Prevention of gastrointestinal infections in India

drzog

SANJAY and Nic, good advice to all...I trust Mrs N is on the improve?

Zeppy see next post

Lactobacillus CG is also known as Lactobacillus rhamnosus and is indeed our friend.


--------------->>>>>>>>>> TD and dysentery are different diseases indeed. The risk factors apart from your excellent list of foods are still relevant, ie poor stomach acid and lower bowel immune competence (75% of the bodies immune system resides in our bowel and livers, and is primarily controlled by gut health and the kinds of bacteria that live there, with which we have a symbiotic relationship with as old as time). The bugs dont do much good if the inner gut wall isnt much good, they live in symbiosis, love them, feed them with pre-biotic foods, which not surpisingly doesnt include sugar or fatty fried meals, they protect you, stress them they cant do their job. Just swallowing a few good bugs is exactly what i didnt suggest.

Over 400 species of bacteria reside in the gastrointestinal tract (GIT), with the enteric flora comprising around 95% of the total number of cells in the human body. With advanced research techniques, providing greater evaluation of the specific microbiology within the body, we now know that normal flora is a dynamic and complex mixture of microbes with diverse functions, including essential nutrient digestion, intestinal physiology maturation, immune system stimulation and harmful bacteria inhibition. The enteric bacteria most publicised and researched for their vital health promoting properties are aptly named “probiotics” meaning “pro-life"

Functions of Intestinal and Colonic Microflora

• Bacteriostatic and bacteriocidal functions
•Modification of bacterial counts and/or metabolic activity on intestinal flora
• Production of vitamins, hormones, antimicrobial substances
• Production of digestive enzymes
• Reduction in colonic pH
• Stimulation of sodium and water resorption in colon.
• Deconjugation of bile acids and cholesterol metabolism
• Development of and competition for attachment sites with potential pathogenic bacteria
• Promotion of intestinal mucus production, mucosal permeability stabilisation
• Development and stimulation of the immune system, locally and systemically
• Stimulation of intestinal transit
• Maturation and turn over of colonic epithelial cells
• Carbohydrate utilisation and protein fermentation
• Lignan and isoflavone metabolism
• Detoxification of carcinogens

Short term gut infections that turn serious may be as much a manifestation of poor gut function or risk factors as which gut bug your consumed in your lassi. Hence the whole herbal/probiotic rant.

Causes of Intestinal Dysbiosis:
Poor nutritional intakes:
- High protein
- High sugar
- High fat
- Low fibre
• Food allergies
• Lack of digestive secretions
• High stress levels
• Antibiotic/drug therapy
• Decreased immune function
• Malabsorption
• Intestinal infection
• Altered pH
• Processed/sterile foods

Common Clinical Applications of Probiotics

Prevention or reduction in antibiotic induced diarrhoea
• ‘Reflorastation’ post antibiotic therapy
• Treatment of infantile diarrhoea (rotavirus)
•Reduction of AIDS related diarrhoea
• Reducing incidence of intestinal and vaginal candidiasis
• Reduction of lactose intolerance
• Reduction of constipation symptoms
• Reduction of hypercholesterolaemia
• Reduction of occurrence of urogenital infections in women
• Possible protection from colon cancer
• Enhancement of gastrointestinal and systemic immune systems
• Treatment of infectious diarrhoea Eschericha coli(E.Coli) and rotavirus
• Treatment of bowel dysfunction such as colitis and IBS
• Inhibition of Helicobacter pylori
• Beneficial effects on mineral metabolism

if none of these functions above serve any purpose in maintaining general health then i am a 3 legged muppet .


Increasing knowledge underlines the important role of
the intestinal flora for maintaining health and in the
prevention of disease. Evidence is emerging that the
intestinal flora does not exist as an entity by itself, but
is constantly interacting (‘communicating’) with the
environment, the central nervous system (CNS), the
endocrine system, and the immune system. Probiotics
offer dietary means to support the balance of intestinal
flora. They may be used to counteract immunological
dysfunctions, to stabilise the gut mucosal barrier
function, to prevent infectious succession of
pathogenic microorganisms or to influence intestinal
metabolism. Probiotics are essentially vital for health
and wellbeing in the current environment that we live
in.


