom=%2Fjtm%2F22%2F2%2F105.atom

Background Compact and short pre‐travel immunization schedules, which include several vaccinations in a single visit, are desirable for many travelers. However, concomitant vaccination could potentially compromise immunogenicity and/or safety of the individual vaccines and, therefore, possible vaccine interferences should be carefully assessed. This article discusses the immunogenicity and safety of travel vaccines for typhoid fever (TF) and yellow fever (YF), when administered with or without a quadrivalent meningococcal glycoconjugate ACWY‐CRM vaccine (MenACWY‐CRM). Methods Healthy adults (18–≤60 years) were randomized to one of three vaccine regimens: TF + YF + MenACWY‐CRM (group I; n = 100), TF + YF (group II; n = 101), or MenACWY‐CRM (group III; n = 100). Immunogenicity at baseline and 4 weeks post‐vaccination (day 29) was assessed by serum bactericidal assay using human complement (hSBA), enzyme‐linked immunosorbent assay (ELISA), or a neutralization test. Adverse events (AEs) and serious adverse events (SAEs) were collected throughout the study period. Results Non‐inferiority of post‐vaccination geometric mean concentrations (GMCs) and geometric mean titers (GMTs) was established for TF and YF vaccines, respectively, when given concomitantly with MenACWY‐CRM vaccine versus when given alone. The percentages of subjects with seroprotective neutralizing titers against YF on day 29 were similar in groups I and II. The antibody responses to meningococcal serogroups A, C, W‐135, and Y were within the same range when MenACWY‐CRM was given separately or together with TF and YF vaccines. The percentage of subjects reporting AEs was the same for TF and YF vaccines with or without MenACWY‐CRM vaccine. There were no reports of SAEs or AEs leading to study withdrawals. Conclusions These data provide evidence that MenACWY‐CRM can be administered with typhoid Vi polysaccharide vaccine and live attenuated YF vaccine without compromising antibody responses stimulated by the individual vaccines. MenACWY‐CRM can, therefore, be incorporated into travelers' vaccination programs without necessitating an additional clinic visit ([NCT01466387][1]). [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT01466387&atom=%2Fjtm%2F22%2F1%2F48.atom

Background A patch vaccine containing heat-labile toxin (LT) from enterotoxigenic Escherichia coli (ETEC) has demonstrated to be beneficial in reducing the rate and severity of travelers' diarrhea in Latin America. To evaluate the efficacy of this transdermal vaccine system in an area with a different diarrheal pathogen profile, an additional phase 2 study was conducted in European travelers to India. Methods For this multicenter, randomized, double-blinded, placebo-controlled field study 723 subjects were recruited; 603 (299 LT vaccine, 304 placebo) were included in the per-protocol-population (PPP). Results Although the LT patch induced a measurable LT immune response in recipients, it failed to protect against LT ETEC or all-cause diarrhea. In the PPP the incidence rate of diarrhea as per primary endpoint was 6.0% (18 of 299) in the vaccine group and 5.9% (18 of 304) in the placebo group. Additionally, lower than expected rates of LT ETEC diarrheas were observed in India. The vaccine delivery system frequently produced rash and pruritus at the site of application, long term hyperpigmentation persisted in a minority of LT recipients, and also few site reactions were noted in the placebo group. Conclusions The evaluated patch vaccine failed to satisfy mainly with respect to protective efficacy. Noninvasive prophylactic agents against travelers' diarrhea, particularly vaccines against the most frequent pathogens, thus continue to be badly needed.

