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Introduction International travellers contribute to the rapid spread of Zika virus (ZIKV) and its sentinel identification globally. We describe ZIKV infections among international travellers seen at GeoSentinel sites with a focus on ZIKV acquired in the Americas and the Caribbean, describe countries of exposure and traveller characteristics, and assess ZIKV diagnostic testing by site. Methods Records with an international travel-related diagnosis of confirmed or probable ZIKV from January 2012 through December 2019 reported to GeoSentinel with a recorded illness onset date were included to show reported cases over time. Records from March 2016 through December 2019 with an exposure region of the Americas or the Caribbean were included in the descriptive analysis. A survey was conducted to assess the availability, accessibility and utilization of ZIKV diagnostic tests at GeoSentinel sites. Results GeoSentinel sites reported 525 ZIKV cases from 2012 through 2019. Between 2012 and 2014, eight cases were reported, and all were acquired in Asia or Oceania. After 2014, most cases were acquired in the Americas or the Caribbean, a large decline in ZIKV cases occurred in 2018–19. Between March 2016 and December 2019, 423 patients acquired ZIKV in the Americas or the Caribbean, peak reporting to these regions occurred in 2016 [330 cases (78%)]. The median age was 36 years (range: 3–92); 63% were female. The most frequent region of exposure was the Caribbean (60%). Thirteen travellers were pregnant during or after travel; one had a sexually acquired ZIKV infection. There was one case of fetal anomaly and two travellers with Guillain-Barré syndrome. GeoSentinel sites reported various challenges to diagnose ZIKV effectively. Conclusion ZIKV should remain a consideration for travellers returning from areas with risk of ZIKV transmission. Travellers should discuss their travel plans with their healthcare providers to ensure ZIKV prevention measures are taken.

Medical crisis management - Emergency response plan - Missing persons - Scene management - Evacuation - Moving an injured person - Repatriation - Telemedicine and communications - Sexual assault - Death on an expedition

Introduction: psychological and psychiatric problems - Stressors in the wilderness - Considerations before departure - Psychiatric conditions - Psychological reactions to traumatic events - Post-traumatic stress disorder - Serious psychological threats - Recreational drugs and alcohol - After the expedition - P—assess perception - I—obtain the person’s invitation - K—give knowledge and information - E—address emotions with empathic responses - S—strategy and summary

International audience

Background: The number of US students studying abroad more than tripled during the past 20 years. As study abroad programmes' destinations diversify, students increasingly travel to resource-limited countries, placing them at risk for infectious diseases. Data describing infections acquired by US students while travelling internationally are limited. We describe illnesses among students who returned from international travel and suggest how to prevent illness among these travellers. Methods: GeoSentinel is a global surveillance network of travel and tropical medicine providers that monitors travel-related morbidity. This study included the records of US resident student international travellers, 17-24 years old, who returned to the USA, had a confirmed travel-related illness at one of 15 US GeoSentinel sites during 2007-17 and had a documented exposure region. Records were analysed to describe demographic and travel characteristics and diagnoses. Results: The study included 432 students. The median age was 21 years; 69% were female. More than 70% had a pre-travel consultation with a healthcare provider. The most common exposure region was sub-Saharan Africa (112; 26%). Students were most commonly exposed in India (44; 11%), Ecuador (28; 7%), Ghana (25; 6%) and China (24; 6%). The median duration of travel abroad was 40 days (range: 1-469) and presented to a GeoSentinel site a median of 8 days (range: 0-181) after travel; 98% were outpatients. Of 581 confirmed diagnoses, the most common diagnosis category was gastrointestinal (45%). Acute diarrhoea was the most common gastrointestinal diagnosis (113 of 261; 43%). Thirty-one (7%) students had vector-borne diseases [14 (41%) malaria and 11 (32%) dengue]. Three had vaccine-preventable diseases (two typhoid; one hepatitis A); two had acute human immunodeficiency virus infection. Conclusions: Students experienced travel-related infections, despite the majority having a pre-travel consultation. US students should receive pre-travel advice, vaccinations and chemoprophylaxis to prevent gastrointestinal, vector-borne, sexually transmitted and vaccine-preventable infections.

