Which vaccine‑preventable, food‑ and water‑borne, and vector‑borne infections are common among travelers to Greece and Italy?

Travel Health Risks in Greece and Italy

For travelers to Greece and Italy, the primary infectious disease concerns are food- and water-borne illnesses (particularly hepatitis A and traveler's diarrhea), with tick-borne encephalitis in certain rural/forested areas, and standard vaccine-preventable diseases like measles that remain uncontrolled in Europe.

Vaccine-Preventable Diseases

Hepatitis A

This is the most relevant vaccine-preventable infection for Mediterranean travelers. Hepatitis A vaccination should be administered to all travelers to Greece and Italy who lack immunity 1. The risk is associated with contaminated food and water, and business travelers have shown particular susceptibility 2.

Measles, Mumps, and Rubella

Measles remains uncontrolled throughout Europe, including Greece and Italy, making MMR vaccination essential for non-immune travelers 3. Approximately 61% of imported measles cases in the U.S. occur among returning citizens, and the risk of acquiring measles while traveling in Europe is greater than within the United States 3. All persons born in or after 1957 who travel to Europe should receive two doses of measles vaccine if not previously vaccinated 3.

Routine Vaccinations

Ensure diphtheria-tetanus boosters are current, as these diseases persist in Europe 4, 5. All routine childhood immunizations should be up-to-date 5.

Food- and Water-Borne Infections

Traveler's Diarrhea

This is the most common illness affecting travelers to the Mediterranean region 1. All travelers should carry ciprofloxacin 500 mg for empirical self-treatment (take twice daily for 3-7 days if moderate-to-severe diarrhea develops) 4, 5. Alternative antibiotics like azithromycin should be considered for pregnant women and children 6.

• Loperamide can be added for symptom relief but should not be used if fever >101°F or bloody stools are present, and must be discontinued if symptoms persist beyond 48 hours 4, 5
• Seek medical attention if diarrhea doesn't improve within 24-36 hours despite treatment, or if severe dehydration, high fever with rigors, or bloody stools develop 6

Prevention Strategies

• Avoid raw or undercooked seafood and meat
• Consume only thoroughly washed produce
• Drink bottled or boiled water
• Avoid unpasteurized dairy products 7

Vector-Borne Diseases

Tick-Borne Encephalitis (TBE)

TBE vaccination should be recommended for travelers who will have outdoor exposure in rural or forested areas of Greece and Italy during April through November 8. The attack rate is approximately 0.5-1.3 per 100,000 exposed persons in endemic areas 8.

• Risk is highest in forested and rural areas up to 1500m altitude
• Ticks may also be found in gardens
• Only 0.1-5% of ticks carry the virus (rarely up to 30% in focal areas) 8
• Transmission can also occur through unpasteurized milk products 8

Mediterranean Spotted Fever (Rickettsiosis)

While less common in Greece and Italy compared to other Mediterranean countries, Rickettsia conorii causes Mediterranean spotted fever and can be severe with a 21% case-fatality rate among hospitalized adults in Portugal 9. The disease presents with fever, myalgia, headache, eschar, and rash involving palms and soles. The primary vector is the brown dog tick (Rhipicephalus sanguineus), and dogs serve as reservoir hosts 9.

Leishmaniasis

Visceral leishmaniasis transmitted by sandflies poses risk in Mediterranean regions, particularly for immunocompromised travelers 5.

Key Prevention Measures

Avoid direct skin contact with soil or sand by wearing shoes, protective clothing, and using towels on beaches where fecal contamination is likely 4, 5. This prevents parasitic infections including strongyloidiasis and hookworm.

Common Pitfalls

• Problem awareness is weak among European tourists traveling within their own continent 1—many don't consider themselves at risk and skip pre-travel consultations
• Only 29% of travelers who developed vaccine-preventable diseases had pre-travel consultations 2
• At least 55% of travelers with vaccine-preventable diseases required hospitalization 2, emphasizing that these are serious infections despite being preventable

Practical Algorithm

1. Ensure MMR immunity (2 doses if born after 1957)
2. Administer hepatitis A vaccine (unless documented immunity)
3. Update tetanus-diphtheria (within 10 years)
4. Prescribe TBE vaccine if rural/outdoor exposure planned during transmission season
5. Provide ciprofloxacin 500mg for self-treatment of traveler's diarrhea
6. Counsel on food/water precautions and tick avoidance in rural areas