Travel Prevention Research Articles

Health status, healthcare use and prevention in Travellers in Nouvelle Aquitaine, France, 2019-2022

Abstract Background The poor health status of underserved populations is compounded by low vaccination uptake, leading to a greater risk of epidemics. On October 2017, a measles outbreak started in the southwest of France among under-vaccinated social groups, including Travellers. We aimed to describe the health status, healthcare use and child measles-mumps-rubella (MMR) vaccination coverage in Travellers according to their environmental and living conditions. Methods A cross-sectional study with a three-stage random sample design was conducted between October 2019 and March 2022 in the Nouvelle-Aquitaine region in France. Trained social workers administered face-to-face questionnaires to collect data on adults and children. Anthropometric measurements, vaccination records, and data using an environmental exposure questionnaire were also collected. Results The participation rate was high (73.6%), with 1030 adults and 337 children included. Concerning the adults, 36.6% had obesity, 14.4% reported diabetes, 24.7% hypertension, and 14.4% major depression. The prevalence of major depression was significantly higher in adults living in precarious and unauthorized housing than in those with adequate housing (19.8 vs. 14.7%, p = 0.03). The unmet health care needs in the last 12 months was 48.4%. With regard to children, 45.3% had full (i.e., 2-dose) MMR vaccination coverage at 24 months and 17.9% had obesity. Finally, 74.5% of the households experienced housing insecurity, and 22.2% did not have a supply of drinking water. Conclusions Traveller children and adults faced deleterious environmental and living conditions potentially affecting their health, healthcare use, and vaccination coverage. These results demonstrate the need for urgent interventions for underserved populations which take into account their difficult living conditions. Key messages • Travellers have a greater burden of chronic diseases than the general French population and measles-mumps-rubella vaccination coverage among Traveller children is lower than in the general population. • The more precarious the housing, the more likely Travellers are to report having a chronic disease (social exclusion gradient).

Antidiarrheal Properties of the Combination of Tannin Albuminate and Ethacridine Lactate - A Narrative Review

Objective To review the efficacy and safety of tannin albuminate and ethacridine lactate monohydrate in the treatment and prevention of diarrhea. Design Narrative review. Data sources: A systematic literature search was conducted in MEDLINE and Embase from inception to September 2022. The search was restricted to English and German language publications. Eligibility criteria for selecting studies: Randomized controlled trials, non-interventional studies, and meta-analyses assessing tannin and/or ethacridine for the treatment or prevention of diarrhea. Results Of 366 titles identified, a total of 13 studies were included in this review. Five randomized controlled trials and four noninterventional trials demonstrate the efficacy and safety of the fixed combination of tannin albuminate and ethacridine lactate monohydrate in treating acute diarrhea and preventing traveler's diarrhea. The fixed combination reduced acute diarrhea duration by improving stool frequency, consistency, and weight and reduced the risk of traveler's diarrhea. Two pilot studies indicate efficacy in chronic diarrhea. Safety and tolerability were very good in all included studies. Two meta-analyses investigated the efficacy of gelatin tannate in children with acute gastroenteritis. Conclusion The efficacy and safety of tannin albuminate and ethacridine lactate monohydrate for the treatment of acute diarrhea and the prevention of traveler's diarrhea are proven in randomized controlled trials. Several noninterventional studies substantiate the real-world effectiveness and tolerability of the fixed combination. Both active ingredients combine antidiarrheal, antimicrobial, mucosal protection, and spasmolytic properties. However, existing clinical data should be updated with larger, well-designed, placebo-controlled trials in adult and pediatric patient populations.

Features of etiology, clinical picture, diagnosis and treatment of travelers’ diarrhea

The article discusses the issues of epidemiology, etiology, clinical manifestations, diagnosis, treatment and prevention of travelers’ diarrhea (TD). This disease most often has a bacterial nature, but can also be caused by viruses and protozoa. TD usually has a favorable course and ends with self-healing. In mild forms of TD, rehydration therapy is suffi cient, as well as the appointment of loperamide or bismuth subsalicylate. In moderately severe and severe forms, the use of antibiotics (fl uoroquinolones, azithromycin, rifaximin) is necessary. Prevention of TD is reduced to compliance with hygienic measures. The appointment of antibiotics for this purpose — taking into account the growing resistance to them — is carried out only for special indications.

