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CDC’s International Travelers’ Health Information: Geographic Health Recommendations

CDC’s International Travelers’ Health Information: Geographic Health Recommendations

Editor’s note: The following information is not a complete medical guide for travelers. Consult with your doctor for specific information related to your needs and your medical history; recommendations may differ for pregnant women, young children, and persons who have chronic medical conditions. Be sure to read the information about all the regions you are planning to visit. The information presented in this section was condensed from the CDC’s web-site. For complete travel health information view CDC’s website on the Internet at http://www.cdc.gov/travel or call CDC’s toll free voice information system at 1-877-394-8747.

CENTRAL AFRICA

EAST AFRICA

NORTH AFRICA

SOUTHERN AFRICA

WEST AFRICA

EAST ASIA

SOUTH ASIA

SOUTHEAST ASIA

AUSTRALIA AND THE SOUTH PACIFIC

CARIBBEAN

MEXICO AND CENTRAL AMERICA

EASTERN EUROPE AND NORTHERN ASIA

WESTERN EUROPE

MIDDLE EAST

NORTH AMERICA

SOUTH AMERICA, TEMPERATE

SOUTH AMERICA, TROPICAL

CENTRAL AFRICA

Date last revised: December 6, 2006

Countries in this region: Angola, Cameroon, Central African Republic, Chad, Congo, Democratic Republic of the Congo (Zaire), Equatorial Guinea, Gabon, Sudan, and Zambia.

Outbreaks

Plague, Democratic Republic of the Congo
Updated:
October 23 and August 18, 2006
Released: June 28, 2006

According to an October 13, 2006 World Health Organization (WHO) report, a suspected pneumonic plague outbreak was reported in 2 health zones of Haut-Uele District, Oriental Province, Democratic Republic of the Congo (DRC). An initial investigation was conducted by the DRC Provincial Health Authority, WHO, and Médecins sans Frontières (MSF Switzerland). Confirmatory laboratory tests are pending. An outbreak of plague was reported in Ituri District of Oriental Province in June 2006. Ituri District is known to be one of the most active areas for plague worldwide and reports approximately 1,000 cases of plague each year. Plague, an infectious disease of animals and humans, is caused by the bacterium Yersinia pestis and is present in wild rodent populations in rural areas of the Americas, Africa, and Asia. Generally, the risk of plague infection for travelers is low, especially for persons staying in hotels in cities, unless they are exposed to an infected flea or animal or to a pneumonic plague patient during an outbreak.

For more information about plague, see http://www.cdc.gov/ncidod/dvbid/plague/index.htm. For more information about this outbreak, see http://www.who.int/csr/don/2006_10_13/en/index.html.

Polio

Updated: December 1, October 27, September 20, June 7, June 2, April 11 and February 10, 2006; December 16, 2005
Released: November 9, 2005

According to the Global Polio Eradication Initiative (GPEI), only 4 countries (Nigeria, India, Pakistan and Afghanistan) remain polio-endemic, an all-time low. Egypt, which had been considered polio-endemic, has remained free of poliovirus transmission for over 22 months.

The following countries, however, have recently reported importations of polio in 2006, after previously being polio-free:

  • Kenya (polio-free for over 6 years)
  • Bangladesh (polio-free for over 5 years)
  • The Democratic Republic of the Congo (polio-free for almost 6 years)
  • Namibia (polio-free for almost 10 years)

Plans are under way for immunization response activities in all affected countries.

Other countries that have reported imported polio cases or cases related to an importation in 2006 are Angola, Cameroon, Ethiopia, Indonesia, Nepal, Niger, Somalia, and Yemen. Chad last reported polio cases in December 2005. Eritrea, Mali, and Sudan reported imported polio cases in 2005 but have not reported additional cases for over 12 months.

Outbreaks of poliovirus continue to be a risk until poliovirus is eliminated worldwide, and the risk for infection is still present for susceptible people. Therefore, to protect themselves from polio, travelers should be sure they and their children are fully immunized. Vaccination is recommended for all travelers to polio-endemic or -epidemic areas. These areas include Africa, South Asia, Southeast Asia, and the Middle East.

Polio is an infectious disease caused by a virus. The disease mainly affects children under 5 years of age. It is spread person-to-person when the virus enters the mouth of a person who has come in contact with the stool of an infected person (for example, by changing diapers and not washing hands before touching the mouth) or from fecal contamination of food or drinking water. Most people infected with the poliovirus have no symptoms, but some infections cause paralysis and even death. Until the 1950s, polio crippled thousands of children in industrialized countries. Soon after the introduction of effective vaccines in the late 1950s (IPV) and early 1960s (OPV), polio was brought under control and practically eliminated as a public health problem in industrialized countries. OPV has not been used in the United States since 2000; however, it is used in many other counties and has played a major role in eliminating polio from large parts of the world. IPV, which is given by intramuscular injection, is now used in the United States and several other industrialized countries. For more information, go to the CDC website at http://www.cdc.gov/travel/yb/.

Avian Influenza A (H5N1) Virus
Most recently updated:
February 2, 2007
Initially released: September 23, 2005

Highly pathogenic avian influenza A (H5N1) (hereafter referred to as “H5N1”) virus has caused serious disease among wild birds and poultry on multiple continents. For a current list of countries reporting outbreaks of H5N1 among poultry and/or wild birds, view updates from the World Organization for Animal Health (OIE). Human infections with H5N1 viruses are still rare, but have occurred in countries in Asia, Africa, Eastern Europe, and the Middle East between 2003—2007. Most cases of H5N1 virus infection in humans are thought to have occurred from direct contact with infected poultry, but in one instance, human cases are thought to have been acquired through close contact with wild swans. Rare occurrences of probable spread (or ‘transmission’) from human to human have been reported. So far, however, this type of transmission has not been sustained. Transmission of H5N1 viruses to two persons through consumption of uncooked duck blood may also have occurred in Vietnam in 2005. Total numbers of confirmed human cases of H5N1 virus by country are available on the World Health Organization (WHO) Avian Influenza website. An assessment of the current situation can be found on the Centers for Disease Control and Prevention (CDC) Avian Influenza website.

Outbreaks of H5N1 virus among bird populations in Asia, parts of Europe, the Middle East and Africa are not expected to diminish significantly in the short term. Consequently, it is expected that human infections resulting from direct contact with infected poultry will continue to occur in countries where poultry flocks are infected. Because no sustained human-to-human transmission of H5N1 virus has been documented anywhere in the world, the current phase of alert, based on the WHO global influenza preparedness plan, remains at Phase 3 (Pandemic Alert). If H5N1 virus were to gain the capacity to spread easily from person to person, an influenza pandemic (worldwide outbreak of disease) could begin. CDC remains in close communication with WHO and continues to monitor the H5N1 virus situation in countries reporting bird outbreaks and human cases.

CDC has not recommended that the general public avoid travel to any of the countries affected by H5N1 viruses. Travelers should check the CDC’s Travelers’ Health Web-site for detailed information on precautions before, during, and after travel to affected regions.

For more information about H5N1 infections in humans, see the World Health Organization influenza website: http://www.who.int/csr/disease/avian_influenza/en/ or the CDC Avian Influenza site: http://www.cdc.gov/flu/avian/index.htm. For avian flu-related travel information: http://www.cdc.gov/travel/other/avian_flu/. For enhanced surveil-lance, diagnostic evaluation, and infection control precautions: http://www.cdc.gov/flu/avian/professional/updates.htm.

Dengue, Tropical and Subtropical Regions
Released:
December 6, 2006

Dengue is caused by one of four viruses (DEN-1, DEN-2, DEN-3, and DEN-4), which can produce clinical illness ranging from a nonspecific viral syndrome to severe fatal hemorrhagic fever. Symptoms of dengue include fever, severe headache, retroorbital eye pain (pain behind the eye), joint and muscle pain, and rash. Dengue has become one of the most common viral diseases transmitted to humans by the bite of infected mosquitoes, usually Aedes aegypti; it is the most common cause of febrile illness in returned travelers from the Caribbean, Central America, and South Central Asia.*

The range of dengue has rapidly expanded in recent years to include most tropical countries throughout Asia (including the Indian Subcontinent), the South Pacific, the Caribbean, South and Central America, and Africa. See the Distribution of dengue maps for areas where it has become endemic. The risk to travelers is related to mosquito exposure, which can vary with the season.

No vaccine is available for dengue; however, travelers can reduce their risk by taking steps to protect themselves from mosquito bites.

Aedes mosquitoes, the principal mosquito vector, usually are active at dusk and dawn, but may feed at any time during the day, especially indoors, in shady areas, or when the weather is cloudy. Additionally, the risk for contracting dengue is greater in urban areas and lower in rural areas or areas at high altitude (above 4,500 feet [1500 meters]).

During 2005, a total of 96 cases of dengue were confirmed by CDC laboratories in U.S. international travelers. Travel destinations available for 73 patients included Central America (including Mexico), the Caribbean, and Asia. Seventeen of the total reported cases required hospitalization, and one was fatal.

During 2001-2004, a total of 77 cases of dengue were laboratory confirmed by CDC in U.S. travelers, with an additional 88 suspect dengue cases for which the diagnosis could not be confirmed. Travel destinations available for 66 of the confirmed cases during 2001-2004 included the Caribbean, Pacific islands, Asia, Central America (including Mexico), and South America; 10 additional cases were attributed to travel to U.S. territories of Puerto Rico, the Virgin Islands, and the Marshall Islands, and the State of Hawaii. Fifteen of the total reported cases required hospitalization, and one was fatal.

Routine Vaccinations

Before travel, be sure you and your children are up to date on all routine immunizations according to schedules approved by the Advisory Committee on Immunization Practice (ACIP). See the schedule for adults and the schedule for infants and children. Some schedules can be accelerated for travel. See your doctor at least 4–6 weeks before your trip to allow time for shots to take effect. If it is less than 4 weeks before you leave, you should still see your doctor. It might not be too late to get your shots or medications as well as other information about how to protect yourself from illness and injury while traveling.

Recommended Vaccinations and Preventive Medications

The following vaccines may be recommended for your travel to Central Africa. Discuss your travel plans and personal health with a health-care provider to determine which vaccines you will need.

  • Hepatitis A or immune globulin (IG). Transmission of hepatitis A virus can occur through direct person-to-person contact; through exposure to contaminated water, ice, or shellfish harvested in contaminated water; or from fruits, vegetables, or other foods that are eaten uncooked and that were contaminated during harvesting or subsequent handling.
  • Hepatitis B, especially if you might be exposed to blood or body fluids (for example, health-care workers), have sexual contact with the local population, or be exposed through medical treatment. Hepatitis B vaccine is now recommended for all infants and for children ages 11– 12 years who did not receive the series as infants.
  • Malaria: your risk of malaria may be high in all countries in Central Africa, including cities. See your health care provider for a prescription antimalarial drug. For details concerning risk and preventive medications, see Malaria Information for Travelers to Central Africa.
  • Meningococcal (meningitis), if you plan to visit countries in this region that experience epidemics of meningococcal disease during December through June.
  • Rabies, pre-exposure vaccination, if you might have extensive unprotected outdoor exposure in rural areas, such as might occur during camping, hiking, or bicycling, or engaging in certain occupational activities.
  • Typhoid vaccine. Typhoid fever can be contracted through contaminated drinking water or food, or by eating food or drinking beverages that have been handled by a person who is infected. Large outbreaks are most often related to fecal contamination of water supplies or foods sold by street vendors
  • Yellow fever, a viral disease that occurs primarily in sub-Saharan Africa and tropical South America, is transmitted to humans through the bite of infected mosquitoes. The virus is also present in Panama and Trinidad and Tobago. Yellow fever vaccination is recommended for travelers to endemic areas and may be required to cross certain international borders. Vacci-nation should be given 10 days before travel and at 10 year intervals if there is on-going risk.
  • As needed, booster doses for tetanus-diphtheria, measles, and a one-time dose of polio vaccine for adults.

Required Vaccinations

  • A certificate of yellow fever vaccination may be required for entry into certain countries in Central Africa.

Malaria

Malaria is always a serious disease and may be a deadly illness. Humans get malaria from the bite of a mosquito infected with the parasite. Your risk of malaria may be high in all countries in Central Africa, including cities. All travelers to Central Africa, including infants, children, and former residents of Central Africa, may be at risk for malaria. Prevent this serious disease by seeing your health care provider for a prescription antimalarial drug and by protecting yourself against mosquito bites. All travelers should take one of the following drugs:

  • atovaquone/proguanil,
  • doxycycline,
  • mefloquine, or
  • primaquine (in special circumstances).

Yellow Fever

A certificate of yellow fever vaccination may be required for entry into certain countries in Central Africa.

Food and Waterborne Diseases

Avoid buying food or drink from street vendors, because it is relatively easy for such food to become contaminated. Make sure your food and drinking water are safe. Food and waterborne diseases are the primary cause of illness in travelers.

Travelers’ diarrhea can be caused by viruses, bacteria, or parasites, which are found throughout Central Africa and can contaminate food or water. Infections may cause diarrhea and vomiting (E. coli, Salmonella, cholera, and parasites), fever (typhoid fever and toxoplasmosis), or liver damage (hepatitis).

Other Disease Risks

Dengue, filariasis, leishmaniasis, and onchocerciasis (river blindness) are other diseases carried by insects that also occur in this region. Protecting yourself against insect bites will help to prevent these diseases. The risk for contracting African sleeping sickness (trypanosomiasis), which is caused by the bite of an infected tsetse fly, is high in northern Angola, Central African Republic, Cameroon, Chad, Congo, Democratic Republic of the Congo, and southern Sudan and there is significant risk of infection for travelers visiting or working in rural areas.

A number of rickettsial infections also occur in this region. Wearing protective clothing and avoiding rural areas or areas of dense vegetation along streams, is the best protection. Schistosomiasis, a parasitic infection, can be contracted in fresh water in this region.

Do not swim in fresh water (except in well-chlorinated swimming pools) in these countries. Other infections that tend to occur more often in longer-term travelers (or immigrants from the region) include tuberculosis, HIV and hepatitis B.

Injuries

Motor vehicle crashes are a leading cause of injury among travelers. Protect yourself from motor vehicle injuries: avoid drinking and driving; wear your safety belt and place children in age-appropriate restraints in the back seat; follow the local customs and laws regarding pedestrian safety and vehicle speed; obey the rules of the road; and use helmets on bikes, motorcycles, and motor bikes. Avoid boarding an overloaded bus or mini-bus. Where possible, hire a local driver.

What You Need To Bring With You

  • Long-sleeved shirt, long pants, and a hat to wear whenever possible while outside, to prevent illnesses carried by insects (e.g., malaria, dengue, filariasis, leishmaniasis, and onchocerciasis).
  • Insect repellent containing DEET.
  • Bed nets treated with permethrin. Overseas, permethrin or another insecticide, deltamethrin, may be purchased to treat bed nets and clothes.
  • Flying-insect spray to help clear rooms of mosquitoes. The product should contain a pyrethroid insecticide; these insecticides quickly kill flying insects, including mosquitoes.
  • Iodine tablets and portable water filters to purify water if bottled water is not available.
  • Sunblock, sunglasses, and a hat for protection from harmful effects of UV sun rays.
  • Prescription medications: make sure you have enough to last during your trip, as well as a copy of the prescription(s) or letter from your health-care provider on office stationery explaining that the medication has been prescribed for you.
  • Always carry medications in their original containers, in your carry-on luggage.
  • Be sure to bring along over-the-counter antidiarrheal medication (e.g., bismuth subsalicylate, loperamide) and an antibiotic prescribed by your doctor to self-treat moderate to severe diarrhea.

Staying Healthy During Your Trip

To stay healthy, do…

  • Wash your hands often with soap and water or, if hands are not visibly soiled, use a waterless, alcohol-based hand rub to remove potentially infectious materials from your skin and help prevent disease transmission.
  • In developing countries, drink only bottled or boiled water, or carbonated (bubbly) drinks in cans or bottles. Avoid tap water, fountain drinks, and ice cubes. If this is not possible, learn how to make water safer to drink.
  • Take your malaria prevention medication before, during, and after travel, as directed. (See your health care provider for a prescription.)
  • To prevent fungal and parasitic infections, keep feet clean and dry, and do not go barefoot, even on beaches.
  • Always use latex condoms to reduce the risk of HIV and other sexually transmitted diseases.

Protect yourself from mosquito insect bites:

  • Wear long-sleeved shirts, long pants, and hats when outdoors.
  • Use insect repellents that contain DEET (N, N-diethylmethyltoluamide).
  • If no screening or air conditioning is available: use a pyrethroid-containing spray in living and sleeping areas during evening and night-time hours; sleep under bed nets, preferably insecticide-treated ones.
  • If you are visiting friends and relatives in your home country, see additional special information about malaria prevention in Recent Immigrants to the U.S.from Malarious Countries Returning ‘Home’ to Visit Friends and Relatives on the CDC Malaria site.

Do not

  • Do not eat food purchased from street vendors or food that is not well cooked to reduce risk of infection (i.e., hepatitis A and typhoid fever).
  • Do not drink beverages with ice.
  • Avoid dairy products, unless you know they have been pasteurized.
  • Do not swim in fresh water to avoid exposure to certain water-borne diseases such as schistosomiasis.
  • Do not handle animals, especially monkeys, dogs, and cats, to avoid bites and serious diseases (including rabies and plague). Consider pre-exposure rabies vaccination if you might have extensive unprotected outdoor exposure in rural areas.
  • Do not share needles for tattoos, body piercing or injections to prevent infections such as HIV and hepatitis B.

Avoid poultry farms, bird markets, and other places where live poultry is raised or kept.

After You Return Home

If you have visited a malaria-risk area, continue taking your antimalarial drug for 4 weeks (mefloquine or doxycycline) or seven days (atovaquone/proguani or primaquine) after leaving the risk area.

Malaria is always a serious disease and may be a deadly illness. If you become ill with a fever or flulike illness either while traveling in a malaria-risk area or after you return home (for up to1 year), you should seek immediate medical attention and should tell the physician your travel history.

EAST AFRICA

Date last revised: February 2, 2007

Countries in this region: Burundi, Comoros, Djibouti, Eritrea, Ethiopia, Kenya, Madagascar, Malawi, Mauritius, Mayotte, Mozambique, Reunion, Rwanda, Seychelles, Somalia, Tanzania, and Uganda.

Outbreaks

Measles and Mumps

Updated: January 3, 2007; October 27, July 28, 24 and 3, June 8, May 12, April 28, and March 31, 2006
Released: November 16, 2005

Measles and mumps remain common diseases in many parts of the world, including some developed countries. For US travelers, the risk for exposure to measles and mumps can be high, and both diseases can be prevented by the MMR (measles, mumps, rubella) vaccine. A measles outbreak in the Ukraine that began in early 2006 has waned. In addition, Kenya and Tanzania in East Africa reported measles outbreaks in 2006 and have since held measles immunization campaigns. Outbreaks in both countries are waning. An outbreak of measles in Uganda, Central Africa, was reported in November 2006, just ahead of its follow-up immunization campaign.

Recent outbreaks of mumps have also been reported among adolescents and young adults in the United States and United Kingdom. The outbreak in the United States began in December 2005 and peaked in April 2006. As of mid-December 2006, the number of reported mumps cases in the United Kingdom had declined compared with the same period in 2005. All travelers should be fully immunized and keep a copy of their immunization record with them as they travel.

Measles is a serious disease. Some of the people who become sick with measles also get an ear infection (7%-9%), diarrhea (8%), or a serious lung infection, such as pneumonia (1%-6%). One of 1,500 people with measles develops inflammation of the brain. In the United States, measles has been fatal in approximately 1-3 of every 1,000 people with measles in recent years. Measles can cause especially severe disease in people who are malnourished or immunosuppressed (i.e., HIV infection, leukemia, lymphoma, or generalized malignancy or persons receiving certain drug or radiation therapies).

Mumps is an infection of the salivary glands caused by a virus. It occurs through direct contact with respiratory droplets, saliva or contact with any surface that has been contaminated with the mumps virus. Early symptoms include fever, headache, and muscle ache; less than half of infected people may have the characteristic swelling of the glands close to the jaw. Mumps infection can lead to meningitis and inflammation of the testicles or ovaries, inflammation of the pancreas and deafness (usually permanent). The MMR vaccine also provides protection against rubella (German measles). Rubella is caused by a virus that is spread through droplet transmission. It can cause a rash, mild fever, and arthritis (mostly in women). If a woman gets rubella while she is pregnant, she could have a miscarriage or her baby could be born with serious birth defects, such as deafness, cataracts, or mental retardation. Since the introduction of vaccines containing measles, rubella, and mumps—and later combined measles-mumps-rubella (MMR) vaccine—in the United States, the numbers of reported cases of measles, mumps, rubella, and birth defects caused by rubella infection (congenital rubella syndrome) have decreased substantially. However, routine surveillance and vaccination remain necessary because of the continuing possibility of introduction of these diseases from other countries. For more information, go to the CDC website at http://www.cdc.gov/travel/yb/.

Polio

Updated: December 1, October 27, September 20, June 7,
June 2, April 11 and February 10, 2006;
December 16, 2005
Released: November 9, 2005

According to the Global Polio Eradication Initiative (GPEI), only 4 countries (Nigeria, India, Pakistan and Afghanistan) remain polio-endemic, an all-time low. Egypt, which had been considered polio-endemic, has remained free of poliovirus transmission for over 22 months.

The following countries, however, have recently reported importations of polio in 2006, after previously being polio-free:

  • Kenya (polio-free for over 6 years)
  • Bangladesh (polio-free for over 5 years)
  • The Democratic Republic of the Congo (polio-free for almost 6 years)
  • Namibia (polio-free for almost 10 years)

Plans are under way for immunization response activities in all affected countries.

Other countries that have reported imported polio cases or cases related to an importation in 2006 are Angola, Cameroon, Ethiopia, Indonesia, Nepal, Niger, Somalia, and Yemen. Chad last reported polio cases in December 2005. Eritrea, Mali, and Sudan reported imported polio cases in 2005 but have not reported additional cases for over 12 months.

Outbreaks of poliovirus continue to be a risk until poliovirus is eliminated worldwide, and the risk for infection is still present for susceptible people. Therefore, to protect themselves from polio, travelers should be sure they and their children are fully immunized. Vaccination is recommended for all travelers to polio-endemic or -epidemic areas. These areas include Africa, South Asia, Southeast Asia, and the Middle East.

Polio is an infectious disease caused by a virus. The disease mainly affects children under 5 years of age. It is spread person-to-person when the virus enters the mouth of a person who has come in contact with the stool of an infected person (for example, by changing diapers and not washing hands before touching the mouth) or from fecal contamination of food or drinking water. Most people infected with the poliovirus have no symptoms, but some infections cause paralysis and even death. Until the 1950s, polio crippled thousands of children in industrialized countries. Soon after the introduction of effective vaccines in the late 1950s (IPV) and early 1960s (OPV), polio was brought under control and practically eliminated as a public health problem in industrialized countries. OPV has not been used in the United States since 2000; however, it is used in many other counties and has played a major role in eliminating polio from large parts of the world. IPV, which is given by intramuscular injection, is now used in the United States and several other industrialized countries. For more information, go to the CDC website at http://www.cdc.gov/travel/yb/.

Avian Influenza A (H5N1) Virus
Most recently updated:
February 2, 2007
Initially released: September 23, 2005

Highly pathogenic avian influenza A (H5N1) (hereafter referred to as “H5N1”) virus has caused serious disease among wild birds and poultry on multiple continents. For a current list of countries reporting outbreaks of H5N1 among poultry and/or wild birds, view updates from the World Organization for Animal Health (OIE). Human infections with H5N1 viruses are still rare, but have occurred in countries in Asia, Africa, Eastern Europe, and the Middle East between 2003—2007. Most cases of H5N1 virus infection in humans are thought to have occurred from direct contact with infected poultry, but in one instance, human cases are thought to have been acquired through close contact with wild swans. Rare occurrences of probable spread (or ‘transmission’) from human to human have been reported. So far, however, this type of transmission has not been sustained. Transmission of H5N1 viruses to two persons through consumption of uncooked duck blood may also have occurred in Vietnam in 2005. Total numbers of confirmed human cases of H5N1 virus by country are available on the World Health Organization (WHO) Avian Influenza website. An assessment of the cur-rent situation can be found on the Centers for Disease Control and Prevention (CDC) Avian Influenza website.

Outbreaks of H5N1 virus among bird populations in Asia, parts of Europe, the Middle East and Africa are not expected to diminish significantly in the short term. Consequently, it is expected that human infections resulting from direct contact with infected poultry will continue to occur in countries where poultry flocks are infected. Because no sustained human-to-human transmission of H5N1 virus has been documented anywhere in the world, the current phase of alert, based on the WHO global influenza preparedness plan, remains at Phase 3 (Pandemic Alert). If H5N1 virus were to gain the capacity to spread easily from person to person, an influenza pandemic (worldwide outbreak of disease) could begin. CDC remains in close communication with WHO and continues to monitor the H5N1 virus situation in countries reporting bird outbreaks and human cases.

CDC has not recommended that the general public avoid travel to any of the countries affected by H5N1 viruses. Travelers should check the CDC’s Travelers’ Health Web-site for detailed information on precautions before, during, and after travel to affected regions.

For more information about H5N1 infections in humans, see the World Health Organization influenza website: http://www.who.int/csr/disease/avian_influenza/en/ or the CDC Avian Influenza site: http://www.cdc.gov/flu/avian/index.htm. For avian flu-related travel information: http://www.cdc.gov/travel/other/avian_flu/. For enhanced surveil-lance, diagnostic evaluation, and infection control precautions: http://www.cdc.gov/flu/avian/professional/updates.htm.

Chikungunya Fever: India and
Indian Ocean Islands
Updated:
October 24, June 19 and June 16, 2006
Released: April 21, 2006

Chikungunya fever is a viral disease transmitted to humans by the bite of infected Aedes and Culex mosquitoes, including the daytime-biting Aedes aegypti and Ae albopictus species. Symptoms can include sudden onset of fever, chills, headache, nausea, vomiting, joint pain with or without swelling, low back pain, and rash. The symptoms are very similar to those of dengue, but, unlike dengue, there is no hemorrhagic or shock syndrome form. This disease is almost always self-limited and rarely fatal.

Since April 2006, a chikungunya fever outbreak has been on-going in the following states in India: Andhra Pradesh, Andaman & Nicobar Islands, Tamil Nadu, Karnataka, Maharashtra, Gujarat, Madhya Pradesh, and Kerala. At this time, investigations are on-going for identification of chikungunya fever in other areas of India, as it is important to confirm the diagnosis of chikungunya fever and rule out other mosquito-borne diseases, such as dengue fever and malaria in India.

A chikungunya fever outbreak on the Indian Ocean islands of Mayotte, Mauritius, Réunion (territory of France), and the Seychelles that began in March 2005 is waning. However, transmission can still occur, and travelers to all tropical and subtropical areas of the world are reminded to take precautions to avoid mosquito bites.

There are no preventive medications or FDA-approved vaccines for chikungunya fever, but travelers should take steps to reduce their risk of being bitten by infected mosquitoes. For more information about chikungunya fever, see the Chikungunya Fever Fact Sheet at http://www.cdc.gov/ncidod/dvbid/Chikungunya/chickvfact.htm.

Dengue, Tropical and Subtropical Regions Released:
December 6, 2006

Dengue is caused by one of four viruses (DEN-1, DEN-2, DEN-3, and DEN-4), which can produce clinical illness ranging from a nonspecific viral syndrome to severe fatal hemorrhagic fever. Symptoms of dengue include fever, severe headache, retroorbital eye pain (pain behind the eye), joint and muscle pain, and rash. Dengue has become one of the most common viral diseases transmitted to humans by the bite of infected mosquitoes, usually Aedes aegypti; it is the most common cause of febrile illness in returned travelers from the Caribbean, Central America, and South Central Asia.*

The range of dengue has rapidly expanded in recent years to include most tropical countries throughout Asia (including the Indian Subcontinent), the South Pacific, the Caribbean, South and Central America, and Africa. See the Distribution of dengue maps for areas where it has become endemic. The risk to travelers is related to mosquito exposure, which can vary with the season.

No vaccine is available for dengue; however, travelers can reduce their risk by taking steps to protect themselves from mosquito bites.

Aedes mosquitoes, the principal mosquito vector, usually are active at dusk and dawn, but may feed at any time during the day, especially indoors, in shady areas, or when the weather is cloudy. Additionally, the risk for contracting dengue is greater in urban areas and lower in rural areas or areas at high altitude (above 4,500 feet [1500 meters]).

During 2005, a total of 96 cases of dengue were confirmed by CDC laboratories in U.S. international travelers. Travel destinations available for 73 patients included Central America (including Mexico), the Caribbean, and Asia. Seventeen of the total reported cases required hospitalization, and one was fatal.

During 2001-2004, a total of 77 cases of dengue were laboratory confirmed by CDC in U.S. travelers, with an additional 88 suspect dengue cases for which the diagnosis could not be confirmed. Travel destinations available for 66 of the confirmed cases during 2001-2004 included the Caribbean, Pacific islands, Asia, Central America (including Mexico), and South America; 10 additional cases were attributed to travel to U.S. territories of Puerto Rico, the Virgin Islands, and the Marshall Islands, and the State of Hawaii. Fifteen of the total reported cases required hospitalization, and one was fatal. For more information about dengue and protection measures, go to the CDC website at http://www.cdc.gov/travel/yb/.

Rift Valley Fever in Kenya
Released:
December 29, 2006

According to the World Health Organization (WHO), the Ministry of Health in Kenya has reported 32 cases of Rift Valley fever resulting in 19 deaths. The outbreak is occurring in remote parts of northeastern Kenya, primarily in flood-affected areas of Garissa, including Korakora, Chanta Abak, Shell Gulliet, and Shimbirey. An investigation and response measures are underway, with the help of several international organizations and agencies.

