Background. The number of US students studying abroad has more than tripled over the past 20 year... more Background. The number of US students studying abroad has more than tripled over the past 20 years. As study abroad programs diversify their destinations, more students are traveling to developing regions, increasing their risk of infectious diseases. Few data exist describing infections acquired by US students while traveling internationally. We describe the spectrum of disease among students who have returned from international travel and suggest how to reduce illness among these travelers. Methods. GeoSentinel is a global network of travel and tropical medicine providers that monitors travel-related morbidity. Records of US resident student travelers, 17-24 years old, who returned to the United States and were given a confirmed travel-related diagnosis at one of 15 US GeoSentinel sites during 2007-2017. Those without ascertainable exposure regions were excluded. Records were analyzed to describe demographic and travel characteristics and diagnoses. Results. There were 432 students included. The median age was 21 years; 69% were female. Over 70% had a pretravel consultation with a healthcare provider. The most common exposure region was sub-Saharan Africa (112 travelers; 26%); the most common exposure countries were India (44 students; 11%), Ecuador (28; 7%), Ghana (25; 6%), and China (24; 6%). Students presented to a GeoSentinel site a median of 8 days (range: 0-181) after travel; 98% were outpatients. The most common diagnosis categories were gastrointestinal (45%) and dermatologic (17%). Of 581 confirmed diagnoses, diarrheal illnesses were most common (165; 28%). Thirty-one (7%) students had a vector-borne disease; 14 (41%) of these were diagnosed with malaria (13 had a pretravel consultation) and 11 (32%) with dengue. Two students were diagnosed with acute HIV. Three had a vaccine-preventable disease (two typhoid; one hepatitis A). Conclusion. Students experienced travel-related infections despite a large proportion receiving pretravel consultations. Students (especially those traveling to a less developed region) should receive specific pretravel instructions (including suggestions for behavioral modification, vaccination, and medication prophylaxis when applicable) to prevent gastrointestinal, vector-borne, sexually transmitted, and vaccine-preventable diseases. Disclosures. All authors: No reported disclosures.
Background: Diarrhea is one of the most common ailments afflicting travelers with attack rates of... more Background: Diarrhea is one of the most common ailments afflicting travelers with attack rates of 30-40% for medium to high-risk destinations. As travelers' diarrhea (TD) is syndromic and caused by a wide range of pathogens, including bacteria, parasites and viruses, multiplex deoxyribonucleic acid (DNA) extraction polymerase chain reaction (PCR) technology can be useful for determining the etiology of TD pathogens. Objective: The goal of this retrospective study was to produce clinically relevant and useful data on gastrointestinal illness related to travel identified by culture-independent methods of diagnosis-use of the multiplex DNA extraction PCR platform (BioFire FilmArray GI Panel) and to describe the use of this technology in detection of enteric pathogens. Method: We reviewed our data in returned travelers from May 2014 to March 2017, looking at demographics, country of travel, number of pathogens found and pathogens by specific region. Results: Stool analysis by DNA extraction PCR was obtained in 388 post-travel patients. Three hundred and twentyseven of these had diarrhea or other enteric symptoms. Sixty-one travelers presented with enteric symptoms and were diagnosed with post infectious irritable bowel syndrome (PI-IBS) after stool analyses were negative. Of those with diarrhea or gastrointestinal (GI) symptoms and excluding those diagnosed with PI-IBS, 207 patients tested positive for at least 1 enteric pathogen (63.4%). Eighty of those patients were found to have multiple pathogens. Viral pathogens were identified in 38 patients, 18% of the total number of cases. Conclusion: The BioFire FilmArray GI Panel was associated with better detection of pathogens than historical controls while also allowing prompt and accurate diagnosis and potential treatment. A higher proportion of viral pathogens compared with historical assumptions was identified as well as mixed infections with multiple pathogens, a phenomenon largely unknown to clinicians before this technology became available.
International travel has resumed while the risk of SARS-CoV-2 persists, leading to consideration ... more International travel has resumed while the risk of SARS-CoV-2 persists, leading to consideration of medications that can treat or prevent Covid-19 when travellers become ill abroad. Nirmatrelvir-ritonavir, molnupiravir and tixagevimab-cilgavimab are available under Emergency Use Authorization or conditional approval. We discuss the potential application of these medications to protect travellers.
