Cambodia

by Dr’s Prabhu and Savita,  TMA members Sydney

Cambodia is one of the most popular tourist destinations in South East Asia; Airfare, accommodation and food are cheap – though you can splash out and spend up to $800 dollars a day in Raffles hotel. We started our 6-day visit in the capital, Phnom Penh with a local cycle rickshaw ride. Hundreds of cycle rickshaws take tourists around the city highlights; the markets, Royal Palace, and the old colonial French area (including the only post office where people have to collect their mail instead of having it delivered to their door.)

Our Palace visit started uneventfully enough, but as our guide walked us to the palace entrance to obtain an entry ticket, an elderly gentleman waiting in the ticket area suddenly collapsed, falling heavily on his face onto the concrete floor. We went to his aid. After his condition improved we learnt he was a holidaymaker from Adelaide travelling in a group – which at that moment was nowhere to be seen. Unfortunately, as he was feeling unwell, he decided to rest while the rest of the group were visiting the Palace. He told us he was diabetic, on medications, and had became unwell the previous night. The heavy fall resulted in a nasty laceration to his face and nose, plus a few missing front teeth.

When his group leader returned, we advised the tour guide that the gentleman needed to be escorted to hospital for medical attention: repair of the laceration and possibly a brain scan to ensure he had not suffered any head injury.

This event highlights the importance of obtaining Travel Insurance prior to departure, just in case of this type of un-foreseen circumstances. Furthermore it is most important that travellers have current Tetanus and Hepatitis B vaccination.

The Royal palace is architecturally well designed and covers a vast area with palace museum, official visiting place for dignitaries, royal residence and stupas. The French occupied Cambodia from 1853 to 1963. However, though the French ruled for well over for 100 years, the young Cambodians all speak English. Cambodians also have a notable preference for American dollars over local currency.

We visited the killing fields close to Phnom Penh, and the School museum. This is a very emotion charged and sad place, where thousands of people were tortured and killed during Pol Pot’s evil regime from 1975 to 1979.

There is monument erected in killing fields which contains thousands of skull and other skeletal remains unearthed in the area: very somber and moving. We had the good fortune to meet one of the killing field survivors, he has published a book, (worth reading)

On Day 3 we travelled from Phnom Penn to Siem Reap. On the way we stopped at a village commonly known spider village. The market sells baskets of cooked spiders, cockroaches, grass hoppers and frogs. These local delicacies were on sale next to cooked birds / sparrows, and an interesting selection of small marble size bird eggs. We were not inspired to taste this exotic fare however.

There is also a museum of land mines. It is a bit disturbing to learn there are still many unidentified land mines, and bombs are detected periodically by the locals.Close to Siem Reap are a series of floating villages on the river. Many houses are built on stilts to avoid being flooded by the river during the rainy season. Thousands of people live on make shift houseboats on the river. Fishing is one of the main industries, and Catfish is one of the most popular meals. The river water is very muddyWe also visited Silver city where detailed solid silver and copper based metal work is undertaken. Small family businesses scrape a living doing slow and meticulous handwork. Children start early and are involved with this type of workSiem Reap, is a fairly modern well-organized tourist city surrounded by splendid historical temples dating back 7th to 12th century. Angkor Wat and Angkor Thom are among the best known temples. April & May in Cambodia are really hot and humid months. Travellers need to take care to stay well hydrated, especially if visiting temples in Siem Reap area. You may be climbing many temple steps.

The region is littered with other ruined palaces and temples – inspired by the ancient Hindu culture. According to history, although initial kings embraced Indian culture and built the temples, later kings adopted Buddhism as their religion, and erected Buddha’s images in the temples along with Stupas

It is nice to see world heritage authorities and other countries helping Cambodia to restore the ruins of temples, and protect them for posterity.