Travel-associated Melioidosis: a narrative review.

Melioidosis, caused by Burkholderia pseudomallei, may be considered a neglected tropical disease which remains underdiagnosed in many geographical areas. Travelers can act as sentinels of disease activity and data from imported cases may help complete the global map of melioidosis. A literature search for imported melioidosis for the period 2016-2022 was performed in PubMed and Google Scholar. In total, 137 reports of melioidosis associated with travel were identified. The majority were males (71%) and associated with exposure in Asia (77%) (mainly Thailand, 41%, and India, 9%). A minority acquired the infection in the Americas-Caribbean area (6%), Africa (5%) and Oceania (2%). The most frequent comorbidity was diabetes mellitus (25%) followed by underlying pulmonary, liver or renal disease (8%, 5% and 3%, respectively). Alcohol/tobacco use were noted for 7 and 6 patients, respectively (5%). Five patients (4%) had associated non-HIV related immunosuppression and 3 patients (2%) had HIV infection. One patient (0.8%) had concomitant COVID-19. A proportion (27%) had no underlying diseases. The most frequent clinical presentations included pneumonia (35%), sepsis (30%), and skin/soft tissue infections (14%). Most developed symptoms <1 week after return (55%) and 29% developed symptoms >12 weeks after. Ceftazidime and meropenem were the main treatments used during the intensive intravenous phase (52% and 41% of patients, respectively) and the majority (82%) received co-trimoxazole alone/combination, for the eradication phase. Most patients had a favorable outcome/survived (87%). The search also retrieved cases in imported animals or cases secondary to imported commercial products. As post-pandemic travel soars, health professionals should be aware of the possibility of imported melioidosis with its diverse presentations. Currently no licensed vaccine is available so prevention in travelers should focus on protective measures (avoiding contact with soil/stagnant water in endemic areas). Biological samples from suspected cases require processing in biosafety level 3 facilities.

Return to Travel in the Coronavirus Disease 2019 Pandemic Recovery Period and Implications for Imported Malaria: Reinforcing Prevention, Early Diagnosis, and Appropriate Treatment of Malaria.

Return to international travel in the COVID-19 pandemic recovery period is expected to increase the number of patients with imported malaria in the United States (US). Malaria prevention in travelers and preparedness for timely diagnosis and appropriate treatment are key to minimize imported malaria morbidity and mortality. Intravenous artesunate (IVAS) is now available from commercial distributors in the US for the treatment of severe malaria. Hospitals and pharmacists should have a plan for malaria treatment, including stocking artemether-lumefantrine for uncomplicated malaria, and stocking or planning for rapid procurement of IVAS for the treatment of severe malaria.

Management and Prevention of Traveler's Diarrhea: A Cross-Sectional Study on Knowledge, Attitudes, and Practices in Italian Occupational Physicians (2019 and 2022).

Even though Italian Occupational Physicians (OP) are increasingly involved in the managing of overseas workers, their knowledge, attitudes, and practices (KAP) in travel medicine are mostly undefined. We, therefore, permed a KAP study specifically targeting the management of travelers' diarrhea (TD) by OP. A total of 371 professionals (43.4% males; mean age 40.8 ± 10.9 years) completed in 2 rounds (2019 and 2022) a specifically designed web questionnaire that inquired participating OP on their knowledge status (KS), risk perception, and management of TD through pre- and post-travel advice and interventions. Multivariable odds ratios (aOR) for predictors of a better knowledge status were calculated through regression analysis. Eventually, the majority of participants (53.4%) had participated in the management of cases of TD in the previous months, but only 26.4% were reportedly involved in pre-travel consultations. The overall knowledge status was unsatisfying (potential range: 0-100%, actual average of the sample 59.6% ± 14.6), with substantial uncertainties in the management of antimicrobial treatment. Interestingly, only a small subset of participants had previously prescribed antimicrobial prophylaxis or treatment (3.5% and 1.9%, respectively). Main effectors of a better knowledge status were: having a background qualification in Hygiene and Public Health (aOR 14.769, 95%CI 5.582 to 39.073), having previously managed any case of (aOR 3.107, 95%CI 1.484 to 6.506), and having higher concern on TD, reported by acknowledging high frequency (aOR 8.579, 95%CI 3.383 to 21.756) and severity (aOR 3.386; 95%CI 1.741 to 6.585) of this disorder. As the adherence of participating OP to official recommendations for TD management was unsatisfying, continuous Education on Travel Medicine should be improved by sharing up-to-date official recommendations on appropriate treatment options for TD.

