Last data update: May 13, 2024. (Total: 46773 publications since 2009)
Records 1-25 (of 25 Records) |
Query Trace: Rao SR[original query] |
---|
Gut microbiome perturbation, antibiotic resistance, and Escherichia coli strain dynamics associated with international travel: a metagenomic analysis
Worby CJ , Sridhar S , Turbett SE , Becker MV , Kogut L , Sanchez V , Bronson RA , Rao SR , Oliver E , Walker AT , Walters MS , Kelly P , Leung DT , Knouse MC , Hagmann SHF , Harris JB , Ryan ET , Earl AM , LaRocque RC . Lancet Microbe 2023 4 (10) e790-e799 BACKGROUND: Culture-based studies have shown that acquisition of extended-spectrum β-lactamase-producing Enterobacterales is common during international travel; however, little is known about the role of the gut microbiome before and during travel, nor about acquisition of other antimicrobial-resistant organisms. We aimed to identify (1) whether the gut microbiome provided colonisation resistance against antimicrobial-resistant organism acquisition, (2) the effect of travel and travel behaviours on the gut microbiome, and (3) the scale and global heterogeneity of antimicrobial-resistant organism acquisition. METHODS: In this metagenomic analysis, participants were recruited at three US travel clinics (Boston, MA; New York, NY; and Salt Lake City, UT) before international travel. Participants had to travel internationally between Dec 8, 2017, and April 30, 2019, and have DNA extractions for stool samples both before and after travel for inclusion. Participants were excluded if they had at least one low coverage sample (<1 million read pairs). Stool samples were collected at home before and after travel, sent to a clinical microbiology laboratory to be screened for three target antimicrobial-resistant organisms (extended-spectrum β-lactamase-producing Enterobacterales, carbapenem-resistant Enterobacterales, and mcr-mediated colistin-resistant Enterobacterales), and underwent DNA extraction and shotgun metagenomic sequencing. We profiled metagenomes for taxonomic composition, antibiotic-resistant gene content, and characterised the Escherichia coli population at the strain level. We analysed pre-travel samples to identify the gut microbiome risk factors associated with acquisition of the three targeted antimicrobial resistant organisms. Pre-travel and post-travel samples were compared to identify microbiome and resistome perturbation and E coli strain acquisition associated with travel. FINDINGS: A total of 368 individuals travelled between the required dates, and 296 had DNA extractions available for both before and after travel. 29 travellers were excluded as they had at least one low coverage sample, leaving a final group of 267 participants. We observed a perturbation of the gut microbiota, characterised by a significant depletion of microbial diversity and enrichment of the Enterobacteriaceae family. Metagenomic strain tracking confirmed that 67% of travellers acquired new strains of E coli during travel that were phylogenetically distinct from their pre-travel strains. We observed widespread enrichment of antibiotic-resistant genes in the gut, with a median 15% (95% CI 10-20, p<1 × 10(-10)) increase in burden (reads per kilobase per million reads). This increase included antibiotic-resistant genes previously classified as threats to public health, which were 56% (95% CI 36-91, p=2 × 10(-11)) higher in abundance after travel than before. Fluoroquinolone antibiotic-resistant genes were aquired by 97 (54%) of 181 travellers with no detected pre-travel carriage. Although we found that visiting friends or relatives, travel to south Asia, and eating uncooked vegetables were risk factors for acquisition of the three targeted antimicrobial resistant organisms, we did not observe an association between the pre-travel microbiome structure and travel-related antimicrobial-resistant organism acquisition. INTERPRETATION: This work highlights a scale of E coli and antimicrobial-resistant organism acquisition by US travellers not apparent from previous culture-based studies, and suggests that strategies to control antimicrobial-resistant organisms addressing international traveller behaviour, rather than modulating the gut microbiome, could be worthwhile. FUNDING: US Centers for Disease Control and Prevention and National Institute of Allergy and Infectious Diseases. |
High-risk US International Travelers Seeking Pretravel Consultation During the COVID-19 Pandemic.
