You can avoid lions, tigers, and bears when you travel abroad and set yourself up with all kinds of creature comforts. Odds are, one of the most uncomfortable and potentially dangerous threats to your trip are food and waterborne germs.

The Centers for Disease Control (CDC) 2016 Yellow Book Pre-travel Consultation says, “Travelers’ diarrhea (TD) is the most predictable travel-related illness. Attack rates range from 30 percent to 70 percent of travelers, depending on the destination and season of travel.” Once upon a time people were forewarned, “boil it, cook it, peel it, or forget it.”  Today, unsanitary restaurants and food preparations are the primary culprits of gastrointestinal disorders during travels.

Eating and drinking in unfamiliar places, especially in third world countries, places you at risk of contracting diarrhea-causing pathogens. Diarrhea is a digestive tract disorder with symptoms which range from mild abdominal cramps and urgent watery stools to severe pain, vomiting and blood in the stools. Diarrhea is an unpleasant topic every savvy world traveler should be well-versed in.  Before you go, know what to look for, what to avoid and what to do in case traveler’s diarrhea causes discomfort.

Diarrhea Risks

Traveler’s diarrhea can occur anywhere and affect otherwise healthy adults. The CDC places risks and causes of diarrhea into three regional destination grades: low, intermediate, and high.

  • Low-risk countries include the United States, Canada, Australia, New Zealand, Japan, and countries in Northern and Western Europe.
  • Intermediate-risk countries include those in Eastern Europe, South Africa, and some of the Caribbean islands.
  • High-risk areas include most of Asia, the Middle East, Africa, Mexico, and Central and South America.

Here are some answers to a few important questions about diarrhea and your body:

  • Traveler’s Diarrhea Prevention: Preventing diarrhea means fighting a bacteria and germ war on several fronts.
  • Watch what you eat and drink: Eat steaming hot food so any bacteria are destroyed during the cooking process. Buffets are risky because food sits at room temperatures and could become contaminated. Packaged and dry foods are generally safe because moisture is needed for bacteria to grow.  Fruits that you peel can be washed in bottled water and peeled safely. Drink beverages from factory sealed containers. Avoid ice cubes and tap water because they could be contaminated. Despite your best efforts, even eating a salad rinsed in contaminated water can cause stomach grumbles, so avoid vegetable trays. Showering and rinsing your toothbrush from the tap can also be problematic.
  • Keep your hands clean:  Wash your hands thoroughly with antibacterial soap and do it often to kill germs, especially after using the toilet and before eating. If you can’t get your hands on soap and clean water, use alcohol-based hand sanitizer (at least 60 percent alcohol). Avoid putting your hands in or around your mouth, or putting foreign objects into your mouth – like the tip of a pen.
  • Vaccinate children: The World Health Organization reports diarrhea is the second leading cause of death of children under five years old.  Oral rotavirus vaccines are recommended for this reason. Rotavirus is spread from feces to mouth.  Hygiene precautions using bacterial cleaning agents to prevent contamination are strongly advised.  Adults can usually recover with rest and hydration, although elderly persons may need special attention.  
  • How to treat diarrhea?
    If you contract diarrhea, take appropriate steps to protect yourself and others promptly.
  • Medications and remedies: A lot of travelers nip traveler’s diarrhea in the bud by carrying antimicrobial drugs such as Pepto-Bismol and antibiotics. A study in Mexico demonstrated taking Pepto-Bismol reduces traveler’s diarrhea by 50 percent. Although children who are under twelve, people who are sensitive to aspirin, and others who have medical conditions are not advised to take Pepto-Bismol.

According to the CDC, “Controlled studies have shown that diarrhea attack rates are reduced by 90 percent or more by the use of antibiotics.”  Be aware that you will want to restore your gut after taking a course of antibiotics.  Antibiotics not only kill bad bacteria, they kill good bacteria, called flora, in the digestive tract. Flora in the gut is necessary to help you digest foods.  To restore gut health, eat bone broth like chicken soup, and fermented foods like pickles, sauerkraut, yogurt and buttermilk, or take a therapeutic grade probiotic.
A timely visit to a travel clinic several weeks before departure is always a good idea. The clinic can offer advice and help protect you with vaccinations for other risks, such as hepatitis, typhoid, and rabies.

