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see also WHO year book  www.who.int/ith/chapter03_02.html#4

TRAVELLERS DIARRHOEA

Developing countries are a popular destination for travellers. Their unsophisticated and often charming cultures provide an exciting and intriguing holiday, well suited to the budget conscious traveller.
Many 1st class hotels have a high standard of sanitation and safe water supply but the people working in them and handling the food may not. Also tourism is an important source of income for many countries and disease risk will often be played down by the locals and even government bodies. Vaccination with oral cholera vaccine (Dukoral) will reduce the incidence of one form of E Coli travellers diarrhoea (LT-ETEC) by 60% but this only accounts for 20% of traveller diarrhoea cases**. More recently Travelan® capsules containing antibodies that bind the ETEC bacteria has been shown to be more successful for these bacteria. www.Travelan.com.au
Most episodes of diarrhoea are short-lived and require no particular treatment The need to treat diarrhoea depends on either its severity or persistence. Transmission is mostly via contaminated food or water.
The WHO have a good pamphlet  copy

  • Choose food which is freshly and thoroughly cooked and served stemming hot
  • Eat fruit or vegetables that you can peel or cut open yourself, eg. banana, citrus fruits, papaya.
  • Dry foods and Breads are generally safe.
  • Canned and bottled drinks are safe.

Dangers

  • Avoid milk, ice cream and other milk products unless made with pasteurised (or boiled) milk.
  • Avoid sauces, mousses, mayonnaise.
  • Avoid smorgasbord even in 5 star restaurants (reheated foods & food sitting at room temperature)
  • Avoid prawns, oysters, fish, unless thoroughly cooked. Hamburger meat can be dangerous as they are often precooked and stand at room temperature.
  • Avoid uncooked leafy vegetables, eg. in salads.
  • Ciguatera: At certain times of the year various species of fish and shellfish (especially the larger reef fish including shark) contain poisonous toxins. The risk of illness is reduced by washing the flesh. Cooking does not inactivate the toxins.
  • Ice is only as safe as the water it is made from.

Purification of water
Safe water for drinking can be prepared by either filtering or using chemicals or both.

  • Iodine: 8 drops of 1% iodine solution in 1 litre of water and let stand for 30 minutes. (Betadine) (Nb chemicals do not eradicate giardia or Amoeba parasites)
  • Filters: The trekker travel well supplied by MASTA and many chemist outlets or camping suppliers is convenient, lightweight, effective and recommended. Approx. cost $100 but worth it. TMVC and some camping stores can also supply these products. TMVC website www.tmvc.com.au/product.html

Children with Diarrhoea - see also Travelling with children
Diarrhoea is unfortunately common, for children and adults alike. But children, especially babies. are much more susceptible to dehydration. Prevention involves eating and drinking safely and attention to personal hygiene, especially handwashing after bowel movements and before eating.
Breast-fed infants are at substantially less risk of food or water-borne infections. Most diarrhoeal illnesses are acute and self-limited. The main complication of dehydration can be avoided in the great majority of cases by adequate fluid intake. Dukoral (oral cholera vaccine can be given to children over 2 years of age and can reduce common travellers diarrhoea by 60%.

Management of Diarrhoea
Because diarrhoea is so common it is important to be aware of how to manage it if prevention fails.
Fluids
Most travellers do not develop dehydrating diarrhoea; almost any beverage coupled with a source of salt (eg., salted crackers) suffices for hydrating most ill travellers
Bottled or canned beverages, tea, broth, foods such as rice, bananas, papaya (pawpaw), potatoes and dry biscuits are tolerated best. Children with diarrhoea are of special concern (see Travelling with children).

