Estimating the vaccine-preventable burden of hospitalized pneumonia among young Mozambican children.

Polysaccharide-protein conjugate vaccines against Haemophilus influenzae type b (Hib) and Streptococcus pneumoniae have proven efficacy against radiologically confirmed pneumonia. Measurement of pneumonia incidence provides a platform to estimate of the vaccine-preventable burden. Over 24 months, we conducted surveillance for radiologically confirmed severe pneumonia episodes among children <2 years of age admitted to a rural hospital in Manhiça, southern Mozambique. Study children were tested for HIV during the second year of surveillance. Severe pneumonia accounted for 15% of 5132 hospital admissions and 32% of in-hospital mortality among children <2 years of age. Also, 43% of chest radiographs were interpreted as radiologically confirmed pneumonia. HIV-infection was associated with 81% of fatal pneumonia episodes among children tested for HIV. The minimum incidence rate of radiologically confirmed pneumonia requiring hospitalization was 19 episodes/1000 child-years. Incidence rates among HIV-infected children were 9.3-19.0-fold higher than HIV-uninfected. Introduction of Hib and pneumococcal conjugate vaccines would have a substantial impact on pneumonia hospitalizations among African children if vaccine effects are similar to those observed in clinical trials.

Histoplasmosis infection in Spanish travelers to Latin America.

The aim of the study presented here was to assess the incidence of histoplasma infection in a cohort of 342 individuals in Spain who had traveled to Latin America for the first time. The histoplasmin skin test was positive in 20% of the travelers, and Central America posed a higher risk for infection than South America (p=0.013). Sleeping outdoors (p=0.031) and the duration of travel (p=0.016) were also identified as significant risk factors. Serological testing demonstrated poor overall sensitivity for detecting infection in the travelers, but for the symptomatic acute cases the results were improved. Histoplasmosis must be considered in patients presenting with fever (odds ratio=3.51 [1.52-8.12]) or cough (odds ratio=4.24 [1.32-13.58]) after visiting Latin America. The results of this study have public health implications and indicate the risks of acquiring histoplasmosis should be included in pre-travel counseling.

Imported schistosomiasis in Europe: sentinel surveillance data from TropNetEurop.

BACKGROUND: Schistosomiasis is a major parasitic disease, increasingly imported into temperate climates by immigrants from and travelers to endemic areas. METHOD: To generate valid data on imported infectious diseases to Europe and to recognize trends over time, the European Network on Imported Infectious Diseases Surveillance (TropNetEurop) was founded in 1999. Three hundred and thirty-three reports of schistosomiasis were analyzed for epidemiologic and clinical features. RESULTS: Male patients accounted for 64% of all cases. The average age of all patients was 29.5 years. The majority of patients were of European origin (53%). Europeans traveled predominantly for tourism (52%). Main reasons for travel for people from endemic areas were immigration and refuge (51%) and visits to relatives and friends (28%). The majority of infections were acquired in Africa; 92 infections were clearly attributable to Schistosoma haematobium, 130 to Schistosoma mansoni, and 4 to Schistosoma intercalatum. Praziquantel was the only treatment used. No deaths were recorded. CONCLUSION: TropNetEurop sentinel provides valuable epidemiologic and clinical data on imported schistosomiasis to Europe.

Epidemiology and clinical features of imported dengue fever in Europe: sentinel surveillance data from TropNetEurop.

Travelers have the potential both to acquire and to spread dengue virus infection. The incidence of dengue fever (DF) among European travelers certainly is underestimated, because few centers use standardized diagnostic procedures for febrile patients. In addition, DF is currently not reported in most European public health systems. Surveillance has commenced within the framework of a European Network on Imported Infectious Disease Surveillance (TropNetEurop) to gain information on the quantity and severity of cases of dengue imported into Europe. Descriptions of 294 patients with DF were analyzed for epidemiological information and clinical features. By far the most infections were imported from Asia, which suggests a high risk of DF for travelers to that region. Dengue hemorrhagic fever occurred in 7 patients (2.4%) all of whom recovered. Data reported by member sites of the TropNetEurop can contribute to understanding the epidemiology and clinical characteristics of imported DF.

Comparative, clinico-epidemiologic study of Schistosoma mansoni infections in travellers and immigrants in Spain.

