Yellow Fever Update:

Recent news reports have raised concerns about yellow fever vaccine safety. It is important to understand the risks and benefits.

For decades, the yellow fever vaccine was considered to be extremely safe. More recently, however, we have become aware of a low rate of serious adverse effects occurring when older travellers are vaccinated for the first time. The two main types of adverse effects are called YEL-AVD and YEL-AND – the first involves damage to organs such as the liver, and the second damages the nervous system. Yellow fever vaccines contain live viruses that do not harm people with a normally functioning immune system but do seem to cause harm in a tiny proportion of people with an ageing immune system, as well as those with reduced immunity from other causes.

In one of the largest medical studies of yellow fever vaccine safety, the rate of YEL-AND in people aged 60-69 was 2.5 per 100,000 people vaccinated, and in over 70s was 1.6 per 100,000. For YEL-AND, the rates were zero and 4.0 per 100,000 respectively.

According to the US Centers for Disease Control, in the absence of a yellow fever outbreak, the “background” risk of yellow fever occurring in unvaccinated travellers on a 2-week trip to a zone where yellow fever is present is calculated to be:

• West Africa: 50 cases per 100,000, with 10 deaths per 100,000
• South America: 5 cases per 100,000, with 1 death per 100,000

Yellow fever vaccinating centres normally explain these risks to everyone they vaccinate, and in particular to travellers aged over 60.  Vaccination for personal protection is recommended where benefit outweighs the risks, and a medical waiver is given when it is not safe for the vaccine to be used. Age alone is not a reason for issuing a waiver.

Other factors that complicate the picture include the following:

• There are active outbreaks of yellow fever in several parts of the world, notably at present in Brazil as well as in several African countries, so the risk to travellers is often much higher than that quoted above.
• Vaccination is the only way to prevent and control yellow fever and is often the only possible public health measure for entire populations.
• Many countries therefore rigorously enforce vaccine requirements as a condition of entry.
• Yellow fever vaccine shortages are common – there is currently a serious shortage in the USA, and the vaccine is not always available when needed.
• Awareness of vaccine risks has come with a stricter approach to recommending vaccine only when travellers are definitely going to be at risk; however, an unintended consequence of this has been to delay the opportunity to vaccinate travellers for the first time until they are older and at greater risk of adverse effects.

The World Health Organization now considers vaccine protection to be life-long, though border officials in several countries do not always recognise this. A small number of recent cases of yellow fever in Brazil among people who had been vaccinated previously has raised further doubt about this policy, and Brazil currently recommends revaccination every 10 years.  Revaccination has not been linked to adverse effects.

There is currently extensive UK press coverage (that has also been picked up in the US) of YF vaccine adverse effects – one death occurred shortly after vaccination in a distinguished cancer researcher, and a psychotic reaction in a former BBC journalist vaccinated in Greece. Both cases were attributed to the vaccine because of the timing. Further clinical details are not available, so we can’t yet be certain of a direct link, but this news will undoubtedly have a considerable impact on public perception of the vaccine.

Written by: Richard Dawood, Medical Director and specialist in travel medicine

Book your yellow fever vaccination today.

Links:

• Cancer pioneer Martin Gore’s sudden death from routine jab  –  Source: The Times
  
• I had a yellow fever jab, then the voices told me: ‘Kill! Kill! Kill!” – Source: The Times

Bosnia is where East meets West.

It is a country on the Balkan Peninsula in southeastern Europe and has become somewhat a destination for adventurous travellers.

Beautiful Ottoman architecture, rugged mountains, captivating castles, raft-able rivers, and humble hiking trails are all reasons why travellers are choosing Bosnia as their next travel destination. The unveiling of the Via Dinarica mega hiking trail means the number of tourists to the Balkan country of Bosnia Hercegovina is expected to rise steeply. The 1930km trail provides a corridor linking traditional cultures between the former Yugoslavian nations. So whether you plan to mill about the city of Mostar, stroll the streets of Sarajevo, or take a hike in the hillside, ensure you follow our top travel tips to stay healthy.

Vaccinations

All travellers are advised to be in date with their routine immunisations, including diphtheria, tetanus and polio (DTP) and measles, mumps and rubella (MMR). Europe has seen huge outbreaks of measles this year alone, so all travellers should make sure they have received at least two doses of the measles-containing vaccination. A simple blood test can be done for all those who are unsure about their immunity. Some travellers may wish to consider vaccinations for Hepatitis A and Hepatitis B, rabies and tick-borne encephalitis. The activities you plan to do whilst travelling will determine which vaccines would be required. If you have any doubts or concerns, we also suggest booking a pre-travel consultation with a specialist travel nurse to discuss your options.

