tag:theconversation.com,2011:/global/topics/diarrhea-2970/articlesDiarrhea – The Conversation2024-02-15T03:31:18Ztag:theconversation.com,2011:article/2235412024-02-15T03:31:18Z2024-02-15T03:31:18ZHow worried should I be about cryptosporidiosis? Am I safe at the pool?<figure><img src="https://images.theconversation.com/files/575532/original/file-20240214-30-7bq8q2.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C998%2C559&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/bright-aqua-blue-swimming-pool-students-2124280826">LBeddoe/Shutterstock</a></span></figcaption></figure><p>You might have heard of something called “<a href="https://www.abc.net.au/news/2024-02-13/nsw-health-alert-cryptosporidiosis-cases/103460468">cryptosporidiosis</a>” recently, closely followed by warnings to stay away from your local swimming pool if you’ve had diarrhoea.</p>
<p>More than 700 cases of this gastrointestinal disease were reported <a href="https://www.health.qld.gov.au/newsroom/doh-media-releases/rapid-increase-in-cryptosporidiosis-cases-hits-queensland">in Queensland</a> in January, which is <a href="https://www.theguardian.com/australia-news/2024/feb/13/avoid-swimming-pools-if-youre-part-of-australias-surge-in-diarrhoea-cases-say-authorities">13 times more</a> than in January last year. Just under 500 cases have been recorded in <a href="https://www.health.nsw.gov.au/news/Pages/20240213_00.aspx">New South Wales</a> this year to-date, while <a href="https://www.health.vic.gov.au/health-advisories/increase-in-cryptosporidiosis-cases-across-victoria">other states</a> have similarly reported an increase in the number of cryptosporidiosis infections in recent months.</p>
<p>Cryptosporidiosis has been listed as a <a href="https://pubmed.ncbi.nlm.nih.gov/12725505/">national notifiable disease</a> in Australia since 2001.
But what exactly is it, and should we be worried?</p>
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Read more:
<a href="https://theconversation.com/what-lies-beneath-the-bugs-lurking-in-your-swimming-pool-51028">What lies beneath: the bugs lurking in your swimming pool</a>
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<h2>What causes cryptosporidiosis, and who is affected?</h2>
<p>Cryptosporidiosis is the disease caused by the parasite <em>Cryptosporidium</em>, of which there are two types that can make us sick. <em>Cryptosporidum hominis</em> only affects humans and is the major cause of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9133686/">recent outbreaks in Australia</a>, while <em>Cryptosporidium parvum</em> can also affect animals. </p>
<p>The infection is spread by spores called oocysts in the stools of humans and animals. When ingested, these oocysts migrate and mature in the small bowel. They damage the small bowel lining and <a href="https://www.cdc.gov/parasites/crypto/general-info.html">can lead to diarrhoea</a>, nausea, vomiting, fever and abdominal discomfort. </p>
<p>Most people develop symptoms anywhere from <a href="https://www.health.vic.gov.au/health-advisories/increase-in-cryptosporidiosis-cases-across-victoria">one to 12 days</a> after becoming infected. Usually these symptoms resolve within two weeks, but the illness may last longer and can be severe in those with a weakened immune system. </p>
<p>Children and the elderly tend to be the most commonly affected. Cryptosporidiosis is more prevalent in young children, particularly those <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(18)30283-3/fulltext">under five</a>, but the disease can affect people of any age. </p>
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<img alt="A 'pool closed' sign in front of a swimming pool." src="https://images.theconversation.com/files/575739/original/file-20240214-18-g0i5b2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/575739/original/file-20240214-18-g0i5b2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=337&fit=crop&dpr=1 600w, https://images.theconversation.com/files/575739/original/file-20240214-18-g0i5b2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=337&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/575739/original/file-20240214-18-g0i5b2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=337&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/575739/original/file-20240214-18-g0i5b2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/575739/original/file-20240214-18-g0i5b2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/575739/original/file-20240214-18-g0i5b2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">A number of public pools have been closed lately due to cryptosporidiosis outbreaks.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/bright-white-sign-local-outdoor-pool-2124260702">LBeddoe/Shutterstock</a></span>
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<h2>So how do we catch it?</h2>
<p>Most major outbreaks of cryptosporidiosis have been due to people drinking contaminated water. The largest recorded outbreak occurred in <a href="https://pubmed.ncbi.nlm.nih.gov/7818640/">Milwaukee in 1993</a> where 403,000 people were believed to have been infected. </p>
<p><em>Cryptosporidium</em> oocysts are very small in size and in Milwaukee they passed through the filtration system of one of the water treatment plants undetected, infecting the city’s water supply. As few as <a href="https://www.sciencedirect.com/science/article/pii/S1286457902016301#BIB26">ten oocysts</a> can cause infection, making it possible for contaminated drinking water to affect a very large number of people.</p>
<p>Four days after infection a person with cryptosporidiosis can shed <a href="https://www.safewater.org/fact-sheets-1/2017/1/23/detailed-cryptosporidium">up to ten billion oocysts</a> into their stool a day, with the shedding persisting for about two weeks. This is why one infected person in a swimming pool can infect the entire pool in a single visit. </p>
<p><em>Cryptosporidium</em> oocysts excreted in the faeces of infected humans and animals can also reach <a href="https://www.safewater.org/fact-sheets-1/2017/1/23/detailed-cryptosporidium">natural bodies of water</a> such as beaches, rivers and lakes directly through sewer pipes or indirectly such as in manure transported with surface runoff after heavy rain. </p>
<p><a href="https://www.sciencedirect.com/science/article/pii/S0043135418308728">One study</a> which modelled <em>Cryptosporidium</em> concentrations in rivers around the world estimated there are anywhere from 100 to one million oocysts in a litre of river water.</p>
<p>In <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9133686/">Australia</a>, cryptosporidiosis outbreaks tend to occur during the late spring and early summer periods when there’s an increase in recreational water activities such as swimming in natural water holes, water catchments and public pools. We don’t know exactly why cases have seen such a surge this summer compared to other years, but we know <em>Cryptosporidium</em> is very infectious. </p>
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Read more:
<a href="https://theconversation.com/explainer-what-is-gastroenteritis-and-why-cant-i-get-rid-of-it-34351">Explainer: what is gastroenteritis and why can't I get rid of it?</a>
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<p>Oocysts have been found in foods such as <a href="https://www.sciencedirect.com/science/article/pii/S0362028X22052693">fresh vegetables</a> and <a href="https://pubmed.ncbi.nlm.nih.gov/10958471/">seafood</a> but these are not common sources of infection in Australia. </p>
<h2>What about chlorine?</h2>
<p>Contrary to popular belief, chlorine doesn’t kill off all infectious microbes in a swimming pool. <em>Cryptosporidium</em> <a href="https://www.sciencedirect.com/science/article/pii/S1286457902016301#BIB26">oocysts are hardy</a>, thick-walled and resistant to chlorine and acid. They are not destroyed by chlorine at the normal concentrations found in swimming pools. </p>
<p>We also know oocysts can be <a href="https://wwwnc.cdc.gov/eid/article/5/4/99-0425_article">significantly protected</a> from the effects of chlorine in swimming pools by faecal material, so the presence of even small amounts of faecal matter contaminated with <em>Cryptosporidium</em> in a swimming pool would necessitate closure and a thorough decontamination. </p>
<p>Young children and in particular children in nappies are known to increase the potential for disease transmission in recreational water. Proper nappy changing, frequent bathroom breaks and showering before swimming to remove faecal residue are helpful ways to reduce the risk. </p>
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<img alt="Two children playing in a body of water." src="https://images.theconversation.com/files/575749/original/file-20240214-26-4wbfib.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/575749/original/file-20240214-26-4wbfib.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/575749/original/file-20240214-26-4wbfib.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/575749/original/file-20240214-26-4wbfib.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/575749/original/file-20240214-26-4wbfib.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/575749/original/file-20240214-26-4wbfib.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/575749/original/file-20240214-26-4wbfib.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Cryptosporidium can spread in other bodies of water, not just swimming pools.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/happy-summertime-healthy-childhood-concept-two-460928809">Yulia Simonova/Shutterstock</a></span>
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<h2>Some sensible precautions</h2>
<p>Other measures you can take to reduce yours and others’ risk of cryptosporidiosis include: </p>
<ul>
<li><p>avoid swimming in natural waters such as rivers and creeks during and for at least three days after heavy rain</p></li>
<li><p>avoid swimming in beaches for at least one day after heavy rain</p></li>
<li><p>avoid drinking untreated water such as water from rivers or springs. If you need to drink untreated water, boiling it first will kill the <em>Cryptosporidium</em></p></li>
<li><p>avoid swallowing water when swimming if you can</p></li>
<li><p>if you’ve had diarrhoea, avoid swimming for at least two weeks after it has resolved</p></li>
<li><p>avoid sharing towels or linen for at least two weeks after diarrhoea has resolved</p></li>
<li><p>avoid sharing, touching or preparing food that other people may eat for at least 48 hours after diarrhoea has resolved</p></li>
<li><p>wash your hands with soap and water after going to the bathroom or before preparing food (<em>Cryptosporidium</em> is <a href="https://www.cdc.gov/parasites/crypto/resources/childcare_outbreak.pdf">not killed</a> by alcohol gels and sanitisers).</p></li>
</ul>
<p>Not all cases of diarrhoea are due to cryptosporidiosis. There are many other <a href="https://theconversation.com/explainer-what-is-gastroenteritis-and-why-cant-i-get-rid-of-it-34351">causes of infectious gastroenteritis</a> and because the vast majority of the time recovery is uneventful you don’t need to see a doctor unless very unwell. If you do suspect you may have cryptosporidiosis you can ask your doctor to refer you for a stool test.</p><img src="https://counter.theconversation.com/content/223541/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Vincent Ho does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The infection is spread by spores called oocysts in the stools of humans and animals.Vincent Ho, Associate Professor and clinical academic gastroenterologist, Western Sydney UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2129492023-11-06T13:33:20Z2023-11-06T13:33:20ZWhy do our noses get snotty when we are sick? A school nurse explains the powers of mucus<figure><img src="https://images.theconversation.com/files/548367/original/file-20230914-21-s25lth.jpg?ixlib=rb-1.1.0&rect=1%2C0%2C1196%2C797&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Use a tissue and wash your hands after a booger explosion.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/schwachs/4352350750/">Joshua Wachs/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span></figcaption></figure><figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/281719/original/file-20190628-76743-26slbc.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/281719/original/file-20190628-76743-26slbc.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=293&fit=crop&dpr=1 600w, https://images.theconversation.com/files/281719/original/file-20190628-76743-26slbc.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=293&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/281719/original/file-20190628-76743-26slbc.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=293&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/281719/original/file-20190628-76743-26slbc.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=368&fit=crop&dpr=1 754w, https://images.theconversation.com/files/281719/original/file-20190628-76743-26slbc.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=368&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/281719/original/file-20190628-76743-26slbc.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=368&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<p><em><a href="https://theconversation.com/us/topics/curious-kids-us-74795">Curious Kids</a> is a series for children of all ages. If you have a question you’d like an expert to answer, send it to <a href="mailto:curiouskidsus@theconversation.com">curiouskidsus@theconversation.com</a>.</em></p>
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<blockquote>
<p><strong>Why do our noses get snotty when we are sick? – Veronica P., age 5, Panama City, Florida</strong></p>
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<p>Not many things are as uncomfortable and annoying as a runny or congested nose when you’re sick. Constantly blowing your nose and not being able to breathe through it may leave you wondering: Why does this happen? </p>
<p>I’m a nurse practitioner who works with kids every day and also <a href="https://stories.purdue.edu/kristin-ahrens/">teaches nursing</a>. The answer is pretty simple. Mucus – or snot – is one of the ways your body helps keep you healthy. </p>
<p>Mucus lines your nose, throat, lungs and other parts of your body to protect it from bad bacteria, viruses and other particles. Your body <a href="https://www.everydayhealth.com/mucus/">continuously creates mucus</a> to fight off germs and help get rid of them. </p>
