Travellers' diarrhoea

Page last reviewed: 13/07/2011

Travellers' diarrhoea is usually described as passing watery stools three or more times a day, either during or shortly after travelling. It usually lasts for around three to five days.

Travellers' diarrhoea is a common but usually mild illness that is spread through poor hygiene. Most cases of travellers' diarrhoea are caused by bacteria that are passed from faeces (stools) to the mouth. This usually happens when someone does not wash their hands after going to the toilet and then handles food that is eaten by travellers.

How common is travellers' diarrhoea?

You are at risk of developing travellers' diarrhoea if you travel anywhere, although the illness is most common in warm countries where standards of sanitation and hygiene are poor. These are usually countries in the developing world, such as parts of Asia and Africa.

  • Around 30-50% of people travelling from a developed country to a developing country will experience an incident of travellers' diarrhoea.
  • Around 8-15% of people visiting a medium-risk country, such as Russia, will experience travellers' diarrhoea.
  • Less than 4% of people visiting a low-risk country, such as the USA or western Europe, will experience travellers' diarrhoea.

Outlook

Travellers' diarrhoea is usually mild, but it is unpleasant and can ruin a holiday. It often clears up without treatment, but it is essential to drink plenty of fluid. In more severe cases, a short course of antibiotics may be prescribed.  

Travellers' diarrhoea may be more serious for people with pre-existing health conditions, such as an inflammatory bowel disease like Crohn's disease. The very young or very elderly may be more at risk of becoming dehydrated (when the normal water content of the body is reduced).

 

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Page last reviewed: 13/07/2011

Travellers' diarrhoea is usually described as passing three or more loose stools in one day, either while travelling or shortly afterwards. Other symptoms include:

  • abdominal pain or cramps,
  • nausea (feeling sick), or
  • vomiting.

The symptoms of travellers' diarrhoea usually start within two to three days of arriving at your destination. Over 90% of cases occur within the first two weeks of a holiday or trip abroad. The symptoms usually get better without medical treatment within three to five days.

In around 5-10% of travellers, the diarrhoea can last for two weeks or longer. For 1-3% of travellers, the diarrhoea can last longer than a month.

At-risk groups

Some people may be more at risk than others of developing complications from diarrhoea, such as  dehydration (when the normal water content of your body is reduced). Those most at risk include:

  • young children and babies,
  • elderly or frail people,
  • people with immune deficiencies, such as HIV and AIDS,
  • people with severe heart disease or kidney disease,
  • people with inflammatory bowel disease, such as Crohn's disease and
  • people with reduced acidity in their stomach, such as those taking proton pump inhibitors (PPIs), a type of medication to treat peptic ulcers and hernias by reducing the amount of acid in the stomach.

Symptoms of travellers' diarrhoea in these people may be more serious and they should be monitored with extra care.

When to seek medical attention

If someone (particularly a child) is dehydrated, seek immediate medical attention. Signs of dehydration include:

  • irritability,
  • restlessness,
  • sunken eyes,
  • dry skin, and
  • increased thirst.

Other signs that require medical attention include:

  • a high temperature (fever) of 38°C (100.4°F) or more,
  • blood in the stools (faeces),
  • finding it hard to keep adequate fluid down because of passing frequent watery stools or repeated vomiting,
  • diarrhoea that lasts longer than three to four days, and
  • diarrhoea that continues after you have taken antibiotics for three days.

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Page last reviewed: 13/07/2011

Travellers' diarrhoea can be caused by:

  • a bacterial infection (responsible for 80-85% of cases),
  • a virus (10-15% of cases), or 
  • a parasite (2-10% of cases).

Possible causes include:

  • Escherichia coli (E. coli): bacteria that are mostly found in undercooked beef and unpasteurised milk.
  • Campylobacter: bacteria that are found in raw meat and poultry, unpasteurised milk and unclean water.
  • Salmonella: bacteria that are found in raw meat and poultry, and dairy products.
  • Shigella: bacteria that are spread through poor hygiene and found in undercooked or raw food.
  • Norovirus or rotovirus: viruses that are passed between humans due to poor hygiene.
  • Giardia intestinalis: a parasite that is found in contaminated water and spread through poor hygiene.
  • Cryptosporidium: a parasite that is found in contaminated food and water.
  • Cyclospora: a parasite that is also found in contaminated food and water.

