Internet and computer-based resources for travel medicine practitioners.

The field of travel medicine is concerned primarily with ways to maintain the health of international travelers. Remaining current in this area requires up-to-date knowledge of global infectious diseases, patterns of drug resistance, advances in preventive measures, and public health regulations pertaining to the crossing of international borders. This review of off-line commercial databases and Internet sources will assist infectious disease consultants in accessing current reliable travel health information. Of the North American pretravel off-line databases, TRAVAX (United States) and The Medical Letter are the most comprehensive, whereas the Global Infectious Disease and Epidemiology Network is extraordinary in its provision of global infectious disease epidemiology for posttravel assessment. A total of 65 Web sites are listed within 9 categories, covering such areas as authoritative government travel health recommendations, commercially-oriented sites, and travel medicine listserv discussion groups. Even among reputable Web sites, contradictory information may be found that demands careful consideration by the clinician and by the traveling public.

Experience of corporate medical assistance clinics during the Centennial Olympic Games, Atlanta, 1996.

The health of travelers returning home from developing countries has received increased attention in recent years. Much of this attention has centered on immunizations, malaria chemoprophylaxis and treatment of traveler's diarrhea. In contrast, there are very few data on the health problems of international travelers to developed countries such as the United States. We studied the experience of two corporate medical assistance clinics established for both national and international travelers to Atlanta, Georgia during the Centennial Summer Olympic Games in 1996.

Evaluation of fever in the returned traveler.

The differential diagnosis of a febrile illness in the returned traveler is extensive. The most commonly encountered tropical infections are malaria, dysentery, hepatitis, and dengue fever; a substantial number of febrile illnesses are never diagnosed. Malaria is by far the most important infection to consider in the returned traveler who presents with fever. As international travel continues to increase in popularity, the ongoing need for clinicians to broaden their knowledge of travel-related diseases is evident. The ability to recognize and manage tropical diseases in travelers is essential because the morbidity and mortality of these infections are often preventable with prompt therapy. When expertise in this area is lacking, febrile returned travelers should be referred to a tropical disease unit or an infectious disease consultant for urgent assessment.

GeoSentinel: the global emerging infections sentinel network of the International Society of Travel Medicine.

GeoSentinel is a network of 22 member travel/tropical medicine clinics (14 in the United States and 8 in other countries) initiated in 1995 by the International Society of Travel Medicine (ISTM). GeoSentinel is based on the concept that these clinics are ideally situated to effectively detect geographic and temporal trends in morbidity among travelers. The core surveillance tool is a single-page faxable form submitted to a central data site for each post-travel patient, including immigrants, refugees, and foreign visitors. Diagnoses are entered either as specific etiologies or as syndromes and are then linked to geographic locations, reference dates, and clinical presentations. In addition, electronic communication with the larger body of worldwide ISTM member clinics is periodically done to obtain broader data collection in response to specific inquiries. The scope of GeoSentinel has broadened from the initial vision of a provider-based sentinel network tracking emerging infections at their point of entry into developed countries. Its present goals are (1) to monitor global trends in disease occurrence among travelers; (2) to ascertain risk factors and morbidity in groups of travelers categorized by travel purpose and type of traveler; (3) to respond to urgent public health queries; (4) to develop educational priorities for travelers' health; and (5) to effect a rapid response by electronically disseminating alerts to surveillance sites, to all ISTM members in 55 countries, and to public health authorities. In addition, a major byproduct of the network, and now one of its strongest assets, has been the growth of partnerships between ISTM, Centers for Disease Control and Prevention and health-care providers around the world, as well as other medical societies, government, and private organizations. The demographic data, travel patterns, and clinical presentations for the first 2813 patient records analyzed from the GeoSentinel sites are summarized in this paper.

Prevention of common travel ailments.

An understanding of the subjects covered in this article is significant in keeping travelers healthy and comfortable. Each section covers a range of problems and suggestions for their prevention. The areas that are reviewed are: 1) fitness to fly; 2) problems in transit; 3) altitude sickness; 4) marine and swimming hazards; 5) insect precautions; 6) pre- and posttravel care; and 7) illness abroad. An effort has been made to provide practical recommendations as in many cases there is little data and no rules, thus the travel health advisor, with the patients' input, will need to determine the best course of action for each individual and itinerary.

