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Archive for the ‘Travel’ Category

Crimean-Congo Hemorrhagic Fever and Travel

Reports of Crimean-Congo hemorrhagic fever (CCHF) related to travel are rare. The following chronology is abstracted from Gideon www.GideonOnline.com and the Gideon e-book series. [1]

1985 – South Africa ex. Democratic Republic of Congo (fatal).
1986 – South Africa ex. Tanzania (nonfatal)
1997 – An English traveler died of probable CCHF contracted in Zimbabwe.
2001 – A German tourist acquired Crimean-Congo hemorrhagic fever in Bulgaria.
2004 – A case of imported Crimean-Congo hemorrhagic fever (nonfatal) was reported in a traveler returning to France from Senegal. Infection in a second French national was diagnosed locally in Senegal.
2009 – An American soldier died in a hospital in Germany after contracting Crimean-Congo hemorrhagic fever in Afghanistan.
2011 – An outbreak (4 cases) in a Pakistan hospital was related to an index patient who had arrived from Afghanistan.
2012 – A patient died of Crimean-Congo hemorrhagic fever in Scotland following acquisition of the disease in Afghanistan.
2013 – A woman died of Crimean-Congo hemorrhagic fever in Uganda following contact with her infected husband in South Sudan.
2014 – A British traveler acquired Crimean-Congo hemorrhagic fever in Bulgaria.

Reference:
1. Berger SA. Crimean-Congo Hemorrhagic Fever: Global Status, 2014. 41 pages, 21 graphs, 658 references. Gideon e-books, http://www.gideononline.com/ebooks/disease/crimean-congo-hemorrhagic-fever-global-status/

Note featured on ProMED

Microbiology References and Vaccination schedules

Over the past couple of months, we have rolled out a number of product updates to the GIDEON web app.

Microbiology References
References have been added to the improved notes and ecology sections for most organisms in the Microbiology sub-modules of Bacteria, Mycobacteria and Yeasts.

Vaccine Schedules
Vaccine schedules for each country have typically appeared in a number of notes in the Diseases module. These vaccine schedules have now been added to the Travel section, so it’s very easy to scroll through countries and compare their vaccination schedules.

For example see the initial travel note for Australia:
Australia vaccination schedule

With easy access to the vaccine abbreviations:

Vaccine abbreviations

Shigellosis Outbreaks Among Travelers

Although sporadic cases of shigellosis are common among travelers and expatriates, overt outbreaks are relatively uncommon. The following chronology was abstracted from reference [1]. Primary references are available on request.

1969 (publication year) – An outbreak of shigellosis was reported among Australian soldiers in Vietnam.
1976 – An outbreak (386 cases) of diarrhea due to Salmonella, Vibrio, Shigella, ETEC and EIEC was reported among passengers of a cruise ship following a visit to Haiti.
1987 – An outbreak (15 cases) of Shigella dysenteriae infection was reported among American tourists in Mexico.
1988 – An outbreak (240 cases) of shigellosis was reported among domestic and international passengers aboard an airline based in the United States.
1989 – An outbreak (84 cases) of Shigella flexneri infection aboard an American cruise ship was caused by contaminated potato salad.
1991 (publication year) – An outbreak (11 cases) of Shigella sonnei infection was reported among children from a Danish day-care institution on tour in Sweden.
1992 – An outbreak of shigellosis was reported among passengers on a cruise ship following a restaurant meal in Saint Lucia.
1994 – An outbreak (610 cases, 1 fatal) of Shigella flexneri infection occurred on a cruise ship sailing between California and Mexico.
1994 – An outbreak (1,062 cases) was reported among Rwandan refugees in Dem. Rep. Congo. A parallel outbreak (77 cases) involved Dutch military personnel who had eaten at an on-site hotel.
1996 – An outbreak (350 cases) was reported on a cruise ship en route from Venice to Crete.
2001 – Outbreaks (30 cases) were reported among travelers returning to New Zealand from Samoa.
2002 – An outbreak (78 cases) of food-borne Shigella sonnei infection was reported among tourists at a hotel resort in the Turks and Caicos Islands.
2003 – An outbreak (99 cases) was reported among Taiwanese tourists on tour in Indonesia.
2004 – An outbreak (45 cases) of Shigella sonnei infection in the United States, Japan, Australia and American Samoa was associated with food served on air flights serviced by a supplier in Hawaii.
2005 – An outbreak (71 cases) was reported among Irish tourists in Egypt.
2005 – An outbreak (6 cases) was reported among Japanese students and family members traveling to Malaysia and Singapore.
2005 (publication year) – An outbreak (14 cases) was reported among tourists at a rural hotel in the Canary Islands.
2006 – An outbreak (23 cases) of Shigella sonnei infection was reported among passengers on a bus from Norway to the Russian Federation.
2008 – Outbreaks (18 cases) were reported among tourists from Hong Kong in Cambodia (11 cases) and Egypt (7 cases).

