Animal Attacks

Jules Eden, travel medicine specialist and founder of e-med, answers travellers' questions - as published in the following national publications

• The Guardian
• Independent On Sunday and/or
• Geographical Magazine

Q. A good friend has invited me to stay with her in a village, north of Bangkok, Thailand where she lives. I find humidity and hot temperatures hard to tolerate but what worries me most are mosquitoes, as I am constantly being bitten by insects like midges and gnats in the UK, and when on holiday in Rhodes I used the plug-in repellents overnight but awoke to many bites, and my boyfriend sleeping alongside awoke to none!

I wonder why they choose me as their victim and how I can have an enjoyable holiday without worrying about contracting malaria! Naturally I would take pills although I hear that none of them offer full protection. Please could you recommend those with maximum effect and minimal side-effects?

A. A lot of the tips of how not to get bitten are apocryphal, and work for some but not others, but the fact that fact that some travellers seem to get bitten more than others is true. We don't really know why, it could be blood or body temperature, it could be pheremonal or just plain bad luck, but try these ideas:

Always sleep with a mosquito net, tucked well in and preferably soaked in DEET, a mossie repellant.

Use a good spray repellant when you go out at dusk when they are most active. There are a few on the market, both homeopathic or DEET based. Try both.

Always wear long sleeves and trousers around mosquito dinner time. Some people suggest garlic capsules are a good deterrent as the excreted odour puts off the bugs.

Finally if all else fails, find someone tastier than you, and marry them!

Q. My son and I swam in Lake Malawi this summer. My son, who is 16, did an intensive 5 day scuba diving course. After reading the travel books, we decided to take action, even though we have no bilharzia symptoms. Six weeks after exposure, our GP agreed reluctantly to send off stool samples for testing for 'all egg infestations'. The results have come back 'normal'. Should we take any other action?

A. Sadly, Lake Malawi is now known for harbouring bilharzia, and I see your point about getting checked for it now you are back. Many people who are infected by this nasty parasite do not get any symptoms for a couple of months, but later they may get blood in the urine, a raised fever or blood on the stool. The best test is in fact a blood test for antibodies to the parasite. If this comes back positive then a single dose of a powerful drug called praziquantel is all that is needed.

So I think you need to get your doctor to do the blood test, but if you are still asymptomatic after all this time then the chances are that you probably do not have the disease.

If you ever go back to the lake, avoid contact with the snail that is the parasite-human vector by wearing dive boots in the reeds near the shore, and best to swim or dive off a boat in the open water.

Q. Hello, I hope you can help me. Last June we holidayed on the Costa Blanca. My husband got very badly bitten (lots more than the rest of our party) and the bites very quickly developed into large blisters, and on bursting, turned into what looked like ulcers. We would like to go to Spain again this year. Should we be going at a different time of the year? Perhaps you can suggest something that he could use?

A. This should be looked at fairly soon by a dermatologist.

An illness called cutaneous leishmaniasis [CL], spread by the sandfly, can occur in Southern Spain.

After a bite from this little nasty a lesion develops that becomes an ulcer. The ulcer then fails to heal when expected and needs a specific treatment to get it better.

If this hasn’t put your husband off the area then the best thing to do is avoid getting bitten next time.

It may be hard in the sun, but loose long trousers and shirts work. Especially if combined with a DEET spray on the exposed areas like ankles, wrists and his neck.

Sandflies also hate the heat, and love cooler temperatures at dusk and night. So maybe time his visits to bug biting areas with this in mind.

Q. In June this year I am planning to backpack alone around remote parts of Argyll, Scotland. This area is renowned for being over run with adders. Can I take any antidote to adder bites with me? What should I do if I am bitten? What can I do to prevent being bitten?

A. The problem with most snake anti-venom is that it has to be kept refrigerated.

So unless you are doing a Tony Hawkes and trailing a fridge around with you then this wont be possible.

However you should not be too concerned as death from adder bites a extremely rare.

Prevention is the key. Wear high sided ankle boots, and look out for them. The most common scenario is that they are basking in the sun, and you step on one, they will strike to defend themselves.

