common travel malady

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• Traveler's diarrhea

Gastrointestinal tract

Your digestive tract stretches from your mouth to your anus. It includes the organs necessary to digest food, absorb nutrients and process waste.

Traveler's diarrhea is a digestive tract disorder that commonly causes loose stools and stomach cramps. It's caused by eating contaminated food or drinking contaminated water. Fortunately, traveler's diarrhea usually isn't serious in most people — it's just unpleasant.

When you visit a place where the climate or sanitary practices are different from yours at home, you have an increased risk of developing traveler's diarrhea.

To reduce your risk of traveler's diarrhea, be careful about what you eat and drink while traveling. If you do develop traveler's diarrhea, chances are it will go away without treatment. However, it's a good idea to have doctor-approved medicines with you when you travel to high-risk areas. This way, you'll be prepared in case diarrhea gets severe or won't go away.

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Traveler's diarrhea may begin suddenly during your trip or shortly after you return home. Most people improve within 1 to 2 days without treatment and recover completely within a week. However, you can have multiple episodes of traveler's diarrhea during one trip.

The most common symptoms of traveler's diarrhea are:

• Suddenly passing three or more looser watery stools a day.
• An urgent need to pass stool.
• Stomach cramps.

Sometimes, people experience moderate to severe dehydration, ongoing vomiting, a high fever, bloody stools, or severe pain in the belly or rectum. If you or your child experiences any of these symptoms or if the diarrhea lasts longer than a few days, it's time to see a health care professional.

When to see a doctor

Traveler's diarrhea usually goes away on its own within several days. Symptoms may last longer and be more severe if it's caused by certain bacteria or parasites. In such cases, you may need prescription medicines to help you get better.

If you're an adult, see your doctor if:

• Your diarrhea lasts beyond two days.
• You become dehydrated.
• You have severe stomach or rectal pain.
• You have bloody or black stools.
• You have a fever above 102 F (39 C).

While traveling internationally, a local embassy or consulate may be able to help you find a well-regarded medical professional who speaks your language.

Be especially cautious with children because traveler's diarrhea can cause severe dehydration in a short time. Call a doctor if your child is sick and has any of the following symptoms:

• Ongoing vomiting.
• A fever of 102 F (39 C) or more.
• Bloody stools or severe diarrhea.
• Dry mouth or crying without tears.
• Signs of being unusually sleepy, drowsy or unresponsive.
• Decreased volume of urine, including fewer wet diapers in infants.

It's possible that traveler's diarrhea may stem from the stress of traveling or a change in diet. But usually infectious agents — such as bacteria, viruses or parasites — are to blame. You typically develop traveler's diarrhea after ingesting food or water contaminated with organisms from feces.

So why aren't natives of high-risk countries affected in the same way? Often their bodies have become used to the bacteria and have developed immunity to them.

Risk factors

Each year millions of international travelers experience traveler's diarrhea. High-risk destinations for traveler's diarrhea include areas of:

• Central America.
• South America.
• South Asia and Southeast Asia.

Traveling to Eastern Europe, South Africa, Central and East Asia, the Middle East, and a few Caribbean islands also poses some risk. However, your risk of traveler's diarrhea is generally low in Northern and Western Europe, Japan, Canada, Singapore, Australia, New Zealand, and the United States.

Your chances of getting traveler's diarrhea are mostly determined by your destination. But certain groups of people have a greater risk of developing the condition. These include:

• Young adults. The condition is slightly more common in young adult tourists. Though the reasons why aren't clear, it's possible that young adults lack acquired immunity. They may also be more adventurous than older people in their travels and dietary choices, or they may be less careful about avoiding contaminated foods.
• People with weakened immune systems. A weakened immune system due to an underlying illness or immune-suppressing medicines such as corticosteroids increases risk of infections.
• People with diabetes, inflammatory bowel disease, or severe kidney, liver or heart disease. These conditions can leave you more prone to infection or increase your risk of a more-severe infection.
• People who take acid blockers or antacids. Acid in the stomach tends to destroy organisms, so a reduction in stomach acid may leave more opportunity for bacterial survival.
• People who travel during certain seasons. The risk of traveler's diarrhea varies by season in certain parts of the world. For example, risk is highest in South Asia during the hot months just before the monsoons.

Complications

Because you lose vital fluids, salts and minerals during a bout with traveler's diarrhea, you may become dehydrated, especially during the summer months. Dehydration is especially dangerous for children, older adults and people with weakened immune systems.

Dehydration caused by diarrhea can cause serious complications, including organ damage, shock or coma. Symptoms of dehydration include a very dry mouth, intense thirst, little or no urination, dizziness, or extreme weakness.

Watch what you eat

The general rule of thumb when traveling to another country is this: Boil it, cook it, peel it or forget it. But it's still possible to get sick even if you follow these rules.

Other tips that may help decrease your risk of getting sick include:

• Don't consume food from street vendors.
• Don't consume unpasteurized milk and dairy products, including ice cream.
• Don't eat raw or undercooked meat, fish and shellfish.
• Don't eat moist food at room temperature, such as sauces and buffet offerings.
• Eat foods that are well cooked and served hot.
• Stick to fruits and vegetables that you can peel yourself, such as bananas, oranges and avocados. Stay away from salads and from fruits you can't peel, such as grapes and berries.
• Be aware that alcohol in a drink won't keep you safe from contaminated water or ice.

Don't drink the water

When visiting high-risk areas, keep the following tips in mind:

• Don't drink unsterilized water — from tap, well or stream. If you need to consume local water, boil it for three minutes. Let the water cool naturally and store it in a clean covered container.
• Don't use locally made ice cubes or drink mixed fruit juices made with tap water.
• Beware of sliced fruit that may have been washed in contaminated water.
• Use bottled or boiled water to mix baby formula.
• Order hot beverages, such as coffee or tea, and make sure they're steaming hot.
• Feel free to drink canned or bottled drinks in their original containers — including water, carbonated beverages, beer or wine — as long as you break the seals on the containers yourself. Wipe off any can or bottle before drinking or pouring.
• Use bottled water to brush your teeth.
• Don't swim in water that may be contaminated.
• Keep your mouth closed while showering.

If it's not possible to buy bottled water or boil your water, bring some means to purify water. Consider a water-filter pump with a microstrainer filter that can filter out small microorganisms.

You also can chemically disinfect water with iodine or chlorine. Iodine tends to be more effective, but is best reserved for short trips, as too much iodine can be harmful to your system. You can purchase water-disinfecting tablets containing chlorine, iodine tablets or crystals, or other disinfecting agents at camping stores and pharmacies. Be sure to follow the directions on the package.

Follow additional tips

Here are other ways to reduce your risk of traveler's diarrhea:

• Make sure dishes and utensils are clean and dry before using them.
• Wash your hands often and always before eating. If washing isn't possible, use an alcohol-based hand sanitizer with at least 60% alcohol to clean your hands before eating.
• Seek out food items that require little handling in preparation.
• Keep children from putting things — including their dirty hands — in their mouths. If possible, keep infants from crawling on dirty floors.
• Tie a colored ribbon around the bathroom faucet to remind you not to drink — or brush your teeth with — tap water.

Other preventive measures

Public health experts generally don't recommend taking antibiotics to prevent traveler's diarrhea, because doing so can contribute to the development of antibiotic-resistant bacteria.

Antibiotics provide no protection against viruses and parasites, but they can give travelers a false sense of security about the risks of consuming local foods and beverages. They also can cause unpleasant side effects, such as skin rashes, skin reactions to the sun and vaginal yeast infections.

As a preventive measure, some doctors suggest taking bismuth subsalicylate, which has been shown to decrease the likelihood of diarrhea. However, don't take this medicine for longer than three weeks, and don't take it at all if you're pregnant or allergic to aspirin. Talk to your doctor before taking bismuth subsalicylate if you're taking certain medicines, such as anticoagulants.

Common harmless side effects of bismuth subsalicylate include a black-colored tongue and dark stools. In some cases, it can cause constipation, nausea and, rarely, ringing in your ears, called tinnitus.

• Feldman M, et al., eds. Infectious enteritis and proctocolitis. In: Sleisenger and Fordtran's Gastrointestinal and Liver Disease: Pathophysiology, Diagnosis, Management. 11th ed. Elsevier; 2021. https://www.clinicalkey.com. Accessed May 25, 2021.
• LaRocque R, et al. Travelers' diarrhea: Microbiology, epidemiology, and prevention. https://www.uptodate.com/contents/search. Accessed May 26, 2021.
• Ferri FF. Traveler diarrhea. In: Ferri's Clinical Advisor 2023. Elsevier; 2023. https://www.clinicalkey.com. Accessed April 28, 2023.
• Diarrhea. National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/digestive-diseases/diarrhea. Accessed April 27, 2023.
• Travelers' diarrhea. Centers for Disease Control and Prevention. https://wwwnc.cdc.gov/travel/yellowbook/2020/preparing-international-travelers/travelers-diarrhea. Accessed April 28, 2023.
• LaRocque R, et al. Travelers' diarrhea: Clinical manifestations, diagnosis, and treatment. https://www.uptodate.com/contents/search. Accessed May 26, 2021.
• Khanna S (expert opinion). Mayo Clinic. May 29, 2021.
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Approximately 1.8 billion people will cross an international border by 2030, and 66% of travelers will develop a travel-related illness. Most travel-related illnesses are self-limiting and do not require significant intervention; others could cause significant morbidity or mortality. Physicians should begin with a thorough history and clinical examination to have the highest probability of making the correct diagnosis. Targeted questioning should focus on the type of trip taken, the travel itinerary, and a list of all geographic locations visited. Inquiries should also be made about pretravel preparations, such as chemoprophylactic medications, vaccinations, and any personal protective measures such as insect repellents or specialized clothing. Travelers visiting friends and relatives are at a higher risk of travel-related illnesses and more severe infections. The two most common vaccine-preventable illnesses in travelers are influenza and hepatitis A. Most travel-related illnesses become apparent soon after arriving at home because incubation periods are rarely longer than four to six weeks. The most common illnesses in travelers from resource-rich to resource-poor locations are travelers diarrhea and respiratory infections. Localizing symptoms such as fever with respiratory, gastrointestinal, or skin-related concerns may aid in identifying the underlying etiology.

Globally, it is estimated that 1.8 billion people will cross an international border by 2030. 1 Although Europe is the most common destination, tourism is increasing in developing regions of Asia, Africa, and Latin America. 2 Less than one-half of U.S. travelers seek pretravel medical advice. It is estimated that two-thirds of travelers will develop a travel-related illness; therefore, the ill returning traveler is not uncommon in primary care. 3 Although most of these illnesses are minor and relatively insignificant clinically, the potential exists for serious illness. The advent of modern and interconnected travel networks means that a rare illness or nonendemic infectious disease is never more than 24 hours away. 4 Travelers over the past 10 years have contributed to the increase of emerging infectious diseases such as chikungunya, Zika virus infection, COVID-19, mpox (monkeypox), and Ebola disease. 3

Although most travel-related illnesses are self-limiting and do not require medical evaluation, others could be life-threatening. 5 The challenge for the busy physician is successfully differentiating between the two. Physicians should begin with a thorough history and clinical examination to have the highest probability of making the correct diagnosis. Travelers at the highest risk are those visiting friends and relatives who stay in a country for more than 28 days or travel to Africa. Most travel-related illnesses become apparent soon after arriving home because incubation periods are rarely longer than four to six weeks. 3 , 6 The most common illnesses in travelers from resource-rich to resource-poor locations are travelers diarrhea and respiratory infections. 7 , 8 The incubation period of an illness relative to the onset of symptoms and the length of stay in the foreign destination can exclude infections in the differential diagnosis ( eTable A ) .

General questions should determine the patient’s pertinent medical history, focusing on any unique factors, such as immunocompromising illnesses or underlying risk factors for a travel-related medical concern. Targeted questioning should focus on the type of trip taken and the travel itinerary that includes accommodations, recreational activities, and a list of all geographic locations visited ( Table 1 3 , 6 , 9 and Table 2 3 , 6 ) . Patients should be asked about any medical treatments received in a foreign country. Modern travel itineraries often require multiple stopovers, and it is not uncommon for the casual traveler to visit several locations with different geographically linked illness patterns in a single trip abroad.

Travel History

Travelers visiting friends and relatives are at a higher risk of travel-related illnesses and more severe infections. 10 , 11 These travelers rarely seek pretravel consultation, are less likely to take chemoprophylaxis, and engage in more risky travel-related behaviors such as consuming food from local sources and traveling to more remote locations. 3 Overall, travelers visiting friends and relatives tend to have extended travel stays and are more likely to reside in non–climate-controlled dwellings.

During the clinical history, inquiries should be made about pretravel preparations, including chemoprophylactic medications, vaccinations, and personal protective measures such as insect repellents or specialized clothing. 12 , 13 Accurate knowledge of previous preventive strategies allows for appropriate risk stratification by physicians. Even when used thoroughly, these measures decrease the likelihood of certain illnesses but do not exclude them. 6 Adherence to dietary precautions and pretravel immunization against typhoid fever do not necessarily eliminate the risk of disease. Travelers often have no control over meals prepared in foreign food establishments, and the currently available typhoid vaccines are 60% to 80% effective. 14 Although all travel-related vaccines are important, the two most common vaccine-preventable illnesses in travelers are influenza and hepatitis A. 12 , 15

Travel duration is also an important but often overlooked component of the clinical history because the likelihood of illness increases directly with the length of stay abroad. The longer travelers stay in a non-native environment, the more likely they are to forego travel precautions and adherence to chemoprophylaxis. 3 The use of personal protective measures decreases gradually with the total amount of time in the host environment. 3 A thorough medical and sexual history should be obtained because data show that sexual contact during travel is common and often occurs without the use of barrier contraception. 16

Clinical Assessment

The severity of the illness helps determine if the patient should be admitted to the hospital while the evaluation is in progress. 3 Patients with high fevers, hemorrhagic symptoms, or abnormal laboratory findings should be hospitalized or placed in isolation ( Figure 1 ) . For patients with a higher severity of illness, consultation with an infectious disease or tropical/travel medicine physician is advised. 3 Patients with symptoms that suggest acute malaria (e.g., fever, altered mental status, chills, headaches, myalgias, malaise) should be admitted for observation while the evaluation is expeditiously completed. 13

Many tools can assist physicians in making an accurate diagnosis. The GeoSentinel is a worldwide data collection network for the surveillance and research of travel-related illnesses; however, this service requires a subscription. The network can guide physicians to the most likely illness based on geographic location and top diagnoses by geography. 4 For example, Plasmodium falciparum malaria is the most common serious febrile illness in travelers to sub-Saharan Africa. 17

Ill returning travelers should have a laboratory evaluation performed with a complete blood count, comprehensive metabolic panel, and C-reactive protein. Additional testing may include blood-based rapid molecular assays for malaria and arboviruses; blood, stool, and urine cultures; and thick and thin blood smears for malaria. 3 Emerging polymerase chain reaction technologies are becoming widely available across the United States. Multiplex and biofilm array polymerase chain reaction platforms for bacterial, viral, and protozoal pathogens are now available at most tertiary health care centers. 4 Multiplex and biofilm platforms include dedicated panels for respiratory and gastrointestinal illnesses and bloodborne pathogens. These tests allow for real-time or near real-time diagnosis of agents that were previously difficult to isolate outside of the reference laboratory setting.

Table 3 lists common tropical diseases and associated vectors. 3 , 6 , 18 Physicians should be aware of unique and emerging infections, such as viral hemorrhagic fevers, COVID-19, and novel respiratory pathogens, in addition to common illnesses. Testing for infections of public health importance can be performed with assistance from local public health authorities. 19 In cases of short-term travel, previously acquired non–travel-related conditions should be on any list of applicable differential diagnoses. References on infectious diseases endemic in many geographic locations are accessible online. The Centers for Disease Control and Prevention (CDC) Travelers’ Health website provides free resources for patients and health care professionals at https://www.cdc.gov/travel .

Febrile Illness

A fever typically accompanies serious illnesses in returning travelers. Patients with a fever should be treated as moderately ill. One barrier to an accurate and early diagnosis of travel-related infections is the nonspecific nature of the initial symptoms of illness. Often, these symptoms are vague and nonfocal. A febrile illness with a fever as the primary presenting symptom could represent a viral upper respiratory tract infection, acute influenza, or even malaria, typhoid, or dengue, which are the most life-threatening. According to GeoSentinel data, 91% of ill returning travelers with an acute, life-threatening illness present with a fever. 20 All travelers who are febrile and have recently returned from a malarious area should be urgently evaluated for the disease. 13 , 21 Travelers who have symptoms of malaria should seek medical attention, regardless of whether prophylaxis or preventive measures were used. Suspicion of P. falciparum malaria is a medical emergency. 13 Clinical deterioration or death can occur in a malaria-naive patient within 24 to 36 hours. 22 Dengue is an important cause of fever in travelers returning from tropical locations. An estimated 50 million to 100 million global cases of dengue are reported annually, with many more going undetected. 23 eTable B lists the most common causes of fever in the returning traveler.

