Stingers, gators, and sharks, OH MY!

jellyfish   beach at palm cove

One of my dreams since high school was to scuba dive at the Great Barrier Reef in Australia.  I loved the movie, “Finding Nemo,” and wanted to show my daughter where Nemo lives. During my sabbatical, I finally had my chance.  I thought I had planned everything out perfectly.  We rented a condo in Palm Cove, Australia for 2 weeks in the middle of December.  It was going to be sunny and hot in the high 80’s or low 90’s.  Great weather to be swimming in the beautiful ocean.  Or so I thought.  When we finally arrived at the beach, the first thing I noticed, besides the blue water and the soft white sand, was that NO ONE was swimming in the water!  No one was even dipping their feet in the water.  And then we started asking the locals why.  We discovered that the waters near the beaches were infested with JELLYFISH (really big and long ones).  On top of that, it was ALLIGATOR mating season.  And to make it worse, plenty of SHARKS were around!  I kept wondering why I never read about this before on Tripadvisor or Lonely Planet.

On every beach in tropical Queensland that we visited, there were signs warning people of jellyfish, or “stingers,”  and bottles of vinegar around.  If you really wanted to swim in the ocean, it was best to wear a “stinger suit,”  which is a full-body wet suit with hoodie, gloves, and shoes.  On some beaches, there were also swimming enclosures with nets to keep the jellyfish out.  But even these preventive measures were not 100% protective.  I witnessed a boy who was wearing a full stinger suit get painfully stung in the ankle, where there was exposed skin between the suit and the shoe!  I think he was crying for about 2 hours. Poor child!

Jellyfish stings are common and PAINFUL but rarely life threatening. If you think you just got stung by a jellyfish, follow these simple steps:

  1. Get out of the water. Calmly.
  2. Rinse the area with seawater.  Don’t rub the area.  If you have vinegar, rinse the area with vinegar for 30 seconds.  (Vinegar helps prevent the tiny stingers, called nematocysts, from firing.)  A paste of baking soda and seawater can also be used.
  3. Use a credit card to scrape off the stingers still on the skin.  
  4. Take Acetaminophen or Ibuprofen for pain.  Ice packs can also help relieve pain and swelling.

If you get stung, you will likely have skin redness, swelling, tingling/numbness, a “print of tentacles” on the skin, and throbbing pain. However, severe jellyfish stings can also occur and affect other body organs.

Call 911 or seek emergency treatment if there are signs of the following:

  1. Trouble breathing
  2. Swollen mouth or tongue
  3. Nausea/Vomiting
  4. Headache and dizziness
  5. Loss of consciousness
  6. Muscle spasms
  7. Stings over a large part of the body or in the eye/mouth
  8. Stung by a very dangerous jellyfish, such as the box jellyfish, Portuguese man-of-war, Lion’s mane jellyfish, or sea nettle.

I was still able to visit the Great Barrier Reef on a boat excursion. We had a great time in the underwater submarine ride.  We did a little bit of snorkeling. My daughter had fun seeing the coral and colorful fish (sadly, no Nemo).  No one in my family got stung by a jellyfish.  But the next time we want to go to a tropical beach destination, I will be sure to ask the locals whether it is safe to swim in the waters there before booking the trip.

Breakbone Fever a.k.a. Dengue Fever

Most travelers have heard about dengue but don’t really know what it is or how bad it can be.  The nickname, breakbone fever, gives people a clue.  Dengue is a viral infection that is transmitted by infected mosquito bites and is endemic throughout the tropics and subtropics.  That means it is common in Mexico, Central and South America, Caribbean, South Asia, Southeast Asia, Africa, and northeastern Australia.  Over 100 countries have a risk of dengue.  According to the WHO, about half of the world’s population is now at risk for dengue.  Over the last few years, I’ve met many U.S. families returning from their trips worried about dengue or knew someone who recently got infected with dengue.  It is a leading cause of fever in returning travelers.

Dengue is a mean and smart virus.  It is more common in urban areas, as opposed to rural areas.  And the mosquitoes that carry dengue like to bite during the daytime as opposed to the nighttime.  There are 4 types of dengue viruses.  This means that many people who live in endemic country get infected with dengue more than once.  About 75% of people who get infected with dengue virus have no symptoms at all.  The rest, however, can develop a range of different symptoms, including fever, nausea/vomiting, abdominal pain, severe headache and eye pain, joint and bone pain, rash, and easy bleeding.  The incubation period ranges from 3-14 days.

