Talk:Wilderness acquired diarrhea/Archive 1

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Archive 1

Rockwell study

Is giardiasis a threat in outdoor recreation?

Robert Rockwell, an engineer by training, quotes James Wilkerson's Medicine for Mountaineering and Other Wilderness Activities. (The Mountaineers, 4th edition, 1992):

"In recent years, frantic alarms about the perils of giardiasis have aroused exaggerated concern about this infestation. Government agencies, particularly the U.S. Park Service and the National Forest Service, have filtered hundreds of gallons of water from wilderness streams, found one or two organisms (far less than enough to be infective), and erected garish signs proclaiming the water hazardous."

Rockwell also quotes two researchers who surveyed health departments in all states and scanned the medical literature looking for evidence that giardiasis is a significant threat to outdoor people:

"Neither health department surveillance nor the medical literature supports the widely held perception that giardiasis is a significant risk to backpackers in the United States. In some respects, this situation resembles (the threat to beachgoers of) a shark attack: an extraordinarily rare event to which the public and press have seemingly devoted inappropriate attention." (Welch, Thomas R. and Welch, Timothy P.: Giardiasis as a Threat to Backpackers in the United States: A Survey of State Health Departments. Wilderness and Environmental Medicine, Vol. 6, 1995)

In his exhaustive article, Rockwell concludes that untreated surface water in the Sierra Nevada is generally safe to drink. He notes that "Giardia and other intestinal bugs are for the most part spread by direct fecal-oral or food-borne transmission, not by contaminated drinking water. Since personal hygiene often takes a backseat when camping, the possibility of contracting giardiasis from someone in your own party someone who is asymptomatic, probably is real. Recalling that up to 7 percent of Americans, or up to 1 in 14, are infected, it is not surprising that wilderness visitors can indeed come home with a case of giardiasis, contracted not from the water...but from one of their friends."^[1]

References

^ Giardia Lamblia and Giardiasis by Robert L. Rockwell, June 4, 2003, Loma Prieta Chapter of the Sierra Club website. Accessed Nov 6, 2006.

Discussion

This material was removed with the edit summary : "original research". To the best of my reckoning, all research is original. The Wikipedia policy, WP:NOR, prohibits only original research by editors. It is a corollary of WP:V, because all information must be verifiable by other editors. Original research (in the WP sense) would be if I attended a baseball game and then wrote about the crowd reactions, or some other detail not elsewhere reported. In this case, we can all verify that the study exists, so we aren't engaged in original research when we report its contents.

While original research isn't a problem, Rockwell's credentials are slightly problematic. He doens't report any training in life sciences. However looking for microbes through a microscope isn't rocket science, and he is a rocket scientist. He appears to have conducted his study rigorously. It was published in "Yosemite Association News Letter #4", cited in papers, and reportedly posted by all federal agencies. So it has been widely accepted as legitimate. The paper appears to have good general information on giardia in addition to the actual study. -Will Beback 07:31, 9 November 2006 (UTC)

You may be right. I think I've read several policy pages that support my decision, but the only one I can find right now is Wikipedia:Verifiability#Sources. --Smack (talk) 05:49, 10 November 2006 (UTC)

Half a loaf is better than none. What other sources do we have for this article? -Will Beback 09:12, 10 November 2006 (UTC)

None that I know of. Outdoor recreaction is painfully short on wiki-reliable sources. --Smack (talk) 06:17, 12 November 2006 (UTC)

Re: "He doens't report any training in life sciences." Here's some info on his dissertation, NONLINEAR ANALYSIS OF PRESSURE- AND SHOCK WAVES IN BLOOD VESSELS by ROCKWELL, ROBERT LAWRENCE Ph.D., Stanford University, 1970, 123 pages. http://disexpress.umi.com/dxweb#search Although this is in the category of life sciences, so far there doesn't appear to be any evidence that he has any credentials in a science related to his article.

Re: "However looking for microbes through a microscope isn't rocket science, and he is a rocket scientist." So far there does not appear to be any evidence that he was looking for microbes through a microscope. Bob K31416 (talk) 23:12, 1 July 2008 (UTC)

Rockwell certainly didn't do any original research. His paper has 66 citations that are all highly legitimate. He points out that National Geographic, after contacting him, published an article that verified his information.

I haven't looked into each one, but I see Rockwell's paper has been cited a number by a number of books, peer-reviewed papers, and other publicaitons.[1] ·:· Will Beback ·:· 23:34, 1 July 2008 (UTC)

Specifically, which ones do you think we can use to help evaluate the Rockwell paper? Bob K31416 (talk) 04:14, 2 July 2008 (UTC)

This one seems to be the most relevant: "Risk Factors for Coliform Bacteria in Backcountry Lakes and Streams in the Sierra Nevada Mountains: A 5-Year Study" Aside from helping us to determine Rockwell's suitability, it looks like a good source on its own. Now we just have to get hold of the actual article. ·:· Will Beback ·:· 04:35, 2 July 2008 (UTC)

I agree, it appears to be very relevant. Since it is so new (June 2008), I doubt that it is free anywhere online. Have you tried accessing it online through the Los Angeles Public Library system? Bob K31416 (talk) 06:10, 2 July 2008 (UTC)

I can't find it on any of the online databses I have access to. I can add it to my list of things to look up next time I go to a research library. ·:· Will Beback ·:· 22:53, 3 July 2008 (UTC)

Good luck. Also, the journal that it appears in, Wilderness and Environmental Medicine, may be a good place to browse and search for more sources. Bob K31416 (talk) 15:55, 5 July 2008 (UTC)

Exactly What is the Rockwell Paper's Conclusion?

Rockwell 2003
At the beginning of the article the advice is to "drink freely and confidently" in the High Sierras. This suggests that the risk of pathogens there is negligible. This is supported, for example, by suggesting that Sierra water has less Giardia than San Francisco tap water, according to the paper's interpretation of some studies.

But then the reader is cautioned to "drink smart" and the term is defined according to a number of rules about where to drink in the Sierras. So in this instance, the Rockwell paper is suggesting that there is a non-negligible risk from pathogens in a significant portion of Sierra water and this somewhat risky water can be avoided by "drinking smart".

For example, one of the "drink smart" rules is:

"Taking water from a lake is best advised at the inlet, with the next best place at the outlet. Inlet water has a tendency to flow somewhat directly to the outlet, undergoing little mixing with the lake water as a whole."

In other words, one concludes from this rule that Sierra lake water has a non-negligible risk from pathogens. If Rockwell thought Sierra lake water was safe, he wouldn't have included this rule.
Bob K31416 (talk) 08:03, 4 July 2008 (UTC)

This wiki's quote of Rockwell's quote of James Wilkerson

Here's the quote:

Building on previous skeptics, Rockwell quotes James Wilkerson's Medicine for Mountaineering and Other Wilderness Activities (Seattle, Washington: The Mountaineers Books, 4th edition, 1992):

"In recent years, frantic alarms about the perils of giardiasis have aroused exaggerated concern about this infestation. Government agencies, particularly the U.S. Park Service and the National Forest Service, have filtered hundreds of gallons of water from wilderness streams, found one or two organisms (far less than enough to be infective), and erected garish signs proclaiming the water hazardous."
_____________________________________
The language of this second-hand quote from 1992 and the lack of a source to substantiate any of the info in the original quote suggests that it is not reliable. Specifically,

1) It refers to "...frantic alarms about the perils of giardiasis..." No source was given to substantiate that there have been frantic alarms. This extreme statement does not appear to be objective or reliable.

2) "...U.S. Park Service and the National Forest Service...erected garish signs proclaiming the water hazardous." There's no source given to support this remark and the language again appears to be extreme and of questionable reliability or a possible misrepresentation.

Also, the allegations are for 1992 or earlier and are not very current, and weren't even very current for the year of the Rockwell article which was 2003.

This quoting someone who quotes someone else is effectively introducing questionable info that should be supported by a reference but isn't. Thus it should be deleted. --Bob K31416 (talk) 22:16, 21 July 2008 (UTC)

I don't agree

The notion that Wilkerson lacks credibility seems a bit beyond the Pale. His book is regularly updated and has for many years been considered the leading work of its kind. Indeed, that is why Rockwell quotes from it.

The reason why Wilkerson is so widely held in high esteem is partly because the work covers advanced first aid instruction that extends to things like tracheotomy and IV delivery for lay persons in extremely remote situations.

But more importantly perhaps, each edition is written by multiple physicians and additional physicians are editors and reviewers. Wilkerson is merely the lead editor.

The publisher is "The Mountaineers" which also produces regularly revised editions of what has been for several decades, the foremost comprehensive mountaineering textbook in the U.S., using a similar process with dozens of writers and editors. I formerly owned a copy of Wilkerson, and vividly recall the quote in question.

Similarly, to even raise a question about the validity of Rockwell's work is unjustified. Rockwell's paper is currently carried on a Web page of the National Park Service, among many others, and it was summarized and confirmed by National Geographic Magazine. He has updated it several times over the past decade and it is meticulously sourced. I have seen primary researchers quote from his paper.

As there are numerous, highly credible sources suggesting that the whole topic of "wilderness diarreha" is a non-issue, I think it sorely misleads the reader to relegate Rockwell and the work of various researchers whom he cites into a "controversy" section. This material ought to be incorporated high up in the body of the article. Calamitybrook (talk) 03:50, 22 July 2008 (UTC)

The issue wasn't Wilkerson, nor his book as a whole, nor the publisher of the book. The issue was a particular quote.

I couldn't find the National Park Service (NPS) webpage that you mentioned that had Rockwell's paper but I did find this webpage of sierranevadawild.gov that has a link to an earlier online publication of Rockwell's article. Perhaps this was the webpage that you were referring to, http://sierranevadawild.gov/features/water-is-it-safe-to-drink Here's an excerpt from that webpage of sierranevadawild.gov which appears to focus on the Sierra Nevada,

"Some of us dream of the good old days…days when you could dip your sierra cup into the nearest mountain stream and take a long refreshing drink—sans filtering. Do you really need to filter your water? Maybe… maybe not. New research sheds some light one of the oldest debates in the sierra: is the water safe to drink? Three articles are featured here that address this question. Do your reading and make up your own mind!"

There is an NPS webpage about giardia that was not focused on the Sierra Nevada, like the Rockwell article was, but probably applied to the national parks as a whole. It is a warning about giardia but not to the extent that is represented by the Wilkerson quote as "frantic". Evidence to support this warning regarding wilderness water is in one of the references about Appalachian Trail hikers that appears in the present wiki, Boulware2003. But we should keep in mind the phrase at the beginning of the Controversy section, "...conditions naturally change according to geography and time." So the conditions on the Appalachian Trail may be different from the conditions in the High Sierras and each may vary with time. Also, the conditions in the High Sierras may be different from the conditions in the Low Sierras. The NPS warning was a general warning for the park system as a whole.

Regarding the notion that the magazine National Geographic Adventure (NGA) confirmed Rockwell's article, it seems that it reported Rockwell's point of view and also reported other points of view, rather than confirming any of the points of view that it reported. That's the job of NGA since it is a magazine, not a scientific journal. Here's the ending of the NGA article,
__________________________________________________________
"Drinking freely in the backcountry can be exhilarating, but know that the choice to do so is always a calculated risk. A few tips for safe guzzling:

* Water is less likely to be contaminated during the spring (the cysts cannot survive freezing winter temperatures), and at higher elevations, where there is less human and animal traffic. The farther water has traveled, the more opportunity it has had to pick up contaminants.

* Cold water from large, fast-flowing streams is your best bet. The colder the water, the more likely it is to be freshly melted and the less likely it is to be contaminated. Given the option, drink from streams that cross the trail rather than run parallel to it.

* At a lake or pond, drink from the inlet or, your next best choice, the outlet. Beware of bodies of water in depressed, swampy areas or near heavily used campsites. Head uphill or upstream for your source.

* On extended backcountry trips, always carry an emergency water-treatment option. Iodine tablets are cheap, light, and effective against many bugs."
__________________________________________________________
Regarding the suitability of putting the topic of potability of backcountry water in a section called Controversy, I agree that it is inappropriate and I tried to change the title of the section, only to have it reverted without reason. Furthermore, recall that this topic was originally in an article of its own, titled "Potability of backcountry water". Without any discussion it was abruptly moved to "Wilderness diarrhea" and considerably changed to put the emphasis on diarrhea rather than potability. I felt that was an inappropriate move and the potability topic should remain in a separate article. Unfortunately I'm new to wikipedia and I don't know enough to change it back and defend the article from future manipulation which may be inappropriate. I would appreciate any help from an experienced editor that agrees and who knows how to correct this situation. --Bob K31416 (talk) 20:29, 22 July 2008 (UTC)

Combining sections

I've added reference to some material from an academic from Tulane Unversity's School of Public Health, T.R. Welch, which is similar to the Rockwell material.

I've also combined the two previous sections and removed a bit concerning Rockwell's quote of Welch, which seemed somewhat redundant after adding direct reference to Welch.

There may be a slight problem with my edits regarding POV, but I can't find any scientific material that counterbalances the view that backcountry water is generally potable.

This article has been around for a number of years and nobody has offered any verifiable countervailing material to Rockwell or Welch, both of whom, one must reasonably assume, made a good faith effort to review all available published research.

It's my opinion that there may be sound reasons for filtering water in certain places, but I and I don't think mere opinion is adequate here. I'm hoping somebody can jump in with solid material.Calamitybrook (talk)

The Welch and Rockwell sources are good, but they are far from comprehensive. Welch is just talking about Giardia (which is very often misdiagnosed by people who never see a doctor - I think the Rockwell paper discusses this), and Rockwell is just talking about the Sierra Nevada. Given the lack of ongoing monitoring for backcountry water sources, I don't really expect any definitive sources to show up, but we should cite what is available. There are also factors such as "can the average hiker understand the difference between a stream which contains runoff from a cattle pasture and one which does not" which is a public education issue. Don't know if that one has been studied (e.g. surveys of hikers or some such). I don't think the article has major POV problems, but we probably could do better at bringing across caveats like distinguishing the areas which undisturbed watersheds versus many popular areas for outdoor recreation which are not so pristine. Based on the Derlet data, I think we can say "backcountry water is generally potable" in places like the High Sierra, but that is pretty much the most favorable definition of "backcountry". Kingdon (talk) 14:59, 17 March 2008 (UTC)

The move of Potability of backcountry water to a subsection of Wilderness Diarrhea

Why was this move made?

This was a significant action that was made without any discussion.

There was too little information in the very brief summary "better title" to understand the reason for the move, especially since the action was much more than simply a change in the title. Also, note that "Wilderness diarrhea" would have been an inappropriate title for an article about water quality where diarrhea was only mentioned once.

So why was Potability of backcountry water moved to a subsection of Wilderness diarrhea? Bob K31416 (talk) 13:41, 5 July 2008 (UTC)

(Please see further comments on this subject in the next section, Definition of wilderness diarrhea.) Bob K31416 (talk) 21:29, 5 July 2008 (UTC)

Definition of wilderness diarrhea

A part of the definition of wilderness diarrhea, which appears in the first sentence of the wiki, seems too limiting.

"Wilderness diarrhea (WD), also called backcountry diarrhea, is a variety of traveler’s diarrhea (TD) afflicting backpackers, hikers, campers and other outdoor recreationalists during temporary visits to relatively remote protected areas."

The symptoms of giardiasis, for example, usually take at least a week to appear after being infected. If one considers only the cases where the diarrhea appears during a traveller's temporary visit to the backcountry, then only a small percentage of the people who contract symptomatic giardiasis would have wilderness diarrhea, according to this definition.

Maybe it is the intention of this wiki to limit discussion to the small percentage of cases of infection where the onset of diarrhea only occurs in the backcountry where medical aid is more difficult to access.

In any case, it doesn't seem reasonable to subordinate the larger topic of Potability of backcountry water to the smaller topic of Wilderness diarrhea. However, I appreciate some of the changes and additions to the topic of Potability of backcountry water that were made. But those nice improvements could have been made without subordinating it. It seems like the two topics Potability and WD should be in separate wikis with links between them. Bob K31416 (talk) 02:22, 6 July 2008 (UTC)

The definition of Wilderness diarrhea was changed without justification and it was initially defined without giving a source. Initially WD was defined for the case of the diarrhea occurring while in the wilderness. It was changed to the case of being infected in the wilderness but not necessarily having diarrhea in the wilderness. This is a significant change because it affects treatment, impact, and the incidence of the condition. Editors are not allowed to make their own definitions of medical conditions because that would be original research. A source for the definition of Wilderness diarrhea is needed to determine which definition is correct. --Bob K31416 (talk) 04:28, 17 July 2008 (UTC)

An attempt was made by an editor to address the above with a citation of the article “Epidemiology of Wilderness-acquired Diarrhea: Implications for Prevention and Treatment”. Unfortunately, this article does not use the term "Wilderness diarrhea". It uses only the term "Wilderness-acquired diarrhea". So a citation that defines "Wilderness diarrhea" is still needed. --Bob K31416 (talk) 02:15, 18 July 2008 (UTC)

A second attempt was made by the editor to address the above with a citation of the journal article "Laboratory Evaluation of the 3-Bowl System Used for Washing-Up Eating Utensils in the Field". Although the term "Wilderness diarrhea" was used in the article, I could not find anything in that article that supported the definition in the present wiki. The definition of "wilderness diarrhea" in the present wiki includes the case where the symptoms may first show up after leaving the wilderness and I couldn't find anything in the cited journal article to support this definition. --Bob K31416 (talk) 20:12, 18 July 2008 (UTC)

"Wilderness diarrhea" is not really a medical term, unless every term used by a doctor is a medical term. For example, it's not in Merck's Manual, nor any medical dictionary. How else would one define a "medical term?

Calamitybrook (talk) 04:15, 22 July 2008 (UTC)

Problem with Reference #2

Bear with my writing here: Within the reference section, there is a long quote from the cited paper's introduction. Much of that introduction concerns expeditionary travel in the third world. This isn't explained.

The quoted material says 75 percent of "adventure trip" participants get diarrhea. However, the actual author of this statement cites with a source footnote, the article "Health problems and self-medication among Swedish travellers" (Scand J Infect Dis. 1994;26:711–717). That Swedish article, appears to be about traveling in third-world countries rather than "wilderness" areas as generally understood by the reader.

I guess I can half-way see the earlier point about a quote by Wilkerson by Rockwell. But in that instance, no such difficulty in fact arises. Because reference 2 isn't strictly speaking, about diarrhea in the wilderness at all, whereas Wilkerson and Rockwell were very much on the same page...

Also, reference #4 suggests that something like 50%+ of people who spent 7 days on the Appalachian Trail reported some form of diarrhea at the immediate conclusion of the hike. This material is included in the body of the main article. E coli is generally from livestock, of which there is little on the AT. Giardiasis requires about six days' incubation time.

No reports were confirmed in a laboratory.

Unlike the author of this reference, I'm not qualified to publish medical papers. But I'm dumbfounded. It simply doesn't sound plausible. I'm all for including this material, maybe in the "Controversy" section, but it must be balanced by the far greater amount of material that suggests a risk level in the 3-5% range or lower.
[The previous unsigned comments were by Calamitybrook (talk) 06:04 and 06:09, 22 July 2008 ]

Regarding ref#4 study of Appalachian Trail hikers, they spent a minimum of 7 days on the trail. The average number of days spent on the trail by the hikers in the study was 139 days. ("Two hundred and eighty backpackers compiled 38,940 wilderness exposure days...") These were very long hikes! So if they got infected they had plenty of time to experience diarrhea on the trail from all sources including giardia. --Bob K31416 (talk) 01:31, 26 July 2008 (UTC)

Runners' Diarrhea?

I just found this described on a Mayo Clinic Web page [[2]]. It says, among other things, that dehydration can cause diarrhea. And come to think of it, I had one episode of puking and diarrhea, in the wilderness, that was apparently from mild heat exhaustion according to a doctor who was accompanying me. Is diarrhea in the wilderness the same as "Wilderness Diarrhea?"

And speaking of dehydration, has anyone studied the side-effects of freeze-dried dinners? Calamitybrook (talk) 14:12, 27 July 2008 (UTC)

Certain Research Suggests Overstatement of Risk

I've done some major stuff to this and changed the heading from "Controversy." I don't think the researchers cited in the section regard their work as particularly controversial, nor do I know of any direct challenges to their work. I certainly can't find any sources to suggest otherwise.

The material I removed is fully laid out in other sections of the article and is therefore redundant. I recast the material from Welch and moved him to the top, since it's apparently the most comprehensive stuff, research-wise, that's presented in the section. I then added Derlet, because he has a medical credential and is nearly as well known as Rockwell on this subject, at least California press accounts.

I added material from Wilkerson, which was subsequently added to further by anther editor, whowever, I somewhat recast this section, which I'm no longer convinced belongs in this section (Maybe a new section?)

I'm going to add relevant material from Zell here also.

It looks like currently, Boulware is the only source in this article that fully supports the notion that Wilderness Acquired Diarrhea is much of a topic. The material cited for Joanna Hargreaves seems to concern third-world environments.

Boulware is criticised directly by Welch, essentially for being simplistic and one might suppose, implicitly by Zell for "failure to follow basic principles of epidemiological research." —Preceding unsigned comment added by Calamitybrook (talk • contribs) July 29, 2008 (UTC)

The material in the "Controversy" section (which I've renamed as such) certainly is controversial! This is evidenced by the fact that the most authoritative textbook (Auerbach's) not only doesn't cite Welch or Rockwell but contradicts their points of view without discussing them. Rockwell and Welch are marginal & not cited in peer-reviewed literature as far as I can tell... 140.139.35.250 (talk) 13:01, 29 July 2008 (UTC)

1) Re: "I don't think the researchers cited in the section regard their work as particularly controversial"

The controversial aspect has been pointed out numerous times by quotes in this article. The quote from Wilkerson's book for example,

"In recent years, frantic alarms about the perils of giardiasis have aroused exaggerated concern about this infestation. Government agencies, particularly the U.S. Park Service and the National Forest Service, have filtered hundreds of gallons of water from wilderness streams, found one or two organisms (far less than enough to be infective), and erected garish signs proclaiming the water hazardous."

Please recall that I deleted this quote previously but you (Calamitybrook) reinstalled it. I was partly motivated by a desire to move the focus away from discussing controversy to discussing water potability in the backcountry.

2) Re: "nor do I know of any direct challenges to their work."

The Boulware study is a significant challenge to their work. In his editorial, Welch failed to mention or respond to the important finding in the Boulware article regarding the significantly increased incidence in diarrhea of those who didn't treat their water or did so inconsistently, compared to those who consistently treated their water. Furthermore, Welch gave much more weight to an article that appeared in the magazine Backpacker, than the Boulware article which appeared in a peer-reviewed scientific journal.

--Bob K31416 (talk) 16:37, 29 July 2008 (UTC)

3) Re: "Boulware is criticised ... one might suppose, implicitly by Zell for "failure to follow basic principles of epidemiological research."

Boulware wasn't criticized by Zell since the comment that was attributed to Zell was made in 1992 and Boulware's article was in 2004. --Bob K31416 (talk) 11:57, 30 July 2008 (UTC)

I completely agree with BobK31416 in critiquing the three previous statements: On #1: Clearly it is controversial to claim that backcountry water is generally no problem & ought not be treated before drinking. Gimme a break! The major textbooks say it, the Park service says it, your family doctor will say it... Welch & Rockwell are a (small) minority position, not even cited in the textbooks... On #2: They are not so much challenged in the major textbooks as IGNORED. (As non-peer reviewed noise usually is.) On #3: This is just sloppy, sloppy, sloppy.... It is important to get the chronology right. 140.139.35.250 (talk) 13:50, 30 July 2008 (UTC)

Re: "(As non-peer reviewed noise usually is.)"
It looks like Welch's main article regarding this subject appeared in a peer-reviewed scientific journal called International Journal of Infectious Diseases. --Bob K31416 (talk) 22:44, 30 July 2008 (UTC)

Agreed. IJID is peer-reviewed. But his essay in Wild. Med. (where he gets most radical) is not. (Essays are not usually peer-reviewed as they are expected to be personal opinion.) 140.139.35.250 (talk) 17:28, 31 July 2008 (UTC)

Reversion to "Controversy

In the interest of neutrality, walling off a report of this other research (the stuff other than Boulware) in a section headed "Certain Research Suggests Overstatement of Risk" is a highly neutral way of reporting on alternate information. The apparently sacrosanct POV of this article can remain intact, and the additional information merely reported in a neutral manner.

The only direct challenge to any research cited anywhere in this article that I've been able to locate, is from Welch, who directly questions the validity of Boulware's work for very specific reasons, which he clearly explains. Other than that, I find no instances of challenge.

Unless one can cite more than one instance, to label this fairly wide range of research as a "controversy" would seem non-factual and a matter of personal interpretation or one's POV. Perhaps in light of this, you can give some justification for your reversion?

When you call Auerbach "the most widely used textbook" where you are getting this information? But a textbook certainly isn't a work of research.

Also, to what "peer reviewed" literature are you referring with regard to Welch? Doesn't, for example, Zell cite him? It seems pretty clear to me that the entire subject of WAD is a marginal subject for research to begin with, outside the Journal of Wilderness Medicine, which isn't exactly JAMA in terms of influence and prestige. WAD ain't cancer, so it's probably not going to change very quickly, if at all. And these continued questions about Rockwell seem a bit unworldly. He's simply a well-respected guy. Part of the problem is an apparent confusion about primary and secondary research. Both are equally valid and useful research activities.

