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Ask the Medical Experts in Indonesia

Do you have a medical question pertaining to living in Indonesia? If so, contact us. Medical staff at International SOS have generously agreed to answer your questions!

The source for information on moving to Indonesia for expats, expatriates and foreigners!

Does anyone have a suggestion regarding a good urologist for consultation?

Pardon me making an assumption from your email address but if you are female and 19, the range of problems for which you may need to see a urologist is quite small; a gynecologist or internal medicine specialist may be preferable if the problem is for example recurrent urinary tract infections, unless the problem is clearly in the bladder or urethra. 19 is too young to usually have to consider the possibility of kidney stones.

Declaration of interest: medical adviser to International SOS: an AEA Company, Jakarta, Indonesia.

Medical information on moving to Indonesia for expatriates!

Do you have a listing of obstetricians/gynocologists who are reputable in the expat community? I am expecting this September and would like to find out my options before I arrive in country.

You will excuse me saying at the outset that I am one of those doctors who regard pregnancy and labor as normal events only in retrospect - after the baby is happily asleep in the cot. In the usual, normal labor and delivery, doctors are often unnecessary nuisances (I realize I risk the wrath of my colleagues in this) but when rarely things go wrong, very rapid and appropriate medical actions and procedures using sophisticated techniques and equipment may be necessary to salvage the situation. As Jakarta does not have NICU (neonatal intensive care units) available to the standard most expatriate mothers-to-be would wish, and as you may be more comfortable in a familiar environment possibly with relatives to assist and a guarantee of Cesarean section or epidural should you wish / need these at the last moment, have you considered delivering at home? In which case you need to fly at 36 weeks with most airlines. (Check this carefully in advance with the airline direct - not the travel agent).

If you wish to deliver locally, may I suggest asking mothers who have delivered locally for recommendations. Also, be clear at the outset with your midwife / doctor and the hospital where you would deliver, who is to be present at your birth - in many hospitals only one attendant is allowed and women have faced the choice of having their husband or their midwife present, but not both. I suggest you tour the facility before you deliver there and check for yourself such expectations such as

  • is there a 24-hour epidural service?

  • is there a pediatrician attending the delivery to look after the baby?

  • is there pediatric and obstetric anesthetic cover?

Remember that it is difficult, dangerous and very expensive to evacuate a sick newborn baby by air ambulance - even assuming it is allowed to exit the country without birth certificate and passport.

Declaration of interest: medical adviser to International SOS, an AEA Company, Jakarta, Indonesia.

Medical information on moving to Indonesia for expatriates!

I would like to ask for referrals a doctor in Singapore who specializes in choosing a child's gender. Would you happen to know anyone there?

Sorry, I can't help much on this one. I know that there are publications that tell you how you can increase the chances of a one or other gender by timing intercourse appropriately, but if a doctor is to be involved presumably this is not what you are looking for! If you do wish a reference to the publication / guidelines please let me know.

Some countries and cultures misuse both ultrasound and abortion by using a scan for pre-natal sex determination and aborting a baby who appears to have the wrong gender (ultrasound is not infallible), but this is in any event not available in Singapore.

Declaration of interest: medical adviser to International SOS, an AEA Company, Jakarta, Indonesia.

Medical information on moving to Indonesia for expatriates!

I am trying, here in Charleston, SC, to set up a workup for my 9-year old grandson currently in Ukraine, but soon en route to Jakarta. He has ADHD. The local specialist in this matter wants followup visits about every 2 months. The grandson will be here early August and then to Jakarta mid-August. What Western-trained physicians are there in Jakarta who could do followup work? I need to present the local Charleston pediatrician with as much hard data as possible.

I regret that any response to this cannot be very reassuring. The disorder is one that is diagnosed more commonly in the continental US -by several orders of magnitude - than in most other countries, and this fact alone inevitably leads to frustration and confusion when seeking care for such a condition elsewhere. Also, even in the last 18 months the popularity of the diagnosis and the huge demand for and increase in the prescription of Ritalin in, for example, the UK, Australia, New Zealand etc. has seen increasing restrictions placed on the supply and prescription of Ritalin. At the same time the consequences of Indonesia's economic straits have ensured that where Ritalin was formerly at least occasionally available in metropolitan Jakarta, at the time of writing it is not.

