May 2011

How To: Ruin a Perfectly Good Vacation

Author: Paula Hart, RN, FNP, CTH

While there is no delicate manner in which to discuss the “D” word, most people will get the idea of the topic when such euphemisms as Delhi belly, Montezuma’s revenge, Aztec two-step and Turista are tossed around (hopefully not at the dinner table) as a vivid memory of a recent trip. This conversation may even take precedence over the more pleasant memories of their travel because it caused several days of misery, trip delay and other euphemisms like, “I was stuck on the throne.” Of course, as you have guessed, we’re referring to travelers’ diarrhea, commonly referred to as TD and the most predictable travel related illness. It’s a problem!

Because of the high risk of acquiring TD during travel, all travelers should have this discussion (how to prevent and how to treat) included as part of their pre-travel consultation.

OCCURANCE
Travelers’ diarrhea is a global problem. The world is generally categorized into three grades of risk: low, intermediate and high. Low risk countries are U.S., Canada, Australia, New Zealand and countries in Northern and Western Europe. Intermediate risk includes Eastern Europe, South Africa and some Caribbean islands. High risk areas are most of Asia, the Middle East, Africa, Mexico and Central and South America.

Statistics show a traveler from a low risk area on a two-week trip to the tropics will have a 30-70 percent chance of contracting TD. Out of that, 25 percent will have to alter plans, 15 percent will be confined to bed, 1 percent will be hospitalized and 3 percent will continue with diarrhea after returning home.

According to the CDC, most diarrheas are caused by one of three infectious agents:
• Bacteria is the most common cause of TD and accounts for approximately 80-90 percent of the diarrheal episodes in travelers. Onset is usually sudden, with abdominal cramping and urgent loose stool. Fever, nausea, vomiting and bloody diarrhea frequently occur and usually does so on the day you need to travel! Incubation period is usually 6-48 hours after coming in contact with the pathogen.

• Viral infections account for 5-8 percent of TD episodes. Symptoms are similar to bacterial pathogens, although vomiting may be more dramatic. The traveler spends most of his or her time in the bathroom due to symptoms. The virus is easily spread, and a traveling companion can often count on being the next victim. Incubation period is the same as bacterial.

• Parasites may account for 10 percent of the cases in longer-term travelers. The onset of symptoms is gradual, with feelings of abdominal bloating, flatulence, loss of appetite, nausea and loose stool or diarrhea. Usually these types of pathogens take 1-2 weeks to appear.

PREVENTION
All travelers are at risk, but again, destination will play a role. For travelers to high-risk areas, there are several precautions that may reduce risk, but will never eliminate it.

• Food and Water Precautions: This is probably the biggest deterrent. The old saying, “Either boil it, cook it, peel it or forget it” continues to ring true.

• Nonantimicrobial drugs for Prevention: Pepto-Bismol and the use of probiotics (i.e. Lactobacillus).

• Hand Sanitizing Gels: Must contain at least 60 percent alcohol.

• Prophylactic Antibiotics: Use remains controversial due to drug resistance to bacteria. May be appropriate for some travelers with health conditions.

TREATMENT
Antibiotics are the main element in the treatment of diarrhea caused by bacterial pathogens. Travelers should carry a course of appropriate treatment with them in the event of diarrhea in addition to antimotility drugs like Imodium or Lomotil for symptomatic treatment.

ORS (oral rehydration solution) may be considered, especially if traveling with small children.

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