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Leprosy is uncommon in Canada. However, immigration from leprosy-endemic areas has introduced the infection to a Canadian context, in which most doctors have little knowledge of the disease. Although post-exposure chemoprophylaxis (PEP) is reported to decrease leprosy transmission, no Canadian guidelines advise clinical decision making about leprosy PEP. Here, we characterize the practice patterns of Canadian infectious disease specialists with respect to leprosy PEP and screening of household contacts by yearly physical examinations.Canadian infectious disease specialists with known experience treating leprosy were identified using university faculty lists. An online anonymous survey was distributed. Certain questions allowed more than one response.The survey response rate was 46.5% (20/43). Thirty-five percent responded that PEP is needed for household contacts, 40.0% responded that PEP is not needed for household contacts, and 25.0% did not know whether PEP is needed (multinomial testConsensus among Canadian infectious diseases specialists is lacking regarding leprosy PEP and screening of household contacts.La lèpre est peu courante au Canada. Cependant, en raison de l’immigration de régions où la lèpre est endémique, cette infection existe, mais la plupart des médecins du Canada la connaissent peu. Même s’il est établi que la chimioprophylaxie post-exposition (PPE) réduit la transmission de la lèpre, il n’existe aucune directive canadienne pour éclairer les décisions cliniques sur la PPE de la lèpre. Les chercheurs caractérisent les schémas d’exercice des infectiologues canadiens au sujet de la PPE de la lèpre et du dépistage des contacts familiaux par des examens physiques annuels des aspects dermatologiques et nerveux périphériques.Les chercheurs ont répertorié les infectiologues canadiens qui ont une expérience démontrée du traitement de la lèpre grâce aux listes des professeurs universitaires. Ils ont distribué un sondage anonyme en ligne. Pour certaines questions, les participants pouvaient fournir plus d’une réponse. Ils pouvaient aussi sauter certaines questions.Le taux de réponse au sondage s’élevait à 46,5 % (20 cas sur 43). De cette proportion, 35,0 % ont répondu que les contacts familiaux avaient besoin d’une PPE, 40,0 %, qu’ils n’en avaient pas besoin, et 25,0 %, qu’ils ne le savaient pas (test multinomial,Il n’y a pas de consensus chez les infectiologues canadiens au sujet de la PPE de la lèpre et du dépistage des contacts familiaux.

This chapter covers nematodes or roundworms, which are the most common parasites infecting humans worldwide. Ascaris lumbricoides, Trichuris trichiura, and hookworms are collectively referred to as geohelminths and infect approximately 1.5 billion people. Also discussed are other important nematodes of humans, such as Strongyloides stercoralis, that completes its entire life cycle within the human host, and Enterobius vermicularis, that is transmitted from person to person. The prevalence and intensity of helminthic infections that are primarily related to poverty, educational and agricultural standards, population density, and sanitary or public health conditions. The majority of geohelminthic infections is asymptomatic and associated with low worm burdens.

Central nervous system (CNS) strongyloidiasis is a known but rare form of disseminated infection. The diagnosis is often made postmortem, with only five published cases of an antemortem diagnosis. We report two fatal cases of CNS strongyloidiasis diagnosed antemortem, with Strongyloides stercoralis larvae visualized in the CNS sample in one case. Risk factors for disseminated strongyloidiasis common to both cases included origination from the Caribbean, underlying human T-lymphotropic virus-1 infection, and recent prednisone use. Both cases occurred in Canada, where the occurrence of Strongyloides is uncommon, and serve as a reminder to maintain a high index of suspicion in patients with epidemiologic or clinical risk factors for dissemination.

Delusional infestation (delusional parasitosis) is a rare disorder in which affected individuals have the fixed, false belief (delusion), against all medical evidence, that they are infected by “bugs”: parasites or other living organisms. It is a delusional disorder of the somatic type, considered to be a form of monosymptomatic hypochondriacal psychosis. The disorder most often affects women over the age of 50 years; many affected individuals are quite functional. Rarely the disorder may be associated with underlying medical or psychiatric disease, substance abuse, or medications. Cutaneous complaints and asymmetric dermatologic findings may be present for months to years before diagnosis. Patients often bring in specimens of skin and other material for examination. Although neuroleptics (e.g., risperidone, aripiprazole, pimozide) are the treatment of choice, and are in many cases are effective, most patients will not accept therapy from a psychiatrist. The key to the management of patients is the development of a strong, therapeutic relationship.

