Long-term Expatriates Research Articles

Seroprevalence of dengue, Japanese encephalitis and Zika among long-term expatriates in Thailand.

Travel to Southeast Asia increases the likelihood of acquiring mosquito-borne Flavivirus infections such as dengue (DENV), Japanese encephalitis (JEV) and Zika viruses (ZIKV). Expatriates are long-term travellers who have a higher risk of mosquito-borne illness at their destination country. The purpose of this study was to evaluate the seroprevalence of DENV, JEV and ZIKV infections and the determinants contributing to seropositivity among expatriates living in Thailand. A cross-sectional study was performed from December 2017 to February 2020. Expatriates from non-Flavivirus endemic countries were recruited. 5mL of blood was collected for DENV 1-4, JEV and ZIKV antibody testing by plaque reduction neutralization test (PRNT50). Individuals with vaccination histories or diagnoses for dengue, Japanese encephalitis, yellow fever and tick-borne encephalitis were excluded. Among 254 participants, most participants (83.1%) were male, the mean age was 65years and the median duration of stay in Thailand was 6years. Seroprevalence rate of any Flavivirus, non-specific DENV, DENV1-4, JEV and ZIKV were 34.3, 30.7, 20.5, 18.1, 18.9, 10.6, 4.7 and 2.8%, respectively. The presence of neutralizing antibodies against DENV1-4 positively correlates with the duration of stay in Thailand. DENV seropositivity was associated with living in urban areas (aOR 2.75, 95% CI 1.36-5.57). Expatriates were unlikely to have detectable anti-JEV antibodies regardless of time spent in a JEV-endemic area. No risk factors were identified that were significantly associated with JEV or ZIKV seropositivity. Only 48.4% received pre-travel counselling services, while only 18.9% visited a travel medicine specialist. A high proportion (34.3%) of long-term expatriates living in Thailand were seropositive for flavivirus, mainly from dengue (30.7%). To minimize risk, travel medicine practitioners should provide adequate pre-travel health risk information on mosquito-borne flavivirus infection and offer advice on mosquito bite prevention strategies. Dengue vaccine might be considered in high-risk travellers such as long-term expatriate.

Transfer from expatriate to local contracts: a multiple case study of an unexpected career transition

ABSTRACT The transfer of company-assigned expatriate employees from balance sheet expatriate contracts to local contracts is an alternative international assignment compensation strategy increasingly adopted by global corporations. Despite its growing popularity, there is a significant lack of research on the impact (both professional and personal) of transferring employees from expatriate to local contracts. The purpose of this qualitative case study was to investigate this emerging international HR trend, with specific focus on exploring the experiences of career transition of company-assigned long-term expatriates (delayed localization) to local contracts at multinational organizations located in Sweden and America. Eight individual cases were analyzed. Findings revealed that localization was an unexpected career transition, a negative type of career shock, characterized by limited support from employers, mentors, and local colleagues. The findings further indicated that localization was a type of career transition rather different from other previous career transitions experienced by participants; it represented a major career and life transition. Based on the findings, we proposed HRD interventions to assist expatriates during the transition from expatriate to local contracts. Areas for future research are also suggested.

Prevalence of Hepatitis A Virus Antibody in Portuguese Travelers: A New Paradigm.

