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  ..  click here for 2 page pdf... see also consular advice
www.smartraveller.gov.au/zw-cgi/view/Advice/Indonesia  & www.bali.indonesia.embassy.gov.au/

BALI & LOMBOK

Bali is probably the most popular overseas travel destination for Australians of all ages. Studies have shown that illness occurs in between 15 - 55% of all travellers with 11% requiring to see a doctor whilst away.
The phrase "Travel broadens the mind and loosens the bowels." is apt but it should also be remembered that less common serious diseases do occur, which can completely ruin ones holiday and even be life threatening. Remember ultimately your health is your own responsibility.
Many coastal resorts such as Kutu and large hotels have a high standard of sanitation and safe water supply but remember most people working in them and handling the food do not.Vaccination with oral cholera vaccine (Dukoral) will reduce the incidence of one form of E Coli travellers diarrhoea (LT-ETEC) by 60% but this only accounts for 20% of traveller diarrhoea cases**. More recently Travelan® capsules containing antibodies that bind the ETEC bacteria has been shown to be more successful for these bacteria. www.Travelan.com.au. The WHO have a good pamphlet  copy

TRAVELLERS DIARRHOEA
Most episodes of diarrhoea are short-lived and require no particular treatment. The need to treat diarrhoea depends on either its severity or persistence. It is caused mostly by contaminated food or water.

  • Choose food which is freshly and thoroughly cooked and served steaming hot
  • Eat fruit or vegetables that you can peel or cut open yourself, eg. banana, citrus fruits, papaya.
  • Dry foods and Breads are generally safe.
  • Canned and bottled drinks are safe.

Dangers

  • Avoid milk, ice cream and other milk products unless made with pasteurised (or boiled) milk.
  • Avoid sauces, mousses, mayonnaise.
  • Avoid smorgasbord even in 5 star restaurants (reheated foods & food sitting at room temperature)
  • Avoid prawns, oysters, fish, unless thoroughly cooked. Hamburger meat can be dangerous as they are often precooked and stand at room temperature.
  • Avoid uncooked leafy vegetables, eg. in salads.
  • Ciguatera: At certain times of the year various species of fish and shellfish (especially the larger reef fish including shark) contain poisonous toxins. The risk of illness is reduced by washing the flesh. Cooking does not inactivate the toxins. .. more >  More information on Ciguatera .. see also www.who.int/ith/chapter03_02.html#4
  • Ice is only as safe as the water it is made from.

Malaria (BALI)
Resort & Urban Areas:  Minimal risk and antimalarial drugs not recommended. The use of insect repellents is recommended as this will also minimise the risk of other diseases from bites such as Dengue.
Inland Forested areas:  The benign vivax form of malaria exists and is sensitive to Chloroquine.
Day Trips:  Antimalarial drugs not required (malarial mosquito is only active from dusk to dawn. Insect repellents should be used for reasons as above.
Lombok: The risk of serious falciparum malaria exists and appropriate antimalarial drugs recommended. (Mefloquine or doxycycline)

Minimisation of exposure to mosquitoes
Stringent measures to prevent mosquito contact reduce the risk of contracting malaria by ten fold.
They include:

  • Minimise night time outside activities.
  • Avoid dark coloured clothing as it attracts mosquitoes as do perfume, cologne & after-shave.
  • Clothing to cover arms and legs in the evenings.  NB. It is common for mosquitoes to attack leg/ankle region.
  • Use of mosquito repellents. The most effective mosquito repellent is (DEET). "Rid" or "Muskol". It is effective for 3 to 4 hours when applied to clothing or skin. It needs to be spread evenly and completely over all exposed skin. Repellents containing more than 20% DEET should be avoided in infants and young children. (see also Children's dosage for antimalarials). Untreated travellers in proximity to treated ones are more apt to be bitten.
  • Mosiguards:- Ankle and wrist bands impregnated with DEET, mosquito nets impregnated with permethrin are available from TMVC, MASTA, camping stores and some chemists.
  • DEET repellents should be kept well away from plastics, including cameras, as it will dissolve them

Dengue & Dengue haemorrhagic fever
The "Dengue" mosquito ( Aedes aegpti ) prefers to feed on humans and has invaded urban tropical environment of many countries including Australia. It is considered the most important mosquito spread viral disease in the world today.
Severe headache, bone & muscle pain, high fever and rash usually occur 4-6 days after an infected bite. There is no vaccination available so avoiding bites is essential.
Anyone suspected of being infected with Dengue, especially the haemorrhagic form (large bruises on skin, bleeding gums or blood from nose or bowel) should seek medical assistance immediately. If untreated or inappropriately treated Dengue haemorrhagic fever can be fatal. *2