Generally, the risk of Rift Valley fever infection is low for travelers, unless they are in areas where an outbreak is occurring and are bitten by infected insects or come in contact with body fluids and aerosols from infected animals (primarily livestock).

Rift Valley fever is a viral disease generally found in subSaharan Africa where sheep and cattle are raised, but the virus has also occurred in Egypt, the Arabian Peninsula and in Madagascar. Rift Valley fever virus primarily affects livestock and can cause disease in a large number of domestic animals. Although the virus is usually transmitted by infected mosquitoes and possibly other biting insects that have virus contaminated mouthparts, Rift Valley Fever virus is occasionally transmitted to humans through contact with the blood, body fluids, or tissues of the infected animals (e.g., exposure through veterinary or obstetric procedures or direct exposure during slaughter). For more information about dengue and protection measures, go to the CDC website at http://www.cdc.gov/travel/yb/.

Routine Vaccinations

Before travel, be sure you and your children are up to date on all routine immunizations according to schedules approved by the Advisory Committee on Immunization Practice (ACIP). See the schedule for adults and the schedule for infants and children. Some schedules can be accelerated for travel.

See your doctor at least 4–6 weeks before your trip to allow time for shots to take effect. If it is less than 4 weeks before you leave, you should still see your doctor. It might not be too late to get your shots or medications as well as other information about how to protect yourself from illness and injury while traveling.

Recommended Vaccinations and Preventive Medications

The following vaccines may be recommended for your travel to East Africa. Discuss your travel plans and personal health with a health-care provider to determine which vaccines you will need.

  • Hepatitis A or immune globulin (IG). Transmission of hepatitis A virus can occur through direct person-to-person contact; through exposure to contaminated water, ice, or shellfish harvested in contaminated water; or from fruits, vegetables, or other foods that are eaten uncooked and that were contaminated during harvesting or subsequent handling.
  • Hepatitis B, especially if you might be exposed to blood or body fluids (for example, health-care workers), have sexual contact with the local population, or be exposed through medical treatment. Hepatitis B vaccine is now recommended for all infants and for children ages 11– 12 years who did not receive the series as infants.
  • Malaria: your risk of malaria may be high in all countries in East Africa, including cities. See your health care provider for a prescription antimalarial drug. For details concerning risk and preventive medications, see Malaria Information for Travelers to East Africa.
  • Meningococcal (meningitis) if you plan to visit countries in this region that experience epidemics of meningococcal disease during December through June.
  • Rabies, pre-exposure vaccination, if you might have extensive unprotected outdoor exposure in rural areas, such as might occur during camping, hiking, or bicycling, or engaging in certain occupational activities.
  • Typhoid vaccine. Typhoid fever can be contracted through contaminated drinking water or food, or by eating food or drinking beverages that have been handled by a person who is infected. Large outbreaks are most often related to fecal contamination of water supplies or foods sold by street vendors
  • Yellow fever, a viral disease that occurs primarily in sub-Saharan Africa and tropical South America, is transmitted to humans through the bite of infected mosquitoes. The virus is also present in Panama and Trinidad and Tobago. Yellow fever vaccination is recommended for travelers to endemic areas and may be required to cross certain international borders. Vacci-nation should be given 10 days before travel and at 10 year intervals if there is on-going risk.
  • As needed, booster doses for tetanus-diphtheria, measles, and a one-time dose of polio vaccine for adults.

Required Vaccinations

  • A certificate of yellow fever vaccination may be required for entry into certain countries in East Africa.

Malaria

Malaria is always a serious disease and may be a deadly illness. Humans get malaria from the bite of a mosquito infected with the parasite. Your risk of malaria may be high in all countries in East Africa, including cities. All travelers to East Africa, including infants, children, and former residents of East Africa, may be at risk for malaria. Prevent this serious disease by seeing your health care provider for a prescription antimalarial drug and by protecting yourself against mosquito bites. All travelers should take one of the following drugs:

  • atovaquone/proguanil,
  • doxycycline,
  • mefloquine, or
  • primaquine (in special circumstances).

Yellow Fever

A certificate of yellow fever vaccination may be required for entry into certain countries in East Africa.

Food and Waterborne Diseases

Avoid buying food or drink from street vendors, because it is relatively easy for such food to become contaminated. Make sure your food and drinking water are safe. Food and waterborne diseases are the primary cause of illness in travelers. Travelers’ diarrhea can be caused by viruses, bacteria, or parasites, which are found throughout East Africa and can contaminate food or water. Infections may cause diarrhea and vomiting (E. coli, Salmonella, cholera, and parasites), fever (typhoid fever and toxoplasmosis), or liver damage (hepatitis).

Other Disease Risks

Dengue, filariasis, leishmaniasis, onchocerciasis (river blindness) and Rift Valley fever are other diseases carried by insects that also occur in this region. Protecting yourself against insect bites will help to prevent these diseases. African sleeping sickness (African trypanosomiasis), which is transmitted through the bite of an infected tsetse fly, can be found in distinct areas of East Africa except Djibouti, Eritrea, Somalia, and the island countries of the Atlantic and Indian Oceans.

The number of cases of African sleeping sickness in travelers, primarily to East African game parks, has increased in recent years. A number of rickettsial infections also occur in this region. Wearing protective clothing and avoiding rural areas or areas of dense vegetation along streams, is the best protection. Schistosomiasis, a parasitic infection, is found in fresh water in the region, including Lake Malawi. Do not swim in fresh water (except in well-chlorinated swimming pools) in these countries. Polio has also resurfaced in Ethiopia since 2003.

Other infections that tend to occur more often in longer-term travelers (or immigrants from the region) include tuberculosis, HIV and hepatitis B.

Injuries

Motor vehicle crashes are a leading cause of injury among travelers. Protect yourself from motor vehicle injuries: avoid drinking and driving; wear your safety belt and place children in age-appropriate restraints in the back seat; follow the local customs and laws regarding pedestrian safety and vehicle speed; obey the rules of the road; and use helmets on bikes, motorcycles, and motor bikes. Avoid boarding an overloaded bus or mini-bus. Where possible, hire a local driver.

What You Need To Bring With You

  • Long-sleeved shirt, long pants, and a hat to wear whenever possible while outside, to prevent illnesses carried by insects (e.g., malaria, Dengue, filariasis, leishmaniasis, and onchocerciasis).
  • Insect repellent containing DEET.
  • Bed nets treated with permethrin. Overseas, permethrin or another insecticide, deltamethrin, may be purchased to treat bed nets and clothes.
  • Flying-insect spray to help clear rooms of mosquitoes. The product should contain a pyrethroid insecticide; these insecticides quickly kill flying insects, including mosquitoes.
  • Iodine tablets and portable water filters to purify water if bottled water is not available.
  • Sunblock, sunglasses, and a hat for protection from harmful effects of UV sun rays.
  • Prescription medications: make sure you have enough to last during your trip, as well as a copy of the prescription(s) or letter from your health-care provider on office stationery explaining that the medication has been prescribed for you.
  • Always carry medications in their original containers, in your carry-on luggage.
  • Be sure to bring along over-the-counter antidiarrheal medication (e.g., bismuth subsalicylate, loperamide) and an antibiotic prescribed by your doctor to self-treat moderate to severe diarrhea.

Staying Healthy During Your Trip

To stay healthy, do…

  • Wash your hands often with soap and water or, if hands are not visibly soiled, use a waterless, alcohol-based hand rub to remove potentially infectious materials from your skin and help prevent disease transmission.
  • In developing countries, drink only bottled or boiled water, or carbonated (bubbly) drinks in cans or bottles. Avoid tap water, fountain drinks, and ice cubes. If this is not possible, learn how to make water safer to drink.
  • Take your malaria prevention medication before, during, and after travel, as directed. (See your health care provider for a prescription.)
  • To prevent fungal and parasitic infections, keep feet clean and dry, and do not go barefoot, even on beaches.
  • Always use latex condoms to reduce the risk of HIV and other sexually transmitted diseases.

Protect yourself from mosquito insect bites:

  • Wear long-sleeved shirts, long pants, and hats when outdoors.
  • Use insect repellents that contain DEET (N, N-diethylmethyltoluamide).
  • If no screening or air conditioning is available: use a pyrethroid-containing spray in living and sleeping areas during evening and night-time hours; sleep under bed nets, preferably insecticide-treated ones.
  • If you are visiting friends and relatives in your home country, see additional special information about malaria prevention in Recent Immigrants to the U.S. from Malarious Countries Returning ‘Home’ to Visit Friends and Relatives on the CDC Malaria site.

Do not

  • Do not eat food purchased from street vendors or food that is not well cooked to reduce risk of infection (i.e., hepatitis A and typhoid fever).
  • Do not drink beverages with ice.
  • Avoid dairy products, unless you know they have been pasteurized.
  • Do not swim in fresh water to avoid exposure to certain water-borne diseases such as schistosomiasis.
  • Do not handle animals, especially monkeys, dogs, and cats, to avoid bites and serious diseases (including rabies and plague). Consider pre-exposure rabies vaccination if you might have extensive unprotected outdoor exposure in rural areas.
  • Do not share needles for tattoos, body piercing or injections to prevent infections such as HIV and hepatitis B.

Avoid poultry farms, bird markets, and other places where live poultry is raised or kept.

After You Return Home

If you have visited a malaria-risk area, continue taking your antimalarial drug for 4 weeks (mefloquine or doxycycline) or seven days (atovaquone/proguanil) after leaving the risk area. Malaria is always a serious disease and may be a deadly illness. If you become ill with a fever or flulike illness either while traveling in a malaria-risk area or after you return home (for up to1 year), you should seek immediate medical attention and should tell your health care provider your travel history.

NORTH AFRICA

Date last revised: December 1, 2006

Countries in this region: Algeria, Canary Islands (Spain), Egypt, Libyan Arab Jamahiriya, Morocco (including Western Sahara), and Tunisia.

Outbreaks

Polio

Updated: December 1, October 27, September 20, June 7,
June 2, April 11 and February 10, 2006;
December 16, 2005
Released: November 9, 2005

According to the Global Polio Eradication Initiative (GPEI), only 4 countries (Nigeria, India, Pakistan and Afghanistan) remain polio-endemic, an all-time low. Egypt, which had been considered polio-endemic, has remained free of poliovirus transmission for over 22 months.

The following countries, however, have recently reported importations of polio in 2006, after previously being polio-free:

  • Kenya (polio-free for over 6 years)
  • Bangladesh (polio-free for over 5 years)
  • The Democratic Republic of the Congo (polio-free for almost 6 years)
  • Namibia (polio-free for almost 10 years)

Plans are under way for immunization response activities in all affected countries.

Other countries that have reported imported polio cases or cases related to an importation in 2006 are Angola, Cameroon, Ethiopia, Indonesia, Nepal, Niger, Somalia, and Yemen. Chad last reported polio cases in December 2005. Eritrea, Mali, and Sudan reported imported polio cases in 2005 but have not reported additional cases for over 12 months.

Outbreaks of poliovirus continue to be a risk until poliovirus is eliminated worldwide, and the risk for infection is still present for susceptible people. Therefore, to protect themselves from polio, travelers should be sure they and their children are fully immunized. Vaccination is recommended for all travelers to polio-endemic or -epidemic areas. These areas include Africa, South Asia, Southeast Asia, and the Middle East. Polio is an infectious disease caused by a virus. The disease mainly affects children under 5 years of age. It is spread person-to-person when the virus enters the mouth of a person who has come in contact with the stool of an infected person (for example, by changing diapers and not washing hands before touching the mouth) or from fecal contamination of food or drinking water. Most people infected with the poliovirus have no symptoms, but some infections cause paralysis and even death. Until the 1950s, polio crippled thousands of children in industrialized countries. Soon after the introduction of effective vaccines in the late 1950s (IPV) and early 1960s (OPV), polio was brought under control and practically eliminated as a public health problem in industrialized countries.

OPV has not been used in the United States since 2000; however, it is used in many other counties and has played a major role in eliminating polio from large parts of the world. IPV, which is given by intramuscular injection, is now used in the United States and several other industrialized countries. For more information, go to the CDC website at http://www.cdc.gov/travel/yb/.

Avian Influenza A (H5N1) Virus
Most recently updated:
February 2, 2007
Initially released: September 23, 2005

Highly pathogenic avian influenza A (H5N1) (hereafter referred to as “H5N1”) virus has caused serious disease among wild birds and poultry on multiple continents. For a current list of countries reporting outbreaks of H5N1 among poultry and/or wild birds, view updates from the World Organization for Animal Health (OIE). Human infections with H5N1 viruses are still rare, but have occurred in countries in Asia, Africa, Eastern Europe, and the Middle East between 2003—2007. Most cases of H5N1 virus infection in humans are thought to have occurred from direct contact with infected poultry, but in one instance, human cases are thought to have been acquired through close contact with wild swans. Rare occurrences of probable spread (or ‘transmission’) from human to human have been reported. So far, however, this type of transmission has not been sustained.

Transmission of H5N1 viruses to two persons through consumption of uncooked duck blood may also have occurred in Vietnam in 2005. Total numbers of confirmed human cases of H5N1 virus by country are available on the World Health Organization (WHO) Avian Influenza website. An assessment of the current situation can be found on the Centers for Disease Control and Prevention (CDC) Avian Influenza website.

Outbreaks of H5N1 virus among bird populations in Asia, parts of Europe, the Middle East and Africa are not expected to diminish significantly in the short term. Consequently, it is expected that human infections resulting from direct contact with infected poultry will continue to occur in countries where poultry flocks are infected. Because no sustained human-to-human transmission of H5N1 virus has been documented anywhere in the world, the current phase of alert, based on the WHO global influenza preparedness plan, remains at Phase 3 (Pandemic Alert). If H5N1 virus were to gain the capacity to spread easily from person to person, an influenza pandemic (worldwide outbreak of disease) could begin. CDC remains in close communication with WHO and continues to monitor the H5N1 virus situation in countries reporting bird outbreaks and human cases. CDC has not recommended that the general public avoid travel to any of the countries affected by H5N1 viruses. Travelers should check the CDC’s Travelers’ Health Website for detailed information on precautions before, during, and after travel to affected regions. For more information about H5N1 infections in humans, see the World Health Organization influenza website: http://www.who.int/csr/disease/avian_influenza/en/ or the CDC Avian Influenza site: http://www.cdc.gov/flu/avian/index.htm. For avian flu-related travel information: http://www.cdc.gov/travel/other/avian_flu/. For enhanced surveillance, diagnostic evaluation, and infection control precautions: http://www.cdc.gov/flu/avian/professional/updates.htm.

Dengue, Tropical and Subtropical Regions
Released:
December 6, 2006

Dengue is caused by one of four viruses (DEN-1, DEN-2, DEN-3, and DEN-4), which can produce clinical illness ranging from a nonspecific viral syndrome to severe fatal hemorrhagic fever. Symptoms of dengue include fever, severe headache, retroorbital eye pain (pain behind the eye), joint and muscle pain, and rash. Dengue has become one of the most common viral diseases transmitted to humans by the bite of infected mosquitoes, usually Aedes aegypti; it is the most common cause of febrile illness in returned travelers from the Caribbean, Central America, and South Central Asia.

The range of dengue has rapidly expanded in recent years to include most tropical countries throughout Asia (including the Indian Subcontinent), the South Pacific, the Caribbean, South and Central America, and Africa. See the Distribution of dengue maps for areas where it has become endemic. The risk to travelers is related to mosquito exposure, which can vary with the season.

No vaccine is available for dengue; however, travelers can reduce their risk by taking steps to protect themselves from mosquito bites. Aedes mosquitoes, the principal mosquito vector, usually are active at dusk and dawn, but may feed at any time during the day, especially indoors, in shady areas, or when the weather is cloudy. Additionally, the risk for contracting dengue is greater in urban areas and lower in rural areas or areas at high altitude (above 4,500 feet [1500 meters]). During 2005, a total of 96 cases of dengue were confirmed by CDC laboratories in U.S. international travelers. Travel destinations available for 73 patients included Central America (including Mexico), the Caribbean, and Asia. Seventeen of the total reported cases required hospitalization, and one was fatal.

During 2001-2004, a total of 77 cases of dengue were laboratory confirmed by CDC in U.S. travelers, with an additional 88 suspect dengue cases for which the diagnosis could not be confirmed. Travel destinations available for 66 of the confirmed cases during 2001-2004 included the Caribbean, Pacific islands, Asia, Central America (including Mexico), and South America; 10 additional cases were attributed to travel to U.S. territories of Puerto Rico, the Virgin Islands, and the Marshall Islands, and the State of Hawaii. Fifteen of the total reported cases required hospitalization, and one was fatal. For more information about dengue and protection measures, go to the CDC website at http://www.cdc.gov/travel/yb/.

Routine Vaccinations

Before travel, be sure you and your children are up to date on all routine immunizations according to schedules approved by the Advisory Committee on Immunization Practice (ACIP). See the schedule for adults and the schedule for infants and children. Some schedules can be accelerated for travel. See your doctor at least 4–6 weeks before your trip to allow time for shots to take effect. If it is less than 4 weeks before you leave, you should still see your doctor. It might not be too late to get your shots or medications as well as other information about how to protect yourself from illness and injury while traveling.

Recommended Vaccinations

The following vaccines may be recommended for your travel to North Africa. Discuss your travel plans and personal health with a health-care provider to determine which vaccines you will need.

  • Hepatitis A or immune globulin (IG). Transmission of hepatitis A virus can occur through direct person-to-person contact; through exposure to contaminated water, ice, or shellfish harvested in contaminated water; or from fruits, vegetables, or other foods that are eaten uncooked and that were contaminated during harvesting or subsequent handling.
  • Hepatitis B, especially if you might be exposed to blood or body fluids (for example, health-care workers), have sexual contact with the local population, or be exposed through medical treatment. Hepatitis B vaccine is now recommended for all infants and for children ages 11– 12 years who did not receive the series as infants.
  • Rabies, pre-exposure vaccination, if you might have extensive unprotected outdoor exposure in rural areas, such as might occur during camping, hiking, or bicycling, or engaging in certain occupational activities.
  • Typhoid vaccine. Typhoid fever can be contracted through contaminated drinking water or food, or by eating food or drinking beverages that have been handled by a person who is infected. Large outbreaks are most often related to fecal contamination of water supplies or foods sold by street vendors
  • As needed, booster doses for tetanus-diphtheria, measles, and a one-time dose of polio vaccine for adults.

Required Vaccinations

  • None.

Malaria

Malaria is always a serious disease and may be a deadly illness. Humans get malaria from the bite of a mosquito infected with the parasite. Prevent this serious disease by seeing your health care provider for a prescription antimalarial drug and by protecting yourself against mosquito bites.

A limited risk of malaria exists in parts of Algeria, Egypt, and Morocco. Taking an antimalarial drug is not recommended as the risk for travelers is considered to be extremely low. However, travelers should use insect repellent with DEET (N, N-diethyl-m-toluamide) to prevent mosquito bites.

Yellow Fever

There is no risk for yellow fever in North Africa. A certificate of yellow fever vaccination may be required for entry into certain of these countries if you are coming from countries in South America or sub-Saharan Africa.

Food and Waterborne Diseases

Avoid buying food or drink from street vendors, because it is relatively easy for such food to become contaminated. Make sure your food and drinking water are safe. Food and waterborne diseases are the primary cause of illness in travelers.

Travelers’ diarrhea can be caused by viruses, bacteria, or parasites, which are found throughout North Africa and can contaminate food or water. Infections may cause diarrhea and vomiting (E. coli, Salmonella, cholera, and parasites), fever (typhoid fever and toxoplasmosis), or liver damage (hepatitis).

Other Disease Risks

Dengue, filariasis, leishmaniasis, and onchocerciasis (river blindness) are other diseases carried by insects that also occur in this region. Protecting yourself against from insect bites will help to prevent these diseases. Schistosomiasis, a parasitic infection, is found in fresh water in the region, including the Nile River. Do not swim in fresh water (except in well-chlorinated swimming pools) in these countries. Other infections that tend to occur more often in longer-term travelers (or immigrants from the region) include tuberculosis, hepatitis B, and hepatitis C (prevalence > 15% in Egypt). Polio is also still endemic in Egypt.

Injuries

Motor vehicle crashes are a leading cause of injury among travelers. Protect yourself from motor vehicle injuries: avoid drinking and driving; wear your safety belt and place children in age-appropriate restraints in the back seat; follow the local customs and laws regarding pedestrian safety and vehicle speed; obey the rules of the road; and use helmets on bikes, motorcycles, and motor bikes. Avoid boarding an overloaded bus or mini-bus. Where possible, hire a local driver.

What You Need To Bring With You

  • Long-sleeved shirt, long pants, and a hat to wear whenever possible while outside, to prevent illnesses carried by insects (e.g., malaria, Dengue, filariasis, leishmaniasis, and onchocerciasis).
  • Insect repellent containing DEET.
  • Bed nets treated with permethrin. Overseas, permethrin or another insecticide, deltamethrin, may be purchased to treat bed nets and clothes.
  • Flying-insect spray to help clear rooms of mosquitoes. The product should contain a pyrethroid insecticide; these insecticides quickly kill flying insects, including mosquitoes.
  • Iodine tablets and portable water filters to purify water if bottled water is not available.
  • Sunblock, sunglasses, and a hat for protection from harmful effects of UV sun rays.
  • Prescription medications: make sure you have enough to last during your trip, as well as a copy of the prescription(s) or letter from your health-care provider on office stationery explaining that the medication has been prescribed for you.
  • Always carry medications in their original containers, in your carry-on luggage.
  • Be sure to bring along over-the-counter antidiarrheal medication (e.g., bismuth subsalicylate, loperamide) and an antibiotic prescribed by your doctor to self-treat moderate to severe diarrhea.

Staying Healthy During Your Trip

To stay healthy, do…

  • Wash your hands often with soap and water or, if hands are not visibly soiled, use a waterless, alcohol-based hand rub to remove potentially infectious materials from your skin and help prevent disease transmission.
  • In developing countries, drink only bottled or boiled water, or carbonated (bubbly) drinks in cans or bottles. Avoid tap water, fountain drinks, and ice cubes. If this is not possible, learn how to make water safer to drink.
  • Take your malaria prevention medication before, during, and after travel, as directed. (See your health care provider for a prescription.)
  • To prevent fungal and parasitic infections, keep feet clean and dry, and do not go barefoot, even on beaches.
  • Always use latex condoms to reduce the risk of HIV and other sexually transmitted diseases.

Protect yourself from mosquito insect bites:

  • Wear long-sleeved shirts, long pants, and hats when outdoors.
  • Use insect repellents that contain DEET (N, N-diethylmethyltoluamide).
  • If no screening or air conditioning is available: use a pyrethroid-containing spray in living and sleeping areas during evening and night-time hours; sleep under bed nets, preferably insecticide-treated ones.
  • If you are visiting friends and relatives in your home country, see additional special information about malaria prevention in Recent Immigrants to the U.S. from Malarious Countries Returning ‘Home’ to Visit Friends and Relatives on the CDC Malaria site.

Do not

  • Do not eat food purchased from street vendors or food that is not well cooked to reduce risk of infection (i.e., hepatitis A and typhoid fever).
  • Do not drink beverages with ice.
  • Avoid dairy products, unless you know they have been pasteurized.
  • Do not swim in fresh water to avoid exposure to certain water-borne diseases such as schistosomiasis.
  • Do not handle animals, especially monkeys, dogs, and cats, to avoid bites and serious diseases (including rabies and plague). Consider pre-exposure rabies vaccination if you might have extensive unprotected outdoor exposure in rural areas.
  • Do not share needles for tattoos, body piercing or injections to prevent infections such as HIV and hepatitis B.

Avoid poultry farms, bird markets, and other places where live poultry is raised or kept.

After You Return Home

Although the risk of malaria in North Africa is limited, travelers who become ill with fever or flu-like illness while traveling in North Africa and up to 1 year after returning home should seek immediate medical attention and should tell their health care provider their travel history.

SOUTHERN AFRICA

Date last revised: December 6, 2006

Countries in the region of Southern Africa: Botswana, Lesotho, Namibia, South Africa, St. Helena (U.K.), Swaziland, and Zimbabwe.

Outbreaks

Polio

Updated: December 1, October 27, September 20, June 7,
June 2, April 11 and February 10, 2006;
December 16, 2005
Released: November 9, 2005

According to the Global Polio Eradication Initiative (GPEI), only 4 countries (Nigeria, India, Pakistan and Afghanistan) remain polio-endemic, an all-time low. Egypt, which had been considered polio-endemic, has remained free of poliovirus transmission for over 22 months.

The following countries, however, have recently reported importations of polio in 2006, after previously being polio-free:

  • Kenya (polio-free for over 6 years)
  • Bangladesh (polio-free for over 5 years)
  • The Democratic Republic of the Congo (polio-free for almost 6 years)
  • Namibia (polio-free for almost 10 years)

Plans are under way for immunization response activities in all affected countries.

Other countries that have reported imported polio cases or cases related to an importation in 2006 are Angola, Cameroon, Ethiopia, Indonesia, Nepal, Niger, Somalia, and Yemen. Chad last reported polio cases in December 2005. Eritrea, Mali, and Sudan reported imported polio cases in 2005 but have not reported additional cases for over 12 months.

Outbreaks of poliovirus continue to be a risk until poliovirus is eliminated worldwide, and the risk for infection is still present for susceptible people. Therefore, to protect themselves from polio, travelers should be sure they and their children are fully immunized. Vaccination is recommended for all travelers to polio-endemic or -epidemic areas. These areas include Africa, South Asia, Southeast Asia, and the Middle East.

Polio is an infectious disease caused by a virus. The disease mainly affects children under 5 years of age. It is spread person-to-person when the virus enters the mouth of a person who has come in contact with the stool of an infected person (for example, by changing diapers and not washing hands before touching the mouth) or from fecal contamination of food or drinking water. Most people infected with the poliovirus have no symptoms, but some infections cause paralysis and even death. Until the 1950s, polio crippled thousands of children in industrialized countries. Soon after the introduction of effective vaccines in the late 1950s (IPV) and early 1960s (OPV), polio was brought under control and practically eliminated as a public health problem in industrialized countries. OPV has not been used in the United States since 2000; however, it is used in many other counties and has played a major role in eliminating polio from large parts of the world. IPV, which is given by intramuscular injection, is now used in the United States and several other industrialized countries. For more information, go to the CDC website at http://www.cdc.gov/travel/yb/.

Dengue, Tropical and Subtropical Regions
Released:
December 6, 2006

Dengue is caused by one of four viruses (DEN-1, DEN-2, DEN-3, and DEN-4), which can produce clinical illness ranging from a nonspecific viral syndrome to severe fatal hemorrhagic fever. Symptoms of dengue include fever, severe headache, retroorbital eye pain (pain behind the eye), joint and muscle pain, and rash. Dengue has become one of the most common viral diseases transmitted to humans by the bite of infected mosquitoes, usually Aedes aegypti; it is the most common cause of febrile illness in returned travelers from the Caribbean, Central America, and South Central Asia.

The range of dengue has rapidly expanded in recent years to include most tropical countries throughout Asia (including the Indian Subcontinent), the South Pacific, the Caribbean, South and Central America, and Africa. See the Distribution of dengue maps for areas where it has become endemic. The risk to travelers is related to mosquito exposure, which can vary with the season.

No vaccine is available for dengue; however, travelers can reduce their risk by taking steps to protect themselves from mosquito bites.

Aedes mosquitoes, the principal mosquito vector, usually are active at dusk and dawn, but may feed at any time during the day, especially indoors, in shady areas, or when the weather is cloudy. Additionally, the risk for contracting dengue is greater in urban areas and lower in rural areas or areas at high altitude (above 4,500 feet [1500 meters]).

During 2005, a total of 96 cases of dengue were confirmed by CDC laboratories in U.S. international travelers. Travel destinations available for 73 patients included Central America (including Mexico), the Caribbean, and Asia. Seventeen of the total reported cases required hospitalization, and one was fatal.

During 2001-2004, a total of 77 cases of dengue were laboratory confirmed by CDC in U.S. travelers, with an additional 88 suspect dengue cases for which the diagnosis could not be confirmed. Travel destinations available for 66 of the confirmed cases during 2001-2004 included the Caribbean, Pacific islands, Asia, Central America (including Mexico), and South America; 10 additional cases were attributed to travel to U.S. territories of Puerto Rico, the Virgin Islands, and the Marshall Islands, and the State of Hawaii. Fifteen of the total reported cases required hospitalization, and one was fatal.

For more information about dengue and protection measures, go to the CDC website at http://www.cdc.gov/travel/yb/..

Routine Vaccinations

Before travel, be sure you and your children are up to date on all routine immunizations according to schedules approved by the Advisory Committee on Immunization Practice (ACIP). See the schedule for adults and the schedule for infants and children. Some schedules can be accelerated for travel.

See your doctor at least 4–6 weeks before your trip to allow time for shots to take effect. If it is less than 4 weeks before you leave, you should still see your doctor. It might not be too late to get your shots or medications as well as other information about how to protect yourself from illness and injury while traveling.

Recommended Vaccinations and Preventive Medications

The following vaccines may be recommended for your travel to Southern Africa. Discuss your travel plans and personal health with a health-care provider to determine which vaccines you will need.

