06 Feb 2014

Travellers’ diarrhoea

Following advice on food and water hygiene is sensible, but travellers should always be prepared to manage the symptoms of TD during their travels Travellers’ diarrhoea

 

Key Messages

Travellers’ diarrhoea (TD) is the most common health problem of overseas travellers, affecting an estimated 20 to 60 percent of those who travel to high risk destinations of the world.
TD can be caused by viruses, bacteria or protozoa.
TD is difficult to prevent for those who cannot prepare their own food and drinks. Following advice on food and water hygiene is sensible, but travellers should always be prepared to manage the symptoms of TD during their travels.

Overview

Travellers’ diarrhoea (TD) is the most common health problem of overseas travellers affecting an estimated 20 to 60 percent of those who travel to high risk destinations of the world [1]. It is defined as three or more unformed stools in a 24 hour period, often accompanied by at least one of the following: fever, nausea, vomiting, cramps, or bloody stools (dysentery) [1]. Symptoms usually start during or shortly after a period of foreign travel [1]. TD can cause substantial disruption to travel itineraries or business trips. Approximately 20 percent of travellers are confined to bed for one or two days, 40 per cent have to change their itinerary, and one per cent are admitted to hospital [2].

TD can be caused by viruses (such as norovirus and rotavirus), bacteria (such as Escherichia coli, Campylobacter, Salmonella and Shigella) and/or protozoa (such as Giardia and Cryptosporidium spp.) [3]. In up to 40 percent of TD cases, the causative pathogen is not identified [4]. Cholera is rarely seen in travellers.

Risk areas

The organisms that cause TD, particularly non-typhoidal Salmonella spp. and Campylobacter spp., are commonly reported worldwide, including in the UK. Other organisms such as Shigella spp. and Giardia lamblia for example are more commonly reported in lower-income countries that have inadequate sanitation facilities and a lack of access to clean water [1].

There are regional differences in the risk of travellers’ diarrhoea and estimates of incidence rates vary in different studies [1, 3, 5, 6]. Low-risk areas include Western Europe, the United States, Canada, Australia, New Zealand and Japan. Seven percent or less of travellers are estimated to experience TD in these areas [1]. Intermediate-risk areas include southern Europe, Israel, South Africa, some parts of the Caribbean and the Pacific islands, with estimated incidence rates of between eight and 20 percent. High-risk areas include most of Asia, the Middle East, Africa, and Latin America; more than 20 percent of travellers from a high-income country may experience TD in these areas [Figure 1].

Figure 1: Map showing risk areas for TD

TD-risk

Source: Health Protection Agency. Foreign travel-associated illness – a focus on travellers’ diarrhoea. 2010 report [1]

Risk for travellers

Estimated incidence rates for TD are described above. There are several risk factors for acquiring TD including: diet, gender, age, host genetics, destination, season of travel and choice of eating establishment [7-9]. Of these, the destination country and choice of eating establishment are considered to be the most important factors [7].

The effects of diarrhoea are generally greater in the very young, the elderly and the frail. Those with special health needs, for example, travellers with immune suppression (lowered immunity), inflammatory bowel disease, chronic (long term) kidney or heart disease and pregnant women should take particular care to avoid contaminated food and water and be prepared to manage the symptoms of TD. Those with reduced acidity in the stomach are also at increased risk of contracting infections with acid-sensitive organisms such as Salmonella and Campylobacter [10, 11].

Travellers’ diarrhoea in travellers from England, Wales and Northern Ireland

Between 2004 and 2008, there were 24,332 cases of laboratory confirmed travel-associated gastrointestinal (GI) illness reported in England, Wales and Northern Ireland (EWNI) [1]. Fifty percent of cases were caused by Salmonella spp. (non typhoid). Other organisms included Campylobacter spp., Shigella spp., Giardia lamblia, and Cryptosporidium spp.

In 2008, travel to countries in North Africa, the Middle East, Asia, sub-Saharan Africa, South America and the Caribbean were associated with higher rates of TD [1].

Transmission

TD is acquired through the consumption of contaminated food or water. Although a change in bowel habit can be caused by the stress of travel, a change in diet, and increased alcohol consumption, most episodes of TD are related to infection [1].

Recreational water such as swimming pools, the sea and freshwater rivers and lakes may also be a source of water-borne infection. In swimming pools, infection may occur if treatment and disinfection of the water are inadequate. Swimming pool-related outbreaks of illness are relatively infrequent, but have been linked to viruses, bacteria, protozoa and fungi [12, 13].

