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Background Travellers' diarrhoea (TD) is a common health problem among visitors to the (sub)tropics. Much research deals with aetiology, prevention, and post-infection sequalae, yet the data may not allow comparisons due to incompatible definitions of TD and No TD control groups. Method The impact of defining TD and No TD control groups was explored by revisiting our recent data. We set up two TD groups: classical TD i.e. ≥3 loose or liquid stools/day and WHO TD (diarrhoea as defined by the WHO) i.e. any diarrhoea, and four No TD groups by TD definition and timing (no classical/WHO TD during travel, no ongoing classical/WHO TD). Results TD was recorded for 37% versus 65% of subjects when using classical versus WHO definitions, respectively; the proportions of the various pathogens proved similar. The strictest criterion for the No TD control group (no WHO TD during travel) yielded pathogens among 61% and the least strict (no ongoing classical TD) among 73% of the travellers; the differences were greatest for enteroaggregative Escherichia coli and Campylobacter. Conclusions Definition of TD and control group design substantially impact on TD study results. The WHO definition yields more cases, but the pathogen selection is similar by both definitions. Design of the No TD control group was found critical: only those remaining asymptomatic throughout the journey should be included.

Background: In developing countries, diarrhoea is the most common cause of death for children under five years of age, with Giardia lamblia, Cryptosporidium and Entamoeba histolytica as the most frequent pathogenic parasites. Traditional microscopy for stool parasites has poor sensitivity and specificity, while new molecular methods may provide more accurate diagnostics. In poor regions with sample storage hampered by uncertain electricity supply, research would benefit from a method capable of analysing dried stools. Methods: A real-time multiplex PCR method with internal inhibition control was developed for detecting Giardia lamblia, Cryptosporidium hominis/parvum and Entamoeba histolytica directly from stool specimens. Applicability to dried samples was checked by comparing with fresh ones in a small test material. Finally, the assay was applied to dried specimens collected from Guinea-Bissauan children with diarrhoea. Results: The PCR's analytical sensitivity limit was 0.1 ng/ml for G. lamblia DNA, 0.01 ng/ml for E. histolytica DNA and 0.1 ng/ml for Cryptosporidium sp. In the test material, the assay performed similarly with fresh and dried stools. Of the 52 Guinea-Bissauan samples, local microscopy revealed a parasite in 15%, while PCR detected 62% positive for at least one parasite: 44% of the dried samples had Giardia, 23% Cryptosporidium and 0% E. histolytica. Conclusions: Our new multiplex real-time PCR for protozoa presents a sensitive method applicable to dried samples. As proof of concept, it worked well on stools collected from Guinea-Bissauan children with diarrhoea. It provides an epidemiological tool for analysing dried specimens from regions poor in resources.

Background Despite the global distribution of the intestinal protozoan Dientamoeba fragilis, its clinical picture remains unclear. This results from underdiagnosis: microscopic screening methods either lack sensitivity (wet preparation) or fail to reveal Dientamoeba (formalin-fixed sample). Aim In a retrospective study setting, we characterised the clinical picture of dientamoebiasis and compared it with giardiasis. In addition, we evaluated an improved approach to formalin-fixed samples for suitability in Dientamoeba diagnostics. Methods This study comprised four parts: (i) a descriptive part scrutinising rates of Dientamoeba findings; (ii) a methodological part analysing an approach to detect Dientamoeba-like structures in formalin samples; (iii) a clinical part comparing demographics and symptoms between patients with dientamoebiasis (n = 352) and giardiasis (n = 272), and (iv) a therapeutic part (n = 89 patients) investigating correlation between faecal eradication and clinical improvement. Results The rate of Dientamoeba findings increased 20-fold after introducing criteria for Dientamoeba-like structures in formalin-fixed samples (88.9% sensitivity and 83.3% specificity). A further increase was seen after implementing faecal PCR. Compared with patients with giardiasis, the symptoms in the Dientamoeba group lasted longer and more often included abdominal pain, cramping, faecal urgency and loose rather than watery stools. Resolved symptoms correlated with successful faecal eradication (p Conclusions Previously underdiagnosed, Dientamoeba has become the most frequently recorded pathogenic enteroparasite in Finland. This presumably results from improved diagnostics with either PCR or detection of Dientamoeba-like structures in formalin-fixed samples, an approach applicable also in resource-poor settings. Symptoms of dientamoebiasis differ slightly from those of giardiasis; patients with distressing symptoms require treatment.

