Travel Outside Research Articles

Prevalence of enteroaggregative Escherichia coli among children with and without diarrhea in Switzerland.

In a prospective study between July 1999 and September 2000, stool specimens of children below the age of 16 years with (n = 187) and without (n = 137) diarrhea were tested for the presence of enterovirulent bacteria by standard culture methods and by PCR. Targets for the PCR were the plasmid pCVD432 for enteroaggregative Escherichia coli (EAEC), the verotoxin 1 and verotoxin 2 genes for enterohemorrhagic E. coli, ipaH for enteroinvasive E. coli (EIEC) and Shigella spp., genes coding for heat-stable and heat-labile toxins for enterotoxigenic E. coli (ETEC), and the eaeA gene for enteropathogenic E. coli. The following bacteria could be associated with diarrhea: Salmonella enterica (P = 0.001), Campylobacter spp. (P = 0.036), ETEC (P = 0.012), and EAEC (P = 0.006). The detection of EAEC, ETEC, and S. enterica was strongly associated with a history of recent travel outside of Switzerland. EAEC isolates were found in the specimens of 19 (10.2%) of 187 children with diarrhea and in those of 3 (2.2%) of 137 children without diarrhea (P = 0.006) and were the most frequently detected bacteria associated with diarrhea. Among the children below the age of 5 years, the specimens of 18 (11.9%) of 151 with diarrhea were positive for EAEC, while this agent was found in the specimens of 2 (2.2%) of 91 controls (P = 0.007). Enteropathogenic E. coli isolates were found in the specimens of 30 (16.4%) of the patients and in those of 15 (10.9%) of the controls, with similar frequencies in all age groups (P > 0.05). We conclude that EAEC bacteria are involved in a significant proportion of diarrhea cases among children. Children younger than 5 years of age are more often affected by EAEC than older children.

Cholera prevention with traditional and novel water treatment methods: an outbreak investigation in Fort-Dauphin, Madagascar.

Cholera prevention with traditional and novel water treatment methods: an outbreak investigation in Fort-Dauphin, Madagascar.

We should always ask our patients about unconventional treatments

Self-treatment with medicines and therapies outside of mainstream medical practice, including herbal medicines and supplements, folk remedies, homeopathy, acupuncture, chiropractic therapy, and massage therapy, is a growing trend in the United States. Forty percent of Americans have used an unconventional therapy, and of those, fewer than 40% have informed their regular physician about it.1 In many cases, patients do not disclose their use of unconventional therapies simply because the doctor does not ask about them,2 rather than out of fear of their physician's disapproval. Similarly, the use of foreign drugs that are banned in the United States is often not disclosed to physicians. Taylor and colleagues report the results of a patient and provider survey in San Diego that found that more than a third of surveyed Hispanic patients had used the banned antipyretic drug dipyrone, whereas nearly three fourths of surveyed physicians were unaware of the drug's indications or adverse effects. This study provides valuable information about a non-English-speaking population group that has been largely underrepresented in most national surveys on the use of unconventional therapies. It would be interesting to know how many of the 76 users of dipyrone had reported their use of this drug to their clinic provider. At first glance, it seems inappropriate and incongruous that the patient survey was conducted in a community clinic setting where all of the patients were Hispanic and uninsured or receiving Medicaid, whereas the provider sample was taken from mailing lists of professional member groups in San Diego, whose patients were mostly non-Hispanic. However, the use of unconventional therapies is distributed across all sociodemographic groups, and providers are likely to encounter such patients in all clinical settings.1 A recent survey of family practice clinic patients showed that the use of alternative therapies was significantly associated with self-perceived poor health and high educational level.3 Often, these patients have a chronic illness, such as cancer, low back pain, or anxiety. In fact, many people who use unconventional therapies are “shopping around” for health care and have the financial resources to pay for therapies not generally reimbursed by health insurance. They may see several nonphysician practitioners or travel outside of the United States for medicines banned by the FDA. In addition, I searched the Internet using the search term “dipyrone” and found many web sites from which the drug could be ordered and shipped to the United States—so you do not need to go outside this country to get hold of a banned drug. The use of alternative treatments does not generally reflect dissatisfaction with conventional medicine, but rather a desire to find treatment alternatives that fit with personal values and cultural beliefs about health care.4 Increasingly, a new health care paradigm is being embraced, one that blends conventional medicine with alternative remedies and practices based on individual motivational and spiritual attitudes toward health. Physicians can best guide their patients by inquiring with a tone of neutrality about all health care practices, including natural remedies, self-care therapies, and practitioner-based treatments, and listening to their patients' perspectives on health, illness, and conventional medicine. Although the goal of the encounter is shared decision making, physicians must be able to advise patients about potentially harmful therapies such as dipyrone. Busy practitioners cannot be expected to be knowledgeable about all of the unconventional therapies reported by their patients. Fortunately, several books and journal articles have been published recently that provide comprehensive information on advising patients on the use of alternative remedies.4,5,6 No longer is a “don't ask, don't know” policy toward unconventional therapies appropriate, because more people are individualizing a health care plan that necessitates proactive management by the primary care provider.