Relatively few doctors in Indonesia and Jakarta have much experience of this diagnosis; the majority of parents with such a child opt to go overseas. However in both Australia and Singapore there are new restrictions on supply and these now mean that the patient has to re-present for a renewal of prescriptions (which is of course costly and inconvenient) and in recent months it has been very difficult and in some cases impossible to get more than 1-3 months supply of the drug at a time.

To find more local resources it would be useful to know what the therapeutic expectations of your Charleston doctor are...

Declaration of interest: medical adviser to International SOS, an AEA Company, Jakarta, Indonesia.

Medical information on moving to Indonesia for expatriates!

Does someone know if there are In Vitro Fecondation centers in Indonesia, and if they can do there ICSI program? Our first child was born from a IVF in Switzerland and we plan to move soon to Indonesia.

Unfortunately, there is no ICSI program in Indonesia.

There is also a programme in Jakarta Bunda Hospital in the Morula clinic. There are IVF programs in Singapore. However, there are many issues if planning to have a baby in Singapore, needing to arrange visas, etc.

Declaration of interest: medical adviser to International SOS, an AEA Company, Jakarta, Indonesia.

Answers to medical questions for expatriates in Indonesia!

I've got a couple of questions about health services in Jakarta. 1. Are there international quality hospitals in Jakarta? Where do most expats go? 2. Do hospitals screen blood for HIV & Hepatitis?

Without wishing to be evasive, the definition of international quality is arguable. Certainly, there are hospitals in Jakarta and in some of the main population centers to which patients can be admitted, cared for, and discharged with satisfaction on both sides. However, when sick, or injured, and without exaggerating in fear of one's life, cultural dissonance in the practice of medical care often assumes huge proportions.

Furthermore, medical care even in the best hospitals in Jakarta does not always meet internationally acceptable standards. One need only note how a large number of Indonesians who can afford to do so go overseas to seek medical care, including ministers and other government dignitaries, to sense that the hospitals in Jakarta do not always have the confidence of those who own, operate, license and inspect them.

Most expatriates and well-to-do Indonesians seek medical care in Singapore, as this is the closest regional center of medical excellence. It is the writer's opinion that medical care in Australia is equally good and is often presented with a more culturally appropriate veneer for Westerners especially compared to Singapore, and of course prices for medical care in Australia are significantly less than for the equivalent care in Singapore, more than offsetting the increase in air fares.

The blood transfusion and screening services in Indonesia are entirely under the supervision of the Indonesian Red Cross, who state that blood is screened for HIV and hepatitis B.

Declaration of interest: medical adviser to International SOS, an AEA Company, Jakarta, Indonesia.

Answers to medical questions for expatriates in Indonesia!

My 18 month old son has a persistent cough which seems to disappear when we return home for holidays. My son's doctor at AEA thinks he may be sensitive to the air in Jakarta. My query is whether purchasing one of the air cleaners available (e.g. Phillips Air Cleaner) would make any difference to the air my son would breathe at night in his room.

Cough is a complex physiologic event that protects the lungs from mechanical, chemical, and thermal injury. It is a normal reflex and therefore helps humans to adapt to an, ever changing environment. It is a common and normal response in all healthy people following the inhalation or aspiration of foreign material. Cough can also be a pathologic reflex i.e., it may be of biologically negative significance in that it gets prolonged well after it becomes unhelpful, OR it may (occasionally, and not likely in an 18-month-old) be an important and often the only sign of serious disease. Also coughs significantly contribute to the spread of airborne infection.

Having said that, it is important to distinguish the frequent, non-productive, throat-clearing irritated cough from that which is likely to be associated with significant disease; and it is equally important to distinguish the acute-onset cough associated with, and lasting for some weeks after an acute infection, from that type of truly chronic cough lasting more than two months.

