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Travel-Associated Zika Virus Disease Acquired in the Americas Through February 2016: A GeoSentinel Analysis.
Ann Intern Med. 2017 Jan 17; 166(2):99-108.AIM

Abstract

Background

Zika virus has spread rapidly in the Americas and has been imported into many nonendemic countries by travelers.

Objective

To describe clinical manifestations and epidemiology of Zika virus disease in travelers exposed in the Americas.

Design

Descriptive, using GeoSentinel records.

Setting

63 travel and tropical medicine clinics in 30 countries.

Patients

Ill returned travelers with a confirmed, probable, or clinically suspected diagnosis of Zika virus disease seen between January 2013 and 29 February 2016.

Measurements

Frequencies of demographic, trip, and clinical characteristics and complications.

Results

Starting in May 2015, 93 cases of Zika virus disease were reported. Common symptoms included exanthema (88%), fever (76%), and arthralgia (72%). Fifty-nine percent of patients were exposed in South America; 71% were diagnosed in Europe. Case status was established most commonly by polymerase chain reaction (PCR) testing of blood and less often by PCR testing of other body fluids or serology and plaque-reduction neutralization testing. Two patients developed Guillain-Barré syndrome, and 3 of 4 pregnancies had adverse outcomes (microcephaly, major fetal neurologic abnormalities, and intrauterine fetal death).

Limitation

Surveillance data collected by specialized clinics may not be representative of all ill returned travelers, and denominator data are unavailable.

Conclusion

These surveillance data help characterize the clinical manifestations and adverse outcomes of Zika virus disease among travelers infected in the Americas and show a need for global standardization of diagnostic testing. The serious fetal complications observed in this study highlight the importance of travel advisories and prevention measures for pregnant women and their partners. Travelers are sentinels for global Zika virus circulation and may facilitate further transmission.

Primary Funding Source

Centers for Disease Control and Prevention, International Society of Travel Medicine, and Public Health Agency of Canada.

