About 20 per cent of travellers will be confined to bed with what’s called Traveler’s Diarrhea, and 10-20 per cent will develop more serious symptoms of fever or blood in the stools, which suggests invasive disease. Up to 10 per cent will have symptoms for over a week. It can have serious consequences for vulnerable travellers such as the elderly or young children.
In order to advise on the most suitable treatment, and provide comprehensive and effective information, the pharmacist needs to go through a systematic process that identifies the main risks. Advice can then be tailored to individual needs. This consultation process should be conducted within an agreed protocol or guideline framework and will include a risk assessment and health education.
Risk assessment will identify destination and personal hazards to health, focusing upon appropriate questions to ask and health education advice to be given.
Health education includes the principles of preventing travellers’ diarrhoea and its management. Carefully go through the indications, contra-indications and written instructions for recommended treatments and advice being given.
Prevention of travellers’ diarrhoea
Key areas for prevention include eating and drinking habits, personal hygiene, vaccination, and antibiotic prophylaxis.
Eating and drinking safely
Advice concerning the Do’s and Don’ts of eating and drinking can be confusing. Aim to discuss the key principles for transmission and prevention with examples as shown in Table 1.
When discussing transmission and precautions to take with food and drink, a useful motto is `Cook it, boil it, peel it, otherwise leave it’. This advice can be used in any situation and a traveller will not go far wrong if they let it guide all their food and drink choices.
Water can be made safe to drink in a variety of ways:
* boiling is effective, but may not be practical when travelling. Water should be boiled for at least ten minutes, or longer at high altitude
* chemical sterilisation using chlorine or iodine-based preparations can be carried out anywhere, and is particularly suitable for travel to remote or high altitude areas. Iodine preparations are effective against amoebic cysts but not recommended during pregnancy or in young children, and need discussion if there is an iodine-related medical problem
* water filters/purifiers use chlorine and iodine as part of the treatment process. There is a variety of preparations available, their suitability depending on travellers’ requirements. Their main benefit is convenience.
Typhoid vaccine is associated with the prevention of diarrhoea. If travellers assume this offers complete protection against all causes of travellers’ diarrhoea, reinforce the message that they must still maintain all precautions.
Prophylactic use of antibiotics in the prevention of travellers’ diarrhoea has been found to be effective. However, there are concerns about side effects and resistance.
Antibiotics are not routinely recommended for prophylaxis but may be considered for vulnerable groups, such as travellers who are at increased risk, are dependant upon local hospitality or who are attending a special event or business meeting.
Travellers need to know how to manage diarrhoea and when to seek medical attention. The main steps to consider in managing the condition are:
1. Identify the severity of diarrhoea. Passing frequent loose stools accompanied by cramps suggests a normal attack of diarrhoea. But travellers need to seek medical attention if:
* blood or mucous is present in the stools
* diarrhoea is watery and profuse, leading to rapid dehydration
* severe diarrhoea is accompanied by vomiting.
These signs and symptoms indicate a more serious invasive organism, which will require medical treatment. A rapid loss of fluid leads to dehydration that can be life threatening, particularly in vulnerable groups.
2. Preventing dehydration is the first priority in self-management. Advise drinking plenty of fluids. If patients pass dark urine, this is a sign of dehydration and they must drink more until the urine becomes pale yellow.
3. Oral rehydration therapy (ORT) helps to maintain the body’s fluid and electrolyte balance. It should be recommended to travellers at particular risk of dehydration. Advise taking ORT after each loose stool and drink plenty of additional safe fluids.
4. Antidiarrhoeal preparations are useful if diarrhoea will be a severe inconvenience. They can be taken when attending business meetings, special events, sporting activities or when travelling on long journeys where access to a toilet is difficult. They should be part of the medical stand-by kit for all travellers, except those contra-indicated to their use. Advise travellers of precautions such as using them for only a short duration and not to take them if signs and symptoms indicate a more serious infection.
5. Antibiotics may be considered for standby treatment, particularly for travellers who may be at additional risk, or who are on business, attending a special event or travelling to remote areas. They need to be advised to discuss this with their doctor.
6. Introduce food gradually, trying to avoid solid food in the first six hours to prevent painful cramps. Initially recommend nourishing clear soups or consomme drinks. Gradually progress, as the stools become firmer, to bland foods such as bread, rice, potatoes or biscuits. Dairy products and spicy foods should be avoided until stools return to normal.
7. Hygiene tips, such as washing hands, not sharing water bottles, food utensils, towels or tooth brushes, need to be reinforced.
8. Persistent diarrhoea that is not severe but lasts longer than a week requires a medical consultation.
When advising travellers about the pros and cons of different treatments, it may help to display the information in a table such as Table 2.
At risk groups, including young children, pregnant women, the elderly and those with a current chronic condition, need specific advice:
* dehydration can be more severe, therefore emphasise the need for rehydration with ORT. If accompanied by vomiting, stress the importance of seeking prompt medical attention
* nutrition is important and helps maintain fluid balance. Babies should remain bottle-feeding or breast feeding
* encourage drinking fluids, such as sealed bottled mineral water. When using bottled mineral water for young children, check the mineral content to ensure salt and mineral levels are low.