Studies have repetitively and convincingly established the association of chronic cough with cigarette smoking and therefore before looking for other causes of cough, check the presence of cigarette smoke in the child's environment; the effects of passive smoking on health are receiving considerable attention, especially in children who may be constantly subjected to smoke at home. Studies in infants under the age of 1 as well as older non-smoking children up to the age of 10 have shown clear evidence of a link between smoking in the home and chronic cough. Mothers' smoking has greater influence on children's coughing than fathers' smoking. Children with both parents who smoke report an even greater frequency of cough. Even more alarming are those statistics that show that respiratory diseases and impaired lung function are more often found in children of smoking parents than those whose parents never smoked.

One surprising finding in large population studies in the United States is a common reporting of chronic cough in nonsmokers. While most studies report a prevalence of 8 to 14 per cent, the results of one showed that as many as 22 per cent of nonsmoking males report cough. In this latter study there was a positive association of persistent cough with sinusitis and post nasal drip, irrespective of smoking habit. These in turn are common problems of people living in crowded, congested and therefore polluted cities; cough in Jakarta has to my knowledge never been studied in such a fashion but anecdotally there is little doubt that Jakarta shares with our polluted conurbations the provocation of chronic cough - and if this child is cough-free outside Jakarta then we can almost certainly rule out disease as a cause and blame pollution. Note that the two most common reasons for an asthmatic cough elsewhere do not apply in Jakarta: the absence of pollen in Jakarta means that fewer coughs are truly allergic in nature, as does the fact that most houses have tile and not carpets, therefore the house dust mite is generally absent or present in only very low numbers. Furthermore

this child is too young to be labeled asthmatic.

The most common cause of an acute self-limiting cough is the common cold. In large groups of patients presenting to emergency departments with acute cough, symptoms of infection were quite common. Viral upper respiratory infections are the most common causes of cough in all age groups and are especially troublesome during the colder months all over the world. Again, unless a child lives solely in an air-conditioned environment, Jakarta is generally a hot climate. In some patients viral illness may lead to a chronic cough syndrome associated with hyper-reactive airways. In this subgroup, despite a normal physical examination, cough lingers for weeks after the upper respiratory infection and is typically worsened by cold air (especially cold dry air from air-conditioning), exercise, and respiratory pollutants. However this hyperreactivity, unlike that seen in asthmatics, is transient and quickly resolves with a change of environment.

Psychogenic cough, performed as a behavioral exercise to attract attention or annoy parents, is easily diagnosed because there is no night-time cough. Again, one would not expect an 18-month-old child to have figured this out!

The three cardinal symptoms of asthma are wheezing, dyspnea (shortness of breath) and cough. The first of these symptoms is considered by many to be necessary for the diagnosis of asthma and often this diagnosis is not considered when wheezing is absent. In recent years though there has been a greater appreciation that asthmatics may present in a variety of ways, in particular cough may be the predominant or at times the only presenting symptom of asthma.

While most asthmatics have their disease in both large and small airways and therefore have both symptoms - cough and wheeze - when bronchoconstrictive or inflammatory responses are greater than usual, mechanical stimulation of the cough receptors may easily occur and results in severe coughing. Dramatic changes in intrathoracic pressure due to cough may cause further deformation of the airways and stimulation of airway receptors and result in more coughing and further bronchoconstriction. This vicious cycle of cough inducing bronchoconstriction and bronchoconstriction inducing cough explains several clinical observations noted in asthmatics: (1) cough invariably occurs in asthmatics during bronchoconstriction induced by severe allergic responses (2) a single cough is often capable of initiating a series of uncontrollable repetitive coughs, and (3) coughing may precipitate severe bronchospasm in a previously stable asthmatic patient. If none of these are present - and the inquiry suggests the above is a far more dramatic presentation than that the parent is concerned about - while cough may be the sole presenting manifestation of asthma, especially in children, this is not that likely if, again, the symptoms settle so quickly in another environment.

Especially in young children cough may be a very prominent symptom of asthma and more apparent to parents than wheezing. Often the cough is worse at night and following vigorous exercise. These children may have night-time cough as the sole symptom of asthma present for many years. Usually there is no obvious history of lung disease and all pulmonary function studies were normal or near normal, but these patients however demonstrate changes in spirometry following exercise similar to those children with exercise-induced asthma. When specific asthma therapy is initiated in these patients cough was significantly or completely abolished. Failure to recognize cough as a manifestation of asthma is probably responsible for significant under-diagnosis of asthma in children but as above, this child is too young to be labeled asthmatic.