So watch where you walk.

If you are bitten then get yourself to a doctor as fast as you can. They will administer the cure.

Remember, sucking out the poison, or applying a tight tourniquet is a myth. Do not attempt it.

If the bite is on a part of the body that can be immobilised, like an arm, then keep this area as still as you can.

If you are hiking alone then it is mandatory that you carry a mobile phone in case of medical emergencies. You are more likely to fall and break an ankle, than you are, getting bitten by snakes. You need to be able to call in help.

Q. I am getting married next month and my fiancée is planning a surprise honeymoon. But my fear is that its going to be to the outback of Australia as I found the tickets the other day, which is a problem as I have a total phobia about spiders which he doesn't know about yet. Am I right in thinking that there are going to be some poisonous spiders out there which could kill me, or should I not worry at all?

A. Well what can I say to reassure you. Not a lot!

To answer your question there are venomous spiders in Australia and they do have the potential to kill you. But as you know Australia is visited by many millions of people and they have a wonderful time without so much as seeing a spider at all, let alone getting bitten by one of the toxic varieties.

The one to look out for in the part you may be visiting on your not such a surprise honeymoon is the Redback spider. This is a close relative of the Black Widow that is found in the Americas. The Redback is not an aggressive spider but contact comes by accident when the unfortunate victim either sits or lays a hand on it. Redbacks are known to live under the seats of lavatories in the outback. So it is advisable to always check before you sit down as the consequences can be a trip to the local Hospital for a shot of antivenom.

The really nasty spider out there doesn't live so much in the outback but more in the suburbs of the bigger towns like Sydney.
It's called the Funnel-Web Spider and is an aggressive spider that can bite you without provocation. It usually lives under raised houses in its funnel shaped web.

They have been known to come out from under the house with the sole purpose of biting the foot of any adult or child that may be in the garden.

If this happens death can come as a result and it is important to lay the victim flat, apply a pressure bandage to the affected area, but not a tourniquet, and make sure they are transported to medical back up with as little fuss as possible.

Symptoms that can develop are the local reaction to the bite, with pain and inflammation right through to paralysis of the nervous system with death due to respiratory failure.

So those are the two worst you could encounter, but there are plenty more that can still inflict a nasty bite, or as one Australian arachnophobe once said to me "I don't care whether they're poisonous or not Doc, just seeing them will give me a heart attack"

Q. Recently, while away on holiday in the heavily-forested north of Hungary, I was bitten by the kullancs, or forest tick. This resulted in prolonged illness and frightening visits to local hospitals, where mild encephalitis was diagnosed. I was extremely lucky to have sought advice at an early stage. A friend recently experienced the same problem closer to home in France, contracting a more serious form of the illness which lasted for months. Is this parasitic condition not worthy of more attention in common travel and medical guides, as I believe it is common in much of northern Europe and America.

A. Yes you're right there.
Kullancs is the regional Hungarian name for a tick that inhabits the long grass and scrub that borders onto forests and the paths through the trees. These ticks are commonly found in most Central and Eastern European countries and are becoming more of a problem to walkers and ramblers.

The general scenario is that a hiker gets bitten by the tick when they are walking along these paths. The tick attatches its head and jaws into the skin and then a virus that infects the tick gets passed into the bloodstream. Not all the ticks that inhabit these areas have the virus, but you should assume that they do, if you are bitten, to be on the safe side. The virus is known as an "arbovirus" and it is this that causes all the problems. To give the illness its full name, tick borne encephalitis, or TBE for short, the symptoms are in its title, that is encephalitis. Literally this means swelling of the brain which can come on even after a few days after the tick bite.

Symptoms start with a mild fever and headache, which can be controlled with simple analgesia, but if you find that these become worse and cannot be easily dulled by available medications then you need to get medical help quickly. As the encephalitis progresses the headache becomes incredibly severe and accompanied by nausea, vomiting and photophobia, which is inability to look into direct light. If left unchecked then paralysis and death are inevitable. There is no real cure to this problem but doctors simply provide supportive measures to decrease the swelling on the brain until your own immunity can fight the problem.

