Travelers Health for Burma, Thailand and Laos
Oct 22nd, 2010, 06:56 AM
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Travelers Health for Burma, Thailand and Laos
I just returned from Healthy Traveler (healthytraveler.com), where Dr. Terry’s practice is limited to travel medicine. Since there have been many contrasting views about the best preventions, I want to summarize what I learned at my visit.
Malarial risk in Burma is almost nil in tourist areas but endemic in Northern Thailand (especially around the Lao and Burma border areas) and Southern Laos. Malaria in these area has become resistant to Lariam so the two choices are Doxycycline and Malerone. Doxycycline is much cheaper but comes with some downsides: a) if you miss even one dose the effectiveness of the program is compromised, 2) it produces significant photosensitivity in many users, 3) it is likely to produce a roaring yeast infection in women so women must have medication for that eventuality, 4) you must take it for 30 days.
Malerone is very expensive --$7.00 a pill. It has few side effects according to Dr. Terry. It is taken 2 days before entering the malarial area, during the duration in that area and for 7 days after leaving the malarial area. I chose Malerone and must take 22 pills.
For traveler’s diarrhea Cipro is no longer recommended for SE Asia. Azithromycin or Levaquin are the treatments of choice. However, if you take Malerone you cannot take Levanquin (it reduces the effectiveness of the Malerone). If you take Azithromycin DO NOT get the Z pak ( the pills tend to break up and other problems I can’t now remember). Take the Azithromycin along with Imodium until the diarrhea stops and no longer.
Besides the usual clothing advise in malarial areas and precautions for food and water, dog and bat bites are becoming bigger problems. Rabies is 100% fatal. If you get a dog bite while in this area, get to Bangkok asap.
There is a 3 shot modern Rabies vaccine that makes treatment after a bite simple: 2 rabies shots, 3 days apart. “Get only cell-culture vaccine” (never nerve tissue vaccines). Even village health centers have these after bite shots. However, if you have not had the series ($800!) in advance then you have to get to Bangkok (or home) within 24 hours to get immediate injection of Rabies immune globulin plus 4 or 5 shots over 14 days. The message is stay away from dogs.
Tetnus vaccine lasts 5 years according to the CDC. I had my last one 4 years ago and Dr. T said their effectiveness diminishes over the 5 years, so I got a new one. I’ll begin my oral typhoid pills in a few weeks.
In response to my questions about the shelf life of products I have, the answers are: Lariam -- good for long after expiration date; sunscreen with deet - long time, epi pen - buy new one annually.
Now I’m really getting in gear for this December trip!
Malarial risk in Burma is almost nil in tourist areas but endemic in Northern Thailand (especially around the Lao and Burma border areas) and Southern Laos. Malaria in these area has become resistant to Lariam so the two choices are Doxycycline and Malerone. Doxycycline is much cheaper but comes with some downsides: a) if you miss even one dose the effectiveness of the program is compromised, 2) it produces significant photosensitivity in many users, 3) it is likely to produce a roaring yeast infection in women so women must have medication for that eventuality, 4) you must take it for 30 days.
Malerone is very expensive --$7.00 a pill. It has few side effects according to Dr. Terry. It is taken 2 days before entering the malarial area, during the duration in that area and for 7 days after leaving the malarial area. I chose Malerone and must take 22 pills.
For traveler’s diarrhea Cipro is no longer recommended for SE Asia. Azithromycin or Levaquin are the treatments of choice. However, if you take Malerone you cannot take Levanquin (it reduces the effectiveness of the Malerone). If you take Azithromycin DO NOT get the Z pak ( the pills tend to break up and other problems I can’t now remember). Take the Azithromycin along with Imodium until the diarrhea stops and no longer.
Besides the usual clothing advise in malarial areas and precautions for food and water, dog and bat bites are becoming bigger problems. Rabies is 100% fatal. If you get a dog bite while in this area, get to Bangkok asap.
There is a 3 shot modern Rabies vaccine that makes treatment after a bite simple: 2 rabies shots, 3 days apart. “Get only cell-culture vaccine” (never nerve tissue vaccines). Even village health centers have these after bite shots. However, if you have not had the series ($800!) in advance then you have to get to Bangkok (or home) within 24 hours to get immediate injection of Rabies immune globulin plus 4 or 5 shots over 14 days. The message is stay away from dogs.
