Imported infectious disease and purpose of travel, Switzerland.We evaluated the epidemiologic factors of patients seeking treatment for travel-associated illness from January 2004 through May 2005 at the University Hospital of Zurich. When comparing persons whose purpose of travel was visiting friends and relatives (VFR VFR abbr. visual flight rules travelers; n = 121) with tourists and other travelers (n = 217), VFR travelers showed a distinct infectious disease Infectious disease A pathological condition spread among biological species. Infectious diseases, although varied in their effects, are always associated with viruses, bacteria, fungi, protozoa, multicellular parasites and aberrant proteins known as prions. and risk spectrum. VFR travelers were more likely to receive a diagnosis of malaria (adjusted odds ratio [OR] = 2.9, 95% confidence interval confidence interval, n a statistical device used to determine the range within which an acceptable datum would fall. Confidence intervals are usually expressed in percentages, typically 95% or 99%. [CI] 1.2-7.3) or viral hepatitis viral hepatitis n. Any of various forms of hepatitis caused by a virus. viral hepatitis, n an inflammatory condition of the liver, caused by the hepatitis viruses: A, B, C, delta, E, F, G, or H. (OR = 3.1, 95% CI 1.1-9) compared with other travelers but were less likely to seek pretravel advice (20% vs. 67%, p = 0.0001). However, proportionate rates of acute diarrhea were lower in VFR (173 vs. 364 per 1,000 ill returnees). Travel to sub-Saharan Africa contributed most to malaria in VFR travelers. In countries with large migrant populations, improved public health strategies are needed to reach VFR travelers. ********** More than 800 million tourist arrivals were registered worldwide in 2005, and an estimated 2% of the world's population lives outside the country of birth (1). Importation of infectious diseases infectious diseases: see communicable diseases. to new countries is likely to increase among both travelers and immigrants. Approximately 80 million people from resource-rich areas worldwide travel to resource-poor countries every year (2) and are exposed to many infections that are no longer prevalent in the countries where they live. Travelers visiting friends and relatives (VFR travelers)--predominantly immigrants and their children returning to their home countries for vacations, to maintain family ties, or to visit sick relatives--are at particularly high risk for preventable infectious diseases, such as malaria, typhoid fever typhoid fever acute, generalized infection caused by Salmonella typhi. The main sources of infection are contaminated water or milk and, especially in urban communities, food handlers who are carriers. , hepatitis A Hepatitis A Definition Hepatitis A is an inflammation of the liver caused by a virus, the hepatitis A virus (HAV). It varies in severity, running an acute course, generally starting within two to six weeks after contact with the virus, and lasting no , hepatitis B Hepatitis B Definition Hepatitis B is a potentially serious form of liver inflammation due to infection by the hepatitis B virus (HBV). It occurs in both rapidly developing (acute) and long-lasting (chronic) forms, and is one of the most common chronic , and tuberculosis (3-5). A recent review of a global surveillance network's data set showed different demographic characteristics and different types of travel-related illnesses among immigrant-VFR, traveler-VFR, and tourist travelers (5). The population of western Europe Western Europe The countries of western Europe, especially those that are allied with the United States and Canada in the North Atlantic Treaty Organization (established 1949 and usually known as NATO). includes [approximately equal to] 20 million persons living in normative countries; most are settled immigrants. One third were born in a country outside of Europe (6). In Switzerland, [approximately equal to] 21% (1.6 million) residents are foreign born (7). Compared with the health of the native population of Switzerland, the health status of the immigrant population is poor (8) because of the high prevalence of infectious diseases in the home countries (9), a difficult psychosocial psychosocial /psy·cho·so·cial/ (si?ko-so´shul) pertaining to or involving both