Or, how I survived 47 days in the Middle East and South Asia to be the only person in the group to not get sick with diarrhea

By Machelle DeRon, Pharm.D., R.Ph.

Delhi belly, Montezuma’s revenge- whatever silly name we give it, at one time or another, many of us adventurers have experienced traveler’s diarrhea. When I first began to travel, I had some nasty tummy troubles in Mexico and the Caribbean. It’s definitely no fun to be out on the beach or on a sailboat and suddenly have to make a panicked, sweaty sprint to the baño. To remedy the bubbling in my belly, I did what everyone does. I took measures to stop the problem after it started, like taking anti-diarrheal medication, hydration and rest. I felt sorry for myself since I was missing out on days of fun, miserably curled up in the bed. Over the years, on more far-reaching adventures I really wanted to be able to enjoy my trips, so I began thinking of how I could be proactive rather than reactive in places where traveler’s diarrhea is a known risk. I don’t want those pesky amoebas and bacteria to see a welcome mat when they get to my gut! If you know something is a real possibility and could throw a wet blanket on your plans for fun, wouldn’t you want to try and stop it from happening in the first place? If that idea sounds good to you, stay tuned! I’ll tell you what I’ve done on several trips that has saved me from having a pity party in the hotel room instead of being in a hot air balloon over the Valley of the Kings or pedaling my way through the Thai countryside. But first, let’s have a little primer on traveler’s diarrhea. Information is power!

Common Signs and Symptoms

• Sudden onset of 3 or more loose, watery stools per day
• Feeling of urgency to go to the toilet
• Abdominal cramping
• Nausea/vomiting/fever

Do you need a doctor?

Traveler’s diarrhea is generally self limiting, meaning it will resolve within a few days, and free of symptoms within a week. Adults experiencing the following symptoms should consider seeking medical attention:

• Diarrhea lasting more than 2 days
• Black or bloody stools 
• Severe pain in the rectum or abdomen
• Dehydration
• Persistent vomiting
• Fever > 102F (39C)

NOTE: Particular bacteria or parasites can cause more severe cases. If so, there are prescription medications to resolve the illness.

What causes traveler’s diarrhea?

Sometimes, simply experiencing new foods can cause traveler’s diarrhea. Most often the cause is drinking water or eating food contaminated with bacteria, parasites or viruses contained in feces. Lack of hand washing or inadequate sanitary conditions play a role here.  

What factors put me at risk?

• Traveling to high-risk locations, such as:
  • Mexico
  • Central America
  • South America
  • Africa
  • South and Southeast Asia
  • Some Caribbean locations
• Age- young adults are a bit more at risk, but there isn’t a clear answer as to why, but more adventurous eating could be a factor.
• Immunocompromised individuals- caused by a medical condition or medicine that suppresses the immune system.
• Diseases which increase risk of infection or more severe infections- such as diabetes, inflammatory bowel disease, severe kidney, liver or heart disease
• Medications that block acid or antacids- we have naturally occurring acids in our stomach which are important for digestion and break down foreign organisms. Decreased stomach acids can allow these organisms to make it past this inhospitable but protective environment. 
• Seasonal travel- risks change by season in certain areas. 

What can I do to decrease my risk?

It’s possible to become ill even if you do “all the things” to prevent it, but here are some helpful reminders regarding food in high risk areas:

• Be cautious with “street food”
• Don’t consume raw or undercooked meats, fish and shellfish
• Be cautious of “moist” (we hate that word, right?) room temperature foods and sauces
• Skip unpasteurized dairy products 
• Consume food that is well cooked and is temperature hot
• Any fruits/vegetable that you consume should be those you can peel (example, banana). Avoid salads and fruits/vegetables you cannot peel

Helpful reminders about water in high-risk areas:

• Do not drink from the tap, a stream, or a well. If you must drink the local water, boil for 3 minutes, let it come to room temperature and keep it in a clean, covered container
• Don’t consume ice or fruit juices made with tap water
• Hot drinks like tea or coffee should be steaming hot
• Drinks in the original containers are safe, provided you are the one to break the seal
• Brush your teeth and rinse your toothbrush with bottled water (keep a bottle by the sink at all times!)
• Keep your mouth closed in the shower

What do I do?

 I have approached these high risk areas with thoughtfulness and planning. I want to see the world and stay as healthy as possible! As I mentioned above, I am proactive; I want to prevent a bout of the “flux”. I do not take antibiotics for prevention because there are many important reasons not to. First, they can contribute to antibiotic resistance, which is a huge worldwide problem. That’s a subject too detailed for discussion here, but if you’re interested in learning more, consult “the Google” and look for reputable resources. Next, viruses and parasites (like amoebas found in water) do not respond to antibiotics. There are plenty of documented side effects associated with antibiotics too, such as sensitivity to the sun (which is no joke!) and yeast infections, to name just a few. Some can cause diarrhea on their own. So, the take away message: it’s not a good idea to take antibiotics for prevention of traveler’s diarrhea.

