Dr Caroline Evans
As long as you stay up to date with your vaccinations and take some basic preventive measures, you'd have to be pretty unlucky to succumb to most of the health hazards covered in this chapter. Africa certainly has an impressive selection of tropical diseases on offer, but you're much more likely to get a bout of diarrhoea (in fact, you should bank on it), a cold or an infected mosquito bite than an exotic disease such as Rift Valley or West Nile fever. When it comes to injuries (as opposed to illness), the most likely reason for needing medical help in Africa is as a result of road accidents – vehicles are rarely well maintained, the roads are potholed and poorly lit, and drink driving is common.
Find out in advance whether your insurance plan will make payments directly to providers or will reimburse you later for overseas health expenditures (in many countries doctors expect payment in cash). It's vital to ensure that your travel insurance will cover the emergency transport to get you to a hospital in a major city, to better medical facilities elsewhere in Africa, or all the way home, by air and with a medical attendant if necessary. Not all insurance covers this, so check the contract carefully. If you need medical help, your insurance company might be able to help locate the nearest hospital or clinic, or you can ask at your hotel. In an emergency, contact your embassy or consulate.
The World Health Organization (www.who.int/ith) recommends that all travellers be covered for diphtheria, tetanus, measles, mumps, rubella and polio, as well as for hepatitis B, regardless of their destination. Planning to travel is a great time to ensure that all routine vaccination cover is complete. The consequences of these particular diseases can be severe, and outbreaks do occur.
According to the Centers for Disease Control and Prevention (www.cdc.gov/travel), the following vaccinations are recommended for all parts of Africa: hepatitis A, hepatitis B, meningococcal meningitis, rabies and typhoid, and boosters for tetanus, diphtheria and measles. A yellow-fever vaccination is not necessarily recommended for all parts of Africa, although the certificate is an entry requirement for a number of countries.
If you are travelling through a malarial area – particularly an area in which falciparum malaria predominates – consider taking a self-diagnostic kit that can identify malaria in the blood from a finger prick.
There is a wealth of travel health advice on the internet. For further information, the Lonely Planet website at www.lonelyplanet.com is a good place to start. The World Health Organization publishes a superb book called International Travel and Health, which is revised annually and is available online at no cost at www.who.int/ith. Other websites of general interest are MD Travel Health at www.mdtravelhealth.com, which provides complete travel health recommendations for every country, updated daily, also at no cost; the Centers for Disease Control and Prevention at www.cdc.gov; and Fit for Travel at www.fitfortravel.scot.nhs.uk, which has up-to-date information about outbreaks and is very user-friendly.
It's also a good idea to consult your government's travel health website before departure, if one is available:
A Comprehensive Guide to Wilderness and Travel Medicine by Eric A Weiss (1998)
How to Stay Healthy Abroad by Richard Dawood (2002)
The Essential Guide to Travel Health by Jane Wilson-Howarth (2009)
Travel in Health by Graham Fry (1994)
Cholera is usually only a problem during natural or artificial disasters, eg war, floods or earthquakes, although small outbreaks can also occur at other times. Travellers are rarely affected.
Spread through Contaminated drinking water.
Symptoms and effects Profuse watery diarrhoea, which causes collapse if fluids are not replaced quickly.
Prevention and treatment Most cases could be avoided by close attention to good drinking water and by avoiding potentially contaminated food. Treatment is by fluid replacement (orally or via a drip), but sometimes antibiotics are needed. Self-treatment is not advised.
Present Sudan, Cameroon, Democratic Republic of Congo (DRC), Senegal, Burkina Faso, Guinea, Ethiopia, Djibouti, Somalia, Madagascar, Mozambique and South Africa.
Spread through Mosquito bites.
Symptoms & effects A feverish illness with headache and muscle pains similar to those experienced with a bad, prolonged attack of influenza. There might be a rash.
Prevention and treatment Mosquito bites should be avoided whenever possible. Self-treatment: paracetamol and rest.
In rare cases in Africa this becomes Severe Dengue Fever, with worsening symptoms including vomiting, rapid breathing and abdominal pain. Seek medical help, as this can be fatal.
Present Throughout Africa.
Spread through Close respiratory contact.