A much more critical point to make however, is that this article urgently needs more sources of primary research besides the questionable Boulware, to show that WAD is a problem worthy of consideration. Welch, et al., have made a fairly good and sustained and successful effort to show that there aren't any such additional sources, but I think there probably are. —Preceding unsigned comment added by Calamitybrook (talk • contribs) July 29, 2008 (UTC)

Boulware is not questionable. He is cited in Auerbach, the definitive textbook (if it's not the definitive one, what is!). Boulware's first paper is published in the American Journal of Medicine, a peer-reviewed journal more prestigious than Wilderness Med. As for Welch, he has NOT been successful at much of anything. He has not even been accorded the credibility of a citation by the real authorities (Backer, DuPont, etc... world authorities on traveler's diarrhea) in their Auerbach chapter. They merely negate his point of view without mentioning him or his papers. 140.139.35.250 (talk) 14:00, 30 July 2008 (UTC)

This review in the journal Wilderness and Environmental Medicine calls Auerbach “the definitive work” of the subspecialty of wilderness medicine. 140.139.35.250 (talk) 14:13, 30 July 2008 (UTC)

Response to Recent Comments

To understand how and where Welch directly criticizes and challenges Boulware, it is necessary to read his editorial as well as his relevant footnote. I gave a fair representation of his criticism of Boulware in the "controversy" section but didn't explain the mechanics about the necessity of reading Welch's footnote etc.

Zell's more general complaint that "most studies rely upon observation and fail to adhere to the principles of basic epidemiological research" could obviously be applied to Boulware, although unlike Welch, Zell doesn't specifically mention Boulware. There are one at least or two other studies (mentioned by Welch) besides Boulware to which this criticism could apply (which would explain Zell's choice of words._

If a medical research team was studying cancer, would they do a man-on- the street survey and ask people whether they had the disease and whether they smoke cigarrettes etc?

I concede the point about controversy. My interpretation of "controversy" was too narrowly intended to mean cases like Welch's direct challenge to Boulware. It's the only instance where I can find one researcher directly criticizing the work of another on this topic, although I am certainly not able to look at the whole picture in the manner of a true secondary researcher.

I am impressed by the review on Auerbach. I was simply uninformed. Although at $199 per copy, I think "Medicine for Mountaineering" (nothing to sneeze at) will probably remain a far more widely read book.

As for "peer review" comments, I don't know. Is "JWM" peer reviewed?

I am remined of this story [[3]] in the New York Times about a peer-reviewed journal that was hoaxed into publishing a completely nonsensical article in the early 1990s.

Not that I'm suggesting anything like that has happened concerning this topic. But it's an amusing story nonetheless.

Still, whatever the actual merits of Boulware, Zell, Welch, Derlet, and Rockwell, I'd still challenge any editor to come up with more research sources for this article on the "non-controversial" point of view. As it stands now, the sourcing is obviously unbalanced in favor of the controversialists.—Preceding unsigned comment added by Calamitybrook (talk • contribs) July 31, 2008 (UTC)

Now I've almost completely re-worked "controversy section," adding more specific information, cutting some stuff I'd previously added. Net result should be greater clarity, without appreciably expanding its length. Calamitybrook (talk) 06:15, 31 July 2008 (UTC)

Added some material on Auerbach and Backer, giving, I think, some nuance to their views.Calamitybrook (talk) 07:17, 31 July 2008 (UTC)

Good comments & good improvements to the "Controversy" section. (I'm glad we agree that it is a controversy!) 140.139.35.250 (talk) 17:30, 31 July 2008 (UTC)

Re: "To understand how and where Welch directly criticizes and challenges Boulware, it is necessary to read his editorial as well as his relevant footnote. I gave a fair representation of his criticism of Boulware in the "controversy" section but didn't explain the mechanics about the necessity of reading Welch's footnote etc."

Is this the part of the TR Welch editorial that you were referring to, and were you referring to footnote 8 as the "relevant footnote"?

The only prospective study examining individuals entering an area thought to have high levels of water contamination yielded no cases of symptomatic giardiasis.⁷ Interestingly, some subjects in this study did develop diarrhea, but they did not have evidence of Giardia lamblia. This reminds us that infection is only 1 of the myriad causes of changing bowel habits during or after a trek. Unfortunately, this lesson has not been learned by others studying the subject.⁸

7. Zell SC, Sorenson SK. Cyst acquisition rate for Giardia lamblia in backcountry travelers to desolation wilderness, Lake Tahoe. J Wilderness Med. 1993;4:147–154.

8. Boulware DR. Influence of hygiene on gastrointestinal illness among wilderness backpackers. J Travel Med. 2004; 11:27–33.

--Bob K31416 (talk) 22:55, 31 July 2008 (UTC)

Hmmm... I misread it as referring to Boulware's "Risk" article. I will remove that bit because it's not as clear as I thought. However, Welch clearly isn't saying that there are myriad causes of infection, he is saying infection is one of myriad causes.

I still think that was a dig by Welch at Boulware. What's your interpretation.....? Maybe it ought to go back in. Calamitybrook (talk) 00:26, 1 August 2008 (UTC)

On second thought, I think it's pretty clear and restored the bit for the time being.Calamitybrook (talk) 00:47, 1 August 2008 (UTC)

Here is the part in question (which is based on the above excerpt from the TR Welch editorial) and was deleted and then restored by Calamitybrook,

In the same editorial for the Wilderness Medical Society [13] he was highly critical of studies by D.R. Boulware,[4] which relied on self-reporting and self-diagnosis by backpackers, and which Welch said failed to recognize "that infection is only one of the myriad causes of changing bowel habits during or after a trek." (See reference to Boulware's studies in "Risk" section above.)

Note that TR Welch did not criticize Boulware for "...self-reporting and self-diagnosis by backpackers..."

Re: "...which Welch said failed to recognize 'that infection is only one of the myriad causes of changing bowel habits during or after a trek'."

It's not clear what Welch means. Does the "only one" cause mean infection by Giardia from water, or infection by Giardia from any source, or is it infection by any pathogen from any source? He doesn't specify any of the other "myriad causes".

--Bob K31416 (talk) 17:05, 1 August 2008 (UTC)

Let's look carefully at Welch's statement.

He believes there are many causes of diarrhea that may affect hikers. He believes infection with bacteria or virus is one of these causes. He believes there are many causes other than infection.

His footnote to this statement refers readers to a study by Boulware, who infers, assumes or states, that all diarrhea among those responding to his surveys, was caused by an unspecified infection.

Welch is thus using the work of Boulware as an illustration of his statement. Interestingly, Boulware's work was not included in TP Welch's meta-analysis, apparently because of its nature and design.

Here (once again) is the complete paragraph:

"Regardless, studies of this topic in the peer-reviewed medical literature continued to be scarce. The only prospective study examining individuals entering an area thought to have high levels of water contamination yielded no cases of symptomatic giardiasis.7 Interestingly, some subjects in this study did develop diarrhea, but they did not have evidence of Giardia lamblia. This reminds us that infection is only 1 of the myriad causes of changing bowel habits during or after a trek. Unfortunately, this lesson has not been learned by others studying the subject.8

8. Boulware DR. Influence of hygiene on gastrointestinal illness among wilderness backpackers. J Travel Med. 2004; 11:27–33."

Does that help somewhat?

Somewhat related to your observation that Welch doesn't mention other causes (he was writing an opinion piece essentially for other doctors), I've added something to the "Causes" section, and am open to discussion on this.

Here's what I added:

It may be that some backpackers experience a variant of so-called runners' diarrhea that affects up to 30 percent of marathoners and is unrelated to infection. This condition, which could be confused with "Wilderness Diarrhea," may result from the diversion of blood from the bowel to the working muscles. Severity depends on the level of effort, response of the individual's bowels, conditioning and degree of dehydration. Diet can be a factor exacerbating the problem. 1 2

I've also been at work tightening "Controversy" language, and made a few similar edits elsewhere, and I've moved recent "Talk" (this stuff) chronologically to bottom of this page.

Calamitybrook (talk) 17:36, 1 August 2008 (UTC)

Another revision prompted by Bob: In "Causes," it now reads:

Frequently, bacterial or viral infection is not the cause of diarrhea in physically active persons, including hikers and atheletes. Causes can include dehydration, the diversion of blood from the bowel to the working muscles (gut ischemia), certain foods and fluids, or the use of tobacco and alcohol, or medications. 1. Severity of gut ischemia depends on the level of effort, response of the individual's bowels, conditioning and degree of dehydration. 2 3 —Preceding unsigned comment added by Calamitybrook (talk • contribs) 20:47, 1 August 2008 (UTC)

Re: "Frequently, bacterial or viral infection is not the cause of diarrhea in physically active persons, including hikers and atheletes. Causes can include dehydration, the diversion of blood from the bowel to the working muscles (gut ischemia), certain foods and fluids, or the use of tobacco and alcohol, or medications. 1."
Do you have a reference to a study that has found that these causes of diarrhea are a problem for hikers that is of any significance compared to pathogens?

A more general comment regarding your editing. Please note that your extremely active editing is very difficult to keep up with. Much of it I don't agree with. I expect that it will eventually be carefully edited to a form that is significantly different from what you have done. Also, rest assured that I will endeavor to explain significant changes that I make. --Bob K31416 (talk) 10:40, 2 August 2008 (UTC)

Under "Risk" I've added Zell's mention of two studies suggesting infection rate of 3% and his mention of another involving a single group where infection rate was 14%.

Under "Cause" in addition to gut ischemia, etc., I've added giardia viability info. I may add a little to Zell section of "Controversy" Calamitybrook (talk) 22:03, 1 August 2008 (UTC)

Re-Write

I've extensively re-worked the wording of this article for readability, using care to retain all content in sections not added previously by me.

Within each existing section, I've re-written awkward sentences, removed unnecessary words and redundancies, and sought to put the most relevant information that each section contained near its top through reorganizations. I've also replaced the abbreviation WD with "Wilderness Diarrhea" and incorporated a few other stylistic changes.

I've tried to provide an improved basis for further editing.

In a number of sections, I've added material, while retaining a NPOV.Calamitybrook (talk) 14:50, 2 August 2008 (UTC)

Bob: re. gut ischemia, etc., The included references says these problems, which cause diarrhea, are very common among "physically active people and athletes" (as is widely known in any case). Hiking up mountain trails with a heavy pack is nothing if not athletic and dehydration-inducing. In fact the NYTimes today has an article about many U.S. Olympic atheletes routinely hiking Pikes Peak for training. Honestly, I don't think additional references are necessary or useful, but the paragraph now includes five sources.

In an article concerning information on the various forms of diarrhea that affect hikers, the reader is well-served by a couple of sentences about this particular and common form. Its omission would be a disservice.

Re. my editing. I've made frequent comments on it here, but can't comment on each one, the majority of which are minor.

—Preceding unsigned comment added by Calamitybrook (talk • contribs) 15:26, 2 August 2008 (UTC)

It's clear that you refuse to give any references that show that non-infective causes of wilderness diarrhea occur with any significance for backpackers. Also, you mentioned in the article that , "Non-imfective causes, however, are not by definition 'Wilderness Diarrhea'." Thus I am deleting the questionable paragraph. --Bob K31416 (talk) 17:18, 2 August 2008 (UTC)

Bob:

Please let's look closely at the lead statement of Putukian, a primary source for the paragraph.

"In Brief: Gastrointestinal symptoms in physically active persons can be caused by gut ischemia, dehydration, the use of tobacco and alcohol, medications, and certain foods and fluids."

Now let's talk briefly about abstract logic.

Not all "physically active persons" are backpackers. Backpacking requires that a person be "physically active." Therefore, all backpackers are "physically active persons."

So, at least according to this very simple form of logic, the lead statement applies to backpackers.

Please, can you suggest a different logical scenario so that your objections can be more fully understood? I would very much appreciate that. Thank you.

Other listed sources (including Auerbach) establish that the maladies discussed by Putukian are (as is generally known) common among the physically active. Heat strain and heat exhaustion are related to gut ischemia and dehydration, as sourced. —Preceding unsigned comment added by Calamitybrook (talk • contribs) 17:57, 2 August 2008 (UTC)

At least one problem is that you don't have a definition for the term "physically active person", as it was used in the beginning statement of the Putukian article titled, "Don't Miss Gastrointestinal Disorders in Athletes". There are many common uses of the term "physically active" that may not be the way it is used in the Putukian article. For example, one might say that a person is physically active if they walk 3 miles every day. You are saying that a person is "physically active" if they backpack. Putukian seems to be using the term to describe people who exercise at a higher intensity. In any case, she didn't include the sizable population of backpackers as one of the groups mentioned in her article.

It seems that you are unable to produce any article that says that non-infected diarrhea is of any significance compared to diarrhea from pathogens for the case of backpacking. Are you pursuing this because you thought that TR Welch was referring to non-infected diarrhea in his editorial? If that is the case, try looking in other articles of TR Welch to see if he discusses it there. On the other hand, perhaps in his editorial, TR Welch meant that infection by waterborne Giardia was only one cause, other pathogens were more causes, another was hygiene, and he used Boulware's article to support this point. --Bob K31416 (talk) 00:23, 3 August 2008 (UTC)

Bob Relative to your latest comment on Welch, it's rational to assume that a person means what they say. To suggest that Welch meant the opposite of what he actually wrote might be unreasonable.

Your other points are interesting. Will discuss later. —Preceding unsigned comment added by Calamitybrook (talk • contribs) 02:15, 3 August 2008 (UTC)

This might be helpful [[4]] Calamitybrook (talk) 02:52, 3 August 2008 (UTC)

Re: "Relative to your latest comment on Welch, it's rational to assume that a person means what they say. To suggest that Welch meant the opposite of what he actually wrote might be unreasonable."

The source of the problem is trying to understand TR Welch's remark out of context. Here is the comment with the sentences preceding it included.

The only prospective study examining individuals entering an area thought to have high levels of water contamination yielded no cases of symptomatic giardiasis.⁷ Interestingly, some subjects in this study did develop diarrhea, but they did not have evidence of Giardia lamblia. This reminds us that infection is only 1 of the myriad causes of changing bowel habits during or after a trek.

In the previous sentences the issue is infection by waterborne giardia, not infection by all pathogens from all sources. His point is that giardia can come from other sources such as inadequate hygiene which was found in the study by Boulware which he cites. Note that if TR Welch was trying to make some very subtle criticism of Boulware, he would have cited the 2003 Boulware article not the 2004 Boulware article that supports TR Welch's point that infection can come from sources other than water. Consequently, I am the deleting the associated sentence in the Controversy section of the article. --Bob K31416 (talk) 15:25, 3 August 2008 (UTC)

Conditions That May Be Confused With Wilderness Diarrhea

I think this addresses the objections. Calamitybrook (talk) 05:04, 3 August 2008 (UTC)

The creation of this section in the article is based on the unsubstantiated premise, previously discussed, that non-infective diarrhea occurs with any significance for backpackers in the wilderness compared with diarrhea from pathogens. The part that was copied from another section is more appropriately placed in the original section. The existence of any significant number of cases of non-infective diarrhea among backpackers in the wilderness, has not been supported by any reference and so far appears to be only the speculative idea of the editor. I am restoring the article to its previous form. --Bob K31416 (talk) 12:20, 3 August 2008 (UTC)

Below is the deleted section. I'd appreciate further discussion of this.

My understanding is that Bob believes that a study of gastrointestinal symptoms in 155 long-distance hikers is irrelevant and worthy of deletion, because this article applies soley to backpackers.

If this is so, then changes to the Definitions and lead sections might be helpful, so that they explicitly state that Wilderness Diarrhea can be acquired only by backpackers, and that diarrhea acquired in the wilderness by hikers, mountaineers, R.V. users, hunters, anglers and all other wilderness users, is not Wilderness Diarrhea. An an explanation for this definition could also be included, and certain other editing would be appropriate.

Alternately, the two paragraphs in question might be propertly restored to the article, either in a new or existing part of the article.

Also, the first paragraph of the deleted material was previously in the "Causes" section, where it is now restored by Bob. The second paragraph of the deleted section expands upon and supports its first paragraph, so I am restoring it under "Causes."

However, neither of these two paragraphs concern causes, and their current placement presents a problem for editors seeking to improve this article's organization.

Thus as things currently stand, only the final two grafs below are in any dispute.

Calamitybrook (talk) 15:02, 3 August 2008 (UTC)

Perhaps this will make my previous point clearer to you.

Compared to the number of cases of diarrhea from pathogens, the existence of any significant number of cases of non-infective diarrhea among people entering the wilderness has not been supported by any reference presented here so far, and appears to be only your speculative idea. You might want to pursue your idea in another setting since Wikipedia doesn't allow original research that hasn't been published elsewhere. --Bob K31416 (talk) 17:20, 3 August 2008 (UTC)

Deleted Section

It may be difficult to confirm that a particular case of diarrhea was acquired via infection occuring in the Wilderness because, in the case of giardiasis for example, incubation periods can vary from one to four weeks. Exposure to the bug outside the wilderness is exceedingly common via many potential vectors including hand-to-mouth fecal transmission, tainted food, public water supplies and other means.

Giardia is ubiquitous and may affect 7.5 million Americans at any one time, according to a report in the New York Times [[5]] More than 34,000 cases were reported to state health departments in 1991, including 19 outbreaks that were waterborne, and two affecting backpackers or campers. [[6]]. About 7% of Americans may carry the disease, although as few as 5% of an infected population may develop symptoms. [[7]]

Gastrointestinal distress unrelated to microbial infection is extremely common as a result of strenuous excercise [[8]] and may potentially be confused with Wilderness Diarrhea. A study of 155 men and women who walked an average of 26 miles a day for four days, found 24% of the subjects experienced gastrointestinal symptoms. No relationship was established between symptoms and age, gender, previous training, or walking speed. [[9]]

Factors in diarrhea related to exercise may include dehydration, the diversion of blood from the bowel to the working muscles (gut ischemia), certain foods and fluids, the use of tobacco and alcohol, or medications, heat strain and heat exhaustion. [[10]][[11]]

Calamitybrook (talk) 14:56, 3 August 2008 (UTC)

An editor, Bob, has made another deletion, this time a clear statement made by a researcher (Welch regarding Boulware) in the "Controversy" section, without offering a cogent explaination beyond speculating that perhaps the researcher meant something other than what he said in a rather simple sentence.

I'm wondering if this is a reasonable deletion, or if such an approach can in fact be widely applied to deletions in general?

Calamitybrook (talk) 16:38, 3 August 2008 (UTC)

The deletion was made because of your misinterpretation of what TR Welch said in his editorial. I described my reasons for the deletion in my 2nd comment in the above Re-write section. --Bob K31416 (talk) 17:34, 3 August 2008 (UTC)

Add Subheads To Lengthy Section

The "Controversy" section's length suggests that it benefits in readability, by use of the added subheads. Also, I tightened language in "textbook" section, without removing any of its ideas or content. —Preceding unsigned comment added by Calamitybrook (talk • contribs) 17:51, 3 August 2008 (UTC)

Interesting, the quote from "Wilderness Medicine" that says "most 'infectious' diarrhea acquired in the U.S. wilderness" is from water-borne pathogens. It's speculation that the word "infectious" was arbitrarily inserted by the author. Better to assume the author understood what he said. This point has an indirect bearing on the deleted study concerning 155 long-distance hikers.

Also, if I were to omitt Welch's mention of Boulware, I wonder of BobK would mind if I restored the Welch material that he deleted? At the moment, I simply don't care much about the Boulware/Welch point, and certainly don't want to get into an "edit war."

Calamitybrook (talk) 18:22, 3 August 2008 (UTC)

Re: "Also, if I were to omitt Welch's mention of Boulware, I wonder of BobK would mind if I restored the Welch material that he deleted?"

What were you referring to? Could you be more specific? Thanks. --Bob K31416 (talk) 11:31, 4 August 2008 (UTC)

Yes, certainly I can respond to a talk page question.

I may propose using some or all of this this material from Welch: "The only prospective study examining individuals entering an area thought to have high levels of water contamination yielded no cases of symptomatic giardiasis.7 Interestingly, some subjects in this study did develop diarrhea, but they did not have evidence of Giardia lamblia. This reminds us that infection is only 1 of the myriad causes of changing bowel habits during or after a trek. Unfortunately, this lesson has not been learned by others studying the subject."

Calamitybrook (talk) 15:21, 4 August 2008 (UTC)

Calamitybrook (talk) 15:21, 4 August 2008 (UTC)
________________________________________________________________

The above TR Welch quote that you are asking about contains information that is outdated, unclear, and redundant and is thus not suitable for this wiki.

outdated - the part of the quote regarding Zell's 1993 paper and "no prospective studies" is no longer correct since Boulware's studies, using rigorous epidemiological methods, were published in 2003 and 2004.

unclear - your misinterpretation of the quote demonstrates that it is unclear

redundant - the idea that giardia infection can come from sources other than water has been already expressed in the wiki

--Bob K31416 (talk) 16:09, 4 August 2008 (UTC)

Is this article turning into the style of a newspaper?

This article seems to have a very unusual style for the Wikipedia. It seems to be evolving into the style of a newspaper. So much naming of the authors of the references in the main text of the article, including their affiliations and other info, is strange in Wikipedia, but normal for a newspaper. Normally authors are only mentioned with their article info in the list of references.

And these new subsection headings that were just put in the Controversy section. They look like headings for stories in a newspaper with a POV.

Researcher: 3% Infection Rate Creates 'Hydrophobia'
Tulane Scientist Screens 104 Articles
34,348 Cases; 2 Among Campers
U.C. Scientist Tests 1,000 Samples
National Geographic: Giardia In Wilds 'Greatly Exaggerated'
Medical Texts Stand Pat On Disinfection

--Bob K31416 (talk) 18:51, 3 August 2008 (UTC)

As an example of changes we should make to correct the above situation, please see the changes I made to the subsection currently titled "Wilderness Giardia with particular attention to the Sierra Nevada" which was formerly titled "National Geographic: Giardia In Wilds 'Greatly Exaggerated'." (Also, please note the edit summary: Changed from POV newspaper style to NPOV Wikipedia style; did not change substance of info - see Discussion re "Newspaper") --Bob K31416 (talk) 15:14, 4 August 2008 (UTC)

Bob:

Just to clarify something fundamental, standard newspaper writing as practiced by for example, the Associated Press, strives for a neutral point of view. [[12]] According to this convention, opinion is reserved for the editorial pages.

Please be careful when stripping content from an article. Present specific and complete reasons on the talk page.

You've offered a general objection about what you perceive as "the style of a newspaper." Please specifically define this and offer reasons why this may not properly serve the reader. Please cite specific Wikipedia policies that aren't being followed. Also present reasoning for removing lead sentence of Rockwell section and its reference to national geographic. Thanks , Calamitybrook (talk) 16:12, 4 August 2008 (UTC)

When a newspaper article gives its sources, it does so in the text of the article like you did because it doesn’t use inline citations. In the Wikipedia this is redundant since that info is given by inline citations that refer to a list of references. Thus the redundancy was deleted.

Section titles in the Wikipedia should give a brief idea of what’s in the whole section. This is accurate but sometimes dry and unexciting. It seems that in a newspaper, story titles are selected to make the story seem as interesting as possible, sometimes with the tradeoff of accuracy. You chose the title "National Geographic: Giardia In Wilds 'Greatly Exaggerated'" It wasn't in National Geographic, it was in the less well known National Geographic Adventure. The section wasn't about the "Wilds" in general, it was about the Sierra Nevada. Since NGA was no longer relevant for the reasons mentioned below, I improved the title by using one that was derived from the title of Rockwell's article.

The NGA reference is superfluous since the Rockwell article citation applies to all the info in the subsection. As far as the info in the subsection is concerned, the NGA article reported what was in the Rockwell article. The reference to “widely quoted in the press” is not relevant since journalists do not peer-review scientific work, they report it, so it was deleted. However, discussions of these aspects can be made on the Talk page when trying to decide whether a reference is suitable for the wiki. What is relevant is that Rockwell’s paper didn’t appear in a peer-reviewed scientific journal nor did reference to it appear in the Auerbach book, but you didn’t mention these points while mentioning “widely quoted in the press”, which suggests POV.

Details about Rockwell himself are also inappropriate in the text but some editors may use them in discussions on this Talk page to help decide whether his work is a suitable reference for the wiki. Also, some editors may consider the “widely quoted in the press” aspect on the Talk page. If a source is of questionable reliability then it shouldn’t be cited in the article. So anything in the wiki text that has the purpose of showing that the author is competent and the source is reliable is superfluous and should be deleted. Aspects relating to source reliability should be brought up on the Talk page and discussed there.

Also note that after you posted your message, a Wikipedia administrator placed a notice at the top of the wiki’s page: “This article may require cleanup to meet Wikipedia's quality standards. Please improve this article if you can.” In the edit summary the administrator explained what “cleanup” meant: “{{cleanup}} - needs to be re-written in an encyclopedic style”. I think we should satisfy this request. What are your thoughts regarding this request?

--Bob K31416 (talk) 08:58, 5 August 2008 (UTC)

Generally some fair-enough points.