Poor hygiene

Most cases of travellers' diarrhoea are spread through the faecal/oral route. This means that they are found in faeces (stools) and are then transferred to your mouth.

This can happen through poor hygiene. For example, if someone does not wash their hands after going to the toilet, any bacteria on their hands will be transferred to whatever they touch. This could be a glass, a kitchen utensil, food, water or ice.

If you touch a contaminated object and touch your face or if you eat contaminated food, you may swallow some of the bacteria. This will then cause the diarrhoea.   

Changing your diet while you are away, for example by eating more spicy foods, can make your bowel movements looser. Drinking excessive amounts of alcohol can also contribute to diarrhoea. 

Risk areas

Your risk of diarrhoea is higher in some countries than others, although it is possible to develop diarrhoea in any area that has low standards of hygiene. The risk is also greater in areas with poor sewage facilities or no access to safe drinking water.

  • High-risk areas: most of Asia, the Middle East, Africa, Mexico and Central and South America. 
  • Medium-risk areas: eastern Europe, Russia, southern Africa and some Caribbean islands.
  • Low-risk areas: northern and western Europe, Canada, Australia, New Zealand, Japan and the USA.

The risk of developing travellers' diarrhoea is usually higher during the summer months, so the time of year that you travel can also affect your chances of getting it.

Risk activities

Some types of holiday and activities increase your chances of having an episode of travellers' diarrhoea. For example, trekking or camping may increase your risk because you may not have access to clean water.

Being a passenger on a cruise ship also increases your risk. Poor hygiene could affect a large number of people, and being in close proximity to many others makes it easier for a virus or bacteria to spread.

What you eat and drink will also affect your risk of developing traveller's diarrhoea. See Preventing travellers' diarrhoea for more information.

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Page last reviewed: 13/07/2011

Travellers' diarrhoea is easily diagnosed from the symptoms. In most cases, it will not require medical attention. However, if you visit your GP or another healthcare professional while you are abroad, they are likely to ask you about some of the following:

  • how long you have had diarrhoea,
  • how often you are going to the toilet,
  • what the consistency of your stools is, for example how watery they are,
  • if there is any blood in your stools,
  • if you have any other symptoms, and
  • where you have been travelling.

Stool sample

If you have other symptoms, such as blood in your stools or a fever, your GP or the healthcare professional treating you may want to run further tests. They may take a stool sample from you and test it in a laboratory to find out the cause of your diarrhoea.

If particular bacteria are responsible for your diarrhoea, the test results may help your GP work out which antibiotic medicine will be most effective at killing the bacteria. 

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Page last reviewed: 13/07/2011

The symptoms of travellers' diarrhoea should clear up without treatment in three to five days. The most important thing that you can do is to make sure that you are drinking enough fluid. See Symptoms of travellers' diarrhoea for advice about when to seek medical attention.

Drink plenty of fluid

Dehydration (when the normal water content of your body is reduced) can be dangerous, particularly in young children, older people or those with pre-existing medical conditions. If you have diarrhoea, make sure that you drink plenty of sterile (clean) water or diluted fruit juice.

Drink two glasses of fluid each time you have a bowel movement and more if you feel thirsty. Avoid drinking alcohol and caffeinated drinks because they will make you more dehydrated. Take small, frequent sips and try to continue drinking even if you are vomiting as well.

Oral rehydration solutions

Oral rehydration solutions, such as Dioralyte, can be used by anyone who has diarrhoea and is at risk of dehydration. They are available in pharmacies and should be mixed with sterile water.

Oral rehydration solutions are not a treatment for diarrhoea. They are used to replace the salt, glucose and other important minerals that you lose through diarrhoea.

Before using oral rehydration solutions, read the manufacturer's instructions, particularly if you are giving them to young children.

Eat as soon as you can

Once you feel able to, eat foods that are high in carbohydrates, such as bread, pasta, rice or potatoes. Eat small, light meals and avoid fatty, spicy or heavy foods.