Travellers visiting South East Asian countries will encounter a great deal of exotic food, but the consequence of tasting these foods should be kept in mind. Care should be taken when choosing food and drink. A medical kit with antibiotics is useful if ‘travellers trots’ should develop. Before departure, all travellers should have routine childhood vaccines up to date and be vaccinated against at least Typhoid and Hepatitis A. Some visitors may also be recommended vaccines to protect against disease such as Japanese Encephalitis and Rabies. Ideally travellers should seek advice from their nearest TMA 6-8 weeks prior to travel.

This months newsletter was prepared by Drs Prabhu and Savita, TMA members in Sydney.Their specialised travel medicine clinic has been operating in Sydney central business district for 14 years, supplying travellers with all necessary information, vaccines, medical kits and other useful travel health supplies. They have both lived in India, Savita has lived in Africa and England. They can speak iHindi, Kannada and Gujarati. They migrated to Australia in 1972. This husband and wife team are holders of an International Society of Travel Medicine Certificate in Travel Health. They are enthusiastic and extensive travellers, with the knowledge and practical expertise to help Sydney travellers make the most of their trips. They consult at three clinics in Sydney CBD, Bella Vista and Seven Hills.For more information about their services, visit their clinic website – click here!
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Kazakhstan

by Leanne Rofet  – practice nurse of TMA member in Ipswich 

Kazakhstan is a country of approximately 16 million people; 70% ethnic Kazakh and 26% ethnic Russian, it shares its borders with Russia, China, Uzbekistan and Kyrgyzstan.The Kazakhs were originally a nomadic people who herded sheep and horses. Their tents are called Yurts, and there are many along the roadside. Some are used as a refreshment stop, and serve fermented horse milk. It’s not recommended to drink this beverage as it is highly alcoholic, and can be toxic. While we were there a traveller died from drinking fermented horse milk at a roadside Yurt. The inside of the Yurt is lined with tapestries, rugs and furs, there are usually small tables and stools to sit on.Drug addiction is a large problem in Kazakhstan, and heroin is easy and cheap to procure, as the Silk Road passes through Kazakhstan from AfghanistanMy husband and I travelled to Kazakhstan to work in Teen Challenge – a drug rehabilitation program – in Taldyqorghan. It’s about a 3 hour drive from Almaty – the capital city – near the Chinese border.

We were able to do some sightseeing in our free time. Our favorite place was a river nearby – clear water and very cold. Taldyqorghan is surrounded by the Steppes – flat, grazing land, but a half hour drive will take you into the mountains where there is snow almost all year round.The markets were amazing, usually open air with matting for the roof; grains, nuts, berries and dried fruits were laid out in stands. Bartering is expected and is always good natured. The ladies in the photo above worked in the meat market, and were happy to have their photos taken so they could be “celebrities” in Australia. There is very little refrigeration and the meat market is open air, slabs of meat hang on hooks around the walls, and whole heads of cows and horses lying on the ground. Buying meat for dinner was something we avoided but the local population doesn’t have an issue with it. We thought the price of meat was reasonably cheap but it is too expensive for most people, the main diet is soup. There are 2 social groups in Kazakhstan, the very rich and the very poor.
Many of the buildings are crumbling and poorly maintained, after Perestroika in 1986 thousands of ethnic Russians returned to Russia and the country collapsed. Kazakhstan welcomed anyone who could help in re-building the country. The population is now 70% Islam and 26% Christian.Most people live in small apartments, in rural areas water is pumped from community wells, so there are not a lot of showers or flushing toilets. Often there is a “Banya” – Russian version of a sauna – in a small hut out the back, and all the families in an apartment building will use this once or twice a week.
Along the roadside there are many quaint stalls selling a variety of delicacies – the photo above is a cheese stall – very smelly cheese tasting like blue vein – again no refrigeration.
Kazakhstan isn’t a tourist destination but definitely an interesting place to visit.
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Japanese Encephalitis

Dr Tu Khai Huynh – TMA Member Ipswich

Japanese Encephalitis (JE) occurs in practically all Asian countries and is also now considered endemic in the Torres Strait region and Papua New Guinea. The incidence of JE in humans varies by season, usually coinciding with the rains and is mainly passed through the bite of the Culex mosquito.

