Pla ra - liver flukes

[randymarsh]

Mentioned in another thread I've been living off pla ra for 2 years in isaan (every type of tam you can imagine, sometimes 2 or 3 a day) without ever googling it to know it kills you.

 

For the last month I've had pain in gallbladder area, nothing severe but general ache, occasional twisting feeling.  Could be completely unrelated and probably is.  Did have an abdomen ultrasound and nothing found.

 

However, 2 years of pla ra is making me think as a precaution I should take praziquantel just in case.  

 

On the dosage, it seems 20mg per kilo of body weight 3 times a day.  I'm 88 kilos, so 1,760mg x 3.  They come in 600mg pills, so this is 9 pills in a day?  Seems a lot and don't want to get this wrong and kill myself.  Some of my gfs family self medicate every 3 months, I assume with praziquantel, and there's no way they take that many in a day...

 

Final thing and I might be mocked for this by all the farang who dismiss isaan food and have continued to eat only pie and chips since moving to Thailand but it is ingrained in daily life here and has become so for me too.  Is there no hope?  Do I have to stop completely, alienating myself from the entire isaan population and being generally depressed at not being able to eat som tam, and all the other amazing food pla ra is used for.  Or do I just make sure it's properly prepared?  I hear fermented for 12 months minimum is safe and no raw fish floating about.  There is no way to know the history of this stuff, especially from food stands outdoors but can I source clean stuff for home use?  How about the bottles that are sold in places like tesco, although not as tasty, I suppose it's worth a compromise for safety.

 

Thanks!

[Sheryl]

The dose for liver fluke is indeed 25 mg/kg 3 times a day for 2 days. So yes, 3 tablets 3 times a day.

 

It is taken in a much lower dose for intestinal worms, but this is the liver fluke dosage.

 

You should really stop eating that stuff.  In addition to liver fluke it can transmit Hepatitis.

[randymarsh]

Thanks.... would.you say it's worth taking it for 'just in case' measures?

 

Is it generally well tolerated?  

[GroveHillWanderer]

As far as I know, many Thais are aware of the dangers of eating uncooked pla ra and many of them, especially the younger, better-educated ones, now only use it if it has been cooked properly (boiled, basically). Despite the old perception that uncooked pla ra tasted better, I remember reading an article where blind taste tests conducted by a doctor doing research into the health risks associated with its consumption, found that the tastes of the cooked and uncooked varieties are indistinguishable. 

[randymarsh]

So as long as I keep on the cooked stuff and I always ask first, I should be ok?

[Sheryl]

Cooked is fine. But be wary of Thsis telling you what you want to hear rather than what is necessarily true...

[Moonlover]

1 hour ago, GroveHillWanderer said:

As far as I know, many Thais are aware of the dangers of eating uncooked pla ra and many of them, especially the younger, better-educated ones, now only use it if it has been cooked properly (boiled, basically). Despite the old perception that uncooked pla ra tasted better, I remember reading an article where blind taste tests conducted by a doctor doing research into the health risks associated with its consumption, found that the tastes of the cooked and uncooked varieties are indistinguishable. 

It is certainly true that Thais are aware of the dangers. There is an education program on this very topic that takes the message out to rural areas and they have programmes in regional hospitals. Our moo baan nurse arranged for residents to attend such a lecture at the government hospital, followed by stool analysis and treatment for any that needed it.

 

But old habits die hard in rural Thailand. One of the folk law rumours is that if you drink Lao Khao with your pla ra, you will kill off the parasite. Phew, what a way to treat your liver. No wonder so many meet with an early death due to renal failure!

 

Back to the OP's queries and not withstanding the local's advice on medication, as I mentioned above you can arrange to have a stool sample analyzed to detect whether you have been infected. Personally, I wouldn't go for self medication without evidence that you are, in fact, infected. That was the advice that my wife and others received during the lecture.

