Main image: Luanda, Angola © Fabian Plock, Shutterstock
People new to exotic travel often worry about tropical diseases, but with the right vaccinations and a sensible attitude to malaria the chances of a serious mishap are small. In fact after malaria, the greatest risk to your health in the African continent are road accidents.
Sadly these are all too common, so be aware and do what you can to reduce risks. Try to travel during daylight hours, always wear a seatbelt and refuse to be driven by anyone who has been drinking. Listen to local advice about areas where violent crime is rife, too.
Since March 2014 there has been an outbreak of the Ebola virus in Liberia and Guinea, and from May 2014 also in Sierra Leone. In June 2016, the WHO declared the end of Ebola virus transmission in Guinea and Liberia. Following this, the countries were under increased surveillance for 90 days to ensure that any new cases were identified rapidly to prevent spread.
The last recorded case of Ebola in Sierra Leone was in January 2016; but like Guinea and Liberia, Sierra Leone remains at heightened risk of small localised outbreaks. Guinea continues to report localised outbreaks as expected, but these are rapidly contained.
Since April 2019 an Ebola outbreak has occurred in the Democratic Republic of the Congo. As of 26 September 2019 there have been 3,175 cases of Ebola, with 3,063 confirmed cases and 2,122 deaths. This gives an overall case fatality rate of 67%.
The risk to travellers continues to be extremely low unless there has been contact with blood or other body fluids from infected people. It is still wise to avoid eating bush meat or handling dead animals during your travels. It is wise to check the FCO updates for information on travel restrictions before travel.
This disease is still common in much of Africa and is highly infectious. For most people the disease is self-limiting, but it can cause serious complications including death. Measles remains a leading cause of death in young children. Two doses of Measles Mumps and Rubella (MMR) vaccine are recommended as part of childhood immunisations. Check to see if you have had these, and, if not and you have no history of disease, then ensure you are vaccinated before you travel. MMR ideally needs to be given four weeks or more either before or after yellow fever, so allow plenty of time.
Don’t think about travelling without a comprehensive medical travel insurance policy: one that will fly you home in an emergency. It is worth testing the company that you pick by posing a scenario and seeing how they respond. Make sure that the policy will cover any activities that you plan to do.
Preparations to ensure a healthy trip to Africa require checks on your immunisation status: it is wise to be up to date on tetanus, polio and diphtheria – now given as an all-in-one vaccine, Revaxis, which lasts for ten years – and MMR (see Measles). Other vaccines that are recommended include hepatitis A and typhoid. Further vaccines that need to be considered include yellow fever, meningococcal meningitis, hepatitis B, rabies and cholera.
Whether or not you need to take the yellow fever vaccine depends on the country you are travelling to, and from which country. There are two reasons for immunising against yellow fever: first to protect against the disease; and, second, as a certificate requirement to gain entry into a particular country. The yellow fever vaccine and its certificate were until recently said to last for ten years. It is now accepted that, for most people, the vaccine offers protection for many decades. As of 11 July 2016, all countries now have to accept that yellow fever vaccine lasts for life, regardless of when it was given. This means that, as long as you have had the yellow fever vaccine and have a certificate, you won’t need to have the vaccine again unless you were immunocompromised or under the age of two at the time it was given. This includes anyone who was pregnant at the time of vaccination. In those cases revaccination is recommended after ten years. If you have not been vaccinated before, then you need to seek specialist advice from a registered yellow fever centre. Whether or not you need the vaccine for health has to be established on an individual basis, determined by the risk of the disease versus the risk to the traveller from having the vaccine. It is extremely unwise to go to countries with a high risk of the disease (eg: West Africa) when you are unable to be vaccinated on medical grounds. The risk of death or serious illness from the disease is too high.
Hepatitis A vaccine (eg: Havrix Monodose, Vaqta or Avaxim) comprises two injections given at least six months apart. The course costs about £120 (but may be available on the NHS), protects for 25 years and can be administered even close to the time of departure. The first dose of hepatitis A vaccine may be protective for up to five years depending on the countries that you intend to visit next. Junior versions of the vaccine can be given to those aged one and over.
Hepatitis B vaccination should be considered for longer trips (two months or more) or for those working with children or in situations where contact with blood is likely. Three injections are needed for the best protection and can be given over a three-week period if time is short for those aged 16 or over. Longer schedules give more sustained protection and are therefore preferred if time allows. Hepatitis A vaccine can also be given as a combination with hepatitis B as ‘Twinrix’, though two doses are needed at least seven days apart to be effective for the hepatitis A component, and three doses are needed for the hepatitis B. Again, this rapid schedule is suitable only for those aged 16 or over. Children aged 1–15 can be vaccinated with a junior version of this vaccine, but the minimum time frame for the three doses is eight weeks. Children aged 1–15 can also be vaccinated with Ambirix, which consists of two doses given 6–12 months apart. One dose gives full protection against hepatitis A and some protection against hepatitis B (though less than Twinrix). Having the second dose completes the course, giving long-term protection against both hepatitis A and hepatitis B. This vaccine is useful for children who are less tolerant of injections and have time for only one dose before travel.
