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Rothstein AP, Jesser KJ, Feistel DJ, Konstantinidis KT, Trueba G, Levy K. Population genomics of diarrheagenic Escherichia coli uncovers high connectivity between urban and rural communities in Ecuador. INFECTION, GENETICS AND EVOLUTION : JOURNAL OF MOLECULAR EPIDEMIOLOGY AND EVOLUTIONARY GENETICS IN INFECTIOUS DISEASES 2023; 113:105476. [PMID: 37392822 PMCID: PMC10599324 DOI: 10.1016/j.meegid.2023.105476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 05/11/2023] [Accepted: 06/28/2023] [Indexed: 07/03/2023]
Abstract
Human movement may be an important driver of transmission dynamics for enteric pathogens but has largely been underappreciated except for international 'travelers' diarrhea or cholera. Phylodynamic methods, which combine genomic and epidemiological data, are used to examine rates and dynamics of disease matching underlying evolutionary history and biogeographic distributions, but these methods often are not applied to enteric bacterial pathogens. We used phylodynamics to explore the phylogeographic and evolutionary patterns of diarrheagenic E. coli in northern Ecuador to investigate the role of human travel in the geographic distribution of strains across the country. Using whole genome sequences of diarrheagenic E. coli isolates, we built a core genome phylogeny, reconstructed discrete ancestral states across urban and rural sites, and estimated migration rates between E. coli populations. We found minimal structuring based on site locations, urban vs. rural locality, pathotype, or clinical status. Ancestral states of phylogenomic nodes and tips were inferred to have 51% urban ancestry and 49% rural ancestry. Lack of structuring by location or pathotype E. coli isolates imply highly connected communities and extensive sharing of genomic characteristics across isolates. Using an approximate structured coalescent model, we estimated rates of migration among circulating isolates were 6.7 times larger for urban towards rural populations compared to rural towards urban populations. This suggests increased inferred migration rates of diarrheagenic E. coli from urban populations towards rural populations. Our results indicate that investments in water and sanitation prevention in urban areas could limit the spread of enteric bacterial pathogens among rural populations.
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Affiliation(s)
- Andrew P. Rothstein
- Department of Environmental and Occupational Health Sciences, School of Public Health, University of Washington, Seattle, WA, USA
| | - Kelsey J. Jesser
- Department of Environmental and Occupational Health Sciences, School of Public Health, University of Washington, Seattle, WA, USA
| | - Dorian J. Feistel
- School of a Biological Sciences, Georgia Institute of Technology, Atlanta, GA, USA
| | - Konstantinos T. Konstantinidis
- School of Civil and Environmental Engineering, Georgia Institute of Technology, Atlanta, GA, USA
- School of a Biological Sciences, Georgia Institute of Technology, Atlanta, GA, USA
| | - Gabriel Trueba
- Instituto de Microbiología, Colegio de Ciencias Biológicas y Ambientales, Universidad San Francisco de Quito, Quito, Pichincha, Ecuador
| | - Karen Levy
- Department of Environmental and Occupational Health Sciences, School of Public Health, University of Washington, Seattle, WA, USA
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Yamakawa M, Tsuda T, Wada K, Nagata C, Suzuki E. Diarrhea and related personal characteristics among Japanese university students studying abroad in intermediate- and low-risk countries. PLoS One 2023; 18:e0279426. [PMID: 36827397 PMCID: PMC9956663 DOI: 10.1371/journal.pone.0279426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 12/06/2022] [Indexed: 02/26/2023] Open
Abstract
Despite an increasing number of students studying abroad worldwide, evidence about health risks while they are abroad is limited. Diarrhea is considered the most common travelers' illness, which would also apply to students studying abroad. We examined diarrhea and related personal characteristics among Japanese students studying abroad. Japanese university students who participated in short-term study abroad programs between summer 2016 and spring 2018 were targeted (n = 825, 6-38 travel days). Based on a 2-week-risk of diarrhea (passing three or more loose or liquid stools per day) among travelers by country, the destination was separated into intermediate- and low-risk countries. After this stratification, the associations between personal characteristics and diarrhea during the first two weeks of their stay were evaluated using logistic regression models. Among participants in intermediate-risk countries, teenagers, males and those with overseas travel experience were associated with an elevated risk of diarrhea; the odds ratios (95% confidence intervals) were 2.42 (1.08-5.43) for teenagers (vs. twenties), 1.93 (1.08-3.45) for males (vs. females) and 2.37 (1.29-4.33) for those with overseas experience (vs. none). Even restricting an outcome to diarrhea during the first week did not change the results substantially. The same tendency was not observed for those in the low-risk countries. Teenage students, males and those with overseas travel experience should be cautious about diarrhea while studying abroad, specifically in intermediate-risk countries.
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Affiliation(s)
- Michiyo Yamakawa
- Department of Epidemiology and Preventive Medicine, Graduate School of Medicine, Gifu University, Gifu, Japan
- Department of Epidemiology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
- * E-mail:
| | - Toshihide Tsuda
- Department of Human Ecology, Graduate School of Environmental and Life Science, Okayama University, Okayama, Japan
| | - Keiko Wada
- Department of Epidemiology and Preventive Medicine, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Chisato Nagata
- Department of Epidemiology and Preventive Medicine, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Etsuji Suzuki
- Department of Epidemiology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
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3
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Muzembo BA, Kitahara K, Ohno A, Okamoto K, Miyoshi SI. Colonization with extended-spectrum beta-lactamase-producing Escherichia coli and traveler's diarrhea attack rates among travelers to India: a systematic review and meta-analysis. Trop Dis Travel Med Vaccines 2022; 8:22. [PMID: 36180932 PMCID: PMC9525155 DOI: 10.1186/s40794-022-00179-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 08/14/2022] [Indexed: 11/07/2022] Open
Abstract
Background India is an attractive destination for travelers. Unfortunately, numerous reports exist on traveler’s diarrhea (TD) and fecal colonization with extended-spectrum beta-lactamase-producing Escherichia coli (ESBL-EC) among international travelers visiting India. Here, we systematically reviewed studies published on the acquisition of ESBL-EC and TD attack rates among international visitors to India. Methods Design: Systematic review and meta-analysis. A systematic search was performed using Google Scholar, PubMed, EMBASE, Web of Science, and gray literature from 2000 to December 2021, for studies containing data for ESBL-EC acquisition or TD experience related to a trip to India. Random effects models were used to compute the prevalence of ESBL-EC acquisition and TD attack. Results The literature search yielded a total of 5023 records. Of these, 31 met our inclusion criteria for systematic review and only 17 could be meta-analyzed (9 for TD, and 8 for ESBL-EC). The overall pooled attack rate of TD was 39% (95% confidence interval, CI: 25–53%). In studies where travelers' memory was used to diagnose TD, the pooled attack rate of TD was slightly higher (42%, 95% CI: 21–64%) compared to those where TD was objectively documented (33%, 95% CI: 17–49%). There were significant risks to be colonized with ESBL-EC among the travelers who experienced TD. The pooled rate of ESBL-EC colonization was 72% (CI: 67–78%). Most ESBL-EC produced CTX-M-15 enzyme. Furthermore, most of the travelers who acquired ESBL-EC were from highly industrialized countries recruited from travel clinics: Canada (n = 80), Germany (n = 69), Netherlands (n = 20), Sweden (n = 18), Japan (n = 10), Finland (n = 8), USA (n = 7), Spain (n = 5), and Denmark (n = 3). Conclusions TD pooled attack rate and ESBL-EC acquisition among international travelers visiting India were high in this study. However, we cannot make generalizations based upon this TD pooled attack rate for the current situation, due to a lack of current data. Our study highlights that travelers should be advised on TD to ensure that they do not disregard the risk of contracting TD and be better prepared as a result. It also illustrates the importance of international travel in acquiring antibiotic-resistant Escherichia coli. Supplementary Information The online version contains supplementary material available at 10.1186/s40794-022-00179-1.
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Affiliation(s)
- Basilua Andre Muzembo
- grid.261356.50000 0001 1302 4472Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, 1-1-1 Tsushimanaka, Kita Ward, Okayama, 700-8530 Japan
| | - Kei Kitahara
- grid.261356.50000 0001 1302 4472Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, 1-1-1 Tsushimanaka, Kita Ward, Okayama, 700-8530 Japan ,Collaborative Research Centre of Okayama University for Infectious Diseases in India, Kolkata 700010, India
| | - Ayumu Ohno
- grid.261356.50000 0001 1302 4472Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, 1-1-1 Tsushimanaka, Kita Ward, Okayama, 700-8530 Japan ,Collaborative Research Centre of Okayama University for Infectious Diseases in India, Kolkata 700010, India
| | - Keinosuke Okamoto
- grid.261356.50000 0001 1302 4472Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, 1-1-1 Tsushimanaka, Kita Ward, Okayama, 700-8530 Japan
| | - Shin-Ichi Miyoshi
- grid.261356.50000 0001 1302 4472Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, 1-1-1 Tsushimanaka, Kita Ward, Okayama, 700-8530 Japan
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Lόpez-Vélez R, Lebens M, Bundy L, Barriga J, Steffen R. Bacterial travellers' diarrhoea: A narrative review of literature published over the past 10 years. Travel Med Infect Dis 2022; 47:102293. [PMID: 35247581 DOI: 10.1016/j.tmaid.2022.102293] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 02/24/2022] [Accepted: 02/28/2022] [Indexed: 02/04/2023]
Abstract
Travellers' diarrhoea (TD) is the most frequent illness experienced by international travellers to lower-income countries with bacterial agents considered to account for 80-90% of cases. In this review, we summarise evidence published on bacterial TD over the past 10 years, focusing on the epidemiology and aetiology of TD. Diarrhoeagenic Escherichia coli (DEC) continue to be the most commonly implicated bacteria in TD, although Enteropathogenic E. coli (EPEC) and Enteroaggregative E. coli (EAEC) now appear to be predominant where Enterotoxigenic E. coli (ETEC) was previously considered most prevalent globally. Where fluroquinolone resistance had primarily been documented for Campylobacter in Southeast Asia, widespread resistance has been observed in most regions of the world for multiple enteropathogens, including Shigella, Salmonella, ETEC and EAEC. Implementation of novel molecular methods for pathogen detection has led to identification of bacterial pathogens, including Clostridium difficile (with and without the use of prior antibiotics), Arcobacter species and Bacteroides fragilis, as aetiological agents in TD. The widespread resistance to first-line antibiotics in multiple bacterial enteropathogens warrants continued surveillance and re-evaluation of current treatment practices. Further investigations are required to determine the prevalence and geographical distribution of bacterial enteropathogens that have been more recently implicated in TD.
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Affiliation(s)
- Rogelio Lόpez-Vélez
- National Referral Unit for Tropical Diseases, Infectious Diseases Department, Ramón y Cajal University Hospital, IRYCIS, 28034, Madrid, Spain.
| | - Michael Lebens
- Department of Microbiology and Immunology, University of Gothenburg, Box 435, SE-40530, Gothenburg, Sweden.
| | - Leah Bundy
- Elements Communications Ltd, Westerham, TN16 1RQ, UK.
| | - Juan Barriga
- Department of Medical Affairs Europe, Emergent BioSolutions, 1455, Madrid, Spain.
| | - Robert Steffen
- Epidemiology, Biostatistics and Prevention Institute, World Health Organization Collaborating Centre for Travelers' Health, University of Zurich, Hirschengraben 84, CH-8001, Zurich, Switzerland; Epidemiology, Human Genetics and Environmental Sciences Division, University of Texas School of Public Health, Houston, TX 77030, Texas, USA.