 

Another factor is that you can carry infection for very long periods, twenty to thirty 30 years was quoted without any noticable symptoms, so it is possible the your symptoms, OP, are something unrelated.

 

And I certainly agree with Sheryl's last paragraph. ''You should really stop eating that stuff. In addition to liver fluke it can transmit Hepatitis''. Why take chances with your health? You can enjoy good Issan food without risking your health.

 

 

 

 

[cooked]

56 minutes ago, randymarsh said:

So as long as I keep on the cooked stuff and I always ask first, I should be ok?

Or you can make it yourself.http://tesathome.com/2015/08/25/how-to-make-pla-ra-padaek/

[randymarsh]

There isn't too much isaan stuff that doesn't use pla ra...

 

I just went to the biggest facino pharmacy around and they no longer hold praziquantel.  They offered me Albendazole instead which has to be taken for 7 days based on drugs.com although pharmacist told me only to take for 2 days.  Also isn't the drug of choice for flukes

 

Usual Adult Dose for Clornorchis sinensis (Liver Fluke)

US CDC recommendations: 10 mg/kg/day orally for 7 days

Comments: Recommended as alternative therapy

 

 

Any ideas of praziquantel is still available?  Seems crazy that it wouldn't be.

 

And on the advice to get tested first, I think I will do.  2 days on praziquantel would have been ok but I'm not taking some random pill for 7 days when it might be for nothing. 

[Moonlover]

I'm coming back in on this, because I've just spotted an anomoly and I'm not sure whether we're on the same page here. OP, you referred to the dish you eat as pla ra. Well, in connection with liver fluke, this doesn't make sense. Pla ra is fermented fish sauce, usually at least six months old. The fish is cooked at the beginning of the proccess.

 

The dish that contains liver fluke is called koi plaa, a salad included finely chopped small fish. If the fish used is not cooked, as is the traditional way, it is potentially dangerous. (My Issan wife is confirming this as I type by the way)

 

Now as I mentioned earlier, my wife is well aware of the dangers of this affliction, but she is very happy when eating pla ra. In fact she loves it. So it could just be that you've got yourself a little confused. You might not be at risk at all!

[randymarsh]

As far as I know, 2 different types of pla ra, used when making all types of tam.  One is cooked and one isn't.  There is definitely a risk of liver flukes from pla ra used in tam if it isn't fermented properly (for long enough), is not cooked properly, contains raw fish, is not clean...

 

Some food stands have 2 types of pla ra to choose from, one they claim is cooked and another which has very visible uncooked fish floating in it.  I stay clear of the second option. 

[peterb17]

This is madness- you are consuming food that you think may do you harm. 

The dangers of liver fluke have been known for years- many threads on here. 

 

I personally never ever take any type of drug - it's not some fight against big Pharma ( as many feel)  Obviously if I was really ill I would take the medication. 

 

It reminds me of a friend who constantly took antibiotics ( tetracycline ) - just in case- it's the same here- eat safe food and do not pop pills.

 

Are the from the USA - so many American posters seem obsessed with their 'meds' 

[randymarsh]

6 minutes ago, peterb17 said:

This is madness- you are consuming food that you think may do you harm. 

The dangers of liver fluke have been known for years- many threads on here. 

 

I personally never ever take any type of drug - it's not some fight against big Pharma ( as many feel)  Obviously if I was really ill I would take the medication. 

 

It reminds me of a friend who constantly took antibiotics ( tetracycline ) - just in case- it's the same here- eat safe food and do not pop pills.

 

Are the from the USA - so many American posters seem obsessed with their 'meds' 

 

No, I have been consuming food that I did not know was dangerous until very recently.

 

If left untreated, will cause death in about 20 or 30 years.  So why not self medicate just in case? Lots of Thais do it.  Tell me how exactly it's better to never take any med until it's too late and untreatable?

[Moonlover]

16 minutes ago, randymarsh said:

As far as I know, 2 different types of pla ra, used when making all types of tam.  One is cooked and one isn't.  There is definitely a risk of liver flukes from pla ra used in tam if it isn't fermented properly (for long enough), is not cooked properly, contains raw fish, is not clean...

