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Letter
International Travel and Sexually
Transmitted Disease
Paul Etkind,* Sylvie Ratelle,* and Harvey George*
*Massachusetts Department of Public Health, Jamaica Plain, Massachusetts,
USA
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://www.cdc.gov/ncidod/EID/vol9no12/03-0210.htm
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 to 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 gonococcal 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).
Acknowledgments
We thank Alfred
DeMaria and Ralph Timperi for their thoughtful reviews and comments
regarding this material.
References
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