<p>When you’re sick, your immune system ramps up to produce extra mucus to flush out germs. While it might seem gross, mucus is also pretty amazing.</p>
<h2>Slimy protector</h2>
<p>Your body creates mucus out of a combination of <a href="https://www.britannica.com/science/mucus">water, proteins and salts</a>. Its sticky consistency traps bad microorganisms and other unwanted particles, like dust, pet dander and mildew, so they can’t get farther into your system. </p>
<p>Some components in mucus <a href="https://www.nibib.nih.gov/news-events/newsroom/disarming-bacteria-mucus-and-phages">stop bacteria from banding together</a> and becoming more dangerous. Other elements can actually <a href="https://doi.org/10.1007/BF02976990">kill the invaders</a> that are trying to make you sick. And though scientists don’t completely understand how, the <a href="https://doi.org/10.1007/BF02976990">proteins and genes in mucus</a> seem to work together to make it thicker and stickier if necessary.</p>
<p>Once germs or other potentially damaging particles are trapped and neutralized, your body’s way of getting rid of them altogether is to make so much mucus that you have to blow, sneeze or cough them out. </p>
<p>You might have noticed that sometimes when you’re sick, your nose can get red too. This is because your immune system, in addition to making mucus, also sends extra white blood cells to the source of an infection. As they rush to the scene to help fight infection, the extra white blood cells <a href="https://my.clevelandclinic.org/health/articles/21196-immune-system/">expand the blood vessels</a> in the area, making your nose look red. All the wiping and blowing can make it red, too.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/548373/original/file-20230914-9125-jab4s8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A chart displaying mucus colors from clear to black and describing what each means." src="https://images.theconversation.com/files/548373/original/file-20230914-9125-jab4s8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/548373/original/file-20230914-9125-jab4s8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=960&fit=crop&dpr=1 600w, https://images.theconversation.com/files/548373/original/file-20230914-9125-jab4s8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=960&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/548373/original/file-20230914-9125-jab4s8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=960&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/548373/original/file-20230914-9125-jab4s8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1206&fit=crop&dpr=1 754w, https://images.theconversation.com/files/548373/original/file-20230914-9125-jab4s8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1206&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/548373/original/file-20230914-9125-jab4s8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1206&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The mucus rainbow.</span>
<span class="attribution"><a class="source" href="https://riseandshine.childrensnational.org/snot-colors-and-what-they-mean/">Children's National Hospital</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span>
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<p>Snot can come in a rainbow of yucky colors. When white blood cells are fighting an infection, they release chemicals that may <a href="https://www.healthline.com/health/snot-color#white-snot">turn your snot yellow</a>. When more of those cells are needed to get the job done, mucus can even turn green. Typically, after a few days, colored mucus changes back to clear and your stuffy nose will go away. </p>
<h2>Not just in your nose</h2>
<p>Mucus isn’t found just in your nose and lungs.</p>
<p>Your <a href="https://theconversation.com/can-you-cry-underwater-205464">eyes also have a thin layer of mucus</a> that helps protect them from particles in the air. When you get sick or get an eye infection, <a href="https://www.verywellhealth.com/eye-mucus-types-3422108">eye mucus</a> can act the same way it does in your nose – catching and killing germs. Eye mucus can also sometimes turn thick and yellow. If that happens, you’ll want to call your health care provider. Don’t ever touch your eyes with your fingers. That can <a href="https://www.nyoph.com/blog/this-is-why-you-shouldnt-rub-your-eyes/">introduce more germs</a>.</p>
<p>Your stomach and intestines also have protective mucus. If you’ve ever had an upset stomach that led to diarrhea, the mucus in your intestinal track was working overtime to help <a href="https://doi.org/10.1038/nrgastro.2013.35">flush out bad bacteria</a>. That’s why your normal poop goes from a solid mush to something more slimy. There are other reasons you can have stomachaches – like stress, constipation or food allergies – but if you have diarrhea, your mucus is definitely hard at work. </p>
<h2>Animals have it too</h2>
<p>Humans aren’t the only animals that use mucus. For example, <a href="https://petriage.com/clinical-insights/your-pets-mucous-membranes/">dogs and cats have mucus</a> too.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/548831/original/file-20230918-31-zzsqlo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A brightly colored fish is surrounded by a mucus cocoon on the sea floor next to some rocks. A smaller fish is nearby." src="https://images.theconversation.com/files/548831/original/file-20230918-31-zzsqlo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/548831/original/file-20230918-31-zzsqlo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/548831/original/file-20230918-31-zzsqlo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/548831/original/file-20230918-31-zzsqlo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/548831/original/file-20230918-31-zzsqlo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/548831/original/file-20230918-31-zzsqlo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/548831/original/file-20230918-31-zzsqlo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Some fish use mucus for protection while sleeping.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Abrolhos_Marine_National_ParkRobertoCostaPinto20.jpg">RobertoCostaPinto/WikiMedia Commons</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p><a href="https://www.montereybayaquarium.org/stories/mucus-slime-snot">Parrotfish</a>, <a href="https://doi.org/10.1098/rsbl.2010.0916">wrasses</a> and <a href="https://cimi.org/blog/mucus-in-the-animal-kingdom/">other sea creatures</a> produce mucus cocoons to help protect them from predators at night. </p>
<p>Chameleons use the sticky <a href="https://www.nationalgeographic.com/animals/article/chameleon-tongue-mucus-sticky-animals">mucus on the end of their tongues</a> to reel in their prey. Earthworms secrete mucus to help them move through the soil, which in turn <a href="https://doi.org/10.5194/egusphere-egu2020-17611">benefits the soil</a>.</p>
<p>In humans, mucus helps neutralize and eliminate the microbial bad guys. So the next time you reach for a tissue to blow your nose, remember: Your body’s natural defenses are doing their best to keep you healthy or make you better. Just think of all that snot as one of your body’s superpowers.</p>
<hr>
<p><em>Hello, curious kids! Do you have a question you’d like an expert to answer? Ask an adult to send your question to <a href="mailto:curiouskidsus@theconversation.com">CuriousKidsUS@theconversation.com</a>. Please tell us your name, age and the city where you live.</em></p>
<p><em>And since curiosity has no age limit – adults, let us know what you’re wondering, too. We won’t be able to answer every question, but we will do our best.</em></p><img src="https://counter.theconversation.com/content/212949/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kristin Ahrens is a member of the National Association of Pediatric Nurse Practitioners (NAPNAP) and the National Association of School Nurses (NASN). </span></em></p>Slimy snot is an important part of how your immune system wards off germs and fights back from infection.Kristin Ahrens, Pediatric Nurse Practitioner, Adjunct Instructor of Nursing at Purdue Global, Purdue UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2119432023-09-04T14:54:17Z2023-09-04T14:54:17ZWagner, conflict and poverty drive Central African Republic death rate above crisis levels: but where’s the aid?<p>The Central African Republic (CAR) is one of the <a href="https://www.statista.com/statistics/728281/gross-domestic-product-gdp-per-capita-in-central-african-republic/">poorest countries</a> in the world. Its GDP per capita in 2022 was estimated at US$491 per year.</p>
<p>The nation of roughly <a href="https://data.who.int/countries/140">5 million</a> people has been in political turmoil since a violent takeover of power in 2013. A <a href="https://www.bbc.com/news/world-africa-13150044">“total breakdown of law and order”</a> has persisted for nearly 20 years. Roughly half of the countryside has been <a href="https://www.polgeonow.com/search/label/central%20african%20republic">outside the government’s control</a>.</p>
<p>In an attempt to gain back control, the government unleashed a campaign led by the Russian mercenaries, the Wagner Group, in 2020. A <a href="https://thesentry.org/reports/architects-of-terror/">report</a> documenting widespread human rights abuses in the CAR by the Wagner Group describes “well-planned campaigns of mass killing, torture, and rape”. This is consistent with the broader content of <a href="https://www.ohchr.org/en/press-releases/2021/11/car-russian-wagner-group-harassing-and-intimidating-civilians-un-experts">press releases</a> and <a href="https://www.ohchr.org/en/speeches/2023/03/central-african-republic-atrocities-must-end-says-volker-turk">speeches</a> coming from the UN Office of the High Commissioner for Human Rights. </p>
<p>The result is that CAR is now experiencing an acute humanitarian crisis.</p>
<p>One of the symptoms of the collapse is the country’s high mortality rate. Two surveys published over the last two years have suggested that large areas of the country were experiencing mortality above the emergency threshold. One was a <a href="https://conflictandhealth.biomedcentral.com/articles/10.1186/s13031-021-00385-2">survey done by Médecins sans Frontières in 2020 in Ouaka Prefecture</a>. The <a href="https://conflictandhealth.biomedcentral.com/articles/10.1186/s13031-021-00381-6">other</a> covered most of Ouham-Pende Prefecture and was done with the International Rescue Committee in 2018. The studies found that 4.9% and 5.0% of the studied populations were dying per year. </p>
<p>These estimates are four times higher than the 2020 <a href="https://data.worldbank.org/indicator/SP.DYN.CDRT.IN?locations=CF">UN mortality estimate of 1.1% per year</a> for the CAR. Most agencies, such as the <a href="https://pesquisa.bvsalud.org/portal/resource/pt/des-11113">Centers for Disease Control and Prevention</a>, consider the doubling of the baseline mortality as a crisis, and four times the baseline is one of the three criteria used to define a famine. </p>
<p>Because of the discordance of recent mortality measures and the official mortality rate, as scholars of public health with research experience in conflict settings, we conducted a survey to measure the nation’s crude mortality rate – the fraction of the population dying per unit of time without considering whether it is a young or old population.</p>
<p>Our <a href="https://pubmed.ncbi.nlm.nih.gov/37072800/">study</a> found that 5.6% of the population died in 2022. This is an astonishing mortality rate, in terms of how people are suffering and how wrong the official statistics are. Most of these deaths were from malaria and diarrhoea. We also found that mortality was markedly higher in the areas outside government control. </p>
<p>The dire conditions under which people are living in the CAR have elicited very little interest or humanitarian response from the rest of the world. Yet, as the mortality figures show, there is a desperate need for food aid, along with work programmes and seed and tool distribution. </p>
<p>This is of particular importance in rural areas outside government control. While some humanitarian actors are doing their best to respond, the crisis-level mortality rate suggests that the needs in the CAR are largely unmet.</p>
<h2>Mortality</h2>
<p>We carried out a survey in two areas. One was in the part of the country within the government’s control (roughly half of the country), and one in the areas mostly outside its control. We randomly selected 40 clusters of 10 households in each. </p>
<p>We found that the birth rate was lower and the death rate markedly higher in areas outside government control. Families described malaria or fever and diarrhoea as the primary reported causes of death. Violence accounted for 6% of all deaths.</p>
<p>People cited access to food and access to medical care as their biggest challenges. Households reported eating roughly half as many meals in 2022 as they had in 2020. Only 15% had received food aid distributions in 2022 despite <a href="https://reports.unocha.org/en/country/car/card/2jVaaAZR3Y/">high levels of malnutrition</a> recorded in the country. </p>
<p>These two challenges interact with each other. Children and other vulnerable people like the elderly who would normally survive an episode of malaria or diarrhoea need competent medical attention to survive when malnourished. Yet, because of economic strife and violence, attendance in rural clinics is generally down compared to previous years. </p>
<p>The cost of healthcare is another factor. Some NGOs provide free healthcare, but most visited by our research team charge a modest user fee. While not standardised, they typically charge an amount equivalent to between half and one US dollar, and sometimes charge separately for drugs. The non-clinic costs such as transport can be even greater.</p>
<p>Another cost is that people are forced to make informal and illegitimate payments when trying to get to healthcare facilities. Many mentioned that police or rebel soldiers demanded money to pass at checkpoints. In Ouaka Prefecture, where the charity Médecins Sans Frontières, also known as Doctors Without Borders, provides medical services with no user fees, an interviewee told us that his daughter had recently given birth at home rather than going to the hospital, because the police at the checkpoints knew a pregnant woman would be desperate to get by and they would charge more than the usual 500 franc (about US$0.8) fee for her to pass.</p>
<h2>What next</h2>