Here’s the scary part.  As many as 5% of people who get dengue develop SEVERE DISEASE, which is called dengue hemorrhagic fever and dengue shock syndrome.  Children are more vulnerable to severe disease and more likely to die.  And people who had dengue in the past are more at risk for severe disease if they get infected with a different type of dengue virus a second time.  Dengue can cause leaky blood vessels which can lead to extra fluid in the lungs and abdomen and SHOCK.  Severe dengue also causes bleeding from GI tract, which shows up as bloody emesis or bloody/dark black stools.  Dengue can also cause hepatitis, pancreatitis, myocarditis, and encephalitis.

There are currently no licensed vaccines, prophylactic medications, or antivirals in the U.S. that protects us from dengue.  However, I learned at a recent international travel medicine conference that there are a few promising dengue vaccines in the pipeline.  The best way to prevent dengue currently is to AVOID MOSQUITO BITES by doing the following:

1. Use insect repellant, such as 20-30% DEET.

2. Wear loose clothing that covers exposed skin.  Clothing can also be pre-treated with permethrin, which will give extra protection.

3. Stay in places with window and door screens, bed netting, or air-conditioning.

4. Cover or avoid having standing or open water containers around the place you are staying in.  These are breeding grounds for mosquitoes.

What do you do if you or your child has a fever and develops other symptoms worrisome for dengue within 2 weeks after you return from your trip?  Go see your doctor right away.  There are blood tests available than can tell whether you have dengue. Many cases of dengue can be mild and be treated supportively at home.  But knowing the signs of severe dengue and getting EARLY appropriate treatment can be life-saving.

How to prevent typhoid fever while eating out on your trip

Eating at a restaurant in Ubud, Bali

The name itself is a little confusing.  Typhoid fever sounds too much like typhus fever, a completely different disease.  Typhoid fever is caused by the bacteria Salmonella typhi, whereas typhus fever is caused by bacteria in the Rickettsia family. You can get typhoid fever from eating or drinking contaminated food or water.  You can get typhus fever by being bitten by an infected human body louse or tick.  Which disease wins in the popularity contest of diseases in U.S. travelers?  Typhoid fever wins by an overwhelming majority.

The CDC estimates that there are about 21 million cases of typhoid fever and 200,000 related deaths each year.  Each year, there are about 5,700 cases of typhoid fever in U.S travelers, most who got the disease while traveling in a developing country.  Which countries have the most cases of typhoid fever?  SOUTH ASIAN COUNTRIES, including INDIA AND PAKISTAN,  have a 6-30X higher risk than other countries.  However, other areas with a high risk of typhoid fever include Southeast Asia, East Asia, Africa, Central and South America, and the Caribbean. Essentially most places you would visit outside of North America, Western Europe, Australia, and New Zealand have a risk of typhoid fever.

So how bad is getting typhoid fever?  Typhoid fever usually causes high fevers, headache, malaise, decreased appetite, enlarged liver or spleen, or a rash consisting of pink “rose spots.”  Diarrhea is uncommon. The serious complications of typhoid fever include intestinal hemorrhage or perforation, which can lead to death.  In the pre-antibiotic era, the fatality rate was up to 20-30%.  Now, antibiotics are the treatment of choice for typhoid fever.  But even with the right antibiotic, it can still take 3-5 days for people with typhoid fever to start feeling better.  Children who get typhoid fever may need to be treated as an inpatient in the hospital.  The incubation period for typhoid fever is 6-30 days.  So even if you’re back home from your travels, remember to tell your doctor about your travel history if you get a high fever.

Families often ask me during a pre-travel visit, “How do I prevent typhoid fever?  First of all, practicing SAFE FOOD AND WATER PRECAUTIONS is very important.  See my previous post “Is this safe to eat?”  for more details on these very essential tips. The same precautions used to prevent traveler’s diarrhea will also prevent typhoid fever.  However, we also know that people who are known as “asymptomatic carriers” can pass typhoid fever on to another person.   For example, if a restaurant waitress, who has recently recovered from typhoid fever, does not wash her hands with soap and water after using the restroom, she can contaminate the food or drinks she serves to a customer.  From my experience, it is RARE to find soap in restaurant bathrooms in Asia.  Have you ever heard of the case of Typhoid Mary?  In 1900, Mary Mallon, aka Typhoid Mary, was a cook in NYC and the first person in the U.S. to be identified as an asymptomatic carrier.  She unknowingly infected 51 people, 3 of whom died.  She spent nearly 30 years in isolation before she died.

