Warning – booooooring! Important though…. This is mainly for us, but also for friends and family planning on joining us and other people (like my dad) who might find it, umm, interesting….
The following represents a summary of vaccinations needed for the countries we will visit:
|Hepatitis A||Recommended for all travellers|
|Typhoid||Recommended for all travellers|
|Yellow fever||Required for all travellers|
|Meningococcus||Recommended for all travellers|
|Polio||One-time booster recommended for any adult traveller who completed the childhood series but never had polio vaccine as an adult|
|Hepatitis B||Recommended for all travellers|
|Rabies||For travellers spending a lot of time outdoors, or at high risk for animal bites, or involved in any activities that might bring them into direct contact with bats|
|Measles, mumps, rubella (MMR)||Two doses recommended for all travellers born after 1956, if not previously given|
|Tetanus-diphtheria||Revaccination recommended every 10 years|
|Botswana||Malaria: Prophylaxis with Lariam (mefloquine), Malarone (atovaquone/proguanil), or doxycycline is recommended for the northern part of the country (north of 22 degrees south in the provinces of Central, Chobe, Ghanzi, and Ngamiland), including safaris to the Okavango Delta area. No risk in the city of Gaborone.|
|Burundi||Malaria: Prophylaxis with Lariam (mefloquine), Malarone (atovaquone/proguanil), or doxycycline is recommended for all areas.|
|Kenya||Malaria: Prophylaxis with Lariam (mefloquine), Malarone (atovaquone/proguanil), or doxycycline is recommended for all areas except Nairobi and the highlands (above 2500 m) of Central, Eastern, Nyanza, Rift Valley, and Western Provinces.|
|Malawi||Malaria: Prophylaxis with Lariam (mefloquine), Malarone (atovaquone/proguanil), or doxycycline is recommended for all areas.|
|Mozambique||Malaria: Prophylaxis with Lariam (mefloquine), Malarone (atovaquone/proguanil), or doxycycline is recommended for all areas.|
|Namibia||Malaria: Prophylaxis with Lariam (mefloquine), Malarone (atovaquone/proguanil), or doxycycline is recommended forthe provinces of Kunene, Ohangwena, Okavango, Omaheke, Omusati, Oshana, Oshikoto, and Otjozondjupa and in the Caprivi Strip.|
|Tanzania||Malaria: Prophylaxis with Lariam (mefloquine), Malarone (atovaquone/proguanil), or doxycycline is recommended for all areas at altitudes less than 1800 m.|
|Zimbabwe||Malaria: Prophylaxis with Lariam (mefloquine), Malarone (atovaquone/proguanil), or doxycycline is recommended for all areas|
OTHER HEALTH CONCERNS
Traveler’s diarrhea is the most common travel-related infection. It may be caused by many different organisms, including bacteria such as E. coli, Salmonella, Shigella, Campylobacter, Aeromonas, Plesiomonas, and vibrios; parasites such as Giardia, Entamoeba histolytica, Cryptosporidium, and Cyclospora; and viruses. In addition to diarrhea, symptoms may include nausea, vomiting, abdominal pain, fever, sweats, chills, headache, and malaise. The chief complication is dehydration, which may become severe, especially in warmer climates.
The best means of prevention is to avoid any questionable foods or beverages. Do not drink tap water unless it has been boiled, filtered, or chemically disinfected. Do not drink unbottled beverages or drinks with ice. Do not eat fruits or vegetables unless they have been peeled or cooked. Avoid cooked foods that are no longer piping hot. Cooked foods that have been left at room temperature are particularly hazardous. Avoid unpasteurized milk and any products that might have been made from unpasteurized milk, such as ice cream. Avoid food and beverages obtained from street vendors. Do not eat raw or undercooked meat or fish, including ceviche. Some types of fish may contain poisonous biotoxins even when cooked. Barracuda in particular should never be eaten. Other fish that may contain toxins include red snapper, grouper, amberjack, sea bass, and a large number of tropical reef fish.
Although antibiotics may be taken prophylactically to prevent travellers’ diarrhea (i.e. taken on a daily basis before symptoms have a chance to occur), this isn’t generally recommended because starting antibiotics after diarrhea begins works well and because increased antibiotic use might lead to a greater incidence of side-effects and the selection of resistant organisms. Prophylactic antibiotics might be appropriate for situations in which diarrhea might prove unusually troublesome (i.e. business trip, diplomatic mission, athletic event) or for travellers who are immunocompromised or who have a history of intestinal disorders, such as those with inflammatory bowel disease. Appropriate regimens include ciprofloxacin (Cipro)(PDF)or levofloxacin (Levaquin)(PDF) 500 mg once daily or (less effectively) trimethoprim-sulfamethoxazole (Bactrim; Septra) one double-strength tablet daily. Bismuth subsalicylate (Pepto-Bismol) (two tablets or two ounces four times daily) will reduce the likelihood of travellers’ diarrhea, but few take this because it is inconvenient. Side-effects may include black tongue, black stools, nausea, constipation, and ringing in the ears (tinnitus). Bismuth subsalicylate should not be taken by those with aspirin allergy, kidney disease, or gout, and should not be taken for more than three weeks. Quinolone antibiotics may bind to metallic cations such as bismuth; they should not be taken concurrently.
