Animal-associated exposure to rabies virus among travelers, 1997-2012.

Among travelers, rabies cases are rare, but animal bites are relatively common. To determine which travelers are at highest risk for rabies, we studied 2,697 travelers receiving care for animal-related exposures and requiring rabies postexposure prophylaxis at GeoSentinel clinics during 1997-2012. No specific demographic characteristics differentiated these travelers from other travelers seeking medical care, making it challenging to identify travelers who might benefit from reinforced pretravel rabies prevention counseling. Median travel duration was short for these travelers: 15 days for those seeking care after completion of travel and 20 days for those seeking care during travel. This finding contradicts the view that preexposure rabies vaccine recommendations should be partly based on longer travel durations. Over half of exposures occurred in Thailand, Indonesia, Nepal, China, and India. International travelers to rabies-endemic regions, particularly Asia, should be informed about potential rabies exposure and benefits of pretravel vaccination, regardless of demographics or length of stay.

How Prolific is Psychotropic Medicines Use in People with Dementia in Australia Within the Community Setting? A Retrospective Analysis.

BACKGROUND: When used for a therapeutic purpose such as for psychiatric illness, psychotropic drugs may enhance quality of life; however, when used to treat behaviours associated with dementia, they may have only a modest effect but lead to negative outcomes. OBJECTIVE: We undertook an analysis of community-dwelling people with dementia or cognitive impairment to ascertain how prolific psychotropic medicine use is within the Australian community setting, which psychotropic medicines are being prescribed and to whom, and whether the use of such medicines is in accordance with therapeutic guidelines. METHODS: We undertook a retrospective review of medication records, including medication charts, for 412 people with cognitive impairment, discharged from a home nursing service in Victoria, Australia, during the 6-month period between 1 January and 30 June 2013. RESULTS: Cholinesterase inhibitor use exceeded the number of individuals with a recorded diagnosis of Alzheimer's disease; in some cases, the dosage exceeded recommendations. Antidepressants were used by more than double the number of people documented with a history of depression. Antipsychotic medicines were prescribed for undocumented purposes, in some cases above maximum response levels, and multiple benzodiazepines were prescribed. CONCLUSIONS: Psychotropic medicine use was common in our study population, and use of these medicines was often not in line with therapeutic guidelines. Further research is required to ascertain reasons for the high use of psychotropic medicines in this group, and greater consideration is required by health professionals of the appropriate use and regular review of psychotropic medicines. Improved documentation of diagnoses and the indications for prescribing psychotropic medicines is needed, as is greater implementation of educational programmes to support care workers and carers.

Dengue among American missionaries returning from Jamaica, 2012.

Dengue is an acute febrile illness caused by any of four mosquito-transmitted dengue virus (DENV) types. Dengue is endemic in Jamaica, where an epidemic occurred in 2012. An investigation was conducted by multiple agencies for 66 missionaries traveling from nine US states to Jamaica after 1 missionary from the group was confirmed to have dengue. Travelers were offered diagnostic testing, and a survey was administered to assess knowledge, behaviors, and illness. Of 42 survey respondents, 9 (21%) respondents reported an acute febrile illness during or after travel to Jamaica. Of 15 travelers that provided serum specimens, 4 (27%) travelers had detectable anti-DENV immunoglobulin M antibody, and 1 traveler also had DENV-1 detected by reverse transcriptase polymerase chain reaction. Recent or past infection with a DENV was evident in 93% (13 of 14) missionaries with available sera. No behavioral or demographic factors were significantly associated with DENV infection. This investigation shows that even trips of short duration to endemic areas present a risk of acquiring dengue.

Health and safety issues for travelers attending the World Cup and Summer Olympic and Paralympic Games in Brazil, 2014 to 2016.

