Zika among international travellers presenting to GeoSentinel sites, 2012-2019: implications for clinical practice.

INTRODUCTION: International travellers contribute to the rapid spread of Zika virus (ZIKV) and its sentinel identification globally. We describe ZIKV infections among international travellers seen at GeoSentinel sites with a focus on ZIKV acquired in the Americas and the Caribbean, describe countries of exposure and traveller characteristics, and assess ZIKV diagnostic testing by site. METHODS: Records with an international travel-related diagnosis of confirmed or probable ZIKV from January 2012 through December 2019 reported to GeoSentinel with a recorded illness onset date were included to show reported cases over time. Records from March 2016 through December 2019 with an exposure region of the Americas or the Caribbean were included in the descriptive analysis. A survey was conducted to assess the availability, accessibility and utilization of ZIKV diagnostic tests at GeoSentinel sites. RESULTS: GeoSentinel sites reported 525 ZIKV cases from 2012 through 2019. Between 2012 and 2014, eight cases were reported, and all were acquired in Asia or Oceania. After 2014, most cases were acquired in the Americas or the Caribbean, a large decline in ZIKV cases occurred in 2018-19.Between March 2016 and December 2019, 423 patients acquired ZIKV in the Americas or the Caribbean, peak reporting to these regions occurred in 2016 [330 cases (78%)]. The median age was 36 years (range: 3-92); 63% were female. The most frequent region of exposure was the Caribbean (60%). Thirteen travellers were pregnant during or after travel; one had a sexually acquired ZIKV infection. There was one case of fetal anomaly and two travellers with Guillain-Barré syndrome. GeoSentinel sites reported various challenges to diagnose ZIKV effectively. CONCLUSION: ZIKV should remain a consideration for travellers returning from areas with risk of ZIKV transmission. Travellers should discuss their travel plans with their healthcare providers to ensure ZIKV prevention measures are taken.

Traveller exposures to animals: a GeoSentinel analysis.

BACKGROUND: Human coexistence with other animals can result in both intentional and unintentional contact with a variety of mammalian and non-mammalian species. International travellers are at risk for such encounters; travellers risk injury, infection and possibly death from domestic and wild animal bites, scratches, licks and other exposures. The aim of the present analysis was to understand the diversity and distribution of animal-related exposures among international travellers. METHODS: Data from January 2007 through December 2018 from the GeoSentinel Surveillance Network were reviewed. Records were included if the exposure was non-migration travel with a diagnosis of an animal (dog, cat, monkey, snake or other) bite or other exposure (non-bite); records were excluded if the region of exposure was not ascertainable or if another, unrelated acute diagnosis was reported. RESULTS: A total of 6470 animal exposures (bite or non-bite) were included. The majority (71%) occurred in Asia. Travellers to 167 countries had at least one report of an animal bite or non-bite exposure. The majority (76%) involved dogs, monkeys and cats, although a wide range of wild and domestic species were involved. Almost two-thirds (62.6%) of 4395 travellers with information available did not report a pretravel consultation with a healthcare provider. CONCLUSIONS: Minimizing bites and other animal exposures requires education (particularly during pretravel consultations) and behavioral modification. These should be supplemented by the use of pre-exposure rabies vaccination for travellers to high-risk countries (especially to those with limited access to rabies immunoglobulin), as well as encouragement of timely (in-country) post-exposure prophylaxis for rabies and Macacine alphaherpesvirus 1 (herpesvirus B) when warranted.

Rabies post-exposure prophylaxis started during or after travel: A GeoSentinel analysis.

