Dengue, chikungunya and Zika virus infections among Dutch travellers to Suriname: a prospective study during the introduction of chikungunya and Zika virus, 2014 to 2017.

BackgroundSuriname, a country endemic for dengue virus (DENV), is a popular destination for Dutch travellers visiting friends and relatives and tourist travellers. Chikungunya and Zika virus (CHIKV, ZIKV) were introduced in 2014 and 2015, respectively. Data on infection risks among travellers are limited.AimWe aimed to prospectively study incidence rate (IR) and determinants for DENV, ZIKV and CHIKV infection in adult travellers to Suriname from 2014 through 2017.MethodsParticipants kept a travel diary and were tested for anti-DENV, anti-ZIKV and anti-CHIKV IgG antibodies (Euroimmun). Selected samples were subjected to an in-house DENV and ZIKV PRNT50. The IR (infections/1,000 person-months of travel) and IR ratio and determinants for infection were calculated.ResultsTravel-acquired infections were found in 21 of 481 participants: 18 DENV, four ZIKV and two CHIKV, yielding an IRDENV of 47.0 (95% CI: 29.6-74.6), IRZIKV of 11.6 (95% CI: 4.4-31.0) and IRCHIKV of 5.6 (95% CI: 1.4-22.2)/1,000 person-months. In nine DENV and three ZIKV infected participants, infections were PRNT50-confirmed, yielding a lower IRDENV of 23.3 (95% CI: 12.1-44.8) and an IRZIKV of 8.4 (95% CI: 2.7-26.1) per 1,000 person-months. Tourist travel was associated with DENV infection. ZIKV and CHIKV infections occurred soon after their reported introductions.ConclusionsDespite an overestimation of serologically confirmed infections, Dutch travellers to Suriname, especially tourists, are at substantial risk of DENV infection. As expected, the risk of contracting ZIKV and CHIKV was highest during outbreaks. Cross-reaction and potential cross-protection of anti-DENV and -ZIKV antibodies should be further explored.

Malaria in long-term travelers: Infection risks and adherence to preventive measures - A prospective cohort study.

BACKGROUND: Chemoprophylaxis and anti-mosquito measures are key to preventing malaria in travelers. Long-term travelers are at higher risk than short-term travelers, but their adherence to preventive measures is lower. Our aim was to determine malaria exposure risks and predictors for adherence to malaria-preventive measures in long-term travelers. METHODS: Long-term travelers (>12 weeks) completed a weekly questionnaire about preventive measures, symptoms, and malaria treatment abroad. Blood samples were tested for seroconversion to Plasmodium falciparum anti-circumsporozoite (PfCSP) antibody. Adherence to preventive measures was defined as number of weeks of their usage divided by number of weeks in malaria-endemic areas. RESULTS: Of 561 travelers, the median travel time was 20 weeks (IQR 16-25). Eighteen were treated for malaria, all in sub-Saharan Africa. Sixteen PfCSP seroconversions were found, of whom only 3 had traveled to high-endemic areas. Of the 18 travelers treated for malaria, only one seroconverted. No associations were found between covariates and seroconversion. Neither treatment abroad nor seroconversion were reliable predictors for exposure. 'Full adherence' to chemoprophylaxis was reported by 52% (218/417) and was associated with travel to Africa, use of mefloquine, lack of prior travel history, shorter duration of travel, and use of DEET. CONCLUSIONS: The risk of malaria in this long-term travelers cohort was low. Our data confirm that anti-PfCSP seroconversion is not a reliable method to retrospectively identify incident infection, or probably exposure. Prevention efforts should focus on more experienced travellers and longer travel duration, for whom mefloquine should be considered as the first-choice chemoprophylaxis.

No chikungunya virus infections among Dutch long-term travellers to (sub)tropical countries: a prospective study 2008-2011.