This group looked at virologic characteristics of the 161 vaccine breakthrough infections in a po... more This group looked at virologic characteristics of the 161 vaccine breakthrough infections in a population of nearly 25,000 vaccinated healthcare workers in the Netherlands. Viral culture and RT PCR were methodologies used. These cases occurred at a time when the delta variant (B.1.617.2) was circulating in great numbers. The results showed that despite
their meritorious editorial commentary [1] on our research showing that antibiotic use predispose... more their meritorious editorial commentary [1] on our research showing that antibiotic use predisposes travelers to colonization with extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) [2]. They cogitate about fundamental problems associated with refraining from antibiotics for travelers ’ diarrhea (TD), listing potential alternative approaches. Acknowledging their valuable discussion on the whole, I was, however, concerned about one proposition—chemoprophylaxis with nonabsorbable antibiotics as an alternative—which essentially contradicts our purport, caution with antibiotics.
their meritorious editorial commentary [1] on our research showing that antibiotic use predispose... more their meritorious editorial commentary [1] on our research showing that antibiotic use predisposes travelers to colonization with extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) [2]. They cogitate about fundamental problems associated with refraining from antibiotics for travelers ’ diarrhea (TD), listing potential alternative approaches. Acknowledging their valuable discussion on the whole, I was, however, concerned about one proposition—chemoprophylaxis with nonabsorbable antibiotics as an alternative—which essentially contradicts our purport, caution with antibiotics.
Background Dignitary medicine is an emerging field of training that involves the specialized care... more Background Dignitary medicine is an emerging field of training that involves the specialized care of diplomats, heads of state, and other high-ranking officials. In an effort to provide guidance on training in this nascent field, we convened a panel of experts in dignitary medicine and using the Delphi methodology, created a consensus curriculum for training in dignitary medicine. Methods A three-round Delphi consensus process was performed with 42 experts in the field of dignitary medicine. Predetermined scores were required for an aspect of the curriculum to advance to the next round. The scores on the final round were used to determine the components of the curriculum. Scores below the threshold to advance were dropped in the subsequent round. Results Our panel had a high degree of agreement on the required skills needed to practice dignitary medicine, with active practice in a provider’s baseline specialty, current board certification, and skills in emergency care and resuscitat...
More than 30,000 malaria cases are reported annually among international travellers. Despite impr... more More than 30,000 malaria cases are reported annually among international travellers. Despite improvements in malaria control, malaria continues to threaten travellers due to inaccurate perception of risk and sub-optimal pre-travel preparation. Records with a confirmed malaria diagnosis after travel from January 2003 to July 2016 were obtained from GeoSentinel, a global surveillance network of travel and tropical medicine providers that monitors travel-related morbidity. Records were excluded if exposure country was missing or unascertainable or if there was a concomitant acute diagnosis unrelated to malaria. Records were analyzed to describe the demographic and clinical characteristics of international travellers with malaria. There were 5689 travellers included; 325 were children <18Â years. More than half (53%) were visiting friends and relatives (VFRs). Most (83%) were exposed in sub-Saharan Africa. The median trip duration was 32Â days (interquartile range 20-75); 53% did not h...
