TRAVELER’S DIARRHEA – Prevention and Treatment in the Mountains
Traveler’s diarrhea is one of the most important medical problems for trekkers and expedition mountaineering. There is no question that the loss of body water and electrolytes impairs the physical and mental capacity significantly and dehydration increases the risk of Acute Mountain
Sickness (AMS), thrombosis/thromboembolism, frostbite, and other altitude- or cold-related health risks. Therefore it is a “must” for any mountaineer to avoid traveler’s diarrhea as much as possible and to treat symptoms consequently. In contrast to the “normal” travelers diarrhea experienced at sea level, the consequences of significant diarrhea can cause an additional increased risk in a high altitude environment, therefore treatment should be started earlier and more “aggressively” than would be the case for “normal” traveler’s visiting resorts or national parks at low altitude.
Organisms that induce traveler’s diarrhea
There are many species that can induce diarrhea and these species fall into at least four different categories: viruses, bacteria, protozoa, and helminths. Therefore there is no “one-and-only prophylaxis” for traveler’s diarrhea. While there are vaccinations against some of them (e.g. hepatitis A, polio, salmonella typhi), most of the different techniques of personal and group hygiene present the only chance to minimize the risk. But even in the best setting >75% of the visitors make significant mistakes in (food) hygiene.
Risk determining factors.
Several factors are important for the individual risk: age <30y., the region visited (e.g. traveler’s diarrhea in the Alps ca. 4%, in Nepal up to 80%), rainy season, duration of sojourn, type of traveling (“adventure travel”, mountaineering), reduced gastric acid (H2-Blockers, acid absorbing drugs, etc.), reduced immunocompetence, diabetes or previous stay in a developing country for >6 months. But it should be mentioned here that the individual risk for traveler’s diarrhea is highly variable. Some observations indicate that a permanent stay in a developing country for >6 months decreases the chance of getting diarrhea, possibly because the bowel gets “conditioned”.
Persons who have one or more of these risk factors should get individual advice from a physician experienced in travel medicine.
Special attention and education should be given to any person – traveler or local staff – who handles food. Hygiene of hands (washing before food handling!), cleaning surfaces or equipment (dishes, spoons, knives…) which get in contact with food is essential. It is a good idea to separate any meat products away from vegetables, fruits, or eggs – Keep separate any food/s that may be contaminated with pathologic microorganisms.
Risk checklist for travelers
1. Food. Safe foods include hot, well done (barbequed, cooked, or roasted), dried products, salad industrial processed and packed, hyperosmolar food (e.g. jam, syrup), sauces, and “salsas”, cooked vegetables and fruits which need to be peeled, washed vegetables or fruits.
Unsafe or less safe foods include uncooked seafood or undercooked or cold meat (e.g. salami), unpeeled fruits, non-pasteurized milk products, cold desserts.
2. Beverages. Safe beverages include carbonated soft drinks, fresh citrus juice, water from springs or wells (not disinfected), industrial-produced carbonated mineral water. Possibly unsafe is bottled water (locally produced). Boiled water, coffee, or tea, ice, industrial processed and packed, Unsafe are ice-cubes or crushed ice for drinks, disinfected water, non-pasteurized or unsterilized milk
3. Setting. Safe are well-known restaurants of international standard. Possibly unsafe are private homes, and restaurants recommended as “high class” in international guidebooks. The safety of street vendors, public markets, restaurants recommended in guidebooks as “cheap” is uncertain but high-volume businesses with many locals using them are usually OK.
Prevention of traveler’s diarrhea
Maintain strict hygiene with respect to water management and managing any
human waste. Maintain strict personal hygiene especially washing hands before handling any kind of food, water, or beverage. Drink only beverages from safe water sources (cooked or treated for disinfection) or safe industrial beverages. Dental hygiene is also important!
No non-cooked milk or milk products. Meat must be well done. No salad. Peeled fruits only, peeled by yourself, otherwise, the problem may not be solved. Be careful: Some fruits are dangerous, even if they are peeled! Melons, for example, are sold by weight. If you inject water at the stipe or at the dried rest of the flower, the fruit will be heavier and therefore more expensive, but if the injected water was unsafe, the water and sugar
containing fruit is an optimal incubator for bacteria, especially if the fruit is stored in the sun!
