310
Knowledge, Attitudes, and Practice of Travelers’ Diarrhea Management among Frontline Providers Aatif M. Hayat, MD, MPH,∗ David R. Tribble, MD, DrPH,† John W. Sanders, MD, MPH & TM,‡ Dennis J. Faix, MD, MPH,§ Danny Shiau, MD, MPH, Adam W. Armstrong, DO,¶ and Mark S. Riddle, MD, DrPH# ∗ Walter
Reed Army Institute of Research, Silver Spring, MD, USA; † Uniformed Services University of the Health Sciences, Bethesda, MD, USA; ‡ Naval Medical Research Center Detachment, Lima, Peru; § Naval Health Research Center, San Diego, CA, USA; Navy Bureau of Medicine and Surgery, Washington DC, USA; ¶ US Naval Medical Research Unit No. 3, Cairo, Egypt; # Naval Medical Research Center, Silver Spring, MD, USA
DOI: 10.1111/j.1708-8305.2011.00538.x
Background. Many studies have found acute gastrointestinal infections to be among the most likely reason for clinic visits among forward deployed soldiers and are considered a significant contributor to morbidity in this population. This occurs despite the controlled food and water distribution systems under which military populations operate. Furthermore, recent studies have indicated that providers often fail to appropriately identify and treat the typical causes of these infections. To adequately address this issue, an assessment of gaps in knowledge, practice, and management of acute diarrhea in deployed troops was conducted. Methods. A multiple-choice survey was developed by clinical researchers with expertise in travelers’ diarrhea (TD) and provided to a convenience sample of clinical providers with a broad range of training and operational experience. The survey evaluated provider’s knowledge of TD along with their ability to identify etiologies of various syndromic categories of acute gastrointestinal infections. Providers were also queried on selection of treatment approaches to a variety of clinical-based scenarios. Results. A total of 117 respondents completed the survey. Most were aware of the standard definition of TD (77%); however, their knowledge about the epidemiology was lower, with less than 24% correctly answering questions on etiology of diarrhea, and 31% believing that a viral pathogen was the primary cause of watery diarrhea during deployment. Evaluation of scenario-based responses showed that 64% of providers chose not to use antibiotics to treat moderate TD. Furthermore, 19% of providers felt that severe inflammatory diarrhea was best treated with hydration only while 25% felt hydration was the therapy of choice for dysentery. Across all provider types, three practitioner characteristics appeared to be related to better scores on responses to the nine management scenarios: having a Doctor of Medicine or Doctor of Osteopathy degree, greater knowledge of TD epidemiology, and favorable attitudes toward antimotility or antibiotic therapy. Conclusion. Results from this survey support the need for improving knowledge and management of TD among deploying providers. The information from this study should be considered to support the establishment and dissemination of military diarrhea-management guidelines to assist in improving the health of military personnel.
T
ravelers’ diarrhea (TD) is a significant contributor to morbidity encountered by forward deployed service members. Recent studies have greatly increased the understanding of the epidemiology and management of TD.1 – 3 However, little has been carried out to study whether this knowledge has been effectively translated and disseminated to operational health care providers.
Corresponding Author: Mark S. Riddle, MD, DrPH, Enteric Diseases Department, Naval Medical Research Center, 503 Robert Grant Ave., Silver Spring, MD 20910, USA. E-mail:
[email protected] © 2011 International Society of Travel Medicine, 1195-1982 Journal of Travel Medicine 2011; Volume 18 (Issue 5): 310–317
TD is typically defined as passing three or more loose stools in a 24-h period in addition to nausea, vomiting, abdominal cramps, fever, fecal urgency, tenesmus, or the passage of bloody or mucoid stools.4 – 6 TD typically resolves spontaneously over a 3- to 5-d period, but up to one-quarter of individuals with TD will have to alter their planned activities and up to 1 of 10 may develop postinfectious irritable bowel syndrome.7,8 With respect to the US military there have been many studies which have established infectious intestinal diseases among the most likely clinic visits for disease and non-battle injury.1,9,10 This occurs despite controlled food and
Knowledge, Attitudes, and Practice of Travelers’ Diarrhea
