Travellers’ diarrhoea

Travellers’ diarrhoea can be very unpleasant and ruin a holiday or business trip. It is a common problem, 20-60% of all travellers will experience a bout of travellers’ diarrhoea when they travel to high risk destinations, particularly those visiting low to middle income countries.

20% of travellers are confined to bed for a couple of days, and 40% have to change their travel plans, and 1% are admitted to hospital (1), so you can see it can be very disruptive!

The organisms responsible for travellers’ diarrhoea are commonly reported worldwide, but there are some areas in the world that are higher risk. These include most of Asia, Africa, Middle East and Latin America, and more than 20% of travellers may experience travellers’ diarrhoea in these destinations.

Source: Health Protection Agency. Foreign travel-associated illness – a focus on travellers’ diarrhoea. 2010 report (2)

What is it?

Travellers’ diarrhoea is defined as 3 or more loose stools per day.  They are often accompanied by at least one of the following symptoms:

• Fever
• Nausea or vomiting
• Cramps
• Faecal urgency
• Bloody diarrhoea (dysentery)

Most cases of travellers’ diarrhoea occur in the first week of travel.

Typically, symptoms last for 3-5 days and most cases get better without any specific treatment.

Mild travellers’ diarrhoea – typically not accompanied by other symptoms and does not generally disrupt your normal activities or significantly alter your travel activities.

Moderate to severe travellers’ diarrhoea – generally accompanied by other symptoms and your normal activities are generally disrupted – 3% of travellers have 10 + stools a day!

What causes it?

Travellers’ diarrhoea can be caused by many different organisms.

Bacteria      –           E. coli, Salmonella, Campylobacter, Shigella, Cholera

80% of all cases of travellers’ diarrhoea

Viruses        –           Norovirus, Rotavirus

5-10% of all cases of travellers’ diarrhoea

Parasites     –           Giardia, Entamoeba histolytica, Crytosporidia, Cylospora

2-10% of all cases of travellers’ diarrhoea –More likely in individuals with                                     symptoms that last more than 2 weeks

All these organisms are spread by the following:

• consuming food and water that is contaminated
• touching your mouth with hands that are contaminated
• other forms of water-borne infections include recreational water – swimming pools, the sea and freshwater rivers and lakes

Stress, change in diet and increased alcohol consumption can also cause travellers’ diarrhoea.

Who is most at risk?

• Backpackers
• Travellers who are visiting friends and family
• All-inclusive holiday travellers – such as in cruise ships
• Children under the age of 6 years
• People who take medication for reflux and other gastric problems
• Travellers who have an immune system condition or those who take medications that cause suppression of the immune system

What can I do to prevent it?

This is tricky! Travellers’ diarrhoea is difficult to prevent if you are not preparing your own food and drinks, but there are some things that you can do to help.

• If the tap water at your destination is not safe to drink you will need to make sure you drink only bottled, sterilised, filtered or boiled water. Beware of fake bottled water. Always check that the bottles are intact and haven’t been tampered with. Carbonated water if safer to drink.

• Avoid ice in your drinks

• Personal hygiene when eating and drinking is really important this includes hand washing before you eat or prepare any food and using clean plates, cups and utensils.

• It is really important to wash your hands after you use the toilet, hand washing facilities may not always be readily available so remember to carry alcohol hand rub and wipes – handwashing can reduce the risk of travellers’ diarrhoea by 30-40%

• Clean your teeth with bottled water.

• Good swimming pool hygiene is important! Don’t swim if you have diarrhoea, and try not to swallow any pool water!

• If you are on a cruise it is important to report any diarrhoea or vomiting immediately to the ship’s medical team, this will help to prevent passing it on to other passengers and the crew! You will be asked to stay in your own cabin until you have been clear of your symptoms for 48 hours, some cruise companies will also ask any cabin companions to do the same.

BOIL IT – COOK IT – WASH IT – PEEL IT – OR FORGET IT!  THIS IS YOUR MANTRA

 Always remember that food that is freshly made, cooked carefully and served when hot is usually safe. It is best to avoid food that has been standing around for any length of time.

