Recommended Vaccines When You Travel to Africa

1) Hepatitis A 

Risk increases with duration of travel and is highest for those who live in or visit rural settings, trek in back-country areas, or frequently eat or drink in areas with poor sanitation.

2) Meningococcal Disease

Risk is increased for travellers to sub-Saharan Africa (the ‘meningitis belt’) during the dry season, especially if there is prolonged contact with locals.

3) Typhoid Fever

Risk is higher where environmental sanitation and personal hygiene may be poor. The adventurous eater venturing “off the beaten track” should also consider vaccination.

4) Rabies

Should be considered in most parts of the world if exposure to animals is expected. Travellers spending time outdoors, especially rural areas, and who are involved in outdoor activities (eg cycling, camping, hiking outdoor work, caving) are at particular risk. Children are also considered higher risk because they tend to play with animals and may not report bites.

5) Yellow Fever

Recommendations may vary by country.

Proof of vaccination (International Certificate of Vaccination) against yellow fever may be required or travel to and from some of the countries in South America and Trinidad and Tobago.

Some countries with endemic yellow fever may waive requirements for travellers coming from non-infected areas and staying less than 2 weeks. Vaccination is recommended for travel in countries that lie in yellow fever endemic zones but do not officially report the disease.

Note: This is a guide only. Advice by your healthcare professional will vary depending on destination, duration of travel, types of accommodation and what types of activities you take part in.


1. Marshall GM. The Vaccine Handbook: A practical guide for clinicians, 4th edition. 2012.

2. Travel Clinics of America. Destinations 

3. World Health Organization. International Travel and Health 2014.

4. Kita Y, et al. Replacement of oral polio vaccine with inactivated polio vaccine and inclusion of Haemophilus influenzae type b vaccine in the national childhood immunization schedule. Epidemiological News Bulletin 2013; 39(2): 27-33

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 Dr. Suraya

Dr. Suraya

Vaccination Practitioner (Adult)



Arteries are blood vessels which transport blood from the heart to our organs which veins transport blood from the organs back to the heart. Blood is prevented from flowing backwards by tiny valves along the veins which open and close to let blood through in one direction, namely back towards the heart. The veins of the lower limbs can be either superficial (just under the skin) and deep (under the muscle).

Varicose veins are swollen and enlarged superficial veins which develop when these small valves are damaged or don’t work properly.

Risk Factors

Factors which can increase your chances of developing varicose veins include:

  • female
  • older age
  • overweight
  • pregnancy
  • abdominal mass such as fibroids
  • having a job that involves long periods of standing

Symptoms and stages of varicose veins

Symptoms of varicose veins include pain which is usually described as heaviness or aching pain leg swelling, itchiness and dark pigmentation of the skin. Severe cases of varicose veins can lead to skin ulcer formation which are slow to heal. Complications include bleeding, deep vein thrombosis (DVT), thrombophlebitis (painful inflammation of the veins) and varicose eczema.

When do you need to see a doctor?

Do not wait until the varicose veins become so bad that it becomes difficult to treat. The earlier it gets treated, the higher the chances of a good outcome. It should be treated when there are symptoms such as itching, bleeding or swelling.

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Mrs M walked into the clinic with her beautiful daughter Maya, aged 5. She is a happily married woman and conceived Maya within their first 6 months of marriage. Her pregnancy was well and Maya was delivered via a caesarean delivery.

The obvious question popped up in my mind, “How can I help you?”

“Well one ain’t enough and we have been trying for a second child for the past one and a half years. I just don’t understand why i am not getting pregnant. I got pregnant with Maya easily. Surely we are not suffering from infertility. But why it is not happening again?”

She is just one out of many women who find it difficult to believe that they are struggling for a second child or what is medically known as secondary sub-fertility.

What leads to secondary sub-fertility? Let’s find out why.

1) Age factor

Image Source: iStock

In a natural pregnancy, age is an important determinant of success rate. This is mainly because a woman’s egg number and egg quality declines with age. Generally, a woman’s fertility start to decline rapidly after the age of 35-37 years old compared to when they were younger. At a younger age, fertility declines more slowly.

This is the reason why doctors (and your mother and mother in-law too!) will advise you to compete your family earlier than later. Thus, your chances to conceive for the second time is not similar to when your had your first child.

2) Ovarian reserve (egg numbers)

Image Source:

A woman’s age do play a crucial role in her ovarian reserve. Ovarian reserve means the number of eggs that you are left with, which correlates with your chances to get pregnant. The lower the ovarian reserve, the lower your chances to get pregnant.

Besides age, there are other factors which can decrease your ovarian reserve.

Ovarian surgery (for ovarian cyst) and endometriosis can decrease your egg numbers. If you have previous surgery to your ovary and find it difficult to conceive again, maybe it’s time to see your doctor.

