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A yellow fever vaccination certificate is required for all visitors over the age of one year. Malaria is prevalent countrywide and insect protection, as well as a prophylactic that has not shown signs of being resisted in the area, are essential. Insect protection is also essential against other insect-borne diseases, like dengue fever. Hepatitis A, polio and typhoid vaccinations are recommended. Cholera is fairly common, though travellers are at low risk. Bilharzia is present, and it is best to avoid swimming in fresh water. African trypanosomiasis (sleeping sickness), meningococcal disease and rabies can also occur. It is recommended that travellers be up-to-date on all routine immunisations. Tap water is to be avoided, unless boiled, filtered or disinfected with chemicals and it is safest to drink bottled water. Avoid drinks with ice. Milk is unpasteurised and should be boiled; any diary product made from milk should be avoided. Food must be well cooked, and all fruit and vegetables should be peeled or cooked. Medical facilities are poor, and health insurance is recommended, as is a supply of basic medication (e.g. for travellers diarrhoea, headaches etc).

View information on diseases: Cholera , Dengue Fever , Hepatitis A , Malaria , Meningococcal disease , Rabies , Schistosomiasis (bilharzia), African Sleeping Sickness , Typhoid fever , Yellow fever

Cholera

Cause: Vibrio cholerae bacteria, serogroups O1 and O139. Transmission: Infection occurs through ingestion of food or water contaminated directly or indirectly by faeces or vomit of infected persons. Cholera affects only humans; there is no insect vector or animal reservoir host. Nature of the disease: An acute enteric (intestine) disease varying in severity. Most infections are asymptomatic (i.e. do not cause any illness). In mild cases, diarrhoea occurs without other symptoms. In severe cases, there is sudden onset of profuse watery diarrhoea with nausea and vomiting and rapid development of dehydration. In severe untreated cases, death may occur within a few hours due to dehydration leading to circulatory collapse. Geographical distribution: Cholera occurs mainly in poor countries with inadequate sanitation and lack of clean drinking water and in war-torn countries where the infrastructure may have broken down. Many developing countries are affected, particularly those in Africa and Asia, and to a lesser extent those in central and south America. Risk for travellers: The risk of cholera is very low for most travellers, even in countries where cholera epidemics occur. Humanitarian relief workers in disaster areas and refugee camps are at risk.
Prophylaxis (protective treatment): Oral cholera vaccines for use by travellers and those in occupational risk groups are available in some countries. Precautions: As for other diarrhoeal diseases. All precautions should be taken to avoid consumption of potentially contaminated food, drink and drinking water. Oral rehydration salts should be carried to combat dehydration in case of severe diarrhoea. Source: WHO.

Dengue Fever

Cause: The dengue virus - a flavivirus of which there are four serotypes. Transmission: Dengue fever is transmitted by the Aedes aegypti mosquito, which bites during daylight hours. There is no direct person-to-person transmission. Monkeys act as a reservoir host in south-east Asia and west Africa. Nature of the disease: Dengue occurs in three main clinical forms: Dengue fever is an acute febrile illness with sudden onset of fever, followed by development of generalized symptoms and sometimes a macular skin rash. It is known as "breakbone fever" because of severe muscular pains. The fever may be biphasic (i.e. two separate episodes or waves of fever). Most patients recover after a few days; Dengue haemorrhagic fever has an acute onset of fever followed by other symptoms resulting from thrombocytopenia, increased vascular permeability and haemorrhagic manifestations; Dengue shock syndrome supervenes in a small proportion of cases. Severe hypotension develops, requiring urgent medical treatment to correct hypovolaemia. Without appropriate treatment, 40-50% of cases are fatal; with timely therapy, the mortality rate is 1% or less. Geographical distribution: Dengue fever is widespread in tropical and subtropical regions of central and south America and south and south-east Asia and also occurs in Africa; in these regions, dengue is limited to altitudes below 600 metres (2,000 feet). Risk for travellers: There is a significant risk for travellers in areas where dengue fever is endemic and in areas affected by epidemics of dengue. Prophylaxis (protective treatment): None. Precautions: Travellers should take precautions to avoid mosquito bites both during the day and at night in areas where dengue occurs. Source: WHO.

