POTENTIAL HAZARD IN AFRICAN REGIONS: a.

Sub-Saharan Africa Sub Saharan Africa comprises Angola, Benin, Burkina faso, Burundi, Cameroon, Cape Verde, Central African Republic, Chad, Comoros, Congo, Cote dIvoire, Democratic Republik of the Congo, Djibouti, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Kenya, Liberia, Madagascar, Malawi, Mali, Mauritania, Mauritius, Mozambique, Niger, Nigeria, Reunion, Rwanda, Sao Tome and Principe, Senegal, Seychelles, Sierra Leone, Somalia, Sudan, Togo, Uganda, United Republic of Tanzania, Zambia, and Zimbabwe. In this area, which lies entirely within the tropics, the vegetation varies from the tropical rain forests of the west and center to the wooded steppes of the east, and form the desert of the north through the Sahel and Sudan savannas to the moist orchard savanna and woodlands north and south of the equator. Many of the disease that can be occur in localized foci and are confined to rural areas. So the international traveler and the medical practitioner concerned become aware of the diseases that may occur. 1. Arthropod-borne Diseases are a major cause of morbidity. Malaria occurs throughout the area, except in places at above 2,600 meters altitude and in the islands of Reunion and the Seychelles. Various forms of Filariasis are widespread in the region Endemic foci of Onchocerciasis (river blindness) exist in all the countries listed, except in the greater part of Kenya and in Djibouti, Gambia, Mauritania, Mozambique, Somalia, Zambia, Zimbabwe, and the island countries of the Atlantic and Indian oceans. However, onchocerciasis exist in the island of Bioko in Equatorial Guinea. Cutaneous and visceral leishmaniasis, particularly in dried areas. Visceral leishmaniasis is epidemic in eastern and southern Sudan. Human trypanosomiasis (sleeping sickness). The transmission rate of human trypanosomiasis is high in Sudan and Uganda and very high in Angola and the

Democratic Republic of the Congo, and there is a significant risk of infection for travelers visiting or working in rural areas. Relapsing fever and louse-, flea-, and tick-borne typhus occur. Angola, the Democratic Republic of the Congo, Kenya, Madagascar, Mozambique, Uganda, the United Republic of Tanzania, and Zimbabwe have reported natural foci of plaque. Widespread incidence of tungiasis. Many viral diseases, some presenting as severe hemorrhagic fevers, are transmitted by mosquitoes, ticks, sandflies, and other insects that are found throughout this region. A substantial outbreak of chikungunya has in 2006 been reported from many islands and countries bordering the Indian ocean. Large outbreaks of yellow fever occur periodically in the unvaccinated population, mainly in Western Africa. The natural focus of flague is a stricly delimited area, where ecological conditions ensure the persistence of plague in wild rodents(and occasionally other animals) for long periods of time and where epizootics and periods of quiescence may alternate. 2. Food-Borne and Waterborne Diseases these are highly endemic in this region. Helminthic infections Dysentries Diarrheal diseases such as giardiasis Typhoid fevers Hepatitis A and E are widespread. Cholera is actively transmitted in many countries in this area. Dracunculiasis occurs in isolated foci. Paragonimiasis (oriental lung fluke) has been reported from Cameroon, Gabon, Liberia, and most recently , from Equatorial Guinea. Echinococcosis (hyatid disease) is widespread in animal-breeding areas.

3. Other Diseases. Hepatitis B is hyperendemic Poliomyelitis (also a food-borne or waterborne disease) since 2003 has again spread throughout many countries of the African continent; in 2007 cases still mainly occur in Nigeria. Schistosomiasis (bilharziasis), is present throughout the area, except in Cape Verde, Comoros, Djibouti, Reunion, and the Seychelles. Trachoma is also widespread in this region. Among other diseases, certain arenavirus hemorrhagic fevers that are often fatal have attained notoriety. Lassa fever, has a virus reservoir in a commonly found multimammate rat. Studies Have shown that an appreciable reservoir exist in some rural areas of West Africa, and people visiting these areas should take particular care to avoid rat-contaminated food or food containers, but the extend of disease should not be exaggerated Ebola and Marbug hemmorhagic fevers are present but are reported only infrequently. Meningococcal meningitis may occur throughout tropical Africa, particularly in the savanna areas during the dry season 4. Other Hazards, include Rabies and Snake bites.

b. Southern Africa

Southern Namibia, Saint

Africa Helena,

(Botswana, South

Lesotho, and

Africa,

Swaziland) has varied physical characteristics,

ranging from the Namib and Kalahari deserts, to the fertile plateus and plains, to the more temperate climate of the southern coast.(1)

1. Anthropod-borne Diseases Crimean-Congo hemorrhagic fevers Malaria Plague Relapsing fever Rift Valley fever Tick-bite fever Typhus (mainly tick-borne) have been reported from most of this area, excepting Saint Helena. Apart from malaria in certain areas, however, they are unlikely to be a major health threat for the traveler. Trypanosomiasis (sleeping sickness) may occur in Botswana and Namibia.(1)

2. Food-borne and Waterborne Diseases Amebiasis Thypoid, are common in some parts of this region Hepatitis A is also prevalent Poliomyelitis, is an outbreak occured in Namibia in 2006. . Imported cases in neighboring countries have occasionally occurred. The Southern Africa countries are

on the verge of becoming poliomyelitis free, thus making the risk of poliovirus infection low. 3. Other Disease. Hepatitis B is hyperendemic Schistosomiasis (bilharziasis) is endemic in Botswana, Namibia, South Africa, and Swaziland. Snake may be a hazard in some areas.