Signs and symptoms

TD is defined as three or more unformed stools in a 24 hour period, often accompanied by at least one of the following: fever, nausea, vomiting, cramps, or bloody stools (dysentery), with symptoms usually starting during or shortly after a period of foreign travel [1]. Vomiting is uncommon, and dysentery (abdominal cramps with blood or mucous in the stool) is infrequent [7]. TD typically occurs during the first week of arrival and is often self-limiting, lasting three to four days. In approximately two percent of cases, symptoms persist for longer than a month [14]. An episode of TD, particularly one with severe symptoms, can lead to irritable bowel syndrome in a small number of travellers [15].

Diagnosis and treatment

TD is caused by a variety of organisms. Where aetiology is known, bacteria are responsible for most cases and include ETEC, Salmonella spp., Shigella spp., and Campylobacter spp. [1]. Enterotoxigenic Bacteroides fragilis has been identified as a likely cause of TD [16]. Other organisms include viruses, such as norovirus, and protozoa (e.g. Cryptosporidium spp., Giardia lamblia).

TD usually resolves spontaneously. Individuals with ongoing symptoms depending on the history and clinical presentation may require further tests, such as; stool microscopy, stool culture, full blood count and/or biochemistry [17].

Screening (laboratory testing) for ETEC is not usually done and up to 40 percent of TD cases never have a particular virus, bacteria, protozoa or fungi identified [4].

The aim of treatment of TD is to avoid dehydration, reduce the severity and duration of symptoms and reduce the interruption to travel plans [18].

Diet and fluid

Travellers should maintain adequate fluid intake to avoid dehydration. For a mild TD illness oral fluids are often all that is necessary.

Adults without existing health problems, with mild to moderate symptoms, can usually stay hydrated by continuing to drink and eat as normal [19]. Dehydration in adults is unusual, but is a concern for young children with diarrhoea. The elderly, pregnant women and those with pre-existing illness are also more susceptible to complications from dehydration [19].

For more severe symptoms or those prone to complications from dehydration, oral rehydration powders can be diluted into clean drinking water to remedy electrolyte (sugar/salt) imbalances. If oral rehydration powers are not available, a salt and sugar solution of six level teaspoons of sugar and one level teaspoon of salt to a litre of ‘safe’ water can be used [20].

Consumption of small quantities of easily digestible foods are recommended to aid gut recovery in those with TD [18]. Breastfeeding should be continued for infants. Children receiving semisolid foods or solid foods should continue to receive their usual diet [19].

Symptomatic treatment

The most common symptomatic treatments for TD are antimotility agents (e.g. loperamide), and bismuth subsalicylate. Loperamide can be considered for travellers when frequent diarrhoea is inconvenient, e.g. those travelling on long bus journeys, or for business meetings. However, it should not be used if the traveller has active inflammatory bowel disease (e.g. ulcerative colitis), a fever or bloody diarrhoea [11, 21]. Loperamide should be used with caution; travellers should follow the instructions on the pack carefully. Loperamide preparations are available over the counter for use in adults and children over 12 years of age. For younger children, parents should seek early medical advice if the child becomes unwell with TD and symptomatic treatment is required. Rehydration is the main treatment for TD in young children.

Bismuth subsalicylate can be recommended for mild diarrhoea and is helpful in reducing nausea. Bismuth subsalicylate preparations are available over the counter for use in adults and children over 16 years of age. However, loperamide has been shown to be more effective in controlling diarrhoea and cramping and works more quickly [22].

Antibiotics

Antibiotic treatment can be considered for treatment of moderate to severe travellers’ diarrhoea. A study of the use of antibiotics for acute diarrhoea in travellers and determined that there were benefits from taking antibiotics [23]. Those who took antibiotics had a shorter duration of diarrhoea, decreased severity of illness, and were more frequently cured within 72 hours of illness onset. Although there were more side effects in those being treated compared with those taking a placebo, these were mostly minor or resolved once the antibiotic had been discontinued.

Fluoroquinolones are often the drugs of choice when indicated [7]. Ciprofloxacin (750mg as a single dose or 500mg twice daily for three days) is prescribed most commonly for travellers to Latin America and sub-Saharan Africa.

Fluoroquinolone resistant Campylobacter and Shigella are more common in some parts of South and Southeast Asia. For travellers to these areas azithromycin is an appropriate choice: 1,000mg single dose or 500mg once daily for three days [24 25].

