Dengue

This viral disease is transmitted by mosquitoes and occurs mainly in tropical and subtropical areas of the world. Generally, there is only a small risk to travellers, except during epidemics, which are usually seasonal (during and just after the wet season). With unstable weather patterns thought to be responsible for large outbreaks of dengue fever in Southeast Asia, travellers to Cambodia may be especially at risk of infection.
Unlike the malaria mosquito, the Aedes aegypti mosquito, which transmits the dengue virus, is most active during the day and is found mainly in urban areas.
Signs and symptoms of dengue fever include a sudden onset of high fever, headache, joint and muscle pains (hence its old name, 'breakbone fever') and nausea and vomiting. A rash of small red spots appears three to four days after the onset of fever. Dengue is commonly mistaken for other infectious diseases, including influenza.
You should seek medical attention if you think you may be infected. A blood test can diagnose infection, but there is no specific treatment for the disease. Aspirin should be avoided, as it increases the risk of haemor-rhaging, but plenty of rest is advised. Recovery may be prolonged, with tiredness lasting for several weeks. Severe complications are rare in travellers but include dengue haem-orrhagic fever (DHF), which can be fatal without prompt medical treatment. DHF is thought to be a result of secondary infection due to a different strain (there are four major strains) and usually affects residents of the country rather than travellers.
There is no vaccine against dengue fever. The best prevention is to avoid mosquito bites at all times - see Malaria, p310, for more details.

Fungal Infections

Fungal infections occur more commonly in hot weather and are usually on the scalp,between the toes (athlete's foot) or fingers, in the groin and on the body (ringworm). You get ringworm (which is a fungal infection, not a worm) from infected animals or other people. Moisture encourages these infections.To prevent fungal infections wear loose, comfortable clothes, avoid artificial fibres, wash frequently and dry yourself carefully. If you do get an infection, wash the infected area at least daily with a disinfectant or medicated soap and water, and rinse and dry well. Apply an antifungal cream or powder like tolnaftate (Tinaderm). Try to expose the infected area to air or sunlight as much as possible. Wash all towels and underwear in hot water, change them often and let them dry in the sun.

Hepatitis

Hepatitis is a general term for inflammation of the liver. It is a common disease worldwide. There are several different viruses that cause hepatitis, and they differ in the way that they are transmitted. The symptoms are similar in all forms of the illness, and include fever, chills, headache, fatigue, feel¬ings of weakness and aches and pains, followed by loss of appetite, nausea, vomiting, abdominal pain, dark urine, light-coloured faeces, jaundiced (yellow) skin and yellow¬ing of the whites of the eyes. People who have had hepatitis should avoid alcohol for some time after the illness, as the liver needs time to recover.
Hepatitis A is transmitted by ingesting contaminated food or water. You should seek medical advice, but there is not much you can do apart from resting, drinking lots of fluids, eating lightly and avoiding fatty foods. Hepatitis E is transmitted in the same way as hepatitis A; it can be particularly serious in pregnant women.
There are almost 300 million chronic carriers of hepatitis B in the world. It is spread through contact with infected blood, blood products or body fluids; foe example, through sexual contact, unsterilised needles and blood transfusions, or contact with blood via small breaks m the skin. Other risk situations include shaving, tattooing or body piercing with contaminated equipment. The symptoms of hepatitis B may be more severe than type A and the disease can lead to long-term problems such as chronic
liver damage, liver cancer or a long-term carrier state. Hepatitis C and D are spread in the same way as hepatitis B and can also lead to long-term complications.
There are vaccines against hepatitis A and B, but there are currently no vaccines against the other types of hepatitis. Following the basic rules about food and water (hepatitis A and E) and avoiding risk situations (hepatitis B, C and D) are important preventative measures.

HIV/AIDS

Infection with the human immunodeficiency virus (HIV) may lead to acquired im-mune deficiency syndrome (AIDS), which is a fatal disease. Any exposure to blood, blood products or body fluids may put the individual at risk.
The disease is often transmitted through sexual contact or dirty needles, so vacci-nations, acupuncture, tattooing and body piercing can be potentially as dangerous as intravenous drug use. HIV/AIDS can also be spread through infected-blood transfu-, sions; although the blood centre in Phnom < Penh does screen blood used for transfu-  ! sions, it is unlikely to be done in many of : the provinces.
If you do need an injection, ask to see the syringe unwrapped in front of you, or take a needle and syringe pack with you. Fear of HIV infection should never preclude any treatment for serious medical conditions.
According to WHO figures, Cambodian rates of infection are highest among sex workers. The group's HIV prevalence increased from 10% in 1992 to over 40% in 1996. Another group with a high prevalence rate is the military.