Hyle EP , Le MH , Rao SR , Mulroy NM , Walker AT , Ryan ET , LaRocque RC . Open Forum Infect Dis 2022 9 (8) ofac399 BACKGROUND: To assess the implications of coronavirus disease 2019 (COVID-19)-related travel disruptions, we compared demographics and travel-related circumstances of US travelers seeking pretravel consultation regarding international travel at US Global TravEpiNet (GTEN) sites before and after the initiation of COVID-19 travel warnings. METHODS: We analyzed data in the GTEN database regarding traveler demographics and travel-related circumstances with standard questionnaires in the pre-COVID-19 period (January-December 2019) and the COVID-19 period (April 2020-March 2021), excluding travelers from January to March 2020. We conducted descriptive analyses of differences in demographics, travel-related circumstances, routine and travel-related vaccinations, and medications. RESULTS: Compared with 16 903 consultations in the pre-COVID-19 period, only 1564 consultations were recorded at GTEN sites during the COVID-19 period (90% reduction), with a greater proportion of travelers visiting friends and relatives (501/1564 [32%] vs 1525/16 903 [9%]), individuals traveling for >28 days (824/1564 [53%] vs 2522/16 903 [15%]), young children (6 mo-<6 y: 168/1564 [11%] vs 500/16 903 [3%]), and individuals traveling to Africa (1084/1564 [69%] vs 8049/16 903 [48%]). A smaller percentage of vaccine-eligible travelers received vaccines at pretravel consultations during the COVID-19 period than before, except for yellow fever and Japanese encephalitis vaccinations. CONCLUSIONS: Compared with the pre-COVID-19 period, a greater proportion of travelers during the COVID-19 period were young children, were planning to visit friends and relatives, were traveling for >28 days, or were traveling to Africa, which are circumstances that contribute to high risk for travel-related infections. Fewer vaccine-eligible travelers were administered travel-related vaccines at pretravel consultations. Counseling and vaccination focused on high-risk international travelers must be prioritized during the COVID-19 pandemic. |
The clinical and economic impact of measles-mumps-rubella vaccinations to prevent measles importations from US pediatric travelers returning from abroad
Bangs AC , Gastaaduy P , Neilan AM , Fiebelkorn AP , Walker AT , Rao SR , Ryan ET , LaRocque RC , Walensky RP , Hyle EP . J Pediatric Infect Dis Soc 2022 11 (6) 257-266 BACKGROUND: Pediatric international travelers account for nearly half of measles importations in the United States. Over one third of pediatric international travelers depart the United States without the recommended measles-mumps-rubella (MMR) vaccinations: 2 doses for travelers 12 months and 1 dose for travelers 6 to <12 months. METHODS: We developed a model to compare 2 strategies among a simulated cohort of international travelers (6 months to <6 years): (1) No pretravel health encounter (PHE): travelers depart with baseline MMR vaccination status; (2) PHE: MMR-eligible travelers are offered vaccination. All pediatric travelers experience a destination-specific risk of measles exposure (mean, 30 exposures/million travelers). If exposed to measles, travelers' age and MMR vaccination status determine the risk of infection (range, 3%-90%). We included costs of medical care, contact tracing, and lost wages from the societal perspective. We varied inputs in sensitivity analyses. Model outcomes included projected measles cases, costs, and incremental cost-effectiveness ratios ($/quality-adjusted life year [QALY], cost-effectiveness threshold $100 000/QALY). RESULTS: Compared with no PHE, PHE would avert 57 measles cases at $9.2 million/QALY among infant travelers and 7 measles cases at $15.0 million/QALY among preschool-aged travelers. Clinical benefits of PHE would be greatest for infants but cost-effective only for travelers to destinations with higher risk for measles exposure (ie, 160 exposures/million travelers) or if more US-acquired cases resulted from an infected traveler, such as in communities with limited MMR coverage. CONCLUSIONS: Pretravel MMR vaccination provides the greatest clinical benefit for infant travelers and can be cost-effective before travel to destinations with high risk for measles exposure or from communities with low MMR vaccination coverage. |
Yellow fever vaccine administration at Global TravEpiNet (GTEN) clinics during a period of limited vaccine availability in the United States, 2017-2018
Walker AT , Gershman MD , Rao SR , LaRocque RC , Ryan ET . Am J Trop Med Hyg 2021 104 (3) 1079-1084 In 2016, Sanofi Pasteur (S-P) experienced a manufacturing disruption of yellow fever vaccine (YF-Vax), the only U.S.-licensed YF-Vax, depleting the U.S. supply by mid-2017. Sanofi Pasteur received approval to import Stamaril, S-P's French-manufactured YF-Vax, for use in 260 U.S. civilian clinics under an expanded access investigational new drug program (EAP). The CDC also broadened its YF-Vax indication in early 2018. Our objective was to assess usage at participating Global TravEpiNet (GTEN) clinics, a U.S. CDC-supported national consortium of clinical sites that administer vaccines, during this period of limited availability and changing recommendations. We analyzed 2012-2018 GTEN data for YF-Vax usage, unavailability, and reasons for refusal. We also performed a brief voluntary survey of GTEN sites to better understand their experience during the shortage. Yellow fever vaccine unavailability at certain GTEN clinics was intermittent and recurrent, starting months before total depletion. Unavailability at GTEN clinics peaked weeks before the total depletion. Compared with historic norms, YF-Vax usage following initial vaccine availability limitations did not change until vaccine recommendations were broadened. Refusal of recommended YF-Vax also decreased during this period. Queried sites participating in the EAP felt their supply of vaccine was adequate. Our analysis suggests that in response to depletion of a travel vaccine, an EAP can make an unlicensed product available, patients will participate in such a program, and the program can respond to expanding recommendations for vaccine usage. |
