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Travel jabs - No passport to safety

MagazineJuly 2013 (Vol. 24 Issue 4)Travel jabs - No passport to safety

Thanks to cheap long-haul airtravel, the world's at your doorstep-but according to your doctor, it's an evermore dangerous place

Thanks to cheap long-haul air travel, the world's at your doorstep-but according to your doctor, it's an ever more dangerous place. If the standard medical advice is to be believed, you shouldn't set foot inside a plane, boat or train until you've jabbed yourself multiple times against a vast coterie of infectious disease.

Most National Health Service recommendations about travel vaccines run to massive overkill. For instance, according to the NHS website National Travel Health Network and Centre, Portugal-an otherwise civilized member of the EU-is raging with risks of hepatitis A and B, rabies, tetanus and typhoid, and you are recommended to not only restrict your use of water and food, but also consider getting jabs against the entire lot.

Even the US, a first-world country the last time we looked, is characterized by a list of similar disease risks, and travellers whose "activities put them at risk" are advised to get a variety of shots against the diseases in question.

There are several problems with this 'just in case' mindset. Aside from promoting fear and xenophobia about travelling outside the UK's borders, it promotes a false sense of security-a simple shot is all it takes to protect yourself-which may lead you to disregard other sensible precautions (like not drinking the water) when you're visiting remote or rural areas.

But even if you do face legitimate risks, the jabs themselves aren't necessarily going to do the job. Vaccines come in a variety of shapes and sizes, are either injected or taken orally, and use either a killed or live but 'attenuated' (weakened) form of virus or bacteria.

The rationale for vaccination rests on the assumption that injecting you with a weakened bug will trick your body into developing antibodies against the disease, as it does when you contract an illness naturally.

But as the evidence shows, this is a blunt and imperfect instrument. Of the vast array of immunizations on offer, travel shots have some of the poorest track records of any around. Some vaccines work better than others, but with many varieties the risks of their side-effects are higher than the risk of contracting the disease. In the case of malaria, there is not only no vaccine, but both growing resistance as well as severe reactions to the drugs used to treat it.

This means that before you mindlessly line up to get your shots, it's vital to ask yourself three important questions about each one:

o How necessary is this vaccine?

o How effective is this vaccine?

o How safe is this vaccine?

Asking these three questions will help you weigh up each jab carefully as to the actual threat of the disease (is it more of a nuisance than a serious risk to my health or life?) vs the dangers of the vaccine itself and the true likelihood that the jab is going to lessen the risk in any meaningful way.

To help you make these decisions, here's the first of a two-part summary of the latest evidence for the most popular travel vaccines and some options for what to do instead, should you decide against them.

CHOLERA

What's it for?

The Vibrio cholerae bacterial infection caught from contaminated food or water, usually due to poor sanitation.

What's the vaccine?

Killed oral whole-cell vaccine (Dukoral(R)), taken in two doses six weeks apart (three doses for children aged 2-5 years, and two taken every two weeks for babies under 1 year old).

How necessary?

Not a widespread threat; only about 30 Britons contract cholera every year. It's not commonly requested or recommended by the World Health Organization (WHO) for anyone other than emergency or relief workers.

How effective?

Decidedly hit or miss. Offers around 67 per cent protection according to a large-scale study in India; in rural Bangladesh the more people were vaccinated, the worse the vaccine worked.1Overall effectiveness just 52 per cent for the first year and only 38 per cent in children under five, according to a review of major studies.2

May not protect against certain newer strains like Bengal cholera.3Effectiveness may be lowered even further when given with yellow fever vaccine.

How safe?

According to Dukoral manufacturer Sanofi Pasteur, the most common effects are abdominal pain, diarrhoea, loose stools, nausea and vomiting.

About one in 10,000 recipients suffers side-effects such as fatigue, severe diarrhoea, joint pain, reduced sense of taste, insomnia, general pain, rashes, flu-like symptoms, weakness, breathlessness, pins and needles, dehydration, facial swelling, high blood pressure, chestiness, itching and swollen lymph glands.

Doesn't work well in the immune-compromised. Contains formaldehyde.

What to do instead

Don't drink the water and don't eat uncooked food. Follow the clean water suggestions on page 36 and try homeopathic alternatives. If you do get it, avoid the effects of severe diarrhoea, which is what eventually kills you, by making sure you replace lost fluids.