Health problems of corporate travelers: risk factors and management.

BACKGROUND: Numerous studies have been done regarding health problems experienced by tourists in developing countries; however, little data exist about these health risks and illnesses experienced by corporate travelers. METHODS: The authors examined by electronic survey the health risks encountered, compliance with pretravel health recommendations, and illnesses and injuries experienced by employees of the Coca-Cola Company who travel internationally. RESULTS: Two hundred twenty-six travelers responded. Although most travelers ate meals at their hotels and chose foods that were cooked and still hot, over half also ate foods that remained at room temperature for prolonged periods and/or ate from cold salad bars. Almost half drank untreated tap water. Thirty-five percent of travelers developed diarrhea and 29% reported respiratory illnesses, with 12% seeking medical attention for their problems. Forty-three percent of those traveling to malarious regions admitted to noncompliance with antimalarial recommendations. Health kits provided were used by only 51% of travelers. CONCLUSIONS: Although many corporate travelers followed pretravel health recommendations, some did not. Injuries, fever, and illnesses such as diarrhea and respiratory infections occurred. Strategies to improve access to the travel clinic and the acquisition of health information and travel health kits are being implemented. The health risks and behaviors of corporate travelers, including the potential impact of psychosocial stressors, need greater attention.

Update on prevention of malaria for travelers.

Individuals from industrialized nations frequently travel to countries with malaria, so health care providers need to be familiar with current recommendations for prevention of malaria. Changes in drug susceptibility of malaria parasites and evolving knowledge of how well drugs are tolerated necessitate periodic review of guidelines for prophylaxis of malaria, especially of chloroquine-resistant Plasmodium falciparum malaria. Mefloquine is the drug of choice for chemoprophylaxis for most travelers, with doxycycline and chloroquine being less effective alternatives. Mefloquine is well tolerated at prophylactic dosages, but anecdotal reports have raised concerns about its adverse effects. Resistance to this drug has emerged in parts of Southeast Asia and may spread to other regions of the world. The major disadvantages of doxycycline are the need for daily dosing, its contraindication for young children and pregnant women, and its adverse effects. Chloroquine is effective for prophylaxis only in Central America, the Caribbean, and parts of the Middle East. Few new drugs will be available in the near future because of reduced funding for antimalarial drug research and development; therefore, the usefulness of currently available drugs needs to be prolonged by rational use. Increased efforts should be made to ensure that alternative drugs will be available for prevention of malaria.

Short course ciprofloxacin therapy for enteric fever.

A short course of ciprofloxacin, 750 mgm b.i.d. for 7 days was found to be effective in the treatment of enteric fever in 21 hospitalized patients with S.typhi (18) and S.paratyphi A(3). Median time for fever response was 3 days. All isolates were susceptible to ciprofloxacin (MIC 0.0078-0.062 mcgm/ml). The mean serum peak and trough levels were 5.4 and 1.6 mcgm/ml respectively. Stool cultures were free of Salmonellae on follow up (11-24 weeks). Two developed recurrence of paratyphoid fever, 17 days and 4 months after therapy.

Culture isolation of Acanthamoeba species and leptomyxid amebas from patients with amebic meningoencephalitis, including two patients with AIDS.

Acanthamoeba species and leptomyxid organisms are free-living amebas that cause meningoencephalitis, primarily in immunocompromised patients. We report the isolation and culture of Acanthamoeba species and leptomyxid amebas from four patients with fatal amebic meningoencephalitis. Acanthamoeba species were cultured from brain abscess specimens from three immunocompromised patients (including two patients with AIDS). In the case of the fourth patient, who had no identifiable immunodeficiency, leptomyxid amebas were cultured from a specimen from a subcutaneous nodule and were identified in amebic granulomas in brain tissue by the indirect immunofluorescence test. Persons with advanced infection due to the human immunodeficiency virus may be at increased risk for amebic meningoencephalitis, but the diagnosis should be considered in the differential diagnosis of any immunocompromised patient with cerebral abscesses.