  • Hepatitis A or immune globulin (IG). Transmission of hepatitis A virus can occur through direct person-to-person contact; through exposure to contaminated water, ice, or shellfish harvested in contaminated water; or from fruits, vegetables, or other foods that are eaten uncooked and that were contaminated during harvesting or subsequent handling.
  • Hepatitis B, especially if you might be exposed to blood or body fluids (for example, health-care workers), have sexual contact with the local population, or be exposed through medical treatment. Hepatitis B vaccine is now recommended for all infants and for children ages 11– 12 years who did not receive the series as infants.
  • Malaria: your risk of malaria may be high in all countries in Southern Africa, including cities. See your health care provider for a prescription antimalarial drug.
  • Rabies, if you might have extensive unprotected outdoor exposure in rural areas, such as might occur during camping, hiking, or bicycling, or engaging in certain occupational activities.
  • Typhoid vaccine. Typhoid fever can be contracted through contaminated drinking water or food, or by eating food or drinking beverages that have been handled by a person who is infected. Large outbreaks are most often related to fecal contamination of water supplies or foods sold by street vendors
  • As needed, booster doses for tetanus-diphtheria, measles, and a one-time dose of polio vaccine for adults.

Required Vaccinations

  • None.

Malaria

Malaria is always a serious disease and may be a deadly illness. Humans get malaria from the bite of a mosquito infected with the parasite. Your risk of malaria may be high in all countries in Southern Africa, including cities. All travelers to Southern Africa, including infants, children, and former residents of Southern Africa, may be at risk for malaria. Prevent this serious disease by seeing your health care provider for a prescription antimalarial drug and by protecting yourself against mosquito bites. All travelers should take one of the following drugs:

  • atovaquone/proguanil,
  • doxycycline,
  • mefloquine, or
  • primaquine (in special circumstances).

Yellow Fever

There is no risk for yellow fever in Southern Africa. A certificate of yellow fever vaccination may be required for entry into certain of these countries if you are coming from countries in South America or sub-Saharan Africa.

Food and Waterborne Diseases

Avoid buying food or drink from street vendors, because it is relatively easy for such food to become contaminated. Make sure your food and drinking water are safe. Food and waterborne diseases are the primary cause of illness in travelers.

Travelers’ diarrhea can be caused by viruses, bacteria, or parasites, which are found throughout Southern Africa and can contaminate food or water. Infections may cause diarrhea and vomiting (E. coli, Salmonella, cholera, and parasites), fever (typhoid fever and toxoplasmosis), or liver damage (hepatitis).

Other Disease Risks

Dengue, filariasis, leishmaniasis, onchocerciasis (river blindness), and trypanosomiasis (sleeping sickness) are other diseases carried by insects that also occur in this region, mostly in rural areas. Protecting yourself against insect bites will help to prevent these diseases (DEET). African tick bite fever, a rickettsial infection, is common in South Africa, Botswana, Swaziland, Lesotho, and Zimbabwe. African sleeping sickness can occur in Botswana and Namibia.

Wearing protective clothing and avoiding rural areas or areas of dense vegetation along streams, is the best protection. Schistosomiasis, a parasitic infection, is found in fresh water in this region, particularly in Botswana, Namibia, South Africa, and Swaziland. Do not swim in fresh water (except in well-chlorinated swimming pools) in Southern African countries.

Injuries

Motor vehicle crashes are a leading cause of injury among travelers. Protect yourself from motor vehicle injuries: avoid drinking and driving; wear your safety belt and place children in age-appropriate restraints in the back seat; follow the local customs and laws regarding pedestrian safety and vehicle speed; obey the rules of the road; and use helmets on bikes, motorcycles, and motor bikes. Avoid boarding an overloaded bus or mini-bus. Where possible, hire a local driver.

What You Need To Bring With You

  • Long-sleeved shirt, long pants, and a hat to wear whenever possible while outside, to prevent illnesses carried by insects (e.g., malaria, Dengue, filariasis, leishmaniasis, and onchocerciasis).
  • Insect repellent containing DEET
  • Bed nets treated with permethrin. Overseas, permethrin or another insecticide, deltamethrin, may be purchased to treat bed nets and clothes.
  • Flying-insect spray to help clear rooms of mosquitoes. The product should contain a pyrethroid insecticide; these insecticides quickly kill flying insects, including mosquitoes.
  • Iodine tablets and portable water filters to purify water if bottled water is not available.
  • Sunblock, sunglasses, and a hat for protection from harmful effects of UV sun rays.
  • Prescription medications: make sure you have enough to last during your trip, as well as a copy of the prescription(s) or letter from your health-care provider on office stationery explaining that the medication has been prescribed for you.
  • Always carry medications in their original containers, in your carry-on luggage.
  • Be sure to bring along over-the-counter antidiarrheal medication (e.g., bismuth subsalicylate, loperamide) and an antibiotic prescribed by your doctor to self-treat moderate to severe diarrhea.

Staying Healthy During Your Trip

To stay healthy, do…

  • Wash your hands often with soap and water or, if hands are not visibly soiled, use a waterless, alcohol-based hand rub to remove potentially infectious materials from your skin and help prevent disease transmission.
  • In developing countries, drink only bottled or boiled water, or carbonated (bubbly) drinks in cans or bottles. Avoid tap water, fountain drinks, and ice cubes. If this is not possible, learn how to make water safer to drink.
  • Take your malaria prevention medication before, during, and after travel, as directed. (See your health care provider for a prescription.)
  • To prevent fungal and parasitic infections, keep feet clean and dry, and do not go barefoot, even on beaches.
  • Always use latex condoms to reduce the risk of HIV and other sexually transmitted diseases.

Protect yourself from mosquito insect bites:

  • Wear long-sleeved shirts, long pants, and hats when outdoors.
  • Use insect repellents that contain DEET (N, N-diethylmethyltoluamide).
  • If no screening or air conditioning is available: use a pyrethroid-containing spray in living and sleeping areas during evening and night-time hours; sleep under bed nets, preferably insecticide-treated ones.
  • If you are visiting friends and relatives in your home country, see additional special information about malaria prevention in Recent Immigrants to the U.S. from Malarious Countries Returning ‘Home’ to Visit Friends and Relatives on the CDC Malaria site.

Do not

  • Do not eat food purchased from street vendors or food that is not well cooked to reduce risk of infection (i.e., hepatitis A and typhoid fever).
  • Do not drink beverages with ice.
  • Avoid dairy products, unless you know they have been pasteurized.
  • Do not swim in fresh water to avoid exposure to certain water-borne diseases such as schistosomiasis.
  • Do not handle animals, especially monkeys, dogs, and cats, to avoid bites and serious diseases (including rabies and plague). Consider pre-exposure rabies vaccination if you might have extensive unprotected outdoor exposure in rural areas.
  • Do not share needles for tattoos, body piercing or injections to prevent infections such as HIV and hepatitis B.

After You Return Home

If you have visited a malaria-risk area, continue taking your antimalarial drug for 4 weeks (mefloquine or doxycycline) or seven days (atovaquone/proguanil) after leaving the risk area. Malaria is always a serious disease and may be a deadly illness. If you become ill with a fever or flulike illness either while traveling in a malaria-risk area or after you return home (for up to1 year), you should seek immediate medical attention and should tell the physician your travel history.

WEST AFRICA

Date last revised: February 2, 2007

Countries in the region of West Africa: contains the countries Benin, Burkina Faso, Cape Verde islands, Côte d’Ivoire, Gambia, Ghana, Guinea, Guinea-Bissau, Liberia, Mali, Mauritania, Niger, Nigeria, São Tomé and Principé, Senegal, Sierra Leone, and Togo.

Outbreaks

Measles and Mumps

Updated: January 3, 2007; October 27, July 28, 24 and 3,
June 8, May 12, April 28, and March 31, 2006
Released: November 16, 2005

Measles and mumps remain common diseases in many parts of the world, including some developed countries. For US travelers, the risk for exposure to measles and mumps can be high, and both diseases can be prevented by the MMR (measles, mumps, rubella) vaccine.

A measles outbreak in the Ukraine that began in early 2006 has waned. In addition, Kenya and Tanzania in East Africa reported measles outbreaks in 2006 and have since held measles immunization campaigns. Outbreaks in both countries are waning. An outbreak of measles in Uganda, Central Africa, was reported in November 2006, just ahead of its follow-up immunization campaign.

Recent outbreaks of mumps have also been reported among adolescents and young adults in the United States and United Kingdom. The outbreak in the United States began in December 2005 and peaked in April 2006. As of mid-December 2006, the number of reported mumps cases in the United Kingdom had declined compared with the same period in 2005.

All travelers should be fully immunized and keep a copy of their immunization record with them as they travel.

Measles is a serious disease. Some of the people who become sick with measles also get an ear infection (7%-9%), diarrhea (8%), or a serious lung infection, such as pneumonia (1%-6%). One of 1,500 people with measles develops inflammation of the brain. In the United States, measles has been fatal in approximately 1-3 of every 1,000 people with measles in recent years. Measles can cause especially severe disease in people who are malnourished or immunosuppressed (i.e., HIV infection, leukemia, lymphoma, or generalized malignancy or persons receiving certain drug or radiation therapies). Mumps is an infection of the salivary glands caused by a virus. It occurs through direct contact with respiratory droplets, saliva or contact with any surface that has been contaminated with the mumps virus. Early symptoms include fever, headache, and muscle ache; less than half of infected people may have the characteristic swelling of the glands close to the jaw. Mumps infection can lead to meningitis and inflammation of the testicles or ovaries, inflammation of the pancreas and deafness (usually permanent).

The MMR vaccine also provides protection against rubella (German measles). Rubella is caused by a virus that is spread through droplet transmission. It can cause a rash, mild fever, and arthritis (mostly in women). If a woman gets rubella while she is pregnant, she could have a miscarriage or her baby could be born with serious birth defects, such as deafness, cataracts, or mental retardation.

Since the introduction of vaccines containing measles, rubella, and mumps—and later combined measles-mumps-rubella (MMR) vaccine—in the United States, the numbers of reported cases of measles, mumps, rubella, and birth defects caused by rubella infection (congenital rubella syndrome) have decreased substantially. However, routine surveillance and vaccination remain necessary because of the continuing possibility of introduction of these diseases from other countries. For more information, go to the CDC website at http://www.cdc.gov/travel/yb/.

Polio

Updated: December 1, October 27, September 20, June 7,
June 2, April 11 and February 10, 2006;
December 16, 2005
Released: November 9, 2005

According to the Global Polio Eradication Initiative (GPEI), only 4 countries (Nigeria, India, Pakistan and Afghanistan) remain polio-endemic, an all-time low. Egypt, which had been considered polio-endemic, has remained free of poliovirus transmission for over 22 months.

The following countries, however, have recently reported importations of polio in 2006, after previously being polio-free:

  • Kenya (polio-free for over 6 years)
  • Bangladesh (polio-free for over 5 years)
  • The Democratic Republic of the Congo (polio-free for almost 6 years)
  • Namibia (polio-free for almost 10 years)

Plans are under way for immunization response activities in all affected countries.

Other countries that have reported imported polio cases or cases related to an importation in 2006 are Angola, Cameroon, Ethiopia, Indonesia, Nepal, Niger, Somalia, and Yemen. Chad last reported polio cases in December 2005. Eritrea, Mali, and Sudan reported imported polio cases in 2005 but have not reported additional cases for over 12 months.

Outbreaks of poliovirus continue to be a risk until poliovirus is eliminated worldwide, and the risk for infection is still present for susceptible people. Therefore, to protect themselves from polio, travelers should be sure they and their children are fully immunized. Vaccination is recommended for all travelers to polio-endemic or -epidemic areas. These areas include Africa, South Asia, Southeast Asia, and the Middle East. Polio is an infectious disease caused by a virus. The disease mainly affects children under 5 years of age. It is spread person-to-person when the virus enters the mouth of a person who has come in contact with the stool of an infected person (for example, by changing diapers and not washing hands before touching the mouth) or from fecal contamination of food or drinking water. Most people infected with the poliovirus have no symptoms, but some infections cause paralysis and even death. Until the 1950s, polio crippled thousands of children in industrialized countries. Soon after the introduction of effective vaccines in the late 1950s (IPV) and early 1960s (OPV), polio was brought under control and practically eliminated as a public health problem in industrialized countries.

OPV has not been used in the United States since 2000; however, it is used in many other counties and has played a major role in eliminating polio from large parts of the world. IPV, which is given by intramuscular injection, is now used in the United States and several other industrialized countries. For more information, go to the CDC website at http://www.cdc.gov/travel/yb/.

Avian Influenza A (H5N1) Virus
Most recently updated:
February 2, 2007
Initially released: September 23, 2005

Highly pathogenic avian influenza A (H5N1) (hereafter referred to as “H5N1”) virus has caused serious disease among wild birds and poultry on multiple continents. For a current list of countries reporting outbreaks of H5N1 among poultry and/or wild birds, view updates from the World Organization for Animal Health (OIE). Human infections with H5N1 viruses are still rare, but have occurred in countries in Asia, Africa, Eastern Europe, and the Middle East between 2003—2007. Most cases of H5N1 virus infection in humans are thought to have occurred from direct contact with infected poultry, but in one instance, human cases are thought to have been acquired through close contact with wild swans. Rare occurrences of probable spread (or ‘transmission’) from human to human have been reported. So far, however, this type of transmission has not been sustained. Transmission of H5N1 viruses to two persons through consumption of uncooked duck blood may also have occurred in Vietnam in 2005. Total numbers of confirmed human cases of H5N1 virus by country are available on the World Health Organization (WHO) Avian Influenza website. An assessment of the cur-rent situation can be found on the Centers for Disease Control and Prevention (CDC) Avian Influenza website.

Outbreaks of H5N1 virus among bird populations in Asia, parts of Europe, the Middle East and Africa are not expected to diminish significantly in the short term. Consequently, it is expected that human infections resulting from direct contact with infected poultry will continue to occur in countries where poultry flocks are infected. Because no sustained human-to-human transmission of H5N1 virus has been documented anywhere in the world, the current phase of alert, based on the WHO global influenza preparedness plan, remains at Phase 3 (Pandemic Alert). If H5N1 virus were to gain the capacity to spread easily from person to person, an influenza pandemic (worldwide outbreak of disease) could begin. CDC remains in close communication with WHO and continues to monitor the H5N1 virus situation in countries reporting bird outbreaks and human cases.

CDC has not recommended that the general public avoid travel to any of the countries affected by H5N1 viruses. Travelers should check the CDC’s Travelers’ Health Web-site for detailed information on precautions before, during, and after travel to affected regions.

For more information about H5N1 infections in humans, see the World Health Organization influenza website: http://www.who.int/csr/disease/avian_influenza/en/ or the CDC Avian Influenza site: http://www.cdc.gov/flu/avian/index.htm.

For avian flu-related travel information: http://www.cdc.gov/travel/other/avian_flu/. For enhanced surveil-lance, diagnostic evaluation, and infection control precautions: http://www.cdc.gov/flu/avian/professional/updates.htm.

Dengue, Tropical and Subtropical Regions
Released:
December 6, 2006

Dengue is caused by one of four viruses (DEN-1, DEN-2, DEN-3, and DEN-4), which can produce clinical illness ranging from a nonspecific viral syndrome to severe fatal hemorrhagic fever. Symptoms of dengue include fever, severe headache, retroorbital eye pain (pain behind the eye), joint and muscle pain, and rash. Dengue has become one of the most common viral diseases transmitted to humans by the bite of infected mosquitoes, usually Aedes aegypti; it is the most common cause of febrile illness in returned travelers from the Caribbean, Central America, and South Central Asia.

The range of dengue has rapidly expanded in recent years to include most tropical countries throughout Asia (including the Indian Subcontinent), the South Pacific, the Caribbean, South and Central America, and Africa. See the Distribution of dengue maps for areas where it has become endemic. The risk to travelers is related to mosquito exposure, which can vary with the season.

No vaccine is available for dengue; however, travelers can reduce their risk by taking steps to protect themselves from mosquito bites.

Aedes mosquitoes, the principal mosquito vector, usually are active at dusk and dawn, but may feed at any time during the day, especially indoors, in shady areas, or when the weather is cloudy. Additionally, the risk for contracting dengue is greater in urban areas and lower in rural areas or areas at high altitude (above 4,500 feet [1500 meters]). During 2005, a total of 96 cases of dengue were confirmed by CDC laboratories in U.S. international travelers. Travel destinations available for 73 patients included Central America (including Mexico), the Caribbean, and Asia. Seventeen of the total reported cases required hospitalization, and one was fatal.

During 2001-2004, a total of 77 cases of dengue were laboratory confirmed by CDC in U.S. travelers, with an additional 88 suspect dengue cases for which the diagnosis could not be confirmed. Travel destinations available for 66 of the confirmed cases during 2001-2004 included the Caribbean, Pacific islands, Asia, Central America (including Mexico), and South America; 10 additional cases were attributed to travel to U.S. territories of Puerto Rico, the Virgin Islands, and the Marshall Islands, and the State of Hawaii. Fifteen of the total reported cases required hospitalization, and one was fatal. For more information about dengue and protection measures, go to the CDC website at http://www.cdc.gov/travel/yb/.

Routine Vaccinations

Before travel, be sure you and your children are up to date on all routine immunizations according to schedules approved by the Advisory Committee on Immunization Practice (ACIP). Some schedules can be accelerated for travel. See your doctor at least 4–6 weeks before your trip to allow time for shots to take effect. If it is less than 4 weeks before you leave, you should still see your doctor. It might not be too late to get your shots or medications as well as other information about how to protect yourself from illness and injury while traveling.

Recommended Vaccinations and Preventive Medications

The following vaccines may be recommended for your travel to West Africa. Discuss your travel plans and personal health with a health-care provider to determine which vaccines you will need.

  • Hepatitis A or immune globulin (IG). Transmission of hepatitis A virus can occur through direct person-to-person contact; through exposure to contaminated water, ice, or shellfish harvested in contaminated water; or from fruits, vegetables, or other foods that are eaten uncooked and that were contaminated during harvesting or subsequent handling.
  • Hepatitis B, especially if you might be exposed to blood or body fluids (for example, health-care workers), have sexual contact with the local population, or be exposed through medical treatment. Hepatitis B vaccine is now recommended for all infants and for children ages 11– 12 years who did not receive the series as infants.
  • Malaria: your risk of malaria may be high in all countries in West Africa, including cities. See your health care provider for a prescription antimalarial drug. For details concerning risk and preventive medications, see Malaria Information for Travelers to West Africa.
  • Meningococcal (meningitis), if you plan to visit countries in this region that experience epidemics of meningococcal disease during December through June.
  • Rabies, if you might have extensive unprotected outdoor exposure in rural areas, such as might occur during camping, hiking, or bicycling, or engaging in certain occupational activities.
  • Typhoid vaccine. Typhoid fever can be contracted through contaminated drinking water or food, or by eating food or drinking beverages that have been handled by a person who is infected. Large outbreaks are most often related to fecal contamination of water supplies or foods sold by street vendors
  • Yellow fever, a viral disease that occurs primarily in sub-Saharan Africa and tropical South America, is transmitted to humans through the bite of infected mosquitoes. The virus is also present in Panama and Trinidad and Tobago. Yellow fever vaccination is recommended for travelers to endemic areas and may be required to cross certain international borders. Vacci-nation should be given 10 days before travel and at 10 year intervals if there is on-going risk.
  • As needed, booster doses for tetanus-diphtheria, measles, and a one-time dose of polio vaccine for adults.

Required Vaccinations

  • A certificate of yellow fever vaccination may be required for entry into certain countries in West Africa.

Malaria

Malaria is always a serious disease and may be a deadly illness. Humans get malaria from the bite of a mosquito infected with the parasite. Your risk of malaria may be high in all countries in West Africa, including cities. All travelers to West Africa, including infants, children, and former residents of West Africa, may be at risk for malaria. Prevent this serious disease by seeing your health care provider for a prescription antimalarial drug and by protecting yourself against mosquito bites. Most travelers to West Africa, including infants, children, and former residents of West Africa, are at risk for malaria.

These travelers should take one of the following drugs (listed alphabetically):

  • atovaquone/proguanil,
  • doxycycline,
  • mefloquine,
  • or primaquine (in special circumstances).

Yellow Fever

A certificate of yellow fever vaccination may be required for entry into certain countries in West Africa.

Food and Waterborne Diseases

Avoid buying food or drink from street vendors, because it is relatively easy for such food to become contaminated. Make sure your food and drinking water are safe. Food and waterborne diseases are the primary cause of illness in travelers. Travelers’ diarrhea can be caused by viruses, bacteria, or parasites, which are found throughout West Africa and can contaminate food or water. Infections may cause diarrhea and vomiting (E. coli, Salmonella, cholera, and parasites), fever (typhoid fever and toxoplasmosis), or liver damage (hepatitis).

Other Disease Risks

Dengue, filariasis, leishmaniasis, and onchocerciasis (river blindness) are other diseases carried by insects that also occur in this region. Endemic foci of river blindness exist in all countries listed except in the greater part of The Gambia, Mauritania. Protecting yourself against insect bites will help to prevent these diseases. The risk for contracting African sleeping sickness (trypanosomiasis), which is caused by the bite of an infected tsetse fly, is high in all countries except The Gambia, Niger, and Mauritania. A number of rickettsial infections also occur in this region. Wearing protective clothing and avoiding rural areas or areas of dense vegetation along streams, is the best protection.

Plague occurs sporadically or in outbreaks. Schistosomiasis, a parasitic infection, can be contracted in fresh water in this region. Do not swim in fresh water (except in well-chlorinated swimming pools) in these countries. Polio is still endemic in Nigeria. Other infections that tend to occur more often in longer-term travelers (or immigrants from the region) include tuberculosis, HIV and hepatitis B.

Injuries

Motor vehicle crashes are a leading cause of injury among travelers. Protect yourself from motor vehicle injuries: avoid drinking and driving; wear your safety belt and place children in age-appropriate restraints in the back seat; follow the local customs and laws regarding pedestrian safety and vehicle speed; obey the rules of the road; and use helmets on bikes, motorcycles, and motor bikes. Avoid boarding an overloaded bus or mini-bus. Where possible, hire a local driver.

What You Need To Bring With You

  • Long-sleeved shirt, long pants, and a hat to wear whenever possible while outside, to prevent illnesses carried by insects (e.g., malaria, Dengue, filariasis, leishmaniasis, and onchocerciasis).
  • Insect repellent containing DEET.
  • Bed nets treated with permethrin. Overseas, permethrin or another insecticide, deltamethrin, may be purchased to treat bed nets and clothes.
  • Flying-insect spray to help clear rooms of mosquitoes. The product should contain a pyrethroid insecticide; these insecticides quickly kill flying insects, including mosquitoes.
  • Iodine tablets and portable water filters to purify water if bottled water is not available.
  • Sunblock, sunglasses, and a hat for protection from harmful effects of UV sun rays.
  • Prescription medications: make sure you have enough to last during your trip, as well as a copy of the prescription(s) or letter from your health-care provider on office stationery explaining that the medication has been prescribed for you.
  • Be sure to bring along over-the-counter antidiarrheal medication (e.g., bismuth subsalicylate, loperamide) and an antibiotic prescribed by your doctor to self-treat moderate to severe diarrhea. Always carry medications in their original containers, in your carry-on luggage.

Staying Healthy During Your Trip

To stay healthy, do…

  • Wash your hands often with soap and water or, if hands are not visibly soiled, use a waterless, alcohol-based hand rub to remove potentially infectious materials from your skin and help prevent disease transmission.
  • In developing countries, drink only bottled or boiled water, or carbonated (bubbly) drinks in cans or bottles. Avoid tap water, fountain drinks, and ice cubes. If this is not possible, learn how to make water safer to drink.
  • Take your malaria prevention medication before, during, and after travel, as directed. (See your health care provider for a prescription.)
  • To prevent fungal and parasitic infections, keep feet clean and dry, and do not go barefoot, even on beaches.
  • Always use latex condoms to reduce the risk of HIV and other sexually transmitted diseases.

Protect yourself from mosquito insect bites:

  • Wear long-sleeved shirts, long pants, and hats when outdoors.
  • Use insect repellents that contain DEET (N, N-diethylmethyltoluamide).
  • If no screening or air conditioning is available: use a pyrethroid-containing spray in living and sleeping areas during evening and night-time hours; sleep under bed nets, preferably insecticide-treated ones.
  • If you are visiting friends and relatives in your home country, see additional special information about malaria prevention in Recent Immigrants to the U.S. from Malarious Countries Returning ‘Home’ to Visit Friends and Relatives on the CDC Malaria site.

Do not

  • Do not eat food purchased from street vendors or food that is not well cooked to reduce risk of infection (i.e., hepatitis A and typhoid fever).
  • Do not drink beverages with ice.
  • Avoid dairy products, unless you know they have been pasteurized.
  • Do not swim in fresh water to avoid exposure to certain water-borne diseases such as schistosomiasis.
  • Do not handle animals, especially monkeys, dogs, and cats, to avoid bites and serious diseases (including rabies and plague). Consider pre-exposure rabies vaccination if you might have extensive unprotected outdoor exposure in rural areas.
  • Do not share needles for tattoos, body piercing or injections to prevent infections such as HIV and hepatitis B.

Avoid poultry farms, bird markets, and other places where live poultry is raised or kept.

After You Return Home

If you have visited a malaria-risk area, continue taking your antimalarial drug for 4 weeks (mefloquine or doxycycline) or seven days (atovaquone/proguanil) after leaving the risk area. Malaria is always a serious disease and may be a deadly illness. If you become ill with a fever or flulike illness either while traveling in a malaria-risk area or after you return home (for up to1 year), you should seek immediate medical attention and should tell the physician your travel history.

EAST ASIA

Date last revised: February 2, 2007

Countries in this region: China, Hong Kong S.A.R. (China), Japan, Democratic People’s Republic of Korea (North), Republic of Korea (South), Macao S.A.R. (China), Mongolia, and Taiwan.

Outbreaks

Avian Influenza A (H5N1) Virus
Most recently updated:
February 2, 2007
Initially released: September 23, 2005

Highly pathogenic avian influenza A (H5N1) (hereafter referred to as “H5N1”) virus has caused serious disease among wild birds and poultry on multiple continents. For a current list of countries reporting outbreaks of H5N1 among poultry and/or wild birds, view updates from the World Organization for Animal Health (OIE). Human infections with H5N1 viruses are still rare, but have occurred in countries in Asia, Africa, Eastern Europe, and the Middle East between 2003—2007.

Most cases of H5N1 virus infection in humans are thought to have occurred from direct contact with infected poultry, but in one instance, human cases are thought to have been acquired through close contact with wild swans. Rare occurrences of probable spread (or ‘transmission’) from human to human have been reported. So far, however, this type of transmission has not been sustained. Transmission of H5N1 viruses to two persons through consumption of uncooked duck blood may also have occurred in Vietnam in 2005. Total numbers of confirmed human cases of H5N1 virus by country are available on the World Health Organization (WHO) Avian Influenza website. An assessment of the current situation can be found on the Centers for Disease Control and Prevention (CDC) Avian Influenza website.

Outbreaks of H5N1 virus among bird populations in Asia, parts of Europe, the Middle East and Africa are not expected to diminish significantly in the short term. Consequently, it is expected that human infections resulting from direct contact with infected poultry will continue to occur in countries where poultry flocks are infected. Because no sustained human-to-human transmission of H5N1 virus has been documented anywhere in the world, the current phase of alert, based on the WHO global influenza preparedness plan, remains at Phase 3 (Pandemic Alert). If H5N1 virus were to gain the capacity to spread easily from person to person, an influenza pandemic (worldwide outbreak of disease) could begin. CDC remains in close communication with WHO and continues to monitor the H5N1 virus situation in countries reporting bird outbreaks and human cases.

CDC has not recommended that the general public avoid travel to any of the countries affected by H5N1 viruses. Travelers should check the CDC’s Travelers’ Health Web-site for detailed information on precautions before, during, and after travel to affected regions.

For more information about H5N1 infections in humans, see the World Health Organization influenza website: http://www.who.int/csr/disease/avian_influenza/en/ or the CDC Avian Influenza site: http://www.cdc.gov/flu/avian/index.htm. For avian flu-related travel information: http://www.cdc.gov/travel/other/avian_flu/. For enhanced surveil-lance, diagnostic evaluation, and infection control precautions: http://www.cdc.gov/flu/avian/professional/updates.htm.

Dengue, Tropical and Subtropical Regions
Released:
December 6, 2006

Dengue is caused by one of four viruses (DEN-1, DEN-2, DEN-3, and DEN-4), which can produce clinical illness ranging from a nonspecific viral syndrome to severe fatal hemorrhagic fever. Symptoms of dengue include fever, severe headache, retroorbital eye pain (pain behind the eye), joint and muscle pain, and rash. Dengue has become one of the most common viral diseases transmitted to humans by the bite of infected mosquitoes, usually Aedes aegypti; it is the most common cause of febrile illness in returned travelers from the Caribbean, Central America, and South Central Asia.

The range of dengue has rapidly expanded in recent years to include most tropical countries throughout Asia (including the Indian Subcontinent), the South Pacific, the Caribbean, South and Central America, and Africa. See the Distribution of dengue maps for areas where it has become endemic. The risk to travelers is related to mosquito exposure, which can vary with the season.

No vaccine is available for dengue; however, travelers can reduce their risk by taking steps to protect themselves from mosquito bites.

Aedes mosquitoes, the principal mosquito vector, usually are active at dusk and dawn, but may feed at any time during the day, especially indoors, in shady areas, or when the weather is cloudy. Additionally, the risk for contracting dengue is greater in urban areas and lower in rural areas or areas at high altitude (above 4,500 feet [1500 meters]).

During 2005, a total of 96 cases of dengue were confirmed by CDC laboratories in U.S. international travelers. Travel destinations available for 73 patients included Central America (including Mexico), the Caribbean, and Asia. Seventeen of the total reported cases required hospitalization, and one was fatal.

