Risk Behavior for Travelers' Diarrhea Among Finnish Travelers

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