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5
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Turunen KA, Kantele A. Revisiting travellers' diarrhoea justifying antibiotic treatment: prospective study. J Travel Med 2021; 28:6054204. [PMID: 33372204 DOI: 10.1093/jtm/taaa237] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 11/03/2020] [Accepted: 11/25/2020] [Indexed: 11/14/2022]
Abstract
BACKGROUND As antimicrobials increase the risk of acquiring multidrug-resistant (MDR) bacteria, unnecessary antibiotics should be avoided for travellers' diarrhoea (TD). Antibiotics are recommended in TD accompanied by fever or incapacitation (TD justifying use of antibiotics, TDjuAB). Seeking tools for reducing antibiotic use, we explored factors predisposing to TDjuAB and scrutinized antibiotic treatment among those with TDjuAB [TDjuAB(+) subgroup] and those with diarrhoea not justifying antibiotics [TDjuAB(-) subgroup]. METHODS We conducted a study among 370 prospectively recruited visitors to the tropics. Stool samples and questionnaires were collected before and after travel. Enteric pathogens were analysed by qPCR for enteropathogenic (EPEC), enteroaggregative (EAEC), enterotoxigenic (ETEC), enterohaemorrhagic (EHEC) and enteroinvasive (EIEC) E. coli/Shigella, Campylobacter, Salmonella, Yersinia and Vibrio cholerae, and for ETEC's toxins LT (heat-labile), STh (human heat-stable) and STp (porcine heat-stable). TD was defined by the WHO criteria and TDjuAB as diarrhoea accompanied by fever, and/or disrupting or preventing daily activities. Multivariable analysis was applied-separately for travel-related factors and pathogens-to identify risk factors for TDjuAB(+). RESULTS Among the 370 travellers, TD was contracted by 253 (68%), categorized as TDjuAB(+) in 93/253 (37%) and TDjuAB(-) in 160/253 (63%) of the cases. Antibiotics were used for TD by 41% in TDjuAB(+) and by 7% in the TDjuAB(-) group. Relative risk ratios (RRR)s are presented for both the TDjuAB(+) and the TDjuAB(-) groups. TDjuAB(+) was associated with long travel duration and young age. Among the 298 subjects not having taken antibiotics, increased RRRs were found e.g. for findings of Campylobacter coli/jejuni and ETEC's STh toxin. CONCLUSIONS The first to analyse risk factors for TDjuAB, our study presents RRRs for demographic and behavioural factors and for various pathogens. Only less than half of those in the TDjuAB(+) group took antibiotics, which demonstrates that most cases meeting the current criteria recover without antimicrobial treatment.
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Affiliation(s)
- K A Turunen
- Human Microbiome Research Program, Faculty of Medicine, University of Helsinki, Haartmaninkatu 3, FI-00014 Helsinki, Finland
- Inflammation Center, Infectious Diseases, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 3, FI-00029 HUS, Helsinki, Finland
| | - A Kantele
- Human Microbiome Research Program, Faculty of Medicine, University of Helsinki, Haartmaninkatu 3, FI-00014 Helsinki, Finland
- Inflammation Center, Infectious Diseases, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 3, FI-00029 HUS, Helsinki, Finland
- Meilahti Vaccination Research Center, MeVac, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 8, FI-00029 HUS, Helsinki, Finland
- Travel Clinic, Aava Medical Center, Annankatu 32, FI-00100 Helsinki, Finland
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Kuenzli E, Jaeger VK, DeCrom S, Sydow V, Muigg V, Frei R, Egli A, Fehr J, Hatz C. Impact of alcohol-based hand-gel sanitizer and hand hygiene advice on travellers' diarrhoea and colonization with extended-spectrum beta-lactamase-producing Enterobacteriaceae: A randomised, controlled trial. Travel Med Infect Dis 2019; 32:101475. [PMID: 31499238 DOI: 10.1016/j.tmaid.2019.101475] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 09/04/2019] [Accepted: 09/05/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Travellers' diarrhoea (TD) is the most common health problem in international travellers. Besides being bothersome for the individual and a considerable economic burden for the public, TD is also known to be associated with becoming colonized with extended-spectrum β-lactamase (ESBL)-producing Enterobacteriacea. Despite the high frequency of TD cases, easy and effective preventive measures are lacking. The aim of this study was to assess the impact of using hand gel sanitizer on the incidence of TD and colonization with ESBL-producing Enterobacteriaceae. METHOD A multicentre randomized intervention trial studying the effect of hand gel sanitizer on the incidence of TD and colonization with ESBL-producing Enterobacteriaceae in travellers to Southeast Asia was performed. RESULTS The intention to treat analysis showed a reduction in the incidence of WHO TD in the intervention group (OR 0.54 (95% CI 0.30-0.97), p = 0.04). No effect was seen or the incidence of becoming colonized with ESBL-producing Enterobacteriaceae. CONCLUSION Using hand gel sanitizer might have a protective effect on the occurrence of TD. Based on the current data, education on the proper use appears to play a key role for its effectiveness.
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Affiliation(s)
- Esther Kuenzli
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland; Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland.
| | - Veronika K Jaeger
- Department of Rheumatology, University Hospital Basel, Basel, Switzerland; Institute for Epidemiology and Social Medicine, University of Münster, Germany
| | - Susan DeCrom
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Véronique Sydow
- Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Veronika Muigg
- Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Reno Frei
- Infectious Diseases & Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Adrian Egli
- Clinical Bacteriology and Mycology, University Hospital Basel, Basel, Switzerland; Applied Microbiology Research, Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Jan Fehr
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland; Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Christoph Hatz
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland; Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland; Infectious Diseases and Hospital Hygiene, Cantonal Hospital, St. Gallen, Switzerland
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Jung KS, Jang YM, Hwang JH, Park GJ, Son TJ. Risk of Water and Food-Borne Communicable Diseases in Travelers Entering Korea. Osong Public Health Res Perspect 2019; 10:215-220. [PMID: 31497492 PMCID: PMC6711720 DOI: 10.24171/j.phrp.2019.10.4.03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Objectives It was supposed to analyze status and affecting factors in water and food-borne communicable disease by screening entrants with diarrhea symptom at the point of entry in Korea. Methods Symptomatic travelers with water and food-borne communicable diseases who entered Korea were diagnosed by a health declaration and detection of causative agents in water and food using laboratory tests. Among those entered in 2017, the affecting factors in the incidence of communicable diseases among those who had diarrhea at the entry into Korea, were analyzed, with frequency and chi-square test. Results The number of travel entrants with gastrointestinal communicable diseases increased by 40.19% from 2013 to 2017. The percentage of causative agents of water and food-borne communicable diseases was the highest at 69.2% from July to September. The rate of detection of causative agents of communicable disease pathogens in travelers from Southeast Asia entering Korea was 70.2%, which was higher than people arriving from East Asia and Central Asia (57.5%; p < 0.001). Conclusion The positive ratio of causative agents of water and food-borne communicable diseases was high among travelers that had entered Korea from July to September, with a high number among entrants from Southeast Asia. Based on the positive detection of causative agents, the entry period and countries visited were statistically significant affecting factors (p < 0.001).
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Affiliation(s)
- Kyung Sook Jung
- Division of Quarantine Management, Korea Centers for Disease Control & Prevention, Cheongju, Korea
| | - Yu Mi Jang
- Division of Quarantine Management, Korea Centers for Disease Control & Prevention, Cheongju, Korea
| | - Ji Hye Hwang
- Division of Quarantine Management, Korea Centers for Disease Control & Prevention, Cheongju, Korea
| | - Gi Jun Park
- Division of Quarantine Management, Korea Centers for Disease Control & Prevention, Cheongju, Korea
| | - Tae Jong Son
- Division of Quarantine Management, Korea Centers for Disease Control & Prevention, Cheongju, Korea
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8
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Steffen R, DuPont HL. Rifamycin SV-MMX® as the recommended self-treatment for moderate to severe travellers' diarrhoea: reply. J Travel Med 2019; 26:5372335. [PMID: 30848824 PMCID: PMC6509471 DOI: 10.1093/jtm/taz014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 02/21/2019] [Accepted: 03/18/2019] [Indexed: 11/13/2022]
Affiliation(s)
- Robert Steffen
- University of Zurich, Epidemiology, Biostatistics and Prevention Institute, Hirschengraben 84, Zurich, CH, Switzerland
| | - Herbert L DuPont
- The University of Texas-Houston School of Public Health and Medical School, Center for Infectious Diseases, 6720 Bertner MC1-164, Houston, TX, USA
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Florens MV, Van Wanrooy S, Dooley J, Aguilera-Lizarraga J, Vanbrabant W, Wouters MM, Van Oudenhove L, Peetermans WE, Liston A, Boeckxstaens GE. Prospective study evaluating immune-mediated mechanisms and predisposing factors underlying persistent postinfectious abdominal complaints. Neurogastroenterol Motil 2019; 31:e13542. [PMID: 30657233 DOI: 10.1111/nmo.13542] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 11/20/2018] [Accepted: 12/10/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND The role of persistent immune activation in postinfectious irritable bowel syndrome (PI-IBS) remains controversial. Here, we prospectively studied healthy subjects traveling to destinations with a high-risk to develop infectious gastroenteritis (IGE) in order to identify immune-mediated mechanisms and risk factors of PI-IBS. METHODS One hundred and one travelers were asked to complete questionnaires on psychological profile and gastrointestinal (GI) symptoms before travel, 2 weeks, 6 months and 1 year after travel. At each visit, blood was collected for PBMC isolation and rectal biopsies were taken. PI-IBS was diagnosed using the Rome III criteria and subjects with persistent postinfectious abdominal complaints (PI-AC) were identified using 3 GSRS symptoms (ie, loose stools, urgency and abdominal pain). RESULTS Forty-seven of the 101 subjects reported IGE during travel. After 1 year, two subjects were diagnosed with PI-IBS and eight subjects were presented with PI-AC versus two subjects with IBS and two with abdominal complaints in the non-infected group. PBMC analysis showed no differences in T and B cell populations in subjects with PI-AC vs healthy. Additionally, no differences in gene expression were observed in the early postinfectious phase or after 1 year. Regression analysis identified looser stools, higher anxiety and somatization before infection and several postinfectious GI symptoms as risk factors for PI-AC. CONCLUSIONS The incidence of PI-IBS is low following travelers' diarrhea and there is need for larger studies investigating the role of immune activation in PI-IBS. Psychological factors before infection and the severity of symptoms shortly after infection are risk factors for the persistence of PI-AC.
