Bali Belly: How to Avoid It and What to Do When It Hits

Bali belly is the local name for travellers' diarrhoea, and it is the most common reason visitors lose a day or two of their holiday. It is rarely dangerous for healthy adults, it usually clears up on its own within a few days, and most of what helps is simple: fluids, rest and knowing when to stop waiting it out.

This guide covers how to lower your chances without living on crackers, what to do when it hits, and where to find a doctor. It is general information, not medical advice, so if in doubt, see a doctor.

What Bali belly actually is

There is nothing uniquely Balinese about it. "Bali belly" is the same travellers' diarrhoea people pick up in many warm countries, caused by germs swallowed with food, water or from unwashed hands. Bacteria cause most cases, with a type of E. coli at the top of the list, followed by others such as Campylobacter, Shigella and Salmonella. Viruses such as norovirus cause a smaller share, and parasites such as Giardia turn up mostly in people who stay longer.

Typical symptoms are loose or watery stools, stomach cramps, nausea, sometimes vomiting, and a washed-out, tired feeling. It usually starts somewhere between a few hours and a few days after the meal or drink that caused it. Viral bouts tend to pass in two or three days. Untreated bacterial diarrhoea commonly lasts three to seven days, and many people feel better well before that.

Why visitors get it

Your gut is simply meeting bacteria it has never met before. People who grew up in Bali have had years to adjust, while a visitor arrives with no tolerance at all. On a two-week trip to a warm destination, somewhere between a third and two thirds of travellers get at least one episode, depending on the place and the season. Having had it once does not protect you from a second round.

The usual routes in are:

• Water. Tap water in Bali is not safe to drink, and the same goes for ice and drinks made with untreated water.
• Food that has been sitting. Buffets, dishes cooked hours ago and kept lukewarm, and sauces left out at room temperature.
• Raw produce. Salads, herbs and fruit rinsed in tap water.
• Hands. Your own, after touching money, phones, handrails and scooter handles.

How to lower your risk

You cannot bring the risk down to zero. Studies of the classic rule "boil it, cook it, peel it or forget it" show that even careful travellers still get sick. What you can do is cut out the obvious risks and keep enjoying the food.

Water and ice

• Drink sealed bottled water, or refills from a filtered dispenser at your hotel, villa or café. In homes and villas the big 19-litre galon bottles are normal, and a sealed, branded galon is a safer bet than an unlabelled refill.
• Check the cap is sealed before you open a bottle.
• Brushing your teeth with tap water is a small risk. If your stomach is sensitive, use bottled water, and keep your mouth closed in the shower.
• Ice in established restaurants, cafés and hotels is usually factory-made from purified water, typically the cylinder-shaped tube ice delivered in sealed bags. Be more careful with ice chipped from large blocks at roadside stalls, since block ice is often produced for keeping things cold rather than for drinks.

Salads, fruit and juices

Cooked food served hot is the safest thing on any menu. Raw salads and garnishes are the higher-risk choice, especially in your first few days, because they may have been rinsed in tap water. Fruit you peel yourself, such as bananas, mangoes, mangosteen and rambutan, is low risk. Fresh juices and smoothies are only as safe as the water and ice that went into them, so in a busy café that makes hundreds a day they are usually fine, while a stall with an open bucket of ice is more of a gamble.

Street food, realistically

Avoiding warungs and street food would mean missing some of the best food on the island, and it is not necessary. A busy warung that cooks to order over a high flame and sells out every day is often a better bet than a hotel buffet that has been sitting under heat lamps since breakfast. A few rules of thumb:

• Pick places with plenty of local customers and fast turnover.
• Watch your food being cooked, and eat it hot.
• Be wary of pre-cooked dishes that sit uncovered for hours, especially rice, eggs and seafood.
• Sambal and sauces in open bowls on the table are a small but real risk.
• Give raw or lightly cooked seafood a miss unless you trust the kitchen.

Hands

This is the step most people skip. Wash with soap and water before you eat and after the toilet. Carry an alcohol hand gel with at least 60 per cent alcohol for when there is no sink, but soap and water work better, especially against norovirus. Many warungs have a sink at the side, so use it.

Probiotics and preventive pills

Probiotics are harmless for most people, but the evidence that they prevent travellers' diarrhoea is mixed. Taking antibiotics "just in case" is not recommended for healthy travellers, because of side effects and the spread of drug-resistant bacteria. If you have a condition that makes diarrhoea more dangerous for you, such as inflammatory bowel disease, kidney problems or a weakened immune system, ask your doctor for a plan before you travel.

When it hits: what to do

Drink, and drink the right thing

The main danger of diarrhoea is losing fluid and salts, not the germ itself. Sip steadily rather than gulping large amounts at once, especially if you feel sick.

Oral rehydration salts are the best option once you are losing a lot of fluid. In Indonesia they are sold as oralit, in small sachets at every apotek (pharmacy), and they cost a few thousand rupiah at most. Most Indonesian sachets are mixed with 200 ml of clean drinking water, but check the pack because brands differ, and use bottled or boiled water, never tap water.

