Health: Miscellaneous Medical Problems
Posted on 29. Dec, 2009 by Mikey Leung in 2. Practical Information
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Travellers’ diarrhoea
Travelling in Bangladesh carries a fairly high risk of getting a dose of travellers’ diarrhoea, or the ‘chitta shittas’ as its sometimes referred to; perhaps half of all visitors will suffer and the newer you are to exotic travel, the more likely you will be to suffer. By taking precautions against travellers’ diarrhoea you will also avoid typhoid, paratyphoid, cholera, hepatitis, dysentery, worms, etc. Travellers’ diarrhoea and the other faecal-oral diseases come from getting other people’s faeces in your mouth. This most often happens from cooks not washing their hands after a trip to the toilet, but even if the restaurant cook does not understand basic hygiene you will be safe if your food has been properly cooked and arrives piping hot. The most important prevention strategy is to wash your hands before eating anything. You can pick up salmonella and shigella from toilet door handles and possibly banknotes. The maxim to remind you what you can safely eat is:
PEEL IT, BOIL IT, COOK IT OR FORGET IT.
This means that fruit you have washed and peeled yourself, and hot foods, should be safe but raw foods, cold cooked foods, salads, fruit salads which have been prepared by others, ice cream and ice are all risky, and foods kept lukewarm in hotel buffets are often dangerous. That said, plenty of travellers and expatriates enjoy fruit and vegetables, so do keep a sense of perspective: food served in a fairly decent hotel in a large town or a place regularly frequented by expatriates is likely to be safe. If you are struck, see box for treatment.
Treating Travellers’ Diarrhoea
Dr Jane Wilson-Howarth
It is dehydration that makes you feel awful during a bout of diarrhoea and the most important part of treatment is drinking lots of clear fluids. Sachets of oral rehydration salts give the perfect biochemical mix to replace all that is pouring out of your bottom but other recipes taste nicer. Any dilute mixture of sugar and salt in water will do you good: try Coke or orange squash with a three-finger pinch of salt added to each glass (if you are salt-depleted you won’t taste the salt). Otherwise make a solution of a four-finger scoop of sugar with a three-finger pinch of salt in a 500ml glass. Or add eight level teaspoons of sugar (18g) and one level teaspoon of salt (3g) to one litre (five cups) of safe water. A squeeze of lemon or orange juice improves the taste and adds potassium, which is also lost in diarrhoea. Drink two large glasses after every bowel action, and more if you are thirsty. These solutions are still absorbed well if you are vomiting, but you will need to take sips at a time. If you are not eating you need to drink three litres a day plus whatever is pouring into the toilet. If you feel like eating, take a bland, high carbohydrate diet. Heavy greasy foods will probably give you cramps.
If the diarrhoea is bad, or you are passing blood or slime, or you have a fever, you will probably need antibiotics in addition to fluid replacement. A dose of norfloxacin or ciprofloxacin repeated twice a day until better may be appropriate (if you are planning to take an antibiotic with you, note that both norfloxacin and ciprofloxacin are available only on prescription in the UK). Ciprofloxacin is considered to be less effective in Bangladesh. If the diarrhoea is greasy and bulky and is accompanied by sulphurous (eggy) burps, one likely cause is giardia. This is best treated with tinidazole (four x 500mg in one dose, repeated seven days later if symptoms persist).
Eye problems
Bacterial conjunctivitis (pink eye) is a common infection in south Asia; people who wear contact lenses are most open to this irritating problem. The eyes feel sore and gritty and they will often be stuck together in the mornings. They will need treatment with antibiotic drops or ointment. Lesser eye irritation should settle with bathing in salt water and keeping the eyes shaded. If an insect flies into your eye, extract it with great care, ensuring you do not crush or damage it otherwise you may get a nastily inflamed eye from toxins secreted by the creature. Small, elongated red-and-black blister beetles carry warning colouration to tell you not to crush them anywhere against your skin.
Prickly heat
This ailment is definitely a common problem in Bangladesh, especially during the hottest months of April–June. A fine pimply rash on the trunk is likely to be heat rash; cool showers, dabbing dry, and talc will help. Treat the problem by slowing down to a relaxed schedule, wearing only loose, baggy,100% cotton clothes and sleeping naked under a fan; if it’s bad you may need to check into an air-conditioned hotel room for a while.
