Safety of DEET (N,N,-diethyl-m-toluamide)

Insect repellents containing DEET are the most effective and the most commonly used world wide. DEET has been available commercially for over 50 years and has been studied extensively.

It is thought that DEET works by interfering with the mosquito antennae function, effectively making humans invisible to the mosquito. Generally, the duration of protection is related to the concentration of DEET. However, at a concentration of 50%, this effect plateaus. 30% DEET is the lowest effective dose.

DEET repellents have a very good safety record, when used as directed. When DEET is applied to the skin, some is absorbed into the circulation. However, if the same amount of DEET were to be taken by mouth, either accidentally, or non-accidentally, blood concentrations will be hundreds of times higher and seizures and death can result. Toxic effects have most often occurred as a result of ingestion, rather than skin application. Repellents should not be applied to the lips, mouth, sunburned skin, damaged skin, or deep skin folds, and hands should be washed after applying DEET.

The risk of disease due to the bite of an insect is far greater than the risk involved in applying DEET insect repellents to the skin. 30% DEET repellents are safe to use and are recommended for adults, pregnant women, breast-feeding women and children over 2 months of age.

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Wife White Knuckles – Hurning to Brisbane – in 5 hour hops

Julie Wright, Admin Staff, TMA Member Brisbane

After 10 years of dreaming, and 8 months of planning, my husband and I embarked on the adventure of a lifetime in August of 2006. (Six weeks prior to departing Brisbane, we of course consulted with Dr Deb Mills to ensure our health was optimal! ) We shared the small cockpit of a single engine Beechcraft Bonanza F33A at 10,000 feet, across half the world. Our fuel tank only allowed a 5 hour flight range, so we had to make 29 stops in 31 days. Our flight path took us – Hurning (Denmark), Copenhagen, Baden Baden, Barcelona, Corsica, Amalfi, Athens, Santorini, Istanbul, Adana, Tabriz, Esfahan, Dubai, Muscat, Karachi, Ahmedabad, Nagpur, Colcutta, Chiang Mai, Bangkok, Phuket, Singapore, Jakarta, Bali, Kupang into Darwin and on to Archerfield airport, Brisbane. To experience the many different cultures in quick succession was a fascinating experience. However, despite our careful preparation, the different terrain, along with language barriers, and unforeseen weather conditions presented both mental and physical challenges. We became known as the “Crazy Aussies” by many air traffic controllers. Sometimes we were met with an incredulous “You’re flying to Australia in that?” from commercial pilots on the ground. We planned the route with a German company that organises flight paths and permissions for cargo aircraft around the world. They successfully applied for our permissions, even organizing us to transit through Iran where we made stops for fuel in Tabriz and Esfahan. To smooth our dealings with Army and security on the tarmac at various terminals, they suggested we wear a uniform, so from Istanbul to Darwin, my husband and I wore collared white shirts with epilates and navy pants. We were seen as flight crew. We were to need it sooner than we thought.

On one occasion we had some problems that resulted in our passport stamped with the words Illegal Aliens… Our aircraft was only rated to fly in good visibility. In Esfahan, Iran, our refueling and paperwork took so long, that it was well into the afternoon before it was finalised. Problem. We had no visa to stay in Iran, only permission to transit. We were marched inside the airport under army guard. We sat for six hours in a tiny room with a young fully armed guard right beside us. We overheard the head of the police and the government officials yelling into their phones, trying to sort out what to do with us. We phoned our contacts, they called the Australian consulate. This went on and on.