However, according to conventional editorial thinking, subheads serve the purpose of breaking blocks of type, which in itself makes things easier for the reader. Also conventionally, subheads summarize content and as such, also assist the reader. They can even assist the writer, by enforcing organization on his or her material (as in an outline) and in Wikipedia, serve to populate the table of contents with an outline of the article's content.

Regarding the added template, it includes a link, presumably carefully chosen, to the Wikipedia style manual. Style in this context refers to nuts-and bolts copy-editing matters rather to "style" as you have described it. For example, the Associated Press style book, which must be followed by A.P. editors, calls for writing out "percent," as in 5 percent. The Wall Street Journal style book call for 5%. The WJ and NY Times style books call for using Mr./Ms Mrs. on second reference to people. A.P. tells editors to omit this. There are a sizable number of questions like these, which, for the sake of editing consistency, require definite answers. Wikipedia style manual concerns itself exclusively with similar matters.

So the link (and I'd argue the template) is apparently irrelevant to the concerns you've raised. Calamitybrook (talk) 16:49, 5 August 2008 (UTC)

It appears that you have been unable to find any specific objection to the specific points that I made, which you requested. Furthermore, it appears that you have decided not to comply with the request of the administrator for cleanup. --Bob K31416 (talk) 21:39, 5 August 2008 (UTC)

Bob, I do agree about more fully identifying "National Geographic Adventure" and don't agree about removing a citable, relevant reference to an immediately recognizable national magazine with 600,000 circulation, especially without discussion. (My specific objection, obviously, is that it contains relevant information from a significant source.) Nevertheless, I leave the matter as it is, in compromise.

If were're still under the heading "Newspaper," I've tried to explain my point without reference to Wikipedia guidelines, but since perhaps this was inadequately specific, here's something from Wikipedia style guide "Writing Better Articles:"

News style Some Wikipedians advocate using a news style. News style is the prose style of short, front-page newspaper stories and the news bulletins that air on radio and television. The main feature of news style is a placement of important information first, with a decreasing importance as the article advances. This was originally developed so editors could cut from the bottom to fit an item in the available layout space. Encyclopedia articles do not have to follow news style, but a familiarity with this convention may help in planning the style and layout of an article.

As I tried to point out above, your premise that newspaper writing implies a point of view or that its basic principles don't apply to Wikipedia is incorrect. This muddies your objections, and makes them difficult to pinpoint. Is it a percieved "point of view" problem?

Regarding your objections to subheads, I tried to explain above some of the advantages of using subheads, alluding to the fact that they are highly standard in numerous other forms of publications including Wikipedia. I don't agree they present a problem per se; I do agree with the thrust of your single change to a subhead, although it's preferable to propose specific content changes before they're made. But again, perhaps I haven't been specific enough. I don't think citing "Writing Better Articles" on this point adds anything, but perhaps it's useful:

Headings Headings help clarify articles and create a structure shown in the table of contents... Headers are hierarchical, so you should start with level 2 headers (==Header==) and follow it with lower levels: ===Subheader===, ====Subsubheader====, and so forth. Whether extensive subtopics should be kept on one page or moved to individual pages is a matter of personal judgment. See also below under #Summary style.

Regarding embedded citations, a Wikipedia guidelines article by that name says the practice "is not particulary recommended" but adds that "One advantage of embedded links is that it is easy for readers and editors to check sources by clicking on the links and jumping immediately to the cited articles. Another advantage is that links are easy to create and maintain." As I mentioned above, I prefer them in a medium like Wikipedia for both reasons. However, I'm more interested in content than the particular format of citations. Please change the format if preferred.

Also mentioned previously the template's link to Wikipedia Manual of Style suggests that there are style issues. I've dilligently gone through the linked manual as suggested by the template, and can't find anything substantive. Please carefully review the link yourself, and perform work that it suggests relative to this article.

Beyond that, more specifics are helpful regarding what is referred to here as "clean-up" Calamitybrook (talk) 03:51, 6 August 2008 (UTC)

Please See Proposal

I currently think that the article gives too much weight to "controversy." I've stated something similar previously, and once again here suggest folding the "controversy" material into the main body of the article, in a truncated form.

I have a rough framework of a proposed revision on my page that does this, and is thus considerably shorter, and perhaps more readable, than current version. Please take a look and respond on this talk page.

Calamitybrook (talk) 16:49, 5 August 2008 (UTC)

The article needs to be cleaned up. --Bob K31416 (talk) 21:40, 5 August 2008 (UTC)

How will the proposed final version compare in size to the current version?

Are you proposing to only change organization and not add or delete substance?

Please note that I have been responding to the administrator's request for cleanup with edits. You will need to incorporate the cleanup in your final version, otherwise your proposed version probably won't be accepted.

Also, you can't expect editing to stop while you're working on your project, so you will need to incorporate any changes in your final version, otherwise your proposed version probably won't be accepted.

--Bob K31416 (talk) 02:36, 6 August 2008 (UTC)

I gather you haven't actually read the proposal. —Preceding unsigned comment added by Calamitybrook (talk • contribs) August 6, 2008 (UTC)

Hi. I was reading it and then I realized that it probably wasn't the final version and would change to something else and I would have to read it again. Is it the final version?

Although I could find the answer to my first question by simply comparing the size of the final version, when it appears, the answer to the second question would be extremely difficult and time consuming to determine. So can you answer the second question? Thanks.

--Bob K31416 (talk) 04:17, 6 August 2008 (UTC)

Thanks for the read. As you well know, there is no "final version." So I guess one can't be spared from "reading it again." As it stands now it's a proposed framework for ongoing editing, as is any article. As far as I'm concerned, it has all the elements I'd like to see, in roughly the proportion I'd like to see them. I think it retains all the earlier content, is accurate and far more concise and readable than what's up there now.

So what do you think of it?Calamitybrook (talk) 05:20, 6 August 2008 (UTC)

Re: As you well know, there is no "final version."

I didn't "well know". It appeared to me that you were putting together a contribution that you wanted people to look at. The format for discussion that you want is too difficult to work with. If you have a definite edit that you are proposing, I will look at that. If you could describe your plan, I will look at that. But to look at something that some or all of it may or may not be contributed to the wiki would not be worthwhile. Furthermore, you have so far refused to answer my question where I have tried to seek clarification of what you were doing, "Are you proposing to only change organization and not add or delete substance?" I'm trying to work with you, and it seems only fair that you should be trying too by answering my question. Thanks. --Bob K31416 (talk) 13:31, 6 August 2008 (UTC)

Am moving this from Bob's talk page to here at Bob's request. Calamitybrook (talk) 01:41, 7 August 2008 (UTC)

Bob: I'm glad you're willing to look at my proposal. When I say there is "no final version" I mean merely that Wikipedia articles are available for editing by anyone at any time, as you know.

I hope it's evident from the proposed changes that what I'm aiming for is to keep all of the current article's content and ideas and most of its present structure, thereby respecting and retaining work of various previous editors.

As you can see, the proposal is considerably shorter than the current version. This is achieved by mostly by de-emphasizing "controversy" and doing away with that section, while dealing with the ideas there in a few sentences.

I've also attempted to shorten many sentences without changing their meaning. Some other points are mentioned at the top of my page, right before the proposal's lead graf.

What do you think? Calamitybrook (talk) 15:07, 6 August 2008 (UTC)

Retrieved from "http://en.wikipedia.org/wiki/User_talk:Bob_K31416"

Your proposal reduced the number of references in the reference list from 16 to 7. Please give your reasons for deleting each of the 9 references. Thanks. --Bob K31416 (talk) 14:06, 7 August 2008 (UTC)

The commentary at the top of the proposal does say that a number of references need to be restored or fixed. It's may be premature to focus on that aspect of the proposal if the idea is to attempt to arrive at consensus. —Preceding unsigned comment added by Calamitybrook (talk • contribs) 00:07, 8 August 2008 (UTC)

Deleted subsection: "U.C. Scientist Tests 1,000 Samples"

There wasn’t any info in this section that is useful for a Wikipedia article for the following reasons: It reported personal info about Derlet, info that Derlet described as his “suspicion”, remarks without giving the references for the studies that they are based on, etc., so it was deleted. The sources for this section were a Q&A session at the REI website and a magazine type of article without references. --Bob K31416 (talk) 04:09, 6 August 2008 (UTC)

Thanks for posting this on "Talk." Please see my comments above on "proposal." Regarding this edit, if possible, an outline of thoughts on these points would be helpful:

why the source doesn't comply with Wikipedia guidelines [[13]].
why a "magazine type article" written by Derlet is insufficient reference to his studies.
how it's unclear that Derlet's advice is based on roughly 1,000 water tests that he has performed.
why Derlet's credentials aren't useful in evaluating his comments.
why material on a page titled "expert advice" is not useful to readers.Calamitybrook (talk) 05:15, 6 August 2008 (UTC)

______________

First of all, you didn't seem to comment on the specific reasons I gave above. Even so, I'll answer your comments, point by point. I hope that in the future you will give me the same courtesy.

why the source doesn't comply with Wikipedia guidelines - that wasn't one of the reasons I gave
why a "magazine type article" written by Derlet is insufficient reference to his studies. - they contained no citations to his studies
why Derlet's credentials aren't useful in evaluating his comments. - If Derlet's credentials were questionable they would be useful in a discussion on the Talk page where references are evaluated. His credentials are not an issue. What he suspects might be the case for Sierra water is his speculation and I loook forward to his findings when he eventually does the study that he seems to be proposing. Derlet's peer-reviewed journal articles are welcomed.
why material on a page titled "expert advice" is not useful to readers. - It is useful when it appears in a peer-reviewed journal where it is backed up with facts that are supported with citations. --Bob K31416 (talk) 13:11, 6 August 2008 (UTC)

Perhaps you need to shift gears and get away from the style of a newspaper in your approach to editing the Wikipedia. --Bob K31416 (talk) 13:47, 6 August 2008 (UTC)

For ease of reference, here is the deleted section:

U.C. Scientist Tests 1,000 Samples

Robert W. Derlet of the University of California-Davis School of Medicine and affiliate faculty member of the school's John Muir Institute of the Environment, estimates that he has tested about 1,000 water samples from the Sierra Nevada to date in what he expects will become a 20-year study. "I, along with other scientists believe that the risk of Giardia has been well overstated," says Deret, adding that "If one wants to be entirely safe, one could purify water, but my suspicion is that perhaps less than 1% of streams in the Sierra would have Giardia significant enough to cause infection in humans." [[14]]

Derlet says water in remote, less-traveled regions of the Sierra is usually free of waterborne pathogens (giardia lamblia, cryptosporidium parvum, et al.). He and various associates routinely drink untreated water in remote regions. Derlet adds that areas affected by cattle and livestock do present risk, and water there should be disinfected. In high-elevation regions of the Sierra, however, "I'd say there is less than a one in 100 chance that a person would get sick drinking untreated water" from side streams, Derlet says.[[15]] Calamitybrook (talk) 05:15, 6 August 2008 (UTC)

Controversy section

I've removed the title "Controversy" while keeping the subsections. I intend to look at what were the former subsections for redundancies with material elsewhere in the article and possible combining with other parts of the article. I will take it one step at a time, explaining each step, so that it is easy for other editors to see what I am doing and comment or object if necessary on any particular step. Thank you.--Bob K31416 (talk) 18:52, 7 August 2008 (UTC)

An invitation to everyone out there

Would any of you out there care to drop in and say Hi and give any of your thoughts about how the article is progressing or about anything else that has been going on here? Thanks. --Bob K31416 (talk) 02:37, 8 August 2008 (UTC)

Hello. Here is a suggestion that can be improved upon for Wilderness diarrhea#Degree of risk section.

The water below cattle is at a greater risk for contamination of coliforms. See --> Derlet RW (2008). "Backpacking in Yosemite and Kings Canyon National Parks and neighboring wilderness areas: how safe is the water to drink?". J Travel Med. 15 (4): 209–15. PMID 18666919. QuackGuru 18:05, 9 August 2008 (UTC)

Hi QuackGuru! That would be good to include in the wiki. Also, thanks for sharing that very recent (Jul-Aug 2008) article. In addition to the point that you mentioned, we could get together other similar points that are derived from data. One point has to do with spring water, where a study of Appalachian Trail hikers found that there was no significant relation between drinking untreated spring water and diarrhea. See -->p. 289 of Boulware DR, Forgey WW, Martin WJ 2nd (2003). "Medical Risks of Wilderness Hiking". Am J Med. 114 (4): 288–93. PMID 12681456.{{cite journal}}: CS1 maint: multiple names: authors list (link) CS1 maint: numeric names: authors list (link) Places to drink seem to range in safety from downstream from cattle, which seems least safe, to spring water, which seems most safe, with other types of places in between these two extremes. Again, thank you for your input. --Bob K31416 (talk) 02:31, 11 August 2008 (UTC)

If I am hiking out in the wilderness I need safe water to drink. This article begs the question. Is there a high quality portable water filteration device for people who are the outdoors type. QuackGuru 03:23, 11 August 2008 (UTC)

The "Prevention" section as currently written blatently contradicts itself. The relative merits of various water-treatment methods are described. Then comes the statement that discussing "the relative merits of various water-treatment methods serves no useful purpose", because personal hygiene is the important thing. Since these differing viewpoints are really reflected in the cited sources, perhaps it would be best to restore the "Controversy" section. 140.139.35.250 (talk) 14:28, 11 August 2008 (UTC)

Thank you for your useful input. The subject statement has been replaced by one that is substantiated by actual epidemiological studies in peer-reveiewed journals that refute it. However, the Prevention section still needs a discussion of how to improve personal hygiene to prevent infection and the Degree of risk section needs discussion of the risk from insufficient hygiene. Thanks again. --Bob K31416 (talk) 20:03, 11 August 2008 (UTC)

I've added info to Prevention and Degree of risk sections re hygiene. --Bob K31416 (talk) 16:51, 12 August 2008 (UTC)

How effective is a portable water purification system. QuackGuru 21:44, 11 August 2008 (UTC)

That's a good question. In an Appalachian Trail study of hikes averaging 139 days, inconsistently treating water resulted in 69% of the hikers getting diarrhea, whereas for those who consistently treated their water the diarrhea was reduced to 45% of the hikers. The data suggests that much of that 45% was due to insufficient hygiene (re hand washing, utensil washing in warm water) rather than bugs that got through the water treatment process. Off hand I couldn't say how much of that 45% could have been due to bugs getting through the water treatment systems. See --> Boulware DR (2004). "Influence of Hygiene on Gastrointestinal Illness Among Wilderness Backpackers". J Travel Med. 11 (1): 27–33. PMID 14769284. and Boulware DR, Forgey WW, Martin WJ 2nd (2003). "Medical Risks of Wilderness Hiking". Am J Med. 114 (4): 288–93. PMID 12681456.{{cite journal}}: CS1 maint: multiple names: authors list (link) CS1 maint: numeric names: authors list (link) An alternative or addition to filters, chemicals, or boiling is a new device that uses ultraviolet light to treat water. It's like a giant electric swizzle stick that you stir the water with while it's killing the bugs with UV. It's called a Steri-pen. --Bob K31416 (talk) 23:20, 11 August 2008 (UTC)

What to do with "Water disinfection" section

What substance there is in this section seems to be covered in other parts of the article. Any thoughts on what to do with it? Thanks. --Bob K31416 (talk) 18:40, 12 August 2008 (UTC)

Causes

In the Causes section of the article, re: "According to a different estimate, about 7% of Americans are infected with giardia from all sources..."

The source for this is apparently the Rockwell article, "Estimates vary, but fully 20 percent of the world’s population have giardiasis, and 4 to 7 percent of Americans, most without any symptoms at all.13, 15, 16, [30]". (See para 3 of the section- The bad news: Giardia lamblia is everywhere.)

Somehow, the editor who put this in changed 4-7% to 7%. Furthermore, checking the sources that Rockwell uses for this, it appears that his source is an article by Backer and the excerpt from the section Epidemiology and Transmission is, "In the United States, 7.2% of stool specimens examined by state diagnostic laboratories contained G lamblia (estimated prevalence of 2% to 5%) (5)" It appears that Rockwell misunderstood the prevalence of Giardia according to the Backer paper since it specifically stated that the estimated prevalence was 2-5%. Any thoughts on these two issues anyone? Thanks. --Bob K31416 (talk) 16:50, 13 August 2008 (UTC)

==

I think the fourth paragraph of "Causes" should be moved to the "Risk" section, since it concerns things that puportedly do not cause wilderness diarrhea. A listing or discussion of non-causes is potentially endless and would seem misplaced in a section on causes.

I propose replacing the first three paragraphs of "Causes" with the material below. The proposed lead sentence is an improvement because it more immediately addresses the headline. Vectors are introduced somewhat later, and grouped with the related question of where a particular case of diarrhea was contracted.

The remaining material provides improved information on the larger public health context within which wilderness diarrhea may be viewed, thus promoting a more complete understanding of the topic. It also provides a better reference for Giardia infection rates.

It documents that a simple change in exercise patterns or diet can cause non-infectious diarrhea. Likewise, because various outdoor activities are sometimes pursued to the point of exhaustion, it provides a discussion of athelete's diarrhea, with an example that concerns long-distance walking. It shows that this is a common malady that can be confused with infectious diarrhea.

Proposed 'Causes' Material

The most common causes of wilderness diarrhea are Giardia and Cryptosporidium ^[1], although several other organisms may play a larger role than generally believed [[16]] . Other infectious agents include Campylobacter, hepatitis A virus, hepatitis E virus, enterotoxogenic E. coli, e. coli 0157:H7, Shigella, and various enteric viruses. More rarely, Yersinia enterocolitica, Aeromonas hydrophila, and Cyanobacterium may also cause disease.

The vectors for infectious diarrhea, both within and outside wilderness, are limited to contaminated food, water, and hand-to-mouth transmission. It may be difficult to accurately associate a particular case with a recent wilderness visit, because incubation can vary widely, up to several weeks or more, while infection outside the wilderness is common.

In assessing a suspected case of wilderness diarrhea, it is helpful to view the disease within the larger context of intestinal complaints. There are an estimated 99 million annual cases of intestinal infectious disease in the United States [[17]] and within any given four-week period, as many as 7.2% of Americans may experience some form of infectious or non-infectious diarrhea [[18]]. The most common causes are viruses, followed by bacteria and parasites, including Giardia and Cryptosporidium. Giardia alone may infect up to 10% of Americans at any one time[[19]]. But because the large majority of those infected with Giardia are asymptomatic, there are only an estimated 2 million cases of giardiasis annually in the United States [[20]].

Other significant causes of diarrhea in the U.S. are non-infectious, and include medications, stress, or a change in eating or exercise patterns. [[21]]. Non-infectious gastrointestinal distress, including diarrhea, is a common result of strenuous excercise [[22]]. A study of 155 men and women who walked an average of 26 miles a day for four days, found 24% of the subjects experienced gastrointestinal symptoms. No relationship was established between symptoms and age, gender, previous training, or walking speed. [[23]] So-called athelete's diarrhea, whether experienced within or outside of the wilderness, may be confused with infectious diarrhea, and pathogens must be excluded by testing before a diagnosis is made [[24]].

Factors in diarrhea related to exercise aren't fully understood, but may include dehydration, the diversion of blood from the bowel to the working muscles (gut ischemia), certain foods and fluids, the use of tobacco and alcohol, or medications, heat strain and heat exhaustion. [[25]][[26]] Calamitybrook (talk) 20:38, 16 August 2008 (UTC)

Re: "I think the fourth paragraph of "Causes" should be moved to the "Risk" section" - I don't object.

I feel that the rest of your proposed changes need to be discussed. Let's start with your proposed replacement of the 2nd paragraph. Here's the current 2nd para,

It may be difficult to causally associate a particular case of diarrhea with a recent visit to the wilderness, lasting a few days or less, because incubation of some types of pathogens to sufficient levels to cause diarrhea, can take up to several weeks or more. Thus, the diarrhea may not be recognized as coming from a trip to the wilderness that occurred a few weeks earlier. On the other hand, in the weeks after the wilderness trip, people who weren't infected in the wilderness may get infected from sources that include public water supplies, swimming pools, contaminated food and hand-to-mouth fecal transmission, and the diarrhea may be incorrectly associated with the trip to the wilderness. Studies of longer trips into the wilderness^[2]^[3] are less susceptible to these types of errors since there is more time for the onset of the diarrhea to occur in the wilderness after a person is infected.

and here's your proposed replacement,

The vectors for infectious diarrhea, both within and outside wilderness, are limited to contaminated food, water, and hand-to-mouth transmission. It may be difficult to accurately associate a particular case with a recent wilderness visit, because incubation can vary widely, up to several weeks or more, while infection outside the wilderness is common.

The current para makes four points. 1) diarrhea may not occur in the wilderness for short visits because of the long incubation time. 2) Someone may not connect later diarrhea with the wilderness. 3) diarrhea acquired after the wilderness from outside the wilderness may be mistakenly thought to have come from the wilderness. 4) Studies of long wilderness trips, like the ave 139-day trips in the references, aren't very susceptible to these errors since the diarrhea most likely occurs in the wilderness. Your replacement only keeps point 3, whereas the other points are at least as important, so I couldn't go along with this replacement. Any thoughts?

There will be more to discuss, but let's settle this first. --Bob K31416 (talk) 06:47, 17 August 2008 (UTC)

=modified response

-- Brevity is a great virtue in writing. Context is also important and it may be difficult and less than optimal to discuss two sentences in isolation.

But as I understand you, there are two concerns; One is with deletion of the 139-day stuff about what you assume is the greater relevance of the Boulware material concerning the rate of infection. The inclusion of this material in a section labeled "Causes" tends to create confusion. Rate of infection is best discussed in the "risk" section, and it may be unnecessary to hit the Boulware material in two separate parts of the article.

Probably, you're more interested in preserving the notion that duration of a trip is relevant, an idea that according to my personal analysis is reasonable. I think an explict citation on this point would make it useful. In the proposed replacement material, the subject of time is included with its mention of "incubation period," and in the concept of "visit," which is of course temporary.

Your other problem seems to be with the elimination of this material:

"Thus, the diarrhea may not be recognized as coming from a trip to the wilderness that occurred a few weeks earlier. On the other hand, in the weeks after the wilderness trip, people who weren't infected in the wilderness may get infected from sources that include public water supplies, swimming pools, contaminated food and hand-to-mouth fecal transmission, and the diarrhea may be incorrectly associated with the trip to the wilderness."

This stuff repeats the ideas contained in the phrases "difficult to associate" "infection outside the wilderness is common," without adding useful information. In fact the second sentence quoted above "On the other hand.." in very large part repeats the vector information now in the current first graf of the section.

I've proposed moving the full description of vectors lower, where the idea that "infection outside the wilderness is common," gets amplified within a larger context and by added information on reference to 99 million annual cases of intestinal infection and etc. User:Calamitybrook|Calamitybrook]] (talk) 15:44, 17 August 2008 (UTC)

Re: "But as I understand you, there are two concerns; One is with deletion of the 139-day stuff about what you assume is the greater relevance of the Boulware material concerning the rate of infection. The inclusion of this material in a section labeled "Causes" tends to create confusion. Rate of infection is best discussed in the "risk" section, and it may be unnecessary to hit the Boulware material in two separate parts of the article."

- There isn't anything specifically about the Boulware article in the Causes section, except for the footnotes [3][4] which simply give them as examples of studies of long trips.

Re: "Probably, you're more interested in preserving the notion that duration of a trip is relevant, an idea that according to my personal analysis is reasonable. I think an explict citation on this point would make it useful. In the proposed replacement material, the subject of time is included with its mention of "incubation period," and in the concept of "visit," which is of course temporary."

- The notion is that if you stay in the wilderness long enough, e.g. 139 days, the disease has enough time to incubate and show symptoms. Its a very simple idea that you apparently agree with.

Re:"This stuff repeats the ideas contained in the phrases "difficult to associate" "infection outside the wilderness is common," without adding useful information. In fact the second sentence quoted above "On the other hand.." in very large part repeats the vector information now in the current first graf of the section."

- Consistent with your comments, I have changed the text to,

"It may be difficult to causally associate a particular case of diarrhea with a recent wilderness trip lasting only a few days because the incubation time may take longer than the length of time of the trip. Studies of long trips into the wilderness,^[3][4] where the trip time is much longer than the mean incubation time of the disease, are less susceptible to these types of errors since the diarrhea is more likely to occur while the person is still in the wilderness."

Re:"I've proposed moving the full description of vectors lower, where the idea that "infection outside the wilderness is common," gets amplified within a larger context and by added information on reference to 99 million annual cases of intestinal infection and etc."

- The vectors are an important aspect of the cause and belong in the lead para, as is. Please note that the "99 million annual cases" that you referred to suggests that there is only one case of diarrhea for every three people in a year in the U.S. population of 300 million. Also, it may not be a good idea to digress into the topic of getting infected in places other than the wilderness.

--Bob K31416 (talk) 17:19, 18 August 2008 (UTC)

This sentence is wordy and not optimally clear: "Studies of long trips into the wilderness,[3][4] where the trip time is much longer than the mean incubation time of the disease, are less susceptible to these types of errors since the diarrhea is more likely to occur while the person is still in the wilderness."

"These types of errors" refers back to "difficult to associate." But the two concepts don't match up.

Let's replace it with: "On trips of longer duration, it may be assumed with greater confidence that infection occurred within the wilderness."