But before you all rush off and sell your hiking boots, there is a good vaccine against this problem. There is a long course with 2 injections spaced 1 month apart that is effective after the second shot. This lasts for 3 years, but if you are off on a hiking or camping holiday in a day or two then there is a quick TBE course. This is just 1 shot, works immediately but is only effective for a month. I do recommend for anyone who is hiking or camping in these countries and Scandinavia too , that they get immunised as like Gary's friend there can be long term problems from the arbovirus.

Finally, with my sensible doctors hat on, I'll mention prevention. The problem is at its height in the early Summer, so try to wear long trousers then if you are in the areas affected, and if you do get a tick then only remove it with tweezers from the head. Don't go trying cigarettes or plucking it out with your fingers as this will only make it discharge it's gut contents into your skin.

Q. I have recently returned from a diving trip to Zanzibar, where due to the fact that all my money was stolen I had to spend a few nights in a dirt cheap hotel until more was wired out to me. Since my return I have had the most awful itching on my hands and feet, but what's odd is that it is mostly at night. Any thoughts on what it could be?

A. I think I can make a diagnosis here with some assurance. You have unfortunately contracted one of those skin infestations that seems to be becoming commoner as more people travel over the world.

It sounds like something called Scabies. This is caused by a tiny mite, Sarcoptes scabeii, which is caught by either being in contact with a person or rarely bed sheets where the mite has previously been.

The mite having got onto your skin normally finds its way to specific areas of your body, notably the wrists and finger webs, also the feet and ankles and finally your genital area.

Having got there, the mite burrows under your skin leaving a tell tale track to its hiding place. The reason the itching occurs is that the next part of its life cycle is that when it is night, it comes out of its burrow and lays its eggs on the surface of your skin. This usually occurs at night as those areas where it lives on your body are now warm and moist which make for a better environment for the eggs.

However the eggs on your skin do cause an intense itching and part of the process is that you reimplant them by scratching your skin and also it helps to spread them over other parts of your body.

The usual signs of this disease are the previously mentioned tracks, and also a rash where you have been scratching your body. I have seen very bad cases of this in the past where the infestation has affected the whole body, and this is what used to happen years ago before any cure was around. In very rare cases it can even lead to death where infection gets into the blood stream from the open scratched sores on the skin.

We are luckier now, though as it is very easy to treat. The basis of the cure is an antiparasitic cream called permethrin which you have to apply to your whole body from neck down to the tip of your toes. Leave the cream on for 24 hours then wash it off and reapply again. One day later wash it off and that should finally get rid of it. As the mite can still live on clothing and sheets for a while then you need to wash anything you have worn or slept on since your return on the hottest wash available to kill off any remaining mites or their eggs.

Finally, this rash and itch usually comes on about 6 weeks after contact, if any diver experiences an itchy rash sooner after diving, then it is wise to make sure it is not a case of "skin bends". This though is more often found on the shoulders and trunk and associated with an odd marbled looking rash. The only effective treatment for this is recompression in a dive chamber, and if you don't know where the closest one is to you, then contact e-med and we can direct you to one.

Q. I am going to Baja California in October and after a nasty sting in the Red Sea by a jellyfish, would like to know more about how to prevent it happening again, and what to do afterwards.

A. Fear not because at least now you are going to a relatively jelly free part of the world. The Sea of Cortez is not as bad as other parts of the Pacific for this problem.

What you always need to do when you are swimming or diving in a new area is ask the locals. They should be able to tell you if there are any jellyfish blooms or a sudden influx of these creatures locally. This can commonly happen after a storm or strong onshore wind.

Now if there are local reports of their presence and you still have to go into the water the best thing to do is prevent yourself from being stung. This is best achieved by wearing a full wetsuit or a suit called a stinger suit. This is made from Lycra, fits snugly and will stop the jelly from stinging you, but only on the non exposed parts of your body.

The way jellyfish feed is by enveloping their prey in their tentacles and paralysing them with "nematocysts". These are tiny bags full of venom that are found on the tentacles, and on contact with a fish or human skin they fire off, releasing the poison into whatever they are in contact with. If this happens to be you or a friend then you need to act quickly.