We report two unusual cases of clinical strongyloidiasis that present as extensive thrombosis: a case of hyperinfection with concurrent eosinophilia and a case of disseminated infection as a complication of immunosuppression. We discuss risk factors for the development of Strongyloides stercoralis infection and thromboembolism, and the recommended management.

Bancroftian filariasis can cause genital abnormalities related to chronic inflammation and obstruction of the afferent lymphatic vessels, and may demonstrate a "filarial dance sign" on scrotal ultrasound with mobile echogenic particles observed. We present a patient with a positive "filarial dance sign," travel within Latin America, and negative filarial serology.

Background The aim of this work was to examine whether a linear retinal pigment epitheliopathy is associated with the amyotrophic lateral sclerosis/parkinsonism-dementia complex of Guam. Methods A total of 918 Guamanian Chamorros, with and without amyotrophic lateral sclerosis/parkinsonism-dementia complex, were examined cross-sectionally for linear retinal pigment epitheliopathy (LRPE). Overall, 239 Guamanians, who were neurologically asymptomatic, were followed for up to 20 years to determine the risk of developing amyotrophic lateral sclerosis/parkinsonism-dementia complex. Results The epitheliopathy was present in 59.7% (117 of 196) patients with amyotrophic lateral sclerosis/parkinsonism-dementia complex, but in only 24.7% (178 of 722) of subjects who were neurologically asymptomatic (age- and sex-adjusted risk difference: 35.0%; 95% confidence interval [CI]: 27.5-42.6; p

A previously healthy 40-year-old man presents to his family physician’s office with a 24-hour history of fever and myalgia. One week earlier, he returned to Canada from Guinea, where he was visiting family. While away, he resided in the same home as his sister and cared for her when she was

Background and Objective: While clinical symptoms of strongyloidiasis are often nonspecific, larva currens (with erythematous, serpiginous, and pruritic papules and plaques) should prompt investigation including stool microscopy, serology, and skin biopsy of the lesion. Appropriate diagnosis and treatment with ivermectin is necessary, especially in the immunocompromised patient who is at increased risk for hyperinfection syndrome and disseminated disease. Conclusion: We present a 61-year-old immunocompromised man with presentation of larva currens of cutaneous strongyloides infection without symptoms of hyperinfection or disseminated disease.

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Two cases of Strongyloides hyperinfection are presented. Ivermectin was initially administered orally and per rectum pending the availability of subcutaneous (SC) preparations. In neither case did rectal suppositories of ivermectin achieve clinically meaningful serum values. Clinicians should use SC preparations of ivermectin as early as possible in Strongyloides hyperinfection and dissemination.

Purpose The prevalence of epilepsy in Cameroon is higher than that of the industrialized world and other developing countries. Neurocysticercosis due to Taenia solium infestation has been reported as a major cause of epilepsy in some parts of Cameroon although there are some conflicting data. The prevalence of epilepsy is especially high in the Momo division of the North-West Province of Cameroon. We hypothesized that individuals with epilepsy in this region have a higher percentage of seropositivity to T. solium than matched controls. Methods We conducted a case–control study in the Momo subdivision of Ngie. Individuals with epilepsy were recruited from the health centers in Ngie. Control subjects were selected from 19 Ngie villages. Potential cases of people with epilepsy (PWE) were identified through a questionnaire applied by trained field workers, using history of epileptic seizures as a key indicator. Blood samples were taken from all consenting individuals by finger prick, stored in StabilZyme Select, and assayed for antibodies to T. solium in an Atlanta based reference laboratory. Results We accrued 249 patients with epilepsy, of whom 237 met the inclusion criteria, and 245 age-matched controls. There was no significant difference in seropositivity to T. solium between those individuals with epilepsy (5%) and controls (4.9%). Conclusions Our data do not support the hypothesis that epilepsy is associated with seropositivity to T. solium . It is highly unlikely that cysticercosis plays a causative role in the high prevalence of epilepsy in this region of Cameroon.

