Some advice from a paddling doctor.....

The 50 Miler was fun last weekend but the 2 days of Dusi guts that followed certainly weren’t! There’s no doubt about it, sometimes that river is toxic. What can we do to protect ourselves except keep our mouths tightly closed when we’re near it?

Unfortunately most of the bugs that cause Dusi guts are bacterial so there are few vaccines available to help protect paddlers. There is some evidence that promoting one’s own gut flora with Probiotics can help boost one’s immunity and decrease the chance of the pathogenic (disease-causing) bacteria proliferating.

Vaccines that are available to us to protect us from certain diseases are Hepatitis A and Tetanus vaccines. Although Hepatitis A is not nearly as common as the usual bugs giving us Dusi guts, it’s a nasty illness to have with jaundice, nausea, abdominal pain, fever and malaise, and recovery can be slow taking up to 6 months. It is certainly prevalent in our communities and since it is spread via the faeco-oral route we are at risk of getting it in our polluted rivers. Hepatitis A vaccine is readily available and is given as 2 vaccines 6 – 18 months apart which gives one immunity for over 10 years. Boosters are recommended after 10 years.

Tetanus is also present in our community but is not spread in the same way, but rather by deep penetrating cuts or wounds that are contaminated. It is not common, but since the disease is scary with muscle spasms, stiffness, sweating, difficulty swallowing and breathing, and it can be fatal, it is definitely worth immunizing oneself against it. A tetanus shot gives immunity for 10 years but it is recommended to get an additional booster every 5 years if you have a deep puncture wound.

Chances are we will get the dreaded Dusi guts from time to time and it’s a matter of staying hydrated, not taking any Immodium, and if you can’t keep any fluid down, or if there’s blood in one’s stool or high fevers or persistent diarrhoea after a few days, to seek medical help.

Written by Dr Landy Taylor.

Waterborne Disease and Canoeists - by Kirsten Oliver

The race was awesome, rains are up, and the churning brown mass of water provided scope for the thrill of a lifetime, smashing into waves that literally take your breath away, and surviving the odd tail walk without swimming. The tales have been embellished, the sore muscles rubbed, and treasured boat safely returned – in one piece – to its resting spot in the garage, and despite all this, you can’t help but notice that unpleasant grumbling in your gut…

Waterborne diseases are a very real, if somewhat frightening, aspect of recreation and sport on rivers in South Africa, and as canoeists, we need to know what we are up against in order to protect ourselves. Unfortunately, with the current state of sanitation infrastructure and services in many rural and peri-urban areas and unsatisfactory agricultural and industrial management of areas that feed into many of our rivers, water quality in most rivers on which we race – especially those that run through urban areas – is very poor.

Water quality is jeopardised by a number of contributing factors. The most obvious of these – for the purposes of diseases – is the contamination of water from raw sewage. In areas where sanitation facilities are inadequate or nonexistent, the chances of overflowing sewer pipes and uncontrolled use of the countryside as a toilet are very high. In addition, overgrazing and uncontrolled use of cattle and domestic livestock of the rivers further contributes to the poor quality of water. During the dry season the effects are fairly limited, but as soon as there is rain, high concentrations of human and animal waste are washed into the river systems, and all the bugs have a field day growing and going on the rampage to find someone to bother.

There are many different kinds of disease that can be contracted from contaminated water, some very serious, and some easily recognisable and easily treatable. Waterborne disease pathogens include viruses, bacteria, parasites, fungi, and chemically induced illnesses, and the range of infection varies from serious diseases such as hepatitis A and B to severely infected wounds. For the purposes of this article, only two common illnesses will be mentioned in detail.

For the average canoeist, the most common waterborne infection has been characteristically termed ‘Dusi Guts’. Being the biggest and best known race in the country, it is unfortunate that over the years diarrhoea has often become synonymous with paddling the Dusi Canoe Marathon. The scenario is, however, very self-explanatory: the Dusi takes place in summer during the rainy season in KwaZulu Natal. Big rain means big water – a canoeists dream come true, and a bug’s ideal opportunity for action.

E. coli
The term “E. coli” is associated with dirty water in canoeing circles. “E. coli” is the abbreviated form of the scientific name for the group of bacteria known as Escherichia coli. These bacteria form part of the digestive system in humans and animals, and therefore if water contains E. coli, it is by definition faecally contaminated. However, as with many other forms of bacteria, most strains of E. coli are quite harmless to humans, and so the presence of E. coli is merely an indicator that the water might be a carrier of more dangerous faecally transmitted pathogens (disease causing bacteria and viruses). The E. coli count in water is relatively easy to determine, and the higher the E. coli count, the more likely that the water is carrying enough pathogens to be dangerous.