<p>Higher nationwide death rates have occurred in Africa in the past. Estimates suggest that at least 500,000 of 7 million <a href="https://www.tandfonline.com/doi/epdf/10.1080/14623528.2019.1703329?needAccess=true&role=button#page=1">Rwandans died violently in 1994</a>. During Nigeria’s secessionist war in Biafra from 1967 to 1970 <a href="https://edisciplinas.usp.br/pluginfile.php/3949853/mod_resource/content/1/Toyin%20Falola%20-%20A%20History%20of%20Nigeria%20cap7.pdf#page=158">between 1 million and 3 million</a> are estimated to have died. These events triggered dramatic escalations in humanitarian response, aid money and political attention. </p>
<p>Our study couldn’t distinguish the relative importance of decades of ongoing conflict, extreme poverty, the economic disruptions since 2020, or the widespread disruption efforts of the Wagner Group in causing the extreme mortality observed in the CAR. </p>
<p>Nevertheless, it’s clear that they are all contributing to the mortality rate. We can find no examples since 1994 of an entire nation dying at such a high rate as we measured in the CAR in 2022. </p>
<p>Humanitarian actors have been raising the alarm <a href="https://reliefweb.int/report/central-african-republic/major-food-crisis-central-african-republic-car-malnutrition-rates">for over a decade</a>. The UN <a href="https://www.ipcinfo.org/ipc-country-analysis/details-map/en/c/1152894/">has been warning</a> of extreme food insecurity for two years. To the credit of certain agencies, households report food distributions in some of the most critical areas. </p>
<p>Our findings show that despite these efforts, aid is woefully insufficient. Given that the <a href="https://www.state.gov/u-s-relations-with-central-african-republic/">US government alone gave over US$330 million</a> in assistance to the CAR in 2021 and 2022, one has to ponder whether the humanitarian community can do better. In particular, are we in the humanitarian community ignoring one of the world’s worst humanitarian crises?</p><img src="https://counter.theconversation.com/content/211943/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The birth rate was lower and the death rate markedly higher in areas outside government control in the Central African Republic.Leslie Roberts, Professor Emeritus of Population and Family Health at CUMC, Columbia UniversityJennifer O'Keeffe, Doctoral Candidate, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins UniversityKarume Baderha Augustin Gang, Doctoral Candidate, Université Evangélique en AfriqueLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1982932023-01-25T20:24:10Z2023-01-25T20:24:10ZGot gastro? Here’s why eating bananas helps but drinking flat lemonade might not<figure><img src="https://images.theconversation.com/files/506221/original/file-20230125-366-gqrc32.jpg?ixlib=rb-1.1.0&rect=53%2C44%2C5919%2C3943&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://images.unsplash.com/photo-1591865641966-2e0f86ba2a85?ixlib=rb-4.0.3&ixid=MnwxMjA3fDB8MHxwaG90by1wYWdlfHx8fGVufDB8fHx8&auto=format&fit=crop&w=2070&q=80">Unsplash</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>Doctors are <a href="https://www.9news.com.au/national/gastroenteritis-sharp-spike-in-gastro-cases-due-to-poor-immunity-gp-warns/9fe43648-b468-4b3b-b3aa-e162e6e6a853">reportedly</a> concerned about a spike in the number of kids with gastroenteritis – when tummy infections can cause nausea, vomiting, diarrhoea, fever, abdominal pain, headache and muscle aches. </p>
<p>Rotavirus is a common cause of gastroenteritis in children and the reported rotavirus rate in New South Wales so far <a href="https://www.health.nsw.gov.au/news/Pages/20230118_00.aspx#:%7E:text=In%20the%20first%20two%20weeks,next%20few%20weeks%20is%20important.">this year</a> is five times what it usually is. </p>
<p>While there’s a lot of gastroenteritis occurring, the good news is the vast majority of cases kids will have an uneventful recovery.</p>
<p>Still, parents and carers get a lot of conflicting advice about the food and drinks kids should consume during recovery from the illness. Let’s look at the evidence. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/gastro-outbreak-how-does-it-spread-and-how-can-we-stop-it-a-gastroenterologist-explains-159329">Gastro outbreak: how does it spread, and how can we stop it? A gastroenterologist explains</a>
</strong>
</em>
</p>
<hr>
<h2>Old advice: the BRAT diet</h2>
<p>One widely known dietary recommendation when recovering from gastroenteritis is the BRAT diet. This stands for bananas, rice, applesauce and toast. These bland foods and are meant to be gentle on the gut, which is important when a person is recovering from gastroenteritis. </p>
<p>Applesauce is a distinctly American food product and indeed the first mention of this diet was in an <a href="https://www.semanticscholar.org/paper/A-COMPREHENSIVE-PLAN-OF-TREATMENT-FOR-THE-SO-CALLED-Powers/e06fd3236648ac61efbaa9e5b4b2a052dc6c7ed4">American report in 1926</a> on the treatment of “intestinal intoxication” in children. </p>
<p>The BRAT diet was historically recommended but has fallen out of favour over the past couple of decades. There are no clinical trials on the diet itself but evidence to support it came from <a href="https://med.virginia.edu/ginutrition/wp-content/uploads/sites/199/2015/11/DuroArticle-June-07.pdf">studies</a> that demonstrated how each food in the BRAT diet could help with gastro recovery. </p>
<p>Bananas and apples are rich in a starch called pectin that can form a gel, which <a href="https://pubmed.ncbi.nlm.nih.gov/25809332/">helps</a> to treat diarrhoea. Green banana pulp and flour in particular was found to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6627159/">reduce</a> diarrhoea in children. Bananas are also a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3355124/">rich source</a> of potassium, which can help to replace potassium lost with diarrhoea. </p>
<p><a href="https://pubmed.ncbi.nlm.nih.gov/1531430/">Rice-based oral rehydration solutions</a> (a drink made from a mixture of water, rice, glucose, sodium, and potassium salts) used to treat gastroenteritis reduce the volume of stools and duration of diarrhoea in patients. A study from <a href="https://www.gastrojournal.org/article/S0016-5085(01)89171-X/pdf">Bangladesh</a> on infants with persistent diarrhoea found a rice-based diet containing green banana or pectin improved stool consistency and reduced the duration more than a diet of rice alone. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/506225/original/file-20230125-22-a722qd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="girl eating several colourful icypoles" src="https://images.theconversation.com/files/506225/original/file-20230125-22-a722qd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/506225/original/file-20230125-22-a722qd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/506225/original/file-20230125-22-a722qd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/506225/original/file-20230125-22-a722qd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/506225/original/file-20230125-22-a722qd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/506225/original/file-20230125-22-a722qd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/506225/original/file-20230125-22-a722qd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">In general, kids recovering from gastro don’t need a restricted diet.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/little-girl-eats-colorful-ice-cream-2015084648">Shutterstock</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-what-is-gastroenteritis-and-why-cant-i-get-rid-of-it-34351">Explainer: what is gastroenteritis and why can't I get rid of it?</a>
</strong>
</em>
</p>
<hr>
<h2>Magic apples</h2>
<p>The use of apples to treat diarrhoea is thought <a href="https://jamanetwork.com/journals/jamapediatrics/article-abstract/1176179">to have started</a> in Germany, where a nurse called Sister Frieda Klimsch used the fruit to treat dysentery (a severe form of gastroenteritis) in a hospital. </p>
<p>Another <a href="https://www.jstor.org/stable/3411901">origin story</a> tells of how a doctor in a German prison camp noticed prisoners with dysentery who ate apples from a nearby orchard had shorter and milder illness. The doctor started encouraging them to eat apples to treat diarrhoea. </p>
<p>Eating apple peel was <a href="https://adc.bmj.com/content/archdischild/14/77/43.full.pdf">observed</a> to lead to vomiting in infants in the 1930s and so the peel was removed. <a href="https://www.jstor.org/stable/3411901">Grated apple</a> was used to treat diarrhoea in children around the same period and was helpful in some cases. </p>
<p>Later, applesauce became the recommended form of apple for gastroenteritis recovery in the United States, and features in the BRAT diet. Interestingly, giving <a href="https://pubmed.ncbi.nlm.nih.gov/27131100/">diluted apple juice</a> to children with mild dehydration from gastroenteritis is both safe and effective.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/506222/original/file-20230125-11-5zag6g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="bowl of applesauce on benchtop" src="https://images.theconversation.com/files/506222/original/file-20230125-11-5zag6g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/506222/original/file-20230125-11-5zag6g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/506222/original/file-20230125-11-5zag6g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/506222/original/file-20230125-11-5zag6g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/506222/original/file-20230125-11-5zag6g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/506222/original/file-20230125-11-5zag6g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/506222/original/file-20230125-11-5zag6g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Applesauce is a distinctly American product, but grated apple works too.</span>
<span class="attribution"><a class="source" href="https://images.unsplash.com/photo-1600984177310-c86c8f8fa9c7?ixlib=rb-4.0.3&ixid=MnwxMjA3fDB8MHxwaG90by1wYWdlfHx8fGVufDB8fHx8&auto=format&fit=crop&w=1770&q=80">Unsplash</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<h2>Why gastro diet advice has changed</h2>
<p>Over the past 20 years or so most health professionals have come to the conclusion the restricted BRAT diet is unhealthy in gastroenteritis recovery because it is low in <a href="https://journals.lww.com/em-news/fulltext/2004/01000/brat_diet__axiom_or_unsubstantiated_myth_.21.aspx">protein, fat, and energy</a>. All these nutrients are necessary for healing.</p>
<p><a href="https://pubmed.ncbi.nlm.nih.gov/2301321/">Studies</a> have <a href="https://academic.oup.com/cid/article/39/4/468/366339">shown</a>, in general, normal eating does not worsen the course of gastroenteritis. So it’s not necessary to restrict your child’s diet. Fasting when recovering from gastroenteritis is not recommended but it’s important to consider the child and ease into the reintroduction of foods. </p>
<p>It turns out fat, lactose and sucrose absorption during diarrhoea <a href="https://academic.oup.com/cid/article/41/Supplement_8/S547/569758">is limited</a> – so it’s sensible to <a href="https://journals.lww.com/em-news/fulltext/2004/01000/brat_diet__axiom_or_unsubstantiated_myth_.21.aspx">avoid fatty foods and foods high in simple sugars</a> (including juices and soft drinks) for moderate to severe diarrhoea as these could worsen symptoms. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/diarrhoea-stomach-ache-and-nausea-the-many-ways-covid-19-can-affect-your-gut-145440">Diarrhoea, stomach ache and nausea: the many ways COVID-19 can affect your gut</a>
</strong>
</em>
</p>
<hr>
<h2>Flat soft drinks?</h2>
<p>Flat soft drinks such as colas and lemonade warrant a special mention. Some view these drinks as an option to replenish fluids and glucose lost by vomiting and diarrhoea. But research has shown that this may not be a good idea. </p>
<p>One <a href="https://ep.bmj.com/content/93/4/129.2">British study</a> searched the medical literature going back to the 1950s for evidence to support the use of soft drinks in gastroenteritis. They found none. </p>
<p>Then the researchers compared the contents of colas and other sodas with commercially available oral-rehydration solutions containing electrolytes and small amounts of sugar. They found the soft drinks not only contained very low amounts of potassium, sodium and other electrolytes, but in some cases as much as seven times the glucose recommended by the World Health Organization for rehydration. </p>
<p>Carbonated drinks, flat or otherwise, are therefore not considered to provide adequate fluid or electrolytes and are not recommended. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/506223/original/file-20230125-18584-lf5yg5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="glass of orange liquid and sachet of powder" src="https://images.theconversation.com/files/506223/original/file-20230125-18584-lf5yg5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/506223/original/file-20230125-18584-lf5yg5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=422&fit=crop&dpr=1 600w, https://images.theconversation.com/files/506223/original/file-20230125-18584-lf5yg5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=422&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/506223/original/file-20230125-18584-lf5yg5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=422&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/506223/original/file-20230125-18584-lf5yg5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=530&fit=crop&dpr=1 754w, https://images.theconversation.com/files/506223/original/file-20230125-18584-lf5yg5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=530&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/506223/original/file-20230125-18584-lf5yg5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=530&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Rehydration solutions are more effective than flat soft drinks and have less sugar.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/electrolyte-drink-glass-white-background-1343744714">Shutterstock</a></span>
</figcaption>
</figure>
<h2>So what should you eat and drink during gastroenteritis recovery?</h2>
<p><a href="https://journals.lww.com/em-news/fulltext/2004/01000/brat_diet__axiom_or_unsubstantiated_myth_.21.aspx">Appropriate foods</a> include fruits, vegetables, lean meats, yogurts, as well as complex carbohydrates such as wheat, rice, bread, potatoes, and cereals. </p>
<p>Parents of young children with mild gastroenteritis should keep them hydrated by encouraging fluid intake through water and milk, and discourage fruit juices and carbonated drinks. </p>