Background: Travelers' diarrhea causes significant morbidity including some sequelae, lost travel... more Background: Travelers' diarrhea causes significant morbidity including some sequelae, lost travel time and opportunity cost to both travelers and countries receiving travelers. Effective prevention and treatment are needed to reduce these negative impacts. Methods: This critical appraisal of the literature and expert consensus guideline development effort asked several key questions related to antibiotic and non-antibiotic prophylaxis and treatment, utility of available diagnostics, impact of multi-drug resistant (MDR) colonization associated with travel and travelers' diarrhea, and how our understanding of the gastrointestinal microbiome should influence current practice and future research. Studies related to these key clinical areas were assessed for relevance and quality. Based on this critical appraisal, guidelines were developed and voted on using current standards for clinical guideline development methodology. Results: New definitions for severity of travelers' diarrhea were developed. A total of 20 graded recommendations on the topics of prophylaxis, diagnosis, therapy and follow-up were developed. In addition, three non-graded consensus-based statements were adopted. Conclusions: Prevention and treatment of travelers' diarrhea requires action at the provider, traveler and research community levels. Strong evidence supports the effectiveness of antimicrobial therapy in most cases of moderate to severe travelers' diarrhea, while either increasing intake of fluids only or loperamide or bismuth subsalicylate may suffice for most cases of mild diarrhea. Further studies are needed to address knowledge gaps regarding optimal therapies, the individual, community and global health risks of MDR acquisition, manipulation of the microbiome in
US residents make 60 million international trips annually. Family practice providers need to be a... more US residents make 60 million international trips annually. Family practice providers need to be aware of travel-associated diseases affecting this growing mobile population. To describe demographics, travel characteristics and clinical diagnoses of US residents who present ill after international travel. Descriptive analysis of travel-associated morbidity and mortality among US travellers seeking care at 1 of the 22 US practices and clinics participating in the GeoSentinel Global Surveillance Network from January 2000 to December 2012. Of the 9624 ill US travellers included in the analysis, 3656 (38%) were tourist travellers, 2379 (25%) missionary/volunteer/research/aid workers (MVRA), 1580 (16%) travellers visiting friends and relatives (VFRs), 1394 (15%) business travellers and 593 (6%) student travellers. Median (interquartile range) travel duration was 20 days (10-60 days). Pre-travel advice was sought by 45%. Hospitalization was required by 7%. Compared with other groups of tra...
Hepatitis A is one of the most common vaccine-preventable infectious diseases in the world. Effec... more Hepatitis A is one of the most common vaccine-preventable infectious diseases in the world. Effective vaccines against hepatitis A have been available since 1992, and they provide long-term immunity against the infection. However, there is no worldwide consensus on how long protection will last or whether there will be a need for hepatitis A virus (HAV) booster vaccinations in the future. In most countries, booster-vaccination policy is guided by manufacturers' recommendations, national authorities, or both. In June 2002, a panel of international experts met to review the long-term immunogenicity and protection conferred by HAV vaccine in different population groups. Data have shown that after a full primary vaccination course, protective antibody amounts persist beyond 10 years in healthy individuals, and underlying immune memory provides protection far beyond the duration of anti-HAV antibodies. The group concluded that there is no evidence to lend support to HAV booster vaccination after a fully primary vaccination course in a healthy individual. However, further investigations are needed before deciding if boosters can be omitted in special patientgroups.
T yphoid fever is endemic in developing nations where poor sanitation and contaminated water supp... more T yphoid fever is endemic in developing nations where poor sanitation and contaminated water supplies allow the spread of Salmonella enterica serovar Typhi, a highly adapted, human-specifi c pathogen. The disease course generally begins with fl ulike symptoms , with increasing levels of fever; most cases involve gastrointestinal symptoms, either constipation or diarrhea. A lack of specifi c signs may make clinical diagnosis diffi cult. Complications, including gastrointestinal perforation or hemorrhage, shock, anemia, and meningitis, affect 10% to 15% of patients and may result in fatal outcomes. 1 World Health Organization data indicate that approximately 200,000 persons, mostly children, die each year from complications due to typhoid fever. 2 In developed nations, typhoid fever is most common in travelers returning from areas with endemic disease, but spread among traveler contacts may result in localized outbreaks. 1
