Traveler's diarrhea
What is traveler's diarrhea?
Traveler's diarrhea is an acute (short-term) infection of your stomach and intestines. It mainly affects residents of developed countries travelling to sub-tropical or third-world regions, with an estimated 40 million cases worldwide each year. [1] While the condition itself is not usually serious, it can cause severe dehydration in vulnerable individuals. Some of the highest-risk areas are Asia, South and Central America, Africa and the Middle East. It can be caused by poor hygiene and food-handling procedures, and water contamination.
A wide range of bacteria, viruses and parasites can cause traveler's diarrhea. The usual symptoms are diarrhea, often with nausea and fatigue. Traveler's diarrhea usually passes within 3-4 days without incident if you are healthy. However, if you are very young or old, or have depleted immunity, it can be more serious and even fatal if left untreated.
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Dehydration
The state of insufficient hydration; excessive loss of water; requiring more water in order to function normally.
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De la Cabada Bauche J. and DuPont H.L. (2011) New developments in traveler’s diarrhea. Gastroenterology and Hepatology 7:88-95.
Causes
The main cause of traveler's diarrhea is infection from bacteria, viruses or parasites. They are commonly due to consuming contaminated food or water. They usually cause the lining of the intestines to become inflamed and irritated. This inflammation stops water from being absorbed, which causes watery stools.
Bacteria
Bacteria are responsible for up to 80% of traveler's diarrhea cases. [2] Common bacterial infections known to cause traveler's diarrhea are:
- Escherichia coli (E. coli) - this strain of bacteria is responsible for most cases of traveler's diarrhea in developing nations. It is transmitted by consumption of water and food contaminated with human waste (feces). It typically affects those who have not built up an immunity to it, which means you may dine with locals and be the only person to fall ill, and;
- Salmonella, Shigella, Staphylococcus aureus, Vibrio cholera and Campylobacter bacteria are also common bacteria that lead to diarrhea. Infection can be spread due to poor hygiene, eating contaminated foods, undercooked meat (especially chicken), or contact with animal or human waste.
Street vendor food may be contaminated by bacteria.
Viruses
Viral infections can also cause traveler's diarrhea. They are highly contagious, therefore they easily spread to your fellow travelers. These viruses include:
- Norovirus - symptoms can be severe;
- Rotavirus;
- Adenovirus - symptoms of this can also include a sore throat, conjunctivitis and respiratory infection, but these are rarely serious, and;
- Astrovirus.
Parasites
Intestinal parasites such as Giardia lamblia, Entamoeba histolytica and Cryptosporidium can cause an infection of the digestive system with nausea, watery diarrhea and severe cramping. Poor hand washing and contact with animal or human wastes are the usual causes of infection.
Unknown cause
In a large percentage of cases, no cause may be found for your diarrhea. It may be due to your digestive system being intolerant to local foods, due to a food allergy or having an infection, which is not easily diagnosed.
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Leder K. (2015) Advising travellers about management of travellers’ diarrhoea. Australian Family Physician 44:34-37.
Risk factors
Travel to developing or tropical regions
If you live in an developed country, it is very common to experience traveler's diarrhea while travelling through developing nations, where sanitation and food hygiene standards may be poor. Infectious agents may be present in drinking water, food and on communal surfaces such as door handles or handrails.
Age
While traveler's diarrhea can happen to anyone, young children tend to be at increased risk.
Weak immune system
You are at greater risk if you have a weakened immune system, heart disease, or due to medications such as proton pump inhibitors (used for heartburn and stomach ulcers) and anti-inflammatories (such as prednisolone).
Time of year
The time of year you travel can influence your chances of becoming ill. In temperate South-East Asia, the hot months just before the monsoon season provide a greater risk of traveler's diarrhea.
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Ulcers
An open sore in the skin or mucous membranes such as those of the stomach lining, intestine or mouth.
Types
The different types of traveler's diarrhea are classified according to the symptoms you are experiencing. The main concern for your doctor will be to identify and treat dehydration, as a result of fluid losses in your stools.
