Traveler's diarrhea 1045467 223529403 2008-07-04T13:45:38Z 72.84.38.182 add info {{Mergewith|Gastroenteritis|talk:Traveler's diarrhea|date=February 2008}} '''Traveler's diarrhea''' (in American English) or '''traveller's diarrhœa''' (in British English), abbreviated to '''TD''', is the most common illness affecting travelers. Traveler's [[diarrhea]] is defined as three or more unformed [[stool]]s in 24 hours in a traveler, commonly accompanied by abdominal [[cramp]]s, [[nausea]], and bloating.<ref name=SWOL-TD>{{cite web|url=http://www.safewateronline.com/travelers_d.htm|title=Travelers' diarrhea|publisher=safewateronline.com}}</ref> ==Incidence== Each year 20%&ndash;50% of international travelers, an estimated 10 million people, develop [[diarrhea]].<ref name=CDC_TD>{{cite web |title=Travelers' Diarrhea |url=http://www.cdc.gov/ncidod/dbmd/diseaseinfo/travelersdiarrhea_g.htm |date=November 21, 2006 |publisher=Centers for Disease Control and Prevention}}</ref> TD is also known to [[mountaineering|mountaineers]], as it can occur in camps due to poor sanitary conditions. ==Risk factors== The primary source of infection is ingestion of [[fecal]]ly contaminated food or water. The most important determinant of risk is the traveler's destination. High-risk destinations are the [[developing country|developing countries]] of [[Latin America]], [[Africa]], the [[Middle East]], and [[Asia]].<ref name=CDC_TD /> Some first world countries are also deemed risky.<ref>{{cite press release|url=http://europa.eu/rapid/pressReleasesAction.do?reference=IP/07/393&format=HTML&aged=0&language=EN&guiLanguage=en|title=Portugal: Commission continues legal action over environmental and human health infringements|publisher=[[European Commission]]|date=March 22, 2007|location=[[Brussels]]|accessdate=2008-02-25}}</ref> A worldwide rating of drinking water safety is kept at Safe Water for International Travelers website.<ref>{{cite web|url=http://www.safewateronline.com|title=Safe Water for International Travelers|publisher=safewateronline.com}}</ref> People at particular high-risk include young adults, [[immunosuppression|immunosuppressed]] persons, persons with inflammatory-bowel disease or [[diabetes]], and persons taking H-2 blockers or [[antacids]]. Attack rates are similar for men and women.<ref name=CDC_TD/> Although traveler's diarrhea usually resolves within three to five days (mean duration: 3.6 days), in about 20 percent of persons the illness is severe enough to cause bed confinement and in 10 percent of cases the illness lasts more than one week.<ref name=SWOL-TD/> For those who get serious infections, TD can occasionally be life-threatening. The serious infections include [[bacillary dysentery]], [[amoebic dysentery]], and [[cholera]].<ref name=SWOL-TD/> ==Common symptoms == The onset of TD usually occurs within the first week of travel, but may occur at any time while traveling, and even after returning home. Most TD cases begin abruptly. The illness usually results in increased frequency, volume, and weight of stool. Altered stool consistency also is common. Typically, a traveler experiences four to five loose or watery bowel movements each day. Other commonly associated symptoms are nausea, vomiting, diarrhea, abdominal cramping, bloating, low fever, urgency, and malaise,<ref name=CDC_TD /> and appetite is usually low or non-existent.<ref name=SWOL-TD/> It is much more serious if there is blood or [[mucus]] in the diarrhea, belly pain, or high fever. [[Dehydration]] is possible. With serious cases of [[cholera]], there is a rapid onset of [[symptom]]s, which include weakness, [[malaise]] (feeling rotten), and torrents of watery diarrhea with flecks of mucus (called "rice water" stools). Dehydration is a serious consequence, with death occurring in as quickly as 24 hours with cholera.<ref name=SWOL-TD/> ==Causes == [[Pathogen|Infectious agent]]s are the primary cause of travellers' diarrhea. [[Bacteria]] represent approximately 61% of the [[microorganism]]s responsible.{{fact|date=June 2008}} [[Enterobacteriaceae|Bacterial enteropathogens]] cause approximately 80% of cases.<ref name=CDC_TD/> The most common causative agent isolated in countries surveyed has been [[Enterotoxigenic Escherichia coli|enterotoxigenic ''Escherichia coli'']] (ETEC).