Travelling the world is an exciting pastime, but you have to be careful about the diseases and sicknesses that are lurking around many corners. Our International Health Travel Guide provides helpful information on what to look out for.
\IThis section includes text from Health Information for International Travel, a guide produced by the U.S. Department of Health and Human Services.\i
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"Contents of Health Information for International Travel 1996-97",2,0,0,0
\BChapter 1\b - \JHealth Hints for the International Traveller\j
\BChapter 2\b - \JRegional Travel Health Information\j
\BChapter 3\b - \JInformation on Diseases for the Traveller\j
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"Health Hints for the International Traveller",3,0,0,0
\BChapter 1 of Health Information for International Travel 1996-97\b
Click on one of these page links to jump directly to that page or simply click on the \INext Page\i button to begin reading this chapter.
- \JHealth Hints for the Traveller (Introduction)\j
- \JEnvironmental Effects on Traveller's Health\j
- \JFood and Drink, Risks to Traveller\j
- \JWater, Precautions for Traveller\j
- \JWater, Treatment for Safe Consumption\j
- \JFood, Precautions for Traveller\j
- \JTraveller's Diarrhoea\j
- \JMosquitoes and Other Arthropod Vectors, Protection Against\j
- \JSwimming Precautions When Abroad\j
- \JPregnant Women Travelling Abroad\j
- \JMotion Sickness\j
- \JInjuries While Abroad\j
- \JAnimal-Associated Hazards\j
- \JMedical Care Abroad\j
- \JPost-Travel Period\j
- \JWHO Blood Transfusion Guidelines for International Travellers\j
- \JDisinsection of Aircraft\j
- \JTuberculosis Risk in Aircraft\j
- \JAnthrax-Contaminated Goatskin Handicrafts\j
- \JImportation or Re-entry of Pets\j
- \JChernobyl, Health Risks to Travellers\j
- \JInfectious Diseases, Emerging\j
- \JHIV Infection and AIDS, General Recommendations to Traveller\j
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"Health Hints for the Traveller (Introduction)",4,0,0,0
This section includes practical information on how to avoid potential health problems while travelling. Some of these recommendations are commonsense precautions; others have been scientifically documented.
Personal and specific preventive measures against certain diseases may require advance planning and advice from a physician concerning immunisation and prophylaxis. If more specific information is needed, travellers should contact their local health department or physician.
Travellers who take prescription medications should carry an adequate supply accompanied by a signed and dated statement from a physician; the statement should indicate the major health problems and dosage of such medications, to provide information for medical authorities in case of emergency.
The traveller should take an extra pair of glasses or lens prescription and a card, tag or bracelet that identifies any physical condition that may require emergency care.
While the information contained in this document is current, it is important that travellers obtain up-to-date information on such things as vaccine requirements, disease outbreaks and current yellow fever-infected countries, which are all subject to change and modification.
Travellers should consult local health departments, physicians, travel agencies, international airlines, travel clinics and other private and public agencies that advise international travellers concerning health risks they may encounter when visiting other countries.
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"Environmental Effects on Traveller's Health",5,0,0,0
International travellers may be subject to certain stresses that may lower resistance to disease, such as crowding, disruption of usual eating and drinking habits and time changes, with 'jet lag' contributing to a disturbed pattern of the sleep and wakefulness cycle. These conditions of stress can lead to nausea, \Jindigestion\j, fatigue or \Jinsomnia\j. Complete adaptation depends on the number of time zones crossed but may take a week or more.
Heat and cold can be directly or indirectly responsible for some diseases and can give rise to serious skin conditions. Dermatophytoses such as athlete's foot are often made worse by warm, humid conditions.
Excessive heat and \Jhumidity\j alone, or immoderate activity under those conditions, may lead to heat exhaustion due to salt and water deficiency and to the more serious heat stroke or hyperthermia. The ultraviolet rays of the sun can cause severe and very debilitating \Jsunburn\j in lighter-skinned persons.
Excessive cold affects persons who may be inadequately dressed and particularly the elderly; it can lead to hypothermia and to frost-bite of exposed parts of the body.
Breathing and swallowing dust when travelling on unpaved roads or in arid areas may be followed by nausea and malaise, and may cause increased susceptibility to infections of the upper respiratory tract.
Travelling in high altitudes may lead to \Jinsomnia\j, headache, nausea and altitude sickness, even in young and healthy persons, and can cause distress to those with cardiac or pulmonary conditions. Individual susceptibility to acute mountain sickness is highly variable. Travellers who are at greatest risk are those who ascend rapidly to tourist sites in the \JAndes\j and the \JHimalayas\j.
You should consult your medical practitioner for advice on drugs which could help the process of acclimatisation to high altitudes.
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"Food and Drink, Risks to Traveller",6,0,0,0
Contaminated food and drink are common sources for the introduction of infection into the body. Among the more common infections that travellers may acquire from contaminated food and drink are \IEscherichia coli \iinfections, shigellosis or bacillary \Jdysentery\j, giardiasis, cryptosporidiosis and hepatitis A.
Other less common infectious disease risks for travellers include typhoid fever and other salmonelloses, \Jcholera\j, infections caused by rotaviruses and Norwalk-like viruses, and a variety of protozoan and helminth parasites (other than those that cause giardiasis and cryptosporidiosis).
Many of the infectious diseases transmitted in food and water can also be acquired directly through the faecal-oral route.
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"Water, Precautions for Traveller",7,0,0,0
Water that has been adequately chlorinated, using minimum recommended water-works standards as practised in the industrialised countries, will afford significant protection against viral and bacterial waterborne diseases. However, \Jchlorine\j treatment alone, as used in the routine disinfection of water, may not kill some enteric viruses and the parasitic organisms that cause giardiasis, amoebiasis and cryptosporidiosis.
In areas where chlorinated tap water is not available, or where hygiene and sanitation are poor, travellers should be advised that only the following may be safe to drink:
1. Beverages, such as tea and \Jcoffee\j, made with boiled water.
2. Canned or bottled carbonated beverages, including carbonated bottled water and soft drinks.
3. Beer and wine.
Where water may be contaminated, ice should also be considered contaminated and should not be used in beverages. If ice has been in contact with containers used for drinking, the containers should be thoroughly cleaned, preferably with soap and hot water, after the ice has been discarded.
It is safer to drink directly from a can or bottle of a beverage than from a questionable container. However, water on the outside of beverage cans or bottles might be contaminated. Therefore, wet cans or bottles should be dried before being opened and surfaces which are contacted directly by the mouth in drinking should first be wiped clean.
Where water may be contaminated, travellers should avoid brushing their teeth with tap water.
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"Water, Treatment for Safe Consumption",8,0,0,0
Boiling is by far the most reliable method to make water of uncertain purity safe for drinking. Water should be brought to a vigorous rolling boil for one minute and allowed to cool to room temperature-do not add ice.
At altitudes above 6,562 feet (2 km), for an extra margin of safety, boil for three minutes or use chemical disinfection. Adding a pinch of salt to each quart or pouring the water several times from one container to another will improve the taste.
Chemical disinfection with \Jiodine\j is an alternative method of water treatment when it is not feasible to boil water. Two well-tested methods for disinfection with \Jiodine\j are the use of tincture of \Jiodine\j and the use of tetraglycine hydroperiodide tablets. The tablets are available from pharmacies and sporting goods stores. The manufacturer's instructions should be followed.
If water is cloudy, the number of tablets should be doubled; if water is extremely cold, an attempt should be made to warm the water and the recommended contact time should be increased to achieve reliable disinfection.
Cloudy water should be strained through a clean cloth into a container to remove any sediment or floating matter, and then the water should be boiled or treated with \Jiodine\j. If tincture of \Jiodine\j is used, very turbid or cold water may require prolonged contact time; let stand up to several hours, if possible.
Chlorine, in various forms, has also been used for chemical disinfection. However, its germicidal activity varies greatly with \JpH\j, temperature and organic content of the water to be purified, and is less reliable than \Jiodine\j.
There are a variety of portable filters currently on the market which according to the manufacturers' data will provide safe drinking water. Although the iodide-impregnated resins and the microstrainer-type filters will kill and/or remove many microorganisms, very few published reports in the scientific literature deal both with the methods used and the results of the tests employed to evaluate the efficacy of these filters against pathogens. Until there is sufficient independent verification of the efficacy of these filters, theCenters For Disease Control and Prevention (CDC) makes no recommendation regarding their use in the general population.
As a last resort, if no source of safe drinking water is available or can be obtained, tap water that is uncomfortably hot to touch may be safer than cold tap water; however, many disease-causing organisms can survive the usual temperature reached by the hot water in overseas hotels, and boiling or proper disinfection is still advised.
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"Food, Precautions for Traveller",9,0,0,0
To avoid illness, food should be selected with care. All raw food is subject to contamination. Particularly in areas where hygiene and sanitation are inadequate, the traveller should be advised to avoid salads, uncooked vegetables, unpasteurised milk and milk products such as cheese, and to eat only food that has been cooked and is still hot, or fruit that has been peeled by the traveller.
Undercooked and raw meat, fish and shellfish may carry various intestinal pathogens. Cooked food that has been allowed to stand for several hours at ambient temperature may provide a fertile medium for bacterial growth and should be thoroughly reheated before serving.
Consumption of food and beverages obtained from street food vendors has been associated with increased risk of illness.
The easiest way to guarantee a safe food source for an infant less than 6 months of age is to have the child breast-feed. If the infant has already been weaned from the breast, formula prepared from commercial powder and boiled water is the safest and most practical food.
Some species of fish and shellfish can contain poisonous biotoxins, even when well cooked. The most common type of fish poisoning in travellers is ciguatera fish poisoning. Barracuda is the most toxic fish and should always be avoided. Red snapper, \Jgrouper\j, amberjack, sea bass and a wide range of tropical reef fish contain the toxin at unpredictable times.
The potential for ciguatera poisoning exists in all subtropical and tropical insular areas of the West Indies, Pacific and Indian Oceans where the implicated fish species are consumed.
Cholera cases have occurred among persons who ate crab brought back from Latin America by travellers. Travellers should not bring perishable seafoods with them when they return.
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"Traveller's Diarrhoea",10,0,0,0
\IEpidemiology\i
Travellers' diarrhoea (TD) is a syndrome characterised by a twofold or greater increase in the frequency of unformed bowel movements. Commonly associated symptoms include abdominal cramps, nausea, bloating, urgency, fever and malaise. Episodes of TD usually begin abruptly, occur during travel or soon after returning home, and are generally self-limited.
The most important determinant of risk is the destination of the traveller. Attack rates in the range of 20 to 50 percent are commonly reported. High-risk destinations include most of the developing countries of Latin America, Africa, the Middle East and Asia. Intermediate risk destinations include most of the Southern European countries and a few Caribbean islands.
Low-risk destinations include Canada, Northern Europe, \JAustralia\j, New Zealand, the United States and a number of the Caribbean islands.
TD is slightly more common in young adults than in older people. The reasons for this difference are unclear, but may include a lack of acquired immunity, more adventurous travel styles and different eating habits. Attack rates are similar in men and women. The onset of TD is usually within the first week, but may occur at any time during the visit, and even after returning home.
TD is acquired through ingestion of faecally contaminated food and/or water. Both cooked and uncooked foods may be implicated if improperly handled.
Especially risky foods include raw or undercooked meat and seafood, and raw fruits and vegetables. Tap water, ice, and unpasteurised milk and dairy products may be associated with increased risk of TD; safe beverages include bottled carbonated beverages (especially flavoured beverages), beer, wine, hot \Jcoffee\j or tea, or water boiled or appropriately treated with \Jiodine\j or \Jchlorine\j.
The place where food is prepared appears to be an important variable, with private homes, restaurants and street vendors listed in order of increasing risk.
TD typically results in 4 to 5 loose or watery stools per day. The median duration of diarrhoea is 3 to 4 days. Ten percent of the cases persist longer than 1 week, approximately 2 percent longer than 1 month, and less than 1 percent longer than 3 months. Persistent diarrhoea is thus quite uncommon and may differ considerably from acute TD with respect to aetiology and risk factors.
Approximately 15 percent of cases experience vomiting and 2 to 10 percent may have diarrhoea accompanied by fever or bloody stools, or both.
Travellers may experience more than one attack of TD during a single trip. Rarely is TD life-threatening.
\IAetiology\i
Infectious agents are the primary cause of TD. Travellers from industrialised countries to developing countries frequently develop a rapid, dramatic change in the type of organisms in their gastrointestinal tract. These new organisms often include potential enteric pathogens. Those who develop diarrhoea have ingested an inoculum of virulent organisms sufficiently large to overcome individual defence mechanisms, resulting in symptoms.
\IEnteric Bacterial Pathogens\i
Enterotoxigenic\I Escherichia coli\i (ETEC) are the most common causative agents of TD in all countries where surveys have been conducted. ETEC produce a watery diarrhoea associated with cramps and a low-grade or no fever.
\ISalmonella\i gastroenteritis is a well-known disease that occurs throughout the world. In the industrialised nations, this large group of organisms is the most common cause of outbreaks of food-associated diarrhoea.
In the developing countries, the proportion of cases of TD caused by non-typhoidal salmonellae varies but is not high. Salmonellae can also cause \Jdysentery\j characterised by bloody mucus-containing small-volume stools.
Shigellae are well-known as the cause of bacillary \Jdysentery\j. The shigellae are the cause of TD in from 0 to about 20 percent of travellers to developing countries.
\ICampylobacter jejuni\i is a common cause of diarrhoea throughout the world and is responsible for a small percentage of the reported cases of TD, some with bloody diarrhoea. Additional studies are needed to determine how frequently it causes TD.
\IVibrio parahaemolyticus\i is associated with ingestion of raw or poorly cooked seafood and has caused TD in passengers on Caribbean cruise ships and in Japanese people travelling in Asia. How frequently it causes disease in other areas of the world is unknown.
Other less common bacterial pathogens include\I E. coli, Yersinia enterocolitica, \JVibrio\j cholerae\i O1 O139 and other non-O1, \IVibrio fluvialis,\i and possibly \IAeromonas hydrophila \iand \IPlesiomonas shigelloides.
Viral Enteric Pathogens: Rotavirus and Norwalk-like Virus\i
Along with the newly acquired bacteria, the traveller may also acquire many viruses.
In six studies, for example, 0 to 36 percent of diarrhoeal illnesses in travellers (median 22 percent) were associated with rotaviruses in the stools. However, a comparable number of asymptomatic travellers also had rotaviruses, and up to 50 percent of symptomatic persons with rotavirus infections also had non-viral pathogens. Ten to 15 percent of travellers develop serologic evidence of infection with Norwalk-like viruses.
The roles of adenoviruses, astroviruses, coronaviruses, enteroviruses or other viral agents in causing TD are even less clear. Although viruses are commonly acquired by travellers, they do
not appear to be frequent causes of TD in adults.
\IParasitic Enteric Pathogens\i
The few studies that have included an examination for parasites reveal that 0 to 6 percent of persons with travellers' diarrhoea have \IGiardia lamblia\i and 0 to 6 percent have \IEntamoeba histolytica.\i \ICryptosporidium \ihas recently been recognised in sporadic cases of TD.
\IDientamoeba fragilis, Isospora belli, Balantidium coli, Cyclospora\i (previously known as cyanobacterium-like bodies) or \IStrongyloides stercoralis\i may cause occasional cases of TD. While not major causes of acute TD, these parasites should be sought in persisting, unexplained cases.
\IUnknown Causes\i
No data have been presented to support non-infectious causes of TD such as changes in diet, jet lag, altitude and fatigue.
Current evidence indicates that in all but a few instances, e.g. drug-induced or pre-existing gastrointestinal disorders, an infectious agent or agents cause diarrhoea in tourists. However, even with the application of the best current methods for detecting bacteria, viruses and parasites, 20 to 50 percent of cases of TD remain without recognised aetiologies.
\IPrevention\i
There are four possible approaches to prevention of TD. They include instruction regarding food and beverage consumption, immunisation, use of non-antimicrobial medications and prophylactic antimicrobial drugs. No available vaccines and none that are expected to be available in the next 5 years are effective against TD.
Data indicate that meticulous attention to food and beverage consumption, as mentioned above, can decrease the likelihood of developing TD. Most travellers, however, encounter difficulty in observing the requisite dietary restrictions.
Several non-antimicrobial agents have been advocated for prevention of TD. For more information, please consult your local medical practitioner.
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"Mosquitoes and Other Arthropod Vectors, Protection Against",11,0,0,0
Although vaccines or chemoprophylactic drugs are available against important vector-borne diseases such as yellow fever and \Jmalaria\j, there are none for most other mosquito-borne diseases such as \Jdengue\j, and travellers should still avail themselves of repellents and other general protective measures against arthropods.
The effectiveness of \Jmalaria\j chemoprophylaxis is variable, depending on patterns of resistance and compliance with medication, and for many vector-borne diseases, no specific preventatives are available.
\IGeneral preventative measures\i
The principal approach to prevention of vector-borne diseases is avoidance.
Tick- and mite-borne infections characteristically are diseases of 'place'; whenever possible, known foci of disease transmission should be avoided. Although many vector-borne infections can be prevented by avoiding rural locations, certain mosquito- and midge-borne arboviral and parasitic infections are transmitted around human residences and in urban locations.
Most vector-borne infections are transmitted seasonally and simple changes in itinerary may greatly reduce risk for acquiring certain infections.
Exposure to arthropod bites can be minimised by modifying patterns of activity or behaviour. Some vector mosquitoes are most active in twilight periods at dawn and dusk or in the evening. Avoidance of outdoor activity during these periods may reduce risk of exposure.
Wearing long-sleeved shirts, long pants and hats will minimise areas of exposed skin. Shirts should be tucked in. Repellents applied to clothing, shoes, tents, mosquito nets and other gear will enhance protection.
When exposure to ticks or mites are a possibility, pants should be tucked into socks and boots should be worn; sandals should be avoided.
During outdoor activity and at the end of the day, travellers should inspect themselves and their clothing for ticks. Ticks are detected more easily on light-coloured or white clothing. Prompt removal of attached ticks may prevent infection.
When accommodations are not adequately screened or air-conditioned, bednets are essential to provide protection and comfort. Bednets should be tucked under mattresses and can be sprayed with repellent.
Aerosol insecticides and mosquito coils may help to clear rooms of mosquitoes; however, some coils contain DDT and should be used with caution.
\IPrecautions to Minimise Potential for Adverse Reactions from Repellents\i
ò Apply repellent sparingly only to exposed skin or clothing.
ò Avoid applying high-concentration (>30% DEET) products to the skin, particularly of children.
ò Do not inhale or ingest repellents or get them into the eyes.
ò Wear long sleeves and long pants when possible, and apply repellents (e.g. permethrin) to clothing to
reduce cutaneous exposure.
ò Avoid applying repellents to portions of children's hands that are likely to have contact with eyes or
mouth.
ò Pregnant and nursing women should minimise use of repellents.
ò Never use repellents on wounds or irritated skin.
ò Use repellent sparingly; one application will last approximately 4 hours. Saturation does not increase
efficacy.
ò Wash repellent-treated skin after coming indoors.
ò If a suspected reaction to insect repellents occurs, wash treated skin and call a physician. Take the
repellent container to the physician
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"Swimming Precautions When Abroad",12,0,0,0
Swimming in contaminated water may result in skin, eye, ear and certain intestinal infections, particularly if the swimmer's head is submerged. Generally for infectious disease prevention, only pools that contain chlorinated water can be considered safe places to swim.
In certain areas, fatal primary amoebic meningoencephalitis has occurred following swimming in warm dirty water. Swimmers should avoid beaches that might be contaminated with human sewage or with dog faeces. Wading or swimming should be avoided in freshwater streams, canals and lakes liable to be infested with the snail hosts of schistosomiasis (bilharziasis) or contaminated with urine from animals infected with \ILeptospira.\i
Biting and stinging fish and corals and jelly fish may provide a hazard to the swimmer. Never swim alone or when under the influence of alcohol or drugs, and never dive head first into an unfamiliar body of water.
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"Pregnant Women Travelling Abroad",13,0,0,0
The problems that a pregnant woman might encounter during international travel are basically the same problems that other international travellers have. These have to do with exposure to infectious diseases and availability of good medical care. There is the additional potential problem that air travel late in \Jpregnancy\j might precipitate labour.
Potential health problems vary from country to country; therefore, if the traveller has specific questions, she should be advised to check with the embassy or local consulate general's office of the country in question before travelling.
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"Motion Sickness",14,0,0,0
Travellers with a history of motion sickness or sea sickness can attempt to avoid symptoms by taking anti-motion-sickness pills or antihistaminics before departure.
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"Injuries While Abroad",15,0,0,0
The major causes of serious disability or loss of life are not infectious. Trauma caused by injuries, principally that suffered in motor vehicle crashes, is the leading cause of death and disability in both developed and developing countries worldwide.
The risk of motor vehicle-related death may be many times greater in developing countries. Motor vehicle crashes result from a variety of factors, including inadequate roadway design, hazardous conditions, lack of appropriate vehicles and vehicle maintenance, unskilled or inexperienced drivers, inattention to pedestrians and pedalcyclists, or impairment due to alcohol or drug use; all these factors are preventable or can be abated. Defensive driving is an important preventive measure.
When driving or riding, insist on a vehicle equipped with safety belts and, where available, use them. Cars should be carefully inspected to assure that tires and brakes are in good condition and that all lights are in good working order. Where available, also request a vehicle equipped with airbags and when renting a large truck, request a vehicle equipped with anti-lock brakes.
As a high proportion of crashes occur at night when returning from 'social events', avoid non-essential night driving, alcohol, and riding with persons who are under the influence of alcohol or drugs.
Pedestrian, \Jbicycle\j and \Jmotorcycle\j travel are often dangerous, and helmet use is imperative for \Jbicycle\j and \Jmotorcycle\j travel.
Fire injuries are also a significant cause of injuries and death-do not smoke in bed, and inquire about whether hotels have smoke detectors and sprinkler systems. Travellers may wish to bring their own smoke detectors with them.
Always look for a primary and alternate escape route from rooms in which you are meeting or staying. Look for improperly vented heating devices which may cause carbon monoxide poisoning. Remember to escape a fire by crawling low under smoke.
Other major causes of injury trauma include drowning (see \JSwimming Precautions When Abroad\j) and injuries to water skiers and divers due to boat propellers. Boats equipped with propeller guards should be used whenever possible.
Protection against potentially hazardous drugs is non-existent in some countries, increasing the risk of adverse reactions. Do not buy medications 'over the counter' unless you are familiar with the product.
Travellers should also be aware of the potential for violence-related injuries. Risk of assault or terrorist attack varies from country to country; heed advice from residents and tour guides about areas to be avoided, going out at night and going out alone. Do not fight attackers. If confronted, give up your valuables.
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"Animal-Associated Hazards",16,0,0,0
Animals in general tend to avoid human beings, but they can attack, particularly if they are with young. In areas of endemic \Jrabies\j, domestic dogs, cats or other animals should not be petted. Wild animals should be avoided.
The bites, stings and contact of some insects cause unpleasant reactions. Medical attention should be sought if an insect bite or sting causes redness, swelling, bruising or persistent pain.
Many insects also transmit communicable diseases. Some insects can bite and transmit disease without the person being aware of the bite, particularly when camping or staying in rustic or primitive accommodations. Insect repellents, protective clothing and mosquito netting are advisable in many parts of the world. (See \JMosquitoes and Other Arthropod Vectors, Protection Against\j)
Poisonous snakes are hazards in many parts of the world, although deaths from snake bites are relatively rare. The Australian brown snake, Russell's viper and cobras in southern Asia, carpet vipers in the Middle East, and \Jcoral\j and rattlesnakes in the Americas are particularly dangerous.
Most snakebites are the direct result of handling or harassing snakes, which bite as a defensive reaction. Attempts to kill snakes are dangerous, often leading to bites on the fingers. The venom of a small or immature snake may be even more concentrated than that of a larger individual, therefore all
snakes should be left strictly alone.
Less than half of all snakebite wounds actually contain venom, but medical attention should be sought anytime a bite wound breaks the skin. A pressure bandage, ice (if available) and immobilisation of the affected limb are recommended first aid measures while the victim is moved as quickly as possible to a medical facility. Specific therapy for snakebite is controversial, and should be left to the judgment of local emergency medical personnel.
Snakes tend to be active at night and in warm weather. As a precaution, boots and long pants may be worn when walking outdoors at night in snake-infested regions.
Bites from scorpions may be painful but seldom are dangerous except possibly in infants. In general, exposure to bites can be avoided by sleeping under mosquito nets and by shaking clothing and shoes before putting them on, particularly in the morning. Snakes and scorpions tend to rest in shoes and clothing.
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"Medical Care Abroad",17,0,0,0
If medical care is needed abroad, travel agents or your embassy or consulate can usually provide names of hospitals, physicians or emergency medical service agencies. Prior to departure, travellers should contact their own insurance companies concerning their coverage.
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"Post-Travel Period",18,0,0,0
Some diseases may not manifest themselves immediately. If travellers become ill after they return home, they should tell their physician where they have travelled. Most persons who acquire viral, bacterial or parasitic infections abroad become ill within 6 weeks after returning from international travel. However, some diseases may not manifest themselves immediately, e.g. \Jmalaria\j may not cause symptoms for as long as 6 months to a year after the traveller returns home.
It is recommended that a traveller always advise a physician of the countries visited within the 12 months preceding onset of illness. Knowledge of such travel and the possibility the patient may be ill with a disease the physician rarely encounters will help the physician arrive at a correct diagnosis.
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"WHO Blood Transfusion Guidelines for International Travellers",19,0,0,0
There is a growing public awareness of the AIDS epidemic and a resulting concern about acquiring the AIDS virus through blood transfusion. Systematic screening of blood donations is not yet feasible in all developing countries.
Requests have been made by persons planning international travels to have their own blood, or blood from their home country, available to them in case of urgent need. These requests raise logistic, technical and ethical issues which are not easy to resolve.
Ultimately, the safety of blood for such persons will depend upon the quality of blood transfusion services in the host country. The strengthening of these services is of the highest priority. While efforts are being made to achieve this end, other approaches are also needed.
\IBasic Principles:\i
1. Unexpected, emergency blood transfusion is rarely required. It is needed only in situations of massive haemorrhage like severe trauma, gynaecologic and obstetric emergency or gastrointestinal bleeding.
2. In many cases, resuscitation can be achieved by use of \Jcolloid\j or crystalloid plasma expanders instead of blood.
3. Blood transfusion is not free of risk, even in the best of conditions. In most developing countries, the risk is increased by limited technical resources for screening blood donors for \JHIV\j infection and other diseases transmissible by blood.
4. The international shipment of blood for transfusion is practical only when handled by agreement between two responsible organisations, such as national blood transfusion services. This mechanism is not useful for emergency needs of individual patients and should not be attempted by private individuals or organisations not operating recognised blood programs.
\ITherefore:\i
1. There are no medical indications for travellers to take blood with them from their home country.
2. The limited storage period of blood and the need for special equipment negate the feasibility of independent blood banking for individual travellers or small groups.
3. Blood should be transfused only when absolutely indicated. This applies even more forcefully in those countries where screening of blood for transmissible diseases is not yet widely performed.
\IProposed Options:\i
1. When urgent resuscitation is necessary, the use of plasma expanders rather than blood should always be considered.
2. In case of emergency need of blood, use of plasma expanders and urgent evacuation home may be the actions of choice.
3. When blood transfusion cannot be avoided, the attending physician should make every effort to ensure that the blood has been screened for transmissible diseases, including \JHIV\j.
4. International travellers should:
a. take active steps to minimise the risk of injury;
b. establish a plan for dealing with medical emergencies;
c. support the development within countries of safe and adequate blood supplies.
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"Disinsection of Aircraft",20,0,0,0
International travellers should be aware that some countries require disinsection of certain passenger \Jaircraft\j in order to prevent the importation of insects such as mosquitoes. Disinsection procedures may include the spraying of the \Jaircraft\j passenger compartment with \Jinsecticide\j while passengers are present.
While the recommended disinsection procedures have been determined to be safe by the World Health Organisation, they may aggravate certain health conditions (i.e. allergies). Travellers with such conditions or who are otherwise interested in determining what disinsection procedures may be performed on a particular flight should contact their travel agent or airline.
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"Tuberculosis Risk in Aircraft",21,0,0,0
The Centers for Disease Control and Prevention (CDC), USA, and other American state and local health departments have conducted six investigations of possible tuberculosis (TB) transmission
on commercial \Jaircraft\j.
In all six instances, a passenger or a member of the flight crew travelled on commercial aeroplanes while infectious with TB. In none of the six instances were the airlines aware of the TB in their passengers. In two of the instances, the Centers For Disease Control and Prevention (CDC) concluded that TB was probably transmitted to others on the aeroplane.
TB is spread from person to person through the air. When a person with infectious TB coughs or sneezes, tiny droplets containing TB bacteria may be released into the air. Other people may inhale these droplets and become infected.
The CDC found that the risk of TB transmission from an infectious person to others on an aeroplane was greater on long flights (i.e. 8 hours or longer). The risk of exposure to TB was higher for passengers and flight crew sitting or working near an infectious person. These persons may inhale droplets containing TB bacteria.
The risk of TB transmission on an aeroplane does not appear to be greater than in any other enclosed space. To prevent the possibility of exposure to TB on aeroplanes, CDC recommends that persons known to have infectious TB travel by private transportation (i.e. not by commercial aeroplanes or other commercial carriers), if travel is required.
CDC has issued guidelines for notifying passengers who may have been exposed to TB aboard aeroplanes. Passengers concerned about a possible exposure to TB should see their primary health care provider for a TB skin test. TB is a treatable and preventable disease.
Anthrax is a disease caused by a bacterial organism that produces spores that are highly resistant to disinfection. These infectious spores may persist on a contaminated item for many years.
Anthrax spores have been found on goatskin handicrafts from \JHaiti\j. Travellers to Caribbean countries are advised not to purchase Haitian goatskin handicrafts. Because of the risk, importation of goatskin handicrafts from \JHaiti\j will not be permitted at some (including US) ports of entry; they will be confiscated and destroyed.
#
"Importation or Re-entry of Pets",23,0,0,0
Pets which are transported internationally should be free of communicable diseases that may be transmissible to humans.
Travellers planning to take a pet to a foreign country are advised to meet entry requirements of the country of destination. To obtain this information write to or call the country's embassy or the consulate nearest you.
#
"Chernobyl, Health Risks to Travellers",24,0,0,0
\IEffects of the radiological release at Chernobyl\i
The \JChernobyl\j Nuclear Power station, located in the \JUkraine\j Republic about 100 kilometres (62 miles) north-west of \JKiev\j and 310 kilometres (193 miles) south-east of Minsk (in Belarus), experienced an uncontrolled release of radioactive material in April 1986. This event seems to have resulted in the largest short-term release of radioactive materials to the atmosphere ever recorded.
The radiological contamination primarily affected three Republics: the \JUkraine\j, \JBelarus\j and \JRussia\j. The highest areas of radioactive ground contamination occurred within 30 km (19 miles) of \JChernobyl\j.
\IArea Considerations\i
Short-term international travellers to the republics of \JUkraine\j, \JBelarus\j and \JRussia\j (i.e. those who plan to stay in the region less than a few months) should not be concerned about residing in areas that are not controlled (i.e. marked with signs or fenced).
However, we do caution longer-term visitors that there are some non-controlled areas where an individual could receive a radiation dose from the radioactive ground contamination in excess of the international radiological health standards recommended for most members of the public.
Long-term visitors should investigate the local conditions prior to choosing a long-term residence. (For example, ground contamination that exceeds 5 curies per square \Jkilometre\j (5 Ci/km2 ) of cesium-137 could result in a radiation dose greater than the recommended standards.)
\IFood and Water Considerations\i
Officials of the three republics attempt to monitor all food stuffs sold in the public markets for levels of \Jradioactivity\j. Radioactive concentration limits have been established for various classes of food, e.g. milk, meat and vegetables. These limits are comparable to standards used by many western nations including the European Economic Community.
Food with contamination levels in excess of these limits is not allowed to be sold in the market. Private farmers, however, regularly make food available for sale outside the official market system. This food is not monitored for \Jradioactivity\j and it is recommended that travellers not consume this food.
Likewise, it is recommended that travellers not consume any wild berries, wild mushrooms or wild game from these regions. And, it is also recommended that travellers drink only bottled water.
\IAge and Health Considerations\i
Young children, unborn babies and nursing infants are potentially at greater risk from exposure to radiation than adults. Pregnant or nursing mothers should pay extra attention to acquiring and consuming food from reliable well-monitored sources.
#
"Infectious Diseases, Emerging",25,0,0,0
Emerging infectious diseases are diseases of infectious origin whose incidence in humans has increased within the past two decades or threatens to increase in the near future.
Many factors, or combinations of factors, can contribute to disease emergence. New infectious diseases may emerge from genetic changes in existing organisms; known diseases may spread to new geographic areas and populations; and previously unknown infections may appear in humans living or working in changing ecologic conditions that increase their exposure to insect vectors, animal reservoirs or environmental sources of novel pathogens.
Re-emergence may occur because of the development of antimicrobial resistance in existing infections (e.g. gonorrhoea, \Jmalaria\j, pneumococcal disease) or breakdowns in public health measures for previously controlled infections (e.g. \Jcholera\j, tuberculosis [TB], pertussis).
#
"HIV Infection and AIDS, General Recommendations to Traveller",26,0,0,0
Acquired immunodeficiency syndrome (AIDS) is a severe, often life-threatening illness caused by the human immunodeficiency virus (HIV). The incubation period for AIDS is very long and variable, ranging from a few months to many years. Some individuals infected with \JHIV\j have remained asymptomatic for more than a decade.
Currently, there is no vaccine to protect against infection with \JHIV\j. Although there is no cure for AIDS, treatments for \JHIV\j infection and prophylaxis for many opportunistic diseases that characterise AIDS are available.
HIV infection and AIDS have been reported worldwide. Comprehensive surveillance systems are lacking in many countries, so that the true number of cases is likely to be far greater than the numbers officially reported from some, particularly the non-industrialised nations.
The number of persons infected with \JHIV\j is estimated by WHO to be approaching 18 million worldwide. Because \JHIV\j infection and AIDS are globally distributed, the risk to international travellers is determined less by their geographic destination than by their sexual and drug-using behaviours.
The global epidemic of \JHIV\j infection and AIDS has raised several issues regarding \JHIV\j infection and international travel. The first is the need for information for international travellers regarding \JHIV\j transmission and how \JHIV\j infection can be prevented.
HIV infection is preventable. \JHIV\j is transmitted through sexual intercourse, needle or syringe-sharing, by medical use of blood or blood components, and peri-natally from an infected woman to her baby.
HIV is not transmitted through casual contact; air, food or water routes; contact with inanimate objects; or through mosquitoes or other arthropod vectors . The use of any public conveyance (e.g. aeroplane, \Jautomobile\j, boat, bus, train) by persons with AIDS or \JHIV\j infection does not pose a risk of infection for the crew or other passengers.
Travellers are at risk if they:
- have sexual intercourse (heterosexual or homosexual) with an infected person;
- use or allow the use of contaminated, unsterilised syringes or needles for any injections or other skin-piercing procedures including \Jacupuncture\j, use of illicit drugs, steroid or vitamin injections, medical/dental procedures, ear or body piercing, or tattooing;
- use infected blood, blood components or clotting factor concentrates. \JHIV\j infection by this route is a rare occurrence in those countries or cities where donated blood/plasma is screened for \JHIV\j antibody.
Travellers should avoid sexual encounters with a person who is infected with \JHIV\j or whose HIV-infection status is unknown. This includes avoiding sexual activity with intravenous drug users and persons with multiple sexual partners, such as male or female prostitutes.
Condoms, when used consistently and correctly, prevent transmission of \JHIV\j. Persons who engage in vaginal, anal or oral-genital intercourse with anyone who is infected with \JHIV\j or whose infection status is unknown should use a \Jlatex\j condom. For those who are sensitive to \Jlatex\j, polyurethane or other plastic condoms are available (look for the words 'for the prevention of disease' on the condom packaging).
In many countries, needlesharing by IV drug users is a major source of \JHIV\j transmission and other infections such as hepatitis B and C. Do not use drugs intravenously or share needles for any purpose.
In the United States, \JAustralia\j, New Zealand, Canada, \JJapan\j and western European countries, the risk of infection with transfusion-associated \JHIV\j has been virtually eliminated through required testing of all donated blood for \Jantibodies\j to \JHIV\j.
In less-developed nations, there may not be a formal program for testing blood or biological products for antibody to \JHIV\j. In these countries, use of unscreened blood clotting factor concentrates or those of uncertain purity should be avoided (when medically prudent).
If transfusion is necessary, the blood should be tested, if at all possible, for \JHIV\j \Jantibodies\j by appropriately-trained laboratory technicians using a reliable test (see WHO Blood Transfusion Guidelines for International Travellers). Needles used to draw blood or administer injections should be sterile, preferably of the single-use disposable type, and pre-packaged in a sealed container.
Insulin-dependent diabetics, haemophiliacs and other persons who require routine or frequent injections should carry a supply of syringes, needles and \Jdisinfectant\j swabs (e.g. alcohol wipes) sufficient to last their entire stay abroad.
International travellers should be aware that some countries serologically screen incoming travellers (primarily those with extended visits, such as for work or study) and deny entry to persons with AIDS and those whose test results indicate infection with \JHIV\j.
Persons who are intending to visit a country for a substantial period or to work or study abroad should be informed of the policies and requirements of the particular country. This information is usually available from consular officials of individual nations.
#
"Regional Travel Health Information",27,0,0,0
\BChapter 2 of Health Information for International Travel 1996-97\b
Click on one of these page links to jump directly to that page or simply click on the \INext Page\i button to begin reading this chapter.
- \JAustralia and the South Pacific (Travel Health Tips)\j
- \JCaribbean (Travel Health Tips)\j
- \JCentral Africa (Travel Health Tips)\j
- \JEast Africa (Travel Health Tips)\j
- \JEast Asia (Travel Health Tips)\j
- \JEastern Europe and the New Independent States of the Former Soviet Union (NIS) (Travel Health Tips)\j
- \JIndian Subcontinent (Travel Health Tips)\j
- \JMexico and Central America (Travel Health Tips)\j
- \JMiddle East (Travel Health Tips)\j
- \JNorth Africa (Travel Health Tips)\j
- \JSoutheast Asia (Travel Health Tips)\j
- \JSouthern Africa (Travel Health Tips)\j
- \JTemperate South America (Travel Health Tips)\j
- \JTropical South America (Travel Health Tips)\j
- \JWest Africa (Travel Health Tips)\j
- \JWestern Europe (Travel Health Tips)\j
#
"Australia and the South Pacific (Travel Health Tips)",28,0,0,0
(Date last rev'd: 7 November 1996)
\ICountries in this region:\i \JAustralia\j, Christmas Island, Cook Island, \JFiji\j, \JGuam\j, Kiribati, Marshall Islands, \JNauru\j, New Caledonia, New Zealand, Niue, Northern Mariana Islands, Palau, Papua New Guinea, Pitcairn, \JSamoa\j, American \JSamoa\j, Solomon Islands, Tahiti, Tokelau, \JTonga\j, \JTuvalu\j, US Trust Territory of the Pacific Islands, Vanuatu, Wake Island, Wallis and Futuna.