BACKGROUND: Recent studies demonstrate that rabies post-exposure prophylaxis (RPEP) in international travelers is suboptimal, with only 5-20% of travelers receiving rabies immune globulin (RIG) in the country of exposure when indicated. We hypothesized that travelers may not be receiving RIG appropriately, and practices may vary between countries. We aim to describe the characteristics of travelers who received RIG and/or RPEP during travel. METHODOLOGY/PRINCIPAL FINDINGS: We conducted a multi-center review of international travelers exposed to potentially rabid animals, collecting information on RPEP administration. Travelers who started RPEP before (Group A) and at (Group B) presentation to a GeoSentinel clinic during September 2014-July 2017 were included. We included 920 travelers who started RPEP. About two-thirds of Group A travelers with an indication for rabies immunoglobulin (RIG) did not receive it. Travelers exposed in Indonesia were less likely to receive RIG in the country of exposure (relative risk: 0.30; 95% confidence interval: 0.12-0.73; P = 0.01). Travelers exposed in Thailand [Relative risk (RR) 1.38, 95% Confidence Interval (95% CI): 1.0-1.8; P = 0.02], Sri Lanka (RR 3.99, 95% CI: 3.99-11.9; P = 0.013), and the Philippines (RR 19.95, 95% CI: 2.5-157.2; P = 0.01), were more likely to receive RIG in the country of exposure. CONCLUSIONS/SIGNIFICANCE: This analysis highlights gaps in early delivery of RIG to travelers and identifies specific countries where travelers may be more or less likely to receive RIG. More detailed country-level information helps inform risk education of international travelers regarding appropriate rabies prevention.

Illness among US resident student travellers after return to the USA: a GeoSentinel analysis, 2007-17.

Background: The number of US students studying abroad more than tripled during the past 20 years. As study abroad programmes' destinations diversify, students increasingly travel to resource-limited countries, placing them at risk for infectious diseases. Data describing infections acquired by US students while travelling internationally are limited. We describe illnesses among students who returned from international travel and suggest how to prevent illness among these travellers. Methods: GeoSentinel is a global surveillance network of travel and tropical medicine providers that monitors travel-related morbidity. This study included the records of US resident student international travellers, 17-24 years old, who returned to the USA, had a confirmed travel-related illness at one of 15 US GeoSentinel sites during 2007-17 and had a documented exposure region. Records were analysed to describe demographic and travel characteristics and diagnoses. Results: The study included 432 students. The median age was 21 years; 69% were female. More than 70% had a pre-travel consultation with a healthcare provider. The most common exposure region was sub-Saharan Africa (112; 26%). Students were most commonly exposed in India (44; 11%), Ecuador (28; 7%), Ghana (25; 6%) and China (24; 6%). The median duration of travel abroad was 40 days (range: 1-469) and presented to a GeoSentinel site a median of 8 days (range: 0-181) after travel; 98% were outpatients. Of 581 confirmed diagnoses, the most common diagnosis category was gastrointestinal (45%). Acute diarrhoea was the most common gastrointestinal diagnosis (113 of 261; 43%). Thirty-one (7%) students had vector-borne diseases [14 (41%) malaria and 11 (32%) dengue]. Three had vaccine-preventable diseases (two typhoid; one hepatitis A); two had acute human immunodeficiency virus infection. Conclusions: Students experienced travel-related infections, despite the majority having a pre-travel consultation. US students should receive pre-travel advice, vaccinations and chemoprophylaxis to prevent gastrointestinal, vector-borne, sexually transmitted and vaccine-preventable infections.

Business travel-associated illness: a GeoSentinel analysis.

Background: Analysis of a large cohort of business travelers will help clinicians focus on frequent and serious illnesses. We aimed to describe travel-related health problems in business travelers. Methods: GeoSentinel Surveillance Network consists of 64 travel and tropical medicine clinics in 29 countries; descriptive analysis was performed on ill business travelers, defined as persons traveling for work, evaluated after international travel 1 January 1997 through 31 December 2014. Results: Among 12 203 business travelers seen 1997-2014 (14 045 eligible diagnoses), the majority (97%) were adults aged 20-64 years; most (74%) reported from Western Europe or North America; two-thirds were male. Most (86%) were outpatients. Fewer than half (45%) reported a pre-travel healthcare encounter. Frequent regions of exposure were sub-Saharan Africa (37%), Southeast Asia (15%) and South Central Asia (14%). The most frequent diagnoses were malaria (9%), acute unspecified diarrhea (8%), viral syndrome (6%), acute bacterial diarrhea (5%) and chronic diarrhea (4%). Species was reported for 973 (90%) of 1079 patients with malaria, predominantly Plasmodium falciparum acquired in sub-Saharan Africa. Of 584 (54%) with malaria chemoprophylaxis information, 92% took none or incomplete courses. Thirteen deaths were reported, over half of which were due to malaria; others succumbed to pneumonia, typhoid fever, rabies, melioidosis and pyogenic abscess. Conclusions: Diarrheal illness was a major cause of morbidity. Malaria contributed substantial morbidity and mortality, particularly among business travelers to sub-Saharan Africa. Underuse or non-use of chemoprophylaxis contributed to malaria cases. Deaths in business travelers could be reduced by improving adherence to malaria chemoprophylaxis and targeted vaccination for vaccine-preventable diseases. Pre-travel advice is indicated for business travelers and is currently under-utilized and needs improvement.

