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Health Information for
International Travel

Health Information for
International Travel
Editor in Chief Gary W. Brunette, MD, MS


Phyllis E. Kozarsky, MD HUMAN SERVICES


Nicole J. Cohen, MD, MS




Richard W. Steketee, MD, MPH
Michelle Weinberg, MD, MPH
Mary Elizabeth Wilson, MD

Megan Crawley O’Sullivan, MPH

Ronnie Henry

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ISSN 0095–3539
ISBN 978–​0–​19–​062861–​1

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Suggested Citation
Centers for Disease Control and Prevention. CDC Yellow Book 2018: Health Information for
International Travel. New York: Oxford University Press; 2017.

Readers are invited to send comments and suggestions regarding this publication to Gary W.
Brunette, Editor in Chief, Centers for Disease Control and Prevention, Division of Global
Migration and Quarantine (E-03), Travelers’ Health Branch (proposed), 1600 Clifton Road NE,
Atlanta, GA 30333, USA.

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List of Boxes, Figures, Maps, & Tables, by Topicâ•… xiii

List of Mapsâ•… xix
Editorial Staffâ•… xxi
CDC Contributorsâ•… xxi
External Contributorsâ•… xxii
Acknowledgmentsâ•… xxv
Prefaceâ•… xxv
In Memoriam: A Tribute to Alan J. Magillâ•… xxvi

1 Introductionâ•…


Introduction to Travel Health & the Yellow Bookâ•… 1

Planning for Healthy Travel: CDC Travelers’ Health Website and Mobile Applicationsâ•… 4
Travel Epidemiologyâ•… 6
Perspectives: WHY GUIDELINES DIFFERâ•… 9
Air Travel Trendsâ•… 13

2 The Pretravel Consultationâ•…

The Pretravel Consultationâ•… 16


General Recommendations for Vaccination & Immunoprophylaxisâ•… 32
Interactions among Travel Vaccines & Drugsâ•… 44
Self-╉Treatable Conditions╅ 48
Travelers’ Diarrheaâ•… 48
Altitude Illnessâ•… 56
Jet Lagâ•… 62
Motion Sicknessâ•… 64
Respiratory Infectionsâ•… 66
Counseling & Advice for Travelersâ•… 69
Food & Water Precautionsâ•… 69
Water Disinfection for Travelersâ•… 72
Food Poisoning from Marine Toxinsâ•… 77

Protection against Mosquitoes, Ticks, & Other Arthropodsâ•… 81

Sun Exposureâ•… 87
Problems with Heat & Coldâ•… 89
Injury Preventionâ•… 94
Safety & Securityâ•… 99
Animal-╉Associated Hazards╅ 101
Environmental Hazardsâ•… 105
Scuba Divingâ•… 107
Medical Tourismâ•… 110
Discussing Complementary & Integrative Health Approaches with Travelersâ•… 115
Deep Vein Thrombosis & Pulmonary Embolismâ•… 120
Mental Healthâ•… 124
Travel Health Kitsâ•… 126
Obtaining Health Care Abroadâ•… 133
Travel Insurance, Travel Health Insurance, & Medical Evacuation Insuranceâ•… 136

3 Infectious Diseases Related to Travelâ•…


Angiostrongyliasis, Neurologicâ•… 140

B virusâ•… 144
Bartonella Infectionsâ•… 146
Cutaneous Larva Migransâ•… 159
Ebola Virus Disease & Marburg Virus Diseaseâ•… 170
Escherichia coli, Diarrheagenicâ•… 174
Filariasis, Lymphaticâ•… 178
Hand, Foot, & Mouth Diseaseâ•… 180


Helicobacter pyloriâ•… 181

Helminths, Soil-╉Transmitted╅ 182
Hepatitis Aâ•…
Hepatitis Bâ•…
Hepatitis Câ•…
Hepatitis Eâ•…
HIV Infectionâ•… 202
Japanese Encephalitisâ•… 214
Legionellosis (Legionnaires’ Disease & Pontiac Fever)â•… 224
Leishmaniasis, Cutaneousâ•… 226
Leishmaniasis, Visceralâ•… 228
Lyme Diseaseâ•… 232
Measles (Rubeola)â•… 256
Meningococcal Diseaseâ•… 261
Middle East Respiratory Syndrome (MERS)â•… 267
Onchocerciasis (River Blindness)â•… 271
Pinworm (Enterobiasis, Oxyuriasis, Threadworm)â•… 275
Plague (Bubonic, Pneumonic, Septicemic)â•… 276
Pneumococcal Diseaseâ•… 277
Q Feverâ•… 286
Rickettsial (Spotted & Typhus Fevers) & Related Infections, including
â•… Anaplasmosis & Ehrlichiosisâ•… 297
Salmonellosis (Nontyphoidal)â•… 304
Sexually Transmitted Diseasesâ•… 314
Perspectives: SEX & TOURISMâ•… 317


