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Medical Advice for Travelers to Indonesia:

Disease Concerns, Health Precautions & Medical Care

Official Health Requirements for Travelers

Proof of yellow fever vaccination for all travelers over 1 year of age who have traveled through infected areas.

In this country, the availability and uptake of immunizations is such that epidemic diseases have not yet been controlled and periodic outbreaks continue to threaten the lives and / or health of residents on a regular basis. Other diseases remain endemic due to natural or manmade environmental factors. Therefore specific precautions, including but not limited to immunizations are necessary to reduce the substantial risks to health (in certain cases protective medication, modifications to living quarters, and a heightened awareness of the potential risks involved in domestic travel may be required).

Recommended Immunizations

All standard immunizations should be current including MMR (measles, mumps and rubella) and DT (diphtheria and tetanus). In addition, the following are recommended:

• Hepatitis A
• Hepatitis B
• Typhoid
• Rabies (depending on location)
• Adult polio booster
• Japanese B encephalitis in certain areas
• Malaria prophylaxis

Disease concerns: insect-borne illness:

• Dengue fever
• Dengue hemorrhagic fever
• Filariasis in (some) rural areas
• Japanese B encephalitis risk - rural, may extend to some resort areas, including those on Bali
• Malaria risk (except in urban areas)
• Scrub typhus
• Typhus

Loose, light clothing protects against insects. When in long grass, tuck trousers into socks; avoid wading through swamps and brushing through wet jungle with unnecessarily exposed skin. Liberal use of repellent at ankles, cuffs, collar and waist will help keep more active crawling or flying invaders at bay.

Ticks (small, eight-legged insects which feed off blood) are an increasing source of infection worldwide. Some transmit serious infections; all leave a bite which can easily be infected by other micro-organisms, and when forcibly or incompletely removed the remnants of the corpse themselves set up an unpleasant reaction in the skin. Backpackers, forest walkers, campers and hitch-hikers need to be more than usually careful in tick-infested areas, especially forests.

In this country mosquitoes carry diseases which are better avoided - so therefore are the mosquitoes. Simple personal protective measures can greatly reduce the risk of being bitten by the anopheles (malaria-carrying) mosquito. Because of its night time feeding habits, malaria transmission occurs primarily between dawn and dusk (whereas the dengue-carrying mosquito bites during the daytime).

Mosquitoes are found worldwide; all varieties breed in or near water that is stagnant or slow moving. The female mosquito requires a blood meal in order to be able to lay her eggs and so she is the only one to bite. When she sucks blood from humans or animals, she may acquire disease organisms which may be transmitted to healthy individuals when the mosquitoes take their next blood meal. The importance of mosquitoes in the transmission of disease is illustrated by the fact that there are over 50 important diseases transmitted by the bite of infected female mosquitoes, including malaria, dengue fever, Japanese B encephalitis, yellow fever, and a variety of forest and jungle fevers.

Urban mosquitoes breed in any pools of standing water such as empty tin cans, old tires and water filled tire tracks, coconut shells, and the saucers under domestic pot plants. Rural mosquitoes breed in rice paddies, stagnant ponds and slow moving streams. Control of mosquito-breeding sites is very important, especially those close to human habitation as mosquitoes usually fly less than one kilometer from where they are hatched.

Personal protective measures can greatly reduce the risk of being bitten by any mosquito.

1. Correct use of mosquito nets (essential if accommodation not air conditioned). For added protection for up to 3 months or longer, mosquito nets can be soaked in 1 % solution of PERMETHRIN (or other repellent / insecticide). If resident in a malarious area, curtains can be treated in a similar manner.
2. Use of mosquito coils and “knockdown spray” (containing pyrethoids) - spray insecticide in cool dark places where mosquitoes lurk.
3. Avoid use of dark colored clothing, perfumes and colognes in the evening and at night all these attract mosquitoes.
4. Use an effective mosquito repellent on exposed skin and clothing. DEET (diethylmethylbenzamide) is an effective safe component of good repellents. The actual concentration of DEET varies widely between different manufacturers, and can be as high as 90% (too high for safety). Choose a repellent with between 30-45% DEET and take the following precautions against adverse reactions:

• apply sparingly and only to exposed skin
• never apply high concentrations to skin (use those for clothing)
• do not inhale or swallow repellent or get it in eyes or mucous membranes
• do not apply to hands that may touch eyes or mouth
• do not apply to wounds, rashes, or abrasions
• wash repellent off after coming indoors to stay
• if skin starts to burn, wash repellent off and seek medical advice

DEET-based repellents should last for up to 4 hours. Although mosquitoes can bite through cloth it is still better to cover up.

