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ncidence Rates of Traveler's Diarrhea in the Initial 2 Weeks of Stay in Various Regions of the World Among Visitors Residing in Industrialized Countries, 1996-2008
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Acute diarrhea is the most common illness that affects travelers to low-income regions of the world. Although improved hygiene has reduced the risk of traveler's diarrhea in many destinations, the risk remains high in others.
To review the current state of knowledge on the etiology, risk factors, prevention, and management of traveler's diarrhea.
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Citations
... Thus, collecting antimicrobial therapy data would be beneficial as it could encourage the reduction of unnecessary antibiotic administration in the future, suppressing resistant bacterial strains. Generally, TD is self-limiting without antimicrobial therapy (1). In this study, 58/731 patients (8%) with unknown causative organisms were prescribed antimicrobial drugs. ...
Traveler's diarrhea (TD) is a global problem, and identifying the causative organisms of TD is important for adequate treatment. Therefore, this study retrospectively analyzed TD cases in patients who returned to Japan after traveling abroad to determine the causative organisms by travel region. We included patients with a final diagnosis of TD registered in the Japan Registry for Infectious Diseases from Abroad database from September 25, 2017, to September 1, 2022, from 14 medical institutions. A total of 919 patients were analyzed; the causative TD pathogen was identified in 188 cases (20%), of which 154 were caused by diarrheagenic bacteria, the most common being Campylobacter spp. (64%). A 2.2 mg/dL C-reactive protein concentration cutoff value had some predictive ability for bacterial TD (negative predictive value, 89%). Therefore, the C-reactive protein level may help rule out bacterial diarrhea and prevent unnecessary antimicrobial administration when patients cannot provide a stool specimen.
... The exhibition of catches for commercialization in trays with no incline and with water-ice that does not comply with norm NOM 251-SSA1-2009 [20] can be another source of contamination of the octopuses. Even in boiled octopus, our analyses found values for TC and FC that exceeded allowable levels, therefore representing a risk for human health when consumed, which, according to Steffen et al. [38], can cause gastrointestinal infections. While the study did not apply a confirmatory test for the presence of Escherichia coli and, thus, the MPN could pertain to this species or some other in the group of thermotolerant bacteria, the presence of fecal coliforms is an indicator of anthropogenic contamination that must be addressed. ...
Simple Summary
The contamination of coastal waters, unhealthy conditions and inadequate handling practices tend to reduce the sanitary quality of fishery products, thus impacting its marketing. With this in mind, we investigate the microbiological quality of the Octopus insularis in each stage of the production chain, comprehending capture, post-capture, processing and commercialization, in terms of the presence of total and fecal coliforms at the Veracruz Reef System, Gulf of Mexico. The environmental and anthropogenic influence on the space–temporal concentration of coliforms were analyzed in sea water, fresh octopus, fresh water, ice and octopus, both packed in ice and boiled. Most relevant results indicated that coliforms are present in the octopus production chain, being highest in the marketing stage. The coliform concentration increased during the rainy season and was highest in the reefs closer to the coast, which has a major anthropogenic influence. These results point out the urgent need to implement an efficient cold chain with adequate handling practices to try to reverse these microbiological conditions and improve the octopus quality and food safety.
Abstract
Coliforms are relatively common in aquatic environments, but their concentrations can be increased by environmental changes and anthropogenic activities, thus impacting fisheries resources. To determine the microbiological quality in the octopus production chain (capture, post-capture, processing and commercialization), total (TC) and fecal (FC) coliforms were quantified in sea water, fresh octopus, fresh water, ice and octopus in two presentations: packed in ice and boiled. Samples came from fishing zones Enmedio, Chopa and La Gallega at the Veracruz Reef System (VRS) during dry, rainy and windy seasons. The coliforms were determined using the most probable number technique (MPN). The most relevant results indicated that octopus packed in ice coming from the commercialization stage had FC levels >540 MPN/100 g, which exceeded the permissible limits (230 MPN/100 g). Therefore, these products present a risk for human consumption. Differences in FC were observed in octopuses between the three fishing zones (H = 8.697; p = 0.0129) and among the three climatic seasons, increasing during the rainy season, highlighting La Gallega with 203.33 ± 63 MPN (H = 7.200; p = 0.0273). The results provide evidence of the environmental and anthropogenic influences on coliform concentrations and the urgent need to implement an efficient cold chain throughout octopus production stages with adequate handling practices to reverse this situation.