Authors+Show Affiliations

From Boston University School of Public Health, Boston Medical Center, Boston University School of Medicine, and Harvard Medical School, Boston, Massachusetts; Centers for Disease Control and Prevention and Emory University, Atlanta, Georgia; Mount Auburn Hospital, Cambridge, Massachusetts; University of Amsterdam, Amsterdam, the Netherlands; University of Zürich Centre for Travel Medicine, WHO Collaborating Centre for Travellers' Health, Epidemiology, Biostatistics and Prevention Institute, Zürich, Switzerland; Harbor Hospital, Rotterdam, the Netherlands; Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, PROSICS Barcelona, Barcelona, Spain; Karolinska University Hospital, Stockholm, Sweden; Groupe Hospitalier Pitié-Salpêtrière, UPMC University, Paris, France; Bronx-Lebanon Hospital Center and Icahn School of Medicine at Mount Sinai, Bronx, New York; Charité-Universitätsmedizin Berlin, Berlin, Germany; Geneva University Hospitals, Geneva, Switzerland; Institute of Tropical Medicine, Antwerp, Belgium; Toronto General Hospital, University of Toronto, and Public Health Ontario Laboratories, Toronto, Ontario, Canada; Aix-Marseille University, Marseille, France; Johns Hopkins School of Medicine, Baltimore, Maryland; Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada; Monash University, Melbourne, Victoria, Australia; McGill University, Montreal, Quebec, Canada; Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France; Pontificia Universidad Católica de Chile, Santiago, Chile; University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Sheba Medical Center, Tel Hashomer, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Heidelberg University, Heidelberg, Germany; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; and Umeå University, Umea, Sweden.From Boston University School of Public Health, Boston Medical Center, Boston University School of Medicine, and Harvard Medical School, Boston, Massachusetts; Centers for Disease Control and Prevention and Emory University, Atlanta, Georgia; Mount Auburn Hospital, Cambridge, Massachusetts; University of Amsterdam, Amsterdam, the Netherlands; University of Zürich Centre for Travel Medicine, WHO Collaborating Centre for Travellers' Health, Epidemiology, Biostatistics and Prevention Institute, Zürich, Switzerland; Harbor Hospital, Rotterdam, the Netherlands; Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, PROSICS Barcelona, Barcelona, Spain; Karolinska University Hospital, Stockholm, Sweden; Groupe Hospitalier Pitié-Salpêtrière, UPMC University, Paris, France; Bronx-Lebanon Hospital Center and Icahn School of Medicine at Mount Sinai, Bronx, New York; Charité-Universitätsmedizin Berlin, Berlin, Germany; Geneva University Hospitals, Geneva, Switzerland; Institute of Tropical Medicine, Antwerp, Belgium; Toronto General Hospital, University of Toronto, and Public Health Ontario Laboratories, Toronto, Ontario, Canada; Aix-Marseille University, Marseille, France; Johns Hopkins School of Medicine, Baltimore, Maryland; Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada; Monash University, Melbourne, Victoria, Australia; McGill University, Montreal, Quebec, Canada; Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France; Pontificia Universidad Católica de Chile, Santiago, Chile; University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Sheba Medical Center, Tel Hashomer, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Heidelberg University, Heidelberg, Germany; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; and Umeå University, Umea, Sweden.From Boston University School of Public Health, Boston Medical Center, Boston University School of Medicine, and Harvard Medical School, Boston, Massachusetts; Centers for Disease Control and Prevention and Emory University, Atlanta, Georgia; Mount Auburn Hospital, Cambridge, Massachusetts; University of Amsterdam, Amsterdam, the Netherlands; University of Zürich Centre for Travel Medicine, WHO Collaborating Centre for Travellers' Health, Epidemiology, Biostatistics and Prevention Institute, Zürich, Switzerland; Harbor Hospital, Rotterdam, the Netherlands; Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, PROSICS Barcelona, Barcelona, Spain; Karolinska University Hospital, Stockholm, Sweden; Groupe Hospitalier Pitié-Salpêtrière, UPMC University, Paris, France; Bronx-Lebanon Hospital Center and Icahn School of Medicine at Mount Sinai, Bronx, New York; Charité-Universitätsmedizin Berlin, Berlin, Germany; Geneva University Hospitals, Geneva, Switzerland; Institute of Tropical Medicine, Antwerp, Belgium; Toronto General Hospital, University of Toronto, and Public Health Ontario Laboratories, Toronto, Ontario, Canada; Aix-Marseille University, Marseille, France; Johns Hopkins School of Medicine, Baltimore, Maryland; Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada; Monash University, Melbourne, Victoria, Australia; McGill University, Montreal, Quebec, Canada; Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France; Pontificia Universidad Católica de Chile, Santiago, Chile; University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Sheba Medical Center, Tel Hashomer, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Heidelberg University, Heidelberg, Germany; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; and Umeå University, Umea, Sweden.From Boston University School of Public Health, Boston Medical Center, Boston University School of Medicine, and Harvard Medical School, Boston, Massachusetts; Centers for Disease Control and Prevention and Emory University, Atlanta, Georgia; Mount Auburn Hospital, Cambridge, Massachusetts; University of Amsterdam, Amsterdam, the Netherlands; University of Zürich Centre for Travel Medicine, WHO Collaborating Centre for Travellers' Health, Epidemiology, Biostatistics and Prevention Institute, Zürich, Switzerland; Harbor Hospital, Rotterdam, the Netherlands; Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, PROSICS Barcelona, Barcelona, Spain; Karolinska University Hospital, Stockholm, Sweden; Groupe Hospitalier Pitié-Salpêtrière, UPMC University, Paris, France; Bronx-Lebanon Hospital Center and Icahn School of Medicine at Mount Sinai, Bronx, New York; Charité-Universitätsmedizin Berlin, Berlin, Germany; Geneva University Hospitals, Geneva, Switzerland; Institute of Tropical Medicine, Antwerp, Belgium; Toronto General Hospital, University of Toronto, and Public Health Ontario Laboratories, Toronto, Ontario, Canada; Aix-Marseille University, Marseille, France; Johns Hopkins School of Medicine, Baltimore, Maryland; Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada; Monash University, Melbourne, Victoria, Australia; McGill University, Montreal, Quebec, Canada; Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France; Pontificia Universidad Católica de Chile, Santiago, Chile; University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Sheba Medical Center, Tel Hashomer, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Heidelberg University, Heidelberg, Germany; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; and Umeå University, Umea, Sweden.From Boston University School of Public Health, Boston Medical Center, Boston University School of Medicine, and Harvard Medical School, Boston, Massachusetts; Centers for Disease Control and Prevention and Emory University, Atlanta, Georgia; Mount Auburn Hospital, Cambridge, Massachusetts; University of Amsterdam, Amsterdam, the Netherlands; University of Zürich Centre for Travel Medicine, WHO Collaborating Centre for Travellers' Health, Epidemiology, Biostatistics and Prevention Institute, Zürich, Switzerland; Harbor Hospital, Rotterdam, the Netherlands; Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, PROSICS Barcelona, Barcelona, Spain; Karolinska University Hospital, Stockholm, Sweden; Groupe Hospitalier Pitié-Salpêtrière, UPMC University, Paris, France; Bronx-Lebanon Hospital Center and Icahn School of Medicine at Mount Sinai, Bronx, New York; Charité-Universitätsmedizin Berlin, Berlin, Germany; Geneva University Hospitals, Geneva, Switzerland; Institute of Tropical Medicine, Antwerp, Belgium; Toronto General Hospital, University of Toronto, and Public Health Ontario Laboratories, Toronto, Ontario, Canada; Aix-Marseille University, Marseille, France; Johns Hopkins School of Medicine, Baltimore, Maryland; Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada; Monash University, Melbourne, Victoria, Australia; McGill University, Montreal, Quebec, Canada; Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France; Pontificia Universidad Católica de Chile, Santiago, Chile; University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Sheba Medical Center, Tel Hashomer, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Heidelberg University, Heidelberg, Germany; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; and Umeå