Travellers to \JAustralia\j and the South Pacific may be exposed to potential diseases from a number of sources. The most frequently reported illness is traveller's diarrhoea, but there are other diseases which are unique to the tropics. This region contains a variety of diseases transmitted by insects, contaminated food and water, or close contact with infected people. Specific diseases are discussed under each of these topical headings.
In order to reduce the risk of infection travellers must (1) protect themselves from insects, (2) ensure the quality of their food and drinking water, and (3) be knowledgeable about potential diseases in the region to be visited.
Finally, diseases are not restricted to cleanly defined geographical areas, i.e. mosquitoes can fly over city or country borders; therefore, all travellers should protect themselves by taking the basic preventive precautions.
\BDiseases Transmitted by Insects:\b see '\JMosquitoes and Other Arthropod Vectors, Protection Against\j'.
In Papua New Guinea, the Solomon Islands and Vanuatu (except Fortuna island), a high risk for \Jmalaria\j exists in all parts of these countries including the urban areas. The dominant form is \IP. falciparum\i (the most dangerous type), which has been reported to be resistant to the drug chloroquine.
In \JAustralia\j, Christmas Island, Cook Island, \JFiji\j, \JGuam\j, Kiribati, Marshall Islands, \JNauru\j, New Caledonia, New Zealand, Niue, Northern Mariana Islands, Palau, Pitcairn, \JSamoa\j, American \JSamoa\j, Tahiti, Tokelau, \JTonga\j, \JTuvalu\j, US Trust Territory of the Pacific Islands, Wake Island and Wallis & Futuna, there is no risk of \Jmalaria\j.
Dengue fever occurs sporadically in many parts of this region: \JAustralia\j (in parts of northern \JQueensland\j and the Torres Strait Islands of Australia), Cook Islands, \JFiji\j, Kiribati, \JKosrae\j, New Caledonia, Niue, Palau, Papua New Guinea, \JSamoa\j, Tahiti, Tokelau, US Trust Territory of the Pacific Islands, Vanuatu, Wallis and Futuna.
The risk of infection is small for most travellers except during periods of epidemic transmission. New Zealand and the rest of the island groups are free of \Jdengue\j.
Even though there is no risk of becoming infected while travelling in \JAustralia\j or countries in the South Pacific, a number of these countries\I require\i a yellow fever \Jvaccination\j if a traveller is coming from areas in \BAfrica\b and \BSouth America,\b where yellow fever is found.
If you are\B only\b travelling from the United States to \JAustralia\j or another country in the South Pacific, you are not required to have, a yellow fever \Jvaccination\j. However, if your travel plans include travelling to or from a country in Africa or South America, you may be required to have a yellow fever \Jvaccination\j.
\IOther Insect Diseases\i
Other diseases spread by mosquitoes, sand flies, black flies or other insects are prevalent, especially in rural areas. These diseases include: filariasis and Ross River Virus (mosquito) and \Jtyphus\j (lice).
\BDiseases Transmitted Through Food and Water:\b see '\JFood and Drink, Risks to Traveller\j', and '\JTraveller's Diarrhoea\j'.
Food and waterborne diseases are the number one cause of illness to travellers and are common in \JAustralia\j and the South Pacific.
Traveller's diarrhoea is the most frequent health problem for travellers. It can be caused by viruses, bacteria or parasites which are found universally throughout the region. Transmission is most often through contaminated food or water. Infections may cause diarrhoea and vomiting (typhoid fever, \Jcholera\j and parasites), liver damage (hepatitis) or muscle paralysis (polio).
Travellers to many of the South Pacific Islands are at risk for typhoid fever, especially when travelling to smaller cities, villages or rural areas. Typhoid fever is rare in \JAustralia\j and New Zealand.
The Centers For Disease Control and Prevention (CDC) recommends a typhoid \Jvaccination\j (either oral or the new injectable ViCPS vaccine) for those travellers who are going off the usual tourist itineraries, travelling to smaller cities and rural areas or staying for six weeks or more. Typhoid \Jvaccination\j is not required for international travel.
Cholera cases have been reported from several islands in the South Pacific. Persons following the usual tourist itinerary who follow the food safety recommendations are at virtually no risk of infection. Because the risk to travellers from many industrialised countries is so low, it is questionable whether \Jvaccination\j is of benefit.
\IHepatitis A\i [see '\JHepatitis, viral, type A (Travel Information)\j']
Travellers are at high risk for hepatitis A (except for travellers to \JAustralia\j and New Zealand), especially if travel plans include visiting rural areas and extensive travel in the countryside, frequent close contact with local persons, or eating in settings of poor sanitation.
A study has shown that many cases of travel-related hepatitis A occur in travellers to developing countries with 'standard' itineraries, accommodations and food consumption behaviours. It is therefore recommended that travellers receive hepatitis A vaccine or IG for protection against hepatitis A. Strict food and water precautions should also be followed.
\IParasitic infections:\i
Travellers to many of the South Pacific Islands are at risk of parasitic infection. Travellers to \JAustralia\j and New Zealand have little or no risk.
There are many types of parasites and infection may occur in several ways: by eating undercooked meats infected with parasites or their \Jlarva\j; by eating food or drinking water contaminated with parasites or their eggs; by contact with soil or water infected with parasites; or through insect bites.
Several types of parasites can penetrate intact skin and travellers are advised to wear shoes and avoid swimming, wading or washing in fresh water [see '\JSchistosomiasis (Travel Information)\j', and '\JSwimming Precautions When Abroad\j'] .
\BDiseases Transmitted Through Intimate Contact with People:\b see '\JHIV Infection and AIDS, General Recommendations to Traveller\j', and '\JWHO Blood Transfusion Guidelines for International Travellers\j'.
HIV/AIDS is found throughout the world. The risk to a traveller depends on whether the traveller will be involved in sexual or needle-sharing contact with a person who is infected with \JHIV\j or receive unscreened blood for transfusion.
\IHepatitis B\i [see '\JHepatitis, viral, type B (Travel Information)\j]
Hepatitis B rates are high in all of the South Pacific Islands, but rates are low in \JAustralia\j and New Zealand.
The risk for acquiring disease is greater if the traveller has contact with blood or secretions containing blood, sex contact with an infected person, or remains in the country for longer than six months and has close contact with the local population.
\B
\BSummary of Recommendations for \JAustralia\j and the South Pacific:\b
Travellers should:
(1) take the appropriate country-specific \Jmalaria\j prevention measures;
(2) follow precautions to prevent insect bites;
(3) pay attention to the quality of their drinking water and food;
(4) have a dose of Immune \JGlobulin\j (IG) or the Hepatitis A vaccine (except \JAustralia\j and New Zealand); and
(5) consider booster doses of tetanus (Td) and polio (eIPV) vaccines.
(6) Depending on the locations to be visited, planned activities and health of the traveller, the following vaccines should be considered: Hepatitis B, Typhoid and \JCholera\j.
(7) Finally, the normal 'childhood' vaccines should be up-to-date: \JMeasles\j, \JMumps\j, Rubella (MMR Vaccine); \JDiphtheria\j, Tetanus, \JPertussis\j (DTP Vaccine) [ < 7 years of age] and Polio vaccine.
#
"Caribbean (Travel Health Tips)",29,0,0,0
(Date last rev'd: 24 June 24 1997)
\ICountries in this region:\i Antigua & Barbuda, \JBahamas\j, \JBarbados\j, \JBermuda\j (UK), \JCayman\j Islands (UK), \JCuba\j, Dominica, Dominican Republic, \JGrenada\j, \JGuadeloupe\j, \JHaiti\j, \JJamaica\j, Martinique (France), Montserrat (UK), Netherlands \JAntilles\j , Puerto Rico (US), St Lucia, St Vincent & the Grenadines, St Kitts & Nevis, Trinidad & Tobago, Virgin Islands (US), Virgin Islands (UK).
Travellers to the Caribbean may be exposed to potential diseases from a number of sources. The most frequently reported illness is traveller's diarrhoea, but there are other diseases which are found in the Caribbean or the tropics. These diseases are transmitted by insects, contaminated food and water or close contact with infected people. Specific diseases are discussed under each of these topical headings.
In order to reduce the risk of infection travellers must (1) protect themselves from insects, (2) ensure the quality of their food and drinking water, and (3) be knowledgeable about potential diseases in the region to be visited.
Finally, diseases are not restricted to cleanly defined geographical areas, i.e. mosquitoes can fly over city or country borders; therefore, all travellers should protect themselves by taking the basic preventive precautions.
\BDiseases Transmitted by Insects:\b see '\JMosquitoes and Other Arthropod Vectors, Protection Against\j'.
Malaria exists throughout the year only in \JHaiti\j and the Dominican Republic. It has been eradicated from the other islands. \IP. falciparum\i (the most dangerous type) has been confirmed in both of these countries.
\IDetailed risk information:\i
Dominican Republic: all rural areas, except no risk in tourist resorts; the highest risk is in the provinces bordering \JHaiti\j. \JHaiti\j: risk in all areas.
Cases of yellow fever have occurred in Trinidad and Tobago. Travellers to the Caribbean should obtain a current list of yellow fever-infected countries and comprehensive information on yellow fever \Jvaccination\j requirements.
\BNote: some countries require yellow fever \Jvaccination\j for entry. \b(Yellow fever vaccine is the \Ionly\i vaccine that may be officially required for entry into certain countries.)\b
\B\b
If you are \Bonly \btravelling to a Caribbean country\I other\i than Trinidad or Tobago, it may not be required, or even recommended, for you to have a yellow fever \Jvaccination\j.
Bermuda, \JCayman\j Islands, \JCuba\j, Dominican Republic, Montserrat (UK), Puerto Rico (US), Virgin Islands (US) and the Virgin Islands (UK) have no yellow fever \Jvaccination\j requirements.
\IPlease note\i\B:\b CDC recommends a yellow fever \Jvaccination\j if you are travelling to areas of risk (such as Trinidad or Tobago).
Antigua & Barbuda, \JBahamas\j, \JBarbados\j, Dominica, \JGrenada\j, \JGuadeloupe\j, \JHaiti\j, \JJamaica\j, Martinique (France), Netherlands \JAntilles\j (for travellers over the age of 6 months), St Lucia, St Vincent & the Grenadines, St Kitts & Nevis, and Trinidad & Tobago, \Ball require a yellow fever \Jvaccination\j for all travellers (age >1, except where otherwise indicated) arriving from any 'infected countries',\b as listed below.
After immunisation, an International Certificate of \JVaccination\j is issued and is valid 10 days after \Jvaccination\j to meet entry and exit requirements for all countries. The Certificate is good for 10 years. You must take the Certificate with you.
Travellers who for medical reasons cannot receive the yellow fever vaccine should check embassies or consulates for specific waiver requirements.
In the Caribbean islands, low level transmission occurs throughout the year on most tourist-oriented islands. Seasonal and sporadic epidemics with higher transmission rates also frequently occur.
The risk of infection is small for most travellers except during periods of epidemic transmission. There is no \Jdengue\j in the \JCayman\j Islands.
\IOther Insect Diseases:\i
Other diseases spread by mosquitoes, sand flies, black flies or other insects are prevalent, especially in rural areas. These diseases include: filariasis (mosquito), \Jleishmaniasis\j (sand fly), Oropouche Virus (gnats or midges) and \Jtyphus\j (lice).
\BDiseases Transmitted Through Food and Water:\b see '\JFood and Drink, Risks to Traveller\j', and '\JTraveller's Diarrhoea\j'.
Food and waterborne diseases are the number one cause of illness to travellers and are very common in the Caribbean.
Traveller's diarrhoea is the most frequent health problem for travellers. It can be caused by viruses, bacteria or parasites which are found universally throughout the region. Transmission is most often through contaminated food or water. Infections may cause diarrhoea and vomiting (typhoid fever, \Jcholera\j and parasites), liver damage (hepatitis) or muscle paralysis (polio).
A recent epidemic of \Jcholera\j has swept through the entire Central and tropical South American Area, but so far it has not reached the Caribbean region. Persons following the usual tourist itinerary who follow the food safety recommendations are at virtually no risk of infection.
Travellers to the Caribbean are at risk for typhoid fever, especially when travelling to smaller cities, villages or rural areas.
\IHepatitis A\i [see '\JHepatitis, viral, type A (Travel Information)\j']
Travellers are at high risk for Hepatitis A, especially if travel plans include visiting rural areas and extensive travel in the countryside, frequent close contact with local persons or eating in settings of poor sanitation.
A study has shown that many cases of travel-related hepatitis A occur in travellers to developing countries with 'standard' itineraries, accommodations and food consumption behaviours.
It is therefore recommended that travellers receive hepatitis A vaccine or IG for protection against hepatitis A. Strict food and water precautions are also recommended.
\IParasitic infections:\i
Travellers to the Caribbean are at risk of parasitic infections. There are many types of parasites and infection may occur in several ways: by eating undercooked meats infected with parasites or their \Jlarva\j; by eating food or drinking water contaminated with parasites or their eggs; by contact with soil or water infected with parasites; or through insect bites.
Several types of parasites can penetrate intact skin and travellers are advised to wear shoes and avoid swimming, wading or washing in fresh water [see '\JSchistosomiasis (Travel Information)\j', and '\JSwimming Precautions When Abroad\j'].
Travellers should eat only thoroughly cooked food, drink safe water, wear shoes, refrain from swimming in fresh water and avoid contact with insects, particularly mosquitoes, biting flies, gnats and midges.
\BDiseases Transmitted Through Intimate Contact with People:\b see '\JHIV Infection and AIDS, General Recommendations to Traveller\j', and '\JWHO Blood Transfusion Guidelines for International Travellers\j'.
HIV/AIDS is found throughout the world. The risk to a traveller depends on whether the traveller will be involved in sexual or needle-sharing contact with a person who is infected with \JHIV\j or receive unscreened blood for transfusion.
\IHepatitis B\i [see '\JHepatitis, viral, type B (Travel Information)\j']
Hepatitis B rates are high in the Dominican Republic and \JHaiti\j, but are intermediate throughout the rest of the region. The risk for acquiring disease is greater if the traveller has contact with blood or secretions containing blood, sex contact with an infected person or remains in the country for longer than six months and has close contact with the local population.
In the Caribbean, schistosomiasis is known to exist in Antigua, the Dominican Republic, \JGuadeloupe\j, Martinique, Montserrat, Puerto Rico and St Lucia. For travellers visiting these areas, the risk is a function of the frequency and degree of contact with contaminated fresh water for bathing, wading or swimming. Avoid contact with potentially contaminated water.
There is a risk of \Jrabies\j infection particularly in rural areas, or in urban areas where large numbers of dogs are found. Some islands of risk are \JCuba\j, Dominican Republic, \JGrenada\j, \JHaiti\j, Puerto Rico and Trinidad and Tobago.
Many Caribbean islands have reported no \Jrabies\j cases for at least the past two years, including: \JAnguilla\j, Antigua & Barbuda, \JBahamas\j, \JBarbados\j, \JBermuda\j, \JCayman\j Islands (UK), Dominica, \JGuadeloupe\j, \JJamaica\j, Martinique (France), Montserrat (UK), Netherlands \JAntilles\j, St Lucia, St Martin, St Vincent & the Grenadines, St Kitts & Nevis, Turks and Caicos, and the Virgin Islands (US & UK).
Check with consulates or local island health officials for specific up-to-date information.
\B
\BSummary of Recommendations for the Caribbean:\b
Travellers should:
(1) take the appropriate country-specific \Jmalaria\j prevention;
(2) follow precautions to prevent insect bites;
(3) pay attention to the quality of their drinking water and food;
(4) have a dose of Immune \JGlobulin\j (IG) or the hepatitis A vaccine; and
(5) consider a booster dose of tetanus (Td) vaccine.
(6) Depending on the locations to be visited, planned activities and health of the traveller, the following vaccines should be considered: Hepatitis B, Yellow Fever, Typhoid, \JRabies\j (pre-exposure) and \JCholera\j.
(7) Finally, the normal 'childhood' vaccines should be up-to-date: \JMeasles\j, \JMumps\j, Rubella (MMR Vaccine); \JDiphtheria\j, Tetanus, \JPertussis\j (DTP Vaccine) [ < 7 years of age] and Polio vaccine. Refer to 'Vaccine Recommendations' for additional information on vaccines.
#
"Central Africa (Travel Health Tips)",30,0,0,0
(Date last rev'd: 7 November 1996)
\ICountries in this region:\i \JAngola\j, \JCameroon\j, Central African Republic, Chad, \JCongo\j, Equatorial Guinea, \JGabon\j, \JSudan\j, Zaire and \JZambia\j.
Travellers to Central Africa may be exposed to potential diseases from a number of sources. The most frequently reported illness is traveller's diarrhoea, but there are other diseases which are unique to Africa or the tropics. These diseases are transmitted by insects, contaminated food and water or close contact with infected people. Specific diseases are discussed under each of these topical headings.
In order to reduce the risk of infection travellers must (1) protect themselves from insects, (2) ensure the quality of their food and drinking water, and (3) be knowledgeable about potential diseases in the region to be visited.
Finally, diseases are not restricted to cleanly defined geographical areas, i.e. mosquitoes can fly over city or country borders; therefore, all travellers should protect themselves by taking the basic preventive precautions.
\BDiseases Transmitted by Insects:\b see '\JMosquitoes and Other Arthropod Vectors, Protection Against\j'.
In \JAngola\j, \JCameroon\j, Central African Republic, Chad, \JCongo\j, Equatorial Guinea, \JGabon\j, \JSudan\j, Zaire and \JZambia\j, a high risk for \Jmalaria\j exists throughout the year in all parts of these countries, including the urban areas. The dominant form is \IP. falciparum\i (the most dangerous type), which has been reported to be resistant to the drug chloroquine.
Outbreaks of yellow fever have occurred in \JAngola\j, \JSudan\j and Zaire. Yellow fever is not always active in all countries of this region, but there is a significant risk to all travellers throughout the year, especially in travel or visits to rural settings. Travellers should check an up-to-date list of yellow fever-infected countries.
\BNote: some countries require yellow fever \Jvaccination\j for entry. \b(Yellow fever vaccine is the \Ionly\i vaccine that may be officially required for entry into certain countries.) In general, if you are travelling to a Central African country, the easiest and safest thing to do is to get a yellow fever \Jvaccination\j and a signed certificate at a designated yellow fever \Jvaccination\j centre.
Zambia has no yellow fever \Jvaccination\j requirements. Chad recommends but does not require yellow fever \Jvaccination\j. A certificate may be required when leaving \JSudan\j.
\BFive central African countries absolutely require a yellow fever \Jvaccination\j certificate:\b \JCameroon\j, Central African Republic, \JCongo\j, \JGabon\j and Zaire.
In addition, if you are travelling from one of the 'endemic' yellow fever-infected countries listed below to a Central African country, you are required to have a yellow fever \Jvaccination\j.
South America: \JBolivia\j, \JBrazil\j, \JColombia\j, \JEcuador\j, French Guiana, \JGuyana\j, Panama, \JPeru\j, Suriname, Venezuela.
\IYellow Fever Certificate:\i
After immunisation, an International Certificate of \JVaccination\j is issued and is valid 10 days after \Jvaccination\j to meet entry and exit requirements for all countries. The Certificate is good for 10 years. You must take the Certificate with you.
Travellers who for medical reasons cannot receive the yellow fever vaccine should obtain a medical waiver and check embassies or consulates for specific waiver requirements.
In addition to the vaccine, travellers should use measures to minimise exposure to mosquitoes and protect themselves from mosquito bites, especially during the evening hours (see '\JMosquitoes and Other Arthropod Vectors, Protection Against\j').
Dengue fever occurs sporadically in \JCameroon\j, \JCongo\j, \JGabon\j and Zaire, with epidemics most recently in \JAngola\j and \JSudan\j. The risk of infection is small for most travellers except during periods of epidemic transmission.
\IOther Insect Diseases:\i
Other diseases spread by mosquitoes, sand flies, black flies or other insects are prevalent, especially in rural areas. These diseases include: filariasis and Chikungunya (mosquito), \Jleishmaniasis\j (sand fly), onchocerciasis (black flies), African trypanosomiasis (flies), Congo-Crimean haemorrhagic fever (ticks), \Jtyphus\j (lice) and plague (fleas).
\BDiseases Transmitted Through Food and Water:\b see '\JFood and Drink, Risks to Traveller\j', and '\JTraveller's Diarrhoea\j'.
Food and waterborne diseases are the number one cause of illness to travellers and are very common in Central Africa.
Traveller's diarrhoea is the most frequent health problem for travellers. It can be caused by viruses, bacteria or parasites which are found universally throughout the region. Transmission is most often through contaminated food or water. Infections may cause diarrhoea and vomiting (typhoid fever, \Jcholera\j and parasites), liver damage (hepatitis) or muscle paralysis (polio).
Travellers to Central Africa are at risk for typhoid fever, especially when travelling to smaller cities, villages or rural areas.
The Centers For Disease Control and Prevention (CDC) recommends a typhoid \Jvaccination\j for those travellers who are going off the usual tourist itineraries, travelling to smaller cities and rural areas or staying for six weeks or more. Typhoid \Jvaccination\j is not required for international travel.
Cholera cases have been reported from most of the countries of Central Africa. Persons following the usual tourist itinerary who follow the food safety recommendations are at virtually no risk of infection.
\IHepatitis A\i [see '\JHepatitis, viral, type A (Travel Information)\j']
Travellers are at high risk for Hepatitis A, especially if travel plans include visiting rural areas and extensive travel in the countryside, frequent close contact with local persons or eating in settings of poor sanitation.
A study has shown that many cases of travel-related hepatitis A occur in travellers to developing countries with 'standard' itineraries, accommodations and food consumption behaviours. It is therefore recommended that travellers receive hepatitis A vaccine or IG for protection against hepatitis A. Strict food and water precautions are also recommended.
\IParasitic infections:\i
Travellers to Central Africa are at risk of parasitic infections. There are many types of parasites and infection may occur in several ways: by eating undercooked meats infected with parasites or their \Jlarva\j; by eating food or drinking water contaminated with parasites or their eggs; by contact with soil or water infected with parasites; or through insect bites.
Several types of parasites can penetrate intact skin and travellers are advised to wear shoes and avoid swimming, wading or washing in fresh water (see '\JSchistosomiasis (Travel Information)\j', and '\JSwimming Precautions When Abroad\j').
Travellers should eat only thoroughly cooked food, drink safe water, wear shoes, refrain from swimming in fresh water and avoid contact with insects, particularly mosquitoes, biting flies, gnats and midges.
\BDiseases Transmitted Through Intimate Contact with People:\b see '\JHIV Infection and AIDS, General Recommendations to Traveller\j', and '\JWHO Blood Transfusion Guidelines for International Travellers\j'.
HIV/AIDS is found throughout the world. The risk to a traveller depends on whether the traveller will be involved in sexual or needle-sharing contact with a person who is infected with \JHIV\j or receive unscreened blood for transfusion.
\IHepatitis B\i [see '\JHepatitis, viral, type B (Travel Information)\j']
Hepatitis B rates are high in Africa and the risk for acquiring disease is greater if the traveller has contact with blood or secretions containing blood, sex contact with an infected person or remains in the country for longer than six months and has close contact with the local population.
There is seasonal risk of meningococcal disease in parts of Central Africa, primarily during the dry season from December through June. When a traveller lives and works around the local population, the risk increases.
Vaccination is not required for entry into any country in this region. The Center For Disease Control and Prevention (CDC) recommends \Jvaccination\j with meningococcal vaccine for travellers going to Mali and all countries directly eastward, including \JCameroon\j, Central African Republic, Chad and \JSudan\j, when travel occurs between December and June.
Schistosomiasis infection is widespread in all Central African countries: \JAngola\j, \JCameroon\j, Central African Republic, Chad, \JCongo\j, Equatorial Guinea, \JGabon\j, \JSudan\j, Zaire and \JZambia\j . The risk is a function of the frequency and degree of contact with contaminated fresh water for bathing, wading or swimming.
Avoid contact with potentially contaminated water.
For countries in Central Africa, there is a risk of \Jrabies\j infection particularly in rural areas, or in urban areas where large numbers of dogs are found.
\B
\BSummary of Recommendations for Central Africa:\b
Travellers should:
(1) follow precautions to prevent insect bites;
(2) pay attention to the quality of their drinking water and food;
(3) have a dose of Immune \JGlobulin\j (IG) or the Hepatitis A vaccine; and
(4) consider booster doses of tetanus (Td) and polio (EIPV) vaccines.
(5) Depending on the locations to be visited, planned activities and health of the traveller, the following vaccines should be considered: Hepatitis B, Yellow Fever, Typhoid, Meningococcal, \JRabies\j (pre-exposure) and \JCholera\j.
(6) Finally, the normal 'childhood' vaccines should be up-to-date: \JMeasles\j, \JMumps\j, Rubella (MMR Vaccine); \JDiphtheria\j, Tetanus, \JPertussis\j (DTP Vaccine) [ < 7 years of age] and Polio vaccine.
#
"East Africa (Travel Health Tips)",31,0,0,0
\ICountries in this region:\i \JBurundi\j, \JComoros\j Island, Djibouti, Eritrea, \JEthiopia\j, \JKenya\j, Madagascar, Malawi, \JMauritius\j, \JMayotte\j, \JMozambique\j, Reunion, \JRwanda\j, \JSeychelles\j, \JSomalia\j, \JTanzania\j and \JUganda\j.
Travellers to East Africa may be exposed to potential diseases from a number of sources. The most frequently reported illness is traveller's diarrhoea, but there are other diseases which are unique to Africa or the tropics. These diseases are transmitted by insects, contaminated food and water or close contact with infected people. Specific diseases are discussed under each of these topical headings.
In order to reduce the risk of infection, travellers must 1) protect themselves from insects, 2) ensure the quality of their food and drinking water, and 3) be knowledgeable about potential diseases in the region to be visited.
Finally, diseases are not restricted to cleanly defined geographical areas, i.e. mosquitoes can fly over city or country borders; therefore, all travellers should protect themselves by taking the basic preventive precautions.
\BDiseases Transmitted by Insects:\b see '\JMosquitoes and Other Arthropod Vectors, Protection Against\j'.
In \JBurundi\j, \JComoros\j Island, Djibouti, Madagascar (especially coastal areas), Malawi, \JMayotte\j, \JMozambique\j, \JRwanda\j, \JSomalia\j, \JTanzania\j and \JUganda\j, a high risk for \Jmalaria\j exists throughout the year in all parts of these countries including the urban areas. The dominant form is\I P. falciparum\i (the most dangerous type), which has been reported to be resistant to the drug chloroquine.
Eritrea: all areas except no risk above 2000 metres. \JEthiopia\j: all areas except no risk in Addis Ababa and above 2000 metres. \JKenya\j: all areas (including game parks), except no risk in \JNairobi\j and above 2,500 metres. \JMauritius\j: risk in the rural areas only, except no risk on Rodriguez Island. Reunion and \JSeychelles\j: no risk.
In addition to using drugs to prevent \Jmalaria\j and treat a possible \Jmalaria\j attack, travellers should use measures to reduce exposure to malaria-carrying mosquitoes and protect themselves from mosquito bites, especially during the evening and night, from dusk to dawn.
Outbreaks of yellow fever have occurred in \JEthiopia\j and \JKenya\j. Yellow fever is not always active in all countries of this region, but there is a significant risk to all travellers throughout the year, especially in travel or visits to rural settings. There is no risk on the islands of \JComoros\j and \JSeychelles\j.
Travellers should check an up-to-date list of yellow fever-infected countries.
\BNote: some countries require yellow fever \Jvaccination\j for entry.\b (Yellow fever vaccine is the \Ionly \ivaccine that may be officially required for entry into certain countries.) In general, if you are travelling to an East African country, the easiest and safest thing to do is to get a yellow fever \Jvaccination\j and a signed certificate at a designated yellow fever \Jvaccination\j centre.
For most countries in East Africa, The Center For Disease Control and Prevention (CDC) recommends and many countries require a yellow fever \Jvaccination\j. However, \JComoros\j and \JMayotte\j do not require, nor does CDC recommend, yellow fever \Jvaccination\j.
\BPlease note: Travellers to \JRwanda\j absolutely require a yellow fever \Jvaccination\j certificate.\b
In addition, travellers to East Africa from the following 'endemic' yellow fever-infected countries are also required to have a yellow fever \Jvaccination\j certificate:
South America: \JBolivia\j, \JBrazil\j, \JColombia\j, \JEcuador\j, French Guiana, \JGuyana\j, Panama, \JPeru\j, Suriname, Venezuela.
Travellers from the above countries will require yellow fever \Jvaccination\j certificates to enter \JBurundi\j, Djibouti, Eritrea, \JEthiopia\j, \JKenya\j, Madagascar, Malawi, \JMauritius\j, \JMozambique\j, Reunion, \JSeychelles\j, \JSomalia\j, \JTanzania\j and \JUganda\j.
\IYellow Fever Certificate\i
After immunisation, an International Certificate of \JVaccination\j is issued and is valid 10 days after \Jvaccination\j to meet entry and exit requirements for all countries. The Certificate is good for 10 years. You must take the Certificate with you.
Travellers who have a medical reason not to receive the yellow fever vaccine should obtain a medical waiver and check embassies or consulates for specific waiver requirements.
In addition to the vaccine, travellers should use measures to reduce exposure to mosquitoes and protect themselves from mosquito bites. These mosquitoes bite mainly during the evening hours.
Dengue fever occurs sporadically in \JBurundi\j, Djibouti, Eritrea, \JEthiopia\j, \JKenya\j, Madagascar, Malawi, \JMauritius\j, \JMozambique\j, Reunion, \JRwanda\j, \JSeychelles\j, \JSomalia\j, \JTanzania\j and \JUganda\j, with epidemics most recently in Djibouti, \JKenya\j, \JMozambique\j and \JSomalia\j. The risk of infection is small for most travellers except during periods of epidemic transmission.
There is no vaccine for \Jdengue\j fever, therefore the traveller should avoid mosquito bites. These mosquitoes bite mainly in the daytime.
\IOther Insect Diseases:\i
Other diseases spread by mosquitoes, sand flies, black flies or other insects are prevalent, especially in rural areas. These diseases include: filariasis and Chikungunya (mosquito), \Jleishmaniasis\j (sandfly), Onchocerciasis (blackflies), African trypanosomiasis (flies), Congo-Crimean haemorrhagic fever (ticks), \Jtyphus\j (lice) and plague (fleas).
\BDiseases Transmitted Through Food and Water:\b see '\JFood and Drink, Risks to Traveller\j', and '\JTraveller's Diarrhoea\j'.
Food and waterborne diseases are the number one cause of illness to travellers and are very common in East Africa.
Traveller's diarrhoea is the most frequent health problem for travellers. It can be caused by viruses, bacteria or parasites which are found universally throughout the region. Transmission is most often through contaminated food or water. Infections cause diarrhoea and vomiting (typhoid fever, \Jcholera\j and parasites), liver damage (hepatitis) or muscle paralysis (polio).
Travellers to East Africa are at risk for typhoid fever, especially when travelling to smaller cities, villages or rural areas.
The Centers For Disease Control and Prevention (CDC) recommends a typhoid \Jvaccination\j for those travellers who are going off the usual tourist itineraries, travelling to smaller cities and rural areas, or staying for six weeks or more. Typhoid \Jvaccination\j is not required for international travel.
Cholera cases have been reported from most of the countries of East Africa. Persons following the usual tourist itinerary who follow the food safety recommendations are at virtually no risk of infection.
\IHepatitis A\i [see '\JHepatitis, viral, type A (Travel Information)\j']
Travellers are at high risk for Hepatitis A, especially if travel plans include visiting rural areas and extensive travel in the countryside, frequent close contact with local persons or eating in settings of poor sanitation.
A study has shown that many cases of travel-related hepatitis A occur in travellers to developing countries with 'standard' itineraries, accommodations and food consumption behaviours.
It is therefore recommended that travellers receive hepatitis A vaccine or IG for protection against hepatitis A. Strict food and water precautions are also recommended.
\IParasitic infections:\i
Travellers to East Africa are at risk of parasitic infections. There are many types of parasites and infection may occur in several ways: by eating undercooked meats infected with parasites or their \Jlarva\j; by eating food or drinking water contaminated with parasites or their eggs; by contact with soil or water infected with parasites; or through insect bites.
Several types of parasites can penetrate intact skin and travellers are advised to wear shoes and avoid swimming, wading or washing in fresh water [see '\JSchistosomiasis (Travel Information)\j', '\JSwimming Precautions When Abroad\j']
Travellers should eat only thoroughly cooked food, drink safe water, wear shoes, refrain from swimming in fresh water and avoid contact with insects, particularly mosquitoes, biting flies, gnats and midges.
\BDiseases Transmitted Through Intimate Contact with People:\b see '\JHIV Infection and AIDS, General Recommendations to Traveller\j', and '\JWHO Blood Transfusion Guidelines for International Travellers\j'.
HIV/AIDS is found throughout the world. The risk to a traveller depends on whether the traveller will be involved in sexual or needle-sharing contact with a person who is infected with \JHIV\j or receive unscreened blood for transfusion.
\IHepatitis B\i [see '\JHepatitis, viral, type B (Travel Information)\j']
Hepatitis B rates are high in Africa and the risk for acquiring disease is greater if the traveller has contact with blood or secretions containing blood, sex contact with an infected person or remains in the country for longer than six months and has close contact with the local population.
There is seasonal risk of meningococcal disease in parts of East Africa, primarily during the dry season from December through June. However, there is year-round risk in \JKenya\j, \JTanzania\j and \JBurundi\j. When a traveller lives and works around the local population, the risk increases.
Vaccination is not required for entry into any country in this region. When travel occurs between December and June, the Centers For Disease Control and Prevention (CDC) recommends \Jvaccination\j with meningococcal vaccine for travellers going to Mali (West Africa) and all countries directly eastward, including Eritrea, \JEthiopia\j and Northern \JSomalia\j.
Vaccination is recommended year-round for all travellers to \JKenya\j, \JTanzania\j and \JBurundi\j because of potential risk.
\BUpdate: meningococcal disease\b
Epidemic meningococcal disease has been reported in April through October in 1989 in \JNairobi\j, \JKenya\j and the Arusha area of northern \JTanzania\j. Control measures have been instituted and the number of reported cases appears to be decreasing. There have been no reports of meningococcal disease in travellers.
Epidemic meningococcal meningitis is also reported in \JBurundi\j and central and southern \JTanzania\j. Since July 1992, over 2,500 cases of meningococcal meningitis were reported in \JBurundi\j. Over 4,500 cases were also reported in \JTanzania\j during the same time period. Mortality is approximately 10%.
The epidemic is ongoing, but the number of reported cases appears to be declining. There are no reports of meningococcal disease in travellers.
The occurrence of meningococcal disease in \JBurundi\j and \JTanzania\j represents continuation of epidemic disease that started in 1991 and 1989, respectively. These outbreaks are caused by serogroup A \INeisseria\i \Imeningitidis,\i possibly the same strain responsible for major epidemics in \JNepal\j (1983-84), Saudi \JArabia\j (1987) and Chad (1988).
The Centers for Disease Control (CDC), USA, recommend that travellers to \JTanzania\j and \JBurundi\j receive the meningococcal polysaccharide vaccine.
Schistosomiasis infection is widespread in all East African countries: \JBurundi\j, Eritrea, \JEthiopia\j, \JKenya\j, Madagascar, Malawi, \JMauritius\j, \JMozambique\j, \JRwanda\j, \JSomalia\j, \JTanzania\j (including the islands) and \JUganda\j. Little or no information is available for \JComoros\j Island, Djibouti, \JMayotte\j, Reunion and \JSeychelles\j.
The risk is a function of the frequency and degree of contact with contaminated fresh water for bathing, wading or swimming. Avoid contact with potentially contaminated water.
For countries in East Africa, there is a risk of \Jrabies\j infection particularly in rural areas or in areas where large numbers of dogs are found. \JMauritius\j and the \JSeychelles\j have reported no \Jrabies\j cases for at least the past two years.
\BSummary of Recommendations for East Africa:\b
Travellers should:
(1) follow precautions to prevent insect bites;
(2) pay attention to the quality of their drinking water and food;
(3) have a dose of Immune \JGlobulin\j (IG) or Hepatitis A vaccine; and
(4) consider booster doses of tetanus (Td) and polio (EIPV) vaccines.
(5) Depending on the locations to be visited, planned activities and health of the traveller, the following vaccines should be considered: Hepatitis B, Yellow Fever, Typhoid, Meningococcal, \JRabies\j (pre-exposure) and \JCholera\j. Details for these recommendations are found in this document.
(6) Finally, the normal 'childhood' vaccines should be up-to-date: \JMeasles\j, \JMumps\j, Rubella (MMR Vaccine); \JDiphtheria\j, Tetanus, \JPertussis\j (DTP Vaccine) [ < 7 years of age] and Polio vaccine.
#
"East Asia (Travel Health Tips)",32,0,0,0
(Date last rev'd: 7 November 1996)
\ICountries in this region:\i China, Hong Kong, \JJapan\j, Democratic People's Republic of Korea (North), Republic of Korea (South), \JMacao\j, \JMongolia\j, \JTaiwan\j.
Travellers to East Asia may be exposed to potential diseases from a number of sources. The most frequently reported illness is traveller's diarrhoea, but there are other diseases which are unique to East Asia or the tropics. These diseases are transmitted by insects, contaminated food and water or close contact with infected people. Specific diseases are discussed under each of these topical headings.
In order to reduce the risk of infection travellers must (1) protect themselves from insects, (2) ensure the quality of their food and drinking water, and (3) be knowledgeable about potential diseases in the region to be visited.
Finally, diseases are not restricted to cleanly defined geographical areas, i.e. mosquitoes can fly over city or country borders; therefore, all travellers should protect themselves by taking the basic preventive precautions.
\BDiseases Transmitted by Insects:\b see '\JMosquitoes and Other Arthropod Vectors, Protection Against\j'.
