Cambodia //

Health

Health care in Cambodia is poor. Even the best hospitals have inadequate facilities, low standards of cleanliness and appalling patient care, so use them only in the event of dire emergency. For anything serious, get to Bangkok if you are able to travel. Should you have no option but to go to a Cambodian hospital, try to get a friend – ideally, a Khmer-speaker – to accompany you for support.

In Phnom Penh a couple of private Western-oriented clinics offer slightly better care at increased cost. If you get ill outside Phnom Penh or Siem Reap, self-diagnosis and treatment is often better than visiting a clinic. Wherever you seek medical attention, you will be expected to pay upfront for treatment, medication and food.

Although every town has a number of pharmacies (typically open daily 7am–8pm) stocking an extensive range of medications, the staff aren’t required to have a dispensing qualification, so you may want to check the product sheets (and even expiry dates) before you buy. Regrettably fake medicines abound and there’s no easy way to determine if what you’re buying is the real thing. Whenever possible buy only in Phnom Penh or Siem Reap which have a couple of reputable pharmacies employing qualified personnel who can help with diagnosis and remedies for simple health problems.

Consider getting a pre-trip dental check-up if you’re travelling for an extended period, as the only places to get dental treatment in Cambodia are in Phnom Penh and Siem Reap; elsewhere you’ll have to grin and bear it. If you wear glasses, it’s worth taking along a copy of your prescription (or a spare pair of glasses); you can get replacements made quite cheaply in Phnom Penh and Siem Reap.

Vaccinations and immunizations

It’s worth checking before you leave that you are up to date with routine immunizations, such as tetanus and diphtheria. For Cambodia, you should consider immunizing yourself against hepatitis A, tuberculosis and typhoid; inoculations against hepatitis B, rabies and Japanese encephalitis are recommended if you are going to be at a particular risk (for example if you’re working in a remote area). You’ll need to produce proof that you’ve been vaccinated against yellow fever in the (admittedly unlikely) event of arriving from an infected area (West and Central Africa, or South America).

It is as well to consult your doctor or travel clinic as early as possible – even while you are planning your trip – since it can take anything up to eight weeks to complete a full course of immunizations (you may also need to take malaria prophylactics in advance). All inoculations should be recorded on an international travel vaccination card, which is worth carrying with you in case you get sick or bitten by a dog.

Hepatitis

Hepatitis A, a viral infection of the liver, can be contracted from contaminated food and water – shellfish sold by hawkers and untreated water are particular risks in Cambodia – or by contact with an infected person. Symptoms include dark-coloured urine, aches and pains, nausea, general malaise and tiredness, with jaundice following after a few days. A blood test is needed for diagnosis, and rest, plenty of non-alcoholic fluids and a high carbohydrate diet are recommended for convalescence. A single shot of immunoglobulin offers short-term protection against hepatitis A.

Far more serious is hepatitis B, passed via contaminated body fluids; it can be contracted through non-sterile needles (including those used in tattooing and acupuncture), sexual contact or from a blood transfusion that hasn’t been properly screened. Symptoms include non-specific abdominal pain, vomiting, loss of appetite, dark-coloured urine and jaundice. Immunization may be recommended if you are staying in Asia for longer than six months. In the event that you think you have contracted hepatitis B, it’s especially important to seek medical attention.

A combined vaccine has recently become available offering ten years’ protection against hepatitis A and five years’ against hepatitis B; your doctor will be able to advise on its suitability.

Tuberculosis, rabies and tetanus

Tuberculosis, contracted from droplets coughed up by infected persons, is widespread in Cambodia and is a major cause of death in young children. You may have been inoculated against the disease in childhood, but if you’re unsure, consider a skin (Heaf) test, which will determine if you already have immunity.

Rabies is contracted from the bite or saliva of an infected animal. Vaccinations are recommended if you’re going to be spending a long time in rural areas; but even if you’ve been vaccinated, if you are bitten (or licked on an open wound) you will need to get two booster injections as quickly as possible, preferably within 24 to 48 hours.

Tetanus, a bacterial infection which causes muscular cramps and spasms, comes from spores in the earth and can enter the blood circulatory system through wounds and grazes. If left untreated it can cause breathing problems and sometimes death. It’s worth checking if you’ve been vaccinated against tetanus in the last ten years and getting a booster if necessary.

Typhoid and cholera

Typhoid and cholera, bacterial infections that affect the digestive system, are spread by contaminated food and water, and outbreaks are thus usually associated with particularly unsanitary conditions.

Symptoms of typhoid include tiredness, dull headaches and spasmodic fevers, with spots appearing on the abdomen after about a week. Vaccination is suggested if you plan to stay in rural areas of Cambodia, but it doesn’t confer complete immunity, so maintaining good standards of hygiene remains important.

