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Health

Decent health care is quite easy to access in Addis Ababa, less so elsewhere. Ethiopia certainly has an impressive selection of tropical diseases on offer, but as long as you stay up to date with your vaccinations and take some basic preventive measures, you’re much more likely to get a bout of diarrhoea, a cold or an infected mosquito bite than an exotic disease such as sleeping sickness.

Before You Go

Recommended Vaccinations

The World Health Organization (www.who.int) recommends that all travellers be covered for diphtheria, tetanus, measles, mumps, rubella and polio, as well as for hepatitis B, regardless of their destination. The consequences of these diseases can be severe, and outbreaks of them do occur.

According to the Centers for Disease Control & Prevention (www.cdc.gov), 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. Proof of yellow-fever vaccination is mandatory for travel to Ethiopia. Depending on where you’ve travelled from, cholera vaccination may also be required.

Health Insurance

Medical insurance is crucial, but policies differ. Check that the policy includes all the activities you want to do. Some specifically exclude ‘dangerous activities’ such as white-water rafting, rock climbing and motorcycling. Sometimes even trekking is excluded. Also find out whether your insurance will make payments directly to providers or will reimburse you later for overseas health expenditures (in Ethiopia many doctors expect payment in cash).

Ensure that your travel insurance will cover the emergency transport required 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. 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.

Membership of the African Medical & Research Foundation (www.amref.org) provides an air evacuation service in medical emergencies in many African countries, including Ethiopia. It also provides air-ambulance transfers between medical facilities. Money paid by members for this service goes into providing grassroots medical assistance for local people.

Medical Checklist

It’s a very good idea to carry a medical and first-aid kit with you, to help yourself in the case of minor illness or injury. Following is a list of items you should consider packing.

  • Acetaminophen (paracetamol) or aspirin
  • Acetazolamide (Diamox) for altitude sickness (prescription only)
  • Adhesive or paper tape
  • Antibacterial ointment (eg Bactroban) for cuts and abrasions (prescription only)
  • Antibiotics (see your medical-health professional for the most useful ones to bring)
  • Antidiarrhoeal drugs (eg loperamide)
  • Antihistamines (for hayfever and allergic reactions)
  • Anti-inflammatory drugs (eg ibuprofen)
  • Antimalaria pills
  • Bandages, gauze, gauze rolls
  • DEET-containing insect repellent for the skin
  • Iodine tablets (for water purification)
  • Oral rehydration salts
  • Permethrin-containing insect spray for clothing, tents, and bed nets
  • Pocket knife
  • Scissors, safety pins, tweezers
  • Sterile needles, syringes and fluids if travelling to remote areas
  • Steroid cream or hydrocortisone cream (for allergic rashes)
  • Sunblock
  • Syringes and sterile needles
  • Thermometer

Since falciparum malaria predominates in Ethiopia, consider taking a self-diagnostic kit that can identify malaria in the blood from a finger prick.

Websites

There’s a wealth of travel-health advice on the internet. For further information, 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. It’s also a good idea to consult your government’s travel health website before departure, if one is available.

Australia (www.dfat.gov.au/travel/Pages/travel.aspx)

Canada (www.hc-sc.gc.ca/index-eng.php)

UK (www.gov.uk/foreign-travel-advice)

USA (wwwnc.cdc.gov/travel)

Other websites of general interest:

Centers for Disease Control and Prevention (www.cdc.gov)

Fit for Travel (www.fitfortravel.scot.nhs.uk) Up-to-date information about outbreaks and is very user-friendly for travellers on the road.

MD Travel Health (www.mdtravelhealth.com) Provides complete travel health recommendations for every country, updated daily, at no cost.

In Ethiopia

Infectious Diseases

The list of diseases that you could conceivably catch in Ethiopia is lengthy, but in truth you'd be extremely unlucky to catch any of them.

Cholera

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. It’s caused by a bacteria and spread via contaminated drinking water. The main symptom is profuse watery diarrhoea, which causes debilitation if fluids are not replaced quickly. An oral cholera vaccine is available in the USA, but it’s not particularly effective. Most cases of cholera 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 isn’t advised.

