Introduction

Travelers Diarrhoea is a clinical syndrome resulting from microbial (bacteria, viruses or parasites) contamination of ingested food and water.

Causative agents: Four principal bacterial microorganisms in most high-risk areas are Enterotoxigenic Escherichia coli (ETEC), Shigella species, Salmonella species and Campylobacter. Pathogen isolation rates vary from 30% to 60%.

Commonest illness among travelers to destinations with low level of hygiene and sanitation. There is a 35 – 60% chance to get a bout of TD during a month-long trip to a lesser-developed country.

Risk very much related to the destination, level of accommodation and travel habits of traveller. High-risk areas include most of Asia, Africa, and Central and South America.

Children tend to have more severe and longer diarrhoea illness than other travelers.

Sign & Symptoms

Loose or watery stools 4- 5 times per day for 2-4 days, and maybe with abdominal cramps, nausea, vomiting, bloating, fever and lethargy.

Occurs during or shortly after travel. Can continue for up to ten days after return. Presents either as acute, watery diarrhea (60% of travelers), dysentery or chronic diarrhea (3% to 5% of travelers).

Complication

Most cases are self limiting.

Treatment

Self treatment

Rest and drink plenty of clear fluids including oral rehydration salt (ORS). ORS such as gastrolyte sachet (dissolved in 200ml water) or tablet is preferable and is in fact the only solution for use in children. It must be made up exactly as directed as if it is too strong it can make it worse. If this is not available or is refused, juice or lemonade (made up as 1 part of juice or lemonade to 4 parts boiled water) or plain water at the rate of 2 cups per hour may prevent dehydration with mild illnesses. Another alternative is sugar-water (1 heaped teaspoon of sugar to 1 cup boiled water) with a pinch of salt.

Only if danger signs are not present (danger signs are fever over 38.8°C, shaking chills, diarrhea with large amounts of blood or mucous, abdominal pain (other than moderate cramping) or diarrhea which persists for more than 2 or 3 days).

If danger signs are present or diarrhoea worsens after 24 – 48 hours, seek medical attention.

Includes taking anti-diarrhoeal medication

e.g. Loperamide, if a traveler has an important meeting or flight to catch. Commonly used preparations are Imodium (loperamide), Lomotil (diphenoxylate) and Arret (loperamide).

Antibiotics

If the condition does not improve, high fever (> 38.5° C), blood or pus in stool example: Norfloxacin 400 mg or ciprofloxacin 500 mg 1 tablet twice daily for 3 days, as advised by the physician.
If the symptoms do not improve within 12 hours, further doses are unlikely to have any benefit.

WHEN TO GET A DOCTOR

IF YOU HAVE A TEMPERATURE
IF THERE IS BLOOD IN THE DIARRHOEA
IF THE AFFECTED PERSON IS CONFUSED
IF THE DIARRHOEA DOESN’T STOP AFTER 72 HOURS
(24 HOURS FOR INFANTS, CHILDREN AND THE ELDERLY)

Prevention & Precautions

a.General advices to prevent infection via faeco-oral route:-

• Wash hands and soap before eating, handling food and after  using toilet.
• Boil any drinking water of unsure cleanliness or drink bottled water (checking seal is in place) or carbonated water.
• Foods that require little handling are safer. Peel all fruit. Avoid salads or uncooked vegetables.
• Ensure that seafood, fish and meat are thoroughly cooked and eaten hot whenever possible.
• Eat early if one is served a buffet.
• Avoid ready – to – eat food from roadside vendors.

b. Use of prophylactic antibiotics e.g. the Fluoroquinolones, may be considered for short-term travelers who are high-risk hosts (e.g. immunosuppressed) or are taking critical trips (e.g. businessperson, diplomat, musician or athlete). Not to be recommended for most travellers due to false sense of security.

c. Use of agents other than antimicrobial drugs for prophylaxis e.g. Bismuth Subsalicylate (BSS). Bismuth subsalicylate (Pepto-Bismol), taken as 1 oz of liquid or two chewable tablets every 30 minutes for eight doses, has been shown to decrease stool frequency and shorten the duration of illness in several placebo-controlled studies. This agent has both antisecretory and antimicrobial properties. BSS should be used with caution in travellers on aspirin therapy or anticoagulants or those who have renal insufficiency. In addition, BSS should be avoided in children with viral infections, such as varicella or influenza, because of the risk of Reye syndrome.

References Organisation/Support

1. International Travel & Health, WHO 2006
2. Control of Communicable Diseases Manual, 18th Edition by David L.Heymann, MD, Editor, 2004
3. http://travelhealth.co.uk/