Risk of Hepatitis B for Travelers: Is Vaccination for All Travelers Really Necessary?

Objectives.  Behavioral studies in travelers suggest that 33% to 76% of all travelers to hepatitis B virus (HBV)–endemic countries are at risk for HBV infection. We study the incidence and risk factors for HBV infection in travelers.
Methods.  Retrospective analysis of the characteristics and risk factors of all reported acute HBV patients in Amsterdam, the Netherlands, from January 1, 1992, until December 31, 2003.
Results.  The estimated incidence in travelers from Amsterdam to HBV-endemic countries is 4.5/100,000 travelers. Two thirds of these patients were immigrants who lived in Amsterdam and who had visited their friends and relatives in their country of origin. In 12 years, only three Dutch short-term tourists contracted HBV while traveling, all by heterosexual contacts.
Conclusions.  Dutch tourists who travel to HBV-endemic countries run a very low risk of contracting HBV. Vaccination of short-term Dutch tourists is not necessary. Immigrants run a higher risk irrespective of travel or duration of travel. This group should be advised vaccination.     

Epidemiological study of gastro-oesophageal reflux disease: reflux in spouse as a risk factor

Background  Gastro-oesophageal reflux disease (GERD) is a growing health-care problem with variable distribution.
Aim  To assess GERD prevalence and risk factors and their possible correlation with pathophysiology in a population-based study.
Methods  Individuals aged 18–65 years were enrolled through random cluster sampling in Tehran. Previously validated self-administered questionnaires were used.
Results  Of the 2500 questionnaires, 2057 were analysed (mean age: 34.8 ± 13.0 years, 55.1% female). Frequent GERD was seen in 18.2%. Minor symptoms increased prevalence. Female gender (OR: 1.55, 95% CI: 1.01–2.41), BMI >30 kg/m² (OR: 1.79, 95% CI: 1.03–3.12), less education (OR: 1.52, 95% CI: 1.02–2.27), smoking (OR: 1.83, 95% CI: 1.12–2.99), NSAID use (OR: 4.23, 95% CI: 1.66–10.74) and GERD in spouse (OR: 1.82, 95% CI: 1.18–2.82) were associated with frequent GERD on multivariable analysis. GERD in first-degree relatives (OR: 1.73, 95% CI: 1.23–2.43) and asthma (OR: 4.09, 95% CI: 1.27–13.15) correlated with infrequent GERD. Minor symptoms correlated with GERD history in first-degree relatives, coffee consumption and NSAID use. Prevalence in the past 3 months was similar to that in the past 12 months ( P  < 0.05).
Conclusions  Gastro-oesophageal reflux disease is common in Tehran. The association of 'infrequent symptoms' with GERD history in first-degree relatives and 'frequent symptoms' with GERD history in spouse may point to the presence of yet unknown precipitating environmental factors inducing GERD in a genetically susceptible host. Minor GERD symptoms seem to have independent contribution to GERD. Assessing GERD in the past 3 months predicts prevalence in the past year.     

Prospective evaluation of transient elastography for the diagnosis of hepatic fibrosis in Asians: comparison with liver biopsy and aspartate transaminase platelet ratio index

Background  Transient elastography (TE) is a reliable non-invasive predictor of hepatic fibrosis, but data on TE in Asians are limited.
Aim  To evaluate prospectively the accuracy of TE for diagnosis of hepatic fibrosis in Asians compared with APRI (aspartate transaminase to platelet ratio index).
Methods  One hundred and twenty consecutive patients who underwent liver biopsy were enrolled. TE (Fibroscan) was performed by two independent operators. Fibrosis was graded by two independent pathologists using the METAVIR classification. Area under receiver operating curves (AUROC) were used to evaluate the accuracy of TE and APRI in diagnosing significant fibrosis (F ≥ 2) and cirrhosis (F4).
Results  Predominant aetiologies were hepatitis B (48%), non-alcoholic steatohepatitis (14%) and hepatitis C (8%). TE was unsuccessful in five patients (4.2%) because of small inter-costal space (three patients), obesity and ascites. There was good correlation between TE and fibrosis ( r  = 0.606). AUROC for diagnosis of significant fibrosis was 0.856 (95% CI 0.779–0.932) for TE and 0.673 (95% CI 0.568–0.777) for APRI. AUROC for diagnosis of cirrhosis was 0.924 (95% CI 0.857–0.990) for TE and 0.626 (95% CI 0.437–0.815) for APRI. Optimal TE value was 9.0 kPa for diagnosis of significant fibrosis and 16.0 kPa for cirrhosis with specificity/sensitivity/PPV/NPV/accuracy of 82.6%/85.2%/80.9%/86.7%/84.1% and 88.9%/82.7%/32.0%/98.8%/83.2%, respectively.
Conclusions  Transient elastography is a reliable predictor of hepatic fibrosis in Asians. Failure of TE in Asians is commonly because of small inter-costal space. TE is superior to APRI for non-invasive diagnosis of hepatic fibrosis and cirrhosis.     

