Chapter 10 Popular Itineraries Asia

Kristina M. Angelo, Michael C. Thigpen, Dora Warren, Grant Ludwig

DESTINATION OVERVIEW

Every year, >5 million international tourists travel to Cambodia. Many tourists to Cambodia visit the Angkor temple complex (which includes Angkor Wat), a collection of approximately 1,000 ancient temples and other structures covering 400 km² (250 square miles) in the northwestern Cambodia jungle (Map 10-20). The Angkor temple complex, located 6 km (4 miles) north of Siem Reap, is considered one of the architectural wonders of the world and in 1992 was designated a World Heritage site. The temples were built between the 9th and 14th centuries AD at the height of the Khmer Empire and were part of the empire’s capital (Angkor means “capital city” in Khmer). These historical structures were decorated with intricately carved Khmer artwork depicting Hindu and Buddhist themes, providing an archaeological portrayal of the empire that ruled much of Southeast Asia for 5 centuries. After the decline of the Khmer Empire, the site was largely abandoned to the surrounding jungle, and remained virtually untouched until descriptions of the ruined temples of Cambodia were published in a journal in the late 19th century. Restorations commenced as international visitors began to arrive, but the emergence of the Khmer Rouge regime, and the ensuing decades of civil war, halted most tourist travel to the site until the late 1990s. As Cambodia has emerged from >20 years of political and economic turmoil, the Angkor temples have become one of the most popular tourist destinations in Southeast Asia. Increasingly, tourists are also visiting other areas of Cambodia, including the capital Phnom Penh, the southern beaches, and the islands in the Gulf of Thailand. Adventure tourism through the rural and forested areas bordering Vietnam and Laos has also become popular.

Cambodia is one of the poorest countries in Southeast Asia, but is currently experiencing a period of rapid economic development. As a result, business-related travel, in addition to tourism, is increasing. Visitors can fly directly to Phnom Penh or Siem Reap from a number of Asian cities, including Bangkok, Singapore, Kuala Lumpur, Seoul, Hong Kong, Taipei, Tokyo, Vientiane, Hanoi, and Ho Chi Minh City. Overland travel from surrounding countries is also possible via direct bus service to Siem Reap and Phnom Penh from Bangkok and Ho Chi Minh City. A network of inter-provincial bus services connect Phnom Penh with Siem Reap and other Cambodian cities. Intercity transport usually involves taxis, tuk-tuks (motorbike taxis), bicycles, or buses (in Phnom Penh). 

HEALTH ISSUES

Immunizations

All travelers to Cambodia should be up-to-date with their routine immunizations, including seasonal influenza, and should be protected against hepatitis A and B and typhoid fever.

Japanese encephalitis (JE) is considered endemic throughout Cambodia; transmission occurs year-round, but peaks during the rainy season from May to October. The vaccine is recommended for travelers who plan to spend ≥1 month in rural areas, and should be considered for short-term travelers who may be at increased risk for JE virus exposure, such as those who will spend substantial time outdoors in rural or agricultural areas, especially during the rainy season. Travelers on a typical 2- to 4-day visit to the main (nonremote) Angkor temples, staying in air-conditioned hotels in Siem Reap, are at minimal risk, but mosquito prevention measures should be employed (see Chapter 3, Mosquitoes, Ticks, & Other Arthropods).

Rabies is endemic throughout Cambodia. Rabies infection results in approximately 800 human deaths annually throughout the country. The chief risk to humans is from dog bites; there are approximately 1 million dog bites annually in Cambodia. For most travelers on a short tour of the Angkor temple complex, the risk is minimal. However, travelers planning more extensive travel in Cambodia, particularly to rural areas, should consider rabies immunization before arrival. The Pasteur Institute of Cambodia in Phnom Penh, as well as some private clinics, can provide rabies vaccine and consultation after an exposure; rabies immunoglobulin is available to the public at the Pasteur Institute of Cambodia.

Although yellow fever is not a disease risk in Cambodia, the government requires travelers arriving from countries with a risk of yellow fever virus transmission to present proof of yellow fever vaccination.

