Correspondence
Prevention and Treatment of Traveler's Diarrhea
N Engl J Med 1993; 329:1584-1585November 18, 1993
- Article
To the Editor:
As Mexicans, we would like to offer another perspective on the recent article on traveler's diarrhea by DuPont and Ericsson (June 24 issue).1 Though it is true that Moctezuma (not Montezuma) can strike travelers with a vengeance, travel to the empire to the north is not entirely risk-free. On the basis of considerable anecdotal evidence, we can say that travelers from differently developed countries who enter the United States are frequently affected by diarrhea within a week of arrival, with at least three unformed stools per day for two to five days, accompanied by abdominal cramps and nausea, but rarely fever. We call this form of traveler's diarrhea “the empire strikes back.” Prophylaxis against or treatment of this form of diarrhea is not warranted but its occurrence is a reminder that changes in environment affect all people, coming or going. Thus, we suggest that DuPont and Ericsson modify their definition of traveler's diarrhea, which was diarrhea that “occurs in a person who normally resides in an industrialized region and who travels to a developing tropical or semitropical country.” A lot of us get traveler's diarrhea in Manhattan, hardly a tropical island.
The evidence that prophylaxis against traveler's diarrhea is effective most of the time is comforting. Now there is one more good reason to venture south of the Rio Grande.
1 ReferencesGabriela Cesarman, M.D.
New York Hospital, Cornell University, New York, NY 10021Ethel Cesarman, M.D., Ph.D.
College of Physicians and Surgeons of Columbia University, New York, NY 10032Georgina Lagos, M.S.
New School for Social Research, New York, NY 100111
DuPont HL ,Ericsson CD . Prevention and treatment of traveler's diarrhea. N Engl J Med 1993;328:1821-1827
Full Text | Web of Science | Medline
To the Editor:
We believe it is also important to consider the possibility of traveler's diarrhea in persons who never leave the United States. In part this is because of the increased demand for fresh fruits and vegetables and the widespread availability of salad bars in restaurants. By 1988, 71 percent of fast-food restaurants in the United States offered salads as entrees or had salad bars1. Produce is imported from Mexico, Central America, and other tropical or semitropical areas to meet this demand. During the winter months, more than 75 percent of many fresh fruits and vegetables consumed in the United States are harvested outside the country and delivered within days to grocery stores and restaurants2. As DuPont and Ericsson point out in their article, fruits and vegetables are major food vehicles for the agents responsible for traveler's diarrhea in developing countries. Recent outbreaks of salmonella infection in the United States and Canada associated with the consumption of watermelon, cantaloupe, and tomatoes indicate that contaminated fruits and vegetables are also important vehicles for the transmission of enteric pathogens in North America3.
As noted by DuPont and Ericsson, enterotoxigenic strains of Escherichia coli are the most important agents causing traveler's diarrhea. Clinical laboratories in this country do not routinely culture stool for enterotoxigenic E. coli; thus, large geographically dispersed outbreaks caused by this pathogen and associated with the consumption of imported fruits and vegetables could occur and go unrecognized. Unless we identify and make available resources and personnel dedicated to surveillance for foodborne disease, we will not be able to address the impact of the changing nature of the food supply on the occurrence of diarrheal disease (particularly illnesses caused by pathogens that may be in imported foods). We will continue to consider traveler's diarrhea to be an illness acquired in foreign countries and will not recognize that imported foods consumed in our own homes or restaurants may cause the same condition.
3 ReferencesMichael T. Osterholm, Ph.D., M.P.H.
Craig W. Hedberg, Ph.D.
Kristine L. MacDonald, M.D., M.P.H.
Minnesota Department of Health, Minneapolis, MN 554401
National Restaurant Association/Gallup Survey, 1988. In: Nutrition awareness and the foodservice industry. Current issues report. Washington, D.C.: National Restaurant Association, 1990.
2
Agricultural Marketing Service. Fresh fruit and vegetable arrival totals, 22 cities. Washington, D.C.: Department of Agriculture, 1991.