SANJAY i respect your dedication and skill in allopathic medicine as a fellow medical practitioner. There are some newly emerging ideas things outside the circle of allopathic medicine that include hepato-enteric-autonomic-immune allostatic vitality, that in particular is emerging as the major potential source of oxidative stress that drives most of the western allopathic disease states, including diabetes, inflammatory bowel disease, heart disease, stokes, PCOS, fatty liver, hormonal and non-hormonal sensitive cancers-colon and breast cancer, obesity, neurological diseases including MS and Alzheimer's disease, the spondyloarthropathies, autoimmune disease in particular Rheumatoid arthritis, vitamin B12 deficiency, steatorrhea, irritable bowel syndrome (IBS) , psoriasis, eczema, cystic acne and chronic fatigue syndrome (CFS).

phew what a long list..

Most of these diseases have likely etiology in a decompensating gut-autonomic control, circadian rhythms are effected and the whole neuro-autonomic-endocrinal-immune axis starts going off the rails...probiotics are indicated in preventative protocols, after all complex disease states have many interacting etiologic factors that combine to manifest as disease.

There is a new vitalism alive in medicine that incorporates allostasis and nutrigenomics into a model of understanding that can explain why probiotics are useful for everyone to take for general health.

Anyway here is a recent BMJ metaanalysis on a related subject if you do end up taking antibiotics...

Aloysius L D’Souza, Chakravarthi Rajkumar, Jonathan Cooke, Christopher J Bulpitt
BMJ VOLUME 324 8 JUNE 2002 bmj.com

Abstract
Objective To evaluate efficacy of probiotics in
prevention and treatment of diarrhoea associated with
the use of antibiotics.
Design Meta-analysis; outcome data (proportion of
patients not getting diarrhoea) were analysed, pooled,
and compared to determine odds ratios in treated and
control groups.
Identification Studies identified by searching Medline
between 1966 and 2000 and the Cochrane Librar y.
Studies reviewed Nine randomised, double blind,
placebo controlled trials of probiotics.
Results Two of the nine studies investigated the
effects of probiotics in children. Four trials used a
yeast (Saccharomyces boulardii), four used lactobacilli,
and one used a strain of enterococcus that produced
lactic acid. Three trials used a combination of
probiotic strains of bacteria. In all nine trials, the
probiotics were given in combination with antibiotics
and the control groups received placebo and
antibiotics. The odds ratio in favour of active
treatment over placebo in preventing diarrhoea
associated with antibiotics was 0.39 (95% confidence
inter val 0.25 to 0.62; P < 0.001) for the yeast and 0.34
(0.19 to 0.61; P < 0.01 for lactobacilli. The combined
odds ratio was 0.37 (0.26 to 0.53; P < 0.001) in favour
of active treatment over placebo.

Conclusions The meta-analysis suggests that
probiotics can be used to prevent antibiotic associated
diarrhoea and that S boulardii and lactobacilli have the
potential to be used in this situation. The efficacy of
probiotics in treating antibiotic associated diarrhoea however
remains to be proved. A further large trial in which
probiotics are used as preventive agents should look
at the costs of and need for routine use of these
agents.

------------
These are several good papers, all can be found on pubmed. Probiotic research at the intersection of gastroenterology, immunology and microbiology is highly dynamic in both the basic and the clinical field at the moment.

Am J Clin Nutr2001;73(suppl):430S–6S.
Protection from gastrointestinal diseases with the use of
probiotics.Philippe R Marteau, Michael de Vrese, Christophe J Cellier, and Jürgen Schrezenmeir

J Pediatr (Rio J). 2006 November/December;82(5 Suppl):S189-S197. Links
The role of probiotics and prebiotics in pediatric practice.de Morais MB,
Jacob CM

World J Gastroenterol 2006 September 14;12(34): 5447-5457
Do probiotics have a therapeutic role in gastroenterology?
Jimmy K Limdi, Catherine O’Neill, John McLaughlin
http://www.wjgnet.com/1007-9327/12/5447.asp

Curr Issues Intest Microbiol. 2006 Sep;7(2):35-51. Links
Influence of the gastrointestinal microbiota on development of the immune system in young animals. Bauer E, Williams BA, Smidt H, Verstegen MW, Mosenthin

__________________
yours in health

http://drzog.blogspot.com

drzog

Zeppy cipro is almost identical to noroxin, maybe a bit stronger. Buscopan is the usual anticramp medication, alternatively hyoscine. Peppermint capsules -enteric coated also work well, herbal teas or powders from the local indian herbarium will be commonly sold for cramps, the herbs i mentioned in post 1 will also help alot.

The side effects of antibioitcs from the drug information provided by the drug companies:

all antibiotics can cause rare cases of Clostridium difficile overgrowth "pseudomembranous colitis", = Antibiotic associated colitis.

