Management of travellers’ diarrhoea
BMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a1746 (Published 06 October 2008) Cite this as: BMJ 2008;337:a1746
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Acute diarrhea represents the most important cause of morbidity and
mortality among low socioeconomic level infants in developing countries
(KOSECK, 2003). The main etiological agents of acute diarrhea are the
pathogenic Escherichia coli bacteria and the intestinal protozoa such as
Entamoeba hystolitica and Giardia intestinalis (Hill and Ryan, 2008).
Enterotoxigenic Escherichia coli (ETEC) is the most common cause of
diarrhoea in developing countries and it has been responsible for 800
million deaths for year, especially in children minor than five years, and
is responsible for the acute diarrhoea that affect traveller’s in endemic
areas (BLACK, 1993). On the other hand, the Enteropatogenic Escherichia
coli (EPEC) is the main etiological agent of acute diarrhoea in infants up
to one year age.
The breastfeeding has been considered an effective intervention for
children’s health protection particularly against respiratory and
gastrointestinal infections (Jones 2003). It has been found that colostrum
phagocytes present bactericidal activity against ETEC and this effect
seems to be mediated by colostrum soluble factors. The functional activity
of phagocytes from this study reinforces the findings of other studies
that demonstrated the importance of breastfeeding against
enterobacteriaceae infections (Honorio-França et al, 1997; Honoro-França
et al, 2001, Oliveira et al, 2007). Literature data has indicated that the
peak incidence of diarrhoea caused by ETEC is higher in children up to two
years of life and slows down in the following years (WHO, 2000).
On the other hand, Entamoeba histolytica amoebiasis is widely world-
wide disseminated with the highest incidences is in places where poor
hygine, poverty and basic sanitary conditions are lack. This disease
affects about 5 to 10% of the world’s population, causing 100,000 deaths a
year, and is the most common cause of diarrhoea, constituting an important
public health problem (Stanley, 2003).
Interaction between the host and immune response and the
establishment of the parasite in amoebiasis may have implications in the
transmission control of this parasitic disease (Carrero et al, 2007).
Giardia intestinalis is a common gastrointestinal protozoan with
worldwide distribution. Its effects on childhood growth in developing
countries where the disease is hyperendemic are devasting (Hollm-Delgado
et al, 2008). Human colostrum phagocytes were able to ingest G. lamblia
trophozoites and presented microbicidal activity in vitro, suggesting that
these phagocytes may act as an additional mechanism of protection against
infant giardiasis through the breastfeeding (França-Botelho et al, 2006)
Therefore, breastfeeding may represent an additional mechanism and
important source of protection against bacterial and protozoan infections
during the early life until complete maturity of the immune system of
infants; it represents a well developed process and a biological
proctection in the management of travellers`diarrhoea in developing
countries.
References
1) Black R.E. (1993) Epidemiology of diarrhoeal disease: implications for
control by vaccines. Vaccine 11:100–6.
2) Carrero JC, Cervantes-Rebolledo C, Aguilar-Díaz H, Diaz-Gallardo MY,
Laclette JP & Morales-Montor J. The role of the secretory immune
response in the infection by Entamoeba histolytica. Parasite Immunology
2007, 29: 331–338.
3) França-Botelho A.C., Honório-França A.C., França E.L., Gomes M.A.,
Costa-Cruz J.M. (2006) Phagocytosis of Giardia lamblia trophozoites by
human colostral leukocytes. Acta Paediatr 95:438-43.
4) Hill DR, Ryan ET. Management of traveller’s diarrhoea. BMJ 2008; 337:
863-7.
5) Hollm-Delgado MG, Gilman RH, Bern C, Cabrera L, Sterling CR, Black RE,
Checkley W. Lack of an Adverse Effect of Giardia intestinalis Infection on
the Health of Peruvian Children (2008) Am J Epidemiol 168:647-55
6) Honório-França A.C., Carvalho M.P., Isaac L., Trabulsi L.R., Carneiro-
Sampaio M.M.S. (1997) Colostral mononuclear phagocytes are able to kill
enteropathogenic Escherichia coli opsonized with colostral IgA. Scand J
Immunol 46:59-66.
7) Honorio-França A.C., Launay P., Carneiro-Sampaio M.M.S. Monteiro
R.C.(2001) Colostral neutrophils express Fc alpha receptors (CD89) lacking
gamma chain association and mediate noninflammatory properties of
secretory IgA. J Leukoc Biol. 69:289-96.