Background Rabies is an invariably fatal zoonotic viral disease. New Zealanders going abroad are largely unaware of the risk of contracting the disease. Prevention is the key to controlling the spread of this disease. Methods Data from 363 individuals presenting to New Zealand travel health clinics between 1998 and 2012 for post-travel consultations on potential rabies exposure were collated retrospectively. The data focused on traveler demographics, the country and nature of exposure, the purpose of travel, and pre-travel rabies awareness. Results The female-to-male ratio of subject travelers presenting was almost equal (1.1 : 1 ratio, respectively); the subjects were typically between 16 and 30 years (44.6%), tourists (64.5%), traveling less than 1 month (55.3%), and likely to have been exposed to animal contact in either Thailand (31.1%), China (13.2%), or Indonesia (12.3%). The animals to which they were exposed were usually dogs (59.5%) or monkeys (28.7%). Most potential exposures were penetrating (69.9%). Injury caused by the animal was more common in the lower limbs (50%) than in the upper limbs (43.4%); 89.4% of exposures were of World Health Organization (WHO) category III. Travelers were more likely to have received pre-travel rabies advice if they had been seen by a travel medicine specialist (96.1%) compared to a general practitioner (GP) (53.3%). Sixteen percent of travelers received rabies preexposure prophylaxis. Of the subjects who were managed following exposure, 79.7% did not receive immunoglobulin when indicated, and 21.5% did not receive any vaccine. Of the travelers that did receive a vaccine, 62.5% did so on the day of exposure. Of the travelers assessed, 16.7% had traveled without insurance. Conclusions New Zealanders require better guidance in understanding the need for travel-related rabies vaccination, as they are not managed abroad according to WHO guidelines. Few travelers had had pre-travel immunization, and only 20.3% of them had received WHO-advised postexposure management. Thus, 79.7% of the cohort theoretically remained at risk for contracting rabies because of inappropriate management following possible exposure to the disease.

To understand geographic variation in travel-related illness acquired in distinct African regions, we used the GeoSentinel Surveillance Network database to analyze records for 16,893 ill travelers returning from Africa over a 14-year period. Travelers to northern Africa most commonly reported gastrointestinal illnesses and dog bites. Febrile illnesses were more common in travelers returning from sub-Saharan countries. Eleven travelers died, 9 of malaria; these deaths occurred mainly among male business travelers to sub-Saharan Africa. The profile of illness varied substantially by region: malaria predominated in travelers returning from Central and Western Africa; schistosomiasis, strongyloidiasis, and dengue from Eastern and Western Africa; and loaisis from Central Africa. There were few reports of vaccine-preventable infections, HIV infection, and tuberculosis. Geographic profiling of illness acquired during travel to Africa guides targeted pretravel advice, expedites diagnosis in ill returning travelers, and may influence destination choices in tourism.

A profile of the recent genesis of the Sub-Faculty of Expedition Medicine into a Faculty of Expedition and Wilderness Medicine of The Australasian College of Tropical Medicine is presented. Information is given on aims, structure, professional grades of membership, and the various activities of the Faculty, including publications and scientific meetings.

BACKGROUND: Commercial expeditions and upmarket tours provide an opportunity for travellers to undertake various specialised travel to more adventurous and extreme destinations often in the relative security of accompanying medical cover provided by an expedition physician. There is limited knowledge of the nature of illnesses and injuries occurring on premium seniors' tours to Asia. This present study was designed to investigate the prevalence of injury and illness suffered by travellers on a premium tour to Indochina. METHODS: In 2004, the tour expedition physician (MTMS) diagnosed and recorded all illnesses and injuries amongst 23 travellers on a premium seniors' tour to Viet Nam and Cambodia. Information recorded included age, sex, number of days into the tour, the nature of the presenting illness, the assessment of the condition and the treatment employed during the field phase of 14 days. Travel was by air, train and coach, for a total period of 18 days. RESULTS: Nineteen (82%) travellers sought medical advice at least once for a total of 35 consultations. Females presented on 66% of occasions. The mean age of the travellers was 62 years (SD=13) with males being significantly older (p=0.002). Primary illnesses diagnosed related to the following systems: gastrointestinal 29%, respiratory 14%, dermatological 14%, cardiovascular 14%, musculoskeletal 9%, central nervous system 6%, ear/nose/throat 6%, dental 6%, and other problems on 3% of occasions. Of the gastrointestinal problems, diarrhoea was the commonest complaint on 17% of occasions, occurring at any stage throughout the journey. There was a mean of 2.5 presentations per day of the field phase of the tour. Presentations were highest on day 12. More than one third of presentations (37%) were handled conservatively without any further need for therapy, 17% requiring dressings, and 46% requiring specific medications. The commonest medications used were: lozenges/gargles (31%), antiemetic (25%), anti-diarrhoeal or other medications (13%). There were six accidents during the journey resulting in minor soft tissue injuries. There were no deaths or other major accidents requiring emergency evacuation or hospitalisation. CONCLUSIONS: On this premium seniors' tour, the health problems encountered were largely similar to those reported for other specialised tours, including premium expeditions. The most common medical problems included gastrointestinal, respiratory, dermatological, cardiovascular and musculoskeletal conditions in descending order. One aspect requiring further study is the psychological adjustments made by travellers on group tours and expeditions. As well as being part of the service provided to travellers, the inclusion of an expedition physician on this premium seniors' tour increased the independence of the travel group on this journey. Language: en