The injectable typhoid vaccines (eg: Typhim Vi, Typherix) last for three years and are about 75% effective. Oral capsules (Vivotif) are also available for those aged 6 and over. Three capsules over five days lasts for approximately three years but may be less effective than the injectable forms as they rely on good patient compliance. Vivotif is also a live vaccine, which is not suitable for everyone. Typhoid vaccine should be encouraged unless the traveller is leaving within a few days for a trip of a week or less, when the vaccine would not be effective in time. Conjugate meningitis vaccine containing strains A, C, W and Y (eg: Nimenrix and Menveo), is ideally recommended for all travellers, and especially for trips of more than four weeks to African countries with a high risk of disease (see Meningitis). Vaccinations for rabies are ideally advised for everyone, but are especially important for travellers visiting more remote areas, especially if you are more than 24 hours from medical help, and definitely if you will be working with animals (see Rabies).
Experts differ over whether a BCG vaccination against tuberculosis (TB) is useful in adults: discuss this with your travel clinic.
Cholera vaccine (Dukoral) may be recommended for travellers who are working in refugee camps, or on trips where they are unable to guarantee a clean supply of water. The disease is more significant in travellers with underlying chronic medical conditions; that said, cholera is actually a rare disease in the western traveller. An oral cholera vaccine (Dukoral) is available which comes as a two-dose schedule for those aged six and over and a three-dose schedule for those aged two to five. All doses must be taken at least one to six weeks apart and should ideally be completed at least one week before travel.
In addition to the various vaccinations recommended above, it is important that travellers should be properly protected against malaria. For detailed advice, see below.
Ideally you should visit your own doctor or a specialist travel clinic to discuss your requirements, if possible at least eight weeks before you plan to travel.
Along with road accidents, malaria poses the single biggest serious threat to the health of travellers in most parts of tropical Africa. It is unwise to travel in malarial parts of Africa whilst pregnant or with very young children unless it is unavoidable: the risk of malaria in many parts is considerable and these travellers are likely to succumb rapidly to the disease. The Anopheles mosquito that transmits the malaria parasite should be assumed to be present at all altitudes below 1,800m.
There is not yet a vaccine against malaria that gives enough protection to be useful to travellers, but there are other ways to avoid it. Since a large part of Africa is very high risk for malaria, travellers must plan their malaria protection properly. Seek current advice on the best anti-malarials to take: usually atovaquone/proguanil (eg: Malarone), doxycycline and sometimes mefloquine. The latter tends to be used for those who are either allergic to other tablets or have used them several times before without ill effect.
In the past, doctors were nervous about prescribing mefloquine to pregnant women, but experience has shown that it is relatively safe and certainly safer than the risk of malaria. If mefloquine is not suitable, then other anti-malaria tablets can be considered. That said, there are other issues, so if you are travelling to Africa whilst pregnant, seek expert advice before departure.
Atovaquone/proguanil (eg: Malarone) is as effective as mefloquine. It has the advantage of having relatively few side effects and need be continued for only one week after returning. However, it is expensive and because of this tends to be reserved for shorter trips. Atovaquone/proguanil may not be suitable for everybody, so advice should be taken from a doctor. The Advisory Committee for Malaria Prevention has advised that it is safe to take atovaquone/proguanil for as long as it is tolerated, ie: far longer than the product licence suggests. There is a paediatric form of the tablet for children under 40kg, and the dose is calculated by body weight.
Another effective alternative is the antibiotic doxycycline (100mg daily). Like atovaquone/proguanil it can be started two days before arrival. Unlike mefloquine it may also be used in travellers with epilepsy, although certain anti-epileptic medication may make it less effective and the dose may need to be increased. In perhaps 1–3% of people there is the possibility of allergic skin reactions developing in sunlight; the drug should be stopped if this happens. It is unsuitable for children under 12 years, in breastfeeding mothers and in pregnant women over 11 weeks’ gestation.
Chloroquine and proguanil are no longer considered to be effective enough for any malarial areas in Africa, but may be considered as a last resort if nothing else is deemed suitable. Pregnant women taking proguanil should take 5mg folic acid at least during the first trimester.
All tablets should be taken with or after the evening meal, washed down with plenty of fluid and, with the exception of atovaquone/proguanil (see above), continued for four weeks after leaving.
Despite all these precautions, it is important to be aware that no anti-malarial drug is 100% protective, although those on prophylactics who are unlucky enough to catch malaria are less likely to get rapidly into serious trouble. In addition to taking anti-malarials, it is important to avoid mosquito bites between dusk and dawn (see Avoiding insect bites).
There is, unfortunately, the occasional traveller who prefers to ‘acquire resistance’ to malaria rather than take preventive tablets, or who takes homeopathic prophylactics thinking these are effective against this killer disease. Homeopathy theory dictates treating like with like. So there is no place for prophylaxis or immunisation in a well person; bone fide homoeopathists do not advocate it. It takes at least 18 months residing in a holoendemic area for someone to get some immunity to malaria, so travellers to Africa will not acquire any effective resistance to malaria. The best way is to prevent malaria in the first place and to take a suitable prophylactic agent.
