Travel-associated Disease Research Articles

Legionella spp. Monitoring in the Water Supply Systems of Accommodation Facilities in Sardinia, Italy: A Two-Year Retrospective Analysis.

Travel-associated Legionnaires' disease is a significant public health concern worldwide. A high number of cases are reported every year among travellers who stay at guest houses, hotels, and spas. Indeed, hot water systems, showers, and air-conditioning systems can be contaminated by Legionella, which grows at 25-42 °C. Studies have shown that in Sardinia, especially during the summer months, the water circulation in the hotels' pipes is exposed to extremely high temperatures. As a result, this study was conducted to assess the colonization of hotel water systems by Legionella in Sardinia, concerning a recent EU directive 2020/2184 for drinking water with a limit of 1000 CFU /L. Methods. A total of 112 accommodation facilities were analyzed, of which 61.3% were found to be colonized with Legionella, and out of a total of 807 samples, 32.5% were positive for Legionella presence. The results showed a higher number of positive samples in the summer season. This was also associated with the higher concentration presence of >1000 CFU/L in the samples. Consequently, this study confirms that local hotel operators should improve their water safety and prevention plans, especially in spring and summer.

Genetic diversity and molecular epidemiology of Middle East Respiratory Syndrome Coronavirus in dromedaries in Ethiopia, 2017–2020

ABSTRACT Middle East respiratory syndrome coronavirus (MERS-CoV) is enzootic in dromedary camels and causes zoonotic infection and disease in humans. Although over 80% of the global population of infected dromedary camels are found in Africa, zoonotic disease had only been reported in the Arabia Peninsula and travel-associated disease has been reported elsewhere. In this study, genetic diversity and molecular epidemiology of MERS-CoV in dromedary camels in Ethiopia were investigated during 2017–2020. Of 1766 nasal swab samples collected, 61 (3.5%) were detected positive for MERS-CoV RNA. Of 484 turbinate swab samples collected, 10 (2.1%) were detected positive for MERS-CoV RNA. Twenty-five whole genome sequences were obtained from these MERS-CoV positive samples. Phylogenetically, these Ethiopian camel-originated MERS-CoV belonged to clade C2, clustering with other East African camel strains. Virus sequences from camel herds clustered geographically while in an abattoir, two distinct phylogenetic clusters of MERS-CoVs were observed in two sequential sampling collections, which indicates the greater genetic diversity of MERS-CoV in abattoirs. In contrast to clade A and B viruses from the Arabian Peninsula, clade C camel-originated MERS-CoV from Ethiopia had various nucleotide insertions and deletions in non-structural gene nsp3, accessory genes ORF3 and ORF5 and structural gene N. This study demonstrates the genetic instability of MERS-CoV in dromedaries in East Africa, which indicates that the virus is still actively adapting to its camel host. The impact of the observed nucleotide insertions and deletions on virus evolution, viral fitness, and zoonotic potential deserves further study.

Travel-Related Diseases and Injuries in Children and Adolescents: A Post-Travel Surveillance Questionnaire Assessment.

Children and adolescents are a relevant and increasing proportion of travelers. Injuries and infectious diseases in children are safety concerns when traveling. However, data on diseases and injuries during international travels in children are not available. The aims of this study were to analyze travel-related diseases and injuries among pediatric travelers during and after international trips, to identify risk factors for travel-associated disease, and to evaluate the compliance and effectiveness of the recommendations provided in pre-travel appointments. We enrolled travelers aged under 18 years attending a pre-travel clinic, in a tertiary hospital (2017 - 2019); 223 of the 370 pediatric travelers attending the pre-travel clinic were included. The study was based on a questionnaire designed to address health and safety issues - vaccines and chemoprophylaxis, including side effects, the occurrence of disease or injury, diagnosis, treatment, and outcomes. The median age at pre-travel evaluation was eight years; 39.7% of the travelers were adolescents, 52.5% were female. The participants traveled to 40 countries across four continents, with a median travel duration of 14.5 days. Asia was the most visited continent. Traveling was safe for 84.8%. From 34 travelers who had illness/injury, gastrointestinal symptoms were elicited in 41.2%. Sixteen (47.1%) travelers required an urgent medical appointment at the destination, and no one was hospitalized. Destinations in Africa and longer trips were significantly associated with a higher occurrence of disease/injury (p = 0.023 and p < 0.001, respectively). In a multivariable model, traveling to Africa was still significantly associated with travel-related disease/injury [OR = 2.736 (1.037 - 7.234)]. Disease/injury occurred in 15.2% of pediatric travelers. Even though 47.1% of the travelers required an urgent medical appointment, the developed conditions were not severe enough to warrant hospitalization. Travels to Africa and longer trips seem to be associated with a higher risk of disease and injury.