water distribution systems during deployment. TD has an average cumulative attack rate of 29% per month, with rates upward of 70% during deployments to high risk areas such as Southwest Asia.2,11 Enterotoxigenic Escherichia coli (ETEC), Campylobacter spp., and Shigella spp. are identified as causative agents for 38% to 45% of diarrheal disease among US military populations overseas.2 TD education, aggressive fluid replacement, antidiarrheal medications, and antibiotics have been the cornerstones of diarrhea management, although practice patterns and treatment guidelines vary. With respect to antibiotic therapy, in 2000, the Cochrane Collaboration Database published a systematic review that demonstrated the effectiveness of antibiotic treatment for TD.12 This review showed that antibiotic therapy decreased the duration of illness by 48 to 72 h and decreased the overall severity of illness. Various guidelines, including the Infectious Disease Society of America (IDSA) 2006 guidelines recommend providing travelers with 3 d of antibiotics and reevaluation after 24 h.8 In addition, a series of clinical trials have accrued which have suggested that combination therapy of antibiotics and antimotility agents offers an advantage over antibiotics alone in most cases of mild to moderate TD.13 Despite the cumulative evidence and available guidelines supporting antibiotic-based management of TD, gaps in appropriate management of diarrhea among deployed troops have been identified. A previous study by Riddle and colleagues showed that knowledge about the epidemiology and management of TD was low among many deployed providers attending a 2004 physician’s assistant professional development and trauma management conference in Doha, Qatar.14 Results from the survey found that less than one third correctly answered questions on etiology, and more than two thirds made incorrect management choices for treatment of mild to moderate watery diarrhea and dysentery. Additionally, other epidemiology studies which have queried service members about treatment received during deployment have found that a majority are not provided antibiotics and often given fluid rehydration only.1,9 To better understand the knowledge and practice patterns of a broader range of providers (physicians, independent duty corpsmen, nurse practitioners), this survey was designed with specific objectives of determining the knowledge and practices related to diarrhea epidemiology and management among military health care providers, and assessing attitudes regarding management options that are available for treatment of infectious diarrhea.
311
Turkey were asked to participate. Participant selection was done by convenience sample utilizing provider networks associated with concurrent training courses in Military Tropical Medicine and deployment provider email list-servers. Participants were also encouraged to forward the survey along with other providers in their network. The exact numbers of physicians that this survey reached is uncertain but solicitations for completion included the Military Tropical Medicine Summer Course (Bethesda, MD, approximately 80 providers), the Incirlik Air Base (Turkey) provider network (approximately 30 providers), and the Al Asad Air Base (Iraq) Provider network (approximately 30 providers). This survey was intended to solicit respondents from a variety of professional backgrounds and service branches. Physicians (Doctor of Medicine or Doctor of Osteopathy), independent duty corpsmen or medics, registered nurses and physicians’ assistants’ participation were solicited.
Methods
Survey A multiple-choice web-based survey was designed and administered to military health care providers between November 15, 2005 and November 20, 2006 using a platform called Surveyz™ (Qualtrics, Provo, UT, USA). The survey was completely anonymous, but collected information on the medical level of the provider (i.e., physician, physician assistant or nurse, medic), branch of service, any specialty training, deployment experience, current assignment location, and any recent education in the area of TD. The survey included multiple types of question formats including ranking, multiple choice, and Likert-type scale. Multiple-choice questions on deployment-related diagnosis and management were scenario-based and designed to have a step-wise increase in complexity and/or severity and included: loose motions (unformed stools that did not meet TD definition), mild TD (three loose stools in 24 h with no activity limitations), mild TD with limitations (two loose stools in 8 h with some activity limitations), moderate to severe TD (six loose stools in 24 h with no activity limitations), moderate TD with limitations (three loose stools in 24 h with some activity limitations), severe inflammatory TD (two loose stools in 8 h with fever and activity limitations), dysentery (three loose stools in 24 h with blood streaks), viral gastroenteritis (two loose stools in 8 h with vomiting predominate illness), and persistent diarrhea (14 d loose stools). The choices of treatment and management, from oral and/or IV rehydration and follow-up to management with antibiotics and nonantibiotic antidiarrheal medications (i.e, bismuth subsalicylate, diphenoxylate/atropine, and loperamide), were identical for each of the clinical scenarios, and one or more treatment modalities could be selected for any given scenario.