Respiratory Illness

Respiratory infections are common in the United States and throughout the world. Ill returning travelers with respiratory concerns are statistically most likely to have a viral respiratory tract infection. 24 Influenza circulates year-round in tropical climates and is one of the most common vaccine-preventable illnesses in travelers. 3 , 12 Influenza A and B frequently present with a low-grade fever, cough, congestion, myalgia, and malaise. eTable C lists the most common causes of respiratory illnesses in the returning traveler.

Gastrointestinal Illness

Gastrointestinal symptoms account for approximately one-third of returning travelers who seek medical attention. 25 Most diarrhea in travelers is self-limiting, with travelers diarrhea being the most common travel-related illness. 7 Diarrhea linked to travel in resource-poor areas is usually caused by bacterial, viral, or protozoal pathogens.

The most often encountered diarrheal pathogens are enterotoxigenic Escherichia coli and enteroaggregative E. coli , which are easily treated with commonly available antibiotics. 26 Physicians should be aware of emerging antibiotic resistance patterns across the globe. The CDC offers up-to-date travel information in the CDC Yellow Book . 3 Although patients are often concerned about parasites, they should be reassured that helminths and other parasitic infections are rare in the casual traveler. 3

The disease of concern in the setting of gastrointestinal symptoms is typhoid fever. Physicians should be aware that typhoid fever and paratyphoid fever are clinically indistinguishable, with cardinal symptoms of fever and abdominal pain. 3 Typhoid fever should be considered in ill returning travelers who do not have diarrhea, because typhoid infection may not present with diarrheal symptoms. The likelihood of typhoid fever also correlates with travel to endemic regions and should be considered an alternative diagnosis in patients not responding to antimalarial medications. A diagnosis of enteric fever can be confirmed with blood or stool cultures. Although less common, community-acquired Clostridioides difficile should be considered in the differential diagnosis in the setting of recent travel and potential antimicrobial use abroad. 27

Another important travel-related pathogen is hepatitis A due to its widespread distribution in the developing world and the small pathogen dose necessary to cause illness. Hepatitis A is a more serious infection in adults; however, many U.S. adults have been vaccinated because the hepatitis A vaccine is included in the recommended childhood immunization schedule. 28 eTable D lists the most common causes of gastrointestinal illnesses in the returning traveler.

Dermatologic Concerns

Dermatologic concerns are common among returning travelers and include noninfectious causes such as sun overexposure, contact with new or unfamiliar hygiene products, and insect bites. The most common infections in returning travelers with dermatologic concerns include cutaneous larva migrans, infected insect bites, and skin abscesses. Cutaneous larva migrans typically presents with an intensely pruritic serpiginous rash on the feet or gluteal region. 3 Questions about bites and bite avoidance measures should be asked of patients with symptomatic skin concerns; however, physicians should remember that many bites go unnoticed. 29

Formerly common illnesses in the United States are common abroad, with measles, varicella-zoster virus infection, and rubella occurring in child and adult travelers. 3 Measles is considered one of the most contagious infectious diseases. More than one-third of child travelers from the United States have not completed the recommended course of measles, mumps, and rubella vaccines at the time of travel due to immunization scheduling. One-half of all measles importations into the United States comes from these international travelers. 30 Measles should always be considered in the differential because of the low or incomplete vaccination rates in travelers and high levels of exposure in some areas abroad. eTable E lists the most common infectious causes of dermatologic concern in the returning traveler.

Data Sources: A PubMed search was completed using the key words prevention, diagnosis, treatment, travel related illness, surveillance, travel medicine, chemoprophylaxis, and returning traveler treatment. The search was limited to English-language studies published since 2000. Secondary references from the key articles identified by the search were used as well. Also searched were the Centers for Disease Control and Prevention and Cochrane databases. Search dates: September 2022 to November 2022, March 2023, and August 2023.

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Army, the U.S. Department of Defense, or the U.S. government.

The World Tourism Organization. International tourists to hit 1.8 billion by 2030. October 11, 2011. Accessed March 2023. https://www.unwto.org/archive/global/press-release/2011-10-11/international-tourists-hit-18-billion-2030

• Angelo KM, Kozarsky PE, Ryan ET, et al. What proportion of international travellers acquire a travel-related illness? A review of the literature. J Travel Med. 2017;24(5):10.1093/jtm/tax046.

Centers for Disease Control and Prevention. CDC Yellow Book: Health Information for International Travel . Oxford University Press; 2023. Accessed August 26, 2023. https://wwwnc.cdc.gov/travel/yellowbook/2024/table-of-contents

Wu HM. Evaluation of the sick returned traveler. Semin Diagn Pathol. 2019;36(3):197-202.

Scaggs Huang FA, Schlaudecker E. Fever in the returning traveler. Infect Dis Clin North Am. 2018;32(1):163-188.

Feder HM, Mansilla-Rivera K. Fever in returning travelers: a case-based approach. Am Fam Physician. 2013;88(8):524-530.

Giddings SL, Stevens AM, Leung DT. Traveler's diarrhea. Med Clin North Am. 2016;100(2):317-330.

Harvey K, Esposito DH, Han P, et al.; Centers for Disease Control and Prevention. Surveillance for travel-related disease–GeoSentinel Surveillance System, United States, 1997–2011. MMWR Surveill Summ. 2013;62:1-23.

Sridhar S, Turbett SE, Harris JB, et al. Antimicrobial-resistant bacteria in international travelers. Curr Opin Infect Dis. 2021;34(5):423-431.

Matteelli A, Carvalho AC, Bigoni S. Visiting relatives and friends (VFR), pregnant, and other vulnerable travelers. Infect Dis Clin North Am. 2012;26(3):625-635.

Ladhani S, Aibara RJ, Riordan FA, et al. Imported malaria in children: a review of clinical studies. Lancet Infect Dis. 2007;7(5):349-357.

Sanford C, McConnell A, Osborn J. The pretravel consultation. Am Fam Physician. 2016;94(8):620-627.

Shahbodaghi SD, Rathjen NA. Malaria. Am Fam Physician. 2022;106(3):270-278.

Freedman DO, Chen LH, Kozarsky PE. Medical considerations before international travel. N Engl J Med. 2016;375(3):247-260.

• Marti F, Steffen R, Mutsch M. Influenza vaccine: a travelers' vaccine?  Expert Rev Vaccines. 2008;7(5):679-687.

Vivancos R, Abubakar I, Hunter PR. Foreign travel, casual sex, and sexually transmitted infections: systematic review and meta-analysis. Int J Infect Dis. 2010;14(10):e842-e851.

Paquet D, Jung L, Trawinski H, et al. Fever in the returning traveler. Dtsch Arztebl Int. 2022;119(22):400-407.

Cantey PT, Montgomery SP, Straily A. Neglected parasitic infections: what family physicians need to know—a CDC update. Am Fam Physician. 2021;104(3):277-287.

Rathjen NA, Shahbodaghi SD. Bioterrorism. Am Fam Physician. 2021;104(4):376-385.

Jensenius M, Davis X, von Sonnenburg F, et al.; Geo-Sentinel Surveillance Network. Multicenter GeoSentinel analysis of rickettsial diseases in international travelers, 1996–2008. Emerg Infect Dis. 2009;15(11):1791-1798.

Tolle MA. Evaluating a sick child after travel to developing countries. J Am Board Fam Med. 2010;23(6):704-713.

Centers for Disease Control and Prevention. About malaria. February 2, 2022. Accessed August 21, 2022. https://www.cdc.gov/malaria/about/index.html

Wilder-Smith A, Schwartz E. Dengue in travelers. N Engl J Med. 2005;353(9):924-932.

Summer A, Stauffer WM. Evaluation of the sick child following travel to the tropics. Pediatr Ann. 2008;37(12):821-826.

Swaminathan A, Torresi J, Schlagenhauf P, et al.; GeoSentinel Network. A global study of pathogens and host risk factors associated with infectious gastrointestinal disease in returned international travellers. J Infect. 2009;59(1):19-27.

Shah N, DuPont HL, Ramsey DJ. Global etiology of travelers' diarrhea: systematic review from 1973 to the present. Am J Trop Med Hyg. 2009;80(4):609-614.

Michal Stevens A, Esposito DH, Stoney RJ, et al.; GeoSentinel Surveillance Network. Clostridium difficile infection in returning travellers. J Travel Med. 2017;24(3):1-6.

Mayer CA, Neilson AA. Hepatitis A - prevention in travellers. Aust Fam Physician. 2010;39(12):924-928.

Herness J, Snyder MJ, Newman RS. Arthropod bites and stings. Am Fam Physician. 2022;106(2):137-147.

Bangs AC, Gastañaduy P, Neilan AM, et al. The clinical and economic impact of measles-mumps-rubella vaccinations to prevent measles importations from U.S. pediatric travelers returning from abroad. J Pediatric Infect Dis Soc. 2022;11(6):257-266.

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10 Common Travel Diseases & How To Prevent Them

2020 has changed the way we travel. 

It’s taught us that staying healthy and keeping each other safe while at home and while traveling are the most important things.

COVID-19 has enforced masks, social distancing, and stocking up on hand sanitizer and hand soap, along with several other germ-free items .

By following strict guidelines from the CDC and the WHO, we will begin to see a safe, healthy, happy world once again and we can’t wait to explore it! 

But for now, let’s stay educated on COVID-19 with the help of WHO , as well as other risks and diseases we face when we travel. 

Here are 10 common travel diseases and how to prevent them. 

West Nile Virus

The West Nile Virus is a virus that is most commonly caused by the bite of a mosquito that has been infected by a bird.

According to the CDC , 8 out of 10 people infected do not show symptoms, about 1 in 150 people develop a severe case. The severe case symptoms can include encephalitis (inflammation of the brain) or meningitis (inflammation of the membranes that surround the brain and spinal cord), and high fever, headache, neck stiffness, stupor, disorientation, coma, tremors, convulsions, muscle weakness, vision loss, numbness, and paralysis.

The West Nile Virus is common in temperate and tropical regions like East Africa, Latin America and the Caribbean.

To protect yourself from mosquito bites, use Environmental Protection Agency (EPA)-registered insect repellents , wear long-sleeved shirts and pants, stay in places with screens on the windows and doors, and use a bed net . 

Typhoid Fever

Typhoid Fever is caused by Salmonella Typhi bacteria. According to the CDC, typhoid fever occurs in countries with poor sanitation.

The person who is infected can spread this bacteria to others when they do not wash their hands and touch things that others touch. The water used to rinse and prepare food and drink can also become contaminated and infect others. People with typhoid fever usually have a high fever of 103–104°F (39–40°C).

Other symptoms include weakness, stomach pain, a rash, headache, diarrhea or constipation, cough, and loss of appetite. Paratyphoid fever is a similar disease also caused by bacteria. 

The best ways to prevent getting typhoid fever include getting vaccinated, choosing food and drinks carefully when you travel, and washing your hands ! (sounds familiar, eh?). 

Cholera is a diarrheal illness caused by infection of the intestine. According to the CDC, the cholera bacterium is usually found in water or food sources that have been contaminated by feces from a person infected with cholera.

Cholera is most likely to be spread in places with poor water treatment, poor sanitation, and poor hygiene. This disease is usually mild with no symptoms but can cause profuse watery diarrhea, vomiting, and leg cramps. 

The five basic cholera prevention steps include drinking and using safe water, washing your hands often, using latrines or burying your poop, cooking food well (can be found in few fish), and cleaning up safely. 

Malaria is caused by a mosquito bite and is found most commonly in Africa, Central, and South America, the Caribbean, Asia, Eastern Europe, and the South Pacific.

Malaria is categorized as either uncomplicated or complicated (severe). Malaria is curable if it is treated and diagnosed properly. Uncomplicated malaria generally presents itself as a cold stage (cold, shivering), a hot stage (fever, headaches, vomiting) and a sweating stage (sweats, returns to normal temperature, tiredness).

More commonly, these symptoms are reported: fever, chills, sweats, headaches, nausea and vomiting, body aches, and general malaise.

Severe malaria occurs when infections are complicated by serious organ failures or abnormalities in the patient’s blood or metabolism. Those symptoms can include cerebral malaria, severe anemia, hemoglobinuria, acute respiratory distress syndrome (ARDS), an inflammatory reaction in the lungs that inhibits oxygen exchange, abnormalities in blood coagulation, low blood pressure, acute kidney injury, hyperparasitemia, metabolic acidosis, and hypoglycemia. 

Check out the CDC site for diagnosis and treatment of malaria.

Norovirus is a contagious virus that causes vomiting and diarrhea in all ages. You can catch this virus from direct contact with an infected person, consuming contaminated food or water and by touching contaminated surfaces and then putting your unwashed hands in your mouth!

The most common symptoms include diarrhea, vomiting, nausea, stomach pain, and is commonly called the ‘stomach bug’ or the ‘stomach flu.’ However, it is not related to the flu. 

According to the CDC, it is the leading cause of illness and outbreaks from contaminated food in the United States.

In order to prevent the norovirus, you need to follow a few preventative measures including washing your hands, handling food properly and safely, cleaning and disinfecting surfaces, and washing laundry thoroughly.

Dengue is another common travel disease spread through mosquito bites. It is common in tropical and subtropical regions, including the Caribbean, Central and South America, Western Pacific Islands, Australia, Southeast Asia, and Africa.

Symptoms include fever, headache, nausea, vomiting, rash, pain in the eyes, joints, and muscles, and minor bleeding. They may take up to two weeks develop, but usually only last about a week, according to the CDC. 

To prevent being bitten by a mosquito, use proper insect repellent, wear long sleeved shirts and pants, use permethrin-treated clothing and gear , sleep in air conditioned rooms, and use bed nets. 

Tetanus is an infection caused by a bacteria called Clostridium tetani . This common travel disease causes painful muscle contractions and is commonly known as “lockjaw” because it causes a person’s neck and jaw muscles to lock, making it hard to open the mouth or swallow.

What’s different about this common travel disease is that it does not transfer from person to person, the bacteria are usually found in soil, dust, and manure and enter the body through breaks in the skin — cuts or wounds caused by contaminated objects.

It’s common in countries that don’t have access to immunization and very rare in the United States.

Tuberculosis

Tuberculosis is common in Asia, Sub-Saharan Africa and South and Central America. Symptoms of tuberculosis depend on where in the body the TB bacteria are growing – most commonly in the lungs.

TB in the lungs includes a bad cough that lasts 3 weeks or longer, pain in the chest, and coughing up blood or phlegm. Other symptoms can include weakness or fatigue, weight loss, no appetite, chills, fever, and night sweats.

You can get TB by being exposed to someone who already has it, however, it is not spread by shaking someone’s hand, sharing food or drink, touching bed linens or toilet seats, sharing toothbrushes, or kissing. It is spread through the air – so when someone who is infected coughs, speaks or sings. 

Getting TB during air travel is very low risk. If you are in contact with someone who has TB, ask about administrative and environmental procedures for preventing exposure to TB. Additional measures include using personal respiratory protective devices.

Pertussis (Whooping Cough)

Pertussis , also known as Whooping Cough, is a disease that spreads to others when those infected with the bacteria cough, sneeze, or share the same breathing space. Early symptoms can include runny nose, low fever, and mild cough.

Later symptoms of the disease may include “fits” of many rapid coughs followed by a high-pitched “whoop,” vomiting, and exhaustion. The coughing fits can last for 10 weeks or more. While the disease is found worldwide, more whooping cough is seen in developing countries where very few people get vaccinated.

Babies can get whooping cough if their relatives have the disease, and it can cause serious and sometimes deadly complications for them.

The best way to prevent whooping cough is to stay up-to-date with whooping cough vaccines.

Yellow Fever

Yellow Fever is a disease caused by a virus that is spread through, you guessed it, mosquito bites!

Symptoms generally include fever, chills, headache, backache, and muscle aches. Severe cases result in bleeding, shock, organ failure, and sometimes death – but this is rare.

You are at risk for Yellow Fever when visiting parts of South America and Africa, getting a vaccine is highly encouraged. The vaccine is recommended at least 10 days before your trip.

In addition, to prevent mosquito bites, cover exposed skin with long sleeves, pants, use the appropriate insect repellent, reapply the repellent as directed, use permethrin-treated clothing and gear, sleep in air-conditioned rooms, and use a bed net when needed.

Now that you’ve seen our list of common travel diseases, what do you think? Did anything surprise you? Leave us a comment below! 

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From Contaminated Food and Water

International travelers can be at risk for a variety of infectious and non-infectious diseases. Travelers may acquire parasitic illnesses:

• through ingestion of contaminated food or water,
• by vector-borne transmission, or
• through person-to-person contact.

Contaminated food and drink are common sources for the introduction of infection into the body. The table below shows some of the more common parasitic infections that travelers can acquire from contaminated food and drink, as well as a few of the less common parasitic diseases that travelers are at risk for acquiring. The risk of acquiring these other protozoa and helminths varies greatly by region of the world and specific country. Many infectious diseases transmitted in food and water can also be acquired directly through the fecal-oral route.

 From Contaminated Food and Water

 more common.

• Cryptosporidiosis
• Cyclosporiasis

 Less Common

• Trichinellosis (trichinosis)
• Taenia  infection
• Fascioliasis

 From Vector-borne Transmission

• Leishmaniasis
• Chagas disease
• Lymphatic filariasis
• African sleeping sickness
• Onchoceriasis

*This list is not comprehensive.