Zika beyond the Americas: Travelers as sentinels of Zika virus transmission. A GeoSentinel analysis, 2012 to 2016.

BACKGROUND: Zika virus (ZIKV) was first isolated in Africa; decades later, caused large outbreaks in the Pacific, and is considered endemic in Asia. We aim to describe ZIKV disease epidemiology outside the Americas, the importance of travelers as sentinels of disease transmission, and discrepancies in travel advisories from major international health organizations. METHODS AND FINDINGS: This descriptive analysis using GeoSentinel Surveillance Network records involves sixty-four travel and tropical medicine clinics in 29 countries. Ill returned travelers with a confirmed or probable diagnosis of ZIKV disease acquired in Africa, Asia and the Pacific seen between 1 January 2012 and 31 December 2016 are included, and the frequencies of demographic, trip, and diagnostic characteristics described. ZIKV was acquired in Asia (18), the Pacific (10) and Africa (1). For five countries (Indonesia, Philippines, Thailand, Vietnam, Cameroon), GeoSentinel patients were sentinel markers of recent Zika activity. Additionally, the first confirmed ZIKV infection acquired in Kiribati was reported to GeoSentinel (2015), and a probable case was reported from Timor Leste (April 2016), representing the only case known to date. Review of Zika situation updates from major international health authorities for country risk classifications shows heterogeneity in ZIKV country travel advisories. CONCLUSIONS: Travelers are integral to the global spread of ZIKV, serving as sentinel markers of disease activity. Although GeoSentinel data are collected by specialized clinics and do not capture all imported cases, we show that surveillance of imported infections by returned travelers augments local surveillance system data regarding ZIKV epidemiology and can assist with risk categorization by international authorities. However, travel advisories are variable due to risk uncertainties.

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.

Rabies postexposure consultations in New Zealand from 1998 to 2012.

BACKGROUND: Rabies is an invariably fatal zoonotic viral disease. New Zealanders going abroad are largely unaware of the risk of contracting the disease. Prevention is the key to controlling the spread of this disease. METHODS: Data from 363 individuals presenting to New Zealand travel health clinics between 1998 and 2012 for post-travel consultations on potential rabies exposure were collated retrospectively. The data focused on traveler demographics, the country and nature of exposure, the purpose of travel, and pre-travel rabies awareness. RESULTS: The female-to-male ratio of subject travelers presenting was almost equal (1.1 : 1 ratio, respectively); the subjects were typically between 16 and 30 years (44.6%), tourists (64.5%), traveling less than 1 month (55.3%), and likely to have been exposed to animal contact in either Thailand (31.1%), China (13.2%), or Indonesia (12.3%). The animals to which they were exposed were usually dogs (59.5%) or monkeys (28.7%). Most potential exposures were penetrating (69.9%). Injury caused by the animal was more common in the lower limbs (50%) than in the upper limbs (43.4%); 89.4% of exposures were of World Health Organization (WHO) category III. Travelers were more likely to have received pre-travel rabies advice if they had been seen by a travel medicine specialist (96.1%) compared to a general practitioner (GP) (53.3%). Sixteen percent of travelers received rabies preexposure prophylaxis. Of the subjects who were managed following exposure, 79.7% did not receive immunoglobulin when indicated, and 21.5% did not receive any vaccine. Of the travelers that did receive a vaccine, 62.5% did so on the day of exposure. Of the travelers assessed, 16.7% had traveled without insurance. CONCLUSIONS: New Zealanders require better guidance in understanding the need for travel-related rabies vaccination, as they are not managed abroad according to WHO guidelines. Few travelers had had pre-travel immunization, and only 20.3% of them had received WHO-advised postexposure management. Thus, 79.7% of the cohort theoretically remained at risk for contracting rabies because of inappropriate management following possible exposure to the disease.

