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Health

Travellers tend to worry about contracting infectious tropical diseases in this part of the world, but infections are a rare cause of serious illness or death in travellers. Pre-existing medical conditions such as heart disease, and accidental injury (especially traffic accidents) account for most life-threatening problems.

Broadly speaking, Bangladesh has decent medical facilities (more in big cities than in small towns) to treat everyday ailments, infections and injuries. That said, falling ill is very much a possibility. Environmental issues such as heat and pollution can cause health problems. Hygiene is generally poor throughout the region, so food- and water-borne illnesses are common. Many insect-borne diseases are present too, particularly in tropical forested areas. Fortunately, most illnesses can either be prevented with basic common sense, or be treated easily with a well-stocked traveller’s medical kit.

The following advice is a general guide only and does not replace the advice of a doctor trained in travel medicine.

Before You Go

Medication

Pack medications in their original, clearly labelled, containers. A signed and dated letter from your physician describing your medical conditions and prescription drugs, including generic names, is very useful. If carrying syringes or needles, be sure to have a physician’s letter documenting their medical necessity. If you have a heart condition, bring a copy of your ECG taken just prior to travelling.

If you take any regular medication, bring double your needs (you may not find the exact combination drug in local pharmacies). In most south Asian countries, including Bangladesh, you can buy many medications – including antibiotics – over the counter without a doctor’s prescription, but it can be difficult to find some of the newer drugs, particularly the latest antidepressant drugs, blood-pressure medications and contraceptive pills.

Health Insurance

Even if you are fit and healthy, don’t travel without health insurance – accidents do happen. Declare any existing medical conditions you have – the insurance company will check if your problem is pre-existing and will not cover you if it is undeclared. If your health insurance doesn’t cover you for medical expenses abroad, consider getting extra insurance. If you’re uninsured, emergency evacuation can cost you dearly.

Find out in advance if your insurance plan will make payments directly to providers, or whether the company will reimburse you later for your overseas health expenditures. In Bangladesh, doctors expect to be paid in cash, although some hospitals accept payments on a credit card.

Required Vaccinations

The only vaccine required by international regulations is yellow fever. Proof of vaccination will only be required if you have visited a country in the yellow-fever zone within six days prior to entering Bangladesh. If you are travelling to Bangladesh from Africa or South America, you should check to see if you will require proof of vaccination.

Recommended Vaccinations

Specialised travel-medicine clinics are your best source of information; they stock all available vaccines and will be able to give specific recommendations for you and your trip.

Most vaccines don’t produce immunity until at least two weeks after they’re given, so visit a doctor four to eight weeks before your planned departure. Ask your doctor for an International Certificate of Vaccination (otherwise known as ‘the yellow booklet’), which will list all the vaccinations you’ve received.

The World Health Organisation (WHO) recommends the following vaccinations for travellers to south Asia:

Adult diphtheria and tetanus Single booster recommended if none in the past 10 years. Side effects include sore arm and fever.

Hepatitis A Provides almost 100% protection for up to a year; a booster after 12 months provides at least another 20 years’ protection. Mild side effects such as headache and sore arm occur in 5% to 10% of people.

Hepatitis B Now considered routine for most travellers. Given as three shots over six months. A rapid schedule is also available, as is a combined vaccination with Hepatitis A. Side effects are mild and uncommon, usually headache and sore arm. In 95% of people, lifetime protection results.

Measles, mumps and rubella Two doses of MMR are required unless you’ve had the diseases. Occasionally a rash and flulike illness can develop a week after receiving the vaccine. Many young adults require a booster.

Polio In 2003 polio was still present in Nepal, India and Pakistan, but it has been eradicated in Bangladesh. Only one booster is required for an adult for lifetime protection. Inactivated polio vaccine is safe during pregnancy.