PREVENTION The following are disease risks that might affect travelers; this is not a complete list of diseases that can be present. Environmental conditions may also change, and up to date information about risk by regions within a country may also not always be available. Dengue, filariasis, leishmaniasis, onchocerciasis (river blindness), African tick bite fever, a rickettsial infection, and African trypanosomiasis (African sleeping sickness), transmitted by the bite of the tsetse fly, are other diseases carried by insects that also occur in Southern African countries, mostly in rural areas. Protecting yourself against insect will help to prevent these diseases. Schistosomiasis, a parasitic infection, is found in fresh water in Southern African countries. Do not swim in fresh water (except in well-chlorinated swimming pools) in Southern African countries. Many countries in this region have high incidence rates of tuberculosis and high HIV prevalence rates. HIV can transmitted during sexual course and blood donor / using same needle injection. So to prentive action for HIV we can use condom, not using the same needle injection to different people, skrining blood donor from HIV. Tuberculosis is transmitted to droplet infection, to prevent spreading tuburculosis we can use mask. Travelers should be aware of the serious health risks associated with visiting caves in certain areas of Africa. These risks include infectious diseases spread by bats, such as Marburg

hemorrhagic fever, rabies, and histoplasmosis. CDC advises people not to enter any caves or mines where bats may live. PRE TRAVEL In pretravel consultations, first and foremost, remember that potential travelers are not usually patients but healthy persons. Most often, initially, they will register and indicate name, address, and birth date. Its important to obtain background on immune status. Potential travelers should then indicate their travel plans, according to a minimum checklist as follows: 1. Destination Sub-sahara or South Africa 2. Purpose ask what the traveller will do at there 3. Hygiene standard expected ask where traveller will stay in there 4. Special activities sub-sahara and south africa are rural area and 5. Date of departure 6. Duration of stay abroad Potential travelers should answer the following set of questions about their health status and medical history. Potential travelers should answer the following set of questions about their health status and medical history. Vaccine Finding out what vaccinations and immunizations you need before you travel to Africa is an important part of planning your trip. This article will help you find out what shots you need to get, where to get them, and which ones come highly recommended so you can stay healthy when you visit Africa. Planning Your Vaccination Schedule Some vaccinations, like that for Rabies, come in a series and you need to plan at least a few months ahead of your departure to fit them all in. Your regular doctor probably won't be able to

give you all the vaccinations you need, so you should contact the nearest travel clinic for an appointment. Finding Out Which Vaccinations You Need The health situation in most African countries requires visitors to be up to date with all common childhood vaccines. This includes Hepatitis B, diphtheria, tetanus, measles, mumps, rubella and polio. If you are traveling with children, make sure they have had all their shots. You may also need to get boosters for tetanus, diphtheria and measles if you haven't had those in a while. The following vaccinations are also highly recommended for travel to every African country: Hepatitis A Meningococcal meningitis Rabies Typhoid

Recommended Vaccinations/Immunizations per Country Some African countries have actual entry requirements and won't let you in unless you have proof you've been vaccinated against a specific disease. The most common is yellow fever. Often, you need this only if you have traveled from a country where yellow fever is prevalent, so for those of you overlanding, it's wise to get the shot before you go. Here's a list of countries where yellow fever immunization is an entry requirement. Double check with the embassy of the country you are traveling to for the latest information. Proof of immunization against cholera used to be a entry requirement for a lot countries but is no longer so. Many doctors agree the vaccine is actually quite useless. Countries in Africa also differ as to which diseases are prevalent and you have to adjust your vaccinations according to your specific destination. While everyone should get the recommended

shots listed above, to find out what you need to get per country. General Health Information for Travelers to Countries in North Africa, West, Centeral, East, and South Africa Recommended Vaccinations and Preventive Medications The following vaccines may be recommended for your travel to North Africa, West Africa, Central Africa, East Africa and South Africa. Discuss your travel plans and personal health with a health-care provider to determine which vaccines you will need. * Hepatitis A or immune globulin (IG). Transmission of Hepatitis A virus can occur through direct person-to-person contact; through exposure to contaminated water, ice, or shellfish harvested in contaminated water; or from fruits, vegetables, or other foods that are eaten uncooked and that were contaminated during harvesting or subsequent handling. * Hepatitis B, especially if you might be exposed to blood or body fluids (for example, healthcare workers), have sexual contact with the local population, or be exposed through medical treatment. Hepatitis B vaccine is now recommended for all infants and for children ages 11-12 years who did not receive the series as infants. * Malaria: your risk of Malaria may be high in some of the countries in the North Africa Region. Your risk of Malaria may be high in all countries in West Africa, Central Africa, East Africa and South Africa including cities. See your health care provider for a prescription antimalarial drug. * Meningococcal (Meningitis), if you plan to visit countries in the Central and West Africa region that experience epidemics of Meningococcal Disease during December through June. * Rabies, pre-exposure vaccination, if you might have extensive unprotected outdoor exposure in rural areas, such as might occur during camping, hiking, or bicycling, or engaging in certain occupational activities. * Typhoid, Typhoid fever can be contracted through contaminated drinking water or food, or by eating food or drinking beverages that have been handled by a person who is infected. Large outbreaks are most often related to fecal contamination of water supplies or foods sold by street