V iral hepatitis is a worldwide health problem; hepatitis A and B viruses (HAV and HBV) account f... more V iral hepatitis is a worldwide health problem; hepatitis A and B viruses (HAV and HBV) account for the majority of cases. In 2003, the US national incidence of hepatitis A and hepatitis B was 2.6 cases per 100,000 people for each virus. 1 Worldwide, approximately 1.5 million cases of hepatitis A are reported every year, 2,3 and HBV has infected 2 billion people (one third of the world ' s population), resulting in 350 to 450 million carriers worldwide and 500,000 to 1.2 million deaths per year caused by cirrhosis and primary hepatocellular carcinoma. 4-6 Extensive regions throughout the world are endemic for these viruses, and many international travelers may be at risk for contracting hepatitis A or hepatitis B. 7 In addition to travel, persons may be at risk for both diseases because of employment, institutionalization, or lifestyle factors. Safe and effective monovalent vaccines against hepatitis A and hepatitis B are available. 8-13 Convenience may be enhanced by the use of a combined hepatitis A and B vaccine (Twinrix, GlaxoSmith-Kline Biologicals, Rixensart, Belgium), which has
Background. The number of US students studying abroad has more than tripled over the past 20 year... more Background. The number of US students studying abroad has more than tripled over the past 20 years. As study abroad programs diversify their destinations, more students are traveling to developing regions, increasing their risk of infectious diseases. Few data exist describing infections acquired by US students while traveling internationally. We describe the spectrum of disease among students who have returned from international travel and suggest how to reduce illness among these travelers. Methods. GeoSentinel is a global network of travel and tropical medicine providers that monitors travel-related morbidity. Records of US resident student travelers, 17-24 years old, who returned to the United States and were given a confirmed travel-related diagnosis at one of 15 US GeoSentinel sites during 2007-2017. Those without ascertainable exposure regions were excluded. Records were analyzed to describe demographic and travel characteristics and diagnoses. Results. There were 432 students included. The median age was 21 years; 69% were female. Over 70% had a pretravel consultation with a healthcare provider. The most common exposure region was sub-Saharan Africa (112 travelers; 26%); the most common exposure countries were India (44 students; 11%), Ecuador (28; 7%), Ghana (25; 6%), and China (24; 6%). Students presented to a GeoSentinel site a median of 8 days (range: 0-181) after travel; 98% were outpatients. The most common diagnosis categories were gastrointestinal (45%) and dermatologic (17%). Of 581 confirmed diagnoses, diarrheal illnesses were most common (165; 28%). Thirty-one (7%) students had a vector-borne disease; 14 (41%) of these were diagnosed with malaria (13 had a pretravel consultation) and 11 (32%) with dengue. Two students were diagnosed with acute HIV. Three had a vaccine-preventable disease (two typhoid; one hepatitis A). Conclusion. Students experienced travel-related infections despite a large proportion receiving pretravel consultations. Students (especially those traveling to a less developed region) should receive specific pretravel instructions (including suggestions for behavioral modification, vaccination, and medication prophylaxis when applicable) to prevent gastrointestinal, vector-borne, sexually transmitted, and vaccine-preventable diseases. Disclosures. All authors: No reported disclosures.
Background: Diarrhea is one of the most common ailments afflicting travelers with attack rates of... more Background: Diarrhea is one of the most common ailments afflicting travelers with attack rates of 30-40% for medium to high-risk destinations. As travelers' diarrhea (TD) is syndromic and caused by a wide range of pathogens, including bacteria, parasites and viruses, multiplex deoxyribonucleic acid (DNA) extraction polymerase chain reaction (PCR) technology can be useful for determining the etiology of TD pathogens. Objective: The goal of this retrospective study was to produce clinically relevant and useful data on gastrointestinal illness related to travel identified by culture-independent methods of diagnosis-use of the multiplex DNA extraction PCR platform (BioFire FilmArray GI Panel) and to describe the use of this technology in detection of enteric pathogens. Method: We reviewed our data in returned travelers from May 2014 to March 2017, looking at demographics, country of travel, number of pathogens found and pathogens by specific region. Results: Stool analysis by DNA extraction PCR was obtained in 388 post-travel patients. Three hundred and twentyseven of these had diarrhea or other enteric symptoms. Sixty-one travelers presented with enteric symptoms and were diagnosed with post infectious irritable bowel syndrome (PI-IBS) after stool analyses were negative. Of those with diarrhea or gastrointestinal (GI) symptoms and excluding those diagnosed with PI-IBS, 207 patients tested positive for at least 1 enteric pathogen (63.4%). Eighty of those patients were found to have multiple pathogens. Viral pathogens were identified in 38 patients, 18% of the total number of cases. Conclusion: The BioFire FilmArray GI Panel was associated with better detection of pathogens than historical controls while also allowing prompt and accurate diagnosis and potential treatment. A higher proportion of viral pathogens compared with historical assumptions was identified as well as mixed infections with multiple pathogens, a phenomenon largely unknown to clinicians before this technology became available.
International travel has resumed while the risk of SARS-CoV-2 persists, leading to consideration ... more International travel has resumed while the risk of SARS-CoV-2 persists, leading to consideration of medications that can treat or prevent Covid-19 when travellers become ill abroad. Nirmatrelvir-ritonavir, molnupiravir and tixagevimab-cilgavimab are available under Emergency Use Authorization or conditional approval. We discuss the potential application of these medications to protect travellers.