Dengue Fever (Break-Bone Fever)

Spread through the bite of the mosquito, dengue fever causes a feverish illness with headache and muscle pains similar to those experienced with a bad, prolonged attack of influenza. There might be a rash. Mosquito bites should be avoided whenever possible. Self-treatment: paracetamol and rest. Aspirin should be avoided.

Diphtheria

Found in all of Africa, diphtheria is spread through close respiratory contact. It usually causes a temperature and a severe sore throat. Sometimes a membrane forms across the throat, and a tracheotomy is needed to prevent suffocation. Vaccination is recommended for 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.

Filariasis

Tiny worms migrating in the lymphatic system cause filariasis. The bite from an infected mosquito spreads the infection. Symptoms include localised itching and swelling of the legs and/or genitalia. Treatment is available.

Hepatitis A

Hepatitis A is spread through contaminated food (particularly shellfish) and water. It causes jaundice and, although it’s 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. 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.

Hepatitis B

Hepatitis B is spread through infected blood, contaminated needles and sexual intercourse. It can also be spread from an infected mother to the baby during childbirth. It affects 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. Those visiting high-risk areas for long periods or those with increased social or occupational risk should be immunised.

Many countries now give hepatitis B as part of the routine childhood vaccinations. It’s given singly or can be given at the same time as hepatitis A (hepatyrix). A course will give protection for at least five years. It can be given over four weeks or six months.

HIV

HIV, the virus that causes AIDS, is an enormous problem throughout Ethiopia and Djibouti. The virus is 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. At present there’s no cure; medication that might keep the disease under control is available, but these drugs are too expensive for the overwhelming majority of Africans, and are not readily available for travellers either. If you think you might have been infected with HIV, a blood test is necessary; a three-month gap after exposure and before testing is required to allow antibodies to appear in the blood.

Leishmaniasis

This is spread through the bite of an infected sandfly. It can cause a slowly growing skin lump or ulcer (the cutaneous form) and sometimes a life-threatening fever with anaemia and weight loss. Dogs can also be carriers of the infection. Sandfly bites should be avoided whenever possible.

Leptospirosis

It’s spread through the excreta of infected rodents, especially rats. It can cause hepatitis and renal failure, which might be fatal. It’s unusual for travellers to be affected unless living in poor sanitary conditions. It causes a fever and sometimes jaundice.

Malaria

Malaria is a serious problem in Ethiopia, with one to two million new cases reported each year. Though malaria is generally absent at altitudes above 1800m, epidemics have occurred in areas above 2000m in Ethiopia. The central plateau, Addis Ababa, the Bale and Simien Mountains, and most of the northern Historical Circuit are usually considered safe areas, but they’re not risk-free.

For short-term visitors, it’s probably wise to err on the side of caution. If you’re thinking of travelling outside these areas, you shouldn’t think twice – take prophylactics.

The antimalarial A to D

  • 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 have been taken.
  • B – Bites are to be avoided 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. 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.

Cause

The disease is caused by a parasite in the bloodstream spread via the bite of the female Anopheles mosquito. There are several types of malaria – falciparum malaria is the most dangerous type and makes up 70% of the cases in Ethiopia. Infection rates vary with season and climate, so check out the situation before departure. Unlike most other diseases regularly encountered by travellers, there’s 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.

Medication

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 of the medication depend on the drug being taken. Doxycycline can cause heartburn, indigestion and increased sensitivity to sunlight; mefloquine (Larium) can cause anxiety attacks, insomnia and nightmares, and (rarely) severe psychiatric disorders; chloroquine can cause nausea and hair loss; and atovaquone and proguanil hydrochloride (malarone) can cause diarrhoea, abdominal pain and mouth ulcers.

These 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.

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 flu-like symptoms to a doctor as soon as possible. Some people advocate homeopathic preparations against malaria, such as Demal200, but as yet there’s no conclusive evidence that this is effective, and many homeopaths don’t recommend their use.

Stand-by Treatment

If you’re 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 used only if you’ll be far 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 were 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. As mentioned earlier, self-diagnostic kits, which can identify malaria in the blood from a finger prick, are also available in the West.

