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Background: The gold standard in diagnosis of malaria is microscopic detection of malaria parasites in thin blood smears. However, the sensitivity and specificity of blood smears depend mostly on the experience of the examiner. In the traveler returning from the tropics, diagnosis of malaria may be difficult when the parasitemia is low. In this circumstance any indicator that suggests the diagnosis of malaria is of great interest. The aim of this study is to determine the value of hypocholesterolemia to the diagnosis of imported malaria.Method: A retrospective case-control study was performed among hospitalized patients with fever returning from a malaria-endemic area, to compare the results of routine biological parameters of 129 malaria cases with those of 92 control patients.Results: Multivariate analysis, using a logistic regression model demonstrates that hypocholesterolemia was the strongest parameter associated with malaria (adjusted odds ratio [OR]: 75.22, 95% confidence interval [CI] 4.60-1227.78) and the most specific (98%, 95% CI 0.95-1.0). The most sensitive abnormality was thrombocytopenia (82%, 95% CI-0.77 0.87). With a malaria prevalence of 52% in our population study, hypocholesterolemia has the strongest positive predictive value among routine biological parameters for malaria diagnosis (96%). The combination of hypocholesterolemia and thrombocytopenia was always associated with diagnosis of malaria in this study.Conclusion: These results show that hypocholesterolemia is significantly associated with malaria. Therefore, in the setting of negative thin and thick blood smears, the presence of hypocholesterolemia, particularly when it is combined with thrombocytopenia, in a febrile traveler returning from a malaria-endemic area, should prompt repetition and careful analysis of blood smears to avoid misdiagnosis. [ABSTRACT FROM AUTHOR]

Background: Cutaneous leishmaniasis (CL) may be emerging among international travellers and migrants. Limited data exist on mucocutaneous leishmaniasis (MCL) in travellers. We describe the epidemiology of travel-associated CL and MCL among international travellers and immigrants over a 20-year period through descriptive analysis of GeoSentinel data., Methods: Demographic and travel-related data on returned international travellers diagnosed with CL or MCL at a GeoSentinel Surveillance Network site between 1 September 1997 and 31 August 2017 were analysed., Results: A total of 955 returned travellers or migrants were diagnosed with travel-acquired CL (n = 916) or MCL during the study period, of whom 10% (n = 97) were migrants. For the 858 non-migrant travellers, common source countries were Bolivia (n = 156, 18.2%) and Costa Rica (n = 97, 11.3%), while for migrants, they were Syria (n = 34, 35%) and Afghanistan (n = 22, 22.7%). A total of 99 travellers (10%) acquired their disease on trips of ≤ 2 weeks. Of 274 cases for which species identification was available, Leishmania Viannia braziliensis was the most well-represented strain (n = 117, 42.7%), followed by L. major (n = 40, 14.6%) and L. V. panamensis (n = 38, 13.9%). Forty cases of MCL occurred, most commonly in tourists (n = 29, 72.5%) and from Bolivia (n = 18, 45%). A total of 10% of MCL cases were acquired in the Old World., Conclusions: Among GeoSentinel reporting sites, CL is predominantly a disease of tourists travelling mostly to countries in Central and South America such as Bolivia where risk of acquiring L. V. braziliensis and subsequent MCL is high. The finding that some travellers acquired leishmaniasis on trips of short duration challenges the common notion that CL is a disease of prolonged travel. Migrants from areas of conflict and political instability, such as Afghanistan and Syria, were well represented, suggesting that as mass migration of refugees continues, CL will be increasingly encountered in intake countries., (© International Society of Travel Medicine 2019. Published by Oxford University Press. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.)

