Traveller’s Diarrhea – Prevention & Management
Being walked in on while hugging the toilet in a small airport stall was not the high point of my trip to Cuba late last august…
I was there with some friends celebrating a bachelor party.
The “snake” we called it.
It seemingly took us down one by one.
Some were hit harder than others. But we all got it; even me… thinking I could escape its binding grip was mistake number one.
Was it the hot Cuban sun? I swear it was that late night tuna sandwich that I knew way better than to eat. Whatever it was, it knocked me down and it rocked my system for several weeks following our trip.
I learned quickly that traveller’s diarrhea was no joke!
And with March break just around the corner, I wanted to share you with you my top 5 lessons for preventing and managing traveller’s diarrhea. Don’t be a Tommy Toilet-Hugger like me on your next vacation!
In this article you’ll learn about how common Traveller’s Diarrhea (TD) is, who’s most at risk and what long-term consequences can result from it.
Finally, I’ll reveal some natural strategies to help protect you and your family from traveller’s diarrhea so that you can R&R like a boss!
What Causes Traveller’s Diarrhea?
Traveller’s diarrhea is a gastrointestinal infection caused by various bacteria, parasites and viruses.
And it’s a pretty big global problem!
In fact, TD happens all the time! Estimates vary by region and time of year, but anywhere from 15-50% of traveller’s heading to higher risk areas will experience infectious diarrhea – that’s a lot of vacation hours lost due to the loo!
While TD is most commonly acquired through improper food handling/cooking or sanitation, there may be other factors involved.
How bad does it get?
From a soft poo to an explosive bloody experience, TD comes in many forms – literally.
Here’s a nice breakdown of the different grades of TD:
Mild (acute): diarrhea that is tolerable, is not distressing, and does not interfere with planned activities.
Moderate (acute): diarrhea that is distressing or interferes with planned activities.
Severe (acute): diarrhea that is incapacitating or completely prevents planned activities; all dysentery (passage of grossly bloody stools) is considered severe.
Persistent: diarrhea lasting 2 weeks.
- Provided by Riddle, Mark S., et al.
Accompanying the diarrhea is often cramping and pain. Nausea and flatulence are all fairly common as well – misery loves company!
But Wait, There’s More….
Just like a nice tan or that t-shirt branded by your favourite Caribbean cerveza, traveller’s diarrhea can come home with you too!
In fact, TD carries with it an increased risk for the development of long-term digestive symptoms such as irritable bowel syndrome (IBS) and something called functional dyspepsia.
As high as 30% of people who develop traveller’s diarrhea will develop symptoms consistent with IBS that persist for up to a year later!
I’m reminded daily just how common these post-infectious digestive issues happen as many patients will often and predictably relate the onset of their symptoms to a single bout of travellers diarrhea.
Maybe you can relate?
Here’s How It Works
These gut infections actually damage the nerves in the digestive lining.
Picture a worn charger cord for a laptop or a mobile device.
After several years of wear and tear that outer layer eventually erodes away to expose those inner wires. Touch them while they’re plugged in and you’re likely to experience an unpleasant sensation!
Get what I’m saying here?
What happens in the gut is much the same. These infections first attack the gut lining which causes an immune response and the development of antibodies.
These antibodies are meant to recognize specific proteins on the pathogen (bad bugs), but they see a similar protein in our intestinal nerve cells and wrongfully attack them instead.
Ahh, the injustice!
What results is a heightened response to all digestive sensations, including pain – a process known as visceral hypersensitivity.
Arguably worse is that this can also lead to chronic motility-related issues such as constipation or diarrhea that are related to a phenomenon known as small intestinal bacterial overgrowth (SIBO).
I wrote at length about both visceral hypersensitivity and SIBO previously.
Who’s At Risk?
Everyone!
But certain people may be more vulnerable to TD than others.
For example, people who either don’t produce enough stomach acid or who are taking acid-blocking medications (such as Nexium and Prevacid) are one such group. Oh, and as we age we lose the natural ability to produce stomach acid so the elderly need to be careful as well.
