Health Tips

Health Problems After International Travel

Fever is one of the commonest health problem a traveler face after return from international travel. Other health problems that may occur after international travel are diarrhea, respiratory illnesses, and skin diseases. But there may also some problems like fatigue and emotional stress and these are usually ignored and commonly seen after long stay.

To diagnose medical and health problems of international traveler require some knowledge about geographical medicine (knowledge of diseases which are prevalent in a particular geographical area) and epidemiology and clinical presentation of infectious disorders.

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Treatment of Traveler’s Diarrhea

Traveler's who suffer from traveler's diarrhea, approximately 20% of them become bedridden and need proper treatment (should not do self treatment if diarrhea becomes severe).

In many cases a specific diagnosis is available to guide treatment and is also not necessary. The treatment should be started based on history, stool examination and severity of dehydration. The empirical treatment regimens for traveler's diarrhea are based on certain clinical syndromes:

(1) Clinical syndrome, watery diarrhea without fever or blood in stool and 1 or 2 unformed stools per day without distressing enteric symptoms:- the tr

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Self-Treatment of Traveler’s Diarrhea

The traveler’s diarrhea is diarrhea which is seen among traveler’s (mainly from developed country to a developing country, but can occur during travel from anywhere to other country and in on study the rate of traveler’s diarrhea was, as low as 8% per 2-week stay in industrialized countries and as high as 55% in parts of Africa, Central and South America, and Southeast Asia), that is generally short lived and self limited. Though short lived about 40% of affected individuals need to alter their scheduled activities and another 20% become bedridden for few days. The causative organisms of traveler’s diarrhea are entero-toxigenic Escherichia coli and entero-aggregative E. coli. Sometimes it may be due to Campylobacter infections, Salmonella, Shigella or rotavirus.

Traveler’s diarrhea can occur despite rigorous precautions regarding food and water during travel to a developing country, all the traveler’s should carry some medication for self-treatment with them (preferably traveler’s medical kit). Antibiotic therapy will generally reduce the duration and severity (reduce frequency of stools) of traveler’s diarrhea in moderate to severe cases. The standard antibiotic regimen for traveler’s diarrhea is 3-day course of quinolone like ciprofloxacin (single double dose of quinolone is equally effective regimen). But if you are traveling to Thailand quinolone like ciprofloxacin will not work due to resistance (in Thailand more then 90% of traveler’s diarrhea is due to Campylobacter infections which are resistant to quinolone like ciprofloxacin) and azithromycin is a better alternative in such cases. Rifaximin (a poorly absorbed rifampin derivative) is also highly effective (especially against noninvasive bacterial pathogens such as entero-toxigenic and entero-aggregative E. coli) alternative to quinolone.

The present recommendation of self-treatment of travelers’ diarrhea is for the traveler to carry three once-daily doses of an antibiotic (azithromycin or ciprofloxacin) and to use as many doses as necessary to correct the diarrhea. If there is no fever or blood in stool, loperamide can be taken in combination with the antibiotic (but never take loperamide if you have fever or blood in stool as it may prolong diarrhea).

Prevention of Traveler’s Diarrhea

Traveler's diarrhea can be prevented if precautions are observed properly during international travel. The main preventive measures of traveler's diarrhea are related to food and water precautions. But studies indicate that indiscretion in eating and drinking water is done by approximately 98% of traveler's upon arrival of their destination within 72 hours. That means only a handful of cautious travelers follow the precautions for prevention of traveler's diarrhea. No wonder that such a large percentage of travelers suffer from traveler's diarrhea. There is a popular slogan for travelers "Boil it, cook it, peel it, or forget it!" and it is easier to remember than following it as the studies indicate.

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Know About Traveler’s Diarrhea

Diarrhea (also known as traveler’s diarrhea) is the leading cause of illness among travelers but it is usually self limiting and short-lived. Approximately 40% of affected travelers need to change their scheduled activities and approximately 20% are confined to bed. For travelers diarrhea, the most important which determines the risk is the destination of the traveler. The rate of incidence of diarrhea among travelers is about 8% in developed countries and as high as 55% or higher in parts of Africa, Central and South America, and Southeast Asia for a 2-week stay. Young people and infants are most vulnerable to get diarrhea. A recent study suggests that there is little correlation between dietary indiscretions (eating what traveler like without thinking of health problems) and the occurrence of travelers’ diarrhea.