Background: Expeditions provide an opportunity for travelers to undertake specialized travel to more extreme destinations in the security of an expeditionary group with medical coverage. Little is known about the illnesses and injuries occurring to expeditioners in Mongolia or access to dental care in the local population. This study was designed to investigate the prevalence of health problems suffered by travelers and managed among the local population on a research expedition to Mongolia. Methods: In June 2005, the expedition physician (MTMS) and dentist (DD) prospectively diagnosed and recorded all illnesses and injuries among 16 travelers (eight males and eight females) as well as any indigenous people on a 22-day paleontological expedition to the Mongolian Gobi Desert. Results: There were 53 health presentations and 14 dental problems among the indigenous population and the Mongolian escort. Males and females presented in equal proportions with the average age of 49 years (SD = 16). Presentations involved locomotor/accident (32%), dermatological (23%), gastrointestinal (19%), neurological (17%), psychological (6%), and with other systems (11%). Most accidents were due to lacerations (85%). Presentations were highest on days 4 and 5 (10% or 18%). Females were significantly more likely to present later in the expedition ( p = 0.013). One quarter (25%) were handled conservatively with 28% requiring topical treatments with others requiring antiemetics (9%) and anti-infl ammatory drugs (4%). There were no dental concerns reported among the expeditioners, although there were 14 cases among the indigenous population. While there were no deaths on the expedition, there were two major incidents, one of which required emergency evacuation. Conclusions: The health problems encountered were largely similar to those reported for other expeditions. The most common problems included trauma as well as dermatological, dental, gastrointestinal, and neurological conditions. It is important that expedition teams are prepared to manage common problems, such as trauma and dental lesions.

Summary Background Commercial expeditions provide an opportunity for travellers to undertake various specialised travel to more adventurous and extreme destinations in the relative security of an expeditionary group with medical cover provided by an expedition physician. Little is known about the illnesses and injuries occurring on premium expeditions. The present study was designed to investigate the prevalence of health problems suffered by travellers on a premium expedition to Iceland and the Arctic Circle. Methods In 2004, the expedition physician diagnosed and recorded all illnesses and injuries amongst 45 travellers on a premium expedition to Iceland. Information recorded included age, sex, number of days into the expedition, the nature of the presenting illness, the assessment of the condition and the treatment employed. The period of the expedition was for 18 days and travel was by chartered aircraft, cruise ship and bus. Results Thirty-one (69%) travellers sought medical advice atleast once for a total of 54 consultations (mean=1.7). Fifty-six health presentations were reported and recorded amongst the travellers. Females presented on 70% occasions, with the average age of expeditioners presenting being 62 years. The types of primary illness diagnosed were largely those related to the following systems: respiratory 34%, gastrointestinal 30%, dermatological 14%, and musculoskeletal 9%, and other problems 13%. Of the gastrointestinal problems, seasickness was the most common single complaint on 27% of occasions, occurring between day 4 and 9, the cruise phase of the journey. In total, the cruise phase accounted for 43 medical presentations with the pre-cruise phase accounting for 11% of them and the post-cruise phase accounting for the remaining 46%. Presentations were highest on day 5. About one third of presentations (34%) were handled conservatively with 23% requiring antiemetics and 6% requiring antibiotics. There were no deaths or other major incidents requiring emergency evacuation or hospitalisation; although 6 accidents were reported. Interestingly, accidents were significantly more likely to occur earlier in the expedition (t-test; t=2.828, df=54, p=0.007). Conclusions On this premium expedition, the health problems encountered were largely similar to those reported for other expeditions. The most common problems included respiratory, gastrointestinal, dermatological conditions and musculoskeletal conditions in descending order. As well as being part of the service provided to travellers, the inclusion of an expedition physician on this premium expedition increased the independence of the travellers on this journey, yet decreased the reliance on local health services, a source which is often scarce or absent on more remote location expeditions.

