Traveler’s Diarrhea

Squat ToiletBasics:  Known around the world by many names including Montezuma’s revenge, Delhi belly and mummy tummy, traveler’s diarrhea (TD) is the most common illness travelers face.  Nothing can slow down a fun trip like TD and this can also have serious health implications.  Staying hydrated is the most important method to avoid serious problems and recognizing warning signs such as blood in the stool, fevers or abdominal cramping can help a savvy traveler know when to seek medical help.  Bacterial infections are the most common cause travelers face.  Typical durations of TD are 4-6 days and 90% of cases occur within the first two weeks of travel .    

Symptoms:  TD has many definitions but the presence of three or more loose-formed stools in one day is a good place to start.  Abdominal cramping, nausea and vomiting and fevers can also occur.  The presence of blood in the stool can indicate the infection has the ability to directly damage the intestinal wall and should be taken seriously. 

Diagnosis:  Diagnosing TD is largely based on symptoms.  The presence of blood in the stool can indicate that there is an invasive process damaging the intestinal lining.  This should be taken seriously.  Diarrhea with fevers and severe abdominal cramping can also signal a more serious illness and should prompt one to seek medical care.

Anatomy:  The Gastrointestinal tract starts at the mouth and ends at the anus.   As food enters the mouth, it passes down the esophagus to the stomach where it sits for approximately 45 minutes.  After being broken down by gastric secretions, the food matter then heads to the small intestine (duodenum, jejunum, and ileum).  The small intestine is the site where most nutrients are absorbed by the body, across the intestinal wall.  From the small intestine, the food matter begins to look more like feces as it progresses to the large intestine or colon.  The colon serves to absorb water from the food material before is passes through the anus and out of the body as feces.

Care/Treatment:  The most important treatment for traveler’s diarrhea is to ensure adequate hydration.  Dehydration is very common in those who suffer from TD due to the large amounts water being lost from the body in the loose stools.  Oral rehydration with sports drinks and clean, pure water should be started the moment diarrhea strikes.  Depending on the causes of the diarrhea, antibiotics may be required to kill bacteria or parasites.  Using anti-diarrheal medications to prevent frequent trips to the toilet have a role, but should be used with caution.  Preventing the infectious diarrhea from leaving your body may trap the bacteria or parasite in the intestines, giving it more time to do damage.  Try to ensure you know the cause of the diarrhea before stopping it with anti-diarrheal medications.

Aircraft bathroomSymptoms continued:  Typical traveler’s diarrhea is loose and watery.  Some doctors advise a “let it flow” approach due to the fact that diarrhea is the body’s way of excreting the infectious agent that causes the symptoms.  While being a very inconvenient way to deal with diarrhea, this is generally a good approach providing there are no warning signs indicating a more serious infection and the person continues to drink large amounts of fluids.  Warning signs of a serious diarrheal infection include the presence of fevers, blood in the stool and severe abdominal cramping.  Perhaps the most serious of these signs is blood.  This indicates that the lining of the intestines is being damaged or penetrated by the causative agent.  Anytime the intestinal lining is being compromised, the possibility of a systemic infection occurs.  Should a traveler suffer from bloody diarrhea, a visit to a health care provider is advised.  This type of diarrhea typically requires antibiotics and may even require further tests to determine the exact cause of the diarrhea.

E. Coli at 10k magnificationDiagnosis and Causes:  The most common cause of traveler’s diarrhea is a gram-negative bacterium called enterotoxic Escherichia Coli (E. Coli or ETEC).  This bacterium has been implicated in up to 70% of traveler’s diarrhea, worldwide .

Campylobacter species, specifically C. Jejuni is considered the second most common cause (30%)  and appears to have seasonal peaks.  For example, in USA C. Jejuni peaks in the summer months while in Northern Africa, the drier, winter months see more cases. 

There are a multitude of bacterial causes for traveler’s diarrhea and while not as common as E. Coli, they deserved to be mentioned.  Salmonella, Shigella, Vibrio species (V. cholera, V. paraheamolyticus and Yersinia enterocolitica are all known causes of TD occurring in roughly 0-15% of cases . 