BACKGROUND: Chikungunya is an arthropod-borne viral disease now identified in over 60 countries in Asia, Africa, Europe, and the Americas. Chikungunya virus (CHIKV) has spread in the last 15 years to many countries, causing large local outbreaks. CHIKV infection can be clinically misdiagnosed in areas where dengue and/or Zika infections occur. Prospective studies are necessary to calculate the true incidence rate of CHIKV infection in travellers. The aim of this study was to obtain the attack and incidence rates of CHIKV infection among long-term travellers and identify associated risk factors. METHODS: A previously collected prospective cohort of Dutch long-term travellers (12-52 weeks) to subtropical and tropical countries was tested. From December 2008 to September 2011, participants were recruited at the travel clinic of the Public Health Service Amsterdam. A weekly diary was kept during travel in which participants recorded their itinerary, symptoms, and physician visits. On return, their pre- and post-travel blood samples were tested for the presence of IgG antibodies to CHIKV antigen. Seroconversions were confirmed by an in-house CHIKV neutralisation test. RESULTS: The median age of 603 participants was 25 years (interquartile range [IQR]: 23-29); 35.7% were male; median travel duration was 20 weeks (IQR: 15-25), and purpose of travel was predominantly tourism (62%). The presence of anti-CHIKV IgG in the pre-travel sample, suggestive of previous CHIKV infection, was found for 3/603 participants (0.5%); all three had been previously travelling in either Africa or Asia. In one traveler who visited Latin America, a seroconversion was found (0.2%) but the CHIKV neutralisation test was negative, making the incidence rate 0. CONCLUSION: No chikungunya virus infections were found in this 2008-2011 prospective cohort of long-term travellers. We recommend the research be repeated, particularly as the sample size of our cohort might have been too small. Also, extensive spread of chikungunya virus has likely increased incidence rates among travellers since 2013.

Hepatitis E in Long-Term Travelers from the Netherlands to Subtropical and Tropical Countries, 2008-2011.

Hepatitis E virus (HEV) is a common cause of acute viral hepatitis. Virus genotypes 1 and 2 infect humans in developing countries by the fecal-oral route. To assess attack rates and disease incidence for travelers, we prospectively studied 604 long-term travelers to subtropical and tropical countries. Participants donated blood samples pretravel and posttravel and kept a diary. A total of 89/604 (15%) pretravel samples were positive for HEV IgG by ELISA, suggesting previous HEV infection. Seroconversion for HEV was found for 19/515 travelers (attack rate 3.7%, incidence 1.8 cases/1,000 person-weeks). We believe there is a substantial risk for acquiring HEV infection among long-term travelers. Although HEV infection does not seem to be a major problem in this healthy cohort, hygienic measures should be stressed in all pretravel health advice, particularly for pregnant women and immunocompromised travelers who are at risk for severe disease.

Low incidence of helminth infections (schistosomiasis, strongyloidiasis, filariasis, toxocariasis) among Dutch long-term travelers: A prospective study, 2008-2011.

BACKGROUND: Despite the considerable burden of helminth infections in developing countries and increasing international travel, little is known about the risks of infection for travelers. OBJECTIVE: We studied the attack and incidence rate of serology confirmed strongyloidiasis, filariasis, and toxocariasis among long-term travelers and associated factors. A second objective was to evaluate eosinophilia as a positive/negative predictive value (PPV/NPV) for a recent helminth infection. METHODS: From 2008 to 2011, clients of the Public Health Service travel clinic planning travel to (sub)tropical countries for 12-52 weeks were invited to participate in a prospective study. Participants kept a weekly diary, recording itinerary, symptoms, and physician visits during travel and completed a post-travel questionnaire. Pre- and post-travel blood samples were serologically tested for the presence of IgG antibodies against Schistosoma species, Strongyloides stercoralis, filarial species, and Toxacara species and were used for a blood cell count. Factors associated with recent infection were analyzed using Poisson regression. Differences among groups of travelers were studied using chi square tests. RESULTS: For the 604 participants, median age was 25 years (interquartile range [IQR]: 23-29), 36% were male, median travel duration was 20 weeks (IQR: 15-25), and travel purpose was predominantly tourism (62%). Destinations were Asia (45%), Africa (18%), and the Americas (37%). Evidence of previous infection was found in 13/604 participants: antibodies against Schistosoma spp. in 5 (0.8%), against S.stercoralis in 3 (0.5%), against filarial species in 4 (0.7%), and against Toxocara spp. in 1 (0.2%). Ten recent infections were found in 9 participants (3, 1, 6, 0 cases, in the above order), making the attack rates 0.61, 0.17, 1.1 and 0, and the incidence rates per 1000 person-months 1.5, 0.34, 2.6 and 0. The overall PPV and NPV of eosinophila for recent infection were 0 and 98%, respectively. CONCLUSIONS: The risk of the helminth infections under study in this cohort of long-term travelers was low. Routine screening for eosinophilia appeared not to be of diagnostic value.

Dengue virus infection among long-term travelers from the Netherlands: A prospective study, 2008-2011.

