Vaccinations

Jules Eden, travel medicine specialist xxx and founder of e-med, answers travellers' questions - as published in the following national publications

• The Guardian
• Independent On Sunday and/or
• Geographical Magazine

Q. I'm going SCUBA diving in Egypt in 2 weeks time and people have mentioned that I should have a Hepatitis A vaccination. What is this illness and when should I get immunised?

A. Your friends are right. Egypt is one of the countries that vaccination against this disease is recommended.

Hepatitis A is a condition where the liver becomes inflammed because of contraction of the virus that causes the illness.

It is related to the other viruses that cause Hepatitis B and C, but is fortunately less severe a condition. The virus is found in contaminated foods and water especially around resorts where sewage may infect local fish and drinking water.

Once contracted the early symptoms are a fever, joint pains, and rather bizarrely, smokers suddenly finding their cigarettes distasteful. As the condition progresses the cardinal sign of jaundice appears. This is where the skin and whites of the eyes take on a lemon yellow hue, something your friends will notice before you, and there may be a delay in recognition if you have worked up a nice suntan.

Hepatitis A is what they call a self limiting condition, it'll get better by itself, but whilst you wait for this then anything that puts a strain on the liver has to be stopped, especially alcohol. Recovery can take from 3 months to a year to occur.

Very rarely it is fatal and that is why doctors insist that you get a shot to prevent you from getting the disease.

Immunisation is simple. One injection will give you a years immunity. It takes 2 weeks for the vaccination to become effective so you had better get it soon. If you have left it too late for this shot then there is another available that works immediately but only gives you 3 months cover. It is called gammaglobulin and used to be the only vaccination available until the latest one year one.

The other good news for needle phobics is that if you have your Hep. A booster within one year of the first shot then the resulting immunity lasts for another 10 years.

Do make a note of when you had the shots on your Vaccination Certificate as you may be asked to show this when travelling into some countries.

Again if you are travelling to Egypt , make sure your tetanus and polio immunisations are up to date [every 10 years] and sometimes a typhoid vaccination is also needed.
Contact your GP or Practice Nurse for the latest information and they should be able to do the shots too.

Q. I am going caving in South America and my doc is not sure what shots I need. Can you help me out?

A. This is a fairly straightforward question, however there is a little twist which you may find interesting.

The baseline shots to make sure you are always up to date with, even if you are in the UK are tetanus and polio.

What you then need to top up with before going out to South America are typhoid, which comes as a single shot in the arm, or there is an oral version for those who don't like the throbbing arm pain that typhoid immunisations always seems to cause.

The next is Hepatitis A, a single injection giving you a years immunity, another shot after 6 months increasing your immunity to 10 years.

You are also advised that South America carries a risk of Yellow Fever, a viral disease spread by forest dwelling mosquitoes, and in many countries it is mandatory that you have a certificate of immunisation against this illness before you enter the country. Yellow fever has recently been spreading into more urban parts of this continent, because human habitation has sadly moved into forested areas, and also the mosquito has been making tracks into areas where it was never found before.

The debate though is whether you need to have a rabies shot. This will not prevent you from getting the disease if you are bitten, but means that if you are you will not need to find the immunoglobulin, which can be very scarce in many parts of South America. You will still need to have a course of rabies injections if you are bitten by a suspect animal but these are easier to get.

So, what are the risks of getting into contact with a rabies carrying animal?

Well, normally its fairly rare, but one species that does carry the rabies virus is the bat. The virus can also be present in the excreta of the bat, which is found on the floor of the large caves where they roost during the day. It has been stated that there is a theoretical risk of contracting rabies if this excreta is inhaled. So if you are caving there is a fair chance that this may happen to you, so I would also recommend that you have a rabies shot too.

The best way to prevent inhaling rabies laden bat excreta is to wear one of those masks that cyclists wear in polluted cities. Likewise I would always ask any local guides what the current information is on the bat colonies that live in the caves you are about to go deep into as they will be far better informed than most other sources.

Finally, don't forget your malaria medication and also a good secure mosquito net.

If you are caving in remote areas you are entering Vampire bat and also Cone-nosed bug territory. We all know about the former, and the latter is the vector that spreads Chagas' disease. So remember a mossie net is not just for keeping off mosquitoes, but all the other biting bugs bats and animals that would cause most travellers sleepless nights as they lie in fear of what will drop onto their heads at night from the ceiling of their hotel room.

Q. My girlfriend and I are travelling to India to work as Diving Instructors for up to twelve months from the end of December 2003.

We have both had jabs for various conditions within the last 5 years. As far as I can remember we've had, Polio, Tetanus, Hep A+B combined, Typhoid, Diptheria, Meningitis. I had all three Rabies jabs but my partner only had two. Would you mind letting us know what we are missing please.

Secondly we are having difficulty getting information regarding Malaria tablets and which are recomended for divers. Also we have heard that some Malaria tablets have antibiotic properties and we are concerned about the effect this may have on the performance of the oral contraceptive my partner takes (Cilest).

We would appreciate your advice on these questions and thank you in advance for your time.

A. I think you both have had more pricks than Mrs Tiggywinkle. You have had the lot for India. The only thing is how out of date some might be after you have had them. Tetanus is 10 yearly, typhoid 2 to 3 yearly. The Heps should be good for 10 years if you had the boosters before the 12 month run off period after the shots.

