Yellow Fever is a serious and sometimes fatal viral disease that is spread by mosquitoes in tropical parts of Africa and South America. It occurs in both jungle and urban environments and is particularly common in the rainy season.

Countries at risk

Yellow fever occurs in tropical parts of South America and sub-Saharan Africa, most commonly West Africa. According to the International health regulation (IHR) it is mandatory to have a valid yellow card as proof of vaccination when travelling to endemic countries. The list of countries is updated regularly. Failure to provide a valid certificate can lead to a traveller being quarantined, immunized or denied entry.

Travel precautions

Yellow fever is transmitted by mosquitoes in rural and urban areas. The risk of exposure is influenced by individual factors: the destination, travel itinerary, length of stay and personal protective measures against mosquitoes.

Prevention

Yellow Fever is preventable by vaccination. Travellers to areas at risk may require a single dose injection of Stamaril.

Hepatitis A is a viral infection affecting the liver and thus causing jaundice. It is spread by contact with contaminated food and water and is endemic in most tropical areas in the world. According to the World Health Organisation, there are an estimated 1.5 million new cases of illness due to hepatitis A each year worldwide.

Countries at risk

Hepatitis A occurs worldwide but is more common in parts of Africa, Asia, Central and South America and more specifically in areas where sanitation may be poor. For most travellers exposure to hepatitis A is from eating contaminated food or water. This is a risk even in up market hotels where the food handlers may carry the virus.

Signs and symptoms

The onset of the disease may e long after the exposure (weeks and rarely months). Fever, muscle ache, nausea, vomiting, diarrhoea, weight loss, loss of appetite, abdominal pain and yellow skin and eyes are all common signs and symptoms of hepatitis A. The severity of the disease differ from person to person and is usually mild in children.

Travel precautions

The most important way to avoid the disease is by eating and drinking the right way. With a few basic rules many food borne illnesses may be avoided. Water: stick to bottled water from a trusted source even for ice and tooth brushing. Eat hot foods freshly prepared and still hot >65⁰ Celsius. Only eat fruit you can peel. Wash hands regularly and thoroughly.

Prevention

Hepatitis A is a vaccine preventable disease and the available vaccines are very effective.

Typhoid fever is caused by a bacterium of the salmonella group. It can affect multiple organs and may be fatal. It causes outbreaks especially in the rainy season.

Countries at risk

Typhoid fever is mostly found in areas where standards of personal and food hygiene are low and sanitation is lacking. The disease is widespread in South Asia and parts of South-East Asia, the Middle East, Central and South America, and Africa. Outbreaks of typhoid have also been reported from countries in Eastern Europe including Kyrgyzstan, Tajikistan, Ukraine and Russia.

Signs and symptoms

Signs and symptoms may include mild fever and headache, muscle aches, chills, nausea, loss of appetite. It can also cause abdominal discomfort, constipation and or diarrhoea.

Treatment

Antibiotic therapy and general medical support may be required; however some strains of typhoid are becoming increasingly resistant to antibiotics, especially in Southeast Asia.

Travel precautions

The most important way to avoid the disease is by eating and drinking the right way. With a few basic rules many food borne illnesses may be avoided. Water: stick to bottled water from a trusted source even for ice and tooth brushing. Eat hot foods freshly prepared and still hot >65⁰ Celsius. Only eat fruit you can peel. Wash hands regularly and thoroughly

Prevention

Typhoid fever is vaccine preventable and is commonly given with Hepatitis A as a single injection.

Polio Poliomyelitisis potentially life threatening acute viral infection that is spread from person to person which may lead to permanent damage to the nerves leading to paralysis of arms and legs. It is still endemic in certain countries in Africa. In South Africa the immunization is part of the public and private immunization schedules.

Prevention

A booster is recommended to all adults travelling to countries with a risk of transmission. (Usually given as a 4 in 1 injection with tetanus, diphtheria and pertussis).

Current situation

Although polio is thought to be extinct by most people (including South Africans) there are still countries with circulating Wild Polio Virus (WPW) and could not be declared polio free by the World health organization (WHO). One of these countries (Somalia) has now caused an outbreak of WPW-1 in the horn of Africa that could potentially affect millions of adults and children.

With the famine political unrest in Somalia there is cross border travel and refugee camps in Kenya and other neighbouring countries causing cross border spread of the disease.

It is recommended to all travellers to be up to date with their immunizations but especially if visiting Somalia, Kenya, and surrounding countries of Djibouti, Ethiopia, South Sudan, Uganda and Tanzania.

What can travellers do to prevent polio?