China: Travellers visiting cities and popular rural sites on usual tourist routes are generally not at risk, and taking drugs to prevent \Jmalaria\j is therefore not recommended. \JMalaria\j risk is found in rural areas only, except no risk in provinces bordering \JMongolia\j and in the western provinces of Heilungkiang, Kirin, Ningsia Hui \JTibet\j and Tsinghai.
North of 33░N latitude, transmission occurs between July and November; in the region between 33░N and 25░N latitude, transmission occurs from May to December; in the region south of 25░N latitude, transmission occurs year-round.
In Hong Kong, \JJapan\j, North Korea, South Korea, \JMacao\j, \JMongolia\j and \JTaiwan\j, there is no risk of \Jmalaria\j.
Since \Jmalaria\j transmission in China is largely confined to the rural areas not visited by most travellers, taking drugs to prevent \Jmalaria\j is only recommended for travellers who will have outdoor exposure during evening and night-time hours in rural areas.
Travellers to China at risk of \Jmalaria\j should seek advice from their medical practitioner on the proper drugs and dosage required to prevent \Jmalaria\j transmission.
Travellers to southern China, Hainan Island and provinces bordering Laos, \JMyanmar\j (Burma) and Vietnam should also consult a physician on the necessary precautions.
In addition to using drugs to prevent \Jmalaria\j, travellers should use measures to reduce exposure to malaria-carrying mosquitoes and protect themselves from mosquito bites. These mosquitoes bite mainly during the evening and night, from dusk to dawn.
Dengue fever occurs in parts of southern China and \JTaiwan\j. The risk of infection is small for most travellers except during periods of epidemic transmission.
\IJapanese \JEncephalitis\j \i[see '\JEncephalitis, Japanese (Travel Information)\j']
Transmission is usually seasonal (associated with the rainy season). There is a risk for travellers to rural areas of Asian countries. In all areas, Japanese \Jencephalitis\j is primarily a rural disease.
The chance that a traveller to Asia will develop Japanese \Jencephalitis\j is extremely small, except for persons who plan long-term residence in rural areas. Travellers who visit rural farming areas for 4 weeks or more during the transmission season should consider immunisation.
Travellers who remain unimmunised should wear mosquito repellents, sleep under bednets and bring insecticidal sprays to use in their sleeping quarters.
Even though there is no risk of becoming infected with yellow fever while travelling in East Asian countries, a number of these countries \Irequire\i a yellow fever \Jvaccination\j if a traveller is coming from areas in Africa and South America where yellow fever is found.
If not required (e.g. for those \Ionly \itravelling from the United States to an East Asian country), it is not recommended to have a yellow fever \Jvaccination\j. However, if your travel plans include travelling to or from a country in Africa or South America, you may be required to have a yellow fever \Jvaccination\j. Travellers should contact embassies or consulates for advice.
\IOther Insect Diseases:\i
Other diseases spread by mosquitoes, sand flies, black flies or other insects are prevalent, especially in rural areas. These diseases include: filariasis (mosquito), \Jleishmaniasis\j (sand fly), Congo-Crimean haemorrhagic fever (tick), \Jtyphus\j (lice) and plague (fleas).
\BDiseases Transmitted Through Food and Water:\b see '\JFood and Drink, Risks to Traveller\j', and '\JTraveller's Diarrhoea\j'.
Food and waterborne diseases are the number one cause of illness to travellers and are very common in East Asia.
Traveller's diarrhoea is the most frequent health problem for travellers. It can be caused by viruses, bacteria or parasites which are found universally throughout the region. Transmission is most often through contaminated food or water. Infections may cause diarrhoea and vomiting (typhoid fever, \Jcholera\j and parasites), liver damage (hepatitis) or muscle paralysis (polio).
Travellers to East Asia are at risk for typhoid fever, especially when travelling to smaller cities, villages or rural areas. Typhoid fever is rare in \JJapan\j.
The Centers For Disease Control and Prevention (CDC) recommends \Jvaccination\j for those travellers who are going off the usual tourist itineraries, travelling to smaller cities and rural areas or staying for six weeks or more. Typhoid \Jvaccination\j is not required for international travel.
Cholera cases have been reported from some countries of East Asia. Persons following the usual tourist itinerary who follow the food safety recommendations are at virtually no risk of infection.
\IHepatitis A \i[see '\JHepatitis, viral, type A (Travel Information)\j']
Travellers are at high risk for Hepatitis A (except travellers to Japan), especially if travel plans include visiting rural areas and extensive travel in the countryside, frequent close contact with local persons or eating in settings of poor sanitation.
A study has shown that many cases of travel-related hepatitis A occur in travellers to developing countries with 'standard' itineraries, accommodations and food consumption behaviours. It is therefore recommended that travellers receive hepatitis A vaccine or IG for protection against hepatitis A. Strict food and water precautions are also recommended.
\IParasitic infections:\i
Travellers to East Asia are at risk of parasitic infections. There are many types of parasites and infection may occur in several ways: by eating undercooked meats infected with parasites or their \Jlarva\j; by eating food or drinking water contaminated with parasites or their eggs; by contact with soil or water infected with parasites; or through insect bites.
Several types of parasites can penetrate intact skin and travellers are advised to wear shoes and avoid swimming, wading or washing in fresh water (see '\JSchistosomiasis (Travel Information)\j' and '\JSwimming Precautions When Abroad\j').
Travellers should eat only thoroughly cooked food, drink safe water, wear shoes, refrain from swimming in fresh water and avoid contact with insects, particularly mosquitoes, biting flies, gnats and midges.
\BDiseases Transmitted Through Intimate Contact with People:\b see '\JHIV Infection and AIDS, General Recommendations to Traveller\j' and '\JWHO Blood Transfusion Guidelines for International Travellers\j'.
HIV/AIDS is found throughout the world. The risk to a traveller depends on whether the traveller will be involved in sexual or needle-sharing contact with a person who is infected with \JHIV\j or receive unscreened blood for transfusion.
\IHepatitis B\i [see '\JHepatitis, viral, type B (Travel Information)\j']
Hepatitis B rates are high in China and the risk for acquiring disease is greater if the traveller has contact with blood or secretions containing blood, sex contact with an infected person or remains in the country for longer than six months and has close contact with the local population.
Schistosomiasis infection is found in some parts of China, including many rivers and lakes of southeastern and eastern China along the valley of Chang Jiang (Yangtze) river and its tributaries. The risk is a function of the frequency and degree of contact with contaminated fresh water for bathing, wading or swimming. Avoid contact with potentially contaminated water.
For some countries in East Asia, there is a risk of \Jrabies\j infection particularly in rural areas, or in urban areas where large numbers of dogs are found. There is no risk in \JJapan\j or \JTaiwan\j.
\BSummary of Recommendations for East Asia:\b
Travellers should:
(1) take the appropriate country-specific \Jmalaria\j prevention;
(2) follow precautions to prevent insect bites;
(3) pay attention to the quality of their drinking water and food;
(4) have a dose of Immune \JGlobulin\j (IG) or the Hepatitis A vaccine (except for travel to Japan); and
(5) consider booster doses of tetanus (Td) and polio (eIPV) vaccines.
(6) Depending on the locations to be visited, planned activities and health of the traveller, the following vaccines should be considered: Japanese \JEncephalitis\j, Hepatitis B, \JRabies\j (pre-exposure), Typhoid and \JCholera\j. Details for these recommendations are found in this document.
(7) Finally, the normal 'childhood' vaccines should be up-to-date: \JMeasles\j, \JMumps\j, Rubella (MMR Vaccine); \JDiphtheria\j, Tetanus, \JPertussis\j (DTP Vaccine) [ < 7 years of age] and Polio vaccine.
#
"Eastern Europe and the New Independent States of the Former Soviet Union (NIS) (Travel Health Tips)",33,0,0,0
Travellers to Eastern Europe and the NIS may be exposed to potential diseases from a number of sources. The most frequently reported illness is traveller's diarrhoea, but there are other diseases transmitted by insects, contaminated food and water or close contact with infected people. Specific diseases are discussed under each of these topical headings.
In order to reduce the risk of infection travellers must (1) protect themselves from insects, (2) ensure the quality of their food and drinking water, and (3) be knowledgeable about potential diseases in the region to be visited.
Finally, diseases are not restricted to cleanly defined geographical areas, i.e. mosquitoes can fly over city or country borders; therefore, all travellers should protect themselves by taking the basic preventive precautions.
\BPlease note:\b An outbreak of \Jdiphtheria\j is occurring in all the New Independent States of the former Soviet Union. Travellers should have their \Jdiphtheria\j immunisation up-to-date.
\BDiseases Transmitted by Insects:\b see '\JMosquitoes and Other Arthropod Vectors, Protection Against\j'.
In \JAzerbaijan\j and Tajikistan, the risk of \Jmalaria\j infection exists in some very small southern border areas. There is no risk of \Jmalaria\j in the other countries of this region.
The risk to travellers who do not visit or work in forested areas and who avoid unpasteurised dairy products is apparently low.
Tickborne \Jencephalitis\j occurs chiefly in Central and Eastern Europe, including the countries of the former Soviet Union. It is of particular importance in \JHungary\j, \JPoland\j, the countries of the former \JCzechoslovakia\j, Soviet Union and Yugoslavia. Tickborne \Jencephalitis\j is found less frequently in \JBulgaria\j and \JRomania\j.
Transmission occurs in the summer months. Travellers are at risk if their plans include hiking, camping or working in or around forested regions. The chance that a traveller to Eastern Europe and the NIS will develop tickborne \Jencephalitis\j is very small.
Travellers visiting eastern Europe and the NIS countries who will be hiking, camping or visiting wooded parks and rural areas are at risk of lyme disease. Travellers should therefore take precautions to prevent tick bites.
Even though there is no risk of becoming infected while travelling in the East European and the NIS countries, a number of these countries \Irequire \ia yellow fever \Jvaccination\j if a traveller is coming from areas in Africa and South America where yellow fever is found.
If not required (e.g. for those \Bonly\b\I \itravelling from the United States to an East European country), it is not recommended to have a yellow fever \Jvaccination\j. However, if your travel plans include travelling to or from a country in Africa or South America, you may be required to have a yellow fever \Jvaccination\j. Travellers should contact embassies or consulates for advice.
\BDiseases Transmitted Through Food and Water:\b see '\JFood and Drink, Risks to Traveller\j', and '\JTraveller's Diarrhoea\j'.
Food and waterborne diseases are the number one cause of illness to travellers and are very common in Eastern Europe and the New Independent States.
Traveller's diarrhoea is the most frequent health problem for travellers. It can be caused by viruses, bacteria or parasites which are found universally throughout the region. Transmission is most often through contaminated food or water. Infections may cause diarrhoea and vomiting (typhoid fever, \Jcholera\j and parasites), liver damage (hepatitis) or muscle paralysis (polio).
Travellers to Eastern Europe and the New Independent States are at risk for typhoid fever, especially when travelling to smaller cities, villages or rural areas.
The Centers For Disease Control and Prevention (CDC) recommends a typhoid \Jvaccination\j for those travellers who are going off the usual tourist itineraries, travelling to smaller cities and rural areas or staying for six weeks or more. Typhoid \Jvaccination\j is not required for international travel.
\IHepatitis A\i [see 'Hepatitis, viral, type A (Travel Information)\j']
In general, travellers to Northern Europe and Western Europe are \Inot\i at risk for hepatitis A. However, increased risk does exist in Eastern Europe, where there are intermediate rates of hepatitis A. Risk is even greater if travel plans include visiting rural areas and extensive travel in the countryside, frequent close contact with local persons or eating in settings of poor sanitation.
A study has shown that many cases of travel-related hepatitis A occur in travellers to developing countries with 'standard' itineraries, accommodations and food consumption behaviours. It is therefore recommended that travellers receive hepatitis A vaccine or IG for protection against hepatitis A. Strict food and water precautions are also recommended.
Cholera cases have been reported from some of the countries of Eastern Europe and the NIS. Persons following the usual tourist itinerary who follow the food safety recommendations are at virtually no risk of infection.
\IParasitic infections:\i
Travellers to Eastern Europe are at risk of parasitic infections. There are many types of parasites and infection may occur in several ways: by eating undercooked meats infected with parasites or their \Jlarva\j; by eating food or drinking water contaminated with parasites or their eggs; or through insect bites (see '\JSwimming Precautions When Abroad\j').
Travellers should eat only thoroughly cooked food, drink safe water, wear shoes and avoid contact with insects, particularly mosquitoes, biting flies, gnats and midges.
\BDiseases Transmitted Through Intimate Contact with People:\b see '\JHIV Infection and AIDS, General Recommendations to Traveller\j', and '\JWHO Blood Transfusion Guidelines for International Travellers\j'.
HIV/AIDS is found throughout the world. The risk to a traveller depends on whether the traveller will be involved in sexual or needle-sharing contact with a person who is infected with \JHIV\j or receive unscreened blood for transfusion.
\IHepatitis B\i [see '\JHepatitis, viral, type B (Travel Information)\j']
Hepatitis B rates are intermediate in Eastern Europe and the NIS. The risk for acquiring disease is greater if the traveller has contact with blood or secretions containing blood, sex contact with an infected person or remains in the country for longer than six months and has close contact with the local population.
For most countries in Eastern Europe, there is a risk of \Jrabies\j infection, particularly in rural areas or in urban areas where large numbers of foxes or dogs are found.
\BUpdate: Diphtheria\b
A diphtheria epidemic began in 1990 in \JRussia\j, spread in 1991 to the \JUkraine\j, and during 1993 and 1994 spread to the remaining New Independent States of the former Soviet Union. During 1994, provisional totals of 47,802 cases (39,907 in Russia) and 1,746 deaths due to \Jdiphtheria\j were reported throughout the New Independent States.
Diphtheria incidence rates in several Caucasian and Central Asian republics now exceed the rate recorded in the \JUkraine\j. There is a risk of \Jdiphtheria\j infection in all countries of the former Soviet Union. Cases are occurring predominantly in urban areas, but increasing numbers are being reported from rural areas. Two cases of \Jdiphtheria\j in American citizens? one visiting Moscow, \JRussia\j, and the other working in southern Ukraine? were recently reported.
Shortages of vaccine, \Jantibiotics\j and \Jdiphtheria\j antitoxin are occurring in most countries except \JRussia\j.
Proof of \Jdiphtheria\j immunity is not required for international travel. However, it is recommended that travellers to areas where \Jdiphtheria\j is occurring should be up-to-date for \Jdiphtheria\j immunisation.
\BUpdate: Polio\b
During 17 April-16 September 1996, an ongoing outbreak of paralytic \Jpoliomyelitis\j in \JAlbania\j resulted in 66 cases of acute flaccid paralysis (AFP), including seven (11%) deaths. Wild poliovirus type 1 was isolated from seven cases.
Cases have been reported from 18 of 37 districts, primarily in the northern and central parts of the country; no cases have been reported from the southernmost districts.
Travellers to \JAlbania\j who have received a primary series of polio vaccine should receive a booster dose before departure. Travellers who are inadequately vaccinated against polio or whose past \Jvaccination\j history is uncertain should contact their physician to discuss polio \Jvaccination\j options before leaving for \JAlbania\j.
\BSummary of Recommendations for Eastern Europe:\b
Travellers should:
(1) follow precautions to prevent insect bites;
(2) pay attention to the quality of their drinking water and food
(3) have a dose of Immune \JGlobulin\j (IG) or the Hepatitis A vaccine; and
(4) consider booster doses of tetanus (Td) and polio (eIPV) vaccines.
(5) Depending on the locations to be visited, planned activities and health of the traveller, the following vaccines should be considered: Hepatitis B, \JRabies\j (pre-exposure) and Typhoid. Details for these recommendations are found in this document. Finally, the normal 'childhood' vaccines should be up-to-date: \JMeasles\j, \JMumps\j, Rubella (MMR Vaccine); \JDiphtheria\j, Tetanus, \JPertussis\j (DTP Vaccine) [ < 7 years of age] and Polio vaccine.
#
"Indian Subcontinent (Travel Health Tips)",34,0,0,0
(Date last rev'd: 7 November 1996)
\ICountries in this region:\i \JAfghanistan\j, \JBangladesh\j, \JBhutan\j, India, \JMaldives\j, \JNepal\j, \JPakistan\j, Sri Lanka.
Travellers to the Indian subcontinent may be exposed to potential diseases from a number of sources. The most frequently reported illness is traveller's diarrhoea, but there are other diseases which are unique to this area or the tropics.
The Indian subcontinent contains a variety of diseases transmitted by insects, contaminated food and water or close contact with infected people. Specific diseases are discussed under each of these topical headings.
In order to reduce the risk of infection travellers must (1) protect themselves from insects, (2) ensure the quality of their food and drinking water, and (3) be knowledgeable about potential diseases in the region to be visited.
Finally, diseases are not restricted to cleanly defined geographical areas, i.e. mosquitoes can fly over city or country borders; therefore, all travellers should protect themselves by taking the basic preventive precautions.
\BDiseases Transmitted by Insects:\b see '\JMosquitoes and Other Arthropod Vectors, Protection Against\j'.
The risk of a \Jmalaria\j infection is relatively low for most travellers to the Indian subcontinent. However, \IP. falciparum\i (the most dangerous type) is present in all countries (except Maldives) and has been reported to be resistant to the drug chloroquine.
Afghanistan: all areas; \JBangladesh\j: all areas, except no risk in the city of \JDhaka\j; \JBhutan\j: rural areas in districts bordering India; India: all areas, except no risk in parts of the States of Himechel, Pradesh, Jammu, Kashmir and \JSikkim\j; \JNepal\j: in Terai and Hill Districts below 1200 metres (3900 feet), no risk in Katmandu; \JPakistan\j: all areas; Sri Lanka: \Jmalaria\j risk in all areas except Colombo, Kalutara and Nuwara Eliya; \JMaldives\j: no risk of \Jmalaria\j.
Travellers at risk for \Jmalaria\j should consult a physician on the necessary precautions.
In addition to using drugs to prevent \Jmalaria\j, travellers should use measures to reduce exposure to malaria-carrying mosquitoes and protect themselves from mosquito bites. These mosquitoes bite mainly during the evening and night, from dusk to dawn.
Dengue fever occurs sporadically in parts of \JBangladesh\j, India, \JMaldives\j and Sri Lanka. Recently Sri Lanka has reported increased activity. The risk of infection is small for most travellers except during periods of epidemic transmission.
\IJapanese Encephalitis\i [see '\JEncephalitis, Japanese (Travel Information)\j']
Transmission is usually seasonal (associated with the rainy season). There is a risk for travellers to rural areas including \JBangladesh\j, India, southern \JNepal\j and Sri Lanka. In all areas, Japanese \Jencephalitis\j is primarily a rural disease. The chance that a traveller to Asia will develop Japanese \Jencephalitis\j is probably very small.
Vaccination should be considered for persons who plan long-term residence in rural areas. Travellers who visit rural farming areas for 3 weeks or more during the transmission season should consider immunisation. Travellers who remain unimmunised should wear mosquito repellents, sleep under bednets and bring insecticidal sprays to use in their sleeping quarters.
Even though there is no risk of becoming infected while travelling in countries in the Indian subcontinent, a number of these countries \Irequire\i a yellow fever \Jvaccination\j if a traveller is coming from areas in Africa and South America where yellow fever is found.
If not required (e.g. for those\B only\b\I \itravelling from the United States to a country in the Indian subcontinent), it is not recommended to have a yellow fever \Jvaccination\j. However, if your travel plans include travelling to or from a country in Africa or South America, you may be required to have a yellow fever \Jvaccination\j. Travellers should contact embassies or consulates for advice.
\IOther Insect Diseases:\i
Other diseases spread by mosquitoes, sand flies, black flies or other insects are prevalent, especially in rural areas. These diseases include: filariasis and Chikungunya (mosquito), \Jleishmaniasis\j (sand fly), Congo-Crimean haemorrhagic fever (tick), \Jtyphus\j (lice) and plague (fleas).
\BDiseases Transmitted Through Food and Water:\b see '\JFood and Drink, Risks to Traveller\j', and '\JTraveller's Diarrhoea\j'.
Food and waterborne diseases are the number one cause of illness to travellers and are very common in the Indian subcontinent.
Traveller's diarrhoea is the most frequent health problem for travellers. It can be caused by viruses, bacteria or parasites which are found universally throughout the region. Transmission is most often through contaminated food or water. Infections may cause diarrhoea and vomiting (typhoid fever, \Jcholera\j and parasites), liver damage (hepatitis) or muscle paralysis (polio).
Travellers to the Indian subcontinent are at increased risk for typhoid fever, especially when travelling to smaller cities, villages or rural areas.
The Centers For Disease Control and Prevention (CDC) recommends a typhoid \Jvaccination\j for those travellers who are going off the usual tourist itineraries, travelling to smaller cities and rural areas or staying for six weeks or more. Typhoid \Jvaccination\j is not required for international travel.
Cholera cases have been reported from most of the countries of the Indian subcontinent. Persons following the usual tourist itinerary who follow the food safety recommendations are at virtually no risk of infection.
\IHepatitis A\i [see '\JHepatitis, viral, type A (Travel Information)\j']
Travellers are at high risk for Hepatitis A, especially if travel plans include visiting rural areas and extensive travel in the countryside, frequent close contact with local persons or eating in settings of poor sanitation.
A study has shown that many cases of travel-related hepatitis A occur in travellers to developing countries with 'standard' itineraries, accommodations and food consumption behaviours.
It is therefore recommended that travellers receive hepatitis A vaccine or IG for protection against hepatitis A. Strict food and water precautions are also recommended.
\IParasitic infections:\i
Travellers to the Indian subcontinent are at risk of parasitic infections. There are many types of parasites and infection may occur in several ways: by eating undercooked meats infected with parasites or their \Jlarva\j; by eating food or drinking water contaminated with parasites or their eggs; by contact with soil or water-infected with parasites; or through insect bites.
Several types of parasites can penetrate intact skin and travellers are advised to wear shoes (see '\JSchistosomiasis (Travel Information)\j', and '\JSwimming Precautions When Abroad\j').
Travellers should eat only thoroughly cooked food, drink safe water, wear shoes and avoid contact with insects, particularly mosquitoes, biting flies, gnats and midges.
\BDiseases Transmitted Through Intimate Contact with People:\b see '\JHIV Infection and AIDS, General Recommendations to Traveller\j', and '\JWHO Blood Transfusion Guidelines for International Travellers\j'.
HIV/AIDS is found throughout the world. The risk to a traveller depends on whether the traveller will be involved in sexual or needle-sharing contact with a person who is infected with \JHIV\j or receive unscreened blood for transfusion.
\IHepatitis B\i [see '\JHepatitis, viral, type B (Travel Information)\j']
Hepatitis B rates are high in the Indian region and the risk for acquiring disease is greater if the traveller has contact with blood or secretions containing blood, sex contact with an infected person or remains in the country for longer than six months and has close contact with the local population.
There is a year-round risk of meningococcal disease in parts of the Indian subcontinent, primarily in India and \JNepal\j. When a traveller lives and works around the local population, the risk increases.
The Centers For Disease Control and Prevention (CDC) recommends \Jvaccination\j with meningococcal vaccine for travellers going to \JNepal\j and the Delhi region of India.
For countries in the Indian subcontinent, there is a risk of \Jrabies\j infection particularly in rural areas, or in urban areas where large numbers of dogs are found. \JRabies\j is not reported in the \JMaldives\j.
\BSummary of Recommendations for the Indian Subcontinent:\b
Travellers should:
(1) follow precautions to prevent insect bites;
(2) pay attention to the quality of their drinking water and food;
(3) have a dose of Immune \JGlobulin\j (IG) or the Hepatitis A vaccine; and
(4) consider booster doses of tetanus (Td) and polio (eIPV) vaccines.
(5) Depending on the locations to be visited, planned activities and health of the traveller, the following vaccines should be considered: Hepatitis B, Japanese \JEncephalitis\j, Typhoid, Meningococcal, \JRabies\j (pre-exposure) and \JCholera\j. Details for these recommendations are found in this document.
(6) Finally, the normal 'childhood' vaccines should be up-to-date: \JMeasles\j, \JMumps\j, Rubella (MMR Vaccine); \JDiphtheria\j, Tetanus, \JPertussis\j (DTP Vaccine) [ < 7 years of age]; and Polio vaccine.
#
"Mexico and Central America (Travel Health Tips)",35,0,0,0
(Date last rev'd: 7 November 1996)
\ICountries in this region:\i \JBelize\j, Costa Rica, El Salvador, \JGuatemala\j, \JHonduras\j, Mexico, \JNicaragua\j, Panama.
Travellers to Central America may be exposed to potential diseases from a number of sources. The most frequently reported illness is traveller's diarrhoea, but there are other diseases which are unique to Central America or the tropics. These diseases are transmitted by insects, contaminated food and water, or close contact with infected people. Specific diseases are discussed under each of these topical headings.
In order to reduce the risk of infection travellers must (1) protect themselves from insects, (2) ensure the quality of their food and drinking water, and (3) be knowledgeable about potential diseases in the region to be visited.
Finally, diseases are not restricted to cleanly defined geographical areas, i.e. mosquitoes can fly over city or country borders; therefore, all travellers should protect themselves by taking the basic preventive precautions.
\BDiseases Transmitted by Insects:\b see '\JMosquitoes and Other Arthropod Vectors, Protection Against\j'.
Malaria exists throughout the year in many parts of the Central American countries, including some urban areas.
Belize: risk in the rural areas (including forest preserves and offshore islands, including the resort areas), except no risk in the central coastal District of \JBelize\j; Costa Rica: limited risk in the rural areas, except no risk in the central highlands (Cartago and San Jose Provinces); El Salvador: risk in the rural areas only; \JGuatemala\j: risk in the rural areas only, no risk in the central highlands; \JHonduras\j: risk in rural areas only; Mexico: risk exists in some rural areas of the following states: Oaxaca, Chiapas, Guerrero, Campeche, Quintana Roo, Sinaloa, Michoacan, Nayarit, Colima and Tabasco. Travellers to the major resort areas on the Mexican Gulf and Pacific coasts need no drugs for \Jmalaria\j prevention. \JNicaragua\j: risk in rural areas only; however, risk exists in outskirts of Chinandega, \JGranada\j, Leon, \JManagua\j, Nandaime and Tipitapa towns; Panama: risk in rural areas of the eastern provinces (Darien and San Blas) and the northwestern provinces (Boca del Toro and Veraguas), and around the Lake Boyana and Lake Gatun areas.
There is no risk in the Canal Zone, Panama City or surrounding vicinity.
Most travellers to Central America who are at risk for \Jmalaria\j should take \Ichloroquine\i to prevent \Jmalaria\j. No other anti-malarial drugs are needed.
Travellers to Panama who will be visiting locations of \Jmalaria\j risk \Bwest\b\I \iof the Canal Zone, Panama \Beast\b of the Canal Zone and to the San Blas Islands, should consult their medical practitioner for advice on the most effective anti-malaria drugs.
In addition to using drugs to prevent \Jmalaria\j, travellers should use measures to reduce exposure to malaria-carrying mosquitoes and protect themselves from mosquito bites. These mosquitoes bite mainly during the evening and night, from dusk to dawn.
Cases of yellow fever are rare for Central American countries (Panama was the last to report a case). Travellers should check an up-to-date list of yellow fever-infected countries.
\BNote: some countries require yellow fever \Jvaccination\j for entry.\b (Yellow fever vaccine is the \Ionly\i vaccine that may be officially required for entry into certain countries.) In general, if you are travelling to an area of risk, the easiest and safest thing to do is to get a yellow fever \Jvaccination\j and a signed certificate. This vaccine is only administered at designated yellow fever centres.
\BPlease note:\b The Centers For Disease Control and Prevention (CDC) recommends a yellow fever vaccination\I only\i if you are travelling to areas of risk (Darien Province in Panama, tropical South America or Africa).
In addition to the vaccine, travellers should use measures to reduce exposure to mosquitoes and protect themselves from mosquito bites. These mosquitoes bite mainly during the evening and morning hours.
\IRequirements:\i
Costa Rica has no yellow fever \Jvaccination\j requirements.
Belize, El Salvador (for travellers over age 6 months), \JGuatemala\j, \JHonduras\j, Mexico (age 6 months) and \JNicaragua\j require a yellow fever \Jvaccination\j for all travellers (age >1 unless otherwise indicated) arriving from all 'infected countries'.
Countries where yellow fever infection occurs are found in tropical South America and East, West and Central Africa. Travellers should check an up-to-date list of yellow fever-infected countries.
\IYellow Fever Certificate\i
After immunisation, an International Certificate of \JVaccination\j is issued and is valid 10 days after \Jvaccination\j to meet entry and exit requirements for all countries. The Certificate is good for 10 years. You must take the Certificate with you.
Travellers who have a medical reason not to receive the yellow fever vaccine should obtain a medical waiver and check embassies or consulates for specific waiver requirements.
In 1995, \Jdengue\j fever occurred in all countries from Mexico through Panama. The risk of infection is small for most travellers except during periods of epidemic transmission. However, every care should be taken to prevent mosquito bites.
\IOther Insect Diseases:\i
Other diseases spread by mosquitoes, sand flies, black flies or other insects are prevalent, especially in rural areas. These diseases include: filariasis (mosquito), \Jleishmaniasis\j (sand fly), onchocerciasis (black flies), American trypanosomiasis or Chagas' disease ('cone nose' or 'kissing' bug), Oropouche virus (gnats or midges), \Jtyphus\j (lice) and plague (fleas).
\BDiseases Transmitted Through Food and Water:\b see '\JFood and Drink, Risks to Traveller\j', and '\JTraveller's Diarrhoea\j'.
\B\b
Food and waterborne diseases are the number one cause of illness to travellers and are very common in Central America.
Traveller's diarrhoea is the most frequent health problem for travellers. It can be caused by viruses, bacteria or parasites which are found universally throughout the region. Transmission is most often through contaminated food or water. Infections may cause diarrhoea and vomiting (typhoid fever, \Jcholera\j and parasites), liver damage (hepatitis) or muscle paralysis (polio).
A recent epidemic of \Jcholera\j has swept through the entire Central American area. Persons following the usual tourist itinerary who follow the food safety recommendations are at virtually no risk of infection.
\ITyphoid Fever\i [see '\JTyphoid Fever\j']
Travellers to Central America are at risk for typhoid fever, especially when travelling to smaller cities, villages or rural areas.
The Centers For Disease Control and Prevention (CDC) recommends a typhoid \Jvaccination\j for those travellers who are going off the usual tourist itineraries, travelling to smaller cities and rural areas or staying for six weeks or more. Typhoid \Jvaccination\j is not required for international travel.
\IHepatitis A\i [see '\JHepatitis, viral, type A (Travel Information)\j']
Travellers are at high risk for hepatitis A, especially if travel plans include visiting rural areas and extensive travel in the countryside, frequent close contact with local persons or eating in settings of poor sanitation.
A study has shown that many cases of travel-related hepatitis A occur in travellers to developing countries with 'standard' itineraries, accommodations and food consumption behaviours. It is therefore recommended that travellers receive hepatitis A vaccine or IG for protection against hepatitis A. Strict food and water precautions are also recommended.
\IParasitic infections:\i
Travellers to Central America are at risk of parasitic infections. There are many types of parasites and infection may occur in several ways: by eating undercooked meats infected with parasites or their \Jlarva\j; by eating food or drinking water contaminated with parasites or their eggs; by contact with soil or water infected with parasites; or through insect bites.
Several types of parasites can penetrate intact skin and travellers are advised to wear shoes [see '\JSchistosomiasis (Travel Information)\j', and '\JSwimming Precautions When Abroad\j'].
Travellers should eat only thoroughly cooked food, drink safe water, wear shoes and avoid contact with insects, particularly mosquitoes, biting flies, gnats and midges.
\BDiseases Transmitted Through Intimate Contact with People:\b see '\JHIV Infection and AIDS, General Recommendations to Traveller\j', and '\JWHO Blood Transfusion Guidelines for International Travellers\j'.
HIV/AIDS is found throughout the world. The risk to a traveller depends on whether the traveller will be involved in sexual or needle-sharing contact with a person who is infected with \JHIV\j or receive unscreened blood for transfusion.
\IHepatitis B\i [see '\JHepatitis, viral, type B (Travel Information)\j']
Hepatitis B rates are intermediate for all of Central America except for Mexico, in which rates are low. The risk for acquiring disease is greater if the traveller has contact with blood or secretions containing blood, sex contact with an infected person or remains in the country for longer than six months and has close contact with the local population.
For countries in Central America, there is a risk of \Jrabies\j infection, particularly in rural areas or in urban areas where large numbers of dogs are found.
\BSummary of Recommendations for Mexico and Central America:\b
Travellers should:
(1) take the appropriate country-specific \Jmalaria\j prevention;
(2) follow precautions to prevent insect bites;
(3) pay attention to the quality of their drinking water and food;
(4) have a dose of Immune \JGlobulin\j (IG) or the Hepatitis A vaccine; and
(5) consider a booster dose of tetanus (Td) vaccine.
(6) Depending on the locations to be visited, planned activities and health of the traveller, the following vaccines should be considered: Hepatitis B, Yellow Fever, Typhoid, \JRabies\j (pre-exposure) and \JCholera\j. Details for these recommendations are found in this document.
(7) Finally, the normal 'childhood' vaccines should be up-to-date: \JMeasles\j, \JMumps\j, Rubella (MMR Vaccine); \JDiphtheria\j, Tetanus, \JPertussis\j (DTP Vaccine) [ < 7 years of age] and Polio vaccine.
#
"Middle East (Travel Health Tips)",36,0,0,0
(Date last rev'd: 17 January 1997)
\ICountries in this region:\i \JBahrain\j, Cyprus, \JIran\j, \JIraq\j, Israel, Jordan, \JKuwait\j, \JLebanon\j, Oman, \JQatar\j, Saudi \JArabia\j, Syrian Arab Republic, Turkey, United Arab Emirates, Yemen.
Travellers to the Middle East may be exposed to potential diseases from a number of sources. The most frequently reported illness is traveller's diarrhoea, but other diseases are important health risks.
The Middle East contains a variety of diseases transmitted by insects, contaminated food and water or close contact with infected people. Specific diseases are discussed under each of these topical headings.
In order to reduce the risk of infection travellers must (1) protect themselves from insects, (2) ensure the quality of their food and drinking water, and (3) be knowledgeable about potential diseases in the region to be visited.
Finally, diseases are not restricted to cleanly defined geographical areas, i.e. mosquitoes can fly over city or country borders; therefore, all travellers should protect themselves by taking the basic preventive precautions.
\BDiseases Transmitted by Insects:\b see '\JMosquitoes and Other Arthropod Vectors, Protection Against\j'.
A low risk for \Jmalaria\j exists in parts of these countries. The dominant form is \IP.falciparum\i (the most dangerous type), which has been reported to be resistant to the drug chlororquine.
Iran: in rural areas only in the provinces of Sistan-Baluchestan and Hormozgan, the southern parts of Fars, Kohgiluyeh-Boyar, Lorestan and Chahar Mahal-Bakhtiara, and the north of Khuzestan; \JIraq\j: in all areas in the northern region, i.e. Dahuk, Erbil, At-ta'min (Kirkuk), Ninawa, Sulaimaniya Provinces; Oman: all areas; Saudi \JArabia\j: all areas in the western provinces, except no risk in the high altitude areas of Asir Province (Yemen border) and the urban areas of Jeddah, Mecca, \JMedina\j and Taif; Syrian Arab Republic: rural areas only, except no risk in the southern and western Districts of Deir-es-zor and Sweida; Turkey: a risk in southeast Anatolia from the coastal city of Mersin to the Iraqi border (Cukurova/Amikova areas); United Arab Emirates: risk in the Northern Emirates, except no risk in the cities of Dubai, \JSharjah\j, \JAjman\j, Umm al Qaiwan and the Emirate of Abu Dhabi; Yemen: all areas, except Aden and the airport perimeter. \JBahrain\j, Cyprus, Israel, Jordan, \JKuwait\j, \JLebanon\j and \JQatar\j: no risk of \Jmalaria\j.
The following prevention information is specific to countries; \Iplease read this information carefully:\i
Travellers to \JIran\j, Oman \JIraq\j, Saudi \JArabia\j, \JSyria\j, Turkey and United Emirates at risk for \Jmalaria\j should consult their local medical practitioner on preventative medication.
In addition to using drugs to prevent \Jmalaria\j, travellers should use measures to reduce exposure to malaria-carrying mosquitoes and protect themselves from mosquito bites. These mosquitoes bite mainly during the evening and night, from dusk to dawn.
Even though there is no risk of becoming infected while travelling in countries in the Middle East, a number of these countries \Irequire\i a yellow fever \Jvaccination\j if a traveller is coming from areas in Africa and South America where yellow fever is found.
If not required (e.g. for those \Bonly\b\I \itravelling from the United States to a country in the Middle East), it is not recommended to have a yellow fever \Jvaccination\j. However, if your travel plans include travelling to or from a country in Africa or South America, you may be required to have a yellow fever \Jvaccination\j. Travellers should contact embassies or consulates for advice.
\IOther Insect Diseases:\i
Other diseases spread by mosquitoes, sand flies, black flies or other insects are prevalent, especially in rural areas. These diseases include: filariasis (mosquito), \Jleishmaniasis\j (sand fly), onchocerciasis (black flies), Congo-Crimean haemorrhagic fever (tick), \Jtyphus\j (lice) and plague (fleas).
\BDiseases Transmitted Through Food and Water:\b see '\JFood and Drink, Risks to Traveller\j', and '\JTraveller's Diarrhoea\j'.
\B\b
Food and waterborne diseases are the number one cause of illness to travellers and are very common in the Middle East.
Traveller's diarrhoea is the most frequent health problem for travellers. It can be caused by viruses, bacteria or parasites which are found universally throughout the region. Transmission is most often through contaminated food or water. Infections may cause diarrhoea and vomiting (typhoid fever, \Jcholera\j and parasites), liver damage (hepatitis) or muscle paralysis (polio).
Travellers to the Middle East are at risk for typhoid fever, especially when travelling to smaller cities, villages or rural areas.
The Centers For Disease Control and Prevention (CDC) recommends a typhoid \Jvaccination\j for those travellers who are going off the usual tourist itineraries, travelling to smaller cities and rural areas or staying for six weeks or more. Typhoid \Jvaccination\j is not required for international travel.
Cholera cases have been reported from some of the countries of the Middle East. Persons following the usual tourist itinerary who follow the food safety recommendations are at virtually no risk of infection.
\IHepatitis A\i [see '\JHepatitis, viral, type A (Travel Information)\j']
Travellers are at intermediate to high risk for Hepatitis A, especially if travel plans include visiting rural areas and extensive travel in the countryside, frequent close contact with local persons or eating in settings of poor sanitation.