Pretravel Health Preparation Among US Residents Traveling to India to VFRs: Importance of Ethnicity in Defining VFRs

Background.  International travelers visiting friends and relatives (VFRs) in lower income countries experience high rates of travel-related infections. We examined demographic characteristics and pretravel preparation practices among US residents traveling to India to determine factors that may contribute to higher infection rates and that would allow for improved prevention strategies.
Methods.  A cross-sectional study was conducted among US residents traveling to India in departure areas for flights to India at three US international airports during August 2005. Eligible travelers were US residents going to India who were English speaking and ≥18 years. Self-administered questionnaires were used to assess knowledge of and compliance with pretravel health recommendations.
Results.  Of 1,574 eligible travelers, 1,302 (83%) participated; 60% were male and the median age was 37. Eighty-five percent were of South Asian/Indian ethnicity and 76% reported VFR as the primary reason for travel. More than 90% of VFRs had at least a college education and only 6% cited financial barriers as reasons for not obtaining travel health services. VFRs were less likely than non-VFR travelers to seek pretravel health advice, to be protected against hepatitis A or typhoid fever, and less likely to be taking appropriate antimalarial chemoprophylaxis. However, when stratified by ethnicity, travelers of South Asian ethnicity were less likely than other travelers to adhere to pretravel health recommendations, regardless of VFR status.
Conclusions.  Similar to previous studies, VFR status was associated with pretravel health practices that leave travelers at risk for important infectious diseases. This association differed by ethnicity, which may also be an important marker of nonadherence to pretravel health recommendations. These findings have important implications for identifying at-risk travelers and properly targeting prevention messages.     

Factors influencing long-term changes in mental health after interferon-alpha treatment of chronic hepatitis C

Background  Antiviral treatment with interferon-alpha (IFN-α) is associated with several acute psychiatric side effects. Little is known about long-term effects on mental health after treatment independent from viral response and the influence of pre-existing psychiatric risk-factors.
Aim  To evaluate long-term effects of antiviral treatment with interferon-alpha (IFN-α) on mental health in patients with psychiatric risk factors.
Method  We prospectively investigated long-term mental health changes in 81 hepatitis C virus-infected patients. Psychiatric outcome was measured with the Montgomery–Asberg Depression Scale (MADRS), Brief Psychiatric Rating Scale, the Global Social Functioning Scale and the Global Clinical Impression Scale 6 months after the end of antiviral treatment with IFN-α and ribavirin.
Results  Six months after antiviral therapy, 49% of the patients showed a worsening and 27.2% an improvement of depression scores. The most important predictor for a long-term improvement of depression scores was a pre-treatment MADRS score ≥5 (OR 14.21, 95% CI: 2.51–81.30). Patients with pre-existing psychiatric disorders (OR = 0.117, 95% CI: 0.024–0.558), methadone substitution (OR = 0.20, 95% CI: 0.045–0.887) or genotype 2/3 (OR = 0.341, 95% CI: 0.138–0.845) were significantly less likely to show a long-term worsening of depressive symptoms.
Conclusions  Pre-existing psychiatric risk factors increase the chance for a long-term improvement and reduce the risk for a long-term worsening of mental health after antiviral treatment of chronic hepatitis C with IFN-α.     

Prognostic Factors Related to Recovery from Diarrhea among U.S. Students with Diarrhea in Mexico

Background: Medical charts of subjects treated with placebo from five double-blinded placebo-controlled clinical trials were reviewed to determine pre-enrollment prognostic factors related to later recovery from diarrhea.
Method: Recovery or time from initiation of a placebo until passage of the last unformed stool after being declared well was calculated for each subject.
Results: A longer duration of diarrhea was associated with presence of fever (rate ratio = 0.34; 95% CI = 0.2–0.9), presence of an invasive pathogen in the stool (rate ratio = 0.35; 95% CI = 0.2–0.7) or a noninvasive pathogen in stool (rate ratio = 0.7; 95% CI = 0.6–1.0), severe abdominal pain or cramps (rate ratio = 0.5; 95% CI = 0.3–0.9), passage of more than five watery stools per 24 hours (rate ratio = 0.58; 95% CI = 0.4–0.8). Severe vomiting predicted a shorter duration of post-enrollment diarrhea (rate ratio = 2.43; 95% CI = 1.1–5.6).
Conclusion: A number of clinical and microbiologic factors found in travelers with diarrhea in the present study predicted duration of untreated diarrhea. The authors suggest the use of antimicrobial therapy in travelers with predictors of a long duration of diarrhea. Data developed in the present study may be used to create a historical control for clinical trials of antidiarrheal compounds using the same study criteria.     

