Search

Background Identifying the causes of Acute Undifferentiated Febrile Illness (AUFI) is key to improve the management of returning travellers with fever. We evaluated a BioFire®FilmArray® prototype panel of multiplex nucleic acid amplification tests (NAAT) targeting different relevant pathogens in travellers returning with fever. Methods Prospective, multicentre study to evaluate a prototype panel in whole blood samples of adult international travellers presenting with AUFI in three European travel Clinics/Hospitals (November 2017–November 2019). We evaluated 15 target analytes: Plasmodium spp., Plasmodium falciparum, Plasmodium knowlesi, Plasmodium malariae, Plasmodium ovale, Plasmodium vivax, chikungunya virus, dengue virus, Zika virus, Anaplasma phagocytophilum, Borrelia spp., Leptospira spp., Orientia tsutsugamushi, Rickettsia spp. and Salmonella spp. Results were compared with composite reference standards (CRSs) for each target infection, including direct methods [smear microscopy, rapid diagnostic test (RDT), reference NAAT and blood cultures] and indirect methods (paired serology). Findings Among 455 travellers with AUFI, 229 target infections were diagnosed; the prototype panel detected 143 (overall sensitivity and specificity of 62.5 and 99.8%, respectively). The panel identified all Plasmodium infections (n = 82). Sensitivity for dengue (n = 71) was 92.9, 80.8 and 68.5% compared with RDT, NAAT and CRS, respectively. Compared with direct methods and CRS, respectively, the prototype panel detected 4/4 and 4/6 chikungunya, 2/2 and 4/29 Leptospira spp., 1/1 and 1/6 O. tsutsugamushi and 2/2 and 2/55 Rickettsia spp., but 0/2 and 0/10 Zika, 0/1 and 0/11 A. phagocytophylum and 0/3 Borrelia spp. diagnosed by serology and only 1/7 Salmonella spp. diagnosed by blood cultures. 77/86 (89.5%) infections not detected by the panel were diagnosed by serology. Interpretation The prototype panel allowed rapid and reliable diagnosis for malaria, dengue and chikungunya. Further improvements are needed to improve its sensitivity for Zika and important travel-related bacterial infections.

Objectives Given the scarcity of data regarding prevalence of various infectious diseases in Latin-American countries, our study aims to assess the burden of T. cruzi, S. stercoralis, HIV and viral hepatitis in Latin-American migrants, with a focus on Bolivian migrants. Methods We performed a retrospective observational study of 565 screening evaluations in adults (≥18 years) carried out at our International Healthcare referral service in Barcelona. We reviewed structured clinical records and microbiological results of patients attended between February 2012 and April 2015. Results The median age was 35 years and 74% were women. Of the population screened, 87% were of Bolivian origin. We found a 48% prevalence of T. cruzi, 16% of S. stercoralis, 0.2% of HIV, 0.2% HBV and 0.2% HCV. Conclusions These results support the relevance of screening for T. cruzi and S. stercoralis in Bolivian migrants but challenge the pertinence of systematic screening for HBV in this population.

Background Diagnosis of undifferentiated non-malaria fevers (NMF) in returning travellers is a great challenge. Currently, there is no consensus about the use of empirical antibiotics in returning travellers with undifferentiated NMF. Although studies in endemic areas showed that a wide range of pathogens implicated in undifferentiated NMF are treatable with doxycycline, the role of doxycycline in returning travellers with fever still has to be explored. Methods Prospective European multicentre cohort study of febrile international travellers (November 2017—November 2019). Immunological and molecular diagnostic techniques for doxycycline responding illnesses (DRI) agents such as Anaplasma phagocytophilum, spotted fever group Rickettsia spp., typhus group Rickettsia spp., Coxiella burnetii, Bartonella spp., Orientia tsutsugamushi, Borrelia miyamotoi, Borrelia recurrentis and Leptospira spp. were systematically performed in all patients with undifferentiated NMF. We estimated the prevalence and predictive factors of DRI in returning travellers with undifferentiated NMF. Results Among 347 travellers with undifferentiated NMF, 106 (30·5%) were finally diagnosed with DRI. Only 57 (53·8%) of the 106 DRI infections were diagnosed by the standard of care. The main causes of DRI were: 55 (51·9%) Rickettsia spp., 16 (15·1%) C. burnetii; 15 (14·2%) Bartonella spp.; 13 (12·3%) Leptospira spp. and 10 (9·5%) A. phagocytophilum. The only predictive factor associated with DRI was presenting an eschar (aOR 39·52, 95%CI 4·85–322·18). Features of dengue such as retro-orbital pain (aOR 0·40, 95%CI 0·21–0·76) and neutropenia (aOR 0·41, 95%CI 0·21–0·79) were negatively associated with DRI. Conclusions Although DRI are responsible for 30% of undifferentiated NMF cases in travellers, those are seldom recognized during the first clinical encounter. Empirical treatment with doxycycline should be considered in returning travellers with undifferentiated fever and negative tests for malaria and dengue, particularly when presenting severe illness, predictive factors for rickettsiosis or no features of dengue.

