Eating in India
 

Hi: we are traveling to southern India in late December, early January and are worried about getting food-borne illness. Would love any tips that healthy India travelers have followed, including restaurants in major southern Indian town, if you have any. Thank you!
GEssa

So glad you asked this question. I have been wondering about the food in southern India after having gotten sick on my last day in northern India. Wondering if I should restrict foods to primarily vegetarian and fish maybe.

Follow food and water precautions. Take a look at www.cdc.gov/travel

In addition, do wash your hands before eating or touching your mouth. Use a hand cleaner if you don't have access to soap and water or if the water is suspect.

Talk with your doctor about what you can take along with you to use should you get ill.

Trying to avoid getting sick in India from food is, in my experience, a futile exercise. You might get sick and you might not and no avoiding one sort of place or eating in upscale restaurants is any help at all. I've traveled for months in India and sometimes I get sick and sometimes I don't. I'm careful but you just can't tell when or from where it will strike.

My last trip, all in the south, both sides, I was quite sick for some time. I finally called a doctor whose advice was "don't eat dairy in the tropics". As I was quite sure one bout was caused by a bad lassi in quite a nice restaurant, I believe him. Another time, in the north, it was I believe a tuna sandwich in a coffee shop in Shimla.

I'm sorry to give you the news, but my feeling is that it's too often part of the India experience. If it's a short trip you may very well be lucky. I tend to be there for a couple of months so the odds against me seem to go up.

We only went to the north of India, but were concerned because many of our friends had become ill for weeks when shooting a film in the south. We were advised by our travel doctor to take the mild antibiotic Rifaximin as a preventative. (She had also gotten very sick in southern India.)

Rifaximin stays in the intestines and does not get absorbed in the bloodstream, so it is very safe and has virtually no side effects. We weren't sure if we needed it because we spend a lot of time in Latin America (I have lived there) and rarely have gastro issues, but our primary care doctor also said he was a big fan of Rifaximin for India. He said 50% of his patients who travel to India normally get food poisoning or traveler's diarrhea, but 0% who take Rifaximin have become ill.

So we chose to take the Rifaximin. It was very expensive two years ago, but now there is an affordable generic on the market. We were still careful - stayed on a vegetarian diet, avoiding meat, poultry, fish and salads, but we did occasionally have street food approved by our guide. Neither of us got sick and we have been recommending Rifaximin to friends ever since. It is also used to treat gastro issues, but we felt there was very little downside and we would definitely take it again.

Oops - meant to say "...take it again as a preventative."

crosscheck - we have heard about Rifaximin, and are considering it for our upcoming three-week trip to India.

I'm wondering exactly how you took it? Did you begin and stay on it even before you were sick? Take it at the first sign of gastro distress? How long? Dosage?

I, like you, have spent a lot of time in Latin America with little illness - although there have been a couple times I know I had food poisoning and was able to pinpoint the source - however, I am somewhat concerned about staying healthy in India. I plan on sticking to a vegetarian diet, and exercising caution about where I eat.

Thanks in advance for any info.

We did not get sick - sorry if I wasn't clear. We took the Rifaximin solely as a preventative - I think 2 X 200mg tablets a day. Took with food. I guess if you do become ill you can up your dosage - discuss that with your travel doc. But our docs reported that 0% of their patients who took it prophylactically became ill.

I never thought I'd be on Fodors pushing an antibiotic, but I know so many people (including docs who like to travel) who are fans, that it's no-brainer to recommend. It has been prescribed by European doctors for years as a preventative and in the US since 2007. Because of the expense, it had been used mostly by high profile travelers who couldn't risk getting ill (politicians, entertainers, finance people -- see my trip report)...but now it's available as a generic and quite reasonable.

If you're on the fence you could take it for the first week and see how you like it. That's what we did and we ended up staying on it for our two full weeks.

I took a probiotic (I like the one from Trader Joe's) starting a few weeks before my trip and I believe it worked quite well. I did have an upset stomach my final morning in Delhi, but two pepto chews and an hour in bed and I was good to go- and on a food tour no less! I believe this happened as I got lazy/cocky regarding my stomach and two days of forgetting the probiotics and poof!

I ate meat every day, and was sure to use handsanitizer religiously. I did have cipro with me in case something happened but I was good to go. I ate in the same restuarants as a couple I was travelling with and they both got very sick, twice. They however, ordered milkshakes at almost every meal, even against the advice of our (multiple) guides!