psychic and social aspects. psy·cho·so·cial adj. Involving aspects of both social and psychological behavior. environment in the new country, inappropriate risk-taking behavior (10), and social inequalities (11). The University Hospital of Zurich serves a large proportion of the city's population, which includes a multiethnic mul·ti·eth·nic adj. Of, relating to, or including several ethnic groups. Adj. 1. multiethnic - involving several ethnic groups multi-ethnic range of patients and immigrants. The outpatient departments treat [approximately equal to] 120,000 patients each year, and the inpatient departments treat >35,000. We evaluated the epidemiology of imported infectious disease of patients seeking treatment for travel-associated illness at the University Hospital of Zurich from January 2004 through May 2005. Patients and Methods The University Hospital of Zurich, as part of the global GeoSentinel surveillance network, contributed clinician-based surveillance data during a 17-month period, January 2004-June 2005, according to according to prep. 1. As stated or indicated by; on the authority of: according to historians. 2. In keeping with: according to instructions. 3. demographic characteristics, risk for infectious disease while traveling, and frequency of pretravel advice. GeoSentinel is a global sentinel surveillance network that was established in 1995 through the Intemational Society for Travel Medicine and the US Centers for Disease Control and Prevention Centers for Disease Control and Prevention (CDC), agency of the U.S. Public Health Service since 1973, with headquarters in Atlanta; it was established in 1946 as the Communicable Disease Center. . The network consists of 33 globally distributed member travel/tropical medicine clinics (12) and has been widely used to document travel-related illnesses (5,13-15). Inclusion Criteria
Inclusion criteria are a set of conditions that must be met in order to participate in a clinical trial. To be eligible, patients must have crossed an international border [less than or equal to] 10 years before seeking treatment and must have sought medical advice for a presumed travel-related illness. Relevant travel details focused only on data from the 6 months before the onset of illness. Only final diagnoses were considered, and >1 diagnosis per patient was possible. Data were collected according to a standardized, anonymous questionnaire. The questionnaire asked for demographic data (age, sex, country of birth, country of residence, current citizenship), travel history during the previous 5 years, inpatient or outpatient status, major clinical symptoms (>1 per patient possible), pretravel visit information, reason for most recent travel, and patient classification. Reasons for most recent travel were immigration immigration, entrance of a person (an alien) into a new country for the purpose of establishing permanent residence. Motives for immigration, like those for migration generally, are often economic, although religious or political factors may be very important. , tourism, business, research/education, missionary/ volunteer work, visit to friends or relatives, and expatriation. Patients were classified as immigrants/refugees, foreign visitors, urban expatriates, nonurban expatriates, students, military personnel, or travelers. Working and final diagnoses were assigned by a physician. Definitions An immigrant/refugee was defined as a foreign-born person who had obtained permanent resident status or immigrant/refugee status in Switzerland. Traveler (or traditional traveler) was defined as a resident of Switzerland who crossed an international border and did not previously immigrate im·mi·grate v. im·mi·grat·ed, im·mi·grat·ing, im·mi·grates v.intr. To enter and settle in a country or region to which one is not native. See Usage Note at migrate. v.tr. to Switzerland. When the purpose of recent travel was visiting friends and relatives, a traveler was termed VFR. Different patient classifications were possible (i.e., immigrant-VFR, traveler-VFR). The rate of illness was calculated as the number of patients with a specific or a summary diagnosis as a proportion of all VFR or traditional travelers, respectively, expressed as number per 1,000 patients. The percentage of "chief complaints" was expressed as the number of