Vaccines Have Serious Side Effects

The Revised Authoritative Guide To Vaccine Legal Exemptions

Comprehensive, authoritative information about vaccine exemptions you can trust, from Alan Phillips, J.D., a leading vaccine rights attorney with years of experience helping clients throughout the U.S. legally avoid vaccines in a wide variety of vaccine-refusal settings. Critical details for parents, students, immigrants, healthcare employees, military personnel and contractors, agencies, attorneys and clientsvirtually anyone concerned with legally avoiding vaccines in the United States. This Guide provides and explains: Important background information about the legal system; How state and federal statutes, regulations, constitutions and legal precedent interact to define the boundaries of your legal exemption rights; How to deal with local authorities and to avoid mistakes that cost others their exemption; Where legal technicalities and practical reality differand what to do about it; More here...

The Revised Authoritative Guide To Vaccine Legal Exemptions Overview

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My The Revised Authoritative Guide To Vaccine Legal Exemptions Review

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Recommended Vaccinations

Since most vaccines don't produce immunity until at least two weeks after they're given, visit a physician four to eight weeks before departure. Ask your doctor for an International Certificate of Vaccination (otherwise known as the yellow booklet), which will list all the vaccinations you've received. This is mandatory for countries that require proof of yellow fever vaccination upon entry, but it's a good idea to carry it wherever you travel. The only required vaccine for entry into Mexico is yellow fever, and that's only if you're arriving from a yellow fever-infected country in Africa or South America. However, a number of vaccines are recommended (see table following). Note that some of these are not approved for use by children and pregnant women - check with your physician.

Sideeffects of Vaccinations

All injected vaccinations can produce slight sorenessand rednessatthe inoculation site, and a mild fever with muscle aches over the first 24 hours. These are least likely with hepatitis A and a little more common with hepatitis B and typhoid inoculations. Typhoid inoculation can cause a sensation of nausea within 24 hours and hepatitis B vaccine can produce temporary joint pains. their destination. Since most vaccines don't produce immunity until at least two weeks after they're given, make sure you visit a physician at least six weeks before departure. A recent influenza vaccination is always a good idea when travelling. If you have not had chicken pox (varicella) consider being vaccinated.

Side Effects of Vaccinations

All vaccinations can produce slight soreness and redness at the inoculation site, and a mild fever with muscle aches over the first 24 hours. These side effects are less likely with hepatitis A inoculations and a little more common with hepatitis B and typhoid inoculations. Japanese B encephalitis vaccine has been associated with allergic reactions that require an antihistamine. Yellow-fever vaccine is dangerous for anyone with an egg allergy, and in about 5 of cases causes a flu-like illness any time within a week of vaccination.

Required Recommended Vaccinations

If you have been in a designated yellow fever country within the previous six days, you need an International Certificate of Vaccination against yellow fever for entry into American Samoa, Fiji, Kiribati, Marshall Islands, Nauru, New Caledonia, Niue, Palau, Pitcairn, Samoa, Solomon Islands and Tonga. Marshall Islands and Palau may require evidence of vaccination against cholera if you have arrived from a currently infected country. For all countries in the region, vaccinations are recommended for hepatitis A, hepatitis B and typhoid fever.

Vaccinations

The only required vaccination for Mexico is yellow fever, and that's only if you're arriving from a yellow fever-infected country in Africa or South America (including Guatemala). However, a number of vaccines are recommended see table below. Rabies injections are only recommended for those who may have contact with animals and won't have access to immediate health care. Vaccine

Infectious Diseases Hepatitis A

Hepatitis A is spread through contaminated food (particularly shellfish) and water. It causes jaundice, and although it is rarely fatal, can cause prolonged lethargy and delayed recovery. Symptoms include dark urine, a yellow colour to the whites of the eyes, fever and abdominal pain. Vaccination against Hepatitis A is recommended for travel to Morocco. The vaccine (Avaxim, VAQTA, Havrix) is given as an injection a single dose will give protection for up to a year, while a booster 12 months later will provide a subsequent 10 years of protection. Hepatitis A and typhoid vaccines can also be given as a single dose vaccine (Hepatyrix or Viatim).

Children Pregnant Women

In general, it's safe for children and pregnant women to go to Jamaica. However, because some of the vaccines listed in this chapter are not approved for use in children and pregnant women, these travelers should be particularly careful not to drink tap water or consume any questionable food or beverage. When traveling with children, make sure that all their routine immunizations are up to date. It's sometimes appropriate to give children some of their vaccines a little early before visiting a developing nation. You should discuss this with your pediatrician. If pregnant, you should bear in mind that, should a complication such as premature labor develop while you're abroad, the quality of medical care available may not be comparable to that in your home country. The yellow fever vaccine is not recommended for pregnant women or children less than nine months old. If arriving from a country with yellow fever, these travelers should obtain a waiver letter, preferably written on...

Traveling With Children Womens Health

In general, it's safe for children and pregnant women to go to Mexico. However, because some of the vaccines listed previously are not approved for use in children and pregnancy, these travelers should be particularly careful not to drink tap water or consume any questionable food or beverage. Also, when traveling with children, make sure they're up to date on all routine immunizations. It's sometimes appropriate to give children some of their vaccines a little early before visiting a developing nation. You should discuss this with your pediatrician. If pregnant, bear in mind that should a complication such as premature labor develop while abroad, the quality of medical care may not be comparable to that in your home country. Since yellow fever vaccine is not recommended for pregnant women or children less than nine months old, if you are arriving from a country with yellow fever, obtain a waiver letter, preferably written on letterhead stationery and bearing the stamp used by...

Infectious Diseases Diphtheria

Diphtheria is spread through close respiratory contact. It causes a high temperature and severe sore throat. Sometimes a membrane forms across the throat requiring a tracheostomy to prevent suffocation. Vaccination is recommended for those likely to be in close contact with the local population in infected areas. The vaccine is given as an Hepatitis A is spread through contaminated food (particularly shellfish) and water. It causes jaundice, and although it is rarely fatal, can cause prolonged lethargy and delayed recovery. Symptoms include dark urine, a yellow colour to the whites of the eyes, fever and abdominal pain. Hepatitis A vaccine (Avaxim, VAQTA, Havrix) is given as an injection a single dose will give protection for up to a year, while a booster 12 months later will provide a subsequent 10 years of protection. Hepatitis A and typhoid vaccines can also be given as a single dose vaccine (hepatyrix or viatim). Infected blood, contaminated needles and sexual intercourse can all...