Rifaximin is also licensed for the treatment of travellers’ diarrhoea that is not associated with fever, blood in the stool or eight or more unformed stools in the previous 24 hours [25]. Clinical data have shown that rifaximin is not effective in the treatment of invasive enteric pathogens that cross the gut wall such as Campylobacter, Salmonella and Shigella which typically produce dysentery-like diarrhoea [25]. As travellers would have to carry a back-up drug in the event of these symptoms, the overall usefulness of rifaximin as a self treatment option remains to be determined.

The combination of loperamide with an antibiotic in moderate travellers’ diarrhoea may lead to more rapid improvement compared with either treatment alone [19].

Medical care

Travellers should seek medical care if symptoms do not improve within three days [15]. They should seek medical care immediately if they have a fever of 38oC or more, blood and/or mucous in the stool or other worrying symptoms such as altered mental status, severe abdominal pain, jaundice or rash. Medical care should be sought earlier for the elderly, children and other vulnerable travellers if they are not tolerating fluids or are showing signs of dehydration.

Preventing Travellers’ diarrhoea

TD is difficult to prevent for those who cannot prepare their own food and drinks [27]. Following [28] is sensible but these measures do not offer full protection [26]; travellers should always be prepared to manage the symptoms of TD.

  • Hands should be washed after visiting the toilet, and always before preparing or eating food. Alcohol gel can be helpful when hand-washing facilities are not available.
  • Antibiotic chemoprophylaxis (continuous use during travel) is not recommended for most travellers. If a traveller is considering this, the risks and benefits of such a course should be thoroughly discussed.
  • Travellers should also practise good swimming pool hygiene by not swimming if they have diarrhoea, ensuring babies and infants are wearing suitable swimwear, and avoiding ingesting any pool water [13, 29].

Vaccine information

There is no vaccine available for the syndrome of travellers’ diarrhoea. The cholera vaccine used in the UK (Dukoral®) may provide some limited cross protection against diarrhoea caused by Escherichia coli producing a heat-labile enterotoxin. However, it is unlicensed in the UK for this use as there is limited data on efficacy in travellers; it is not recommended for this indication [30-32]. There are vaccines available for some organisms acquired through the consumption of contaminated food or water such as Salmonella Typhi, poliomyelitis, hepatitis A, and Vibrio cholerae, however, these organisms do not cause the illness known as travellers’ diarrhoea and should be considered separately as part of the overall travel health risk assessment.

Resources

Further reading

  • Steffen R, Hill DR & Du Pont HL. Traveler’s Diarrhea A Clinical Review. JAMA 2015; 313(1):71-80
  • Heather CS. Travellers’ diarrhoea. BMJ Clin Evid. 2015; Apr 30; pii: 0901
  • Zollner-Schwetz I, Krause R. Therapy of acute gastroenteritis: role of antibiotics
  • Clin Microbiol Infect. 2015; 21(8), 744-749