Antibiotic associated colitis has been rarely reported with ciprofloxacin, but it should be considered in patients who develop diarrhoea when taking these medicines.

Antibiotic associated pseudomembranous colitis has been reported with many antibiotics including ciprofloxacin and norfloxacin. A toxin produced by Clostridium difficile appears to be the primary cause. The severity of the colitis may range from mild to life threatening. It is important to consider this diagnosis in patients who develop diarrhoea or colitis in association with antibiotic use (this may occur up to several weeks after cessation of antibiotic therapy). Mild cases usually respond to drug discontinuation alone. However, in moderate to severe cases appropriate therapy such as oral antibacterial agents effective against Cl. difficile should be considered. Fluids, electrolytes and protein replacement should be provided when indicated.

Drugs which delay peristalsis, e.g. opiates and diphenoxylate with atropine (Lomotil), may prolong and/or worsen the condition and should not be used.


Effects on tendons. Achilles and other tendon ruptures that required surgical repair or resulted in prolonged disability have been reported with ciprofloxacin and other quinolones. Patients who are elderly or have had prior systemic treatment with corticosteroids are thought to be at particular risk. Therapy should be discontinued if the patient experiences pain, inflammation or rupture of a tendon.

Superinfections. As with other broad spectrum antimicrobial agents, prolonged use of ciprofloxacin may result in overgrowth of nonsusceptible organisms. Repeated evaluation of the patient's condition is essential. If superinfection occurs during therapy, appropriate measures should be taken.

Pseudomonas aeruginosa infections in cystic fibrosis. Although clinical improvement has been observed in patients with respiratory exacerbation of cystic fibrosis associated with Ps. aeruginosa, bacterial eradication is usually not achieved. Resistance to ciprofloxacin has been shown to develop in a significant proportion of Ps. aeruginosa infections in cystic fibrosis patients following a single course of the drug.

Anaphylactoid reactions. Serious, and occasionally fatal, anaphylactoid reactions, some following the first dose, have been reported in patients receiving quinolones (including ciprofloxacin). In these cases C-Flox should be discontinued and appropriate medical treatment given.

Phototoxicity. Ciprofloxacin has been shown to be phototoxic in a number of in vitro and in vivo studies. Nalidixic acid, the prototype quinolone antibiotic, and other quinolone antibiotics, produce photosensitivity reactions. Patients taking ciprofloxacin should avoid direct exposure to sunlight. Therapy should be discontinued if photosensitisation occurs.

Effects on the central nervous system. As with other quinolones, ciprofloxacin may cause central nervous system (CNS) stimulation, which may lead to transient tremor, restlessness, lightheadedness, confusion and, very rarely, to hallucinations or convulsive seizures. Ciprofloxacin should be used with caution in patients with CNS disorders such as severe cerebral arteriosclerosis or epilepsy.

Nervous system. Ciprofloxacin might exacerbate symptoms of myasthenia gravis. Therefore, at any clinical sign or symptom of an exacerbation of myasthenia gravis, a doctor should be consulted.

Cytochrome P450. Ciprofloxacin is known to be a moderate inhibitor of the CYP450 1A2 enzymes. Care should be taken when other drugs are administered concomitantly which are metabolised via the same enzymatic pathway (e.g. theophylline, methylxantines, caffeine, duloxetine). Increased plasma concentrations associated with drug specific side effects may be observed due to inhibition of their metabolic clearance by ciprofloxacin (see Interactions).

Crystalluria. The solubility of ciprofloxacin is pH dependent and is greatly reduced between pH 5 and 9. Crystals of ciprofloxacin have been observed in the urine of laboratory animals given high doses of the drug, but also in some patients receiving standard therapeutic doses. Crystalluria seems to occur under alkaline conditions of the urine and is less likely in nonvegetarians, who usually have an acidic urine. Patients receiving ciprofloxacin should be well hydrated and alkalinity of the urine should be avoided. It should, however, be noted that the activity of ciprofloxacin is significantly reduced in acid media.

Epileptic patients. As with other quinolones, ciprofloxacin may cause CNS stimulation which may lead to transient tremor, restlessness, lightheadedness, confusion and, very rarely, to hallucinations or convulsive seizures.

Ciprofloxacin should be used with caution in epileptics and in patients who have suffered from previous CNS disorders (e.g. lowered convulsion threshold, previous history of convulsion, reduced cerebral blood flow, altered brain structure or stroke). Ciprofloxacin should only be used where the benefits of treatment exceed the risks, since these patients are endangered because of possible central nervous side effects.