Non

In January 2019, five of 11 travellers to Koh Lanta, Thailand, contracted chikungunya, symptoms starting 4 days after presumed transmission. Four cases were hospitalised, one child treated in intensive care; 6 weeks after disease onset, all three adults have persistent arthralgias/arthritis, incapacitating for two. Together with a recent report of eight chikungunya cases among travellers to various destinations in Thailand, the high attack rate in our cluster points to an ongoing outbreak in the country. Non

Travellers' diarrhoea (TD) remains the most frequent health problem encountered by visitors to the (sub) tropics. Traditional stool culture identifies the pathogen in only 15% of cases. Exploiting PCR-based methods, we investigated TD pathogens with a focus on asymptomatic travellers and severity of symptoms. Pre- and post-travel stools of 382 travellers with no history of antibiotic use during travel were analysed with a multiplex quantitative PCR for Salmonella, Yersinia, Campylobacter, Shigella, Vibrio cholerae and five diarrhoeagenic Escherichia coli: enteroaggregative (EAEC), enteropathogenic (EPEC), enterotoxigenic (ETEC), enterohaemorrhagic (EHEC) and enteroinvasive (EIEC). The participants were categorized by presence/absence of TD during travel and on return, and by severity of symptoms. A pathogen was indentified in 61% of the asymptomatic travellers, 83% of those with resolved TD, and 83% of those with ongoing TD; 25%, 43% and 53% had multiple pathogens, respectively. EPEC, EAEC, ETEC and Campylobacter associated especially with ongoing TD symptoms. EAEC and EPEC proved more common than ETEC. To conclude, modern methodology challenges our perception of stool pathogens: all pathogens were common both in asymptomatic and symptomatic travellers. TD has a multibacterial nature, but diarrhoeal symptoms mostly associate with EAEC, EPEC, ETEC and Campylobacter. (C) 2016 The Authors. Published by Elsevier Ltd on behalf of European Society of Clinical Microbiology and Infectious Diseases.

Influenza A(H1N1)pdm09 viruses have been circulating throughout the world since the 2009 pandemic. A/California/07/2009 (H1N1) virus was included in seasonal influenza vaccines for seven years altogether, providing a great opportunity to analyse vaccine-induced immunity in relation to the postpandemic evolution of the A(H1N1)pdm09 virus. Serum antibodies against various epidemic strains of influenza A (H1N1)pdm09 viruses were measured among health care workers (HCWs) by haemagglutination inhibition and microneutralization tests before and after 2010 and 2012 seasonal influenza vaccinations. We detected high responses of vaccine-induced neutralizing antibodies to six distinct genetic groups. Our results indicate antigenic similarity between vaccine and circulating A(H1N1)pdm09 strains, and substantial vaccine-induced immunity against circulating epidemic viruses. (C) 2019 Published by Elsevier Ltd.

Background As antibiotics predispose travelers to acquiring multidrug-resistant intestinal bacteria, they should no longer be considered a mainstay for treating travelers' diarrhea. It has been claimed that stand-by antibiotics are justified as a means to avoid visits to local healthcare providers which often lead to polypharmacy. Method We revisited the traveler data of 316 prospectively recruited volunteers with travelers' diarrhea by retrieving from questionnaires and health diaries information on antibiotic use, stand-by antibiotic carriage, and visits with local healthcare. Multivariable analysis was applied to identify factors associated with antibiotic use. Results Among our 316 volunteers with travelers' diarrhea, however, carrying stand-by antibiotics seemed not to reduce the rate of healthcare-seeking; on the contrary, antibiotic use was more frequent among stand-by antibiotic carriers (34%) than non-carriers (11%). Antibiotics were equally taken for severe and incapacitating travelers' diarrhea, but compared to non-carriers, stand-by antibiotic carriers resorted to medication also for mild/moderate (38% vs. 4%) and non-incapacitating disease (29% vs. 5%). Antibiotic use was associated with stand-by antibiotic carriage (OR 7.2; 95%CI 2.8–18.8), vomiting (OR 3.5; 95%CI 1.3–9.5), incapacitating diarrhea (OR 3.6; 95%CI 1.3–9.8), age (OR 1.03; 95%CI 1.00–1.05), and healthcare visit for diarrhea (OR 465.3; 95%CI 22.5–9633.6). Conclusions Carriage of stand-by antibiotics encouraged less cautious use of antibiotics. Recommendations involving prescription of antibiotics for all travelers require urgent revision.

