title: Travel-associated infection presenting in Europe (2008-12): an analysis of EuroTravNet longitudinal, surveillance data, and evaluation of the effect of the pre-travel consultation.
abstract: BACKGROUND
  Travel is important in the acquisition and dissemination of infection. We aimed to assess European surveillance data for travel-related illness to profile imported infections, track trends, identify risk groups, and assess the usefulness of pre-travel advice.
  
  
  METHODS
  We analysed travel-associated morbidity in ill travellers presenting at EuroTravNet sites during the 5-year period of 2008-12. We calculated proportionate morbidity per 1000 ill travellers and made comparisons over time and between subgroups. We did 5-year trend analyses (2008-12) by testing differences in proportions between subgroups using Pearson's χ(2) test. We assessed the effect of the pre-travel consultation on infection acquisition and outcome by use of proportionate morbidity ratios.
  
  
  RESULTS
  The top diagnoses in 32 136 patients, ranked by proportionate morbidity, were malaria and acute diarrhoea, both with high proportionate morbidity (>60). Dengue, giardiasis, and insect bites had high proportionate morbidity (>30) as well. 5-year analyses showed increases in vector borne infections with significant peaks in 2010; examples were increased Plasmodium falciparum malaria (χ(2)=37·57, p<0·001); increased dengue fever (χ(2)=135·9, p<0·001); and a widening geographic range of acquisition of chikungunya fever. The proportionate morbidity of dengue increased from 22 in 2008 to 36 in 2012. Five dengue cases acquired in Europe contributed to this increase. Dermatological diagnoses increased from 851 in 2008 to 1102 in 2012, especially insect bites and animal-related injuries. Respiratory infection trends were dominated by the influenza H1N1 pandemic in 2009. Illness acquired in Europe accounted for 1794 (6%) of all 32 136 cases-mainly, gastrointestinal (634) and respiratory (357) infections. Migration within Europe was associated with more serious infection such as hepatitis C, tuberculosis, hepatitis B, and HIV/AIDS. Pre-travel consultation was associated with significantly lower proportionate morbidity ratios for P falciparum malaria and also for acute hepatitis and HIV/AIDS.
  
  
  CONCLUSIONS
  The pattern of travel-related infections presenting in Europe is complex. Trend analyses can inform on emerging infection threats. Pre-travel consultation is associated with reduced malaria proportionate morbidity ratios and less severe illness. These findings support the importance and effectiveness of pre-travel advice on malaria prevention, but cast doubt on the effectiveness of current strategies to prevent travel-related diarrhoea.
  
  
  BACKGROUND
  European Centre for Disease Prevention and Control, University Hospital Institute Méditerranée Infection, US Centers for Disease Control and Prevention, and the International Society of Travel Medicine.
authors.affiliation: University of Zürich Centre for Travel Medicine, WHO Collaborating Centre for Travellers' Health, Epidemiology, Biostatistics, and Prevention Institute, Zürich, Switzerland. Electronic address: pat@ifspm.uzh.ch.
authors.forename: Patricia
authors.initials: P
authors.lastname: Schlagenhauf
authors.affiliation: EuroTravNet, Victoria, BC, Canada.
authors.forename: Leisa
authors.initials: L
authors.lastname: Weld
authors.affiliation: Centre for Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
authors.forename: Abraham
authors.initials: A
authors.lastname: Goorhuis
authors.affiliation: University Hospital Institute for Infectious and Tropical Diseases, Aix-Marseille University, Marseille, France.
authors.forename: Philippe
authors.initials: P
authors.lastname: Gautret
authors.affiliation: University Hospital, Department of Infectious Diseases, University of Zürich, Switzerland.
authors.forename: Rainer
authors.initials: R
authors.lastname: Weber
authors.affiliation: Department of Infectious Diseases and Tropical Medicine, Ludwig-Maximilian's University of Munich, Munich, Germany.
authors.forename: Frank
authors.initials: F
authors.lastname: von Sonnenburg
authors.affiliation: Tropical Medicine and Clinical Parasitology, Infectious Diseases Department, Ramón y Cajal Hospital, Madrid, Spain.
authors.forename: Rogelio
authors.initials: R
authors.lastname: Lopez-Vélez
authors.affiliation: Department of Infectious Diseases, Oslo University Hospital, Oslo, Norway.
authors.forename: Mogens
authors.initials: M
authors.lastname: Jensenius
authors.affiliation: University Medical Center Hamburg-Eppendorf, Department of Tropical Medicine and Infectious Diseases, Bernhard Nocht Clinic, Hamburg, Germany.
authors.forename: Jakob P
authors.initials: JP
authors.lastname: Cramer
authors.affiliation: InterHealth Worldwide and National Travel Health Network and Centre (NaTHNaC), London, UK.
authors.forename: Vanessa K
authors.initials: VK
authors.lastname: Field
authors.affiliation: University Division of Infectious and Tropical Diseases, University of Brescia and Brescia Spedali Civili General Hospital, Brescia, Italy.
authors.forename: Silvia
authors.initials: S
authors.lastname: Odolini
authors.affiliation: Department of Infectious Diseases, Addenbrooke's Hospital, Cambridge, UK.
authors.forename: Effrossyni
authors.initials: E
authors.lastname: Gkrania-Klotsas
authors.affiliation: Division of Tropical and Humanitarian Medicine, Geneva University Hospitals, Geneva, Switzerland.
authors.forename: Francois
authors.initials: F
authors.lastname: Chappuis
authors.affiliation: Department of Internal Medicine and Tropical Disease, University Hospital Centre, Bordeaux, France.
authors.forename: Denis
authors.initials: D
authors.lastname: Malvy
authors.affiliation: Institute for Tropical Disease, Harbour Hospital, Rotterdam, The Netherlands.
authors.forename: Perry J J
authors.initials: PJ
authors.lastname: van Genderen
authors.affiliation: Institute of Tropical Medicine and International Health, Charité-Universitätsmedizin Berlin, Germany.
authors.forename: Frank
authors.initials: F
authors.lastname: Mockenhaupt
authors.affiliation: Service des Maladies Infectieuses et Tropicales (Department of Infectious and Tropical Diseases), Hôpital Pitié-Salpétrière, Paris, France.
authors.forename: Stéphane
authors.initials: S
authors.lastname: Jauréguiberry
authors.affiliation: Travel Medicine and International Health Team, Health Protection Scotland, NHS National Services Scotland, Glasgow, UK.
authors.forename: Catherine
authors.initials: C
authors.lastname: Smith
authors.affiliation: Liverpool School of Tropical Medicine and National Institute for Health Research Unit in Emerging and Zoonotic Infections, Liverpool, UK.
authors.forename: Nicholas J
authors.initials: NJ
authors.lastname: Beeching
authors.affiliation: Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden.
authors.forename: Johan
authors.initials: J
authors.lastname: Ursing
authors.forename: Christophe
authors.initials: C
authors.lastname: Rapp
authors.affiliation: University Hospital Institute for Infectious and Tropical Diseases, Aix-Marseille University, Marseille, France.
authors.forename: Philippe
authors.initials: P
authors.lastname: Parola
authors.affiliation: Centre for Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
authors.forename: Martin P
authors.initials: MP
authors.lastname: Grobusch
mesh_terms: D000328:Adult; D000818:Animals; D003140:Communicable Disease Control / Q000379:methods*; D003141:Communicable Diseases / Q000453:epidemiology*; D062665:Epidemiological Monitoring; D005060:Europe / Q000453:epidemiology; D005260:Female; D006801:Humans; D015994:Incidence; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D014195:Travel