Population Active duty military providers currently stationed in the continental United States (CONUS), Iraq, Europe, and
Statistical analysis In addition to univariate analyses describing provider characteristics and knowledge, attitude and practices J Travel Med 2011; 18: 310–317
312
outcomes, multiple-choice questions were scored as correct/incorrect based on consensus among three clinicians (D. R. T, J. W. S., M. S. R.) with greater than 30 years of combined experience in research and clinical management of TD during deployment and from referenced published treatment guidelines.6,15 For each of nine TD management scenarios, a score was assigned based on a provider’s selection from among 10 various treatment options which included: fluid therapy [rehydration (oral), rehydration (IV)], nonantibiotic antidiarrheal medications (bismuth subsalicylate, diphenoxylate/atropine, and loperamide), and antibiotic antidiarrheal medications (ciprofloxacin, azithromycin, trimethoprim/sulfamethoxazole, rifaximin, and metronidazole). A provider could select any single or combination of therapy for each scenario. Specific to each scenario, a particular therapy could be scored as 1 (well evidenced), 0 (acceptable, not optimal), or −1 (not recommended). Depending on the appropriateness of each class of therapy for a given scenario (antimotility/antisecretory agent, antibiotic, antiparasitic), multiple selections in a particular class (very rare) was only counted based on a single selection from that therapeutic class. For each provider, a score for each scenario was computed and then totaled for all scenarios. Analyses using chi-square or Fishers’ exact tests were conducted to determine if there were differences between knowledge based on various provider characteristics including, but not limited to, provider type, provider specialty, and service branch and whether a provider recently (previous 2 months) had education in management of TD. For the scenarios ANOVA or Student’s t-test was used to evaluate differences in the total scenario score by multiple category or dichotomous groups of provider characteristic. Statistical significance for all associations was set at the p < 0.05 level (twotail). Analysis was performed using Stata Version 10 (StataCorp, College Station, TX, USA). Human Subjects Research These data were collected in an anonymous manner and obtained under a protocol exempted from IRB review as determined by the Naval Medical Research Unit No. 3, Cairo, Egypt Institutional Review Board. Results A total of 117 providers responded to the survey. The majority of respondents were physicians (74%) followed by independent duty corpsmen or medics (12%) (Table 1). There was a variety of training backgrounds with operational specialties (general medical officers and flight surgeon/undersea medicine officers) making up 37% and primary care (family physicians, pediatrics, and internal medicine) accounting for 40% of the total respondents (Table 1). All respondents report having deployed at least once while 36% were currently deployed overseas in Iraq, and the median number of J Travel Med 2011; 18: 310–317
Hayat et al. Table 1 Characteristics of providers responding to travelers’ diarrhea-management survey Provider characteristic Terminal degree, n (%) MD/DO IDC/Medic RN PA MD/DO specialty training (n = 86), n (%) GMO Family practice Pediatrics Flight surgeon/Undersea medicine Internal medicine Prev med Other specialty Emergency medicine OB/Gyn Surgery Service branch, n (%) Navy Army Air Force Other Average number of years in practice (95% CI) Median number of prior deployments (IQR) Current assignment location, n (%) Iraq Continental United States Europe Turkey Other Current practice setting Level I (basic life support and advanced trauma life support care) Level II (basic radiology, laboratory, and holding capabilities) Level III (surgical capabilities) Not currently in practice
Estimate
86 (74) 14 (12) 10 (9) 7 (6) 24 (28) 21 (24) 8 (9) 8 (9) 6 (7) 5 (6) 5 (6) 4 (5) 3 (4) 2 (2) 80 (68) 25 (21) 10 (9) 2 (2) 5.9 (4.9–6.9) 2 (1–3) 42 (36) 36 (31) 21 (18) 10 (9) 8 (7) 51 (44) 32 (28) 25 (21) 9 (8)
MD = Doctor of Medicine; DO = Doctor of Osteopathy; IDC = Independent Duty Corpsman; RN = Registered Nurse; PA = Physician Assistant; GMO = General Medical Officer; OB/Gyn = Obstetrician/Gynecologist; CI = confidence interval; IQR = interquartile range.