The study presented here aimed to contrast the marked clinical differences in the presentation of Schistosoma mansoni-induced infection between immigrants and travellers entering Spain from endemic regions, and to elucidate the therapeutic implications of these infections. A total of 200 African immigrants and 80 travellers with schistosomiasis were included in the study. Among the immigrants, 25 patients were diagnosed with Schistosoma mansoni infection; 15 presented with nonspecific symptoms, and 10 were asymptomatic. Hepatosplenomegaly was observed in nine. Among the travellers, 14 were diagnosed with Schistosoma mansoni infection; four were asymptomatic, four had Katayama syndrome, four had diarrhoea, and two had prostatitis. All of the patients were treated with praziquantel. Patients diagnosed with Katayama syndrome received praziquantel and dexamethasone for 3 days, with the praziquantel treatment being repeated at 3-4 weeks. The significant differences observed in the clinical presentation of Schistosoma mansoni-induced infection, indicate that a well-differentiated therapeutic strategy is required when this infection is diagnosed in a non-immune (traveller) or a semi-immune (immigrant) patient.

Imported Falciparum malaria in Europe: sentinel surveillance data from the European network on surveillance of imported infectious diseases.

Malaria continues to have a high morbidity rate associated among European travelers. Thorough recording of epidemiological and clinical aspects of imported malaria has been helpful in the detection of new outbreaks and areas of developing drug resistance. Sentinel surveillance of data collected prospectively since 1999 has begun within TropNetEurop, a European network focusing on imported infectious diseases. TropNetEurop appears to cover approximately 10% of all patients with malaria seen in Europe. Reports of 1659 immigrants and European patients with Plasmodium falciparum malaria were analyzed for epidemiological information and data on clinical features. Regional data were quite diverse, reflecting local patterns of immigration and international travel. By far, the most infections were imported from West Africa. Europeans had more clinical complications; consequently, all deaths occurred in this group. Compared with European standards, the mortality rate was low (0.6% in Europeans). Data from TropNetEurop member sites can contribute to our understanding of the epidemiological and clinical findings regarding imported falciparum malaria.

Cholera outbreak in southern Tanzania: risk factors and patterns of transmission.

To identify risk factors and describe the pattern of spread of the 1997 cholera epidemic in a rural area (Ifakara) in southern Tanzania, we conducted a prospective hospital-based, matched case- control study, with analysis based on the first 180 cases and 360 matched controls. Bathing in the river, long distance to water source, and eating dried fish were significantly associated with risk for cholera. Toxigenic Vibrio cholerae O1, biotype El Tor, serotype Ogawa, was isolated in samples from Ifakara's main water source and patients' stools. DNA molecular analyses showed identical patterns for all isolates.

[Sexual behavior risk in Spanish international travelers]. / Riesgo del comportamiento sexual de los viajeros españoles al extranjero.

BACKGROUND: To know the sexual behavior of Spanish international travelers and its association with geographical destinations and sexually transmitted disease acquisition. PATIENTS AND METHOD: 1,008 consecutive patients who attended a tropical out-patient clinic during 26 months were surveyed by means of a previously designed clinical questionnaire that included specific questions regarding sexual practices during the trip. RESULTS: 19% of travelers had sexual intercourse; 53.6% of them having employed a condom. There were no differences regarding gender or destination. 3.4% of travelers who had unprotected sexual intercourse acquired HIV. CONCLUSIONS: A high proportion of travelers have unprotected, risk sexual contacts. A low but alarm

[Cyclosporiasis: a clinical and epidemiological study in travellers with imported Cyclospora cayetanensis infection]. / Ciclosporiasis: estudio clinicoepidemiológico en viajeros con Cyclospora cayetanensis importada.

BACKGROUND: To assess the clinical and epidemiological characteristics of the enteritis produced by Cyclospora cayetanensis. PATIENTS AND METHOD: A microbiological, epidemiological and clinical protocol in travelers to tropical and temperate areas affected by travelers diarrhea (TD). RESULTS: C. cayetanenesis was isolated from 55 patients. 96% of them suffered TD. Persistent diarrhea (> 2 weeks) was present in 69% and weight loss > or = 3 kg in 38%. In 36% of cases, TD began after returning from the trip. Although C. cayetanensis has a cosmopolitan distribution, it was mostly isolated from travellers to Latin America, the Indian subcontinent and South East Asia. In only five cases a potential risk factor was detected: strawberries (3), buffalo's milk (1) and marinated fish "ceviche" (1). CONCLUSIONS: C. cayetanensis is an emerging enteropathogen, isolated in 2-4% of Spanish travellers suffering from TD, and should be considered in the diferential diagnosis of this clinical entity.