Sudden, watery diarrhoea and rapid dehydration are among the symptoms of cholera, and medical advice is essential to treat the infection with antibiotics. Vaccination is no longer recommended for cholera due to its poor efficacy. From time to time there are outbreaks of cholera in Cambodia which are well publicized in the media.

General precautions

Cambodia is a hot and humid country, and dehydration is a potential problem, its onset indicated by headaches, dizziness, nausea and dark urine. Cuts and raw blisters can rapidly become infected and should be promptly treated by cleaning and disinfecting the wound and then applying an air-permeable dressing.

Bites and stings

Insects and flies are legion in Cambodia and are at their worst at the start of the dry season when there are stagnant pockets of water left from the rains. Even during the hot season (March–May) they come out in the evenings, swarming around light bulbs and warm flesh, though they are annoying rather than harmful (with the exception of mosquitoes).

On the coast, sand flies appear in the late afternoon and evening, delivering nasty bites which don’t erupt until a few hours later, when they become incredibly red and itchy. Once you scratch, the bites become even more inflamed and can take up to a month to recede, leaving behind nasty scars. These little blighters have a limited range and mostly attack victims on the sand; if on or near the beach, it’s probably best to use an insect repellent.

Sun and heat

Even when the sky is overcast the Cambodian sun is fierce, and you should take precautions against sunburn and heat stroke wherever you are. Cover up, use a high-protection-factor sunscreen, wear a hat and drink plenty of fluids throughout the day.

Hygiene and stomach complaints

Though catering facilities at many restaurants and food stalls can appear basic, the food you’ll be served is usually absolutely fresh; all ingredients are bought daily and are mostly cooked to order. A good rule of thumb when selecting a place to eat is to pick one that is popular with local people, as the Khmers are fussy about their food and seldom give a place a second chance if they’ve found the food isn’t fresh. Food from street hawkers is usually okay if it’s cooked in front of you. Bottled water is available everywhere and it’s best to stick to drinking that and to be cautious with ice, which is often cut up in the street from large blocks and handled by several people before it gets to your glass (though in Western restaurants it will probably come from an ice-maker).

Stomach complaints

The most common travellers’ ailment is upset tummy. Travellers’ diarrhoea often occurs in the early days of a trip as a result of a simple change in diet, though stomach cramps and vomiting may mean it’s food poisoning. If symptoms persist for more than a couple of days, seek medical help as you may need antibiotics to clear up the problem.

Most diarrhoea is short-lived and can be handled by drinking plenty of fluids and avoiding rich or spicy food. Activated charcoal tablets sold across the counter at pharmacies help by absorbing the bad bugs in your gut and usually speed recovery. It’s often a good idea to rest up for a day or two if your schedule allows. In the event of persistent diarrhoea or vomiting, it’s worth taking oral rehydration salts, available at most pharmacies (or make your own from half a teaspoon of salt and eight teaspoons of sugar per litre of bottled water).

Unless you’re going on a long journey, avoid taking Imodium and Lomotil. These bung you up by stopping gut movements and can extend the problem by preventing your body expelling the bugs that gave rise to the diarrhoea in the first place.

Dysentery and giardiasis

If there is blood or mucus in your faeces and you experience severe stomach cramps, you may have dysentery, which requires immediate medical attention. There are two forms of the disease, the more serious of which is amoebic dysentery. Even though the symptoms may well recede over a few days, the amoebae will remain in the gut and can go on to attack the liver; treatment with an antibiotic, metronidazole (Flagyl) is thus essential. Equally unpleasant is bacillary dysentery, also treated with antibiotics.

Giardiasis is caused by protozoa usually found in streams and rivers. Symptoms, typically watery diarrhoea and bad-smelling wind, appear around two weeks after the organism has entered the system and can last for up to two weeks. Giardiasis can be diagnosed from microscope analysis of stool samples, and is treated with metronidazole.

Mosquito-borne diseases

Given the prevalence in Cambodia of serious diseases spread by mosquitoes, including multi-resistant malaria, it is important to avoid being bitten. In the provinces and high-risk areas – in the jungle for example – most guesthouses provide mosquito nets; if there isn’t one in your room, make sure to ask. Some guesthouses don’t provide nets as they have installed window screens, but these are seldom completely effective as mosquitoes can also get in through ventilators or the gaps under doors. It’s also worth asking for your room to be sprayed with insecticide when you go out in the evening; the disgusting stuff will have time to dissipate by the time you return.

Wearing long trousers, socks and a long-sleeved top will reduce the chances of being bitten. Insect repellents containing DEET are the most effective, although you may want to consider a natural alternative such as those based on citronella.