Country Peak transmission


Korea, Japan May to September
Temperate South East Asia (Thailand,Vietnam, Cambodia) April to October
Nepal, Northern India September to December
Malaysia, Indonesia and Philippines and tropical regions of South East Asia All year round
Humans are infected by the virus (JEV) when living in close proximity its natural hosts (pigs and wading birds). This usually occurs in rural areas where there is breeding of the vectors in flooded rice fields. Nearly 3 billion people are believed to be at risk for JE virus infection and approximately 20,000 clinical cases with 6,000 deaths are reported annually.

Infection is characterized by sudden onset of fever, chills, muscle aches, and confusion. It is recognised, however, that most infections are asymptomatic; published estimates of the symptomatic to asymptomatic infection ratio vary in different populations from 1:25 to 1:1000.. The case fatality rate ranges from 5-30% but approximately 30-50 % of the surviving patients have permanent brain damage and complete recovery occurs in only one-third of patients.

 Culex mosquito – Females bite usually during the day time but peak at dawn and at dusk. All travellers to Asia (and other tropical regions) must be fully aware of the need to take appropriate measures to avoid mosquito bites, such as effective insect repellent and appropriate clothing.
Risk for travellers

The risk to short term travellers to Asia is very low, particularly if they are only visiting urban areas, with overall estimates of one case per million travellers. The risk becomes greater for persons who intend to live or travel in risk areas for long periods of time, and have rural trips during transmission seasons. Certain activities may increase the risk such as fieldwork, camping, or cycling in rural areas. The risk amongst rural travellers has been estimated to be in the range of 1 case per 5,000 travellers to 1 per 20,000 per week.

Treatment

There is no specific treatment, but rather supportive management.

Prevention

Apart from personal protective measures to avoid being bitten, vaccination of humans is the most effective means of preventing JE. Two different vaccines are available for use in Australia – these would be discussed with your doctor.

JE vaccination is recommended for:

  1. Travellers (≥12 months of age) spending 1 month or more in rural areas of high-risk countries in Asia and Papua New Guinea (see 4.8.3 Epidemiology above); however, should be considered for shorter-term travellers, particularly if the travel is during the wet season, or anticipated to be repeated, and/or there is considerable outdoor activity, and/or the accommodation is not mosquito-proof.
  2. All other travellers spending a year or more in Asia (except Singapore), even if much of the stay is in urban areas.

Please consult your travel doctor for timely advice about Japanese encephalitis if you are going to Asia or PNG, especially those times listed above, and especially if your travel will involve a lot of rural activity.

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Singapore Traffic Adventure

by Diana Gillatt, TMA Member Tanunda

Despite your travel doctor’s warnings about exotic illnesses like typhoid, malaria and rabies, the fact is that the most common health problems suffered by travellers are much more mundane things like diarrhoea, coughs and colds and accidents / injuries.

Abroad as at home, motor vehicle injuries are a major cause of trauma and for travellers there are the added hazards of unfamiliar traffic rules and often quite different general attitudes to traffic safety in foreign countries. In fact for travellers in developing countries it is more often as pedestrians, cyclists or on public transport that we are injured, rather than as the driver or passenger in a car.

This was brought home to me recently during a short visit to Singapore. Now Singapore is one of the more developed countries in Asia, with good roads and appearances in the city not so different from at home. But even here travellers need to be aware that they are not at home.

Walking back to my motel along the paved footpath beside the river, I was offered a ride on a Trishaw by a pleasant elderly gentleman. The price was reasonable and it seemed like the chance for a quiet easy ride along the leafy Esplanade and a rest for my feet after a day exploring Chinatown.

Unbeknownst to me, however, there was apparently one section of this Esplanade with some steps that the Trishaw couldn’t negotiate, so once I had agreed the price and climbed aboard, my charming host headed off in the opposite direction! After he assured me he really was taking me to the correct motel, he proceeded to ride out to the main road and to my horror left the footpath to take up position in the middle of a busy major intersection!