Gay Lesbian Travellers

There is currently no vaccine available to prevent bird flu. For up-to-date information, check the websites www.who.int en and www.avianinfluenza.com.au. Required Vaccinations Yellow Fever Proof of vaccination is required if entering China within six days of visiting an infected country. If you are travelling to China from Africa orSouth America, check with a travel medicine clinic about whether you need the vaccine. Recommended Vaccinations Hepatitis B Now considered a routine vaccination for most travellers. Given as three shots over six months, this vaccine can be combined with Hepatitis A (Twinrix). In most people the course gives lifetime protection. Mild side effects include a sore arm and headaches. Measles Mumps Rubella (MMR) Two lifetime doses of MMR are recommended unless you have had the diseases. Many adults under the age of 35 require a booster. Occasionally a rash and flu-like illness occur about a week after vaccination. Varicella (chickenpox) If you haven't had...

Meningococcal Meningitis

Meningococcal infection is spread through close respiratory contact and is more likely in crowded situations, such as dormitories, buses and clubs. Infection is uncommon in travellers. Vaccination is particularly recommended for long stays and is especially important towards the end of the dry season (see p621). Symptoms include a fever, severe headache, neck stiffness and a red rash. Immediate medical treatment is necessary. The ACWY vaccine is recommended for all travellers in sub-Saharan Africa. This vaccine is different from the meningococcal meningitis C vaccine given to children and adolescents in some countries it is safe to be given both types of vaccine.

Availability Of Health Care

It is a serious infection of the brain and vaccination is advised for those in risk areas who are unable to avoid tick bites (such as campers, forestry workers and walkers). Two doses of vaccine will give a year's protection, three doses up to three years'. These are spread through contaminated food (particularly shellfish) and water. Typhoid can cause septicaemia Hepatitis A causes liver inflammation and jaundice. Neither is usually fatal but recovery can be prolonged. Hepatitis A and typhoid vaccines can be given as a single-dose vaccine, Hepatyrix or Viatim.

Recommended Immunisations

There are no required vaccinations for entry into Hong Kong or Macau unless you have travelled from a country infected with yellow fever. In this case, you will have to show your yellow-fever vaccination certificate. Hong Kong is a highly developed city and as such immunisations are not really necessary unless you will be travelling on to the mainland or elsewhere in the region. Since most vaccines don't produce immunity until at least two weeks after they're given, visit a physician four to eight weeks before departure. Ask your doctor for an International Certificate of Vaccination (or 'ydkw booklet'), which will list all of the vaccinations you've received.

Medical Kit Check List

REQUIRED & RECOMMENDED VACCINATIONS Vaccinations you may want to consider for a trip to Cambodia are listed here, but it is imperative that you discuss your needs with your doctor. For more details about the diseases themselves, see the individual entries later in this section. Diphtheria and tetanus - vaccinations for these two diseases are usually combined. After an initial course of three injections (usually given in childhood), boosters are necessary every 10 years. Hepatitis A - this vaccine provides long-term immunity after an initial injection and a booster at six to 12 months. Alternatively, an injection of gamma globulin can provide short-term protection against hepatitis A - two to six months, depending on the dose. It is reasonably effective and, unlike the vaccine, is protective immediately but, because it is a blood product, there are current concerns about its long-term safety. The hepatitis A vaccine is also available in a combined form with the hepatitis B vaccine -...

Health Special Concerns

Costa Rica is the most modern and sanitary country of the Central American isthmus, so it presents few health worries. No shots are required, but if you're traveling on to more remote sections of Central America - such as Guatemala, Panama, El Salvador or Honduras - a vaccination against hepatitis A is strongly recommended. Contaminated water is the common source a shot of immune globulin gives adequate temporary protection. A doctor friend of ours, who has vacationed in Central America for the past 25 years, recommends a hepatitis vaccine to all travelers regardless of where they go in the world - Cartago or Copenhagen.

Alexandre Yersin Museum

Today, the Pasteur Institute in Nha Trang coordinates vaccination and hygiene programmes for the country's southern coastal region. The institute produces vaccines and carries out medical research and testing to European standards. Physicians at the clinic here offer medical advice to around 70 patients a day. Vietnam's two other Pasteur Institutes are in HCMC and Dalat.

Travelling With Children

All travellers with children should know how to treat minor ailments and when to seek medical treatment. Make sure children are up to date with routine vaccinations, and discuss possible travel vaccines well before departure as some vaccines are not suitable for children aged under one year. You may want to consider giving children the BCG vaccine for tuberculosis (TB) if they haven't already had it - see p689 for more information.

Jet Lag Motion Sickness

REQUIRED & RECOMMENDED VACCINATIONS The WHO recommends the following vaccinations for travel to Mongolia Hepatitis A Provides almost 100 protection for up to a year a booster after 12 months provides at least another 20 years' protection. Mild side effects such as headache and sore arm occur with some people. Hepatitis B Now considered routine for most travellers, it provides lifetime protection for 95 of people. Immunisation is given as three doses oversix months, though a rapid schedule is also available, as is a combined vaccination for Hepatitis A. Side effects are mild and uncommon, usually headache and sore arm. Measles, Mumps & Rubella (MMR) Two doses of MMR are recommended unless you have had the diseases. Occasionally a rash and flu-like illness can develop a week after receiving the vaccine. Many young adults need a booster. Typhoid Recommended unless your trip is less than a week. The vaccine offers around 70 protection, lasts for two to three years and comes as a...

Availability Of Health Care Costs

This mosquito-borne disease is becomingly increasingly problematic throughout Myanmar. As there is no vaccine available it can only be prevented by avoiding mosquito bites. The mosquito that carries dengue bites day and night, so use insect-avoidance The only sexually transmitted disease that can be prevented by vaccination, hepatitis B is spread by body fluids, including sexual contact. In some parts of this region up to 20 of the population are carriers of hepatitis B, and usually are unaware of this. The long-term consequences can include liver cancer and cirrhosis. Hepatitis E is transmitted through contaminated food and water and has similar symptoms to hepatitis A, but is far less common. It is a severe problem in pregnant women and can result in the death of both mother and baby. There is currently no vaccine, and prevention is by following safe eating and drinking guidelines. aches, runny nose, cough and sore throat. It can be very severe in people over the age of 65 or in...

