Travellers’ Diarrhea – What Can I Eat and Drink?

I present quite often on travel medicine and often get questions regarding the prevention and treatment of common travel-related conditions. I thought I would provide some background on travellers’ diarrhea as it is the most is the most predictable travel-related illness and occurs in a large number of travellers to resort destination .1

Travellers’ Diarrhea

The incidence rates of travellers’ diarrhea (TD) range from 20% to 90% for travel to low and middle-income countries (e.g. much of the Caribbean and Mexico).2 Attack rates range from 30% to 70% of travellers, depending on the destination and season of travel.1

Key Facts About Travellers’ Diarrhea

  • Mainly caused by the ingestion of contaminated food and beverages
  • Bacterial pathogens are responsible for most infections.
    • Bacteria account for 80-90% of TD1 with enterogenic Escherichia coli (ETEC) accounting for 1/3 of the cases from the Caribbean and Latin America2
  • Viral and protozoal infections account for the remaining 10-20% of TD cases1
  • Untreated bacterial TD usually lasts 3–7 days. Viral TD generally lasts 2–3 days.1
  • The risk of TD varies based on the region of travel. The world can be divided into three different TD risk categories:1
    • Low-risk countries include the United States, Canada, Australia, New Zealand, Japan, and countries in Northern and Western Europe
    • Intermediate-risk countries include those in Eastern Europe, South Africa, and some Caribbean islands
    • High-risk areas include most of Asia, the Middle East, Africa, Mexico, and Central and South America
  • Most travellers with TD will completely recover within a few days. Approximately 3% to 17% of patients with TD will develop post-infectious irritable bowel syndrome (PI-IBS).3

Did you know?

One bout of TD does not prevent future attacks. It is common to have >1 episode of TD during a single trip.1

Clinical Presentation

  • Travellers’ diarrhea symptoms not only include the passage of loose stools but commonly include:2
    • Nausea
    • Vomiting
    • Abdominal cramps or pain
    • Fever
    • Blood in stools (dysentery)

Changes in Classification of Travellers’ Diarrhea

In the past, severity of TD was determined by the number of bowel movements in a day. The 2017 International Society of Travel Medicine (ISTM) Guidelines for the prevention and treatment of travelers’ diarrhea: a graded expert panel report, recommended a change in classification from the number of bowel movements to the level of impairment caused by the TD.4 This classification was recommended as some patients with infrequent bowel movements (1-2 stools) with severe cramps and fever may be significantly more distressed than more frequent bowel movements without cramps or pain.4

ISTM Classification of Travellers’ Diarrhea4
Mild (acute) Diarrhea that is tolerable, is not distressing, and does not interfere with planned activities
Moderate (acute) Diarrhea that is distressing or interferes with planned activities
Severe Diarrhea that is incapacitating or completely prevents planned activities; all dysentery (passage of grossly bloody stools) is considered severe

NOTE: if there is significant blood in the stools, the traveller should seek medical care

Food and Beverage Recommendations for Travellers

The Travel Medicine: Expert Consult is a great reference for all healthcare professionals interested in travel medicine. In the travellers’ diarrhea chapter they have some excellent food and beverage recommendations.

Food, Beverage and Setting Recommendations for Travellers5
Category Safest choice Probably safe Unsafe
Food Hot, thoroughly grilled, boiled

Processed and packaged

Cooked vegetables and peeled fruits

Dry items

Hyperosmolar items (jams, syrup)

Washed vegetables and fruits (if washed in potable water)

Salads

Sauces and salsas

Uncooked seafood

Raw or poorly cooked meats

Unpeeled fruits

Fruit without a thick peel like berries

Unpasteurized dairy products

Cold desserts

Beverages Carbonated soft drinks

Carbonated water

Boiled water

Purified water (iodine or chlorine

Fresh citrus juices

Bottled water

Packaged ice (machine made)

Tap water

Chipped ice

Unpasteurized milk

Setting Recommended restaurants Local home Street vendors

Prevention and Treatment with Pharmacotherapy

I will cover the role of antibiotics, Dukoral®, bismuth subsalicylate, loperamide and probiotics in the prevention and prevention of TD in a future post.

References

  1. Connor B. Travelers’ Diarrhea – Chapter 2 – 2018 Yellow Book | Travelers’ Health | CDC. https://wwwnc.cdc.gov/travel/yellowbook/2018/the-pre-travel-consultation/travelers-diarrhea. Accessed June 26, 2017.
  2. Public Health Agency of Canada Government of Canada. Statement on Travellers Diarrhea. http://www.phac-aspc.gc.ca/tmp-pmv/catmat-ccmtmv/diarrhea-diarrhee-eng.php. Published April 31, 2015. Accessed December 10, 2017.
  3. Steffen R, Hill DR, DuPont HL. Traveler’s Diarrhea: A Clinical Review. JAMA. 2015;313(1):71. doi:10.1001/jama.2014.17006.
  4. Riddle MS, Connor BA, Beeching NJ, et al. Guidelines for the prevention and treatment of travelers’ diarrhea: a graded expert panel report. J Travel Med. 2017;24(suppl_1):S63-S80. doi:10.1093/jtm/tax026.
  5. Ericsson CD. Chapter 17 – Prevention of Travelers’ Diarrhea. In: Keystone JS, Kozarsky PE, Freedman DO, Nothdurft HD, Connor BA, eds. Travel Medicine (Second Edition). Edinburgh: Mosby; 2008:191-196.

 

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