Malaria: diagnosis and treatment
Even those who take their malaria tablets meticulously and do everything possible to avoid mosquito bites may contract a strain of malaria that is resistant to prophylactic drugs. Untreated malaria is likely to be fatal, but even strains resistant to prophylaxis respond well to prompt treatment. Because of this, your immediate priority upon displaying possible malaria symptoms – including a rapid rise in temperature (over 38°C), and any combination of a headache, flu-like aches and pains, a general sense of disorientation, and possibly even nausea and diarrhoea – is to establish whether you have malaria, ideally by visiting a clinic. From seven days or more into your trip, assume that any high fever over 38°C lasting more than a few hours is malaria regardless of whether you have any other symptoms or not. Also remember that it is still possible to develop malaria several months (technically up to a year) after leaving a malarial area, so make sure that you tell the treating doctor where you have been.
Diagnosing malaria is not easy, which is why consulting a doctor is sensible: there are other dangerous causes of fever in Africa which require different treatments. A negative test does not mean you haven’t got malaria. It takes three negative tests on consecutive days to eliminate the possibility. Other diseases can present like malaria and also need treating, eg: typhoid or paratyphoid, so staying near medical facilities if you are not admitted to start with is important.
Carrying a course of malaria treatment is recommended for all travellers on long overland trips, or those working or volunteering in remote areas, and even those who travel to Africa regularly. Some people advocate taking a rapid diagnostic test kit with them, though these have been shown to be difficult to use by people who are sick or who haven’t had a lot of practice using them. Ideally, you should get to medical help as soon as possible and let those with experience make the diagnosis. With malaria, it is normal enough to go from feeling healthy to having a high fever in the space of a few hours (and it is possible to die from falciparum malaria within 24 hours of the first symptoms). In such circumstances, assume that you have malaria and act accordingly – whatever risks are attached to taking an unnecessary cure are outweighed by the dangers of untreated malaria. Experts differ on the costs and benefits of self-treatment, but it is hard not to agree that treatment may save your life. There is also some division about the best treatment for malaria, but either atovaquone/proguanil (eg: Malarone) or Coarthemeter are the current treatments of choice. Discuss your trip with a specialist ideally before you travel.
As the sun is going down, don long clothes and apply repellent on any exposed flesh. Pack a DEET-based insect repellent – ideally around 50% (roll-ons or sticks are the least messy preparations for travelling) for use on all exposed skin and even some unexposed areas such as under your socks. Insect repellent should be applied after sunscreen, ideally after a 20-minute interval. You also need either a permethrin-impregnated bednet, or a permethrin spray so that you can ‘treat’ bednets in hotels. Permethrin treatment makes even very tatty nets protective and prevents mosquitoes from biting through the impregnated net when you roll against it; it also deters other biters. Otherwise retire to an air-conditioned room, burn mosquito coils or sleep under a fan. Coils and fans reduce rather than eliminate bites. Travel clinics usually sell a good range of nets, treatment kits and repellents. For those who are allergic to DEET, then 20% Icaradin (Picaridin) is a good substitute. Natural repellents containing PMD, eg: Incognito, can be used but are equivalent to about 15% DEET and therefore need to be reapplied every 1–2 hours.
Mosquitoes and many other insects are attracted to light. If you are camping, never put a lamp near the opening of your tent, or you will have a swarm of biters waiting to join you when you retire. In hotel rooms, be aware that the longer your light is on, the greater the number of insects will be sharing your accommodation.
Aside from avoiding mosquito bites between dusk and dawn, which will protect you from elephantiasis and a range of nasty insect-borne viruses, as well as malaria, it is important to take precautions against other insect bites. During the day it is wise to wear long, loose (preferably 100% cotton) clothes if you are pushing through scrubby country; this will keep off ticks and also tsetse and day-biting Aedesmosquitoes which may spread viral fevers, such as dengue fever, zika virus and yellow fever. For those who are particularly tasty to mosquitoes, consider using a clothing spray (eg: EX4) that also contains permethrin and will kill mosquitoes on contact. Impregnating clothing is best done at home before travel. The insecticide will survive for six or so washes and is very effective.
Tsetse flies hurt when they bite and it is said that they are attracted to the colour blue; locals will advise on where they are a problem and where they transmit sleeping sickness.
Minute pestilential biting blackflies spread river blindness in some parts of Africa between 19°N and 17°S; the disease is caught close to fast-flowing rivers since flies breed there and the larvae live in rapids. The flies bite during the day but long trousers tucked into socks will help keep them off. Citronella-based natural repellents (eg: Mosi-guard) do not work against them.
Tumbu flies or putsi, aka mango flies, are a problem where the climate is hot and humid. The adult fly lays her eggs on the soil or on drying laundry, and when the eggs come into contact with human flesh (when you put on clothes or lie on a bed), they hatch and bury themselves under the skin. Here they form a crop of ‘boils’ each with a maggot inside. Smear a little Vaseline over the hole, and they will push their noses out to breathe. It may be possible to squeeze them out, but it depends if they are ready to do so as the larvae have spines that help them to hold on.
