Should You Become Sick While Traveling
Should you develop fever while traveling, there are a number of possible causes. It is important to remember that without the appropriate laboratory tests, it can be very difficult to determine the cause. With that being said, there are five main causes of fever that the traveler would be most likely to encounter. You may click on any of the headings below to obtain more comprehensive information from the Disease portion of this site.
Malaria
The main symptoms of malaria are fever, chills, muscle aches, and headaches.
Vomiting and diarrhea may also occur. These symptoms may come and go in a cyclical pattern
(every 2-3 days) or they may be present all the time. Either way, if you are in a
malarious region, even if you have been taking malaria prophylaxis, you should assume
until proven otherwise that you have malaria. Seek medical attention immediately
should you develop these symptoms. The Canadian embassy can often give advice on local
physicians.
It is possible to develop malaria after your return to Canada, even if you have taken the pills as prescribed. The risk can persist for 4-6 years after your return. Always tell your own physicians of your travels and this risk if you are being seen for a fever.
Flu (Influenza Virus)
The flu has very similar symptoms to malaria at the onset, but perhaps less severe, and
much less life-threatening. Approximately two days after being exposed to the virus, you
will experience fever, muscle ache, headache and occasionally shaking chills.
Within the next day, though, a cough usually develops and becomes worse over the next few
days. The symptoms usually resolve within a week, but the cough may persist for several
more weeks.
It is important to remember that children with these symptoms should not be given aspirin as it increases their risk of developing Reye’s syndrome. Reye’s syndrome is a very serious complication of the flu involving the liver and the brain. There is an influenza vaccine that is around 70% effective, and must be received annually.
Dengue Fever
Dengue fever is characterized by sudden onset, high fever, severe frontal headache, joint
and muscle pain. You may also experience nausea, vomiting, and rash. The pink rash
usually appears 3-5 days after onset of fever and may spread from the torso to the arms,
legs, and face. The disease usually resolves itself without long-term effects, although
the course of the illness may be prolonged. Many cases of nonspecific or even
subclinical infection occur, but dengue may also present as a severe, fatal hemorrhagic
disease called dengue hemorrhagic fever (DHF).
There is no specific treatment for dengue and there is no vaccine. As of 1998, dengue viruses have become endemic in most tropical countries of the South Pacific, Asia, the Caribbean Basin, Mexico, Central and South America, and Africa. Travelers to endemic and epidemic areas, therefore, should take precautions to avoid mosquito bites. The principal vector mosquito, Aedes aegypti, prefers to feed on humans during the daytime and most frequently is found in or near human habitations.
Hepatitis
The symptoms of hepatitis include fever, malaise, nausea, vomiting, abdominal tenderness,
jaundice and dark urine. Symptoms range from very mild and short-lived to
fulminating and severe.
There are several different viruses that can cause hepatitis, including Hepatitis A, B,C an E. Hepatitis A and E are transmitted through unpurified water and uncooked food and is the most likely to be acquired by travelers. Hepatitis B and C are transmitted by body secretions, needles and close personal/sexual contact, and are more rarely the cause of hepatitis in the traveler. There are vaccines available for Hepatitis A and B, but not Hepatitis C.
Typhoid
Typhoid fever is an acute, life-threatening febrile illness caused by the bacterium Salmonella
typhi. The persisting fever may be associated with constipation, diarrhea or no
abdominal symptoms.
A Typhoid vaccination does exist. It is not required for international travel, but it is recommended for travelers to areas where there is a recognized risk of exposure to Salmonella typhi. Risk is greatest for travelers to the Indian Subcontinent and to other developing countries (in Asia, Africa, and Latin America) who will have prolonged exposure to potentially contaminated food and drink. Vaccination is particularly recommended for those who will be traveling in smaller cities, villages, and rural areas off the usual tourist itineraries. Travelers should be cautioned that typhoid vaccination is not 100% effective and is not a substitute for careful selection of food and drink.
