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The Swiss Expert Committee on Travel Medicine (ECTM) - a body of the Swiss Society of Tropical Medicine and Travel Medicine (FMH) - publishes recommendations and information on travel medicine on the website www.healthytravel.ch in four languages (German, French, Italian, English). HealthyTravel.ch, which has replaced Safetravel.ch, is the reference website for travelers' health advice in Switzerland supported by the Federal Office of Public Health (FOPH). It consists of a free version with basic travel medicine recommendations for the public, and a fee-based PRO version for professionals, containing more detailed information and recommendations. This article provides an overview of the available content and tips on how to make the best use of www.healthytravel.ch., Competing Interests: Les auteurs de cet article font partie du Comité suisse d’experts en médecine des voyages (CEMV) et sont co-auteurs du contenu de HealthyTravel.ch.

Undoubtedly, the COVID-19 pandemic has had impacts in many areas, including travel and by extension on daily practice in tropical and travel medicine. The intercontinental travelers in decline have been replaced by a new population of travelers who previously did not require specific consultations. SARS-CoV-2 has earned its place in the pre-travel consultation in view of the medical and administrative implications. Furthermore, the global health effects of the pandemic are broader than its direct medical consequences and should not be underestimated. The increase in malaria mortality worldwide is just one example. Preventive measures prior to exposure are more important than ever., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

Hepatic cystic echinococcosis (HCE), is a cosmopolitan parasitic zoonosis. Autochtonous HCE cases are rare and the majority of cases are imported from endemic areas. It induces the development in the liver of Echinococcus granulosus larvae. Extrahepatic localizations are also possible. Cyst development is slow with an often-late diagnosis. In Switzerland, HCE discovery is usually fortuitous, during an abdominal radiological examination. More rarely, an acute clinical picture reveals a complication that can be severe or even fatal. The diagnosis is based on ultrasound findings that allows cyst characterization according to the WHO classification. This guides the therapeutic choice: simple monitoring, albendazole therapy, percutaneous procedures or surgery., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

What is the status of travel medicine in the context of the COVID-19 pandemic? This article describes the evolution of travel medicine consultations at the University Hospital of Geneva with the introduction of pre-travel screening for the SARS-CoV-2 virus. 9141 travelers were screened between August 2020 and January 2021 for various destinations, one third of which were intra-European. The various international restrictions led to the creation of thirteen separate medical certificates and a list of requirements for 150 countries updated weekly. A significant increase in positivity (up to 5%) in the asymptomatic traveler was associated with the months of October and November 2020 and with certain destinations. This rate of positivity in the asymptomatic traveler population could be a sentinel indicator of viral transmission in the community., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

Before a trip, a screening for SARS-CoV-2 infection by RT-PCR is often required and raises the problem of detection of residual viral RNA at distance from the acute infection (post-Covid). At the University Hospital of Geneva, we developed an expertise to distinguish acute from post-Covid infections. Between October and December 2020, 30% of the people tested positive were able to travel because the result corresponded to post-Covid and 65% were put in isolation because of an acute infection with a risk of transmission. To overcome the detection of residual viral RNA by RT-PCR, a rapid antigenic test would be an interesting and less expensive alternative. It could also be performed a few hours before departure., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec l’article.

Humanitarian work is stressful and can have an impact on the mental health of humanitarian expatriates. In order to reduce stress and its consequences, humanitarian organizations are implementing various measures to keep their staff healthy. Humanitarian workers, on the other hand, must take care of themselves and apply self-protection mechanisms. Most humanitarian workers are doing well. The treating doctor plays a key role in detecting people and behavior at risk. He/she encourages the expatriate to use his/her resources and provide the adequate support and medical follow-up if necessary. Collaboration with the staff health units of humanitarian organizations allows for optimal care of humanitarian workers' medical conditions., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

As part of the epidemiological surveillance of malaria, cases reported in Geneva during the period 2005‑2016 were analyzed and compared to a similar retrospective study covering the period 1998‑2004. A total of 600 cases were reported, averaging 50 cases per year. African patients traveling to visit friends and relatives remain at particular risk. The disease was acquired in Africa in 89,6% of cases and Plasmodium falciparum was the predominant species (84,2 %). 41% of patients did not benefit from a pre-travel consultation. The recent rise in imported malaria observed in Geneva since 2014 is a reminder of the need to apply effective prevention measures (chemoprophylaxis) in highly endemic countries, and to train all physicians to screen for malaria all febrile travelers returning from the tropics., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

Zika virus suddenly emerged in Latin America in 2015‑2016. Congenital malformations have been observed in infected pregnant women, causing a major public health impact in affected countries, particularly in Brazil. In addition, sexual transmission of Zika virus has been well documented. This led to the development of prevention strategies and recommendations for travellers visiting at risk countries. These documents are regularly amended depending on the evolution of scientific knowledge, the epidemiologic trends and the national and international guidelines. Through practical cases, we present here the guidelines developed by the Geneva University Hospitals.

