GeoSentinel - Faculty of Medicine

GeoSentinel:
GeoSentinel
The Global Surveillance
Network of the ISTM and CDC
A worldwide
communications and
data collection network
of travel/tropical
medicine clinics
www.geosentinel.org

CME FACULTY DISCLOSURE
Dr. Freedman
has no affiliation with the manufacturer of any commercial
product or provider of any commercial service discussed in
this CME activity.

Provider-based Provider based Sentinel Surveillance
The 3 Functions of GeoSentinel
1. Surveillance – Response
– Alarming sentinel events
2. Surveillance – ongoing trends
3. Analysis of morbidity and estimating risk
– Diagnosing the ill-returnee; ill returnee; the clinician
perspective
– Advising the Prospective Traveler; the traveler
perspective
– Defining associations between patient
characteristics and disease

Provider-based Provider based Sentinel Surveillance
The 3 Functions of GeoSentinel
1. Surveillance – Response
– Alarming sentinel events
2. Surveillance – ongoing trends
3. Analysis of morbidity and estimating risk
– Diagnosing the ill-returnee; the clinician
perspective
– Advising the Prospective Traveler; the traveler
perspective
– Defining associations between patient
characteristics and disease

STL UTH
FNO
USC
MSP
BIR
OTW
TOR
ATL
ORL
CHL
MTL
What is GeoSentinel?
BOS CAM
NYC BRX BXL HUD
BTH
CBG
LDN
TLY
MUC
HAM
PRS
GVA
ZUR
MAD
MRS
OSL
• Provider-based Surveillance of international travelers and migrants.
Does not cover endemic diseases in local populations
41 travel/tropical medicine clinics globally (since 1996)
& 175 Network Members on all 6 continents (since 2002)
ISR
KAT
BKK
SIN
BJG
HCM
HKG
MEL
YOK
TYO
AUC

Leptospirosis –
EcoChallenge, EcoChallenge,
2000
• September 11, 2000; London site Queries by e-mail e mail
concerning ill returnees from Eco-Challenge, Eco Challenge, Sabah 2000
• Query-Response Query Response to GeoS sites: Cases from NYC and
Toronto. Elapsed time = 8 hours.
• Participants worldwide still within incubation period. Wide
broadcast of GeoSentinel Alert to to ISTM, ProMed, ProMed,
IDSA,
TropMed. TropMed.
Elapsed time = 14 hours.
• GeoSentinel sites interface directly with public health
authorities in USA, UK, Australia and Canada to contact all
at risk individuals. Elapsed time = 48 hours.

GeoSentinel Response Capabilities
• Rapid Query-Response Query Response loop
• 40 GeoSentinel Sites
• 166 GeoSentinel Network Members
• ISTM members
(TravelMed TravelMed; ; 2400 members in 75 countries)
• Partners
(WHO, ProMed, ProMed,
IDSA, TropMed, TropMed,
CDC, etc)
• Outgoing Alerts/Advisories
– Broadcast radius is situation dependent
• Collaboration with public health partners

Impact on Travel Medicine Recommendations Globally

Proportion of ill diagnoses per month
Schistosomiasis in Travelers
29-patient Outbreak Reported by ISR
Month of office visit

Schistosomiasis –
Tanzania, 2007
• Aug 26, 2007 – Eli Schwartz (ISR) reports a point source outbreak of
schistosomiasis localized to an artificial swimming “pond pond” at a small exclusive
tented camp hotel near Lake Eyasi, Eyasi,
Tanzania during Apr 2007.
– 23/25 Israeli travelers seropositive, seropositive,
17/23 symptomatic. No other exposures
(except 2 Israeli guides). Predominant S. mansoni by WB.
• Aug 31 – Frank von Sonnenburg (MUC) confirms egg positive
S. mansoni in German journalist who swam in same pool Jan 2007.
• Sept 4 – ProMED-mail ProMED mail posting.
• Oct 26 – US patient ill with confirmed schisto contacts GeoSentinel after
googling “Eyasi Eyasi schisto” schisto and reading ProMed posting. 4/7 in her party who were
tested are seropositive. seropositive.
No previous exposures, all swam once for