Typhoid Recommended for all travellers to Bangladesh, even if you only visit urban areas. The vaccine offers around 70% protection, lasts for two to three years and comes as a single shot. Tablets are also available, however the injection is usually recommended as it has fewer side effects. Sore arm and fever may occur.

Varicella If you haven’t had chickenpox, discuss this vaccination with your doctor.

These are recommended for long-term travellers (more than one month) or those at special risk:

Japanese B Encephalitis Three injections in all. Booster recommended after two years. Sore arm and headache are the most common side effects. Rarely, an allergic reaction comprising hives and swelling can occur up to 10 days after any of the three doses.

Meningitis Single injection. There are two types of vaccination: the quadravalent vaccine gives two to three years’ protection; meningitis group C vaccine gives around 10 years’ protection. Recommended for long-term backpackers aged under 25.

Rabies Three injections in all. A booster after one year will then provide 10 years’ protection. Side effects are rare – occasionally headache and sore arm.

Tuberculosis A complex issue. Long-term adult travellers are usually recommended to have a TB skin test before and after travel, rather than vaccination. Only one vaccine given in a lifetime.

Websites

World Health Organization (www.who.int/ith) Publishes the superb International Travel and Health, which is revised annually and available for free online.

MD Travel Health (www.mdtravelhealth.com) Provides complete travel-health recommendations for every country and is updated daily.

Centers for Disease Control and Prevention (www.cdc.gov) Good general information.

Further Reading

Travelling Well (Dr Deborah Mills) Also has its own website (www.travellingwell.com.au) and smartphone app.

Traveller’s Health (Dr Richard Dawood)

Feature: Medical Travel Kit

The following items could be considered for your personal medical kit:

  • antibacterial cream eg Mupirocin
  • antibiotics for skin infections eg Amoxicillin/Clavulanate or Cephalexin
  • antibiotics for diarrhoea eg Norfloxacin or Ciprofloxacin; for bacterial diarrhoea, Azithromycin; for giardia or amoebic dysentery, Tinidazole
  • antifungal cream eg Clotrimazole
  • antihistamine: there are many options, eg Cetrizine for daytime and Promethazine for night
  • antiseptic eg Betadine
  • antispasmodic for stomach cramps, eg Buscopan
  • contraceptive method
  • decongestant eg Pseudoephedrine
  • DEET-based insect repellent
  • diarrhoea treatment: consider an oral rehydration solution (eg Gastrolyte), diarrhoea ‘stopper’ (eg Loperamide) and antinausea medication (eg Prochlorperazine)
  • first-aid items such as scissors, elastoplasts, bandages, gauze, thermometer (but not mercury), sterile needles and syringes, safety pins and tweezers
  • Ibuprofen or another anti-inflammatory
  • indigestion tablets such as Quick Eze or Mylanta
  • iodine tablets to purify water (unless you are pregnant or have a thyroid problem)
  • laxative eg Coloxyl
  • migraine medicine: take your personal medicine
  • paracetamol
  • permethrin to impregnate clothing and mosquito nets
  • steroid cream for allergic/itchy rashes, eg 1% to 2% hydrocortisone
  • sunscreen and hat
  • throat lozenges
  • thrush (vaginal yeast infection) treatment eg Clotrimazole pessaries or Diflucan tablet
  • Ural or equivalent, if you’re prone to urine infections.

In Bangladesh

Availability & Cost of Health Care

Medical facilities in Bangladesh are not quite up to international standards, especially for critical and serious cases (for which evacuation may be the only option). Facilities are limited outside Dhaka and bigger cities such as Sylhet and Chittagong, and it can be very difficult to find reliable medical care in rural areas. Your embassy and insurance company can be good contacts. Note that doctors expect up-front payment for medical treatments, usually in cash.

Self-treatment may be appropriate if your problem is minor (eg traveller’s diarrhoea or common cold), if you are carrying the relevant medication and if you cannot attend a recommended clinic. If you think you may have a serious disease, such as dengue or malaria, do not waste time – travel to the nearest quality facility to receive attention.