I went to Thailand with Sarah in February 2020, at the very beginning of the pandemic. While I was on alert about that, not much was known early on how the virus was transmitted, etc. I was also very concerned about getting the Bangkok boom boom, and at the same time couldn’t wait for all that amazing food! I wanted to control what I could. What I decided to do was take OTC (over the counter) medications in combination based on what they do in the GI tract.

Here is my “formula” for high risk locations:

• Starting two weeks before boots on the ground, I begin taking a probiotic- once per day in the morning. I continue this every morning for as long as I am in the high risk area, and for one to two weeks after I get home.
• Every morning, while in the area, I take one single strength, chewable Pepto-Bismol (generic is fine)
• Every morning, while in the area, I take one activated charcoal capsule

So, every morning, I take three things. I’m sure you might be wondering why I chose these things, so let me give the easy explanation of how they work to help you understand.

• Bismuth subsalicylate (Pepto or generic) helps decrease diarrhea by reducing inflammation, decreasing hypermotility (think of cramping) and promoting reabsorption of fluids and electrolytes (sodium for one), which reduces fluid loss
• Activated charcoal adsorbs (not absorbs) toxins in the gastrointestinal tract and keeps them from being absorbed into our system
• Adsorption is when substances adhere to the surface of a solid material. Absorption is when a fluid penetrates the entire volume of a material (think of a sponge)
• Probiotics reinforce the healthy “friendly” bacteria already in our system    

Real talk- I adjust the quantity of Pepto I take based on the quality and quantity (yep, I said it) of my stool. Since it can cause constipation, and if that happens, I might skip a day or so of taking it, but keep taking the other things.  If I notice my stool is becoming watery or I’ve had more than one #2- I’ll increase how many I take, never exceeding the recommended dosage. Please take responsibility and read the label, or take a photo of it. If Pepto isn’t helping to keep things in control, then you can switch to Imodium, but keeping the other two meds onboard. 

Again, this is what I do. It works for me. This kept me healthy in Thailand, and 47 days consecutively in the Middle East and South Asia. EVERY single person on that trip (not all were on the entire 47 days, but joined in various countries) got sick, and I did not. One other thing I did on the 47 days was avoid meat. I ate it a handful of times and not much when I did.  

The only time it didn’t work for me was in Morocco, when I didn’t stick to this plan (why oh why didn’t I??). As soon as I resumed these meds, I was better in about a day. This is just my personal plan and experience. Since I’ve had multiple successful trips following this blueprint, many people have asked how I survived all those countries without getting sick. I’m sharing my experience to be helpful. This plan may not be suitable for some people. 

Note: Bismuth subsalicylate can interact some other medications. It can also cause black tongue or black stools, which is temporary and harmless. Pepto Bismol has a really nice website, so consult there for questions or concerns.

https://pepto-bismol.com/en-us

In my opinion, Pepto (or generic) is one of the more under appreciated products I know of. It really does help with everything the silly commercial song says. Don’t overlook that!

Activated charcoal capsules may be found in the supplements area, the health food area or gastrointestinal area of pharmacies or big box stores. If not, you can probably find it on the big river of the internet!

Don’t forget- traveler’s diarrhea is contagious- so be considerate or your fellow adventurers and wash your hands, and if soap is not available, hand gel is highly recommended. There is a reason you see hand gel dispensers in hospitals.

What if I don’t want to be proactive?

Many countries sell medications to treat traveler’s diarrhea. If you become ill, don’t wait until it becomes totally debilitating. Consult a pharmacist or a doctor. In my experience, the pharmacists have been extremely helpful when you describe symptoms and I think these medications do not require a prescription. This can vary from country to country, so be aware. 

An example is nifuroxazide, which is sold in many countries under various brand names, such as Antinal (Egypt), Erfuzide (Thailand), etc. Secnidazole is another helpful medication, sold in Jordan. While you don’t need to remember these names, I’m mentioning them to let you know help is available, and it works. Ask how to take the medication or check inside the box for the information pamphlet, because there might not be a label. One other option is to request a prescription from your local physician prior to your trip for metronidazole, which treats amoebiasis, which is a parasite found in water. This would be as an “insurance” policy, only to take if you get legitimately ill and something like Imodium isn’t helping.

How can I feel better during recovery?

If you unfortunately get sick, avoid caffeine, alcohol, dairy products, and drink plenty of fluids (just not the tap water!!). You might also consider rehydration salts of some sort. Examples include Nuun, LMNT, SaltStick. 

Safe, healthy and happy travels, everyone!