blog post

According to the CDC (Center for Disease Control) contaminated drinking water is one of the leading sources of health problems for travelers, and can cause anything from mild gastrointestinal distress to serious bacterial diseases.

The most common cause of water-borne illness is bacteria, such as E. coli, cholera and salmonella, but illness can also be caused by protozoa (including giardia and cryptosporidium), viruses (like hepatitis A, polio and rotavirus) and chemical pollutants.

In many cases, travelers become ill simply because the pathogens in the water are foreign to their immune systems, while locals have adapted to the water supply and can drink it without problems.

Where Do I Have to Worry About the Water?

The world is generally divided into three grades of risk: low, intermediate, and high.

• Low-risk countries include the United States, Canada, Australia, New Zealand, Japan, and countries in Northern and Western Europe.
• Intermediate-risk countries include those in Eastern Europe, South Africa, and some of the Caribbean islands.
• High-risk areas include most of Asia, the Middle East, Africa, Mexico, and Central and South America.

There may be pockets of good water in high risk areas, for example, the tap water in Israel was fine but I ran into trouble after eating Shwarma from an outdoor spit.   Any food from an outdoor stand is risky. .

If you are traveling in a high risk area it is important to follow these guidelines to avoid contracting “Traveler’s Diarrhea” and other gastrointestinal illnesses:

• Don’t drink beverages with ice.   The ice is usually made with tap water.
• Safe beverages include only those that are bottled and sealed, carbonated or boiled.  (Bottled soft drinks, bottled water, coffee and tea.)
• Drink reliable brands of bottled water such as Evian. However, be wary of street vendors that may simply be reselling infected water in recycled water bottles. Check the seals!
• Don’t rinse your mouth or toothbrush with tap water. Throw away your toothbrush and get a new one if you forget!  (You better bring extras)  Keep a water bottle next to the sink and bring colored tape to put around the faucet as a reminder.  As vigilant as I am about this I’ve stuck my toothbrush under the tap several times just because of habit.   If you are staying in a 5-Star hotel it’s easy to forget that you can’t drink the water!
• Avoid salads and uncooked vegetables. (They are probably washed in contaminated water)
• Avoid fruits you cannot peel yourself (so eat a lot of bananas and oranges!)
• Don’t eat dairy products unless you know they have been pasteurized. This includes unpasteurized cheeses.  (I got sick from eating French Onion Soup in Cancun…It had to have been the cheese)
• Eat only food that has been cooked well and is still hot.
• Be wary of seafood, especially shellfish.  Make sure it is well cooked.
• Meats should also be well cooked.
• Remember the adage "If you can't boil it, cook it or peel it - don't eat it!"
• Don’t get brave after doing well for several days.   Letting your guard down may have disastrous effects!  If your hotel claims to have purified water, be wary.
• Don’t eat food purchased from street vendors.
• Avoid foods that have been stored for long periods at room temperature such as pre-made sandwiches.

Vigilance is necessary to prevent major inconvenience on your trip.  You may need to adjust your eating habits quite severely to remain healthy but it will be worth it!   I eat a lot of salads and fresh foods at home so this has always been an adjustment for me.   I have found that if I adjust my mindset to cooked meals instead of fresh ones it is much easier.   For uncooked food, stick with bread, oranges and bananas (peeled yourself of course).  There are many wonderful regional dishes that can be safely enjoyed in developing countries.    (Remember that good eating and exercise habits at home will help you build a healthy immune system to guard you on the road.)

Additional Traveler’s Diarrhea Prevention Methods

• Pepto-Bismol (Active Ingredient - Bismuth Subsalicylate)

The CDC web site cites a study done in Mexico which concluded that taking two Pepto-Bismol chewable tablets (or 2 oz of liquid), four times a day reduced the incidence of TD from 40% to 14%.   It went on to state that this treatment should be avoided by travelers with aspirin allergy, renal insufficiency, and gout, and by those taking anticoagulants, probenecid, or methotrexate.  Pepto-Bismol should not be combined with aspirin, especially with children, because of the risk for Reyes syndrome.  It is not recommended for children under 3 years of age.  Ask your doctor before using Pepto-Bismol.

• Pro-Biotics 

The use of probiotics, such as Lactobacillus GG and Saccharomyces boulardii, has been suggested for prevention of traveler’s diarrhea but studies to its efficacy have been inconclusive, partially because standardized preparations of these bacteria are not reliably available.

·        Prophylactic Antibiotics

Prophylactic antibiotics (take to ward off infection rather than cure infection) have been demonstrated to be quite effective in the prevention of TD, as most cases are bacterial rather than viral.  However, physicians are reluctant to prescribe antibiotics on a prophylactic basis for fear of increasing resistance to the strain.   For this reason, normally only those whose immune systems are weakened should consider this type of prevention.   Talk to your physician about whether this would be right for you.

 Traveler’s Diarrhea Treatment

• Antibiotics 

For serious cases antibiotics may be needed.  (This would include continuous vomiting and diarrhea for more than 24 hours).  As bacterial causes of TD far outnumber viral causes, antibiotics are usually prescribed.   Ask your physician (travel specialty physicians will be up on the latest therapies) for a prescription that you can have filled and take with you in case of an outbreak.  Been there, done that and it worked.  Actually I would have preferred the prophylactic as the bug I got in Egypt was the worst I’ve ever had, but my doctor wouldn’t give it to me for the above reasons.  Wish I had known about the Pepto Bismol prevention at the time!

• Antimotility Agents (Imodium and Like Products)

Antimotility agents provide symptomatic relief and can be a life saver if you can’t stay in your hotel room all day.   It effectively binds you up for a time, masking, not curing, the symptoms.   Don’t leave home without it!

·        Get Re-hydrated!

Fluids and electrolytes are lost in cases of TD, and replenishment is important, especially in young children or adults with chronic medical illness.    If you’ve had severe vomiting and diarrhea, a sport drink with added electrolytes will help to re-hydrate quickly.

TREATING WATER

If you are in an area without bottled water, consider boiling, filtering or disinfecting your water with iodine.  You can read more information about this on the CDC website at the following link:

http://wwwnc.cdc.gov/travel/content/water-treatment.aspx

In summary, never has the old adage “An ounce of prevention is worth a pound of cure” been so aptly applied!   Prevent, and enjoy many new and exotic cultures!