  • Antimotility drugs ('stoppers'). Since most diarrhoeal illnesses last only a few days, these drugs may be very helpful in relieving diarrhoea and cramps. Do not use if high fever or blood in motions. Do not use in children under 6, and be cautious in children under 6. Adult Dosage: loperamide (Imodium) -2 capsules (each 2 mg) followed by 1 cap after each unformed stool. (maximum 8 caps per day.)
  • Antibiotics. Diarrhoea with high fever, distressing symptoms or blood in motions:
    A single dose of two tablets of any of the following drugs should be effective. If response is not dramatic after 12 hours continue 1 tab twice a day for a further 3 days. (Norfloxacin 400mg, ciprofloxacin 500mg , doxycycline 100mg, Co-trimoxazole.)
  • Prolonged diarrhoea greater than 10 days and without fever: 
    A bowel parasite "giardiasis" is the commonest cause. The best treatment is tinidasole (Fasigyn) - 4 x 500mg tablets (2g) in a single dose. Metronidazole 400mg three times a day for 5 days is an alternative. If this is not completely effective amoebic dysentery is a possibility. Tinidazole (Fasigyn) - 4 x 500mg tablets (2g) daily for 3 successive days should be effective.

When diarrhoea is prolonged and with fever seek medical attention

Antibiotics to prevent Diarrhoea.
This is reasonable for short trips (less than 3 weeks). Indications include persons with

  • Inflammatory bowel disease, Immunocompromised persons including individuals who have had their spleen removed or poorly functioning spleen (eg  Hodgkin's lymphoma).
  • Insulin dependant diabetics
  • Persons on strong H2 blockers or proton pump inhibitors.(Losec, Somac, Zantac)
  • Business travellers whose purpose of the trip would be ruined will often chose this option. - Norfloxacin 400mg daily, Ciprofloxacin 500mg daily or Bactrim 1 DS daily could be used. Doxycycline is less effective. Azithromycin is useful for pregnant women and children ** WHO

Children with Diarrhoea
Mild diarrhoea:-
give extra fluids such as water, oral rehydration solution (ORS eg Gastrolyte) or dilutions of drinks as follows:

  • cordials (not low calorie) - I part to 6 parts water.
  • lemonade (not low calorie) - 1 part to 4 parts water.
  • fruit juice (not concentrated) - 1 part to 4 parts water.
  • home made ORS solution - Using a 5 ml teaspoon, 8 level spoons of table sugar and half a level teaspoon of salt can he added to a litre of water.

Severe diarrhoea: give one cup of ORS for every watery stool. Adults travelling with children should carry a supply of Gastrolyte sachets. If the child is hungry give a normal diet.
The most reliable signs of dehydration are weight loss and a fall in urine output.  A dehydrated child will drink ORS avidly and should be given as much as he/she will drink. A child who vomits will retain some ORS if given frequent small sips. Feeding, particularly breast feeding, should be continued. Solids should be stopped for no longer than 24 hours and preferably not at all. Starvation delays recovery.
Antidiarrhoeal drugs and anti-nausea drugs such as prochlorperazine (Stemetil) and metoclopramide (Maxolon) should not be used in young children because they can cause serious problems. Medical help should be sought if;

  • there is blood in the stool
  • a high fever is present
  • diarrhoea persists for more than 3 days in a child or 1 day in a baby.
  • any other cause for concern is present.

See Also Gastroenterology Institute Sheet

Medical Examination after travel: It is advisable (if not essential) to visit your local doctor promptly if you

  • suffer from a chronic disease, such as cardiovascular disease, diabetes mellitus, chronic respiratory disease;

    experience illness in the weeks following their return home, particularly if fever, persistent diarrhoea, vomiting, jaundice, urinary disorders, skin disease or genital infection occurs;

    consider that you may have been exposed to a serious infectious disease while travelling;

  • have spent more than 3 months in a developing country.

** page 203, Manual of Travel Medicine

Information mostly taken from: "International Travel and Health" (WHO year book - internet only)
Australian Immunisation Handbook, 8th Edition - 9/2003 - Part1 - Part 2 & Part 3 (large pdf files)
Centre for Disease Control, USA -  www.cdc.gov/travel Travel Health Seminar Oct 96, June 97,Feb 98, March 99, May 2000, August 2002 & March 2005 - Victorian Medical Postgraduate Foundation.
Manual of Travel Medicine, Melbourne, Oct 2004. Updated 3rd edion 2011.  Additional references & disclaimer.

August 24, 2014

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