During 2001-2004, a total of 77 cases of dengue were laboratory confirmed by CDC in U.S. travelers, with an additional 88 suspect dengue cases for which the diagnosis could not be confirmed. Travel destinations available for 66 of the confirmed cases during 2001-2004 included the Caribbean, Pacific islands, Asia, Central America (including Mexico), and South America; 10 additional cases were attributed to travel to U.S. territories of Puerto Rico, the Virgin Islands, and the Marshall Islands, and the State of Hawaii. Fifteen of the total reported cases required hospitalization, and one was fatal.

For more information about dengue and protection measures, go to the CDC website at http://www.cdc.gov/travel/yb/.

Routine Vaccinations

Before travel, be sure you and your children are up to date on all routine immunizations according to schedules approved by the Advisory Committee on Immunization Practice (ACIP). See the schedule for adults and the schedule for infants and children. Some schedules can be accelerated for travel. See your doctor at least 4–6 weeks before your trip to allow time for shots to take effect. If it is less than 4 weeks before you leave, you should still see your doctor. It might not be too late to get your shots or medications as well as other information about how to protect yourself from illness and injury while traveling.

Recommended Vaccinations and Preventive Medications

The following vaccines may be recommended for your travel to East Asia. Discuss your travel plans and personal health with a health-care provider to determine which vaccines you will need.

  • Hepatitis A or immune globulin (IG). Transmission of hepatitis A virus can occur through direct person-to-person contact; through exposure to contaminated water, ice, or shellfish harvested in contaminated water; or from fruits, vegetables, or other foods that are eaten uncooked and that were contaminated during harvesting or subsequent handling.
  • Hepatitis B, especially if you might be exposed to blood or body fluids (for example, health-care workers), have sexual contact with the local population, or be exposed through medical treatment. Hepatitis B vaccine is now recommended for all infants and for children ages 11– 12 years who did not receive the series as infants.
  • Japanese encephalitis, if you plan to visit rural farming areas and under special circumstances, such as a known outbreak of Japanese encephalitis.
  • Malaria: if you are traveling to a malaria-risk area in this region, see your health care provider for a prescription antimalarial drug.
  • Rabies, if you might have extensive unprotected outdoor exposure in rural areas, such as might occur during camping, hiking, or bicycling, or engaging in certain occupational activities.
  • Typhoid, particularly if you are visiting developing countries in this region. Typhoid fever can be contracted through contaminated drinking water or food, or by eating food or drinking beverages that have been handled by a person who is infected. Large outbreaks are most often related to fecal contamination of water supplies or foods sold by street vendors
  • As needed, booster doses for tetanus-diphtheria and measles.

Required Vaccinations

  • None.

The preventive measures you need to take while traveling in East Asia depend on the areas you visit and the length of time you stay. You should observe the precautions listed in this document in most areas of this region. However, in highly developed areas of Japan, Hong Kong, South Korea, and Taiwan, you should observe health precautions similar to those that would apply while traveling in the United States.

Malaria

Malaria is always a serious disease and may be a deadly illness. Humans get malaria from the bite of a mosquito infected with the parasite. Prevent this serious disease by seeing your health care provider for a prescription antimalarial drug and by protecting yourself against mosquito bites. Travelers to some areas in China, North Korea, and South Korea may be at risk for malaria. Travelers to malaria-risk areas in China, North Korea, and South Korea should take an antimalarial drug.

There is no risk of malaria in Japan, Taiwan, Hong Kong S.A.R. (China), Macau S.A.R. (China), and Mongolia.

Yellow Fever

There is no risk for yellow fever in East Asia. A certificate of yellow fever vaccination may be required for entry into certain of these countries if you are coming from countries in South America or sub-Saharan Africa.

Food and Waterborne Diseases

Avoid buying food or drink from street vendors, because it is relatively easy for such food to become contaminated. Make sure your food and drinking water are safe. Food and waterborne diseases are the primary cause of illness in travelers. Travelers’ diarrhea can be caused by viruses, bacteria, or parasites, which are found throughout East Asia and can contaminate food or water. Infections may cause diarrhea and vomiting (E. coli, Salmonella, cholera, and parasites), fever (typhoid fever and toxoplasmosis), or liver damage (hepatitis).

Other Disease Risks

Dengue, filariasis, Japanese encephalitis, leishmaniasis, and plague are diseases carried by insects that also occur in this region. Protecting yourself against insect bites will help to prevent these diseases. Avian influenza is also present in China.

Outbreaks of severe acute pulmonary syndrome (SARS) occurred in mainland China, Hong Kong, and Taiwan in 2003. Avian influenza is present in the region. If you visit the Himalayan Mountains, ascend gradually to allow time for your body to adjust to the high altitude, which can cause insomnia, headaches, nausea, and altitude sickness. In addition, use sunblock rated at least SPF 15, because the risk of sunburn is greater at high altitudes.

Injuries

Motor vehicle crashes are a leading cause of injury among travelers. Protect yourself from motor vehicle injuries: avoid drinking and driving; wear your safety belt and place children in age-appropriate restraints in the back seat; follow the local customs and laws regarding pedestrian safety and vehicle speed; obey the rules of the road; and use helmets on bikes, motorcycles, and motor bikes. Avoid boarding an overloaded bus or mini-bus. Where possible, hire a local driver.

What You Need To Bring With You

  • Long-sleeved shirt, long pants, and a hat to wear whenever possible while outside, to prevent illnesses carried by insects (e.g., malaria, Dengue, filariasis, leishmaniasis, and onchocerciasis).
  • Insect repellent containing DEET.
  • Bed nets treated with permethrin. Overseas, permethrin or another insecticide, deltamethrin, may be purchased to treat bed nets and clothes.
  • Flying-insect spray to help clear rooms of mosquitoes. The product should contain a pyrethroid insecticide; these insecticides quickly kill flying insects, including mosquitoes.
  • Iodine tablets and portable water filters to purify water if bottled water is not available.
  • Sunblock, sunglasses, and a hat for protection from harmful effects of UV sun rays.
  • Prescription medications: make sure you have enough to last during your trip, as well as a copy of the prescription(s) or letter from your health-care provider on office stationery explaining that the medication has been prescribed for you.
  • Always carry medications in their original containers, in your carry-on luggage.
  • Be sure to bring along over-the-counter antidiarrheal medication (e.g., bismuth subsalicylate, loperamide) and an antibiotic prescribed by your doctor to self-treat moderate to severe diarrhea.

Staying Healthy During Your Trip

To stay healthy, do…

  • Wash your hands often with soap and water or, if hands are not visibly soiled, use a waterless, alcohol-based hand rub to remove potentially infectious materials from your skin and help prevent disease transmission.
  • In developing countries, drink only bottled or boiled water, or carbonated (bubbly) drinks in cans or bottles. Avoid tap water, fountain drinks, and ice cubes. If this is not possible, learn how to make water safer to drink.
  • Take your malaria prevention medication before, during, and after travel, as directed. (See your health care provider for a prescription.)
  • To prevent fungal and parasitic infections, keep feet clean and dry, and do not go barefoot, even on beaches.
  • Always use latex condoms to reduce the risk of HIV and other sexually transmitted diseases.

Protect yourself from mosquito insect bites:

  • Wear long-sleeved shirts, long pants, and hats when outdoors.
  • Use insect repellents that contain DEET (N, N-diethylmethyltoluamide).
  • If no screening or air conditioning is available: use a pyrethroid-containing spray in living and sleeping areas during evening and night-time hours; sleep under bed nets, preferably insecticide-treated ones.
  • If you are visiting friends and relatives in your home country, see additional special information about malaria prevention in Recent Immigrants to the U.S. from Malarious Countries Returning ‘Home’ to Visit Friends and Relatives on the CDC Malaria site.

Do not

  • Do not eat food purchased from street vendors or food that is not well cooked to reduce risk of infection (i.e., hepatitis A and typhoid fever).
  • Do not drink beverages with ice.
  • Avoid dairy products, unless you know they have been pasteurized.
  • Do not swim in fresh water to avoid exposure to certain water-borne diseases such as schistosomiasis.
  • Do not handle animals, especially monkeys, dogs, and cats, to avoid bites and serious diseases (including rabies and plague). Consider pre-exposure rabies vaccination if you might have extensive unprotected outdoor exposure in rural areas.
  • Do not share needles for tattoos, body piercing or injections to prevent infections such as HIV and hepatitis B.

Avoid poultry farms, bird markets, and other places where live poultry is raised or kept.

After You Return Home

If you have visited a malaria-risk area, continue taking your antimalarial drug for 4 weeks (mefloquine or doxycycline) or seven days (atovaquone/proguanil) after leaving the risk area.

Malaria is always a serious disease and may be a deadly illness. If you become ill with a fever or flulike illness either while traveling in a malaria-risk area or after you return home (for up to1 year), you should seek immediate medical attention and should tell the physician your travel history.

SOUTH ASIA

Date last revised: February 2, 2007

Countries in thies region: Afghanistan, Bangladesh, Bhutan, British Indian Ocean Territory, India, Maldives, Nepal, Pakistan, Sri Lanka.

Outbreaks

Avian Influenza A (H5N1) Virus
Most recently updated:
February 2, 2007
Initially released: September 23, 2005

Highly pathogenic avian influenza A (H5N1) (hereafter referred to as “H5N1”) virus has caused serious disease among wild birds and poultry on multiple continents. For a current list of countries reporting outbreaks of H5N1 among poultry and/or wild birds, view updates from the World Organization for Animal Health (OIE). Human infections with H5N1 viruses are still rare, but have occurred in countries in Asia, Africa, Eastern Europe, and the Middle East between 2003—2007. Most cases of H5N1 virus infection in humans are thought to have occurred from direct contact with infected poultry, but in one instance, human cases are thought to have been acquired through close contact with wild swans. Rare occurrences of probable spread (or ‘transmission’) from human to human have been reported. So far, however, this type of transmission has not been sustained. Transmission of H5N1 viruses to two persons through consumption of uncooked duck blood may also have occurred in Vietnam in 2005.

Total numbers of confirmed human cases of H5N1 virus by country are available on the World Health Organization (WHO) Avian Influenza website. An assessment of the current situation can be found on the Centers for Disease Control and Prevention (CDC) Avian Influenza website. Outbreaks of H5N1 virus among bird populations in Asia, parts of Europe, the Middle East and Africa are not expected to diminish significantly in the short term. Consequently, it is expected that human infections resulting from direct contact with infected poultry will continue to occur in countries where poultry flocks are infected. Because no sustained human-to-human transmission of H5N1 virus has been documented anywhere in the world, the current phase of alert, based on the WHO global influenza preparedness plan, remains at Phase 3 (Pandemic Alert). If H5N1 virus were to gain the capacity to spread easily from person to person, an influenza pandemic (worldwide outbreak of disease) could begin. CDC remains in close communication with WHO and continues to monitor the H5N1 virus situation in countries reporting bird outbreaks and human cases.

CDC has not recommended that the general public avoid travel to any of the countries affected by H5N1 viruses. Travelers should check the CDC’s Travelers’ Health Web-site for detailed information on precautions before, during, and after travel to affected regions.

For more information about H5N1 infections in humans, see the World Health Organization influenza website: http://www.who.int/csr/disease/avian_influenza/en/ or the CDC Avian Influenza site: http://www.cdc.gov/flu/avian/index.htm.

For avian flu-related travel information: http://www.cdc.gov/travel/other/avian_flu/. For enhanced surveil-lance, diagnostic evaluation, and infection control precautions: http://www.cdc.gov/flu/avian/professional/updates.htm.

Polio

Updated: December 1, October 27, September 20, June 7,
June 2, April 11 and February 10, 2006;
December 16, 2005
Released: November 9, 2005

According to the Global Polio Eradication Initiative (GPEI), only 4 countries (Nigeria, India, Pakistan and Afghanistan) remain polio-endemic, an all-time low. Egypt, which had been considered polio-endemic, has remained free of poliovirus transmission for over 22 months.

The following countries, however, have recently reported importations of polio in 2006, after previously being polio-free:

  • Kenya (polio-free for over 6 years)
  • Bangladesh (polio-free for over 5 years)
  • The Democratic Republic of the Congo (polio-free for almost 6 years)
  • Namibia (polio-free for almost 10 years)

Plans are under way for immunization response activities in all affected countries. Other countries that have reported imported polio cases or cases related to an importation in 2006 are Angola, Cameroon, Ethiopia, Indonesia, Nepal, Niger, Somalia, and Yemen. Chad last reported polio cases in December 2005. Eritrea, Mali, and Sudan reported imported polio cases in 2005 but have not reported additional cases for over 12 months.

Outbreaks of poliovirus continue to be a risk until poliovirus is eliminated worldwide, and the risk for infection is still present for susceptible people. Therefore, to protect themselves from polio, travelers should be sure they and their children are fully immunized. Vaccination is recommended for all travelers to polio-endemic or -epidemic areas. These areas include Africa, South Asia, Southeast Asia, and the Middle East.

Polio is an infectious disease caused by a virus. The disease mainly affects children under 5 years of age. It is spread person-to-person when the virus enters the mouth of a person who has come in contact with the stool of an infected person (for example, by changing diapers and not washing hands before touching the mouth) or from fecal contamination of food or drinking water. Most people infected with the poliovirus have no symptoms, but some infections cause paralysis and even death. Until the 1950s, polio crippled thousands of children in industrialized countries. Soon after the introduction of effective vaccines in the late 1950s (IPV) and early 1960s (OPV), polio was brought under control and practically eliminated as a public health problem in industrialized countries.

OPV has not been used in the United States since 2000; however, it is used in many other counties and has played a major role in eliminating polio from large parts of the world. IPV, which is given by intramuscular injection, is now used in the United States and several other industrialized countries. For more information, go to the CDC website at http://www.cdc.gov/travel/yb/.

Chikungunya Fever: India and Indian Ocean Islands This information is current as of today, January 18, 2007, 02:12:09 PM
Updated: October 24, June 19 and June 16, 2006
Released: April 21, 2006

Chikungunya fever is a viral disease transmitted to humans by the bite of infected Aedes and Culex mosquitoes, including the daytime-biting Aedes aegypti and Ae. albopictus species. Symptoms can include sudden onset of fever, chills, headache, nausea, vomiting, joint pain with or without swelling, low back pain, and rash. The symptoms are very similar to those of dengue, but, unlike dengue, there is no hemorrhagic or shock syndrome form. This disease is almost always self-limited and rarely fatal.

Since April 2006, a chikungunya fever outbreak has been on-going in the following states in India: Andhra Pradesh, Andaman & Nicobar Islands, Tamil Nadu, Karnataka, Maharashtra, Gujarat, Madhya Pradesh, and Kerala. At this time, investigations are on-going for identification of chikungunya fever in other areas of India, as it is important to confirm the diagnosis of chikungunya fever and rule out other mosquito-borne diseases, such as dengue fever and malaria in India.

A chikungunya fever outbreak on the Indian Ocean islands of Mayotte, Mauritius, Réunion (territory of France), and the Seychelles that began in March 2005 is waning. However, transmission can still occur, and travelers to all tropical and subtropical areas of the world are reminded to take precautions to avoid mosquito bites.

There are no preventive medications or FDA-approved vaccines for chikungunya fever, but travelers can take steps to reduce their risk of being bitten by infected mosquitoes.

No specific drug treatment against chikungunya fever is available; thus, treatment of chikungunya fever is supportive: bed rest, fluids, and mild pain medications such as ibuprofen, naproxen, acetaminophen, or paracetamol may relieve symptoms of fever and aching, provided that the person has no contraindications to these medications. Because aspirin can increase the risk of bleeding and possibly increase the risk for Reye’s syndrome, it should be avoided during the acute stages of the illness. Few cases are severe enough to warrant hospitalization. All persons with chikungunya fever should be protected against additional mosquito bites to reduce the risk of further transmission of the virus.

For more information about chikungunya fever, see the Chikungunya Fever Fact Sheet at the CDC website.

Dengue, Tropical and Subtropical Regions
Released:
December 6, 2006

Dengue is caused by one of four viruses (DEN-1, DEN-2, DEN-3, and DEN-4), which can produce clinical illness ranging from a nonspecific viral syndrome to severe fatal hemorrhagic fever. Symptoms of dengue include fever, severe headache, retroorbital eye pain (pain behind the eye), joint and muscle pain, and rash. Dengue has become one of the most common viral diseases transmitted to humans by the bite of infected mosquitoes, usually Aedes aegypti; it is the most common cause of febrile illness in returned travelers from the Caribbean, Central America, and South Central Asia.

The range of dengue has rapidly expanded in recent years to include most tropical countries throughout Asia (including the Indian Subcontinent), the South Pacific, the Caribbean, South and Central America, and Africa. See the Distribution of dengue maps for areas where it has become endemic. The risk to travelers is related to mosquito exposure, which can vary with the season.

No vaccine is available for dengue; however, travelers can reduce their risk by taking steps to protect themselves from mosquito bites.

Aedes mosquitoes, the principal mosquito vector, usually are active at dusk and dawn, but may feed at any time during the day, especially indoors, in shady areas, or when the weather is cloudy. Additionally, the risk for contracting dengue is greater in urban areas and lower in rural areas or areas at high altitude (above 4,500 feet [1500 meters]).

During 2005, a total of 96 cases of dengue were confirmed by CDC laboratories in U.S. international travelers. Travel destinations available for 73 patients included Central America (including Mexico), the Caribbean, and Asia. Seventeen of the total reported cases required hospitalization, and one was fatal.

During 2001-2004, a total of 77 cases of dengue were laboratory confirmed by CDC in U.S. travelers, with an additional 88 suspect dengue cases for which the diagnosis could not be confirmed. Travel destinations available for 66 of the confirmed cases during 2001-2004 included the Caribbean, Pacific islands, Asia, Central America (including Mexico), and South America; 10 additional cases were attributed to travel to U.S. territories of Puerto Rico, the Virgin Islands, and the Marshall Islands, and the State of Hawaii. Fifteen of the total reported cases required hospitalization, and one was fatal.

For more information about dengue and protection measures, go to the CDC website at http://www.cdc.gov/travel/yb/.

Routine Vaccinations

Before travel, be sure you and your children are up to date on all routine immunizations according to schedules approved by the Advisory Committee on Immunization Practice (ACIP). See the schedule for adults and the schedule for infants and children. Some schedules can be accelerated for travel.

See your doctor at least 4–6 weeks before your trip to allow time for shots to take effect. If it is less than 4 weeks before you leave, you should still see your doctor. It might not be too late to get your shots or medications as well as other information about how to protect yourself from illness and injury while traveling.

Recommended Vaccinations and Preventive Medications

The following vaccines may be recommended for your travel to South Asia. Discuss your travel plans and personal health with a health-care provider to determine which vaccines you will need.

  • Hepatitis A or immune globulin (IG). Transmission of hepatitis A virus can occur through direct person-to-person contact; through exposure to contaminated water, ice, or shellfish harvested in contaminated water; or from fruits, vegetables, or other foods that are eaten uncooked and that were contaminated during harvesting or subsequent handling.
  • Hepatitis B, especially if you might be exposed to blood or body fluids (for example, health-care workers), have sexual contact with the local population, or be exposed through medical treatment. Hepatitis B vaccine is now recommended for all infants and for children ages 11– 12 years who did not receive the series as infants.
  • Japanese encephalitis, if you plan to visit rural farming areas and under special circumstances, such as a known outbreak of Japanese encephalitis.
  • Malaria: your risk of malaria may be high in these countries, including cities. See your health care provider for a prescription antimalarial drug. For details concerning risk and preventive medications, see Malaria Information for Travelers to South Asia.
  • Rabies, if you might have extensive unprotected outdoor exposure in rural areas, such as might occur during camping, hiking, or bicycling, or engaging in certain occupational activities.
  • Typhoid. Typhoid fever can be contracted through contaminated drinking water or food, or by eating food or drinking beverages that have been handled by a person who is infected. Large outbreaks are most often related to fecal contamination of water supplies or foods sold by street vendors Vaccination is particularly important because of the presence of S. typhi strains resistant to multiple antibiotics in this region. There have been recent reports of typhoid drug resistance in India and Nepal.
  • As needed, booster doses for tetanus-diphtheria and measles, and a one-time dose of polio for adults.

Required Vaccinations

  • None.

Malaria

Malaria is always a serious disease and may be a deadly illness. Humans get malaria from the bite of a mosquito infected with the parasite. Prevent this serious disease by seeing your health care provider for a prescription antimalarial drug and by protecting yourself against mosquito bites. Your risk of malaria may be high in these countries, including cities. Travelers to malaria-risk areas, including infants, children, and former residents of the Indian Sub-continent, should take an antimalarial drug. NOTE: Chloroquine is NOT an effective antimalarial drug in the Indian Subcontinent and should not be taken to prevent malaria in this region. Prevent this serious disease by seeing your health care provider for a prescription antimalarial drug and by protecting yourself against mosquito bites.

Yellow Fever

There is no risk for yellow fever in the Indian Subcontinent. A certificate of yellow fever vaccination may be required for entry into certain of these countries if you are coming from countries in South America or sub-Saharan Africa.

Food and Waterborne Diseases

Avoid buying food or drink from street vendors, because it is relatively easy for such food to become contaminated.

Make sure your food and drinking water are safe. Food and waterborne diseases are the primary cause of illness in travelers. Travelers’ diarrhea can be caused by viruses, bacteria, or parasites, which are found throughout South Asia and can contaminate food or water. Infections may cause diarrhea and vomiting (E. coli, Salmonella, cholera, and parasites), fever (typhoid fever and toxoplasmosis), or liver damage (hepatitis).

Other Disease Risks

Filariasis is common in Bangladesh, India, and the southwestern coastal belt of Sri Lanka. A sharp rise in the incidence of visceral leishmaniasis has been observed in Bangladesh, India, and Nepal. In Pakistan, it is mainly reported from the north (Baltisan). Cutaneous leishmaniasis occurs in Afghanistan, India (Rajasthan), and Pakistan. Outbreaks of dengue fever can occur in Bangladesh, India, Pakistan, and Sri Lanka, and the hemorrhagic form has been reported from eastern India and Sri Lanka. Japanese encephalitis occurs widely except in mountainous areas. Protecting yourself against insect bites will help to prevent these diseases.

Polio is still endemic in India and Afghanistan. Rabies is common in the region and poses a risk to travelers, especially to rural areas.

Leptospirosis, a bacterial infection often contracted through recreational water activities in contaminated water is common in tropical areas of this region. If you visit the Himalayan Mountains, ascend gradually to allow time for your body to adjust to the high altitude, which can cause insomnia, headaches, nausea, and altitude sickness. In addition, use sunblock rated at least 15 SPF, because the risk of sunburn is greater at high altitudes.

Injuries

Motor vehicle crashes are a leading cause of injury among travelers. Protect yourself from motor vehicle injuries: avoid drinking and driving; wear your safety belt and place children in age-appropriate restraints in the back seat; follow the local customs and laws regarding pedestrian safety and vehicle speed; obey the rules of the road; and use helmets on bikes, motorcycles, and motor bikes. Avoid boarding an overloaded bus or mini-bus. Where possible, hire a local driver.

What You Need To Bring With You

  • Long-sleeved shirt, long pants, and a hat to wear whenever possible while outside, to prevent illnesses carried by insects (e.g., malaria, Dengue, filariasis, leishmaniasis, and onchocerciasis).
  • Insect repellent containing DEET.
  • Bed nets treated with permethrin. Overseas, permethrin or another insecticide, deltamethrin, may be purchased to treat bed nets and clothes.
  • Flying-insect spray to help clear rooms of mosquitoes. The product should contain a pyrethroid insecticide; these insecticides quickly kill flying insects, including mosquitoes.
  • Iodine tablets and portable water filters to purify water if bottled water is not available.
  • Sunblock, sunglasses, and a hat for protection from harmful effects of UV sun rays.
  • Prescription medications: make sure you have enough to last during your trip, as well as a copy of the prescription(s) or letter from your health-care provider on office stationery explaining that the medication has been prescribed for you.
  • Always carry medications in their original containers, in your carry-on luggage.
  • Be sure to bring along over-the-counter antidiarrheal medication (e.g., bismuth subsalicylate, loperamide) and an antibiotic prescribed by your doctor to self-treat moderate to severe diarrhea.

Staying Healthy During Your Trip

To stay healthy, do…

  • Wash your hands often with soap and water or, if hands are not visibly soiled, use a waterless, alcohol-based hand rub to remove potentially infectious materials from your skin and help prevent disease transmission.
  • In developing countries, drink only bottled or boiled water, or carbonated (bubbly) drinks in cans or bottles. Avoid tap water, fountain drinks, and ice cubes. If this is not possible, learn how to make water safer to drink.
  • Take your malaria prevention medication before, during, and after travel, as directed. (See your health care provider for a prescription.)
  • To prevent fungal and parasitic infections, keep feet clean and dry, and do not go barefoot, even on beaches.
  • Always use latex condoms to reduce the risk of HIV and other sexually transmitted diseases.

Protect yourself from mosquito insect bites:

  • Wear long-sleeved shirts, long pants, and hats when outdoors.
  • Use insect repellents that contain DEET (N, N-diethylmethyltoluamide).
  • If no screening or air conditioning is available: use a pyrethroid-containing spray in living and sleeping areas during evening and night-time hours; sleep under bed nets, preferably insecticide-treated ones.
  • If you are visiting friends and relatives in your home country, see additional special information about malaria prevention in Recent Immigrants to the U.S. from Malarious Countries Returning ‘Home’ to Visit Friends and Relatives on the CDC Malaria site.

Do not

  • Do not eat food purchased from street vendors or food that is not well cooked to reduce risk of infection (i.e., hepatitis A and typhoid fever).
  • Do not drink beverages with ice.
  • Avoid dairy products, unless you know they have been pasteurized.
  • Do not swim in fresh water to avoid exposure to certain water-borne diseases such as schistosomiasis.
  • Do not handle animals, especially monkeys, dogs, and cats, to avoid bites and serious diseases (including rabies and plague). Consider pre-exposure rabies vaccination if you might have extensive unprotected outdoor exposure in rural areas.
  • Do not share needles for tattoos, body piercing or injections to prevent infections such as HIV and hepatitis B.

Avoid poultry farms, bird markets, and other places where live poultry is raised or kept.

After You Return Home

If you have visited a malaria-risk area, continue taking your antimalarial drug for 4 weeks (doxycycline or mefloquine) or seven days (atovaquone/proguanil) after leaving the risk area.

Malaria is always a serious disease and may be a deadly illness. If you become ill with a fever or flulike illness either while traveling in a malaria-risk area or after you return home (for up to 1 year), you should seek immediate medical attention and should tell the physician your travel history.

SOUTHEAST ASIA

Date last revised: February 2, 2007

Counties in this region: Brunei Darussalam, Burma (Myanmar), Cambodia, East Timor, Indonesia, Lao People’s Democratic Republic (Laos), Malaysia, Philippines, Singapore, Thailand, and Vietnam.

Outbreaks

Polio

Updated: December 1, October 27, September 20, June 7,
June 2, April 11 and February 10, 2006;
December 16, 2005
Released: November 9, 2005

According to the Global Polio Eradication Initiative (GPEI), only 4 countries (Nigeria, India, Pakistan and Afghanistan) remain polio-endemic, an all-time low. Egypt, which had been considered polio-endemic, has remained free of poliovirus transmission for over 22 months.

The following countries, however, have recently reported importations of polio in 2006, after previously being polio-free:

  • Kenya (polio-free for over 6 years)
  • Bangladesh (polio-free for over 5 years)
  • The Democratic Republic of the Congo (polio-free for almost 6 years)
  • Namibia (polio-free for almost 10 years)

Plans are under way for immunization response activities in all affected countries.

Other countries that have reported imported polio cases or cases related to an importation in 2006 are Angola, Cameroon, Ethiopia, Indonesia, Nepal, Niger, Somalia, and Yemen. Chad last reported polio cases in December 2005. Eritrea, Mali, and Sudan reported imported polio cases in 2005 but have not reported additional cases for over 12 months.

Outbreaks of poliovirus continue to be a risk until poliovirus is eliminated worldwide, and the risk for infection is still present for susceptible people. Therefore, to protect themselves from polio, travelers should be sure they and their children are fully immunized. Vaccination is recommended for all travelers to polio-endemic or -epidemic areas. These areas include Africa, South Asia, Southeast Asia, and the Middle East.

Polio is an infectious disease caused by a virus. The disease mainly affects children under 5 years of age. It is spread person-to-person when the virus enters the mouth of a person who has come in contact with the stool of an infected person (for example, by changing diapers and not washing hands before touching the mouth) or from fecal contamination of food or drinking water. Most people infected with the poliovirus have no symptoms, but some infections cause paralysis and even death. Until the 1950s, polio crippled thousands of children in industrialized countries. Soon after the introduction of effective vaccines in the late 1950s (IPV) and early 1960s (OPV), polio was brought under control and practically eliminated as a public health problem in industrialized countries.

OPV has not been used in the United States since 2000; however, it is used in many other counties and has played a major role in eliminating polio from large parts of the world. IPV, which is given by intramuscular injection, is now used in the United States and several other industrialized countries. For more information, go to the CDC website at http://www.cdc.gov/travel/yb/.