While waiting for the traffic lights to change, I held on to the hope that we were going to cross with the pedestrians to the other side, but no. In fact he didn’t even wait for the lights, but decided that the time was ripe for us to launch out into the main thoroughfare, do a U-turn and carry on down the road ignoring the rushing vehicles all around us! Being overtaken by a bus and a truck while we were in the right hand turning lane didn’t phase him at all, and of course he gently guided us around a corner and eventually back on to the quiet riverside esplanade again. I had just about stopped quaking enough to pay him the fare by the time we arrived at the motel.

Needless to say there was no opportunity of a bicycle helmet on a trip like this, and the risk taking that was obviously an every day event for my driver left this Australian quaking and looking for the nearest Singapore Sling to calm her nerves.

I can look back on this little episode and laugh now, but many travellers aren’t so lucky.

And these roads in Singapore are rather tame when compared to some other countries…

Hiring a motorbike to get around a beach resort in Indonesia or Thailand may seem fun, but is there a helmet provided? Do you know which side of the road you are meant to ride on? Are the road rules different from at home, and does anyone pay them any attention?

It’s great to have a some adventure on your travels, but don’t leave all your common sense behind!

Here are a few tips:

  • Be aware of the local road rules – for instance, which side of the road are vehicles meant to drive on?
  • Take extra care as a pedestrian – don’t expect the traffic to try to avoid you!
  • Ask for a helmet if cycling or riding a motor bike.
  • If you hire a car, ask for one that has seat belts and air bags. Avoid driving at night.
  • Take a first aid kit with you on your travels so you can manage minor injuries yourself.

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Japan and Your Medications

… Prepared by TMA Member Maitland NSW:Dr Puru Sagar Chromis Sept 2012

It is generally well known that you can’t take certain medications into Middle Eastern countries but did you know that there are restrictions on medications imported into Japan, even for personal use? It is illegal to bring into Japan some over-the-counter medications including cough and cold, sinus, and allergy medications containing stimulants or codeine. Did you know that your body (specifically, your liver) can convert a 30mG tablet of codeine into as much as about 5mG of actual morphine? In Japan, codeine is thus considered a narcotic and its importation is prohibited. An illegal or backyard chemist can distil as much as 23mG of morphine out of a 30mG tablet.

Japan will generally allow up to a month’s supply of your personal medication as long as it is not a prohibited substance (such as narcotics and stimulants). However, you will still need to declare your medication at customs. Quantities larger than a month’s supply, including syringes, pumps, and CPAP machines, may still be allowable provided you have pre-arranged an import certificate called the “Yakkan Shoumei”. You will need two copies of an Import Report of Medications, a signed Declaration, an Explanation of the Products, a copy of a doctor’s Prescription or Direction, your travel documents listing arrival date and port, and a return envelope with Japanese postal stamps. Only when the Pharmaceutical Inspector “can confirm that your application documents are complete and he admits that you speak the truth, he will send you a ‘Yakkan Shoumei’ by post”. The Japan Ministry of Health lists an example form filled out by one Sherlock Holmes trying to import morphine for personal use during a conference in Japan!

The US Government warns its citizens that “some US prescription medications cannot be imported into Japan, even when accompanied by a customs declaration and a copy of the prescription” and that Japanese officials have detained travellers carrying prohibited items “sometimes for several weeks”. Apparently, Japanese officials do not make on-the-spot humanitarian exceptions.

If you are going longer than a month, please note that Japanese doctors can prescribe similar, but not identical, medications to yours (the generic will be the same but the brand name will be different). You can generally find a list of English-speaking doctors and medical facilities on the web, noting that medical treatment in Japan is world class but expensive. Buying drugs such as Viagra or Prozac on the black market in Japan can lead to arrest and imprisonment.

Prior to travelling overseas, it is wise to undertake some preliminary research well in advance of your travel date about medication importation, even if that medication is for personal use. A good place to start is atwww.smartraveller.gov.au but more comprehensive information is generally available from the embassy/high commission websites or that country’s Ministry of Health website. If in doubt,  ask your TMA doctor.

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