Javnozdravstveni nadzor nad legionarskom bolešću povezanom sa putovanjima u Evropi i Crnoj Gori

The aim of this study is to show how public health surveillance of travel-associated Legionnaires' disease was conducted in Europe, as well as in Montenegro. The estimations of the European Centre for Disease Prevention and Control (ECDC) indicate that every year about one thousand tourists from Europe get infected by legionellae during their holiday and stay at hotels across the continent. The European Legionnaires' Disease Surveillance Network (ELDSNet) was established with the aim to detect, control and prevent cases, clusters and sources of outbreaks of travel-associated Legionnaires' disease within the European Union (EU) and European Economic Area (EEA), and to assist with detection and response to outbreaks outside the EU/EEA. Sharing information leads to concrete and timely actions of member states of ELDSNet, so that residents of the EU/EEA who travel abroad are protected. ECDC recommends a set of measures that should be followed by public health authorities and tourist sector of the country which was visited by the traveler who caught this disease. If the measures are not carried out, information is published online and European tour operators can use the information when booking holiday packages abroad. Operating procedures provide a set of common measures which should be followed by all EU/ EEA member states involved in the protection of their residents against Legionnaires' disease. Each case of Legionnaires' disease which is reported in tourists, who stayed in Montenegro, is epidemiologically analyzed according to the operating procedures of ELDS Network.

Case Report of Maggot Infestation on Diabetic Foot Ulcer

Myiasis is originated from the Greek word, Miya, which means fly. Fly larva are called maggots. Infestation in humans by maggots is called myiasis. Fly maggots feed on and develop in the tissues of living beings and this condition is known as myasis. The maggot (larvae) invades the skin and subcutaneous tissue is known as Maggot infestation. It was found that farmers who are working in agricultural fields are more susceptible to this infestation. Myiasis symptoms may vary according to the fly type, the number of larvae, and the location of the infected area. Many organs can be infested by these larvae and the most common form is cutaneous myasis. The predisposing factors of cutaneous myasisare cutaneous immobilization, advanced age, poor social conditions, mental retardation, diabetes mellitus, alcoholism, vascular occlusive disease, and infected dermatitis as myiasis. Myiasis is more common in tropical and subtropical countries, especially in rural regions where people are in close contact with animals.Myiasisrepresents the fourth most common travel-associated skin disease. Here we report case on 55-year-old female patient was admitted with complaints of diabetic foot ulcer over left foot for 1 and half months and maggots were examined in the wound. The complete blood cell count [CBC] test shows that her HbA1c level was increased to 10.1%. The patient has undergone wound debridement on left forefoot and maggots were completely removed.

"Go To Travel" Campaign and Travel-Associated Coronavirus Disease 2019 Cases: A Descriptive Analysis, July-August 2020.

