Centers for disease control and prevention

Date Last Rev'd: March 9, 1995

FOOD AND WATER AND TRAVELER'S DIARRHEA

Contaminated food and drink are the major sources of stomach or intestinal

illness while traveling. Intestinal problems due to poor sanitation are

found in far greater numbers outside the United States and other

industrialized nations.

WATER

In areas with poor sanitation only the following beverages may be safe to

drink: Boiled water, hot beverages, such as coffee or tea, made with boiled

water, canned or bottled carbonated beverages, beer, and wine. Ice may be

made from unsafe water and should be avoided. It is safer to drink from a

can or bottle of beverage than to drink from a container that was not known

to be clean and dry. However, water on the surface of a beverage can or

bottle may also be contaminated. Therefore, the area of a can or bottle that

will touch the mouth should be wiped clean and dry. Where water is

contaminated, travelers should not brush their teeth with tap water.

TREATMENT OF WATER

Boiling is the most reliable method to make water safe to drink. Bring water

to a vigorous boil, then allow it to cool; do not add ice. At high altitudes

allow water to boil vigorously for a few minutes or use chemical

disinfectants. Adding a pinch of salt or pouring water from one container to

another will improve the taste.

Chemical disinfection can be achieved with either iodine or chlorine, with

iodine providing greater disinfection in a wider set of circumstances. For

disinfection with iodine use either tincture of iodine or tetraglycine

hydroperiodide tablets, such as, Globaline*, Potable-Aqua*, and others.

These disinfectants can be found in sporting goods stores and pharmacies.

Read and follow the manufacturer's instructions. If the water is cloudy then

strain it through a clean cloth, and double the number of disinfectant

tablets added. If the water is very cold, either warm it or allow increased

time for disinfectant to work.

CDC makes no recommendation as to the use of any of the portable filters

on the market due to lack of independently verified results of their efficacy.

As a last resort, water that is uncomfortably hot to touch may be safe for

drinking and brushing teeth after it is allowed to cool. However, many

disease-causing organisms can survive the usual temperature reached by the

hot water in overseas hotels.

FOOD

Food should be selected with care. Any raw food could be contaminated,

particularly in areas of poor sanitation. Foods of particular concern

include: salads, uncooked vegetables and fruit, unpasteurized milk and milk

products, raw meat, and shellfish. If you peel fruit yourself, it is

generally safe. Food that has been cooked and is still hot is generally

safe.

For infants less than 6 months of age, breast feed or give powdered

commercial formula prepared with boiled water.

Some fish are not guaranteed to be safe even when cooked because of the

presence of toxins in their flesh. Tropical reef fish, red snapper,

amberjack, grouper, and sea bass can occasionally be toxic at unpredictable

times if they are caught on tropical reefs rather than open ocean. The

barracuda and puffer fish are often toxic, and should generally not be eaten.

Highest risk areas include the islands of the West Indies, and the tropical

Pacific and Indian Oceans.

TRAVELER'S DIARRHEA

The typical symptoms of traveler's diarrhea (TD) are diarrhea, nausea,

bloating, urgency, and malaise. TD usually lasts from 3 to 7 days. It is

rarely life threatening. Areas of high risk include the developing countries

of Africa, the Middle East, and Latin America. The risk of infection varies

by type of eating establishment the traveler visits - from low risk in

private homes, to high risk for food from street vendors.

TD is slightly more common in young adults than in older people, with no

difference between males and females. TD is usually acquired through

ingestion of fecally contaminated food and water.

The best way to prevent TD is by paying meticulous attention to choice of

food and beverage. CDC does not recommend use of antibiotics to prevent

TD because they can cause additional problems themselves.

For treatment, oral fluids should be administered to sufferers of diarrhea.

Fruit juices, soft drinks, preferably without caffeine, and salted crackers

are advised. For severe dehydration the use of an oral rehydration solution

(ORS) is advised (see below). Avoid dairy products, and all beverages that

contain water of questionable quality.

Antimicrobial drugs such as doxycycline, and trimethoprim/sulfamethoxazole

(Bactrim * , Septra *) may shorten the length of illness. Consult your

physician for prescription and dose schedules. Antidiarrheals, such as

Lomotil* or Immodium*, can decrease the number of diarrheal stools, but

can cause complication for persons with serious infections.

It is important for the traveler to consult a physician about treatment of

diarrhea in children and infants, because some of the drugs mentioned are

not recommended for them. The greatest risk for children and especially

infants is dehydration. Prevention of dehydration through administration of

soups, thin porridges, and other safe beverages is advised. Infants with

diarrhea who exhibit signs of mild dehydration, such as thirst and

restlessness, should be given an oral rehydration solution (ORS) to drink.

This is a packet of salt and carbohydrates that should be prepared following

the package instructions and using boiled or treated water. It is widely

available abroad. If bloody diarrhea, dehydration, fever in excess of 102 F

degrees, or persistent vomiting occurs, seek immediate medical help.

Most episodes of TD resolve in a few days. As with all diseases it is best

to consult a physician rather than attempt self-medication, especially for

pregnant women and children. Travelers should seek medical help if

diarrhea is severe, bloody, or does not resolve within a few days, or if it is

accompanied by fever and chills, or if the traveler is unable to keep fluids

intake up and becomes dehydrated.