The physical exam is usually not helpful in distinguishing the cough-variant asthmatic. Occasionally deep inhalation or hyperventilation provokes severe paroxysms of coughing. Similarly patients might report excessive coughing to non-specific environmental irritants such as smoke or dust. Occasionally a strong family history of asthma or family or personal history of atopic allergy supports the diagnosis. Alternatively a therapeutic trial of bronchodilator such as therapy with a beta agonist may be given. If this therapy successfully eliminates the cough, a presumptive diagnosis can be made. If no clinical improvement occurs referral to a respiratory specialist for bronchoprovocation could be done to confirm or rule out the diagnosis before additional therapy is given. Like the typical asthmatic, cough-variant asthmatics may require several therapeutic agents including corticosteroids, but prior to initiation of corticosteroids the clinician must search carefully for other diseases that might also be causing the cough. For instance, chronic rhinosinusitis associated with postnasal drip is frequently associated with cough-variant asthma in adults and children. A child needs to see a pediatrician specializing in respiratory illness if such is suspected.

I have no knowledge of trials of commercial air cleaners but these are unlikely to have a significant effect on the air concentration of most urban / hydrocarbon pollutants - I'd be interested to hear of any clinical trials done with these machines. I suggest starting by making the child's ambient environment less susceptible to sudden changes in air temperature - by keeping the house warmer so there is less difference between outside and inside may be worth a try (as change in temperature as well as cold air may trigger cough), and ensuring no-one smokes near the child or in the child's environment.

Declaration of interest: medical adviser to International SOS, an AEA Company, Jakarta, Indonesia.

Answers to medical questions for expatriates in Indonesia!

I'm moving to Surabaya to work next week, and I've run up against a problem. I was told here in the UK that I didn't need vaccination for Japanese B encephalitis in Java, and that I could get myself vaccinated there (for holidays and onward travel). I know the first part of that advice is true - but what about the second? My boss-to-be has contacted a couple of clinics who think it's unavailable. Since I'm leaving so soon, I could only have the first shot. Should I just bring the other doses of the vaccine in a chilled environment, with the risk of getting it overheated at some point in the journey (I have a stopover in Singapore), or are there other ways to deal with the problem (having it delivered?) Any advice very welcome.

Japanese encephalitis is a viral infection spread via the bite of an infected mosquito. Illness ranges from asymptomatic infection to a severe encephalitis with a high mortality and a high rate (about 30%) of residual neurological sequelae in survivors. Approximately 1 in 200 infections are estimated to lead to invasive neurological disease. Throughout SE Asia it is the leading cause of viral encephalitis. It is endemic in rural areas, especially wet areas such as rice fields where mosquitoes flourish and where pig farming occurs (pigs and wading birds are the most common hosts). Epidemics occur in both urban and rural areas. Highest transmission rates are when mosquitoes are most active, i.e., during and just after the wet season. In temperate regions this is normally approximately May to September; in tropical and subtropical areas, seasonal patterns vary both within individual countries and from year to year.

The risk for travelers of acquiring JE is extremely low, but travel during the transmission season and exposure in rural areas contribute to the risk. It is estimated that fewer than 3% of the vector mosquitoes are infected. JE vaccine is recommended for expatriates whose principal residence is in an area where JE is endemic or epidemic. Risk of acquiring JE among expatriates is variable and depends principally on the specific location of intended residence, housing conditions, nature of activities and the possibility of unanticipated exposure to high-risk areas. Risk varies regionally and within specific countries and can fluctuate from year to year in a given location. Although JE transmission largely occurs in rural areas where there are close associations between man, mosquitoes, pigs and waterfowl, one exception may be in Bali where three symptomatic infections occurred in tourists in 1996 alone. This may be due to the juxtaposition of rural agricultural activities, pig husbandry and tourist resort development throughout the island. Employees and their physicians should weigh individual risk factors and disease risk in the area and the potential for vaccine side effects. For example, some authorities in the UK are currently recommending the vaccine for travelers spending a total 30 days in Bali over the two-to-three-year period of vaccine protection.