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Affiliation(s)
- Morgane V Florens
- Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Sander Van Wanrooy
- Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - James Dooley
- Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium.,Autoimmune Genetics Laboratory, VIB, Leuven, Belgium
| | | | - Winde Vanbrabant
- Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Mira M Wouters
- Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Lukas Van Oudenhove
- Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Willy E Peetermans
- Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium.,Laboratory for Clinical Infectious and Inflammatory Disorders, KU Leuven, Leuven, Belgium
| | - Adrian Liston
- Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium.,Autoimmune Genetics Laboratory, VIB, Leuven, Belgium
| | - Guy E Boeckxstaens
- Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
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Epidemiology and etiology of diarrhea in UK military personnel serving on the United Nations Mission in South Sudan in 2017: A prospective cohort study. Travel Med Infect Dis 2019; 28:34-40. [DOI: 10.1016/j.tmaid.2018.12.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 12/10/2018] [Accepted: 12/11/2018] [Indexed: 02/07/2023]
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Olson S, Hall A, Riddle MS, Porter CK. Travelers' diarrhea: update on the incidence, etiology and risk in military and similar populations - 1990-2005 versus 2005-2015, does a decade make a difference? Trop Dis Travel Med Vaccines 2019; 5:1. [PMID: 30675367 PMCID: PMC6332902 DOI: 10.1186/s40794-018-0077-1] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 12/20/2018] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Travelers' diarrhea remains a prevalent illness impacting individuals visiting developing countries, however most studies have focused on this disease in the context of short term travel. This study aims to determine the regional estimates of travelers' diarrhea incidence, pathogen-specific prevalence, and describe the morbidity associated with diarrheal disease among deployed military personnel and similar long term travelers. METHODS We updated a prior systematic review to include publications between January 1990 and June 2015. Point estimates and confidence intervals of travelers' diarrhea and pathogen prevalence were combined in a random effects model and assessed for heterogeneity. Eighty-two studies were included in the analysis, including 29 new studies since the prior systematic review. RESULTS Military personnel were evaluated in 69% of studies and non-military long term travelers in 34%, with a median duration of travel of 4.9 months, and travel predominantly to the Middle East, Southeast Asia, and Latin America and the Caribbean. Sixty-two percent of tested cases were due to bacterial pathogens, with enterotoxigenic E. coli (ETEC), enteroaggregative E. coli (EAEC), and Campylobacter predominating, and significant regional variability. The incidence of TD from studies with longitudinal data was 36.3 cases per 100 person-months, with the highest rates in Southeast Asia, Latin America and the Caribbean, and the Middle East, with higher estimates from those studies using self-reporting of disease. Morbidity remained significant, with 21% being incapacitated or placed sick in quarters (SIQ) by their illness, 15% requiring intravenous fluids, and 3% requiring hospitalization. CONCLUSIONS In comparison to results from the prior systematic review, there were no significant differences in incidence, pathogen prevalence, or morbidity; however there was a trend toward improved care-seeking by sick individuals.
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Affiliation(s)
- Scott Olson
- Enteric Disease Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910 USA
| | - Alexis Hall
- Enteric Disease Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910 USA
| | - Mark S. Riddle
- Uniformed Services University of the Health Sciences, Bethesda, MD USA
| | - Chad K. Porter
- Enteric Disease Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910 USA
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12
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Traveler's Diarrhea Recommendations for Solid Organ Transplant Recipients and Donors. Transplantation 2018; 102:S35-S41. [PMID: 29381576 DOI: 10.1097/tp.0000000000002015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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13
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McFarland LV, Goh S. Are probiotics and prebiotics effective in the prevention of travellers' diarrhea: A systematic review and meta-analysis. Travel Med Infect Dis 2018; 27:11-19. [PMID: 30278238 DOI: 10.1016/j.tmaid.2018.09.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 09/13/2018] [Accepted: 09/18/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Travellers' diarrhea (TD) impacts annually over 20 million tourists, business travellers and military troops on a worldwide basis. Reliance on antibiotic prophylaxis and educational programs has not lead to a significant reduction in TD rates. Previous reviews of probiotics for TD have not accounted for the strain-specificity of probiotic efficacy nor have investigated prebiotics for the prevention of TD. METHODS Standard literature databases were searched from 1977 to June 2018 unrestricted by language. Inclusion criteria included: Probiotic, probiotic or symbiotic interventions, randomized, controlled clinical trials (RCTs) and ≥2 RCTs with the same probiotic strain or mixture. RESULTS Of 158 screened articles, 12 RCT were included in the systematic review and 6 RCTs (with nine treatment different arms) were included in the meta-analysis. Saccharomyces boulardii CNCM I-745 showed a significant reduction in TD incidence (RR = 0.79, 95% C.I. 0.72-0.87, p < 0.001), while L. rhamnosus GG showed a trend (p = 0.08) and L. acidophilus showed no significant (p = 0.16) reduction of TD. CONCLUSIONS The number of trials using probiotics or prebiotics for the prevention of TD continues to be limited in number. Only one of three probiotics showed significant efficacy for the prevention of TD. More research is needed for other probiotics strains and prebiotics to determine if they could also prevent TD.
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Affiliation(s)
- Lynne V McFarland
- Department of Medicinal Chemistry, School of Pharmacy, University of Washington, Seattle, WA, 98195, USA.
| | - Shan Goh
- Department of Biological and Environmental Sciences, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, AL10 9AB, United Kingdom.
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14
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Yamakawa M, Sasai M, Kasai Y, Tsuda T, Suzuki E. Diarrhea and related factors among passengers on world cruises departing from Japan. Travel Med Infect Dis 2018; 23:56-63. [DOI: 10.1016/j.tmaid.2018.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 12/08/2017] [Accepted: 01/17/2018] [Indexed: 11/28/2022]
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15
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Hitch G, Fleming N. Antibiotic resistance in travellers' diarrhoeal disease, an external perspective. J Travel Med 2018; 25:S27-S37. [PMID: 29718437 DOI: 10.1093/jtm/tay014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 02/08/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND There are many recommendations on the use of antibiotics for prophylaxis and treatment of travellers' diarrhoea (TD). As pharmacists with a special interest in antimicrobial stewardship, we examine and offer our perspective on advice that is recommended to travellers in terms of prevention, treatment and management of TD with a focus on antibiotic use and resistance. METHODS Publications on TD were identified through PubMed, Google Scholar and Cochrane Library databases searches using search terms 'travellers diarrhoea', 'travellers diarrhoea', 'travellers' diarrhoea' 'guidelines', 'expert opinion', 'expert reviews', 'South Asia' and 'South East Asia' (S and SE Asia), 'antibiotics', 'resistance genes', 'travel advice', 'pharmacists', 'guidelines', 'prevention' and 'treatment'. References of articles were also screened for additional relevant studies. RESULTS Whilst most guidelines and expert reviews were in agreement with the restricted use of antibiotics unless there was a clinical need, the literature review identified gaps in research into behaviours of travellers regarding non-compliance with the pre-travel advice provided and the need for in depth training and education for all healthcare professionals in providing 'tailored' advice for travellers going to high-risk destinations. CONCLUSIONS Travellers should be made aware of the problems of antimicrobial resistance in their destination and home countries and offered alternative forms of prophylaxis for TD. Strategies for prevention of TD, other than the use of antibiotics, also need to be emphasized. All healthcare professionals involved in giving advice about TD should be familiar with the epidemiology of the condition as this will inform responsible behaviours, risk assessment and management strategies in different geographical areas.
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Affiliation(s)
- Geeta Hitch
- Department of Life Sciences/Pharmacy, JMS Building, University of Sussex, Falmer, Brighton BN1 9RH, UK
| | - Naomi Fleming
- Department of Pharmacy, Kettering General Hospital, Rothwell Road, Kettering, Northamptonshire NN16 8UZ, UK
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16
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Abstract
Context: Because sports participation at all levels often requires international travel, coaches, athletic trainers, and team physicians must effectively protect athletes from gastrointestinal infections. Traveler’s diarrhea is the most common travel-related illness and can significantly interfere with training and performance. Evidence Acquisition: A review of relevant publications was completed using PubMed and Google Scholar. Study Design: Clinical review. Level of Evidence: Level 5 Results: Enterotoxigenic and enteroaggregative Escherichia coli are the most common bacterial causes of traveler’s diarrhea. Traveler’s diarrhea generally occurs within 4 days of arrival, and symptoms tend to resolve within 5 days of onset. There are several prophylactic agents that physicians can recommend to athletes, including antibiotics, bismuth subsalicylate, and probiotics; however, each has its own unique limitations. Decision-making should be based on the athlete’s destination, length of stay, and intent of travel. Conclusion: Prophylaxis with antibiotics is highly effective; however, physicians should be hesitant to prescribe medication due to the side effects and risks for creating antibiotic-resistant bacterial strains. Antibiotics may be indicated for high-risk groups, such as those with a baseline disease or travelers who have little flexible time. Since most cases of traveler’s diarrhea are caused by food and/or water contamination, all athletes should be educated on the appropriate food and water consumption safety measures prior to travel.
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Affiliation(s)
- Akash R. Patel
- Children’s Orthopaedic Center Sports Medicine and Concussion Program, Children’s Hospital Los Angeles, Los Angeles, California
| | - Daniel Oheb
- Children’s Orthopaedic Center Sports Medicine and Concussion Program, Children’s Hospital Los Angeles, Los Angeles, California
| | - Tracy L. Zaslow
- Children’s Orthopaedic Center Sports Medicine and Concussion Program, Children’s Hospital Los Angeles, Los Angeles, California
- Keck School of Medicine, University of Southern California, Los Angeles, California
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17
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Andreeva IV, Stetsiouk O.U. OU. Current approaches to prophylaxis and treatment of travelers’ diarrhea. CLINICAL MICROBIOLOGY AND ANTIMICROBIAL CHEMOTHERAPY 2018. [DOI: 10.36488/cmac.2018.3.172-180] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Travelers’ diarrhea is the most common infectious disease in this subpopulation and usually develops within the first week of travel. This review presents summarized data on epidemiology and etiology of travelers’ diarrhea. Nonspecific precautions and medical treatments (antimicrobials, probiotics) to prevent this infection are described in detail. Current approaches to the treatment of travelers’ diarrhea (oral rehydration, probiotics, antidiarrheals, antimicrobials) in adults and children depending on disease severity are also considered.
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Affiliation(s)
- Irina V. Andreeva
- Institute of Antimicrobial Chemotherapy, Smolensk State Medical University
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18
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Kuenzli E, Juergensen D, Kling K, Jaeger VK, DeCrom S, Steffen R, Widmer AF, Battegay M, Hatz C, Neumayr A. Previous exposure in a high-risk area for travellers' diarrhoea within the past year is associated with a significant protective effect for travellers' diarrhoea: a prospective observational cohort study in travellers to South Asia. J Travel Med 2017; 24:4085919. [PMID: 28931148 DOI: 10.1093/jtm/tax056] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/30/2017] [Indexed: 01/27/2023]
Abstract
BACKGROUND Travellers' diarrhoea is the most common health problem in travellers. Depending on the region visited, up to 40% of travellers develop diarrhoea during a 2-week trip. The aim of this study was to assess risk factors for TD among travellers to the Indian subcontinent. METHODS An observational prospective multicentre cohort study investigated travellers to the Indian subcontinent. Participants completed questionnaires assessing the incidence of travellers' diarrhoea and identifying potential risk factors. Covariates were assessed univariately, followed by a multivariate regression. RESULTS Two-hundred and twenty-six travellers were enrolled into the study, 178 filled in both pre- and post-travel questionnaires. Overall, the attack rate of travellers' diarrhoea was 38.2%. Travel destination is a key risk factor for the occurrence of TD. Travelling to India or Nepal vs Bhutan is associated with an increased risk for TD (OR 6.68 and 6.62, respectively). A length of stay of more than 3 weeks compared to less than 2 weeks is also associated with a significantly increased risk (OR 5.45). Having stayed in a high-risk area for travellers' diarrhoea within the past year before the current trip is associated with a significantly decreased risk (OR 0.19). No association was found between consumption of high risk food (i.e. tap water, ice cream, raw meat and hamburgers) and travellers' diarrhoea. CONCLUSION Travellers' diarrhoea is a frequent problem in travellers to the Indian subcontinent. Previous exposure in a high-risk area for travellers' diarrhoea within the past year appears to have a significant protective effect. Furthermore, an association between the occurrence of travellers' diarrhoea and travel destination and length of stay, respectively, was observed. Consumption of risk food did not confer a TD risk in our study.