Background: Increased travel to exotic destinations around the world is escalating the risk of exposure to animal-associated injuries with a risk of acquiring rabies. Methods: We have examined data reported to GeoSentinel Surveillance Network to highlight characteristics of animal-associated injuries in travellers. Results: A total of 320 cases were reported from 1998 to 2005. Travellers were predominantly tourists from developed countries with median travel duration of 23 days. A pre-travel encounter was recorded in 45.0% of the cases. A significantly greater proportion of patients with animal-related injuries were female compared to other travel associated diagnosis (54.7% versus 47.4%) and were most likely patients aged < 15 years (6.2% versus 2.6%). The proportionate morbidity for sustaining an animal bite was higher among travellers visiting Southeast Asia (3.9%) and the rest of Asia (2.2%) compared to Australia-New Zealand (1.9%), Africa (1.0%), Latin America (0.8%), North America (0.9%) and Europe (1.2%). Seventy-five percent of cases occurred in countries endemic for rabies. Dogs were involved in 51.3% of cases, monkeys in 21.2%, cats in 8.2%, bats in 0.7% and humans in 0.7%. The higher likelihood for animal-related injuries among female travellers was dependant on the animal species involved, with monkeys accounting for the majority of injuries. In contrast, males were more likely to be injured by dogs. Only 66.1 % of all patients reported with animal-related injury received rabies post-exposure prophylaxis. Conclusions: This data shows that animal-associated injuries are not uncommon among returned travellers presenting to GeoSentinel sites. The highest proportion of injuries was recorded in travellers to Asia, mostly in regions, which are endemic for rabies, and this had led to a requirement for PEP.

Although illness makes up a considerable proportion of problems encountered by travelers abroad, accidents and injury are also a significant concern. It is important that travel health advisors discuss with travellers the importance of taking out travel insurance appropriate for their destination and activities and also for any pre-existing medical and dental conditions. They also need to discuss how to access emergency assistance through their travel insurance provider and other avenues for finding medical and dental care abroad. While Although travel insurance may provide assistance with hospitalizsation and arranging for medical transport, including aeromedical evacuation in some situations, it is also important that travellers are advised how to manage emergencies until medical assistance is sourced as well and how to deal with minor ailments and injuries abroad. To this end, the contents of a traveller's medical kit appropriate for their destination and activities and for their personal health should be discussed during a pre-travel consultation and travellers advised on the use of its contents, as well as in addition to being encouraged to ensure that someone in the travelling group has undertaken first aid training.

Traditionally, travel medicine has been practised on a part-time basis, most usually in the primary care setting. As it develops into a speciality in its own right, the provision of pre-travel health care is more frequently being provided in dedicated centers by specialists in the discipline. Once the decision to set up a travel clinic has been made, thorough research and consideration of the practicalities of opening and running a specialist center is are essential. This will ensure that the clinic is clinically and financially successful, and, more importantly, is able to provide the consistently high standard of care expected of such a clinic.

Key Points • Many of those wanting to travel live with immunocompromised health. • Preparing an immunocompromised patient for travel is a challenge because of the risk of infectious disease. • Careful consideration of the cause and degree of immunocompromise will mitigate the risk of vaccine preventable disease. • Vaccinations tend to be less safe or effective than in the immunocompetent traveller, so pretravel consultation is fundamental for safe travel. • Patients with leukaemia, lymphoma or other malignancies whose disease is in remission, who have restored immunocompetence and who completed chemoor radiotherapy at least 3 months previously can receive live attenuated vaccines. • Some specifi c malignancies, particularly Hodgkin’s, may be associated with signifi cant defi cits in cell-mediated immunity that can persist even after cure. For these travellers, pretravel counselling is essential.