International travelers can take a number of simple steps before and during travel to avoid potential health problems. International travelers should

• contact their physicians, local health departments, or private or public agencies that advise international travelers at least 4 to 6 weeks before departure to schedule an appointment to receive current health information on the countries they plan to visit,
• obtain vaccinations and prophylactic medications as indicated, and
• address any special needs.

CDC’s Travelers’ Health Web site contains detailed advice for health care providers. Health departments, the travel industry, multinational corporations, missionary and volunteer organizations, and travelers can also use this information to help make international travel as healthy and safe as possible.

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Travelers’ Diarrhea: A Clinical Review

Alexander k.c. leung, amy a.m. leung, alex h.c. wong, background:.

Travelers’ diarrhea is the most common travel-related malady. It affects millions of international travelers to developing countries annually and can significantly disrupt travel plans.

To provide an update on the evaluation, diagnosis, treatment, and prevention of traveler’s diar-rhea.

A PubMed search was completed in Clinical Queries using the key term “traveler’s diarrhea”. The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews. The search was restricted to English literature. Patents were searched using the key term “traveler’s diarrhea” from www.freepatentsonline.com .

Between 10% and 40% of travelers develop diarrhea. The attack rate is highest for travelers from a developed country who visit a developing country. Children are at particular risk. Travelers’ diarrhea is usually acquired through ingestion of food and water contaminated by feces. Most cases are due to a bac-terial pathogen, commonly, Escherichia coli, and occur within the first few days after arrival in a foreign country. Dehydration is the most common complication. Pretravel education on hygiene and on the safe selection of food items is important in minimizing episodes. For mild travelers’ diarrhea, the use of antibi-otic is not recommended. The use of bismuth subsalicylate or loperamide may be considered. For moder-ate travelers’ diarrhea, antibiotics such as fluoroquinolones, azithromycin, and rifaximin may be used. Loperamide may be considered as monotherapy or adjunctive therapy. For severe travelers’ diarrhea, antibiotics such as azithromycin, fluoroquinolones, and rifaximin should be used. Azithromycin can be used even for the treatment of dysentery whereas fluoroquinolones and rifaximin cannot be used for such purpose. Recent patents related to the management of travelers’ diarrhea are discussed.

Conclusion:

Although travelers’ diarrhea is usually self-limited, many travelers prefer expedient relief of diarrhea, especially when they are traveling for extended periods by air or ground. Judicious use of an antimotility agent and antimicrobial therapy reduces the duration and severity of diarrhea.

1. INTRODUCTION

Travelers’ diarrhea is generally defined as the passage of ≥ 3 unformed stools per 24 hours plus at least one additional symptom (such as nausea, vomiting, abdominal cramps, fever, blood/mucus in the stools, or fecal urgency) that develop while abroad or within 10 days of returning from any resource-limited destinations [ 1 - 3 ]. In the pediatric age group,

travelers’ diarrhea is defined as a ≥ 2-fold increase in the frequency of unformed stools rather than ≥ 3 unformed stools per 24 hours, with other aforementioned conditions applied [ 1 , 4 ]. Travelers’ diarrhea is the most common travel-related malady. It affects millions of individuals traveling to developing countries annually and can disrupt travel plans, ruining a holiday not only for the patient but for the entire family. During prolonged ground or air transportation, diarrhea may incapacitate the traveler [ 5 ]. Anticipatory guidance on prudent food and beverages selection and preparation, observance of personal hygiene, pretravel vaccination with appropriate enteric vaccines if indicated, and judicious use of antimicrobial and antimotility agents can reduce the incidence and severity of travelers’ diarrhea. Due to the popularity of international travels, the incidence of travelers’ diarrhea is increasing [ 1 ]. Clinicians have to be knowledgeable in the recognition and management of this condition. This paper provides an update on the epidemiology, etiology, clinical manifestations, complications, diagnosis, management, and prevention of travelers’ diarrhea. Recent patents related to the management of travelers’ diarrhea are also discussed.

3. DEFINITIONS

The expert panel of the International Society of Travel Medicine uses the following functional impact to define the severity of travelers’ diarrhea [ 6 ].

Mild (acute) diarrhea is tolerable, not distressing, and does not interfere with planned activities. Moderate (acute) diarrhea is distressing or interferes with planned activities. Severe (acute) diarrhea is incapacitating or completely prevents planned activities. All dysentery (passage of grossly bloody stools) is considered severe.

The expert panel defines persistent diarrhea as diarrhea that lasts for ≥ 14 days [ 6 ]. Conventionally, chronic diarrhea is defined as diarrhea that lasts for ≥ 1 month [ 4 ].

4. EPIDEMIOLOGY

Overall, travelers’ diarrhea affects 10 to 40% of travelers [ 1 , 2 , 7 , 8 ]. The incidence varies according to the traveler’s destination of travel and country of origin, the duration of exposure, and the season of travel [ 1 , 2 , 7 , 8 ]. The sex ratio is approximately equal [ 9 , 10 ]. There is a genetic predisposition to the development of travelers’ diarrhea [ 11 ]. More than one episode of diarrhea might develop within a single trip.

The incidence is highest in destinations where hygienic practices and sanitation are poor, particularly in those regions with warmer climates [ 2 , 9 ]. High-risk destinations (incidence rate of travelers’ diarrhea ≥ 20%) include Africa (with the exception of South Africa), South and Central America, South and Southeast Asia, Mexico, Haiti, and the Dominican Republic [ 2 , 12 ]. Intermediate-risk destinations (incidence rate of travelers’ diarrhea 8 to < 20%) include Southern and Eastern Europe, Central and East Asia (including China and Russia), the Middle East (including Israel), South Africa, and Caribbean Islands [ 2 ]. Low-risk destinations (incidence rate of travelers’ diarrhea < 8%) include North America, Northern and Western Europe, Australia, New Zealand, Singapore, and Japan. The risk of acquiring travelers’ diarrhea is highest for travelers from a developed country who visit a developing country [ 2 , 4 , 5 , 13 ]. In contrast, the risk is lower for travelers from a developing country who visit another developing country, possibly because of previous exposure and subsequent immunity to the offending pathogens [ 4 ]. The incidence is lower in winter months and higher in summer months in the same tourist destinations [ 2 , 3 , 9 , 14 ].

Travelers’ diarrhea is usually acquired by the fecal-oral transmission of the causative pathogen, typically through ingestion of food or water contaminated by feces. Occasionally, travelers’ diarrhea may be acquired by handling contaminated objects or from accidental swallowing of contaminated water from swimming pools and other recreational water sources [ 5 ]. Insects particularly flies are important vectors for some foodborne enteric pathogens.

Children, especially the young ones, are at higher risk because of their natural curiosity and propensity to indiscriminately touch multiple objects and to put objects into their mouths. Furthermore, they are less selective in the type and source of food they consume, less likely to receive pretravel medical advice, and less likely to constantly adhere to the recommended hygiene measures [ 1 , 4 , 7 ].

Other risk factors include gastric hypochlorhydria, use of antacids (especially proton pump inhibitors), pre-existing medical conditions ( e.g ., inflammatory bowel disease, diabetes mellitus, chronic renal failure, immunodeficiency) and adventurous eating habits [ 3 - 5 , 9 , 15 ]. Generally, campers and backpackers are also at higher risk than those who stay in hotels, possibly reflecting different standards of hygiene [ 3 , 9 ].

5. ETIOLOGY

Generally, pathogens can be identified in approximately 85% of cases [ 4 ]. Bacteria account for up to 90% of identified pathogens for travelers’ diarrhea [ 16 ]. Escherichia coli , especially Enterotoxigenic E. coli (ETEC), is the most common pathogen worldwide. ETEC is responsible for 30 to 60% of all cases of travelers’ diarrhea and is a significant cause of childhood morbidity and mortality in the developing world, especially in Africa and Lain America [ 1 ]. Other bacterial pathogens include Enteroaggregative E. coli (EAEC), Enteroinvasive E. coli (EIEC), Diffusely Adherent E. coli (DAEC), Salmonella spp, Shigella spp, Campylobacter spp, and Yersinia enterocolitica [ 2 , 4 , 17 - 19 ]. Less common bacterial pathogens include Plesiomonas shigelloides , Aeromonas hydrophilia , Bacteroides fragilis , Arcobacter spp, Clostridium difficile , Vibrio cholerae , and Vibrio parahaemolyticus [ 7 , 20 - 22 ]. Travelers taking medications for prophylaxis of malaria or antibiotics might develop diarrhea due to Clostridium difficile [ 2 ]. Infection with Vibrio species is often associated with ingestion of partially cooked or raw seafood [ 4 ].

Viral pathogens such as norovirus, rotavirus, astrovirus, and enteric adenovirus may be responsible for up to 10% of cases of travelers’diarrhea [ 17 , 21 , 23 , 24 ].

Protozoal parasites such as Giardia lamblia (also known as Giardia intestinalis ), Entamoeba histolytica , Cyclospora cayetanensis , Dientamoeba fragilis , Cystoisospora belli (also known as Isospora belli ), Cryptosporidium parvum , and Microsporidium spp are less common causes; however, they are increasing in importance when the diarrhea lasts for ≥ two weeks [ 2 , 4 , 7 , 25 , 26 ]. Recently, Yoshikawa et al . identified Ancylostoma ceylanicum as a novel etiological agent for travelers’ diarrhea [ 27 ]. The authors reported four Japanese patients who visited Southeast Asia and Papua Guinea and developed travelers’ diarrhea secondary to Ancylostoma ceylanicum infection.

6. PATHOPHYSIOLOGY

Travelers’ diarrhea may be caused by increased secretion and/or decreased absorption of fluid and electrolytes across the intestinal epithelium. Pathogens that can lead to secretory diarrhea include, ETEC, Vibrio cholera and rotavirus [ 9 , 23 , 28 ]. Infection by these pathogens leads to the secretion of neurotransmitters ( e.g ., 5-hydroxytryptamine) from enteroendocrine cells and activation of afferent neurons that stimulate submucosal secretomotor neurons resulting in an outpouring of electrolytes and fluid into the intestinal lumen [ 8 ]. Activation of adenylate cyclase and elevation of intracellular cAMP in the enterocytes mediated by the bacterial toxins may account for the pathogenesis of secretory diarrhea [ 29 ]. The majority of cholera is caused by the cholera toxin-producing V. cholerae strains of 01 and 0139 serogroups [ 29 , 30 ]. ETEC can produce a heat-labile enterotoxin (LT), a heat-stable enterotoxin (ST), or both enterotoxins (LT/ST) [ 21 , 31 ]. Approximately two-thirds of ETEC produce LT, which is functionally and structurally similar to cholera toxin. The enterotoxins produced by ETEC are responsible for ETEC’s virulence [ 31 ]. Other virulence factors include adhesion properties and colonization factors [ 31 ].

Impaired absorption of fluid and electrolytes with resultant diarrhea may result from the direct invasion of the intestinal mucosa or the destruction of enterocytes by the cytolytic toxins released by the pathogens [ 15 ]. Examples of these pathogens include Salmonella spp, Shigella spp, Campylobacter spp, Yersinia enterocolitica , and ETEC [ 32 , 33 ].

7. CLINICAL MANIFESTATIONS

The majority of the diarrheal episodes develop during the first few days of exposure after arrival in a foreign country, with > 90% of the diarrheal episodes developing within the first two weeks of exposure [ 25 ]. The majority of bacterial and viral causative pathogens have an incubation period of < 24 hours. The incubation period for Campylobacter jejuni is longer at 3 to 10 days [ 4 ]. On the other hand, the incubation periods of Giardia lamblia and Entamoeba histolytica are 3 to 25 days and 2 to 4 weeks, respectively [ 4 ].

The diarrhea is watery in approximately 86% of cases; however, it can also be loose, mucousy or bloody [ 1 , 34 ]. Approximately 3% of patients have ≥ 10 unformed stools per 24 hours [ 7 , 34 ]. Most patients have 3 to 5 unformed stools per 24 hours [ 34 ]. Other symptoms include fecal urgency in 90 to 100%, tenesmus in 71 to 80%, colicky abdominal pain/abdominal discomfort in 40 to 77%, nausea in 10 to 70%, malaise in 50 to 58%, fever in 10 to 30%, vomiting in 5 to 20%, mucoid stools in 3 to 10%, and bloody stools in 2 to 10% of cases [ 4 , 34 ]. Symptoms vary according to the causative pathogen. Characteristically, ETEC present mainly with watery diarrhea without bloody stools or fever [ 4 ]. Yersinia enterocolitica , C. jejuni , and Shigella dysenteriae , on the other hand, often cause dysentery-like diarrhea, with bloody stools, fever, fecal urgency, and abdominal cramps [ 4 , 25 ]. Vomiting is characteristic of Norwalk virus and Rotavirus infection [ 23 ]. Profuse watery diarrhea is characteristically seen in Vibrio cholerae, Cyclospora cayetanensis , and Cryptosporidium parvum infection [ 34 ]. Upper gastrointestinal symptoms such as nausea, bloating, belching, vomiting, and abdominal pain are typically seen in patients with giardiasis [ 25 , 34 ].

8. DIAGNOSIS AND LABORATORY INVESTIGATIONS

The diagnosis is mainly clinical based on the history of passage of ≥ 3 unformed stools per 24 hours, plus at least one additional symptom (such as nausea, vomiting, abdominal cramps, fever, blood/mucus in the stools, or fecal urgency) that develops while abroad or within 10 days of returning from travel to a resource-limited setting [ 1 , 3 , 34 ]. Laboratory evaluation is generally unnecessary unless the patient appears toxic, has a high fever, is hospitalized, develops bloody, mucoid, or cholera-like diarrhea has severe abdominal cramps, is immunocompromised, has a significant underlying medical condition, or has persistent diarrhea not responding to empiric therapy [ 6 , 7 , 15 ]. If that is the case, a fresh stool sample should be sent for culture. Freshly passed stool samples should be collected on three different days and sent for microscopic examination for ova, cysts, and parasites. The likelihood that protozoal pathogens such as Giardia lamblia, Entamoeba histolytica , or Cryptosporidium parvum rather than a bacterium will be isolated from a stool specimen increases with the duration of diarrhea [ 6 ]. An assay for C. difficile toxin should be ordered if the patient has a history of antimicrobial therapy within the month preceding the onset of diarrhea. A real-time multiplex Polymerase Chain Reaction (PCR) has been developed for rapid identification of a broad array of pathogens in a single assay to define the cause of travelers’ diarrhea with high sensitivity and specificity [ 7 , 21 , 35 , 36 ]. However, multiplex PCR testing is expensive and not widely available. In addition, multiplex PCR testing cannot distinguish between viable and non-viable pathogens, may detect microorganisms that may not be the cause of diarrhea, and does not provide antibacterial susceptibility [ 36 - 38 ]. As such, good clinical judgement must be exercised. The use of multiplex PCR should be considered for patients hospitalized with travelers’ diarrhea when rapid results are desirable and those with persistent diarrhea when non-molecular tests have failed to establish a diagnosis [ 6 , 21 ].

9. COMPLICATIONS

Dehydration with or without electrolyte imbalance is the most common complication, particularly in children. Inappropriate rehydration solutions (excessively high glucose content or excessively low electrolyte content) might compound the problem [ 39 , 40 ]. Other less common complications include sepsis, hemolytic-uremic syndrome, postinfectious irritable bowel syndrome, C. difficile colitis (after antibiotic use), Guillain-Barré syndrome (after infection with C. jejuni ), reactive arthritis (often associated with HLA-B27), acute myocarditis (rarely after infection with C. jejuni ), and permanent short-term memory loss (after shellfish poisoning) [ 41 - 48 ]. Travelers’ diarrhea can disrupt business trips and holidays. The financial loss and economic burden associated with travelers’ diarrhea can be considerable.

10. MANAGEMENT

The goals of management are to maintain optimal hydration, minimize the severity and duration of diarrheal illness, prevent cancellation of planned activities, restore functional status, and eradicate the offending pathogen. Individuals at the extremes of age are particularly susceptible to and less tolerant of fluid and electrolyte loss. For most cases of travelers’ diarrhea, correction of water and electrolyte loss is the mainstay of treatment and this can be accomplished preferably with properly designed oral rehydration solutions that can facilitate glucose and sodium cotransport across the intestinal membrane [ 5 , 39 , 49 , 50 ]. Prepackaged oral rehydration salt should be mixed with clean, boiled, bottled, or filtered water [ 39 ]. Breastfeeding should be encouraged in infants who are breastfed [ 51 ]. These infants should be supplemented with an oral rehydration solution if necessary [ 51 ].