THYPOID FEVER

What's it for?

A bacterial infection caused by Salmonella enterica typhi through ingesting food and water contaminated by the faeces of an infected person.

What's the vaccine?

Live oral Ty21a 9 (Vivotif) given in three doses (four in North America) two days apart.

How necessary?

Only about 200 British holidaymakers return with typhoid every year. Despite this, the vaccine is routinely recommended for areas where typhoid is common and sanitation primitive or there's a high risk of being exposed to contaminated food and water.

How effective?

Toss a coin. Reviews of studies of the live oral vaccines show they offer protection on average 48 per cent of the time,4and work even less in those with an immune disorder or taking immune-suppressing medical treatment. Even manufacturer Berna Biotech admits: "Not all recipients of Vivotif will be fully protected against typhoid fever."

How safe?

Berna's list of vaccine side-effects includes abdominal pain, nausea, vomiting, fever, headache, diarrhoea and rash in up to a quarter of patients. Less common: allergic shock, skin reactions like dermatitis or sudden rash, sudden weakness, malaise, tiredness, shivering, numbness or pins and needles, dizziness, arthralgia (joint pain) and myalgia (muscle pain).

Avoid jab if you're vomiting or suffering from persistent diarrhoea, or during an acute gastrointestinal illness. Also avoid if taking sulphonamides, antibiotics or antimalarial drugs, all of which render vaccine less effective.

What to do instead

Follow the advice for food and drink safety, and consider homeopathic alternatives.

Precautions for food and water safety

If you're travelling to places with tropical diseases, do the following:

o Only drink canned or bottled carbonated drinks, beer and wine, and beverages made with boiled water.

o Avoid bottled still water, which may simply be refilled tap water.

o Avoid ice cubes and any alcoholic mixed drinks containing water, as the booze won't make tap water safe.

o Avoid non-disposable glassware and dishes, and drink only from the original drink container using sanitary straws.

o Boil your own water supply for brushing your teeth and washing anywhere near your mouth by boiling vigorously for one minute for each 1,000 feet (300 metres) above sea level; an immersion coil water heater is an inexpensive and easy-to-carry option if you can't treat water with either iodine additives or tetracycline hydroperiodide tablets.

o Avoid uncooked vegetables and salads, cold meats, mayonnaise and creamy desserts.

o Eat fruits, nuts and vegetables only if they are well cleaned and have an intact thick skin or shell that you peel yourself.

o Order meat, fish and seafood cooked well done and piping hot, and eat bread fresh from the oven.

o Don't eat grains (like rice) allowed to sit for a long time at room temperature.

o Steer clear of buffets and street vendors.

o Avoid unpasteurized dairy products like cheese and yoghurt, and stick to canned milk.

o Don't swim or fish in polluted waters, and don't eat fish caught in such waters.

o Wash your hands well if you've been out before eating, and keep them away from your face.


YELOW FEVER

What's it for?

The Flavivirus disease transmitted to humans by mosquitoes.

What's the vaccine?

Live strain of the 17D vaccine given as a single injection.

How necessary?

Depends on where you're going. Unavoidable if you're travelling to certain parts of Africa (mostly the North) and northern South America that require vaccination certificates on entry (see box, below right). Risk highest in rural West Africa during July-October and in northern South America during January-May, with peak incidence in February-March.

Otherwise, chances of catching it are remote: the WHO records just 1,500 cases/year worldwide. In the last 40 years, only nine cases were reported in unvaccinated travellers from the US and Europe who went to West

Africa (five cases) and South America (four cases). All but one died. Fatalities occur in one-fifth to one-half of those who get sick.


How effective?

Considered one of vaccination's success stories. One report showed 94 per cent effectiveness in adults, but only 60 per cent in babies in another study.5

How safe?

The-operation-was-successful-but-the-patient-died scenario. Safety profile is now recognized as a myth.

Serious side-effects include abdominal organ damage, especially the intestines, and multiple organ failure (fatal 60 per cent of the time), plus neurological diseases like encephalitis (brain inflammation) and autoimmune disease affecting the protective myelin sheath covering the nerves.6

Organ issues arise in one in every 25,000 doses and neurological events in one per 1,250 doses. About a quarter of patients suffer side-effects like muscle (myalgia) and nerve pain and inflammation, hives, jaundice and low-grade fever; more than one in every 10 a post-vaccine syndrome of multiple pains and fever.7

Reasonable risk the vaccine's virus will turn virulent and cause . . . yellow fever.6

Avoid if you have thymus gland problems.

