Data from the Health Board on imported infectious diseases during the last 5 years are presented by disease and country of infection. This data is helpful in order to give timely information on possible risks of infection and recommendations on preventive measures to medical officers, tourists and tour operators to prevent the import and spread of infections.
In recent years, the number of foreign tourists visiting Estonia has increased dramatically. During the last five years, the passenger port of Tallinn alone welcomes approximately 7 million passengers annually. In 2010 nearly 8 million people arrived in Tallinn through the port, including 400,000 cruise tourists from all over the world. Cruise tourists usually come during the peak season that lasts from the beginning of May until the end of September. The citizens of Estonia also continue to expand the destinations of their travels. Some also visit countries with unfavourable epidemiological situations for various infections. This article provides overview of infectious diseases related to travel during the last 5 years in Estonia.
Materials and Methods
An imported case of an infectious disease is a case of infection that was contracted abroad and diagnosed and registered in Estonia. The Department of Health conducts epidemiological surveillance over infectious diseases including imported cases, in Estonia. The Department of Health has access to the most complete and systematic data on imported cases of infections from 2006.
The majority of infections were imported either from popular tourist destinations (Egypt, India, Turkey) or from neighbouring states (Finland, Russia, Latvia). The number of cases of infectious diseases imported during 2006 – 2010 from the countries where the patients were most likely infected is shown in Table 1.
Table 1. Number of imported infections in Estonia by country of infection, 2006- 2010
Table 2. Number of imported infectious diseases in Estonia by nosological form compared with all reported cases, 2006-2010
In 2009, 300 imported cases of infectious diseases were registered in Estonia. About a third of the cases (95) were imported pandemic influenza A(H1N1)2009 infections. The cases were registered at the initial stage of the pandemic, from the beginning of May through November 11, 2009. Out of 95 imported pandemic influenza cases, nearly half came from the USA (14), Ukraine (10), Great Britain (9), and Spain (9).
In 2009, 66 cases of infectious diseases were imported from Finland, including 44 cases of norovirus infection registered among tourists shortly after they arrived from Finland and stayed at a hotel in Estonia. Thirty four cases of infectious diseases were imported from Egypt in 2009 including 15 cases of shigellosis, 4 cases of salmonellosis and 8 cases of viral hepatitis A. In 2008 almost twice as many infections (64) were imported from Egypt. In 2009, 22 tourists were infected in Turkey, 19 in Russia and 17 in India (including 4 cases of viral hepatitis A, 2 cases of typhoid fever, 5 cases of shigellosis and one case of salmonellosis).
In 2009, 9 cases of infections were associated with travels to Latvia, including 2 cases of viral hepatitis A, 4 cases of salmonellesis, one case of rotaviral enteritis and 2 cases of intestinal infections of unknown etiology.
In 2009, 4 cases of malaria (3 cases of Р.falciparum and one case of Р.vivax) were imported to Estonia from Africa and South America. One case had a lethal outcome. Three patients had not taken malaria prophylaxis before their travels and one patient had started but not completed the chemoprophylaxis course. In 2006-2007, 11 cases of malaria were imported to Estonia from Africa and India. Nine patients did not take malaria chemoprophylaxis.
One half of the shigellosis cases registered in 2009 were imported. Of 19 viral hepatitis A cases registered in Estonia in 2009, 17 cases were imported (8 from Egypt, 4 from India, 2 from Latvia, 2 from Thailand and 1 from Turkmenistan).
In 2010, the number of travel-associated cases of infectious diseases decreased considerably with only 135 imported cases registered. Over 60% of the cases were intestinal infections (salmonellosis, shigellosis, campylobacteriosis as well as intestinal infections of unknown etiology). In 2010, 5 of the 6 registered cases of viral hepatitis A were imported (3 from Egypt, 1 from Gambia and 1 from Latvia). One third of all shigellosis cases registered during 2010 were imported.
In 2010, 1721 cases of Lyme borreliosis (Lyme disease) were diagnosed in Estonia, including 7 cases imported from Finland, Lithuania, Latvia, Russia and Germany. One case of malaria (Р.vivax) was imported from South Africa.
In 2010, most of infectious cases (27) were imported from Egypt, including one case of infectious mononucleosis, 3 cases of viral hepatitis A, one case of viral hepatitis C, 5 cases of salmonellosis, 7 cases of shigellosis, 3 cases of campylobacteriosis, one case of yersiniosis and 5 cases of intestinal infections of unknown etiology. Discussion and Conclusions
As the tourist industry develops and international travel increases, public health care services must consider the possibility of imported cases of infectious diseases, including rare and dangerous infections, in estimating epidemic risks and planning epidemic preparedness for the country. Travellers must receive information about the possible risks of infection and recommended preventive measures in order to preventing the import and spread of infectious. In addition, health care workers must be alert and the diagnostic capacity and expertise of the national health care system must be developed.
A law addressing the prevention and control of infectious diseases, which was introduced in Estonia in 2003, makes it obligatory for travel companies to inform their customers about the possible risks of infections in the destination countries and, if necessary, to advise clients to consult their doctor before departure. An employer must also inform employees about health-related issues before work abroad.
It is also very important for the public health care services responsible for the surveillance and control of infectious diseases to get the most up-to-date information about epidemiological situations in other countries, especially in the neighbouring states and popular tourist destinations. The population, the tourist sector and the international transport staff should informed about the risks of infections and the recommended preventive measures. References
1. Health Board web-page. Travel and Health.Updated 2011:
2. WHO International Travel and Health 2010: http://www.who.int/ith/en/