Is this safe to eat?

Street food in Chinafrogs in singapore

One of my favorite things about traveling internationally is eating good food.  Our friends know that we love to eat street food.  The street food in Asia is delicious, cheap, and convenient.  In China, the street vendors sell juicy pork buns and meat skewers.  In Bali, bicyclists sell noodle soup with fish balls.  In Thailand, they sell fruit skewers with spiced pineapple and fresh mango pieces.  Most of our memories and pictures of our international trips are of the delicious food we eat there.   Much to my husband’s dismay, this all changed after our daughter was born and started coming with us on our trips.

When we brought our three year old to Asia, one of my main concerns was how to keep her from getting sick.  Like most mothers, I was more concerned about my child’s health than my own.  Most people who were born or grew up in a developing country know about the risks of eating street food but do it anyway.    I was raised in the U.S. while my husband grew up in the Philippines.   He has fond memories of the food he ate as a child. Bangus, fish balls, halo halo, to name a few.  Every time we passed a food stall in Asia, he would stop and buy a small bite to eat, even if the food looked a little sketchy and unhygienic.  And I would often give in and taste it as well.  I can never resist trying a new ethnic food.   Perhaps this is why I got “Bali Belly” mid-way through our trip.   Perhaps this is why the incidence of traveler’s diarrhea is very high in developing countries, roughly  30-70%, depending on where and when you go.  Along with respiratory illnesses, traveler’s diarrhea is by far one of the most common illnesses tourists get while abroad.

Bali belly.  Montezuma’s revenge.  Delhi belly.  Turkey trots.  Whatever you call it, traveler’s diarrhea is no fun when you are on vacation in a foreign land, where the bathrooms are places you try as much as you can to avoid.  Traveler’s diarrhea (TD) can be mild in some people or can be quite severe in others.  TD can often cause fever, bloody stools, vomiting, abdominal pain, and dehydration.  Young children are more likely to get dehydrated due to TD.  Young children are also more likely to get hospitalized due to traveler’s diarrhea.  Getting traveler’s diarrhea can more than ruin your trip.

The good news is that traveler’s diarrhea is preventable and treatable.  Most people have heard the popular saying, “boil, peel it, or forget it.”  This rule is a good one to follow with regards to food safety but there is more to know for travelers.  The CDC also has a helpful free app for travelers called “Can I Eat This?”

1.  Choose foods that are freshly cooked and piping hot.  Those meat skewers I saw in China may have been sitting around all day. Avoid raw meats or seafood.  Avoid raw vegetables.

2. Choose fruits that you can peel yourself or wash in clean, disinfected water.   The fruit skewers in Thailand are peeled but could still be contaminated by unclean water.  The fresh tomatoes in salsa in Mexico are probably not washed in clean water or peeled.

3. Avoid food from street vendors since their level of hygiene is generally poor.

4.  Drink only disinfected or bottled water.  Boiling water for 1 minute will  make it safe to drink.  Some water  bottles in Asia may have teen tampered with so always check the cap to make sure it is sealed.  When I was in China, I bought a carton of milk from a grocery store.  When I got back to our hotel, I discovered that it had already been opened.  Filtered water is also not clean water. Also, use disinfected water for brushing teeth.

5.  Avoid ice in drinks at restaurants as it may have been made with unclean water.

6.  Avoid unpasteurized dairy products and juices.  Be wary of ice cream prepared in contaminated containers.

7. Always wash your hands with soap and water before you eat and after you go to the restroom.  One thing I had a hard time finding in public restrooms in Asia was soap.  Hand sanitizer helps but does not kill Norovirus.  You may want to carry around a little bottle of soap when you are traveling.

Now, even if you follow all of these food and drink safety rules, there are no guarantees.  You can still get traveler’s diarrhea.  You cannot control the hygiene of the restaurants you eat at. For people going to developing countries with young children, I advise them to bring ORS (oral rehydration solution) salts.  If your child gets diarrhea, start ORS salts right away as this could prevent dehydration.  In the U.S., we use pedialyte electrolyte solution.  However, in other countries, the equivalent is ORS salts, commonly sold in pharmacies.  You can buy it online to have in your travel health kit before you go on your trip.  Sports drinks or soda have too much sugar and not the right amount of electrolytes that young children need.  If your child is vomiting, you can give a teaspoon every 5 minutes.   Once your child can keep down liquids, you can give him/her food.  But avoid food that is sugary or fatty while your child is still recovering as those foods can sometimes make the diarrhea worse.

In developing countries, 80-90% of traveler’s diarrhea is due to a bacteria.  The most common culprit is enterotoxigenic E.coli, followed by campylobacter, shigella, and salmonella species.  Conversely, diarrhea in the U.S. is predominantly due to a virus.  Traveler’s diarrhea can be severe and cause dehydration, especially in children.  This is why I recommend bringing a prescription antibiotic, like Azithromycin, with you if you are going to a developing country.  This antibiotic should be used for severe diarrhea, not just mild or moderate diarrhea.  Taking it early can help you feel better faster and prevent complications.  Imodium and pepto-bismol is not recommended for kids under 12 due to possible serious side effects.  When I developed bloody diarrhea in Bali, I was so glad that I had brought Azithromycin.   I still spent 3 days lying in bed in my hotel room, but it could have been much worse. At least my daughter did not get it.

But what about antibiotic resistance?  It’s been shown recently in a study that travelers who have taken antibiotics have a higher risk of being colonized with ESBL (extended spectrum beta-lactamase) producing bacteria.  And we already know that most TD causing bacteria in South and Southeast Asia are now resistant to Cipro.   The trends of antibiotic resistance are scary.  This is why people should reserve using antibiotics only for severe diarrhea.  What about probiotics? Will they help?  As of now, there is not enough data to show that probiotics help treat traveler’s diarrhea. Many people with TD who seek medical care overseas are also very likely to get intravenous antibiotics, not just oral antibiotics.  Then, there is also new evidence that treating traveler’s diarrhea with antibiotics will lessen the risk of developing a potential chronic problem, such as irritable bowel syndrome (IBS).  The debate is ongoing.

Remember that antibiotics do not kill viruses or parasites, which are also common pathogens in developing countries.  If your child’s diarrhea does not improve within 3 days, or if he/she develops high fevers, dehydration, or severe bloody stools, you will need to seek medical care.  Getting a stool sample tested may be recommended.

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