primary symptoms that led to a clinic visit per total patients in each group. More than 1 chief complaint per patient was possible. Countries were assigned to 1 of 15 regional classifications (13). Because of small case numbers, a more simplified regional classification was sometimes used: sub-Saharan Africa, south-central America (South and Central America Central America, narrow, southernmost region (c.202,200 sq mi/523,698 sq km) of North America, linked to South America at Colombia. It separates the Caribbean from the Pacific. ), Asia (south-central, southeast, east, and north Asia North Asia or Northern Asia is a subregion of Asia. The most common definition of the term is;
The countries of eastern Europe, especially those that were allied with the USSR in the Warsaw Pact, which was established in 1955 and dissolved in 1991. . "All other regions" include those with no assigned travel destination. For travelers or VFR who entered >1 region, the most likely place of exposure during travel was determined to be the single region visited. Summary diagnosis were defined as follows: "respiratory tract infection Noun 1. respiratory tract infection - any infection of the respiratory tract respiratory infection infection - the pathological state resulting from the invasion of the body by pathogenic microorganisms " included upper and lower respiratory infections Noun 1. lower respiratory infection - infection of the lower respiratory tract respiratory infection, respiratory tract infection - any infection of the respiratory tract ; "malaria" infections included all malaria-causing species; "diarrhea" included acute diarrhea of parasitic, viral, bacterial or unknown origin; "hepatitis" included chronic or acute viral hepatitis; "viral syndrome" included any nonspecific nonspecific /non·spe·cif·ic/ (non?spi-sif´ik) 1. not due to any single known cause. 2. not directed against a particular agent, but rather having a general effect. nonspecific 1. viral symptoms; and "AIDS/HIV/STI" included asymptomatic HIV HIV (Human Immunodeficiency Virus), either of two closely related retroviruses that invade T-helper lymphocytes and are responsible for AIDS. There are two types of HIV: HIV-1 and HIV-2. HIV-1 is responsible for the vast majority of AIDS in the United States. , acute HIV, AIDS, gonorrhea gonorrhea (gŏnərē`ə), common infectious disease caused by a bacterium (Neisseria gonorrhoeae), involving chiefly the mucous membranes of the genitourinary tract. , syphilis syphilis (sĭf`əlĭs), contagious sexually transmitted disease caused by the spirochete Treponema pallidum (described by Fritz Schaudinn and Erich Hoffmann in 1905). , and other sexually transmitted infections (STIs). Syndrome groups such as "dermatologic dermatological, dermatologic pertaining to dermatology; of or affecting the skin. disorder" were defined as previously described (15). Statistics Stata software (version 9.1, Stata Corporation, College Station, TX, USA) was used for statistical analysis. Odds ratios (OR) of binary, categorical That which is unqualified or unconditional. A categorical imperative is a rule, command, or moral obligation that is absolutely and universally binding. Categorical is also used to describe programs limited to or designed for certain classes of people. , or continuous variables were determined by logistic regression In statistics, logistic regression is a regression model for binomially distributed response/dependent variables. It is useful for modeling the probability of an event occurring as a function of other factors. (multivariate The use of multiple variables in a forecasting model. or univariate) and adjusted to age and sex if indicated. Statistical significance of dichotomous di·chot·o·mous adj. 1. Divided or dividing into two parts or classifications. 2. Characterized by dichotomy. di·chot variables was achieved by using [chi square chi square (kī), n a nonparametric statistic used with discrete data in the form of frequency count (nominal data) or percentages or proportions that can be reduced to frequencies. ] or nonparametric tests. Results General Description and Demographic Data We analyzed 451 patients included in the database: 181 immigrants, 227 travelers, 25 foreign visitors, and 18 others (expatriates, students, military personnel). Age range was 16-87 years (median 33, interquartile range In descriptive statistics, the interquartile range (IQR), also called the midspread, middle fifty and middle of the #s, is a measure of statistical dispersion, being equal to the difference between the third and first quartiles. 