Also, unless I'm missing something, the Boulware studies don't address the statement and should be therefore be removed as citations.

A digression to previous "risk section discussion: By way of compromise, let's use your suggestion in the "Risk" section concerning some sort of reference to duration relative to Boulware and the five other "rate of infection" studies. The problems with this mentioned earlier, can perhaps be overcome with a label something like "one might assume these five studies..." -- if you like.

In the interest of clarity, a lead sentence should address the headlined topic. Vector is neither a cause, nor an "aspect" of cause. For example, the common cold is caused by a virus. Air is not an aspect of the virus, nor a cause, but rather, a vector. It's important to understand vector, but first one must define the cause.

How does the 99M estimate suggest "one case of diarrhea for every three U.S. residents' annually?

The National Institutes of Health estimate: "99 million annual cases of intestinal infectious disease in the United States." Also from NIH in same proposed section: "Other significant causes of diarrhea in the U.S. are non-infectious, and include medications, stress, or a change in eating or exercise patterns."

To avoid OR problems, citations can and should be included for the following proposed sentence: "In assessing a suspected case of wilderness diarrhea, it is helpful to view the disease within the larger context of intestinal complaints."

Providing context does introduce complexity, but is not ipso facto, digression. Rather, context is invariably critical to understanding any topic. Perhaps there are those who contradict this idea relative to the topic of this article. If so, their views can be included. Calamitybrook (talk) 00:07, 19 August 2008 (UTC)

Degree of risk

Hi Calamitybrook, Your last article edit resulted in this sentence, "However, a review of four other similar studies suggested a much lower infection rate of 3% to 5%.[1]" where the reference is the 1992 Zell article. I didn't see this info in the Zell article. Could you point out where it is? Also, did you mean infection by Giardia? Please note that the Zell article was mainly about his study of 41 hikers with overnight permits where he found that 5.7% acquired Giardia infection. Thanks. --Bob K31416 (talk) 05:57, 17 August 2008 (UTC)

In "Epidemiology of Wilderness-acquired Diarrhea: Implications for Prevention and Treatment," Zell uses data from three studies in Utah and one in Colorado. The discussion begins on the second page of his article, which is labeled page 242 and extends to page 243.

Surprisingly, I am missing the reference to his study of 41 hikers with overnight permits. Perhaps it's in a different article. If you can show where this is is discussed, then obviously we should correct the above number to "five" from "four."

As to the question "infection by Giardia?" Zell is explicit in his both his article's title and its text regarding wilderness-acquired diarrhea. Boulware's study concerned unidentified infectious diarrhea. Zell is discussing "similar studies." Our subsection hed "Risk," in a WP article titled "Wilderness Diarrhea," also enables the WP reader to understand Zell's reference. Calamitybrook (talk) 13:27, 17 August 2008 (UTC)

I mistakenly looked at my hard copy of the Zell93 paper instead of Zell92, so thanks for helping me sort that out. Here's a link to Zell93 abstract that you requested.

It appears that in Zell92 there were 3 studies in Utah and only the data from the last study of 203 back country travelers was used to make an estimate of 3-4.5% experiencing giardiasis. The next study in Rocky Mountain NP surveyed 556 people that were mostly day hikers, many of whom brought their own water, and 111 drank water from a natural source. Of the 111, 3% had diarrhea after their trip. The next two studies that were mentioned, the Grand Teton NP and CDC studies, were unrelated to the percentage estimate. In the summary on p. 244, "The attack rate for backcountry travelers is probably less than 10%, with scant data placing it in the 3-5% range."

Also, please note that the studies Zell92 used for the 3-5% figure relied on data about diarrhea that occurred after leaving the wilderness. The Boulware study used data for diarrhea that occurred during the trips to the wilderness that averaged 139 days and didn't have to rely on data about diarrhea that occurred after leaving the wilderness. This is one reason why the Boulware study is unique and significantly better than the other mentioned studies. So for these reasons it would be misleading to say that the Boulware study is similar.

Please note that the figure of 3-5% does not contradict the 56% diarrhea rate in Boulware2003 and Boulware2004 since the 56% rate was for trips averaging 139 days and the 3-5% figure was for much shorter hikes. The significantly greater time exposed for participants in the Boulware study would be expected to result in a significantly larger percentage of participants experiencing diarrhea.

For these reasons, I feel that the current sentence, " However, a review of four other similar studies suggested a much lower infection rate of 3% to 5%. " should be restored to the previous version, " For hikers on shorter trips, a lower infection rate of about 3% to 5% was inferred by two other studies. " --Bob K31416 (talk) 19:51, 17 August 2008 (UTC)

-- Zell 92 did mention that the Colorado study was mostly of day hikers. We apparently have no information about the duration of hikes in the other three studies. It's a reasonable assumption that Zell, in arriving at his 3-5% figure, applied an "analysis of variables" technique to the various studies, as is standard for meta-analytical work.

We don't know what statistical or other methods Zell may have used. Zell does show awareness of the duration factor in a different context elsewhere in his discussion. He may or may not have included an adjustment for it in his analysis. (I'm gonna take a wild guess that he didn't adjust, but also don't want to include wild guessing about the length of hikers' hikes in the studies, nor about Zell's analytical technique, without some particular basis.)

The Grand Teton study is labeled as "a separate study" and I attempted to make clear that it relates not to rate of infection, but rather to the risk of Giardia infection relative to other infectious and non-infectious diarrhea. It would therefore seem relevant and useful. I'll take a look and see if it can be made more clear.

I don't think the stuff Zell looked at "contradicts" Boulware, nor do I find one superior to another, although apparently only Boulware failed to do follow-up work. It is, after all, mere data.

As for Zell 93, thanks for the link. Good info. I'll add a sentence about it.

I added Zell 93, and sharpened up the Grand Teton stuff. Also sought to address Bob's question about "infection with Giardia?" above. Got to looking carefully at some of the stuff I'd previously added in the Risk section, and realized that some of the numbers were incorrectly transcribed. I think I've now fixed that stuff. I also removed the data (I'd previously added) on reported Giardia in several municipal water systems referred to by Rockwell. It's obviously not directly relevant to risk of wilderness-acquired diarrhea. I also added info on one or two backcountry water surveys, and very slightly tweaked wording of Boulware stuff, soley for clarity and brevity. I have a question about this sentence: "The study found much of that 45% was due to insufficient hygiene, i.e. inadequate washing of hands and eating utensils." How much is "much of"? and did Boulware speculate or offer any specific findings with regard to hygiene and the 69% chunk who treated water? Calamitybrook (talk) 05:10, 18 August 2008 (UTC)

Re: "Zell 92 did mention that the Colorado study was mostly of day hikers. We apparently have no information about the duration of hikes in the other three studies. It's a reasonable assumption that Zell, in arriving at his 3-5% figure, applied an "analysis of variables" technique to the various studies, as is standard for meta-analytical work.

We don't know what statistical or other methods Zell may have used. Zell does show awareness of the duration factor in a different context elsewhere in his discussion. He may or may not have included an adjustment for it in his analysis. (I'm gonna take a wild guess that he didn't adjust, but also don't want to include wild guessing about the length of hikers' hikes in the studies, nor about Zell's analytical technique, without some particular basis.)"

-DURATION OF HIKES - There was nothing to indicate that the hikes in the study of Zell92 were atypical as far as duration, i.e. mainly consisting of dayhikers, backpackers that go out for less than a week, and a smaller percentage that go out for more than a week. The Appalachian Trail hikes in the Boulware study were extraordinarily long, lasting an average of 139 days and covering an average of 1919 miles for the 192 hikers that reached their goal, and an average of 1018 miles for the 88 hikers that didn't. I think it is safe to say that the hikes in the Zell92 study were shorter than the hikes in the Boulware study.

ZELL92 METHOD OF ANALYSIS - The method used in Zell92 was explained on p. 242-3. This was for a study that followed two previous studies of only BYU students. Here is the quote,

"However, a retrospective survey of a more heterogenous group of 203 backcountry travelers was completed to determine acquisition of a diarrheal illness compatible with giardiasis. Approximately 4.5% experienced an illness satisfying a case definition of giardiasis, but only two-thirds of those contacted responded. Assuming the latter one-third of backcountry travelers were not compelled to do so because of a lack of illness, the adjusted incidence rate of WAD in this large heterogenous group may rest between 3-4.5%."

It was a simple analysis of the survey of 203 backcountry travelers and the article made no mention of combining studies using meta-analytical techniques. The only way the article used another study that got 3% was to confirm that the 3-4.5% was approximately correct. He apparently reported 3-5% by simple rounding up 4.5 to 5 since the precision of the result didn't justify more significant digits.

For these reasons I have changed the sentence to "Studies of shorter duration hikes resulted in a lower rate of infection or illness, which is expected because of less exposure. In one study, an illness rate of 3-5% was found.".

(I will continue later with your other points in this section of the Talk page.) --Bob K31416 (talk) 00:46, 19 August 2008 (UTC)

Bob: you need to carefully re-read Zell 92 in order to represent it more correctly and accurately. If a source doesn't specify information, an editor cannot simply make it up. If a source cites five studies, an editor can't say that the source cites four. (Yes, Zell 92 included five rate-of-infection studies, not four. Please see his footnote 10.)

I tried to fix these problems with an eye toward retaining the larger point you wanted to make, but you have reverted the fixes, unfortunately reintroducing inaccuracies and unsupported assumptions, and removing useful context.

Zell is among the more important source for our article. Zell's conclusion is simply that "Epidemiological studies are limited, but those available place the infection rate in the range of 3% to 5%."

Not presenting this honestly in Zell's own simple terms, is disrespectful toward both Zell's work and to the reader. Calamitybrook (talk) 04:48, 19 August 2008 (UTC)

Pause in article editing

Hi Calamitybrook, There are a considerable number of issues that should be addressed and discussed. I suggest that neither of us edit the article until we resolve these issues. Agreed? --Bob K31416 (talk) 11:02, 19 August 2008 (UTC)

Sure. Let's start with the flaws in Zell material. Calamitybrook (talk) 13:33, 19 August 2008 (UTC)

Zell 1992 article

Zell SC (1992). "Epidemiology of Wilderness-acquired Diarrhea: Implications for Prevention and Treatment" (PDF). J Wilderness Med. 3 (3): 241–9.

Barbour, Alan G. (1976). "An outbreak of giardiasis in a group of campers". Am J Trop Med Hyg. 25 (3): 384–9. PMID 937629. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)

_________________________________________

The three Utah studies mentioned in Zell92 were obtained from Barbour76 (citation above).

study name, number of participants in study, trip duration, illness rate

1st study (Uinta, UT) – 53 participants, in a 13 day BYU program, 65%
2nd study (Escalante, UT) - 160, in a 1 month BYU program, 14.4%
3rd study (NF registrants in Uinta, UT) – 133, duration of each trip not given, 4.5%
(The people in the 3rd study were "campers whose names were obtained from National Forest Service registrations")

4th study (Rocky Mountain NP, CO) – 111, duration of each trip not given, 3%
(The 111 came from a group of 556 that were mostly dayhikers although there were probably less dayhikers percentage-wise in the 111.)

It looks like Zell92 used the 3rd and 4th studies to get his figure of 3-5%. I didn't find the 5th study of illness rate that you referred to. Which one was it?

--Bob K31416 (talk) 00:01, 20 August 2008 (UTC)

--- Bob: Indeed I've made a mistake about the existence of the fifth study through a mis-reading of Zell. Sorry. And sorry for my earlier comment.

As to the duration, you've located apparently located good information for two of the four studies in a source the WP article apparently hasn't cited. Nice job.

Perhaps similar information about the other two studes is also available? Currently that's still a problem. Also, further information on the number of subjects in each study might help in making your point.

It does seem possible, as you suggest, that Zell threw out the first and second study. If so, then instead half the information you want, there'd be no information at all on duration in the studies Zell used?

However, Zell only says that "available studies place the rate of infection" at 3%-4.5%. Why is it warranted to add one's personal assumptions about his work in order to present it?

Do you believe that Boulware's work is uniquely more valid or valuable than the other rate-of-infection studies we've cited? If so, locate a researcher or other source holding this view, either about Boulware's work or the topic generally, and then present that material in the article. That would be really good stuff. Does Boulware comment on this? Alternately the six (or whatever) rate-of-infection studies and two meta-analysts cited (Zell and Welch) can speak for themselves.

Calamitybrook (talk) 05:40, 20 August 2008 (UTC)

Calamitybrook, Please note that Barbour76 is Zell92's footnote 10 and I gave the citations for both Zell92 and Barbour76 at the beginning of this section.

Re: "Also, further information on the number of subjects in each study might help in making your point."

I didn't understand this comment since the number of subjects in each study is specified in my previous comment. Could you please clarify what you mean by "further information on the number of subjects"?

Re: "Do you believe that Boulware's work is uniquely more valid or valuable than the other rate-of-infection studies we've cited? If so, locate a researcher or other source holding this view, either about Boulware's work or the topic generally, and then present that material in the article. That would be really good stuff."

- Please note the comment in Backer, Howard D. (2007). "Field Water Disinfection". In Auerbach, Paul S. (ed.). Wilderness Medicine (5th edition ed.). Philadelphia, PA: Mosby Elsevier. pp. 1368–1417. {{cite encyclopedia}}: |edition= has extra text (help); Cite has empty unknown parameter: |coauthors= (help) (See p. 1368),

"There is little information demonstrating the benefits of water disinfection in the U.S. Wilderness. Boulware and colleagues demonstrated that drinking untreated water correlated with higher rates of diarrhea among Appalachian trail hikers.²²"

(Yes, it seems like both of these sentences are worth mentioning in the article.)

Regarding TP Welch’s article, of the 256 references mentioned in the Backer2007 article in Auerbach's book, there was no mention of Welch's article. I should also mention that Welch was unable to do a true meta-analysis. Welch explains this in the Discussion section of his paper.

Backer2007 did not discuss the Zell92 illness rates. The Zell92 paper itself did not seem to express confidence in the studies that it looked at. Whereas the data resulted in an illness rate of 3-5%, Zell92 would only commit to saying "probably less than 10%" and called the data "scant". Here's the exact quote from p. 244 of Zell92, "The attack rate for backcountry travelers is probably less than 10%, with scant data placing it in the 3-5% range."

--Bob K31416 (talk) 02:14, 21 August 2008 (UTC)

Bob: Yes, I now notice that you've got the number of subjects nailed. Good. I think the geographic area stuff is good also.

Actually, I was thinking that to nail your point about the 139-day hikes, you might cite a source on that particular aspect of Boulware's work. Even a comment on this from Boulware would do nicely. Since Boulware is somewhat the outlier among the various studies, something like this might be useful.

The selected Backer quote above states the obvious, and is unrelated to the hike duration issue, but if you feel this particular quote provides additional context or other value, that's okay. In grouping like ideas together, it would belong within the presentation of the Boulware material.

I noticed today that Backer "agrees with much of [Zell's] risk analysis," but not with Zell's "conclusions for treatment and prevention." [[27]]. This article should be included in WP, at least as external references.

I'm open to the idea that quoting these various people by name may be helpful to the reader, although it's contrary to the simpler idea of letting the primary research speak for itself as I suggested at one point.

Also, I meant to check whether there were additonal rate-of-infection studies mentioned in Welch, or whether he included any length-of -hike stuff that is currently missing. I know he mentioned some or all of the studies cited by Zell, but maybe there's more there. Calamitybrook (talk) 05:28, 21 August 2008 (UTC)

Hi Calamitybrook, One of the most important pieces of information about a work is when the author criticizes his own result. In my previous message I mentioned that Zell criticized his result of 3-5% and I would request your response regarding this. Here it is again,

The Zell92 paper itself did not seem to express confidence in the studies that it looked at. Whereas the data resulted in an illness rate of 3-5%, Zell92 would only commit to saying "probably less than 10%" and called the data "scant". Here's the exact quote from p. 244 of Zell92, "The attack rate for backcountry travelers is probably less than 10%, with scant data placing it in the 3-5% range."

--Bob K31416 (talk) 14:06, 21 August 2008 (UTC)

Definitely scant, especially by standards of public health research. The WP article ought to mention that a number of researchers seem to agree on this point. But Zell and Welch and the rest found it worth their while to look at the available data. I guess we're in the same boat. Calamitybrook (talk) 15:00, 21 August 2008 (UTC)

Hi Calamitybrook, Please note that Zell92’s remark regarding scant data was made in 1992 and does not apply to Boulware articles which were in 2003 and 2004.

Re: Wilderness trip duration for the participants in the two studies used in Zell92 to get a 3-5% illness rate.

None of the participants in the two studies used by Zell92 to obtain the 3-5% illness rate were in the wilderness long enough to get ill while still in the wilderness. Please see Barbour76, p. 387 and Zell92, p. 243.

--Bob K31416 (talk) 15:42, 22 August 2008 (UTC)

--

Bob: To say "It looks like Zell92 used the 3rd and 4th studies to get his figure of 3-5%," is to rely on your own personal conclusions (which seem to ignore Zell's "available studies" comment). It would be standard to instead rely on Zell (or other outside sources) for what Zell has to say.

Apart from this, what information about duration of hikes in studies 3 & 4? I only have access to Barbour's abstract and I don't have access to the RMNP study.

Am stumped on how we get exactly where you want to go with this.

It may be there is a larger, underlying point you're trying to include which could be addressed using available information. Calamitybrook (talk) 17:56, 22 August 2008 (UTC)

Re: “To say "It looks like Zell92 used the 3rd and 4th studies to get his figure of 3-5%," is to rely on your own personal conclusions (which seem to ignore Zell's "available studies" comment).

I didn’t understand your comment because previously in the “Degree of risk” section of this talk page I quoted the part of Zell92 that said the 3rd study was used to get the 3-4.5% result. Here it is again,

"However, a retrospective survey of a more heterogenous group of 203 backcountry travelers was completed to determine acquisition of a diarrheal illness compatible with giardiasis. Approximately 4.5% experienced an illness satisfying a case definition of giardiasis, but only two-thirds of those contacted responded. Assuming the latter one-third of backcountry travelers were not compelled to do so because of a lack of illness, the adjusted incidence rate of WAD in this large heterogenous group may rest between 3-4.5%."

--Bob K31416 (talk) 22:09, 22 August 2008 (UTC)

You now believe Zell was only using one study, and not two? Regardless, where does Zell say his conclusion is based on one study, two, or anything other than "available studies?" And where is the missing information about duration?

Is your point that on a wilderness visit, infection risk increases with duration? A few well-sourced sentences that substantively address this topic would improve the article. Does the risk increase by a lot, by a little? How many backpackers go out for 139 days and how does their experience correlate to the risk faced by the average backpacker? Is the "risk" we're talking about in this section measured in the context of some normative standard for trip duration? Is the data inadequate?

I have a non-central point of my own that is a slight digression, though relevant. It happens that I am most familiar with the Appalachian Trail in New York State, 40 minutes from Manhattan. Can you get "wilderness diarrhea" there?Calamitybrook (talk) 23:32, 22 August 2008 (UTC)

If I understand your position, you claim that the above quote from Zell92 does not say that it got its figure of 3-4.5% from the specified retrospective survey. Is that what you are saying? Thanks. --Bob K31416 (talk) 23:59, 22 August 2008 (UTC)

The quote describes one of four rate-of-infection studies Zell discussed. Elsewhere in the essay, Zell presents his conclusion that "available studies" place the rate at 3%-4.5%. Calling the sky blue, is not a "claim" and I don't have a "position" on it.

We can say additionally that "Wikipedia editors have determined that Zell based his conclusion on a single study." I favor including that sentence merely to move this discussion forward.

Did you find any more usable information on duration and its relevance?Calamitybrook (talk) 13:40, 23 August 2008 (UTC)

Re: "We can say additionally that "Wikipedia editors have determined that Zell based his conclusion on a single study." I favor including that sentence merely to move this discussion forward."

It appears that you agree that Zell92 based it's 3-5% figure on the one retrospective study. Am I understanding you correctly?

Putting the phrase "Wikipedia editors have determined..." in the article would be a very unique piece of editing for the Wikipedia and inappropriate. Do you agree?

Thanks. --Bob K31416 (talk) 14:32, 23 August 2008 (UTC)

Maybe you're right. Did you have a source other than "Wikipedia editors" for what Zell based in conclusion on?

Also, I guess we'll also need to say that Wikipedia editors have determined that Zell's statement that his conclusions are based on "available studies" is an error -- or bad faith -- on his part. Which do you prefer?

Any more usable info about duration?Calamitybrook (talk) 14:25, 24 August 2008 (UTC)

Re: "Maybe you're right. Did you have a source other than "Wikipedia editors" for what Zell based in conclusion on?"

The source is Zell92 itself, as mentioned before. Here again is the Zell92 quote that shows how the conclusion was obtained,

"However, a retrospective survey of a more heterogenous group of 203 backcountry travelers was completed to determine acquisition of a diarrheal illness compatible with giardiasis. Approximately 4.5% experienced an illness satisfying a case definition of giardiasis, but only two-thirds of those contacted responded. Assuming the latter one-third of backcountry travelers were not compelled to do so because of a lack of illness, the adjusted incidence rate of WAD in this large heterogenous group may rest between 3-4.5%."

Do you agree that this is how Zell92 came to its conclusion regarding illness rate of 3-5%?

--Bob K31416 (talk) 15:54, 24 August 2008 (UTC)

(I will be on vacation and return 3 Sep 2008. --Bob K31416 (talk) 08:42, 25 August 2008 (UTC))

As I think you may have pointed out earlier, Zell92 says by way of "summary" that "the attack rate for backcountry travelers is probably less than 10%, with scant data placing it in the 3-5% range."

The quote you've chosen refers to an important bit of the "scant data," but obviously, not the only bit.

Earlier, you said "It looks like Zell92 used the 3rd and 4th studies to get his figure of 3-5%." It "looks like" to whom? The two rates were 3% and 4.5%. Where did Zell's 5% come from? Where did his "less than 10%" come from?

Your reasoning remains unexplained while flatly contradicting Zell's statements on page 241 and 244.

Calamitybrook (talk) 16:43, 26 August 2008 (UTC)

Calamitybrook & Bob K31416, may I ask you a personal question? Are you both rabbis? 140.139.35.250 (talk) 20:01, 26 August 2008 (UTC)

Third Opinion

My comments so far:

I don't get what the big deal is. This dispute seems to be nitpicking a source's methods. That would seem like WP:OR to me. When in doubt, quote the source. If another editor doesn't like it, quote another source. Let the reader decide whom to trust.
This seems like a big deal over not too much. I think the article would be better served by finding a solution and moving on.
I'd really like a one sentence summary from both of you describing what you believe the issue to be from your respective perspectives. Jclemens (talk) 02:43, 27 August 2008 (UTC)

Thanks a great deal for the input. Here's my summary sentence:

Zell is one of a tiny handful of sources that have done broad-based reviews of available research and I therefore believe his work (and that of similar sources) should be fully and fairly characterized in its own terms without inserting OR analysis.Calamitybrook (talk) 03:34, 27 August 2008 (UTC)

The Zell92 quote in my 2nd to last message above shows that his result was obtained from the indicated study and shows how the result was obtained. --Bob K31416 (talk) 08:25, 3 September 2008 (UTC)

RFC Wilderness Diarrhea

What needs more viewpoints? Should be something specific for editors to comment on!Yobmod (talk) 12:07, 29 August 2008 (UTC)

I believe you're right. I've temporarily removed RFCCalamitybrook (talk) 15:27, 29 August 2008 (UTC)

Added Material under "Risk" and "Causes" Sections

Under "Risk," I've added information on field research projects, and all available info on duration of subjects' trips for all projects. Removed some inaccurate material on duration. Removed apparent OR/unsourced material regarding the meaning of trip duration. Added sourced context material under "Causes."

Eliminated "Water Disinfection" heading and moved its material to "Prevention" for reasons of logic and redundancy. Also in Prevention, added relevant commentary material from two books on wilderness medicine as well as commentary from editors of one of these books. Also commentary from TR Welch and R. Rockwell.

Calamitybrook (talk) 04:55, 29 August 2008 (UTC)

Editing by Calamitybrook Aug 29, 2008

The extensive editing that Calamitybrook recently did on Aug 29, 2008 is unfortunately a step backward. Calamitybrook has gone against a consensus of two editors and an administrator. Calamitybrook’s previous actions in this regard resulted in an objection by me which was supported by an administrator who put up a cleanup notice at the top of the article page (here). Calamitybrook did not cooperate with the administrator or me or another editor that supported the cleanup notice. Since Calamitybrook showed no inclination to clean up the problem, I corrected it. When this was done, the administrator removed the cleanup notice (here). This was discussed in the Talk page section: Is this article turning into the style of a newspaper? and on the administrator’s talk page.

Calamitybrook has essentially reverted my work that fixed this problem. Also, note that Calamitybrook’s recent editing eliminated 6 references from the reference list without any explanation.

Since the problems that Calamitybrook has again caused are significant and embedded in the extensive editing that Calamitybrook has recently done, I have reverted the article to the last edit that doesn’t have these problems. --Bob K31416 (talk) 07:27, 3 September 2008 (UTC)

RfC: Is removal of relevant and sourced material justified?

Is the removal of relevant sourced material justified?