I’ve talked about the many downfalls of ant-acid medications here. You see, stomach acid plays a critical role in the protection against intestinal infections. Most bad bugs can’t survive the harsh acidity of stomach acid. Suffice it to say if you don’t produce enough acid you’re more likely to have issues!
Also, anyone who has low levels of secretory immunoglobulin A (sIgA) will also have an increased risk of TD. sIgA is an immune protein secreted from your intestinal tract who’s job it is to screen and tag pathogens to be eliminated – snakes included!
Low levels of sIgA allow pathogens to disrupt the small intestine causing inflammation, immune responses and significant fluid secretion into the bowels – ultimately what gives you the runs!
An Ounce Of Prevention…
Following my digestive misfortunes I was rudely reminded just how much I take my healthy gut function for granted. But with life comes lessons and I’d like to share a few of those with you in the hopes of preventing or lessening traveller’s diarrhea for you!
Lesson 1 – Don’t just pick any probiotic product thinking it will protect you!
I’m big on picking the right strain for the job, a lesson I should have heeded myself.
I thought bringing any probiotic would do the job. I was wrong!
There’s actually not much research to support probiotics in the prevention of TD.
With that being said, the strain Saccharomyces boulardii CNCM I-745 has the best evidence and one of the only strains to demonstrate a reduction in risk for TD. It can also lessen the intensity and shorten the duration of diarrhea if you do get it. This strain has been shown to increase levels of sIgA in the intestine, can reduce pathogen binding and has properties that help restore the integrity of the intestinal lining during episodes of infectious diarrhea.
Need I say more??
One suggestion is to begin taking your probiotics a few days before your trip, taking it throughout the duration of your stay and then for a few days after you return.
If you’re interested in learning more about the strain-specific benefits of probiotics then check out my beginner’s guide to probiotics.
Lesson 2 – Get a water bottle with a high-quality filter!
Drinking bottled water everyday may not be realistic for you, it certainly wasn’t for us. I literally had to bribe the cleaning staff to give me a few extra water bottles – even those lasted a day at most!
I’m a big fan of LifeStraw® as their filtered water bottles are BPA free, filter out common pathogens like Giardia and E.coli and even remove microplastics, chlorine and herbicides. Part of proceeds also go towards providing clean water for children in developing countries – everyone wins!
Lesson 3 – Don’t eat the sketchy looking tuna sandwich!!
In fact, stay away from late night foods all together –during the day stick to the local produce and make sure your meats are well cooked. I understand you likely won’t be cooking your own food so just be selective (if you can).
If you have low stomach acid then it will be more important than ever to be careful with questionably-cooked meats.
You may want to discuss the necessity of your antacid medication with your doctor several weeks (preferably months) prior to going on vacation.
In my experience most patients who address lifestyle and diet are often able to get off these medications without symptom recurrence… but that’s not everyone so talk to your doctor! (And let’s chat if this is something you need help with!)
Lesson 4 – This ones IMPORTANT! IF you do get traveller’s diarrhea, don’t freak out!
Hey, it happened to me and I survived to happily tell you all about it.
Even the best interventions will only lower the risk of TD by approximately 50%. And depending on the area you are travelling to that risk may still be quite high.
The goal should be to have an enjoyable uninterrupted vacation while preventing post-infectious complications down the road!
Lesson 5 – Consider packing some antimicrobial herbs such as oregano oil.
On our trip these became affectionately known as the “snake pills”. Drops may work even better here as a few drops in your water before meals may be more realistic than slugging back 3 to 4 pills a day.
“It’s Too Late, I Have All The Diarrhea!! What Do I Do Now?!”
Keep Calm and Rehydrate!
I’m certainly not against using over the counter medicines such as loperamide (Imodium) or bismuth subsalicylate (Pepto-Bismol) as these can be extremely helpful in a pinch or when you have to endure a long bus ride!
