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PubMed2001

Water disinfection for international and wilderness travelers.

Acquisition of waterborne disease is a substantial risk for international travelers to countries with inadequate sanitation facilities. It also poses smaller but still significant risks for wilderness travelers who rely on surface water in developed countries with low rates of diarrheal illness, such as the United States. This article reviews the etiology and risks associated with waterborne disease that might be encountered by both types of travelers. It also summarizes--and makes recommendations for--the various water-treatment methods available to travelers for reducing their risk of contracting waterborne disease.

Alum Compounds↗
PubMed2002

Drug prophylaxis for travelers' diarrhea.

Travelers' diarrhea is the most common health impairment in persons visiting developing countries, affecting 20% to >50% of tourists. Although it is usually benign, travelers' diarrhea represents a considerable socioeconomic burden for both the traveler and the host country. The most common enteropathogens are enterotoxigenic and enteroaggregative Escherichia coli. Travelers' compliance with dietary precautionary measures is poor. Despite the excellent protection rates provided by antibiotics, routine administration of prophylaxis is currently not recommended because of potential adverse reactions. Of the various antibiotics that have been tested, quinolones are considered to be the first choice worldwide; however, quinolone-resistant pathogens are increasingly being isolated. Because it is frequently administered and provides only moderate protection, bismuth subsalicylate is not considered a recommendable option for prophylaxis in Europe, where it is rarely available anyhow. To date, no probiotic has been able to demonstrate clinically relevant protection worldwide. In conclusion, there is no satisfactory prophylactic option, and worldwide monitoring of antimicrobial susceptibility patterns and the search for novel antimicrobial agents, such as nonabsorbed antibiotics, and nonantibiotic medications should continue.

4-Quinolones↗
PubMed2002

Markers of inflammation in bacterial diarrhea among travelers, with a focus on enteroaggregative Escherichia coli pathogenicity.

The intestinal inflammatory response of traveler's diarrhea acquired in Goa, India, and Guadalajara, Mexico, was studied. Fecal lactoferrin was found in stool samples in which enteroaggregative Escherichia coli (EAEC), enterotoxigenic E. coli, or Salmonella or Shigella species were isolated, with Shigella-positive cases showing the highest level. Samples from cases of Shigella-associated diarrhea had the highest concentrations of fecal cytokines. Travelers to India who had EAEC-associated diarrhea showed elevated levels of interleukin (IL)-8 (median, 341.15 pg/mL) and IL-1beta (median, 749.90 pg/mL). Although 15 travelers to Mexico who had EAEC-associated diarrhea had a median concentration of 0 pg/mL for both IL-8 and IL-1beta, 2 had high levels of IL-8 (1853 and 11,786 pg/mL), and 5 showed elevated levels of IL-1beta (1-1240 pg/mL). Samples from patients in India who had pathogen-negative diarrhea or from patients in Mexico who had asymptomatic EAEC infection were negative for cytokines. Bacterial pathogens causing traveler's diarrhea commonly produce intestinal inflammation, although a subset of patients with EAEC-associated diarrhea fail to develop an inflammatory response.

Biomarkers↗
PubMed2002

Fungal infections among returning travelers.

Endemic mycoses, such as histoplasmosis, coccidioidomycosis, and penicilliosis, have emerged as important health threats among travelers to regions of the world where these infections are endemic. Travelers have developed fungal infections as a result of a wide range of recreational and work activities, many of which have involved well-recognized risk factors for these diseases. In some instances, infections have been acquired during short trips, whereas, in other instances, infection has been acquired during a longer period of residence in an area where the infection is endemic. Travelers need to be made aware of the risks of acquiring mycotic diseases when visiting such regions. Health care providers need to consider these infections in their differential diagnosis among returning travelers with respiratory illness and should be familiar with the treatment and prevention of these diseases.

Coccidioidomycosis↗
PubMed2003

Azithromycin found to be comparable to levofloxacin for the treatment of US travelers with acute diarrhea acquired in Mexico.

Increased drug resistance among enteropathogens is an emergent problem in travelers' diarrhea. This randomized, double-blind trial was conducted in Guadalajara, Mexico, during the summers of 1999-2001 to compare azithromycin with levofloxacin for the treatment of travelers' diarrhea. A total of 217 US adults were randomized to receive a single oral dose of azithromycin (1000 mg; 108 persons) or levofloxacin (500 mg; 109 persons), with a follow-up period of 4 days. Three patients in each group dropped out of the study. The median time between initiation of therapy and passage of the last unformed stool (azithromycin group, 22.3 h; levofloxacin group, 21.5 h) and the number of unformed stools passed during the 4-day follow-up period (azithromycin group, 6.5; levofloxacin group, 5.5) were similar. Treatment failure occurred in 10 patients (9.5%) receiving azithromycin and 8 patients (7.5%) receiving levofloxacin. Possible minor, self-limiting adverse events occurred in 57 patients in each treatment group. Azithromycin was found to be a safe and effective alternative to levofloxacin for the treatment of acute travelers' diarrhea in US adult travelers to Mexico.