University, Umea, Sweden.From Boston University School of Public Health, Boston Medical Center, Boston University School of Medicine, and Harvard Medical School, Boston, Massachusetts; Centers for Disease Control and Prevention and Emory University, Atlanta, Georgia; Mount Auburn Hospital, Cambridge, Massachusetts; University of Amsterdam, Amsterdam, the Netherlands; University of Zürich Centre for Travel Medicine, WHO Collaborating Centre for Travellers' Health, Epidemiology, Biostatistics and Prevention Institute, Zürich, Switzerland; Harbor Hospital, Rotterdam, the Netherlands; Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, PROSICS Barcelona, Barcelona, Spain; Karolinska University Hospital, Stockholm, Sweden; Groupe Hospitalier Pitié-Salpêtrière, UPMC University, Paris, France; Bronx-Lebanon Hospital Center and Icahn School of Medicine at Mount Sinai, Bronx, New York; Charité-Universitätsmedizin Berlin, Berlin, Germany; Geneva University Hospitals, Geneva, Switzerland; Institute of Tropical Medicine, Antwerp, Belgium; Toronto General Hospital, University of Toronto, and Public Health Ontario Laboratories, Toronto, Ontario, Canada; Aix-Marseille University, Marseille, France; Johns Hopkins School of Medicine, Baltimore, Maryland; Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada; Monash University, Melbourne, Victoria, Australia; McGill University, Montreal, Quebec, Canada; Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France; Pontificia Universidad Católica de Chile, Santiago, Chile; University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Sheba Medical Center, Tel Hashomer, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Heidelberg University, Heidelberg, Germany; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; and Umeå University, Umea, Sweden.From Boston University School of Public Health, Boston Medical Center, Boston University School of Medicine, and Harvard Medical School, Boston, Massachusetts; Centers for Disease Control and Prevention and Emory University, Atlanta, Georgia; Mount Auburn Hospital, Cambridge, Massachusetts; University of Amsterdam, Amsterdam, the Netherlands; University of Zürich Centre for Travel Medicine, WHO Collaborating Centre for Travellers' Health, Epidemiology, Biostatistics and Prevention Institute, Zürich, Switzerland; Harbor Hospital, Rotterdam, the Netherlands; Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, PROSICS Barcelona, Barcelona, Spain; Karolinska University Hospital, Stockholm, Sweden; Groupe Hospitalier Pitié-Salpêtrière, UPMC University, Paris, France; Bronx-Lebanon Hospital Center and Icahn School of Medicine at Mount Sinai, Bronx, New York; Charité-Universitätsmedizin Berlin, Berlin, Germany; Geneva University Hospitals, Geneva, Switzerland; Institute of Tropical Medicine, Antwerp, Belgium; Toronto General Hospital, University of Toronto, and Public Health Ontario Laboratories, Toronto, Ontario, Canada; Aix-Marseille University, Marseille, France; Johns Hopkins School of Medicine, Baltimore, Maryland; Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada; Monash University, Melbourne, Victoria, Australia; McGill University, Montreal, Quebec, Canada; Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France; Pontificia Universidad Católica de Chile, Santiago, Chile; University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Sheba Medical Center, Tel Hashomer, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Heidelberg University, Heidelberg, Germany; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; and Umeå University, Umea, Sweden.From Boston University School of Public Health, Boston Medical Center, Boston University School of Medicine, and Harvard Medical School, Boston, Massachusetts; Centers for Disease Control and Prevention and Emory University, Atlanta, Georgia; Mount Auburn Hospital, Cambridge, Massachusetts; University of Amsterdam, Amsterdam, the Netherlands; University of Zürich Centre for Travel Medicine, WHO Collaborating Centre for Travellers' Health, Epidemiology, Biostatistics and Prevention Institute, Zürich, Switzerland; Harbor Hospital, Rotterdam, the Netherlands; Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, PROSICS Barcelona, Barcelona, Spain; Karolinska University Hospital, Stockholm, Sweden; Groupe Hospitalier Pitié-Salpêtrière, UPMC University, Paris, France; Bronx-Lebanon Hospital Center and Icahn School of Medicine at Mount Sinai, Bronx, New York; Charité-Universitätsmedizin Berlin, Berlin, Germany; Geneva University Hospitals, Geneva, Switzerland; Institute of Tropical Medicine, Antwerp, Belgium; Toronto General Hospital, University of Toronto, and Public Health Ontario Laboratories, Toronto, Ontario, Canada; Aix-Marseille University, Marseille, France; Johns Hopkins School of Medicine, Baltimore, Maryland; Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada; Monash University, Melbourne, Victoria, Australia; McGill University, Montreal, Quebec, Canada; Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France; Pontificia Universidad Católica de Chile, Santiago, Chile; University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Sheba Medical Center, Tel Hashomer, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Heidelberg University, Heidelberg, Germany; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; and Umeå University, Umea, Sweden.From Boston University School of Public Health, Boston Medical Center, Boston University School of Medicine, and Harvard Medical School, Boston, Massachusetts; Centers for Disease Control and Prevention and Emory University, Atlanta, Georgia; Mount Auburn Hospital, Cambridge, Massachusetts; University of Amsterdam, Amsterdam, the Netherlands; University of Zürich Centre for Travel Medicine, WHO Collaborating Centre for Travellers' Health, Epidemiology, Biostatistics and Prevention Institute, Zürich, Switzerland; Harbor Hospital, Rotterdam, the Netherlands; Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, PROSICS Barcelona, Barcelona, Spain; Karolinska University Hospital, Stockholm, Sweden; Groupe Hospitalier Pitié-Salpêtrière, UPMC University, Paris, France; Bronx-Lebanon Hospital Center and Icahn School of Medicine at Mount Sinai, Bronx, New York; Charité-Universitätsmedizin Berlin, Berlin, Germany; Geneva University Hospitals, Geneva, Switzerland; Institute of Tropical Medicine, Antwerp, Belgium; Toronto General Hospital, University of Toronto, and Public Health Ontario Laboratories, Toronto, Ontario, Canada; Aix-Marseille University, Marseille, France; Johns Hopkins School of Medicine, Baltimore, Maryland; Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada; Monash University, Melbourne, Victoria, Australia; McGill University, Montreal, Quebec, Canada; Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France; Pontificia Universidad Católica de Chile, Santiago, Chile; University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Sheba Medical Center, Tel Hashomer, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Heidelberg University, Heidelberg, Germany; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; and Umeå University, Umea, Sweden.From Boston University School of Public Health, Boston Medical Center, Boston University School of Medicine, and Harvard Medical School, Boston, Massachusetts; Centers for Disease Control and Prevention and Emory University, Atlanta, Georgia; Mount Auburn Hospital, Cambridge, Massachusetts; University of Amsterdam, Amsterdam, the Netherlands; University of Zürich Centre for Travel Medicine, WHO Collaborating Centre for Travellers' Health, Epidemiology, Biostatistics and Prevention Institute, Zürich, Switzerland; Harbor Hospital, Rotterdam, the Netherlands; Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, PROSICS Barcelona, Barcelona, Spain; Karolinska University Hospital, Stockholm, Sweden; Groupe Hospitalier Pitié-Salpêtrière, UPMC University, Paris, France; Bronx-Lebanon Hospital Center and Icahn School of Medicine at Mount Sinai, Bronx, New York; Charité-Universitätsmedizin Berlin, Berlin, Germany; Geneva University Hospitals, Geneva, Switzerland; Institute of Tropical Medicine, Antwerp, Belgium; Toronto General Hospital, University of Toronto, and Public Health Ontario Laboratories, Toronto, Ontario, Canada; Aix-Marseille University, Marseille, France; Johns Hopkins School of Medicine, Baltimore, Maryland; Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada; Monash University, Melbourne, Victoria, Australia; McGill University, Montreal, Quebec, Canada; Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France; Pontificia Universidad Católica de Chile, Santiago, Chile; University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Sheba Medical Center, Tel Hashomer, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Heidelberg University, Heidelberg, Germany; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; and Umeå University, Umea, Sweden.From