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CLINICAL: TRAVEL HEALTH


commercial rehydration sachets (eg, Electrolade or Dioralyte). If the traveller will not tolerate commercial rehydration sachets, flat fizzy juice can be substituted: a pinch of salt in a can or bottle of juice will remove the fizz and increase the salt intake of the traveller. Anti-diarrhoeal medicines should be used with caution in adults, and never in children because it can cause intestinal obstruction. They may be useful if a traveller has to, for example, take a long bus journey where access to a toilet will be restricted. In the rare instances where travellers‘ diarrhoea is severe enough to be life-threatening, it is adequate fluid replacement, not antibiotics, or antidiarrhoeal agents that prove life-saving. For those requiring antibiotic treatment, fluoroquinolones are typically the drugs of choice. Ciprofloxacin (750mg as a single dose or 500mg twice a day for three days) is prescribed for travellers to Latin America and Sub-Saharan Africa. However campylobacter is


BOX 1. GENERAL RULES TO HELP TRAVELLERS AVOID TD


Wash your hands after going to the toilet and before every meal. Use paper hankies, kitchen roll, napkins etc, to hold food if you have to eat with your fingers. Drink bottled water - carbonation ensures the bottle has been factory produced. Avoid buying water from street vendors: more likely to have been re-filled. Avoid jugs or unlabelled bottles of water in hotel fridges and in restaurants. Avoid ice in drinks: freezing doesn’t kill bugs. Use bottled water to brush teeth. Water brought to a rolling boil for one minute will be safe to use for drinking, brushing teeth, washing fruit and vegetables. If you are unable to use either boiled or bottled water, chlorine dioxide is the chemical of choice for water purification. Never give babies under one year bottled water as it contains too much sodium (in general) for their kidneys. Use cooled, boiled water for making up babies’ formula feeds, diluting juice, and cold-sterilising bottles. Use only pasteurised dairy products such as milk, yogurt, cheese and ice cream. Peel fruit before eating. If you are unable to avoid eating the skin, eg, grapes, wash with treated or bottled water. Avoid buying fruit that has already been cut by the vendor due to possibility of contamination from an infected knife, hands, or flies. Avoid ‘freshly squeezed’ fruit juices or milk shakes from street vendors due to possibility of infected equipment. Wash salad vegetables in treated or bottled water. Avoid these foods as much as possible if not preparing them yourself. Avoid food from street vendors that has been lying uncovered, eg, sweetmeats or dates, due possibility of contamination from flies. Food should be hot, cooked thoroughly and fresh, not lying around. Avoid semi-cooked food such as rare steaks, eggs, and mayonnaise-based products. Avoid bowls of communal nuts or crisps in bar areas and restaurants.


frequently resistant to fluoroquinolones and is a higher risk for travellers to South and South East Asia. For travellers to those areas and (if essential), during pregnancy, azithromycin (1000mg as a single dose or 500mg once daily for three days) is the drug of choice. If a traveller is provided with an antibiotic to take with them on their trip, this should be provided on a private prescription and detailed instructions about when to use should be provided in writing for the traveller. All travellers should be encouraged not to starve themselves when they experience an episode of TD, but to eat a light ‘dry’ diet such as crackers and rice.


WHEN TO SEEK MEDICAL ATTENTION? Box 2 highlights the warning signs and symptoms for which a trav- eller should seek medical advice.


CONCLUSION TD is the most commonly-acquired travel health problem. It usually occurs in the first week of travel, and is more common when travelling to high-risk areas. It can be easily prevented by following some simple food and water ‘rules,’ and is most often self-limiting without the need for antibiotic treatment.


REFERENCES 1. World Health Organisation (WHO). International Travel and Health. Geneva: WHO; 2011.


2. DuPont HL, Ericsson CD, Farthing MJG. et al. Expert Review of the Evidence Base for Prevention of Travelers’ Diarrhea. JTM 2009;16:149- 160.


3. Bavishi C, Du Pont HL. Systematic Review: the use of proton pump inhibitors and increased susceptibility to enteric infection. AP&T 2011;34:1269-1281.


4. Behrens R, Barer M. Diseases spread mainly by food, drink and poor hygiene. In: Dawood R, ed. Travellers Health: How to stay healthy abroad. Oxford: Oxford University Press; 2002.


5. Zwar NA, Torda A. Investigation of diarrhoea in a traveller just returned from India. BMJ 2011;342:d2978.


6. Schlagenhauf P, Chen L H, Wilson M E. Sex and gender differences in Travel-Associated Disease. CID 2010;50:826-832.


7. Health Protection Agency (HPA). Foreign travel-associated illness: a focus on travellers’ diarrhoea. London: Health Protection Agency; 2010.


RESOURCES National Travel Health Network and Centre (NaTHNaC) TD factsheet www.nathnac.org/pro/factsheets/trav_dir.htm World Health Organisation (WHO) advice on safe drinking water www.who.int/water_sanitation_health/hygiene/envsan/sdwtravel.pdf


BOX 2. WARNING SIGNS


Pyrexia. Blood or mucus in stools. Vomiting as well as diarrhoea. Lethargy, confusion or drowsiness. Diarrhoea lasting more than 24 hours in the very young and the very old. Diarrhoea lasting more than 72 hours in those with no previous medical conditions.


68 Nursing in Practice March/April 2012


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