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Affiliation(s)
- Esther Kuenzli
- Swiss Tropical and Public Health Institute Basel, University of Basel, Socinstrasse 57, Basel, Switzerland.,Epidemiology, Biostatistics and Prevention Institute, University of Zürich, Hirschengraben 84, Zürich, Switzerland
| | - David Juergensen
- Epidemiology, Biostatistics and Prevention Institute, University of Zürich, Hirschengraben 84, Zürich, Switzerland
| | - Kerstin Kling
- Swiss Tropical and Public Health Institute Basel, University of Basel, Socinstrasse 57, Basel, Switzerland
| | - Veronika K Jaeger
- Department of Rheumatology, Basel University Hospital, Petersgraben 4, Basel, Switzerland
| | - Susan DeCrom
- Epidemiology, Biostatistics and Prevention Institute, University of Zürich, Hirschengraben 84, Zürich, Switzerland
| | - Robert Steffen
- Epidemiology, Biostatistics and Prevention Institute, University of Zürich, Hirschengraben 84, Zürich, Switzerland
| | - Andreas F Widmer
- Division for Infectious Diseases and Hospital Epidemiology, Basel University Hospital, Petersgraben 4, Basel, Switzerland
| | - Manuel Battegay
- Division for Infectious Diseases and Hospital Epidemiology, Basel University Hospital, Petersgraben 4, Basel, Switzerland
| | - Christoph Hatz
- Swiss Tropical and Public Health Institute Basel, University of Basel, Socinstrasse 57, Basel, Switzerland.,Epidemiology, Biostatistics and Prevention Institute, University of Zürich, Hirschengraben 84, Zürich, Switzerland
| | - Andreas Neumayr
- Swiss Tropical and Public Health Institute Basel, University of Basel, Socinstrasse 57, Basel, Switzerland
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19
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Muehlenbein MP. Primates on display: Potential disease consequences beyond bushmeat. AMERICAN JOURNAL OF PHYSICAL ANTHROPOLOGY 2017; 162 Suppl 63:32-43. [PMID: 28105720 DOI: 10.1002/ajpa.23145] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 11/17/2016] [Accepted: 11/18/2016] [Indexed: 11/11/2022]
Abstract
Human interactions with nonhuman primates vary tremendously, from daily cultural engagements and food commodities, to pet ownership and tourist encounters. These interactions provide opportunities for the exchange of pathogenic organisms (both zoonoses and anthroponoses). As exposures are not limited to areas where bushmeat usage continues to be a major problem, we must work to understand better our motivations for engaging in activities like owning primates as pets and having direct physical contact with wild primates within the context of nature-based tourism. These topics, and the theoretical potential for pathogen transmission, are reviewed in the present manuscript. This is followed by a case study utilizing 3845 survey responses collected from four international locations known for primate-based tourism, with results indicating that while a majority of people understand that they can give/get diseases to/from wild primates, a surprising percentage would still touch or feed these animals if given the opportunity. Many people still choose to touch and/or own primates, as their drive to bond with animals outweighs some basic health behaviors. Desires to tame, control, or otherwise establish emotional connections with other species, combined with the central role of touch for exploring our environment, necessitate the development of better communication and educational campaigns to minimize risks of emerging infectious diseases.
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20
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Stoney RJ, Han PV, Barnett ED, Wilson ME, Jentes ES, Benoit CM, MacLeod WB, Hamer DH, Chen LH. Travelers' Diarrhea and Other Gastrointestinal Symptoms Among Boston-Area International Travelers. Am J Trop Med Hyg 2017; 96:1388-1393. [PMID: 28719282 PMCID: PMC5462577 DOI: 10.4269/ajtmh.16-0447] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 02/11/2017] [Indexed: 11/07/2022] Open
Abstract
AbstractThis prospective cohort study describes travelers' diarrhea (TD) and non-TD gastrointestinal (GI) symptoms among international travelers from the Boston area, the association of TD with traveler characteristics and dietary practices, use of prescribed antidiarrheal medications, and the impact of TD and non-TD GI symptoms on planned activities during and after travel. We included adults who received a pre-travel consultation at three Boston-area travel clinics and who completed a three-part survey: pre-travel, during travel, and post-travel (2-4 weeks after return). TD was defined as self-reported diarrhea with or without nausea/vomiting, abdominal pain, or fever. Demographic and travel characteristics were evaluated by χ2 test for categorical and Wilcoxon rank-sum test for continuous variables. Analysis of dietary practices used logistic generalized estimating equation models or logistic regression models. Of 628 travelers, 208 (33%) experienced TD and 45 (7%) experienced non-TD GI symptoms. Of 208 with TD, 128 (64%), 71 (36%), and 123 (62%) were prescribed ciprofloxacin, azithromycin, and/or loperamide before travel, respectively. Thirty-nine (36%) of 108 took ciprofloxacin, 20 (38%) of 55 took azithromycin, and 28 (28%) of 99 took loperamide during travel. Of 172 with TD during travel, 24% stopped planned activities, and 2% were hospitalized. Of 31 with non-TD GI symptoms during travel, six (13%) stopped planned activities. International travelers continue to experience diarrhea and other GI symptoms, resulting in disruption of planned activities and healthcare visits for some. Although these illnesses resulted in interruption of travel plans, a relatively small proportion took prescribed antibiotics.
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Affiliation(s)
- Rhett J. Stoney
- Division of Global Migration and Quarantine, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Pauline V. Han
- Division of Global Migration and Quarantine, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Elizabeth D. Barnett
- Maxwell Finland Laboratory for Infectious Diseases, Boston Medical Center, Boston, Massachusetts
| | - Mary E. Wilson
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Emily S. Jentes
- Division of Global Migration and Quarantine, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Christine M. Benoit
- Maxwell Finland Laboratory for Infectious Diseases, Boston Medical Center, Boston, Massachusetts
| | - William B. MacLeod
- Center for Global Health and Development, Boston University School of Public Health (BUSPH), Boston, Massachusetts
- Department of Global Health, BUSPH, Boston, Massachusetts
| | - Davidson H. Hamer
- Center for Global Health and Development, Boston University School of Public Health (BUSPH), Boston, Massachusetts
- Department of Global Health, BUSPH, Boston, Massachusetts
- Section of Infectious Diseases, Boston University School of Medicine, Boston, Massachusetts
| | - Lin H. Chen
- Division of Infectious Diseases and Travel Medicine, Mount Auburn Hospital, Cambridge, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
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21
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Sheen PAJ, Zahid MSB, Fagbemi A, Fullwood C, Whitehead K. 'Holiday sickness'-reported exploratory outcome of over 500 United Kingdom holidaymakers with travellers' diarrhoea. J Travel Med 2017; 24:taw077. [PMID: 28077608 DOI: 10.1093/jtm/taw077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Indexed: 11/14/2022]
Abstract
AIMS To ascertain any predictors of potential food poisoning pathogens and development of post-infective irritable bowel syndrome (IBS) in UK travellers. An analysis was undertaken on prospectively collected data on 527 patients reporting symptoms of suspected food poisoning between June 2012 and June 2015. MAIN OUTCOME MEASURES Positive stool sample indicative of food poisoning pathogens and diagnosis of post-infective IBS. RESULTS Data on 527 patients were examined. The large majority of patients did not provide a stool sample on return from holiday (n = 430, 81.6%) as few visited a Doctor locally or in the UK. Only 18 patients (18.6%, 95% confidence interval [CI] 11.4-27.7) who provided a stool sample were positive for microbiological food poisoning pathogens. Univariate analysis indicated a significant relationship between a positive stool sample and whether the individual sought any medical assistance at the resort (odds ratio [OR] 0.24, 95% CI 0.08-0.70) and whether they took any treatment (including self-medicated), (OR 0.21, 95% CI 0.06-0.67). Of the 527 patients only 30 (5.7%, 95% CI 3.9-8.1) experienced post-infective IBS. Univariate regression indicated a significant relationship between experiencing Per Rectal (PR) bleeding and a diagnosis of post-infective IBS (OR 3.64, 95% CI 1.00-10.49). Univariate regression also indicated an increase in the risk of developing post-infective IBS with increasing duration of symptoms (OR 1.04, 95% CI 1.02-1.05). No significant relationship was found between a positive stool sample and developing post-infective IBS (P = 0.307). CONCLUSIONS Very few patients provide a stool sample after experiencing holiday sickness abroad. Of those that do, only a small proportion have a positive stool sample indicative of a food poisoning microorganism. Around 6% of individuals were diagnosed with post-infective IBS. Those individuals with PR bleeding and symptoms persisting for longer durations were significantly more at risk of developing post-infective IBS, whilst medical aid and treatment abroad was found to reduce the odds of a positive stool sample.