Adult↗
PubMed2005

Antibacterial chemoprophylaxis in the prevention of traveler's diarrhea: evaluation of poorly absorbed oral rifaximin.

The use of antibacterial drugs was first shown to effectively reduce the occurrence of traveler's diarrhea nearly 50 years ago. The approach was not encouraged for general use by a Consensus Development Conference in 1985 because of concerns about adverse effects of the drugs and the possible development of resistance against systemically absorbed drugs. When therapy with poorly absorbed rifaximin was shown to be as effective as therapy with systemically absorbed drugs in shortening the duration of traveler's diarrhea, without the development of resistant coliform flora, the use of rifaximin for the prevention of traveler's diarrhea was studied. In the present study, rifaximin provided 72% protection against the development of diarrhea and 77% protection against active or treated diarrhea during 2 weeks of drug administration to United States students in Mexico. Rifaximin offers a potentially useful approach for preventing traveler's diarrhea. Potential areas of future study include use of the drug to prevent diarrhea due to mucosally invasive bacteria, including ciprofloxacin-resistant Campylobacter species, and to reduce the occurrence of postinfectious irritable bowel syndrome.

Adolescent↗
PubMed2005

Non-travel-associated hepatitis E in England and Wales: demographic, clinical, and molecular epidemiological characteristics.

Between 1996 and 2003, 186 cases of hepatitis E were serologically diagnosed. Of these, 17 (9%) were not associated with recent travel abroad. Patients were >55 years old (range, 56-82 years old) and tended to be male (76%). Two patients presented with fulminant hepatitis. A total of 129 (69%) cases were associated with recent travel to countries where hepatitis E virus (HEV) is hyperendemic. Compared with patients with travel-associated disease, patients with non-travel-associated disease were more likely to be older, living in coastal or estuarine areas, not of South Asian ethnicity, and infected by genotype 3 strains of HEV. The genotype 3 subgenomic nucleotide sequences were unique and closely related to those from British pigs. Patients infected by HEV indigenous to England and Wales tended to belong to a distinct demographic group, there were multiple sources of infection, and pigs might have been a viral reservoir.

Aged↗
PubMed1998

Enteroaggregative Escherichia coli strains as a cause of traveler's diarrhea: a case-control study.

To elucidate the importance of enteroaggregative Escherichia coli (EAggEC) strains as a cause of traveler's diarrhea in Spanish travelers, a prospective case-control 1:1 study was done in a university hospital clinic for travelers. EAggEC strains were isolated from 23 of 165 case-patients and from 4 of 165 controls (P = .0003). In 16 patients, this was the only isolate recovered. Six of the EAggEC-positive isolates from the case-patients and 2 from the controls were positive for the enteroaggregative stable toxin type 1 gene. Other enteropathogens were also isolated. Shigella and enterotoxigenic E. coli strains showed significant differences between cases and controls (P = .0023 and P < .0001, respectively). Geographic distribution of the EAggEC strains was homogeneous, and the clinical symptom, secretory diarrhea, did not differ statistically with that for the enterotoxigenic E. coli strains. EAggEC strains are a cause of secretory diarrhea in Spaniards traveling to developing countries.

Case-Control Studies↗
PubMed1999

Enteroaggregative Escherichia coli as a cause of traveler's diarrhea: clinical response to ciprofloxacin.

The purpose of this study was to determine the role of enteroaggregative Escherichia coli (EAEC) in the development of traveler's diarrhea and the clinical response of patients with EAEC diarrhea following treatment with ciprofloxacin. Sixty-four travelers with diarrhea and no other recognized enteropathogen were enrolled in treatment studies in Jamaica and Mexico from July 1997 to July 1998. EAEC was isolated from 29 travelers (45.3%). There was a significant reduction in the duration of posttreatment diarrhea in the 16 patients treated with ciprofloxacin, as compared with that in the 13 patients who received placebo (mean of 35.3 versus 55.5 hours; P = .049). There was a nonsignificant reduction in the mean number of unformed stools passed during the 72 hours after enrollment in the ciprofloxacin-treated group (5.6), as compared with that in the placebo group (7.5) (P = .128). This study provides additional evidence that EAEC should be considered as a cause of antibiotic-responsive traveler's diarrhea.

