Health Precautions Taken by Travelers to Countries with Ebola Virus Disease

To the Editor: To facilitate early recognition of Ebola virus disease (EVD), the New York City Department of Health and Mental Hygiene (DOHMH) actively monitored persons who had recently traveled from an EVD-affected country (1,2). Clinical manifestations of EVD are nonspecific and can resemble common travel-associated illnesses, such as malaria and influenza, both of which are potentially preventable through use of certain health precautions (3,4). Given the consequences of missing an EVD diagnosis, symptomatic persons under active monitoring who actually have non-EVD illnesses are often first isolated and tested for Ebola virus, which can delay appropriate care for the true cause of their illness and consume substantial resources. We evaluated the health precautions taken by persons traveling to EVD-affected countries. 
 
During March 16, 2015–December 29, 2015 (the last day of EVD active monitoring by DOHMH), persons who underwent active EVD monitoring by DOHMH and who reported living in the United States for most of the previous year were asked about health precautions taken when traveling to an EVD-affected country, regardless of whether they had symptoms. Health precautions assessed were whether a healthcare provider was visited for pretravel medical advice, whether malaria prophylaxis was used during the previous 7 days (if the date of departure from the EVD-affected country was within the previous 7 days), and whether influenza vaccination was received within the past year. Health precautions were examined by country visited, sex, age, reason for travel, and citizenship. Relative risks (RRs) and 95% CIs were calculated. 
 
During the evaluation period, DOHMH actively monitored 4,230 persons, of whom 2,032 (48.0%) reported living in the United States. Among these 2,032 persons, only 1,265 (62.3%) received pretravel medical advice and 1,198 (59.0%) received influenza vaccination. Among the 1,992 persons whose date of departure from the EVD-affected country was within the previous 7 days of the date of data collection, 822 (41.3%) used malaria prophylaxis (Table). 
 
 
 
Table 
 
Health precautions taken by 2,032 travelers to countries with Ebola virus disease who underwent active monitoring by the New York City Department of Health and Mental Hygiene after returning to the United States, March–December 29,2015* 
 
 
 
The most common reason for travel to an EVD-affected country was to visit friends or relatives, which was reported by 1,655 (81.4%) of 2,032 persons. Female travelers were more likely than male travelers to use each of the health precautions. Persons who traveled for business reasons (RR 1.54, 95% CI 1.37–1.75) or for service-related reasons (humanitarian aid, missionary, volunteer, research, or military reasons; RR 2.07, 95% CI 1.78–2.40) were more likely to use malaria prophylaxis than those who traveled to visit friends or relatives, although there were no differences for receiving pretravel medical advice. US citizens were more likely to receive pretravel medical advice than citizens of the 3 EVD-affected countries and more likely to use malaria prophylaxis than citizens of Guinea (RR 0.76, 95% CI 0.65–0.89) or Sierra Leone (RR 0.65, 95% CI 0.48–0.88). 
 
In summary, persons traveling to EVD-affected countries frequently did not use major health precautions, despite federal travel warnings for EVD-affected countries and the consequences of a febrile illness developing (5). Our findings are notable because New York City represents >20% of all persons actively monitored for EVD in the United States (more than any other jurisdiction) (1). Most persons reported in this study traveled to visit friends or relatives and were less likely to use malaria prophylaxis than those who traveled for business or service-related reasons, which is consistent with previously reported data and of concern given that malaria can be a life-threatening illness (4). Nonetheless, a surprisingly low proportion of persons who traveled for business or service-related reasons received pretravel medical advice, used malaria prophylaxis, and received influenza vaccination. Public health agencies should work closely with organizations sending personnel abroad to improve their use of health precautions during travel. Furthermore, although most persons who traveled to visit friends or relatives received pretravel medical advice, few used malaria prophylaxis. The reason for this discrepancy deserves further evaluation. 
 
Public health agencies should also work closely with communities whose members are likely to visit friends or relatives abroad and with medical providers caring for these communities to increase the use of travel health precautions, particularly when exceptional circumstances apply as during the EVD outbreak. Increasing the use of health precautions among persons traveling to an area for which active monitoring is recommended could directly benefit the travelers and improve the specificity of active monitoring by reducing the occurrence of malaria, influenza, and other preventable travel-associated illnesses.