Requirements For Vaccination.- Indications For Immunisation, Recommending Vaccines.- Travel Vaccines At A Glance.- General Contraindications.- Accelerated Courses In Immunisation.- Special Risk Groups.- Faqs.

Many travellers are not properly immunised before travel. Often this is because they do not understand the significance of the diseases that they may encounter.

Current licensed available vaccines are very safe and effective. However, all centres practising travel medicine must have an emergency response policy that is re-evaluated annually.

The following regional guide for vaccinations is a generalization of what may be required for vaccine-preventable disease travel to the region only. Each vaccination should be recommended by the travel health professional only after a full risk assessment as to its actual need for an individual traveller. It is important to note that not all vaccinations suggested in the regions will necessarily be advised or required.

Chemicals are added to vaccines to inactivate either bacteria or viruses and stabilise a vaccine, helping to preserve it and prevent it from losing its potency over time.

The United Nations High Commission for Refugees (UNHCR) reports that there are more than 20 million refugees and displaced persons internationally.1 Australia is among the top three resettlement countries in the world, with an annual quota of 4000 persons.2 This component is in addition to a planned intake of 2000 asylum-seekers on-shore, and a further 6000 persons who may be eligible for humanitarian non-refugee visas. There is no limit to the number of refugees who may be recognised onshore.2 Although most immigrants and refugees have come to Australia under a legal migration scheme, a number of refugees travel to Australia as illegal immigrants. These illegal immigrants come by boat or are transported to Australian waters, where they are left at various locations, such as Ashmore Reef, to be picked up by the authorities. Some refugees coming to Australia in this way may perish. Those that reach Australia, and are retrieved by the Royal Australian Navy undertaking border surveillance, are handed subsequently over to Australian Customs.

A New Zealander travelling recreationally to Asia became exposed to Bancroftian filariasis. The traveller had presented incidentally with gastrointestinal illness. In addition to diarrhoea, the traveller's symptoms were non-specific and there was no eosinophilia, lymphoedema, lymphangitis, lymphadenitis, or pain. The immunochromatographic test for Wuchereria bancrofti was positive indicating that there was or had been an adult filarial worm. The illness resolved completely following treatment with ivermectin.

The modern Olympic Games, conducted only once every 4 years since 1900, will be held in Sydney, Australia, from September 15 to October 1, 2000. There will be approximately 35 competition venues, 5 villages, 100 training venues, a media center, and sponsor hospitality areas.1 There will be about 300 events for 28 sports, involving 10,300 athletes from 200 countries, 5,100 team officials, 50,000 volunteers, 15,000 media, a world wide audience of around 3.5 billion viewers and listeners, and up to several hundred-thousand spectators at any one time.1 The Paralympic Games will also be held in Sydney, after the Olympic Games, from October 18 to 29, 2000, with more than 4,000 athletes competing.1 This paper focuses on health and safety issues for travelers to Australia in general, although it makes specific references to advice for visiting Olympic and Paralympic athletes and team staff, who will be traveling to the games. It must be remembered that travel health advice can change, and that travelers should be advised to seek up-to-date travel health advice for Australia closer to their departure.

Background: commercial expeditions provide an opportunity for travelers to undertake various specialized travel to more adventurous destinations in the relative security of an expeditionary group. Little is known about the illnesses and injuries occurring on such expeditions. Methods: from the commencement of the Blake Expedition in 2001, the expedition physician recorded all illnesses and injuries reported among the crew and also among the indigenous people encountered, while undertaking the expedition. The duration of the expedition was two and a half months, and involved travel by yacht, riverboat and jungle canoe or "bongo". The crew numbered 26 personnel: 24 men, including the expedition physician, and two women. Results: seventy-eight health problems were reported and recorded among 19 (73.1%) members of the expeditionary team. There was one death, but there were no other major incidents requiring emergency evacuation or hospitalization. Types of illness were largely those related to ear, nose and throat disease (15/78, 19%), injuries (12/87, 15%), bites and stings (12/87, 15%), and respiratory (10/78, 13%), dermatologic (9/78, 12%) and gastroenterologic conditions (7/78, 9%). A further 24 health problems were reported and recorded among 22 indigenous people who approached the expedition physician for treatment. Types of illness were largely related to dermatologic conditions (9/24, 38%), accidents and injuries (4/24, 17%), and malaria (4/24, 17%). Conclusions: this expedition was both noteworthy and newsworthy because of the death of the team leader, Sir Peter Blake, although the health problems encountered were largely similar to those reported for other expeditions. Tropical disease was uncommon. Adequate pre-trip preparation of expedition teams is considered important, and the inclusion of an expedition physician decreased the reliance on local health services, which are often scarce or absent on more remote-location expeditions. Adequate psychological preparation of expedition teams should also be included, to prepare expedition teams for unexpected outcomes, such as death or severe injury.

