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Rush to Flush

Medical maladies are the bane of travel. Gastroenteritis, respiratory tract infections and cuts and scrapes are bad enough on home turf, but even self-limited illnesses while traveling ruin the trip for the afflicted as well as all traveling companions.

The most common medical problem when visiting developing countries is traveler’s diarrhea. Bacteria, viruses and parasites are the usual culprits. For years, cruise ships passed off nausea and vomiting caused by the Norovirus as seasickness, when in reality a single infected passenger who vomits in a well-traveled corridor can spew enough virus to infect everyone on the ship.

Noroviruses also infect land-based travelers, but bacteria outnumber all viruses and parasites by far as the cause of traveler’s diarrhea in adults. The most common culprit is E. coli, usually friendly bacteria that make up a substantial amount of our normal colonic flora. In countries with less than pristine water and food supplies from Mexico to China, local strains of toxin producing E. coli are common. The ability to produce various toxins turns these usually docile bacteria into intestinal terrors.

For a recent winter interlude in Cuba, I flew from Miami to Havana with a merry band of Wisconsin natives and their dear ones, including two preschool children. An American tour leader with InsightCuba met us at the airport along with an official Cuban guide and a multitalented bus driver. A brand new appearing Chinese minibus conveyed us from nearly one end of the island to the other over our almost two-week trip.

Prevention is always preferable to treatment. The old adage “boil it, cook it, peel it or forget it” is still officially in force. Government websites warn against eating food served at room temperature, food from street vendors and raw fruits or vegetables that you yourself didn’t peel or wash in clean water. You are advised to drink water only from sealed bottles and avoid iced drinks, as ice is often not made from bottled or disinfected water.

Personally, I’ll take my chances. Who wants to go to Cuba and drink a mojito without ice? Who can pass up juicy hunks of steaming and not overly cooked pork from a Santiago street vendor on New Year’s Eve? And no way am I going to skip the ubiquitous salad of thinly sliced tomatoes, lettuce and cucumbers served with each main meal in Cuba. And pass on the peeled mango presented on the breakfast platter? No way, señor.

And indeed, gastroenteritis reared its ugly end a couple of days after our bus pulled out of Havana. It began with what epidemiologists called an index case. “I see it all the time,” said Hilary Duffy, our tour leader and cheerleader par excellence for the trip. “One person gets sick and it spreads through the group one by one.”

Traveler’s diarrhea is an easy self-diagnosis for persons on vacation in resource poor countries. Having some effective medication on hand can erase the symptoms in hours, compared to spending a percentage of some poor country’s gross national product on toilet paper and feeling miserable for up to a week untreated.

The best insurance against full-blown traveler’s diarrhea is to travel with a supply of effective medications. A single dose of the right quinolone antibacterial agent along with Lomotil or Imodium AD will usually abort traveler’s diarrhea, if both are taken together at the first symptom of gastrointestinal distress.

Ciprofloxacin is the most commonly used quinolone. Ofloxacin has slightly broader antibacterial coverage but is less common than plain old generic Cipro. For garden variety uncomplicated traveler’s diarrhea, a cocktail of 500 milligram Cipro and two Lomotils will restore peace to your intestines and reduce your visits to toilets you wish you had only seen in a horror movie.

Pregnant women and children should not take quinolones. In addition, intense antimicrobial pressure has bred quinolone-resistant E. coli in some areas of the world. A single dose of azithromycin, the same antimicrobial in the popular and way over-used Z-Pack is an alternative for children, pregnant women and travelers to areas with established quinolone resistance. And obviously if symptoms persist or if high fevers or bloody stools complicate the picture, it’s time to report to a local clinic or hospital.

A fast resolution of the “Hershey Squirts” helps avoid extended tours of public restrooms. “I found one with four stars,” announced Nola Hitchcock Cross, the organizer and den mother of my trip to Cuba. A few five-star toilets surfaced, but most were three stars or less. The Hitchcock Cross rating system for public and private restrooms: “One star for a structural toilet, another if it had an actual toilet seat, another for toilet paper, another for running water and a final star if the toilet actually flushed on its own.”

“When Cuba opens up, I want the franchise for toilet seats,” said Dr. Rene Loupare, a New Orleans internist who also recently visited Cuba. While porcelain toilets are more common than wooden outhouses over a hole, Cuba does indeed have a major toilet seat shortage. Maybe Castro got tired of hearing he always left the seat up. For whatever reason, you can practice for Cuban toilet usage by doing your business before you go by sitting on the edge of the bowl. Toilet seats in Cuba are as rare as American-bottled Coca-Cola.


Medications That Travel

Local health professions share their lists
Tylenol, Advil, Imodium, Pepto-Bismol, Zithromax, Cipro and Tamiflu.
Najy Masri M.D., Director of LSU Medicine Residents and Education, Ochsner Medical Center – Kenner
My DOPP kit always contains Pepto-Bismol tablets, Benadryl, Motrin, a tube of hydrocortisone cream and Visine eye drops. When traveling abroad, I always add water purification tablets, an epinephrine pen and an antibiotic.

Arthur M. Mora Ph.D., Department of Global Health Management and Policy, Tulane University School of Public Health and Tropical Medicine
I take whatever allergy/cold/sinus medication containing phenylephrine or ephedrine that’s working for me at the time. Generally, I like to avoid combinations with aspirin or Tylenol, as I like to control the amount in the medication. When I have a sinus headache, I want treatment immediately and not to have to worry about when a pharmacy is open and explain my needs to a pharmacist, even if they speak French or English well. I also take a tube of triple antibiotic ointment as little scratches and insect bites can become infected. Quick treatment is a swipe of the ointment and a Band-Aid.

Ann Byerly RN, MPH, Emeritus Alumni Board, Tulane School of Public Health
I always have Zofran, as nausea will ruin any day. Over the counter pain meds are an obvious, with Aleve being my personal preference. Topical steroids and a triple antibiotic cream just in case. And some allergy med. I use Zyrtec with or without Astelin, but everyone responses differently to different ones. That’s my medicine cabinet here and abroad.

Aimee Aysenne M.D., Director of Neurocritical Care, Tulane Neurosurgery Clinic



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