Outbreak of Wilderness/Backcountry/Travelers’ Diarrhea at a Himalayan Base Camp at 4000 m/13,125 ft

Document Type: Original Article

Authors

1 Clinical Microbiology and Infectious Diseases, Army College of Medical Sciences and Base Hospital, New Delhi, India

2 Armed Forces Medical College, Pune, India

3 INHS Kalyani, Vishakhapatnam, India

4 Army College of Medical Sciences and Base Hospital, New Delhi, India

5 Armed Forces Clinic, New Delhi, India

6 Pension Paying Office, Dharan, Nepal

7 Army Hospital Research and Referral, New Delhi, India

8 ESI Hospital Basaidarapur, New Delhi, India

Abstract

Introduction: Wilderness or backcountry diarrhea is a type of travelers’ diarrhea commonly caused by Cryptosporidium and Giardia, which can survive freezing temperatures. Campsites pose additional risks worldwide, irrespective of developing or developed regions, due to inadequate hygiene.
Methods: In a first of its kind, an outbreak of wilderness diarrhea at a semi-permanent Himalayan Base Camp at 4000 m/13,125 ft in Uttarkashi, India, was investigated and managed by empirical antimicrobials. Return of normal bowel function was considered as primary outcome, and return to routine training at Base Camp was considered secondary outcome.
Results: Sixty-two personnel presented with wilderness diarrhea of 5.58 days mean duration with onset after mean stay of 10.26 days, despite provisions for adequate camp hygiene and sanitation. Both primary and secondary outcomes were reached by all except three students who were evacuated on foot to the district referral hospital 56 km downhill from Base Camp. Hygiene was compromised due to cold weather/water. Epidemiological surveillance was not contributory.
Conclusion: Wilderness diarrhea can present in outbreak proportions from formerly safe water sources due to variable microbial contamination. On-site diagnostics and management are required to control outbreaks of wilderness diarrhea. Traveler risk management strategies and traveler awareness/education can be a targeted mandatory intervention to enhance preparedness and resilience capital in outdoor and mountain environments.