A significant amount of fully sourced research was recently removed from this page without discussion using a revert. Was this edit justified or warranted? —Preceding unsigned comment added by Calamitybrook (talk • contribs) 16:35, 3 September 2008

Outside view by David Ruben

That is untrue ("was recently removed from this page without discussion using a revert") - the revert has an edit summary and there is a lengthy post in the immediately preceeding section from earlier today (did you read that ?). In the circumstances the revert was justified (i.e. followed process), as to whether it is warrented (i.e. makes for a better article or not), I suggest you respond above to the points raised :-) David Ruben ^Talk 19:14, 3 September 2008 (UTC)

The "clean-up" tag that BobK mentioned links here [[28]] and no relevant style matters were identified in response to my previous inquiries, other than citation methods, on which there is no official Wikipedia consensus, and about which I'm indifferent. For info on citation methods, please see [[29].

Matters of style, in any case, are non-germane to a discussion of the removal of a significant amount of fully sourced and highly relevant material.

There has been in fact no meaningful discussion. Calamitybrook (talk) 22:18, 3 September 2008 (UTC)

Outside view by User:WhatamIdoing

Calamity, I was going to suggest that you begin your longed-for "meaningful discussion" with explaining how your "fully sourced expansion" ended up with eight fewer references than the previous version. However, I strongly dislike both versions of this article. I list here just the two biggest problems and suggest that immediate attention be given to them by all the regular editors at this page:

Summarize those studies. Do not report every bloody detail about how many people were enrolled, how many days were spent hiking, who published it. Give us the big picture: "One study found that consistently disinfecting water reduces the rate of diarrhea from 69% of long-distance hikers to 45%. The remaining cases were attributed to poor hygiene."
Use reviews instead of the primary literature. There are reviews for this subject -- the article even cites some -- and they should be the mainstay of all of your medical and epidemiological information. Single, uncomfirmed studies deserve very little space. Editors at this page might wish to take a look at WP:MEDRS for more information about selecting appropriate sources.

Let me emphasize that this is an encyclopedia article, not a comprehensive review of the scientific literature or a handy place to stick links to studies that you personally might want to look up again some day. Make it readable for a high school student that has never heard of a meta-analysis and doesn't know why a prospective study is better than a retrospective one. The entirely unsourced "Symptoms" section is much more encyclopedic than this "Degree of risk" section. WhatamIdoing (talk) 06:07, 4 September 2008 (UTC)

Dear "What"

Thanks so much for your comments!

The word "sourced" means "sources" rather than references. The reverted, current version of "risk" I think has three sources, and the earlier version refers, I think, to seven sources.

Your comment that Wikipedia articles should be readable by high-school students ignores the standards set by innumerable Wikipedia articles on science and medicine. It also disrespects readers' intelligence, which is a frequent and unfortunate error made by many accomplished writers. To improve your effectiveness as an editor, you ought to closely examine this question.

Regarding your comment on detail, it may be helpful to point out that unlike many public health topics that have been thoroughly examined in many large-scale studies, work on wilderness-acquired diarrhea is truly marginal.

The relative handful of studies, including those omitted, were extremely small-scale, with widely varying standards. Whereas some used a couple of dozen subjects, others had 300, Some were based soley on questionaires and others included follow-up and stool-sampling. Readers need such information to judge validity of such marginal research.

Calamitybrook (talk) 17:33, 4 September 2008 (UTC)

Please thread (indent) your talk page comments for ease of other readers. I've fixed your previous comments.

As someone who has been significantly involved in setting the style and source standards for Wikipedia articles on medicine, I think I have a good grasp of what the actual goals are. If you will take a look at some good examples of medicine-related articles, I think you will find that the style used here is at minimum "distinctly uncommon".

I realize that there are not hundreds of good quality medical reviews. But some exist, and you should rely strongly on those. When (if) it's important to go beyond those, then you can communicate the study's strength in general terms: "A large survey of long-distance hikers", for example. Poor-quality studies should not be mentioned here at all, or should be significantly downplayed: "One small study suggested that X might be relevant." WhatamIdoing (talk) 19:45, 4 September 2008 (UTC)

Soft keep - clearly

What:

Raising your experience editing Wikipedia articles is a red herring that skirts the issues I've tried to respond to.

Your comments do raise several basic questions: What's a "large study" in public health? In wilderness medicine? Who defines "large" and how? Why would not simply identifying its actual size be relevant and useful? How is it helpful to deprive the reader of this information? What is a "poor quality" study, and who is the judge, expecially when research is only marginally available? Calamitybrook (talk) 21:07, 4 September 2008 (UTC)

Last point runs the risk of WP:notable and WP:Verify might require all of the information to be cut by encyclopaedic copyediting red pen - for if really no good sources for a point, then it is de facto unsourced and has no place in wikipedia (NB this applies irrespective of whether "true" or not because, as an encyclopaedia, WP does not lead a field with WP:Scientific point of view but only reports after the facts that which can be reported - so, where there is only "marginally available" stuff to report, there is marginal stuff to include). Assuming instead therefore that small and somewhat "poor quality" studies are still worthy of citing to verify, there remains no need to give all the details that might be found in each paper's abstract (shortage of source material does not mean one needs to report each source in greater detail to bulk up the article). David Ruben ^Talk 22:27, 4 September 2008 (UTC)

Your first point seems to veer off into some hypothetical extreme that isn't relevant to the article in question here. Other than that, simply asserting that "there's no need" for basic and obvious details begs the question. [[30]] Calamitybrook (talk) 22:57, 4 September 2008 (UTC)

Calamity, If you'll read my comment a little closer, you'll find that I made no reference to editing Wikipedia articles. I specified that I've helped to write the Wikipedia guidelines that specifically apply to this issue in this article. I submit to you that a person that helps form the contents of these guidelines is likely to have a good grasp of what the standards actually are. Again, I invite you to go read them: Manual of Style (medicine-related articles) and Reliable sources (medicine-related articles).

If no really good sources exist, then why are you providing this information at all? Do you really think that the article is improved by providing significant details about a marginal study? WhatamIdoing (talk) 05:24, 5 September 2008 (UTC)

What:

Nice work on those items you mentioned. Please see Appeal to Authority for a relevant perspective on your experience in the context of this discussion.

On your other recent points, if you can refer to something specific, either in current revert or earlier version, a response might be possible. Wilderness medicine is itself very much at the margins of public health, so in that sense, all its studies are "marginal."

Also, if you'd like to support your viewpoint more generally, response to the several questions I raised above about judgment would be of interestCalamitybrook (talk) 17:59, 5 September 2008 (UTC)

Calamitybrook, suggest you stop wikilawyering and obfuscating with logical principles, and start collaborating with others as this article is at real risk of getting merged/deleted. That WhatamIdoing was involved in developing the WP:MEDRS is a fact (go look at its history), that he therefore is well aware of the guideline is therefore also true, bickering over what was intended as good advice from an editor experienced in medical-topic writing is a breach of WP:AGF - an apology might help reset the tone here :-)

The article is currently in a really poor state, "marginal" research (your term not mine nor WhatamIdoing), is highly problematic. The research cited is by restricted number of researchers and (currently) risks therefore being questioned for WP:Notability, indeed if only supported "very much at the margins of public health", then might not "Wilderness diarrhea" be somewhat of a neologism by a trivial minority of researchers ? If so, then under WP:NPOV that would have this article heading for the chop. It would be good to try and improve the article - but attacking others will not achieve this, risks scaring off the more timid, and will have others cast a more critical eye on this article. David Ruben ^Talk 02:55, 6 September 2008 (UTC)

Dave

You feel there aren't currently enough research sources? I'm not currently understanding WhatamIdoing's view on this.

The recent revert of "Risk" section removed half its sources, and I gather BobK has, or wants to do, similar work on trimming sources out of other parts of the article.

Do you believe that Wikipedia's editing policy (not guideline) on preserving information at this link [[31]] is applicable here?

If you'd like to propose this article for deletion, I'd be fairly neutral, although there's was a very good article dealing with Wikipedia and deletion in the NY Review of Books that I recommend below to WhatamIdoing. I recommend it to you also. Please see [[32]].

Calamitybrook (talk) 19:37, 6 September 2008 (UTC)

Should this article exist?

On basis of needing to check for myself what "marginal" actually means here, I've searched PubMed - just 9 hits makes this a neoligism or trivially held term - would not a merger into traveler's diarrhea (342 hits) seem more appropriate, but even that is currently proposed for merger to gastroenteritis (123,889 pubmed hits). I've tagged this article as a possible neoligism. David Ruben ^Talk 03:24, 6 September 2008 (UTC)

(I've re-formatted to keep the size of these sections smaller.) That's an interesting question. Searching for wilderness diarrhea seems to miss some obviously relevant studies, such as PMID 15974258 ("Gastroenteritis outbreak among mountaineers") and PMID 17029137 (which compares diarrhea rates in organized tours to backpacking in the same area). I believe that none of these turned up in your original search: PMID 16245401, PMID 15473456, PMID 8482936, PMID 937629, PMID 16884402, PMID 11231206? They seem highly related to me.

The quoted phrase turns up no studies at all in PubMed, which is strong evidence for it being a neologism. The quoted phrase on Google turns up about a dozen pages after you exclude copies of the Wikipedia article.

Based on the scientific literature, I'm inclined to redirect to traveler's diarrhea instead of gastroenteritis. It's more specific and therefore more likely to be what the reader is looking for. WhatamIdoing (talk) 06:27, 6 September 2008 (UTC)

I'm very much open to deleting this article. It's a bit like something entitled "Catching a Cold While Driving a Car." There is a good argument to be made that there is nothing unique about the wilderness relative to diarrhea. There are also good, potential arguments for not deleting it [[33]].

As for the term "wilderness diarrhea," it appears to have been coined by a Wikipedia editor (and as such, using good, high school English, is neologistic).

WhatamIdoing now seems to now imply that reference to various minor studies be added to the article, though he previously argued the opposite. I no longer believe I understand his viewpoint.

Regardless, his above list includes an item currently covered in the article (last version I checked), and one that among several removed by the recent revert. A further item uncovered by WhatamIdoing is some slicing and dicing of Boulware's data, which is currently included.

Two items he's pointed out concern "developing world" tropical environments and another is based on the British definition of "backpacking" and is non-wilderness related.

That leaves one that seems unavailable, and one that we missed, although West Buttress Denali climbers don't rely on "surface water" as the term is generally understood, and are in a intensively traveled area, and thus deal with atypical wilderness conditions, relative to subject at hand (so to speak).

As for examining the logic of various views and pointing out classic red herrings, I'm afraid that's simply a legitimate and useful part of discussion.Calamitybrook (talk) 16:21, 6 September 2008 (UTC)

I make no claim that these studies should be included. I merely point out that they are on the same topic, without using the same terms. These studies represent evidence that this term is not in widespread use.

Your continued insistence that I don't know Wikipedia's standards for medicine-related articles even though I have helped write them is highly offensive. I do not suffer from dementia. WhatamIdoing (talk) 19:21, 6 September 2008 (UTC) (who is female, by the way)

What-

Yeah, it appears "wilderness diarrhea" is a dubious term. So then, should somebody propose deletion of the article? Merge? Change the term? I'm very open to alternatives, though merely changing the term may not accomplish much.

I do understand now, that you "make no claim" regarding inclusion of your list of "obviously relevant studies."

But to the extent that they are "obviously relevant" (see above), in my view, they deserve mention, especially given the relative dearth of available research. Rather than label them marginal, small-scale (large-scale?) studies, with modest (poor?) quality standards, I'd simply provide enough information to permit those judgments by the reader.

Your knowledge of "Wikipedia standards" isn't at issue. But argumentum ad verecundiam (the fancy term) is no argument at all. That's a mere fact that might be helpful, rather than harmful. Taking offense is unwarranted. I'm sorry.

Calamitybrook (talk) 22:20, 6 September 2008 (UTC)

Does this mean that you withdraw your inaccurate claim about "the standards set by innumerable Wikipedia articles on science and medicine"?

I wouldn't have even mentioned the guidelines at all if you hadn't demonstrated a complete lack of familiarity with the actual standards for medicine-related articles. WhatamIdoing (talk) 04:25, 7 September 2008 (UTC)

Comment withdrawn, as long as you promise not to post your resume on the talk page (I can offer a similar promise). Can we focus on appropriate discussion about whether to delete this article, etc.? Calamitybrook (talk) 05:13, 7 September 2008 (UTC)

merger

I've started adding information from this article to Traveler's diarrhea. Some of it was originally copied from that article, so it's been pretty easy. Here's what's left for the next stage:

Causes
Degree of risk
Prevention
Water disinfection

David, are you willing to take on the next stage of turning this into a redirect? I don't want to move too quickly; the TD editors need a chance to absorb the changes and participate in the process. WhatamIdoing (talk) 19:42, 9 September 2008 (UTC)

I've recently added roughly ten sources to Wilderness Diarrhea, some of which had been deleted earlier in a revert by BobK.

I've also posted the following on Talk:Traveler's diarrhea:

Note two of the article Traveler's diarrhea which indirectly supports a merger proposal with Wilderness Diarrhea, is an incorrect citation. It was added by WhatamIdoing on Sept. 9 on the day he proposed the merger.

The cited document (top of page 248)[[34]] merely contrasts (rather than equates) the terms wilderness-acquired diarrhea and travelers' diarrhea. This is the document's only mention of the term traveler's diarrhea.

As presented, the note implies that the document supports the statement that WD is a term that some prefer for TD, when in fact it suggests the opposite.

Either a different citation is required, or the sentence should be removed.

I'd suggest that the merger proposal, as well as other possibilities (deletion, etc.) first raised above, be discussed here on Talk:Wilderness Diarrhea for the sake of convenience. Unsure which venue is best.

Calamitybrook (talk) 00:19, 10 September 2008 (UTC)

Generally merger proposal discussed at the target site, as {{mergeto}} and {{mergefrom}} tagging so point by default. Discussion already started at tagged Traveler's diarrhea, so I've added the missing paired tag to this article - further discussion should be at Talk:Traveler's diarrhea#Merge proposal David Ruben ^Talk 18:52, 10 September 2008 (UTC)

Switched order of sections "Causes" and "Degree of risk"

The Causes section should precede the Degree of risk section for the following reason. Discussion of the risk of diarrhea involves the risk of encountering one or more of the causes of diarrhea (giardia, crypto, etc.). Thus the causes should be discussed before the risk of encountering the causes is discussed. --Bob K31416 (talk) 01:04, 6 September 2008 (UTC)

Enteroviruses

This is from my talk page:

Thank you for your recent contribution and interest in Wilderness diarrhea. I sincerely appreciate your effort.

I was looking for a reference to support the assertion in your edit summary that "Enteroviruses do not cause diarrhea" and I found an article that seems to contain a counterexample. Here's a quote from the abstract [35]

"Enterovirus 71 (EV71) infection may be asymptomatic or may cause diarrhea, rashes, and hand, foot, and mouth disease (HFMD)."

Could you help clarify the situation? Thank you. --Bob K31416 (talk) 05:00, 7 September 2008 (UTC)

OK, these are the viruses that cause diarrhoea; Norovirus, Rotavirus (Groups other than A in adults), Astrovirus, and two serotypes of Adenovirus ( types 40 and 41).

In contrast these are the non-enterpathogenic viruses found in faeces; Poliovirus, Coxsackievirus, Echovirus, Reovirus, Hepatitis A virus, Hepatitis E virus, Reovirus, Adenovirus (types 1-39) and Enterovirus.

Enterovirus has been detected in the stools of people with diarrhoea but, apart from a few anecdotal reports in the literature, (primary sources), their aetiological role has been proven. Given that these viruses replicate in the gut, in is not surprising that they turn up from time to time in folk with diarrhoea. Note that the abstract says "may cause diarrhea" - the paper reiterates this caution. In short, it would be non-verifiable to list enteroviruses in this article. There is very little proof that they a cause of diarrhoea and absolutlely no proof that they cause Travellers' or Wilderness diarrhoea.

Graham Colm ^Talk 11:53, 7 September 2008 (UTC)

Thank you for your input. I have edited the article accordingly. I expect that any further contributions that you would care to make would be welcomed. Thanks again. --Bob K31416 (talk) 15:42, 7 September 2008 (UTC)

Edits To Add Sourced Material, Restore Non-Preserved Content

Will add various sources and some new material to this section, and plan to restore deletions and add additional material to the "Risk" section. This will add nine sources to Risk which were either previously deleted or are wholly new.

To conform with WP:PRESERVE I will scrupulously avoid removing sourced content that won't be restored elsewhere.

In "Cause" will move the Grand Teton study from "Risk" section, as it is a measurement of causes and not risk. Also will move information on "incubation periods" to here from "Symptoms" because it is clearly not a symptom, is related to cause, and is useful to understand certain background information that follows.

I will also move material related to two sources from "Cause" section to the "risk" section. The two sources are ""Risk of giardiasis from consumption of wilderness water in North America" and "Giardiasis as a Threat To Backpackers." Their titles should largely explain the rationale for moving them to "Risk."

Have also included a ^{[citation needed]} note on this sentence: 'Studies of long trips into the wilderness,[3][4] where the trip time is much longer than the mean incubation time of the disease, are less susceptible to these types of errors since the diarrhea is more likely to occur while the person is still in the wilderness." The references refer to the studies, and not the sentence's assertion. The assertion should be documented or removed.

Calamitybrook (talk) 18:42, 9 September 2008 (UTC)

Editing by Calamitybrook Sep 9, 2008

The extensive editing that Calamitybrook recently did on Sep 9, 2008 is unfortunately another step backward. Calamitybrook has gone against a consensus of two editors and an administrator. Calamitybrook’s original actions in this regard resulted in an objection by me which was supported by an administrator who put up a cleanup notice at the top of the article page (here). Calamitybrook did not cooperate with the administrator or me or another editor that supported the cleanup notice. Since Calamitybrook showed no inclination to clean up the problem, I corrected it. When this was done, the administrator removed the cleanup notice (here). This was discussed in the Talk page section: Is this article turning into the style of a newspaper? and on the administrator’s talk page.

Calamitybrook has essentially reverted my work that fixed this problem. Also, note that Calamitybrook’s recent editing eliminated references from the reference list without any explanation. The current edit is in such turmoil that, who knows what the state of the references is? The last edit of Calamitybrook's before this turmoil had 3 references missing from the reference list.

Since the problems that Calamitybrook has again caused are significant and embedded in the extensive editing that Calamitybrook has recently done, I have reverted the article to the state before Calamitybrook's recent editing.

(Does this sound familiar? It's essentially what I wrote previously in the section above regarding Calamitybrook's Aug 29 edits. Calamitybrook didn't respond to those issues raised by me as was recently advised by another administrator. Instead, Calamitybrook argued with the administrator that Calamitybrook had called in for a third opinion and Calamitybrook repeated the same types of problems for a third time.) --Bob K31416 (talk) 02:59, 10 September 2008 (UTC)

I agree with you. In addition Calamitybrook just changed the name of the article to Wilderness and diarrhea which makes NO sense. The term is Wilderness diarrhea and that is the way the vast majority of references refer to the condition. That is what the article should be called.LiPollis (talk) 01:09, 11 September 2008 (UTC)

WP Preserve

BobK

Please, see WP:PRESERVE. This is a policy, not a guideline.

There are guidelines that refer to citation methods, although the guidelines specifically cite the fact that there "is no consensus" on citation methods. If you want to change the citation methods used in this article, I invite you to do so.

In my edit, I haven't removed any content, in part because that would violate Wikipedia policy. I am therefore, for the first time, reverting to restore the content you've removed.

Please do not ignore Wikipedia policy.

Calamitybrook (talk) 03:29, 10 September 2008 (UTC)

Calamitybrook, I didn't understand your message that attempted to justify your recent revert of my revert. I explained my reasons for my revert in my previous message and they didn't involve citation methods. --Bob K31416 (talk) 04:35, 10 September 2008 (UTC)

Bob

Perhaps it would be more clear if you explain your thinking using explicit examples from the current article and without reference to various previous discussion.

Policies are different than guidelines (see WP:PG)

If you haven't read yet Wikipedia's policy on preserving information, I will paste a copy below.

Preserve information

re WP:PRESERVE

Whatever you do, endeavour to preserve information. Instead of removing, try to:

rephrase
correct the inaccuracy while keeping the content
move text within an article or to another article (existing or new)
add more of what you think is important to make an article more balanced
request a citation by adding the {{fact}} tag

Exceptions include:

original research
duplication or redundancy
irrelevancy
patent nonsense
copyright violations
inaccuracy (attempt to correct the misinformation or discuss the problems first before deletion)
unsourced controversial claims about living persons

—Preceding unsigned comment added by Calamitybrook (talk • contribs) 16:21, 10 September 2008

Let's see if I understand what you are trying to do. First some background material from above.

The extensive editing that Calamitybrook recently did on Sep 9, 2008 is unfortunately another step backward. Calamitybrook has gone against a consensus of two editors and an administrator. Calamitybrook’s original actions in this regard resulted in an objection by me which was supported by an administrator who put up a cleanup notice at the top of the article page (here). Calamitybrook did not cooperate with the administrator or me or another editor that supported the cleanup notice. Since Calamitybrook showed no inclination to clean up the problem, I corrected it. When this was done, the administrator removed the cleanup notice (here). This was discussed in the Talk page section: Is this article turning into the style of a newspaper? and on the administrator’s talk page.

If I understand you correctly, you feel that it is OK to reintroduce the above mentioned problems as long as you preserve information. Is that your position? Thanks. --Bob K31416 (talk) 17:23, 10 September 2008 (UTC)

You made extensive edits to this article following the above-referenced discussions. I've carefully preserved all of this information, although there may have been some inadvertant changes to reference list.

The reference list issue can be easily fixed, expecially if you can point out, specifically, the problem. Obviously, we can continue editing this article, but please don't ignore WP:Preserve.

Calamitybrook (talk) 18:09, 10 September 2008 (UTC)

But that overlooks that this whole topic is a neologism, and trivial term, and as such seems suitable for merger into traveler's diarrhea. Also currently quite inappropriate (for wikipedia) lengthy description of individual studies should at very least be drastically summarised as typical for other medical topics. This is not question of removing facts, just of no need to give all the commentary on the facts directly here (vs allowing the reader to follow references to the sources). As a couple of examples:

Currently (in 'Causes' section): In a study of causes of diarrhea at Grand Teton National Park, visitors suffering from active gastrointestinal complaints were invited to a free clinic. Of 178 people tested, 69% had no identifiable disease-causing pathogens. Campylobacter was the most common agent isolated at 23%, followed by Giardia at 8%. Campylobacter enteritis occurred most frequently in young adults who had been hiking in wilderness areas and was associated with drinking untreated surface water in the week before illness.[36]

Rephrase: A study at Grand Teton National Park, found 69% of diarrhea affected visitors had no identifiable cause, with 23% having Campylobacter and 8% Giardia; Campylobacter enteritis occurred most frequently in young adults who had hiked in wilderness areas and drunk untreated surface water in the week prior.[37]

Currently (in 'Other studies' section): A survey of available literature on the risk of giardiasis from consumption of wilderness water in North America in 2000 by TP Welch of the Tulane School of Public Health found a high incidence of confirmed giardiasis among outdoor recreationalists, but little association between drinking backcountry water and acquiring giardiasis.^[4] Of 104 articles identified in the initial screening, nine met the inclusion criteria. In the articles analyzed, neither of two case reports (report of the diagnosis, treatment, and follow-up of an individual patient) met the criteria of the Centers for Disease Control for waterborne disease outbreak. Two "prospective" studies (data on subjects who were followed forward in time) showed no significant association of backcountry water with infection. Of four studies that included control groups, none showed a significant relationship between backcountry water and infection.

Rephrase: In 2000 a North America literature review found a high incidence of confirmed giardiasis among outdoor recreationalists, but little association between drinking backcountry water and acquiring giardiasis.^[5]

In the last example the details are irrelevant excess for a reader using a general encyclopaedia - if they wish to verify the fact, or indeed read up more about this, then the reference source is given, but wikipedia is not itself a journal review (WP summarises knowledge rather than collate it all together as reprints of article abstracts) David Ruben ^Talk 18:44, 10 September 2008 (UTC)

Dave

Your rephrasing looks good. Why don't you make the edits? Please observe WP:PRESERVE.

Given the widely divergent findings of each study, a meaningful summary may be impossible.

Not to overlook merger proposal, here are good reasons WP:MERGE:

Duplicate - There are two or more pages on exactly the same subject and having the same scope.
Overlap - There are two or more pages on related subjects that have a large overlap. Wikipedia is not a dictionary; there does not need to be a separate entry for every concept in the universe. For example, "Flammable" and "Non-flammable" can both be explained in an article on Flammability.
Text - If a page is very short and is unlikely to be expanded within a reasonable amount of time, it often makes sense to merge it with a page on a broader topic. For instance, parents or children of a celebrity who are otherwise unremarkable are generally covered in a section of the article on the celebrity, and can be merged there.
Context - If a short article requires the background material or context from a broader article in order for readers to understand it. For instance, minor characters from works of fiction are generally covered in a "List of characters in <work>", and can be merged there; see also WP:FICT.

Calamitybrook (talk) 19:40, 10 September 2008 (UTC)

Wilderness And Diarrhea

A neologism no longer. So simple.

Did some very minor edits to conform with new title; may require one or two more.

There remains, as always of course, potential to restore original title; other editing.

