REVIEW

CURRENT
OPINION An update on travelers’ diarrhea
Deenaz Zaidi and Eytan Wine

Purpose of review
Travelers’ diarrhea, affecting millions of travelers every year globally, continues to be a leading cause of
morbidity despite advances in vaccination, prevention, and treatment. Complications of travelers’ diarrhea
often present to gastroenterologists and some patients followed by gastroenterologists are at higher risk of
developing travelers’ diarrhea. This review will provide an update on recent progress made in the
epidemiology, pathogenesis, diagnosis, prevention, and treatment of travelers’ diarrhea.
Recent findings
Most causes of travelers’ diarrhea remain bacterial, but newly recognized pathogens are emerging.
Patient-related and travel-related factors affect disease development risk and should guide prophylaxis and
treatment. Although specific vaccines are being developed, they have not yet had a major impact on
travelers’ diarrhea, and understanding their roles and limitations is especially important. Prophylaxis and
treatment of populations at risk (children, chronically ill patients, and those on immunosuppressive
medications) remain challenging and require a tailored approach.
Summary
Travelers’ diarrhea will continue to challenge patients and physicians despite the use of sanitation advice,
prophylactic vaccines, and treatment with antibiotics. Effects may extend beyond the time of travel, such as
postinfectious complications and exacerbation of preexisting disease. Future research should focus on novel
strategies for reducing exposure to pathogens, vaccine development, early detection, and targeted
treatments.
Keywords
gastroenteritis, travelers’ diarrhea, vaccination

INTRODUCTION GLOBAL DISTRIBUTION OF TRAVELERS’

Travelers’ diarrhea is a common complication that
occurs through the acquisition of specific pathogens
while traveling. Typically, the term is used when
individuals from developed countries (e.g., North
America or Europe) travel to developing countries.
Travelers’ diarrhea is defined as three or more stools
with or without associated fever, abdominal cramps,
and vomiting within a 24-h period and is the most
common travel-related morbidity. Ten to sixty
percent of travelers will develop diarrhea, especially
when traveling to Latin America, Africa, the Indian
subcontinent, and to a lesser extent Russia, Middle
East, China, and south-east Asia (8–15%) [1,2]. With
more than a billion travelers globally per year,
travelers’ diarrhea has huge health and economic
impacts. This review will focus on recent data on
epidemiology, pathophysiology, prevention, treat-
ment, and specific conditions frequently managed
by gastroenterologists in which travelers’ diarrhea
may be encountered.
DIARRHEA
According to the global travel surveillance con-
ducted by the GeoSentinel Surveillance System
(1997–2011), acute bacterial and unspecified diar-
rhea, chronic diarrhea of unknown cause, postin-
fectious irritable bowel syndrome (PI-IBS), and
giardiasis were the most commonly diagnosed dis-
orders out of 13 059 posttravel diagnoses in 10 032
&&
cases [3 ]. A multitude of factors, such as geographi-
cal variation, prevalence of specific microbes, host
Division of Pediatric Gastroenterology and Nutrition, Department of
Pediatrics, University of Alberta, Edmonton, Alberta, Canada
Correspondence to Eytan Wine, MD, PhD, Division of Pediatric Gastro-
enterology and Nutrition, Department of Pediatrics, University of Alberta,
Edmonton Clinic Health Academy, Room 4–577, 11405 87th Avenue,
Edmonton, AB T6G 1C9, Canada. Tel: +1 780 248 5420; fax: +1 888
353 1157; e-mail: wine@ualberta.ca
Curr Opin Gastroenterol 2015, 31:7–13
DOI:10.1097/MOG.0000000000000133

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 Gastrointestinal infections
KEY POINTS

Basic preventive measures, such as sanitation and food
safety, are important, but have not eliminated travelers’
diarrhea.

Up-to-date knowledge on destination-specific pathogens
is important for appropriate selection of vaccines,
prophylactic antibiotics, and treatment.

Emerging vaccines against specific pathogens are
promising, but as each could only eliminate a small
portion of all infections, development of multitarget
vaccines is warranted.

Patients on immunosuppressive treatments (e.g., IBD
and transplant) require additional measures and
tailored prophylaxis and treatment.
factors, and comorbid conditions, determine the
global pattern of travelers’ diarrhea, adding to the
complexity of managing travelers’ diarrhea. Man-
agement requires knowledge of host and pathogen
factors and global variation to guide travelers’
diarrhea treatment.
