Foreign Travel

Health: The traveler’s most valuable possession

When travelers begin to plan a trip, it is common for them to construct a careful itinerary to evaluate how much money will be needed and to read about the area they will visit. Perhaps they picture themselves walking along ancient byways or examining grand vistas.

You never picture yourself confined to the hotel for days with diarrhea, yet almost half of travelers to developing countries will end up this way if they don’t take precautions. Illness not only may wreck a costly trip, but also it may put some travelers in awkward or even dangerous positions. Sometimes, diseases acquired during travel may have prolonged effects on your health or, in the extreme case, may be fatal. Simple precautions taken prior to travel can reduce your risk of illness far away from home.

• Travel to well-developed countries: Travel to tourist areas of Canada, Europe, and other well-developed parts of the world generally requires you to take along a supply of only your regular prescription medications. Exceptions exist, however. For example, some experts recommend that travelers to southern Europe take along medications to treat traveler’s diarrhea. If travel extends beyond the usual tourist routes, special precautions may also be needed.



• Travel to developing countries: Travel to these countries may pose greater risks. You must take precautions before you go and while you are in foreign countries far different from your own. This discussion is not a complete catalogue of all tropical diseases and is not a substitute for the advice of a knowledgeable doctor. It covers diseases of interest to the routine tourist. Serious adventure travelers will need additional resources.

• Preparing for the trip: Travel to a developing country requires careful planning.
  
  
  • From a health standpoint, most travelers should contact their doctor at least 6 weeks prior to travel.
    
    
  • Adventure travelers, those who plan prolonged stays, and those who will leave the usual tourist routes should contact their doctor 6 months prior to travel.
    
    
  • Advice may also be obtained from the Centers for Disease Control and Prevention (CDC) or the World Health Organization. Although vaccinations may be recommended or even required for travel to a developing country, no vaccines are required for re-entry into the United States.

• Food and water precautions: Both food and water can be contaminated with bacteria or parasites. Light contamination may not affect the taste or smell of the material but may still cause disease. The usual admonition "don't drink the water" is good advice in developing countries.
  
  
  • Tap water may contain organisms that could cause days of diarrhea or, less commonly, more serious illnesses. Some hotels will provide a carafe of drinking water at the bedside. This is often filled from the tap in the kitchen and is not reliable.
    
    
  • Bottled water is usually safe, especially if carbonated. Check the seal on the bottle: Some bottles are re-used and refilled from tap water to be sold to unwary tourists. Boiled water and drinks made with boiled water are usually safe. This includes coffee and tea.
    
    
  • Ice is no safer than water. It is usually best to stick with bottled water, boiled water, or sodas.
    
    
  • What about brushing your teeth? Basically, use bottled water or no water when brushing your teeth. However, the risk of disease is proportional to the amount of water consumed. So some experts feel that it is all right to brush your teeth with small amounts of (hot) tap water.
    
    
  • Foods that are safest are those that are fully cooked and served hot.
    
    
    • Fruits that you peel yourself, such as bananas, are usually safe. The exception is watermelon, which may be injected with tap water to increase its weight at market.
      
      
    • Human night soil (areas where humans urinate and defecate in the soil) is a common fertilizer in developing countries. Fruits grown near the ground, such as strawberries, are more often contaminated than those grown on trees. Lettuce is risky. Its crevices are almost impossible to clean, and the water used to do so is often contaminated.
      
      
    • Spices do not kill bacteria. Sushi that is so spicy as to burn the tongue is no safer than unseasoned sushi. Shellfish are notorious causes of disease because they are often grown in contaminated water and build up high concentrations of bacteria.
      
      
  • The prudent traveler’s menu is limited. Certainly, prudence must be tempered with practicality. Part of the fun of travel is to experience new dishes. The goal of food and water precautions is to help travelers make informed choices. There is nothing wrong with eating sushi in a developing country if you are aware of the risks and are willing to take them. For many travelers, a little bit of common sense and keeping some medications on hand will result in an enjoyable experience.
  
  
• Insect precautions: Insects spread many tropical diseases.
  
  
  • For most travelers, the biggest danger comes from mosquitoes. Travelers to developing countries should carry an insect repellent containing the ingredient DEET. Mosquitoes can spread very serious diseases including malaria and yellow fever. This is not a time for herbal preparations or Avon Skin-So-Soft. Insect repellents should be applied and reapplied according to package directions. Remember that the malaria mosquito bites at night. In malarious areas, wear insect repellent to bed and use mosquito netting if it is available. Room sprays containing permethrin may also be used. For prolonged travel, clothing may be treated with permethrin to serve as a long-term repellent.
    
    
  • During the day, wear light protective clothing. Long sleeves and pants help reduce the risk of bites. Ticks are a concern in many developing countries. If traveling in fields or woods, tuck your pant legs into your socks. At the end of the day, check yourself for ticks. The risk of disease increases if ticks are allowed to attach for more than 24 hours. Insect repellents reduce the risk of tick attachment.
  