Your body is able to take care of minor doses of most pathogens – this is after all the principle of vaccination. To get sick you need to get a large enough dose, known medically as an “infective dose”. A little splashing is not generally that dangerous – what you want to avoid is swallowing lots of water. This has fairly obvious implications – if you happen to be unfortunate enough to not make it though the tail walk without swimming, make sure you take a big breath before you hit the water, and clamp your jaws shut so the little critters can’t get in.

If you are one of the many who were too late taking your breath, and got a mouthful of water instead of a lungful of air, don’t panic about bugs just yet, you have other more imminent dangers to worry about. Once you have recovered your boat and made your way safely to the finish, and you experience that nauseating, stomach clenching, toilet summoning sensation over the next few days, you can be certain you have picked up one of the many bugs that can cause “Duzi Guts”. In most cases the best treatment is plenty of fluids and electrolytes to replace those lost through diarrhoea. It is not recommended that you take antibiotics if you have a mild dose, as these build up in your body and increase the immunity of the bug to the medication. Most infected persons recover without medication (but really, do make sure about drinking lots of electrolyte solutions, and possibly taking an Immodium or two) within a week or so. If, however, you develop a high fever, vomiting and severe stomach ache, or if the diarrhoea persists, it is advised that you consult a doctor as the implications are often more serious and can lead to hospitalisation if left untreated.

Bilharzia (Schistosomiasis)
While there are those illnesses that can be fairly well avoided by not ingesting any water, there are also, unfairly, those that you can pick up simply from a splash of water. The one most commonly found in canoeists is Bilharzia. Ranked second behind Malaria as a disease affecting social and economic well being in tropical and subtropical areas, Bilharzia is a disease recreational water users, including canoeists are regularly faced with. The Bilharzia bug is a blood fluke or a parasitic flatworm that relies on specific hosts to complete its lifecycle, and the average canoeist thrashing away on the river makes the perfect definitive host. Once in a human or animal, the adult worms live in the veins surrounding the bladder or intestines, and lay eggs that pass into the bladder and are eliminated with the faeces or urine of the host. If the eggs come into contact with water, they hatch, and the larva (miracidium) locate and penetrate their initial host body - commonly a Bulinus snail. After two generations within the snail’s body, the miracidia produce and release thousands of cercariae, a free-swimming stage, into the water. The cercariae locate a definitive host – Joe Soap canoeist standing in the water emptying his boat after an untimely swim – and enter his body though any exposed skin. Once there, they migrate through Joe’s tissues to enter the blood stream, develop into adults and mate. Thus the lifecycle is complete, and within a few weeks, Joe may start – possibly without even noticing – to feel a bit lethargic and experience some lower back pain. Often, however, the disease is asymptomatic and he may not be aware that he has the bug at all for a long time. Left untreated though, he may start to feel really bad, and could end up with seriously life-threatening complications, not to mention possibly spreading the disease into other rivers and canoeists (if he feels well enough to go canoeing at all, that is).

Luckily, treatment of Bilharzia is usually highly effective. The drug Praziquantl is easily accessible on prescription in the tablet drug Biltricide or the cheaper generic tablet Cysticide. If you suspect you may have Bilharzia, tell your doctor and get tested. On rare occasions (there have been a few cases locally recently) the Bilharzia worms may become lodged in the vital organs eg liver, kidneys or spine and can cause much more serious and difficult to diagnose and treat illnesses. Ensure that any specialist treating you is aware that you are a paddler and the potential for this.

Other bugs
Bugs are all around us, we have zillions of them inside us all the time, but most are fairly innocuous. Thankfully, with the advance in science today, doctors are aware of most of the various waterborne diseases and can treat them effectively without too much suffering on your part. To lessen your chances of getting ‘bugged’, take note of the precautions below, and be aware of what’s out there and how things like sudden rainfall in large doses affects the quality of rivers. Actually, your best bet is just not to swim too much, take up slalom and learn the tricks to keep you in the boat.

