Typhoid fever infection – Antibiotic resistance and vaccination strategies: A narrative review

Typhoid fever is a bacterial infection caused by the Gram-negative bacterium Salmonella enterica subspecies enterica serovar Typhi (S. Typhi), prevalent in many low- and middle-income countries. In high-income territories, typhoid fever is predominantly travel-related, consequent to travel in typhoid-endemic regions; however, data show that the level of typhoid vaccination in travellers is low. Successful management of typhoid fever using antibiotics is becoming increasingly difficult due to drug resistance; emerging resistance has spread geographically due to factors such as increasing travel connectivity, affecting those in endemic regions and travellers alike. This review provides an overview of: the epidemiology and diagnosis of typhoid fever; the emergence of drug-resistant typhoid strains in the endemic setting; drug resistance observed in travellers; vaccines currently available to prevent typhoid fever; vaccine recommendations for people living in typhoid-endemic regions; strategies for the introduction of typhoid vaccines and stakeholders in vaccination programmes; and travel recommendations for a selection of destinations with a medium or high incidence of typhoid fever

Awareness of Meningococcal disease among travelers from the United Kingdom to the meningitis belt in Africa

Meningococcal disease causes considerable morbidity and has a high case-fatality rate. In the United Kingdom, the meningococcal quadrivalent vaccine is recommended for travelers visiting the meningitis belt of Africa. We analyzed 302 responses to a cross-sectional study conducted in 2010 of travelers who had visited the meningitis belt recently or were shortly due to travel there. Using the results of an online questionnaire, we assessed knowledge and understanding of meningococcal disease and likelihood of uptake of meningococcal immunization before travel. Meningococcal vaccine uptake was 30.1%. Although global scores in the questionnaire did not correlate with vaccine uptake, knowledge of the meningitis belt and knowledge of certain key symptoms or signs were statistically associated with high vaccine uptake. We conclude that improved education of travelers may improve vaccine uptake before travel to the meningitis belt in Africa

Non-Adherence to Malaria Chemo-Prophylaxis in Travelers: Mind to the Care Gap!

Background: Travelers are at risk of contracting malaria when moving to endemic areas. Yet, despite effective malaria chemoprophylaxis, imported cases of malaria still occur worldwide. Indeed, some studies have shown a varied adherence level; consequently, a traveler care gap could occur. Methods: A prospective cohort study was carried out in 2017 to evaluate the rate of malaria chemoprophylaxis adherence among Spanish travelers. Results: A post-travel questionnaire was completed by 402 travelers to malaria endemic areas that were prescribed chemoprophylaxis: 67 (16.7%) did not take any dose of chemoprophylaxis and 41 (10.2%) had not even carried it while travelling abroad. The adherence of chemoprophylaxis was 68,7% of travelers, being statistically different according to travel duration, onset of adverse events and type of drug prescribed. The non-adherent travelers reported not continuing with administration mainly because of forgetfulness, fear of side effects and low perceived risk because itinerary changes. Regarding the onset of the medication's secondary adverse events, one in three (35.2%) reported at least one, being more frequent among patients that took mefloquine than atovaquone-proguanil (p=0.01). The main adverse events reported by chemoprophylaxis users were gastrointestinal or sleeping disorders. Conclusions: The suboptimal compliance of chemoprophylaxis is a major lost opportunity to achieve malaria prevention, so it is an important contributor to the traveler care gap

Pre-travel health care attendance among migrant travellers visiting friends and relatives (VFR): a 10-year retrospective analysis

Background: Travellers visiting friends and relatives (VFR) define a specific population of travellers exposed to higher risks for health and safety than tourists. The aim of this study was to assess differentials in pre-travel health care in VFR travellers compared to other travellers. Methods: A retrospective cohort study was performed including attendees of the Travel Medicine Clinic of the Hospital Universitari de Bellvitge, Barcelona, Spain, between January 2007 and December 2017. Results: Over the 10-year period, 47,022 subjects presented to the travel clinic for pre-travel health care, 13.7% of whom were VFR travellers. These showed higher rates of vaccination against yellow fever and meningococcus, but lower rates for hepatitis A, hepatitis B, influenza, rabies, cholera, polio, typhoid IM vaccine and tetanus vaccine boosters. Regarding malaria prevention measures, results highlighted that VFR travellers, when compared with tourists, were more likely to be prescribed with chemoprophylaxis, particularly with mefloquine, than with atovaquone/proguanil. Conclusions: Findings from this large-scale study indicated differences in vaccination rates and completion, as well as in chemoprophylaxis for malaria, between VFR and non-VFR travellers, fostering specific interventions for promoting adherence to pre-travel health advice among migrant travellers

