UNDERSTANDING TRAVELERS’ DIARRHEA
Travelers’ diarrhea (TD) is the most frequent health problem experienced by individuals traveling internationally, most often due to poor hygiene practices in local restaurants. TD is estimated to impact up to 70% of travelers, depending on the location and season of travel. Based on tourism travel projections, TD can affect up to 20 million travelers annually.
TD has equal incidence among men and women. There are several environmental factors, often found in resource-challenged countries, that promote TD. Tropical environments with large populations and poor plumbing or sanitation systems may have environmental solid waste contamination. Countries with inadequate electrical capacity and inconsistent refrigeration systems may have food storage conditions that promote bacterial growth. Regions that lack purified or safe drinking water may have microbial water contamination. Lack of running water as a regular resource may also lead to absent or infrequent hand hygiene practices and poor cleaning of utensils and cooking surfaces for foods, which may expose restaurant patrons and food consumers to microbial organisms from poor food handling.1 It is also important to note that, while less common, TD may also still occur during travel to more industrialized countries, perhaps due to poor personal food and beverage choices. As a result, all travelers to international destinations need to take appropriate precautions to prevent or minimize their risk of TD.
There are several factors that influence the risk for TD, the most important being destination. Globally, regions are identified as low, intermediate, or high risk for TD. The highest risk areas include Asia, the Middle East, Africa, Mexico, and Central and South America. Intermediate-risk areas include eastern Europe, South Africa, and some Caribbean islands. Low-risk countries include the United States, Canada, Australia, New Zealand, Japan, and northern and western Europe.
Other risk factors for TD include type of travel, duration of stay, and age of the traveler. Individuals on vacation or honeymoons have a higher incidence of TD than business travelers. TD rates are also higher for a duration of stay greater than 1 week. However, recent travel within 6 months to a tropical country may have a protective effect for TD. The age groups most susceptible to TD are infants, toddlers, and young adults aged between 13 and 30 years. Additionally, the type of accommodations may also influence risk, with adventure travel having the highest rates followed by tour group trips and beach vacations at a resort having the lowest rates. Individuals who take acid-suppressing medications, such as proton pump inhibitors, are also at an increased risk for TD.
Symptoms of TD range in severity and may be defined via a classical symptom framework or by functional impact. The classical definition of moderate TD is passage of 3 or more unformed stools within 24 hours. An alternate method of classification defines the severity of TD based on the impact on the traveler’s regularly scheduled activities and the need for changes or adjustment to a planned itinerary. However, any diarrhea that occurs while traveling overseas is considered TD. Acute TD is defined as mild, moderate, or severe. Persistent TD is defined as diarrhea that continues for greater than 2 weeks. TD may be accompanied by other symptoms, such as abdominal pain and cramping, severe flatulence, nausea, vomiting, defecation urgency, passing bloody stools, or fever. Dysentery, which is a severe form of TD characterized by grossly bloody stool and often accompanied by fever, may also occur.
Short-term consequences of TD include dehydration, incapacitation, and in rare cases, hospitalization. Potential long-term, but rare, systemic complications may include reactive arthritis, Guillain-Barré syndrome (GBS), and irritable bowel syndrome (IBS). Reactive arthritis as a complication of TD is described as symptom onset 1 to 4 weeks after enteric infection and may persist for months to years. The arthritis most often impacts joints of the lower extremities. Salmonella, Shigella, Campylobacter, and Yersinia are the pathogens most often associated with reactive arthritis. GBS is an autoimmune response targeting peripheral nerves. The advancement of GBS leads to peripheral neuropathy and neuromuscular failure. Neurologic symptoms include limb weakness, bulbar palsy, and eye-movement disorders. Severe GBS can progress to respiratory weakness requiring ventilatory support. Campylobacter infections are most often associated with post-infectious GBS. The incidence of GBS following enteric infection is approximately 1 case for every 1000 Campylobacter infections.
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