8) Jones G., Steketee W., Black R.E., Bhutta Z.A, Morris S.S. (2003) How
many child deaths can we prevent this year? Lancet 362:65-71.
9) Kosek M, Bern C, Guerrant RL. (2003) The global burden of diarrhoeal
disease, as estimated from studies published between 1992 and 2000. Bull
World Health Organ 81:197-204.
10) Oliveira I.R., Bessler H.C., Bao S.N., Lima R.L., Giugliano R.L.
(2007) Inhibition of Enterotoxicogenic Escherichia coli (ETEC) adhesion to
CACO-2 cells by human milk and its immunoglobulin and non-immunoglobulin
fractions. Braz. J. Microbiol 38:86-92.
11) Stanley SL. Amoebiasis. Lancet 2003; 361: 1025-1034.
12) WHO (2000) Collaborative Study Team on the Role of Breastfeeding on
the Prevention of Infant Mortality. Effect of breastfeeding on infant and
child mortality due to infectious diseases in less developed countries: a
pooled analysis. Lancet 355:451-5.
Competing interests:
None declared
Competing interests: No competing interests
Perhaps Acute Schistosomiasis with bloody diarrhoea and fever is not
considered under Travellers'Diarrhoea in the present time?
Competing interests:
None declared
Competing interests: No competing interests
Entamoeba histolytica and travelers' diarrhoea
Travelers' diarrhoea is the most common illness affecting travelers,
it can be caused by bacteria, viruses and parasites. In the causative
organisms are found in about half the cases of travellers' diarrhoea, this
is possibly because the sudden change in the environment, especially the
diet, can expose you to a new variety of bacteria or "normal flora" in
your intestine which may trigger off an attack of diarrhoea. However you
may experience difficulty in the diagnosis too. For example, Entamoeba
histolytica is not always found in every stool sample, may be necessary
several stool samples from several different days. One problem is that
other parasites and cells can look very similar to E. histolytica when
seen under a microscope. So while the scientific literature did not find
many reports of the E. histolytica as cause the travelers' diarrhoea, it
is possible that an agent is more important than may seem. There are few
reports in the literature, among the few reports there is a case with E.
histolytica were identified in 17 patients with inflammatory diarrhoea
(KORZENIOWSKI et al. 1994). Another study was undertaken to learn the
prevalence of amoebiasis and to assess the clinical importance of E.
histolytica in high-risk groups: 2700 travelers returning from the tropics
4.0% of the travelers had E. histolytica infections (WEINKE et al., 1990).
The CDC (Centers for Disease Control and Prevention) recommends that
when traveling to a country that has poor sanitary conditions:
What should
I eat and drink there so I will not become infected with E. histolytica or
other such germs?
Drink only bottled or Boiled (for 1 minute) water or carbonated (bubbly)
drinks in cans or bottles.
Do not drink fountain drinks or any drinks with ice cubes. Another way to
make water safe is by filtering it through an "absolute 1 micron or less"
filter and Dissolving chlorine, chlorine dioxide, or iodine tablets in the
filtered water. "Absolute 1 micron" filters can be found in camping /
outdoor supply stores.
Do not eat fresh fruit or vegetables that you did not peel yourself.
Do not eat or drink milk, cheese, or dairy products that may not have been
pasteurized.
Do not eat or drink anything sold by street vendors.
These recommendations also confirm the importance of E. histolytica as
agent of travelers' diarrhoea.
REFERENCES
1)CDC. Centers for Disease Control and Prevention (2009).
http://www.cdc.gov/ncidod/dpd/parasites/Amebiasis/factsht_Amebiasis.htm
[Accessed 30 June 2009]
2)Korzeniowski O.M., Dantas W., Trabulsi L.R., Guerrant R.L. (1984) A
controlled study of endemic sporadic diarrhoea among adult residents of
southern Brazil. Trans R Soc Trop Med Hyg 78:363-9.
3)Weinke T., Friedrich-Jänicke B., Hopp P., Janitschke K. (1990)
Prevalence and clinical importance of Entamoeba histolytica in two high-
risk groups: travelers returning from the tropics and male homosexuals. J
Infect Dis 161:1029-31.
Competing interests:
None declared
Competing interests: No competing interests