Traveler's diarrhea (TD) is a digestive tract disorder that causes nausea, abdominal cramping, and diarrhea. TD often occurs when travelers from industrialized countries travel to developing or underdeveloped countries. There are many causes of TD, with bacteria being the most frequent and parasites and viruses being less common. It is considered the most common illness that causes sickness to international travelers. Traveler's diarrhea has many nicknames, such as “Montezuma's revenge,” “Tut's tummy,” and tourista.
Every year, more than 60 million people travel from industrialized to developing or underdeveloped countries. Of these, as many as half (estimates range from 20% to 55%, with most near the higher end) will develop traveler's diarrhea. Some estimates suggest that 50,000 cases of TD occur each day.
Traveler's diarrhea is a common disease. As a form of food poisoning, TD is caused by consuming water or food contaminated with bacteria, viruses, or parasites that attack the digestive system. The disease is usually mild and does not require professional medical care, but it can alter travelers' plans and make them quite miserable for a few days.
The likelihood of getting TD depends primarily on the traveler's destination. The World Health Organization (WHO) designates countries as either high, moderate, or low risk for TD based on their degree of hygiene and public sanitation. Only travelers, not natives, tend to be affected in high- and moderate-risk countries. People living in those countries are exposed to the organisms that cause TD from childhood and so their bodies develop ways to combat or tolerate them.
Destinations designated as high risk, where there is more than a 50% chance of getting TD, include:
Intermediate-risk destinations include:
Low-risk countries are industrialized countries that have in place reliable systems for treating sewage and drinking water. These include:
Although anyone can get traveler's diarrhea, young children, the elderly, pregnant women, and people with weakened immune systems (such as those with human immunodeficiency virus/acquired immune deficiency syndrome [HIV/AIDS]) often have more severe and long-lasting cases than other groups. People with inflammatory bowel syndrome or diabetes or who are taking drugs that reduce the acidity of the stomach (e.g., antacids, cimetidine [Tagamet], omeprazole [Prilosec], esomeprazole [Nexium]) are also more likely to develop severe infections.
Traveler's diarrhea is contracted when people travel to areas where the sanitation and food preparation standards are less stringent than those in their home area. Drinking water contaminated with feces or eating foods prepared with contaminated water, including fruit and salad vegetables washed in contaminated water, often causes the disease. The organisms that cause TD can also be transferred to food by food handlers who have washed their hands in contaminated water or who are infected. Eating raw or undercooked meat and seafood can also cause symptoms of TD. Eating food bought from street vendors increases the chances of getting sick with TD. In high-risk countries, eating in restaurants is no guarantee that conditions are sanitary and that the food will not be contaminated.
Many different organisms can cause TD. According to the U.S. Centers for Disease Control and Prevention (CDC), about 85% of all TD cases are caused by bacteria. Another 10% are caused by parasites, and the remaining 5% by viruses. Because of the different causes, no single treatment will cure every case of traveler's diarrhea.
Symptoms of TD caused by bacteria—nausea, diarrhea, abdominal cramps, and sometimes vomiting and fever—come on suddenly, most often during the first week of travel. The most common cause of TD is infection with the bacteria Enterotoxigenic Escherichia coli (ETEC). E. coli are a larger genus of bacteria, many of which are found in the intestines of mammals. Some subtypes of E. coli are beneficial; in humans, they help with digestion and the absorption of nutrients in the intestines. Many other subtypes of E. coli are neither helpful nor harmful, but some, such as ETEC and Enteroaggregative E. coli (EAEC), can cause unpleasant digestive upset. Both these types of E. coli cause watery diarrhea and abdominal cramps but little or no fever.
Campylobacter are a genus of bacteria that more commonly cause TD in Asia than in other parts of the world. Some members of this genus cause bloody diarrhea and fever. Campylobacter bacteria are found in contaminated water, but they are also found in almost all raw poultry, even in developed countries such as the United States and Canada. Cooked food can be contaminated if it is placed on an unwashed surface that previously held raw poultry. Shigella are another common genus of bacteria that, like Campylobacter, cause bloody diarrhea, nausea, vomiting, fever, and abdominal cramps.
Giardia lambia is the most common parasitic cause of TD. Symptoms caused by parasites take longer to appear than symptoms caused by bacterial or viral infections. Often symptoms persist for several weeks, much longer than other cases of TD.
Viruses cause only a small amount of TD cases, although they are the largest cause of gastrointestinal upsets in the United States and other industrialized countries. Their symptoms are similar to those caused by bacterial infections.
The main symptom of TD is frequent loose, watery stools that begin fairly abruptly. Stools may or may not contain blood, depending on the organism causing the disease. Diarrhea may lead to dehydration. Other common symptoms that may occur along with the diarrhea are nausea, vomiting (in about 15% of people), bloating, abdominal cramps, and fever. Traveler's diarrhea usually lasts only from three to five days even without treatment except for TD caused by parasites, which tends to begin more slowly and to linger longer.
