GERM
00:00:09.760 – 00:00:10.960
Nihao! My name is Germ.

WORM
00:00:11.040 – 00:00:11.920
I’m Worm.

GERM
00:00:12.240 – 00:00:27.760
Welcome to episode 94 of the Germ and Worm Travel Health Podcast. Southeast Asia: Should you go? Of course you should! It’s a big planet. See it in good health. I’m Dr. Paul Pottinger, also called Germ. I’m a professor of Infectious diseases at University of Washington in Seattle.

WORM
00:00:28.150 – 00:00:35.990
I’m Dr. Chris Sanford, also known as Worm, Associate professor in the Departments of Family Medicine and Global Health, also at the University of Washington.

GERM
00:00:36.230 – 00:01:35.530
What an exciting episode Chris, all Southeast Asia, all the time. Here are some of the questions that we will answer coming to us from listeners across the country and around the world. Where in Southeast Asia have Germ and Worms spent the most time? What are your favorite countries? Street food: It’s really tasty… Should I go for it? Where can I get the vaccine for dengue fever? (Spoiler alert. It’s not in the United States). And safety wise, where, if anywhere in Southeast Asia, should I avoid?

These questions and more. They come to us from you, our listeners. Please reach out to us with your own travel health questions or if you have stories of success or failure tips that you want to share with the rest of Germ and Worm Nation, just send them to us by email germandworm@gmail.com or visit our website germandworm.com we’d love to see you there.

Before we jump in our medical disclaimer, this podcast is designed to inform, inspire and entertain. However, you should not use this podcast as clinical care before you travel. Please see a qualified healthcare professional for recommendations specific to you and your itinerary.

WORM
00:01:36.090 – 00:02:46.050
So I thought I would start off just by giving a few definitions because people throw around a lot of geographic terms and this is a little pedantic, but just so that we’re clear on what we’re talking about, Asia is the whole continent plus the islands that surround it. South Asia. It’s confusing. This used to be called the Indian subcontinent. Now we call it South Asia. And basically this is India, Pakistan, Bangladesh.

East Asia is China, Japan, south and North Korea. And then West Asia is also a confusing term. Most people call this the Middle east, but technically West Asia is Saudi Arabia, Iran, Iraq, and so on.

And then another one that has two names. The technical term is Central Asia, but I call them the Stans. And these are Kyrgyzstan, Tajikistan, Turkmenistan, Uzbekistan, and so on.

And then there’s what we’re talking about today, which is Southeast Asia, and there’s some that are mainland and some that are more island, and the mainland ones are Thailand, Vietnam, Cambodia, Laos, Myanmar, and then there’s some that are mostly or all islands. And this includes Malaysia, Singapore, Indonesia, Philippines.

GERM
00:02:46.850 – 00:02:58.450
So, Chris, let’s talk about this. Thanks for those definitions. That helps me because I still get confused between all these different terminologies.

Let’s talk about our own experiences. Where have you spent time in Southeast Asia?

WORM
00:02:59.010 – 00:04:18.110
Well, I’ve had the good fortune to have been to most of these, almost all of them. I’ve probably spent the most time in Vietnam and Thailand. I spent a month in Vietnam about a year ago with my wife, and that was wonderful.

I hadn’t been before. We saw north and South, Ho Chi Minh City to the south, Hanoi to the north, a lot of villages. And it was just a long, wonderful trip.

People were friendly, it was inexpensive, it was safe. It was different, it was lovely. And as a K, growing up, the war with Vietnam was on the news every night.

So it was fascinating for me to go back and just see this country. And among the things that we did is we went to a number of museums about the war.

And in Vietnam, they don’t call it the Vietnamese War, they call it the American War, because Vietnam has been at war for a couple hundred years with a lot of countries, including China and France in the US and one message I took home is don’t go to war in Vietnam because Vietnam wins. You know, they threw the French out eventually. They. They threw the Chinese out. They beat the Americans.

So anyway, going to these museums, it was a very sometimes sad experience to see the devastation on both sides. But the cuisine was good, and I would love to go back and see even more of the country.

GERM
00:04:19.470 – 00:06:07.340
It’s so exciting. You’ve inspired me to put all these places onto my own itinerary.