Find out more about our travel and wellness vaccinations.

Trekking and Ticks

Bosnia offers a wealth of outdoor activities. Those who plan to take advantage of the great outdoors should strongly consider vaccination against tick-borne encephalitis (TBE). TBE is a bacterial infection. Usually, it is spread through an infected tick bite. However, during Spring to Autumn, the consumption of unpasteurised dairy produce also carries a risk. Contracting the illness causes a fever with neurological complications.  It is vaccine-preventable. Protection requires  2 doses of the vaccination, given at least 2-weeks apart.  A third dose is given 5-12 months later to give longterm protection. You should also avoid ticks by wearing long trousers and socks. Using DEET insect repellant should also repel them.

If you spot a tick on you, it needs to be removed promptly. Use some flat tweezers or a tick remover and clean the bite with alcohol to reduce the risk of infection.

See our Ultimate Bug Kit.

Rabies

Rabies is a fatal virus that can be found in the saliva of an infected mammal. Most commonly a wild dog. Exposure can happen through a bite, scratch or a lick to an open area of the skin. You cannot catch rabies from another person and it cannot spread through unbroken skin. You should, where possible avoid contact with animals when travelling, especially wild or stay animals.

Rabies is almost always fatal once symptoms appear, but treatment before this is very effective. Pre-travel rabies vaccination offers great protection. And means that in the unlikely event you come into contact with the rabies virus, fast and effective treatment can be given easily and in the country of the incident.

Pre-travel rabies protection requires a series of 3 vaccinations given as injections into your upper arm. Your vaccines will be given over a 3-week period, or over 1 week if an accelerated course is needed, prior to travel. Travellers at greater risk are those who plan to do outdoor activities such as hiking, trekking, cycling or caving. You should consider a rabies vaccine if you plan to do any of these activities whilst visiting Bosnia.

First Aid Kit

For those trekking in the hills, packing good basic first aid kit is essential. When travelling in rural areas, access to healthcare can be limited. Travelling with a medical kit will give you access to basic provisions needed to treat minor injuries and pains.

Basic provisions include pain relief, plasters and medication to treat an upset stomach, such as loperamide and oral rehydration salts. If access to safe water may be limited, consider packing chlorine dioxide tablets. Cuts, scapes blisters and even a twisted ankle can occur, so take blister pads, some waterproof dressings and a bandage to deal with any minor injuries whilst you are there. If you take regular prescription medication, ensure you pack enough for the duration of your trip and carry the prescription with you.

Book your travel appointment today

By Anna Chapman |  Travel Nurse | August 2019

Tanzania is the perfect haven for adventurous travellers. Not only does it boast three of Africa’s Seven Natural Wonders, but it is home to the ancient nomadic stewards, the iconic, Maasai people. It is also the perfect place for an African safari adventure, with it’s 16 national parks accounting for more than 30% of the country.  

Tanzania is blessed with the highest peak in Africa. Mount Kilimanjaro beckons visitors from all over the world. It is the world’s highest free-standing volcano and gets an estimated 30,000 travellers attempting to summit the peak each year. Climbers by the thousands venture here to challenge themselves on its muddy slopes, rocky trails and slippery scree.

It’s crowning jewel is the island, Zanzibar. The island is famous for its mix of exotic white sand beaches, dense palm trees and coral seas. A true paradise. It hosts famous spice plantations and is rich with diverse culture. Unguja (the main island in Zanzibar) is also home to many endangered species including the red colobus monkey and green turtle.

Whether you are visiting for an action-packed safari, challenging yourself to reach the peak of Mt. Kilimanjaro or relaxing on the island of Zanzibar, ensure you follow our top travel tips to stay healthy in Tanzania.

Vaccines

All travellers should ensure they are in date with all their routine immunisations, including diphtheria, tetanus and polio (DTP), and measles, mumps and rubella (MMR). 

You should consider specialist travel vaccinations prior to travel. Hepatitis A and Typhoid are highly recommended. Furthermore, some travellers may also wish to be vaccinated against Rabies, Hepatitis B and Cholera for extra precautions. Especially if travelling to more rural areas.

For more information on our vaccines, please visit our travel and wellness vaccination pages.

Yellow Fever

In Tanzania, there is no risk of yellow fever. If you are only travelling directly from the UK and back, it generally isn’t advised to have yellow fever vaccine. There is, however, a requirement for travellers to have a certificate of vaccination if they enter Tanzania from another country that has Yellow Fever. Bordering countries such as Kenya, Uganda, Rwanda, Burundi & DRC would all require a certificate. In this instance, a vaccination or a waiver certificate may be advised. It is best to speak with a specialist travel nurse, who will look at your route and access what vaccinations and certificates you would require.