Conventional rabies pre-exposure prophylaxis (PrEP) and Japanese encephalitis (JE) primary series vaccination regimens each require up to 4 weeks to complete and, thus, may not be feasible for individuals who need these immunizations on short notice. This Phase 3b, randomized, controlled, observer-blind study evaluated the immunogenicity and safety of concomitant administration of a purified chick embryo cell culture rabies vaccine and an inactivated, adsorbed JE vaccine according to an accelerated (1 week) regimen when compared with the conventional regimens (4 weeks). This report describes the kinetics of immune responses up to 1 year after vaccination.A total of 661 healthy adults (18 to ≤65 years) were randomized into the following accelerated or conventional vaccine regimens: Rabies + JE-Conventional, Rabies + JE-Accelerated, Rabies-Conventional and JE-Conventional. Immunogenicity was assessed by virus neutralization tests. Safety and tolerability were also evaluated.Irrespective of rabies vaccination regimen, ≥97% of subjects had adequate levels of rabies virus neutralizing antibody (RVNA) concentrations (≥0.5 IU/ml) up to Day 57, with percentages of subjects with RVNA concentrations ≥0.5 IU/ml at Day 366 ranging between 68% in the Rabies + JE-Accelerated group and 80% of subjects in the Rabies-Conventional group. The Rabies + JE-Accelerated group revealed high JE neutralizing antibody titers at all-time points. At Day 366, the percentage of subjects with antibody titers indicative of seroprotection (PRNT50 titers ≥1:10) remained high across JE vaccine groups (86-94%).The accelerated PrEP rabies and JE vaccination regimens, once licensed, could represent a valid alternative in the short-term to currently recommended conventional regimens. The concomitant administration of these two vaccines does not compromise immune responses to any of the vaccine antigens particularly when aiming for short-term protection. Further evidence will clarify the need for and timing to administration of rabies vaccine booster doses in subjects primed with an accelerated PrEP regimen. (NCT01662440).

Background Malaria poses a significant threat to military personnel stationed in endemic areas; therefore, it is important to examine the risks of military operations, particularly in areas where malaria-related data are scarce. The recent deployment of Japan Ground Self-Defense Force (JGSDF) for a peacekeeping operation in East Timor provided an opportunity to investigate these risks. The results of these studies may be translated into chemoprophylactic strategies for travelers. Methods A total of 1,876 members were deployed between April 2002 and September 2003. They consisted of three battalions; each remained for 6 months and was put on mefloquine prophylaxis. Malaria infection was investigated, including exposure to Plasmodium falciparum sporozoites, assessed by seroconversion for anticircumsporozoite (anti-CS) protein antibodies. Adherence to and adverse events (AEs) of mefloquine were studied via questionnaires. Results Four members were evacuated: one each with optic neuritis, lung cancer with brain metastasis, IgA nephropathy, and psychotic reactions that may have been precipitated by mefloquine. Six clinical episodes of Plasmodium vivax occurred, including one relapse, but there were no clinical cases of P falciparum, yielding a crude malaria attack rate of 0.32% for the 6-month period. Overall, 3.1% of the study population seroconverted for the anti-CS protein antibodies, with some regional differences noted. About 24% of questionnaire respondents, reported AEs; however, none of the AEs was severe. The AEs tended to emerge during the initial doses of chemoprophylaxis. Conclusions The implementation of mefloquine prophylaxis among JGSDF personnel in East Timor, where P falciparum constitutes a moderate risk, appears to have been a success. Mefloquine prophylaxis was generally safe for Japanese unless predisposed to neuropsychiatric illness. However, given that mefloquine is the only chemoprophylactic agent available, a risk-benefit analysis tailored to the traveler is required for visits to countries such as East Timor.

Background: Traveling to tropical regions is related to increased health risks. Travelers' diarrhea is the most frequent health problem, but the range of travel-related diseases also includes potential life-threatening diseases such as malaria. The actual risk of European travelers acquiring specific infectious diseases and other hazards in the tropics is to a large extent unknown and is therefore often adopted from that of the indigenous population. The objective of this study was to elucidate the risk for travel-related diseases, symptoms, and accidents in a population of Europeans who travel to popular tourist destinations. Methods: From July 2003 to June 2004, 794 travelers consulting the travel clinic of the Berlin Institute of Tropical Medicine were recruited for a questionnaire-based observational study before traveling to Kenya, Tanzania, Senegal, the Gambia, India, Nepal, Thailand, or Brazil. Results: Overall, illness was reported by 42.9% of travelers, with 10.2% reporting more than one adverse health event. Most frequently gastrointestinal symptoms were noted (34.6%), followed by respiratory symptoms (13.7%). More than 5% experienced an accident. Travel to the Indian subcontinent nearly doubled the risk of becoming ill; travel to Thailand significantly decreased the risk. Additional risk factors were a long duration of staying abroad, young age, and traveling under basic conditions. Of all travelers, 80% did not follow the traditionally recommended dietary restrictions. Among travelers visiting malaria-endemic areas, 20% did not carry any antimalarial drugs with them, not continuous chemoprophylaxis or standby medication. Conclusions: Because of the rising travel activity, especially to tropical countries, the importance of qualified pretravel advice consultation is increasing. To improve the travelers' health, attention needs to be paid to individual risk factors, the prevention and therapy of travelers' diarrhea, malaria prophylaxis, management of respiratory illness, and personal safety.

