This update is being sent to members of the Wisconsin Travel Health Network.

Global Health Update

Mpox in the Democratic Republic of the Congo and neighboring countries

On August 7, 2024, the Centers for Disease Control and Prevention (CDC) issued a Health Alert Network (HAN) advisory to provide additional information about the outbreak of monkeypox virus (mpox) in the Democratic Republic of the Congo (DRC); the first Health Advisory about this outbreak was released in December 2023.

Since January 2023, the DRC has reported the largest number of yearly suspected clade I mpox cases on record. While clade I mpox is endemic in DRC, the current outbreak is more widespread than any previous DRC outbreak and has resulted in clade I mpox transmission to some neighboring countries. The Republic of the Congo (ROC), which borders DRC to the west, declared a clade I mpox outbreak in April 2024, and there have been confirmed cases in the Central African Republic (CAR). While clade I mpox is endemic in ROC and CAR, the epidemiologic pattern of recent cases suggests a possible link to DRC.

In late July 2024, Burundi, Rwanda, and Uganda, which sit on the eastern border of DRC, reported confirmed cases of mpox, with some cases having linkages to DRC. Rwanda and Uganda have confirmed these cases are due to clade I mpox; in Burundi, clade-specific testing is underway, but cases are presumed to be clade I due to DRC’s proximity. Mpox is not known to be endemic in these countries.

Because there is a risk of additional spread, CDC recommends clinicians and jurisdictions in the United States maintain a heightened index of suspicion for mpox in patients who have recently been in DRC or to any country sharing a border with DRC (ROC, Angola, Zambia, Rwanda, Burundi, Uganda, South Sudan, CAR) and present with signs and symptoms consistent with mpox. These can include: rash that may be located on the hands, feet, chest, face, mouth, or near the genitals; fever; chills; swollen lymph nodes; fatigue; myalgia (muscle aches and backache); headache; and respiratory symptoms like sore throat, nasal congestion, and cough.

Clinicians should notify the Wisconsin Department of Health Services (DHS) by contacting the Bureau of Communicable Diseases at 608-267-9003 during routine business hours or by calling the DHS 24/7 on-call services number (800) 943-0003 (option 4) after hours if they have a patient with signs and symptoms consistent with mpox and recent travel to DRC or to any country sharing a border with DRC. Clinicians should also work with DHS to submit lesion specimens for clade-specific testing for these patients. 

Please see the HAN for further details.

CDC Travel Health Notices for international travelers 

Level 4 – Avoid All Travel

None at this time.

Level 3 – Reconsider Non-Essential Travel

None at this time.

Level 2 – Practice Enhanced Precautions

Zika in the state of Maharashtra, India 

 The CDC has issued a level 2 travel health notice for an outbreak of Zika in the state of Maharashtra, India. Zika virus can be spread through mosquito bites, passed from a pregnant person to their fetus, and spread person to person through sex. Many people infected with Zika virus will have mild or no symptoms. Zika virus infection during pregnancy can lead to congenital Zika syndrome and other birth defects. All travelers to Maharashtra should take steps to prevent mosquito bites and sexual transmission of Zika virus during and after travel. Pregnant people should avoid travel to Maharashtra when possible and strictly follow the Zika prevention recommendations if travel is unavoidable. Travelers to Maharashtra should seek medical care immediately if they develop fever, rash, headache, joint or muscle pain, or red eyes during or after travel.

Global polio 

The CDC issued an updated level 2 travel health notice for global polio. Polio has been eliminated from most of the world, but some international destinations have circulating poliovirus. Before any international travel, adults and children should make sure they are up to date on polio vaccines. Before travel to any destination with poliovirus detected within the last 12 months, adults may additionally receive a single, one-time booster dose of inactivated polio vaccine (IPV).