<ref name=CDC_TD/> Enteroaggregative ''[[Escherichia coli|E. coli]]'' is increasingly recognized and many studies do not look for this important bacterium.<ref name=SWOL-TD/> ''[[Shigella]] spp.'' are the other most common bacteria involved. Incidents in which other bacteria, such as ''[[Salmonella]]'', ''[[Campylobacter]]'', ''[[Yersinia]]'', ''[[Aeromonas]]'', and ''[[Plesiomonas]] spp.'', have caused diarrhea are isolated and occur less often. [[Protozoa]]n [[parasite]]s such as ''[[Giardia lamblia]]'' and ''[[Cryptosporidium]]'' may also cause diarrhea. Some bacteria release [[toxin]]s which bind to the [[intestine]]s and cause diarrhea; others damage the intestines themselves by their direct presence. In infants and children, it is estimated that nearly 70% of diarrhea is due to [[virus]]es; for adult travelers, this drops to around 30%. Diarrhea caused by viral agents is usually self-limited.<ref name=SWOL-TD/> Pathogens implicated in travellers' diarrhea are:<ref name=SWOL-TD/> <table border="2" cellpadding="4" cellspacing="0" bgcolor="#B1CBE4"> <tr> <td width="50%">''E. coli'', enterotoxigenic</td> <td width="50%">20-75%</td> </tr> <tr> <td width="50%">''E. coli'', enteroaggregative</td> <td width="50%">0-20%</td> </tr> <tr> <td width="50%">''E. coli'', enteroinvasive</td> <td width="50%">0-6%</td> </tr> <tr> <td width="50%">''Shigella'' spp</td> <td width="50%">2-30%</td> </tr> <tr> <td width="50%">''Salmonella'' spp&nbsp;</td> <td width="50%">0-33%</td> </tr> <tr> <td width="50%">''[[Campylobacter jejuni]]''</td> <td width="50%">3-17%</td> </tr> <tr> <td width="50%">''[[Vibrio parahemolyticus]]''</td> <td width="50%">0-31%</td> </tr> <tr> <td width="50%">''[[Aeromonas hydrophila]]''</td> <td width="50%">0-30%</td> </tr> <tr> <td width="50%">''Giardia lamblia''</td> <td width="50%">0 to less than 20%</td> </tr> <tr> <td width="50%">''[[Entameba histolytica]]&nbsp;''</td> <td width="50%">0-5%</td> </tr> <tr> <td width="50%">''Cryptosporidium sp''</td> <td width="50%">0 to less than 20%</td> </tr> <tr> <td width="50%">[[Rotavirus]]</td> <td width="50%">0-36%</td> </tr> <tr> <td width="50%">[[Norovirus|Norwalk virus]]</td> <td width="50%">0-10%</td> </tr> </table> A sub-type of travelers' diarrhea aflicting hikers and campers, sometimes known as [[wilderness diarrhea]], may have a somewhat different frequency distribution of pathogens. ==Treatment== TD usually is a self-limited [[disease|disorder]] and often resolves without specific treatment; however, [[oral rehydration therapy]] is often beneficial to replace lost fluids and [[electrolytes]]. Clear liquids are routinely recommended for adults.<ref name=CDC_TD/> Water that is purified is best, along with oral rehydration salts to replenish lost [[electrolyte]]s. [[Carbonated water]] (soda), which has been left out so that the [[carbonation]] fizz is gone, is useful if nothing else is available.<ref name=SWOL-TD/> Travelers who develop three or more loose stools in a 24-hour period — especially if associated with [[nausea]], [[vomiting]], [[abdominal]] [[cramps]], [[fever]], or [[blood in stool]]s — should be treated by a doctor and may benefit from [[antimicrobial]] therapy.<ref name=CDC_TD/> [[Antibiotic]]s usually are given for 3–5 days,<ref name=CDC_TD/> but single dose [[azithromycin]] or [[levofloxacin]] have been used.<ref>{{cite journal|title=Azithromycin and loperamide are comparable to levofloxacin and loperamide for the treatment of traveler's diarrhea in United States military personnel in Turkey|author=Sanders JW, Frenck RW, Putnam SD, ''et al.''|journal=Clin Infect Dis|year=2007|volume=45|pages=294&ndash;301|url=http://www.journals.uchicago.edu/CID/journal/issues/v45n3/50169/brief/50169.abstract.html|doi=10.1086/519264|format={{dead link|date=June 2008}} &ndash; <sup>[http://scholar.google.co.uk/scholar?hl=en&lr=&q=intitle%3AAzithromycin+and+loperamide+are+comparable+to+levofloxacin+and+loperamide+for+the+treatment+of+traveler%27s+diarrhea+in+United+States+military+personnel+in+Turkey&as_publication=Clin+Infect+Dis&as_ylo=2007&as_yhi=2007&btnG=Search Scholar search]</sup>}}</ref> If diarrhea persists despite therapy, travelers should be evaluated and treated for possible parasitic infection.