Countries requiring certificates of vaccination for yellow fever upon entry

  • Angola
  • Benin
  • Burkina Faso
  • Burundi
  • Cameroon
  • Central African Republic
  • C^ote d'Ivoire
  • Democratic Republic of Congo
  • French Guiana
  • Gabon
  • Ghana
  • Guinea-Bissau
  • Liberia
  • Mali
  • Niger
  • Rwanda
  • S~ao Tom'e and Pr'incipe
  • Sierra Leone
  • Togo


HEPATITIS A

What's it for?

The hepatitis A virus that causes acute infection of the liver and spreads through contaminated food and water, especially where sanitation is primitive, and through contact with contaminated people.

What's the vaccine?

Inactivated hepatitis A virus jab (Avaxim), used pretty much everywhere except in China and India and available for children aged 1-15 years and adults. Involves two shots usually given six months apart, the last one two weeks before you travel, sometimes combined with typhoid shots. Alternatively, gamma globulin, a passive vaccine, introduces antibodies into the system. Most current versions have been inactivated with formaldehyde or contain aluminium.

How necessary?

Not a big risk for British travellers. Of the 2,000 British cases seen every year, only several hundred are contracted abroad. Only recommended for areas where the disease is highly endemic as risk is thought to be declining.

How effective?

Overall, hep A vaccines offer around 88-90 per cent effectiveness, according to the latest review of all studies so far.8 One review of 13 studies of gamma globulin involving more than half a million recipients found that it significantly reduced the incidence of hepatitis A, but the protection didn't last for more than just a few months.9

How safe?

Certainly safer than the old live vaccines, which affected two-thirds of recipients. The killed version affects about a sixth of those who receive it.10 Side-effects (according to manufacturer Sanofi Pasteur) affecting 27 per cent of patients: fever, flu-like symptoms, drowsiness, headache, joint and muscle pain, gastrointestinal upset and behavioural changes.

Not recommended for children under 2.

What to do instead

Follow meticulous hygiene (see box, right) and try homeopathic alternatives (see page 35).

Homeopathic 'vaccines'

If you prefer not to take drugs, the following is the standard schedule for homeopathic nosodes, or homoeopathic preparations of the diseases in question, used for many generations as vaccinations.

Cholera

One Camphor 30 at bedtime and one on rising, to be taken two weeks before travelling to an infected country

Hepatitis

One Chelidonium 30, to be taken eight days before departure; repeat the dose once a week for your stay.

Malaria

One Natrum Muriaticum 30, to be taken six days before departure; repeat the dose once every week of your stay.

Yellow fever

One Arsenicum Album 30, to be taken five days before departure.

Typhoid

One Manganum Metallicum 30, to be taken three days before departure.

Protection against deadly mozzies

The best protection from mosquito-borne illnesses is a mosquito net. Deaths from malaria among African five-year-olds have been cut by up to a third and hospital admissions by more than a third simply by using bed and door nets impregnated with the biodegradable insecticide pyrethroid. The WHO estimates that 500,000 children's lives could be saved each year by using nets.

Nets also allow immunity to develop naturally among children living in affected countries.1 If you're going to danger zones for any mozzie-borne illness, carry a portable bed net with you.

In addition:

o avoid being outdoors during cooler hours (at dusk and dawn)

o wear mosquito repellent (if you're in danger zones, you may need to opt for the industrial chemical nasty DEET), and stay in air-conditioned or well-screened rooms

o if you're using DEET, watch how much you spray on your children, as they can suffer neurological problems from it

o wear socks, long trousers and long-sleeved shirts to reduce skin exposure

o consider using aerosol room insecticides to kill indoor mosquitoes and applying permethrin (a mosquito repellent/insecticide) to clothing and mosquito netting if risk is high.


References

1 . Am J Trop Med Hyg, 1996; 55: 144-9]

MALARIA

What's it for?

A disease (most commonly due to the protozoan parasite Plasmodium falciparum) carried by the female Anopheles mosquito.

What's the vaccine?

As yet, nothing ready for the market. To date, the best of them only reduce episodes of malaria rather than prevent them.11

Presently, doctors offer travellers drugs designed to treat malaria-atovaquone-proguanil, doxycycline, chloroquine (often with proguanil), quinine, mefloquine (Lariam) and artemisinin combination therapy (ACT)-before, during and after travel to high-risk areas in the hope that it will ward off the disease.