[Katayama fever in Spanish tourists: analysis of 25 cases]. / Fiebre de Katayama en turistas españoles: análisis de 25 casos.

BACKGROUND: Awareness about the clinical presentation and the clinical and terapeutical management of acute schistosomiasis in the non immune traveller. PATIENTS AND METHOD: Febrile patients with epidemiological history of swimming in endemic areas. Prospective protocol 1984-1999. RESULTS: 21% of patients with a diagnosis of schistosomiasis developed the Katayamna syndrome. Nine patients had also a clinical picture of swimmer's itch dermatitis. Diagnosis was suspected on the basis of epidemiology, fever and eosinophilia. Diagnostic confirmation was established through serology in 10 cases and parasitology in 11. In 2 cases both methods were positive. CONCLUSIONS: Fever and eosinophilia after being exposed to infested waters should rise alarm on the syndrome. Availability of serological tests with an earlier positivization and badly needed at present. In Spain two trips, to Mali (Dogon country) and Uganda, are responsible for 75% of the infections. The subject should be introduced routinely in our travellers clinics.

[Neurocysticercosis: an imported disease?]. / Neurocisticercosis: ¿una enfermedad importada?

BACKGROUND: Neurocysticercosis is the CNS involvement caused by Taenia solium larvae and the most frequent cerebral parasitation. It has a cosmopolitan distribution but endemic in the low income countries. The paper analizes the geographic origin, clinical characteristics of patients and the diagnostic and therapeutic modalities. PATIENTS AND METHOD: Retrospective revision of clinical files in patients with the diagnosis of neurocysticercosis between the period January 1990 to March 2000. RESULTS: Ten patients were included of which only one was of Spanish nationality. The others were immigrants or travellers to Central/South America (7), Africa (1) and South East Asia (1). Nine patients presented with convulsive crisis, generalized in 7 and 3 cases suffered headaches. The diagnosis was obtained through biopsy technique (3 cases) and the rest through CT scan or MR and serology. ELISA specific serology was positive in 60% of cases. Eight patients were treated with praziquantel or albendazol solely with good clinical evolution. CONCLUSIONS: Neurocysticercosis is prevalent among the immigrant population and in our case imported mostly from Latin America. Diagnosis is reached through imaging and serological techniques. Treatment with praziquantel or albendazol improves the clinical picture and controls the convulsive crisis.

Quinolone resistance in enterotoxigenic Escherichia coli causing diarrhea in travelers to India in comparison with other geographical areas.

Enterotoxigenic Escherichia coli isolates were identified as a cause of traveler's diarrhea in 82 of 520 (16%) patients and tested for resistance to seven antimicrobial agents. Thirty patients (36%) needed antimicrobial therapy: 17 (56%) for persistence of symptoms and 13 (44%) for severity of symptoms. Ampicillin, tetracycline, and trimethoprim-sulfamethoxazole resistance was high. Chloramphenicol showed moderate activity, and amoxicillin plus clavulanic acid, nalidixic acid, and ciprofloxacin showed very good activity. Five nalidixic acid-resistant strains were isolated, four from patients visiting India.

Imported histoplasmosis in Spain.

Histoplasma capsulatum is a dimorphic fungus endemic in the American continent but not in Europe, where cases are usually imported. Its favorite habitat is in warm humid soils. Guano from birds and bats enhance the sporulation of the mycelial phase.1 Man acquires H. capsulatum through inhalation of spores. Most people infected by this fungi remain asymptomatic, but around 10-50% can start an illness ranging from acute pulmonary histoplasmosis to chronic histoplasmosis. In both, there is close clinical resemblance to pulmonary tuberculosis. Immunodepressed patients undergo a more severe form of the disease, usually presenting in the acute disseminated form. We present seven immunocompetent patients with histoplasmosis acquired after traveling to several American countries.