At midnight we were taken from the airport, thankfully to a hotel, still under police guard – at least the guard stayed outside the room! How could we sleep with visions of being trapped in Iran forever running through our heads. The next morning, we were returned to the airport. Yet another official met with me. This time, thankfully, he had a big grin. I think he was as happy as we were, that a solution had been found. Our passports had been blessed overnight with a 7 day visa. In fact the now smiling official even warmly welcomed us to stay a few days in Iran! We made all the proper polite comments and hurried to our aircraft. As we were waiting on the tarmac, running through our flight checks, we heard a huge roar from the runway. A mick fighter took off and flew vertically at great speed in front of us. What a sight! I looked over at the Iranian police, unsure why the tower had put the mick fighter up in the air before our take off. The officials were all smiling, pointing to the fighter in the air and hands on their hearts yelling, “Ours, ours!” with much pride. Now it was our turn, my husband and I sat waiting for the radio signal from the tower that would giving permission to take off. Silence…. We watched the fighter land and be towed off the runway. Only then, were we given permission to take off. As we looked over at the smiling Iranians, we realised that we had been honoured with a display and fighter ‘send off’.

I earned the nick name ‘wife white knuckles’ after episodes like that, along with sand storms in Tabriz, dust storms in Dubai and a raging torrential storm over Singapore. The realization of our dream would not have been possible without an extraordinary team of many helpers from across the world. In 2006, we, “the Crazy Aussies”, were the 187th in the world to fly this particular route in a small single engine aircraft.

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Traveling with Diabetes

While you’re having a great time on your holiday, if you have diabetes you need to continue your monitoring and care routine.

Having meals later or more irregularly than usual, time zone changes and the heat of tropical countries can all affect how well you manage your blood sugar levels. Before you hit the road, have a look at some of these suggestions click here for info.

The Heat of Summer or the Tropics

Heat can affect your blood glucose (sugar) levels and also increase the absorption of some fast-acting insulin, meaning you will need to test your blood glucose more often and perhaps adjust your intake of insulin, food and liquids.

  • Drink plenty of fluids, especially water (always bottled or boiled if in less developed countries!), to avoid dehydration. Avoid sugar-sweetened soft drinks and fruit juices.
  • Check the product information in your boxes of medications to learn when high temperatures can affect them.
  • If you’re traveling with insulin pens or vials, don’t store them in direct sunlight or in a hot vehicle. Keep it in a cooler if possible, but do not place it directly on ice or on a gel pack to avoid freezing it.
  • Check glucose meter and test strip packages for information on use during times of high heat and humidity. Do not leave them in a hot car, by a pool or on the beach.
  • Heat can damage insulin pumps and other equipment. Do not leave the disconnected pump or supplies in the direct sun.
  • Undertake physical activity in air-conditioned areas, or exercise outside early or late in the day, during cooler temperatures.
Don’t Forget Your Medication
  • Take more medication than you would expect to need, in case of travel delays or lost luggage.
  • Keep snacks, glucose gel, or tablets with you in case you have a ‘hypo’. If you use insulin, speak to your Doctor before you go about taking a glucagon kit; this is an injection that can e given in case of a more severe drop in blood sugar.
  • Carry medical identification that says you have diabetes.
  • Keep time zone changes in mind so you’ll know when to take medication.
  • Keep all insulin in the original pharmacy labeled packaging. Get a letter from your Doctor stating you need to take syringes or insulin pens with you.
  • Take copies of prescriptions with you.
In the Air
  • Place all diabetes supplies in carry-on luggage in case checked in luggage goes missing. Keep medications and snacks at your seat for easy access.
  • If a meal will be served during your flight, call ahead for a diabetic, low fat, or low cholesterol meal. Wait until your food is about to be served before you take your insulin.
  • Make sure to pack snacks in case of flight delays.
  • Reduce your risk for blood clots by moving around every hour or two.
  • More Info on using insulin pumps during flight here.
Staying Healthy
  • Changes in what you eat, activity levels and time zones can affect your blood glucose. Check levels often. Stick with your exercise routine. Make sure to get at least 150 minutes of physical activity each week.
  • Protect your feet. Be especially careful of hot pavement by pools. Wet or sweaty feet are more prone to tinea as well; consider taking an anti fungal cream such as Lamisil with you.
  • Make sure you have all the vaccinations you need for your destination.
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Riding Motorbikes in Vietnam; THINK TWICE!