Malaria

Malaria is prevalent year-round, throughout the country – with the exception of Phnom Penh and the area closest to the Tonle Sap; in 2009, over 60,000 cases were reported, some resulting in death. It is a risk in Siem Reap and at Angkor Wat, and mefloquine resistance is reported on the western and northern borders from Koh Kong to Stung Treng. Malaria is contracted from the night-biting female anopheles mosquito, which injects a parasite into the bloodstream. Chills, fevers and sweating ensue after an incubation period of around twelve days, often along with aching joints, a cough and vomiting, and the symptoms repeat after a couple of days. In Cambodia the dangerous falciparum strain of the disease predominates; if untreated, it can be fatal.

Before you travel, it is important to take advice on a suitable prophylaxis regime, as a course of antimalarial medication needs to be started in advance of arriving in a risk area. Mefloquine (aka Larium) may be recommended, but has much-publicized side effects which should be discussed with your doctor. If you take it, you’ll need to start a couple of weeks before you enter the malarial area and continue medication for at least four weeks after leaving, to cover the incubation period of the parasite. Where mefloquine-resistance is found alternatives are the antibiotic doxycycline, which should be taken a couple of days before you enter the malarial zone and continued for two weeks after you leave, or Malarone, an atovaquone/proguanil combination that has recently been approved. Note that taking antimalarials doesn’t guarantee that you won’t contract the disease, a fact which reinforces the need to avoid being bitten.

Emergency treatment for falciparum malaria is 600mg of quinine sulphate, taken three times a day for three days, followed by a single dose of three Fansidar tablets once the quinine course is completed. These tablets are available over the counter at pharmacies throughout Cambodia, but if you suspect malaria you should still see a doctor for a diagnostic blood test.

Dengue fever

Outbreaks of dengue fever occur annually in Cambodia with 37 deaths reported in 2009. Spread by the day-biting female aedes mosquito, this is a viral disease which takes about a week to develop following a bite. It resembles a bad case of flu; symptoms include high fever, aches and pains, headache and backache. After a couple of days a red rash appears on the torso, gradually spreading to the limbs. There may also be abnormal bleeding, which requires medical attention.

No vaccine is available at the time of writing, and there is no effective treatment, although paracetamol can be taken to relieve the symptoms (not aspirin, which can increase the potential for bleeding); you should also drink plenty of fluids and get lots of rest. Although the symptoms should improve after five or six days, lethargy and depression can last for a month or more – consult a doctor if symptoms persist. Those who have previously contracted dengue fever are at particular risk if they subsequently contract a different virus strain, which can result in dengue haemorrhagic fever. In this condition the usual symptoms of dengue fever are accompanied by abdominal pain and vomiting; immediate medical help should be sought, as this condition can be fatal.

Japanese encephalitis

Japanese encephalitis is a serious viral disease carried by night-biting mosquitoes which breed in the rice fields. The risk is highest between May and October. It’s worth considering vaccination if you’re going to be in rural areas of Cambodia for an extended period or are visiting during the high-risk period. Symptoms, which appear five to fifteen days after being bitten, include headaches, a stiff neck, flu-like aches and chills; there’s no specific treatment, but it’s wise to seek medical advice and take paracetamol or aspirin to ease the symptoms.

Sexually transmitted diseases

Cambodia is seriously at risk of an HIV/AIDS epidemic, with over one percent of the male population aged between 15 and 49 already infected. It isn’t known how the virus first arrived in Cambodia, but a steep rise in the number of prostitutes during the UNTAC years certainly didn’t help. A high proportion of Khmer men visit prostitutes and have a cultural aversion to the use of condoms, which sex-education programmes haven’t resolved. This fact, allied to an increase in intravenous drug abuse, means that the virus is now running unchecked through the population.

Syphilis and gonorrhoea are rife, but while both are unpleasant and require a medical diagnosis, they can be treated effectively with antibiotics. Using reliable condoms – preferably Western brands – will reduce the chances of contracting an infection.

Other hazards

Avian flu (bird flu) was first identified in poultry in Southeast Asia in 2003. Occurring primarily in wild and domesticated birds (among which it is highly contagious and deadly), the virus is spread by contact with affected birds. At the time of writing, the WHO advises that there is no threat to health from the consumption of poultry or poultry products, including eggs. Although most reported cases of the virus have been contracted by bird-to-human contact, experts believe that human-to-human transmission is increasing, although currently only the closest family members of infected people have been contaminated. Symptoms are similar to influenza, with fever, sore throat and cough. Nine fatalities from the virus have been confirmed in Cambodia to date, the most recent in early 2010. However, the virus is not thought to pose a serious threat to tourists.

If you are at all concerned about swine flu, consider getting a general influenza vaccination before leaving home, as the latest vaccine may include the necessary antibodies to the H1N1 virus. Symptoms of swine flu are a general malaise, fever and headache, with flu-like aches and pains.