Evidence that the topic is typically and widely discussed independently from travelers' diarrhea

two national newspapers:

[[38]]

[[39]]

Three articles on a U.S. government Web site:

[[40]]

A national magazine: [[41]]

A Canadian government Web site:

[[42]]

Various pages from New York State government:

[[43]]

Okay, I can put up more later.

Calamitybrook (talk) 22:12, 10 September 2008 (UTC)

In midst of a merge proposal, renaming is unhelpful at best. "Wilderness and diarrhea" still a neologism - find extensive use of this term - counts as WP:SYNTHESIS. David Ruben ^Talk 01:04, 11 September 2008 (UTC)

I agree with David's assessment. Furthermore, making significant changes to this article is probably a waste of time, as most of it will be thrown out during the merge. WhatamIdoing (talk) 01:35, 11 September 2008 (UTC)

I also agree that renaming this article is unhelpful. LiPollis (talk) 02:22, 11 September 2008 (UTC)

Isn't it clear that the source of the problems is Calamitybrook? Shouldn't we work together to protect the article from Calamitybrook? Merging the article may simply result in the same problems occurring at the new venue. --Bob K31416 (talk) 02:59, 11 September 2008 (UTC)

Easy now everyone. We don't need to beat up on anyone for trying to help. Gentle, civil suggestions work best. We're all working together on this and we will figure it out. Given the situation, I think it's best that we freeze any significant development on either page until we reach consensus regarding the merge proposal here: Talk:Traveler's diarrhea#Merge proposal. Let's get to a resolution on this first, and then we can make the appropriate changes. Chaldor (talk) 03:22, 11 September 2008 (UTC)

Chaldor, I can understand that you are trying to be fair. Here's my last message to Calamitybrook and give me your opinion on whether the situation described there, with links to the evidence, describes a person that is trying to help.

________________________________________________________

Let's see if I understand what you are trying to do. First some background material from above.

The extensive editing that Calamitybrook recently did on Sep 9, 2008 is unfortunately another step backward. Calamitybrook has gone against a consensus of two editors and an administrator. Calamitybrook’s original actions in this regard resulted in an objection by me which was supported by an administrator who put up a cleanup notice at the top of the article page (here). Calamitybrook did not cooperate with the administrator or me or another editor that supported the cleanup notice. Since Calamitybrook showed no inclination to clean up the problem, I corrected it. When this was done, the administrator removed the cleanup notice (here). This was discussed in the Talk page section: Is this article turning into the style of a newspaper? and on the administrator’s talk page.

If I understand you correctly, you feel that it is OK to reintroduce the above mentioned problems as long as you preserve information. Is that your position? Thanks. --Bob K31416 17:23, 10 September 2008 (UTC)

________________________________________________________

Please notice in Calamitybrook's response that the above question wasn't answered but instead evaded. --Bob K31416 (talk) 03:51, 11 September 2008 (UTC)

Please don't poison the well. It is clear that you two have differring opinions regarding the content and style of the article, but that does not mean you should dismiss someone because he/she does not agree with you. In fact, diversity of opinion is instrumental in creating articles that avoid WP:BIAS and maintain WP:NPOV. If we all agreed and spoke from one mind, articles would end up horribly one-sided. Always remember WP:CIVIL. Pointing fingers and blaming others never helps us make progress. Unless you are opening a formal motion for banning a particular user from an article/wikipedia, please keep in mind that he/she simply has a very different opinion than yours and his/her opinion is equally valid as yours. We expect the same level of respect both in word and in action from all contributors, and those impeding progress will be addressed with in due course. That being said, I kindly ask both your and Calamity's official votes/opinions on the merger proposal being discussed on Talk:Traveler's diarrhea#Merge proposal. Thanks. Chaldor (talk) 06:33, 11 September 2008 (UTC)

I would like to hear other editors' comments on what Chaldor just wrote and on my previous message. Thank you. --Bob K31416 (talk) 16:48, 11 September 2008 (UTC)

Bob, I don't think that dissecting Calamity's problems is going to be helpful at this point, and I do think that you can safely assume that all experienced editors can see the problems that exist. WhatamIdoing (talk) 03:12, 12 September 2008 (UTC)

Whatamidoing, Thanks. I was just about to post the following response to Chaldor when I got an edit conflict error message since you had posted your message. Here it is:

Chaldor, Thanks for your response. Some of it threw me off at first. I took a second look at what you wrote and tried to look at it as a whole. Basically you seem to be advising to put aside the confrontation "and those impeding progress will be addressed with in due course." This sounds OK to me. --Bob K31416 (talk) 03:29, 12 September 2008 (UTC)

Cheers, let's make some wikimagic. Chaldor (talk) 04:43, 12 September 2008 (UTC)

Here's to optimism for a successful article.. --Bob K31416 (talk) 17:40, 12 September 2008 (UTC)

________________________________________________________

I feel that

(1) this article should be titled "Wilderness-Acquired Diarrhea," as that is the accepted name used most in the cited articles from the medical journals. Or failing that, "Wilderness Diarrhea." Certainly not "Wilderness and diarrhea" which makes no sense.

(2) the idea of merging this article with Traveller's Diarrhea is a poor one. The two subjects have very little in common and WAD is clearly a separate disease, and a separate topic. —SaxTeacher (talk) 01:12, 12 October 2008 (UTC)

Merge Aim Unabated

From WhatamIdoing's talk page: The reasons for opposing the merge, which can be found at Talk:Traveler's diarrhea are:

the belief that diarrhea caused by fecal coliform bacteria, various viruses, and giardia acquired while hiking in your own country is materially different from diarrhea caused by the exactly same organisms through exactly the same routes of transmission if acquired while hiking or otherwise traveling in another country, and
the assertion that the WD article, much of which is either cut-and-paste out of TD or suffers from needless bloat, is clearly so long that it needs its own space.

It seems useful to refine WD, both for its own sake and also with an eye to a possible future merge.

What:

You simply ignore that so many prominent outside published sources have established this subject as separate from travelers' diarrhea, and also, that neither wilderness-acquired diarrhea nor travelers diarrhea are diseases, but, rather syndromes, based on contexts that have important differences.

Your continued desire to merge this article flys in the face of this widely established precident, and is obviously contrary to the most minimal Wikipedia editing standards.

You also seem to feel that your view is superior to various other editors here, as well as that of the editors and publishers of numerous outside articles in many national publications.

Since such feelings on your part don't seem reasonably warranted, and because you may be unable to appreciate these various significant factors, perhaps you ought to permanently recuse yourself from the entire subject.

Calamitybrook (talk) 05:58, 14 October 2008 (UTC)

Calamitybrook, Please note Wikipedia:Civility and Wikipedia:No personal attacks. Thank you. --Bob K31416 (talk) 07:12, 14 October 2008 (UTC)

Thanks for sharing your opinion. I will give it all the consideration it deserves. In the meantime, if you have any objections to the actual improvements that have recently been made in this article, please start a new section to discuss them. WhatamIdoing (talk) 16:38, 14 October 2008 (UTC)

42 Editors and 3 Years: Now 2-3 Editors Seek Merge

It appears this article has been edited by 42 people over a three-year period. Yet WhatamIdoing and perhaps, one or two others, believe they have uniquely determined that it is not properly a separate topic for Wikipedia, and will be merged.

WhatamIdoing has very clearly asserted that she has in some key way, helped to establish current Wikipedia medical publishing standards. This may indeed be a laudable achievement. Yet the merger proposal suggests a peculiar editing standard.

WhatamIdoing asserts that because WAD is potentially a form of a water borne disease, it is the same as TD. But no credible volume of countervailing material is offered to counterbalance the rather vast number of citations and the evidently prevailing societal view that WAD is an essentially separate syndrome from traveler's diarrhea.

Calamitybrook (talk) 06:02, 15 October 2008 (UTC)

Combining refs

We have three separate full citations for the Wilderness Medicine text (==References== plus 22 and 29). They all need to be resolved so that it doesn't look like we're using three different books. Which do you like best?

Also, the "Rockwell" papers appear to be simply different versions of the same paper. Can we pick one and merge? WhatamIdoing (talk) 23:07, 15 October 2008 (UTC)

I changed what was formerly ref 29 from Adachi2007 to the correct reference Backer2007, although I felt like I was putting a bandaid on a gangrenous finger (the paragraph) that is about to be amputated.

In the "footnotes" there are two kinds that refer to the Backer2007 article in the Auerbach book.

1) One kind refers to specific pages within the Backer2007 article and ultimately refers to the full Backer2007 article in the "references". These are needed because it is a big article and the specific points are hard to find without the specific page numbers.

2) The other kind (just one entry in the footnotes section) refers to the whole Backer2007 article.

Is it OK now?

Re your second item, Rockwell2002 and Rockwell2003 are very similar, although I haven't checked to see what the exact difference is. If they aren't significantly different, or at least not different for our purposes, the 2002 article would be more preferable because it is in an online journal whereas the 2003 article is on the website of a chapter of the Sierra Club and may change at any time. However, if we wanted the 2003 article we may be able to make it more stable with web archiving. (I haven't tried web archiving of anything yet. Just recently found out about it.) I'll take a look at them with your concerns in mind, but I can't promise to do it immediately. : )

--Bob K31416 (talk) 23:50, 15 October 2008 (UTC)

About Backer, why aren't we using the same style in ref [22] that we are in ref [4]? (That is, why not list (Backer 2007:[insert range of pages in the chapter here]?)

About Rockwell, I suggest taking a look at them. They're "very similar" in the sense that every place I happened to check showed exactly the same text. However, one of them (the 2003, I think) listed about 50% more refs, so presumably it was expanded. WhatamIdoing (talk) 02:54, 16 October 2008 (UTC)

re your 1st item, your suggestion seems fine to me so I made the change.
re your 2nd item, I'll look at them. The 50% more refs that you observed is a good point that I'll look for.

--Bob K31416 (talk) 09:03, 16 October 2008 (UTC)

I looked at how the two Rockwell versions were used and the only instance of the use of Rockwell2003 was in this excerpt (with different footnote numbering from article):

==Diagnosis==

However, because most carriers are asymptomatic,^[6] there are only an estimated 2 million U.S. cases of symptomatic giardiasis annually^[7] spread mostly by fecal-oral or food-borne transmission.^[8]

The Rockwell2003 footnote is the one at the end of the sentence. I looked through Rockwell2003 and it doesn't support this assertion re the general population so I removed the citation. This leaves only one version in the article, viz. Rockwell2002.

--Bob K31416 (talk) 12:30, 16 October 2008 (UTC)

I made a side-by-side comparison of Rockwell2002 and Rockwell2003 and Rockwell2003 seems to be an improvement. For example, in Rockwell2003 the author added that in his work on the subject that he mainly looked at high elevations in the Sierras, "The emphasis has always been to waters of the High Sierra—“High” meaning elevations of 8,000 or 9,000 feet and above..." I didn't look carefully at all the new footnotes in Rockwell2003 so I can't say how many of them are worthwhile. For example, there are a number that refer to private communications.

The online journal that Rockwell2002 is in does not appear to be peer-reviewed and there didn't seem to be anything in Rockwell2003 that would preclude its appearance in the same online journal. I archived Rockwell2003 using WebCite and will add the paper's archived URL to the citation so that a more stable link is available if needed and I am about to change the citation from Rockwell2002 to Rockwell2003.

--Bob K31416 (talk) 14:52, 17 October 2008 (UTC)

Recent Editing

In my view the recent edits on this article have been responsible and have resulted in significant improvements.

In the case of the two Appalachian Trail studies, however, these edits notably mischaracterize the referenced research, and the inaccuracies ought to be corrected with additional detail.

Also, recent edits have, for reasons that are unclear, eliminated information about sampling size and duration of hikes. One notes for example, in the distantly related realm of political polling, the excellent Web site Real Clear Politics, weights recent polls according to the size of the sample -- for obvious reasons.

On the same theme, the NOLS research encompasses a vastly larger sample than other cited studies, and ought thus be the "lede" survey, following the inverted pyramid of "newspaper style," as well as any reasonable measure of its notability or significance. Yet it's been moved to the bottom of the section for reasons that are unclear.

Perhaps the most relevant question about "WAD" in the minds of hikers, is the extent to which it is an actual concern or threat in the U.S. and Canada. This is why the epidemiology section is key to WAD article and perhaps ought to somehow be moved much higher.

In the case of TD, there is no parallel question or uncertainty, which is a among the reasons why this is almost universally seen a separate topic.

Calamitybrook (talk) 06:25, 17 October 2008 (UTC)

Because providing details is not the job of an encyclopedia article. Encyclopedias concisely summarize information. WhatamIdoing (talk) 20:36, 17 October 2008 (UTC)

I tend to agree with the idea that details should not be needlessly included. With this in mind, I recently changed one of my edits from "139 days" to "many months" and I feel it reads better now. Some mention of duration was needed because longer trips have greater exposure to diarrhea causes and will have higher illness rates for hikers. That is one important reason why the illness rates vary between studies. --Bob K31416 (talk) 13:23, 21 October 2008 (UTC)

"Several months" or "four months" might be more descriptive. "Many months" could be misinterpreted as "about a year." WhatamIdoing (talk) 20:25, 21 October 2008 (UTC)

That sounds fine to me. I was a little uncomfortable with "many" too. 139 days is a little more that 4 1/2 months so I changed it from "many" to "almost 5 months". --Bob K31416 (talk) 23:27, 21 October 2008 (UTC)

Re the placement of the Epidemiology section, it currently conforms to the order mentioned in the Manual of Style and it may be best to keep it that way unless there is a strong enough reason to deviate, which I haven't seen. Also, reading the previous sections might help with the understanding of the studies in the Epidemiology section. --Bob K31416 (talk) 19:02, 19 October 2008 (UTC)

I started a new subsection below showing how the order of the WAD sections compares to the order of the corresponding sections of the Manual of style if anyone wanted to discuss it further. --Bob K31416 (talk) 00:48, 20 October 2008 (UTC)

Appalachian trail studies

CalamityBrook, re the Appalachian Trail studies, could you please be more specific about what you were referring to when you wrote, "In the case of the two Appalachian Trail studies, however, these edits notably mischaracterize the referenced research, and the inaccuracies ought to be corrected with additional detail." Here's the excerpt from the article re the Appalachian Trail studies:

Surveys among hikers who completed the Appalachian Trail reported more than half experienced at least one episode of diarrhea, usually of two days or less in duration.^[2]^[3]^[9] Treating water and routinely washing hands with soap and water after defecation reduced the incidence.

--Bob K31416 (talk) 16:02, 17 October 2008 (UTC)

Briefly, the Crouse-Josephs AT study with 180 subjects found no correlation between treating water and diarrhea, and is silent on question of hygiene.

Confusingly, perhaps, it says 22% reported gastrointestinal complaints (the key figure) and 63% reported diarrhea, with 58% lasting 1-2 days. Infectious diarrhea, a working definition of WAD, TD, and various other maladies, is unlikely to last 1-2 days.

Calamitybrook (talk) 19:01, 17 October 2008 (UTC)

I don't think that your assumptions about infectious diarrhea are accurate. Untreated infectious diarrhea caused by enterotoxic bacteria might last for about a week, but viral "stomach flu" frequently causes diarrhea for about two days. WhatamIdoing (talk) 20:38, 17 October 2008 (UTC)

Your point sounds entirely plausible. A question is, how is this research accurately presented to readers in fairness to the authors.

It's not clear why the authors of the Crouse-Josephs study used two numbers. Since they mention 22% twice, and focus on it in their "discussion" section, perhaps they believed this was the more significant number. There seem to be tables missing from available copy. The current thrust of the Wikipedia WAD article, for better or worse, suggests that a case lasting 1-2 days would be unusual.

This relates to the question that would bring people to this page: to what is extent is WAD an actual concern or threat in the U.S. and Canada. This is why the epidemiology section is key to WAD article and perhaps ought to somehow be moved much higher.

There is no parallel question regarding TD; yet the topic of WAD is well-established in clinical and popular literature.

Regarding the AT reseacrch, the lack of correlation with water treatment in Crouse-Josephs is, however, unambigous, despite the authors' caveats.

Calamitybrook (talk) 22:06, 17 October 2008 (UTC)

The point that Calamitybrook brought up regarding the inconsistency of diarrhea rates in the Crouse article is a serious problem for the article. Here's two excerpts showing the problem which appears to give contradictory results:

"The majority of the gastrointestinal complaints, which affected 22% of the hikers, were general symptoms of gastroenteritis or diarrhea."

"Sixty-three percent (63%) of the hikers experienced diarrhea at least one time during the course of their hiking."

The second excerpt is clearly stated and can't be simply dismissed.

The other two references to articles by Boulware and colleagues don't have this problem and are consistent with the statements in the paragraph.

Furthermore, the statement in Crouse1993 regarding no significant diarrhea differences between treated and untreated water was made without giving any data or statistical analysis, i.e. odds ratios, confidence intervals, and p-values. Again, the other two references by Boulware and colleagues didn't have this problem and had the statistical analysis of a good epidemiological study that demonstrated that there was a difference. This was noted by Backer2007 on p. 1368, "Boulware and colleagues demonstrated that drinking untreated water correlated with higher rates of diarrhea among Appalachian trail hikers."

For these reasons, I will delete the problem reference from the article. --Bob K31416 (talk) 08:56, 18 October 2008 (UTC)

I support the removal, and add that another reason for its removal is its age. 15 years is a long time in modern science.

Additionally, Calamity's assertion that readers primarily care about the risk in the US and Canada is a problem. This is a worldwide encyclopedia. We need information that applies to every country -- or at least every developed country. WhatamIdoing (talk) 18:45, 18 October 2008 (UTC)

Sampling size and NOLS

Although the National Outdoor Leadership School (NOLS) article was a study with a large cohort, it had relatively little information regarding wilderness acquired diarrhea (WAD). The only useful information that I saw in the article that was related to WAD was how low an incidence of diarrhea there is for an outdoor skills school that supervised its students and emphasized "strict hand-washing techniques, water disinfection, and washing of common cooking utensils". No details were given. For example, there were no comparisons of students who had good hygiene and were good about disinfecting water and those who weren't, who may simply have been too small a minority to matter since it was a supervised outdoor skills school. If anyone sees anything else that is useful in the NOLS article, please point it out so that we can consider using it in the WAD article. Thanks. --Bob K31416 (talk) 11:23, 18 October 2008 (UTC)

Comparison of MOS and WAD sections

Sections in WAD article compared to corresponding Manual of style (Medicine related articles) sections.

Manual of Style	WAD
Classification	Names and definitions
Symptoms	Causes
Causes	Symptoms
Diagnosis	Diagnosis
Prevention	Treatment
Treatment	Prevention
Epidemiology	Epidemiology
See also	See also
References	References; Footnotes

--Bob K31416 (talk) 00:48, 20 October 2008 (UTC)

2.3 Million "user days" In NOLS

The NOLS sample of roughly 2.3 million field days makes it quite significant in the field of public health and medical studies. It's so vastly larger (100x++??) than anything else mentioned here that its omission or downplaying might be negligent.

One peruses many studies prepared for FDA approval purposes in search of financial news, and by comparison, all these WAD studies -- apart from NOLS -- are by hobbbiests who happen to be doctors somewhere with an academic sideline. If FDA approval is the standard, then they ought to be deleted from Wikipedia

But science really is science, regardless of funding or scale. Hence the value of all of these studies with regard to a subject where, as is apparent from various data, no firm conclusions seem readily available. (Unlike TD, as S. Zell cogently observes.)

WW Wiki Vs. Geography Etc.

The world-wide character of Wikipedia is well-known, but whether a given category of health concerns like gastro-intestinal distress, water-borne disease, etc., might have definitive geographical and behavioral and public health variables...

Would be a separate question... No?

Calamitybrook (talk)

Calamitybrook, RE NOLS, please rest assured that there is no considering that it be omitted or downplayed. On the other hand, there is no good reason to highlight it. Please note that although the National Outdoor Leadership School (NOLS) article was a study with a large cohort, it had relatively little information regarding wilderness acquired diarrhea (WAD). The only useful information that I saw in the article that was related to WAD was how low an incidence of diarrhea there is for an outdoor skills school that supervised its students and emphasized "strict hand-washing techniques, water disinfection, and washing of common cooking utensils". As I mentioned in the above section "Sampling size and NOLS", if you see anything else that is useful in the NOLS article, please point it out. Thanks. --Bob K31416 (talk) 10:11, 20 October 2008 (UTC)

--

Please correct my arithemetic, but the NOLS database is at least 2,000+ times larger than these other studies? Boulware for example counted about 100 treatment/handwashers x100 days? I no longer precisely remember.

The WAD article currently omits the size of various "cohorts," leading the reader to surmise that all bits of contradictory data mentioned are in this respect equal.

Calamitybrook (talk)

RE NOLS and Boulware, what "contradictory data" are your referring to? Thanks. --Bob K31416 (talk) 19:40, 20 October 2008 (UTC)

--It's not NOLS and Boulware per se, but that the various studies say the rate is x or y, or z. No conclusion can be drawn. Certainly NOLS and Boulware have much different rates for treatment/handwashers. Calamitybrook (talk) 23:02, 20 October 2008 (UTC)

Which is exactly why we need to continue removing the contradictory and overly precise rates in favor of a qualitative description. WhatamIdoing (talk) 01:05, 21 October 2008 (UTC)

NOLS and Boulware diarrhea rates aren't contradictory because they cover different cases. NOLS covered only the case of "strict hand-washing techniques, water disinfection, and washing of common cooking utensils" where Boulware covered the other cases where the subjects did some but not all three of the prevention methods. The NOLS and Boulware studies complement each other. --Bob K31416 (talk) 03:33, 21 October 2008 (UTC)

--

I might again emphasize my view that this article is moving in a very positive direction.

But (please do correct my math) NOLS has a database that is at least 2.3 thousand times larger than the other studies mentioned.

The potential reasons for avoiding the trivial number of words needed to present to the reader the size of these various studies has not been adequately articulated.

The above-referenced view about NOLS vs. Boulware may not be justified by available information. Also, are such detailed generalizations about 2.3 million field days reasonable or possible?

Also, why is C-J study now omitted? This seems very nearly as significant as Boulware, statistically, and its complete lack of correlation with water treatment seems like a notable finding.

Calamitybrook (talk)

Calamitybrook, I answered your question re C-J in the above section "Appalachian trail studies". Also, please reread my discussion of NOLS re lots of data but only one limited result and no details. However, I still think NOLS is a worthwhile article. For the sake of efficiency in this discussion, please check previous remarks before raising issues and check if your issues have already been addressed. Thank you --Bob K31416 (talk) 13:18, 21 October 2008 (UTC)

Trip duration

I'm curious about the calculation of trip duration's effect on the incidence of diarrhea. Is it calculated on a per-trip or a per-day basis? It matters: If you assumed (for sake of argument) that every healthy adult has diarrhea one day each year, then a trip of two days' duration has a 2/365 chance of diarrhea, but a trip of four months' duration has a 1/3 chance of diarrhea -- just based on random chance. WhatamIdoing (talk) 20:26, 21 October 2008 (UTC)

That's a good question and I'll give you a serial response since I need to get the 1st part of your Q clarified and the 2nd part may require a bit of work.

Re "I'm curious about the calculation of trip duration's effect on the incidence of diarrhea. Is it calculated on a per-trip or a per-day basis?"

First some background. Most articles express diarrhea rates as the percentage of people who get diarrhea from a trip, i.e. the percentage of trips that cause diarrhea at least once. (When you wrote, "per-trip" I think this is what you meant?) This is where the problem comes in when comparing percentage rates from studies with different trip durations.

Boulware2004 expresses diarrhea rates in this way and in another way as "frequency", i.e. the number of days of diarrhea per month while on the trip. Also, in Boulware2004's Figure 1, there are plots of 1) the percentage of hikers who had diarrhea at least once, versus the time since the beginning of the hike. (As expected, this percentage increased with time.) 2) the number of days per month of diarrhea per person while on the trip, i.e. frequency. (Perhaps "frequency" is equivalent to what you meant by "per-day"?)

McIntosh2007, i.e. NOLS article, expressed diarrhea rates as frequency, e.g. 0.26 incidents per 1000 person days, i.e. per 1000 days per person.

Expressing diarrhea rates as frequency allows better comparison of results of different studies that have trips of different average duration.

Just for fun, let's see how the frequencies of Boulware2004 for all the hikers (good and bad, hygiene and water treatment) compares to McIntosh2007. Eyeballing Boulware2004 Figure 1, it looks like the time-averaged frequency is roughly 0.7 days of diarrhea per month per person. Converting to the units of McIntosh2007, this is about 0.7 x 1000/30 = 23 days of diarrhea per 1000 person days. And since the average diarrhea episode duration in Boulware2004 was 2 days, the incident rate is roughly 12 per 1000 person days.

One thing to note is that trip duration may have an effect on the occurrence of diarrhea at NOLS if it isn't long enough compared to illness incubation period. Although there was no specific info in the McIntosh2007 NOLS article re average trip duration, it mentioned that courses were from 2 weeks to 3 months. So one wouldn't expect a significant error from not counting incidents of diarrhea where the infection was acquired in the wilderness but the diarrhea appeared afterwards at home. This isn't a concern with Boulware2004 since those trips averaged almost 5 months and diarrhea from infection acquired in the wilderness would most likely occur in the wilderness.