… Prepared by TMA Member Narre Warren: Dr Michael Long

There is plenty of evidence statistics to suggest that Vietnam is quite simply in love with the motorbike. Motorbike travel in Vietnam was popularised further with Western TV viewers with the 2008-9 Top Gear Vietnam special where the heroic Jeremy Clarkson with his friends May and Hammond sputtered their way on feeble underpowered motorcycles from Saigon to Ha Long Bay.

“Motos” are a common sight on the roads of Vietnam and far outnumber cars. The current estimate of the motorbike population in Vietnam is approximately 20 million, one for every four and a half people of their population of 90 million; (indeed they are often the family sedan with Mum, Dad and 2 kids traveling on a small 50-100cc motorbike or motor scooter.)

Motos are not just for transporting people either. Not having a car doesn’t hold the Vietnamese back at all as you can just attach 3 metre lengths of timber cross ways across your moto, attach 30 coconuts to the back, pull a motorbike trailer behind you carrying anything, or even carry a moto on the back of your moto! (the writer observed all of these on a recent trip).

Driving on the right hand side of the road is the least of your worries riding motos in Vietnam. Road rules are often regarded as optional, motos ride on footpaths in Saigon peak hour, no one gives way at roundabouts and pedestrian crossings are completely ignored. The country’s rampant love affair with motorbikes has been associated with a substantial number of collisions; the road toll in Vietnam is approximately 13,000 per year which is 2-3 times the rate per capita in Australia.

Despite their kamikaze attitude to road rules and safety, there remains a great interest in motorbikes in Vietnam. You don’t need a license to ride a moto in Vietnam, but remember the commonest cause of death in travelers overseas is not some exotic illness like malaria, but is due to the depressingly familiar occurrence of motor vehicle accidents.

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Exploring the World’s Remotest Rivers

… Prepared by Kevin Casey (visitor to Brisbane TMA members clinic)

 

 

One of the very best things about exploring the least known and most pristine rivers on the planet is that I experience the earth in its most natural state. What I do as the Remote River Man is certainly unique – I venture into extremely remote places, normally alone for a month or more, usually with only what can be carried on my back, or in a kayak or pack raft. I have filmed bears in Canada, been leech-bait in Borneo, trekked and paddled the most isolated parts of the Kimberley, got lost (on purpose) in an Argentinean swamp and shared meals with African pygmies. I plan these journeys, conduct them, film the adventures with lightweight video gear, and edit it all when I get home. I have no script, no film crew and no support team. The trips are expensive, so I can’t afford to get sick or have a careless accident while I’m enjoying myself out in the middle of nowhere. It’s not unusual for me to go a whole month in the wild without seeing another human, or be 400 kilometres away from the nearest one.

So how do I go medically with these far-flung journeys? So far pretty well, in over a quarter century of remote river exploration. I did get malaria once in New Guinea, and have had a few stomach complaints in various countries, and suffered the odd blister, cut or bruise, but the dangers of wild places are grossly exaggerated. I like to say (only half joking) that the most dangerous part of my remote river explorations is the car trip to and from the airport.

The real dangers in wilderness are the mundane ones – a sharp branch at eye level, loose rock on downhill slopes, a bad infection, drinking bad water or eating contaminated food, pushing too hard in the heat, etc. The insects make life interesting, too.

When it comes to food, I’ve eaten all sorts – donkey stew, lizard, wood grubs, roasted grasshoppers, raw queen fish (30 seconds after it came out of the ocean), stewed antelope, termite soup and a range of plant foods, from waterlily seed damper and hibiscus buds to palm heart and boab nut pulp. A lot of natural foods are actually more nutritious than the more adulterated stuff you buy in the shop. Generally the rivers I explore have no human habitation upstream which is always a help, but there are still plenty of microbes just waiting patiently for the ill prepared.