I'm someone who regularly gets an attack of GI when I'm away, including in France, the Netherlands, The Gambia, Australia, and even at home in the UK.

No problems at all in Sri Lanka - and I ate everything going - milk in tea, salads, seafood, fruit bought from road-side stalls - everything you are warned against. We did take hand sanitiser, but took no antibiotics etc.

No, I don't understand it either.

Sri Lanka, for a number of reasons I suspect, is known as "India Lite". That may explain a great deal, also if you haven't traveled in India.

Crosscheck, do you live in the U.S.? I don't think the generic version of rifaximin is on the market yet. I believe it exists only as the brand product Xifaxan. The manufacturer still holds the patent.

The generic is available in other countries, but there's some question about erratic differences from batch to batch with the generics.

Unless the FDA has recently approved the generic version and I didn't hear about it ...

It appears Jeff is correct about no generic in the US and this puts it out of my range: "Price quotes received on February 21, 2013 for Xifaxan 550 mg in the Denver Metro area were between $23.57 and $26.72 per tablet."

However this may be helpful: "In India it is available under the brand names Ciboz and Xifapill."

Both above from https://en.wikipedia.org/wiki/Rifaximin

I've read that the soonest the U.S. patent would expire would be 2017, but more likely later. Canada has not approved the generic either, even though a few Canadian companies are selling it mail order to U.S. customers. Health Canada, their FDA counterpart, recommends not buying Canadian generic rifaximin.

Because of the expense, would prescription insurance even pay for the brand Xifaxan? It is approved for certain liver and GI medical conditions, and it would probably be covered in those cases. For traveler's diarrhea? I can see an insurance company saying, no, we'll pay for Cipro instead. It's a lot less expensive. ;)

Hi,

As long as you stick to the high-class restaurants located either in hotels or in tourist areas you should be fine. Ask for non-spicy dishes if you're not used to Indian spices.

I'm not sure where in South India you're planning to go. Below are some articles on good restaurants in Kochi, Hyderabad and Chennai.

www.remotetraveler.com/kochi/restaurants/

www.remotetraveler.com/hyderabad/restaurants/

www.remotetraveler.com/chennai/restaurants/


Happy and safe travels!!

Jeff - We do live in the U.S. When we took the Rifaximin (brand name Xifaxan) in 2012, it was indeed about $25 a pill, but our insurance covered 50%. I was wrong about the two pills a day -- we each took one, not sure of the dose. Still not cheap, but as I said, our travel doctor talked us into it.

Then, in 2013 we were going to Peru and the same doc suggested Rifaximin again. This time we scored: She gave us four discount rebate coupons (something like these: http://www.rxpharmacycoupons.com/xif...oupon.html)and the pills were only $1.50 each. Sadly, we had to cancel that trip because our son broke his thumb the day before we were leaving and we thought he needed surgery.

We ended up giving the pills back to our doctor before they expired. She then told us that Rifaximin was becoming generic in Canada and the U.K. version (Xifaxanta) was also available online (I guess that was before the Health Canada warning). http://www.canadianpharmacyking.com/...old+in+the+USA

So, you're right - not generic yet in the U.S., but in my opinion worth getting in India, when changing planes at Heathrow, or with a coupon here in the U.S.

Sharpen - I'm afraid you can get sick anywhere...even in highly acclaimed restaurants and hotels. We ate something bad at our last meal in karims in Delhi and I later saw an article in the New York Times listing it as one of the top restaurants. Fortunately my trip was not ruined - only my journey back home where I suffered miserably on the airplane and for a full week afterward. Still, I plan to return in February and will consider sticking mainly to vegetarian meals.

As you stated, rifaximin works by staying in the GI tract and not being absorbed. From what I read, the problem with the generic product is that some are absorbed into the body in significant amounts. The quality control is lacking in some of them.

A couple of people here seem to saying the south is more of a problem than the north? Is that a good rule of thumb?

Regarding north vs south, I've spent 2 months in India 3 times. Twice in the north, once in the south. One of the 2 times I was in the north I was sick, and 1 of the 1 times in the south I was sick. That could mean 50% in the north and 100% in the south. Unless I go to the south again and don't get sick, then the odds would be the same. My long-winded way of saying, I don't think there's really any way to know.

I will say, however, that at no time was I ever afflicted only south of the waistline. All 3 times I was as sick as I think it's possible to be from food, short of dying, or so it seemed. A British doctor who I'd had dinner with on one of the occasions was concerned it was worse than just food poisoning. Maybe cholera, if I recall. It turned out not to be, fortunately, but I am saying don't underestimate the power of eating something bad in India. You might very well wish you were dead.