I mean, it’s interesting for me because I spent a lot of time in East Asia and South Asia, but very little in Southeast Asia. I think of the list of countries you went through a moment ago. Yeah. The only Southeast Asian country I’ve been to is Singapore, which happens to be just last month. And what a great experience that was. It was very short trip. It was my wife’s plus one for a work gig that she had. And so we spent four days there. And I wish I could have spent more. It’s a very strange, small country, Singapore, because it’s tiny. It’s really basically an island or the end of a peninsula, you know, attached to a much bigger land mass. But nationally speaking, it’s basically a city state. And the lifeblood of this place is immigration. Its immigrants, mostly from PRC, from China, over the years, but has a very large population of Malaysians who are there as well. That’s where they’re most geographically proximal to. And then also people from India and the South Asian continent. So great food, great cuisine, and it’s really a financial center, meaning it’s expensive and it’s safe and it’s tidy and almost hermetically sealed away. And so does it represent all of Southeast Asia? Hell, no. But it is still an authentic place. And I think it’s some, you know, even though it’s tiny, it’s a place that I would hope people would consider adding on a day or transiting through.

And if you do transit through Singapore, please try to add a day or two so you can actually get away from the airport, get out into the city, see what, you know, what the food is, how that can be offered. We’ll come to street food in a minute. You know, I just have really mostly very, very good things to say about Singapore.

WORM
00:06:08.380 – 00:06:22.140
The joke that I recall about Singapore, and I was there briefly a few years ago, a famous bar there is Raffles. And it is said that the wood bar there is so long that if you put your head to it, you can see the curvature of the world.

GERM
00:06:23.900 – 00:06:56.600
I think you could see the curvature of anything because you’d be so drunk on Singapore Slings. That’s the name of their. Their patented drink. No, you’re. You’re not. Well, let’s talk about vaccines. Chris, I’d love for you to give us an overview.

One of the things our listeners want to hear about, of course, is what shots do I need before I travel? And so let’s think about them as a group, please.

Would you give me your overview about vaccines, how you think about them when you advise people before a trip to Southeast Asia?

WORM
00:06:56.760 – 00:08:26.540
You bet. The first thing I think of is all the domestic stuff.

So before we get fancy with international vaccines, you should get your tetanus shot and your flu shot and your Covid shot and hepatitis A and B. So, you know, a lot of people, when they think vaccines, they think immediately. The more ones you need only for international travel.

But actually when we look at illnesses that travelers get, people who don’t get vaccines, the most common ones are not the exotic ones. They’re the more pedantic ones like influenza and Covid. So for openers, get everything on the US domestic schedule.

And for recommendations, I would recommend going to a professional society such as American Academy of Pediatrics, American Academy of Family Practice first versus the cdc, which for reasons that Paul and I have described in some detail has become less evidence based of late. In addition to all the domestic stuff, the other things a bit dependent on your itinerary.

One that I would recommend for virtually everybody, though, is typhoid fever vaccine. Typhoid fever, bacterial illness spread by contaminated food and water present in most of Southeast Asia.

And you can either do a shot in the arm or a series of pills, but I’d recommend that one for most travelers to Southeast Asia. But then there are some other ones that we don’t recommend universally, but really it depends on the duration of stay in your itinerary.

And some of these more rare ones that Paul and I will talk about one by one include Japanese encephalitis, chikungunya, and dengue fever.

GERM
00:08:27.260 – 00:13:55.640
So when it comes to these, what’s the deal here? For Japanese encephalitis? This is a shot which we think is good to protect you for a lifetime against this particular viral infection.

Japanese encephalitis is spread to us by the bite of a mosquito.

And although the name says Japanese encephalitis, not just in Japan, actually, there’s a number of places in Southeast Asia where this would be at risk. It’s not these countries as a whole, right, Chris?

I mean, these mosquitoes are more likely to bite you if you are in an area that is not urban, but more rural, and if you’re there for a longer period of time.

So I’m thinking about an exchange student, high school student who’s going to live in a vill, attending the rice paddies, something like this, for a period of more than a couple of weeks. That’s when I start really thinking about Japanese encephalitis.

You’re not going to cities to see museums, you’re going camping, you’re doing rural and farm life tours. Think about Japanese encephalitis. The vaccine’s very safe. It’s based on the technology for yellow fever vaccine.

Indeed, the yellow fever virus and Japanese encephalitis virus are very genetically linked. And so we have long track record of safety with these vaccines. It’s an older style of vaccine, the Japanese encephalitis shot.

It is based on a live attenuated virus.