Travel Prevention Using Telepsychiatric Services: A Review

Background: Telepsychiatry is a type of mental health service delivery using information and communication technology for patients living far from psychiatrists It can reduce the number of travelers looking for mental health services. This study aimed to review articles that reported the percentage of prevented travels or referrals using telepsychiatry.Methods: The PubMed database was searched in September 2019 for this review study. Data were extracted from admitted studies based on a series of variables consisting of author, country, modality, referral setting, urgency, study design, sample size, and percentage of prevented travel. Descriptive statistics were used to analyze data.Results: Eight studies were included. Half of these studies were conducted in Australia. Real-time telepsychiatry modality was used in most of the studies (75%). The hospital was the most referral setting in the studies (62.5%). The type of telepsychiatry services delivered in 75% of the studies was elective. The study design of 62.5% of studies was prospective. The number of included participants in the studies ranged from 28 to 1943. The percentage of avoided travels ranged from 12 to 79.Conclusion: Successful telepsychiatry systems could prevent unnecessary referrals and travels. However, the effective use of telepsychiatry services depends on various factors, including the type and period of the disease, the therapist’s efficacy in terms of correct diagnosis and treatment, and patient cooperation.

Economic analysis of the stand-by emergency treatment (SBET) for malaria in travellers

Abstract Background Stand-by emergency treatment (SBET) is a possible approach for malaria prevention in travellers to low transmission areas (such as South-Eastern Asia [SEA]), but current evidence casts doubts on its feasibility and does not allow to decide whether this strategy is economically rational. Thus, this research aimed to appraise SBET in terms of cost-benefit/cost-effectiveness analysis from the perspective of the National Health Service (NHS). Methods To design a specific model, SBET benefits (valued as avoided direct and indirect costs of illness) were weighted against the costs associated with SBET doses to be prescribed in order to avoid one imported case of malaria. Direct healthcare costs were obtained allocating last surveillance data for imported malaria to the charge of the corresponding diagnosis-related group category and estimating outpatient care costs. Indirect social costs were calculated in terms of lost productivity. The economic framework was adjusted for the probability of malaria transmission in SEA region and weighed on the Italian context. Results In the model, for five malaria cases estimated to be imported from SEA to Italy in 2017, it was calculated that NHS would be charged with around € 22,487·50. Social costs were determined at € 7,100. Thus, the total Italian public expenditure for malaria cases in SEA travellers was of € 29,587·50 in 2017. In contrast, 50,000 doses were considered to be carried to avoid one malaria imported case, with a cost of € 2.5 million. Conclusions At cost-effectiveness analysis, reimbursement strategy does not lead to a favourable gain owing to the total cost of the SBET doses to be prescribed for avoiding one malaria case. The appraisal of costs and benefits brings into question the economic validation of SBET, also calling for further strategies to be reassessed for travellers to low-risk areas. Key messages Besides the evidence of incorrect SBET use among travellers, the appraisal of costs and benefits brings into question the economic validation of this strategy. Reimbursement for SBET seems to be not cost–effective from the perspective of National Health Services.

Guidelines for malaria prevention in travellers: what is new?

Practice nurses are at the forefront of malaria prevention in travellers. Mary Gawthrop gives an overview of the recent changes to the UK guidelines Malaria is a severe and potentially life-threatening febrile illness caused by infection with the parasite Plasmodium. Malaria does not currently occur naturally in the UK, but continues to be a significant, preventable risk for UK travellers visiting malaria-endemic countries. Public Health England (PHE) provide annual updated guidelines for health professionals advising UK travellers on malaria prevention. The PHE guidelines provide country-specific malaria recommendations, including malaria prevalence maps, advice for special risk travellers like pregnant women, and contain a frequently asked questions section. This article covers the updates made in the most recently published version of the guidelines.