Health Without Wealth

Achievements are impressive and wide ranging homegrown treatment for over 15,000 Chernobyl victims, the successful vaccination of 1.5 million Haitian children against measles, the production of the world's first meningitis B vaccine (subsequently licensed by drug multinational GlaxoSmithKline), heart transplants, cancer research and one of the world's lowest AIDS rates.

In Vanuatu New Caledonia

This is a virus disease causing liver inflammation. Fever, debility and jaundice (yellow skin and eyes, dark urine) occur, recovery is slow, and it can be dangerous to people with other liver disease, to the elderly and sometimes to pregnant women. It is spread by contaminated food or water. Self-treatment consists of rest, a low-fat diet and avoidance of alcohol. The vaccine is close to 100 protective. Like hepatitis A, hepatitis B is a virus disease causing liver inflammation, but it is more serious and frequently causes chronic liver disease and even cancer. It is spread, like HIV, by mixing body fluids, by using contaminated needles and by accidental blood contamination. Treatment is complex and specialised but vaccination is highly effective. There is no malaria in Aneityum or Fu-tuna in Vanuatu, and none in New Caledonia. It is also quite rare in Vila. Elsewhere, take extreme care. It is a parasite infection transmitted by mosquitoes that feed in dull light (ie at night, when...

Getting There Away Entering South Africa

If you're coming to South Africa after travelling through the yellow-fever zone in Africa (which includes most of East, West and Central Africa) or South America, you must have an international vaccination certificate against yellow fever. No other vaccinations are mandatory, although there are some you should consider (see p766).

Japanese B Encephalitis

This viral disease is transmitted by mosquitoes, but is very rare in travellers. Most cases occur in rural areas, and vaccination is recommended for travellers spending more than one month outside cities. There is no treatment, should take precautions. Vaccination is usually only given to children under the age of five, but adults at risk are recommended to undertake pre- and post-travel TB testing. The main symptoms are fever, cough, weight loss, night sweats and tiredness. This serious bacterial infection is spread via food and water. It gives a high and slowly worsening fever and headache, and may be accompanied by a dry cough and stomach pain. It is diagnosed by blood tests and treated with antibiotics. Vaccination is recommended for all travellers spending more than a week in Korea and travelling outside Seoul. Be aware that vaccination is not 100 effective, so you must still be careful with what you eat and drink.

The Pet Travel Scheme

However, it should be noted that it is necessary to wait six months after vaccination and a successful blood test result before a pet is entitled to enter the UK under the travel scheme. This is because if a pet is infected before vaccination, it can take up to 6 months for rabies to incubate.

Traveling With Children

In general, it's safe for children to go to Cuba. However, because some of the vaccines listed previously are not approved for use in children (or during pregnancy), travelers with children should be particularly careful not to drink tap water or consume any questionable food or beverage. Also, when traveling with children, make sure they're up-to-date on all routine immunizations. It's sometimes appropriate to give children some of their vaccines a little early before visiting a developing nation. You should discuss this with your pediatrician.

Infectious Diseases Dengue

This mosquito-borne disease is becomingly increasingly problematic in the tropical world, especially in the cities. As there is no vaccine it can only be prevented by avoiding mosquito bites. The dengue carrying mosquito bites both day and night so use insect avoidance measures at all times. Symptoms include high fever, severe headache and body ache (dengue was previously known as 'breakbone fever'). Some people develop a rash and experience diarrhoea. There is no specific treatment - just rest and paracetamol do not take aspirin because it increases the likelihood of haem-orrhaging. See a doctor for diagnosis and monitoring.

Travelers With Disabilities

Canada, 416 652-0137 www.iamat. org) for tips on travel and health concerns in the countries you're visiting, and lists of local, English-speaking doctors. The United States Centers for Disease Control and Prevention (& 800 311-3435 www.cdc.gov) provides up-to-date information on necessary vaccines and health hazards by region or country. Any foreign consulate can provide a list of area doctors who speak English. If you get sick, consider asking your hotel concierge to recommend a local doctor even his or her own. You can also try the emergency room at a local hospital many have walk-in clinics for emergency cases that are not life-threatening. You may not get immediate attention, but you won't pay the high price of an emergency room visit.

Infectious Diseases Dengue Fever

There is no treatment for dengue fever except to take analgesics such as acetaminophen or paracetamol (Tylenol) and drink plenty of fluids. Severe cases may require hospitalization for intravenous fluids and supportive care. There is no vaccine. The cornerstone of prevention is insect-protection measures, described on opposite.

Availability Cost Of Health Care

Tampons and pads are readily available in main centres. Dengue fever, especially in the first three months of pregnancy, poses a hazard because of fever but otherwise there is no reason why a normal pregnancy should prevent travel to the region. However, on general principles immunisation in the first three months of pregnancy is not recommended and yellow fever vaccines should not be given.

Infectious Diseases Malaria

There is no specific treatment for dengue fever, except to take analgesics such as acetaminophen paracetamol (Tylenol) and drink plenty of fluids. Severe cases may require hospitalization. There is no vaccine. The cornerstone of prevention is insect protection measures (see p280). The vaccine for hepatitis A is extremely safe and highly effective. If you get a booster six to 12 months later, it lasts for at least 10 years. You should get it before you go to Mexico. Because the safety of hepatitis A vaccine has not been established for pregnant women or children aged under two, they should instead be given a gammaglobulin injection. Like hepatitis A, hepatitis B is a liver infection that occurs worldwide but is more common in developing nations. Unlike hepatitis A, the disease is usually acquired by sexual contact or by exposure to infected blood, generally through blood transfusions or contaminated needles. The vaccine is recommended only for long-term travelers (on the road more than...

In Russia China Mongolia

This will be your main health concern across Russia and China, particularly in winter. Symptoms include muscle ache, high fever, runny nose, cough and sore throat. Vaccination is particularly recommended for those aged 65 and over. fatal unless treated promptly. Animal handlers should be vaccinated, as should those travelling to remote areas where a reliable source of postbite vaccine is not available within 24 hours see p337. Spread by tick bites, this is a serious infection of the brain and vaccination is advised for those in risk areas who are unable to avoid tick bites (such as campers, forestry workers and walkers). Two doses of vaccine will give a year's protection, three doses up to three years'. For more information see www .masta.org tickalert. is no vaccination against the disease. Treatment should be sought as soon as possible for best results. All travellers with children should know how to treat minor ailments and when to seek medical treatment. Make sure the children are...