Although antisecretory/antimotility agents do not eradicate the pathogen, they can shorten the duration and reduce the severity of diarrhea. Antisecretory/antimotility agents should be considered for travelers who prefer expedient relief of diarrhea. This is especially so when they have to travel for extended periods by air or ground. The short-term use of loperamide (Imodium) has been approved for the treatment of individuals ≥ 2 years of age with travelers’ diarrhea [ 52 ]. Loperamide is an opioid-like agent that is taken orally [ 53 ]. The medication is relatively nonabsorbable; hence only insignificant amounts reaches the systemic circulation. It has a potent antisecretory effect in addition to its antimotility activity [ 53 ]. The drug has a rapid onset of action [ 54 ]. It is particularly useful in the management of mild and moderate travelers’ diarrhea [ 53 ]. The recommended loading dose for individuals ≥ 12 years is 4mg, followed by 2mg per episode of diarrhea (maximum 16mg per day) [ 53 ]. For children 6 to 11 years, the recommended loading dose is 2mg, followed by 1mg per episode of diarrhea (maximum 6mg per day) and that for children 2 to 5 years old, the recommended loading dose is 1mg, followed by 1mg per episode of diarrhea (maximum 3mg per day). Loperamide has a favorable safety profile but should be avoided if the patient has a high fever, severe abdominal cramps, or dysentery because of the risk of toxic megacolon and intestinal perforation [ 1 , 25 ]. The medication should not be given to children ≤ 2 years of age because of the potential risk of central nervous system depression [ 1 , 7 ]. Two systematic reviews including 28 studies concluded that adding loperamide to antibiotic therapy may hasten resolution of travelers’ diarrhea with no or minimal side effects compared to antibiotic therapy alone [ 55 ]. Diphenoxylate (Lomotil), an antimotility agent, is also effective for the treatment of travelers’ diarrhea by reducing the rate of stool frequency [ 34 ]. It is a centrally active opioid drug of the phenylpiperidine series that is used in combination with a subtherapeutic dose of atropine for the treatment of diarrhea. The recommended dose for individuals ≥ 13 years is 5mg of diphenoxylate/0.5mg of atropine every 6 hours for a maximum of 48 hours. The safety and effectiveness of diphenoxylate have not been established in children < 12 years of age. Bismuth subsalicylate (Pepto Bismol) is also effective for the treatment of travelers’ diarrhea [ 56 ]. The medication possesses antisecretory properties and is capable of neutralizing the toxins of ETEC [ 11 ]. The recommended dose for individuals ≥ 12 years is four tablets (262mg/tablet) or 60ml (regular strength) every 30 to 60 minutes until diarrhea subsides or eight doses have been taken [ 34 ]. The recommended dose for children 10 to 11 years, 6 to 9 years, and 3 to 5 years is 1 tablet or 15ml, 2/3 tablet or 10ml, and 1/3 tablet or 5ml, respectively. The medication, however, is less effective than loperamide [ 25 , 56 ]. Other disadvantages include the large and frequent doses of the liquid preparation of medication needed and the potential for adverse events such as blackening of the tongue, black stools, salicylate toxicity, Reye’s syndrome, and tinnitus. This drug is not recommended for pregnant women and children [ 56 ]. For those patients with coexisting severe nausea and vomiting, ondansetron (Zofran) may be given [ 49 , 57 - 59 ].

Antimicrobial therapy is effective in reducing the duration and severity of traveler’s diarrhea [ 52 , 60 ]. For travelers going to moderate and high-risk areas, it might be appropriate to provide them with a short course of a suitable antibiotic with the advice to start antimicrobial treatment should they develop moderate or severe diarrhea [ 25 ]. The choice of the antibiotic should be guided by resistance surveillance data as well as careful assessment of the benefits and risks associated with its use to both the patient and society [ 61 ]. Differences in effectiveness of antimicrobials between regions are likely due to the local pattern of antimicrobial resistance [ 56 ]. Fluoroquinolones, such as ciprofloxacin (Cipro), levofloxacin (Levaquin, Leva-Pak, Quixin), and ofloxacin (Floxin), are efficacious against a broad spectrum of bacterial enteric pathogens. The recommended dose of ciprofloxacin for adults is 750mg as a single dose (children, 20 to 30mg/kg/day in 1 or 2 divided doses) or 500mg daily for 3 days, that of levofloxacin is 500mg as a single dose (children, 10 to 20mg/kg/day in 1 or 2 divided doses) or for 3 days, and that of ofloxacin is 400mg as a single dose or for 3 days [ 6 ]. The safety and efficacy of ofloxacin have not been established in children < 12 years of age. Fluoroquinolones are drugs of choice for most destinations [ 7 ]. Resistance to fluoroquinolones is increasing, particularly in Southeast Asia where Campylobacter jejuni is a common cause of travelers’ diarrhea. Fluoroquinolones are contraindicated in pregnant women and are not recommended for children under 8 years of age [ 18 ]. Azithromycin (Zithromax, Azithrocin) and fluoroquinolones have similar efficacy [ 18 ]. The recommended dose of azithromycin is 500mg (children, 10mg/kg/day, maximum 500mg) daily for three days or 1000mg as a single dose. The single dose regimen may have to be repeated if symptoms persist for up to three days [ 1 , 6 , 18 , 34 ]. Azithromycin is highly effective against most pathogens that cause travelers’ diarrhea and is effective in the treatment of patients with Campylobacter infection that is resistant to fluoroquinolones. It is the drug of choice for treatment of severe or febrile travelers’ diarrhea, dysentery, and moderate to severe travelers’ diarrhea among travelers to Southeast Asia where fluoroquinolone-resistant pathogens are prevalent [ 6 , 7 , 18 , 34 ]. The medication is safe to use in pregnant women and children. Rifaximin (Xifaxan, Xifaxante, Normix) is a nonabsorbable (< 0.4% absorbed), locally active antimicrobial that can achieve high concentrations in the intestines [ 62 , 63 ]. The medication binds to the beta subunit of the bacterial RNA polymerase and inhibits bacterial RNA synthesis. Rifaximin has a broad spectrum of activity and has been approved for the treatment of individuals ≥ 12 years of age who present with uncomplicated travelers’ diarrhea [ 4 , 64 ]. The recommended dose of rifaximin is 200mg three times a day for three days [ 6 , 34 ]. The medication is poorly absorbed from the gastrointestinal tract, thereby achieving high concentration in the intestines [ 48 ]. The medication has minimal side effects [ 63 ]. Rifaximin is less effective for the treatment of invasive pathogens and should not be used for the treatment of dysentery [ 6 ].

The expert panel of the International Society of Travel Medicine has made the following recommendations for the treatment of travelers’ diarrhea depending on its severity in addition to the conservative treatment such as fluid and electrolyte replenishment [ 6 ]:

For mild travelers’ diarrhea, the use of antibiotic is not recommended (strong recommendation, moderate level of evidence). The use of bismuth subsalicylate or loperamide may be considered (strong recommendation, moderate level of evidence) [ 6 ].

For moderate travelers’ diarrhea, antibiotics such as fluoroquinolones (strong recommendation, moderate level of evidence), azithromycin (strong recommendation, high level of evidence), and rifaximin (weak recommendation, moderate level of evidence) may be used [ 6 ]. Loperamide may be considered as monotherapy (strong recommendation, high level of evidence) for the treatment of moderate travelers’ diarrhea and adjunctive therapy (strong recommendation, high level of evidence) for the treatment of moderate to severe travelers’ diarrhea [ 6 ].

For severe travelers’ diarrhea, antibiotics such as azithromycin (strong recommendation, moderate level of evidence), fluoroquinolones (weak recommendation, moderate level of evidence), and rifaximin (weak recommendation, moderate level of evidence) should be used [ 6 ]. In this regard, azithromycin can be used even for the treatment of dysentery whereas fluoroquinolones and rifaximin cannot be used for such purpose [ 6 ].

The majority of cases of travelers’ diarrhea are mild and self-limited. Most cases do not require treatment with antibiotics or antimotility/antisecretory agents. Medical attention should be sought if there are symptoms/signs of dehydration, bloody diarrhea, intractable vomiting, severe abdominal pain, and high fever, especially in those who did not improve with empiric antibiotic therapy within 36 hours [ 5 , 34 ].

11. ADJUNCTIVE THERAPIES

Probiotics such as Lactobacillus rhamnosus GG , Lactobacillus acidophilus , and Saccharomyces boulardii have been used in the treatment as well as the prevention of travelers’ diarrhea because of their beneficial effects on intestinal flora and resultant suppression of pathogenic bacteria [ 65 , 66 ]. A 2018 meta-analysis of 12 randomized clinical trials with a total of 16 intervention arms (n = 3,736) showed a significant reduction in travellers’ diarrhea with S. boulardii prophylaxis (risk ratio: 0.79; 95% confidence interval: 0.72 to 0.87; p < 0.001) [ 67 ]. There was a trend of reduction in travelers’ diarrhea with L . rhamnosus GG prophylaxis (p = 0.008) while there was no reduction in travelers’ diarrhea with L . acidophilus prophylaxis. It has been suggested that the second generation of bifidobacterial-galacto-oligosaccharides prebiotic has the potential in the prevention of travelers’ diarrhea [ 68 ]. The prebiotic, however, has not been subjected to rigorous clinical trials [ 69 ]. Further studies will be needed to determine if prebiotics and probiotics could be used in the prevention of travelers’ diarrhea.

12. PROPHYLAXIS

The majority of diarrheal diseases can be prevented by implementing Water, Sanitation, and Hygiene (WASH) programs aiming at interrupting fecal-oral route of transmission [ 70 ]. Travelers to high-risk areas should be counseled on self-diagnosis and treatment of travelers’ diarrhea. They should also be counseled on personal hygiene and on prudent food and beverages selection and preparation. Frequent handwashing with soap/alcohol-based detergents/hand sanitizer and with the cleanest water available, especially after defecation and urination and before preparing or eating food, is of utmost importance. The rule “cook it, boil it, peel it, or forget it” is logical but is difficult to closely follow [ 9 ]. High-risk products that can be easily contaminated should be avoided. These items include cream-filled desserts, cold sauces and dressings, salads, raw and leafy vegetables that are difficult to clean, fruits that are difficult to peel, undercooked/raw meat and seafood, cooked food that has been left at room temperature for several hours, food brought from street vendors, unpasteurized dairy products, ice cubes and tap water [ 5 ]. Buffet foods and reheated prepared foods are associated with a higher risk of contamination. Fresh and thoroughly cooked meats and vegetables that are still hot, fruit juice or carbonated soft drinks with intact seals, fruits that are peeled by the traveler just prior to eating, pasteurized dairy products, bottled or canned water, hot tea, and hot coffee are usually safe. Food should be well cooked with the interior of the cooked food measuring ≥ 70 o C to kill the pathogens [ 9 ]. Travelers should be advised to avoid shellfish from water that is contaminated as marine toxins cannot be killed by cooking. Boiled beverages should be served at ≥ 60 o C [ 7 ]. Contact with potentially contaminated recreational waters should be avoided [ 5 ].

Chemoprophylaxis should not be routinely used because of the potential of the alteration of gut flora, development of adverse events, development of antimicrobial resistance, possible drug interactions, the expense of the medication, a false sense of security, and confusion as to how to treat those with diarrhea in spite of chemoprophylaxis [ 2 ]. Antimicrobial prophylaxis should be considered for individuals who cannot afford to become sick, such as politicians or elite athletes. It should also be considered for those individuals who have greater susceptibility to travelers’ diarrhea and who are at high risk of severe complications, such as those who are very old, are immunocompromised, are prone to complications ( e.g ., dehydration) from diarrhea, or have a chronic illness ( e.g ., inflammatory bowel disease, short bowel syndrome, gastric hypochlorhydria, congestive heart failure, diabetes mellitus, chronic renal failure) [ 6 , 25 ]. Chemoprophylaxis, if necessary, should be short-term. It should not exceed 14 days [ 71 ]. Rifaximin is effective and safe. It is the drug of choice for the prevention of travelers’ diarrhea [ 2 , 6 , 48 , 71 ]. A meta-analysis of five randomized controlled trials (n = 879) comparing rifaximin with placebo found significant reduction in risk of travelers’ diarrhea with rifaximin (pooled risk ratio: 0.478; 95% confidence interval: 0.375 to 0.610; p < 0.001), especially in individuals who are at risk for travelers’ diarrhea [ 72 ]. If rifaximin is used for prophylaxis, azithromycin should be used to treat break-through travelers’ diarrhea. Since azithromycin is effective in the treatment of travelers’ diarrhea, including invasive forms of travelers’ diarrhea, it is recommended that azithromycin should not be used for prophylaxis [ 62 ]. The use of fluoroquinolones for prophylaxis of travelers’ diarrhea is not recommended either because of increasing bacterial resistance and adverse effects associated with prolonged use of fluoroquinolones [ 6 ].

Bismuth subsalicylate may also be considered for the prevention of travelers’ diarrhea [ 6 ]. The medication provides a protective rate of 60 to 65% against travelers’ diarrhea [ 6 ]. The dosing schedule (2.1 to 4.2 g per day divided into 4 divided doses to be given with meals and at bedtime) is inconvenient for the traveler because of the large quantities of medication that have to be taken four times a day [ 2 , 71 ]. Also, bismuth subsalicylate has an unpleasant taste, turns the tongue and stool black, and has the potential for salicylate toxicity and encephalopathy [ 2 , 52 ]. The medication is not recommended for children or for individuals with aspirin allergy, renal insufficiency, or gout, or for those who are taking anticoagulants, probenecid, or methotrexate.

WC-rBSCT (Dukoral) vaccine is an oral, killed whole-cell cholera vaccine that consists of V. cholerae 01 organisms and the nontoxic, B subunit of cholera toxin [ 73 ]. The vaccine has overall efficacy of 85% against challenge with V. cholerae O1 but not effective against 0139 serogroups [ 4 , 73 ]. The antigenic similarity between nontoxic, B subunit of cholera toxin and LT of ETEC allows protection against diarrhea caused by LT-ETEC and LT/ST-ETEC [ 2 , 4 ]. The vaccine, primarily designed for the prevention of cholera, has been recommended by some investigators for the prevention of travelers’ diarrhea in people visiting endemic areas [ 74 , 75 ]. The vaccine has been proven to be safe and well tolerated [ 73 ]. Two doses of the Dukoral vaccine are recommended and they should be given at least seven days apart on an empty stomach. Based on randomized controlled trials, a Cochrane review, however, found that there is no significant difference in efficacy between Dukoral vaccine and placebo in the prevention of travelers’ diarrhea [ 74 ]. Although there is insufficient evidence to support the routine use of Dukoral vaccine for the prevention of travelers’ diarrhea caused by ETEC [ 52 ], some investigators suggest that Dukoral vaccine should be considered for travelers ≥ 2 years of age who will be visiting areas where there are high risk of contracting travelers’ diarrhea caused by ETEC. The vaccine may also benefit those individuals who are at high risk of severe complications, such as those who are immunocompromised, are prone to complications from diarrhea, or have a chronic illness [ 52 , 76 ].

Vaxchora, a live attenuated, single dose, oral cholera vaccine, is the only vaccine approved by the Food and Drug Administration (FDA) for the prevention of cholera [ 70 , 77 ]. Cholera is caused by V. cholerae serogroup 01, which is responsible for the majority of outbreaks (> 99% of global cases) [ 70 , 77 ]. The vaccine is recommended for adults 18 to 64 years of age traveling to areas where cholera is epidemic or endemic and should be considered for those who are at high risk of exposure [ 2 , 77 , 78 ]. Vaxchora is well tolerated with no significant adverse events [ 79 ]. The vaccine, however, has not been shown to be effective against serogroup 0139 or other non-01 serogroups [ 78 ]. Shanchol is an oral vaccine containing killed V. cholerae 01 and 0139 organisms [ 80 ]. The vaccine has been found to be immunogenic, effective, and safe [ 81 ]. Two doses of the Shanchol vaccine are recommended and they should be given at least 14 days apart [ 80 ]. The vaccine was subjected to a large-scale field trial in Kolkata in India where cholera was endemic [ 82 ]. It was found that 69 of 31,932 vaccine recipients and 219 of 34,968 controls developed cholera during a 5-year follow-up. The cumulative protective efficacy of the Shanchol vaccine at 5 years was 65% (95% confidence interval: 52 to 74; p < 0.0001) [ 82 ]. Euvichol is another oral vaccine containing killed V. cholerae 01 and 0139 organisms [ 83 ]. The vaccine still has an efficacy of 65% after 5 years for those children > 5 years of age [ 83 ].

Typhoid fever is caused by Salmonella enterica serotype Typhi [ 84 ]. Typhoid vaccine is recommended for travelers to areas with poor sanitation and hygiene. Two typhoid vaccines are globally available, namely, a parenteral inactivated Vi Capsular Polysaccharide vaccine (ViCPS) and an oral live-attenuated vaccine, Ty21a [ 84 ]. Only a single dose of the inactivated vaccine (ViCPS) given intramuscularly is required and should be administered ≥ 2 weeks prior to travel [ 10 ]. On the other hand, 4 doses of the oral vaccine (Ty21a) are required and should be administered two days apart, with the last dose given ≥ 1 week prior to travel [ 10 ]. The oral vaccine has to be refrigerated and taken on an empty stomach with a glass of cool water [ 10 ]. Both vaccines provide approximately 75% protection that lasts for 2 to 3 years [ 84 ]. The ViCPS vaccine is licensed for use for individuals ≥ 2 years whereas the Ty21a for individuals ≥ 5 years [ 10 , 84 ]. Antibiotics and antimalarials, if taken concurrently, may inhibit the oral typhoid vaccine because these agents may prevent a sufficient immune response from the oral vaccine [ 10 ]. The WHO recommends that oral typhoid vaccine should be given at least one week before or after the ingestion of antibiotics and antimalarials. The newly available Tybar-TCV is a typhoid conjugate vaccine which contains Vi capsular polysaccharide of Salmonella enterica serovar typhi Ty2 conjugated to a tetanus toxoid carrier protein. One single dose of Tybar-TCV injected intramuscularly is necessary and should be administered ≥ 2 weeks prior to travel. The vaccine has been proven to be safe, well tolerated, and efficacious. Recently, the WHO has recommended Tybar-TCV as the preferred vaccine for the prevention of typhoid fever [ 85 ].