Oropouche in Cuba 

The CDC has issued a level 2 travel health notice for an outbreak of Oropouche in Cuba after multiple cases were reported in U.S. and European travelers. Oropouche is a disease caused by the Oropouche virus. It is spread through the bites of infected midges (small flies) and mosquitos. Symptoms of Oropouche include headache, fever, muscle aches, stiff joints, nausea, vomiting, chills, and sensitivity to light. Severe cases of Oropouche may result in neuroinvasive disease. There are also concerns about an increase of possible cases of Oropouche infection being passed from a pregnant person to their fetus with negative outcomes. All travelers to Cuba should take steps to prevent bug bites during travel to prevent infection. They should also take steps to prevent bug bites for three weeks after travel to avoid possibly spreading the virus to others in the U.S. Pregnant people should reconsider non-essential travel to Cuba and strictly follow the Oropouche prevention recommendations if travel is unavoidable. Travelers who develop symptoms of Oropouche infection within 2 weeks after travel should seek medical care immediately.

Clade I Mpox in the Democratic Republic of the Congo (DRC) and neighboring countries

The CDC has issued a level 2 travel health notice for an outbreak of clade I mpox in the DRC. Countries sharing boarders with DRC are considered at risk for spread. Cases have been reported in Burundi, Central African Republic, the Republic of Congo, Rwanda, and Uganda. Person-to-person transmission has occurred during this outbreak including through sexual contact, household contact, and within health care settings. Vaccination against mpox is recommended for people with certain risk factors. Additional prevention strategies for travelers can be found on the CDC Travelers’ Health Mpox web page. Travelers should seek care immediately if they develop a new, unexplained skin rash, with or without fever and chills and should avoid contact with others. 

Level 1 – Practice Usual Precautions

Oropouche in South America

Global Dengue (Updated 8/14/2024

Global Measles (Updated 8/14/2024)

Travel for Sporting Event in South America As summer is starting to wind down, some Wisconsinites may be starting to look forward to fall and all that comes with the season in our state. One fall activity that many people may be looking forward to is the start of football season. This season is particularly exciting due to the highly anticipated football season opener between the Green Bay Packers and the Philadelphia Eagles being held in São Paulo, Brazil on September 6, 2024. Wisconsinites planning travel to Brazil for the game may be seeking health care prior to travel. The CDC Traveler Health destination page for Brazil is a great resource for travel health providers looking for the most up-to-date recommendations for travel to the county.

August is National Immunization Awareness Month (NIAM) National Immunization Awareness Month is an annual observance held in August to highlight the importance of vaccination for people of all ages. Together, we can help raise awareness about the importance of vaccination and encourage people to talk to a health care provider they trust about staying up to date on their vaccinations. Immunizations for travel All travelers, regardless of their destination, should be up to date on routine vaccines. This is because many diseases that are less common in the United States are still spreading throughout different parts of the world. Childhood vaccines in the U.S. have helped limit the severity and spread of these diseases here. Ensuring travelers are vaccinated before they travel will help keep them from getting sick and potentially spreading disease when they return home. Important routine vaccines include: Measles-mumps-rubella (MMR) vaccine. Diphtheria-tetanus-pertussis vaccine. Varicella (chickenpox) vaccine. Polio vaccine. This year's flu shot. Travelers may be recommended to get additional vaccines or take other steps to avoid illnesses that are common in their destination. Additionally, some countries may have specific requirements and recommendations that they need to comply with when visiting. Travelers should visit CDC's Destinations webpage, or check directly with their destination, to learn about entry and exit requirements and to view the latest travel health notices.

Fungal Disease Awareness Fungal diseases are increasing worldwide with all signs suggesting that this trend will continue. Despite the increasing prevalence of these diseases, they are often misdiagnosed. With few tools available to treat and prevent infection, increasing awareness of fungal diseases is important for early diagnosis and treatment of infections. Travel can increase the risk of exposure to certain fungal infections. Travel associated fungal infections Valley fever is a fungal lung infection caused by breathing in spores from the fungus, Coccidioides. The fungus that causes Valley fever is endemic to Central and South America, northern Mexico, and parts of the United States, specifically Arizona and Southern California. Travelers, including long-term travelers, travelers visiting friends and family, students studying abroad, travelers doing humanitarian aid work, and adventure travelers, are at risk if they participate in activities that expose them to soil or dust.   More information about Valley fever and other travel associated fungal infections can be found in the 2024 CDC Yellow Book. Medical tourism associated fungal infections Medical tourism is a term used to describe international travel for the purpose of receiving medical care. The practice of medical tourism continues to grow with millions of U.S. residents travelling internationally for medical care each year. Infection is a common complication from seeking medical care abroad. In addition, the risk of acquiring antibiotic-resistant infections, including fungal infections such as Candida auris, might be greater in certain countries or regions where U.S. residents travel for medical tourism.  More information about fungal infections associated with medical tourism can be found in the 2024 CDC Yellow Book.