(References available on request)

  • Ask your travel health practitioner to find out if you are up-to-date with your polio vaccination and whether you need a booster dose before travelling. Even if you were vaccinated as a child or have been sick with polio before, you may need a booster shot to make sure that you are protected.
  • Make sure children are vaccinated.
  • Food that is cooked and served hot
  • Hard-cooked eggs
  • Fruits and vegetables you have washed in clean water or peeled yourself
  • Pasteurized dairy products
  • Food served at room temperature
  • Food from street vendors
  • Raw or soft-cooked (runny) eggs
  • Raw or undercooked (rare) meat or fish
  • Unwashed or unpeeled raw fruits and vegetables
  • Peelings from fruit or vegetables
  • Condiments (such as salsa) made with fresh ingredients
  • Salads
  • Unpasteurized dairy products
  • ”Bushmeat” (monkeys, bats, or other wild game)
  • Bottled water that is sealed (carbonated is safer)
  • Water that has been disinfected (boiled, filtered, treated)
  • Ice made with bottled or disinfected water
  • Carbonated drinks
  • Hot coffee or tea
  • Pasteurized milk
  • Tap or well water
  • Ice made with tap or well water
  • Drinks made with tap or well water (such as reconstituted juice)
  • Flavored ice and popsicles
  • Unpasteurized milk
  • Wash your hands often.
  • If soap and water aren’t available, clean hands with hand sanitizer (containing at least 60% alcohol).
  • Don’t touch your eyes, nose, or mouth. If you need to touch your face, make sure your hands are clean.
  • Cover your mouth and nose with a tissue or your sleeve (not your hands) when coughing or sneezing.
  • Try to avoid close contact, such as kissing, hugging, or sharing eating utensils or cups with people who are sick.
  • Tetanus is caused by a bacterium Clostridium Tetani that produces a toxin causing muscle spasm (locked jaw). Any break in skin can introduce the bacterium (cuts, bruises, puncture wounds, bite marks). The disease is not seen very often in South Africa because of good vaccine coverage.

    Prevention

    Tetanus immunization is part of the childhood immunizations and most adults travellers only need a booster (Usually given as a 4 in 1 injection with polio, diphtheria and pertussis).

    Pertussis (whooping cough) As the name suggest the disease is marked by coughing paroxysms followed by a sudden inspiration (whoop) but the classical picture is not seen in young infants and adults. In babies it can cause apnoea (interruption of breathing) and sudden death. In adults it is usually only marked by a persistent dry cough (up to 48 days).

    Prevention

    As the immunity after the childhood immunization weans over time there still a risk in all adults even if all childhood immunizations are up to date. Protection is needed especially in those who has contact with small babies (grandmothers and –fathers, mothers and fathers, brothers and sisters) to prevent pertussis in small infants (cocoon effect). A booster is thus recommended to all adults. (Usually given as a 4 in 1 injection with tetanus, diphtheria and polio).

    Diphtheria is a bacterial infection characterized by a pseudo membranous pharingitis (inflammation of the throat with a white –grey membrane). Although it can occur throughout the word, immunization programs have to a large extent eliminated the disease.

    Prevention

    Although this is a rare disease in travellers a booster is usually given with tetanus, pertussis, and polio.

    Meningitis (Meningococcal Meningitis) is a serious potentially fatal bacterial infection of the meningis (linings of the brain). It can affect any person at any stage but some types causes outbreaks in crowded spaces or places where close contact is unavoidable (dormitories).

    Countries at risk

    Meningitis occurs worldwide, but outbreaks is more common in the meningitis belt of sub-Saharan Africa.

    Risk for travellers

    Risk for travellers is highest towards the end of the dry season when the disease spreads rapidly, resulting in large outbreaks within very short periods. Meningitis is spread through coughing, sneezing and close contact with an infected person. All Hajj and Umrah pilgrims are required to show certification of vaccination on arrival in Saudi Arabia.

    Signs and symptoms

    Symptoms can appear suddenly and include severe headache, fever, stiff neck, sensitivity to bright light, vomiting, muscle and joint pain, sleepiness, confusion, seizures and loss of consciousness. Babies, children and adolescents are particularly at risk. Symptoms may be hard to identify in babies and young children, who may exhibit the following signs: refusing feeds, unusual crying or moaning, irritability, listlessness, unresponsiveness, jerky movements or becoming stiff or floppy and very rapid breathing. Blood poisoning caused by meningitis can cause a red, purplish rash that does not fade when pressure is applied.

