The highest conceivable value is one. Country-specific HDI were available for 1995, 2000, and 2005 from the United Nations Development Programme Database (UNDP).14 The SI estimates the proportion of the population having access to sanitary means of excreta disposal. It includes connection to a public

sewer or septic system, pour-flush latrine, simple pit latrine, and ventilated improved pit latrine. The WSI estimates the proportion of the population having access to safe drinking water. Such access is defined as the availability of at least 20 L per person per day from a source within 1 km of the user’s dwelling. It includes ABT-263 price a household connection, a public standpipe, a bore hole, a protected dug well, a protected spring, and rainwater collection. Sanitation index and WSI were available for 1995, 2000, and 2006 from the United Nations’ Millennium Development Goals Indicators Database.15 Indices range between 0 and 1. Region-specific indices were calculated by combining the country-specific indices, which were weighted by the size of each country’s population.14 The crude annual attack rates per 100,000 Dutch travelers were calculated by dividing the number of travel-related cases by the estimated BIBW2992 manufacturer total number of travelers to a specific country or region. Trends in annual attack

rates were assessed using the chi-square test for linear trend in Epi Info version 3.5.1 (CDC, Atlanta, GA, USA). Linear regression analysis was carried out in SPSS for Windows version 15.0 (SPSS Inc., Chicago, IL, USA) to evaluate region-specific

correlations between annual attack rates and hygienic markers during the 12-year study period. Because data on HDI, SI, and WSI were available only for the years 1995, 2000, and 2005/2006, and the three data points suggest linear curves, linear interpolation was carried out between these three data points to obtain indices for the missing years. All statistical tests were two-tailed, and an effect with a p value < 0.05 was considered to be significant. During the 12-year study period, 7,507 cases of hepatitis A, 416 cases of typhoid fever, and 4,000 cases of shigellosis were reported in the Netherlands. The country of exposure was known for 7,101 (94.6%), Hydroxychloroquine 408 (98.1%), and 3,876 (96.9%) cases, respectively. Of these, 2,036 (28.6%), 375 (91.9%), and 2,846 (71.2%) cases were most probably acquired in a developing country, respectively. Table 1 shows the characteristics of the hepatitis A, typhoid fever, and shigellosis cases in the study population. The male–female ratio was 1.15, 1.16, and 0.82, respectively; the median age was 10, 26, and 32 years. For hepatitis A and shigellosis, the predominant region of exposure was the Arab region; for typhoid fever this was Asia. For all three diseases, the absolute annual number of cases fluctuated, but on average they declined. Of typhoid fever cases with known reported vaccination status (n = 344), 79 (23%) were vaccinated.