THE INTERNATIONAL MOUNTAINEERING AND CLIMBING FEDERATION
UNION INTERNATIONALE DES ASSOCIATIONS D’ALPINISME
Office: Monbijoustrasse 61 ! Postfach
CH-3000 Berne 23 ! SWITZERLAND
Tel.: +41 (0)31 3701828 ! Fax: +41 (0)31 3701838
e-mail: office@uiaa.ch
V 2-1 Page: 1 / 7
CONSENSUS STATEMENT
OF THE
UIAA MEDICAL COMMISSION
VOL: 5
Traveller’s Diarrhoea – Prevention and
Treatment in the Mountains
Intended for Doctors, Interested Non-Medical Persons
and Trekking or Expedition Operators
Th. Küpper, V. Schoeffl, J. Milledge
2008
UIAA MedCom Consensus Statement No.5: Traveller’s Diarrhoea in the Mountains
Page: 2 / 7
Introduction
Traveller’s diarrhoea is one of the most important medical problems for trekkers and
expedition mountaineering. Although the detail of the data are still in discussion 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 traveller’s
diarrhoea as much as possible and to treat symptoms consequently. In contrast to
the “normal” travellers diarrhoea experienced at sea level, the consequences of
significant diarrhoea 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” traveller’s visiting resorts or national parks at low
altitude.
For water hygiene / disinfection see UIAA MedCom Consensus Paper No. 6!
Germs to induce traveller’s diarrhoea
There are many species which can induce diarrhoea and these species fall into at
least four different categories: viruses, bacteria, protozoa, and helminths. Therefore
there is no “one-and-only prophylaxis” for traveller’s diarrhoea. While there are
vaccinations against some of them (e.g. hepatitis A, polio, salmonella typhi), for most
of them 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.
traveller’s diarrhoea in the Alps ca. 4%, in Nepal up to 80%), rainy season, duration
of sojourn, type of travelling (“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 traveller’s diarrhoea is highly variable. Some
observations indicate, that a permanent stay in a developing country for >6 months
decreases the chance of getting diarrhoea, possibly because the bowel gets
“conditioned”.
Persons who have one or more of these risk factors should get individual advice by a
physician experienced in travel medicine.
Special attention and education should be given to any person – traveller 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 which may be contaminated with
pathologic microorganisms.
UIAA MedCom Consensus Statement No.5: Traveller’s Diarrhoea in the Mountains
Page: 3 / 7
Risk checklist for travellers
1. Food
Safe Relatively safe Unsafe or less Safe
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
Uncooked seafood or
undercooked or cold meat
(e.g. salami), unpeeled
fruits, non-pasteurized
milk products, cold
desserts
2. Beverages
Safe Relatively safe Unsafe or less safe
Carbonated soft drinks Fresh citrus juice Water from springs or
wells (not disinfected)
Industrial produced
carbonated mineral water
Bottled water (locally
produced)
Tap water
Boiled water, coffee, or
tea
Ice, industrial processed
and packed
Ice-cubes or crushed ice
for drinks
Disinfected water (see
UIAA MedCom
Consensus Paper No. 6)
Non-pasteurized or
unsterilized milk
3. Setting
Safe Relatively safe Unsafe or less safe
Well-known restaurants of
international standard
Private homes,
restaurants recommended
as “high class” in
international guidebooks
Street vendors, public
markets, restaurants
recommended in
guidebooks as “cheap”
UIAA MedCom Consensus Statement No.5: Traveller’s Diarrhoea in the Mountains
Page: 4 / 7
Prevention of traveller’s diarrhoea
! Maintain strict hygiene with respect to water management and managing any
human waste (see also UIAA MedCom Recommendation No. 6)
! Maintain strict personal hygiene
o 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
o – dental hygiene is also important!