Fever with Diarrhea
Infectious diarrhea may be associated with fever. Most often, there are certain bacteria that are responsible for the diarrhea. These include Shigella, Campylobacter, and Salmonella. Travelers should consult a physician rather than attempt self-medication if the diarrhea is severe or does not resolve within several days; if there is blood and/or mucus in the stool; if fever occurs with shaking chills; or if there is dehydration with persistent diarrhea. See below for more information on prevention and treatment.
Travelers’ diarrhea (TD) is a syndrome characterized by a twofold or greater increase in the frequency of unformed bowel movements. Commonly associated symptoms include abdominal cramps, nausea, bloating, urgency, fever, and malaise. Episodes of TD usually begin abruptly, occur during travel or soon after returning home, and are generally self-limited (5-10 days). Infectious agents are the primary cause of TD.
Should you develop diarrhea, it is probably because you ingested enough of a virulent organism to overcome your individual defense mechanisms, resulting in the symptoms mentioned above.
The Microorganisms:
Enterotoxigenic Escherichia coli (ETEC) are the most common causative agents of TD in all countries where surveys have been conducted. ETEC produce a watery diarrhea associated with cramps and a low-grade or no fever.
Salmonella gastroenteritis is a well-known disease that occurs throughout the world. In the industrialized nations, this large group of organisms is the most common cause of outbreaks of food-associated diarrhea. In developing countries, the proportion of cases of TD caused by non-typhoidal salmonellae varies but is not high. Salmonellae also can cause dysentery characterized by small-volume diarrheal stools containing bloody mucus.
Shigellae are also a well known cause of dysentery. The shigellae are the cause of TD in up to 20% of travelers to developing countries.
Campylobacter jejuni is a common cause of diarrhea throughout the world and is responsible for a small percentage of the reported cases of TD, some with bloody diarrhea.
Treatment
Although specific rehydration measures are often not required for the usual case of travelers' diarrhea, fluid loss may be disastrous in hot climates, particularly when children or the elderly are affected. Commercially prepared packets of sugar and salts can be purchased at pharmacies and taken with the traveler for use in an emergency. Such packets (e.g. Gastrolyte, Pedialyte, Rapolyte) are mixed in boiled or commercially purified bottled water and the resulting drink is consumed until thirst is quenched. A traveller should have a sufficient number of packets to produce 2-4 litres of rehydration drink.
Rehydration packets are also usually available throughout the tropics at pharmacies and they follow the World Health Organization guidelines for:
- sugar: 20 g glucose
- salts: 3.5 g. sodium chloride 2.9 g trisodium citrate or 2.5 g sodium bicarbonate
- 1.5 g potassium chloride
These packets make an excellent rehydration drink when mixed in the quantity of purified water suggested on the packet. In an emergency, when salt and sugar packets are not available, a less ideal but satisfactory rehydration drink can be made from:
- 1 level teaspoon of table salt (level it with a knife) and
- 3 heaping teaspoons of table sugar
- Mixed in 1 litre of boiled or commercially bottled water
This drink lacks the bicarbonate and potassium of the rehydration packets but is much better than plain water or soft drinks. Mashed bananas eaten in small frequent amounts may replace some of the potassium lost.
Iced drinks and noncarbonated bottled fluids made from water of uncertain quality should be avoided. Dairy products aggravate diarrhea in some people and should be avoided.
Although packets or homemade preparations should be mixed with purified water, the use of suspect water for rehydration is better than no rehydration at all. It is important that infants continue breast-feeding as desired during the period of rehydration.
Medications
For mild diarrhea (l-5 movements per day) it is probably best to let "nature" take its course. A number of medications are available; these include Lomotil® (diphenoxylate) and Imodium® (loperamide) tablets, or Pepto Bismal® (bismuth subsalicylate) preparation (liquid or pill.) These pills come in convenient dosage forms and provide prompt symptomatic but temporary relief of uncomplicated TD. There is concern about taking large amounts of bismuth subsalicylate without physician supervision, especially for individuals who may be intolerant of salicylates, who have renal insufficiency, or who take salicylates (i.e. aspirin) for other reasons.
