Health problems and exposure to infectious risks in returning humanitarian aid workers.

BACKGROUND: Humanitarian aid workers are exposed to deployment-related health threats. Identifying subgroups at a higher risk of infection in this diverse population could help optimize prevention. METHODS: We carried out a retrospective study based on anonymized data of humanitarian aid workers that visited our clinic for a post-deployment visit between 1 January 2018 and 31 December 2021. We conducted a descriptive analysis of basic demographic data, self-reported risk exposure and health problems encountered during deployment extracted from a standard questionnaire. RESULTS: The questionnaire was administered to 1238 aid workers during 1529 post-deployment medical consultations. The median age was 37.2 years (IQR 31.7-44.3), and 718/1529 (47.0%) were female aid workers. The median duration of deployment was 6 months (IQR 3-12 months). Most deployments (1321/1529 (86.4%)) were for a medical organization and in Sub-Saharan Africa (73.2%). The most common risk exposures were contact with freshwater in schistosomiasis endemic regions (187/1308 (14.3%)), unprotected sexual contact with a person other than a regular partner (138/1529 (9.0%)), suspected rabies exposure (56/1529 (3.7%)) and accidental exposure to blood (44/1529 (2.9%)). Gastrointestinal problems (487/1529 (31.9%)), malaria (237/1529 (15.5%)) and respiratory tract infections (94/1529 (6,2%)) were the most encountered health problems. Fifteen volunteers (1%) were hospitalized during deployment and 19 (1.2%) repatriated due to health problems. Adherence to malaria chemoprophylaxis was poor, only taken according to the prescription in 355 out of 1225 (29.0%) of aid workers for whom prophylaxis was indicated. CONCLUSION: Humanitarian aid workers deployed abroad encounter significant rates of health problems and report a high level of risk exposure during their deployment, with the risks being greatest among younger people, those deployed to rural areas, and those working for non-medical organizations. These findings help guide future pre-deployment consultations, to increase awareness and reduce risk behaviour during deployment, as well as focus on adherence to medical advice such as malaria chemoprophylaxis.

[A 19-year-old male migrant with urethritis and vesicular rash]. / Un migrant de 19 ans consulte pour une urétrite et une éruption vésiculeuse.

We report the case of a 19-year-old Malian patient, who presented with urethritis and a vesicular rash during the summer of 2022, following a probable heterosexual intercourse. The epidemic context among the male homosexual population and the clinical picture without genital lesions or lymphadenopathy allowed us to discuss both chickenpox and mpox, the latter being finally confirmed by the detection of Monkeypox virus DNA from vesicular fluid.

Complete Genome Sequences of Monkeypox Virus from a French Clinical Sample and the Corresponding Isolated Strain, Obtained Using Nanopore Sequencing.

We report the whole-genome sequences of a monkeypox virus from the skin lesion of a French patient and the corresponding isolated viral strain. Both viral genomic sequences were successfully obtained by applying shotgun metagenomics using the Oxford Nanopore Technologies sequencing approach.

Rifampin-moxifloxacin-metronidazole combination therapy for severe Hurley stage 1 hidradenitis suppurativa: prospective short-term trial and 1-year follow-up in 28 consecutive patients.

BACKGROUND: Severe Hurley stage 1 hidradenitis suppurativa (HS1) is a difficult-to-treat form of the disease. OBJECTIVE: To assess the efficacy and tolerance of the oral combination of rifampin (10 mg/kg once daily)/moxifloxacin (400 mg once daily)/metronidazole (250-500 mg 3 times daily) (RMoM) treatment strategy in patients with severe HS1. METHODS: Prospective, open-label, noncomparative cohort study in 28 consecutive patients. Nineteen patients were treated for 6 weeks by RMoM, followed by 4 weeks of rifampin/moxifloxacin alone, then by cotrimoxazole after remission. Moxifloxacin was replaced by pristinamycin (1 g 3 times daily) in 9 patients because of contraindications or intolerance. The primary endpoint was a Sartorius score of 0 (clinical remission) at week 12. RESULTS: The median Sartorius score dropped from 14 to 0 (P = 6 × 10-6) at week 12, with 75% of patients reaching clinical remission. A low initial Sartorius score was a prognosis factor for clinical remission (P = .049). The main adverse effects were mild gastrointestinal discomfort, mucosal candidiasis, and asthenia. At 1 year of follow-up, the median number of flares dropped from 21/year to 1 (P = 1 × 10-5). LIMITATIONS: Small, monocentric, noncontrolled study. CONCLUSIONS: Complete and prolonged remission can be obtained in severe HS1 by using targeted antimicrobial treatments.