3) Ovulation Problem

Image Source: Getty Images

Ovulation is crucial for a natural conception. When ovulation is irregular, it increases your difficulty to get pregnant naturally simply because you can not time your ‘fertile’ window accurately.

But why ovulation become irregular now and not before when you conceived your first child?

Your weight has an effect on your ovulation. If you have put on weight after your first child, it can affect your ovulation and your monthly period cycles.

For some who have been diagnosed with Polycystic Ovarian Syndrome (PCOS), period irregularity may start later in life. In PCOS, the woman is not ovulating regularly.

In this situation, once all the other causes are excluded, the simplest thing to do is to make the ovulation regular. In most cases, weight reduction together with some fertility medication is sufficient.

4) Tubal factor

Image Source: Dr Kashi

Women have a pair of Fallopian tubes attached to the womb. This tube picks up the ovulated egg and fertilisation of the egg by the sperm happens in the tube.

If the tubes are damaged or blocked, chances to get pregnant naturally is much reduced or impossible (in the case of bilateral blocked tubes).

Fallopian tubes are at risk of being damaged or blocked when a woman undergoes any kind of pelvic surgery including a caesarean section, ovarian cyst removal or removal of a uterine fibroid.

Pelvic infections (such as Chlamydia) can also lead to tubal blockage. Thus, a woman with these risk factors should check the patency of their tubes.

5) Endometriosis 

Image Source: News Medical

Endometriosis is not an uncommon cause of secondary subfertility. Endometriosis can lead to ovarian cyst, which can have a direct negative effect on egg numbers.

Endometriosis can also lead to tubal blockage due to continuos process of bleeding and scar formation.

While there is no magic treatment that can eliminate endometriosis completely, if diagnosed early, it can be controlled while in some cases, fertility treatment offered before the condition worsens.

6) Uterine factor

Image Source: Biosphere Medical, 2002

The womb or the uterus, is rarely the cause of subfertility. If you had successfully delivered a child before, it means that your uterus is able to carry a pregnancy.

However, after a major uterine surgery such as removal of numerous uterine fibroids, the anatomy of the uterus can be distorted and the lining of the uterus where the pregnancy implants can be damaged.

Another common uterine factor is a gynaecological condition called adenomyosis. In this condition, the uterus is gradually getting ‘swollen’. Severe adenomyosis has been linked with reduced fertility.

7) Sperm quality

Image Source: Phoenix Sperm Bank

To have a successful pregnancy, you need a healthy egg and a healthy sperm. Even though male fertility declines slowly than their female partner, sperm quality is still an important factor in secondary sub-fertility.

Environmental factors such as cigarette smoke, unhealthy diet and pollutants are known to reduce the quality of sperm. Thus it is important for male partners to get themselves checked together with their wives.

8) Smoking

Image Source: 123rf

Smoking, for both women and men, has adverse effect on their fertility. Long term smoking can lead to poorer egg quality. Likewise, smoking also reduces men’s sperm quality even though his sperm quantity is normal.

So, you could have easily conceived your first child, but continuous smoking can make it harder to conceive your second child.

9) Stress

Image Source: Canva

Stress is widely linked to sub-fertility. It’s not only work related stress, but stress of caring for your first child.

You may have sleep deprivation, time pressure and pressure juggling between work and child care. These can make it more challenging to try for a baby during the fertile period of the woman.

10) Change in health status

Image Source: 123rf

The older you get, chances are that you may have developed health conditions such as high blood pressure and diabetes. When these conditions are not well controlled, it reduces your fertility. It is important to have regular health check ups and initiate early intervention if needed.

The above are some common causes of secondary sub-fertility. If you are one of them, take the necessary step today to get yourself checked.

Last but not least, remember: “You have done it once, and you can do it again.”

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Dr. Agilan Arjunan

Dr. Agilan Arjunan

Obstetrician & Gynaecologist (infertility)



What is an AVF / Dialysis Access?

A Dialysis Access is a place which is constructed to allow doctors and nurses to have easy access to your blood circulation during haemodialysis. It is constructed situated just under the skin usually on your arm or sometimes on your thigh.

There are 2 types of AVF / Dialysis Access

  1. Arterio-Venous Fistula

The surgery will increase the blood flow in the fistula resulting in an increase in the diameter of the vein and the thickness of the vein wall which is important for the maturation of the site. The time for maturation ranges from 6-9 weeks before it can be used. If the fistula fails to mature, an additional procedure (such as Fistuloplasty or Balloon Assisted Maturation) or open repair may be required.

  1. Graft

A graft is placed under the skin and it bridges the artery and the vein. Grafts do not require time for maturation and can be used after 2-3 weeks once the swelling has subsided. A graft may be required for patients with veins that are too small for fistula creation. The disadvantage of a graft is that it has a shorter lifespan than a fistula and has a higher rate of infection.

What happens before the surgery?