Disease Spotlight: Rabies

Rabies is a fatal, acute, progressive encephalitis (brain infection) caused by rabies virus or a related Lyssavirus. Rabies is present worldwide; however, the epidemiology of rabies varies regionally. Rabies is primarily a disease of animals; human cases occur from virus spillover from wild or domestic animal reservoirs. Tens of thousands of human deaths occur annually worldwide and the canine (dog) rabies virus variant accounts for approximately 98% of those cases. Up to 95% of human rabies cases and deaths occur in Asia and Africa where dog rabies is not well controlled. Children under 15 years are often victims.

In the United States, approximately 25% of human rabies cases result from international travel, and nearly all of these are caused by the bite of an infected dog. The majority of human rabies cases acquired domestically are caused by bat rabies virus variants.

What are the symptoms?

Signs and symptoms most commonly develop within several weeks to months after exposure. Pain and paresthesia (tingling, numbness) at the site of exposure are often the first symptoms of disease. The disease then progresses rapidly from a prodromal phase (fever and nonspecific, vague symptoms) to a neurologic phase characterized by anxiety, paralysis, paresis, and other signs of encephalitis. Swallowing muscle spasm can be stimulated by the sight, sound, or perception of water (hydrophobia). Delirium and convulsions can develop, followed soon thereafter by coma and death.

Suspected human rabies cases are a Category I reportable disease in Wisconsin and should be reported immediately by telephone to the patient’s local health officer.

Who is at risk?

In the U.S., canine variant rabies has been eliminated, however rabies exists in several wildlife reservoirs which vary regionally. In Wisconsin, bats are the primary wildlife reservoir. Elsewhere in the U.S., terrestrial mesocarnivores such as skunks, raccoons, and foxes are also major rabies virus reservoirs. In Puerto Rico, mongooses are rabies virus reservoirs. Domestic animals such as dogs and cats are highly susceptible when unvaccinated and, if infected, and serve as a “bridge” for human exposure to wildlife rabies. Similarly, livestock might pose a risk for transmission.

In the U.S., people at highest risk of rabies exposure include those with occupational or recreational exposures to animals such as animal control officers, veterinarians, field biologists, trappers, and spelunkers. However, cases are most often associated with bat variants in people who did not seek medical evaluation and rabies post-exposure prophylaxis (RPEP). Additionally, certain travelers may be at increased risk of rabies depending on the presence of rabies virus reservoirs (especially where rabies is endemic in dogs), their occupational or recreation activities and length of stay, and the reliability of prompt access to RPEP.

How is rabies transmitted?

Rabies virus replicates in the brain and then moves via nerves to the salivary glands. Rabies virus is shed in the saliva and most commonly is transmitted through the bite of an infected animal. Other materials, such as nervous system tissue (brain, spinal cord), cerebrospinal fluid (CSF), or tears are also potentially infectious.

Exposure types include:

• Bite exposures—any penetration of the skin by teeth.
• Non-bite exposures—the introduction of infectious material (saliva, nervous system tissue, CSF, tears) into an open wound or mucous membrane; organ transplantation. Rabies from non-bite exposures is rare.

Although all mammals are likely susceptible to rabies, not all species represent equal risk for rabies transmission to humans. For example, bites from small wild rodents or rabbits almost never necessitate RPEP, however, the circumstances of every animal bite should be carefully considered. Rabies PEP can also be considered for people who were in the same room as a bat, but who might be unaware that a bite or direct contact had occurred (for example: a sleeping person awakens to find a bat in the room, or an adult witnesses a bat in the room with a previously unattended child, person with a intellectual or developmental disability, or intoxicated person).

Where is rabies found?

Rabies is found nearly worldwide. However, the epidemiology of rabies varies by country and regionally. Up to 95% of human rabies cases and deaths occur in Asia and Africa where dog rabies is not well controlled. Wildlife reservoirs exist even in areas where dog rabies is well-controlled or eliminated, and spillover into companion animals or livestock can occur, especially when unvaccinated.

