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This months bulletin discusses Travellers Diarrhoea in the older traveller.

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Welcome to the May 2016 Travel Health Bulletin. This month we look at Travellers’ Diarrhoea in the older traveller and self-treatment options that should be considered in consultation discussion.

Travellers’ diarrhoea in the older traveller

 

As we know Travellers’ diarrhoea (TD) is the most common illness for travellers visiting developing countries The most common cause of TD are bacterial infections such a E.coli and Campylobacter.

Due to a natural decline in immunity in older people, older travellers are more likely to experience TD than younger travellers. It is important to consider that TD can be a serious risk factor for older travellers who have these pre existing medical conditions. TD can cause considerable fluid loss and electrolyte imbalance causing dehydration.  This has the potential to increase risk of myocardial infarction, cerebral infarction, atrial fibrillation, angina and arrhythmias.

Dehydration in travellers taking diuretics or ace inhibiters for cardiovascular diseases can cause a fall in blood pressure which could result in dizziness light headedness, increasing risk of accidents.

Consideration has to be taken into account that the absorption of important medicines may be affected increasing the risk of complications of well maintained conditions. It is therefore important that discussion should be had on ways to help reduce the risk of TD and the management options available to prevent dehydration or worsening symptoms whilst taking into account medical history and itinerary. This is particularly in older adventure travellers venturing off usual tourist routes in developing countries where supportive medical treatment is not readily available.
 

Pre and probiotics

 

There is currently ongoing research into the use of prebiotics and probiotics in the prevention of TD and taking this prior to and during travel may offer some protection in preventing TD by increasing friendly bacteria in the gut and supporting the guts natural defences.  There are several products on the market for travel such as Bimuno Travel aid and Optibac - for travelling abroad.
 

Loperamide




Loperamide is an anti-motility drug that brings symptom relief by reducing the number of unformed stools. Some healthcare professionals a well as travellers believe that loperamide keeps the bacteria in the gut, prolonging the illness and causing harm so are reluctant to advise it in TD, however the anti –peristaltic effect of Loperamide increases intestinal absorption of fluids and electrolytes to help maintain hydration and normalises intestinal transit times. If it is used correctly, it is an important medicine in the management of mild TD particularly in the older travel to reduce the risk of dehydration.
 

Antibiotics

 

Antibiotics for the treatment of moderate to severe symptoms (3 or more loose motions within 24 hours with distressing symptoms abdominal cramping and or fever) can be given with or without loperamide, however symptom control is better if loperamide is taken at the same time as the antibiotic. Ciprofloxacin and Azithromycin are two of the most common antibiotics recommended and should be considered in some travellers, particularly if elderly. The list below describes the potential indications and occasionally e.g. if very immunocompromised, might be given as continual prophylaxis:

•    Long term travellers to developing countries with poor access to healthcare
•    Those taking Proton Pump inhibiters such as Lansoprazole, Omperazole (increased susceptibility to infections that cause TD because of achlorhydria)
•    Those with Inflammatory bowel diseases such as Crohn’s and Ulcerative colitis (risk of complications of current disease if to develop TD)
•    Those who are immunocompromised (taking immunosuppressive/ steroid drugs). (Increased susceptibility to gastrointestinal infection)
•    Diabetes ( TD affecting blood glucose levels)

We know that compliance to advice regarding food and water hygiene is generally poor among travellers of all ages and that approximately 30 – 50% of travellers will develop TD after a one- two week trip in a high risk countries such as South East Asia, Middle East, South and Central America. Discussion on TD management is therefore an important part of the travel health consultation. We can only hope that compliance to management is not as poor.

Resources
Heath Information for Overseas Travel NaTHNac 2010
Travel & Health – Management and Care of the older traveller by Ian B. McIntosh
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