In putsi areas either dry your clothes and sheets within a screened house or dry them in direct sunshine until they are crisp, or iron them.
Jiggers or sand fleas are another flesh-feaster which can be best avoided by wearing shoes. They latch on if you walk barefoot in contaminated places and set up home under the skin of the foot, usually at the side of a toenail where they cause a painful, boil-like swelling. They need picking out by a local expert.
Zika virus is a flavivirus, which is similar to dengue and was first reported in 1947 in Uganda. It is spread by the day-biting Aedes mosquito. Most of Africa is not considered high risk for zika virus at the present time; however, countries that are listed as a moderate risk include Angola, Burkina Faso, Burundi, Cameroon, Cape Verde, Central African Republic, Cote D’Ivoire, Gabon, Guinea Bissau, Nigeria, Senegal and Uganda. As the situation of any country may change, travellers are advised to check the link at the end of this section.
The infection is often asymptomatic but, in those with symptoms, the disease is usually mild, with an itchy rash, fever, joint pains and red, sore eyes. Severe disease is uncommon.
Travellers are advised to use DEET-based repellents during the daytime on all exposed skin. In areas where mosquitoes are particularly prevalent, then covering up and using a permethrin spray on clothing is also advised.
Pregnant women need to discuss their travel plans with healthcare professionals and should, wherever possible, cancel the trip if they are going to an area that is reporting zika virus. Women wishing to become pregnant who are travelling to zika virus risk areas should use barrier methods of contraception whilst travelling, and for two months after leaving the affected area. If travelling with their partners, then barrier precautions need to be used during the trip and for three months after leaving. For up-to-date details, follow the link here.
Lassa Fever in Nigeria
Since December 2017 there have been a total of 1,386 cases of suspected Lassa Fever, 365 cases have been confirmed and there have been 114 deaths.
More recently, between 1 January and 10 February 2019, 327 cases of Lassa Fever (324 confirmed) with 72 deaths across 20 states and the Federal Capital Territory have been reported. Most cases were reported from Edo and Ondo. There have been 12 cases among healthcare workers.
The majority of patients are asymptomatic or have mild disease. The remaining 20% have multisystem disease with an overall case fatality of around 1%. This rises to 10–15% in hospitalised patients. However, during epidemics this can rise to 50%.
For most travellers the disease is low risk unless you are living in poor and overcrowded conditions in rural areas. Healthcare workers are at risk if there is a breach in infection control and barrier nursing methods are not maintained.
Travellers who develop symptoms either in country or within 21 days of return should seek medical advice. Symptoms include fever, sore throat, conjunctivitis, muscle pain, retrosternal chest pain, abdominal pain, headache, nausea, vomiting and diarrhoea.
There is no vaccine for Lassa fever but cases have been successfully treated with Ribavirin.
Polio in Nigeria and Somalia
Nigeria and Somalia are two of the countries in the world that has active polio. For travellers intending to spend four weeks or more in either country, proof of vaccination of polio may be required on leaving the country. An International Certificate of Vaccination or Prophylaxis (ICVP) should reflect that polio vaccination has been received within four weeks to 12 months before departure. Failure to produce a certificate may result in vaccination in country. This is most likely to be with oral polio vaccine, which is live and may not be suitable for everyone.
Polio requirements for Egypt
Egypt has recently announced that it requires a certificate of vaccination for polio for travellers arriving into Egypt from the following countries: Afghanistan, Nigeria, Pakistan, Papua New Guinea and Somalia – all these countries have wild polio virus circulating. They may also require a certificate from the Democratic Republic of the Congo, Kenya, Niger and Syria. These countries have vaccine-derived polio virus circulating.
If you are intending to travel from one of these countries into Egypt, please ensure that you have an International Certificate of Vaccine Prophylaxis for polio issued at least four weeks to 12 months before entry.
Protection from the sun
Give some thought to packing suncream. The incidence of skin cancer is rocketing as Caucasians are travelling more and spending more time exposing themselves to the sun. Head for the shade between 11 a.m. and 3 p.m. and, if you must expose yourself to the sun, build up gradually from 20 minutes a day. To avoid burning, cover up in tightly woven clothing that is loose to allow air to circulate and wear a broad-brimmed hat. Be especially careful of exposure in the middle of the day and of sun reflected off water, and wear a T-shirt and lots of waterproof suncream (at least SPF25 and a UVA of four stars or more) when swimming. Sun exposure ages the skin, makes people prematurely wrinkly and increases the risk of skin cancer. The glare and dust can be hard on the eyes, too, so bring UV-protecting sunglasses (British standard BS2724 1987) and, perhaps, a soothing eyebath. Remember, children are particularly vulnerable and an SPF of factor 50 is recommended.
