Travel Medicine Consult: Destination Ethiopia

I don't blog for weeks, and now three blogs almost simultaneously.....hmm..maybe I am procrastinating (big assignment due on Monday).

I notice on a lot of the Ethiopian adoption forums many discussion about vaccinations necessary for travel to Ethiopia.  Because I work in travel medicine (and am pro-vaccine)  I thought I would write a travel medicine consult for a trip to Ethiopia, just like I would give a patient who came into my office.  Take it or leave it, but here is what I would advise.

I am going to break this post up a bit, start with vaccines and then go into other diseases/ infections later...

Re: Comments after I post this

I know that a lot of people do not get any vaccines and have strong beliefs regarding this.  Many people travel, and do not get sick.  That is great!  However, this post is what I would advise someone from a medical perspective in travel health.  I would advise patients to receive vaccines and go as prepared as possible for any unwanted medical conditions.  

General:

Ethiopia falls within the lowest 25% of the world economies.  By western medicine standards Ethiopian medical care is considered substandard.  Mainly due to lack of resources.  For serious illness or infection travelers should make every effort to go to Nairobi for medical care.   

Vaccinations:

Hepatitis A:  Hepatitis A is a viral illness that is transmitted through food and water.  It is transmitted via fecal material (i.e. people don't was their hands properly).  Hepatitis A occurs more prevalently in third world countries, however it is present throughout the world, including Canada.  There is a hepatitis A vaccine.  This vaccine is available in many forms.  

Havrix: Hepatitis A only.  Two shots required for lifelong immunity.  1 shot, booster in 12 months.

Vivaxim: Hepatitis A and Typhoid combination (I will go into Typhoid later) 1 shot Vivaxim, booster Havrix in 12 months

Twinrix: Hepatitis A and Hepatitis B vaccine combined.   3 shots (lower dose of Hep A in vaccine therefore requires 3 shots).  Shots on regular schedule given at 0, 1 and 6 months.  

Shots should be given as soon as possible and at least 2 weeks before departure.  If taking twinrix patients should have at least 2 shots before departure.  

Typhoid:

Typhoid is caused by the bacteria Samonella Typhi.  It is transmitted via food and water, fecally contaminated (same as Hepatitis A).  With typhoid you develop a high fever and have gasto symptoms, vomiting and diarrhea.  Typhoid is usually non fatal, but can last 10-14 days.  It is generally treated with antibiotics such as Ampicillin or Amoxicillin.  

But..there is a vaccine for this.  

The vaccine is available in two formulations in Canada.

The injection:  Lasts 2 years.  Can be combined with Hepatitis A vaccine

The pills: Studies have shown better immune uptake of the vaccine from the intestine, therefore the capsules provide 4 years protection.  You cannot take the capsules if you have irritable bowel syndrome.

Hepatitis B:

Hepatitis B is also a viral hepatitis that effects the liver.  It is transmitted via blood and body fluids, including sexual fluids.  It is 1000x more infectious than HIV and is more common in third world countries.  Although most people are able to resolve a Hep B infection, it can cause perminent damage to the liver.  

The vaccine is now offered to all infants in BC at 2, 4 and 6 months of age.  Once you have completed the series you are considered protected for life.  (There are some patients who are non responders...but that is a whole other discussion).

You can have the Hepatitis B vaccine either alone or in combination with Hepatitis A.

If taking the Twinrix the traveller should have 2 shots prior to departure for maximum protection.  

They didn't use to recommend Hepatitis B regularly to travellers who were not going to engage in sexual contact, however, any traveller who is at potential risk of physical injury or who wants maximum protection should consider the vaccine.

Yellow Fever

Yellow Fever is a viral disease that is transmitted by mosquito's who bite during the day.  It incubates in the body for 3-5 days before symptoms develop.  In mild cases the patients may experience flu like symptoms, with a fever and headache.  In more severe cases includes fever, hemmorhage, vomiting, coma and death.  It is estimated that yellow fever has approximately 50% mortality.  

Many major cities do spray to try and keep the mosquito population at bay, therefore often cities in yellow fever endemic zones are excluded from active yellow fever reports.  It is more common in rural travel to wetland areas.  

Yellow Fever vaccine is required for any person coming from a yellow fever endemic country.  Proof of vaccine may be required upon entry. 

Contrary to published reports, the World Health Organization has received report of 4 travelers from Europe being denied entry into Ethiopia due to non vaccination (September 2008).  So be prepared to encounter problems if you don't have this vaccine or a waiver. 

The Yellow fever vaccine is a live vaccine.  That means there is a theoretical risk that you can develop yellow fever from having the shot.  The risk of this is 1/ 40 000 vs the disease 1/600.  The adverse events were reported in patients who were over the age of 60 with immunocompromise at the time of vaccination.

If a patient is not able to receive the vaccine they may be able to receive a legal waiver which should permit entry into the country without the vaccine.  

There is only one vaccine used in Canada, it provides 10 years of protection.

Meningitis:

Ethiopia falls within the meningitis belt of Africa. 

It is recommended travellers at any time of year who are going to have prolonged contact with the local population receive a quadravelent meningitis vaccine.  (A,C,Y W-135).

Cholera:  

Only recommended for aid and refugee workers.  

Dukoral:

This is the travellers diarrhea vaccine.

It is approximately 50% effective (some reports higher).  If travellers are prone to diarrhea they often want to consider this.  

This vaccine contains 3 months protection against E Coli and 2 years protection against Cholera.  It is an oral vaccine.  It tastes that raspberry baking soda fizzy drink (kind of gross).  I usually don't recommend this one strongly (like the Hepatitis A and Typhoid), but I do discuss it.  

Influenza:

Influenza is present year round in temperate climates, so I do recommend all travelers receive the influenza vaccine.  Especially when going to have contact with small children, some of whom may have a lowered immune system.  You can carry the influenza virus and pass it on without getting sick.  Contrary to popular belief, you cannot get sick from the influenza vaccine.  It does not contain any live components.  It can give you a bit of a fever/ headache in the 24 hours after vaccination.

Routine Vaccinations

I always recommend patients update all their routine immunizations.  These are provided free in British Columbia.

This includes:

Tetanus/ Diptheria (every 10 years)

Polio: one update in adult life only.  Fecally orally transmitted.  Important if going to have contact with children who might carry the illness.

MMR: Measles, mumps and rubella.  This is the vaccine I receive the most questions about.  This vaccine does not cause Autism (as shown in multiple renowned studies).  I believe in this vaccine and encourage everyone to have it.

So re: any questions.  No, I do not work for a vaccine company.  No I am not paid or given gifts from vaccine companies to promote their products.  I really do believe that vaccination is one of the best ways we can protect ourselves from disease and illness.  Most of these diseases are not present in Canada, and one of the things I have noticed from working in this field is that Canadians are often more hesitant to vaccinate than non Canadians.  When I am counselling patients from Africa and I discuss vaccines they are extremely happy to have the opportunity to vaccinate themselves and their families.  They have often seen the devastating consequences of the actual diseases and want to try and prevent them if possible.

Again, choosing to vaccinate is an individual decision.

I would recommend that everyone, whether you are for or against vaccines, visit a travel clinic before your international trip.  That way you can have an individual consult, taking into account your own personal medical history, vaccination history and meds.  Even if you don't vaccinate there are lots of other important things you can do to protect yourself from illness when traveling.