First Published :   06 Feb 2014
Last Updated :   10 Feb 2016

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  1. Ericsson CD. Travelers’ diarrhea. Epidemiology, prevention, and self-treatment. Infect Dis Clin North Am 1998; 12: 285–303 cited in Al-Abri, S.S. Beeching, N.J. Nye F.J. Traveller’s diarrhoea. Lancet Infect Dis. 2005 Jun; 5 (6):349-60.
  2. Shah N, DuPont HL, Ramsey DJ. Global etiology of travelers’ diarrhea: systematic review from 1973 to the present. Am J Trop Med Hyg. 80:609-14, 2009.
  3. Peltola H and Gorbach SL. Chapter 12.1: Travelers’ Diarrhea – Epidemiology and Clinical Aspects. In: DuPont HL and Steffen R. Textbook of Travel Medicine and Health. Hamilton; BC Decker: 1997.
  4. Greenwood Z, Black J, Weld L et al. Gastrointestinal infection among international travelers globally. J Trav Med. 15:221-8, 2008.
  5. Steffen R. Epidemiology of traveler’s diarrhea. Clin Infect Dis. 41(Suppl 8):S536-40, 2005.
  6. Hill DR, Beeching NJ. Travelers’ diarrhea. Cur Opin Infect Dis. 23:481-7, 2010.
  7. Al-Abri, S.S. Beeching, N.J. Nye F.J. Traveller’s diarrhoea. Lancet Infect Dis.2005 Jun; 5(6):349-60.
  8. Swaminathan A, Torresi J, Schlagenhauf P et al. A global study of pathogens and host risk factors associated with infectious gastrointestinal disease in returned international travellers. J. Infect; 2009 Jul; 59(1):19-27.
  9. Bavishi C, Dupont HL. Systematic review: the use of proton pump inhibitors and increased susceptibility to enteric infection, Aliment Pharmacol Ther. 2011 Dec; 34(11-12):1269-81.
  10. National Institute for Health and Care Excellence (NICE) Diarrhoea prevention and advice for travellers [Accessed August 2015]
  11. Galmes A, Nicolau A, Gomis E, Guma M, Hernandez-Pezzi G, and Soler P. Cryptosporidiosis outbreak in British tourists who stayed at a hotel in Majorca, Spain. Eurosurveillance 2003; 7 (33). [Accessed August 2015]
  12. World Health Organization, Guidelines for safe recreational water environments, volume 2, 2006 [Accessed June 2015]
  13. Hill DR. Occurrence and self-treatment of diarrhea in a large cohort of Americans travelling to developing countries. Am J Trop Med Hyg. 62:585-9, 2000.
  14. Pitzurra R, Fried M, Rogler G et al. Irritable bowel syndrome among a cohort of European travelers to resource-limited destinations. J Trav Med. 18:250-6, 2011.
  15. Jiang ZD, Dupont HL, Brown EL et al. Microbial etiology of travelers’ diarrhea in Mexico, Guatemala and India. Importance of enterotoxigenic Bacteroides fragilis and Arcobacter species. J Clin Microbiol. 48:1417-9, 2010.
  16. Hearn P, Doherty T. Diarrhoea in travellers. Medicine 42(2):84-88, 2014.
  17. Hill DR, Ryan ET. Management of travellers’ diarrhoea. Br Med J. 337:863-7, 2008.
  18. DuPont HL, Ericsson CD Farthing MJG et al. Expert Review of the Evidence Base for Self-Therapy of Travelers’ Diarrhea J Trav Med. Vol 16, issue 3, 161-171, 2009. [Accessed August 2015]
  19. World Health Organization. A guide on safe food for travellers. [Accessed August 2015]
  20. Field VF, Ford L, Hill DR eds. Health Information for Overseas Travel. National Travel Health Network and centre, London, UK, 2010.
  21. Johnson PC, DuPont HL, Morgan DR et al. Comparison of loperamide with bismuth subsalicylate for the treatment of acute travelers’ diarrhea. JAMA. 255:757-60, 1986.
  22. De Bruyn G, Hahn S, Borwick A. Antibiotic treatment for travellers’ diarrhoea. Cochrane Database of Systematic Reviews 2000; Issue 3; Art. No: CD002242. [Reprinted 2009]. [Accessed August 2015]
  1. Ericsson CD, DuPont HL, Okhuysen PC et al. Loperamide plus azithromycin more effectively treats travelers’ diarrhea in Mexico than azithromycin alone. J Travel Med. 14:312-9, 2007.
  2. Tribble DR, Saunders JW, Pang LW et al. Traveler’s diarrhea in Thailand: randomized, double-blind trial comparing single-dose and 3-day azithromycin-based regimens with a 3-day levofloxacin regimen. Clin Infect Dis. 44:338-46, 2007.
  3. Norgine, Rifaximin Summary of Product Characteristics, 22 February 2013 [Accessed August 2015]
  4. Shlim DR. Looking for evidence that personal hygiene precautions prevent traveler’s diarrhea. Clin Infect Dis. 41 Suppl 8:S531-5, 2005.
  5. TravelHealthPro Factsheet; Food and water hygiene. February 2015 [Accessed August 2015]
  6. ABTA, How to have a safe and healthy holiday in the sun, [Accessed August 2015]
  1. Hill DR, Ford L and Lalloo, DG. Oral cholera vaccines: use in clinical practice. Lancet Infect Dis. 6:361-73, 2006.
  2. Jansen-Cilag Ltd. Dukoral Oral Cholera Vaccine – Summary of Product Characteristics. 9 October 2014. [Accessed August 2015]
  3. Ahmed T, Bhuiyan TR, Zaman K et al. Vaccines for preventing enterotoxigenic Escherichia coli (ETEC) diarrhoea, Cochrane Database Syst Rev. 2013 Jul 5;7: [Accessed August 2015]

 

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