Background: Giardiasis has been well characterized in individuals traveling from areas of low to high endemicity. Methods: Clinical features, travel and medical histories in 352 patients with giardiasis who presented to a German outpatient clinic for Infectious and Tropical Diseases were investigated in order to identify common epidemiological factors and potential strategies of prevention. Results: Compared to the total patient population of the outpatient clinic during the period of investigation (n=13, 566 patients), patients who presented with giardiasis traveled longer (median 28 days versus 19 days, p < .001). While only 19.2% of the total patient population had traveled to the Indian subcontinent prior to referral, 32.1% of the patients with giardiasis acquired the infection there (p < .0001). Similar results were obtained for West Africa: in contrast to 19% of patients with giardiasis (p < .0001), only 5.4% of the total patient population traveled there. Conclusion: The risk of infection appears to be highest when making an extended journey to the Indian subcontinent. Short‐time visitors to other parts of Asia and Latin America are apparently at a markedly lower risk. Risk factors such as type, duration and destination of the journey should be considered in pretravel counseling.

Few diseases match the global impact of hepatitis A in terms of affected individuals. The disease is mainly transmitted by oral-fecal route with a very high attack rate and asymptomatic individuals, mainly young children, posing as transmission hosts. Improved sanitary conditions in many parts of the world have caused changes in the epidemiological situation: a shift can be observed towards HAV infection occurring later in life, when the likelihood of symptomatic disease is much higher. As the number of susceptible individuals in adolescence and early adulthood in countries with intermediate endemicity increases, the risk of epidemics with large numbers of clinically apparent infections is rising. Highly protective inactivated vaccines have become available in the last years as an effective protective measure against HAV. Immunization programs for children and adolescents in areas with decreasing incidence of hepatitis A appear advisable. Without doubt, hepatitis A is a disease with considerable global impact. It accounts for 20‐25% of clinical hepatitis worldwide. 1 The worldwide reported incidence of this disease is averaging 1.4 million cases/year but estimates for the true incidence are commonly placed 3‐10 times higher. 2 The problem of underreporting is particularly great: a considerable percentage of patients remain unnotified due to the frequently mild course of clinical disease. Within the United States, acute hepatitis is most commonly caused by hepatitis A virus (HAV): it accounts for approximately 47% of all cases. 3 In the period from 1984 until 1993,between 43,012 and 64,075 cases of acute hepatitis were reported annually, 4 with many more remaining unreported. Hepatitis A virus (HAV) is

Background Due to time constrains imposed by pending departure dates of travelers, the application of multiple vaccinations is commonly practiced in pretravel counseling. However, data regarding the tolerability of schedules with simultaneous vaccinations with different products are sparse. Method In order to investigate effects of this practice, a prospective study was conducted with 1,183 healthy travelers who presented prior to their departure. Standardized questionnaires covering possible side effects were collected during and after vaccination. Results Results showed an increase of the overall frequency of side effects with an increasing number of simultaneously applied vaccines. In travelers with two or more vaccinations, side effects occurred less frequently than previously published. In double vaccinations, side effects occurred in 36.7% of vaccinees, triple vaccinations in 40.3%, in more than three vaccinations in 50.0%. Subjective rating by the vaccinees showed an excellent tolerability of multiple vaccinations. Conclusion Multiple vaccines can be given at the same time with limited subjective side effects. These findings may increase the acceptability of vaccinations given in combination to travelers.

Background: Schistosomiasis is a major parasitic disease, increasingly imported into temperate climates by immigrants from and travelers to endemic areas. M e t h o d : To generate valid data on imported infectious diseases to Europe and to recognize trends over time, the Euro p e a n Network on Imported Infectious Diseases Surveillance (TropNetEurop) was founded in 1999. Three hundred and thirtythree reports of schistosomiasis were analyzed for epidemiologic and clinical features. R e s u l t s : Male patients accounted for 64% of all cases. The average age of all patients was 29.5 years. The majority of patients were of European origin (53%). Europeans traveled predominantly for tourism (52%). Main reasons for travel for people f rom endemic areas were immigration and refuge (51%) and visits to relatives and friends (28%). The majority of infections w e re acquired in Africa; 92 infections were clearly attributable to Schistosoma haematobium, 130 to Schistosoma mansoni, and 4 to Schistosoma intercalatum. Praziquantel was the only treatment used. No deaths were recorded. C o n c l u s i o n : Tro p N e t E u rop sentinel provides valuable epidemiologic and clinical data on imported schistosomiasis to Europe.

