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Traveler's diarrhea (TD) is a syndrome characterized by a twofold or greater increase in the frequency of unformed bowel movements. Commonly associate symptoms include abdominal cramps, nausea, bloating, urgency, fever, and malaise. Episodes of TD usually begin abruptly, occur during travel or soon after returning home, and are generally self-limited. The most important determinate of risk is the destination of the traveler. Attack rates in the range of 20 to 50 percent are commonly reported. High risk destinations include most of the developing countries of Latin America, Africa, the Middle East, and Asia. Intermediate risk destinations include most of the Southern European countries and a few Caribbean islands. Low risk destinations include Canada, Northern Europe, Australia, New Zealand, the United States and a number of the Caribbean islands.
TD is slightly more common in young adults than in older people. The reasons for this difference are unclear, but may include a lack of acquired immunity, more adventurous travel styles and different eating habits. Attack rate are similar in men and women. The onset of TD is usually within the first week, but may occur at any time during the visit, and even after returning home.
TD is acquired through ingestion of fecally contaminated food and or water. Both cooked land uncooked foods may implicated if improperly handled. Especially risky foods include raw meat, raw seafood, and raw fruits and vegetables. Tap water, ice, and unpasteurized milk and dairy products may be associated with increased risk of TD; safe beverages include bottled carbonated beverages (especially flavored beverage), beer, wine, hot coffee or tea, or water boiled or appropriately treated with iodine or chlorine.
Infectious agents are the primary cause of TD. Travelers from industrialized countries to developing countries frequently develop a rapid, dramatic change in the type of organisms in their gastrointestinal tract. These new organisms often include potential enteric pathogens. Those who develop diarrhea have ingested an inoculum of virulent organisms sufficiently large to overcome individual defense mechanism, resulting in symptoms.
There are four possible approaches to prevention of TD. They include instruction regarding food and beverage consumption, immunization, use of non-antimicrobial medications, and prophylactic antimicrobial drugs.
Data indicate that meticulous attention to food and beverage consumption can decrease the likelihood of developing TD. Most travelers, however, encounter difficulty in observing the requisite dietary restrictions.
No available vaccines and none that are expected to be available in the next 5 years are effective against TD.
Individuals with TD have two major complaints for which they desire relief -- abdominal cramps and diarrhea. Many agents have been proposed to control these symptoms, but few have been demonstrated to be effective by rigorous clinical trials.
Nonspecific Agents: A variety of "adsorbents" have been used in treating diarrhea. For example, activated charcoal has been found to be ineffective in the treatment of diarrhea. Kaolin and pectin have been widely used for diarrhea. The combination appears to give the stools more consistency but has often shown to decrease cramps and frequency of stools nor to shorten the course of infectious diarrhea.
Antimicrobial Treatment:Travelers should consult a physician, rather than attempt self-medication, if the diarrhea is severe or does not resolve within several days; if there is blood and/or mucus in the stool; if fever occurs with shaking chills; or if there is dehydration with persistent diarrhea.
Oral Fluids: Most cases of diarrhea are self-limited and require only simple replacement of fluids and salts lost in diarrheal stools. This is best achieved by use of an oral rehydration solution such a World Health Organization Oral Rehydration Salts (ORS) solution. This solution is appropriate for treating as well as preventing dehydration. ORS packets are available at stores or pharmacies in almost all developing countries. ORS is prepared by adding one packet to boiled or treated water. Packet instructions should be checked carefully to ensure the salts are added to the correct volume of water. ORS solution should be consumed or discarded within 12 hours if held at room temperature, or 24 hours if held refrigerated.
Excerpted from:U. S. Department of Health and Human Services, Centers for Disease Control and Prevention. HHS Publication No. (CDC) 94-8280. June, 1994. pgs. 163-169.
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