Tetnus vaccine lasts 5 years according to the CDC. I had my last one 4 years ago and Dr. T said their effectiveness diminishes over the 5 years, so I got a new one. I’ll begin my oral typhoid pills in a few weeks.
In response to my questions about the shelf life of products I have, the answers are: Lariam -- good for long after expiration date; sunscreen with deet - long time, epi pen - buy new one annually.
Now I’m really getting in gear for this December trip!
Oct 22nd, 2010, 07:17 AM
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Hi Robbie, you must be getting excited about your trip!
I wanted to add a few things to your info. Under the info for doxycycline, i know you meant to say that you must take it for 30 days after leaving the malarial risk area.
I'm a little confused about Dr. Terry's comments about Malaria in Northern Thailand. Throughout most of northern Thailand, the risk of malaria is low, only in border areas with Laos, Burma and Cambodia are anti-malarials recommended. That may be what you mean in your summary, but I wanted to clarify it.
Here is the malarial risk map for Thailand:
http://www.fitfortravel.nhs.uk/desti...laria-map.aspx
I disagree with his comments about risk in tourist areas of Burma being nil. Malarial risk maps are drawn from the data provided to WHO. Burma (as your would guess) is not very forthcoming with this data. But we do know that the largest number of malarial deaths in Asia occur in Burma. That's a pretty dramatic statement for such a tiny country.
Here is the malarial risk map for Burma:
http://www.fitfortravel.nhs.uk/desti...laria-map.aspx
As you can see most of the country is termed "variable risk: antimalarials usually advised." Only the areas right around Yangon and Mandalay are considered low risk.
We chose to take antimalarials for our stay in Burma.
I wanted to add a few things to your info. Under the info for doxycycline, i know you meant to say that you must take it for 30 days after leaving the malarial risk area.
I'm a little confused about Dr. Terry's comments about Malaria in Northern Thailand. Throughout most of northern Thailand, the risk of malaria is low, only in border areas with Laos, Burma and Cambodia are anti-malarials recommended. That may be what you mean in your summary, but I wanted to clarify it.
Here is the malarial risk map for Thailand:
http://www.fitfortravel.nhs.uk/desti...laria-map.aspx
I disagree with his comments about risk in tourist areas of Burma being nil. Malarial risk maps are drawn from the data provided to WHO. Burma (as your would guess) is not very forthcoming with this data. But we do know that the largest number of malarial deaths in Asia occur in Burma. That's a pretty dramatic statement for such a tiny country.
Here is the malarial risk map for Burma:
http://www.fitfortravel.nhs.uk/desti...laria-map.aspx
As you can see most of the country is termed "variable risk: antimalarials usually advised." Only the areas right around Yangon and Mandalay are considered low risk.
We chose to take antimalarials for our stay in Burma.
Oct 22nd, 2010, 07:27 AM
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Most of the Malaria cases reported in Thailand comes from migrant workers from Myanmar, Laos and Cambodia. Medical care in Thailand is superior to those of the mentioned countries and I believe that gives the false infected numbers to the border areas as the migrant workers are diagnosed and treated there.
Oct 22nd, 2010, 02:11 PM
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thanks robbie for this...
a couple of things we have frequently been told at our harvard teaching hospital: start malerone 1 day before entering an affected area and one week after leaving as you said...
also tetnus has a 10 year life.... this may have changed??
make sure fred has double shots, and that's not vodka
a couple of things we have frequently been told at our harvard teaching hospital: start malerone 1 day before entering an affected area and one week after leaving as you said...
also tetnus has a 10 year life.... this may have changed??
make sure fred has double shots, and that's not vodka
Oct 22nd, 2010, 02:58 PM
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Kathie thank you for your careful reading and your map citations. I will speak with Dr. Terry. I did take out my big Burma map and see that our itinerary goes only to the variable risk areas (Rangoon, Mandalay, Pagan and Maymyo) but why worrry, I'll likely just take another 7 pills.
Dr. Bob, I'll pass on your recommendation to Fred. Fortunately for me, I have built up natural immunity to him over the years. Yes, I'm getting very excited. WIll post balance of trip itinerary after finalizing details.
