Handle traveler's diarrhea

Traveling and Traveler’s diarrhea!

By May A.

According to the Centers for Disease Control and Prevention (CDC) website, nearly 30 to 70 percent of tourists are affected by traveler's diarrhea. This health problem is benign and rarely causes complications, but can disrupt your activities and even your itinerary while traveling; these disadvantages can last up to 3 to 5 days and cause significant costs.

What is traveler's diarrhea?

It is a gastrointestinal infection also known as "Turista". This infection can be caused by various pathogens including bacteria (the most common cause), parasites or viruses. One of the most common symptoms of traveler's diarrhea is the presence of a minimum of 3 unformed stools in 24 hours with usualy one of the following symptoms:

1. Nausea

2. Vomiting

3. Abdominal cramps

4. Abdominal pain or tenesmus

5. Mucus or blood in the stool

6. Fever > 38.3˚C

How is it transmitted?

Travelers' diarrhea is transmitted mainly through contaminated water and food due to non-compliant sanitation practices and frequent power outages that may affect the food chain preservation. Person-to-person transmission is also possible in a fecal-oral context.

Which countries are the most endemic?

The risk of contracting traveler's diarrhea is present in all countries, but especially in Central America, South America, parts of the West Indies, Africa, Asia (except Singapore) and the Middle East.

What are the different preventive measures?

  • Vaccination

In Canada, Dukoral oral vaccine is approved for cholera and ECET diarrhea. It protects up to 52% against traveler's diarrhea caused by ECET. Regarding cholera, the World Health Organization (WHO) recommends the vaccine for endemic areas only. With respect to traveler's diarrhea, the Advisory Committee on Tropical Medicine and Travel Medicine (CATMAT) focuses primarily on non-pharmacological measures and vaccine for those particularly at risk.

Ask your pharmacist for more information!

  • Antisecretory agent

Bismuth subsalicylate

According to references, taking bismuth subsalicylate (Pepto-Bismol®) 2 tablets (524mg) four times a day provides 60% protection against traveler's diarrhea. In addition, a Mexican study evaluated the effectiveness of the drug when taken twice a day and the result was 40% protection. Its use should not exceed more than 3 weeks. This medication may cause some side effects, including black staining of the tongue and stools, and tinnitus.

Bismuth subsalicylate is contraindicated in:

·     Pregnant women

·     Children under 12 years

·     People taking acetylsalicylic acid (ASA, aspirin), doxycycline, anticoagulant, methotrexate or probenecid

·     Renal insufficiency

·     People with an active problem of gout, chicken pox or allergy to salicylates

Check with a pharmacist if such a product is right for you!  

  • Probiotics

The effectiveness of probiotics has so far not been proven in prevention against traveler's diarrhea. However, some strains studied seem promising such as Saccharomyces boulardij and Lactobacillus rhamnosus GG. These products are generally safe and may be recommended for travelers who wish to take probiotics despite lack of evidence of efficacy. These must usually be started 5 to 7 days before the trip and continued until 7 days after their return.

Check with a pharmacist if such a product is right for you!

  • Other measures

In endemic areas, follow the following motto throughout the trip: "Peel, cook, boil or do not eat it" 7. It is important to wash your hands regularly with soap and water, and if water is not available, have an alcohol-based disinfectant with a concentration of at least 60% .

Here are other recommendations for food and beverages:

·     Eat foods at their appropriate temperature, cold or warm

·     Drink purified or bottled water

·     Avoid ice, unpasteurized dairy products and ice cream

·     Avoid food from street kiosks

·     Avoid swimming in polluted or contaminated water

·     Use bottled water to brush your teeth

What is the treatment of traveler's diarrhea?  

  • Rehydration and nutrition

It is very important for a traveler to include oral rehydrating solution (either in the form of powder sachets, effervescent tablets or a ready to use solution) in their travel kit. On the diet side, it is recommended to continue your usual diet however, it is suggested to avoid fatty foods that slow down gastric emptying and foods rich in sugars, because they can exacerbate the episodes of diarrhea. Beverages such as caffeine, tea and alcohol are also to be avoided because they have a diuretic effect and can cause dehydration.

  • Antiperistaltic drugs

There are two antiperistal agents on the market: loperamide, an over-the-counter drug, and diphenoxylate hydrochloride, available with a prescription. These medications are suggested in cases of mild diarrhea only. These drugs should be avoided in severe cases (more than 6 liquid stools per 24 hours or blood or fever or mucus), because they can delay healing and even cause a toxic megacolon. They can be used for up to 48 hours and the main side effect of these medications is constipation. It is best not to use these drugs in children under 12 years of age without the recommendation of a doctor.

  • Antibiotics

Self-treat antibiotics use while traveling reduces the duration of symptoms and improves the quality of stay. The main antibiotics prescribed are ciprofloxacin, levofloxacin, azithromycin and cefixime. An antibiotic treatment can be started if the diarrhea is moderate (more than 3 liquid stools in 24 hours), persist for more than 48 hours and if there is an impairment of the general state. The antibiotic can usually be stopped when the symptoms are over.

If the diarrhea is severe (more than 6 liquid stools in 24 hours with fever or blood or mucus), it is recommended to continue the treatment until the end. However, if you do not see any improvement after 36 hours, it is important to consult a doctor.

It is important to plan your vacation to take full advantage of it because, as the old saying goes, "Prevention is better than cure"

REFERENCES

1.   "Travel Health Intervention Guide 2015", National Institute of Public Health of Quebec, Quebec Advisory Committee on Travelers' Health. Online at https://www.inspq.qc.ca/sante-voyage/guide/risques/diarrhee-des-voyageurs

2.   "Statement on the Diarrhea of the Traveler". Advisory Committee on Tropical Medicine and Travel Medicine (CATMAT). Available online at https://www.canada.ca/en/public-health/services/reports-publications/release-transmissible-cities-canada-rmtc/numer-mensual/2015-41/rmtc-volume-41-11 -5-November-2015-disease-origin-food / rmtc-volume-41-11-5-November-2015-disease-origin-food-2.html

3.   CONNOR, BA. "Traveler's diarrhea. The Yellow Book Centers for Disease Control and Prevention. Online at https://wwwnc.cdc.gov/travel/yellowbook/2018/the-pre-travel-consultation/travelers-diarrhea

4.   "Diarrhea of the traveler". Health Canada. Online at https://travel.gc.ca/travel/health-safety/maladies/diarrhee

5.   Act 41 Algorithm developed by the Quebec Association of Banners and Drug Stores. Online (private site)

6.   "Oral rehydration solutions". Health Canada. Online at https://travel.gc.ca/travel/health-safety/drinking

7.   Charbonneau, Kim. "Diarrhea of the traveler", [In pdf] Quebec Pharmacy. February-March 2014, pp.29-36.