Intestinal Worms

These parasites are most common in rural, tropical Cambodia. The various worms have different ways of infecting people. Some may be ingested in food such as undercooked meat (eg tapeworms) and some enter through your skin (eg hook-worms). Infestations may not show up for some time, and although they are generally not serious, if left untreated they may cause severe health problems later. Consider having a stool test when you return home to check for worms and for your doctor to determine the appropriate treatment.

Japanese B Encephalitis

This viral infection of the brain is transmitted by mosquitoes. Most cases occur in locals living in rural areas, as the virus exists in pigs and wading birds. Symptoms include fever, headache and alteration in consciousness. Hospitalisation is needed for correct diagnosis and treatment. There is a high mortality rate among those who have symptoms; of those who survive many are intellectually disabled.

Malaria

This serious and potentially fatal disease is spread by mosquitoes. If you are travelling in endemic areas it is extremely important to avoid mosquito bites and to take tab¬lets to prevent the disease developing if you become infected. There is no malaria in Phnom Penh, Siem Reap and most other major urban areas in Cambodia, so visitors on short trips to the most popular places do not need to take medication. Malaria self-test kits are widely available in Cambodia, but are not that reliable.
Symptoms of malaria include fever, chills and sweating, headache, aching joints, diar-rhoea and stomach pains, usually preceded by a vague feeling of ill health. Seek medical help immediately if malaria is suspected, as, without treatment, the disease can rapidly become more serious or even fatal.
If medical care is not available, malaria tablets can be used for treatment. You need to use a different malaria tablet to the one you were taking when you contracted the disease, as obviously the first type didn't work. If travelling widely in rural areas of Cambodia, it is worth visiting a pharmacy to purchase a treatment dose -this will save you from complications in the event of an emer¬gency. Antimalarials are available cheaply throughout Cambodia, although buy them from a clinic to be sure they are not fakes.
Travellers are advised to prevent mosquito bites at all times. The main messages:
Wear light-coloured clothing. Wear long trousers and long-sleeved shirts.
Use mosquito repellents containing the compound DEBT on exposed areas (pro-longed overuse of DEET may be harmful, especially to children, but its use is considered preferable to being bitten by disease-transmitting mosquitoes) Avoid perfumes or aftershave.
Use a mosquito net impregnated with mosquito repellent (permethrin) - it may be worth taking your own. i Impregnate clothes with permethrin to effectively deter mosquitoes and other insects.

MALARIA MEDICATION

Antimalarial drugs do not prevent you from being infected but they kill the malaria parasites during their developmental stage, significantly reducing the risk of becoming very ill or dying. Expert advice on medication should be sought, as there are many factors to consider, including the area to be visited, the risk of exposure to malaria-carrying mosquitoes, the side effects of medication, your medical history and whether you are a child or an adult and whether you're pregnant. Travellers heading to isolated areas in Cambodia should carry a treatment dose of medication for use if symptoms occur. A new drug called Malarine, supplied and subsidised by the European Union (EU) and WHO, is available in pharmacies throughout Cambodia • for just 7900r, and is undoubtedly the most effective malaria killer available in Cambodia today. See a doctor for advice about the dosage appropriate for you.

Schistosomiasis

Also known as bilharzia, this disease is transmitted by minute worms. They infect certain varieties of freshwater snails found in rivers, streams, lakes and, in particular, dams. The worms multiply and are eventually discharged into the water.
The worm enters through the skin and attaches itself to the intestines or bladder. The first symptom may be feeling generally unwell, or a tingling and sometimes a light rash around the area where the worm entered. Weeks later a high fever may develop. Once the disease is established, abdominal pain and blood in the urine are other signs. The infection often causes no symptoms until the disease is well established (several months to years after exposure), when damage to internal organs is irreversible.
The main method of preventing the disease is avoiding swimming or bathing in fresh water where bilhafzia is present. Even deep water can be infected. If you do get wet, dry off quickly and dry your clothes as well. • A blood test is the most reliable way to diagnose the disease, but the test will not show positive until a number of weeks after exposure.