Rabies
Rabies has occurred on the islands of Java, Timor & Lombok but the Island of Bali is rabies free

Other Considerations
Medical Kit:
Panadol, sunscreens, sunburn cream, antihistamines, antiseptic (Betadine), antifungal (tinea and thrush), diarrhoea medications (antibiotic, gastrolyte if taking children), bandages and dressings, condoms.
Heat and Humidity: Plenty of drinks rich in mineral salts (fruit and vegetable juices, clear soups and even a little table salt) are recommended. Daily showering, loose cotton clothing and talcum powder will reduce heat rash. Risk of severe sunburn needs consideration.
Shoewear: Shoes and clothing should be examined before use - particularly in the morning - as snakes tend to rest in them. ... Leather goods made from inadequately treated skins may contain anthrax spores causing life threatening skin sores.
Accident Prevention: Traffic accidents are a leading cause of accidents among travellers. Vehicles are often unroadworthy. Unfamiliarity with roads, poor condition of roads and drunk drivers add to the dangers. Kuta beach in bali is considered a dangerous beach for swimming and on average 6 tourists drown each year.
Plane Trip: Drink plenty of fluids, exercise legs, avoid excessive alcohol & coffee.
Travel Insurance: Travel insurance should cover not only medical & hospital expenses but also costs due to general accidents, medical evacuation, loss of luggage & money, as well as delays due to strikes.
Sexually Transmitted Disease: There is a high risk of HIV in developing countries (NB. 42% of those already infected with HIV being women 1*). Also most travellers contracting STD had not planned to have sexual contact whilst away. (coerced by the culture and or alcohol) Local condoms are unreliable . There is no evidence that HIV or any other sexually transmitted infections are acquired from insect bites.

Treatment of Illness

Management of Diarrhoea
Because diarrhoea is so common it is important to be aware of how to manage it if prevention fails.
Fluids
Most travellers do not develop dehydrating diarrhoea; almost any beverage coupled with a source of salt (eg., salted crackers) suffices for hydrating most ill travellers
Bottled or canned beverages, tea, broth, foods such as rice, bananas, papaya (pawpaw), potatoes and dry biscuits are tolerated best. Children with diarrhoea are of special concern (see Travelling with children).

  • Antimotility drugs ('stoppers'). Since most diarrhoeal illnesses last only a few days, these drugs may be very helpful in relieving diarrhoea and cramps. Do not use if high fever or blood in motions. Do not use in children under 6, and be cautious in children under 12. Adult Dosage: loperamide (Imodium) -2 capsules (each 2 mg) followed by 1 cap after each unformed stool. (maximum 8 caps per day.)
  • Antibiotics. Diarrhoea with high fever, distressing symptoms or blood in motions:
    A single dose of two tablets of any of the following drugs should be effective. If response is not dramatic after 12 hours continue 1 tab twice a day for a further 3 days. (Norfloxacin 400mg, ciprofloxacin 500mg , doxycycline 100mg, Co-trimoxazole.)
  • Prolonged diarrhoea greater than 10 days and without fever: 
    A bowel parasite "giardiasis" is the commonest cause. The best treatment is tinidasole (Fasigyn) - 4 x 500mg tablets (2g) in a single dose. Metronidazole 400mg three times a day for 5 days is an alternative. If this is not completely effective amoebic dysentery is a possibility. Tinidazole (Fasigyn) - 4 x 500mg tablets (2g) daily for 3 successive days should be effective.

When diarrhoea is prolonged and with fever seek medical attention

Antibiotics to prevent Diarrhoea.
This is reasonable for short trips (less than 3 weeks). Indications include persons with

  • Inflammatory bowel disease, Immunocompromised persons including individuals who have had their spleen removed or poorly functioning spleen (eg  Hodgkin's lymphoma).
  • Insulin dependant diabetics
  • Persons on strong H2 blockers or proton pump inhibitors.(Losec, Somac, Zantac)
  • Business travellers whose purpose of the trip would be ruined will often chose this option. - Norfloxacin 400mg daily, Ciprofloxacin 500mg daily or Bactrim 1 DS daily could be used. Doxycycline is less effective. Azithromycin is useful for pregnant women and children ** WHO

Snake Bite
Poisonous snakes occur in many parts of the world. As for snake bite within Australia the general principles of

  • immediately apply a firm broad bandage
  • immobilise the limb with a splint
  • leave the bandage and splint in place until medical care and antivenom available.

