A new era for travel medicine education.

The COVID-19 pandemic has had significant impact on travel medicine practice and practitioners alike with many individuals leaving the field altogether. Yet, when travellers return for advice in abundance, good care will be more important than ever. The standard of care and the quality of travel medicine trainers is vital as the Faculty of Travel Medicine highlighted in their Good Practice Guidelines for Providing a Travel Medicine Service in October 2020 found at https://rcpsg.ac.uk/travel-medicine/good-practice-guidance-for-providing-a-travel-health-service.

[Collateral effects of the COVID-19 pandemic on the practice of tropical and travel medicine]. / Effets de la pandémie de Covid-19 sur la pratique de médecine tropicale et des voyages.

Undoubtedly, the COVID-19 pandemic has had impacts in many areas, including travel and by extension on daily practice in tropical and travel medicine. The intercontinental travelers in decline have been replaced by a new population of travelers who previously did not require specific consultations. SARS-CoV-2 has earned its place in the pre-travel consultation in view of the medical and administrative implications. Furthermore, the global health effects of the pandemic are broader than its direct medical consequences and should not be underestimated. The increase in malaria mortality worldwide is just one example. Preventive measures prior to exposure are more important than ever.

Indubitablement, la pandémie de Covid-19 a eu des impacts dans de nombreux domaines, notamment les voyages, et par extension sur la pratique quotidienne en médecine tropicale et des voyages. Les voyageurs intercontinentaux en diminution ont été remplacés par une nouvelle population de voyageurs qui ne nécessitait pas jusqu'alors de consultations particulières. Le SARS-CoV-2 a gagné sa place dans la consultation prévoyage au vu des implications médicales et administratives. Par ailleurs, les effets de la pandémie sur la santé globale sont plus larges que ses conséquences médicales directes et ne devraient pas être sous-estimés. L'augmentation de la mortalité due à la malaria dans le monde n'en est qu'un exemple. Les mesures préventives avant exposition sont plus que jamais d'actualité.

Underestimation of travel-associated risks by adult and paediatric travellers compared to expert assessment: A cross-sectional study at a hospital-based family pre-travel clinic.

BACKGROUND: Travellers' perception of their risk for acquiring travel-related conditions is an important contributor to decisions and behaviors during travel. In this study, we aimed to assess the differences between traveller-perceived and expert-assessed risk of travel-related conditions in children and adults travelling internationally and describe factors that influence travellers' perception of risk. METHODS: Children and adults were recruited at the Hospital for Sick Children's Family Travel Clinic between October 2014 and July 2015. A questionnaire was administered to participants to assess their perceived risk of acquiring 32 travel-related conditions using a 7-point Likert scale. Conditions were categorized as vector-borne diseases, vaccine-preventable diseases, food and water borne diseases, sexually transmitted infections and other conditions. Two certified travel medicine experts reviewed each patient's chart and assigned a risk score based on the same 7-point Likert scale. Traveller and expert risk scores were compared using paired t-tests. RESULTS: In total, 207 participants were enrolled to participate in this study, 97 children (self-reported, n = 8; parent-reported, n = 89), and 110 adults. Travel-related risk for adults and parents answering for their children were significantly underestimated when compared to expert-assessed risk for 26 of the 32 assessed conditions. The underestimated conditions were the same for both adults and parents answering for children. Travel-related risk was not over-estimated for any condition. CONCLUSIONS: Adults underestimated their children's and their own risk for most travel-related conditions. Strategies to improve the accuracy of risk perception of travel-related conditions by travellers are needed to optimize healthy travel for children and their families.

Ready-To-Go Questionnaire - Development and validation of a novel medical pre-travel risk stratification tool.