The Japanese government initiated the Go To Travel campaign on 22 July 2020, offering deep discounts on hotel charges and issuing coupons to be used for any consumption at travel destinations in Japan. In the present study, we aimed to describe the possible epidemiological impact of the tourism campaign on increasing travel-associated cases of coronavirus disease 2019 (COVID-19) in the country. We compared the incidence rates of travel-associated and tourism-related cases prior to and during the campaign. The incidence of travel-associated COVID-19 cases during the tourism campaign was approximately three times greater than the control period 22 June to 21 July 2020 and approximately 1.5 times greater than the control period of 15 to 19 July. The incidence owing to tourism was approximately 8 times and 2–3 times greater than the control periods of 22 June to 21 July and 15 to 19 July, respectively. Although the second epidemic wave in Japan had begun to decline by mid-August, enhanced domestic tourism may have contributed to increasing travel-associated COVID-19 cases during 22 to 26 July, the early stage of the Go To Travel campaign.

How New York City Health + Hospitals System-Wide Special Pathogens Program Responded to COVID-19.

How New York City Health + Hospitals System-Wide Special Pathogens Program Responded to COVID-19.

Travel-associated neurological disease terminated in a postmortem diagnosed atypical HSV-1 encephalitis after high-dose steroid therapy \u2013 a case report

BackgroundHuman encephalitis can originate from a variety of different aetiologies, of which infection is the most common one. The diagnostic work-up is specifically challenging in patients with travel history since a broader spectrum of unfamiliar additional infectious agents, e. g. tropical disease pathogens, needs to be considered. Here we present a case of encephalitis of unclear aetiology in a female traveller returning from Africa, who in addition developed an atypical herpes simplex virus (HSV) encephalitis in close temporal relation with high-dose steroid treatment.Case presentationA previously healthy 48-year-old female presented with confusion syndrome and impaired vigilance which had developed during a six-day trip to The Gambia. The condition rapidly worsened to a comatose state. Extensive search for infectious agents including a variety of tropical disease pathogens was unsuccessful. As encephalitic signs persisted despite of calculated antimicrobial and antiviral therapy, high-dose corticosteroids were applied intravenously based on the working diagnosis of an autoimmune encephalitis. The treatment did, however, not improve the patient’s condition. Four days later, bihemispheric signal amplification in the insular and frontobasal cortex was observed on magnetic resonance imaging (MRI). The intracranial pressure rapidly increased and could not be controlled by conservative treatment. The patient died due to tonsillar herniation 21 days after onset of symptoms. Histological examination of postmortem brain tissue demonstrated a generalized lymphocytic meningoencephalitis. Immunohistochemical reactions against HSV-1/2 indicated an atypical manifestation of herpesviral encephalitis in brain tissue. Moreover, HSV-1 DNA was detected by a next-generation sequencing (NGS) metagenomics approach. Retrospective analysis of cerebrospinal fluid (CSF) and serum samples revealed HSV-1 DNA only in specimens one day ante mortem.ConclusionsThis case shows that standard high-dose steroid therapy can contribute to or possibly even trigger fulminant cerebral HSV reactivation in a critically ill patient. Thus, even if extensive laboratory diagnostics including wide-ranging search for infectious pathogens has been performed before and remained without results, continuous re-evaluation of potential differential diagnoses especially regarding opportunistic infections or reactivation of latent infections is of utmost importance, particularly if new symptoms occur.

Myiasis incidences reported in and around central province of Sri Lanka.

Myiasis, or the invasion of living tissues of humans and other mammals by dipterous larvae, is considered the world's fourth most common travel-associated skin disease after cutaneous larval migrants, pyodermas, and pruritic arthropod-reactive dermatitis. The present study recorded the cause, anatomical position, and severity of the wounds of myiasis patients admitted to 11 hospitals located in the central region of Sri Lanka from February 2016 to July 2017. Altogether, 28 myiasis incidences were noted within the study period. Of the total identified myiasis patients, nine were female while the remainder were male. The greatest number of patients was recorded from the Mawanella Base Hospital and Peradeniya Teaching Hospital (seven patients each). The ages of recorded patients ranged between 30 and 92 years with the average being 59.4 years. The greatest number of myiasis cases was diagnosed in wounds located in lower limbs (24). In addition, scalp, urogenital, and umbilical infestations were recorded. Eighteen out of the total patients had diabetes mellitus, and two patients suffered from filarial lymphedema. Psychiatric illnesses were a predisposing factor of larval infestation of six patients including the recorded scalp and two urogenital myiasis patients. Of the 28 myiasis cases, 27 were caused by the old world screwworm, Chrysomya bezziana Villeneuve (Diptera: Calliphoridae), and one by the blowfly, Chrysomya megacephala Fabricius (Diptera: Calliphoridae). The awareness of patients with ulcers about this disease helps to decrease further risk of being infected by fly larvae.

