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 quite 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 is higher in the tropics and subtropics. 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 very 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 is especially important to wash your hands regularly and often. You should also try not to touch your face with unwashed hands.
- Depending on where you travel to, the following tips may help lower your risk of infection:
- Wash your hands regularly with soap, 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 is not 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.
- Avoid 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.
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. People traveling to high-risk areas are advised to have a cholera vaccine.
What kinds of bacteria 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. The following are examples of infections caused by bacteria:
- 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 or mucus.
- Cholera: The risk of getting cholera on a normal holiday in the Tropics is very low. Cholera bacteria are spread through water, raw foods and the bodily secretions of infected people. Direct person-to-person transmission tends to be rare. 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 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, mild nausea and flatulence. The diarrhea is relatively mild but can continue for weeks, 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 stomach cramps. Further symptoms may include nausea, headaches, achy muscles, exhaustion and a mild fever. The symptoms usually clear up within two days.
When is medication recommended?
If you have diarrhea and have a long journey ahead of you, for instance on a bus, the drugs loperamide and 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 not without 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 certain whether these drugs help to clear up the symptoms 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 and take it with them on their travels. Alternatively, it is possible to make a solution yourself by adding the following ingredients to a liter of boiled water and stirring the solution:
- Five tablespoons of sugar
- One and a half level tablespoons of table salt
- 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 the stool more solid. There is not enough good research in this area to be able to say how well these products work in the treatment of acute diarrhea.
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 stool
- High fever, frequent vomiting, severe pain or circulation problems
- 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 state of health
- Sunken eyes, cheeks or face
- Faster breathing rate or higher pulse than usual.
- Less elastic skin: If you pinch the skin on your arm or belly and hold it for a few seconds, then pull it slightly and release it, it does not immediately return to its original position. A visible skin fold remains.
- Other early signs of dehydration include feeling very thirsty or dazed, having dark urine, no urge to urinate, dry eyes, dry lips or a dry tongue.
- Older people might also have chest pain or muscle cramps.
Where can you find reliable information about overseas travel?
The websites of the following institutions offer information and advice about diseases, vaccines, preventive measures and treatment options (some of the information is only in German because we are a Germany-based website):
- German Foreign Ministry
- Bernard Nocht Institute for Tropical Medicine
- World Health Organization (WHO)
Auswärtiges Amt. Infos des Gesundheitsdienstes. Cholera. July 18, 2012.
Auswärtiges Amt. Gesundheitsdienst. Merkblatt für Beschäftigte und Reisende. Durchfall (Diarrhoe). 2007.
Auswärtiges Amt. Gesundheitsdienst. Merkblatt für Beschäftigte und Reisende. Krankheitsprävention und Hygiene im Ausland. 2007.
Deutsche Gesellschaft für Tropenmedizin und Internationale Gesundheit e.V. (DTG). Cholera.
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). Epidemiologisches Bulletin. Aktuelle Daten und Informationen zu Infektionskrankheiten und Public Health. Ständige Impfkommission (STIKO) am RKI. Änderung der Empfehlungen zur Impfung gegen Cholera. Nr. 31. 2010.
Robert Koch-Institut (RKI). Campylobacter-Enteritis. RKI-Ratgeber für Ärzte. March 26, 2015.
Robert Koch-Institut (RKI). Kryptosporidiose. RKI-Ratgeber für Ärzte. June 23, 2014.
Robert Koch-Institut (RKI). Norovirus-Gastroenteritis. RKI-Ratgeber für Ärzte. July 26, 2008.
Robert Koch-Institut (RKI). Rotaviren-Gastroenteritis. RKI-Ratgeber für Ärzte. July 31, 2013.
Robert Koch-Institut (RKI). Steckbriefe seltener und importierter Infektionskrankheiten. Berlin 2011.
Robert Koch-Institut (RKI). Salmonellose. RKI-Ratgeber für Ärzte. April 20, 2016.
Robert Koch-Institut (RKI). Wann ist der Fall ein Fall? Neues zur Diagnostik von darmpathogenen Escherichia coli. March 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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