Schistosomiasis – Tanzania, 2007
Kisima Ngeda Tented Camp

Archive Number 20070904.2912
Published Date 04-SEP-2007
Subject PRO/EDR> Schistosomiasis - Tanzania (Lake Eyasi)
SCHISTOSOMIASIS - TANZANIA (Lake Eyasi)
*******************************************
A ProMED-mail post
ProMED-mail is a program of the International Society for Infectious Diseases
Date: Tue 4 Sep 2007
Source: GeoSentinel [edited]
Schistosomiasis outbreak in safari camp
--------------------------
GeoSentinel, the global surveillance program of the International Society of Travel Medicine, wishes to report on an
ongoing significant point source outbreak of acute travel-related schistosomiasis apparently localized to an artificial
swimming pond at a small tented camp hotel near to Lake Eyasi, Tanzania.
As the small man-made pool seems heavily contaminated, there may be still undiagnosed returned travelers out there
worldwide either with non-specific illnesses of unknown origin or without symptoms. Once diagnosed a simple course of
praziquantel will cure most infections.
[case reports from Eli Schwartz (ISR) & Frank von Sonnenburg (MUC) omitted from this slide]
... A review of the hotel website indicates that the camp is located on a former farm and that the toilets drain into some
sort of septic system. One wonders if there is a flaw in the design of the drainage system.
The lesson is likely that there is really no safe fresh water in Africa and that the advice of most travel medicine advisors
to avoid any fresh water exposure in Africa is sound. It is hard to track acute changes in some environmental factor,
perhaps in this case, a new drainage pattern for fecal waste. The safari camp has been contacted and we understand they
have now ceased all bathing activity in the artificial pool.
GeoSentinel advises clinicians to consider schistosomiasis in ill travelers from Tanzania especially those with an
eosinophilia. Any traveler with exposure that may be linked to this focal outbreak should be screened with serology for
schistosomiasis even if clinically well and with no abnormalities in other blood tests.
GeoSentinel would appreciate hearing of further suspected cases so as to be able to prepare comprehensive
documentation for formal publication.
--
David O. Freedman, MD, University of Alabama at Birmingham, United States
Eli Schwartz, Sheba Medical Center, Tel Hashomer, Israel
Frank von Sonnenburg, University of Munich, Germany
for GeoSentinel

Schistosomiasis in GeoSentinel
(3/97-12/04; (3/97 12/04; after travel; n = 247)
Predictor Variables for
Confirmed/Presumptive Schisto Dx Regions of Exposure
Predictor Variable OR (95% CI)
Age < 45 years 1.69 (1.19-2.40) (1.19 2.40)
Male gender 1.51 (1.16-1.97) (1.16 1.97)
Had pre-travel pre travel consult 1.41 (1.06-1.89) (1.06 1.89)
Traveler type ‡
Tourist traveler 1.00 (--- ( ---)
Visiting
friends/relatives
0.56 (0.33-0.95) (0.33 0.95)
Missionary/Volunteer 1.83 (1.29-2.62) (1.29 2.62)
Long-term Long term business 1.61 (0.90-2.88) (0.90 2.88)
Short-term Short term business 0.70 (0.42-1.17) (0.42 1.17)
Research/Education 0.86 (0.45-1.64) (0.45 1.64)
‡ Tourist traveler = reference group
Region Number (%)*
Africa 204 (83)
East 110 (45)
West 38 (15)
Central 10 (4)
North 5 (2)
South 5 (2)
Multiple regions 36 (15)
Asia 15 (6)
Other/Unknown 28 (11)
*% all patients with confirmed or presumptive
diagnosis of schistosomiasis

Interesting Leads / Threads Maintained on
Network Members Restricted Access Website