Immunogenicity and Reactogenicity of Avaxim (160 AU) as Compared with Havrix (1440 EL.U) as a Booster Following Primary Immunization with Havrix (1440 EL.U) against Hepatitis A

Background: Hepatitis A vaccination is recommended for travelers from the UK to areas of moderate or high endemicity. Two licensed hepatitis A vaccines are now available in the UK, and this trial was undertaken to determine whether Avaxim can be used as a booster following a primary course of Havrix.
Methods: One hundred and eighty-five subjects were randomized to receive a booster dose of either Avaxim (n=92) or Havrix (n=93), 6 to 7 months after a primary dose of Havrix. Subjects were observed for 30 minutes for immediate reactions and subsequently completed a diary card for a further 2 weeks. Serology samples for HAV antibody titers were taken at 28 ± 7 days later.
Results: One month following the booster dose, all subjects in both treatment groups achieved HAV antibody titers ± 20 mlU/mL. In the Avaxim group, geometric mean liter (GMT) values increased from 642 mlU/mL (97.5% Cl 330–1250 mlU/mL) to 6669 mlU/mL (4566–9740 mlU/mL), compared with 739 mlU/mL (379–1443 mlU/mL) at baseline to 4460 mlU/mL (2880–6908 mlU/mL) following the administration of Havrix. The increase in GMT following the administration of Avaxim was significantly greater than that following Havrix (p=.02). Eight percent of subjects reported pain at the injection site following a booster dose of Havrix, compared with none following Avaxim. This difference in reactogenicity was statistically significant (p=.01). In all other respects, both preparations were safe and equally well tolerated.
Conclusion: Either Avaxim or Havrix may be given as a booster dose of hepatitis A vaccine when Havrix has been administered as the primary dose.     

Immunogenicity and safety of a virosomal hepatitis A vaccine (Epaxal) in the elderly

BACKGROUND: Protection against hepatitis A virus (HAV) in the elderly is becoming more important as more senior travelers visit areas of high HAV endemicity, and less have protective antibodies acquired after natural infection during childhood. This study assessed the immunogenicity and safety of hepatitis A vaccine in elderly compared to young adults. METHODS: In this open, uncontrolled study, subjects of 18 to 45 years or < or = 50 years of age received two doses of aluminum-free, virosomal HAV vaccine, Epaxal (Berna Biotech Ltd, formerly Swiss Serum and Vaccine Institute, Bern, Switzerland) 12 months apart. RESULTS: After both the basic and the booster doses, geometric mean titers (GMT) for anti-HAV antibodies were 1.7-fold higher in subjects younger than 45 years compared with those < or = 50 years of age. The proportional increase in GMT after the booster dose, however, was similar in younger and older subjects. Seroprotection (< or = 20 mIU/mL) rates in the younger and older subjects were 100 and 65%, respectively, after the first vaccination and 100 and 97%, respectively, after the booster dose. Systemic and local adverse events were mainly mild and short-lived. CONCLUSION: These data show that HAV virosomal vaccine (Epaxal) is well tolerated and immunogenic in elderly subjects. The clinical relevance of lower seroconversion rates after the primary dose is unknown in this population of travelers.     

Clinical trial: interferon alpha-2b continuous long-term therapy vs. repeated 24-week cycles for re-treating chronic hepatitis C