Assessment of dental Implants with modified calcium-phosphate surface in a multicenter, prospective, non-interventional study: results up to 50 months of follow-Up

Prescription of implant treatments is very widespread at present, mainly due to the low rate of annual loss and, to date, few studies have assessed their survival in the routine clinical practice of dentistry. The purpose of this observational study was to evaluate the effectiveness of dental implants with a calcium-phosphate surface in the daily practice of dental clinics. A multicenter, prospective, non-interventional, observational study was performed, in which three experienced practitioners (one maxillofacial and two oral surgeons) inserted implants using standard external and internal hexagon connections in adult patients requiring 1 osseointegrated implants to replace missing teeth. Follow-up was performed for 24 months after implant loading. Two hundred and twelve subjects were included (51.5% men), with a mean age of 51.2 11.90 years, in whom 544 implants were inserted. 87.2% of the patients received 1-4 implants. The preferred connection system was internal hexagon (73.5%). There were nine failures, with an interval survival rate (ISR) at 24 months of 100% and a cumulative survival rate (CSR) of 98.3%. In conclusion, implants with a modified calcium-phosphate surface are associated with a high rate of survival and may be considered a method of choice in clinical practice

Combining varenicline and nicotine patches: a randomized controlled trial study in smoking cessation

Background: Some smokers may benefit from a therapy that combines different nicotine replacement therapies (NRT) or drugs with different mechanisms of action. The aim of this study was to determine the efficacy of the combined therapy of varenicline and nicotine patches versus varenicline monotherapy. Methods: Three hundred forty-one smokers who smoked 20 or more cigarettes per day were recruited from a smoking cessation clinic between February 2012 and June 2013. The participants were randomized to receive a varenicline plus nicotine patch of 21 mg every 24 hours (170) or varenicline plus a placebo patch (171). All of the smokers received a standard 12-week course of varenicline and an 11-week course of either the placebo patch or the active patch after the target quit day. Both groups received behavioral support. The primary outcome was continuous abstinence for weeks 2 through 12 confirmed by exhaled levels of carbon monoxide. Post hoc subgroup analyses were performed to evaluate the treatment effects for a specific endpoint in subgroups of smokers. Results: The combination of the nicotine patch with varenicline was not associated with higher rates of continuous abstinence at 12 weeks (39.1% versus 31.8%; odds ratio (OR) 1.24; 95% confidence interval (CI) 0.8 to 2.6) and 24 weeks (32.8% versus 28.2%; OR 1.17; 95% CI 0.4 to 1.9). When participants were analyzed by subgroups according to cigarette consumption, the abstinence rates among smokers who smoked more than 29 cigarettes per day at 12 weeks (OR 1.39; 95% CI 1.2 to 2.5) and 24 weeks (OR 1.46; 95% CI 1.2 to 2.8) were significantly higher in the combination group. Other post hoc analyses based on level of dependence and previous quit attempts did not show subgroup differences. No differences between the groups for the reported adverse events were observed (χ2 value 0.07; P 0.79). Conclusions: The combination of varenicline with the nicotine patch does not improve abstinence rates at 12 and 24 weeks compared with varenicline used as monotherapy when all smokers were analyzed as a whole, independent of consumption level

Stand-by emergency treatment (SBET) of malaria in Spanish travellers: a cohort study

Background: Among strategies for malaria prevention, stand-by emergency treatment (SBET) is a possible approach, but scarce evidences exists investigating travellers' adherence and behaviours toward its use; therefore, the presented study aimed to determine travellers' compliance toward the SBET when prescribed in travel clinics. Methods: A prospective cohort study was performed at the Travel Health Clinic of the Hospital Universitari de Bellvitge, Barcelona, Spain, during 2017. The research was planned on survey-based design, using pre- and post-travel questionnaires. Results: In the study period, of 5436 subjects who attended the HUB Travel Medicine Clinic, 145 travellers to malariaendemic areas were prescribed SBET, and all patients agreed to participate in the study by completing the pre-travel questionnaire. Approximately half the participants were women (n=75, 51.7%), and the median age of all travellers was 29 years (range 13-57), mainly travelling to South-East Asia (n=69, 47.6%), with Indonesia and the Philippines as the most popular destinations. The length of travels had a median duration of 29 days (range 10-213). Of the recruited participants, 98 replied to the online post-travel survey, reaching a response rate of 67.6%. A total of 62.2% of travellers to which SBET was prescribed did not buy and carry drugs while travelling abroad. No participants' baseline or travel characteristic was shown to be signifcantly associated (p>0.05) with this behaviour. Four women (4.1%) experienced fever and self-administered SBET, without seeking medical attention. No malaria cases were observed. Conclusions: This cohort study addressed travellers' adherence and behaviour toward SBET, highlighting an incorrect use of the emergency treatment in case of presumptive malaria symptoms. This should be taken into account during pre-travel consultation, since the success of this strategy for malaria prevention depends on travellers' strong adher‑ ence to it