Recently, concern has been raised about the emergence of human monkeypox virus and the occasionally severe clinical presentation bearing resemblance to that of smallpox. In 2018 3 patients in the UK were diagnosed with monkeypox, and the frequency and geographic distribution of cases across West and Central Africa have increased in recent years. In Nigeria, most monkeypox patients are aged

Introduction Antimicrobial resistance is increasing rapidly in countries with low hygiene levels and poorly controlled antimicrobial use. The spread of resistant bacteria poses a threat to healthcare worldwide. Refugees and migrants from high-prevalence countries may add to a rise in multidrug-resistant (MDR) bacteria in low-prevalence countries. However, respective data are scarce. Methods We retrospectively collected microbiological and clinical data from asylum seekers and refugees treated at Helsinki University Hospital between January 2010 and August 2017. Results Of 447 asylum seekers and refugees (Iraq: 46.5%; Afghanistan: 10.3%; Syria: 9.6%, Somalia: 6.9%); 45.0% were colonised by MDR bacteria: 32.9% had extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE), 21.3% meticillin-resistant Staphylococcus aureus (MRSA), 0.7% carbapenemase-producing Enterobacteriaceae (CPE), 0.4% multiresistant Pseudomonas aeruginosa (MRPA), 0.4% multiresistant Acinetobacter baumannii (MRAB); no vancomycin-resistant Enterococcus (VRE) were found. Two or more MDR bacteria strains were recorded for 12.5% of patients. Multivariable analysis revealed geographical region and prior surgery outside Nordic countries as risk factors of MRSA colonisation. Young age ( Conclusion We found MDR bacterial colonisation to be common among asylum seekers and refugees arriving from current conflict zones. In particular we found a high prevalence of MRSA. Refugees and migrants should, therefore, be included among risk populations requiring MDR screening and infection control measures at hospitals.

Background One third of travellers to low- and middle-income regions of the tropics and subtropics become colonized by extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE). The risk varies by destination and, for each traveller, may be substantially further increased by travellers’ diarrhoea (TD) and antibiotic use. Despite the risk of TD in Africa, ESBL-PE acquisition rates in all studies are lower there than in Asia. Africa has become increasingly popular as a destination for international travellers, yet minimal data are available from the continent’s subregions and countries. Methods We analysed subregion- and country-specific data on carriage and risk factors for ESBL-PE colonization pooled from three prospective studies conducted between 2009 and 2013 among Finnish and Dutch travellers. The data were subjected to multivariable analysis of risk factors. In addition, we compared our data to two recent large investigations reporting data by subregion and country. Results Our joint analysis comprised data on 396 travellers. The ESBL-PE colonization rate was highest in Northern Africa, followed by Middle and Eastern Africa, and lowest in Southern and Western Africa. Of individual countries with more than 15 visitors, the highest rates were seen for Egypt (12/17; 70.6%), Ghana (6/23; 26.1%), and Tanzania (14/81; 17.3%); the rates among travellers to Egypt were comparable to those reported in South and Southeast Asia. In a pooled multivariable analysis, travel destination, age, overnight hospitalisation abroad, TD, and use of fluoroquinolones were independently associated with increased ESBL-PE colonization rates. Conlusions Even in areas with relatively low risk of colonization, antimicrobials clearly predispose to colonization with ESBL-PE. Travellers to Africa should be cautioned against unnecessary use of antibiotics. Electronic supplementary material The online version of this article (10.1186/s12879-018-3245-z) contains supplementary material, which is available to authorized users.

Antimicrobial drug treatment of travelers’ diarrhea is known to increase the risk for colonization with extended-spectrum β-lactamase-producing Enterobacteriaceae. Among 288 travelers with travelers’ diarrhea, the colonization rate without medications was 21%. For treatment with loperamide only, the rate was 20%; with antimicrobial drugs alone, 40%; and with loperamide and antimicrobial drugs, 71%.