The surgery is usually performed as a day ward admission under local anaesthesia. The non-dominant arm is the preferred site. Your doctor will examine the blood vessels carefully and may also perform an ultrasound to choose the optimal site. Patients with diabetes, hypertension, heart failure or blood vessel disease may have poorer quality blood vessels to choose from.

What to expect after the surgery?

After surgery, it is advisable to keep the hand slightly elevated to reduce the swelling and take some analgesia to reduce any pain. The hand may feel slightly cold because blood may flow into the fistula resulting in less blood flow to the hand (known as ‘steal syndrome’). The wound care post-surgery includes the following:

  • Ensure the wound is dry for at least 3 days
  • Avoid lifting heavy objects exceeding 8kgs
  • Avoid compression or sleeping on the arm
  • Do some exercises like squeezing a soft ball to help healing and maturation

If there is excessive pain, swelling or bleeding, see your doctor as soon as possible

What are the possible complications?

The complications include narrowing of the vein, blood clots in the vein, swelling or aneurysm of fistula, wound infection and bleeding.

How to take care of the AVF / Dialysis Access?

Taking good care of your dialysis access is extremely important as it is the life line of all patients with kidney failure. See your doctor as soon as possible when you suspect there is a problem.

1) Check your fistula regularly. There is a buzz (‘thrill’) when the fistula is functioning properly

2) There is minimal bleeding after dialysis. If the bleeding is excessive or it takes longer than usual to stop, please inform your doctor, nurse or the dialysis staff

3) Try not to sleep on the arm with the fistula

4) The site of the fistula or graft must be kept clean at all times

5) Look out for signs of infection such as redness, swelling or pain

6) Do not wear tight clothing or jewelry which could block the fistula flow

7) Do not carry heavy objects using the hand with the fistula

8) Do not have blood or blood pressure taken from the arm with the fistula

9) Do not have any injections or drug infusions into the arm with the fistula

10) Do not apply any cream or lotion on the puncture site

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VMAT is the latest arc therapy technique which delivers more tightly focused treatment to tumours in a significantly shorter time. Using VMAT, single or multiple radiation beams sweep in uninterrupted arc(s) around the patient. VMAT technique provides the oncologists with greater freedom of choice on how an optimum dose can be delivered to cancer cells.

How VMAT works

Using VMAT, radiation is precise targeted at the intended area allowing oncologists to preserve more of the surrounding healthy normal tissue. VMAT treatment which consists of one or several arcs, enables the radiation to remain on while the linear accelerator movements occur. During VMAT treatment, the shape and intensity of the radiation beams changes as the machine rotates. The radiation beam comes from an infinite number of angles, thereby reducing the dose to the surrounding tissue while increasing the dose to the cancer cells.

As such, with VMAT treatment, the duration of the procedure is shortened and the patient spends less time on the treatment table. The simplest treatment can be completed as fast as 2 minutes while more complex cases may take up to only 5 minutes.

What equipment is used?

A medical linear accelerator is used in delivering VMAT. The machine is about the size of a small car approximately 10 feet in height and 15 feet in length.

Types of Cancers which can be treated with VMAT

Most cancer types can benefit from VMAT treatment. Every case is unique but VMAT treatment is typically used for cancers of the :

  • Prostate
  • Lung
  • Head and lung
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Stereotactic Radiosurgery is a highly precise form of radiation therapy which can be used to treat:

  • Brain tumours
  • Extra cranial lesions (Stereotactic Body Radiotherapy – SBRT)
  • Post-operative treatment to eliminate any residual tumour tissue
  • Abnormal blood vessels (known as AVM)

Despite its name, Stereotactic Radiosurgery does NOT involve any surgery. It is a procedure which allows precisely focused high-dose X-ray beams to be delivered to a small, localised area targeting the tumour.

Goal of Stereotactic Radiosurgery

The goal of radio surgery is to destroy tumour cells without harming surrounding healthy normal tissue.

Advantages of using Stereotactic Radiosurgery

It works the same way as other forms of radiation treatment. It does not remove the tumour but it will damage the DNA inside cells making them unable to divide or reproduce. Abnormal cancer cells are more sensitive to radiation because they divide more quickly than normal cells. After the treatment, benign tumours usually shrink over a period of 18-24 months. In malignant tumours, the shrinkage many occur more rapidly.

Types of Cancers which can be treated with Stereotactic Radiosurgery:

  • Meningioma
  • Astrocytoma
  • Glioblastoma
  • Brain lymphoma
  • Nasopharyngeal carcinoma
  • Liver metastasis
  • Prostate cancer
  • Small cell lung carcinoma
  • Acoustic neuroma
  • Arteriovenous malformation (AVM)

Side effects of Stereotactic Radiosurgery

Like radiation therapy, the general side effects include fatigue, loss of appetite and headache. The side effects vary from person to person depending on the location of the treatment. Some people experience no side effects at all.

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