vendors. * Yellow Fever, a viral disease that occurs primarily in Sub-Saharan Africa (West Africa) and Tropical South America, is transmitted to humans through the bite of infected mosquitoes. The virus is also present in Panama and Trinidad and Tobago. Yellow fever vaccination is recommended for travelers to endemic areas and may be required to cross certain international borders. Vaccination should be given 10 days before travel and at 10 year intervals if there is ongoing risk. * As needed, booster doses for Tetanus-Diphtheria, Measles, and a one-time dose of Polio Vaccine for adults. Required Vaccinations A certificate of Yellow Fever vaccination may be required for entry into certain countries in Central, West, East and South Africa. Diseases found in North Africa, West, Central, East and South Africa (risk can vary by country and region within a country; quality of in-country surveillance also varies) From the potensial high risk, area of Sub-Sahara lies entirely within the tropics, the vegetation varies from the tropical rain forest of the west and center to the wooded steppes of the east, and from the desert of the north through the Sahel and Sudan savannas to the moist orchard savana and woodlands north and south of the equator. Many of the diseases occur in that area like: Sub-Sahara a. Arthropod-borne disease Malaria

Prophylaxis for malaria and its complication is based on four principles: - Information about malaria - Personal protection measures against mosquito bites - Chemoprophylaxis (usually, chemosuppression), where appropriate Example of pharmacology chemoprophylaxis of malaria:

- Atovaquone and Proguanil - Azthromycin - Chloroquine - Doxycycline - Mefloquine - Proguanil Filariasis Endemic foci of onchocerciasis (river blindness) Cutaneous and viseral leismaniasis Human trypanosomiasis (sleeping sickness) Avoid the insect vector Relapsing fever and louse-, flea-, and tick-borne typhus Tungiasis Severe haemorrhagic fevers transmitted by mosquitoes, ties, sandflies, and other insects Chikungunya Yellow fever Personal protection measures against mosquitos bites There is no chemoprophylaxis Immunoprophylaxis (immunology and pharmacology) Viability live attenuated 17D, given by single injection at least 10 days before departure

Southern Africa a. Arthropod-borne disease Crimean-Congo hemorrhagic fevers To prevent this diseases, the following measures should routinely be employed like yellow fever vaccine, mosquito-avoidance measures (prepare protective clothing, pants tucked into sock and shoes or boots, tick repellent, and body searches for ticks) Malaria Plague Relapsing fever Rift Valley fever Tick-bite fever Types Trypanosomiasis

Pretravel health advise: Minimizing Exposure To risk After knowing the risk or hazards, its important to give some education for travellers and how to preventive occur of the risk. Main instruction target to avoid risk of this arthropod-borne disease: 1. Avoiding vector-borne disease Measure area against mosquitos bites Travellers must prevent mosquitoes bites in rural area work to avoid malaria. Dengue, Filariasis, Leishmaniasis, Onchocerciasis (River Blindness), and Trypanosomiasis (Sleeping Sickness) are other diseases carried by insects that

also occur in this region, mostly in rural areas. Protecting yourself against insect bites will help to prevent these diseases (DEET). African Tick Bite Fever, a rickettsial infection, is common in South Africa, Botswana, Swaziland, Lesotho, and Zimbabwe. African Sleeping Sickness can occur in Botswana and Namibia. Wearing protective clothing and avoiding rural areas or areas of dense vegetation along streams, is the best protection. Schistosomiasis, a parasitic infection, is found in fresh water in this region, particularly in Botswana, Namibia, South Africa, and Swaziland. Do not swim in fresh water (except in well-chlorinated swimming pools) in Southern African countries.

2. Screened rooms, air-conditioning, clothing While outdoor, tell travellers to bring clothing which can cover arms, legs, and particulary the ankles. Mosquito bites may penetrate thin clothes (< 1 mm thick and openings > 0,02 mm), which obviously are preferred in a tropical climate.

3. Repellents It is recommended to spray clothing with repellent or, even better, with insecticides. Individuals should protect the uncovered skin with a repellent.

Sub-Sahara b. Food-borne and water-borne diseases Helminthic infections Dysenteries Diarrheal diseases such Giardiasis, typhoid fever Hepatitis A and E

Cholera Travelers could virtually avoid cholera by being careful about what they eat and drink. Tell travelers to avoid raw or undercooked seafood and tap water in that area Chemoprophylaxis: antibiotics for prophylaxis may provide some protection against cholera Immunoprophylaxis: oral cholera vaccine CVD 103-HgR (orochol, mutacol)

Dracunculiasis Tell travelers to filtering drinking water through a mesh fiber or boiling it before drinking

Paragonimiasis Echinococcosis (hydatid disease)

Southern African b. Food-borne and water-borne diseases Amebiasis Typhoid Do sanitary practices, advice to select only freshly cooked food that is served at temperatures of at least 60C Chemoprophylaxis: no spesific prophylaxis recommended for typhoid fever, those using quinolones for spesial risk groups Immunoprophylaxis by typhoid vaccines: there are two different typhoid vaccines, the oral and the parenteral Vi-vaccines Hepatitis A Immunoprophylaxis: use hepatitis A vaccines like Avaxim, Epaxal, Havrix, Vaqta

Pretravel health advise: Minimizing Exposure To risk Main instruction target to avoid risk of this food-borne and water-borne disease: Advice to avoid contamination food and beverage Food: boil it, cook it, and peel it Fluids: avoid tap water, drink plenty