 

Some food stands have 2 types of pla ra to choose from, one they claim is cooked and another which has very visible uncooked fish floating in it.  I stay clear of the second option. 

This may or may not be true. Personally, following discussion with my knowledgeable wife, I have some doubts about this.

 

None the less, I would certainly stick to my earlier advice about having an analysis if you are concerned, rather than self medicating 'just in case'. 

[randymarsh]

Cheryl can comfirm but definitely a risk from pla ra and my gf has confirmed the same. She no longer buys som tam with the fish floating in.

 

Not to mention the raw crab in tam pu pla ra which again cause flukes.

 

Koi pla is just one of many many isaan meals that will cause flukes as it contains raw fish.  

[Moonlover]

41 minutes ago, randymarsh said:

Cheryl can comfirm but definitely a risk from pla ra and my gf has confirmed the same. She no longer buys som tam with the fish floating in.

 

Not to mention the raw crab in tam pu pla ra which again cause flukes.

 

Koi pla is just one of many many isaan meals that will cause flukes as it contains raw fish.  

You seem to be determined to argue you way into some dreaded disease, no matter what is said. So I'll leave you to get on with it.

 

Good luck.

[randymarsh]

13 minutes ago, Moonlover said:

You seem to be determined to argue you way into some dreaded disease, no matter what is said. So I'll leave you to get on with it.

 

Good luck.

No worries.  Hopefully your wife has learnt something too. 

 

Very alarming that even the Thais who have been educated on these risks believe them to be limited to a single dish.

[Moonlover]

24 minutes ago, randymarsh said:

No worries.  Hopefully your wife has learnt something too. 

 

Very alarming that even the Thais who have been educated on these risks believe them to be limited to a single dish.

I take that as an insult to my wife's intergity, whom I'm quite sure knows a lot more about Thai and Issan food than you do.

 

[Laza 45]

5 hours ago, Sheryl said:

The dose for liver fluke is indeed 25 mg/kg 3 times a day for 2 days. So yes, 3 tablets 3 times a day.

 

It is taken in a much lower dose for intestinal worms, but this is the liver fluke dosage.

 

You should really stop eating that stuff.  In addition to liver fluke it can transmit Hepatitis.

Yep.. if you want to eat som tam.. use fish sauce out of a bottle.. no the smelly crap they smelly  in the market..  there is lots of other Thai food to enjoy... 

 

[randymarsh]

40 minutes ago, Moonlover said:

I take that as an insult to my wife's intergity, whom I'm quite sure knows a lot more about Thai and Issan food than you do.

 

I'm asking my gf more details now.  Pla ra essentially isn't cooked but if it's fermented properly for the correct amount of time, it can sometimes be safe.  At the end of the process, ideally 12 months later, this is where the optional cooking comes into it (adding actual heat).  At this point, sugar, coffee, or more water is added and heated to make the sauce that is used in som tam.  Generally the heated pla ra is used in som tam, the overall ingredients vary the taste meaning some restaurants are more renowned for their tasty pla ra.... but some Thais still prefer the uncooked stuff in their som tam that still has 6 month old dead fish floating about.  Not safe!!

 

[randymarsh]

45 minutes ago, randymarsh said:

I'm asking my gf more details now.  Pla ra essentially isn't cooked but if it's fermented properly for the correct amount of time, it can sometimes be safe.  At the end of the process, ideally 12 months later, this is where the optional cooking comes into it (adding actual heat).  At this point, sugar, coffee, or more water is added and heated to make the sauce that is used in som tam.  Generally the heated pla ra is used in som tam, the overall ingredients vary the taste meaning some restaurants are more renowned for their tasty pla ra.... but some Thais still prefer the uncooked stuff in their som tam that still has 6 month old dead fish floating about.  Not safe!!

