TRAVELERS' DIARRHEA -- INFORMATION FOR TRAVELERS

What is it:

Traveler's diarrhea is a syndrome characterized by frequent loose bowel movements, abdominal cramps, nausea, bloating, and fatigue. The symptoms begin abruptly, occur during travel or soon after returning home and generally last several days before improvement occurs.

The most common cause of traveler's diarrhea is a bacteria (a toxic strain of E. Coli), although other bacteria, viruses and parasites can also cause this disorder. The toxic E. Coli is acquired through fecally contaminated food or water.

Where does it occur?

High risk areas (30-50% diarrhea rates), include most of the developing countries including Mexico and Latin America, Africa, the Middle East, and Asia. Moderate risk areas (15-20% diarrhea rates) include: Southern Italy, Portugal, Spain, Greece, and Israel. Low risk areas (5% diarrhea rates), include the United States, Canada, Northern Europe, Australia, New Zealand, and most of the Caribbean.

What foods are at Risk?

Even cooked foods may be at risk if improperly handled. Especially risky foods include uncooked foods (raw meat, raw seafood), raw or unpeeled fruit, raw vegetables, and unwashed salads. Unboiled tap water, ice, and unpasteurized milk and dairy products also increase the risk of traveler's diarrhea. Safe beverages include bottled carbonated beverages (especially flavored beverages), beer, wine, hot coffee or tea, water boiled or appropriately treated with iodine or chlorine. The eating place may also be important with private homes, restaurants, and street vendors listed in order of increasing risk.

Prophylaxis: Medications to Prevent Traveler's Diarrhea

There is controversy about the necessity to treat prophylactically. The concerns are that most travelers don't need antibiotic medication (most people don't get sick), and the disease itself is usually self limited and often mild. There is also concern about the development of resistant bacteria and about the side effects of the medications.

An alternative to the prophylactic use of antibiotics is the prophylactic use of Bismuth Subsalicylate tablets (Pepto-bismol). Two tablets four times daily can prevent diarrhea in 65-85% of travelers. A minor side effect is that Pepto-bismol turns the tongue and bowel movements black. You should not take Pepto-bismol if you are allergic to aspirin, and you should stop this medication if ear ringing occurs. Note that the relatively large amount of Pepto-bismol used over a period of several weeks has not yet been studied for major side effects and is not a Food and Drug Administration approved regimen. The Center for Disease Control states: "Available data is not extensive enough to exclude a risk to the traveler from the use of such large doses of Pepto-bismol over a period of several weeks".

Treatment of Traveler's Diarrhea

Somewhat less controversial is treatment with antibiotics when symptoms occur. If you are not allergic to sulfa antibiotics, treatment with sulfa type antibiotics (Septra, Bactrim), twice a day for 3-5 days appears to markedly reduce abdominal pain, nausea, and the frequency of loose bowel movements. Doxycycline antibiotics twice a day for five days is also effective. Doxycycline, a type of tetracycline, can make you more sensitive to the sun, so wear a sunscreen. Other antibiotics, such as ciprofloxacin ( Cipro), are sometimes used. These antibiotic regimens do not treat amoebic dysentery.

IF YOU HAVE A FEVER OVER 101 DEGREES FOR MORE THAN 24 HOURS, OR IF YOU HAVE BLOOD IN THE BOWEL MOVEMENTS, OR IF YOU DO NOT RESPOND TO ANTIBIOTIC TREATMENT WITHIN 5 DAYS, CONSULT A PHYSICIAN.

For symptomatic relief of cramps and diarrhea, Loperamide (Imodium), or Diphenoxylate (Lomotil), can be used. Discuss with your health practitioner the advantages and disadvantages of using these medications. If you are using these medications, discontinue if symptoms persist beyond 48 hours and do not use if you develop a high fever or blood in the stool.

Replacement of fluids lost in Diarrheal Disease

Most cases of traveler's diarrhea which lasts a few days only require replacement of fluids and salts lost in the loose diarrheal bowel movements. Fruit juices and soft drinks (preferably caffeine free), and salted crackers will maintain fluid and salt balance. Avoid non-carbonated bottled fluids or ice drinks of uncertain quality. Dairy products can make diarrhea worse in some people. A bland diet with bread, rice, and crackers and avoidance of fatty, rich, or spicy foods is helpful.

A formula for treatment of diarrheal disease is provided here.*

Prepare 2 separate glasses of the following:

Glass Number 1

Orange, apple, or other fruit juice..........................8 ounces
(rich in potassium)

Honey or corn syrup .........................................1/2 teaspoon
(contains glucose necessary for absorption of essential salts)

Salt, table .................................................1 pinch
(contains sodium and chloride)

Glass Number 2

Water .......................................................8 ounces
(carbonated or boiled)

Soda, baking ................................................1/4 teaspoon
(contains sodium bicarbonate)

Drink alternately from each glass until thirst is quenched. Supplement as desired with carbonated beverages, water, or tea made with boiled or carbonated water. Avoid solid foods and milk until recovery occurs. It is important that infants continue breast-feeding and receive water as desired while receiving these salt solutions.

*From the Health Information for International Travel - 1988, Center for Disease Control*

What If Diarrhea Persists?

You should see a physician if the diarrhea persists for more than 3-5 days. Other organisms such as Giardia or the amoebic dysentery parasite might be causing the symptoms. You should also seek medical help if you develop a high volume loss of diarrheal fluid, have blood in the stool, or experience a high fever.