Bacterial Gastroenteritis in Nicaragua

Bacterial Gastroenteritis in Nicaragua

Montezuma's Revenge, typically caused by Entertoxigenic E coli (ETEC), is well known to travellers to Central America. The bacteria is a home grown problem too. In a 1997 study of infants in Leon, Nicaragua, ETEC were the cause of 38% of diarrhea episodes. 

Enterotoxigenic E coli, courtesy of Stanford Medicine.

There are many other bacteria that cause bloody diarrhea and abdominal cramps. The table below lists the more common causes.

Bacteria	Possible Source	Incubation (days)	Antibiotic
Aeromonas	meats, seafood	0	Cefixime
Campylobacter	dairy, meats, poultry	2 to 4	Erythromycin
Cholera (Vibrio)	seafood	0 to 1	Tetracycline, Sulfa/Trimeth
Enterotoxigenic  E coli		1 to 3	Sulfa/Trimeth Quinolone
Enterhemorrhagic E coli	meats	1 to 8	None
Listeria	dairy	20 hrs	Ampicillin Sulfa/Trimeth
Salmonella	dairy, eggs, meats	0 to 3	Ampicillin Sulfa/Trimeth Quinolone
Shigella		0 to 2	Ampicillin Sulfa/Trimeth Quinolone
Staph aureus	dairy, meats	2 to 6 hrs
Yersinia	pork	0 to 6	Sulfa/Trimeth Quinolone

The "Possible Source" column clarifies why I avoid dairy (milk, cheese, yogurt, ice cream) and why I am very fussy about meat when I travel.

These bacteria include some of the classic tropical diseases such as Cholera and Typhoid (Salmonella). Shigella is one of the famous causes of dysentery in the tropics. Enterhemorrhagic E coli is the cause of Hemolytic Uremic Syndrome (Hamburger Disease), which was a huge part of my clinical life several decades ago when I was the Head of Paediatric Nephrology at the University of Calgary.

Most bacterial infections have a incubation period that lasts a few days. The exception is food poisoning with Staph aureus, which only requires a few hours of incubation. I experienced Staph aureus food poisoning in 1978 when I was competing in a 505 (international class two-man sailboat) qualifying event in Rhode Island. The local club prepared ham, cheese, and mayonnaise sandwiches for lunch and the fleet was on the water for about 6 hours. Within a few hours of eating I was nauseous and started to vomit. That day I crewed for one of Canada's Olympic Team. He didn't eat the sandwiches and he didn't get sick. My performance suffered, and he was not patient with me. On one tack I came in off the trapeze and kicked a new and very expensive watch off his wrist. A full gale blew in and we reduced sail and limped home. We finished twelfth in a fleet of about 80 boats. Four boats were lost in the gale. When we arrived back at the club, half the sailors were retching on the beach or on their way to the local hospital. I realized that we all had Staph aureus food poisoning, which is a self limited illness, so I rested on the beach, drank lots of fluids, and the episode passed as an interesting memory.

My personal preparations for the winter trips to Nicaragua will include booster immunizations for Typhoid and Cholera. While in Nicaragua, I will avoid dairy and only eat meat that I either cook or that is prepared by someone I trust.

To help treat bacterial gastroenteritis in Nicaragua, I will bring all of the medications in the list above, except Tetracycline, which is contraindicated in children.

Diarrhea Folklore in Nicaragua

Diarrhea Folklore In Nicaragua

Traditional "folklore" explanations and treatments are common in communities without modern medical care. Nicaragua is no exception.

According to a recent study, at least 12 types of diarrhea are recognized by Nicaraguan mothers. A basic classification in a paediatric text usually lists only three causes depending on whether the infection is due a virus, a bacteria, or a parasite.

Even without exposure to routine modern health care, most Nicaraguan mothers recognize that diarrhea is mostly about hygiene. The table below lists the causes recognized by the mothers.

Spanish	English
por la suciedad	because of dirtiness
falta de higiene	lack of hygiene
por las moscas	because of flies
las pachas sucias	dirty baby bottles
manos sucias	dirty hands

Some mothers have the mistaken belief that diarrhea is due to a problem with breastmilk. According to this erroneous belief, breast milk can be spoiled by eating cabbages or avocado during breast feeding, excessive maternal exposure to heat or sun, strong emotion or sadness, or breastfeeding while pregnant. Based on this folklore, Nicaraguan mothers sometimes stop breastfeeding, which makes the illness worse.

The table below lists the symptoms of diarrhea described by mothers.

Spanish	English
obra churre	bowel movements are loose
le pega llorazon en la barriga	belly cries
como si fuera agua	as if it were water
obra exigido	child has demanding defecations
obra seguido	child defecates continuously
ensucia mas de lo necesario	child dirties more than necessary
le pega maleza en el estomago	stomach becomes ill
obra ralo	child defecates liquid
obra demasiado	excessive defecations
se le afloja el estomago	stomach is loose

A small percentage of Nicaraguan mothers believe in causes that are not conventional. The table below lists some of these folklore causes.

Spanish	English
ojo	caused by the evil eye
pujo	caused by the presence of a drunk or sweating person or a woman in her first pregnancy
colerin	from eating pork from a pig that was enraged "con la colera del animal"

Folklore about parasitic infestation is common. The blood and pus in the stool is because the parasite knows how to bite the intestine. Children with parasites sleep with their eyes open, grind their teeth, drool, and eat but do not gain weight. The full moon stimulates parasites to move around in the intestine. Garlic is a good remedy and can be worn around the neck or rubbed on the belly.

Folklore treatments are common and the confidence of the mothers in these interventions is sometimes greater than their confidence in modern medical interventions. Folklore interventions include camomile, guava in leaves, bark and buds, hibiscus roots, granate, sago starch, achote, guasimo, and cinnamon.

Reference
Vázquez ML, Mosquera M, Kroeger A. People's concepts on diarrhea and dehydration in Nicaragua: the difficulty of the intercultural dialogue. Bras. Saude Mater. Infant. vol.2 no.3 Recife Sept./Dec. 2002.