1. Berger SA. Shigellosis: Global Status. 150 pp., 891 refs. 2010, Gideon e-book series http://www.gideononline.com/ebooks/disease/shigellosis-global-status/

Update: Posted in ProMED

Legionellosis in Spain

A recent outbreak in Alcoy reminds us that rates of legionellosis have been increasing in Spain. The following background data are abstracted from the GIDEON e-book series. [1,2]

Graph 1 summarizes disease incidence and rates per 100,000 population.


Graph Notes:
1. 47 cases were reported in the Balearic Islands during 2001 to 2003.
2. 460 cases were reported among Spanish tourists during 2002 to 2006; 30 in 2005; 73 in 2006.
Individual years:
1993 – Included 57 cases in Cataluna
2003 – 5.82 per 100,000 in the Balearic Islands

As seen in Graph 2, this increase has also affected tourists in Spain.

Graph Notes:
1. 281 cases were acquired by foreign tourists in Spain during 1987 to 1995 – 67% of these from Great Britain. 37% of these were acquired in the Balearic Islands.
2. 627 cases were acquired by foreign tourists in Spain during 1989 to 2001.
3. 6,411 cases of legionellosis were reported during 1999 to 2004 – 565 (9%) involving Spanish travelers, and 426 involving foreign travelers in Spain.
4. 73 travel-associated cases were reported in 2006; 68 in 2007.
Individual years:
2003 – Included nine Spanish citizens touring within Spain.

Legionellosis accounts for 3% of community-acquired pneumonia in Palma de Mallorca (1992 to 1994)

Outbreaks – an overview:
– 1989 to 1998 – 55 outbreaks of legionellosis were reported – 36 of these associated with tourism, 11 nosocomial and 8 community-acquired.
– A single hotel in Benidorm was implicated in the infection of 3 tourists in 1989, 1 in 1990, 2 in 1995, 1 in 1996; 3 in 1997; 8 (1 fatal) in 1998.
– 1990 to 1991 – 54 outbreaks involving 805 cases (and additional 1,358 sporadic cases) were reported.
– 1990 to 2004 – 118 outbreaks involving 690 patients were reported in Catalonia – 35.6% involving water towers, and 14.4% involving water distribution systems in public buildings.
– 1999 to 2001 – Four outbreaks affected over 160 people in Alcoy.
– 2000 – Seven outbreaks were reported – 4 of these nosocomial. An additional 4 clusters were reported among tourists to Spain.
– 2000 – Girona reported 32 cases (3 fatal); Barcelona 48 (1 fatal); Vigo 30 (4 fatal) and Alcala de Henares 249 (11 fatal).
– 2001 to 2003 – 135 cases (10 fatal) in 46 clusters were acquired by European travelers to Spain, including 85 in 2002
– 1999 to 2003 – Eight outbreaks (approximately 300 cases) were reported in Alcoy, Alicante.
– 2003 – 55 outbreaks (247 cases) were reported.