Smallpox & Other Orthopoxvirus-╉Associated Infections╅ 321

Tickborne Encephalitisâ•… 326
Trypanosomiasis, African (Sleeping Sickness)â•… 331
Trypanosomiasis, American (Chagas Disease)â•… 332
Typhoid & Paratyphoid Feverâ•… 342
Varicella (Chickenpox)â•… 346
Viral Hemorrhagic Feversâ•… 349
Yellow Feverâ•… 352
Yellow Fever & Malaria Information, by Countryâ•… 372

4 Select Destinationsâ•…
Rationale for Select Destinationsâ•… 425

Africa & the Middle Eastâ•… 426

East Africa: Safarisâ•… 426
Saudi Arabia: Hajj/╉Umrah Pilgrimageâ•… 430
South Africaâ•… 436
Tanzania: Kilimanjaroâ•…
The Americas & the Caribbeanâ•… 444
Dominican Republicâ•… 452
Peru: Cusco, Machu Picchu, & Other Regionsâ•… 463
Burma (Myanmar)â•… 468


5 Post-╉Travel Evaluation╅
General Approach to the Returned Travelerâ•… 495

Fever in Returned Travelersâ•… 499

Persistent Travelers’ Diarrheaâ•… 504
Skin & Soft Tissue Infections in Returned Travelersâ•… 507
Screening Asymptomatic Returned Travelersâ•… 512

6 Conveyance & Transportation Issuesâ•…

Air Travelâ•… 517

Cruise Ship Travelâ•… 521

Death during Travelâ•… 527
Taking Animals & Animal Products across International Bordersâ•… 529

7 International Travel with Infants & Childrenâ•…

Traveling Safely with Infants & Childrenâ•… 533

Vaccine Recommendations for Infants & Childrenâ•… 541

Travel & Breastfeedingâ•… 546
International Adoptionâ•… 550

8 Advising Travelers with Specific Needsâ•…

Immunocompromised Travelersâ•… 557

Travelers with Chronic Illnessesâ•… 571

Pregnant Travelersâ•… 576
Travelers with Disabilitiesâ•… 582
Immigrants Returning Home to Visit Friends & Relatives (VFRs)â•… 584
Health Care Workersâ•… 588
Advice for Air Crewsâ•… 594
Humanitarian Aid Workersâ•… 597
Long-╉Term Travelers & Expatriates╅ 602
Last-╉Minute Travelers╅ 611


Special Considerations for US Military Deploymentsâ•… 615

Study Abroad & Other International Student Travelâ•… 621
Travel to Mass Gatheringsâ•… 627
Newly Arrived Immigrants & Refugeesâ•… 629
Wilderness & Expedition Medicineâ•… 636
Work-╉Related Travel╅ 640

Appendicesâ•… 645
Appendix A: Promoting Quality in the Practice of Travel Medicineâ•… 645
Appendix B: Travel Vaccine Summary Tableâ•… 649
Photography Creditsâ•… 667


List of Boxes, Figures, Maps,

& Tables, by Topic


General Travel Health Risks

TABLE 5-​3. Common infections, by incubation period  501
TABLE 5-​4. Common clinical findings and associated infections  502

General Vaccine Information

BOX 2-​1. The Advisory Committee on Immunization Practices (ACIP)  33
TABLE 2-​2. Vaccines to update or consider during pretravel consultations  19
TABLE 2-​5. Recommended and minimum ages and intervals between vaccine doses  38
TABLE 8-​1. Immunization of immunocompromised adults  559
TABLE 8-​2. Immunosuppressive biologic agents that preclude use of live vaccines  566
TABLE B-​1. Travel vaccine summary  650

Acute Mountain Sickness and Altitude Illness

BOX 2-​3. Tips for acclimatization  57
TABLE 2-​7. Risk categories for acute mountain sickness  58
TABLE 2-​8. Ascent risk associated with various underlying medical conditions  59
TABLE 2-​9. Recommended medication doses to prevent and treat altitude illness  60

Deep Vein Thrombosis and Pulmonary Embolism

BOX 2-​10. Venous thromboembolism (VTE) risk factors  121

BOX 3-​1. Guidelines for classifying dengue  166
FIGURE 3-​1. Relative sensitivity of detection of dengue virus nucleic acid, antigen, and IgM  168
MAP 3-​1. Dengue risk in the Americas and the Caribbean  163
MAP 3-​2. Dengue risk in Africa and the Middle East  164
MAP 3-​3. Dengue risk in Asia and Oceania  165
TABLE 8-​4. Diseases for which VFR travelers are at increased risk, proposed reasons for risk variance, and
recommendations to reduce risks  586