Systematic Booster after Rabies Pre-Exposure Prophylaxis to Alleviate Rabies Antibody Monitoring in Individuals at Risk of Occupational Exposure.

Pre-exposure rabies prophylaxis (PrEP) is recommended for people at frequent or increased risk of professional exposure to lyssavirus (including rabies virus). PrEP provides protection against unrecognized exposure. After the primary vaccination, one's immune response against rabies may decline over time. We aimed to evaluate the immune response to rabies in individuals immunized for occupational reasons before and after a booster dose of the rabies vaccine. With this aim, we retrospectively documented factors associated with an inadequate response in individuals vaccinated for occupational purposes. Our findings analyzed data from 498 vaccinated individuals and found that 17.2% of participants had an inadequate antibody titration documented after their primary vaccination without the booster, while inadequate response after an additional booster of the vaccine was evidenced in 0.5% of tested participants. This study showed that a single booster dose of vaccine after PrEP conferred a high and long-term immune response in nearly all individuals except for rare, low responders. A systematic rabies booster after primary vaccination may result in alleviating the monitoring strategy of post-PrEP antibody titers among exposed professionals.

Immune response to rabies post-exposure prophylaxis in patients with non-HIV secondary immunodeficiencies.

BACKGROUND: This study sought to determine the proportion of individuals with non-HIV secondary immunodeficiencies presenting inadequate antibody titers after rabies post-exposure prophylaxis (PEP) and to identify variables associated with inadequate response. METHODS: A retrospective review of the records of immunocompromised patients having received a full course of PEP after a rabies exposure and having been tested for post-PPE antibody titers in two French Antirabies Clinics, between 2013 and 2018, was conducted. Antibody titers < 0.5 EU/ml (ELISA) were classified as inadequate. RESULTS: A total of 28 individuals were included, 6 had inadequate post-PPE titers. None of the tested variable was independently associated with inadequate titers. CONCLUSIONS: Inadequate response was unpredictable and not explained either by the characteristics of patients or by the PEP regimen they received. These findings support the WHO recommendation to systematically assess post-PEP response in immunocompromised patients to detect non-responders, who might require an additional dose.

Immunogenicity and Safety of Yellow Fever Vaccine in Allogeneic Hematopoietic Stem Cell Transplant Recipients After Withdrawal of Immunosuppressive Therapy.

As a live attenuated vaccine, yellow fever vaccine (YFV) is not routinely performed after allogeneic hematopoietic stem cell transplant (HSCT) despite it being the only efficient preventive therapy. We retrospectively identified 21 HSCT recipients immunized with YFV at a median of 39 months after HSCT and a median of 33 months after withdrawal of immunosuppression without any side effects. Eighteen evaluable patients had protective immunity after YFV. We also observed that a third of the recipients vaccinated with YFV before HSCT had persistent protective immunity after HSCT.

Liposomal amphotericin B in travelers with cutaneous and muco-cutaneous leishmaniasis: Not a panacea.