A study has shown that many cases of travel-related hepatitis A occur in travellers to developing countries with 'standard' itineraries, accommodations and food consumption behaviours. It is therefore recommended that travellers receive hepatitis A vaccine or IG for protection against hepatitis A. Strict food and water precautions are also recommended.
\IParasitic infections:\i
Travellers to the Middle East are at risk of parasitic infections. There are many types of parasites and infection may occur in several ways: by eating undercooked meats infected with parasites or their \Jlarva\j; by eating food or drinking water contaminated with parasites or their eggs; by contact with soil or water infected with parasites; or through insect bites.
Several types of parasites can penetrate intact skin and travellers are advised to wear shoes and avoid swimming, wading or washing in fresh water (see '\JSchistosomiasis (Travel Information)\j', and '\JSwimming Precautions When Abroad\j'.
Travellers should eat only thoroughly cooked food, drink safe water, wear shoes and avoid contact with insects, particularly mosquitoes, biting flies, gnats and midges.
\BDiseases Transmitted Through Intimate Contact with People:\b see '\JHIV Infection and AIDS, General Recommendations to Traveller\j', and '\JWHO Blood Transfusion Guidelines for International Travellers\j'.
HIV/AIDS is found throughout the world. The risk to a traveller depends on whether the traveller will be involved in sexual or needle-sharing contact with a person who is infected with \JHIV\j or receive unscreened blood for transfusion.
\IHepatitis B\i [see '\JHepatitis, viral, type B (Travel Information)\j']
Hepatitis B rates are intermediate to high in the Middle East and the risk for acquiring disease is greater if the traveller has contact with blood or secretions containing blood, sex contact with an infected person or remains in the country for longer than six months and has close contact with the local population.
There is very low risk of meningococcal disease in most of the Middle East; however, \Bvaccination is required for pilgrims to Mecca for the annual Hajj.\b When a traveller lives and works around the local population, the risk increases.
Except for Saudi \JArabia\j, \Jvaccination\j is not required for entry into any country. Except as required, CDC normally does not recommend \Jvaccination\j with meningococcal vaccine for travellers to most of the Middle Eastern countries.
Travellers to Mecca should have a Meningococcal Vaccine Certificate showing \Jvaccination\j within the last three years. The vaccine must be administered at least 10 days before arriving.
Schistosomiasis infection is localised to certain areas of the Middle East. It can be found in parts of \JIran\j, \JIraq\j, \JLebanon\j, Oman, Saudi \JArabia\j, \JSyria\j, Turkey and Yemen. The risk is a function of the frequency and degree of contact with contaminated fresh water for bathing, wading or swimming.
Avoid contact with potentially contaminated water.
For countries in the Middle East, there is a risk of \Jrabies\j infection particularly in rural areas, or in urban areas where large numbers of dogs are found. \JBahrain\j and Cyprus have reported no \Jrabies\j cases for at least the past two years.
\BSummary of Recommendations for the Middle East:\b
Travellers should:
(1) take the appropriate country-specific \Jmalaria\j prevention measures;
(2) follow precautions to prevent insect bites;
(3) pay attention to the quality of their drinking water and food;
(4) have a dose of Immune \JGlobulin\j (IG) or the Hepatitis A vaccine; and
(5) consider booster doses of tetanus (Td) and polio (eIPV) vaccines.
(6) Depending on the locations to be visited, planned activities and health of the traveller, the following vaccines should be considered: Hepatitis B, Typhoid, Meningococcal, \JRabies\j (pre-exposure) and \JCholera\j. Details for these recommendations are found in this document. Finally, the normal 'childhood' vaccines should be up-to-date: \JMeasles\j, \JMumps\j, Rubella (MMR Vaccine); \JDiphtheria\j, Tetanus, \JPertussis\j (DTP Vaccine) [ < 7 years of age] and Polio vaccine.
#
"North Africa (Travel Health Tips)",37,0,0,0
(Date last rev'd: 7 November 1996)
\ICountries in this region:\i \JAlgeria\j, Canary Islands (islands in North Africa), \JEgypt\j, Libyan Arab Jamahiriya, Morocco, \JTunisia\j.
Travellers to North Africa may be exposed to potential diseases from a number of sources. The most frequently reported illness is traveller's diarrhoea, but North Africa contains a variety of diseases transmitted by insects, contaminated food and water or close contact with infected people. Specific diseases are discussed under each of these topical headings.
In order to reduce the risk of infection travellers must (1) protect themselves from insects, (2) ensure the quality of their food and drinking water, and (3) be knowledgeable about potential diseases in the region to be visited.
Finally, diseases are not restricted to cleanly defined geographical areas, i.e. mosquitoes can fly over city or country borders; therefore, all travellers should protect themselves by taking the basic preventive precautions.
\BDiseases Transmitted by Insects:\b see '\JMosquitoes and Other Arthropod Vectors, Protection Against\j'.
In \JAlgeria\j, \JEgypt\j, Libyan Arab Jamahiriya, Western Sahara and Morocco there is a very limited risk of \Jmalaria\j. Travellers following the usual tourist itineraries do not need drugs for \Jmalaria\j prevention.
Travellers to \JEgypt\j who intend to spend the night in rural areas of the Nile Delta, the El Faiyum area, the oases and southern \JEgypt\j near the \JSudan\j border should consult their local medical practitioner on preventative medication. Persons taking cruises on the Nile do not need preventive medication. The dominant form is \IP. vivax\i , which has not been reported to be resistant to the drug chloroquine.
The Canary Islands and \JTunisia\j: no risk.
In addition to using drugs to prevent \Jmalaria\j and treat a possible \Jmalaria\j attack, travellers should use measures to reduce exposure to malaria-carrying mosquitoes and protect themselves from mosquito bites. These mosquitoes bite mainly during the evening hours.
There is little or no risk of yellow fever infection in North Africa. However, some countries such as \JAlgeria\j, \JEgypt\j, Libyan Arab Jamahiriya and \JTunisia\j may require a yellow fever \Jvaccination\j and certificate for entry. The Canary Islands and Morocco do not require a yellow fever \Jvaccination\j.
\BNote: some countries require yellow fever \Jvaccination\j for entry.\b (Yellow fever vaccine is the \Ionly\i vaccine that may be officially required for entry into certain countries; please check the following information.)\b
In general, CDC does not recommend a yellow fever \Jvaccination\j when travelling to a North African country from countries not infected with yellow fever. However, some countries require a yellow fever \Jvaccination\j when travellers arrive from certain African and South American countries (see Requirements section below). Therefore, sometimes the easiest and safest thing to do is to get a yellow fever \Jvaccination\j and a signed certificate.
This vaccine is only administered at designated yellow fever centres. Consult a medical practitioner for precautions.
\IYellow Fever Certificate:\i
After immunisation, an International Certificate of \JVaccination\j is issued and is valid 10 days after \Jvaccination\j to meet entry and exit requirements for all countries. The Certificate is good for 10 years. You must take the Certificate with you.
Travellers who have a medical reason not to receive the yellow fever vaccine should obtain a medical waiver and check embassies or consulates for specific waiver requirements.
\IRequirements:\i
Algeria, Libyan Arab Jamahiriya and \JTunisia\j require yellow fever \Jvaccination\j and certificates from travellers from the 'Endemic Yellow Fever-Infected Countries' listed below.
Egypt requires the \Jvaccination\j and certificate from travellers from these countries, \Ias well as those from \JBotswana\j, Malawi and \JZambia\j.
\i
The Canary Islands and Morocco have no yellow fever \Jvaccination\j entry requirements.
Dengue fever occurs sporadically in \JEgypt\j. The risk of infection is small for most travellers except during periods of epidemic transmission.
\IOther Insect Diseases:\i
Other diseases spread by mosquitoes, sand flies, black flies or other insects are prevalent, especially in rural areas. These diseases include: filariasis and Chikungunya (mosquito), \Jleishmaniasis\j (sand fly), onchocerciasis (black flies), \Jtyphus\j (lice) and plague (fleas).
\BDiseases Transmitted Through Food and Water:\b see '\JFood and Drink, Risks to Traveller\j', and '\JTraveller's Diarrhoea\j'.
\B\b
Food and waterborne diseases are the number one cause of illness to travellers and are very common in North Africa.
Traveller's diarrhoea is the most frequent health problem for travellers. It can be caused by viruses, bacteria or parasites which are found universally throughout the region. Transmission is most often through contaminated food or water. Infections may cause diarrhoea and vomiting (typhoid fever, \Jcholera\j and parasites), liver damage (hepatitis) or muscle paralysis (polio).
Travellers to North Africa are at risk for typhoid fever, especially when travelling to smaller cities, villages or rural areas.
CDC recommends a typhoid \Jvaccination\j for those travellers who are going off the usual tourist itineraries, travelling to smaller cities and rural areas or staying for six weeks or more. Typhoid \Jvaccination\j is not required for international travel.
Cholera cases have been reported from most of the countries of North Africa. Persons following the usual tourist itinerary who follow the food safety recommendations are at virtually no risk of infection.
\IHepatitis A\i [see '\JHepatitis, viral, type A (Travel Information)\j']
Travellers are at high risk for Hepatitis A, especially if travel plans include visiting rural areas and extensive travel in the countryside, frequent close contact with local persons or eating in settings of poor sanitation.
A study has shown that many cases of travel-related hepatitis A occur in travellers to developing countries with 'standard' itineraries, accommodations and food consumption behaviours. It is therefore recommended that travellers receive hepatitis A vaccine or IG for protection against hepatitis A. Strict food and water precautions are also recommended.
\IParasitic infections:\i
Travellers to North Africa are at risk of parasitic infections. There are many types of parasites and infection may occur in several ways: by eating undercooked meats infected with parasites or their \Jlarva\j; by eating food or drinking water contaminated with parasites or their eggs; by contact with soil or water infected with parasites; or through insect bites.
Several types of parasites can penetrate intact skin and travellers are advised to wear shoes and avoid swimming, wading or washing in fresh water (see '\JSchistosomiasis (Travel Information)\j' and '\JSwimming Precautions When Abroad\j').
Travellers should eat only thoroughly cooked food, drink safe water, wear shoes and avoid contact with insects, particularly mosquitoes, biting flies, gnats and midges.
\BDiseases Transmitted Through Intimate Contact with People:\b see '\JHIV Infection and AIDS, General Recommendations to Traveller\j', and '\JWHO Blood Transfusion Guidelines for International Travellers\j'.
HIV/AIDS is found throughout the world. The risk to a traveller depends on whether the traveller will be involved in sexual or needle-sharing contact with a person who is infected with \JHIV\j or receive unscreened blood for transfusion.
\IHepatitis B\i [see '\JHepatitis, viral, type B (Travel Information)\j']
Hepatitis B rates are high in Africa and the risk for acquiring disease is greater if the traveller has contact with blood or secretions containing blood, sex contact with an infected person or remains in the country for longer than six months and has close contact with the local population.
The main risk of schistosomiasis is in the Nile River delta and valley region of \JEgypt\j. Schistosomiasis infection also can be found in the North African countries of \JAlgeria\j and \JLibya\j. The risk is a function of the frequency and degree of contact with contaminated fresh water for bathing, wading or swimming. Avoid contact with potentially contaminated water.
For countries in North Africa, there is a risk of \Jrabies\j infection particularly in rural areas, or in urban areas where large numbers of dogs are found.
\BSummary of Recommendations for North Africa:\b
Travellers should:
(1) take the appropriate country-specific \Jmalaria\j prevention measures;
(2) follow precautions to prevent insect bites;
(3) pay attention to the quality of their drinking water and food;
(4) have a dose of Immune \JGlobulin\j (IG) or the Hepatitis A vaccine; and
(5) consider booster doses of tetanus (Td) and polio (eIPV) vaccines.
(6) Depending on the locations to be visited, planned activities and health of the traveller, the following vaccines should be considered: Hepatitis B, Yellow Fever, Typhoid, Meningococcal, \JRabies\j (pre-exposure) and \JCholera\j. Details for these recommendations are found in this document.
(7) Finally, the normal 'childhood' vaccines should be up-to-date: \JMeasles\j, \JMumps\j, Rubella (MMR Vaccine); \JDiphtheria\j, Tetanus, \JPertussis\j (DTP Vaccine) [ < 7 years of age] and Polio vaccine.
#
"Southeast Asia (Travel Health Tips)",38,0,0,0
(Date last rev'd: 7 November 1996)
\ICountries in this region:\i \JBrunei\j Darussalam, \JCambodia\j, \JIndonesia\j, Lao People's Democratic Republic (Laos), \JMalaysia\j, \JMyanmar\j (Burma), \JPhilippines\j, \JSingapore\j, \JThailand\j, Vietnam.
Travellers to Southeast Asia may be exposed to potential diseases from a number of sources. The most frequently reported illness is traveller's diarrhoea, but there are other diseases which are unique to Southeast Asia or the tropics. These diseases are transmitted by insects, contaminated food and water or close contact with infected people. Specific diseases are discussed under each of these topical headings.
In order to reduce the risk of infection travellers must (1) protect themselves from insects, (2) ensure the quality of their food and drinking water, and (3) be knowledgeable about potential diseases in the region to be visited.
Finally, diseases are not restricted to cleanly defined geographical areas, i.e. mosquitoes can fly over city or country borders; therefore, all travellers should protect themselves by taking the basic preventive precautions.
\BDiseases Transmitted by Insects:\b see '\JMosquitoes and Other Arthropod Vectors, Protection Against\j'.
A risk for \Jmalaria\j exists throughout the year in all parts of these countries, including some urban areas.
Cambodia: \Jmalaria\j risk in all areas, except Phnom Penh.
Indonesia: in general, \Jmalaria\j risk in rural areas only (largely confined to rural areas not visited by most travellers? most travel to rural areas is in the daytime hours when there is minimal risk of exposure), except high risk in all areas of Irian Jaya (western half of the island of New Guinea); no risk in the big cities and resort areas of Java and Bali.
Lao People's Democratic Republic: \Jmalaria\j risk in all areas, except no risk in city of \JVientiane\j.
Malaysia: for peninsular \JMalaysia\j and \JSarawak\j (NW Borneo) \Jmalaria\j risk is limited to the rural hinterlands; urban and coastal areas are malaria-free; \JSabah\j (NE Borneo) has \Jmalaria\j throughout.
Myanmar (Burma): \Jmalaria\j risk in rural areas only (largely confined to rural areas not visited by most travellers? most travel to rural areas is in the daytime hours when there is minimal risk of exposure).
Philippines: \Jmalaria\j risk in rural areas only, except no risk in Provinces of Bohol, Catanduanes, Cebu and Leyte. \JMalaria\j transmission is largely confined to rural areas not visited by most travellers. (Most travel to rural areas is in the daytime hours when there is minimal risk of exposure.)
Thailand: \JMalaria\j transmission is confined to the forested areas of its borders with \JCambodia\j and \JMyanmar\j (Burma). These areas are not visited by most travellers. Therefore, most travellers to \JThailand\j are not at risk for \Jmalaria\j. (In \JThailand\j use \Idoxycycline\i for \Jmalaria\j prevention.)
Vietnam: \Jmalaria\j risk in rural areas only, except no risk in the Red and Mekong Deltas. In this region the dominant form of \Jmalaria\j is \IP. falciparum\i (the most dangerous type), which has been reported to be resistant to the drug chloroquine.
Brunei Darussalam and \JSingapore\j: no risk of \Jmalaria\j.
Travellers to \JCambodia\j, \JIndonesia\j, Lao People's Democratic Republic, \JMalaysia\j, \JMyanmar\j and Vietnam at risk for \Jmalaria\j should take \Imefloquine\i to prevent \Jmalaria\j. (For travellers to the \JPhilippines\j and \JThailand\j, different prevention instructions apply.) Consult a physician for other precautions.
Travellers to \JThailand\j who overnight in the few areas of risk should take \Idoxycycline \i(check specific dosage, scheduling and precautions). If doxycycline is used, there is no need to take other preventive drugs, such as chloroquine.
In the \JPhilippines\j, since \Jmalaria\j transmission is largely confined to the rural areas not visited by most travellers, taking drugs to prevent \Jmalaria\j is only recommended for travellers who will have outdoor exposure during evening and night-time hours in rural areas.
Travellers to the rural areas of the \JPhilippines\j at risk of \Jmalaria\j should take one of two drugs to prevent \Jmalaria\j transmission. Travellers to the rural areas on the Philippine islands of \JLuzon\j, Basilian, \JMindoro\j, \JPalawan\j, Mindanao and Sulu Archipelago should take \Imefloquine\i for prevention of \Jmalaria\j. If travelling to rural areas other than those listed above, travellers should take \Ichloroquine.\i
In addition to using drugs to prevent \Jmalaria\j, travellers should use measures to reduce exposure to malaria-carrying mosquitoes and protect themselves from mosquito bites. These mosquitoes bite mainly during the evening and night, from dusk to dawn.
Dengue fever occurs throughout Southeast Asia with epidemics most recently in \JCambodia\j, \JIndonesia\j, Laos, East and West \JMalaysia\j, \JMyanmar\j, \JPhilippines\j, \JSingapore\j, \JThailand\j and Vietnam. The risk of infection is small for most travellers except during periods of epidemic transmission.
\IJapanese Encephalitis\i [see '\JEncephalitis, Japanese (Travel Information)\j']
Transmission is usually seasonal (associated with the rainy season). There is a risk for travellers to rural areas of Southeast Asian countries, including \JBurma\j, \JThailand\j, \JCambodia\j, \JIndonesia\j, Laos, \JMalaysia\j, the \JPhilippines\j, \JThailand\j and Vietnam. The chance that a traveller to Asia will develop Japanese \Jencephalitis\j is extremely small.
Even though there is no risk of becoming infected while travelling in Southeast Asian countries, a number of these countries \Irequire\i a yellow fever \Jvaccination\j if a traveller is coming from areas in Africa and South America where yellow fever is found.
If not required (e.g. for those \Ionly \itravelling from the United States to a Southeast Asian country), it is not recommended to have a yellow fever \Jvaccination\j. However, if your travel plans include travelling to or from a country in Africa or South America, you may be required to have a yellow fever \Jvaccination\j. Travellers should contact embassies or consulates for advice.
\IOther Insect Diseases:\i
Other diseases spread by mosquitoes, sand flies, black flies or other insects are prevalent, especially in rural areas. These diseases include: filariasis and Chikungunya (mosquito), \Jleishmaniasis\j (sand fly), \Jtyphus\j (lice) and plague (fleas). Travellers should therefore take care to avoid insect bites.
\BDiseases Transmitted Through Food and Water:\b see '\JFood and Drink, Risks to Traveller\j', and '\JTraveller's Diarrhoea\j'.
\B\b
Food and waterborne diseases are the number one cause of illness to travellers and are very common in Southeast Asia.
Traveller's diarrhoea is the most frequent health problem for travellers. It can be caused by viruses, bacteria or parasites which are found universally throughout the region. Transmission is most often through contaminated food or water. Infections may cause diarrhoea and vomiting (typhoid fever, \Jcholera\j and parasites), liver damage (hepatitis) or muscle paralysis (polio).
Travellers to Southeast Asia are at risk for typhoid fever, especially when travelling to smaller cities, villages or rural areas.
CDC recommends a typhoid \Jvaccination\j for those travellers who are going off the usual tourist itineraries, travelling to smaller cities and rural areas or staying for six weeks or more. Typhoid \Jvaccination\j is not required for international travel.
Cholera cases have been reported from some of the countries of Southeast Asia. Persons following the usual tourist itinerary who follow the food safety recommendations are at virtually no risk of infection.
\IHepatitis A\i [see '\JHepatitis, viral, type A (Travel Information)\j']
Travellers are at high risk for Hepatitis A, especially if travel plans include visiting rural areas and extensive travel in the countryside, frequent close contact with local persons or eating in settings of poor sanitation.
A study has shown that many cases of travel-related hepatitis A occur in travellers to developing countries with 'standard' itineraries, accommodations and food consumption behaviours.
It is therefore recommended that travellers receive hepatitis A vaccine or IG for protection against hepatitis A. Strict food and water precautions are also recommended.
\IParasitic infections:\i
Travellers to Southeast Asia are at risk of parasitic infections. There are many types of parasites and infection may occur in several ways: by eating undercooked meats infected with parasites or their \Jlarva\j; by eating food or drinking water contaminated with parasites or their eggs; by contact with soil or water infected with parasites; or through insect bites.
Several types of parasites can penetrate intact skin and travellers are advised to wear shoes and avoid swimming, wading or washing in fresh water (see '\JSchistosomiasis (Travel Information)\j' and '\JSwimming Precautions When Abroad\j').
Travellers should eat only thoroughly cooked food, drink safe water, wear shoes and avoid contact with insects, particularly mosquitoes, biting flies, gnats and midges.
\BDiseases Transmitted Through Intimate Contact with People:\b see '\JHIV Infection and AIDS, General Recommendations to Traveller\j' and '\JWHO Blood Transfusion Guidelines for International Travellers\j'.
HIV/AIDS is found throughout the world. The risk to a traveller depends on whether the traveller will be involved in sexual or needle-sharing contact with a person who is infected with \JHIV\j or receive unscreened blood for transfusion.
\IHepatitis B\i [see '\JHepatitis, viral, type B (Travel Information)\j']
Hepatitis B rates are high in Southeast Asia and the risk for acquiring disease is greater if the traveller has contact with blood or secretions containing blood, sex contact with an infected person or remains in the country for longer than six months and has close contact with the local population.
Schistosomiasis infection is found in some parts of a few Southeast Asian countries. \JCambodia\j, \JIndonesia\j, Laos, the \JPhilippines\j and \JThailand\j all have specific areas of potential infection. The risk is a function of the frequency and degree of contact with contaminated fresh water for bathing, wading or swimming. Avoid contact with potentially contaminated water.
For most countries in Southeast Asia, there is a risk of \Jrabies\j infection particularly in rural areas, or in urban areas where large numbers of dogs are found. \JSingapore\j, the Malaysian Islands and parts of \JIndonesia\j (excluding Java, \JSumatra\j, Sulawesi and Kalimantan) have not reported \Jrabies\j cases for at least the past two years.
\BSummary of Recommendations for Southeast Asia:\b
Travellers should:
(1) take appropriate country-specific \Jmalaria\j prevention measures;
(2) follow precautions to prevent insect bites;
(3) pay attention to the quality of their drinking water and food;
(4) have a dose of Immune \JGlobulin\j (IG) or the Hepatitis A vaccine; and
(5) consider booster doses of tetanus (Td) and polio (eIPV) vaccines.
(6) Depending on the locations to be visited, planned activities and health of the traveller, the following vaccines should be considered: Hepatitis B, Japanese \JEncephalitis\j, Typhoid, \JRabies\j (pre-exposure) and \JCholera\j. Details for these recommendations are found in this document.
(7) Finally, the normal 'childhood' vaccines should be up-to-date: \JMeasles\j, \JMumps\j, Rubella (MMR Vaccine); \JDiphtheria\j, Tetanus, \JPertussis\j (DTP Vaccine) [ < 7 years of age] and Polio vaccine.
#
"Southern Africa (Travel Health Tips)",39,0,0,0
(Date last rev'd: 7 November 1996)
\ICountries in this region:\i \JBotswana\j, \JLesotho\j, \JNamibia\j, South Africa, St Helena (an island in the South Atlantic), \JSwaziland\j and Zimbabwe.
Travellers to Southern Africa may be exposed to potential diseases from a number of sources. The most frequently reported illness is traveller's diarrhoea, but Southern Africa contains a variety of diseases transmitted by insects, contaminated food and water or close contact with infected people. Specific diseases are discussed under each of these topical headings.
In order to reduce the risk of infection travellers must (1) protect themselves from insects, (2) ensure the quality of their food and drinking water, and (3) be knowledgeable about potential diseases in the region to be visited.
Finally, diseases are not restricted to cleanly defined geographical areas, i.e. mosquitoes can fly over city or country borders; therefore, all travellers should protect themselves by taking the basic preventive precautions.
\BDiseases Transmitted by Insects:\b see '\JMosquitoes and Other Arthropod Vectors, Protection Against\j'.
Malaria risk areas include: \JBotswana\j: northern part of the country (north of 21░S); \JNamibia\j: all areas of Ovamboland and Caprivi Strip; South Africa: rural areas (including the game parks) in the north, east and western low altitude areas of \JTransvaal\j and in the Natal coastal areas north of 28░S; \JSwaziland\j: all lowland areas; Zimbabwe: a high risk exists throughout the year in all parts of the country, including the urban areas. In \JLesotho\j and St Helena, there is no risk.
In addition to using drugs to prevent \Jmalaria\j and treat a possible \Jmalaria\j attack, travellers should use measures to reduce exposure to malaria-carrying mosquitoes and protect themselves from mosquito bites. These mosquitoes bite mainly during the evening and night, from dusk to dawn.
There is little or no risk of yellow fever infection in Southern Africa. However, some countries such as \JLesotho\j, \JNamibia\j, South Africa and \JSwaziland\j, require a yellow fever \Jvaccination\j and certificate for entry. \JBotswana\j and St Helena do not require a yellow fever \Jvaccination\j. Travellers should check an up-to-date list of yellow fever-infected countries.
\BNote: some countries require yellow fever \Jvaccination\j for entry. \b(Yellow fever vaccine is the \Ionly\i vaccine that may be officially required for entry into certain countries; therefore please check the following information.)
In general, the Centers For Disease Control and Prevention (CDC) does not recommend a yellow fever \Jvaccination\j when travelling to a Southern African country from countries not infected with yellow fever. However, some countries require a yellow fever \Jvaccination\j when travellers arrive from certain African and South American countries. Therefore, sometimes the easiest and safest thing to do is to get a yellow fever \Jvaccination\j and a signed certificate.
This vaccine is only administered at designated yellow fever centres. Consult a physician for cautions.
\IRequirements:\i
Botswana and St Helena have no yellow fever entry requirements.
However, if you are travelling from any of the African or South American countries listed below to a South African country (except for \JBotswana\j or St Helena), you are required to have a yellow fever \Jvaccination\j and certificate.
\IEndemic Yellow Fever-Infected Countries:\i
Africa: \JAngola\j, Benin, Burkina Faso, \JBurundi\j, \JCameroon\j, Central African Republic, Chad, \JCongo\j, Cote d'Ivoire (Ivory Coast), Equatorial Guinea, \JEthiopia\j, \JGabon\j, Gambia, \JGhana\j, Guinea, Guinea-Bissau, \JKenya\j, \JLiberia\j, Mali, \JMauritania\j, \JNiger\j, \JNigeria\j, \JRwanda\j, Sao Tome and Principe, \JSenegal\j, Sierra Leone, \JSomalia\j, Sudan,Tanzania, \JTogo\j, \JUganda\j and Zaire.
South America: \JBolivia\j, \JBrazil\j, \JColombia\j, \JEcuador\j, French Guiana, \JGuyana\j, Panama, \JPeru\j, Suriname, Venezuela.
Travellers from the above-listed countries require yellow fever vaccinations and certificates for entry to \JLesotho\j, \JNamibia\j, South Africa, \JSwaziland\j and Zimbabwe.
\IYellow Fever Certificate:\i
After immunisation, an International Certificate of \JVaccination\j is issued and is valid 10 days after \Jvaccination\j to meet entry and exit requirements for all countries. Travellers should view a correctly-completed International Certificate of \JVaccination\j. The Certificate is good for 10 years. You must take the Certificate with you.
Travellers who have a medical reason not to receive the yellow fever vaccine should obtain a medical waiver and check embassies or consulates for specific waiver requirements.
Dengue fever occurs occasionally in South Africa, \JSwaziland\j and Zimbabwe. The risk of infection is small for most travellers except during periods of epidemic transmission.
\IOther Insect Diseases:\i
Other diseases spread by mosquitoes, sand flies, black flies or other insects are prevalent, especially in rural areas. These diseases include: filariasis and Chikungunya (mosquito), \Jleishmaniasis\j (sand fly), onchocerciasis (black flies), African trypanosomiasis (flies), Congo-Crimean haemorrhagic fever (ticks), \Jtyphus\j (lice) and plague (fleas).
\BDiseases Transmitted Through Food and Water:\b see '\JFood and Drink, Risks to Traveller\j' and '\JTraveller's Diarrhoea\j'.
\B\b
Food and waterborne diseases are the number one cause of illness to travellers and are very common in Southern Africa.
Traveller's diarrhoea is the most frequent health problem for travellers. It can be caused by viruses, bacteria or parasites which are found universally throughout the region. Transmission is most often through contaminated food or water. Infections may cause diarrhoea and vomiting (typhoid fever, \Jcholera\j and parasites), liver damage (hepatitis) or muscle paralysis (polio).
Travellers to Southern Africa are at risk for typhoid fever, especially when travelling to smaller cities, villages or rural areas.
CDC recommends a typhoid \Jvaccination\j for those travellers who are going off the usual tourist itineraries, travelling to smaller cities and rural areas or staying for six weeks or more. Typhoid \Jvaccination\j is not required for international travel.
Cholera cases have been reported from most of the countries of Southern Africa. Persons following the usual tourist itinerary who follow the food safety recommendations are at virtually no risk of infection.
\IHepatitis A\i [see '\JHepatitis, viral, type A (Travel Information)\j']
Travellers are at high risk for Hepatitis A, especially if travel plans include visiting rural areas and extensive travel in the countryside, frequent close contact with local persons or eating in settings of poor sanitation.
A study has shown that many cases of travel-related hepatitis A occur in travellers to developing countries with 'standard' itineraries, accommodations and food consumption behaviours. It is therefore recommended that travellers receive hepatitis A vaccine or IG for protection against hepatitis A. Strict food and water precautions are also recommended.
\IParasitic infections:\i
Travellers to Southern Africa are at risk of parasitic infections. There are many types of parasites and infection may occur in several ways: by eating undercooked meats infected with parasites or their \Jlarva\j; by eating food or drinking water contaminated with parasites or their eggs; by contact with soil or water infected with parasites; or through insect bites.
Several types of parasites can penetrate intact skin and travellers are advised to wear shoes and avoid swimming, wading or washing in fresh water (see '\JSchistosomiasis (Travel Information)\j' and '\JSwimming Precautions When Abroad\j').
Travellers should eat only thoroughly cooked food, drink safe water, wear shoes and avoid contact with insects, particularly mosquitoes, biting flies, gnats and midges.
\BDiseases Transmitted Through Intimate Contact with People:\b see '\JHIV Infection and AIDS, General Recommendations to Traveller\j', and '\JWHO Blood Transfusion Guidelines for International Travellers\j'.
HIV/AIDS is found throughout the world. The risk to a traveller depends on whether the traveller will be involved in sexual or needle-sharing contact with a person who is infected with \JHIV\j or receive unscreened blood for transfusion.
\IHepatitis B\i [see '\JHepatitis, viral, type B (Travel Information)\j']
Hepatitis B rates are high in Africa and the risk for acquiring disease is greater if the traveller has contact with blood or secretions containing blood, sex contact with an infected person or remains in the country for longer than six months and has close contact with the local population.
Schistosomiasis infection can be found in the Southern African countries of \JBotswana\j, \JNamibia\j, South Africa, \JSwaziland\j and Zimbabwe. The risk is a function of the frequency and degree of contact with contaminated fresh water for bathing, wading or swimming. Avoid contact with potentially contaminated water.
For countries in the Southern African Region, there is a risk of \Jrabies\j infection particularly in rural areas or in urban areas where large numbers of dogs are found.
\BSummary of Recommendations for Southern Africa:\b
Travellers should:
(1) take appropriate drug for \Jmalaria\j prevention;
(2) follow precautions to prevent insect bites;
(3) pay attention to the quality of their drinking water and food;
(4) have a dose of Immune \JGlobulin\j (IG) or the Hepatitis A vaccine; and
(5) consider booster doses of tetanus (Td) and polio (eIPV) vaccines.
(6) Depending on the locations to be visited, planned activities and health of the traveller, the following vaccines should be considered: Hepatitis B, Yellow Fever, Typhoid, \JRabies\j (pre-exposure) and \JCholera\j. Details for these recommendations are found in this document.
(7) Finally, the normal 'childhood' vaccines should be up-to-date: \JMeasles\j, \JMumps\j, Rubella (MMR Vaccine); \JDiphtheria\j, Tetanus, \JPertussis\j (DTP Vaccine) [ < 7 years of age] and Polio vaccine.
#
"Temperate South America (Travel Health Tips)",40,0,0,0
(Date last rev'd: 7 November 1996)
\ICountries in this region:\i Argentina, \JChile\j, Falkland Islands, Uruguay.
Travellers to temperate South America may be exposed to potential diseases from a number of sources. The most frequently reported illness is traveller's diarrhoea, but there are other diseases. Temperate South America contains diseases transmitted by insects, contaminated food and water or close contact with infected people. Specific diseases are discussed under each of these topical headings.
In order to reduce the risk of infection travellers must (1) protect themselves from insects, (2) ensure the quality of their food and drinking water, and (3) be knowledgeable about potential diseases in the region to be visited.
Finally, diseases are not restricted to cleanly defined geographical areas, i.e. mosquitoes can fly over city or country borders; therefore, all travellers should protect themselves by taking the basic preventive precautions.
\BDiseases Transmitted by Insects:\b see '\JMosquitoes and Other Arthropod Vectors, Protection Against\j'.
For Argentina, the risk for \Jmalaria\j infection occurs only in rural areas of northern Argentina that border \JBolivia\j (Salta and Jujuy Provinces). In \JChile\j, the Falkland Islands and Uruguay, there is no risk of \Jmalaria\j.
Travellers at risk for \Jmalaria\j should take \Ichloroquine\i to prevent \Jmalaria\j. No other anti-malarial drugs are needed.
In addition to using drugs to prevent \Jmalaria\j and treat a possible \Jmalaria\j attack, travellers should use measures to reduce exposure to malaria-carrying mosquitoes and protect themselves from mosquito bites.
A low risk of yellow fever infection occurs only in the northeastern forest areas of Argentina. There is no risk of yellow fever in \JChile\j, the Falkland Islands or Uruguay. Travellers should check an up-to-date list of yellow fever-infected countries.
\BNote: some countries require yellow fever \Jvaccination\j for entry.\b (See 'Requirements' below.) In general, if you are travelling to an area of risk, the easiest and safest thing to do is to get a yellow fever \Jvaccination\j and a signed certificate. This vaccine is only administered at designated yellow fever centres.
In addition to the vaccine, travellers should use measures to reduce exposure to mosquitoes and protect themselves from mosquito bites. These mosquitoes bite mainly during the evening and morning hours.
\IRequirements:\i
\BPlease note:\b CDC recommends a yellow fever \Jvaccination\j \Ionly\i if you are travelling to areas of risk (northeastern Argentina, tropical South America or Africa).
Argentina, \JChile\j, the Falkland Islands and Uruguay have no yellow fever \Jvaccination\j requirements. If your travel plans include travelling to or from other countries in Africa or South America, then you should check the yellow fever \Jvaccination\j requirements for those countries, as you may be required to have a yellow fever \Jvaccination\j. (Yellow fever vaccine is the \Ionly\i vaccine that may be officially required for entry into certain countries.)
\IYellow Fever Certificate:\i
After immunisation, an International Certificate of \JVaccination\j is issued and is valid 10 days after \Jvaccination\j to meet entry and exit requirements for all countries. View a correctly-completed International Certificate of \JVaccination\j. The Certificate is good for 10 years. You must take the Certificate with you.
Travellers who have a medical reason not to receive the yellow fever vaccine should obtain a medical waiver and check embassies or consulates for specific waiver requirements.
\IOther Insect Diseases\i
Other diseases spread by mosquitoes, sand flies, black flies or other insects are prevalent, especially in rural areas. These diseases include: \Jleishmaniasis\j (sand fly), American trypanosomiasis or Chagas' disease ('cone nose' or 'kissing' bug), \Jtyphus\j (lice) and plague (fleas).
\BDiseases Transmitted Through Food and Water:\b see '\JFood and Drink, Risks to Traveller\j' and '\JTraveller's Diarrhoea\j'.
\B\b
Food and waterborne diseases are the number one cause of illness to travellers and are very common in temperate South America.
Traveller's diarrhoea is the most frequent health problem for travellers. It can be caused by viruses, bacteria or parasites which are found universally throughout the region. Transmission is most often through contaminated food or water. Infections may cause diarrhoea and vomiting (typhoid fever, \Jcholera\j and parasites), liver damage (hepatitis) or muscle paralysis (polio).
A recent epidemic of \Jcholera\j has swept through the entire South American area. Persons following the usual tourist itinerary who follow the food safety recommendations, however, are at virtually no risk of infection.
Travellers to temperate South America are at risk for typhoid fever, especially when travelling to smaller cities, villages or rural areas.
The Centers For Disease Control and Prevention (CDC) recommends a typhoid \Jvaccination\j for those travellers who are going off the usual tourist itineraries, travelling to smaller cities and rural areas or staying for six weeks or more. Typhoid \Jvaccination\j is not required for international travel.
\IHepatitis A\i [see '\JHepatitis, viral, type A (Travel Information)\j']
Travellers are at high risk for Hepatitis A, especially if travel plans include visiting rural areas and extensive travel in the countryside, frequent close contact with local persons or eating in settings of poor sanitation.
A study has shown that many cases of travel-related hepatitis A occur in travellers to developing countries with 'standard' itineraries, accommodations and food consumption behaviours.
It is therefore recommended that travellers receive hepatitis A vaccine or IG for protection against hepatitis A. Strict food and water precautions are also recommended.
\IParasitic infections:\i
Travellers to temperate South America are at risk of parasitic infections. There are many types of parasites and infection may occur in several ways: by eating undercooked meats infected with parasites or their \Jlarva\j; by eating food or drinking water contaminated with parasites or their eggs; by contact with soil or water infected with parasites; or through insect bites.
Several types of parasites can penetrate intact skin and travellers are advised to wear shoes and avoid swimming, wading or washing in fresh water (see '\JSchistosomiasis (Travel Information)\j' and '\JSwimming Precautions When Abroad\j').
Travellers should eat only thoroughly cooked food, drink safe water, wear shoes and avoid contact with insects, particularly mosquitoes, biting flies, gnats and midges.
\BDiseases Transmitted Through Intimate Contact with People:\b see '\JHIV Infection and AIDS, General Recommendations to Traveller\j', and '\JWHO Blood Transfusion Guidelines for International Travellers\j'.
HIV/AIDS is found throughout the world. The risk to a traveller depends on whether the traveller will be involved in sexual or needle-sharing contact with a person who is infected with \JHIV\j or receive unscreened blood for transfusion.
For countries in temperate South America, there is a risk of \Jrabies\j infection particularly in rural areas, or in urban areas where large numbers of dogs are found. Uruguay has reported no \Jrabies\j cases for at least the past two years.