Personal first-aid kit
A minimal kit contains:
- A good drying antiseptic, eg: iodine or potassium permanganate (don’t take antiseptic cream)
- Water purification tablets (chlorine dioxide) or a filter bottle, eg: Aquapure
- A few small dressings (Band-Aids)
- Insect repellent; anti-malarial tablets; impregnated bed-net or permethrin spray
- A painkiller/anti-inflammatory (Do not use aspirin or ibuprofen if you think you have dengue fever)
- Antifungal cream (eg: Canesten)
- Antibiotics for severe diarrhoea/bacillary dysentery
- Tinidazole for giardia or amoebic dysentery (see below for regime)
- Antibiotic eye drops, for sore, ‘gritty’, stuck-together eyes (conjunctivitis)
- A pair of fine-pointed tweezers (to remove hairy caterpillar hairs, thorns, splinters, coral, etc)
- Alcohol-based hand rub and soap (either a bar in a plastic box or as a liquid)
- Condoms or femidoms
- Needle and syringe kit accompanied by a letter from a healthcare professional
- A digital thermometer (for those going to remote areas) and malaria treatment for longer or more remote travel
Long-haul flights, clots and DVT
Any prolonged immobility including travel by land or air can result in deep vein thrombosis (DVT) with the risk of embolus to the lungs. Certain factors can increase the risk, and these include:
- Previous clot or close relative with a history
- People over 40, but greater risk over 80 years
- Having had an operation in the past two months
- Broken leg in a plaster
- Some blood-clotting disorders
- Recent severe illness such as pneumonia, heart failure or a heart attack
- Hormone therapy such as HRT or the combined oral contraceptive pill
- People who are very tall (over 6ft/1.8m) or short (under 5ft/1.5m)
A DVT causes painful swelling and redness of the calf or sometimes the thigh. It is dangerous only if a clot travels to the lungs (pulmonary embolus). Symptoms of a pulmonary embolus include chest pain, shortness of breath, and sometimes coughing up small amounts of blood and commonly start three to ten days after a long flight. Anyone who thinks that they might have a DVT needs to see a doctor immediately.
Prevention of DVT
- Keep mobile before and during the flight
- Bend and straighten your legs, feet and toes every half an hour when seated
- Drink plenty of fluids during the flight
- Avoid taking sleeping pills and excessive tea, coffee and alcohol
- Consider wearing compression stockings (flight socks) – these must be measured and worn correctly. Ill-fitting stockings can actually increase the risk of DVT.
If you think you are at increased risk of a clot consult with a doctor. You may be prescribed blood-thinning drugs to lessen the risk or be advised not to travel.
A full list of current travel clinic websites worldwide is available on ISTM. For other journey preparation information, consult Travel Health Pro (UK) or CDC (USA). Information about various medications may be found on Net Doctor. All advice found online should be used in conjunction with expert advice received prior to or during travel.
Common medical problems
You can fall ill from drinking contaminated water, so try to drink from safe sources (eg: bottled water) where available. If you are planning to visit more remote areas where safe bottled water is unlikely to be available, then consider buying a water filter system such as Aquapure. The filter in this system will remove all micro-organisms and silt, etc, and will filter around 350 litres of water before it stops working. No chemicals are involved so it works immediately and it is more environmentally friendly as there is no need to dispose of all the plastic bottles. Failing that, boil the water thoroughly or sterilise with chlorine dioxide tablets. The latter are not the most pleasant tasting and take about 10 minutes to be effective. They do not work if the water contains any particulate matter.
Travelling in Africa carries a fairly high risk of getting a dose of travellers’ diarrhoea. Perhaps half of all visitors will suffer; and the newer you are to exotic travel, the more likely you will be to suffer. By taking precautions against travellers’ diarrhoea you will also avoid typhoid, paratyphoid, cholera, hepatitis, dysentery, worms, etc. Travellers’ diarrhoea and the other faecal-oral diseases come from getting other peoples’ faeces in your mouth. This most often happens from cooks not washing their hands after a trip to the toilet; but even if the restaurant cook does not understand basic hygiene, you will be safe if your food has been properly cooked and arrives piping hot. The most important prevention strategy is to wash your hands before eating anything. You can pick up salmonella and shigella from toilet door handles and possibly bank notes. The maxim to remind you what you can safely eat is:
PEEL IT, BOIL IT, COOK IT OR FORGET IT.
This means that fruit you have washed and peeled yourself, and hot foods, should be safe but raw foods, cold cooked foods, salads, fruit salads which have been prepared by others, ice cream and ice are all risky, and foods kept lukewarm in hotel buffets are often dangerous. That said, plenty of travellers and expatriates enjoy fruit and vegetables, so do keep a sense of perspective: food served in a fairly decent hotel in a large town or a place regularly frequented by expatriates is likely to be safe. If you are struck, see below for treatment.