Use over-the-counter products to ease diarrhea symptoms.  Most pharmacies carry Lomotil and Imodium. These will help reduce constant sprints to the bathroom and help with fluid retention. They are useful to make bus or plane rides more comfortable. Psyllium husks are a bulking fiber also used to treat constipation, diarrhea, and irritable bowel syndrome. You can take psyllium in capsule or powder form mixed with water. Be careful, psyllium powder or husks should be mixed with water before swallowing to avoid choking. A commonly known psyllium product is Metamucil. There is evidence psyllium also helps lower cholesterol and glucose.

  • Rest: Give your body the strength it needs to recover by taking a break to rest. This is also a considerate way to protect others from contamination. Remember to wash your hands frequently and avoid contaminating commonly used objects around your living area and sharing drinking and eating utensils.
  • Drink, drink, drink: Diarrhea causes dehydration from fluid loss.  It is important to replace those fluids, especially with electrolytes if possible. The CDC recommends using “only beverages that are sealed, treated with chlorine, boiled, or are otherwise known to be purified. For severe fluid loss, replacement is best accomplished with oral rehydration solution (ORS), prepared from packaged oral rehydration salts.” Sealed sports drinks are a good option.  (See Number 4 below.)
  • When to see a doctor: Occasional diarrhea is annoying. Acute diarrhea can be fatal. It’s important to know the difference. Twenty percent of all diarrhea becomes persistent.  Diarrhea occurs worldwide and causes 4 percent of all deaths and 5 percent of health loss to disability. It is most commonly caused by gastrointestinal infections which kill around 2.2 million people globally each year, mostly children in developing countries. Here are a few signs that you may need professional help to recover from diarrhea:
  • Duration: Most mild cases of diarrhea end in a couple of days. If yours lasts a couple of weeks, you may be in trouble. See a doctor as soon as you can. A red flag is waving if your symptoms continue after you get home. It could mean that you have a parasite or an inflammatory bowel disease.
  • Blood: Blood in the stool is a sign of dysentery. Dysentery is very dangerous because of its ability to lead to anorexia, rapid weight loss, and damage to the intestines. Another danger is sepsis, harmful bacteria in tissues. Stay intimate with your stools and report to your doctor if you see blood.  Blood in the stool can look bright red, maroon, black or tarry and is very smelly.
  • Nocturnal diarrhea: Can be symptomatic of infectious colitis or severe inflammatory bowel disease.  Please see your doctor.
  • Nausea and vomiting: If you also have nausea and vomiting, you might have something more serious than an upset stomach. The Medical Dictionary says, “Severe dehydration leads to changes in the body’s chemistry and could become life-threatening. Dehydration from diarrhea can result in kidney failure, neurological symptoms, arthritis, and skin problems.” Please seek appropriate medical attention.
  • Weight loss: Seek medical attention promptly.  Diarrhea is caused by bacteria and viruses. Persistent diarrhea because of inadequate home or health care needs escalation.
  • Understanding diarrhea and dehydration: Everyone gets diarrhea at some time or another. Severe diarrhea can cause death by dehydrating the body. It is critically important to understand dehydration and to stay hydrated, especially when you have vomiting or diarrhea. Water and nutrition help your body:
    1. Maintain a normal temperature  
    2. Keep joints lubricated
    3. Protect your spinal cord and other sensitive tissues
    4. Remove waste through urination, perspiration, and bowel movements

How much water you need really depends on what you’re doing and who you are. You lose water every time you breathe, sweat or excrete waste. The Institute of Medicine found average men should drink 13 cups of water per day, and women should drink nine cups. Most people are familiar with the 8 by 8 rule:   eight ounces of water eight times per day. When in doubt, try to drink more.  

Moderation is key.  Drinking too much water too fast can cause water intoxication, a condition called hyponatremia.  It is very serious and can be deadly because it causes sodium levels to fall too low.  

Drinking water should be a priority if you live in a hot or arid climate, exercise often, or become ill.

Traveling is an exotic enticement in a world where tourism consumer safety is poor to lacking.  People just don’t get warnings before they buy or fly.  To have a safe rewarding trip consider this summary with helpful tips:

  • Prepare your medications: Keep your prescription, and medications in their original containers and order more than enough to meet your needs during your stay. Check with the Transportation Security Administration (TSA) on rules regarding traveling with medications.
  • Visit a travel clinic:  A pre-trip checkup weeks before you depart is advised so you can acquire preventive medications and give recommended vaccinations a chance to incubate.
  • Purchase travel medical insurance: A reputable travel insurance company will help you get to the best possible health care facility if you become ill while traveling.   – Private hospitals and medical evacuation can be costly; travel medical insurance make good health and financial sense. Make sure they offer a 24×7 hotline with translation service.  International trips can cost thousands; travel insurance can potentially save your life and hundreds of thousands of dollars.
  • Know how to get in touch with your local embassy and consulate: Your United States Embassy or Consulate is your lifeline in your destination. Register your trip before you leave and transfer the Embassy contact telephone number and address into your telephone contacts.  Your U.S. Embassy can’t help you if they don’t know how to reach you or where you are. It is also a good idea to read country-specific warnings and alerts before you purchase a ticket at  
  • Talk to your fellow travelers: Warding off disease is much easier when your entire group and living space is healthy. Talk to your companions about these safe practices to include and engage them.  Make a policy to keep your living space disinfected and clean, especially your bathroom and kitchen. If one of you gets sick, it will be harder for the rest of you to remain healthy.
  • Know safe food and water resources:  Make sure you have access to clean food and water. Study your trip beforehand.  If safe water is an issue, perhaps you’ll want to purchase water bottles or pack some chlorine tablets or water filters to safeguard yourself and family. As a precaution, purchase packaged dry foods to keep with you just in case options are slim.
  • Power of attorney: Your emergency contacts will need powers of attorney, active passports good for six months beyond your return date, and funds to get to you and support you.  It is a good idea for them to also travel insured.
  • Your health records: Your most important personal health information should be translated into the local language.  It should include your emergency contact info.  Your emergency contacts should have a copy of your health information so you can get prompt and appropriate medical attention. Your care providers need to know if you have had prior procedures, have a current medical condition, or take medications.  
  • Closest Hospital: Don’t wait until you need a hospital to know where to go for help.  The U.S. Department of State will generally list reputable hospitals on their country specific pages at

For a free travel safety checklist visit Depart Smart. Follow us on social media for consumer driven travel safety advocacy.  

Dr. Sarah Kohl, TravelReadyMD, offers the following recommendations for Travelers Diarrhea.

What are you recommending for your patients with Travelers Diarrhea (TD)?

It’s rather unmentionable, yet TD is one of the most common ailments for international travelers. The CDC estimates that between 30 and 70% of international travelers will suffer  this malady. It’s a global problem that causes lost time, changes to itinerary and even (rarely) hospitalization. It’s downright misery for your patients. To make matters worse, a significant number of patients who get TD go on to have irritable bowel syndrome for years afterwards. Prevention and self-treatment of TD are the gold standards of pre-travel health advice.

Are you giving the right recommendations?

Like most things in medicine, the pre-travel care of travelers has changed over the years. No longer do you say “Cook it, peel it or forget it” and give a few doses of Bactrim ‘just in case’.

Who really cooks their own food when traveling? When was the last time you were able to get a knife through TSA airport screening?

This advice seems a bit out of synch with modern travel. Gone, too are the days of one-size-fits-all antibiotics for the trip. The bacteria have developed resistance. You need to be concerned about selecting the right antibiotics for travel. More importantly, your patients can acquire and bring home resistant bacteria that they can spread around your community. Give medically sound advice that most people can follow.

Experts in the field of TD recently released a consensus statement {read here}

Summary of the new expert recommendations for TD:

  • Prevent TD with QID dosing of bismuth subsalicylate (BSS) Remember this is not for children due to Rye’s Syndrome.
  • Mild diarrhea, with minimal symptoms, should not be treated with antibiotics. Instead treat symptoms with rehydrating drinks, BSS, and loperamide.
  • Moderate diarrhea, with a little distress, may be treated with an antibiotic or simply use supportive therapy as for mild symptoms.
  • Severe diarrhea, with incapacitating symptoms, should be treated with antibiotics. Choose the proper antibiotic based upon resistance patterns in the location of travel.

There are a lot of subtleties to the new guidelines so you’ll want to read them yourself. The major emphasis is to minimize antibiotic use to prevent acquisition of resistant bacteria that can cause your patient difficulties upon return home. Be very careful with your recommendation to use antibiotics. Many patients are unaware that the use of antibiotics for acute TD substantially increases their risk of acquiring extended spectrum beta-lactamase producing Enterobacteriacae (ESBL). Those with TD who used antibiotics were colonized with EBSL 4 times more likely to acquire EBSL than those with TD who didn’t use antibiotics. Stated another way, 46% of those  with TD who used antibiotics became colonized with EBSL. Fortunately BSS has a good track record and can reduce the chance of TD by 60%. When you provide excellent advice, offer timely, in-office travel services your patients will look to you for travel advice over and over again.