Cholera in travellers: a systematic review.

Exposure to cholera is a risk for individuals and groups travelling to endemic areas, and the bacteria can be imported to cholera-free countries by returning travellers. This systematic review of the literature describes the circumstances in which cholera infection can occur in travellers and considers the possible value of the cholera vaccine for prevention in travellers. PubMed and EMBASE were searched for case reports of cholera or diarrhoea among travellers, with date limits of 1 January 1990–30 April 2018. Search results were screened to exclude the following articles: diarrhoea not caused by cholera, cholera in animals, intentional cholera infection in humans, non-English articles and publications on epidemics that did not report clinical details of individual cases and publications of cases pre-dating 1990. Articles were reviewed through descriptive analytic methods and information summarized. We identified 156 cases of cholera imported as a consequence of travel, and these were reviewed for type of traveller, source country, serogroup of cholera, treatment and outcomes. The case reports retrieved in the search did not report consistent levels of detail, making it difficult to synthesize data across reports and draw firm conclusions from the data. This clinical review sheds light on the paucity of actionable published data regarding the risk of cholera in travellers and identifies a number of gaps that should drive additional effort. Further information is needed to better inform evidence-based disease prevention strategies, including vaccination for travellers visiting areas of cholera risk. Modifications to current vaccination recommendations to include or exclude current or additional traveller populations may be considered as additional risk data become available. The protocol for this systematic review is registered with PROSPERO (registration number: 122797).

Emerging concepts in the diagnosis, treatment, and prevention of travelers' diarrhea.

Traveller's diarrhea, though not life-threatening. is often a vexing problem, which impacts overall function of the traveller while on holiday. Increasing data is available regarding molecular diagnostic techniques, which may help obtain an early etiologic diagnosis. Use of antibiotics for traveller's diarrhea is controversial in this era of multidrug resistance and microbiome disruption. Travel to the tropics promotes gut colonization with drug-resistant bacteria and this risk increases after treatment with antibiotics, leading to potential ecological impacts in the country of residence. Traveller's diarrhea is common and can impact a traveller's itinerary leading to significant inconvenience, and occasional longer term sequelae. Though bacterial causes predominate, recommended treatment is conservative in mild-to-moderate cases. Molecular techniques for early diagnosis of traveller's diarrhea may help with appropriate management. Treatment with antibiotics is sometimes required but is associated with gut colonization by multidrug-resistant bacteria.

Pre-travel malaria enquiries to the United Kingdom national travel advice line 2016: Advice mainly needed on malaria maps and risk groups.

Malaria prevention in travellers can be complex and requires consideration of a number of factors. UK healthcare professionals providing pre-travel malaria advice can access specialist support from the National Travel Health Network and Centre (NaTHNaC) telephone advice line. The aim of this study is to characterise queries to the NaTHNaC telephone advice line regarding pre-travel malaria advice. Telephone calls received to NaTHNaC's advice line are recorded using an online data capture form. All calls relating to malaria advice during 2016 were selected and data extracted. Analysis was undertaken using Microsoft Excel and STATA. During 2016, 1803 malaria-related calls were received; the majority from general practice and calls were from across the UK. The most common type of pre-travel malaria query was country-specific followed by travellers with special health needs. Many queries related to pregnant and breastfeeding travellers, children under 5 years and travellers over 60 years. This review presents a large and exceptional dataset and reflects the ambiguity amongst some healthcare professionals regarding malaria advice. We have identified potential knowledge gaps, and as a result will strengthen future guidance, enhance existing malaria maps, and inform the development of future clinical educational activity.

Travelers' Diarrhea: A Clinical Review.