Buying medication over the counter is easy, but not generally recommended, as fake medications and drugs that have been poorly stored or are out of date are common.

Infectious Diseases

Influenza

Present year-round in the tropics, influenza (flu) symptoms include high fever, muscle aches, runny nose, cough and sore throat. It can be very severe in people over the age of 65 or in those with underlying medical conditions such as heart disease or diabetes – vaccination is recommended for these individuals. There is no specific treatment, just rest and take paracetamol to control the fever.

Avian influenza has been confirmed in Bangladesh; short-term travellers are not considered to be at high risk.

Rabies

This is a common problem in south Asia. Around 30,000 people die from rabies in India alone each year, and there are more than 2000 deaths annually in Bangladesh. This uniformly fatal disease is spread by the bite or lick of an infected animal – most commonly a dog or monkey. You should seek medical advice immediately after any animal bite and commence post-exposure treatment. Having pre-travel vaccination means the post-bite treatment is greatly simplified. If an animal bites you, gently wash the wound with soap and water, and apply an iodine-based antiseptic. If you are not pre-vaccinated, you will need to receive rabies immunoglobulin as soon as possible. This is very difficult to obtain outside of Dhaka.

Coughs, Colds & Chest Infections

Respiratory infections are common in Bangladesh. This usually starts as a virus and is exacerbated by environmental conditions such as pollution in the cities. Commonly a secondary bacterial infection will intervene – marked by fever, chest pain and coughing up discoloured or blood-tinged sputum. If you have the symptoms of an infection, seek medical advice or commence a general antibiotic.

Measles

Measles remains a significant problem in Bangladesh. This highly contagious bacterial infection is spread via coughing and sneezing. Most people born before 1966 are immune as they had the disease in childhood. Measles starts with a high fever and rash, and can be complicated by pneumonia and brain disease. There is no specific treatment.

STDs

Sexually transmitted diseases most common in Bangladesh include herpes, warts, syphilis, gonorrhoea and chlamydia. People carrying these diseases often have no signs of infection. Condoms will prevent gonorrhoea and chlamydia but not warts or herpes. If, after a sexual encounter, you develop any rash, lumps, discharge or pain when passing urine, seek immediate medical attention. If you have been sexually active during your travels, have an STD check on your return home.

Tuberculosis

While TB is rare in travellers, those who have significant contact with the local population, such as medical and aid workers, and long-term travellers, should take precautions. Vaccination is usually only given to children under the age of five, but adults at risk are recommended to have pre- and post-travel TB testing. The main symptoms are fever, cough, weight loss, night sweats and tiredness.

Hepatitis E

Transmitted through contaminated food and water, hepatitis E has similar symptoms to hepatitis A, but is far less common. It is a severe problem in pregnant women and can result in the death of both mother and baby. There is currently no vaccine, and prevention is by following safe eating and drinking guidelines.

Hepatitis A

A problem throughout the region, this food- and water-borne virus infects the liver, causing jaundice (yellow skin and eyes), nausea and lethargy. There is no specific treatment for hepatitis A; you just need to allow time for the liver to heal. All travellers heading to south Asia should be vaccinated against hepatitis A.

Typhoid

This serious bacterial infection is spread via food and water. It gives a high and slowly progressive fever and headache, and may be accompanied by a dry cough and stomach pain. It is diagnosed by blood tests and treated with antibiotics. Vaccination is recommended for all travellers spending more than a week in south Asia. In Bangladesh the risk is medium level but the infection is also antibiotic resistant. Be aware that vaccination is not 100% effective, so you must still be careful with what you eat and drink.

Anthrax

Several hundred cases of the cutaneous form of anthrax were reported in Bangladesh in 2010, in people who consumed beef or had contact with diseased animals. This disease shows up as a boil-like skin lesion that forms an ulcer. Further outbreaks could occur, and the World Health Organisation (WHO) advises travellers to buy beef and beef products from reliable sources and ensure they are well cooked.