Mild
You have had one or two episodes of diarrhea in the previous 24 hours, but no other symptoms.
Moderate
You have had at least two episodes of diarrhea in the past 24 hours and one or more of the following symptoms: abdominal pain, nausea, vomiting, fever, or blood in the stools.
Severe
You have had three or more episodes of diarrhea in the past 24 hours and one or more of the following symptoms: abdominal pain, nausea, vomiting, fever, or blood in the stools. Severe traveler's diarrhea often leads to dehydration and can require hospitalization for rehydration.
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Dehydration
The state of insufficient hydration; excessive loss of water; requiring more water in order to function normally.
Signs and symptoms
The signs and symptoms of traveler's diarrhea, which tend to happen very abruptly. They include:
- Diarrhea, usually explosive, urgent and watery. About 4-5 (or more) episodes a day can be expected;
- Severe stomach cramps with bloating;
- Loss of appetite;
- Nausea and vomiting;
- Muscle aches and tiredness, and;
- Sometimes, fever and headache.
Traveler's diarrhea can cause severe stomach cramps and bloating.
Methods for diagnosis
While the majority of cases go undiagnosed, your doctor may suggest the following tests to find the cause of your diarrhea:
- Blood tests - to check your blood count, electrolytes and liver function;
- Stool microscopy, culture and sensitivity (MCS) - this uses a stool sample to check for bacteria, viruses and parasites, and;
- Stool polymerase chain response - this test uses a stool sample to rapidly detect the presence of viruses and some bacteria.
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Electrolytes
Substances that form ions when dissolved in water. These include potassium and sodium minerals that are necessary for normal functioning of the body and all its cells.
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Stool microscopy, culture and sensitivity
A stool test used to check if there is a disease-causing organism or virus in the digestive tract with the added benefit of finding which medications would be most useful in targeting that organism or virus.
Types of treatment
Depending on the severity of your symptoms, you may be advised to stay at home and do the following:
Self care
The following measures may be of help:
- Have complete bed rest to conserve your energy;
- Regularly wash your hands with soap, especially after visiting the toilet, to prevent infecting others or re-infecting yourself;
- Take small sips of clear liquids to stay hydrated, preferably water and oral rehydration drinks;
- Avoid spicy or greasy foods and try to eat mainly bland foods, such as dry crackers, until your symptoms settle, and;
- Unless prescribed by your doctor, avoid taking antibiotics, antidiarrheal or anti-nausea medications, which can prolong infections and delay recovery.
For severe cases, hospitalization for dehydration is not uncommon and may involve insertion of an intravenous (IV) drip or nasogastric tube, to get fluids back into your system.
Medications
In most cases of traveler's diarrhea, unless severe, medications may not be needed. Unless prescribed by your doctor, medications can make your condition worse. Parasitic and some bacterial infections can be treated with anti-parasitic medications and antibiotics, respectively. Sometimes, anti-nausea and antidiarrheal medications may also be prescribed by your doctor.
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Dehydration
The state of insufficient hydration; excessive loss of water; requiring more water in order to function normally.
Potential complications
- Dehydration - especially in children (dehydration in children);
- Electrolyte imbalance, and;
- Haemolytic-uraemic disorder - caused by E. coli, this is a very rare condition that affects young children. If your child has blood in their diarrhea, seek medical attention immediately.
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Dehydration
The state of insufficient hydration; excessive loss of water; requiring more water in order to function normally.
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Haemolytic-uraemic disorder
A rare condition triggered by certain infections, medications or unknown factors, which causes the rapid destruction of red blood cells and subsequently life-threatening kidney failure.
Prognosis
The outlook for most cases of traveler's diarrhea is good. The main concern though, is dehydration, which can prove dangerous.
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Dehydration
The state of insufficient hydration; excessive loss of water; requiring more water in order to function normally.
