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CLINICAL: TRAVEL HEALTH


Margaret Umeed MSc (Trav Med) RGN MFTM (RCPS, Glas) FQNIS


Specialist Nurse Practitioner (General Practice) Glasgow


Avoiding and treating


travellers’ diarrhoea Help travellers avoid ruining their trip and experiencing unpleasant symptoms with some straightforward advice


T


ravellers’ Diarrhoea (TD) is a clinical syndrome associated with contaminated food or water that occurs during, or shortly after, travel. It is the most common health problem affecting travellers and may affect up to 80% of travellers to high-risk destinations, depending on the length of stay. Various viruses, bacteria and parasites are known


to cause TD, but the majority of cases are caused by bacteria. Diarrhoea is often associated with nausea, vomiting, abdominal cramps and fever.1


about TD, to enable the health care professional to provide appropriate advice to the traveller identified as being at risk.


WHAT CAUSES TD? TD is caused by a variety of enteropathogens of which enterotoxi- genic E. Coli (ETEC), enteroaggregative E. Coli (EAEC) and norovirus appear to be the most important. Other bacterial infections such as Shigella, Salmonella, Campylobacter and Vibrio Cholerae are also implicated, as are parasitic infections, particu- larly for those living in high-risk areas for long periods of time.2


In


order to cause TD, the organism has to be ingested either with infected food or water. In some situations, eg, during a norovirus outbreak on a cruise ship, infection may be acquired by touching an infected hand rail and then inadvertently transferring the infection from hand to mouth. There is some evidence that travellers who take a proton pump inhibitor (PPI) may be at greater risk from TD because of the acid suppression which would provide natural gastric protection.3


WHAT ARE THE RISKS FOR TRAVELLERS? When a traveller travels from a low-risk area to a high-risk area, the likelihood of developing TD is approximately 40%. When a traveller travels from a low risk area to an intermediate risk area, the risk of TD in approximately 10%. Even for a traveller to travel between low risk areas the likelihood of TD is between 2-5%.4


HOW TO YOU PREVENT IT? Prevention of TD relies on good hygiene measures both by the traveller and the host country. ‘Rules’ for the general traveller on preventing TD are listed in Box 1.


HOW DO YOU TREAT TD? The most important aspect of treatment for TD is rehydration. TD may cause dehydration even if mild, and sweating in hot climates leads to considerable body fluid loss. Fluid replacement is difficult to predict, but thirst is a good indicator that the body needs fluids. Young children cannot communicate their thirst other than by crying, and drowsiness is an important indicator of dehydration in this age group.4


Rehydration fluid should be offered in small


amounts to avoid vomiting. Travellers should be reminded that bottled or treated water needs to be used if reconstituting


This article aims to summarise the key points


More than 15 million travellers are estimated to experience TD each year, with rates varying between 20-90% for each two-week stay.5


Usually occurring during the first week of travel, TD can


often disrupt planned activities, with studies indicating women are affected by acute and chronic diarrhoea more than men.6


In


addition, there is evidence that TD can trigger an inflammatory bowel response in some travellers resulting in chronic inflamma- tory bowel disease (IBD).


WHAT HAPPENS WHEN YOU GET IT? The usual definition of TD is three or more unformed stools passed by a traveller in a 24-hour period, with accompanying symptoms such as cramps, nausea, vomiting, fever, blood in the stools and faecal urgency.5


Health Protection Agency (HPA) data


suggest that 24,000 cases of laboratory-confirmed gastrointesti- nal infections were reported between 2004-08, however much TD goes unreported, either due to the self-limiting nature of the disease, or due to incomplete reporting of travel history by the clinician.7


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