Acquisition and long-term carriage of multidrug-resistant organisms in US international travelers
Worby CJ , Earl AM , Turbett SE , Becker M , Rao SR , Oliver E , Taylor Walker A , Walters M , Kelly P , Leung DT , Knouse M , Hagmann SHF , Ryan ET , LaRocque RC . Open Forum Infect Dis 2020 7 (12) ofaa543 We performed prospective screening of stool for multidrug-resistant organisms from 608 US international travelers and identified an acquisition rate of 38% following travel. Carriage rates remained significantly elevated for at least 6 months post-travel. Travel-related diarrhea was a risk factor for acquisition, as well as for long-term carriage upon return. |
The effect of transport temperature and time on the recovery of antimicrobial-resistant Enterobacterales in stool
Turbett SE , Becker M , Desrosiers L , Oliver E , Rao SR , Walker AT , Walters M , Ryan ET , LaRocque RC . Diagn Microbiol Infect Dis 2020 99 (2) 115210 Surveillance for antibiotic-resistant (AR) bacteria is challenging. We evaluated AR Enterobacterales survival in stool over various transport conditions. Stool in Cary-Blair medium was spiked with AR Enterobacterales, held at 3 °C, 20 °C, or 37 °C, and cultured on days 3, 8, and 15. Stool from US international travelers sent through the US mail was also screened. We compared recovery rates using Fisher's exact tests and linear regression models. AR Enterobacterales recovery reduced with time (86% versus 75% versus 61% at days 3, 8, and 15; Beta for linear trend=-0.02, r(2)=0.99, P=0.02) and colder temperatures [56% (3 °C) versus 89% (20 °C) versus 86% (37 °C); P=0.003]. Traveler sample recovery also reduced with transport time (Beta for linear trend=-0.03, r(2)=0.70, P=0.01) but not with season [20% (cold) versus 22% (warm), P=0.7]. AR Enterobacterales are found over variable transport conditions, providing rationale for expanding surveillance sample processing timelines. |
Clinical practices for measles-mumps-rubella vaccination among US pediatric international travelers
Hyle EP , Rao SR , Bangs AC , Gastanaduy P , Fiebelkorn AP , Hagmann SHF , Walker AT , Walensky RP , Ryan ET , LaRocque RC . JAMA Pediatr 2019 174 (2) e194515 Importance: The US population is experiencing a resurgence of measles, with more than 1000 cases during the first 6 months of 2019. Imported measles cases among returning international travelers are the source of most US measles outbreaks, and these importations can be reduced with pretravel measles-mumps-rubella (MMR) vaccination of pediatric travelers. Although it is estimated that children account for less than 10% of US international travelers, pediatric travelers account for 47% of all known measles importations. Objective: To examine clinical practice regarding MMR vaccination of pediatric international travelers and to identify reasons for nonvaccination of pediatric travelers identified as MMR eligible. Design, Setting, and Participants: This cross-sectional study of pediatric travelers (ages >/=6 months and <18 years) attending pretravel consultation at 29 sites associated with Global TravEpiNet (GTEN), a Centers for Disease Control and Prevention-supported consortium of clinical sites that provide pretravel consultations, was performed from January 1, 2009, through December 31, 2018. Main Outcomes and Measures: Measles-mumps-rubella vaccination among MMR vaccination-eligible pediatric travelers. Results: Of 14602 pretravel consultations for pediatric international travelers, 2864 travelers (19.6%; 1475 [51.5%] males; 1389 [48.5%] females) were eligible to receive pretravel MMR vaccination at the time of the consultation: 365 of 398 infants aged 6 to 12 months (91.7%), 2161 of 3623 preschool-aged travelers aged 1 to 6 years (59.6%), and 338 of 10581 school-aged travelers aged 6 to 18 years (3.2%). Of 2864 total MMR vaccination-eligible travelers, 1182 (41.3%) received the MMR vaccine and 1682 (58.7%) did not. The MMR vaccination-eligible travelers who did not receive vaccine included 161 of 365 infants (44.1%), 1222 of 2161 preschool-aged travelers (56.5%), and 299 of 338 school-aged travelers (88.5%). We observed a diversity of clinical practice at different GTEN sites. In multivariable analysis, MMR vaccination-eligible pediatric travelers were less likely to be vaccinated at the pretravel consultation if they were school-aged (model 1: odds ratio [OR], 0.32 [95% CI, 0.24-0.42; P < .001]; model 2: OR, 0.26 [95% CI, 0.14-0.47; P < .001]) or evaluated at specific GTEN sites (South: OR, 0.06 [95% CI, 0.01-0.52; P < .001]; West: OR, 0.10 [95% CI, 0.02-0.47; P < .001]). The most common reasons for nonvaccination were clinician decision not to administer MMR vaccine (621 of 1682 travelers [36.9%]) and guardian refusal (612 [36.4%]). Conclusions and Relevance: Although most infant and preschool-aged travelers evaluated at GTEN sites were eligible for pretravel MMR vaccination, only 41.3% were vaccinated during pretravel consultation, mostly because of clinician decision or guardian refusal. Strategies may be needed to improve MMR vaccination among pediatric travelers and to reduce measles importations and outbreaks in the United States. |
Characteristics and preparation of the last-minute traveler: analysis of vaccine usage in the Global TravEpiNet Consortium