Viral infections are estimated to cause 20% of TD cases in adults  with the Norwalk virus being a common agent, especially on cruise ships.  Rota Virus, Hepatitis A and E can also cause diarrhea in travelers.  Rota Virus is more likely seen in pediatric patients than adults. 

Parasitic infections can be causes of traveler’s diarrhea and protozoan infections are considered most common.  Giardia lamblia, Cryptosporidium, Cyclospora, Entamoeba and Isospora species are implicated in roughly 5% of TD cases .   

Less common causes of traveler’s diarrhea can include helminth infections, food poisonings and seafood toxidromes.

           
Toilet paperDiarrhea Evaluation in the Returned Traveler:  Further studies into the etiology of the traveler’s diarrhea starts with thorough travel history, focusing on destinations and eating habits/history.  The majority of classical TD cases occur within the first 1-2 weeks of travel and last 4-6 days.  Thus, a typical traveler with complaints of diarrhea upon return to home will likely be suffering from recurrent or prolonged diarrhea.  Only 5-10% of travelers have TD symptoms longer than 2 weeks . 

Initial laboratory investigations into diarrhea in a traveler should include electrolyte panels and stool studies looking at the presence of fecal red blood cells, white blood cells, ova and parasitic studies and a bacterial culture.  A Wright’s stain for fecal leukocytes has 82% sensitivity and 83% specificity for presence of invasive bacterial pathogens, although some clinicians feel this test is no longer useful due to cost and labor .  The rational is to limit this test for severely dehydrated, immunocompromised, toxic appearing patients.  

Gastro-intestinal tractAnatomy and Diet:  Knowledge of the intestinal anatomy and physiology is key to understand proper dietary modifications and treatment for those effected by traveler’s diarrhea.  The inner lining of the intestinal wall on the small intestines is lined with a brush border that contains enzymes to assist in food digestion.  The specific enzyme (lactase) that breaks down lactose (found in dairy products) is the concern and can be particularly fragile.  When someone suffers from diarrhea, this brush border containing lactase is frequently damaged and excreted with the diarrhea.  This person is now without the ability to digest lactose as effectively as they did before their diarrheal illness.  Thus, the bits of food containing lactose in their intestines go undigested and can act as an osmotic attractant to the water in their body.  Basically, the undigested bits of dairy food (cheese, milk, etc) actually draw more water into the intestine, causing more diarrhea and water loss.  Avoidance of dairy products during diarrheal illnesses should be considered for this reason.  After a few days to 1 week of no symptoms, the brush border typically re-grows to the level it was at before the diarrhea.

Prevention of Traveler’s Diarrhea:  Prevention of TD centers around three methods: dietary safety, immunizations and chemoprophylaxis (medications taken to prevent diarrhea).
 
Education on safe eating practices should form the basis of protection.  Hand washing before meals should become second nature.  Avoid eating at locations that look dirty or if the chef has a sore on their hand.  Ensure your food is properly cooked and drink only from clean and purified water sources.  Bottled water is good but poured over ice made from contaminated water does not help you avoid illness. 
Fruit BowlThe Travel and Tropical Medicine Manual advises these 10 rules for selection of safe food and water:
1) Drink purified water or bottled carbonated water
2) Eat foods that are thoroughly cooked and served piping hot
3) Eat fruits that have thick skins and these should be peeled at the table by the traveler
4) Avoid salads that include raw vegetables, especially green leafy vegetables
5) Do not use ice cubes in any beverages, including alcoholic beverages
6) Only eat and drink dairy products made from pasteurized milk
7) Avoid shellfish and raw or undercooked seafood, even if “preserved” with lime/lemon juice or vinegar
8) Do not buy and eat food sold by street vendors
9) If canned beverages are cooled by submersion of the can in a bucket of ice water or stream, be sure to dry off the outside of the can prior to drinking
10) Use purified water for brushing teeth and taking medications

I have to admit that I do not always follow all of these rules.  I am what expedition doctors call an “adventurous eater” and am considered higher risk for acquiring TD because of these actions.  Sticking to these rules can go along way in preventing traveler’s diarrhea.

Immunizations to prevent traveler’s diarrhea:  Few vaccines exist to prevent TD.  Some to consider include the vaccine against Hepatitis A and the typhoid vaccine, both of which are very effective at preventing those specific causes of TD.  There is also a vaccine against Cholera, which is not very effective.