<p>For moderate or severe cases the appropriate fluid for oral rehydration is commercially available oral rehydration solution (such a Gastrolyte or Hydralyte). </p>
<p>A <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6281220/">systematic review and meta-analysis of 174 studies</a> concluded the use of a probiotic (<em>Saccharomyces boulardii</em>) and zinc supplementation can help during recovery from gastroenteritis, reducing the duration of diarrhoea as well as stool volume.</p>
<p>If symptoms or <a href="https://www.rch.org.au/kidsinfo/fact_sheets/Dehydration/">dehydration</a> are severe then you should take your child to see a GP or go to the closest hospital emergency department.</p><img src="https://counter.theconversation.com/content/198293/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Vincent Ho does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>There are a lot of tummy bugs about, especially in NSW. But does the old advice of what to eat and drink during recovery still hold true?Vincent Ho, Associate Professor and clinical academic gastroenterologist, Western Sydney UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1856852022-06-29T12:11:35Z2022-06-29T12:11:35ZClimate change is putting food safety at risk more often, and not just at picnics and parties – blackouts are a growing problem<figure><img src="https://images.theconversation.com/files/471485/original/file-20220628-14234-gop3kl.jpg?ixlib=rb-1.1.0&rect=491%2C0%2C4682%2C3086&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Dairy, meats and eggs can get risky when left in warm conditions.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/portrait-of-smiling-boy-holding-sandwich-with-his-royalty-free-image/691049473">Westend61 via Getty Images</a></span></figcaption></figure><p><em>Every year, <a href="https://www.cdc.gov/foodborneburden/2011-foodborne-estimates.html">almost 1 in 6 Americans</a> gets a foodborne illness, and about 3,000 people die from it, according to Centers for Disease Control and Prevention estimates. Picnics and parties where food sits out for hours are a common source, but heat waves and power outages are another silently growing threat.</em></p>
<p><em>As global temperatures rise, the risk of foods going bad during blackouts in homes or stores or during transit in hot weather rises with them. <a href="https://nutrition.tufts.edu/profile/faculty/elena-n-naumova">Elena Naumova</a>, an epidemiologist and data scientist at Tufts University, explains the risk and what you need to know to stay safe.</em></p>
<h2>What does climate change have to do with foodborne illness?</h2>
<p>The link between foodborne illness and climate change is quite straightforward: The pathogens that cause many foodborne infections are sensitive to temperature. That’s because warm, wet weather conditions stimulate bacterial growth.</p>
<p>Three main factors govern the spread of foodborne illness: 1) the abundance, growth, range and survival of pathogens in crops, livestock and the environment; 2) the transfer of these pathogens to food; and 3) human exposure to the pathogens.</p>
<p>Safety measures like warning labels and product recalls can help slow the spread of harmful bacteria and parasites, but these measures don’t always evolve rapidly enough to keep pace with the changing risk.</p>
<p>One growing problem is that heat waves, wildfires and severe storms are increasingly triggering power outages, which in turn affect food storage and food handling practices in stores, production and distribution sites and homes. A review of federal data in 2022 found that major U.S. <a href="https://apnews.com/article/wildfires-storms-science-business-health-7a0fb8c998c1d56759989dda62292379">power outages linked to severe weather had doubled</a> over the previous two decades. California often experiences <a href="https://www.bloomenergy.com/bloom-energy-outage-map/">smaller-scale outages</a> during heat waves and periods of high wildfire risk.</p>
<p>This can happen on the hottest and, in some areas, most humid days, creating ideal conditions for bacteria to grow.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/471456/original/file-20220628-14253-8980uj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/471456/original/file-20220628-14253-8980uj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=503&fit=crop&dpr=1 600w, https://images.theconversation.com/files/471456/original/file-20220628-14253-8980uj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=503&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/471456/original/file-20220628-14253-8980uj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=503&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/471456/original/file-20220628-14253-8980uj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=632&fit=crop&dpr=1 754w, https://images.theconversation.com/files/471456/original/file-20220628-14253-8980uj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=632&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/471456/original/file-20220628-14253-8980uj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=632&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Salmonella bacteria, in pink, a common cause of foodborne disease, invade a human epithelial cell.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/niaid/5613656967">NIAID</a></span>
</figcaption>
</figure>
<h2>Which causes of foodborne illness are increasing with the heat?</h2>
<p>Nationwide, many types of foodborne infection <a href="https://doi.org/10.1038/s41598-020-74435-9">peak in warm summer months</a>.</p>
<p><a href="https://www.cdc.gov/parasites/cyclosporiasis/gen_info/faqs.html"><em>Cyclospora</em></a>, a tiny parasite that causes intestinal infections and is transmitted through food or water contaminated with feces, often on imported vegetables and fruits, peaks in early June. </p>
<p>The bacteria <a href="https://www.cdc.gov/campylobacter/faq.html"><em>Campylobacter</em></a>, a common cause of diarrhea that’s often linked to undercooked meat; <a href="https://www.cdc.gov/vibrio/faq.html"><em>Vibrio</em></a>, linked to eating raw or undercooked shellfish; <a href="https://www.cdc.gov/salmonella/general/index.html"><em>Salmonella</em></a>, which causes diarrhea and is linked to animal feces; and STEC, a common type of <a href="https://www.cdc.gov/ecoli/general/index.html"><em>E. coli</em></a>, peak in mid-July. And the parasite <a href="https://www.cdc.gov/parasites/crypto/index.html"><em>Cyptosporidium</em></a>, germ <a href="https://www.cdc.gov/listeria/faq.html"><em>Listeria</em></a> and bacteria <a href="https://www.cdc.gov/shigella/general-information.html"><em>Shigella</em></a> peak in mid-August.</p>
<p>Many of these infections cause upset stomach, but they can also lead to severe diarrhea, dehydration, vomiting and even longer-term illnesses, such as meningitis and multiple organ failures.</p>
<figure class="align-center ">
<img alt="A man stands in front of a dark freezer case packed with pizzas and other frozen meals." src="https://images.theconversation.com/files/471487/original/file-20220628-14234-33ofq8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/471487/original/file-20220628-14234-33ofq8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=408&fit=crop&dpr=1 600w, https://images.theconversation.com/files/471487/original/file-20220628-14234-33ofq8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=408&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/471487/original/file-20220628-14234-33ofq8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=408&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/471487/original/file-20220628-14234-33ofq8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=513&fit=crop&dpr=1 754w, https://images.theconversation.com/files/471487/original/file-20220628-14234-33ofq8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=513&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/471487/original/file-20220628-14234-33ofq8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=513&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">When refrigerators lose power, they can keep foods cool for only so long. This store owner in New York during the 2006 blackout said, ‘I’ll have to throw all this out.’</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/grocery-store-owener-asim-calik-surveys-a-freezer-full-of-news-photo/71510428">Chris Hondros/Getty Images</a>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>In our studies, my colleagues and I have also found that <a href="https://doi.org/10.3390/ijerph19094947">food recalls increase</a> during summer months. </p>
<p>Typically, the U.S. sees about 70 foodborne outbreaks per month, with about two of them resulting in a food recall. In summer, the number of outbreaks can exceed 100 per month, and the number of recall-related outbreaks goes up to six per month, increasing from 3% to 6% of all reported and investigated outbreaks nationwide. </p>
<p>The rate of individual infections can also <a href="https://doi.org/10.1017/S0950268806006698">easily double or triple</a> the annual average during summer months. </p>
<p><iframe id="JhwJ1" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/JhwJ1/7/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>Precisely estimating infection numbers is very challenging because the vast majority of foodborne illness outbreaks – an estimated <a href="https://doi.org/10.1038/s41598-020-74435-9">80% of illnesses and 56% of hospitalizations</a> – are not attributed to known pathogens due to insufficient testing, and many foodborne illnesses are not even reported to the health authorities.</p>
<h2>What types of food should people worry about?</h2>
<p>Watch out for perishable products, including meat, poultry, fish, dairy and eggs, along with anything labeled as requiring refrigeration. How warm a food item can get before becoming risky varies, so the simplest rule for keeping food safe is to follow food labels and instructions.</p>
<p>The <a href="https://www.cdc.gov/foodsafety/index.html%5D(https://www.cdc.gov/foodsafety/index.html">CDC website</a> emphasizes four basic rules to prevent food poisoning at home: clean, separate, cook and chill.</p>
<p>It also offers some guidelines for when the power goes out, starting with keeping refrigerator and freezer doors closed. “A full freezer <a href="https://www.cdc.gov/foodsafety/food-safety-during-a-power-outage.html">will keep food safe for 48 hours</a> (24 hours if half-full) without power if you don’t open the door. Your refrigerator will keep food safe for up to four hours without power if you don’t open the door,” it says.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/471484/original/file-20220628-14613-gop3kl.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="An infographic offers advice also discussed in the article." src="https://images.theconversation.com/files/471484/original/file-20220628-14613-gop3kl.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/471484/original/file-20220628-14613-gop3kl.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=776&fit=crop&dpr=1 600w, https://images.theconversation.com/files/471484/original/file-20220628-14613-gop3kl.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=776&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/471484/original/file-20220628-14613-gop3kl.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=776&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/471484/original/file-20220628-14613-gop3kl.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=976&fit=crop&dpr=1 754w, https://images.theconversation.com/files/471484/original/file-20220628-14613-gop3kl.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=976&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/471484/original/file-20220628-14613-gop3kl.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=976&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Food safety tips.</span>
<span class="attribution"><a class="source" href="https://www.cdc.gov/foodsafety/food-safety-during-a-power-outage.html">CDC</a></span>
</figcaption>
</figure>
<p>After four hours without power or a cooling source, the CDC recommends that most meat, dairy, leftovers and cut fruits and vegetables in the refrigerator be thrown out.</p>
<p>Unfortunately, you cannot see, smell or taste many harmful pathogens that cause foodborne illness, so it’s better to be safe than sorry. Rule of thumb: When in doubt, throw it out.</p>
<h2>What’s the best response if a person gets sick from food?</h2>
<p>If you do get sick, it can be hard to pinpoint the culprit. Harmful bacteria can take anywhere from <a href="https://doh.wa.gov/you-and-your-family/food-safety/food-safety-myths">a few hours to several days</a> to make you sick. And people respond in different ways, so the same food might not make everyone ill.</p>
<p>Check with your doctor <a href="https://www.fda.gov/food/consumers/what-you-need-know-about-foodborne-illnesses">if you think you have food poisoning</a>. Get tested so your case will be reported. That helps public health authorities get a better sense of the extent of infections. The full extent of infections is typically vastly underreported.</p>
<p>I recommend checking health department websites, <a href="https://doh.wa.gov/you-and-your-family/food-safety/food-safety-myths">like Washington state’s</a>, for more advice, and <a href="https://www.fsis.usda.gov/recalls">check on food recalls</a> during the hot months.</p><img src="https://counter.theconversation.com/content/185685/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Elena N. Naumova receives funding from the National Science Foundation. She is affiliated with Tufts University. </span></em></p>Climate change has a clear link to rising foodborne illnesses. Blackouts during heat waves and wildfires are a growing part of the problem.Elena N. Naumova, Professor of Epidemiology and Data Science, Tufts UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1738792022-02-14T13:22:23Z2022-02-14T13:22:23ZWhy do people get diarrhea?<figure><img src="https://images.theconversation.com/files/442542/original/file-20220125-23-5eakbl.jpg?ixlib=rb-1.1.0&rect=0%2C519%2C5058%2C2800&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">No matter its cause, diarrhea is uncomfortable.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/man-holding-toilet-tissue-roll-in-bathroom-royalty-free-image/1249645235">Rapeepong Puttakumwong/Moment via Getty Images</a></span></figcaption></figure><figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/281719/original/file-20190628-76743-26slbc.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/281719/original/file-20190628-76743-26slbc.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=293&fit=crop&dpr=1 600w, https://images.theconversation.com/files/281719/original/file-20190628-76743-26slbc.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=293&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/281719/original/file-20190628-76743-26slbc.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=293&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/281719/original/file-20190628-76743-26slbc.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=368&fit=crop&dpr=1 754w, https://images.theconversation.com/files/281719/original/file-20190628-76743-26slbc.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=368&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/281719/original/file-20190628-76743-26slbc.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=368&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption"></span>