prior deployments of providers completing the survey was two [interquartile range (IQR) 1–3]. The majority of respondents (77%) were correctly able to identify the definition of TD (Table 2). However, only 24% of providers thought that the most common cause of TD was due to bacterial organisms, while 30% believed it was viral in nature. Respondents also incorrectly believed that norovirus was the most common cause of watery diarrhea (31%) while only 25% thought it was ETEC. Nearly half of providers correctly thought Shigella spp. (30%) or Campylobacter spp. (14%) were the most common cause of dysentery, although roughly one third (30%) thought ETEC was the primary cause of dysentery. Evaluation of provider responses to scenario-based questions showed a range of responses for clinical scenarios. The five most frequent management choices for
313
Knowledge, Attitudes, and Practice of Travelers’ Diarrhea Table 2 Provider correct responses to multiple-choice questions on travelers’ diarrhea case definition and epidemiology (n = 117) Knowledge area
n/N (%)∗
Correct answer
Definition Epidemiology Most common cause† Watery‡
89/115 (77)
Dysentery‡ Persistent‡ Vomiting predominant‡
Bacteria Enterotoxigenic Escherichia coli Shigella Giardia Norwalk
26/109 (24) 29/116 (25) 35/115 (30) 46/115 (40) 50/116 (43)
∗ Denominator
changes for each knowledge area due to missing responses. phrased as, ‘‘The cause of most diarrhea in our deployed troops is:’’; possible answers were: change in normal intestinal flora, change in environment, viral infection, parasitic infection, bacterial infection, unknown etiology. ‡ Questions phrased as, ‘‘Which of the following infectious causes of diarrhea is the most likely cause of ‘‘watery diarrhea/dysentery/persistent/vomiting predominant’’ in our deployed troops in Iraq?’’; possible answers were: ameba, Campylobacter, Cryptosporidium, enterotoxigenic Escherichia coli (ETEC), Giardia, Salmonella, Shigella, Norwalk virus (norovirus), Vibrio cholerae (cholera). † Question
each scenario are shown in Table 3. For the scenario describing mild TD with no activity limitations, most providers (49%) chose oral rehydration therapy alone, while almost 7% felt that IV hydration was appropriate Table 3
in this situation. For mild diarrhea with some limitations, the most common response (18% of providers) was IV hydration alone. In moderate to severe diarrhea with no activity limitations, the use of antibiotics represented the fifth most common choice with only 9% of providers choosing it for therapy compared to 20% choosing oral hydration and 19% choosing loperamide. A total of 64% of providers chose not to use antibiotics in this scenario. In the scenario for moderate diarrhea with some activity limitations, antibiotics were only the third most common choice for providers. The two most popular treatment choices in this scenario were IV fluids (16%) and oral hydration (11%) only, with 10% of providers recommending ciprofloxacin as appropriate therapy. For the scenario describing severe inflammatory TD, the most frequent response that providers chose was an antibiotic (ciprofloxacin 25%). However, 19% of providers felt that this scenario was best treated with hydration only (11% IV and 8% oral hydration). Many providers also chose to treat dysentery with fluids only (19% oral and 6% IV) while 14% of providers chose to use an antimotility agent either alone or in combination with other medications as a treatment option in this scenario. Over half (53%) of providers selected the antibiotic metronidazole for treatment of the scenario
Top five regimen choices selected by survey respondents for nine travelers’ diarrhea deployment scenarios, N = 102
Scenario
First choice (%)
Second choice (%)
Third choice (%)
Fourth choice (%)
Fifth choice (%)
Loose motions∗ Mild, no limitations† Mild, some limitations‡ Moderate to Severe, no limitations§ Moderate, some limitations||
ORF (72) ORF (49)
ORF + LOP (9) ORF + LOP (13)
ORF + BSS (7) LOP (10)
LOP (6) IVF (6)
BSS (2) ORF + BSS (6)
IVF (18)
ORF (12)
CIP (9)
BSS (8)
ORF + CIP (8)
ORF (20)
LOP (19)
IVF (14)
ORF + LOP (11)
ORF + LOP + CIP (9)
IVF (16)
ORF (11)
CIP (10)
IVF + LOP (5)
Severe inflammatory¶ Dysentery#
CIP (25)
IVF (11)
ORF (8)
LOM (6) ORF + CIP (6) BSS (6) ORF + LOP + CIP (6) ORF + CIP (7)
CIP (19) ORF (19)
ORF + CIP (13)
AZM (6) IVF (6)
IVF (25)
ORF (16)
CIP (7)
MTZ (4) STX (4) ORF + LOP + CIP (4) ORF + LOP (5)
MTZ (27)
ORF + MTZ (15)
CIP (10)
IVF (5)
Viral gastroenteritis∗∗ Persistent††
IVF + CIP (5) ORF + AZM (3)
LOP (4) IVF + LOP (4) ORF + LOP + CIP (4) RIF(4) STX (4) ORF + CIP + MTZ (4)
ORF = oral rehydration fluids; LOP = loperamide; BSS = bismuth subsalicylate; IVF = intravenous fluids; CIP = ciprofloxacin; LOM = diphenoxylate/atropine; AZM = azithromycin; MTZ = metronidazole; STX = trimethoprim/sulfamethoxazole; RIF = rifaximin. ∗ 8-h history of two watery, loose stools, no other symptoms. † 1-d history of three watery, loose stools, no activity limitations. ‡ 8-h history of two watery, loose stools with abdominal cramps, headache, and some activity limitations. § 1-d history of six watery stools, no activity limitations. || 1-d history of three watery, loose stools with abdominal cramps, headache, and mild activity limitations. ¶ 8-h history of two watery, loose stools with abdominal cramps, and fever (oral temperature ≥ 101◦ F). # 1-d history of three loose stools, with blood streaks in toilet and toilet paper. ∗∗ 8-h history of two watery, loose stools with four episodes of vomiting. †† 14-d history of five watery, loose stools per day with abdominal cramps, and flatulence.
