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Frequently Asked
Travel Health Questions

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Infections

Jules Eden, travel medicine specialist and founder of e-med, answers travellers' questions - as published in the following national publications

  • The Guardian
  • Independent On Sunday and/or
  • Geographical Magazine

Q. I have spent the last two winters in Singapore and do quite a lot of walking, always making sure I carry adequate water. The second winter after recovering from some bug I picked up (on the aircraft I assumed) I felt nauseous and had a job making myself eat and lacked my usual energy, not getting back to normal until I came home some weeks later. In "the old days" we were advised to take salt tablets in tropical climates. Could this help?

A. Not really. Things have moved on since then. I assume you had some kind of chest or upper respiratory infection, as they are the most commonly caught on planes. So the nausea and lack of vigour was a part of that.

Salt tablets had their place in those suffering fluid loss, either through excessive sweat or diarrhoea. Sodium acts osmotically to retain fluid in the body so keeping it hydrated. But your problem, probably was not related to lack of circulating fluid volume, but just a general bug in your system. If it were to do with the dreaded D, then there are better salts on the market like Dioralyte that also replaces potassium and glucose. And it comes in different flavours, rather than "salty".

Q. My son has spent seven years guiding in Africa where he contracted malaria. On a recent trip home he hoped to have blood tests for that and to confirm he hadn't picked up anything else (he has travelled extensively beyond Africa and also took part in the Gulf war). Unless he was showing symptoms when he could present himself at a local A&E, the answerphone message at the Tropical Diseases Hospital recommended referral from a GP which took too long. Is there a walk-in one-stop-shop for comprehensive testing for diseases or one that would arrange an appointment by email prior to his next trip to the UK?

A. This is one of those issues that the NHS does not do very well. As your son is well but simply wants tests to confirm this after travelling, he comes way down the list in any hospital referral system. It would be a long wait for the tests and then the results, perhaps up to 3 months.

I suggest he tries a private clinic in London where any travel health related test can be done. From stool samples for giardia to blood tests for bilharzia, it is possible to have them all done with the results in a few days.

Q. I have recently returned from living in a hot climate and have developed a fungus under some of my toe- nails. I have been advised that the only way to treat this is with a steroid treatment, which has an 80% chance of success, takes 4 months and has nasty side effects. Do you know of any other possible treatment I could try?

A. Your advice was well off the mark there. Steroids have no place whatsoever in treating fungal nail infections. You need anti-fungals.

The difficulty in treating these infections is that concentrating the drug into the heavy keratin of the toe-nail takes a while. A tablet taken by mouth disperses into the whole body via the arterial blood supply, and toe-nails have little in the way of this sort of supply.

So your advice is correct with the length of treatment.

Probably the best tablet is called terbinafine. Taken daily for 4 months, it does have a good success rate, but a few side effects. Your liver function has to monitored at intervals and the treatment stopped if the blood results show liver changes.

Another treatment favoured by podiatrists is Loceryl. This is a nail paint applied directly onto the nail for a long time. Results are less good than terbinafine, but there are no adverse effects on the rest of the body.

When you are travelling or living in warm sweaty climates, prevention is all. Make your toes as inhospitable to fungal infections as possible.

Keep your feet dry and your nails cut short.

Q. I have recently returned from a diving trip to Zanzibar, where due to the fact that all my money was stolen I had to spend a few nights in a dirt cheap hotel until more was wired out to me. Since my return I have had the most awful itching on my hands and feet, but what's odd is that it is mostly at night. Any thoughts on what it could be

A. I think I can make a diagnosis here with some assurance. You have unfortunately contracted one of those skin infestations that seems to be becoming commoner as more people travel over the world.

It sounds like something called Scabies. This is caused by a tiny mite, Sarcoptes scabeii, which is caught by either being in contact with a person or rarely bed sheets where the mite has previously been.

The mite having got onto your skin normally finds its way to specific areas of your body, notably the wrists and finger webs, also the feet and ankles and finally your genital area.

Having got there, the mite burrows under your skin leaving a tell tale track to its hiding place. The reason the itching occurs is that the next part of its life cycle is that when it is night, it comes out of its burrow and lays its eggs on the surface of your skin. This usually occurs at night as those areas where it lives on your body are now warm and moist which make for a better environment for the eggs.