Rotavirus is the most common cause of gastroenteritis in children [ 23 ]. Clinical trials showed that three doses of a live pentavalent (G1, G2, G3, G4, and P1), human-bovine reassortant vaccine, (RotaTeq ® ) and two doses of a monovalent human-attenuated rotavirus vaccine RIX4414 (Rotarix ® ) are highly effective in the prevention of severe rotavirus diarrhea and its associated mortality and morbidity [ 86 , 87 ]. More recently, an oral human-bovine natural reassortant vaccine (116E) (Rotavac) produced in India has also been shown to be effective [ 88 ]. Bhandari et al . randomly assigned 4532 and 2267 children ≤ 2 years of age to receive three doses of Rotavac vaccine and placebo, respectively [ 88 ]. The authors found that the efficacy of Rotavac vaccine against severe gastroenteritis in these children was 55.1% (95% confidence interval: 39.9 to 66.4; p < 0.001). Co-infections may lead to an approximately 11% decrease in vaccine efficacy [ 89 ].

13. PROGNOSIS

Travelers’ diarrhea is usually self-limited. If left untreated, approximately 50% of the patients are spontaneously cured in 48 hours and, in the majority of patients, the average duration diarrhea is 4 to 5 days [ 7 , 90 ]. Approximately 5% and 1% of affected individuals have diarrhea that persists for longer than 14 days and 1 month, respectively [ 16 , 25 , 91 ]. Approximately 13% of patients are confined to bed for 1 to 2 days, and about 0.4% of patients require hospital admission while abroad or after returning home [ 7 ]. The clinical course tends to be more severe and prolonged in children, especially those younger than 2 years of age.

Travelers’ diarrhea is the most common cause of disability among international travelers to developing countries. Travelers to the high-risk region should receive pretravel counseling on personal hygiene and anticipatory guidance on food safety and pretravel vaccination with enteric vaccines. They should exercise caution by careful selection of safer food. Judicious use of antimicrobial and antimotility agents can reduce the severity of travelers’ diarrhea. Nevertheless, reduction in the incidence of travelers’ diarrhea depends more on the level of sanitation at the destination site rather than the precautions and intervention implemented by the traveler [ 7 ].

CURRENT & FUTURE DEVELOPMENTS

Currently, there are no vaccines licensed for the prevention of ETEC infection which is the principal cause of travelers’ diarrhea [ 92 , 93 ]. Research is urgently needed for the development of ETEC vaccines [ 93 ]. Colonization Factors (CF) and LT enterotoxin are antigens in the development of major ETEC candidate vaccines [ 31 ]. LT entertoxin exerts its toxic effect by binding to ganglioside 1 (GM 1 ) at the apical surface of intestinal cells [ 31 ]. GM 1 -binding LT is a strong immunogen and adjuvant and can serve as a carrier or platform for multivalent vaccine development against ETEC and other pathogens [ 94 ]. Huang et al . identified LT epitopes and demonstrated that substitution of LT epitopes eliminated LT enterotoxicity without altering GM 1 -binding [ 94 ]. ETEC vaccine development has been hindered by a lack of suitable animal models [ 95 ]. Travelers could serve as ideal candidates for clinical trials for the development of future vaccines.

Borde et al . developed a novel multivalent oral vaccine which contains killed ETEC over-expressing the main ETEC colonization factors and a recombinant enterotoxin B subunit protein given together with a recently developed intestinal-mucosal adjuvant double mutated LT [ 96 ]. The authors produced a dry-powder formulation by freeze-drying the vaccine using insulin as a stabilizer. Oral-intragastric immunization of mice with the vaccine elicited strong intestinal mucosal and serum antibody responses against all vaccine antigens.

It has been shown that CFaE, a subunit of the Colonization Factor Antigen 1 (CFA/1), is required for the adhesion of ETEC to intestinal cells of the host [ 92 ]. As such, human antibodies against CFaE by blocking colonization of ETEC may serve as immunoprophylactic agents for the prevention of ETEC-related diarrhea. Recently, Giuntini et al . identified a panel of anti-CFaE human monoclonal antibodies that are active against ETEC with high potency [ 92 ]. Oral administration of anti-CFaE human monoclonal antibodies in either IgG or secretary IgA form inhibited intestinal colonization in mice challenged with ETEC [ 92 ]. In the absence of an effective vaccine against ETEC infection, these anti-CFaE human monoclonal antibodies have the potential to be oral immunoprophylactic agents against ETEC infection.

Very recently, a live, heat-stable, oral Bovine Rotavirus Pentavalent Vaccine (BRV-PV) has been developed in India. A Phase III randomized controlled trial of the vaccine in 3508 infants in Niger showed an efficacy of 66.7% (95% confidence interval: 49.9 to 77.9) against severe rotavirus gastroenteritis [ 97 ].

Current typhoid vaccine cannot be used in children < 2 years of age due to poor immunogenicity [ 98 ]. Mitra et al . prepared a novel Vi-TT conjugate typhoid vaccine (PedaTyph TM ) by binding Vi to tetanus toxoid [ 98 ]. Two doses of the vaccine are required and should be given 6 weeks apart. Of the 1765 children aged 6 months to 12 years recruited into the study, 905 children received the vaccine intramuscularly and 860 children served as the control. The authors found that the vaccine was highly immunogenic and efficacious with minimal adverse events. GelSite-OAC™ is a novel synthetic typhoid vaccine that is currently being developed [ 84 ]. The vaccine is based on the fact that O-acetylated high molecular weight polygalacturonic acid shares the same backbone as Vi polysaccharide of S. typhi [ 84 ]. Preliminary data showed that the vaccine is safe, highly immunogenic, and effective even in individuals under 2 years of age.

Racecadotril is an anti-secretory agent effective in the treatment of diarrhea. The drug, however, has not been studied in travelers who have diarrhea.

It has been shown that the ST produced by ETEC is poorly immunogenic and potently toxic [ 99 ]. Thus, ST itself cannot induce anti-ST immunity, nor could it be a safe antigen even if it were immunogenic. Therefore, there is an unmet need to produce a vaccine which can elicit an immune response and can also induce protective immunity to multiple CFA antigens, as well as anti-LT and anti-ST immunity that would be broadly protective against ETEC. Sack and Zhang disclosed polypeptides comprising up to 9 antigenic elements of ETEC virulence determinants: 7 CFA adhesins [CFA/I, CFA/II (CS1, CS2, CS3), CFA/IV (CS4, CS5, CS6)] and 2 enterotoxins (LT, ST) that were genetically fused together [ 99 ]. These polypeptides can be used in the development of vaccines effective in the prevention of travelers' diarrhea caused by ETEC.

Savkovic and Roy disclosed an invention for the prevention and/or treatment of enteropathogenic bacterial infection in the gastrointestinal tract by concurrently administering to the subject a low molecular weight polyethylene glycol in combination with other antibiotic and antidiarrheal agents [ 100 ]. According to the authors, the low molecular weight polyethylene glycol has a molecular weight between about 100 daltons and 5000 daltons. The authors claimed that the invention is effective in the prevention and/or treatment of enteropathogenic bacterial pathogens, such as ETEC, EIEC, Salmonella , and Shigella which are important causes of travelers' diarrhea.

Savarino disclosed a method for the induction of immunity and prevention of diarrhea resulting from Escherichia coli [ 101 ]. The method provides for the induction of B-cell mediated immunity and for the induction of antibody capable of inhibiting the adherence and colonization of Escherichia coli , to intestinal cells of the host, thereby travelers' diarrhea can be prevented. An immune response can be induced by administrating a priming dose of an immunogen comprising whole or an antigenic polypeptide fragment of Escherichia coli fimbriae or whole or antigenic polypeptide fragment of Escherichia coli fibrillae with unit dose ranging from 50μg to 1 mg of the immunogen in a buffered aqueous solution. Booster doses should be administered at least 1 week after priming dose with a unit dose ranging from 50μg to 1mg of the immunogen in a buffered aqueous solution.

It is a well-known fact that different polymorphic forms of the same drug may have substantial differences in certain pharmaceutically important properties. Because amorphous solids do not have lattice energy, they usually dissolve in a solvent more rapidly and consequently may provide enhanced bioavailability characteristics such as a higher rate and extent of absorption of the compound from the gastrointestinal tract. Also, amorphous forms of a drug may offer significant advantages over crystalline forms of the same drug in the manufacturing process of solid dosage form such as compressibility. Consequently, it would be a significant contribution to the art to provide an amorphous form of rifaximin having increased solubility. Rao et al . disclosed an invention which can provide amorphous rifaximin in bulk form [ 102 ]. The amorphous rifaximin is substantially pure with polymorphic purity of 99% or more.

As rifaximin is sparingly soluble in water, a formulation chemist often finds it difficult to prepare a consistent formulation using the known polymorphic forms. Hence, there is a need to prepare rifaximin in a form which is suitable for formulation and has increased solubility and stability. Ghagare et al . disclosed a complex comprising rifaximin and a complexing agent, wherein the complexing agent is a polyvinyl pyrrolidone or a cyclodextrin [ 103 ]. The complex of this invention exhibits enhanced solubility and stability of rifaximin.

Driessen disclosed dietary supplements for the prevention or treatment of traveler's diarrhea [ 104 ]. The supplements comprise of approximately 1000mg green tea extract with at least 90% catechins, 4g partially hydrolyzed guar gum, 100mg L-theanine, and 5g non-sugar sweetener not containing a polyol.

Cheng disclosed an invention pertaining to the use of the calcium-sensing receptor-activating nutrients for the prevention and/or treatment of diarrheal diseases [ 105 ]. The anti-diarrheal composition consists of an aqueous solution of calcium, potassium, magnesium, zinc, sodium, chloride, bicarbonate, tryptophan; and, optionally, one or more ingredients selected from vitamins; preservatives; flavorings; buffers; carbohydrates; and the conjugate acid and conjugate base of butyrate and acetic acid, respectively. The invention is formulated for oral administration. The author claimed that the invention is effective in the treatment of diarrhea caused by E. coli , Vibrio cholerae , Vibrio parahaemolyticus , Clostridium perfringens , Clostridium difficile , Staphylococcus aureus , Salmonella spp., parvovirus, rotavirus, adenovirus, calicivirus, astrovirus, Cryptosporidia , Giardia lamblia , and Entamoeba histolytica .

Lefevre et al disclosed an invention comprising lyophylized Saccharomyces boulardii as an active ingredient and as sole probiotic, optionally in association with a pharmaceutically acceptable vehicle, wherein the composition is in a closed vial. The first airtight compartment comprising lyophilized S. boulardii powder and a second compartment comprising a solution, can be brought in airtight communication with one another to yield a suspension of S. boulardii to be administered to an individual upon opening of the vial [ 106 ]. According to the authors, the invention is effective in the prevention or treatment of travelers' diarrhea.

ACKNOWLEDGEMENTS

Professor Alexander K.C. Leung is the principal author. Dr Amy A.M. Leung, Dr Alex H.C. Wong, and Professor Kam L. Hon are the co-authors who contributed and helped with the drafting of this manuscript.

CONSENT FOR PUBLICATION

Not applicable.

This work was not funded, there was no honorarium, grant, or other form of payment received by the authors.

CONFLICT OF INTEREST

Professor Alexander K.C. Leung, Dr. Amy A.M. Leung, Dr. Alex H.C. Wong, and Professor Kam L. Hon confirm that this article has no conflicts of interest.

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Travel-Associated Infection & Prevention

Travel-related illnesses and injuries can be reduced with prevention and preparation. Many children and teens travel internationally. Some study abroad in Europe, while others may visit family, go on safari in Africa or do medical mission work in South America. Children can be exposed to illnesses commonly found in geographic regions where they travel but rarely found in the United States.

Parents who plan to travel overseas with their children should consult a pediatric travel medicine specialist to learn about how to:

• Prepare for travel out of the country
• Avoid exposure to germs that may cause illness
• Use preventive medicines
• Receive specialized travel vaccines
• Update routine vaccines
• Stay medically safe while traveling
• Appropriately access healthcare resources while traveling

Preparation and pre-travel counseling with a travel medicine specialist is recommended six weeks before the travel departure date. Preventive medicines (especially against malaria) and vaccinations are necessary for many children and family members who are traveling. When traveling to countries known to have malaria and other mosquito-transmitted diseases, children should appropriately use an effective insect repellent that contains DEET or picaridin.

Common travel-related illnesses include:

• Diarrheal disease . Most travel-related diarrheal diseases are acquired by consuming contaminated water and food.
• Hepatitis A . Hepatitis A is a highly contagious liver infection caused by the hepatitis A virus. It is usually acquired by consuming contaminated water and food.
• Malaria . This is a condition caused by a parasite and acquired by the bite of an infected mosquito.
• Dengue fever . This is a viral illness acquired through the bite of a mosquito.
• Parasitic infections . This group of infectious diseases can be acquired by eating contaminated food, swimming or wading in infested water or walking barefoot on the ground or beach sand.
• Tuberculosis . Tuberculosis (TB) is a condition caused by bacteria that usually attacks the lungs. It is transmitted person-to-person after prolonged stays abroad.
• Typhoid fever . This bacterial illness spreads through contaminated food and water or close contact with an infected person.
• Yellow fever . This virus spreads to humans by the bite of an infected mosquito.
• Japanese encephalitis . This virus is the leading cause of vaccine-preventable encephalitis.
• Leptospirosis . This bacterial infection is mostly acquired by contact with contaminated fresh water such as waterfalls, ponds and lakes. The urine of infected animals contains the bacteria.
• Chikungunya . This viral illness spreads to humans through the bite of an infected mosquito.
• Rabies . This deadly virus spreads to people from the saliva of infected animals, usually from an animal bite.

The symptoms of travel-related infectious diseases vary and may include:

• Persistent diarrhea
• Skin conditions or rash
• Respiratory infections
• Chronic cough

If a child returns home with symptoms suggestive of a travel-related infection, have them see a pediatric travel medicine specialist.

Diagnosis of Travel-Associated Infections

Travel-related infectious diseases are often hard to diagnose and often require evaluation by an infectious disease specialist. Infectious disease doctors at Riley at IU Health will evaluate your child’s symptoms and ask where your child has traveled.

Common screening tests may include:

• A complete blood count (CBC) blood test , which measures the number and type of white blood cells in the blood
• A stool specimen to test pathogens (bacteria, viruses or other microorganisms that can cause an illness)
• Blood specimens to test for malaria and other parasites
• Blood specimens for antibody tests for various germs, such as hepatitis viruses

Treatment for children who have travel-related illnesses will vary depending on the specific illness or syndrome. Once a diagnosis is made, your child's doctor will review all treatment options with you in detail. There are specific medicines to treat malaria, parasitic infections and travel-associated diarrhea.

Many travel-associated bacterial infections will require treatment with an antibiotic. If your child has a viral infection such as dengue or chikungunya, the doctor will just recommend supportive therapy. However, your child will need to be monitored for complications. Respiratory infections caused by influenza may at times require antiviral treatment.

If your child has a fever, it may be managed with medicines that reduce fever, such as acetaminophen or ibuprofen. A feverish child returning from a tropical country needs to be seen by a healthcare provider soon after return. While most feverish illnesses are uncomplicated viral infections, conditions such as malaria and typhoid fever can have serious complications and require prompt diagnosis and treatment. These children need to be evaluated by a specialist familiar with travel-related infections.

Some travel-related infections may require inpatient care.

Key Points to Remember

• Travel-related illnesses and injuries can be reduced with prevention and preparation.
• Parents who plan to travel overseas with their children should consult a pediatric travel medicine specialist six weeks before their departure date.
• The symptoms of travel-related infectious diseases vary and may include diarrhea, rash, fever, respiratory infection and chronic cough.
• Travel-related infectious diseases are often hard to diagnose and often require evaluation by an infectious disease specialist.
• Treatment for children who have travel-related illnesses will vary depending on the specific illness.

Support Services & Resources

Visit the websites below to learn more about travel-related infections and how to prevent illness when traveling abroad.

Riley at IU Health offers a broad range of supportive services to make life better for families who choose us for their children's care.

Learn More About Riley Support Services

This government website provides in-depth explanations of travel-related infections, including diarrheal illnesses, dermatologic conditions, malaria and respiratory disorders.

This website provides important, up-to-date information about international travel and health.

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Golfers Vasculitis: A Common But Often Misdiagnosed Boomer Travel Malady

A long day of walking leads to a case of Golfers Vasculitis

When we recently toured the hill town of Orvieto, Italy , the temperature was in the mid 90s as it had been for days. In addition to the oppressive heat, the humidity was uncomfortably high.

Glancing at my Fitbit later that day, I realized we had clocked nearly four miles of walking on cobblestone streets (apart from the time we had spent standing on our feet in museums and churches).

Because we were running from place to place, and appointment to appointment, trying to soak in all of the city’s sights, I made the mistake of not drinking enough water.

After returning to our hotel that evening, I glanced down and noticed a rash with unsightly dark red spots on both legs  —just above the line of my athletic socks. Yikes, it looked dreadful!