  
• The traveler’s medical kit: In developing countries, even simple medical supplies may be hard to find. For this reason, pack some basic supplies (see traveler's medical kit).
  
  
  • Keep prescription drugs in their original bottles. Customs officials are not pleased to see plastic bags full of loose pills. For travelers with complex medical problems, a letter from a doctor or a copy of a recent electrocardiogram may be helpful.
    
    
  • The American Embassy usually will be able to provide a list of doctors who speak English if you need a doctor.
  
  
• Sex, cars, and drugs: Sexually transmitted diseases including AIDS are common in developing countries. The best rule is to abstain from sexual contact with native populations and fellow travelers. Travelers who violate this rule would be wise to carry a supply of condoms.
  
  
  • Automobile accidents are one of the most common causes of death in travelers. Look both ways before crossing the street, use seatbelts if available, and don't get in the car if the driver is drunk.
    
    
  • Possession or use of illegal drugs is a very serious offense in most countries. Long prison sentences have been meted out for small amounts of illicit substances.
  
  
• Travel under special conditions: International travelers often seek adventure.
  
  
  • Take special precautions when climbing mountains to limit the risk of mountain sickness. Mountain sickness can cause headache, nausea, weakness, shortness of breath, and fatigue. In its severe form, brain swelling can cause disorientation, severe headache, bizarre behavior, loss of consciousness, pulmonary edema, or death. The most effective way to prevent symptoms is to ascend gradually (1,000 feet per day) and to avoid alcoholic beverages and narcotics. Medications are available to reduce the risk of symptoms.
    
    
  • Scuba diving poses the risk of decompression problems such as the bends and puts a strain on the heart. Travelers planning to dive should become certified prior to the trip because courses at resorts are often too short and not adequate. Divers should follow all safety precautions. People who are out of condition should limit the depth and duration of their dives.
    
    
  • In general, chronic medical conditions and disabilities do not limit travel if you take sensible precautions. It is best to have a letter from a doctor describing the medical condition and listing all active medications and doses. Medical insurance may not pay for care abroad. Travelers should contact their insurance carrier to arrange for extended coverage. Travelers with significant medical conditions should wear medical alert identification bracelets or necklaces.
    
    
  • Travelers with disabilities may find limited information on accessibility from the Centers for Disease Control and Prevention or the US Architectural and Transportation Barriers Compliance Board.  However, information on conditions in foreign countries is limited. In general, it is best to call ahead to ensure the availability of wheelchairs, specially adapted cars, ground floor rooms, elevators, and other aids. Make alternate plans in case the promised aids are not available on arrival. US air carriers and cruise lines are required to make reasonable efforts to allow access by disabled persons.
    
    
  • Pregnancy should not keep you at home unless you have complications from an unstable medical condition or impending labor.
    
    
    • Some activities should be curtailed or eliminated. For example, water skiing and scuba diving pose potential threats to the fetus and should be avoided. Very strenuous activity may cause pre-term labor. Hot tubs should be avoided. Activities that require you to be far from medical care, such as high-altitude hiking, should probably be avoided.
      
      
    • Air travel is not advised after the 36th week of gestation and for travelers with impending labor. During flight, it is important that pregnant travelers move around to avoid blood clots from developing and to drink adequate amounts of water or other fluids.
      
      
    • Certain vaccines and medications that are normally recommended for travelers might be prohibited during pregnancy. All pregnant women who plan to travel should consult their doctors.
    
    
  • In general, children should receive protection against the same diseases as adult travelers. All children should be up to date on routine vaccinations. An accelerated vaccination schedule is available for some of the preventive vaccines and may be useful for children who will spend a long period of time in a developing country. Many vaccines are not effective in very young children. Parents should consult their child's doctor for specific information.

 [#Medical Kit]The following items are recommended for a traveler’s medical kit: 

• Prescription medication: Keep in the original bottle. Keep in carry-on luggage. Take along more than enough to last the entire trip.
  
  
• Foot care products: Bring pads to protect blistered feet from further injury. Consider packing athlete’s foot powder if hiking in tropical or damp areas.
  
  
• Cold remedies: Cough drops, runny-nose remedy, and tissues.
  
  
• Diarrhea remedies: Imodium, Lomotil, or Pepto-Bismol. Consider carrying an antibiotic. See Traveler’s Diarrhea.
  
  
• Pain/fever remedies: Aspirin, acetaminophen, or others.
  
  
• Motion sickness medicine: Over-the-counter remedies or prescription medication such as scopolamine patches.
  
  
• Insect repellents: Containing DEET. Also consider insecticide room sprays and mosquito nets. Permethrin may be applied to clothing and bed nets.
  
  
• Skin products: Sunscreen (SPF 8 or higher), lip balm, tropical antibiotic ointment, topical cortisone cream for rashes and bites.
  
  
• First aid and miscellaneous supplies: Bandages, adhesive tape, gauze, tweezers, scissors, pocket knife, needle and thread, safety pins, matches, flashlight, sunglasses, thermometer, laxative, toilet paper, premoistened towelette.
  
  
• For women: Sanitary napkins/tampons. Medication for vaginal yeast infection.