The currently available vaccine is derived from killed JE virus grown in live suckling mice brains. There are concerns about vaccine contamination with neuroproteins that might 'sensitize' vaccinees and cause encephalomyelitis and indeed occasional anecdotal reports of post-vaccination encephalomyelitis have occurred in Japan, Korea and Denmark; but the incidence is estimated to be quite low (1:50,000 to

1:106,000) given that no association has emerged in 30 years of extensive vaccine use in Asia. The vaccine has been shown to have about 90% efficacy.

Although two doses 1-4 weeks apart are used in many parts of Asia and are said to give short term immunity in 80% of vaccinees, studies in the United States and Britain have shown that 3 doses (at days 0, 7 and 30) are needed to provide protective levels of neutralizing antibody in most vaccinees. Therefore we currently recommend for a primary course, three doses of 1ml (0.5ml for children aged 1-3 years) by deep subcutaneous injection on days 0, 7 and 30. Full immunity takes up to a month to develop. The vaccine is not recommended, unless the risk is unavoidable, for children under one year of age.

The duration of protection is not precisely known. Neutralizing antibody persists for at least 2 years after a 3 -dose primary course. A booster may be given after this time.

Local, non-specific adverse vaccination events with JE vaccine are relatively common. These are mild, self-limited and no different than many other vaccines. These events include:

  • Local tenderness, redness or swelling at site of injection in 20%

  • Mild systemic symptoms, chiefly headache, low-grade fever, myalgia, malaise and GI symptoms by 10-30%

Recent prospective or retrospective studies have found risk of an more severe allergic adverse event to be in the range of 18 to 64 per 10,000 vaccinees. The cause of the reactions is uncertain but felt to be related to stabilization compounds (gelatin, albumin) added to the vaccine and, rarely, to vaccine proteins. But because there is this small (<1%) risk of a severe allergic reaction (urticaria and angio-oedema) - which can occur within minutes to up to two weeks after receiving the vaccine - it is recommended that people given JE vaccine are kept under observation at the vaccination center for about 30 minutes and that the course is completed at least 10 days prior to departure. If this is not possible, and as it is highly desirable to complete the course using the same vaccine as immunization was started with, will your UK doctor be able to supply the next two doses and (as you say) can you keep the cold chain intact on the trip over? If not, you can get the full course of the vaccine in Jakarta and / or have it sent by courier to Surabaya - assuming you trust the courier service to deliver it on time to preserve the cold chain.

Contraindications to immunization:

  • History of allergy to the vaccine, gelatin, other rodent derived products.

  • History of Gullain-Barre syndrome, multiple sclerosis or other demyelinating disorders.

  • Risk of the hypersensitivity reactions (angio-oedema and generalized urticaria) is increased in individuals with an allergic condition, e.g., asthma, allergic rhinitis, food allergy.

Repellents and other protective measures are recommended in any case because other vector-borne diseases may be transmitted in the same areas. General anti-mosquito precautions are especially important to travelers in whom vaccine is contraindicated, who are unable to complete immunization because of departure on short notice, or who do not chose to be immunized because of their visits to high-risk areas are brief or carry an equivocal risk.

Declaration of interest: medical adviser to International SOS, an AEA Company, Jakarta, Indonesia.

Answers to medical questions for expatriates in Indonesia!

We wish to take a holiday in Lombok at one of the coastal resorts. Last week (end of October) we heard that cerebral malaria is on the increase in Lombok. What is the opinion of the experts of this? Is Lombok becoming more risky than in previous years? We haven't booked yet, but just want to examine the risks.

As far as we know, this is a Jakarta rumor... Problem is, there is no good case surveillance there though, which means that if there have been even one or two well-talked-about cases then the talk will skew the apparent risk without of course ever relating to the actual risk (which is not known but which on Lombok is high).

