Bites and stings

Rabies

It is a great advantage to live in a rabies-free island (but see later about bats) and important to prevent the re-introduction of the disease to Britain. Many people feared that this might happen with the opening of the Channel tunnel, but the risk from France should not be over-dramatised.

In Europe, foxes are the main vector of rabies; however, distribution of vaccine on chicken bait dropped from helicopters in rural areas is helping to reduce the problem.

In general, dogs on the Continent are not rabid. Of course anyone bitten by a dog, cat or other animal in Europe must go for medical assessment and possibly a rabies vaccine, because the domestic animal may have been in contact with a fox, but rabid animals are not common near to urban areas. Excellent treatment is usually available quickly (a major brand of rabies vaccine is French) and so human cases of rabies should be preventable – and, although the course of vaccine is time-consuming and expensive, it is not unpleasant these days.

The real danger to travellers from rabies occurs in countries where the dog population may be infected and where treatment may be less than ideal. Many developing countries are included in this category. The Indian subcontinent and Thailand both have widespread dog rabies and, although dogs constitute the highest risk, any bite or scratch from a warm-blooded animal must be treated. An estimated 40,000 people die from rabies in India each year.

This should not cause panic in visitors to that country, because treatment, including vaccine, given promptly after the bite should prevent development of the disease. Of course treatment must be sought as promptly as possible after the bite, and is easier and likely to work faster if you have been immunised in advance. Therefore if you are staying in a country where rabies is endemic for some time or in a place where it would be difficult to get medical treatment, this option is worth considering. It is worthwhile even though you will still need some ‘treatment’ vaccine (really it is prevention) after an exposure.

Many people still believe that rabies immunisation is painful and comprises many doses given into the stomach. In fact, the modern vaccine is virtually painless and given into the arm. Most countries have an adequate version of the modern vaccine, even if not the very best one. A few rural areas in the African and American continents are still rumoured to have only the old-style vaccine.

There are still a few countries that do not harbour rabies in land animals (terrestrial) and these include Ireland, Australia, New Zealand, some Caribbean and Pacific islands, and some parts of Europe. However, any animal bite or scratch on holiday abroad should be properly cleaned and you should have a tetanus injection and antibiotics if appropriate, and seek medical advice as to whether rabies vaccine is necessary.

Recently, there have been isolated cases of bats carrying a rabies-like virus being found in Australia and a few in the UK. In 2002 a bat handler in Tayside, Scotland was bitten by such a bat and tragically died from the disease. Rabies vaccine is considered likely to protect against this strain carried by bats, and handling bats in the UK and all other countries should be avoided. Bat handlers should take precautions to avoid bites, should be immunised routinely and take further vaccine after a bite. Anyone who unavoidably has to touch a bat should wear gloves and seek medical advice if there is a chance that he or she has been bitten. Indeed, medical advice must be sought for bat bites in any country.

Animal bites

A bite or scratch from any warm-blooded animal (usually dog, cat, monkey or bat) in a country where rabies exists must be treated as a possible rabies risk (see ‘Rabies’ above). In the UK (or any other country), bat bites must be medically checked.

Wash the wound thoroughly in soap and water, apply antiseptic and go immediately for preventive vaccine, and for prevention of tetanus and other infections.

If there is imminent danger of being bitten by a large carnivore such as a lion or tiger, rabies is unlikely to be uppermost in your mind. The advice, if about to be charged by a big cat – frighteningly difficult to follow – is not to turn and run, thus looking like prey, but to stand and face it, shouting and throwing stones in the hope of putting it off its stride.

It is far better to avoid any such dangerous situations; do not get out of the car to photograph a sleepy looking lion in Africa. It sounds incredible, but people have been taken in by their docile appearance. Similarly, big cats in UK safari parks or zoos are not partly tame even if they appear so. In recent years, keepers have been killed in British parks and zoos.