However the eggs on your skin do cause an intense itching and part of the process is that you reimplant them by scratching your skin and also it helps to spread them over other parts of your body.

The usual signs of this disease are the previously mentioned tracks, and also a rash where you have been scratching your body. I have seen very bad cases of this in the past where the infestation has affected the whole body, and this is what used to happen years ago before any cure was around. In very rare cases it can even lead to death where infection gets into the blood stream from the open scratched sores on the skin.

We are luckier now, though as it is very easy to treat. The basis of the cure is an antiparasitic cream called permethrin which you have to apply to your whole body from neck down to the tip of your toes. Leave the cream on for 24 hours then wash it off and reapply again. One day later wash it off and that should finally get rid of it. As the mite can still live on clothing and sheets for a while then you need to wash anything you have worn or slept on since your return on the hottest wash available to kill off any remaining mites or their eggs.

Finally, this rash and itch usually comes on about 6 weeks after contact, if any diver experiences an itchy rash sooner after diving, then it is wise to make sure it is not a case of "skin bends". This though is more often found on the shoulders and trunk and associated with an odd marbled looking rash. The only effective treatment for this is recompression in a dive chamber, and if you don't know where the closest one is to you, then contact e-med and we can direct you to one.

Q. I am shortly going to the Maldives for a dive holiday. I have been there before together with diving previously in Indonesia and the Caribbean. Every time I dive in plankton rich water I end up with an ear infection, despite using fresh water to rinse my ears on surfacing, trying "Swim Ear" and using other treatments. The infection in the outer ear is always painful and keeps me out of the water for a few days, which is unpleasant and inconvenient. It has been suggested by an instructor friend that I use a mixture of 5% acetic acid in propylene Glycol to "oil" the ears and prevent infection. The question is where do I get this stuff from and do you think it would work?

A. This is an all to frequent problem for those on extended diving holidays and one which happens to me each time I go away, so I will give you a few tips on how to avoid what we call "otitis externa" or "OE" next time you dive.

Firstly though, you cant blame the poor old plankton all the time as this is far more frequently caused by water borne bacteria that are plentiful the closer you dive to major coastal conurbations and areas where the tidal flow is poor. So as a consequence you have to be really on your guard in the Meditterrannean especially around Southern Spain and Italy. Likewise in some developing countries the sewage outfall from a hotel or resort is often to only yards off the shore and onto the reef where people dive.

The key to outer ear infection is in the prevention, and your Instructors cocktail of vinegar and propylene glycol acts in very much the same way as Swim Ear, in that it breaks down the surface tension of the water that is left in your ear canal after a dive so it can run out more easily when you shake your head. As well as this the alcohol component helps in evaporating any water left there too. This would mean that any bacteria are expelled so the infection can't take a hold.

But the consequences of OE are that although its not going to cause you any long term harm, the fact that you are off diving is enough to make this minor problem a major irritation. I always take antibiotic ear drops with me as well to use after a days diving and I've showered off. These can give the peace of mind that if there are any bacteria that have managed to hang on in the ear canal then they will be killed off by the antibiotic before they can cause OE. My preferred drops are called Gentisone as there is a small amount of steroid in the drops, so if OE has taken a hold the steroid can reduce the inflammation which is the main cause of the pain in this condition.

These are prescription only drops so ask your GP for a scrip, which will have to be a private one as you are taking them " just in case" but expect to pay around £4 to £5 at the chemist.

So my suggestion is Swim Ear after each dive and a couple of the antibiotic drops at the end of the day and that should see you well on your next trip.

A final point here is that if OE has set in then only drops will work for it and I have seen a lot of people treated with oral antibiotic tablets for this problem which don't work as they are not concentrated in the tissues of the ear canal in high enough doses to be of any real use.

If OE does not clear up quickly then insist that your GP does an ear swab to culture any bacteria as there are some rarer bacterial causes such as Pseudomonas which may need a far stronger antibiotic to treat it.

Q. I am going to India over New Year but have heard stories about street beggars having leprosy. Is it possible to catch this awful disease from them if they were to touch me or is it quite safe really? I am hoping to do some charity work out there and direct contact with these people is a strong possibility.