27-43); 48% were female, and 20% were inpatients. The median duration of travel was 17.5 days (interquartile range 13-29 days). For these patients, 671 diagnoses were counted. Leading complaints were "fever" (43.0%), "gastrointestinal" (42.7%), "head-ear-nose" (25.2%), "respiratory" (24.3%), "musculoskeletal musculoskeletal /mus·cu·lo·skel·e·tal/ (-skel´e-t'l) pertaining to or comprising the skeleton and muscles. mus·cu·lo·skel·e·tal adj. Relating to or involving the muscles and the skeleton. " (12.8%), and "skin" (11.9%, data not shown). The visits were evenly distributed during the calendar year, with no seasonal abnormities or significant associations. Comparison of VFR and Traditional Travelers Our analysis included 217 traditional travelers and 121 VFR travelers. For traditional travelers, the reason for most recent travel was tourism or business. Most VFR travelers (86%) were in the category "immigrants." Birth country regions of VFR travelers were Asia (30%), sub-Saharan Africa (24%), Eastern Europe (17%), and Central or South America South America, fourth largest continent (1991 est. pop. 299,150,000), c.6,880,000 sq mi (17,819,000 sq km), the southern of the two continents of the Western Hemisphere. (11%). The basic demographic pattern was comparable (Table 1). VFR travelers traveled on average for a longer period than traditional travelers, were slightly older, were more likely to have inpatient status, and were less likely to seek pretravel advice. Traveled regions were also comparable (Table 1). Fever and gastrointestinal disorders were the most frequent reasons for seeking treatment (Table 2). Traditional travelers had more gastrointestinal symptoms (53.91% vs. 39.66%, p = 0.03). When the disease spectrums were compared, acute diarrhea was more often diagnosed in traditional travelers (26%) than in VFR travelers (11%). The summary diagnosis HIV/AIDS/STI was more commonly established in VFR travelers (9.9% vs. 4.3%); the same was true for malaria (7.7% vs. 2.7%). The proportionate illness patterns are shown graphically in the online Appendix Figure (available from www.cdc.gov/EID/content/13/2/217-appG.htm). When comparing VFR with traditional travelers, VFR travelers were more likely to receive a diagnosis of malaria, acute or chronic viral hepatitis, and HIV/AIDS/STI (Table 3) but less likely to receive a diagnosis of acute diarrhea. In contrast, traditional travelers were more likely to receive a diagnosis of diarrhea (OR 2.1, 95% confidence interval [CI] 1.2-3.6, p = 0.007; data not shown). Respiratory diseases and viral syndromes were significantly associated with VFR travelers only in the univariate analysis (Table 3). Traditional travelers were significantly more likely to seek pretravel advice compared with VFR travelers (Table 1). A different infectious disease spectrum and a trend toward a distinct pattern in both VFR and traditional travelers were also found when selecting different travel regions (Figure). Malaria cases were almost exclusively imported from the sub-Saharan Africa region; 33.3% of diagnoses after travel to this region were attributed to malaria in VFR travelers, compared with 12.3% in traditional travelers. In total, 27 malaria cases were recorded in the GeoSentinel database during the 17-month period: 14 in VFR travelers, 8 in tourist travelers, 4 in recent immigrants, and 1 in an immigrant/refugee. Of these, 22 cases were imported from sub-Saharan Africa and 1 from Turkey; for 4 case-patients, no specified travel region or no information on place of exposure was available. When data were stratified stratified /strat·i·fied/ (strat´i-fid) formed or arranged in layers. strat·i·fied adj. Arranged in the form of layers or strata. by VFR versus traditional traveler, the risk for malaria in sub-Saharan Africa was twice as high in the VFR traveler group than in the traditional traveler group (data not shown). [GRAPHIC OMITTED] Discussion The GeoSentinel site based at the University Hospital of Zurich represents a large population in Switzerland. However, GeoSentinel is