Hiding Places: Thoreau’s Geographies

For Henry David Thoreau, penetrating landscape observation provided an unfailing point of departure for natural description, ecstatic contemplation, and violently paradoxical social commentary. His texts express, question, naturalize, and deploy many presuppositions about geographic order in the landscape. His writing life, ending in 1862, spanned a time when teleological explanations of the landscape were challenged by the gradual “detheologization” of scientific thought. The new views on the ultimate geographic role of Providence all made some room for empirical, proximate explanations of geography’s grand theme: the fit between humanity and the earth. The effect of Thoreau’s development from transcendental idealism to a penetrating yet fussy empiricism was to dissolve the unity of the human and natural worlds. His odd, shifting, rhetorical appropriation of place, his resistance to unqualified generalization, and his purported aversion to travel (outside of Concord) all contrast with the path geography took during the second—Darwinian—half of the century. Because he was well informed about the science of his time and about Humboldt and Guyot in particular, and because his texts are rich literary contrivances, geographers may fruitfully examine his work in two ways: first, as a register of educated thought about landscape before geography's modern institutionalization as a discipline, and second, as a complex of written landscapes, inscribing and erasing places in varied ways, expressing the contradictions of early modernism.

Diarrheal disease incidence and morbidity among United States military personnel during short-term missions overseas.

Outpatient medical surveillance of U.S. troops was conducted during 11 different overseas missions between 1981 and 1990. In addition, at the end of each of 18 overseas missions during the same period, a sample of troops was queried regarding illnesses and exposures experienced in the preceding time overseas. Diarrhea was among the leading causes of morbidity during all of these short-term missions. Diarrhea incidence rates were found to be highest during summer months, and were higher during missions to Thailand (median = 25%, range = 20-29%), Latin America (median = 26%, range = 1-43%), and northeastern Africa and southwest Asia (median = 19%, range = < 1-52%). Rates were lowest in troops deployed to the Republic of South Korea (median = 16%, range = 8-27%). During April and May 1990, a focused surveillance and questionnaire study was conducted during a five-week, joint U.S.-Thai military training exercise in central Thailand. Among 2,600 U.S. personnel, diarrheal illness was found to be the most common medical problem for troops (estimated cumulative incidence = 29%). Travel outside of the base of operations and consumption of ice were found to be important risk factors. The 10-year database analyzed for this report is the largest, published summary showing the significant impact of diarrheal diseases on U.S. military forces during short-term deployments to less developed areas.

Identification of a site for a cohort study on natural history of HIV infection in Ethiopia.