Short-course treatment of typhoid fever with ciprofloxacin in south India.

This study assessed the performance of short-course ciprofloxacin for the treatment of 34 adult patients with culture-positive typhoid fever. Patients received ciprofloxacin, 750 mg orally twice daily for 7 d. Measurement of response was based upon time from initial treatment to fever lysis, to afebrile state, and to symptom resolution. Ciprofloxacin-treated patients defervesced in a mean of 3.21 d (+/- 0.56), with stabilization of temperature in 4.0 +/- 0.73 d. After 90 d follow-up, no relapse or carrier was identified. Side effects during therapy were minimal.

Culture-confirmed pneumonia due to Chlamydia pneumoniae.

Diagnosis of infection caused by Chlamydia pneumoniae, a newly recognized respiratory pathogen, has proved difficult. Between July 1987 and April 1988, culture and serologic tests for C. pneumoniae were done on specimens from 49 patients with pneumonia seen at an Atlanta hospital emergency room. Cultures from 3 patients (6%) grew C. pneumoniae. Genus-specific Chlamydia complement fixation titers and microimmunofluorescence titers for C. pneumoniae were suggestive of acute infection in all 3 culture-positive patients. Three other patients had evidence of acute disease by published criteria for antibody titers. Most studies of C. pneumonia have not had culture-proven cases; the 6% rate of positive cultures in this study support the role of C. pneumoniae as a cause of pneumonia. More widespread availability of simplified culture systems for C. pneumoniae is needed. Caution should be used when interpreting serologic tests in the absence of culture confirmation.

Plasmid analysis of simultaneous nosocomial outbreaks of methicillin-resistant Staphylococcus aureus.

A large outbreak of infections caused by methicillin and aminoglycoside resistant Staphylococcus aureus provided the opportunity to evaluate mechanisms of resistance and compare the usefulness of typing systems. Between January 1979 and December 1980, 63 patients developed infections with S aureus resistant to multiple antibiotics, including methicillin and tobramycin. All isolates had an identical antibiogram and were phage type 47/54/75/77/83A. Beginning in January 1981, a superimposed outbreak caused by S aureus of the same phage type but with a resistance pattern now including gentamicin occurred. The two strains contained different aminoglycoside inactivating enzymes. The initial strain contained a single plasmid of 21.5 mDa molecular weight, whereas the subsequent strain which had acquired gentamicin resistance contained this plasmid plus a heavier one of 33 mDa. Plasmid analysis complements the analysis of antibiograms and phage types and aids in defining epidemiologic patterns of transmission.

Fly larva adherent to corneal endothelium.

Anterior ophthalmomyiasis is a rare condition in which a fly larva invades the globe, causing iridocyclitis and sometimes subluxation of the lens. Humans are accidental hosts in whom such larvae, after entering the eye, undergo little development. We report a case in which the first larval stage of a rodent or rabbit botfly, Cuterebra sp., invaded the anterior chamber, produced a transient iridocyclitis, and adhered to the posterior cornea where it remained as a dead, slightly atrophic body. Identification of the organism was made by slit-lamp and specular photomicrographs. Tapering doses of topical corticosteroids controlled the inflammation. During 27 months of observation the larva changed only slightly in appearance, the surrounding corneal endothelium remained normal, the cornea remained clear, and the visual acuity remained 20/20.

Development of antibiotic resistance by staphylococcus aureus in a single patient. Confirmation by phage typing, antibiograms, and plasmid analysis.

A patient is described who had colonization and infection with strains of Staphylococcus aureus increasingly resistant to multiple antibiotics while receiving several courses of broad-spectrum antibiotics. S. aureus strains with different phage types, antibiograms, and plasmid profiles were isolated from different sites at the same time. After the patient was transferred to an intermediate-care service where he received only supportive care and no further antibiotics, culture samples from areas previously colonized or infected (sputum, anterior nares, perineal region, rectum) showed no S. aureus. This patient graphically demonstrates that antibiotics may create an environment allowing the overgrowth of resistant organisms and that withdrawal of this selection pressure may allow more sensitive organisms to recolonize.