This group looked at virologic characteristics of the 161 vaccine breakthrough infections in a po... more This group looked at virologic characteristics of the 161 vaccine breakthrough infections in a population of nearly 25,000 vaccinated healthcare workers in the Netherlands. Viral culture and RT PCR were methodologies used. These cases occurred at a time when the delta variant (B.1.617.2) was circulating in great numbers. The results showed that despite
their meritorious editorial commentary [1] on our research showing that antibiotic use predispose... more their meritorious editorial commentary [1] on our research showing that antibiotic use predisposes travelers to colonization with extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) [2]. They cogitate about fundamental problems associated with refraining from antibiotics for travelers ’ diarrhea (TD), listing potential alternative approaches. Acknowledging their valuable discussion on the whole, I was, however, concerned about one proposition—chemoprophylaxis with nonabsorbable antibiotics as an alternative—which essentially contradicts our purport, caution with antibiotics.
their meritorious editorial commentary [1] on our research showing that antibiotic use predispose... more their meritorious editorial commentary [1] on our research showing that antibiotic use predisposes travelers to colonization with extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) [2]. They cogitate about fundamental problems associated with refraining from antibiotics for travelers ’ diarrhea (TD), listing potential alternative approaches. Acknowledging their valuable discussion on the whole, I was, however, concerned about one proposition—chemoprophylaxis with nonabsorbable antibiotics as an alternative—which essentially contradicts our purport, caution with antibiotics.
Background Dignitary medicine is an emerging field of training that involves the specialized care... more Background Dignitary medicine is an emerging field of training that involves the specialized care of diplomats, heads of state, and other high-ranking officials. In an effort to provide guidance on training in this nascent field, we convened a panel of experts in dignitary medicine and using the Delphi methodology, created a consensus curriculum for training in dignitary medicine. Methods A three-round Delphi consensus process was performed with 42 experts in the field of dignitary medicine. Predetermined scores were required for an aspect of the curriculum to advance to the next round. The scores on the final round were used to determine the components of the curriculum. Scores below the threshold to advance were dropped in the subsequent round. Results Our panel had a high degree of agreement on the required skills needed to practice dignitary medicine, with active practice in a provider’s baseline specialty, current board certification, and skills in emergency care and resuscitat...
More than 30,000 malaria cases are reported annually among international travellers. Despite impr... more More than 30,000 malaria cases are reported annually among international travellers. Despite improvements in malaria control, malaria continues to threaten travellers due to inaccurate perception of risk and sub-optimal pre-travel preparation. Records with a confirmed malaria diagnosis after travel from January 2003 to July 2016 were obtained from GeoSentinel, a global surveillance network of travel and tropical medicine providers that monitors travel-related morbidity. Records were excluded if exposure country was missing or unascertainable or if there was a concomitant acute diagnosis unrelated to malaria. Records were analyzed to describe the demographic and clinical characteristics of international travellers with malaria. There were 5689 travellers included; 325 were children <18Â years. More than half (53%) were visiting friends and relatives (VFRs). Most (83%) were exposed in sub-Saharan Africa. The median trip duration was 32Â days (interquartile range 20-75); 53% did not h...