Effects on the liver. There can be a temporary increase in transaminases, alkaline phosphatase or cholestatic jaundice, especially in patients with previous liver damage.

Nick-H

Doctors... How many visitors to India, at a guess, in round numbers, catch dysentery? Recently on IndiaMike I've heard of one --- and he went on to tell us that he never bought bottled water, drank whatever came out of the tap wherever he went, and so on. I'm taking another guess here (waits for the doctors to jump on me ) but I'd say the chances of getting malaria are way higher. File it away under basic hygiene and basic precautions and forget about it.

I'd say that you would have to be very careless or work quite hard to put yourself at high risk of it? If you should get caught out in a monsoon-flooded village that has no sewage system anyway with no bottled water --- yikes! You'd be lucky to get out of there without catching something pretty bad

Most TD is a nuisance. Not particularly painful, you just have to know where the nearest loo is at all times. Living here, something upsets my stomach every few months. I spend half a day at home and its over. But as a visitor, it would last me several days. But it only once kept me in the room or caused me to cancel anything (although I didn't hang around Kochi fish market long ). Worst I ever suffered laid me low for my first week back in London, but I blame that one on the airline: you would not have wanted to even be in my house during that week at the end of which I got my doc's recomemendation of kaolin and morphine, which stopped the flow.

Now for those long train trips. Don't take a heap of medicine: take a couple of toilet rolls!!!! Unlike a few hours car trip, you will never be far from the loo in the train and you can follow my old mum's advice: "better out than in". But having your toilet roll or tissue box would be a great comfort. I do --- and I don't even use the stuff at home!

__________________
.


Just one member of the IndiaMike Mod Team

Zeppy

Thanks, doctors, for the helpful suggestions and the wealth of information! And Nick-H, your olympian editorial perspective is reassuring. But let's not lose sight of how all these queries from about-to-be India tourists started. The first post on this thread painted a rather dire picture:

If these are the symptoms of "mere" TD--and not of the more serious and rarer dysentery--it sure sounds bad enough to me!!

Nick-H

...It happens!

Here's a cliche for you: don't be afraid, be prepared.

If carrying a heap of medicines makes you feel good: do it! You can buy them all without prescriptions here. But the next stage is taking them, and I am not nearly so easy-going about all that self-prescription.

Basic care and hygiene will get you through: but mistakes happen too. My wife's ice-cream made her more ill than I have been in India for years! And she is the one always telling me to be careful...

zennn

(Lactobacil sachets contain a probiotic powder to be mixed in water. Darolac capsules are available. In India)

are those Lactobacillus GG (LGG)? Is neem a probiotic?
I am going in Idia in less than two months and would like to start taking probiotics does anyone knows a brand that i could buy in Canada that includes LGG?

SANJAY_DEL

It is best to avoid frozen foods like ice cream. It can harbor salmonellae, the bacteria that can cause severe gastro-enteritis.
Similarly canned food that goes bad carries Clostridia that can again lead to major gastro-intestinal upsets.
Staphylococcal food poisoning is often seen in the form of a local epidemic after a party or feast.

drzog

Zennn, In Canada I am sure you will be able to goto a good quality health food shop or chemist, inquire about probiotics with LCG or L. rhamnosus (same thing) in them. Ask if they have any heat stable ones for travel, otherwise pick up some of Sanjay's suggestions once in the motherland.

Neem is a herb not a probiotic: Azadirachta indica
check out http://www.neemfoundation.org/aboutneem.htm

Description
Deciduous tree up to 12 m tall with a straight trunk and long spreading branches. The neem tree is common on the plains of India.
DoseExtract
10 to 25 mL per week (1:2)

Indications
acne, boils, constipation, diarrhoea, dysentery, eczema, hyperacidity, infestation, worms, pruritus, psoriasis, ulcer, gastriointestinal infection

Contra Indications
pregnancy

Qualities
cold, bitter

Actions
anti-inflammatory, antiemetic, antimicrobial, antipruritic, antipyretic, antitussive, antiviral (systemically), depurative, emmenagogue

Nick-H

Many people say that daily eating of curd (yoghurt) is good for keeping up healthy gut flora: myth or reality?

drzog

Summary of a Review Article:
Freely available at the AJCN.org website


Yogurt and gut function
Oskar Adolfsson, Simin Nikbin Meydani, and Robert M Russell
Am J Clin Nutr 2004;80:245–56