In The Caribbean Islands

The cornerstone of prevention is protection against insect bites see p842 . The vaccine for hepatitis A is extremely safe and highly effective. If you get a booster six to 12 months later, it lasts for at least 10 years. You should get it before you go to any developing nation. Because the safety of hepatitis A vaccine has not been established for pregnant women or children under the age of two, they should instead be given a gammaglobulin injection. in developing nations. The disease is usually acquired by sexual contact or by exposure to infected blood, generally through blood transfusions or contaminated needles. In the Caribbean the risk is greatest in Haiti and the Dominican Republic. The vaccine is recommended only for long-term travelers (on the road more than six months) who expect to live in rural areas or have close physical contact with locals. Additionally, the vaccine is recommended for anyone who anticipates sexual contact with the local inhabitants...

In The Samoan Islands Tonga

Tampons and pads are readily available in main centres. Dengue fever, especially in the first three months of pregnancy, poses a hazard because of fever but otherwise there is no reason why a normal pregnancy should prevent travel to the region. However, on general principles immunisation in the first three months of pregnancy is not recommended and yellow fever vaccines should not be given. Dengue fever is a virus disease spread by the bite of a day-biting mosquito. It causes a feverish illness with headache and severe muscle pains similar to those experienced with a bad, prolonged attack of influenza. Another name is 'break bone fever' and that's what it feels like. Danger signs include prolonged vomiting, blood in the vomit and a blotchy rash. There is no preventive vaccine and mosquito bites should be avoided whenever possible. Self-treatment involves paracetamol, fluids and rest. Do not use aspirin, as this can cause bleeding. Haem-orrhagic dengue has been reported only...

Specialized Travel Resources

Contact the International Association for Medical Assistance to Travelers (IAMAT) (& 716 754-4883 www.iamat.org) for tips on travel and health concerns in Italy and lists of local, English-speaking doctors (in Canada, call & 519 836-0102). The United States Centers for Disease Control and Prevention (& 800 311-3435 www.cdc.gov) provides up-to-date information on necessary vaccines and health hazards by region or country. (The booklet Health Information for International Travel is 29 by mail on the Internet, it's free.)

Rabies

This is an increasingly common problem in China. This fatal disease is spread by the bite or lick of an infected animal - most commonly a dog. Seek medical advice immediately after any animal bite and commence post-exposure treatment. Having pretravel vaccination means the post-bite treatment is gready simplified. If an animal bites you, gendy wash the wound with soap and water, and apply an iodine-based antiseptic. If you are not prevaccinated you will need to receive rabies immunoglobulin as soon as possible, followed by a series of five vaccines over the next month. Those prevaccinated require only two shots of vaccine after a bite. Contact your insurance company to find the nearest clinic that stocks rabies immunoglobulin and vaccine. It's common that immunoglobulin is unavailable outside of major centres - it's crucial that you get to a clinic that has immunoglobulin as soon as possible if you have had a bite that has broken the skin.

Insurance

REQUIRED & RECOMMENDED VACCINATIONS If you have been in a country affected by yellow fever within six days of arriving in Fiji, you will need an International Certificate of Vaccination for yellow fever to be allowed entry into the country. Vaccinations are recommended for hepatitis A, hepatitis B and typhoid fever. All injected vaccinations can produce slight soreness and redness at the inoculation site, and a mild fever with muscle aches over the first 24 hours. These are least likely with hepatitis A and a little more common with hepatitis B and typhoid inoculations.Typhoid inoculation can cause a sensation of nausea within 24 hours and the hepatitis B vaccine can produce temporary joint pains. An allergy to eggs or poultry is a condition that makes the ye I low-fever vaccination inadvisable an exemption certificate can be issued. Very rarely, an acute allergic (anaphylactic shock) reaction can occur within minutes of any vaccination. More commonly a flu like illness of varying...

Before You Go

RECOMMENDED VACCINATIONS Diphtheria & Tetanus Recommended for everyone, vaccinations for these two diseases are usually combined. Vaccines including Avaxim, Havrix 1440 and VAQTA provide long-term immunity after an initial injection, then a booster at six to 12 months. Alternatively, an injection of gamma globulin can provide short-term immediate protection it's reasonably effective, unlike the vaccine, but because it is a blood product, there are current concerns about its long-term safety. Hepatitis A vaccine is also available as Twinrix, combined with hepatitis B vaccine. Three injections over a six-month period are required, the first two providing substantial protection against hepatitis A. This vaccination, involving three injections with a booster at 12 months, is recommended for Russia. Rapid courses are available. Consider vaccination if spending a month or longer in parts of the Russian Far East and Siberia, or if making repeated trips to at-risk areas. It involves three...

Immunizations

Although no vaccines are legally mandated, a number are strongly recommended Vaccine long-term travelers in close contactwith the local population travelers born after 1956 who've had only 1 measles vaccination travelers who may have contact with animals & may not have access to medical care

Hepatitis B

Infected blood, contaminated needles and sexual intercourse can all transmit hepatitis B. It can cause jaundice, and affects the liver, occasionally causing liver failure. All travellers should make this a routine vaccination. (Many countries now give hepatitis B vaccination as part of routine childhood vaccination.) The vaccine is given singly, or at the same time as the hepatitis A vaccine (Hepatyrix). A course will give protection for at least five years. It can be given over four weeks or six months.

Yellow Fever

Yellow fever no longer occurs in Central America, but many Central American countries, including Honduras, require yellow-fever vaccine before entry if you're arriving from a country in Africa or South America where yellow fever occurs. If you're not arriving from a country with yellow fever, the vaccine is neither required nor recommended. Yellow-fever vaccine is given only in approved yellow-fever vaccination centers, which provide validated International Certificates of Vaccination ('yellow booklets'). The vaccine should be given at least 10 days before departure and remains effective for approximately 10 years. Reactions to the vaccine are generally mild and may include headaches, muscle aches, low-grade fevers or discomfort at the injection site. Severe, life-threatening reactions have been described but are extremely rare.