In contrast to nontravel diarrhea, most infec-
tious causes of travelers’ diarrhea are bacterial. Some
of the commonly identified pathogens causing trav-
elers’ diarrhea include pathogenic Escherichia coli
strains, Campylobacter jejuni, Shigella, Salmonella,
norovirus, astrovirus, and rotavirus; enteroaggrega-
tive E. coli (EAEC), norovirus, and enterotoxigenic
E. coli (ETEC) are the most common pathogens
&
globally [4 ]. However, recently, relatively unknown
pathogens, such as Aeromonas and Plesiomonas, have
&&
also been implicated [5 ]. As the cause differs
worldwide, the world is divided into three travelers’
diarrhea risk regions (low, intermediate, and high;
Table 1), with specific pathogens linked to each
location. For example, ETEC is the causative agent
of travelers’ diarrhea in most Americans traveling to
Mexico or South America, whereas Giardia infec-
&
tions commonly occur in travelers to Russia [6 ].
Although many pathogens remain unknown, some
of the leading causes, according to the geographical
location, are listed in Table 2.
Table 1. Risk stratification of travelers’ diarrhea by region
Low-risk regions United States, Canada, Australia, New
Zealand, Japan, northern and
western European countries
Intermediate-risk Eastern European and South African
regions countries, some Caribbean islands.
High-risk regions Asia, Africa, Middle East, central
America, South America, Mexico.
Modified from [5
&&
].
8 www.co-gastroenterology.com
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Table 2. Major enteropathogens causing travelers’
diarrhea in various regions of the world
Southern Asia (Indian Latin America
subcontinent) and Africa
Campylobacter (20%) ETEC (33%)
ETEC (19%) Norovirus (15%)
EAEC (16%) EAEC (13%)
Vibrios (10%) Shigella (8%)
Parasites (10%) Campylobacter (4%)
Salmonella (8%) Salmonella (4%)
Shigella (5%) Parasites (4%)
Plesiomonas (5%) Unknown (44%)
Norovirus (4%)
Aeromonas (3%)
Unknown (38%)
EAEC, enteroaggregative Escherichia coli; ETEC, enterotoxigenic Escherichia
coli.
Adapted from [1,2].
Less common causes are diagnostically challeng-
ing and, therefore, deserve additional attention.
Schistosomiasis, acquired during travel, can present
with diarrhea, developing into a chronic condition.
A case report describes a French woman with Giardia
lamblia who was also diagnosed with colonic schis-
tosomiasis on colonoscopy 5 years after traveling to
&
Laos [7]. A recent study [8 ] reported cases of acute
schistosomiasis in German students who returned
from Lake Tanganyika, Tanzania. As schistosomiasis
is increasingly found in travelers returning from
tropical regions, development of accurate, sensitive,
and specific diagnostic tests is crucial, as current
diagnostic tests have poor sensitivity [9].
Another uncommon cause of travelers’ diarrhea
is demonstrated through a case of Plasmodium
knowlesi (infects humans in south-east Asia), appear-
ing in a Scottish traveler returning from Borneo,
Malaysia, who developed diarrhea, fever, and chills
13 days after the return. Thus, in patients traveling
to south-east Asia, specially those presenting
with symptoms of malaria, but testing negative
for malaria, specific PCR for P. knowlesi should be
considered [10].
Another excellent and highly relevant example
of an emerging infectious cause of diarrhea is Ebola
virus, which presents with fever, severe diarrhea,
and vomiting (although other systemic symptoms,
including headache, myalgia, and weakness, are
typically present as well). An outbreak of this highly
contagious cause of hemorrhagic fever is of major
global concern at the time of the writing of this
review and is already affecting travel to Africa
&
[11 ,12].
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Number 1
January 2015

The GeoSentinel Network revealed that acute
nonparasitic diarrhea was among the most com-
monly diagnosed diseases in returning travelers
from Indian Ocean islands (mainly Madagascar
&
and Maldives) [13 ]. A study to assess travel-acquired
diseases in tourists from New South Wales, Australia,
indicated that shigellosis caused 48.7% of travelers’
&
diarrhea cases [14 ]. Some European destinations are
also prone to travelers’ diarrhea; a retrospective
study [15] analyzing foreign travelers to Greece
ranked travelers’ diarrhea high among conditions
affecting visitors.
