Travellers

Travellers Infomation

Travellers' Diarrhoea

Introduction

Travellers' diarrhoea (TD) is a syndrome that commonly affects travellers and is caused by one of several different organisms, most of which are endemic worldwide.

Cholera is rare as a cause of diarrhoea in travellers.

Risk for Travellers

Travellers' diarrhoea is the most common illness in those travelling from resource rich to resource poor countries and occurs in 20-50% of travellers. (1)

Those who travel rough and are adventurous in their eating habits may be at higher risk. The effects of diarrhoea are generally greater in the very young, the elderly and those with special needs.

Transmission

Eating contaminated food and to a lesser degree drinking contaminated liquids are the predominant way of acquiring travellers' diarrhoea. The highest risk foods are those that have not been thoroughly heated or that have been left out at room temperature. It is recommended that food is thoroughly cooked and served piping hot, as most diarrhoea causing enteropathogens are inactivated at temperatures above 60C.

Although a change in bowel habit can be caused by stress, a change in diet, increased alcohol consumption and hot weather, most episodes of diarrhoea are related to infection.

Signs and Symptoms

Travellers' diarrhoea is usually defined as the passage of 3 or more unformed stools in a 24-hour period, or any number of loose stools if accompanied by abdominal pain, fever, nausea or vomiting. (1) Travellers' diarrhoea typically occurs during the latter part of the first week of arrival and is often self-limiting, lasting three to four days. Approximately 3% of travellers' diarrhoea persists for longer than a month.

Treatment

Generally, travellers' diarrhoea is a self-limiting illness lasting between one and several days. The majority of travellers will recover with symptomatic treatment only.

  • Diet and Fluid. The most important aspect of management in all cases of diarrhoea is to maintain adequate fluid replacement. Oral rehydration powders or tablets (e.g. Dioralyte or Electolade) can be diluted into plain safe drinking water to remedy electrolyte imbalances and hydrate the traveller. These may be particularly useful for small children or those with special medical needs. Otherwise healthy adults can rehydrate with available fluids.

    Fluids may be all that is required for most cases of diarrhoea that are mild and self-limiting. Dehydration in adults is rare, but is the greatest risk for children with diarrhoea. (2) The elderly and those with pre existing illness are also more susceptible to complications. Breastfeeding should be continued for infants.

    As improvement occurs bland foods, for example bread, cereals, potatoes, soup, rice, bananas, chicken, should be introduced as tolerated. Milk containing products should be avoided for several days after recovery as a temporary lactose intolerance may occur.

  • Loperamide. Loperamide may be considered for those travellers in whom frequent episodes of diarrhoea is inconvenient, e.g. those travelling on long bus journeys, or for business meetings etc. However, it should not be used if the traveller has active ulcerative colitis, a fever or bloody diarrhoea. (3) Loperamide should be used with caution and only under specialist supervision in children under the age of 12 years.
  • Antibiotics. Antibiotic treatment can be considered, especially for those travellers that have a serious underlying medical condition or whose travel plans would be severely disrupted by illness, e.g. business travellers and athletes. Ciprofloxacin, in the absence of contraindications, is generally the drug of choice. Azithromycin can be considered when there is concern about resistant intestinal organisms at the destination. An antibiotic course can be as short as a single day or up to three days. The choice and suitability of antibiotics should be discussed with the GP or travel clinic.

    The combination of loperamide with an antibiotic in moderate travellers' diarrhoea may lead to more rapid clinical improvement compared with either agent alone.

  • Medical Advice. Medical care should be sought if symptoms do not improve within a few days, blood and/or mucous is present in stools, or if a fever develops. Medical care should be sought earlier for those with special health risks including the elderly, and immediately for children whose diarrhoea is accompanied by dehydration, vomiting, fever or bloody diarrhoea.

Prevention

Following a few simple guidelines on food and water hygiene can reduce the risk of travellers' diarrhoea.

Antibiotic chemoprophylaxis is not recommended for most travellers.

Excess alcohol should be avoided and unfamiliar foods sampled in moderation, as both of these can also contribute to diarrhoea.

There is no vaccine available in the UK for travellers' diarrhoea. There are vaccines available for other faecal-oral transmitted organisms such as Salmonella typhi and hepatitis A.

The newly released oral cholera vaccine Dukoral™ should not be used to try to prevent travellers' diarrhoea.

References

  1. Ericsson CD, DuPont HL. Travelers' diarrhoea: approaches to prevention and treatment. Clinical Infectious Diseases 1993; 16: 616-24
  2. CDC Food and water precautions and travelers' diarrhoea, in Travelers' Health. 2003-2004
  3. Which? What to do about travellers' diarrhoea. Drugs and Therapeutics Bulletin. 2002;5:36-8

Reading List

Ericsson C, DuPont H, Steffen R. Travelers' Diarrhea. 2003 BC Decker

Keystone JS, Kozarsky PE, Nothdurft HD, et al. Travel Medicine. London: Harcourt Publishers Ltd., 2003