And that means that although it’s appropriate, safe, and good for almost everybody, there are some people with a dramatically reduced immune system who probably should not get Japanese encephalitis vaccine. And the reason I raise this is to say, you know, there are some online.

We talked about this because there’s some online travel consultancies show up at a pharmacy, get your shot.

And this is one where I want you to talk with a qualified healthcare professional, especially a board certified physician, about whether JE is indicated for you and whether it’s something that would be safe for you. So seeing a travel medicine specialist and talking about Japanese encephalitis, that’s on the list chikungunya we’ve talked about as well.

Now I just got back from a separate trip over to Sri Lanka. Sri Lanka is going through a very big epidemic of chikungunya.

In fact, many of the people new friends that I met over there have themselves and their families have been affected by chikungunya just within the last year. So I did get my chikungunya shot before going to Sri Lanka. I was like, hell no. I don’t have time for the chikungunya. This is another viral infection.

It’s also spread by the bite of mosquito. And it’s kind of like dengue in that you have a flu like illness with fever and sweats and shakes and chills and fatigue.

But then in some cases, this post infectious sequel, a side effect of the infection, swelling and pain in the joints. And it can almost give you an instantaneous case of arthritis.

And one of my friends over there is still dealing with this in one ankle, still bothering him a year after he had that disease. So this can be one of those bad infections to get over, in part because it just takes so long to get better from it.

And unfortunately, we do not have a good remedy for the joint and arthritis effects of chikungunya. It just takes time. So the good news is we have a good vaccine for this here in the United States. It’s called Vimcunia.

It’s based on a virus like particle technology that’s the same technology that protects people from cervical and penile cancer, for example. So I love this vaccine. I did receive it myself. I had a little bit of pain at the injection site. That was it. No other side effects.

And I do recommend chikungunya vaccine vimkunya to anyone who’s headed into these endemic areas for dengue. Very similar illness to chikungunya.

The challenge, as you said, is that at least here in the United States, Chris, where you and I live and work, we do not have a FDA approved effective dengue vaccine available to us. It’s a huge problem because so many of our patients, our friends, family, countrymen, we love to go to places where there’s dengue.

This is a tropical mosquito borne infection. It is very much on our doorstep here in the good old US of A.

Our friends in Mexico deal with this very routinely and we have transmission of this infection in border states, including Texas. So it’s not an exotic thing and it can make you feel like. Make you feel like crap.

It’s definitely one to try to avoid because of that clinical illness.

There’s also concern if you get it again and again, that different serotypes, sister viruses to each other, they can cause an overwhelming, very much dysfunctional inflammatory state where people can go into shock, leaky vessels, hemorrhage. This can be a fatal infection in very rare cases. So I would love to get my Kudenga vaccine.

Qdenga is the vaccine that I would recommend to myself, family and friends and my patients. It’s two doses given three months apart and it’s quite effective.

Now this is generally given to people who are age 4 and older, at least where it’s permitted. For example, in Britain, in Europe, Indonesia, where they have a ton of this.

It’s just that it’s not actually looked at for safety and effectiveness in older adults. So a lot of our listeners who travel are over the age of 60. Kudenga hasn’t really, to my knowledge, been studied effectively in that context.

So the point is, if you are overseas, you may have the opportunity to get your Kudenga vaccine. And that’s something to talk about with your physician before you go. They cannot give it to you, but they can have that conversation, right, Chris?

To say, is this something that they would look for when they travel?

WORM
00:13:56.760 – 00:14:47.770
Yeah, exactly. And I’m like you, I plan to get this. It’s on my one year to do list. Dengue is common.

You know, one thing Paul and I have learned practicing post travel medicine as we do is what happens where. And for example, although malaria is worldwide, most of the malaria we see comes from Africa.

And although dengue is worldwide, the most common place that travelers come from who get dengue back to at least Washington state is Southeast Asia.

And so because this is common and because it’s a nasty infection that makes you feel crummy for a long time, definitely getting the Qdenga vaccine is something that I want to do.

But whereas it’s in about 40 countries, including a lot of European countries, as you say, it’s not available yet in the US and also I don’t think it will be anytime soon because I don’t think the company that makes it is currently starting the FDA process to get approval.

GERM
00:14:48.250 – 00:15:02.290
When I was in Singapore and Sri Lanka recently. I tried to get the, the dengue shot and I couldn’t get it. They just didn’t have it in those particular countries. So I’ll keep looking at.