Prevention
Avoiding risk factors is the main way to reduce your incidence of developing traveler's diarrhea:
- Only drink bottled water - also use it to brush your teeth;
- Do not have ice in drinks;
- Avoid unpasteurized milk products;
- Only drink bottled or canned beverages and clean the lid with a cloth beforehand;
- Avoid all raw or peeled fruits and vegetables (or peel them yourself);
- Avoid green leafy vegetables, such as spinach and lettuce, that may have been washed in tap water;
- Avoid raw or undercooked meat, especially poultry;
- Avoid food from street vendors;
- Do not eat food that has been left sitting outside for too long, and;
- Avoid food buffets.
Discuss vaccination requirements and travel hygiene with your doctor prior to travelling. Some doctors may also provide a useful traveler's medical kit that can include simple medications and written advice for diarrhea.
Good hygiene
- Always wash your hands with soap and water, and dry them thoroughly, after using the toilet and before preparing foods;
- Wash and thoroughly dry any cooking utensils or glasses after use;
- Use an alcohol-based hand sanitizer when unable to wash hands, and;
- Ensure raw and cooked foods are not handled using the same utensils, and do not allow them to come into contact with each other.
Prevention for children
- Do not allow children to put unwashed hands in their mouths;
- Do not allow them to play on the floor in risky areas - put down a blanket or rug;
- Only offer bottled or boiled water;
- Discuss travel vaccination requirements for your children at least two weeks prior to travelling;
- Do not allow children to play in water that may be contaminated, and;
- Ensure children wash their hands often, especially before eating and after visiting the bathroom.
Avoid contaminated water
Infectious agents are often present in water that may look clean. In areas with poor sanitation, water is often contaminated by animal and human waste and chemical run-off.
If you are considering swimming in a pool, spa, lagoon or river, it is advisable to keep the following in mind:
- Do not enter if you have open cuts, wounds, fresh piercings or tattoos;
- Keep your head above water and do not let it enter eyes, ears or your mouth, and;
- Keep small children and babies out of the water.
Vaccination
It is difficult to avoid developing traveler's diarrhea, but some vaccines may help prevent diarrheal disease. Typhoid fever and cholera are two diarrheal illnesses that have vaccinations. Discuss your vaccination requirements with a travel doctor at least two weeks prior to travel.
References
- De la Cabada Bauche J. and DuPont H.L. (2011) New developments in traveler’s diarrhea. Gastroenterology and Hepatology 7:88-95.
- Leder K. (2015) Advising travellers about management of travellers’ diarrhoea. Australian Family Physician 44:34-37.
- Travellers Diarrhea - Chapter 2 - 2014 Yellow Book | Travellers Health | CDC. Accessed 16 July 2014 from file:///C:/Users/karen.mccloskey/AppData/Roaming/Zotero/Zotero/Profiles/xgn8mfnk.default/zotero/storage/EKCGC8E5/travelers-diarrhea.html
- Travel Clinics Australia | Vaccinations Immunisations Malaria tablets & gastro prevention for travellers. The Travel Clinics. Accessed 17 July 2014 from link here
- Diarrhoea - Diagnosis - NHS Choices. Accessed 16 July 2014 from link here
- For the Record: A History of the Definition & Management of Travellers Diarrhea - Chapter 2 - 2014 Yellow Book | Travellers Health | CDC. Accessed 16 July 2014 from file:///C:/Users/karen.mccloskey/AppData/Roaming/Zotero/Zotero/Profiles/xgn8mfnk.default/zotero/storage/4Z9H6S8Q/for-the-record-a-history-of-the-definition-and-management-of-travelers-diarrhea.html
- Genome Biology | Full text | Diarrhea in young children from low-income countries leads to large-scale alterations in intestinal micro biota composition. Accessed 17 July 2014 from link here
- HPA - Search Results. Accessed 17 July 2014 from link here
- Microsoft Word - ITH_country_list.docx - ITH_country_list.pdf. Accessed 17 July 2014 from link here