Symptoms

Malaria can present in several ways. 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. Anyone who develops a fever in a malarial area should assume they have a malarial infection until a blood test proves negative, even if they 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, and the death rate might still be as high as 10%, even in the best intensive-care facilities in the country.

Meningococcal Meningitis

Meningococcal infection is spread through close respiratory contact and is more likely in crowded situations, such as buses. Infection is uncommon in travellers. Vaccination is recommended for long stays and is especially important towards the end of the dry season. Symptoms include a fever, severe headache, neck stiffness and a red rash. 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; it’s safe to be given both types of vaccine.

Onchocerciasis (River Blindness)

This is caused by the larvae of a tiny worm, which is spread by the bite of a small fly. The earliest sign of infection is intensely itchy, red, sore eyes. Travellers are rarely severely affected. Treatment in a specialised clinic is curative.

Poliomyelitis

Generally spread through contaminated food and water. It’s 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. Polio can be carried asymptomatically (ie showing no symptoms) and could cause a transient fever. In rare cases it causes weakness or paralysis of one or more muscles, which might be permanent.

Rabies

Rabies is spread by receiving the bites or licks of an infected animal on broken skin. It’s always fatal once the clinical symptoms start (which might be up to several months after an infected bite), so post-bite vaccination should be given as soon as possible. Post-bite 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 post-bite vaccine isn’t available within 24 hours. Three preventive injections are needed over a month. If you have not been vaccinated you’ll need a course of five injections starting 24 hours or as soon as possible after the injury. If you have been vaccinated, you’ll need fewer post-bite injections, and have more time to seek medical help.

Schistosomiasis (Bilharzia)

This disease is spread by flukes (minute worms) that are carried by a species of freshwater snail. The flukes are carried inside the snail, which then 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’re passed out via stool or urine and could contaminate fresh water, where the cycle starts again. Paddling or swimming in suspect freshwater lakes or slow-running rivers should be avoided. 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. 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 not treated the infection can cause kidney failure or permanent bowel damage. It’s not possible for you to infect others.

Travellers’ Diarrhoea

Although it’s not inevitable that you’ll get diarrhoea while travelling in Ethiopia, it’s certainly very likely. Diarrhoea is the most common travel-related illness: figures suggest that at least half of all travellers will get diarrhoea at some stage. Sometimes dietary changes, such as increased spices or oils, are the cause. To help prevent diarrhoea, avoid tap water. 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 (lots), and some salt and sugar. 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 antidiarrhoeal agent (such as loperamide) if you’re not within easy reach of a toilet. If diarrhoea is bloody, persists for more than 72 hours or is accompanied by fever, shaking chills or severe abdominal pain, seek medical attention.

Amoebic Dysentery

Contracted by eating contaminated food and water, amoebic dysentery causes blood and mucus in the faeces. It can be relatively mild and tends to come on gradually, but seek medical advice if you think you have the illness as it won’t clear up without treatment (which is with specific antibiotics).

Giardiasis

Caused by ingesting contaminated food or water. The illness usually appears a week or more after you have been exposed to the offending parasite. Giardiasis might cause only a short-lived bout of typical travellers’ diarrhoea, but it can also cause persistent diarrhoea. Ideally, seek medical advice if you suspect you have giardiasis.

Tuberculosis (TB)

TB is spread through close respiratory contact and occasionally through infected milk or milk products. BCG vaccination is recommended for those likely to be mixing closely with the local population, although it gives only moderate protection against TB. It’s more important for long stays than for short-term stays. Inoculation with the BCG vaccine isn’t available in all countries. It’s given routinely to many children in developing countries. The vaccination causes a small permanent scar at the site of injection, and is usually given in a specialised chest clinic. It’s a live vaccine and should not be given to pregnant women or immunocompromised individuals.

TB 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.

Trypanosomiasis (Sleeping Sickness)

Spread via the bite of the tsetse fly. It causes a headache, fever and eventually coma. There’s an effective treatment.

Typhoid

This is spread through food or water contaminated by infected human faeces. The first symptom is usually a fever or a pink rash on the abdomen. Sometimes septicaemia (blood poisoning) can occur. 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.