PATHOGENESIS AND DETECTION OF
COMMON PATHOGENS
Clinical presentation is dependent on both host and
pathogen factors and is a reflection of disease patho-
genesis. Mechanisms of diarrhea are complex in
most cases, and include combinations of osmotic,
secretory, and inflammatory processes. Viruses (e.g.,
norovirus) and bacterial toxins will commonly
cause acute watery diarrhea with vomiting. Most
common bacteria strains (e.g., ETEC, EAEC, and
Vibrio) cause watery diarrhea, whereas more invasive
strains (e.g., Shigella, Campylobacter, and Salmonella)
can lead to bloody and inflammatory diarrhea. Per-
sistent diarrhea (>14 days) is commonly caused by
parasites (e.g., Giardia, Cryptosporidium) [1,16 ].
&&
A major challenge in identifying and studying
pathogenic E. coli strains is that they share many
biochemical and genetic features with the more
abundant commensal strains. ETEC, one of the most
common and studied diarrheal causes, especially
among children, causes damage through secretion
of both heat-labile and heat-stable enterotoxins
[17]. Additional virulence factors, such as E. coli
attaching and effacing homolog (EaeH), further con-
&
tribute to pathogenesis [18 ]. EAEC is a perplexing
pathogen because of a vast phylogenetic diversity.
Basic virulence features include adherence to enter-
ocytes with biofilm formation, production of enter-
otoxins and cytotoxins, and induction of mucosal
inflammation [19]. Traditionally, research focus has
been on aggregative adherence regulator (AggR), a
transcriptional regulator, but differences in other
EAEC virulence genes complicate the understanding
& &
of pathogenesis and diagnosis [20 ].
The pathogenesis of norovirus, the most com-
mon viral cause of diarrhea across the world and a
common cause of travelers’ diarrhea, remains poorly
understood due to limited cell and animal models.
The control of disease is also challenged by pro-
longed virus shedding after the resolution of diar-
&&
rhea [21 ]. Serological features of norovirus were
assessed to identify vaccine targets in a cohort of
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An update on travelers’ diarrhea Zaidi and Wine
American students traveling to Mexico. Pretravel
mean serum levels of immunoglobulins were lower
against six predominant variants of norovirus
(G1–G6), relative to other viruses, suggesting an
involvement in pathogenesis [22].
Serotype analysis of Shigella conducted on stool
samples and rectal swabs of children below 5 years of
age in Africa and Asia confirmed the predominance
of Shigella sonnei and S. flexneri and showed that O
antigen-based quadrivalent vaccine could offer
&
effective protection [23 ].
Current laboratory-based immunoassays and
cultures for the detection of pathogens are time
consuming and with low yield. A multiplex quan-
titative PCR test was recently developed to detect
nine travelers’ diarrhea-associated pathogens in just
4 h. The pathogens covered were Campylobacter,
Yersinia, Salmonella, Vibrio cholerae, Shigella, enter-
opathogenic E. coli, ETEC, enterohemorrhagic E.
coli, and EAEC, and were tested on stool samples
from 96 travelers’ diarrhea cases. The assay’s sensi-
tivity and specificity for the detection of these
pathogens were 100%. Most travelers (76%) had at
least one pathogen identified, compared with the
routine methods that detected pathogens in only
&&
17% of the travelers [16 ].
LONG-TERM SEQUELAE OF TRAVELERS’
DIARRHEA: FOCUS ON EMERGING
PATHOGENS
Although typically an acute infection, travelers’
diarrhea can at times have detrimental long-term
consequences, such as reactive arthritis, chronic
&
diarrhea, PI-IBS [4 ] and Guillain–Barre syndrome
[24]. Persistent diarrhea (>14 days) can result from
infection with less common pathogens (usually
parasites), triggering of a previously unknown con-
dition [e.g., inflammatory bowel diseases (IBD)], or
&
postinfectious complications (PI-IBS) [25 ].