Malaria
Early diagnosis and treatment of malaria

Any fever developing after 8 days or upon return (particularly within the first 3 months) may be due to malaria. You should consult a doctor, voice your suspicion of malaria, and ask for a blood film to be done. You should do so within 48 hours of onset of fever, or earlier if you are more than moderately unwell.
Remember No malarial prevention drug gives 100% protection

Antimalarial Drugs & Common side effects ... Childrens dosages

Chloroquine: Minor side effects such as stomach upset and blurred vision occur frequently. These can lessened by taking tablets with food, or taking half the dose on 2 occasions each week. They are safe in pregnant women and children in correct doses. Pruritus (itch) in dark skin individuals is common. . If you have had generalised psoriasis, chloroquine and other chloroquine-like drugs, including primaquine, quinidine and proguanil should be avoided. Retinal changes including eye damage and blindness may occur after prolonged use but on the usual 300mg per week dose it would take 6-7 years.

Malarone:  - a combination of atovaquone and proguanil in a single tablet, is a new addition for malaria prevention. Its use has been approved for treatment and prevention of malaria (TGA-Australia) since November 2001. It is particularly useful where malaria is resistant to chloroquine and mefloquine (Larium). On evidence to date, it appears to be very safe and effective, but is expensive.

For prevention of malaria, Malarone is taken once a day, starting 1 day before entering malarial risk area and continuing for 1 week after leaving the malarious area. It should be taken with food or milk. This regime is simple and suited to business & frequent travellers.  Nb. When Malarone is used for malaria prevention, side effects are uncommon . However, nausea, vomiting, abdominal pain, and diarrhoea occur when higher doses of the drug are used for treatment. Convulsions and rash have rarely been reported.

Doxycycline: It is an alternative to mefloquine for short-term travellers. Doxycycline at 100 mg/day is approved for a period of up to 8 weeks only (NHMRC 1994) but is probably safe for longer use. Side Effects include thrush, stomach & bowel upsets, (particularly if medication is taken on an empty stomach) and sunlight sensitivity. The exaggerated sunburn reaction may be minimised by avoidance of sunlight, using sunscreen and taking the drug in the evening. Drinking copious quantities of water after swallowing the drug is recommended to reduce heartburn. Using Doxycycline may make the Contraceptive pill unreliable. The Therapeutic guidelines 2002 states that: "A second form of contraception is not necessary, but may be offered." & "Women who develop breakthrough bleeding might consider using barrier methods for the duration of antibiotic therapy". Discuss this matter with your doctor.

Mefloquine: Side-effects ('Lariam') Minor side effects such as nausea, vomiting, heartburn and loose stools occur in about 20% of users, but this is no more frequent than with other antimalarials and usually subside with continued use. Taking ½ tab twice a week with food, and drinking copious water with medication will help reduce these.

Unfortunately mefloquine frequently produces annoying adverse neurological effects such as insomnia, vivid dreams, dizziness, mental clouding, anxiety and coordination problems. These are sufficient to interfere with daily activities in up to 10% of users and are probably aggravated by use of alcohol and cannabis.
Disabling side effects sufficient to recommend the cessation of mefloquine occur in 0.5% of users. However despite this, some  5 - 10% of users will stop the drug.  Consequently any person requiring a clear mind and good co-ordination should not use mefloquine. This may involve travellers to high altitude and definitely those contemplating aqualung (scuba) diving. Other contra indications include persons with a history of seizures, neuro-psychiatric disorder, the first 3 months of pregnancy and those with cardiac conduction problems. Women are advised to use contraceptives during and for 3 months after administration of mefloquine.

Mefloquine is probably best commenced 3 -4 weeks before entering a malarious area as it takes this long to build up to satisfactory blood levels. (half life of 21 days).  Also this provides time to detect those travellers that develop unacceptable side-effects and thus enable a change in medication. Commencing 1 or 2 weeks before departure is not adequate.
A recent report involving soldiers taking mefloquine 250mg daily for 3 days to enable a quick build up in blood levels was surprisingly well tolerated.
US authorities are prepared to use mefloquine for up to 2 years continuously in Peace Corps Volunteers overseas.

