BACKGROUND:Although global typhoid fever burden has declined, African destination-level risk remains incompletely characterised for travel medicine. We assessed trends, demographic drivers and traveller-relevant typhoid risk across African destinations. METHODS:We analysed GBD 2023 modelled estimates for typhoid fever in 54 African Union destinations, 2010-2023. Outcomes were incidence, prevalence, deaths and DALYs. We estimated age-standardised rates, all-age numbers and trends, developed a burden-trend typology, attributed DALY-count changes to population growth, age-structure change and age-specific DALY-rate change, and estimated destination-specific expected cases per 100 000 travellers. This model-derived metric was used for relative destination ranking, not as an observed individual-level traveller risk estimate. We also performed exploratory interrupted time-series, ecological deaths-to-incidence ratio and 2030 scenario extrapolation analyses. RESULTS:From 2010 to 2023, estimated incident cases declined from approximately 1.36 million to 902 000, and age-standardised incidence from 103.8 to 52.3 per 100 000. Age-standardised prevalence, death and DALY rates declined from 6.6 to 3.3, 1.3 to 0.7, and 96.9 to 53.9 per 100 000, respectively. The highest 2023 incidence rates occurred in the Central African Republic, the Republic of the Congo, the Democratic Republic of the Congo, Gabon and Angola; the Democratic Republic of the Congo had the largest absolute burden. Malawi was the only high-burden, non-declining destination across incidence, deaths and DALYs. DALY counts decreased by approximately 403 000, mainly due to lower age-specific DALY rates. Traveller risk ranged from 0.03 to 9.0 expected cases per 100 000 travellers, with the five highest-risk destinations in Central Sub-Saharan Africa. Scenario extrapolation suggested incidence may decline to 36.1 per 100 000 by 2030. CONCLUSIONS:Typhoid fever incidence is declining overall, but substantial heterogeneity persists across African destinations. These findings support destination-specific risk assessment, typhoid vaccination where appropriate, food and water precautions, and clinical vigilance for febrile returning travellers from higher-risk destinations.
BACKGROUND:Early recognition of severe imported malaria is essential because treatment decisions frequently need to be made before reliable parasite density measurements become available. Objective tools to support early risk stratification during this interval are lacking. This study developed and externally validated SEVMALrisk, an explainable clinical risk score derived from a machine-learning prediction model using routinely available admission laboratory parameters. METHODS:Adult patients with confirmed malaria from the Rotterdam Malaria Cohort (n = 832) were used for prediction model development. Eight supervised machine-learning algorithms were compared. The best-performing model was optimized, interpreted using SHapley Additive exPlanations (SHAP) and translated into the SEVMALrisk clinical risk score. Independent external validation was performed in a multicenter cohort (n = 124). RESULTS:Random Forest showed the highest discriminative performance and was selected for model development. The optimized prediction model achieved an area under the receiver operating characteristic curve (AUROC) of 0.962 with good calibration (Brier score 0.048). SHAP analysis identified eight routinely available laboratory parameters (total bilirubin, ASAT, leukocytes, thrombocytes, erythrocytes, creatinine, CRP and urea) for inclusion in the clinical risk score. The predefined decision threshold (26 points) remained unchanged during external validation. Internal validation yielded likelihood ratios of 9.39 (LR+) and 0.19 (LR-), corresponding to post-test probabilities of 51.9% and 2.1%, respectively. External validation demonstrated comparable performance (LR+ 8.02; LR- 0.18), with post-test probabilities of 59.2% and 3.2%. CONCLUSION:SEVMALrisk is an explainable and externally validated clinical risk score for early risk stratification of severe imported malaria. Rather than replacing parasite density assessment or WHO severity criteria, it supports evidence-based treatment decisions before reliable parasite quantification becomes available.
BACKGROUND:Chikungunya virus (CHIKV), primarily transmitted by Aedes mosquitoes, has increasingly caused autochthonous outbreaks in temperate regions, including Italy. In 2025, a local CHIKV outbreak occurred in Verona province, Veneto Region. We report the findings of integrated epidemiological, virological, and entomological investigations. METHODS:In 2025, a dedicated surveillance protocol was implemented to assess local transmission of arboviral infections in Verona province, enabling early detection of a local CHIKV circulation. Following notification of the index case, investigations were conducted in accordance with the national and regional arbovirus surveillance plans, including comprehensive epidemiological, virological, and entomological analyses. RESULTS:The index case was identified on 6 August 2025, with retrospective detection of the first case with symptom onset on 31 July; the primary case was not identified. As of 15 October, 69 cases were reported (62 confirmed, 7 probable), with a mean age of 55 years; 91.3% had identifiable epidemiological links, mainly clustered in two municipalities of the Verona province. Most cases (76.8%) occurred between mid-August and mid-September. The outbreak lasted approximately fifteen weeks, from the end of July to the mid of October. CHIKV-RNA was detectable in whole blood and, less frequently, urine only within the first five days after symptom onset, with higher viral loads in blood. CHIKV-specific IgM antibodies were detectable from days 4-5 and IgG from days 7-10. A total of 225 Aedes albopictus specimens were collected, all testing negative for CHIKV. Phylogenetic analysis revealed a highly homogeneous, monophyletic cluster within the East-Central-South African (ECSA) genotype, closely related to strains from the 2024-2025 Réunion outbreak. CONCLUSIONS:This outbreak underscores the value of dedicated surveillance protocols for early detection of febrile/suspected arboviral cases, while also highlighting key vulnerabilities, namely, an undetected primary case and negative entomological findings, pointing to the need for lower testing thresholds and earlier, risk-based vector sampling.