<ref name=CDC_TD/> There are different medications needed for bacterial [[dysentery]], for amoebic dysentery, for giardia and for worms. There is no medication for ''[[Cryptosporidium]]'', which can devastate people with [[AIDS]]. There can be 100% recovery from [[cholera]] when properly treated, which usually only means rehydration, usually through an [[intravenous drip|intravenous line]].<ref name=SWOL-TD/> ===Antimotility agents=== Antimotility agents ([[loperamide]], diphenoxylate, and paregoric) primarily reduce diarrhea by slowing transit time in the gut, and, thus, allows more time for absorption. Some persons{{Who|date=February 2008}} believe diarrhea is the body's defense mechanism to minimize contact time between gut pathogens and intestinal mucosa. In several studies{{Who|date=February 2008}}, antimotility agents have been useful in treating travelers' diarrhea by decreasing the duration of diarrhea. However, these agents should never be used by persons with fever or bloody diarrhea, because they can increase the severity of disease by delaying clearance of causative organisms. Because antimotility agents are now available [[over-the-counter drug|over the counter]], their injudicious use is of concern. Adverse complications ([[toxic megacolon]], [[sepsis]], and [[disseminated intravascular coagulation]]) have been reported{{Who|date=February 2008}} as a result of using these medications to treat diarrhea.<ref name=CDC_TD/> ==Prophylaxis== It is not recommended to take [[antimicrobial]] drugs to prevent TD, because they kill off beneficial bacteria and create resistant breeds of [[pathogen]]ic (disease-causing) bacteria. Among the primary measures to prevent gastrointestinal illness are keeping good hygiene, getting specific [[vaccine]]s and [[prophylaxis|prophylactic]] medications. Studies show a decrease in the incidence of TD with use of [[bismuth subsalicylate]] and with use of antimicrobial [[chemoprophylaxis]].<ref name=SWOL-TD/> [[Dukoral]] has been shown to prevent TD and cholera - one dose a few weeks before travel, and another about a week before travel. Traveler's diarrhea is fundamentally a [[sanitation]] failure, leading to bacterial contamination of [[drinking water]] and food. It is best prevented through proper water quality management systems as found in responsible [[hotel]]s and resorts. In the absence of that, the next best option for travelers is to take precautions to prevent the disease: * Maintain good hygiene and only use [[safe water]] for drinking and teeth brushing.<ref name=SWOL-TD/> * Use only safe [[bottled water]] and avoid ice. Reports of locals filling bottles with [[tap water]], then sealing them and then selling the bottled water as purified water have come out of several countries.<ref name=SWOL-TD/> *Drink safe beverages — these include bottled [[carbonated]] beverages, hot [[tea]] or [[coffee]], [[beer]], [[wine]], and water boiled or appropriately treated by the traveler.<ref name=SWOL-TD/> * Active intervention involves boiling water for three to five minutes (depending on elevation), filtering water with appropriate filters or using [[chlorine bleach]] (2 drops per [[litre]]) or tincture of [[iodine]] (5 drops per litre) in the water. The wide availability of safe bottled water makes these interventions usually unnecessary for all but the most remote destinations.<ref name=SWOL-TD/> * Avoid eating raw fruits and vegetables unless the traveler peels them.<ref name=CDC_TD /> * Recently an ultraviolet (UV) water purification device entered the market that allows people to quickly and conveniently treat small amounts of water, even in restaurant settings. The method of action is UV light bonding [[thymine]] rungs of the DNA molecule, destroying the organisms' ability to live or replicate. The major advantage (besides convenience) is that UV light also kills viruses when filtration does not. Many travelers are opting for this method because it adds no taste to the water, allows the drinking of cold water, and is extremely economical compared with the cost of buying bottled water. If handled properly, well-cooked and packaged foods are usually safe.