If you’re going to eat ‘street food’ always try to choose food that is freshly cooked to a high temperature and is served to you immediately whilst it is still hot!

Potential unsafe foods

• Salads – they can be contaminated by flies or soil or washed in water
• Raw fruit or vegetables, unless you have peeled it yourself – Berries are best avoided as they are difficult to clean. Have you ever tried to peel a raspberry? It’s very difficult!

• Raw or poorly cooked meats and poultry

• Fish and Shellfish – can be risky at certain times of the year, even if well cooked

• Sauces

• Food left exposed to flies

• Food that is shared with lots of people – buffets!

• Unpasteurised products – including dairy products, ice-cream and fruit juices

• Undercooked or reheated foods – especially fish, rice and meat

• Takeaways and street food

Did you know that the humble watermelon can be dangerous?

They can be ‘injected’ with pink water to make them look more tempting when they are cut! Best to avoid the watermelon seller on the beach!  

Water and drinks

Unopened carbonated, commercial fruit, water and pasteurised drinks that have been manufactured in a factory can be considered safe to drink. Also drinks that are made with boiling water such as coffee and tea are generally safe.

How do I treat my water?

This is a good question, there are a variety of ways you can do this.

Boiling it – it is a reliable way to disinfect your water but it is not always easy to do.

Chemical treatments – the effectiveness of these treatments can vary. Always follow the manufacturer’s instructions carefully. Chlorine based preparations are normally the most safe and effective way to chemically treat your water. Iodine is no longer recommended (EU directive 2009). (3)

Filtering it – this is useful for very remote travellers who only access to water from rivers and streams, the filter remover the particulate matter. There are lots of filters on the market.

UV light – battery operated UV light devices can be used to disinfect water. The water needs to be clear of particles before treating.

We sell the Aquapure Traveller filter bottle in Sussex Travel Clinic. It uses Mechanically Advanced Disinfection (MAD) technology which is based on electro adhesion that eliminates nearly 100% of bacteria, viruses, larger pathogens and many chemicals, heavy metals, dirt and odour in water.

Bottle feeding babies – it is generally not recommended that you make formula feeds for babies with bottled water because they can contain too much salt (sodium/Na) and is probably not sterile. However when you are travelling this may be a safer option than using tap water. If you do use bottled water check the label make sure is contains < 200mg/l of sodium and up to 25mg of sulphate. Avoid mineral water as it generally exceeds these levels. Look out for unsealed bottles or ones that look like they have been tampered with. It is recommended that bottled water is boiled and allowed to cool before you make up infant formula. Another alternative is to take ready-made formula with you on your trip. (4)

What else can I do?

Reduce your risk of getting travellers’ diarrhoea by taking BIMUNO

This is a pre-biotic that helps to reduce your risk of travellers’ diarrhoea by introducing special nutrients called oligosaccharides into your gut thus resetting and increasing friendly gut bacteria.

Just start taking it daily for one week before you travel and every day you are away on your trip! We sell this at Sussex Travel Clinic.

Pepto Bismol

Bismuth subsalicylate can help to reduce nausea and can be recommended for mild diarrhoea. Bismuth subsalicylate preparations are available over the counter for use in adults and children over 16 years of age (5)

Travellers’ diarrhoea packs

Antibiotic self-treatment is unnecessary for majority of travellers and are not routinely recommended. However they may be considered for those at high risk.

Travellers suitable for self-treatment may include:

• Travellers to remote areas who cannot access immediate medical help.
• Travellers with pre-existing bowel problems such as IBD where infection may trigger a relapse.
• Travellers with pre-existing medical conditions which may be compromised by severe infection.
• Travellers with a tendency to severe travellers’ diarrhoea – based on previous travel experience.

Travellers’ diarrhoea packs can be purchased at Sussex Travel clinic. All kits are designed for self-treatment of travellers’ diarrhoea and contains full instructions.