Symptoms and effects Usually causes a temperature and a severe sore throat. Sometimes a membrane forms across the throat, and a tracheostomy is needed to prevent suffocation.
Prevention and treatment Vaccination is recommended for all travellers, particularly those likely to be in close contact with the local population in infected areas. More important for long stays than for short-term trips. The vaccine is given as an injection alone or with tetanus, and lasts 10 years. Self-treatment: none.
Present Most parts of West, Central, East and southern Africa, and in Sudan in North Africa.
Spread through Mosquito bites, then tiny worms migrating in the lymphatic system.
Symptoms and effects Can include localised itching and swelling of the legs and or genitalia.
Prevention and treatment Avoid mosquito bites. Treatment is available, but self-treatments are not.
Present Throughout Africa.
Spread through Contaminated food (particularly shellfish) and water.
Symptoms and effects Jaundice and, although it is rarely fatal, it can cause prolonged lethargy and delayed recovery. If you've had hepatitis A, you shouldn't drink alcohol for up to six months afterwards, but once you've recovered, there won't be any long-term problems. The first symptoms include dark urine and a yellow colour to the whites of the eyes. Sometimes a fever and abdominal pain might be present.
Prevention and treatment Hepatitis A vaccine (Avaxim, VAQTA, Havrix) is given as an injection: a single dose will give protection for up to a year, and a booster after a year gives 10-year protection. Hepatitis A and typhoid vaccines can also be given as a single-dose vaccine, hepatyrix or viatim. Self-treatment: none.
Present Thoughout Africa.
Spread through Infected blood, contaminated needles and sexual intercourse. It can also be spread from an infected mother to the baby during childbirth.
Symptoms and effects Attacks the liver, causing jaundice and occasionally liver failure. Most people recover completely, but some people might be chronic carriers of the virus, which could lead eventually to cirrhosis or liver cancer.
Prevention and treatment Those visiting high-risk areas for long periods or at social or occupational risk should be immunised. Many countries now give hepatitis B as part of the routine childhood vaccination. It is given singly or can be given at the same time as hepatitis A. A course will give protection for at least five years. It can be given over four weeks or six months. Self-treatment: none.
Present Throughout Africa.
Spread through Infected blood and blood products, by sexual intercourse with an infected partner, and from an infected mother to her baby during childbirth and breastfeeding. It can be spread through 'blood to blood' contacts, such as with contaminated instruments during medical, dental, acupuncture and other body-piercing procedures, and through sharing used intravenous needles.
Prevention and treatment At present there is no cure; medication that might keep the disease under control is available, but many countries in Africa do not have access to it for their own citizens, let alone for travellers. If you think you might have put yourself at risk of HIV infection, a blood test is necessary; a three-month gap after the exposure and before testing is required to allow antibodies to appear in the blood. Self-treatment: none.
Present North Africa.
Spread through Bite of an infected sandfly.
Symptoms and effects Can cause a slowly growing skin lump or ulcer (the cutaneous form) and sometimes develop into a serious life-threatening fever with anaemia and weight loss. Dogs can also be carriers of Leishmaniasis.
Prevention and treatment Sandfly and dog bites should be avoided whenever possible. Self-treatment: none.
Present West and southern Africa; in Chad, Congo and DRC in Central Africa; in Algeria, Morocco and Sudan in North Africa; and in Ethiopia and Somalia in East Africa.
Spread through The excreta of infected rodents, especially rats.
Symptoms and effects A fever, sometimes jaundice, hepatitus and renal failure.
Prevention and treatment It is unusual for travellers to be affected unless living in poor sanitary conditions.Self-treatment: none.
Present Endemic in Central, East, West and southern Africa; slight risk in North Africa (except for Sudan, where the risk is significant). The risk of malarial transmission at altitudes higher than 2000m is rare.
Spread through The bite of the female Anopheles mosquito. There are several types of malaria; falciparum malaria is the most dangerous type and the predominant form in Africa. Infection rates vary with season and climate, so check out the situation before departure. Unlike most other diseases regularly encountered by travellers, there is no vaccination against malaria (yet). However, several different drugs are used to prevent malaria, and new ones are in the pipeline. Up-to-date advice from a travel health clinic is essential, as some medication is more suitable for some travellers than others. The pattern of drug-resistant malaria is changing rapidly, so what was advised several years ago might no longer be the case.