 

And happy to be corrected on any this because getting info on anything remotely controversial Thai related from my gf is like blood from a stone.  Plus I'm not completely convinced she knows the full process and its timings and variances. 

[Moonlover]

4 minutes ago, randymarsh said:

And happy to be corrected on any this because getting info on anything remotely controversial Thai related from my gf is like blood from a stone.  Plus I'm not completely convinced she knows the full process and its timings and variances. 

Ok, here goes.

 

The usual fish used in Pla ra, cooked or raw is Snakehead fish or Catfish. Note that both these fish have a smooth, mucas covered skin and, in fact the Catfish is virtually scaleless. Have you ever tried to pick one up? They have evolved that way to facilitate their expeditions across land, which they are both known for.

 

The Liver Fluke's larvae, once it leaves the snail in which it develops seeks a host in the water. Its preferred host is a Cyprinidae. You can look it up if you like, but I'll tell you, it's a large group of fishes that are all scaly. The larvae does not penetrate its host, it slithers under the scales and takes up residence there next to the skin.

 

Because the Catfish and the Snakehead fish, used in Pla ra are smooth skinned, the larvae cannot attach itself to them. Therefore Pla ra is a very unlikely source of liver fluke infection. Do note that the freshwater crabs that you sited. would not be a likely host for the larvae either for similar reasons.

 

The reason why  koi plaa is a threat is because it contains small, uncooked scaly fish, with the larvae still attached to the skin. Cooking the fish first is the recommended way to prevent infection.

 

That's it. It's dinner time and I think Catfish curry is on the menu. Yummy!

[bangkokairportlink]

You should only eat Plara made by someone you know or by family.

 

And you should not eat your Somtam so spicy, or at least it it with bread !

 

 

[bangkokairportlink]

2 hours ago, Moonlover said:

I take that as an insult to my wife's intergity, whom I'm quite sure knows a lot more about Thai and Issan food than you do.

 

 

You are dreaming about what your wife knows, OF COURSE.

She just knows nothing that all the local who need to die of cancer to start thinking that they did something wrong. As the ones who need to die on the road to start thinking that they were not driving safely.

 

 

[Sheryl]

1 hour ago, Moonlover said:

 

Because the Catfish and the Snakehead fish, used in Pla ra are smooth skinned, the larvae cannot attach itself to them. Therefore Pla ra is a very unlikely source of liver fluke infection. Do note that the freshwater crabs that you sited. would not be a likely host for the larvae either for similar reasons.

 

 

"Thais’ love of “pla ra” or raw fish used in somtam, as well as other undercooked foods are responsible for increased rates of worm infections, which can lead to liver cancer. "

https://www.thaivisa.com/forum/topic/981687-somtam-slowly-killing-many-thais-cancer-center-says/

 

"A cross sectional survey on opisthorchiasis was conducted from August to September 1933 in Tambon Nai Muang, Sawankhalok district, Sukhothai Province. The 1,964 villagers were stool examined and it was found that 384 of them had liver fluke infection. Of these 1,608, who were older than 12 years, were interviewed in order to detect potential risk factors of liver fluke infection. The study found that the population at risk were those older than 24 years of age (p < 0.05) and the possible risk factor was eating incomplete cooked fresh water fish (p < 0.05). The food prepared from incomplete cooked fish which was harmful to the villagers were pickle fish so called pla ra (p < 0.05) and papaya salad with pickle fish so called som tam pla ra (p < 0.05)."

https://www.ncbi.nlm.nih.gov/pubmed/10774677

[randymarsh]

1 hour ago, Moonlover said:

Ok, here goes.

 

The usual fish used in Pla ra, cooked or raw is Snakehead fish or Catfish. Note that both these fish have a smooth, mucas covered skin and, in fact the Catfish is virtually scaleless. Have you ever tried to pick one up? They have evolved that way to facilitate their expeditions across land, which they are both known for.