\BSummary of Recommendations for Temperate South America:\b
Travellers should:
(1) take the appropriate country-specific \Jmalaria\j prevention;
(2) follow precautions to prevent insect bites;
(3) pay attention to the quality of their drinking water and food;
(4) have a dose of Immune \JGlobulin\j (IG) or the Hepatitis A vaccine; and
(5) consider a booster dose of tetanus (Td) vaccine.
(6) Depending on the locations to be visited, planned activities and health of the traveller, the following vaccines should be considered: Yellow Fever, Typhoid, \JRabies\j (pre-exposure) and \JCholera\j. Details for these recommendations are found in this document.
(7) Finally, the normal 'childhood' vaccines should be up-to-date: \JMeasles\j, \JMumps\j, Rubella (MMR Vaccine); \JDiphtheria\j, Tetanus, \JPertussis\j (DTP Vaccine) [ < 7 years of age] and Polio vaccine.
#
"Tropical South America (Travel Health Tips)",41,0,0,0
(Date last rev'd: 7 November 1996)
\ICountries in this region:\i \JBolivia\j, \JBrazil\j, \JColombia\j, \JEcuador\j, French Guiana, \JGuyana\j, \JParaguay\j, \JPeru\j, Suriname and Venezuela.
Travellers to tropical South America may be exposed to potential diseases from a number of sources. The most frequently reported illness is traveller's diarrhoea, but there are other diseases which are unique to tropical South America and the tropics in general. These diseases are transmitted by insects, contaminated food and water or close contact with infected people. Specific diseases are discussed under each of these topical headings.
In order to reduce the risk of infection travellers must (1) protect themselves from insects, (2) ensure the quality of their food and drinking water, and (3) be knowledgeable about potential diseases in the region to be visited.
Finally, diseases are not restricted to cleanly defined geographical areas, i.e. mosquitoes can fly over city or country borders; therefore, all travellers should protect themselves by taking the basic preventive precautions.
\BDiseases Transmitted by Insects:\b see '\JMosquitoes and Other Arthropod Vectors, Protection Against\j'.
Malaria exists throughout the year in many parts of the tropical South American countries, including some urban areas.\I P. falciparum\i (the most dangerous type), which has been reported to be resistant to the drug chloroquine, has been confirmed in most of these countries.
\IDetailed risk information:\i
Bolivia: \JMalaria\j risk in rural areas only, except no risk in the highland areas, i.e. Departments of Oruro, Southern and Central \JPotosi\j, La Paz and the Provinces of Ingavi, Los \JAndes\j, Omasuyos and Pacajes.
Brazil: \JMalaria\j risk in Acre and Rondonia States, Territories of Amapß and Roraima, and in rural areas of Amazonas, Goißs, Maranahao, Mato Grosso and Parß States. Travellers who will only visit the coastal states from the 'horn' south to the Uruguay border, including Iguassu Falls, are not at risk and need not take preventive drugs.
Colombia: \JMalaria\j risk in rural areas only, except no risk in Bogota and vicinity. \JMalaria\j risk in the rural areas of Uraba (Antioquia Dept.), Bajo Cauca-Nechi (Cauca and Antioquia Dept.), Magdalena Medio, Caqueta (Caqueta Intendencia), Sarare (Arauca Intendencia), Catatumbo (Norte de Santander Dept.), Pacifico Central and Sur, Putumayo (Putumayo Intendencia), Ariari (Meta Dept.), Alto Vaupes (Vaupes Comisaria), Amazonas and Guainia (Comisarias).
Ecuador: \JMalaria\j risk in all areas in the provinces along the eastern border and the Pacific coast, i.e. El Oro, Esmeraldas, Guayas (including Guayaquil), Los Rios, Manabi, Morona-Santiago, Napo, Pastaza, \JPichincha\j and Zamora-Chinchipe provinces. Travellers who visit only \JQuito\j and vicinity, the central highlands tourist areas or the Galapagos Islands are not at risk and need not take preventive drugs.
French Guiana: \JMalaria\j risk in all areas.
Guyana: \JMalaria\j risk in rural areas in the southern interior and northwest coast, i.e. Rupununi and North West Regions.
Paraguay: \JMalaria\j risk in rural areas bordering \JBrazil\j.
Peru: \JMalaria\j risk exists in rural areas. Travellers who will only visit Lima and vicinity, coastal areas south of Lima or the highland tourist areas of Cuzco, Machu Picchu or Lake Titicaca are not at risk and need not take preventive drugs. Risk exists in rural areas of Departments of Amazonas, Cajamarca (except Hualgayoc Prov.), La Libertad (except Otuxco, Santiago de Chuco Prov.), Lambayeque, Loreto, Piura (except Talara Prov.), San Martin and Tumbes, Provinces of Santa (Ancash Dept.); parts of La Convension (Cuzco Dept.), Tayacaja (Huancavelica Dept.), Satipo (Junin Dept.).
Suriname: \JMalaria\j risk exists in rural areas, except no risk in the Paramaribo District and the coastal area north of 5? N. lat.
Venezuela: \JMalaria\j risk exists in rural areas of all border states and territories and the states of Barinas, Merida and Portuguesa.
Travellers should note that regardless of preventive method employed, it is still possible to contract \Jmalaria\j. \IP. falciparum\i is reported in all these countries, but less so in \JPeru\j and \JParaguay\j. \IP. falciparum\i highly resistant to chloroquine and Fansidar is reported in some of these areas.
\IPrevention:\i
Most travellers to tropical South America (including travellers to \JPeru\j's eastern and northern border provinces) at risk for \Jmalaria\j should take \Imefloquine\i to prevent \Jmalaria\j. (Travellers to the other areas in \JPeru\j and \JParaguay\j have other recommendations.) Consult a physician for precautions.
Travellers to all areas of \JPeru\j (except the eastern and northern border provinces) and \JParaguay\j should take \Ichloroquine\i to prevent \Jmalaria\j. For these areas in \JPeru\j, no other anti-malarial drugs are needed.
In addition to using drugs to prevent \Jmalaria\j, travellers should use measures to reduce exposure to malaria-carrying mosquitoes and protect themselves from mosquito bites. These mosquitoes bite mainly during the evening and night, from dusk to dawn.
Outbreaks of yellow fever have occurred in \JBolivia\j and \JPeru\j. Yellow fever is not always active in all countries of this region, but there is a significant risk to all travellers throughout the year, especially in travel or visits to rural settings.
Areas of higher risk are: \JBolivia\j: the Departments of Beni, Chuquisaca, Cochabamba, Pando, Santa Cruz, Tarija and part of La Paz; \JBrazil\j: rural areas of Acre, Amazonas, Goias, Maranhao, Mato Grosso, Mato Grosso do Sul, Para and Rondonia States, and the Territories of Amapa and Roraima; \JColombia\j: middle valley of the Magdalena River, foothills of the Cordillera Oriental from border of \JEcuador\j to Venezuela, Uraba, foothills of Sierra Nevada, Orinoquia and Amazonia; \JPeru\j: central and northern jungle regions; Venezuela: State of Bolivar, forest around Lake \JMaracaibo\j and San Camilo jungle.
Ecuador, French Guiana, \JGuyana\j, \JParaguay\j and Suriname have reported only a few cases. Travellers should check an up-to-date list of yellow fever-infected countries.
\BNote: some countries require yellow fever \Jvaccination\j for entry.\b (Yellow fever vaccine is the \Ionly\i vaccine that may be officially required for entry into certain countries.)\b
In general, if you are travelling to a tropical South American country, the easiest and safest thing to do is to get a yellow fever \Jvaccination\j and a signed certificate. This vaccine is only administered at designated yellow fever \Jvaccination\j centres.
In addition to the vaccine, travellers should use measures to reduce exposure to mosquitoes and protect themselves from mosquito bites. These mosquitoes bite mainly during the evening and morning hours.
\IRequirements:\i
\BPlease note:\b If you are travelling to tropical South America, the Centers For Disease Control and Prevention (CDC) \Irecommends and many countries require a yellow fever vaccination.\i\b
French Guiana requires a yellow fever certificate for all travellers. \JBolivia\j, \JBrazil\j (travellers age 6 months), \JEcuador\j, \JGuyana\j, \JPeru\j (age 6 months) and Suriname require a yellow fever \Jvaccination\j for all travellers (age >1, except where otherwise indicated) arriving from all infected countries. \JParaguay\j requires a certificate for travellers leaving the country to infected countries.
In addition, \JBrazil\j, \JBolivia\j, \JColombia\j and \JPeru\j recommend a \Jvaccination\j, especially if visiting rural areas.
Therefore, if you are travelling from a country listed below to a tropical South American country, you are required to have a yellow fever \Jvaccination\j.
\IEndemic Yellow Fever-Infected Countries for Travel to Tropical South America:\i
Cote d'Ivoire (Ivory Coast), Equatorial Guinea, \JEthiopia\j, \JGabon\j, Gambia, \JGhana\j, Guinea, Guinea- \JBissau\j, \JKenya\j, \JLiberia\j, Mali, \JMauritania\j, \JNiger\j, \JNigeria\j, \JRwanda\j, Sao Tome and Principe, \JSenegal\j, Sierra Leone, \JSomalia\j, \JSudan\j, \JTanzania\j, \JTogo\j, \JUganda\j and Zaire.
South America: \JBolivia\j, \JBrazil\j, \JColombia\j, \JEcuador\j, French Guiana, \JGuyana\j, Panama, \JPeru\j, Suriname, Venezuela.
For travel to: \JBolivia\j, \JBrazil\j, \JEcuador\j, French Guiana, \JGuyana\j, \JPeru\j and Suriname.
\BThus, except for \JParaguay\j, all tropical South American countries require yellow fever vaccinations and certificates from travellers from the above countries. \BFor \JGuyana\j, travellers from \JBelize\j, Costa Rica, \JGuatemala\j, \JHonduras\j and \JNicaragua\j also need to be vaccinated.\b
\IYellow Fever Certificate\i
After immunisation, an International Certificate of \JVaccination\j is issued and is valid 10 days after \Jvaccination\j to meet entry and exit requirements for all countries. View a correctly-completed International Certificate of \JVaccination\j. The Certificate is good for 10 years. You must take the Certificate with you.
Travellers who have a medical reason not to receive the yellow fever vaccine should obtain a medical waiver and check embassies or consulates for specific waiver requirements.
Dengue fever occurs throughout tropical South America, with recent epidemics in \JBrazil\j, \JColombia\j, \JEcuador\j, French Guiana, Suriname, Venezuela and the tropical parts of \JBolivia\j, \JParaguay\j and \JPeru\j. The risk of infection is small for most travellers except during periods of epidemic transmission.
\IOther Insect Diseases\i
Other diseases spread by mosquitoes, sand flies, black flies or other insects are prevalent, especially in rural areas. These diseases include: filariasis (mosquito), \Jleishmaniasis\j (sand fly), onchocerciasis (black flies), American trypanosomiasis or Chagas' Disease ('cone nose' or 'kissing' bug), Oropouche Virus (gnats or midges), \Jtyphus\j (lice) and plague (fleas).
\BDiseases Transmitted Through Food and Water:\b see '\JFood and Drink, Risks to Traveller\j' and '\JTraveller's Diarrhoea\j'.
\B\b
Food and waterborne diseases are the number one cause of illness to travellers and are very common in tropical South America.
Traveller's diarrhoea is the most frequent health problem for travellers. It can be caused by viruses, bacteria or parasites which are found universally throughout the region. Transmission is most often through contaminated food or water. Infections may cause diarrhoea and vomiting (typhoid fever, \Jcholera\j and parasites), liver damage (hepatitis) or muscle paralysis (polio).
A recent epidemic of \Jcholera\j has swept through the entire tropical South American area. Persons following the usual tourist itinerary who follow the food safety recommendations, however, are at virtually no risk of infection.
Travellers to tropical South America are at risk for typhoid fever, especially when travelling to smaller cities, villages or rural areas.
The Centers For Disease Control and Prevention (CDC) recommends a typhoid \Jvaccination\j for those travellers who are going off the usual tourist itineraries, travelling to smaller cities and rural areas or staying for six weeks or more. Typhoid \Jvaccination\j is not required for international travel.
\IHepatitis A\i [see '\JHepatitis, viral, type A (Travel Information)\j']
Travellers are at high risk for Hepatitis A, especially if travel plans include visiting rural areas and extensive travel in the countryside, frequent close contact with local persons or eating in settings of poor sanitation.
A study has shown that many cases of travel-related hepatitis A occur in travellers to developing countries with 'standard' itineraries, accommodations and food consumption behaviours. It is therefore recommended that travellers receive hepatitis A vaccine or IG for protection against hepatitis A. Strict food and water precautions are also recommended.
\IParasitic infections:\i
Travellers to tropical South America are at risk of parasitic infections. There are many types of parasites and infection may occur in several ways: by eating undercooked meats infected with parasites or their \Jlarva\j; by eating food or drinking water contaminated with parasites or their eggs; by contact with soil or water infected with parasites; or through insect bites.
Several types of parasites can penetrate intact skin and travellers are advised to wear shoes and avoid swimming, wading or washing in fresh water (see '\JSchistosomiasis (Travel Information)\j' and '\JSwimming Precautions When Abroad\j').
Travellers should eat only thoroughly cooked food, drink safe water, wear shoes and avoid contact with insects, particularly mosquitoes, biting flies, gnats and midges.
\BDiseases Transmitted Through Intimate Contact with People:\b see '\JHIV Infection and AIDS, General Recommendations to Traveller\j', and '\JWHO Blood Transfusion Guidelines for International Travellers\j'.
HIV/AIDS is found throughout the world. The risk to a traveller depends on whether the traveller will be involved in sexual or needle-sharing contact with a person who is infected with \JHIV\j or receive unscreened blood for transfusion.
\IHepatitis B\i [see '\JHepatitis, viral, type B (Travel Information)\j']
Hepatitis B rates are high in the Amazon Basin and are intermediate for the rest of tropical South America. The risk for acquiring disease is greater if the traveller has contact with blood or secretions containing blood, sex contact with an infected person or remains in the country for longer than six months and has close contact with the local population.
In tropical South America, schistosomiasis infection may be found in parts of \JBrazil\j, Suriname and Venezuela. For travellers visiting these areas, the risk is a function of the frequency and degree of contact with contaminated fresh water for bathing, wading or swimming. Avoid contact with potentially contaminated water.
For countries in tropical South America, there is a risk of \Jrabies\j infection particularly in rural areas, or in urban areas where large numbers of dogs are found.
\BSummary of Recommendations for Tropical South America:\b
Travellers should:
(1) take the appropriate country-specific \Jmalaria\j prevention measures;
(2) follow precautions to prevent insect bites;
(3) pay attention to the quality of their drinking water and food;
(4) have a dose of Immune \JGlobulin\j (IG) or the Hepatitis A vaccine; and
(5) consider booster doses of tetanus (Td).
(6) Depending on the locations to be visited, planned activities and health of the traveller, the following vaccines should be considered: Hepatitis B, Yellow Fever, Typhoid, \JRabies\j (pre-exposure) and \JCholera\j. Details for these recommendations are found in this document.
(7) Finally, the normal 'childhood' vaccines should be up-to-date: \JMeasles\j, \JMumps\j, Rubella (MMR Vaccine); \JDiphtheria\j, Tetanus, \JPertussis\j (DTP Vaccine) [ < 7 years of age] and Polio vaccine.
#
"West Africa (Travel Health Tips)",42,0,0,0
(Date last rev'd: 7 November 1996)
\ICountries in this region:\i Benin, Burkina Faso, Cape Verde Islands, Cote d'Ivoire, Gambia, \JGhana\j, Guinea, Guinea-Bissau, \JLiberia\j, Mali, \JMauritania\j, \JNiger\j, \JNigeria\j, Sao Tome & Principe, \JSenegal\j, Sierra Leone, \JTogo\j.
Travellers to West Africa may be exposed to potential diseases from a number of sources. The most frequently reported illness is traveller's diarrhoea, but there are other diseases which are unique to Africa or the tropics. These diseases are transmitted by insects, contaminated food and water or close contact with infected people. Specific diseases are discussed under each of these topical headings.
In order to reduce the risk of infection travellers must (1) protect themselves from insects, (2) ensure the quality of their food and drinking water, and (3) be knowledgeable about potential diseases in the region to be visited.
Finally, diseases are not restricted to cleanly defined geographical areas, i.e. mosquitoes can fly over city or country borders; therefore, all travellers should protect themselves by taking the basic preventive precautions.
\BDiseases Transmitted by Insects:\b see '\JMosquitoes and Other Arthropod Vectors, Protection Against\j'.
In Benin, Burkina Faso, Cote d'Ivoire, Gambia, \JGhana\j, Guinea, Guinea-Bissau, \JLiberia\j, Mali, \JMauritania\j, \JNiger\j, \JNigeria\j, Sao Tome & Principe, \JSenegal\j, Sierra Leone and \JTogo\j, a high risk for \Jmalaria\j exists throughout the year in all parts of these countries including the urban areas. The dominant form is \IP. falciparum\i (the most dangerous type), which has been reported to be resistant to the drug chloroquine.
Cape Verde Islands have no risk of \Jmalaria\j except on the Island of Sßo Tiago; no prophylaxis is recommended.
Travellers at risk for \Jmalaria\j should take \Imefloquine\i to prevent \Jmalaria\j. Consult a physician for precautions.
In addition to using drugs to prevent \Jmalaria\j, travellers should use measures to reduce exposure to malaria-carrying mosquitoes and protect themselves from mosquito bites. These mosquitoes bite mainly during the evening and night, from dusk to dawn.
Outbreaks of yellow fever have occurred in Burkina Faso, Cote d'Ivoire, Gambia, \JGhana\j, Mali, \JMauritania\j, \JNigeria\j, \JSenegal\j, Sierra Leone and \JTogo\j. Yellow fever is not always active in all countries of this region, but there is a significant risk to all travellers throughout the year, especially in travel or visits to rural settings. Travellers should obtain a current list of yellow fever-infected countries.
\BNote: some countries require yellow fever \Jvaccination\j for entry.\b (See Requirements below.) In general, if you are travelling to a West African country, the easiest and safest thing to do is to get a yellow fever \Jvaccination\j and a signed certificate. This vaccine is only administered at designated yellow fever centres.
In addition to the vaccine, travellers should use measures to reduce exposure to mosquitoes and protect themselves from mosquito bites. These mosquitoes bite mainly during the evening and morning hours.
\IRequirements:\i
\BPlease note:\b If you are travelling to any country in West Africa, the Centers For Disease Control and Prevention (CDC) \Irecommends and many countries require a yellow fever vaccination.\i (Yellow fever vaccine is the \Ionly\i vaccine that may be officially required for entry into certain countries.)\b
\I12 West African Countries Absolutely Require A Yellow Fever \JVaccination\j Certificate:\i
Benin, Burkina Faso, \JCameroon\j, Cote d'Ivoire (Ivory Coast), \JGabon\j, \JGhana\j, \JLiberia\j, Mali, \JMauritania\j, \JNiger\j, Sao Tome and Principe, and \JTogo\j.
In addition, if you are travelling from one of the African or South American countries listed below to a West African country, you are required to have a yellow fever \Jvaccination\j.
South America: \JBolivia\j, \JBrazil\j, \JColombia\j, \JEcuador\j, French Guiana, \JGuyana\j, Panama, \JPeru\j, Suriname, Venezuela.
For travel to: Cape Verde Islands, Equatorial Guinea, Gambia, Guinea, Guinea-Bissau, \JNigeria\j, \JSenegal\j, Sierra Leone.
Travellers should obtain comprehensive yellow fever \Jvaccination\j requirements.
\IYellow Fever Certificate\i
After immunisation, an International Certificate of \JVaccination\j is issued and is valid 10 days after \Jvaccination\j to meet entry and exit requirements for all countries. View a correctly-completed International Certificate of \JVaccination\j. The Certificate is good for 10 years. You must take the Certificate with you.
Travellers who have a medical reason not to receive the yellow fever vaccine should obtain a medical waiver and check embassies or consulates for specific waiver requirements.
Dengue fever occurs sporadically in epidemics, most recently in Burkina Faso, Cote d'Ivoire (Ivory Coast), Guinea, \JNigeria\j and \JSenegal\j. The risk of infection is small for most travellers except during periods of epidemic transmission.
\IOther Insect Diseases:\i
Other diseases spread by mosquitoes, sand flies, black flies or other insects are prevalent, especially in rural areas. These diseases include: filariasis and Chikungunya (mosquito), \Jleishmaniasis\j (sand fly), onchocerciasis (black flies), African trypanosomiasis (flies), Congo-Crimean haemorrhagic fever (ticks), \Jtyphus\j (lice) and plague (fleas).
\BDiseases Transmitted Through Food and Water:\b see '\JFood and Drink, Risks to Traveller\j' and '\JTraveller's Diarrhoea\j'.
\B\b
Food and waterborne diseases are the number one cause of illness to travellers and are very common in West Africa.
Traveller's diarrhoea is the most frequent health problem for travellers. It can be caused by viruses, bacteria or parasites which are found universally throughout the region. Transmission is most often through contaminated food or water. Infections may cause diarrhoea and vomiting (typhoid fever, \Jcholera\j and parasites), liver damage (hepatitis) or muscle paralysis (polio).
Travellers to West Africa are at risk for typhoid fever, especially when travelling to smaller cities, villages or rural areas. The Centers For Disease Control and Prevention (CDC) recommends a typhoid \Jvaccination\j for those travellers who are going off the usual tourist itineraries, travelling to smaller cities and rural areas or staying for six weeks or more. Typhoid \Jvaccination\j is not required for international travel.
Cholera cases have been reported from most of the countries of West Africa. Persons following the usual tourist itinerary who follow the food safety recommendations, however, are at virtually no risk of infection.
\IHepatitis A\i [see '\JHepatitis, viral, type A (Travel Information)\j']
Travellers are at high risk for Hepatitis A, especially if travel plans include visiting rural areas and extensive travel in the countryside, frequent close contact with local persons or eating in settings of poor sanitation.
A study has shown that many cases of travel-related hepatitis A occur in travellers to developing countries with 'standard' itineraries, accommodations and food consumption behaviours. It is therefore recommended that travellers receive hepatitis A vaccine or IG for protection against hepatitis A. Strict food and water precautions are also recommended.
\IParasitic infections:\i
Travellers to West Africa are at risk of parasitic infections. There are many types of parasites and infection may occur in several ways: by eating undercooked meats infected with parasites or their \Jlarva\j; by eating food or drinking water contaminated with parasites or their eggs; by contact with soil or water infected with parasites; or through insect bites.
Several types of parasites can penetrate intact skin and travellers are advised to wear shoes and avoid swimming, wading or washing in fresh water (see '\JSchistosomiasis (Travel Information)\j' and '\JSwimming Precautions When Abroad\j').
Travellers should eat only thoroughly cooked food, drink safe water, wear shoes and avoid contact with insects, particularly mosquitoes, biting flies, gnats and midges.
\BDiseases Transmitted Through Intimate Contact with People:\b see '\JHIV Infection and AIDS, General Recommendations to Traveller\j', and '\JWHO Blood Transfusion Guidelines for International Travellers\j'.
HIV/AIDS is found throughout the world. The risk to a traveller depends on whether the traveller will be involved in sexual or needle-sharing contact with a person who is infected with \JHIV\j or receive unscreened blood for transfusion.
\IHepatitis B\i [see '\JHepatitis, viral, type B (Travel Information)\j']
Hepatitis B rates are high in Africa and the risk for acquiring disease is greater if the traveller has contact with blood or secretions containing blood, sex contact with an infected person or remains in the country for longer than six months and has close contact with the local population.
There is seasonal risk of meningococcal disease in parts of West Africa, primarily during the dry season from December through June. When a traveller lives and works around the local population, the risk increases.
Vaccination is not required for entry into any country in this region. CDC recommends \Jvaccination\j with meningococcal vaccine for travellers going to Mali and all countries directly eastward, including Burkina Faso, \JNiger\j, Benin and \JNigeria\j, when travel occurs between December and June.
\BUpdate\b
A large outbreak of meningococcal disease has been reported in the Gambia, with approximately 700 cases and 115 deaths reported during this outbreak. It is generally confined to the Basse region (approximately 350 kilometres east of Banjul) in the Upper River Division. The Ministry of Health has undertaken a mass \Jvaccination\j effort in the Basse region.
In sub-Saharan Africa, epidemics of serogroup A or C meningococcal disease occur frequently during the dry season (December through June), particularly in the savanna areas known as the 'meningitis belt'.
Meningococcal disease in travellers to such areas is rare and there have been no reports of meningococcal disease in travellers to the Gambia at this time. Because of the potential risk for exposure in this area of the Gambia at the present time, however, it is recommended that travellers to this region receive the meningococcal polysaccharide vaccine.
Schistosomiasis infection is widespread in West Africa, especially in the savanna regions of Burkina Faso, Mali, \JNiger\j and \JNigeria\j. The risk is a function of the frequency and degree of contact with contaminated fresh water for bathing, wading or swimming. Avoid contact with potentially contaminated water.
For countries in West Africa, there is a risk of \Jrabies\j infection particularly in rural areas, or in urban areas where large numbers of dogs are found.
\BSummary of Recommendations for West Africa: \b
Travellers should:
(1) take the appropriate drug for \Jmalaria\j prevention;
(2) follow precautions to prevent insect bites;
(3) pay attention to the quality of their drinking water and food;
(4) have a dose of Immune \JGlobulin\j (IG) or the Hepatitis A vaccine; and
(5) consider booster doses of tetanus (Td) and polio (eIPV) vaccines.
(6) Depending on the locations to be visited, planned activities and health of the traveller, the following vaccines should be considered: Hepatitis B, Yellow Fever, Typhoid, Meningococcal, \JRabies\j (pre-vaccine) and \JCholera\j. Details for these recommendations are found in this document.
(7) Finally, the normal 'childhood' vaccines should be up-to-date: \JMeasles\j, \JMumps\j, Rubella (MMR Vaccine); \JDiphtheria\j, Tetanus, \JPertussis\j (DTP Vaccine) [ < 7 years of age] and Polio vaccine.
#
"Western Europe (Travel Health Tips)",43,0,0,0
(Date last rev'd: 7 November 1996)
\ICountries in this region:\i \JAndorra\j, \JAustria\j, \JAzores\j, \JBelgium\j, Denmark, Faroe Island, \JFinland\j, \JFrance\j, \JGermany\j, \JGibraltar\j, \JGreece\j, \JGreenland\j, \JIceland\j, Ireland, \JItaly\j, \JLiechtenstein\j, Luxembourg, Madeira, Malta, Monaco, Netherlands, \JNorway\j, \JPortugal\j, San Marino, \JSpain\j, Sweden, \JSwitzerland\j, United Kingdom.
Travellers to Western Europe may be exposed to potential diseases from a number of sources. The most frequently reported illness is traveller's diarrhoea, but there are other diseases transmitted by insects, contaminated food and water, or close contact with infected people. Specific diseases are discussed under each of these topical headings.
In order to reduce the risk of infection travellers must (1) protect themselves from insects, (2) ensure the quality of their food and drinking water, and (3) be knowledgeable about potential diseases in the region to be visited.
Finally, diseases are not restricted to cleanly defined geographical areas, i.e. mosquitoes can fly over city or country borders; therefore, all travellers should protect themselves by taking the basic preventive precautions.
\BDiseases Transmitted by Insects:\b see '\JMosquitoes and Other Arthropod Vectors, Protection Against\j'.
The risk to travellers who do not visit or work in forested areas and who avoid unpasteurised dairy products is apparently low.
Tickborne \Jencephalitis\j occurs chiefly in Central and Western Europe, including the countries from the Mediterranean to Scandinavia. It is of particular importance in \JAustria\j, \JGermany\j and \JSwitzerland\j. Tickborne \Jencephalitis\j is found less frequently in \JFinland\j and Sweden, and is rare in Denmark and \JFrance\j.
Transmission occurs in the summer months. Travellers are at risk if their plans include hiking, camping or working in or around forested regions. The chance that a traveller to Western Europe will develop tickborne \Jencephalitis\j is very small.
Preventing tick-bites is sufficient protection for nearly all travellers to tickborne encephalitis-infested areas.
Inactivated vaccines are produced in \JAustria\j and \JGermany\j but are not available in the United States. They can be obtained in Europe. Persons at risk should arrange to receive the vaccine at the country of destination; however, the immunisation schedule is impractical and unnecessary for most tourists. Travellers who remain unimmunised should protect themselves from ticks and check for ticks daily.
Travellers visiting western European countries who will be hiking, camping or visiting wooded parks and rural areas are at risk of lyme disease. They should take precautions to prevent tick bites.
Even though there is no risk of becoming infected while travelling in Western European countries, a number of these countries \Irequire\i a yellow fever \Jvaccination\j if a traveller is coming from areas in Africa and South America where yellow fever is found.
If not required (e.g. for those \Ionly \itravelling from the United States to a Western European country), it is not recommended to have a yellow fever \Jvaccination\j. However, if your travel plans include travelling to or from a country in Africa or South America, you may be required to have a yellow fever \Jvaccination\j. Travellers should contact embassies or consulates for advice.
\BDiseases Transmitted Through Food and Water:\b see '\JFood and Drink, Risks to Traveller\j' and '\JTraveller's Diarrhoea\j'.
\B\b
Food and waterborne diseases are the number one cause of illness to travellers and are found in Western Europe.
Traveller's diarrhoea is the most frequent health problem for travellers. It can be caused by viruses, bacteria or parasites which are found universally throughout the region. Transmission is most often through contaminated food or water. Infections may cause diarrhoea and vomiting (typhoid fever, \Jcholera\j and parasites), liver damage (hepatitis) or muscle paralysis (polio).
\IHepatitis A\i [see '\JHepatitis, viral, type A (Travel Information)\j']
In general, travellers to Northern and Western Europe are \Inot\i at increased risk for hepatitis A. However, increased risk does exist in Southern Europe where there are intermediate rates of hepatitis A. Risk is even greater if travel plans include visits to rural areas, extensive travel in the countryside, frequent, close contact with local persons or eating in settings of poor sanitation.
A study has shown that many cases of travel-related hepatitis A occur in travellers to developing countries with 'standard' itineraries, accommodations and food consumption behaviours. Strict food and water precautions are recommended.
\BDiseases Transmitted Through Intimate Contact with People:\b see '\JHIV Infection and AIDS, General Recommendations to Traveller\j', and '\JWHO Blood Transfusion Guidelines for International Travellers\j'.
HIV/AIDS is found throughout the world. The risk to a traveller depends on whether the traveller will be involved in sexual or needle-sharing contact with a person who is infected with \JHIV\j or receive unscreened blood for transfusion.
\IHepatitis B\i [see '\JHepatitis, viral, type B (Travel Information)\j']
There is a risk of \Jrabies\j infection particularly in rural areas and in areas where large numbers of foxes are found.
Dog \Jrabies\j is found in the European portion of Turkey. There is little risk in mainland \JSpain\j and \JPortugal\j, and some Western European countries have reported no \Jrabies\j cases for at least the past two years, including: Cyprus, Faroe Islands, \JFinland\j, \JGibraltar\j, \JGreece\j, \JIceland\j, Ireland, Malta, Monaco, \JNorway\j (mainland), Sweden and the United Kingdom.
\BSummary of Recommendations for Western Europe:\b
Travellers should:
(1) follow precautions to prevent insect bites;
(2) pay attention to the quality of their drinking water and food;
(3) travellers to Southern Europe should have a dose of Immune \JGlobulin\j (IG) or Hepatitis A vaccine; and
(4) consider booster dose of tetanus (Td).
(5) Depending on the locations to be visited, planned activities and health of the traveller, the following vaccines should be considered: Hepatitis B vaccine (Malta), \JRabies\j (pre-exposure) and Typhoid. Details for these recommendations are found in this document.
(6) Finally, the normal 'childhood' vaccines should be up-to-date: \JMeasles\j, \JMumps\j, Rubella (MMR Vaccine); \JDiphtheria\j, Tetanus, \JPertussis\j (DTP Vaccine) [ < 7 years of age] and Polio vaccine.
#
"Information on Diseases for the Traveller",44,0,0,0
\BChapter 3 of Health Information for International Travel 1996-97\b
Click on one of these page links to jump directly to that page or simply click on the \INext Page\i button to begin reading this chapter.
African trypanosomiasis is confined to tropical Africa between 15? North and 20? South latitude. It is transmitted by the bite of the tsetse fly, a large grey-brown insect approximately the size of a \Jhoneybee\j, which bites during the day.
Chronic trypanosomiasis (caused by the parasite \ITrypanosoma brucei gambiense)\i may not cause symptoms until months to years following travel to an endemic area, but the incubation period of acute trypanosomiasis (caused by the parasite \ITrypanosoma brucei rhodesiense)\i ranges from 6 to 28 days, and travellers frequently become ill during their trips or shortly after returning home. Fever, rash or skin lesions, lethargy and confusion are usually the predominate signs and symptoms.
Although the risk to international travellers is relatively low, persons travelling to game parks and sparsely inhabited areas should take precautions. The main risk is to travellers on safari in rural areas.
Tsetse flies appear to be attracted to moving vehicles and dark, contrasting colours. The flies are capable of biting through lighter weight clothing. Areas of heavy infestation tend to be sporadically distributed and are usually well known to local inhabitants. Avoidance of such areas is the best means of prevention.
Travellers at risk should use DEET-containing insect repellents liberally and wear clothing of wrist and ankle length that blends with the background environment and is constructed of heavy (e.g. canvas weight) fabric. (See '\JMosquitoes and Other Arthropod Vectors, Protection Against\j').
#
"Amoebiasis (Travel Information)",46,0,0,0
Amoebiasis, which is caused by the protozoan parasite \IEntamoeba histolytica,\i occurs worldwide, especially in regions with poor sanitation. Infection is acquired by the faecal-oral route, either by person-to-person contact or indirectly by eating or drinking faecally contaminated food or water.
Travellers to developing countries are advised to follow the precautions included under '\JFood and Drink, Risks to Traveller\j'.
The clinical spectrum of intestinal amoebiasis ranges from asymptomatic infection to fulminant \Jcolitis\j. Most infected persons do not have symptoms. In infected persons who are symptomatic, the most common symptom is diarrhoea. The diarrhoea may evolve to painful, bloody bowel movements, with or without fever (amoebic dysentery). Occasionally, amoebiasis causes disease outside the intestines, most notably in the liver (amoebic liver abscess).
Chagas' disease occurs throughout much of the Western hemisphere from Mexico to Argentina. The disease is caused by the protozoan parasite,\I Trypanosoma cruzi.\i Chagas' disease is usually transmitted by contact with faeces of an infected reduviid ('cone nose' or 'kissing') bug; transmission may also occur through blood transfusion or via transplacental infection.
Acute infection may be asymptomatic or accompanied by a febrile illness with meningoencephalitis and/or myocarditis. Manifestations of chronic infection include cardiomyopathy and intestinal 'mega' syndromes, e.g. megaesophagus and megacolon.
Reduviid bugs typically infest buildings constructed of mud, adobe brick or palm thatch, particularly those with cracks or crevices in the walls and roof. Avoidance of overnight stays in dwellings infested by the reduviid bug vector greatly reduces the risk of acquiring the infection. Alternate preventive measures include \Jinsecticide\j spraying of infested houses and the use of bed netting. The latter is recommended if camping or sleeping out-of-doors in highly endemic areas.
In some regions, travellers should be aware that blood for transfusion may not be routinely tested or treated for \IT. cruzi.\i While anti-trypanosomal treatment exists for acute disease, currently there is no accepted anti-parasitic treatment for chronic infection. Persons with chronic cardiac or mega-syndromes may, however, benefit from symptomatic therapy.
#
"Chikungunya Fever (Travel Information)",48,0,0,0
Chikungunya fever is a viral infection transmitted by mosquitoes found in Africa, the Indian subcontinent and Southeast Asia. Sporadic cases as well as large outbreaks have occurred in these areas.
Symptoms include fever, headache, nausea, rash and the abrupt onset of pain in one or more joints. Deaths rarely occur from Chikungunya fever, but residual joint stiffness can last for weeks or months. Treatment is limited and no vaccine is available.
#
"Cholera (Travel Information)",49,0,0,0
Cholera is an acute, diarrhoeal illness caused by infection of the \Jintestine\j with the toxigenic bacterium \IVibrio\i \Icholerae\i O-group 1 or O-group 139. The infection is often mild and self-limited or without symptoms, but sometimes it can be severe. Approximately one in 20 infected persons has severe disease characterised by profuse watery diarrhoea, vomiting and leg cramps. In these persons, rapid loss of body fluids leads to \Jdehydration\j and shock. Without treatment, death can occur within hours.
A person may get \Jcholera\j by drinking water or eating food contaminated with the \Jcholera\j bacterium. In an epidemic, the source of the contamination is usually the faeces of an infected person. The disease can spread rapidly in areas with inadequate treatment of sewage and drinking water.
The \Jcholera\j bacterium may also live in the environment in brackish rivers and coastal waters. Shellfish eaten raw have been a source of \Jcholera\j, and a few persons in the United States have contracted \Jcholera\j after eating raw or undercooked shellfish from the Gulf of Mexico.
The disease is not likely to spread directly from one person to another; therefore, casual contact with an infected person is not a risk for becoming ill.
The risk for \Jcholera\j is very low for travellers from industrialised countries visiting areas with epidemic \Jcholera\j. When simple precautions are observed, contracting the disease is unlikely.
Persons following the usual tourist itinerary who follow the food safety recommendations below while in countries reporting \Jcholera\j are at virtually no risk of infection.
All travellers to areas where \Jcholera\j has occurred should observe the following recommendations:
òDrink only water that you have boiled or treated with \Jchlorine\j or \Jiodine\j. Other safe beverages include tea and \Jcoffee\j made with boiled water and carbonated, bottled beverages with no ice.
òEat only foods that have been thoroughly cooked and are still hot or fruit that you have peeled yourself.
òAvoid undercooked or raw fish or shellfish, including ceviche.
òMake sure all vegetables are cooked; avoid salads.
òAvoid foods and beverages from street vendors.
òDo not bring perishable seafood back to your country.
A simple rule of thumb is: \IBoil it, cook it, peel it, or forget it.\i
Cholera can be simply and successfully treated by immediate replacement of the fluid and salts lost through diarrhoea. Patients can be treated with oral rehydration solution, a pre-packaged mixture of sugar and salts to be mixed with purified water and drunk in large amounts. This solution is used throughout the world to treat diarrhoea. Severe cases may require intravenous fluid replacement. With prompt rehydration, fewer than 1% of \Jcholera\j patients die.
Antibiotics shorten the course and diminish the severity of the illness, but they are not as important as rehydration. Persons who develop severe diarrhoea and vomiting in countries where \Jcholera\j occurs should seek medical attention promptly.