Symptoms and effects The early stages include headaches, fevers, generalised aches and pains, and malaise, which could be mistaken for flu. Other symptoms can include abdominal pain, diarrhoea and a cough.
Prevention and treatment Anyone who develops a fever in a malarial area should assume malarial infection until a blood test proves negative, even if you have been taking antimalarial medication. If not treated, the next stage could develop within 24 hours (particularly if falciparum malaria is the parasite): jaundice, then reduced consciousness and coma (also known as cerebral malaria) followed by death. Treatment in hospital is essential, though the death rate might still be as high as 10% even in the best intensive-care facilities.
Many travellers are under the impression that malaria is a mild illness, that treatment is always easy and successful, and that taking antimalarial drugs causes more illness through side effects than actually getting malaria. In Africa, this is unfortunately not true. Side effects depend on the drug being taken. Doxycycline can cause heartburn and indigestion; mefloquine (Larium) can cause anxiety attacks, insomnia and nightmares, and (rarely) severe psychiatric disorders; chloroquine can cause nausea and hair loss; and proguanil can cause mouth ulcers. Side effects are not universal, and can be minimised by taking medication correctly, eg with food. Also, some people should not take a particular antimalarial drug, eg people with epilepsy should avoid mefloquine, and doxycycline should not be taken by pregnant women or children younger than 12.
People of all ages can contract malaria, and falciparum malaria causes the most severe illness. Repeated infections might result eventually in less serious illness. Malaria in pregnancy frequently results in miscarriage or premature labour. Adults who have survived childhood malaria have developed immunity and usually only develop mild cases of malaria; most Western travellers have no immunity at all. Immunity wanes after 18 months of nonexposure, so even if you have had malaria in the past and used to live in a malaria-prone area, you might no longer be immune. One million children die annually from malaria in Africa.
If you decide that you really do not wish to take antimalarial drugs, you must understand the risks, and be obsessive about avoiding mosquito bites. Use nets and insect repellent, and report any fever or flulike symptoms to a doctor as soon as possible. Some people advocate homeopathic preparations against malaria, such as Demal200, but as yet there is no conclusive evidence that they are effective, and many homeopaths do not recommend their use.
If you are planning a journey through a malarial area, particularly where falciparum malaria predominates, consider taking stand-by treatment. Emergency stand-by treatment should be seen as emergency treatment aimed at saving the patient's life and not as routine self-medication. It should be advised only if you will be remote from medical facilities and have been advised about the symptoms of malaria and how to use the medication. Medical advice should be sought as soon as possible to confirm whether the treatment has been successful. The type of stand-by treatment used will depend on local conditions, such as drug resistance, and on what antimalarial drugs are being used before stand-by treatment. This is worthwhile because you want to avoid contracting a particularly serious form such as cerebral malaria, which affects the brain and central nervous system and can be fatal in 24 hours. Self-diagnostic kits, which can identify malaria in the blood from a finger prick, are also available in the West.
The risks from malaria to both mother and foetus during pregnancy are considerable. Unless good medical care can be absolutely guaranteed, travel throughout Africa when pregnant – particularly to malarial areas – should be discouraged unless essential. Self-treatment: see stand-by treatment if you are more than 24 hours away from medical help.
A Awareness of the risk. No medication is totally effective, but protection of up to 95% is achievable with most drugs, as long as other measures are taken.
B Bites – avoid at all costs. Sleep in a screened room, use a mosquito spray or coils, sleep under a permethrin-impregnated net at night. Cover up at night with long trousers and long sleeves, preferably with permethrin-treated clothing. Apply appropriate repellent to all areas of exposed skin in the evenings.
C Chemical prevention (ie antimalarial drugs) is usually needed in malarial areas. Expert advice is needed as resistance patterns can change, and new drugs are in development. Not all antimalarial drugs are suitable for everyone, particularly for children, pregnant women or people with depression or epilepsy. Most antimalarial drugs need to be started at least a week in advance and continued for four weeks after the last possible exposure to malaria.
