This guest post is by Matt Brandon, a travel photographer now based in Malaysia. He works with NGO's “to tell their stories and to train their field staff to do the same.” Please follow Matt on Twitter. He is a terrific resource, as you will see from his blog post here.
One of the most frustrating things that can happen to you when you travel is getting to a new and amazing place only to get sick. Then having to spend the next several days recovering. It happens way too often and used to happen to me … a lot. In fact, travelers' diarrhea (TD) is the most common illness affecting travelers. Each year between 20-50% of international travelers, an estimated 10 million persons, develop diarrhea. (from Centers for Disease Control and Prevention) I used to suffer from TD a lot till I got a few simple little tricks under my belt. Please, don't misunderstand what I am saying, I still get sick, just not as often with travelers' diarrhea . Quite frankly, most of the time it is just a cold or the flu because I have pushed my self too hard for too long. Thankfully for me the infamous “Delhi belly”, “Montezuma's revenge”, “Aztec two step”, “Thai-dal wave” or the “Katmandu quickstep” is much a thing of the past. Why? Because I take some simple precautions.
First let's define some terms. There is travelers' diarrhea or TD and traveler's stomach. I differentiate the two because often when you travel you eat new and strange food and it takes a few days for your system to get use to it. Don't panic, often these new spices are hard on your gut and on top of that, your internal clock is messed up so you just need time to adjust. It is a recipe for upset stomach. After a few days things will settle down and life will be good again. But, full-on TD, aka Delhi Belly, is a sanitation issue and can be quite dangerous. It is often bacteria from bad water, poorly handled food or quite frankly from your own hands and it is bad news. Not to gross you out, but this bacteria lives in feces – as in poo – you know, sh*t. So how does this … stuff get into your mouth? The reality is in many of the countries I visit people often use their left hand to clean themselves after they defecate. Thus, the whole idea of the left hand being unclean and eating with your right hand. But unfortunately cooks don't use only their right hand to prepare food. Plus many of the countries I visit have water systems that have long ago failed. To get clean water you would have to drink it right from the filtration plant. You see, most of the city's pipes are rusted and cracked allowing every sort of germ and bacteria to enter the city's water system. So, what do I do to prevent these little germs from entering my system?
Pretty simple really. The best way to insure this is: if in doubt, don't. If you think the water in your hotel is not properly treated or that the country as a whole has dicey water purification, then drink bottled water. For the most part bottled water is fine. If it is legitimate. I am sure you saw “Slum Dog Millionaire” where they casually fill old bottles with tap water, reglue the tops and serve them to unsuspecting guest. This isn't very common, but it is good to inspect and open them yourself.
I know many people who will also brush their teeth with bottled water. It is a good practice to get into. I generally don't, but then my gut, after living in India for 13 years is a little stronger than most. What if you don't have bottled water available? If you don't have it, then you can boil it. This last trip to China, I went off to bed and didn't have any bottled water and I needed to take some medicine. The hotel had a tea kettle in the room so I simply boiled some water and then let it cool and I was good to go. Boiling water is great, but remember, if you are at higher altitude water boils at a lower temperature. To kill those bugs the water temp needs to be at or above 170º F or 76º C or so I have been told.
Another little thing that some folks forget, is avoiding ice. Freezing water does not kill anything and once you put frozen bad water into your clean water, you get a nice cup of cold bad water.
I generally don't worry about tea and most of the time coffee. Most tea needs to be boiled to be steeped and so you are safe. If the coffee is Nescafe, like most coffee in Asia (who knows why?!) make sure the water is boiled. It only takes warm to hot water to make Nescafe and warm water won't kill all the bugs. Here is a general rule of thumb, if it can't burn your tongue it wont kill the bugs.
Here is another little tip. Stay away from uncooked food like raw fruits and vegetables unless you can peel them. In many South Asian countries you are served raw onions or radishes in a small plate before the meal – sort of a salad. Think of them as a plate of poison! Don't eat them. There are many reasons why they could be contaminated. First is they just might not be washed and you could be eating something that was handled by everyone in the market where it was purchased. Yuck! As your mother once said, “You don't know were those hands have been!” Another reason is the cook's hands may not be clean. One more reason is that if those veggies were washed, the water used was probably right form the tap and may still be present on the food. Not good. OK, now that I have grossed you out, lets move on.
Stay away from shellfish and most uncooked sea foods. Sea food is a risk anytime. It can harbor all kinds of nasties, but when you are traveling to countries you might describe as “developing”, make it a habit to just say no! It is not worth hours and hours of hugging the toilet or wearing down the carpet between your bed and the bathroom in your hotel room.
One last way you can prevent these guys from kicking your butt is treating them prophylactic. Now, I don't do this, but I have known a few doctors who I have traveled with that will take 2 tablets of Pepto Bismol 4 times daily or 2 fluid ounces 4 times daily as a prophylactic for travelers' diarrhea. They swear by this and I never saw them sick on the trip. At least not with E. Coli or giardia.
So prevention is great, but what happens if you get E. Coli or giardia in your tummy? First understand that E. Coli is bacteria and giardia is a little bug and they do different things to you and must be treated differently. Not all baddies are created equal.
Let me say here, I am not a doctor and I am not prescribing a treatment. I am telling you what I do and that is it. There is a good chance you have a bacteria like E. Coli when you have a sudden onset of nausea, vomiting, diarrhea, abdominal cramping, bloating and fever. If I can, I will go to a medical lab and give them a stool specimen. But often I am not in an area where I can do that so I must self diagnose and self medicate. Commonly prescribed treatment is 500 mg of ciprofloxacin twice a day or 400 mg of norfloxacin twice a day for 3-5 days. I have had doctors tell me if the symptoms leave after a day then you can stop. It is not like taking a full course of antibiotics. If you can manage to ride it out and have time to stay in bed for a day or two… or three it might resolve its self. Most cases are benign and resolve in 1-2 days without treatment. TD is rarely life-threatening. The natural history of TD is that 90% of cases resolve within 1 week, and 98% resolve within 1 month. (source, Centers for Disease Control and Prevention) But I never have that kind of time or the willingness to hang out at my toilet bowl for a month. So I nuke these guys.
Giardia's symptoms are not as violent as E. Coli. Usually giardia will show up over a longer time and come on gradually as diarrhea, nasty rotten egg smelling gas or flatulence, greasy stool that can float, stomach cramps, upset stomach or nausea especially after a meal. Again, if you can, it's best to go to a clinic and get tested. Often you will have to give several stool samples for giardia as it shows up intermittent. Treatment for this little bug (and it is a real bug by the way) is with metronidazole or tinidazole.
Often diagnosis is hard to tell without lab test and if your up in the mountains that just might not be possible. In India and other countries where these bugs are prevalent you can find a cocktail of one of the “zole” drugs and an antibiotic i.e. tinidazole and norfloxacin. This combination will just about kill everything. When I say everything, I mean it and that is not always good. Your gut needs bacteria in it. So you can travel with pro-biotics or you can eat the local yogurt. I know many folks don't like yogurt, but the local stuff is really good for you. Because it has all the local bacteria and can actually strengthen your tummy.
So, there you go. That is how I keep my gut healthy when I am on the road in some really dicey places. In closing, remember, I am not a doctor and you should never use this blog post as a way to diagnose your illness, The best thing you can do is get to a good clinic or hospital if you think you have these symptoms and get checked out and listen to your doctor.