J Travel Med 2011; 18: 310–317
314
Hayat et al.
Figure 1 Mean scores for covariates; terminal degree, specialty training, service branch, current station, level of care, and recent travelers’ diarrhea training.
describing persistent diarrhea. In the scenario designed to represent the typical case of viral gastroenteritis, 29% of providers stated that they would prescribe antibiotics in management of these individuals. The providers who did not respond to these management of clinical scenarios differed from those who responded with respect to current country of assignment. Nonresponders were more likely to be currently assigned in Europe (47% vs 13%; p = 0.01), and less likely to have been currently stationed in CONUS (7% vs 34%; Fisher’s exact, p = 0.01). Providers were scored in each scenario based on whether they correctly identified the appropriate medications or combination of medications. The means of total scores for all scenarios are plotted by select provider characteristics in Figure 1. Based on a total possible score, range from −23 to 20, the overall average total score was 7.8 (SD 4.6) and ranged from −4 to 17. Average total scores were highest for physicians (MD/DO) (mean 8.7, SD 4.2), followed by physician assistants (mean 6.6, SD 5.7), with registered nurses and independent duty corpsmen averaging 3.4 (SD 4.4) and 4.0 (SD 3.6), respectively (ANOVA p = 0.003, df = 3). There were no other provider characteristics that differentiated average total scores that reached statistical significance, however, among MD/DO providers, primary care, operational medicine, preventive medicine, OB/Gyn, and emergency room physician scored higher than the overall provider population average. Air Force providers and those based in Turkey scored relatively well, as did those who reported not currently being in practice. Providers who reported recent TD training did not score significantly J Travel Med 2011; 18: 310–317
higher than those who had not received any training (Student’s t-test, p > 0.29). To further explore possible factors associated with differential summative scenario scores, providers responses from the TD scenarios were also compared to performance on TD etiology questions. Providers were dichotomized as to whether they answered fewer than three, or at least three questions correctly of the five etiology of TD questions. Those providers who demonstrated a greater understanding of TD (based on correctly answering three or more of the etiology questions) scored an average of 9.8 while those with a lesser understanding (less than three answered correctly) scored an average of 7.3 on the scenarios (p = 0.03). Evaluation of responses to frequency-based questions was similar to scenario-based responses. Forty-nine percent of providers reported rare use of combination therapy for treatment of TD (Table 4). To measure overall burden to the military, providers were asked whether they restrict troops from duty, confine to quarters, or require follow-up visits when treating diarrhea. Forty-six percent of providers said they sometimes would confine those soldiers with diarrhea to quarters and 14% said they would often confine to quarters. Furthermore, 51% of providers stated they would sometimes restrict soldiers from duty and 30% would sometimes require a follow-up visit. Thirty-one percent of providers felt that soldiers usually self treat when managing diarrheal illness. When evaluating providers’ attitudes toward antimotility agents, it was noted that 46% of providers agree or strongly agreed with the statement that these
315
Knowledge, Attitudes, and Practice of Travelers’ Diarrhea Table 4
Reported frequency of diarrhea illness management modalities
Diarrhea illness management, n (%) (N = denominator) Use IV fluids (N = 95) Loperamide alone (N = 95) Loperamide + ABX (N = 94) Confine to quarters (N = 95) ABX alone (N = 94) Believe troops self treat (N = 93) Restrict from duty (N = 95) Require f/u visit (N = 94)
Rarely (90% of the time)
47 (49) 46 (48) 46 (49) 32 (34) 63 (67) 8 (9) 32 (34) 61 (65)
35 (37) 21 (22) 27 (29) 44 (46) 26 (28) 23 (25) 48 (51) 28 (30)
9 (9) 11 (12) 9 (10) 13 (14) 3 (3) 26 (28) 10 (11) 2 (2)
2 (2) 14 (15) 9 (10) 5 (5) 1 (1) 29 (31) 5 (5) 2 (2)
2 (2) 3 (3) 3 (3) 1 (1) 1 (1) 7 (8) 0 (0) 1 (1)
IV = intravenous; ABX = antibiotics; f/u = follow-up.