Infectious Diseases

Cholera is caused by a bacteria, and spread via contaminated drinking water. In South Africa, the risk to travellers is very low you're likely to encounter it only in eastern rural areas, where you should avoid tap water and unpeeled or uncooked fruits and vegetables. The main symptom is profuse watery diarrhoea, which causes debilitation if fluids are not replaced quickly. An oral cholera vaccine is available in the USA, but it is not particularly effective. Most cases of cholera can be avoided by close attention to drinking water and by avoiding potentially contaminated food. Treatment is by fluid replacement (orally or via a drip), but sometimes antibiotics are needed. Self-treatment is not advised. shouldn't drink alcohol for up to six months afterwards, but once you've recovered, there won't be any long-term problems. The first symptoms include dark urine and a yellow colour to the whites of the eyes. Sometimes a fever and abdominal pain might be present. Hepatitis A vaccine...

Standby Treatment

Meningococcal infection is spread through close respiratory contact and is more likely in crowded places, such as dormitories, buses and clubs. While the disease is present in Tanzania, infection is uncommon in travellers. Vaccination is recommended for long stays and is especially important towards the end of the dry season. Symptoms include a fever, severe headache, neck stiffness and a red rash. Immediate medical treatment is necessary. The ACWY vaccine is recommended for all travellers in sub-Saharan Africa. This vaccine is different from the meningococcal meningitis C vaccine given to children and adolescents in some countries it is safe to be given both types of vaccine. Self-treatment none. This disease is generally spread through contaminated food and water. It is one of the vaccines given in childhood and should be boosted every 10 years, either orally (a drop on the tongue) or else as an injection. Polio can be carried asymptomatically (ie showing Rabies is spread via the...

Tuberculosis TB

TB is spread through close respiratory contact and occasionally through infected milk or milk products. BCG vaccination is recommended for those likely to be mixing closely with the local population, although it gives only moderate protection against TB. It is more important for long stays than for short-term visits. Inoculation with the BCG vaccine is not available in all countries, but it is given routinely to many children in developing nations. The vaccination causes a small permanent scar at the site of injection, and is usually given in a specialised chest clinic. It is a live vaccine and should not be given to pregnant women or immunocompromised individuals.

Diphtheria

Found in all of East Africa, diphtheria is spread through close respiratory contact. It usually causes a temperature and a severe sore throat. Sometimes a membrane forms across the throat, and a tracheostomy is needed to prevent suffocation. Vaccination is recommended for those likely to be in close contact with the local population in infected areas and is more important for long stays than for short-term trips. The vaccine is given as an injection, alone or with tetanus, and lasts 10 years.

Medical Checklist

REQUIRED & RECOMMENDED VACCINATIONS The only vaccine required by international regulations is yellow fever. Proof of vaccination will only be required if you have visited a country in the yellow-fever zone within the six days prior to entering Myanmar. If you are travelling to Myanmarfrom Africa or South America you should check to see if you require proof of vaccination. The World Health Organization recommends the following vaccinations for all travellers to Myanmar Hepatitis A Provides almost 100 protection forup to a year a booster after 12 months provides at least another 20 years' protection. Mild side effects such as headache and sore arm occur in 5 to 10 of people. Hepatitis B Now considered routine for most travellers. Given as three shots over six months. A rapid schedule is also available, as is a combined vaccination with Hepatitis A. Side effects are mild and uncommon, usually headache and sore arm. Lifetime protection occurs in 95 of people. Measles, mumps and rubella...

Health

Insurance 275 Required & Recommended Vaccinations 275 Since most vaccines don't produce immunity until at least two weeks after they're given, visit a physician four to eight weeks before departure. Ask your doctor for an International Certificate of Vaccination (otherwise known as the yellow booklet), which will list all the vaccinations you've received. This is mandatory for countries that require proof of yellow-fever vaccination upon entry (sometimes required in Australia, see following), but it's a good idea to carry it wherever you travel. REQUIRED & RECOMMENDED VACCINATIONS Proof of yellow-fever vaccination is required only from travellers entering Australia within six days of having stayed overnight or longer in a yellow-fever infected country. For a full list of these countries visit the websites of the World Health Organization (www.who.int ith) or that of the Centers for Disease Control & Prevention (www.cdc.gov travel). If you're really worried about health when...

Antimalarial A To D

Is always fatal once the clinical symptoms start (which might be up to several months after an infected bite), so postbite vaccination should be given as soon as possible. Postbite vaccination (whether or not you've been vaccinated before the bite) prevents the virus from spreading to the central nervous system. Animal handlers should be vaccinated, as should those travelling to remote areas where a reliable source of postbite vaccine is not available within 24 hours. Three preventive injections are needed over a month. If you have not been vaccinated you'll need a course of five injections starting 24 hours or as soon as possible after the injury. If you have been vaccinated, you'll need fewer postbite injections, and have more time to seek medical help. Self-treatment none. Tuberculosis (TB) is spread through close respiratory contact and occasionally through infected milk or milk products. BCG vaccination is recommended if you'll be mixing closely with the local population,...

Customs regulations

- have an international passport issued by a licensed veterinarian proving they have been vaccinated against rabies, or have be re-vaccinated in line with the recommendations of the manufacturing laboratory, carried out on that kind of animal with an inactivated vaccine with at least one antigen unit per dose (WHO standard) not more than 30 days prior in the case of a first, primary vaccination

Diseases

Hepatitis B is a virus spread via bodily fluids, eg through sexual contact, shared needles or unclean medical facilities. It is also the only sexually transmitted disease that can be prevented by vaccination. In the short term, hepatitis B can cause the typical symptoms of hepatitis - jaundice, tiredness, nausea - but long-term consequences can include liver cancer and cirrhosis. Long-term travellers or those who might be exposed to bodily fluids should be vaccinated. Influenza (the flu) is primarily transmitted from November to April. The flu is caused by a virus and gives you a high fever, general body aches and generalised respiratory symptoms such as cough, a sore throat and runny nose. If you do happen to get the flu you should rest up and take symptomatic treatment such as pain killers - antibiotics won't help. All high-risk individuals should ensure that they have been vaccinated before travelling, and all travellers should consider the vaccine if visiting in the winter months....

