When we first come across with the word traveler’s diarrhea the very first thing comes into our mind is that diarrhea which is caused during the traveling and which is most common most of the peoples all over the world. Acute diarrhea is most common with 55 percent people who travel into developed and developing countries. In a study of Americans 46 percent people who travel to developing countries have common issue of diarrhea. The very basic definition of Traveler’s diarrhea is that three or more unformed stools in 24 hours. Traveler’s diarrhea mainly digestive disorder which commonly causes abdominal cramps and watery or sometimes blood in stool.
Destination is the most significant risk factor for developing traveler’s diarrhea. Traveler’s Diarrhea acquired in the people who travel from developed countries to developing countries. Regions with the highest risk are Africa, South Asia, Latin America, and the Middle East. Most countries in Southern Europe and a few Caribbean islands are deemed intermediate risk. Low risk areas include Australia, Canada, Northern Europe, Japan, New Zealand, U.S and Caribbean islands.
Poor sanitation, the presence of stool in the environment, and absence of safe restaurant practices leads to risk of diarrhea from eating variety of foods contaminated by fecal organism especially bacteria. It causes due to consumption of contaminated food and drinking contaminated water. It’s a serious issue but also unpleasant sometimes. Food and contaminated water are the main reservoirs of pathogen to cause traveler’s diarrhea. Like unsafe fruits, salads, unpeeled fruits, uncooked meat, unsafe food and unpasteurized milk and tap water.
Causes of Traveler’s diarrhea:
It is mainly caused due to bacteria, viruses, parasites, and acute food poisoning.
Sources: Shellfish could be harvested from polluted waters containing Hepatitis A virus, aeromones, salmonella, or Cholera. Chicken and beef can be focally contaminated when slaughtered, picking up salmonella or E coli. Uncooked vegetables could be contaminated in the field from contaminated soil and transmit bacteria and parasites. Unpasteurized dairy products made with milk from sick cattle can cause brucellosis, listeriosis, and tuberculosis.
- Bacteria : – Diarrhea caused into the developing countries due to Enter toxigenic Escherichia coli, Other types of coli types (e.g., enter aggregative E. coli) is also cause of traveler’s diarrhea. Campylobacter, Salmonella (non-typhoid), Shigella are also common cause of diarrhea. Aeromonas and Vibrio (non-cholera) are less common cause.
- Parasites:- Protozoal parasites like Giardia lamblia, Entamoeba histolytica, Cyclospora cayetanensis, Cryptosporidium parvum are the uncommon causes of traveler’s diarrhea, but increase the importance when diarrhea last for more than two weeks. Parasites diagnosed more frequently during returning travelers due to incubation period.
- Viruses:- Rotavirus and Noroviruses are the infrequent causes of traveler’s diarrhea.
Traveler’s diarrhea mainly begins during traveling or shortly after return at home and it gets improve within one or two days without any treatment or recover completely within a week. Sometimes people may have multiple episodes of traveler’s diarrhea during trip.
The most common signs and symptoms of traveler’s diarrhea are:
- Abrupt onset of passage of three or more loose stools a day
- An urgent need to defecate
- Abdominal cramps
Sometimes, people experience moderate to severe dehydration, persistent vomiting, a high fever, bloody stools, or severe pain in the abdomen or rectum. If you and your child experience any of these signs or symptoms or if the diarrhea lasts longer than a few days, it’s time to see a doctor.
When to see your doctor:
For adult patient:
- If diarrhea persist for more than two days
- If patient has severe dehydration along with continuous vomiting
- Having fever above 39 °C
- Having bloody or black stool
- Having abdominal and Rectal pain
Traveler’s Diarrhea in Infants, Children and Pregnant Women: 
There is high risk of traveler’s diarrhea in younger children than adult. As the child patient has less immune power than adult may get suffer easily from traveler’s diarrhea with below mentioned symptoms. In infants have two or more loose unformed stool the alternative definition for TD in this age group is twofold increase in the frequency of unformed stool.
