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Travel is important in the acquisition and dissemination of infection. We aimed to assess European surveillance data for travel-related illness to profile imported infections, track trends, identify risk groups, and assess the usefulness of pre-travel advice. We analysed travel-associated morbidity in ill travellers presenting at EuroTravNet sites during the 5-year period of 2008–12. We calculated proportionate morbidity per 1000 ill travellers and made comparisons over time and between subgroups. We did 5-year trend analyses (2008–12) by testing differences in proportions between subgroups using Pearson's χ2 test. We assessed the effect of the pre-travel consultation on infection acquisition and outcome by use of proportionate morbidity ratios. The top diagnoses in 32 136 patients, ranked by proportionate morbidity, were malaria and acute diarrhoea, both with high proportionate morbidity (>60). Dengue, giardiasis, and insect bites had high proportionate morbidity (>30) as well. 5-year analyses showed increases in vector borne infections with significant peaks in 2010; examples were increased Plasmodium falciparum malaria (χ2=37·57, p<0·001); increased dengue fever (χ2=135·9, p<0·001); and a widening geographic range of acquisition of chikungunya fever. The proportionate morbidity of dengue increased from 22 in 2008 to 36 in 2012. Five dengue cases acquired in Europe contributed to this increase. Dermatological diagnoses increased from 851 in 2008 to 1102 in 2012, especially insect bites and animal-related injuries. Respiratory infection trends were dominated by the influenza H1N1 pandemic in 2009. Illness acquired in Europe accounted for 1794 (6%) of all 32 136 cases—mainly, gastrointestinal (634) and respiratory (357) infections. Migration within Europe was associated with more serious infection such as hepatitis C, tuberculosis, hepatitis B, and HIV/AIDS. Pre-travel consultation was associated with significantly lower proportionate morbidity ratios for P falciparum malaria and also for acute hepatitis and HIV/AIDS. The pattern of travel-related infections presenting in Europe is complex. Trend analyses can inform on emerging infection threats. Pre-travel consultation is associated with reduced malaria proportionate morbidity ratios and less severe illness. These findings support the importance and effectiveness of pre-travel advice on malaria prevention, but cast doubt on the effectiveness of current strategies to prevent travel-related diarrhoea. European Centre for Disease Prevention and Control, University Hospital Institute Méditerranée Infection, US Centers for Disease Control and Prevention, and the International Society of Travel Medicine.

More than 17,000 ill returned travelers were evaluated within the GeoSentinel network, 30 specialized travel clinics around the globe. Some of the most common pathogens identified were those causing malaria, dengue, and rickettsial disease. The proportionate morbidity of various travel-related infectious diseases was calculated according to region of travel. More than 17,000 ill returned travelers were evaluated within specialized travel clinics around the globe. Some of the most common pathogens identified were those causing malaria, dengue, and rickettsial disease. Health problems are self-reported by 22 to 64 percent of travelers to the developing world 1 ); most of these problems are mild, self-limited illnesses such as diarrhea, respiratory infections, and skin disorders. More importantly, each year, up to 8 percent of the more than 50 million travelers to these regions, or 4 million persons, are ill enough to seek health care either while abroad or on returning home. 1 – 3 Much of the current understanding of morbidity profiles among ill returned travelers is based on data that were collected in the 1980s. 1 – 4 Although some morbidity studies have been designed to . . .

Travel is thought to be a risk factor for the acquisition of sexually transmitted infections (STIs), but no multicentre analyses have been done. We aimed to describe the range of diseases and the demographic and geographical factors associated with the acquisition of travel-related STIs through analysis of the data gathered by GeoSentinel travel medicine clinics worldwide. We gathered data from ill travellers visiting GeoSentinel clinics worldwide between June 1, 1996, and Nov 30, 2010, and analysed them to identify STIs in three clinical settings: after travel, during travel, or immigration travel. We calculated proportionate morbidity for each of the three traveller groups and did logistic regression to assess the association between STIs and demographic, geographical, and travel variables. Our final analysis was of 112 180 ill travellers—64 335 patients seen after travel, 38 287 patients seen during travel, and 9558 immigrant patients. 974 patients (0·9%) had diagnoses of STIs, and 1001 STIs were diagnosed. The proportionate STI morbidities were 6·6, 10·2, and 16·8 per 1000 travellers in the three groups, respectively. STIs varied substantially according to the traveller category. The most common STI diagnoses were non-gonococcal or unspecified urethritis (30·2%) and acute HIV infection (27·6%) in patients seen after travel; non-gonococcal or unspecified urethritis (21·1%), epididymitis (15·2%), and cervicitis (12·3%) in patients seen during travel; and syphilis in immigrant travellers (67·8%). In ill travellers seen after travel, significant associations were noted between diagnosis of STIs and male sex, travelling to visit friends or relatives, travel duration of less than 1 month, and not having pretravel health consultations. The range of STIs varies substantially according to traveller category. STI preventive strategies should be particularly targeted at men and travellers visiting friends or relatives. Our data suggest target groups for pretravel interventions and should assist in post-travel screening and decision making. US Centers for Disease Control and Prevention, and International Society of Travel Medicine.