Immigrant health status may be improved if certain health conditions are identified early through the implementation of a screening program. This document presents the recommendations resulting from the Screening in immigrant population project (CRIBMI) aimed at implementing a screening program for infectious diseases (HIV, HBV, HCV, tuberculosis, strongyloidiasis, schistosomiasis and Chagas disease), as well as female genital mutilation and mental health (MH) in migrant population at Primary Care level. Screening recommendations were based on: coming from an endemic country for strongyloidiasis, schistosomiasis, and Chagas diseases; on a threshold level of prevalence for HIV (> 1%), HBV (> 2%), and HCV (> 2%), and on incidence (> 50 cases/100,000-inhabitants) for active tuberculosis in immigrants with < 5 years in Europe. Exploring the risk of FGM is recommended in women from countries where this practice is prevalent. Evaluation of MH status is recommended for people from areas of conflict and violence.

Background Etiological diagnosis of febrile illnesses in returning travelers is a great challenge, particularly when presenting with no focal symptoms [acute undifferentiated febrile illnesses (AUFI)], but is crucial to guide clinical decisions and public health policies. In this study, we describe the frequencies and predictors of the main causes of fever in travelers. Methods Prospective European multicenter cohort study of febrile international travelers (November 2017–November 2019). A predefined diagnostic algorithm was used ensuring a systematic evaluation of all participants. After ruling out malaria, PCRs and serologies for dengue, chikungunya and Zika viruses were performed in all patients presenting with AUFI ≤ 14 days after return. Clinical suspicion guided further microbiological investigations. Results Among 765 enrolled participants, 310/765 (40.5%) had a clear source of infection (mainly traveler’s diarrhea or respiratory infections), and 455/765 (59.5%) were categorized as AUFI. AUFI presented longer duration of fever (p Conclusions Over 40% of returning travelers with AUFI were diagnosed with malaria or dengue, infections that can be easily diagnosed by rapid diagnostic tests. Arboviruses were the most common cause of AUFI (above malaria) and most cases were diagnosed during Aedes spp. high season. This is particularly relevant for those areas at risk of introduction of these pathogens. Empirical antibiotic regimens including doxycycline or azithromycin should be considered in patients with AUFI, after ruling out malaria and arboviruses.

Different diagnostic tests were evaluated in a cluster of six European travellers with acute schistosomiasis (AS) acquired in Mozambique. Adult worm and soluble egg antibodies, circulating anodic antigen (CAA) and DNA detection allowed early confirmation of AS. CAA permitted monitoring treatment response and Sm1-7 polymerase chain reaction allowed identification of Schistosoma mansoni complex.

Background Although tick-borne pathogens have been reported as an important cause of imported fever, the incidence of Anaplasma phagocytophilum, the causative agent of human granulocytic anaplasmosis (HGA), in travellers is unknown. Methods We conducted a prospective cohort study to investigate the aetiologies of fever in returning travellers (November 2017—July 2019). Polymerase chain reaction for msp2 gene amplification and indirect immunofluorescence assay for A. phagocitophilum were performed in all returning travellers with undifferentiated non-malarial fever. Results Among 141 travellers included, 8 patients were diagnosed with probable or confirmed HGA. The overall incidence rate of HGA was 19.9 cases/1000 person—week of travel. The main destination of travel was Asia, accounting for 62.5% patients with HGA. Co-infections were found in 37.5% of patients with HGA. Conclusions Diagnosis of HGA and empirical treatment with doxycycline should be considered in travellers with fever.