When you feel like it, start to eat other foods. Salty foods, such as soup, can help replace the salt that has been lost from your system.

Not eating, if you feel too sick to eat, should not do you any harm, but continue to drink fluids and eat as soon as you are able to.

Medication

Some medications are available to help relieve diarrhoea, but avoid taking them if you can. Loperamide (Imodium) may be useful if the diarrhoea is particularly inconvenient, for example if you have a long journey to make.

These medications stop you from going to the toilet, which means that any bacteria or poisons are trapped within your body. They can also cause constipation (difficulty passing stools) and should not be used for more than one or two days.

Medications to help relieve diarrhoea are available over-the-counter (OTC) in pharmacies. Always read the manufacturer's instructions before using them.

Children who are under 12 years of age should not use loperamide. Do not use it if you have an active inflammatory bowel disease, such as ulcerative colitis. It is not suitable if you have a fever or blood in your stools.

Antibiotics

In some cases, antibiotics can be used to treat travellers' diarrhoea. However, they are not always suitable. For example, antibiotics do not work against viruses, so diarrhoea that is caused by a virus cannot be treated with antibiotics.

Most cases of travellers' diarrhoea are caused by bacteria and antibiotics can be effective in these cases. Evidence suggests that a short course of antibiotics can reduce the severity of the diarrhoea, as well as its duration.

In Ireland, antibiotics can only be prescribed by your GP. In some cases, you may be prescribed antibiotics to take with you when you go travelling (see Preventing travellers' diarrhoea). However, most people will need to seek medial attention abroad if they think that antibiotics may be necessary.

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Medical treatment abroad

Before leaving Ireland, make sure that you know how to access medical treatment in the country (or countries) that you are visiting. For further advice, check the wesite of the Department of Foreign Affairs www.dfa.ie

Alternatively, talk to your travel agent, if you have one. You can also get information from the tourist office, embassy or high commission of the country that you are visiting while you are there.

When getting medical treatment abroad, you may find the advice listed below useful.

  • Make sure that you have got all the documents you need: your passport, travel insurance details and European Health Insurance Card (EHIC) if travelling in Europe, proof of Irish residence (for example, your driving licence) and vaccination certificates.
  • Contact your travel company representative, if you have one.
  • Give the healthcare professional treating you the name of any medication that you are taking (give them the generic name as well as the brand name).
  • Tell them if you have been to any other countries on this trip.
  • Keep the names and addresses of a few friends and relatives with your passport so that they can be contacted if necessary.
  • Contact Irish Embassy or Consular officials if you need to get back to Ireland quickly. They may be able to arrange this for you, but you will have to pay.
  • Keep all receipts, proof of purchase, price tags and labels of treatment or medication that you pay for and plan to claim on your insurance, or get a refund for.

Page last reviewed: 13/07/2011

Dehydration

The main complication of travellers' diarrhoea is dehydration (when the normal water content of your body is reduced). Symptoms of dehydration include:

  • increased thirst,
  • irritability,
  • restlessness,
  • sunken eyes,
  • dry skin, including the lips,
  • dark, concentrated urine, and
  • dizziness or light-headedness.

Get medical attention immediately if you or someone else is dehydrated.

Other medication

If you are taking other medication, diarrhoea may make it less effective. This is because the medication will be passed from your body before it is absorbed, and so will not have any effect.

This can affect any medication. Take particular care if you are taking the oral contraceptive pill or the anticoagulant (blood-thinning medicine) warfarin.

If you take the oral contraceptive pill and have diarrhoea, it may not provide effective contraception because the pill will not have time to work before being passed in your stool (faeces). This could lead to an unplanned pregnancy.

If you take warfarin and have diarrhoea, you may be at risk of blood clots forming inside your blood vessels. This can lead to serious complications, such as deep vein thrombosis (when a blood clot forms in one of the deep veins in your body) or a stroke (when a blood clot disrupts the blood supply to your brain).

Long-term diarrhoea

In some cases, travellers' diarrhoea may last for over a month while you are travelling abroad. If you are losing a lot of weight, seek medical attention. It may be worth changing your diet to see if this helps reduce your symptoms. You could try cutting out:

  • milk and dairy products,
  • fatty, oily and spicy foods, or
  • alcohol.

