The facts on Enterotoxigenic E.coli (ETEC) diarrhea and how to avoid the worst thing that can happen while on vacation

It’s that time of year again. You’re sick of the snow and ready to escape to a beach somewhere near the equator!  If you’re anything like me, you’ve already started planning, and are probably thinking about the essential steps… booking your travel and accommodation, packing the right clothes, ensuring you have enough spending money, planning excursions, etc. However, if you want to avoid any unexpected illnesses while on vacay – you should add chatting with your healthcare professional for pre-travel health advice to your to-do list!

The majority of Canadians are not as travel-savvy as they should be when it comes to the potential causes, symptoms and risks of a gastrointestinal infection. Approximately seven out of every ten Canadians may experience travelers’ diarrhea while on vacation. This makes it one of the most common travel-related diseases. If you’ve had  diarrhea during travel before – you know this is NOT how you want to be spending your time on vacay!

What are the risk factors?

The most detrimental risk factor for the development of travelers’ diarrhea is the destination. Developing countries all over the world represent the highest risk of diarrheal disease. Those being the Caribbean, Latin America, Africa, the Middle East, and Asia.

Travelers’ diarrhea is typically contracted by ingesting bacteria-contaminated food or water, with food being the primary cause.  Approximately 80% of reported cases of travelers’ diarrhea are caused by bacteria, specifically Escherichia coli (E. coli). 

There are six unique classes of E. coli that can cause inflammation of the stomach and bowels and are termed enterovirulent E. coli (EEC).  Brace yourself, you may not be able to pronounce these classes, but it doesn’t mean you won’t get them! They include: 

1. Enterotoxigenic E. coli (ETEC) is the most common cause of diarrhea in travelers and produces a toxin that acts on the intestinal lining.
2. Enteroinvasive E. coli (EIEC) invades (passes into) the intestinal wall to produce severe diarrhea.
3. Enterohemorrhagic E. coli (EHEC) can cause bloody diarrhea and hemolytic uremic syndrome (anemia and kidney failure).
4. Enteropathogenic E. coli (EPEC) can cause diarrhea outbreaks in newborn nurseries.
5. Enteroinvasive E. coli (EIEC) invade the epithelial cells causing diarrhea with mucus and blood.
6. Enteroaggregative E. coli (EAggEC) can cause acute and chronic (long-lasting) diarrhea.

The most common bacterium that causes diarrhea in travelers is enterotoxigenic E. coli (ETEC). 

Symptoms and Complications

Enterotoxigenic E. coli (ETEC) causes up to one-third of the cases of diarrhea in travelers and is characterized by a sudden onset of not-so-pleasant symptoms including:

• watery diarrhea
• fever
• nausea
• vomiting
• abdominal pain
• chills
• headache
• muscle aches
• bloating

These symptoms can occur 1-3 days after ingesting contaminated food or water.

The effects of diarrhea during travel can be very serious, especially for children and older adults.  ’ Diarrhea during travel is uncomfortable, inconvenient and can lead to severe dehydration which can be life-threatening. 

Clinical findings also strongly suggest that ETEC infections in travelers can increase the risk of subsequent functional bowel disorders. For example, 10–14% of travelers recovering from ETEC diarrhea may go on to develop irritable bowel syndrome (IBS), further highlighting the importance of preventative measures including vaccination.

Which travelers are at risk for diarrhea during travel?

Men and women are at equal risk for developing diarrhea during travel, but some individuals are more commonly afflicted.

Certain groups of people are also more likely to develop diarrhea during travel. 

At-risk groups include:

• immunosuppressed persons (such as HIV, cancer, chemotherapy, steroid use)
• those with chronic illnesses such as diabetes, chronic renal failure, and congestive heart failure
• persons with underlying abdominal disorders (inflammatory bowel diseases, irritable bowel syndrome, gastrectomy, achlorhydria, patients taking proton pump inhibitors).
• history of repeated severe traveler’s diarrhea

How to avoid ETEC diarrhea you ask?

If you’re like us, you’ve probably skipped right to the part about how to protect yourself from getting ETEC diarrhea while on vacation. 

You should pay close attention to diet as it is of foremost importance in the prevention of travelers’ diarrhea. We’ve compiled a list of things to keep in mind while on vacation:

• Foods should be well-cooked and served warm.
• Raw vegetables, uncooked meat or seafood, and other foods maintained at room temperature should be avoided.
• Dairy products, tap water and ice (including frozen drinks not made from filtered water) are also high-risk foods.
• Carbonated beverages, beer and wine, hot coffee and tea, fruits that can be peeled, and canned products generally are safe.
• The risk for developing diarrhea increases when eating at restaurants and when purchasing food from street vendors.
• Frequent hand washing with soap and clean water will decrease the likelihood of the bacteria spreading, especially to others that you may be travelling with.

Knowing how to manage food and water intake, and personal hygiene, is so important while on vacation. Before you head on vacation, sit down with your health care professional to discuss preventative measures. These may include:

• Vaccines (Dukoral^® – Oral Inactivated Cholera and ETEC diarrhea vaccine)
• Antibiotics (fluoroquinolones, azithromycin, rifaximin)
• Antisecretory (Bismuth subsalicylate)
• Probiotics, prebiotics and synbiotics

Certain over-the-counter medications and probiotic supplementation may be beneficial.  Antibiotics can be effective in preventing travelers’ diarrhea but are not recommended for most people due to possible side effects, including photosensitivity and additional diarrhea which can be major problems.

Antibiotics can be considered for the ‘at higher risk’ individuals mentioned previously, who have underlying medical diseases where diarrhea is more likely to occur or who may be profoundly affected by diarrhea.

On the vaccine front, in addition to cholera protection, Dukoral^® is indicated for the prevention of and protection against diarrhea caused by heat-labile toxin (LT)-producing enterotoxigenic E.coli in adults and children two years of age and older who will be visiting areas where there is a risk of contracting diarrhea caused by ETEC.

With ETEC being the most common bacterium responsible for diarrhea in travelers in many parts of the world coupled with a well-established safety profile, the Canadian Digestive Health Foundation (CDHF) recommends considering Dukoral^® as an option to prevent LT-ETEC diarrhea during travel. It should be noted that Dukoral^® should not replace standard hygienic measures. Like any vaccines, Dukoral^® may not protect 100% of susceptible people. 

Learn more

If you are interested in learning more about Dukoral^®, please visit: DukoralCanada.com

You can order their patient brochures through CDHF.ca at:  https://cdhf.ca/health-lifestyle/dukoral/

Are you a health care professional? Order resources for your office/clinic here.