A. Your fears, you will be glad to hear, are not well founded. Leprosy, or to give it it's other name of Hansen's Disease, named after it's discoverer, is infact not transmitted by direct contact with the skin of a sufferer.

Current figures show that this disease afflicts over 15 million people worldwide. These cases are found around Africa and India mainly, and are seen in the poorer sector of the population.

Leprosy is caused by bacteria which live in the lining of the nose and also in the nerves of sufferers, and it is because of the latter that the affects of the disease are seen.

Because the nerves that supply the feeling of sensation to various parts of the body get inflamed during the infective process then they cease to function properly. This then results in what we call painless injury. People with this problem can easily cut themselves, or pick up objects that are far too hot, and even break bones without realising, and because of this deformities arise all too easily. The skin depigmentation seen in this disease is due to scalding or also sometimes as the bacteria can also cause inflammation in the skin. The sad thing about leprosy is that it is easy to diagnose and also very easy to treat in the early stages with simple antibiotic treatment, but the problem goes unchecked in the developing world due to lack of resources and also the persons fear of the stigma of the disease.

The way that it is spread is via respiratory droplets full of bacteria being sneezed and then inhaled by the recipient. Early symptoms are non- itching rash or blood stained nasal discharge, and if you are diagnosed at this stage then a course of dapsone will cure it. But this really is a hard disease to catch and you wouldn't get it from just passing contact but by sharing a room with a sufferer for quite some time and it is definitely not passed on by touching a patient.

If you are doing charitable work in India and are spending a lot of time amongst sufferers then I would suggest you take your own surgical masks with you as these are easy to carry and wear and will prevent any droplets containing bacteria from being inhaled.

Interestingly the leprosy bacteria is only able to infect humans and one other animal species, the 9-banded armadillo, which of course is now blamed for the spread of disease in parts of the Americas.

The other myth to dispel here is that parts of limbs do not fall off in this illness, so don't worry, it is a hard disease to get and an easy one to get rid of.

Q. I am very prone to getting bladder infections, which I treat with various over the counter remedies. However I am going on a long safari and a friend has told me that I ought to take some antibiotics with me "just in case". My question is which ones and is there anything I can do to prevent it from happening?

A. Your friend is right. You suffer from what we call cystitis, which is where bacteria that normally inhabit your lower gastrointestinal tract can find their way to your bladder and multiply causing you the symptoms of pain on urination, increased frequency of urination and often an odd odour to your urine. The reason that women get it far more frequently than men is due to the length of their urethra. This is the tube that takes the urine from the bladder to the outside world, which in men is considerably longer than in women. So because of this bacteria can easily find their way up to the bladder and so cause the problem.

When you are back home the fact is that if the problem didn't get any better with the over the counter remedies you can quickly see your doctor who can prescribe you the antibiotics needed. But of course on safari you may be a long way from medical help and if left untreated the real problems can set in.

Leading into the bladder from the kidneys is another tube called the ureter, and in some cases the bacteria can ascend this tube and cause a full on kidney infection. This would lead to a severe fever, vomiting and pain in your lower back at the side of the infection. This can sometimes lead to dehydration, delirium and hospitalisation.

What I suggest is that you take your usual remedies with you, and if you get symptoms of cystitis then you should try these for a day. If there is no improvement after this then you need to really increase your fluid consumption to about 5 litres a day, especially as you will be in a hot climate and will be dehydrating at a faster rate than at home and you should start the antibiotics immediately.

There are several you can take, and currently I would suggest either trimethoprim 200mg twice a day for 3 days or cephalexin 250mg twice a day for the same time. The strongest and widest spectrum antibiotic is called ciprofloxacin and is taken at a dose of 100mg twice daily for 3 days as well.

If you are going for a long time I recommend you get hold of 2 courses of one of the first 2 and one course of the ciprofloxacin for your medical bag.

To prevent it occurring in the first place, always drink plenty of fluids, especially cranberry juice, make sure you wipe your bottom from front to back after going to the toilet and try to pass urine as soon as you can after intercourse as this can also aid the passage of bacteria up to the bladder.

On a final note, if you are suffering cystitis that often then you should make sure that your doctor has screened you for diabetes as this can make you prone to recurrent infections as the high sugar content of your urine becomes a great breeding ground for most bacteria.

