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Delhi belly, or diarrhea, affects close to one-third of travellers

by Dr. Mark Wise

For travellers to far-flung places, some things never change. Baggage gets lost, bugs bite, and ‘poop’ happens! By the latter, I refer to the fact that around 30% of you off to warmer climes will experience traveller’s diarrhea, more affectionately known as Montezuma’s Revenge, Delhi Belly, Tourista and much more.

Why does this continue to be the case, you ask? Poverty. And where there is poverty, you will generally find problems with hygiene and sanitation, meaning the food and water. The 7-star hotel is certainly less of a risk than the Peruvian ceviche stand in the street, but as I often say, you are only as safe as the last person or fly to handle your food.

The majority of cases of traveller’s diarrhea are due to bacterial infections, with E. coli accounting for the majority. This bug usually causes a mild case of the runs which gets better in a few days, with or without treatment. What I suffered through in the ‘70s in Ecuador was much worse, and was likely caused by a more virulent bacterium, such as Salmonella, Shigella or Campylobacter. While not the most enjoyable moment of my traveller career, it certainly remains one of the most memorable.

An ounce of prevention…

I don’t preach total obsessiveness when it comes to one’s culinary habits in the tropics and developing countries, but I do suggest common sense and some caution, as well as some preparedness to avoid Dehli Belly and other infections.

‘Boil it, bottle it, peel it, cook it …. or forget it’ still makes a great deal of sense. But let me elaborate.

If you plan to boil your water, just bring it to a rolling boil for a minute or two. Any longer will rob you of your fuel and your water. When it comes to bottled water …buyer beware. Look for that unbroken seal, and don’t patronize that cute boy selling bottles from behind the taco stand. If you are a bit further off the proverbial beaten path, you might want to disinfect your water with products on the market (ask your travel doctor for her/his suggestions) or use one of the many available water filters. Beer, wine and carbonated drinks should all be safe, though the ice added to drinks may be suspect. I say, avoid the ice completely.

Food that is cooked is safer than that skewer of mystery meat being offered to you at the bus stop. So by all means, eat in the markets, but eat what is cooked, make that ‘well cooked’, and cooked in front of your very own eyes. Fruits should not present a problem, just peel them. If you just absolutely crave that Caesar salad, then you need to soak your romaine in some chlorine, a.k.a. bleach (sodium hypochlorite, 5% – 2 drops per litre) or a product called AQUATABS®.

A trip to the druggist…

Aside from being picky, is there anything else you can do or take to prevent diarrhea? Yes, you could take Dukoral, an oral vaccine, prior to travel. This will reduce your overall risk of getting sick by about 30%. You could also take Pepto Bismol (2 tablets or tbsp 4 times a day), which has been shown to reduce the risk by about 50%. Pepto Bismol will also turn your stools and tongue black. Don’t panic. It’s nothing to worry about. Probiotics, grapefruit seed extract, oregano, and ‘a scotch’ a day are other less proven preventative measures.

Following the above guidelines increases your chance of a diarrhea free holiday, but does not guarantee it. Hence, go prepared, just in case. The treatment of diarrhea should be fairly straight forward. Firstly, stay hydrated. This can be accomplished with water, but better still, with solutions containing some salt, some bicarbonate, and some sugar. Soup with salt, tea with sugar, flat Coke, or oral rehydration salts should all suffice. Imodium, or loperamide, may tide you over if you want some symptomatic relief, but please use it in small quantities, or you may not defecate again for several months.

Visit your doctor before you travel. Recalling that acute diarrhea is most often a bacterial event, then it makes sense that an appropriate antibiotic may be helpful, especially if you are very uncomfortable, not getting better, or just have this weird craving to get better faster. Ask your doctor for a brief (3 days) script for ciprofloxacin or azithromycin. This can be used with or without loperamide for the quickest relief.

Some common questions

(1) Can I shower in the local water – yes, just keep your mouth shut.

(2) Are the ice cubes with the holes OK? – the holes are fine but don’t trust the ice.

(3) If I eat all the local food and drink the local water at the beginning of my trip, will I become immune – don’t count on it.

(4) Is all diarrhea infectious? – No, not all diarrhea is infectious. Too much sun, too much booze, bowls of fruit and a change in time zones may all conspire to change the consistency of your stools. Some travellers react in the opposite way, and they would crave a loose bowel movement or two. On the subject of constipation — drink plenty of water and pack prunes to be snacked on as needed.

Luck plays a big role in who succumbs to Montezuma’s Revenge. Some travellers break all of the rules and get off unscathed. Others are quite anal (excuse the adjective), and still get sick. Well, that’s the joy of travel. You never know what’s going to happen from one day to the next. So exercise that caution and common sense … and have the best time of your life.

Mark Wise is a family doctor and runs The Travel Clinic in Toronto, Canada, He is the author of the book, THE TRAVEL DOCTOR, and is the chairman of the board of Canadian Feed The Children (www.canadianfeedthechildren.ca). We asked Mark to give us some of his practical advice for avoiding stomach upsets and diarrhea when we are off exploring the world. 

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