Yates JA , Rao SR , Walker AT , Esposito DH , Sotir M , LaRocque RC , Ryan ET . J Travel Med 2019 26 (6) BACKGROUND: Last-minute travellers (LMTs) present challenges for health care providers because they may have insufficient time for recommended vaccinations or pre-travel preparation. Our objective was to obtain a better understanding of LMTs in order to help travel medicine providers develop improved strategies to decrease the number of LMTs and potentially reduce travel-related morbidity. METHODS: We defined LMTs as travellers with a departure date of 7 days or fewer from the medical encounter. We analysed the characteristics and health preparation of 12 494 LMTs who presented to a network of US clinical practices for pre-travel health advice between January 2009 and December 2015. RESULTS: LMTs comprised 16% of all travellers. More LMTs than non-LMTs travelled for business or to visit friends and relatives (VFR) (26% vs 16% and 15% vs 8%, respectively; P < 0.0001). More LMTs also travelled for longer than 1 month (27% vs 21%; P < 0.0001) and visited only urban areas (40% vs 29%; P < 0.0001). At least one travel vaccine was deferred by 18% of LMTs because of insufficient time before departure. Vaccines that required multiple vaccinations, such as Japanese encephalitis and rabies, were the most likely to be deferred because of time constraints. CONCLUSION: Interventions to improve the timing of pre-travel health consultations should be developed, particularly for business and VFR travellers. Recently endorsed accelerated vaccine schedules for Japanese encephalitis and rabies may help some LMTs receive protection against these infections despite late presentation for pre-travel health care. |
The clinical impact and cost-effectiveness of measles-mumps-rubella vaccination to prevent measles importations among international travelers from the United States
Hyle EP , Fields NF , Fiebelkorn AP , Walker AT , Gastanaduy P , Rao SR , Ryan ET , LaRocque RC , Walensky RP . Clin Infect Dis 2019 69 (2) 306-315 BACKGROUND: Measles importations and the subsequent spread from US travelers returning from abroad are responsible for most measles cases in the United States. Increasing measles-mumps-rubella (MMR) vaccination among departing US travelers could reduce the clinical impact and costs of measles in the United States. METHODS: We designed a decision tree to evaluate MMR vaccination at a pretravel health encounter (PHE), compared with no encounter. We derived input parameters from Global TravEpiNet data and literature. We quantified Riskexposure to measles while traveling and the average number of US-acquired cases and contacts due to a measles importation. In sensitivity analyses, we examined the impact of destination-specific Riskexposure, including hot spots with active measles outbreaks; the percentage of previously-unvaccinated travelers; and the percentage of travelers returning to US communities with heterogeneous MMR coverage. RESULTS: The no-encounter strategy projected 22 imported and 66 US-acquired measles cases, costing $14.8M per 10M travelers. The PHE strategy projected 15 imported and 35 US-acquired cases at $190.3M per 10M travelers. PHE was not cost effective for all international travelers (incremental cost-effectiveness ratio [ICER] $4.6M/measles case averted), but offered better value (ICER <$100 000/measles case averted) or was even cost saving for travelers to hot spots, especially if travelers were previously unvaccinated or returning to US communities with heterogeneous MMR coverage. CONCLUSIONS: PHEs that improve MMR vaccination among US international travelers could reduce measles cases, but are costly. The best value is for travelers with a high likelihood of measles exposure, especially if the travelers are previously unvaccinated or will return to US communities with heterogeneous MMR coverage. |
Potentially serious drug interactions resulting from the pretravel health encounter
Sbaih N , Buss B , Goyal D , Rao SR , Benefield R , Walker AT , Esposito DH , Ryan ET , LaRocque RC , Leung DT . Open Forum Infect Dis 2018 5 (11) ofy266 Travelers seen for pretravel health encounters are frequently prescribed new travel-related medications, which may interact with their previously prescribed medications. In a cohort of 76 324 travelers seen at 23 US clinics, we found that 2650 (3.5%) travelers were prescribed travel-related medications with potential for serious drug interactions. |
Enabling clinicians to easily find location-based travel health recommendations-is innovation needed
Lash RR , Walker AT , Lee CV , LaRocque R , Rao SR , Ryan ET , Brunette G , Holton K , Sotir MJ . J Travel Med 2018 25 (1) Background: The types of place names and the level of geographic detail that patients report to clinicians regarding their intended travel itineraries vary. The reported place names may not match those in published travel health recommendations, making traveler-specific recommendations potentially difficult and time-consuming to identify. Most published recommendations are at the country level; however, subnational recommendations exist when documented disease risk varies within a country, as for malaria and yellow fever. Knowing the types of place names reported during consultations would be valuable for developing more efficient ways of searching and identifying recommendations, hence we inventoried these descriptors and identified patterns in their usage. Methods: The data analyzed were previously collected individual travel itineraries from pretravel consultations performed at Global TravEpiNet (GTEN) travel clinic sites. We selected a clinic-stratified random sample of records from 18 GTEN clinics that contained responses to an open-ended question describing itineraries. We extracted and classified place names into nine types and analyzed patterns relative to common travel-related demographic variables. Results: From the 1756 itineraries sampled, 1570 (89%) included one or more place names, totaling 3366 place names. The frequency of different types of place names varied considerably: 2119 (63%) populated place, 336 (10%) tourist destination, 283 (8%) physical geographic area, 206 (6%) vague subnational area, 163 (5%) state, 153 (5%) country, 48 (1%) county, 12 (1%) undefined. Conclusions: The types of place names used by travelers to describe travel itineraries during pretravel consultations were often different from the ones referenced in travel health recommendations. This discrepancy means that clinicians must use additional maps, atlases or online search tools to cross-reference the place names given to the available recommendations. Developing new clinical tools that use geographic information systems technology would make it easier and faster for clinicians to find applicable recommendations for travelers. |
Travel Characteristics and Pretravel Health Care Among Pregnant or Breastfeeding U.S. Women Preparing for International Travel