Boston University School of Public Health, Boston Medical Center, Boston University School of Medicine, and Harvard Medical School, Boston, Massachusetts; Centers for Disease Control and Prevention and Emory University, Atlanta, Georgia; Mount Auburn Hospital, Cambridge, Massachusetts; University of Amsterdam, Amsterdam, the Netherlands; University of Zürich Centre for Travel Medicine, WHO Collaborating Centre for Travellers' Health, Epidemiology, Biostatistics and Prevention Institute, Zürich, Switzerland; Harbor Hospital, Rotterdam, the Netherlands; Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, PROSICS Barcelona, Barcelona, Spain; Karolinska University Hospital, Stockholm, Sweden; Groupe Hospitalier Pitié-Salpêtrière, UPMC University, Paris, France; Bronx-Lebanon Hospital Center and Icahn School of Medicine at Mount Sinai, Bronx, New York; Charité-Universitätsmedizin Berlin, Berlin, Germany; Geneva University Hospitals, Geneva, Switzerland; Institute of Tropical Medicine, Antwerp, Belgium; Toronto General Hospital, University of Toronto, and Public Health Ontario Laboratories, Toronto, Ontario, Canada; Aix-Marseille University, Marseille, France; Johns Hopkins School of Medicine, Baltimore, Maryland; Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada; Monash University, Melbourne, Victoria, Australia; McGill University, Montreal, Quebec, Canada; Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France; Pontificia Universidad Católica de Chile, Santiago, Chile; University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Sheba Medical Center, Tel Hashomer, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Heidelberg University, Heidelberg, Germany; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; and Umeå University, Umea, Sweden.From Boston University School of Public Health, Boston Medical Center, Boston University School of Medicine, and Harvard Medical School, Boston, Massachusetts; Centers for Disease Control and Prevention and Emory University, Atlanta, Georgia; Mount Auburn Hospital, Cambridge, Massachusetts; University of Amsterdam, Amsterdam, the Netherlands; University of Zürich Centre for Travel Medicine, WHO Collaborating Centre for Travellers' Health, Epidemiology, Biostatistics and Prevention Institute, Zürich, Switzerland; Harbor Hospital, Rotterdam, the Netherlands; Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, PROSICS Barcelona, Barcelona, Spain; Karolinska University Hospital, Stockholm, Sweden; Groupe Hospitalier Pitié-Salpêtrière, UPMC University, Paris, France; Bronx-Lebanon Hospital Center and Icahn School of Medicine at Mount Sinai, Bronx, New York; Charité-Universitätsmedizin Berlin, Berlin, Germany; Geneva University Hospitals, Geneva, Switzerland; Institute of Tropical Medicine, Antwerp, Belgium; Toronto General Hospital, University of Toronto, and Public Health Ontario Laboratories, Toronto, Ontario, Canada; Aix-Marseille University, Marseille, France; Johns Hopkins School of Medicine, Baltimore, Maryland; Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada; Monash University, Melbourne, Victoria, Australia; McGill University, Montreal, Quebec, Canada; Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France; Pontificia Universidad Católica de Chile, Santiago, Chile; University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Sheba Medical Center, Tel Hashomer, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Heidelberg University, Heidelberg, Germany; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; and Umeå University, Umea, Sweden.From Boston University School of Public Health, Boston Medical Center, Boston University School of Medicine, and Harvard Medical School, Boston, Massachusetts; Centers for Disease Control and Prevention and Emory University, Atlanta, Georgia; Mount Auburn Hospital, Cambridge, Massachusetts; University of Amsterdam, Amsterdam, the Netherlands; University of Zürich Centre for Travel Medicine, WHO Collaborating Centre for Travellers' Health, Epidemiology, Biostatistics and Prevention Institute, Zürich, Switzerland; Harbor Hospital, Rotterdam, the Netherlands; Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, PROSICS Barcelona, Barcelona, Spain; Karolinska University Hospital, Stockholm, Sweden; Groupe Hospitalier Pitié-Salpêtrière, UPMC University, Paris, France; Bronx-Lebanon Hospital Center and Icahn School of Medicine at Mount Sinai, Bronx, New York; Charité-Universitätsmedizin Berlin, Berlin, Germany; Geneva University Hospitals, Geneva, Switzerland; Institute of Tropical Medicine, Antwerp, Belgium; Toronto General Hospital, University of Toronto, and Public Health Ontario Laboratories, Toronto, Ontario, Canada; Aix-Marseille University, Marseille, France; Johns Hopkins School of Medicine, Baltimore, Maryland; Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada; Monash University, Melbourne, Victoria, Australia; McGill University, Montreal, Quebec, Canada; Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France; Pontificia Universidad Católica de Chile, Santiago, Chile; University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Sheba Medical Center, Tel Hashomer, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Heidelberg University, Heidelberg, Germany; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; and Umeå University, Umea, Sweden.From Boston University School of Public Health, Boston Medical Center, Boston University School of Medicine, and Harvard Medical School, Boston, Massachusetts; Centers for Disease Control and Prevention and Emory University, Atlanta, Georgia; Mount Auburn Hospital, Cambridge, Massachusetts; University of Amsterdam, Amsterdam, the Netherlands; University of Zürich Centre for Travel Medicine, WHO Collaborating Centre for Travellers' Health, Epidemiology, Biostatistics and Prevention Institute, Zürich, Switzerland; Harbor Hospital, Rotterdam, the Netherlands; Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, PROSICS Barcelona, Barcelona, Spain; Karolinska University Hospital, Stockholm, Sweden; Groupe Hospitalier Pitié-Salpêtrière, UPMC University, Paris, France; Bronx-Lebanon Hospital Center and Icahn School of Medicine at Mount Sinai, Bronx, New York; Charité-Universitätsmedizin Berlin, Berlin, Germany; Geneva University Hospitals, Geneva, Switzerland; Institute of Tropical Medicine, Antwerp, Belgium; Toronto General Hospital, University of Toronto, and Public Health Ontario Laboratories, Toronto, Ontario, Canada; Aix-Marseille University, Marseille, France; Johns Hopkins School of Medicine, Baltimore, Maryland; Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada; Monash University, Melbourne, Victoria, Australia; McGill University, Montreal, Quebec, Canada; Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France; Pontificia Universidad Católica de Chile, Santiago, Chile; University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Sheba Medical Center, Tel Hashomer, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Heidelberg University, Heidelberg, Germany; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; and Umeå University, Umea, Sweden.From Boston University School of Public Health, Boston Medical Center, Boston University School of Medicine, and Harvard Medical School, Boston, Massachusetts; Centers for Disease Control and Prevention and Emory University, Atlanta, Georgia; Mount Auburn Hospital, Cambridge, Massachusetts; University of Amsterdam, Amsterdam, the Netherlands; University of Zürich Centre for Travel Medicine, WHO Collaborating Centre for Travellers' Health, Epidemiology, Biostatistics and Prevention Institute, Zürich, Switzerland; Harbor Hospital, Rotterdam, the Netherlands; Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, PROSICS Barcelona, Barcelona, Spain; Karolinska University Hospital, Stockholm, Sweden; Groupe Hospitalier Pitié-Salpêtrière, UPMC University, Paris, France; Bronx-Lebanon Hospital Center and Icahn School of Medicine at Mount Sinai, Bronx, New York; Charité-Universitätsmedizin Berlin, Berlin, Germany; Geneva University Hospitals, Geneva, Switzerland; Institute of Tropical Medicine, Antwerp, Belgium; Toronto General Hospital, University of Toronto, and Public Health Ontario Laboratories, Toronto, Ontario, Canada; Aix-Marseille University, Marseille, France; Johns Hopkins School of Medicine, Baltimore, Maryland; Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada; Monash University, Melbourne, Victoria, Australia; McGill University, Montreal, Quebec, Canada; Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France; Pontificia Universidad Católica de Chile, Santiago, Chile; University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Sheba Medical Center, Tel Hashomer, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Heidelberg University, Heidelberg, Germany; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; and Umeå University, Umea, Sweden.From