Provider-based Provider based Sentinel Surveillance
The 3 Functions of GeoSentinel
1. Surveillance – Response
– Alarming sentinel events
2. Surveillance – ongoing trends
3. Analysis of morbidity and estimating risk
– Diagnosing the ill-returnee; the clinician
perspective
– Advising the Prospective Traveler; the traveler
perspective
– Defining associations between patient
characteristics and disease

Proportion of ill diagnoses per month
Trends by Month
Data collected continuously
60 diagnosis/syndromes plotted routinely
Dengue
Month of office visit

Dengue Morbidity in Sentinel Travelers Can Herald Regional Epidemics
2002 ProMED report
by GeoSentinel
Schwartz E, et al., for the GeoSentinel Surveillance Network.
Emerg Infect Dis. 2008 Jul; [Epub ahead of print].

Seasonality of Dengue in Returned Travelers by
Region
Schwartz E, et al., for the GeoSentinel Surveillance Network. Emerg Infect Dis. 2008; (in press).

Rapid Institution of Enhanced Surveillance
Example: Weekly trend analysis during SARS
Suspected Pneumonia in Travelers

Provider-based Provider based Sentinel Surveillance
The 3 Functions of GeoSentinel
1. Surveillance – Response
– Alarming sentinel events
2. Surveillance – ongoing trends
3. Analysis of morbidity and estimating risk
– Diagnosing the ill-returnee; the clinician
perspective
– Advising the Prospective Traveler; the traveler
perspective
– Defining associations between patient
characteristics and disease

How does GeoSentinel Work?
Patients with
travel-related
condition
GeoSentinel Site
or
GeoSentinel Network
Rapid Query
Response
Loop
Reports
Surveillance Data
Data analysis by Sites
Central
Database
TravelMed +/-
ISTM Membership +/-
Partners (TropMed,
ProMed, IDSA, etc) +/-
Secondary
Response
Arm

Display of
Complete
Patient Record

GeoSentinel Dataset, March 2008
Number of Patients in
GeoSentinel (n = 83,584)
Place of Likely Exposure in
Patients Seen After Travel

Who are GeoSentinel patients?
(as of March 2008)
Complete Database
(n = 83,584)
After Travel Visits
(n = 42,033)

GeoSentinel
Contribution by Treating Site 2007
n = 15,461 patients
Israel
4%
Nepal
22%
Europe
29%
US
16%
Asia
13%
Canada
14%
North America
30%
Aus/NZ
2%

Rich Database of Travel Morbidity
• Benefits
– Guide diagnostic approach
– Guide empiric therapy
– Prioritize pre-travel pre travel prevention strategies

What Sentinel Networks Can and Can’t Can t
Do • Physician verified diagnoses
• Don’t Don t describe all illness in all travelers
– Focus is on medically important, not mild or self-limited self limited
illness
– Focus is on illness presenting at specialized centers
• Attribution of place of exposure not possible in all
ill travelers
– Multi-country Multi country itineraries, some diseases with long or
variable incubation periods
– Easy to narrow to region, not always to country
• Perceived “risky risky” destinations may be over- over
represented
• Patients seen after-travel after travel must be analyzed
separately from those seen during travel

Provider-based Provider based Sentinel Surveillance
The 3 Functions of GeoSentinel
1. Surveillance – Response
– Alarming sentinel events
2. Surveillance – ongoing trends
3. Analysis of morbidity and estimating risk
– Diagnosing the ill-returnee; ill returnee; the clinician
perspective
– Advising the Prospective Traveler; the traveler
perspective
– Defining associations between patient
characteristics and disease

Diagnoses in ill returned travelers
to the Developing World
n=17,353 =17,353 reported to GeoSentinel
Diagnosis
Cases per 1000 ill
returned travelers
Systemic febrile illness 226
Acute diarrhea 222
Dermatologic disorder 170
Chronic diarrhea 113
Nondiarrheal gastrointestinal disorder 82
Respiratory disorder 77
Freedman DO, et al., for the GeoSentinel Surveillance Network.
N Engl J Med. 2006 Jan 12;354(2):119-130.