Japanese B Encephalitis

This viral disease is transmitted by mosquitoes and is rare in travellers. Like most mosquito-borne diseases, it is becoming a more common problem in tropical countries. Most cases occur in rural areas and vaccination is recommended for travellers spending more than one month outside of cities. There is no treatment, and a third of infected people will die, while another third will suffer permanent brain damage.

Dengue Fever

This mosquito-borne disease (locally pronounced 'dengoo') is becoming increasingly problematic in the tropical world, especially in the cities. As there is no vaccine available it can only be prevented by avoiding mosquito bites. The mosquito that carries dengue bites day and night, so use insect avoidance measures at all times. Symptoms include high fever, severe headache and body ache (dengue was previously known as ‘breakbone fever’). Some people develop a rash and experience diarrhoea. There is no specific treatment, just rest and take paracetamol – do not take aspirin as it increases the likelihood of haemorrhaging. See a doctor to be diagnosed and monitored.

Hepatitis B

The only sexually transmitted disease that can be prevented by vaccination, hepatitis B is spread by body fluids, including sexual contact. In some parts of south Asia, up to 20% of the population are carriers of hepatitis B, and usually are unaware of this. In Bangladesh the number of carriers is just below 10%. The long-term consequences can include liver cancer and cirrhosis.

Malaria

For such a serious and potentially deadly disease, there is an enormous amount of misinformation concerning malaria. You must get expert advice as to whether your trip puts you at risk. In the Chittagong Hill Tracts region in particular, the risk of contracting malaria far outweighs the risk of any tablet side effects. Remember that malaria can be fatal. Before you travel, seek medical advice on the right medication and dosage for you. Malaria in south Asia, including Bangladesh, is chloroquine resistant.

Malaria is caused by a parasite, transmitted through the bite of an infected mosquito. The most important symptom of malaria is fever, but general symptoms such as headache, diarrhoea, cough or chills may also occur. A diagnosis can only be made by taking a blood sample.

Two strategies should be combined to prevent malaria: mosquito avoidance and antimalarial medications. Most people who catch malaria are taking inadequate or no antimalarial medication.

There is a variety of antimalarial medications:

Doxycycline This daily tablet is a broad-spectrum antibiotic that has the added benefit of helping to prevent a variety of tropical diseases including leptospirosis, tick-borne diseases and typhus. The potential side effects include photosensitivity (a tendency to sunburn), thrush in women, indigestion, heartburn, nausea and interference with the contraceptive pill. More serious side effects include ulceration of the oesophagus – you can help prevent this by taking your tablet with a meal and a large glass of water, and never lying down within half an hour of taking it. It must be taken for four weeks after leaving the risk area. Note: while we advise you bring any antimalarial medication with you from home, Doxycycline is available to buy at Lazz Pharma, a 24-hour pharmacy in Dhaka.

Lariam (Mefloquine) Lariam has received much bad press, some of it justified, some not. This weekly tablet suits many people. Serious side effects are rare but include depression, anxiety, psychosis and having fits. Anyone with a history of depression, anxiety, other psychological disorders or epilepsy should not take Lariam. It is considered safe in the second and third trimesters of pregnancy. Tablets must be taken for four weeks after leaving the risk area.

Malarone This drug is a combination of Atovaquone and Proguanil. Side effects are uncommon and mild, most commonly nausea and headache. It is the best tablet for scuba divers and for those on short trips to high-risk areas. It must be taken for one week after leaving the risk area.

A final option is to take no preventive medication but to have a supply of emergency medication should you develop the symptoms of malaria. This is less than ideal, and you’ll need to get to a good medical facility within 24 hours of developing a fever. If you choose this option, the most effective and safest treatment is Malarone (four tablets once daily for three days). Other options include Mefloquine and Quinine but the side effects of these drugs at treatment doses make them less desirable. Fansidar is no longer recommended.