Q. I recently read about the West Nile Virus in the Boston region in mid September. Would inoculations be wise or necessary as my fiancée is quite prone to insect bites. What would you recommend?

A. West Nile Virus appeared last year on the Upper Eastern seaboard of the US.

It caused many cases of infection but thankfully only a handful of fatalities. It is a virus originating in birds but then transferred to humans via mosquito bites.

Since it's appearance last year the Federal Agencies responsible for it's eradication have worked hard to kill off the mosquitoes that spread the infection, including spraying insecticide across parts of New York and advising people on how to stop the insect breeding by not letting any water stagnate near human habitation.

This has been very successful, and there have been a lot fewer cases since then..

There are no inoculations for this illness at present, and in reality you or your fiancée don't really need them. This is because the virus normally only causes a mild flu like illness, which passes in a few days. The people who are most at risk are the elderly and those who already have other serious medical problems. Infact of the 4 deaths in New York last year, the average age was 82 and they all had other conditions too.

Rarely West Nile can cause an encephalitis, this is an inflammation around the brain that needs steroids to control the symptoms. New Yorkers are told to look out for any flu like illness that then leads on into a severe unremitting headache and neck stiffness. It is then possible to diagnose the infection with a blood test, but there is no immediate cure, just supportive measures until your own immune system has beaten the infection.

Of course it's not much fun being bitten by bugs when you're away anyway. Your fiancée should take all the usual protective measures if she is prone to attack.. I suggest she buy a local insect repellent, which always seem to work better than imported ones, to spray on any exposed areas. If you are in a bug infested area, like a swamp or still creek then wear long sleeved shirts and long trousers especially at dusk when the bugs are hungrier. Another travellers trick is to take a daily Vitamin B12 tablet, or some prefer a clove of garlic a day as this seems to make you less of a tasty meal to these mosquitoes.

Finally, I always take a sedating antihistamine with me , like Piriton as bug bites always seem to itch more at night, and these tablets can stop the itching and help you sleep when taken in the evening.

Q. I recently went to try and give blood at the Blood Transfusion Centre. I went through the questions successfully until the travel questions came up and when I revealed that I had travelled to Venezuela back in 95 and in a rural area I was promptly told "sorry but due to the possibility of you having trypanosomiasis and their is no test for it at present try Dracula for your donation". So what is this strange disease, is there a test, and why aren't travellers made aware of this before they go?

A. Thanks for this interesting question. This is not such a strange disease really but it commonly is known by another name. Chagas' disease. It is caused by a single celled organism called a trypanasome, which infects the blood and more importantly other cells in our body that are responsible for our immunity. Chagas' disease is only found in the Americas from Central America southwards with it's range ending before Patagonia. It is commonest in Brazil. The reason it has this distribution is that, like a lot of tropical illnesses, it needs an insect vector to spread the disease from human to human. In the case of Chagas' it is the Cone-nosed bug.

This is a large beetle like creature measuring up to 4 cms long, with a nose shaped like its name suggests. The way the traveller gets infected is by being bitten by the bug, which excretes the trypanasome that lives in its digestive tract and then the organism enters through the bite wound. Now the good thing about this illness is that the cone-nosed bug only likes living in the walls of mud huts in semi rural areas. These are rarely stayed in by travellers as they tend to be the houses for poorer locals on the fringes of the bigger cities.

Protection against the bug bites is simple by using a standard mosquito net and sleeping away from the walls of the hut , however there is no vaccination against this disease at the moment. Now the reason that you were told that by the Transfusion Service is that it can be very difficult to detect the infection after 3 weeks have elapsed after the bug bite, and it is very easy to pass on to others with a blood transfusion. What I suggest is that anyone coming back from these sort of areas and who have stayed in adobe walled huts should have a blood test within 3 weeks of their return when Chagas' is detectable. But if you have been to these sorts of areas and not been tested on your return then as it is hard to detect the trypanasome in your body you cannot be considered for blood donation until a reliable test becomes available.

