Who here has been personally victimized by traveler’s diarrhea? 

You are not alone.

The stress of traveling… next door

While “traveler’s diarrhea” might often be associated with places like Mexico or India, intestinal distress can happen even if we just travel to the next nearest city or state. Perhaps you experience a day or two of constipation when traveling, or find yourself more sensitive to foods. 

These mild intestinal discomforts and interruptions can be due to disrupted meal and sleep routines, lack of hydration, stress (even if you’re happy or excited about your travel), and/or anxiety about going to the bathroom in a new place. To help prevent these mild symptoms, focus on hydrating, increase fiber intake before travel and in the first few days, stick to your eating and sleep schedule as much as possible, take stretch and exercise breaks when driving or flying, and reduce stress when possible.

The stress of traveling… a bit further!

As many as 70% of international travelers are likely to suffer from travel-related diarrhea, or TD (Heather, 2014). There is not a universal system of hygiene or water treatment, and different types of bacteria thrive in different areas of the world based on environment and said water treatment types. These can both lead to microbiome trauma or dysbiosis, when the body interacts with bacteria and microbiota it is not accustomed to, resulting in symptoms such as diarrhea, bloating, constipation, nausea, and more.

Most TD is caused by ingestion of bacteria from the traveler or food preparer not washing hands after using the bathroom, unsafe food storage, unsafe food handling and preparation, or unsafe cleaning of surfaces and utensils. TD may also be caused by ingesting viruses or parasites, but that is less common. 

Bacteria make us sick via one or more of the following paths: 

• the bacteria is new to our body and our body overreacts

• the bacteria is in such high quantities that it overtakes some of our existing bacteria and such disruption causes illness

• the bacteria itself is dangerous and our system hasn’t had a lifetime to adapt as the locals may have

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How to help prevent TD

The best way to help prevent traveler’s diarrhea is to wash your hands often and be cautious of your food and drink.  In high-risk areas for US citizens, such as Africa, Asia, Central and South America, and the Middle East, where the common bacteria species and hygiene practices may differ from what you are accustomed to, it is important to only drink sealed bottled drinks and avoid raw and fresh foods, including salads and fruit. Fully cooked food and boiled liquids are the most safe. It is recommended to use bottled water or water that has been boiled or chemically disinfected for brushing your teeth, washing food, washing your hands and face, and cleaning.

More official research is needed, but travelers can use probiotics such as Lactobacillus GG and Saccharomyces boulardii as a strategy to attempt to overcrowd the pathogenic bacteria. If you’re not already a regular probiotic user, probiotics should be taken in preparation for the trip, during, and for about ten days after returning home. 

Some studies have shown the effectiveness of bismuth subsalicylate (BSS), which is the active ingredient of Pepto-Bismol and Kaopectate when taken daily during travel, but some potential side-effects such as blackening of the tongue and stool, nausea, and constipation may not make it a viable strategy for everyone. 

If you are particularly concerned or susceptible to gastrointestinal distress, you can ask your doctor ahead of time about preventative antibiotic options such as ciprofloxacin, rifaximin, levofloxacin, or azithromycin. They might prescribe them for you to take while traveling or at the first sign of symptoms. Antibiotics should be used with strong caution and used explicitly as directed by your doctor. Note that antibiotics often increase sensitivity to sun, which can be an important factor if you have an outdoorsy or beach trip planned!

How to help

If you find yourself in the 70% group mentioned earlier, there are some actions you can take on your own to help reduce diarrhea. The most important step is to drink clean water- more than you usually do- in order to rehydrate. It can be helpful to switch to a diet of sealed bottled water and sealed juice, and packaged foods that are also easy to digest, such as crackers. Avoid alcohol and any food, drink, or activity that you think may have led to the illness. Reducing stress by resting and getting fresh air (but not too much sun) can be helpful for recovery.

Antimotility drugs such as loperamide, also known as Immodium AD or anti-diarrheal, may be helpful at reducing diarrhea.  Loperamide should be taken at the first loose bowel movement, and it’s best to consult your doctor or pharmacist. 

When to contact your doc

-If diarrhea persists more than a few days.

-If you are urinating less, as this may be a sign of dehydration.

-If your stools are bloody or painful.

-If you have a high fever.

-If you have persistent gut pain.

Fear not

Should the fear of diarrhea stop you from traveling, trying new cuisines, or exploring? No! Not unless you have a medical condition and/or your doctor recommends against it.  I’ve personally had an E. coli infection- even been to the emergency room due to it- and I have no plans to slow down on traveling. Now I pack extra snacks when traveling so I have backups when safe food is not available, I focus on hydrating with safe water, I wash my hands often, I use probiotics before/during/after travel, and I know the signs of danger in my body. With some preparation and reasonable caution, you too should be ready to explore and learn from experiencing other places and cultures in a safe and healthy way.

TLDR: Traveler’s diarrhea affects up to 70% of international travelers, and it typically resolves on its own after a few days. Quite a few interventions can help reduce symptoms, but persistent diarrhea should be addressed by your doctor. The best prevention strategies when traveling in high-risk areas include washing hands with soap often, drinking bottled and sealed drinks, and avoiding raw foods, even fruits and vegetables.

Sources and other info:

Connor, B. A. (2020). CDC yellow book 2020: Health information for international travel. Oxford University Press. https://wwwnc.cdc.gov/travel/yellowbook/2020/preparing-international-travelers/travelers-diarrhea 

Dupont, H.L. (2009), Systematic review: the epidemiology and clinical features of travellers’ diarrhoea. Alimentary Pharmacology & Therapeutics, 30: 187-196. https://doi.org/10.1111/j.1365-2036.2009.04028.x 

Heather C. S. (2015). Travellers' diarrhoea. BMJ clinical evidence, 2015, 0901. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4415508/pdf/2015-0901.pdf 

Johns Hopkins Medicine, https://www.hopkinsmedicine.org/health/conditions-and-diseases/travelers-diarrhea