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Traveller’s Diarrhea What should I know about traveller’s diarrhea (TD)? Diarrhea is the most common medical problem affecting travelers to developing countries. About 30-50% of travelers from industrialized nations who travel to underdeveloped countries get TD over a 1-2 week stay. TD usually begins suddenly and stops on its own within 1-5 days (average 3 days). 80-90% of cases of TD are caused by bacteria. Who is most at risk? Adventurous eaters. People with decreased stomach acid, including those taking Losec, Nexium, Pariet, Prevacid, or Tecta. Those with underlying medical problems (e.g. cancer, inflammatory bowel disease, immunocompromised AIDS). Pregnant travelers. Children under 3 years of age experience more episodes of TD. See “Traveller's Diarrhea in Children” fact sheet. People who routinely get diarrhea when they travel. Where does traveler’s diarrhea occur? High risk destinations include most of Central and South America, Mexico, Africa, the Middle East and Asia. Intermediate risk destinations include Eastern Europe, South Africa and some of the Caribbean islands. How do I become ill with diarrhea? TD is usually caused by food contaminated with bacteria or water contaminated with microorganisms. Bacteria and viruses have an incubation period of 6 – 48 hours. Food may be contaminated through: - unhygienic food handling practices - inadequate storage and transportation of food - the practice of fertilizing of crops with human/animal feces - flies in contact with food - unreliable refrigeration - lack of pasteurization “Food poisoning” involves the ingestion of preformed toxins in foods and symptoms usually resolve within 12 hours. Not all diarrhea is caused by an infection. Too much sun, alcohol, fruit, spices or greasy food can also cause diarrhea. What are the symptoms and signs of TD? Sudden onset of loose bowel movements, ≥ 3 per day Stomach cramps, bloating, and gas (50-73%) Nausea (46-50%), vomiting (15%) Fever (37%) Weakness/malaise (50-58%) Bloody stools (2-10%) Dehydration Headache How can I prevent getting TD? Wash your hands frequently using soap and clean water. Use hand sanitizers (60% alcohol content). “Boil it, cook it, peel it, or forget it”. Know which food and beverages are safer. Refer to the “Food and Water Safety” fact sheet. Dukoral® vaccine provides some protection against cholera and TD caused by the ETEC bacteria. It is available through pharmacies. How can I treat TD? Mild – loose stools and minimal symptoms – just go to the bathroom more frequently, no treatment required. . . . . . . . .2 Moderate – loose stools and symptoms such as nausea, cramps and gas – use Pepto Bismol if no contraindication, consider Immodium and if over 10 years of age, drink up to 2 liters a day of safe water. Severe – frequent watery stools with intense cramps, vomiting, fever, chills, or bloody stools – use Immodium to prevent water loss, start oral rehydration, and antibiotics. Travelers should feel better within 6 – 24 hours with antibiotic treatment. How can I prevent dehydration? Prevent dehydration by replacing fluids and electrolytes. This is especially important for children and the elderly. Buy a commercial product (e.g. Gastrolyte) or make your own rehydration solution: 1 litre purified water 8 teaspoons sugar 1 teaspoon salt Consume oral rehydration solutions within 12 hours, if at room temperature, or within 24 hours if refrigerated. Sports drinks (e.g. Gatorade) are not appropriate for fluid replacement. Drink plenty of clear fluids, enough to produce pale colored urine. Avoid milk products, prune juice, orange juice and apple juice – which may aggravate diarrhea. Drink clear broth or eat salted crackers to compensate for loss of salt. Avoid caffeinated beverages, alcohol and spicy or greasy foods which tend to be irritating. Medications: Bring high quality drugs from a reliable supplier in your own country. 20 – 50% of the drugs on shelves may be counterfeit. For prevention, consider Pepto Bismol (bismuth subsalicylate) 2 tabs (or 30 ml liquid) 4 times daily with meals. This can decrease the incidence of TD by 60%. Side effects include temporary black tongue or stools, nausea, constipation. Do not use for more than 3 weeks or if you are allergic to aspirin, have kidney disease, a bleeding disorder, gout, or take anticoagulants, probenecid or methotrexate. Pepto Bismol can interfere with absorption of doxycycline. It is not approved for children < 3 years old. For children > 3 years old, consult a physician or pharmacist. For treatment, Pepto Bismol 30 ml of liquid or 2 tablets every 30 minutes, for a total of 8 doses, can lessen/shorten diarrhea. Imodium (loperamide): use for moderate to severe TD or when bathroom usage is not convenient, such as a travel day. It is not safe for children under 2 years of age. Use only on the advice of a physician for children under 12 years of age and pregnant women. Do not use Imodium for more than 48 hours if diarrhea persists. Antibiotics: Travelers may want to take an antibiotic for self-treatment. The usual antibiotics are ciprofloxacin 500 mg twice daily or norfloxacin 400 mg twice daily, for 1 – 3 days. An alternative antibiotic is azithromycin 500 mg twice daily for 1-3 days. Any of these antibiotics may be stopped after 1 day if symptoms resolve. Azithromycin is the antibiotic of choice in Thailand, India and Haiti. Long-term travellers to Nepal may wish to consider TMP-SMX for treatment of Cyclosporiasis. Please refer to the “TD in Children” and “Pregnancy and Travel” fact sheets for the appropriate antibiotics in these groups. When should I see a doctor? Tell your doctor you have been traveling. If you have a fever, especially if you've visited a malarious area. If severe diarrhea is not getting better, after 3-4 days, despite treatment. If you have any severe medical conditions, a suppressed immune system, or blood in your bowel movements. If diarrhea lasts more than 2 weeks, stool specimens are recommended. For more information, call the International Travel Centre at (306) 655-4780 www.saskatoonhealthregion.ca/internationaltravel DC-90 (buff) 05-12 © 2007, Saskatoon Health Region