In Portugal, the prevalence of hepatitis A virus infection has decreased in the past decades, especially in young adults. The aim of this study was to detect the prevalence of antibody to hepatitis A virus in a population observed in our Travel Clinic. Antibodies against hepatitis A, hepatitis B, hepatitis C and human immunodeficiency virus were tested using standard enzyme immunoassay in patients older than 18. The exclusion criteria were: prior vaccination for hepatitis A virus, previous diagnosis of infection with hepatitis B virus, hepatitis C virus and/or human immunodeficiency virus, foreign travelers and long-term expatriates. We applied an epidemiological survey and data was statistically analyzed with SPSS® 18.0. In the 665 travelers studied, natural immunity to hepatitis A virus was present in 57.6% (n = 383). They were stratified into 8 age groups and for each one hepatitis A immunity was clarified: 5.0% (n = 1) in 18 - 25 years, 32.3% (n = 21) in 26 - 30 years, 40.9% (n = 47) in 31 - 35 years, 45.8% (n = 54) in 36 - 40 years, 68.7% (n = 79) in 41 - 45 years, 70.1% (n = 68) in 46 - 50 years, 80.8% (n = 63) in 51 - 55 years and 87.7% (n = 50) over 56 years old. In those who accepted further screening, positivity for hepatitis B core antibody was found in 0.6% (n = 3) travelers, hepatitis C virus infection in 1.1% (n = 6) and human immunodeficiency virus infection in 0.5% (n = 3) whose previous status was unknown. The most frequent travel destination was sub-Saharan Africa (72.6%; n = 483). We found 49.1% (n = 260) travelers under 50 years old susceptible to hepatitis A virus infection and for those between 40 and 50 years, 30.7% (n = 65) still need vaccine protection. Across age groups there is a trend towards lower prevalence of hepatitis A virus antibody, in particular among youngsters, when compared with older Portuguese studies.

Schistosomiasis in European Travelers and Migrants: Analysis of 14 Years TropNet Surveillance Data.

Schistosomiasis remains one of the most prevalent parasitic diseases worldwide and the infection is frequently found in travelers and migrants. The European Network for Tropical Medicine and Travel Health conducted a sentinel surveillance study on imported schistosomiasis between 1997 and 2010. This report summarizes epidemiological and clinical data from 1,465 cases of imported schistosomiasis. Direct pathogen detection and serology were the main diagnostic tools applied. Of these, 486 (33%) cases were identified among European travelers, 231 (16%) among long-term expatriates, and 748 (51%) among non-European immigrants. Overall, only 18.6% of travelers had received pretravel advice; 95% of infections were acquired in the African region. On species level, Schistosoma mansoni was identified in 570 (39%) and Schistosoma haematobium in 318 (22%) cases; 57.5% of patients were symptomatic. Acute symptoms were reported in 27% of patients leading to earlier presentation within 3 months. Praziquantel was used in all patients to treat schistosomiasis. Many infections were detected in asymptomatic patients. In 47.4% of asymptomatic patients infection was detected by microscopy and in 39% by serology or antigen testing. Schistosomiasis remains a frequent infection in travelers and migrants to Europe. Travelers should be made aware of the risk of schistosomiasis infection when traveling to sub-Saharan Africa. Posttravel consultations particularly for returning expatriates are useful given the high potential for detecting asymptomatic infections.

The flexpatriate psychological contract: a literature review and future research agenda

Since the 1980s, research on international assignments (IA) has principally focused on traditional long-term expatriates. However, due to pressures to reduce long-term expatriate assignments and the emergence of a portfolio of more flexible staffing options, there has recently been a growing focus on the deployment of alternative forms of IA. This paper focuses on one form of alternative IA, flexpatriation, where employees undertake frequent international business trips without relocating. More specifically, we critically examine the flexpatriate employment relationship by applying psychological contract theory to yield insight into both the employer and the employee perspectives, which has been neglected in previous research. The article also examines some of the key HR challenges in managing flexpatriates and contributes to both the IHRM and psychological contract literature by presenting an agenda for future research in this area.

Effectiveness of twice a week prophylaxis with atovaquone-proguanil (Malarone®) in long-term travellers to West Africa.