<ref name=CDC_TD /> Eating raw or undercooked meat and seafood should be avoided. [[Pasteurization|Unpasteurized]] milk, dairy products, [[mayonnaise]] and pastry [[icing (food)|icing]] are associated with increased risk for TD, as are foods or drinking beverages purchased from street vendors or other establishments where unhygienic conditions are present.<ref name=SWOL-TD/> Several [[probiotics]] (''[[Saccharomyces boulardii]]'' and a mixture of ''[[Lactobacillus acidophilus]]'' and ''[[Bifidobacterium bifidum]]'') have significant efficacy. In a [[meta-analysis]] by McFarland (2005), no serious adverse reactions were reported in the 12 trials. Probiotics may offer a safe and effective method to prevent TD.<ref>{{cite journal | last = McFarland | first = Lynn | title = Meta-analysis of probiotics for the prevention of traveller’s diarrhoea | journal = Travel Medicine and Infectious Disease | volume = 5 | issue = 2 | pages = 97–105 | url = http://www.dtecta.co.uk/casestudies/McFarland_L._V._(2005)_Meta_analysis_of_probiotics_for_the_prevention_of_travellers_diarrhoea_Travla_DTECTA_Probiotics_www.dtecta.co.uk.pdf?cmd=Retrieve&db=PubMed&list_uids=8682428&dopt=Abstract | doi = 10.1016/j.tmaid.2005.10.003 | year = 2007}}</ref> According to a study published in June, 2008, in the Lancet, researchers found that patients given a travelers’ diarrhea vaccine (made by the Iomai Corporation) were significantly less likely to suffer from clinically significant diarrhea than those who received a placebo. The study, which followed 170 healthy travelers ages 18-64 to Mexico and Guatemala, found that of the 59 individuals who received the new vaccine, only three suffered from moderate or severe diarrhea, while roughly two dozen of the 111 who received a placebo suffered from moderate or severe diarrhea. Only one of the 59 volunteers in the vaccine group reported severe diarrhea, compared with 12 in the placebo group.<ref>[http://newswise.com/articles/view/541631/ Newswise: Researchers Discover Significant Efficacy of Travelers’ Diarrhea Vaccine] Retrieved on June 11, 2008.</ref> ==Colloquial names== There are a number of [[colloquialism]]s for travelers' diarrhea contracted in various localities, such as "Montezuma's revenge" for travelers' diarrhea contracted in [[Mexico]], "Delhi belly" in [[India]], or "Bali Belly" in [[Bali]]. A recent local term in [[Pattaya]], [[Thailand]], is "Thai-dal wave". ====Montezuma's revenge==== '''Montezuma's revenge''' (var. '''Moctezuma's revenge''') is the colloquial term for any cases of traveler's diarrhea contracted by tourists visiting [[Mexico]]. The name humorously refers to [[Montezuma II]] (1466-1520), the [[Tlatoani]] (ruler) of the [[Aztec]] civilization who was defeated by [[Hernándo Cortés]] the [[Spanish conquest|Spanish conquistador]]. It is estimated that 40% of foreign traveler [[vacation]]s in Mexico are disrupted by infection.<ref name="pmid831463">{{cite journal |author=Dupont HL, Haynes GA, Pickering LK, Tjoa W, Sullivan P, Olarte J |title=Diarrhea of travelers to Mexico. Relative susceptibility of United States and Latin American students attending a Mexican University |journal=Am. J. Epidemiol. |volume=105 |issue=1 |pages=37–41 |year=1977 |pmid=831463 |doi=}}</ref> Most cases are mild and resolve in a few days with no treatment. Severe or extended cases, however, may result in extensive fluid loss and/or dangerous [[electrolyte disturbance|electrolytic imbalance]] which pose a severe medical risk and may prove fatal if mismanaged. The oversight of a medical professional is advised. Not all water supplies in Mexico are contaminated and many hotels have water purification systems that eliminate risk. Certain resort destinations also have large-scale water purification systems which provide safe water city-wide. Roadside and popular food stalls specifically should be avoided. ==See also== * [[Gastroenteritis]] * [[Travel medicine]] * [[Wilderness diarrhea]] ==References== <references/> {{CDC}} [[Category:Gastroenterology]] [[Category:Foodborne illnesses]] [[Category:Water-borne diseases]] [[Category:Infectious diseases]] [[Category:Symptoms]] [[Category:Digestive disease symptoms]] [[Category:Tourism in Mexico]] [[de:Reisediarrhoe]] [[fr:Diarrhée du voyageur]] [[ja:旅行者下痢]] [[ru:Диарея путешественников]] [[no:Moctezumas hevn]] [[sv:Moctezumas hämnd]]