An immunocompetent 52-year-old man presented with lesions and inflammation on his left arm after lacerating his index finger while cleaning a fish tank ([Figure 1][1]). The lesions appeared at the laceration site two weeks after the injury and continued to progress for five months. He had no fever

Background: International travel continues to increase, particularly to Asia and Africa. Clinicians are increasingly likely to be consulted for advice before travel or by ill returned travelers. Objective: To describe typical diseases in returned travelers according to region, travel reason, and patient demographic characteristics; describe the pattern of low-frequency travel-associated diseases; and refine key messages for care before and after travel. Design: Descriptive, using GeoSentinel records. Setting: 53 tropical or travel disease units in 24 countries. Patients: 42 173 ill returned travelers seen between 2007 and 2011. Measurements: Frequencies of demographic characteristics, regions visited, and illnesses reported. Results: Asia (32.6%) and sub-Saharan Africa (26.7%) were the most common regions where illnesses were acquired. Three quarters of travel-related illness was due to gastrointestinal (34.0%), febrile (23.3%), and dermatologic (19.5%) diseases. Only 40.5% of all ill travelers reported pretravel medical visits. The relative frequency of many diseases varied with both travel destination and reason for travel, with travelers visiting friends and relatives in their country of origin having both a disproportionately high burden of serious febrile illness and very low rates of advice before travel (18.3%). Life-threatening diseases, such as Plasmodium falciparum malaria, melioidosis, and African trypanosomiasis, were reported. Limitations: Sentinel surveillance data collected by specialist clinics do not reflect healthy returning travelers or those with mild or self-limited illness. Data cannot be used to infer quantitative risk for illness. Conclusion: Many illnesses may have been preventable with appropriate advice, chemoprophylaxis, or vaccination. Clinicians can use these 5-year GeoSentinel data to help tailor more efficient pretravel preparation strategies and evaluate possible differential diagnoses of ill returned travelers according to destination and reason for travel. Primary Funding Source: Centers for Disease Control and Prevention. Accepted version

Introduction Since 1947, Zika virus has been identified sporadically in humans in Africa and Asia; however, clinically consequential Zika virus disease had not been documented prior to the current outbreak in the Americas. Considering 6 decades have passed since the first identification of the virus, it is perhaps unexpected that Zika virus was recognised only recently as capable of causing disease epidemics. Substantial work on understanding the epidemiology of Zika virus has been conducted since the virus9 first outbreak in 2007 in Micronesia; however, there has been little study of the earlier data on Zika virus. Methods A systematic literature search was conducted to identify evidence of Zika virus infection in humans from 1947 to 2007. Data extracted included seroprevalence of Zika virus infection, age distributions of positive test results and serologic test modalities used. Country-level and age-specific seroprevalence was calculated. Estimates of seroprevalence by different serologic test modalities were compared. Results 12 026 citations were retrieved by the literature search, and 76 articles were included in this review. Evidence of Zika virus infection in humans was found in 29 countries in Africa, 8 countries in Asia and 1 country in Europe. Country-level seroprevalence of Zika virus infection ranged from 0.4% to 53.3%. Seroprevalence of Zika virus infection was found to increase across the lifespan; 15–40% of reproductive-age individuals may have been previously infected. No significant difference was found between estimates of seroprevalence by different serologic test modalities. Discussion Zika virus has likely been endemic for decades in certain regions of the world; however, the majority of reproductive-age individuals have likely not been infected. Historical evidence of Zika virus infection exists regardless of the serologic test modality used.

To describe patient characteristics and disease spectrum among foreign visitors to Haiti before and after the 2010 earthquake, we used GeoSentinel Global Surveillance Network data and compared 1 year post-earthquake versus 3 years pre-earthquake. Post-earthquake travelers were younger, predominantly from the United States, more frequently international assistance workers, and more often medically counseled before their trip than pre-earthquake travelers. Work-related stress and upper respiratory tract infections were more frequent post-earthquake; acute diarrhea, dengue, and Plasmodium falciparum malaria were important contributors of morbidity both pre- and post-earthquake. These data highlight the importance of providing destination- and disaster-specific pre-travel counseling and post-travel evaluation and medical management to persons traveling to or returning from a disaster location, and evaluations should include attention to the psychological wellbeing of these travelers. For travel to Haiti, focus should be on mosquito-borne illnesses (dengue and P. falciparum malaria) and travelers' diarrhea.