D Diagnosis. If you have a fever or flulike illness within a year of travel to a malarial area, malaria is a possibility, and immediate medical attention is necessary.
Present Central, West and East Africa; only in Sudan in North Africa; and only in Namibia, Malawi, Mozambique and Zambia in southern Africa.
Spread through Close respiratory contact and is more likely in crowded situations, such as dormitories, buses and clubs. Infection is uncommon in travellers. Vaccination is recommended for long stays and especially towards the end of the dry season, which is normally from June to November.
Symptoms and effects Fever, severe headache, neck stiffness and a red rash.
Prevention and treatment Immediate medical treatment is necessary. The ACWY vaccine is recommended for all travellers in sub-Saharan Africa. This vaccine is different from the meningococcal meningitis C vaccine given to children and adolescents in some countries, and it is safe to be given both types of vaccine. Self-treatment: none.
Present Throughout Africa.
Spread through Contaminated food and water.
Symptoms and effects Polio can be carried asymptomatically (ie showing no symptoms) and can cause a transient fever. In rare cases it causes weakness or paralysis of one or more muscles, which might be permanent.
Prevention and treatment It is one of the vaccines given in childhood and should be boosted every 10 years, either orally (a drop on the tongue) or as an injection. Self-treatment: none.
Present Throughout Africa.
Spread through The bites or licks of an infected animal on broken skin.
Symptoms and effects It is always fatal once the clinical symptoms start (which might be up to several months after an infected bite), so postbite vaccination should be given as soon as possible.
Prevention and treatment Avoid contact with animals, particularly dogs. Postbite vaccination (whether or not you've been vaccinated before the bite) prevents the virus from spreading to the central nervous system. Animal handlers should be vaccinated, as should those travelling to remote areas where a reliable source of postbite vaccine is not available within 24 hours. Three preventive injections are needed over a month. If you have not been vaccinated you will need a course of five injections starting 24 hours or as soon as possible after the injury. If you have been vaccinated, you will need fewer postbite injections, and have more time to seek medical help. Self-treatment: none.
Present Throughout Africa with possible exception of Morocco, Algeria and Libya.
Spread through Flukes (minute worms) that are carried by a species of freshwater snail. The flukes are carried inside the snail, which sheds them into slow-moving or still water. The parasites penetrate human skin during paddling or swimming and then migrate to the bladder or bowel. They are passed out via stool or urine and could contaminate fresh water, where the cycle starts again.
Symptoms and effects There might be no symptoms. There might be a transient fever and rash, and advanced cases might have blood in the stool or in the urine.
Prevention and treatment Avoid paddling or swimming in freshwater lakes or slow-running rivers anywhere. A blood test can detect antibodies if you might have been exposed, and treatment is then possible in specialist travel or infectious disease clinics. If left untreated the infection could cause kidney failure or permanent bowel damage. It is not possible for you to infect others. Self-treatment: none.
Present Throughout Africa.
Spread through Close respiratory contact and occasionally through infected milk or milk products.
Symptoms and effects Can be asymptomatic, only being picked up on a routine chest X-ray. Alternatively, it can cause a cough, weight loss or fever, sometimes months or even years after exposure.
Prevention and treatment BCG vaccination is recommended for those likely to be mixing closely with the local population. It is more important for long stays than for short-term stays. Inoculation with the BCG vaccine is not available in all countries. It is given routinely to many children in developing countries. In some countries, for example the UK, it is given to babies if they will be travelling with their families to areas with a high-risk of TB, and to previously unvaccinated school-age children if they live in areas of higher TB risk (eg multiethnic immigrant populations). The BCG gives a moderate degree of protection against TB. It causes a small permanent scar at the site of injection, and is usually given in a specialised chest clinic. It is a live vaccine and should not be given to pregnant women or immunocompromised individuals. Self-treatment: none.
Present Throughout Africa.
Spread through Food or water contaminated by infected human faeces.
Symptoms and effects Starts usually with a fever or a pink rash on the abdomen. Sometimes septicaemia (blood poisoning) can occur.
Prevention and treatment A typhoid vaccine (typhim Vi, typherix) will give protection for three years. In some countries, the oral vaccine Vivotif is also available. Antibiotics are usually given as treatment, and death is rare unless septicaemia occurs. Self-treatment: none.