Background  Treatment options are limited for patients with hepatitis C virus who do not experience sustained viral eradication with pegylated interferon and ribavirin therapy.
Aim  To compare, in an open-label, randomized study, long-term continuous interferon alpha-2b treatment with repeated 24-week courses in patients with chronic hepatitis C virus that relapsed after prior interferon monotherapy.
Methods  A total of 499 patients received 24 weeks of interferon alpha-2b, 3 MIU administered 3 TIW. Responders (normal alanine aminotransferase and negative hepatitis C virus -RNA, n  =   244) were then randomized to continuous interferon therapy (1, 2 or 3 MIU TIW depending on response) or cyclical therapy (3 MIU TIW for 24 weeks per relapse). Mean Knodell inflammation (I + II + III) and necrosis (IV) scores at baseline vs. year 2 were compared.
Results  Patients receiving continuous low-dose therapy vs. cycled therapy had larger reductions in inflammation (−3.9 vs. −3.1) and fibrosis (−0.49 vs. −0.24). Among both groups, the mean change was −3.4 for inflammation and −0.36 for fibrosis. Overall, 73% (95% CI: 67–79) of patients experienced reduced inflammation and 28% (95% CI: 22–34) had reduced fibrosis.
Conclusions  Our results suggest hepatitis C virus patients experiencing viral suppression during long-term maintenance therapy with interferon demonstrate histological improvement. Further prospective trials testing this hypothesis are in progress.     

Clinical trial: oral ondansetron for reducing vomiting secondary to acute gastroenteritis in children – a double-blind randomized study

Background  Vomiting as a consequence of gastroenteritis frequently occurs in children. It is still debatable whether vomiting should be treated with antiemetic drugs.
Aim  To investigate potential beneficial effects of ondansetron in treating vomiting during acute gastroenteritis.
Methods  A randomized, double blind, placebo-controlled trial was performed in our emergency departments. Children, aged 5 months to 8 years, were randomized to receive either ondansetron 0.2 mg/kg or placebo at 8h intervals. The primary outcome measure was the frequency of emesis during an 8-h-period after enrolment.
Results  A hundred and nine patients were enrolled; 54 received placebo and 55 received ondansetron. As compared with the children who received placebo, children who received ondansetron were less likely to vomit both during the first 8-h follow-up in the emergency department [relative risk (RR): 0.33, 95% CI: 0.19–0.56, NNT: 2, 95% CI: 1.6–3.5], and during the next 24-h follow-up (RR: 0.15, 95% CI: 0.07–0.33, NNT: 2, 95% CI: 1.3–2.1).
Conclusion  Ondansetron may be an effective and efficient treatment that reduces the incidence of vomiting from gastroenteritis during both the first 8 h and the next 24 h, and is probably a useful adjunct to oral rehydration.     

Obesity and weight gain as risk factors for erosive oesophagitis in men

Background  Although obesity and weight gain increase the risk for symptoms of gastro-oesophageal reflux disease, their association with erosive oesophagitis is still unclear in the male population.
Aim  To evaluate, in men, the association of body mass index (BMI) and weight gain with endoscopically proven erosive oesophagitis.
Methods  A total of 8571 Korean men in a comprehensive screening cohort were enrolled. Effects of BMI and abdominal obesity on erosive oesophagitis were estimated with odds ratios (ORs) and 95% confidence intervals (CIs) using logistic regression analysis. We also evaluated the association between erosive oesophagitis and BMI change after 1–3 years.
Results  The prevalence of erosive oesophagitis was 6.4% (552/8571). In univariate analysis, the ORs for erosive oesophagitis increased as BMI or waist circumference increased ( P for trend <0.001, both). In multivariate analysis, OR for erosive oesophagitis increased as BMI increased ( P for trend = 0.002), while the significance of waist circumference was attenuated ( P for trend = 0.13). Increase in BMI (≥1 kg/m²) was associated with persistence of erosive oesophagitis (OR = 2.83, 95% CI: 1.01–7.92, P  = 0.04) and new development of the disease (OR = 2.13, 95% CI: 1.38–3.28, P  = 0.001) compared with BMI change less than 1 kg/m².
Conclusions  Elevated BMI and weight gain have a significant association with erosive oesophagitis.     

Japanese Encephalitis: Defining Risk Incidence for Travelers to Endemic Countries and Vaccine Prescribing From the UK and Switzerland

Background.  Large numbers of Western travelers visit countries endemic for Japanese encephalitis (JE). The risk of infection is unknown. This study attempts at estimating a risk incidence for visitors from two European countries with the available data.
Methods.  Using the total number of case reports between 1978 and 2008, the number of visits made by European tourists to endemic regions, and total doses of vaccines sold in the two study countries, the risk incidence of JE in travelers was estimated. The proportion of vaccinated visitors to endemic regions was retrieved from the data of two travel clinics (in London and Basel) and related to vaccine prescribing in UK and Swiss travelers.
Results.  In 2004, an estimated 0.16% to 0.3% of UK and Swiss travelers were vaccinated against JE, with no surveillance reports of JE cases. Between 116,000 and 152,000 European travelers would receive vaccination. More than 99% travel to endemic countries without vaccination. Only 40 cases of JE infection have been reported in travelers for the past 30 years. The risk incidence is thus 1.3 per year in 7.1 million visits of the 17 million European travelers who are at a potential risk of JE infection.
Conclusions.  This study and the analysis of the existing literature support the recommendation that all travelers should be informed about the risk of JE infection but also suggest that there is no evidence for justifying a general recommendation for JE vaccination in travelers to endemic areas.     