Skin infections
Any mosquito bite or small nick in the skin gives an opportunity for bacteria to foil the body’s usually excellent defences; it will surprise many travellers how quickly skin infections start in warm humid climates and it isessential to clean and cover even the slightest wound. Creams are not as effective as a good drying antiseptic such as dilute iodine, potassium permanganate (a few crystals in half a cup of water) or crystal (or gentian) violet. One of these should be available in most towns. If the wound starts to throb, or becomes red and the redness starts to spread, or the wound oozes, and especially if you develop a fever, antibiotics will probably be needed: flucloxacillin (250mg four times a day) or cloxacillin (500mg four times a day). For those allergic to penicillin, erythromycin (500mg twice a day) for five days should help. See a doctor if the symptoms do not start to improve within 48 hours.
Fungal infections also get a hold easily in hot, moist climates so wear 100% cotton socks and underwear and shower frequently. An itchy rash in the groin or flaking between the toes is likely to be a fungal infection. This needs treatment with an antifungal cream such as Canesten (clotrimazole); if this is not available try Whitfield’s ointment (compound benzoic acid ointment) or crystal violet (although this will turn you purple!).
Other insect-borne diseases
Malaria is by no means the only insect-borne disease to which the traveller may succumb. Others include sleeping sickness and river blindness (see box Avoiding insect bites, page 000). Dengue fever is common in Bangladesh and there are many other similar arboviruses. These mosquito-borne diseases may mimic malaria but there is no prophylactic medication against them. The Aedes mosquitoes that carry dengue fever viruses bite during the daytime, so it is worth applying repellent if you see any of these mosquitoes around. After killing it, you can identify such a mosquito by the presence of white bands on its legs. These mosquitoes generally acquire the dengue virus after feeding on the blood of an infected person, and after an incubation period of eight to ten days the mosquito is capable of transmitting the disease for the rest of its life. Infected people are the main carriers and multipliers of this virus, generally circulating in the blood of the infected person at the same time that they have their fever.
Symptoms of dengue include strong headaches, rashes and excruciating joint and muscle pains and high fever. Viral fevers usually last about a week or so and are not usually fatal. Complete rest and paracetamol are the usual treatment; plenty of fluids also help. Some patients are given an intravenous drip to keep them from dehydrating. It is especially important to protect yourself if you have had dengue fever before, since a second infection with a different strain can result in the potentially fatal dengue haemorrhagic fever.
Avoiding Insect Bites
As the sun is going down, don long clothes and apply repellent on any exposed flesh. Pack a DEET-based insect repellent (roll-ons or stick are the least messy preparations for travelling). You also need either a permethrin-impregnated bed-net or a permethrin spray so that you can ‘treat’ bed-nets in hotels. Permethrin treatment makes even very tatty nets protective and prevents mosquitoes from biting through the impregnated net when you roll against it; it also deters other biters. Otherwise retire to an air-conditioned room or burn mosquito coils (which are widely available and cheap in Bangladesh) or sleep under a fan. Coils and fans reduce rather than eliminate bites. Travel clinics usually sell a good range of nets,
treatment kits and repellents.Mosquitoes and many other insects are attracted to light. If you are camping, never put a lamp near the opening of your tent, or you will have a swarm of biters waiting to join you when you retire. In hotel rooms, be aware that the longer your light is on, the greater the number of insects will be sharing your accommodation.
Aside from avoiding mosquito bites between dusk and dawn, which will protect you from elephantiasis and a range of nasty insect-borne viruses, as well as malaria (see page 000), it is important to take precautions against other insect bites. During the day it is wise to wear long, loose (preferably 100% cotton) clothes; this will keep off ticks and day-biting Aedes mosquitoes which may spread viral fevers, including yellow fever.
Bilharzia or schistosomiasis
with thanks to Dr Vaughan Southgate of the Natural History Museum, London, and Dr Dick Stockley, The Surgery, Kampala
Bilharzia or schistosomiasis is a disease that commonly afflicts the rural poor of the tropics. It is an unpleasant problem that is worth avoiding, though can be treated if you do get it. This parasite is common in almost all water sources in Bangladesh. The most risky places are where infected people use water, wash clothes or bathe, etc.