Avian Influenza A (H5N1) Virus
Most recently updated:
February 2, 2007
Initially released: September 23, 2005

Highly pathogenic avian influenza A (H5N1) (hereafter referred to as “H5N1”) virus has caused serious disease among wild birds and poultry on multiple continents. For a current list of countries reporting outbreaks of H5N1 among poultry and/or wild birds, view updates from the World Organization for Animal Health (OIE). Human infections with H5N1 viruses are still rare, but have occurred in countries in Asia, Africa, Eastern Europe, and the Middle East between 2003—2007. Most cases of H5N1 virus infection in humans are thought to have occurred from direct contact with infected poultry, but in one instance, human cases are thought to have been acquired through close contact with wild swans. Rare occurrences of probable spread (or ‘transmission’) from human to human have been reported. So far, however, this type of transmission has not been sustained. Transmission of H5N1 viruses to two persons through consumption of uncooked duck blood may also have occurred in Vietnam in 2005. Total numbers of confirmed human cases of H5N1 virus by country are available on the World Health Organization (WHO) Avian Influenza website. An assessment of the cur-rent situation can be found on the Centers for Disease Control and Prevention (CDC) Avian Influenza website.

Outbreaks of H5N1 virus among bird populations in Asia, parts of Europe, the Middle East and Africa are not expected to diminish significantly in the short term. Consequently, it is expected that human infections resulting from direct contact with infected poultry will continue to occur in countries where poultry flocks are infected. Because no sustained human-to-human transmission of H5N1 virus has been documented anywhere in the world, the current phase of alert, based on the WHO global influenza preparedness plan, remains at Phase 3 (Pandemic Alert).

If H5N1 virus were to gain the capacity to spread easily from person to person, an influenza pandemic (worldwide outbreak of disease) could begin. CDC remains in close communication with WHO and continues to monitor the H5N1 virus situation in countries reporting bird outbreaks and human cases.

CDC has not recommended that the general public avoid travel to any of the countries affected by H5N1 viruses. Travelers should check the CDC’s Travelers’ Health Web-site for detailed information on precautions before, during, and after travel to affected regions.

For more information about H5N1 infections in humans, see the World Health Organization influenza website: http://www.who.int/csr/disease/avian_influenza/en/ or the CDC Avian Influenza site: http://www.cdc.gov/flu/avian/index.htm.

For avian flu-related travel information: http://www.cdc.gov/travel/other/avian_flu/. For enhanced surveil-lance, diagnostic evaluation, and infection control precautions: http://www.cdc.gov/flu/avian/professional/updates.htm.

Dengue, Tropical and Subtropical Regions
Released:
December 6, 2006

Dengue is caused by one of four viruses (DEN-1, DEN-2, DEN-3, and DEN-4), which can produce clinical illness ranging from a nonspecific viral syndrome to severe fatal hemorrhagic fever. Symptoms of dengue include fever, severe headache, retroorbital eye pain (pain behind the eye), joint and muscle pain, and rash. Dengue has become one of the most common viral diseases transmitted to humans by the bite of infected mosquitoes, usually Aedes aegypti; it is the most common cause of febrile illness in returned travelers from the Caribbean, Central America, and South Central Asia.

The range of dengue has rapidly expanded in recent years to include most tropical countries throughout Asia (including the Indian Subcontinent), the South Pacific, the Caribbean, South and Central America, and Africa. See the Distribution of dengue maps for areas where it has become endemic. The risk to travelers is related to mosquito exposure, which can vary with the season.

No vaccine is available for dengue; however, travelers can reduce their risk by taking steps to protect themselves from mosquito bites.

Aedes mosquitoes, the principal mosquito vector, usually are active at dusk and dawn, but may feed at any time during the day, especially indoors, in shady areas, or when the weather is cloudy. Additionally, the risk for contracting dengue is greater in urban areas and lower in rural areas or areas at high altitude (above 4,500 feet [1500 meters]).

During 2005, a total of 96 cases of dengue were confirmed by CDC laboratories in U.S. international travelers. Travel destinations available for 73 patients included Central America (including Mexico), the Caribbean, and Asia. Seventeen of the total reported cases required hospitalization, and one was fatal. During 2001-2004, a total of 77 cases of dengue were laboratory confirmed by CDC in U.S. travelers, with an additional 88 suspect dengue cases for which the diagnosis could not be confirmed. Travel destinations available for 66 of the confirmed cases during 2001-2004 included the Caribbean, Pacific islands, Asia, Central America (including Mexico), and South America; 10 additional cases were attributed to travel to U.S. territories of Puerto Rico, the Virgin Islands, and the Marshall Islands, and the State of Hawaii. Fifteen of the total reported cases required hospitalization, and one was fatal. For more information about dengue and protection measures, go to the CDC website at http://www.cdc.gov/travel/yb/.

Routine Vaccinations

Before travel, be sure you and your children are up to date on all routine immunizations according to schedules approved by the Advisory Committee on Immunization Practice (ACIP). Some schedules can be accelerated for travel. See your doctor at least 4–6 weeks before your trip to allow time for shots to take effect. If it is less than 4 weeks before you leave, you should still see your doctor. It might not be too late to get your shots or medications as well as other information about how to protect yourself from illness and injury while traveling.

Recommended Vaccinations and Preventive Medications

The following vaccines may be recommended for your travel to Southeast Asia. Discuss your travel plans and personal health with a health-care provider to determine which vaccines you will need.

  • Hepatitis A or immune globulin (IG). Transmission of hepatitis A virus can occur through direct person-to-person contact; through exposure to contaminated water, ice, or shellfish harvested in contaminated water; or from fruits, vegetables, or other foods that are eaten uncooked and that were contaminated during harvesting or subsequent handling.
  • Hepatitis B, especially if you might be exposed to blood or body fluids (for example, health-care workers), have sexual contact with the local population, or be exposed through medical treatment. Hepatitis B vaccine is now recommended for all infants and for children ages 11– 12 years who did not receive the series as infants.
  • Japanese encephalitis, if you plan to visit rural farming areas and under special circumstances, such as a known outbreak of Japanese encephalitis.
  • Malaria: your risk of malaria may be high in some of the countries in this region. See your health care provider for a prescription antimalarial drug. For details concerning risk and preventive medications, see Malaria Information for Travelers to Southeast Asia.
  • Rabies, if you might have extensive unprotected outdoor exposure in rural areas, such as might occur during camping, hiking, or bicycling, or engaging in certain occupational activities.
  • Typhoid, particularly if you are visiting developing countries in this region. Typhoid fever can be contracted through contaminated drinking water or food, or by eating food or drinking beverages that have been handled by a person who is infected. Large outbreaks are most often related to fecal contamination of water supplies or foods sold by street vendors.
  • As needed, booster doses for tetanus-diphtheria and measles.

Required Vaccinations

  • None.

Malaria

Malaria is always a serious disease and may be a deadly illness. Humans get malaria from the bite of a mosquito infected with the parasite. Your risk of malaria may be high in some of the countries in this region. Travelers to malaria-risk areas, including infants, children, and former residents of Southeast Asia, should take an antimalarial drug. Prevent this serious disease by seeing your health care provider for a prescription antimalarial drug and by protecting yourself against mosquito bites.

There is no malaria risk in Singapore and Brunei.

For additional information on malaria risk and prevention, see Malaria Information for Travelers to Southeast Asia.

Yellow Fever

There is no risk for yellow fever in Southeast Asia. A certificate of yellow fever vaccination may be required for entry into certain of these countries if you are coming from countries in South America or sub-Saharan Africa.

Food and Waterborne Diseases

Avoid buying food or drink from street vendors, because it is relatively easy for such food to become contaminated.

Make sure your food and drinking water are safe. Food and waterborne diseases are the primary cause of illness in travelers. Travelers’ diarrhea can be caused by viruses, bacteria, or parasites, which are found throughout Southeast Asia and can contaminate food or water. Infections may cause diarrhea and vomiting (E. coli, Salmonella, cholera, and parasites), fever (typhoid fever and toxoplasmosis), or liver damage (hepatitis).

Other Disease Risks

Dengue, filariasis, Japanese encephalitis, and plague are diseases carried by insects that also occur in this region. Protecting yourself against insect bites will help to prevent these diseases. Avian influenza is also present throughout this region. Polio has resurfaced in Indonesia. Rabies is common in the region and poses a risk to travelers, especially to rural areas. Do not swim in fresh water (except in well-chlorinated swimming pools) in certain areas of Cambodia, Indonesia, Laos, Philippines, and Thailand to avoid infection with schistosomiasis. Leptospirosis, a bacterial infection often contracted through recreational water activities in contaminated water, such as kayaking, is common in tropical areas of this region. An outbreak was reported among expedition travelers in 2000.

Injuries

Motor vehicle crashes are a leading cause of injury among travelers. Protect yourself from motor vehicle injuries: avoid drinking and driving; wear your safety belt and place children in age-appropriate restraints in the back seat; follow the local customs and laws regarding pedestrian safety and vehicle speed; obey the rules of the road; and use helmets on bikes, motorcycles, and motor bikes. Avoid boarding an overloaded bus or mini-bus. Where possible, hire a local driver.

What You Need To Bring With You

  • Long-sleeved shirt, long pants, and a hat to wear whenever possible while outside, to prevent illnesses carried by insects (e.g., malaria, Dengue, filariasis, leishmaniasis, and onchocerciasis).
  • Insect repellent containing DEET.
  • Bed nets treated with permethrin. Overseas, permethrin or another insecticide, deltamethrin, may be purchased to treat bed nets and clothes.
  • Flying-insect spray to help clear rooms of mosquitoes. The product should contain a pyrethroid insecticide; these insecticides quickly kill flying insects, including mosquitoes.
  • Iodine tablets and portable water filters to purify water if bottled water is not available.
  • Sunblock, sunglasses, and a hat for protection from harmful effects of UV sun rays.
  • Prescription medications: make sure you have enough to last during your trip, as well as a copy of the prescription(s) or letter from your health-care provider on office stationery explaining that the medication has been prescribed for you.
  • Always carry medications in their original containers, in your carry-on luggage.
  • Be sure to bring along over-the-counter antidiarrheal medication (e.g., bismuth subsalicylate, loperamide) and an antibiotic prescribed by your doctor to self-treat moderate to severe diarrhea.

Staying Healthy During Your Trip

To stay healthy, do…

  • Wash your hands often with soap and water or, if hands are not visibly soiled, use a waterless, alcohol-based hand rub to remove potentially infectious materials from your skin and help prevent disease transmission.
  • In developing countries, drink only bottled or boiled water, or carbonated (bubbly) drinks in cans or bottles. Avoid tap water, fountain drinks, and ice cubes. If this is not possible, learn how to make water safer to drink.
  • Take your malaria prevention medication before, during, and after travel, as directed. (See your health care provider for a prescription.)
  • To prevent fungal and parasitic infections, keep feet clean and dry, and do not go barefoot, even on beaches.
  • Always use latex condoms to reduce the risk of HIV and other sexually transmitted diseases.

Protect yourself from mosquito insect bites:

  • Wear long-sleeved shirts, long pants, and hats when outdoors.
  • Use insect repellents that contain DEET (N, N-diethylmethyltoluamide).
  • If no screening or air conditioning is available: use a pyrethroid-containing spray in living and sleeping areas during evening and night-time hours; sleep under bed nets, preferably insecticide-treated ones.
  • If you are visiting friends and relatives in your home country, see additional special information about malaria prevention in Recent Immigrants to the U.S. from Malarious Countries Returning ‘Home’ to Visit Friends and Relatives on the CDC Malaria site.

Do not

  • Do not eat food purchased from street vendors or food that is not well cooked to reduce risk of infection (i.e., hepatitis A and typhoid fever).
  • Do not drink beverages with ice.
  • Avoid dairy products, unless you know they have been pasteurized.
  • Do not swim in fresh water to avoid exposure to certain water-borne diseases such as schistosomiasis.
  • Do not handle animals, especially monkeys, dogs, and cats, to avoid bites and serious diseases (including rabies and plague). Consider pre-exposure rabies vaccination if you might have extensive unprotected outdoor exposure in rural areas.
  • Do not share needles for tattoos, body piercing or injections to prevent infections such as HIV and hepatitis B.

Avoid poultry farms, bird markets, and other places where live poultry is raised or kept.

After You Return Home

If you have visited a malaria-risk area, continue taking your antimalarial drug for 4 weeks (chloroquine, doxycycline, or mefloquine) or seven days (atovaquone/proguanil) after leaving the risk area.

Malaria is always a serious disease and may be a deadly illness. If you become ill with a fever or flulike illness either while traveling in a malaria-risk area or after you return home (for up to 1 year), you should seek immediate medical attention and should tell the physician your travel history.

AUSTRALIA AND THE SOUTH PACIFIC

Date last revised: December 6, 2006

Countries in this region: Australia and the South Pacific includes the countries Australia, Christmas Island, Cook Island, Federated States of Micronesia, Fiji, French Polynesia (Tahiti), Guam, Kiribati, Marshall Islands, Nauru, New Caledonia, New Zealand, Niue, Northern Mariana Islands, Palau, Papua New Guinea, Pitcairn, Samoa, American Samoa, Solomon Islands, Tokelau, Tonga, Tuvalu, Vanuatu, Wake Island, Wallis and Futuna.

Outbreaks

Dengue, Tropical and Subtropical Regions
Released:
December 6, 2006

Dengue is caused by one of four viruses (DEN-1, DEN-2, DEN-3, and DEN-4), which can produce clinical illness ranging from a nonspecific viral syndrome to severe fatal hemorrhagic fever. Symptoms of dengue include fever, severe headache, retroorbital eye pain (pain behind the eye), joint and muscle pain, and rash. Dengue has become one of the most common viral diseases transmitted to humans by the bite of infected mosquitoes, usually Aedes aegypti; it is the most common cause of febrile illness in returned travelers from the Caribbean, Central America, and South Central Asia.

The range of dengue has rapidly expanded in recent years to include most tropical countries throughout Asia (including the Indian Subcontinent), the South Pacific, the Caribbean, South and Central America, and Africa. See the Distribution of dengue maps for areas where it has become endemic. The risk to travelers is related to mosquito exposure, which can vary with the season.

No vaccine is available for dengue; however, travelers can reduce their risk by taking steps to protect themselves from mosquito bites.

Aedes mosquitoes, the principal mosquito vector, usually are active at dusk and dawn, but may feed at any time during the day, especially indoors, in shady areas, or when the weather is cloudy. Additionally, the risk for contracting dengue is greater in urban areas and lower in rural areas or areas at high altitude (above 4,500 feet [1500 meters]). During 2005, a total of 96 cases of dengue were confirmed by CDC laboratories in U.S. international travelers. Travel destinations available for 73 patients included Central America (including Mexico), the Caribbean, and Asia. Seventeen of the total reported cases required hospitalization, and one was fatal.

During 2001-2004, a total of 77 cases of dengue were laboratory confirmed by CDC in U.S. travelers, with an additional 88 suspect dengue cases for which the diagnosis could not be confirmed. Travel destinations available for 66 of the confirmed cases during 2001-2004 included the Caribbean, Pacific islands, Asia, Central America (including Mexico), and South America; 10 additional cases were attributed to travel to U.S. territories of Puerto Rico, the Virgin Islands, and the Marshall Islands, and the State of Hawaii. Fifteen of the total reported cases required hospitalization, and one was fatal. For more information about dengue and protection measures, go to the CDC website at http://www.cdc.gov/travel/yb/.

Routine Vaccinations

Before travel, be sure you and your children are up to date on all routine immunizations according to schedules approved by the Advisory Committee on Immunization Practice (ACIP). See the schedule for adults and the schedule for infants and children. Some schedules can be accelerated for travel. See your doctor at least 4–6 weeks before your trip to allow time for shots to take effect. If it is less than 4 weeks before you leave, you should still see your doctor. It might not be too late to get your shots or medications as well as other information about how to protect yourself from illness and injury while traveling.

Recommended Vaccinations and Preventive Medications

The following vaccines may be recommended for your travel to Australia and the South Pacific. Discuss your travel plans and personal health with a health-care provider to determine which vaccines you will need.

  • Hepatitis A or immune globulin (IG). (except for Australia and New Zealand). Transmission of hepatitis A virus can occur through direct person-to-person contact; through exposure to contaminated water, ice, or shellfish harvested in contaminated water; or from fruits, vegetables, or other foods that are eaten uncooked and that were contaminated during harvesting or subsequent handling.
  • Hepatitis B, especially if you might be exposed to blood or body fluids (for example, health-care workers), have sexual contact with the local population, or be exposed through medical treatment. Hepatitis B vaccine is now recommended for all infants and for children ages 11– 12 years who did not receive the series as infants.
  • Japanese encephalitis, Papua New Guinea or the Islands of Torres Strait in Australia. Local transmission documented but rare.
  • Malaria: if you are traveling to a malaria-risk area in this region, see your health care provider for a prescription antimalarial drug. For details concerning risk and preventive medications, see Malaria Information for Travelers to Australia and the South Pacific.
  • Rabies, if you might have extensive unprotected outdoor exposure in rural areas, such as might occur during camping, hiking, or bicycling, or engaging in certain occupational activities.
  • Typhoid, (except for Australia and New Zealand), particularly if you are visiting developing countries in this region. Typhoid fever can be contracted through contaminated drinking water or food, or by eating food or drinking beverages that have been handled by a person who is infected. Large outbreaks are most often related to fecal contamination of water supplies or foods sold by street vendors.
  • As needed, booster doses for tetanus-diphtheria and measles.

Required Vaccinations

  • None.

The preventive measures you need to take while traveling in this region depend on the areas you visit and the length of time you stay. You should observe the precautions listed in this document in most areas of this region. However, in highly developed areas of Australia and New Zealand, you should observe health precautions similar to those that would apply while traveling in the United States.

Malaria

Malaria is always a serious disease and may be a deadly illness.

Humans get malaria from the bite of a mosquito infected with the parasite. Prevent this serious disease by seeing your health care provider for a prescription antimalarial drug and by protecting yourself against mosquito bites. All travelers to malaria-risk areas in Papua New Guinea, the Solomon Islands, and Vanuatu, including infants, children, and former residents of these countries should take an antimalarial drug. Papua New Guinea has risk in all areas under the elevation of 1800 meters (5906 feet). The Solomon Islands has risk in all areas, except for the southern province of Rennell Island and Bellona Island. Vanuatu has risk throughout all its islands. There is no risk for malaria in Australia, Christmas Island, Cook Island, Federated States of Micronesia, Fiji, French Polynesia (Tahiti), Guam, Kiribati, Marshall Islands, Nauru, New Caledonia, New Zealand, Niue, Northern Mariana Islands, Palau, Pitcairn, Samoa, American Samoa, Tokelau, Tonga, Tuvalu, Wake Island, Wallis and Futuna.

Yellow Fever

There is no risk for yellow fever in Australia and the South Pacific. A certificate of yellow fever vaccination may be required for entry into certain of these countries if you are coming from countries in South America or subSaharan Africa.

Food and Waterborne Diseases

Avoid buying food or drink from street vendors, because it is relatively easy for such food to become contaminated.

Make sure your food and drinking water are safe. Food and waterborne diseases are the primary cause of illness in travelers. Travelers’ diarrhea can be caused by viruses, bacteria, or parasites, which are found throughout Australia and the South Pacific and can contaminate food or water. Infections may cause diarrhea and vomiting (E. coli, Salmonella, cholera, and parasites), fever (typhoid fever and toxoplasmosis), or liver damage (hepatitis).

Other Disease Risks

Risk of infection is quite variable within this region. Vaccine rates are high in Australia and New Zealand, but rates of certain infectious diseases are high in travelers to other islands. Dengue, filariasis, Ross River virus, and Murray Valley encephalitis are diseases carried by insects that also occur in this region. Scrub typhus and other rick-ettsial infections are present in this region. Protecting yourself against insect and tick bites will help to prevent these diseases. Japanese encephalitis is present in Papua New Guinea and the Torres Strait and far northern Australia. Other hazards for travelers include ciguatera poisoning, which occurs frequently on some of the islands. Snake and spider bites are also a risk.

Injuries

Motor vehicle crashes are a leading cause of injury among travelers. Protect yourself from motor vehicle injuries: avoid drinking and driving; wear your safety belt and place children in age-appropriate restraints in the back seat; follow the local customs and laws regarding pedestrian safety and vehicle speed; obey the rules of the road; and use helmets on bikes, motorcycles, and motor bikes. Avoid boarding an overloaded bus or mini-bus. Where possible, hire a local driver.

What You Need To Bring With You

  • Long-sleeved shirt, long pants, and a hat to wear whenever possible while outside, to prevent illnesses carried by insects (e.g., malaria, Dengue, filariasis, leishmaniasis, and onchocerciasis).
  • Insect repellent containing DEET.
  • Bed nets treated with permethrin. Overseas, permethrin or another insecticide, deltamethrin, may be purchased to treat bed nets and clothes.
  • Flying-insect spray to help clear rooms of mosquitoes. The product should contain a pyrethroid insecticide; these insecticides quickly kill flying insects, including mosquitoes.
  • Iodine tablets and portable water filters to purify water if bottled water is not available.
  • Sunblock, sunglasses, and a hat for protection from harmful effects of UV sun rays.
  • Prescription medications: make sure you have enough to last during your trip, as well as a copy of the prescription(s) or letter from your health-care provider on office stationery explaining that the medication has been prescribed for you.
  • Always carry medications in their original containers, in your carry-on luggage.
  • Be sure to bring along over-the-counter antidiarrheal medication (e.g., bismuth subsalicylate, loperamide) and an antibiotic prescribed by your doctor to self-treat moderate to severe diarrhea.

Staying Healthy During Your Trip

To stay healthy, do…

  • Wash your hands often with soap and water or, if hands are not visibly soiled, use a waterless, alcohol-based hand rub to remove potentially infectious materials from your skin and help prevent disease transmission.
  • In developing countries, drink only bottled or boiled water, or carbonated (bubbly) drinks in cans or bottles. Avoid tap water, fountain drinks, and ice cubes. If this is not possible, learn how to make water safer to drink.
  • Take your malaria prevention medication before, during, and after travel, as directed. (See your health care provider for a prescription.)
  • To prevent fungal and parasitic infections, keep feet clean and dry, and do not go barefoot, even on beaches.
  • Always use latex condoms to reduce the risk of HIV and other sexually transmitted diseases.

Protect yourself from mosquito insect bites:

  • Wear long-sleeved shirts, long pants, and hats when outdoors.
  • Use insect repellents that contain DEET (N, N-diethylmethyltoluamide).
  • If no screening or air conditioning is available: use a pyrethroid-containing spray in living and sleeping areas during evening and night-time hours; sleep under bed nets, preferably insecticide-treated ones.
  • If you are visiting friends and relatives in your home country, see additional special information about malaria prevention in Recent Immigrants to the U.S. from Malarious Countries Returning ‘Home’ to Visit Friends and Relatives on the CDC Malaria site.

Do not

  • Do not eat food purchased from street vendors or food that is not well cooked to reduce risk of infection (i.e., hepatitis A and typhoid fever).
  • Do not drink beverages with ice.
  • Avoid dairy products, unless you know they have been pasteurized.
  • Do not handle animals, especially monkeys, dogs, and cats, to avoid bites and serious diseases (including rabies and plague). Consider pre-exposure rabies vaccination if you might have extensive unprotected outdoor exposure in rural areas.
  • Do not share needles for tattoos, body piercing or injections to prevent infections such as HIV and hepatitis B.

After You Return Home

If you have visited a malaria-risk area in the South Pacific, continue taking your antimalarial drug for 4 weeks (doxycycline or mefloquine) or 7 days (atovaquone/proguanil) after leaving the risk area. Malaria is always a serious disease and may be a deadly illness. If you become ill with a fever or flulike illness either while traveling in a malaria-risk area or after you return home (for up to 1 year), you should seek immediate medical attention and should tell the physician your travel history.

CARIBBEAN

Date last revised: December 22, 2006

Countries in this region: Anguilla (U.K.), Antigua & Barbuda, Bahamas, Barbados, Bermuda (U.K.), Cayman Islands (U.K.), Cuba, Dominica, Dominican Republic, Grenada, Guadeloupe including St. Martin Island (France), Haiti, Jamaica, Martinique (France), Montserrat (U.K.), Netherlands Antilles (including Aruba, Bonaire, Curacao, and Sint Maarten islands), Puerto Rico (U.S.), St. Lucia, St. Vincent & the Grenadines, St. Kitts & Nevis, Trinidad & Tobago, Turks and Caicos (U.K.), Virgin Islands (U.S.), and Virgin Islands (U.K.)

Outbreaks

Malaria in Kingston, Jamaica:
Recommendations for Travelers
This information is current as of January 18, 2007.

Updated: December 22, 2006
Released: December 4, 2006

In late November 2006, the Centers for Disease Control and Prevention (CDC) received a report of a case of malaria infection in a U.S. resident who traveled to Kingston, Jamaica, from October 29 through November 6. To date, active surveillance by health authorities in Jamaica identified 107 confirmed cases. Jamaica is a country where malaria transmission does not normally occur and where CDC has not previously recommended antimalarial prophylactic drugs for U.S. travelers. The outbreak is believed to have started in late October 2006. All confirmed infections were caused by Plasmodium falciparum.

Malaria is not considered endemic on the island of Jamaica. The Ministry of Health in Jamaica has responded with heightened surveillance for malaria cases, mosquito control measures (larviciding and spraying), and education of the local population. The Caribbean Epidemiology Center and the Pan American Health Organization/World Health Organization are assisting the Ministry of Health with these response measures. CDC is assisting the Ministry of Health by augmenting their laboratory diagnostic capacity.

As of December 4, 2006, CDC is recommending prophylactic antimalarial medication for travelers who stay overnight in Kingston, Jamaica, only. Travelers to other areas of the island do not need to take an antimalarial drug. This recommendation is expected to be temporary. Travelers should periodically check the CDC Travelers’ Health website for updates.

Chloroquine, which is the recommended antimalarial chemoprophylaxis drug for Jamaica, has a long history of use and safety and is well tolerated by most people, including children. People with an allergy to chloroquine should discuss an alternative antimalarial drug with their healthcare provider. Because no antimalarial drugs is 100% protective, travelers to Jamaica should take precautions to protect against mosquito bites. For more information about dengue and protection measures, go to the CDC website at http://www.cdc.gov/travel/yb/.

Dengue, Tropical and Subtropical Regions
Released:
December 6, 2006

Dengue is caused by one of four viruses (DEN-1, DEN-2, DEN-3, and DEN-4), which can produce clinical illness ranging from a nonspecific viral syndrome to severe fatal hemorrhagic fever. Symptoms of dengue include fever, severe headache, retroorbital eye pain (pain behind the eye), joint and muscle pain, and rash. Dengue has become one of the most common viral diseases transmitted to humans by the bite of infected mosquitoes, usually Aedes aegypti; it is the most common cause of febrile illness in returned travelers from the Caribbean, Central America, and South Central Asia. The range of dengue has rapidly expanded in recent years to include most tropical countries throughout Asia (including the Indian Subcontinent), the South Pacific, the Caribbean, South and Central America, and Africa. See the Distribution of dengue maps for areas where it has become endemic. The risk to travelers is related to mosquito exposure, which can vary with the season.

No vaccine is available for dengue; however, travelers can reduce their risk by taking steps to protect themselves from mosquito bites.

Aedes mosquitoes, the principal mosquito vector, usually are active at dusk and dawn, but may feed at any time during the day, especially indoors, in shady areas, or when the weather is cloudy. Additionally, the risk for contracting dengue is greater in urban areas and lower in rural areas or areas at high altitude (above 4,500 feet [1500 meters]).

During 2005, a total of 96 cases of dengue were confirmed by CDC laboratories in U.S. international travelers. Travel destinations available for 73 patients included Central America (including Mexico), the Caribbean, and Asia. Seventeen of the total reported cases required hospitalization, and one was fatal.

During 2001-2004, a total of 77 cases of dengue were laboratory confirmed by CDC in U.S. travelers, with an additional 88 suspect dengue cases for which the diagnosis could not be confirmed. Travel destinations available for 66 of the confirmed cases during 2001-2004 included the Caribbean, Pacific islands, Asia, Central America (including Mexico), and South America; 10 additional cases were attributed to travel to U.S. territories of Puerto Rico, the Virgin Islands, and the Marshall Islands, and the State of Hawaii. Fifteen of the total reported cases required hospitalization, and one was fatal. For more information about dengue and protection measures, go to the CDC website at http://www.cdc.gov/travel/yb/.

Routine Vaccinations

Before travel, be sure you and your children are up to date on all routine immunizations according to schedules approved by the Advisory Committee on Immunization Practice (ACIP). See the schedule for adults and the schedule for infants and children. Some schedules can be accelerated for travel.

See your doctor at least 4–6 weeks before your trip to allow time for shots to take effect. If it is less than 4 weeks before you leave, you should still see your doctor. It might not be too late to get your shots or medications as well as other information about how to protect yourself from illness and injury while traveling.

Recommended Vaccinations and Preventive Medications

The following vaccines may be recommended for your travel to The Caribbean. Discuss your travel plans and personal health with a health-care provider to determine which vaccines you will need. Hepatitis A or immune globulin (IG). Transmission of hepatitis A virus can occur through direct person-to-person contact; through exposure to contaminated water, ice, or shellfish harvested in contaminated water; or from fruits, vegetables, or other foods that are eaten uncooked and that were contaminated during harvesting or subsequent handling.

  • Hepatitis B, especially if you might be exposed to blood or body fluids (for example, health-care workers), have sexual contact with the local population, or be exposed through medical treatment. Hepatitis B vaccine is now recommended for all infants and for children ages 11– 12 years who did not receive the series as infants.
  • Malaria: if you are traveling to a malaria-risk area in this region, see your health care provider for a prescription antimalarial drug. For details concerning risk and preventive medications, see Malaria Information for Travelers to the Caribbean.
  • Rabies, if you might have extensive unprotected outdoor exposure in rural areas, such as might occur during camping, hiking, or bicycling, or engaging in certain occupational activities.
  • Typhoid, particularly if you are visiting developing countries in this region. Typhoid fever can be contracted through contaminated drinking water or food, or by eating food or drinking beverages that have been handled by a person who is infected. Large outbreaks are most often related to fecal contamination of water supplies or foods sold by street vendors.
  • Yellow fever, a viral disease that occurs primarily in sub-Saharan Africa and tropical South America, is transmitted to humans through the bite of infected mosquitoes. The virus is also present in Panama and Trinidad and Tobago. Yellow fever vaccination is recommended for travelers to endemic areas and may be required to cross certain international borders. Vaccination should be given 10 days before travel and at 10 year intervals if there is on-going risk.
  • As needed, booster doses for tetanus-diphtheria and measles.