For a mild bout, any safe drink helps: water, clear soup, weak tea, or isotonic drinks such as the Pocari Sweat sold in every minimart. Coconut water is gentle and pleasant but low in salt, so it does not replace oralit when you are losing a lot. Go easy on very sugary soft drinks, and skip alcohol and strong coffee until you are better. A simple check that you are drinking enough: you are passing pale urine regularly.

Rest and eat simply

Stay out of the sun, skip the surf session and let your body do its work. Eat when you feel like it. Plain rice, bubur (Indonesian rice porridge), toast, bananas, crackers and clear broth are easy on the stomach. Leave fried, very spicy and rich food, dairy and alcohol until things settle.

Anti-diarrhoea tablets

Loperamide (sold in many countries as Imodium) slows the gut and can make a long drive or flight bearable. It does not cure the infection, and it should not be used if you have a fever, blood or mucus in your stool, or for young children. Read the leaflet and ask the pharmacist if you are unsure. Indonesian pharmacies also sell adsorbent remedies such as activated charcoal tablets. None of these replace fluids.

Antibiotics

Antibiotics can shorten a bacterial bout by a day or two, but most cases do not need them, and they come with side effects. In Indonesia they are prescription-only. If your symptoms are severe, or you have a fever or blood in your stool, see a doctor, who can decide whether you need one and which.

Warning signs: when to see a doctor

See a doctor promptly, ideally the same day, if you have any of these:

• Blood or mucus in your stool, or black, tarry stool.
• A fever of 38.5°C or higher.
• Vomiting that stops you keeping fluids down.
• Signs of dehydration: very little or very dark urine, dizziness when you stand up, a dry mouth, a racing heart, confusion or unusual drowsiness.
• Severe or constant stomach pain.
• No improvement after about three days, or diarrhoea that drags on for more than two weeks.

Lower the bar for babies and young children, older people, pregnant women and anyone with a long-term illness, because they become dehydrated faster.

One point that matters in Bali: a high fever with stomach symptoms is not always Bali belly. Dengue and typhoid can both start with fever, aches and an upset stomach. If you have a high fever, get checked and ask for a blood test rather than waiting it out. Until a doctor has ruled out dengue, avoid ibuprofen and aspirin.

Where to get help in Bali

Doctors who come to you

If you feel too unwell to travel, you do not have to. Many clinics in the south and in Ubud send doctors to hotels and villas, and BIMC, for example, lists home visits and teleconsultations among its services. Your hotel reception or villa manager will usually know a local on-call doctor. A visiting doctor can assess how dehydrated you are, treat you on the spot or arrange tests, and send you to a clinic if you need more.

Indonesian telemedicine apps such as Halodoc let you chat or video-call a doctor licensed in Indonesia, get an electronic prescription where appropriate, and have medicines delivered from a nearby pharmacy, often within about an hour. Set the app up while you are well rather than when you are doubled over.

Clinics and hospitals by area

For most cases of Bali belly a clinic is all you need. These are well-known options with 24-hour emergency care or round-the-clock clinics. Details change, so check before you go, and call your insurer first if you can.

• Kuta, Legian, Seminyak and the airport area: BIMC Hospital Kuta on Jalan Bypass Ngurah Rai, and Siloam Hospitals Bali on Sunset Road.
• Nusa Dua and Jimbaran: BIMC Hospital Nusa Dua in the ITDC resort area, and Kasih Ibu Hospital in Kedonganan, near Jimbaran.
• Uluwatu and the Bukit: clinics such as Unicare Clinic on Jalan Raya Uluwatu, which runs around the clock. Serious cases go on to Jimbaran, Nusa Dua or Kuta.
• Canggu: several 24-hour clinics on the main roads, with hospitals in Kuta and Denpasar.
• Sanur and Denpasar: Bali International Hospital in Sanur, Kasih Ibu Hospital on Jalan Teuku Umar, and RSUP Prof. Ngoerah (formerly Sanglah Hospital), the island's main public referral hospital.
• Ubud: BIMC Ubud on Jalan Raya Sanggingan, with a 24-hour emergency room and pharmacy, plus clinics such as Unicare in Pengosekan and Ubud Care in Peliatan.

Go to a hospital emergency department rather than a clinic if you are badly dehydrated, confused, have blood in your stool with a high fever, or cannot keep anything down. In an emergency dial 112, or 118 or 119 for an ambulance. In heavy traffic, a taxi or ride-hailing car to the nearest emergency department is often quicker than waiting.

Paying for treatment

Private clinics and hospitals often ask for payment, a deposit or a guarantee from your insurer before treatment, so carry a card and your policy details. Keep every receipt and the doctor's report for your claim.

A small kit to pack

• A few sachets of oral rehydration salts, or buy oralit on your first day.
• Loperamide for travel days, and paracetamol for aches and fever.
• Alcohol hand gel.
• Your travel insurer's 24-hour assistance number, saved in your phone.