Current guidelines recommend daily dosing of atovaquone-proguanil (AP), beginning a day before travel to endemic areas and continuing for 7days after departure. Adherence of long-term travellers to daily malaria chemoprophylaxis tends to be poor, even when residing in highly endemic malaria regions. Evidence from a volunteer challenging study suggests that non-daily, longer intervals dosing of AP provides effective protection against Plasmodium falciparum This study examines the effectiveness of twice weekly AP prophylaxis in long-term travellers to highly endemic P. falciparum areas in West Africa. An observational surveillance study aimed to detect prophylactic failures associated with twice weekly AP, during the years 2013-2014, among long-term expatriates in two sites in West Africa. The expatriates were divided according to the malaria prophylaxis regimen taken: AP twice weekly; mefloquine once weekly and a group refusing to take prophylaxis. Malaria events were recorded for each group. The incidence-density of malaria was calculated by dividing malaria events per number of person-months at risk. Among 122 expatriates to West Africa the malaria rates were: 11.7/1000 person-months in the group with no-prophylaxis (n = 63); 2.06/1000 person-months in the 40 expatriates taking mefloquine (P = 0.006) and no cases of malaria (0/391 person-months, P = 0.01) in the twice weekly AP group (n = 33). No prophylaxis failures were detected among the group of expatriates taking AP prophylaxis twice weekly compared with 11.7/1000 person-months among the no-prophylaxis group. Twice weekly AP prophylaxis may be an acceptable approach for long-term travellers who are unwilling to adhere to malaria chemoprophylaxis guidelines.

Cost effectiveness of interferon-gamma release assay for tuberculosis screening using three months of rifapentine and isoniazid among long-term expatriates from low to high incidence countries.

Long-term expatriates from low to high tuberculosis (TB) incidence countries get high rates of active TB and latent TB infection (LTBI). TB screening for expatriates is important for occupational health. Interferon-gamma release assays are more accurate than tuberculin skin test (TST). Rifapentine plus isoniazid for 3 months (3HP) is as effective as 9 months of isoniazid (9H) with a higher treatment-completion rate. Decision trees and Markov models were constructed using a societal perspective on a lifetime horizon. The target population was a hypothetical cohort of 30 year-old expatriates. Seven strategies; TST with 3HP or 9H, QuantiFERON®-TB Gold In-Tube (QFT) with 3HP or 9H, T-SPOT®.TB (TSPOT) with 3HP or 9H and chest X-ray examination (CXR) were modeled. The main outcome measure of effectiveness was quality-adjusted life-years (QALYs) gained. QFT with 3HP yielded the greatest benefits with the lowest cost ($US 674.8; 25.95660 QALYs [year 2012 values]). CXR was the least cost-effective ($US 13,666.8; 24.62917 QALYs). Cost-effectiveness was sensitive to adherence rate of 3HP and QFT specificity, but not to BCG vaccination rate. Entry LTBI screening using QFT treated with 3HP is recommended on the basis of cost effectiveness among long-term expatriates from low to high incidence countries.

Not all expatriates are the same: non-traditional South Korean expatriates in China

Non-traditional expatriates, those expatriates whose assignments tend to be shorter, involve specialist work and often do not involve families relocating, have not been the subject of sustained research. What we do know about this group of expatriates has been mainly derived from research on Western multinational enterprises (MNEs). The current study explores the trend towards, and the management of, these non-traditional expatriates in South Korean MNEs operating in China. Using a qualitative case study approach involving in-depth, semi-structured interviews with expatriates and local managers, this study reveals that the use of non-traditional expatriates has been on rise in the sample MNEs and that they undertake similar roles to the long-term expatriates including control, problem-solving, management development and knowledge transfer. This shift towards non-traditional expatriation has been brought about by the decreased need for long-term assignments and the desire to gain more organizational flexibility. We conclude that such changes represent a strategic response to the longer term issues surrounding traditional expatriates such as family, career and expatriate failure. Such a shift is not without problems as the research found that there was a lack of formal recruitment and selection processes and that training for non-traditional expatriates was limited.