... Travelers' diarrhea (TD) is the most common travel-related illness, affecting approximately 10-14 million people annually [1][2][3][4]. Vaccine development remains a primary prevention strategy, particularly for the most common etiologies such as enterotoxigenic Escherichia coli (ETEC), Shigella, Campylobacter, and norovirus [4][5][6]. Additionally, the emergence of antimicrobial resistance (AMR) in common bacterial TD pathogens has increased the need for primary prevention and has led public health stakeholders to urge for the acceleration of vaccine development [7,8]. ...
... Only developed for subjects meeting protocol definition of TD (>3 unformed or watery stools in 24-h period, accompanied by >1 accompanying gastrointestinal (GI) symptom (GI) of any intensity/severity (see Table 1). 3 Comparable PE (57%; p = 0.22) was seen if subjects indicated their ETEC TD episode caused a change in their daily activity. NS = Not Significant. ...
... loose or watery stools in a 24-h period, accompanied by abdominal pain or cramps, nausea, or vomiting of any intensity, plus ETEC as the sole pathogen isolated. 2 ETEC TD, plus at least one moderate to severe GI symptom or ETEC TD, or changes in activity due to illness severity.3 At a higher arrival threshold, anti-CTB serum IgA titer of ≥640, OKV significantly reduced the risk of Campylobacter infection, in addition to protection against Campylobacter TD (RR = 0.29, CI 0.06-1.3; ...
The efficacy of an Oral Whole Cell ETEC Vaccine (OEV) against Travelers’ Diarrhea (TD) was reexamined using novel outcome and immunologic measures. More specifically, a recently developed disease severity score and alternative clinical endpoints were evaluated as part of an initial validation effort to access the efficacy of a vaccine intervention for the first time in travelers to an ETEC endemic area. A randomized, double-blind, placebo-controlled trial followed travelers to Guatemala or Mexico up to 28 days after arrival in the country following vaccination (two doses two weeks apart) with an ETEC vaccine. Fecal samples were collected upon arrival, departure, and during TD for pathogen identification. Serum was collected in a subset of subjects to determine IgA cholera toxin B subunit (CTB) antibody titers upon their arrival in the country. The ETEC vaccine’s efficacy, utilizing a TD severity score and other alternative endpoints, including the relationship between antibody levels and TD risk, was assessed and compared to the per-protocol primary efficacy endpoint. A total of 1435 subjects completed 7–28 days of follow-up and had available data. Vaccine efficacy was higher against more severe (≥5 unformed stools/24 h) ETEC-attributable TD and when accounting for immunologic take (PE ≥ 50%; p < 0.05). The vaccine protected against less severe (3 and 4 unformed stools/24 h) ETEC-attributable TD when accounting for symptom severity or change in activity (PE = 76.3%, p = 0.01). Immunologic take of the vaccine was associated with a reduced risk of infection with ETEC and other enteric pathogens, and with lower TD severity. Clear efficacy was observed among vaccinees with a TD score of ≥4 or ≥5, regardless of immunologic take (PE = 72.0% and 79.0%, respectively, p ≤ 0.03). The vaccine reduced the incidence and severity of ETEC, and this warrants accelerated evaluation of the improved formulation (designated ETVAX), currently undergoing advanced field testing. Subjects with serum IgA titers to CTB had a lower risk of infection with ETEC and Campylobacter jejuni/coli. Furthermore, the TD severity score provided a more robust descriptor of disease severity and should be included as an endpoint in future studies.
... Globally, previous studies found up to 20% of diarrhea among travelers, mostly due to poor hygiene and food safety (Steffen et al., 2015). Acute diarrhea is common during travel, especially in lowmiddle-income countries, including Indonesia. ...
Background: The availability of safe, healthy, and clean food in tourism places is essential to ensure customers’ satisfaction. Most previous studies focused on food safety practices among food handlers. However, personal food safety practices are needed to prevent foodborne diseases. Objective: This study aimed to identify the factors associated with food safety practices among people who visited Depok Beach. Methods: A quantitative approach was done on 211 Depok Beach visitors selected by the accidental sample method. This study was conducted from September to October 2022. Descriptive statistics, chi-square, and binary logistic regression were used for data analysis. Results: This study found that factors such as marital status, knowledge, and attitude were 2.8, 1.2, and 2.2 times, respectively, more likely to practice poor food safety practices. Conclusion: The food safety practice among visitors was less than average. The factors associated with food safety practices among visitors were marital status, knowledge, and attitude about food safety. Health promotion about food safety for customers is needed. Further studies could mix with the qualitative approach to get comprehensive findings.