Other Health and Safety Risks

TRAVELERS' DIARRHEA

Diarrhea and foodborne infections in travelers are common in Cambodia. Avoid water that is not bottled, ice, and food from street vendors. Safe, bottled water is readily available. Travelers should practice safe food and water precautions (see Chapter 2, Food & Water Precautions) and carry an antibiotic for self-treatment. Because fluoroquinolone resistance is widespread in Cambodia and other areas of Southeast Asia, azithromycin is preferred (see Chapter 2, Travelers’ Diarrhea for self-treatment recommendations).

DENGUE

Dengue is endemic throughout Cambodia, and large epidemics occur every several years. All 4 dengue serotypes circulate in Cambodia, with types 2 and 3 causing most reported cases. Peak transmission occurs during the rainy season, although cases occur year-round even in nonepidemic years. Travelers to Cambodia should take measures to protect themselves from mosquito bites to prevent dengue (see Chapter 3, Mosquitoes, Ticks, & Other Arthropods and Chapter 4, Dengue.

MALARIA

The highest risk of malaria infection for the traveler in Cambodia is in forested areas. There is little transmission of malaria around the main temples (such as Angkor Wat) of the Angkor temple complex, Tonle Sap Lake, Siem Reap city, and Phnom Penh. On a typical 2- to 4-day visit that involves exploring the  main (nonremote) temples of the Angkor temple complex during the day and staying in an air-conditioned hotel in Siem Reap at night, malaria risk is minimal. However, mosquito protection measures should still be employed. Travelers planning to visit the more remote Angkor temples deeper in the forest, or who travel outside the main tourist sites in Phnom Penh, especially to forested areas, should receive malaria chemoprophylaxis. The recommended chemoprophylaxis regimen for Banteay Meanchey, Battambang, Kampot, Koh Kong, Odder Meanchey, Pailin, Preah Vihear Province, Pursat, and Siem Reap is atovaquone-proguanil or doxycycline. Mefloquine is an additional option in all other areas (see Chapter 3, Malaria, for more information). All travelers should protect themselves by using mosquito precautions (see Chapter 2, Protection against Mosquitoes, Ticks & Other Arthropods).

CHIKUNGUNYA

Chikungunya was reintroduced into Cambodia in 2011, and a large outbreak occurred in southeastern Cambodia in March 2012. Travelers can protect themselves by preventing mosquito bites (see Chapter 4, Chikungunya for additional details).

ZIKA VIRUS

Zika virus in Cambodia was first detected in 2010. Since this time, sporadic cases have been identified retrospectively. Zika can be sexually transmitted from a person who has Zika to his or her sex partners, even while they are not symptomatic (see Chapter 3, Zika for additional details). Because Zika infection in pregnant women can cause serious birth defects, women who are pregnant should not travel to Cambodia. Travelers should consult the CDC Travelers’ Health website for the most current recommendations for Zika.

SCHISTOSOMIASIS

Liver flukes, such as Schistosoma mekongi, are found in the Mekong River basin from the border of Laos to Kratie Province in Cambodia, where the freshwater dolphins attract tourists. Swimming in natural freshwater settings such as lakes, rivers, and ponds should be avoided (see Chapter 4, Schistosomiasis).

SNAKEBITES

At least 17 known venomous snake species are found in Cambodia; therefore, travelers should use precautions to avoid snakebites. A snakebite is a medical emergency, and a bitten traveler needs immediate treatment; effective antivenom is available only in some international hospitals, including the Royal Angkor International Hospital in Siem Reap and the Calmette Hospital in Phnom Penh (see Chapter 3, Animal-Associated Hazards). Traditional medicine (thnam boran) is popular in rural Cambodia but should not be used to treat snakebites because it often causes increased harm and delays effective treatment.

TRANSPORTATION

Motor vehicle crashes are the leading cause of death in Cambodia, and deaths related to traffic accidents have doubled since 2005.The most common means of transport in Cambodia is motorbike, and although both drivers and passengers are required to wear helmets, this law is infrequently followed or enforced. Travelers should always wear a helmet when on a motorbike. In addition to the ever-growing number of cars and motorbikes, there is lax enforcement of traffic laws and scant understanding of rules of the road. Travelers should carefully look in every direction before crossing the street. In cities and at the Angkor temple complex, most travelers use tuk-tuks (usually 3-wheeled motorbikes), which are readily available, or hire cars with a driver guide. The fare should be negotiated at the outset. It is increasingly common to rent bicycles to get around the cities and the Angkor temple complex. If renting a bicycle, travelers must be forewarned to yield to motorized traffic and use extreme caution. Six national highways link Cambodia’s capital city, Phnom Penh, to other cities and beach resorts. During the rainy season, road conditions deteriorate rapidly, and travel after dark on the highways is discouraged. Intoxicated drivers are common during the evening hours, and tourists should stay off the road at night if possible. Travelers should avoid traveling by boat because safety equipment may be lacking, and boats are often overcrowded.