    Treatment

    Meningitis is a medical emergency requiring urgent hospital treatment, as blood poisoning can develop rapidly. Treatment includes intravenous antibiotics.

    Prevention

    A single immunization every three years.

    Hepatitis B is a viral infection affecting the liver. It is spread through bodily fluids, needles and other sharp objects (tattooing, shaving of hair with shared shavers and piercings) and can also be spread sexually. Hepatitis B is 100 times more infectious than HIV.

    Countries at risk

    Hepatitis B occurs worldwide. Areas where there is a higher risk of exposure to Hepatitis B include Eastern Europe, Russia, India, China, South and Central America, Africa, South East Asia and many south pacific islands.

    Signs and symptoms

    The signs and symptoms of Hepatitis B include mild fever, gastro-intestinal upset, nausea and vomiting, diarrhoea and abdominal pain, yellow skin and eyes.

    Travel precautions

    If you are a tourist or short-term traveller, your risk is low. However, risk is linked to behaviour - any activity causing contact with blood or body fluids can put you at risk. Travellers may be exposed when receiving medical or dental treatment while abroad. Travellers can also become infected via sexual intercourse, needle sharing, blood transfusions and injections. Tattooing, body piercing and acupuncture are other ways in which the virus may be spread.

    Prevention

    Hepatitis B is a vaccine preventable disease. In South Africa Hepatitis B is part of the immunizations given to children. A Booster is recommended to all travellers (especially those with high risk behaviours.

    Rabies s an invariably fatal disease characterized by encephalitis (infection of the brain). Rabies can only be prevented by the correct immunization and treatment of exposure and there is currently no treatment for rabies.

    Countries at risk

    Rabies occurs in all continents except Antarctica and New Zeeland. Over 15 million people are exposed to potentially rabid animals annually with approximately 40,000 to 70,000 deaths every year.

    Travel precautions

    The rabies virus is spread by infected mammals by their bite, scratch or a lick on to broken skin. All mammals are susceptible to the virus including skunks, jackals, mongooses, foxes and raccoons, dogs, cats, monkeys and bats. Dogs account for the majority of human deaths, with the majority of these occurring in the Indian subcontinent, Asia and Africa.

    Bilharzia is a parasitic worm infection that is acquired by skin contact with infested fresh water. Fresh water snails release microscopic infective parasites into the water that penetrate skin on contact. The snails usually live on weed and stones near the surface of water - but not exclusively. Currents can spread the parasites to areas well away from the contaminated water. It causes different clinical illnesses, most commonly blood in urine (haematuria).

    Recommendations for travellers:

    Do's

  • Avoid activities in affected regions that may involve direct water contact , this includes paddling, swimming, diving, snorkelling, rafting, canoeing, water etc. (even standing in water is not advised).
  • Swim only in chlorinated swimming pools or safe sea water in affected areas.
  • Check to ensure water facilities (showers, baths etc) at accommodation/recreational facilities are safe (many hotels/facilities draw water directly from nearby lakes, untreated this water can transmit schistosomiasis).
  • Avoid drinking tap water when travellin, stick to bottled or boiled water instead.
  • Don't's

  • Rely on other travellers/locals to inform you if a water source is infected or not – try and find out from an official/reliable source.
  • Use insect repellent to prevent infection. There is no evidence that this works and most repellent is water-soluble and so will simply wash off.
  • Rely on vigorous towel drying of skin after water contact – there is no reliable evidence to prove that this works.
  • Buy treatment for schistosomiasis overseas. This is often sold in resorts and is either counterfeit, taken at the wrong dose or taken too early to cure infection – the drug only works when taken 8 weeks after exposure.
  • Malaria prophylaxis: to take or not to take?

    Many travelers do not take malaria prophylaxis because they believe that the symptoms will be hidden and thus the disease will not be diagnosed in time. This is not true.

    The current recommended malaria prophylaxis actually kills the malaria parasite before it enters the liver (before getting ill). If taken correctly the efficacy ranges between 90% and 98%. In combination with mosquito avoidance measures this can be as high as 100%.

    Depending on what you plan to do (camping/outdoors vs. corporate travel) a suitable option can be prescribed offering piece of mind and making it possible to enjoy your holiday. Remember that most malaria areas do not offer nearby medical services and one should take the distance to the nearest medical help into consideration.

    Side effects are a real concern and it should be discussed with someone with experience in travel health. It differs from medication to medication and most people should be able to take one type of medication. It is wise to drink the medication before departing to see if the side effects are unbearable.

    Many tourist routes have a risk of malaria. At the Heidelberg travel clinic the risk can be calculated for each individual traveler.

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