Keywords


  1. Johnson C, Winsor S. Oxford handbook of Expedition and Wilderness Medicine. Oxford University Press; 2015:822. doi:10.1093/med/9780199688418.001.0001.
  2. Feng Y, Xiao L. Zoonotic potential and molecular epidemiology of Giardia species and giardiasis. Clin Microbiol Rev. 2011;24(1):110- 140. doi:10.1128/CMR.00033-10.
  3. Auerbach PS. Wilderness Medicine E-Book: Expert Consult Premium Edition - Enhanced Online Features. 6th ed. Elsevier Health Sciences; 2011:2304.
  4. Boulware DR. Influence of hygiene on gastrointestinal illness among wilderness backpackers. J Travel Med. 2004;11(1):27-33. doi:10.2310/7060.2004.13621.
  5. Zell SC. Epidemiology of wilderness-acquired diarrhea: implications for prevention and treatment. J Wilderness Med. 1992;3(3):241-249. doi:10.1580/0953-9859-3.3.241.
  6. Boulware DR, Forgey WW, Martin WJ 2nd. Medical risks of wilderness hiking. Am J Med. 2003;114(4):288-293.
  7. McIntosh SE, Leemon D, Visitacion J, Schimelpfenig T, Fosnocht D. Medical incidents and evacuations on wilderness expeditions. Wilderness Environ Med. 2007;18(4):298-304. doi:10.1580/07-WEME-OR-093R1.1.
  8. Meyer DJ, Costantino A, Spano S. An assessment of diarrhea among long-distance backpackers in the Sierra Nevada. Wilderness Environ Med. 2017;28(1):4-9. doi:10.1016/j.wem.2016.12.002.
  9. Welch TR. Evidence-based medicine in the wilderness: the safety of backcountry water. Wilderness Environ Med. 2004;15(4):235- 237. doi:10.1580/1080-6032(2004)015[0235:EMITWT]2.0.CO;2.
  10. Khan ID, Khan SA, Asima B, Hussaini SB, Zakiuddin M, Faisal FA. Morbidity and mortality amongst Indian Hajj pilgrims: a 3-year experience of Indian Hajj medical mission in mass-gathering medicine. J Infect Public Health. 2017. doi:10.1016/j.jiph.2017.06.004.
  11. Shlim DR. Looking for evidence that personal hygiene precautions prevent traveler’s diarrhea. Clin Infect Dis. 2005;41 Suppl 8:S531-S535. doi:10.1086/432947.
  12. Leder K. Advising travellers about management of travellers’ diarrhoea. Aust Fam Physician. 2015;44(1-2):34-37.
  13. DuPont HL. Therapy for and prevention of traveler’s diarrhea. Clin Infect Dis. 2007;45 Suppl 1:S78-84. doi:10.1086/518155.
  14. Khan ID. Extreme altitude pulmonary oedema (EAPO) in acclimatized soldiers. Med J Armed Forces India. 2012;68(4):339- 345. doi:10.1016/j.mjafi.2012.04.018.
  15. Khan ID. Comorbid cerebral and pulmonary edema at 7010 M/23000 Ft: An Extreme Altitude Perspective. J Med. 2013;14(2):153-155. doi:10.3329/jom.v14i2.19668.
  16. Khan ID. Cerebral venous sinus thrombosis masquerading as high altitude cerebral edema at extreme altitude. Int J Travel Med Glob Health. 2016;4(3):96-98. doi:10.21859/ijtmgh-040306.
  17. Khan ID. On-site management of frostbite in the Himalayas. Int J Travel Med Glob Health. 2017;5(1):28-32. doi:10.15171/IJTMGH.2017.05.
  18. Khan ID, Sahni AK. Possession syndrome at high altitude (4575 m/15000 ft). Kathmandu Univ Med J. 2013;11(43):253-255.
  19. De Bruyn G, Hahn S, Borwick A. Antibiotic treatment for travellers’ diarrhoea. Cochrane Database Syst Rev. 2000(3):Cd002242. doi:10.1002/14651858.CD002242.
  20. DuPont HL, Ericsson CD, Farthing MJ, et al. Expert review of the evidence base for prevention of travelers’ diarrhea. J Travel Med. 2009;16(3):149-160. doi:10.1111/j.1708-8305.2008.00299.x.
  21. The Lancet Infectious D. Cholera in Yemen: war, hunger, disease... and heroics. Lancet Infect Dis. 2017;17(8):781. doi:10.1016/S1473-3099(17)30406-1.
  22. Qadri F, Islam T, Clemens JD. Cholera in Yemen - an old foe rearing its ugly head. N Engl J Med. 2017;377(21):2005-2007. doi:10.1056/NEJMp1712099.
  23. The L. Yemen and cholera: a modern humanity test. Lancet. 2017;390(10095):626. doi:10.1016/S0140-6736(17)32210-9.
  24. Khan ID, Asima B, Khan SA. Operations throughput as a determinant of golden-hour in mass-gathering medicine. Int J Med Med Res. 2017;3(1):53-59. doi:10.11603/ijmmr.2413-6077.2017.1.7804.
  25. Khan ID, Sahni AK, Sen S, Gupta RM, Basu A. Outbreak of Prototheca wickerhamii algaemia and sepsis in a tertiary care chemotherapy oncology unit. Med J Armed Forces India. 2017. doi:10.1016/j.mjafi.2017.07.012.
  26. Khan ID, Sahni AK, Bharadwaj R, Lall M, Jindal AK, Sashindran VK. Emerging organisms in a tertiary healthcare set up. Med J Armed Forces India. 2014;70(2):120-128. doi:10.1016/j.mjafi.2013.09.005.
  27. Khan ID. The world in 21st century: a sea of challenges and a mountain of opportunities Up. http://www.globalethicsnetwork.org/profiles/blogs/the-world-in-21st-century-a-sea-of-challenges-and-a-mountain-of. Published December 30, 2014.
  28. Khan ID, Khan S, Khan MA, et al. Indian medical mission at Hajj- 2016: mass-gathering medicine perspectives, challenges, and opportunities in a mission posture. Int J Travel Med Glob Health. 2017;5(3):94-101. doi:10.15171/ijtmgh.2017.20.
  29. Khan ID. Extreme Altitude Chronic Mountain Sickness Misdiagnosed As High Altitude Cerebral Edema. Int J Travel Med Glob Health. 2016;4(4):132-134. doi:10.21859/ijtmgh-040408.
  30. Khan ID, Hussaini SB, Khan S, et al. Emergency response of Indian Hajj medical mission to heat illness among Indian pilgrims in Tent- Clinics at Mina and Arafat during Hajj, 2016. Int J Travel Med Glob Health. 2017;5(4):135-139. doi:10.15171/ijtmgh.2017.26.
  31. Khan ID, Sahni AK. Rapid diagnosis of dengue outbreaks in resource limited facilities. West Indian Med J. 2017;66(1):4-9. doi:10.7727/wimj.2016.095.
  32. Khan ID, Gupta N, Rangan NM, Singh R, Sharma AK, Khurana A, et al. Evaluation of pre and post analytical variables in clinical microbiology services in multidisciplinary ICU of a medical college and tertiary care hospital. J Basic Clin Med. 2016;5(1):2-4.