Sexually Transmitted infections (STIs)

Gonorrhoea, herpes and syphilis are among these infections. Sores, blisters or a rash around the genitals and discharges or pain when urinating are common symptoms. With some STIs, such as wart virus or chlamydia, symptoms may be less marked or not observed at ail, especially in women. Syphilis symptoms eventually disappear completely, but the disease continues and can cause severe problems in later years. While abstinence from sexua! contact is the only 100% effective prevention, using condoms is also effective. Reliable condoms ire widely available throughout urban areas of Cambodia. Different STIs each require specific antibiotics. The treatment of gonorrhoea and syphilis is with antibiotics. There s no cure for herpes or AIDS

Typhoid

Typhoid fever is a dangerous gut infection caused by contaminated water and food. Medical help must be sought.
In its initial stages sufferers may feel they have a bad cold or flu on the-way, as early symptoms are a headache, body aches and i fever that rises a little each day until it B around 40°C (104°F) or higher. The victim's pulse is often slow relative to the degree of fever present - unlike a normal fever where the pulse increases. There may also be vomiting, abdominal pain, diarrhea or constipation.
In the second week the high fever and low pulse continue, and a few pink spots nay appear on the body; trembling, delirium, weakness, weight loss and dehydration nay occur. Complications such as pneumolia, perforated bowel or meningitis may also present themselves.

TRAVELLER'S DIARRHOEA

Simple things like a change of water, food or climate can all cause a mild bout of diarrhea, but a few rushed toilet trips with 10 other symptoms are not indicative of a major problem. Almost everyone gets a mild bout of the runs on a longer visit to Cambodia.
Dehydration is the main danger with diarrhea, particularly in children or the elderly as dehydration can occur quite quickly. Under all circumstances fluid replacement (at least equal to the volume being lost) is the most important thing to remember. Weak black tea with a little sugar, soda water, or soft drinks allowed to go flat and diluted 50% with clean water are all good. You need to drink at least the same volume of fluid that you are losing in bowel movements and vomiting. Urine is the best guide to the ad-equacy of replacement-if you have small amounts of concentrated urine, you need to drink more. Keep drinking small amounts often. Stick to a bland diet as you recover.
With severe diarrhoea, a rehydrating solution is preferable to replace lost minerals and salts. Commercially available oral rehydration salts are very useful; add them to boiled or bottled water. In an emergency you can make up a solution of six teaspoons of sugar and a half-teaspoon of salt to a litre of boiled or bottled water.
Gut-paralysing drugs such as Lomotil or Imodium can be used to bring relief from the symptoms of diarrhoea, although they do not actually cure the problem. Only use these drugs if you do not have access to toilets, eg if you must travel. For children under 12 years the use of Lomotil and Imodium is not recommended. Do not use these drugs if the person has a high fever or is severely dehydrated.
In certain situations antibiotics may be required: diarrhoea with blood or mucus (dysentery), any diarrhoea with fever, profuse watery diarrhoea, persistent diarrhoea not improving after 48 hours and severe diarrhoea. These suggest a more serious cause of diarrhoea, and gut-paralysing drugs should be avoided.
In these situations, a stool test may be necessary to diagnose what bug is causing your, diarrhoea, so you should seek medi¬cal help urgently. Where this is not possible the recommended drugs for bacterial diarrhoea - the most likely cause of severe diarrhoea in travellers - are norfloxacin (400mg twice daily for three days), or cip-rofloxacin (soomg twice daily for five days). These are not recommended for children or pregnant women. The drug of choice for children would be co-trimoxazole (Bactrim, Septrin or Resprim) with dosage dependent on weight. A five-day course is given. Ampicillin or amoxycillin may be given in pregnancy, but medical care is necessary.

Amoebic Dysentery & Giardiasis

Two other causes of persistent diarrhoea in travellers are amoebic dysentery and giardiasis.
Amoebic dysentery, caused by the protozoan Entamoeba histolytica, is characterised by a gradual onset of low-grade diarrhoea, often with blood and mucus. Cramping ab-dominal pain and vomiting are less likely than in other types of diarrhoea, and fever may not be present. Amoebic dysentery will persist until treated and can recur and cause other health problems.
Giardiasis is caused by a common parasite, Giardia lamblia. Symptoms include stomach cramps, nausea, a bloated stomach, watery, foul-smelling diarrhoea and frequent gas. Giardiasis can appear several weeks after you have been exposed to the parasite. The symptoms may disappear for a few days and then return; this can go on for several weeks.
: You should seek medical advice if you think you have giardiasis or amoebic dys-entery, but where this is not possible, tini-dazole (Fasigyn) or metronidazole (Flagyl) are the recommended drugs to take, although the side effects of Flagyl are severe. Treatment is a 2g single dose of Fasigyn or 250mg of Flagyl three times daily for five to 10 days.