Taking antibiotics before and during a trip does not seem to offer more protection and better outcomes for travellers with mild to moderate diarrhea.
Finally, it’s important to know that these treatments do not prevent post-infectious IBS and are not suitable for everyone to take, including pregnant women and those presenting with fever and bloody diarrhea.
Antibiotics should be reserved for those who develop severe traveller’s diarrhea.
For more information you can check out the CDC’s recommendations on managing traveller’s diarrhea here.
Backpacking “Au Naturel”?
A natural option I’ll mention here is enteric-coated peppermint oil (ECPO). While not specifically studied for traveller’s diarrhea, strong benefits have been seen in diarrhea-predominant IBS.
What makes ECPO an ideal candidate for TD are its strong anti-spasmodic effects – helpful for soothing intestinal spasms – and it’s significant anti-microbial activity, which help deal with the infection. It may be worth trying!
Now for those of who have persistent diarrhea there aren’t many treatment options that will help you from preventing the development of post-infectious IBS.
However, there is one you should know about:
L-Glutamine.
Many of you know this as the quintessential gut-healing nutrient. L-glutamine works like plaster to “tighten” a leaky gut – a consequence of intestinal infections.
Taking L-Glutamine over 8 weeks following a gut infection reduced the symptoms of post-infectious IBS by greater than 50%. Stool form and frequency and markers of leaky gut all dramatically improved as well!
IBS symptoms, if left untreated, can significantly impact your quality of life.
So If you have persistent diarrhea, my advice is to get on this sooner rather than later! If you need help navigating the world of post-infectious IBS, let’s set up an appointment to get you feeling better.
Final Thoughts
So whether you’re backpacking across South East Asia or sitting on a sunny Caribbean resort, these tips and tricks should help protect you and your family.
And just remember that if you do experience diarrhea, don’t sweat it! Symptoms are usually mild and should pass within a few days. It most certainly shouldn’t deter you from having a great time!
Bon Voyage!
References:
Sniffen, Jason C., et al. “Choosing an appropriate probiotic product for your patient: An evidence-based practical guide.” PloS one 13.12 (2018): e0209205.
Gascón, Joaquim. “Epidemiology, etiology and pathophysiology of traveler’s diarrhea.” Digestion 73.Suppl. 1 (2006): 102-108.
Riddle, Mark S., et al. “Guidelines for the prevention and treatment of travelers’ diarrhea: a graded expert panel report.” Journal of travel medicine 24.suppl_1 (2017): S63-S80.
Stier, Heike, and Stephan C. Bischoff. “Influence of Saccharomyces boulardii CNCM I-745on the gut-associated immune system.” Clinical and experimental gastroenterology 9 (2016): 269.
More, Margret I., and Alexander Swidsinski. “Saccharomyces boulardii CNCM I-745 supports regeneration of the intestinal microbiota after diarrheic dysbiosis–a review.” Clinical and experimental gastroenterology 8 (2015): 237.
Schwille‐Kiuntke, J., N. Mazurak, and P. Enck. “Systematic review with meta‐analysis: post‐infectious irritable bowel syndrome after travellers’ diarrhoea.” Alimentary pharmacology & therapeutics 41.11 (2015): 1029-1037.
Thompson, John Richard. “Is irritable bowel syndrome an infectious disease?.” World journal of gastroenterology 22.4 (2016): 1331.
Khanna, Reena, John K. MacDonald, and Barrett G. Levesque. “Peppermint oil for the treatment of irritable bowel syndrome: a systematic review and meta-analysis.” Journal of clinical gastroenterology48.6 (2014): 505-512.
Centers for Disease Control and Prevention. CDC health information for international travel 2014: The yellow book. Oxford University Press, 2013.
Zhou, QiQi, et al. “Randomised placebo-controlled trial of dietary glutamine supplements for postinfectious irritable bowel syndrome.” Gut(2018): gutjnl-2017.