(please note natural yogurt should not contain sugar for health benefits)


ABSTRACT
In recent years, numerous studies have been published on the health
effects of yogurt and the bacterial cultures used in the production of
yogurt. In the United States, these lactic acid–producing bacteria
(LAB) include Lactobacillus and Streptococcus species. The bene-
fits of yogurt and LAB on gastrointestinal health have been inves-
tigated in animal models and, occasionally, in human subjects. Some
studies using yogurt, individual LAB species, or both showed prom-
ising health benefits for certain gastrointestinal conditions, includ-
ing lactose intolerance, constipation, diarrheal diseases, colon can-
cer, inflammatory bowel disease, Helicobacter pylori infection, and
allergies. Patients with any of these conditions could possibly benefit
from the consumption of yogurt. The benefits of yogurt consumption
to gastrointestinal function are most likely due to effects mediated
through the gut microflora, bowel transit, and enhancement of gas-
trointestinal innate and adaptive immune responses.

INTRODUCTION
In many modern societies, fermented dairy products make up
a substantial proportion of the total daily food consumption.
Furthermore, it has long been believed that consuming yogurt
and other fermented milk products provides various health ben-
efits. Studies from the 1990s on the possible health properties
of yogurt added to this belief.

Yogurt is one of the best-known of the foods that contain
probiotics. Yogurt is defined as a coagulated milk product that
results from the fermentation of lactic acid in milk by
Lactobacillus bulgaricus and Streptococcus thermophilus.
Other lactic acid bacteria (LAB) species
are now frequently used to give the final product unique charac-
teristics. As starter cultures for yogurt production, LAB species
display symbiotic relations during their growth in milk medium.
Thus, a carefully selected mixture of LAB species is used to
complement each other and to achieve a remarkable efficiency in
acid production. Furthermore, to increase the number of LAB
that survive the low pH and high acidity of the gastrointestinal
environment, some LAB species that are indigenous to the hu-
man intestine have been used in yogurt production. To meet the
National Yogurt Association’s criteria for “live and active cul-
ture yogurt,” the finished yogurt product must contain live LAB
in amounts > 10 to the power of 8 organisms/g at the time of manufacture, and
the cultures must remain active at the end of the stated shelf life,
as ascertained with the use of a specific activity test.

NUTRITIONAL VALUE OF YOGURT

The final nutritional composition of
yogurt is affected by the species and strains of bacteria used
in the fermentation, the source and type of milk solids that may
be added before fermentation, and the temperature and duration
of the fermentation process.

Dairy products have generally been considered an excellent
source of high-quality protein, calcium, potassium, phosphorus,
magnesium, zinc, and the B vitamins riboflavin, niacin, vitamin
B-6, and vitamin B-12.

Bacteria present in yogurt, such as L. bulgaricus and S. thermophilus, expressed functional lactase, the enzyme that breaks down lactose. This ex-
pression may also contribute to better tolerance of lactose in yogurt
than of lactose in milk by persons with lactose maldigestion.

During fermentation, both heat treatment and acid production
result in finer coagulation of casein, which may also contribute to
the greater protein digestibility of yogurt than of milk. Proteins in
yogurt are of excellent biological quality, as are those in milk,
because the nutritional value of milk proteins is well preserved
during the fermentation process (20). Both the caseins and the
whey proteins in yogurt are rich sources of all the essential amino
acids,

Yogurt has been shown to have a higher
concentration of conjugated linoleic acid (CLA), a long-chain derivative of linoleic acid (an essential fatty acid). A fermented dairy product
from India, referred to as dahi, has also been shown to have higher
CLA content than does nonfermented dahi. The major sources
of CLA in our diets are animal products from ruminants, in which
CLA is synthesized by rumen bacteria. CLA was reported to have immunostimulatory and anticarcinogenic properties. In a recent study of breast and colon cancer cells, Kemp et al showed that the anticarcinogenic
properties of CLA may be due to the ability of CLA to inhibit tumor growth.

Yogurt is an excellent source of calcium and phosphorus. In fact, dairy prod-
ucts such as milk, yogurt, and cheese provide most of the highly
bioavailable calcium in the typical Western diet. Because of the
lower pH of yogurt compared with that of milk, calcium and
magnesium are present in yogurt mostly in their ionic forms.

MECHANISTIC RATIONALE FOR POTENTIAL BENEFITS OF YOGURT ON GUT FUNCTION AND HEALTH

It has been suggested that yogurt and lactic acid bacteria (LAB) contribute to several facets of gastrointestinal health: the makeup of the gastro-
intestinal flora, the immune response, and laxation.

