Q:With interest I read the What Doctors Don't Tell You about hepatitis B (Vol 3 No 4.). However what to do if one goes to a foreign country? In December of this year, I will visit Nepal and will have to have a number of vaccinations. I wonder if you would be so kind as to give me any suggestions as to whether these vaccinations are so dangerous. J. V. H., Chichester.
A:Most travellers heading anywhere but Europe or North America resemble human pin cushions by the time their GP has given all their jabs. For Nepal, the vaccines usually recommended (but not mandated) are: cholera, typhoid and polio. It's also recommended that you take anti malarial pills. The only requirement you may have is to produce a certificate proving you've had a yellow fever vaccine if you intend to enter an area infected with the disease.With travel vaccines doctors usually don't admit that 1) they have no idea what you ought to have in various countries and 2) the medical literature shows that many of these jabs are rubbish ie, won't afford you the protection you need. Currently, for travel to most parts of Africa, the Middle East, Asia and South and Central America, MIMS, the British doctor's drugs bible, recommends that travellers get typhoid, cholera, polio, tetanus, hepatitis A and B, yellow fever and malaria pills. There are also vaccines for rabies and Japanese B encephalitis travellers.
We put your questions to our panel member and resident vaccination expert J. Anthony Morris, formerly of the American Food and Drug Administration and National Institutes of Health. His quotes appear in Roman type under the headings about the various vaccines:
"It is generally recognized that there is no satisfactory cholera vaccine. The product available up to the present has been largely a public relations gambit. So distrusted is the current vaccine that the medical authorities didn't bother to rush the drug to Peru during the outbreak there last year." As MIMS Magazine noted (15 May 1991): "Cholera vaccine is of low efficacy and Iitsuse is declining. A single dose satisfied certification requirements." In other words, even though doctors know it doesn't work, you are required to have it whenever you cross infected areas at certain times of the year.
Last year (5 July) a copy of GP, the newspaper sent to all general practitioners, confirmed this view: "Certain vaccines such as that given for cholera are known to be of no value, and the emphasis in general practice should really shift more towards proper advice, which can often be more time consuming than injections."
The British Medical Journal (17 February 1990) also acknowledged that cholera vaccine was overprescribed by GPs. Nevertheless, it was the view of correspondent P. G. Baddeley, a GP in Gloucestershire, that although the Department of Health booklet "Before You Go" is "overgenerous" in its recommendations for cholera vaccinees:
"It has never been the contractual responsibility of British general practitioners to advise patients who are about to travel abroad on health requirements." Furthermore, he says, "It could create confusion and worry if the general practitioner or the practice nurse did not take time to explain adequately why they were apparently ignoring official DoH advice. Unlike the author, we concluded that it might be simpler and even cheaper to stick to the DoH recommendations."
Finally, he said that the onus should be on the traveller to get information on vaccinations from embassies or consulates of the country about to be visited.
So, despite what seems to be general knowledge about the uselessness of the cholera vaccine, the DoH and most GPs still recommend that adults have a single shot and children two doses and a booster before heading to infected areas. Be wary of this shot, which is a dead form of the organism, and only purports to be effective for six months. Besides fever, you can experience serious allergic reactions to this drug, nerve damage and even mental problems.
"It is generally recognized by the medical literature that there is no satisfactory typhoid vaccine currently available. Protection afforded by the current strain is negligible."
Again, like cholera, there is an "emperor's new clothes" view about this vaccine. GP recommends that two injections of typhoid separated by one month will give protection for three years, and a child is recommended to get two doses plus a booster. This drug should not be used in children under 1 year, and its harmful effects are worse in people over 35. People who receive the shot have fewer side effects if it is given into the skin (ie, intradermally), rather than under it.
This is one shot you may not be able to avoid if you are travelling to certain part of Africa or South America, since you need a certificate of vaccination upon entry. If you are dead set against the shot, which again is said to require an improved version to be effective, it may be wise to avoid any areas requiring the certificate. This vaccine, which is given live, can cause encephalitis (inflammation of the brain), especially in children under 9 months.
Dr Morris believes that it may be prudent to consider this vaccine if you are travelling to very high risk areas in summer months and haven't had the vaccine before , since polio has largely disappeared from the West and you would not have built up natural immunity. If you have had a vaccine before, (as most of us have) you can request to have a blood test to measure antibody response (serum titre) to avoid having a booster you don't need.
Another way to avoid this vaccine is to simply travel to places like Egypt in the winter, when there is less risk of contracting the disease. If you must get vaccinated consider having the killed vaccine, which carries less risk of spread among unvaccinated individuals than does the current live vaccine taken orally. See WDDTY Vol 2 No 4 (or the Vaccination Handbook) for the considerable dangers of contracting polio from the live polio vaccine.
"There is, to date, no reliable vaccine for malaria and many of the drugs don't work anymore."
Although several drugs developed during World War II to be taken against malaria used to be effective, most strains of the disease have developed active resistance. Last spring the Lancet (14 March 1992) carried an editorial which said that few tropical countries are now unaffected by strains resistant to chloroquine, the first anti malarial pill; resistance to quinine is now increasing. "In South East Asia especially, there is a real possibility that . . . malaria could become untreatable within this decade," said the story. GP (5 July 1991) noted that ". . . experts have found it difficult to be authoritative, and schedules of drugs used in prophylaxis [as preventatives] are changed quite frequently." The general rule of thumb at the moment is to use combinations of drugs in areas where resistance is known to be extremely high. And of course there are a number of known toxic effects with all these drugs, such as nausea, vomiting, severe gastrointestinal disturbances, and even psychotic reactions. Prolonged high doses of chloroquine can lead to damage to the cornea of the eyes or ringing of the ears.
However, there is one exciting development on the horizon: a plant called qinghao, or wormwood, in the West, also known as Artemisia annua by the Chinese. This herb was recognized as an antimalarial drug by the Chinese in the early Seventies. The Chinese have purified the herb and in clinical trials over 2000 patients, demonstrated that this plant was more rapidly acting than any other antimalarial, with no evident toxicity.
So impressive is the action of this herb that it merited a laudatory editorial in The Lancet (14 March 1992). The problem is that at the moment, no drug company shows the slightest interest in conducting the extensive testing that would allow licensing here. If you can get hold of an experienced Chinese herbalist, it might be prudent to take this herb, which has a better track record than most of the drugs now on the market.
MIMS recommends that all travellers consider getting a tetanus vaccination, regardless of whether they are travelling to remote areas.
One of the problems with this drug is that it has been so purified that it doesn't work very well anymore. This was the view of an 1982 American government subcommittee on Investigations and General Oversight, which also noted that the degree of potency of the vaccine "can vary considerably from preparation to preparation." Furthermore, according to the Journal of the American Medical Association (November 14 1990) many patients react to thimerosol, the mercury containing preservative used in it.
Perhaps the best preventative, whether or not you decide to get your travel jabs, is make sure to follow certain rules in consuming food and water, as most diseases are transmitted in this manner. Only drink water that has been boiled or purified (include the water to clean your teeth), so that usually means the bottled variety. Take a supply of chlorine or iodine based purification tablets with you, since they may be hard to find once you arrive at your destination. One way of assuring that your water is potable is to stick to carbonated water, which is less likely to be tap water dressed up in a bottle. Don't eat salads, ices or ice cream, ice cubes, shellfish, dairy products (which may be unpasteurized) or fruit, unless it is peeled or thoroughly washed in purified water. All food you eat should be cooked thoroughly. Try not to swallow sea water.