Travellers’ Diarrhoea Pack 1 – For mild travellers’ diarrhoea – Loperamide only

12 years old and over only

Handy bag containing the following items:

• Loperamide tablets
• Hand gel
• Oral rehydration salts

Cost Per Pack – £15.00

Antibiotics may be recommended by your nurse if you are more at risk from travellers’ diarrhoea during your travels

Traveller’s Diarrhoea Pack 2 – for use in Africa, Central America and South America

Over 18 years only

Handy bag containing the following items:

• Ciprofloxacin 500 mg
• Loperamide tablets
• Hand gel
• Oral rehydration salts

Cost Per Pack – £20.00

Travellers’ Diarrhoea Pack 3 – for use in South and South East Asia

Over 18 years only

Handy bag containing the following items:

• Azithromycin 500 mg
• Loperamide tablets
• Hand gel
• Oral rehydration salts

Cost Per Pack – £20.00

What if I’m still not well when I get back from my trip?

If you are still experiencing symptoms when you return from your trip and they are not improving you should see your doctor. Seek urgent medical care if you have the following symptoms:

• High temperature – 38°C or more
• Blood and or mucous in your stool
• Severe abdominal pain
• Jaundice
• Rash
• Any change in your mental status

Children and the elderly are more vulnerable and medical advice should be sought earlier if fluids cannot be tolerated or there signs of dehydration.

To book an appointment to discuss travellers’ diarrhoea or purchase a travellers’ diarrhoea pack please call the clinic on 01273 749100 or 01903 254774 or book ONLINE

Happy travelling from the team

Written by Nicki Harrison – Lead Nurse

Sussex Travel Clinic

References:

1          Ericsson CD. Travelers’ diarrhea. Epidemiology, prevention, and self-  treatment.             Infect Dis Clin North Am 1998; 12: 285–303 cited in Al-Abri, S.S. Beeching, N.J. Nye   F.J. Traveller’s diarrhoea. Lancet Infect Dis. 2005 Jun; 5 (6):349-60.

2        Foreign travel-associated illness: a focus on travellers’ diarrhoea –           http://webarchive.nationalarchives.gov.uk/20140714084352/http:/www.hpa.org.uk/            webc/HPAwebFile/HPAweb_C/1287146380314

3          Fit for Travel – http://www.fitfortravel.nhs.uk/advice/disease-prevention-            advice/travellers-diarrhoea.aspx

4          NHS Choices. Can I use bottled water to make up baby formula (infant formula)? 22             June 2016. [Accessed 18 August 2016].

5          Nathnac – http://travelhealthpro.org.uk/factsheet/53/travellers-diarrhoea

Bibliography:

Food Standards Agency, UK. The Natural Mineral Water, Spring Water and Bottled Drinking Water Regulations 2007. [Accessed 18 August 2016]

Nathnac – http://travelhealthpro.org.uk/factsheet/53/travellers-diarrhoea

TRAVAX – http://www.travax.nhs.uk/health-information/general-health-advice/travellers-diarrhoea.aspx

The  Public Health Ministry of Cuba reported  last week that there has been an increase in diarrhoeal illness in recent weeks. The  main province affected is Granma, with most cases reported from the municipality of Manzanillo. There have been approximately 1,000 cases, with three deaths being reported. Cholera has been isolated in 53 cases. [1]. Sanitation methods have been put in place to keep the outbreak under control.

What is Cholera?

Cholera is transmitted through contaminated water or food in areas where there is poor sanitation. The main symptoms include profuse and sudden watery diarrhoea.  Severe diarrhoea can cause dehydration. The very young, elderly and those with poor immune systems are more vunerable. Cholera can be fatal, however, with prompt fluid replacement cholera is nearly always cured.

What is my risk?

For most travellers the risk of contracting cholera is low, the cholera vaccine is only usually recommended for aid workers  travelling to remote areas or working in a disaster area or refugee camp.

