Risk of infection with Mycobacterium tuberculosis in travellers to areas of high tuberculosis endemicity

Abstract

Background: No data exist on risks of infection with Mycobacterium tuberculosis in travellers. We studied incidences of and risk factors for tuberculin skin-test conversion among Dutch long-term travellers to countries of high tuberculosis endemicity.

Methods: In a multicentre, prospective cohort study based in travel and tuberculosis clinics in the Netherlands, 1072 BCG-naive immunocompetent travellers to countries with an estimated annual risk of M. tuberculosis infection of at least 1% were skin tested before departure with 1 tuberculin unit purified protein derivative (PPD) of M. tuberculosis in Tween-80. Those with results less than 2 mm were retested 2-4 months after their return with simultaneous testing for cross-sensitivity to environmental mycobacteria (1 tuberculin unit PPD of M. scrofulaceum in Tween-80). M. tuberculosis infection was defined as a post-travel M. tuberculosis tuberculin skin-test result of at least 10 mm that was 3 mm or more larger than the M. scrofulaceum result.

Findings: Post-travel skin-test results were available for 656 (66%) of 988 individuals who were eligible for follow-up. Among these, 12 M. tuberculosis infections were identified (1.8%). The overall incidence rate was 3.5 per 1000 person-months of travel (95% CI 2.0-6.2), and 2.8 per 1000 person-months of travel (1.2-5.5) after exclusion of health-care workers. Two had active tuberculosis at the time of testing (incidence rate 0.6 per 1000 person-months of travel [0.3-2.3]). Work in patient care abroad was an independent risk factor (adjusted rate ratio 5.34, p=0.015).

Interpretation: The risk of M. tuberculosis infection in long-term travellers to high-endemicity countries, even if not engaged in health-care work, is substantial and of similar magnitude to the average risk for the local population. BCG vaccination or post-travel tuberculin skin-testing of high-risk travellers should be considered.