Hagmann SHF , Rao SR , LaRocque RC , Erskine S , Jentes ES , Walker AT , Barnett ED , Chen LH , Hamer DH , Ryan ET . Obstet Gynecol 2017 130 (6) 1357-1365 OBJECTIVE: To study characteristics and preventive interventions of adult pregnant and breastfeeding travelers seeking pretravel health care in the United States. METHODS: This cross-sectional study analyzed data (2009-2014) of pregnant and breastfeeding travelers seen at U.S. travel clinics participating in Global TravEpiNet. Nonpregnant, nonbreastfeeding adult female travelers of childbearing age were used for comparison. We evaluated the prescription of malaria chemoprophylaxis and antibiotics for this population as well as the administration of three travel-related vaccines: hepatitis A, typhoid, and yellow fever. We also evaluated use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis and influenza vaccines, because these are widely recommended in pregnancy. RESULTS: Of 21,138 female travelers of childbearing age in Global TravEpiNet, 170 (0.8%) were pregnant and 139 (0.7%) were breastfeeding. Many traveled to destinations endemic for mosquito-borne illnesses, including malaria (pregnant: 95%; breastfeeding: 94%), dengue (pregnant: 87%; breastfeeding: 81%), or yellow fever (pregnant: 35%; breastfeeding: 50%). Compared with nonpregnant, nonbreastfeeding adult female travelers, eligible pregnant travelers were less likely to be vaccinated against hepatitis A (28% compared with 51%, P<.001) and typhoid (35% compared with 74%, P<.001). More than 20% of eligible pregnant travelers did not receive influenza vaccination. Yellow fever vaccine was occasionally provided to pregnant and breastfeeding travelers traveling to countries entirely endemic for yellow fever (6 [20%] of 30 pregnant travelers and 18 [46%] of 39 breastfeeding travelers). Half of pregnant travelers and two thirds of breastfeeding travelers preparing to travel to malaria-holoendemic countries received a prescription for malaria prophylaxis. CONCLUSION: Most pregnant and breastfeeding travelers seen for pretravel health consultations traveled to destinations with high risk for vector-borne or other travel-related diseases. Destination-specific preventive interventions were frequently underused. |
Missed opportunities for measles, mumps, rubella vaccination among departing U.S. Adult travelers receiving pretravel health consultations
Hyle EP , Rao SR , Jentes ES , Fiebelkorn AP , Hagmann SHF , Walker AT , Walensky RP , Ryan ET , LaRocque RC . Ann Intern Med 2017 167 (2) 77-84 Background: Measles outbreaks continue to occur in the United States and are mostly due to infections in returning travelers. Objective: To describe how providers assessed the measles immunity status of departing U.S. adult travelers seeking pretravel consultation and to assess reasons given for nonvaccination among those considered eligible to receive the measles, mumps, rubella (MMR) vaccine. Design: Observational study in U.S. pretravel clinics. Setting: 24 sites associated with Global TravEpiNet (GTEN), a Centers for Disease Control and Prevention-funded consortium. Patients: Adults (born in or after 1957) attending pretravel consultations at GTEN sites (2009 to 2014). Measurements: Structured questionnaire completed by traveler and provider during pretravel consultation. Results: 40 810 adult travelers were included; providers considered 6612 (16%) to be eligible for MMR vaccine at the time of pretravel consultation. Of the MMR-eligible, 3477 (53%) were not vaccinated at the visit; of these, 1689 (48%) were not vaccinated because of traveler refusal, 966 (28%) because of provider decision, and 822 (24%) because of health systems barriers. Most MMR-eligible travelers who were not vaccinated were evaluated in the South (2262 travelers [65%]) or at nonacademic centers (1777 travelers [51%]). Nonvaccination due to traveler refusal was most frequent in the South (1432 travelers [63%]) and in nonacademic centers (1178 travelers [66%]). Limitation: These estimates could underrepresent the opportunities for MMR vaccination because providers accepted verbal histories of disease and vaccination as evidence of immunity. Conclusion: Of U.S. adult travelers who presented for pretravel consultation at GTEN sites, 16% met criteria for MMR vaccination according to the provider's assessment, but fewer than half of these travelers were vaccinated. An increase in MMR vaccination of eligible U.S. adult travelers could reduce the likelihood of importation and transmission of measles virus. Primary Funding Source: Centers for Disease Control and Prevention, National Institutes of Health, and the Steve and Deborah Gorlin MGH Research Scholars Award. |
Characteristics of US travelers to Zika virus-affected countries in the Americas, March 2015-October 2016
Lammert S , Walker AT , Erskine S , Rao SR , Esposito DH , Ryan ET , Robbins GK , LaRocque RC . Emerg Infect Dis 2017 23 (2) 324-327 Zika virus has recently been introduced to the Americas and is spreading rapidly. We evaluated the characteristics of US travelers to Zika virus-affected countries who were seen at Global TravEpiNet sites during March 2015-October 2016. Nearly three quarters of travelers were men or women of reproductive age. |
Refusal of recommended travel-related vaccines among U.S. international travellers in Global TravEpiNet