IMPORTANCE: Travelers from around the globe will attend the 2014 Fédération Internationale de Football Association (FIFA) World Cup and the 2016 Olympic and Paralympic Games in Brazil. Travelers to these mass gathering events may be exposed to a range of health risks, including a variety of infectious diseases. Most travelers who become ill will present to their primary care physicians, and thus it is important that clinicians are aware of the risks their patients encountered. OBJECTIVE: To highlight health and safety concerns for people traveling to these events in Brazil so that health care practitioners can better prepare travelers before they travel and more effectively diagnose and treat travelers after they return. EVIDENCE REVIEW: We reviewed both peer-reviewed and gray literature to identify health outcomes associated with travel to Brazil and mass gatherings. Thirteen specific infectious diseases are described in terms of signs, symptoms, and treatment. Relevant safety and security concerns are also discussed. FINDINGS: Travelers to Brazil for mass gathering events face unique health risks associated with their travel. CONCLUSIONS AND RELEVANCE: Travelers should consult a health care practitioner 4 to 6 weeks before travel to Brazil and seek up-to-date information regarding their specific itineraries. For the most up-to-date information, health care practitioners can visit the Centers for Disease Control and Prevention (CDC) Travelers' Health website (http://wwwnc.cdc.gov/travel) or review CDC's Yellow Book online (http://wwwnc.cdc.gov/travel/page/yellowbook-home-2014).

Possible rabies exposures in Peace Corps volunteers, 2011.

We surveyed Peace Corps Medical Officers (PCMOs) to determine the frequency of and responses to possible rabies exposures of U.S. Peace Corps volunteers (PCVs). Surveys were sent to 56 PCMOs serving in countries with moderate or high rabies vaccine recommendations from the U.S. Centers for Disease Control and Prevention (CDC), of which 38 (68%) responded. Thirty-seven PCMOs reported that, of 4,982 PCVs, 140 (3%) experienced possible rabies exposures. Of these, 125 (89%) had previously received rabies vaccination, 129 (92%) presented with adequately cleansed wounds, and 106 (76%) were deemed to require and were given post-exposure prophylaxis (PEP). Of 35 respondents, 30 (86%) reported that rabies vaccine was always accessible to PCVs in their country within 24 hours. Overall, the Peace Corps is successful at preventing and treating possible rabies exposures. However, this study identified a few gaps in policy implementation. The Peace Corps should continue and strengthen efforts to provide education, preexposure vaccination, and PEP to PCVs.

Surveillance for travel-related disease--GeoSentinel Surveillance System, United States, 1997-2011.