ACT drugs combine one or more standard drugs for malaria plus the compound artemisinin, derived from the plant Artemisia annua (wormwood), used in Chinese medicine to treat malaria.

How necessary?

The most prevalent tropical disease, malaria infects 10,000 to 30,000 international travellers each year; every year 2,000 Britons contract malaria, 12 of whom die. (In America where fewer people travel to Asia and Africa, several hundred patients contract it every year.)

Risk greatest in both rural and urban parts of Africa, particularly at night, but far less in Asia and South America if you stick to towns and resorts, and limit your risk of exposure in rural areas by going out only during daylight hours.

How effective?

Most strains of malaria quickly develop resistance to drugs, including ACTs, so doctors and even the WHO rely on frequently swapping drug schedules in the hope of keeping one step ahead of the bugs.

The WHO discourages travellers from using any one drug, especially artemisinin, lest resistance to this-the most effective treatment left-builds up. A recent comparison of all ACT drugs found dihydroartemisinin-piperaquine to be particularly effective.12

How safe?

Studies comparing three antimalarial drugs in children found that mefloquine (vs atovaquone-proguanil and doxycycline) had the most side-effects, including neuropsychiatric, gastrointestinal and mood disturbances. Another review by the British Ministry of Defence found more than 500 published case reports of mefloquine's adverse effects, two-thirds of which involved tourists and business travellers, with four fatalities attributed to mefloquine. In the same review, thousands of soldiers taking mefloquine stopped the drug because of adverse side-effects.13

Mefloquine (Lariam) side-effects include severe psychological disturbances like panic attacks and hallucinations, vomiting, dizziness, headache, weight loss, seizures, tinnitus, emotional problems and heart attack.14

ACT side-effects include nausea, vomiting, anorexia and dizziness, plus mild blood abnormalities and allergic reactions,15 plus all the reactions of the drugs used in the combo therapies.

Chloroquine side-effects include bone marrow suppression, heart problems, a neuropsychiatric syndrome and brain dysfunction, hair loss and skin depigmentation, damage to the retina of the eyes, ringing in the ears (tinnitus) and convulsions.

Quinine side-effects include dysphoria (a general feeling of unhappiness), tinnitus and deafness, hypoglycaemia and even serious cardiovascular and nervous system effects.

What to do instead

Take the natural herb Artemisia annua (qinghao in Chinese medicine) itself, as it's a proven preventative and effective treatment for malaria. Works faster than any other antimalarial with no evident toxicity,16 although its widespread use as an 'active ingredient' in drugs may mean its effectiveness is waning.

Other natural possibilities: extracts of cinchona bark, the natural source of quinine, used in South America for centuries to treat malaria-type fevers.17

References

1.Lancet, 2009; 374: 1694-702; Int J Epidemiol, 2006; 35: 1044-50

2.Cochrane Database Syst Rev, 2011; 3: CD008603

3.Natl Med J India, 1997; 10: 17-8

4.Cochrane Database Syst Rev, 2007; 3: CD001261

5.J Biol Stand, 1986; 14: 289-95; W Afr J Med, 1990; 9: 200-3

6.Expert Rev Vaccines, 2011; 10: 1609-20

7.Bull Soc Pathol Exot Filiales, 1986; 79: 772-6

8.Cochrane Database Syst Rev, 2012; 7: CD009051

9.Cochrane Database Syst Rev, 2009; 2: CD004181

10.Vaccine, 1996; 14: 982-6; Zhonghua Liu Xing Bing Xue Za Zhi, 2013; 34: 24-7

11.Cochrane Database Syst Rev, 2006; 4: CD006199

12.Cochrane Database Syst Rev, 2009; 3: CD007483

13.Cochrane Database Syst Rev, 2009; 4: CD006491; Cochrane Database Syst Rev, 2000; 4: CD000138

14.BMJ, 1996; 313: 525-8

15.Drug Saf, 2004; 27: 25-61; Trans R Soc Trop Med Hyg, 2001; 95: 182-3

16.Lancet, 1993; 341: 603-8; Trans R Soc Trop Med Hyg, 1994; 88 [suppl 1]: S9-S11

17. N Engl J Med, 1992; 327: 1519-21


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