title: Cutaneous larva migrans and tungiasis in international travelers exiting Brazil: an airport survey.
abstract: BACKGROUND
  Hookworm-related cutaneous larva migrans (CLM) and tungiasis are commonly diagnosed in travelers returning from endemic areas, but reliable data on disease occurrence do not exist. To describe the occurrence of CLM and tungiasis in international travelers, a cross-sectional study was done.
  
  
  METHODS
  We conducted an airport survey in European travelers exiting northeast Brazil. Questionnaires were distributed at the departure gate of the international airport of Fortaleza (Ceará State) while passengers were waiting to board their plane. The questionnaire included questions on personal characteristics, pretravel health advice, acquired parasitic skin diseases during their stay in Brazil, and clinical characteristics of the infestation. To help identify CLM and tungiasis, photographs of the typical appearances of the infestations were presented.
  
  
  RESULTS
  Data from 372 tourists (aged 16-76 y, median = 40 y) were available for analysis; 45% had obtained pretravel health advice, usually from travel clinics (46.2%) and Internet sites (39.6%). Only 14% of those who obtained advice had been informed about CLM as a travel health risk and 22% about tungiasis. During their stay in Brazil, 12 (3.2%) tourists had experienced tungiasis and 3 (0.8%) CLM. In all cases, lesions were confined to the feet. The three travelers with CLM complained of irritability; itching was present in two cases. Pain (58.3%) and itching (50%) were the most common symptoms in travelers with tungiasis. The length of stay was a clear predictor for tungiasis, with a 20 times higher occurrence in travelers who had stayed for more than 4 weeks in Brazil.
  
  
  CONCLUSIONS
  Tungiasis and CLM are not rare in international tourists departing from Brazil, and pretravel counseling is insufficient. Pretravel health advice should include information on the risk of acquiring tungiasis and CLM and how to prevent an infestation. Airport surveys using questionnaires can be used to obtain incidence data on both parasitic infestations.
authors.affiliation: Department of Community Health, School of Medicine, Federal University of Ceará, Fortaleza, Ceará, Brazil. heukelbach@web.de
authors.forename: Jörg
authors.initials: J
authors.lastname: Heukelbach
authors.forename: Marcia
authors.initials: M
authors.lastname: Gomide
authors.forename: Francisco
authors.initials: F
authors.lastname: Araújo
authors.forename: Nathalia S R
authors.initials: NS
authors.lastname: Pinto
authors.forename: Rafael D
authors.initials: RD
authors.lastname: Santana
authors.forename: João R M
authors.initials: JR
authors.lastname: Brito
authors.forename: Hermann
authors.initials: H
authors.lastname: Feldmeier
mesh_terms: D000328:Adult; D000818:Animals; D001938:Brazil / Q000453:epidemiology; D016009:Chi-Square Distribution; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D007815:Larva Migrans / Q000453:epidemiology*; D008297:Male; D008875:Middle Aged; D012307:Risk Factors; D005423:Siphonaptera; D012876:Skin Diseases, Parasitic / Q000453:epidemiology*; D011795:Surveys and Questionnaires; D014195:Travel