Clusters of Legionnaires' disease in period hotels with complex water systems: lessons learnt in the West Midlands, UK

BackgroundIn 2017 there were two distinct clusters of local travel-associated Legionnaires' disease associated with period hotels built in the 17th and 18th centuries in the West Midlands, UK. Both hotels had undergone frequent structural modifications. Five cases occurred 3 months to 2 years apart. The aim of this report is to share the learning from the investigations and challenges faced in achieving control of Legionella pneumophila in the water systems of dated buildings. MethodsEpidemiological information was obtained through structured cases interviews and through linked cases by the national surveillance scheme database. Hotel water system maintenance records were reviewed, and samples were taken at numerous timepoints and different locations, with an initial focus on facilities and rooms used by the cases. Sputum and environmental samples were tested in the reference laboratory and sequence-based typing was undertaken. FindingsUnsatisfactory levels of L pneumophila serogroup 1 were detected from hot and cold water outlets in both hotels. At one of the hotels L pneumophila serogroup 1, sequence type ST62 subtypes in clinical and environmental samples were indistinguishable. Both hotels were closed for business for months to undertake extensive remediation work. This closure was temporarily effective in achieving adequate control of legionella but 6 months later routine monitoring detected unsatisfactory levels. Achieving sustained legionella control in dated water systems and verifying safe endpoints for hotel re-opening has proven challenging for the regulatory bodies. InterpretationSustaining legionella control in the dated water systems of period buildings was demanding, and public confidence in the effectiveness of control measures was compromised. There were four key challenges: defining a cluster and the timely confirmation of when an outbreak has developed; using the cluster and outbreak definitions to inform the risk assessments and review of control measures in the environmental investigations; communicating the risk to the public and the media through clear messages; and seeking assurance on safety of water management systems in defining the endpoint for a cluster or outbreak investigation. FundingNone.

Population-Based Surveillance of Birth Defects Potentially Related to Zika Virus Infection - 15 States and U.S. Territories, 2016.

Zika virus infection during pregnancy can cause serious birth defects, including microcephaly and brain abnormalities (1). Population-based birth defects surveillance systems are critical to monitor all infants and fetuses with birth defects potentially related to Zika virus infection, regardless of known exposure or laboratory evidence of Zika virus infection during pregnancy. CDC analyzed data from 15 U.S. jurisdictions conducting population-based surveillance for birth defects potentially related to Zika virus infection.* Jurisdictions were stratified into the following three groups: those with 1) documented local transmission of Zika virus during 2016; 2) one or more cases of confirmed, symptomatic, travel-associated Zika virus disease reported to CDC per 100,000 residents; and 3) less than one case of confirmed, symptomatic, travel-associated Zika virus disease reported to CDC per 100,000 residents. A total of 2,962 infants and fetuses (3.0 per 1,000 live births; 95% confidence interval [CI] = 2.9-3.2) (2) met the case definition.† In areas with local transmission there was a non-statistically significant increase in total birth defects potentially related to Zika virus infection from 2.8 cases per 1,000 live births in the first half of 2016 to 3.0 cases in the second half (p = 0.10). However, when neural tube defects and other early brain malformations (NTDs)§ were excluded, the prevalence of birth defects strongly linked to congenital Zika virus infection increased significantly, from 2.0 cases per 1,000 live births in the first half of 2016 to 2.4 cases in the second half, an increase of 29 more cases than expected (p = 0.009). These findings underscore the importance of surveillance for birth defects potentially related to Zika virus infection and the need for continued monitoring in areas at risk for Zika.