3
Multistate outbreak of Salmonella poona infections -- United States and Canada, 1991
Medline
To the Editor:
In their review of traveler's diarrhea, DuPont and Ericsson suggest that parents of children under two years of age carry commercial oral rehydration solutions when they travel abroad. Carrying several liters of prepared oral rehydration solution is not always practical, and powdered forms for reconstitution in water are not widely available in the United States.
As an alternative, parents can be instructed how to make cereal-based oral rehydration solutions from readily available constituents according to the following formula1: mix one-half cup of dry, precooked baby rice cereal with two cups of water (preferably bottled, or boiled and cooled) and one-quarter teaspoon of salt. This should produce a solution with about 60 g of rice per liter and 50 mmol of sodium per liter. The salt must be measured carefully; the mixture should be thick but pourable and drinkable, and should not taste salty. Parents should be given written instructions and should pack a measuring cup, measuring spoon, rice cereal, and salt.
Cereal-based oral rehydration solutions are as efficacious as glucose-based solutions in preventing and treating dehydration and have the added advantage of reducing the volume and duration of diarrhea2.
2 ReferencesAlan Meyers, M.D., M.P.H.
Boston City Hospital, Boston, MA 021181
Meyers A ,Siegel B ,Vinci R . Oral rehydration for children with diarrhea. JAMA 1991;266:517-517
CrossRef | Web of Science2
Gore SM ,Fontaine O ,Pierce NF . Impact of rice based oral rehydration solution on stool output and duration of diarrhea: meta-analysis of 13 clinical trials. BMJ 1992;304:287-291
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Author/Editor Response
The authors reply:
To the Editor: Cesarman et al. indicate that the term “traveler's diarrhea” should apply to diarrhea occurring in all travelers regardless of their origin and destination. When people leave their own environments, they frequently eat at restaurants, often consume greater than customary amounts of alcohol, and may eat food that contains undigestible substances. All these factors are associated with a change in bowel habits if not diarrhea. Mild diarrhea occurs in 2 to 4 percent of those who travel from high- or low-risk areas to low-risk areas1,2. When one is considering the prevention and treatment of traveler's diarrhea, it is reasonable to focus on the illness that occurs among those who move from low-risk areas to high-risk areas, where illness occurs in up to 40 percent of travelers and one fifth of those afflicted are confined to bed for one to two days3.
With the increasing importation of foods from Mexico to the United States, more enteropathogens will be imported. Osterholm and his colleagues have taken the lead in arousing our concern about the potential for foodborne enteric disease in the United States. When diarrheal illness occurs after the ingestion of contaminated food, it is difficult to trace the origin of the problem unless the illness is so severe that public health authorities become involved (e.g., hemorrhagic colitis and the hemolytic uremic syndrome caused by infection with E. coli O157:H7 acquired from fast-food chains or chronic [Brainerd] diarrhea caused by raw milk) or the outbreak involves persons who have the attention of the news media (e.g., air-travel-associated shigellosis in a professional football team). We agree that routine surveillance for foodborne disease is needed; at the least public health authorities should be prepared to investigate all types of foodborne illness promptly.
Meyers suggests that a salt-augmented, cereal-based oral rehydration solution be used by parents for infants who acquire diarrhea while traveling. The main problem with this approach is the potential for the administration of excessive amounts of sodium by a parent who improperly mixes the solution or fails to provide water in addition to the solution4.
4 ReferencesHerbert L. DuPont, M.D.
Charles D. Ericsson, M.D.
University of Texas Medical School, Houston, TX 772251
Ryder RW ,Wells JG ,Gangarosa EJ . A study of travelers' diarrhea in foreign visitors to the United States. J Infect Dis 1977;136:605-607
CrossRef | Web of Science2
Steffen RM ,Rickenbach M ,Wilhelm U ,Helminger A ,Schar M . Health problems after travel to developing countries. J Infect Dis 1987;156:84-91
CrossRef | Web of Science | Medline3
Gorbach SL ,Edelman R . Travelers' diarrhea: National Institutes of Health Consensus Development Conference. Rev Infect Dis 1986;8:Suppl 2:S109-S233
CrossRef | Medline4
Cleary TG ,Cleary KR ,DuPont HL , et al. The relationship of oral rehydration solution to hypernatremia in infantile diarrhea. J Pediatr 1981;99:739-741
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