In Russia Belarus

Spread through bites or licks on broken skin from an infected animal, rabies is always fatal unless treated promptly. Animal handlers should be vaccinated, as should those travelling to remote areas where a reliable source of postbite vaccine is not available within 24 hours. Spread by tick bites, tickborne encephalitis is a serious infection of the brain and vaccination is advised for those in risk areas who are unable to avoid tick bites (such as campers, forestry workers and walkers). Two doses of vaccine will give a year's protection, three doses up to three years'. For more information see the website www .masta.org tickalert .

Typhoid

This serious bacterial infection is also spread via food and water. It gives a high and slowly progressive fever and headache, and may be accompanied by a dry cough and stomach pain. It is diagnosed by blood tests and treated with antibiotics. Vaccination is recommended for all travellers spending more than a week in South Asia. India and Nepal pose a particularly high risk and have the added problem of significant antibiotic resistance. In Bangladesh the risk is medium level but the infection is also antibiotic resistant. Be aware that vaccination is not 100 effective, so you must still be careful with what you eat and drink.

Womens Health

Vanuatu is not ideal for a pregnant woman. Malaria can cause miscarriage or premature labour and prevention cannot be guaranteed even with antimalarial tablets. The recommended vaccinations (against hepatitis A, hepatitis B and typhoid fever) do not contain live organisms so are not a problem, but the mumps measles rubella vaccine should not be given in pregnancy.

Veterinary services

Pets (dogs, cats and animals of the marten family) which are either travelling through the Republic of Croatia in the company of their owners, or which are staying in the country on a temporary basis, must, prior to entering the country, be fitted with a microchip or be clearly and legibly tattooed with a number prior to being entered in the international certificate issued in accordance with legislation valid in the Republic of Croatia. After the first vaccination against rabies carried out at the age of three months, animals must be vaccinated at least six months and no more than one year prior to undertaking the journey, and in the case of subsequent vaccinations (boosters) the period between vaccination and the journey undertaken shall not be greater than one year. No import into, or temporary residence in, the Republic of Croatia shall be permitted in the case of possibly dangerous dogs of the terrier breed, which have not been entered in the register of the International Kennel...

Entry Requirements

The territory of Guadeloupe Is a French Overseas Department. As a result, it is possible to enter under the same conditions asfor mainland France. European and French citizens will only need to present their identity card, passport or French residence permit. Travellers from other parts of the world must hold a valid passport and a visa. For further information, please contact your nearest French Embassy. No special vaccination is required to enter Guadeloupe. There are excellent health structures, as well as a University Hospital Centre which will provide all the necessary treatment if the case arises.

Customs

Customs officers are pretty lax while police and customs officers are entitled to search you at any time, especially in border areas, they rarely do. Even searches at the airport tend to be perfunctory. The exception is if something in your appearance or demeanor suggests to the officer you may be carrying drugs. Beyond drugs, travelers are not allowed to remove any ancient artifact or endangered animal or plant, whether live or a product made from one. It's smart to keep receipts for any item you buy, and especially for one that may be confused for being a restricted product, like an especially good Maya replica. If you're traveling with a pet, you may be asked to provide proof of vaccination and a medical certificate from home.

Before You Leave

For the latest information on infectious diseases and travel risks, and particularly on the constantly changing situation with malaria, consult the World Heath Organization (www. who.int) and the Centers for Disease Control in Atlanta (www.cdc.gov). Look for the latest information on SARS, which may continue long after the media have become bored of reporting it. Note that family doctors are rarely up to date on vaccination requirements, so when looking for advice at home, consult a specialist travel clinic. To begin with, your standard inoculations, typically for polio, diphtheria, and tetanus, should be up to date. You may also need inoculations against typhoid fever, meningococ-cal meningitis, cholera, hepatitis A and B, and Japanese B encephalitis. If you will be arriving in mainland China from a country with yellow fever, you may be asked for proof of vaccination, although border health inspections are cursory at best. See also advice on malaria, below.

Hiv Aids

Infection with human immunodeficiency virus (HIV) may lead to acquired immune deficiency syndrome (AIDS), which is a fatal disease if untreated. Any exposure to blood, blood products or body fluids may put the individual at risk. The disease is often transmitted by sexual contact or dirty needles. Vaccination, acupuncture, tattooing and body piercing can be potentially as dangerous as intravenous drug use. HIV AIDS can also be spread through infected blood transfusions some developing countries cannot afford to screen blood used for transfusions.

Staying Healthy

No shots or inoculations are required for entry to the SAR, but you will need proof of a vaccination against cholera if you have been in an infected area during the 14 days preceding your arrival. Check with your travel agent or call the Hong Kong Tourist Authority if you are traveling through Asia before reaching Hong Kong.

Entering The Country

Proof of 20 per day or a credit card is usually evidence of sufficient funds. However, international airlines flying to Quito may require a round-trip or onward ticket or a residence visa before they let you on the plane you should be prepared for this possibility, though it's unlikely. Though not law, you may be required to show proof of vaccination against yellow fever if you are entering Ecuador from an infected area.

Visas Documents

For visa applications, you'll need your passport (valid for at least three months) and one passport photo. Some embassies also require you to show proof of an onward ticket before they'll issue a visa. Most embassies require you to possess a certificate as evidence of yellow-fever vaccination if you will be arriving in Eritrea within six days of visiting an infected area.

Volunteer Work

Other organisations that may be interested in your time and commitment Goa Foundation (g 0832-2256479 www.goacom .com goafoundatlon G 8St Britto's Apt, Feira Alta, Mapusa, 403 508) A research-based environment and conservation organisation. International Animal Rescue (Animal Tracks g 0832-2268328 www.lar.org.uk Madungo Vaddo, Assagao, Bardez) Their animal sterilisation and vaccination programmes are making a noticeable Impact on the street. Visitors are welcome to the centre guided tours run at 11am and 3.30pm. For more Information see p48.

Malaria

There is only a slight risk of malaria in Algeria. One million children die annually from malaria in Africa. The risk of malarial transmission at altitudes higher than 2000m is rare. The disease is caused by a parasite in the bloodstream spread via the bite of the female Anopheles mosquito. There are several types of malaria falciparum malaria being the most dangerous type and the predominant form in Africa. Infection rates vary with season and climate, so check out the situation before departure. Unlike most other diseases regularly encountered by travellers, there is no vaccination against malaria (yet). However, several different drugs are used to prevent malaria and new ones are in the pipeline. Up-to-date advice from a travel health clinic is essential as some medication is more suitable for some travellers than others. The pattern of drug-resistant malaria is changing rapidly, so what was advised several years ago might no longer be used.