Yellow Fever

Yellow fever is spread by infected mosquitoes. Symptoms range from a flu-like illness to severe hepatitis (liver inflammation), jaundice and death. The yellow-fever vaccination must be given at a designated clinic and is valid for 10 years. It’s a live vaccine and must not be given to immunocompromised or pregnant travellers.

Travellers must carry a certificate as evidence of vaccination to obtain a visa for Ethiopia. You may also have to present it at immigration upon arrival. There’s 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.

Environmental Hazards

High temperatures mean that you should pay close attention to your fluid intake and make sure that you use some protection from the sun. Bites and stings from insects are common but relatively easy to prevent, while snake bites are extremely rare.

Heat Exhaustion

This condition 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 include headache, dizziness and tiredness. Dehydration is already happening by the time you feel thirsty; aim to drink sufficient water to produce pale, diluted urine. Take particular care in the Danakil Depression.

Self-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.

Heatstroke

Heat exhaustion is a precursor to the much more serious condition of heatstroke. In this case there’s damage to the sweating mechanism, with an excessive rise in body temperature; irrational and hyperactive behaviour; and eventually loss of consciousness and death. Rapid cooling by spraying the body with water and fanning is ideal. Emergency fluid and electrolyte replacement is usually also required by intravenous drip.

Insect Bites & Stings

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 as you would for avoiding malaria. Use DEET-based insect 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’re one of these people, carry an ‘epipen’: an adrenaline (epinephrine) injection, which you can give yourself. This could save your life.

Scorpions are frequently found in arid or dry climates. They can cause a painful bite that is sometimes life-threatening. If bitten by a scorpion, take a painkiller. Medical treatment should be sought if collapse occurs.

Fleas and bed bugs are often found in cheap hotels. Fleas are also common on local and long-distance buses and in the rugs of some remote churches. They lead to very itchy, lumpy bites. Spraying the mattress with crawling-insect killer after removing 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.

Snake Bites

Basically, do all you can to avoid getting bitten! Do not walk barefoot, or stick your hand into holes or cracks. However, 50% of people bitten by venomous snakes are not actually injected with poison (envenomed). If you are 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 try to cut or suck the bite. Get medical help as soon as possible so you can get treated with an antivenene if necessary.

Tape Worms

These parasites are relatively common in Ethiopia and the Horn. Eating Ethiopian traditional food like kitfo and tere sega (raw meat dishes) in rural areas is usually the cause. Consider having your stool tested when you get home to avoid future health problems.

Availability & Cost of Health Care

Health care in Ethiopia is varied: Addis Ababa has good facilities with well-trained doctors and nurses, but outside the capital health care is patchy at best. Medicine and even sterile dressings and intravenous fluids might need to be purchased from a local pharmacy by patients or their relatives. The standard of dental care is equally variable, and there’s an increased risk of hepatitis B and HIV transmission via poorly sterilised equipment. By and large, public hospitals in the region offer the cheapest service, but will have the least up-to-date equipment and medications; mission hospitals (where donations are the usual form of payment) often have more reasonable facilities; and private hospitals and clinics are more expensive but tend to have more advanced drugs and equipment and better trained medical staff.

Most drugs can be purchased over the counter in the region, without a prescription. Try to visit a pharmacy rather than a ‘drug shop’ or ‘rural drug vendor’, as they’re the only ones with trained pharmacists who can offer educated advice. Many drugs for sale in 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 larger towns, but remote villages will be lucky to have a couple of paracetamol tablets. It’s strongly recommended that all drugs for chronic diseases be brought from home.

Although condoms are readily available (sometimes boxes – yes boxes! – are in hotel rooms), their efficacy cannot be relied upon, so bring all the contraception you’ll need. Condoms bought in Africa might not be of the same quality as in Europe or Australia, and they might have been incorrectly stored.

There’s a high risk of contracting HIV from infected blood if you receive a blood transfusion in the region. 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.

Tap Water

Never drink tap water unless it has been boiled, filtered or chemically disinfected (such as with iodine tablets). Never drink from streams, rivers and lakes. It’s also best to avoid drinking from pumps and wells: some do bring pure water to the surface, but the presence of animals can still contaminate supplies.

Bottled water is available everywhere, though it’s better for the environment if you treat/filter local water.