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Before You Go

Health Insurance

Medical insurance is crucial for travel in Rwanda, but policies differ. Check that the policy includes all the activities you want to do. Some specifically exclude ‘dangerous activities’ such as trekking. Also find out whether your insurance will make payments directly to providers or will reimburse you later for overseas health expenditures (in Rwanda 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.

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 Rwanda.

In Rwanda

Availability & Cost of Health Care

Good, Western-style medical care is available in Kigali, and to a lesser extent in Huye (Butare). Elsewhere, reasonable to good care is available in larger towns. If you fall ill in an unfamiliar area, ask staff at top-end hotels or resident expatriates where the best nearby medical facilities are; in an emergency, contact your embassy.

Well-stocked pharmacies are found in major towns. It’s best to bring whatever you think you may need from home, including malaria pills and a malaria test kit. Always check the expiry date before buying medications, especially in smaller towns.

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.

For Western standards, expect to pay Western prices.

Infectious Diseases

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.

Malaria

Malaria is endemic in Rwanda (except at altitudes higher than 2000m, where risk of transmission is low), particularly in eastern Rwanda and during the rainy season.

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, with falciparum malaria the most dangerous type and the predominant form in Rwanda. 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.

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 and present it at immigration upon arrival in Rwanda.

Environmental Hazards

Altitude Sickness

The lack of oxygen at high altitudes (over 2500m) affects most people to some extent. Symptoms of Acute Mountain Sickness (AMS) usually develop in the first 24 hours at altitude but may be delayed up to three weeks. Mild symptoms are headache, lethargy, dizziness, difficulty sleeping and loss of appetite. Severe symptoms are breathlessness, a dry, irritated cough (followed by the production of pink, frothy sputum), severe headache, lack of coordination, confusion, vomiting, irrational behaviour, drowsiness and unconsciousness. There's no rule as to what is too high: AMS can be fatal at 3000m, but 3500m to 4500m is the usual range when it can cause problems. In Rwanda, this can be a problem when trekking in the Volcanoes National Park, where a few summits are over 3000m. Ascend slowly; drink extra fluids; eat light, high-carbohydrated meals for more energy; and avoid alcohol, sedatives and tobacco.

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.

Tsetse flies can also be unwelcome companions in some areas, especially in Akagera National Park, delivering painful, swelling bites. To minimise the nuisance, wear thick, long-sleeved shirts and trousers in khaki or other drab shades, and avoid bright, contrasting and very dark clothing.

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.

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.

Tap Water

Don’t drink tap water in Rwanda unless it has been boiled, filtered or chemically disinfected (such as with iodine tablets). Don’t drink from streams, rivers and lakes. It’s also best to avoid drinking from pumps, boreholes and wells; some bring pure water to the surface, but the presence of animals can contaminate supplies. Bottled water is widely available throughout the country.