Endothelial cell activation in muscle biopsy samples is related to clinical severity in human cerebral malaria.

To test the hypothesis of vascular sequestration of parasitized erythrocytes in Plasmodium falciparum malaria in vivo, a pathologic and immunohistochemical study was done of the microvasculature of skeletal muscle biopsy samples from P. falciparum malaria patients at different stages of severity. Parasitized red blood cells sequestered in the skeletal muscle vessels were observed in samples from necropsies but were never demonstrated in biopsy specimens. Vascular cell adhesion molecule-1 and E-selectin expression was consistent only in specimens from cerebral malaria patients. Samples from such patients had strong staining of the constitutive endothelial adhesion molecules tested. The staining intensity gradually decreased in samples from persons with milder forms of the disease. Four of 13 patients with severe malaria had aggregates of red blood cells, occasionally parasitized inside the muscle fibers. These data suggest that skeletal muscle biopsy could be a useful model for the study of the pathogenesis of malaria in vivo.

[Dengue: a re-emerging disease. A clinical and epidemiological study in 57 Spanish travelers]. / Dengue: una enfermedad reemergente. Estudio clinicoepidemiológico en 57 viajeros españoles.

Dengue infection is nowadays considered a re-emergent disease. It has a worldwide tropical and subtropical distribution. The dengue virus in a member of the flavivirus family composed by 4 different serotypes. The virus is transmitted by mosquitos of the Aedes genus. With the increment of travels to the endemic areas, dengue is now observed frequently in our country. We analyzed 57 patients, 30 with imported dengue (ID) and 27 with dengue fever suffered during the trip (DDT). This series is compared with other published ones and a review of the subject is presented. Patients with ID followed a protocol as a febril syndrome returning from the tropics. Dengue was diagnosed through a compatible clinico-epidemiological history, the absence of other ferbil illness and positivity of specific serology. All patients had travelled to endemic areas (Central America 28 cases, Indian subcontinent 15, South-East Asia 10, South America 2, West Africa one, and Pacific one). The following were the most important clinical characteristics: fever and asthenia (100%), headache (98%), mialgia (84%), arthralgia (72%), morbilliform rash (61%) and retroocular pain (65%). For ID cases, the most helpful analitical results were: leucopenia (70%), reactive lymphocytes in peripheral blood smear (70%), thrombocytopenia (70%), and increased hepatic enzymes ALAT (53%), ASAT (63%) and LDH (100% in the 7 patients tested for this enzyme). Dengue must be included in differential diagnosis of fever in patients coming back to travels to tropical areas.

Schistosomiasis in northern Mozambique.

A survey of 12 schools in Cabo Delgado, northern Mozambique, was performed to assess the extent of schistosomiasis infection. Questionnaires validated by parasitological examination of stools and urine were used. Very high prevalences of Schistosoma haematobium infection were found in all schools (77.5% was the lowest recorded), so the questionnaires did not distinguish 'high risk' schools. However, they clearly indicated a good knowledge of the infection by students and teachers. The disease was recognized by teachers to be a public health problem in the area. S. mansoni infection was rare. It had not been reported in previous surveys, but its vector Biomphalaria was discovered in the area. Revised mapping of the disease is advisable in view of probable changes after many years of conflict.

Campylobacter jejuni as a cause of traveler's diarrhea: clinical features and antimicrobial susceptibility.

Traveler's diarrhea is the most common health problem of international travelers. Although enterotoxigenic Escherichia coli seems to be the most frequent cause of traveler's diarrhea, many other microorganisms, such as Campylobacter jejuni, may cause this infectious disease. Campylobacter jejuni is recognized as a leading cause of enteritis in humans both in developing and in developed countries. However, a few reports on the incidence and antimicrobial resistance of Campylobacter spp. as a cause of traveler's diarrhea have been published. The limited data on the treatment of C. jejuni infections suggest that ciprofloxacin may shorten the duration of symptoms. However, treatment failure associated with the emergence of quinolone-resistant strains of C. jejuni has been documented. The purpose of this study was to determine the prevalence of C. jejuni associated with traveler's diarrhea and to analyze the geographic distribution as well as the clinical features and susceptibility to antibiotics.