- Persistent vomiting
- A fever of 102 F (39 °C) or more
- Bloody stools or severe diarrhea
- Dry mouth or crying without tears
- Signs of being unusually sleepy, drowsy or unresponsive
- Decreased volume of urine, including fewer wet diapers in infants
Traveler’s Diarrheas have more risk in pregnant women than the non-pregnant women because lowered gastric acid and increased gastrointestinal time.
Counseling the traveler’s does not eliminate the risk of Traveler’s diarrhea, and non-antibiotic prophylaxis treatment always requires continuous dosing but does not eliminate the risk of diarrhea. In addition to that travelers have difficulty in finding medical care unit. Quality of care may be poor the antibiotics used in abroad are having substandard quality. However, because antibiotics reduce the duration and severity of traveler’s diarrhea and generally are well tolerated, providing the traveler with the means for empiric self-treatment can effectively reduce morbidity from traveler’s diarrhea. Antibiotic drugs recommended if the patient have severe diarrhea with above mentioned sign and symptoms. The patients have to show to the physician in severe diarrhea cases and took the medications as suggested by physician. Most of the times the physician prescribe some well-known antibiotics which are listed below.
- Norfloxacin: 800 mg by mouth once or 400 mg by mouth twice daily.
- Ofloxacin: 400 mg by mouth once or 200 mg by mouth twice daily
- Levofloxacin: 500 mg by mouth once or 500 mg once daily
- Ciprofloxacin: The physician recommend 500 mg dose tablet for every 12 hours up to 3 days. If still diarrhea not recovered then have to take tablets for 5 days as recommended by the physician.
- Azithromycin: 500 mg daily for one day. 250 mg daily for 4 days. 5 days total.
- Bactrim DS: 1 tablet every 12 hours for 5 days. Discontinue if skin rash occurs.
- Doxycycline: 100 mg. capsule or tablet. Dosage up to 100 mg. every 12 hours for 3-5 days. Discontinue if upset stomach occurs.
Antibiotic drugs approved in children:
Floroquinolones are not approved drug for children having TD as per USFDA. Rifaximin is best choice of drug in children above 12 years. Azithromycin is best choice of drug used in child patients. Nalidixic acid is best choice of drug in children with 55 milligram of dose and dose should be divided into four parts as maintain dose and it should not exceed the limit of 1 gram into 24 hours.
Antibiotic drugs approved in pregnant women:
Quinolone drugs are not approved in pregnant women. Azithromycin is safe drug that can be used in pregnant women having traveler’s diarrhea. Rifaximin is not absorbed. Loperamide is safe drug to be used in pregnant women.
Symptomatic therapy alone can be given to people with mild to moderate traveller’s diarrhea (one or two loose stools in 24 hours with or without mild enteric symptoms).
- Bismuth subsalicylate (Pepto Bismol): 525mg (30mlliquidortwotablets of regular strength preparation, Chewed) every half an hour for eight doses Reduces number of loose stools by about 50%.
- Loperamide: 4 mg by mouth, then 2 mg after each loose stool. Not to exceed 16 mg daily more rapid onset of action compared with bismuth subsalicylate. Should not be used with fever (temperature >38.5°C) or gross blood in stools.
During traveling if the patient had traveler’s diarrhea then due to vomiting or due to stool more than 2 times dehydration of body occurs. For to overcome this problem suggested to take oral-rehydration salt solution (as prepared by WHO).
- Oral rehydration salt: World Health organization formula – i.e. one packet in 1 liter of clean, boiled or treated water.
Prepare 2 separate glasses of the following:
- Glass 1
- Orange, apple or other fruit juice (rich in potassium) – 8 oz.
- Honey or corn syrup (contains necessary glucose for salt absorption) – ½ tsp.
- Table salt (contains sodium and chloride
- Glass 2
- Water (carbonated or boiled) – 8 oz.
- Baking Soda (contains sodium bicarbonate) – ¼ tsp.
