By Dr Eddy Bajrovic*
If you develop diarrhoea, nausea, vomiting, painful stomach cramps, with or without fever, it is a safe bet you’ve got acute infectious gastroenteritis or ‘gastro’.
Gastro comes under the term ‘traveller’s diarrhoea’ or, more colourfully, Pharaoh’s Curse, Bali Belly, or Montezuma’s Revenge (depending on where you encounter it).
Traveller’s diarrhoea (TD) is a very common travel complaint: half of all travellers visiting a developing country for a 2-week stay will experience it to some degree, according to the experts at the US Centres for Disease Control and Prevention (CDC).
Whether your symptoms are mild or severe, how effectively you treat them will usually determine how quickly you recover. More on how to treat TD and when to use ‘stopper’ drugs and antibiotics later in this article.
As your appetite returns, it’s just as important that you eat and drink the right things to help your recovery.
Fluids – what’s been lost must be replaced
Oral rehydration is the key to recovering from mild to moderate dehydration, especially for infants and young children, and adults with chronic illness. Two aspects are important: restoring lost body fluids and replenishing lost electrolytes. With frequent diarrhoea and/or vomiting, your body loses both water and important electrolytes, such as sodium and potassium. Replacing both will make you feel better quicker.
There are excellent over-the-counter oral rehydration solutions (ORS), such as Gastrolyte, which can be purchased in most developing countries in powder or tablet form. These just need to be dissolved in the correct quantity (usually a litre) of bottled, boiled or treated water. If ORS is not immediately available, then begin by rehydrating with safe water or whatever other safe liquid until it is available.
A word of warning: Sports drinks are designed to replace the fluids lost through sweating during exercise. They aren’t recommended for treating TD – particularly in children – as they don’t contain the same balance of electrolytes required to recover after diarrhoea.
Food – to start with, keep it light
Now the worst is behind you (so to speak), what should you eat?
The experts generally advise starting with small, light meals and gradually building back up to a normal, unrestricted diet. However, until your stomach completely settles down, avoid dairy products and sugary or fatty foods, as well as caffeine and alcohol (both can worsen the effects of dehydration).
The BRAT diet (bananas, rice, apple sauce and toast) has long been recommended for people recovering from gastro. On the plus side, the bananas and rice supply fibre, leading to more solid stools and less frequent diarrhoea.
However, BRAT is only a short-term option as it lacks the protein your body needs. Most people with TD should begin eating a regular diet, including fruits and vegetables, within 24-48 hours after vomiting or the start of diarrhoea.
TD in kids presents special challenges
Not only are infants and young kids more likely to get gastro, but they dehydrate more quickly, too.
It was once thought that withholding food for a day or so before allowing a child to gradually resume breastfeeding or eating was the way to treat gastro in infants or young children. When it was realised that an infection was the cause of gastro rather than a reaction to food, the approach to treatment changed dramatically.
We now know…
INFANTS – Uninterrupted breastfeeding is safe for babies with diarrhoea. Bottle formula-fed infants should continue their usual formula feeds but will probably need an increase in volume. Switching to a lactose-free formula is usually not necessary.
KIDS OVER SIX MONTHS – Normal feeding should continue, but foods high in simple sugars should be avoided as these can worsen diarrhoea.
Child or adult, it is always advisable to see a doctor if there are clear signs of dehydration – thirst, dry or sticky mouth, a reduction in urine output, a headache, and dry skin that loses its elasticity. If left untreated, severe dehydration can lead to potentially serious outcomes, including rapid heartbeat and breathing, sunken eyes, and a reduced level of consciousness.
Prevention and treatment – take the right course
The best way to prevent TD is to avoid contaminated food and water, or using eating utensils washed in contaminated water.
But even with strict personal hygiene, hand washing and use of alcohol-based gels before eating, TD is very difficult to avoid. In fact, most travellers will have transgressed the safe food and water guidelines within a week or two of their arrival.
So what’s effective?
While there is no vaccine to prevent traveller’s diarrhoea, the oral cholera vaccine, Dukoral has been shown to reduce the incidence of diarrhoea caused by enterotoxigenic E coli, which is responsible for around 20% of TD cases in developing countries – notably south Asian countries. Indeed, it’s believed that a small proportion of TD cases among travellers visiting cholera-endemic regions are actually mild, undiagnosed cholera.
Anti-motility or ‘stopper’ drugs like Imodium and Lomotil can relieve cramp and diarrhoea, but they don’t eliminate TD-causing organisms. Take them only for mild diarrhoea and for no longer than 48 hours. (Stopper drugs should NOT be taken by someone with a fever over 38°C or with blood in their stool, a child under 6 years, or a pregnant woman.)
When to use antibiotics – and not
Antibiotics can kill beneficial bacteria in the lower intestine, allowing resistant bacteria to take their place.
Travellers who take antibiotics to prevent or treat diarrhoea risk becoming ‘colonised’ with these resistant bacteria if they eat food and beverages that contain them. Returned travellers can shed drug-resistant organisms for months, with potentially disastrous consequences for the wider community.
There’s still a place for using antibiotics to treat more severe traveller’s diarrhoea, but your age, general health (i.e. chronic conditions, allergies), and the type of bacterial resistance known to exist at your destination need to be considered to determine the right medication. (Discuss your options during your pre-travel medical consultation.)
DON’T TAKE ANTIBIOTICS if the symptoms are only mild or even moderate. Instead, restore your electrolyte balance and maintain hydration by drinking plenty of safe water and a rehydration fluid. Your body’s likely to eliminate the TD-causing bug naturally within 2-3 days.
DO TAKE ANTIBIOTICS if you have fever above 38°C, cramps causing severe pain, or blood in your bowel motions i.e. have dysentery. In short, take antibiotics only if you’re REALLY sick with traveller’s diarrhoea.
Every traveller should have a first-aid kit, including medications for TD.
Your kit should contain a 'stopper' drug, a course of appropriate antibiotics, a thermometer, and sachets of Oral Rehydration Solution. For longer stays, especially to remote areas, include an anti-parasitic medication for diarrhoea caused by parasites such as giardia, and be familiar with its symptoms.
* Dr Bajrovic is the Medical Director of Travelvax Australia.
Get more advice on healthy travel for your next overseas trip by calling our travel advisory service on 1300 360 164 (toll-free from landlines). Our experienced medical professionals can also advise you on vaccinations and medication to consider during a pre-travel consultation.