BACKGROUND: Complex cutaneous and muco-cutaneous leishmaniasis (CL and MCL) often requires systemic therapy. Liposomal amphotericin B (L-AmB) has a strong potential for a solid clinical benefit in this indication. METHODS: We conducted a retrospective analysis of data from a French centralized referral treatment program and from the "LeishMan" European consortium database. All patients with parasitologically proven CL or MCL who received at least one dose of L-AmB were included. Positive outcome was based on ulcer closure as per recent WHO workshop guidelines. RESULTS: From 2008 through 2016, 43 travelers returning from 18 countries (Old World n = 28; New World n = 15) were analyzed with a median follow-up duration of 79 days [range 28-803]. Main clinical forms were: localized CL with one or multiple lesions (n = 32; 74%) and MCL (n = 8; 19%). As per published criteria 19 of 41 patients (46%) were cured 90 days after one course of L-AmB. When the following items -improvement before day 90 but no subsequent follow-up, delayed healing (>3 months) and healing after a second course of L-AmB- were included in the definition of cure, 27 of 43 patients (63%) had a positive outcome. Five patients (MCL = 1; CL = 4) experienced a relapse after a median duration of 6 months [range 3-27] post treatment and 53% of patients (23/43) experienced at least one adverse event including severe hypokalaemia and acute cardiac failure (one patient each). In multivariate analysis, tegumentary infection with L. infantum was associated with complete healing after L-AmB therapy (OR 5.8 IC 95% [1.03-32]) while infection with other species had no impact on outcome. CONCLUSION: In conditions close to current medical practice, the therapeutic window of L-AmB was narrow in travellers with CL or MCL, with the possible exception of those infected with L. infantum. Strict follow-up is warranted when using L-AmB in patients with mild disease.

CHRONOVAC VOYAGEUR: A study of the immune response to yellow fever vaccine among infants previously immunized against measles.

For administration of multiple live attenuated vaccines, the Advisory Committee on Immunization Practices recommends either simultaneous immunization or period of at least 28days between vaccines, due to a possible reduction in the immune response to either vaccine. The main objective of this study was to compare the immune response to measles (alone or combined with mumps and rubella) and yellow fever vaccines among infants aged 6-24months living in a yellow fever non-endemic country who had receivedmeasles and yellow fever vaccines before travelling to a yellow fever endemic area. SUBJECTS AND METHODS: A retrospective, multicenter case-control study was carried out in 7 travel clinics in the Paris area from February 1st 2011 to march 31, 2015. Cases were defined as infants immunized with the yellow fever vaccine and with the measles vaccine, either alone or in combination with mumps and rubella vaccine, with a period of 1-27days between each immunization. For each case, two controls were matched based on sex and age: a first control group (control 1) was defined as infants having received the measles vaccine and the yellow fever vaccine simultaneously; a second control group (control 2) was defined as infants who had a period of more than 27days between receiving the measles vaccine and yellow fever vaccine. The primary endpoint of the study was the percentage of infants with protective immunity against yellow fever, measured by the titer of neutralizing antibodies in a venous blood sample. RESULTS: One hundred and thirty-one infants were included in the study (62 cases, 50 infants in control 1 and 19 infants in control 2). Of these, 127 (96%) were shown to have a protective titer of yellow fever antibodies. All 4 infants without a protective titer of yellow fever antibodies were part of control group 1. DISCUSSION: The measles vaccine, alone or combined with mumps and rubella vaccines, appears to have no influence on humoral immune response to the yellow fever vaccine when administered between 1 and 27days. The absence of protective antibodies against yellow fever was observed only among infants who received both vaccines simultaneously. CONCLUSION: These results may support a revision of current vaccination recommendations concerning the administration of these two live attenuated vaccines either on the same day or at least 28days apart. Our findings show no statistically significant difference if the interval between both vaccines is more than 24 h, but the immune response seems to be reduced when the two vaccines are given at the same time.

[The pregnant traveller]. / La femme enceinte voyageuse.

Pregnancy is a physiological situation that requires specific and careful preparation before travel. Malaria, dengue fever and viral hepatitis E are more severe in pregnancy and at higher risk of adverse obstetrical outcome. Medical and obstetrical contra-indications to travel should be listed during pre-travel evaluation. Vaccine indications are the same as in the general population, and must be discussed after a rigorous benefit-risk analysis. Pregnant women should avoid or delay travel in areas of high malarial chloroquino-resistance.

High Rate of Acquisition but Short Duration of Carriage of Multidrug-Resistant Enterobacteriaceae After Travel to the Tropics.