Chemoprophylaxis to prevent traveler’s diarrhea:  Taking medicine to prevent TD is not necessarily for every traveler, for a variety of reasons.  Should you be considering this regime, speak with your personal travel health provider before your trip.  Conditions and travelers who may benefit from such prophylaxis include those on honeymoon, business travelers, athletes and travelers with prior chronic medical conditions.  Generally, travelers should be encouraged to carry antibiotics to treat TD once acquired rather than taking a daily medication to prevent illness.  Common routines can include:

Bismuth-Subsalicylate(Pepto-Bismol)
2 tablets or 60mL solution taken every 6 hours
Studies have shown this to be less effective than antibiotics; not for use by those with aspirin allergies, those taking other salicylate medicines, pregnant travelers or children.  Frequent doses and large numbers of tablets required to be packed may effect compliance.

trimethoprim160mg/sulfamethoxazole 800mg(Bactrim, Septra)
One tablet daily
Not to be used by those with sulfa allergy, may be ineffective in some parts of the world due to bacterial drug resistance

Doxycycline 100mg
One tablet daily
Not for use by pregnant travelers, children under age 8 years.  May cause vaginal yeast infections and increased sun sensitivity.

Ciprofloxacin 500mg
One tablet daily
Not for use by pregnant travelers, children under age 18 years and those with allergies to quinolone antibiotics.  Some drug-drug interactions are possible, especially with caffeine

Probiotics
Saccharomyces boulardii and  Lactobacillus species have been shown to decrease rates of TD by approximately 8% .  This appeared more effective in children than adults and in decreasing diarrhea rates in those already taking antibiotics.  Further studies need to be done to clearly note efficacy for use in TD prevention. 

Treatment of Travelers Diarrhea Symptoms:  Treatment of TD typically centers on rehydration, lessening diarrheal symptoms and antibiotic medication.  Self-treatment of TD is simply the traveler getting a prescription of antibiotics to take upon the onset of symptoms, while on their trip.  When attempting self-treatment, the traveler needs to first ensure they are adequately rehydrating.  Rehydration can be achieved with copious amounts of pure water and electrolyte replacement drinks.  Lessening diarrheal symptoms can be accomplished by taking medications designed to decrease the frequency of the stools.  Common choices for symptomatic relief of TD include:

Bismuth-subsalicylate(Pepto-Bismol)
2 tabs or 30mL solution every 30 minutes for 8 total doses

Diphenoxylate-Atropine(Lomotil)
2 tabs for first dose then 1 tab after each loose stool, not to exceed 8 tabs in 24 hours.
Do not use if blood is present in stool.

Loperamide(Imodium)
2 capsules for first dose then 1 capsule after each loose stool, not to exceed 8 capsules in 24 hours.  Do not use of there is blood present in stool.

Caution should be used when taking medications to prevent diarrhea symptoms.  Diarrhea is the body’s way or excreting harmful pathogens and trapping them inside the intestines can cause more harm.  The presence of blood in the stool should prompt one to seek medical treatment and avoid the use of medications designed to prevent diarrhea symptoms. 

Antibiotics for self-treatment of traveler’s diarrhea:  Choice of empiric antibiotic treatment is base on several factors including location of the trip and resistance of local pathogens, age of the traveler and prior medical conditions.  Antibiotic choices should be discussed with a travel health professional prior to the trip.

Trimethoprim160mg/Sulfamethoxazole 800mg(Bactrim, Septra)
One double strength tablet every 12 hours for 3 days
Not to be used by those with sulfa allergy, may be ineffective in some parts of the world due to bacterial drug resistance

Ciprofloxacin500mg (Cipro)
One tablet every 12 hours for 3 days
Not for use by pregnant travelers, children under age 18 years and those with allergies to quinolone antibiotics.  Some drug-drug interactions are possible, especially with caffeine and antibiotic resistance is increasing worldwide

Azithromycin(Zithromax)
One gram as a single dose or 500mg daily for 3 days
The drug of choice for quinolone resistant Campylobacter species

Rifaximin(Xifaxin)
200mg tablet every 8 hours for 3 days
Use with children over the age of 12 years and adults only

 Tetracycline
2.5 grams as a single dose or 500mg every 6 hours for 3-5 days
Not for use by pregnant travelers, children under age 8 years.  May cause vaginal yeast infections and increased sun sensitivity.