BACKGROUND:Chikungunya is an expanding global health threat, with chronic arthralgia representing the main long-term driver of disability. Although many studies have assessed post-chikungunya outcomes, evidence remains fragmented and contradictory. We aimed to identify reproducible predictors of chronic arthralgia (≥3 months) after laboratory-confirmed chikungunya and to distinguish stable prognostic signals from context-dependent associations. METHODS:We searched PubMed, Embase, Cochrane Library, and BVS/LILACS from inception to Feb 6, 2026, without restrictions. Eligible studies compared participants with and without chronic arthralgia at follow-up and reported extractable baseline or acute-phase factors. Two reviewers independently screened records, extracted data, and assessed risk of bias using QUIPS. Random-effects restricted maximum likelihood meta-analyses pooled odds ratios and mean differences, with subgroup analyses by follow-up window. PROSPERO: CRD420251169320. RESULTS:Of 1784 records, 29 studies were included, comprising 4108 participants: 1838 with chronic arthralgia and 2230 without. After harmonization, 22 predictors were meta-analyzed. The most consistent associations were female sex (OR 2.08, 95% CI 1.77-2.46; I2=8.3%), comorbidity presence (1.99, 1.55-2.55; I2=0%), and high blood pressure (1.52, 1.13-2.04; I2=33.4%). In contrast, several acute-phase manifestations and treatment-related markers showed less stable, timing-dependent, or study-sensitive associations. Overall risk of bias was high in most studies and moderate in the remainder. CONCLUSIONS:Chronic post-chikungunya arthralgia was most reproducibly associated with readily identifiable baseline host factors, rather than with a uniform acute-severity phenotype. These findings suggest that risk stratification should not rely only on acute symptom burden, and that pre-existing vulnerability may define a clinically important high-risk group. Point-of-care identification of patients with these characteristics could support prioritization of follow-up and resource allocation during outbreaks, inform post-outbreak surveillance and guideline development, and may guide future burden-based vaccination strategies in endemic settings.
We report two cases of Mycobacterium abscessus surgical site infection, occurring 2 years apart, following hair transplantation procedure performed in Turkey. Whole genome sequencing and epidemiologic data strongly support a common-source outbreak. These findings highlight risks of medical tourism and the role of genomic testing in cross-border surveillance.
BACKGROUND:Despite the considerable burden of diarrheal disease in Asia, etiology-specific patterns remain insufficiently characterized. This study aimed to provide a comprehensive assessment of the diarrheal disease burden across Asia from 1990 to 2023, focusing on the implications for travelers' diarrhea. METHODS:We estimated the burden of diarrheal disease in Asia, including Central, East, South, Southeast Asia, and High-income Asia Pacific, across 34 countries from 1990 to 2023 using the Global Burden of Diseases Study 2023. Disease burden was calculated using age-standardized disability-adjusted life year rates (ASDRs) per 100,000 population, with 95% uncertainty intervals (UIs). Additionally, we assessed the burden attributable to risk factors and calculated pathogen-specific estimates for 13 major etiologies. RESULTS:From 1990 to 2023, ASDRs of diarrheal disease declined across Asia, with the largest decline in South Asia from 9124.29 (95% UI, 7594.46-11,673.82) per 100,000 population to 1216.90 (965.73-1633.55). The decline was accompanied by reductions in cumulative etiologic burden, particularly for rotavirus. Although norovirus was the leading etiology in High-income Asia Pacific, rotavirus remained dominant across all other Asian regions in 2023. Burdens were concentrated among those aged <5 years and ≥95 years. Among children aged <5 years, rotavirus and adenovirus were the leading etiologies, with adenovirus showing a particularly high age-specific DALY rate in South Asia (891.96 [484.65-1392.81] per 100,000 population). Among adults aged ≥ 95years, Clostridium difficile and norovirus had the highest burdens. Sex-specific burdens were generally higher in males, except in South Asia. In 2023, unsafe water sources were the leading risk factor, especially in South Asia, 831.77 (423.32-1206.25) per 100,000 population. For viral, parasitic, and gram-negative etiologies, burdens consistently declined with increasing SDI, whereas Clostridium difficile showed a U-shaped pattern with SDI. CONCLUSIONS:The heterogeneity in etiology-specific burden, age- and sex-related vulnerability, and associations with SDI across Asia underscores the need for destination-specific risk assessment and context-sensitive prevention strategies for travelers' diarrhea in Asia.