Hepatitis A

Cause: Hepatitis A virus, a member of the picornavirus family. Transmission: The virus is acquired directly from infected persons by the faecal-oral route or by close contact, or by consumption of contaminated food or drinking water. There is no insect vector or animal reservoir (although some non-human primates are sometimes infected). Nature of the disease: An acute viral hepatitis with abrupt onset of fever, malaise, nausea and abdominal discomfort, followed by the development of jaundice a few days later. Infection in very young children is usually mild or asymptomatic (e.g. causes no symptoms); older children are at risk of symptomatic disease. The disease is more severe in adults, with illness lasting several weeks and recovery taking several months; case-fatality is greater than 2% for those over 40 years of age and 4% for those over 60. Geographical distribution: Worldwide, but most common where sanitary conditions are poor and the safety of drinking water is not well controlled. Risk for travellers: Non-immune travellers to developing countries are at significant risk of infection. The risk is particularly high for travellers exposed to poor conditions of hygiene, sanitation and drinking water control. Prophylaxis (protective treatment): Vaccination. Precautions: Travellers who are non-immune to hepatitis A (i.e. have never had the disease and have not been vaccinated) should take particular care to avoid potentially contaminated food and water. Source: WHO.

Malaria

General considerations: Malaria is a common and life-threatening disease in many tropical and subtropical areas. It is currently endemic in over 100 countries, which are visited by more than 125 million international travellers every year. Each year many international travellers fall ill with malaria while visiting countries where the disease is endemic, and well over 10,000 fall ill after returning home. Fever occurring in a traveller within three months of leaving a malaria-endemic area is a medical emergency and should be investigated urgently. Cause: Human malaria is caused by four different species of the protozoan parasite Plasmodium: Plasmodium falciparum, P. vivax, P. ovale and P. malariae. Transmission: The malaria parasite is transmitted by various species of Anopheles mosquitoes, which bite mainly between sunset and sunrise. Nature of the disease: Malaria is an acute febrile illness with an incubation period of 7 days or longer. Thus, a febrile illness developing less than one week after the first possible exposure is not malaria. The most severe form is caused by P. falciparum, in which variable clinical features include fever, chills, headache, muscular aching and weakness, vomiting, cough, diarrhoea and abdominal pain; other symptoms related to organ failure may supervene, such as: acute renal failure, generalized convulsions, circulatory collapse, followed by coma and death. It is estimated that about 1% of patients with P. falciparum infection die of the disease. The initial symptoms, which may be mild, may not be easy to recognize as being due to malaria. It is important that the possibility of falciparum malaria is considered in all cases of unexplained fever starting at any time between the seventh day of first possible exposure to malaria and three months (or, rarely, later) after the last possible exposure, and any individual who experiences a fever in this interval should immediately seek diagnosis and effective treatment. Early diagnosis and appropriate treatment can be life-saving. Falciparum malaria may be fatal if treatment is delayed beyond 24 hours. A blood sample should be examined for malaria parasites. If no parasites are found in the first blood film but symptoms persist, a series of blood samples should be taken and examined at 6-12-hour intervals. Pregnant women, young children and elderly travellers are particularly at risk. Malaria in pregnant travellers increases the risk of maternal death, miscarriage, stillbirth and neonatal death. The forms of malaria caused by other Plasmodium species are less severe and rarely life-threatening. Prevention and treatment of falciparum malaria are becoming more difficult because P. falciparum is increasingly resistant to various antimalarial drugs. Of the other malaria species, drug resistance has to date been reported for P. vivax, mainly from Indonesia (Irian Jaya) and Papua New Guinea, with more sporadic cases reported from Guyana. P. vivax with declining sensitivity has been reported for Brazil, Colombia, Guatemala, India, Myanmar, the Republic of Korea, and Thailand. P. malariae resistant to chloroquine has been reported from Indonesia. Geographical distribution: The risk for travellers of contracting malaria is highly variable from country to country and even between areas in a country. In many endemic countries of Latin America and the Caribbean, Asia and the Mediterranean region, the main urban areas, but not necessarily the outskirts of towns, are free of malaria transmission. However, malaria can occur in main urban areas in Africa and India. There is usually less risk of the disease at altitudes above 1,500 metres, but in favourable climatic conditions it can occur at altitudes up to almost 3,000 metres. The risk of infection may also vary according to the season, being highest at the end of the rainy season. There is no risk of malaria in many tourist destinations in South-East Asia, Latin America and the Caribbean. Source: WHO.