Illness and injury to students on a school excursion to Peru.

BACKGROUND: School-organized travels abroad provide an opportunity for students to undertake supervised travel that reinforces scholastic study of various geographical locations under the direction and protection of experienced tour leaders and health professional support. Little is known concerning the nature of illnesses and injuries occurring on overseas school excursions. This study was designed to investigate the prevalence of injury and illness suffered by older teenagers on a school excursion to South America. METHODS: In 2010, the school's tour physician (EH) diagnosed and recorded all illnesses and injuries among 29 school girls and 6 accompanying adults on a school excursion to Peru. Information recorded included age, sex, the nature of the presenting illness, number of days into the tour, the assessment of the condition, and the treatment employed during the excursion's field phase of 21 days. RESULTS: A total of 32 (91%) travelers sought medical advice at least once for a total of 371 consultations, resulting in 153 separate diagnoses. The mean age of the students was 16 years with six adults accompanying the students being significantly older. Primary illnesses diagnosed were related to the following systems and conditions: gastrointestinal (58, 37%), respiratory (25, 16%), altitude sickness (19, 12%), genitourinary (8, 5%), dermatological (10, 7%), trauma (7, 5%), neurological (7, 5%), anxiety or psychological adjustment (7, 5%), adverse drug reactions (4, 3%), and musculoskeletal (5, 3%). The most commonly used medications were antidiarrheal and antiemetic medication. There were six accidents during the journey resulting in minor soft-tissue injuries. There were no deaths or other major accidents requiring emergency evacuation or hospitalization. CONCLUSIONS: On this school excursion, the health problems encountered were consistent with those reported for other specialized tours, including expeditions and premium tours, although altitude illness needs to be carefully planned for in tours to higher elevation destinations as in South America. As well as being part of the service provided to the school students, the inclusion of a physician with appropriate medical supplies for this tour increased the independence of the travel group. A proposed medical kit for such an excursion is presented.

Travel-associated diseases, Indian Ocean Islands, 1997-2010.

Data collected by the GeoSentinel Surveillance Network for 1,415 ill travelers returning from Indian Ocean islands during 1997-2010 were analyzed. Malaria (from Comoros and Madagascar), acute nonparasitic diarrhea, and parasitoses were the most frequently diagnosed infectious diseases. An increase in arboviral diseases reflected the 2005 outbreak of chikungunya fever.

Travel-associated illness in older adults (>60 y).

BACKGROUND: Older individuals represent a substantial proportion of international travelers. Because of physiological changes and the increased probability of underlying medical conditions, older travelers might be at higher risk for at least some travel-associated diseases. METHODS: With the aim of describing the epidemiology of travel-associated diseases in older adults, medical data were prospectively collected on ill international travelers presenting to GeoSentinel sites from 1997 to 2009. Seven thousand thirty-four patients aged 60 years and over were identified as older travelers and were compared to 56,042 patients aged 18-45 years, who were used as the young adult reference population. RESULTS: The proportionate morbidity of several etiological diagnoses was higher in older ill travelers compared to younger ill, including notably lower respiratory tract infections, high-altitude pulmonary edema, phlebitis and pulmonary embolism, arthropod bites, severe malaria, rickettsiosis, gastritis, peptic ulcers, esophagitis and gastroesophageal reflux disease, trauma and injuries, urinary tract infections, heart disease, and death. In contrast, acute diarrhea, upper respiratory tract infections, flu and flu-like illnesses, malaria, dengue, genital infections, sexually transmitted diseases, and schistosomiasis proportionate morbidities were lower among the older group. CONCLUSION: Older ill travelers are more likely to suffer from certain life-threatening diseases and would benefit from reinforcement of specific preventive measures including use of anti-thrombosis compression stockings and sufficient hydration and exercises during long-distance flights, hand hygiene, use of disposable handkerchiefs, consideration of face-masks in crowded conditions, influenza and pneumococcal vaccines, progressive acclimatization to altitude, consideration of acetazolamide, and use of repellents and mosquito nets. Antibiotics for the presumptive treatment of respiratory and urinary tract infections may be considered, as well as antacid medications. At-risk patients should be referred to a specialist for medical evaluation before departing, and optimal control of co-morbidities such as cardiovascular and chronic obstructive pulmonary diseases should be achieved, particularly for high-altitude travel.