A cross-sectional survey was carried out in a sugar estate in central Ethiopia to identify a subgroup for a cohort study on the natural history of HIV infection. HIV prevalence was 2.8% (95% confidence interval [CI], 1.7%-3.9%) in 957 adults aged 15 to 54 years randomly selected for the initial survey. A follow-up survey including only factory workers of the estate aged 18 to 45 years (n = 280) showed a higher HIV prevalence in male factory workers (n = 262) compared with the male estate workers of the same age of the initial survey (n = 484; 8.8% versus 3.1 %; p < .05). Factors independently associated with HIV infection in male factory workers were number of lifetime sexual partners, positive syphilis serology, higher income, and absence of travel outside the residential area. Among male estate workers, only older age was associated with HIV infection. Both factory workers and male estate workers were stable residents and were willing to participate in a long-term study on HIV/ AIDS. However, because of the higher HIV prevalence in factory workers and the higher prevalence of behaviors associated with an increased risk for HIV infection, factory workers were selected for the long-term cohort study on the natural history of HIV infection.

Malaria surveillance in New York City: 1991–1996

Background: The transmission of malaria has increased in recent years in many countries where it was once eradicated or under control, and malaria remains a major cause of morbidity and mortality throughout the developing world. Imported cases of malaria have been increasing in New York City and throughout the United States during the past decade. The New York City Department of Health has modified its malaria surveillance program in order to improve the assessment of diagnosis and treatment of malaria in New York City residents and to provide appropriate advice to health professionals who treat these patients. Objectives: To describe the epidemiologic and clinical characteristics of laboratory-confirmed cases of malaria diagnosed in New York City residents from January 1, 1991, through December 31, 1996. Methods: The retrospective study of case reports was carried out by the Malaria Surveillance Program of the Bureau of Communicable Diseases, New York City Department of Health, New York City, NY. It included the laboratory diagnosis of malaria and the species involved, and included also descriptive epidemiclogic information of patients with malaria (age, sex, race/ethnicity, date and place of onset of illness, travel history, immigration status, previous history of malaria, history of blood transfusion, drugs used for treatment or prophylaxis), as well as a record of clinical complications of the infection (thrombocytopenia, hemolysis, anemia, cerebral malaria, renal failure, respiratory distress syndrome, fatal outcome). Results: Malaria was diagnosed in 988 residents of New York City during the 5-year period from January 1, 1991, through December 31, 1995. The largest number of cases, 254 (26%), occurred in 1996, with the majority of these cases (76%) observed between the months of May and October. Sixty-four percent (627) of these cases were males. The age range of cases was from newborn (first day of life) to 83 years (median, 31 years). Of the 962 cases of whom the racial/ethnic identity was known, 580 (59%) were black/non-Hispanic and 255 (26%) were Asian/Pacific Islander. Travel outside of the United States was reported by 958 patients, the majority to Africa ( 569 958 , 59%). Only 139 patients (14%) claimed the use of malaria prophylaxis during travel. Plasmodium falciparum was identified in 505 (51 %) and P. vivax in 356 (36%) of the cases. Clinical complications included hemolysis with severe anemia, thrombocytopenia, cerebral malaria, renal failure, and respiratory distress syndrome. All four fatal cases involved infections with P. falciparum, either alone or in combination with another plasmodia species. Conclusions: Imported cases of malaria occur frequently in New York City and may be associated with serious complications. Health care providers should consider this diagnosis in patients who have recently travelled or arrived from abroad, presenting with headache, fever, and other constitutional symptoms. There are many missed opportunities for the use of malaria prophylaxis, and physicians should familiarize themselves with current recommendations for malaria prophylaxis for travel to areas of the world where people are at risk for the transmission of malaria.

Human Immunodeficiency Virus Infection in Long-Distance Truck Drivers in East Africa