Dermatologic Conditions
TABLE 5-​5. Ten most common skin lesions in returned travelers, by cause  508

Diarrheal Illnesses
BOX 2-​2. Travelers’ diarrhea definitions  53
TABLE 2-​6. Travelers’ diarrhea treatment recommendations  53
TABLE 8-​4. Diseases for which VFR travelers are at increased risk, proposed reasons for risk variance, and
recommendations to reduce risks  586

Escherichia coli
TABLE 3-​1. Mechanism of pathogenesis and typical clinical syndrome of Escherichia coli pathotypes  176

TABLE 5-​1. Illnesses associated with fever presenting in the first 2 weeks after travel  497
TABLE 5-​2. Common causes of fever, by geographic area  500

Hepatitis A
TABLE 3-​2. Vaccines to prevent hepatitis A  185
TABLE 8-​4. Diseases for which VFR travelers are at increased risk, proposed reasons for risk variance, and
recommendations to reduce risks  586

Hepatitis B
MAP 3-​4. Prevalence of hepatitis B virus infection  188
TABLE 3-​3. Interpretation of serologic test results for hepatitis B virus infection  190
TABLE 3-​4. Vaccines to prevent hepatitis B  192
TABLE 8-​4. Diseases for which VFR travelers are at increased risk, proposed reasons for risk variance, and
recommendations to reduce risks  586

Hepatitis C
MAP 3-​5. Prevalence of hepatitis C virus infection  194
TABLE 8-​4. Diseases for which VFR travelers are at increased risk, proposed reasons for risk variance, and
recommendations to reduce risks  586

Hepatitis E
MAP 3-​6. Hepatitis E endemic countries  200
TABLE 8-​4. Diseases for which VFR travelers are at increased risk, proposed reasons for risk variance, and
recommendations to reduce risks  586

BOX 3-​5. Summary of sexual health recommendations for travelers  318
TABLE 8-​4. Diseases for which VFR travelers are at increased risk, proposed reasons for risk variance, and
recommendations to reduce risks  586
TABLE 8-​1. Immunization of immunocompromised adults  559

MAP 3-​7. Distribution of highly pathogenic avian influenza A (H5N1) virus  208
TABLE 3-​5. Recommended dosage and duration of antiviral medications for treatment and prophylaxis of
influenza A and B  212

FIGURE 2-​2. Leading causes of injury death for US citizens in foreign countries, 2013 & 2014  95
TABLE 2-​13. Recommended strategies to reduce injuries while abroad  96

Japanese Encephalitis
MAP 3-​8. Distribution of Japanese encephalitis  216
TABLE 3-​6. Vaccine to prevent Japanese encephalitis (JE)  217



TABLE 3-​7. Risk for Japanese encephalitis (JE), by country  218

TABLE 8-​4. Diseases for which VFR travelers are at increased risk, proposed reasons for risk variance, and
recommendations to reduce risks  586

BOX 3-​2. Clinical highlights for malaria  235
BOX 3-​3. What is a reliable supply?  239
BOX 8-​7. Practical advice on malaria prophylaxis for long-​term travelers and expatriates  610
MAP 3-​9. Malaria-​endemic countries in the Western Hemisphere  234
MAP 3-​10. Malaria-​endemic countries in the Eastern Hemisphere  236
MAP 3-​18. Malaria in Bolivia  380
MAP 3-​19. Malaria in Botswana  381
MAP 3-​21. Malaria in Brazil  383
MAP 3-​24. Malaria in Colombia  388
MAP 3-​26. Malaria in Ecuador  392
MAP 3-​28. Malaria in Ethiopia  394
MAP 3-​29. Malaria in India  398
MAP 3-​31. Malaria in Kenya  401
MAP 3-​32. Malaria in Mexico  404
MAP 3-​33. Malaria in Nicaragua  406
MAP 3-​35. Malaria in Panama  409
MAP 3-​37. Malaria in Peru  412
MAP 3-​38. Malaria in South Africa  416
MAP 3-​40. Malaria in Venezuela  421
TABLE 3-​8. Reliable supply regimens for the treatment of malaria  240
TABLE 3-​9. Considerations when choosing a drug for malaria prophylaxis  241
TABLE 3-​10. Drugs used in the prophylaxis of malaria  244
TABLE 3-​11. Half-​lives of malaria chemoprophylaxis drugs  248
TABLE 3-​12. Changing medications as a result of side effects during chemoprophylaxis  250
TABLE 3-​13. Food and Drug Administration recommendations for deferring blood donation in people returning
from malarious areas  251
TABLE 8-​4. Diseases for which VFR travelers are at increased risk, proposed reasons for risk variance, and
recommendations to reduce risks  586
TABLE 8-​6. Differences between CDC recommendations and US military’s use of malaria
chemoprophylaxis  619