Imported loiasis in Italy: an analysis of 100 cases.

loiasis is a neglected filariasis, affecting millions of individuals living in the rainforest areas of West and Central Africa. Aim of this study was to compare clinical and parasitological manifestations of loiasis between subjects born in endemic areas and expatriates/travelers. we report clinical and parasitological manifestations of 100 patients with imported loiasis seen between 1993 and 2013 at the Center of Tropical Diseases, Negrar, Italy. among the 100 patients, 30 were African immigrants, 70 were Europeans (59 long-term expatriates and 11 travelers). Thirty-five patients (19 Africans and 16 Europeans) had positive microfilaremia. Calabar swellings were twice as frequent in Europeans (90%) than in Africans (46.7%), while a history of "eyeworm" was recorded in a higher proportion of Africans (43.3%) than in Europeans (17.4%). The median duration of exposure in the non-endemic group was also fairly long (14.6 years). Different drug regimens were used for treatment. we suggest that the differences between Africans and Europeans are more likely to be related to genetic differences, rather than to chronicity. Moreover the management of imported loiasis needs standardization.

Expatriate return on investment in the Asia Pacific: An empirical study of individual ROI versus corporate ROI

The return on investment (ROI) from international assignments is a crucial aspect of expatriate management. The literature has taken a mostly organizational perspective of this important phenomenon, with little attention to the ‘individual ROI’ expatriates gain when undertaking an assignment. Especially lacking is research on expatriate ROI in the Asia Pacific region. Based on interviews with 31 long-term expatriates in 10 Asian countries, we use psychological contract theory to examine (1) how ‘individual ROI’ acts as a key driver of ‘corporate ROI’ and (2) the challenges and opportunities that expatriation in the Asia Pacific presents to individuals and organizations.

It’s a New Era for Expatriates

Globalization is causing companies to rethink their business strategy. In support, global talent management strategies are changing as well. Companies are focused on emerging markets to provide a growing percentage of their revenues. They are learning that they need to hire local talent that understands all the nuances of local business instead of using traditional long-term expatriates. This article looks at the history of talent management globally, the global “war for talent” in the “new normal” and a number of talent alternatives for companies to choose from based on each operation’s specific need.

The most vulnerable travelers: patients with mental disorders

Severe mental illness occurring abroad is a difficult situation for patients, their families, and the local medical community. Patients with mental problems are stigmatized due to both their mental illness and the fact that they are foreigners in an unfamiliar country 1. The appropriate treatment is often delayed, while patients are often dealt with in a manner that violates their human rights. Repatriation, which is associated with a better outcome of the mental disorder 2, is often delayed due to the lack of international protocols for the transportation and treatment of mentally ill travelers. Acute travel-induced psychotic attacks are a well-known phenomenon in travelers without a previous history of psychosis. Young adults may experience their first psychiatric episode abroad 3. Elderly people are also susceptible to these attacks 4. Patients with a pre-existing mental illness almost never seek for pre-travel advice, so the prevention of any acute exacerbation is difficult. Specialists in travel medicine usually have little experience with these issues as they usually focus on infectious diseases. There is research evidence that 11.3% of travelers experience some kind of psychiatric problem, with 2.5% suffering from severe psychosis and 1.2% requiring more than two months of therapy at home 5,6. The acute psychotic attacks represent about one fifth of travel-related psychiatric problems. Psycho-organic problems during leisure activities are as high as 5% 7. In a French sample, 15–20% of repatriations were due to psychiatric illness. These problems were predominant in long-term travelers, migrants or expatriates. According to international standards, public transportation should not be used for acute psychotic patients, unless stabilized on medication and accompanied by a knowledgeable companion 8. Most travel insurance policies exclude treatment and repatriation costs incurred due to acute mental illness. Modifying the approach to this issue by police, airport security, and insurance companies represents a challenge for psychiatrists. We believe that a clear set of guidelines, similar to those recently published by the WPA on other mental health issues 1,9,10,11, could help in detecting and managing the traveler with mental disorders abroad. An appropriate preparation of people with mental disorders who have to travel and the application of a protocol for repatriation when needed should decrease the reluctance of insurance companies to cover these patients. The issue, however, is more complex than it may appear. In fact, while it is probably true that many clinicians have difficulties to memorize, recall and correctly apply operational diagnostic criteria, it should not be taken for granted that they will not have problems to memorize, recall and correctly apply prototypes proposed by a diagnostic system. Many clinicians are reluctant to change the templates of mental disorders they have built up in their mind along the years. Being influenced by those templates, they may selectively catch or recall the various features of a prototype, or may read in a prototype description elements which are not actually there. Moreover, the expectation that a given patient will present the various components of a prototype may lead the clinician to infer the presence of clinical aspects which do not actually appear in that patient. Finally, a clinician may conclude that a patient matches a given prototype because several elements of the prototype description are present, while another clinician may conclude that the same patient does not match that prototype because some other aspects are absent. These are indeed the biases that the operational approach aimed to correct, and the risk of a return to the diagnostic chaos preceding the publication of the DSM-III should not be overlooked.