Feature: Help Prevent Mosquito Bites

  • Use a DEET-containing insect repellent on exposed skin. Wash this off at night, as long as you are sleeping under a mosquito net. Natural repellents such as citronella can be effective, but must be applied more frequently than products containing DEET.
  • Sleep under a mosquito net impregnated with permethrin.
  • Choose accommodation with screens and fans (if not air-conditioned).
  • Impregnate clothing with permethrin in high-risk areas.
  • Wear long sleeves and trousers in light colours.
  • Use mosquito coils.
  • Spray your room with insect repellent before going out for your evening meal.

HIV

HIV is spread via contaminated body fluids. Avoid unsafe sex, unsterile needles (including those in medical facilities) and procedures such as tattoos. The rate of HIV infection in south Asia is growing rapidly, although Bangladesh itself is a low HIV-prevalence country, with less than 0.1% of the population estimated to be HIV-positive.

Traveller’s Diarrhoea

Traveller’s diarrhoea is by far the most common problem affecting travellers; between 30% and 70% of people will suffer from it within two weeks of starting their trip. In over 80% of cases, traveller’s diarrhoea is caused by bacteria, and therefore responds promptly to treatment with antibiotics. Treatment with antibiotics will depend on your situation – how sick you are, how quickly you need to get better, where you are etc.

Traveller’s diarrhoea is defined as the passage of more than three watery bowel actions within 24 hours, plus at least one other symptom such as fever, cramps, nausea, vomiting or generally feeling unwell.

Treatment consists of staying well hydrated; rehydration solutions such as Gastrolyte are the best for this. Antibiotics such as Norfloxacin, Ciprofloxacin or Azithromycin will kill the bacteria quickly.

Loperamide is just a ‘stopper’ and doesn’t get to the root of the problem. It can be helpful, for example, if you have to go on a long bus ride. Don’t take Loperamide if you have a fever, or blood in your stools. Seek medical attention quickly if you do not respond to an appropriate antibiotic.

Amoebic Dysentery

Amoebic dysentery is rare in travellers but is often misdiagnosed by poor-quality labs in south Asia. Symptoms are similar to bacterial diarrhoea: fever, bloody diarrhoea and generally feeling unwell. You should always seek reliable medical care if you have blood in your diarrhoea. Treatment involves two drugs: Tinidazole or Metronidazole to kill the parasite in your gut, and then a second drug to kill the cysts. If left untreated, complications such as liver or gut abscesses can occur. Bacterial dysentery is more common.

Giardiasis

Giardia is a water-borne parasite that is relatively common in travellers. Symptoms include nausea, bloating, excess gas, fatigue and intermittent diarrhoea. ‘Eggy’ burps are often attributed solely to giardia, but work in Nepal has shown that they are not specific to giardia. The parasite will eventually go away if left untreated, but this can take months. The treatment of choice is Tinidazole, with Metronidazole being a second-line option.

Environmental Hazards

Heat

Parts of Bangladesh are hot and humid throughout the year. For most people it takes at least two weeks to adapt to the hot climate. Swelling of the feet and ankles is common, as are muscle cramps caused by excessive sweating. Prevent these by avoiding dehydration and excessive activity in the heat. Take it easy when you first arrive. Don’t eat salt tablets (they aggravate the gut); drinking rehydration solution or eating salty food helps. Treat cramps by stopping activity, resting, rehydrating with double-strength rehydration solution, and gently stretching.

Heat Exhaustion

Dehydration is the main contributor to heat exhaustion. Symptoms include feeling weak, headache, irritability, nausea or vomiting, sweaty skin, a fast, weak pulse and a slightly elevated body temperature. Treatment involves getting out of the heat and/or sun, fanning the victim and applying cool, wet cloths to the skin, laying the victim flat with their legs raised, and rehydrating with water containing one-quarter of a teaspoon of salt per litre. Recovery is usually rapid, but it is common to feel weak for some days afterwards.