... Amongst gastroenteritis agents associated with PI-IBS, enterotoxigenic Escherichia coli is the predominant cause in South America, Africa and Southern Asia whilst Campylobacter is more common in Southern and South-East Asia. 1,5 We subsequently examined risk factors for PI-IBS. Stomach cramps during travel were the strongest independent predictor for PI-IBS acquisition (OR adjusted 5.92, 95%CI 2.17-16.12) ...
By longitudinally following a large cohort of intercontinental travellers, this study highlights the importance of considering multiple risk factors to comprehend post-infectious Irritable Bowel Syndrome (PI-IBS). Stomach cramps, antibiotic use and nausea during travel were among the variables that predicted PI-IBS development following an episode of traveller's diarrhoea.
... Approximately 30% of the bacteremia cases in hospitals are caused by this bacterium -for example, a 71% increase in the bloodstream infections reported by the European Antimicrobial Resistance Surveillance Network. This figure is responsible for approximately 280 million cases of diarrhea and bloodstream infections and 400,000 deaths every year, most of them among young children from all over the world (Salame-Khouri et al., 2018;Steffen et al., 2015). In addition, the antibiotic resistance of some E. coli strains has been detected in all parts of the world and is one of the major public health challenges. ...
In developing countries, the risk of getting sick from eating food contaminated with Escherichia coli is very high. As a consequence of the multidrug resistance of this bacterium, a therapeutic alternative has been sought in the plant kingdom. The Objective of this research was to evaluate the antibacterial effect of pot marigold (Calendula officinalis) essential oil (EO) on the growth of E. coli. Design/Methodology/Approach: The antibacterial activity was determined using a Kirby-Bauer disk diffusion susceptibility test. A 90 to 60% dilution of EO generated 24 to 22 mm halos. The EA was subjected to a GC/MS analysis. The results showed that cadinene (53.8%) was the main constituent, followed by germacrene (22.5%). The minimum inhibitory concentration was 7 μg mL-1. Findings/Conclusions: C. officinalis EO can be considered as an option in the treatment against this enterobacteria.
... Incidence rates for travelers' diarrhea are generally in the range of 20-40% in high-risk countries including Asia, Africa, and Latin America. [5][6][7] There are several challenges associated with TD management. Epidemiologic and clinical studies showed that bacterial enteropathogens accounted for 80-90% of cases and that antimicrobial resistance to fluroquinolones and azithromycin has increased in high-risk destination countries. ...
... Epidemiologic and clinical studies showed that bacterial enteropathogens accounted for 80-90% of cases and that antimicrobial resistance to fluroquinolones and azithromycin has increased in high-risk destination countries. [5][6][7][8][9][10][11] Additionally, systemic antibiotics for treating TD are associated with increased acquisition (8.8% to 80.0%) and transmission of the extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE). [10,[12][13][14][15][16] Non-absorbable antibiotics, such as rifamycin-SV, for treating non-dysenteric TD are associated with significantly lower ESBL-PE acquisition than ciprofloxacin. ...
Background:
Travellers' diarrhoea (TD) is frequently reported with incidence up to 40% in high-risk destinations. Previous studies showed that the number of loose stools alone is inadequate to holistically predict the severity of TD.1-3 To improve prediction of prognosis and to optimize treatments, a simple risk-based clinical severity classification has been developed.
Methods:
Pooled baseline data of signs and symptoms and number of loose stools from 1098 subjects enrolled in two double-blind Phase 3 trials of rifamycin-SV were analysed with correlation, multiple correspondence analyses, prognostic factor criteria, and Contal and O'Quigley method to generate a TD severity classification (mild, moderate, severe). The relative importance of this classification on resolution of TD was assessed by Cox proportional model hazard model on the time to last unformed stool (TLUS).
Results:
The analysis showed TLUS were longer for the severe [HR 0.24; p < 0.001; N = 173] and moderate [HR 0.54; p = 0.0272; N = 912] vs. mild. Additionally, when the treatment assigned in the studies was investigated in the severity classification, the results yielded that rifamycin-SV significantly shortened TLUS vs. placebo for all subjects (HR 1.9; p = 0.0006), severe (HR 5.9; p = 0.0232), and moderate (HR 1.7; p = 0.0078) groups and was as equally efficacious as ciprofloxacin for all subjects, moderate, and severe groups (HRs: 0.962, 0.9, 1.2; all p = NS, respectively). When re-assessed by this classification, rifamycin-SV showed consistent efficacy with the Phase 3 studies.
