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Traveler’s Diarrhea

Definition

Traveler’s diarrhea is an increase in loose, watery stools that often occurs when travelers from industrialized countries travel to developing or underdeveloped countries. Traveler’s diarrhea has many nicknames such as Montezuma’s revenge, Tut’s tummy, or tourista.

Description

Traveler’s diarrhea is a common disease. It is a form of food poisoning caused by consuming water or food contaminated with bacteria, viruses, or parasites that attack the digestive system. Normally the disease is mild and does not require professional medical care, but it can alter the plans of travelers’ and make them quite miserable for a few days.

Every year, more than 60 million people travel from industrialized countries to developing or underdeveloped countries. Of these, as many has half (estimates range from 20-55%, with most near the higher end) will develop traveler’s diarrhea. Other estimates suggest that 50,000 cases of traveler’s diarrhea occur each day. The likelihood of getting traveler’s diarrhea depends primarily on the traveler’s destination. The World Health Organization (WHO) has designated countries as either high, moderate, or low risk for traveler’s diarrhea based on their degree of hygiene and public sanitation. Only traveler’s, not natives, tend to be affected in high and moderate risk countries. People living in those countries are exposed to the organisms that cause traveler’s diarrhea from childhood and their bodies develop ways to combat or tolerate them.

Destinations designated as high risk destinations where there is more than a 50% chance of getting traveler’s diarrhea include:

  • Mexico
  • all of Latin America
  • northern and central South America, including Brazil, Venezuela, Colombia, Bolivia, Guyana, and Surinam
  • Most of Africa except South Africa
  • Most of the Middle East, including Saudi Arabia, Turkey, Iran, and Iraq
  • Most of Asia, excluding the former Russian republics, but including China, India, Thailand, Bangladesh, Viet Nam, Korea, Malaysia, and the Pacific Islands north of Australia

Intermediate risk destinations include:

  • the countries of Eastern and Southern Europe such as Poland, Romania, Croatia, the Czech Republic, Portugal, Greece, and the Balkan countries
  • most islands of the Caribbean
  • Argentina
  • South Africa
  • Israel

Low risk countries are industrialized countries that have in place reliable systems for treating sewage and drinking water. These include:

Areas of Risk for Travelers’ Diarrhea

(Illustration by GGS Information Services/Thomson Gale.)

KEY TERMS

Feces—waste from the bowels; stool

  • United States
  • Canada
  • Most countries in Northern and Western Europe including the Scandinavian countries, Great Britain, France, Spain, Austria, and Germany
  • New Zealand
  • Australia
  • Japan

Demographics

People of any age, race, or gender can get traveler’s diarrhea, although peak rates occur among travelers in their twenties. There is no clear explanation of why this group is more likely to get traveler’s diarrhea. Some experts have suggested it this finding is related more to the travel habits of young adults rather than to any biological explanation. Traveler’s diarrhea is more common in warm months and during the rainy season than at other times of the year.

Although everyone gets traveler’s diarrhea, young children, the elderly, pregnant women, and people with weakened immune systems such as those with HIV/ AIDS often have more severe and long-lasting cases than other groups. People with inflammatory bowel syndrome, diabetes, and who are taking drugs that reduce the acidity of the stomach (e.g. antacids, Tagamet, Prilo-sec, Nexium) also are likely to have severe infections.

Causes and symptoms

Many different organisms can cause traveler’s diarrhea. According to the United States Centers for Disease Control (CDC), about 85% of all cases are caused by bacteria. Another 10% are caused by parasites, and the remaining 5% by viruses. In practical terms, this means that no single treatment will cure every case of traveler’s diarrhea.

Symptoms of traveler’s diarrhea caused by bacteria—nausea, diarrhea, abdominal cramps, and sometimes vomiting and fever— come on suddenly, most often during the first week of travel. The most common cause of traveler’s diarrhea is infection with the bacteria Enterotoxigenic Escherichia coli (ETEC). E. coli are a larger genus of bacteria many of which are found in the intestines of mammals. Some subtypes of E. coli are helpful. In humans they help with digestion and the absorption of nutrients in the intestines. Many other subtypes of E. coli are neither helpful nor harmful. Some, such as ETEC and Enteroaggregative E. coli (EAEC), can cause unpleasant digestive upset. Both these types of E. coli cause watery diarrhea and abdominal cramps but little or no fever.

Campylobacter are a genus of bacteria that are a more common cause of traveler’s diarrhea in Asia than in other parts of the world. Some members of this genus cause bloody diarrhea and fever. Campylobacter bacteria are found in contaminated water, but they are also found in almost all raw poultry, even in developed countries such as the United States and Canada. Cooked food can be contaminated if it is placed on an unwashed surface that previously held raw poultry. Shigella are another common genus of bacteria that, like Campylobacter cause bloody diarrhea, nausea, vomiting, fever, and abdominal cramps.

Giardia lambia is the most common parasite to cause traveler’s diarrhea. Symptoms of traveler’s diarrhea caused by parasites take longer to appear than do symptoms caused by bacterial or viral infections.

Often symptoms persist for several weeks, much longer than the 3–5 days that most bacteria-caused traveler’s diarrhea lasts.

Viruses cause only a small amount of traveler’s diarrhea, although they are the largest cause of gastrointestinal upsets in the United States and other industrialized countries. Their symptoms are similar to those caused by bacterial infections.

The main symptom of traveler’s diarrhea is frequent loose, watery stools that begin fairly abruptly. Stools may or may not contain blood, depending on the organism causing the disease. Diarrhea may lead to dehydration. Other common symptoms that appear along with the diarrhea are nausea, vomiting (in about 15% of people), bloating, abdominal cramps, and fever. Traveler’s diarrhea usually lasts only 3–5 days even without treatment except for disease caused by parasites, which tends begin more slowly and to linger longer.

