Distribution Agreement in Presenting This Thesis Or Dissertation As A
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Distribution Agreement In presenting this thesis or dissertation as a partial fulfillment of the requirements for an advanced degree from Emory University, I hereby grant to Emory University and its agents the non-exclusive license to archive, make accessible, and display my thesis or dissertation in whole or in part in all forms of media, now or hereafter known, including display on the world wide web. I understand that I may select some access restrictions as part of the online submission of this thesis or dissertation. I retain all ownership rights to the copyright of the thesis or dissertation. I also retain the right to use in future works (such as articles or books) all or part of this thesis or dissertation. Signature: _____________________________ ______________ Jillian Leigh Fitzpatrick Date Travel-related zoonotic diseases associated with human exposure to rodents: a review of GeoSentinel Surveillance Data, 1996 – 2011 By Jillian Leigh Fitzpatrick Master of Public Health Epidemiology _________________________________________ Dr. John McGowan, Jr. Committee Chair _________________________________________ Dr. Nina Marano Committee Member Travel-related zoonotic diseases associated with human exposure to rodents: a review of GeoSentinel Surveillance Data, 1996 – 2011 By Jillian Leigh Fitzpatrick Bachelor of Science Xavier University 2009 Faculty Committee Chair: John E. McGowan, Jr., MD An abstract of A thesis submitted to the Faculty of the Rollins School of Public Health of Emory University in partial fulfillment of the requirements for the degree of Master of Public Health in Epidemiology 2012 Abstract Travel-related zoonotic diseases associated with human exposure to rodents: a review of GeoSentinel Surveillance Data, 1996 – 2011 By Jillian Leigh Fitzpatrick Current knowledge of the incidence and risk factors associated with rodent-borne zoonoses in travelers is limited. Travelers and physicians alike must be properly educated so that they are aware of the risks and the protective measures that should be taken. This study investigated rodent-borne zoonoses in travelers and associated risk factors using GeoSentinel, a multi-site global surveillance network established for the surveillance of travel-related morbidity. 18 rodent-borne zoonoses were chosen for analysis. This study analyzed only diseases that were either directly transmitted from rodents to humans (including contact with infected urine or droppings) or indirectly transmitted via an arthropod reservoir, where the rodent plays a major role in the life cycle of the disease. Over a 15 year span there were 962 reports of illness associated with one or more of these 18 rodent-borne zoonotic diseases. Ill travelers with rodent zoonoses were found to be significantly more likely to be male and traveling as tourists than those ill travelers with some other diagnosis. Adventure travel and risky behavior may increase the risk of contact with rodent zoonoses for both groups, as males were more likely to engage in adventure travel than females and tourists were also more likely to engage in risk taking behavior. Further, when compared to all other ill travelers, those with rodent zoonoses were 21 times more likely to have been exposed in South America, 12 times more likely to have been exposed in Sub-Saharan Africa, and 11 times more likely to have been exposed in Central America. Travelers to these areas should be aware of their increased risk of contracting a rodent-borne zoonosis and should take proper preventative measures. Analysis of the GeoSentinel database can provide epidemiologic information about rodent-borne zoonoses in travelers and ultimately decrease the disease burden in this population. Travel-related zoonotic diseases associated with human exposure to rodents: a review of GeoSentinel Surveillance Data, 1996 – 2011 By Jillian Leigh Fitzpatrick Bachelor of Science Xavier University 2009 Thesis Committee Chair: John E. McGowan, Jr., MD A thesis submitted to the Faculty of the Rollins School of Public Health of Emory University in partial fulfillment of the requirements for the degree of Master of Public Health in Epidemiology 2012 ACKNOWLEDGEMENTS I am heartily thankful to Nina Marano, Noelle Molinari, and John McGowan, Jr., whose encouragement, guidance and support from the initial to the final level enabled me to develop an understanding of the subject. Lastly, I offer my regards and blessings to all of those who supported me in any respect during the completion of the project. Jillian L. Fitzpatrick Contents BACKGROUND .................................................................................................................1 LITERATURE REVIEW ....................................................................................................4 Directly Transmitted Rodent Zoonoses ...........................................................................4 Indirectly Transmitted Rodent Zoonoses.........................................................................6 Rodent Zoonoses in Travelers........................................................................................11 METHODS........................................................................................................................13 Hypotheses:....................................................................................................................13 Objectives: .....................................................................................................................13 Dataset:...........................................................................................................................14 Rodent Zoonosis Classification: ....................................................................................14 Variable Descriptions:....................................................................................................15 Comparison Groups: ......................................................................................................15 Analysis Plan (Specific Aims):......................................................................................15 Sample Size and Power Calculations.............................................................................16 RESULTS..........................................................................................................................18 DISCUSSION....................................................................................................................23 Strengths and Limitations ..............................................................................................25 Future Directions............................................................................................................26 REFERENCES ..................................................................................................................27 TABLES ............................................................................................................................29 Appendix 1.........................................................................................................................42 LIST OF TABLES Table 1. Frequency of Directly and Indirectly Transmitted Rodent Zoonoses in GeoSentinel, March 1996-2011 Table 2a. Characteristics of Travelers with Rodent Zoonoses Compared to Travelers without Rodent Zoonoses in GeoSentinel, March 1996-2011 Table 2b. Characteristics of Travelers with Rodent Zoonoses Compared to Travelers without Rodent Zoonoses in GeoSentinel, March 1996-2011 Table 3. Bivariate Analyses of Characteristics Associated with Travelers with Rodent Zoonoses Compared to Travelers without Rodent Zoonoses in GeoSentinel, March 1996- 2011 Table 4. Multivariate Analyses of Characteristics Associated with Travelers with Rodent Zoonoses Compared to Travelers without Rodent Zoonoses in GeoSentinel, March 1996- 2011 Table 5. Relative Contribution of Each Rodent Zoonosis to Risk Factors of Interest in GeoSentinel, March 1996-2011 Table 6. Symptoms of Travelers with Rodent Zoonoses Compared to Travelers without Rodent Zoonoses in GeoSentinel, March 1996-2011 Table 7. Bivariate Analyses of Symptoms in Travelers with Rodent Zoonoses Compared to Travelers without Rodent Zoonoses in GeoSentinel, March 1996-2011 Table 8. Multivariate Analyses of Symptoms in Travelers with Rodent Zoonoses Compared to Travelers without Rodent Zoonoses in GeoSentinel, March 1996-2011 Table 9. All Rodent Zoonoses Compared to Cutaneous Leishmaniasis and Rickettsial Diagnoses Only in GeoSentinel, March 1996-2011 Table 10. Region of Exposure of Travelers with Rodent Zoonoses Compared to Travelers without Rodent Zoonoses in GeoSentinel, March 1996-2011 Table 11. Region of Exposure Bivariate Analysis of Travelers with Rodent Zoonoses Compared to Travelers without Rodent Zoonoses in GeoSentinel, March 1996-2011 Table 12. Region of Exposure Multivariate Analysis of Travelers with Rodent Zoonoses Compared to Travelers without Rodent Zoonoses in GeoSentinel, March 1996-2011 1 BACKGROUND Since the end of the 20th century, emerging and re-emerging zoonotic diseases have garnered increased attention, both globally and in the United States. An estimated 75% of all emerging infectious diseases are of zoonotic origin (1). Of all human pathogens, 60% are zoonotic, and of these, 71% originate from wildlife (2). This emergence has brought with it a great need for an increase in surveillance, detection, and control of zoonotic diseases. Escalating speed and ease of travel have expanded