Based on past experience and cases from this area I would take both precautions and anti-malarial prophylaxis even for a few-days' trip even if staying at the international hotels and lying on the beach. Falciparum malaria (which can but does not always result in cerebral malaria) has always been a problem in the area. For more information on Malaria.

Declaration of interest: medical adviser to International SOS, an AEA Company, Jakarta, Indonesia.

Answers to medical questions for expatriates in Indonesia!

I am an American who is interested in visiting Indonesia to see for myself what it is like and if I would like to make my home there. I do have a medical question though, which I hope you can help me with. Being as I am an Insulin dependent Diabetic ..... how do I negotiate having the needles I need (either bringing them with me or purchasing them while I'm there) to give myself my Insulin injections ??? I understand Indonesia has a bad drug problem and penalties are severe for those breaking (or mistakenly perceived as breaking) the current drug laws). I also take some other prescription drugs in pill form. Any helpful information you could give me would be much appreciated.

Bringing insulin syringes for personal use into Indonesia has not been a problem in our experience. However we have checked again with Customs in CKG airport, and have been informed by the duty officer that as one would expect (and indeed as is standard practice in most countries), for the syringes and the insulin to legally come in Jakarta for the patient's personal medical use, he will require a letter from the treating physician stating the quantities of drug and syringes involved, that they are required for treatment of his illness, and that they will be wholly used by the patient alone. (The letter can be typed in English but should be original, with a medical letterhead and the doctor's written signature and full contact details).

Should the patient have a treating physician in Indonesia, letters from both doctors would obviously be preferred. The above does not of course guarantee no problems on arrival. However we have had no reports from our diabetic patients that they have encountered any problems. Re-supply of syringes and particular types of insulin after arrival can be a problem - it will be best to import as much as you are allowed to bring from your home country.

Declaration of interest: medical adviser to International SOS, an AEA Company, Jakarta, Indonesia.

Answers to medical questions for expatriates in Indonesia!

What is the rational explanation of thrombocytpenia in dengue fever?? What does happen to the structure of platelets, what does it release, and what is causing the low thrombocyte count. Does it have something to do with the bleeding in gum, nose, etc.?? What does the virus do to the platelet?

Very briefly, my understanding is that it is an immune reaction that causes destruction of the platelets. The platelets get the virus on them and then they are destroyed as they appear as if they are foreign material, not your own platelets. If your platelets go below 15,000 then often people get symptoms such as bleeding gums, bleeding nose, bleeding under the skin, etc. This if it continues can lead to dengue heamorragic shock syndrome.

Declaration of interest: medical adviser to International SOS, an AEA Company, Jakarta, Indonesia.

Answers to medical questions for expatriates in Indonesia!

I am due to fly home to have my baby in July. My doctor in Jakarta has prescribed the drug DUVADILAN, which he says I should take just before the flight. Is this OK?

Duvadilan is used to stop premature labor. So it is generally well tolerated in late pregnancy. However there are better drugs to take and as Duvadilan has been associated with some problems it is not as generally used as other tocolytics (drugs to stop premature labor). I would not take anything at all unless you begin to get contractions.

Declaration of interest: medical adviser to International SOS, an AEA Company, Jakarta, Indonesia.

Answers to medical questions for expatriates in Indonesia!

We are currently living in Bali and my 3 year old son has just been diagnosed with Salmonella Typhi. The report says it is Salmonella Paratyphi A. We had the blood test done yesterday at Quantum. I'm not so sure that I trust the diagnoses totally and would like to know of other tests I may need to ask for. His symptoms have been on and off for the last 3 weeks. First week he had a fever for 2 days. The second week he had fever for 3 days with sore ears and glands were enlarged. No thirst. The 3 rd week, he has a very sore mouth with small white blisters and the gums are red and swollen. There is a red line around some of the bottom teeth. It looks to be coming away from the gums. A very yellow tongue. The doctor says his abdomen does not seem normal. He has a soft stool each morning but not diahorreah. His fever has broke now but I am worried that it will come back worse next week. Have you ever heard of these mouth symptoms before? Is there any info you can give me? I would appreciate ANY help. I am not a great believer in antibiotics but am about to start him on Thyamphenicol.