Diagnosis

Diagnosis is made on the basis of signs and symptoms. Laboratory tests are usually not done unless there are unexpected complications.

Treatment

In addition to drinking fluids, over-the-counter medications such as bismuth subsalicylate (Pepto-Bismol) and loperamide (Imodium) help give the individual more control over their bowel movements. However, these medications should not be used if by people who have blood in their stool or who have a high fever and bismuth subsalicylate should not be used by people allergic to aspirin.

Although bacteria cause most traveler’s diarrhea, antibiotics are not usually prescribed to prevent the disease. They may, however, be used to treat traveler’s diarrhea. The specific antibiotic depends on symptoms such as whether the stool is bloody and whether diarrhea is accompanied by fever or vomiting. Ciprofloxacin (Cipro), azithromycin (Zithromax) and rifaximin (Xifaxan) are the antibiotics most often prescribed. Medical care may be difficult to obtain in underdeveloped countries. Depending on where they plan to travel, individuals may want to discuss the possibility of traveler’s diarrhea with their doctor before leaving home and take along a supply of antibiotics, over-the-counter medications, and oral rehydration salts to be used as needed.

Nutrition/Dietetic concerns

The greatest health risk accompanying traveler’s diarrhea is dehydration. This is a potentially serious problem in infants and small children who can become dehydrated from vomiting and diarrhea within hours. A main goal of treatment is to keep the individual from becoming dehydrated. Infants, children, the elderly, and others who are losing large amounts of fluid from diarrhea should be given an oral rehydration solution. Oral rehydration solutions have the proper balance of salts and sugars to restore fluid and electrolyte balance. In industrialized countries, already-mixed oral rehydration solutions are available in cans or bottles at supermarkets and pharmacies. In the rest of the world, dry packets of WHO oral rehydration salts are available. The contents of the packet are mixed with 1 L of clean (i.e. boiled or purified) water. This solution can be given to young children in small sips as soon as vomiting and diarrhea start. Children may continue to vomit and have diarrhea, but some of the fluid will be absorbed. In the past, parents were told to withhold solid food from children who had diarrhea. New research indicates that it is better for children should to be allowed to eat solid food should they want it, even though diarrhea continues.

Older children and adults can stay hydrated by drinking liquids that they know are uncontaminated, such as bottled water, bottled fruit juice, caffeine-free soft drinks, hot tea, or hot broth. Normally 2-3 quarts (2-3 L) should be drunk in the first 24 hours after diarrhea starts, moving to solid food as symptoms improve.

Prognosis

Although traveler’s diarrhea can make anyone feel miserable, most people recover from the disease within 3 to 5 days with nothing worse than disrupted travel plans. About 20% of travelers are sick enough to stay in bed for at least one day, and in about 10% of people the symptoms last more than a week. People with compromised immune systems, kidney disease, or who are very young or elderly may be sicker longer than other individuals. People who develop diarrhea a few days after returning home from an area where traveler’s diarrhea is common should take into consideration that they may have brought a parasitic infection home with them.

Prevention

It is difficult to prevent all traveler’s diarrhea, although with care, the chances of getting sick can be reduced. Some common sense preventative measures include the following:

  • Avoid tap and well water including ice cubes in drinks.
  • Avoid raw peeled fruits and raw vegetables.
  • avoid unpasteurized milk, dairy products (e.g. ice cream, yogurt) and unpasteurized fruit juices.
  • Do not buy food from street vendors.
  • Wash hands often in uncontaminated water.
  • Choose hot drinks such as coffee or tea or canned or bottled drinks

BOOKS

Parker, James N. The Official Patient’s Sourcebook on Travelers’ Diarrhea. San Diego: CA Icon Health Publications, 2002.

PERIODICALS

Steffen, Robert, Francesco Castelli, Hans Dieter, et al.; “Vaccination Against Enterotoxigenic Escherichia Coli, A Cause of Travelers’ Diarrhea.” Journal of Travel Medicine. 12, no.2 (2005):102-107.

Yates, Johnnie. “Traveler’s Diarrhea.” American Family Physician. 71, no.11 (June 1. 2005): 2095ff. <http://www.aafp.org/afp/20050601/2095.html>

ORGANIZATIONS

United States Centers for Disease Control and Prevention (CDC). 1600 Clifton Road, Atlanta, GA 30333. Telephone: (800) 311-3435 or (404) 639-3534. Website: <http://www.cdc.gov>

OTHER

Buscaglia, Anthony L. and Ronald M. Moscati. “Traveler’s Diarrhea.” http://eMedicineHealth.com, August 10, 2005 2005. <http://www.emedicinehealth.com/travelers_diarrhea/article_em.htm>

Centers for Disease Control and Prevention “Traveler’s Diarrhea.” November 21, 2006. <http://www.cdc.gov/ncidod/dbmd/diseaseinfo/travelersdiarrhea_g.htm>

Centers for Disease Control and Prevention, “Risks from Food and Water.” In Traveler’s Health: Yellow Book. Chapter 2: Pre- and Post- Travel General Information,; 2005-2006 edition. <http://www2.ncid.cdc.gov/>

Centers for Disease Control and Prevention, “Travelers’ Diarrhea.” In Traveler’s Health: Yellow Book. Chapter 4: Prevention of Specific Infectious Diseases, 2005-2006 edition. <http://www2.ncid.cdc.gov/>

Mayo Clinic Staff. “Traveler’s Diarrhea.” MayoClinic.com, June 15, 2005. <http://www.mayoclinic.com/health/travelers-diarrhea/DS00318>

University of Texas Houston, Ericsson, ed. “Traveler’s Diarrhea.” BC Decker Inc., 2007 (CD-ROM)

Tish Davidson, A.M.


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