TABLE 2-​4. Recommended intervals between administration of antibody-​containing products and
measles-​containing vaccine or varicella-​containing vaccine  35

MAP 3-​11. Areas with frequent epidemics of meningococcal meningitis  262
TABLE 3-​14. Meningococcal vaccines licensed in the United States  264



BOX 3-​4. World Health Organization, human rabies case definition  288
TABLE 3-​15. Criteria for preexposure immunization for rabies  290
TABLE 3-​16. Preexposure immunization for rabies  291
TABLE 3-​17. Postexposure immunization for rabies  292

Rickettsial and Related Infections

TABLE 3-​18. Classification, primary vector, and reservoir occurrence of rickettsiae known to cause disease
in humans  298
TABLE 8-​4. Diseases for which VFR travelers are at increased risk, proposed reasons for risk variance, and
recommendations to reduce risks  586

MAP 3-​12. Distribution of schistosomiasis  310
TABLE 8-​4. Diseases for which VFR travelers are at increased risk, proposed reasons for risk variance, and
recommendations to reduce risks  586

Sexually Transmitted Diseases

BOX 3-​5. Summary of sexual health recommendations for travelers  318
TABLE 8-​4. Diseases for which VFR travelers are at increased risk, proposed reasons for risk variance, and
recommendations to reduce risks  586

Tickborne Encephalitis
TABLE 3-​19. Tickborne encephalitis (TBE) vaccines licensed in Europe and Russia  329

MAP 3-​13. Estimated tuberculosis incidence rates  336
TABLE 3-​20. Estimated proportion of MDR TB cases in high-burden countries  338
TABLE 8-​4. Diseases for which VFR travelers are at increased risk, proposed reasons for risk variance, and
recommendations to reduce risks  586

TABLE 3-​21. Vaccines to prevent typhoid fever  344
TABLE 8-​4. Diseases for which VFR travelers are at increased risk, proposed reasons for risk variance, and
recommendations to reduce risks  586

Varicella (Chickenpox)
TABLE 2-​4. Recommended intervals between administration of antibody-​containing products and
measles-​containing vaccine or varicella-​containing vaccine  35

Yellow Fever
FIGURE 3-​2. Example International Certificate of Vaccination or Prophylaxis (ICVP)  362
FIGURE 3-​3. Medical Contraindication to Vaccination section of the International Certificate of Vaccination
or Prophylaxis (ICVP)  363
MAP 3-​14. Yellow fever vaccine recommendations in Africa  364
MAP 3-​15. Yellow fever vaccine recommendations in the Americas  365



MAP 3-​16. Yellow fever vaccine recommendations in Argentina  376

MAP 3-​17. Yellow fever vaccine recommendations in Bolivia  379
MAP 3-​20. Yellow fever vaccine recommendations in Brazil  382
MAP 3-​23. Yellow fever vaccine recommendations in Colombia  387
MAP 3-​25. Yellow fever vaccine recommendations in Ecuador  391
MAP 3-​27. Yellow fever vaccine recommendations in Ethiopia  393
MAP 3-​30. Yellow fever vaccine recommendations in Kenya  400
MAP 3-​34. Yellow fever vaccine recommendations in Panama  408
MAP 3-​36. Yellow fever vaccine recommendations in Peru  411
MAP 3-​39. Yellow fever vaccine recommendations in Venezuela  420
MAP 3-​41. Yellow fever vaccine recommendations in Zambia  423
TABLE 3-​22. Countries with risk of yellow fever virus (YFV) transmission  353
TABLE 3-​23. Countries with low potential for exposure to yellow fever virus (YFV)  354
TABLE 3-​24. Vaccine to prevent yellow fever  355
TABLE 3-​25. Contraindications and precautions to yellow fever vaccine administration  356
TABLE 3-​26. Countries that require proof of yellow fever vaccination from all arriving travelers  361
TABLE 3-​27. Categories of recommendations for yellow fever vaccination  373
TABLE 8-​4. Diseases for which VFR travelers are at increased risk, proposed reasons for risk variance, and
recommendations to reduce risks  586