To the Editor: Intravenous artesunate is recommended by the World Health Organization as first-line treatment for severe malaria. While artemisinin-based therapies are well tolerated, recent studies have reported cases of severe delayed hemolysis after artesunate treatment for malaria (1–5). To date, all reported cases have been associated with the use of artesunate not produced under Good Manufacturing Practice (GMP) standards. The United States and Canada are the only countries that use GMP artesunate, and a recent review concluded that delayed hemolysis may be related to differences in GMP versus non-GMP artemisinins (5). We report a case of severe delayed hemolysis after administration of GMP artesunate to treat a patient with severe malaria. During October 2012, A previously healthy, 31-year-old Canadian-born man sought treatment at a hospital in Toronto, Ontario, Canada, after 3 days of fever and severe headaches. He had returned 10 days earlier from a 10-day work trip to South Sudan. He did not use malaria chemoprophylaxis while there but did sleep under an insecticide-treated net. During initial assessment, a blood smear showed Plasmodium falciparum malaria with parasitemia of 22% (1,100,000 parasites/μL) and the following levels: bilirubin, 88 (reference range 5–17) μmol/L; aminotransferase, 105 (reference range 10–38) U/L; creatinine, 130 (reference range 80–115) μmol/L; hemoglobin, 144 (reference range 140–160) g/L, and a platelet count of 17 × 109/L (reference range 150–450 × 109/L). In the emergency department, he was given 1 dose each of doxycycline, atovaquone/proguanil, and artemether/lumefantrine; within an hour of ingestion of these drugs, he vomited. He was transferred to a tertiary level hospital for admission to the intensive care unit and exchange transfusion. Intravenous artesunate was administered (2.4 mg/kg at 0, 12, 24, and 48 h), then a 3-day course of oral atovaquone/proguanil was ordered. On admission, his chest radiograph showed no abnormalities, and blood cultures were negative; his hemoglobin level was 125 g/L; no treatment was initiated for decreased hemoglobin. Parasitemia was undetectable within 36 hours of admission to the intensive care unit. The patient was discharged 5 days later. Four days after discharge, the patient returned to the tertiary level hospital seeking treatment. He reported that beginning 2 days after discharge, he had fever and “merlot-colored” urine. On admission, he was noted to be jaundiced. Laboratory values included levels of bilirubin of 89 μmol/L, lactate dehydrogenase (LDH) of 1,976 (reference 120–240) U/L, hemoglobin of 81 g/L and marked hemoglobinuria. Multiple thick and thin blood smears were negative for Plasmodium spp. During the course of his second admission, he required 8 blood transfusions to maintain his hemoglobin level above 75 g/L. He continued to have unexplained hemolysis and hemoglobinuria: laboratory results showed a nadir of hemoglobin at 68 g/L and an LDH peak of 3,429 U/L and a low haptoglobin level (

Using the GeoSentinel database, an analysis of ill patients returning from throughout sub-Saharan Africa over a 13-year period was performed. Systemic febrile illness, dermatologic, and acute diarrheal illness were the most common syndromic groupings, whereas spotted fever group rickettsiosis was the most common individual diagnosis for travelers to South Africa. In contrast to the rest of sub-Saharan Africa, only six cases of malaria were documented in South Africa travelers. Vaccine-preventable diseases, typhoid, hepatitis A, and potential rabies exposures were uncommon in South Africa travelers. Pre-travel advice for the travelers to the 2010 World Cup should be individualized according to these findings.

Travel vaccines comprise an essential component of pretravel health advice; however, many travelers do not take advantage of this preventive health strategy to decrease their risk of travel-related illness. Factors that impact on a traveler's decision on whether or not to be vaccinated are related to the knowledge, attitudes and beliefs of the traveler regarding travel vaccines, vaccine-preventable diseases, and other factors. Further research is required to increase travelers' awareness of the need for pretravel vaccination and then to translate that awareness into positive attitudes leading to increased travel vaccine uptake.

Selected data collected for travelers to China from 1998 through November 2007 by the GeoSentinel Surveillance Network were used to provide an evidence base for prioritizing recommendations for Olympic and other future travelers to China. Respiratory illness and injuries were common among patients seen during their travel; acute diarrhea and dog bites were common among those seen after travel. Tropical and parasitic diseases were rare. Pre-travel consultation for China travelers should be individualized according to these findings.