BACKGROUND: Multidrug-resistant Enterobacteriaceae (MRE) are widespread in the community, especially in tropical regions. Travelers are at risk of acquiring MRE in these regions, but the precise extent of the problem is not known. METHODS: From February 2012 to April 2013, travelers attending 6 international vaccination centers in the Paris area prior to traveling to tropical regions were asked to provide a fecal sample before and after their trip. Those found to have acquired MRE were asked to send fecal samples 1, 2, 3, 6, and 12 months after their return, or until MRE was no longer detected. The fecal relative abundance of MRE among all Enterobacteriaceae was determined in each carrier. RESULTS: Among 824 participating travelers, 574 provided fecal samples before and after travel and were not MRE carriers before departure. Of these, 292 (50.9%) acquired an average of 1.8 MRE. Three travelers (0.5%) acquired carbapenemase-producing Enterobacteriaceae. The acquisition rate was higher in Asia (142/196 [72.4%]) than in sub-Saharan Africa (93/195 [47.7%]) or Latin America (57/183 [31.1%]). MRE acquisition was associated with the type of travel, diarrhea, and exposure to ß-lactams during the travel. Three months after return, 4.7% of the travelers carried MRE. Carriage lasted longer in travelers returning from Asia and in travelers with a high relative abundance of MRE at return. CONCLUSIONS: MRE acquisition is very frequent among travelers to tropical regions. Travel to these regions should be considered a risk factor of MRE carriage during the first 3 months after return, but not beyond. CLINICAL TRIALS REGISTRATION: NCT01526187.

No booster dose for yellow fever vaccination: what are the consequences for the activity of vaccination in travel clinics?

In April 2013, the Strategic Advisory Group of Experts (SAGE) on immunization stated that a single dose of yellow fever (YF) vaccine is sufficient in the general population to confer a lifelong protection against YF. When the period of validity of the International Certificate of Vaccination (ICV) will be extended to a lifetime in June 2016, no booster dose will be needed. The objective of this prospective study was to determine the potential impact of the SAGE recommendations on the vaccination activity of our travel clinics. We showed that among 1,037 subjects seen in our three travel clinics for a YF vaccination in 2013, about 32.3% went for a booster dose that is no longer useful according to the SAGE. A drop in vaccination activity has to be expected by travel clinics in the next years, and changes in daily exercise have to be anticipated, as YF vaccination is a large part of the regular work of many healthcare providers specialized in travel medicine.

Bacterial pathogens associated with hidradenitis suppurativa, France.

Hidradenitis suppurativa (HS) is a skin disease characterized by recurrent nodules or abscesses and chronic suppurating lesions. In the absence of clear pathophysiology, HS is considered to be an inflammatory disease and has no satisfactory medical treatment. Recently, prolonged antimicrobial treatments were shown to improve or resolve HS lesions. We prospectively studied the microbiology of 102 HS lesions sampled from 82 patients using prolonged bacterial cultures and bacterial metagenomics on 6 samples. Staphylococcus lugdunensis was cultured as a unique or predominant isolate from 58% of HS nodules and abscesses, and a polymicrobial anaerobic microflora comprising strict anaerobes, milleri group streptococci, and actinomycetes was found in 24% of abscesses or nodules and in 87% of chronic suppurating lesions. These data show that bacteria known to cause soft tissue and skin infections are associated with HS lesions. Whether these pathogens are the cause of the lesions or are secondary infectious agents, these findings support targeted antimicrobial treatment of HS.

Prevention of infections during primary immunodeficiency.

Because infectious diseases are a major source of morbidity and mortality in the majority of patients with primary immunodeficiencies (PIDs), the application of a prophylactic regimen is often necessary. However, because of the variety of PIDs and pathogens involved, and because evidence is scarce, practices are heterogeneous. To homogenize practices among centers, the French National Reference Center for PIDs aimed at elaborating recommendations for anti-infectious prophylaxis for the most common PIDs. We performed a literature review of infectious complications and prophylactic regimens associated with the most frequent PIDs. Then, a working group including different specialists systematically debated about chemoprophylaxis, immunotherapy, immunization, and recommendations for patients. Grading of prophylaxis was done using strength of recommendations (decreasing from A to D) and evidence level (decreasing from I to III). These might help infectious diseases specialists in the management of PIDs and improving the outcome of patients with PIDs.