Travellers' Diarrhoea: Prevention & Treatment

Travellers' diarrhoea is defined as passing three or more loose or watery stools in a 24-hour period, often with stomach cramps, nausea, vomiting, bloating, an urgent need to go, or sometimes fever. Symptoms typically begin during a trip or within about ten days of returning home. It is the most frequent health problem reported by international travellers and, while unpleasant, is usually self-limiting and resolves on its own. The cause is almost always something eaten or drunk that has been contaminated by faecal material. Bacteria are responsible for the majority of cases, with enterotoxigenic E. coli, Campylobacter, Shigella and Salmonella among the most common culprits. Viruses such as norovirus and parasites such as Giardia and Cryptosporidium also occur, and in many cases no specific organism is ever identified.

The chance of developing travellers' diarrhoea depends heavily on your destination and how you travel. Western Europe, North America, Australia, New Zealand and Japan are generally low-risk. Southern Europe, the Caribbean, South Africa and parts of the Pacific carry an intermediate risk. The highest risk is in most of Asia, the Middle East, Africa and Latin America, where more than one in five travellers may be affected. Backpacking, adventure travel, long stays and visiting friends and relatives in your country of origin all tend to increase exposure, as does eating from street vendors or in places with limited refrigeration. Knowing your risk before you go allows you to pack the right supplies and plan ahead, which is exactly what we cover during a pre-travel consultation.

Careful food and water hygiene is the cornerstone of prevention, although no precautions offer complete protection, so it is wise to be prepared to manage symptoms too. As a general principle, choose food that has been freshly and thoroughly cooked and is served piping hot, and stick to drinks from sealed, factory-produced bottles or cans, or hot drinks made with boiled water such as tea and coffee. Where the safety of tap water is uncertain, avoid ice and treat water by boiling it to a rolling boil, using a fine water filter, or using chemical disinfection (chlorine dioxide is more effective than chlorine against parasites such as Giardia and Cryptosporidium). Good hand hygiene makes a real difference, so wash your hands with soap and clean water after using the toilet and before eating, and carry an alcohol-based hand gel for when facilities are limited.

The single most important treatment is replacing the fluid and salts lost through diarrhoea and vomiting. For mild illness in otherwise healthy adults, this can be as simple as drinking plenty of safe fluids and continuing to eat as normal once you feel able. For more significant illness, and especially for young children, older travellers and anyone at risk of dehydration, oral rehydration salts (ORS) such as Dioralyte are recommended; these come as sachets dissolved in a measured volume of clean, safe water and provide the right balance of salts and sugar. If no commercial product is available, a reasonable emergency substitute is six level teaspoons of sugar and half a teaspoon of salt dissolved in one litre of safe water. Drink steadily in small, frequent sips if you feel nauseous, and aim to keep your urine pale. We recommend most travellers to higher-risk areas pack ORS sachets, and we can advise on suitable products before you travel.

Loperamide can be useful for adults aged 12 and over when frequent diarrhoea would be particularly inconvenient, such as during a long journey, by reducing the number of trips to the toilet; it is available over the counter. Loperamide and bismuth subsalicylate should be avoided if there is a high fever, blood or mucus in the stool, severe abdominal pain, or in people with inflammatory bowel disease. Most travellers' diarrhoea does not need antibiotics, as it settles by itself, and taking antibiotics routinely throughout a trip to prevent it is not recommended for most people. For selected travellers at higher risk, or those heading somewhere remote where prompt medical care is unavailable, a course of standby antibiotics may be appropriate to carry; azithromycin is generally preferred, while older fluoroquinolone antibiotics are no longer recommended because of rising resistance and safety concerns. Any standby treatment should be discussed individually so you understand exactly when and how to use it.

Most episodes improve within three to five days. You should seek medical advice if diarrhoea lasts longer than about three days, or sooner if you develop a fever of 38C or above, blood or mucus in the stool, persistent vomiting that prevents you keeping fluids down, severe or worsening abdominal pain, confusion, jaundice or a new rash. Signs of dehydration, such as dark and strong-smelling urine, passing much less urine than usual, dizziness, or marked tiredness, also warrant prompt attention. Some groups should seek help early rather than waiting: babies and young children, older adults, pregnant women, people with weakened immune systems, those with inflammatory bowel disease, and anyone who takes medicines that reduce stomach acid. If symptoms continue after you get home, mention your recent travel to your healthcare professional, as this can change which tests and treatments are appropriate.

No vaccine prevents travellers' diarrhoea outright, but vaccination still plays an important part in protecting your gut and overall health when travelling. The oral cholera vaccine Dukoral is used mainly against cholera but may also offer limited, short-term cross-protection against diarrhoea caused by some strains of E. coli, and may be considered for certain travellers. Typhoid and hepatitis A are both spread through contaminated food and water in many of the same destinations, so vaccination against these is often recommended alongside good hygiene. At Crewe Travel Clinic we provide pre-travel risk assessments and vaccinations for travellers across Crewe, Nantwich, Sandbach, Alsager and Stoke-on-Trent and the wider Cheshire area, tailoring advice on hygiene, rehydration and any standby medicines to your specific itinerary.