Table 5
Attitudes toward use of chemotherapeutic agents
Attitudes toward use of chemotherapeutic agents (N = denominator) Antimotility agents keep toxins or pathogens in you where they do more damage to the gut (N = 94) Antimotility agents prolong illness by delaying excretion of the pathogen (N = 91) Antibiotics should not be used in most cases because the affected individual will develop immunity (N = 94)
Strongly disagree n (%)
Disagree n (%)
Neutral n (%)
Agree n (%)
Strongly agree n (%)
10 (11)
25 (27)
16 (17)
35 (37)
8 (9)
10 (11)
29 (32)
14 (15)
35 (38)
3 (3)
24 (26)
38 (40)
11 (12)
19 (20)
2 (2)
agents kept toxins or pathogens inside the body and could lead to more intestinal damage (Table 5). Also, 41% of providers agreed/strongly agreed with the statement that antimotility agents prolonged illness by delaying excretion of the pathogen, but only 22% of respondents agreed/strongly agreed with the statement that antibiotics should not be used for treating TD because it would lead to increased immunity. Evaluation of provider’s attitudes toward treatment of TD was compared with their scores from the scenario responses. Providers were divided into whether they favored allowing for the natural progression of disease (agree or strongly agree with two of the three statements regarding the adverse consequences of loperamide or antibiotic therapies), favored treatment of TD (disagree or strongly disagree with two of the statements regarding the adverse consequences of loperamide or antibiotic therapies), or were neutral (did not fall into the favored natural progress or treatment of TD categories). Providers who favored treatment of TD scored an average of 9.7 on the scenario responses while those who had a neutral attitude toward antimotility and/or antibiotics averaged 8.75 (Figure 1). Providers who favored allowing for the natural progression of disease scored an average of 5.6 on the TD scenariobased questions. These differences were statistically significant (Kruskal − Wallis p = 0.002).
Discussion The results of this survey are consistent with previous studies that demonstrate a need for comprehensive education for providers managing TD.14,16 Although the majority of providers knew the definition of TD, few were able to correctly identify the most common cause or most common etiologic agent for common clinical syndromes of TD, which likely impacts their clinical decisions. The scenario-based responses suggested a provider tendency toward nonantibiotic therapy and fluid hydration when treating mild to moderate diarrhea. Six to sixteen percent of providers in these scenarios also felt that IV fluids were appropriate stand alone therapy. Furthermore, 64% of providers chose not to use antibiotics for moderate to severe TD while 19% felt that fluids only were sufficient to treat severe inflammatory diarrhea. These prescribing behaviors generally go against current practices for these clinicalbased scenarios.6,8,17,18 In all of the scenarios a low percentage of providers prescribed combination therapy of antimotility agents with antibiotics, a strategy which has been found to significantly reduce the duration of illness compared to antibiotics alone in most cases of uncomplicated watery diarrhea.13 Of particular concern, the current study finds that many of the military providers continue to recommend fluids only or antimotility agents for treatment of TD J Travel Med 2011; 18: 310–317
316
(independent of severity). It may be that providers base these management decisions on treatment of acute gastrointestinal infections in the United States, which are known to be predominantly viral in origin. Although some resources recommend these agents alone in mild cases of diarrhea, including the revised edition of US Army Center for Health Promotion and Preventive Medicine Technical Guide-273,18 it may be advisable to treat even these mild cases more aggressively depending on the operational tempo given the potential impact on mission readiness and the predisposition to dehydrating comorbid illness in the austere deployment environments. Providers’ responses to amount of time off and limited duty given to soldiers with TD is an important reflection of the burden these common infections have on the fighting strength. With 46% of providers saying they would sometimes confine those soldiers with diarrhea to quarters, and 14% saying they would often confine to quarters, the amount of duty days lost due to these frequent illnesses are considerable.19 These data are concordant with observations obtained directly from afflicted soldiers where Sanders and colleagues reported that nearly half of troops surveyed who developed diarrhea went to seek medical care at least once, and 46.1% of episodes of diarrhea resulted in decreased job performance.9 The provider attitudes toward antimotility agents revealed some common misunderstandings regarding treatment