Sub Sahara c. Other diseases Hepatitis B Immunoprophylaxis by hepatitis B vaccine Poliomyelitis Immunoprophylaxis by inactivated vaccines (Salk vaccine) or oral vaccine (Sabin vaccine) Schistosomiasis Tell travelers to avoid contact with water that contains cercariae, using cleansers containing hexachlorophene (not for long term use), use of 1% niclosamide lotion for protection, use of soap during bathing with bath water hetaing to 50 C Trachoma Lassa fever Ebola and Marburg hemorrhagic fever Meningococcal meningitis Tell to avoid crowded situation

Immunoprophylaxis: polysaccharides vaccines or conjugate vaccines or group B vaccines Southern Africa c. Other diseases Poliomyelitis Hepatitis B

Sub-Sahara d. Other hazards Rabies Avoid bitting by infected animals Immunoprophylaxis: Human diploid cell vaccines, purified chick embryo cell vaccines, purified duck embryo vaccines, vero cell rabies vaccines, chromatography purified rabies vaccines Snake bite

STAYING HEALTHY DURING YOUR TRIP Prevent Insect Bites Many diseases, like malaria and dengue, are spread through insect bites. One of the best protections is to prevent insect bites by: Using insect repellent (bug spray) with 30%-50% DEET. Picaridin, available in 7% and 15% concentrations, needs more frequent application. There is less information available on how effective picaridin is at protecting against all of the types of mosquitoes that transmit malaria. Wearing long-sleeved shirts, long pants, and a hat outdoors.

 Remaining indoors in a screened or air-conditioned area during the peak biting period for malaria (dusk and dawn). Sleeping in beds covered by nets treated with permethrin, if not sleeping in an air-conditioned or well-screened room. Spraying rooms with products effective against flying insects, such as those containing pyrethroid. Prevent Animal Bites and Scratches Direct contact with animals can spread diseases like rabies or cause serious injury or illness. It is important to prevent animal bites and scratches. Be sure you are up to date with tetanus vaccination. Do not touch or feed any animals, including dogs and cats. Even animals that look like healthy pets can have rabies or other diseases. Help children stay safe by supervising them carefully around all animals. If you are bitten or scratched, wash the wound well with soap and water and go to a doctor right away. After your trip, be sure to tell your doctor or state health department if you were bitten or scratched during travel. Be Careful about Food and Water Diseases from food and water are the leading cause of illness in travelers. Follow these tips for safe eating and drinking: Wash your hands often with soap and water, especially before eating. If soap and water are not available, use an alcohol-based hand gel (with at least 60% alcohol). Drink only bottled or boiled water, or carbonated (bubbly) drinks in cans or bottles. Avoid tap water, fountain drinks, and ice cubes. If this is not possible, learn how to make water safer to drink.

 Do not eat food purchased from street vendors. Make sure food is fully cooked. Avoid dairy products, unless you know they have been pasteurized. Diseases from food and water often cause vomiting and diarrhea. Make sure to bring diarrhea medicine with you so that you can treat mild cases yourself. Other Health Tips To avoid infections such as HIV and viral hepatitis do not share needles for tattoos, body piercing, or injections. To reduce the risk of HIV and other sexually transmitted diseases always use latex condoms. To prevent fungal and parasitic infections, keep feet clean and dry, and do not go barefoot, especially on beaches where animals may have defecated. POST TRAVEL Persons who spend considerable time in a tropical region are invariability exposed recurrently to infectious and non infectious health treats. Accidents are common, exposure to blood products may occur secondary to sexual contact, use of intravenous drugs of receipt of blood products and infectious agents are found in food, drinking or recreational water, air, or insects. It is important to evaluate such expariates upon return to their home country for acquired illnesses and infecting agents. For all returning expatriates, a careful history, physical examination and routine laboratory tests should be carried out as a routine. Address abnormalities and treat. Travelers returning from abroad often request consultation for persisting health problems. The clinician should assess the following : 1. Travelling history : Destination is sub sahara and southern Africa Potential exposure :

Arthoropod borne diseases : Malaria, filariasis, onchocerciasis,cutaneus and visceral leishmaniasis, trypanosomiasis, hemorrhagic fevers,

chikungunya, yellow fever. Plague.relapsing fever, thypus. Food borne and water borne dis : helminthic infections, dysenteries, diarrheal disease, cholera, darcunculiasis, paragonimiasis, echinococcosis. And other disease : hepatitis B, poliomyelitis, schistomiasis, trachoma, lassa fever, snakes bite. 2. Preventives measures taken, such as immunization, medication (and compliance) 3. Symptoms and their chronology (consideration of the incubation period) 4. Physical examination 5. Blood sample in all febrile patients to promptly diagnose malaria 6. Other laboratory and technical evaluation as indirect under the circumstances. Liver function studis : bilirubin, alkhaline phosphate, SGOT, SGPT, albumin, globulin. Tuberculin skin test and chest x-ray if positive Urinalysis Stool ova and parasite examination done of two different samples Special studies as suggested by history and or physical