Insects are never to be taken lightly. I soak all my clothes in a permethrin solution before I go away, and carry a good repellent. 25-30% DEET is more than enough, unless you want to chemically burn holes in your nylon tarp, or melt the plastic case of your camera or sunnies. I like the Repel roll-on myself. I always sleep in either a mozzie-proof tent or in my trusty netted Clark Jungle Hammock. If I’m headed for a tropical country where I suspect bedbugs, fleas or other surprises might be joining me in my hotel bed, I’ll carry a very lightweight one-man Bug Bivy (Outdoor Research makes a nice one) and actually set that up right on top of the hotel bed, so nothing can get at me during the night. You can’t always assume a third-world hotel is going to provide a mozzie net, or if it does, that it won’t be full of well-hidden holes.

A comprehensive first aid kit is a must, and it’s always a struggle to balance keeping it lightweight and ‘covering all the bases’.

Getting into Dr. Deb’s Travel Medicine Clinic is something I always do at least 3-4 months before I head off overseas on a remote river exploration. Sooner is better than later for sorting out what’s needed, and since some of my destinations are exotic and seldom visited by tourists, it’s especially important for me to have up-to-date expertise, so I can then get down to the challenging business of exploring my chosen river, getting some amazing footage, and returning home safely so I can start editing all those Remote River Man DVDs!. Checkout Kevin’s website www.remoteriverman.com.

 

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Traveller’s Thrombosis

 … Prepared by Dr Cormac Carey – TMA member Toowoomba

Travellers Thrombosis or Deep Vein thrombosis (DVT) is a rare but dangerous medical problem which occurs when blood in the legs of travellers clots. The serious problems occur when the clot dislodges from the leg and moves to the heart or lungs where it interferes with their performance.

While it is several years since “Economy Class Syndrome” entered our travel jargon the recent release of newer and safer anti- clotting agents make it pertinent to reappraise our approach to this issue. In practical terms, risk factors need to be identified and their importance weighed against appropriate medical advice for each individual traveller.

Risk factors for travellers thrombosis

The following factors may increase an individual travellers’ risk of suffering a thrombosis during travel:

  • Flights longer than 5 hours
  • Family history of abnormal clotting
  • Genetic clotting disorders
  • Recent lower limb surgery
  • Recent soft tissue injury of lower limbs
  • Pregnancy or shortly after delivery
  • Recent abdominal or pelvic surgery
  • Cancer
  • Female smokers who take the contraceptive pill

Persons with more than one risk factor are at even higher risk; E.G. Use of hormone replacement therapy in a woman, coupled with a genetic predisposition can lead to a thirteen times increased risk compared to the average traveller.

Perhaps the most important risk of all is having had a past episode of a Deep Vein Thrombosis with no recognised obvious trigger.

Some travellers have no particular risk factors. In that case, exercises as described on the aircraft instruction cards, plus plenty of water e.g. 200mls per hour are sensible precautions.

Low Risk Travellers

This would include persons over 40 years of age, overweight, or who have had recent minor surgery.
This group would be recommended to do as per low risk plus flight socks or grade 1 wear compression stockings
Note that persons with diabetes should seek medical advice before wearing any compression stockings.

Medium Risk Travellers

People aged over 50 years, previous DVT or pulmonary embolism (clot on lung), recent lower limb injury, treatment for heart failure, or women who have had a baby less than 6 weeks earlier.
Consideration should be given to booking an aisle seat, and wearing grade 2 compression stockings. Such stockings provide 20-30mmHg compression and only need to be knee high. They should be tried well in advance of the flight, as they can be difficult to put on when new.

High Risk Travellers

This category includes persons who have had DVT within the past twelve months, persons with a lower limb in a plaster cast or immobilizing splint, who have had a recent stroke or heart attack or major surgery within previous three months.
In addition to exercises, fluids, and aisle seat, consideration would usually be given to taking injections of low molecular weight heparin to lessen clotting during flight. Patients already on warfarin do not need heparin as well.

Persons who are hesitant to give themselves an injection prior to a flight, or who will have trouble carrying and storing injectible medication, will be happy to know there is now a medical breakthrough. There are new oral anti-clotting agents e.g. rivaroxaban. This is a prescription medicine that has been shown to prevent deep vein thrombosis in patients following hip and knee replacement surgery. Common dose for travel is one tablet daily, on the day before the flight, the day of the flight and the day after the flight.

