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Medical tourism to Dominican Republic results in multistate mycobacteria outbreak

A rash of mycobacteria surgical site infections among travelers has been linked to cosmetic procedures conducted in Dominican surgical clinics, according to an investigation recently published in Emerging Infectious Diseases.

Interviews with the affected patients suggested that many participated in medical tourism to save money, according to David Schnabel, MD, epidemic intelligence officer for the CDC, and colleagues, who are advising health care providers and officials servicing immigrant populations to remain vigilant for infections associated with this type of travel.

“Infections with rapidly growing mycobacteria (RGM), which include the species Mycobacterium abscessus, M. chelonae and M. fortuitum, are difficult to diagnose,” Schnabel and colleagues wrote. “Infections by these organisms acquired in health care settings are most often associated with breeched sterile technique and exposure to nonsterile water. Outbreaks in these settings have been reported and include those associated with cosmetic surgeries performed in the United States and internationally.”

Cost of procedures influence decision to travel
In August 2013, the Maryland Department of Health and Mental Hygiene received reports of M. abscessus complex-positive surgical site infections (SSIs) in two women who had recently undergone cosmetic surgery at a private clinic in the Dominican Republic. After interviews with both women raised concerns of additional unrecognized cases, the CDC and other health departments launched an investigation to determine the scope of this potential RGM outbreak among medical travelers.

“Little systematically collected data is available about the scope of and risks for medical tourism,” the investigators wrote. “Industry estimates regarding the number of U.S. residents who travel abroad for medical services vary widely … [although] most reports indicate that the frequency of medical tourist activities and subsequent public health effects will likely increase in the future because of ease of travel, increased marketing and communications, and anticipated cost savings.”

To locate additional cases, the investigation team distributed health alerts to targeted clinicians and public health officials and disseminated general RGM infection warnings to clinicians and patients through mainstream and social media outlets. The team interviewed probable case patients — defined as those who had a cosmetic surgery procedure in the Dominican Republic from March 2013 to February 2014 and were diagnosed with soft tissue infection unresponsive to standard therapy — to determine common exposures or experiences and better characterize the disease. Participating clinical and public health laboratories submitted patient wound culture isolates to the CDC for organism confirmation and pulsed-field gel electrophoresis (PFGE) testing, in addition to those from New York that were collected and tested by the New York City Public Health Laboratory.

The investigation revealed 18 confirmed and three probable cases living in six northeastern states. The median age of these patients was 40 years; all were women. Fifteen were born in the Dominican Republic, two in the U.S., three in other countries and one from an unknown country. Sixty-two percent learned of the clinic where they had surgery from a friend or family member, and 15 of 16 responding patients reported cost had some impact on their decision to undergo procedures there.

More than half of the case-patients underwent a surgical procedure at the same clinic (clinic A). Patients most often received liposuction (71%); 18 underwent more than one procedure.

Case-patients reported varying degrees of infection control and sanitation after their surgeries, and the investigators identified no common exposures upon return to the U.S. Among the 18 confirmed RGM infections, 16 were M. abscessus complex, and two were M. fortuitum. Eleven of the 15 M. abscessus complex isolates analyzed using PFGE had indistinguishable patterns, and 10 of these came from clinic A.

Illness onset was a median 24 days after surgery. Sign and symptoms were more often wound-related than systematic, and some patients required multiple hospitalizations. Only one of 12 patients contacted 9 months after their surgeries reported full recovery.

Schnabel and colleagues warned that more cases may have been missed, and that providers should remain vigilant for similar outbreaks among at-risk populations.

“Understanding the role of medical tourism in disease risk and increasing patient protections in this context will require an ongoing effort by the international public health and medical communities,” the researchers wrote. “Clinicians and public health officials, particularly those service communities with connections to immigrants from medical tourism destinations, should be vigilant and consider RGM infections in the differential diagnosis for persons who have wound infections after surgery in these destinations.”

Xenotourism to blame for 2014 outbreak of Q fever
While the RGM investigation implicated cost as a primary concern for individuals considering surgery abroad, interest in an unapproved procedure was the driving factor in another medical tourism outbreak reported in 2015.

After a Canadian resident received a diagnosis of Q fever — a zoonotic disease caused by Coxiella burnetii — in July 2014, a warning notification of potential exposure led to five additional diagnoses in New York. All cases reported traveling to Germany to receive intramuscular injections of fetal sheep cells, with symptoms beginning 1 week after therapy and lasting 10 to 90 days.

Each patient was interviewed by local health departments, but only two of the U.S. patients agreed to a follow-up. They reported traveling as a group for the injections twice a year for the previous 5 years, and that they were not informed ofQ fever risks before treatment.