A Treat for the Traveler

Infectious diarrhea is by far the most common illness among people traveling to developing countries. Traveler's diarrhea occurs in about 50% of people in the first 2-4 weeks and one episode won't immunize you against further attacks. If you think you can deal with a case of diarrhea, remember that although the most likely result of contaminated food and water is T.D. it is also the vehicle for hepatitis A and E, typhoid, cholera, brucellosis, amebic dysentery, trichinosis, tapeworm disease and polio.

What's Causing It?

The most common culprits of T.D. are bacteria including E.coli, salmonella, shigella and campylobacter. Viruses and parasites are also popular choices. They cause frequent watery stools accompanied by abdominal cramps, nausea and vomiting, malaise, and sometimes fever. It usually starts abruptly and lasts 2-5 days. Some infectious agents have longer incubation times (giardiasis 5-25 days and hepatitis A 15-45 days) so that you may not become ill until after returning home. Parasitic agents generally cause a more gradual onset of symptoms and have a longer duration.

People can develop some immunity to their local contaminants, so just because the residents eat and drink it doesn't mean you can. By following food and beverage precautions and frequent hand sanitizing the risk can be minimized while still enabling you to enjoy the local culture and cuisine.

Precautions:

Avoid Contaminated Water:

• Commercially bottled water and drinks are generally safe. The same can not be said for the water on the outside of the container.
• Ice may be made from contaminated water and should be avoided.
• If you are not sure about the sanitation of local water systems do not drink tap water unless it has been boiled (vigorously for one minute), chemically disinfected or filtered (variable effectiveness).
• Use safe water for brushing teeth

Avoid Contaminated Food:

• Contaminated food causes more disease than contaminated water.
• Eat foods that are thoroughly cooked and served hot - foods that are lukewarm or reheated are the most risky.
• Avoid salads, cold cuts and puddings.
• Eat fruits and vegetables that you have peeled or properly washed yourself. Avoid thin-skinned fruit such as apples and grapes.
• Never eat raw shellfish.
• Avoid large carnivorous fish, especially from reef areas that may contain ciguatera toxin.
• Don't consume un-pasteurized dairy products.
• Always wash your hands in safe water or use a hand sanitizer before preparing or eating food.

Street Vendor Guidelines:

• Choose food that is cooked, boiled, steamed or grilled directly in front of you.
• Avoid food handled excessively by the vendor.

So. You Were Careful and You Still Got Sick!

What To Do?

1. Drink plenty of fluids

   • It is important to replace lost fluids and then some, especially in tropical climates. Drink clear liquids such as bottled water, diluted soft drinks or weak tea. Avoid alcohol, caffeine and dairy products.
   • Use electolyte replacement packets, salty broth or crackers to replace salt.
   • Prepackaged oral rehydration solution (ORS) is available that contains the right balance of glucose and electrolytes. You can create a basic version by adding 1/2 teaspoon of salt and 2-3 tablespoons of sugar to a liter of safe water.

2. Medication

   • For mild diarrhea consisting of 3 or 4 unformed stools a day and mild cramping no drug treatment may be necessary. Drugs to slow the diarrhea such as Pepto-Bismol or Imodium can be used to lessen frequency of stools if needed for travel.
   • For moderate diarrhea with increased frequency of unformed stools along with low grade fever, abdominal pain or nausea and vomiting treatment with an antibiotic and Imodium can shorten your illness.

3. Antibiotics

   • One of the following antibiotics will usually be effective for diarrhea caused by bacterial infections.
   • Ciprofloxacin:  500mg 2 times a day for 1-3 days.
   • Levofloxacin:  500mg once a day for 1-3 days.
   • For those under 18, pregnant, traveling in Thailand or Nepal, or allergic to quinolones: Azithromycin 1gm once or 500mg daily for 1-3 days.
   • Rifaximin:  200mg 3 times a day for 3 days. Should not be used if blood in the stool or fever are present.

4. Seek help if

   • If you have blood in your stool, especially if accompanied by fever
   • If there is no improvement in your symptoms after 24-36 hours
   • If you are not able to keep adequately hydrated (you feel weak, light-headed, and have little or no urine)
   • If you continue to have significant diarrhea after 72 hours