options for TD. The majority of providers felt that antimotility agents kept toxins or pathogens inside the body and could lead to more intestinal damage. The majority also felt that antimotility agents prolonged illness by delaying excretion of the pathogen. McIntosh and colleagues found similar attitudes by providers toward prescribing antimotility agents in 2001. In a survey of 504 health professionals, they found that 51.9% of providers agreed or strongly agreed that ‘‘antidiarrheals keep toxins or pathogens inside of you where they do more damage to the gut’’ while 53.8% agreed or strongly agreed that ‘‘antidiarrheals prolong illness by delaying excretion of the pathogen.’’16 Concern has been raised that the use of loperamide and antibiotics in dysentery infections can precipitate shock and enterocolitis;20,21 however, the data supporting this concern have been in pediatric patients and have not been observed as a risk in infected adults. The use of antimotility agents combined with antibiotics in severe diarrhea and dysentery remains controversial with most guidelines advocating against use of antimotility agents, although at least one small study found no adverse treatment effects in a population being treated for bacillary dysentery.24 Additional well-controlled studies treating all-type ambulatory diarrhea (including dysentery and inflammatory types) should be conducted to evaluate safety and efficacy of combined regimens. While practice patterns among all providers were not found to be consistent with current management guidelines, we identified three practitioner J Travel Med 2011; 18: 310–317
Hayat et al.
characteristics which appear to be related to relatively better scoring on the treatment scenarios posed in this study; having and MD/DO, greater knowledge about TD epidemiology/etiology, and favorable attitudes toward the safety and effectiveness of antimotility agents and antibiotics. This is the first study which has evaluated the effect of practitioner type on treatment of TD. While lower than the overall provider average, physician assistants scored relatively higher on the scenario responses compared to nurses and medics/independent duty corpsman. Given that these allied health professionals are important frontline providers, improvements in education and training of these provider types should be a priority. Although providers who reported recent TD training did not score significantly higher than those who had not received any training, it is encouraging that we were able to identify improved scores among providers who had a better understanding of TD etiology and more favorable attitudes toward the safety and usefulness of antimotility agents and antibiotics. This finding suggests that improved education of providers of all levels on what is causing TD and what field efficacy studies have demonstrated should increase provider performance and ultimately result in more effective management and reduction of duty time lost. An expert review of TD literature performed by DuPont and colleagues recommended pretravel education as an important means of combating TD.22 Increasing provider’s knowledge of management and treatment of TD should also translate to improved pretravel guidance directed toward patients traveling to high risk areas. The main limitations of this study included the small convenience sample size and the implications on generalizability of the results. The respondents were those who were within certain provider networks, and self-selected to complete the survey and, therefore, may not be reflective all deployed providers. No information on the number and type of providers who chose not to complete the survey were obtained. As a web-based survey, many frontline providers may not have had online computer access, although over one third reported being in Iraq at the time of the survey. Furthermore, the validity of the instrument used to measure knowledge of TD was not formally assessed, although it was developed from a previously published survey and was pilot tested with a limited number of each provider type.9 Although there was anonymity in the survey, providers may not have accurately described what they most often do in a scenario similar to the ones described. The providers may have selected the choice that they felt was the most ‘‘correct’’ even though it is not what they tended to do in practice due to situational influences such as pressure from the patient for their preferred treatment. Also, the multiple response categories in various scenarios may have led to confusion as to the definitions of phases of TD, causing providers to choose incorrect management responses. In addition, with the general public health concern of increasing antibiotic resistance and the drive
Knowledge, Attitudes, and Practice of Travelers’ Diarrhea