BACKGROUND: There are no validated pre-travel self-assessment tools to stratify travellers' health risks and identify their needs for pre-travel medical preparation. This study presents a novel pre-travel risk stratification tool (Ready-To-Go Questionnaire). METHODS: The Ready-To-Go Questionnaire was developed by travel medical experts. It assesses information on travellers' itinerary and current health status, thereby assigning travellers to one out of four risk categories. To explore the Ready-To-Go Questionnaire's validity, we analysed the agreement between the risk categories resulting from the questionnaire and predefined validation criteria. This study was carried out at the Travel Clinic, University of Zurich, Switzerland. RESULTS: One hundred travellers attending a pre-travel consultation were included. 82% corresponded to the substantial-risk category, 17% to the high-risk category, 1% to the moderate-risk category and 0% to the low-risk category. The concordance between the risk categories and the consultants' risk assessment, was 0.39 and 0.29 (unweighted/weighted Cohen's Kappa). No significant concordance was found between the risk categories and additional validation criteria. CONCLUSION: The Ready-To-Go Questionnaire is a medical triage tool developed to identify different levels of travel-related health risks. This tool assists in better understanding travellers' needs, shaping modern travel consultations and offering patient-centred travel medicine services. CLINICAL TRIAL REGISTRATION NUMBER: ISRCTN10172086.

Analysis of Imported Cases of COVID-19 in Taiwan: A Nationwide Study.

In the early stages of the 2019 novel coronavirus disease (COVID-19) pandemic, containment of disease importation from epidemic areas was essential for outbreak control. This study is based on publicly accessible data on confirmed COVID-19 cases in Taiwan extracted from the Taiwan Centers for Disease Control website. We analysed the characteristics, infection source, symptom presentation, and route of identification of the 321 imported cases that were identified from 21 January to 6 April 2020. They were mostly returned Taiwanese citizens who had travelled to one or more of 37 countries for tourism, business, work, or study. Half of these cases developed symptoms before arrival, most of the remainder developed symptoms 1-13 days (mean 4.0 days) after arrival, and 3.4% never developed symptoms. Three-quarters of the cases had respiratory symptoms, 44.9% had fever, 13.1% lost smell or taste, and 7.2% had diarrhoea. Body temperature and symptom screening at airports identified 32.7% of the cases. Of the remainder, 27.7% were identified during home quarantining, 16.2% were identified via contact tracing, and 23.4% were reported by hospitals. Under the strict enforcement of these measures, the incidence of locally acquired COVID-19 cases in Taiwan remains sporadic. In conclusion, proactive border control measures are effective for preventing community transmission of this disease.

No time to die: An in-depth analysis of James Bond's exposure to infectious agents.

Global travelers, whether tourists or secret agents, are exposed to a smörgåsbord of infectious agents. We hypothesized that agents pre-occupied with espionage and counterterrorism may, at their peril, fail to correctly prioritize travel medicine. To examine our hypothesis, we examined adherence to international travel advice during the 86 international journeys that James Bond was observed to undertake in feature films spanning 1962-2021. Scrutinizing these missions involved ∼3113 min of evening hours per author that could easily have been spent on more pressing societal issues. We uncovered above-average sexual activity, often without sufficient time for an exchange of sexual history, with a remarkably high mortality among Bond's sexual partners (27.1; 95% confidence interval 16.4-40.3). Given how inopportune a bout of diarrhea would be in the midst of world-saving action, it is striking that Bond is seen washing his hands on only two occasions, despite numerous exposures to foodborne pathogens. We hypothesize that his foolhardy courage, sometimes purposefully eliciting life-threatening situations, might even be a consequence of Toxoplasmosis. Bond's approach to vector-borne diseases and neglected tropical diseases is erratic, sometimes following travel advice to the letter, but more often dwelling on the side of complete ignorance. Given the limited time Bond receives to prepare for missions, we urgently ask his employer MI6 to take its responsibility seriously. We only live once.

Efficient and targeted COVID-19 border testing via reinforcement learning.

Throughout the coronavirus disease 2019 (COVID-19) pandemic, countries have relied on a variety of ad hoc border control protocols to allow for non-essential travel while safeguarding public health, from quarantining all travellers to restricting entry from select nations on the basis of population-level epidemiological metrics such as cases, deaths or testing positivity rates1,2. Here we report the design and performance of a reinforcement learning system, nicknamed Eva. In the summer of 2020, Eva was deployed across all Greek borders to limit the influx of asymptomatic travellers infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and to inform border policies through real-time estimates of COVID-19 prevalence. In contrast to country-wide protocols, Eva allocated Greece's limited testing resources on the basis of incoming travellers' demographic information and testing results from previous travellers. By comparing Eva's performance against modelled counterfactual scenarios, we show that Eva identified 1.85 times as many asymptomatic, infected travellers as random surveillance testing, with up to 2-4 times as many during peak travel, and 1.25-1.45 times as many asymptomatic, infected travellers as testing policies that utilize only epidemiological metrics. We demonstrate that this latter benefit arises, at least partially, because population-level epidemiological metrics had limited predictive value for the actual prevalence of SARS-CoV-2 among asymptomatic travellers and exhibited strong country-specific idiosyncrasies in the summer of 2020. Our results raise serious concerns on the effectiveness of country-agnostic internationally proposed border control policies3 that are based on population-level epidemiological metrics. Instead, our work represents a successful example of the potential of reinforcement learning and real-time data for safeguarding public health.