It is very difficult to diagnose without seeing the child or the blood tests. However, from what you have told me I would also wonder about the diagnosis of typhoid. It is very overdiagnosed here. I presume he had a Widal test and it came back as positive but it would be useful to know whether it was the O titre or the H titre and how high it was (This is only an indication you need 2 tests to say for sure it is typhoid). The symptoms are not that consistent.

Normally with typhoid you would have high fever 40 degrees every day for weeks on end. It does not tend to be recurrent. I have not heard of mouth lesions in children with typhoid. I would also like to know the white cell count (WCC) as this is often low in typhoid and his HB and platelets.

The common causes of the mouth lesions that come to mind are first attack of cold sores (Herpes type II). In this condition a child will have high fevers, and ulcers all through his mouth, and up on his palate. They will often not eat and drool. Most people get this in the first 4 years of life. It's viral, so no treatment.

The other possibility is hand foot and mouth disease. Look for little blisters on his feet and fingers. Once again viral, so no treatment.

Oral thrush is another cause especially after antibiotics. Measles can cause white spots (kopliks spots) but then you should have sore eyes, runny nose and rash.

It is complicated to diagnose over the internet. If you decide to use antibiotics though Chloramphenical is a good treatment for typhoid it does have side effects especially in children and I would be more tempted to use bactrim as the side effects are less dangerous.

Declaration of interest: medical adviser to International SOS, an AEA Company, Jakarta, Indonesia.

Answers to medical questions for expatriates in Indonesia!

I am a thirty year old male of Mediterranean origin, and have G6PD. I would like to know from you what chemical prophylactics I can safely take while traveling into a malaria area for work purposes. Any response in this regard would be much appreciated.

I presume you mean you have G6PD deficiency. Doxycycline would be the best prophylaxis for you if you were staying short term. Mefloquine if you were going to be in a malaria area long term. We would need your travel schedule to be able to properly advise you as different regions vary in regard to resistance. Many of the major cities in Indonesia are malaria free today . The main concern with G6PD deficiency is that you cannot take the normal dose of primaquine as this will cause haemolysis. Primaquine is normally used after infection with Vivax malaria to eradicate it from the liver. Some people use it prophylactically. You should obviously not take it prophylactically.

Declaration of interest: medical adviser to International SOS, an AEA Company, Jakarta, Indonesia.

Answers to medical questions for expatriates in Indonesia!

Are CT scans of head available in either Bali, or Jakarta? If so, where?

In Bali Sanglah hospital has a CT scan (the main hospital in Denpasar). In Jakarta many large hospitals have them, e.g. Medistra, Pondok Indah, Puri Cinere, MMC, etc. The quality of the results vary and depend in part on the condition that is being scanned. We may advise people to go to Singapore or other locations.

Declaration of interest: medical adviser to International SOS, an AEA Company, Jakarta, Indonesia.

Answers to medical questions for expatriates in Indonesia!

Can you recommend a good physiotherapy clinic in Jakarta, preferably with Iso-kinetic machines.

In general the physiotherapy is not as professional as in developed countries but clinics are available. I do not know about Iso-kinetic machines. Most tend to have ultrasounds and electric pulse machines. I have provided two clinics and their numbers below.

EastWest Physiotherapy and Rehabilitation 7278-8361
Sasana Husada Kebayoran Baru 722-2410
The Medical Scheme Clinic 525-5367

Big hospitals such as Medistra, Pondok Indah, MMC, Siloam Gleneagles and Bintaro Hospital often have physiotherapy units attached as well. Occasionally an expat physio may come accompanying her husband and do some work from home.

Declaration of interest: medical adviser to International SOS, an AEA Company, Jakarta, Indonesia.

Answers to medical questions for expatriates in Indonesia!