Chronic diarrhea in returning travelers poses a
diagnostic challenge as pathogens are different from
&&
those typically screened for (Table 3) [26 ]. Further-
more, one must recognize additional causes for
chronic diarrhea. For instance, tropical sprue, which
rarely presents in developed countries, should be
considered a possible cause of chronic diarrhea after
traveling. In a retrospective study [27 ] of patients
diagnosed with either tropical sprue or celiac dis-
ease, with the same length of stay in tropical regions,
both conditions had similar presentation and histo-
logical findings, but celiac disease was characterized
by the presence of anti-endomysial or anti-tissue
transglutaminase antibodies. This is important to
appropriately guide the treatment (prolonged anti-
&
biotics or diet, respectively) [27 ].
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 Gastrointestinal infections

Table 3. Pathogens causing persistent travelers’ diarrhea
Areas with high risk
Pathogen of acquisition
Giardia lamblia Middle East, South America,
south Asia
Entamoeba histolytica Middle East, South America,
south Asia, south-east Asia
Strongyloides Latin America, South
America, Asia, Africa,
Oceania, Caribbean
Schistosoma South America, Asia, Africa
Shigella South Asia, south-east Asia,
Oceania, north Africa
Campylobacter South-east and south Asia
Salmonella serovar typhi Africa, south Asia
Nontyphoidal Salmonella Oceania, south-east Asia
Guidelines for healthy travelers
Prevention includes reducing exposure and travel
behavior, prophylactic antibiotics, and vaccines. An
example for specific destination-based recommen-
dations is the recent FIFA 2014 World Cup, in which
emphasis was made on proper food sanitation. In
fact, a risk evaluation tool for food services was
created based on foodborne disease data with associ-
&
ated statistical analysis [32 ]. Travel clinics and avail-
able public resources focus on sanitation – from
drinking only sealed bottled beverages (no ice) to
avoiding salad dressing and raw vegetables, peeling
fruits yourself, eating fully and freshly cooked food,
hand washing, etc. Such advice is associated
with protection, but has not eliminated travelers’
&&
diarrhea [5 ]. In an attempt to improve pretravel
counseling for travelers’ diarrhea, a community-
&&

&&
Adapted from [26 ].
Tropheryma whipplei, the infectious cause of
Whipple’s disease, has also recently been associated
with persistent travelers’ diarrhea. PCR analysis of
stool samples collected from two French travelers to
Senegal, who were T. whipplei-negative pretravel,
showed the presence of T. whipplei after they
returned. However, this could be an underestima-
tion as many participants received doxycycline pro-
phylaxis. Nevertheless, this pathogen, which is now
known to also cause acute diarrhea [28], should be
considered in the differential diagnosis of persistent
& &&
travelers’ diarrhea [29 ].
Another potential travelers’ diarrhea pathogen,
not previously considered as a cause of travelers’
diarrhea, is Clostridium difficile, highly prevalent in
low-income countries. Travelers might become
infected through hospitals and communities in such
countries. A literature review by Neuberger et al. [30]
revealed 48 cases of travelers’ diarrhea attributed to
C. difficile infection. Infected travelers were mostly
young, more likely to visit developing countries,
acquire infection in the community, and exposed
to antibiotics, especially fluoroquinolones.
PI-IBS is a common sequela of infectious diar-
rhea and is linked to travelers’ diarrhea. A question-
naire-based prospective Swiss study [31] following
2500 travelers showed an odds ratio of 3.7 for devel-
oping IBS after travelers’ diarrhea; however, adverse
life events and previous diarrhea were also risk fac-
tors and may have biased results.
PREVENTION AND TREATMENT
Below are the suggestions for the prevention and
treatment of travelers’ diarrhea, tailored to individ-
uals from different groups.
based retrospective observational study [33 ] was
conducted on 525 precounseled travelers. Results
showed that travelers’ diarrhea was associated with
longer duration of travel (>14 days). Through a
quality-improvement approach, the group modified
the survey to collect information about duration,
comorbid conditions, accommodations at destina-
&&
tion, and the reason for visit [33 ].
Prophylactic use of antibiotics remains contro-
versial and should probably be limited to individuals
at high risk (e.g., patients receiving immunosuppres-
sant medications, as discussed below) [34]; however,
many practitioners will provide patients with anti-
biotics for use if diarrhea develops (e.g., rifaximin,
ciprofloxacin) [35 ].