It’s a nice quest. A good reason to go on a worldwide tour to try to find that vaccine.

WORM
00:15:02.770 – 00:15:04.370
And Paul, what do you think about TBE?

GERM
00:15:05.010 – 00:16:48.120
Oh yeah, thanks. I was gonna say there’s this other concern. I get this sometimes among my patients. There’s a disease called tick borne encephalitis.

As the name says, you catch it when you’re bitten by a tick and a virus gets into your body that causes encephalitis, that’s swelling of the brain, brain inflammation and swelling. It can be a very serious disorder, in some cases life threatening.

And so people ask this, do I need my Ticovac, which is the US form of tick borne encephalitis vaccine? And the answer is that we actually think there’s very little tbe tick borne encephalitis in Southeast Asia.

It’s in East Asia, parts of China, especially northern China. And Chris, as you called it, appropriately the stands, that’s a different situation. And honestly, parts of Eastern Europe, it is common.

So common that I think it’s actually part of their standard schedule. But if you’re going to Southeast Asia, that’s one that you actually do not need to worry about.

The other one that comes to mind for me, Chris, is cholera. People asking about whether they need a cholera shot. I think the risk for cholera infection, number one, higher in South Asia than Southeast Asia.

Number two, if you’re going to Southeast Asia, you might need a, you might benefit from a cholera shot. But in that context you’d have to be at a very high risk exposure.

Refugee camps, helping people who are displaced where there’s very low sanitation, a lot of people crowded together, and ineffective sanitary conditions for a prolonged period of time. This is usually healthcare workers, it’s usually volunteers.

Those people should talk with their travel medicine specialist before they go because it’s a good vaccine, it works well, but it’s uncommonly necessary outside of those contexts. Is that your take too, Chris?

WORM
00:16:48.680 – 00:17:48.390
Yeah, you bet. Your basic tourist, your risk is phenomenally low, less than one in a million.

But if you’re a medical person, you’re at a refugee camp or of course you have exposure to, to something like sewage, then I think you would be in the minority who would benefit from this vaccine.

And then the next thing we talk about after all of these vaccines is should you do bug repellent and for the answer for that, I can give a pretty much unequivocal yes. That’s a high priority for everybody going to Southeast Asia because there’s so many things that are spread by mosquitoes and other insects there.

So I won’t go into it in detail because we’ve talked, talked about this before, but basically you want to do bug repellent to your exposed skin, either DEET or Picaridin, and then put permethrin on your clothing. Sleep under a bed net at night if you don’t have air conditioning.

And this will bring down your risk of mosquito and other insect bites, which brings down your risk of dengue and all the other stuff that we just talked about.

GERM
00:17:48.710 – 00:18:16.250
Yeah, agree. And the other benefit is not just keeping away the infections, but reducing the bite of nuisance mosquitoes. Right.

A lot of mosquito bites are not dangerous, they’re just, just a hassle. So that’s another good reason to, to do this. And I have to tell you, before I travel to any tropical area, I always respray my clothes.

I mean, the spray that we do with permethrin should last for a certain number of wash cycles. I love this stuff so much, I’ll spray it again and again because I just hate getting bitten through my trousers by a mosquito.

WORM
00:18:16.250 – 00:18:29.590
Yeah. And if you’re well to do, you can buy clothing pre impregnated with permethrin. They sell it at RAI and other places and it’s legit, it works.

So if the tag says good for 30 washings, from my reading, that tends to be accurate.

GERM
00:18:29.670 – 00:18:41.910
Agree. It’s expensive, but it can work.

And Chris, what about malaria in particular? When should people take malaria pills to prevent catching the infection?

WORM
00:18:42.390 – 00:19:52.730
Well, I can definitely say it depends. And what it depends on is where you’re going. There’s a different distribution in every country and I can’t really give a. One rule fits all.

But basically, before you go to a given country, go to a site like the CDC and their malaria information remains accurate and just see where there’s malaria and where there isn’t. So, for example, in Singapore, there’s none. You don’t need a malaria pill if you go to Singapore.

If you go to Thailand, I’ll just do a couple of examples. There’s malaria there, but it’s not throughout the country. So there’s none in Bangkok or Phuket to the south. None in Chiang Mai, Chiang Rai.

But if you’re on the Burmese border, then there’s a lot of malaria. You need to take Preventative medication. In Vietnam, by contrast, there’s very little malaria, but there’s a little area up by the Chinese border.