It is the dehydration that makes you feel awful during a bout of diarrhoea and the most important part of treatment is drinking lots of clear fluids. Sachets of oral rehydration salts give the perfect biochemical mix to replace the fluids and electrolytes you are losing in the diarrhoea. If you don’t have any to hand then any dilute mixture of sugar and salt in water will be suitable substitute: try Coke or orange squash with a three-finger pinch of salt added to each glass (if you are salt-depleted you won’t taste the salt). Otherwise make a solution of a four-finger scoop of sugar with a three-finger pinch of salt in a 500ml glass and add a squeeze of lemon or orange juice to improve the taste. The juice also adds potassium, which is lost in diarrhoea. Drink two large glasses after every bowel action, and more if you are thirsty. These solutions are still absorbed well if you are vomiting, but you will need to take sips at a time. If you are not eating you need to drink 3 litres a day plus the equivalent volume of whatever is pouring into the toilet. If you feel like eating, take a bland, high-carbohydrate diet. Heavy, greasy foods will probably give you cramps.
Some people like to carry an antibiotic either because they will be remote from medical help or to treat traveller’s diarrhoea more quickly. Drugs such as ciprofloxacin and rifaximin can be used to shorten a bout of traveller’s diarrhoea if they are started early enough in the illness. If the diarrhoea is bad, you are passing blood or slime, or you have a fever, you will probably need a longer course of antibiotics in addition to fluid replacement. Some travellers also like to take antibiotics with them to treat bacillary dysentery, eg: azithromycin. Whether to treat simple traveller’s diarrhoea or bacillary dysentery, depends on the sensitivity of the organisms in the countries being visited and personal medical history, so seek expert advice before you travel. If the diarrhoea is greasy and bulky and is accompanied by sulphurous (eggy) burps, one likely cause is giardia. This requires a different treatment (tinidazole for preference, but metronidazole will do). Again, some people like to take these medications with them.
Always seek medical advice as soon as possible if you have symptoms of giardia, if you are vomiting or have other symptoms of bacillary dysentery, or if simple diarrhoea fails to settle after a couple of days. Similarly, if the diarrhoea fails to settle after two doses of ciprofloxacin or the three-day course of rifaximin, then you should seek medical advice. Remember, children can succumb more rapidly to dehydration and it is not advisable to given them antibiotics without consulting a doctor first.
Bacterial conjunctivitis (pink eye) is a common infection in Africa; people who wear contact lenses are most open to this irritating problem. The eyes feel sore and gritty and they will often be stuck together in the mornings. They will need treatment with antibiotic drops or ointment. Lesser eye irritation should settle with bathing in salt water and keeping the eyes shaded. If an insect flies into your eye, extract it with great care, ensuring you do not crush or damage it otherwise you may get a nastily inflamed eye from toxins secreted by the creature. Small elongated red-and-black blister beetles carry warning coloration to tell you not to crush them anywhere against your skin.
A fine pimply rash on the trunk is likely to be heat rash; cool showers, dabbing dry, and talc will help. Treat the problem by slowing down to a relaxed schedule, wearing only loose, baggy, 100%-cotton clothes and sleeping naked under a fan; if it’s bad you may need to check into an air-conditioned hotel room for a while.
Any mosquito bite or small nick in the skin gives an opportunity for bacteria to foil the body’s usually excellent defences; it will surprise many travellers how quickly skin infections start in warm humid climates and it is essential to clean and cover even the slightest wound. Creams are not as effective as a good drying antiseptic such as dilute iodine, potassium permanganate (a few crystals in half a cup of water), or crystal (or gentian) violet. One of these should be available in most towns. If the wound starts to throb, or becomes red and the redness starts to spread, or the wound oozes, and especially if you develop a fever, antibiotics will probably be needed: flucloxacillin (250mg four times a day) or cloxacillin (500mg four times a day). For those allergic to penicillin, erythromycin (500mg twice a day) for five days should help. See a doctor if the symptoms do not start to improve within 48 hours.
Fungal infections also get a hold easily in hot, moist climates so wear 100% cotton socks and underwear, and shower frequently. An itchy rash in the groin or flaking between the toes is likely to be a fungal infection. This needs treatment with an antifungal cream such as Canesten (clotrimazole); if this is not available, try Whitfield’s ointment (compound benzoic acid ointment) or crystal violet (although this will turn you purple!).
Other insect-borne diseases
Malaria is by no means the only insect-borne disease to which the traveller may succumb. Others include sleeping sickness and river blindness (see Avoiding insect bites). Dengue fever is increasingly being found in parts of Africa and there are many other similar arboviruses, such as Chikungunya. These mosquito-borne diseases may mimic malaria, but there is no prophylactic medication against them. The mosquitoes that carry the dengue fever virus typically bite during the daytime, so it is worth applying repellent if you see any mosquitoes around. Symptoms include strong headaches, rashes and excruciating joint and muscle pains and high fever. Viral fevers usually last about a week or so and are not usually fatal. Complete rest and paracetamol are the usual treatment; plenty of fluids also help. Aspirin or ibuprofen should never be used as they can increase the risk of bleeding. Some patients are given an intravenous drip to keep them from dehydrating. It is especially important to protect yourself if you have had dengue fever before, since a second infection with a different strain can result in the potentially fatal dengue haemorrhagic fever.
African trypanosomiasis, or sleeping sickness, is a parasitic infection caused by Trypanosoma brucei, transmitted by the tsetse fly. There are two sub-species: one predominates in East Africa and usually causes an acute infection, whereas the other predominates in Central and West Africa and causes a slower progressive, chronic infection. In the UK, travel-associated cases are rare, but those that have been reported have usually been associated with travel to the game parks of East Africa. Most recently a case was reported in a UK traveller who had returned from Zambia and Zimbabwe.