Background: With increasing international travel and historically high numbers of residents visiting friends and relatives overseas, travel-associated illnesses are frequent in Marseille, France. We report the changing epidemiology of travel-related illnesses over a 12-year period., Methods: A single site GeoSentinel surveillance analysis was undertaken for 3460 ill returned travellers presenting to two public hospitals in Marseille, France from March 2003 to October 2015, with travel-related illnesses. Demographic characteristics, travel history, presenting symptoms and information on pre-travel consultations were collected., Results: There was a predominance of travel to sub-Saharan Africa, in particular to Comoros archipelago. Tourism was the main reason for travel (1591/3460, 46%), followed by visiting friends or relatives (VFR) (895/3460, 26%), with a mean duration of 29 days; 35% (1212/3460) of travellers reported a pre-travel health consultation. The most common syndromic diagnoses were febrile systemic illness (1343, 39%), dermatologic (716, 21%), gastrointestinal (340, 10%) and respiratory/ear-nose-throat (331, ENT) (10%). Hospitalization rates were highest amongst travellers from sub-Saharan Africa (858/ 1632, 53%), and VFR (573/ 895, 64%, P < 0.001). Frequent diagnoses included malaria (797, 23%), dengue (96, 2.77%) and chikungunya (75, 2.17%), reflecting global trends. Comparison of two periods (2003-10 to 2011-15) demonstrated an increase in chikungunya and decrease in malaria and influenza-like illness. We report an increase in ill travellers from the Caribbean, Middle East and South-East Asia., Conclusion: Surveillance of travellers provides relevant sentinel information on the changing epidemiology of infectious diseases across the globe, most notably for malaria, dengue and chikungunya. We demonstrate the use of travel surveillance in improving pre-travel consultation needs and to address autochthonous vector-borne viral risks.

Background: Limited data exist on infectious diseases imported to various locations in Europe, particularly after travel within the continent., Methods: To investigate travel-related disease relevant to Europe that is potentially preventable through pre-travel intervention, we analyzed the EuroTravNet database of 5,965 ill travelers reported by 16 centers in "Western" Europe in 2011., Results: There were 54 cases of vaccine-preventable disease, mostly hepatitis A (n = 16), typhoid fever (n = 11), and measles (n = 8); 6 cases (including 3 measles cases) were associated with travel within "Western" Europe. Malaria was the most commonly diagnosed infection (n = 482, 8.1% of all travel-related morbidity). Among patients with malaria, the military most commonly received pre-travel advice (95%), followed by travelers for missionary, volunteer, research, or aid work (81%) but travelers visiting friends and relatives (VFRs) were least likely to receive pre-travel advice (21%). The vast majority (96%) of malaria patients were resident in "Western" Europe, but over half (56%) were born elsewhere. Other significant causes of morbidity, which could be reduced through advice and behavioral change, include Giardia (n = 221, 3.7%), dengue (n = 146, 2.4%), and schistosomiasis (n = 131, 2.2%). Of 206 (3.5%) travelers with exposure in "Western" Europe, 75% were tourists; the highest burden of disease was acute gastrointestinal infection (35% cases). Travel from "Eastern" Europe (n = 132, 2.2%) was largely associated with migration-related travel (53%); among chronic infectious diseases, tuberculosis was frequently diagnosed (n = 20). Travelers VFRs contributed the largest group of malaria patients (46%), but also had the lowest documented rate of pre-travel health advice in this subset (20%). Overall, 44% of nonimmigrant ill travelers did not receive pre-travel advice., Conclusion: There is a burden of infectious diseases in travelers attending European health centers that is potentially preventable through comprehensive pre-travel advice, chemoprophylaxis, and vaccination. Targeted interventions for high-risk groups such as travelers VFRs and migration-associated travelers are of particular importance., (© 2014 International Society of Travel Medicine.)

Background: The number of people, both adults and children, traveling abroad, is on the rise. Some seek counseling at travel medicine centers before departure., Methods: A prospective study was conducted among children <16 years visiting a travel medicine center in Marseille, France, from February 2010 to February 2011. Parents were contacted by telephone 4 weeks after their return, and asked about compliance with pre-travel advice., Results: One hundred sixty-seven children were evaluated after their trip. Compliance with immunizations, malaria chemoprophylaxis, and food-borne disease prevention was 71, 66, and 31%, respectively. Compliance with malaria chemoprophylaxis varied significantly with destination, and was higher for African destinations. Significant features associated with poor compliance with chemoprophylaxis were a trip to Asia or the Indian Ocean, age <5 years, and a monoparental family. Compliance with prevention of food- and water-borne diseases was higher in children < 2 years of age., Conclusions: A ≥ 80% compliance with pre-travel counseling in children traveling overseas was achieved only for drinking bottled water, using repellents, a routine vaccine update, and yellow fever immunization., (© 2013 International Society of Travel Medicine.)

We report the first confirmed case of tick-borne borreliosis by molecular tools in a French traveler returning from Ethiopia with unusual presentation: the presence of cutaneous eschar after a hard tick-bite suggesting firstly to clinicians a diagnosis of tick-borne rickettsiosis., (© 2012 International Society of Travel Medicine.)