In summary for the comparison of rates of incidence of diarrhea, McIntosh2007 was 0.26 per 1000 person days and Boulware2004 was roughly 12 per 1000 person days. Please remember that McIntosh2007 NOLS rates were for strict hygiene, dish/utensil cleaning and water treatment, whereas the Boulware2004 result is for all hikers in that study with diverse attention to hygiene, disinfection and cleaning.

--Bob K31416 (talk) 01:17, 22 October 2008 (UTC)

I looked at this NOLS webpage to try to get a feel for the average trip duration in their courses. Although it's hard to tell very accurately what the average trip duration is, it still looks long enough to avoid significant underestimation errors due to diarrhea after a course ends from infection acquired during the course.

Re 2nd part of question: Suppose we take the McIntosh2007 NOLS frequency of gastrointestinal illness, 0.26 incidents per 1000 person days, as an upper limit of the frequency from non-wilderness causes of diarrhea. Then trips would have on average frequency less than 0.26 x 30 / 1000 = 0.0078 incidents per month per person from non-wilderness causes. This is quite low compared to the Boulware2004 frequency for all hikers in the Appalachian Trail study of 0.7 / 2 = 0.35 incidents per month per person. Thus, non-wilderness causes of diarrhea are expected to cause a negligible percentage of the cases of diarrhea in the studies, except possibly in the McIntosh2007 NOLS study which had strict prevention methods.

For the 4 month trip duration that you were considering, the non-wilderness caused diarrhea incidence per person, for the healthy type of people who go on hikes, would be less than (0.26/1000days) x 4 months x (30 days / month) = 0.03 or about a less than 3% chance of diarrhea in the 4 months, which is small. Recall that this is based on the McIntosh2007 NOLS frequency of diarrhea. --Bob K31416 (talk) 03:02, 23 October 2008 (UTC)

Limitations of small-scale studies

In such an obscure field of inquiry, some degree of shortcoming in research is perhaps unsurprising and inevitable.

Boulware, one of the better studies, in the available summary of his work, says 45% of his subjects who treated water consistently reported diarrhea, and 69% of those reporting inconsistent water treatment, also reported diarrhea. Subjects numbered 334 who hiked at least seven days, and 280 of these people logged a total of 38,000 field days.

Frankly, I don't fully and precisely understand the Boulware numbers.

Bob: Probably I've not read you closely enough, but which among these various numbers are you using to compare with the NOLS data?

CJ note

Recently, I received some personal correspondence from one of the authors of the 1993 Crouse-J study of 180 hikers. Regarding lack of clarity about reported 22% vs 63% he told me:

"Good question... it has been a while since I pulled the file on this study. The issue comes from two different questions asked.

1 question specifically asked if they had ever experienced diarrhea and if so how long did it last - the 63% response rate... 1 question asked for listing of injury or illness experienced during the trip and in this less directed question, GI complaints were cited by 22% It would seem that most felt diarrhea was not an illness but a normal happening..."

This information from author qualifies as "original research" on my part, I suppose... and thus I'd not propose adding it to WAD article.

Besides, surprisingly or NOT, it doesn't clear up uncertainty about the reported data, which found no correlation with water treatment.

........ Yet it may be revealing, in some manner that I won't immediately attempt to characterize here. Regardless I was very pleased to hear an explaination from the author...

Nols vs AT data

Significant point: The NOLS information, if somewhat limited, is much less ambiguous, and offers a vastly larger database and far, far longer term. Perhaps also, its methodology of third-person reporting (instructors) adds to its credibility? Though this view might veer toward a merely personal opinion...

Interestingly, results of the C-J and Boulware studies (each concerning AT, where NOLS doesn't operate) though significantly different, are much closer to each other than the NOLS data, which concerns a far wider geographic base.

Also, there is no comparable ambiguity regarding various and apparently copious data on the subject of traveler's diarrhea, which in general seems closer to the very limited AT data than that of NOLS.

Finally (note to Bob) consulting current NOLS Web site isn't useful or relevant. The NOLS study itself gives complete information on data regarding duration, geography, historical periods and etc.

Calamitybrook (talk) 07:25, 23 October 2008 (UTC)

The McIntosh2007 NOLS article wasn't specific about trip duration except to say that course duration in the study was from 2 weeks to 3 months which agrees with the info at the NOLS website, which had somewhat more info because it listed the number of courses for various durations. However, we still don't have the average trip duration for the McIntosh2007 NOLS study. In the end, it didn't affect the results of my analysis.

Upon further comparison of the McIntosh2007 NOLS and Boulware2004 articles, I found an interesting point regarding the amount of diarrhea data. In the McIntosh2007 NOLS article there were only 113 gastrointestinal incidents since it was concerned with a school which supervised its students and emphasized strict prevention methods. These are fewer diarrhea incidents to study compared to Boulware2004 which had about 440 incidents. Furthermore, in Boulware2004 there were results regarding the risk associated with various behaviors which were described and analyzed. So in spite of having 440,000 days of NOLS data for diarrhea frequency in the McIntosh2007 article compared to 40,000 days for Boulware2004, the McIntosh2007 article had less comprehensive data with regard to the number of diarrhea incidents (113 vs 440). --Bob K31416 (talk) 15:09, 23 October 2008 (UTC)

Didn't Boulware provided separate rates for treatment-and-hygiene hikers? Would this not be the more relevant material for direct comparison with NOLS data?

The considerably wider question... implied above.... may suggest a need for more specificity about the various studies in order to help readers form a reasonable personal view about various wholly valid but widely diverging data.

Alternately, one might merely state that measured rates range from much less than 1% to 60% or more, according to various studies, and footnote them. The assumption being, perhaps, that readers don't care, and/or, can indeed look elsewhere for the information.

Interestingly, in the related but separate topic of travelers diarrhea (pizza vs Neopolitan cuisine??) there is no comparable uncertainty.

Calamitybrook (talk) 05:58, 22 October 2008 (UTC)

Really? So you think "an estimated 20-50% of international travelers" is highly precise? WhatamIdoing (talk) 17:18, 23 October 2008 (UTC)

Off-topic

I have removed:

In a 1991 giardiasis survey of 48 state health departments in the United States, 34,348 cases were reported. Of these, 19 were attributed to contaminated drinking water and 2 were reported among campers and backpackers. ^[10]

as not being on topic. This belongs in the giardiasis article. WhatamIdoing (talk) 21:35, 25 October 2008 (UTC)

Organization of Epidemiology section

Organizing the Epidemiology section is not an easy task. Here's some thoughts regarding organizing it.

There are two main considerations regarding causes of WAD: 1) hygiene 2) water potability. The first consideration of hygiene should be independent of the locale of a study. The second consideration of water potability is most likely dependent on locale .

In the present form of the article, an attempt was made to make a general characterization by using a quote from Zell1992,

The general rate of infectious diarrhea acquired in the wilderness "is probably less than 10%, with scant data placing it in the 3% to 5% range."

Unfortunately, this quote from Zell1992 is not based on general information nor is it current. The phrase "scant data placing it in the 3% to 5% range" is based on a 1976 article that had a retrospective survey of backcountry travelers in 1974 in the Uinta mountain range of Utah,

Barbour, Alan G. (1976). "An outbreak of giardiasis in a group of campers". Am J Trop Med Hyg. 25 (3): 384–9. PMID 937629. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)

Topics that might be used to organize the Epidemiology section are: hygiene, water, and geographical area. I expect that hygiene would be independent of geographical area whereas water would be dependent on geographical area. The geographical areas for water would be eastern US (mainly Appalachian Trail) and western US (mainly Sierras).

--Bob K31416 (talk) 15:34, 26 October 2008 (UTC)

Overall, I think your ideas are fine. The "geographical" issue doesn't work for me. First of all, diarrhea is a problem for backpackers all over the world, not just in the U.S. Furthermore, the "location" that really matters appears to be how many animals (including humans) are pooping in the watershed, not just which mountain range (or other location) you're in. That aspect should be re-thought or downplayed. (Seasons matter, too.) WhatamIdoing (talk) 01:58, 27 October 2008 (UTC)

Thanks. My impression has been that Sierra water is safer than Appalachian Trail water but on second thought it may not be very clear from the Sierra studies. I'll have to carefully reexamine the Sierra studies and rethink the geographical issue. Anyhow, here's some comments re your response.

re "First of all, diarrhea is a problem for backpackers all over the world, not just in the U.S." - I certainly agree. The problem we have is that so far in this article, no studies for outside the US have come up, except possibly the McIntosh2007 NOLS study which unfortunately was limited in case type and didn't give locale details.

re "Furthermore, the "location" that really matters appears to be how many animals (including humans) are pooping in the watershed, not just which mountain range (or other location) you're in." - I agree for the most part but one should recognize that different locales have different animal and backpacker populations. In the eastern US the mountains are, for example, 6000' and lower along the Appalachian Trail, whereas in the west the mountains and trails are much higher, up to 14,500'. Different elevations have different animal populations. For example, at elevations around tree line and above, approx. 11,000' in the Sierras, I would expect that animal populations and their poop become scarce due to lack of vegetation. However, on high elevation busy trails there would still be the human population and their poop to be concerned about. Also, in high altitude wilderness areas where very few backpackers percentage-wise go, the water might be quite safe.

A practical difference for us regarding the study of east vs west water potability is that in the east there haven't been any studies in this article that measured the pathogen levels of water along the Appalachian Trail (AT). Whereas in the west there haven't been any studies that are comparable to the diarrhea rate studies of Boulware2003 -2004 of the AT which are conclusive regarding the correlation between drinking untreated water on the AT and diarrhea, according to Backer2007.

--Bob K31416 (talk) 16:36, 27 October 2008 (UTC)

P.S. There was one important point in my original comments that wasn't specifically addressed concerning the general remark that was based on a quote from Zell1992. I intend to delete that sentence from the article unless there are objections that should be discussed first. --Bob K31416 (talk) 12:55, 28 October 2008 (UTC)

"Treating water" subsection - short trips

This is at the end of the "Treating water" subsection,

One researcher, in discussing evidence for Giardia contamination of backountry water sources, suggested that if Giardia lamblia is an uncommon isolate and wilderness-acquired diarrhea is infrequent, then it may not be cost effective to recommend filtering for recreationalists involved in short-duration trips.[1]

1. Zell SC (1992). "Epidemiology of Wilderness-acquired Diarrhea: Implications for Prevention and Treatment" (PDF). J Wilderness Med. 3 (3): 241–9.

The above came from the second to last paragraph on p 247 of the cited Zell1992 article. Zell compared treating water and the cost of buying a filter to not treating water and the cost of seeing a doctor if one is among the estimated 5% on a short trip that gets ill with what might be giardiasis. The fallacy in this cost analysis is that the filter can be used many times on future trips without additional cost whereas there is a cost for seeing a doctor for each incidence of WAD from future trips. --Bob K31416 (talk) 03:24, 28 October 2008 (UTC)

--

Perhaps Zell's point is too obscure for the "high-school level reader" that Wikipedia medical articles are said to be properly aimed at.

If so, the truly intelligent and curious, reader must simply look elsewhere to gain an understanding of the topic at hand. One might hope Wikipedia can at least provide various sources via citations and references.

Bob's point about Zell is certainly interesting --but may be merely a personal observation

Calamitybrook (talk) 06:16, 28 October 2008 (UTC)

Calamitybrook, I intend to delete the above mentioned excerpt from the article. Did you have any objections to that? If you do, please specify the error in my reasoning that shows that the excerpt is based on incorrect reasoning. Thanks. --Bob K31416 (talk) 12:38, 28 October 2008 (UTC)

Your reasoning is probably a violation of WP:No original research. However, I think it would be on the side of "good editorial judgment" to at least minimize the Zell claim -- perhaps something about giardiasis being so uncommon that the cost-effectiveness of filtering has been questioned.

As for removing it: even though doing our own analysis of someone else's analysis is improper, I'm not sure that the article would be "incomplete" without a sentence about this, and we could certainly justify removal on the grounds of none of the other reliable sources supporting this (and some even opposing it). WhatamIdoing (talk) 18:41, 28 October 2008 (UTC)

I think there's some misunderstandings here. Maybe you, maybe me. Anyhow let's try to clear it up. : )

Re "Your reasoning is probably a violation of WP:No original research." - This only applies to material that goes into the article, and I can assure you that I have no intention of putting my discussion of the error in Zell1992 into the article. What I did was identify an item in the Zell1992 article that was incorrect and that item shouldn't go into the WAD article for that reason. --Bob K31416 (talk) 21:50, 28 October 2008 (UTC)

--

If memory serves, Welch makes a similar point, as does Derlet, as well as perhaps the most widely read researcher in the field, Robert Rockwell, who is not currently mentioned in this article. I believe Backer comes close to saying something similar as well with regard to "pristine water." Zell's point is unique only insofar as it is based on a cost-benefit analysis.

Also, an assertion that the study "Giardiasis as a threat to backpackers in the United States: a survey of state health departments" is "not on topic" for this article wasn't clearly explained -- seems like an odd interpretation.

Calamitybrook (talk) 20:50, 28 October 2008 (UTC)

--

Bob-

Both WhatAmIdoing and I seem to say that your personal analysis of Zell, what ever its possible merits, amounts to "original research."

WhatAmIdoing suggests some potentially reasonable means of ignoring this OR problem.... Depending on ends, these means may or may not be advisable.

But to suggest that Zell's tentative point -- a question, really, according to his phrasing-- isn't supported by more affirmative conclusions of a very sizable number of credible published WAD researchers (a majority perhaps of those directly commenting?), is obviously incorrect. Calamitybrook (talk) 07:20, 29 October 2008 (UTC)

Calamitybrook, Please read WP:No original research and note that it pertains to what goes into the article. Thoughts expressed on the talk page regarding whether information is valid are proper, and if it is shown that information in the article is incorrect, then such information should be removed. --Bob K31416 (talk) 14:28, 29 October 2008 (UTC)

Not exactly. "I'm going to delete this sourced item because it disagrees with my own analysis" is a violation of WP:NOR, even if it's an example of something going out of an article instead of going into an article. WhatamIdoing (talk) 19:54, 29 October 2008 (UTC)

Before we continue, please note that your quote is not something I wrote here. If you would like to quote something I actually wrote, try this "Thoughts expressed on the talk page regarding whether information is valid are proper, and if it is shown that information in the article is incorrect, then such information should be removed." This is currently the best expression of my position on this issue. We can continue our discussion using this quote of mine that directly preceded your last message. Thanks. --Bob K31416 (talk) 23:19, 29 October 2008 (UTC)

No, I merely summarize. You say that (1) you have carefully read the source, (2) independently thought of circumstances that the source doesn't seem to have adequately accounted for, (3) rejected the conclusions of the published source on the basis of your personal, original analysis, and (4) proposed removal. I therefore summarize your view as "I'm going to delete this sourced item because it disagrees with my own analysis".

Note that I don't object to removal, or to countering with other sources, or anything else. I merely state that the original reason you gave for removing the information is technically a violation of one of Wikipedia's policies. If you choose to invoke another Wikipedia policy, you will get no objections from me. WhatamIdoing (talk) 00:43, 31 October 2008 (UTC)

I think that you just wrote that you don't object to removal of the item. Speaking in practical terms, does this mean that if I removed it you wouldn't revert the removal? Is that correct or am I misunderstanding you? Better yet, could you remove it? Then there wouldn't be any chance of misunderstanding. --Bob K31416 (talk) 04:08, 31 October 2008 (UTC)

You understand my position exactly: I have no opposition to its removal. I just wanted to point out that your first reason (and you seem to have several) may technically violate WP:NOR. WhatamIdoing (talk) 02:01, 1 November 2008 (UTC)

Thanks for the clarification. I only gave the one reason for deletion. Which other ones are you referring to?

BTW, there was another deletion that I was proposing that might have gotten lost in the shuffle. It's not in this section of the talk page but in the previous section "Organization of the epidemiology section". But note that an editor has changed it a little today, but my reason for the deletion still applies. Could you look at it and tell me what you think? --Bob K31416 (talk) 02:32, 1 November 2008 (UTC)

==

Speaking in practical terms, what reasons are offered for proposed for deletion? I'm guessing there remains a practical problem with Origninal Research, but I've kinda lost the thread of this discussion.

Am thinking there could be a more broad-based and very well-sourced statement, based on a sizable range of credible researchers, regarding efficacy of water treatment in actual "wilderness" settings.

A definition of "wilderness" is ipso facto, relevant to article on WAD. Personally I often hike on Appalachian Trail in sight of Manhattan and this is not by any standard "wilderness."

But if such a definition is NOT relevant to WAD, then the premise of the article may in fact be irretrievably flawed. Is this Orignal Research? References are probably unavailable.

Calamitybrook (talk) 06:21, 31 October 2008 (UTC)

I guess you are claiming that you have proved by original research that the Appalachian Trail is not in the wilderness. I don't see it. First of all, you gave no verification that you can see Manhattan from the trail. It may be so but there is nothing but your testimony. Secondly, if you could see Manhattan from the trail, this says nothing about the rest of the 2100 mile trail nor does it say anything about whether the trail at that point is not in the wilderness. For example, the city of Lone Pine, CA can be seen from the John Muir Wilderness. So your reasoning is incorrect in every way.

I showed that the item in the article was based on false reasoning, without any personal experience and without using anything that anyone couldn't see for themselves, and no one has disputed that. --Bob K31416 (talk) 01:12, 1 November 2008 (UTC)

In order to get the discussion back on track, I started a new section below where I put the items under discussion and summarized the points of contention. --Bob K31416 (talk) 17:14, 31 October 2008 (UTC)

Proposed deletion of statement re cost effectiveness of filters vs medical care

The following item at the end of the "Treating water" subsection of "Wilderness acquired diarrhea" (WAD) is being considered for deletion.

One researcher, in discussing evidence for Giardia contamination of backountry water sources, suggested that if Giardia lamblia is an uncommon isolate and wilderness-acquired diarrhea is infrequent, then it may not be cost effective to recommend filtering for recreationalists involved in short-duration trips.[1]

1. Zell SC (1992). "Epidemiology of Wilderness-acquired Diarrhea: Implications for Prevention and Treatment" (PDF). J Wilderness Med. 3 (3): 241–9.

The above item from the WAD article is based on the following excerpt from p 247 of the above cited article (Zell1992):

"If Giardia lamblia is an uncommon isolate and the incidence of WAD infrequent, it may not be cost effective to recommend filtration for recreationalists involved in short duration trips. Assuming the First Need Filter (retail price $40.00), can be shared by a group of four persons, for every hundred backpackers, a total of $1000 would be spent for such a device. On the contrary, if recreationalists focused on empiric treatment directed at bacteria or viruses and experienced giardiasis at an attack rate of 5%, dollar expenditures for a single physician visit, ova and parasite analysis and drug therapy would be roughly equivalent (five persons at $220.00 per individual, totalling $1100.00). However, this latter figure assumes that all cases would be due to giardiasis and that dollar expenditures would be lower if this were not the case."

According to the premises of the above quote, the cost of filters for treating water on a short duration trip is $1000 for 100 backpackers whereas for another 100 backpackers who didn't buy filters for treating water, the medical costs for the 5% that would get ill is $1100. Note that this is for one trip. For a future trip, the filter can be reused so there is no additional cost whereas for the cohort that doesn't use filters there would be an additional cost of $1100 from the medical expenses for 5% who get ill. ...and so on for future trips. Thus the filters are more cost effective and the subject statement in the article is based on false reasoning and should be deleted.

The correctness of this criticism has so far not been disputed. What has been disputed is that the subject statement should not be deleted because the above criticism on this talk page is considered original research.--Bob K31416 (talk) 17:12, 31 October 2008 (UTC)

RfC: Proposed deletion of statement re cost effectiveness of filters vs medical care

The correctness of the criticism of an item in the article has so far not been disputed. What has been disputed is that the subject statement should not be deleted because the criticism on this talk page is considered original research. See previous section “Proposed deletion of statement re cost effectiveness of filters vs medical care”

1) Is the item in the article based on false reasoning? 2) Should the item in the article be deleted?

--Bob K31416 (talk) 21:06, 31 October 2008 (UTC) ==

I see the Empire State Building from the Appalachian Trail pretty darn often year after year (though we miss the WTC). Dunno if that's "original research" but regardless, I don't think I'm hallucinating.

New Jersey, Southern New York, Connecticut etc., which covers 20% or more of AT, just ain't wilderness. This is pretty easy to verify. Data that relates to this region is probably not relevant to "wilderness diarrhea," assuming the term is meaningful.

Your analysis of Zell's point is based on certain assumptions that, while not wildly unreasonable, would be difficult or impossible to verify using outside sources. It's on that basis that your criticism has been already been disputed as "original research." Whether your assumptions are correct or not is simply not accessible information.

But Zell is a credible and published researcher regarding the topic at hand. If your goal is deleting Zell's point, a completely different approach would be more fruitful.

Personally, I do think the narrow point ought to be deleted in favor of a more broad, relevant and simple statement to the effect that many -- perhaps the majority-- of credible researchers question the efficacy of water treatment in actual wilderness settings with regard to WAD.

The citations for such a statement would include Zell, as well as Rockwell, Derlet, Backer, TR Welch, TP Welch, et alia.

Calamitybrook (talk)

Perhaps you can address this by expanding the paragraph slightly to include the basis of the cost effectiveness calculation? This would not then be WP:OR but would allow the reader to perform the calculation themselves without resorting to looking up the reference. For example:

"One researcher suggests that.... may not be economical viable based on the assumption that filtration can be achieved at a cost of $1,000 per 100 people compared to $1,100 for medical treatment if 5% of the same size group suffer a giardiasis attack". Just a thought. Unusual? Quite ^TalkQu 23:21, 6 November 2008 (UTC)

Re templates placed in Water risk avoidance section

Re {{OR}} template - The subject text in the article was referring to the personal experience of the reference's author and others mentioned in his article. I've made changes to avoid any misunderstanding.
Re {{howto|section}} template - Made changes to satisfy this template request.

WhatamIdoing, Glad that you noticed the "how to" problems which I have just corrected. --Bob K31416 (talk) 21:57, 3 November 2008 (UTC)

food contamination

It would help if someone could find some info on food contamination/spoiling re wilderness travellers for the Prevention section. Thanks. --Bob K31416 (talk) 03:09, 6 November 2008 (UTC)

??

Personally, I do think the narrow point ought to be deleted in favor of a more broad, relevant and simple statement to the effect that many -- perhaps the majority-- of credible researchers question the efficacy of water treatment in actual wilderness settings with regard to WAD. The citations for such a statement would include Zell, as well as Rockwell, Derlet, Backer, TR Welch, TP Welch, et alia.

Calamitybrook (talk) 07:19, 6 November 2008 (UTC)

How many references support that statement of the 256 references in Backer, Howard D. (2007). "Chapter 61: Field Water Disinfection". In Auerbach, Paul S. ed. (ed.). Wilderness Medicine (5 ed.). Philadelphia, PA: Mosby Elsevier. pp. 1368–417. ISBN 9780323032285. {{cite book}}: |editor= has generic name (help); Cite has empty unknown parameter: |coauthors= (help)? Backer's review article is the largest in the field and doesn't reference any of the authors that you listed except for Zell, only to dispute his findings. Note that among the folks that you listed, Rockwell, as far as I know is an engineer who has never published anything in any peer-reviewed journal on any subject, and TP Welch has only a BA degree. What scientists are the "et alia" that you referred to?

But among the most important issues regarding the usefulness of your statement is that Boulware and colleagues in 2003 refuted the notion that water treatment is not efficacious in the wilderness with actual data which was acknowledged by Backer in his 2007 review article,

"Boulware and colleagues demonstrated that drinking untreated water correlated with higher rates of diarrhea among Appalachian trail hikers."

--Bob K31416 (talk) 10:31, 6 November 2008 (UTC)

Is there really any reason that we can't simply say that different people have different opinions on the subject? A simple statment like "Most experts support routine disinfection of water,^{[ref][ref][ref]} but others do not.^[ref][ref]" neatly summarizes the actual state of opinion. WhatamIdoing (talk) 19:17, 6 November 2008 (UTC)

One has to keep in mind that the finding of Boulware and colleagues in 2003 is a fact, not opinion. Boulware2003 isn't considered in Rockwell2003 and of course it isn't considered in any articles prior to 2003. --Bob K31416 (talk) 05:59, 7 November 2008 (UTC)

Experts don't usually admit much of a distinction between their professional opinions and the actual facts: they are supposed to be identical, after all.

But there is some disagreement on this point. So why not just say that, and let it go? WhatamIdoing (talk) 05:28, 8 November 2008 (UTC)

Prior to the work of Boulware and colleagues there was no work that separated the contribution to wilderness acquired diarrhea due to insufficient hygiene from the contribution due to insufficient water treatment. Thus, there were those that contended that the diarrhea was due to insufficient hygiene rather than insufficient water treatment.

As pointed out by Backer in 2007, Boulware and colleagues demonstrated that there was a correlation between drinking untreated water and diarrhea. Any opinion that promotes the safety of wilderness water that doesn't specifically address this fact is probably uninformed or biased and should not be put into the article. The only exception may be comments regarding the safety of water in a particular wilderness area, but a general statement about the safety of all areas is unacceptable because of the finding by Boulware and colleagues in 2003 which is fact, not opinion.