Prevent Malaria

Whether you plan to visit Zanzibar or the mainland,  all areas of Tanzania have a risk of malaria. Therefore, you should take anti-malarial medication. Malaria is spread by mosquitoes that are most active between dusk and dawn. A common question is whether or not you need to take them if you plan to trek Mount Kilimanjaro. Even though the risk of malaria is low in areas above 2,500m, the start and finish of the trek take you well below this altitude. In short, you should take medication to prevent it. You should take precautions to reduce the risk of being bitten in the first place.

Precautions include:

• Wear long, loose clothing
• Wear plenty of mosquito repellent with a minimum of 50% DEET
• Use clothes spray containing permethrin – you can spray before you travel for short-duration trips
• Sleep under a mosquito net

See our Ultimate Bug Kit for everything you need to keep the mosquitos at bay.

Climbing Kilimanjaro

If you are trekking Kilimanjaro, make sure your pre-travel plans take this into account. Trekking is physically demanding and exposes you to the risk of altitude sickness. The summit of the peak is 5,895m and treks can take anything from 5-9 days. Altitude sickness is unpleasant. Not only this but it can develop into something more serious and become life-threatening. Take time to acclimatise. This will reduce your risk of developing altitude sickness. Ideally, choose a longer trek. A slower ascent over more days will reduce your risk considerably. Alternatively, you can get a prescription of acetazolamide (Diamox) to aid the process. Speak to a specialist travel nurse about this at your pre-travel consultation. Don’t let altitude sickness ruin your trip.

Book your travel appointment today

By Anna Chapman |  Travel Nurse | August 2019

Osteopathic manipulation, or HVT (high-velocity thrust) as it is more technically known, is the “click” that many people associate with osteopathic treatment.

It is by no means always used by an osteopath, but when it is, it can prove to be a quick, efficient, and pain-free way of restoring function to a joint.

Many patients’ conditions may not be suitable for HVT, and many may not be keen to have it done anyway. In these cases, the osteopath will treat with a whole collection of other highly effective ways. HVT should be seen as a useful tool in some circumstances, but not a be-all and end-all of osteopathy.

So how does it work?

HVT is placing a short sharp tug though a joint, most often a spinal facet (which is what we will concentrate on here), a click may or may not be heard. The noise itself is a bit of a by-product. What it is has been disputed a little but the generally accepted explanation is that when the joint is stretched, the synovial fluid inside the joint itself physically does not stretch, so gas is forced out of solution causing gas bubbles that allow the joint to gap slightly, causing the clicking noise. This also explains why another click cannot be produced for a little while until the gas has been reabsorbed.
The gapping of the joint is the key to the effectiveness of HVT.

What I must point out at this point though is that the click is not a relocation of a joint.
Barely a day goes past that someone doesn’t tell me their osteopath “clicked something back in” often assuming it was a disc. As much as it can feel miraculous like this sometimes, and a patient can often feel and be quite a bit straighter following treatment, the HVT is about restoring function to the joint, not putting it back in place. Discs especially do not just “pop back in”.

So what does the gapping achieve?

Well, here we have to get a little technical. There are three predominant effects caused by HVT as far as we can tell.

Firstly, post-contractile sensory discharge or PCSD.

Imagine that the brain keeps many muscles at a gentle tension, this allows you to hold your posture. When an area is identified as problematic (painful or inflamed etc), the brain may choose to cause the muscles around the area to spasm, often to protect the area. The spasm itself may cause further pain. This then becomes a vicious circle and dysfunction.

Tension in the muscles is controlled by spindle fibres. This is what detects the short sharp tug of the muscles in HVT. Imagine the short sharp tug as a reset for these fibres. The brain then has to determine the level of muscle tension required and often can reset to the original tension, immediately bringing the joint out of spasm.

Massage of muscles, slow stretching over a longer period, has a similar effect but unfortunately can’t be performed on the small, deep muscles directly around and holding the joint.

Secondly, pain gate theory.

Even when nerves are reporting pain in a certain area, it is important that the body can still detect a soft touch in the same area. To achieve this soft touch and position detecting nerves override deep pain detecting ones. Where you ever told to rub your knee or elbow after you bumped it and it hurt? That’s pain gate, the soft-touch overrides the deep pain. It won’t stop it completely of course but even a little relief will make it feel better. In turn, this may again stop the brain causing the area to spasm.
HVT moves the joint quickly and sharply. This causes the positional detectors to immediately report this to the brain, inhibiting the deep pain.