BACKGROUND:Brazil is a popular travel destination that experiences recurrent outbreaks of dengue, chikungunya, and yellow fever (YF), posing a significant health risk to both residents and international travellers. We aimed to identify high-risk regions for arboviral infections and develop a user-friendly, map-based resource to support clinical decision-making in travel medicine. METHODS:We analysed laboratory-confirmed cases and deaths from dengue, chikungunya, and YF reported to Brazil's national surveillance system from 2019 to 2024 (from 2015 for YF). Data were aggregated into 133 Intermediate Geographic Regions (IGRs). IGRs without a confirmed case during the studied period were excluded. A composite risk score was calculated for each IGR by combining (i) transmission duration (months with reported cases per year, score 0-12) and (ii) disease burden, based on national quartiles of monthly incidence and mortality (score 1-4). Annual scores were summed to produce risk maps for each arbovirus. High-risk IGRs (defined as the top quartile of composite score) were overlaid with popular tourist destinations to create an intuitive visual guide. RESULTS:We analysed 4.35 million dengue, 294,921 chikungunya, and 2,312 YF cases, resulting in 7,846, 565, and 794 deaths, respectively. Dengue affected all IGRs, with high-risk IGRs in the Midwest, including the Pantanal. Chikungunya was also identified in all IGRs, with high-risk IGRs in the Northeast, overlapping with popular beaches such as Recife. YF was identified in 38.3% of IGRs, notably in the Southeast, including São Paulo state. CONCLUSIONS:Arboviruses pose a diverse risk across Brazil. Our spatially integrated map provides a novel tool for travel medicine, enabling healthcare practitioners to offer tailored advice and pre-travel vaccinations to travellers.
BACKGROUND:Dengue virus is transmitted by Aedes mosquitoes, which are now prevalent in destinations commonly visited by UK travelers. Increased international travel and factors including climate change, contribute to the global increase in dengue cases. Here, we evaluate the healthcare burden of dengue in England. METHODS:This retrospective, descriptive, cohort study (2010-2023) utilized data collected from National Health Service healthcare records in the Clinical Practice Research Datalink (CPRD) Aurum linked with Hospital Episode Statistics, and Office for National Statistics mortality data. The primary objective was to determine the occurrence of hospitalized dengue. Other objectives were evaluation of healthcare resource utilization and costs, characteristics of hospitalized dengue cases, and complications due to dengue. Exploratory cohorts for suspected dengue in primary care were also reported. RESULTS:Data from CPRD-linked records for 596 patients comprising the hospitalized dengue cohort were evaluated; the incidence rate of hospitalized dengue progressively increased from 2010 until the highest in 2019 (5.8 per million person-years); rates increased in 2022 after COVID-19 lockdowns. Approximately one-third of hospitalized dengue cases were aged 18-29 years, most were White or Asian, and the most common complication was gastrointestinal conditions (gastroenteritis/colitis; 34.7 cases per 1000 person-years). Healthcare costs in the year following hospitalized dengue cases were mostly driven by inpatient admission costs; ~20% of cases had a subsequent hospital admission (~50% were dengue-related). A total of 2286 suspected cases of dengue were reported in primary care, with 1066 unconfirmed and 1220 confirmed cases. CONCLUSIONS:Increasing incidence of dengue cases in England has followed global trends. The associated healthcare burden of imported dengue suggests a need for targeted public health strategies, particularly among younger travelers. Improvements in general practitioners' reporting of suspected dengue cases and associated details of symptoms and travel history are warranted.
Closed travel cohorts can produce precise denominators but misleading inference. The MV Hondius Andes virus outbreak shows why cruise-ship modelling must first define exposure-specific risk sets, distinguish ecological exposure from limited secondary transmission, and integrate onset, genomic, excursion, contact and mobility data.
Why has WHO declared the 2026 Ebola outbreak in the Congo a global emergency, but not the deadly hantavirus cruise ship outbreak? This article explains how transmission dynamics, epidemic potential, impact on travel and trade and geopolitics shape the decision to declare a 'Public Health Emergency of International Concern.'
The 2026 World Cup will take place amid a Public Health Emergency of International Concern (PHEIC) related to an Ebola strain with no licensed vaccine or therapeutic treatment being currently available. Host nations have put in place entry bans and 21-day quarantines despite limited epidemiological justification. There is an urgent need for an evidence-based, risk-proportionate travel health protocol for infectious disease preparedness and management during large-scale international mass gatherings.