Adult↗
PubMedDate not supplied

Travelers' diarrhea: microbiologic bases for prevention and treatment.

The microbiology of travelers' diarrhea has become reasonably well defined, although new bacterial agents are probably yet to be described. The most common etiologic agent, enterotoxigenic Escherichia coli (ETEC), has been studied extensively and, because of the importance of this etiology, strategies for prevention and treatment of ETEC diarrhea with antimicrobial agents have been devised. The prevention of travelers' diarrhea by immunization will, to a large extent, depend on the development of vaccines against ETEC. Because the etiologic agents that cause travelers' diarrhea are the same ones (with the exception of rotavirus) that cause acute diarrhea in small children living in the developing world that tourists visit, any advances in prevention and treatment of diarrhea in travelers will be directly applicable to the worldwide problem of diarrhea in children, which is far more important on a global scale.

Anti-Bacterial Agents↗
PubMed1995

Dermatoses associated with travel to tropical countries: a prospective study of the diagnosis and management of 269 patients presenting to a tropical disease unit.

The full spectrum of skin diseases related to travel in tropical areas is unknown. We prospectively studied 269 consecutive patients with travel-associated dermatosis who presented to our tropical disease unit in Paris during a 2-year period. The median age of these patients was 30 years; 137 patients were male; 76% of the patients were tourists; 38% had visited sub-Saharan Africa; and 85% had been appropriately vaccinated against tetanus. Cutaneous lesions appeared while the patient was still abroad in 61% of cases and after the patient's return to France in 39%. The diagnosis was definite in 260 cases; 137 of these cases (53%) involved an imported tropical disease. The most common diagnoses were cutaneous larva migrans (25%); pyodermas (18%); pruritic arthropod-reactive dermatitis (10%); myiasis (9%); tungiasis (6%); urticaria (5%); fever and rash (4%); and cutaneous leishmaniasis (3%). Hospitalization was necessary in 27 cases (10%), with a median duration of 5 days (range, 2-21 days). Travelers should be advised on how to avoid exposure to the agents and vectors of infectious dermatoses. Travel first-aid kits should include insect repellents and antibiotics effective against bacterial skin infections.

Adolescent↗
PubMedDate not supplied

Antimicrobial prophylaxis of travelers' diarrhea: a selected summary.

This paper summarizes the published controlled studies of the prophylaxis of travelers' diarrhea in which the following drugs have been used: neomycin, nonabsorbable sulfonamides, Streptotriad, doxycycline, erythromycin, and mecillinam. These studies have shown that antimicrobial prophylaxis can be highly effective in preventing episodes of travelers' diarrhea. The protection, however, lasts only as long as the drugs are being taken; there is no evidence that subclinical infections occur while the drug is being taken. None of the data suggest that antimicrobial prophylaxis increases the probability of infection with drug-resistant enteric pathogens. In these studies few subjects have experienced adverse drug reactions; however, the number of subjects has been too small to allow determination of accurate incidence data. Antimicrobial prophylaxis for travelers' diarrhea can be effectively and safely used on an individualized basis for persons traveling to areas of high risk.

Amdinocillin↗
PubMed1981

Biweekly prophylactic doxycycline for travelers' diarrhea.

A double-blind study to determine the efficacy of biweekly oral doxycycline in the prevention of travelers' diarrhea was conducted among 46 Peace Corps volunteers during their first six weeks in Honduras. The volunteers took either 100 mg of doxycycline per dose or a placebo for three weeks and were observed for an additional three weeks. There was no significant difference in the number of persons with travelers' diarrhea in the two groups (eight of 24 in the doxycycline group and 10 of 22 in the placebo group) in the three weeks when the drug was taken. However, significantly fewer episodes (P less than 0.05) of travelers' diarrhea occurred in the doxycycline group than in the placebo group at the end of the second, third, and fourth weeks. Enterotoxigenic Escherichia coli (ETEC) was the most common pathogen identified. ETEC from 13 (62%) of 21 stool samples were resistant to doxycycline. Biweekly doxycycline was only marginally effective in preventing travelers' diarrhea and did not prevent diarrhea secondary to doxycycline-resistant ETEC.

Adult↗
PubMed1981

Travelers' diarrhea in panamanian tourists in Mexico.