A cross-sectional survey was performed to determine the seroprevalence and correlates of human immunodeficiency virus (HIV) infection among long-distance truck drivers in Kenya. Truck drivers along the Mombasa-Nairobi highway were enrolled at a roadside research clinic. A standardized interview and serologic evaluation for HIV and syphilis were conducted. We enrolled 970 truck drivers and their assistants of whom 257 (27%) had HIV antibodies. In univariate analysis, HIV infection was correlated with older age, non-Kenyan nationality, Christian religion, longer duration of truck driving, travel outside of Kenya, less frequent visits to wives, and more frequent visits to prostitutes. Uncircumcised status, history of genital ulcer disease or urethritis during the previous 5 years, and a positive Treponema pallidum hemagglutination assay for syphilis were each associated with positive HIV serostatus. Univariate correlates of uncircumcised status included younger age, non-Kenyan nationality, Christian religion, travel outside of Kenya, and less frequent visits to prostitutes. There was a significant association between uncircumcised status and 5-year history of genital ulcer disease or serologic evidence of syphilis, but not with 5-year history of urethritis. In multivariate analysis, HIV infection was independently associated with uncircumcised status (adjusted odds ratio [OR], 4.9; 95% confidence interval [CI], 2.8 to 8.4), history of genital ulcer disease (adjusted OR, 2.4; 95% CI, 1.5 to 4.1), history of urethritis (adjusted OR, 1.8; 95% CI, 1.1 to 2.9), more frequent sex with prostitutes (more than once per month; adjusted OR, 1.7; 95% CI, 1.1 to 2.8), and positive T pallidum hemagglutination assay (adjusted OR, 1.2; 95% CI, 1.0 to 1.4). The attributable risk percentage for the association between HIV and uncircumcised status was 70%, and the population attributable risk was 25%. Truck drivers in east Africa are at high risk of HIV infection. The strongest correlates of HIV seropositivity were uncircumcised status and history of both ulcerative and nonulcerative sexually transmitted diseases.

Hepatitis type E in a French population: detection of anti-HEV by a synthetic peptide-based enzyme-linked immunosorbent assay

Four synthetic peptides were used to develop an ELISA for detecting hepatitis type E infections. Antibodies to HEV were detected in 54 of 64 patients present during two outbreaks previously recognized as being due to hepatitis E virus. Those patients included French soldiers stationed in Chad at the time, and Algerian civilians residing in Algeria and considered as positive controls. Anti-HEV were also detected in 3 out of 74 cases of sporadic non-A, non-B, non-C hepatitis in France, and in 2 out of 150 anti-HAV-IgM-positive sporadic cases, also in France, but in none of 278 healthy adults from the general French population. Among a total of 34 anti-HEV-positive cases in French subjects, 32 were shown to be associated with travel outside of western Europe; in two cases, however, HEV transmission appeared to have taken place in Europe. Using this ELISA, a rapid drop in anti-HEV antibodies to undetectable levels following the acute phase of the disease was observed in a high proportion of the infected subjects. Thus, the present test would appear to be more suitable for diagnostic purposes than for epidemiological investigations.

Status of Ixodes dammini(Acari: Ixodidae) in Illinois

Ixodes dammini Spielman, Clifford, Piesman & Corwin was found for the first time in Illinois in November 1987, when two adult females were collected from two deer in Jo Daviess County in the northwestern corner of the state. In 1988, in a study of six state parks in northern Illinois, questing adults and nymphs were encountered in one park in Ogle County. During the firearm deer hunt in November 1988, adult female and male ticks were found in several counties, with a high rate of infestation (greater than 25%) in two counties (Ogle and Rock Island) along the Rock River, which flows from Wisconsin into the Mississippi River. Several cases in humans with no history of travel outside of the state have been reported, primarily from northern Illinois. We suspect that infiltration of infected ticks and wildlife from Wisconsin is resulting in the emergence of Lyme disease in Illinois. Because all the components necessary for the completion of the tick life cycle and for the transmission of Borrelia burgdorferi are available throughout much of the state, I. dammini and Lyme disease can spread and become established in large portions of Illinois.

Endomyocardial fibrosis in a European woman and its successful surgical treatment

A case of endomyocardial fibrosis of the right ventricle in a European woman is presented. The patient had no history of travel or residency outside of the United Kingdon, Echocardiography was helpful in defining the abnormality. Excision of the fibrotic tissue in the right ventricle and tricuspid valve replacement resulted in symptomatic relief. There was also coincidental absence of the right pulmonary artery.