Vaccines are obviously very attractive, but also
challenging as multiple pathogens cause travelers’
diarrhea at any destination. Although vaccines
against cholera are available, a recent systematic
review did not recommend cholera vaccine for the
prevention of travelers’ diarrhea [36]. Effective ETEC
vaccines are available but others are still in develop-
ment. Whole-cell/recombinant-B-subunit (Dukoral,
Crucell Vaccines Canada, a division of Janssen Inc.,
Toronto, Ontario, Canada), a commercially avail-
able oral cholera vaccine with some cross-activity
against ETEC, was prospectively shown to prevent
28% of travelers’ diarrhea cases in a Spanish study
&
[37 ]. Although the development of a transcu-
taneous vaccine, using the heat-labile ETEC toxin,
which is effectively delivered, had shown promise
[38], it did not prevent ETEC travelers’ diarrhea
& &
[39 ]. Another study [40 ] on ETEC suggested that
targeting a combination of antigens and colonizing
factors is important for the development of effective
vaccines. Another complex vaccine, constructed
using nontoxigenic E. coli strains expressing colo-
nizing factors, an ETEC-based B subunit protein, and
nontoxic double-mutant heat-labile toxin molecule

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January 2015

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(dmLT) as the adjuvant, increased serological
responses in mice [41]. Similarly, a phase 1 clinical
trial of 36 adults has shown that oral administration
of a dmTL enhanced immune responses of dmLT-
specific antibodies in lymphocyte supernatant [42].
Once travelers’ diarrhea develops, treatment
includes symptomatic support or relief and anti-
biotics. Oral rehydration remains the backbone of
supportive therapy for severe watery diarrhea and is
especially important when cholera or other enter-
otoxin-mediated infections are suspected. The use of
antibiotics requires knowledge of local resistance
patterns. In general, rifaximin is appropriate for
noninvasive travelers’ diarrhea and fluoroquino-
lones are useful for most invasive infections,
although azithromycin may be preferred in Asia
due to antibiotics resistance of many Campylobacters
&&
[2,35 ].
Role of probiotics in travelers’ diarrhea
prevention
There is a strong rationale for the use of probiotics
for the prevention of travelers’ diarrhea, but
available data are still limited and conflicting. A
meta-analysis from 2007 found a risk reduction for
travelers’ diarrhea (relative risk ¼ 0.85) with Saccha-
& &&
romyces boulardii prophylaxis. Other studies [43,44 ]
suggest a role for various strains and combination,
including Lactobacillus bulgaricus, L. acidophilus,
Lactobacillus GG, and Streptococcus thermophilus, but
a recommendation for the broad use of probiotics
could not be made at this point. A recent study [45]
on Agri-King Symbiotic (combination of two probi-
otic strains and prebiotics; Agri-King Inc, Fulton,
Illinois, USA) for preventing travelers’ diarrhea failed
to prove efficacy.
Guidelines for children
Recommendations for prevention and treatment
of travelers’ diarrhea in the pediatric population
are age-dependent. Immunizations should be opti-
mized after consultation and according to age and
destination-specific risks. Antibiotic prophylaxis is
not recommended, especially for children below
2 years of age, but rather oral rehydration should
be provided for diarrhea. Azithromycin is suggested
as a treatment for children below 2 years of age for
most destinations. Although fluoroquinolones are
not recommended for children, they can be used in
areas with multidrug resistance. Loperamide and
bismuth subsalicylate are also an option for symp-
tomatic treatment, but should be used with caution,
& &
especially in young children [6 ,46 ]. There have
been no studies investigating the use of prebiotics
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An update on travelers’ diarrhea Zaidi and Wine
and probiotics in the setting of travelers’ diarrhea in
&
children [47 ].
Guidelines for immunocompromised patients
Many patients followed by gastroenterologists,
specifically those after solid-organ transplant and
IBD patients receiving immunosuppressive drugs,
require additional attention. A retrospective ana-
lysis of 277 Dutch IBD patients reported that most
patients felt that their disease limited their travel
and did seek travel advice. Diarrhea developed in
32%, but it was difficult to conclude whether this
was travelers’ diarrhea or a flare of their disease as
19% felt that their disease flared within 2 months
[48]. Another Dutch study [49], prospectively
following 150 traveling pairs, in which one had
IBD or was taking immunosuppressants and the
companion was healthy, did not show higher rates
of travelers’ diarrhea among patients, although they
did report more vomiting. Fever, diarrhea, and
respiratory symptoms were the most common
symptoms in traveling transplant patients (8–29%
of travelers). Acute rejection was rare (two cases
out of more than 500), but given the clinical com-
plexity of these individuals, seeking advice from
both transplant and travel clinics prior to travel is
recommended [50 ].