How to protect yourself
- In the unfortunate eventuality that you are knocked unsuspectingly out your boat, keep your mouth shut (at the time anyway, you can talk about it later if you want to!).
- Don’t, under any circumstances, drink water out of the river (especially rivers like the Umgeni/Duzi, Berg River).
- If you have any reason to suspect you may have contracted bilharzia, see a doctor, get tested and if you are positive, get treatment. This is not a disease to leave untreated. Some paddlers take Biltracide every year as a precaution, but it is preferable not to treat yourself unless you have to.
- Clean and disinfect any wounds, cat scratches, open blisters etc. thoroughly after being in the water.
- If you train on ‘dirty’ water, make sure you shower after your session to eliminate any surface bugs before they have a chance to get too active.
- If you are uncertain about a possible problem, see a doctor.

Written by Kirsten Oliver for DUCT.

Bilharzia - are you safe? - interview with Dr Richard Anderson

Bilharzia – are you safe?

Martin Dreyer was reported to have discovered he had bilharzia just prior to the 2007 Dusi, and it seems that more and more paddlers are finding that they have bilharzia. A parasitic infection that causes tiredness and loss of energy, and can sometimes cause death if left long enough untreated, this is not an illness to take lightly.

Do you know if you have bilharzia, or would you rather not know?
Do you simply take Biltracide every year as a precaution?
Is that a safe practice?

DUCT talked to Maritzburg GP and 15 times Duzi finisher Dr Richard Anderson to learn more about this recreational hazard that all paddlers in KZN waters live with.

DUCT: How many cases of bilharzia would you estimate you see in your practice each year, and do you think you are you seeing any more cases of bilharzia in your practice now than you did, say, ten or twenty years ago?

I see about 30 cases of bilharzia per year of which over 90% are paddlers. Nearly all are seen between October and April. There seems to be a greater awareness now and people are volunteering for/ requesting testing, whereas 15 years ago the investigations were doctor-driven.

DUCT: Has the strain of bilharzia encountered in our local rivers changed in the last 30 years?

Those presenting long ago used to come in when they observed blood in their urine. This is rarely seen nowadays and is due to the Schistasoma Haematobium. Today the Schistasoma Mansoni which settles in the intestinal tract is more common and is physically identified in stool analysis and histological examination of the bowel wall and appendix. Paddlers most susceptible to aggressive bilharzial infection appear to be those exposed for the first time later in life. Early childhood infections seem to be tolerated well and provide lifelong immunity as evidenced in many of canoeing’s “old ballies”.

DUCT: Some paddlers have been told there is no point in having a blood test for bilharzia, as once they have tested positive they will always test positive. Please explain how the blood test results should be interpreted and understood.

Because of the difficulty in physical identification of the parasite, blood tests are performed. These blood tests measure two immunoglobulins – one indicating recent exposure (IgM), and the other indicating past infection and consequent resistance to current exposures to bilharzia (IgG). Testing for levels of IgM are very relevant as they indicate the level of current infection from which the effectiveness of medication can be gauged and the individual’s resistance determined. Obviously the IgG remains positive and is less relevant.

DUCT: When is the best time to have yourself tested and treated?

The timing of the appearance of IgM depends upon the intensity of parasite exposure and the levels of IgG in the body due to past infections. However, the general rule is to wait about two months after the end of the canoeing season before testing (i.e until April/May).

DUCT: Some paddlers simply take the anti-bilharzia medication once per year without having themselves tested. This obviously saves on medical bills for the testing, but it may not be advisable long-term. What is your view?

It is unwise to take any medication if it is unnecessary, more especially anti-bilharzials which are toxic and not without temporary side effects. Therefore, don’t take ant-bilarzials routinely at the end of the paddling season, but only if a sustained high IgM is present or if the IgM titre has increased.

Dr Richard Anderson graduated from Wits in 1975. He completed his first Dusi in 1973, and has completed a Dusi as recently as 2006. In all he has entered 17 Dusis and completed 15 (that’s a strike rate of 88%, better than most of our cricket team - Ed). He was a founding member of the Wits Canoe Club, and, in July 1972 became the first paddler to launch a racing kayak onto Emmarentia Dam, which is now home of the Dabulamanzi Canoe Club.

While bilharzia mostly just results in tiredness and general malaise, it can in some cases lead to neural damage in the brain or spine. Therefore if you paddle in KZN rivers, get yourself tested and if necessary treated at least once per year. April-May is the ideal time to do this. Why give the parasite until just before Dusi time to multiply and make merry in your body?

To learn more about bilharzia, the following website is easy to use and comprehensive: http://en.wikipedia.org/wiki/Schistosomiasis