Boston University School of Public Health, Boston Medical Center, Boston University School of Medicine, and Harvard Medical School, Boston, Massachusetts; Centers for Disease Control and Prevention and Emory University, Atlanta, Georgia; Mount Auburn Hospital, Cambridge, Massachusetts; University of Amsterdam, Amsterdam, the Netherlands; University of Zürich Centre for Travel Medicine, WHO Collaborating Centre for Travellers' Health, Epidemiology, Biostatistics and Prevention Institute, Zürich, Switzerland; Harbor Hospital, Rotterdam, the Netherlands; Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, PROSICS Barcelona, Barcelona, Spain; Karolinska University Hospital, Stockholm, Sweden; Groupe Hospitalier Pitié-Salpêtrière, UPMC University, Paris, France; Bronx-Lebanon Hospital Center and Icahn School of Medicine at Mount Sinai, Bronx, New York; Charité-Universitätsmedizin Berlin, Berlin, Germany; Geneva University Hospitals, Geneva, Switzerland; Institute of Tropical Medicine, Antwerp, Belgium; Toronto General Hospital, University of Toronto, and Public Health Ontario Laboratories, Toronto, Ontario, Canada; Aix-Marseille University, Marseille, France; Johns Hopkins School of Medicine, Baltimore, Maryland; Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada; Monash University, Melbourne, Victoria, Australia; McGill University, Montreal, Quebec, Canada; Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France; Pontificia Universidad Católica de Chile, Santiago, Chile; University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Sheba Medical Center, Tel Hashomer, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Heidelberg University, Heidelberg, Germany; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; and Umeå University, Umea, Sweden.From Boston University School of Public Health, Boston Medical Center, Boston University School of Medicine, and Harvard Medical School, Boston, Massachusetts; Centers for Disease Control and Prevention and Emory University, Atlanta, Georgia; Mount Auburn Hospital, Cambridge, Massachusetts; University of Amsterdam, Amsterdam, the Netherlands; University of Zürich Centre for Travel Medicine, WHO Collaborating Centre for Travellers' Health, Epidemiology, Biostatistics and Prevention Institute, Zürich, Switzerland; Harbor Hospital, Rotterdam, the Netherlands; Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, PROSICS Barcelona, Barcelona, Spain; Karolinska University Hospital, Stockholm, Sweden; Groupe Hospitalier Pitié-Salpêtrière, UPMC University, Paris, France; Bronx-Lebanon Hospital Center and Icahn School of Medicine at Mount Sinai, Bronx, New York; Charité-Universitätsmedizin Berlin, Berlin, Germany; Geneva University Hospitals, Geneva, Switzerland; Institute of Tropical Medicine, Antwerp, Belgium; Toronto General Hospital, University of Toronto, and Public Health Ontario Laboratories, Toronto, Ontario, Canada; Aix-Marseille University, Marseille, France; Johns Hopkins School of Medicine, Baltimore, Maryland; Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada; Monash University, Melbourne, Victoria, Australia; McGill University, Montreal, Quebec, Canada; Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France; Pontificia Universidad Católica de Chile, Santiago, Chile; University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Sheba Medical Center, Tel Hashomer, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Heidelberg University, Heidelberg, Germany; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; and Umeå University, Umea, Sweden.From Boston University School of Public Health, Boston Medical Center, Boston University School of Medicine, and Harvard Medical School, Boston, Massachusetts; Centers for Disease Control and Prevention and Emory University, Atlanta, Georgia; Mount Auburn Hospital, Cambridge, Massachusetts; University of Amsterdam, Amsterdam, the Netherlands; University of Zürich Centre for Travel Medicine, WHO Collaborating Centre for Travellers' Health, Epidemiology, Biostatistics and Prevention Institute, Zürich, Switzerland; Harbor Hospital, Rotterdam, the Netherlands; Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, PROSICS Barcelona, Barcelona, Spain; Karolinska University Hospital, Stockholm, Sweden; Groupe Hospitalier Pitié-Salpêtrière, UPMC University, Paris, France; Bronx-Lebanon Hospital Center and Icahn School of Medicine at Mount Sinai, Bronx, New York; Charité-Universitätsmedizin Berlin, Berlin, Germany; Geneva University Hospitals, Geneva, Switzerland; Institute of Tropical Medicine, Antwerp, Belgium; Toronto General Hospital, University of Toronto, and Public Health Ontario Laboratories, Toronto, Ontario, Canada; Aix-Marseille University, Marseille, France; Johns Hopkins School of Medicine, Baltimore, Maryland; Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada; Monash University, Melbourne, Victoria, Australia; McGill University, Montreal, Quebec, Canada; Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France; Pontificia Universidad Católica de Chile, Santiago, Chile; University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Sheba Medical Center, Tel Hashomer, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Heidelberg University, Heidelberg, Germany; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; and Umeå University, Umea, Sweden.From Boston University School of Public Health, Boston Medical Center, Boston University School of Medicine, and Harvard Medical School, Boston, Massachusetts; Centers for Disease Control and Prevention and Emory University, Atlanta, Georgia; Mount Auburn Hospital, Cambridge, Massachusetts; University of Amsterdam, Amsterdam, the Netherlands; University of Zürich Centre for Travel Medicine, WHO Collaborating Centre for Travellers' Health, Epidemiology, Biostatistics and Prevention Institute, Zürich, Switzerland; Harbor Hospital, Rotterdam, the Netherlands; Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, PROSICS Barcelona, Barcelona, Spain; Karolinska University Hospital, Stockholm, Sweden; Groupe Hospitalier Pitié-Salpêtrière, UPMC University, Paris, France; Bronx-Lebanon Hospital Center and Icahn School of Medicine at Mount Sinai, Bronx, New York; Charité-Universitätsmedizin Berlin, Berlin, Germany; Geneva University Hospitals, Geneva, Switzerland; Institute of Tropical Medicine, Antwerp, Belgium; Toronto General Hospital, University of Toronto, and Public Health Ontario Laboratories, Toronto, Ontario, Canada; Aix-Marseille University, Marseille, France; Johns Hopkins School of Medicine, Baltimore, Maryland; Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada; Monash University, Melbourne, Victoria, Australia; McGill University, Montreal, Quebec, Canada; Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France; Pontificia Universidad Católica de Chile, Santiago, Chile; University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Sheba Medical Center, Tel Hashomer, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Heidelberg University, Heidelberg, Germany; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; and Umeå University, Umea, Sweden.From Boston University School of Public Health, Boston Medical Center, Boston University School of Medicine, and Harvard Medical School, Boston, Massachusetts; Centers for Disease Control and Prevention and Emory University, Atlanta, Georgia; Mount Auburn Hospital, Cambridge, Massachusetts; University of Amsterdam, Amsterdam, the Netherlands; University of Zürich Centre for Travel Medicine, WHO Collaborating Centre for Travellers' Health, Epidemiology, Biostatistics and Prevention Institute, Zürich, Switzerland; Harbor Hospital, Rotterdam, the Netherlands; Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, PROSICS Barcelona, Barcelona, Spain; Karolinska University Hospital, Stockholm, Sweden; Groupe Hospitalier Pitié-Salpêtrière, UPMC University, Paris, France; Bronx-Lebanon Hospital Center and Icahn School of Medicine at Mount Sinai, Bronx, New York; Charité-Universitätsmedizin Berlin, Berlin, Germany; Geneva University Hospitals, Geneva, Switzerland; Institute of Tropical Medicine, Antwerp, Belgium; Toronto General Hospital, University of Toronto, and Public Health Ontario Laboratories, Toronto, Ontario, Canada; Aix-Marseille University, Marseille, France; Johns Hopkins School of Medicine, Baltimore, Maryland; Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada; Monash University, Melbourne, Victoria, Australia; McGill University, Montreal, Quebec, Canada; Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France; Pontificia Universidad Católica de Chile, Santiago, Chile; University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Sheba Medical Center, Tel Hashomer, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Heidelberg University, Heidelberg, Germany; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; and Umeå University, Umea, Sweden.From Boston