Perhaps surprisingly, buffaloes and hippos are more dangerous than lions, in that more people are attacked. Hippos are aggressive especially on land, if you are between them and the water. Despite their bulk, they can move terrifyingly fast. Buffaloes, especially lone animals surprised in the bush, are able to gore humans fatally and can also bite. Don’t walk in the bush without a knowledgeable guide. If charged get behind or up a tree, if at all possible. Climbing trees is no escape from the grizzly bears of the American National Parks. Twelve people were killed in the 20 years to 1986 in the three major parks. Between 1980 and 2002, 32 people were injured by bears in Yellowstone National Park alone, but a greater number were injured by bison. Rangers will give visitors up-to-date safety advice, but it has been said that lying down pretending to be dead may be the best defence because bears prefer to kill their own food.

Chimpanzees and baboons can appear friendly and playful, and then deliver nasty bites. Obviously obtain medical help for such injuries.

Insect bites and stings

A variety of diseases is transmitted by insect bites, and even when they are not dangerous they may be uncomfortable.

Some people have an allergic skin reaction to bites from mosquitoes, midges and horseflies even while on holiday in England and Scotland. The bite becomes itchy and the skin around it swells and becomes inflamed.

In acute cases infection spreads in red streaks up the arm or leg or even via the blood (septicaemia). Once this has happened antibiotics are required urgently, but it is better to reduce the itching earlier on and, therefore, the scratching and chance of infection. Individuals liable to ‘swell up’ with bites should reduce the tendency by taking antihistamine tablets. Antihistamine creams put on to bites work in the short term, but may themselves cause itchiness eventually. Calamine lotion is an alternative.

For older children and adults, preparations containing a little hydrocortisone will help to reduce the inflammation, and crotamiton to reduce the itchiness. Even better, reduce the quantity of bites by repelling the insects, which can reduce the risk of disease carried by sandflies, as well as mosquitoes and ticks. (See earlier about ticks in Europe and be aware that ticks overseas may carry typhus, and ticks in the New Forest of England and eastern USA can carry Lyme disease.) Although repellents are effective for most insects, some insects, such as tsetse flies in eastern and southern Africa, are not affected.

Likewise, wasps and bees are not always deterred by insect repellent. Summer holiday picnics are a favourite time to be stung and their stings can of course be painful. If a bee sting is left behind, try to remove it by scraping it out carefully with a fingernail or knife (squeezing it with tweezers may release more venom). Holding ice over it reduces the pain, elevation of the part and/or antihistamine tablets reduce swelling. Painkiller tablets, for example paracetamol, may help.

In a few people these stings can be fatal. Sometimes these victims have had multiple stings, for example beekeepers, or receive multiple stings from a swarm. On very rare occasions, it can happen after a single sting because a serious allergy has developed that causes anaphylactic shock (collapse of the circulation and breathing difficulties); this can be fatal if not treated rapidly with adrenaline. Those who have had a warning reaction should carry a syringe with adrenaline (EpiPen), which can be injected in an emergency and enquire about medical desensitisation. Another way that a single sting can require emergency adrenaline and antihistamine is one at the back of the mouth that swells to obstruct breathing. It usually happens eating food or drinking outside, and it is essential to check each mouthful during al fresco holiday meals when wasps are around.

Snake bites

Most people are terrified by the thought of a snake bite, believing that it could be rapidly fatal. Indeed there are estimated to be between 50,000 and 100,000 deaths a year across the tropics, mostly in agricultural workers. In Australia between 1980 an 2007 there were about 40 deaths from snakebites, and in the USA there are about half a dozen deaths from rattlesnakes a year.

Despite the numbers in the tropics, few tourists are bitten and there are important points to remember for avoidance. Snakes do not attack humans unless cornered.

Not all snakes possess poisonous venom and, even when a venomous snake bites a human, very little may be injected. It is therefore important not to panic and rush about, which only speeds up the circulation of the poison. Venom usually takes hours, rather than minutes, to kill and so there should be time to get to help. Try to stay calm and reassure the victim.

Wipe the wound gently but do not suck or incise it. Try to immobilise the limb with a sling or splint, and transport the victim urgently to a medical centre (on a stretcher if possible). Tourniquets are more often dangerous than helpful. A description of the snake could be useful if anti-venoms are available, which should be used only by experienced people because they can cause serious allergic reactions.

Obviously prevention is paramount and snakes should never be touched even if they appear dead. Take care to avoid stepping on them, use a torch or stick to check that the path is clear at night, wear shoes or boots in vegetation, and do not put your hand under any rocks, down holes or into dark corners in snake-infested areas.