7. Address abnormalities and treat

Dont forget to ask the patient about his/her condition, like how do you feel? How about your journey? And we can ask patient some symptoms like Fever, Chills, Sweats, Headache, body aches, nausea and vomiting, Fatigue. Its use to meansure that there is any promblem in his / her healthy. If one of them positif, the doctor have to examine patient and ask more about his / her condition. The doctor have to know about some disease related to post travelling in sub saharan and southern africa. AIDS/HIV: In the 2010 Report on the Global AIDS Epidemic the UNAIDS/WHO Working Group estimated that around 5,300,000 adults aged 15 or over in South Africa were living with HIV. Heterosexual contact is the predominate mode of transmission. HIV-1 prevalence is estimated at up to 86% of the high-risk urban population. Transmission of HIV can be prevented by avoiding: sexual contact with a high-risk partner; injecting drug use with shared needles; non-sterile medical injections; unscreened blood transfusions. The threat of HIV/AIDS should not be a primary concern for the traveler. However, there may be a concern for a subset of travelers who may be exposed to HIV, the virus that causes AIDS, through contact with the body fluid of another person or their blood. Although travel has contributed in a general way to the global spread of AIDS, fear of traveling because of this disease is not warranted. Accidents & Medical Insurance: Accidents and injuries are the leading cause of death among travelers under the age of 55 and are most often caused by motor vehicle and motorcycle crashes; drownings, aircraft crashes, homicides, and burns are lesser causes. Heart attacks cause most fatalities in older travelers. Infections cause only 1% of fatalities in overseas travelers, but, overall, infections are the most common cause of travel-related illness. MEDICAL INSURANCE: Travelers are advised to obtain, prior to departure, supplemental travel health insurance with specific overseas coverage. The policy should provide for direct payment to the overseas hospital and/or physician at the time of service and include a medical evacuation benefit. The policy should also provide 24-hour hotline access to a multilingual assistance center that can help arrange and monitor delivery of medical care and determine if medevac or air ambulance services are required.

Health insurance is essential. East African Flying Doctor Services, based in Nairobi, have introduced special Tourist Membership which guarantees that any member injured or ill while on safari can call on a flying doctor for free air transport. African Sleeping Sickness (Trypanosomiasis): Sleeping sickness is prevalent in scattered areas countrywide. During November 2007, 12 people were diagnosed with sleeping sickness at one health centre in the Mayuge Region. Major risk of disease persists in the southeast (extending from the northern shore of Lake Victoria and Lake Kyoga), with foci of Gambiense disease primarily in north-western and north central areas (along the White Nile and the Sudanese border). Travelers at most risk are those on safari and game-viewing holiday. Travelers to urban areas are at very low risk. The tsetse fly comes out in the early morning and the late afternoon. Insect repellent applied to the skin does not prevent tsetse fly bites, so travelers should wear protective clothing and sleep under a bed net. Initial symptoms: The bite of tsetse fly can be painful and may develop into a raised red sore, called a chancre. The initial sore may subside or develop into an expanding red, tender, swollen area, followed by a generalized illness with fever, myalgia, abdominal discomfort, diarrhea, vomiting, headache, rigors, and sweats. Animal Hazards: Animal hazards include snakes (vipers, cobras), centipedes, scorpions, and black widow spiders. Crocodiles are known to attack boats and people on shore. Cholera: Although this disease is reported active, the threat to tourists is low. Cholera is an rare disease in travelers from developed countries. Cholera vaccine is recommended only for relief workers or health care personnel who are working in a high-risk endemic area under less than adequate sanitary conditions, or travelers who work or live in remote, endemic or epidemic areas and who do not have ready access to medical care. Canada, Australia, and countries in the European Union license an oral cholera vaccine. The cholera vaccine is not available in the United States. The main symptom of more severe cholera is copious watery diarrhea. Antibiotic therapy is a useful adjunct to fluid replacement in the treatment of cholera by substantially reducing the duration and volume of diarrhea and thereby lessening fluid requirements and shortening the duration of hospitalization.

 A single 1-gm oral dose of azithromycin is effective treatment for severe cholera in adults. This drug is also effective for treating cholera in children. Crime/Security/Civil Unrest: We strongly advise you not to travel to northern Uganda (particularly the Nebbi, Arua, Moyo, Yumbe, Adjumani, Apac, Gulu, Kitgum, Lira and Pader districts) and areas bordering Sudan and the DRC (including Lake Albert and Murchison Falls National Park) because of the serious risk of attacks and abductions by rebel groups, including the Lords Resistance Army (LRA), and the risk of banditry in these areas. North-eastern Uganda: We strongly advise you not to travel to the Karamoja region of northeastern Uganda (particularly the Kotido, Moroto, Nakapiripirit and Katakwi districts north of Kate Kyoga), because of the risk of banditry and inter-tribal clashes. Far south-western borders with the DRC: We strongly advise you not to travel to the far southwestern borders with the DRC, including Bwindi Impenetrable National Park and the Mgahinga Gorilla Park, due to the risk of banditry and cross-border attacks by rebel groups. We strongly advise you not to take gorilla trekking tours that cross into the DRC. Crime: Petty crime such as pickpocketing and bag snatching is common, especially on public transport. Theft from vehicles which are stationary in heavy traffic or stopped at traffic lights occurs frequently. You should ensure valuables are out of sight and that vehicle windows are up and doors are locked. There is a risk of armed robbery and carjacking when travelling outside the capital, Kampala, particularly to the east and in areas around Lake Victoria. Isolated incidents of violence have also occurred in urban centres, such as Kampala, Jinja and Kasese. Residential burglaries have turned violent. Security risks are heightened after dark. Do not accept food or drink from strangers as it may be drugged. Local Travel: The Ugandan Government periodically closes tourist areas considered to be at risk of rebel activity. You should seek local advice about the current situation prior to travel. Driving in Uganda can be hazardous due to poor road conditions, vehicle maintenance, bad driving habits, excessive speeds and poor lighting, especially at night. Traffic accidents are common and pose a significant risk to tourists. For further advice, see our bulletin on Overseas Road Safety. Long distance bus travel is also hazardous and accidents have resulted in fatalities.