Pneumonia is a major cause of death worldwide, with Streptococcus pneumoniae one of the most frequent pathogens [1, 2]. Control of the disease through vaccination has become an objective for preventive health care. The disease begins by the establishment of S. pneumoniae colonization in the upper respiratory tract (URT), followed by descent of the bacteria into the lower respiratory tract (LRT) to bring about a symptomatic infection [1, 2]. Nasopharyngeal carriage is clearly a prerequisite for all S. pneumoniae diseases [2], yet the immunological factors protecting against transition from carriage to disease are not adequately understood. Mucosal antibodies capable of preventing colonization may offer a key approach to protection [3–7]. Indeed, in animal models mucosal vaccines eliciting mucosal antibodies have proved to confer protection against local disease [5, 7, 8]. To develop better vaccination strategies, local immune mechanisms need to be explored in greater detail in humans. Pneumococcal vaccines, either as 23-valent polysaccharide preparations (PPV) or 10- or 13-valent polysaccharide vaccines conjugated to a protein carrier (PCV10 and PCV13, respectively), are licensed in many countries. PPV covers a broader spectrum of serotypes and confers protection against invasive pneumococcal disease, while the efficacy against local, noninvasive pneumonia remains controversial [9–11]. PCVs cover fewer serotypes and are not only effective against invasive pneumococcal disease [12], but also seem to confer some protection against noninvasive pneumonia (efficacy, 20%–37%) [13–15]. The insufficient ability of vaccines to elicit mucosal immune response has been suggested to account for their shortcomings in providing protection against local disease [5]. During an immune response, effector B lymphocytes (plasmablasts) do not spread equally across the body but instead are guided to travel to sites of expected antigen encounter. This tissue-specific homing of lymphocytes from blood into tissues is based on interaction between lymphocyte surface chemokine receptors (CCRs) and homing receptors with chemokines and specific homing receptor-ligands, addressins, on the endothelial cells of the target tissues, respectively [16, 17]. Tissue-specific homing receptors have been identified: L-selectin (CD62L) guides the lymphocytes to the peripheral lymph nodes [18], α4β7-integrin guides lymphocytes to the intestinal lamina propria [19], and cutaneous lymphocyte antigen (CLA) guides lymphocytes to skin tissue [20]. Analysis of the homing receptor and/or CCR profiles of the circulating plasmablasts provides an approach to evaluate the targeting of an immune response elicited at the site of antigen encounter [21–24]. The homing receptors guiding lymphocytes to the LRT have not been identified, but it has been suggested that instead of a single homing receptor, a variety of homing receptors are involved [16, 17, 25]. We have recently detected S. pneumoniae–specific plasmablasts in the circulation of humans with acute pneumococcal pneumonia [26]. These cells are presumed to originate in the LRT and to be responsible for distributing the immune response to various immunological compartments of the body [26]. Exploring these S. pneumoniae–specific plasmablasts allows study of the localization of the immune effector cells of the LRT. Comparing the homing receptor profiles of S. pneumoniae–specific plasmablasts between patients with pneumonia and volunteers who receive parenteral S. pneumoniae vaccines may throw new light on possible differences between natural infection and PPV or PCV in targeting the immune response.

Objectives: Eighty million travellers visiting (sub)tropical regions contract travellers' diarrhoea (TD) each year, yet prospective data comparing the prevalence of TD pathogens in various geographical regions are scarce. Our recent study using modern molecular methods found enteropathogenic (EPEC) and enteroaggregative (EAEC) Escherichia coli to be the most frequent pathogens, followed by enterotoxigenic E. coli (ETEC) and Campylobacter. We revisited our data to compare the findings by geographical region. Methods: A total of 459 prospectively recruited travellers provided stool samples and completed questionnaires before and after visiting destinations in various geographical regions. A multiplex quantitative real-time PCR assay was used to analyse Salmonella, Yersinia, Campylobacter jejuni/Campylobacter coli, Shigella, Vibrio cholerae, EPEC, EAEC, ETEC, enterohaemorrhagic E. coli and enteroinvasive E. coli. Results: TD was contracted by 69% (316/459) of the subjects; EPEC and EAEC outnumbered ETEC and Campylobacter in all regions. Multiple pathogens were detected in 42% (133/316) of the samples. The proportions of all pathogens varied by region. The greatest differences were seen for Campylobacter: while relatively frequent in South Asia (n = 11; 20% of the 55 with TD during travel) and Southeast Asia (15/84, 15%), it was less common in East and West Africa (5/71, 7% and 1/57, 2%) and absent in South America and the Caribbean (0/40). Conclusions: EPEC and EAEC outnumbered ETEC and Campylobacter everywhere, yet the proportions of pathogen findings varied by region, with ETEC and Campylobacter rates showing the greatest differences. The high frequency of multibacterial findings in many regions indicates a need for further investigation of the clinical role of each pathogen. (C) 2017 The Authors. Published by Elsevier Ltd on behalf of European Society of Clinical Microbiology and Infectious Diseases.

