No inoculations are compulsory for entry to The Gambia, but it is recommended that prospective travellers take medical advice at least three weeks before departing for the country. Recommended vaccinations include Typhoid, Yellow Fever, Meningitis A, Hepatitis A and Polio. Anti-malarial medication is generally advised. Visitors are advised to carry with them preparations for dehydration, stomach upsets, insect bites and cuts, as well as mosquito repellent and sun block, because these are not readily available in The Gambia. Food poisoning is a major risk in The Gambia and travellers are advised to make sure their food and water are safe; drink only bottled water, ensure meat and vegetables are well cooked and avoid unpeeled fruit and vegetables. Travel insurance is recommended.

You must discuss your own particular needs and contraindications to vaccines or tablets with your doctor or practice nurse. Advice can change so check again for future visits.

Ensure you are fully insured for medical emergencies including repatriation. The ‘T6’ leaflet (from Post Offices) gives details of health care agreements between countries and an application form for care within EC countries, which must be completed before departure

• Courses or boosters usually advised: hepatitis A; typhoid; diphtheria; yellow fever.
• Vaccines sometimes advised: hepatitis B; poliomyelitis; rabies; tuberculosis; meningococcal A & C.
• Yellow fever certificate required if over 1 year old and entering from an endemic or infected area .

NOTES ON THE DISEASES MENTIONED BELOW

Malaria is a serious and sometimes fatal disease transmitted by mosquitoes. You cannot be vaccinated against malaria.

MALARIA PRECAUTIONS

Malaria precautions are essential in all areas, all year round. Avoid mosquito bites by covering up with clothing such as long sleeves and long trousers especially after sunset, using insect repellents on exposed skin and, when necessary, sleeping under a mosquito net.

Check with your doctor or nurse about suitable antimalarial tablets.

(Mefloquine OR doxycycline OR Malarone is usually recommended).

Prompt investigation of fever is essential. If travelling to remote areas, a course of emergency 'standby' treatment should be carried.

Tetanus is contracted through dirty cuts and scratches and poliomyelitis spread through contaminated food and water. They are serious infections of the nervous system.

Typhoid and hepatitis A are spread through contaminated food and water. Typhoid causes septicaemia and hepatitis A causes liver inflammation and jaundice. In risk areas you should be immunised if good hygiene is impossible.

Tuberculosis is most commonly transmitted via droplet infection. Those going to countries where it is common, especially those mixing closely with the local population and those at occupational risk, e.g. health care workers, should ensure that they have previously been immunised. Check with your doctor or nurse.

Meningococcal meningitis and diphtheria are also spread by droplet infection through close personal contact. Vaccination is advised if close contact with locals in risk areas is likely.

Yellow fever is spread by mosquito bites. It is uncommon in tourist areas but can cause serious, often fatal illness so most people visiting risk areas are immunised.

Hepatitis B is spread through infected blood, contaminated needles and sexual intercourse, It affects the liver, causes jaundice and occasionally liver failure. Those visiting high risk areas for long periods or at social or occupational risk should be immunised.

Rabies is spread through bites or licks on broken skin from an infected animal. It is always fatal. Vaccination is advised for those going to risk areas that will be remote from a reliable source of vaccine. Even when pre-exposure vaccines have been received urgent medical advice should be sought after any animal bite.

Hepatitis A

Cause: Hepatitis A virus, a member of the picornavirus family. Transmission: The virus is acquired directly from infected persons by the faecal-oral route or by close contact, or by consumption of contaminated food or drinking water. There is no insect vector or animal reservoir (although some non-human primates are sometimes infected). Nature of the disease: An acute viral hepatitis with abrupt onset of fever, malaise, nausea and abdominal discomfort, followed by the development of jaundice a few days later. Infection in very young children is usually mild or asymptomatic (e.g. causes no symptoms); older children are at risk of symptomatic disease. The disease is more severe in adults, with illness lasting several weeks and recovery taking several months; case-fatality is greater than 2% for those over 40 years of age and 4% for those over 60. Geographical distribution: Worldwide, but most common where sanitary conditions are poor and the safety of drinking water is not well controlled. Risk for travellers: Non-immune travellers to developing countries are at significant risk of infection. The risk is particularly high for travellers exposed to poor conditions of hygiene, sanitation and drinking water control. Prophylaxis (protective treatment): Vaccination. Precautions: Travellers who are non-immune to hepatitis A (i.e. have never had the disease and have not been vaccinated) should take particular care to avoid potentially contaminated food and water. Source: WHO.