Professional organisation profile: a faculty of expedition and wilderness medicine for Australasia.

A profile of the recent genesis of the Sub-Faculty of Expedition Medicine into a Faculty of Expedition and Wilderness Medicine of The Australasian College of Tropical Medicine is presented. Information is given on aims, structure, professional grades of membership, and the various activities of the Faculty, including publications and scientific meetings.

Plasmodium knowlesi in a traveller returning to New Zealand.

The recent discovery that Plasmodium knowlesi causes malaria in human populations, established it as the fifth species of plasmodium that may do so. A case of P. knowlesi malaria is described in a helicopter pilot from New Zealand, who became ill after returning from recurring visits to Malaysian Borneo in June 2010. His P. knowlesi infection was not detected using microscopic examination and a rapid diagnostic test for malaria, but was confirmed by both PCR (polymerase chain reaction) and sequence analysis showing homology with the ribosomal RNA gene for P. knowlesi. He responded rapidly to treatment with artemether & lumefantrine combination. The evolution of a rapid diagnostic kit to diagnose P. knowlesi is needed, for early identification and appropriate anti-malarial therapy of suspect cases are both critical in the prevention of the potentially life-threatening disease through P. knowlesi. Clinicians need to consider knowlesi infection in the differential diagnosis in recent-onset febrile travellers to areas of forestation in Southeast Asia.

Travelling to India for the Delhi XIX Commonwealth Games 2010.

The 19th Commonwealth Games, conducted once in every four years since 1930, will be held in New Delhi from the 3rd through until the 14th of October, 2010. There will be approximately 17 sports on display and there will also be 15 para-sporting events. This paper focuses on health and safety issues for travellers to India in general, although it provides specific references to advice for visiting Commonwealth Games athletes and team staff, who will be travelling to the games. Whilst it needs be remembered that travel health advice can change, travellers are advised to seek up-to-date travel health advice for India, from their professional providers, closer to their departure.

Professional organisation profile: a sub-Faculty of expedition medicine for Australasia.

A review of the recent foundation by The Australasian College of Tropical Medicine of the Sub-Faculty of Expedition Medicine is presented. Information is given on aims, professional grades of membership, and the various activities of the Sub-Faculty, including publications and scientific meetings.

Illness and injury to travellers on a premium seniors' tour to Indochina.

BACKGROUND: Commercial expeditions and upmarket tours provide an opportunity for travellers to undertake various specialised travel to more adventurous and extreme destinations often in the relative security of accompanying medical cover provided by an expedition physician. There is limited knowledge of the nature of illnesses and injuries occurring on premium seniors' tours to Asia. This present study was designed to investigate the prevalence of injury and illness suffered by travellers on a premium tour to Indochina. METHODS: In 2004, the tour expedition physician (MTMS) diagnosed and recorded all illnesses and injuries amongst 23 travellers on a premium seniors' tour to Viet Nam and Cambodia. Information recorded included age, sex, number of days into the tour, the nature of the presenting illness, the assessment of the condition and the treatment employed during the field phase of 14 days. Travel was by air, train and coach, for a total period of 18 days. RESULTS: Nineteen (82%) travellers sought medical advice at least once for a total of 35 consultations. Females presented on 66% of occasions. The mean age of the travellers was 62 years (SD=13) with males being significantly older (p=0.002). Primary illnesses diagnosed related to the following systems: gastrointestinal 29%, respiratory 14%, dermatological 14%, cardiovascular 14%, musculoskeletal 9%, central nervous system 6%, ear/nose/throat 6%, dental 6%, and other problems on 3% of occasions. Of the gastrointestinal problems, diarrhoea was the commonest complaint on 17% of occasions, occurring at any stage throughout the journey. There was a mean of 2.5 presentations per day of the field phase of the tour. Presentations were highest on day 12. More than one third of presentations (37%) were handled conservatively without any further need for therapy, 17% requiring dressings, and 46% requiring specific medications. The commonest medications used were: lozenges/gargles (31%), antiemetic (25%), anti-diarrhoeal or other medications (13%). There were six accidents during the journey resulting in minor soft tissue injuries. There were no deaths or other major accidents requiring emergency evacuation or hospitalisation. CONCLUSIONS: On this premium seniors' tour, the health problems encountered were largely similar to those reported for other specialised tours, including premium expeditions. The most common medical problems included gastrointestinal, respiratory, dermatological, cardiovascular and musculoskeletal conditions in descending order. One aspect requiring further study is the psychological adjustments made by travellers on group tours and expeditions. As well as being part of the service provided to travellers, the inclusion of an expedition physician on this premium seniors' tour increased the independence of the travel group on this journey.