Drink alternately from each glass. Supplement with carbonated beverages or water and tea made
From boiled or carbonated water as desired.
Foods to avoid:
- Raw vegetables used in salad in restaurants.
- Raw eggs or uncooked eggs.
- Unpasteurized milk or fruit juice prepared from unpasteurized milk
- Raw meat and avoid raw fish
- Street vendor foods unless hot and well cooked
- The food that have not proper refrigeration
- Fruits have punctured skin or not peeled properly
- Airline and restaurant food in developing countries.
- Make sure whatever food you eat is hot and clean
- Always eat those fruits that you can peel easily. Such as banana, oranges, and avocados. And try to avoid taking salads and fruits that you can’t peel such as grapes and berries.
- Try to avoid taking beverages outside as don’t know which water or ice they have mixed during preparation.
Water and beverage advice:
- Avoid unsterilized water – don’t drink water in five star restaurants as well if you are not sure that water is safe.
- Don’t drink tap water
- At least boil the water 1-3 minutes to avoid diarrhea.
- Don’t drink the street side juices in which tap water is used or ice of tap water.
- Don’t eat ice-creams as well which are made of unpasteurized milk.
- Don’t swim in water that is contaminated
- Use bottle water to clean your teeth.
- Use bottle water to mix the baby formula
- Keep your mouth closed while you are showering.
- Order hot beverages such as hot coffee or tea and make sure its steaming hot
- Feel free to drink canned or bottled beverages or water as they are contamination free and also they are in there original containers but keep in mind whenever you just seal them of the container then wipe out the bottle neck before drinking or pouring into glass.
- Use Iodine tablets: don’t use such tablets in pregnant women as it harms to the fetal growth of thyroid gland development
- Use chlorine 4-6 % bleach- Add 2 drops in 1 liter of water if clear and from tap. And 4 drops if water is cold and cloudy and not from tap.
Follow additional tips:
Following are some tips which reduce the risk of traveler’s diarrhea:
- Always try to use clean and dry utensils to prepare food.
- Try to keep always your floor clean use phenyl, or the products available in market.
- Don’t keep your child on dirty floor and keep away him/her from keeping fingers and other things like toys into mouth.
- Always wash your hands with water or if water is contaminated then use sanitizer with 60 % alcohol which kills maximum bacteria and gives you more protection.
- Seek out the food which requires handling preparation.
Other preventive measures:
- Public health measures do not recommend using antibiotics to prevent from traveler’s diarrhea because doing so can contribute to development of resistance power into bacteria or pathogen to antibiotics.
- As preventive measure the physician recommends to take the bismuth subsalicylate. Reduces the number of loose stools by about 50 %. The physician also recommends that don’t use Bismuth subsalicylate more than three weeks and don’t use it in pregnant women and patient having aspirin allergy. If the patient is on anticoagulants then talk to your physician before taking bismuth salicylate.
- Bismuth Subsalicylate drug is not used in the child patients because of having high risk of Reye’s syndrome.
- Bismuth Subsalicylate should not be used pregnant women because it may lead to infection of listeriosis which can cause miscarriage. And hepatitis E infection can cause maternal mortality.
- Antibiotics which don’t have preventive action against viruses and parasites. Which gives false sign to traveler’s to consume street side food and which may give side effects like skin rashes, skin reaction due to sunlight, virginal infection.
- Some common harmless side effects of bismuth subsalicylate are that produce dark stools and black tongue. And sometimes gives harmful side effects like constipation, vomiting, nausea and ringing in ear.
Traveler’s Diarrhea can be prevented by following recommendation such as “Boil it, Cook it, Peel it, or forget it.”
- David R Hill, Edward T Ryan Clinical Review Management of traveller’s diarrhea.
- MSU Travel clinic traveler’s diarrhea – information sheets.
- JOHNNIE YATES, M.D, CIWEC Traveler’s Diarrhea Clinic Travel Medicine Center, Kathmandu, Nepal.
- Mayoclinic of traveler’s Diarrhea.