GETTING THE TYPHOID FEVER VACCINE before your trip will also prevent typhoid fever.  There are 2 safe typhoid fever vaccines available that offer 50-80% protection from the disease.  The injectable Typhim Vi vaccine  can be given to people age 2 and older.  The oral live attenuated typhoid vaccine, Vivotif, can be given to people age 6 and older, who can swallow pills (4 relatively large pills over the course of 7 days).  The oral vaccine needs to be refrigerated and completed at least 1 week before your trip.  The injectable vaccine is best given 2 weeks before your trip to give time for the immunization to work.   But even if your trip is in a few days, it is still better to get the vaccine late than not getting it at all. For the repeat travelers, the injectable Typhim vaccine will need to be given again in 2 years and the oral Vivotif vaccine will need to be given again in 5 years.  Side effects of typhoid vaccines are uncommon and mild.  For the typhoid shot, fever, headache, and local skin reactions are the usual side effects.  For the oral typhoid vaccine, fever, headache, and the rare stomach upset can occur.

Typhoid fever vaccine is the #1 vaccine I recommend most for travelers to developing countries.  Primarily because this disease is still so common in developing countries, where sanitation is poor and contaminated water is common.  I love to eat at local restaurants when I travel, but I cannot guarantee the safety of their food or the level of hygiene their staff practices.  And knowing how ill people with typhoid fever can get was the primary reason why I vaccinated myself and my daughter from this disease before our trip to East and Southeast Asia.

Will she remember this when she grows up?

Chasing Daddy around temple in Shanghai

This was a question that many friends and coworkers asked me when I told them what I was planning for my 3 month sabbatical last year. We were about to embark on a multi-country, “around the world”  trip with a toddler in tow.  I knew it wasn’t going to be easy with a 3 year old but I was willing to risk it for the sake of having these once in a lifetime experiences.  But was she going to remember the places we would visit or the people we would meet?

Traveling with young children requires you to slow down and prepare for the unexpected.  Children love routines and traveling takes them out of their comfort zone.  A different bed, place, and time zone throws off their sleep routines. It takes longer for children to adjust to a different time zone.  I tell families to expect it to take up to a week for their child to start sleeping well again.  Unfamiliar foods can also be difficult for young children to eat.  Overtired and hungry is a formula for toddler meltdowns.  We sure had our fair share of these tantrums towards the beginning of our travels.

What always surprises me about kids though is their RESILIENCE.  Children deserve more credit than what they are given.  When one of our flights in the Phillippines was delayed for 3 hours, we had to sit in a 90 degree room with no air-conditioning in a tiny airport.  My 3 year old daughter just had fun visiting the tiny gift shop 20 times and looking at the pictures and videos we had taken on our ipad.  Then, when we were told that our flight was cancelled because of “lack of sunlight” and that we would have to spend the night in a nearby hotel, she again was happy just with the thought of going swimming again.  As long as children are fed and rested, they can handle more than you could imagine.

What I realized through my travels is that my daughter relished just BEING with us and having our FULL attention.  When we are home, we are constantly distracted by work and house chores.  Technology also takes our attention away from the people we love most.  When we are away from home, we play games, explore new playgrounds, hold hands, and just simply talk to each other more.   I also saw my husband develop a stronger connection with my daughter that has continued to last, even 6 months after our return.  She no longer demands that I be the one to put her to bed every night or that I be the one to help give her a bath.

Taking a child on an international trip has its pros and cons.  We were not able to stay out past 9 pm or do any adventurous activities.  However, my daughter did get a chance to pet an Australian koala, float (while we snorkeled) in the water on the Great Barrier Reef, ride on a donkey up a volcano in the Phillippines, sit on a bamboo raft going down the Li River in Guilin, and see clownfishes swimming in sea anemones.  She was also able to give food to homeless Filipino street children, see a tarsier, the world’s smallest monkey, and taste the sweetest mangoes and lychees we’ve ever had.  She missed 3 months of school and we spent a lot of our savings.  But she was able to learn and experience things she could never learn in a classroom or at home.  And our connection as a family has deepened as a result. This is what I find most valuable about traveling with children .