A vaccine for \Jcholera\j is available. However, this vaccine provides only about 50 percent effectiveness in reducing clinical illness from \IVibrio cholerae\i O1 infection for 3-6 months after \Jvaccination\j, with the greatest protection for the first 2 months. This vaccine probably provides no protection against illness caused by the recently discovered \IVibrio cholerae\i O-group 139.
The risk of \Jcholera\j to travellers from industrialised countries is so low that it is questionable whether \Jvaccination\j is of benefit.
Currently no country or territory requires \Jvaccination\j as a condition for entry. Local authorities, however, may continue to require documentation of \Jvaccination\j against \Jcholera\j; in such cases, a single dose of vaccine is sufficient to satisfy local requirements.
The complete series is suggested only for special high-risk groups that work and live in highly endemic areas under less than adequate sanitary conditions. The primary series need never be repeated for the booster doses to be effective.
Cholera vaccine is not recommended for infants under 6 months of age.
\IReactions\i
Vaccination often results in 1-2 days of pain, erythema and induration at the site of injection. The local reaction may be accompanied by fever, malaise and headache. Serious reactions to \Jvaccination\j are extremely rare. If a person has experienced a serious reaction to the vaccine, re-vaccination is not advisable.
\IPregnancy\i
Specific information is not available on the safety of \Jcholera\j vaccine during \Jpregnancy\j. Therefore, it is prudent on theoretical grounds to avoid vaccinating pregnant women.
\IThe spread of cholera\i
Cholera has been very rare in industrialised nations for the last 100 years; however, the disease is still common today in other parts of the world, including the Indian subcontinent and sub-saharan Africa.
In January 1991, epidemic \Jcholera\j appeared in South America and quickly spread to several countries. A few cases have occurred in the United States among persons who travelled to South America or ate contaminated food brought back by travellers.
Predicting how long the epidemic in Latin America will last is difficult. The \Jcholera\j epidemic in Africa has lasted more than 20 years. In areas with inadequate sanitation, a \Jcholera\j epidemic cannot be stopped immediately, and there are no signs that the epidemic in the Americas will end soon.
Latin American countries that have not yet reported cases are still at risk for \Jcholera\j in the coming months and years. Major improvements in sewage and water treatment systems are needed in many of these countries to prevent future epidemic \Jcholera\j.
The global picture of \Jcholera\j changes periodically, so travellers should seek updated information on countries of interest.
For more detailed information on \Jcholera\j, contact your local health authority.
This viral infection is found in Eastern Europe, Central Asia, the Indian Subcontinent and Africa, and is transmitted by the bite of an infected tick. Symptoms include sudden onset of fever, chills, aches and pains, headache, and severe pain in the arms or legs. A rash may appear and internal bleeding sometimes occurs. The illness can be severe and deaths have been reported. Treatment is limited and no vaccine is available.
#
"Cryptosporidiosis (Travel Information)",51,0,0,0
Cryptosporidiosis occurs worldwide. Transmission occurs after ingestion of faecally contaminated food or water, including water swallowed while swimming; from exposure to faecally contaminated environmental surfaces; and from person-to-person by the faeces-to-hands-to-mouth route (e.g. changing diapers or caring for an infected person) or direct faecal-oral route, particularly sexual behaviour involving contact with faeces.
Symptoms include watery diarrhoea, abdominal cramps and a slight fever, which normally last 1 to 3 weeks in immunocompetent individuals. In persons with a severely weakened immune system, cryptosporidiosis is not self-limiting and can be fatal.
There is no known chemoprophylaxis for cryptosporidiosis and no anti-parasitic drug has yet been found that can shorten the duration of infection. To avoid contracting cryptosporidiosis, travellers should follow the precautions included under '\JFood and Drink, Risks to Traveller\j'.
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"Cyclospora (Travel Information)",52,0,0,0
\ICyclospora cayetanensis,\i previously known as cyanobacterium-like, coccidia-like and Cyclospora-like body (CLB) is a protozoan (one-celled) parasite that causes gastrointestinal infection. Travellers to tropical countries may be at increased risk for this infection, with the risk sometimes varying with season (e.g. in \JNepal\j, risk is highest during the rainy season).
Infection is acquired by ingestion of something (e.g. water, food) contaminated with the parasite. Travellers to developing countries are advised to follow the precautions included under '\JFood and Drink, Risks to Traveller\j'. Direct person-to-person transmission is unlikely.
Infection can be asymptomatic or be manifested by such symptoms as watery diarrhoea, loss of appetite, weight loss, bloating, increased gas, \Jstomach\j cramps, nausea, vomiting, tiredness, muscle aches and low-grade fever. Some persons first notice flu-like symptoms. If untreated, the illness can last for weeks to months.
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"Dengue Fever (Travel Information)",53,0,0,0
Dengue is a mosquito-transmitted viral disease occurring chiefly in tropical and subtropical areas of the world. There are four \Jdengue\j viruses which are immunologically related, but which do not provide cross-protective immunity.
Dengue viruses are transmitted by urban \IAedes\i mosquitoes, usually \IAedes aegypti,\i which are most active during the day. Mosquitoes that transmit \Jdengue\j usually are found near human dwellings. There are two peaks of biting activity, in the morning for several hours after daybreak and in the late afternoon for several hours before dark. The mosquito may feed at any time during the day, however, especially indoors, in shady areas, or when it is overcast.
Larval habitats include artificial water containers such as discarded tires, barrels, buckets, flower vases/pots, cans and cisterns.
Dengue is predominant in urban centres, but may be found in rural areas; it is rarely found at elevations above 4000 feet. Epidemic transmission is usually seasonal, during and shortly after the rainy season.
Dengue fever is characterised by sudden onset, high fever, severe headaches, joint and muscle pain, nausea, vomiting and rash. The rash appears 3-4 days after the onset of fever and may spread from torso to arms, legs and face.
Infection is diagnosed by a special laboratory test of blood that detects the presence of the virus or \Jantibodies\j. The disease is usually benign and self-limited, although convalescence may be prolonged. The illness may last up to 10 days, but complete recovery can take 2 to 4 weeks.
Dengue is commonly confused with other infectious illnesses such as influenza, \Jmeasles\j, \Jmalaria\j, typhoid and scarlet fever. The symptoms of \Jdengue\j can be treated with bed rest, fluids and medications to reduce fever, such as acetaminophen; aspirin should be avoided. \JDengue\j does not produce long-term complications.
Many cases of subclinical or non-specific infection occur, but \Jdengue\j may also present as a severe and fatal haemorrhagic disease called \Jdengue\j haemorrhagic fever (DHF) or 'dengue shock syndrome', which is very rare among travellers. Symptoms initially are indistinguishable from \Jdengue\j fever, but the illness progresses to faintness, shock and generalised bleeding.
There is no specific treatment for \Jdengue\j infection and vaccines are not available.
There are no travel restrictions for any country with regard to \Jdengue\j, although many cases have been reported in travellers returning from the Indian Subcontinent, Southeast Asia, Southern China, Central and South America (except \JChile\j and Argentina), the Caribbean (except \JCuba\j and the \JCayman\j Islands), Mexico and Africa.
There is a somewhat lower risk for travellers to \JTaiwan\j and the Pacific Islands. The Middle East and Northern \JAustralia\j have a still lower risk of \Jdengue\j transmission. New Zealand is free of \Jdengue\j fever.
Dengue fever is rapidly expanding in most tropical areas of the world. In the past 20 years, it has become the most important arborvirus disease of humans. There are now over 2 billion persons at risk of infection and millions of cases occur each year.
Epidemics caused by all four virus serotypes have become progressively more frequent and larger. Since 1982, major epidemics have occurred for the first time in over 30 years in \JBolivia\j, \JBrazil\j, Costa Rica, \JEcuador\j, Panama, \JParaguay\j, \JPeru\j and Venezuela in the Americas; Saudi \JArabia\j; \JSomalia\j, \JKenya\j, Djibouti, \JMozambique\j, \JAngola\j and Burkino Faso in Africa; and China and \JTaiwan\j in Asia.
In 1996, \Jdengue\j viruses are endemic in most tropical countries of the South Pacific, Asia, the Caribbean Basin, Mexico, Central and South America, and Africa. It is not possible to accurately predict future \Jdengue\j incidence, but it is anticipated that there will be increased \Jdengue\j transmission in all tropical areas of the world during the next several years.
The incidence of the severe disease, DHF, has increased dramatically in Southeast Asia in the past 20 years, with major epidemics occurring in most countries every 3 to 4 years.
Dengue haemorrhagic fever first occurred in the Americas in 1981, with a major epidemic in \JCuba\j. A second major epidemic of DHF occurred in Venezuela in 1989-90, and smaller outbreaks have occurred in \JBrazil\j, \JColombia\j, French Guiana and \JNicaragua\j. DHF has also been confirmed as sporadic cases in many countries of the region including Mexico, El Salvador, \JHonduras\j, Suriname, \JEcuador\j, Curacao, \JAruba\j, St Lucia, Puerto Rico and the Dominican Republic.
Although not completely understood, current data suggest that virus strain, together with age, immune status and genetic background of the human host are the most important risk factors for developing DHF. In Asia, children under the age of 15 years who are experiencing a second \Jdengue\j infection appear to have the highest risk. Although adults can also develop DHF, this suggests that most international travellers from non-endemic areas are at low risk for severe \Jdengue\j infection.
The risk of \Jdengue\j infection for the international traveller thus appears to be small, unless an epidemic is in progress. However, cases of \Jdengue\j are confirmed every year in travellers returning from visits to endemic areas. Travellers to endemic and epidemic areas, therefore, should take precautions to avoid mosquito bites.
Travellers can reduce their risk of acquiring \Jdengue\j by remaining in well-screened or air-conditioned areas when possible, by wearing clothing that adequately covers the arms and legs, and by applying mosquito repellent. The most effective repellents are those containing N,N-diethyl-metatoluamide (DEET) at a concentration equal to or greater than 30 percent. High concentration (>30% DEET) products for the skin, particularly in children, should be avoided.
Travellers should advise their physician of any acute febrile illness occurring within 1 month after returning from an endemic area. Be prepared to give your complete travel itinerary, so that the physician can evaluate the possibility that your symptoms were caused by a \Jdengue\j infection.
Physicians should notify the state health department of any suspected or confirmed case of \Jdengue\j.
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"Diphtheria, Tetanus and Pertussis (Travel Information)",54,0,0,0
Diphtheria remains a serious disease throughout much of the world. In particular, large outbreaks of \Jdiphtheria\j are currently occurring throughout the New Independent States of the former Soviet Union (NIS). Most cases occur in unimmunised or inadequately immunised persons.
Tetanus is a global health problem. The disease occurs almost exclusively in persons who are unimmunised or inadequately immunised or whose history is unknown. In developing countries most reported illness occurs in infants and young children.
Pertussis primarily occurs in children and is common in countries where immunisation is not generally provided. It is highly communicable, often associated with complications, and has a relatively high case? fatality ratio in infants.
\IAdverse Reactions\i
Local reactions (generally erythema and induration with or without tenderness) are common after the administration of vaccines containing \Jdiphtheria\j, tetanus and \Jpertussis\j antigens. Mild systemic reactions such as fever, drowsiness, fretfulness and anorexia occur frequently.
Moderate-to-severe systemic events, including high fever (i.e. temperature greater than 40.5░ C [105░ F]); persistent or inconsolable crying lasting more than 3 hours; collapse (hypotonic-hyporesponsive episode); or short-lived convulsions (usually febrile) occur infrequently. These events appear to be without sequelae.
Rarely, severe neurologic events, such as a prolonged convulsion or encephalopathy, have occurred after receiving DTP. Some children who develop acute encephalopathy within 7 days of \Jpertussis\j
vaccination may develop permanent neurologic sequelae. In 1994, the Institute of Medicine (USA) reported that the available evidence is consistent with (but insufficient to prove) a causal relationship between DTP and chronic nervous system dysfunction in such children.
The receipt of DTP is not causally related to sudden infant death syndrome (SIDS).
Rarely, anaphylactic reactions have been reported after receiving a preparation containing \Jdiphtheria\j, tetanus and/or \Jpertussis\j. Arthus-type \Jhypersensitivity\j reactions, characterised by severe local reactions, may follow receipt of tetanus and \Jdiphtheria\j toxoids, particularly in adults who have received frequent (e.g. annual) boosters of tetanus and/or \Jdiphtheria\j toxoid.
The rates of local reactions, fever and other common systemic symptoms following receipt of DTaP (combination \Jdiphtheria\j and tetanus toxoids and acellular \Jpertussis\j vaccine) are lower than those following whole-cell DTP \Jvaccination\j.
\IPrecautions and Contraindications\i
Neurologic conditions characterised by changing developmental findings are considered contraindications to receipt of \Jpertussis\j vaccine. Such disorders include uncontrolled \Jepilepsy\j, infantile spasms and progressive encephalopathy.
Children who because of perinatal complications or other phenomena are felt to be at an increased risk of latent onset of central nervous system disorders should have immunisation with DTP or DT (excluding \Jpertussis\j vaccine) delayed until further observation and study have clarified the child's neurologic status. The decision whether to commence immunisation with DTP or with DT should be made no later than the child's first birthday.
Infants and children with stable neurologic conditions such as cerebral palsy and developmental delay or even well-controlled seizures may be vaccinated. The occurrence of a single seizure (not temporally associated with DTP) does not contraindicate DTP \Jvaccination\j, particularly if the seizures can be satisfactorily explained.
Parents of infants and children with personal or family histories of convulsion should be informed of the increased risk of simple febrile seizures following immunisation. Acetaminophen should be given to children with such histories to reduce the possibility of post-vaccination fever.
Infants and children who have received more than one dose of DTP and who experience a neurologic disorder (e.g. a seizure) not temporally associated with the \Jvaccination\j, but before the next scheduled dose, should have their neurologic status evaluated and clarified before a subsequent dose of DTP is given, or the decision made to use DT instead.
When an infant or child returns for the next dose of DTP, the parent should always be questioned about any adverse events that might have occurred following the previous dose. Further \Jvaccination\j with DTP is contraindicated if an anaphylactic reaction immediately followed a DTP dose, or if an encephalopathy not due to another identifiable cause occurred within 7 days of receipt of DTP.
If any of the following events occur in temporal relation to receipt of DTP, the decision to give subsequent doses of vaccine containing the \Jpertussis\j component should be carefully considered.
Although these events were considered absolute contraindications in previous ACIP recommendations, there may be circumstances, such as a high incidence of \Jpertussis\j, in which the potential benefits outweigh possible risks, particularly because these events are not associated with permanent sequelae.
The following events were previously considered contraindications and are now considered precautions:
1. Temperature of more than 40.5░ C (105░ F) within 48 hours not due to another identifiable cause.
2. Collapse or shock-like state (hypotonic-hyporesponsive episode) within 48 hours.
3. Persistent, inconsolable crying lasting more than 3 hours, occurring within 48 hours.
4. Convulsions with or without fever occurring within 3 days.
If the decision is to discontinue further \Jvaccination\j with DTP, DT should be substituted for any remaining scheduled doses of DTP.
The only contraindication to tetanus and \Jdiphtheria\j toxoids is a history of a neurologic or severe \Jhypersensitivity\j reaction following a previous dose. There is no evidence that tetanus and \Jdiphtheria\j toxoids are teratogenic.
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"Encephalitis, Japanese (Travel Information)",55,0,0,0
Japanese \Jencephalitis\j (JE) is a common mosquito-borne viral \Jencephalitis\j in Asia. Transmission is seasonal and occurs in the summer and autumn in the temperate regions of China, \JJapan\j, Korea and eastern areas of \JRussia\j. Elsewhere, seasonal patterns of disease are more extended or vary with the rainy season and irrigation practices.
Most infections are asymptomatic, but among patients who develop a clinical illness, the case? fatality rate may be as high as 30%. Neuropsychiatric sequelae are reported in 50% of survivors.
In endemic areas, children are at greatest risk of infection; however, multiple factors such as occupation, recreational exposure, gender (possibly reflecting exposure), previous \Jvaccination\j and naturally acquired immunity, alter the potential for infection and illness.
A higher case? fatality rate is reported in the elderly, but serious sequelae are more frequent in the very young, possibly because they are more likely to survive a severe infection.
JE virus is transmitted chiefly by the bites of mosquitoes in the \ICulex vishnui\i complex: the individual vector species in specific geographic areas differ.
In China and many endemic areas in Asia, \ICulex tritaeniorhyncus\i is the principal vector. This species feeds outdoors beginning at dusk and during evening hours until dawn, and has a wide host range including domestic animals, birds and man. Larvae are found in flooded rice fields, marshes and small stable collections of water around cultivated fields.
In temperate zones the vectors are present in greatest numbers from June through September and are inactive during winter months. Swine and certain species of wild birds function as viremic amplifying hosts in the transmission cycle. Habitats supporting the transmission cycle of JE virus are principally in rural, agricultural locations. In many areas of Asia, however, the appropriate ecological conditions for virus transmission occur near or occasionally within urban centres.
The risk to short-term travellers and persons who confine their travel to urban centres is very low. Expatriates and travellers living for prolonged periods in rural areas where JE is endemic or epidemic are at greatest risk.
Travellers with extensive unprotected outdoor, evening and night-time exposure in rural areas, such as during bicycling, camping or certain occupational activities, may be at high risk even if their trip is brief. Travellers are advised to stay in screened or air-conditioned rooms, to use bednets when such quarters are unavailable, to use insecticidal space sprays as necessary, and mosquito repellents and protective clothing to avoid mosquito bites.
\IVaccination\i
Vaccination should only be considered for persons who plan to live in areas where JE is endemic or epidemic and for travellers whose activities include trips into rural, farming areas.
Short-term travellers (less than 30 days), especially those whose visits are restricted to major urban areas, are at a lower risk for acquiring JE and, generally, should not receive the vaccine. Evaluation of an individual traveller's risk should consider their itinerary activities, and the current level of JE activity in the country.
\IAdverse Reactions\i
JE vaccine is associated with local reactions and mild systemic side effects (fever, headache, myalgias, malaise) in about 20% of vaccinees. More serious allergic reactions including generalised \Jurticaria\j, angioedema, respiratory distress and \Janaphylaxis\j have occurred within minutes to as long as one week after immunisation. Such \Jhypersensitivity\j reactions occur in approximately 0.6% of vaccinees.
Reactions have been responsive to therapy with epinephrine, \Jantihistamines\j and/or steroids. Vaccinees should be observed for 30 minutes after immunisation and warned about the possibility of delayed allergic reactions.
The full course of immunisation should be completed at least 10 days before departure and vaccinees should be advised to remain in areas with access to medical care. Persons with a past history of \Jurticaria\j appear to have a greater risk for developing more serious allergic reactions and this must be considered when weighing the risks and benefits of the vaccine. A history of \Jallergy\j to JE or other mouse-derived vaccines is a contraindication to further immunisation.
\IContraindications\i
Persons with known \Jhypersensitivity\j to the vaccine should not be vaccinated. Persons with multiple allergies, especially a history of allergic \Jurticaria\j or angioedema, are at higher risk for allergic complications from JE vaccine.
Vaccination during \Jpregnancy\j should be avoided unless the risk of acquiring Japanese \Jencephalitis\j outweighs the theoretical risk of \Jvaccination\j.
Tickborne \Jencephalitis\j (TBE), also known as spring-summer \Jencephalitis\j, is a viral infection of the central nervous system transmitted by the bites of certain vector ticks. The disease occurs in Scandinavia, Western and Central Europe, and countries that comprise the former Soviet Union.
Risk of acquiring the disease is greatest from April through August when \IIxodes ricinus,\i the principal tick vector, is most active.
TBE is common in \JAustria\j, the Czech Republic, \JSlovakia\j, \JGermany\j, \JHungary\j, \JPoland\j, \JSwitzerland\j, \JRussia\j, \JUkraine\j, \JBelarus\j and northern Yugoslavia. It occurs at a lower frequency in \JBulgaria\j, \JRomania\j, Denmark, \JFrance\j, the Aland Islands and neighbouring Finnish coastline, and along the coastline of southern Sweden, from \JUppsala\j to Karlshamn. Serologic evidence for TBE infection or sporadic cases have been reported from \JAlbania\j, \JGreece\j, \JItaly\j, \JNorway\j and Turkey.
A closely related disease, Russian spring-summer \Jencephalitis\j, transmitted by \IIx. persulcatus\i ticks, occurs in China, Korea, \JJapan\j and eastern areas of \JRussia\j. The severity of disease, incidence of sequelae and case? fatality rates are higher in the Far East and eastern regions of \JRussia\j than in western and central Europe.
Human infections follow bites of infected \IIx. ricinus\i ticks, usually in persons who visit or work in forests, fields or pastures. Infection also may be acquired by consuming unpasteurised dairy products from infected cows, goats or sheep.
The risk to travellers who do not visit forested areas or consume unpasteurised dairy products is low. Travellers should be advised to avoid tick-infested areas and to protect themselves from tick bites by dressing appropriately and using repellents. The repellent N,N-diethyl-metatoluamide (DEET) can be applied either to clothing or directly on the skin. Compounds containing permethrin have an acaricidal and repellent effect and should be used on clothing and camping gear.
Consumption of unpasteurised dairy products should be avoided.
Although effective vaccines may be obtained in Europe from Immuno, Vienna, \JAustria\j, and Behring, \JGermany\j, available data do not support a recommendation for its use in travellers.
\IEscherichia coli\i O157:H7 is an emerging cause of foodborne illness. An estimated 10,000 to 20,000 cases of infection occur in the United States each year. Infection often leads to bloody diarrhoea, and occasionally to kidney failure.
Most illness has been associated with eating undercooked, contaminated ground beef. Person-to-person contact in families and child care centres is also an important mode of transmission. Infection can also occur after drinking raw milk and after swimming in or drinking sewage-contaminated water.
Consumers can prevent \IE. coli\i O157:H7 infection by thoroughly cooking ground beef, avoiding unpasteurised milk and washing hands carefully.
Eating meat, especially ground beef, that has not been cooked sufficiently to kill\I E. coli\i O157:H7 can cause infection. Contaminated meat looks and smells normal. Although the number of organisms required to cause disease is not known, it is suspected to be very small.
Bacteria in diarrhoeal stools of infected persons can be passed from one person to another if hygiene or handwashing habits are inadequate. This is particularly likely among toddlers who are not toilet- trained. Family members and playmates of these children are at high risk of becoming infected. Young children typically shed the organism in their faeces for a week or two after their illness resolves. Older children rarely carry the organism without symptoms.
\IE. coli\i O157:H7 infection often causes severe bloody diarrhoea and abdominal cramps; sometimes the infection causes non-bloody diarrhoea or no symptoms. Usually little or no fever is present, and the illness resolves in 5 to 10 days.
In some persons, particularly children under 5 years of age and the elderly, the infection can also cause a complication called haemolytic uremic syndrome, in which the red blood cells are destroyed and the \Jkidneys\j fail. About 2-7% of infections lead to this complication. In the United States, haemolytic uremic syndrome is the principal cause of acute kidney failure in children, and most cases of haemolytic uremic syndrome are caused by \IE. coli\i O157:H7.
Infection with \IE. coli\i O157:H7 is diagnosed by detecting the bacterium in the stool. Most laboratories that culture stool do not test for \IE. coli\i O157:H7, so it is important to request that the stool specimen be tested on sorbitol-MacConkey (SMAC) \Jagar\j for this organism. All persons who suddenly have diarrhoea with blood should get their stool tested for \IE. coli\i O157:H7.
Persons who only have diarrhoea usually recover completely. Most persons recover without \Jantibiotics\j or other specific treatment in 5-10 days. There is no evidence that \Jantibiotics\j improve the course of disease, and it is thought that treatment with some \Jantibiotics\j may precipitate kidney complications. Anti-diarrhoeal agents, such as loperamide (Imodium), should also be avoided.
Haemolytic uremic syndrome is a life-threatening condition usually treated in an intensive care unit. Blood transfusions and kidney \Jdialysis\j are often required.
With intensive care, the death rate for haemolytic uremic syndrome is 3-5%. About one-third of persons with haemolytic uremic syndrome have abnormal kidney function many years later, and a few require long-term \Jdialysis\j. Another 8% of persons with haemolytic uremic syndrome have other lifelong complications, such as high blood pressure, seizures, \Jblindness\j, paralysis, and the effects of having part of their bowel removed.
\IPreventing E. coli infection\i
òCook all ground beef or hamburger thoroughly. Make sure that the cooked meat is grey or brown throughout (not pink), any juices run clear and the inside is hot.
òIf you are served an undercooked hamburger in a restaurant, send it back for further cooking. òConsume only pasteurised milk and milk products. Avoid raw milk.
òMake sure that infected persons, especially children, wash their hands carefully and frequently with soap to reduce the risk of spreading the infection.
òDrink municipal water that has been treated with adequate levels of \Jchlorine\j or other effective disinfectants.
Lymphatic filariasis affects an estimated 100 million persons in tropical areas of the world including sub-Saharan Africa, \JEgypt\j, southern Asia, the western Pacific Islands, the northeastern coast of South and Central America, the Indian subcontinent and the Caribbean.
The two major species of filariae which cause lymphatic disease in humans are \IWuchereria bancrofti \iand \IBrugia malayi.\i Disease is thought to be caused primarily by the adult worms, which live in the lymphatic vessels; the female worms release microfilariae which circulate in the peripheral blood and are ingested by mosquitoes; thus infected mosquitoes transmit the infection from person to person.
Clinical manifestations include asymptomatic infection, acute \Jinflammation\j of the \Jlymph\j nodes ('filarial fever'), tropical pulmonary eosinophilia, lymphedema that may progress to \Jelephantiasis\j, and testicular hydrocele.
Short-term travellers to endemic areas are at low risk for this infection. Persons who visit endemic areas for extended periods of time and who are intensively exposed to infected mosquitoes may become infected.
Effectiveness of chemoprophylaxis has not been well-documented and no vaccine is available. Protective measures include avoidance of mosquito bites through the use of personal protection measures.
#
"Giardiasis (Travel Information)",59,0,0,0
Giardiasis occurs worldwide. Transmission occurs after ingestion of faecally contaminated water or food, from exposure to faecally contaminated environmental surfaces, and from person-to-person by the faecal-oral route.
Symptoms include diarrhoea, abdominal cramps, fatigue, weight loss, flatulence, anorexia or nausea, in various combinations, and usually last for more than 5 days. Fever and vomiting are uncommon. There is no known chemoprophylaxis.
To prevent infection, travellers to disease-endemic areas should follow the precautions included under '\JFood and Drink, Risks to Traveller\j'.
#
"Haemophilus Influenzae Type b Meningitis and Invasive Disease (Travel Information)",60,0,0,0
\IHaemophilus influenzae\i type b causes meningitis and other severe bacterial illnesses (e.g. \Jpneumonia\j, septic \Jarthritis\j, epiglottitis and sepsis), primarily among children less than 5 years of age. Severe disease is most common in children 6 months to 1 year of age, but approximately 20-35 percent of severe disease occurs in children 18 months of age or older. It was the most common cause of bacterial meningitis in the United States before use of Haemophilus b conjugate vaccines (HbCV) dramatically reduced incidence of this disease.
The risk of exposure to persons with the organism and the disease while travelling outside the United States is at least as high as that within industrialised countries such as the United States.
\ISide Effects and Adverse Reactions\i
HbCV is considered relatively free of side effects. Redness and/or swelling following receipt of the current HbCV occurs in less than 2 percent of recipients. About 1 out of every 100 recipients will have a fever of 101.3░ F or higher. These reactions begin within 24 hours and generally subside rapidly. Severe \Jhypersensitivity\j reactions have been rare.
\IPrecautions and Contraindications\i
Recurrent upper respiratory diseases, including otitis media and sinusitis, are not considered indications for \Jvaccination\j. HbOC or PRP-D vaccines should not be considered as an immunising agent against \Jdiphtheria\j. PRP-OMP should not be considered as an immunising agent against meningococcal disease.
#
"Hepatitis, viral, type A (Travel Information)",61,0,0,0
Hepatitis A is an enterically transmitted viral disease which is highly endemic throughout the developing world but of low endemicity in developed countries such as the United States.
In developing countries, hepatitis A virus (HAV) is usually acquired during childhood, most frequently as an asymptomatic or mild infection. Transmission may occur by direct person-to-person contact; or from contaminated water, ice, or shellfish harvested from sewage-contaminated water; or from fruits, vegetables or other foods which are eaten uncooked, but which may become contaminated during handling.
HAV is inactivated by boiling or cooking to 85░C (1 minute); cooked foods cannot serve as
vehicles for disease unless contaminated after cooking. Adequate chlorination of water as practised in the industrialised countries will inactivate HAV.
The risk of acquiring HAV infection while travelling abroad varies with living conditions, length of stay and incidence of hepatitis A in the area visited.
Travellers to North America (except Mexico) and developed countries in Europe, \JJapan\j, \JAustralia\j and New Zealand are at no greater risk of infection than in their home countries. For travellers to developing countries, risk of infection increases with duration of travel, and will be highest in those who live in or visit rural areas, trek in back-country areas, or frequently eat or drink in settings of poor sanitation.
Nevertheless, many cases of travel-related hepatitis A occur in travellers to developing countries with 'standard' tourist itineraries, accommodations and food consumption behaviours.
In developing countries, travellers should minimise their risk of acquiring hepatitis A and other enteric diseases by avoiding potentially contaminated water or food. Drinking water (and beverages with ice) of unknown purity, uncooked shellfish, and uncooked fruits or vegetables which are not peeled or prepared by the traveller, should be avoided.
Hepatitis A vaccine or immune \Jglobulin\j (IG, formerly immune serum \Jglobulin\j and gamma globulin) is recommended for all susceptible persons travelling to or working in countries with intermediate or high endemicity of infection.
Travellers should note that preparations manufactured in foreign countries may or may not meet the requirements of such countries as the United States, where IG for intramuscular administration is prepared by the 'Cohn-Oncley' procedure to avoid transmission of infectious agents such as hepatitis B virus or \JHIV\j. Persons needing repeat doses in other countries should use products that meet such standard license requirements.
Vaccination of children 2 years of age and older, adolescents and adults with the age-appropriate
dose is preferred for persons who plan to travel repeatedly or reside for long periods in these high-risk areas. IG is recommended for travellers less than 2 years of age and for persons of all ages desiring only short-term protection.
Pre-vaccination testing is not indicated for children because of their expected low prevalence of prior HAV infection.
For some adult travellers who are likely to have had hepatitis in the past (i.e. persons older than 40 years of age, persons born in parts of the world with intermediate or high rates of hepatitis A or persons with clotting disorders), screening for hepatitis A \Jantibodies\j (anti-HAV) before travel may be useful to determine susceptibility and eliminate unnecessary \Jvaccination\j or IG prophylaxis of immune persons.
Such serologic screening for susceptibility may be indicated for adult travellers who are likely to have had prior HAV infection if the cost of screening (laboratory and office visit) is less than the cost of \Jvaccination\j or IG prophylaxis and if testing will not interfere with subsequent receipt of vaccine or IG.
Post-vaccination testing for serologic response is not indicated.
Data on long-term persistence of antibody after hepatitis A \Jvaccination\j are limited because the currently available vaccines have been under evaluation for only 4-5 years. Estimates of antibody persistence derived from kinetic models of antibody decline suggest that protective levels of anti-HAV could persist for at least 20 years.
Persons can be assumed to be protected by 4 weeks after receiving the first vaccine dose, although a second dose 6 to 12 months later is necessary for long-term protection. Because protection may not be complete until 4 weeks after vaccine administration, persons travelling to high-risk areas less than 4 weeks after the initial dose should also be given IG, but at a different injection site.
\ISafety\i
Experience to date indicates that hepatitis A vaccine has an excellent safety profile. No serious vaccine-related adverse experiences were observed during clinical trials.
The most common side effects are mild problems that usually disappear within 1 to 2 days. These may include soreness or swelling at the site of injection, headache, tiredness and/or loss of appetite. As with any medication, there are very small risks that serious problems such as severe allergic reaction and even death could occur after getting the vaccine. Most people who have received hepatitis A vaccine have no problems from it.
For serious adverse events for which background incidence data are known (e.g. Guillain-BarrΘ syndrome and brachial plexus neuropathy), the rates among vaccine recipients are not higher than would be expected among an unvaccinated population (Centers For Disease Control and Prevention, unpublished data). In Europe, the ratio of reported adverse events to number of doses distributed is similar for the manufacturer's hepatitis A and hepatitis B vaccines (SmithKline Beecham Biologicals, unpublished data).
Hepatitis A vaccine should not be administered to persons with a history of \Jhypersensitivity\j
reactions to \Jalum\j or the preservative 2-phenoxyethanol. \JVaccination\j of an immune person is not contraindicated and does not increase the risk of adverse effects. Because the vaccine is inactivated, no special precautions need to be taken in \Jvaccination\j of immunocompromised persons.
\IPregnancy\i
The safety of hepatitis A \Jvaccination\j during \Jpregnancy\j has not been determined. However, because hepatitis A vaccine is produced from inactivated HAV, the theoretical risk to the developing foetus is expected to be low. The risk of \Jvaccination\j should be weighted against the risk of hepatitis A in women who may be at high risk for exposure to HAV.
#
"Hepatitis, viral, type B (Travel Information)",62,0,0,0
The risk of hepatitis B virus (HBV) infection for international travellers is generally low, except for certain travellers in countries with high HBV endemicity. Factors to consider when assessing risk include: 1) the prevalence of HBV carriers in the local population, 2) the extent of direct contact with blood or secretions, or of intimate sexual contact with potentially infected persons, and 3) the duration of travel.
The prevalence of HBV carriers is high (more than 8%) in all socioeconomic groups in certain areas: all of Africa, Southeast Asia including China, Korea, \JIndonesia\j and the \JPhilippines\j; the Middle East except Israel; South and Western Pacific Islands, interior Amazon Basin and certain parts of the Caribbean, i.e. \JHaiti\j and the Dominican Republic.
It is moderate (2%-7%) in South Central and Southwest Asia, Israel, \JJapan\j, Eastern and Southern Europe and \JRussia\j, and most of Middle and South America.
In Northern and Western Europe, North America, \JAustralia\j and New Zealand, HBV carrier prevalence is low (less than 1%) in the general population.
HBV is primarily transmitted through activities which result in exchange of blood or blood-derived fluids; and through sexual activity, either heterosexual or homosexual, between an infected and a susceptible person.
Principal activities which may result in blood exposure include work in health care fields, i.e. medical, dental and laboratory, which entail direct exposure to human blood; receipt of blood transfusions which have not been screened for HBV; and having dental, medical or other exposure to needles (e.g. \Jacupuncture\j, tattooing or injecting drug use) which have not been appropriately sterilised.
In addition, in less developed areas, open skin lesions in children or adults due to factors such as impetigo, \Jscabies\j and scratched insect bites, may play a role in disease transmission if direct exposure to wound exudates occurs.
Hepatitis B \Jvaccination\j is currently recommended for all persons who work in health care fields (medical, dental, laboratory or other) which entail exposure to human blood. Previously unvaccinated persons who will work in health care fields for any duration in high or moderate HBV endemicity areas are strongly advised to receive hepatitis B vaccine prior to such travel.
Hepatitis B \Jvaccination\j should also be considered for persons who plan to reside for more than 6 months in areas with intermediate to high levels of endemic HBV transmission and who will have any of the previously discussed types of contact with the local population.
In particular, persons who anticipate sexual contact with the local population, who will live in rural areas and/or have daily physical contact with local populations; and persons who are likely to seek medical, dental or other treatment in local facilities during their stay should receive the vaccine.
Vaccination should be considered for short-term travellers (< 6 months) who will have direct contact with blood or sexual contact with residents of areas with moderate to high levels of endemic HBV transmission.
Vaccination should ideally begin at least 6 months before travel in order to complete the full vaccine series prior to departure. There is no evidence of interference between hepatitis B vaccine and other simultaneously administered vaccine(s) or with \Jimmunoglobulin\j.
The optimum site of injection in adults is the deltoid muscle; \Jvaccination\j in the buttocks results in poorer antibody response.
Long-term studies of healthy adults and children indicate that immunologic memory remains intact for at least 12 years and confers protection against chronic HBV infection, even though hepatitis B surface antibody (anti-HBs) levels may become low or decline below detectable levels. For children and adults whose immune status is normal, booster doses of vaccine are not recommended, nor is serologic testing to assess antibody levels necessary.
\ISafety\i
Hepatitis B vaccines have been shown to be safe when administered to both adults and children. Over 4 million adults have been vaccinated in the United States, and at least that many children have received hepatitis B vaccine worldwide.
The major side-effects observed with hepatitis B vaccines have been soreness and redness at the site of injection. In the United States, surveillance of adverse reactions has shown a possible association between Guillain-BarrΘ syndrome (GBS) and receipt of the first dose of plasma-derived hepatitis B vaccine. Available data from reporting systems for adverse events do not indicate an association between receipt of recombinant vaccine and GBS.
\IPregnancy\i
On the basis of limited data, there is no apparent risk of adverse events to the developing foetus when hepatitis B vaccine is administered to pregnant women. The vaccine contains non-infectious HBsAg particles, and should cause no risk to the foetus.
HBV infection affecting a pregnant woman may result in serious disease for the mother and chronic infection for the newborn. Therefore, neither \Jpregnancy\j or \Jlactation\j should be considered a contraindication for \Jvaccination\j.
In recent years, epidemic and endemic transmission of hepatitis E virus (HEV) spread by water or close personal contact has been reported from several areas of Asia (Afghanistan, \JBangladesh\j, China, Central Asian Republics of the former Soviet Union, \JIndonesia\j, \JMalaysia\j, \JMongolia\j, \JMyanmar\j, \JPakistan\j and India), North Africa, and from rural areas of central Mexico. Such epidemics generally affect adults and cause an unusually high mortality in pregnant women.
HEV has been transmitted to experimental animals and the virus has been cloned and sequenced. Several experimental assays to detect antibody to HEV (anti-HEV) have been developed, although none are yet available for commercial use in the United States.
Immune \Jglobulin\j (IG) prepared from plasma collected in non-HEV endemic areas has not been effective in preventing clinical disease during hepatitis E outbreaks. The efficacy of IG prepared from plasma collected in HEV-endemic areas is unclear.
Travellers to areas where hepatitis E occurs may be at some risk of acquiring this disease by close contact with cases or through contaminated food or water. The best prevention of infection is to avoid potentially contaminated food and water, as with hepatitis A and other enteric infections.
#
"Lassa Fever (Travel Information)",64,0,0,0
Lassa fever is a severe, often fatal, haemorrhagic fever that occurs in rural areas of West Africa and is caused by a virus transmitted from asymptomatically-infected rodents to man. The risk of infection in international travellers is considered small. Treatment with the anti-viral drug ribavirin may be life-saving. There are no vaccines currently available.