Background: Swift diagnosis of falciparum malaria in nonendemic areas is frequently complicated by lack of experience on the side of involved laboratory personnel. Diagnostic tools based on the dipstick principle for the detection of plasmodial histidine-rich protein 2 (HRP-2) (ICT Malaria P.f.®) and parasite-specific lactate-dehydrogenase (pLDH) (OptiMal®), respectively, have become available for the qualitative detection of falciparum malaria. Methods: In order to evaluate currently available assays, a series of studies was conducted: sensitivity and specificity were evaluated by investigation of specimens from 231 febrile returnees from endemic areas, cross reactivity in patients with rheumatoid factor (RF) was assessed among 92 patients from a rheumatology unit, and the quality of dipstick self-use by febrile travelers was tested in Kenya. Results: Whereas the test kit based on the detection of HRP-2 performed with a sensitivity of 92.5% and a specificity of 98.3%, the kit for the detection of pLDH showed a sensitivity of 88.5% and a specificity of 99.4%. Cross-reactions with sera positive for rheumatoid factor occurred in 6.6% with the ICT Malaria P.f.®, and in 3.3% with the OptiMal® test. Only ICT Malaria P.f.® was tested for quality of self-use among travelers. This dipstick assay was performed successfully by 67 patients (68.4%), but 31 (31.6%) were unable to obtain a result. Conclusion: Dipstick tests have the potential of enhancing speed and accuracy of the diagnosis of falciparum malaria, especially if nonspecialized laboratories are involved. However, microscopical testing remains mandatory in every single patient with the possible diagnosis of malaria. Self-use of dipstick tests for malaria diagnosis by travelers should only be recommended after appropriate instruction and training, including a successful performance of the test procedure.

Background: The incidence of typhoid fever in the developing world remains high and has been estimated at 540 cases per 100,000 of the population per year. International travelers to such areas are at risk of infection, especially if they travel under low hygienic standards. Methods: In order to identify the risk factors leading to infection in travelers and expatriates, travel histories, anamnestic and clinical features of 31 patients with typhoid fever, who presented to a German travel clinic, were investigated. Results: Compared to the total patient population of the outpatient clinic during the period of investigation (n = 17,029 patients), patients who presented with typhoid fever were older (39 years versus 31 years, p.001) and traveled longer (58 days versus 19 days, p.001). While only 19.2% of the total patient population had traveled to the Indian subcontinent prior to referral, 35.4% of the patients with typhoid fever had acquired the infection there (p.001). Similar results were obtained for South East Asia and Indonesia: twenty percent of the total patient population traveled there in contrast with 32.2% of patients with typhoid fever (p.001). Latin America was visited by 16.3% of all patients, but only 6.4% of patients with typhoid (p.001).

Background: Several outbreaks of schistosomiasis among travelers, expatriates, and military serviceman have been reported in recent years. Methods: The travel histories and anamnestic and clinical features of 62 patients with schistosomiasis, who presented to a German outpatient clinic specializing in infectious and tropical diseases, were investigated to identify risk factors that could lead to infection in travelers and expatriates. Results: All patients remembered incidents that led to a likely exposure to cercariae of Schistosoma sp. Fifty nine patients (95%) acquired infection in Africa, two (3%) in South America, and one each (2% each) in Iraq and the Mekong River, respectively. The highest proportion of infection (45%) was imported from West Africa. Patients returning from West Africa reported either contact with tributaries of the Niger (including freshwater pools in the Dogon country, Mali) or with waters of the Volta River, notably Lake Volta and/or its delta. Six patients (10%) acquired infection in little-visited areas such as Central Africa and the Congo Basin. East Africa (especially Lake Victoria) and Lake Malawi contributed 14 patients (22%) to our study group; a further nine patients (14%) became infected after contact with waters of the Zambezi River. Conclusions: The most sensitive method for detection of possible infection with schistosomiasis appeared to be a combination of thorough travel history and serologic testing by indirect hemagglutination (IHA), immunofluorescence antibody test (IFAT), and enzyme-linked immunosorbent assay (ELISA). Most infections were acquired by travelers on lengthy and adventurous journeys or by expatriates venturing outside their normal areas of activity. Most patients knew that they had traveled in an area endemic for schistosomiasis, but were uninformed about behavioral risks they had taken in specific settings.

