Intestinal protozoa in returning travellers: a GeoSentinel analysis from 2007 to 2019
Thomas Weitzel, Ashley F. Brown, Michael Libman, Cecilia Perret, Ralph Huits, Lin H. Chen, Daniel T. Leung, Karin Leder, Bradley A. Connor, Marta Díaz‐Menéndez, Hilmir Ásgeirsson, Eli Schwartz, Fernando Salvador, Denis Malvy, M. Saio, Francesca Norman, Bhawana Amatya, Alexandre Duvignaud, Stephen Vaughan, Marielle Glynn, the GeoSentinel Network, Carsten Schade Larsen, Christian Wejse, Martin P. Grobusch, Abraham Goorhuis, Emmanuel Bottieau, Marc Shaw, Annemarie Hern, Watcharapong Piyaphanee, Wasin Matsee, José Muñóz, Israel Molina, Frank P. Mockenhaupt, Francesco Castelli, Alberto Matteelli, Christina Coyle, Paul Kelly, Cosmina Zeana, Simin Aysel Florescu, Corneliu Petru Popescu, Stephen Vaughan, Susan Kuhn, Susan Anderson, Kunjana Mavunda, Carmelo Licitra, François Chappuis, Gilles Éperon, Jesse J. Waggoner, Henry H. L. Wu, Sabine Jordan, Johnnie Yates, Phi Truong Hoang Phu, Prativa Pandey, Michael Beadsworth, José A. Pérez‐Molina, Philippe Gautret, Émilie Javelle, Noreen A. Hynes, Elizabeth D. Barnett, Dan Bourque, Ann Settgast, Christina Greenaway, Sapha Barkati, Cédric P. Yansouni, Arpita Chakravarti, Camilla Rothe, Mirjam Schunk, Federico Gobbi, Nancy Piper Jenks, Marina Rogova, John D. Cahill, Ben Wyler, Frank Patterson, Anne Marie McCarthy, Éric Caumes, Oula Itani, Els van Nood, Hedvig Glans, Mugen Ujiie, Satoshi Kutsuna, Shaun K. Morris, Kescha Kazmi, Terri Sofarelli, Katherine Plewes, Yazdan Mirzanejad, Pierre Plourde, Jacquie Shackel, Yukihiro Yoshimura, Natsuo Tachikawa, Patricia Schlagenhauf, Annelies Zinkernage, Kristina M Angelo
Abstract
BACKGROUND: Prolonged diarrhoea is common amongst returning travellers and is often caused by intestinal protozoa. However, the epidemiology of travel-associated illness caused by protozoal pathogens is not well described. METHODS: We analysed records of returning international travellers with illness caused by Giardia duodenalis, Cryptosporidium spp., Cyclospora cayetanensis or Cystoisospora belli, reported to the GeoSentinel Network during January 2007-December 2019. We excluded records of travellers migrating, with an unascertainable exposure country, or from GeoSentinel sites that were not located in high-income countries. RESULTS: There were 2517 cases, 82.3% giardiasis (n = 2072), 11.4% cryptosporidiosis (n = 287), 6.0% cyclosporiasis (n = 150) and 0.3% cystoisosporiasis (n = 8). Overall, most travellers were tourists (64.4%) on long trips (median durations: 18-30 days). Cryptosporidiosis more frequently affected people < 18 years (13.9%) and cyclosporiasis affected people ≥ 40 years (59.4%). Giardiasis was most frequently acquired in South Central Asia (45.8%) and sub-Saharan Africa (22.6%), cryptosporidiosis in sub-Saharan Africa (24.7%) and South-Central Asia (19.5%), cyclosporiasis in South East Asia (31.3%) and Central America (27.3%), and cystoisosporiasis in sub-Saharan Africa (62.5%). Cyclosporiasis cases were reported from countries of uncertain endemicity (e.g. Cambodia) or in countries with no previous evidence of this parasite (e.g. French Guiana). The time from symptom onset to presentation at a GeoSentinel site was the longest amongst travellers with giardiasis (median: 30 days). Over 14% of travellers with cryptosporidiosis were hospitalized. CONCLUSIONS: This analysis provides new insights into the epidemiology and clinical significance of four intestinal protozoa that can cause morbidity in international travellers. These data might help optimize pretravel advice and post-travel management of patients with travel-associated prolonged gastrointestinal illnesses. This analysis reinforces the importance of international travel-related surveillance to identify sentinel cases and areas where protozoal infections might be undetected or underreported.