Monday, April 27, 2009

A question of malaria

There is alot of angst out there in travel land, or at least on travel forums, about the question of malaria. What countries have malaria and what should a visitor do to prevent getting the disease?

There's also alot of advice given, much of it misleading, from other travellers. Some push the paranoid and erroneous view that everyone should take antimalarial prophylaxis and all will be safe, others scoff and debunk all the pills as capable of causing severe side effects, and anyway, they never got malaria despite taking nothing. Information from a visit a few years back can quickly become irrelevant as public health measures make more areas, especially in Asia, malaria free. There's quite a few well balanced remarks, but the poor punter who asked the question has now been bombarded with so many opposing opinions that he/she is pretty confused. My advice? See a doctor.

But it's not that simple, because many of your average GPs don't have much experience of travel medicine and may need to do a bit of research themselves to determine malarial risk. They also need to find out about the latest medications, potential side effects and discuss all this with their patient. Something many GPs just don't have the time to do when a client turns up wanting advice within a couple of weeks of the departure date.

Following is a general guide to all things antimalarial. If your doctor is not asking these questions then you should seriously consider going elsewhere. A travel medicine clinic is a good option, but even so a healthy dose of scepticism is in order, because doctors also aren't immune to having fixed ideas about what plan of "medical action" should take place. A little bit of your own research therefore helps.

So let's start with a comprehensive travel interrogation. Where are you going and for how long? Will you be spending most of your time in larger cities and what sort of accommodation will you be staying in? Will you be spending much time in rural areas and will you be staying overnight there or simply doing day trips? Are you a keen birdwatcher/photographer/nature lover who spends their dawns and dusks out in the elements or are you usually safe and sound in your bed or a bar at those times?

It's not simply a matter of looking up a particular country and determining its malaria risk and applying that to all travellers to that country. A typical example is Thailand, where Bangkok and most of the rural areas are now considered malaria free. There are still some areas of Thailand where malaria prevalence is quite high (though only moderate risk) and knowing this information usually involves a little more detailed research.

We've touched on a couple of epidemiology terms here. One of them is prevalence. This is a measure of how much disease is present in a given community. To determine the level of risk of acquiring malaria there needs to be both a presence/absence of the mosquito which transmits the disease and a reservoir of infected individuals to maintain a source. Australia, for instance, is considered malaria free because although there are plenty of anopheles mosquitos in the tropical climes, there is very little, if any, untreated malaria in the community to provide a reservoir for further spread. That's the advantage of a well funded public health system.

If your stay is mostly in large cities in malaria prone countries, risk is considered quite low. This risk assessment assumes that you will be staying in modest accommodation, with air conditioning or perhaps just a fan, rather than staying with local people in substandard conditions. Both aircon and moving air from a fan will reduce mosquito numbers in a room, and the use of a permethrin impregnated mossie net, and/or spraying the room with insect repellant prior to leaving for your evening meal will further reduce your risk of being bitten whilst sleeping or at dawn. Light coloured clothing that limits skin exposure during the anopheles' active times of dusk and dawn, and the use of repellants with DEET, also prevent you being bitten.

Where do you stand if you have determined that you will be spending time in an area which is not malaria free? This is where it gets tricky, because there are low risk, moderate risk and high risk areas. Then there's the actual amount of time you will be spending there, and then your medical history as to whether the use of antimalarials would be harmful for you.

The general rule is the longer you take an antimalarial medication, the higher the risk of significant side effects. This is why most expats living in a malaria prone country rarely take them. But as a short term traveller in an area, your risks are different. And if you are travelling to many places, some with high prevalence, others low or no risk, it all starts to get quite bewildering. Particularly as some of the available medications need to be commenced prior to entering the malaria zone, and must be continued for up to a month after leaving it.

