CORRESPONDENCE

Mediterranean Spotted Fever in Travelers from the United States

To the Editor: We read with interest a recent article in thelournal

ofrravel Medicine’ presenting a case of imported infection due to Rickettsia conorii in a physician who had recently traveled to Zimbabwe and Zambia.

While we agree that many physicians are not famil- iar with the signs and symptoms of this infection, the abstract may be incorrect in stating that no case of imported infection due to R. conorii into the United States has been reported during the last 7 years.

In 1992, we reported a case of rickettsial spotted fever in a 63-year-old man returning from safari in South A€rica.‘ During the last days of his trip, our patient traveled through Kruger National Park in an open land rover, but did not recall any tick bites. Within days of returning to the United States he developed fever and a lesion on his left calf. Two days later he developed a non- pruritic rash on his aims and back which then spread to h s trunk and palms. O n examination he had a tache noire on his lower left calfjust above the stocking line and a diffuse eruption involving the trunk and extremities, including the palms. Many of the lesions were maculo- papular but approximately one-half were small vesicles centered on an erythematous base or atop a papule.

A diagnosis of tick-bite fever was made and he received doxycycline with a prompt response. Indirect immunofluorescence antibody titers confirmed rick- ettsial infection most consistent with R. conorii (serolo- gies performed by the California State Department of Health Services, Viral and kckettsial Disease Laboratory, Berkeley, CA) .

Since the time of that report, D. Raoult has reported the existence of another rickettsial species, R. a*icae, in South Mica. The possibility that our patient was infected with this organism cannot be excluded.

Carol A. Kempev, MD, Clinical Assistant Professor of Medi- cine, and Stan Deresinski, MD, Clinical Projessor ofMedicine, Division oflnfectious Diseases, Stanjord University, and Divi- sion of Infectious Diseases, Santa Clara Wl ley Medical C e n - tev, Sun Jose, Calqornia

References

1. Palau LA, Pankey GA. Mediterranean spotted fever in trav- elers from the United States. J Travel Med 1997;4:179-182.

2. Kemper CA, et al. Atypical cutaneous papulovesicular rash due to infection with Rickettsia conorii. Clin Infect Dis 1992; 15:591-594.

Adriatic Nautical Academy-Medical Manual for Nautical Tourists

To the Editor: Nautical tourism is a developing form of tourism

in Croatia. All over the world, sailing and cruising has become a way of spending summer holidays. People usually sail on their cruising or racing yachts, 7 to 11 meters long, with four to eight people on board. A large number of nautical tourists come to the Adriatic Coast every year, and have been since the war years.

It is not surprising that the Adriatic Sea is so attrac- tive to that kind of tourist. There are more than 1000 islands in 800 km of coastal waters. The distance between the islands is therefore very short and can be traveled in 1 day. That proximity makes cruising safer, but after further logistical analysis of the situation, the availability of med- ical facilities and distance &om them, it becomes clear that the situation is not so ideal, especially in bad weather condtions. Nautical tourists spend their holidays in coastal- traffic conditions, not more than 12 hours from a port of call, whch distinguishes them fiom other kinds of tourists.’ That fact and the large number of tourists, demands that special attention be paid to their health care, and of course that a completely different approach be used.2

A few years ago, at The Second International Mediterranean Conference on Tourist Health in Rim- ini, we presented for the first time our system of med- ical assistance designed for nautical tourists.3 It is an adaptation of the system of medical assistance in use by seamen at sea all over the world.4 The quality of that sys- tem depends on the medical education of the person giv- ing assistance, on the quality of the radio-medico advice, on the quality of the medical supplies aboard, and on the quality of the corresponding medical manual.’

This year in the “Adriatic Nautical Academy,” our sailing school for skippers, in AC1-marina Zut, we started a program of medical training for the skippers. It is designed after the Model Course 2 of the Model Med- ical Training Courses for Seafarers developed by IMO and WHO and given in Regulation No. 11/5 of the “International Convention of Standards of Training, Certification and Watchkeeping for Seafarers.”‘ ILO Convention No. 164/1987 includes identical training lev- e l ~ . ~ We presented that program at the Third International Conference on Tourist Health in Venice, 1990.8.9

This year we are proud to present our Adriatic N a u - ticalAcademy-Medical Manual for Nautical Tourists. It cor- responds with the program of training in our sailing school and it exceeds the scope of a standard first-aid man- ual. It has chapters about typical injuries on sailing boats,

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C o r r e s p o n d e n c e 159

and lessons about poisonous sea animals, motion sickness, food poisoning and scornbrotoxism, drug administration routes and radio-medico service. The manual has 97 pages and 90 illustrations and photographs, black and white, as well as color. It also has a map of places on our coast where medical help is available, and protocols to be used when radio-medico advice is requested. The man- ual is written in Croat language and an English edition is in print at the moment. Because our sailing school is international, Itahan and German editions are planned too.