High Prevalence of Sexually Transmitted Infections Among Young Peruvians Who Have Sexual Intercourse With Foreign Travelers in Cuzco

Background.  Sexual networking in popular tourist destinations is a problem worldwide. In Peru, locals sexually interacting with travelers bridge high-risk groups, the general population, and travelers.
Methods.  A cross-sectional study was conducted in Cuzco about sexual behavior among young Peruvians who admitted having sex with travelers. A subgroup of the participants had serologic testing for Chlamydia trachomatis , Herpes simplex virus (HSV) type 2, and Treponema pallidum .
Results.  Eighty-eight subjects volunteered for blood sampling. Their mean age was 22.9 years (±4.1) and 53.4% were male. The majority were single (86.2%), but 12.6% had a stable relationship. The median number of sexual partners in the 3 months prior to the study was 2 [interquartile range (IQR): 1–4]. During that period, 43.1% reported foreign partners, 28.4% reported foreign and Peruvian partners, 17% reported Peruvian partners, and the remaining 11.5% reported combinations of Peruvian, foreign, and sex workers partners. The median number of foreign partners in the 12-month period prior to the study was 4 (IQR: 2–8). Only 25.3% reported consistent condom use. Alcohol (69%) and drugs (36.8%) were commonly used before sexual activity. Seventy-eight percent tested positive for HSV type 2, 25% for C trachomatis , and 1.1% for T pallidum .
Conclusions.  The core group of young Peruvians we report on demonstrated a high-risk sexual behavior and a high prevalence of sexually transmitted infections. Our results underscore the need for education on safer sex practices among this group and among travelers.     

Systematic review: nutritional support in acute pancreatitis

Background  There has been controversy concerning the merits of enteral and parenteral nutrition compared with no supplementary nutrition in the management of patients with acute pancreatitis.
Aim  To perform a systematic review of the data from randomized controlled trials (RCTs) in acute pancreatitis that compares enteral nutrition with no supplementary nutrition, parenteral nutrition with no supplementary nutrition and enteral nutrition with parenteral nutrition.
Methods  A search was undertaken in the MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials.
Results  Fifteen RCTs were included. Enteral nutrition, when compared with no supplementary nutrition, was associated with no significant change in infectious complications: ratio of relative risks (RR) 0.56, 95% confidence interval (CI) 0.07–4.32, P  = 0.58, but a significant reduction in mortality: ratio of RR 0.22, 95% CI 0.07–0.70, P  = 0.01. Parenteral nutrition, when compared with no supplementary nutrition, was associated with no significant change in infectious complications: RR 1.36, 95% CI 0.18–10.40; P  = 0.77, but a significant reduction in mortality: RR 0.36, 95% CI 0.13–0.97, P  = 0.04. Enteral nutrition, when compared with parenteral nutrition, was associated with a significant reduction in infectious complications: RR 0.41, 95% CI 0.30–0.57, P  < 0.001, but no significant change in mortality: RR 0.60, 95% CI 0.32–1.14, P  = 0.12.
Conclusions  The use of either enteral or parenteral nutrition, in comparison with no supplementary nutrition, is associated with a lower risk of death in acute pancreatitis. Enteral nutrition is associated with a lower risk of infectious complications compared with parenteral nutrition.     

The association between coeliac disease and cardiovascular disease

Background  Coeliac disease is more prevalent than was previously thought. The association between coeliac disease and cardiovascular outcome is not clear.
Aim  To investigate whether coeliac disease patients have an increased risk of cardiovascular events.
Methods  A community-based cohort study using a record-linkage database. Three hundred and sixty-seven coeliac patients identified by a positive antiendomysial antibody test or a diagnosis with small bowel biopsy, and 5537 subjects who were tested and had a negative coeliac immunology, were included in the study.
Results  The crude rates of cardiovascular events were 9.5 per 1000 person-years (95% CI: 4.4–14.6) in the coeliac cohort and 8.9 per 1000 person-years (95% CI: 7.6–10.3) in the antiendomysial antibody-negative cohort. Compared with the antiendomysial antibody-negative cohort, the adjusted relative risk of cardiovascular events for coeliac cohort was 1.9 (95% CI: 1.00–3.60). When we excluded patients who had previous hospitalization for cardiovascular disease, the adjusted relative risk was 2.5 (95% CI: 1.22–5.01). The use of any cardiovascular drugs prior to and after entry to the study were 36% and 29% for the coeliac cohort ( P  = 0.05), and 34% and 26% for the antiendomysial antibody-negative cohort ( P  < 0.01).
Conclusion  Our findings suggest that coeliac disease seems to be associated with an increased risk of cardiovascular outcome.     