Symptoms of Chagas' vary from the bite itself with some local swelling around it, through fever and enlarged glands in the area of the bite, to some very serious complications of infection that can develop at a later date. Because the trypanasomes infect the immune cells they are very difficult to get rid of without destroying many other cells in the body, so there is no real effective treatment at the moment. But don't be put off going to South America because if you stay in normal brick walled accommodation, camp in the jungle or use a mossy net you will be fine

Q. I went to Istanbul for a long weekend last July and within a few days of returning home I was unable to move, to pull myself out of bed or really do anything for myself. I was put on strong drugs (sorry can't remember the name out) and anti-ulcer drugs.

I was referred to rheumatologist and he said I had caught a viral arthritis. All my joints were swollen and the drugs made my ankles and fingers swell, my joints throbbed and were extremely painful, I put on 2 stone in weight and lost all my energy. Apparently I caught this out in Istanbul and it has taken nearly a year for it to go completely.

I still get a throbbing sensation in my hands and ankles.(I could have caught it from a bite or otherwise apparently). So if Turkey is the next up and coming destination, have they sorted out their sanitation and hygiene? My little brother went to Kusadasi a few years ago and came back with jaundice.

A. It sounds like your brother should have had a Hepatitis A shot.

Your case though is interesting. It sounds like a case of Lyme's Disease. This is an arthritic condition brought on after a tick bite.

When biting you the ticks saliva contains a bacteria called Borrelia bergdorfi which then causes all the symptoms you describe.

This is a condition normally associated with North America, and you are very unfortunate to get it in Turkey.

Standards of hygiene are improving there. I visited in the early 80's and had no problems at all, except for an earthquake!

So don't blame the country, but put it down to bad luck as this sort of thing can happen to anyone in any country.

Q. I have recently spent six months in South china but while there developed a pain in my right hip which spread to my knee. The left hip and knee soon followed suit but not quite as bad. Both knees are now turned inwards and the pain in both knees and hips is on the increase. I also have pain starting in my elbows. Any ideas?

A. If you are young and fit and below the age of osteoarthritis, and with no family history of rheumatoid arthritis then there really is only one thing left.

It's called "reactive arthritis"

I had some feedback to an earlier question last week from the Arthritis Research Campaign on this issue.

They tell me:

"Reactive arthritis normally occurs as a result of bacterial infection, most commonly as a result of food poisoning, flu, streptococcus (sore throat/tonsillitis) or sexually transmitted infections. Classic symptoms are the swelling of fingers and toes ('sausage digits') and extreme fatigue and joint pain. Treatment normally involves a course of antibiotics to treat the infection, and anti-inflammatories. Further treatment in the form ofsteroids and immuno-suppressants may be required for cases persisting over 6 months. Reactive arthritis is not uncommon in this country too and it is estimated that 1-2% of people involved in every major food poisoning outbreak may develop it. Taking commonsense precautions to reduce the risk of food poisoning while abroad should minimise one's risk of contracting reactive arthritis."

The Arthritis Research Campaign produces a free leaflet on Reactive Arthritis which can be downloaded or ordered online from their website: www.arc.org.uk, or by phoning 01246 558033.

Q. I am going to Russia for a long holiday and a friend said to watch out for something called giardia.

What is it?

A. If you are eating anything right now then stop. The next bit is fairly unpleasant.

Giardia Lamblia to give it its full name is an intestinal parasite. It is very easily contracted from infected foods or water. The first signs are a gastric upset of the usual variety. Stomach cramps, diarrohea and wind. But wind of the most noxious variety. It is loud and the smell will kill a horse at twenty paces. This infact is the main warning sign to a doctor that you have it. To prevent getting giardia, take all the usual steps to prevent any gastric infection when you are away. Drink bottled water, wash it, peel it and so on.

But if this bug slips through the net and your partner starts making comments about your flatulence then please seek medical help. Rarely if you have a particular genetic make up a giardia infection can lead to Reiter's Syndrome. This is a nasty disease where you get arthritis and balanitis or swelling of the penis.

The doc will need a stool sample but the symptoms are very obvious so treatment should start immediately rather than waiting 3 weeks fro the results to come back. Take the antibiotic metronidazole for a week. This is the one you really cannot drink alcohol with.

Giardia is common in Eastern Europe so watch out and don't hesitate in seeing your GP if you have a problem on your return.

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