Numerous exotic diseases await travelers to developing countries, but some simple precautions and vaccines can minimize the risk.

The most commonly acquired disease is traveler’s diarrhea that affects up to 40% of travelers. Hepatitis A, a more serious disease, affects less than 1% of travelers. Typhoid fever, malaria, yellow fever, and meningitis are even rarer. The latter diseases are potentially fatal, and the sensible traveler should take precautions against them. Some of these diseases are transmitted by biting insects, others by eating contaminated food or inhaling organisms.

• The following list shows ways certain diseases are spread:
  
  
  • Diseases spread by contaminated food and water – Traveler’s diarrhea, hepatitis A, thyroid fever, polio, cholera
    
    
  • Diseases spread by mosquitoes and other insects – Malaria, yellow fever, Japanese encephalitis
    
    
  • Diseases spread through coughs and close respiratory contact – Meningococcal meningitis, tuberculosis, influenza
    
    
  • Disease spread by animals - Rabies
    
    
• Traveler’s diarrhea: Diarrhea is among the most frequent health problem encountered by travelers. Up to 40% of short-term travelers to developing countries and up to 70% of long-term travelers will experience at least one bout of diarrhea. Because traveler's diarrhea is caused by eating or drinking contaminated food and water, people traveling under primitive conditions are at highest risk.
  
  
  • The risk of diarrhea varies according to the destination, with the highest risk (30-70%) found in Asia, Africa, and Latin America. Travel to the Caribbean, the Mediterranean, Pacific islands, southern Europe, Israel, and Japan carries a lower risk.
    
    
  • Many different types of organisms cause traveler’s diarrhea. The most common cause is a simple bacteria or giardiasis. Symptoms vary, but most affected travelers have 4-5 stools per day for 3-4 days. Some people have only a few hours of diarrhea. More unfortunate travelers have profuse and frequent stools. About 30% of affected travelers are confined to their rooms, and 40% have to curtail their scheduled activities. High fever, significant abdominal pain, and bloody stools are hallmarks of a more serious type of diarrhea and should cause the traveler to seek medical attention.
    
    
  • Select food and drink with care. In most cases, the traveler should carry along an antibiotic to take in case diarrhea develops. The most commonly used drugs are called fluoroquinolones. If diarrhea is mild, bismuth subsalicylate (Pepto-Bismol), loperamide (Imodium), or diphenoxylate hydrochloride (Lomotil) may be taken to slow things down while the antibiotic is working. These medicines should not be taken if bloody diarrhea, severe abdominal pain, or high fever is present.
    
    
  • It is possible to reduce the risk of diarrhea by taking antibiotics or bismuth subsalicylate daily. However, this approach has its own risks and inconveniences. It should be reserved for the rare traveler for whom even a couple hours of diarrhea would be a serious inconvenience.

• Cholera: Although cholera calls up visions of medieval plagues and can be a major cause of anxiety in tourists, it is really very hard to catch. The risk of cholera has been estimated at 2 cases per million travelers.
  
  
  • Cholera is a problem in areas where significant amounts of human waste contaminate food or water. The level of contamination must be very high, because a large number of the cholera bacteria must be ingested to cause disease. This causes the food to smell or taste so bad that few tourists are tempted to eat it. Occasionally, the taste is covered in spicy sauces. Raw shellfish have been a source of disease in some areas.
    
    
  • For the rare tourist who gets cholera, the good news is that symptoms are usually limited to a few days of diarrhea. If careful attention is paid to drinking fluids, and in severe cases to replacement of salts and sugars, the symptoms go away and do not return. With severe disease, you may have much watery diarrhea that may exceed 1 liter per hour.
    
    
  • The cholera vaccine is not very effective. Currently, vaccination is not recommended or required for international travel.
  
  
• Hepatitis A: Hepatitis is an inflammation of the liver. Hepatitis A is found throughout the world and is transmitted primarily when tiny amounts of human waste are inadvertently swallowed. The disease is caused by a virus that attacks the liver.
  
  
  • Food that is handled by infected workers can transmit the disease to unwary tourists, as can vegetables or fruit grown in human night soil. The average risk of acquiring disease in a developing country is about 0.3-1% per month of stay.
    
    
  • Symptoms don't appear immediately. It takes about a month before the sudden onset of fever, fatigue, nausea, and a yellowing of the skin called jaundice. Full recovery may take weeks. Death is rare but does occur. Unlike other types of hepatitis, hepatitis A goes away completely and does not cause chronic disease.
    
    
  • Protection against hepatitis A is recommended for all travelers to developing countries. The vaccine is especially important for those who will visit rural areas or eat in local restaurants. Two options exist to protect the traveler from hepatitis A:
    
    
    • A single dose of the inactivated vaccine in adults is up to 90% effective in preventing disease and provides protection for at least 1 year. Frequent travelers or those with prolonged stays should get a booster dose at least 6 months after the first shot. Estimates suggest that the booster shot may protect against hepatitis A for 20 years. The vaccine is not approved for children younger than 2 years.
      