Since 2007, the incidence and mortality of malaria caused by Plasmodium falciparum have declined. However, this trend has not been seen with Plasmodium vivax which has biological features. Severe vivax malaria is increasingly reported in endemic countries even though P. vivax has been thought of as a benign disease. Diagnosis is challenging: the usual rapid diagnostic tests are less sensitive in detecting P. vivax and there is no test for the detection of the dormant forms (hypnozoites). The treatment of the acute phase is an artemisinin based combination, e.g. artemetherlumefantrine. Primaquine, which is the only currently available treatment against hypnozoites for the prevention of relapses, may trigger acute haemolytic anaemia in individuals with G6PD deficiency.

Children increasingly travel to the tropics. Compared with adults, the risks of severe malaria, dehydration due to diarrhea, and the number of infectious episodes, are higher. Paradoxically, children receive less pre-travel advice than adults, and some parents are opposed to vaccinations. The consultation must target essential prevention topics. We present the age-related schedules for immunizations against yellow and typhoid fevers, hepatitis A and B, tick-borne and Japanese encephalitis, and rabies. We discuss the preventive measures for malaria, accidents, altitude, and prescriptions for antimalarial drugs, rehydration solutions and standby antibiotics according to weight.

People living with HIV (PLHIV) frequently travel, including to the tropics, with a variable risk of infection by one of the species of Plasmodium, the hemoprotozoan parasite responsible for malaria. The HIV-malaria co-infection increases the risk of severe malaria, in proportion to the degree of immunosuppression. Protective measures against mosquito bites and antimalarial drug prophylaxis are recommended for PLHIV travelling to malaria highly endemic areas. PLHIV, as compared to the general population, are less likely to attend a pre-travel consultation prior to departure. Among returning travelers with malaria, early diagnosis and artemisinin-based treatments are the main determinants of successful treatment outcome.

Arboviral diseases transmitted by mosquitoes such as Dengue, Chikungunya and West Nile are global health issues of growing magnitude. Their dissemination in new areas is triggered by increased mobility of persons, animal reservoirs and vectors. This article describes virological, epidemiological and clinical aspects of Chikungunya, which causes sporadic cases or epidemics, sometimes massive, such as the one spreading in the Americas since December 2013. Chikungunya should be suspected in all travellers presenting with fever, arthralgia and sometimes a rash returning from an endemic area. In the absence of vaccine, individual protection relies on the prevention of mosquito bites.

Thanks to improved health and transport means, an increasing number of elderly people travel. This population shows characteristics that necessitate adaptations of the pre-travel consultation. Travel-associated diseases are related to the presence of pre-existing underlying conditions. Indeed, a healthy elderly traveller does not have more risk to get sick during travel than a younger traveller. However, the frequency and severity of complications of some travel-related diseases are increased. The aim of the pre-travel consultation in elderly will not be restrained to the usual prevention advices and immunization, but will also evaluate the risks of decompensation of pre-existing comorbidities, adapt if necessary ongoing medications to the conditions of travel, and plan access to care in case of acute decompensation.

Travels, migration and circulation of goods facilitate the emergence of new infectious diseases often unrecognized outside endemic areas. Most of emerging infections are of viral origin. Muscular Sarcocystis infection, an acute illness acquired during short trips to Malaysia, and Chagas disease, a chronic illness with long incubation period found among Latin American migrants, are two very different examples of emerging parasitic diseases. The former requires a preventive approach for travelers going to Malaysia and must be brought forth when they return with fever, myalgia and eosinophilia, while the latter requires a proactive attitude to screen Latin American migrant populations that may face difficulties in accessing care.

Cutaneous leishmaniasis is a parasitic disease that causes various clinical features depending on the infecting Leishmania species and the host immune response. Transmission occurs through the bite of an infected sand fly (subfamily of Phlebotominae). Leishmaniasis must be part of the differential diagnosis of persistent cutaneous lesions in travellers returning from an endemic area. The disease is most frequently characterized by one or more ulcerative lesions, which are predominant on the exposed parts of the body. The diagnosis is confirmed by microscopical observation of the parasite on a scraping or biopsy of the lesion, or by PCR, the latter allowing an identification of the Leishmania species. Treatment is dependent on the clinical presentation, the species of Leishmania and the comorbidities of the patient.