Sexual risk behavior of travelers who consulted a pretravel clinic

Objective.  The objective of this study was to determine to which degree travelers who received pretravel advice at a travel clinic have protected or unprotected sexual contact with a new partner and what factors influence this behavior.
Method.  An anonymous questionnaire was sent to travelers who came to a pretravel clinic between June 1 and August 31, 2005. Risk factors for casual travel sex and predictors of protected sex were studied in a multivariate model.
Results.  A total of 1,907 travelers were included (response rate 55%) in the study. Only 4.7% of the respondents had sexual contact with a new partner, and 63.1% of these new partners were from the country of destination. Of those who had casual travel sex, 52.4% did not expect this (women 75%), 30.9% did not always use condoms, and 41% were not protected against hepatitis B. Independent risk factors for casual travel sex were traveling without steady partner (OR 14.4), expecting casual travel sex (OR 9.2), having casual sexual contacts in the home country (OR 2.4), non-tourist journeys (OR 2.2), being male (OR 2.1), the fact that the information on sexually transmitted infections (STI) had been read (OR 2.0), and traveling to South and Central America (OR 2.0). Taking condoms along (OR 5.4) and reading the information on STI (OR 3.3) were identified as independent predictors of protected sex.
Conclusions.  Travelers have substantial sexual risk behavior. Casual sex is usually not expected, and the most important predictor is traveling without a steady partner. We would advice every client of a travel clinic who will travel without a steady partner to read the STI information, to take condoms along, and to be vaccinated against hepatitis B.     

Screening differences and risk of cervical cancer in inflammatory bowel disease

Background  Cervical cancer risk is high among immune suppressed women.
Aim  To evaluate inflammatory bowel disease (IBD) with medications and risk of cervical cancer.
Methods  Members of Kaiser Permanente Northern California (KPNC), 15–68 years from 1996 to 2006 with IBD were compared with age-matched women without IBD. Cervical cancer was ascertained using the KPNC Cancer Registry. IBD medications of interest were aminosalicylates (ASA), corticosteroids, immune modulators and infliximab. Odds of cervical cancer were analysed with adjusted logistic regression. The prevalence of Pap smear testing was compared using a log binomial model.
Results  Ten cervical cancer cases occurred among 1165 women with IBD and 72 cancers among 12 124 controls. The adjusted odds ratio (OR) of IBD with risk of cervical cancer was 1.45 [95% confidence interval (CI) 0.74–2.84]. Medication ORs were 1.65 for ASA, 2.79 for corticosteroids and 3.45 for immune modulators (all P  > 0.05). No cancer case used infliximab. The adjusted absolute increase in Pap smears among IBD women compared to women without IBD was 4% (95% CI 2–5%).
Conclusions  Although a trend of elevated risk for cervical cancer with IBD and IBD medications was observed, it was not statistically significant. Regular cervical cancer screening for women with IBD is recommended.     

Risk Estimates of Dengue in Travelers to Dengue Endemic Areas Using Mathematical Models

Background.  Dengue has emerged as a frequent problem in international travelers. The risk depends on destination, duration, and season of travel. However, data to quantify the true risk for travelers to acquire dengue are lacking.
Methods.  We used mathematical models to estimate the risk of nonimmune persons to acquire dengue when traveling to Singapore. From the force of infection, we calculated the risk of dengue dependent on duration of stay and season of arrival.
Results.  Our data highlight that the risk for nonimmune travelers to acquire dengue in Singapore is substantial but varies greatly with seasons and epidemic cycles. For instance, for a traveler who stays in Singapore for 1 week during the high dengue season in 2005, the risk of acquiring dengue was 0.17%, but it was only 0.00423% during the low season in a nonepidemic year such as 2002.
Discussion.  Risk estimates based on mathematical modeling will help the travel medicine provider give better evidence-based advice for travelers to dengue endemic countries.