! No non-cooked milk or milk products
! Meat must be well done
! No salad
! Peeled fruits only
o Peeled by yourself, otherwise the problem may not be solved
o 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
o At least the final cleaning. If safe water is a problem, unsafe water can
be used for basic cleaning.
o The member who is ill with diarrhoea 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 from the kind of processing. Or, as an African
physician tells the villagers: “If you cook shit, you’ll eat cooked shit!” (citation from a
course for public health). Ensure the quality of any food eaten (processed or not)
is of a good quality. Or remember a five star hotel can have a zero start kitchen if
there are no hand washing 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).
UIAA MedCom Consensus Statement No.5: Traveller’s Diarrhoea in the Mountains
Page: 5 / 7
Symptoms of traveller’s diarrhoea
! 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
o 10% >1 week
o 1% chronic diarrhoea (>3 weeks)
! Course of the disease
o Gastroenteritis / enterocolitis (most cases)
” Watery, in some cases mucous diarrhoea
” Diffuse abdominal pain
” Vomiting
” Body temperature up to 38.5°C
” Note: Burbing with disgusting taste, stinking flatulence,
abdominal pain, bloating and nausea may indicate Giardia
infection (relatively common especially in India and Nepal).
Therapeutic options [1]: metronidazole 750-1000mg/d for 5 days
(3x 250mg) or tinnidazole 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.
o Dysenteria (about 10% of patients)
” Purulent or ensanguined stool
” Tenesmen
” Fever up to >40°C
o Most cases are self-limiting!
Therapy of traveller’s diarrhoea
! Rehydration!
o Start early to limit the consequences!
o About ¼ l per defecation (= 2 glasses) for adults (children: 1 glass)
o Except in case of minimal symptoms use electrolytes for rehydration
(Oral Rehydration Solution (ORS), see table 1). Note: some
commercially available products are for adults only! If used for children
take care for adequate dosage.
! Moderate symptoms
o 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)
UIAA MedCom Consensus Statement No.5: Traveller’s Diarrhoea in the Mountains
Page: 6 / 7
! Severe symptoms
o Rehydration plus
” Loperamide (see above) plus chinolon (e.g. ofloxacine, 400
mg/d, or ciprofloxacine, 500 mg/d)
” Note: Camphylobacter is a common cause of traveller’s
diarrhoea in Nepal. Here (and in other regions of south-east Asia
Azithromycin is recommended (500 mg 1x/d for 3 days). If
Azithromycin should have 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!
Ingredient WHO recommendation Home made mixture
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
Table 1: Ingredients to prepare 1 litre of oral rehydration solution (ORS) using
sterilised water. Dosage (after each diarrhoeic defecation): ½ teapot for preschool
children (2-5 yrs.), childs (6-12yrs.) 1 teapot, adolescents and adults 2 teapots
UIAA MedCom Consensus Statement No.5: Traveller’s Diarrhoea in the Mountains
Page: 7 / 7
References
1. Adachi, J.A., H.D. Backer, and H.L. DuPont, Infectious diarrhea from wilderness and foreign
travel, in Wilderness Medicine, P.S. Auerbach, Editor. 2007, Mosby Inc.: St. Louis (Missouri,
USA). p. 1418-1444.
Members of UIAA MedCom
C. Angelini (Italy), B. Basnyat (Nepal), J. Bogg (Sweden), A.R. Chioconi (Argentina),
S. Ferrandis (Spain), U. Gieseler (Germany), U. Hefti (Switzerland), D. Hillebrandt
(U.K.), J. Holmgren (Sweden), M. Horii (Japan), D. Jean (France), A. Koukoutsi
(Greece), J. Kubalova (Czech Republic), T. Kuepper (Germany), H. Meijer
(Netherlands), J. Milledge (U.K.), A. Morrison (U.K.), H. Mosaedian (Iran), S. Omori
(Japan), I. Rotman (Czech Republic), V. Schoeffl (Germany), J. Shahbazi (Iran), J.
Windsor (U.K.)
History of this recommendation paper
The version presented here was approved at the UIAA MedCom Meeting at
Adršpach – Zdo”ov / Czech Republic in 2008.