The parasite is transmitted by the bite of an infected tsetse fly. Tsetse flies are around the size of a honey bee. In West Africa, the main reservoir for the parasite is humans. The tsetse flies responsible tend to inhabit damp river areas. In East Africa, the main reservoirs for the parasites are domestic and wild animals such as antelope and cattle. The tsetse flies here tend to inhabit savannah and woodland areas. One bite from an infected tsetse fly is enough for a human to become infected. Trypanosomiasis cannot be spread directly from person to person.
For East African trypanosomiasis, the first symptoms (skin lesion around the bite with lymphadenopathy) will occur 5–15 days after the bite, with fever occurring after one to three weeks. For West African trypanosomiasis, symptoms may not present for some weeks after the infective bite. East African trypanosomiasis is a much faster progressing disease than the West African form, which can progress over a number of years.
There is no vaccine or drug to prevent sleeping sickness. The only way to prevent it is to avoid tsetse fly bites and be aware of the risk. Tsetse flies are attracted by movement and dark colours, particularly blue. They have been known to follow moving vehicles, therefore windows should remain closed when driving through endemic areas. Travellers are advised to wear insecticide-treated close-weave and loose-fitting clothing and use a good repellent containing N, N-diethylmetatoluamide (DEET) on exposed skin. If sunscreen is also being used, repellent must be applied after sunscreen. More information about the disease is available from the NaTHNaC website.
Bilharzia or schistosomiasis
with thanks to Dr Vaughan Southgate of the Natural History Museum, London, and Dr Dick Stockley, The Surgery, Kampala
Bilharzia or schistosomiasis is a disease that commonly afflicts the rural poor of the tropics. Two types exist in sub-Saharan Africa – Schistosoma mansoni and Schistosoma haematobium. It is an unpleasant problem that is worth avoiding, though can be treated if you do get it. This parasite is common in many water sources throughout Africa, even places advertised as ‘bilharzia free’. The most risky shores will be close to places where infected people use water, wash clothes, etc.
It is easier to understand how to diagnose it, treat it and prevent it if you know a little about the life-cycle. Contaminated faeces are washed into the lake, the eggs hatch and the larva infects certain species of snail. The snails then produce about 10,000 cercariae (larvae) a day for the rest of their lives. The parasites can digest their way through your skin when you wade or bathe in infested fresh water.
Winds disperse the snails and cercariae. The snails in particular can drift a long way, especially on windblown weed, so nowhere is really safe. However, deep water and running water are safer, while shallow water presents the greatest risk. The cercariae penetrate intact skin, and find their way to the liver. There male and female meet and spend the rest of their lives in permanent copulation. No wonder you feel tired! Most finish up in the wall of the lower bowel, but others can get lost and can cause damage to many different organs. Schistosoma haematobium goes mostly to the bladder.
Although the adults do not cause any harm in themselves, after about four to six weeks they start to lay eggs, which cause an intense but usually ineffective immune reaction, including fever, cough, abdominal pain, and a fleeting, itching rash called ‘safari itch’. The absence of early symptoms does not necessarily mean there is no infection. Later symptoms can be more localised and more severe, but the general symptoms settle down fairly quickly and eventually you are just tired. ‘Tired all the time’ is one of the most common symptoms among expats in Africa, and bilharzia, giardia, amoeba and intestinal yeast are the most common culprits.
Although bilharzia is difficult to diagnose, it can be tested at specialist travel clinics. Ideally tests need to be done at least six weeks after likely exposure and will determine whether you need treatment. Fortunately it is easy to treat at present.
If you are bathing, swimming, paddling or wading in fresh water that you think may carry a bilharzia risk, try to get out of the water within 10 minutes.
- Avoid bathing or paddling on shores within 200m of villages or places where people use the water a great deal, especially reedy shores or where there is lots of water weed.
- Dry off thoroughly with a towel; rub vigorously.
- If your bathing water comes from a risky source, try to ensure that the water is taken from the lake in the early morning and stored snail-free, otherwise it should be filtered, or Dettol or Cresol added.
- Bathing early in the morning is safer than bathing in the last half of the day.
- Cover yourself with DEET insect repellent before swimming: it may offer some protection.
The risks of sexually transmitted infection are extremely high in many countries in Africa, whether you sleep with fellow travellers or locals. About 40% of HIV infections in British heterosexuals are acquired abroad (most of which come from Africa). If you must indulge, use condoms or femidoms, which help reduce the risk of transmission. If you notice any genital ulcers or discharge, get treatment promptly since these increase the risk of acquiring HIV. If you do have unprotected sex, visit a clinic as soon as possible; this should be within 24 hours, or no later than 72 hours, for post-exposure prophylaxis.
