Volume 9, Number 12—December 2003
International Travel and Sexually Transmitted Disease
To the Editor: Recent articles in the professional literature (1–3) have offered advice regarding the importance of taking a careful travel history, particularly in this time of unprecedented levels of international travel (4). Such screening serves an important public health purpose as well, especially for sexually transmitted disease (STD) control.
Sexual behaviors associated with travel can change the level of risks for STD transmission (5–7), and the epidemiology of STDs is not uniform throughout the world (8,9). These geographic differences may increase the risk of a traveler’s becoming infected, or, conversely, increase the risk of a traveler’s introducing a sexually transmitted pathogen, possibly one that is resistant to treatment, into a low-incidence area (10). In addition, different strains of pathogens may be common in different parts of the world (11–14). For example, quinolone-resistant Neisseria gonorrhoeae (QRNG) is much more common in Asia (up to 40% of all isolates) (15). These strains of QRNG were first introduced in the United States by persons who engaged in sexual activity abroad, but now California and Hawaii have an increasing incidence of infection attributable these strains (16). Indeed, QRNG has become endemic in those states, and incidence is no longer related to travel. During 1999–2001, only 3 QRNG isolates (0.28%) were identified among the 1,066 synococcal isolates cultured in the STD Laboratory, State Laboratory Institute, Massachusetts Department of Public Health (Massachusetts Department of Public Health, unpub. data). However, in 2002, 9 (2.1%) of 425 isolates of Neisseria gonorrhoeae were quinolone resistant. None of the persons recently infected reported a history of travel outside of New England. Unfortunately, few had reliable information to identify their partner(s). Those partners who were identified were either not located or did not agree to speak with the disease intervention specialist.
This experience with antimicrobial resistance of Neisseria gonorrhoeae should serve as a model for STD prevention planning and programming. It highlights the importance of retaining the laboratory capacity to monitor antimicrobial susceptibilities of bacterial STD isolates. Treatment protocols should be adjusted in light of the prevalence of resistant strains of sexually transmitted pathogens. In cases in which symptoms associated with a bacterial STD persist after what is usually considered appropriate treatment, clinicians should obtain cultures and perform susceptibility tests on isolates. Nucleic acid amplification technologies do not provide critical antibiotic susceptibility information. In this situation, the public health STD program or laboratory should be contacted for guidance. Determining the sensitivity pattern of the pathogen in an expeditious fashion will ensure that appropriate and timely therapy can be initiated for the infected patient as well as enable more effective follow-up and treatment to sexual contacts. Asking patients who seek treatment for a possible STD about their own and their partner’s travel histories is important to broaden the differential diagnosis (17). The increase in population mixing facilitated by travel and Internet-generated contacts may be diminishing the importance of the focality of traditional STD epidemiology. Finally, STD prevention messages should be a part of the health advice offered to travelers (7,18,19).
We thank Alfred DeMaria and Ralph Timperi for their thoughtful reviews and comments regarding this material.
- Ryan ET, Wilson ME, Kain KC. Illness after international travel. N Engl J Med. 2002;347:505–16.
- Ryan ET, Kain KC. Health advice and immunizations for travelers. N Engl J Med. 2000;342:1716–25.
- Harry TC. Infectious syphilis and importance of travel history. Lancet. 2002;359:447–8.
- World Health Organization. The state of the world health. In: The world health report 1996: fighting disease, fostering development. Geneva: The Organization; 1997. p. 1–62.
- Matteelli A, Carosi G. Sexually transmitted disease in travelers. Clin Infect Dis. 2001;32:1063–7.
- Cabada MM, Echevarria JI, Seas CR, Navarte G, Samalvides F, Freedman D, Sexual behavior of international travelers visiting Peru. Sex Transm Dis. 2002;29:510–3.
- Bloor M, Thomas M, Hood K, Abdeni D, Goujon C, Hausser D, Differences in sexual risk behaviour between young men and women travelling abroad from the UK. Lancet. 1998;352:1664–8.
- Gerbase AC, Rowley JT, Mertens TE. Global epidemiology of sexually transmitted diseases. Lancet. 1998;351(Suppl 3):2–4.
- Wasserheit JN, Aral SO. The dynamic topology of sexually transmitted disease epidemics: implications for prevention strategies. J Infect Dis. 1996;174(Suppl 2):S201–13.
- Thompson MM, Najera R. Travel and the introduction of human immunodeficiency virus type 1 non-B subtype genetic forms into western countries. Clin Infect Dis. 2001;32:1732–7.
- World Health Organization/Global Program on AIDS. Global prevalence and incidence estimates of selected curable sexually transmitted diseases: Overview and estimates. Geneva. Organization. 1995; 1–26.
- Van Dyck E, Crabbe E, Neila N, Bogaerts J, Munyabikali JP, Ghys P, Increasing persistence of Neisseria gonorrhoeae in west and central Africa. Consequence on therapy of gonococcal infection. Sex Transm Dis. 1997;24:32–7.
- Tapsall JW, Phillips EA, Schultz TR, Thacker C. Quinolone-resistant Neisseria gonorrhoeae isolated in Sydney, Australia, 1991 to 1995. Sex Transm Dis. 1996;23:425–8.
- Lewis DA, Bond M, Butt KD, Smith CP, Shafi MS, Murphy SM. A one-year survey of gonococcal infection seen in the genitourinary medicine department of a London district general hospital. Int J STD AIDS. 1999;10:588–94.
- Western Pacific Gonococcal Antimicrobial Surveillance Programme WHO. Surveillance of antibiotic resistance in Neisseria gonorrhoeae in the WHO Western Pacific Region, 2000. Commun Dis Intell. 2001;25:274–6.
- Centers for Disease Control and Prevention. Increases in fluoroquinolone-resistant Neisseria gonorrhoeae—Hawaii and California. MMWR Morb Mortal Wkly Rep. 2002;51:1041–4.
- Kingston M, Warren C, Carlin E. Tropical warts. Lancet. 2001;358:808.
- Mulhall BP. Sexual behaviour in travellers. Lancet. 1999;353:595–6.
- Abdullah AS, Hedley AJ, Fielding R. Sexual behaviour in travellers. Lancet. 1999;353:595–6.
Suggested citation: Etkind P, Ratelle S, George H. International travel and sexually transmitted disease. Emerg Infect Dis [serial online] 2003 Dec [date cited]. Available from: URL: http://wwwnc.cdc.gov/eid/article/9/12/03-0210.htm