Mosquitoes, a love hate relationship

They love me.  I hate them.  I seem to attract mosquitoes every time I go on a vacation to a warm place.  When I get a mosquito bite, my skin swells up like a giant tennis ball and itches like crazy for a week.  My husband never seems to get bitten. And if he does, the mosquito bites disappear after a few hours.  I don’t know why I am so unlucky.  Unfortunately, my 3 year old daughter appears to have inherited my genes in this respect.  The mosquitoes also love her.

Mosquito bites are incredibly annoying.  In many developing countries in Asia, Middle East, South America, and Africa, mosquitoes also carry deadly diseases, such as malaria, dengue fever, chikungunya, yellow fever, and Japanese encephalitis.  We are lucky not to have to worry about these diseases in the U.S.  However, I fear that travelers often forget about how common and dangerous these diseases are in other countries and don’t take the necessary precautions.

In my practice, I have many families who travel to India to visit friends or relatives and stay for many weeks at a time.  Malaria is endemic in ALL of India, rural and urban areas.  The disease is more common during the wet monsoon season, which is roughly June through September.  This coincides perfectly with our summer break, when most families take the time to take long international trips.  Parents will often tell me how they knew of someone who got malaria in India.

Getting malaria can be very scary.  Malaria usually presents as high fevers, chills, and flu-like symptoms, such as body aches and fatigue.  Malaria can also cause severe anemia, jaundice (yellowing of the skin), seizures, kidney failure, coma, mental confusion, acute respiratory distress syndrome, and death.  Children under age 5 are particularly vulnerable to these severe complications of malaria.  There are 4 different types of malaria, with Plasmodium Falciparum being the  worst type.  Infection with this species is known to cause rapid and severe illness.  In fact, infection with this type of malaria is considered a medical emergency!  Over the last 2 decades, the rates of Plasmodium falciparum infection is increasing in India with an estimated incidence of >40% of all malaria infections in that country.

The good news is that malaria is PREVENTABLE.  There is no anti-malaria vaccine yet but there are exciting new treatments in the horizon.  The Bill and Melinda Gates Foundation are developing some exciting new anti-malaria drugs. For now, the best way to prevent malaria is to take medications to prevent malaria called chemoprophylaxis and use insect repellants, such as DEET.  Most of these malaria prophylactic medications are safe, well-tolerated, and effective for people of all ages.  In addition, I recommend travelers use repellants with 20-30% DEET, even on infants as young as 2 months.  Use mosquito nets when your accommodation does not have window screens or air conditioning. Permethrin can also be applied to clothing and bed nets.  The type of mosquito that carries the malaria parasite tends to bite during the twilight hours, between dusk and dawn. Be careful when you’re visiting those night markets or having dinner at sunset.

How do you know if there is a risk for malaria at your trip destination?  Check the   CDC website.  If there is a risk, visit your doctor or a travel medicine specialist at least 2 weeks before your trip since some medications need to be started a couple weeks before you leave.  Since nausea or vomiting is the most common side effect with these prophylactic medications, take it with food and water.  You can also call your doctor and switch your medication if you get an unwanted side effect before you leave on your trip. Many parents are reluctant to give medications to their children.  I get it.  I usually don’t like giving unnecessary medications to children either.  But when I weigh the risk of my child getting a deadly disease, like malaria, with the possible side effects  of the medication, I would choose to give the prophylactic medication every time.

Malaria symptoms can develop as early as 7 days after initial exposure and as late as several months after departure.  If you have visited a malaria endemic area and come down with high fevers, don’t forget to mention your recent travel to your doctor.  Prompt diagnosis and treatment of malaria is life-saving.

Now what about the other bad diseases that mosquitoes can transmit? Like dengue fever or Japanese encephalitis?  Tune in for future posts on these mean and smart bugs!

Is the orphanage you are supporting a fake one?

Something I’ve learned about recently has made me very upset and concerned. Many well-intentioned people travel to developing countries to volunteer their time and donate their money to orphanages.   I completely understand this desire to help those less fortunate, especially children.  I am a pediatrician and seeing pictures of poor orphans make me sad. I have joined short-term medical missions to Mexico and Nepal in the past and have found these experiences to be profoundly rewarding.  But I am now discovering that these experiences have rewarded me much more than they have rewarded those I was serving.