That leaves the rabies really. This is necessary if you are both in the remote wilds of India. However if you are in the dive zone then I guess that you are in Goa where local hospitals will have all the proper rabies shots if you were bitten by a mad salivating dog.

So you probably don't need that shot any more. Forget meningitis for India, you will be safe there.

Malaria is the big question. You have 3 or 4 options. One is mefloquine, but that will make you barmy at times. Best to go for malarone in the short term. But this is expensive as it has to be taken daily and is not off-patent yet. As you are there for a whole year you are best off with the combination of paludrine and chloroquine. The former daily, the latter weekly. Go for that , but remember that not getting malaria is more than just taking tablets. Long sleeved shirts, mossie nets and repellant are needed too. You could always just keep wearing your wetsuits all night fortotal protection.

For the latest info on all vaccines and anti-malarial shots for any country in the world, we have a form for this on the Travel Pages of the e-med. Fill it in and you get the complete breakdown of what's needed.

And if you're off to Cancun then don't forget to leave that part of your brain responsible for "aesthestic taste" behind and meet it in Tulum.

Would inoculations be wise or necessary as my fiancée is quite prone to insect bites.

What would you recommend?

A. West Nile Virus appeared last year on the Upper Eastern seaboard of the US.

It caused many cases of infection but thankfully only a handful of fatalities. It is a virus originating in birds but then transferred to humans via mosquito bites.

Since it's appearance last year the Federal Agencies responsible for it's eradication have worked hard to kill off the mosquitoes that spread the infection, including spraying insecticide across parts of New York and advising people on how to stop the insect breeding by not letting any water stagnate near human habitation.

This has been very successful, and there have been a lot fewer cases since then..

There are no inoculations for this illness at present, and in reality you or your fiancée don't really need them. This is because the virus normally only causes a mild flu like illness, which passes in a few days. The people who are most at risk are the elderly and those who already have other serious medical problems. Infact of the 4 deaths in New York last year, the average age was 82 and they all had other conditions too.

Rarely West Nile can cause an encephalitis, this is an inflammation around the brain that needs steroids to control the symptoms. New Yorkers are told to look out for any flu like illness that then leads on into a severe unremitting headache and neck stiffness. It is then possible to diagnose the infection with a blood test, but there is no immediate cure, just supportive measures until your own immune system has beaten the infection.

Of course it's not much fun being bitten by bugs when you're away anyway. Your fiancée should take all the usual protective measures if she is prone to attack.. I suggest she buy a local insect repellent, which always seem to work better than imported ones, to spray on any exposed areas. If you are in a bug infested area, like a swamp or still creek then wear long sleeved shirts and long trousers especially at dusk when the bugs are hungrier. Another travellers trick is to take a daily Vitamin B12 tablet, or some prefer a clove of garlic a day as this seems to make you less of a tasty meal to these mosquitoes.

Finally, I always take a sedating antihistamine with me , like Piriton as bug bites always seem to itch more at night, and these tablets can stop the itching and help you sleep when taken in the evening.

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A. Travellers who are positive for HIV or infact anyone who is immunosuppressed, such as post transplant patients, should think long and hard as to where they go travelling.

There are a couple of total no-no's when it comes to having shots. Firstly any live bacterial or viral vaccine should be avoided. This means the BCG against TB and the live oral polio vaccine are out. There is an injectable inactivated polio vaccine available and that should be used in preference.

The yellow fever vaccine poses a bit of a dilemma. It is live and viral, however there is a theoretical risk of encephalitis, or swelling of the brain as a side effect if given to an immunosuppressed person. This though has never really been seen. So doctors weigh up the balance of the need to travel to a yellow fever area against your ability to avoid mosquitoes, or the real prevalence of yellow fever in an area. It is unlikely in cities for example.

I suggest you avoid areas where yellow fever and TB are commonly caught, so try to stay out of central Africa and South American jungles, whilst being very careful in India.

Tetanus and typhoid will be fine.

As for other infections like lung, bowel and bladder, take a good stock of antibiotics with you and treat any bugs early and aggressively.

Q. In December, we are flying to Dar Es Salaam and crossing immediately to Zanzibar by ferry for a holiday travelling around the island. I read somewhere that all travellers flying into Dar must have a yellow fever certificate to enter Zanzibar, even if they have just transferred straight form the airport to the port for onward travel by ferry to Stonetown. Can you confirm if this is correct please? And if it is, provide details of the shots needed and the best time to have them.

A. This is correct. Even though you have flown in and transferred to a non yellow fever risk area immediately you still need the shot and the certificate.

It's their rules and we have to abide by them.

However I do think it's a good idea to have a yellow fever shot before going to Zanzibar as of course in Africa at times nothing is guaranteed. I have been holed up in Dar for a while before waiting for ferry crossings to Zanzibar, and of course you are suddenly at risk when waiting.

In my experience many African border crossings are a law unto themselves. Rules can be made up on the spot. So to minimise the risk of being promptly sent back to Dar by a recalcitrant official try to have everything in order. I was once done for the same crime in Uganda. My vaccination cert was in my rucksack merrily rotating on the carousel. This was behind the customs official who wouldn't let me get it unless I could prove my Yellow Fever immunity. Arguments. Impasse. $20 later he let me through to get it to prove me right.

As for the other shots. Get Hepatitis A and typhoid immunisations about 4 weeks before you go.