- Microsoft Word - SAFE DRINKING WATER FOR TRAVELLERS 05 2005-06-27 final.doc - sdwtravel.pdf. Accessed 17 July 2014 from link here
- Perspectives: Prevention of Travellers DiarrheaIts Not Only WHAT You Eat & Drink - Chapter 2 - 2014 Yellow Book | Travellers Health | CDC. Accessed 17 July 2014 from link here
- RACGP - Parasitic causes of prolonged diarrhoea in travellers - Diagnosis and management. Accessed 18 July 2014 from link here
- Table of Contents | 2014 Yellow Book | Travellers Health | CDC. Accessed 17 July 2014 from link here
- Travel Clinics Australia | Vaccinations Immunisations Malaria tablets & gastro prevention for travellers. The Travel Clinics. Accessed 17 July 2014 from link here
- Travelers diarrhea diet: MedlinePlus Medical Encyclopaedia. Accessed 18 July 2014 from link here
- Travellers Diarrhea - Chapter 2 - 2014 Yellow Book | Travellers Health | CDC. Accessed 16 July 2014 from file:///C:/Users/karen.mccloskey/AppData/Roaming/Zotero/Zotero/Profiles/xgn8mfnk.default/zotero/storage/EKCGC8E5/travelers-diarrhea.html
- Travellers diarrhoea | Better Health Channel. Accessed 17 July 2014 from link here
- What are the symptoms of E. coli infection? | E. coli Food Poisoning. Accessed 16 July 2014 from link here
- WHO | World Health Organization. Accessed 17 July 2014 from link here
- Vaccination for International Travel | The Australian Immunisation Handbook 10th Edition 2013. Accessed 13th August from 2014.link here
- Travelers diarrhea | Up to Date. Accessed 13th August 2014 from link here
- Faecal Multiplex PCR Testing | Dorevitch Pathology. Accessed 13th August 2014 from link here
10 Most frequently asked questions (FAQs)
What is traveler's diarrhea? Traveler's diarrhea is an acute (short-term) infection of your stomach and intestines. It primarily affects residents of industrialized regions travelling to sub-tropical regions and is the most common health issue for people travelling through developing nations. What are the symptoms of traveler's diarrhea? The main symptom of traveler's diarrhea is diarrhea (no surprises there). It's usually explosive, urgent and watery. Between four to five episodes a day are normal. Stomach cramps, vomiting, slight fever, muscle aches and fatigue are also common symptoms. How is traveler's diarrhea diagnosed? Usually a physical examination and full medical history will be enough to diagnose traveler's diarrhea, but sometimes further tests are required. These may be blood tests to check your blood count, electrolytes, liver function and antibodies, or a feces microscopy culture and sensitivity (MCS), to check for live bacteria, ova, cysts and parasites (OCP). How is traveler's diarrhea treated? Most cases of traveler's diarrhea resolve without any treatment except for self-care measures such as bed rest and oral rehydration drinks. Certain types of bacteria, parasites and viruses will require medications. Is traveler's diarrhea serious? In most cases traveler's diarrhea isn't serious, but it can be fatal to small children or vulnerable adults if they become seriously dehydrated.
Related topics
Diarrhea is a common digestive complaint that involves frequent, urgent, and watery bowel movements. Although most cases clear up at home without much treatment, be aware that diarrhea can lead to severe dehydration, especially in children and the elderly. Gastroenteritis is a common condition sometimes called ‘gastro’ or ‘stomach flu’. The main symptoms are diarrhoea, vomiting, and abdominal pain. Most people are at risk of developing it at some point in their lives. Bowel obstruction occurs when you have a complete or partial blockage of your bowel, stopping liquids, solids and gas passing through your small or large intestine. This can cause severe abdominal pain, bloating, nausea and vomiting. Bowel obstruction requires prompt medical assessment. Cholera is an infectious disease that causes severe diarrhoea. It is usually acquired by consuming contaminated food or water during travel to areas where cholera is common. The greatest danger is the dehydration diarrhoea causes. Following some advice can help prevent this condition.