There’s a little area kind of in the middle of the country, but you don’t need any in say Hanoi or Ho Chi Minh City. So again, it’s different city by city, country by country. But do a little research before you go.

What you wouldn’t want to do is go to an area with malaria and not take a preventative medication because then you could get malaria, which is a life threatening infection.

GERM
00:19:53.770 – 00:20:35.590
I just want to emphasize this before and we’ve talked about it before and we’re going to talk about it again coming up in the month of May for malaria when we’ll talk more about malaria prevention. But folks, the quick answer is if your healthcare provider tells you that you are at risk for acquiring malaria, please take the pills.

I mean, we hear this again and again, people saying, do I really have to do this? I have friends in Europe who don’t bother with this. Can I just take a pill if I come back sick? You don’t want malaria, we will fix you.

If you come home, we will almost certainly more than 95% chance we’ll be able to save your life. But you’re just going to be sick as hell. This is one where an ounce of prevention is worth £20 of cure.

So thank you for being malaria conscious and malaria focused.

WORM
00:20:36.150 – 00:20:47.680
Yeah, your basic post travel physician tends to be a nice person, but you really don’t want to meet him in the context of hey, I have a high fever and sweats and I hate my life and what’s going on. The pill is the safer option.

GERM
00:20:48.470 – 00:21:07.350
Agree. And then Chris, let’s talk about, let’s talk about feces. Let’s, let’s talk about poop. And because poop happens, everybody poops.

But we always hear this question from our listeners. I’m traveling to a certain area. Will I get traveler’s diarrhea? How do you answer that question?

WORM
00:21:07.830 – 00:21:57.980
I use my favorite phrase. It depends. Or you may and yeah, it’s there. You can get it. You know, if you’ve traveled very much internationally, you’ve probably had this infection.

It tends to be irritating, not life threatening, tends to be self resolving. Bottom line is a be a little careful about food.

So we’ll talk in a minute about some safe food guidelines and our personal practices, which is not a perfect match for what we recommend always. I have to admit, I think taking a couple medications is reasonable, taking them along with you.

One is loperamide also called Imodium, which is a gut anti motility agent that tends to help with mild diarrhea. And then for more severe diarrhea, diarrhea, one option which is not mandatory because it’s self resolving if you don’t take it.

But you can take an antibiotic such as azithromycin which if you have more severe diarrhea will tend to make it resolve faster.

GERM
00:21:58.780 – 00:22:22.820
Yeah, I think that’s right. You should plan for it to happen and then when it doesn’t, you’re going to feel so stealthy and like a cagey veteran.

But when it does, you just want to be able to handle it and. Well, as my, as my friend Chris Sanford says, it’s a low tax to go to high exciting places and sometimes it’s just the price that we pay.

So plan for it and I think you’ll be surprised how often you can get away without it.

WORM
00:22:23.380 – 00:23:31.500
Now, in terms of safe food guidelines, there actually is not a lot of correlation in research between trying to eat safely and having a lower risk. But nonetheless, traditional wisdom, you’ve all heard the boil it, peel it, cook it or forget it.

And so the list of things that you’re supposed to avoid includes street food, roadside stands, lettuce and salads, rock food, ice. Now that takes us to street food. It really tastes good. You’ve gone a long distance and there’s this delicious food that you don’t have at home.

And frankly, I eat it. Things that I look for, I kind of prefer something freshly cooked.

What I wouldn’t do is like a goopy sauce that’s been sitting there under the sun for hours and hours. However, eating street food may elevate your risk of diarrhea. So it’s a matter of personal choice. Do what you’re comfortable with.

If you want to avoid it, that’s totally reasonable. But it’s really good. In Vietnam, my wife and I did a Banh Mi sandwich tour.

Didn’t get sick, had like eight different types of Banh Mi sandwiches and it was a real high point of the trip. So traditional wisdom is avoided. Personally, I have to say that I go for it. And Paul, what do you do?

GERM
00:23:31.740 – 00:26:13.320
Well, what I’m going to do is a Banh Mi tour. Like that sounds amazing. You need to get me that tour guide. So what I do, what I’ve been doing lately, not only Southeast Asia, but just generally.

It’s what you said just a moment ago, the culinary tour. Look, here’s my I’m 57 years old and I’ve had so much diarrhea. Like I’ve had all the diarrhea.