-Gut-associated immune response

The mucosal lymphoid tissue of the gastrointestinal tract plays
an important role as a first line of defense against ingested patho-
gens. The interactions of LAB with the mucosal epithelial lining
of the gastrointestinal tract, as well as with the lymphoid cells
residing in the gut, have been suggested as the most important
mechanism by which LAB enhances gut immune function. Sev-
eral factors have been identified as contributing to the immuno-
modulating and antimicrobial activities of LAB, including the
production of low pH, organic acids, carbon dioxide, hydrogen
peroxide, bacteriocins, ethanol, and diacetyl; the depletion of
nutrients; and competition for available living space .
The gastrointestinal tract is a complex immune system tissue.
The main site of the mucosal immune system in the gut is referred
to as gut-associated lymphoid tissue (GALT), which can be di-
vided into inductive and effector sites. In the small intestine, the
inductive sites are in the Peyer’s patches, which consist of large
lymphoid follicles in the terminal small intestine. The best-
defined effector component of the mucosal adaptive immune
system is secretory immunoglobulin A (sIgA). sIgA is the main
immunoglobulin of the humoral immune response, which to-
gether with the innate mucosal defenses provides protection
against microbial antigens at the intestinal mucosal surface (54).
In a healthy person, sIgA inhibits the colonization of pathogenic
bacteria in the gut, as well as the mucosal penetration of patho-
genic antigens. At least 80% of all the body’s plasma cells, the
source of sIgA, are located in the intestinal lamina propria
throughout the length of the small intestine. IgA is the most
abundantly produced immunoglobulin in the human body. The
production of intestinal sIgA requires the presence of commensal
microflora, which indicates that the production of intestinal
sIgA is induced in response to antigenic stimulation.

Thus the IgA-enhancing effect of yogurt intake may have both an effect on the gut and a systemic effect.

CONCLUDING REMARKS AND RECOMMENDATIONS FOR FUTURE STUDIES

It has long been believed that the consumption of yogurt and
other fermented milk products provides various health benefits.
Recent studies of the possible health benefits of yogurt in gut-
associated diseases substantiate some of these beliefs. Of partic-
ular interest are the reduction— by yogurt, yogurt bacteria, or
both—in the duration of diarrheal diseases in children, the pre-
ventive or therapeutic (or both) effects on IBD and colon cancer
as suggested by epidemiologic evidence and animal studies, and
the possible beneficial effects in increasing the eradication rate of
H. pylori as indicated by in vitro and preliminary human studies.
In addition, there is ever-increasing evidence of the beneficial
effect of yogurt containing live and active cultures on the diges-
tion of lactose in persons with lactose intolerance.

DrZ

SANJAY_DEL

Strength in Yogurt

An interesting article on the benefits of yogurt:

Link: http://www.webmd.com/content/article/42/1668_50852.htm

johngradycole

Many thanks Drzog and Sanjay_Del again for your extraordinary well-informed posts!

Well here we are, Mr and Mrs Jason, in India for the first ever time and utterly boggled by the whole experience. As for eating we're being good good good following all of your advice and so far we are fine. However there are a couple of questions we'd really like your expert advice on.

Here's one that didn't occur to either of us before we left: how safe is it to drink tea/coffee at a cafe or restaurant? Presumably ths is made with tap water, boiled. Is this enough to make it safe (presumably not) and is there any way to drink a cup of coffee with a clear conscience?

The other one is: Neem sounds brilliant. Can't find it anywhere though. Where would we look? Would we need to track down a speciality chemist's shop (not the easiest thing in the world s far)?

I apologise for the sheer ignorance that I know these questions betray. If anyone can help to cure my ignorance, I'd be ever so grateful.

Cheers,

Jason

Nick-H

I've never got sick from tea. Even from street shops, though I often wonder what the glasses were washed in, and drinking from them is against my [Indian] wife's advice...

In hotels and restaurants you should be fine with tea and coffee.

Especially tea, which just doesn't work unless the water is boiling, and especially Indian tea, which should be simmered.

Neem... Hmmm. You could look for makes like 'Himalaya' who may do it as tablets. Others probably no more...

cyberbaba

neem.
it's a tree.
ask the locals which one.
pick the leaves and eat them.
take some with you as you go.
bitter... but that's why they work.
you will get used to them.

Nick-H

Wash then first!