--Bob K31416 (talk) 15:23, 8 November 2008 (UTC)

I'm still mulling over the above comments.

But please bear in mind that apart from the NOLS data, each of these field studies was of extremely small scale, and as such, are inconclusive.

Also, it does seem that perhaps the majority of researchers raise some doubt about the efficacy of water treatment in areas of true wilderness. As far as et alia, certainly Byron Crouse would be among the rest and there are certainly at least several others.

Calamitybrook (talk) 20:56, 8 November 2008 (UTC)

Calamity, the point behind threading comments is so that they line up neatly: A reply under the comment it applies to. Therefore the appropriate number of colons to include at the start changes every single time you write a message.

Bob, I don't understand why this matters. Does Boulware define a case of diarrhea in the wilderness due to contaminated fingers as being materially different from a case of diarrhea in the wilderness due to drinking (without disinfecting) the water that you just washed your fingers in? WhatamIdoing (talk) 21:06, 10 November 2008 (UTC)

Bob, that data from a given study is X, is a fact, not an opinion. But I think you may be reading too much into that notion.

Today there were a couple of medical studies reported in the NYT. One involved 18,000 people and was supposed to last five years. Experts are currently debating how to interpret the data. Another involved nearly 3,000 people followed for 25 years, and I suppose there is a similar debate about that one.

Most of these WAD studies are of course, extremely modest in size and quality. Yes there are differences. The difference between $1 and $2 is 100%. To pick one of these little studies and call it definitive might be the wrong approach. (With little money, every dollar helps). And Boulware certainly wasn't the only one to discuss water treatment in the bunch. I think there were two AT studies. One found a correlation and the other didn't. Or am I wrong about that?

What, Sorry and thanks. I'll definitely look into your colon thing.

Calamitybrook (talk) 00:56, 11 November 2008 (UTC)

There's a description of that technique on this page, if you're interested. WhatamIdoing (talk) 01:57, 11 November 2008 (UTC)

Efficacy of Water Treatment

Desite the fact that widely published advise suggests that water treatment is well advised, a majority of researchers (seven, at the least) have raised doubts, either via their data and/or expert opinion, about the efficacy of treating surface water in the wilderness as a means of avoiding WAD

Let's review:

Boulware surveyed something like 350 people on AT, while Crouse surveyed 180 people on AT.

The groups in both surveys did the full length of the AT. Both assessed efficacy of water treatment. B. found a correlation and Crouse did not.

Gardiner, et al., did a field survey of 155 on Vermont's Long Trail. Gardiner reported infection rates that were quite close to that reported by Crouse, and much lower than those shown by Boulware. Gardiner would thus seem to lend credence to Crouse's data, though he apparently didn't address efficacy of water treatment.

(Objectively, a significant portions of the AT, and parts of LT, are not "wilderness" as defined by this article. Because this is obvious to the well-informed, perhapse it need not be stated.)

Welch and Rockwell did wide-ranging surveys of literature concerning the Sierra Nevada and wilderness areas in general, and concluded that water treatment is not useful in avoiding WAD. The other Welch guy's research backs this up.

Zell did a similar though smaller survey of literature, and also performed a small, though relatively rigorous field study, and says water filtration may not be cost effective.

Derlet has widely sampled water in Sierra Nevada and says treatment in wilderness isn't useful.

Backer says that in pristine wilderness, water treatment is not needed. The editor of "Wilderness Medicine" says that it is.

The NOLS database of 2.59 million field days in a program which emphasizes water treatment shows truly negligible infection rates.

The NOLS rates are far, far lower than Boulware's data concerning those who told him they treated water. It may be reasonable to assume that many instances of exposure to potential contamination was included in the NOLS field days, although this would be mere intuition on the part of readers -- and needless OR for editors.

So to make a specific summary, you've got Crouse, TP Welch, TR Welch, Rockwell Zell Derlet and Backer raising explicit doubts, vs Boulware, WM editor on the other side. I don't think of any of these guys' work as "the Gold Standard" in science, and don't think absolute judgments are appropriate or even possible on the part of Wikipedia editors.

Am I missing somebody?

Calamitybrook (talk) 07:25, 12 November 2008 (UTC)

Most if not all of your above remarks have been discussed and disputed on this talk page already. If you want to resurrect any of those discussions you need to refer to them specifically, otherwise we are starting from scratch with issues that have already extensively been discussed and as I recall you were never able to put up a viable argument. --Bob K31416 (talk) 15:30, 12 November 2008 (UTC)

Proposed Copy

Here is roughly what I'd probably add, along with the necessary verification notes. Deletion of existing material is not at issue, nor certainly, is addition of any verifiable material of any sort.

"Data obtained by at least one researcher has found a correlation between water treatment and avoidance of wilderness-acquired diarrhea, and much widely published advise reflect this material

Yet among less than a dozen notable researchers in the field of wilderness diarrhea, a majority have raises questions about the efficacy of water treatment in pristine wilderness settings as a means of avoiding disease. Their research suggests that most WAD cases result from inadequate personal hygiene rather than contaiminated water.

Howard Backer has told interviewers that in "pristine" settings, filtrations may be unnecessary. Byron Crouse, surveying 180 hikers on the Appalachian Trail, failed to discover a correlation between water treatment and illness.

Sam Zell, who reviewed a range of research on the subject and conducted a small, but comparatively rigorous field study, suggested that on brief wilderness trips, water treatment may not be cost effective.

TP Welch, in an editorial in the journal "Wilderness Medicine" said that based on wide-ranging evidence, water treatment is ineffective as a means of avoiding WAD, and hand-washing should receive emphasis in educational programs.

T.R. Welch reviewed nearly 200 research papers on the subject of WAD, and reached a similar conclusion.

Robert Derlet, who collected and analyzed hundreds of backcountry water samples over a period of years, suggests that water treatment, in general, is not useful and that it appears the vast majority of WAD cases stem from improper hygiene.

Robert Rockwell reviewed more than sixty sources of research on the subject of WAD, and in a widely diseminated paper that he revised several times over a period of years to include additional material, advised that wilderness diarrhea is normally contracted from hand-to-mouth contamination rather than from contaminated water."

(The above unsigned comment was by Calamitybrook.)

This unreferenced material is filled with misrepresentations and presented in a style that would degrade the article and further discussion is not worthwhile since many of the problems with the above has been discussed before. --Bob K31416 (talk) 14:55, 13 November 2008 (UTC)

I think it is much, much too long and detailed. Where there are disagreements, we can admit them, but we do not need to bother with exactly which researcher surveyed exactly how many people in exactly what location. This is an encyclopedia; we summarize information. WhatamIdoing (talk) 02:06, 14 November 2008 (UTC)

So in the interest of a fair and accurate summary, you may prefer only the following (accompanied by all necessary verification notes)?

"Data obtained by at least one small-scale researcher has found a correlation between water treatment and avoidance of wilderness-acquired diarrhea, and much widely published advise reflect this view. Yet among less than a dozen similar researchers in the field, a majority have raised questions about the efficacy of water treatment in pristine wilderness settings as a means of avoiding disease. This research suggests that most WAD cases result from inadequate personal hygiene rather than contaiminated water."

Boulware may or may not be the only reliable resercher that has ever examined this topic. But I don't think this is likely or knowable, nor can it be credibly argued from available information.

In the case of whether cigarettes cause cancer (for example), there is certainly no need to "bother" with detail on historical research (although this information may well be notable and interesting nonetheless).

But to apply the same standard in the case of WAD does require a materially different set of reasons, because the data is vastly more limited and weak.

Here, incidently, are two blogs by the Tod Schimelpfenig, curriculum director of wilderness medicine for NOLS, that summarize a few of the doubts raised by researchers, specifically Welch and Derlet. Schimelpfenig presents no coutervailing research in either item, although he only indirectly challenges NOLS policy of advising disinfection. To dismiss this material in a Wikipedia article would certainly be questionable.

[[44]]

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Calamitybrook (talk) 06:23, 14 November 2008 (UTC)

Re "Here, incidently, are two blogs by the Tod Schimelpfenig, curriculum director of wilderness medicine for NOLS, that summarize a few of the doubts raised by researchers, specifically Welch and Derlet. Schimelpfenig presents no coutervailing research in either item, although he only indirectly challenges NOLS policy of advising disinfection. To dismiss this material in a Wikipedia article would certainly be questionable."

It shouldn't be included. Sorry but this fellow doesn't have any new info and is clearly unreliable. At the end of his remarks he writes that on his personal time, "...but mostly I disinfect my water." Why would he do that if he thought the water was OK?

Calamitybrook, Why didn't you consider that before you argued for putting that fellow's remarks in the article? This is a serious question because this type of behavior is taking up editors' time that could be better spent on productively improving the article. And your message isn't an isolated incident and I have pointed out even more serious problems in this discussion in my previous messages, such as resurrecting previous issues while ignoring all the discussion about them in the past that disputed your point of view. --Bob K31416 (talk) 14:21, 14 November 2008 (UTC)

"Effective" and "cost-effective" are not the same thing. I could hire a team of experts to dust my furniture every hour of the day, and it would be effective in the sense that the furniture would be clean, but it would cost a small fortune. Nobody is claiming that routinely disinfecting water prevents zero cases of diarrhea -- only that it might not prevent enough cases of diarrhea to be worth the expense. WhatamIdoing (talk) 18:36, 14 November 2008 (UTC)

--

Bob, I mentioned Schimelpfenig's blogs "incidently," and don't suggest that they should be included. The point is the notability of the work of Derlet and Welch. Schimelfpenig, a man of some standing in the field, amplifies their work by writing about it on the NOLS wilderness medicine Web site.

With regard to his employer, NOLS, Schimelpenig says, "I respect the [employer's] position and...I have better things to do than argue this question." To me at least, this seems like a wise statement when posting material that contradicts one's boss.

What, there are probably several ways to arrive at a yes or no answer to the question of whether water treatment is reasonable in wilderness settings.

But to try and get back on track:

I think this article ought to be clear and neutral in stating that the popular press (books, magazines, etc.) invariably advises wilderness travelers to disinfect water, and perhaps also, that two researchers on the Appalachian trail (traversing some of the most densely populated U.S. regions) produced split data concerning this notion.

Also a statement that the majority of wilderness field research has raised doubts on the topic.

This is verifiable, and would not include an independent evaluation (OR) of data on the part of Wikipedia editors.

Calamitybrook (talk) 23:21, 14 November 2008 (UTC)

You're still ignoring previous discussions of these issues. --Bob K31416 (talk) 00:13, 15 November 2008 (UTC)

Can you summarize here?

Calamitybrook (talk) 02:31, 15 November 2008 (UTC)

They are the ones that you are currently raising. You might start by rereading and understanding your last message. Simply look for the discussions of those issues that you have previously had on this talk page. Sorry but I prefer to improve the article rather than go round and round in circles, having to repeat myself on the same issues. Good luck in your future Wikipedia experience. --Bob K31416 (talk) 02:59, 15 November 2008 (UTC)

--

My "last message" is that data from a majority of field researchers have raised doubts about water disinfection in wilderness environments, and that this is verifiable statement -- a "topic sentence" which can then be elaborated on. The article might then go into more or less detail on these various findings, and I'm open to either direction, as long as the material is sourced.

Bob, the previous discussions to which you apparently refer, have established that your belief in Boulware as the only credible field research on this topic, is based soley on your personal analysis, and that this amounts to OR and is inappropriate criteria for Wikipedia.

I might add that I do indeed respect your personal opinion.

Boulware's data concerns people traveling through southern New York, New Jersey and Connecticut, and if the term "wilderness-acquired diarrhea" is to be indeed meaningful, I'd be interested in your views on how to handle this as part of an even-handed effort to reflect the various research available on the topic at hand.

Calamitybrook (talk) 03:59, 15 November 2008 (UTC)

Immediate Improvements

Part of the section titled "Names and definitions" is currently gibberish. An editor ought to address this section.

I refer particularly to this bit:

"Use of the terms "wilderness acquired diarrhea" and "wilderness diarrhea" has been limited to a small number of journal articles although it has been the subject of many. The term "wilderness acquired diarrhea" has appeared in articles where the traveller is infected during a wilderness trip and may have symptoms during or after the trip,[1][5] whereas the term "wilderness diarrhea" has appeared exclusively in articles where the trips are long enough so that the symptoms most likely appear during the trip.[2][3] But this is not clearly definitive because of the small number of articles that use the terms"

Calamitybrook (talk) 07:56, 16 November 2008 (UTC)

I find the distinction between the two nearly identical terms to be both WP:OR and entirely unimportant. I think we should remove these sentences. WhatamIdoing (talk) 23:39, 16 November 2008 (UTC)

Gee! I'm surprised at these comments. There was previous extensive discussions here about these terms being neoligisms that you participated in and earlier about a distinction between the two. If we don't give this support for the terms, then where do we go to validate their meanings with references? Please look at the previous discussions. Thank you.

Also, I'm curious about the OR point. Could you give details about why you consider that paragraph OR? Also, please note that any criteria for identifying OR in this paragraph might be used to eliminate much of Wikipedia in general, so please be careful about what you call OR and please don't use that term so easily. Thank you. --Bob K31416 (talk) 15:09, 17 November 2008 (UTC)

It's original research because the method that you (the Wikipedia editor) apparently used to determine the difference between "WAD" and "WD" was to look at the original papers and draw your own conclusions about which kind of papers preferred which term. This is practically the definition of original research. Supporting this distinction requires finding an actual reliable source (ie, not you, not me, not Calamity) that actually published a statement about how the two terms are used. Instead, you cite four sources that happen to use the terms, and announce what you personally think the difference is.

And as far as I can tell, this paragraph has not been discussed: You added it on November 3, and I see not a single line on this page about your decision to include this. WhatamIdoing (talk) 19:18, 17 November 2008 (UTC)

WhatamIdoing, Could you please define wilderness acquired diarrhea and wilderness diarrhea? Thanks. --Bob K31416 talk) 05:24, 18 November 2008 (UT)

WhatamIdoing, The reason I'm asking is that you have concluded that Wilderness acquired diarrhea and Wilderness diarrhea are the same thing. Somehow you have determined that the term Wilderness diarrhea is not limited to cases of diarrhea that occur in the wilderness. Could you give a source for your conclusion that the term Wilderness diarrhea is not limited to the situation where the diarrhea occurs in the wilderness? As far as I can see this is your personal conclusion without any references to back it up.

Please note that we don't have any references that specifically define the terms. There are no references that specifically say that the terms mean the same thing or that they mean different things. All we have to go on as far as the references are concerned was described in the paragraph. As far as I can see, the paragraph is not concluding what the meaning of terms is but is simply presenting what the state of the situation is regarding the limited use of the terms.

You have no right to conclude that the terms mean the same thing, nor do you have references to back up that conclusion. --Bob K31416 (talk) 12:11, 18 November 2008 (UTC)

Bob, the most immediate problem with this section is the syntax of this sentence:

"Use of the terms "wilderness acquired diarrhea" and "wilderness diarrhea" has been limited to a small number of journal articles although it has been the subject of many."

Less pressing: I don't understand the sourcing of this section or the distinctions it attempts to make. I view the verb "acquired" as trivial. "Wilderness" is an operative term worthy of definition.

Calamitybrook (talk) 06:19, 18 November 2008 (UTC)

Calamitybrook, Re "I view the verb 'acquired' as trivial." - Then why do you think the journal article authors included it in the term 'Wilderness acquired diarrhea'? --Bob K31416 (talk) 12:18, 18 November 2008 (UTC)

Maybe for the same reason some authors call it "traveler's diarrhea" and others call it "travelers diarrhea." By the way, I think "wilderness-acquired diarrhea" takes a hyphen.

I do agree that the whole section is a another instance of OR.

Calamitybrook (talk) 14:49, 18 November 2008 (UTC)

Bob, my personal views are completely unimportant. We have no reliable source that draws a distinction between the two terms. We therefore cannot include a paragraph that asserts a distinction between the two terms. We don't have to assert that they're identical: we are merely required to refrain from asserting that they are different. The paragraph must be deleted. WhatamIdoing (talk) 19:39, 19 November 2008 (UTC)

WhatamIdoing, Re "We don't have to assert that they're identical: we are merely required to refrain from asserting that they are different." - The unreferenced assertion that Wilderness acquired diarrhea is also called Wilderness diarrhea already exists in the first line of the article and you may have put it there. Furthermore, by denying the possiblity that they may have different meanings, you are asserting that they are identical without any reference to back you up. (I'll address your other remarks after you have addressed this issue. Thank you.) --Bob K31416 (talk) 23:39, 19 November 2008 (UTC)

I just looked at the history of the first line and I found that I had changed it here from a form that didn't have the problems that I have identified!! We can modify the first sentence accordingly and then I wouldn't object to deleting the paragraph at issue. --Bob K31416 (talk) 02:46, 20 November 2008 (UTC)

The burden of proof is always on the editor that wants to include the information. You must be able to produce a reliable source that directly verifies the specific information that you want to include. You can't do that; we all know that you can't do that. So the paragraph must be removed.

You should feel free to apply that standard to any statement that you honestly suspect is in error and for which no reliable source can be found to directly support it. WhatamIdoing (talk) 03:30, 20 November 2008 (UTC)

Re "You can't do that; we all know that you can't do that." Are you sure you want to take that tone? Anyhow this discussion is over as far as I'm concerned. --Bob K31416 (talk) 05:38, 20 November 2008 (UTC)

Thanks for deleting the OR. Makes other problems in that brief section a non-issue.

Calamitybrook (talk) 08:50, 20 November 2008 (UTC)

again

Bob, I see that you reverted the deletion of your original research. You've got two editors here and two editors at the Original Research Noticeboard that have told you that you don't have sufficient references to justify its inclusion.

Under Wikipedia's policies (specifically WP:V#Burden_of_evidence), the editor that wants to include material must provide adequate reliable sources to support it. You have not done that. Please either (A) provide appropriate sources that directly support the distinction that you're drawing or (B) quit adding this paragraph back into the article.

Thanks for your compliance with Wikipedia's core policies, WhatamIdoing (talk) 22:57, 22 November 2008 (UTC)

Hey there, I don't understand what your problem is since I wrote previously, "We can modify the first sentence accordingly and then I wouldn't object to deleting the paragraph at issue." I also referred to this in the edit summary when I previously reverted your edit. Well, I modified the first sentence accordingly so I don't have any objections to your deletion now since you apparently accepted the changes I made to the first sentence. Peace. --Bob K31416 (talk) 00:39, 23 November 2008 (UTC)

Wow. This stuff has some really surprising turns. I looked back in the history of the article and the essential feature needed in the first sentence that I restored, after I had previously changed it many edits ago, was originally included by Calamitybrook here. --Bob K31416 (talk) 02:05, 23 November 2008 (UTC)

My "problem" is that you deliberately added information that does not comply with Wikipedia's policies, even after four editors told you that it did not comply with Wikipedia's policies. Your other edits will be evaluated on their own merits. Speaking of which, you might want to look at Wikipedia:LEAD#First_sentence_content, specifically the sentence that says, "If possible, the page title should be the subject of the first sentence," which your recent changes do not comply with. WhatamIdoing (talk) 02:40, 23 November 2008 (UTC)

Long-Term Improvements

The very few people following this article recently may realize I haven't edited it for more than two months. Since then, I believe it has vastly improved.

I note that most of the edits have been done by Bob, but I think the influence of WhatamIDoing is extremely clear. Both deserve credit, apparently, for these significant improvements, which believe it or not, I haven't closely followed.

Calamitybrook (talk) 09:29, 21 November 2008 (UTC)

Sadly, there remains an obvious problem with OR, irrelevance and lack of clarity in the "Definitions" section, as explained in the recent discussion.

When and how can this be fixed??

Calamitybrook (talk) 22:14, 21 November 2008 (UTC)

Happily, that particular shortcoming is once again fixed by WhatamIdoing.

Bob's comment that he doesn't understand the problem certainly isn't the optimal agreement on mutually understood editing principles....But at the moment, the article overall is looking pretty reasonable.

Calamitybrook (talk) 02:24, 23 November 2008 (UTC)

Restored Rockwell citation

The Rockwell article cites roughly 40 medical and public health articles, studies, etc., concerning backcountry water safety, and as such for the general reader, is a useful summary of much relevant research.

Rockwell is somewhat widely cited as an expert by general circulation newspapers, magazines, etc.

Calamitybrook (talk) 17:26, 7 July 2009 (UTC)

^ Backer, Howard D. (2007), “Field Water Disinfection”, In: Auerbach, Paul S. (editor), Wilderness Medicine, 5th edition, Philadelphia, Pennsylvania: Mosby Elsevier, pg 1369.
^ ^a ^b Boulware DR, Forgey WW, Martin WJ 2nd (2003). "Medical Risks of Wilderness Hiking". Am J Med. 114 (4): 288–93. PMID 12681456.{{cite journal}}: CS1 maint: multiple names: authors list (link) CS1 maint: numeric names: authors list (link)
^ ^a ^b Boulware DR (2004). "Influence of Hygiene on Gastrointestinal Illness Among Wilderness Backpackers". J Travel Med. 11 (1): 27–33. PMID 14769284.
^ Welch TP (2000). "Risk of giardiasis from consumption of wilderness water in North America: a systematic review of epidemiologic data". Int. J. Infect. Dis. 4 (2): 100–3. PMID 10737847.
^ Welch TP (2000). "Risk of giardiasis from consumption of wilderness water in North America: a systematic review of epidemiologic data". Int. J. Infect. Dis. 4 (2): 100–3. PMID 10737847.
^ Brody, Jane E. (2008-10-15). "HEALTH: Diagnostics; Test Unmasks a Parasitic Disease". New York Times. New York Times Company. Retrieved 2008-10-15. {{cite news}}: Cite has empty unknown parameter: |coauthors= (help)
^ Hlavsa, Michele C. (2005-01-28). "Giardiasis Surveillance --- United States, 1998--2002". Morbidity and Mortality Weekly Report. Centers for Disease Control and Prevention. Retrieved 2008-10-15. {{cite web}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
^ Rockwell, Robert L. (2003). "Giardia Lamblia and Giardiasis With Particular Attention to the Sierra Nevada" (PDF). Peak Climbing Section, Loma Prieta Chapter, Sierra Club. Retrieved 2008-08-07.
^ Crouse BJ, Josephs D (1993). "Health care needs of Appalachian trail hikers". The Journal of family practice. 36 (5): 521–5. PMID 8482936. {{cite journal}}: Unknown parameter |month= ignored (help)
^ Welch TR, Welch TP (1995). "Giardiasis as a threat to backpackers in the United States: a survey of state health departments". Wilderness Environ Med. 6 (2): 162–6. PMID 11995903. {{cite journal}}: Unknown parameter |month= ignored (help)

[1] Giardia Lamblia and Giardiasis by Robert L. Rockwell, June 4, 2003, Loma Prieta Chapter of the Sierra Club website. Accessed Nov 6, 2006.

[2] Backer, Howard D. (2007), “Field Water Disinfection”, In: Auerbach, Paul S. (editor), Wilderness Medicine, 5th edition, Philadelphia, Pennsylvania: Mosby Elsevier, pg 1369.

[Boulware2003-3] Boulware DR, Forgey WW, Martin WJ 2nd (2003). "Medical Risks of Wilderness Hiking". Am J Med. 114 (4): 288–93. PMID 12681456.{{cite journal}}: CS1 maint: multiple names: authors list (link) CS1 maint: numeric names: authors list (link)

[Boulware2004-4] Boulware DR (2004). "Influence of Hygiene on Gastrointestinal Illness Among Wilderness Backpackers". J Travel Med. 11 (1): 27–33. PMID 14769284.

[5] Welch TP (2000). "Risk of giardiasis from consumption of wilderness water in North America: a systematic review of epidemiologic data". Int. J. Infect. Dis. 4 (2): 100–3. PMID 10737847.

[6] Welch TP (2000). "Risk of giardiasis from consumption of wilderness water in North America: a systematic review of epidemiologic data". Int. J. Infect. Dis. 4 (2): 100–3. PMID 10737847.

[Brody2008-7] Brody, Jane E. (2008-10-15). "HEALTH: Diagnostics; Test Unmasks a Parasitic Disease". New York Times. New York Times Company. Retrieved 2008-10-15. {{cite news}}: Cite has empty unknown parameter: |coauthors= (help)

[Hlavsa2005-8] Hlavsa, Michele C. (2005-01-28). "Giardiasis Surveillance --- United States, 1998--2002". Morbidity and Mortality Weekly Report. Centers for Disease Control and Prevention. Retrieved 2008-10-15. {{cite web}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)

[Rockwell2003-9] Rockwell, Robert L. (2003). "Giardia Lamblia and Giardiasis With Particular Attention to the Sierra Nevada" (PDF). Peak Climbing Section, Loma Prieta Chapter, Sierra Club. Retrieved 2008-08-07.

[Crouse1993-10] Crouse BJ, Josephs D (1993). "Health care needs of Appalachian trail hikers". The Journal of family practice. 36 (5): 521–5. PMID 8482936. {{cite journal}}: Unknown parameter |month= ignored (help)

[TRWelch1995-11] Welch TR, Welch TP (1995). "Giardiasis as a threat to backpackers in the United States: a survey of state health departments". Wilderness Environ Med. 6 (2): 162–6. PMID 11995903. {{cite journal}}: Unknown parameter |month= ignored (help)

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