Visas

Depending on which countries you're visiting, you may need the following a vaccination certificate to show you have had all the right jabs (see p766) a driving licence, and perhaps an International Driving Permit (for the rare occasions when it may be required to hire a vehicle, or for insurance purposes if you're buying a vehicle) as well as a youth hostel card and a student or youth identity card (such as ISIC), which may be good for discounts on flights, long-distance buses and visits to sites of interest (especially museums).

Getting Started

Answers - on a range of topics, for discussions with inquisitive locals Patience - for everyday delays, especially on public transport Vaccination card, insect repellent and malaria prophylaxis Disposable nappies - if you actually have kids Common sense - for avoiding scams (p354) Lots of camera film

Typhoid Hepatitis A

Vaccine (typhim Vi, typherix) will give protection for three years. In some countries, the oral vaccine Vivotif is also available. Hepatitis A vaccine (Avaxim, VAQTA, Havrix) is given as an injection a single dose will give protection for up to a year, a booster after a year gives 10 years' protection. Hepatitis A and typhoid vaccines can also be given as a single-dose vaccine, hepatyrix or viatim.

Hepatitis A

Fatal, can cause prolonged lethargy and delayed recovery. Symptoms include dark urine, a yellow colour to the whites of the eyes, fever and abdominal pain. Hepatitis A vaccines (Avaxim, VAQTA, Havrix) are given as an injection a single dose will give protection for up to a year, while a booster 12 months later will provide a subsequent 10 years of protection. Hepatitis A and typhoid vaccines can also be given as a single dose vaccine, Hepatyrix or Viatim.

Tuberculosis

Tuberculosis (TB) is spread through close respiratory contact and occasionally through infected milk or milk products. BCG vaccine is recommended for those likely to be mixing closely with the local population. It is more important for those visiting family or planning on a long stay, and those employed as teachers and health-care workers. TB can be asymptomatic, although symptoms can include cough, weight loss or fever months or even years after exposure. An X-ray is the best way to confirm if you have TB. BCG gives a moderate degree of protection against TB. It causes a small permanent scar at the site of the injection, and is usually only given in specialised chest clinics. As it's a live vaccine it should not be given to pregnant women or immunocompromised individuals. The BCG vaccine is not available in all countries.

Further Reading

'Health Advice for Travellers' (currently called the 'T6' leaflet) is a leaflet that is updated annually by the Department of Health in the UK and is available free in UK post offices. As well as some general information, it outlines legally required and recommended vaccines for different countries, reciprocal health agreements and includes an EHIC application form.

Dengue Fever

Dengue fever is a virus spread by the bite of a day-biting mosquito. It causes a feverish illness with headache and severe muscle pains similar to those experienced with a bad, prolonged attack of influenza. Another name for the disease is 'break bone fever' and that's what it feels like. Danger signs include prolonged vomiting, blood in the vomit and a blotchy rash. There is no preventive vaccine and mosquito bites should be avoided

Leptospirosis

Treatment, but a minority of cases are complicated by jaundice or meningitis. There is no vaccine. You can minimize your risk by staying out of bodies of fresh water that may be contaminated by animal urine. If you're visiting an area where an outbreak is in progress, as occurred in Cuba in 1994, you can take 200mg of doxycycline once weekly as a preventative measure. If you actually develop leptospirosis, the treatment is lOOmg of doxycycline twice daily.

Cholera

Cholera is usually only a problem during natural or artificial disasters, eg war, floods or earthquakes, although small outbreaks can also occur at other times. Travellers are rarely affected. It is caused by a bacteria and spread via contaminated drinking water. The main symptom is profuse watery diarrhoea, which causes debilitation if fluids are not replaced quickly. An oral cholera vaccine is available in the USA, but it is not particularly effective. Most cases of cholera could be avoided by close attention to good drinking water and by avoiding potentially contaminated food. Treatment is by fluid replacement (orally or via a drip), but sometimes antibiotics are needed. Attempting self-treatment is not advised.

Dengue

Dengue fever is a virus disease spread by the bite of a day-biting mosquito. It causes a feverish illness with headache and severe muscle pains similar to those experienced with a bad, prolonged attack of influenza. Another name is 'break bone fever' and that's what it feels like. Danger signs include prolonged vomiting, blood in the vomit and a blotchy rash. There is no preventive vaccine and mosquito bites should be avoided whenever possible. Self-treatment involves paracetamol, fluids and rest. Do not use aspirin, as this can cause bleeding. Haem-orrhagic dengue has been reported only occasionally, manifested by signs of bleeding and shock and requires medical care.

Route Pasteur

Almost every single town in France has at least one street, square or garden named after Louis Pasteur, the great 19th-century chemist who invented pasteurisation and developed the first rabies vaccine. In the Jura, it is even more the case since the illustrious man was a local lad, born and raised in the region, and a regular visitor for holidays (he worked mostly in Paris).

Hepatitis

There are vaccines against hepatitis A and B, but there are currently no vaccines against the other types of hepatitis. Following the basic rules about food and water (hepatitis A and E) and avoiding risk situations (hepatitis B, C and D) are important preventative measures.

Other Infections

Leishmaniasis occurs in the mountains and jungles of all Central American countries. The infection is transmitted by sand flies. Leishmaniasis may be limited to the skin, causing slowly growing ulcers over exposed parts of the body. The disease may be particularly severe in those with HIV. There is no vaccine for leishmaniasis. To protect yourself from sand flies, follow the same precautions as for mosquitoes (right), except that netting must be finer mesh (at least 18 holes to the linear inch).

Leishmaniasis

Leishmaniasis occurs in the mountains and jungles of all Central American countries. The infection is transmitted by sand flies, which are about one-third the size of mosquitoes. Leishmaniasis may be limited to the skin, causing slowly-growing ulcers over exposed parts of the body, or (less commonly) may disseminate to the bone marrow, liver and spleen. The disease may be particularly severe in those with HIV. The disseminated form is rare in Mexico and is limited chiefly to the Balsas River basin in the southern states of Guerrero and Puebla. There is no vaccine for leishmaniasis. To protect yourself from sand flies, follow the same precautions as

Staying Safe

And health concerns in the countries you're visiting, and lists of local, English-speaking doctors. The United States Centers for Disease Control and Prevention (& 800 311-3435 www.cdc. gov) provides up-to-date information on necessary vaccines and health hazards by region or country.