Background: Travelers' diarrhea causes significant morbidity including some sequelae, lost travel... more Background: Travelers' diarrhea causes significant morbidity including some sequelae, lost travel time and opportunity cost to both travelers and countries receiving travelers. Effective prevention and treatment are needed to reduce these negative impacts. Methods: This critical appraisal of the literature and expert consensus guideline development effort asked several key questions related to antibiotic and non-antibiotic prophylaxis and treatment, utility of available diagnostics, impact of multi-drug resistant (MDR) colonization associated with travel and travelers' diarrhea, and how our understanding of the gastrointestinal microbiome should influence current practice and future research. Studies related to these key clinical areas were assessed for relevance and quality. Based on this critical appraisal, guidelines were developed and voted on using current standards for clinical guideline development methodology. Results: New definitions for severity of travelers' diarrhea were developed. A total of 20 graded recommendations on the topics of prophylaxis, diagnosis, therapy and follow-up were developed. In addition, three non-graded consensus-based statements were adopted. Conclusions: Prevention and treatment of travelers' diarrhea requires action at the provider, traveler and research community levels. Strong evidence supports the effectiveness of antimicrobial therapy in most cases of moderate to severe travelers' diarrhea, while either increasing intake of fluids only or loperamide or bismuth subsalicylate may suffice for most cases of mild diarrhea. Further studies are needed to address knowledge gaps regarding optimal therapies, the individual, community and global health risks of MDR acquisition, manipulation of the microbiome in
US residents make 60 million international trips annually. Family practice providers need to be a... more US residents make 60 million international trips annually. Family practice providers need to be aware of travel-associated diseases affecting this growing mobile population. To describe demographics, travel characteristics and clinical diagnoses of US residents who present ill after international travel. Descriptive analysis of travel-associated morbidity and mortality among US travellers seeking care at 1 of the 22 US practices and clinics participating in the GeoSentinel Global Surveillance Network from January 2000 to December 2012. Of the 9624 ill US travellers included in the analysis, 3656 (38%) were tourist travellers, 2379 (25%) missionary/volunteer/research/aid workers (MVRA), 1580 (16%) travellers visiting friends and relatives (VFRs), 1394 (15%) business travellers and 593 (6%) student travellers. Median (interquartile range) travel duration was 20 days (10-60 days). Pre-travel advice was sought by 45%. Hospitalization was required by 7%. Compared with other groups of tra...
Hepatitis A is one of the most common vaccine-preventable infectious diseases in the world. Effec... more Hepatitis A is one of the most common vaccine-preventable infectious diseases in the world. Effective vaccines against hepatitis A have been available since 1992, and they provide long-term immunity against the infection. However, there is no worldwide consensus on how long protection will last or whether there will be a need for hepatitis A virus (HAV) booster vaccinations in the future. In most countries, booster-vaccination policy is guided by manufacturers' recommendations, national authorities, or both. In June 2002, a panel of international experts met to review the long-term immunogenicity and protection conferred by HAV vaccine in different population groups. Data have shown that after a full primary vaccination course, protective antibody amounts persist beyond 10 years in healthy individuals, and underlying immune memory provides protection far beyond the duration of anti-HAV antibodies. The group concluded that there is no evidence to lend support to HAV booster vaccination after a fully primary vaccination course in a healthy individual. However, further investigations are needed before deciding if boosters can be omitted in special patientgroups.
T yphoid fever is endemic in developing nations where poor sanitation and contaminated water supp... more T yphoid fever is endemic in developing nations where poor sanitation and contaminated water supplies allow the spread of Salmonella enterica serovar Typhi, a highly adapted, human-specifi c pathogen. The disease course generally begins with fl ulike symptoms , with increasing levels of fever; most cases involve gastrointestinal symptoms, either constipation or diarrhea. A lack of specifi c signs may make clinical diagnosis diffi cult. Complications, including gastrointestinal perforation or hemorrhage, shock, anemia, and meningitis, affect 10% to 15% of patients and may result in fatal outcomes. 1 World Health Organization data indicate that approximately 200,000 persons, mostly children, die each year from complications due to typhoid fever. 2 In developed nations, typhoid fever is most common in travelers returning from areas with endemic disease, but spread among traveler contacts may result in localized outbreaks. 1
V iral hepatitis is a worldwide health problem; hepatitis A and B viruses (HAV and HBV) account f... more V iral hepatitis is a worldwide health problem; hepatitis A and B viruses (HAV and HBV) account for the majority of cases. In 2003, the US national incidence of hepatitis A and hepatitis B was 2.6 cases per 100,000 people for each virus. 1 Worldwide, approximately 1.5 million cases of hepatitis A are reported every year, 2,3 and HBV has infected 2 billion people (one third of the world ' s population), resulting in 350 to 450 million carriers worldwide and 500,000 to 1.2 million deaths per year caused by cirrhosis and primary hepatocellular carcinoma. 4-6 Extensive regions throughout the world are endemic for these viruses, and many international travelers may be at risk for contracting hepatitis A or hepatitis B. 7 In addition to travel, persons may be at risk for both diseases because of employment, institutionalization, or lifestyle factors. Safe and effective monovalent vaccines against hepatitis A and hepatitis B are available. 8-13 Convenience may be enhanced by the use of a combined hepatitis A and B vaccine (Twinrix, GlaxoSmith-Kline Biologicals, Rixensart, Belgium), which has
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