Get out of the water as soon as you can and have someone help get any tentacles off your skin. They must first of all stop any remaining nematocysts from firing off and the best thing for this is ordinary household vinegar. Pour this over the area affected and on any remaining tentacles. If there is no vinegar handy then there are other fluids you can use, the best of which is urine, which may seem bizarre but has good medical grounding due to its relative warmth and acidity.

Having been doused in whatever liquid try to take off any remaining tentacles with gloved hands so you don't get stings on your fingers.

Now, depending on what sort of jellyfish it was appropriate action needs to be taken.

If you were in Eastern Australia where the deadly Box Jellyfish frequents then you need to get some antivenom as soon as possible and go under medical supervision for a while, but fortunately most stings are not deadly , just really painful.
Take a simple analgesic such as ibuprofen and apply some calamine lotion on the affected area twice a day too.
Finally, if you're diving remember to always look up when surfacing after a dive, as this is where most problems happen, and going up headfirst into a Portuguese Man'o'War is not the best way to enjoy Baja.

Q. I am planning a trip to East Africa in a few months. I've heard that there is a problem with something called bilharzia in Lake Malawi, where I was planning on staying a while. What is it? And is it safe to swim there or not?

A. What you have heard , sadly is correct. Lake Malawi used to be one of the only lakes in Africa where you could swim in the knowledge that there were no problems with bilharzia, however now there are reports of cases of this problem being contracted out there.

Bilharzia, or schistosomiasis as it is known medically, is an illness caused by a nasty little worm. Like a lot of parasites it needs a host to lay their eggs in, which unfortunately is us, and then another intermediary vector for the young worms to grow in before completing the cycle and reinfecting humans again. In the case of the bilharzia worm the other vector is a freshwater snail that lives in the reeds and grasses beside African lakes.

It is in these areas that we can get infected, when walking barefoot through , or swimming close to the lakeside. The worm can penetrate our skin and then goes to lay its eggs in the liver, bladder or blood supply to both.

Symptoms can range from feeling mildly unwell, through to passing of blood on urination or even liver failure in the later stages. But before you worry too much, it is very easy to diagnose and easy to treat too.

It is possible to pick up the infection before the eggs have been laid by a simple blood test, and the treatment is a day's worth of tablets called praziquantel.

You can try to prevent the worm from coming into contact with you by either swimming farther out in the lake, from a boat for example, and also by wearing protective shoes if you are wading through the reeds.

There are some parts of the Lake that seem to be more affected than others, and it the worst appears to be in the South at Cape Maclear. Sadly , for me, this is the most beautiful part but I know there are boats there to take you out farther from the shore to go snorkelling or diving, just keep your boots on when disembarking.

So, if you do go swimming and feel unwell up after a couple of weeks, then go to a doctor who will be able to test your blood and effect a cure if it comes back positive.

Enjoy your trip, and remember the advice is the same for the other Central African lakes too.

Q. We are travelling to Thailand this summer and will be visiting Bangkok, Ko Samui and surrounding islands.  We also plan a day trip to the Ang Thong National Park.  I am susceptible to biting insects and sometimes find that the bites swell quite badly.  I shall use a suitable repellent containing 50% DEET to protect myself but need to know if the effectiveness of these products is compromised by the use of cosmetics, moisturisers, sun tan cream and after sun lotions.

Will I need to apply a repellent all of the time or will dusk to dawn be adequate?

A. There are no real hard and fast rules here. Just plain old common sense. If you have to use several creams as well as your mossie repellant then I suggest you apply the latter last of all.

Moisturisers obviously need to be worked nicely into your outer layer of skin, the epidermis, to work. It's the same with after sun too. But DEET, the main ingredient of insect repellant, works best if it is sensed by the bugs, and hence prevents bites by repelling them. Scented creams could reduce this effect if used at the same time, and likewise if you start to massage Factor 30 on top of a bit of DEET then it can only reduce it's effect. So I suggest applying the mossie spray last of all, and liberally too, but do watch it on friable cosmetics like mascara or eye shadow as they can run.