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"Leishmaniasis (Travel Information)",65,0,0,0
Leishmaniasis is a parasitic disease acquired in tropical and subtropical areas of the world (Central and South America, Africa, Indian subcontinent and parts of Europe). Persons become infected through the bite of some species of sand flies. The infection usually is acquired in rural areas but may be acquired in some urban areas as well.
The disease most commonly manifests either in a cutaneous (skin) form or in a visceral (internal organ) form. Cutaneous \Jleishmaniasis\j is characterised by one or more skin sores (either open or closed) that develop weeks to months after a person is bitten by infected sand flies. The manifestations of visceral \Jleishmaniasis\j, such as fever, enlargement of the \Jspleen\j and liver, and anaemia, typically develop months, but sometimes years after a person becomes infected.
Vaccines and drugs for preventing infection are not currently available. Preventive measures for the individual traveller are aimed at reducing contact with sand flies.
Outdoor activities should be avoided when sand flies are most active (dusk to dawn). Although sand flies are primarily night-time biters, infection may be acquired during the daytime if resting sand flies are disturbed. Sand fly activity in an area may easily be underestimated because sand flies are noiseless fliers, and rare bites may go unnoticed.
Protective clothing and insect repellent should be used for supplementary protection. Clothing should cover as much of the body as possible and tolerable in the climate.
Repellent with DEET (N,N-diethylmetatoluamide) should be applied to exposed skin and under the edges of clothing, such as under the ends of sleeves and pant legs. It should be applied according to the manufacturer's instructions; repeated applications may be necessary under conditions of excessive perspiration, wiping and washing. Although impregnation of clothing with permethrin may provide additional protection, it does not eliminate the need for repellent on exposed skin and should be repeated after every five washings.
Contact with sand flies can be reduced by mechanical means, such as bednets and screening of doors and windows. Fine-mesh netting (at least 18 holes to the linear inch; some sources say even finer) is required for an effective barrier against sand flies, which are about one-third the size of mosquitoes. However, such closely woven bed nets may be difficult to tolerate in hot climates. Impregnating bed nets and window screens with permethrin \Jaerosol\j may provide some protection, as may spraying dwelling with insecticides.
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"Lyme Disease (Travel Information)",66,0,0,0
Lyme disease is a bacterial infection caused by the bite of certain very small, infected ticks. The illness is characterised by an expanding circular rash of 2 inches or more with a 'bull's-eye' appearance. The rash is often accompanied by flu-like symptoms of fever, headache, tiredness, and sometimes generalised aches and pains.
If untreated, Lyme disease can cause further problems involving the heart, joints and nervous system. Lyme disease can be treated effectively with \Jantibiotics\j.
#
"Malaria (Travel Information)",67,0,0,0
Malaria in humans is caused by one of four protozoan species of the \Jgenus\j \IPlasmodium:\i \IP. falciparum,\i \IP. vivax,\i\I P. ovale\i and \IP. malariae.\i All are transmitted by the bite of an infected female\I Anopheles\i mosquito. Occasionally transmission occurs by blood transfusion or congenitally from mother to foetus.
The disease is characterised by fever and flu-like symptoms, including chills, headache, myalgias and malaise; these symptoms may occur at intervals. \JMalaria\j may be associated with anaemia and \Jjaundice\j, and \IP. falciparum \iinfections may cause kidney failure, coma and death. Deaths due to \Jmalaria\j are preventable; methods to prevent \Jmalaria\j infection are described in this section.
Information on \Jmalaria\j risk in specific countries is derived from various sources, including the World Health Organisation. While this is the most accurate information available at the time of publication, factors that may vary from year to year, such as local weather conditions, mosquito vector density and prevalence of infection, can have a marked effect on local \Jmalaria\j transmission patterns.
\IRisk of Acquiring Malaria\i
Malaria transmission occurs in large areas of Central and South America, \JHispaniola\j, sub-Saharan Africa, the Indian subcontinent, Southeast Asia, the Middle East and \JOceania\j. The estimated risk of a traveller acquiring \Jmalaria\j varies markedly from area to area. This variability is a function of the intensity of transmission within the various regions and of the itinerary and time and type of travel.
Estimating the risk of infection for different categories of travellers is difficult and may be significantly different even for persons who travel or reside temporarily in the same general areas within a country. For example, tourists staying in air-conditioned hotels may be at lower risk than backpackers or adventure travellers. Similarly, longer-term residents living in screened and air-conditioned housing are less likely to be exposed than are missionaries or Peace Corps volunteers.
\IUS Case studies\i
From 1980-93, 3,005 cases of \IP. falciparum\i among US civilians were reported to the CDC. Of these, 2,472 (82%) were acquired in sub-Saharan Africa; 219 (8%) were acquired in Asia; 163 (5%) were acquired in the Caribbean and South America; and 151 (5%) were acquired in other parts of the world. During this time period there were 53 fatal \Jmalaria\j infections among US civilians; 51 (96%) were caused by \IP. falciparum\i-of which 40 (78%) were acquired in sub-Saharan Africa.
Thus, most imported \IP. falciparum\i \Jmalaria\j among American travellers was acquired in Africa south of the Sahara, even though only 130,000 arrivals from the United States were reported by countries in that region in 1991. In contrast, 20 million arrivals from the United States were reported that year in other countries with \Jmalaria\j, including 15 million travellers to Mexico (World Tourism Organisation).
This disparity in the risk of acquiring \Jmalaria\j may reflect the fact that travellers to Africa tend to spend considerable time, including evening and night-time hours, in rural areas where \Jmalaria\j risk is highest. Travellers to Asia and South America, in contrast, spend most of their time in urban or resort areas where there is limited, if any, risk of exposure, and travel to rural areas mainly during daytime hours when the risk of infection is limited.
\IDrug Resistance\i
Resistance of \IP. falciparum\i to chloroquine has been confirmed or is probable in all countries with \IP. falciparum\i \Jmalaria\j except the Dominican Republic, \JHaiti\j, Central America west of the Panama Canal Zone, \JEgypt\j and most countries in the Middle East.
In addition, resistance to both chloroquine and Fansidar (US tradename) is widespread in \JThailand\j, \JMyanmar\j (formerly Burma), \JCambodia\j and the Amazon basin area of South America, and resistance has also been reported sporadically in sub-Saharan Africa.
Resistance to mefloquine has been confirmed in those areas of \JThailand\j with \Jmalaria\j transmission.
\IGeneral Advice for Travellers to Malaria-Endemic Areas\i
All travellers to malarious areas of the world are advised to use an appropriate drug regimen and personal protection measures to prevent \Jmalaria\j; however, travellers should be informed that regardless of methods employed, \Jmalaria\j still may be contracted.
Malaria symptoms can develop as early as 6 days after initial exposure in a malaria-endemic area and as late as several months after departure from a malarious area, after chemoprophylaxis has been terminated. Travellers should understand that \Jmalaria\j can be treated effectively early in the course of the disease, but that delay of appropriate therapy can have serious or even fatal consequences.
Individuals who have symptoms of \Jmalaria\j should seek prompt medical evaluation, including thick and thin blood smears, as soon as possible.
\IPersonal Protection Measures\i
Because of the nocturnal feeding habits of \IAnopheles\i mosquitoes, \Jmalaria\j transmission occurs primarily between dusk and dawn. Travellers should take protective measures to reduce contact with mosquitoes, especially during these hours. Such measures include remaining in well-screened areas, using mosquito nets, and wearing clothes that cover most of the body.
Additionally, travellers should be advised to purchase insect repellent before travel for use on exposed skin. The most effective repellents contain N,N-diethylmetatoluamide (DEET), an ingredient in many commercially available insect repellents. The actual concentration of DEET varies among repellents and can be as high as 95%, although such high concentrations are not recommended. Repellents with DEET concentrations between 30% and 35% are quite effective and the effect should last for about 4 hours.
Rarely, children exposed to DEET have had toxic encephalopathy. The possibility of adverse reactions to DEET will be minimised if the following precautions are taken: apply repellent sparingly and only to exposed skin or clothing; avoid applying high-concentration (? 35%) products to the skin; do not inhale or ingest repellents or get them in the eyes; avoid applying repellents to portions of children's hands that are likely to have contact with eyes or mouth; never use repellents on wounds or irritated skin; and wash repellent-treated skin after coming indoors.
If a reaction to insect repellent is suspected, wash treated skin and seek medical attention.
Travellers should use a pyrethroid-containing flying-insect spray in living and sleeping areas during evening and night-time hours.
In addition, persons who will not be staying in well-screened or air-conditioned rooms should take additional precautions, which include sleeping under mosquito netting, i.e. bednets. Permethrin (Permanone) may be sprayed on clothing and bednets for additional protection against mosquitoes. Bednets are more effective if they are treated with permethrin or deltamethrin insecticides (spray or liquid).
\IChemoprophylaxis\i
In choosing an appropriate chemoprophylactic regimen before travel, persons should consider several factors. The travel itinerary should be reviewed in detail and compared with the information on areas of risk within a given country to determine whether the traveller will actually be at risk of acquiring \Jmalaria\j. Whether the traveller will be at risk of acquiring drug-resistant \IP. falciparum\i \Jmalaria\j should also be determined.
In addition, it should be established whether the traveller has previously experienced an allergic or other reaction to the antimalarial drug of choice and whether medical care will be readily accessible during travel.
Malaria chemoprophylaxis should preferably begin 1-2 weeks before travel to malarious areas (except for doxycycline, which can begin 1-2 days before). This allows any potential side effects to be evaluated and treated by the traveller's physician before departure. Chemoprophylaxis should continue during travel in the malarious areas and for 4 weeks after leaving the malarious areas.
For more information on \Jmalaria\j prevention drugs and other precautionary methods, consult a medical practitioner. It is always advisable to consult with a physician before administering any antimalarial drugs.
\B\I\i\BNOTE: OVERDOSE OF ANTIMALARIAL DRUGS CAN BE FATAL. MEDICATION SHOULD BE ADMINISTERED ONLY AS DIRECTED AND ALWAYS STORED IN CHILDPROOF CONTAINERS OUT OF THE REACH OF CHILDREN.\b
\BChecklist for Travellers to Malarious Areas\b
The following is a checklist of key issues to be considered in advising travellers.
Risk of \Jmalaria\j ? Travellers should be informed about the risk of \Jmalaria\j infection and the presence
of drug-resistant \IP. falciparum\i \Jmalaria\j in their areas of destination.
Anti-mosquito measures ? Travellers should know how to protect themselves against mosquito bites.
In case of illness ? Travellers should be:
- Informed that symptoms of \Jmalaria\j may be mild, and that they should suspect \Jmalaria\j if they experience unexplained fever or other symptoms such as persistent headaches, muscular aching and weakness, vomiting or diarrhoea.
- Informed that \Jmalaria\j may be fatal if treatment is delayed. Medical help should be sought promptly if \Jmalaria\j is suspected, and a blood sample should be taken and examined for \Jmalaria\j parasites on one or more occasions.
- Reminded that self-treatment should be taken only if prompt medical care is not available and that medical advice should still be sought as soon as possible after self-treatment.
Special categories
- Pregnant women and young children require special attention because of the potential effects of \Jmalaria\j illness and inability to use some drugs (for example, doxycycline).
#
"Measles (Rubeola) (Travel Information)",68,0,0,0
Measles is often a severe disease frequently complicated by middle ear infection or broncho-pneumonia.
Since vaccine licensure in 1963, \Jmeasles\j elimination efforts in the United States have resulted in record low numbers of reported \Jmeasles\j cases. Although the number of reported \Jmeasles\j cases increased in 1989-1991, chances remain low that individuals will be exposed to natural \Jmeasles\j; unvaccinated persons may reach older ages still susceptible to \Jmeasles\j.
The risk of exposure to \Jmeasles\j outside the United States may be high. Between 5 and 20 percent of \Jmeasles\j cases reported in the United States between 1991 and 1994 were internationally imported cases. Some of these were among returning US citizens exposed abroad.
Although \Jvaccination\j against \Jmeasles\j is not a requirement for entry into any country, all travellers are strongly urged to be immune to \Jmeasles\j. In general, persons can be considered immune to \Jmeasles\j if they have documentation of physician-diagnosed \Jmeasles\j, laboratory evidence of \Jmeasles\j immunity, or proof of receipt of two doses of live \Jmeasles\j vaccine on or after the first birthday.
Consideration should be given to providing one dose of \Jmeasles\j vaccine to persons born in or after 1957 who travel abroad who have not previously received 2 doses of \Jmeasles\j vaccine, and who do not have other evidence of \Jmeasles\j immunity, unless there is a contraindication. Most persons born before 1957 are likely to have been infected naturally and generally need not be considered susceptible.
However, \Jmeasles\j vaccine may be given to older persons if there is reason to believe they may be susceptible.
A single dose of live, attenuated \Jmeasles\j vaccine* administered subcutaneously in the volume specified by the manufacturer induces antibody formation in at least 95% of susceptibles vaccinated at 12-15 months of age or older. A second dose is expected to induce immunity in most vaccinees who do not respond to the first dose.
The use of a combined vaccine including rubella and/or \Jmumps\j vaccine should be considered to insure immunity to these viruses.
* Official name: \JMeasles\j Virus Vaccine, Live, Attenuated.
\ISide Effects and Adverse Reactions\i
Primary \Jvaccination\j may be associated with mild fever and transient rash beginning 7-12 days after \Jvaccination\j and usually lasting several days. About 5-15% of vaccinees may develop fever of higher than 103░ F (39.4░ C). Central nervous system conditions including \Jencephalitis\j and encephalopathy (less than 1 case for every million doses administered) have been reported.
However, the incidence rate of these conditions following \Jmeasles\j \Jvaccination\j is lower than the observed incidence rate of \Jencephalitis\j of unknown aetiology, suggesting the reported neurologic disorders may be caused by other factors. These adverse events should be anticipated only in susceptible vaccinees and do not appear to be age-related.
After re-vaccination, reactions should be expected to occur only among the small proportion of persons who failed to respond to the first dose. There is no evidence of a greater risk of reaction to live \Jmeasles\j vaccine for those who have previously received live \Jmeasles\j vaccine or had natural \Jmeasles\j.
Although recipients of killed \Jmeasles\j vaccine may be more likely to experience local and systemic reactions after re-vaccination with live \Jmeasles\j vaccine, these individuals should be re-vaccinated to avoid the severe atypical form of disease which often occurs after their exposure to natural \Jmeasles\j.
\IPrecautions and Contraindications
Pregnancy\i
Live \Jmeasles\j vaccine when given as a component of MR or MMR should not be given to females known to be pregnant or who might become pregnant within 3 months after \Jvaccination\j. Women who are given monovalent \Jmeasles\j vaccine should not become pregnant for at least 30 days after \Jvaccination\j. This precaution is based on the theoretical risk of foetal infection.
\IFebrile Illness\i
Although \Jvaccination\j of persons with severe febrile illness should be postponed until recovery, minor illnesses such as upper respiratory infections with or without low-grade fever do not preclude \Jvaccination\j.
\IAllergies\i
Live \Jmeasles\j vaccine is produced in chick embryo cell culture. \JHypersensitivity\j reactions very rarely follow the administration of live \Jmeasles\j vaccine. Most of these reactions are considered minor and consist of wheal and flare or \Jurticaria\j at the injection site.
However, persons with a history of anaphylactic reactions (hives, swelling of the mouth and throat, difficulty breathing, hypotension or shock) subsequent to egg ingestion should be vaccinated only with extreme caution. Protocols have been developed for vaccinating such individuals (J. Pediatr, 1983, 102:196-199; J. Pediatr, 1988, 113:504-6).
Evidence indicates that persons are not at increased risk if they have egg allergies that are not anaphylactic in nature. Such persons should be vaccinated in the usual manner. There is no evidence to indicate that persons with allergies to chickens or feathers are at increased risk of reaction to the vaccine.
Since \Jmeasles\j vaccine contains trace amounts of neomycin, persons who have experienced anaphylactic reactions to topically or systemically administered neomycin should not receive \Jmeasles\j vaccine. Most often, neomycin \Jallergy\j is manifested as a contact \Jdermatitis\j which is a delayed-type (cell-mediated) immune response rather than \Janaphylaxis\j. In such individuals, the adverse reaction, if any, to neomycin in the vaccine would be an erythematous, pruritic nodule or papule at 48-96 hours.
A history of contact \Jdermatitis\j to neomycin is not a contraindication to receiving \Jmeasles\j vaccine.
\ISimultaneous Administration of \JMeasles\j Vaccines\i
Live measles-containing vaccine may be administered simultaneously (but in a different site) with any other live or inactivated vaccine. Inactivated vaccines and oral polio virus vaccine may be administered at any time before or after live measles-containing vaccine. However, if live \Jmeasles\j vaccine and live yellow fever vaccine are not administered simultaneously they should be separated by an interval of at least 30 days.
\IRecent Administration of Immune \JGlobulin\j (IG)* or Other Antibody-Containing Blood Products\i
Measles vaccine should be administered at least 14 days before the administration of antibody-containing blood products, such as IG. Because passively acquired \Jantibodies\j might interfere with the response to the vaccine, MMR should be delayed following administration of blood products. The length of the delay varies from 3-11 months, depending on the type of blood product received.
* Formerly called immune serum \Jglobulin\j and gamma \Jglobulin\j.
\ITuberculosis and measles\i
Tuberculosis may be exacerbated by natural \Jmeasles\j infection. There is no evidence, however, that live \Jmeasles\j virus vaccine has such an effect. Therefore, tuberculosis skin testing should not be a prerequisite for \Jmeasles\j \Jvaccination\j.
If tuberculin skin testing is needed for other reasons, it can be performed the same day the \Jmeasles\j vaccine is administered. Otherwise, the test should be postponed for 4-6 weeks because \Jmeasles\j \Jvaccination\j may temporarily suppress tuberculin reactivity.
\IAltered Immunity\i
Replication of live \Jmeasles\j vaccine virus may be enhanced in patients with immune deficiency diseases and by the suppressed immune responses that occur with leukemia, lymphoma, generalised malignancy and therapy with corticosteroids, alkylating drugs, antimetabolites and radiation. Patients with such conditions should not be given live \Jmeasles\j virus vaccine.
However, because of the risk of severe \Jmeasles\j in symptomatic HIV-infected persons, and because limited studies of \Jmeasles\j, \Jmumps\j and rubella (MMR) immunisation in symptomatic patients have not documented serious or unusual adverse events, administration of \Jmeasles\j vaccine alone or in combination with rubella and \Jmumps\j vaccine should be considered for all susceptible HIV-infected travellers, regardless of the presence or absence of symptoms.
Vaccination against meningococcal disease is not a requirement for entry into any country, \Iexcept for pilgrims to Mecca, Saudi \JArabia\j, for the annual Hajj.\i Vaccine is indicated for travellers to countries recognised as having epidemic meningococcal disease caused by a vaccine-preventable serogroup (i.e. A, C, Y, W135).
In sub-Saharan Africa epidemics of serogroup A or C meningococcal disease occur frequently during the dry season (December through June), particularly in the savanna areas extending from Mali eastward to \JEthiopia\j known as the 'meningitis belt'.
Meningococcal disease in persons from developed countries travelling in such areas is rare. However, because of the lack of established surveillance and timely reporting from many of these countries, travellers to the meningitis belt during the dry season should receive meningococcal vaccine, especially if prolonged contact with the local populace is likely.
Recent serogroup A meningococcal epidemics have also occurred outside the 'meningitis belt' in \JKenya\j, \JTanzania\j, \JBurundi\j and \JMongolia\j; travellers to these countries should also receive the vaccine. Advisories for travellers to other countries will be issued when epidemics of meningococcal disease caused by vaccine-preventable serogroups are recognised.
\IAreas with Frequent Epidemics of Meningococcal Meningitis\i
Serogroup A is the most common cause of epidemics outside the United States, but serogroup C and serogroup B can also cause epidemic disease. No vaccine is yet available to offer protection against serogroup B.
Meningococcal vaccines are chemically defined antigens consisting of purified bacterial capsular polysaccharides, each inducing serogroup-specific immunity.
Serogroup A vaccine has not been shown to be effective in children less than 3 months of age, and may be less than fully effective in children 3-11 months of age. Serogroup C vaccine has not been shown to be effective in children less than 2 years of age. The group Y and W-135 polysaccharides have been shown to be safe and immunogenic in adults; the response of children to these polysaccharides is unknown.
\IPrecautions and Contraindications
Reactions\i
Adverse reactions to meningococcal vaccine are infrequent and mild, consisting principally of localised erythema that lasts for 1-2 days. Up to 2% of young children develop fever transiently after \Jvaccination\j.
\IPregnancy\i
The safety of meningococcal vaccines in pregnant women has not been established, although the use of the vaccine in pregnant women during an epidemic in \JBrazil\j resulted in no adverse effects. On theoretical grounds, it is prudent not to use them unless there is a substantial risk of infection.
#
"Mumps (Travel Information)",70,0,0,0
Mumps is primarily a disease of school-age children. Susceptible children, adolescents and adults should be vaccinated with a single dose of vaccine* unless \Jvaccination\j is contraindicated. Combination with \Jmeasles\j and rubella vaccines (MMR) is the vaccine of choice.
Mumps vaccine is of particular value for children approaching puberty and for adolescents and adults, particularly males, who have not had \Jmumps\j. Persons can be considered susceptible unless they have documentation of (1) previous \Jvaccination\j on or after the first birthday, (2) physician-diagnosed \Jmumps\j, or (3) laboratory evidence of immunity.
Many persons in the United States will receive two doses of \Jmumps\j vaccine as a result of the two-dose schedule for MMR \Jvaccination\j which is now recommended in the United States. Most adults born before 1957 are likely to have been infected naturally and generally may be considered immune, even if they did not have clinically recognisable disease.
Because there is no evidence that persons who have previously either received the vaccine or had \Jmumps\j are at any risk of local or systemic reactions from receiving live \Jmumps\j vaccine, testing for susceptibility before \Jvaccination\j is unnecessary.
Vaccination against \Jmumps\j is not a requirement for entry into any country.
* Official name: \JMumps\j Virus Vaccine, Live.
\ISide Effects and Adverse Reactions\i
Parotitis temporally related to receipt of vaccine has been reported rarely. Allergic reactions including rash, pruritus and purpura have been associated temporally with \Jmumps\j \Jvaccination\j but are uncommon, usually mild and of brief duration. Very rarely, manifestations of CNS involvement, such as febrile seizures, aseptic meningitis, unilateral nerve \Jdeafness\j and \Jencephalitis\j within 30 days of \Jmumps\j \Jvaccination\j, are reported. Almost all have recovered completely.
\IPrecautions and Contraindications
Pregnancy\i
Although \Jmumps\j virus is capable of infecting the placenta and foetus, there is no good evidence that it causes congenital malformations in humans. However, because of a theoretical risk to the developing foetus, \Jmumps\j vaccine should not be given to pregnant women, and vaccinated women should not become pregnant within 3 months of \Jvaccination\j.
\IFebrile Illness\i
Although \Jvaccination\j of persons with serious illnesses should be postponed until recovery, minor illnesses such as upper respiratory infections with or without low-grade fever do not preclude \Jvaccination\j.
\IAllergies\i
Live \Jmumps\j vaccine is produced in chick-embryo cell culture. Persons with a history of anaphylactic reactions (hives, swelling of the mouth and throat, difficulty breathing, hypotension or shock) subsequent to egg ingestion should be vaccinated only with extreme caution. Several investigators have developed special protocols for vaccinating such individuals (J. Pediatr, 1983, 102:196-199; J. Pediatr, 1988, 113:504-6).
Evidence indicates that persons are not at increased risk if they have egg allergies that are not anaphylactic in nature. Such persons may be vaccinated in the usual manner. There is no evidence to indicate that persons with allergies to chickens or feathers are at increased risk of reaction to the vaccine.
Since \Jmumps\j vaccine contains trace amounts of neomycin, persons who have experienced anaphylactic reactions to topically or systemically administered neomycin should not receive \Jmumps\j vaccine. A history of contact \Jdermatitis\j to neomycin is not a contraindication to receiving \Jmumps\j vaccine. Live \Jmumps\j virus vaccine does not contain \Jpenicillin\j.
\ISimultaneous Administration of \JMumps\j Vaccine\i
Mumps vaccine may be administered simultaneously (but in a different site) with any other live or inactivated vaccine. Inactivated vaccines and oral polio virus vaccines may be administered at any time before or after the \Jmumps\j vaccine. However, if the \Jmumps\j vaccine is not given simultaneously with the yellow fever vaccine, they should be administered at least 30 days apart.
\IRecent Administration of Immune \JGlobulin\j (IG)* or Other Antibody-Containing Blood Products\i
Vaccine should be administered at least 14 days before administration of IG or other blood products because passively acquired \Jantibodies\j might interfere with the response to the vaccine.
Administration of MMR should be delayed following administration of blood products. The length of the delay varies from 3-11 months depending on the type of blood product received. \JMumps\j \Jvaccination\j using products that do not contain \Jmeasles\j vaccine should be deferred for at least 3 months after administration of blood products.
* Formerly called immune serum \Jglobulin\j and \Jimmunoglobulin\j.
\IAltered Immunity\i
Replication of the \Jmumps\j vaccine virus may be potentiated in patients with immune deficiency diseases and by the suppressed immune responses that occur with leukemia, lymphoma, generalised malignancy, or with therapy with corticosteroids, alkylating drugs, antimetabolites or radiation. Patients with such conditions should not be given live \Jmumps\j virus vaccine.
However, \Jmumps\j \Jvaccination\j generally given as MMR can be considered for susceptible HIV-infected travellers, regardless of symptoms. There is no contraindication to using \Jmumps\j vaccine, since limited studies of \Jmeasles\j, \Jmumps\j and rubella (MMR) immunisation in symptomatic HIV-infected patients have not documented serious or unusual adverse events.
Onchocerciasis is a parasitic worm infestation transmitted by the bite of black flies. Symptoms include lumps under the skin, itchy rash or eye lesions. The disease is caused by the pre-larval (microfilaria) and adult stages of the \Jnematode\j \IOnchocerca volvulus\i and may result in \Jdermatitis\j, subcutaneous nodules, lymphadenitis and visual impairment, including \Jblindness\j.
Onchocerciasis is endemic in over 25 nations located in a broad band across the central part of Africa. Small endemic foci are also present in the Arabian peninsula (Yemen and Saudia Arabia) and in Latin America (Southern Mexico, \JGuatemala\j, \JColombia\j, Venezuela, \JEcuador\j, Brazil).
Onchocerciasis is transmitted by the bite of female \ISimulium\i flies (black flies) that bite by day and are
found near rapidly flowing rivers and streams. Short-term travellers to onchocerciasis-endemic
regions, such as most tourists, appear to be at low risk for this condition.
However, temporary residents and others who visit endemic regions for 3 months or more and live or work near black fly habitats are at increased risk for infection. Infections tend to occur in expatriate groups such as missionaries and their families, field scientists and Peace Corps volunteers.
No effective chemoprophylaxis is available. Protective measures include avoidance of black fly habitats and the use of personal protection measures against biting insects such as those outlined in '\JMosquitoes and Other Arthropod Vectors, Protection Against\j'.
Large outbreaks of this non-fatal viral infection have occurred in some urban areas of the Amazon Basin. The virus is transmitted by gnats or midges found in \JBrazil\j, Panama and Trinidad. Symptoms include abrupt high fever, severe headache, muscle and joint pain, nausea and diarrhoea. Treatment is limited and no vaccine is available.
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"Plague (Travel Information)",73,0,0,0
Plague is a bacterial infection transmitted by the bite of an infected \Jflea\j or, sometimes, through exposure to plague-infected animals or their tissue. Epidemic plague is generally associated with domestic rats. Almost all of the cases reported during the decade were rural and occurred among people living in small towns, villages or agricultural areas rather than in larger, more developed towns and cities. Plague can be spread from person to person.
The bacterium may be introduced through \Jflea\j bites or a cut or break in the skin during exposure to rodents or rabbits. Classic plague symptoms include a very painful, usually swollen and often hot-to-the-touch \Jlymph\j node, fever and extreme exhaustion.
Plague continues to be enzootic in rural rodent populations in several continents with occasional outbreaks among commensal rodents in villages and small towns. Urban outbreaks are rare and limited.
Wild rodent plague poses a real, though limited, risk to humans. When infection spreads to domestic or peridomestic rodents in urban or populated areas, humans are at markedly increased risk of exposure.
Wild rodent plague exists in the western third of the United States, in widely scattered areas of South America, in north-central, eastern and southern Africa, Madagascar, Iranian Kurdistan, along the frontier between Yemen and Saudi \JArabia\j, Central and Southeast Asia (Myanmar, China, India, \JIndonesia\j, \JMongolia\j, Vietnam, Kazakstan), and portions of the Russian Federation.
In recent years, human plague has been reported from \JAngola\j, India, \JKenya\j, \JLesotho\j, Madagascar, \JMozambique\j, \JNamibia\j, South Africa, \JBotswana\j, \JTanzania\j, \JUganda\j, Zimbabwe, Zaire, \JMyanmar\j, China, \JMongolia\j, Vietnam, the United States, the former Soviet Union, \JBrazil\j, \JBolivia\j, \JEcuador\j and \JPeru\j. Risk to travellers in any of these areas is small.
The efficacy of plague vaccine in humans has not been demonstrated in a controlled trial. Only limited indirect data are available that suggest the vaccine may offer protection against acquiring flea-borne plague.
Vaccination against plague is not required by any country as a condition for entry. There are few indications to vaccinate persons other than those who are at particularly high risk of exposure because of research laboratory activities or certain field activities in epizootic areas.
In most of the countries of Africa, Asia and the Americas where plague is reported, the risk of infection exists primarily in rural mountainous or upland areas. \JVaccination\j is rarely indicated for travellers to countries reporting cases, particularly if their travel is limited to urban areas with modern hotel accommodations.
Selective \Jvaccination\j might be considered for persons who will have direct contact with wild or commensal rodents or other animals in plague-epizootic areas and for persons who will reside or work in plague-endemic rural areas where avoidance of rodents and fleas is difficult; no safety and immunogenicity data are available supporting vaccine use in persons less than 18 or greater than 61 years old.
Travellers who genuinely may be at risk for acquiring plague should consider antibiotic chemoprophylaxis with tetracycline during periods of exposure in an active epizootic or epidemic
area. The recommendation for tetracycline chemoprophylaxis is inferred from experience with the drug in treating plague. Controlled trials that demonstrate the efficacy of tetracycline chemoprophylaxis in preventing plague have not been reported.
\IReactions\i
Mild pain, erythema and side effects such as induration at the vaccine injection site occur frequently. With repeated doses, fever, headache and malaise are more common and tend to be more severe. Sterile abscesses occur rarely. No fatal or disabling complications have been reported.
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"Poliomyelitis (Travel Information)",74,0,0,0
Travellers to countries where \Jpoliomyelitis\j is epidemic or endemic are considered to be at increased risk of \Jpoliomyelitis\j and should be fully immunised. In general, travellers to developing countries (excluding countries in Latin America) should be considered to be at increased risk of exposure to wild poliovirus.
A primary series consists of either three doses of trivalent oral poliovirus vaccine (OPV)* or enhanced-potency inactivated polio virus vaccine (IPV)å. Unvaccinated or partially vaccinated travellers should complete a primary series with the vaccine that is appropriate to their age and previous immunisation status.
Persons who have previously received a primary series may need additional doses of a polio vaccine before travelling to areas with an increased risk of exposure to wild poliovirus.
* Official name: Poliovirus Vaccine, Live, Oral, Trivalent.
å Official name: Poliovirus Vaccine, Inactivated
\IChildren and Adolescents\i
Trivalent oral poliovirus vaccine (OPV) is the vaccine of choice for all infants, children and adolescents (up to 18th birthday) if there are no contraindications to \Jvaccination\j with OPV.
Those who have not completed a primary series should do so. If time is a limiting factor, at least one dose of OPV should be given. Those who have completed a primary series of OPV (or a primary series and a supplementary dose administered between 4 and 6 years of age) should be given, once, a single additional dose of OPV.
Likewise, those who have completed a primary series of any type (or a primary series and a supplementary dose administered between 4 and 6 years of age) should be given a dose of IPV or OPV. The need for further supplementary doses of OPV or IPV has not been established.
\IAdults
Unvaccinated or unknown immunisation status\i
For unvaccinated adults and adults whose immunisation status is unknown who are travelling to countries in which the risk of exposure to wild polio virus is increased, primary immunisation with IPV is recommended whenever feasible. IPV is preferred because the risk of vaccine-associated paralysis following OPV is slightly higher in adults than in children.
\ISide Effects and Adverse Reactions\i
In rare instances, administration of OPV has been associated with paralysis in healthy recipients and their contacts. Although this risk is extremely small for vaccinees and their susceptible close contacts, they should be informed of this risk. No serious side effects of IPV have been documented.
Since IPV may contain trace amounts of \Jstreptomycin\j, neomycin and polymyxin B, persons with a history of an anaphylactic reaction following receipt of these \Jantibiotics\j should not receive IPV. Persons with a history of reactions that are not anaphylactic are not at increased risk and can be vaccinated.
\IPrecautions and Contraindications
Pregnancy\i
There is no convincing evidence of adverse effects of either OPV or IPV in pregnant women or developing foetuses; regardless, it is prudent on theoretical grounds to avoid vaccinating pregnant women. However, if immediate protection against \Jpoliomyelitis\j is needed, OPV, not IPV, is recommended.
\IAltered Immunity\i
Patients with a congenital immune deficiency disease, an acquired immune deficiency disease or an altered immune state due to disease or to immunosuppressive therapy are at increased risk for paralysis associated with OPV.
Therefore, if polio immunisation is indicated, these persons (including asymptomatic and symptomatic HIV-infected persons) and their household members and other close contacts should receive IPV, not OPV. Although a protective immune response from receipt of IPV cannot be assured, some protection may be provided to the immunocompromised patient.
Also, OPV should not be given to a member of a household in which there is a history of congenital or
hereditary immunodeficiency unless the potential recipient and other household members are known to be immunocompetent.
If OPV is inadvertently administered to a household or other close contact of an immunodeficient patient, close physical contact between the patient and the recipient of OPV should be avoided for approximately 1 month after \Jvaccination\j. This is the period of maximum excretion of vaccine virus.
#
"Rabies (Travel Information)",75,0,0,0
Travellers to rabies-endemic countries should be warned about the risk of acquiring \Jrabies\j, although \Jrabies\j \Jvaccination\j is not a requirement for entry into any country.
Rabies is almost always transmitted by bites which introduce the virus into wounds. Very rarely, \Jrabies\j has been transmitted by non-bite exposures which introduce the virus into open cuts or mucous membranes.
Although dogs are the main reservoir of the disease in many developing countries, the \Jepidemiology\j of the disease in animals differs sufficiently from one region or country to another to warrant the evaluation of all \Jmammal\j bites. Any animal bite or scratch should receive prompt local treatment by thoroughly cleansing the wound with copious amounts of soap and water; this local treatment significantly reduces the risk of \Jrabies\j.
Persons who may have been exposed to \Jrabies\j should always contact local health authorities immediately for advice about post-exposure prophylaxis and should also contact their personal physician or State health department as soon as possible thereafter.
Pre-exposure \Jvaccination\j with human diploid cell \Jrabies\j vaccine (HDCV)* or \JRabies\j Vaccine Adsorbed (RVA) may be recommended for international travellers based upon the local incidence of \Jrabies\j in the country to be visited, the availability of appropriate anti-rabies biologicals, and the intended activity. It may include: veterinarians, animal handlers, field biologists, spelunkers and certain laboratory workers.
For international travellers, the risk of \Jrabies\j is highest in areas of the world where dog \Jrabies\j remains highly endemic, including (but not limited to) parts of Mexico, El Salvador, \JGuatemala\j, \JPeru\j, \JColombia\j, \JEcuador\j, India, \JNepal\j, \JPhilippines\j, Sri Lanka, \JThailand\j and Vietnam. The disease is also found in dogs in most of the other countries of Africa, Asia, Central and South America.
Pre-exposure prophylaxis may provide protection when there is an no apparent or no recognised exposure to \Jrabies\j and when post-exposure therapy may be delayed. Pre-exposure prophylaxis is also of particular importance for persons at high risk of being exposed in countries where the locally available \Jrabies\j vaccines may carry a high risk of adverse reactions.
Pre-exposure \Jvaccination\j does not eliminate the need for additional therapy after a \Jrabies\j exposure but simplifies post-exposure treatment by eliminating the need for \Jrabies\j immune \Jglobulin\j (RIG) and by decreasing the number of doses of vaccine required.
There are a number of countries (for example, \JAustralia\j; see following list) which have reported no cases of \Jrabies\j during the most recent two-year period for which information is available (formerly referred to as 'rabies-free countries'). Additional information can be obtained from local health authorities of the country of destination, or the embassy or local consulate general's office .
Chloroquine phosphate (and possibly other structurally related antimalarials such as mefloquine, administered for \Jmalaria\j chemoprophylaxis) may interfere with the antibody response to HDCV. The intramuscular (IM) dose/route of pre-exposure prophylaxis, however, provides a sufficient margin of safety in this setting.
HDCV should not be administered by the intradermal (ID) dose/route when chloroquine, mefloquine or other drugs which may interfere with the immune response are being used. For international travellers, the ID dose/route should be initiated early, to allow the three-dose series to be completed 30 days or more before departure; otherwise the IM dose/route should be used.
RVA should never be administered ID.
* Official name: \JRabies\j Vaccine.
\IPrecautions and Contraindications
Reactions after \Jvaccination\j with HDCV or RVA\i
Persons may experience local reactions such as pain, erythema and swelling or itching at the injection site, or mild systemic reactions such as headache, nausea, abdominal pain, muscle aches and dizziness. Approximately 6% of persons receiving booster vaccinations with HDCV may experience an immune complex-like reaction characterised by \Jurticaria\j, pruritis and malaise.
Once initiated, \Jrabies\j post-exposure prophylaxis should not be interrupted or discontinued because of local or mild systemic reactions to \Jrabies\j vaccine.
\IPregnancy\i
Pregnancy is not a contraindication to post-exposure prophylaxis.
\IAge\i
In infants and children, the dose of HDCV or RVA for pre-exposure or post-exposure prophylaxis is the same as that recommended for adults. The dose of RIG for post-exposure prophylaxis is based on body weight.
\ICountries Reporting No Cases of Rabies*\i
The following countries and political units stated that \Jrabies\j was not present.
Africa: \JMauritius\j å ; \JLibya\j å ; Djibouti å ; \JLesotho\j å ; \JSeychelles\j å
Americas: \INorth:\i \JBermuda\j; St. Pierre and Miquelon.
