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Traveler's Diarrhea


Alan Spira, M.D., DTM&H

While not exactly everyone's favorite topic, Traveler's Diarrhea is the most common infection to ruin a trip, and is worth our attention. After all, over 30 million Americans travel abroad annually, with at least 4-5 million visiting developing regions. It has been estimated that more than a fourth of travelers suffer from diarrhea during their journey, and as more people travel year after year, more people will suffer from The Runs. Most diarrhea is not serious -- just your body's adjusting to new organisms and environmental conditions. Most diarrhea will resolve on its own in less than three days, but of course, who wants to lose three days of precious travel time?

There are many causes of diarrhea and it is important to recognize which ones are serious and which are not. Most diarrhea is spread through the water supply in areas where hygiene and sanitation are lacking. It is spread by microbes such as salmonella and shigella, viruses, and Vibrio cholera, just a few among many. Some bacteria release toxins which bind to the intestines and causes diarrhea; others damage the intestines themselves by their direct presence. In infants and children it is estimated that nearly 70% of diarrhea is due to viruses; for adult travelers, this drops to around 30%.

Most Traveler's Diarrhea is caused by enteric bacteria, such as E. coli, Campylobacter, B. cereus, and others. The majority of these infections are self-limited, meaning that the body is able to handle them and recover after a few days. Occasionally the diarrhea can be from protozoa or worm infections. Giardia is the most common protozoa giving our traveling intestinal tracts grief:. Some people have only a few parasites and feel terrible; others have thousands yet have no symptoms. Other protozoa that cause intestinal infections include the amoeba Entamoeba histolytica, cryptosporidium and cyclospora. In contrast, the serious infections include bacillary dysentery, amoebic dysentery, and cholera. According to the Pan-American Health Organization, cholera is still spreading over Latin America, with 1.3 million cases since the last epidemic began in Peru in January 1991.

What are the signs and symptoms? There are strict medical and scientific definitions for diarrhea and there are several different such definitions! To keep ourselves down to earth, let's call the great event Traveler's Diarrhea when there is at least twice the normal number of bowel movements, whether soft or watery or bloody. Frequently there is cramping in the abdomen along with the diarrhea; there may or may not be nausea or vomiting, and usually the appetite is low or non-existent. It is much more serious -- dysentery -- if you have blood or mucous in the diarrhea, if you have belly pain, or if there is a fever. Dehydration is possible. With serious cases of cholera, there is a rapid onset of symptoms, which include weakness, malaise (feeling rotten), and torrents of watery diarrhea with flecks of mucous -- called rice water stools. Dehydration is a serious consequence, with death occurring in as quickly as 24 hours with cholera. There are cases of malabsorption after Traveler's Diarrhea which can last months on end -- and the reason is not always clear. Some are from an unusual infection, such as Whipple's Disease; others may be from Tropical Sprue; most others, unfortunately, are never identified.

What Can You Do About It? Most diarrheal diseases are easily preventable and actually are also easily treated once diagnosed. Among the primary measures to prevent gastrointestinal illness are washing your hands, getting specific vaccines and prophylactic medications. There are great vaccines against typhoid fever, which is caused by salmonella, and for the Hepatitis A virus. The vaccine for cholera that is available in the USA is not very good, whereas there is a more reliable and longer-acting one available in Europe. Some people want to take medication to prevent diarrhea from ever starting. This can be done with bismuth-subsalicylate (Pepto-Bismol) but you need to take quite a lot of it and quite frequently for it to work. Some recommend taking antibiotics before an intestinal infection develops to prevent Traveler's Diarrhea. DO NOT do this -- you will kill off your beneficial bacteria and create resistant breeds of bad bacteria, which will come back to haunt you. For treatment, the first measure is to give plenty of fluids in order to stay well hydrated; most cases will pass on their own, and if given enough fluids, patients recover completely. Water that is purified is best, along with oral rehydration salts to replenish lost electrolytes. Sodas which have been left out so that the carbonation fizz is gone are useful in a pinch. Antibiotics are recommended when there is fever, abdominal pain, blood or mucous in the stools. There are different medications needed for bacterial dysentery, for amoebic dysentery, for giardia and for worms. There is no medication for cryptosporidium, which can devastate people with AIDS. There can be 100% recovery from cholera when properly treated -- which usually only means rehydration -- usually through an intravenous line.

As with all things, it is better to avoid a problem than to fix one. When traveling, maintain good hygiene and make sure that you drink filtered and purified water. Reports of locals filling bottles with tap water, then sealing them and then selling the bottled water as Purified Water have come out of several countries. Drink carbonated drinks (without ice, of course!) or filter the water yourself. There are several very good water filters on the market that are lightweight and affordable, such as the Pur Portable and the PentaPure Oasis which is a sports bottle with a filter that works down to the level of viruses.

If you come home and the symptoms persist, then visit a specialist in travel or tropical medicine, who can take stool or blood tests to identify the offending creature and then give you the appropriate medication to help you. Not every visitor to the region who drinks local water will get Traveler's Diarrhea -- but the risk is clearly higher. With sensible precautions, and seeking treatment if the disease should develop, travelers will do very well indeed.

Healthy Travels!

© 1997 Alan Spira M.D., The Travel Medicine Center Beverly Hills, California.

Document Date: October 18, 1997

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