Heatstroke

Heatstroke is a serious medical emergency. Symptoms come on suddenly and include weakness, nausea, a hot, dry body with a temperature of over 41°C, dizziness, confusion, loss of coordination, fits and eventually collapse and loss of consciousness. Seek medical help and commence cooling by getting the person out of the heat, removing their clothes, fanning them, and applying cool, wet cloths or ice to their body, especially to the groin and armpits.

Prickly Heat

Prickly heat is a common rash in the tropics, caused by sweat being trapped under the skin. The result is an itchy rash of tiny lumps. Treat by moving out of the heat and into an air-conditioned area for a few hours and by having cool showers. Creams and ointments clog the skin, so they should be avoided. Locally bought prickly-heat powder can be helpful.

Insect Bites & Stings

Ticks

Ticks are contracted after walking in rural areas. They are commonly found behind the ears, on the belly and in the armpits. If you have had a tick bite and experience symptoms such as a rash at the site of the bite or elsewhere, fever or muscle aches, you should see a doctor. Doxycycline prevents tick-borne diseases.

Bedbugs

Bedbugs don’t carry disease, but their bites are very itchy. They live in the cracks of furniture and walls, and then migrate to the bed at night to feed on you. You can treat the itch with an antihistamine.

Leeches

Leeches are found in humid rainforest areas. They do not transmit any disease, but their bites are often intensely itchy for weeks afterwards and can easily become infected. Apply an iodine-based antiseptic to any leech bite to help prevent infection.

Skin Problems

Fungal rashes are common in humid climates. There are two common fungal rashes that affect travellers. The first occurs in moist areas that get less air, such as the groin, armpits and between the toes. It starts as a red patch that slowly spreads and is usually itchy. Treatment involves keeping the skin dry, avoiding chafing and using an antifungal cream such as Clotrimazole or Lamisil. Tinea versicolor is also common – this fungus causes small, light-coloured patches, most commonly on the back, chest and shoulders. Consult a doctor.

Cuts and scratches become easily infected in humid climates. Take meticulous care of any cuts and scratches to prevent complications such as abscesses. Immediately wash all wounds in clean water and apply antiseptic. If you develop signs of infection (increasing pain and redness), see a doctor.

Air Pollution

If you have severe respiratory problems, speak with your doctor before travelling to any heavily polluted urban centres. Dhaka and Chittagong are among the most polluted cities in the world. This pollution also causes minor respiratory problems such as sinusitis, dry throat and irritated eyes. If troubled by the pollution, leave the city for a few days and get some fresh air. There’s plenty of it in Bangladesh!

Food

Eating in unhygienic restaurants can cause traveller’s diarrhoea. Ways to avoid it include eating only freshly cooked food, and avoiding shellfish and food that has been sitting around in buffets. There have also been reports in recent times of vegetables and fruits being sprayed with formaldehyde by some unscrupulous vendors in the country, with the objective of increasing their shelf life. Peel all fruit, cook vegetables, and soak salads in iodine water for at least 20 minutes. If you order salads or fresh fruit for meals, make sure you do it only at a restaurant which has a steady local patronage and a high turnover of customers. Even so, insist that they are washed well before being served.

Tap Water

  • Never drink tap water, and avoid ice.
  • Bottled water is generally safe – check that the seal is intact, and that it is labelled ‘arsenic free’.
  • Avoid fresh juices – especially in smaller eateries. They may have been watered down.
  • Boiling water for 10 minutes is the most efficient method of purifying it.
  • The best chemical purifier is iodine. It should not be used by pregnant women or those with thyroid problems.
  • Water filters should also filter out viruses. Ensure your filter has a chemical barrier such as iodine and a small pore size, eg less than four microns.

Sunburn

Even on a cloudy day sunburn can occur rapidly. Always use a strong sunscreen (at least factor 30) and always wear a wide-brimmed hat and sunglasses outdoors.