Meningococcal disease

Cause: The bacterium Neisseria meningitidis, of which 12 serogroups are known. Most cases of meningococcal disease are caused by serogroups A, B and C; less commonly, infection is caused by serogroups Y and W-135. Epidemics in Africa are usually caused by N. meningitidis type A. Transmission: occurs by direct person-to-person contact, including aerosol transmission and respiratory droplets from the nose and pharynx of infected persons, patients or carriers. There is no animal reservoir or insect vector. Nature of the disease: Most infections do not cause clinical disease. Many infected people become asymptomatic (i.e. cause no symptoms) carriers of the bacteria and serve as a reservoir and source of infection for others. In general, susceptibility to meningococcal disease decreases with age, although there is a small increase in risk in adolescents and young adults. Meningococcal meningitis has a sudden onset of intense headache, fever, nausea, vomiting, photophobia and stiff neck, plus various neurological signs. The disease is fatal in 5-10% of cases even with prompt antimicrobial treatment in good health care facilities; among individuals who survive, up to 20% have permanent neurological sequelae. Meningococcal septicaemia, in which there is rapid dissemination of bacteria in the bloodstream, is a less common form of meningococcal disease, characterized by circulatory collapse, haemorrhagic skin rash and high fatality rate. Geographical distribution: Sporadic cases are found worldwide. In temperate zones, most cases occur in the winter months. Localized outbreaks occur in enclosed crowded spaces (e.g. dormitories, military barracks). In sub-Saharan Africa, in a zone stretching across the continent from Senegal to Ethiopia (the African "meningitis belt"), large outbreaks and epidemics take place during the dry season (November-June). Risk for travellers: Generally low. However, the risk is considerable if travellers are in crowded conditions or take part in large population movements such as pilgrimages in the Sahel meningitis belt. Localized outbreaks occasionally occur among travellers (usually young adults) in camps or dormitories.Prophylaxis (protective treatment): Vaccination is available for N. meningitidis types A, C, Y and W-135. Precautions: Avoid overcrowding in confined spaces. Following close contact with a person suffering from meningococcal disease, medical advice should be sought regarding chemoprophylaxis. Source: WHO.

Rabies

Cause: The rabies virus, a rhabdovirus of the genus Lyssavirus. Transmission: Rabies is a zoonotic disease affecting a wide range of domestic and wild animals, including bats. Infection of humans usually occurs through the bite of an infected animal. The virus is present in the saliva. Any other contact involving penetration of the skin occurring in an area where rabies is present should be treated with caution. In developing countries transmission is usually from dogs. Person-to-person transmission has not been documented. Nature of the disease: An acute viral encephalomyelitis, which is almost invariably fatal. The initial signs include a sense of apprehension, headache, fever, malaise and sensory changes around the site of the animal bite. Excitability, hallucinations and aerophobia are common, followed in some cases by fear of water (hydrophobia) due to spasms of the swallowing muscles, progressing to delirium, convulsions and death a few days after onset. A less common form, paralytic rabies, is characterized by loss of sensation, weakness, pain and paralysis. Geographical distribution: Rabies is present in animals in many countries worldwide. Most cases of human infection occur in developing countries. Risk for travellers: In rabies-endemic areas, travellers may be at risk if there is contact with both wild and domestic animals, including dogs and cats. Prophylaxis (protective treatment): Vaccination for travellers with a foreseeable significant risk of exposure to rabies or travelling to a hyperendemic area where modern rabies vaccine may not be available. Precautions: Avoid contact with wild animals and stray domestic animals, particularly dogs and cats, in rabies-endemic areas. If bitten by an animal that is potentially infected with rabies, or after other suspect contact, immediately clean the wound thoroughly with disinfectant or with soap or detergent and water. Medical assistance should be sought immediately. The vaccination status of the animal involved should not be a criterion for withholding post-exposure treatment, unless the vaccination has been thoroughly documented and vaccine of known potency has been used. In the case of domestic animals, the suspect animal should be kept under observation for a period of 10 days. Rabies post-exposure treatment: In a rabies-endemic area, the circumstances of an animal bite, other contact with the animal, and the animal's behaviour and appearance may suggest that it is rabid. In such situations, medical advice should be obtained immediately. Post-exposure treatment to prevent the establishment of rabies infection involves first-aid treatment of the wound followed by administration of rabies vaccine and antirabies immunoglobulin in the case of a bite or exchange of saliva. The administration of vaccine, and immunoglobulin if required, must be carried out, or directly supervised, by a physician. Source: WHO.