</figcaption>
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<p><em><a href="https://theconversation.com/us/topics/curious-kids-us-74795">Curious Kids</a> is a series for children of all ages. If you have a question you’d like an expert to answer, send it to <a href="mailto:curiouskidsus@theconversation.com">curiouskidsus@theconversation.com</a>.</em></p>
<hr>
<blockquote>
<p><strong>Why do people get diarrhea? – A.A.A., age 10, Philadelphia</strong></p>
</blockquote>
<hr>
<p>The digestive system breaks down everything you eat and drink to absorb nutrients and make the energy your body needs. Whatever solids can’t be broken down and used get <a href="https://www.ncbi.nlm.nih.gov/books/NBK539732/">excreted as poop</a>.</p>
<p>Poop comes in many shapes, sizes, colors and consistencies.</p>
<p><a href="https://scholar.google.com/citations?user=mHFFJtUAAAAJ&hl=en&oi=ao">Doctors like me</a> who treat people with digestive issues use what’s called the <a href="https://dx.doi.org/10.1016%2Fj.jpeds.2011.03.002">Bristol stool scale</a> to grade poop texture. It goes from Type 1 – separate hard lumps – to Type 7 – liquid with no solid pieces. The texture of the best poops, Type 4, resembles a mushy banana.</p>
<p>When your <a href="https://blog.katescarlata.com/2021/04/19/common-disorders-associated-with-diarrhea/">poop is loose and watery</a> and comes out that way at least three times a day, you have <a href="https://www.who.int/news-room/fact-sheets/detail/diarrhoeal-disease">diarrhea</a>. It can be uncomfortable and inconvenient, because diarrhea tends to come out quickly and with little warning. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/442540/original/file-20220125-15-n9shj2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Illustration of the seven categories of poop, ranging from overly firm to liquid." src="https://images.theconversation.com/files/442540/original/file-20220125-15-n9shj2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/442540/original/file-20220125-15-n9shj2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/442540/original/file-20220125-15-n9shj2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/442540/original/file-20220125-15-n9shj2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/442540/original/file-20220125-15-n9shj2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/442540/original/file-20220125-15-n9shj2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/442540/original/file-20220125-15-n9shj2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The Bristol stool scale puts poop into seven categories that range from the hard pellets of constipation to the splotchy liquid of diarrhea.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/bristol-stool-chart-tool-for-faeces-type-royalty-free-illustration/1250463401">VectorMine/iStock via Getty Images Plus</a></span>
</figcaption>
</figure>
<h2>Beware of bad germs</h2>
<p>By the time food passes out of the stomach, it’s a liquid that travels through the small intestine, where nutrients are absorbed. The leftovers flow into the large intestine, where water is absorbed and poop forms.</p>
<p>When the small intestine or the large intestine can’t do its job, poop will be liquid. </p>
<p>Diarrhea usually occurs because of infections caused by many different <a href="https://www.doi.org/10.4161/gmic.1.1.11036">viruses, bacteria and parasites</a>.</p>
<p>That’s why there are <a href="https://www.epa.gov/dwreginfo/drinking-water-regulations">rules about keeping drinking water clean</a> and <a href="https://www.fsis.usda.gov/food-safety/safe-food-handling-and-preparation/food-safety-basics/steps-keep-food-safe">food safe</a>. It’s also why you should wash your hands before eating. </p>
<p>These germs cause diarrhea a few different ways. Often, they irritate the intestines, interfering with water absorption. Some germs cause diarrhea by <a href="https://www.mayoclinic.org/diseases-conditions/cholera/symptoms-causes/syc-20355287">releasing chemicals</a> that make the intestines release fluid, making poop even more watery. When these <a href="https://www.cdc.gov/foodsafety/foodborne-germs.html">germs come from food</a>, symptoms can include vomiting, belly pain and diarrhea.</p>
<p>To be sure, not all microbes are bad.</p>
<p>In fact, your <a href="https://doi.org/10.1038/nature11053">digestive system is filled with billions of bacteria</a> and other germs that help you digest food and protect you from bad germs. <a href="https://doi.org/10.2217/17460913.3.5.563">Taking antibiotics for an infection can cause diarrhea</a> by killing off these good bacteria along with the ones that originally made you sick. But people usually get better once they finish prescribed antibiotics and the good bacteria have a chance to recover.</p>
<p>People with diarrhea need to consume lots of liquids to stay hydrated. Water is best. Avoid <a href="https://doi.org/10.1001/archpedi.1985.02140070077039">juice</a> and <a href="https://irritablebowelsyndrome.net/food/no-soda">soda</a>, which can worsen diarrhea. Also refrain from foods that can make your digestive system work harder, like dairy products.</p>
<p><a href="https://www.childrens.com/health-wellness/how-to-treat-diarrhea-in-kids">Eating sweet potatoes, oats, beets</a> and other high-fiber foods may help firm up loose poops. Never take a medication, even if doesn’t require a prescription, for diarrhea without asking a doctor first. </p>
<h2>Many other causes</h2>
<p>There are many other causes of diarrhea.</p>
<p>Some people are born with or develop conditions over the course of their lives that can cause diarrhea.</p>
<p>A common example is <a href="http://dx.doi.org/10.1136/gutjnl-2019-318404">lactose intolerance</a>. Lactose is a sugar that is in milk that requires a <a href="https://www.britannica.com/science/lactase">special enzyme, called lactase</a>, to digest it in the small intestine. There are people who have little, or even none, of this enzyme in their small intestine. As a result, lactose travels into their large intestine without being broken down and absorbed – leaving poop very runny.</p>
<p><a href="https://doi.org/10.3389/fped.2018.00350">Celiac disease</a> can also trigger diarrhea. People with it have <a href="https://www.health.harvard.edu/healthbeat/getting-out-the-gluten">trouble digesting gluten</a>, a protein found in wheat and additional grains. For people with celiac disease, eating gluten can damage the small intestine by activating their own immune system. This damage is reversible through a gluten-free diet, but diarrhea may continue until the small intestine heals and can do its job.</p>
<p>Others have <a href="https://doi.org/10.3389/fmed.2017.00261">digestive system allergies</a>. They need to avoid eating specific foods to prevent diarrhea and other symptoms. </p>
<p>Some medications make you poop more often.</p>
<p>There are also medical conditions, like <a href="https://doi.org/10.1053/j.gastro.2021.04.063">inflammatory bowel disease</a>, such as <a href="https://www.mayoclinic.org/diseases-conditions/crohns-disease/symptoms-causes/syc-20353304">Crohn’s disease</a> and <a href="https://www.mayoclinic.org/diseases-conditions/ulcerative-colitis/symptoms-causes/syc-20353326">ulcerative colitis</a>, in which the small intestine, large intestine or both become inflamed over a period of time.</p>
<p>Even your brain can play a role: Experiencing anxiety or <a href="https://www.healthline.com/health/anxiety-diarrhea">getting stressed out</a> can bring about loose poops. Some conditions, like <a href="https://doi.org/10.14309/ajg.0000000000001036">irritable bowel syndrome</a>, where the brain and the intestines do not communicate well with each other, can lead to belly pain and diarrhea, particularly amid stress. </p>
<p><a href="https://www.mayoclinic.org/diseases-conditions/cancer/in-depth/diarrhea/art-20044799">Certain cancers</a> and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6867674/">some tumors</a> can cause diarrhea too. </p>
<p>Finally, for some people, eating spicy or fatty food or consuming artificial sweeteners or <a href="https://www.healthline.com/health/foods-that-cause-diarrhea#food-and-diarrhea">large amounts of caffeine</a> can result in diarrhea. </p>
<p>Even if you find it icky, I recommend you pay attention to your poop. If you’re having diarrhea all the time, rather than occasionally, you may need to see a doctor.</p>
<hr>
<p><em>Hello, curious kids! Do you have a question you’d like an expert to answer? Ask an adult to send your question to <a href="mailto:curiouskidsus@theconversation.com">CuriousKidsUS@theconversation.com</a>. Please tell us your name, age and the city where you live.</em></p>
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<p class="fine-print"><em><span>Hannibal Person does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Poop comes in many shapes, sizes and textures. The kind that’s too runny might be the result of wayward germs, Crohn’s disease or lactose intolerance.Hannibal Person, Assistant Professor of Gastroenterology and Hepatology, School of Medicine, University of WashingtonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1565562021-03-15T15:05:44Z2021-03-15T15:05:44ZShigella outbreak in Vancouver’s Downtown Eastside ‘a disease of destitution’<figure><img src="https://images.theconversation.com/files/388901/original/file-20210310-23-7jcwrb.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5160%2C3453&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Ambulances waiting outside the emergency room at St. Paul's Hospital in downtown Vancouver, where an outbreak of Shigellosis is affecting marginalized people.</span> <span class="attribution"><span class="source">(Ben Huang)</span>, <span class="license">Author provided</span></span></figcaption></figure><p>Already fighting a global pandemic, doctors in Vancouver are now facing an outbreak of dysentery in the Downtown Eastside, the <a href="https://vancouver.ca/files/cov/profile-dtes-local-area-2013.pdf">poorest neighbourhood in the city</a>. </p>
<p>The disease, called <a href="http://www.bccdc.ca/health-info/diseases-conditions/shigella">shigellosis</a>, is caused by a highly contagious bacterium known as shigella, which causes symptoms of dysentery: profuse mucous or even bloody diarrhea, low-grade fevers and abdominal cramps. Shigellosis usually occurs in <a href="https://www.ncbi.nlm.nih.gov/books/NBK8038/#_A1277_">developing countries</a> where sanitation is poor, making an outbreak in urban Vancouver, where I work as a resident emergency doctor, highly unusual.</p>
<p>“I don’t ever remember there being a previous outbreak … in the Downtown Eastside,” says Dr. Daniel Kalla, head of the emergency department at St. Paul’s Hospital in downtown Vancouver.</p>
<p>The local medical health officer for Vancouver Coastal Health was contacted for an interview but was unavailable.</p>
<p>There are <a href="https://www.cdc.gov/shigella/general-information.html">four subtypes</a> of shigella, with <em>shigella flexneri</em> being <a href="http://www.vch.ca/Documents/26%20Feb%202021%20Physicians%20Update%20Shigella%20Outbreak%20Hep%20A%20Cases.pdf">identified</a> as the species behind Vancouver’s current outbreak. The bacteria are usually spread via contaminated hands or sexual contact, and patients can become infected from exposure to only <a href="https://www.canada.ca/en/public-health/services/laboratory-biosafety-biosecurity/pathogen-safety-data-sheets-risk-assessment/shigella.html">10 organisms</a>, compared with <a href="https://www.canada.ca/en/public-health/services/laboratory-biosafety-biosecurity/pathogen-safety-data-sheets-risk-assessment/salmonella-enterica.html">1,000 to 100,000</a> required to transmit salmonella. Patients can remain contagious for up to <a href="https://www.cmaj.ca/content/167/3/281">four weeks</a>, long after initial symptoms resolve. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/388973/original/file-20210311-21-1dxirva.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Pink capsule-shaped bacteria covered with short filaments against a dark background" src="https://images.theconversation.com/files/388973/original/file-20210311-21-1dxirva.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/388973/original/file-20210311-21-1dxirva.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=464&fit=crop&dpr=1 600w, https://images.theconversation.com/files/388973/original/file-20210311-21-1dxirva.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=464&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/388973/original/file-20210311-21-1dxirva.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=464&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/388973/original/file-20210311-21-1dxirva.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=583&fit=crop&dpr=1 754w, https://images.theconversation.com/files/388973/original/file-20210311-21-1dxirva.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=583&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/388973/original/file-20210311-21-1dxirva.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=583&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Medical illustration of drug-resistant Shigella bacteria.</span>
<span class="attribution"><span class="source">(CDC Antibiotic Resistance Coordination and Strategy Unit/Stephanie Rossow)</span></span>
</figcaption>
</figure>
<p>“If someone has shigella and doesn’t clean their hands well enough, even a small amount could lead to transmission,” says Dr. Victor Leung, medical director for Infection Prevention and Control at St. Paul’s Hospital. </p>
<p>“And even cases that resolve may still be transmitting,” he says, especially when there are shared washrooms. </p>
<h2>Emerging patterns</h2>
<p>Leung says he first heard about cases in downtown Vancouver on Feb. 20.