Malaria

General considerations: Malaria is a common and life-threatening disease in many tropical and subtropical areas. It is currently endemic in over 100 countries, which are visited by more than 125 million international travellers every year. Each year many international travellers fall ill with malaria while visiting countries where the disease is endemic, and well over 10,000 fall ill after returning home. Fever occurring in a traveller within three months of leaving a malaria-endemic area is a medical emergency and should be investigated urgently. Cause: Human malaria is caused by four different species of the protozoan parasite Plasmodium: Plasmodium falciparum, P. vivax, P. ovale and P. malariae. Transmission: The malaria parasite is transmitted by various species of Anopheles mosquitoes, which bite mainly between sunset and sunrise. Nature of the disease: Malaria is an acute febrile illness with an incubation period of 7 days or longer. Thus, a febrile illness developing less than one week after the first possible exposure is not malaria. The most severe form is caused by P. falciparum, in which variable clinical features include fever, chills, headache, muscular aching and weakness, vomiting, cough, diarrhoea and abdominal pain; other symptoms related to organ failure may supervene, such as: acute renal failure, generalized convulsions, circulatory collapse, followed by coma and death. It is estimated that about 1% of patients with P. falciparum infection die of the disease. The initial symptoms, which may be mild, may not be easy to recognize as being due to malaria. It is important that the possibility of falciparum malaria is considered in all cases of unexplained fever starting at any time between the seventh day of first possible exposure to malaria and three months (or, rarely, later) after the last possible exposure, and any individual who experiences a fever in this interval should immediately seek diagnosis and effective treatment. Early diagnosis and appropriate treatment can be life-saving. Falciparum malaria may be fatal if treatment is delayed beyond 24 hours. A blood sample should be examined for malaria parasites. If no parasites are found in the first blood film but symptoms persist, a series of blood samples should be taken and examined at 6-12-hour intervals. Pregnant women, young children and elderly travellers are particularly at risk. Malaria in pregnant travellers increases the risk of maternal death, miscarriage, stillbirth and neonatal death. The forms of malaria caused by other Plasmodium species are less severe and rarely life-threatening. Prevention and treatment of falciparum malaria are becoming more difficult because P. falciparum is increasingly resistant to various antimalarial drugs. Of the other malaria species, drug resistance has to date been reported for P. vivax, mainly from Indonesia (Irian Jaya) and Papua New Guinea, with more sporadic cases reported from Guyana. P. vivax with declining sensitivity has been reported for Brazil, Colombia, Guatemala, India, Myanmar, the Republic of Korea, and Thailand. P. malariae resistant to chloroquine has been reported from Indonesia. Geographical distribution: The risk for travellers of contracting malaria is highly variable from country to country and even between areas in a country. In many endemic countries of Latin America and the Caribbean, Asia and the Mediterranean region, the main urban areas, but not necessarily the outskirts of towns, are free of malaria transmission. However, malaria can occur in main urban areas in Africa and India. There is usually less risk of the disease at altitudes above 1,500 metres, but in favourable climatic conditions it can occur at altitudes up to almost 3,000 metres. The risk of infection may also vary according to the season, being highest at the end of the rainy season. There is no risk of malaria in many tourist destinations in South-East Asia, Latin America and the Caribbean. Source: WHO.

Meningococcal disease

Cause: The bacterium Neisseria meningitidis, of which 12 serogroups are known. Most cases of meningococcal disease are caused by serogroups A, B and C; less commonly, infection is caused by serogroups Y and W-135. Epidemics in Africa are usually caused by N. meningitidis type A. Transmission: occurs by direct person-to-person contact, including aerosol transmission and respiratory droplets from the nose and pharynx of infected persons, patients or carriers. There is no animal reservoir or insect vector. Nature of the disease: Most infections do not cause clinical disease. Many infected people become asymptomatic (i.e. cause no symptoms) carriers of the bacteria and serve as a reservoir and source of infection for others. In general, susceptibility to meningococcal disease decreases with age, although there is a small increase in risk in adolescents and young adults. Meningococcal meningitis has a sudden onset of intense headache, fever, nausea, vomiting, photophobia and stiff neck, plus various neurological signs. The disease is fatal in 5-10% of cases even with prompt antimicrobial treatment in good health care facilities; among individuals who survive, up to 20% have permanent neurological sequelae. Meningococcal septicaemia, in which there is rapid dissemination of bacteria in the bloodstream, is a less common form of meningococcal disease, characterized by circulatory collapse, haemorrhagic skin rash and high fatality rate. Geographical distribution: Sporadic cases are found worldwide. In temperate zones, most cases occur in the winter months. Localized outbreaks occur in enclosed crowded spaces (e.g. dormitories, military barracks). In sub-Saharan Africa, in a zone stretching across the continent from Senegal to Ethiopia (the African "meningitis belt"), large outbreaks and epidemics take place during the dry season (November-June). Risk for travellers: Generally low. However, the risk is considerable if travellers are in crowded conditions or take part in large population movements such as pilgrimages in the Sahel meningitis belt. Localized outbreaks occasionally occur among travellers (usually young adults) in camps or dormitories.Prophylaxis (protective treatment): Vaccination is available for N. meningitidis types A, C, Y and W-135. Precautions: Avoid overcrowding in confined spaces. Following close contact with a person suffering from meningococcal disease, medical advice should be sought regarding chemoprophylaxis. Source: WHO.