Present West Africa, parts of Central and Eastern Africa. Travellers should carry a certificate as evidence of vaccination if they have recently been in an infected country, to avoid any possible difficulties with immigration. For a full list of these countries visit the Centers for Disease Control and Prevention website (www.cdc.gov/travel.htm). There is always the possibility that a traveller without a legally required, up-to-date certificate will be vaccinated and detained in isolation at the port of arrival for up to 10 days or possibly repatriated.
Spread through Infected mosquitoes.
Symptoms and effects Range from a flulike illness to severe hepatitis (liver inflammation), jaundice and death.
Prevention and treatment The yellow fever vaccination must be given at a designated clinic and is valid for 10 years. It is a live vaccine and must not be given to immunocompromised or pregnant travellers. Self-treatment: none.
The following list is a guide only. Please check with your doctor and the embassy of the country to which you are travelling for the most recent requirements.
Central Africa Mandatory in Central African Republic (CAR), Congo, DRC, Equatorial Guinea and Gabon, and recommended in Chad.
East Africa Mandatory in Rwanda and Uganda; it is advised for Burundi, Ethiopia, Kenya, Somalia and Tanzania.
North Africa Not mandatory for any areas of North Africa, but Algeria, Libya and Tunisia require evidence of yellow fever vaccination if entering from an infected country. It is recommended for travellers to Sudan, and might be given to unvaccinated travellers leaving the country.
Southern Africa Not mandatory for entry into any countries of southern Africa, although it is necessary if entering from an infected country.
West Africa Mandatory in Benin, Burkina Faso, Cameroon, Côte d'Ivoire, Ghana, Liberia, Mali, Niger, São Tomé & Príncipe and Togo, and recommended for The Gambia, Guinea, Guinea-Bissau, Mauritania, Nigeria, Senegal and Sierra Leone.
Present Throughout Africa. Although it's not inevitable that you will get diarrhoea, it's certainly very likely. Diarrhoea is the most common travel-related illness – figures suggest that at least half of all travellers to Africa will get diarrhoea at some stage.
Spread through Sometimes caused by dietary changes, such as increased spices or oils.
Symptoms and effects A few loose stools don't require treatment, but if you start having more than four or five stools a day, you should start taking an antibiotic (usually a quinoline drug, such as ciprofloxacin or norfloxacin) and an antidiarrheal agent (such as loperamide) if you are not within easy reach of a toilet.
Prevention and treatment To help prevent diarrhoea, avoid tap water unless you're sure it's safe to drink. You should also only eat fresh fruits or vegetables if cooked or peeled, and be wary of dairy products that might contain unpasteurised milk. Although freshly cooked food can often be a safe option, plates or serving utensils might be dirty, so you should be highly selective when eating food from street vendors (make sure that cooked food is piping hot all the way through).
If you develop diarrhoea, be sure to drink plenty of fluids, preferably an oral rehydration solution containing water, and salt and sugar. If diarrhoea is bloody, persists for more than 72 hours or is accompanied by fever, shaking chills or severe abdominal pain, you should seek medical attention.
Present Throughout Africa
Spread through Eating contaminated food and water
Symptoms and effects Amoebic dysentry causes blood and mucus in the faeces. It can be relatively mild and tends to come on gradually. Giardiasis usually appears a week or more after you have been exposed to the offending parasite. It causes only a short-lived bout of typical travellers' diarrhoea, but it can also cause persistent diarrhoea.
Prevention and treatment Seek medical advice as soon as possible if you think you have either illness as they won't clear up without treatment (which is with specific antibiotics).
Causes Heat exhaustion is a precursor to the much more serious condition of heatstroke.
Symptoms and effects Damage to the sweating mechanism, with an excessive rise in body temperature; irrational and hyperactive behaviour; and eventually loss of consciousness and death.
Treatment Rapid cooling by spraying the body with water and fanning is ideal. Emergency fluid and electrolyte replacement is often also required by intravenous drip.
Causes Occurs following heavy sweating and excessive fluid loss with inadequate replacement of fluids and salt, and is particularly common in hot climates when taking unaccustomed exercise before full acclimatisation.