“We got a call from the clinical teaching unit saying, ‘We’re noticing some cases of infectious (diarrhea) in patients who are homeless … and it looks like it’s shigella,’” he says.</p>
<p>Over the next few days, as new cases were confirmed, there seemed to be an emerging pattern of patients being homeless or living in single-room occupancies (SROs), a form of low-income housing.</p>
<p>Beyond that, it was difficult to identify a specific source of the outbreak.</p>
<p>“Each individual didn’t seem to have a common shelter or SRO and their food situations were different. And … one of the patients was recently diagnosed with COVID and was at a COVID isolation hotel,” says Leung, adding that the timeline of the patient’s symptom onset suggests the infection could have been acquired there.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/388975/original/file-20210311-22-a92fl1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A group of tents and temporary structures in a park, shot from above" src="https://images.theconversation.com/files/388975/original/file-20210311-22-a92fl1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/388975/original/file-20210311-22-a92fl1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=375&fit=crop&dpr=1 600w, https://images.theconversation.com/files/388975/original/file-20210311-22-a92fl1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=375&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/388975/original/file-20210311-22-a92fl1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=375&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/388975/original/file-20210311-22-a92fl1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=471&fit=crop&dpr=1 754w, https://images.theconversation.com/files/388975/original/file-20210311-22-a92fl1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=471&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/388975/original/file-20210311-22-a92fl1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=471&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A homeless camp in Strathcona Park close to the downtown core of Vancouver on March 9, 2021.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Jonathan Hayward</span></span>
</figcaption>
</figure>
<p>Approximately 20 cases of shigellosis have been reported to the <a href="http://covid-19.bccdc.ca">BC Centre for Disease Control</a>, according to Dr. Linda Hoang, a medical microbiologist for the organization with a focus on public health. The rate of new cases seemed to slow down this week, says Hoang.</p>
<p>But because most cases have mild symptoms, says Leung, there may be more people unknowingly infected if patients aren’t seeking medical care. The pandemic may exacerbate this, because of restrictions limiting access to clinics as well as fear of possible COVID-19 exposure.</p>
<p>“COVID has used a lot of resources in the whole health system,” says Leung. “People are afraid to access care.”</p>
<h2>Treatment and followup</h2>
<p>Most mild infections <a href="http://www.bccdc.ca/health-info/diseases-conditions/shigella">don’t need</a> antibiotics, and overusing antibiotics for diarrhea can increase <a href="https://dx.doi.org/10.2147/IDR.S219755">bacterial resistance</a>. But Leung notes that during an outbreak, pre-emptive treatment may help control spread by decreasing the duration of bacterial shedding, which transmits the infection.</p>
<p>The current strain of <em>shigella flexneri</em> is resistant to the preferred treatment, the antibiotic ciprofloxacin, as well as others such as ampicillin and trimethoprim/sulfamethoxazole. <a href="http://www.vch.ca/Documents/26%20Feb%202021%20Physicians%20Update%20Shigella%20Outbreak%20Hep%20A%20Cases.pdf">Vancouver Coastal Health is advising</a> physicians to treat suspected patients with azithromycin or cefixime. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-other-pandemic-once-treatable-diseases-are-growing-resistant-to-antibiotics-153246">The other pandemic: Once-treatable diseases are growing resistant to antibiotics</a>
</strong>
</em>
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<p>In the emergency room, ensuring that patients complete treatment and followup is a major consideration for those being discharged home, especially when “home” doesn’t have a fixed address.</p>
<p>“Azithromycin is a three-day course, so we give patients their first dose in hospital and then we give them two tablets to go so they’re more likely to have it and take it,” says Kalla. As for testing, he notes that “Compliance wouldn’t be good if we sent stool [testing] kits to go … [so] I like to keep patients until they produce a stool sample for culture.” </p>
<p>When it’s time for discharge, Kalla says, all patients are referred to social workers who notify shelters so they can be aware and make preparations for them.</p>
<p>Deciding whom to admit to hospital can be a difficult question, he says, but admission is usually reserved for high-risk patients who are very frail or significantly dehydrated.</p>
<h2>Marginalized patients</h2>
<p>Leung says this outbreak is the result of years of marginalization occurring in the Downtown Eastside. </p>
<p>“You have an increasing number of evictions due to rent increases, <a href="https://www.citynews1130.com/2021/02/16/strathcona-park-move-out-deadline/">forcing a lot of people into homelessness</a> in parks like <a href="https://thetyee.ca/News/2020/10/28/Strathcona-Park-Tent-City-Place-of-Refuge/">Strathcona</a> or <a href="https://www.cbc.ca/news/canada/british-columbia/campers-at-oppenheimer-park-receive-eviction-notice-1.5252034">Oppenheimer</a>, where you have no hygiene measures.… You expect to see dysentery in places in the world that are underdeveloped. It’s less common in developed countries except in <a href="https://www.cbc.ca/news/canada/british-columbia/dtes-vancouver-statistics-anecdotes-1.5253897">crowded places with poor living conditions</a>.”</p>
<p>And Leung is not surprised that one of the cases may have been transmitted at a COVID-19 isolation hotel.</p>
<p>“The people going to a COVID isolation hotel are those who have no ability to have supported isolation — people living in SROs with mental illness exacerbated by substance use disorders,” he says.</p>
<p>The most effective method of prevention is thorough and frequent hand washing with soap and water, says Leung.</p>
<p>“But when you have people who are homeless and marginalized, how do you promote adherence? This is a disease of destitution.”</p><img src="https://counter.theconversation.com/content/156556/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ben Huang does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Infectious dysentery, usually found in developing countries with poor living conditions, is turning up in Vancouver’s most marginalized neighbourhood.Ben Huang, Resident Doctor, Emergency Medicine, University of British ColumbiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1253302019-10-15T15:20:17Z2019-10-15T15:20:17ZMost people don’t wash their hands properly – here’s how it should be done<figure><img src="https://images.theconversation.com/files/297177/original/file-20191015-98653-iqr2x7.jpg?ixlib=rb-1.1.0&rect=26%2C13%2C4426%2C2951&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.pexels.com/photo/person-washing-his-hand-545014/">Pexels</a></span></figcaption></figure><p>It’s something most people do everyday, often without really thinking about it, but how you wash your hands can make a real difference to your health and the well-being of those around you.</p>
<p>Washing your hands is the one most <a href="https://www.ijidonline.com/article/S1201-9712(04)00172-9/fulltext">effective method</a> to prevent cross-contamination which can cause the spread of illness and infections. And many research studies have shown how improvements in hand hygiene have resulted in reductions in illness. </p>
<p><a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004265.pub3/information">A look at research from around the world</a> on the promotion of washing hands with soap, found that such interventions resulted in a <a href="https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1365-3156.2006.01568.x">30% reduction</a> in diarrhoea episodes and respiratory illnesses such as colds. <a href="https://www.ajicjournal.org/article/S0196-6553(17)30041-X/fulltext">Hand hygiene interventions</a> at elementary schools in the US similarly helped to reduce sick days associated with acute gastrointestinal illness by 31%.</p>
<p>The impact of good hand hygiene is even greater among people that have an increased risk of infection. A <a href="https://www.microbiologyresearch.org/content/journal/jmm/10.1099/jmm.0.46867-0#tab2">study</a> from 2007, for example, found that patients with AIDS who washed their hands more frequently got ill less often.</p>
<p>But as <a href="https://jfoodprotection.org/doi/abs/10.4315/0362-028X.JFP-17-378">our recent research shows</a>, despite awareness of the importance of washing your hands, people often fail to do it properly. In our study, we observed how adults over the age of 60 prepared food in a domestic kitchen set up with CCTV cameras, and found that only 30% of people properly washed and dried their hands before preparing food. </p>
<p>We found that 90% of people failed to wash and dry their hands properly immediately after handling raw chicken. And that 62% failed to rub hands, palms and between fingers when washing hands. We also discovered that 47% of people in our study failed to use soap during one or more hand washing attempt.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/297144/original/file-20191015-98661-1p6wgp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/297144/original/file-20191015-98661-1p6wgp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/297144/original/file-20191015-98661-1p6wgp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=374&fit=crop&dpr=1 600w, https://images.theconversation.com/files/297144/original/file-20191015-98661-1p6wgp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=374&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/297144/original/file-20191015-98661-1p6wgp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=374&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/297144/original/file-20191015-98661-1p6wgp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=470&fit=crop&dpr=1 754w, https://images.theconversation.com/files/297144/original/file-20191015-98661-1p6wgp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=470&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/297144/original/file-20191015-98661-1p6wgp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=470&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The model domestic kitchen.</span>
</figcaption>
</figure>
<p>We also swabbed the kitchen and found that those who adequately washed their hands, had significantly lower levels of microbiological contamination levels in the kitchen following food preparation sessions.
<a href="https://www.emerald.com/insight/content/doi/10.1108/00070700510606873/full/html">Other studies</a> have also determined that failing to wash hands adequately after handling raw poultry can transfer bacteria to domestic kitchen surfaces – such as the handles of taps and refrigerators. All of which highlights the importance of properly washing your hands.</p>
<h2>How to wash your hands</h2>
<p>The World Health Organisation <a href="https://www.who.int/foodsafety/publications/consumer/manual_keys.pdf">recommends</a> that to wash your hands effectively, it needs to be done with clean water and soap. Hands should be rubbed together for at least 20 seconds, followed by rinsing. Hands must also be dried using either disposable kitchen paper or a clean hand towel.</p>
<p>The use of soap is particularly important for hand washing to be effective. Indeed, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3037063/">research</a> has shown that washing with soap significantly reduced the presence of bacteria on hands. </p>
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</figure>
<p>The soap doesn’t have to be antibacterial to be effective – though antibacterial soap works on reducing the number of bacteria not just removing them. And research has <a href="https://ajph.aphapublications.org/doi/full/10.2105/AJPH.2007.124610">shown</a> that the use of non-antibacterial soap is successful for preventing both gastrointestinal and respiratory illnesses.</p>
<p>You should spend 20 seconds washing and drying your hands. Here’s how to do it properly: wet your hands with clean water, use soap, rub palm to palm, rub back of hands, rub between fingers, rub fingernails, rinse your hands. Then dry them using a clean towel or kitchen paper.</p>
<h2>Dry them properly too</h2>
<p>Hand drying is also very important to prevent contamination from hands to food, surfaces and equipment as the transmission of bacteria is <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2809004/">more likely</a> to occur from wet skin than from dry skin. So the proper drying of hands after washing should be an <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3538484/">integral part</a> of hand hygiene. </p>
<p>Drying your hands properly also removes a significant number of bacteria following hand washing – drying with a towel removes pathogens by means of friction, on top of the removal of moisture. Though this means that a hand towel can become a site for cross-contamination. Indeed, in <a href="https://jfoodprotection.org/doi/abs/10.4315/0362-028X.JFP-17-378">our study</a> we found that 37% of people used the same towel for drying hands and equipment.</p>
<p>It is essential to wash hands on occasions when they may be contaminated such as before, during, and after preparing food – particularly after handing raw meat and poultry – after using the toilet, after blowing your nose, coughing, or sneezing and after touching an animal.</p>
<p>This is important, because washing our hands properly can mean the difference between sickness and health. And for people with compromised immune systems it can even mean the difference between life and death – so make sure you do it properly. If in doubt follow the tips above and sing “<a href="https://tools.cdc.gov/medialibrary/index.aspx#/media/id/302345">Happy Birthday</a>” twice to allow enough time to remove and rinse away any germs.</p><img src="https://counter.theconversation.com/content/125330/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ellen W. Evans received funding for research referred to in this article from the Cardiff Metropolitan University Vice Chancellor's Doctoral Award and Tenovus Cancer Care. She is affiliated with the International Association for Food Protection. This article refers to research co-authored with Dr Elizabeth C. Redmond.</span></em></p>Despite awareness of the importance of hand washing, most people often fail to do it properly.Ellen W. Evans, Junior Research Fellow, Cardiff Metropolitan UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1077762018-12-21T11:41:37Z2018-12-21T11:41:37ZWhy you may be more at risk for foodborne infections during the holidays<figure><img src="https://images.theconversation.com/files/251595/original/file-20181219-45391-1vio4dj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Foodborne pathogens can cause mild to serious intestinal distress.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/handsome-young-man-suffering-stomach-ache-587451794?src=xxt6injCEkbG0q0e5ZCmag-1-9">Africa Studios/Shutterstock.com</a></span></figcaption></figure><p>There’s no place like home for the holidays, many people agree, and millions of people will travel long distances to get there.