Profile of proportionate
morbidity in ill returned
travelers from the
developing world by
region of travel

Clin Infect Dis 2003:211;36-44.
Clin Infect Dis 2004:39;1104-12.

Malaria Risk by Region
, Reference group
Clin Infect Dis 2004:39;1104-1112

Animal-associated Animal associated Injuries in
GeoSentinel 1998-2005 1998 2005
1.4% (320) of 23,509 ill-returned ill returned travelers
Gautret P, et al., for the GeoSentinel Surveillance Network. Vaccine. 2007; 25:2656-2663.

Skin Diagnoses in ill returned travelers
to the Developing World
n=4,592 =4,592 reported to GeoSentinel
Diagnosis % of skin
diagnoses
Cutaneous larva migrans 9.8
Insect bite 8.2
Skin abscess 7.7
Superinfected insect bite 6.8
Allergic rash 5.5
Rash, unknown etiology 5.5
Dog bite 4.3
Diagnosis % of skin
diagnoses
Superficial fungal
infection
Lederman E, et al., for the GeoSentinel Surveillance Network.
Int J Infect Dis. 2008;12(x):xxx-x (in press).
4.0
Dengue 3.4
Leishmaniasis 3.3
Myiasis 2.7
Spotted fever group
rickettsiae
1.5
Scabies 1.5

Gastrointestinal Infection by Region
Region
Travelers Travelers to only One Region
*
(10 6 ) Cases Rate/10 7 RRR 95% Confidence Interval
Western & Northern Europe 1104.8 40 0.4 1.0 reference
North America 393.0 28 0.7 2.0 1.2-3.2
Central/East Europe 485.0 69 1.4 3.9 2.7-5.8
Southern Europe 888.2 212 2.4 6.6 4.7-9.2 Low
North-East Asia 416.1 155 3.7 10.3 7.3-14.6
Australasia 40.2 25 6.2 17.2 10.4-28.3
Oceania 17.0 25 14.7 40.6 24.6-66.9
Middle East 183.7 399 21.7 60.0 43.3-88.0
North Africa 68.0 187 27.5 76.0 54.0-106.9 Moderate
Central America 151.6 475 31.3 86.5 62.7-119.5
Caribbean 104.3 356 34.1 94.3 68.0-130.7
South-East Asia 256.8 967 37.7 104.0 75.8-142.7
South America 90.2 663 73.5 203.0 147.6-279.3 High
Sub-Sahara Africa 118.5 1209 102.0 281.8 205.7-386.1
South Asia 39.6 1276 322.2 890.0 649.7-1219.2 Very high
Gastrointestinal infection reporting rate and reporting rate ratios (RRR) by region of
travel, GeoSentinel 2000-2005.
* Number of travelers to the region in 2000-2005 reported to WTO.
† Number of cases of gastrointestinal infections after travel with exposure in the region as
reported to GeoSentinel 2000-2005.
Greenwood Z, et al., for the GeoSentinel Surveillance Network. J Travel Med. in press.

Top countries of exposure to
filarial parasites
Country N
Cameroon 62
Guyana 22
Liberia 11
Nigeria 10
Sierra
Leone
10
Ethiopia 9
Ghana 9
India 8
Gabon 7
Lipner E, et al., for the GeoSentinel
Surveillance Network. PLoS Negl
Trop Dis. 2007; PLoS Negl Trop
Dis. 2007;1(3):e88.

Trip duration by filarial infection
among nonendemic visitors
• 7/9 with O. volvulus = Trip duration

Reason for travel among persons with filarial
infections reported to GeoSentinel
Lipner E, et al., for the GeoSentinel Surveillance Network.
PLoS Negl Trop Dis. 2007; PLoS Negl Trop Dis.
2007;1(3):e88.