Long-term diarrhoea often gets better without treatment after you return home because you will no longer be exposed to the same bacteria and viruses that caused it.

In rare cases, long-term diarrhoea in travellers is due to another cause. The diarrhoea could be the start of another health problem that has nothing to do with your travels.

For example, diarrhoea can be a symptom of irritable bowel syndrome (IBS) or inflamatory bowel disease (IBD), which are long-term disorders that affects the digestive system. IBS and IBD will require a full medical assessment by your GP.

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Page last reviewed: 13/07/2011

There is no effective vaccine for travellers' diarrhoea. However, taking some precautions before you leave and while you are away could reduce your chances of getting it.

Before you leave

If you are planning a trip abroad, check the health advice for the country you are visiting. You can check with your GP or with a travel health clinic.

Make sure you that have adequate travel insurance for the countries that you are visiting. If you are travelling in Europe, you will need a European Health Insurance Card (EHIC), as well as travel insurance. An EHIC is free and could save you a lot of money and hassle if you need medical help while you are away.

If you have a long-term health condition, such as diabetes, speak to your GP before you leave. They may be able to offer you additional advice about avoiding diarrhoea or may prescribe preventative antibiotics.

While you are away

Follow the advice below to prevent an episode of travellers' diarrhoea while you are away.

Water and ice precautions

  • Water should only be drunk if you are sure that it is sterile (clean).
  • If the water is not sterile, boil it for several minutes or use chemical disinfection or a reliable filter. This also applies to water that is used for making ice cubes, washing fruit or salad and for cleaning your teeth.
  • Avoid ice because it could be made with unclean water or it may have been touched by someone with dirty hands.
  • If you want a cold drink, pack ice around the outside of the glass or bottle.
  • Avoid drinks that are made with crushed ice, such as lassies (a drink that is common in hot countries and is made with crushed ice and yoghurt) as the ice may have been contaminated. 
  • Bottled water is usually safe, but make sure that the seal is not broken.

Food and drink precautions

  • Hot tea and coffee and beer and wine are usually safe. 
  • If milk is pasteurised, it is safe. If you are not sure whether it is pasteurised, boil it first.
  • Yoghurt is usually safe.
  • Take care when buying cheese or ice-cream. These are often made from unpasteurised milk so they may not be safe. Buy them from large, well-established companies as they are likely to be safer.
  • Food should be completely cooked and served piping hot. Once food reaches a temperature of over 60°C (140°F), any bacteria inside it will usually be killed.
  • Avoid eating leftovers or food that has been left out at room temperature.   
  • Fried rice is high risk because it is often made with 'bits' that are lying around in the kitchen, and flash frying does not sterilise everything.
  • Food from markets and street vendors and some restaurants should be avoided unless the hot food has been kept hot and the cold food has been kept refrigerated or packed in ice.
  • Fish and shellfish can be hazardous at certain times of year, even if they are well cooked. Take local advice about seafood but, if in doubt it, avoid it.
  • Vegetables should only be eaten when they have been thoroughly cooked.
  • Avoid salads, unless you make them yourself, and wash everything in sterile water.
  • Fruit, including tomatoes, should be peeled. Avoid smoothies because the fruit may have been contaminated when the smoothie was made.
  • If you are washing fruit to eat, the water needs to be sterile. Smooth-skinned fruit is easier to wash. Strawberries are very hard to clean. Avoid fruit that has split skin.  

Personal hygiene

  • Wash your hands thoroughly before eating or handling food and after using the toilet.
  • Dry your hands in the air or on a clean towel after washing them.
  • Make sure that any cutlery, plates, cups or glasses you use are sterile.  
  • On expeditions or while camping, do not allow anyone to do the cooking if they are unwell. 
  • Short fingernails are easier to keep clean than long ones.
  • Take a plastic bottle of soapy water and antiseptic wipes or a hand sanitiser when you are away from running water. 

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Content provided by NHS Choices www.nhs.uk and adapted for Ireland by the Health A-Z.

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