Background: With the current increase of international travel to tropical endemic areas, the incidence of malaria being imported into nonendemic countries has increased significantly. Disagreement concerning malaria chemoprophylaxis and inadequate knowledge of malarious areas, morbidity, and pretravel advise has led to confusion among both health professionals as well as travelers. Therefore, this study was conducted to investigate malaria imported into Germany by identifying the high-risk endemic areas, clinical presentations, and chemoprophylactic and therapeutic regimens related to reported cases. Methods: Between 1990 and 1993, the 160 nonimmune travelers, all German nationals or residents for more than 10 years, presenting to our travel clinic with microscopically confirmed malaria were investigated. For each, the travel history, chemoprophylaxis used during travel, symptoms, pathological diagnosis, and treatment efficacy were analyzed. Results: Africa (73%), Asia (21%), and Central South America (6%) were the endemic countries visited by our patients, of whom only 3% used the chemoprophylaxis recommended for their destination. Plasmodium falciparum was the most common pathogen, found in more than half of our patients, and P. vivax (29%), P. ova le (6%), P. malariae(6%), a mixed infection with P.falciparum and P vivax (3%) were also detected. All patients presented with fever and headaches, a majority with profuse night sweats, insomnia, arthralgias, and myalgias, and diarrhea and abdominal cramps were experienced in 13% and 8%, respectively. In falciparum malaria, a recrudescence was observed in all patients who received chloroquine only, whereas quinine, halofantrine, and mefloquine were highly effective. In vivax malaria, a relapse rate of 14% was noted in the patients treated with the currently recommended regimen of chloroquine and primaquine. Conclusions: Visitors to endemic countries, especially to Africa, are of significant risk. Given the low compliance rate of chemoprophylaxis, a high percentage of malaria in our patients could have been avoided by an appropriate prophylaxis regimen and optimal pretravel counseling.

Burchard and colleagues 1recommend a new Japanese encephalitis vaccine (Ixiaro) for any individual with a travel itinerary that includes a rural area in Asia. They also present an array of medical indications for the vaccine applicable to urban travelers. Since no duration or season is specified, their recommendations effectively encompass the great majority …

Background A survey was designed to assess travelers’ willingness to take antibiotic chemoprophylaxis against travelers’ diarrhea (TD) or to intervene with antibiotic or symptomatic treatments. Methods A brief written questionnaire was administered to clients in North American (United States and Canadian) and European (UK and German) travel clinic waiting rooms to assess length, purpose, and destination of their upcoming trips; their perceived risk of developing TD at their destination; and their preferences for hypothetical treatment or chemoprophylaxis options, which included descriptions, but no mention of brand names, of a systemically absorbed antibiotic based on a fluoroquinolone, a nonabsorbed antibiotic based on rifaximin, and an over-the-counter antidiarrheal similar to loperamide. Results The 209 UK and German travelers planned significantly longer travel than the 277 US and Canadian travelers (25 vs 15 d, p < 0.001) and correctly recognized high risk of TD more often than the North Americans (81% vs 61%, p < 0.001). More of the North Americans preferred any therapy options compared with the Europeans; only 14% of the North Americans preferred no treatment compared with 29% of the Europeans (p < 0.001). More of the North Americans and the Europeans preferred the nonabsorbed antibiotic than the systemically absorbed antibiotic, regardless of if combined with the antidiarrheal agent. Significantly more of the Europeans preferred not to take antibiotic chemoprophylaxis than North Americans (66% vs 37%, p < 0.001). Among the North Americans, significantly more travelers preferred chemoprophylaxis with the nonabsorbed than the systemic antibiotic (45% vs 33%, p= 0.003). Conclusions Among the relatively small groups of travelers studied, the UK and German travelers were more cognizant of TD risk than US and Canadian travelers. The Europeans were less inclined to take chemoprophylaxis or treatment. Both groups preferred treatment or prophylaxis with the nonabsorbed antibiotic over the systemically absorbed antibiotic or the antidiarrheal agent.