Symptoms and effects Headache, dizziness and tiredness.
Prevention Dehydration is already happening by the time you feel thirsty – aim to drink sufficient water to produce pale, diluted urine.
Treatment Fluid replacement with water and/or fruit juice, and cooling by cold water and fans. The treatment of the salt loss component consists of consuming salty fluids, as in soup, and adding a little more table salt to foods than usual.
Basically, avoid getting bitten! Do not walk barefoot, or stick your hand into holes or cracks. However, 50% of those bitten by venomous snakes are not actually injected with poison (envenomed). If bitten by a snake, do not panic. Immobilise the bitten limb with a splint (such as a stick) and apply a bandage over the site, with firm pressure – similar to bandaging a sprain. Do not apply a tourniquet, or cut or suck the bite. Get the victim to medical help as soon as possible, where antivenom can be given if needed.
Mosquitoes might not always carry malaria or dengue fever, but they (and other insects) can cause irritation and infected bites. To avoid these, take the same precautions you would for avoiding malaria. Use DEET-based insect repellents, although these are not the only effective repellents. Excellent clothing treatments are also available; mosquitoes that land on treated clothing will die.
Bee and wasp stings cause real problems only to those who have a severe allergy to the stings (anaphylaxis.) If you are one of these people, make sure you carry an 'epipen' – an adrenalin (epinephrine) injection, which you can give yourself. This could save your life.
Sandflies are found around the Mediterranean beaches. They usually only cause a nasty itchy bite but can carry a rare skin disorder called cutaneous Leishmaniasis. Prevention of bites with DEET-based repellents is sensible.
Scorpions are frequently found in arid climates. They can cause a painful sting that is sometimes life-threatening. If stung by a scorpion, take a painkiller. Medical treatment should be sought if collapse occurs.
Bed bugs are often found in hostels and cheap hotels. They lead to very itchy, lumpy bites. Spraying the mattress with crawling insect killer after changing bedding will get rid of them.
Scabies is also frequently found in cheap accommodation. These tiny mites live in the skin, particularly between the fingers. They cause an intensely itchy rash. The itch is easily treated with malathion and permethrin lotion from a pharmacy; other members of the household also need treating to avoid spreading scabies, even if they do not show any symptoms.
At least 80% of the African population relies on traditional medicine, either because they can't afford conventional Western-style medicine, because of prevailing cultural attitudes and beliefs, or simply because (in some cases) it works. It might also be because there's often no other choice.
Rather than attempting to entirely stamp out traditional practices, or simply pretend they are not happening, a positive first step taken by some African countries is the regulation of traditional medicine through the creation of healers' associations and by offering courses on such topics as sanitary practices. Although it remains unlikely that even a basic level of conventional Western-style medicine will be made available to all the people of Africa any time soon, traditional medicine will almost certainly continue to be practised widely throughout the continent.
Health care in Africa is varied: it can be excellent in the major cities, which generally have well-trained doctors and nurses, but it is often patchy off the beaten track.
Most drugs can be purchased over the counter throughout Africa, without a prescription. Many drugs for sale within Africa might be ineffective – they might be counterfeit or might not have been stored under the right conditions. The most common examples of counterfeit drugs are malaria tablets and expensive antibiotics, such as ciprofloxacin. Most drugs are available in capital cities, but in remote villages you will be lucky to find a couple of paracetamol tablets. It is strongly recommended that all drugs for chronic diseases be brought with you from home. Also, the availability and efficacy of condoms cannot be relied upon – bring all the contraception you'll need. Condoms bought in Africa might not be of the same quality as in Europe, North America or Australia, and they might have been stored in too hot an environment. Keep all condoms as cool as you can.
There is a high risk of contracting HIV from infected blood if you receive a blood transfusion in Africa. The BloodCare Foundation (www.bloodcare.org.uk) is a useful source of safe, screened blood, which can be transported to any part of the world within 24 hours.
The cost of health care might seem very cheap compared to first-world countries, but good care and drugs might be not be available. Evacuation to good medical care (within Africa or to your own country) can be very expensive indeed. Unfortunately, adequate – let alone good – health care is available only to very few residents of Africa.