Tuesday, 9 August 2011

Had an encounter with Traveller’s Diarrhoea? Talk to Dr. Richard Dawood, travel medicine specialist

Cancelled meetings, Reduced productivity and Lost Opportunities: the invisible impact of Travellers’ Diarrhoea
Every year, 80 million people travel from developed to developing countries: it is estimated that up to half these contract travellers’ diarrhoea (TD), making this by far the most common illness affecting travellers1,2. There is a broad perception that TD is a trivial problem, but the reality is different: 30% of sufferers are confined to bed, forced to abandon their travel plans2. The impact upon leisure travellers and holidaymakers can be bad enough, but for business travellers the practical and economic consequences are insufficiently recognised: it can be a deal-breaker, and in terms of lost productivity alone, the cost exceeds €448 million per year in the EU – with €207 million spent on post-travel medical costs1.

Compared with leisure travellers, business travellers are often at higher risk. There’s a misguided perception that business travel is a uniformly luxurious experience, from sitting at the front of the plane to enjoying lavish suites at five-star hotels. But the majority of people who travel for work experience something rather different: last-minute trips with little opportunity to prepare for them; a tough schedule of meetings and long journeys; having to cope with jetlag, hot or cold temperatures, disorientation, isolation and language difficulties; and eating and drinking in a setting that other people have chosen, in circumstances where it is often hard to refuse meals that seem unappetising or unsafe.


A recent report by the Health Protection Agency (HPA)3 calls for much wider awareness of food hygiene precautions and preventive measures, and a much higher awareness of the scale of the problem amongst travellers, health professionals and the travel industry. Perhaps we need to focus our attention on the highly likely risk of TD as well as the far less likely, more exotic diseases that might grab the headlines. TD is a very common, very unpleasant and potentially dangerous problem yet is highly amenable to prevention and treatment.

The report also makes interesting reading from a geographical perspective, highlighting Africa, Latin America, the Middle East and Asia as posing the highest risk for contracting travellers’ diarrhoea. But as the HPA itself points out, the reported data exposes only the tip of a much larger and more alarming iceberg. The data only hints at the true number of travellers who become ill abroad but do not seek help, or the numbers of travellers who receive treatment without having tests. Recent research4 on over 1,000,000 travellers on UK package holidays revealed some insight in to the countries most at risk. Egypt topped the list of all destinations with an estimated incidence of over 45%, putting the risk of shark attacks at Sharm-el-Sheikh into perspective. Closely following Egypt in the rankings were Sri Lanka, Kenya, Cuba and the Bahamas. Closer to home, Morocco, Tunisia, Turkey, Cyprus and Spain were also revealed to be areas of risk.

Risk Zones For Travellers' Diarrhoea

Research shows that only half of people travelling to a high-risk country seek medical advice prior to the trip1. The situation with business travellers may be even worse – familiarity with a destination, and the sense of security engendered by big-name hotel chains can breed complacency. At luxury hotels, the risk may be even higher – with food that is more likely to be prepared by hand, leading to an increased risk of contamination2.

The main cause of travellers’ diarrhoea is bacterial infection from contaminated food or drink caused by poor food standards of personal hygiene. The most common cause of travellers’ diarrhoea is infection with a particular strain of E. coli bacteria.5 Particularly risky foods include undercooked meat, poultry, seafood, raw fruits and vegetables. Tap water, ice, and unpasteurised milk and dairy products are also associated with increased risk. In the UK, we drink water straight from the tap and rarely consider that the water may be the source of disease but when the cleanliness of a water supply is in doubt, it is much safer to stick to bottled water.

Prevention and treatment
There are two approaches to combating TD that should always go hand in hand. The first is a cautious approach to food hygiene in high-risk countries – and indeed, almost everywhere outside your home environment when you are dependent on meals prepared by someone else. Basic precautions such as frequent hand washing, sticking to bottled water and avoiding ice in drinks, are well known. The challenge is to apply these precautions in practice: for example, when we are tired, hungry, or tempted by a delicious-looking array of delicacies.

The second approach is for every traveller to seek pre-travel advice so they have a clear idea of what to do if symptoms of travellers’ diarrhoea appear. That includes: being able to treat fluid losses by using oral rehydration; using over-the-counter medication to control diarrhoea symptoms; and where necessary, using a standby treatment from your GP or travel clinic.


1. Speak with your GP, specialist travel clinic or your company’s health provider before you travel and get their advice – especially if you’re travelling to a resource-poor country because as well as the risk of diarrhoea, you may be at risk of other illnesses such as malaria
2. Wash hands with soap and warm water as frequently as possible – before meals and after lavatory trips, or use alcohol gel or hand sanitiser. Don’t touch your mouth unless you’re sure your hands are clean
3. Don’t consume tap water or ice unless it’s made with bottled water
4. When hygiene is poor, the following options are most likely to be safe:
• Freshly, thoroughly cooked food, served hot (i.e. heat sterilized)
• Fruit easily peeled or sliced open without contamination (bananas, papayas)
• Freshly baked bread
• Packaged or canned food (take emergency supplies)
• Bottled drinks opened in your presence - safest carbonated
• If there's nothing safe on the menu, ask for chips, omelettes, or any dish that must be cooked to order

Travellers’ diarrhoea FACT FILE

• Usually involves 3 or more unformed stools per 24 hours during / shortly after foreign travel with or without at least one symptom of cramps, nausea, fever or vomiting
• Symptoms last 3-4 days (average), typically causing incapacitation for ½ to 1 day
• Longer term complications may also occur – research shows around 10% of travellers who have had an episode of travellers’ diarrhoea may go on to develop irritable bowel syndrome (IBS) which can persist for years6
• High risk regions are South America, Africa, Southern Asia


1. Wang M, Szecs TD, Steffen R. Economic aspects of travellers’ diarrhoea. J Travel Med. 2008; 15(2): 110-118
2. Steffen R. Epidemiology of Traveler’s Diarrhea. CID 2005: 41 (Suppl 8): S536-40
3. Health Protection Agency UK - Foreign travel-associated illness: A focus on travellers’ diarrhoea: 2010 Report: National Travel Health Network & Centre; 2010
4. Incidence of self-reported subjective travellers’ diarrhoea on UK package holidays during winter months 2008-2010 based on a sample of 1,033,131 travellers (Professor Rodney Cartwright, Royal Society of Public Health)
5. Shah N, et al. Global Etiology of Travelers’ Diarrhoea: Systematic Review from 1973 to the Present Am J Trop Med Hyg 2009;80(4):609-614
6. Du Pont HL. Systematic review : prevention of travellers’ diarrhoea. Aliment Pharmacol Ther 2008;27:741-751