All of the above treatments should not be used if you have high fever or blood in the stool. In such a case, seek the advice of a physician. These drugs should also be discontinued if symptoms persist beyond 48 hours. Diphenoxylate and loperamide should not be used in children under the age of 2. Imodium® (loperamide) can be bought from a pharmacy without a doctor's prescription.
For more severe diarrheas, (5-l5 movements per day) you may benefit from antibiotic treatment, especially if the diarrhea is associated with nausea, vomiting, abdominal cramps, fever, or blood in the stools. The pill Ciprofloxacin (an antibiotic), taken twice daily for 3 days, has been shown to significantly shorten the illness. A prescription for this medication can be obtained and the pills purchased before your trip. You will also benefit from replacing fluid lost in severe diarrhea: strength and well-being improve greatly.
For severe diarrheas associated with fever and/or blood in the bowel movement and/or marked weakness, see a doctor immediately. If this is absolutely impossible, begin taking Ciprofloxacin as stated above while seeking medical care.
Prophylaxis: Preventing Travellers Diarrhea
Several nonantimicrobial agents have been advocated for prevention of TD. Available controlled studies indicate that prophylactic use of difenoxine, the active metabolite of diphenoxylate (Lomotil ® ), actually increases the incidence of TD, in addition to producing other undesirable side effects. Antiperistaltic agents (e.g., Lomotil ® and Imodium ® ) are not effective in preventing TD.
Bismuth subsalicylate, taken as the active ingredient of Pepto-Bismol ® (2 oz. 4 times a day, or two tablets 4 times a day), has decreased the incidence of diarrhea by about 60% in several placebo-controlled studies. Side effects include temporary blackening of tongue and stools, occasional nausea and constipation, and rarely, ringing of the ears. Available data is not extensive enough to exclude a risk to the traveler from the use of such large doses of bismuth subsalicylate for a period of greater than 3 weeks. Bismuth subsalicylate should be avoided by persons with aspirin allergy, renal insufficiency, and gout, and by those who are taking anticoagulants, probenecid, or methotrexate. In patients already taking salicylates for arthritis, large concurrent doses of bismuth subsalicylate can produce toxic serum concentrations of salicylate.
Because of the uncertain risk of widespread administration of antimicrobial agents (antibiotics), their prophylactic use is not recommended. Although it seems reasonable to use prophylactic antibiotics in certain high-risk groups, such as travelers with immunosuppression or immunodeficiency, no data directly support this practice.
The best prevention is attention to the food and water that you eat. However, the length of your travels may dictate the diligence you observe.
Rash can evolve from many different causes. Rash may develop as an allergic
reaction to anything from medication to food. Heat rash may also develop as a result
of blocked sweat glands on the body. Rash may be a sign of a bacterial infection or
local insect bite, or it may be part of a larger disease process, as with Dengue fever or Typhus fever.
Any rash that looks suspicious and is not relieved by a simple anti-itch cream such as calamine lotion, or is associated with other symptoms such a fever, diarrhea, vomiting or severe fatigue should be investigated by physician.
Nausea and vomiting may have many causes. A single evening of nausea and
vomiting may be related to food (food poisoning) you ate that was not agreeable. It
may also be caused by a passing viral infection. More serious causes of nausea and
vomiting can include Hepatitis A and Hepatitis B. If nausea and vomiting is
prolonged, you could become dehydrated. It is important to continue to take liquids
to try to prevent dehydration. (See rehydration above.)
Source: CDC Yellow Book 1999 and LCDC http://www.hc-sc.gc.ca/pphb-dgspsp/tmp-pmv/travel/advice_e.html 1999-2000.