Background: One third of travellers to the poor regions of the (sub) tropics become colonized by extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE). Co-resistance to non-betalactam antibiotics complicates the treatment of potential ESBL-PE infections. Methods: We analysed co-resistance to non-beta-lactams among travel-acquired ESBL-PE isolates of 90 visitors to the (sub) tropics with respect to major risk factors of colonization: destination, age, travellers' diarrhoea (TD) and antibiotic (AB) use. Results: Of the ESBL-PE isolates, 53%, 52%, 73%, and 2% proved co-resistant to ciprofloxacin, tobramycin, co-trimoxazole, and nitrofurantoin, respectively. The rates were similar among those with (TD+) or without (TD-) travellers' diarrhoea. Among fluoroquinolone-users vs. AB non-users, the co-resistance rates for ciprofloxacin were 95% versus 37% (p = 0.001), for tobramycin 85% versus 43% (p = 0.005), co-trimoxazole 85% versus 68% (p = 0.146), and nitrofurantoin 5% versus 2% (p = 0.147). In multivariable analysis co-resistance to ciprofloxacin was associated with increasing age, fluoroquinolone use, and tobramycin resistance. Conlusions: While TD predisposes to ESBL-PE non-selectively, antimicrobial use favours strains resistant to drug taken and, simultaneously, any drug with resistance genetically linked to the drug used. Antibiotics taken during travel predispose to ESBL-PE with a high co-resistance rate. (C) 2017 The Author(s). Published by Elsevier Ltd.

Background: Although infections represent the most common health problem of travellers abroad, data on morbidity and incidences of various infections are scarce. Method: Data on infections of Finnish travellers during 2010-2012 were retrieved from the database of SOS International, an assistance organization covering 95% of Finns requiring aid abroad. The study included 30,086 cases. For incidence calculation, the data were linked to the numbers of Finns visiting these regions during the same period as recorded by the Official Statistics of Finland. Results: The incidence of infections was particularly high in Africa, southern Europe plus the eastern Mediterranean, and Asia plus Oceania. The most frequent diagnoses were acute gastroenteritis (38.0%) and respiratory-tract infections (RTI) (34.5%), followed by infections of the ear (12.6%), skin or subcutaneous tissue (5.1%), urogenital tract (4.2%), eye (3.1%), and systemic febrile infections (2.2%). Vaccinepreventable diseases (VPD) accounted for 0.8% of cases, with varicella as most (49%) and influenza as second-most (27%) common. Conclusions: Incidence of infections was higher in southern than in eastern and western Europe. Gastroenteritis and RTI proved the most frequent diagnoses, whereas systemic febrile infections were uncommon. Despite pre-travel immunizations, VPDs still occurred; pre-travel consultation should cover both varicella and influenza. (C) 2016 Elsevier Ltd. All rights reserved.

