Risk Behavior for Travelers' Diarrhea Among Finnish Travelers.

Background: Contaminated food and drink are the primary sources of traveler's diarrhea (TD). Identification of the characteristics that make a traveler more prone to TD is needed to improve prevention and therapy of this illness. Methods: We evaluated, by questionnaire, the association of dietary errors with TD among 933 adult Finnish tourists vacationing in Morocco. A stool specimen was obtained from patients in the group that developed TD at the onset of the diarrheal episode, and from all participants in the study on their return to Finland. Results: Only 5% of the 933 subjects who responded to the questionnaire, and who gave a stool sample, had adhered strictly to generally accepted recommendations. About 45% made five or more dietary errors during the trip; of these, 75% consumed raw vegetables, 65% salads, 33% puddings, 32% mayonnaise or other cold dressings, 31% consumed food bought from street vendors, 29% consumed cold meat, 18% cold sandwiches, 4% drank tap water, and 2% consumed raw meat. The age of the subjects did not correlate with the number of dietary errors. Subjects who had been abroad during the preceding 12 months committed more dietary errors than those who had not (mean 3.9 versus 4.5; p <.001). Also, subjects who spent 2 weeks in Morocco committed more dietary errors than those who spent only 1 week (mean 4.0 versus 4.8; p <.001). However, no association between TD and the number of dietary errors was observed. Differences with respect to eating habits were not observed between subjects, with or without TD or with or without an identified pathogen in stool specimens. There was no correlation between eating habits and the presence, or absence, of a specific pathogen in the stool sample; this is with the exception of Campylobacter spp: subjects with this pathogen consumed steak tartar or salad more often than did other subjects. Conclusions: Etiologic agents are so ubiquitous in this high-risk area that instructions to avoid certain foodstuffs commonly thought to be contaminated may be to some extent without value. Moreover, dietary self restraint proved to be impossible in the real situation. (J Travel Med 2:77-84, 1995)

Short-term treatment of traveler's diarrhea with norfloxacin: a double-blind, placebo-controlled study during two seasons.

Clinical efficacy of norfloxacin for treatment of traveler's diarrhea in 106 Finnish tourists vacationing in Morocco was evaluated during two different seasons. When the criteria for diagnosis of traveler's diarrhea were fulfilled, norfloxacin (400 mg) or a placebo was given orally, twice daily for 3 days. All symptoms and signs subsided sooner in the norfloxacin group. The clearest difference was observed in the duration of diarrhea: 1.2 days in the norfloxacin group vs. 3.3 days in the placebo group (P < .001). The duration of diarrhea due to particular species was as follows for the two groups: in cases due to Salmonella enterica, 1.1 vs 4.1 days (P < .01); in cases due to Campylobacter jejuni, 1.8 vs. 5.0 days (P < .01); and in cases due to enterotoxigenic Escherichia coli, 1.0 day vs. 3.1 days (P < .01). The rate of full recovery during administration of norfloxacin or a placebo was also greater among the norfloxacin recipients: 84% vs. 47% (P < .001). No significant adverse effects were reported. Norfloxacin proved to be safe and effective in therapy for traveler's diarrhea.

The occurrence of human intestinal parasites in Finland.

The survey of the occurrence of intestinal parasites presented here covers 726 hospital patients, 175 healthy adults and 212 children, and 976 healthy Finnish holiday-makers prior to their trip abroad. Two faecal samples from each individual were examined. Further, 344 children were tested for Enterobius vermicularis. The total prevalence of intestinal parasites in the hospital patients was 4.2%, and that of pathogenic parasites 2.9%. The prevalence rates in healthy subjects were 4.9% and 1.5%, respectively. Three species of pathogenic parasites were found: Giardia lamblia, Entamoeba histolytica and Diphyllobothrium latum. A test for Enterobius vermicularis was positive in 5.2% of children examined.

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.

Detection of Plasmodium falciparum DNA in a microtitration plate-based hybridization test.

A rapid DNA-test, depending on the affinity based hybrid collection principle, was developed for the detection of Plasmodium falciparum DNA from clinical specimens. In this method, hybridization takes place in solution and the hybrids are collected onto a solid phase for measurement. Two probes are used, one labelled with an affinity tag (biotin) and the other with a detectable label (32P). In the present test a single oligonucleotide complementary to a 21-base pair sequence which is highly repeated in the parasite genome served both as capture and detector probe. The test is a 2-h hybridization performed in streptavidin coated microtitration plate wells, onto which the labelled hybrids simultaneously bind. The sensitivity of the assay with a crude erythrocyte lysate specimen was 1.6 x 10(9) repeat units corresponding to about 160 parasites in one microliter blood. The results allowed quantification of the repeat sequences and thus estimation of the degree of parasitemia in clinical specimens.

Leishmaniasis diagnosed from bronchoalveolar lavage.