Background Migrants form 9% of Germany’s population and 13% of its capital Berlin. Only limited data are available regarding general health status and prevalence of tropical diseases among migrants in Germany. This study was conducted to investigate the spectrum and frequency of tropical diseases among migrants in Berlin and to evaluate the quality of the medical care provided. The necessity of a routine screening for tropical diseases among migrants was assessed. Methods Anonymized data of migrants presenting to the Berlin Institute of Tropical Medicine between 1999 and 2004 with a stay in Germany below 1 year (n= 153) were analyzed. Results Of all examined migrants, 48% needed immediate medical treatment and 38% carried an infectious disease, mainly nematodes and intestinal protozoa. 19% suffered from a noninfectious disease, mainly anemia, and 12% were transferred to other specialists for further investigation. These figures were similar among asymptomatic and symptomatic patients. The median duration of stay in Germany until presentation was 42 days. While 40% of the migrants were examined within the first 4 weeks of their stay, 20% had not received a medical examination after 6 months. Of this population, 50% required treatment upon presentation. Conclusions The high proportion of delayed diagnosis and treatment indicates a lack of medical service for migrants. While this clearly translates into increased health risks for the individual patient, it also indicates a potential risk for transmission of communicable diseases in the community. The lack of a correlation between symptoms and detected infectious disease indicates the need for a standardized routine screening examination in all migrants.

J Travel Med 2004; 11:161–170. where the mosquito vector Aedes aegypti is common. In Queensland,northern Australia, several sporadic outbreaks occurred due to the introduction of dengue viruses via international travelers returning from endemic countries.8,9 Since dengue surveillance, if performed at all, is passive, and since dengue virus infection presents either as a short and self-limiting viral disease or even asymptomatically, it is certainly one of the most underdiagnosed tropical infections in travelers.

Dengue is an acute, mosquito-transmitted viral disease characterized by fever, arthralgia, myalgia, rash, nausea, and vomiting and caused by any of four different serotypes of the virus (DEN-1, DEN-2, DEN-3, and DEN-4).1 The disease is endemic in most tropical areas of the world and has been reported in international travelers returning from such areas.2 The incidence of epidemic and endemic dengue has increased substantially in the Americas since 1977, and various epidemics have occurred.1-4

Background: Since travelers are now frequently advised to carry emergency self medication for the treatment of suspected malaria, the issue of retrospective diagnosis of malaria in nonimmune patients has recently gained more importance. Reliable methods for evaluating the frequency and justifying the use of self medication in clinically suspected malaria are warranted. Methods: One hundred and eighty-five sera from 132 nonimmune travelers returning to a nonendemic area, and with a microscopically confirmed diagnosis of malaria, were investigated for the presence of antibodies against blood stages of Plasmodium falciparum or Plasmodium vivax, by the indirect fluorescence antibody test (IFAT). Eighty-eight patients suffered from infection with P. falciparum and 44 from the infection with P. vivax. In falciparum malaria, 97.1% of patients had positive reactions during a period of 15–60 days after onset of symptoms. During the same period after onset of symptoms, significant titers were demonstrated in 88.2% of patients with vivax malaria. Extended cross-reactions between the antigens used and a wide range of interindividual differences in antibody titers were observed. One hundred sera from Germans recovering from nonmalarial febrile illnesses were used as negative control group in the investigation, of which none resulted in a positive IFAT. Conclusions: We conclude from these results that the IFAT is a specific and sensitive tool for the retrospective confirmation of malaria in the differential diagnosis of fever imported from endemic areas by nonimmune travelers. Nevertheless, when dealing with the individual patient, a careful interpretation, with inclusion of all available clinical data, is mandatory. However, by using blood stage antigens, the IFAT can be considered a sensitive tool in epidemiologic surveys. The tool can be used with a high degree of reliability, even without access to additional clinical data.

Dengue is an acute, mosquito-transmitted viral disease characterized by fever, arthralgia, myalgia, rash, nausea, and vomiting and caused by any of four different serotypes of the virus (DEN-1, DEN-2, DEN-3, and DEN-4).1 The disease is endemic in most tropical areas of the world and has been reported in international travelers returning from such areas.2 The incidence of epidemic and endemic dengue has increased substantially in the Americas since 1977, and various epidemics have occurred.1-4