When people travel to faraway countries, their stomach and bowel often have to get used to new foods and new ways of preparing food. Diarrhea is common during travels to distant countries. Traveler's diarrhea typically only lasts a few days and usually doesn't need to be treated. There are certain things you can do to try to avoid getting it.
The risk of getting diarrhea is higher in countries with a hot and humid climate. There are a number of reasons for this. For instance, your stomach and bowel might have a hard time coping with unfamiliar foods such as spicy dishes and exotic ingredients. Poor hygiene, high temperatures and inadequate cooling of foods make it easier for bacteria to thrive in foods or water. Traveler's diarrhea is most often caused by bacteria. But viruses can also be transmitted through foods or water.
If diarrhea is severe or lasts a long time, it is particularly important to replace the lost fluids and salts. You should see a doctor if the symptoms don't improve or if you develop severe diarrhea within a few days or weeks of returning from travels to a distant country.
How can you prevent diarrhea while traveling?
Germs are often spread through foods or through contact with contaminated objects – for instance, if you touch a doorknob that has some germs on it with your hand, and then touch your mouth with your hand. So if you want to avoid getting diarrhea when traveling, it's especially important to wash your hands thoroughly and often. You should also avoid touching your face with your hands if you haven't washed them.
Depending on where you travel to, the following tips may help lower your risk of infection:
- Wash your hands regularly, especially before eating and after going to the bathroom. Have disinfectant wipes or gels at the ready in case it isn't possible to wash your hands while you're out and about. Dry your hands with disposable paper towels if available.
- Don't drink tap water. Instead, drink water from bottles or other containers, making sure the seal isn't broken when you buy them. Also avoid ice cubes and drinks that have been diluted with water.
- Use bottled water to brush your teeth and rinse your mouth.
- Do not drink water from fountains, wells, streams, rivers, springs, waterfalls or standing water.
- Only eat fruits, raw vegetables, lettuce and herbs if you peel them yourself or wash them thoroughly with bottled water.
- Don't eat undercooked meat or fish.
- Avoid contact with animals because they can also spread bacteria or viruses.
- Keep flies away from food.
Can vaccines offer protection?
It is generally a good idea to find out which vaccinations are recommended in the country or part of the world you are traveling to before you go there. But there are currently no vaccinations against the germs that often lead to traveler's diarrhea.
People traveling to high-risk areas are advised to have a cholera vaccine. But this oral vaccine is only recommended if you're going to stay in a place with poor hygiene standards for a long time, or if you will be providing medical help in high-risk areas. People often say that the cholera vaccine can also reduce the risk of an ETEC infection. But there's no clear scientific proof that this is true.
What kinds of bacteria can cause diarrhea?
Some of the bacteria that travelers may come across in warm countries are also found in Western countries. These include Campylobacter and Salmonella bacteria. But they may be exposed to other bacteria while traveling too, including the following:
- ETEC: Enterotoxigenic Escherichia coli (ETEC) are spread through raw or undercooked foods, unpasteurized fruit juices or unpasteurized milk. The stool of cattle and other animals that chew the cud (e.g. goats, sheep) is a further potential source of infection. ETEC bacteria are sometimes found in bodies of water too. The symptoms break out three to ten days after infection. They usually include watery diarrhea, nausea, vomiting, abdominal pain and occasionally fever.
- Shigellosis, also known as bacillary dysentery or Marlow syndrome: Shigella bacteria are spread through contact with an infected person or by touching contaminated objects, as well as through contaminated water or foods. Flies can transmit Shigella bacteria too. The first signs of infection are usually watery diarrhea and abdominal cramps. They start about twelve hours to four days after becoming infected. In more serious cases, the bowel becomes inflamed, leading to a fever and diarrhea containing blood and pus.
- Cholera: The risk of getting cholera while on holiday in a distant country is very low. Cholera bacteria are spread through water, raw foods and the bodily secretions of infected people. They are rarely spread directly from one person to another. Symptoms start two to three days after infection, and include watery diarrhea and severe vomiting that can quickly lead to dehydration. Left untreated, cholera can become life-threatening.
Illnesses like typhoid and malaria, which are usually accompanied by a high fever, sometimes cause diarrhea too.
Which parasites cause diarrhea?
The most common parasitic infection in tropical countries is giardiasis, also known as beaver fever. The second most common infection is cryptosporidiosis ("crypto"). The parasites (giardia and cryptosporidia) are spread through contact with infected people or contaminated objects, as well as through contaminated drinking water, foods and bodies of standing water.
Giardiasis symptoms start about one week after infection and include a feeling of pressure in the upper abdomen (belly), mild nausea and flatulence. The diarrhea is relatively mild but can continue for weeks, sometimes accompanied by vomiting. Patients often report loud gurgling sounds from their stomach, tiredness and weight loss.
Cryptosporidiosis can lead to watery diarrhea seven to ten days after infection. Further possible symptoms include abdominal pain, nausea, fever and weight loss. But the infection may also go unnoticed.
Which viruses can lead to diarrhea?
Noroviruses and rotaviruses are found all over the world. One to three days after infection, the rotavirus often leads to sudden watery diarrhea, frequently mixed with mucus. This symptom is sometimes accompanied by vomiting, abdominal pain, and occasionally fever and breathing problems too. The infection usually lasts two to six days.
Norovirus symptoms start six hours to two days after infection and include severe diarrhea, violent projectile vomiting and abdominal pain. Further symptoms may include nausea, headaches, joint pain, exhaustion and a mild fever. The symptoms usually last two days at the most.
When is medication recommended?
If you have diarrhea and have a long journey ahead of you, for instance on a bus, the drugs loperamide or racecadotril can help reduce the symptoms. Loperamide isn’t suitable for children under the age of twelve. Low-dose racecadotril is available for children in the form of soluble granules, but only with a prescription.