No cold sauces or products made from fresh eggs without cooking.
Clean dishes, cutlery, pans, and pots always with safe water. At least the final cleaning. If safe water is a problem, unsafe water can be used for basic cleaning.
The member who is ill with diarrhea may not be able to climb. Do not ask him/her to prepare food or work in the kitchen so that food is ready on return for those who continue to climb!
Note! The slogan “peel it, boil it, cook it, or forget it” does not guarantee safe food! Because some germs produce toxins, the quality of the food which will be cooked is very important, independent of the kind of processing. Or, as an African physician tells the villagers: “If you cook shit, you’ll eat cooked shit!”. Ensure the quality of any food eaten (processed or not) is of good quality. Or remember a five-star hotel can have a zero-star kitchen if there are no handwashing facilities for the staff. Ensure that any person who is involved in the handling or preparation of food regularly washes his/her hands before touching food or kitchen equipment and before eating!
There will be many situations where safe water is sparse. Here hygienic towels with disinfectant may be used for hands, cutlers, and dishes (after a rough cleaning with unsafe water).
Symptoms of traveler’s diarrhea
Onset: in most cases occurs on the 3rd day after arrival (incubation period 6
hrs to some days).
Duration of symptoms (untreated): 3 -4 days, 10% >1 week, 1% chronic diarrhea (>3 weeks).
Symptoms: Gastroenteritis / enterocolitis (most cases). Watery, in some cases mucous diarrhea, diffuse abdominal pain, vomiting. body temperature up to 38.5°C. Note that burning with disgusting taste, stinking flatulence, abdominal pain, bloating and nausea may indicate Giardia infection (relatively common especially in India and Nepal). Therapeutic options: metronidazole 750-1000mg/d for 5 days (3x 250mg) or tinidazole 2g single dose for adults. For children <6y. 15-30 mg/kg/day in 2-3 dosages for 7 days). There is no single drug available which is able to treat all patients with Giardia effectively. If symptoms persist try another one. Dysentery (about 10% of patients). purulent or ensanguined stool, tenesmus (marked urgency to have a bowel movement, fever up to >40°C
Therapy of traveler’s diarrhea
Most cases are self-limiting.
Rehydration: Start early to limit the consequences. About ¼ l per defecation (= 2 glasses) for adults (children: 1 glass). Except in cases of minimal symptoms use electrolytes for rehydration (Oral Rehydration Solution (ORS), Note: some commercially available products are for adults only! If used for children take care of adequate dosage.
Moderate symptoms: rehydration plus Loperamide – 1st dosage 4 mg (2 capsules), then 1 capsule for every liquid defecation (not more than 12 mg/day or longer than for 48 hours), for patients >8 years only (special dosage for 2-8 years)
Severe symptoms: rehydration plus Loperamide (see above) plus antibiotic (e.g. ofloxacin, 400 mg/d, or ciprofloxacin, 500 mg/d)
Campylobacter is a common cause of traveler’s diarrhea in Nepal. Here (and in other regions of south-east Asia) – Azithromycin is recommended (500 mg 1x/d for 3 days). If Azithromycin has no sufficient effect, consider nonbacterial germs (use metronidazole as mentioned above) or switch to Levofloxacin (500 mg/day for 5 days).
Contact a physician in case of the following situations fever >39°C, vomiting, which doesn’t stop for >2 d, dysentery (see above), symptoms >5 days, pregnancy, small child (<6-8 y, or so), elderly person (>65 y, or so)
No further ascent until the symptoms have been cured and the patient is
completely rehydrated!
WHO recommendation Home-made mixture: Ingredients to prepare 1 liter of oral rehydration solution (ORS) using sterilized water: Table salt 3.5 gr. 1 teaspoon of table salt, Sodium bicarbonate 2.5 gr. ½ teaspoon of baking powder, Potassium chloride 1.5 gr. Eat 1 banana, glucose 20.0 gr. 4 teaspoons, or normal sugar 40.0 gr. 8 teaspoons. Dosage (after each diarrheic defecation): ½ teapot for preschool children (2-5 yrs.), children (6-12yrs.) 1 teapot, adolescents and adults 2 teapots.