Lammert SM , Rao SR , Jentes ES , Fairley JK , Erskine S , Walker AT , Hagmann SH , Sotir MJ , Ryan ET , LaRocque RC . J Travel Med 2016 24 (1) BACKGROUND: International travellers are at risk of travel-related, vaccine-preventable diseases. More data are needed on the proportion of travellers who refuse vaccines during a pre-travel health consultation and their reasons for refusing vaccines. METHODS: We analyzed data on travellers seen for a pre-travel health consultation from July 2012 through June 2014 in the Global TravEpiNet (GTEN) consortium. Providers were required to indicate one of three reasons for a traveller refusing a recommended vaccine: (1) cost concerns, (2) safety concerns or (3) not concerned with the illness. We calculated refusal rates among travellers eligible for each vaccine based on CDC recommendations current at the time of travel. We used multivariable logistic regression models to examine the effect of individual variables on the likelihood of accepting all recommended vaccines. RESULTS: Of 24 478 travellers, 23 768 (97%) were eligible for at least one vaccine. Travellers were most frequently eligible for typhoid (N = 20 092), hepatitis A (N = 12 990) and influenza vaccines (N = 10 539). Of 23 768 eligible travellers, 6573 (25%) refused one or more recommended vaccine(s). Of those eligible, more than one-third refused the following vaccines: meningococcal: 2232 (44%) of 5029; rabies: 1155 (44%) of 2650; Japanese encephalitis: 761 (41%) of 1846; and influenza: 3527 (33%) of 10 539. The most common reason for declining vaccines was that the traveller was not concerned about the illness. In multivariable analysis, travellers visiting friends and relatives (VFR) in low or medium human development countries were less likely to accept all recommended vaccines, compared with non-VFR travellers (OR = 0.74 (0.59-0.95)). CONCLUSIONS: Travellers who sought pre-travel health care refused recommended vaccines at varying rates. A lack of concern about the associated illness was the most commonly cited reason for all refused vaccines. Our data suggest more effective education about disease risk is needed for international travellers, even those who seek pre-travel advice. |
Pre-travel medical preparation of business and occupational travelers: an analysis of the Global TravEpiNet consortium, 2009 to 2012
Khan NM , Jentes ES , Brown C , Han P , Rao SR , Kozarsky P , Hagmann SH , LaRocque RC , Ryan ET . J Occup Environ Med 2015 58 (1) 76-82 OBJECTIVES: The aim of the study was to understand more about pre-travel preparations and itineraries of business and occupational travelers. METHODS: De-identified data from 18 Global TravEpiNet clinics from January 2009 to December 2012 were analyzed. RESULTS: Of 23,534 travelers, 61% were non-occupational and 39% occupational. Business travelers were more likely to be men, had short times to departure and shorter trip durations, and commonly refused influenza, meningococcal, and hepatitis B vaccines. Most business travelers indicated that employers suggested the pre-travel health consultation, whereas non-occupational travelers sought consultations because of travel health concerns. CONCLUSIONS: Sub-groups of occupational travelers have characteristic profiles, with business travelers being particularly distinct. Employers play a role in encouraging business travelers to seek pre-travel consultations. Such consultations, even if scheduled immediately before travel, can identify vaccination gaps and increase coverage. |
Immunocompromised travelers: demographic characteristics, travel destinations, and pretravel health care from the U.S. Global TravEpiNet Consortium
Schwartz BS , Rosen J , Han PV , Hynes NA , Hagmann SH , Rao SR , Jentes ES , Ryan ET , LaRocque RC . Am J Trop Med Hyg 2015 93 (5) 1110-1116 An increasing number of immunocompromised individuals are pursuing international travel, and a better understanding of their international travel patterns and pretravel health care is needed. We evaluated the clinical features, itineraries, and pretravel health care of 486 immunocompromised international travelers seen at Global TravEpiNet sites from January 2009 to June 2012. We used bivariate analyses and logistic regressions using random intercept models to compare demographic and travel characteristics, vaccines administered, and medications prescribed for immunocompromised travelers versus 30,702 immunocompetent travelers. Immunocompromised travelers pursued itineraries that were largely similar to those of immunocompetent travelers, with nearly one-third of such travelers visiting countries with low human development indices. Biological agents, including tumor necrosis factor blockers, were commonly used immunosuppressive medications among immunocompromised travelers. A strong collaboration between travel-medicine specialists, primary care doctors, and specialist physicians is needed to prepare immunocompromised people for international travel. Incorporating routine questioning and planning regarding travel into the primary care visits of immunocompromised people may be useful. |
Use of Japanese encephalitis vaccine in US travel medicine practices in Global TravEpiNet
Deshpande BR , Rao SR , Jentes ES , Hills SL , Fischer M , Gershman MD , Brunette GW , Ryan ET , LaRocque RC . Am J Trop Med Hyg 2014 91 (4) 694-698 Few data regarding the use of Japanese encephalitis (JE) vaccine in clinical practice are available. We identified 711 travelers at higher risk and 7,578 travelers at lower risk for JE who were seen at US Global TravEpiNet sites from September of 2009 to August of 2012. Higher-risk travelers were younger than lower-risk travelers (median age = 29 years versus 40 years, P < 0.001). Over 70% of higher-risk travelers neither received JE vaccine during the clinic visit nor had been previously vaccinated. In the majority of these instances, clinicians determined that the JE vaccine was not indicated for the higher-risk traveler, which contradicts current recommendations of the Advisory Committee on Immunization Practices. Better understanding is needed of the clinical decision-making regarding JE vaccine in US travel medicine practices. |
Pre-travel preparation of US travelers going abroad to provide humanitarian service, Global TravEpiNet 2009-2011
Stoney RJ , Jentes ES , Sotir MJ , Kozarsky P , Rao SR , Larocque RC , Ryan ET . Am J Trop Med Hyg 2014 90 (3) 553-559 We analyzed characteristics of humanitarian service workers (HSWs) seen pre-travel at Global TravEpiNet (GTEN) practices during 2009-2011. Of 23,264 travelers, 3,663 (16%) travelers were classified as HSWs. Among HSWs, 1,269 (35%) travelers were medical workers, 1,298 (35%) travelers were non-medical service workers, and 990 (27%) travelers were missionaries. Median age was 29 years, and 63% of travelers were female. Almost one-half (49%) traveled to 1 of 10 countries; the most frequent destinations were Haiti (14%), Honduras (8%), and Kenya (6%). Over 90% of travelers were vaccinated or considered immune for hepatitis A, typhoid, and yellow fever. However, for hepatitis B, 292 (29%) of 990 missionaries, 228 (18%) of 1,298 non-medical service workers, and 76 (6%) of 1,269 medical workers were not vaccinated or considered immune. Of HSWs traveling to Haiti during 2010, 5% of travelers did not receive malaria chemoprophylaxis. Coordinated efforts from HSWs, HSW agencies, and clinicians could reduce vaccine coverage gaps and improve use of malaria chemoprophylaxis. |