Health Precautions Taken by Travelers to Countries with Ebola Virus Disease
To the Editor: To facilitate early recognition of Ebola virus disease (EVD), the New York City Department of Health and Mental Hygiene (DOHMH) actively monitored persons who had recently traveled from an EVD-affected country (1,2). Clinical manifestations of EVD are nonspecific and can resemble common travelassociated illnesses, such as malaria and influenza, both of which are potentially preventable through use of certain health precautions (3,4). Given the consequences of missing an EVD diagnosis, symptomatic persons under active monitoring who actually have non-EVD illnesses are often first isolated and tested for Ebola virus, which can delay appropriate care for the true cause of their illness and consume substantial resources. We evaluated the health precautions taken by persons traveling to EVD-affected countries.
During year were asked about health precautions taken when traveling to an EVD-affected country, regardless of whether they had symptoms. Health precautions assessed were whether a healthcare provider was visited for pretravel medical advice, whether malaria prophylaxis was used during the previous 7 days (if the date of departure from the EVD-affected country was within the previous 7 days), and whether influenza vaccination was received within the past year. Health precautions were examined by country visited, sex, age, reason for travel, and citizenship. Relative risks (RRs) and 95% CIs were calculated.
During the evaluation period, DOHMH actively monitored 4,230 persons, of whom 2,032 (48.0%) reported living in the United States. Among these 2,032 persons, only 1,265 (62.3%) received pretravel medical advice and 1,198 (59.0%) received influenza vaccination. Among the 1,992 persons whose date of departure from the EVD-affected country was within the previous 7 days of the date of data collection, 822 (41.3%) used malaria prophylaxis (Table).
The most common reason for travel to an EVD-affected country was to visit friends or relatives, which was reported by 1,655 (81.4%) of 2,032 persons. Female travelers were more likely than male travelers to use each of the health precautions. Persons who traveled for business reasons (RR 1.54, 95% CI 1.37-1.75) or for service-related reasons (humanitarian aid, missionary, volunteer, research, or military reasons; RR 2.07, 95% CI 1.78-2.40) were more likely to use malaria prophylaxis than those who traveled to visit friends or relatives, although there were no differences for receiving pretravel medical advice. US citizens were more likely to receive pretravel medical advice than citizens of the 3 EVD-affected countries and more likely to use malaria prophylaxis than citizens of Guinea (RR 0.76, 95% CI 0.65-0.89) or Sierra Leone (RR 0.65, 95% CI 0.48-0.88).
In summary, persons traveling to EVD-affected countries frequently did not use major health precautions, despite federal travel warnings for EVD-affected countries and the consequences of a febrile illness developing (5). Our findings are notable because New York City represents >20% of all persons actively monitored for EVD in the United States (more than any other jurisdiction) (1). Most persons reported in this study traveled to visit friends or relatives and were less likely to use malaria prophylaxis than those who traveled for business or  service-related reasons, which is consistent with previously reported data and of concern given that malaria can be a life-threatening illness (4). Nonetheless, a surprisingly low proportion of persons who traveled for business or service-related reasons received pretravel medical advice, used malaria prophylaxis, and received influenza vaccination. Public health agencies should work closely with organizations sending personnel abroad to improve their use of health precautions during travel. Furthermore, although most persons who traveled to visit friends or relatives received pretravel medical advice, few used malaria prophylaxis. The reason for this discrepancy deserves further evaluation.
Public health agencies should also work closely with communities whose members are likely to visit friends or relatives abroad and with medical providers caring for these communities to increase the use of travel health precautions, particularly when exceptional circumstances apply as during the EVD outbreak. Increasing the use of health precautions among persons traveling to an area for which active monitoring is recommended could directly benefit the travelers and improve the specificity of active monitoring by reducing the occurrence of malaria, influenza, and other preventable travelassociated illnesses.
To the Editor: War, infection, and disease have always made intimate bedfellows, with disease recrudescence characterizing most conflict zones (1). Recently, increasing violence from civil war and terrorist activity in the Middle East has caused the largest human displacement in decades. A neglected consequence of this tragedy has been the reemergence of a cutaneous leishmaniasis epidemic.
Old World cutaneous leishmaniasis is one of the most prevalent insectborne diseases within the World Health Organization's Eastern Mediterranean Region (2). Zoonotic cutaneous leishmaniasis is caused by the protozoan parasite Leishmania major, which is transmitted through the infectious bite of the female Phlebotomus papatasi sand fly; the animal reservoirs are the rodent genera Rhombomys, Psammomys, and Meriones. Anthroponotic cutaneous leishmaniasis is caused by L. tropica and transmitted between humans by the Ph. sergenti sand fly.
Until 1960, cutaneous leishmaniasis prevalence in Syria was restricted to 2 areas to which it is endemic (Aleppo and Damascus); preconflict (c. 2010) incidence was 23,000 cases/year (3). However, in early 2013, an alarming increase to 41,000 cutaneous leishmaniasis cases was reported (3,4). The regions most affected are under Islamic State control; 6,500 cases occurred in Ar-Raqqah, Diyar Al-Zour, and Hasakah. Because these places are not historical hotspots of cutaneous leishmaniasis, this change might be attributed to the massive human displacement within Syria and the ecologic disruption of sand fly (Ph. papatasi) habitats. According to the United Nations High Commissioner for Refugees, >4.2 million Syrians have been displaced into neighboring countries; Turkey, Lebanon, and Jordan have accepted most of these refugees. As a result, cutaneous leishmaniasis has begun to emerge in areas where displaced Syrians and disease reservoirs coexist (5).
According to the Lebanese Ministry of Health, during 2000-2012, only 6 cutaneous leishmaniasis cases were