      
    • Immune globulin, also known as gamma globulin, is about 85% effective in preventing hepatitis A. Unfortunately, the protection lasts only 2-5 months (depending on the dose).
  
  
• Hepatitis B: Like hepatitis A, hepatitis B is caused by a virus that attacks the liver. The 2 diseases have significant differences, however.
  
  
  • Hepatitis B is transmitted through sexual intercourse, dirty needles used to inject drugs, and contaminated blood transfusions. Hepatitis B is not transmitted with more casual contact such as shaking hands, eating, or drinking.
    
    
  • Once the virus enters the body, the virus begins to attack the liver. It takes an average of 4 months for symptoms to develop. Symptoms include fatigue and nausea. The hallmark of the disease is the yellowing of the skin called jaundice. Death is rare, but does occur.
    
    
  • Most people can clear their body of the virus after a few weeks, but about 10% of adults and 35% of children fail to clear the virus and become chronic carriers of the disease. Chronic carriers may develop cirrhosis or primary cancer of the liver.
    
    
  • There is an effective vaccine to prevent hepatitis B, and it is recommended for travelers contemplating sexual intercourse abroad, those staying for prolonged periods (6 months or more), and those providing health care. The vaccine is safe and is actually recommended as one of the routine childhood vaccines for US children. Complete protection requires 3 shots over 6 months, but even 1 or 2 shots offer significant protection.
  
  
• Japanese encephalitis: Japanese encephalitis is caused by a virus that is transmitted by mosquitoes. This rare disease exists in much of Asia, but it is very rare for travelers to get it. Transmission is more marked in rural areas, in flooded rice paddies, and during wet seasons. Even where the disease is common, only 1-3% of mosquitoes are infected. The risk to the average traveler is less than 1 case per million per year. Risk is increased by prolonged stays in infected areas.
  
  
  • Symptoms include fever, lethargy, and coma. Up to 1 in 5 infected people die, and the remainder often have nerve problems or brain damage.
    
    
  • An effective vaccine is given as a 3-shot series over 2-4 weeks. The vaccine can cause side effects including arm pain, fever, and even serious allergic reactions. Vaccination should be reserved for long-term (usually more than 1 month in duration) travelers to Asia with significant exposure to infected areas during appropriate seasons (often May through October). The CDC has listed the important areas and seasons for transmission on their Web site.
  
  
• Malaria: Malaria is spread by the female Anopheles mosquito that bites between dusk and dawn. Infected mosquitoes are found in many developing countries. In some countries, widespread use of insecticides has eliminated disease in major cities. Because the mosquito is not found at higher altitudes, the risk of malaria decreases substantially beyond 1,500 meters above sea level. Country-specific data on occurrence of malaria may be found in Health Information for International Travel, published annually by the US Department of Health and Human Services or on the CDC Web site.
  
  
  • Fever is the major symptom of malaria. The disease must always be suspected when fever occurs during or after travel to an infected area. Coma and kidney failure may develop, and the disease is sometimes fatal.
    
    
  • Travelers should observe mosquito precautions that include protective clothing, screened windows, mosquito netting, and insect repellants. Travelers who will be in infected areas between dusk and dawn should take medication to help prevent clinical infection. The choice of medication depends on the traveler's destination.
    
    
  • The medicine does not stop the mosquito from biting or the organism from entering the bloodstream. The goal of taking medicines is to destroy the organisms before they have a chance to take hold. Thus, the medications must be continued for 4 weeks after leaving the malaria-prone area.
  
  
• Meningococcal meningitis: Meningococcal meningitis is spread from person to person through the air. The bacteria infect the lining of the brain and spinal cord.
  
  
  • The disease occurs sporadically throughout the world. Much of sub-Saharan Africa has regular outbreaks every year. During the Hajj, the annual pilgrimage to Mecca, Saudi Arabia hosts thousands of wayfarers from all over the world. Crowded conditions and arrivals from the infected zone of Africa combine to create the potential for an epidemic. For this reason, vaccination is required before entry to Saudi Arabia during the pilgrimage season.
    
    
  • Symptoms include headache, fever, stiff neck, and confusion or coma. Although most people recover with antibiotic treatment, the disease can be rapid and may be fatal.
    
    
  • The bacteria that cause meningococcal meningitis have developed into 5 slightly different strains, known as serotypes. The vaccine covers 4 of the strains including the ones most likely to cause disease in developing countries. Travelers who will visit infected areas should be vaccinated. Protection begins to wane after about 2 years, and the vaccine has limited effectiveness in young children.
  
  
• Plague: Plague is caused by the bacillus Yersinia pestis and is transmitted by fleas on rodents. It has gained attention in recent years as a potential weapon of bioterrorists. Transmission usually requires close contact with rodents in a rural area. Almost three-fourths of the 770 cases in 1989 came from Vietnam and Madagascar. Only a handful of cases have been reported in American travelers in the last century. Due to the very low risk of disease, plague is not a concern for the routine traveler. There is no vaccine available. Travelers who will live or work in close contact with rodents, such as field biologists, may consider daily doxycycline to reduce the risk of disease.
  
