 This update is being sent to members of the Wisconsin Travel Health Network.
Global Health Update
Medical tourism risk mitigation
Medical tourism is the term used to describe international travel for the purpose of receiving medical care. Surveillance data indicate that millions of U.S. residents travel internationally for medical care each year. Medical tourists from the United States most frequently travel to Mexico, Canada, Central America, South America, and the Caribbean. Common procedures that people undergo on medical tourism trips include dental care, cosmetic surgery, fertility treatments, organ and tissue transplantation, and cancer treatment.
Among medical tourists, the most common complications are healthcare-associated infections. Inadequate infection control practices place people at increased risk for bloodborne infections, including hepatitis B, hepatitis C, and HIV; bloodstream infections; donor-derived infections; and wound infections. Traveling during the post-operative or post-procedure recovery period or during treatment for a medical condition could pose additional risks for patients.
When reviewing the risks associated with seeking health care abroad, encourage medical tourists to consider several factors besides the procedure, including the destination, the facility, the locations where the procedure and recovery will take place, and the treating provider. Medical tourists can help minimize risks by taking the following actions:
- Research the clinician and facility.
- Schedule a pretravel consultation at least 4-6 weeks before the trip.
- Bring copies of medical records on the trip.
- Get copies of medical records from the medical facility before returning home.
- Arrange for follow-up care before traveling.
Review additional guidance for U.S .health care providers on medical tourism and risk mitigation in the CDC Yellow Book 2024.
Fungal infections following surgical procedures in Mexico
The Centers for Disease Control and Prevention (CDC) issued a Level 2 Alert for fungal infections following surgical procedures in Mexico. Recently, some U.S. residents returning from Matamoros, Mexico, were diagnosed with suspected fungal meningitis infections that have led to severe illness and death. Travelers with these infections had medical or surgical procedures that involved injection of an anesthetic into the area around the spinal column (that is, epidural). Symptoms of fungal meningitis infections include fever, headache, stiff neck, nausea, vomiting, confusion, or sensitivity to light.
If you encounter a patient, with or without symptoms, who has had a medical or surgical procedure involving epidural injection of an anesthetic in Matamoros, Mexico, anytime since January 1, 2023, please take the following actions:
Marburg virus outbreaks in Tanzania and Equatorial Guinea declared over
The Ministry of Health of the United Republic of Tanzania declared the end of its first documented outbreak of Marburg virus disease and the CDC Level 1 Travel Health Notice for Tanzania was removed on June 2. Similarly, the World Health Organization declared an end to the outbreak in Equatorial Guinea on June 8 and the CDC removed the Level 2 Travel Alert.
CDC Yellow Book 2024
CDC announced the launch of the CDC Yellow Book 2024. The CDC Yellow Book is a source of the U.S. Government’s recommendations on travel medicine and has been a trusted resource among the travel medicine community for over 50 years. Health care professionals can use the print and digital versions to find the most up-to-date travel medicine information to better serve their patients’ health care needs. Topics featured in this edition include:
- COVID-19 precautions for international travelers.
- Updates on practicing travel medicine in a virtual environment.
- New standalone vaccine tables for bacterial and viral diseases.
- Updated travel health recommendations for highly allergic, immunocompromised, and chronically ill travelers, travelers with substance use disorders, and medical tourists.
- Country-specific mosquito avoidance, yellow fever vaccine, and malaria prevention recommendations.
The CDC Yellow Book is available in print through Oxford University Press and online.
Traveler Health Webpage
The Wisconsin Department of Health Services’ Traveler Health webpage is now live. This webpage provides guidance for people who are planning to travel domestically or internationally. It also houses helpful resources that can be shared with travelers such as the Safe Travel Checklist.
Disease Spotlight: Dengue
Dengue is an illness spread by the bite of infected Aedes aegypti and Aedes albopictus mosquitoes. Cases of dengue in Wisconsin residents have averaged about 10 per year since 2012 and have occurred in people who have traveled to tropical or subtropical regions with a high risk of dengue, including the Caribbean, South and Central America, Asia, and parts of tropical Africa. Dengue is very rarely spread in the U.S.; however, there have been outbreaks in Florida, Texas, Hawaii, Guam, and Puerto Rico. Globally, it is estimated that there are 100–400 million dengue infections each year.
Who is at risk?
Anyone who travels to areas where dengue is spread can get the illness, but people who spend more time outdoors are at a higher risk of being bitten by an infected mosquito. It is important to take preventive steps when traveling to areas with dengue virus, such as wearing protective clothing, using insect repellents, and using mosquito netting.