to decrease unnecessary antibiotic use within the US, many providers may have biased their response toward less antibiotic use when this is not an adequate reflection of their actual practice. However, the results were generally concordant with the prior survey of Army physician assistants and information regarding specific treatments provided to troops who had sought care for treatment of diarrhea during recent deployments.1,9 Despite these study limitations the lack of knowledge that the providers displayed toward TD epidemiology was evident and there is room for improvement. This study may provide a novel approach on how to query providers on targeting problem areas and where to focus education for TD. Training which focuses specifically on the deficiencies identified by this study may enhance the management and treatment of TD. The Department of Defense may benefit from actively disseminating resources on TD management and treatment, as well as further developing evidenced-based guidelines as new therapies and consensus recommendations emerge. These measures need to be implemented to ensure that frontline providers have proper training to diagnose and treat TD and continue to preserve the fighting strength of military personnel. Declaration of Interests The authors state they have no conflicts of interest to declare. References 1. Putnam SD, Sanders JW, Frenck RW, et al. Self-reported description of diarrhea among military populations in operations iraqi freedom and enduring freedom. J Travel Med 2006; 13:92–99. 2. Riddle MS, Sanders JW, Putnam SD, Tribble DR. Incidence, etiology, and impact of diarrhea among long-term travelers (US military and similar populations): a systematic review. Am J Trop Med Hyg 2006; 74:891–900. 3. Riddle MS, Tribble DR. Reaching a consensus on management practices and vaccine development targets for mitigation of infectious diarrhoea among deployed US military forces. J Eval Clin Pract 2008; 14:266–274. 4. Ericsson CD. Travelers’ diarrhea. Epidemiology, prevention, and self-treatment. Infect Dis Clin North Am 1998; 12:285–303. 5. DuPont HL. Diarrhoeal disease: current concepts and future challenges. Antimicrobial therapy and prophylaxis. Trans R Soc Trop Med Hyg 1993; 87(Suppl 3):31–34. 6. Adachi JA, Ostrosky-Zeichner L, DuPont HL, Ericsson CD. Empirical antimicrobial therapy for traveler’s diarrhea. Clin Infect Dis 2000; 31:1079–1083.
317 7. Gascon J. Epidemiology, etiology and pathophysiology of travelers’ diarrhea. Digestion 2006; 73:102–108. 8. Hill DR, Ericsson CD, Pearson RD, et al. The practice of travel medicine: guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2006; 43: 1499–1539. 9. Sanders JW, Putnam SD, Frankart C, et al. Impact of illness and non-combat injury during Operations Iraqi Freedom and Enduring Freedom (Afghanistan). Am J Trop Med Hyg 2005; 73:713–719. 10. Riddle MS, Tribble DR, Putnam SD, et al. Past trends and current status of self-reported incidence and impact of disease and nonbattle injury in military operations in Southwest Asia and the Middle East. Am J Public Health 2008; 98:2199–2206. 11. Sanchez JL, Gelnett J, Petruccelli BP, et al. Diarrheal disease incidence and morbidity among United States military personnel during short-term missions overseas. Am J Trop Med Hyg 1998; 58:299–304. 12. De Bruyn G, Hahn S, Borwick A. Antibiotic treatment for travellers’ diarrhoea. Cochrane Database Syst Rev 2000: CD002242. 13. Riddle MS, Arnold S, Tribble DR. Effect of adjunctive loperamide in combination with antibiotics on treatment outcomes in traveler’s diarrhea: a systematic review and meta-analysis. Clin Infect Dis 2008; 47:1007–1014. 14. Riddle MS, Tribble DR, Jobanputra NK, et al. Knowledge, attitudes, and practices regarding epidemiology and management of travelers’ diarrhea: a survey of frontline providers in Iraq and Afghanistan. Mil Med 2005; 170:492–495. 15. DuPont HL. Treatment of travelers’ diarrhea. J Travel Med 2001; 8(Suppl 2):S31–S33. 16. McIntosh IB, Swanson V, Howell K. Health professionals’ attitudes toward acute diarrhea management. J Travel Med 2001; 8:60–65. 17. DuPont HL, Ericsson CD, Farthing MJ, et al. Expert review of the evidence base for self-therapy of travelers’ diarrhea. J Travel Med 2009; 16:161–171. 18. USACHPPM. Technical guide 273 diagnosis and treatment of diseases of tactical importance to U.S. central command; 2005. 19. Riddle MS, Tribble DR, Cachafiero SP, et al. Development of a travelers’ diarrhea vaccine for the military: how much is an ounce of prevention really worth? Vaccine 2008; 26:2490–2502. 20. Minton NA, Smith PG. Loperamide toxicity in a child after a single dose. Br Med J (Clin Res Ed) 1987; 294:1383. 21. Chow CB, Li SH, Leung NK. Loperamide associated necrotising enterocolitis. Acta Paediatr Scand 1986; 75:1034–1036. 22. DuPont HL, Ericsson CD, Farthing MJ, et al. Expert review of the evidence base for prevention of travelers’ diarrhea. J Travel Med 2009; 16:149–160.
J Travel Med 2011; 18: 310–317