Enteric fever among children: 50 cases in a French tertiary care centre

Enteric fever in France is primarily travel-associated. Characteristics of paediatric cases are scarce and information from field studies in endemic countries might not be generalizable to non-endemic countries. In this retrospective study, we reviewed all cases of typhoid and paratyphoid fever treated in a French paediatric tertiary care centre from 1993 to 2015. Fifty cases of enteric fever due to Salmonella enterica serovar Typhi (n = 44) and Paratyphi (n = 6) were identified. Sixty-one percent of the children had travelled to Africa and 34% to the Indian subcontinent. Among travel-associated cases, 85% were visiting friends and relatives (VFR). Ninety-six percent had high fever associated with gastrointestinal symptoms. Anaemia (66%), elevated C-reactive protein (80%), transaminitis (87%) and mild hyponatremia (50%) were the main biological findings. Blood cultures were positive in 90% of cases. Twelve strains (24%) were resistant at least to one antibiotic, and all of them had been isolated since 2003, increasing the resistance rate during this last period to 43% (12/28). Ceftriaxone was administered to 71 patients for a median duration of 6 days (interquartile range (IQR): 4-8). The median time to apyrexia after the onset of treatment was 4 days (IQR: 2-5 days). Complications occurred in nine children with five (10%) presenting neurologic disorders. All 50 patients recovered. In France, paediatric enteric fever is mainly a travel-associated disease and occurs in patients returning from a prolonged stay in an endemic area. Children VFR are at high risk and should be a priority target group for pre-travel preventive measures. The increase in antibiotic resistance reflects the situation in endemic countries and is a major concern.

Hepatitis E: Still Waters Run Deep.

Hepatitis E is an infectious inflammatory disease of the liver caused by the hepatitis E virus (HEV), a single-stranded RNA virus. Today, it is estimated that there are more than 20 million HEV infections every year, leading to 3.3 million symptomatic cases and more than 56,000 deaths. For a long time it was believed that HEV was a travel-associated disease, endemic in developing countries with poor hygienic standards and unsafe water supply. However, over the past years, publications have demonstrated that autochthonous HEV infections in industrialized countries are far more common than previously thought. Awareness for HEV amongst health care practitioners in industrialized countries is still limited. This relatively rare disease is of great importance, especially in immunocompromised patients where it can cause chronic liver disease. This article comprehensively reviews current literature to give an overview on clinically important topics. It will focus on epidemiological aspects, acute and chronic HEV infection as well as extra-hepatic manifestations, diagnostic approach and treatment options. Furthermore, the article is concluded with a brief outlook on perspectives and urgent problems to be addressed in the future.

Hepatitis E virus in wild rabbits and European brown hares in Germany.

Recently, a change of hepatitis E from being a typical travel-associated disease to an autochthonous zoonosis in Germany was observed. An increasing number of autochthonous infections with the hepatitis E Virus (HEV) have been recognized in developed countries. Venison from wild boar is already known to be a potential source of infection, if not prepared properly by the consumer. In Germany, certain wild animals are known to be a reservoir for HEV. However, current information is missing about European brown hares (Lepus europaeus) and wild rabbits (Oryctolagus cuniculus). Thus, a total of 833 hunting-harvested animals (European brown hares n=669; wild rabbits n=164) were tested for the occurrence of HEVRNA and HEV antibodies. For this, liver and blood specimens were taken after hunts in six German federal states. HEV antibodies were found by ELISA in 2.2% (624/14) of European brown hares, but no HEV RNA was detectable by nested real-time RT-PCR. In contrast, a seroprevalence of 37.3% (126/47) was observed for wild rabbits, and 17.1% (164/28) of the samples were HEV RNA positive. Genomic analysis revealed that these partial sequences clustered within the rabbit clade of HEV-3 genotype. In addition, one rabbit sequence segregated into subtype 3g of HEV-3. Highest seroprevalences for hares and rabbits were detected in the federal states of Bavaria and of Schleswig-Holstein, respectively. Comparing urban, rural and insular areas, the highest seroprevalence was shown for wild rabbits in rural areas and for European brown hares on the northern island Fehmarn. This study provides evidence that European brown hares and wild rabbits from Germany can be infected with HEV. The different prevalences indicate that wild rabbits are a potential reservoir for HEV in Germany, whereas European brown hares seem to be only of minor importance for the epidemiology of HEV.