Like all medications including the injectible heparin there is a potential for bleeding in the event of an injury, or a risk of interactions with other medications. The treating travel medicine doctor would consider these factors.

Aspirin

There is still no evidence that aspirin is helpful in preventing DVT as it affects the platelets and stops arterial clotting, but has very little effect on clotting in the veins. Users may experience side effects and be lulled into a false sense of security. If a person has significant risk, they should be on effective anticlotting medication as noted above.

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Exercise in Type 1 Diabetics

… Prepared by Dr Norman Hohl – TMA member Gold Coast

A fascinating presentation in Perth late yesterday at the Australian Diabetes Conference by a Paul Fournier showed the progressive fall in glucose for 2hrs after moderate exercise in Type 1 Diabetes, can be prevented by a 10 sec maximum intensity sprint immediately after the moderate exercise. This could be of critical benefit for travellers who find themselves unexpectedly without their carbohydrate emergency supply at hand.

(For regular sports, or adventure travellers, he showed convincingly that a 4 sec burst of max intensity sprinting every 2 minutes during moderate exercise, also decreased significantly the hypoglycaemia occurring in the 2hrs after.)

Clearly this is only for the emergency as carrying the glucose is better, but the unintended can happen, particularly when travelling, and this could prevent loss of consciousness.

A unique resource is now available for specific effective practical advice on exercise for type 1 diabetes. This is really an amazing web-based tool, that I am sure any Type 1 diabetes (T1D) traveller would find invaluable, as well as those who are fearful or confused about exercise and are not travelling.
Have a look at www.exT1D.com.au site here.

Allan Bolton has put enormous personal effort into writing this and has had to charge a subscription fee to make it viable. He is lobbying to get it available free without biased sponsorship deals, but currently it costs $85, but any T1D who likes sport and travel, or parent who wants their child to be active and liberated would find it well worthwhile.

 

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If You Can’t Afford Insurance You Can’t Afford To Travel

… Prepared by Dr Robyn Dawson TMA Member Burnie, Tasmania

Australians are making 6 million overseas trips each year. The first half of this year saw 1.5 million more travellers departing Australia than incoming tourists.

In keeping with Australian’s larrikin reputation, travellers are becoming more adventurous, exploring more remote and dangerous destinations with more challenging activities.

To assist persons in trouble overseas, the Department of Foreign Affairs provides Consular services. The number of services in a year has been know to exceed 35,000, spanning 163 countries.

Situations where assistance has been requested have included loss of property or passports, natural disasters (tsunami, earthquake, flood), civil unrest or terrorism, airline strikes, crime, serious accident, disabled cruise ship, serious illness or even death.

Thailand is a very popular destination, with its attraction of sun, surf and bars. However DFAT figures show that Thailand is the most dangerous country for Australians, with 343 deaths recorded from July 2005-June 2010. Causes reported include; Accident 62, Illness 147, Murder 5, Natural 48, Suicide 11, Unknown 70.

Trailing Thailand is Vietnam with 236 deaths, USA 229, Greece 239, Phillipines 225, Indonesia 195, Germany 188, UK 164, Hong Kong 155, China 144.

Travellers take uncharacteristic risks e.g. Driving scooters without helmets, wearing shorts and sandals. There is always the lure of drinking excessively on holidays and experimenting with drugs and casual sex.

The take home message is TAKE CARE – BEWARE. Travel Insurance is absolutely necessary.

In case of an emergency a medical evacuation could be required and this can be very expensive. If you are not covered by travel insurance the cost is yours. It is estimated that only 14% of travellers have all recommended vaccinations. Full medical preparation and insurance will give you peace of mind.

Be prepared and you will enjoy the adventure.

 

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Sri Lanka Tour

… Prepared by Dr Robyn Dawson TMA Member Burnie, Tasmania

Here I am sitting poolside somewhere between overheated and hot just from the exertion of walking from the hotel room up through the reception and dining room of this magic old English colonial hotel with a romantic story to keep you on the edge of your seat. I will have to leave you there for another time.