We are planning on spending 4 days in Lombok with our 6 year old and 10 year old daughters. We will be staying in the coastal resorts in very good hotels, in Kuta and Senggigi. I am hesitant to give them the weekly chloroquine pills and daily proguanil pills that have been recommended for such a trip as I am worried about side effects while we are in Bali where the medical attention won't be as good as it is in England. Would it make sense to give them the pills several weeks ahead of time while we are still in England to see if they have a bad reaction? What kind of risk are we running if we give them no pills at all but take preventative measures? Is there a risk if we give them just the chloroquine pills weekly? Just how prevalent is the chloroquine resistant strains of malaria? I understand that Malarone is another alternative but not available in the UK. Is it thought that Malarone is preferable for young children?

Unfortunately Senggigi beach is renown for malaria in particular falciparum malaria and this is often chloroquine resistant. Thus if you don't take proguanil you run the risk of getting this strain of malaria. If you do all the preventative things, mosquito repelant, staying in at sunset and sunrise and wearing long sleeves there is still a risk. Malarone is not available in Singapore or Indonesia you could try ordering it through an online site. The other option being used in children is mefloquine these days. You should discuss this with your doctor. All malaria tablets should be started a week before entering a malarious area if you wish to try them earlier for side effects you can do this.

Declaration of interest: medical adviser to International SOS, an AEA Company, Jakarta, Indonesia.

Answers to medical questions for expatriates in Indonesia!

My wife has been having a noise in her left ear for the last 2 weeks. It seemed to start with a cold but that has cleared up now and the noise remains. At times it is quite loud and disturbing. It seems to diminish during the day but increases when trying to sleep at night. Its very stressful and the Dr. she has seen has prescribed antibiotics without really explaining what the cause and treatment is. Can you suggest a proper plan to diagnose this and perhaps an ENT expert to visit?

Tinnitus is quite a common problem and can be very frustrating. I would advise she sees an ENT doctor, at one of the big hospitals like Pondok Indah, GlenEagles, MMC, Medistra, or visit the ENT surgeon here at SOS. The frustrating thing is that they probably will not be able to do to much except check the ear and make sure there is no treatable pathology. Tinnitus is something that usually either gets better by itself or stays for ever. I would suggest you ask for an audiometry (hearing test) as this may help to elucidate if there has been any damage done to the hearing.

Declaration of interest: medical adviser to International SOS, an AEA Company, Jakarta, Indonesia.

Answers to medical questions for expatriates in Indonesia!

We are a group, who regularly dives in the Thousand Island area. We are trying to establish an emergency plan in case of any diving emergency. When diving in Matahari, Sepa, Bira area, if an accident happens, who should we contact for transfer to Jakarta, medical assistance, etc.? Are there any decompression chambers in Jakarta open to the public (who to contact?). Your assistance in this will be highly appreciated.

There is a diving chamber in Jakarta. If you are members of DAN there is a network you can contact. If you require further assistance International SOS has two expat doctors trained in diving related medicine and we can fly you in a sea level cabin on 100% oxygen to Singapore, Darwin, or Cairns (depending on site in Indonesia) where we believe there is a higher quality of care. Please contact International SOS 750-6001 if you require further information.

Declaration of interest: medical adviser to International SOS, an AEA Company, Jakarta, Indonesia.

Answers to medical questions for expatriates in Indonesia!

I moved to Indonesia - Jakarta some 4 months ago and I would like to know if you knew about a recognized lung specialist/allergist in Jakarta and if not here, what are the options in Singapore or Australia? I have reocuring bronchitis - more especifically acquired bronchiectasis and in these past months have had continuous cough with sputum. I have visited 2 specialists in a major hospital, but I don't seem to get better and have a bit of difficulties in comunicating.

There is an allergist in Pondok Indah hospital if you think the problem is allergy related. There are numerous respiratory specialists around I would try the big hospitals such as Medistra, Pondok Indah and Siloam GlenEagles. We often refer expats to Singapore as the overall quality of care and ability to communicate and understand the problem is better. If you were considering going to Singapore we would recommend Cheng Heok Hee in Tan Tock Seng (65) 256-6011 (allergist) Goh Teck Chong (65) 479-9316 (resp physician)

Declaration of interest: medical adviser to International SOS, an AEA Company, Jakarta, Indonesia.

Answers to medical questions for expatriates in Indonesia!

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If you live in Indonesia and have a question to ask of medical professionals, see Ask the Experts.

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