Typhoid fever

Cause: Salmonella typhi, the typhoid bacillus, which infects only humans. Similar paratyphoid and enteric fevers are caused by other species of Salmonella, which infect domestic animals as well as humans. Transmission: Infection with typhoid fever is transmitted by consumption of contaminated food or water. Occasionally direct faecal-oral transmission may occur. Shellfish taken from sewage-polluted beds are an important source of infection. Infection occurs through eating fruit and vegetables fertilized by night soil and eaten raw, and milk and milk products that have been contaminated by those in contact with them. Flies may transfer infection to foods, resulting in contamination that may be sufficient to cause human infection. Pollution of water sources may produce epidemics of typhoid fever, when large numbers of people use the same source of drinking water. Nature of the disease: Typhoid fever is a systemic disease of varying severity. Severe cases are characterized by gradual onset of fever, headache, malaise, anorexia and insomnia. Constipation is more common than diarrhoea in adults and older children. Without treatment, the disease progresses with sustained fever, bradycardia, hepatosplenomegaly, abdominal symptoms and, in some cases, pneumonia. In white-skinned patients, pink spots (papules), which fade on pressure, appear on the skin of the trunk in up to 50% of cases. In the third week, untreated cases develop additional gastrointestinal and other complications, which may prove fatal. Around 2-5% of those who contract typhoid fever become chronic carriers, as bacteria persist in the biliary tract after symptoms have resolved. Geographical distribution: Worldwide. The disease occurs most commonly in association with poor standards of hygiene in food preparation and handling and where sanitary disposal of sewage is lacking. Risk for travellers: Generally low risk for travellers, except in parts of north and west Africa, in south Asia and in Peru. Elsewhere, travellers are usually at risk only when exposed to low standards of hygiene with respect to food handling, control of drinking water quality, and sewage disposal. Prophylaxis (protective treatment): Vaccination. Precautions: Observe all precautions against exposure to foodborne and waterborne infections. Source: WHO.

Yellow fever

Cause: The yellow fever virus, an arbovirus of the Flavivirus genus. Transmission: Yellow fever in urban and some rural areas is transmitted by the bite of infective Aedes aegypti mosquitoes and by other mosquitoes in the forests of south America. The mosquitoes bite during daylight hours. Transmission occurs at altitudes up to 2,500 metres. Yellow fever virus infects humans and monkeys. In jungle and forest areas, monkeys are the main reservoir of infection, with transmission from monkey to monkey carried out by mosquitoes. The infective mosquitoes may bite humans who enter the forest area, usually causing sporadic cases or small outbreaks. In urban areas, monkeys are not involved and infection is transmitted among humans by mosquitoes. Introduction of infection into densely populated urban areas can lead to large epidemics of yellow fever. In Africa, an intermediate pattern of transmission is common in humid savannah regions. Mosquitoes infect both monkeys and humans, causing localized outbreaks. Nature of the disease: Although some infections are asymptomatic, most lead to an acute illness characterized by two phases. Initially, there is fever, muscular pain, headache, chills, anorexia, nausea and/or vomiting, often with bradycardia. About 15% of patients progress to a second phase after a few days, with resurgence of fever, development of jaundice, abdominal pain, vomiting and haemorrhagic manifestations; half of these patients die 10-14 days after onset of illness. Geographical distribution: The yellow fever virus is endemic in some tropical areas of Africa and central and south America. The number of epidemics has increased since the early 1980s. Other countries are considered to be at risk of introduction of yellow fever due to the presence of the vector and suitable primate hosts (including Asia, where yellow fever has never been reported). Risk for travellers: Travellers are at risk in all areas where yellow fever is endemic. The risk is greatest for visitors who enter forest and jungle areas. Prophylaxis (protective treatment): Vaccination. In some countries, yellow fever vaccination is mandatory for visitors. Precautions: Avoid mosquito bites during the day as well as at night. Endemic Countries: The World Health Organization considers the following countries to be endemic for yellow fever: Angola, Benin, Bolivia, Brazil, Burkino Faso, Burundi, Cameroon, Central African Republic, Chad, Colombia, Congo, Congo, Côte d'Ivoire, Democratic Republic of the Congo, Ecuador, Equatorial Guinea, Ethiopia, French Guyana, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Guyana, Kenya, Liberia, Mali, Niger, Nigeria, Panama, Peru, Rwanda, Sao Tome and Principe, Senegal, Sierra Leone, Somalia, Sudan, Suriname, Togo, Trinidad and Tobago, Uganda, United Republic of Tanzania and Venezuela. Source: WHO.