All travellers should practice strict food and water hygiene:

• Drink bottled or boiled water only.
• Avoid ice in your drinks, unless you can be sure it comes for a safe water supply.
• Brush your teeth with bottled water only.
• Practice good hygiene measures – wash hands regularly.
• Take an alcohol hand gel to use in case you can not wash your hands.
• Consider taking a water filter bottle.
• Salads are often washed in water – avoid eating salads if you can not be sure that the salad has been wash in safe water.
• Avoid undercooked or raw fish, meat or shellfish.
• Consider taking a pre- biotic such as Bimuno. These reduce your risk of travellers diarrhoea.

Reduces your risk of diarrhoeal illness

For further advice please call 01273 749100. To purchase travel products pop into the clinic or buy online.

References

1. http://www.nathnac.org/travel/news/choleras_cuba_050712.htm

Traveller’s diarrhoea (TD) can be very unpleasant and ruin a holiday or business trip. It is estimated that as many as 60% of all travellers will experience a bout of TD when they travel overseas. Many illnesses such as Hepatitis A, Typhoid and Cholera are spread through eating and drinking contaminated food and water. Thankfully, there are vaccinations that can offer some protection against these illnesses. However, many other bacterial infections such as E.Coli and parasites such as Giardia cannot be vaccinated against. It is extremely important to follow strict food and water hygiene to avoid infection.

Advice for Travellers

• Drink bottled water. Beware of fake bottled water- in many countries seals have been tampered with and the bottle actually contains unsafe tap water.
• Avoid ice in your drinks, unless you are sure it has come from a safe supply of water.
• Don’t clean your teeth with tap water- use bottled or boiled water.
• Boiled water is safe to drink- bringing water to the boil and boiling for 1 minute is enough to purify it.
• Use chlorine tablets or a water filter if you haven’t got access to clean drinking water.
• Avoid salads that may have been washed in unsafe water.
• Avoid raw fruit and vegetables- these are ok if you can peel them.
• Avoid buffet food that may have been left out for a number of hours or been exposed to flies.
• Avoid unpasteurised dairy products such as milk, yogurt and cheese.
• Always wash your hands well before you eat and if you don’t have access to washing facilities carry an alcohol hand gel.
• Avoid street food, unless it is cooked freshly in front of you.
• Don’t assume food served in a 5* hotel will be safe- staff may not have practiced strict food. Water and personal hygiene.

Prevention

Bimuno is a pre- biotic powder or pastille that can keep your tummy healthy on a trip abroad. Clinical studies have shown it to be effective in reducing your risk of TD. It works by sustaining a healthy level of good bacteria in the gut, helping to prevent bad bacteria from becoming established.

Ask your nurse about water purification products – Bimuno, Chlorine Tablets and Water Filters or purchase online in our shop.

Over the coming weeks I will be posting some common questions that we get asked at the Travel Clinic. This week’s post looks at vaccinations required for travel to Egypt.

Q: I am travelling to Egypt for a 2 week holiday, do I need any vaccinations or malaria tablets?

A: Egypt is becoming an increasingly popular destination for UK travellers. The year round climate makes it the perfect choice for those wanting to escape the UK weather for some guaranteed sunshine all year round. Many people who book a holiday to Egypt do not realise that any vaccinations are required.

The recommended vaccinations for travel to Egypt are Diphtheria, Tetanus and Polio, Hepatitis A and Typhoid. Protection against food and water-borne diseases such as Polio, Hepatitis A and Typhoid are very important as you could become infected through eating or drinking contaminated food or water. Staying in a 5* hotel does not reduce your risk, as the people preparing your food may live in areas where sanitation is poor and could pass on these diseases whilst preparing your food.  

Malaria tablets are generally not required for Egypt, as malaria is not present in the popular tourist destinations. However, there will still be lots of mosquitoes around, so you should take a good DEET based insect repellent to apply on your skin and help you avoid bites. Book an appointment with your travel clinic, ideally at least 2 weeks before departure, to get your vaccinations and to get further travel health advice on food and water hygiene and mosquito bite avoidance.

Egypt is a high risk destination for traveller’s diarrhoea. Bimuno has been shown to reduce your risk of getting diarrhoea- Available to purchase in clinic.

To book an appointment at Sussex Travel Clinic call 01273 749100 or book ONLINE