SAFETY

Travelers should be alert at all times and use common-sense measures such as not walking or traveling alone at night. Travelers are also advised to only carry what they are willing to lose. The most common type of theft is “snatch and grab” robbery. Travelers should keep belongings out of sight if traveling via tuk-tuk, and carry items and bags away from the street side while walking.

LAND MINES

Although the areas around the Angkor temple complex and major towns have been cleared, land mines and unexploded ordnance from the decades of conflict are still found in rural areas in Cambodia, including Battambang, Banteay Meanchey, Pursat, Siem Reap, and Kampong Thom provinces. Travelers to those areas should exercise caution, especially when venturing out to the more remote temples and forest, by staying on roads and paths and using a guide with knowledge of local hazards. Travelers should not touch anything resembling a mine or unexploded ordnance. If these items are observed, the Cambodia Mine Action Centre should be notified.

COUNTERFEIT DRUGS

Local pharmacies provide a limited number of prescription and over-the-counter medications, but because the quality of locally obtained medications can vary greatly, travelers should bring an adequate supply of medications. Counterfeit drugs are commonly found and often indiscernible from authentic medication (see Chapter 6, Perspectives: Avoiding Poorly Regulated Medicines and Medical Products During Travel). If needed, medications should only be purchased from licensed pharmacies, which can be recognized easily by a green cup-and-snake sign.

CLIMATE

Cambodia has a tropical climate and is generally hot and humid throughout the year. The hottest months are March through May, but heat precautions should be taken year-round when exploring the temples or visiting other tourist areas. Travelers should stay hydrated, especially during midday. Many travelers explore the temples in the early mornings and late afternoon, taking a midday break in the comfort of an air-conditioned restaurant. Rainy season is from late April or early May through October. During this time, risk of vectorborne disease transmission increases.

MEDICAL CARE

Medical facilities in Cambodia do not meet international standards. A few internationally run clinics and hospitals in Siem Reap and Phnom Penh can provide basic medical care and stabilization. Some information on health facilities and pharmacies in Cambodia can be found on the website for the US embassy in Phnom Penh. For anything other than basic care and stabilization, travelers should seek medical care in Bangkok or Singapore. For this reason, travel health insurance that includes medical evacuation insurance should be strongly considered.

BIBLIOGRAPHY

1. Cambodia Ministry of Tourism, Tourism Statistics Report — Executive Summary Report in March 2017. Ministry of Tourism; 2017 [cited 2017 June 15]. Available from: http://www.tourismcambodia.org/images/mot/statistic_reports/Executive%20Summary%20Report%20in%20March%202017.pdf
2. CDC. Chikungunya outbreak—Cambodia, February–March 2012. MMWR Morb Mortal Wkly Rep. 2012 Sep 21; 61:737–40.
3. Embassy of the United States, Phnom Penh, Cambodia. Medical assistance in Cambodia. Phnom Penh: US Department of State; 2017 [cited 2017May 2]. Available from: https://kh.usembassy.gov/u-s-citizen-services/local-resources-of-u-s-citizens/doctors/   
4. Ly S, Buchy P, Heng NY, Ong S, Chhor N, Bourhy H, et al. Rabies situation in Cambodia. PLoS Negl Trop Dis. 2009;3(9):e511.
5. US Department of State. Cambodia country-specific information. Washington, DC: US Department of State; 2016 [cited 2017 May 5]. Available from: http://travel.state.gov/content/passports/en/country/cambodia.html
6. World Health Organization. Cambodia. In: World Malaria Report, 2016. Geneva: World Health Organization; 2016 [cited 2017 May 5]. Available from: http://www.who.int/malaria/publications/world-malaria-report-2016/report/en/