If the diarrhea is caused by bacteria, antibiotics are often recommended. Studies have found that antibiotics don’t help against salmonella infections. It is still not clear whether these drugs help in the treatment of shigellosis or cholera.
Giardiasis is usually treated with antibiotics too. If you have cryptosporidiosis, making sure you get enough fluids is usually enough.
What can you do about diarrhea yourself?
When you have diarrhea, your body loses a lot of fluid and salts. Sweating in tropical temperatures makes this problem worse. So the most important thing is to drink as much as you can, and replace the lost salts and sugar. This is particularly true for babies, children and older people because they are more likely to become dehydrated compared to healthy adults.
People are often advised to buy oral rehydration solution at a pharmacy or drugstore and take it with them on their travels. Alternatively, you can make a solution yourself by adding the following ingredients to 1 liter of boiled water and stirring the solution:
- 4 teaspoons of sugar,
- ¾ teaspoon of salt and
- one glass of packaged orange juice.
Sometimes people recommend taking charcoal tablets or products made from a certain kind of yeast (Perenterol, Florastor). They are meant to make your poo more solid. There is not enough good research in this area to be able to say how well these products work, though. People who have a very weak immune system shouldn't take yeast products.
In order to go easy on your stomach and bowels, it can be a good idea to avoid fatty and spicy foods as well as alcohol and coffee. Foods that are gentle on the stomach are often recommended too, such as rice, bananas or rusk bread.
When do you need to see a doctor?
It is advisable to see a doctor if you have the following symptoms:
- Blood or mucus in your poo
- High fever, frequent vomiting, severe pain, dizziness or feeling faint
- Severe diarrhea that lasts longer than 48 hours, particularly in children and older adults
- Signs of dehydration (too little fluid in your body)
The signs of dehydration include:
- Worsening of general health
- Sunken eyes, cheeks or face
- Faster breathing or higher pulse than normal
- Less elastic skin: When you pinch some of the skin on the arm or belly and let go, it doesn't immediately bounce back to its original position. Instead, a small visible skin fold remains.
- Extreme thirst, feeling dizzy or faint, dark-colored pee or lack of urge to pee, as well as dry eyes or lips, or a dry tongue.
- Older people may sometimes have chest pain or muscle cramps.
Where can you find reliable health information for overseas travel?
The websites of the following institutions offer information and advice about diseases, vaccines, preventive measures and the treatment options (some of the information is only in German because we are a Germany-based website):
- German Federal Foreign Office
- Bernard Nocht Institute for Tropical Medicine
- World Health Organization (WHO)
Auswärtiges Amt, Gesundheitsdienst. Cholera - Informationen für Beschäftigte und Reisende. April 2019.
Auswärtiges Amt, Gesundheitsdienst. Merkblatt für Beschäftigte und Reisende. Durchfall (Diarrhoe). September 2018.
Auswärtiges Amt, Gesundheitsdienst. Merkblatt für Beschäftigte und Reisende. Krankheitsprävention und Hygiene im Ausland (insb. Tropen). Kurzfassung für den eiligen Leser. July 2016.
Deutsche Gesellschaft für Tropenmedizin und internationale Gesundheit (DTG). Cholera. 2019.
Duplessis CA, Gutierrez RL, Porter CK. Review: chronic and persistent diarrhea with a focus in the returning traveler. Trop Dis Travel Med Vaccines 2017; 3: 9.
Gordon M, Akobeng A. Racecadotril for acute diarrhoea in children: systematic review and meta-analyses. Arch Dis Child 2016; 101(3): 234-240.
Granados CE, Reveiz L, Uribe LG, Criollo CP. Drugs for treating giardiasis. Cochrane Database Syst Rev 2012; (12): CD007787.
Leibovici-Weissman Y, Neuberger A, Bitterman R, Sinclair D, Salam MA, Paul M. Antimicrobial drugs for treating cholera. Cochrane Database Syst Rev 2014; (6): CD008625.
Onwuezobe IA, Oshun PO, Odigwe CC. Antimicrobials for treating symptomatic non-typhoidal Salmonella infection. Cochrane Database Syst Rev 2012; (11): CD001167.
Robert Koch-Institut (RKI). Infektionsepidemiologisches Jahrbuch meldepflichtiger Krankheiten für 2018. Berlin: RKI; 2019.
Robert Koch-Institut (RKI). RKI-Ratgeber Campylobacter-Enteritis. June 7, 2018. (Epidemiologisches Bulletin; Band 23).
Robert Koch-Institut (RKI). RKI-Ratgeber: Campylobacter-Enteritis. June 1, 2018.
Robert Koch-Institut (RKI). RKI-Ratgeber: Kryptosporidiose. February 8, 2019.
Robert Koch-Institut (RKI). RKI-Ratgeber: Norovirus-Gastroenteritis. June 11, 2019.
Robert Koch-Institut (RKI). RKI-Ratgeber: Rotaviren-Gastroenteritis. June 11, 2019.
Robert Koch-Institut (RKI). RKI-Ratgeber: Salmonellose. February 8, 2019.
Robert Koch-Institut (RKI). RKI-Ratgeber: Shigellose. May 1, 2012.
Robert Koch-Institut (RKI). Steckbriefe seltener und importierter Infektionskrankheiten. Berlin: RKI; 2011.
Robert Koch-Institut (RKI). Wann ist der Fall ein Fall? Neues zur Diagnostik von darmpathogenen Escherichia coli. Fortbildung für den öffentlichen Gesundheitsdienst. Berlin, March 26th-28th, 2014.
Sinclair D, Abba K, Zaman K, Qadri F, Graves PM. Oral vaccines for preventing cholera. Cochrane Database Syst Rev 2011; (3): CD008603.
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