BACKGROUND: Dengue is increasing rapidly in endemic regions. Data on incidence among travelers to these areas are limited. Five prospective studies have been performed thus far, mainly among short-term travelers. OBJECTIVE: To obtain the attack and incidence rate (AR, IR) of dengue virus (DENV) infection among long-term travelers and identify associated risk factors. METHODS: A prospective study was performed among long-term travelers (12-52 weeks) attending the Public Health Service in Amsterdam. Clients planning to travel to (sub)tropical countries were invited to participate. Participants kept a travel diary, recording itinerary, symptoms, and physician visits. Pre- and post-travel blood samples were serologically tested for the presence of Anti-DENV IgG antibodies. Seroconversion was considered suggestive of a primary DENV infection. Anti-DENV IgG present in both corresponding samples in combination with a post-/pre-travel ratio of ≥4:1 was suggestive of a secondary infection. Risk factors for a DENV infection were studied using poisson regression. RESULTS: In total, 600 participants were included; median age was 25 years (IQR: 23-29), 35.5% were male, and median travel duration was 20 weeks (IQR: 15-25). In 39 of 600 participants (AR: 6.5%; 95% CI 4.5-8.5%) anti-DENV IgG test results were suggestive of a recent infection, yielding an IR of 13.9 per 1,000 person-months traveling (95%CI: 9.9-19.1). No secondary infections were found. IR for Asia, Africa, and America were comparable and 13.5, 15.8, and 13.6 per 1,000 person-months respectively. Of participants with a recent DENV infection, 51% did not report dengue-like illness (DLI) or fever, but 10% were hospitalized. In multivariable analysis, travelers who seroconverted were significantly more likely to be vaccinated with ≥2 flavivirus vaccines for the current trip or to have reported DLI in >1 consecutive weeks. CONCLUSIONS: Long-term travelers are at substantial risk of DENV infection. Half of those with a DENV infection reported no symptoms, but 10% were hospitalized, demonstrating the importance of advising anti-mosquito measures during travel.

High prevalence of previous dengue virus infection among first-generation Surinamese immigrants in the Netherlands.

BACKGROUND: A substantial portion of Dutch travellers is comprised of immigrants returning to their country of origin to visit friends and relatives (VFRs), including VFRs returning to dengue-endemic areas such as Suriname. Limited attention has been focused on dengue among immigrants, therefore it is unknown whether immigration has effect on the epidemiology of (severe) dengue among VFRs.To get more insight in the seroprevalence of dengue among Surinamese immigrants, we conducted a seroprevalence study on a convenience sample of first-generation Surinamese immigrants living in the Netherlands. METHODS: Blood samples were tested for IgG antibodies to DENV antigen serotypes (1, 2, 3 and 4). Gender, age, years lived in Suriname before immigration, history of yellow fever vaccination, and time between yellow fever vaccination and blood sample collection were examined as possible predictors for previous infection. RESULTS: Of the studied 400 Surinamese travellers with a mean age of 52 years (range 18-89), 37% were male. Serology suggestive of past DENV infection was found in 325 individuals (81.3%; 95% CI: 77-85%). The time lived in Suriname before immigration was the only significant predictor for previous DENV infection. CONCLUSIONS: Most first-generation Surinamese immigrants have evidence of past DENV infection, probably comparable to Surinamese inhabitants. Whether this influences the number of cases of (severe) dengue when travelling requires more study.

Dutch travel health nurses: prepared to prescribe?

BACKGROUND: In travel medicine, as in other specialties, independent prescribing of medication has traditionally been the domain of practitioners like physicians, dentists, and midwives. However, a 2011 ruling in the Netherlands expands independent prescribing and introduces supplementary prescribing by nurses, with expected implementation over the next few years. As specialist nurses will not be eligible for independent prescribing, this study addresses supplementary prescribing, specifically by travel health nurses. Such nurses will work in partnership with an independent prescriber, usually a physician. After the physician evaluates a patient's condition and needs, the nurse may prescribe from an open or limited formulary. This supplementary approach seems appropriate in travel medicine, which is highly protocolized. A questionnaire survey was conducted to assess whether travel health nurses themselves aspire and feel competent to prescribe, and what training they might need. METHODS: All travel health nurses in the Netherlands received a questionnaire seeking their anonymous response. RESULTS: The response rate was 58%. Self-reported compliance with protocols and quality criteria was high; 82% of respondents aspire to prescribe and 77% feel competent to prescribe. Of the latter, 22% indicated that ongoing access to a doctor would remain important, and 14% preferred to prescribe under certain conditions like a restricted number of medicines. The reason most frequently given for not feeling competent was the need for additional education before obtaining prescribing rights (40%). Aspiration to prescribe was the only significant predictor for feeling competent to prescribe (odds ratios: 6.8; 95% confidence intervals: 3.5-13). Of all the responding nurses, 95% reported one or more educational needs related to prescribing, particularly in pharmacology. CONCLUSIONS: Most Dutch travel health nurses aspire to prescribe and feel competent for the supplementary approach, but require further education before the approach is implemented in travel medicine.