Chagas disease constitutes a public health problem, and Spain is the non-endemic country with the highest burden of disease outside the Americas. It represents a model for non-endemic countries regarding health policies to control the disease. This study is aimed to generate estimates of the T.cruzi prevalence and the number of undetected and untreated individuals with the infection in Spain and to compare them with the actual number of cases reported by official sources.Using aggregate data collected from the literature and official sources (Spanish National Statistics Institute; Spanish Agency of Medicines and Medical Devices) from 2010 to 2018, this study estimates the number of Chagas disease cases, plus the underdiagnosis and undertreatment rates.We estimated that 55,367 out of 2,602,285 migrants originally from endemic countries were living with Chagas disease in Spain in 2018, accounting for a prevalence of 2.1%. Only 1% of these cases(613/455,566) were children aged 14 years or less resulting in a prevalence of 0.1%. Bolivian migrants accounted for 53.9% of the total estimated cases. The index of underdiagnosis and undertreatment were heterogeneous across different Spanish autonomous regions, but the overall index of underdiagnosis was around 71%, and the overall index of undertreatment was 82.5% in patients aged 15 years or older, and 60% in children.The burden of Chagas disease in Spain is considerable. Index of underdiagnosis and undertreatment are high, particularly in women of childbearing age, but they have improved in children since the implementation of antenatal screening programmes.

Introduction: Spain is the non-endemic country with the highest burden of Chagas disease outside the Americas, and it represents a model for non-endemic countries concerning health policies to control the disease. This study generates high-resolution estimates of the burden of undetected and untreated T.cruzi infection cases in Spain and compare them with the actual number of cases reported by official sources. Methods: A study using aggregate data collected from the literature and official sources (Spanish National Statistics Institute; Spanish Agency of Medicines and Medical Devices) was undertaken, from 2010 to 2018, to estimate the number of Chagas disease cases and the underdiagnosis and undertreatment rates. Results: We estimated a total of 55,367 migrants living with Chagas disease in Spain in 2018, out of them 613 (1%) were children under 15 years of age. Bolivian migrants represented 54% of the total estimated cases. Underdiagnosis and undertreatment rates were heterogeneous among the different Spanish autonomous regions, being the estimated global underdiagnosis rate of around 71%. The global rate of undertreatment in Spain was estimated to be 82·5% among patients older than 14 years. Conclusion: The burden of Chagas disease in Spain remains high, with both considerable underdiagnosis and undertreatment rates, particularly notorious in childbearing age women despite being a priority group; but much improved in children, suggesting the efficacy of antenatal screening programmes implemented in the country. Funding: None to declare Declaration of Interest: All authors declare not competing interest

Introduction: Strongyloidiasis is a prevailing helminth infection ubiquitous in tropical and subtropical areas, however, seroprevalence data are scarce in migrant populations, particularly for those coming for Asia. Methods: This study aims at evaluating the prevalence of S. stercoralis at the hospital level in migrant populations or long term travellers being attended in out-patient and in-patient units as part of a systematic screening implemented in six Spanish hospitals. A cross-sectional study was conducted and systematic screening for S. stercoralis infection using serological tests was offered to all eligible participants. Results: The overall seroprevalence of S. stercoralis was 9.04% (95%CI 7.76&ndash, 10.31). The seroprevalence of people with a risk of infection acquired in Africa and Latin America was 9.35% (95%CI 7.01&ndash, 11.69), 9.22% (7.5&ndash, 10.93), respectively. The number of individuals coming from Asian countries was significantly smaller and the overall prevalence in these countries was 2.9% (95%CI &minus, 0.3&ndash, 6.2). The seroprevalence in units attending potentially immunosuppressed patients was significantly lower (5.64%) compared with other units of the hospital (10.20%) or Tropical diseases units (13.33%) (p &lt, 0.001). Conclusions: We report a hospital-based strongyloidiasis seroprevalence of almost 10% in a mobile population coming from endemic areas suggesting the need of implementing strongyloidiasis screening in hospitalized patients coming from endemic areas, particularly if they are at risk of immunosuppression.

Although there is a lot of aspects we stil need to understand about treatment with artemisinins[1], there is no doubt about their efficacy in treating malaria. Artesunate (AS) has demonstrated its superiority against quinine for treatment of severe malaria in terms of reduction of mortality in different randomized clinical trials performed in endemic countries and subsequent meta-analysis[2-4]. Despite having been established as the first line treatment by WHO and several national guidelines[5,6], its full implementation in non-endemic countries has not been completed.