Searching for a diagnosis

Because I always tend to think of the worst-case scenario, my first thought was that I had cellulitis. My husband hypothesized it might be an allergic reaction to a new detergent I had used in the self-service laundry on the cruise ship we had been on the week before.

But after “Googling” and reading hundreds of anecdotal reports on MedHelp.org and looking at some of the medical literature, I’m convinced that I had a case of “ Golfers Vasculitis. ” Some people also call it “ Golfers Ankle .” 

No, I’m not a golfer but playing 18 rounds of golf is the common precipitating event that has given this condition its name.

The ailment has also been documented in otherwise healthy people who discover the rash on their ankles after spending hours on their feet in hot, humid climates in a variety of circumstances besides playing golf, such as hiking, participating in charity walks, taking cruise excursions and visiting amusement parks, like Disney World and Dollywood.

The characteristic rash usually appears above the ankles, on both legs, sometimes extending up as high as the knees. Golfers vasculitis is more likely to occur in women than men, in older people rather than younger ones.

(See the photo of Golfers Vasculitis below).

Although it’s vascular, even doctors often mistake it for cellulitis or a skin condition. It has also been variously called “ Exercise-Induced Vasculitis (EIV) ” and “ Disney Rash. ”

Golfers Vasculitis: The course of the rash

Although this rash with red, hot spots can feel like sunburn, it doesn’t blister or cause much pain. It is self-limiting, usually resolving without any treatment within a week or so.

Mine almost disappeared after five days of unsightliness. Some people are left with a light brown pigmentation that doesn’t go away. Unfortunately, once you have had it, you are more prone to experience it again.

The good news is that there’s no established connection with venous disease but there also is no definitive approach to either prevention or treatment.

Some patients and doctors recommend the following:

• Staying hydrated when doing a lot of walking in a warm climate.
• Wearing compression hosiery (although I can’t imagine wearing those socks in the heat.)
• Wearing open shoes like flip-flops rather than closed athletic sneakers (although this could create other types of problems).

For more information on Golfers Vasculitis:

• Anecdotal (patient) reports on MedHelp.org
• Clinical report: Rash emerges after 18 holes of golf
• Journal article on Golfer’s Vasculitis

My article on Forbes: Are You At Risk For This Common Travel Malady?

Golfer’s Vasculitis: Oops, I Did It Again!

Swollen Ankles When Flying: 8 Questions and Answers

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10 Comments

Never heard of this before- – it sounds almost like heat rash? Is that similar? Glad you’re okay and it was nothing more serious. That’s a LOT of walking in the heat!

We were out that day for over 10 hours….returned completely destroyed:-) The heat was incredible. From what I read, I don’t think it is related to heat rash, which might have more to do with the skin.

So glad you’re okay and it’s not serious! I have some great walking sandals that you could wear all day. I sent you the pins.

Thanks! In this case, I don’t think it was the shoes…although I’m always on the hunt for good walking shoes that come highly recommended!

I had a similar thing happen in Venice over cobblestone — I saw my FitBit said 12 miles and then looked at my ankle and it was swollen and turned black and blue over the next few days. Doctor told me that cobblestones can aggravate the tendons – and they can get strained and as a result you get bruising.. so glad to know I am not the only one who gets so excited about where I am traveling and what I am seeing that I forget to take care !

Another friend wrote me on Facebook that she also experienced this condition. I guess it may be more common than people realize. It’s easy to dismiss as a sunburn.

I was at Hollywood over the weekend, when I got back to my room, after 8 hrs of walking, pulled my socks off, and there’s this horrible looking red color, flat, smooth rash obove my sock line, I freaked out, and it was also on other leg, will this go away, and when, its hot weather, and I can’t even wear shorts. It doesn’t itch, it just looks so bad,

I can’t diagnose it but if it is Golfer’s Vasculitis, it should start getting lighter very gradually. If you are concerned, you might want to check with your physician.

I am a security guard and I get it frequently walking.. good grief I was in Hawaii and my ankles swelled up and I had that rash…. ugh

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April 16, 2024

10 min read

New Prostate Cancer Treatments Offer Hope for Advanced Cases

Major discoveries during the past 10 years have transformed prostate cancer treatment, enabling it to proceed even for the most advanced form of the disease

By Marc B. Garnick

David Cheney

D eciding how to diagnose and treat prostate cancer has long been the subject of controversy and uncertainty. A prime example involves prostate-specific antigen (PSA) testing, a blood test for a telltale protein that can reveal cancer even when the patient has no symptoms. After its introduction in the early 1990s, PSA testing was widely adopted—millions of tests are done in the U.S. every year. In 2012, however, a government task force indicated that this test can lead to overtreatment of cancers that might have posed little danger to patients and so might have been best left alone.

While arguments for and against PSA testing continue to seesaw back and forth, the field has achieved a better grasp on what makes certain prostate cancers grow quickly, and those insights have paved the way for better patient prognoses at every stage of the disease, even for the most advanced cases. A prostate cancer specialist today has access to an enhanced tool set for treatment and can judge when measures can be safely deferred.

The importance of these advances cannot be overstated. Prostate cancer is still one of the most prevalent malignancies. Aside from some skin cancers, prostate cancers are the most common cancers among men in the U.S. Nearly 270,000 people in America will be diagnosed with prostate cancer this year, and it is the fourth most common cancer worldwide. Fortunately, the vast majority of patients will live for years after being diagnosed and are more likely to die of causes unrelated to a prostate tumor.

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At its most basic level, prostate cancer is a malignancy that occurs in the prostate gland, which produces fluid that mixes with sperm from the testicles to make semen. The prostate is located in front of the rectum, below the bladder and above the penis, and cancer in the gland has four major stages.

Early on, localized tumors show no evidence of extension beyond the prostate gland. A second, “regionally advanced” form of the disease remains close to the prostate. Then there are metastatic prostate cancers, which spread outside the gland to other parts of the body. Treatment of tumors in this category has benefited from improved diagnostic imaging tests. In fact, with these tests, cancer specialists have characterized the fourth category, oligometastatic prostate cancer, a disease stage on a continuum between localized prostate cancer and more broadly dispersed metastatic disease. Major discoveries in the past 10 years have transformed the way we approach each type of prostate cancer, and these advances are likely to continue for decades to come.

The first treatment steps for people with localized cancer involve risk stratification. Through this process, a physician gauges the likelihood of a cancer’s being eliminated or cured by local treatment (usually surgery or radiation) and, if it does abate, of its returning. A physician determines the risk based on PSA results, physical examination of the prostate gland and inspection of cells from the biopsied tumor.

The right course of action for a patient with elevated PSA levels continues to undergo constant revision. Until five to seven years ago, a physician evaluated a person with high PSA by feeling their prostate gland for potentially cancerous abnormalities. Invariably, the next step would be a needle biopsy—an uncomfortable procedure in which the physician obtains snippets of prostate tissue through the rectum.

But we now have a way to biopsy through the perineum—the area between the back of the scrotum and the anal-rectal area. Thanks to technical improvements, it can be done in an outpatient setting without general anesthesia or sedation. The technique reduces the patient’s risk of infection and need for antibiotics because it doesn’t disrupt the bacterial flora in the rectum. In a recent study, researchers compared outcomes in patients who underwent a trans­rectal biopsy and received antibiotics with those for people who had a transperineal biopsy with minimal to no antibiotics. They found the two approaches comparable in terms of complications from infections.

Even more exciting is the prospect of eliminating biopsies altogether. When a patient has an abnormal PSA value but their rectal examination shows no obvious evidence of cancerous deposits, physicians can now use magnetic resonance imaging (MRI) to look at the prostate and surrounding tissue. MRI scans are best for identifying clinically significant cancers—those that, if left untreated or undiagnosed, could eventually spread. MRI can also uncover more extensive cancer spread or tumors in unusual locations such as the front of the prostate.

Another benefit of MRI procedures is that they identify fewer clinically insignificant cancers—those that are unlikely to cause problems and might best be left alone. In this case, failure to detect certain cancers is a good thing because it spares people unnecessary treatment. In some medical centers in the U.S. and many in Europe, a physician will perform a biopsy only if the MRI scan does reveal evidence of clinical significance. Studies that have compared the two diagnostic approaches—routine biopsy for all patients with elevated PSA levels versus biopsies based on abnormal MRI findings—found they are similarly effective at detecting clinically significant cancers.

Once a patient is diagnosed with prostate cancer, what happens next? For decades the debate over treatment has been just as contentious as the debate over diagnosis. Fortunately, new research from the U.K. has provided some clarity. Investigators there studied several thousand people with elevated PSA levels whose prostate biopsies showed cancer. These patients were randomized to receive surgical removal of the cancerous gland, radiation treatments or no active treatment at all. At the end of 15 years of comprehensive follow-up, about 3 percent of patients in each group had died of prostate cancer, and nearly 20 percent in each group had died of unrelated causes.

Based on the results of this study and others, more people are now being offered “active surveillance” after a prostate cancer diagnosis, in which treatment is either delayed or avoided altogether. Careful monitoring of patients who have not undergone surgery or radiation is becoming more common; it is now being extended even to those with more worrisome tumors. The monitoring involves a range of measures: PSA testing every three to six months, physical examination of the prostate gland and assessment of the patient’s urinary symptoms. Those tests are followed by repeat biopsies at increasing intervals, as long as there are no significant pathological changes.

If a cancer is identified as having either intermediate- or high-risk features, doctors need to track its progression, usually with bone scans using radio­­pharma­ceut­i­cals and with abdominal-pelvic computed tomography (CT) scans, which may show any spread in the areas to which prostate cancer most often metastasizes. Unfortunately, these techniques are not sensitive enough to reliably detect cancer in structures less than a centimeter in diameter, such as lymph nodes. Consequently, small areas of metastatic disease may go undetected. These cases are said to be “understaged.”

Understaging can now be studied through more precise diagnostic testing. Typically patients whose disease is understaged are not treated until the cancer becomes detectable through symptoms such as urination problems or pain. The disease then may require intensive therapies, and there is less of a chance of long-term remission. One technology that can help address understaging is advanced scanning that combines radiodiagnostic positron-emission tomography (PET) with CT.

These scans can detect molecules commonly found in prostate cancer cells, such as prostate-specific membrane antigen (PSMA). If PSMA is present outside the prostate gland, such as in pelvic lymph nodes, the affected areas can be identified, and a plan can be made for targeted radiation treatments or surgical removal.

Let’s consider how PET-CT scanning can be used in clinical practice. One of my patients, a 68-year-old man, was diagnosed with prostate cancer that was localized but had high-risk features. The traditional diagnostic bone and CT scans did not show any evidence of cancer spread outside the prostate. A PET-CT scan for PSMA, however, did reveal the presence of several small deposits of cancer cells in well-defined areas of the pelvis, indicating the cancer had spread to the lymph nodes. This finding prompted treatment that included radiation therapy in the prostate gland and the cancerous lymph nodes, as well as androgen-deprivation therapy (ADT), a treatment that reduces levels of testosterone, the hormone that enables prostate cancer to grow and progress.

The more precise identification of small tumor deposits in a limited number of pelvic lymph nodes—diagnosed as oligometastatic prostate cancer—enabled a new use for an old technology in oncology called metastasis-directed therapy (MDT), which targets cancer-containing lymph nodes or bony areas with radiation. At times, surgical removal of the abnormal lymph nodes may also be incorporated into MDT. Recently published studies on the use of MDT in conjunction with conventional treatments show, in some cases, long-term remission lasting through years of follow-up. Until recently, such a scenario was unthinkable for people whose prostate cancer had spread to their lymph nodes. My patient had the PSMA scan and MDT, as well as a relatively short course of ADT. He is cancer-free for now.

Precise identification of small metastatic deposits has other positive benefits. ADT has for decades been the mainstay for treating many forms of prostate cancer. Patients must continue the therapy for years, sometimes for the rest of their lives. Side effects of ADT are similar to those experienced during menopause. In fact, “andropause” is the term that captures the effects of ADT. Lower levels of testosterone are accompanied by a multitude of symptoms, including but not limited to loss of libido, erectile dysfunction, weight gain, hot flashes, bone loss, cognitive impairment, mood changes, diminished energy, and worsening of preexisting heart and vascular problems.

Studies of MDT for oligometastatic prostate cancer have raised the question of whether ADT could be delayed, administered for a shorter duration or even omitted in patients who otherwise would have required it. By strategically deploying traditional forms of localized treatment—usually surgery to remove the prostate gland or radiation—with added MDT for oligometastatic disease, doctors can significantly shorten the duration of ADT or potentially eliminate it. Such an approach would have been difficult to imagine five years ago. Longer-term follow-up studies will help scientists determine whether some people diagnosed in this fashion can go into an extended remission.

F or advanced forms of prostate cancer that have spread to other parts of the body, ADT has been the main treatment. Physicians historically have generally recommended surgical removal of the testicles—the primary source of testosterone—or the administration of other hormones that block the production and action of testosterone. In the mid-1980s I was involved with research on drugs called luteinizing hormone–releasing hormone analogues that lowered testosterone by shutting off the signal in the brain that instructs the testicles to make testosterone. Today newer agents have been added that further lower and block testosterone’s action.

The goal of prostate cancer treatment at later stages is to eliminate multiple sources of testosterone. As noted earlier, testosterone in the body comes predominantly from the testicles; the adrenal glands also produce a small amount. But prostate cancer cells can evolve to produce their own androgens. Testosterone and its active form, dihydrotestosterone (DHT), traverse the membranes of prostate cancer cells and interact with androgen receptors in the cytoplasm, a cell’s liquid interior. The receptors then transport DHT to the nucleus, where it instructs the cancer cell to grow, replicate and spread.

Traditional ADT does little to affect either the production of testosterone by the adrenal glands or androgen-producing prostate cancer cells, and it doesn’t block the activity of androgen receptors. But new approaches to ADT may address these shortcomings. Drug combinations that affect all these processes have substantially improved survival in people with metastatic prostate cancer—and, more important, patients are able to tolerate these more intensive treatment programs.

Instead of just one drug to decrease testosterone, new standards for treatment prescribe combinations of two or even three drugs. In addition to traditional ADT, there are medications such as do­cetaxel, a chemotherapy, and other new drugs that can block the production of testosterone by the adrenal glands or cancer cells or stop it by interfering with the activity of androgen receptors. All these drug combinations have resulted in meaningful improvements in survival.

Yet another therapy for advanced disease involves the identification of PSMA-expressing cancer cells that can be targeted with pharmaceuticals designed to deliver radioactive bombs. An injectable radiopharmaceutical can be delivered selectively to these cells, leaving healthy cells mostly unaffected. This therapy, lutetium-177-­PSMA-617 (marketed as Pluvicto), has been approved by the U.S. Food and Drug Administration for the treatment of prostate cancer that has become resistant to other forms of ADT and chemotherapy. It is likely to become an important therapy for even earlier stages of prostate cancer.

Genetics and genomic testing of patients and cancers have also helped in the quest for improvement of symptoms and longer survival. Some genetic mutations that are known to increase the risk of breast and ovarian cancer have also been associated with a heightened risk of prostate cancer. Testing for such mutations is becoming much more common, and patients who have them can be treated with specific therapies that block their deleterious effects, leading to better outcomes.

An understanding of the type of mutation is also critical—for both patients and their family members. Germline mutations are inherited from a patient’s biological parents by every cell in the body. These mutations can be passed along to the patient’s children. A somatic mutation, in contrast, is not inherited but develops in the cancer itself. Targeted therapies designed specifically to correct the effects of either germline or somatic mutations have produced significant improvements in patient longevity. Some of the most commonly recognized cancer mutations—either somatic or germline—are those in BRCA genes, which have been associated with early-onset breast and ovarian cancer.

When researchers studied cancer in families with BRCA mutations, they uncovered many cases of prostate cancer. This finding led to the discovery that BRCA mutations appeared in both men and women in these families. The mutations change the way DNA is repaired, introducing defects that can result in cancer formation. Drugs have now been developed that treat cancers linked to the BRCA mutations. Several such drugs—those in a class called poly­(ADP-ribose) polymerase (PARP) inhibitors—have recently received FDA approval for use as a treatment in people with these mutations. This research has led to more widespread genetic testing of patients with prostate cancer and, when germline mutations are found, family genetic counseling.

All these advances have occurred over the past decade—an incredibly short interval in the context of cancer oncology. Current options for early-stage prostate cancer enable physicians and patients to feel more at ease with conservative choices rather than immediate interventions with negative side effects. For patients whose cancers are advanced at initial diagnosis or progress and become metastatic, the treatment of oligometastases now often leads to long-term remission and requires fewer treatments with harmful systemic side effects. For those with more widespread metastatic disease, their cancer can now be managed with improved therapeutics based on a better understanding of disease biology. These new strategies have begun to transform this once rapidly fatal disease into a chronic condition that people can live with for years or even for their full life expectancy.

Marc B. Garnick is Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center in Boston. He is editor in chief of Harvard Medical School’s 2024–2025 Report on Prostate Diseases.

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What the data says about abortion in the U.S.

Pew Research Center has conducted many surveys about abortion over the years, providing a lens into Americans’ views on whether the procedure should be legal, among a host of other questions.