Sixty-seven percent of French pilgrims reported to have traveled out of France just before the 2010 Hajj (mainly in North Africa) and 26% planned to do so after leaving Saudi Arabia. Surveillance of Hajj-associated infectious diseases in returned French pilgrims should be coordinated between France and North African countries., (© 2012 International Society of Travel Medicine.)

Among a cohort of 274 French pilgrims participating in the 2009 Hajj, 77.4% used hand disinfectant, 89.8% used disposable handkerchiefs, and 79.6% used face masks; 97.4% were vaccinated against seasonal flu, 5.8% against H1N1, and 31.4% against pneumococcus. Influenza vaccine and face mask use did not significantly reduce respiratory symptoms., (© 2010 International Society of Travel Medicine.)

Objective: To investigate travel-associated illnesses in French travelers to Senegal., Methods: A prospective cohort follow-up was conducted in 358 travelers recruited at a pre-travel visit in Marseille and compared to data from ill travelers collected from the GeoSentinel data platform in two clinics in Marseille., Results: In the cohort survey, 87% of travelers experienced health complaints during travel, which most frequently included arthropod bites (75%), diarrhea (46%), and sunburns (36%). Severe febrile illness cases, notably malaria and salmonella, were detected only through the surveillance system, not in the cohort follow-up. Food hygiene was inefficient in preventing diarrhea. Arthropod bites were more frequent in younger patients and in patients with pale phototypes. Sunburns were also more frequent in younger patients. Finally, we demonstrate that mild travel-related gastrointestinal symptoms and the lack of arthropod bites are significantly associated with poor observance of antimalarial prophylaxis., Conclusions: In this study, we suggest the complementary nature of using cohort surveys and sentinel surveillance data. Effective protection of skin from arthropod bites and sun exposure should result in significantly reduced travel-associated diseases in Senegal. Travelers to Senegal should be informed that diarrhea is extremely common despite preventive measures, but it is mild and transitory and should not lead to the disruption of malaria chemoprophylaxis., (© 2010 International Society of Travel Medicine.)

Background: Travelers are exposed to a variety of health risks in unfamiliar environments and fever is a common problem in patients returning from travel abroad. Rickettsial diseases are increasingly frequently being reported among international travelers. Here we present cases of Rickettsia typhi infection, the agent of murine typhus, that were identified in our laboratory the last year, in travelers from Tunisia., Methods: For each patient we tested an acute-phase serum sample and for one patient we tested a convalescent-phase serum sample. IgG and IgM antibody titers were estimated with use of the microimmunofluorescence (MIF) assay. Western blot (WB) assay was performed for all the patients., Results: We identified three cases of murine typhus after a travel in Tunisia. All cases were observed during late summer and early autumn and patients were suffering by persistent fever. None of them presented rash or inoculation eschar. MIF was positive for Rickettsia sp. in the acute-phase serum samples of two patients. In one patient, two acute-phase serum samples were Rickettsia sp. negative whereas a third convalescent-phase serum sample that was obtained 2 weeks after was Rickettsia sp. positive. By WB assay we identified infection by R typhi. A treatment was immediately started and patients became apyretic., Conclusions: In the countries of North Europe, although autochthones cases of murine typhus have not been described, sporadic cases of R typhi infection are identified in travelers who visited murine typhus endemic areas. Murine typhus should be considered in the diagnosis of febrile illness without rash in travelers returning from disease endemic areas, like the south Mediterranean area., (© 2010 International Society of Travel Medicine.)

Mass gathering is well known to concentrate and amplify the transmission of infectious respiratory diseases. Here we report a possible case of coinfection with influenza A/H1N1 and varicella in a young French traveler returning from a rock festival in Hungary. We report a cluster of influenza A/H1N1 cases at this festival.