Q. My husband and I visited our son in Malawi. We swam in Lake Malawi and believe there may be a possibility we could have contracted Bilharzia.

We had a urine test carried out on our return, as recommended by the Lonely Planet guide, this was negative. However, we would be grateful for advice regarding symptoms to look out for and the name of any treatment we may require. We understand that it can sometimes be months before any symptoms show.

A. Bilharzia is caused by a worm that reproduces in the body of freshwater snails, and us.

If you swim in infected areas the worm burrows through the skin and you become infected. An early symptom here is "swimmer's itch" at the point of entry.

The later phase of an infection can be symptom free for up to 10 weeks. In the egg-laying cycle there is fever, swollen lymph glands, tiredness. Later bleeding in the urine or stool shows advanced infection.

Diagnosis is made by blood tests or urine tests as you have had. If it is
all clear then do not worry, but treatment by a drug called praziquantel can be effective at any stage.

If you are still concerned then have a blood test to supplement the urine test done earlier.

Q. My wife and I have just returned from a walking holiday in The Alpujarras - but the same problem arises every year wherever we seem to go.

I am bitten by every blood loving insect; she escapes with almost no bites - this year with literally none. We go to the same places, sleep in the same bed, eat similar food. I apply lashings of insect repellant spray - she uses none.

Not only do I carry the marks of multiple insect piercing, I am
hypervigilant for the buzz of fly and the whine of a mosquito, and can never relax with a book by the pool, or a beer on the terrace.

But worst of all is my reaction to the bites. I seem to experience extreme reactions - this year my left calf swelled to the size of two after a couple of bites, despite taking antihistamines throughout the holiday.

Why do I get bitten and she doesn't. Why do I experience such reactions. What's the best way to prevent and treat.

This is important. We're planning a trip to Australia!

A. I have experienced exactly the same problem but luckily for me it was the other person who gets the bites.

Various theories have done the rounds as to why only you should get bitten, including body and blood temperature. Apparently some mossies like us to be more chambre than chilled, like a good claret.

My advice is to try something like garlic capsules or some of the Vitamin B compounds. These can be excreted in the sweat and make you far less palatable.

As for what to do to prevent the massive reactions after a bite, it sounds like you should try something a bit stronger than over the counter antihistamines. Steroid tablets can be used to prevent swelling. If the swelling is very hot and red then it could be an infection of the skin tissues. Called "cellulitis" it needs prompt antibiotics.

Q. Last year I was bitten by a wasp and had a very bad reaction - hospital and GP treatment, took ages for the swelling to go down. All I have from my GP is some slighter strong anti-histamines should I be bitten in the future. I read with horror about someone dying from a wasp sting and wonder whether I should take one of those adrenaline packs with me when I am travelling? I am in my mid fifties and gather these allergies get worse rather than better.

A. Once bitten, twice dead.

This is the issue for some with allergies to wasp stings. The first sting sensitises you, creating a mass of antibodies.

The next time it happens a huge allergic reaction can occur, and yes, some have died as a consequence.

If you had a nasty reaction the first time there is a possibility it could happen, but it is very remote. So do not run screaming every time you see a wasp.

I think the best thing is to have the antihistamines and use these as a first line after a sting. But have an adrenaline pen too. If you find yourself getting short of breath after a sting, obviously seek medical attention, but if you are in the wilds use the pen.

You need a scrip for the pen, and it has a shelf life, so make sure you have a within date one at all times.

Q. Last year my partner and myself went to Cephalonia in Greece where in spite of all the usual protection from mosquitoes bites i.e. using topical lotions and a plug in source of protection and keeping covered, my partner was severely bitten and on returning home was taken ill the following week with a severe viral infection, the symptoms of which were a severe headache, dizziness, nausea and on one occasion collapsing with the headache. He was of course, seen by our GP who diagnosed a virus. When this continued into a second week with the headache improving slightly. The GP felt it could have been caused by the mosquitoes.

Anyway, my question is, what else can my partner take or use to prevent being bitten in such a severe way again. We are returning to Cephalonia this year and my partner is dreading going as he was so badly bitten and felt so unwell as a result of this. Our GP just recommends the usual, which he was using anyway.