Doxycycline
100mg tablet every 8 hours for 3-5 days
Not for use by pregnant travelers, children under age 8 years.  May cause vaginal yeast infections and increased sun sensitivity.  Drug resistance increasing worldwide

Tapeworms and travel

Pork Tapeworm Head

Pork Tapeworm Head

A friend of mine recently returned from a surfing trip in Mexico, for several weeks.  While he was there, he had a great time and got some really good waves.  He also got sick when he came back and was diagnosed with having an intestinal tapeworm, he assumes he acquired during his travels.  He asked for some more information on the infection and here’s what I told him.

Basics: There are two main types of  “tapeworms” in humans.  Taenia Saginata is associated with undercooked beef and Taenia Solium is associated with undercooked pork.  Tapeworms like to live in the intestines of the host.  The eggs may be found anywhere in the body and can cause seizures if in brain tissue (neurocysticercosis).

 Location: Worldwide, prevalent in areas where undercooked beef or pork are eaten

Transmission/ Incubation: Acquired by the ingestion of undercooked beef or pork meat that is infected with the larval stage of either species. The patient may be asymptomatic for years before diagnosis.

Prevention: Adequately cooking beef and pork, education about fecal contamination of soil, water, livestock pens

Diagnosis: Demonstration of eggs or proglottids in fecal smear. The eggs of both species are indistinguishable, only proglottids are different
 
Treatment: Praziquantel is considered first-line and albendazole may be used for neurocysticercosis. Consider steroids for cerebral edema in neurologically symptomatic patient, especially during treatment, as the larvae die.
 
Taenia saginata (beef tapeworm)

Taenia saginata (beef tapeworm)

This infection is far more common than people believe and is actually a fairly common cause of “first time” seizures, in adults.  Typically, the infected person has minor bouts of diarrhea and vomiting, and after a few weeks, may notice some weight loss.  More serious problems an occur if the worm begins to obstruct the intestines, causing appendicitis or localized inflammation in the liver or pancreas.  The adult worms can get long…up to 10 meters!  The parasite pictured on the left is only about 4 meters in length.
 
  
Overall, travelers need to know that their food, especially beef and pork, should be completely cooked.  This generally kills the worms that may live in the flesh and is sufficient to prevent infection.  The incubation period is varied and patients may not show signs of infection for years, although a few weeks is common.  This means that most travelers will deal with the illness when they return back home, unless they are on extended travels or an expat
 
One of my favorite “home remedies” and the subject of myth is the use of a cigarette to kill the parasite.  One of my favorite books, the Special Forces Medical Handbook, discusses this method.  I certainly do not advise this method, as there are much better antibiotics that effectively kills the parasites.  However, the books section on primitive treatments lists several treatments of this nature.  The basic premise is too change the environment of the intestinal tract, thus causing the worm too de-attach and get passed out in feces. 
  • Four tablespoons of salt taken in one quart of warm water, as a one time dose
  • Tobacco, 1 to 1.5 cigarettes, uses the nicotine to stun the parasite, allowing the worm to be passed.  This treatment should not be repeated more than once in 48 hours and only tried twice
  • Hot peppers used as a steady and frequent part of the diet may offer some protection

I am interested in these “primitive remedies” but do not advocate their use, especially when safe and proper antibiotics can be easily obtained.

The best thing a travel can do, to prevent this, is to make sure their food is properly cooked.  A simple examination of the feces (under microscope) is usually good enough to diagnose the infection and antibiotic treatment is simple. 

Vaccine for Giardia

Giardia lamblia

Giardia lamblia

Vaccines can do wonderful things for people and especially travelers.  Scientists are one step closer to creating a vaccine against Giardia, scourge of the traveler and outdoor adventurer.  A recent article, published in Nature, looks at a discovery that should play a vital role in the development of  a vaccine for Giardia. 

Giardia is a protozoan infection that effects the small intestine, most frequently.  Symptoms of infection can range from none at all to “explosive diarrhea”, flatulenceand abdominal cramping.  This difficult to kill bug is most commonly acquired through drinking infected water or poor sanitation such as “hand to mouth” contact with infected feces, also known as fecal-oral transmission.  Unfortunately, giardia can be found worldwide and is responsible for 100,000 to 2.5 million infections per year, in the US, alone.  