Travelers returning to their country of origin to visit friends and relatives (VFRs) have increased risk of travel-related health problems. We examined GeoSentinel data to compare travel characteristics and illnesses acquired by 3 groups of travelers to low-income countries: VFRs who had originally been immigrants (immigrant VFRs), VFRs who had not originally been immigrants (traveler VFRs), and tourist travelers. Immigrant VFRs were predominantly male, had a higher mean age, and disproportionately required treatment as inpatients. Only 16% of immigrant VFRs sought pretravel medical advice. Proportionately more immigrant VFRs visited sub-Saharan Africa and traveled for >30 days, whereas tourist travelers more often traveled to Asia. Systemic febrile illnesses (including malaria), nondiarrheal intestinal parasitic infections, respiratory syndromes, tuberculosis, and sexually transmitted diseases were more commonly diagnosed among immigrant VFRs, whereas acute diarrhea was comparatively less frequent. Immigrant VFRs and traveler VFRs had different demographic characteristics and types of travel-related illnesses. A greater proportion of immigrant VFRs presented with serious, potentially preventable travel-related illnesses than did tourist travelers.

Background. Increasing international migration may challenge healthcare providers unfamiliar with acute and long latency infections and diseases common in this population. This study defines health conditions encountered in a large heterogenous group of migrants. Methods. Migrants seen at GeoSentinel clinics for any reason, other than those seen at clinics only providing comprehensive protocol-based health screening soon after arrival, were included. Proportionate morbidity for syndromes and diagnoses by country or region of origin were determined and compared. Results. A total of 7629 migrants from 153 countries were seen at 41 GeoSentinel clinics in 19 countries. Most (59%) were adults aged 19–39 years; 11% were children. Most (58%) were seen >1 year after arrival; 27% were seen after >5 years. The most common diagnoses were latent tuberculosis (22%), viral hepatitis (17%), active tuberculosis (10%), human immunodeficiency virus (HIV)/AIDS (7%), malaria (7%), schistosomiasis (6%), and strongyloidiasis (5%); 5% were reported healthy. Twenty percent were hospitalized (24% for active tuberculosis and 21% for febrile illness [83% due to malaria]), and 13 died. Tuberculosis diagnoses and HIV/AIDS were reported from all regions, strongyloidiasis from most regions, and chronic hepatitis B virus (HBV) particularly in Asian immigrants. Regional diagnoses included schistosomiasis (Africa) and Chagas disease (Americas). Conclusions. Eliciting a migration history is important at every encounter; migrant patients may have acute illness or chronic conditions related to exposure in their country of origin. Early detection and treatment, particularly for diagnoses related to tuberculosis, HBV, Strongyloides, and schistosomiasis, may improve outcomes. Policy makers should consider expansion of refugee screening programs to include all migrants.

Background Europeans represent the majority of international travellers and clinicians encountering returned patients have an essential role in recognizing, and communicating travel-associated public health risks. Methods To investigate the morbidity of travel associated infectious diseases in European travellers, we analysed diagnoses with demographic, clinical and travel-related predictors of disease, in 6957 ill returned travellers who presented in 2008 to EuroTravNet centres with a presumed travel associated condition. Results Gastro-intestinal (GI) diseases accounted for 33% of illnesses, followed by febrile systemic illnesses (20%), dermatological conditions (12%) and respiratory illnesses (8%). There were 3 deaths recorded; a sepsis caused by Escherichia coli pyelonephritis, a dengue shock syndrome and a Plasmodium falciparum malaria. GI conditions included bacterial acute diarrhea (6.9%), as well as giardiasis and amebasis (2.3%). Among febrile systemic illnesses with identified pathogens, malaria (5.4%) accounted for most cases followed by dengue (1.9%) and others including chikungunya, rickettsial diseases, leptospirosis, brucellosis, Epstein Barr virus infections, tick-borne encephalitis (TBE) and viral hepatitis. Dermatological conditions were dominated by bacterial infections, arthropod bites, cutaneous larva migrans and animal bites requiring rabies post-exposure prophylaxis and also leishmaniasis, myasis, tungiasis and one case of leprosy. Respiratory illness included 112 cases of tuberculosis including cases of multi-drug resistant or extensively drug resistant tuberculosis, 104 cases of influenza like illness, and 5 cases of Legionnaires disease. Sexually transmitted infections (STI) accounted for 0.6% of total diagnoses and included HIV infection and syphilis. A total of 165 cases of potentially vaccine preventable diseases were reported. Purpose of travel and destination specific risk factors was identified for several diagnoses such as Chagas disease in immigrant travellers from South America and P. falciparum malaria in immigrants from sub-Saharan Africa. Travel within Europe was also associated with health risks with distinctive profiles for Eastern and Western Europe. Conclusions In 2008, a broad spectrum of travel associated diseases were diagnosed at EuroTravNet core sites. Diagnoses varied according to regions visited by ill travellers. The spectrum of travel associated morbidity also shows that there is a need to dispel the misconception that travel, close to home, in Europe, is without significant health risk.