To determine whether residents of developing countries are unlikely to acquire travelers' diarrhea, 64 Panamanians of widely divergent socioeconomic strata were studied during a 15-day tour through Mexico. Twenty-three (36%) tourists experienced 27 episodes of travelers' diarrhea that were caused by seven different pathogens. The most commonly identified etiologic agents were rotavirus (26%), Norwalk virus (15%), and Campylobacter fetus (11%), whereas enterotoxigenic Escherichia coli was not frequently associated with travelers' diarrhea. Acquisition of travelers' diarrhea was correlated directly with high socioeconomic status. Varying levels of immunity to enteropathogens that are endemic in Panama may explain the different isolation rates of pathogens.

Adolescent↗
PubMed1987

Efficacy of malaria prophylaxis in American and Swiss travelers to Kenya.

The protective effect of malaria chemoprophylaxis with either Fansidar (pyrimethamine-sulfadoxine) or chloroquine was estimated by determining the attack rates of Plasmodium falciparum infections acquired in Kenya and imported by U.S. and Swiss travelers who had used no chemoprophylaxis, who had used only chloroquine for prophylaxis, and who had used Fansidar weekly, either alone or in combination with chloroquine. The estimated attack rates were almost identical in U.S. and Swiss travelers. The attack rate per 100,000 travelers averaged 280 in those who did not use chemoprophylaxis, 162 in those who took 4-aminoquinolines (P greater than .05), and 27 in those who used Fansidar for prophylaxis (P less than .001). Non-immune travelers to Kenya have an appreciable risk of acquiring a P. falciparum infection and need to be informed of current guidelines for chemoprophylaxis. The changing drug susceptibility patterns in Africa require continuous evaluation of the efficacy of recommended drug regimens for malaria prophylaxis.

Aminoquinolines↗
PubMed1987

Health problems after travel to developing countries.

Travelers to developing countries participated in a follow-up study of the health risks associated with short (less than three months) visits to these nations. Travelers to the Greek or Canary Islands served as a control cohort. Participants completed a questionnaire to elicit information regarding pretravel vaccinations, malaria prophylaxis, and health problems during and after their journey. Relevant infections were confirmed by the respondent's personal physician. The questionnaire was completed by 10,524 travelers; the answer rate was 73.8%. After a visit to developing countries, 15% of the travelers reported health problems, 8% consulted a doctor, and 3% were unable to work for an average of 15 days. The incidence of infection per month abroad was as follows: giardiasis, 7/1,000; amebiasis, 4/1,000; hepatitis, 4/1,000; gonorrhea, 3/1,000; and malaria, helminthiases, or syphilis, less than 1/1,000. There were no cases of typhoid fever or cholera.

Adult↗
PubMed1992

Seasonal variation in etiology of travelers' diarrhea. Finnish-Moroccan Study Group.

The etiology of travelers' diarrhea was studied in 579 adult Finnish tourists participating in two packaged tours to Morocco in the winter (n = 233) and fall (n = 346) of 1989. A research team accompanied the travelers, and a laboratory for enteric pathogens was established in Agadir. At least one pathogen was found in 62% of the 60 diarrhea cases in winter and in 58% of the 111 diarrhea cases in fall. Multiple pathogens were found less often in winter (8%) than in fall (21%, P less than .05). Campylobacter strains were the leading cause of travelers' diarrhea in winter, found alone or with other pathogens in 28% of the cases (but in only 7% in fall), whereas enterotoxigenic Escherichia coli (ETEC) was the most common pathogen in fall, present in 32% of the cases (8% in winter). Both differences are highly significant (P less than .001). Salmonella enterica was almost as common as ETEC in fall (25% of diarrhea cases) but rare in winter (10%, P less than .05). Thus, the etiology of travelers' diarrhea varied according to the season in the same tourist destination. This finding has relevance to both antimicrobial treatment and prophylaxis.

Adolescent↗
PubMed1995

Hepatitis A in travelers: the European experience.

Each year approximately 14 million Europeans travel to developing countries in Africa, Asia, and Latin American as well as to infrequently visited countries in eastern Europe. Without protection, travelers develop symptomatic hepatitis A at the rate of 3 cases per 1000 people per month of stay. Those who eat and drink under poor hygienic conditions have an even higher risk, 20/1000/month. Studies show that hepatitis A is the most frequent vaccine-preventable disease in travelers to developing countries. Immunity to hepatitis A virus is infrequent among northern European travelers, except for those born before 1945, with a history of jaundice, or who lived for > 1 year in a developing country.

Europe↗