a health facility-based surveillance system and does not actively screen for certain diseases. Patients included in the database do not necessarily represent the whole population or the epidemiology or frequency of the disease. Besides the unknown number of ill returned travelers going to general practitioners general practitioner n. Abbr. GP A physician whose practice consists of providing ongoing care covering a variety of medical problems in patients of all ages, often including referral to appropriate specialists. or nonspecialized clinics, the number of travelers returning in good health is also unknown. Incidence rates or relative risks therefore cannot be estimated. Similarly, patients with mild or self-limiting disease are likely to see a general practitioner rather than to go to a specialized center, although many VFR travelers do not have a regular general practitioner. On the other hand, Zurich is a large city with a socioculturally mixed population that offers an opportunity to study immigrant-VFR travelers, and many of these patients may prefer to go to a more anonymous university hospital than to a general practitioner. A limitation of the study is the relatively small number of patients included in the database during the 17-month period, which made it necessary to form summary diagnoses and regions. In our analysis, VFR travelers showed a different infectious disease and risk spectrum than did traditional travelers; were more likely to receive a diagnosis of malaria, viral hepatitis, or HIV/AIDS/STI; and were less likely to seek pretravel advice. Traditional travelers (mainly tourists) were significantly more likely to seek advice before traveling and to have a posttravel diagnosis of acute diarrhea. This is consistent with previous studies from European migrants returning to their home countries (16), as well as a recent review of the global GeoSentinel database (5). Malaria is most likely to be acquired in the sub-Saharan Africa region, according to our data and those of others (13,15). By contrast, acute diarrhea was the greatest problem in traditional travelers, with an illness rate of 364 per 1,000 ill returned travelers compared with 173/1,000 in VFR travelers. Acute diarrhea, or traveler's diarrhea Traveler's Diarrhea Definition The occurrence of multiple loose bowel movements in someone traveling to an area outside their usual surroundings (usually from temperate industrialized regions to tropical areas), is known as Traveler's diarrhea (TD). , is known to affect >50% of travelers, depending on the destination (17). The protective effect in VFR travelers could reflect immunity due to recent exposure or exposure in childhood. Acute or chronic viral hepatitis was also significantly associated with VFR travel, which correlates with a recent study of hepatitis A virus Noun 1. hepatitis A virus - the virus causing hepatitis A enterovirus - any of a group of picornaviruses that infect the gastrointestinal tract and can spread to other areas (especially the nervous system) infections in Swiss travelers during a period of 12 years that identified VFR travelers as a high-risk group high-risk group Epidemiology A group of people in the community with a higher-than-expected risk for developing a particular disease, which may be defined on a measurable parameter–eg, an inherited genetic defect, physical attribute, lifestyle, habit, , especially children of immigrants (18). Other significant associations of disease between VFR and traditional travelers were not found; however, this does not necessarily mean that no such relationship exists. Systemic febrile febrile /feb·rile/ (feb´ril) pertaining to or characterized by fever. feb·rile adj. Of, relating to, or characterized by fever; feverish. illnesses, including malaria and typhoid fever, tuberculosis, and respiratory syndromes 'respiratory syndrome' A relatively specific immune response to high-dose rifampin therapy, characterized by a flu-like complex, dyspnea and wheezing, leukopenia, thrombocytopenia; other hypersensitivity reactions caused by rifampin include flushing, fever, , are more frequently diagnosed among VFR travelers (5). In our study, respiratory diseases contributed to the relatively high rate of illness in both VFR and traditional travelers (181 vs. 184 per 1,000 ill returnees). No