Differing Disease Diagnosis Profiles in
Immigrant-VFRs
Immigrant VFRs vs. Traveler-VFRs
Traveler VFRs (1997-2004)
(1997 2004)
All dermatologic disease
STD
Schistosomiasis
Tuberculosis
All respiratory illness
Influenza
Hepatitis A
Intestinal parasite
Chronic diarrhea
All acute diarrhea
Parasitic diarrhea
Bacterial diarrhea
All systemic febrile illness Immigrant-VFR vs. Tourist-Traveler
Typhoid fever
(n=1,813) (n=10,021)
Immigrant-VFR vs. Traveler-VFR
Dengue fever
(n=1,813) (n=670)
Malaria
0.1 1 10 100 1000
Adjusted Odds Ratios and 95% CIs
Leder K, et al., for the GeoSentinel Surveillance Network. Clin Infect Dis. 2006 Nov 1;43(9):1185-93.

GeoSentinel Publications 2006-
Gautret P, Shaw M, Soula G, et al. Rabies post-exposure post exposure prophylaxis in returned
injured travelers from France, Australia, New Zealand: a retrospective retrospective
study. J
Travel Med. 2008;15:25-30.
2008;15:25 30.
Lipner EM, Law MA, Barnett E, et al. Filariasis in travelers presenting to the
GeoSentinel Surveillance Network. PLoS Neglected Trop Dis. 2007;1:e88.
Boggild AK, Costiniuk C, Kain KC, Pandey P. Environmental hazards in Nepal:
altitude illness, environmental exposures, injuries, and bites in in
travelers and
expatriates. J Travel Med. 2007;14:361-8.
2007;14:361 8.
Wilson ME, Weld LH, Boggild A, et al. Fever in returned travelers: Results from the
GeoSentinel Surveillance Network. Clin Infect Dis. 2007;44:1560-8.
2007;44:1560 8.
Gautret P, Schwartz E, Shaw M, et al. Animal-associated Animal associated injuries and related
diseases among returned travelers: a review of the GeoSentinel Surveillance
Network. Vaccine. 2007;25:2656-63.
2007;25:2656 63.
Fenner L, Weber R, Steffen R, Schlagenhauf P. Imported infectious disease and
purpose of travel, Switzerland. Emerg Infect Dis. 2007;13:217-22.
2007;13:217 22.
Leder K, Tong S, Weld L, et al. Illness in travelers visiting friends and relatives: a
review of the GeoSentinel Surveillance Network. Clin Infect Dis. 2006;43:1185-93
2006;43:1185 93
Boggild AK, Yohanna S, Keystone JS, Kain KC. Prospective analysis of parasitic
infections in Canadian travelers and immigrants. J Travel Med. 2006;13:138-44.
2006;13:138 44.
Freedman DO, Weld LH, Kozarsky PE, et al. Spectrum of disease and relation to
place of exposure among ill returned travelers. N Engl J Med. 2006;354:119-30.
2006;354:119 30.

GeoSentinel Publications in press
Leder K, Wilson ME, Freedman DO, Torresi J. A comparative
analysis of methodological approaches used for estimating risk
in travel medicine. J Travel Med. 2008; in press.
Lederman ER, Weld LH, Elyazar IRF, et al. Dermatologic
conditions of the ill returned traveler: an analysis from the
GeoSentinel Surveillance Network. Int J Infect Dis. 2008; in
press.
Greenwood Z, Black J, Weld L, et al. Gastrointestinal infection
among international travelers globally. J Travel Med. 2008; in
press.
Schwartz E, Weld LH, Wilder-Smith Wilder Smith A, et al. Seasonality, annual
trends, and characteristics of dengue in ill returned travelers.
Emerg Infect Dis. 2008 Jul; [Epub [ Epub ahead of print].