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Affiliation(s)
- Prof Aali J Sheen
- Department of Surgery, Central Manchester NHS Foundation Trust, Oxford Road, Manchester, UK .,Department of Microbiology Research, School of Healthcare Sciences, Manchester Metropolitan University, Manchester, UK
| | - M Saad B Zahid
- Department of Surgery, Central Manchester NHS Foundation Trust, Oxford Road, Manchester, UK
| | - Andrew Fagbemi
- Department of Paediatric Gastroenterology, Central Manchester NHS Foundation Trust, Oxford Road, Manchester, UK
| | - Catherine Fullwood
- Centre for Biostatistics, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Research & Innovation, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, UK
| | - Kathryn Whitehead
- Department of Microbiology Research, School of Healthcare Sciences, Manchester Metropolitan University, Manchester, UK
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22
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Schleenvoigt BT, Zahlten A, Loebermann M, Seidel T, Pfister W, Pletz MW. Does medical education predispose to risk behaviour during travel? Travel Med Infect Dis 2017; 15:74-75. [DOI: 10.1016/j.tmaid.2016.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 10/19/2016] [Accepted: 10/25/2016] [Indexed: 10/20/2022]
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23
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Thomson CA, Gibbs RA, Heyworth JS, Giele C, Firth MJ, Effler PV. Pretravel Health Advice Among Australians Returning From Bali, Indonesia: A Randomized Controlled Trial Protocol. JMIR Res Protoc 2016; 5:e236. [PMID: 27927608 PMCID: PMC5177736 DOI: 10.2196/resprot.6549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 10/19/2016] [Accepted: 10/22/2016] [Indexed: 11/24/2022] Open
Abstract
Background The effect of pretravel health advice (PTHA) on travel-related illness rates is poorly understood, and to date there are no published randomized controlled trials evaluating the impact of PTHA outcomes. Objective This study aims to determine the effect of an online PTHA intervention on travel-related illness rates in Western Australians visiting Bali, Indonesia. Methods Western Australian travelers to Bali will be recruited online before departure and will be randomly allocated to an intervention or control group by computer algorithm. The intervention in this study is a short animated video, with accompanying text, containing PTHA relevant to Bali. An online posttravel survey will be administered to all participants within two weeks of their return from Bali. The primary outcome is the difference in self-reported travel-related illness rates between control and intervention groups. Secondary outcomes include the difference in risk prevention behaviors and health risk knowledge between the control and intervention groups. Further secondary outcomes include whether individuals in the control group who sought external PTHA differ from those who did not with respect to risk prevention behaviors, health risk knowledge, and health risk perception, as well as the rate of self-reported travel-related illness. Results The study began recruitment in September 2016 and will conclude in September 2017. Data analysis will take place in late 2017, with results disseminated via peer-reviewed journals in early 2018. Conclusions This will be the first randomized controlled trial to examine the effect of a novel PTHA intervention upon travel-related illness. In addition, this study builds upon the limited existing data on the effectiveness of PTHA on travel-related illness. ClinicalTrial Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12615001230549; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=369567 (Archived by WebCite at http://www.webcitation.org/6m0G7xJg1)
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Affiliation(s)
- Chloe A Thomson
- School of Population Health, Faculty of Medicine and Dentistry, The University of Western Australia, Perth, Australia.,Communicable Disease Control Directorate, Department of Health, Western Australian Government, Perth, Australia
| | - Robyn A Gibbs
- Communicable Disease Control Directorate, Department of Health, Western Australian Government, Perth, Australia
| | - Jane S Heyworth
- School of Population Health, Faculty of Medicine and Dentistry, The University of Western Australia, Perth, Australia
| | - Carolien Giele
- Communicable Disease Control Directorate, Department of Health, Western Australian Government, Perth, Australia
| | - Martin J Firth
- Centre for Applied Statistics, School of Mathematics and Statistics, The University of Western Australia, Perth, Australia
| | - Paul V Effler
- Communicable Disease Control Directorate, Department of Health, Western Australian Government, Perth, Australia.,School of Pathology and Laboratory Medicine, Faculty of Medicine and Dentistry, The University of Western Australia, Perth, Australia
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24
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Vila J, Oliveira I, Zboromyrska Y, Gascon J. [Traveller's diarrhoea]. Enferm Infecc Microbiol Clin 2016; 34:579-584. [PMID: 27234415 DOI: 10.1016/j.eimc.2016.04.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 04/14/2016] [Indexed: 01/07/2023]
Abstract
Traveller's diarrhoea (TD) is acquired primarily through ingestion of food and drinks contaminated with pathogens that cause diarrhoea. They can be bacteria, protozoa, helminths, and viruses. Globally, the most common causes of TD are two pathotypes of Escherichia coli (enterotoxigenic and enteroaggregative) and Campylobacter, although there are significant variations by geographic area visited. Most TD occurs in individuals traveling to low-middle income countries. The type of travel, length of stay, traveller's age, and the presence of certain underlying conditions are important risk factors to consider for the acquisition of TD. While TD is usually a mild and self-limiting disease, half of travellers with TD experience some limitation of activities during their trip, while up to 10% will experience persistent diarrhoea or other complications. The purpose of this article is to provide an updated microbiological, epidemiological, and clinical profile of traveller's diarrhoea, including known risk factors, as well as to make recommendations on the prevention and treatment of TD.
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Affiliation(s)
- Jordi Vila
- ISGlobal, Barcelona Centre for International Health Research (CRESIB), Hospital Clínic, Universitat de Barcelona, Barcelona, España; Servicio de Microbiología, Hospital Clínic, Barcelona, España.
| | - Ines Oliveira
- ISGlobal, Barcelona Centre for International Health Research (CRESIB), Hospital Clínic, Universitat de Barcelona, Barcelona, España; Servicio de Salud Internacional, Hospital Clínic, Barcelona, España
| | - Yuliya Zboromyrska
- ISGlobal, Barcelona Centre for International Health Research (CRESIB), Hospital Clínic, Universitat de Barcelona, Barcelona, España; Servicio de Microbiología, Hospital Clínic, Barcelona, España
| | - Joaquim Gascon
- ISGlobal, Barcelona Centre for International Health Research (CRESIB), Hospital Clínic, Universitat de Barcelona, Barcelona, España; Servicio de Salud Internacional, Hospital Clínic, Barcelona, España
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25
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Siikamäki H, Kivelä P, Fotopoulos M, Kantele A. A closer look at travellers' infections abroad: Finnish nationwide data with incidences, 2010 to 2012. Travel Med Infect Dis 2016; 15:29-36. [PMID: 27773779 DOI: 10.1016/j.tmaid.2016.10.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 10/08/2016] [Accepted: 10/18/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Although infections represent the most common health problem of travellers abroad, data on morbidity and incidences of various infections are scarce. METHOD Data on infections of Finnish travellers during 2010-2012 were retrieved from the database of SOS International, an assistance organization covering 95% of Finns requiring aid abroad. The study included 30,086 cases. For incidence calculation, the data were linked to the numbers of Finns visiting these regions during the same period as recorded by the Official Statistics of Finland. RESULTS The incidence of infections was particularly high in Africa, southern Europe plus the eastern Mediterranean, and Asia plus Oceania. The most frequent diagnoses were acute gastroenteritis (38.0%) and respiratory-tract infections (RTI) (34.5%), followed by infections of the ear (12.6%), skin or subcutaneous tissue (5.1%), urogenital tract (4.2%), eye (3.1%), and systemic febrile infections (2.2%). Vaccine-preventable diseases (VPD) accounted for 0.8% of cases, with varicella as most (49%) and influenza as second-most (27%) common. CONCLUSIONS Incidence of infections was higher in southern than in eastern and western Europe. Gastroenteritis and RTI proved the most frequent diagnoses, whereas systemic febrile infections were uncommon. Despite pre-travel immunizations, VPDs still occurred; pre-travel consultation should cover both varicella and influenza.
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Affiliation(s)
- Heli Siikamäki
- Inflammation Center, Division of Infectious Diseases, University of Helsinki and Helsinki University Hospital, POB 348, FI-00029 HUS, Helsinki, Finland; SOS International, Nitivej 6, DK-2000, Frederiksberg, Denmark.
| | - Pia Kivelä
- Inflammation Center, Division of Infectious Diseases, University of Helsinki and Helsinki University Hospital, POB 348, FI-00029 HUS, Helsinki, Finland.
| | | | - Anu Kantele
- Inflammation Center, Division of Infectious Diseases, University of Helsinki and Helsinki University Hospital, POB 348, FI-00029 HUS, Helsinki, Finland; Karolinska Institute, Department of Medicine/Solna, Unit of Infectious Diseases, SE 17176 Stockholm, Sweden.
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26
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Vilkman K, Pakkanen SH, Lääveri T, Siikamäki H, Kantele A. Travelers' health problems and behavior: prospective study with post-travel follow-up. BMC Infect Dis 2016; 16:328. [PMID: 27412525 PMCID: PMC4944265 DOI: 10.1186/s12879-016-1682-0] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 06/20/2016] [Indexed: 11/17/2022] Open
Abstract
Background The annual number of international tourist arrivals has recently exceeded one billion, yet surprisingly few studies have characterized travelers’ behavior, illness, and risk factors in a prospective setting. Particularly scarce are surveys of data spanning travel, return, and follow-up of the same cohort. This study examines behavior and illness among travelers while abroad, after return home, and at follow-up. Patterns of behavior connected to type of travel and illness are characterized so as to identify risk factors and provide background data for pre-travel advice. Methods Volunteers to this prospective cohort study were recruited at visits to a travel clinic prior to departure. Data on the subjects’ health and behavior were collected by questionnaires before and after journeys and over a three-week follow-up. In addition, the subjects were asked to fill in health diaries while traveling. Results The final study population consisted of 460 subjects, 79 % of whom reported illness during travel or on arrival: 69 % had travelers’ diarrhea (TD), 17 % skin problems, 17 % fever, 12 % vomiting, 8 % respiratory tract infection, 4 % urinary tract infection, 2 % ear infection, 4 % gastrointestinal complaints other than TD or vomiting, and 4 % other symptoms. Of all subjects, 10 % consulted a doctor and 0.7 % were hospitalized; 18 % took antimicrobials, with TD as the most common indication (64 %). Ongoing symptoms were reported by 25 % of all travelers upon return home. During the three-week follow-up (return rate 51 %), 32 % of respondents developed new-onset symptoms, 20 % visited a doctor and 1.7 % were hospitalized. Factors predisposing to health problems were identified by multivariable analysis: certain regions (Southern Asia, South-Eastern Asia, and Eastern Africa), female gender, young age, and long travel duration. Conclusions Despite proper preventive measures like vaccinations, malaria prophylaxis, and travel advice, the majority of our subjects fell ill during or after travel. As the symptoms mostly remained mild, health care services were seldom needed. Typical traveler profiles were identified, thereby providing a tool for pre-travel advice. The finding that one third reported new-onset illness during follow-up attests to the importance of advising clients on potential post-travel health problems already during pre-travel visits. Electronic supplementary material The online version of this article (doi:10.1186/s12879-016-1682-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Katri Vilkman
- Department of Bacteriology and Immunology, University of Helsinki, Haartmaninkatu 3, (P.O. Box 21), 00014, Helsinki, Finland.,Inflammation Center, Clinic of Infectious Diseases, Helsinki University Hospital and University of Helsinki, Aurora Hospital, Nordenskiöldinkatu 20, (P.O. Box 348), Helsinki, Finland
| | - Sari H Pakkanen
- Department of Bacteriology and Immunology, University of Helsinki, Haartmaninkatu 3, (P.O. Box 21), 00014, Helsinki, Finland
| | - Tinja Lääveri
- Inflammation Center, Clinic of Infectious Diseases, Helsinki University Hospital and University of Helsinki, Aurora Hospital, Nordenskiöldinkatu 20, (P.O. Box 348), Helsinki, Finland
| | - Heli Siikamäki
- Inflammation Center, Clinic of Infectious Diseases, Helsinki University Hospital and University of Helsinki, Aurora Hospital, Nordenskiöldinkatu 20, (P.O. Box 348), Helsinki, Finland
| | - Anu Kantele
- Inflammation Center, Clinic of Infectious Diseases, Helsinki University Hospital and University of Helsinki, Aurora Hospital, Nordenskiöldinkatu 20, (P.O. Box 348), Helsinki, Finland. .,Institute of Clinical Medicine, University of Helsinki, Helsinki, Finland. .,Aava Travel Clinic, Medical Centre Aava, Annankatu 32, 00100, Helsinki, Finland. .,Unit of Infectious Diseases, Solna, Karolinska Institutet, SE-171 76, Stockholm, Sweden.
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Abstract
Traveler's diarrhea (TD) is the most common travel-related illness, and it can have a significant impact on the traveler. Pretravel consultation provides an excellent opportunity for the clinician to counsel the traveler and discuss strategies such as food and water hygiene, vaccinations, and medications for prophylaxis or self-treatment that may decrease the incidence and impact of TD. Postinfectious sequelae, such as postinfectious irritable bowel syndrome, reactive arthritis, and Guillain-Barre syndrome, may develop weeks or months after return.
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Affiliation(s)
- Stanley L Giddings
- Division of Infectious Diseases, Department of Medicine, University of Utah School of Medicine, 30 North 1900 East, Salt Lake City, UT 84132, USA
| | - A Michal Stevens
- Division of Infectious Diseases, Department of Medicine, University of Utah School of Medicine, 30 North 1900 East, Salt Lake City, UT 84132, USA
| | - Daniel T Leung
- Division of Infectious Diseases, Department of Medicine, University of Utah School of Medicine, 30 North 1900 East, Salt Lake City, UT 84132, USA; Division of Microbiology & Immunology, Department of Pathology, University of Utah School of Medicine, 15 North Medical Drive East, Salt Lake City, UT 84112, USA.