Travel-Associated Zika Virus Disease Acquired in the Americas Through February 2016: A GeoSentinel Analysis.

Zika virus has spread rapidly in the Americas and has been imported into many nonendemic countries by travelers. To describe clinical manifestations and epidemiology of Zika virus disease in travelers exposed in the Americas. Descriptive, using GeoSentinel records. 63 travel and tropical medicine clinics in 30 countries. Ill returned travelers with a confirmed, probable, or clinically suspected diagnosis of Zika virus disease seen between January 2013 and 29 February 2016. Frequencies of demographic, trip, and clinical characteristics and complications. Starting in May 2015, 93 cases of Zika virus disease were reported. Common symptoms included exanthema (88%), fever (76%), and arthralgia (72%). Fifty-nine percent of patients were exposed in South America; 71% were diagnosed in Europe. Case status was established most commonly by polymerase chain reaction (PCR) testing of blood and less often by PCR testing of other body fluids or serology and plaque-reduction neutralization testing. Two patients developed Guillain-Barré syndrome, and 3 of 4 pregnancies had adverse outcomes (microcephaly, major fetal neurologic abnormalities, and intrauterine fetal death). Surveillance data collected by specialized clinics may not be representative of all ill returned travelers, and denominator data are unavailable. These surveillance data help characterize the clinical manifestations and adverse outcomes of Zika virus disease among travelers infected in the Americas and show a need for global standardization of diagnostic testing. The serious fetal complications observed in this study highlight the importance of travel advisories and prevention measures for pregnant women and their partners. Travelers are sentinels for global Zika virus circulation and may facilitate further transmission. Centers for Disease Control and Prevention, International Society of Travel Medicine, and Public Health Agency of Canada.

Travel-Associated Zika Virus Disease Cases Among U.S. Residents--United States, January 2015-February 2016.

Zika virus is an emerging mosquito-borne flavivirus. Recent outbreaks of Zika virus disease in the Pacific Islands and the Region of the Americas have identified new modes of transmission and clinical manifestations, including adverse pregnancy outcomes. However, data on the epidemiology and clinical findings of laboratory-confirmed Zika virus disease remain limited. During January 1, 2015-February 26, 2016, a total of 116 residents of 33 U.S. states and the District of Columbia had laboratory evidence of recent Zika virus infection based on testing performed at CDC. Cases include one congenital infection and 115 persons who reported recent travel to areas with active Zika virus transmission (n = 110) or sexual contact with such a traveler (n = 5). All 115 patients had clinical illness, with the most common signs and symptoms being rash (98%; n = 113), fever (82%; 94), and arthralgia (66%; 76). Health care providers should educate patients, particularly pregnant women, about the risks for, and measures to prevent, infection with Zika virus and other mosquito-borne viruses. Zika virus disease should be considered in patients with acute onset of fever, rash, arthralgia, or conjunctivitis, who traveled to areas with ongoing Zika virus transmission (http://www.cdc.gov/zika/geo/index.html) or who had unprotected sex with a person who traveled to one of those areas and developed compatible symptoms within 2 weeks of returning.