Schistosomiasis (bilharzia)

Cause: Several species of parasitic blood flukes (trematodes), of which the most important are Schistosoma mansoni, S. japonicum and S. haematobium. Transmission: Infection with bilharzia occurs in fresh water containing larval forms (cercariae) of schistosomes, which develop in snails. The free-swimming larvae penetrate the skin of individuals swimming or wading in water. Snails become infected as a result of excretion of eggs in human urine or faeces. Nature of the disease: Chronic conditions in which adult flukes live for many years in the veins (mesenteric or vesical) of the host where they produce eggs, which cause damage to the organs in which they are deposited. The symptoms of bilharzias depend on the main target organs affected by the different species, with S. mansoni and S. japonicum causing hepatic and intestinal signs and S. haematobium causing urinary dysfunction. The larvae of some schistosomes of birds and other animals may penetrate human skin and cause a self-limiting dermatitis, "swimmers itch". These larvae are unable to develop in humans. Geographical distribution: S. mansoni occurs in many countries of sub-Saharan Africa, in the Arabian peninsula, and in Brazil, Suriname and Venezuela. S. japonicum is found in China, in parts of Indonesia, and in the Philippines (but no longer in Japan). S. haematobium is present in sub-Saharan Africa and in eastern Mediterranean areas. Risk for travellers: In endemic areas, travellers are at risk to bilharzias while swimming or wading in fresh water. Prophylaxis (protective treatment): None. Precautions: Avoid direct contact (swimming or wading) with potentially contaminated fresh water in endemic areas. In case of accidental exposure, dry the skin vigorously to reduce penetration by cercariae. Avoid drinking, washing, or washing clothing in water that may contain cercariae. Water can be treated to remove or inactivate cercariae by paper filtering or use of iodine or chlorine. Source: WHO.

African Sleeping Sickness

Cause: Protozoan parasites Trypanosoma brucei (T. b.) gambiense and T. b. rhodesiense. Transmission: Infection with African trypanosomiasis (sleeping sickness) occurs through the bite of infected tsetse flies. Humans are the main reservoir host for T. b. gambiense. Domestic cattle and wild animals, including antelopes, are the main animal reservoir of T. b. rhodesiense. Nature of the disease: T. b. gambiense causes a chronic illness with onset of symptoms after a prolonged incubation period of weeks or months. T. b. rhodesiense causes a more acute illness, with onset a few days or weeks after the infected bite; often, there is a striking inoculation chancre. Initial clinical signs include severe headache, insomnia, enlarged lymph nodes, anaemia and rash. In the late stage of the disease, there is progressive loss of weight and involvement of the central nervous system. Without treatment, the disease is invariably fatal. Geographical distribution: T. b. gambiense is present in foci in the tropical countries of western and central Africa. T. b. rhodesiense occurs in east Africa, extending south as far as Botswana. Risk for travellers: Travellers are at risk of African sleeping sickness in endemic regions if they visit rural areas for hunting, fishing, safari trips, sailing or other activities in remote areas. Prophylaxis (protective treatment): None. Precautions: Travellers should be aware of the risk in endemic areas and as far as possible avoid any contact with tsetse flies. However, bites are difficult to avoid because tsetse flies can bite through clothing. Travellers should be warned that tsetse flies bite during the day and are not repelled by available insect-repellent products. The bite is painful, which helps to identify its origin, and travellers should seek medical attention promptly if symptoms develop subsequently. Source: WHO.