It is easier to understand how to diagnose it, treat it and prevent it if you know a little about the life cycle. Contaminated faeces are washed into the lake, the eggs hatch and the larva infects certain species of snail. The snails then produce about 10,000 cercariae a day for the rest of their lives. The parasites can digest their way through your skin when you wade, or bathe in infested fresh water.
Winds disperse the snails and cercariae. The snails in particular can drift a long way, especially on windblown weed, so nowhere is really safe. However, deep water and running water are safer, while shallow water presents the greatest risk. The cercariae penetrate intact skin, and find their way to the liver. There male and female meet and spend the rest of their lives in permanent copulation. No wonder you feel tired! Most finish up in the wall of the lower bowel, but others can get lost and can cause damage to many different organs. Schistosoma haematobium goes mostly to the bladder.
Although the adults do not cause any harm in themselves, after about four to six weeks they start to lay eggs, which cause an intense but usually ineffective immune reaction, including fever, cough, abdominal pain, and a fleeting, itching rash called ‘safari itch’. The absence of early symptoms does not necessarily mean there is no infection. Later symptoms can be more localised and more severe, but the general symptoms settle down fairly quickly and eventually you are just tired. ‘Tired all the time’ is one of the most common symptoms among expats in south Asia, and bilharzia, giardia, amoeba and intestinal yeast are the most common culprits.
Although bilharzia is difficult to diagnose, it can be tested at specialist travel clinics. Ideally tests need to be done at least six weeks after likely exposure and will determine whether you need treatment. Fortunately it is easy to treat at present.
Avoiding bilharzia
If you are bathing, swimming, paddling or wading in fresh water which you think may carry a bilharzia risk, try to get out of the water within ten
minutes.
- Avoid bathing or paddling on shores within 200m of villages or places where people use the water a great deal, especially reedy shores or where there is lots of water weed.
- Dry off thoroughly with a towel; rub vigorously.
- If your bathing water comes from a risky source try to ensure that the water is taken from the lake in the early morning and stored snail-free, otherwise it should be filtered or Dettol or Cresol added.
- Bathing early in the morning is safer than bathing in the last half of the day.
- Cover yourself with DEET insect repellent before swimming: it may offer some protection.
HIV/AIDS
The risks of sexually transmitted infection are extremely high in Bangladesh, whether you sleep with fellow travellers or locals. About 80% of HIV
infections in British heterosexuals are acquired abroad. If you must indulge, use condoms or femidoms, which help reduce the risk of transmission. If you notice any genital ulcers or discharge, get treatment promptly since these increase the risk of acquiring HIV. If you do have unprotected sex, visit a clinic as soon as possible; this should be within 24 hours, or no later than 72 hours, for post-exposure prophylaxis.
In Bangladesh, HIV/AIDS prevalence remains extremely low, probably a result of the conservative culture of the country, although the incidence of more minor sexually transmitted diseases is high. For HIV/AIDS, occurrence rates are quite high amongst intravenous drug users and there is little knowledge or prevention action taken in the country. Therefore, it could become a high-prevalence area a few years down the track.
Meningitis
This is a particularly nasty disease as it can kill within hours of the first symptoms appearing. The telltale symptoms are a combination of a blinding
headache (light sensitivity), a blotchy rash and a high fever. Immunisation protects against the most serious bacterial form of meningitis and the tetravalent vaccine ACWY is recommended for Bangladesh by British travel clinics, but if this is not available then A+C vaccine is better than nothing.
Although other forms of meningitis exist (usually viral), there are no vaccines for these. Local papers normally report localised outbreaks. A severe headache and fever should make you run to a doctor immediately. There are also other causes of headache and fever, one of which is typhoid, which occurs in travellers to Bangladesh. Seek medical help if you are ill for more than a few days.