Objectives: The pandemic spread of multidrug-resistant (MDR) bacteria poses a threat to healthcare worldwide, with highest prevalence in indigent regions of the (sub) tropics. As hospitalization constitutes a major risk factor for colonization, infection control management in low-prevalence countries urgently needs background data on patients hospitalized abroad. Methods: We collected data on 1122 patients who, after hospitalization abroad, were treated at the Helsinki University Hospital between 2010 and 2013. They were screened for methicillin-resistant Staphylococcus aureus (MRSA), extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE), vancomycin-resistant enterococci, carbapenemase-producing Enterobacteriaceae (CPE), multiresistant Pseudomonas aeruginosa and multiresistant Acinetobacter baumannii. Risk factors for colonization were explored by multivariate analysis. Results: MDR colonization rates were higher for those hospitalized in the (sub) tropics (55%; 208/377) compared with temperate zones (17%; 125/745). For ESBL-PE the percentages were 50% (190/377) versus 12% (92/745), CPE 3.2% (12/377) versus 0.4% (3/745) and MRSA 6.6% (25/377) versus 2.4% (18/745). Colonization rates proved highest in those returning from South Asia (77.6%; 38/49), followed by those having visited Latin America (60%; 9/16), Africa (60%; 15/25) and East and Southeast Asia (52.5%; 94/179). Destination, interhospital transfer, short time interval to hospitalization, young age, surgical intervention, residence abroad, visiting friends and relatives, and antimicrobial use proved independent risk factors for colonization. Conclusions: Post-hospitalization colonization rates proved higher in the (sub) tropics than elsewhere; 11% (38/333) of carriers developed an MDR infection. We identified several independent risk factors for contracting MDR bacteria. The data provide a basis for infection control guidelines in low-prevalence countries (C) 2017 The Author(s). Published by Elsevier Ltd on behalf of European Society of Clinical Microbiology and Infectious Diseases.

Background The annual number of international tourist arrivals has recently exceeded one billion, yet surprisingly few studies have characterized travelers’ behavior, illness, and risk factors in a prospective setting. Particularly scarce are surveys of data spanning travel, return, and follow-up of the same cohort. This study examines behavior and illness among travelers while abroad, after return home, and at follow-up. Patterns of behavior connected to type of travel and illness are characterized so as to identify risk factors and provide background data for pre-travel advice. Methods Volunteers to this prospective cohort study were recruited at visits to a travel clinic prior to departure. Data on the subjects’ health and behavior were collected by questionnaires before and after journeys and over a three-week follow-up. In addition, the subjects were asked to fill in health diaries while traveling. Results The final study population consisted of 460 subjects, 79 % of whom reported illness during travel or on arrival: 69 % had travelers’ diarrhea (TD), 17 % skin problems, 17 % fever, 12 % vomiting, 8 % respiratory tract infection, 4 % urinary tract infection, 2 % ear infection, 4 % gastrointestinal complaints other than TD or vomiting, and 4 % other symptoms. Of all subjects, 10 % consulted a doctor and 0.7 % were hospitalized; 18 % took antimicrobials, with TD as the most common indication (64 %). Ongoing symptoms were reported by 25 % of all travelers upon return home. During the three-week follow-up (return rate 51 %), 32 % of respondents developed new-onset symptoms, 20 % visited a doctor and 1.7 % were hospitalized. Factors predisposing to health problems were identified by multivariable analysis: certain regions (Southern Asia, South-Eastern Asia, and Eastern Africa), female gender, young age, and long travel duration. Conclusions Despite proper preventive measures like vaccinations, malaria prophylaxis, and travel advice, the majority of our subjects fell ill during or after travel. As the symptoms mostly remained mild, health care services were seldom needed. Typical traveler profiles were identified, thereby providing a tool for pre-travel advice. The finding that one third reported new-onset illness during follow-up attests to the importance of advising clients on potential post-travel health problems already during pre-travel visits. Electronic supplementary material The online version of this article (doi:10.1186/s12879-016-1682-0) contains supplementary material, which is available to authorized users.

New biomarkers are needed for discriminating active tuberculosis (TB) from latent TB infection (LTBI), especially in vulnerable groups representing the major diagnostic challenge. This pilot study was carried out to explore the diagnostic potential of selected genes, IFN-gamma, IL-17, IL-4, and FoxP3, associated with TB immunity and immunopathology. IFN-gamma, IL-17, IL-4, and FoxP3 mRNA expression levels were measured by quantitative reverse transcription PCR (RT-qPCR) from antigen-stimulated peripheral blood mononuclear cells of patients with active TB (n = 25); patients with miscellaneous inflammatory disorders and concomitant LTBI (n = 20), rheumatoid arthritis (RA) being the most predominant in the group (n = 11); and in healthy Bacillus Calmette Guerin (BCG) vaccinees (n = 8). While the levels of FoxP3 mRNA did not differ between the tested groups, the cumulative expression levels of purified protein derivative -stimulated IFN-gamma, IL-17, and IL-4 mRNAs were found to distinguish active TB from the whole group of LTBI with 48% sensitivity and 85% specificity. When restricting the LTBI group to RA cases only, the sensitivity was 56% and specificity 100%. When interpreting the result as positive in at least one of the mRNAs IFN-gamma, IL-17, or IL-4, sensitivity of 64% and specificities of 75% (heterogeneous group of LTBI) or 100% (LTBI with RA) were achieved. Moderate discrimination of active TB from LTBI with miscellaneous inflammatory underlying conditions by using combined quantitative expression of IFN-gamma, IL-17, and IL-4 mRNA seems not to be of high diagnostic potential.