Background: The majority of published studies on Hajj-related diseases were based on hospitalized patient cohorts., Methods: A total of 545 Hajj pilgrims from Marseille were enrolled in a prospective epidemiological study to evaluate the incidence of common health hazards. They were administered a questionnaire before traveling addressing demographic factors and health status indicators and a post-travel questionnaire about travel-associated diseases., Results: Respondents had a median age of 61 years and originated mainly from North Africa (81%). A significant proportion of individuals had chronic medical disorders such as walking disability (26%), diabetes mellitus (21%), and hypertension (21%). A total of 462 pilgrims were administered a questionnaire on returning home. A proportion of 59% of travelers presented at least one health problem during the pilgrimage and 44% of the cohort attended a doctor during travel; 3% were hospitalized. Cough was the main complaint among travelers (attack rate of 51%), followed by headache, heat stress, and fever. Few travelers suffered diarrhea and vomiting. Cardiovascular diseases, neurological disorders, trauma, skin and gastrointestinal problems were not frequently observed in our survey, suggesting that their prevalence among the causes of admission to Saudi hospitals reflects a bias of selection. Cough episodes were significantly more frequent in individuals >55 years. We also evidenced that women were more likely to present underlying chronic cardiovascular disorder and diabetes compared to men and that they more frequently suffered from cough episodes associated with fever during the Hajj., Conclusions: Health risks associated with the Hajj in our experience are much more related to crowding conditions than to travel. Our work suggests that the studies performed in Saudi specialized units probably overestimate the part of certain diseases within the spectrum of Hajj-associated diseases. Our results also suggest that old female Hajjes should be considered as a high-risk population and that preventive measures should be reinforced before departing for Saudi Arabia.

Objective: To assess the awareness of the mode of rabies transmission, travel-associated rabies risk, and adequate preventive measures among French travelers., Methods: Three hundred travelers were administered a detailed questionnaire prior to pretravel advice, addressing their knowledge, attitudes, and practices (KAP) with respect to animal-related injuries and rabies risk. Two hundred and nine were administered a post-travel questionnaire by telephone, addressing the occurrence of contacts with animals during travel., Results: Countries visited were at risk for rabies in 84.7% of the cases. Only 6.7% of travelers knew that the risk of rabies was important, while 40.1% considered it moderate or low. Dog bites appeared to be a well-known mode of transmission of rabies. By contrast, licks on broken skin or contamination of the mucous membrane with saliva (10%) and scratches (0.7%) were rarely known. Cats (23.7%), foxes (28.3%), monkeys (10.3%), and bats (5.0%) were rarely mentioned as possible rabies vectors. Only 50.7% of travelers were aware of the preventive vaccination. Approximately 57.6% of individuals traveling to rabies-endemic countries presented to the clinic less than 21 days before departing, rendering a complete preventive vaccination against rabies unfeasible. Immediate washing of the injury with water and soap was mentioned by only 3.0% of individuals and self-disinfection with antiseptics by 21.3%. Of those who traveled in a rabies-risk country, 3.8% declared that they had been attacked by animals; however, none was injured. Animal encounters were frequent with dogs (53.8%), monkeys (39.5%), bats (17.9%), and cats (15.4%)., Conclusions: The KAP of French travelers with regard to travel-associated rabies risk need to be improved, particularly regarding the prevention of animal bites, postbite measures, and their urgency.

Background: There is little published information available describing rabies pre- and postexposure prophylaxis (PEP) in tourists returning to their home country and seeking care for animal-associated injuries, especially those associated with a rabies risk., Method: We analyzed 261 travelers seeking care on returning to their home country following an animal-related injury acquired abroad. Information on individual cases of rabies (PEP) including preexposure status, type of contact with a potentially rabid animal, type of animal, and the nature of rabies PEP was collected by retrospectively analyzing records from May 1997 to May 2005., Results: The majority of injuries were acquired in South-east Asia and North Africa. Only 6.8% of injured patients were previously vaccinated against rabies, while 75.4% of the cohort experienced a severe injurious contact with animals (World Health Organization category III). Of travelers who sustained a high-risk injury, only 24% received both vaccination and rabies immune globulin,(RIG) while 76% received vaccination only. Of the travelers who did not receive RIG, 43% had received a first dose of vaccine more than 7 days after return and before presenting to a clinic in their home country., Conclusions: This study highlights important deficiencies in rabies PEP for travelers who acquire high-risk, animal-associated injuries in rabies-endemic countries, with the majority not receiving adequate PEP or experiencing a substantial delay before receiving rabies vaccination.

A cohort of 461 Hajj pilgrims to Mecca departing from Marseille was surveyed. Most of travelers originated from North Africa and one third were geriatric patients. An overall low rate of vaccination was observed. The proportions of travelers without correct vaccination were 67% for influenza, 70% for tetanus, 75% for diphteria and poliomyelitis, and 87% for pertussis and hepatitis A.