The commonest identified pathogens for traveler’s diarrhea are entero-toxigenic Escherichia coli (ETEC) and entero-aggregative E. coli. But in some parts of the world traveler’s diarrhea like northern Africa and Southeast Asia, is due to Campylobacter infections. Other organisms found to cause traveler’s diarrhea are Salmonella, Shigella, rotavirus, and norovirus (this virus has caused numerous outbreaks on cruise ships) etc. Parasitic infections like giardiasis may cause traveler’s diarrhea some times, but other parasitic infections are uncommon causes of travelers’ diarrhea. A huge problem that is emerging in case of travelers’ diarrhea is development of antibiotic resistance among many bacterial pathogens (strains of Campylobacter are resistant to quinolones like ciprofloxacin and strains of E. coli, Shigella, and Salmonella resistant to trimethoprim + sulfamethoxazole combination).

The clinical features of traveler’s diarrhea include frequent stool and some times abdominal pain, but these symptoms disappear within few days (self limiting) even without any treatment. Treatment of traveler’s diarrhea is usually not required in maximum number of patients as it goes off by itself with a few days. The dehydration is usually mild and no aggressive rehydration is not required. If it persists or as a precaution oral rehydration salts (ORS) can be taken as required.

Prevention of Malaria and other Insect Borne Diseases during Travel

Malaria and other infectious diseases are a huge health problem among travelers. In many developed countries the cases of malaria are mainly of travelers returning from an malaria endemic area. The risk of contracting malaria depends on factors like area of travel, whether chemoprophylaxis is taken or not and the endemicity of malaria in the particular area.

The risk of contracting malaria vary if different parts of the world. Highest risk in sub-Saharan Africa and Oceania regions where it is estimated that the chance of contracting malaria is as high as 1 in 5 (1:5) to 1 in 50 (1:50) per month of stay, if chemoprophylaxis is not taken. The intermediate (malarious) areas are Indian subcontinent and in Southeast Asia where chance of contracting malaria is 1:250–1:1000 per month of stay. Low risk areas are South and Central America where the chance of contracting malaria is 1:2500–1:10,000 per month of stay.

In US more than 1000 cases of malaria are reported annually and out of these more than 90% are due to Plasmodium falciparum (most serious form of malaria and can involve brain and develop cerebral malaria). Almost all the cases are seen among travelers returning from or immigrating from Africa and Oceania.

There is worldwide increase in chloroquine- and multi drug-resistant falciparum malaria and the decision on chemoprophylaxis has become complicated. Recently there is spread of malaria due to primaquine- and chloroquine-resistant strains of Plasmodium vivax. This also has med the treatment of malaria more complicated. The case-fatality rate of falciparum malaria in the United States is 4% but the fact is only about one third of these fatal cases of malaria are diagnosed or thought of diagnosis of malaria before death.

Many studies indicate that less than 50% of the travelers follow the basic recommendations for malaria prevention. The main protective measure of malaria during travel are personal protection measures against mosquito bites (especially between dusk and dawn) and malaria chemoprophylaxis. The personal protection measures against mosquito bites include use of DEET-containing insect repellents, permethrin-impregnated bed-nets and clothing, screened sleeping accommodations, and protective clothing (the important motto of this is “sun down sleeves down” and for this traveler should use full sleeve dress). Personal protection measures against mosquito also help prevent other insect-transmitted illnesses, like dengue fever.

A new insect repellent with picaridin as active ingredient is quite efficacious and is available in the United States, but only in low-concentration formulations that require frequent reapplications. So, in regions where infections like malaria are transmitted (very high chance of transmission), DEET products (25–50%) are recommended, even for children and infants who are above 2 months of age.

CDC recommends the following anti malarial drugs for chemoprophylaxis according to region:

• Chloroquine: For Central America (north of Panama), Haiti, Dominican Republic, Iraq, Egypt, Turkey, northern Argentina, and Paraguay. Mefloquine, Doxycycline, Atovaquone + proguanil are the alternatives to Chloroquine.
• Mefloquine, Doxycycline, Atovaquone + proguanil (Malarone): Recommended for South America including Panama (except northern Argentina and Paraguay); Asia (including Southeast Asia), Africa and Oceania. Primaquine is an alternative to all the above.
• Doxycycline, Atovaquone + proguanil (Malarone): For Thai-Myanmar and Thai-Cambodian borders.