An assessment of rabies status by country can be found on the CDC Rabies Status web page.

How are exposures treated?

Although rabies is nearly always fatal once symptoms begin, development of rabies can nearly always be prevented after an exposure through prompt administration of a rabies post-exposure prophylaxis (RPEP) regimen. RPEP is considered a medical urgency rather than an emergency. Although RPEP decisions should not be unnecessarily delayed, follow-up to determine the rabies status of the offending animal (through testing or 10-day observation) is usually appropriate prior to initiating RPEP. More detail regarding exposure assessment, animal follow-up, and RPEP recommendations can be found in the DHS Rabies Algorithm/Rabies Prevention Flowchart.

In the U.S., as recommended by Advisory Committee on Immunization Practices (ACIP), the rabies post-exposure prophylaxis regimen for a previously unvaccinated person includes:

• Immediate wound cleansing with soap and water or a virucidal agent,
• Human rabies immunoglobulin (HRIG) infiltrated around the wound, with any remaining volume (calculated by weight) injected intramuscularly, and
• Four doses of rabies vaccine intramuscularly on days 0, 3, 7, and 14. Note that day 0 is the date on which the series is started, not necessarily the date of exposure.
• If a person has been previously vaccinated, the RPEP regimen includes:
  • Immediate wound cleansing with soap and water or a virucidal agent, and
  • Two doses of rabies vaccine intramuscularly on days 0 and 3.

If started in another country, RPEP may follow a schedule recognized by WHO (an intradermal 2-2-2 or intramuscular 2-1-1 schedule, with or without RIG depending on exposure category). In most cases, the RPEP regimen started in another country can be completed with vaccines available in the U.S. according to the prescribed schedule without the need to start the series over. Every effort should be made to adhere to a recognized ACIP or WHO schedule.

Travel recommendations

Pre-exposure immunization, or pre-exposure prophylaxis (PrEP), should be considered for certain international traveler categories based on multiple factors: the occurrence of animal rabies in the destination country; the availability of anti-rabies biologics; the traveler’s intended activities, especially in remote areas; and the traveler’s duration of stay. A decision to receive PrEP might also be based on the likelihood of repeat travel to at-risk destinations or long-term travel to a high-risk destination.

According to the CDC Yellow Book 2024, PrEP should be considered for travelers who will have extensive outdoor activities in remote rural areas, including activities in caves that may lead to direct contact with bats, and for animal handlers, field biologists, cavers, missionaries, and veterinarians. PrEP should also be considered for travel where timely access to adequate PEP is not guaranteed.

Rabies PrEP guidelines and schedules were updated by the ACIP in 2022 and recommend the following PrEP regimens:

• If the period of risk, such as international travel, does not exceed 3 years: A new shorter regimen of two doses of rabies vaccine, 1 week apart (days 0 and 7) is recommended.
• If the period of risk is expected to exceed 3 years, one of the following should also occur:
• An additional (third) dose of rabies vaccine any time during the 3 weeks to 3 years after the first rabies vaccine dose, OR
• Measurement of a rabies serology titer after 1 year but before 3 years following the first rabies vaccine dose, followed with a rabies vaccine booster if needed.

View ACIP’s updated (2022) rabies pre-exposure prophylaxis guidelines for more detail.

Regardless of whether they received PrEP, travelers should be cautioned not to approach or interact with stray dogs or cats, non-human primates, bats, or other wildlife, and to seek RPEP if a bite is sustained. Travelers might wish to purchase medical evacuation insurance if they are travelling to areas where the risk for rabies is high or prompt access to effective RPEP is questionable.

Who can I contact with questions?

Travelers or members of the public should contact their health care provider or Local Health Department.

Health care providers or health departments may contact the Bureau of Communicable Disease Epidemiology Section at dhsdphbcd@dhs.wisconsin.gov or 608-267-9003, or if urgent, by calling the DHS 24/7 on-call services number (800) 943-0003 (option 4).

Please do not reply directly to this email message. Send questions and inquiries to DHSBCDTravelHealth@dhs.wisconsin.gov.