Illness and injury to travelers and access to dental care on a research expedition to Mongolia.

BACKGROUND: Expeditions provide an opportunity for travelers to undertake specialized travel to more extreme destinations in the security of an expeditionary group with medical coverage. Little is known about the illnesses and injuries occurring to expeditioners in Mongolia or access to dental care in the local population. This study was designed to investigate the prevalence of health problems suffered by travelers and managed among the local population on a research expedition to Mongolia. METHODS: In June 2005, the expedition physician (MTMS) and dentist (DD) prospectively diagnosed and recorded all illnesses and injuries among 16 travelers (eight males and eight females) as well as any indigenous people on a 22-day paleontological expedition to the Mongolian Gobi Desert. RESULTS: There were 53 health presentations and 14 dental problems among the indigenous population and the Mongolian escort. Males and females presented in equal proportions with the average age of 49 years (SD = 16). Presentations involved locomotor/accident (32%), dermatological (23%), gastrointestinal (19%), neurological (17%), psychological (6%), and with other systems (11%). Most accidents were due to lacerations (85%). Presentations were highest on days 4 and 5 (10% or 18%). Females were significantly more likely to present later in the expedition (p= 0.013). One quarter (25%) were handled conservatively with 28% requiring topical treatments with others requiring antiemetics (9%) and anti-inflammatory drugs (4%). There were no dental concerns reported among the expeditioners, although there were 14 cases among the indigenous population. While there were no deaths on the expedition, there were two major incidents, one of which required emergency evacuation. CONCLUSIONS: The health problems encountered were largely similar to those reported for other expeditions. The most common problems included trauma as well as dermatological, dental, gastrointestinal, and neurological conditions. It is important that expedition teams are prepared to manage common problems, such as trauma and dental lesions.

Rabies postexposure management of travelers presenting to travel health clinics in Auckland and Hamilton, New Zealand.

BACKGROUND: Rabies is a fatal disease, and travelers going to endemic areas need to take precautions. Little is known about the rabies postexposure management of travelers from New Zealand. METHODS: A total of 459 post-travel records from October 1998 until February 2006 at two travel medicine clinics, in Auckland and Hamilton, were examined for those who reported postexposure management to animals while abroad. RESULTS: Fifty-four patients were included, 48 (88.9%) were New Zealand residents and 52.0% were male. The mean age of exposed travelers was 30.4 years (SD = 15.5). There was an adult to child ratio of 5:1. The highest exposure risk group was those aged 16 to 30 years. South and Southeast Asia were the most prominent geographical regions where exposure occurred, with 45 (83.3%) of subjects being potentially exposed to rabies. Dogs were the commonest animals involved, accounting for two thirds of incidents (36; 66.7%). The commonest sites of animal exposure on the body were the thigh and lower leg (26; 48.1%) and the hand (10; 18.5%). Forty-six (85.2%) of the animal exposures were graded as World Health Organization (WHO) category III. Forty-nine (90.7%) of the travelers had not had preexposure prophylaxis. Once in New Zealand, the correct WHO postexposure prophylaxis regime was applied on 44 of 52 (84.6%) occasions. However, overall, only 25% of the sample received postexposure treatment consistent with WHO guidelines, reflecting inappropriate management abroad. CONCLUSIONS: Post-travel consultations at two New Zealand travel clinics were analyzed for prophylactic rabies postexposure management. The majority were travelers aged 16 to 30 years, who sustained WHO category III exposures to the lower limb in Asia, predominantly from dogs. Few of these travelers had been immunized prior to travel, and only 25% of them received postexposure prophylaxis consistent with WHO guidelines. Thus, 75% of the study sample remains at theoretical risk of contracting rabies due to inappropriate management overseas.