Thanks, MmePerdu. I asked because a couple of people here seemed to suggest a north vs south difference, and I've heard that from other people too.

Jeff, I suspect people working in some kitchens the world over are only as careful as they think they need to be and some will miscalculate. I don't just mean hand-washing and general human hygiene, but also at what point do I throw away food items when they don't get used in a timely manner. That says to me also that those responsible for such decisions in the south may throw things out slightly before those in the north. But where profit is concerned, some will always push their luck. Meaning, take a chance on poisoning their customers. So I think it all evens out and, in any case, who knows who is being careful where. Eat veg, take expensive pills, or hope for the best everywhere.

MmePerdu ,

Thanks for the laugh, although I'm a bit frightened! Was hoping to hear it's safer in the south as I've already experienced a food born illness from the north which would have ruined a week of my trip had I not contracted it from the last meal I ate before flying home.

Do you think it is safe to eat exclusively vegetarian? I hate to miss out on the delicious foods, but I'm hesitant to eat chicken (which I suspect I got sick on last time) or mutton and wonder about the fish dishes which I was hoping to try in the south.

One often hears people say they'll eat only veg and maybe there's a good reason, other than religious reasons, for that in some parts of the world. But I always get distracted by the wonderful-sounding meat dishes and can never stick to it. Also, if you decide to include dairy along with your veg, it's another opportunity for dire consequences, as I mentioned earlier. To answer your question, I don't know if eating veg works 100% but so many do in India it might very well mean at least an improvement in the odds. If/when I go back I'm certainly going to try.

By the way, we can chuckle about it, but you should be frightened. I think the longer one stays, the better the chances for illness so that may be a good reason for a quick trip. But I just don't seem to be the quick trip type so may be doomed.

Regarding fish, on a trip to Israel, I had fish for dinner before going to the airport for my flight home. I was deathly sick most of the way home to CA, on an El Al flight with 1 toilet broken and lines for the rest. I just went to the front of the line, apologized and went in. No one gave me a hard time. I suppose just glad it wasn't them.

Eating exclusively vegetarian won't insure no illness, but some people believe it reduces the chances. Bacteria cling to vegetables as tenaciously as to meats. And as mentioned above, dairy can be problematic.

I figure the best one can do is to follow food and water precautions. I am "religious" about it when I first arrive in a new developing country, then may flex the rules when I know more about the place. For instance, I've been going to Bangkok since the mid-1980s, and have the sense that I know what is/is not safe to eat. So far, I've guessed pretty well, as I've never gotten sick in Bangkok (but then, I don't eat street food there). But I do eat fresh fruits and salads at places I know.

I did once get food poisoning from shrimp in Singapore... one of the cleanest places in the world! I was sick all the way home on the plane. I was flying in First and the flight attendants are all worried about me because I wasn't eating anything.

Sticking to a vegetarian diet was very easy in India because so much of the population eats that way, and the food is so delicious without meat, poultry or fish. Also spices are so ubiquitous that I would think it would be difficult to taste rancid mead or fish. Avoiding dairy is not as easy because ghee (clarified butter) is in most dishes.

But, as Kathie pointed out, what probably matters most is WHERE you eat. We stuck to finer hotels and more touristy restaurants than we usually do.

We travel to many developing countries and are rarely paranoid (we were very adventurous eaters in Thailand and visit Latin American countries several times a year without incident). But for us India was different. We know many people like Mme. Perdu (and Indian friends who live in the US) who relayed nightmare scenarios, that for us it was a no brainer to go with the very mild rifaximin. (And the expense was not really that outrageous compared to the rest of the trip.) Speak to your travel doc and go from there.

I honestly don't think there is any way to predict where one could be affected and by what foods. And, it could be poor luck of the draw. You could eat exactly the same thing as your traveling partner and get away completely scot free while s/he was unlucky enough to get the piece of food that had somehow been contaminated.

We have now taken three long trips to the area--6 weeks in the north, 3 weeks in the north combined with 3 weeks in Nepal, and this past year 6 week in the south. We have been lucky in that on each trip we have had nothing worse than travelers' diarrhea--maybe one bout each per trip, and the last trip my husband had no problems at all.

It used to be that our travel clinic advised waiting a bit to see if the diarrhea would resolve itself. No more; now they advise to start taking an antibiotic (prescribed for us to have on hand) as soon as symptoms develop.