significant association could be established between influenza, long trip duration, and travel involving visiting friends and relatives as described before (14), probably because of small numbers and very few cases of influenza. Viral syndrome, a rather loosely defined summary diagnosis with unspecific Adj. 1. unspecific - not detailed or specific; "a broad rule"; "the broad outlines of the plan"; "felt an unspecific dread" broad general - applying to all or most members of a category or group; "the general public"; "general assistance"; "a general rule"; viral symptoms, was also frequently diagnosed and can be interpreted as a flulike syndrome. Other typical tropical infectious diseases, such as typhoid fever, leishmaniasis leishmaniasis (lēsh'mənī`əsĭs), any of a group of tropical diseases caused by parasitic protozoans of the genus Leishmania. , dengue fever dengue fever (dĕng`gē, –gā), acute infectious disease caused by four closely related viruses and transmitted by the bite of the Aedes mosquito; it is also known as breakbone fever and bone-crusher disease. , or brucellosis brucellosis (br  'səlō`sĭs) or Bang's disease, infectious disease of farm animals that is sometimes transmitted to humans. , were rarely diagnosed.This study shows that VFR travelers are at greater risk for certain infectious diseases and have a disease spectrum distinct from that of traditional travelers. Malaria is the most important, life-threatening imported disease for both nonimmune and VFR travelers, and malaria acquisition is even more likely in VFR travelers. For other infectious diseases, HIV and STIs must also be included in the differential diagnosis differential diagnosis n. Determination of which one of two or more diseases with similar symptoms is the one from which the patient is suffering. Also called differentiation. , particularly for VFR travelers. VFR travelers are vulnerable because they may visit more rural destinations, live under poor sanitary conditions, and stay away for longer periods (3,4). Moreover, the health condition of the immigrant population in Switzerland is poor compared with that of the native population (8). Prevalence gaps in disease and disparities in access to care exist not only between countries but also between population groups within countries. In addition, VFR travelers often did not seek pretravel advice. Thus, culturally sensitive strategies for pretravel contact with VFR travelers are greatly needed. Further surveillance of traveler groups with denominator data is needed, and prospective studies focusing on behavioral aspects of disease prevention would allow for evidence-based interventions as part of a public health strategy. Acknowledgments We are grateful to Elena Axelrod for help in preparing the data set, Leisa Weld for statistical consultancy, and Hanspeter Jauss for technical assistance. We also thank the GeoSentinel network, the local site at Zurich, and the medical staff at Zurich University Hospital for their cooperation. References (1.) Gushulak BD, MacPherson DW. Globalization globalization Process by which the experience of everyday life, marked by the diffusion of commodities and ideas, is becoming standardized around the world. Factors that have contributed to globalization include increasingly sophisticated communications and transportation of infectious diseases: the impact of migration. Clin Infect Dis. 2004;38:1742-8. (2.) World Tourism Organisation Facts and Figures. [cited 2006 Jun 12]. Available from http://www.world-tourism.org/facts/menu.html (3.) Bacaner N, Stauffer B, Boulware DR, Walker PF, Keystone JS. Travel medicine considerations for North American North American named after North America. North American blastomycosis see North American blastomycosis. North American cattle tick see boophilusannulatus. immigrants visiting friends and relatives. JAMA JAMA abbr. Journal of the American Medical Association . 2004;291:2856-64. (4.) Angell SY, Cetron MS. Health disparities