The incidence of alveolar echinococcosis in Switzerland is on the rise, probably due to the proliferation of foxes observed between 1980 and 1995 in both urban and rural areas. This is nevertheless a rare disease as humans are not a natural host for the parasite. Hepatic tumor-like lesions discovered during a workup for jaundice or abdominal pain is the most frequent mode of presentation. In the presence of typical radiological features (echography, CT-Scan, MRI), diagnostic confirmation can be made by serology. If diagnosis remains doubtful, a biopsy of the lesion with histopathological examination and PCR is indicated. Curative radical surgery is possible in only 25 to 35% of cases. In non-operable cases, long standing antiparasitic therapy allows to stop the progression of lesions.

The use of PCR-based molecular diagnosis in travel medicine remains limited to specific indications such as clinical suspicion of some of the viral hemorrhagic fevers (e.g. Ebola, Marburg), differential diagnosis between Entamoeba histolytica (pathogen) and E. dispar (non pathogen) in the stools, and parasitological diagnosis of cutaneous leishmaniasis. The scope of indications is likely to expand in the coming years with the development of techniques (e.g. multiplex PCR) able to identify several pathogens from a single sample. Simplification and cost-reduction of molecular techniques, which would allow for more equitable access to these diagnostic tools in countries where the targeted diseases are highly prevalent, pose major technological and ethical challenges.

Chagas disease, or American trypanosomiasis, is a parasitic infection endemic in Latin America. The late onset chronic complications can be fatal. Several cases have been recently diagnosed in Switzerland, where systematic screening of groups at risk should be implemented. Considering the variable transmission patterns, screening strategies should be adapted to the different groups at risk. As the vast majority of persons at risk belong to marginalized communities with limited access to care, systematic screening and treatment of infected individuals represent a major challenge in order to interrupt the congenital transmission and improve the long-term prognosis.

Hijacking, crime, aggression and theaft when people travel abroad are regularly reported by the media. This increases travellers' fears. As there is little research that quantifies risks, subjectivity and preconceived ideas prevail. A survey done among travellers in Geneva, Lausanne and Lyon showed that the risk of incidents was lower in countries located outside of Europe, usually in cities. Most frequently it was baggage stealing, or stealing in the street, during the day. In Europe, stealing by breaking into cars was most frequent. Without becoming paranoid about aggression and burglary, some simple rules can be followed. Keep constant situational awareness, be respectful of the people in countries visited, avoid provocative attitudes and avoid insecure areas.

Travellers' diarrhoea represents the most frequent health problem when travelling in developing countries. In most cases it is a self-limited disease. Nonetheless it can cause incapacitation and significant morbidity. It can become persistent in up to 3% of travellers who have suffered from acute diarrhoea in regions at high risk. This article discusses the investigations and the management of diarrhoea in returning travellers, preventive measures and its management during travel.

Intestinal parasites represent an important burden of disease mainly in developing countries. Physicians practicing in Europe can be exposed to these diseases, mainly seen in immigrants or travellers returning from tropical countries. Several parasitic diseases remain ubiquitous and can be contracted in developed countries. Most often, parasitic infections cause no or only few symptoms, but some can lead to serious disease in immuno-compromised patients. Diagnostic procedures and treatments available are discussed.

Japanese encephalitis is the primary cause of viral encephalitis in Asia where it is annually responsible for the death of around 20,000 people. The virus is transmitted by night-biting mosquitoes in wet rural areas. The classical clinical presentation includes fever, paresis, decreased level of consciousness and convulsions. There is no efficient anti-viral treatment available. Avoidance of mosquito bites and vaccination are the only effective measures to prevent the disease. Vaccination is recommended for travellers and expatriates who will stay in rural endemic areas for at least one month during the rainy season. The vaccine is contra-indicated in individuals with a previous history of severe allergic reaction.

The consumption of dishes made from raw fresh- or see-water fishes exposes many individuals (residents, visitors or migrants) from tropical to arctic regions to the risk of helminthiasis. Anisakiasis, diphyllobothriasis, clonorchiasis, opistorchiasis and gnathostomiasis have distinct parasitic cycles and various clinical presentations, from sub-clinical infections to life-threatening hemorragic or tumoral complications. In-depth history, clinical presentation, stool examination for ova and parasites and serology usually allow for a specific diagnosis to be made. The common anti-parasitic drugs, such as albendazole, ivermectin and praziquantel, are efficacious against most of these helminthiasis. Sufficient cooking or freezing of fishes before consumption are very efficient preventive measures.