  
• Polio: Although vaccination has eliminated naturally occurring polio in North and South America, rare cases continue to occur in developing countries of Africa, Asia, the Middle East, and Eastern Europe. The disease is caused by a virus that is spread when human waste is inadvertently swallowed. Symptoms include muscle aches and paralysis. Many infected people never have any symptoms. Travelers to infected areas should be immune to polio. For most adults who have already been vaccinated in the remote past, this means a single vaccine dose before travel.
  
  
• Rabies: Rabies is spread through contact with infected secretions, often from a bite wound from an infected animal. Infected saliva can spread disease into open cuts. In caves, disease may occur when bat guano is aerosolized and inhaled. Dogs, cats, skunks, raccoons, bats, cattle, and foxes are among animals that can transmit rabies.
  
  
  • Rabies is caused by a virus that works its way into the brain over days to months. Once there, the virus causes coma and is always fatal. Travelers at high risk include veterinarians, spelunkers (cave explorers), and those who will handle wild animals. Travelers should avoid petting, touching, or playing with animals in developing countries.
    
    
  • Travelers to developing countries who will not have access to medical care for prolonged periods should consider vaccination.
    
  • Bite wounds should be cleaned immediately with soap and water. Unless there is a way of ensuring that the animal is free of rabies, the bitten traveler should be evaluated by experienced medical personnel and will require vaccination to prevent rabies from occurring. Although the vaccine available in the United States is relatively safe, vaccines available in developing countries may cause significant side effects. Further, the cleanliness of needles used for injection may be a concern. In most cases, evacuation to a developed country for vaccination is recommended even if this would delay vaccination by a few days. Sometimes, an injection of rabies antibodies is also needed. Even travelers who have been vaccinated in the past need to be evaluated and often vaccinated after bite wounds.
  
  
• Smallpox: Smallpox is caused by a virus that is transmitted from person-to-person. Naturally occurring smallpox was eradicated from the globe in 1980. Smallpox remains a concern only as a potential weapon for bioterrorists. An effective vaccine exists but is not recommended on the basis of travel to a developing country. No country requires vaccination for entry.
  
  
• Typhoid fever: Typhoid fever is caused by bacteria and spread when human waste is ingested in contaminated food and water. Make careful food selections. The amount of contamination required to produce disease is significant but less than for cholera. Although cases are reported from virtually all countries, disease is concentrated in developing countries and areas with inadequate sanitation. Each year, about 250 cases are reported in American travelers.
  
  
  • Fever is the hallmark of disease. Rash (rose spots), headache, and diarrhea may occur. Although most people clear the bacteria from their system, a few may appear to recover but still shed the bacteria in their stool. These carriers feel fine but can inadvertently spread the disease to others.
    
    
  • Two new typhoid vaccines are available. One is available as a capsule to be swallowed. The other is an injection. Both are safe and moderately effective. Vaccination is recommended for travelers to developing countries, especially those travelers traveling under primitive conditions or planning to eat from local restaurants or street vendors.
  
  
• Yellow fever: Yellow fever is caused by a virus and is spread by the bite of a mosquito. Symptoms occur a few days to a week after being bitten. Infected people get fatigued, become feverish, and their skin turns yellow. A small number die. The disease occurs in parts of South America and Africa. There is no yellow fever in Asia.
  
  
  • All travelers to infected areas should minimize exposure to biting insects. An effective and safe vaccine is available. The vaccine is recommended for all travelers to infected areas. The CDC provides current information about which countries and regions are affected.
    
    
  • Vaccination is required sometimes before travelers are permitted to enter selected countries. Some countries require vaccination only if the traveler is coming from an infected area. The United States is not an infected area. Proof of vaccination is afforded by an International Certificate of Vaccination stamped by an official vaccinating center. In the United States, the Centers for Disease Control and Prevention is responsible for licensing official vaccination centers. The official vaccination certificate is good for 10 years.
  
  
• Other immunizations and diseases: A visit to a physician for travel-related vaccines is a good time to make sure your routine vaccines are up to date.
  
  
  • In the United States, tetanus boosters are recommended every 10 years.
    
    
  • People born after 1956 should make certain that their measles vaccines are up to date. Older people are usually assumed to have had measles as children.
    
    
  • Influenza occurs in the winter season in temperate areas and year-round in the tropics. Vaccination should be considered in older travelers and persons with chronic medical conditions.
    
    
  • Tuberculosis has a worldwide distribution. Long-term travelers may want to consider getting a skin test prior to departure. Travelers with negative skin tests should have a repeat test after returning. The BCG vaccine is of uncertain value and is neither recommended nor available in the United States.

The following are general recommendations. Specific recommendations depend on the travel itinerary and the medical history of the traveler.