Together with appropriate medical knowledge of skippers, medical kits and radio-medico advice, this man- ual will contribute to improvement of safety on the Adriatic Sea. Nebojya Nikolit, MD, MSci Faculty o f Maritime Studies, Rieka, Croatia

References

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Nikolit N, Ivani? N, TroSelj-Vukit B. First aid kit for health care in tourist navigators. Proceedings of The First Yugodav Symposium on Medical Problems in Tourism, 1988: 271-275. Nikolit N. Health care for nautical tourists. Bull Inst Mar Trop Med Gdynia 1992,43:& Nikclit N, MavriC T. Health care rendering in tourist navi- gators at the Adriatic Sea. Second International Mediterranean Conference on Tourist Health, Kimini, 1989. External Assistance. In: International medical guide for ships. Geneva: WHO, 1988: 277-282. Urner CJ. Occupational medicine at sea: the seafarer as a patient. J Occup Med 1987; 24:917-922. International Convention on Standards of Training, Certifi- cation and Watchkeeping for Seafarers, 1978 (IMO). ILO Convention 164. Health protection and medical care for seafarers. International Labour Protection, Geneva, 1987. Nikolit N,MavriC T Program ofmedcal training for the iiaLi-

tical tourists on the Adriatic Sea. Proceedings of The Third International Conference on Tourist Health, Venice, 1990. NkoliC N, MavriC T. Program of medical training for the skip- pers in nautical tourism.Trave1 Med Int 1992; 10(4):162-164.

Dental Precautions far Travelers

To the Editor: We read with interest the excellent article by Ked-

jarune and Leggat.’ We disagree, however, with their state- ment that “there have been no reports of transmission ofdiseases such as AIDS 6om infected dentists to patients.”

In 1990-91, the Centers for Disease Control described six patients who acquired HIV infection while receiving care from a dentist with HIV infectiom2,j We agree that it still remains unknown how these patients became infected, but on the other hand transmission of hepatitis B from dentist to patients during dental pro- cedures has also been r e p ~ r t e d . ~ . ~ Given the prevalence of HIV, hepatitis B and hepatitis C infections in devel- oping countries and the fact that universal precautions

are not always applied, there may be a small risk of transmission of these infections from health care work- ers to patients during invasive procedures. The main risk, however, is the patient-to-patient transmission because of inadequate sterilization procedures.

Eric Florence, Alfons Van Gompel, and Robert Colebunders, Institute ofXopica1 Medicine, Antwev, Belgium

References

1. Florence E, Van Gompel A, Colebunders R. Dental precau- tions for travelers [Letter]. J Travel Med 1998; 5:159. Kedjarune U, Leggat PA. Dental precautions for travelers. J Travel Med 1997; 4:38-40. Centers for Disease Control. Possible transmission of human immunodeficiency virus to a patient during an invasive den- tal procedure. MMWR 1990; 39:489-493. Hillis DM, Huelsenbeck JF? Support for dental HIV trans- mission. Nature 1994; 369:24-25. Saw FE Jr, Barrett CL, Hamm R, et al. Lethal outbreak of hepatitis B in a dental practice.JAMA 1986; 255:3260-3264. Kane MA, Lettau LA. Transmission of HBV from dental personnel to patients. J Am Dent Assoc 1985; 110:634-636.

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The Authors Reply

To the Editor: The letter by Florence, Van Gompel and Colebun-

ders’ correctly reinforces our statement that “the serious risks (of dental treatment abroad for travelers) are HIV, hepatitis B, hepatitis C and similarly transmitted viruses.”’ The statement referred to, that “however, there have been no reports of transmission of diseases such as AIDS &om infected dentists to patients,” needs to be taken in the con- text of the former statement made in t h s sentence, as above, where we acknowledge the “serious risks.”’

Although Florence et al. acknowledge that trans- mission of HIV in the case series de~c r ibed~ .~ remains obscure, we agree that HIV transmission from dentist to patients is possible. As pointed out by Florence et al., hepatitis B transnllssion from dentists to patients is known to and, in our paper, we went further to suggest that, for those patients intending to have dental treatment abroad, hepatitis B vaccination should be discussed.

Florence et al. also reinforce the issue of “cross- infection”raised in our paper, since perhaps the greatest risk is transmission of these viruses is “patient-to-patient trans- mission because of inadequate sterilization procedures.”’ Ureporn Kedjarune, DDS, PhD, Lecturev, Department o f Oral Biology and Occlusion, Prince of Songkla University, Hat Yai, 901 12 Thailand PeterA. Leggat, FAFPHM, FACTM, Deputy Head, School of Public Health and Tropical Medicine,

James Cook University, Townsville, 481 1 Australia