Live vaccinations are contraindicated with any
significant immunosuppression; therefore, patients
should avoid traveling to areas endemic with yellow
fever. However, other types of prophylaxis, such
as trimethoprim and sulfamethoxazole, passive
vaccines, and antimalarials when indicated, should
be encouraged. Antibiotics, especially azithromycin
and fluoroquinolones, should be considered for
prophylaxis for shorter travel duration (weighed
against risks of antibiotic-related complications)
and should certainly be provided for treatment in
&
case travelers’ diarrhea develops [51 ]. An updated,
detailed guideline from the Centers for Disease Con-
trol and Prevention serves as an excellent resource
&&
[52 ].
CONCLUSION
Developing diarrhea during travel can be devastat-
ing and, in some cases, dangerous. Despite advances
in epidemiology, pathogenesis, vaccines, and
treatment of travelers’ diarrhea, these conditions
remain a challenge to patients and practitioners.
Geographic variation and a multitude of potential
pathogens add complexity to prophylaxis and
treatment, especially in patients with chronic
illness requiring immunosuppressive medications.
Changes in travel patterns, bacterial resistance, and
www.co-gastroenterology.com 11
 Gastrointestinal infections
even global warming define travelers’ diarrhea
as a moving target, requiring frequent updates.
However, improvements in diagnosis and develop-
ment of new vaccines, together with better guid-
ance and good hygiene practices, will likely
improve outcomes. Travel clinics and online resour-
ces should be better utilized, certainly for complex
patients.
Acknowledgements
D.Z. is a graduate student funded by the Women and
Children’s Health Research Institute. E.W. is funded by
an Independent Investigator Award by Alberta Innovates
Health Solutions.
Conflicts of interest
There are no relevant conflicts of interest.
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Edson Guzman
Firmado digitalmente por Edson Guzman
Nombre de reconocimiento (DN): cn=Edson
Guzman, o, ou=HNERM,
email=edson_guzman@hotmail.com, c=PE
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20. Estrada-Garcia T, Perez-Martinez I, Bernal-Reynaga R, Zaidi MB. Enteroag-
& gregative coli: a pathogen bridging the north and south. Curr Trop Med Rep
2014; 1:88–96.
This detailed review describes the basic and the clinical aspects of EAEC, one of
the leading causes of travelers’ diarrhea, including epidemiology, pathogenesis,
clinical manifestations, and treatment.
21. Karst SM, Wobus CE, Goodfellow IG, et al. Advances in norovirus biology.
&& Cell Host Microbe 2014; 15:668–680.
This excellent review details the molecular virology, cell and animal models,
pathogenesis, host immune responses, and insights into vaccine development
for the most common cause of infectious diarrhea, norovirus.
22. Ajami NJ, Kavanagh OV, Ramani S, et al. Seroepidemiology of norovirus-
associated travelers’ diarrhea. J Travel Med 2014; 21:6–11.
23. Livio S, Strockbine NA, Panchalingam S, et al. Shigella isolates from the
& global enteric multicenter study inform vaccine development. Clin Infect Dis
2014; 159:933–941.
As part of the Global Enteric Multicenter Study, this study analyzed 1130 isolates
of Shigella to identify potential targets for future vaccine development that would
cover a large variety of serotypes.
24. Zautner AE, Johann C, Strubel A, et al. Seroprevalence of campylobacteriosis
and relevant postinfectious sequelae. Eur J Clin Microbiol Infect Dis 2014;
33:1019–1027.
25. Connor BA. Persistent travelers’ diarrhea. In: Brunette G, editor. The Yellow
& Book: CDC Health Information for International Travel 2014. New York, New
York: Oxford University Press; 2014. pp. 479–482.