Febrile Illnesses

Roughly 10% of travelers to developing countries experience a febrile illness during travel or on return. The likelihood of developing a medical condition during travel relates to an individual's past medical history, travel destination, duration of travel, level of accommodation, immunization history, adherence to indicated chemoprophylactic regimens, activities during travel, and history of exposure to infectious agents prior to and during travel. The risk for acquiring a tropical infection is primarily affected by the activities of the traveler. For example, immigrants from developing countries return home to visit friends and relatives (VFR) in their place of birth and usually don’t take preventive therapy for malaria. Long-term expatriates, on the other hand, have unique risk profiles. Fever is a leading reason for post travel consultation. Careful questioning of patients about the pattern of fever and associated symptoms is useful. Several papers around the world have reported data about returning travelers with fever. The Geosentinel has reviewed its data on 24,920 travelers from 1997 to 2006. They reported that 28% of returned travelers seen at clinics presented with fever as their chief reason for seeking medical care. Fever was a marker of a serious illness requiring hospitalization. In this report, causes of fever varied by region visited and by time of presentation after travel. The exposure history is crucial to the formulation of a differential diagnosis. Knowledge of infectious disease outbreaks like the novel H1N1 Influenza pandemics in a specific region where the patient has traveled is very helpful. Travelers to Latin America can be exposed to different infectious agents that can give a systemic febrile illness. The most common ones include respiratory tract infections, mononucleosis, dengue, malaria, and typhoid fever. Sometimes no specific cause is reported. Laboratory diagnosis has to be done promptly and efficaciously to avoid delays in treatment. Abstracts for SupplementInternational Journal of Infectious DiseasesVol. 14Preview Full-Text PDF Open Archive

Samuel Cocking and the Rise of Japanese Photography

This study analyses the various contributions of the Anglo-Australian merchant Samuel Cocking to the photographic community of nineteenth-century Japan. It argues for his central role in the importation and supply of photographic goods, the promotion of a local manufacturing industry, the founding of informal learned societies, and the general advancement of the technology in Japan. Contrary to recent studies that have tended to separate the careers of foreign photographers active in Japan from their Japanese counterparts, this study argues that any such approach misrepresents the everyday interaction and proximity of the two groups. The author aims to emphasise the significance of informed, long-term foreign expatriates as cultural advisers and supporters of the local photographic community. In so doing, this study questions the application of recent critical approaches that have emphasised the camera's role as a technology of colonial expansion and cultural imperialism. Instead, the essay highlights the importance of photography as a shared interest and passion of foreign and Japanese practitioners that could promote dialogue and mutual awareness across cultures.

