Visitors often expect to see tropical diseases in a tropical country. However here in Uganda most tropical diseases are rare and seldom seen in visitors and expatriates. Two exceptions are Malaria and Bilharzia.

This does not mean that visitors are seldom sick. In fact they tend to get everything that is going due to lack of immunity to local germs. In particular, a lot of common colds, flu and a lot of diarrhea. Eventually you become immune to the local bugs and pathogens and you can go anywhere and eat anything with renewed confidence.

Diarrhoea in Uganda
Almost everyone will get an upset stomach soon after arrival – or even before getting off the plane! A host of new germs are here waiting to colonize the newly arrived intestine:- viruses, bacteria, yeast and protozoa. If you are not immune to them, they can give diarrhea and sometimes vomiting when they first move in. In the new arrival the most common cause of fever is stomach infections:- a good reason not to accept “malaria” as the diagnosis in every fever.

Prevention of Stomach Infections
Common sense hygiene is important. Wash your hands properly before eating, don’t eat raw fruit or vegetables without washing it first, and be careful about cheap eating joints. Excessive hygiene such as soaking lettuce in milton for half an hour is unnecessary. Kampala tap water is safe if simply boiled, bottled and put in the fridge. Filter if you wish, most people don’t bother. Commercial bottled water is fine.

The bottom line is, never mind what precautions you take, you are still likely to get a few attacks of Diarrhea and Vomiting! The whole environment is contaminated: door knobs, bank notes, shaking hands, plates and cutlery; all can carry an infectious dose of salmonella and shigella. However common sense will prevent most attacks, or keep the infectious dose low and the disease hopefully mild.

These are some of the common causes of Diarrhea in Uganda:
Salmonella
Common ordinary “food poisoning”. Different salmonella species are found all over the world. Poorly cooked meat can harbour it, as can contaminated food, water and eating utensils. Most cases give short lived but violent diarrhea and vomiting about 12-24 hrs after infection. It usually gets better on its own, but in adults treatment gets you back on your feet sooner. Typhoid is a salmonella, however it behaves quite differently, and does not usually cause diarrhea. It will be dealt with separately.

Shigella
Another cause of acute Diarrhea and Vomiting, often with blood. “Dysentery” means diarrhea with blood, but we tend to use it for any shigella infection even if no blood is apparent. Shigella is more often invasive so is more likely to cause fever, headache and illness than salmonella. Again it can get into you from food, water, shaking hands, bank notes etc. It will get better on its own, and usually does. A lot of fever and diarrhea diagnosed and treated as “malaria”, is probably a self-limiting infection with shigella.

Shigella and salmonella can be fatal but very rarely. They can also become chronic i.e. going on for a long time. Treatment can turn a 5-day disease into a 1-day nuisance, so adults with shigella we normally treat.

E.Coli
This bacteria is notorious for rapidly becoming resistant to drugs, and some vicious strains called “enteropathic E coli” have caused outbreaks and even death all over the world. It can cause diarrhea and vomiting with fever and blood, just like shigella, or just a mild “disagreed with something I ate” 2-day tummy upset. Every time we move house we have to get used to the local E coli. All guts are colonized with our “own” E coli and if we leave them alone they help us digest our food and help prevent foreign infiltration. It is best not to take antibiotics for mild upset stomachs as antibiotics may well kill off our local friendly bacteria and encourage antibiotic resistant ones to grow.

Viruses
A lot of acute diarrhea and vomiting is probably viral. There may be fever and sudden watery diarrhea. If there is no blood, it lasts a short time, and the blood white cell count is normal, then no treatment is needed.

Yeast
Yeast infections are very interesting. Only a few years ago “intestinal candidiasis” was not a recognised disease. However, we saw that a lot of people with chronic gassy diarrhea had candida in the stools. We treated it and they got better. I now believe that candida is a common cause of fatigue, general malaise and chronic diarrhea.

Giardia
The notorious cause of “eggy burps” well known to all travellers and visitors. About 30% of people tested on return to Europe have giardia as an uninvited guest. Giardia causes chronic on/off gassy, greasy diarrhea, often difficult to flush. Along with candida and bilharzia, it is one of the classic causes of chronic fatigue. Unfortunately diagnosis is often guesswork, as the cysts come in showers, every 3 or 4 days. Many people recognize the symptoms of vague gassy diarrhoea, eggy burps, bloating and tiredness and just treat it anyway.

Other causes
Campylobacter causes acute diarrhea and pain and is easily recognised under the microscope.

Trichomonas hominis causes chronic watery diarrhea and is also easily recognized, often recurrent. I finally got rid of it when my wife changed the house girl, so ever since it’s a matter of “treat one, treat all” to prevent recurrence.

Amoeba – Nothing like as common as people think. Causes acute or chronic bloody diarrhea, but can also cause fatigue, odd abdominal pains and pains in the rectum from amoebic ulcers.

Most people with amoebic cysts in the stool are harboring harmless strains or even harmless species and should probably be left alone. Real “amoebic dysentery” is easily seen under the microscope and should be treated.

Worms – Worms don’t cause diarrhea. They may be washed out by diarrhea, in which case they are an innocent victim. Whip worm can cause diarrhea, but who has ever seen it?

Other rare causes are rarely seen but may be picked up by a diligent microscopist.

Treatment
We advise travellers to carry Norfloxacin for acute bloody or watery diarrhea with cramps and fever. It is less absorbed and penetrates tissue less than the other floxacins, so causes less damage to normal flora. It cuts a 5-day disease down to 24 hours so self-treatment makes good sense. Most E coli, shigella and salmonella infections will get better within 24 hours on Norfloxacin.

Other causes really need microscopy to get it right. Yeast and giardia can cause similar symptoms, as can Bilharzia, trichuris and blastocystis, so if self-treatment doesn’t work, come in with a stool!

Children with Diarrhea
Acute diarrhea and vomiting in children is very common, but there are a number of problems. The Norfloxacin group of drugs are not licensed for use in children in most European countries, due to concern on their effect on growing joints. The “usual” antibiotics given to children no longer work on most strains of bacteria causing diarrhea, so giving them is probably worse that giving nothing. Most children with shigella, salmonella, E coli, campylobacter etc will get better on their own.

The safest and most effective treatment is a drug that can only be given by injection – usually intravenous, as it is less painful. An alternative is a blockbuster bowel sterlizer that kills about everything including giardia and amoeba. It is not absorbed so it is safe for children and pregnant women, but kills “friendly” bacteria too.

Therefore each child has to be carefully assessed and a decision made with the parents whether to treat, or wait, reassess next day and keep open the option of the injection.

Self-treatment of children is therefore not encouraged. Best action is plenty of fluids, wait and see. Bring in the child with a specimen if there is fever, blood, or it goes on longer than 3 days.

Immodium etc.
These are roadblocks. They paralyze the gut and stop the diarrhea from passing. They do not reduce the volume of stools passed. So they are useful if you are flying a plane, preaching or delivering a lecture, travelling on a public bus etc.. Otherwise my advise is leave out the middle man and drop it down the toilet directly.

In summary
You’re bound to get diarrhea sometime. You build up immunity to the local germs over the years. A lot of self-medication is useless or makes things worse, especially in children. Unless you are up-country, the best thing to do is to come in with a specimen before taking any medicine.

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