Economics of malaria prevention in US travelers to West Africa
Adachi K , Coleman MS , Khan N , Jentes ES , Arguin P , Rao SR , LaRocque RC , Sotir MJ , Brunette G , Ryan ET , Meltzer MI . Clin Infect Dis 2014 58 (1) 11-21 BACKGROUND: Pretravel health consultations help international travelers manage travel-related illness risks through education, vaccination, and medication. This study evaluated costs and benefits of that portion of the health consultation associated with malaria prevention provided to US travelers bound for West Africa. METHODS: The estimated change in disease risk and associated costs and benefits resulting from traveler adherence to malaria chemoprophylaxis were calculated from 2 perspectives: the healthcare payer's and the traveler's. We used data from the Global TravEpiNet network of US travel clinics that collect de-identified pretravel data for international travelers. Disease risk and chemoprophylaxis effectiveness were estimated from published medical reports. Direct medical costs were obtained from the Nationwide Inpatient Sample and published literature. RESULTS: We analyzed 1029 records from January 2009 to January 2011. Assuming full adherence to chemoprophylaxis regimens, consultations saved healthcare payers a per-traveler average of $14 (9-day trip) to $372 (30-day trip). For travelers, consultations resulted in a range of net cost of $20 (9-day trip) to a net savings of $32 (30-day trip). Differences were mostly driven by risk of malaria in the destination country. CONCLUSIONS: Our model suggests that healthcare payers save money for short- and longer-term trips, and that travelers save money for longer trips when travelers adhere to malaria recommendations and prophylactic regimens in West Africa. This is a potential incentive to healthcare payers to offer consistent pretravel preventive care to travelers. This financial benefit complements the medical benefit of reducing the risk of malaria. |
Pre-exposure rabies vaccination among US international travelers: findings from the Global TravEpiNet Consortium
Dolan SB , Jentes ES , Sotir MJ , Han P , Blanton JD , Rao SR , Larocque RC , Ryan ET , The Global Travepinet Consortium . Vector Borne Zoonotic Dis 2013 14 (2) 160-7 BACKGROUND: People who travel to areas with high rabies endemicity and have animal contact are at increased risk for rabies exposure. We examined characteristics of international travelers queried regarding rabies vaccination during pretravel consultations at Global TravEpiNet (GTEN) practices during 2009-2010. MATERIAL AND METHODS: We performed bivariate and multivariable analyses of data collected from 18 GTEN clinics. Travel destinations were classified by strength level of rabies vaccination recommendation. RESULTS: Of 13,235 travelers, 226 (2%) reported previous rabies vaccination, and 406 (3%) received rabies vaccine at the consultation. Common travel purposes for these 406 travelers were leisure (26%), research/education (17%), and nonmedical service work (14%). Excluding the 226 who were previously vaccinated, 8070 (62%) of 13,009 travelers intended to visit one or more countries with a strong recommendation for rabies vaccination; 1675 (21%) of these 8070 intended to travel for 1 month or more. Among these 1675 travelers, 145 (9%) were vaccinated, 498 (30%) declined vaccination, 832 (50%) had itineraries that clinicians determined did not indicate vaccination, and 200 (12%) remained unvaccinated for other reasons. In both bivariate and multivariate analyses, travelers with trip durations >6 months versus 1-3 months (adjusted odds ratio [OR]=4.9 [95% confidence interval [CI] 2.1, 11.4]) and those traveling for "research/education" or to "provide medical care" (adjusted OR=5.1 [95% CI 1.9, 13.7] and 9.5 [95% CI 2.2, 40.8], respectively), compared with leisure travelers, were more likely to receive rabies vaccination. CONCLUSIONS: Few travelers at GTEN clinics received rabies vaccine, although many planned trips 1 month long or more to a strong-recommendation country. Clinicians often determined that vaccine was not indicated, and travelers often declined vaccine when it was offered. The decision to vaccinate should take into account the strength of the vaccine recommendation at the destination country, duration of stay, availability of postexposure prophylaxis, potential for exposure to animals, and likelihood of recurrent travel to high-risk destinations. |
Travel characteristics and yellow fever vaccine usage among US Global TravEpiNet travelers visiting countries with risk of yellow fever virus transmission, 2009-2011
Jentes ES , Han P , Gershman MD , Rao SR , Larocque RC , Staples JE , Ryan ET . Am J Trop Med Hyg 2013 88 (5) 954-961 Yellow fever (YF) vaccine-associated serious adverse events and changing YF epidemiology have challenged healthcare providers to vaccinate only travelers whose risk of YF during travel is greater than their risk of adverse events. We describe the travel characteristics and YF vaccine use among US travelers visiting Global TravEpiNet clinics from January of 2009 to March of 2011. Of 16,660 travelers, 5,588 (34%) had itineraries to areas with risk of YF virus transmission. Of those travelers visiting one country with YF risk (N = 4,517), 71% were vaccinated at the visit, and 20% were presumed to be immune from prior vaccination. However, travelers visiting friends and relatives (odds ratio [OR] = 2.57, 95% confidence interval [95% CI] = 1.27-5.22) or going to Nigeria (OR = 3.01, 95% CI = 1.37-6.62) were significantly more likely to decline vaccination. To optimize YF vaccine use, clinicians should discuss an individual's risk-benefit assessment of vaccination and close knowledge gaps regarding vaccine use among at-risk populations. |