Diseases to Consider When Traveling to Specific Areas

Disease	Africa	Asia and Middle East	Eastern Europe	South America	Oceania
Travelers Diarrhea	X	X	X	X	X
Hepatitis A	X	X	X	X	X
Japanese Encephalitis	--	X	--	--	--
Malaria	X	X	--	X	X
Meningitis	X	X	--	--	--
Typhoid Fever	X	X	X	X	X
Yellow Fever	X	--	--	X	--

All travelers should follow food and water and insect precautions. These diseases may be limited to selected locations or countries within the above areas. This is not a comprehensive listing of all possible diseases. Please consult your physician to receive recommendations specific to your travel itinerary.

• Africa: Travelers should be up to date on routine vaccinations, such as tetanus. Hepatitis A vaccine and typhoid vaccine are recommended. The CDC recommends updating polio immunizations. Yellow fever vaccine is recommended for travel to infected areas and may be required before admission to the country is allowed. Meningococcal meningitis occurs in much of sub-Saharan Africa. Malaria exists in most countries. Consult the CDC Web site to determine if your travels will bring you into contact with malaria. Long-term travelers and health care workers should consider hepatitis B vaccination. Rabies vaccine is recommended for long-term travelers and people, such as veterinarians, who will handle animals.

• Asia and the Middle East: Travelers should be up to date on routine vaccinations, such as tetanus. Hepatitis A vaccine and typhoid vaccine are recommended for travelers to developing countries and rural areas. The CDC recommends updating polio vaccinations. Meningococcal vaccine is recommended for pilgrims to Saudi Arabia. Proof of immunity may be required during the Hajj, before entry to Saudi Arabia is permitted. A risk of malaria exists in selected areas. Long-term travelers and health care workers should consider hepatitis B vaccination. Rabies vaccine is recommended for long-term travelers and people, such as veterinarians, who will handle animals. Japanese encephalitis vaccine is recommended for travelers who will have prolonged exposure to rural areas in infected zones. Yellow fever does not occur in Asia, but travelers who have recently visited South America or Africa may be required to show proof of immunity.

• Eastern Europe and the former Soviet Union: Travelers should be up to date on routine vaccinations such as tetanus. The risk of hepatitis A, typhoid fever, and polio increases as political systems break down and sanitation declines. Malaria exists in limited areas not visited by most travelers.

• Oceania: Travel to Australia and New Zealand does not require special immunizations or medications. Other countries may harbor tropical illnesses. Malaria occurs in Papua New Guinea and some surrounding islands. People who may travel under unsanitary conditions, those who plan to eat in local restaurants, and those who travel to developing countries should consider hepatitis A vaccination and typhoid vaccination. The CDC recommends updating polio vaccinations. Long-term travelers and health care workers should consider hepatitis B vaccination. Rabies vaccine is recommended for long-term travelers and people, such as veterinarians, who will handle animals.

• South America and Central America: Travelers should be up to date on routine vaccinations, such as tetanus. Hepatitis A vaccine and typhoid vaccine should be considered for most travelers. Yellow fever vaccine is recommended for travelers to selected areas and may be required before admission to the country is allowed. A risk of malaria exists in some countries. Long-term travelers and health care workers should consider hepatitis B vaccination. Rabies vaccine is recommended for long-term travelers and people, such as veterinarians, who will handle animals.

• International Society of Travel Medicine 
  
  
• American Society of Tropical Medicine and Hygiene — for a listing of clinics in your area
  
  
• Centers for Disease Control and Prevention (CDC), National Center for Infectious Diseases, Traveler's Health 
  
  
• World Health Organization, International travel and health 
  
  
• Travel Health Online

foreign travel, traveler’s diarrhea, cholera, hepatitis A, hepatitis B, Japanese encephalitis, malaria, meningitis, polio, rabies, typhoid fever, yellow fever, travel to foreign country

1. Ansdell VE, Ericsson CD. Prevention and empiric treatment of traveler's diarrhea. Med Clin North Am. Jul 1999;83(4):945-73, vi. [Medline].

2. Baird JK, Hoffman SL. Prevention of malaria in travelers. Med Clin North Am. Jul 1999;83(4):923-44, vi. [Medline].

3. Castelli F, Patroni A. The human immunodeficiency virus-infected traveler. Clin Infect Dis. Dec 2000;31(6):1403-8. [Medline].

4. CDC. Malaria Surveillance - United States, 2000. MMWR Morb Mortal Wkly Rep. 2002;51:SS-5, 9-23.

5. CDC. Prevention of hepatitis A through active or passive immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. Oct 1 1999;48(RR-12):1-37. [Medline].

6. CDC. Recommendations of the Advisory Committee on Immunization Practices: revised recommendations for routine poliomyelitis vaccination. MMWR Morb Mortal Wkly Rep. Jul 16 1999;48(27):590. [Medline].

7. CDC. Update: recommendations to prevent hepatitis B virus transmission--United States. MMWR Morb Mortal Wkly Rep. Jan 22 1999;48(2):33-4. [Medline].

8. CDC. Centers for Disease Control and Prevention. Typhoid immunization: recommendations of the Advisory Committee on Immunization Practices. 1994. Typhoid immunization: recommendations of the Advisory Committee on Immunization Practices. 1994.