Travel-Associated Zika Virus Disease Cases Among U.S. Residents — United States, January 2015–February 2016

Travel-Associated Zika Virus Disease Cases Among U.S. Residents — United States, January 2015–February 2016

Legionnaires' Disease in Hotels and Passenger Ships: A Systematic Review of Evidence, Sources, and Contributing Factors.

Travel-associated Legionnaires' disease (LD) is a serious problem, and hundreds of cases are reported every year among travelers who stayed at hotels, despite the efforts of international and governmental authorities and hotel operators to prevent additional cases. A systematic review of travel-associated LD events (cases, clusters, outbreaks) and of environmental studies of Legionella contamination in accommodation sites was conducted. Two databases were searched (PubMed and EMBASE). Data were extracted from 50 peer-reviewed articles that provided microbiological and epidemiological evidence for linking the accommodation sites with LD. The strength of evidence was classified as strong, possible, and probable. Three of the 21 hotel-associated events identified and four of nine ship-associated events occurred repeatedly on the same site. Of 197 hotel-associated cases, 158 (80.2%) were linked to hotel cooling towers and/or potable water systems. Ship-associated cases were most commonly linked to hot tubs (59/83, 71.1%). Common contributing factors included inadequate disinfection, maintenance, and monitoring; water stagnation; poor temperature control; and poor ventilation. Across all 30 events, Legionella concentrations in suspected water sources were >10,000 cfu/L, <10,000 cfu/L, and unknown in 11, 3, and 13 events, respectively. In five events, Legionella was not detected only after repeated disinfections. In environmental studies, Legionella was detected in 81.1% of ferries (23/28) and 48.9% of hotels (587/1,200), while all 12 cruise ships examined were negative. This review highlights the need for LD awareness strategies targeting operators of accommodation sites. Increased standardization of LD investigation and reporting, and more rigorous follow-up of LD events, would help generate stronger, more comparable evidence on LD sources, contributing factors, and control measure effectiveness.

Cluster of Leptospirosis Acquired Through River Surfing in Switzerland.

Background. In Switzerland, leptospirosis is still considered as a travel-associated disease. After the surprising diagnosis of leptospirosis in a patient who was initially suspected as having primary human immunodeficiency virus infection, we recognized that acquisition of leptospirosis occurred through recreational activities and we identified additional affected individuals. Methods. Detailed anamnesis, excluding occupational exposure, acquisition abroad, and pet contacts, enabled us to detect the source of infection and identify a cluster of leptospirosis. Convalescent sera testing was performed to confirm Leptospira infection. Microscopic agglutination tests were used to determine the infecting serovar. Results. We identified a cluster of leptospirosis in young, previously healthy persons. Acquisition of leptospirosis was traced back to a surfing spot on a river in Switzerland (Reuss, Aargau). Clinical presentation was indistinct. Two of the 3 reported cases required hospitalization, and 1 case even suffered from meningitis. Serologic tests indicated infection with the serovar Grippotyphosa in all cases. With the exception of the case with meningitis, no antibiotics were administered, because leptospirosis was diagnosed after spontaneous resolution of most symptoms. Despite a prolonged period of convalescence in 2 cases, full recovery was achieved. Recent reports on beavers suffering from leptospirosis in this region underline the possible water-borne infection of the 3 cases and raise the question of potential wildlife reservoirs. Conclusions. Insufficient awareness of caregivers, which may be promoted by the missing obligation to report human leptospirosis, combined with the multifaceted presentation of the disease result in significant underdiagnosis. More frequent consideration of leptospirosis as differential diagnosis is inevitable, particularly as veterinary data suggest re-emergence of the disease.

Identifying Risk Factors for Vivax Malaria

Plasmodium vivax is responsible for up to 300 million new cases of malaria annually and is the most common cause of this disease outside of Africa. Mortality is generally thought to be low. Vivax malaria (like illness caused by the much-rarer Plasmodium ovale ) can remain dormant for months or years, and travel-associated disease offers a good …