Along the journey, however, you may be at higher risk of becoming infected with a foodborne pathogen also along for the ride. </p>
<p>And, that pathogen could make your day a real downer, bringing diarrhea.</p>
<p>Intestinal illness is experienced by almost everyone at least once in their lifetime. At the minimum, it is an unpleasant and inconvenient experience. At its worst, diarrhea is <a href="https://www.sciencedirect.com/science/article/pii/S1473309918303621?via%3Dihub">a leading cause of death</a>, particularly in young children. </p>
<p>Here are my tips on how to avoid foodborne pathogens and the misery they cause, from my perspective as a microbiologist.</p>
<h2>You can run, but you can’t hide</h2>
<p>We people live in a microbial world where microbes inhabit every corner of the Earth. A very small proportion of those microbes have figured out ways to inhabit us in a manner that makes us sick. A proportion of the disease-causing microbes can do it in our digestive tract. These are foodborne pathogens, germs that have special means to survive in our digestive tract and cause damages. </p>
<p><em>Escherichia coli</em> (<em>E. coli</em>) and <em>Salmonella enterica</em> (<em>Salmonella</em>) are two infamous bacterial pathogens collectively responsible for <a href="https://wwwnc.cdc.gov/eid/article/17/1/p1-1101-t2">more than 1.5 million episodes</a> of foodborne illnesses per year. They are common causes of <a href="https://www.fsis.usda.gov/wps/portal/fsis/topics/recalls-and-public-health-alerts/current-recalls-and-alerts">food recalls</a> and appear frequently in news coverage. </p>
<p>In fact, in a quick search using the <a href="https://www.xwordinfo.com/Finder">XWord Info search tool</a>, <em>E. coli</em> and <em>Salmonella</em> have appeared in New York Times crossword puzzles more than 80 times since 1992. Norovirus, a viral pathogen that causes <a href="https://wwwnc.cdc.gov/eid/article/17/1/p1-1101-t2">more episodes of foodborne illnesses than all bacterial pathogens combined</a>, has not yet received such honor of recognition by the New York Times crossword. </p>
<h2>Not quite famous, but dangerous</h2>
<p>Another dangerous but less recognized foodborne pathogen is <a href="https://www.cdc.gov/listeria/index.html"><em>Listeria monocytogenes</em></a>, a bacterium found in all kinds of environments and the cause of infections with a high mortality rate in susceptible individuals. Infections by <em>Listeria monocytogenes</em> go beyond diarrhea. Once inside our intestines, this bacterial pathogen can cross our intestinal barrier and enters our circulation to reach other parts of our body where infections lead to death. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/251596/original/file-20181219-45388-1t64u91.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/251596/original/file-20181219-45388-1t64u91.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/251596/original/file-20181219-45388-1t64u91.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/251596/original/file-20181219-45388-1t64u91.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/251596/original/file-20181219-45388-1t64u91.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/251596/original/file-20181219-45388-1t64u91.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/251596/original/file-20181219-45388-1t64u91.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Deli meats can be breeding grounds for a bacterium called listeria.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/big-group-meat-bread-vegetables-50635486?src=Blzya-TAotynLG9rRft_mA-1-1">Olga Nayashkova/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>If it reaches our central nervous system, it breaches the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4292164/">blood-brain barrier</a>, which protects our brain from general circulation, and causes meningitis. In a pregnant woman, it can invade the placenta and infect the developing fetus. For this particular risk, pregnant women are often advised to avoid ready-to-eat food products, such as deli meats and soft cheeses, where <em>Listeria monocytogenes</em> can grow to lethal numbers. <em>Listeria monocytogenes</em> is well-adapted to grow under typical food preservation conditions, <a href="https://www.tandfonline.com/doi/abs/10.1080/10408390701856272?src=recsys&journalCode=bfsn20#_i5">such as refrigeration temperatures</a>, rendering the pathogen extremely difficult to eliminate.</p>
<p>The best strategy against <em>Listeria monocytogenes</em> infections, similar to other foodborne infections, is prevention. We have to consume these pathogens to get sick. If we can reduce the amount of pathogens we consume, we reduce the risk of infections. Individuals can <a href="https://www.fda.gov/Safety/Recalls/default.htm">sign up for email alerts</a> from the Food and Drug Administration to stay informed of ongoing recalls in the United States and avoid potentially contaminated food products. </p>
<p>Following <a href="https://www.fsis.usda.gov/wps/portal/fsis/topics/food-safety-education/get-answers/food-safety-fact-sheets/safe-food-handling/keep-food-safe-food-safety-basics/ct_index">basic food safety guidelines</a> when shopping, preparing and storing food is effective in minimizing exposure to foodborne pathogens and preventing subsequent illnesses. In addition, the United States Department of Agriculture hosts <a href="https://www.fsis.usda.gov/wps/portal/informational/askkaren">a live chat</a>, available also as the Ask Karen mobile app for <a href="https://itunes.apple.com/us/app/ask-karen-from-usda/id439084571?mt=8">iOS</a> and <a href="https://play.google.com/store/apps/details?id=askkaren.gov&hl=en_US">Google Play</a>, between 10 a.m. and 6 p.m. EST on weekdays to answer any food safety questions.</p>
<h2>Sleep well, eat well</h2>
<p>After all the precautions to minimize your exposure to foodborne pathogens, what else can you do? An individual’s susceptibility to infections is also determined by the state of the immune system. A competent immune defense can protect us from illnesses or reduce the severity of illnesses even if we unknowingly consume some <em>E. coli</em> or <em>Salmonella</em>. White blood cells are a critical group of immune cells that protect us from diseases.</p>
<p>As it turns out, subsets of white blood cells respond strongly to our sleep pattern as well as our circadian rhythm, resulting in <a href="https://nyaspubs.onlinelibrary.wiley.com/doi/full/10.1111/j.1749-6632.2009.05300.x">diurnal cycles of immune responses</a> during nocturnal sleep and daytime wakefulness. </p>
<p>In <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2513447">a large population study</a> with 22,726 individuals, when adjusted for age and sex, those with five hours or less of sleep each night were more likely to report respiratory infections or illnesses than those with seven to eight hours of sleep. While this study did not address susceptibility to foodborne infections, it showcases a potential role for the amount of sleep in our immune defenses. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/251599/original/file-20181219-45413-1k04wa3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/251599/original/file-20181219-45413-1k04wa3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/251599/original/file-20181219-45413-1k04wa3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/251599/original/file-20181219-45413-1k04wa3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/251599/original/file-20181219-45413-1k04wa3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/251599/original/file-20181219-45413-1k04wa3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/251599/original/file-20181219-45413-1k04wa3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Holiday travel is great, but it exposes travelers to new communities of bacteria.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/happy-family-suitcases-airport-326490512?src=2ErSX0OiKwbxbBuin_k80g-1-66">AboutLife/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>Traveling also elevates our risk for infections. In addition to sleep disruption, traveling for long distances also exposes us to pathogens not common in our hometowns. Without prior exposure and immunity, these exposures may lead to higher risk of infections and more severe diseases. Traveler’s diarrhea is a real thing and <a href="https://wwwnc.cdc.gov/travel/page/travelers-diarrhea">the most common travel-related illness</a>. The most common cause of traveler’s diarrhea is enterotoxigenic <em>E. coli</em>, a close cousin of <em>E. coli</em> O157:H7 that was the culprit of the most recent outbreak associated with <a href="https://www.fda.gov/Food/RecallsOutbreaksEmergencies/Outbreaks/ucm626330.htm">romaine lettuce</a>. </p>
<p>While <a href="https://www.sciencedirect.com/science/article/pii/S0140673605711442"><em>E. coli</em> O157:H7</a> produces shiga toxin and causes bloody diarrhea that can lead to haemotlyic uremic syndrome, <a href="https://www.cdc.gov/ecoli/etec.html">enterotoxigenic <em>E. coli</em></a> produces two different types of toxins that result in watery diarrhea. Check out these <a href="https://wwwnc.cdc.gov/travel/">travel guidelines</a> prior to traveling to be ready and stay safe. Some important things to know: Eat only food that is served hot, and eat only vegetables that you clean and peel yourself. Also, avoid ice in drinks, and do not consume unpasteurized milk products, including ice cream.</p>
<p>As the holiday season starts, whether we are losing sleep from traveling or trying out new and exciting food in a foreign locale, let’s be conscientious of what is going into our mouths. Be part of the holiday celebration, not a foodborne infection outbreak!</p><img src="https://counter.theconversation.com/content/107776/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Yvonne Sun received funding from American Heart Association.</span></em></p>Millions of people travel during the holidays, eager to spend time with loved ones. That travel, along with exposure to new bacteria, can make you more vulnerable to foodborne illnesses.Yvonne Sun, Assistant Professor, Microbiology, University of DaytonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/902302018-01-22T22:27:33Z2018-01-22T22:27:33ZEverything you need to know about fresh produce and E. coli<figure><img src="https://images.theconversation.com/files/202669/original/file-20180120-110094-se5g8w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A worker harvests romaine lettuce in Salinas, Calif. </span> <span class="attribution"><span class="source">(AP Photo/Paul Sakuma)</span></span></figcaption></figure><p>While the recent outbreak of <em>E. coli</em> infections linked to romaine lettuce <a href="https://www.canada.ca/en/public-health/services/public-health-notices/2017/public-health-notice-outbreak-e-coli-infections-linked-romaine-lettuce.html">has been declared over</a>, Canadian public health officials are still working to determine the cause of the contamination.</p>
<p><a href="https://www.nytimes.com/2018/01/05/health/e-coli-romaine-lettuce.html">Several people in the U.S. and eastern Canada</a> were sickened after eating romaine, with two reported deaths.</p>
<p>I am a food safety expert. Here’s what consumers need to know about <em>E. coli</em> and produce:</p>
<h2>Why produce and why E. coli?</h2>
<p><a href="https://www.cdc.gov/ecoli/general/index.html"><em>E. coli</em> are bacteria</a> that live naturally in the intestines of cattle, poultry and other animals. For the most part, they co-exist with these animals, and hence they don’t become sick.</p>
<p>Most of the <em>E. coli</em> strains associated with humans are harmless, and, in fact, are an important part of a healthy human intestinal tract. However, some <em>E. coli</em> strains are pathogenic, meaning they can cause human illness. Pathogenic <em>E. coli</em> that can cause diarrhea can be transmitted through contaminated water or food, or through contact with animals or people.</p>
<h2>How does produce become contaminated?</h2>
<p>There are many different ways that produce can become contaminated. Firstly, in the farmer’s field, it can become contaminated with pathogenic <em>E. coli</em> through direct contact with animal feces.</p>
<p>For example, wild animals, like feral pigs and deer rummaging through farm fields, have previously been found to be linked to cases of illness due to spinach and strawberries, respectively. </p>
<p>In fact, any time produce in the field makes contact with animal feces, it could lead to the contamination of that produce with a pathogen. Contaminated irrigation water, bird feces or improperly composted manure are other potential sources of pathogenic bacteria. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/202853/original/file-20180122-182976-1otuvae.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/202853/original/file-20180122-182976-1otuvae.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=403&fit=crop&dpr=1 600w, https://images.theconversation.com/files/202853/original/file-20180122-182976-1otuvae.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=403&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/202853/original/file-20180122-182976-1otuvae.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=403&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/202853/original/file-20180122-182976-1otuvae.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=507&fit=crop&dpr=1 754w, https://images.theconversation.com/files/202853/original/file-20180122-182976-1otuvae.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=507&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/202853/original/file-20180122-182976-1otuvae.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=507&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A red-winged blackbird rests on the head of a deer as it looks up from grazing in a sun-drenched farmer’s field in Vermont in 2011.</span>
<span class="attribution"><span class="source">(AP Photo/Toby Talbot)</span></span>
</figcaption>
</figure>
<p>Once produce is sent from the farmers’ fields to processing plants, there are other potential sources of microbial contamination, including the water used to wash the produce and the equipment used to cut up the leafy greens. </p>
<p>Further along the food chain, at the retail store, if the produce is not bagged, there is also the chance for cross-contamination in the store from raw foods — for example, from cutting boards and counters that have been in contact with raw meat, and which haven’t been properly disinfected between uses. </p>
<h2>More produce-related outbreaks now?</h2>
<p>It appears that there are now more cases of illness due to produce. There are a few reasons for this.</p>
<p>Firstly, there has been a large increase in the sale of bagged greens and salad kits as consumers are making an effort to try to eat more fruits and vegetables.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/202671/original/file-20180120-110113-fvw7m8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/202671/original/file-20180120-110113-fvw7m8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/202671/original/file-20180120-110113-fvw7m8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/202671/original/file-20180120-110113-fvw7m8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/202671/original/file-20180120-110113-fvw7m8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1131&fit=crop&dpr=1 754w, https://images.theconversation.com/files/202671/original/file-20180120-110113-fvw7m8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1131&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/202671/original/file-20180120-110113-fvw7m8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1131&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A grocery store worker stocks prepackaged salads at a Toronto shop.</span>
<span class="attribution"><span class="source">(CP PHOTO/Frank Gunn)</span></span>
</figcaption>
</figure>
<p>Secondly, we’re getting much better at detecting and stopping food-borne outbreaks in their tracks due to a new molecular typing technique referred to as <a href="https://www.fda.gov/Food/FoodScienceResearch/WholeGenomeSequencingProgramWGS/">whole genome sequencing (WGS)</a>, which is a much more sensitive typing method than ones public health officials have been using. </p>
<p>WGS identifies pathogens isolated from food or environmental samples. These can then be compared to clinical samples isolated from patients. </p>
<p>The technology has proven to be extremely valuable in making a link between a food-borne illness and a contaminated food. Previously, outbreaks caused by contaminated produce were either missed, or a food product could not be linked to illnesses because of the poor sensitivity of the typing method. Thanks to WGS, those links are now more quickly identified and tied to a specific fruit or vegetable.</p>
<h2>Trace an outbreak back to a certain farm</h2>
<p>In some cases, it may be straightforward to trace a contaminated produce item back to a certain field or farm. However, in other cases, because of the complex distribution systems, there may be a co-mingling of products from many different farms going into one central farm distribution centre, which then ships products to Canada. </p>
<p>This can make it extremely difficult to trace a product back to its source. </p>