9. CDC. Cholera Infected Countries (Blue Sheet). 2001. Cholera Infected Countries (Blue Sheet). 2001.

10. CDC. Health Information for International Travel. US Department of Health and Human Services. 2000. Health Information for International Travel. US Department of Health and Human Services. 2000.

11. CDC. Human rabies prevention-United States. 1999. Human rabies prevention-United States. 1999.

12. CDC. Inactivated Japanese Encephalitis virus vaccine. 2001. Inactivated Japanese Encephalitis virus vaccine. 2001.

13. CDC. Malaria. 2001. Malaria. 2001.

14. CDC. Prevention and control of meningococcal disease. 2001. Prevention and control of meningococcal disease. 2001.

15. CDC. Prevention of hepatitis. A through active or passive immunization. 2001. Prevention of hepatitis. A through active or passive immunization. 2001.

16. CDC. Yellow Fever Infected Countries (Blue Sheet). 2002. Yellow Fever Infected Countries (Blue Sheet). 2002.

17. Centers for Disease Control, Department of Health and Human Services. Diphtheria, tetanus, and pertussis: guidelines for vaccine prophylaxis and other preventive measures. Recommendation of the Immunization Practices Advisory Committee. Ann Intern Med. Dec 1985;103(6 ( Pt 1)):896-905. [Medline].

18. Cleland J. Travelling with heart disease. Practitioner. Feb 1998;242(1583):130-3. [Medline].

19. Craven RB, Maupin GO, Beard ML, et al. Reported cases of human plague infections in the United States, 1970-1991. J Med Entomol. Jul 1993;30(4):758-61. [Medline].

20. Dewey CM, Riley WJ. Have diabetes, will travel. Postgrad Med. Feb 1999;105(2):111-3, 117-8, 124-6. [Medline].

21. Dumont L, Mardirosoff C, Tramèr MR. Efficacy and harm of pharmacological prevention of acute mountain sickness: quantitative systematic review. BMJ. Jul 29 2000;321(7256):267-72. [Medline].

22. Fischer PR. Travel with infants and children. Infect Dis Clin North Am. Jun 1998;12(2):355-68. [Medline].

23. Fishbein DB, Robinson LE. Rabies. N Engl J Med. Nov 25 1993;329(22):1632-8. [Medline].

24. Fradin MS. Mosquitoes and mosquito repellents: a clinician's guide. Ann Intern Med. Jun 1 1998;128(11):931-40. [Medline].

25. Fradin MS, Day JF. Comparative efficacy of insect repellents against mosquito bites. N Engl J Med. Jul 4 2002;347(1):13-8. [Medline].

26. Frey SE, Couch RB, Tacket CO, et al. Clinical responses to undiluted and diluted smallpox vaccine. N Engl J Med. Apr 25 2002;346(17):1265-74. [Medline].

27. Hackett PH, Roach RC. High-altitude illness. N Engl J Med. Jul 12 2001;345(2):107-14. [Medline].

28. Hawkes S, Hart G. The sexual health of travelers. Infect Dis Clin North Am. Jun 1998;12(2):413-30. [Medline].

29. Henderson DA, Inglesby TV, Bartlett JG, et al. Smallpox as a biological weapon: medical and public health management. Working Group on Civilian Biodefense. JAMA. Jun 9 1999;281(22):2127-37. [Medline].

30. Inglesby TV, Dennis DT, Henderson DA, et al. Plague as a biological weapon: medical and public health management. Working Group on Civilian Biodefense. JAMA. May 3 2000;283(17):2281-90. [Medline].

31. Jong EC. Travel immunizations. Med Clin North Am. Jul 1999;83(4):903-22, vi. [Medline].

32. Kain KC, Keystone JS. Malaria in travelers. Epidemiology, disease, and prevention. Infect Dis Clin North Am. Jun 1998;12(2):267-84. [Medline].

33. Karp CL. Preparation of the HIV-infected Traveler to the Tropics. Curr Infect Dis Rep. Feb 2001;3(1):50-58. [Medline].

34. Klocke DL, Decker WW, Stepanek J. Altitude-related illnesses. Mayo Clin Proc. Oct 1998;73(10):988-92; quiz 992-3. [Medline].

35. Koff RS. Hepatitis A, hepatitis B, and combination hepatitis vaccines for immunoprophylaxis: an update. Dig Dis Sci. Jun 2002;47(6):1183-94. [Medline].

36. Lapostolle F, Surget V, Borron SW, et al. Severe pulmonary embolism associated with air travel. N Engl J Med. Sep 13 2001;345(11):779-83. [Medline].

37. Lee WM. Hepatitis B virus infection. N Engl J Med. Dec 11 1997;337(24):1733-45. [Medline].

38. Lien D, Turner M. Recommendations for patients with chronic respiratory disease considering air travel: a statement from the Canadian Thoracic Society. Can Respir J. Mar-Apr 1998;5(2):95-100. [Medline].

39. L?scher T, Keystone JS, Steffen R. Vaccination of travelers against hepatitis A and B. J Travel Med. Jun 1999;6(2):107-14. [Medline].