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Summary of the Committee to Advise on Tropical Medicine and Travel (CATMAT) Statement on Travellers' Diarrhea. ACTA ACUST UNITED AC 2015; 41:272-284. [PMID: 29769922 DOI: 10.14745/ccdr.v41i11a03] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background Most travellers' diarrhea (TD) infections occur during travel to low- and middle-income countries. Type of travel, duration of stay, age of traveller and presence of certain medical conditions are important factors to consider for risk of TD. The Committee to Advise on Tropical Medicine and Travel (CATMAT) assembled a TD working group to develop recommendations on prevention and treatment of TD in travellers. This document is a summary of the Statement on Travellers' Diarrhea. Methods Following a systematic review of the literature, recommendations on the prevention and treatment of TD were developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to evaluate data quality, benefits and harms of the intervention, and values and preferences of the traveller. Other recommendations were based on a review of the literature and expert opinion. Recommendations Using the GRADE methodology, CATMAT concluded that oral cholera vaccine should not be routinely recommended to prevent TD in Canadian travellers. This recommendation was based on moderate quality data that showed this vaccine was not effective in preventing TD in travellers compared to placebo. Bismuth subsalicylate (BSS), fluoroquinolones or rifaximin are options for the prevention of TD based on high-quality data for BSS and fluoroquinolones and moderate evidence for rifaximin. For the treatment of TD, loperamide (alone or in combination with antibiotics), fluoroquinolones, azithromycin and rifaximin are all options, with varying degrees of data quality. Based on available evidence and expert opinion, CATMAT recommends handwashing or the use of hand sanitizer, as well as prudent choice and preparation of food and beverages as best practices for preventing diarrhea while travelling. At this time, a recommendation cannot be made for either the use of probiotics and prebiotics to prevent TD or the use of BSS to treat TD due to insufficient available evidence. Conclusion With the exception of BSS for prevention of TD (strong recommendation for use), CATMAT conditionally recommends the use of each of the other GRADE-evaluated preventive and therapeutic products assessed in this Statement. These CATMAT recommendations should be considered as options in the prevention and treatment of TD based on the particular situation of the traveller.
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Shady I, Gaafer M, Bassiony L. Travel risk behaviors as a determinants of receiving pre-travel health consultation and prevention. Trop Dis Travel Med Vaccines 2015; 1:3. [PMID: 28883935 PMCID: PMC5526366 DOI: 10.1186/s40794-015-0003-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 05/20/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND An estimated 30-60 % of travelers experience an illness while traveling. The incidence of travel-related illness can be reduced by preventive measures such as those provided by the Traveler Health Clinic (THC) in Kuwait. METHODS The present study is an analytical comparative study between groups of travelers visiting the THC during the study period (May 2009 - December 2010) and an age- and gender-matched control group of non-visitors (800 people). Both groups completed a modified pre-departure questionnaire. RESULTS Bivariate analysis revealed that Kuwaitis (68.2 %), those traveling for work (25.3 %) or leisure (59.5 %), those living in camps (20.4 %) or hotels (64.0 %), and those with knowledge of the THC from the media (28.1 %) or other sources (57.3 %), were more likely to be associated with a high frequency of visits to the THC (p < 0.001). Additionally, travelers heading to Africa (47 %) and South America (10 %) visited the THC more than did others (P < 0.05). Multivariate analysis revealed that nationality, followed by purpose of travel, duration of stay, and choice of travel destination are independent predictors of receiving pre-travel consultation from the THC. CONCLUSION Nationality, purpose of travel, length of stay, and travel destination are predictors for receiving a pre-travel consultation from the THC.
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Affiliation(s)
- Ibrahim Shady
- Faculty of Medicine, Mansoura University, 35516 Mansoura, Egypt
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Lalani T, Maguire JD, Grant EM, Fraser J, Ganesan A, Johnson MD, Deiss RG, Riddle MS, Burgess T, Tribble DR. Epidemiology and self-treatment of travelers' diarrhea in a large, prospective cohort of department of defense beneficiaries. J Travel Med 2015; 22:152-60. [PMID: 25483360 PMCID: PMC4409454 DOI: 10.1111/jtm.12179] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Revised: 09/25/2014] [Accepted: 10/06/2014] [Indexed: 01/26/2023]
Abstract
BACKGROUND Infectious diarrhea is a common problem among travelers. Expert guidelines recommend the prompt use of antibiotics for self-treatment of moderate or severe travelers' diarrhea (TD). There is limited data on whether travelers follow these self-treatment guidelines. We evaluated the risk factors associated with TD, the use of TD self-treatment, and the risk of irritable bowel syndrome (IBS) during travel. METHODS Department of Defense beneficiaries traveling outside the United States for ≤6.5 months were enrolled in a prospective cohort study. Participants received pre- and post-travel surveys, and could opt into a travel illness diary and follow-up surveys for symptoms of IBS. Standard definitions were used to assess for TD and IBS. Suboptimal self-treatment was defined as the use of antibiotics (with or without antidiarrheal agents) for mild TD, or the use of antidiarrheals alone or no self-treatment in cases of moderate or severe TD. RESULTS Twenty-four percent of participants (270/1,120) met the criteria for TD. The highest incidence was recorded in Africa [8.6 cases/100 person-weeks, 95% confidence interval (CI): 6.7-10.5]. Two hundred and twelve participants with TD provided information regarding severity and self-treatment: 89 (42%) had mild TD and 123 (58%) had moderate or severe TD. Moderate or severe TD was independently associated with suboptimal self-treatment [OR 10.4 (95% CI: 4.92-22.0)]. Time to last unformed stool did not differ between optimal and suboptimal self-treatment. IBS occurred in 4.5% (7/154) of TD cases and in 3.1% (16/516) of cases without TD (p = 0.39). Among TD cases, a lower incidence of IBS was noted in participants who took antibiotics [4.8% (5/105) vs 2.2% (1/46)] in those who did not, but the difference did not reach statistical significance (p = 0.60). CONCLUSIONS Our results suggest the underutilization of antibiotics in travelers with moderate or severe TD. Further studies are needed to systematically evaluate pre-travel instruction and traveler adherence to self-treatment guidelines, and the impact of suboptimal self-treatment on outcomes.
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Affiliation(s)
- Tahaniyat Lalani
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, MD, USA; Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA; Division of Infectious Diseases, Naval Medical Center, Portsmouth, VA, USA
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Travel style is a major risk factor for diarrhoea in India: a prospective cohort study. Clin Microbiol Infect 2015; 21:676.e1-4. [PMID: 25882361 DOI: 10.1016/j.cmi.2015.03.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2015] [Revised: 03/19/2015] [Accepted: 03/19/2015] [Indexed: 11/23/2022]
Abstract
Although some studies suggested specific foods/beverages as risk factors for travellers' diarrhoea (TD), details of transmission remain unclear. We assessed the influence of travel style (luxury/middle-class versus backpacking) on TD risk. TD attack rates were compared in a prospective study among travellers to India at the University of Zurich's Travel Clinic. Information on consumption of foods/beverages was collected. Seventy-one luxury/middle-class travellers and 21 backpackers completed the study; overall 37% suffered from TD (62% backpackers, 30% luxury/middle-class travellers, OR 4.43, p 0.022). Travel style rather than the consumption of specific foods/beverages appears to be a risk factor for TD development.
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Leder K, Steffen R, Cramer JP, Greenaway C. Risk assessment in travel medicine: how to obtain, interpret, and use risk data for informing pre-travel advice. J Travel Med 2015; 22:13-20. [PMID: 25378126 DOI: 10.1111/jtm.12170] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Revised: 08/22/2014] [Accepted: 08/22/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND It has been recommended that numerical risk data should be provided during the pre-travel consultation in order for travelers to make informed decisions regarding uptake of preventive interventions. METHODS In this article, we review the definitions of the various risk measures, particularly as they relate to travel health, and discuss the study designs and methodological details required to obtain each measure. RESULTS Risk measures can be broadly divided into absolute risk measures (including incidence rate, attack rate, and incidence density) and risk factor measures (including relative risk, risk ratio, and odds ratio). Although there are limitations inherent to each measure, absolute risk measures estimate the baseline risk for an "average" traveler, and risk factor measures help determine whether the risks for an individual traveler are likely to be higher or lower than this average, which is determined by specific traveler and itinerary characteristics. Incremental risk considerations add additional complexity, and risk communication plus risk perception/risk tolerance have additional impact on the individual traveler's interpretation of risk measures. CONCLUSIONS Travel health practitioners should be aware of the complexities, limitations, and difficulties in understanding numerical risk data, as these factors are important in travelers' acceptance or rejection of interventions offered.
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Affiliation(s)
- Karin Leder
- Infectious Disease Epidemiology Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Victorian Infectious Disease Service, Melbourne Health, Parkville, Australia
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DuPont HL, Petersen A, Zhao J, Mundt A, Jiang ZD, Miller S, Flores J, Shringarpure R, Moro L, Bagin RG, Ballard ED, Totoritis MC. Targeting of rifamycin SV to the colon for treatment of travelers' diarrhea: a randomized, double-blind, placebo-controlled phase 3 study. J Travel Med 2014; 21:369-76. [PMID: 25345982 DOI: 10.1111/jtm.12168] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 08/25/2014] [Accepted: 08/26/2014] [Indexed: 12/28/2022]
Abstract
BACKGROUND Rifamycin SV is under development for treatment of travelers' diarrhea (TD) in a new oral formulation, Rifamycin SV MMX (RIF-MMX; Santarus Inc., San Diego, CA, USA), which targets its delivery to the colon, making it a unique rifamycin drug. METHODS This was a randomized, double-blind, phase 3 study of adult travelers to Mexico or Guatemala experiencing acute diarrhea. A total of 264 patients received RIF-MMX (2 × 200 mg twice daily for 3 days, n = 199) or placebo (n = 65) in a 3 : 1 ratio. The primary endpoint was the length of time between the administration of first dose of study drug and passage of the last unformed stool (TLUS; after which clinical cure was declared). Other endpoints included eradication of pathogens from the stools, pathogen minimum inhibitory concentration (MIC), and adverse events (AEs). RESULTS TLUS was significantly shorter in the RIF-MMX group (median: 46.0 hours) compared with placebo (median: 68.0 hours; p = 0.0008) and a larger percentage of RIF-MMX treated patients (81.4%) achieved clinical cure compared with placebo patients (56.9%). TLUS was significantly shorter in the subgroups of patients with enteroaggregative, enterotoxigenic, or diffusely adherent Escherichia coli infections (p = 0.0035) with nonsignificant activity against invasive bacteria (p = 0.3804). Overall pathogen eradication rates were numerically higher in the RIF-MMX group (67.0%) compared with placebo (54.8%) but the difference did not reach significance (p = 0.0836). In vitro resistance to rifamycin SV was observed in some bacteria remaining after treatment of patients with RIF-MMX but was not associated with lower efficacy in them. AEs appeared to be more frequent with placebo (38.5%) than with RIF-MMX (29.6%). CONCLUSIONS RIF-MMX shortened the duration of TD in patients with a broad range of pathogens and was well tolerated. The unique pharmacokinetic properties of the drug offer evidence that TD pathogens work at the level of the colon.