Notable outbreaks:
1973 – An outbreak (89 cases, 3 fatal) was associated with a hotel in Benidorm.
1978 (publication year) – An outbreak (2 fatal cases) was associated with a hotel in Benidorm.
1983 – An outbreak (35 cases) in Valencia was related to contaminated shower heads and toilet tanks.
1984 (publication year) – An outbreak was reported in Los Castillejos.
1984 – An outbreak (32 cases) was reported among Dutch tourists at a hotel in Pineda de Mar (Barcelona region, Spain).
1988 – An outbreak (56 cases) was reported in Barcelona.
1992 (publication year) – An outbreak (6 cases) in a private apartment building in Zaragoza was associated with potable water.
1992 (publication year) – An outbreak was reported in a hospital in Badalona.
1993 – An outbreak (4 British tourists and 1 French tourist) was reported at a hotel in Spain.
1994 – An outbreak (20 cases) was reported in L’Espluga de Francoli, Tarragona.
1996 – An outbreak (260 cases, 197 hospitalized, 14 fatal) was reported in Madrid region (Alcala de Henares). This was the largest outbreak reported in Europe to date.
1996 – An outbreak (4 cases) was reported among British tourists at a hotel in Minorca.
1998 – An outbreak (3 cases, all fatal) was reported in a hospital in Zaragoza.
1999 – An outbreak (6 cases) was reported among foreign tourists to a spa in Cestona (Guipuzcoa Province).
1999 – An outbreak (7 cases, 1 fatal) was associated with a hotel outbreak in Benidorm.
2000 – An outbreak (70 cases, 2 fatal) was reported in Alcoy (Valencia region).
2000 – An outbreak (28 cases) was associated with a cooling tower in the region of a hospital in Vigo (Galicia).
2000 – An outbreak (54 cases, 17 hospitalized, 3 fatal) was reported in the “La Barceloneta” district of Barcelona.
2001 (publication year) – An outbreak (2 cases, both fatal) was reported among mechanics working on a cargo ship in the port of Barcelona.
2001 – An outbreak of 751 clinical cases (449 confirmed, 2 fatal) was reported in Santa Maria de Gracia (Murcia) – the world’s largest recorded outbreak to that time. The source of infection was an outdoor hospital cooling tower.
2001 – An outbreak (18 cases, 3 fatal) was reported from a hospital in Pamplona. A contaminated hot water system was implicated.
2002 – An outbreak (124 cases, 2 fatal) in Matara, Catalonia was related to a local cooling tower.
2003 – Outbreaks (25 total cases, 1 fatal) were reported in Valencia.
2003 – An outbreak (4 cases) was reported at a spa on Tenerife. An additional suspect case was reported in a Venezuelan visitor to the spa.
2004 – An outbreak (28 confirmed cases, 1 fatal) was reported at a hospital in Zaragoza. Contaminated cooling towers were implicated.
2004 – An outbreak (33 cases, 2 fatal) in Vallarca, Barcelona was caused by a contaminated air conditioning system at a private clinic.
2005 – An outbreak (19 cases, 3 fatal) was reported in Barcelona.
2005 – An outbreak (28 cases, including 21 foreigners – 0 fatal) was associated with a shopping center in Torrevieja.
2005 – An outbreak (55 cases, 3 fatal) was associated with a cooling tower in Catalonia.
2006 – An outbreak (146 cases, 0 fatal) in Pamplona was ascribed to contaminated cooling towers.
2006 – An outbreak (5 cases) was reported among ceramic workers in Castellon.
2006 – An outbreak (12 cases) in Catalonia was related to a contaminated mist machine.
2007 (publication year) – An outbreak of Legionnaires’ disease was reported among immunosuppressed patients at a cancer centre in Barcelona.
2007 to 2008 – An outbreak (3 cases) on a hospital surgical ward was associated with a contaminated oxygen humidifier.