GeoSentinel: past, present and future†.

RATIONALE FOR REVIEW: In response to increased concerns about emerging infectious diseases, GeoSentinel, the Global Surveillance Network of the International Society of Travel Medicine in partnership with the US Centers for Disease Control and Prevention (CDC), was established in 1995 in order to serve as a global provider-based emerging infections sentinel network, conduct surveillance for travel-related infections and communicate and assist global public health responses. This review summarizes the history, past achievements and future directions of the GeoSentinel Network. KEY FINDINGS: Funded by the US CDC in 1996, GeoSentinel has grown from a group of eight US-based travel and tropical medicine centers to a global network, which currently consists of 68 sites in 28 countries. GeoSentinel has provided important contributions that have enhanced the ability to use destination-specific differences to guide diagnosis and treatment of returning travelers, migrants and refugees. During the last two decades, GeoSentinel has identified a number of sentinel infectious disease events including previously unrecognized outbreaks and occurrence of diseases in locations thought not to harbor certain infectious agents. GeoSentinel has also provided useful insight into illnesses affecting different traveling populations such as migrants, business travelers and students, while characterizing in greater detail the epidemiology of infectious diseases such as typhoid fever, leishmaniasis and Zika virus disease. CONCLUSIONS: Surveillance of travel- and migration-related infectious diseases has been the main focus of GeoSentinel for the last 25 years. However, GeoSentinel is now evolving into a network that will conduct both research and surveillance. The large number of participating sites and excellent geographic coverage for identification of both common and illnesses in individuals who have traversed international borders uniquely position GeoSentinel to make important contributions of travel-related infectious diseases in the years to come.

Aetiology of fever in returning travellers and migrants: a systematic review and meta-analysis.

BACKGROUND: Numerous publications focus on fever in returning travellers, but there is no known systematic review considering all diseases, or all tropical diseases causing fever. Such a review is necessary in order to develop appropriate practice guidelines. OBJECTIVES: Primary objectives of this review were (i) to determine the aetiology of fever in travellers/migrants returning from (sub) tropical countries as well as the proportion of patients with specific diagnoses, and (ii) to assess the predictors for specific tropical diseases. METHOD: Embase, MEDLINE and Cochrane Library were searched with terms combining fever and travel/migrants. All studies focusing on causes of fever in returning travellers and/or clinical and laboratory predictors of tropical diseases were included. Meta-analyses were performed on frequencies of etiological diagnoses. RESULTS: 10 064 studies were identified; 541 underwent full-text review; 30 met criteria for data extraction. Tropical infections accounted for 33% of fever diagnoses, with malaria causing 22%, dengue 5% and enteric fever 2%. Non-tropical infections accounted for 36% of febrile cases, with acute gastroenteritis causing 14% and respiratory tract infections 13%. Positive likelihood ratios demonstrated that splenomegaly, thrombocytopenia and hyperbilirubinemia were respectively 5-14, 3-11 and 5-7 times more likely in malaria than non-malaria patients. High variability of results between studies reflects heterogeneity in study design, regions visited, participants' characteristics, setting, laboratory investigations performed and diseases included. CONCLUSION: Malaria accounted for one-fifth of febrile cases, highlighting the importance of rapid malaria testing in febrile returning travellers, followed by other rapid tests for common tropical diseases. High variability between studies highlights the need to harmonize study designs and to promote multi-centre studies investigating predictors of diseases, including of lower incidence, which may help to develop evidence-based guidelines. The use of clinical decision support algorithms by health workers which incorporate clinical predictors, could help standardize studies as well as improve quality of recommendations.