Treatment of mosquito nets with permethrin is a safe and effective treatment which can be used on curtains and drapes as well as mosquito nets. A mosquito net treated in this way is effective for up to three months.

Other useful precautions are to change the water in flower pots once a week and wash them thoroughly. Do not let plants stand in trays containing water. Scrub trays weekly to get rid of any mosquito eggs. Cover all water containers and any objects that can trap rain water. Invert any used buckets and containers that can trap water, and ensure that roof gutters are not clogged. Environmental measures should include the filling or draining of areas of impounded water except for swimming pools and ornamental pools if they are aerated by a pump or fountain or similar. The use of mosquito larvicides or mosquito larvae-eating fish in waters that cannot be drained is often useful. In endemic mosquito areas, insist owners, employers and landlords supply screens on doors and windows and mosquito nets on beds.

Disease Concerns: Food- and Water-borne Illnesses

• Bacterial, parasitic and viral gastroenteritis (epidemic)
• Cholera (rare)
• Clonorchiasis
• Hydatid disease
• Melioidosis
• Parasitic worms and fluke
• Typhoid fever (common)
• Viral hepatitis

In this country public health controls are not effective. The overall incidence of food and water borne disease is very high; clean water, modern sanitation, and safe food storage and processing facilities are rarely available. The traveler or resident needs to take great care and personal responsibility for maintaining a supply of safe food and drink due to the very high risk of food poisoning, infectious diarrhea, bacterial and viral diseases such as cholera, typhoid fever, and viral hepatitis, and parasitic diseases such as tapeworm, fluke and hydatid disease. Drink only water known to be safe - in some cases even bottled or carbonated water or other processed beverages on sale may not have been prepared to the necessary minimum standards to be safe. Avoid ice, salads, (uncooked) seafood and peeled fruit. Water should be briskly boiled for at least twenty minutes. For this reason, it is often recommended that water be heated for longer periods, to ensure that boiling has occurred for the minimum of twenty minutes to destroy any heat-resistant cysts (some organisms such as amoebae change into a resistant cyst form if conditions do not suit them. They can then persist in food and water for long periods without dying).

Disease Concerns: Other Illnesses

HIV / AIDS: Human Immunodeficiency Virus infection (AIDS) is spread by blood and body fluids. This can be (and is most commonly) by sexual contact, as well as by transfusion with infected blood, or exposure to improperly sterilized or re-used medical equipment such as needles and syringes. The traveler should take EVERY necessary precaution to avoid the risk of contracting HIV infection (as well as other blood-borne infections such as hepatitis B and C). In some cases this may mean traveling a considerable distance to seek medical treatment elsewhere or overseas.

• Rabies (in 22 of 27 provinces)
• Schistosomiasis (only in Sulawesi)
• Yaws

Other Hazards

Plants and pollution levels in urban areas may cause problems for asthmatics.

Medical Facilities

The standard of care given by most medical facilities is not up to the best international standard. Not all drugs are available, and certain advanced medical investigations and techniques are either generally unknown or the medical infrastructure is such that they cannot be safely practiced. The blood supply is reportedly screened for HIV and Hepatitis B (but not Hepatitis C). The usual international standards of sterile supply are not always adhered to, especially outside the more expensive clinics and hospitals in the main centers; needles, syringes and gloves which should be single-use-only are often re-used, usually due to economic necessity. Standards of medical and nursing care can fall below internationally acceptable guidelines, especially in emergency, cardiac, neonatal and intensive care (even - with some exceptions - in hospitals in the bigger cities, and in the better private hospitals). Ambulances are sometimes poorly equipped, are not always staffed by paramedics, and in a medical emergency the response in terms of time and medical assistance is not of an internationally acceptable standard, regardless of the limitations of geography and the roads. Unless in an emergency, definitive medical care should be deferred if possible until after exiting the country.

Most doctors and medical facilities will expect immediate payment for their services, perhaps suspecting that most transient patients will be poor payers of invoices sent after their departure from the country. This extends to a request for a guarantee of payment before treatment starts, even before a foreign patient is admitted to a hospital bed. Service providers in this country do not accept a guarantee of payment from an overseas insurance or medical assistance company, unless perhaps the company has an office in the same city, so it is necessary to have sufficient funds in cash to meet the expenses - and few medical service providers are equipped to or will agree to take credit cards, even if credit cards can be used for meeting hotel, transportation and restaurant expenses. Therefore as well as adequate insurance protection, the traveler should carry or have rapid access to sufficient funds to pay the emergency and initial medical costs.