Ebola/Marburg Hemorrhagic Fever: According to the Ministry of Health, 1 case of Ebola hemorrhagic fever has been confirmed from Bombo (Luwero District) 25 km (15 miles) north of Kampala since May 2011. Historically, cases occur in periodic clusters so additional cases may be present. Travelers to the area should be advised that transmission of Ebola virus is via direct contact with blood or body fluids of acutely ill patients. As of 2011, research supports, but does not yet confirm, the role of bats as reservoirs of Ebola virus in equatorial Africa; however, it does not explain the patchy nature of outbreaks of human disease. The number of outbreaks and cases has been increasing since 2000. Almost all human cases have been due to the Zaire Ebola virus (in the regions of Gabon, Republic of Congo, and DRC) and to the Sudan Ebola virus (in Sudan and Uganda). Serological surveys in selected populations suggest that the virus is endemic in equatorial Africa. It is essential for physicians to be alert to the possibility of Ebola infection in the febrile traveler returned from equatorial Africa. Ebola virus is also transmitted through close personal contact with severely ill patients and direct contact with infected blood, secretions, and organs. Travelers should take precautions against the virus, which include careful hand-washing, avoiding contact with potentially-infected patients and avoiding any contact with ill or dead animals. There is little, if any, direct threat to travelers to Uganda from this illness. Travelers should know that there are serious health risks associated with visiting caves in the Maramagambo Forest in Uganda and in other areas of Africa. These risks include diseases spread by bats, such as Marburg, rabies, and histoplasmosis. The Uganda Ministry of Health has advised people not to enter any caves or mines where bats may live. Recommendations for U.S. travelers from the CDC: The main ways that travelers may get Marburg virus are through direct contact with a person very sick with Marburg or through direct contact with infected bats, monkeys, or other wild animals that may be infected. The risk of Marburg for travelers is very low. However, travelers should take the following steps to help protect themselves. Avoid direct contact with bats and other wild animals. Travelers should not enter caves where bats may live.

 Go to a doctor right away if you have a fever AND you have visited bat-infested caves in Africa during the past three weeks. Tell the doctor that you have been around bats. If you are bitten or scratched by an animal or if body fluid (such as saliva) from the animal gets into your eyes, nose, mouth, or a wound, take these steps: 1. Wash the area thoroughly with soap and water. 2. Go to a doctor or hospital right away. 3. Consider buying medical evacuation insurance if you are visiting a country where there may not be good access to medical care. Filariasis: Sporadic cases are reported. Travelers to this country are advised to take protective measures against blackfly bites. Hepatitis: All travelers not previously immunized against hepatitis A should be vaccinated against this disease. Travelers 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. Travelers who will have access to safe food and water are at lower risk. Those at higher risk include travelers visiting friends and relatives, long-term travelers, and those visiting areas of poor sanitation. Transmission of the hepatitis E virus (HEV) occurs primarily through drinking water contaminated by sewage and also through raw or uncooked shellfish. In developing countries, prevention of hepatitis E relies primarily on the provision of clean water supplies and overall improved sanitation and hygiene. There is no vaccine. Hepatitis B is hyperendemic. The overall hepatitis B (HBsAg) carrier rate in the general population is estimated at >10%. Hepatitis B is transmitted via infected blood or bodily fluids. Travelers may be exposed by needle sharing and unprotected sex; from non-sterile medical or dental injections, and acupuncture; from unscreened blood transfusions; by direct contact with open skin lesions of an infected person. The average traveler is at low risk for acquiring this infection. Vaccination against hepatitis B is recommended for: persons having casual/unprotected sex with new partners; sexual tourists; injecting drug users; long-term visitors; expatriates, and anybody wanting increased protection against the hepatitis B virus.

 Hepatitis C is endemic with a prevalence of 1.2% in the general population. Most hepatitis C virus (HCV) is spread either through intravenous drug use or, in lesser-developed countries, through blood contamination during medical procedures. Over 200 million people around the world are infected with hepatitis C - an overall incidence of around 3.3% of the population of the world. Statistically, as many people are infected with HCV as are with HIV, the virus that causes AIDS. Influenza: Influenza is transmitted year-round in the tropics. The flu vaccine is recommended for all travelers >6 months of age. Leishmaniasis: Visceral leishmaniasis occurs in the northeast province of Karamoja. Sporadic cases of cutaneous leishmaniasis are reported from the Mt. Elgon vicinity. Schistosomiasis is transmitted through exposure to contaminated water while wading, swimming, and bathing. Schistosoma larvae, released from infected freshwater snails, penetrate intact skin to establish infection. All travelers should avoid swimming, wading, or bathing in freshwater lakes, ponds, streams, cisterns, aqueducts, or irrigated areas. There is no risk in chlorinated swimming pools or in seawater. Loiasis: Sporadic cases are reported. Travelers to this country are advised to take protective measures against blackfly bites.