Travellers Diarrhoea

In these situations, a stool test may be necessary to diagnose what bug is causing your diarrhoea, so you should seek medical help urgently. Where this is not possible the recommended drugs for bacterial diarrhoea (the most likely cause of severe diarrhoea in travellers) are norfloxacin 400mg twice daily for three days or ciprofloxacin 500mg twice daily for three days. These are not recommended for children or pregnant women. There can be resistance to these medications for some of the bacterial causes of diarrhoea in those cases, azithromycin, 500mg once a day, is recommended. This is also the drug of choice for children with dosage dependent on weight. A three-day course is given. Azithromycin may be considered under medical supervision in pregnancy. There is a new oral cholera vaccine that offers some protection against travellers diarrhoea, but only about 20 for three months. It may be suggested if you are at high risk of complications from diarrhoea.

Insect Bites Stings

If you are travelling with children you should know how to treat minor ailments and when to seek medical treatment. Make sure children are up-to-date with routine vaccinations, and discuss possible travel vaccines well before departure, as some vaccines are not suitable for children under a year.

Hepatitis E

Hepatitis E is transmitted through contaminated food and water, has similar symptoms to hepatitis A, but is far less common. It's a severe problem in pregnant women and can result in the death of both mother and baby. There is currently no vaccine, and prevention is by following safe eating and drinking guidelines while you're travelling in Borneo.

Lyme Disease

This is a tick-transmitted infection that may be acquired throughout the region. It usually begins with a spreading rash at the site of the tick bite, accompanied by fever, headache, extreme fatigue, aching joints and muscles and mild neck stiffness. If untreated, these symptoms usually resolve over several weeks, but over subsequent months disorders of the nervous system, heart and joints may develop. There is no vaccination against the disease. Treatment should be sought as soon as possible for best results.

Transport

To be issued a visa on arrival in Samoa, you must have an onward ticket, a passport valid for at least another six months, and a contact address within the country (have the name of a hotel handy). An international yellow fever vaccination certificate will also be required if you've visited a high-risk country in the six days prior to your arrival in Samoa (see p296). Citizens of most countries are granted a 31 -day visitors visa on arrival in Tonga upon presentation of a passport with at least six months' validity and an onward ticket. An international yellow fever vaccination certificate will be necessary if you've been to a high-risk area in the past six days.

Health Concerns

The Dominican Republic has no vaccination requirements for international travelers. However, before traveling abroad, it's always a good idea to check with your doctor - preferably a specialist in travel medicine - to see if there have been any recent contagious disease outbreaks in the areas you plan to visit, or any special precautions you need to take if you plan to venture beyond the cities and typical tourist resorts - if you plan to stay on a farm, for example, or spend much time in wilderness areas. It's also vital for everyone to keep certain vaccinations up-to-date (whether you're at home or abroad). These include shots for tetanus and diphtheria measles, mumps, and rubella and Hepatitis B. Your doctor can advise you whether or not you should be vaccinated for other risks such as Hepatitis A, pneumonia, influenza, rabies, cholera, typhoid, and yellow fever.

Malaria Medication

This infection is contracted by skin contact with soil. It is rare in travellers. The symptoms are very similar to those experienced by tuberculosis sufferers. There is no vaccine but it can be treated with medication. This uniformly fatal disease is spread by the bite or lick of an infected animal - most commonly a dog or monkey. You should seek medical advice immediately after any animal bite and commence post-exposure treatment. Having a pretravel vaccination means the postbite treatment is greatly simplified. If an animal bites you, gently wash the wound with soap and water, and apply iodine based antiseptic. If you are not vaccinated you will need to receive rabies immunoglobulin as soon as possible. Tuberculosis (TB) is very rare in short-term travellers. Medical and aid workers, and long-term travellers who have significant contact with the local population should take precautions, however. Vaccination is usually only given to children under the age of five, but adults at risk...

Contributing Authors

Michael Sorokin wrote the Health chapter. Dr Sorokin has extensive experience as a physician and GP in South Africa, the UK, the Pacific Islands and rural South Australia. He has special interests in rheumatology, infectious diseases and preventative medicine. Dr Sorokin was recently awarded the Order of Fiji in recognition of his services to health care in Fiji. He is partly responsible for the maintenance of the Traveller's Medical & Vaccination Centre (TMVC) database and helps with reference material for the continuing education of TMVC medical staff.

In Belize

There is no treatment available for dengue fever except to take analgesics such as acetaminophen paracetamol (Tylenol) and drink plenty of fluids. Severe cases may require hospitalization for intravenous fluids and supportive care. There is no vaccine. The cornerstone of prevention is protection against insect bites (see p304). The vaccine for hepatitis A is extremely safe and highly effective. If you get a booster six to 12 months later, it lasts for at least 10 years. Vaccination is recommended for travelers visiting Belize. Because the safety of hepatitis A vaccine has not been established for pregnant women or children under age two, they should instead be given a gamma-globulin injection. Like hepatitis A, hepatitis B is a liver infection that occurs worldwide but is more common in developing nations. Unlike hepatitis A, the disease is usually acquired by sexual contact or by exposure to infected blood, generally through blood transfusions or contaminated needles. The vaccine is...

Taking Pets To Italy

A traveller entering Italy with a dog or cat must have a veterinarian's certificate (EU pet passport) stating the animal is in good health and has a current rabies vaccination. The pet must also have been fitted with a microchip for identification. The pet passport must be issued by a qualified veterinary surgeon.

Typhoid Fever

Typhoid vaccine is recommended for all travelers to Haiti, and for travelers to the other islands who expect to stay in rural areas for an extended period or who may consume potentially contaminated food or water. Typhoid vaccine is usually given orally, but is also available as an injection. Neither vaccine is approved for use in children under age two. If you get typhoid fever, the drug of choice is usually a quinolone antibiotic such as ciprofloxacin (Cipro) or levo-floxacin (Levaquin), which many travelers carry for treatment of travelers' diarrhea.

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