Dr. Bob, I'll pass on your recommendation to Fred. Fortunately for me, I have built up natural immunity to him over the years. Yes, I'm getting very excited. WIll post balance of trip itinerary after finalizing details.
Oct 23rd, 2010, 02:24 AM
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Most of the Laos malaria cases around Luang Prabang are from hill tribe residents. Very few cases in Luang Prabang itself. Of FAR greater concern is Dengue fever which has reached affected many people. Of course there is no prophylactic for dengue fever.
Oct 23rd, 2010, 05:57 AM
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I am soooo on the fence about anti Malarial medication. I have friends who are health care workers, two who live in Zanzibar, and they are very adament that you do not take anti malarial meds.
One reason is that the medication hides the symptoms, so you dont know that you have it. Even if you take the meds you can still get malaria and have to be treated.
On our last two trips, India and Tanzania, we did not take the medication by choice.
My concern this time is lack of health care in Laos and the fact I am travelling alone and getting to Thailand in a hurry if I get sick.
I may relent and take Malarone while in southern Laos for this reason......still thinking.
Thanks so much for posting this Robbie and especially valuable is the information about Cipro as we usually take that with us when we travel. I shall look into the others instead.
One reason is that the medication hides the symptoms, so you dont know that you have it. Even if you take the meds you can still get malaria and have to be treated.
On our last two trips, India and Tanzania, we did not take the medication by choice.
My concern this time is lack of health care in Laos and the fact I am travelling alone and getting to Thailand in a hurry if I get sick.
I may relent and take Malarone while in southern Laos for this reason......still thinking.
Thanks so much for posting this Robbie and especially valuable is the information about Cipro as we usually take that with us when we travel. I shall look into the others instead.
Oct 23rd, 2010, 06:31 AM
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Thanks for this info. I would like to learn more about why the Z-pack is not the vehicle of choice for this medicine, apart from possible crumbling of pills.
(I've got several in my home from previous trips..)
The rabies risk in Burma (and probably elsewhere, too) is very real and we were told two rather scary stories of people being bitten and having a heck of a time locating the proper antidote. Village health centers in Burma most definitely do not stock this as routine.
Malarone is covered by some US insurance plans.
(I've got several in my home from previous trips..)
The rabies risk in Burma (and probably elsewhere, too) is very real and we were told two rather scary stories of people being bitten and having a heck of a time locating the proper antidote. Village health centers in Burma most definitely do not stock this as routine.
Malarone is covered by some US insurance plans.
Oct 23rd, 2010, 05:46 PM
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"My concern this time is lack of health care in Laos"
A lot of people say this and it is no longer the case in Vientiane anyway. My local village doctor is Japanese trained and excellent. There are a number of these and Vietnamese trained doctors now. The French clinic has a very fine doctor, who picked up a misdiagnosis from GPs in Australia immediately. The Australian clinic here is well staffed and very good, albeit expensive. The local Mahosot Hospital has an annexe especially for foreigners. True, Luang Prabang health care still leaves a bit to be desired, and the north certainly does.
rhkkmk: "as a visitor, why would you not take preventative care?" Because I don't like putting chemicals into my body when it is not necessary. As I have to use deet and cover up for Dengue anyway, why should I poison my system? But each to his own.
Here are some malaron side effects -
Cough; diarrhea; dizziness; headache; loss of appetite; mouth sores; nausea; stomach pain; vomiting; weakness.
Seek medical attention right away if any of these SEVERE side effects occur when using Malarone:
Severe allergic reactions (rash; hives; itching; difficulty breathing; tightness in the chest or throat; swelling of the mouth, face, lips, or tongue; unusual hoarseness); dark urine; fever, chills, or persistent sore throat; mood or mental changes; muscle or back pain; pale stools; red, blistered, swollen, or peeling skin; ringing in the ears; seizures; severe or persistent vomiting, diarrhea, or stomach pain; shortness of breath; unusual fatigue or weakness; weight loss; yellowing of the skin or eyes.
A lot of people say this and it is no longer the case in Vientiane anyway. My local village doctor is Japanese trained and excellent. There are a number of these and Vietnamese trained doctors now. The French clinic has a very fine doctor, who picked up a misdiagnosis from GPs in Australia immediately. The Australian clinic here is well staffed and very good, albeit expensive. The local Mahosot Hospital has an annexe especially for foreigners. True, Luang Prabang health care still leaves a bit to be desired, and the north certainly does.
rhkkmk: "as a visitor, why would you not take preventative care?" Because I don't like putting chemicals into my body when it is not necessary. As I have to use deet and cover up for Dengue anyway, why should I poison my system? But each to his own.