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Affiliation(s)
- Herbert L DuPont
- Center for Infectious Diseases, University of Texas School of Public Health, Houston, TX, USA
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Does the use of alcohol-based hand gel sanitizer reduce travellers' diarrhea and gastrointestinal upset? : A preliminary survey. Travel Med Infect Dis 2014; 12:494-8. [DOI: 10.1016/j.tmaid.2014.07.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Revised: 07/03/2014] [Accepted: 07/08/2014] [Indexed: 11/20/2022]
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Lewis JM, Goodwin L, Beadsworth MBJ. The returning traveller with diarrhoea. Br J Hosp Med (Lond) 2014; 75:C133-6. [DOI: 10.12968/hmed.2014.75.9.c133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- JM Lewis
- Specialist Trainee in Infectious Diseases
| | - L Goodwin
- Specialist Trainee in Infectious Diseases
| | - MBJ Beadsworth
- Consultant in Infectious Diseases in the Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, Liverpool L7 8XP
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Angelin M, Evengård B, Palmgren H. Travel health advice: Benefits, compliance, and outcome. ACTA ACUST UNITED AC 2014; 46:447-53. [DOI: 10.3109/00365548.2014.896030] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Lääveri T, Pakkanen SH, Antikainen J, Riutta J, Mero S, Kirveskari J, Kantele A. High number of diarrhoeal co-infections in travellers to Benin, West Africa. BMC Infect Dis 2014; 14:81. [PMID: 24521079 PMCID: PMC3928613 DOI: 10.1186/1471-2334-14-81] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Accepted: 02/10/2014] [Indexed: 11/22/2022] Open
Abstract
Background Travellers’ diarrhoea (TD) is the most frequent health problem among travellers to the tropics. Using routine techniques, the aetiology mostly remains unresolved, whereas modern molecular methods enable reducing the number of equivocal cases considerably. While many studies address the aetiology of TD in Asian, Central American and North African tourist resorts, only few focus on Western Africa. Methods Stool samples from 45 travellers travelling in Benin, West Africa, were analyzed by a new multiplex qPCR assay for Salmonella, Yersinia, Campylobacter, Vibrio cholerae, Shigella or enteroinvasive (EIEC), enterohaemorrhagic (EHEC), enterotoxigenic (ETEC), enteroaggregative (EAEC), and enteropathogenic Escherichia coli (EPEC). Results All 18 pre-travel samples proved negative for bacterial pathogens. Of the 39/45 (87%) travellers having had TD, EPEC was detected in post-travel samples in 30 (77%) cases, EAEC in 23 (59%), ETEC in 22 (56%), Shigella or EIEC in 7 (18%), EHEC in two (5%), and Salmonella in one (3%). In 31(79%) of the TD cases two or more bacterial pathogens were identified. Two (8%) samples remained negative: both patients had taken antimicrobials for TD. Conclusions EPEC, EAEC and ETEC were the most common findings. 79% of the cases had a co-infection. As modern diagnostics reveals in most patients a multitude of pathogens, the role of each pathogen should be re-evaluated.
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Affiliation(s)
| | | | | | | | | | | | - Anu Kantele
- Division of Infectious Diseases, Department of Medicine, Helsinki University Central Hospital, PO Box 348, 00029 HUS Helsinki, Finland.
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Launders NJ, Nichols GL, Cartwright R, Lawrence J, Jones J, Hadjichristodoulou C. Self-reported stomach upset in travellers on cruise-based and land-based package holidays. PLoS One 2014; 9:e83425. [PMID: 24427271 PMCID: PMC3888385 DOI: 10.1371/journal.pone.0083425] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2013] [Accepted: 11/04/2013] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND International travellers are at a risk of infectious diseases not seen in their home country. Stomach upsets are common in travellers, including on cruise ships. This study compares the incidence of stomach upsets on land- and cruise-based holidays. METHODS A major British tour operator has administered a Customer Satisfaction Questionnaire (CSQ) to UK resident travellers aged 16 or more on return flights from their holiday abroad over many years. Data extracted from the CSQ was used to measure self-reported stomach upset in returning travellers. RESULTS From summer 2000 through winter 2008, 6,863,092 questionnaires were completed; 6.6% were from cruise passengers. A higher percentage of land-based holiday-makers (7.2%) reported stomach upset in comparison to 4.8% of cruise passengers (RR = 1.5, p<0.0005). Reported stomach upset on cruises declined over the study period (7.1% in 2000 to 3.1% in 2008, p<0.0005). Over 25% of travellers on land-based holidays to Egypt and the Dominican Republic reported stomach upset. In comparison, the highest proportion of stomach upset in cruise ship travellers were reported following cruises departing from Egypt (14.8%) and Turkey (8.8%). CONCLUSIONS In this large study of self-reported illness both demographic and holiday choice factors were shown to play a part in determining the likelihood of developing stomach upset while abroad. There is a lower cumulative incidence and declining rates of stomach upset in cruise passengers which suggest that the cruise industry has adopted operations (e.g. hygiene standards) that have reduced illness over recent years.
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Affiliation(s)
- Naomi J. Launders
- Gastrointestinal, Emerging and Zoonotic Infections Department, Public Health England, London, United Kingdom
- EU Shipsan Trainet Project, Public Health Program, European Agency for Health and Consumers, Luxembourg, Luxembourg
| | - Gordon L. Nichols
- Gastrointestinal, Emerging and Zoonotic Infections Department, Public Health England, London, United Kingdom
- EU Shipsan Trainet Project, Public Health Program, European Agency for Health and Consumers, Luxembourg, Luxembourg
- Department of Hygiene and epidemiology, Medical Faculty, University of Thessaly, Larissa, Greece
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | | | - Joanne Lawrence
- Travel and Migrant Health Section, Public Health England, London, United Kingdom
| | - Jane Jones
- Travel and Migrant Health Section, Public Health England, London, United Kingdom
| | - Christos Hadjichristodoulou
- EU Shipsan Trainet Project, Public Health Program, European Agency for Health and Consumers, Luxembourg, Luxembourg
- Department of Hygiene and epidemiology, Medical Faculty, University of Thessaly, Larissa, Greece
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DeYoung KH, Riddle MS, May L, Porter CK. A case-control study of incident rheumatological conditions following acute gastroenteritis during military deployment. BMJ Open 2013; 3:e003801. [PMID: 24319273 PMCID: PMC3855532 DOI: 10.1136/bmjopen-2013-003801] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES The aim of this study was to assess the risk of incident rheumatological diagnoses (RD) associated with self-reported diarrhoea and vomiting during a first-time deployment to Iraq or Afghanistan. Such an association would provide evidence that RD in this population may include individuals with reactive arthritis (ReA) from deployment-related infectious gastroenteritis. DESIGN This case-control epidemiological study used univariate and multivariate logistic regression to compare the odds of self-reported diarrhoea/vomiting among deployed US military personnel with incident RD to the odds of diarrhoea/vomiting among a control population. SETTING We analysed health records of personnel deployed to Iraq or Afghanistan, including responses on a postdeployment health assessment and medical follow-up postdeployment. PARTICIPANTS Anonymous data were obtained from 891 US military personnel with at least 6 months of medical follow-up following a first-time deployment to Iraq or Afghanistan in 2008-2009. Cases were defined using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes; controls had an unrelated medical encounter and were representative of the study population. MAIN OUTCOME MEASURES The primary measure was an association between incident RD and self-reported diarrhoea/vomiting during deployment. A secondary measure was the overall incidence of RD in this population. RESULTS We identified 98 cases of new onset RD, with a total incidence of 161/100 000 persons. Of those, two participants had been diagnosed with Reiter's disease (i) (3.3/100 000 persons) and the remainder with non-specific arthritis/arthralgia (157.5/100 000 persons). The OR for acute diarrhoea was 2.67 (p=0.03) after adjusting for important covariates. CONCLUSIONS Incident rheumatological conditions, even those classified as 'non-specific,' are significantly associated with prior severe diarrhoea in previously deployed military personnel, potentially indicating ReA and need for preventive measures to reduce diarrhoeagenic bacterial exposures in military personnel and other travellers to the developing regions.
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Affiliation(s)
- Kathryn H DeYoung
- Denver Public Health, Denver, Colorado, USA
- Department of Epidemiology and Biostatistics, School of Public Health and Health Services, George Washington University, Washington DC, USA
| | - Mark S Riddle
- Enteric Diseases Department, Naval Medical Research Center, Silver Spring, Maryland, USA
| | - Larissa May
- Department of Epidemiology and Biostatistics, School of Public Health and Health Services, George Washington University, Washington DC, USA
- Department of Emergency Medicine, George Washington University, Washington DC, USA
| | - Chad K Porter
- Enteric Diseases Department, Naval Medical Research Center, Silver Spring, Maryland, USA
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Safety and immunogenicity of a single oral dose of recombinant double mutant heat-labile toxin derived from enterotoxigenic Escherichia coli. CLINICAL AND VACCINE IMMUNOLOGY : CVI 2013; 20:1764-70. [PMID: 24049109 DOI: 10.1128/cvi.00464-13] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Enterotoxigenic Escherichia coli (ETEC) is a primary cause of traveler's diarrhea for which there is no licensed vaccine. This phase 1 trial determined the safety and immunogenicity of a recombinantly produced double mutant heat-labile enterotoxin (dmLT) of ETEC. It was administered as a single oral dose of dmLT in escalating doses of 5 μg, 25 μg, 50 μg, and 100 μg, followed by a 72-h inpatient observation, outpatient visits at 8, 14, and 28 days, and telephone calls at 2 and 6 months postvaccination. Safety was assessed by frequency of adverse events, and immune responses determined after immunization included dmLT-specific serum IgA and IgG, fecal IgA, antibody-secreting cells (ASC), and antibodies in lymphocyte supernatant (ALS) responses. All doses were well tolerated by the 36 healthy adults enrolled. Immune responses were limited in the 5- and 25-μg dose recipients. The 50-μg dose recipients trended toward stronger responses than the 100-μg dose recipients by serum IgA (67% versus 33%, P = 0.22), serum IgG (58% versus 33%, P = 0.41), and fecal IgA (58% versus 33%, P = 0.41). By day 14 postvaccination, there were significantly more positive responders (≥4-fold increase from baseline) among the 50- versus 100-μg dose recipients for serum IgA (P = 0.036) but not serum IgG (P = 0.21). In conclusion, a single oral dose of dmLT was well tolerated and immunogenic, with immune responses plateauing at the 50-μg dose. (This clinical trial is registered at www.clinicaltrials.gov, registration number NCT01147445.).
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Dupont HL. Chronic complications after travelers' diarrhea. J Travel Med 2013; 20:273-4. [PMID: 23992567 DOI: 10.1111/jtm.12045] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Accepted: 01/28/2013] [Indexed: 02/01/2023]
Affiliation(s)
- Herbert L Dupont
- University of Texas School of Public Health, Houston, TX, USA: St. Luke's Episcopal Hospital, Houston, TX, USA; Baylor College of Medicine, University of Texas School of Public Health, Houston, TX, USA
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The Diagnosis of Traveler’s Diarrhea Disguises an Unusual Cause of Ileus. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2013. [DOI: 10.1097/ipc.0b013e31827ddec9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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43
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Caillet-Gossot S, Laporte R, Noël G, Gautret P, Soula G, Delmont J, Faucher B, Parola P, Osei L, Minodier P. Family compliance with counseling for children traveling to the tropics. J Travel Med 2013; 20:171-6. [PMID: 23577863 DOI: 10.1111/jtm.12016] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Revised: 12/04/2012] [Accepted: 12/05/2012] [Indexed: 11/30/2022]
Abstract
BACKGROUND The number of people, both adults and children, traveling abroad, is on the rise. Some seek counseling at travel medicine centers before departure. METHODS A prospective study was conducted among children <16 years visiting a travel medicine center in Marseille, France, from February 2010 to February 2011. Parents were contacted by telephone 4 weeks after their return, and asked about compliance with pre-travel advice. RESULTS One hundred sixty-seven children were evaluated after their trip. Compliance with immunizations, malaria chemoprophylaxis, and food-borne disease prevention was 71, 66, and 31%, respectively. Compliance with malaria chemoprophylaxis varied significantly with destination, and was higher for African destinations. Significant features associated with poor compliance with chemoprophylaxis were a trip to Asia or the Indian Ocean, age <5 years, and a monoparental family. Compliance with prevention of food- and water-borne diseases was higher in children < 2 years of age. CONCLUSIONS A ≥ 80% compliance with pre-travel counseling in children traveling overseas was achieved only for drinking bottled water, using repellents, a routine vaccine update, and yellow fever immunization.