Background Despite the high frequency of upper respiratory tract (URT) infections and use of the nasal mucosa as route for vaccination, the local immune mechanism and dissemination of effector lymphocytes from the URT have been insufficiently characterized. To devise a single-cell approach for studying the mucosal immune response in the URT, we explored URT-originating B effector lymphocytes in the circulation of patients with one of two common respiratory infections, acute sinusitis or tonsillitis. Methods Patients with acute sinusitis (n = 13) or tonsillitis (n = 11) were investigated by ELISPOT for circulating pathogen-specific antibody-secreting cells (ASCs) of IgA, IgG and IgM isotypes approximately one week after the onset of symptoms. These cells' potential to home into tissues was explored by assessing their expression of tissue-specific homing receptors alpha(4)beta(7), L-selectin, and cutaneous lymphocyte antigen (CLA). Results Pathogen-specific ASCs were detected in the circulation of all patients, with a geometric mean of 115 (95% CI 46-282) /10(6) PBMC in sinusitis, and 48 (27-88) in tonsillitis. These responses were mainly dominated by IgG. In sinusitis alpha(4)beta(7) integrin was expressed by 24% of the ASCs, L-selectin by 82%, and CLA by 21%. The proportions for tonsillitis were 15%, 80%, and 23%, respectively. Healthy individuals had no ASCs. Conclusions URT infections-acute sinusitis and tonsillitis-both elicited a response of circulating pathogen-specific plasmablasts. The magnitude of the response was greater in sinusitis than tonsillitis, but the homing receptor profiles were similar. Human nasopharynx-associated lymphoid structures were found to disseminate immune effector cells with a distinct homing profile.

We report a case of pulmonary cystic echinococcosis in a child from eastern Finland with no history of travelling abroad. The cyst was surgically removed and the organism molecularly identified as Echinococcus canadensis genotype G10. This parasite is maintained in eastern Finland in a sylvatic life cycle involving wolves and moose; in the present case, the infection was presumably transmitted by hunting dogs.

To the Editor—I warmly thank Drs Bradley Connor and Jay Keystone for their meritorious editorial commentary [1] on our research showing that antibiotic use predisposes travelers to colonization with extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) [2]. They cogitate about fundamental problems associated with refraining from antibiotics for travelers' diarrhea (TD), listing potential alternative approaches. Acknowledging their valuable discussion on the whole, I was, however, concerned about one proposition—chemoprophylaxis with nonabsorbable antibiotics as an alternative—which essentially contradicts our purport, caution with antibiotics. Although attacking the pathogen, antimicrobials also kill innocent bystanders, members of microbiota providing colonization resistance against invaders [3, 4]. Disrupting this barrier within the gut, antibiotics—absorbable or not—make space for newcomers. Rifaximin, a nonabsorbable antimicrobial used, for example, for TD, has a broad-spectrum in vitro activity against aerobic and anaerobic, Gram-positive and -negative bacteria [5–8]. From our present perspective, the broader the spectrum, the greater the damage. Although possibly less efficient than fluoroquinolones and azithromycin in selecting multidrug-resistant microbes [8], rifaximin ultimately functions like any antimicrobial: it opens a door to local newcomers. When taken in an environment with a high prevalence of (multi)resistant intestinal bacteria plus poor hygiene, the newcomers inevitably also include resistant bacteria. Therefore, with respect to colonization, nonabsorbables are not safe for travelers, either; and prophylactic antimicrobials against TD would, indeed, be the last alternative, putting anyone involved at an unnecessary risk. I also wish to comment on one point presented, not in the editorial, but in professional online discussions triggered by our study. I agree with the view that travelers' antibiotics probably do not contribute greatly to the total increase in the resistance, representing a minor proportion of the antimicrobials consumed in developing countries. Here, the central point seems to be missed: what travelers do is facilitate the spread of resistant bacteria to low-prevalence countries. With around 300 million annual visits to (sub)tropical regions [9], travelers' role is obvious. In our data, 67% had TD; ESBL-PE was contracted by 11% of healthy travelers (TD−AB−), 21% of those with TD not using antimicrobials (TD+AB−), and 37% with TD using antimicrobials (TD+AB+) [2]. Applying these figures to the total of travelers, and hypothesizing that nobody took antibiotics for TD, 300 million annual travelers would make 53 million ESBL carriers. If antibiotics were used in all TD cases, the count would be 85 million: 30 million extra carriers returning to low-prevalence regions—and still more, if all travelers took antibiotics as chemoprophylaxis. Even with these rough figures the result is unignorable. By advising travelers, we can protect them from colonization and potential infections with resistant bacteria and significantly reduce the numbers of carriers ending up in our countries. The resistance problem, although primarily to be tackled in developing regions, is incontestantly global. Besides supporting the struggle in high-risk regions, we in developed countries have a responsibility to fight the global spread—and the right to protect our countries and hospitals. Travel medicine practitioners not wishing their clients to import resistant bacteria should advise them against antibiotics for mild/moderate TD.