University School of Public Health, Boston Medical Center, Boston University School of Medicine, and Harvard Medical School, Boston, Massachusetts; Centers for Disease Control and Prevention and Emory University, Atlanta, Georgia; Mount Auburn Hospital, Cambridge, Massachusetts; University of Amsterdam, Amsterdam, the Netherlands; University of Zürich Centre for Travel Medicine, WHO Collaborating Centre for Travellers' Health, Epidemiology, Biostatistics and Prevention Institute, Zürich, Switzerland; Harbor Hospital, Rotterdam, the Netherlands; Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, PROSICS Barcelona, Barcelona, Spain; Karolinska University Hospital, Stockholm, Sweden; Groupe Hospitalier Pitié-Salpêtrière, UPMC University, Paris, France; Bronx-Lebanon Hospital Center and Icahn School of Medicine at Mount Sinai, Bronx, New York; Charité-Universitätsmedizin Berlin, Berlin, Germany; Geneva University Hospitals, Geneva, Switzerland; Institute of Tropical Medicine, Antwerp, Belgium; Toronto General Hospital, University of Toronto, and Public Health Ontario Laboratories, Toronto, Ontario, Canada; Aix-Marseille University, Marseille, France; Johns Hopkins School of Medicine, Baltimore, Maryland; Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada; Monash University, Melbourne, Victoria, Australia; McGill University, Montreal, Quebec, Canada; Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France; Pontificia Universidad Católica de Chile, Santiago, Chile; University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Sheba Medical Center, Tel Hashomer, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Heidelberg University, Heidelberg, Germany; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; and Umeå University, Umea, Sweden.From Boston University School of Public Health, Boston Medical Center, Boston University School of Medicine, and Harvard Medical School, Boston, Massachusetts; Centers for Disease Control and Prevention and Emory University, Atlanta, Georgia; Mount Auburn Hospital, Cambridge, Massachusetts; University of Amsterdam, Amsterdam, the Netherlands; University of Zürich Centre for Travel Medicine, WHO Collaborating Centre for Travellers' Health, Epidemiology, Biostatistics and Prevention Institute, Zürich, Switzerland; Harbor Hospital, Rotterdam, the Netherlands; Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, PROSICS Barcelona, Barcelona, Spain; Karolinska University Hospital, Stockholm, Sweden; Groupe Hospitalier Pitié-Salpêtrière, UPMC University, Paris, France; Bronx-Lebanon Hospital Center and Icahn School of Medicine at Mount Sinai, Bronx, New York; Charité-Universitätsmedizin Berlin, Berlin, Germany; Geneva University Hospitals, Geneva, Switzerland; Institute of Tropical Medicine, Antwerp, Belgium; Toronto General Hospital, University of Toronto, and Public Health Ontario Laboratories, Toronto, Ontario, Canada; Aix-Marseille University, Marseille, France; Johns Hopkins School of Medicine, Baltimore, Maryland; Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada; Monash University, Melbourne, Victoria, Australia; McGill University, Montreal, Quebec, Canada; Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France; Pontificia Universidad Católica de Chile, Santiago, Chile; University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Sheba Medical Center, Tel Hashomer, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Heidelberg University, Heidelberg, Germany; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; and Umeå University, Umea, Sweden.From Boston University School of Public Health, Boston Medical Center, Boston University School of Medicine, and Harvard Medical School, Boston, Massachusetts; Centers for Disease Control and Prevention and Emory University, Atlanta, Georgia; Mount Auburn Hospital, Cambridge, Massachusetts; University of Amsterdam, Amsterdam, the Netherlands; University of Zürich Centre for Travel Medicine, WHO Collaborating Centre for Travellers' Health, Epidemiology, Biostatistics and Prevention Institute, Zürich, Switzerland; Harbor Hospital, Rotterdam, the Netherlands; Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, PROSICS Barcelona, Barcelona, Spain; Karolinska University Hospital, Stockholm, Sweden; Groupe Hospitalier Pitié-Salpêtrière, UPMC University, Paris, France; Bronx-Lebanon Hospital Center and Icahn School of Medicine at Mount Sinai, Bronx, New York; Charité-Universitätsmedizin Berlin, Berlin, Germany; Geneva University Hospitals, Geneva, Switzerland; Institute of Tropical Medicine, Antwerp, Belgium; Toronto General Hospital, University of Toronto, and Public Health Ontario Laboratories, Toronto, Ontario, Canada; Aix-Marseille University, Marseille, France; Johns Hopkins School of Medicine, Baltimore, Maryland; Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada; Monash University, Melbourne, Victoria, Australia; McGill University, Montreal, Quebec, Canada; Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France; Pontificia Universidad Católica de Chile, Santiago, Chile; University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Sheba Medical Center, Tel Hashomer, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Heidelberg University, Heidelberg, Germany; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; and Umeå University, Umea, Sweden.From Boston University School of Public Health, Boston Medical Center, Boston University School of Medicine, and Harvard Medical School, Boston, Massachusetts; Centers for Disease Control and Prevention and Emory University, Atlanta, Georgia; Mount Auburn Hospital, Cambridge, Massachusetts; University of Amsterdam, Amsterdam, the Netherlands; University of Zürich Centre for Travel Medicine, WHO Collaborating Centre for Travellers' Health, Epidemiology, Biostatistics and Prevention Institute, Zürich, Switzerland; Harbor Hospital, Rotterdam, the Netherlands; Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, PROSICS Barcelona, Barcelona, Spain; Karolinska University Hospital, Stockholm, Sweden; Groupe Hospitalier Pitié-Salpêtrière, UPMC University, Paris, France; Bronx-Lebanon Hospital Center and Icahn School of Medicine at Mount Sinai, Bronx, New York; Charité-Universitätsmedizin Berlin, Berlin, Germany; Geneva University Hospitals, Geneva, Switzerland; Institute of Tropical Medicine, Antwerp, Belgium; Toronto General Hospital, University of Toronto, and Public Health Ontario Laboratories, Toronto, Ontario, Canada; Aix-Marseille University, Marseille, France; Johns Hopkins School of Medicine, Baltimore, Maryland; Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada; Monash University, Melbourne, Victoria, Australia; McGill University, Montreal, Quebec, Canada; Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France; Pontificia Universidad Católica de Chile, Santiago, Chile; University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Sheba Medical Center, Tel Hashomer, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Heidelberg University, Heidelberg, Germany; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; and Umeå University, Umea, Sweden.From Boston University School of Public Health, Boston Medical Center, Boston University School of Medicine, and Harvard Medical School, Boston, Massachusetts; Centers for Disease Control and Prevention and Emory University, Atlanta, Georgia; Mount Auburn Hospital, Cambridge, Massachusetts; University of Amsterdam, Amsterdam, the Netherlands; University of Zürich Centre for Travel Medicine, WHO Collaborating Centre for Travellers' Health, Epidemiology, Biostatistics and Prevention Institute, Zürich, Switzerland; Harbor Hospital, Rotterdam, the Netherlands; Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, PROSICS Barcelona, Barcelona, Spain; Karolinska University Hospital, Stockholm, Sweden; Groupe Hospitalier Pitié-Salpêtrière, UPMC University, Paris, France; Bronx-Lebanon Hospital Center and Icahn School of Medicine at Mount Sinai, Bronx, New York; Charité-Universitätsmedizin Berlin, Berlin, Germany; Geneva University Hospitals, Geneva, Switzerland; Institute of Tropical Medicine, Antwerp, Belgium; Toronto General Hospital, University of Toronto, and Public Health Ontario Laboratories, Toronto, Ontario, Canada; Aix-Marseille University, Marseille, France; Johns Hopkins School of Medicine, Baltimore, Maryland; Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada; Monash University, Melbourne, Victoria, Australia; McGill University, Montreal, Quebec, Canada; Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France; Pontificia Universidad Católica de Chile, Santiago, Chile; University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Sheba Medical Center, Tel Hashomer, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Heidelberg University, Heidelberg, Germany; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; and Umeå University, Umea, Sweden.From Boston University