Typhoid fever

Cause: Salmonella typhi, the typhoid bacillus, which infects only humans. Similar paratyphoid and enteric fevers are caused by other species of Salmonella, which infect domestic animals as well as humans. Transmission: Infection with typhoid fever is transmitted by consumption of contaminated food or water. Occasionally direct faecal-oral transmission may occur. Shellfish taken from sewage-polluted beds are an important source of infection. Infection occurs through eating fruit and vegetables fertilized by night soil and eaten raw, and milk and milk products that have been contaminated by those in contact with them. Flies may transfer infection to foods, resulting in contamination that may be sufficient to cause human infection. Pollution of water sources may produce epidemics of typhoid fever, when large numbers of people use the same source of drinking water. Nature of the disease: Typhoid fever is a systemic disease of varying severity. Severe cases are characterized by gradual onset of fever, headache, malaise, anorexia and insomnia. Constipation is more common than diarrhoea in adults and older children. Without treatment, the disease progresses with sustained fever, bradycardia, hepatosplenomegaly, abdominal symptoms and, in some cases, pneumonia. In white-skinned patients, pink spots (papules), which fade on pressure, appear on the skin of the trunk in up to 50% of cases. In the third week, untreated cases develop additional gastrointestinal and other complications, which may prove fatal. Around 2-5% of those who contract typhoid fever become chronic carriers, as bacteria persist in the biliary tract after symptoms have resolved. Geographical distribution: Worldwide. The disease occurs most commonly in association with poor standards of hygiene in food preparation and handling and where sanitary disposal of sewage is lacking. Risk for travellers: Generally low risk for travellers, except in parts of north and west Africa, in south Asia and in Peru. Elsewhere, travellers are usually at risk only when exposed to low standards of hygiene with respect to food handling, control of drinking water quality, and sewage disposal. Prophylaxis (protective treatment): Vaccination. Precautions: Observe all precautions against exposure to foodborne and waterborne infections. Source: WHO.

Yellow fever

Cause: The yellow fever virus, an arbovirus of the Flavivirus genus. Transmission: Yellow fever in urban and some rural areas is transmitted by the bite of infective Aedes aegypti mosquitoes and by other mosquitoes in the forests of south America. The mosquitoes bite during daylight hours. Transmission occurs at altitudes up to 2,500 metres. Yellow fever virus infects humans and monkeys. In jungle and forest areas, monkeys are the main reservoir of infection, with transmission from monkey to monkey carried out by mosquitoes. The infective mosquitoes may bite humans who enter the forest area, usually causing sporadic cases or small outbreaks. In urban areas, monkeys are not involved and infection is transmitted among humans by mosquitoes. Introduction of infection into densely populated urban areas can lead to large epidemics of yellow fever. In Africa, an intermediate pattern of transmission is common in humid savannah regions. Mosquitoes infect both monkeys and humans, causing localized outbreaks. Nature of the disease: Although some infections are asymptomatic, most lead to an acute illness characterized by two phases. Initially, there is fever, muscular pain, headache, chills, anorexia, nausea and/or vomiting, often with bradycardia. About 15% of patients progress to a second phase after a few days, with resurgence of fever, development of jaundice, abdominal pain, vomiting and haemorrhagic manifestations; half of these patients die 10-14 days after onset of illness. Geographical distribution: The yellow fever virus is endemic in some tropical areas of Africa and central and south America. The number of epidemics has increased since the early 1980s. Other countries are considered to be at risk of introduction of yellow fever due to the presence of the vector and suitable primate hosts (including Asia, where yellow fever has never been reported). Risk for travellers: Travellers are at risk in all areas where yellow fever is endemic. The risk is greatest for visitors who enter forest and jungle areas. Prophylaxis (protective treatment): Vaccination. In some countries, yellow fever vaccination is mandatory for visitors. Precautions: Avoid mosquito bites during the day as well as at night. Endemic Countries: The World Health Organization considers the following countries to be endemic for yellow fever: Angola, Benin, Bolivia, Brazil, Burkino Faso, Burundi, Cameroon, Central African Republic, Chad, Colombia, Congo, Congo, Côte d'Ivoire, Democratic Republic of the Congo, Ecuador, Equatorial Guinea, Ethiopia, French Guyana, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Guyana, Kenya, Liberia, Mali, Niger, Nigeria, Panama, Peru, Rwanda, Sao Tome and Principe, Senegal, Sierra Leone, Somalia, Sudan, Suriname, Togo, Trinidad and Tobago, Uganda, United Republic of Tanzania and Venezuela. Source: WHO.

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