Conclusions:
This newly developed TD clinical severity classification demonstrated strong prognostic value and clinical utility by combining patients' multiple signs and symptoms of enteric infection and number of loose stools to provide a holistic assessment of TD. By expanding on the current classification by incorporating patient reported outcomes in addition to TLUS, a classification like the one developed, may help optimize patient selection for future clinical studies.
... While abroad, students need to be aware of the dangers of developing health problems in an unfamiliar living environment [4]. Among them, diarrhea is the most common problem among travelers moving from developed to tropical and developing regions [5,6]. This may also apply to students studying abroad, although past studies mostly targeted tourists [7][8][9]. ...
... This may also apply to students studying abroad, although past studies mostly targeted tourists [7][8][9]. Based on the data about travelers' diarrhea risk during the first two weeks of stay, destinations have been categorized into three groups: low risk (<8%), intermediate risk (�8 to <20%), and high risk (�20%) [5]. ...
... In general, travelers' personal characteristics (e.g., age, country of origin, immunity, and low-gastric acidity) were shown to be associated with a higher risk of diarrhea [5,6]. However, despite an increasing number of students studying abroad, evidence about their personal characteristics associated with diarrhea remains sparse. ...
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.
... These pathogens are a predominant cause of acute diarrheal illness as well as deaths due to diarrhea in developing countries among young children. Likewise, ETEC are perennially the major cause of traveler's diarrhea (51,52). ETEC have also been linked repeatedly to poorly understood sequelae among young children in LMICs including enteropathic changes to the small intestine and accompanying nutrient malabsorption and growth stunting (53)(54)(55)(56)(57). ...
The pathogenic Escherichia coli can be parsed into specific variants (pathovars) depending on their phenotypic behavior and/or expression of specific virulence factors. These pathogens are built around chromosomally-encoded core attributes and through acquisition of specific virulence genes that direct their interaction with the host. Engagement of E. coli pathovars with CEACAMs is determined both by core elements common to all E. coli as well as extrachromosomally-encoded pathovar-specific virulence traits, which target amino terminal immunoglobulin variable-like (IgV) regions of CEACAMs. Emerging data suggests that engagement of CEACAMs does not unilaterally benefit the pathogen and that these interactions may also provide an avenue for pathogen elimination.
... 193 Traveler's Diarrhea SA carries a high risk of traveler's diarrhea in transplant recipients, with an incidence of 10% to 40%. 193,194 The risk is highest during the first 14 d of travel. 193,195 The most common causes of traveler's diarrhea include Enterotoxigenic E coli followed by Enteroaggregative E coli, Shigella Salmonella, and Campylobacter jejuni. ...
... 193,195 The most common causes of traveler's diarrhea include Enterotoxigenic E coli followed by Enteroaggregative E coli, Shigella Salmonella, and Campylobacter jejuni. 194 Additionally, traveler's diarrhea can occur because of other parasitic and helminthic infections in SA like Cryptosporidium, Cyclospora, Giardia, Ascaris, and helminths. 193,194 Amebiasis is common and should always be included in the differential diagnosis of traveler's diarrhea. ...
... 194 Additionally, traveler's diarrhea can occur because of other parasitic and helminthic infections in SA like Cryptosporidium, Cyclospora, Giardia, Ascaris, and helminths. 193,194 Amebiasis is common and should always be included in the differential diagnosis of traveler's diarrhea. Mycophenolate mofetil can sometimes cause chronic diarrhea, occasionally triggered by an infection. ...
These guidelines discuss the epidemiology, screening, diagnosis, posttransplant prophylaxis, monitoring, and management of endemic infections in solid organ transplant (SOT) candidates, recipients, and donors in South Asia. The guidelines also provide recommendations for SOT recipients traveling to this region. These guidelines are based on literature review and expert opinion by transplant physicians, surgeons, and infectious diseases specialists, mostly from South Asian countries (India, Pakistan, Bangladesh, Nepal, and Sri Lanka) as well as transplant experts from other countries. These guidelines cover relevant endemic bacterial infections (tuberculosis, leptospirosis, melioidosis, typhoid, scrub typhus), viral infections (hepatitis A, B, C, D, and E; rabies; and the arboviruses including dengue, chikungunya, Zika, Japanese encephalitis), endemic fungal infections (mucormycosis, histoplasmosis, talaromycosis, sporotrichosis), and endemic parasitic infections (malaria, leishmaniasis, toxoplasmosis, cryptosporidiosis, strongyloidiasis, and filariasis) as well as travelers' diarrhea and vaccination for SOT candidates and recipients including travelers visiting this region. These guidelines are intended to be an overview of each topic; more detailed reviews are being published as a special supplement in the Indian Journal of Transplantation.