St Maarten, and St Eustatius); St Christopher (St Kitts) and Nevis; St Lucia; St Martin; St Vincent and Grenadines; Turks and Caicos Islands; Virgin Islands (UK and US).
\ISouth:\i Uruguay å .
Asia: \JBahrain\j; Hong Kong; \JJapan\j; Republic of Korea å ; \JKuwait\j; \JMalaysia\j (Malaysia-Sabah å ); \JMaldives\j; \JSingapore\j; \JTaiwan\j.
Oceania: American \JSamoa\j; \JAustralia\j; Cook Islands; \JFiji\j; French \JPolynesia\j; \JGuam\j; \JIndonesia\j (with exception of Java, \JKalimantan\j, \JSumatra\j and Sulawesi); Kiribati; New Caledonia; New Zealand; Niue; Papua New Guinea; Solomon Islands; \JTonga\j; Vanuatu.
Most of Pacific \JOceania\j is 'rabies-free'. For information on specific islands not listed above, contact the Centers for Disease Control and Prevention, Division of Quarantine, USA.
*Bat \Jrabies\j exists in some areas that are free of terrestrial \Jrabies\j.
å Countries whose classifications should be considered provisional.
#
"Relapsing Fever (Travel Information)",76,0,0,0
This is a bacterial infection endemic to South America, Africa, Asia and western North America which is transmitted through the bite of either lice or ticks. Symptoms include fever, headaches, vomiting, diarrhoea, enlarged liver or \Jspleen\j, and a rash. If untreated, the fever can recur approximately every other week. There is no vaccine for prevention, but treatment is available.
#
"Rift Valley Fever (Travel Information)",77,0,0,0
Rift Valley Fever (RVF) is a viral disease that affects primarily livestock and humans. It is transmitted by several means including the bites of mosquitoes and other biting insects, and percutaneous \Jinoculation\j or inhalation of aerosols from contaminated blood or fluids of infected animals.
The risk of RVF infection to persons who travel to endemic areas generally is low. Occasionally, outbreaks occur involving large numbers of human cases, e.g. the Nile Delta, \JEgypt\j (1978 and 1993) and the lower \JSenegal\j River Basin of \JMauritania\j (1987).
Travellers can reduce their risk of exposure by avoiding contact with livestock and minimising their exposure to arthropod bites. No commercial human vaccine is available.
#
"Ross River Virus (Epidemic Polyarthritis) (Travel Information)",78,0,0,0
Ross River Virus infection is found in \JAustralia\j and a few South Pacific Islands and is transmitted by mosquito bites. Symptoms include the abrupt onset of low-grade fever, joint pain and a rash. After infection, a prolonged \Jarthritis\j can occur, but generally the \Jarthritis\j will clear up in weeks or months. Treatment is limited and no vaccine is available.
#
"Rubella (Travel Information)",79,0,0,0
Rubella infection may be associated with significant \Jmorbidity\j in adults and is associated with a high rate of foetal wastage or anomalies if contracted in the early months of \Jpregnancy\j.
The risk of exposure to rubella outside the United States may be high. Therefore, although \Jvaccination\j against rubella is not a requirement for entry into any country, all travellers, particularly women of child-bearing age, should be immune to rubella. Persons should be considered to be susceptible to rubella unless they have documentation of (1) previous \Jvaccination\j on or after the first birthday or (2) laboratory evidence of immunity.
Because many illnesses can appear similar to rubella clinically, a history of rubella illness, even if physician-diagnosed, should not be considered sufficient evidence of immunity. A single dose of rubella virus vaccine is recommended for all susceptible children, adolescents and adults, particularly females, unless \Jvaccination\j is contraindicated. Combination with \Jmeasles\j and \Jmumps\j vaccines (MMR) is the vaccine of choice.
Because there is no evidence that persons who have previously either received the vaccine or had rubella are at any risk of local or systemic reactions from receiving live rubella vaccine, testing for susceptibility before \Jvaccination\j is unnecessary.
\ISide Effects and Adverse Reactions\i
Vaccinees can develop low-grade fever, rash and lymphadenopathy after \Jvaccination\j. Adult women may have transient arthralgia and \Jarthritis\j following \Jvaccination\j. Arthralgias have been reported in 25% of susceptible adult women; \Jarthritis\j has been reported in 10%. Arthralgia and transient \Jarthritis\j occur more frequently and tend to be more severe in susceptible women than in men or children.
Transient peripheral neuritic complaints, such as paraesthesias and pain in the arms and legs, have occurred rarely. There is no increased risk of these reactions for persons who are already immune when vaccinated. The vaccine virus is not transmitted from vaccinees to pregnant, susceptible contacts.
There have been infrequent reports that susceptible vaccinees, primarily adult women, have developed chronic or recurrent arthralgias, sometimes with \Jarthritis\j or other symptoms (paraesthesias, blurred vision, carpal tunnel syndrome). While one group has reported the frequency of chronic joint symptoms in susceptible adult women to be 5 percent, other data from the United States and other countries that use the RA 27/3 strain suggest that such phenomena are rare events.
In comparative studies, the frequency of chronic joint symptoms is substantially higher following natural infection than following \Jvaccination\j.
\IPrecautions and Contraindications
Pregnancy\i
Rubella vaccine should not be given to women known to be pregnant, nor should a vaccinated woman become pregnant within 3 months of \Jvaccination\j, because of theoretical risks to the developing foetus from rubella vaccine infection.
Based on studies conducted in the US and abroad, the Advisory Committee on Immunisation Practices of the US Public Health Service believes that the risk to the foetus of vaccine-associated malformations is so small as to be negligible. If, however, a pregnant woman is vaccinated, or if she becomes pregnant within 3 months of \Jvaccination\j, she should be counselled on the theoretical risks.
Rubella \Jvaccination\j during \Jpregnancy\j should not ordinarily be a reason to recommend interruption of \Jpregnancy\j, although the final decision rests with the individual patient and her physician.
\IFebrile Illness\i
Although \Jvaccination\j of persons with serious illness should be postponed until recovery, minor illnesses such as upper respiratory infections with or without low-grade fever do not preclude \Jvaccination\j.
\IAllergies\i
Hypersensitivity reactions very rarely follow the administration of live rubella vaccine. Most of these reactions are considered minor. Live rubella vaccine is produced in human diploid cell culture. Consequently, a history of an anaphylactic reaction to egg ingestion needs to be taken into consideration only if \Jmeasles\j or \Jmumps\j \Jantigen\j are to be included with rubella vaccine.
Since rubella vaccine contains trace amounts of neomycin, persons who have experienced anaphylactic reactions to topically or systemically administered neomycin should not receive rubella vaccine. A history of contact \Jdermatitis\j to neomycin is not a contraindication to receiving rubella vaccine. Live rubella vaccine does not contain \Jpenicillin\j.
\ISimultaneous Administration of Rubella Vaccine\i
Rubella \Jvaccination\j may be administered simultaneously (but in a different site) with most widely used live or inactivated vaccines. Inactivated vaccines and oral polio vaccines may be administered at any time before or after the rubella \Jvaccination\j. However, if live rubella vaccine is not given simultaneously with the yellow fever vaccine, they should be administered at least 30 days apart.
\IRecent Administration of Immune \JGlobulin\j (IG)* or Other Antibody-Containing Blood Products\i
Vaccination should be administered at least 14 days before administration of IG or other blood products, because passively acquired \Jantibodies\j might interfere with the response to the vaccine.
Administration of MMR should be delayed following administration of blood product. The length of the delay varies from 3-11 months depending on the type of blood product received. Rubella \Jvaccination\j using products that do not contain \Jmeasles\j vaccine should be deferred for at least 3 months after administration of blood products.
* Formerly called immune serum \Jglobulin\j and \Jimmunoglobulin\j.
\IAltered Immunity\i
Replication of live rubella vaccine virus may be potentiated in patients with immune deficiency diseases and by the suppressed immune responses that occur with leukemia, lymphoma, generalised malignancy and therapy with large dose corticosteroids, alkylating drugs, antimetabolites and radiation. Patients with such conditions should not be given live rubella virus vaccine.
However, rubella \Jvaccination\j, generally given as MMR, can be considered for susceptible HIV-infected travellers, regardless of symptoms. There is no contraindication to using rubella vaccine, since limited studies of \Jmeasles\j, \Jmumps\j and rubella (MMR) immunisation in symptomatic HIV-infected patients have not documented serious or unusual adverse events.
#
"Schistosomiasis (Travel Information)",80,0,0,0
Schistosomiasis, an infection estimated to occur worldwide among some 200 million people, is caused by flukes whose complex life cycles utilise specific fresh water snail species as intermediate hosts. Infected snails release large numbers of minute free-swimming larvae (cercariae) which are capable of penetrating the unbroken skin of the human host. Even brief exposures to contaminated water can result in infection.
Exposure to schistosomiasis is a health hazard for travellers to endemic areas of the Caribbean, South America, Africa and Asia. Outbreaks of schistosomiasis have occurred among adventure travellers participating in river trips in Africa as well as resident expatriates and Peace Corps volunteers.
The countries where schistosomiasis is most prevalent include: \JBrazil\j; \JEgypt\j and most of sub-Saharan Africa; and southern China, the \JPhilippines\j and Southeast Asia.
Those at greatest risk are travellers who engage in wading or swimming in fresh water in areas where poor sanitation and appropriate snail hosts are present. Bathing with contaminated fresh water can also transmit infection. Human schistosomiasis cannot be acquired by wading or swimming in salt water (oceans or seas).
Clinical manifestations of acute infection can occur within 2-3 weeks of exposure to cercariae-infected water, but most acute infections are asymptomatic. The most common acute symptoms are: fever, lack of appetite, weight loss, abdominal pain, weakness, headaches, joint and muscle pain, diarrhoea, nausea and cough.
Rarely, the central nervous system can be involved to produce seizures or transverse myelitis as a result of mass lesions of the brain or spinal cord. Chronic infections can cause disease of the lung, liver, intestines and/or bladder. Many people who develop chronic infections can recall no symptoms of acute infection.
Diagnosis of infection is usually confirmed by serologic studies or by finding schistosome eggs on microscopic examination of stool and urine. Schistosome eggs may be found as soon as 6-8 weeks after exposure but are not invariably present. Safe and effective oral drugs are available for the treatment of schistosomiasis.
Since there is no practical way for the traveller to distinguish infested from non-infested water, fresh water swimming in rural areas of endemic countries should be avoided. In such areas, heating bathing water to 50░ C (122░ F) for 5 minutes or treating it with \Jiodine\j or \Jchlorine\j in a manner similar to the precautions recommended for preparing drinking water will destroy cercariae and make the water safe. Thus, swimming in adequately chlorinated swimming pools is virtually always safe, even in endemic countries.
Filtering water with paper \Jcoffee\j filters may also be effective in removing cercariae from bathing water. If these measures are not feasible, allowing bathing water to stand for 3 days is advisable since cercariae rarely survive longer than 48 hours.
Vigorous towel-drying after accidental water exposure has been suggested as a way to remove cercariae in the process of skin penetration. Although such towelling may prevent some infections, to recommend this to travellers might give them a false sense of security; it is far safer to recommend avoiding contact with contaminated water.
At this time there are no available drugs which are known to be effective as chemoprophylactic agents.
Upon return from foreign travel, if you think you may have been exposed to schistosome-infected
fresh water, be sure to see a physician to undergo screening tests.
International travellers are at risk of contracting sexually transmitted diseases (STDs) including human immunodeficiency virus (HIV, the cause of AIDS) if they have sex with partners who have these diseases.
Travellers should be aware that the risk of STDs is high in some parts of the world. AIDS has become a global health problem and the prevalence of \JHIV\j infection in many populations continues to escalate. Also of concern are the antibiotic-resistant STD agents, particularly penicillin-, tetracycline- and quinolone-resistant strains of \INeisseria gonorrhoeae.
\i
To avoid acquiring STDs, travellers should not have sexual contact with persons who may be infected. Persons most likely to be infected are those with numerous sex partners. In many places, persons who make themselves available for sex with travellers are likely to be persons, such as prostitutes, with many partners. In addition, injecting drug users are at high risk of being infected with \JHIV\j, regardless of the number of their sex partners.
Since determining whether a person has an STD is impossible, travellers who wish to absolutely protect themselves from acquiring an STD should refrain from sexual contact.
If, however, they choose not to do this, travellers can reduce their risk of acquiring infection by consistently and correctly using a \Jlatex\j condom during sexual contact, whether vaginal, oral or anal. The condom should be placed on before any genital contact and, following ejaculation, held firmly against the base of the penis during withdrawal, which should be done while the penis is still erect to prevent slippage.
If lubricants are used during sex, only water-based lubricants (e.g. K-Y Jelly or glycerine) should be used with \Jlatex\j condoms, as oil-based lubricants (e.g. \Jpetroleum\j jelly, shortening, mineral oil, massage oils) can weaken \Jlatex\j.
Anyone who may have been exposed to an STD who develops either a vaginal or urethral discharge, an unexplained rash or genital lesion, or genital or pelvic pain should cease sexual activity and promptly seek competent medical care.
Because STDs are often asymptomatic, especially in women, anyone who believes that they may have been exposed to an STD should consult their physician regarding the advisability of screening for STD.
#
"Smallpox (Travel Information)",82,0,0,0
In May 1980, the World Health Organisation (WHO) declared the global eradication of smallpox. There is no evidence of smallpox transmission anywhere in the world.
The last reported case of endemic smallpox occurred in \JSomalia\j in October 1977, and the last reported case of laboratory-acquired smallpox occurred in the United Kingdom in 1978. WHO amended the International Health Regulations January 1, 1982, deleting smallpox from the diseases subject to the Regulations.
\BNOTE: Smallpox \Jvaccination\j should not be given for international travel.\b
The risk from smallpox \Jvaccination\j, although very small, now exceeds the risk of smallpox; consequently, smallpox \Jvaccination\j of civilians is indicated \Ionly for laboratory workers directly involved with smallpox or closely related orthopox viruses, e.g. monkeypox, vaccinia and others.\i
Health-care workers whose contact to these viruses is limited to contaminated materials (e.g. dressings) are at lower risk of inadvertent infection than laboratory workers, but may be considered for \Jvaccination\j.
\IMisuse of Smallpox Vaccine\i
Smallpox vaccine should never be used therapeutically. There is no evidence that \Jvaccination\j has therapeutic value in the treatment of recurrent herpes simplex infection, warts or any other disease.
#
"Tetanus (Travel Information)",83,0,0,0
[see \JDiphtheria, Tetanus and Pertussis (Travel Information)\j]
#
"Tuberculosis (Travel Information)",84,0,0,0
In many countries, tuberculosis is much more common than in the developed nations, and it is an increasingly serious public health problem.
To become infected, a person usually would have to spend a long time in a closed environment where the air was contaminated by a person with untreated tuberculosis who is coughing and has numerous \IMycobacterium tuberculosis\i organisms (or tubercle bacilli) in secretions from the lungs.
Tuberculosis infection is generally transmitted through the air; therefore, there is virtually no danger of its being spread by dishes, linens and items that are touched, or by food. However, it can be transmitted through unpasteurised milk or milk products.
Travellers who anticipate possible prolonged exposure to tuberculosis should have a tuberculin skin test before leaving. If the reaction is negative, they should have a repeat test upon returning home.
Because persons with \JHIV\j infection are more likely to have an impaired response to the tuberculin skin test, travellers with \JHIV\j infection should inform their physician about their \JHIV\j status. Physicians can then determine whether to perform anergy testing.
Except for travellers with impaired immunity (e.g. \JHIV\j infection), travellers who already have a positive tuberculin reaction are unlikely to be reinfected.
All persons who are infected or who become infected with \IMycobacterium tuberculosis\i can be treated to prevent tuberculosis disease. Travellers who suspect that they have been exposed to tuberculosis should inform their physician of the possible exposure and receive an appropriate medical evaluation.
Tuberculosis disease can be treated successfully with multiple medications.
#
"Typhoid Fever (Travel Information)",85,0,0,0
Typhoid fever is a life-threatening illness caused by the bacterium \ISalmonella typhi.\i Typhoid fever is rare in the industrialised nations but is still common in the developing world, where it affects about 12.5 million persons each year, and it can be acquired while travelling internationally.
\ISalmonella\i \Ityphi\i lives only in humans. Persons with typhoid fever carry the bacteria in their bloodstream and intestinal tract. In addition, a small number of persons, called carriers, recover from typhoid fever but continue to carry the bacteria. Both ill persons and carriers shed \IS. typhi\i in their faeces (stool). Once \IS. typhi\i bacteria are eaten or drunk, they multiply and spread into the bloodstream. The body reacts with fever and other signs and symptoms.
You can get typhoid fever if you eat food or drink beverages that have been handled by a person who is shedding\I S. typhi\i or if sewage contaminated with \IS. typhi\i bacteria gets into the water you use for drinking or washing food. Therefore, typhoid fever is more common in areas of the world where handwashing is less frequent and water is likely to be contaminated with sewage.
Typhoid fever is common in most parts of the world except in industrialised regions such as the United States, Canada, western Europe, \JAustralia\j and \JJapan\j. Therefore, if you are travelling to the developing world, you should consider taking precautions. Over the past 10 years, travellers to Asia, Africa and Latin America have been especially at risk.
Persons with typhoid fever usually have a sustained fever as high as 103░ to 104░ F (39░ to 40░ C). They may also feel weak or have \Jstomach\j pains, headache or loss of appetite. In some cases, patients have a rash of flat, rose-coloured spots. The only way to know for sure if an illness is typhoid fever is to have samples of stool or blood tested for the presence of \IS. typhi.\i
If you suspect you have typhoid fever, see a doctor immediately. If you are travelling in a foreign country, you can usually call your consulate for a list of recommended doctors.
You will probably be given an antibiotic to treat the disease. Three commonly prescribed \Jantibiotics\j are ampicillin, trimethoprim-sulfamethoxazole and ciprofloxacin. Persons given \Jantibiotics\j usually begin to feel better within 2 to 3 days, and deaths rarely occur. However, persons who do not get treatment may continue to have fever for weeks or months, and as many as 20% may die from complications of the infection.
Even if your symptoms seem to go away, you may still be carrying \IS. typhi.\i If so, the illness could return, or you could pass the disease to other people. In fact, if you work at a job where you handle food or care for small children, you may be barred legally from going back to work until a doctor has determined that you no longer carry any typhoid bacteria.
If you are being treated for typhoid fever, it is important to do the following:
òKeep taking the prescribed \Jantibiotics\j for as long as the doctor has asked you to take them.
òWash your hands carefully with soap and water after using the bathroom, and do not prepare or serve food for other people. This will lower the chance that you will pass the infection on to someone else.
òHave your doctor perform a series of stool cultures to ensure that no \IS. typhi\i bacteria remain in your body.
\IPrevention\i
Typhoid fever can be prevented and can usually be treated with \Jantibiotics\j. Two basic actions can protect you from typhoid fever:
òAvoid risky foods and drinks. Remember: Boil it, cook it, peel it? or forget it.
òGet vaccinated against typhoid fever.
Watching what you eat and drink when you travel is as important as being vaccinated. This is because the vaccines are not completely effective. Avoiding risky foods will also help protect you from other illnesses, including traveller's diarrhoea, \Jcholera\j, \Jdysentery\j and hepatitis A.
\IFood and beverages:\i
òIf you drink water, buy it bottled or bring it to a rolling boil for 1 minute before you drink it. Bottled carbonated water is safer than uncarbonated water.
òAsk for drinks without ice unless the ice is made from bottled or boiled water. Avoid popsicles and flavoured ices that may have been made with contaminated water.
òEat foods that have been thoroughly cooked and that are still hot and steaming.
òAvoid raw vegetables and fruits that cannot be peeled. Vegetables like \Jlettuce\j are easily contaminated and are very hard to wash well.
òWhen you eat raw fruit or vegetables that can be peeled, peel them yourself. (Wash your hands with soap first.) Do not eat the peelings.
òAvoid foods and beverages from street vendors. It is difficult for food to be kept clean on the street, and many travellers get sick from food bought from street vendors.
\IVaccination\i
If you are travelling to a country where typhoid is common, you should consider being vaccinated against typhoid. Visit a doctor or travel clinic to discuss your \Jvaccination\j options.
Remember that you will need to complete your \Jvaccination\j at least 1 week before you travel so that the vaccine has time to take effect. Typhoid vaccines lose effectiveness after several years; if you were vaccinated in the past, check with your doctor to see if it is time for a booster \Jvaccination\j. Taking \Jantibiotics\j will not prevent typhoid fever; they only help treat it.
Typhoid \Jvaccination\j is not required for international travel, but it is recommended for travellers to areas where there is a recognised risk of exposure to \ISalmonella typhi.\i Risk is greatest for travellers to developing countries (e.g. countries in Asia, and Africa and Latin America) who will have prolonged exposure to potentially contaminated food and drink. \JVaccination\j is particularly recommended for those who will be travelling in smaller cities, villages and rural areas off the usual tourist itineraries.
Travellers should be cautioned that typhoid \Jvaccination\j is not 100% effective and is not a substitute for careful selection of food and drink.
\IContraindications\i
Theoretical concerns have been raised regarding the immunogenicity of live-attenuated Ty21a vaccine in persons concurrently receiving \Jantibiotics\j, \Jimmunoglobulin\j, antimalarials or viral vaccines.
The growth of the live Ty21a strain is inhibited by various antibacterial agents and by the antimalarial prophylactic agent mefloquine. \JVaccination\j with Ty21a should be delayed for at least 24 hours after the administration of any of these agents.
Chloroquine does not significantly inhibit the growth of Ty21a and may be given concurrently.
No data exist on the immunogenicity of Ty21a when administered concurrently or within 30 days of viral vaccines (e.g. oral polio, measles/mumps/rubella or yellow fever vaccines). In the absence of such data, if typhoid \Jvaccination\j is warranted, it should not be delayed because of the administration of viral vaccines. Simultaneous administration of Ty21a and \Jimmunoglobulin\j does not appear to pose a problem.
Information is not available on the safety of any of the three vaccines when used during \Jpregnancy\j; it is therefore prudent on theoretical grounds to avoid vaccinating pregnant women.
Live-attenuated Ty21a vaccine should not be given to immunocompromised persons, including those infected with human immunodeficiency virus (HIV). The two available parenteral vaccines present theoretically safer alternatives for this group.
The only contraindication to \Jvaccination\j with either ViCPS or with parenteral inactivated vaccine is a history of severe local or systemic reactions following a previous dose. None of the three available vaccines should be given to persons with an acute febrile illness.
\ITyphoid and Paratyphoid A and B Vaccines\i
The effectiveness of paratyphoid A vaccine has never been established, and field trials have shown that the usually small amounts of paratyphoid B antigens contained in vaccines combining typhoid and paratyphoid A and B antigens ('TAB' vaccines) are not effective. Knowing this and recognising that combining paratyphoid A and B antigens with typhoid vaccine increases the risk of vaccine reaction, typhoid vaccine should be used alone.
#
"Typhus Fever (Travel Information)",86,0,0,0
Several distinct rickettsiae cause a disease known as \Jtyphus\j in humans. Each agent has a distinct \Jepidemiology\j but all cause disease with similarities of fever, headache and rash.
Murine \Jtyphus\j is relatively common throughout the world and is transmitted by fleas. Highest incidence of cases occurs during the summer months when rats and their fleas are most active and abundant.
Epidemic \Jtyphus\j is rare except during periods when municipal services are disrupted as in war or natural disaster. Incidence of epidemic \Jtyphus\j can occur during the winter months when laundering of louse-infested clothing is absent and person-to-person spread of lice is common. Endemic foci of epidemic \Jtyphus\j exist in highland populations in Africa and South America, but tourists are at minimal risk of acquiring lice and disease.
Scrub \Jtyphus\j is a common cause of fever among susceptible persons who engage in occupational or recreational behaviour that bring them in contact with larval mite-infested scrub brush habitats. Incidence is highest during the spring and summer when the activity of humans brings them in contact with mites seeking animal hosts. The disease is limited to Pacific islands and southeast and east Asia.
Tick \Jtyphus\j, actually a form of spotted fever, is not uncommon in travellers who spend time trekking or on safari in Africa or the Indian subcontinent. Prompt removal of attached ticks and use of repellents to prevent tick attachment provide the best preventions against disease.
Vaccination against \Jtyphus\j is not required by any country as a condition for entry. Production of \Jtyphus\j vaccine in the United States has been discontinued and there are no plans for commercial production of a new vaccine.
#
"Yellow Fever (Travel Information)",87,0,0,0
Yellow fever is a mosquito-borne viral disease that occurs only in parts of Africa and South America.
Illness varies in severity from a flu-like syndrome to severe hepatitis and haemorrhagic fever.
In South America, sporadic infections occur almost exclusively in \Jforestry\j and agricultural workers who are exposed occupationally in or near forests.
In Africa, the virus is transmitted in three geographic regions: principally and foremost, in the moist savanna zones of West and Central Africa during the rainy season; secondly, outbreaks occur occasionally in urban locations and villages in Africa; and finally, to a lesser extent, in jungle regions.
Yellow fever has rarely occurred in travellers, but it is preventable by a safe and effective vaccine, and international regulations require proof of \Jvaccination\j for travel to and from certain countries.
In addition to \Jvaccination\j, travellers should take precautions against exposure to mosquitoes when travelling in areas with yellow fever transmission (see Prevention of Mosquito Bites, below and '\JMosquitoes and Other Arthropod Vectors, Protection Against\j').
\IVaccination\i
For purposes of international travel, yellow fever vaccine produced by different manufacturers worldwide must be approved by WHO and administered at an approved Yellow Fever \JVaccination\j Centre.
A number of countries require a certificate from travellers arriving from infected areas or from countries with infected areas. Some countries in Africa require evidence of \Jvaccination\j from all entering travellers; others may waive the requirements for travellers coming from non-infected areas and staying less than 2 weeks.
Vaccination is also recommended for travel outside the urban areas of countries that do not officially report the disease, but which lie in the yellow fever endemic zone. Practitioners should note that the actual areas of yellow fever virus activity may extend beyond the officially reported infected zones. Fatal cases of yellow fever have occurred in unvaccinated tourists visiting rural areas within the yellow fever endemic zone.
\IYellow Fever Certificate\i
Some countries require an individual, even if only in transit, to have a valid International Certificate of \JVaccination\j if he or she has been in countries either known or thought to harbour yellow fever virus. Such requirements may be strictly enforced, particularly for persons travelling from Africa or South America to Asia.
An International Certificate of \JVaccination\j is issued after immunisation and is valid 10 days after \Jvaccination\j to meet entry and exit requirements for all countries. The Certificate is good for 10 years. You must take the Certificate with you.
Travellers with a specific contraindication to the yellow fever vaccine should obtain a medical waiver before travelling to countries requiring \Jvaccination\j (see Precautions and Contraindications). Most countries will accept a medical waiver for persons with a medical reason not to receive the vaccine (e.g. infants less than 4 months old, pregnant women, persons hypersensitive to eggs or those with an immunosuppressed condition.)
When required, the Centers For Disease Control and Prevention (CDC) recommends obtaining written waivers from consular or embassy officials before departure. A physician's letter clearly stating the medical reason not to receive the vaccine might be acceptable to some governments. It should be written on letterhead stationery and bear the stamp used by a health department or official immunisation centre to validate the International Certificate of \JVaccination\j. Check embassies or consulates for specific waiver requirements.
\IPrecautions and Contraindications
Age\i
Infants under 6 months of age are more susceptible to serious adverse reactions (encephalitis) than older children and should never be immunised. The risk of this complication appears to be age-related. Immunisation should be delayed until age 9-12 months except when the risk of infection is high.
\IPregnancy\i
A small study showed that yellow fever vaccine virus given in \Jpregnancy\j can infect the developing foetus, but the potential risk of adverse events associated with congenital infection is unknown. Therefore, it is prudent to avoid vaccinating pregnant women and for non-immunised pregnant women to postpone travel to epidemic areas until after delivery.
If the travel itinerary of a pregnant woman does not present a substantial risk of exposure and immunisation is contemplated solely to comply with an international travel requirement, then efforts should be made to obtain a waiver letter from the traveller's physician.
Pregnant women who must travel to areas with active ongoing transmission should be vaccinated. It is believed that under these circumstances, the small theoretical risk for mother and foetus from \Jvaccination\j is far outweighed by the risk of yellow fever infection.
\IAltered immune states\i
Infection with yellow fever vaccine virus poses a theoretical risk to patients with immunosuppression in association with acquired immunodeficiency syndrome (AIDS) or other manifestations of human immunodeficiency virus (HIV) infection; leukemia; lymphoma; generalised malignancy or with administration of corticosteroids, alkylating drugs, antimetabolites or radiation.
There are no anecdotal reports or systematically collected data, however, linking an immunosuppressed state with adverse events in a yellow fever vaccine recipient. The decision to immunise immunocompromised patients with yellow fever vaccine should be based on a physician's evaluation of the patient's state of immunosuppression weighed against the risk of exposure to the virus.
If travel to a yellow fever-infected zone is necessary and immunisation is contraindicated, patients should be advised of the risk, instructed in methods to avoid bites of vector mosquitoes, and a \Jvaccination\j waiver letter should be supplied by the traveller's physician.
Persons with asymptomatic \JHIV\j infections who cannot avoid potential exposure to yellow fever virus should be offered the choice of immunisation. Vaccinees should be monitored for possible adverse effects. Because immunisation of these individuals may be less effective than for uninfected persons, it may be desirable to measure the neutralising antibody response following \Jvaccination\j prior to travel.
Anecdotal experience suggests that low-dose or short-term (less than 2 weeks) corticosteroid therapy or intra-articular, bursal or \Jtendon\j injections with corticosteroid do not pose a risk to recipients of yellow fever vaccine.
Family members of immunosuppressed persons, who themselves have no contraindications, may receive yellow fever vaccine.
\IHypersensitivity\i
Live yellow fever vaccine is produced in chick embryos and should not be given to persons clearly hypersensitive to eggs; generally persons who are able to eat eggs or egg products may receive the vaccine.
If \Jvaccination\j of an individual with a questionable history of egg \Jhypersensitivity\j is considered essential because of a high risk of exposure, an intradermal test dose may be administered under close medical supervision. Specific directions for skin testing are found in the package insert. In some instances, small test doses of vaccine administered intradermally have led to an antibody response.
If you have one of the conditions described above and international travel regulations are the only reason to receive \Jvaccination\j, your doctor will be able to help you decide whether you should be vaccinated, should delay your travel, or should obtain a waiver.
In all cases, the decision to immunise an infant between 6 and 9 months of age, a pregnant woman, or an immunocompromised patient should be made on an individual basis. The physician should weigh the risks of exposure and contracting the disease against the risks of immunisation, and possibly consider alternative means of protection.
If you decide to obtain a waiver, a physician's letter clearly stating the contraindication to \Jvaccination\j has been acceptable to some governments. (Ideally, it should be written on letterhead stationery and bear the stamp used by the health department and official immunisation centres to validate the International Certificate of Vaccination.)
Under these conditions, it is also useful for the traveller to obtain specific and authoritative advice from the embassy or consulate of the country or countries he or she plans to visit. Waivers of requirements obtained from embassies or consulates should be documented by appropriate letters and retained for presentation with the International Certificate of \JVaccination\j.
Yellow fever \Jvaccination\j requirements and recommendations are given in the Regional Travel Information (e.g. Tropical South America, West Africa, etc.)
\IReactions\i
Reactions to yellow fever vaccine are generally mild. Two percent to 5% of vaccinees have mild headaches, myalgia, low-grade fevers or other minor symptoms 5-10 days after \Jvaccination\j. Fewer than 0.2% of vaccinees find it necessary to curtail regular activities. Immediate \Jhypersensitivity\j reactions, characterised by rash, \Jurticaria\j and/or \Jasthma\j, are extremely uncommon (incidence less than 1/1,000,000) and occur principally in persons with histories of egg \Jallergy\j.
\ISimultaneous Administration of Other Vaccines and Drugs\i
Studies have shown that the seroimmune response to yellow fever vaccine is not inhibited by administration of certain other vaccines concurrently or at various intervals of a few days to 1 month. \JMeasles\j and yellow fever vaccines, and BCG and yellow fever vaccines, have been administered in combination without interference.
Additionally, severity of reactions to \Jvaccination\j was not amplified by concurrent administration of yellow fever and \Jmeasles\j vaccines. Hepatitis B and yellow fever vaccine may be given concurrently.
If live virus vaccines are not given concurrently, 4 weeks should be allowed to elapse between sequential vaccinations.
Some data have indicated that persons given yellow fever and \Jcholera\j vaccines simultaneously or 1-3 weeks apart had lower-than-normal antibody responses to both vaccines. Unless there are time constraints, \Jcholera\j and yellow fever vaccines should be administered at a minimal interval of 3 weeks. If the vaccines cannot be administered at least 3 weeks apart, then the vaccines can be given simultaneously or at any time within the 3-week interval.
There are no data on possible interference between yellow fever and typhoid, paratyphoid, \Jtyphus\j, plague, \Jrabies\j or Japanese \Jencephalitis\j vaccines.
A prospective study of persons given yellow fever vaccine and 5 cc of commercially available immune \Jglobulin\j revealed no alteration of the immunologic response to yellow fever vaccine when compared to controls.
Although chloroquine inhibits replication of yellow fever virus in vitro, it does not adversely affect antibody responses to yellow fever vaccine in humans receiving the drug as antimalarial prophylaxis.
\IPrevention Of Mosquito Bites\i
Yellow fever is rarely transmitted in urban areas except in the context of an epidemic. Travellers to rural areas of Africa and South America, however, may be exposed sporadically to mosquitoes transmitting yellow fever and other mosquito-borne diseases.
Mosquitoes that transmit urban yellow fever generally feed during the day both indoors and outdoors. Staying in air-conditioned or well-screened quarters and wearing long-sleeved shirts and long pants will help to prevent mosquito bites.
Insect repellents containing N,N-diethyl-metatoluamide (DEET) should be used on exposed skin only. Permethrin-containing repellents should be applied to clothing. Travellers to rural areas should bring mosquito nets and insecticidal space sprays. (For further prevention information see section entitled '\JMosquitoes and Other Arthropod Vectors, Protection Against\j').
\BDefinitions\b
Active immunisation\b-The production of immunity in response to the administration of a vaccine or a toxoid.
\BAetiology\b-The study of the factors that cause disease.
\BAntigen(s)\b-Substances inducing the formation of an immune response.
\BAntitoxin\b-A solution of \Jantibodies\j derived from the serum of animals immunised with specific antigens used to achieve passive immunity or to effect a treatment.
\B'Blue Sheet'\b-Summary of Health Information for International Travel, published biweekly by CDC.
\BCDC\b-Centers for Disease Control and Prevention, USA.
\BDEET\b-N,N-diethylmetatoluamide-the principal ingredient of most insect repellents.
\BDirect transit area\b-A special area established in an airport, approved and supervised directly by the health administration concerned, for segregating passengers and crews breaking their air voyage without leaving the airport.
\BDiseases Subject to International Health Regulations\b-Cholera, yellow fever and plague.
\BEndemic\b-The usual frequency of occurrence of a disease, including possible seasonal variations, in a human population.
\BEnteric\b-Pertaining to the small \Jintestine\j.
\BEnzootic\b-The usual frequency of occurrence of a disease, including possible seasonal variations, in an animal population.
\BEpidemic\b-More than the expected number of cases of disease which would occur in a community or region during a given time period.
\BEpizootic\b-The occurrence of a disease in a defined animal population at a higher than expected rate.
\BImmune \Jglobulin\j (IG)\b-A sterile solution containing antibody from human blood. It is primarily indicated for routine maintenance of certain immunodeficient persons, and for passive immunisation against \Jmeasles\j and hepatitis A.
\BImmunisation\b-The process of inducing or providing immunity artificially by administering an immunobiologic. Immunisation can be active or passive.
\BImported case\b-A person who acquired an infection outside of a specified area.
\BInfected area\b-An area which harbours a particular agent of infection and which because of population characteristics, density and mobility, and/or vector and animal reservoir potential, could support transmission of disease(s) identified there. It is defined on epidemiologic principles by the health administration reporting the disease and need not correspond to administrative boundaries.
\BInternational Certificate of Vaccination\b-The official certificate used to document the vaccinations a traveller has received, when and where received, and who administered them.
\BIsolation\b-The separation of a person or group of persons from others (except the health staff on duty) to prevent the spread of infection.
\BMotion sickness\b-A functional disorder thought to be brought on by repetitive motion and characterised by nausea or vomiting.
\BMMWR\b-Morbidity and Mortality Weekly Report, published by CDC.
\BParasitic disease\b-A disease caused by an organism that lives in or on another organism.
\BPassive immunisation\b-The provision of temporary immunity by the administration of pre-formed antitoxin or \Jantibodies\j.
\BPathogen\b-Any disease-producing microorganism or material.
\BQuarantine\b-That state or condition during which measures are applied by a health administration to a ship, an \Jaircraft\j, a train, road vehicle, other means of transport or container, or individuals to prevent the spread of disease from the object of quarantine to reservoirs, vectors of disease or other individuals.
\BQuarantinable diseases\b-The diseases designated by International Health Regulations as quarantinable are: \Jcholera\j, yellow fever and plague.
\BRecommended vaccination\b-Vaccination not required by International Health Regulations but suggested for travellers visiting or living in certain countries.
\BRequired vaccination\b-Vaccination the traveller must have for entry into or exit from a country. The traveller must present a validated International Certificate of \JVaccination\j which documents the vaccination(s) received.
\BSpecific immune globulin\b-Special preparations obtained from donor pools pre-selected for a high antibody content against a specific disease.
\BToxoid\b-A modified bacterial toxin that has been rendered non-toxic but that retains the ability to stimulate the formation of antitoxin.
\BTravellers' diarrhoea\b-A syndrome characterised by a twofold or greater increase in the frequency of unformed bowel movements. Commonly associated symptoms include abdominal cramps, nausea, bloating, urgency, fever and malaise. Episodes of travellers' diarrhoea usually begin abruptly, occur during travel or soon after returning home, and are generally self-limited.
\BVaccination\b-The administration of any vaccine or toxoid without regard to whether the recipient is successfully made immune.
\BVaccine\b-A suspension of attenuated live or killed microorganisms, or fractions thereof administered to induce immunity and thereby prevent infectious disease.
\BValidation\b-Application of an official stamp or seal to the International Certificate of \JVaccination\j by the health department or other appropriate agency.
\BValid certificate\b-An International Certificate of \JVaccination\j that has been fully completed, signed and validated with an official stamp or seal.
\BWHO\b-World Health Organisation.
\BYellow Fever \JVaccination\j Centre\b-A centre designated under the authority of the health administration of a country to administer yellow fever vaccine.
