Dear Doctor Column, June 21, 2004

With Precautions, Travelers' Diarrhea Needn't Ruin Vacation

Question:

My fiancé and I are planning our honeymoon. We are thinking about going to Jamaica or some island in the Caribbean and buying an "all-inclusive" resort package to cut down on the chances of getting travelers' diarrhea. As high school students, we both traveled to Mexico and spent half the time in the bathroom. I got so sick I swore I'd never go somewhere again where you couldn't drink the water or eat fresh fruit. Are there precautions we can take? Is eating at one hotel safer? I don't want to repeat my previous experience. Thank you so much.

Answer:

You and your fiancé should have a healthy trip to Jamaica or any developing country, if you follow some basic rules. Although a trip to a foreign country by no means guarantees gastrointestinal upset, studies show travelers' diarrhea affects up to 40% of people who journey from industrialized to developing countries each year, according to physicians at UAB's Traveler's Health Clinic, http://www.health.uab.edu/hospital/show.asp?durki=10465. In addition to frequent watery stools, symptoms of travelers' diarrhea can include vomiting, abdominal cramps, and on occasion, a moderate fever. Usually, the source of the infection can be traced to bacteria (most commonly Escherichia coli [E. coli]) found in contaminated food and water.

Though you may not believe it at the time, the condition is seldom life-threatening for healthy adults, and even without treatment, usually improves within 3 to 7 days. Rarely, persistent vomiting or a temperature greater than 102º Fahrenheit occurs. If any of these symptoms happen, or if the diarrhea lasts longer than 5 days, see a doctor as soon as possible. Children tend to have more severe illness and are particularly susceptible to dehydration.

Your main defense against travelers' diarrhea is to be cautious about what you put in your mouth. You should memorize the old adage, "If you can't cook it, boil it, or peel it, then forget it!" Even food, water, and ice served in the most expensive and luxurious hotels in developing countries can be unsafe.

In a study published in The Journal of the American Medical Association, researchers surveyed more than 30,000 visitors to Jamaica. The youngest age category studied, those aged 16 to 35 years, had the highest rate of travelers' diarrhea (26% versus 12% among those aged 55 years and older), presumably because the younger group ate more, and therefore, were exposed to a higher dose of pathogens.

Interestingly, the vast majority of tourists (74%) chose an all-inclusive package (all meals and beverages at the hotel included) and had a significantly higher rate of travelers' diarrhea compared with tourists who opted for various other meal plans. Ninety-five percent of travelers had ice cubes in their drinks and 90% ate salads (both usually on a daily basis); approximately 80% consumed dairy products and tap water; and more than 55% ate ice cream, hamburgers, and incompletely cooked chicken, lobster, or shrimp.

To limit your chances of travelers' diarrhea when traveling in these countries, take precautions:

• Drink only bottled or canned beverages, or stick to hot drinks, such as tea or coffee made with boiling water.
• Avoid fruit juices, which may be diluted with contaminated water.
• Never use tap water, even for brushing your teeth.
• Pass up ice cubes, even when mixed with alcohol.
• Do not eat uncooked vegetables, particularly salad greens. Raw fruit is fine only if you peel it yourself. Be certain not to wash fruit in tap water.
• Forego foods sitting at room temperature for extended periods, such as sauces, salads, and buffet offerings.
• Avoid rare meats, undercooked eggs, and all dairy products, since it is hard to be certain if they are pasteurized.
• Never buy food from street vendors.
• Make sure dishes and utensils are clean and dry before using them.

Despite all precautions, travelers' diarrhea may still occur. If it does, anti-motility drugs, such as loperamide hydrochloride (Imodium, and others) can decrease stool frequency and temporarily relieve cramps. Along with drinking plenty of safe liquids to keep well hydrated, this may be the only treatment needed, and symptoms usually disappear in less than 24 hours. Loperamide is approved for use in children aged 2 years and older.

If loperamide alone proves ineffective, a round of antibiotics, such as ciprofloxacin or levofloxacin, may be necessary; begin antibiotics if the loperamide fails to work within a few hours. This treatment stops typical travelers' diarrhea in 85% of cases within 24 hours. Because these antibiotics are prescription drugs, you need to have them prescribed by your doctor before you leave on your trip, along with instructions on how and when to use them.

Bismuth subsalicylate (Pepto-Bismol, and others) also can prevent diarrhea in travelers who take two tablets 4 times a day, but is less effective than antibiotics.

For information about measures to take when visiting specific countries, visit www.tripprep.com.