Diagnosis is made on the basis of signs and symptoms. TD is normally considered to occur when a traveler has three or more loose stools (including nausea, cramping, and bloating) within a 24-hour period while traveling. Laboratory tests are usually not performed unless there are unexpected complications. The diagnosis is also based on the region where the patient is traveling. If a person is in a country where TD is commonly caused by a particular bacteria, then the diagnosis is more likely to be based on historical precedence. In undeveloped countries where medical facilities are lacking, little diagnosis is undertaken. If a laboratory test is used, the stool is often examined for parasites and observed under a culture for bacteria.
In addition to drinking fluids, over-the-counter medications such as bismuth subsalicylate (Pepto-Bismol) and loperamide (Imodium) help give the individual more control over their bowel movements. However, these medications should not be used by people who have blood in their stool or who have a high fever. Bismuth subsalicylate should not be used by people allergic to aspirin.
Although bacteria cause most instances of TD, antibiotics are not usually prescribed to prevent the disease. They may, however, be used as treatment. The specific antibiotic given depends on the patient's symptoms, such as whether the stool is bloody or whether diarrhea is accompanied by fever or vomiting. Ciprofloxacin (Cipro), azithromycin (Zithromax), and rifaximin (Xifaxan) are the antibiotics most often prescribed. Medical care may be difficult to obtain in underdeveloped countries. Depending on where they plan to travel, individuals may wish to discuss the possibility of contracting TD with their physicians before leaving home and pack a supply of antibiotics, over-the-counter medications, and oral rehydration salts to be used as needed.
Although most cases of TD clear up within a few days, medical care should be sought if severe symptoms continue for more than three days, if a high fever develops, if there is blood in the stool, or if the individual shows signs of dehydration. Infants and children need prompt medical care if they appear to be dehydrated, disoriented, lethargic, have a fever over 102°F (39°C), or have uncontrolled vomiting and diarrhea.
The greatest health risk accompanying TD is dehydration. It is a potentially serious problem in infants and small children, who can become dehydrated from vomiting and diarrhea within hours. A primary goal of TD treatment is to keep the individual from becoming dehydrated. Infants, children, the elderly, and others who are losing large amounts of fluid from diarrhea should be given an oral rehydration solution. Oral rehydration solutions contain the proper balance of salts and sugars to restore fluid and electrolyte balance. In industrialized countries, already-mixed oral rehydration solutions are available in cans or bottles at supermarkets and pharmacies. In the rest of the world, dry packets of WHO oral rehydration salts are available. The contents of the packet are mixed with about 34 fluid ounces (1 L) of clean (i.e., boiled or purified) water. This solution can be given to young children in small sips as soon as vomiting and diarrhea start. Children may continue to vomit and have diarrhea, but some of the fluid will be absorbed. In the past, parents were told to withhold solid food from children who had diarrhea. New research indicates that it is better for children to be allowed to eat solid food should they want it, even though diarrhea continues.
Older children and adults can stay hydrated by drinking liquids that they know are uncontaminated, such as bottled water, bottled fruit juice, caffeine-free soft drinks, hot tea, or hot broth. Normally 2 to 3 quarts (2 to 3 L) should be drunk in the first 24 hours after diarrhea starts, moving to solid food as symptoms improve.
It is difficult to prevent all cases of TD, but with care, the chances of getting sick can be reduced. Some preventative measures include the following:
See also Diarrhea diet ; Giardiasis .
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American College of Gastroenterology, 6400 Goldsboro Rd., Ste. 450, Bethesda, MD, 20817, (301) 263-9000, http://www.acg.gi.org .
American Gastroenterological Association, 4930 Del Ray Ave., Bethesda, MD, 20814, (301) 654-2055, Fax: (301) 654-5920, (800) 877-1600, firstname.lastname@example.org, http://www.gastro.org .
International Foundation for Functional Gastrointestinal Disorders, PO Box 170864, Milwaukee, WI, 53217-8076, (414) 964-1799, Fax: (414) 964-7176, (888) 964-2001, email@example.com, http://www.iffgd.org .
National Institute of Diabetes and Digestive and Kidney Diseases, 31 Center Drive, MSC 2560, Bethesda, MD, 20892-2560, (301) 496-3583, (800) 891-5389, http://www2.niddk.nih.gov .
U.S. Centers for Disease Control and Prevention, 1600 Clifton Rd., Atlanta, GA, 30333, (301) 263-9000, (800) 232-4636, firstname.lastname@example.org, http://www.cdc.gov .
World Health Organization, Avenue Appia 20, 1211 Geneva 27, Switzerland, +41 22 791-2111, Fax: +41 22 791-3111, email@example.com, http://www.who.int .
Tish Davidson, AM
Revised by William A. Atkins, BB, BS, MBA