Required Vaccinations

Some countries may require a yellow fever vaccination if traveling from an endemic zone. Check the CDC website for country specific information on yellow fever vaccine requirements.

The preventive measures you need to take while traveling in the Caribbean depend on the areas you visit and the length of time you stay. You should observe the precautions listed in this document in most areas of this region.

Malaria

Malaria is always a serious disease and may be a deadly illness. Humans get malaria from the bite of a mosquito infected with the parasite. Prevent this serious disease by seeing your health care provider for a prescription antimalarial drug and by protecting yourself against mosquito bites. All travelers to malaria-risk areas in Haiti and the Dominican Republic, including infants, children, and former residents of these islands, should take an antimalarial drug. All travelers to Haiti are at risk for malaria, except no risk in the cruise port of Labadee (Labadie). Travelers to rural areas of the Dominican Republic are at risk for malaria, with the highest risk in provinces bordering Haiti. In addition, risk in all areas of La Altagracia Province, including Punta Cana and Bavaro Beach (Updated October 21, 2005). Travelers to malaria-risk areas in Haiti and Dominican Republic should take chloroquine to prevent malaria.

There is no risk for malaria in: Anguilla (U.K.), Antigua & Barbuda, Bahamas, Barbados, Bermuda (U.K.), Cayman Islands (U.K.), Cuba, Dominica, Grenada, Guadeloupe, Martinique (France), Montserrat (U.K.), Netherlands Antilles, Puerto Rico (U.S.), St. Kitts & Nevis, St. Lucia, St. Vincent & the Grenadines, Trinidad & Tobago, Turks & Caicos (U.K.), Virgin Islands (U.K., U.S.).

Yellow Fever

Yellow fever is present only in Trinidad & Tobago in this region. A certificate of yellow fever vaccination may be required for entry into certain countries in the region if you have visited Trinidad & Tobago or an endemic area in South America or sub-Saharan Africa.

Food and Waterborne Diseases

Avoid buying food or drink from street vendors, because it is relatively easy for such food to become contaminated.

Make sure your food and drinking water are safe. Food and waterborne diseases are the primary cause of illness in travelers. Travelers’ diarrhea can be caused by viruses, bacteria, or parasites, which are found throughout the Caribbean and can contaminate food or water. Infections may cause diarrhea and vomiting (E. coli, Salmonella, cholera, and parasites), fever (typhoid fever and toxoplasmosis), or liver damage (hepatitis). Illness caused by a parasitic worm (Angiostrongylus cantonensis) can occur in this region. People can get infected by eating raw or under-cooked snails or slugs that are infected with the parasite.

Other Disease Risks

Dengue is transmitted by mosquitoes in this region. Protecting yourself against insect bites will help to prevent this disease.

Cutaneous larval migrans is a risk for travelers with exposures on beaches and leptospirosis is present. Eosinophilic meningitis caused by Angiostongylus cantonensis occurred in travelers to Jamaica. Anthrax occurs in Haiti. Other infections that tend to occur more often in longer-term travelers (or immigrants from this region) include lymphatic filariasis (Dominican Republic and Haiti), cutaneous leishmaniais (Dominican Republic), tuberculosis (Haiti), HIV (Haiti), and hepatitis B (Haiti and the Dominican Republic). There remains very limited risk of schistosomiasis in few areas. Other hazards for travelers include toxic fish poisoning.

Injuries

Motor vehicle crashes are a leading cause of injury among travelers. Protect yourself from motor vehicle injuries: avoid drinking and driving; wear your safety belt and place children in age-appropriate restraints in the back seat; follow the local customs and laws regarding pedestrian safety and vehicle speed; obey the rules of the road; and use helmets on bikes, motorcycles, and motor bikes. Avoid boarding an overloaded bus or mini-bus. Where possible, hire a local driver.

What You Need To Bring With You

  • Long-sleeved shirt, long pants, and a hat to wear whenever possible while outside, to prevent illnesses carried by insects (e.g., malaria, Dengue, filariasis, leishmaniasis, and onchocerciasis).
  • Insect repellent containing DEET.
  • Bed nets treated with permethrin. Overseas, permethrin or another insecticide, deltamethrin, may be purchased to treat bed nets and clothes.
  • Flying-insect spray to help clear rooms of mosquitoes. The product should contain a pyrethroid insecticide; these insecticides quickly kill flying insects, including mosquitoes.
  • Iodine tablets and portable water filters to purify water if bottled water is not available.
  • Sunblock, sunglasses, and a hat for protection from harmful effects of UV sun rays.
  • Prescription medications: make sure you have enough to last during your trip, as well as a copy of the prescription(s) or letter from your health-care provider on office stationery explaining that the medication has been prescribed for you.
  • Always carry medications in their original containers, in your carry-on luggage.
  • Be sure to bring along over-the-counter antidiarrheal medication (e.g., bismuth subsalicylate, loperamide) and an antibiotic prescribed by your doctor to self-treat moderate to severe diarrhea.

Staying Healthy During Your Trip

To stay healthy, do…

  • Wash your hands often with soap and water or, if hands are not visibly soiled, use a waterless, alcohol-based hand rub to remove potentially infectious materials from your skin and help prevent disease transmission.
  • In developing countries, drink only bottled or boiled water, or carbonated (bubbly) drinks in cans or bottles. Avoid tap water, fountain drinks, and ice cubes. If this is not possible, learn how to make water safer to drink.
  • Take your malaria prevention medication before, during, and after travel, as directed. (See your health care provider for a prescription.)
  • To prevent fungal and parasitic infections, keep feet clean and dry, and do not go barefoot, even on beaches.
  • Always use latex condoms to reduce the risk of HIV and other sexually transmitted diseases.

Protect yourself from mosquito insect bites:

  • Wear long-sleeved shirts, long pants, and hats when outdoors.
  • Use insect repellents that contain DEET (N, N-diethylmethyltoluamide).
  • If no screening or air conditioning is available: use a pyrethroid-containing spray in living and sleeping areas during evening and night-time hours; sleep under bed nets, preferably insecticide-treated ones.
  • If you are visiting friends and relatives in your home country, see additional special information about malaria prevention in Recent Immigrants to the U.S. from Malarious Countries Returning ‘Home’ to Visit Friends and Relatives on the CDC Malaria site.

Do not

  • Do not eat food purchased from street vendors or food that is not well cooked to reduce risk of infection (i.e., hepatitis A and typhoid fever).
  • Do not drink beverages with ice.
  • Avoid dairy products, unless you know they have been pasteurized.
  • Do not swim in fresh water to avoid exposure to certain water-borne diseases such as schistosomiasis.
  • Do not handle animals, especially monkeys, dogs, and cats, to avoid bites and serious diseases (including rabies and plague). Consider pre-exposure rabies vaccination if you might have extensive unprotected outdoor exposure in rural areas.
  • Do not share needles for tattoos, body piercing or injections to prevent infections such as HIV and hepatitis B.

After You Return Home

If you have visited a malaria-risk area in Haiti or the Dominican Republic, continue taking your chloroquine for 4 weeks after leaving the risk area.

Malaria is always a serious disease and may be a deadly illness. If you become ill with a fever or flulike illness either while traveling in a malaria-risk area or after you return home (for up to1 year), you should seek immediate medical attention and should tell the physician your travel history.

MEXICO AND CENTRAL AMERICA

Date last revised: August 18, 2006

Countries in this region: Belize, Costa Rica, El Salvador, Guatemala, Honduras, Mexico, Nicaragua, and Panama.

Outbreaks

Dengue, Tropical and Subtropical Regions
Released:
December 6, 2006

Dengue is caused by one of four viruses (DEN-1, DEN-2, DEN-3, and DEN-4), which can produce clinical illness ranging from a nonspecific viral syndrome to severe fatal hemorrhagic fever. Symptoms of dengue include fever, severe headache, retroorbital eye pain (pain behind the eye), joint and muscle pain, and rash. Dengue has become one of the most common viral diseases transmitted to humans by the bite of infected mosquitoes, usually Aedes aegypti; it is the most common cause of febrile illness in returned travelers from the Caribbean, Central America, and South Central Asia. The range of dengue has rapidly expanded in recent years to include most tropical countries throughout Asia (including the Indian Subcontinent), the South Pacific, the Caribbean, South and Central America, and Africa. See the Distribution of dengue maps for areas where it has become endemic. The risk to travelers is related to mosquito exposure, which can vary with the season.

No vaccine is available for dengue; however, travelers can reduce their risk by taking steps to protect themselves from mosquito bites.

Aedes mosquitoes, the principal mosquito vector, usually are active at dusk and dawn, but may feed at any time during the day, especially indoors, in shady areas, or when the weather is cloudy. Additionally, the risk for contracting dengue is greater in urban areas and lower in rural areas or areas at high altitude (above 4,500 feet [1500 meters]).

During 2005, a total of 96 cases of dengue were confirmed by CDC laboratories in U.S. international travelers. Travel destinations available for 73 patients included Central America (including Mexico), the Caribbean, and Asia. Seventeen of the total reported cases required hospitalization, and one was fatal.

During 2001-2004, a total of 77 cases of dengue were laboratory confirmed by CDC in U.S. travelers, with an additional 88 suspect dengue cases for which the diagnosis could not be confirmed. Travel destinations available for 66 of the confirmed cases during 2001-2004 included the Caribbean, Pacific islands, Asia, Central America (including Mexico), and South America; 10 additional cases were attributed to travel to U.S. territories of Puerto Rico, the Virgin Islands, and the Marshall Islands, and the State of Hawaii. Fifteen of the total reported cases required hospitalization, and one was fatal.

For more information about dengue and protection measures, go to the CDC website at http://www.cdc.gov/travel/yb/.

Routine Vaccinations

Before travel, be sure you and your children are up to date on all routine immunizations according to schedules approved by the Advisory Committee on Immunization Practice (ACIP). See the schedule for adults and the schedule for infants and children. Some schedules can be accelerated for travel.

See your doctor at least 4–6 weeks before your trip to allow time for shots to take effect. If it is less than 4 weeks before you leave, you should still see your doctor. It might not be too late to get your shots or medications as well as other information about how to protect yourself from illness and injury while traveling.

Recommended Vaccinations and Preventive Medications

The following vaccines may be recommended for your travel to Mexico and Central America. Discuss your travel plans and personal health with a health-care provider to determine which vaccines you will need.

  • Hepatitis A or immune globulin (IG). Transmission of hepatitis A virus can occur through direct person-to-person contact; through exposure to contaminated water, ice, or shellfish harvested in contaminated water; or from fruits, vegetables, or other foods that are eaten uncooked and that were contaminated during harvesting or subsequent handling.
  • Hepatitis B, especially if you might be exposed to blood or body fluids (for example, health-care workers), have sexual contact with the local population, or be exposed through medical treatment. Hepatitis B vaccine is now recommended for all infants and for children ages 11– 12 years who did not receive the series as infants.
  • Malaria: if you are traveling to a malaria-risk area in this region, see your health care provider for a prescription antimalarial drug. For details concerning risk and preventive medications, see Malaria Information for Travelers to Central America and Mexico.
  • Rabies, if you might have extensive unprotected outdoor exposure in rural areas, such as might occur during camping, hiking, or bicycling, or engaging in certain occupational activities.
  • Typhoid vaccine. Typhoid fever can be contracted through contaminated drinking water or food, or by eating food or drinking beverages that have been handled by a person who is infected. Large outbreaks are most often related to fecal contamination of water supplies or foods sold by street vendors.
  • Yellow fever, a viral disease that occurs primarily in sub-Saharan Africa and tropical South America, is transmitted to humans through the bite of infected mosquitoes. The virus is also present in Panama and Trinidad and Tobago. Yellow fever vaccination is recommended for travelers to endemic areas and may be required to cross certain international borders. Vacci-nation should be given 10 days before travel and at 10 year intervals if there is on-going risk.
  • As needed, booster doses for tetanus-diphtheria and measles.

Required Vaccinations

Some countries may require a yellow fever vaccination if traveling from an endemic zone. Check the CDC website for country specific information on yellow fever vaccine requirements.

Malaria

Malaria is always a serious disease and may be a deadly illness. Humans get malaria from the bite of a mosquito infected with the parasite. Prevent this serious disease by seeing your health care provider for a prescription antimalarial drug and by protecting yourself against mosquito bites. Your risk of malaria may be high in these countries, including some cities. Travelers to malaria-risk areas, including infants, children, and former residents of Mexico and Central America, should take an antimalarial drug. Chloroquine is the recommended drug for Mexico, Belize, Guatemala, El Salvador, Nicaragua, Honduras, Costa Rica, and the Bocas Del Toro Province of Panama. Travelers to Darién Province and San Blas Province in Panama (including the San Blas Islands) should take one of the following antimalarial drugs: (listed alphabetically): atovaquone/proguanil, doxycycline, mefloquine, or primaquine (in special circumstances).

Yellow Fever

Yellow fever is present only in Panama in this region. A certificate of yellow fever vaccination may be required for entry into certain countries in the region if you have visited Panama, Trinidad & Tobago, or an endemic area in South America or sub-Saharan Africa.

Food and Waterborne Diseases

Avoid buying food or drink from street vendors, because it is relatively easy for such food to become contaminated. Make sure your food and drinking water are safe. Food and waterborne diseases are the primary cause of illness in travelers. Travelers’ diarrhea can be caused by viruses, bacteria, or parasites, which are found throughout this region and can contaminate food or water. Infections may cause diarrhea and vomiting (E. coli, Salmonella, cholera, and parasites), fever (typhoid fever and toxoplasmosis), or liver damage (hepatitis). Gnathostomiasis (roundworms) has increased in Mexico, with many cases being reported from the Acapulco area, infection has been reported in travelers. Humans become infected by eating undercooked fish or poultry, or reportedly by drinking contaminated water.

Other Disease Risks

Dengue, filariasis, leishmaniasis, onchocerciasis, and American trypanosomiasis (Chagas disease) are diseases carried by insects that also occur in this region. Myiasis (botfly) is endemic in Central America. Protecting yourself against insect bites will help to prevent these diseases. Motor vehicle crashes are a leading cause of injury among travelers. Protect yourself from motor vehicle injuries: avoid drinking and driving; wear your safety belt and place children in age-appropriate restraints in the back seat; follow the local customs and laws regarding pedestrian safety and vehicle speed; obey the rules of the road; and use helmets on bikes, motorcycles, and motor bikes. Avoid boarding an overloaded bus or mini-bus. Where possible, hire a local driver.

What You Need To Bring With You

  • Long-sleeved shirt, long pants, and a hat to wear whenever possible while outside, to prevent illnesses carried by insects (e.g., malaria, Dengue, filariasis, leishmaniasis, and onchocerciasis).
  • Insect repellent containing DEET.
  • Bed nets treated with permethrin. Overseas, permethrin or another insecticide, deltamethrin, may be purchased to treat bed nets and clothes.
  • Flying-insect spray to help clear rooms of mosquitoes. The product should contain a pyrethroid insecticide; these insecticides quickly kill flying insects, including mosquitoes.
  • Iodine tablets and portable water filters to purify water if bottled water is not available.
  • Sunblock, sunglasses, and a hat for protection from harmful effects of UV sun rays.
  • Prescription medications: make sure you have enough to last during your trip, as well as a copy of the prescription(s) or letter from your health-care provider on office stationery explaining that the medication has been prescribed for you.
  • Always carry medications in their original containers, in your carry-on luggage.
  • Be sure to bring along over-the-counter antidiarrheal medication (e.g., bismuth subsalicylate, loperamide) and an antibiotic prescribed by your doctor to self-treat moderate to severe diarrhea.

Staying Healthy During Your Trip

To stay healthy, do…

  • Wash your hands often with soap and water or, if hands are not visibly soiled, use a waterless, alcohol-based hand rub to remove potentially infectious materials from your skin and help prevent disease transmission.
  • In developing countries, drink only bottled or boiled water, or carbonated (bubbly) drinks in cans or bottles. Avoid tap water, fountain drinks, and ice cubes. If this is not possible, learn how to make water safer to drink.
  • Take your malaria prevention medication before, during, and after travel, as directed. (See your health care provider for a prescription.)
  • To prevent fungal and parasitic infections, keep feet clean and dry, and do not go barefoot, even on beaches.
  • Always use latex condoms to reduce the risk of HIV and other sexually transmitted diseases.

Protect yourself from mosquito insect bites:

  • Wear long-sleeved shirts, long pants, and hats when outdoors.
  • Use insect repellents that contain DEET (N, N-diethylmethyltoluamide).
  • If no screening or air conditioning is available: use a pyrethroid-containing spray in living and sleeping areas during evening and night-time hours; sleep under bed nets, preferably insecticide-treated ones.
  • If you are visiting friends and relatives in your home country, see additional special information about malaria prevention in Recent Immigrants to the U.S. from Malarious Countries Returning ‘Home’ to Visit Friends and Relatives on the CDC Malaria site.

Do not

  • Do not eat food purchased from street vendors or food that is not well cooked to reduce risk of infection (i.e., hepatitis A and typhoid fever).
  • Do not drink beverages with ice.
  • Avoid dairy products, unless you know they have been pasteurized.
  • Do not swim in fresh water to avoid exposure to certain water-borne diseases such as schistosomiasis.
  • Do not handle animals, especially monkeys, dogs, and cats, to avoid bites and serious diseases (including rabies and plague). Consider pre-exposure rabies vaccination if you might have extensive unprotected outdoor exposure in rural areas.
  • Do not share needles for tattoos, body piercing or injections to prevent infections such as HIV and hepatitis B.

After You Return Home

If you have visited a malaria-risk area, continue taking your antimalarial drug for 4 weeks (chloroquine, doxycycline, or mefloquine) or seven days (atovaquone/proguanil) after leaving the risk area.

Malaria is always a serious disease and may be a deadly illness. If you become ill with a fever or flulike illness either while traveling in a malaria-risk area or after you return home (for up to 1 year), you should seek immediate medical attention and should tell the physician your travel history.

EASTERN EUROPE AND NORTHERN ASIA

Date last revised: February 2, 2007

Countries in this region: Albania, Armenia, Azerbaijan, Belarus, Bosnia/Herzegovina, Bulgaria, Croatia, Czech Republic, Estonia, Georgia, Hungary, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, Macedonia, Moldova, Poland, Romania, Russia, Serbia/Montenegro, Slovakia (Slovak Republic), Slovenia, Tajikistan, Turkmenistan, Ukraine, and Uzbekistan.

Outbreaks

Measles and Mumps

Updated: January 3, 2007; October 27, July 28, 24 and 3,
June 8, May 12, April 28, and March 31, 2006
Released: November 16, 2005

Measles and mumps remain common diseases in many parts of the world, including some developed countries. For US travelers, the risk for exposure to measles and mumps can be high, and both diseases can be prevented by the MMR (measles, mumps, rubella) vaccine.

A measles outbreak in the Ukraine that began in early 2006 has waned. In addition, Kenya and Tanzania in East Africa reported measles outbreaks in 2006 and have since held measles immunization campaigns. Outbreaks in both countries are waning. An outbreak of measles in Uganda, Central Africa, was reported in November 2006, just ahead of its follow-up immunization campaign.

Recent outbreaks of mumps have also been reported among adolescents and young adults in the United States and United Kingdom. The outbreak in the United States began in December 2005 and peaked in April 2006. As of mid-December 2006, the number of reported mumps cases in the United Kingdom had declined compared with the same period in 2005.

All travelers should be fully immunized and keep a copy of their immunization record with them as they travel.

Measles is a serious disease. Some of the people who become sick with measles also get an ear infection (7%-9%), diarrhea (8%), or a serious lung infection, such as pneumonia (1%-6%). One of 1,500 people with measles develops inflammation of the brain. In the United States, measles has been fatal in approximately 1-3 of every 1,000 people with measles in recent years. Measles can cause especially severe disease in people who are malnourished or immunosuppressed (i.e., HIV infection, leukemia, lymphoma, or generalized malignancy or persons receiving certain drug or radiation therapies). Mumps is an infection of the salivary glands caused by a virus. It occurs through direct contact with respiratory droplets, saliva or contact with any surface that has been contaminated with the mumps virus. Early symptoms include fever, headache, and muscle ache; less than half of infected people may have the characteristic swelling of the glands close to the jaw. Mumps infection can lead to meningitis and inflammation of the testicles or ovaries, inflammation of the pancreas and deafness (usually permanent).

The MMR vaccine also provides protection against rubella (German measles). Rubella is caused by a virus that is spread through droplet transmission. It can cause a rash, mild fever, and arthritis(mostly in women). If a woman gets rubella while she is pregnant, she could have a miscarriage or her baby could be born with serious birth defects, such as deafness, cataracts, or mental retardation.

Since the introduction of vaccines containing measles, rubella, and mumps—and later combined measles-mumps-rubella (MMR) vaccine—in the United States, the numbers of reported cases of measles, mumps, rubella, and birth defects caused by rubella infection (congenital rubella syndrome) have decreased substantially. However, routine surveillance and vaccination remain necessary because of the continuing possibility of introduction of these diseases from other countries. For more information, go to the CDC website at http://www.cdc.gov/travel/yb/.

Avian Influenza A (H5N1) Virus
Most recently updated:
February 2, 2007
Initially released: September 23, 2005

Highly pathogenic avian influenza A (H5N1) (hereafter referred to as “H5N1”) virus has caused serious disease among wild birds and poultry on multiple continents. For a current list of countries reporting outbreaks of H5N1 among poultry and/or wild birds, view updates from the World Organization for Animal Health (OIE). Human infections with H5N1 viruses are still rare, but have occurred in countries in Asia, Africa, Eastern Europe, and the Middle East between 2003—2007. Most cases of H5N1 virus infection in humans are thought to have occurred from direct contact with infected poultry, but in one instance, human cases are thought to have been acquired through close contact with wild swans. Rare occurrences of probable spread (or ‘transmission’) from human to human have been reported. So far, however, this type of transmission has not been sustained. Transmission of H5N1 viruses to two persons through consumption of uncooked duck blood may also have occurred in Vietnam in 2005. Total numbers of confirmed human cases of H5N1 virus by country are available on the World Health Organization (WHO) Avian Influenza website. An assessment of the current situation can be found on the Centers for Disease Control and Prevention (CDC) Avian Influenza website. Outbreaks of H5N1 virus among bird populations in Asia, parts of Europe, the Middle East and Africa are not expected to diminish significantly in the short term. Consequently, it is expected that human infections resulting from direct contact with infected poultry will continue to occur in countries where poultry flocks are infected. Because no sustained human-to-human transmission of H5N1 virus has been documented anywhere in the world, the current phase of alert, based on the WHO global influenza preparedness plan, remains at Phase 3 (Pandemic Alert). If H5N1 virus were to gain the capacity to spread easily from person to person, an influenza pandemic (worldwide outbreak of disease) could begin. CDC remains in close communication with WHO and continues to monitor the H5N1 virus situation in countries reporting bird outbreaks and human cases. CDC has not recommended that the general public avoid travel to any of the countries affected by H5N1 viruses. Travelers should check the CDC’s Travelers’ Health Website for detailed information on precautions before, during, and after travel to affected regions.

For more information about H5N1 infections in humans, see the World Health Organization influenza website: http://www.who.int/csr/disease/avian_influenza/en/ or the CDC Avian Influenza site: http://www.cdc.gov/flu/avian/index.htm. For avian flu-related travel information: http://www.cdc.gov/travel/other/avian_flu/. For enhanced surveil-lance, diagnostic evaluation, and infection control precautions: http://www.cdc.gov/flu/avian/professional/updates.htm.

Routine Vaccinations

Before travel, be sure you and your children are up to date on all routine immunizations according to schedules approved by the Advisory Committee on Immunization Practice (ACIP). See the schedule for adults and the schedule for infants and children. Some schedules can be accelerated for travel. See your doctor at least 4–6 weeks before your trip to allow time for shots to take effect. If it is less than 4 weeks before you leave, you should still see your doctor. It might not be too late to get your shots or medications as well as other information about how to protect yourself from illness and injury while traveling.

Recommended Vaccinations and Preventive Medications

The following vaccines may be recommended for your travel to Eastern Europe and Northern Asia. Discuss your travel plans and personal health with a health-care provider to determine which vaccines you will need.

  • Hepatitis A or immune globulin (IG). Transmission of hepatitis A virus can occur through direct person-to-person contact; through exposure to contaminated water, ice, or shellfish harvested in contaminated water; or from fruits, vegetables, or other foods that are eaten uncooked and that were contaminated during harvesting or subsequent handling.
  • Hepatitis B, especially if you might be exposed to blood or body fluids (for example, health-care workers), have sexual contact with the local population, or be exposed through medical treatment. Hepatitis B vaccine is now recommended for all infants and for children ages 11– 12 years who did not receive the series as infants.
  • Malaria: if you are traveling to a malaria-risk area in this region, see your health care provider for a prescription antimalarial drug. For details concerning risk and preventive medications, see Malaria Information for Travelers to Eastern Europe and Northern Asia.
  • Rabies, if you might have extensive unprotected outdoor exposure in rural areas, such as might occur during camping, hiking, or bicycling, or engaging in certain occupational activities.
  • Typhoid, particularly if you are visiting developing countries in this region. Typhoid fever can be contracted through contaminated drinking water or food, or by eating food or drinking beverages that have been handled by a person who is infected. Large outbreaks are most often related to fecal contamination of water supplies or foods sold by street vendors.
  • As needed, booster doses for tetanus-diphtheria and measles. Outbreaks of diphtheria have been reported in states of the former Soviet Union. Travelers to these areas should be sure that their diphtheria immunization is up to date.

Required Vaccinations

  • None

Malaria

Malaria is always a serious disease and may be a deadly illness. Humans get malaria from the bite of a mosquito infected with the parasite. Prevent this serious disease by seeing your health care provider for a prescription antimalarial drug and by protecting yourself against mosquito bites.

All travelers to malaria-risk areas in Eastern Europe, including infants, children, and former residents of Eastern Europe, are at risk for malaria. Parts of the countries of Armenia, Azerbaijan, Georgia, Kyrgyzstan, Tajikistan, Turkmenistan, and Uzbekistan have malaria risk. Travelers to malaria-risk areas in Armenia, Azerbaijan, Georgia, Kyrgyzstan, Tajikistan, Turkmenistan, and Uzbekistan should take the antimalarial drug chloroquine to prevent malaria. In Uzbekistan, the risk of malaria is low and varies along its border with Tajikistan; travelers to Uzbeki-stan or their health care provider should contact CDC (Malaria Hotline, 770-488-7788) for risk and prevention advice. There is no risk for malaria in Albania, Belarus, Bosnia/Herzegovina, Bulgaria, Croatia, Czech Republic, Estonia, Hungary, Kazakhstan, Latvia, Lithuania, Macedonia, Moldova, Poland, Romania, Russia, Serbia/Montenegro, Slovakia (Slovak Republic), Slovenia, and Ukraine.

Yellow Fever

There is no risk for yellow fever in Eastern Europe and Northern Asia. A certificate of yellow fever vaccination may be required for entry into certain of these countries if you are coming from countries in South America or subSaharan Africa.

Food and Waterborne Diseases

Avoid buying food or drink from street vendors, because it is relatively easy for such food to become contaminated.

Make sure your food and drinking water are safe. Food and waterborne diseases are the primary cause of illness in travelers. Travelers’ diarrhea can be caused by viruses, bacteria, or parasites, which are found throughout Eastern Europe and can contaminate food or water. Infections may cause diarrhea and vomiting (E. coli, Salmonella, cholera, and parasites), fever (typhoid fever and toxoplasmosis), or liver damage (hepatitis). The risk of hepatitis A can be high in parts of the region.

Other Disease Risks

Tickborne encephalitis, a viral infection of the central nervous system occurs in the southern part of the nontropical forest belt in Europe and Asia (to Pacific Ocean). Most intense transmission has been reported in Russia, Czech Republic, Latvia, Lithuania, Estonia, Hungary, Poland, and Slovenia. Travelers are at risk who visit or work in forested areas during the summer months and who consume unpasteurized dairy products. Vaccine for this disease is not available in the United States at this time. A number of rickettsial infections also occur in this region. To prevent tickborne infections travelers should take precautions to prevent tick bites.

Other infections that tend to occur more often in longer-term travelers (or in immigrants from the region) include tuberculosis, hepatitis B, hepatitis C (especially in Romania), and cutaneous and visceral leishmaniasis in parts of Azerbaijan and Tajikistan. Outbreaks of diphtheria have been reported in states of the former Soviet Union. There is a vaccine available to prevent diphtheria.

Injuries

Motor vehicle crashes are a leading cause of injury among travelers. Protect yourself from motor vehicle injuries: avoid drinking and driving; wear your safety belt and place children in age-appropriate restraints in the back seat; follow the local customs and laws regarding pedestrian safety and vehicle speed; obey the rules of the road; and use helmets on bikes, motorcycles, and motor bikes. Avoid boarding an overloaded bus or mini-bus. Where possible, hire a local driver.