In a  Center survey  conducted nearly a year after the Supreme Court’s June 2022 decision that  ended the constitutional right to abortion , 62% of U.S. adults said the practice should be legal in all or most cases, while 36% said it should be illegal in all or most cases. Another survey conducted a few months before the decision showed that relatively few Americans take an absolutist view on the issue .

Find answers to common questions about abortion in America, based on data from the Centers for Disease Control and Prevention (CDC) and the Guttmacher Institute, which have tracked these patterns for several decades:

How many abortions are there in the U.S. each year?

How has the number of abortions in the u.s. changed over time, what is the abortion rate among women in the u.s. how has it changed over time, what are the most common types of abortion, how many abortion providers are there in the u.s., and how has that number changed, what percentage of abortions are for women who live in a different state from the abortion provider, what are the demographics of women who have had abortions, when during pregnancy do most abortions occur, how often are there medical complications from abortion.

This compilation of data on abortion in the United States draws mainly from two sources: the Centers for Disease Control and Prevention (CDC) and the Guttmacher Institute, both of which have regularly compiled national abortion data for approximately half a century, and which collect their data in different ways.

The CDC data that is highlighted in this post comes from the agency’s “abortion surveillance” reports, which have been published annually since 1974 (and which have included data from 1969). Its figures from 1973 through 1996 include data from all 50 states, the District of Columbia and New York City – 52 “reporting areas” in all. Since 1997, the CDC’s totals have lacked data from some states (most notably California) for the years that those states did not report data to the agency. The four reporting areas that did not submit data to the CDC in 2021 – California, Maryland, New Hampshire and New Jersey – accounted for approximately 25% of all legal induced abortions in the U.S. in 2020, according to Guttmacher’s data. Most states, though,  do  have data in the reports, and the figures for the vast majority of them came from each state’s central health agency, while for some states, the figures came from hospitals and other medical facilities.

Discussion of CDC abortion data involving women’s state of residence, marital status, race, ethnicity, age, abortion history and the number of previous live births excludes the low share of abortions where that information was not supplied. Read the methodology for the CDC’s latest abortion surveillance report , which includes data from 2021, for more details. Previous reports can be found at  stacks.cdc.gov  by entering “abortion surveillance” into the search box.

For the numbers of deaths caused by induced abortions in 1963 and 1965, this analysis looks at reports by the then-U.S. Department of Health, Education and Welfare, a precursor to the Department of Health and Human Services. In computing those figures, we excluded abortions listed in the report under the categories “spontaneous or unspecified” or as “other.” (“Spontaneous abortion” is another way of referring to miscarriages.)

Guttmacher data in this post comes from national surveys of abortion providers that Guttmacher has conducted 19 times since 1973. Guttmacher compiles its figures after contacting every known provider of abortions – clinics, hospitals and physicians’ offices – in the country. It uses questionnaires and health department data, and it provides estimates for abortion providers that don’t respond to its inquiries. (In 2020, the last year for which it has released data on the number of abortions in the U.S., it used estimates for 12% of abortions.) For most of the 2000s, Guttmacher has conducted these national surveys every three years, each time getting abortion data for the prior two years. For each interim year, Guttmacher has calculated estimates based on trends from its own figures and from other data.

The latest full summary of Guttmacher data came in the institute’s report titled “Abortion Incidence and Service Availability in the United States, 2020.” It includes figures for 2020 and 2019 and estimates for 2018. The report includes a methods section.

In addition, this post uses data from StatPearls, an online health care resource, on complications from abortion.

An exact answer is hard to come by. The CDC and the Guttmacher Institute have each tried to measure this for around half a century, but they use different methods and publish different figures.

The last year for which the CDC reported a yearly national total for abortions is 2021. It found there were 625,978 abortions in the District of Columbia and the 46 states with available data that year, up from 597,355 in those states and D.C. in 2020. The corresponding figure for 2019 was 607,720.

The last year for which Guttmacher reported a yearly national total was 2020. It said there were 930,160 abortions that year in all 50 states and the District of Columbia, compared with 916,460 in 2019.

• How the CDC gets its data: It compiles figures that are voluntarily reported by states’ central health agencies, including separate figures for New York City and the District of Columbia. Its latest totals do not include figures from California, Maryland, New Hampshire or New Jersey, which did not report data to the CDC. ( Read the methodology from the latest CDC report .)
• How Guttmacher gets its data: It compiles its figures after contacting every known abortion provider – clinics, hospitals and physicians’ offices – in the country. It uses questionnaires and health department data, then provides estimates for abortion providers that don’t respond. Guttmacher’s figures are higher than the CDC’s in part because they include data (and in some instances, estimates) from all 50 states. ( Read the institute’s latest full report and methodology .)

While the Guttmacher Institute supports abortion rights, its empirical data on abortions in the U.S. has been widely cited by  groups  and  publications  across the political spectrum, including by a  number of those  that  disagree with its positions .

These estimates from Guttmacher and the CDC are results of multiyear efforts to collect data on abortion across the U.S. Last year, Guttmacher also began publishing less precise estimates every few months , based on a much smaller sample of providers.

The figures reported by these organizations include only legal induced abortions conducted by clinics, hospitals or physicians’ offices, or those that make use of abortion pills dispensed from certified facilities such as clinics or physicians’ offices. They do not account for the use of abortion pills that were obtained  outside of clinical settings .

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The annual number of U.S. abortions rose for years after Roe v. Wade legalized the procedure in 1973, reaching its highest levels around the late 1980s and early 1990s, according to both the CDC and Guttmacher. Since then, abortions have generally decreased at what a CDC analysis called  “a slow yet steady pace.”

Guttmacher says the number of abortions occurring in the U.S. in 2020 was 40% lower than it was in 1991. According to the CDC, the number was 36% lower in 2021 than in 1991, looking just at the District of Columbia and the 46 states that reported both of those years.

(The corresponding line graph shows the long-term trend in the number of legal abortions reported by both organizations. To allow for consistent comparisons over time, the CDC figures in the chart have been adjusted to ensure that the same states are counted from one year to the next. Using that approach, the CDC figure for 2021 is 622,108 legal abortions.)

There have been occasional breaks in this long-term pattern of decline – during the middle of the first decade of the 2000s, and then again in the late 2010s. The CDC reported modest 1% and 2% increases in abortions in 2018 and 2019, and then, after a 2% decrease in 2020, a 5% increase in 2021. Guttmacher reported an 8% increase over the three-year period from 2017 to 2020.

As noted above, these figures do not include abortions that use pills obtained outside of clinical settings.

Guttmacher says that in 2020 there were 14.4 abortions in the U.S. per 1,000 women ages 15 to 44. Its data shows that the rate of abortions among women has generally been declining in the U.S. since 1981, when it reported there were 29.3 abortions per 1,000 women in that age range.

The CDC says that in 2021, there were 11.6 abortions in the U.S. per 1,000 women ages 15 to 44. (That figure excludes data from California, the District of Columbia, Maryland, New Hampshire and New Jersey.) Like Guttmacher’s data, the CDC’s figures also suggest a general decline in the abortion rate over time. In 1980, when the CDC reported on all 50 states and D.C., it said there were 25 abortions per 1,000 women ages 15 to 44.

That said, both Guttmacher and the CDC say there were slight increases in the rate of abortions during the late 2010s and early 2020s. Guttmacher says the abortion rate per 1,000 women ages 15 to 44 rose from 13.5 in 2017 to 14.4 in 2020. The CDC says it rose from 11.2 per 1,000 in 2017 to 11.4 in 2019, before falling back to 11.1 in 2020 and then rising again to 11.6 in 2021. (The CDC’s figures for those years exclude data from California, D.C., Maryland, New Hampshire and New Jersey.)

The CDC broadly divides abortions into two categories: surgical abortions and medication abortions, which involve pills. Since the Food and Drug Administration first approved abortion pills in 2000, their use has increased over time as a share of abortions nationally, according to both the CDC and Guttmacher.

The majority of abortions in the U.S. now involve pills, according to both the CDC and Guttmacher. The CDC says 56% of U.S. abortions in 2021 involved pills, up from 53% in 2020 and 44% in 2019. Its figures for 2021 include the District of Columbia and 44 states that provided this data; its figures for 2020 include D.C. and 44 states (though not all of the same states as in 2021), and its figures for 2019 include D.C. and 45 states.

Guttmacher, which measures this every three years, says 53% of U.S. abortions involved pills in 2020, up from 39% in 2017.

Two pills commonly used together for medication abortions are mifepristone, which, taken first, blocks hormones that support a pregnancy, and misoprostol, which then causes the uterus to empty. According to the FDA, medication abortions are safe  until 10 weeks into pregnancy.

Surgical abortions conducted  during the first trimester  of pregnancy typically use a suction process, while the relatively few surgical abortions that occur  during the second trimester  of a pregnancy typically use a process called dilation and evacuation, according to the UCLA School of Medicine.

In 2020, there were 1,603 facilities in the U.S. that provided abortions,  according to Guttmacher . This included 807 clinics, 530 hospitals and 266 physicians’ offices.

While clinics make up half of the facilities that provide abortions, they are the sites where the vast majority (96%) of abortions are administered, either through procedures or the distribution of pills, according to Guttmacher’s 2020 data. (This includes 54% of abortions that are administered at specialized abortion clinics and 43% at nonspecialized clinics.) Hospitals made up 33% of the facilities that provided abortions in 2020 but accounted for only 3% of abortions that year, while just 1% of abortions were conducted by physicians’ offices.

Looking just at clinics – that is, the total number of specialized abortion clinics and nonspecialized clinics in the U.S. – Guttmacher found the total virtually unchanged between 2017 (808 clinics) and 2020 (807 clinics). However, there were regional differences. In the Midwest, the number of clinics that provide abortions increased by 11% during those years, and in the West by 6%. The number of clinics  decreased  during those years by 9% in the Northeast and 3% in the South.

The total number of abortion providers has declined dramatically since the 1980s. In 1982, according to Guttmacher, there were 2,908 facilities providing abortions in the U.S., including 789 clinics, 1,405 hospitals and 714 physicians’ offices.

The CDC does not track the number of abortion providers.

In the District of Columbia and the 46 states that provided abortion and residency information to the CDC in 2021, 10.9% of all abortions were performed on women known to live outside the state where the abortion occurred – slightly higher than the percentage in 2020 (9.7%). That year, D.C. and 46 states (though not the same ones as in 2021) reported abortion and residency data. (The total number of abortions used in these calculations included figures for women with both known and unknown residential status.)

The share of reported abortions performed on women outside their state of residence was much higher before the 1973 Roe decision that stopped states from banning abortion. In 1972, 41% of all abortions in D.C. and the 20 states that provided this information to the CDC that year were performed on women outside their state of residence. In 1973, the corresponding figure was 21% in the District of Columbia and the 41 states that provided this information, and in 1974 it was 11% in D.C. and the 43 states that provided data.

In the District of Columbia and the 46 states that reported age data to  the CDC in 2021, the majority of women who had abortions (57%) were in their 20s, while about three-in-ten (31%) were in their 30s. Teens ages 13 to 19 accounted for 8% of those who had abortions, while women ages 40 to 44 accounted for about 4%.

The vast majority of women who had abortions in 2021 were unmarried (87%), while married women accounted for 13%, according to  the CDC , which had data on this from 37 states.

In the District of Columbia, New York City (but not the rest of New York) and the 31 states that reported racial and ethnic data on abortion to  the CDC , 42% of all women who had abortions in 2021 were non-Hispanic Black, while 30% were non-Hispanic White, 22% were Hispanic and 6% were of other races.

Looking at abortion rates among those ages 15 to 44, there were 28.6 abortions per 1,000 non-Hispanic Black women in 2021; 12.3 abortions per 1,000 Hispanic women; 6.4 abortions per 1,000 non-Hispanic White women; and 9.2 abortions per 1,000 women of other races, the  CDC reported  from those same 31 states, D.C. and New York City.

For 57% of U.S. women who had induced abortions in 2021, it was the first time they had ever had one,  according to the CDC.  For nearly a quarter (24%), it was their second abortion. For 11% of women who had an abortion that year, it was their third, and for 8% it was their fourth or more. These CDC figures include data from 41 states and New York City, but not the rest of New York.

Nearly four-in-ten women who had abortions in 2021 (39%) had no previous live births at the time they had an abortion,  according to the CDC . Almost a quarter (24%) of women who had abortions in 2021 had one previous live birth, 20% had two previous live births, 10% had three, and 7% had four or more previous live births. These CDC figures include data from 41 states and New York City, but not the rest of New York.

The vast majority of abortions occur during the first trimester of a pregnancy. In 2021, 93% of abortions occurred during the first trimester – that is, at or before 13 weeks of gestation,  according to the CDC . An additional 6% occurred between 14 and 20 weeks of pregnancy, and about 1% were performed at 21 weeks or more of gestation. These CDC figures include data from 40 states and New York City, but not the rest of New York.

About 2% of all abortions in the U.S. involve some type of complication for the woman , according to an article in StatPearls, an online health care resource. “Most complications are considered minor such as pain, bleeding, infection and post-anesthesia complications,” according to the article.

The CDC calculates  case-fatality rates for women from induced abortions – that is, how many women die from abortion-related complications, for every 100,000 legal abortions that occur in the U.S .  The rate was lowest during the most recent period examined by the agency (2013 to 2020), when there were 0.45 deaths to women per 100,000 legal induced abortions. The case-fatality rate reported by the CDC was highest during the first period examined by the agency (1973 to 1977), when it was 2.09 deaths to women per 100,000 legal induced abortions. During the five-year periods in between, the figure ranged from 0.52 (from 1993 to 1997) to 0.78 (from 1978 to 1982).

The CDC calculates death rates by five-year and seven-year periods because of year-to-year fluctuation in the numbers and due to the relatively low number of women who die from legal induced abortions.

In 2020, the last year for which the CDC has information , six women in the U.S. died due to complications from induced abortions. Four women died in this way in 2019, two in 2018, and three in 2017. (These deaths all followed legal abortions.) Since 1990, the annual number of deaths among women due to legal induced abortion has ranged from two to 12.

The annual number of reported deaths from induced abortions (legal and illegal) tended to be higher in the 1980s, when it ranged from nine to 16, and from 1972 to 1979, when it ranged from 13 to 63. One driver of the decline was the drop in deaths from illegal abortions. There were 39 deaths from illegal abortions in 1972, the last full year before Roe v. Wade. The total fell to 19 in 1973 and to single digits or zero every year after that. (The number of deaths from legal abortions has also declined since then, though with some slight variation over time.)

The number of deaths from induced abortions was considerably higher in the 1960s than afterward. For instance, there were 119 deaths from induced abortions in  1963  and 99 in  1965 , according to reports by the then-U.S. Department of Health, Education and Welfare, a precursor to the Department of Health and Human Services. The CDC is a division of Health and Human Services.

Note: This is an update of a post originally published May 27, 2022, and first updated June 24, 2022.

Support for legal abortion is widespread in many countries, especially in Europe

Nearly a year after roe’s demise, americans’ views of abortion access increasingly vary by where they live, by more than two-to-one, americans say medication abortion should be legal in their state, most latinos say democrats care about them and work hard for their vote, far fewer say so of gop, positive views of supreme court decline sharply following abortion ruling, most popular.

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The largest country in the world at 17,075,400 square kilometres (or 6,592,800 sq mi), Russia has accumulated quite an impressive reputation. Covering more than an eight of the Earth's land area, 142 million people live there making it the ninth largest nation by population . Still known for its impressive days as the expansive Union of Soviet Socialist Republics (USSR), Russia was the world's first and largest constitutionally socialist state. A recognized superpower, the USSR was known for its excellence in both arts and science winning many awards in both fields.

Russia changed drastically after the dissolution of the Soviet Union in 1991, but it continues to be a powerful and important nation. It has one of the world's fastest growing economies and the world's eight largest GDP by nominal GDP. Russia is also one of the five countries which officially recognized nuclear weapons states. In conjunction with this title, Russia is also a permanent member of the United Nations Security Council, the G8, APEC and the SCO, and is a leading member of the Commonwealth of Independent States.

A European city in a country that lies over a vast part of Asia, Moscow holds one-tenth of all Russian residents . The city is located in the western region of Russia and is the capital and epicentre of political, economic, cultural, religious, financial, educational, and transportation happenings. "Muscovites" , as residents are known, tend to be cultured and worldly. This may be due to the many scientific, educational, and artistic institutions that are based here. An intoxicating mix of the exotic and the familiar, it is the largest city in Europe with the Moscow metropolitan area ranking among the largest urban areas in the world.

The city is situated on the banks of the Moskva River which flows through much of central Russia. Moscow is actually located in a basin for the Volga, Oka, Klyazma, and Moscow rivers. The city of Moscow is 994 sq. km with 49 bridges spanning the rivers and canals that criss-cross the city.

Forests are another part of Moscow's make-up. They coveer over a third of the territory in the region. A variety of animals like elk, wild boar, deer, foxes, weasels, lynx, martens, and birds make their home here.

Located in the UTC+3 time zone , Moscow has a humid continental climate. The summers tend to be warm and humid and the winters are long, cold, and hard. High temperatures occur during the warm months of June, July and August at about 23 °C (73 °F). Heat waves sometimes grip the city anywhere between May to September with temperatures spiking up to 30 °C (86 °F). Winters are harshly chilly with temperatures dropping to approximately 9 °C (15.8 °F). There is consistent snow cover for 3 to 5 months a year, usually from November to March.