Relationship between smoking and acute mountain sickness: a meta-analysis of observational studies

Aims. Previous epidemiological investigations of the relationship between smoking and acutemountain sickness (AMS) risk yielded inconsistent findings.Therefore, a meta-analysis of observational studies was performed to determine whether smoking is related to the development of AMS. Methods. Searches were performed on PubMed, Scopus, Embase, and Web of Science for relevant studies that were published before November 2016 reporting smoking prevalence and AMS. Two evaluators independently selected studies, extracted data, and assessed study quality.Thepooled relative risks (RRs) and 95% confidence intervals (CIs) were obtained using random-effects models. Subgroup analyses were performed according to the type of participant, altitude, and study design. Results. A total of 11 observational studies involving 7,106 participants, 2,408 of which had AMS, were eligible for inclusion in this meta-analysis. The summary RR for AMS comparing smokers to nonsmokers was 1.02 (95% CI: 0.83 to 1.26). Specific analyses for altitude, type of participant, and study design yielded similar results.There was significant heterogeneity for all studies ( = 37.43; < 0.001; 2 = 73%, 95% CI: 51% to 85%). No publication bias was observed (Egger's test: = 0.548, Begg's test: = 0.418). Conclusions.The meta-analysis indicates that no difference was found in AMS risk with regard to smoking status

Knowledge about E-Cigarettes and tobacco harm reduction among public health residents in Europe

Introduction: Although electronic cigarettes (e-cigarettes) and other tobacco-related products are becoming widely popular as alternatives to tobacco, little has been published on the knowledge of healthcare workers about their use. Thus, the aim of this study was to elicit the current knowledge and perceptions about e-cigarettes and tobacco harm reduction (THR) among medical residents in public health (MRPH). Material and Methods: A Europe-wide cross-sectional study was carried out amongst MRPH from the countries associated with the European Network of MRPH from April to October 2018 using an online questionnaire. Results: 256 MRPHs agreed to participate in the survey. Approximately half the participants were women (57.4%), with a median age of 30 years, and were mainly Italian (26.7%), Spanish (16.9%) and Portuguese (16.5%). Smoking prevalence was 12.9%. Overall, risk scores significantly differed for each investigated smoking product when compared with e-cigarettes; with tobacco cigarettes and snus perceived as more risky, and nicotine replacement therapy (NRT) and non-NRT oral medications seen as less risky (p 0.01 for all). Regarding the effects of nicotine on health, the vast majority of MRPHs associated nicotine with all smoking-related diseases. Knowledge of THR was low throughout the whole sample. Conclusions: European MRPH showed a suboptimal level of knowledge about e-cigarettes and THR. Training programs for public health and preventive medicine trainees should address this gap

Relationship of altitude mountain sickness and smoking: a Catalan traveller's cohort study

Objectives: The aim of this study is to analyse the relationship between smoking and altitude mountain sickness in a cohort of travellers to 2500 metres above sea level (masl) or higher. Setting: Travel Health Clinic at the Hospital Universitari de Bellvitge, in Barcelona, Spain. Participants: A total of 302 adults seeking medical advice at the travel clinic, between July 2012 and August 2014, before travelling to 2500 masl or above, who agreed to participate in the study and to be contacted after the trip were included. Individuals who met the following criteria were excluded: younger than 18 years old, taking carbonic anhydrase inhibitors for chronic use, undergoing treatment with systemic corticosteroids and taking any medication that might prevent or treat altitude mountain sickness (AMS) prior to or during the trip. The majority of participants were women (n=156, 51.7%). The mean age was 37.7 years (SD 12.3). The studied cohort included 74 smokers (24.5%), 158 (52.3%) non-smokers and 70 (23.2%) ex-smokers. No statistical differences were observed between different sociodemographic characteristics, constitutional symptoms or drug use and smoking status. Outcomes: The main outcome was the development of AMS, which was defined according to the Lake Louise AMS criteria. Results: AMS, according to the Lake Louise score, was significantly lower in smokers; the value was 14.9%, 95% CI (6.8 to 23.0%) in smokers and 29.4%, 95% CI (23.5 to 35.3%) in non-smokers with an adjusted OR of 0.54, 95% CI (0.31 to 0.97) independent of gender, age and maximum altitude reached. Conclusions: These results suggest that smoking could reduce the risk of AMS in non-acclimated individuals. Further studies should be performed in larger cohorts of travellers to confirm these results. Despite the results, smoking must be strongly discouraged because it greatly increases the risk of cardiorespiratory diseases, cancer and other diseases