SummaryHepatitis A virus (HAV) and hepatitis B virus (HBV) are vaccine-preventable. Current recommendations advocate vaccination of non-immune adults at risk of exposure, including travelers to HAV or HBV endemic areas, individuals with high risk of contracting a sexually transmitted infection, and some correctional facility inmates. We review the use of an accelerated schedule to administer the combination hepatitis A and hepatitis B vaccine (Twinrix®). Administering three doses over three weeks and a fourth at 12 months provides rapid initial protection of most individuals for whom the standard 6-month vaccination schedule would not be suitable, including last-minute travelers and short-term correctional facility inmates. Furthermore, we consider the role of a universal vaccination strategy in preventing the spread of HAV and HBV.

Chagas' disease is caused by infection with the protozoan agent Trypanosoma cruzi. An estimated sixteen to eighteen million people are infected in Latin America. Outside of endemic regions, Chagas' disease may be transmitted through the transfusion of infected blood components, congenital infection and organ transplantation. We sought to determine the sero-prevalence of antibodies to T. cruzi in a community sample of Latin American refugees and immigrants to Canada.This was a sero-prevalence study in Latin American refugees and immigrants living in Canada. Eligible subjects were born in South America, Central America or in Mexico. Participants were recruited from a variety of community settings, as well as from medical clinics. Serum was tested by enzyme-linked immunoassay for antibodies to T. cruzi.A total of 102 participants were enrolled. One sample tested positive for antibodies for T. cruzi. The seroprevalence in our sample was 1.0% (95% CI: 0.2%- 5.3%).We found a low sero-prevalence of Chagas' disease in a community sample of Latin American immigrants and refugees. Physicians who treat Latin American immigrants should consider the risk profile and clinical status of the individual in their decision to screen for Chagas' disease.

Summary An increasing number of children travel internationally each year. Minimising the risk of acquiring infectious diseases during travel by appropriate anticipatory guidance is a key role of the travel physician. A child's routine, required and recommended travel vaccines must be brought up to date prior to travel. Malaria prevention depends on the use of personal protective measures and chemoprophylaxis as determined by the child's age and travel itinerary. The impact of travellers’ diarrhoea can be decreased by following food and water precautions, paying attention to hydration status, and antibiotic therapy if diarrhoea develops. Any child who develops symptoms after travel should seek prompt medical evaluation.

BACKGROUND Approximately 8 percent of travelers to the developing world require medical care during or after travel. Current understanding of morbidity profiles among ill returned travelers is based on limited data from the 1980s. METHODS Thirty GeoSentinel sites, which are specialized travel or tropical-medicine clinics on six continents, contributed clinician-based sentinel surveillance data for 17,353 ill returned travelers. We compared the frequency of occurrence of each diagnosis among travelers returning from six developing regions of the world. RESULTS Significant regional differences in proportionate morbidity were detected in 16 of 21 broad syndromic categories. Among travelers presenting to GeoSentinel sites, systemic febrile illness without localizing findings occurred disproportionately among those returning from sub-Saharan Africa or Southeast Asia, acute diarrhea among those returning from south central Asia, and dermatologic problems among those returning from the Caribbean or Central or South America. With respect to specific diagnoses, malaria was one of the three most frequent causes of systemic febrile illness among travelers from every region, although travelers from every region except sub-Saharan Africa and Central America had confirmed or probable dengue more frequently than malaria. Among travelers returning from sub-Saharan Africa, rickettsial infection, primarily tick-borne spotted fever, occurred more frequently than typhoid or dengue. Travelers from all regions except Southeast Asia presented with parasite-induced diarrhea more often than with bacterial diarrhea. CONCLUSIONS When patients present to specialized clinics after travel to the developing world, travel destinations are associated with the probability of the diagnosis of certain diseases. Diagnostic approaches and empiric therapies can be guided by these destination-specific differences.