There are no reciprocal medical arrangements between the government of this country and other countries.

Note: When in pain or apprehensive about the cause of mysterious symptoms, miscommunications and misunderstandings greatly magnify concern. If you are not reasonably adept in the language the doctor or nurse speaks, try to have an interpreter present. If this is not possible, you'll need a dictionary as well as a phrasebook; tourist-orientated language guides are fine for “where is the toilet” but lack the content to describe pain and bodily functions adequately. If at all possible, while waiting or traveling to see the doctor, work with your friends or an interpreter to compose a written summary of your symptoms in the local language.

Indonesian physicians communicate less with patients than some are accustomed to and may be insulted when patients ask questions about treatments or express a need for a second opinion.

There is a metropolitan ambulance service said to be operating in most Indonesian cities (the telephone number is 118). Do not rely only on this service in case of an emergency. The ambulances are poorly equipped, there are long delays and the ambulance will only take you to the nearest hospital which may not be the one where you would like to go.

Foreign doctors are NOT allowed to practice in Indonesia. However some Indonesian doctors have done some or all of their postgraduate training overseas.

Recommended Immunizations

We currently recommend Typhoid fever, Hepatitis-A as minimal vaccination. Additionally, patients are advised to keep their Tetanus vaccine up to date. These vaccinations are "active" vaccines, which boost the body to produce immunity, as if an infection has happened. The risk of not being vaccinated is that a real infection with Typhoid fever, Hepatitis-A or even worse but less likely Hepatitis-B takes place. Typhus and Hepatitis-A are widely around in all of Indonesia, Hepatitis-B can be easier avoided by lifestyle and caution.

Avian Flu

All persons traveling to or living in Indonesia to monitor local news reports about avian influenza outbreaks and to consult with their health care providers about prevention of avian influenza and steps to take in case of possible exposure to avian influenza. It is important to avoid contact with sick or dead poultry. This is particularly critical for children. Most human cases of H5N1 have occurred through direct contact with sick or dead poultry. All foreigners resident in Indonesia to be vigilant about food preparation and handling when cooking chicken or eggs and to wash hands after touching uncooked poultry or poultry products.

Food Preparation Tips

Food Hygiene

1. Separate raw meat from cooked or ready-to-eat foods. Do not use the same chopping board or the same knife for preparing raw meat and cooked or ready-to-eat food.
2. Do not handle either raw or cooked foods without washing your hands in between.
3. Do not place cooked meat back on the same plate or surface it was on before it was cooked.
4. All foods from poultry, including eggs and poultry blood, should be cooked thoroughly. Egg yolks should not be runny or liquid. Because influenza viruses are destroyed by heat, the cooking temperature for poultry meat should reach 70°C (158° F).
5. Wash egg shells in soapy water before handling and cooking, and wash your hands afterwards.
6. Do not use raw or soft-boiled eggs in foods that will not be cooked.
7. After handling raw poultry or eggs,? wash your hands and all surfaces and utensils thoroughly with soap and water.

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Kebersihan Makanan

1. Pisahkan daging mentah dari makanan yang telah dimasak atau siap untuk dimakan. Jangan gunakan talenan atau pisau yang sama untuk memotong daging mentah dan makanan yang telah dimasak atau siap untuk dimakan.
2. Jangan mengolah daging mentah maupun makanan yang telah dimasak tanpa mencuci tangan terlebih dahulu.
3. Jangan meletakkan daging yang telah dimasak ke wadah atau piring tempat daging tersebut diletakkan waktu sebelum dimasak.
4. Semua makanan dari produk unggas, termasuk telur dan darah unggas, harus dimasak sampai matang. Kuning telur tidak boleh dibiarkan cair. Oleh karena virus influenza akan mati pada suhu yang panas, daging unggas harus dimasak hingga mencapai 70ºC (158ºF).
5. Cucilah kulit telur dalam air sabun sebelum diolah dan dimasak, kemudian cucilah tangan sesudahnya.
6. Jangan mencampurkan telur mentah atau setengah-matang ke dalam makanan yang tidak untuk dimasak.
7. Setelah selesai mengolah daging unggas atau telur mentah, cucilah tangan serta seluruh peralatan masak sampai bersih dengan sabun dan air.

We trust this information will assist you to make correct choices for your health and welfare. However it is not, and is not intended to be, a substitute for personalized advice from your medical advisor.

Our appreciation to Dr. Rene de Jongh of International SOS, An AEA Company who has contributed this article in response to a growing need for medical advice for expatriates in Indonesia.

If you have medical-related questions about living in Indonesia to ask of medical professionals, see Ask the Experts.

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