Life Cycle

The life cycle of giardia has two basic forms, a cyst and a trophozoite.  The trophozoite is responsible for the symptoms associated with the illness.  Trophozoites are a very fragile form and do not live long, outside of a host.  The cyst is the method of transportation and is remarkably durable.  Cysts can even survive both freezing and boiling, for short periods of time.  When a person becomes infected, it is usually through ingestion of cysts, as stomach acid kills the trophozoite form.  Once ingested, the cysts mature into the damaging trophozoite form, in the intestines.

Lifecycle

Lifecycle

Portable water filter

Portable water filter

Water Purification

Hopefully, most all adventurers know that water purification is an important step in preventing illness.  Giardia is one of the reasons why you want to treat or purify your water.   While there are many methods to prepare water for human consumption, not all of them are effective against the giardia cysts.

Boiling is effective at killing cysts, if done for a long enough time.  Water temperatures of 100 degrees Celsius (212 F) are generally able to kill the cysts on contact.  Water at a temperature at only 60 degrees Celsius (140 F) requires 10 minutes and only offers a 98% inactivation of cysts.  Also remember that boiling times vary depending on altitude.

Filtration is effective at keeping cysts out of your drinking water, provided the pores in the filter are small enough.  3-5 micrometers is considered the maximum pore size for stopping the cysts.  Remember that only a few cysts are required to cause infection in humans.  One study showed that only 10-25 cysts caused infection in 8 of 25 people and more than 25 cysts caused 100% infection.

Halogens, such as iodine and chlorine, kill giardia cysts, as well.  Some difficulties begin to arise, using these methods, for several reasons.  Higher concentrations of halogens are required to kill cysts, than other typical water bacteria.  This means more of that unpleasant iodine or chlorine taste in your water.  Longer “contact time” is also required, meaning that you will have to wait longer to drink the water your are preparing, giving the halogens more time to work.  Lastly, water temperature effects the halogen’s effectiveness.  Data for using chlorine, to achieve a 99.9% kill, shows that 0.5 mg per liter concentration requires 6-24 hours at 3-5 degrees Celsius.  A solution of 1.5 mg per liter takes only 10 minutes at room temperature.

Clearly, the prevention of giardia is a difficult task and that is just for personal use!  A vaccine for giardia prevention would also help alleviate mortality associated with massive dehydration due to diarrhea, in developing nations.

Back to the Vaccine

The difficulty for producing a vaccine against giardia centers around it’s ability to express 190 different surface proteins.  This basically allows giardia to have one outer coating, then for a previously unknown reason, switch to another.   Anything that has 190 different “doors” is tough to find a key for.  The exciting thing about the work being done, by Dr. Lujan and his group, is that they have found a way to force giardia to express all of it’s 190 surface proteins at one time.  Basically, the protozoa is made to show all of the defensive adaptations, at one time.

Dr. Lujan and his team also feel that this may be an important step towards development of vaccines for trypanosomes such as those responsible for “sleeping sickness” and Leishmania

Antigenic variation in Giardia Lamblia is regulated by RNA interference, published in “Nature” issue 456

Cholera/Diarrheal Illness Updates

Promed has posted some new updates and it looks like Vietnam is getting into some trouble. 1216 people form 13 provinces have contracted acute diarrheal illness. This is since October 23, 2007. 157 cases are positive for Cholera. This appears to be linked to the raw shrimp paste, frequently used in local foods, and poor food hygiene.

This is not just a disease of rural areas, 2 chefs at a 5 star hotel restaurant tested positive for cholera bacteria, just yesterday!

A quote from the Promed Article that covered sums it up:
On Thu 8 Nov 2007, alone, the country detected 165 new infection
cases, including 47 from Hanoi capital, 41 from northern Ha Tay
province, and 20 from northern Hung Yen province.

Baghdad and Iraq continue to have an increase in cases, with the number of cholera cases increasing sharply from 11 to 24 in one week. The areas hardest hit appear to be in the north, with some activity in the center of the country, as well.

Adventure Doc Traveler’s Diarrhea

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