Pre-travel health care of immigrants returning home to visit friends and relatives
Larocque RC , Deshpande BR , Rao SR , Brunette GW , Sotir MJ , Jentes ES , Ryan ET . Am J Trop Med Hyg 2012 88 (2) 376-380 Immigrants returning home to visit friends and relatives (VFR travelers) are at higher risk of travel-associated illness than other international travelers. We evaluated 3,707 VFR and 17,507 non-VFR travelers seen for pre-travel consultation in Global TravEpiNet during 2009-2011; all were traveling to resource-poor destinations. VFR travelers more commonly visited urban destinations than non-VFR travelers (42% versus 30%, P < 0.0001); 54% of VFR travelers were female, and 18% of VFR travelers were under 6 years old. VFR travelers sought health advice closer to their departure than non-VFR travelers (median days before departure was 17 versus 26, P < 0.0001). In multivariable analysis, being a VFR traveler was an independent predictor of declining a recommended vaccine. Missed opportunities for vaccination could be addressed by improving the timing of pre-travel health care and increasing the acceptance of vaccines. Making pre-travel health care available in primary care settings may be one step to this goal. |
Global TravEpiNet: A national consortium of clinics providing care to international travelers--analysis of demographic characteristics, travel destinations, and pretravel healthcare of high-risk US international travelers, 2009-2011
LaRocque RC , Rao SR , Lee J , Ansdell V , Yates JA , Schwartz BS , Knouse M , Cahill J , Hagmann S , Vinetz J , Connor BA , Goad JA , Oladele A , Alvarez S , Stauffer W , Walker P , Kozarsky P , Franco-Paredes C , Dismukes R , Rosen J , Hynes NA , Jacquerioz F , McLellan S , Hale D , Sofarelli T , Schoenfeld D , Marano N , Brunette G , Jentes ES , Yanni E , Sotir MJ , Ryan ET , Global TravEpiNet Consortium . Clin Infect Dis 2012 54 (4) 455-462 BACKGROUND: International travel poses a risk of destination-specific illness and may contribute to the global spread of infectious diseases. Despite this, little is known about the health characteristics and pretravel healthcare of US international travelers, particularly those at higher risk of travel-associated illness. METHODS: We formed a national consortium (Global TravEpiNet) of 18 US clinics registered to administer yellow fever vaccination. We collected data regarding demographic and health characteristics, destinations, purpose of travel, and pretravel healthcare from 13235 international travelers who sought pretravel consultation at these sites from January 2009 through January 2011. RESULTS: The destinations and itineraries of Global TravEpiNet travelers differed from those of the overall population of US international travelers. The majority of Global TravEpiNet travelers were visiting low- or lower-middle-income countries, and Africa was the most frequently visited region. Seventy-five percent of travelers were visiting malaria-endemic countries, and 38% were visiting countries endemic for yellow fever. Fifty-nine percent of travelers reported ≥1 medical condition. Atovaquone/proguanil was the most commonly prescribed antimalarial drug, and most travelers received an antibiotic for self-treatment of travelers' diarrhea. Hepatitis A and typhoid were the most frequently administered vaccines. CONCLUSIONS: Data from Global TravEpiNet provide insight into the characteristics and pretravel healthcare of US international travelers who are at increased risk of travel-associated illness due to itinerary, purpose of travel, or existing medical conditions. Improved understanding of this epidemiologically significant population may help target risk-reduction strategies and interventions to limit the spread of infections related to global travel. |
Pre-travel health advice-seeking behavior among US international travelers departing from Boston Logan International Airport
Larocque RC , Rao SR , Tsibris A , Lawton T , Anita Barry M , Marano N , Brunette G , Yanni E , Ryan ET . J Travel Med 2010 17 (6) 387-91 BACKGROUND: Globally mobile populations are at higher risk of acquiring geographically restricted infections and may play a role in the international spread of infectious diseases. Despite this, data about sources of health information used by international travelers are limited. METHODS: We surveyed 1,254 travelers embarking from Boston Logan International Airport regarding sources of health information. We focused our analysis on travelers to low or low-middle income (LLMI) countries, as defined by the World Bank 2009 World Development Report. RESULTS: A total of 476 survey respondents were traveling to LLMI countries. Compared with travelers to upper-middle or high income (UMHI) countries, travelers to LLMI countries were younger, more likely to be foreign-born, and more frequently reported visiting family as the purpose of their trip. Prior to their trips, 46% of these travelers did not pursue health information of any type. In a multivariate analysis, being foreign-born, traveling alone, traveling for less than 14 days, and traveling for vacation each predicted a higher odds of not pursuing health information among travelers to LLMI countries. The most commonly cited reason for not pursuing health information was a lack of concern about health problems related to the trip. Among travelers to LLMI countries who did pursue health information, the internet was the most common source, followed by primary care practitioners. Less than a third of travelers to LLMI countries who sought health information visited a travel medicine specialist. CONCLUSIONS: In our study, 46% of travelers to LLMI countries did not seek health advice prior to their trip, largely due to a lack of concern about health issues related to travel. Among travelers who sought medical advice, the internet and primary care providers were the most common sources of information. These results suggest the need for health outreach and education programs targeted at travelers and primary care practitioners. |
- Page last reviewed:Feb 1, 2024
- Page last updated:May 13, 2024
- Content source:
- Powered by CDC PHGKB Infrastructure