 

The Liver Fluke's larvae, once it leaves the snail in which it develops seeks a host in the water. Its preferred host is a Cyprinidae. You can look it up if you like, but I'll tell you, it's a large group of fishes that are all scaly. The larvae does not penetrate its host, it slithers under the scales and takes up residence there next to the skin.

 

Because the Catfish and the Snakehead fish, used in Pla ra are smooth skinned, the larvae cannot attach itself to them. Therefore Pla ra is a very unlikely source of liver fluke infection. Do note that the freshwater crabs that you sited. would not be a likely host for the larvae either for similar reasons.

 

The reason why  koi plaa is a threat is because it contains small, uncooked scaly fish, with the larvae still attached to the skin. Cooking the fish first is the recommended way to prevent infection.

 

That's it. It's dinner time and I think Catfish curry is on the menu. Yummy!

 

You haven't particularly corrected anything about the process of making the pla ra used in tam; just claimed the fish used can't cause flukes.  Evidence suggests it does (if not cooked).

 

[Dumbastheycome]

9 hours ago, Sheryl said:

The dose for liver fluke is indeed 25 mg/kg 3 times a day for 2 days. So yes, 3 tablets 3 times a day.

 

It is taken in a much lower dose for intestinal worms, but this is the liver fluke dosage.

 

You should really stop eating that stuff.  In addition to liver fluke it can transmit Hepatitis.

Recently there  a warning  from  Thai  Health  about the  long term risk of  consuming local fish sauce due to the  fact that the parasitic and other infections of the liver  areapparently involved in the  alarming  percentage of liver cancer deaths  in the  Issan  area. 

The commercial  brands  in Tesco  etc  are a  different safer kettle  of  fish  altogether!

[Moonlover]

1 hour ago, bangkokairportlink said:

 

You are dreaming about what your wife knows, OF COURSE.

She just knows nothing that all the local who need to die of cancer to start thinking that they did something wrong. As the ones who need to die on the road to start thinking that they were not driving safely.

 

 

Both of my wife's brothers died of liver cancer. quite recently. Believe me she has studied the cause  of liver fluke very thoroughly indeed! 

[kickstart]

32 minutes ago, randymarsh said:

 

You haven't particularly corrected anything about the process of making the pla ra used in tam; just claimed the fish used can't cause flukes.  Evidence suggests it does (if not cooked).

 

3

Haveing  worked with cattle  and sheep for a lot of years ,in farang land  and here in Thailand , liver fluke is mainly a disease of cattle and sheep , cattle and sheep get infected   by grazing waterlogged pasture   ,the  host liver fluke  snail  live in  wet conditions, as for  it spreading  to  fish  in large quantities  to cause  liver fluke, I would say the odds on would be small.

. My wife  needless to say  eats Pla ra ,and  most of the Pla ra she buys  has no  Catfish  or  Snake head  fish in it, with Snake Head fish selling at 100 baht/Kg to expensive ,ok may be some  smaller  one  get in , most Pla ra is made of  Blar-Soi, a plentiful  small fish that is  cheap , this, by the way,  is central   Thailand .

[Dumbastheycome]

25 minutes ago, kickstart said:

Haveing  worked with cattle  and sheep for a lot of years ,in farang land  and here in Thailand , liver fluke is mainly a disease of cattle and sheep , cattle and sheep get infected   by grazing waterlogged pasture   ,the  host liver fluke  snail  live in  wet conditions, as for  it spreading  to  fish  in large quantities  to cause  liver fluke, I would say the odds on would be small.

. My wife  needless to say  eats Pla ra ,and  most of the Pla ra she buys  has no  Catfish  or  Snake head  fish in it, with Snake Head fish selling at 100 baht/Kg to expensive ,ok may be some  smaller  one  get in , most Pla ra is made of  Blar-Soi, a plentiful  small fish that is  cheap , this, by the way,  is central   Thailand .

The host snail live in  wet  conditions.

The  fish live where? Any  species !