Rabies is a fatal infection and immunisation is important to consider in those travellers going to rabies endemic areas. In those at high risk, a course of three immunisations may be given by the intramuscular (IM) or intradermal (ID) route, both of which are approved by the World Health Organization (WHO) and the Centers for Disease Control (CDC). Little is known in the New Zealand context regarding the effectiveness of pre-exposure ID rabies immunisation.The data was collected prospectively on all travellers requiring the immunisation from July 2001 to September 2003 in Auckland. The standard WHO rabies immunisation protocol was used with three ID injections of 0.1 ml, given on days 0, 7, and 21 or 28 with a booster after 12 months. The vaccine used was the Pasteur Merieux human diploid cell vaccine (HDCV) or the Rabipur Purified chick embryo cell (PCEC) vaccine. Both vaccines are approved by the WHO and the CDC, and are interchangeable. Serology was performed approximately 2 weeks after completion of the primary immunisation course or after a booster, wherever possible. Antibody levels were measured using EIA, and levels of0.5 IU/ml were considered protective.Of the 263 travellers assessed in this study, 125 were males and 138 were females. The mean age of the cohort was 34.8 years (SD=11.7). There were not found to be any statistically significant correlations between age and antibody levels neither was there any significant association between gender and antibody levels. In addition to the sample group, a further 12 travellers had rabies serology performed but were excluded from the study because they had IM vaccines as part of their primary course. Whilst rabies serology ranged from 0.2 to 27.9 IU/ml in the study cohort, the mean antibody level for the group was 4.7 IU/ml (SD=4.1 IU/ml). The mean antibody level for males was 4.3 IU/ml (SD=3.3), and for females, 5.2 IU/ml (SD=4.6). Of the 263 travellers, all had some level of detectable antibodies. The overall seroconversion rate was 95.1%.ID rabies immunisation appears effective, when given according to the standard WHO protocol, in New Zealand. ID rabies immunisation is also more affordable for travellers, especially those on a restrictive budget. ID rabies immunisation can continue to be recommended, particularly where follow-up serology can be done before travel and where there are staff who are experienced in ID immunisation.

OBJECTIVE: to describe illnesses of returned travellers presenting at GeoSentinel sites in New Zealand. METHODS: record data for all patients presenting for travel-related illnesses seen at two GeoSentinel sites, operating as commercial travel clinics, in Auckland and Hamilton, NZ, were extracted for the period November 1997 to December 2001. RESULTS: 205 patients were identified with 262 diagnoses. Just over half were females (54.21%) and nearly half were in the 25-35 years age group (47.3%). About two-fifths of patients reported a pre-travel health consultation (41.0%). The commonest diseases diagnosed were diarrhoeal illnesses (23%), dermatological diagnoses (16%, excluding animal bites), animal bites (10%), and non-specific viral illnesses (8%), many of which manifest as respiratory infections. Tropical diseases, such as schistosomiasis (4%) malaria (2%) and dengue fever (0.5%), were not common. CONCLUSIONS: information on travel-related illnesses, when reported through a global reporting system, can be useful for the travel health adviser in identifying issues of current concern. Although the frequency of tropical disease is low, it remains important to prevent these potentially fatal diseases. IMPLICATIONS: GeoSentinel makes a global contribution to the surveillance of emerging and re-emerging infectious diseases through a network of individual sites in various countries including New Zealand. This information can be used to help provide preventive advice for travellers as well as help in assessing illness in post-travel patients and potentially assist in preventing the secondary spread of some diseases acquired abroad following return.