School of Public Health, Boston Medical Center, Boston University School of Medicine, and Harvard Medical School, Boston, Massachusetts; Centers for Disease Control and Prevention and Emory University, Atlanta, Georgia; Mount Auburn Hospital, Cambridge, Massachusetts; University of Amsterdam, Amsterdam, the Netherlands; University of Zürich Centre for Travel Medicine, WHO Collaborating Centre for Travellers' Health, Epidemiology, Biostatistics and Prevention Institute, Zürich, Switzerland; Harbor Hospital, Rotterdam, the Netherlands; Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, PROSICS Barcelona, Barcelona, Spain; Karolinska University Hospital, Stockholm, Sweden; Groupe Hospitalier Pitié-Salpêtrière, UPMC University, Paris, France; Bronx-Lebanon Hospital Center and Icahn School of Medicine at Mount Sinai, Bronx, New York; Charité-Universitätsmedizin Berlin, Berlin, Germany; Geneva University Hospitals, Geneva, Switzerland; Institute of Tropical Medicine, Antwerp, Belgium; Toronto General Hospital, University of Toronto, and Public Health Ontario Laboratories, Toronto, Ontario, Canada; Aix-Marseille University, Marseille, France; Johns Hopkins School of Medicine, Baltimore, Maryland; Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada; Monash University, Melbourne, Victoria, Australia; McGill University, Montreal, Quebec, Canada; Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France; Pontificia Universidad Católica de Chile, Santiago, Chile; University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Sheba Medical Center, Tel Hashomer, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Heidelberg University, Heidelberg, Germany; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; and Umeå University, Umea, Sweden.From Boston University School of Public Health, Boston Medical Center, Boston University School of Medicine, and Harvard Medical School, Boston, Massachusetts; Centers for Disease Control and Prevention and Emory University, Atlanta, Georgia; Mount Auburn Hospital, Cambridge, Massachusetts; University of Amsterdam, Amsterdam, the Netherlands; University of Zürich Centre for Travel Medicine, WHO Collaborating Centre for Travellers' Health, Epidemiology, Biostatistics and Prevention Institute, Zürich, Switzerland; Harbor Hospital, Rotterdam, the Netherlands; Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, PROSICS Barcelona, Barcelona, Spain; Karolinska University Hospital, Stockholm, Sweden; Groupe Hospitalier Pitié-Salpêtrière, UPMC University, Paris, France; Bronx-Lebanon Hospital Center and Icahn School of Medicine at Mount Sinai, Bronx, New York; Charité-Universitätsmedizin Berlin, Berlin, Germany; Geneva University Hospitals, Geneva, Switzerland; Institute of Tropical Medicine, Antwerp, Belgium; Toronto General Hospital, University of Toronto, and Public Health Ontario Laboratories, Toronto, Ontario, Canada; Aix-Marseille University, Marseille, France; Johns Hopkins School of Medicine, Baltimore, Maryland; Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada; Monash University, Melbourne, Victoria, Australia; McGill University, Montreal, Quebec, Canada; Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France; Pontificia Universidad Católica de Chile, Santiago, Chile; University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Sheba Medical Center, Tel Hashomer, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Heidelberg University, Heidelberg, Germany; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; and Umeå University, Umea, Sweden.From Boston University School of Public Health, Boston Medical Center, Boston University School of Medicine, and Harvard Medical School, Boston, Massachusetts; Centers for Disease Control and Prevention and Emory University, Atlanta, Georgia; Mount Auburn Hospital, Cambridge, Massachusetts; University of Amsterdam, Amsterdam, the Netherlands; University of Zürich Centre for Travel Medicine, WHO Collaborating Centre for Travellers' Health, Epidemiology, Biostatistics and Prevention Institute, Zürich, Switzerland; Harbor Hospital, Rotterdam, the Netherlands; Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, PROSICS Barcelona, Barcelona, Spain; Karolinska University Hospital, Stockholm, Sweden; Groupe Hospitalier Pitié-Salpêtrière, UPMC University, Paris, France; Bronx-Lebanon Hospital Center and Icahn School of Medicine at Mount Sinai, Bronx, New York; Charité-Universitätsmedizin Berlin, Berlin, Germany; Geneva University Hospitals, Geneva, Switzerland; Institute of Tropical Medicine, Antwerp, Belgium; Toronto General Hospital, University of Toronto, and Public Health Ontario Laboratories, Toronto, Ontario, Canada; Aix-Marseille University, Marseille, France; Johns Hopkins School of Medicine, Baltimore, Maryland; Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada; Monash University, Melbourne, Victoria, Australia; McGill University, Montreal, Quebec, Canada; Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France; Pontificia Universidad Católica de Chile, Santiago, Chile; University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Sheba Medical Center, Tel Hashomer, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Heidelberg University, Heidelberg, Germany; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; and Umeå University, Umea, Sweden.From Boston University School of Public Health, Boston Medical Center, Boston University School of Medicine, and Harvard Medical School, Boston, Massachusetts; Centers for Disease Control and Prevention and Emory University, Atlanta, Georgia; Mount Auburn Hospital, Cambridge, Massachusetts; University of Amsterdam, Amsterdam, the Netherlands; University of Zürich Centre for Travel Medicine, WHO Collaborating Centre for Travellers' Health, Epidemiology, Biostatistics and Prevention Institute, Zürich, Switzerland; Harbor Hospital, Rotterdam, the Netherlands; Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, PROSICS Barcelona, Barcelona, Spain; Karolinska University Hospital, Stockholm, Sweden; Groupe Hospitalier Pitié-Salpêtrière, UPMC University, Paris, France; Bronx-Lebanon Hospital Center and Icahn School of Medicine at Mount Sinai, Bronx, New York; Charité-Universitätsmedizin Berlin, Berlin, Germany; Geneva University Hospitals, Geneva, Switzerland; Institute of Tropical Medicine, Antwerp, Belgium; Toronto General Hospital, University of Toronto, and Public Health Ontario Laboratories, Toronto, Ontario, Canada; Aix-Marseille University, Marseille, France; Johns Hopkins School of Medicine, Baltimore, Maryland; Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada; Monash University, Melbourne, Victoria, Australia; McGill University, Montreal, Quebec, Canada; Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France; Pontificia Universidad Católica de Chile, Santiago, Chile; University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Sheba Medical Center, Tel Hashomer, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Heidelberg University, Heidelberg, Germany; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; and Umeå University, Umea, Sweden.From Boston University School of Public Health, Boston Medical Center, Boston University School of Medicine, and Harvard Medical School, Boston, Massachusetts; Centers for Disease Control and Prevention and Emory University, Atlanta, Georgia; Mount Auburn Hospital, Cambridge, Massachusetts; University of Amsterdam, Amsterdam, the Netherlands; University of Zürich Centre for Travel Medicine, WHO Collaborating Centre for Travellers' Health, Epidemiology, Biostatistics and Prevention Institute, Zürich, Switzerland; Harbor Hospital, Rotterdam, the Netherlands; Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, PROSICS Barcelona, Barcelona, Spain; Karolinska University Hospital, Stockholm, Sweden; Groupe Hospitalier Pitié-Salpêtrière, UPMC University, Paris, France; Bronx-Lebanon Hospital Center and Icahn School of Medicine at Mount Sinai, Bronx, New York; Charité-Universitätsmedizin Berlin, Berlin, Germany; Geneva University Hospitals, Geneva, Switzerland; Institute of Tropical Medicine, Antwerp, Belgium; Toronto General Hospital, University of Toronto, and Public Health Ontario Laboratories, Toronto, Ontario, Canada; Aix-Marseille University, Marseille, France; Johns Hopkins School of Medicine, Baltimore, Maryland; Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada; Monash University, Melbourne, Victoria, Australia; McGill University, Montreal, Quebec, Canada; Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France; Pontificia Universidad Católica de Chile, Santiago, Chile; University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Sheba Medical Center, Tel Hashomer, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Heidelberg University, Heidelberg, Germany; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; and Umeå University, Umea, Sweden.No affiliation info available