It's a bit of a no brainer to work out that if you are going to a high risk area for a short period of time then it makes sense to take antimalarials. The rest of the scenarios however are less black and white. There is in fact no right answer to the question: should I take antimalarials? And the reason: because no medical evidence to this day has proven, categorically, that the taking of antimalarial prophylaxis actually prevents you contracting malaria. In fact there is some evidence that it may mask symptoms and delay diagnosis and appropriate treatment. But it's still recommended that travellers to malaria prone places take it, so you wonder why you're so confused?? No, it's not the Larium!!

Your doctor and you should now have a fairly good idea about where you are going, what sort of activities you are planning, and therefore what your risks are. Then you will probably be given a choice of a number of scenarios. 1. take antimalarials for your entire trip and for the appropriate tailing off period on your return. 2. take antimalarials just during the times when you are going to be in moderate or high risk areas, and for the ensuing time period afterwards. 3. take no prophylaxis but carry a course or two of treatment should you be in an area where medical help is unreliable.

For short trips, up to a month, I'd tend to favour option 1. Option 2 is a bit of a headache, as the tailing off times can mean alot of time on a drug with potential side effects. It also gets very expensive. Doxycycline, much cheaper than Malarone, can degrade quickly in the heat, so carrying large supplies may not be such a good idea, and purchasing it from local pharmacies is fraught with risks of poor quality or substitution. My favoured option is number three, particularly useful now that Malarone is more easily available and can be taken as a treatment course over four days. But the real message is:


Preventing getting bitten requires planning, execution and consistency. A long day out in the country may mean returning after dark, when your sleeveless top and shorts now offer no protection from the beasties. Or an afternoon session with some new friends turns into evening and you've left the DEET in your bag in your room. Remember, antimalarials don't prevent you getting bitten, and only not getting bitten prevents you getting malaria.

So plan early to see your doctor, you may even need to catch up on a few immunisations too. Then both you and your doctor will have time to be so well informed that you too can start answering those antimalarial questions on your favourite travel forum!!

Friday, April 17, 2009

Arrived safe and sound

One of the great joys of travel for a lass like myself is shopping, especially for exotic curios for my house and for presents for friends and family. In particular I love my textiles, and will travel quite a way to visit weaving villages or places where cottage industry occurs.

But buying things means either travelling with it, or sending it home. Lugging around any extra weight is anathema to me, so it was off to the local PO to run the gauntlet of bureacracy. And in some countries this meant visiting various counters to get boxes, forms, stamps and of course the pay clerk! Guess it keeps people in jobs!

I've learnt alot about the postal services in the various countries I've visited, about how to get the best value for money, and which services not to trust. I didn't try out Indonesian or Cambodian services on the recommendations of others that they were unreliable, but my purchases sent from Thailand, Vietnam, China and Laos have all arrived home safe and sound.

I only used post offices in large cities, where an English speaking employee would be found to help me. The staff were always extremely friendly and helpful, and nothing was too difficult. I just had to hope that my purchases would arrive home.

Packages from Bangkok (I used a suburban PO) arrived very quickly, with one surface/air package only taking 10 days, quite a feat when it's rare I get that service from east coast Australia to my house in regional Western Australia. The two packages from Vietnam, both sent surface mail, had arrived within a month, though I learnt the hard way that I would have saved alot of money by sending just one package instead of two. My China package also took a month, but having met a China expat enroute in Laos who had less than complimentary things to say about the service, I had been a little apprehensive whether it would arrive at all.

When I got home in February, all my packages were waiting for me, excluding the one I'd sent from Bangkok only a week previously (which arrived 3 days later) and one package from Laos. It had only been a month, and since it was surface mail and I'd been told it would take 2-3 months, I wasn't so concerned. But as March became April and April progressed, I began to get a little worried. Not that there was anything I could do...

In Laos I had bought some silk weaving as well as some hand batiked traditional Hmong cloth which I had been really thrilled to find in a market in Sam Neua. I had also found some kids' Hmong skirts - the modern synthetic ones - that will make perfect presents for my three nieces. I remember as a little girl wishing I had a skirt that really swished, well these ones certainly do. And lastly I'd bought something special for a friend due her first baby in May.