Epidemiological surveillance of malaria cases reported in Geneva between 1998 and 2004 is analysed and compared to a similar retrospective study conducted in 1988-1994. A total of 426 cases have been reported, with a mean of 61 cases per year and an increase of 29,4% compared to the initial study. Most of the increase was seen in patients of African origin, from 115 to 170 cases, of whom 56% visited friends and relatives. Malaria was acquired predominantly in sub-Saharan Africa (88,5%), mainly West and Central Africa. P. falciparum was the predominant species (75,3%), with significant seasonality during the summer and in January. This was not the case for other species. Two third of cases did not take any chemoprophylaxis. These results stress the importance of the disease and the need for adequate protection of travellers.

Travelling when pregnant? possible, but... Travelling when pregnant is possible. We recommend to travel during the 2nd trimester, avoid region of high malaria endemicity, choose destination where good medical service exist, check for adequate insurance coverage, favour comfortable type of travel, without long air or road transportation, avoid travelling if at risk pregnancy. For any vaccination or medication risks and benefits should be carefully weighed, pregnant women are more vulnerable and at higher risk of complications.

Transesophageal echocardiography provides a new window for ultrasound examination of the heart. The approach allows ultrasonic access to the heart in patients with transthoracic images of inadequate quality. Furthermore, transesophageal examination may provide information additional to that from the conventional transthoracic approach in the search for lesions including complications of endocarditis, mitral prosthesis dysfunction, aortic dissection, embolism of cardiac origin and selected cardiac malformations.

We have developed a new method of measuring absolute coronary blood flow (CBF) in all major branches of the coronary circulation using computer analysis of conventional cineangiograms. A coronary cineangiogram is obtained in any biplane projections at 50 fps and digitized into a 512 x 512 x 8 matrix. The artery is reconstructed in 3D using the x-ray projection matrices calculated from a cube filmed in the same projections. All diameters along the artery are automatically determined. The arterial volume is calculated from the 3D reconstructed true arterial length and diameters. The absolute flow is obtained by dividing the arterial volume filled by contrast medium during the first cardiac cycle following the injection by the duration of that cycle. The method was validated in vivo by comparing LAD flow measured by angiography with great cardiac vein flow simultaneously measured by thermodilution. Ten patients were studied at baseline and during pacing-induced hyperemia at 100 and 120/min. Mean flow was 52.1 ml/min (range 28-93) by angiography and 51.5 ml/min (range 11-115; NS) by thermodilution. The two methods correlated well: r = 0.82, SE = 9.8 ml/min, n = 27, p less than 0.0001. Thus, absolute CBF can be measured by computer analysis of conventional biplane coronary cineangiograms.

In cardiology, digital subtraction angiography after intravenous injection of contrast medium allows only the visualization of relative large structures as the ventricles and the great vessels. Subselective intra-arterial injections are attractive, but do not provide an appreciable reduction of the injected amount of contrast medium. A reduction is possible with selective injections, but good subtraction is only possible for non-moving arteries or for arteries with truly periodic movement (ECG gated subtraction). With the improvement of spatial and temporal resolution, digital angiography (without image subtraction) could replace conventional angiography, provided that the main problem of prohibitive costs associated to the stockage of image sequences with high spatial (1024 x 1024) and temporal (25 images/s) resolution is solved. At the present, however, the cinefilm 35 mm is still unbeaten in density of information, handling and costs. In interventional cardiology, the visualization of small coronary branches and of fine, fast moving guide-wires is improved by the digitalization of the images at the source, pulsed fluoroscopy, progressive scanning of the TV camera with temporary stockage of image sequences and the selective reinforcement of the image contrast in real time. Digital angiography is also more attractive than the cinefilm in view of a better exploitation of the information contained in angiographic sequences by sophisticated, computer assisted methods. For instance, parametric imaging for analysis of the contraction and relaxation of the left ventricle, or for the visualization of the progression of contrast medium to investigate the coronary circulation, condensing in one single image the information looked for, are fields where digital angiography has given new impulses to cardiologic research.

A 25-year-old Senegalese woman with severe multivalvular disease presented with jaundice (unconjugated bilirubin) augmented by exertion without evidence of frank anemia. Following the exclusion of all other causes of hemolysis, the diagnosis of mechanical hemolysis secondary to deformed valves was established. The jaundice and laboratory evidence of hemolysis diminished markedly after placement of (Starr) aortic and mitral valve prostheses and a tricuspid commissurotomy. While chronic hemolysis due to ball or disc valve prostheses is usually clinically insignificant yet often described in the literature, hemolysis complicating non-operated valvulopathies is a rare clinical condition and, in contrast to the case presented, usually less severe than hemolysis following valve prosthesis insertion.