This Centers for Disease Control and Prevention’s ‘Yellow Book’ chapter focuses
on persistent travelers’ diarrhea and provides background for understanding the
relationship between travelers’ diarrhea and PI-IBS. It is available through the
following link: http://wwwnc.cdc.gov/travel/yellowbook/2014/chapter-5-post-
travel-evaluation/persistent-travelers-diarrhea.
26. Ross AGP, Olds GR, Cripps AW, et al. Enteropathogens and chronic illness
&& in returning travelers. N Engl J Med 2013; 368:1817–1825.
This detailed review on chronic complications of travelers’ diarrhea highlights
leading parasitic and bacterial pathogens, in relation to travel destination, and
discusses the diagnosis and treatment.
27. Langenberg MCC, Wismans PJ, van Genderen PJJ. Distinguishing tropical
& sprue from celiac disease in returning travellers with chronic diarrhoea: a
diagnostic challenge? Travel Med Infect Dis 2014; 12:401–405.
In this interesting report, comparison is made between the related diagnoses –
celiac disease and tropical sprue.
28. Raoult D, Fenollar F, Rolain JM, et al. Tropheryma whipplei in children with
gastroenteritis. Emerg Infect Dis 2010; 16:776–782.
29. Gautret P, Lagier J-C, Benkouiten S, et al. Does Tropheryma whipplei
& contribute to travelers’ diarrhea?: a PCR analysis of paired stool samples
in French travelers to Senegal. Travel Med Infect Dis 2014; 12:264–267.
Tropheryma whipplei is traditionally thought to cause chronic diarrhea. In this
study, it is discussed as a cause of acute symptoms in the context of returning
travelers.
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30. Neuberger A, Saadi T, Shetern A, Schwartz E. Clostridium difficile infection in
travelers: a neglected pathogen? J Travel Med 2013; 20:37–43.
31. Pitzurra R, Fried M, Rogler G, et al. Irritable bowel syndrome among a cohort of
European travelers to resource-limited destinations. J Travel Med 2011;
18:250–256.
32. Gallego V, Berberian G, Lloveras S, et al. The 2014 FIFA World Cup:
& communicable disease risks and advice for visitors to Brazil – A review from
the Latin American Society for Travel Medicine (SLAMVI). Travel Med Infect
Dis 2014; 12:208–218.
In preparation for the 2014 FIFA World Cup in Brazil, this timely study summarized
the major communicable diseases that travelers may encounter and how to reduce
risk of exposure; this advice is probably applicable to other travel destinations.
33. Mackaness CA, Osborne A, Verma D, et al. A quality improvement initiative
&& using a novel travel survey to promote patient-centered counseling. J Travel
Med 2013; 20:237–242.
Recognizing the limited ability of current approaches to prevent travelers’ diarrhea,
this study outlines a quality improvement approach for guiding travelers through
the analysis of a survey.
34. Alajbegovic S, Sanders JW, Atherly DE, Riddle MS. Effectiveness of rifaximin
and fluoroquinolones in preventing travelers’ diarrhea (TD): a systematic
review and meta-analysis. Syst Rev 2012; 1:39.
35. Nair D. Travelers’ diarrhea: prevention, treatment, and posttrip evaluation.
&& J Fam Pract 2013; 62:356–361.
This practical guide for the practitioner provides simple and supported advice on
prevention and management of travelers’ diarrhea. It includes details on choice and
doses of antibiotics.
36. Nickonchuk T, Lindblad AJ, Kolber MR. Oral cholera vaccine for traveler’s
diarrhea prophylaxis. Can Fam Physician 2014; 60:451.
37. López-Gigosos R, Campins M, Calvo MJ, et al. Effectiveness of the WC/rBS
& oral cholera vaccine in the prevention of traveler’s diarrhea: a prospective
cohort study. Hum Vaccin Immunother 2013; 9:692–698.
In this prospective, randomized study on the whole-cell/recombinant-B-subunit
Cholera/ETEC vaccine, two of every seven cases of traveler’s diarrhea were
prevented by the vaccine.
38. Frech SA, Dupont HL, Bourgeois AL, et al. Use of a patch containing heat-
labile toxin from Escherichia coli against travellers’ diarrhoea: a phase II,
randomised, double-blind, placebo-controlled field trial. Lancet 2008;
371:2019–2025.