Giardia, shigella, etec, you name it, I’ve had it and I’ve had it. I’m just so tired of this. And so what I’ve done, the pendulum for me has swung away on some recent trip.

I thought, oh my God, I just, I cannot do street food. I’m so scared of getting sick. And then I say, look, I can change, baby, I can change. Like I’m in the contemplative phase of change.

I want to be like Chris and just go out and try stuff again and feel great about it. So what would make me really nervous about street food? Number one, if it just looks sketchy as hell, use your horse sense.

Number two, if somebody has no stomach acid, let’s say you’re on chronic H2 blockers or you’re using a lot of Tums. And remember, stomach acid is there to protect as it digests your food, but it’s also there to kill the germs.

So if you’re somebody who has achlorhydria, low stomach acid, that might make me a little bit more nervous about it, but with that exception, yeah, I think the answer is if it’s a place that’s recommended by the host family that you’re with, the hotel where you’re staying, or if you go with a culinary guide, man, they have zero incentive to get you sick. They’re only going to choose the places that are high quality. That’s what I’ve done most recently.

And I have really, really enjoyed that way of doing things. And that’s coming from me, the king of diarrhea. So it can be done safely. I would also say there are just different options.

I may have mentioned this on a previous episode when we were in Singapore most recently, I was blown away by the hawkers. These are the hawker alleys or, or food centers. What the government said was, okay, there’s going to be street food, let’s control it.

This is what Singapore does. They control everything. They’re very heavy handed with their regulations, which is really a problem when it comes to democracy and free speech.

But it’s great when it comes to food safety because they have raided every single stall, they’ve put them into centers where they can be kept clean, regulated, and every one of them is inspected. And you can see on a little app on your phone how clean the place is that you’re going to.

And so I mean that’s, that’s not what we’re talking about, it’s almost not street food. Honestly, it was so well regulated. But my point is, take, take hint other members of the Southeast Asian food community.

This can be done, and I would have zero concern about going to eat at any of those places. So there are some exceptions that break the rule.

WORM
00:26:19.090 – 00:27:17.680
In terms of security. My overall impression is this is a relatively low crime, safe place to go to. There are a few rules. One, as anywhere, have good manners.

And they, they have some particular buttons. So, for example, in Hong Kong now, Chinese, you don’t want to make fun of the Chinese government that can put you in jail in Thailand.

Don’t make any jokes about the royalty. They take the royalty very seriously. There’s. And actually it’s illegal to say negative things about the royalty.

One place I wouldn’t go to currently is Myanmar, also called Burma. The US Department of State has a level four warning. Do not go. It’s not stable. There’s ongoing warfare.

The US May not be able to do anything for you should you get into trouble there.

So I wouldn’t go to Myanmar with the exception of that, though, I think it is a, as I say, a low crime, reasonably safe place to go to as a, as a region of the world.

GERM
00:27:18.320 – 00:28:40.140
Yeah, thanks. I think when it comes to personal safety, the rules that apply in Southeast Asia apply anywhere.

So if you’re into the club and bar scene, that’s a, that’s a real issue. We’ve talked about this before. Do not go drinking alone. Go with trusted friends. Do not accept drinks from unknown people.

You don’t want to get preyed upon by bad actors. That is true in New York City, as it is in Hanoi, for example. I would say recreational drugs. Please be very careful on this topic.

There are some countries that are very lax and you can smoke dope if you want to, and there’s others that will kill you. You will literally be executed if you even come into contact with this stuff. So you really, basically, please do not use illicit drugs overseas.

I’m just, I’m all about this, but know the, the local crime scene and what. Well, crime and punishment in all of these different countries may be a little bit different from each other.

Even in where I was in Singapore, you know, no shenanigans, whatever, right, Chris? I mean, if you spit on the street, you can be fined. If you, you’re not allowed to chew gum because it could end up on the sidewalk.

And they will, they may put you in jail and cane you. If you are up to drunken shenanigans in public.

So the point is, some of these places are still wonderful to visit and you can feel, feel ethically good about it, but you just don’t want to, you don’t want to make a fool of yourself.

WORM
00:28:43.180 – 00:28:56.380
Now, to go back to one topic you were discussing. Paul, as the king of diarrhea, can you comment on the toilet scene in Southeast Asia? Does one sit? Does one squat?

How does otherwise one relieve oneself?