The standard recommendation is for travellers at risk to bring along an antibiotic and an antidiarrheal drug to be started promptly if significant diarrhea occurs, defined as three or more loose stools in an 8-hour period or five or more loose stools in a 24-hour period, especially if associated with nausea, vomiting, cramps, fever or blood in the stool. A quinolone antibiotic is usually prescribed: either ciprofloxacin (Cipro)(PDF) 500 mg twice daily or levofloxacin (Levaquin)(PDF) 500 mg once daily for a total of three days. Quinolones should not be given to children, pregnant women, or anyone with a history of quinolone allergy. Alternative regimens include a three day course of rifaximin (Xifaxan) 200 mg three times daily or azithromycin (Zithromax) 500 mg once daily. Rifaximin should not be used by those with fever or bloody stools and is not approved for pregnant women or those under age 12. Azithromycin should be avoided in those allergic to erythromycin or related antibiotics. For children, the dosage of azithromycin is 10 mg/kg on day 1, up to 500 mg, and 5 mg/kg on days 2 and 3, up to 250 mg. Another option is trimethoprim/sulfamethoxazole (Bactrim), which is used less often today because of increasing bacterial resistance but may be appropriate for children or those unable to tolerate other antibiotics. The dosage is one double-strenth tablet twice daily for adults and 5 mg/kg trimethoprim/25 mg/kg sulfa twice daily for children. Trimethoprim-sulfamethoxazole should not be given to pregnant women or those with a history of sulfa allergy. An antidiarrheal drug such as loperamide (Imodium) or diphenoxylate (Lomotil) should be taken as needed to slow the frequency of stools, but not enough to stop the bowel movements completely. Diphenoxylate (Lomotil) and loperamide (Imodium) should not be given to children under age two.
Most cases of travellers’ diarrhea are mild and do not require either antibiotics or antidiarrheal drugs.
Adequate fluid intake is essential. Oral rehydration solutions, which are rich in salt and sugar, are widely available and highly effective. If fluids that do not contain salt are used, plain salted foods, such as crackers, are recommended. Dairy products should be avoided until diarrhea has subsided, as these are often difficult to digest while the intestine is inflamed.
If diarrhea is severe or bloody, or if fever occurs with shaking chills, or if abdominal pain becomes marked or if diarrhea persists for more than 72 hours, medical attention should be obtained, if possible
Food and water precautions
Do not drink tap water unless it has been boiled, filtered, or chemically disinfected. Do not drink unbottled beverages or drinks with ice. Do not eat fruits or vegetables unless they have been peeled or cooked. Avoid cooked foods that are no longer piping hot. Cooked foods that have been left at room temperature are particularly hazardous. Avoid unpasteurized milk and any products that might have been made from unpasteurized milk, such as ice cream. Avoid food and beverages obtained from street vendors. Do not eat raw or undercooked meat or fish.
Insect and Tick Protection
Wear long sleeves, long pants, hats and shoes (rather than sandals). For rural and forested areas, boots are preferable, with pants tucked in, to prevent tick bites. Apply insect repellents containing 25-50% DEET (N,N-diethyl-3-methylbenzamide) or 20% picaridin (Bayrepel) to exposed skin (but not to the eyes, mouth, or open wounds). DEET may also be applied to clothing. Products with a lower concentration of either repellent need to be reapplied more frequently.
Products with a higher concentration of DEET carry an increased risk of neurologic toxicity, especially in children, without any additional benefit. Do not use either DEET or picaridin on children less than two years of age. For additional protection, apply permethrin-containing compounds to clothing, shoes, and bed nets. Permethrin-treated clothing appears to have little toxicity. Don’t sleep with the window open unless there is a screen. If sleeping outdoors or in an accomodation that allows entry of mosquitoes, use a bed net, preferably impregnated with insect repellent, with edges tucked in under the mattress. The mesh size should be less than 1.5 mm. If the sleeping area is not otherwise protected, use a mosquito coil, which fills the room with insecticide through the night. In rural or forested areas, perform a thorough tick check at the end of each day with the assistance of a friend or a full-length mirror. Ticks should be removed with tweezers, grasping the tick by the head. Many tick-borne illnesses can be prevented by prompt tick removal.
Swimming and bathing precautions
Avoid swimming, wading, or rafting in bodies of fresh water, such as lakes, ponds, streams, or rivers. Do not use fresh water for bathing or showering unless it has been heated to 150 degrees F for at least five minutes or held in a storage tank for at least three days. Towelling oneself dry after unavoidable or accidental exposure to contaminated water may reduce the likelihood of schistosomiasis, but does not reliably prevent the disease and is no substitute for the precautions above. Chlorinated swimming pools are considered safe.
Bring adequate supplies of all medications in their original containers, clearly labeled. Carry a signed, dated letter from the primary physician describing all medical conditions and listing all medications, including generic names. If carrying syringes or needles, be sure to carry a physician’s letter documenting their medical necessity. If you wear glasses or contacts, bring an extra pair. If you have significant allergies or chronic medical problems, wear a medical alert bracelet. Make sure your health insurance covers you for medical expenses abroad. If not, supplemental insurance for overseas coverage, including possible evacuation, should be seriously considered. If illness occurs while abroad, medical expenses including evacuation may run to tens of thousands of dollars. Bring your insurance card, claim forms, and any other relevant insurance documents.
Pack a personal medical kit, customized for your trip. Take appropriate measures to prevent motion sickness and jet lag, discussed elsewhere.
Avoid contact with stray dogs and other animals. If an animal bites or scratches you, clean the wound with large amounts of soap and water and contact local health authorities immediately.