title: Syndromic Approach to Arboviral Diagnostics for Global Travelers as a Basis for Infectious Disease Surveillance.
abstract: BACKGROUND
  Arboviruses have overlapping geographical distributions and can cause symptoms that coincide with more common infections. Therefore, arbovirus infections are often neglected by travel diagnostics. Here, we assessed the potential of syndrome-based approaches for diagnosis and surveillance of neglected arboviral diseases in returning travelers.
  
  
  METHODS
  To map the patients high at risk of missed clinical arboviral infections we compared the quantity of all arboviral diagnostic requests by physicians in the Netherlands, from 2009 through 2013, with a literature-based assessment of the travelers' likely exposure to an arbovirus.
  
  
  RESULTS
  2153 patients, with travel and clinical history were evaluated. The diagnostic assay for dengue virus (DENV) was the most commonly requested (86%). Of travelers returning from Southeast Asia with symptoms compatible with chikungunya virus (CHIKV), only 55% were tested. For travelers in Europe, arbovirus diagnostics were rarely requested. Over all, diagnostics for most arboviruses were requested only on severe clinical presentation.
  
  
  CONCLUSIONS
  Travel destination and syndrome were used inconsistently for triage of diagnostics, likely resulting in vast under-diagnosis of arboviral infections of public health significance. This study shows the need for more awareness among physicians and standardization of syndromic diagnostic algorithms.
authors.affiliation: Erasmus Medical Centre, Rotterdam, The Netherlands; National Institute for Public Health and Environment (RIVM), Bilthoven, The Netherlands.
authors.forename: Natalie B
authors.initials: NB
authors.lastname: Cleton
authors.affiliation: Erasmus Medical Centre, Rotterdam, The Netherlands.
authors.forename: Chantal B E M
authors.initials: CB
authors.lastname: Reusken
authors.affiliation: Erasmus Medical Centre, Rotterdam, The Netherlands.
authors.forename: Jiri F P
authors.initials: JF
authors.lastname: Wagenaar
authors.affiliation: University of Reading, Reading, Berkshire, United Kingdom.
authors.forename: Elske E
authors.initials: EE
authors.lastname: van der Vaart
authors.affiliation: National Institute for Public Health and Environment (RIVM), Bilthoven, The Netherlands.
authors.forename: Johan
authors.initials: J
authors.lastname: Reimerink
authors.affiliation: Erasmus Medical Centre, Rotterdam, The Netherlands.
authors.forename: Annemiek A
authors.initials: AA
authors.lastname: van der Eijk
authors.affiliation: Erasmus Medical Centre, Rotterdam, The Netherlands; National Institute for Public Health and Environment (RIVM), Bilthoven, The Netherlands.
authors.forename: Marion P G
authors.initials: MP
authors.lastname: Koopmans
mesh_terms: D001102:Arbovirus Infections / Q000175:diagnosis* / Q000453:epidemiology* / Q000473:pathology; D062665:Epidemiological Monitoring; D005260:Female; D006801:Humans; D008297:Male; D014195:Travel