GERM
00:28:57.100 – 00:30:15.340
Each country is just a little bit different, right? So many of these countries will have a sitting toilet, what we have here called a Western toilet. You sit on it, do your business and get up and go.

But in some parts that’s not true. You may have the squatting style. Now this is the rule of thumb in South Asia and some parts of Southeast Asia too.

So if you go to a public lavatory to relieve yourself and there’s no toilet, there’s just a porcelain hole in the ground. Do not freak out. We talked about this in episode 36 go back and binge German worm 36. You want to talk about toilets. These are not unsafe.

You will not catch an infection from them. You squat down over them. Most people on planet Earth do squat to do this. Their their business. And you might want to practice this before you go.

So don’t be intimidated. And for God’s sakes, do not hold it in. That’s how you can catch a UTI or get constipated or something. Just let it flow.

When it comes to diarrhea, let it flow and be ready to use these facilities. To answer your question, what’s the the pro tip? Bring your own toilet paper. Some of these places just do not have toilet paper.

Now there’s probably a bucket with water or a little hose that you’re meant to use to, to wash yourself off. They’re way ahead of us when it comes to the bidet toilet craze that’s now coming to the US and Europe. But you may not want to do that.

So if you want to use toilet paper and you have my blessing, bring it. Bring it with you. Byot. Byotp.

WORM
00:30:16.060 – 00:31:25.660
Yeah, yeah. Toilet paper. I, I don’t go anywhere without toilet paper. Always helpful.

Hey, one more thing I want to touch on that we haven’t touched on yet. Transportation and motorcycles. Motor scooters are super prevalent essentially in every country in Southeast Asia. And unfortunately, they’re dangerous. The stats are not good.

When I was in Vietnam, at the north, by the Chinese border, it’s really popular to go on motorcycle tours. And indeed the landscape is Beautiful. But these things have a fairly crummy safety record. So despite every.

Anyone locally being on a motor scooter, I would encourage travelers to travel by car with a seat belt. And that just makes all of the numbers better.

And actually, although Paul and I have focused on infectious things, when we look at travelers, the rare traveler who has an unfortunate outcome, something of a trauma nature, like a car crash, is much more common than something infectious. So again, sort of up there, very high on your list with toilet paper, should be traveling within a car with a seatbelt. And don’t get on a motorcycle.

A lot of people don’t do that, I realize, but that’s my advice.

GERM
00:31:26.380 – 00:33:22.040
I just couldn’t agree more. And I, you know, our job is to say yes, right, Chris? We want people to go out, travel. We want to enable people to have a great adventure.

I gotta tell you, I hate motorcycles. I just think they’re dangerous. Anything that is, that wants to fall over, if you leave it alone, that is unstable.

And so I know they’re super fun, but I just, I couldn’t agree more. Moped or motorcycle? That’s true. Now, some of our listeners may be planning to do a bicycle tour, Southeast Asia or elsewhere.

I actually think they’re a little bit different because in bicycling, I mean, a bicyclist is already terrified of cars, right? You’re going to try to avoid busy streets. You’re going to go into more dedicated back roads.

I think that honestly, to me is much more safe than a motorized scooter or, or motorcycle. So let us know folks out there if you had a good experience with any of these tours, bicycle or motorcycle. We would love to hear from you.

Don’t be embarrassed if you think we’re wrong about motorcycle safety. Let us know. We’ll have a debate with you. It’d be our pleasure. Just shoot us a message. Germandworm gmail.com we’d love to hear from you, Everyone.

Thanks so much for joining us for episode 94 of Germ and Worm. As always, as I said a moment ago, we really do want to hear from you.

Please reach out to us by email or just go to our website, germandworm.com where you’ll be able to to search and binge previous episodes. And there’s also a way for you to send us questions and comments. We’d love to be connected with you.

If you’ve enjoyed this episode, please consider subscribing, rating us favorably and spreading the word with friends, family and on the socials. Those are free ways to support this podcast. I’m Germ.

WORM
00:33:22.200 – 00:33:25.600
I’m Worm. It’s a big planet. See it in good health.

GERM
00:33:25.600 – 00:33:47.000
We’ll see you next time.

This podcast is designed to inform, inspire and entertain, but it does not establish a doctor patient relationship and so this podcast should not replace your conversation with a qualified healthcare professional. Please see one before your next adventure.

The opinions in this podcast are Dr. Sanford’s and Dr. Pottinger’s alone and do not necessarily represent the opinions of the University of Washington or UW Medicine.