Date of Award

January 2023

Document Type

Open Access Thesis

Degree Name

Master of Public Health (MPH)


School of Public Health

First Advisor

James Hadler


Background: Enterotoxigenic Escherichia coli (ETEC) is known colloquially as “traveler’s diarrhea” in the United States. The state of Connecticut (CT) began collecting data about ETEC in 2019. As few clinical laboratories in CT routinely test for ETEC, it is likely that current detection and reporting methods, in conjunction with trends in healthcare-seeking behavior, only capture a small proportion of ETEC cases. Methods: Data were obtained from the CT Department of Public Health (DPH), the 2019 FoodNet Population Survey, and the 2020 US Census. The demographics of ETEC cases 2019-2022 and the 2020 CT population were compared. A multivariate analysis was conducted to identify potential risk factors for ETEC exposure. A probabilistic multiplier model was utilized to estimate the true burden of ETEC in CT from 2019-2022. Results: The population groups experiencing the largest ETEC burden were non-Hispanic whites, Hispanics, and 18–44-year-olds, while the highest relative risk was among Hispanics and <18-year-olds. Approximately 38% of cases reported recent international travel. The most significant risk factors for domestic exposure included recent contact with farm animals or contact with an individual experiencing diarrhea. We estimate that only 32% of domestic and 30% of international travel-associated ETEC cases who seek medical care and submit clinical specimens for testing are being diagnosed with ETEC. We further estimate that another 85.6% of ETEC cases never seek medical care or do so but do not get diagnostic specimens taken. Conclusions: The burden of ETEC in CT is inadequately captured by current methods for detection. As the incidence of domestically-acquired ETEC grows, priority should be placed on increasing the testing capacity for ETEC in CT clinical laboratories. This will increase detection among those who seek care from providers who send diagnostic specimens to clinical laboratories that do not test for ETEC.


This is an Open Access Thesis.

Open Access

This Article is Open Access