Rabies
Rabies is carried by all mammals (beware the village dogs and small monkeys that are used to being fed in the parks) and is passed on to man through a bite, scratch or a lick of an open wound. You must always assume any animal is rabid, and seek medical help as soon as possible. Meanwhile scrub the wound with soap under a running tap or while pouring water from a jug. Find a reasonably clear-looking source of water (but at this stage the quality of the water is not important), then pour on a strong iodine or alcohol solution of gin, whisky or rum. This helps stop the rabies virus entering the body and will guard against wound infections, including tetanus.
Pre-exposure vaccinations for rabies are ideally advised for everyone, but is particularly important if you intend to have contact with animals and/or are likely to be more than 24 hours away from medical help. Ideally three doses should be taken over a minimum of 21 days, though even taking one or two doses of vaccine is better than none at all. Contrary to popular belief these vaccinations are relatively painless
If you are bitten, scratched or licked over an open wound by a sick animal, then post-exposure prophylaxis should be given as soon as possible, though it is never too late to seek help, as the incubation period for rabies can be very long. Those who have not been immunised will need a full course of injections. The vast majority of travel health advisers including the WHO recommend rabies immunoglobulin (RIG), but this product is expensive (around US$800) and may be hard to come by – another reason why pre-exposure vaccination should be encouraged.
Tell the doctor if you have had pre-exposure vaccine, as this should change the treatment you receive. And remember that, if you do contract rabies, mortality is 100% and death from rabies is probably one of the worst ways to go.
Tickbite fever
South Asian ticks are not the rampant disease transmitters they are in the Americas, but they may spread tickbite fever and a few dangerous rarities in Bangladesh. Tickbite fever is a flu-like illness that can easily be treated with doxycycline, but as there can be some serious complications it is important to visit a doctor.
Ticks should ideally be removed as soon as possible as leaving them on the body increases the chance of infection. They should be removed with special tick tweezers that can be bought in good travel shops. Failing that you can use your fingernails: grasp the tick as close to your body as possible and pull steadily and firmly away at right angles to your skin. The tick will then come away complete, as long as you do not jerk or twist. If possible douse the wound with alcohol (any spirit will do) or iodine. Irritants (eg: Olbas oil) or lit cigarettes are to be discouraged since they can cause the ticks to regurgitate and therefore increase the risk of disease. It is best to get a travelling companion to check you for ticks; if you are travelling with small children, remember to check their heads, and particularly behind the ears.
Spreading redness around the bite and/or fever and/or aching joints after a tick bite imply that you have an infection that requires antibiotic treatment, so seek advice.
Snake bite
Snakes rarely attack unless provoked, and bites in travellers are unusual. You are less likely to get bitten if you wear stout shoes and long trousers when in the forests of Bangladesh, plus these will help ward off leeches. The only other time where there is a risk of snake bite is during the flood seasons in Bangladesh, when the snakes, like people, attempt to move to higher ground. Most snakes are harmless and even venomous species will dispense venom in only about half of their bites. If bitten, then, you are unlikely to have received venom; keeping this fact in mind may help you to stay calm. Many so-called first-aid techniques do more harm than good: cutting into the wound is harmful; tourniquets are dangerous; suction and electrical inactivation devices do not work. The only treatment is antivenom. In case of a bite that you fear may have been from a venomous snake:
- Try to keep calm – it is likely that no venom has been dispensed.
- Prevent movement of the bitten limb by applying a splint.
- Keep the bitten limb BELOW heart height to slow the spread of any venom.
- If you have a crêpe bandage, wrap it around the whole limb (eg: all the way from the toes to the thigh), as tight as you would for a sprained ankle or a muscle pull.
Evacuate to a hospital that has antivenom. At the time of writing this is only known to be available in Dhaka. Many centres have an Indian antivenom but unfortunately this isn’t effective against the most common biting snakes in Bangladesh. Antivenom that includes all the common biters is held by ICCDR Travellers Clinic (68 Shaheed Tajuddin Ahmed Sharani, Mohakhali;
tel: 02 8860523–32; e-mail : info@icddrb.org; www.icddrb.org; time : 09.00–12.00 & 14.00–17.00
Sun–Thu).
And remember:
- NEVER give aspirin; you may take paracetamol, which is safe.
- NEVER cut or suck the wound.
- DO NOT apply ice packs.
- DO NOT apply potassium permanganate.