Traveling to far-away places to help another community has become increasingly popular and a very lucrative business. However, I have learned that this business has also become another way to dupe tourists.  Fake orphanages have been fueled by the rise in voluntourism.  In Cambodia, a country that suffered tremendously 30 years ago by the Khmer Rouge, UNICEF discovered that the number of orphanages increased by 75% from 2005-2010.  What was shocking was that 77% of these orphans were not actually true orphans! Most of them had a living parent.  Many of these children are from poor families who give up their children in return for money or promise for a better future for their children.  Many poor Cambodian parents falsely believe that if they send their children to orphanages, they will have a better education, better access to medical care, and better nutrition.  These children are often asked to dance and sing for tourists.  They are asked to show a sad face and wear dirty clothes to seek more donations from tourists.  In Cambodia, this has become a multi-million dollar business. Most of the money are not going to the children, but to the orphanage directors.  And more and more children are being abandoned by their families and exploited as a result.  Some children are even being sold to adoptive parents from rich countries.  Cambodia is not the only country where this is happening.  Nepal has seen a surge in fake orphanages, especially in the aftermath of the recent earthquake. Indonesian orphanages are deliberately kept in poor condition to get more money from tourists.

Children, who are true orphans, are much better off in a foster care system and not in a residential care facility.  We all know this is true.  Why then do we continue to give money or volunteer at orphanages in other countries?  Many people who volunteer also have no experience and no background check.  This makes more children more vulnerable to sexual exploitation as well.  Is it VOLUNtourism or volunTOURISM?  There are some legitimate orphanages out there but it is difficult for the tourist to figure that out.  Asking a local NGO would be a first step.  Organizations that require a background criminal check and have strong supporting staff is also a plus.  Tourists love spending time with children.  But then leaving after a few days will continue the cycle of abandonment for orphans. I favor organizations that require a minimum time commitments of several weeks in order to truly make a positive impact on orphans.  I would also look for organizations that actively promote family reunification. Help poor families take care of their children, not take the children away from them.

Is this safe to eat?

Street food in Chinafrogs in singapore

One of my favorite things about traveling internationally is eating good food.  Our friends know that we love to eat street food.  The street food in Asia is delicious, cheap, and convenient.  In China, the street vendors sell juicy pork buns and meat skewers.  In Bali, bicyclists sell noodle soup with fish balls.  In Thailand, they sell fruit skewers with spiced pineapple and fresh mango pieces.  Most of our memories and pictures of our international trips are of the delicious food we eat there.   Much to my husband’s dismay, this all changed after our daughter was born and started coming with us on our trips.

When we brought our three year old to Asia, one of my main concerns was how to keep her from getting sick.  Like most mothers, I was more concerned about my child’s health than my own.  Most people who were born or grew up in a developing country know about the risks of eating street food but do it anyway.    I was raised in the U.S. while my husband grew up in the Philippines.   He has fond memories of the food he ate as a child. Bangus, fish balls, halo halo, to name a few.  Every time we passed a food stall in Asia, he would stop and buy a small bite to eat, even if the food looked a little sketchy and unhygienic.  And I would often give in and taste it as well.  I can never resist trying a new ethnic food.   Perhaps this is why I got “Bali Belly” mid-way through our trip.   Perhaps this is why the incidence of traveler’s diarrhea is very high in developing countries, roughly  30-70%, depending on where and when you go.  Along with respiratory illnesses, traveler’s diarrhea is by far one of the most common illnesses tourists get while abroad.

Bali belly.  Montezuma’s revenge.  Delhi belly.  Turkey trots.  Whatever you call it, traveler’s diarrhea is no fun when you are on vacation in a foreign land, where the bathrooms are places you try as much as you can to avoid.  Traveler’s diarrhea (TD) can be mild in some people or can be quite severe in others.  TD can often cause fever, bloody stools, vomiting, abdominal pain, and dehydration.  Young children are more likely to get dehydrated due to TD.  Young children are also more likely to get hospitalized due to traveler’s diarrhea.  Getting traveler’s diarrhea can more than ruin your trip.