The Travel and Tropical Medicine Manual, 4th Edition

Like the previous editions of The Travel and Tropical Medicine Manual, the 4th edition continues to successfully teach the fundamentals of travel and tropical medicine and serve as a useful reference. The manual is well-organized and literally (measuring 12 × 20 cm) and figuratively handy. It has many appealing tables and figures, a colorful cover, and a reasonable price. It remains appropriately titled, with some chapters written from a travel perspective and others from a tropical medicine perspective. The manual contains 45 chapters divided into 7 sections (Pre-Travel Advice, Advice for Special Travelers, Fever, Diarrhea, Skin Lesions, Sexually Transmitted Diseases, and Worms). The current edition has a new coeditor (Christopher A. Sanford) and new chapters on urban medicine and health advice for long-term expatriates. Its audience should continue to be primary care providers who routinely counsel patients on travel-related issues, infectious disease physicians with an interest in travel medicine, other travel medicine practitioners, and trainees doing rotations in travel medicine. However, its technical terminology and concepts prevent the manual from achieving its stated goal of being a “perfect source” for travelers. The greatest strengths of the manual continue to be its practical suggestions for counseling travelers prior to their departure and evaluating patients with post-travel illnesses. Notable chapters discuss general approaches to travel medicine, immunizations, managing jet lag and motion sickness, counseling HIV-infected travelers, malaria prevention, avoiding and self-treating travelers’ diarrhea, evaluating diarrhea in returned travelers, tropical dermatology and sexually transmitted infections. The manual also has outstanding tables in its approach to travel medicine chapter. Other informative tables describe the safe selection of food and water, drugs for preventing and treating traveler’s diarrhea, the use of melatonin to prevent jet lag, potential interactions between antiretroviral and travel-related medications, and the differential diagnoses of travel-related skin lesions. The manual wisely refers readers to internet sites such as www.cdc.gov/travel for up-to-date travel advice. Although the manual has shortcomings, it has no serious deficiencies. Incorporating contributions from 49 authors results in chapters of variable quality, some redundancies, and occasional omissions. A 20-page chapter on water disinfection appears disproportionately lengthy when compared with the immediately preceding 12-page chapter on the prevention and self-treatment of traveler’s diarrhea. Although the chapter on women travelers discusses male condoms superficially, this important topic is well addressed in the chapter on sexually transmitted infections. In future editions of the manual, the editors should consider including more than 2 photographs in the 74-page section on skin lesions, using a larger font, and enlarging the figures. Clinicians who routinely evaluate patients before or after traveling should definitely consider purchasing this manual, reading select chapters in the pretravel and special travelers sections, and keeping it in their travel clinic as a useful reference.

Vaccine-preventable Diseases in Long-term Expatriates

The term "expatriates" refers to professionals and their families who live abroad for several months or years. Owing to potential prolonged exposure, and living conditions that may be closer to those of the local population, they are at higher risk of acquiring infectious diseases that are endemic in their new place of residence. They often have reduced access to medical services, putting them at higher risk of complications and more severe outcomes. Vaccination is probably one of the most effective means of preventing expatriates from acquiring endemic or epidemic diseases. Incapacitation or sickness in the field may cause serious disruption to project activities and impose an extra workload on the local team. It may also result in repatriation, with further extra direct and indirect costs for the organization. Predeparture advice and preparation, to promote risk reduction behavior, coupled with adequate support in the field are key ingredients to ensure effective and successful activities of collaborators. Institutions and organizations sending expatriates to developing countries have a clear responsibility, and it is in their own interests to promote the health of their employees working abroad.

Malaria vaccines: a toy for travelers or a tool for eradication?

The demonstration of efficacy of two candidate malaria vaccines in children living in malaria-endemic areas, namely RTS,S from the circumsporozoite protein that reduced infection and clinical malaria in Mozambique, and an asexual blood-stage vaccine combining MSP1/MSP2/RESA that reduced parasite density in Papua New Guinea, allows one to believe that a malaria vaccine will be available for the fight against malaria in the next decade. Even if long-lasting impregnated bednets and indoor residual spraying have proven to be effective in reducing malaria transmission, these interventions may not be sufficient in the long-run since they rely on too few compounds and are, thus, vulnerable to the emergence of resistance. New tools, such as malaria vaccines, may, therefore, provide an added value to achieve the goal of local elimination and subsequent eradication of malaria. A promising candidate for that purpose would be a highly efficacious multicomponent vaccine that includes at least a sexual-stage antigen, the appropriate initial setting would be an area with low endemicity and limited population exchange, and the most suitable mode of delivery would be mass vaccination. For nonimmune populations, such as travelers visiting malaria-endemic areas, the usefulness of the first generation of malaria vaccine(s) will be limited, since the level of protection that is foreseen is unlikely to achieve that of malaria chemoprophylaxis. Only long-term travelers, expatriates and soldiers might realistically benefit from a pre-erythrocytic and/or blood-stage vaccine with an intermediate level of efficacy.