What some of you are describing sounds more like food poisoning to me. Several years ago my husband had a bad raw oyster in Mexico; he was really sick for about two days. When we visited Vietnam I somehow contracted campylobacter from something, while he didn't get sick at all.

My advice is don't be completely paranoid about the food, but don't take foolish risks either. Part of the joy of traveling is having the opportunity to try to local dishes you can't get at home. And, obviously use bottled or purified water even for teeth brushing. Speaking of water, for our last two trips (12 weeks in total) we never purchased bottled water. Instead, we used our camelbak UV purifier and purified the water right from the tap.

"My advice is don't be completely paranoid about the food, but don't take foolish risks either."

Again, while this advice sounds utterly logical, one can take no risks, eat only in upscale places and still get sick. I think there simply is no other answer except, if you want to avoid food-borne illness and not starve, avoid developing countries. And I, despite my stories, am leaving for Mexico shortly.

Eating in "upscale" places is certainly no guarantee. On my last trip to India - six weeks in the south - I got sick in the most expensive hotel of the entire trip. And I ate in a couple of decidedly dodgy looking places without getting sick. But, I ate veg in the dodgy places and chicken in the posh one. YMMV.

I'm joining in a little late here but, here's my two cents...

- Vegetarian is better. The meats served may not be the animal advertised (ie: pigeon for chicken) and the care taken to keep it refrigerated is sketchy.
- Avoid dairy and milk based sweets.
- Avoid salads and cold items. Fruit is best if you can wash it and peel it yourself.
- Bottled water is fine, but check that the seal appears from the factory. There is an underground booming business of refilling water bottles and selling them.
- Bring food with you if you'll be out for several hours and not sure of where you will be able to eat. Ask your hotel about making a lunch for you to take with you of foods that will do well at room temperature.
- Avoid food from the street vendors - delicious as it may look and smell. The locals eat there, but they too risk food borne illness and fevers.
- The more expensive/upscale restaurants are more likely to have trained their kitchen personnel in proper food handling and storage.

'Trying to avoid getting sick in India from food is, in my experience, a futile exercise.'

I think eating veggie is worse - at least meat is cooked, ususally well cooked, whilst vegetable are not always.
MmePerdu nailed it !

Stats on being sick :
I only go to India for work.
Been there 3 times, never been sick - I break the record of my colleagues... Usually all of them are sick 1 out of 3 times on average.
Been eating in a canteen, same food as locals (yes, live like a local !), on an aluminium plate, with no fork or knife.
I saw how they washed the tray when I left - I'm still dumbfunded as to how I didn't get sick as hell.

Will go in coming months, all odds are against me !

Um, pariswat, do you use a spoon in India, chopsticks or use your fingers to push food onto a roti bread? Here in T'land locals use only fingers when eating sticky rice. The make a ball, dip the ball into a sauce and pop it into the mouth. Works well.

My advice, for what it's worth, since I grew up in India but have lived in the US for the last 16 years is -

- Drink bottled water.
- Don't limit yourself to vegetarian food. There are delicious meat based curries, kebabs and dishes, both in the North and the South, so if you enjoy Indian food, you don't have to miss it.
- Don't limit yourself to eating in expensive restaurants or hotels. This does not guarantee you will not fall sick. Recommended small restaurants or shacks even, with a high turnover of local patrons, usually means that the food is very good and fresh.
- Most Westerners don't enjoy Indian sweets because they're, well, too sweet. However, if you do, I think it's safe to have them as well, if bought from a well known shop. If you're in Rajasthan, definitely try fresh hot jalebis. If you're in the South, Chennai has some great options.
- If you're in the South, drink lots of fresh coconut water.
- Lastly, it's important that you don't get food poisoning or severe diarrhea. But, having a mild case of the runs is fine, IMO, and something easily taken care of by an Imodium or two. Our stomachs need some time to get used to the food. We go back to India every year to visit family, and our stomachs take a day or two to settle down, even though we eat quite a bit of Indian food here in the US.

My advice is very simple

1. Eat only if you see the food cooked in front of you and is steaming hot.

2. If the place is busy that's a good sign, these vendors need to feed their family and if are getting people sick they go out of business very simple.

3. Do not drink water from the tap make sure it is bottled water and the seal is not broken.

4. No ice at all lots of Indian homes have filters but not in the shops etc.

5. Try the food the people who go to India and do not try the food are missing out.

6. Don't be put off by people saying you are going to get sick.

7. Most important is have fun I loved India and going back in Nov.

Hi Jobin
I used fingers at the plant, like everybody :-)