The good news is that traveler’s diarrhea is preventable and treatable.  Most people have heard the popular saying, “boil, peel it, or forget it.”  This rule is a good one to follow with regards to food safety but there is more to know for travelers.  The CDC also has a helpful free app for travelers called “Can I Eat This?”

1.  Choose foods that are freshly cooked and piping hot.  Those meat skewers I saw in China may have been sitting around all day. Avoid raw meats or seafood.  Avoid raw vegetables.

2. Choose fruits that you can peel yourself or wash in clean, disinfected water.   The fruit skewers in Thailand are peeled but could still be contaminated by unclean water.  The fresh tomatoes in salsa in Mexico are probably not washed in clean water or peeled.

3. Avoid food from street vendors since their level of hygiene is generally poor.

4.  Drink only disinfected or bottled water.  Boiling water for 1 minute will  make it safe to drink.  Some water  bottles in Asia may have teen tampered with so always check the cap to make sure it is sealed.  When I was in China, I bought a carton of milk from a grocery store.  When I got back to our hotel, I discovered that it had already been opened.  Filtered water is also not clean water. Also, use disinfected water for brushing teeth.

5.  Avoid ice in drinks at restaurants as it may have been made with unclean water.

6.  Avoid unpasteurized dairy products and juices.  Be wary of ice cream prepared in contaminated containers.

7. Always wash your hands with soap and water before you eat and after you go to the restroom.  One thing I had a hard time finding in public restrooms in Asia was soap.  Hand sanitizer helps but does not kill Norovirus.  You may want to carry around a little bottle of soap when you are traveling.

Now, even if you follow all of these food and drink safety rules, there are no guarantees.  You can still get traveler’s diarrhea.  You cannot control the hygiene of the restaurants you eat at. For people going to developing countries with young children, I advise them to bring ORS (oral rehydration solution) salts.  If your child gets diarrhea, start ORS salts right away as this could prevent dehydration.  In the U.S., we use pedialyte electrolyte solution.  However, in other countries, the equivalent is ORS salts, commonly sold in pharmacies.  You can buy it online to have in your travel health kit before you go on your trip.  Sports drinks or soda have too much sugar and not the right amount of electrolytes that young children need.  If your child is vomiting, you can give a teaspoon every 5 minutes.   Once your child can keep down liquids, you can give him/her food.  But avoid food that is sugary or fatty while your child is still recovering as those foods can sometimes make the diarrhea worse.

In developing countries, 80-90% of traveler’s diarrhea is due to a bacteria.  The most common culprit is enterotoxigenic E.coli, followed by campylobacter, shigella, and salmonella species.  Conversely, diarrhea in the U.S. is predominantly due to a virus.  Traveler’s diarrhea can be severe and cause dehydration, especially in children.  This is why I recommend bringing a prescription antibiotic, like Azithromycin, with you if you are going to a developing country.  This antibiotic should be used for severe diarrhea, not just mild or moderate diarrhea.  Taking it early can help you feel better faster and prevent complications.  Imodium and pepto-bismol is not recommended for kids under 12 due to possible serious side effects.  When I developed bloody diarrhea in Bali, I was so glad that I had brought Azithromycin.   I still spent 3 days lying in bed in my hotel room, but it could have been much worse. At least my daughter did not get it.

But what about antibiotic resistance?  It’s been shown recently in a study that travelers who have taken antibiotics have a higher risk of being colonized with ESBL (extended spectrum beta-lactamase) producing bacteria.  And we already know that most TD causing bacteria in South and Southeast Asia are now resistant to Cipro.   The trends of antibiotic resistance are scary.  This is why people should reserve using antibiotics only for severe diarrhea.  What about probiotics? Will they help?  As of now, there is not enough data to show that probiotics help treat traveler’s diarrhea. Many people with TD who seek medical care overseas are also very likely to get intravenous antibiotics, not just oral antibiotics.  Then, there is also new evidence that treating traveler’s diarrhea with antibiotics will lessen the risk of developing a potential chronic problem, such as irritable bowel syndrome (IBS).  The debate is ongoing.

Remember that antibiotics do not kill viruses or parasites, which are also common pathogens in developing countries.  If your child’s diarrhea does not improve within 3 days, or if he/she develops high fevers, dehydration, or severe bloody stools, you will need to seek medical care.  Getting a stool sample tested may be recommended.