A 51-year-old renal transplant patient, whose spleen had been removed 11 years ago, was admitted to hospital for elective surgery, which was cancelled as she developed spiking fever and nonproductive cough and her general condition deteriorated. After 2 weeks, leishmaniasis was unexpectedly diagnosed from a bronchoalveolar lavage specimen, which had been subjected to parasitological examination under the suspicion of pneumocystosis. Isoenzyme typing identified the parasite as Leishmania infantum. The patient had visited Malaga, Spain, twice a year, the last trip taking place 1 month before admission. Specific treatment was followed by rapid recovery without relapse during 1.5 years. Splenectomy and immunosuppressive medication obscured the clinical suspicion of leishmaniasis. The case is a reminder of the interstitial pneumonitis in leishmaniasis and emphasizes the value of broad-spectrum methods detecting a variety of parasites.

Prevention of travellers' diarrhoea by oral B-subunit/whole-cell cholera vaccine.

B-subunit/whole-cell cholera vaccine (BS-WC) has been shown to give Bangladeshi mothers and children only 3 months' protection against severe diarrhoea due to enterotoxigenic Escherichia coli (ETEC). Since a long-lasting effect is not necessary for protection against travellers' diarrhoea, a prospective double-blind study was conducted among tourists who went to Morocco from Finland. 307 tourists received two oral doses of BS-WC, whereas 308 controls received a placebo before departure. A research team went out with tourists and a laboratory for enteric pathogens was set up on location. A faecal specimen was taken from 100 randomly selected subjects before departure, from all travellers with diarrhoea, and routinely after return. Enteropathogenic bacteria were not isolated from any of the pre-departure specimens but were present during or after the holiday in 47% of tourists with travellers' diarrhoea, and in 14% of those without diarrhoea. BS-WC induced a 52% protection (p = 0.013) against diarrhoea caused by ETEC. The protection was better for mixed infections (65%, p = 0.016). The protective efficacy against a combination of ETEC and any other pathogen was 71% (p = 0.02), and that against ETEC plus Salmonella enterica even better at 82% (p = 0.01). Partial protection against travellers' diarrhoea is thus obtainable by active immunisation with BS-WC.

Diagnosis of falciparum malaria delayed by long incubation period and misleading presenting symptoms: life-saving role of manual leucocyte differential count.

In countries where malaria is not endemic the diagnosis of the disease is often delayed or overlooked, particularly if the clinical symptoms are atypical and if automated cell analyzers are used instead of blood films for leucocyte differential counts. We report 2 cases of severe Plasmodium falciparum malaria with unusual clinical features: a 46-year-old man with an exceptionally long incubation period and a 22-year-old woman with presenting symptoms suggesting viral hepatitis. In both cases the diagnosis of malaria was unexpectedly made by observant laboratory technicians examining stained blood films for differential counts.

Intestinal parasitism of children and mothers in rural Somalia.

A survey on intestinal parasitism was carried out by microscopic examination of stool specimens from 517 children (0 to 16 years old) or from mothers living in two rural towns in Somalia. Burao represented the hot and dry region in the north and Kismayo the more humid area in the south. The overall prevalances of intestinal parasitism were 48 and 88%, respectively. Protozoal infestation was found in 46% (potentially pathogenic protozoa in 20%) in Burao and 37% (potentially pathogenic protozoa in 17%) in Kismayo. In contrast a major difference between the two towns was observed with helminthic infection. In Burao only 6% of the specimens showed worm eggs or larvae, whereas in Kismayo the prevalence was 84% (P less than 0.001). The difference in helminthic infection rates might be explained by the different climatic factors, different population densities or habits of the people. Among 14 detected parasitoses the following five were found with an overall frequency of 10% or greater: trichuriasis (45%); entamebiasis coli (23%); ascariasis (17%); giardiasis (16%); and ancylostomiasis (15%).

Cutaneous leishmaniasis in a 3-year-old Finnish visitor to France.

A child with non-ulcerating cutaneous leishmaniasis after a 3-week visit to Southern France is reported. Diagnosis was histological. The possibility of the patient having had a visceral infection was taken into account when designing the final treatment.

Trips to the South--a health hazard. Morbidity of Finnish travellers.

In all, 2665 Finns chosen at random who had made short visits to Spain and her islands, to North Africa or to Thailand, or who had taken an around-the-world tour or a West African cruise were asked to answer a questionnaire concerning the state of their health while abroad. One-third (33%) reported they were ill or had been ill; 48% had had some health complaint during the trip which in 93% lasted for 2 weeks or less. The most common health problems were diarrhoea (18%), sunburn (10%), upper respiratory symptoms with or without headache or fever (10%), insect stings (3%), and problems related to excessive consumption of alcohol (1.5%). 7% deemed it possible that they had contracted a venereal disease. The incidence of the complaints varied with the geographical area visited. It is concluded that mass tourism is accompanied by a morbidity whose dimensions are far from fully recognized.