What are the symptoms?
Symptoms usually show up four to 10 days after being bitten by an infected mosquito. Most people (about 75%) infected with dengue never develop symptoms. Those that become sick may develop significant flu-like symptoms and recover after about one week. However, some people may develop a severe form of dengue, also called dengue hemorrhagic fever, or dengue shock syndrome. When this happens, the person develops warning signs of serious complications three to seven days after the first symptoms appear, right after the fever has started to decrease. It is important to go to an emergency room immediately if any of the warning signs appear. Severe dengue can cause shock, internal bleeding, and death.
There are four different kinds of dengue virus, so past infection with dengue will not always make you immune to the virus in the future. You will only be immune to the type of virus that infected you in the past.
First signs and symptoms:
- High fever
- Severe headache
- Severe pain behind the eyes
- Muscle aches and/or bone pain
- Joint pain
- Rash
- Mild bleeding (nose, gums, purple spots under the skin, easy bruising)
- Low white blood cell count
Severe dengue warning signs and symptoms (usually 24–48 hours after the fever goes away):
- Severe stomach pain or persistent vomiting
- Red spots or patches on the skin
- Bleeding from the nose or gums
- Vomiting blood
- Black, tarry feces
- Drowsiness or irritability
- Pale, cold, or clammy skin
- Difficulty breathing
How is it spread?
Dengue is spread to humans through the bite of an infected mosquito. Mosquitoes get infected with dengue by feeding on humans that have been infected with the virus.
- After about one week, the virus may end up inside of the mosquito.
- Once it has the virus, a mosquito may spread the virus to uninfected humans when it takes another blood meal.
- Sick people can carry the virus in their blood a few days before symptoms develop and during the first week of infection when they have a fever. If they are bitten by an uninfected mosquito, they can transmit the virus to the mosquito, continuing the cycle.
- The mosquitoes that spread dengue are most active during the daytime. Peak biting hours are early in the morning and in the evening before dusk.
It is possible to get infected with dengue from organ transplants or blood transfusions from infected donors, or from mother to fetus during pregnancy. However, these cases are rare.
What are the diagnostic challenges?
Dengue and Zika viruses are closely related mosquito-borne flaviviruses with similar transmission cycles, distribution throughout the tropics and subtropics, and disease manifestations including fever, rash, myalgia, and arthralgia. For patients with suspected dengue or Zika virus disease, nucleic acid amplification tests (NAATs) are the preferred method of diagnosis.
For patients with clinically suspected dengue presenting during the first week after onset of symptoms, diagnostic testing should include a dengue NAAT (PCR or NS1 antigen) and dengue immunoglobulin M (IgM) performed on serum. Depending on the patient’s clinical presentation and travel history, it may also be useful to include NAATs for Zika and chikungunya viruses.
For patients presenting more than one week after onset of symptoms, IgM antibody testing against dengue virus may be most useful. Depending on the patient’s clinical presentation and travel history, it may also be useful for include IgM against chikungunya virus. IgM antibody testing can identify additional infections and remains an important diagnostic tool, but interpreting the results is complicated by antibody cross-reactivity between dengue and Zika viruses and determining the specific timing of infection can be difficult. These limitations are a particular challenge for pregnant patients in determining whether Zika virus infection occurred during or before the pregnancy. Currently, Zika virus IgM is not routinely recommended for diagnosis of Zika virus disease, except for in pregnant persons with ultrasound findings consistent with congenital Zika virus syndrome.
Positive IgM antibody test results with negative NAAT results should be confirmed by neutralizing antibody tests when clinically or epidemiologically indicated, including for all pregnant patients. Data on the epidemiology of viruses known to be circulating at the location of exposure and clinical findings should be considered when deciding which tests to perform and for interpreting results.
Is there treatment for dengue?
There is currently no treatment for dengue. A new dengue vaccine, Dengvaxia, has been approved for use in children aged 9–16 years with laboratory-confirmed previous dengue virus infection and living in areas where dengue is endemic. Endemic areas include some U.S. territories and freely associated states. The vaccine is not approved for use in U.S. travelers who are visiting but not living in an area where dengue is common.
Over-the-counter pain relievers, such as Tylenol, may be given to relieve the symptoms. Do not take aspirin or ibuprofen, as they can increase the risk of bleeding. It is important to get plenty of rest and drink fluids. In severe cases, patients may need to be hospitalized to receive supportive treatment.
If you or a family member has recently traveled to an area with dengue, and believe you may have dengue virus, contact your doctor.
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