39. Behrens RH, Cramer JP, Jelinek T, et al. Efficacy and safety of a patch vaccine
& containing heat-labile toxin from Escherichia coli against travellers’ diarrhoea:
a phase 3, randomised, double-blind, placebo-controlled field trial in travellers
from Europe to Mexico and Guatemala. Lancet Infect Dis 2014; 14:197–204.
This randomized double-blind, placebo-controlled trial on an ETEC heat-labile
toxin-based vaccine patch was negative. Although the vaccine was effectively
absorbed, it did not reduce travelers’ diarrhea in the treatment group.
40. Rivera FP, Medina AM, Aldasoro E, et al. Genotypic characterization of
& enterotoxigenic Escherichia coli strains causing traveler’s diarrhea. J Clin
Microbiol 2013; 51:633–635.
In an attempt to identify vaccine targets for ETEC, this study surveyed 52 clinical
isolates and characterized common colonization factors.
0267-1379 ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
An update on travelers’ diarrhea Zaidi and Wine
41. Holmgren J, Bourgeois L, Carlin N, et al. Development and preclinical
evaluation of safety and immunogenicity of an oral ETEC vaccine containing
inactivated E. coli bacteria overexpressing colonization factors CFA/I, CS3
CS5 and CS6 combined with a hybrid LT/CT B subunit antigen, administered
alone and together with dmLT. Vaccine 2013; 31:2457–2464.
42. El-Kamary SS, Cohen MB, Bourgeois a L, et al. Safety and immunogenicity of
a single oral dose of recombinant double mutant heat-labile toxin derived from
enterotoxigenic Escherichia coli. Clin Vaccine Immunol 2013; 20:1764–
1770.
43. McFarland LV. Meta-analysis of probiotics for the prevention of traveler’s
diarrhea. Travel Med Infect Dis 2007; 5:97–105.
44. Sarowska J, Choroszy-Król I, Regulska-Ilow B, et al. The therapeutic effect of
& probiotic bacteria on gastrointestinal diseases. Adv Clin Exp Med 2013;
22:759–766.
This review article details current knowledge on probiotic use for intestinal
conditions with some comments on travelers’ diarrhea.
45. Virk A, Mandrekar J, Berbari EF, et al. A randomized, double blind, placebo-
controlled trial of an oral synbiotic (AKSB) for prevention of travelers’ diarrhea.
J Travel Med 2013; 20:88–94.
46. Fox TG, Manaloor JJ, Christenson JC. Travel-related infections in children.
& Pediatr Clin North Am 2013; 60:507–527.
This review discusses pediatric-specific considerations related to travel, including
travelers’ diarrhea.
47. Vandenplas Y, De Greef E, Devreker T, et al. Probiotics and prebiotics in
& infants and children. Curr Infect Dis Rep 2013; 15:251–262.
This review on probiotics use in children includes a section on probiotics for
travelers’ diarrhea, highlighting the paucity of data.
48. Soonawala D, van Eggermond AM, Fidder H, Visser LG. Pretravel preparation
and travel-related morbidity in patients with inflammatory bowel disease.
Inflamm Bowel Dis 2012; 18:2079–2085.
49. Baaten GG, Geskus RB, Kint JA, et al. Symptoms of infectious diseases in
immunocompromised travelers: a prospective study with matched controls.
J Travel Med 2011; 18:318–326.
50. Rosen J. Travel medicine and the solid-organ transplant recipient. Infect Dis
&& Clin North Am 2013; 27:429–457.
Focusing on patients after solid-organ transplant, this study provides an excellent
resource, including risk assessment and practical vaccination and treatment
advice with a section on travelers’ diarrhea in this setting.
51. Askling HH, Dalm VA. The medically immunocompromised adult traveler and
& pretravel counseling: status quo 2014. Travel Med Infect Dis 2014; 12:219–
228.
This review highlights travel-related concerns in immunocompromised patients.
First, different classes of immunosuppressive medications are defined and then
advice on prophylaxis and treatment is provided.
52. Kotton CN, Freedman DO. Immunocompromised travelers. In: Brunette GW,
&& editor. The Yellow Book: CDC Health Information for International Travel
2014. New York, New York: Oxford University Press; 2014. pp. 544–556.
This Centers for Disease Control and Prevention’s ‘Yellow Book’ chapter on
immunocompromised travelers is an excellent resource on different levels of
immune deficiency and their impact on vaccination and travel advice.
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