Ironically, my partner is mixed race (white and afro-Caribbean) and has the sickle-cell trait!

A. There are several ways of going about this. I have mentioned the use of vitamin B before. A letter from a pharmacist, Dermot Ball has also shed good light on specifically which one.

He says " it's the thiamine that has the effect, and you probably need 25-50mg. daily (Benerva tablets - available OTC at all good chemists!) to get a good effect, as Vitamin B capsules only tend to contain 1-5mg. thiamine"

Another trick to consider is that garlic if eaten and sweated in hot climates has repellent effects on the mossies. Apparently it's used by our soldiers on jungle training. There are many mosquito sprays on the market. Some contain DEET, a proven repellent, some are homeopathic and also work well. I do suggest he finds one that works for him, or even buy the brand used by the local people. Long sleeved shirts, long trousers, mosquito coils, electric zappers.the list is endless.

But to keep it simple, a net at night, clothing, DEET spray and thiamine by day.

I would welcome any other suggestions I have missed. Please e-mail them.

A. Jellyfish sting with something called a nematocyst. This is a poison filled sac on their tentacles that on contact releases the venom into their prey or unsuspecting swimmers. If you get stung, the first thing to do is neutralise the poison and prevent further nematocysts from firing. So pour vinegar on the stung area and remove any remaining tentacles with a gloved hand.

The rash and pain can last for a few weeks after a sting. I suggest you try an antibiotic and strong steroid cream twice a day from now to speed recovery. Fucibet is good.

Next time you swim it would be wise to ask a local lifeguard for a jellyfish report. They tend to be seasonal and come in swarms into swimming areas. Finally, get a "stinger suit" to swim in. This is a 1mm lycra suit that is enough to prevent stinging from most breeds of jellies.

Q. Last year in India I was bitten by a dog on the leg. This was stitched in the local hospital but the resulting scar is horrific.

Someone recently told me that it maybe shouldn't have been treated like this.

What do you think?

A. Your friend maybe right here. It all depends on how deep the cut or wound is.

If it has gone deep enough to slice through an artery then the doc has no option than to put a suture in to stop the massive blood loss.

But most dog bites will be superficial with multiple puncture wounds and torn skin that is hard to piece back together.

A dog's mouth is a bacteria's dream home. A bite from this animal will result in probable infection. So the standard way of dealing with this is not to close the wound with a suture. This will lock in the bugs and then any infection or abscess formation can derange the skin above it and cause a bad scar.

So the best way of treating a standard dog bite is to clean the wound, stop any bleeding and then use Steristrip like plasters to bring the wound edges together. These will pull the skin close enough to leave a good cosmetic result, but still let any pus out.

You must then dress it with a sterile dressing such as Mepore, and change this every day.

Of course antibiotics are needed to treat any bacteria there too. Best to use a combination like metronidazole and Penicillin V.

Q. I have suffered from psoraisis for 7 years and since returning from a 3 week holiday in Thailand I am pleased to see it distinctly less noticeable. However, during the holiday and since my return I have been experiencing excrutiatingly itchy hands and feet (palms and soles). I was also shocked to see my fingers and toes swell a few days after my return (lasting 12 hours). I have also begun to feel a terrible internal ache like a cramp/bruised feeling behind my knees and in the bend of my arms from time to time. Any ideas on my weird midlimb aches and end of limb itchiness? Do you think it's related to my psoraisis?

A. No, this does not sound like a psoriatic symptom. If your skin is looking better it would be odd for the body to be feeling like this.

It is more likely to be a new infection or more probably an infestation.

A likely candidate could be scabies. This little mite burrows into the skin of the limbs and lays it eggs on the skin surface at night. The eggs cause a reaction with the skin that gives you an itch like you have never had before. The cycle is complete for the scabies mite when you reimplant the eggs by itching or pass them on elsewhere after contact.

So see your GP quickly as if it is scabies you need to treat yourself to a complete covering with a lotion such as Ascabiol. It quickly treats the problem which never returns if you have hot washed any clothes or sheets you may have come into contact with too.