What You Need To Bring With You

  • Long-sleeved shirt, long pants, and a hat to wear whenever possible while outside, to prevent illnesses carried by insects and ticks.
  • Insect repellent containing DEET.
  • Bed nets treated with permethrin. Overseas, permethrin or another insecticide, deltamethrin, may be purchased to treat bed nets and clothes.
  • Flying-insect spray to help clear rooms of mosquitoes. The product should contain a pyrethroid insecticide; these insecticides quickly kill flying insects, including mosquitoes.
  • Iodine tablets and portable water filters to purify water if bottled water is not available.
  • Sunblock, sunglasses, and a hat for protection from harmful effects of UV sun rays.
  • Prescription medications: make sure you have enough to last during your trip, as well as a copy of the prescription(s) or letter from your health-care provider on office stationery explaining that the medication has been prescribed for you.
  • Always carry medications in their original containers, in your carry-on luggage.
  • Be sure to bring along over-the-counter antidiarrheal medication (e.g., bismuth subsalicylate, loperamide) and an antibiotic prescribed by your doctor to self-treat moderate to severe diarrhea.

Staying Healthy During Your Trip

To stay healthy, do…

  • Wash your hands often with soap and water or, if hands are not visibly soiled, use a waterless, alcohol-based hand rub to remove potentially infectious materials from your skin and help prevent disease transmission.
  • In developing countries, drink only bottled or boiled water, or carbonated (bubbly) drinks in cans or bottles. Avoid tap water, fountain drinks, and ice cubes. If this is not possible, learn how to make water safer to drink.
  • Take your malaria prevention medication before, during, and after travel, as directed. (See your health care provider for a prescription.)
  • To prevent fungal and parasitic infections, keep feet clean and dry, and do not go barefoot, even on beaches.
  • Always use latex condoms to reduce the risk of HIV and other sexually transmitted diseases.

Protect yourself from mosquito insect bites:

  • Wear long-sleeved shirts, long pants, and hats when outdoors.
  • Use insect repellents that contain DEET (N, N-diethylmethyltoluamide).
  • If no screening or air conditioning is available: use a pyrethroid-containing spray in living and sleeping areas during evening and night-time hours; sleep under bed nets, preferably insecticide-treated ones.
  • If you are visiting friends and relatives in your home country, see additional special information about malaria prevention in Recent Immigrants to the U.S. from Malarious Countries Returning ‘Home’ to Visit Friends and Relatives on the CDC Malaria site.

Do not

  • Do not eat food purchased from street vendors or food that is not well cooked to reduce risk of infection (i.e., hepatitis A and typhoid fever).
  • Do not drink beverages with ice.
  • Avoid dairy products, unless you know they have been pasteurized.
  • Do not swim in fresh water to avoid exposure to certain water-borne diseases such as schistosomiasis.
  • Do not handle animals, especially monkeys, dogs, and cats, to avoid bites and serious diseases (including rabies and plague). Consider pre-exposure rabies vaccination if you might have extensive unprotected outdoor exposure in rural areas.
  • Do not share needles for tattoos, body piercing or injections to prevent infections such as HIV and hepatitis B.

Avoid poultry farms, bird markets, and other places where live poultry is raised or kept.

After You Return Home

If you have visited a malaria-risk area, continue taking your antimalarial drug for 4 weeks (doxycycline or mefloquine) or seven days (atovaquone/proguanil) after leaving the risk area. Malaria is always a serious disease and may be a deadly illness. If you become ill with a fever or flulike illness either while traveling in a malaria-risk area or after you return home (for up to 1 year), you should seek immediate medical attention and should tell the physician your travel history.

WESTERN EUROPE

Date last revised: February 2, 2007

Countries in this region: Andorra, Austria, Azores, Belgium, Denmark, Faroe Island, Finland, France, Germany, Gibraltar, Greece, Greenland, Iceland, Ireland, Italy, Liechtenstein, Luxembourg, Madeira, Malta, Monaco, Netherlands, Norway, Portugal, San Marino, Spain, Sweden, Switzerland, United Kingdom.

Outbreaks

Avian Influenza A (H5N1) Virus
Most recently updated: February 2, 2007
Initially released: September 23, 2005

Highly pathogenic avian influenza A (H5N1) (hereafter referred to as “H5N1”) virus has caused serious disease among wild birds and poultry on multiple continents. For a current list of countries reporting outbreaks of H5N1 among poultry and/or wild birds, view updates from the World Organization for Animal Health (OIE). Human infections with H5N1 viruses are still rare, but have occurred in countries in Asia, Africa, Eastern Europe, and the Middle East between 2003—2007. Most cases of H5N1 virus infection in humans are thought to have occurred from direct contact with infected poultry, but in one instance, human cases are thought to have been acquired through close contact with wild swans. Rare occurrences of probable spread (or ‘transmission’) from human to human have been reported. So far, however, this type of transmission has not been sustained. Transmission of H5N1 viruses to two persons through consumption of uncooked duck blood may also have occurred in Vietnam in 2005. Total numbers of confirmed human cases of H5N1 virus by country are available on the World Health Organization (WHO) Avian Influenza website. An assessment of the current situation can be found on the Centers for Disease Control and Prevention (CDC) Avian Influenza website.

Outbreaks of H5N1 virus among bird populations in Asia, parts of Europe, the Middle East and Africa are not expected to diminish significantly in the short term. Consequently, it is expected that human infections resulting from direct contact with infected poultry will continue to occur in countries where poultry flocks are infected. Because no sustained human-to-human transmission of H5N1 virus has been documented anywhere in the world, the current phase of alert, based on the WHO global influenza preparedness plan, remains at Phase 3 (Pandemic Alert). If H5N1 virus were to gain the capacity to spread easily from person to person, an influenza pandemic (worldwide outbreak of disease) could begin. CDC remains in close communication with WHO and continues to monitor the H5N1 virus situation in countries reporting bird outbreaks and human cases.

CDC has not recommended that the general public avoid travel to any of the countries affected by H5N1 viruses. Travelers should check the CDC’s Travelers’ Health Web-site for detailed information on precautions before, during, and after travel to affected regions. For more information about H5N1 infections in humans, see the World Health Organization influenza website: http://www.who.int/csr/disease/avian_influenza/en/ or the CDC Avian Influenza site: http://www.cdc.gov/flu/avian/index.htm.

For avian flu-related travel information: http://www.cdc.gov/travel/other/avian_flu/. For enhanced surveil-lance, diagnostic evaluation, and infection control precautions: http://www.cdc.gov/flu/avian/professional/updates.htm.

Measles and Mumps

Updated: January 3, 2007; October 27, July 28, 24 and 3,
June 8, May 12, April 28, and March 31, 2006
Released: November 16, 2005

Measles and mumps remain common diseases in many parts of the world, including some developed countries. For US travelers, the risk for exposure to measles and mumps can be high, and both diseases can be prevented by the MMR (measles, mumps, rubella) vaccine.

A measles outbreak in the Ukraine that began in early 2006 has waned. In addition, Kenya and Tanzania in East Africa reported measles outbreaks in 2006 and have since held measles immunization campaigns. Outbreaks in both countries are waning. An outbreak of measles in Uganda, Central Africa, was reported in November 2006, just ahead of its follow-up immunization campaign.

Recent outbreaks of mumps have also been reported among adolescents and young adults in the United States and United Kingdom. The outbreak in the United States began in December 2005 and peaked in April 2006. As of mid-December 2006, the number of reported mumps cases in the United Kingdom had declined compared with the same period in 2005.

All travelers should be fully immunized and keep a copy of their immunization record with them as they travel.

Measles is a serious disease. Some of the people who become sick with measles also get an ear infection (7%-9%), diarrhea (8%), or a serious lung infection, such as pneumonia (1%-6%). One of 1,500 people with measles develops inflammation of the brain. In the United States, measles has been fatal in approximately 1-3 of every 1,000 people with measles in recent years. Measles can cause especially severe disease in people who are malnourished or immunosuppressed (i.e., HIV infection, leukemia, lymphoma, or generalized malignancy or persons receiving certain drug or radiation therapies).

Mumps is an infection of the salivary glands caused by a virus. It occurs through direct contact with respiratory droplets, saliva or contact with any surface that has been contaminated with the mumps virus. Early symptoms include fever, headache, and muscle ache; less than half of infected people may have the characteristic swelling of the glands close to the jaw. Mumps infection can lead to meningitis and inflammation of the testicles or ovaries, inflammation of the pancreas and deafness (usually permanent).

The MMR vaccine also provides protection against rubella (German measles). Rubella is caused by a virus that is spread through droplet transmission. It can cause a rash, mild fever, and arthritis(mostly in women). If a woman gets rubella while she is pregnant, she could have a miscarriage or her baby could be born with serious birth defects, such as deafness, cataracts, or mental retardation.

Since the introduction of vaccines containing measles, rubella, and mumps—and later combined measles-mumps-rubella (MMR) vaccine—in the United States, the numbers of reported cases of measles, mumps, rubella, and birth defects caused by rubella infection (congenital rubella syndrome) have decreased substantially. However, routine surveillance and vaccination remain necessary because of the continuing possibility of introduction of these diseases from other countries. For more information, go to the CDC website at http://www.cdc.gov/travel/yb/.

Routine Vaccinations

Before travel, be sure you and your children are up to date on all routine immunizations according to schedules approved by the Advisory Committee on Immunization Practice (ACIP). See the schedule for adults and the schedule for infants and children. Some schedules can be accelerated for travel.

See your doctor at least 4–6 weeks before your trip to allow time for shots to take effect. If it is less than 4 weeks before you leave, you should still see your doctor. It might not be too late to get your shots or medications as well as other information about how to protect yourself from illness and injury while traveling.

Required Vaccinations

  • None.

The preventive measures you need to take while traveling in Western Europe depend on the areas you visit and the length of time you stay. For most areas of this region, you should observe health precautions similar to those that would apply while traveling in the United States.

Disease Risks

In 2004–2005 there has been a marked increase in reported cases of mumps in the United Kingdom. Tick-borne encephalitis, a viral infection of the central nervous system, occurs in Austria, Germany, Finland, Sweden, Switzerland, Denmark (only on the island of Bornholm); a few cases have also been reported from Italy, Norway, and France. Travelers are at risk who visit or work in forested areas during the summer months and who consume unpasteurized dairy products. The vaccine for this disease is not available in the United States at this time. To prevent tickborne encephalitis, as well as Lyme disease, travelers should take precautions to prevent tick bites.

Leishmaniasis (cutaneous and visceral) is found in countries bordering the Mediterranean, with the highest number of cases from Spain, where it is an important opportunistic infection in HIV-infected persons. Legion-naries disease, caused by the Legionella bacterium, is sporadic; some outbreaks have involved tourists at resort hotels.

Yellow Fever

There is no risk for yellow fever in Western Europe. A certificate of yellow fever vaccination is required for entry into the Azores, Madeira, and Malta if you are coming from countries in South America or sub-Saharan Africa where yellow fever is endemic.

Food and Waterborne Diseases

Avoid buying food or drink from street vendors, because it is relatively easy for such food to become contaminated. Make sure your food and drinking water are safe. Food and waterborne diseases are the primary cause of illness in travelers. Travelers’ diarrhea can be caused by viruses, bacteria, or parasites, which are found throughout Western Europe and can contaminate food or water. Variant Creutzfeldt-Jacob (in animals bovine spongiform encephalopathy/mad-cow disease) cases have been reported primarily from the United Kingdom, though a small number of cases have been reported from other countries. Large outbreaks of trichinosis have occurred; outbreaks in France have been linked to horsemeat.

Injuries

Motor vehicle crashes are a leading cause of injury among travelers. Protect yourself from motor vehicle injuries: avoid drinking and driving; wear your safety belt and place children in age-appropriate restraints in the back seat; follow the local customs and laws regarding pedestrian safety and vehicle speed; obey the rules of the road; and use helmets on bikes, motorcycles, and motor bikes. Avoid boarding an overloaded bus or mini-bus. Where possible, hire a local driver.

What You Need To Bring With You

  • Insect repellent containing DEET during the summer.
  • Sunblock, sunglasses, hat during summer months.
  • Prescription medications: make sure you have enough to last during your trip, as well as a copy of the prescription(s) or letter from your health-care provider on office stationery explaining that the medication has been prescribed for you.
  • Always carry medications in their original containers, in your carry-on luggage.
  • Be sure to bring along over-the-counter antidiarrheal medication (e.g., bismuth subsalicylate, loperamide) and an antibiotic prescribed by your doctor to self-treat moderate to severe diarrhea.

Staying Healthy During Your Trip

To stay healthy, do…

Protect yourself from tick bites if visiting forested areas during the summer:

  • Wear long-sleeved shirts, long pants, and hats when outdoors.
  • Use insect repellents that contain DEET (N, N-diethylmethyltoluamide).
  • Always use latex condoms to reduce the risk of HIV and other sexually transmitted diseases.

Do not

  • Do not eat food that is not well cooked to reduce risk of infection.
  • Avoid dairy products, unless you know they have been pasteurized.
  • Do not share needles for tattoos, body piercing or injections to prevent infections such as HIV and hepatitis B.

Avoid poultry farms, bird markets, and other places where live poultry is raised or kept.

After You Return Home

If you become ill after your trip—even as long as a year after you return—tell your doctor where you have traveled.

MIDDLE EAST

Date last revised: February 2, 2007

Countries in this region: Bahrain, Cyprus, Iran, Iraq, Israel, Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, Syrian Arab Republic, Turkey, United Arab Emirates, and Yemen.

Outbreaks

Polio

Updated: December 1, October 27, September 20, June 7,
June 2, April 11 and February 10, 2006;
December 16, 2005
Released: November 9, 2005

According to the Global Polio Eradication Initiative (GPEI), only 4 countries (Nigeria, India, Pakistan and Afghanistan) remain polio-endemic, an all-time low. Egypt, which had been considered polio-endemic, has remained free of poliovirus transmission for over 22 months.

The following countries, however, have recently reported importations of polio in 2006, after previously being polio-free:

  • Kenya (polio-free for over 6 years)
  • Bangladesh (polio-free for over 5 years)
  • The Democratic Republic of the Congo (polio-free for almost 6 years)
  • Namibia (polio-free for almost 10 years)

Plans are under way for immunization response activities in all affected countries.

Other countries that have reported imported polio cases or cases related to an importation in 2006 are Angola, Cameroon, Ethiopia, Indonesia, Nepal, Niger, Somalia, and Yemen. Chad last reported polio cases in December 2005. Eritrea, Mali, and Sudan reported imported polio cases in 2005 but have not reported additional cases for over 12 months.

Outbreaks of poliovirus continue to be a risk until poliovirus is eliminated worldwide, and the risk for infection is still present for susceptible people. Therefore, to protect themselves from polio, travelers should be sure they and their children are fully immunized. Vaccination is recommended for all travelers to polio-endemic or -epidemic areas. These areas include Africa, South Asia, Southeast Asia, and the Middle East.

Polio is an infectious disease caused by a virus. The disease mainly affects children under 5 years of age. It is spread person-to-person when the virus enters the mouth of a person who has come in contact with the stool of an infected person (for example, by changing diapers and not washing hands before touching the mouth) or from fecal contamination of food or drinking water. Most people infected with the poliovirus have no symptoms, but some infections cause paralysis and even death. Until the 1950s, polio crippled thousands of children in industrialized countries. Soon after the introduction of effective vaccines in the late 1950s (IPV) and early 1960s (OPV), polio was brought under control and practically eliminated as a public health problem in industrialized countries.

OPV has not been used in the United States since 2000; however, it is used in many other counties and has played a major role in eliminating polio from large parts of the world. IPV, which is given by intramuscular injection, is now used in the United States and several other industrialized countries. For more information, go to the CDC website at http://www.cdc.gov/travel/yb/.

Avian Influenza A (H5N1) Virus
Most recently updated:
February 2, 2007
Initially released: September 23, 2005

Highly pathogenic avian influenza A (H5N1) (hereafter referred to as “H5N1”) virus has caused serious disease among wild birds and poultry on multiple continents. For a current list of countries reporting outbreaks of H5N1 among poultry and/or wild birds, view updates from the World Organization for Animal Health (OIE). Human infections with H5N1 viruses are still rare, but have occurred in countries in Asia, Africa, Eastern Europe, and the Middle East between 2003—2007. Most cases of H5N1 virus infection in humans are thought to have occurred from direct contact with infected poultry, but in one instance, human cases are thought to have been acquired through close contact with wild swans. Rare occurrences of probable spread (or ‘transmission’) from human to human have been reported. So far, however, this type of transmission has not been sustained. Transmission of H5N1 viruses to two persons through consumption of uncooked duck blood may also have occurred in Vietnam in 2005. Total numbers of confirmed human cases of H5N1 virus by country are available on the World Health Organization (WHO) Avian Influenza website. An assessment of the current situation can be found on the Centers for Disease Control and Prevention (CDC) Avian Influenza website.

Outbreaks of H5N1 virus among bird populations in Asia, parts of Europe, the Middle East and Africa are not expected to diminish significantly in the short term. Consequently, it is expected that human infections resulting from direct contact with infected poultry will continue to occur in countries where poultry flocks are infected. Because no sustained human-to-human transmission of H5N1 virus has been documented anywhere in the world, the current phase of alert, based on the WHO global influenza preparedness plan, remains at Phase 3 (Pandemic Alert). If H5N1 virus were to gain the capacity to spread easily from person to person, an influenza pandemic (worldwide outbreak of disease) could begin. CDC remains in close communication with WHO and continues to monitor the H5N1 virus situation in countries reporting bird outbreaks and human cases.

CDC has not recommended that the general public avoid travel to any of the countries affected by H5N1 viruses. Travelers should check the CDC’s Travelers’ Health Web-site for detailed information on precautions before, during, and after travel to affected regions.

For more information about H5N1 infections in humans, see the World Health Organization influenza website: http://www.who.int/csr/disease/avian_influenza/en/ or the CDC Avian Influenza site: http://www.cdc.gov/flu/avian/index.htm.

For avian flu-related travel information: http://www.cdc.gov/travel/other/avian_flu/. For enhanced surveil-lance, diagnostic evaluation, and infection control precautions: http://www.cdc.gov/flu/avian/professional/updates.htm.

Dengue, Tropical and Subtropical Regions
Released:
December 6, 2006

Dengue is caused by one of four viruses (DEN-1, DEN-2, DEN-3, and DEN-4), which can produce clinical illness ranging from a nonspecific viral syndrome to severe fatal hemorrhagic fever. Symptoms of dengue include fever, severe headache, retroorbital eye pain (pain behind the eye), joint and muscle pain, and rash. Dengue has become one of the most common viral diseases transmitted to humans by the bite of infected mosquitoes, usually Aedes aegypti; it is the most common cause of febrile illness in returned travelers from the Caribbean, Central America, and South Central Asia. The range of dengue has rapidly expanded in recent years to include most tropical countries throughout Asia (including the Indian Subcontinent), the South Pacific, the Caribbean, South and Central America, and Africa. See the Distribution of dengue maps for areas where it has become endemic. The risk to travelers is related to mosquito exposure, which can vary with the season.

No vaccine is available for dengue; however, travelers can reduce their risk by taking steps to protect themselves from mosquito bites. Aedes mosquitoes, the principal mosquito vector, usually are active at dusk and dawn, but may feed at any time during the day, especially indoors, in shady areas, or when the weather is cloudy. Additionally, the risk for contracting dengue is greater in urban areas and lower in rural areas or areas at high altitude (above 4,500 feet [1500 meters]). During 2005, a total of 96 cases of dengue were confirmed by CDC laboratories in U.S. international travelers. Travel destinations available for 73 patients included Central America (including Mexico), the Caribbean, and Asia. Seventeen of the total reported cases required hospitalization, and one was fatal. During 2001-2004, a total of 77 cases of dengue were laboratory confirmed by CDC in U.S. travelers, with an additional 88 suspect dengue cases for which the diagnosis could not be confirmed. Travel destinations available for 66 of the confirmed cases during 2001-2004 included the Caribbean, Pacific islands, Asia, Central America (including Mexico), and South America; 10 additional cases were attributed to travel to U.S. territories of Puerto Rico, the Virgin Islands, and the Marshall Islands, and the State of Hawaii. Fifteen of the total reported cases required hospitalization, and one was fatal. For more information about dengue and protection measures, go to the CDC website at http://www.cdc.gov/travel/yb/.

Routine Vaccinations

Before travel, be sure you and your children are up to date on all routine immunizations according to schedules approved by the Advisory Committee on Immunization Practice (ACIP). Some schedules can be accelerated for travel. See your doctor at least 4–6 weeks before your trip to allow time for shots to take effect. If it is less than 4 weeks before you leave, you should still see your doctor. It might not be too late to get your shots or medications as well as other information about how to protect yourself from illness and injury while traveling.

Recommended Vaccinations and Preventive Medications

The following vaccines may be recommended for your travel to the Middle East. Discuss your travel plans and personal health with a health-care provider to determine which vaccines you will need.

  • Hepatitis A or immune globulin (IG). Transmission of hepatitis A virus can occur through direct person-to-person contact; through exposure to contaminated water, ice, or shellfish harvested in contaminated water; or from fruits, vegetables, or other foods that are eaten uncooked and that were contaminated during harvesting or subsequent handling.
  • Hepatitis B, especially if you might be exposed to blood or body fluids (for example, health-care workers), have sexual contact with the local population, or be exposed through medical treatment. Hepatitis B vaccine is now recommended for all infants and for children ages 11– 12 years who did not receive the series as infants.
  • Malaria: if you are traveling to a malaria-risk area in this region, see your health care provider for a prescription antimalarial drug. For details concerning risk and preventive medications, see Malaria Information for Travelers to the Middle East.
  • Rabies, pre-exposure vaccination, if you might have extensive unprotected outdoor exposure in rural areas, such as might occur during camping, hiking, or bicycling, or engaging in certain occupational activities.
  • Typhoid vaccine. Typhoid fever can be contracted through contaminated drinking water or food, or by eating food or drinking beverages that have been handled by a person who is infected. Large outbreaks are most often related to fecal contamination of water supplies or foods sold by street vendors Risk is greater if you are visiting developing countries in this region.
  • As needed, booster doses for tetanus-diphtheria, measles, and a one-time dose of polio vaccine for adults.

Required Vaccinations

Travelers to Saudi Arabia during the Hajj should check for special vaccination requirements at http://www.cdc.gov/travel/other/2006/recs_hajj_saudi_arabia.htm.

The preventive measures you need to take while traveling in the Middle East depend on the areas you visit and the length of time you stay. You should observe the precautions listed in this document in most areas of this region. However, in highly developed areas of Israel, you should observe health precautions similar to those that would apply while traveling in the United States.

Malaria

Malaria is always a serious disease and may be a deadly illness. Humans get malaria from the bite of a mosquito infected with the parasite. Prevent this serious disease by seeing your health care provider for a prescription antimalarial drug and by protecting yourself against mosquito bites. Your risk of malaria may be high in these countries, including some cities. Travelers to malaria-risk areas, including infants, children, and former residents of the Middle East, should take an antimalarial drug. Travelers to some areas of Iran, Iraq, Oman, Saudi Arabia, the Syrian Arab Republic, Turkey, and Yemen may be at risk for malaria.

  • Chloroquine is the recommended antimalarial drug for Iraq, Syria, and Turkey.
  • Travelers to Iran, Saudi Arabia, and Yemen should take one of the following antimalarial drugs: (listed alphabetically): atovaquone/proguanil, doxycycline, mefloquine, or primaquine (in special circumstances).
  • In Oman, the risk of malaria is in the Musandam Province only; because the risk is very limited, no antimalarial drug is needed in this area.

There is no risk of malaria in Bahrain, Cyprus, Israel, Jordan, Kuwait, Lebanon, Qatar, and the United Arab Emirates.

Yellow Fever

There is no risk for yellow fever in the Middle East. A certificate of yellow fever vaccination may be required for entry into certain of these countries if you are coming from countries in South America or sub-Saharan Africa. For detailed information, see Comprehensive Yellow Fever Vaccination Requirements. Also, find the nearest authorized U.S. yellow fever vaccine center.

Food and Waterborne Diseases

Avoid buying food or drink from street vendors, because it is relatively easy for such food to become contaminated. Make sure your food and drinking water are safe. Food and waterborne diseases are the primary cause of illness in travelers. Travelers’ diarrhea can be caused by viruses, bacteria, or parasites, which are found throughout the Middle East and can contaminate food or water. Infections may cause diarrhea and vomiting (E. coli, Salmonella, cholera, and parasites), fever (typhoid fever and toxoplasmosis), or liver damage (hepatitis).

Other Disease Risks

Cutaneous leishmaniasis is reported throughout the area; visceral leishmaniasis, although rare throughout most of the area, is common in central Iraq, in the southwest of Saudi Arabia, in the northwest of Syria, in Turkey (southeast Anatolia only), and in the west of Yemen. Many cases of leishmaniasis have been reported in the US military in Iraq. A rise in West Nile fever has been seen recently in Israel. Outbreaks of dengue occurred in Saudi Arabia and Yemen in 2002. Protecting yourself against insect bites (see below) will help to prevent these diseases. Other infections that tend to occur more often in longer-term travelers (or immigrants from this region) include tuberculosis (Yemen), lymphatic filariasis and onchocerciasis (Yemen), hepatitis B, and schistosomiasis (Saudi Arabia, Yemen, Iraq, and Syria) To prevent schistosomiasis, do not swim in fresh water (except in well-chlorinated swimming pools) in these countries. Polio has resurfaced in Yemen. Pilgrims to the Hajj in Saudi Arabia have acquired meningococcal infections caused by serotypes A and W-135, as well as influenza.

Injuries

Motor vehicle crashes are a leading cause of injury among travelers. Protect yourself from motor vehicle injuries: avoid drinking and driving; wear your safety belt and place children in age-appropriate restraints in the back seat; follow the local customs and laws regarding pedestrian safety and vehicle speed; obey the rules of the road; and use helmets on bikes, motorcycles, and motor bikes. Avoid boarding an overloaded bus or mini-bus. Where possible, hire a local driver.

What You Need To Bring With You

  • Long-sleeved shirt, long pants, and a hat to wear whenever possible while outside, to prevent illnesses carried by insects (e.g., malaria, Dengue, filariasis, leishmaniasis, and onchocerciasis).
  • Insect repellent containing DEET.
  • Bed nets treated with permethrin. For use and purchasing information, see Insecticide Treated Bednets on the CDC malaria site. Overseas, permethrin or another insecticide, deltamethrin, may be purchased to treat bed nets and clothes.
  • Flying-insect spray to help clear rooms of mosquitoes. The product should contain a pyrethroid insecticide; these insecticides quickly kill flying insects, including mosquitoes.
  • Iodine tablets and portable water filters to purify water if bottled water is not available. See Preventing Cryptosporidiosis: A Guide to Water Filters and Bottled Water for more detailed information.
  • Sunblock, sunglasses, and a hat for protection from harmful effects of UV sun rays. See Skin Cancer Questions and Answers for more information.
  • Prescription medications: make sure you have enough to last during your trip, as well as a copy of the prescription(s) or letter from your health-care provider on office stationery explaining that the medication has been prescribed for you.
  • Always carry medications in their original containers, in your carry-on luggage.
  • Be sure to bring along over-the-counter antidiarrheal medication (e.g., bismuth subsalicylate, loperamide) and an antibiotic prescribed by your doctor to self-treat moderate to severe diarrhea. See suggested over-the-counter medications and first aid items for a travel kit.

Staying Healthy During Your Trip

To stay healthy, do…

  • When using repellent on a child, apply it to your own hands and then rub them on your child. Avoid children’s eyes and mouth and use it sparingly around their ears.
  • Wash your hands often with soap and water or, if hands are not visibly soiled, use a waterless, alcohol-based hand rub to remove potentially infectious materials from your skin and help prevent disease transmission.
  • In developing countries, drink only bottled or boiled water, or carbonated (bubbly) drinks in cans or bottles. Avoid tap water, fountain drinks, and ice cubes. If this is not possible, learn how to make water safer to drink.
  • Take your malaria prevention medication before, during, and after travel, as directed. (See your health care provider for a prescription.)
  • To prevent fungal and parasitic infections, keep feet clean and dry, and do not go barefoot, even on beaches.
  • Always use latex condoms to reduce the risk of HIV and other sexually transmitted diseases.

Protect yourself from mosquito insect bites:

  • Wear long-sleeved shirts, long pants, and hats when outdoors.
  • Use insect repellents that contain DEET (N, N-diethylmethyltoluamide).
  • If no screening or air conditioning is available: use a pyrethroid-containing spray in living and sleeping areas during evening and night-time hours; sleep under bed nets, preferably insecticide-treated ones.
  • If you are visiting friends and relatives in your home country, see additional special information about malaria prevention in Recent Immigrants to the U.S. from Malarious Countries Returning ‘Home’ to Visit Friends and Relatives on the CDC Malaria site.

Do not

  • Do not eat food purchased from street vendors or food that is not well cooked to reduce risk of infection (i.e., hepatitis A and typhoid fever).
  • Do not drink beverages with ice.
  • Avoid dairy products, unless you know they have been pasteurized.
  • Do not swim in fresh water to avoid exposure to certain water-borne diseases such as schistosomiasis.
  • Do not handle animals, especially monkeys, dogs, and cats, to avoid bites and serious diseases (including rabies and plague). Consider pre-exposure rabies vaccination if you might have extensive unprotected outdoor exposure in rural areas. For more information, please see Animal-Associated Hazards.
  • Do not share needles for tattoos, body piercing or injections to prevent infections such as HIV and hepatitis B.

Avoid poultry farms, bird markets, and other places where live poultry is raised or kept.

After You Return Home

If you have visited a malaria-risk area, continue taking your antimalarial drug for 4 weeks (chloroquine, doxycycline, or mefloquine) or seven days (atovaquone/proguanil) after leaving the risk area.