Thirdly, meniscoid theory.

In a joint, smooth cartilaginous surfaces rub together, but they may not be quite as smooth as we used to think. Small pieces of cartilage appear to be in the joint. Possibly to fill small gaps; craters on a moonscape is a good way to think of it. It has been suggested that when the joint spasms, these small bits of cartilage, which are attached to the capsule around the joint can become trapped out of place. Gapping the joint allows the tethers to the capsule to quickly pull them back into place.

It’s possibly worth pointing out before I finish, that although I said earlier that the click is an unnecessary by-product, I do wonder if it could be argued that the psychological effect of hearing the click could be put forward as a fourth effect. Hearing a click and knowing that it may have relieved a painful joint does often make a patient immediately relax. This may itself be part of the healing process.

Osteopathic manipulation is often a quick efficient way of relieving dysfunction of a joint. It is not a miracle cure. Many other things have to be taken into account for the osteopath to treat fully and effectively.

HVT will not immediately heal damaged tissue or disperse inflammation, but it often is a good way to kick start the process.

Book an osteopathy appointment

By Andrew Doody |  Osteopath | August 2019

What is Cyclospora?

Cyclospora is a tiny, single-celled parasite, spread by contaminated food. It can cause diarrhoea, abdominal cramps, nausea, loss of appetite, bloating, gas, fatigue, mild fever, and weight loss.

 Why is it in the news?

There’s been an outbreak in travellers to Mexico, with at least 204 reported cases in returning holidaymakers since June. However, it is difficult to detect using standard tests. Because it is uncommon in the UK, most labs don’t look for it and may miss the diagnosis. So the true number is probably much higher.

 What’s the most reliable way of detecting it?

The best way is called a rapid PCR test, which detects the parasite’s DNA. The test also looks for DNA and genetic material from 21 other diarrhoea-causing parasites, bacteria and viruses at the same time – so there is a very high probability of finding the right cause. As you’d expect, the test is available at the Fleet Street Clinic. Importantly, we can have a result within an hour or so of receiving a sample.

How can I prevent it?

Outbreaks have been linked to eating fresh uncooked berries/unpeeled fruit and salad items that have not been washed in safe water. Sticking to foods that have been freshly and thoroughly cooked, when you travel, is the safest option.

 How is it treated?

Confirmed cases can be treated with an antibiotic called co-trimoxazole. Some of the more commonly-used antibiotics for travellers’ diarrhoea may not be effective.

If you have any concerns about cyclospora and other parasites, our PCR test service can help detect the exact cause of any issue you might have. What this allows is proper diagnosis and treatment. Usually,  guess-work on what bug a patient is carrying or general prescriptions to tackle the illness might be given by medical professionals. The PCR test offers accuracy like nothing else.

You can book an appointment online.

Imagine you’re holidaying in a tropical paradise, walking barefoot on the beach. Would you consider this a health risk? What if this simple, carefree activity could turn your trip into a nightmare?

Unfortunately, this is what happened to a Canadian couple in the Dominican Republic, who contracted hookworm in Punta Cana after walking on the beach without shoes.

Fleet Street Clinic’s medical director, Dr Richard Dawood, is Telegraph Travel’s medical expert and shared his medical opinion on the case in a recent article. 

The article details the story of the couple, who shared their plight on social media to raise awareness of the parasitic worm infection.

Hookworm can infect humans if soil contaminated with their larva comes into contact with bare skin. Most commonly, hookworm infection can occur in Africa, the Americas, China and south-east Asia, according to the NHS.

Dr Dawood explained to the Telegraph how you can spot a hookworm infection:

“Typically there is a linear rash that follows the track of the migrating larva. It can become almost unbearable itchy, much worse than an insect bite, which is an important clue. There’s a local allergic reaction, which can then blister, making the line pattern harder to spot.”

And how to treat: “There are a number of different anti-parasitic treatments that work, either taken as tablets, or made into a cream and applied locally. The larvae can sometimes also be killed using cryotherapy to freeze them. Blisters or scratching can easily lead to infection, necessitating antibiotic treatment.”

To avoid hookworm, avoid coming into contact with soil or sand that could be contaminated. If walking on the beach, it’s advisable to wear shoes at all times!

Dr Richard Dawood at Fleet Street Clinic

Dr Richard Dawood is founder of Fleet Street Clinic in London and has practiced for over 35 years. He was one of the first doctors in the UK to establish Travel Medicine as a distinct speciality. Richard is the most senior UK travel medicine specialist working exclusively in a private setting.

You can book a travel consultation appointment online.