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Fletcher SM, McLaws ML, Ellis JT. Prevalence of gastrointestinal pathogens in developed and developing countries: systematic review and meta-analysis. J Public Health Res 2013; 2:42-53. [PMID: 25170480 PMCID: PMC4140330 DOI: 10.4081/jphr.2013.e9] [Citation(s) in RCA: 92] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Accepted: 05/14/2013] [Indexed: 12/13/2022] Open
Abstract
ABSTRACT Diarrhoeal illness is a leading cause of child mortality and morbidity worldwide. There are no precise or current estimates of the types and prevalence of pathogens associated with diarrheal illnesses in developed and developing settings. This systematic review assessed data from 60 studies published in the English language from five developing regions and developed countries worldwide to provide regional estimates of enteric pathogens affecting children. The random-effect method was used to establish the weighted average prevalence of pathogens in adults and children for each region. Significantly more pathogens were reported by studies from developing regions compared with Organisation for Economic Co-operation and Development countries (P<0.016). The identification rates of pathogens from community based and hospital based studies were similar (58.5% and 58.1% respectively, P<0.619). The overall detection of enteric pathogens in developing countries was higher in adults (74.8%; 95% CI 63.1-83.8%) compared with children (56.7%; 95% CI 53.0-60.4%) (P<0.001). Rotavirus was the most frequently detected pathogen in all regions with the highest rate, 24.8% (95% CI 18.0-33.1%), detected in the developed countries. This systematic review is the first to provide an estimate of the prevalence of enteric pathogens associated with diarrhoeal illnesses in adults and children in developed and developing settings. While pathogen detection rate is greater in developing regions the consistently high prevalence of rotavirus in both developed and developing settings underscores the urgent need for access to rotavirus vaccines. Increased travel between developing and developed countries increases disease risk, and hence developed countries have a vested interest in supporting vaccine accessibility in developing settings.
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Affiliation(s)
- Stephanie M. Fletcher
- The iThree Institute and School of Medical and Molecular Biosciences, University of Technology, Sydney
| | | | - John T. Ellis
- The iThree Institute and School of Medical and Molecular Biosciences, University of Technology, Sydney
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Abstract
Malaria, diarrhea, respiratory infections, and cutaneous larva migrans are common travel-related infections observed in children and adolescents returning from trips to developing countries. Children visiting friends and relatives are at the highest risk because few visit travel clinics before travel, their stays are longer, and the sites they visit are more rural. Clinicians must be able to prepare their pediatric-age travelers before departure with preventive education, prophylactic and self-treating medications, and vaccinations. Familiarity with the clinical manifestations and treatment of travel-related infections will secure prompt and effective therapy.
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Leder K, Torresi J, Libman MD, Cramer JP, Castelli F, Schlagenhauf P, Wilder-Smith A, Wilson ME, Keystone JS, Schwartz E, Barnett ED, von Sonnenburg F, Brownstein JS, Cheng AC, Sotir MJ, Esposito DH, Freedman DO. GeoSentinel surveillance of illness in returned travelers, 2007-2011. Ann Intern Med 2013; 158:456-68. [PMID: 23552375 PMCID: PMC4629801 DOI: 10.7326/0003-4819-158-6-201303190-00005] [Citation(s) in RCA: 329] [Impact Index Per Article: 29.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND International travel continues to increase, particularly to Asia and Africa. Clinicians are increasingly likely to be consulted for advice before travel or by ill returned travelers. OBJECTIVE To describe typical diseases in returned travelers according to region, travel reason, and patient demographic characteristics; describe the pattern of low-frequency travel-associated diseases; and refine key messages for care before and after travel. DESIGN Descriptive, using GeoSentinel records. SETTING 53 tropical or travel disease units in 24 countries. PATIENTS 42 173 ill returned travelers seen between 2007 and 2011. MEASUREMENTS Frequencies of demographic characteristics, regions visited, and illnesses reported. RESULTS Asia (32.6%) and sub-Saharan Africa (26.7%) were the most common regions where illnesses were acquired. Three quarters of travel-related illness was due to gastrointestinal (34.0%), febrile (23.3%), and dermatologic (19.5%) diseases. Only 40.5% of all ill travelers reported pretravel medical visits. The relative frequency of many diseases varied with both travel destination and reason for travel, with travelers visiting friends and relatives in their country of origin having both a disproportionately high burden of serious febrile illness and very low rates of advice before travel (18.3%). Life-threatening diseases, such as Plasmodium falciparum malaria, melioidosis, and African trypanosomiasis, were reported. LIMITATIONS Sentinel surveillance data collected by specialist clinics do not reflect healthy returning travelers or those with mild or self-limited illness. Data cannot be used to infer quantitative risk for illness. CONCLUSION Many illnesses may have been preventable with appropriate advice, chemoprophylaxis, or vaccination. Clinicians can use these 5-year GeoSentinel data to help tailor more efficient pretravel preparation strategies and evaluate possible differential diagnoses of ill returned travelers according to destination and reason for travel. PRIMARY FUNDING SOURCE Centers for Disease Control and Prevention.
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Affiliation(s)
- Karin Leder
- Victorian Infectious Disease Service, Royal Melbourne Hospital, Monash University, Austin Hospital, Melbourne University.
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Abstract
Travelers' diarrhea (TD) is the most important health issue among international travelers. In high risk areas, 50-90% of travelers may experience an episode of TD. The risk of acquiring TD is influenced by factors such as the destination, duration of stay, standard of accommodation, type of travel, age of the traveler, and also by individual risk factors. Most cases of TD are caused by bacteria; treatment for TD are loperamide and antibiotics. Preventive strategies such as hygiene measures have limited impact. Prophylactic intake of antibiotics or vaccines to prevent from TD can be considered in special situations.
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Affiliation(s)
- Herwig Kollaritsch
- Institute of Specific Prophylaxis and Tropical Medicine, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria
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Marchou B. Diarrhées du voyageur : épidémiologie, prévention et conduite à tenir. Presse Med 2013; 42:76-81. [DOI: 10.1016/j.lpm.2012.10.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2012] [Accepted: 10/04/2012] [Indexed: 01/10/2023] Open
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Hu Y, Ren J, Zhan M, Li W, Dai H. Efficacy of rifaximin in prevention of travelers' diarrhea: a meta-analysis of randomized, double-blind, placebo-controlled trials. J Travel Med 2012; 19:352-6. [PMID: 23379704 DOI: 10.1111/j.1708-8305.2012.00650.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2012] [Revised: 07/17/2012] [Accepted: 07/24/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND Rifaximin has been used successfully for the prevention of travelers' diarrhea (TD), the most general cause of disability among international travelers to developing tropical and semitropical regions. METHODS We sought to better evaluate the efficacy of rifaximin in the prevention of TD. Randomized controlled trials (RCTs) of rifaximin for the prevention of TD published in Pubmed, the Cochrane Central Register of Controlled Trials, Embase, and the Science Citation Index were searched. [Correction added on 3 October 2012, after first online publication: the phrase "protection of TD" was replaced with "prevention of TD".] The primary efficacy outcome was occurrence of TD over a 2-week treatment period. Secondary outcomes were requirement for antibiotic treatment, occurrence of mild diarrhea (MD), occurrence of TD in the third week after drug withdrawal, incidence of TD associated with isolation of diarrheagenic Escherichia coli (ie, ETEC, EAEC), and adverse events. RESULTS Four RCTs with 502 participants were included in the systematic review. Rifaximin treatment showed a significant protection against TD (risk ratios, RR: 0.41, 95% CI: 0.30-0.56, p < 0.00001) and needed antibiotic-treated TD (relative risk [RR]: 0.30, 95% confidence interval [CI]: 0.18-0.49, p < 0.00001). There was no significant difference between rifaximin and placebo in the occurrence of MD (RR: 1.11, 95% CI: 0.78-1.59, p = 0.55) and the occurrence of TD in the third week after drug withdrawal (RR: 0.73, 95% CI: 0.30-1.73, p = 0.47). Enterotoxigenic E. coli was the major cause of TD, and all trials reported no differences in adverse events between rifaximin and placebo. CONCLUSIONS Rifaximin can prevent TD caused by non-invasive enteric pathogens. Further research is needed for the treatment of invasive enteric pathogens. [Correction added on 3 October 2012, after first online publication: the phrase "Rifaximin can protect TD" was replaced with "Rifaximin can prevent TD".].
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Affiliation(s)
- Yangmin Hu
- Department of Pharmacy, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
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50
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Gautret P, Gaudart J, Leder K, Schwartz E, Castelli F, Lim PL, Murphy H, Keystone J, Cramer J, Shaw M, Boddaert J, von Sonnenburg F, Parola P. Travel-associated illness in older adults (>60 y). J Travel Med 2012; 19:169-77. [PMID: 22530824 DOI: 10.1111/j.1708-8305.2012.00613.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Older individuals represent a substantial proportion of international travelers. Because of physiological changes and the increased probability of underlying medical conditions, older travelers might be at higher risk for at least some travel-associated diseases. METHODS With the aim of describing the epidemiology of travel-associated diseases in older adults, medical data were prospectively collected on ill international travelers presenting to GeoSentinel sites from 1997 to 2009. Seven thousand thirty-four patients aged 60 years and over were identified as older travelers and were compared to 56,042 patients aged 18-45 years, who were used as the young adult reference population. RESULTS The proportionate morbidity of several etiological diagnoses was higher in older ill travelers compared to younger ill, including notably lower respiratory tract infections, high-altitude pulmonary edema, phlebitis and pulmonary embolism, arthropod bites, severe malaria, rickettsiosis, gastritis, peptic ulcers, esophagitis and gastroesophageal reflux disease, trauma and injuries, urinary tract infections, heart disease, and death. In contrast, acute diarrhea, upper respiratory tract infections, flu and flu-like illnesses, malaria, dengue, genital infections, sexually transmitted diseases, and schistosomiasis proportionate morbidities were lower among the older group. CONCLUSION Older ill travelers are more likely to suffer from certain life-threatening diseases and would benefit from reinforcement of specific preventive measures including use of anti-thrombosis compression stockings and sufficient hydration and exercises during long-distance flights, hand hygiene, use of disposable handkerchiefs, consideration of face-masks in crowded conditions, influenza and pneumococcal vaccines, progressive acclimatization to altitude, consideration of acetazolamide, and use of repellents and mosquito nets. Antibiotics for the presumptive treatment of respiratory and urinary tract infections may be considered, as well as antacid medications. At-risk patients should be referred to a specialist for medical evaluation before departing, and optimal control of co-morbidities such as cardiovascular and chronic obstructive pulmonary diseases should be achieved, particularly for high-altitude travel.
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Affiliation(s)
- Philippe Gautret
- Infectious Diseases and Tropical Medicine Unit, North University Hospital, AP-HM, Marseille, France.
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