Malaria is always a serious disease and may be a deadly illness. If you become ill with a fever or flulike illness either while traveling in a malaria-risk area or after you return home (for up to 1 year), you should seek immediate medical attention and should tell the physician your travel history.

NORTH AMERICA

Date last revised: January 3, 2007

Countries in this region: Canada, St. Pierre and Miquelon [France], United States [including Hawaii].

Outbreaks

Measles and Mumps

Updated: January 3, 2007; October 27, July 28, 24 and 3,
June 8, May 12, April 28, and March 31, 2006
Released: November 16, 2005

Measles and mumps remain common diseases in many parts of the world, including some developed countries. For US travelers, the risk for exposure to measles and mumps can be high, and both diseases can be prevented by the MMR (measles, mumps, rubella) vaccine.

A measles outbreak in the Ukraine that began in early 2006 has waned. In addition, Kenya and Tanzania in East Africa reported measles outbreaks in 2006 and have since held measles immunization campaigns. Outbreaks in both countries are waning. An outbreak of measles in Uganda, Central Africa, was reported in November 2006, just ahead of its follow-up immunization campaign.

Recent outbreaks of mumps have also been reported among adolescents and young adults in the United States and United Kingdom. The outbreak in the United States began in December 2005 and peaked in April 2006. As of mid-December 2006, the number of reported mumps cases in the United Kingdom had declined compared with the same period in 2005. All travelers should be fully immunized and keep a copy of their immunization record with them as they travel.

Measles is a serious disease. Some of the people who become sick with measles also get an ear infection (7%-9%), diarrhea (8%), or a serious lung infection, such as pneumonia (1%-6%). One of 1,500 people with measles develops inflammation of the brain. In the United States, measles has been fatal in approximately 1-3 of every 1,000 people with measles in recent years. Measles can cause especially severe disease in people who are malnourished or immunosuppressed (i.e., HIV infection, leukemia, lymphoma, or generalized malignancy or persons receiving certain drug or radiation therapies).

Mumps is an infection of the salivary glands caused by a virus. It occurs through direct contact with respiratory droplets, saliva or contact with any surface that has been contaminated with the mumps virus. Early symptoms include fever, headache, and muscle ache; less than half of infected people may have the characteristic swelling of the glands close to the jaw. Mumps infection can lead to meningitis and inflammation of the testicles or ovaries, inflammation of the pancreas and deafness (usually permanent).

The MMR vaccine also provides protection against rubella (German measles). Rubella is caused by a virus that is spread through droplet transmission. It can cause a rash, mild fever, and arthritis(mostly in women). If a woman gets rubella while she is pregnant, she could have a miscarriage or her baby could be born with serious birth defects, such as deafness, cataracts, or mental retardation.

Since the introduction of vaccines containing measles, rubella, and mumps—and later combined measles-mumps-rubella (MMR) vaccine—in the United States, the numbers of reported cases of measles, mumps, rubella, and birth defects caused by rubella infection (congenital rubella syndrome) have decreased substantially. However, routine surveillance and vaccination remain necessary because of the continuing possibility of introduction of these diseases from other countries. For more information, go to the CDC website at http://www.cdc.gov/travel/yb/.

Disease Risks, United States and Canada

In 1994, an international commission certified the eradication of endemic wild poliovirus from the Americas. Ongoing surveillance in formerly endemic Central and South American countries (Tropical and Temperate) confirms that poliovirus transmission remains interrupted.

The incidence of communicable diseases is such that they are unlikely to prove a hazard for international travelers greater than that found in their own country. There are, of course, health risks, but in general, the precautions required are minimal. Certain diseases occasionally occur, such as plague, rabies in wildlife, including bats, raccoons, foxes, and other wild animals. Rocky Mountain spotted fever, tularemia, arthropod-borne encephalitis, and seasonal outbreaks of influenza. The comprehensive CDC Influenza site answers questions raised about this 2003-2004 influenza season. Coccidioidomycosis is endemic in southwestern United States and can occur in visitors to the area. Histoplasmosis is highly endemic, especially in the Mississippi, Ohio, and the St. Lawrence river valleys.

Rodent-borne hantavirus pulmonary syndrome has been identified, predominantly in the western states of the United States. Lyme disease is endemic in the northeastern United States, Mid-Atlantic, and the upper Midwest and the southwestern provinces of Canada. Occasional cases have been reported from the Pacific Northwest. Recently, cases of West Nile virus have occurred throughout North America. During recent years, the incidence of certain foodborne diseases, e.g., E. coli O157:H7 and salmonellosis, has increased in some regions. Although the risk of hepatitis A infection is considered low in the United States and Canada, outbreaks have occurred in some areas. Other hazards include poisonous snakes (please see Animal-Associated Hazards), poison ivy, and poison oak. In the north, a serious hazard is the very low temperature in the winter. In the United States, proof of immunization against diphtheria, measles, poliomyelitis, and rubella is now universally required for entry into school. In addition, the school entry requirements of most states include immunization against tetanus (49 states), pertussis (44 states), mumps (46 states), and hepatitis B (26 states). Haemophilus influenzae type b (Hib) vaccine is not required for school entry but is required in 49 states for attendance in day care facilities. Because the incidence of reported hepatitis A is substantially higher in 11 states, mostly in the west, some states now require hepatitis A vaccination for school or day care entry.

Isolated cases of bovine spongiform encephalopathy (BSE/mad cow disease) have been reported in Canada and the United States. For more information, see http://www.cdc.gov/ncidod/dvrd/bse/ and http://www.usda.gov.

SOUTH AMERICA, TEMPERATE

Date last revised: December 6, 2006

Countries in this region: Argentina, Chile, Falkland Islands (U.K.), and Uruguay.

Outbreaks

Dengue, Tropical and Subtropical Regions
Released: December 6, 2006

Dengue is caused by one of four viruses (DEN-1, DEN-2, DEN-3, and DEN-4), which can produce clinical illness ranging from a nonspecific viral syndrome to severe fatal hemorrhagic fever. Symptoms of dengue include fever, severe headache, retroorbital eye pain (pain behind the eye), joint and muscle pain, and rash. Dengue has become one of the most common viral diseases transmitted to humans by the bite of infected mosquitoes, usually Aedes aegypti; it is the most common cause of febrile illness in returned travelers from the Caribbean, Central America, and South Central Asia. The range of dengue has rapidly expanded in recent years to include most tropical countries throughout Asia (including the Indian Subcontinent), the South Pacific, the Caribbean, South and Central America, and Africa. See the Distribution of dengue maps for areas where it has become endemic. The risk to travelers is related to mosquito exposure, which can vary with the season.

No vaccine is available for dengue; however, travelers can reduce their risk by taking steps to protect themselves from mosquito bites. Aedes mosquitoes, the principal mosquito vector, usually are active at dusk and dawn, but may feed at any time during the day, especially indoors, in shady areas, or when the weather is cloudy. Additionally, the risk for contracting dengue is greater in urban areas and lower in rural areas or areas at high altitude (above 4,500 feet [1500 meters]).

During 2005, a total of 96 cases of dengue were confirmed by CDC laboratories in U.S. international travelers. Travel destinations available for 73 patients included Central America (including Mexico), the Caribbean, and Asia. Seventeen of the total reported cases required hospitalization, and one was fatal.

During 2001-2004, a total of 77 cases of dengue were laboratory confirmed by CDC in U.S. travelers, with an additional 88 suspect dengue cases for which the diagnosis could not be confirmed. Travel destinations available for 66 of the confirmed cases during 2001-2004 included the Caribbean, Pacific islands, Asia, Central America (including Mexico), and South America; 10 additional cases were attributed to travel to U.S. territories of Puerto Rico, the Virgin Islands, and the Marshall Islands, and the State of Hawaii. Fifteen of the total reported cases required hospitalization, and one was fatal. For more information about dengue and protection measures, go to the CDC website at http://www.cdc.gov/travel/yb/.

Routine Vaccinations

Before travel, be sure you and your children are up to date on all routine immunizations according to schedules approved by the Advisory Committee on Immunization Practice (ACIP). See the schedule for adults and the schedule for infants and children. Some schedules can be accelerated for travel. See your doctor at least 4–6 weeks before your trip to allow time for shots to take effect. If it is less than 4 weeks before you leave, you should still see your doctor. It might not be too late to get your shots or medications as well as other information about how to protect yourself from illness and injury while traveling.

Recommended Vaccinations and Preventive Medications

The following vaccines may be recommended for your travel to Temperate South America. Discuss your travel plans and personal health with a health-care provider to determine which vaccines you will need.

  • Hepatitis A or immune globulin (IG). Transmission of hepatitis A virus can occur through direct person-to-person contact; through exposure to contaminated water, ice, or shellfish harvested in contaminated water; or from fruits, vegetables, or other foods that are eaten uncooked and that were contaminated during harvesting or subsequent handling.
  • Hepatitis B, especially if you might be exposed to blood or body fluids (for example, health-care workers), have sexual contact with the local population, or be exposed through medical treatment. Hepatitis B vaccine is now recommended for all infants and for children ages 11– 12 years who did not receive the series as infants.
  • Malaria: if you are traveling to a malaria-risk area in this region, see your health care provider for a prescription antimalarial drug. For details concerning risk and preventive medications, see Malaria Information for Travelers to Temperate South America.
  • Rabies, pre-exposure vaccination, if you might have extensive unprotected outdoor exposure in rural areas, such as might occur during camping, hiking, or bicycling, or engaging in certain occupational activities.
  • Typhoid vaccine. Typhoid fever can be contracted through contaminated drinking water or food, or by eating food or drinking beverages that have been handled by a person who is infected. Large outbreaks are most often related to fecal contamination of water supplies or foods sold by street vendors.
  • Yellow fever, a viral disease that occurs primarily in sub-Saharan Africa and tropical South America, is transmitted to humans through the bite of infected mosquitoes. The virus is also present in Panama and Trinidad and Tobago. Yellow fever vaccination is recommended for travelers to endemic areas and may be required to cross certain international borders. Vacci-nation should be given 10 days before travel and at 10 year intervals if there is on-going risk.
  • As needed, booster doses for tetanus-diphtheria and measles.

Required Vaccinations

Some countries may require a yellow fever vaccination if traveling from an endemic zone. Check the CDC website for country specific information on yellow fever vaccine requirements.

Malaria

Malaria is always a serious disease and may be a deadly illness. Humans get malaria from the bite of a mosquito infected with the parasite. Prevent this serious disease by seeing your health care provider for a prescription antimalarial drug and by protecting yourself against mosquito bites. Your risk of malaria may be high in some provinces of Argentina. In Argentina, you are at risk for malaria only in rural areas in the northern provinces bordering Bolivia and Paraguay.

There is no risk for malaria in Chile, the Falkland Islands, and Uruguay.

Yellow Fever

Yellow fever is present only in the northeastern forest areas of Argentina in this region. A certificate of yellow fever vaccination may be required for entry into certain countries in the region if you have visited endemic areas in South or Central America, Trinidad & Tobago, or subSaharan Africa.

Food and Waterborne Diseases

Avoid buying food or drink from street vendors, because it is relatively easy for such food to become contaminated.

Make sure your food and drinking water are safe. Food and waterborne diseases are the primary cause of illness in travelers. Travelers’ diarrhea can be caused by viruses, bacteria, or parasites, which are found throughout Temperate South America and can contaminate food or water. Infections may cause diarrhea and vomiting (E. coli, Salmonella, cholera, and parasites), fever (typhoid fever and toxoplasmosis), or liver damage (hepatitis).

Other Disease Risks

Dengue, American trypanosomiasis (Chagas disease), and leishmaniasis are diseases carried by insects that also occur in this region. In 2002, locally transmitted cases of dengue fever occurred for the first time in Chile on Easter Island. Protecting yourself against insect bites will help to prevent these diseases. Rodent-borne hantavirus pulmonary syndrome has been identified in the north-central and southwestern regions of Argentina and in Chile.

If you visit the Andes Mountains, ascend gradually to allow time for your body to adjust to the high altitude, which can cause insomnia, headaches, nausea, and altitude sickness. In addition, use sunblock rated at least 15 SPF, because the risk of sunburn is greater at high altitudes.

Injuries

Motor vehicle crashes are a leading cause of injury among travelers. Protect yourself from motor vehicle injuries: avoid drinking and driving; wear your safety belt and place children in age-appropriate restraints in the back seat; follow the local customs and laws regarding pedestrian safety and vehicle speed; obey the rules of the road; and use helmets on bikes, motorcycles, and motor bikes. Avoid boarding an overloaded bus or mini-bus. Where possible, hire a local driver.

What You Need To Bring With You

  • Long-sleeved shirt, long pants, and a hat to wear whenever possible while outside, to prevent illnesses carried by insects (e.g., malaria, Dengue, filariasis, leishmaniasis, and onchocerciasis).
  • Insect repellent containing DEET.
  • Bed nets treated with permethrin. Overseas, permethrin or another insecticide, deltamethrin, may be purchased to treat bed nets and clothes.
  • Flying-insect spray to help clear rooms of mosquitoes. The product should contain a pyrethroid insecticide; these insecticides quickly kill flying insects, including mosquitoes.
  • Iodine tablets and portable water filters to purify water if bottled water is not available.
  • Sunblock, sunglasses, and a hat for protection from harmful effects of UV sun rays.
  • Prescription medications: make sure you have enough to last during your trip, as well as a copy of the prescription(s) or letter from your health-care provider on office stationery explaining that the medication has been prescribed for you.
  • Always carry medications in their original containers, in your carry-on luggage.
  • Be sure to bring along over-the-counter antidiarrheal medication (e.g., bismuth subsalicylate, loperamide) and an antibiotic prescribed by your doctor to self-treat moderate to severe diarrhea.

Staying Healthy During Your Trip

To stay healthy, do…

  • Wash your hands often with soap and water or, if hands are not visibly soiled, use a waterless, alcohol-based hand rub to remove potentially infectious materials from your skin and help prevent disease transmission.
  • In developing countries, drink only bottled or boiled water, or carbonated (bubbly) drinks in cans or bottles. Avoid tap water, fountain drinks, and ice cubes. If this is not possible, learn how to make water safer to drink.
  • Take your malaria prevention medication before, during, and after travel, as directed. (See your health care provider for a prescription.)
  • To prevent fungal and parasitic infections, keep feet clean and dry, and do not go barefoot, even on beaches.
  • Always use latex condoms to reduce the risk of HIV and other sexually transmitted diseases.

Protect yourself from mosquito insect bites:

  • Wear long-sleeved shirts, long pants, and hats when outdoors.
  • Use insect repellents that contain DEET (N, N-diethylmethyltoluamide).
  • If no screening or air conditioning is available: use a pyrethroid-containing spray in living and sleeping areas during evening and night-time hours; sleep under bed nets, preferably insecticide-treated ones.
  • If you are visiting friends and relatives in your home country, see additional special information about malaria prevention in Recent Immigrants to the U.S. from Malarious Countries Returning ‘Home’ to Visit Friends and Relatives on the CDC Malaria site.

Do not

  • Do not eat food purchased from street vendors or food that is not well cooked to reduce risk of infection (i.e., hepatitis A and typhoid fever).
  • Do not drink beverages with ice.
  • Avoid dairy products, unless you know they have been pasteurized.
  • Do not handle animals, especially monkeys, dogs, and cats, to avoid bites and serious diseases (including rabies and plague). Consider pre-exposure rabies vaccination if you might have extensive unprotected outdoor exposure in rural areas.
  • Do not share needles for tattoos, body piercing or injections to prevent infections such as HIV and hepatitis B.

After You Return Home

If you have visited a malaria-risk area in Argentina, continue taking your chloroquine for 4 weeks after leaving the risk area.

Malaria is always a serious disease and may be a deadly illness. If you become ill with a fever or flulike illness either while traveling in a malaria-risk area or after you return home (for up to 1 year), you should seek immediate medical attention and should tell the physician your travel history.

SOUTH AMERICA, TROPICAL

Date last revised: January 3, 2007

Countries in this region: Bolivia, Brazil, Colombia, Ecuador, French Guiana, Guyana, Paraguay, Peru, Suri-name, and Venezuela.

Outbreaks

Measles and Mumps

Updated: January 3, 2007; October 27, July 28, 24 and 3,
June 8, May 12, April 28, and March 31, 2006
Released: November 16, 2005

Measles and mumps remain common diseases in many parts of the world, including some developed countries. For US travelers, the risk for exposure to measles and mumps can be high, and both diseases can be prevented by the MMR (measles, mumps, rubella) vaccine.

A measles outbreak in the Ukraine that began in early 2006 has waned. In addition, Kenya and Tanzania in East Africa reported measles outbreaks in 2006 and have since held measles immunization campaigns. Outbreaks in both countries are waning. An outbreak of measles in Uganda, Central Africa, was reported in November 2006, just ahead of its follow-up immunization campaign.

Recent outbreaks of mumps have also been reported among adolescents and young adults in the United States and United Kingdom. The outbreak in the United States began in December 2005 and peaked in April 2006. As of mid-December 2006, the number of reported mumps cases in the United Kingdom had declined compared with the same period in 2005. All travelers should be fully immunized and keep a copy of their immunization record with them as they travel.

Measles is a serious disease. Some of the people who become sick with measles also get an ear infection (7%-9%), diarrhea (8%), or a serious lung infection, such as pneumonia (1%-6%). One of 1,500 people with measles develops inflammation of the brain. In the United States, measles has been fatal in approximately 1-3 of every 1,000 people with measles in recent years. Measles can cause especially severe disease in people who are malnourished or immunosuppressed (i.e., HIV infection, leukemia, lymphoma, or generalized malignancy or persons receiving certain drug or radiation therapies).

Mumps is an infection of the salivary glands caused by a virus. It occurs through direct contact with respiratory droplets, saliva or contact with any surface that has been contaminated with the mumps virus. Early symptoms include fever, headache, and muscle ache; less than half of infected people may have the characteristic swelling of the glands close to the jaw. Mumps infection can lead to meningitis and inflammation of the testicles or ovaries, inflammation of the pancreas and deafness (usually permanent).

The MMR vaccine also provides protection against rubella (German measles). Rubella is caused by a virus that is spread through droplet transmission. It can cause a rash, mild fever, and arthritis(mostly in women). If a woman gets rubella while she is pregnant, she could have a miscarriage or her baby could be born with serious birth defects, such as deafness, cataracts, or mental retardation.

Since the introduction of vaccines containing measles, rubella, and mumps—and later combined measles-mumps-rubella (MMR) vaccine—in the United States, the numbers of reported cases of measles, mumps, rubella, and birth defects caused by rubella infection (congenital rubella syndrome) have decreased substantially. However, routine surveillance and vaccination remain necessary because of the continuing possibility of introduction of these diseases from other countries. For more information, go to the CDC website at http://www.cdc.gov/travel/yb/.

Dengue, Tropical and Subtropical Regions
Released:
December 6, 2006

Dengue is caused by one of four viruses (DEN-1, DEN-2, DEN-3, and DEN-4), which can produce clinical illness ranging from a nonspecific viral syndrome to severe fatal hemorrhagic fever. Symptoms of dengue include fever, severe headache, retroorbital eye pain (pain behind the eye), joint and muscle pain, and rash. Dengue has become one of the most common viral diseases transmitted to humans by the bite of infected mosquitoes, usually Aedes aegypti; it is the most common cause of febrile illness in returned travelers from the Caribbean, Central America, and South Central Asia.

The range of dengue has rapidly expanded in recent years to include most tropical countries throughout Asia (including the Indian Subcontinent), the South Pacific, the Caribbean, South and Central America, and Africa. See the Distribution of dengue maps for areas where it has become endemic. The risk to travelers is related to mosquito exposure, which can vary with the season.

No vaccine is available for dengue; however, travelers can reduce their risk by taking steps to protect themselves from mosquito bites.

Aedes mosquitoes, the principal mosquito vector, usually are active at dusk and dawn, but may feed at any time during the day, especially indoors, in shady areas, or when the weather is cloudy. Additionally, the risk for contracting dengue is greater in urban areas and lower in rural areas or areas at high altitude (above 4,500 feet [1500 meters]).

During 2005, a total of 96 cases of dengue were confirmed by CDC laboratories in U.S. international travelers. Travel destinations available for 73 patients included Central America (including Mexico), the Caribbean, and Asia. Seventeen of the total reported cases required hospitalization, and one was fatal.

During 2001-2004, a total of 77 cases of dengue were laboratory confirmed by CDC in U.S. travelers, with an additional 88 suspect dengue cases for which the diagnosis could not be confirmed. Travel destinations available for 66 of the confirmed cases during 2001-2004 included the Caribbean, Pacific islands, Asia, Central America (including Mexico), and South America; 10 additional cases were attributed to travel to U.S. territories of Puerto Rico, the Virgin Islands, and the Marshall Islands, and the State of Hawaii. Fifteen of the total reported cases required hospitalization, and one was fatal. For more information about dengue and protection measures, go to the CDC website at http://www.cdc.gov/travel/yb/.

Routine Vaccinations

Before travel, be sure you and your children are up to date on all routine immunizations according to schedules approved by the Advisory Committee on Immunization Practice (ACIP). See the schedule for adults and the schedule for infants and children. Some schedules can be accelerated for travel.

See your doctor at least 4–6 weeks before your trip to allow time for shots to take effect. If it is less than 4 weeks before you leave, you should still see your doctor. It might not be too late to get your shots or medications as well as other information about how to protect yourself from illness and injury while traveling.

Recommended Vaccinations and Preventive Medications

The following vaccines may be recommended for your travel to Tropical South America. Discuss your travel plans and personal health with a health-care provider to determine which vaccines you will need.

  • Hepatitis A or immune globulin (IG). Transmission of hepatitis A virus can occur through direct person-to-person contact; through exposure to contaminated water, ice, or shellfish harvested in contaminated water; or from fruits, vegetables, or other foods that are eaten uncooked and that were contaminated during harvesting or subsequent handling.
  • Hepatitis B, especially if you might be exposed to blood or body fluids (for example, health-care workers), have sexual contact with the local population, or be exposed through medical treatment. Hepatitis B vaccine is now recommended for all infants and for children ages 11– 12 years who did not receive the series as infants.
  • Malaria: your risk of malaria may be high in these countries, including some cities. See your health care provider for a prescription antimalarial drug. For details concerning risk and preventive medications, see Malaria Information for Travelers to Tropical South America.
  • Rabies, if you might have extensive unprotected outdoor exposure in rural areas, such as might occur during camping, hiking, or bicycling, or engaging in certain occupational activities.
  • Typhoid vaccine. Typhoid fever can be contracted through contaminated drinking water or food, or by eating food or drinking beverages that have been handled by a person who is infected. Large outbreaks are most often related to fecal contamination of water supplies or foods sold by street vendors.
  • Yellow fever, a viral disease that occurs primarily in sub-Saharan Africa and tropical South America, is transmitted to humans through the bite of infected mosquitoes. The virus is also present in Panama and Trinidad and Tobago. Yellow fever vaccination is recommended for travelers to endemic areas and may be required to cross certain international borders. Vacci-nation should be given 10 days before travel and at 10 year intervals if there is on-going risk.
  • As needed, booster doses for tetanus-diphtheria and measles.

Required Vaccinations

Yellow fever is present in this region and vaccination is recommended if you travel to the endemic zones in any of these countries. A certificate of yellow fever vaccination may be required for entry into certain countries if you have visited an endemic area.

Malaria

Malaria is always a serious disease and may be a deadly illness. Humans get malaria from the bite of a mosquito infected with the parasite. Prevent this serious disease by seeing your health care provider for a prescription antimalarial drug and by protecting yourself against mosquito bites. Your risk of malaria may be high in these countries, including some cities. Travelers to malaria-risk areas, including infants, children, and former residents of South America, should take an antimalarial drug.

  • Chloroquine is the recommended drug for Paraguay.
  • Travelers to Bolivia, Brazil, Colombia, Ecuador, French Guiana, Guyana, Peru, Suriname, and Venezuela should take one of the following antimalarial drugs: (listed alphabetically): atovaquone/proguanil, doxycycline, mefloquine, or primaquine (in special circumstances).

Yellow Fever

Yellow fever is present in this region and vaccination is recommended if you travel to the endemic zones. A certificate of yellow fever vaccination may be required for entry into certain countries if you have visited an endemic area.

Food and Waterborne Diseases

Avoid buying food or drink from street vendors, because it is relatively easy for such food to become contaminated.

Make sure your food and drinking water are safe. Food and waterborne diseases are the primary cause of illness in travelers. Travelers’ diarrhea can be caused by viruses, bacteria, or parasites, which are found throughout Tropical South America and can contaminate food or water. Infections may cause diarrhea and vomiting (E. coli, Salmonella, cholera, and parasites), fever (typhoid fever and toxoplasmosis), or liver damage (hepatitis). Brucellosis is occasionally seen in travelers, most commonly acquired through eating or drinking contaminated milk products.

Other Disease Risks

Dengue, filariasis, leishmaniasis, onchocerciasis, and American trypanosomiasis (Chagas disease) are other diseases carried by insects that also occur in this region. Epidemics of viral encephalitis and dengue fever occur in some countries in this area. Bartonellosis, or Oroya fever (a sand fly-borne disease), occurs in arid river valleys on the western slopes of the Andes up to 3,000 meters (9,842 feet). Louse-borne typhus, a rickettsial infection is often found in mountain areas of Colombia and Peru. Protecting yourself against insect bites will help to prevent these diseases. Schistosomiasis, a parasitic infection that can be contracted in fresh water in this region, is found in Brazil, Suriname, and north-central Venezuela. Do not swim in fresh water (except in well-chlorinated swimming pools) in these countries. If you visit the Andes Mountains, ascend gradually to allow time for your body to adjust to the high altitude, which can cause insomnia, headaches, nausea, and altitude sickness. In addition, use sunblock rated at least 15 SPF, because the risk of sunburn is greater at high altitudes.

Injuries

Motor vehicle crashes are a leading cause of injury among travelers. Protect yourself from motor vehicle injuries: avoid drinking and driving; wear your safety belt and place children in age-appropriate restraints in the back seat; follow the local customs and laws regarding pedestrian safety and vehicle speed; obey the rules of the road; and use helmets on bikes, motorcycles, and motor bikes. Avoid boarding an overloaded bus or mini-bus. Where possible, hire a local driver.

What You Need To Bring With You

  • Long-sleeved shirt, long pants, and a hat to wear whenever possible while outside, to prevent illnesses carried by insects (e.g., malaria, Dengue, filariasis, leishmaniasis, and onchocerciasis).
  • Insect repellent containing DEET.
  • Bed nets treated with permethrin. Overseas, permethrin or another insecticide, deltamethrin, may be purchased to treat bed nets and clothes.
  • Flying-insect spray to help clear rooms of mosquitoes. The product should contain a pyrethroid insecticide; these insecticides quickly kill flying insects, including mosquitoes.
  • Iodine tablets and portable water filters to purify water if bottled water is not available.
  • Sunblock, sunglasses, and a hat for protection from harmful effects of UV sun rays.
  • Prescription medications: make sure you have enough to last during your trip, as well as a copy of the prescription(s) or letter from your health-care provider on office stationery explaining that the medication has been prescribed for you.
  • Always carry medications in their original containers, in your carry-on luggage.
  • Be sure to bring along over-the-counter antidiarrheal medication (e.g., bismuth subsalicylate, loperamide) and an antibiotic prescribed by your doctor to self-treat moderate to severe diarrhea.

Staying Healthy During Your Trip

To stay healthy, do…

  • Wash your hands often with soap and water or, if hands are not visibly soiled, use a waterless, alcohol-based hand rub to remove potentially infectious materials from your skin and help prevent disease transmission.
  • In developing countries, drink only bottled or boiled water, or carbonated (bubbly) drinks in cans or bottles. Avoid tap water, fountain drinks, and ice cubes. If this is not possible, learn how to make water safer to drink.
  • Take your malaria prevention medication before, during, and after travel, as directed. (See your health care provider for a prescription.)
  • To prevent fungal and parasitic infections, keep feet clean and dry, and do not go barefoot, even on beaches.
  • Always use latex condoms to reduce the risk of HIV and other sexually transmitted diseases.

Protect yourself from mosquito insect bites:

  • Wear long-sleeved shirts, long pants, and hats when outdoors.
  • Use insect repellents that contain DEET (N, N-diethylmethyltoluamide).
  • If no screening or air conditioning is available: use a pyrethroid-containing spray in living and sleeping areas during evening and night-time hours; sleep under bed nets, preferably insecticide-treated ones.
  • If you are visiting friends and relatives in your home country, see additional special information about malaria prevention in Recent Immigrants to the U.S. from Malarious Countries Returning ‘Home’ to Visit Friends and Relatives on the CDC Malaria site.

Do not

  • Do not eat food purchased from street vendors or food that is not well cooked to reduce risk of infection (i.e., hepatitis A and typhoid fever).
  • Do not drink beverages with ice.
  • Avoid dairy products, unless you know they have been pasteurized.
  • Do not swim in fresh water to avoid exposure to certain water-borne diseases such as schistosomiasis.
  • Do not handle animals, especially monkeys, dogs, and cats, to avoid bites and serious diseases. Consider pre-exposure rabies vaccination if you might have extensive unprotected outdoor exposure in rural areas.
  • Do not share needles for tattoos, body piercing or injections to prevent infections such as HIV and hepatitis B.

After You Return Home

If you have visited a malaria-risk area, continue taking your antimalarial drug for 4 weeks (chloroquine, doxycycline, or mefloquine) or seven days (atovaquone/proguanil) after leaving the risk area. Malaria is always a serious disease and may be a deadly illness. If you become ill with a fever or flulike illness either while traveling in a malaria-risk area or after you return home (for up to 1 year), you should seek immediate medical attention and should tell the physician your travel history.

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