Background. Many nations are struggling to develop structured systems and guidelines to optimize the health of new arrivals, but there is currently no international consensus about the best approach. Methods. Data on 7792 migrants who crossed international borders for the purpose of resettlement and underwent a protocol-based health assessment were collected from the GeoSentinel Surveillance network. Demographic and health characteristics of a subgroup of these migrants seen at 2 US-based GeoSentinel clinics for protocol-based health assessments are described. Results. There was significant variation over time in screened migrant populations and in their demographic characteristics. Significant diagnoses identified in all migrant groups included latent tuberculosis, found in 43% of migrants, eosinophilia in 15%, and hepatitis B infection in 6%. Variation by region occurred for select diagnoses such as parasitic infections. Notably absent were infectious tuberculosis, soil-transmitted helminths, and malaria. Although some conditions would be unfamiliar to clinicians in receiving countries, universal health problems such as dental caries, anemia, ophthalmologic conditions, and hypertension were found in 32%, 11%, 10%, and 5%, respectively, of screened migrants. Conclusions. Data from postarrival health assessments can inform clinicians about screening tests to perform in new immigrants and help communities prepare for health problems expected in specific migrant populations. These data support recommendations developed in some countries to screen all newly arriving migrants for some specific diseases (such as tuberculosis) and can be used to help in the process of developing additional screening recommendations that might be applied broadly or focused on specific at-risk populations.

Background. Fever is a marker of potentially serious illness in returned travelers. Information about causes of fever, organized by geographic area and traveler characteristics, can facilitate timely, appropriate treatment and preventive measures. Methods. Using a large, multicenter database, we assessed how frequently fever is cited as a chief reason for seeking medical care among ill returned travelers. We defined the causes of fever by place of exposure and traveler characteristics. Results. Of 24,920 returned travelers seen at a GeoSentinel clinic from March 1997 through March 2006, 6957 (28%) cited fever as a chief reason for seeking care. Of patients with fever, 26% were hospitalized (compared with 3% who did not have fever); 35% had a febrile systemic illness, 15% had a febrile diarrheal disease, and 14% had fever and a respiratory illness. Malaria was the most common specific etiologic diagnosis, found in 21% of ill returned travelers with fever. Causes of fever varied by region visited and by time of presentation after travel. Ill travelers who returned from sub-Saharan Africa, south-central Asia, and Latin America whose reason for travel was visiting friends and relatives were more likely to experience fever than any other group. More than 17% of travelers with fever had a vaccine-preventable infection or falciparum malaria, which is preventable with chemoprophylaxis. Malaria accounted for 33% of the 12 deaths among febrile travelers. Conclusions. Fever is common in ill returned travelers and often results in hospitalization. The time of presentation after travel provides important clues toward establishing a diagnosis. Preventing and promptly treating malaria, providing appropriate vaccines, and identifying ways to reach travelers whose purpose for travel is visiting friends and relatives in advance of travel can reduce the burden of travel-related illness.

Since 1996, the scientific community has become aware of 14 reports of yellow fever vaccine (YEL)-associated viscerotropic disease (YEL-AVD) cases and four reports of YEL-associated neurotropic disease (YEL-AND) worldwide, changing our understanding of the risks of the vaccine. Based on 722 adverse event reports after YEL submitted to the U.S. Vaccine Adverse Event Reporting System in 1990–2002, we updated the estimates of the age-adjusted reporting rates of serious adverse events, YEL-AVD and YEL-AND. We found that the reporting rates of serious adverse events were significantly higher among vaccinees aged ≥60 years than among those 19–29 years of age (reporting rate ratio = 5.9, 95% CI 1.6–22.2). Yellow fever is a serious and potentially fatal disease. For elderly travelers, the risk for severe illness and death due to yellow fever infection should be balanced against the risk of a serious adverse event due to YEL.

In 1998, the US Centers for Disease Control and Prevention was notified of three patients who developed severe illnesses days after yellow fever vaccination. A similar case occurred in 1996. All four patients were more than 63 years old. Vaccine strains of yellow fever virus, isolated from the plasma of two patients and the cerebrospinal fluid of one, were characterised by genomic sequencing. Clinical samples were subjected to neutralisation assays, and an immunohistochemical analysis was done on one sample of liver obtained at biopsy. The clinical presentations were characterised by fever, myalgia, headache, and confusion, followed by severe multisystemic illnesses. Three patients died. Vaccine-related variants of yellow fever virus were found in plasma and cerebrospinal fluid of one vaccinee. The convalescent serum samples of two vaccinees showed antibody responses of at least 1:10 240. Immunohistochemical assay of liver tissue showed yellow fever antigen in the Kuppfer cells of the liver sample. The clinical features, their temporal association with vaccination, recovery of vaccine-related virus, antibody responses, and immunohistochemical assay collectively suggest a possible causal relation between the illnesses and yellow fever vaccination. Yellow fever remains an important cause of illness and death in South America and Africa; hence, vaccination should be maintained until the frequency of these events is quantified.