Ivermectin has recently shown efficacy against SARS-CoV-2 in-vitro. We retrospectively reviewed severe COVID-19 patients receiving standard doses of ivermectin and we compared clinical and microbiological outcomes with a similar group of patients not receiving ivermectin. No differences were found between groups. We recommend the evaluation of high-doses of ivermectin in randomized trials against SARS-CoV-2.

Dear Editor, the changing epidemiology of Zika virus infection has been described before and in this letter we would like to show how the local epidemiology of Zika in Cuba is reflected in imported cases in returning travellers to Barcelona. The spread of the 2015 Zika epidemic was mostly reported in South America and the Caribbean. While increasing numbers of cases raised in South-America, Cuba was still free of cases. On 2nd March 2016 the first imported case from Cuba (Artemisa province) was reported. The first autochthonous case was reported on 16th March 2016 in La Habana. Onwards, cases were reported in Camagüey, Cienfuegos, Guantánamo, Havana and Santiago. During 2017 transmission has been reported in municipalities of Arroyo Naranjo and Regla in the province of Havana .

Resumen La salud de la población inmigrante puede mejorarse si ciertas condiciones de salud se identifican de una forma temprana a través de la implementación de un programa de cribado. Este documento presenta las recomendaciones obtenidas en el marco del proyecto Cribado en población inmigrante (CRIBMI), cuyo objetivo es implementar un programa de cribado de enfermedades infecciosas (VIH, VHB, VHC, tuberculosis, estrongiloidiasis, esquistosomiasis y enfermedad de Chagas), así como mutilación genital femenina (MGF) y salud mental (SM) entre la población inmigrante a nivel de Atención Primaria. Las recomendaciones se basaron en: procedencia de países endémicos para estrongiloidiasis, esquistosomiasis y enfermedad de Chagas; umbral de prevalencia en el país de origen del 1% para VIH, 2% para VHC, VHB y una incidencia de > 50 casos/100.000 habitantes para tuberculosis activa en migrantes con menos de 5 años en Europa. Explorar el riesgo de MGF se recomienda en mujeres que proceden de países donde esta práctica es habitual. La evaluación de SM se recomienda a personas que vienen de áreas en conflicto o alta tensión.

Chagas disease is an emerging but still largely unrecognised infectious parasitic disease in European countries.1 It has important public health implications because, although the classic vector-borne route of transmission only occurs in endemic areas of Latin America, the less common transmission routes—blood transfusion, transplantation, and vertical transmission from mother to child—have been shown in Europe.2 Therefore, providing policy makers with accurate estimates of country-specific prevalence of Chagas disease should inform the design and implementation of the most cost-effective health interventions.

Background Water, sanitation and hygiene (WASH) are major health determinants, responsible for an estimated world-wide disease burden of 5.7%. However, the debate about the effect of water quality, hygiene and sanitation in preventing diarrhoea is still ongoing. The aim of this study is to describe access to improved water supply and sanitation infrastructure, as defined by the Joint Monitoring Programme, in the Manhica Health Research Centre (CISM) study area and evaluate its association with morbidity and mortality indicators. Methods We conducted a retrospective cohort study. All children under 15 living in the study area during the period 2012–2015 were included (N=61900). Children were followed up until they moved from the study area, turned 15 or until 2015. Water and sanitation household data were obtained from the CISM demographic surveillance system (DSS) in the Manhica district, an area of around 2380 km2. Clinical data were obtained from CISM9s round-the-clock morbidity surveillance system covering outpatient and hospital admissions at the Manhica District Hospital (MDH) and rural health posts. A negative binomial regression model using Wald test was performed to assess the minimum community-based incidence rates (MCBIR) for every morbidity-mortality indicator. Results Preliminary data showed that 86% of the children lived at least once in a household with unimproved sanitation facilities, 27% with an unimproved water source. Spatial distribution of unimproved water and sanitation facilities showed to be clustered. Access to unimproved sanitation and water facilities was associated to higher rates of diarrhoea, a significant 30% of diarrhoea rate increase was observed for rivers, lakes and ponds as water sources. Other morbidity indicators (malnutrition, parasitaemia, anaemia) also showed a rate increase with the use of unimproved water and sanitation facilities. Conclusions Obtained results are useful to inform sector-related decision-making processes and ultimately improve access to safe drinking water and sanitation in rural southern Mozambique.