40. Medical Letter on Drugs and Therapeutics. Advice for travelers. Med Lett Drugs Ther. Apr 23 1999;41(1051):39-42. [Medline].

41. Mileno MD, Bia FJ. The compromised traveler. Infect Dis Clin North Am. Jun 1998;12(2):369-412. [Medline].

42. Morrison G. Zoonotic infections from pets. Understanding the risks and treatment. Postgrad Med. Jul 2001;110(1):24-6, 29-30, 35-6 passim. [Medline].

43. Newton HB. Neurologic complications of scuba diving. Am Fam Physician. Jun 1 2001;63(11):2211-8. [Medline].

44. Pathak MA. Sunscreens: progress and perspectives on photoprotection of human skin against UVB and UVA radiation. J Dermatol. Nov 1996;23(11):783-800. [Medline].

45. Raufman JP. Cholera. Am J Med. Apr 1998;104(4):386-94. [Medline].

46. Robertson SE, Hull BP, Tomori O, et al. Yellow fever: a decade of reemergence. JAMA. Oct 9 1996;276(14):1157-62. [Medline].

47. Rosenstein NE, Perkins BA, Stephens DS, et al. Meningococcal disease. N Engl J Med. May 3 2001;344(18):1378-88. [Medline].

48. Rousseau MC, Moreau J, Delmont J. Vaccination and HIV: a review of the literature. Vaccine. Dec 10 1999;18(9-10):825-31. [Medline].

49. Ryan ET, Calderwood SB. Cholera vaccines. Clin Infect Dis. Aug 2000;31(2):561-5. [Medline].

50. Ryan ET, Kain KC. Health advice and immunizations for travelers. N Engl J Med. Jun 8 2000;342(23):1716-25. [Medline].

51. Ryan ET, Wilson ME, Kain KC. Illness after international travel. N Engl J Med. Aug 15 2002;347(7):505-16. [Medline].

52. Samuel BU, Barry M. The pregnant traveler. Infect Dis Clin North Am. Jun 1998;12(2):325-54. [Medline].

53. Sartori C, Allemann Y, Duplain H, et al. Salmeterol for the prevention of high-altitude pulmonary edema. N Engl J Med. May 23 2002;346(21):1631-6. [Medline].

54. Shears P. Recent developments in cholera. Curr Opin Infect Dis. Oct 2001;14(5):553-8. [Medline].

55. Sood SK. Immunization for children traveling abroad. Pediatr Clin North Am. Apr 2000;47(2):435-48, viii. [Medline].

56. Stauffer WM, Kamat D. Traveling with infants and children. Part 2: immunizations. J Travel Med. Mar-Apr 2002;9(2):82-90. [Medline].

57. Stauffer WM, Konop RJ, Kamat D. Traveling with infants and young children. Part I: Anticipatory guidance: travel preparation and preventive health advice. J Travel Med. Sep-Oct 2001;8(5):254-9. [Medline].

58. Steffen R, Ericsson CD. Special section:travel medicine. Clin Infect Dis. May 2000;30(5):809-10. [Medline].

59. The Medical Letter on Drugs and Therapeutics. Advice for travelers. Med Lett Drugs Ther. Apr 15 2002;44(1128):33-8. [Medline].

60. Thompson RF, Bass DM, Hoffman SL. Travel vaccines. Infect Dis Clin North Am. Mar 1999;13(1):149-67, vii. [Medline].

61. Virk A. Medical advice for international travelers. Mayo Clin Proc. Aug 2001;76(8):831-40. [Medline].

62. Waner S, Durrheim DN, Leggat PA, Ross MH. Preventing infectious diseases in long-term travelers to rural Africa. J Travel Med. Nov-Dec 2001;8(6):304-8. [Medline].

63. Wellems TE, Plowe CV. Chloroquine-resistant malaria. J Infect Dis. Sep 15 2001;184(6):770-6. [Medline].

64. Whitley RJ, Gnann JW. Viral encephalitis: familiar infections and emerging pathogens. Lancet. Feb 9 2002;359(9305):507-13. [Medline].

65. Wilson ME. Travel-related vaccines. Infect Dis Clin North Am. Mar 2001;15(1):231-51. [Medline].

66. Wolfe MS. Protection of travelers. Clin Infect Dis. Aug 1997;25(2):177-84; quiz 185-6. [Medline].

Author: Mary Nettleman, MD, MS, Chair, Department of Medicine, Michigan State University.

Coauthor(s): Stephen Sigworth, MD, Assistant Professor, Department of Internal Medicine, Division of Primary Care Medicine, Virginia Commonwealth University School of Medicine.

Editors: Scott H Plantz, MD, FAAEM, Research Director, Assistant Professor, Department of Emergency Medicine, Mount Sinai School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, ; Jeter (Jay) Pritchard Taylor III, MD, Vice-Chief, Compliance Officer, Attending Physician Emergency Medicine Residency, Department of Emergency Medicine, Palmetto Richland Memorial Hospital, University of South Carolina.