As I look across the inviting pool of Mt Lavinia Hotel to the rolling surf where the Arabian sea meets the Indian Ocean, to the skyline of a bustling city, I give away my location as being in Sri Lanka. With almost three weeks behind me in this land of contrasts I am reluctantly packing to catch the early morning flight to Singapore.

Ones first impressions are that at least 2 things are missing here …

  1. Seagulls which are replaced by a plethora of noisy black ravens, even on the beach, and
  2. Road rules. One sees many and varied modes of transport with “L” plates. I am not sure what they are learning except survival. You can do anything if you have a horn!

We started and ended our time in five star luxury that thrills the wallet, but spent 15 days on an Intrepid tour that covered all the major historic places. These included Anuradhapura, Polonnaruwa, Kandy, Colombo and Dambulla, each with their fascinating mix of ancient kingdoms, Portuguese, Dutch and English influence. Most of the lodgings were 2 star but clean and acceptable. Cheap tasty meals made up for reduced aesthetics and lack of fluffy white towels.

Just when almost “Templed” out our guide took us trekking through beautiful cool mountain tracks to the tea plantations and cascading waterfalls to stay in an original Managers Bungalow. We were entertained by our guides with local music (one of those special moments in the life of a traveller).

We visited spice gardens; saw a turtle rehabilitation centre; climbed 200m to a citadel in Sigariya; and then spent 2 days at a beach in pounding surf. We learnt to eat without knife and fork and not to roll our eyes when rice and curry where being suggested yet again. I wonder if my new found skill will go down well at home.

Another special occasion was when our guide, and now friend Bruno, took us to a family friend’s home and we all helped to cook a lively meal and learn the differences in curries, and how to make coconut cream and milk. His wife also joined in – we were family now.

Considering some of the off beat places we ate at and the prevalence of many stray mangy dogs and monkeys we were grateful for good advice from our travel doctor before our departure.

So now the thoughts of home and work are fast becoming a reality, we say goodbye. There is still much to explore here and while peace prevails here we promise to return.

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Elephantiasis – Sri Lanka

… Prepared by TMA Member Yeppoon, Qld: Megan Young (medical student)

Travelling to third world countries as part of a medical attachment can be a life changing event with life long learned skills and memorable experiences. This 64 year old gent was happy to share his story with Megan Young, our final year medical student, presently attached to a hospital in Sri Lanka. He has suffered this condition for 22 years. The risk to visiting travellers is quite low.

Lymphatic filariasis, also known as Elephantiasis, is a parasitic nematode infection spread me mosquitoes, in which the worms obstruct the lymphatic system, causing severe chronic lymphoedema. It may result in deformity and cause disability and is associated with social stigma. (WHO)

Aetiology:
Wucheria bancrofti is responsible for around 90% of lymphatic filariasis infections, but Brugia malayi and B. timori may also be the cause. Infection occurs when mosquitoes (Culex, Anopheles and Aedes species) carrying the larvae of filaria bite a human, transferring larvae into the blood. The larvae enter the lymphatic system, where they mature into adult worms, where they form ‘nests’ which obstruct the lymphatic system causing lymphoedema, and, in more severe cases, elephantiasis (where the skin and tissues thicken). This occurs over a period of several years. Lymphoedema may occur in the limbs, genital and breasts. (WHO)

Epidemiology:
Lymphatic filariasis occurs in 83 countries in the tropics of Asia, Africa, and the Pacific and in certain regions of the Caribbean and South America.

Risk for Travellers:
Risk for travellers to endemic areas is low; however, lymphatic filariasis can occur in travellers who stay for extended periods in endemic areas.

Prevention:
There is no vaccination or prophylactic medication for lymphatic filariasis. It must be prevented throughprevention of mosquito bites.

Treatment:
Treatment of lymphatic filariasis is through mass drug administration (MDA) of albendazole 400mg with either ivermectin (150 – 200 mcg/kg) diethelcarbamazine citrate (6mg/kg). Treatment also aims to reduce lymphoedema and prevent secondary infections in the affected limb. (WHO)

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