Background: Travelers’ diarrhea is the most common travel-related malady. It affects millions of international travelers to developing countries annually and can significantly disrupt travel plans.Objective: To provide an update on the evaluation, diagnosis, treatment, and prevention of traveler’s diar-rhea.Methods: A PubMed search was completed in Clinical Queries using the key term “traveler’s diarrhea”. The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews. The search was restricted to English literature. Patents were searched using the key term “traveler’s diarrhea” from www.freepatentsonline.com.Results: Between 10% and 40% of travelers develop diarrhea. The attack rate is highest for travelers from a developed country who visit a developing country. Children are at particular risk. Travelers’ diarrhea is usually acquired through ingestion of food and water contaminated by feces. Most cases are due to a bac-terial pathogen, commonly, Escherichia coli, and occur within the first few days after arrival in a foreign country. Dehydration is the most common complication. Pretravel education on hygiene and on the safe selection of food items is important in minimizing episodes. For mild travelers’ diarrhea, the use of antibi-otic is not recommended. The use of bismuth subsalicylate or loperamide may be considered. For moder-ate travelers’ diarrhea, antibiotics such as fluoroquinolones, azithromycin, and rifaximin may be used. Loperamide may be considered as monotherapy or adjunctive therapy. For severe travelers’ diarrhea, antibiotics such as azithromycin, fluoroquinolones, and rifaximin should be used. Azithromycin can be used even for the treatment of dysentery whereas fluoroquinolones and rifaximin cannot be used for such purpose. Recent patents related to the management of travelers’ diarrhea are discussed.Conclusion: Although travelers’ diarrhea is usually self-limited, many travelers prefer expedient relief of diarrhea, especially when they are traveling for extended periods by air or ground. Judicious use of an antimotility agent and antimicrobial therapy reduces the duration and severity of diarrhea.

Geographic expansion of artemisinin resistance.

Artemisinin-based combination therapy (ACT) is the global standard of care for uncomplicated falciparum malaria. First reports of ACT resistance came from western Cambodia and the Thailand-Cambodia border in 2002-2004. The subsequent emergence and expansion of Plasmodium falciparum strains resistant to the artemisinin component and ACT are now threatening the efficacy of falciparum malaria treatment. We performed a literature review on the history and the current degree of geographic expansion of artemisinin and ACT resistance. Resistance against artemisinins is defined as >5% of patients carrying PfKelch13 (K13) mutations, all of whom have been found to have persistent parasitaemia by microscopy on Day 3 after treatment. Several studies including the multi-centre Tracking Resistance to Artemisinin Collaboration study investigated artemisinin resistance in Southeast Asia and beyond and demonstrated increasing prevalence of P. falciparum infections with slow parasite clearance rates in the Greater Mekong Subregion (GMS). K13 mutations were strongly associated with delayed P. falciparum parasite clearance, and the prevalence of the mutation PfKelch13 C580Y is increasing in the GMS. Resistance to ACT regimens is now well established in western Cambodia and in eastern Thailand, southern Laos and southern Vietnam. Moreover, the prevalence of slow P. falciparum parasite clearance has continuously increased over the past 10-15years at the Thailand-Myanmar border, in nearly all regions of Myanmar, and at the Myanmar-China border. Multidrug resistant malaria is a rapidly increasing problem, but fortunately still limited to Southeast Asia, in particular to the GMS. In the long-term it may threaten global progress in malaria control but is not yet of concern with regards to malaria prophylaxis, as ACTs are not used for prevention in travellers, current ACT regimens are still effective in most malaria endemic areas outside the GMS and the preferred travellers' prophylaxis atovaquone-proguanil and doxycycline remain protective. However, artemsinin resistance in the GMS is of real concern to travellers as it will affect the choice of malaria treatment including standby-emergence treatment.

Are probiotics and prebiotics effective in the prevention of travellers' diarrhea: A systematic review and meta-analysis.

Travellers' diarrhea (TD) impacts annually over 20 million tourists, business travellers and military troops on a worldwide basis. Reliance on antibiotic prophylaxis and educational programs has not lead to a significant reduction in TD rates. Previous reviews of probiotics for TD have not accounted for the strain-specificity of probiotic efficacy nor have investigated prebiotics for the prevention of TD. Standard literature databases were searched from 1977 to June 2018 unrestricted by language. Inclusion criteria included: Probiotic, probiotic or symbiotic interventions, randomized, controlled clinical trials (RCTs) and ≥2 RCTs with the same probiotic strain or mixture. Of 158 screened articles, 12 RCT were included in the systematic review and 6 RCTs (with nine treatment different arms) were included in the meta-analysis. Saccharomyces boulardii CNCM I-745 showed a significant reduction in TD incidence (RR = 0.79, 95% C.I. 0.72-0.87, p < 0.001), while L. rhamnosus GG showed a trend (p = 0.08) and L. acidophilus showed no significant (p = 0.16) reduction of TD. The number of trials using probiotics or prebiotics for the prevention of TD continues to be limited in number. Only one of three probiotics showed significant efficacy for the prevention of TD. More research is needed for other probiotics strains and prebiotics to determine if they could also prevent TD.