Health disparities (also called health inequalities in some countries) refer to gaps in the quality of health and health care across racial, ethnic, and socioeconomic groups. among travelers visiting friends and relatives abroad. Ann Intern intern /in·tern/ (in´tern) a medical graduate serving in a hospital preparatory to being licensed to practice medicine. in·tern or in·terne n. Med. 2005;142:67-72. (5.) Leder K, Tong S, Weld L, Kain KC, Wilder-Smith A, von Sonnenburg F, et al. for the GeoSentinel Surveillance Network. Illness in travelers visiting friends and relatives: a review of the GeoSentinel Surveillance Network. Clin Infect Dis. 2006;43: 1185-93. (6.) Siem H. Migration and health--the international perspective. Schweiz Rundsch Med Prax. 1997;86:788-93. (7.) Statistical Data on Switzerland 2004. Neuchatel, Switzerland: Swiss Federal Statistical Office; April 2004. [cited 2007 Jan 10]. Available from http://www.bfs.admin.ch/bfs/portal/en/index/ dienstleistungen/publikationen_statistik/publikationskatalog. Document.49104.html (8.) Bischoff A. Migration and health in Switzerland. Geneva Geneva, canton and city, Switzerland Geneva (jənē`və), Fr. Genève, canton (1990 pop. 373,019), 109 sq mi (282 sq km), SW Switzerland, surrounding the southwest tip of the Lake of Geneva. : Swiss Federal Office of Public Health; 1997. (9.) Loutan L, Chaignat CL. Refugees in Switzerland: which health problems do they encounter? Swiss Journal of Military Medicine. 1994;71: 105-9. (10.) Ferron C, Haour-Knipe M, Tschumper A, Narring F, Michaud PA. Health behaviours and psychosocial adjustment of migrant adolescents in Switzerland. Schweiz Med Wochenschr. 1997;127:1419-29. (11.) Egger M, Minder CE, Smith GD. Health inequalities and migrant workers in Switzerland. Lancet. 1990;336:816. (12.) Freedman freed·man n. A man who has been freed from slavery. freedman Noun pl -men History a man freed from slavery Noun 1. DO, Kozarsky PE, Weld LH, Cetron MS. GeoSentinel: the global emerging infections sentinel network of the International Society of Travel Medicine. J Travel Med. 1999;6:94-8. (13.) Leder K, Black J, O'Brien D, Greenwood Z, Kain KC, Schwartz E, et al. Malaria in travelers: a review of the GeoSentinel Surveillance Network. Clin Infect Dis. 2004;39:1104-12. (14.) Leder K, Sundararajan V, Weld L, Pandey P, Brown G, Torresi J. Respiratory tract infections in travelers: a review of the GeoSentinel Surveillance Network. Clin Infect Dis. 2003;36:399-406. (15.) Freedman DO, Weld LH, Kozarsky PE, Fisk Fisk , James 1834-1872. American railroad financier and speculator who attempted in 1869 to corner the gold market with Jay Gould, leading to Black Friday, a day of nationwide financial panic. T, Robins R, von Sonnenburg F, et al. Spectrum of disease and relation to place of exposure among ill returned travelers. N Engl J Med. 2006;354:119-30. (16.) Schlagenhauf P, Steffen R, Loutan L. Migrants as a major risk group for imported malaria in European countries. J Travel Med. 2003; 10:106-7. (17.) Al-Abri SS, Beeching NJ, Nye FJ. Traveller's diarrhoea. Lancet Infect Dis. 2005;5:349-60. (18.) Mutsch M, Spicher VM, Gut C, Steffen R. Hepatitis A virus infections in travelers, 1988-2004. Clin Infect Dis. 2006;42:490-7. Address for correspondence: Patricia Schlagenhauf, University of Zurich History The University of Zurich was founded in 1833 with existing colleges of theology (founded by Huldrych Zwingli in 1525), law and medicine merged together with a new faculty of Philosophy. Centre for Travel Medicine, World Health Organization Collaborating Centre for Travellers Health, University of Zurich, Hirschengraben 84, CH-8001 Zurich, Switzerland; email: pat@ifspm.unizh.ch Lukas Fenner, * (1) Rainer Weber, * Robert Steffen, * and Patricia Schlagenhauf * * University of Zurich, Zurich, Switzerland (1) Current affiliation: University Hospital Basel, Basel, Switzerland Dr Fenner obtained his medical degree from the Medical Faculty of Basel, Switzerland, and is resident microbiologist at the University Hospital, Basel. His research interests include international health and infectious diseases epidemiology.
Table 1. Demographic data on persons included in the study whose
purpose of travel was visiting friends and relatives (VFR) versus
traditional travelers (travelers), Switzerland
Travelers, no. VFR, no. (%), p value
(%), n = 217 n = 121
Sex
Male 119 (54.8) 61 (50.4) 0.43
Female 98 (45.2) 60 (49.6)
Age (y)
Median 32 39 0.008
Interquartile range 32-46 26-45
Patient type
Outpatient 185 (84.5) 84 (70.6) 0.002
Inpatient 34 (15.5) 35 (29.4)
Travel duration (d)
Median 15 21 0.006
Interquartile range 11-24 14-31
Sought pretravel advice?