Malaria: Risk is present year-round throughout this country, including urban areas. Falciparum malaria accounts for approximately 80% of cases. Other cases of malaria are due to the P. malariae species, followed by P. ovale and (rarely) P. vivax. Chloroquine-resistant falciparum malaria is reported. Prophylaxis with atovaquone/proguanil (Malarone), mefloquine (Lariam), or doxycycline is recommended. Malaria is transmitted via the bite of an infected female Anopheles mosquito. Anopheles mosquitoes feed predominantly during the hours from dusk to dawn. All travelers should take measures to prevent evening and nighttime mosquito bites. Insect-bite prevention measures include applying a DEET-containing repellent to exposed skin, applying permethrin spray or solution to clothing and gear, and sleeping under a permethrin-treated bednet. DEET-based repellents have been the gold standard of protection under circumstances in which it is crucial to be protected against insect bites that may transmit disease. Nearly 100% protection can be achieved when DEET repellents are used in combination with permethrin-treated clothing. NOTE: Picaridin repellents (20% formulation, such as Sawyer GoReady or Natrapel 8-hour) are now recommended by the CDC and the World Health Organization as acceptable non-DEET alternatives to protect against malaria-transmitting mosquito bites. Picaridin is also effective and ticks and biting flies. You should consider the diagnosis of malaria if you develop an unexplained fever during or after being in this country. Long-term travelers who may not have access to medical care should bring along medications for emergency self-treatment should they develop symptoms suggestive of malaria, such as fever, chills, headaches, and muscle aches, and cannot obtain medical care within 24 hours.

Meningitis: In early 2009, outbreaks were reported in Masindi, Hoima, Arua, Adjumani, and Moyo districts. Some of these areas are just outside the meningitis belt, however such transmission activity is not unusual at this time of year. Quadrivalent conjugate meningitis vaccine is recommended for those travelers anticipating living or working closely with local people, especially in the north. The risk is greatest in the dry season, from November to May/June. Vaccination should be considered for all travelers venturing into epidemic regions at any time of year. Uganda lies partially within the sub-Saharan meningitis belt. Areas in sub-Saharan Africa with frequent epidemics of meningococcal meningitis

Onchocerciasis: Sporadic cases are reported. Travelers to this country are advised to take protective measures against blackfly bites.

Other Diseases/Hazards: African tick typhus (contracted from dog ticks and from bush ticks) Brucellosis Chikungunya fever (mosquito-transmitted) Crimean-Congo hemorrhagic fever (tick-borne; cases reported from Entebbe) Eechinococcosis Lleptospirosis Ttyphus Toxoplasmosis Plague: Outbreaks of plague occur regularly in this country. One hundred and twenty cases, including 10 deaths, have been recently reported from the Arua and Masindi Regions. Plague most commonly occurs when plague-infected fleas bite humans, who then develop bubonic plague. Some patients will also develop a bloodstream infection (septicemic plague). A small minority of persons with either bubonic or septicemic plague will develop secondary pneumonic plague, and they can then spread the plague bacterium by coughing out respiratory droplets. Persons who inhale these droplets can develop so-called primary pneumonic plague. There is no vaccine against plague. Intravenous gentamicin or oral doxycycline are effective treatments. Doxycycline, tetracycline or ciprofloxacin are effective for post-exposure prophylaxis. Poliomyelitis (Polio): All travelers should be fully immunized. A one-time dose of IPV (Inactivated Polio Vaccine) is recommended for any traveler >age 18 who completed the primary childhood series but never received an additional dose of polio vaccine as an adult. Rabies: Increased incidence of rabies is reported in Kampala and Karamoja Provinces. Preexposure rabies vaccine is recommended for travel longer than 3 months, for shorter stays in rural when travelers plan to venture off the usual tourist routes and where they may be more exposed to the stray dog population; when travelers desire extra protection; or when they will not be able to get immediate medical care.

 All animal bite wounds, especially from a dog, should be thoroughly cleansed with soap and water and then medically evaluated for possible post-exposure treatment, regardless of your vaccination status. Pre-exposure vaccination eliminates the need for rabies immune globulin, but does not eliminate the need for two additional booster doses of vaccine. Even if rabies vaccine was administered before travel, a 2-dose booster series of vaccine is needed after the bite of a rabid animal. Schistosomiasis: Intestinal schistosomiasis occurs primarily in the northwest and along the northern shore of Lake Victoria. Urinary schistosomiasis is confined to northern central Uganda, north of Lake Kyoga. Schistosomiasis is transmitted through exposure to contaminated water while wading, swimming, and bathing. Schistosoma larvae, released from infected freshwater snails, penetrate intact skin to establish infection. All travelers should avoid swimming, wading, or bathing in freshwater lakes, ponds, streams, cisterns, aqueducts, or irrigated areas. There is no risk in chlorinated swimming pools or in seawater. Travelers' Diarrhea: High risk. Supplies of potable water are inadequate to meet the needs of the population. Piped water supplies may be grossly contaminated. Outside of hotels and resorts, we recommend that you boil, filter or purify all drinking water or drink only bottled water or other bottled beverages and do not use ice cubes. Avoid unpasteurized milk and dairy products. Do not eat raw or undercooked food, especially meat, fish, raw vegetable. Peel all fruits. Good hand hygiene reduces the incidence of travelers diarrhea by 30%. All travelers should bring along an antibiotic and an antidiarrheal drug to be started promptly if significant diarrhea occurs, defined as three or more loose stools in an 8-hour period or five or more loose stools in a 24-hour period, especially if associated with nausea, vomiting, cramps, fever or blood in the stool. A quinolone antibiotic is usually prescribed: either ciprofloxacin (Cipro)(PDF) 500 mg twice daily or levofloxacin (Levaquin) (PDF) 500 mg once daily for a total of three days. Quinolones are generally well-tolerated, but occasionally cause sun sensitivity and should not be given to children, pregnant women, or anyone with a history of quinolone allergy. Alternative regimens include a three day course of rifaximin (Xifaxan) 200 mg three times daily or azithromycin (Zithromax) 500 mg once daily. Rifaximin should not be used by those with