PROBLEM/CONDITION: In 2012, the number of international tourist arrivals worldwide was projected to reach a new high of 1 billion arrivals, a 48% increase from 674 million arrivals in 2000. International travel also is increasing among U.S. residents. In 2009, U.S. residents made approximately 61 million trips outside the country, a 5% increase from 1999. Travel-related morbidity can occur during or after travel. Worldwide, 8% of travelers from industrialized to developing countries report becoming ill enough to seek health care during or after travel. Travelers have contributed to the global spread of infectious diseases, including novel and emerging pathogens. Therefore, surveillance of travel-related morbidity is an essential component of global public health surveillance and will be of greater importance as international travel increases worldwide. REPORTING PERIOD: September 1997-December 2011. DESCRIPTION OF SYSTEM: GeoSentinel is a clinic-based global surveillance system that tracks infectious diseases and other adverse health outcomes in returned travelers, foreign visitors, and immigrants. GeoSentinel comprises 54 travel/tropical medicine clinics worldwide that electronically submit demographic, travel, and clinical diagnosis data for all patients evaluated for an illness or other health condition that is presumed to be related to international travel. Clinical information is collected by physicians with expertise or experience in travel/tropical medicine. Data collected at all sites are entered electronically into a database, which is housed at and maintained by CDC. The GeoSentinel network membership program comprises 235 additional clinics in 40 countries on six continents. Although these network members do not report surveillance data systematically, they can report unusual or concerning diagnoses in travelers and might be asked to perform enhanced surveillance in response to specific health events or concerns. RESULTS: During September 1997-December 2011, data were collected on 141,789 patients with confirmed or probable travel-related diagnoses. Of these, 23,006 (16%) patients were evaluated in the United States, 10,032 (44%) of whom were evaluated after returning from travel outside of the United States (i.e., after-travel patients). Of the 10,032 after-travel patients, 4,977 (50%) were female, 4,856 (48%) were male, and 199 (2%) did not report sex; the median age was 34 years. Most were evaluated in outpatient settings (84%), were born in the United States (76%), and reported current U.S. residence (99%). The most common reasons for travel were tourism (38%), missionary/volunteer/research/aid work (24%), visiting friends and relatives (17%), and business (15%). The most common regions of exposure were Sub-Saharan Africa (23%), Central America (15%), and South America (12%). Fewer than half (44%) reported having had a pretravel visit with a health-care provider. Of the 13,059 diagnoses among the 10,032 after-travel patients, the most common diagnoses were acute unspecified diarrhea (8%), acute bacterial diarrhea (5%), postinfectious irritable bowel syndrome (5%), giardiasis (3%), and chronic unknown diarrhea (3%). The most common diagnostic groupings were acute diarrhea (22%), nondiarrheal gastrointestinal (15%), febrile/systemic illness (14%), and dermatologic (12%). Among 1,802 patients with febrile/systemic illness diagnoses, the most common diagnosis was Plasmodium falciparum malaria (19%). The rapid communication component of the GeoSentinel network has allowed prompt responses to important health events affecting travelers; during 2010 and 2011, the notification capability of the GeoSentinel network was used in the identification and public health response to East African trypanosomiasis in Eastern Zambia and North Central Zimbabwe, P. vivax malaria in Greece, and muscular sarcocystosis on Tioman Island, Malaysia. INTERPRETATION: The GeoSentinel Global Surveillance System is the largest repository of provider-based data on travel-related illness. Among ill travelers evaluated in U.S. GeoSentinel sites after returning from international travel, gastrointestinal diagnoses were most frequent, suggesting that U.S. travelers might be exposed to unsafe food and water while traveling internationally. The most common febrile/systemic diagnosis was P. falciparum malaria, suggesting that some U.S. travelers to malarial areas are not receiving or using proper malaria chemoprophylaxis or mosquito-bite avoidance measures. The finding that fewer than half of all patients reported having made a pretravel visit with a health-care provider indicates that a substantial portion of U.S. travelers might not be following CDC travelers' health recommendations for international travel. PUBLIC HEALTH ACTION: GeoSentinel surveillance data have helped researchers define an evidence base for travel medicine that has informed travelers' health guidelines and the medical evaluation of ill international travelers. These data suggest that persons traveling internationally from the United States to developing countries remain at risk for illness. Health-care providers should help prepare travelers properly for safe travel and provide destination-specific medical evaluation of returning ill travelers. Training for health-care providers should focus on preventing and treating a variety of travel-related conditions, particularly traveler's diarrhea and malaria.

It is possible: availability of lymphedema case management in each health facility in Togo. Program description, evaluation, and lessons learned.

Lymphatic filariasis (LF) is a vector-borne parasitic disease that can clinically manifest as disabling lymphedema. Although the LF elimination program aims to reduce disability and to interrupt transmission, there has been a scarcity of disease morbidity management programs, particularly on a national scale. This report describes the implementation of the first nationwide LF lymphedema management program. The program, which was initiated in Togo in 2007, focuses on patient behavioral change. Its goal is two-fold: to achieve a sustainable program on a national-scale, and to serve as a model for other countries. The program has five major components: 1) train at least one health staff in lymphedema care in each health facility in Togo; 2) inform people with a swollen leg that care is available at their dispensary; 3) train patients on self-care; 4) provide a support system to motivate patients to continue self-care by training community health workers or family members and providing in home follow-up; and 5) integrate lymphedema management into the curriculum for medical staff. The program achieved the inclusion of lymphedema management in the routine healthcare package. The evaluation after three years estimated that 79% of persons with a swollen leg in Togo were enrolled in the program. The adherence rate to the proposed World Health Organization treatment of washing, exercise, and leg elevation was more than 70% after three years of the program, resulting in a stabilization of the lymphedema stage and a slight decrease in reported acute attacks among program participants. Health staff and patients consider the program successful in reaching and educating the patients. After the external funding ended, the morbidity management program is maintained through routine Ministry of Health activities.