Yes 65 (67) 18 (20) 0.0001
No 32 (33) 70 (81)
Traveled region
Sub-Saharan Africa 43 (19.81) 27 (22.31)
Asia 61 (28.11) 21 (17.35)
Eastern Europe 6 (2.76) 21 (17.35)
Central/South America 22 (10.13) 9 (7.43)
All other regions 85 (39.17) 43 (35.53)
Table 2. Primary symptoms of persons seeking treatment at a clinic,
frequent summary diagnosis, and syndrome groups in persons whose
purpose of travel was visiting friends and relatives (VFR) versus
traditional travelers (travelers), Switzerland
Travelers, no. VFR, no.
(%) * (%) *
Primary symptom
Fever 108 (49.76) 57 (47.10)
Gastrointestinal 117 (53.91) 48 (39.66)
Head-ear-nose 54 (24.88) 38 (31.40)
Respiratory 52 (23.96) 34 (28.09)
Musculoskeletal 25 (11.52) 22 (18.18)
Skin 30 (13.82) 14 (11.57)
Fatigue 24 (11.05) 13 (10.74)
Other 18 (8.29) 16 (13.22)
Total 428 242
Summary diagnosis and syndrome groups
Diarrhea, acute 79 (26.33) 21 (11.53)
Respiratory infection 40 (13.33) 22 (12.09)
HIV/AIDS 12 (4) 15 (8.24)
Malaria, all species 8 (2.67) 14 (7.69)
Viral syndrome 23 (7.67) 10 (5.49)
Viral hepatitis, acute/chronic 6 (2) 10 (5.49)
Urinary tract infection 3 (1) 3 (1.65)
Febrile illness, unspecified 10 (3.33) 1 (0.55)
Dengue fever (uncomplicated) 4 (1.33) 1 (0.55)
Sexually transmitted infection 1 (0.33) 3 (1.65)
Loa loa -- 2 (1.1)
Cutaneous leishmaniasis 1 (0.33) --
Typhoid/paratyphoid fever 1 (0.33) 1 (0.55)
Brucellosis -- 1 (0.55)
Extraintestinal amebiasis 1 (0.33) --
Dermatologic disorder 22 (7.33) 9 (4.95)
Chronic diarrhea 7 (2.33) 5 (2.75)
Healthy 4 (1.33) 2 (1.1)
Adverse drug or vaccine reaction 3 (1) 1 (0.55)
Cardiovascular disorder 2 (0.67) 3 (1.65)
Neurologic disorder 2 (0.67) 2 (1.1)
Lost to follow-up 2 (0.67) --
Pulmonary embolism 1 (0.33) 2 (1.1)
Psychological disorder 1 (0.33) 2 (1.1)
Death 1 (0.33) 1 (0.55)
Other diagnosis 66 (22) 51 (28.02)
Total 300 182
* Percentage expressed as number of primary symptoms that led to a
clinic visit per total patients in each group.
Table 3. Association of infectious disease in persons returning to
Switzerland whose purpose of travel was visiting friends and
relatives versus traditional travelers *
Odds ratio p value 95% CI
Univariate analysis
HIV/AIDS/STI 2.42 0.019 1.15-5.07
Malaria 3.04 0.014 1.25-7.40
Diarrhea, acute 0.36 0.0001 0.21-0.61
Viral hepatitis 2.84 0.046 1.01-7.97
Respiratory
infection 0.89 0.692 0.51-1.55
Viral syndrome 0.7 0.362 0.32-1.50
Multivariate analysis (adjusted to age and sex)
HIV/AIDS/STI 2.63 0.014 1.21-5.69
Malaria 2.93 0.021 1.17-7.32
Diarrhea, acute 0.47 0.007 0.27-0.81
Viral hepatitis 3.15 0.032 1.10-9.02
* CI, confidence interval; STI, sexually transmitted infection.
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