Groups at high risk of malaria

With malaria the most serious parasitic disease in humans, it is vital for health professionals to have a good understanding of the guidance for prevention in travellers, says Catherine Brewer

HIV pre-exposure prophylaxis (PrEP): Is it time to rethink HIV prevention in travelers?

HIV pre-exposure prophylaxis (PrEP): Is it time to rethink HIV prevention in travelers?

Malaria Chemoprophylaxis for Travelers: The Knowledge of Physicians in the State of Qatar, 2017

Introduction: Malaria is among the most significant travel-related infections encountered by travelers to endemic countries in terms of morbidity and mortality. In Qatar, imported malaria has increased over the last 5 years; 493 travel-related cases were confirmed in 2016. In the current study, the knowledge of malaria chemoprophylaxis among physicians in the State of Qatar was assessed. Methods: This was a cross-sectional study conducted during a national travel health workshop at the Ministry of Public Health, Qatar. Physicians participating in the workshop from different national healthcare institutions providing travel medicine services were invited to voluntarily complete a self-administered, structured questionnaire. Results: Forty-two medical doctors participated in the study (92 response rate). Based on their specialty, almost two-thirds (64.3%) of the participants were family medicine physicians, and one-fifth (21.43%) were general practitioners. Furthermore, most of the doctors were untrained in travel medicine. The majority of participants demonstrated a good knowledge of the malaria parasite (100%), Plasmodium species (64.3%), incidence (83.3%), transmission (66.7%), and drug-resistance (95.2%) of malaria. Additionally, most physicians (>90) were knowledgeable about the major features of severe or complicated malaria as well as malaria prevention and chemoprophylaxis. Conclusion: This study highlights several areas of good knowledge on travel-related malaria prophylaxis and prevention among the study participants; however, there are still a few knowledge gaps that require mitigation. Continuing training programs on malaria prevention in travelers will sustain this good level of knowledge among physicians and improve the quality of pre-travel advice provided by travel medicine practitioners in Qatar.

Clinical implications of Plasmodium resistance to atovaquone/proguanil: a systematic review and meta-analysis.

BackgroundAtovaquone/proguanil, registered as Malarone®, is a fixed-dose combination recommended for first-line treatment of uncomplicated Plasmodium falciparum malaria in non-endemic countries and its prevention in travellers. Mutations in the cytochrome bc1 complex are causally associated with atovaquone resistance.MethodsThis systematic review assesses the clinical efficacy of atovaquone/proguanil treatment of uncomplicated malaria and examines the extent to which codon 268 mutation in cytochrome b influences treatment failure and recrudescence based on published information.ResultsData suggest that atovaquone/proguanil treatment efficacy is 89%–98% for P. falciparum malaria (from 27 studies including between 18 and 253 patients in each case) and 20%–26% for Plasmodium vivax malaria (from 1 study including 25 patients). The in vitro P. falciparum phenotype of atovaquone resistance is an IC50 value >28 nM. Case report analyses predict that recrudescence in a patient presenting with parasites carrying cytochrome b codon 268 mutation will occur on average at day 29 (95% CI: 22, 35), 19 (95% CI: 7, 30) days longer than if the mutation is absent.ConclusionsEvidence suggests atovaquone/proguanil treatment for P. falciparum malaria is effective. Late treatment failure is likely to be associated with a codon 268 mutation in cytochrome b, though recent evidence from animal models suggests these mutations may not spread within the population. However, early treatment failure is likely to arise through alternative mechanisms, requiring further investigation.

Malaria prevention in travellers 2017: Changes to the guidelines and implications for practice

The new 2017 malaria prevention guidelines provide practical and comprehensive advice and recommendations for practice nurses working in travel health