Today the box arrived, well it may have arrived earlier in the week for all I know, as the delivery man left it on the front seat of my unlocked car rather than next to the front door (he's a dear the local delivery guy!) and I haven't used the car all week. What a sigh of relief and great joy to unpack another little box of treasures. And just in time for Odette's birthday too!

Australian Customs opened two of my boxes, but didn't confiscate anything as I'm a savvy enough traveller to know what not to send and what has to accompany me through the red zone at the airport so I can talk my way through. I'm not that impressed by the thoroughness of the quarantine inspectors on my arrivals into Australia, though apparently the TV program suggests otherwise. Anything iffy I carry through myself, and usually it's fine, whereas if I send it I'm scared they'll just confiscate it without recourse.

So now it's off to the Australian post office to send off the skirts to my nieces. Interestingly the mail is much quicker west to east than the reverse! And then maybe Matty will put up piccies of the girls swishing in their Hmong skirts on his blog!

Friday, April 10, 2009

It just couldn't last

I blame it all on Rod and Vida. Vida is an old uni friend who with her partner Rod have set up a business offering conferences at ski fields in Canada in January every year. Otherwise known as a tax deductible holiday! Well I'm on their mailing list and the other day Rod sent me an email regarding the dates for 2010. I'd love to ski Canada, and given that my legs are probably in the best shape they've been for years, I started perusing airline websites for possible flights. Now that depressed me somewhat, so I then decided to look up flights to NZ. And then on an impulse I booked them!!!

Well I'll have been back working for 4 or 5 months and will definitely need a holiday by then!! And it seems such a waste to have nice boots and skis sitting gathering dust in the garage. I am not even going to think right now about whether I can fit into my jazzy red ski bunny suit.....oh my god!! Thank goodness feet don't grow!

Skiing is notoriously expensive, so I've booked into the backpackers for two weeks for an absolute bargain price, and will do the shuttle bus up the mountain every day. This will give me ten whole days at my number one favourite ski resort, Treble Cone, and also a chance to check out the wacky local cinema I've been told about in Wanaka.

So now I've got to keep up the cycling (I'm doing 90km a week currently) and start doing a few squats to get those ski legs back. And steel myself to try on the bunny suit......

Wednesday, April 1, 2009

Just like a broken heart

I've now been back at work 3 weeks and it feels funny. Having burnt out so spectacularly over a year ago then crawled my way back from the depths of depression and physical unfitness, I'm feeling rather ambivalent about it all. It's like I want to get involved but am putting up huge personal barriers because I'm scared of getting hurt again.

Working in Aboriginal Health is definitely an emotionally draining experience, but it's also extremely rewarding, and Aboriginal people are so warm and genuine, I love working for and with them. I couldn't envisage moving into "normal" general practice and coping with the "tears and smears", I'd go totally loopy. So it's a complete no-brainer for me to return back to my previous employer.

I tend to have high expectations both of my performance and that of my colleagues - a perfect recipe for being disappointed and getting burnt out again. I know this and so have to restrain my enthusiasm as well as my willingness to do anything beyond the call of duty so to speak. And there's always someone wanting you to do just that little bit more. So having decided to use the no word lots, I now have to learn not to feel guilty for doing so. This is so very hard for me to do, but I am determined to not go down that slippery slope again. And there is no doubt that I am scared shitless that it is going to happen again.

I think I may benefit from some counselling, especially if I can learn more constructive ways to deal with the demands of my job. But in the meantime, I'll just stick with my two and a half days, try not to dig myself into any ditches, and keep up the cycle commuting - nothing like a bit of exercise to clear the mind!!

Meanwhile, I'm steadily editting and uploading more photos onto the new website, and have bought myself a new camera which has a few more bells and whistles. I'll soon be back to doing the Greenough River walks again (Fridays) and have plans to visit some new walking sites on top of the Moresby Ranges. Stay tuned!!