References:
1. Berger SA. Infectious Diseases of Spain, 516 pp. Gideon Informatics, Inc. 2010, http://www.gideononline.com/ebooks/country/infectious-diseases-of-spain/
2. Berger SA. Legionellosis: Global Status, 84 pp. Gideon Informatics, Inc. 2010, http://www.gideononline.com/ebooks/disease/legionellosis-global-status/

GIDEON review in Travel Medicine and Infectious Disease

Dr. Stephen Toovey wrote a nice review of GIDEON in the Travel Medicine and Infectious Disease journal. He says “…there is no doubt that travel medicine practitioners, infectious disease physicians and microbiologists in need of a serious database will have to consider Gideon”

Traveling to Haiti

Even before the earthquake, travelers to Haiti were advised to consult with an expert in Travel Medicine.  The new situation has significantly increased the risk for a variety of infectious diseases – both common and “exotic.”   Needless to say, there are many health risks which are not related to infection – excessive heat and sun exposure, political violence, psychological trauma, etc.

Clearly, the most common problems will be related to contamination of food and water: dysentery, salmonellosis and other forms of gastroenteritis.  Cholera is not currently encountered in Haiti.  There is no vaccine for these diseases, and preventative measures (if possible) will include adequate heating of food, bottled water, etc.  Many experts would also suggest that the traveler carry antibiotics (Azithromycin or Ciprofloxacin) to be taken in the event of symptoms.

Among the food / water-borne diseases, Hepatitis A (and possibly Hepatitis E) and typhoid constitute a genuine risk.  All travelers should be vaccinated as far in advance as possible before embarking for Haiti.  Several food borne parasitic infections are also common in Haiti.

The rate of AIDS in Haiti is particularly high.  Although most HIV infection in Haiti has been acquired through sex, exposure to blood will now become a major risk factor.

Malaria is endemic to 75% of Haiti.  Although the local parasite strain is often associated with severe illness, and even death, it is sensitive to anti-malarial drugs.   People traveling to Haiti should take two tablets of Choroquine, once weekly.  Another common mosquito-borne disease, dengue, can only be prevented by vigorous use of insect repellents.  Such measures might also prevent a number of local exotic parasitic diseases (Wuchereriasis, Mansonelliasis).

Animal contact should also be avoided – rabies, anthrax and other “zoonoses” are not uncommon in this country.

Contrary to common belief, contact with dead bodies is not considered a health risk.  A person who did not have cholera or typhoid in life will not begin to spread these diseases because she has died.

Anyone returning from Haiti should arrange for a stool examination – even if they feel well. Parasitic infestation is not necessarily associated with symptoms.  Needless to say, if fever, diarrhea, headache or any other symptom of infection develops, a physician should be consulted.

Also check out GIDEON’s free ebook: Infectious Diseases of Haiti

Common Travel Illnesses

forbes-traveler-logoFollowing up on The Ten Worst Travel-Related Diseases post, Terry Ward at Forbes Travel interviewed Dr. Steve Berger for her article, 8 most common travel illnesses. Steve spoke about diarrhea:

“It’s very hard to avoid. About 40 percent of people will get diarrhea when traveling in an undeveloped country, which covers most of the world,” says Dr. Stephen Berger, founder and medical advisor for GIDEON, an online infectious diseases database. Exposure to different strains of the E. coli bacteria, present in all of our bodies, says Berger, is what usually causes diarrhea in travelers, and it can happen in any country.

… referenced chikungunya:

“And with the chikungunya outbreak in Italy in 2007, that’s not tropical any more either,” says Dr. Berger, referring to another mosquito-borne illness that manifests with terrible joint pain, muscle pain, a fever, and often a rash. An outbreak in Ravenna, Italy, in 2007 showed the disease was spreading beyond the tropical realm. “The mosquitoes that cause these things turn out to be mosquitoes that also invade non-tropical areas,” says Berger, “Chikungunya is extremely common in the Indian Ocean region, and it’s becoming more and more common to see it in travelers in the U.S. and Europe, too.”

and more.

Read both the article and the slide show.

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