Update 10/07/2009

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Claudia Looi

Touring the Top 10 Moscow Metro Stations

By Claudia Looi 2 Comments

Komsomolskaya metro station looks like a museum. It has vaulted ceilings and baroque decor.

Hidden underground, in the heart of Moscow, are historical and architectural treasures of Russia. These are Soviet-era creations – the metro stations of Moscow.

Our guide Maria introduced these elaborate metro stations as “the palaces for the people.” Built between 1937 and 1955, each station holds its own history and stories. Stalin had the idea of building beautiful underground spaces that the masses could enjoy. They would look like museums, art centers, concert halls, palaces and churches. Each would have a different theme. None would be alike.

The two-hour private tour was with a former Intourist tour guide named Maria. Maria lived in Moscow all her life and through the communist era of 60s to 90s. She has been a tour guide for more than 30 years. Being in her 60s, she moved rather quickly for her age. We traveled and crammed with Maria and other Muscovites on the metro to visit 10 different metro stations.

Arrow showing the direction of metro line 1 and 2

Moscow subways are very clean

To Maria, every street, metro and building told a story. I couldn’t keep up with her stories. I don’t remember most of what she said because I was just thrilled being in Moscow.   Added to that, she spilled out so many Russian words and names, which to one who can’t read Cyrillic, sounded so foreign and could be easily forgotten.

The metro tour was the first part of our all day tour of Moscow with Maria. Here are the stations we visited:

1. Komsomolskaya Metro Station  is the most beautiful of them all. Painted yellow and decorated with chandeliers, gold leaves and semi precious stones, the station looks like a stately museum. And possibly decorated like a palace. I saw Komsomolskaya first, before the rest of the stations upon arrival in Moscow by train from St. Petersburg.

2. Revolution Square Metro Station (Ploshchad Revolyutsii) has marble arches and 72 bronze sculptures designed by Alexey Dushkin. The marble arches are flanked by the bronze sculptures. If you look closely you will see passersby touching the bronze dog's nose. Legend has it that good luck comes to those who touch the dog's nose.

Touch the dog's nose for good luck. At the Revolution Square station

Revolution Square Metro Station

3. Arbatskaya Metro Station served as a shelter during the Soviet-era. It is one of the largest and the deepest metro stations in Moscow.

Arbatskaya Metro Station

4. Biblioteka Imeni Lenina Metro Station was built in 1935 and named after the Russian State Library. It is located near the library and has a big mosaic portrait of Lenin and yellow ceramic tiles on the track walls.

Lenin's portrait at the Biblioteka Imeni Lenina Metro Station

5. Kievskaya Metro Station was one of the first to be completed in Moscow. Named after the capital city of Ukraine by Kiev-born, Nikita Khruschev, Stalin's successor.

Kievskaya Metro Station

6. Novoslobodskaya Metro Station  was built in 1952. It has 32 stained glass murals with brass borders.

Novoslobodskaya metro station

7. Kurskaya Metro Station was one of the first few to be built in Moscow in 1938. It has ceiling panels and artwork showing Soviet leadership, Soviet lifestyle and political power. It has a dome with patriotic slogans decorated with red stars representing the Soviet's World War II Hall of Fame. Kurskaya Metro Station is a must-visit station in Moscow.

Ceiling panel and artworks at Kurskaya Metro Station

8. Mayakovskaya Metro Station built in 1938. It was named after Russian poet Vladmir Mayakovsky. This is one of the most beautiful metro stations in the world with 34 mosaics painted by Alexander Deyneka.

Mayakovskaya station

One of the over 30 ceiling mosaics in Mayakovskaya metro station

9. Belorusskaya Metro Station is named after the people of Belarus. In the picture below, there are statues of 3 members of the Partisan Resistance in Belarus during World War II. The statues were sculpted by Sergei Orlov, S. Rabinovich and I. Slonim.

10. Teatralnaya Metro Station (Theatre Metro Station) is located near the Bolshoi Theatre.

Teatralnaya Metro Station decorated with porcelain figures .

Taking the metro's escalator at the end of the tour with Maria the tour guide.

Have you visited the Moscow Metro? Leave your comment below.

January 15, 2017 at 8:17 am

An excellent read! Thanks for much for sharing the Russian metro system with us. We're heading to Moscow in April and exploring the metro stations were on our list and after reading your post, I'm even more excited to go visit them. Thanks again 🙂

December 6, 2017 at 10:45 pm

Hi, do you remember which tour company you contacted for this tour?

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On The Red Carpet

Jeezy, common and more talk hip-hop and politics in new hulu documentary.

'Hip-Hop and the White House' shows the relationship between the genre and presidential policies

LOS ANGELES -- The evolution will be televised.

The new documentary, "Hip-Hop and the White House" explores the relationship between the music genre of hip-hop and the politicians who shape the policies of this nation.

"We feel that this is really timely because we've had the 50th anniversary of the creation of hip-hop and then we have this election. And hip-hop has more influence than it ever had before," writer/director Jesse Washington told On The Red Carpet.

"We really had to set the stage for what hip-hop came out of and the political consciousness that was baked into the culture from the beginning just by virtue of existing in this country and being on the receiving end of presidential policies since the 1970s," he continued.

KRS-One, Roxanne Shante, Bun B, YG, Common and Waka Flocka Flame are among those featured in the documentary, along with Jeezy, who narrates the film.

Their stories go back to the 1970s and 1980s, from the war on drugs, which so many rappers wrote about, to NWA to Eazy-E attending a Republican group's luncheon with then President George H.W. Bush, to rapper YG's anthem railing against former President Donald Trump.

"The first rapper to engage meaningfully with a president was Eazy-E. And then you go all the way to the other side of the spectrum and you've got YG, another LA dude," Washington said. "And so when you approach a YG, when you approach a Jeezy, who has probably the most powerful political anthem in history with "My President," I think they welcomed the opportunity to talk about the making of these records and what was behind it and what they were thinking and their own personal political evolutions."

In the documentary, Jeezy reveals how months prior to the 2008 election of President Barack Obama, he kept hearing this beat in his head, singing to himself, "my President is Black," and decided to go to the studio right then to record it.

"What we want people to take away from this film is this is the history of where hip-hop comes from. It's not just trivial, a lot of the artists that you think might not have a political consciousness really have something to say," Washington continued.

"We want people to think that we, as a hip-hop community, those of us who live and love and respect and appreciate the culture have a power and a voice in this political process that we may be underestimating. And so this year in particular and in future years moving forward, hip-hop has something to say and that means you the hip-hop audience as well have a role to play in this process."

"Hip-Hop and the White House" streams on Hulu April 22.

Disney is the parent company of Hulu and this ABC station.

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Spatial Variations of the Activity of 137 Cs and the Contents of Heavy Metals and Petroleum Products in the Polluted Soils of the City of Elektrostal

• DEGRADATION, REHABILITATION, AND CONSERVATION OF SOILS
• Open access
• Published: 15 June 2022
• Volume 55 , pages 840–848, ( 2022 )

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• D. N. Lipatov 1 ,
• V. A. Varachenkov 1 ,
• D. V. Manakhov 1 ,
• M. M. Karpukhin 1 &
• S. V. Mamikhin 1  

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The levels of specific activity of 137 Cs and the contents of mobile forms (1 M ammonium acetate extraction) of heavy metals (Zn, Cu, Ni, Co, Cr, Pb) and petroleum products were studied in the upper soil horizon of urban landscapes of the city of Elektrostal under conditions of local radioactive and chemical contamination were studied. In the soils within a short radius (0–100 m) around the heavy engineering plant, the specific activity of 137 Cs and the contents of mobile forms of Pb, Cu, and Zn were increased. The lognormal distribution law of 137 Cs was found in the upper (0–10 cm) soil layer; five years after the radiation accident, the specific activity of 137 Cs varied from 6 to 4238 Bq/kg. The coefficients of variation increased with an increase in the degree of soil contamination in the following sequence: Co < Ni < petroleum products < Cr < 137 Cs < Zn < Pb < Cu ranging from 50 to 435%. Statistically significant direct correlation was found between the specific activity of 137 Cs and the contents of mobile forms of Pb, Cu, and Zn in the upper horizon of urban soils, and this fact indicated the spatial conjugacy of local spots of radioactive and polymetallic contamination in the studied area. It was shown that the specific activity of 137 Cs, as well as the content of heavy metals and petroleum products in the upper layer (0–10 cm) of the soils disturbed in the course of decontamination, earthwork and reclamation is reduced.

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INTRODUCTION

Contaminants migrate and accumulate in urban ecosystems under the impact of both natural and technogenic factors. The processes of technogenic migration of 137 Cs are most pronounced in radioactively contaminated territories. It was found in urboecological studies that the intensity of sedimentation of aerosol particles containing radionuclides and heavy metals is determined by the types of the surfaces of roofs, walls, roads, lawns, and parks and by their position within the urban wind field [ 12 , 26 ]. Traffic in the cities results in significant transport of dust and associated contaminants and radionuclides [ 15 , 24 ]. During decontamination measures in the areas of Chernobyl radioactive trace, not only the decrease in the level of contamination but also the possibility of secondary radioactive contamination because of the transportation of contaminated soil particles by wind or water, or anthropogenic transfer of transferring of ground were observed [ 5 , 6 ]. Rainstorm runoff and hydrological transport of dissolved and colloidal forms of 137 Cs can result in the accumulation of this radionuclide in meso- and microdepressions, where sedimentation takes place [ 10 , 16 ]. Different spatial distribution patterns of 137 Cs in soils of particular urban landscapes were found in the city of Ozersk near the nuclear fuel cycle works [ 17 ]. Natural character of 137 Cs migration in soils of Moscow forest-parks and a decrease in its specific activity in industrial areas have been revealed [ 10 ]. Determination of the mean level and parameters of spatial variations of 137 Cs in soils is one of primary tasks of radioecological monitoring of cities, including both unpolluted (background) and contaminated territories.

Emissions and discharges from numerous sources of contamination can cause the accumulation of a wide range of toxicants in urban soils: heavy metals (HMs), oil products (OPs), polycyclic aromatic hydrocarbons (PAHs), and other chemical substances. Soil contamination by several groups of toxicants is often observed in urban landscapes [ 20 , 23 ] because of the common contamination source or close pathways of the migration of different contaminants. A comprehensive analysis of contamination of urban soils by radionuclides and heavy metals has been performed in some studies [ 21 , 25 ]. The determination of possible spatial interrelationships between radioactive and chemical contaminations in urban soils is an important problem in urban ecology.

A radiation accident took place in the Elektrostal heavy engineering works (EHEW) in April 2013: a capacious source of 137 Cs entered the smelt furnace, and emission of radioactive aerosols from the aerating duct into the urban environment took place. The activity of molten source was estimated at about 1000–7000 Ci [ 14 ]. The area of contamination in the territory of the plant reached 7500 m 2 . However, radioactive aerosols affected a much larger area around the EHEW, including Krasnaya and Pervomaiskaya streets, and reached Lenin Prospect.

Geochemical evaluation of contamination of the upper soil horizon in the city of Elektrostal was carried out in 1989–1991. This survey indicated the anomalies of concentrations of wolfram, nickel, molybdenum, chromium, and other heavy metals related to accumulation of alloying constituent and impurities of non-ferrous metals in the emissions of steelmaking works [ 19 ].

The aim of our work was to determine the levels of specific activity of 137 Cs, concentrations of mobile forms of heavy metals (Zn, Cu, Ni, Co, Cr, and Pb) and oil products in the upper soil horizons in different urban landscapes of the city of Elektrostal under the conditions of local radioactive and chemical contamination.

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D. N. Lipatov, V. A. Varachenkov, D. V. Manakhov, M. M. Karpukhin & S. V. Mamikhin

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Lipatov, D.N., Varachenkov, V.A., Manakhov, D.V. et al. Spatial Variations of the Activity of 137 Cs and the Contents of Heavy Metals and Petroleum Products in the Polluted Soils of the City of Elektrostal. Eurasian Soil Sc. 55 , 840–848 (2022). https://doi.org/10.1134/S1064229322060072

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Published : 15 June 2022

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DOI : https://doi.org/10.1134/S1064229322060072

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Christmas gift guide to Moscow surroundings

Visitors from America and Western Europe might be surprised to discover that Russia celebrates Christmas on January 7th. That’s because the Russian Orthodox Church follows the Julian calendar. After the end of the Soviet Union, some Russians have begun celebrating Christmas on December 25 in accordance with the Gregorian calendar. But many Russians still observe the tradition of fasting on January 6th, breaking the fast with a large feast on Christmas Eve after the first star has appeared in the sky.

During the Soviet era, Christmas and religious traditions were banned in Russia. Santa Claus was replaced by Ded Moroz, or, Grandfather Frost, an old man with a long white beard who would bring gifts to children on New Year’s instead of Christmas. According to Russian tradition, Ded Moroz is accompanied by his granddaughter, Snegurochka, the Snowmaiden, who helps him on his journey to give presents to children.

Although the tradition of having a Christmas tree, known as a yolka in Russian, was also banned during Soviet times, Russians got around this by having New Year’s trees from which they hung homemade decorations. Today, the restrictions of the Soviet Union have faded into history, and during the Christmas season visitors to Russia can even purchase Christmas ornaments in the shape of matryoshka dolls, or religious icons that depict nativity scenes.

Heading counterclockwise around the Golden Ring this holiday season, northeast of Moscow, your first stop will most likely be the city of Vladimir, home to some of Russia’s most striking churches and cathedrals. The Vladimir region is known for its fine crystal. Stop by the Crystal, Lacquer Miniatures, and Embroidery Museum ( 2 Bolshaya Moskovskaya ) for an overview of traditional crafts before visiting the gift shop in the museum to browse the crystal selection. Vladimir Chic ( 2 Dvoryanskaya ) also sells local glass and crystal work.

Typical souvenirs are also for sale in Vladimir’s old town, especially by the Golden Gate, a triumphal arch and defensive tower that is one of the last-remaining parts of the wall that once surrounded ancient Vladimir and a sure stop on any tour of the Golden Ring.

Just 63 kilometers from Vladimir lays the nearby city of Gus-Khrustalny , the ‘Crystal Goose,’ also home to a rich glass and crystal making tradition. You can visit the glassmaking factory in Gus-Khrustalny and buy gifts ranging from plates and vases to decanters, or visit the outlet store back in Moscow ( 4 Ilyinka ) just east of the Kremlin.

North of Vladimir, you’ll arrive in Suzdal, one of the Golden Ring route’s more tranquil towns. Suzdal boasts a number of small bazaars and stands outside the main tourist sites where visitors can purchase local honey mead, called medovukha, along with traditional crafts, like a pair valenki, or Russian woolen boots, which make an ideal Christmas gift for friends and family back home. The shopping stands outside Suzdal’s Museum of Wooden Architecture and Peasant Life ( Ul. Pushkarskaya ) are also highly recommended. Market Square ( Torgovaya Pl ) houses a number of shops where visitors can search for arts and crafts.

Following the Golden Ring north of Suzdal, many tours will stop in the city of Kostroma, a former trading outpost on the immense Volga River. One of the city’s highlights is the Museum of Linen and Birchbark ( 38 Tereshkova ), where visitors can view exhibits on traditional Russian crafts woven from flax and bark. A gift shop in the basement sells tablecloths, napkins, baskets, linen dolls, and traditional clothing typical of the region.

South from Kostroma, stop in the city of Rostov-Veliky for enamel jewelry, a craft which allows artists to produce small paintings on metal that are then fired to produce a thin glaze over the image. Rostov became famous for its tradition of enamel work. Today, visitors can purchase rings, earrings, bracelets, brooches, and jewelry boxes in the gift shop of the Rostov Enamel factory ( 3 Borisoglebskoye Highway ).

While you’re in Rostov, visit the House of Crafts ( 16 Vtoraya Tolstovskaya Naberezhnaya ) for local pottery and the Souvenirs shop ( 5 Ul. Kamennyi Most ) for ushanka hats—Russian fur caps with earflaps—paintings, and samovars for tea lovers.

The last two stops on a tour of the Golden Ring are the cities of Pereslavl-Zalesskiy and Sergiev Posad. Pereslavl is most famous for its embroidery work, available at the Art Salon ( 12 Ul. Sovetskaya ) along with souvenirs made of wood and stone. Nearby Sergiev Posad is considered the place where Russia’s matryoshka dolls were first invented, and was the chief production center of the dolls before Soviet times. Visit the city’s Toy Museum ( 123 Pr. Krasny Armii ) to get a better sense of the birthplace of one of Russia’s most recognizable toys, then head over to the market alongside the Trinity Monastery of St. Sergius—one of the city’s most important sites—to load up on matryoshka dolls, painted eggs, and icons before going home.

If you’ll be in the Golden Ring during New Years, the city of Vladimir hosts an impressive Christmas fair, with an iceskating rink and performances by local artists, in the main square ( Sobornaya Pl ). In most other Golden Ring cities you’ll find similar events in the center square as Christmas nears.

Most shops and markets in the Golden Ring are open year round. If you’re coming to Russia for a short period of time, whether in winter or summer, consider a trip to this stunning part of the country, and bring an extra bag if you plan to go shopping for Christmas gifts.

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