AUSTRALIAN GASTROENTEROLOGY INSTITUTE
(educational arm of the Gastroenterological Society of Australia)
Website: www.gesa.org.au ... Copies reviewed January 2006

TRAVELLERS' DIARRHOEA

Travellers' Diarrhoea is a common and uncomfortable problem for travellers which frequently disrupts an otherwise well planned holiday. It is caused by eating or drinking food or water which has been contaminated with germs. Almost always, the illness lasts a couple of days only. This guide will help you minimize the risk of developing diarrhoea and will give you advice on what to do if you should develop this problem. Very simple precautions greatly reduce the risk of travellers' diarrhoea.

PREVENTION
Follow these basic rules.

General Hygiene Advice  

1. Always wash hands thoroughly after using the toilet and before eating.
2. Never drink tap water unless it is boiled or purified first. (See Purification of Water)
3. Use bottled water, other pre-packaged drinks, eg. bottles or cans of soft drink, and hot drinks such as tea and coffee.
4. Refuse ice in drinks, as there is a significant risk of this having been made with contaminated water.
5. Avoid salads.
6. Always peel fruit (or wash it thoroughly in purified water).
7. Choose restaurants where the staff, surroundings and food appear clean.
8. Choose restaurants where there are plenty of people eating, as news of a source of illness usually results in less patronage.
9. Ask for lukewarm food to be replaced with fresh, hot food.
10. Never eat raw seafood.

Medical Prevention

Effective vaccines are available to prevent some infections, including hepatitis A and typhoid. Your doctor can give advice about which vaccines are required for your travel. Cholera vaccine is not pleasant, nor very effective and is not recommended by the World Health Organisation.

Some travellers take antibiotics or other medications to try to prevent diarrhoea. Although these may have some protective effect, they can cause side-effects such as rashes or stomach upset and are not recommended for most travellers. However, they are used in some situations and in some individuals with particular health problems which put them at special risk. If you wish further information, please discuss this with your doctor.

The best way of avoiding sickness is to carefully follow the simple rules given above.

Special Precautions

People with significant medical illnesses and children may be more prone to certain infections, and should seek special advice from their doctor before travel.

PURIFICATION OF WATER

The requirements are:

1. a water bottle
2. some tap or stream water
3. patience

Purification methods:

1. Boiling: Minimum of 10 minutes required. This is the only absolutely safe method. However, you need a way to heat the water.

Iodine tablets: Can be purchased from many pharmacies, hiking equipment shops, and medical clinics. These are the most convenient method for disinfecting water as nearly all bugs can be killed by following the instructions.

1. Iodine solution: As above but potentially very messy.
2. Chlorine tablets: As for iodine, but may not be as effective.
3. Filters: Not recommended as none can filter all viruses.

TREATMENT

• Before you leave Australia see your doctor for advice about what medications to take with you.
• If you become unwell with diarrhoea it is most important to maintain your fluid intake. Special rehydration solutions can be bought from a pharmacy or you can prepare your own. Set out below is a plan to follow if you do become unwell.
• If you pass blood with the diarrhoea or have bad stomach cramps or a fever above 38C, it is important not to take any anti diarrhoea medication, even from a chemist, and that you try to see a doctor. In some settings, medications that slow down the contractions of the bowel can make the infection more dangerous. If there is no doctor available, take antibiotics.
• Sometimes diarrhoea will continue after you return home from holiday. If so, see your doctor who will organise tests to identify the cause and give you appropriate treatment. Remember to say that you have recently been overseas!

PATIENT TREATMENT PLAN

So you have got Bali belly, Montezuma's revenge, Tourista, Delhi belly, the Jamaican runs. This will usually require no specific treatment, as normally your natural body defences overcome the infection. Typically, on the first day you will have between three and five loose watery bowel actions, or sometimes more, mild stomach cramping pain, and possibly a low grade fever, and nausea and vomiting. Things will look better after 24-48 hours and the illness will usually have resolved completely by the fourth or fifth day.

The Plan:
1. You must rest if you feel tired, fatigued or exhausted.

2. You must have plenty of fluids to drink. Drink an increased volume of fluids, at least 3 litres a day. Proprietary oral rehydration solutions (eg Gastrolyte™) are the best, or make up your own with:

• sodium bicarbonate ½ teaspoon,
• salt ½ teaspoon,
• honey 2 tablespoons (or sugar 4 tablespoons) and
• glass of fruit juice made up to 1 litre of safe or purified water

or, if these ingredients are not available,

• 1 part of fruit juice mixed with 4 parts of safe or purified water.

3. If you have to get on that bus, plane or tour, consider taking antidiarrhoeal medication provided that the illness is mild. Suitable drugs are atropine with diphenoxylate (Lomotil™) or loperamide (Imodium™). Never take these if you have blood in the stool, severe abdominal pain, or high fever (temperature more than 38°C). These drugs must not be given to children.

Your doctor has prescribed………………………………………..

4. Consider taking antibiotics if you have 3 or more bowel actions associated with nausea, vomiting, cramps, or fever. Stop after 3 days if you are better, otherwise continue for 5 days.

Your doctor has prescribed………………………………………..

5. If nausea is troubling you, tablets such as metoclopramide (Maxolon™) or prochlorperazine (Stemetil™) may be helpful. These drugs must not be given to children.

Your doctor has prescribed………………………………………..

6. You must consult a doctor and take antibiotics if you have blood in the stool, severe abdominal pain, or high fever (temperature above 38°C). If you have these problems do NOT take antidiarrhoeals [atropine with diphenoxylate (Lomotil™) or loperamide (Imodium™)].

7. If you are in a cholera area and have profuse watery diarrhoea, start taking doxycycline tablets immediately and seek medical advice without delay.

If you have persistent loose diarrhoea, you might have an infection caused by giardia and can take tinidazole (Fasigyn™), 4 tablets as a single dose. If you have been passing blood with the diarrhoea for over 5 days despite antibiotics, you might have amoebic infection. In that situation you should take tinidazole (Fasigyn™), 4 tablets each day for three days, and seek medical advice.

Remember that if you are on the oral contraceptive pill, the combination of the diarrhoea and antibiotics may prevent the oral contraceptive pill from being effective. To be on the safe side you should continue to take the pill, but use other means of contraception as well.

AUSTRALIAN GASTROENTEROLOGY INSTITUTE

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Administrative Officer
Australian Gastroenterology Institute
145 Macquarie Street, SYDNEY NSW 2000
Tel (02) 9256 5455 Fax: (02) 9241 4586