GeoSentinel ProMED-mail Postings 2006-2007
Freedman DO, Burchard G. Malaria - Germany ex Bahamas (Great Exuma). Exuma).
ProMED-mail.
ProMED mail. 16-APR 16 APR-2008. 2008. Archive Number: 20080416.1369.
Freedman DO, Schwartz E, von Sonnenburg F. Schistosomiasis - Tanzania (Lake
Eyasi). Eyasi).
ProMED-mail.
ProMED mail. 04-SEP 04 SEP-2007. 2007. Archive Number: 20070904.2912.
Freedman DO and Schwartz E. Malaria - Israel ex Thailand. ProMED-mail.
ProMED mail. 20- 20
MAY-2006. MAY 2006. Archive Number: 20060520.1431.
Freedman DO. Chikungunya - Indian Ocean Update (05): Spread to Europe [3]
France (Marseilles), Switzerland (Geneva) and Germany (Munich). ProMED- ProMED
mail. 04-MAR 04 MAR-2006. 2006. Archive Number: 20060304.0695.
Publications Highlighting GeoSentinel 2006-2007
Doudier B, Bogreau H, DeVries A, et al. Possible autochtonous malaria from
Marseille to Minneapolis. Emerg Infect Dis. 2007;13:1236-8.
Ledford H. Jetsetters are key clues to epidemics: Travellers who bring illness
home act as sentinels of disease. news@nature.com. Published online: 29
January 2007; |doi:10.1038/news070129-5.
Ross K. Tracking the spread of infectious disease: Two networks prove the power
of international collaboration. EMBO Rep. 2006;7:855-8.
Public Health Agency Canada (PHAC) Travel Medicine Program Travel Health
Advisory. Malaria in the Dominican Republic. January 31, 2006.
Hill DR. The burden of illness in international travelers. N Engl J Med.
2006;354:115-7.

GeoSentinel Project Staff
Project Directors
• D. Freedman - University of Alabama at Birmingham
• P. Kozarsky - Emory University
• N. Marano (Interim) - Div. Global Migration & Quarantine, NCID/CDC
ISTM Staff
• E. Axelrod - Data Manager
• A. Plier (UAB) - Program Manager
• B. Bagwell - Financial Management, Travel Coordination
Div. of Global Migration & Quarantine, NCID/CDC
• M. Cetron - Special Consultant
• X. Davis - Statistician
• P. Han - Data Analyst

GeoSentinel Site Directors
USA
A. Anglim; Los Angeles CA
E. Barnett; Boston MA
L. Chen; Cambridge MA
B. Connor; New York NY
C. Coyle; Bronx NY
D. Freedman; Birmingham AL
S. Hagmann, A. Miller; Bronx-Lebanon NY
D. Hale; Salt Lake City UT
J. Haulman, D. Roesel; Seattle WA
N. Jenks; Peekskill NY
P. Kozarsky, C. Franco; Atlanta GA
C. Licitra, A. Crespo; Orlando FL
M. Lynch; Fresno CA
T. Nutman, A. Klion; Bethesda MD
W. Stauffer, P. Walker; Minneapolis/St. Paul MN
Canada
M. Libman, J. Maclean; Montreal
J. Keystone, K. Kain; Toronto
A. McCarthy; Ottawa
South America
C. Perret; Santiago
Europe
G. Burchard; Hamburg
G. Carosi, F. Castelli; Brescia
E. Caumes, A. Perignon; Paris
V. Field; London
E. Gkrania-Klotsas; Cambridge UK
M. Jensenius; Oslo
R. Lopez-Velez; Madrid
L. Loutan, F. Chappuis; Geneva
P. Parola, F. Simon; Marseille
P. Schlagenhauf, R. Weber; Zürich
F. von Sonnenburg; Munich
Asia
T. Batchelor; Ho Chi Minh City
S. Borwein; Hong Kong
S. Kanagawa, Tokyo
P. Lim; Singapore
S. MacDonald; Beijing
P. Pandey; Katmandu
W. Piyaphanee, U. Silachamroon; Bangkok
N. Tachikawa; Yokohama
Australia & New Zealand
K. Leder, J. Torresi; Melbourne
M. Shaw; Auckland
Middle East
E. Schwartz; Jerusalem