Snakes do not only exist overseas; people do occasionally get bitten on holiday in the UK, although these bites should not be fatal. Prevention also follows the principle of not stepping on or cornering an adder or a grass snake. Go for medical treatment because infection, including tetanus, can be caused by either, and anti-venom may be advised for the poisonous adder bite.

Some dangerous sea creatures

Although people fear land snakes, few have thought about sea snakes. They are mostly poisonous, brightly coloured and can be seen swimming in some tropical waters. Like their land cousins, they should be strictly avoided; they do not attack unless molested. The bite can be serious and rapid medical treatment is required. However, as with land snakes, remember that no venom may have been injected, although, as symptoms can take some hours to develop, the patient must be checked medically.

There are also venomous fish and jellyfish, mostly a problem in warmer waters, but among those that can be found around the British coast (for example, Cornwall in summer) is the weaver fish. This produces a very painful sting when trodden on while paddling. There is a story that a trawlerman cut off his toes to get relief from the terrible pain.

In the tropics stonefish are among several species that are dangerous when stepped on. Some relief can be gained by long soaking of the foot in water as hot as can be tolerated, while waiting for medical attention.

Stingrays also lie in shallow waters and can inflict lacerations as well as release venom by flicking their long tails. Wearing shoes to paddle and swim reduces most of these dangers, although the stingrays can flick on to your legs, so walking cautiously is the only prevention.

Enquire locally about poisonous marine creatures, and what to look out for.

All wounds should be seen at a medical centre to remove any fish spines and to provide painkillers and any specific treatment that exists. Wounds are prone to infection if not cleaned professionally.

In tropical waters the jellyfish threat appears to be increasing. One of the most dangerous is the box jellyfish, which is responsible for more deaths in Australia than snakes, sharks and salt water crocodiles put together. It can kill by causing respiratory paralysis. Mouth-to-mouth resuscitation may be necessary while the victim is got to medical help.

The tentacles must be removed without releasing more stinging capsules and vinegar splashed over the skin helps to inactivate them (box jellyfish only). There is specific anti-venom in Australia. Box jellyfish risk varies with the season and area around Australian and south-east Asian waters. Local advice must be obtained for each area for this and other poisonous jellyfish.

Portuguese man-o’-war jellyfish are also venomous, but less dangerous than the box species. It is sometimes found in British waters. Wetsuits and clothing when swimming reduce the risk of stings. First aid includes removing tentacles with tweezers, carefully without rubbing. An ice pack may reduce the pain before you get to a doctor for wound cleaning and possible local anaesthetic. Small children should always be medically checked.

Sea urchins, starfish and octopuses should also not be touched. Indeed local instruction on any dangers should be requested specifically if scuba diving or snorkelling.

Sharks are probably a more publicised danger in tropical waters, although deaths from shark attack each year are far fewer than the number of people who drown in UK waters.

It is not always known why a particular shark may attack a certain victim, but thrashing about or blood may attract them. Again, it is wise to heed any local advice.

Saltwater crocodiles are very dangerous, as are their freshwater relatives, and can grow to enormous sizes. They inhabit estuaries in south-east Asia, India, Sri Lanka and northern Australia. Do not swim in undeveloped areas unless you are sure that it is safe.

Scorpions

Scorpion stings are far more common than snake bites. They are rarely fatal to adults, although southern India and Mexico are two of the areas where scorpion bites may be. Far more varieties are lethal to children and, in anyone, the sting can be excruciatingly painful. As with snakes, avoidance is the key. You should shake out shoes, avoid putting your hands under rocks, etc.

Once you are stung, very little helps the pain until you can get to a medical centre for an injection of local anaesthetic. There are anti-venoms for some of the poisonous varieties. Go for help even more urgently if a child is stung.

Key points

• Those who are allergic to bee or wasp stings should carry a prepared adrenaline injection (EpiPen)

   

• Avoidance is paramount in preventing snake bites, scorpion stings, sea snake and jellyfish stings

   

• Seek prompt medical attention for a bite or scratch from a warm-blooded animal in a country where rabies exists and bat bites in any country

   

• Bears, bison/buffaloes, hippos and even lions may appear docile, when they can in fact move very quickly; heed all park warnings