Pub Type(s)

Journal Article

Language

eng

PubMed ID

27893080

Citation

Hamer, Davidson H., et al. "Travel-Associated Zika Virus Disease Acquired in the Americas Through February 2016: a GeoSentinel Analysis." Annals of Internal Medicine, vol. 166, no. 2, 2017, pp. 99-108.
Hamer DH, Barbre KA, Chen LH, et al. Travel-Associated Zika Virus Disease Acquired in the Americas Through February 2016: A GeoSentinel Analysis. Ann Intern Med. 2017;166(2):99-108.
Hamer, D. H., Barbre, K. A., Chen, L. H., Grobusch, M. P., Schlagenhauf, P., Goorhuis, A., van Genderen, P. J., Molina, I., Asgeirsson, H., Kozarsky, P. E., Caumes, E., Hagmann, S. H., Mockenhaupt, F. P., Eperon, G., Barnett, E. D., Bottieau, E., Boggild, A. K., Gautret, P., Hynes, N. A., ... Esposito, D. H. (2017). Travel-Associated Zika Virus Disease Acquired in the Americas Through February 2016: A GeoSentinel Analysis. Annals of Internal Medicine, 166(2), 99-108. https://doi.org/10.7326/M16-1842
Hamer DH, et al. Travel-Associated Zika Virus Disease Acquired in the Americas Through February 2016: a GeoSentinel Analysis. Ann Intern Med. 2017 Jan 17;166(2):99-108. PubMed PMID: 27893080.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Travel-Associated Zika Virus Disease Acquired in the Americas Through February 2016: A GeoSentinel Analysis. AU - Hamer,Davidson H, AU - Barbre,Kira A, AU - Chen,Lin H, AU - Grobusch,Martin P, AU - Schlagenhauf,Patricia, AU - Goorhuis,Abraham, AU - van Genderen,Perry J J, AU - Molina,Israel, AU - Asgeirsson,Hilmir, AU - Kozarsky,Phyllis E, AU - Caumes,Eric, AU - Hagmann,Stefan H, AU - Mockenhaupt,Frank P, AU - Eperon,Gilles, AU - Barnett,Elizabeth D, AU - Bottieau,Emmanuel, AU - Boggild,Andrea K, AU - Gautret,Philippe, AU - Hynes,Noreen A, AU - Kuhn,Susan, AU - Lash,R Ryan, AU - Leder,Karin, AU - Libman,Michael, AU - Malvy,Denis J M, AU - Perret,Cecilia, AU - Rothe,Camilla, AU - Schwartz,Eli, AU - Wilder-Smith,Annelies, AU - Cetron,Martin S, AU - Esposito,Douglas H, AU - ,, Y1 - 2016/11/22/ PY - 2016/11/29/pubmed PY - 2017/5/13/medline PY - 2016/11/29/entrez SP - 99 EP - 108 JF - Annals of internal medicine JO - Ann. Intern. Med. VL - 166 IS - 2 N2 - Background: Zika virus has spread rapidly in the Americas and has been imported into many nonendemic countries by travelers. Objective: To describe clinical manifestations and epidemiology of Zika virus disease in travelers exposed in the Americas. Design: Descriptive, using GeoSentinel records. Setting: 63 travel and tropical medicine clinics in 30 countries. Patients: Ill returned travelers with a confirmed, probable, or clinically suspected diagnosis of Zika virus disease seen between January 2013 and 29 February 2016. Measurements: Frequencies of demographic, trip, and clinical characteristics and complications. Results: Starting in May 2015, 93 cases of Zika virus disease were reported. Common symptoms included exanthema (88%), fever (76%), and arthralgia (72%). Fifty-nine percent of patients were exposed in South America; 71% were diagnosed in Europe. Case status was established most commonly by polymerase chain reaction (PCR) testing of blood and less often by PCR testing of other body fluids or serology and plaque-reduction neutralization testing. Two patients developed Guillain-Barré syndrome, and 3 of 4 pregnancies had adverse outcomes (microcephaly, major fetal neurologic abnormalities, and intrauterine fetal death). Limitation: Surveillance data collected by specialized clinics may not be representative of all ill returned travelers, and denominator data are unavailable. Conclusion: These surveillance data help characterize the clinical manifestations and adverse outcomes of Zika virus disease among travelers infected in the Americas and show a need for global standardization of diagnostic testing. The serious fetal complications observed in this study highlight the importance of travel advisories and prevention measures for pregnant women and their partners. Travelers are sentinels for global Zika virus circulation and may facilitate further transmission. Primary Funding Source: Centers for Disease Control and Prevention, International Society of Travel Medicine, and Public Health Agency of Canada. SN - 1539-3704 UR - https://www.unboundmedicine.com/medline/citation/27893080/Travel_Associated_Zika_Virus_Disease_Acquired_in_the_Americas_Through_February_2016:_A_GeoSentinel_Analysis_ L2 - https://www.annals.org/aim/fullarticle/doi/10.7326/M16-1842 DB - PRIME DP - Unbound Medicine ER -