This is a particularly nasty disease as it can kill within hours of the first symptoms appearing. The tell-tale symptoms are a combination of a blinding headache (light sensitivity), a blotchy rash and a high fever. Immunisation protects against the most serious bacterial form of meningitis and the tetravalent vaccine ACWY is recommended for the meningitis belt in Africa by British travel clinics. Currently the conjugate vaccines (eg: Nimenrix, Menveo) are superior in protection and prevention of carrier status to the older polysaccharide vaccines and last for five years.
Although other forms of meningitis (usually viral) exist, there are no vaccines for these. Local papers normally report localised outbreaks. A severe headache and fever should make you run to a doctor immediately.
Rabies is carried by all warm-blooded mammals (beware the village dogs and small monkeys that are used to being fed in the parks) and is passed on to humans through a bite, scratch or even a lick over even the smallest abrasion or insect bite. You must always assume any animal is rabid as they can often look well but can still be infectious. Have a low threshold for seeking medical help as soon as possible after any potential exposure. Meanwhile, scrub the area that has been contaminated by animal saliva with soap under a running tap or while pouring water from a jug for a good 10–15 minutes. The source of the water is not important at this stage, but if you do have antiseptic to hand then put this on afterwards. The soap helps stop the rabies virus entering the body and along with an antiseptic will guard against wound infections, including tetanus.
Pre-exposure vaccination for rabies is ideally advised for everyone, but is particularly important if you intend to have contact with animals and/or are likely to be more than 24 hours away from medical help. Ideally three doses should be taken over a minimum of 21 days, although there is now an accelerated course given on days 0, 3 and 7, with a booster at a year if time is short. The more pre-exposure doses of vaccine you have, the less post-exposure treatment you will need. If you are bitten, scratched or licked by any mammal, then post-exposure prophylaxis should be given as soon as possible, though it is never too late to seek help, as the incubation period for rabies can be very long. Those who have not been immunised before will need a four to five doses of rabies vaccine given over 21–28 days and may also be advised to have a product called Rabies Immunoglobulin (RIG), either human or horse. The RIG is injected round the wound to try and neutralise any rabies virus present and is a pivotal part of the treatment if you have not had pre-exposure vaccine. RIG is expensive and is often not readily available as there is a global shortage, so it is important to insist on getting to a place that has it. Another reason for having good insurance.
Tell the doctor if you have had two or more doses of the pre-exposure vaccine, as this will change the treatment you receive. If you have had all three doses, then you will no longer need to have RIG and will probably only need a couple of doses of vaccine ideally given three days apart. If you have had two doses of rabies vaccine pre-exposure, then in most cases you won’t need RIG but would still need to get four or five post-exposure doses of rabies vaccine over about 28 days. Anyone who is immunosuppressed needs to take specialist advice. And remember that, if you do contract rabies, mortality is 100% and death from rabies is probably one of the worst ways to go.
African ticks are not the rampant disease transmitters they are in the Americas, but they may spread tickbite fever and a few dangerous rarities. Tickbite fever is a flu-like illness that can easily be treated with doxycycline, but as there can be some serious complications it is important to visit a doctor.
Ticks should ideally be removed as soon as possible as leaving them on the body increases the chance of infection. They should be removed with special tick tweezers that can be bought in good travel shops. Failing that you can use your finger nails: grasp the tick as close to your body as possible and pull steadily and firmly away at right angles to your skin. The tick will then come away complete, as long as you do not jerk or twist. If possible, douse the wound with alcohol (any spirit will do) or iodine. Irritants (eg: Olbas oil) or lit cigarettes are to be discouraged since they can cause the ticks to regurgitate and therefore increase the risk of disease. It is best to get a travelling companion to check you for ticks; if you are travelling with small children, remember to check their heads, and particularly behind the ears.
Spreading redness around the bite and/or fever and/or aching joints after a tick bite imply that you have an infection that requires antibiotic treatment, so seek advice.
Snakes rarely attack unless provoked, and bites in travellers are unusual. You are less likely to get bitten if you wear stout shoes and long trousers when in the bush. Most snakes are harmless and even venomous species will dispense venom in only about half of their bites. If bitten, then, you are unlikely to have received venom; keeping this fact in mind may help you to stay calm. Many so-called first-aid techniques do more harm than good: cutting into the wound is harmful; tourniquets are dangerous; suction and electrical inactivation devices do not work. The only treatment is anti-venom. In case of a bite that you fear may have been from a venomous snake:
- Try to keep calm – it is likely that no venom has been dispensed.
- Lie the patient down away from the snake.
- Do not apply a tourniquet.
- Prevent movement of the bitten limb by applying a splint.
- Keep the bitten limb BELOW heart height to slow the spread of any venom.
- If you have a crêpe bandage, wrap it around the whole limb (eg: all the way from the toes to the thigh), as tight as you would for a sprained ankle or a muscle pull.
- Evacuate to a hospital that has the relevant anti-venom.
NEVER give aspirin; you may take paracetamol, which is safe.
NEVER cut or suck the wound.
DO NOT apply ice packs.
DO NOT apply potassium permanganate.
If the offending snake can be captured without risk of someone else being bitten, take this to show the doctor – but beware since even a decapitated head is able to bite.
Updated 1 October 2019