Examining the overseas staffing options utilized by Australian headquartered multinational corporations

MNCs need to use a range of options to manage their international operations. The aim of this study was to enhance understanding of how MNCs staff international management positions using a sample of top Australian MNCs across a range of industries. The rationales executives gave for their MNCs' staffing of international management supported selecting managers with higher competency levels for complex overseas assignments. Staffing options were chosen to reduce risks from cultural friction, divergent goals, and asymmetry in knowledge between the parent company and the host operation, chiefly through staffing by parent country nationals (i.e. long-term expatriates, Australians or Westerners already living in the host country or abroad, domestic international managers). Host country managers were used to reduce risks that arose from not being responsive to the host environment and to avoid costs, and when they were least risky to the firm. By contrast, the staffing options also served practical purposes, including deploying expatriate managers to provide skills (competencies) and, less frequently, to develop managers for future management positions in the organization.

Emerging viral pathogens in long-term expatriates (I): Hepatitis E virus.

Hepatitis E virus (HEV) is one of the so-called 'emerging' viral pathogens, whose role is increasingly being recognized. To estimate the risk of HEV infection during long-term stays in HEV-endemic countries, 500 serum samples obtained from development aid workers and their family members who had spent on average 9 years in HEV-endemic regions were tested for antibodies against HEV by ELISA and Immunoblot. We found seroprevalence rates of 5-6% with no significant differences related to gender or area of upbringing (raised in an HEV-endemic vs. nonendemic region). Seroprevalence rates did not increase with increasing number of stays or number of expatriate years. None of 77 children and adolescents tested was positive for anti-HEV. The Indian subcontinent showed the highest seropositive rate with 10%. In subjects returning from West and Central Africa, East Africa, South-east Asia and Latin America seroprevalence rates were around 7%. We found a comparatively low seroprevalence rate of 2.1% for the Arab countries and the Middle East. Our results show that there definitely is a risk for long-term expatriates to acquire HEV infection; however, in most of our cases infection seems to have been non- or oligo-symptomatic.

Clinical Importance of Salmonella Paratyphi A Infection to Enteric Fever in Nepal.

Background: Enteric fever in Nepal is caused by infection with Salmonella typhi or Salmonella paratyphi A. The clinical presentation of these two illnesses has never been compared in a population of travelers and expatriates. If the illnesses are clinically comparable, and if S. paratyphi A infection is sufficiently common, the choice of typhoid vaccine for Nepal may have to take into account the vaccine's efficacy in preventing infection with S. paratyphi A. Methods: NonNepalese patients presenting to the CIWEC Clinic with a history of 3 days of fever or greater were considered eligible for the study. Patients with positive blood or stool cultures for S. typhi or S. paratyphi A were entered into the study (along with three patients who had positive Widal titers only). A questionnaire was administered by a physician to determine signs and symptoms. Treatment with oral chloramphenicol was openly compared to treatment with oral ciprofloxacin. Results: Forty-five cases of enteric fever were diagnosed during the 2 years of the study. Infection with S. typhi accounted for 20 cases, and S. paratyphi A was isolated in 22 cases. The illnesses were clinically indistinguishable. Treatment with chloramphenicol and ciprofloxacin was clinically comparable. Conclusions: Infection with S. paratyphi A accounts for a significant percentage of enteric fever presentations among tourists in Nepal, and the illness is comparable to infection with S. typhi. Therefore, the choice of typhoid vaccine for long-term travelers or expatriates in Nepal should take into account the vaccine's potential ability to also prevent S. paratyphi A infection. The only typhoid vaccine that can currently offer this type of cross protection is the whole-cell killed preparation.