The number of international tourist arrivals reached 1,000 million in 2012. Assessment of travellers' health problems has relied on proportionate morbidity data. Given the lack of data on number of visitors to each region, incidences have been impossible to calculate. This study, largest yet reporting travellers' health problems, is the first to present incidence of illness and injury. Data on Finnish travellers with health problems abroad during 2010 to 2012 were retrieved from the database of an assistance organisation, SOS International, covering 95% of those requiring aid abroad. The numbers were compared with those of Finnish travellers in the database of the Official Statistics of Finland. The SOS International database included 50,710 cases: infections constituted the most common health problem (60%), followed by injuries (14%), diseases of skin (5%), musculoskeletal system and connective tissue (5%), digestive tract (3%), and vascular system (2%). Gastroenteritis (23%) and respiratory infections (21%) proved the most frequent diagnoses. Overall incidence of illness or injury was high in Africa (97.9/100,000 travel days; 95% Bayesian credible interval (BCI): 53.1-145.5), southern Europe plus the eastern Mediterranean (92.3; 95% BCI: 75.4-110.1) and Asia (65.0; 95% BCI: 41.5-87.9). The data show significant differences between geographical regions, indicating the main risks and thus providing destination-specific tools for travellers' healthcare.

The newly discovered Merkel Cell Polyomavirus (MCPyV) resides in approximately 80% of Merkel cell carcinomas (MCC). Causal role of MCPyV for this rare and aggressive skin cancer is suggested by monoclonal integration and truncation of large T (LT) viral antigen in MCC cells. The mutated MCPyV has recently been found in highly purified leukemic cells from patients with chronic lymphocytic leukemia (CLL), suggesting a pathogenic role also in CLL. About 50–80% of adults display MCPyVspecific antibodies. The humoral immunity does not protect against the development of MCC, as neutralizing MCPyV antibodies occur in higher levels among MCC patients than healthy controls. Impaired T-cell immunity has been linked with aggressive MCC behavior. Therefore, cellular immunity appears to be important in MCPyV infection surveillance. In order to elucidate the role of MCPyV-specific Th-cell immunity, peripheral blood mononuclear cells (PBMC) of healthy adults were stimulated with MCPyV VP1 virus-like particles (VLPs), using human bocavirus (HBoV) VLPs and Candida albicans antigen as positive controls. Proliferation, IFN-c, IL-13 and IL-10 responses were examined in 15 MCPyV-seropositive and 15 seronegative volunteers. With the MCPyV antigen, significantly stronger Th-cell responses were found in MCPyVseropositive than MCPyV-seronegative subjects, whereas with the control antigens, the responses were statistically similar. The most readily detectable cytokine was IFN-c. The MCPyV antigen tended to induce stronger IFN-c responses than HBoV VLP antigen. Taken together, MCPyV-specific Th-cells elicit vigorous IFN-c responses. IFN-c being a cytokine with major antiviral and tumor suppressing functions, Th-cells are suggested to be important mediators of MCPyV-specific immune surveillance.