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see also Australian consular advice: www.smartraveller.gov.au/zw-cgi/view/Advice/Thailand

THAILAND

Thailand is a country of extremes. Whilst common tourist destinations such as Bangkok, central Thailand, Changmai (city), or the major southern costal resorts (Phuket, Pattaya, Koh Samui, Koh Pee Pee, Koh Samet) are considered safe, travel to hilly forested border areas (with Myanmar & Cambodia), or rural parts of peninsular Thailand pose serious health risks.
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 in city and resort areas, which can completely ruin ones holiday and even be life threatening. The recent tsunami disaster will require travellers to check CDC & WHO websites for disease outbreak news. ( CDC tsunami website - www.bt.cdc.gov/disasters/tsunamis )
Remember most people working in the best tourist resorts and handling the food may  not themselves, have a high standard of sanitation.

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.

RABIES (illness is 100% fatal to humans)
Source: mostly dogs, cats & monkeys (even minor scratch or lick of graze). Incubation period 10 days to 10 years. Be wary of all animals whether tame or not.

MALARIA
Malaria is a potentially life-threatening infection prevalent in most of the tropics. It is a parasitic disease spread by the bite of Anopheles mosquito which is active between dusk and dawn
Resort, City & Urban Areas: Minimal risk and antimalarial drugs not recommended. However use of insect repellents is recommended as other diseases spread by daytime biting mosquitoes in urban areas (eg dengue)
Inland Forested areas: Highly drug resistant malaria occurs throughout the year particularly near the borders with Cambodia & Myanmar. Doxycycline and Stringent use of insect repellents is recommended

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

  • Mosquito nets preferably impregnated with permethrin-emulsifiable concentrate. Permethrin is an insecticide but not a repellent; is safe, colourless, odourless; is stable; adheres well to fabric; survives 5-10 washing's in hot or cold water; but is not recommended for skin application.
  • Avoidance of 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 an insecticide aerosol in the room to kill mosquitoes before retiring. (Knock Down sprays)
  • Use of mosquito coils or vaporising mat containing a pyrethrin.
  • Use of mosquito repellents. The most effective mosquito repellent is (DEET). "Rid" or "Muskol" are commercial preparations containing DEET. Roll-on preparations are recommended as spray cans may explode in luggage compartments. 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. Untreated travellers in proximity to treated ones are more apt to be bitten.
  • DEET is absorbed through the skin. Preparations containing less than 50% DEET are almost free of side effects when applied to the skin of adults. In children the repeated,  extensive inappropriate application of as low as 20% DEET has lead to staggers, agitation, tremors, slurred speech, convulsions and death.
  • DEET repellents should be kept well away from plastics, including cameras, as it will dissolve them.
  • In addition MASTA (Medical Advisory Service for Travellers Abroad) can provide a large range of travel equipment including impregnated mosquito nets, wrist and ankle insect repellent bands (mosi-guards). These products can be obtained through some chemists or by mail : MASTA PO Box 168, Dee Why, NSW 2099 Tel:(02) 971 1499 or Fax (02) 971 0239. TMVC and some camping stores can also supply these products. TMVC website www.tmvc.com.au ; also Travel Clinics, Australia www.travelclinic.com.au/products.htm

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

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.
Bathing, Bare Feet & Shoewear: Skin penetrating parasites abound in fresh water lakes and rivers of south-east Asia. These vary from the harmless but prolonged skin irritation of cercarial dermatitis (Swimmers Itch) up to the serious infestations of schistosomiasis and leptospirosis. Other parasites in soil and can penetrate the soft skin of tourists walking barefoot. ... Shoes and clothing should be examined before use - particularly in the morning - as snakes and scorpions 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.
Plane Trip: Drink plenty of fluids, exercise legs, avoid excessive alcohol & coffee.
Prolonged Travel: Extra pair of spectacles
Dental Check up advisable - Dental treatment in developing countries could be a health risk.
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.

Thailand: Treatment measures

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.) or Azithromycin 1 Gm. Nb Azithromycin safe for children >12 months and in pregnancy.
  • 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

MALARIA
Malarial symptoms can occur after 8 days following an infected bite. The classic symptoms are fever, malaise, headache, chills and sweats.
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.

Antimalarial Drugs Common side effects ... Childrens dosages

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.

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

Multi-drug resistant malaria occurs in areas bordering Thailand and western Cambodia. The National authorities in Thailand recommend a combination of mefloquine and artesunate. If not available, a regime to cure this is 25mg/kg mefloquine, given as 15mg/kg initially followed 6-8 hrs later by 10mg/kg, or with oral quinine 10mg/kg every 8hrs for 7 days, plus oral tetracycline 500mg every 8hrs for 7 days.*3.  The new drug Malarone (Atovaquone + Proguanil) is now recommended by most Australian authorities and  is highly effective. Preventive drugs should be continued after treatment for malaria.

Rabies
Post-exposure immunisation
You should wash the wound immediately with soap and water and then disinfect with iodine (betadine). Seek medical attention if risk seems high (unprovoked attack, irritable animal) and have post-exposure vaccine as soon as possible (preferably within 48 hours). Otherwise at least seek medical advice on return.

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.

Source: WHO - http://whqlibdoc.who.int/publications/2005/9241580364_chap1.pdf  (page 8)

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 06/09/2006.  Additional references & disclaimer.

 

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