fever or bloody stools and is not approved for pregnant women or those under age 12. Azithromycin should be avoided in those allergic to erythromycin or related antibiotics. An antidiarrheal drug such as loperamide (Imodium) or diphenoxylate (Lomotil) should be taken as needed to slow the frequency of stools, but not enough to stop the bowel movements completely. Diphenoxylate (Lomotil) and loperamide (Imodium) should not be given to children under age two. A quinolone antibiotic, or azithromycin, combined with loperamide (Imodium), is recommended for the treatment of diarrhea. Diarrhea not responding to antibiotic treatment may be due to a parasitic disease such as giardiasis, amebiasis, or cryptosporidiosis. Most cases of travelers' diarrhea are mild and do not require either antibiotics or antidiarrheal drugs. Adequate fluid intake is essential. If diarrhea is severe or bloody, or if fever occurs with shaking chills, or if abdominal pain becomes marked, or if diarrhea persists for more than 72 hours, medical attention should be sought. Though effective, antibiotics are not recommended prophylactically (i.e. to prevent diarrhea before it occurs) because of the risk of adverse effects, though this approach may be warranted in special situations, such as immunocompromised travelers. Seek qualified medical care if you have bloody diarrhea and fever, severe abdominal pain, uncontrolled vomiting, or dehydration.

Tuberculosis: Globally, more than 9 million new TB cases and nearly 2 million TB-related deaths occur each year. TB occurs throughout the world, but the incidence varies. In the United States, the annual incidence is approximately 4 per 100,000 population, but in some countries in sub-Saharan Africa and Asia, the annual incidence is several hundred per 100,000. Tuberculosis is highly endemic in tropical region. Tuberculosis (TB) is transmitted following inhalation of infectious respiratory droplets. Most travelers are at low risk. Travelers at higher risk include those who are visiting friends and relatives (particularly young children), long-term travelers, and those who have close contact, prolonged contact with the local population. There is no prophylactic drug to prevent TB. Travelers with significant exposure should have PPD skin testing done to evaluate their risk of infection. Based on WHO recommendations, Bacillus Calmette-Gurin (BCG) vaccine is used once at birth in most developing countries to reduce the

severe consequences of TB in infants and children. However, BCG vaccine has variable efficacy in preventing the adult forms of TB and interferes with testing for LTBI with the TST. Therefore, BCG is not routinely recommended for use in the United States. Recently, some experts have advocated BCG vaccination for people who are likely to be exposed to MDR or XDR TB patients in settings where the TB infection control measures recommended in the United States are not fully implemented. BCG may offer some protection in this circumstance; however, people who receive BCG vaccination must follow all recommended TB infection control precautions to the extent possible. Additionally, IGRA is preferred over the TST for pre- and post-travel testing in people vaccinated with BCG. To prevent infections due to M. bovis, travelers should also avoid eating or drinking unpasteurized dairy products. Typhoid Fever: Typhoid fever is the most serious of the Salmonella infections. Typhoid vaccine is recommended by the CDC for all unvaccinated people traveling to or working in sub-Saharan Africa, especially if visiting smaller cities, villages, or rural areas and staying with friends or relatives where exposure might occur through food or water. Current vaccines against Salmonella typhi are only 50-80% protective and do not protect against Salmonella paratyphi, the cause of paratyphoid fever. (Paratyphoid fever bears similarities with typhoid fever, but the course is generally more benign.) Travelers should continue to practice strict food, water and personal hygiene precautions, even if vaccinated.

Yellow Fever: Travelers over 9 months of age should be vaccinated before travel to subsaharan and sothern africa A yellow fever vaccination certificate is required for all travelers >1 year of age arriving from any infected area in the yellow fever endemic zone country in Africa or the Americas. Yellow fever is transmitted via the bite of an infected Aedes mosquito (mainly Aedes aegypti). Aedes mosquitoes feed predominantly during daylight hours. Insect-bite prevention measures include applying a DEET-containing repellent to exposed skin and applying permethrin spray or solution to clothing and gear. Sleeping under a permethrin-treated bednet at night gives you extra protection. There is risk of yellow fever in all areas of this country. A map of yellow fever endemic countries in Africa

Daftar Pustaka 1. Steffen R, Dupont HL, Wilder-Smith A. Manual of Travel Medicine and Health. 3nd edition. USA: PMPH; 2007
2. Center for Diseases and Prevention. Health Information for Travelers to South Africa.

Updated: july 11, 2011. Available at : http://wwwnc.cdc.gov/travel/destinations/southafrica.htm . Accessed on Juny, 14 2012. 3. Lanham. 2012. Vaccine. Updated: 2010. Available at:

http://www.vaccinesdoctor.com/africa_travel_medicine.html. Accessed on Juny, 14

4.

International society of travel medicine. Promoting healthy travel worldwide. Update may 2012. Available at: www.istm.org. Accessed on Juny, 14 2012.

5. WHO. WHO Vaccine Preventable Disease: Monitoring System. Geneva: WHO;2000.R 27, 39, 158, 179