Rates of global travel and tourism are increasing dramatically, especially to regions with medium or high endemicity for hepatitis A and B, such as Asia, Africa, Latin America, and the Middle East. International travelers to these areas should be protected against both hepatitis A and B, regardless of their anticipated length of stay. However, many travelers depart within weeks of planning their trip (too late to complete the accelerated 0-, 1-, 2-month regimen for hepatitis B), and a majority of those traveling depart without being vaccinated. Although extended-stay travelers are at high risk for hepatitis B, short-stay travelers also are at risk. The most commonly encountered risk factors for travel-related hepatitis B are casual sexual activity with a new partner, medical and dental care abroad, and in the expatriate community, adoption of children who are hepatitis B carriers. Although efficacy studies of accelerated schedules for hepatitis B immunization have not been conducted, the results of immunogenicity studies in healthy volunteers who received an accelerated, 3-dose regimen on a 0-,7-, and 21-day schedule suggest that excellent, rapid, and long-term protection will be conferred. More data are needed to assess the efficacy of accelerated schedules in persons aged >40 years and to determine whether a fourth dose of hepatitis B vaccine is needed in all age groups.

Malaria prevention has benefited from many diverse disciplines of research, including epidemiologic monitoring, development of laboratory techniques, assessment of insect repellents, or pharmaceutical innovations. Strategies in all these sectors have been explored in recent years, resulting in improved options to prevent travelers' malaria. The addition of atovaquone-proguanil for malaria chemoprophylaxis and the recommendation of primaquine as primary prophylaxis have been significant advances. Tafenoquine seems promising. Standby treatment recommendations have been refined. Many areas still need better strategies. Problematic areas include chemoprophylaxis for long-term travelers, expatriates, and pregnant women; optimal criteria for terminal prophylaxis; and the prevention of malaria in populations that are least likely to seek pretravel evaluations, such as those visiting friends and relatives in their home countries (VFRs). Finally, research in travel and tropical medicine should continue to focus on additional strategies to confront the ever-widening challenge of drug-resistant malaria.

An increasingly large proportion of immigrants to developed countries is arriving from less developed countries in Africa, Asia, and Latin America. When these immigrants return to their country of origin to visit friends and relatives, they are at high risk of acquiring tropical infections, compared with other travelers. Immigrants who return to their country of origin to visit friends and relatives (VFRs) are more likely to travel to rural areas for long periods of time, to consume contaminated food and beverages, and to have more prolonged, intimate contact with local populations. As a group, they are less likely to seek pretravel advice or take antimalarial chemoprophylaxis. This article discusses the increased risk of tuberculosis, malaria, food- and waterborne illnesses, hepatitis A, and HIV and other sexually transmitted infections in VFRs.

In recent years, numerous studies have focused on the importance of imported drug-resistant bacteria, especially extended-spectrum β-lactamase–producing Enterobacteriaceae (ESBL-PE) and carbapenemase-producing Enterobacteriaceae [1]. Although initial reports were related to travelers who sought healthcare in developing countries, it is now clear that healthy returned travelers are at risk for colonization with ESBL-PE and potentially spreading these into the community, especially to those whose underlying health problems put them at risk for severe infection due to antibiotic-resistant organisms.Travel,travelers’diarrhea(TD), and antibiotic use independent of travel have all been shown to be associated with carriage of ESBL-PE; however, previous studies have not looked at these risk factors in concert, particularly the role of antibiotic self-treatment of TD. In this edition, Kantele and colleagues present the results of an excellent prospective study that provides very compelling evidence that antimicrobials increase a traveler’s risk of colonization by ESBLPE [2]. In their study of 430 Finnish travelers, 21% became colonized by ESBL-PE. Remarkably, 80% of travelers who selftreated TD with antibiotics in the Indian subcontinent were found to be colonized with ESBL-PE. They found that geographic region, occurrence of TD, and the use of antimicrobials for TD were independent risk factors associated with acquisition of ESBL-PE, and call for caution in the reflexive use of antibiotics for mild or moderate TD. Unsurprisingly and quite reasonably, the authors’ primary concern is that colonized travelers might contribute to the spread of resistant intestinal bacteria to the population at large in developed countries. In reality, however, one can see why a traveler who spends a considerable amount of money on an exotic international trip would want to carry and use an antibiotic for self-treatment for rapid relief of TD. Furthermore, the widespread problem in developing countries of counterfeit drugs, and the use of injections not infrequently administered with unsterile equipment to treat TD, would be a strong impetus for travelers to carry an antibiotic for self-treatment. A survey of healthcare providers in tourist resorts showed that 20%–86% of travelers would have undergone an invasive procedure (infusions, injections, and diagnostic venipuncture) if they had presented with diarrhea and fever [3]. “So what?” you say. A global World Health Organization survey has shown that 10%–75% of injections administered in developing countries may be given with unsterile equipment [4].