<p>A lot of progress, however, has been made toward the ambitious goal of being able to quickly trace contaminated produce back to its field of origin. One example of this is the <a href="https://www.producetraceability.org/">Produce Traceability Initiative</a>, an organization sponsored by North American produce associations that helps the industry track fruits and vegetables.</p>
<h2>Why no romaine recall?</h2>
<p>In the most recent outbreak, there was epidemiological evidence collected initially that found an association between the human cases and the consumption of romaine lettuce. </p>
<p>However, in spite of all the evidence that was gathered during the outbreak in Canada, no common supplier, distributor or retailer of romaine lettuce was identified <a href="https://consumersunion.org/news/cu-urges-health-officials-to-take-more-aggressive-steps-to-identify-source-of-e-coli-outbreak-as-cdc-reports-more-illnesses/">as a possible source of the outbreak. </a></p>
<p>In fact, people reported eating romaine lettuce at home, restaurants, fast-food chains and from prepared salads bought at grocery stores, further complicating the picture. </p>
<p>In addition, all test samples of romaine lettuce in question were negative. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/202855/original/file-20180122-182955-s9ebqg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/202855/original/file-20180122-182955-s9ebqg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/202855/original/file-20180122-182955-s9ebqg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/202855/original/file-20180122-182955-s9ebqg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/202855/original/file-20180122-182955-s9ebqg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/202855/original/file-20180122-182955-s9ebqg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/202855/original/file-20180122-182955-s9ebqg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">In the e. Coli recent outbreak, those who became ill reported eating romaine lettuce at home, in restaurants and at fast-food outlets.</span>
<span class="attribution"><span class="source">(AP Photo/Matthew Mead)</span></span>
</figcaption>
</figure>
<p>It therefore becomes difficult for regulatory agencies to do a recall when they can’t pinpoint the actual origin of the product. Further complicating the issue is lettuce’s relatively short shelf life. In most cases much of the product that caused the illnesses has already been consumed or spoiled, and so isn’t available for tracing information or microbiological analysis.</p>
<p>Furthermore, regulatory agencies don’t want to issue a recall too quickly because of public pressure. </p>
<p>For example, in the late 1990s, a big food-borne outbreak occurred due a protozoan parasite called <em>Cyclospora</em>, and the outbreak was quickly blamed on Californian strawberries. </p>
<p>However, the outbreak was later linked to <a href="http://www.foodsafetynews.com/2013/07/last-big-cyclospora-outbreak-was-traced-to-guatemalan-raspberries/#.WmSjIbQ-fq0">Guatemalan raspberries</a>. The mistake caused the California strawberry industry millions of dollars. </p>
<h2>Did Canadian health officials do the right thing?</h2>
<p>On Dec. 11, 2017, officials at the Public Health Agency of Canada said that they were investigating the outbreak of <em>E. coli</em> 0157 linked to the consumption of romaine lettuce, which was occurring in three provinces. </p>
<p>On Dec. 14, the notice was updated to include two additional provinces, Ontario and Nova Scotia, which had reported illnesses linked to the outbreak, bringing the total number of cases to 30 cases, including one death.</p>
<p>On Dec. 21, the notice was updated to include 10 additional cases (a total of 40 cases) and advised consumers in Ontario, Quebec, New Brunswick, Nova Scotia and Newfoundland and Labrador that they should consider consuming other types of lettuce instead of romaine until more was known about the outbreak and the cause of contamination.</p>
<p>Furthermore, on Dec. 28, the notice was again updated to include one additional case, and stated that there is still an ongoing risk of <em>E. coli</em> infections associated with the consumption of romaine lettuce in Canada’s eastern provinces.</p>
<p>Finally, on Jan. 10 of this year, <a href="https://www.theglobeandmail.com/news/national/e-coli-outbreak-linked-to-romaine-lettuce-appears-to-be-over-health-agency/article37568371/">federal officials put out a notice stating that the outbreak appeared to be over</a> and that the overall risk to Canadians had returned to low. At this point, they were no longer advising individuals in affected provinces to avoid romaine lettuce.</p>
<p>Thus, consumers in Canada’s eastern provinces were told for about 20 days not to eat romaine, and it took about 10 days from the start of the outbreak until they were told this. </p>
<p>Is this a reasonable time period? Should there have been a recall of romaine lettuce in the affected provinces? </p>
<p>I think so. </p>
<p>Some stores pulled romaine lettuce and others kept it on the shelves, confusing the consumer. </p>
<p>This outbreak in particular would benefit from a post-mortem analysis to see what, if anything, could have been done better and what consumers truly understood in light of all the warnings and social media chatter.</p>
<h2>Should consumers wash their pre-washed bags of produce?</h2>
<p>Consumers do not need to wash their packaged triple-washed bags of leafy greens, and can actually make things worse if they do, as during the course of washing, they can cross-contaminate the product. </p>
<p>If consumers feel better doing the extra wash, they should use safe-handling practices to avoid any cross-contamination. Start with hand-washing for 20 seconds with warm water and soap before and after handling the product.</p>
<p>Then it’s critical that consumers wash their cutting boards before using (of course as well as dishes, salad spinners, utensils, and countertops) to avoid cross-contamination between, for example, raw meats and ready-to-eat leafy greens. Plastic cutting boards can be placed in the dishwasher to be disinfected. </p>
<p>When you’re washing your cutting board by hand, you should first rinse off any visible debris and then scrub the cutting board with soap and water. Finally, you should <a href="http://www.eatright.org/resource/homefoodsafety/four-steps/wash/safe-care-and-washing-of-cutting-boards">be sanitizing the cutting board.</a></p>
<p>Bagged leafy greens should of course also be refrigerated, and consumers should consume the product before its best-before date. </p>
<h2>Reducing consumer risk</h2>
<p>Firstly, consumers should buy their produce from reputable retail operations. </p>
<p>When shopping, keep your fruits and vegetables separated from raw meat, poultry and fish to prevent cross-contamination</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/202672/original/file-20180120-110121-s2ih6w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/202672/original/file-20180120-110121-s2ih6w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/202672/original/file-20180120-110121-s2ih6w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/202672/original/file-20180120-110121-s2ih6w.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/202672/original/file-20180120-110121-s2ih6w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/202672/original/file-20180120-110121-s2ih6w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/202672/original/file-20180120-110121-s2ih6w.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Wash your produce under running water.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>At home, store your fruits and vegetables in the refrigerator in a produce drawer separate from the raw meat, poultry or fish. Follow the aforementioned washing techniques.</p>
<p>Wash your hands with hot, soapy water for at least 20 seconds before and after handling fresh fruits and vegetables, and wash them well under running water (do not use soap or chemicals), including those that come from farmers’ markets, roadside stands or your home garden.</p><img src="https://counter.theconversation.com/content/90230/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jeffrey M. Farber does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The recent E. coli outbreak in North America was linked to romaine lettuce. Many such outbreaks are often linked to fresh produce. Here’s what you need to know to keep your family safe.Jeffrey M. Farber, Professor of Food Safety, University of GuelphLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/842272017-09-25T16:58:33Z2017-09-25T16:58:33ZWhat’s driving multiple outbreaks of cholera in Nigeria<figure><img src="https://images.theconversation.com/files/187354/original/file-20170925-17375-owq8gy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A woman takes an oral cholera vaccine in a hospital. But cholera vaccines are not always effective and never long lasting. </span> <span class="attribution"><span class="source">REUTERS/Andres Martinez Casares</span></span></figcaption></figure><p>This year, 16 of Nigeria’s 36 states have experienced <a href="http://www.ncdc.gov.ng/reports/weekly">cholera outbreaks</a>. This has <a href="http://www.ncdc.gov.ng/reports/weekly">resulted in</a> 1,622 suspected cases of the disease and 33 deaths. This is a steady increase in cholera cases after a remarkable sharp decline, from a total of 5,301 cases (186 deaths) in 2015 to 768 cases and <a href="http://www.ncdc.gov.ng/reports/weekly">32 deaths in 2016</a></p>
<p>Lagos witnessed the last outbreak in <a href="http://www.ncdc.gov.ng/reports/15/2016-november-week-45">October 2016</a> but in the last couple of weeks there have been outbreaks in Nigeria’s Lagos, Kwara and Borno states.</p>
<p>Regional disparities in the death rates from cholera expose the different levels of emergency preparedness and health resources available. Understanding why this threat persists can help health authorities to reduce it, in Nigeria and elsewhere.</p>
<p>Cholera is an intestinal infection characterised by <a href="http://www.webmd.com/a-to-z-guides/cholera-faq#1">watery stool and diarrhoea</a>. It is caused by the Vibrio cholerae, a bacterium, which releases toxins in the human intestine. This toxin activates excess secretion of water from the intestinal lumen that often lead to severe dehydration and sometimes death. Conditions that can lead to outbreaks include a disruption in water supply, poor basic sanitation and poor hygiene. Infected people show symptoms within two to five days. They can spread the disease <a href="http://science.jrank.org/pages/1450/Cholera-Transmission-cholera.html">even when they are not ill themselves</a> by shedding the bacteria in their faeces. </p>
<p>As in other developing countries, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3428179/">cholera outbreaks occur mainly during the rainy season in Nigeria</a> although they also sometimes occur in dry season. Flooding can cause septic tanks to contaminate surface water, especially open wells used for <a href="http://www.water-research.net/index.php/bacteria">drinking and food preparation</a>. Contaminated flood water from the rains can also flow to vegetables and fruits which, if not properly washed, can cause an outbreak. </p>
<p>Cholera outbreaks happen when groups of people share infected water or food. When this happens, many people will require help at the same time. Health facilities and resources are often inadequate and ill-prepared to deal with such pressure. </p>
<p>The outbreaks in different parts of Nigeria are often driven by different factors. What they all point to, however, is that the country has not yet taken sufficient steps to address the “epidemiological triangle” that drives cholera outbreaks – host, agent and environmental factors. This includes early detection, better and stronger sanitation infrastructure that can withstand heavy rains as well as basic health infrastructure.</p>
<h2>The outbreaks and what caused them</h2>
<p>Lagos is the commercial centre of the country, with a densely settled population of <a href="http://worldpopulationreview.com/world-cities/lagos-population/">over 20 million people</a>. It lies along the coast and is prone to <a href="http://www.ncfnigeria.org/about-ncf/item/81-lagos-ncf-call-for-actions-to-save-coastal-areas">flooding</a>. Despite the enormous efforts put into strengthening its primary health care system, it <a href="https://www.vanguardngr.com/2017/07/diarrhoea-outbreak-lagos-2-dead-25-quarantined/">recorded 27</a> suspected cases of cholera and two deaths in July 2017. The outbreak has been attributed to heavy rainfall which eroded water sources, and <a href="http://www.informationng.com/2017/07/cholera-outbreak-lagos-2-persons-killed-25-others-hospitalised.html">to people getting help too late</a>. </p>
<p>To reduce the number of outbreaks in the future, Lagos must tackle the factors that cause flooding. It must also take decisive steps to relocate residents from the most flood prone areas and improve on environmental sanitation and public health campaigns.</p>
<p>Kwara State recorded 17 deaths from over 1,000 suspected cases. Health authorities there attributed the outbreak to <a href="http://thenewsnigeria.com.ng/2017/06/kwara-confirms-cholera-outbreak/">contaminated fruit consumed to break the Ramadan fast</a>. In 2011, 12 deaths were recorded from cholera outbreak and although the health authorities were silent on the cause, the residents blamed it on <a href="https://www.dailytrust.com.ng/news/health/cholera-outbreak-claims-over-12-in-kwara/200744.html">heaps of refuse that had not been removed</a>. The state’s growing population seems to have surpassed its <a href="https://www.thecable.ng/cholera-kwara-environmentalist-perspective">waste disposal infrastructure</a> </p>
<p>Borno State recorded the most serious outbreak of the three states. This northeastern state is the epicentre of the battle against the Islamic militant group Boko Haram. The outbreak affected the camp set up to accommodate people who had been displaced by the conflict. About 20,000 people are sheltered in this camp on the outskirts of Maiduguri, the Borno capital. The camp is overcrowded and <a href="https://www.vanguardngr.com/2017/09/14-people-die-cholera-borno/">lacks good amenities</a>. People there are poorly nourished and don’t have clean drinking water and sanitation.</p>
<p>Conflicts usually result in the destruction of infrastructure and disruption of services. This has worsened the situation in Borno, which already lagged behind other parts of Nigeria in <a href="http://www.unocha.org/nigeria/about-ocha-nigeria/about-crisis">social development</a>. Health facilities are poorly equipped and staffed, and women in particular have low levels of education which usually means lower earnings, poor choices, slow reaction to illnesses and <a href="https://www.ahrq.gov/professionals/education/curriculum-tools/population-health/zimmerman.html">low problem solving abilities</a>. These factors add to the risk of disease outbreaks and deaths. </p>
<h2>Why cholera endures</h2>
<p>It has been difficult to eradicate cholera because of the “epidemiological triangle” of host, agent and environmental factors. </p>
<p>Humans are the hosts. They carry and spread the disease. A person who has received treatment and is healthy again is still capable of spreading the infection to others. Vaccines are <a href="http://www.who.int/mediacentre/factsheets/fs107/en/">not very effective or long-lasting</a>. </p>
<p>Vibrio cholerae is the agent. It is ingested from contaminated food or water. The organisms that survive the stomach’s acidity travel to the small intestine of the human host, where they multiply. The bacteria <a href="https://www.ncbi.nlm.nih.gov/books/NBK8407/">attach to the mucous membrane of the intestines and can stay</a> there for years.</p>
<p>The environmental factors include poor access to clean, safe water and the lack of basic sanitation facilities. </p>
<p>To prevent and wipe out cholera, it’s necessary to interrupt the host-agent-environment relationship. This can be achieved through more effective vaccines, improved host immunity, water chlorination and better ways of disposing of sanitary waste. </p>
<p>In poor countries, the lack of standard infection prevention and control in health facilities adds to the risk of <a href="http://www.who.int/csr/resources/publications/4EPR_AM2.pdf">diseases spreading</a>. Health workers need to be continuously trained to detect, correctly diagnose and manage cases of cholera in a safe and effective manner. </p>
<p>Eradicating cholera and other diarrhoeal diseases in Nigeria will require a multi-sectoral approach. The ministries of water resources, rural development, urban planning and health must contribute, and government must show the political will to invest in infrastructure as well as health sector development.</p><img src="https://counter.theconversation.com/content/84227/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Doyin Ogunyemi does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Many states in Nigeria are reeling from cholera outbreaks. They need better health and sanitation infrastructure to disrupt transmission of the bacteria which cause the disease.Doyin Ogunyemi, Public Health Physician and Lecturer, College of Medicine, University of LagosLicensed as Creative Commons – attribution, no derivatives.