Serious neuropsychological side effects can occur when mefloquine is used in high doses. (click important note )
see also Malarial misconceptions: http://www.hc-sc.gc.ca/pphb-dgspsp/publicat/ccdr-rmtc/00vol26/26s2/26s2n_e.html or copy

Proguanil: One of the safest antimalarial drugs. Mouth ulcers is an annoying complication in up to 37% of travellers. (when taken with Chloroquine). Proguanil is taken 2 tabs daily, starting 1 day before entering malarial area and continuing for 4 weeks after leaving the area.  Chloroquine is taken 2 tabs weekly…. Confusing your tablets could be deadly.
Contrarily  to WHO recommendations, Australian travel physicians mostly limit the use of Chloraquine + Proguanil, to travellers unable to take mefloquine or doxycycline.

Stand by Treatment
Since malaria can become life-threatening within a short time you should not delay seeking medical attention. Travellers who are likely to be more than 24 hours away from medical help, are often given one or more treatment courses of the following to take with them.

Business persons & Frequent Travellers
Some travellers make frequent short stops to endemic areas, over a prolonged period of time. Such travellers may eventually choose to reserve chemoprophylaxis for high-risk areas only. Malarone may be the most useful malarial prevention drug here, as it only needs to be taken for 1 week after leaving the malarial area. When antimalarial drugs are not used, rigorous self-protection measures against mosquito bites should be employed and they should be prepared for an attack of malaria: they should always carry a course of antimalarials for stand-by emergency treatment, seek immediate medical care in cases of fever, and take self-treatment if medical help is not available.*(*p 135 WHO 2002 year book - www.who.int/ith/chapter07_03.html#10)

Standby malarial treatment:

  • Malarone (Atovaquone + Proguanil) - The dosage is 4 tabs daily for 3 days with food and is now considered the drug of choice. (but expensive approx $100 Aus). 
  • Riamet (Co-artemether which contains artemether 20mg and lumefantrine 120mg) - 4 tablets twice a day 3 days. Advantage of being very quick acting.
  • Fansidar (3 tablets for an adult) - becoming less reliable

  • Mefloquine for adults > 65kg, 3 tablets followed 6-8 hours later by another 1 tablet (high side effects & no longer recommended)

  • Quinine (adult dose 600 mg three times a day for 7 days) - eg pregnancy
    see also WHO year book (Stand by treatment)- www.who.int/ith/chapter07_03.html#10

(Nb. If taking malarone for prevention, a supply of Riamet should be taken)

ICT Malaria P.f/P.v test  - This test, provides a realistic alternative for people in this category, particularly those who have had significant side-effects from either mefloquine or doxycycline. This test detects circulating antigens of falciparum malaria. A finger prick blood sample gives a result in 5 minutes. For Plasmodium falciparum infection the test is close to 100% reliable, but false positives can occur (rheumatoid factor, previously treated malaria in the last month). For vivax malaria reliabilty is very low. The test is stable at 37 degrees C for 4 months. Cost approx $30 for 2 test kit.  - NB. The test is very reliable in experienced hands but reliability in a sick febrile traveller (self testing) is questionable.
Last edited: 14-Sep-2005

Preventive drugs should be continued after treatment for malaria. As serious neurological side effects may occur when mefloquine is used in the high doses needed for treatment, it should only be used in a true emergency situation when medical attention is not available. Standby use of mefloquine is not recommended for persons already taking mefloquine for malarial prevention. (click important note ) -- Also see Full Information

Travel Checklist & Medical Kit

Medical Examination after travel: It is advisable (if not essential) to visit your local doctor promptly if you

  • suffer from a chronic disease, such as cardiovascular disease, diabetes mellitus, chronic respiratory disease;
  • experience illness in the weeks following their return home, particularly if fever, persistent diarrhoea, vomiting, jaundice, urinary disorders, skin disease or genital infection occurs;
  • consider that you may have been exposed to a serious infectious disease while travelling;
  • have spent more than 3 months in a developing country.
  ** page 203, Manual of Travel Medicine

Information mostly taken from: "International Travel and Health" (WHO year book - internet only)
Australian Immunisation Handbook, 8th Edition - 9/2003 - Part1 - Part 2 & Part 3 (large pdf files)
Centre for Disease Control, USA -  www.cdc.gov/travel Travel Health Seminar Oct 96, June 97,Feb 98, March 99, May 2000, August 2002 & March 2005 - Victorian Medical Postgraduate Foundation.
Manual of Travel Medicine, Melbourne, Oct 2004. Updated 3rd edition 2011.  Additional references & disclaimer.

August 24, 2014

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