Here are some malaron side effects -
Cough; diarrhea; dizziness; headache; loss of appetite; mouth sores; nausea; stomach pain; vomiting; weakness.
Seek medical attention right away if any of these SEVERE side effects occur when using Malarone:
Severe allergic reactions (rash; hives; itching; difficulty breathing; tightness in the chest or throat; swelling of the mouth, face, lips, or tongue; unusual hoarseness); dark urine; fever, chills, or persistent sore throat; mood or mental changes; muscle or back pain; pale stools; red, blistered, swollen, or peeling skin; ringing in the ears; seizures; severe or persistent vomiting, diarrhea, or stomach pain; shortness of breath; unusual fatigue or weakness; weight loss; yellowing of the skin or eyes.
Oct 23rd, 2010, 06:09 PM
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I'm sure most of you are aware that the FDA requires that every complaint made by a person taking a tested drug during the final trials must be recorded and listed under possible side effects whether or not that effect is related in any way to the drug. Therefore, the catalogue of possible side effects is of little practical use. The separate listing showing incidence of side effects is more helpful.
That said, Malarone has the fewest side effects of any of the anti-malarials, and the incidence of side effects is quite low.
Each person, hopefully in conjunction with their healthcare provider, must make their own decision about what kinds of precautions they want to take to prevent malaria. Malaria, after all has some pretty serious side effects itself, including death.
That said, Malarone has the fewest side effects of any of the anti-malarials, and the incidence of side effects is quite low.
Each person, hopefully in conjunction with their healthcare provider, must make their own decision about what kinds of precautions they want to take to prevent malaria. Malaria, after all has some pretty serious side effects itself, including death.
Oct 23rd, 2010, 09:35 PM
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Vientianeboy. When I said my concern was lack of health care in Laos I was meaning in the 4000 island/Pakse area as that is where I need to take the malaria meds. From what I have read of that area you need to go to Thailand for anything major.
I agree with you, the reason that I personally dont want to take the meds is because I dont like putting anything chemical into my body that I dont have too, even tylenol. I dont like using the deet either but I guess this is the trade off for wanting to go travelling.
That is why I said I was on the fence with this. I am not sure which way to go with it.
In Tanzania I purchased a drug that you take if you do get malaria, however it would not work for malaria contracted in Laos unfortunately. Is there such a thing to purchase from a doctor or pharmacy in Laos?
In Canada Malaria meds or any kind of travel medication is not covered by health care, but that is not the main issue for me anyhow. It would be nice to be re-embursed though.
I agree with you, the reason that I personally dont want to take the meds is because I dont like putting anything chemical into my body that I dont have too, even tylenol. I dont like using the deet either but I guess this is the trade off for wanting to go travelling.
That is why I said I was on the fence with this. I am not sure which way to go with it.
In Tanzania I purchased a drug that you take if you do get malaria, however it would not work for malaria contracted in Laos unfortunately. Is there such a thing to purchase from a doctor or pharmacy in Laos?
In Canada Malaria meds or any kind of travel medication is not covered by health care, but that is not the main issue for me anyhow. It would be nice to be re-embursed though.
Oct 24th, 2010, 02:32 AM
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Is there such a thing to purchase from a doctor or pharmacy in Laos?
Don't know. You can pick up most anything over the counter. Interesting that you mention Tanzania. A US friend of mine just came back from Tanzania. She took doxy there as she is a blood donor. Her clinic told her if she took malarone she could not donate for 3 years afterwards!
Don't know. You can pick up most anything over the counter. Interesting that you mention Tanzania. A US friend of mine just came back from Tanzania. She took doxy there as she is a blood donor. Her clinic told her if she took malarone she could not donate for 3 years afterwards!
Oct 24th, 2010, 02:47 AM
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I think something got lost in translation or in the process of he said she said about Malarone and blood donation. Really, Malaronr is no problem. You are able to donate while taking it. It is if you have had malaria that you can't donate blood for three years. http://wwwnc.cdc.gov/travel/yellowbo...2/malaria.aspx