BOX 3-​6. Zika in pregnancy  370

General Resources
BOX 1-​1. CDC contact information for clinicians  2
BOX 2-​9. About dietary supplements and unproven therapies  116
FIGURE 1-​1. CDC Travelers’ Health website homepage  4
MAP 1-​1. Estimated number of US air travelers received  14
TABLE 1-​1. Estimated number of US air passengers departing to the top 10 destination countries, 2015  14

Insect Avoidance
BOX 2-​4. Maximizing protection from mosquitoes and ticks  82
BOX 2-​5. Bed bugs and international travel  86
BOX 8-​6. Practical advice on personal protective measures for clinicians counseling long-​term travelers
and expatriates  609
FIGURE 2-​1. Sample repellency awareness graphic for skin-​applied insect repellents  84

Pretravel Consultation
BOX 8-​1. Key patient education points for the immunocompromised traveler  570
BOX 8-​2. Pretravel consultation checklist for pregnant travelers  577
TABLE 2-​1. Information necessary for a risk assessment during pretravel consultations  17
TABLE 2-​2. Vaccines to update or consider during pretravel consultations  19
TABLE 2-​3. Major topics for discussion during pretravel consultations  21



Water Treatment
TABLE 2-​10. Comparison of water disinfection techniques  73
TABLE 2-​11. Microorganism size and susceptibility to filtration  74
TABLE 2-​12. Summary of field water disinfection techniques  77


Cruise Ship Passengers

BOX 4-​1. Cruising down the Yangtze: what to consider  474
BOX 6-​1. Cruise travel health precautions  525

Health Care Workers

BOX 8-​4. Health care workers in extreme circumstances  589

Immigrants and Migrants

BOX 8-​8. Additional migrant health resources for clinicians  633
TABLE 8-​8. Top 10 countries of birth for newly arriving refugees and immigrants (from overseas locations),
fiscal year 2014  630
TABLE 8-​9. Recommended postarrival laboratory screening tests for immigrants and refugees receiving
medical care in the United States  635

TABLE 8-​1. Immunization of immunocompromised adults  559
TABLE 8-​2. Immunosuppressive biologic agents that preclude use of live vaccines  566

Infants and Children

MAP 7-​1. Breastfeeding support group locations  547
TABLE 2-​5. Recommended and minimum ages and intervals between vaccine doses  38

Long-​Term Travelers
BOX 8-​5. Key findings from a review on studies relevant to long-​term travelers and expatriates  608
BOX 8-​6. Practical advice on personal protective measures for clinicians counseling long-​term travelers
and expatriates  609
BOX 8-​7. Practical advice on malaria prophylaxis for long-​term travelers and expatriates  610

Medical Tourists
BOX 2-​6. Guiding principles on medical tourism  112
BOX 2-​7. Patient checklist for obtaining safe dental care during international travel  113
BOX 2-​8. Helpful resources on medical tourism  114

TABLE 8-​5. Differences between military populations and civilian traveling populations  616
TABLE 8-​6. Differences between CDC recommendations and US military’s use of malaria
chemoprophylaxis  619



Pregnant Travelers
BOX 8-​2. Pretravel consultation checklist for pregnant travelers  577
BOX 8-​3. Contraindications for travel during pregnancy  578

Returning Travelers
BOX 5-​1. Important elements of a medical history in an ill returned traveler  496
TABLE 5-​1. Illnesses associated with fever presenting in the first 2 weeks after travel  497
TABLE 5-​2. Common causes of fever, by geographic area  500
TABLE 5-​3. Common infections, by incubation period  501
TABLE 5-​4. Common clinical findings and associated infections  502
TABLE 5-​5. Ten most common skin lesions in returned travelers, by cause  508

TABLE 8-​7. Study-​abroad resources  623

Travelers with Chronic Illnesses

TABLE 8-​3. Special considerations for travelers with chronic medical illnesses  573

Travelers Visiting Friends and Relatives

TABLE 8-​4. Diseases for which VFR travelers are at increased risk, proposed reasons for risk variance, and
recommendations to reduce risks  586

List of Maps
Dengue, the Americas and the Caribbean (Map 3-​1)  163
Dengue, Africa and the Middle East (Map 3-​2)  164
Dengue, Asia and Oceania (Map 3-​3)  165
Hepatitis B (Map 3-​4)  188
Hepatitis C (Map 3-​5)  194
Hepatitis E (Map 3-​6)  200
Influenza, Avian (H5N1) (Map 3-​7)  208
Japanese encephalitis (Map 3-​8)  216
Malaria, Eastern Hemisphere (Map 3-​10)  236
Malaria, Western Hemisphere (Map 3-​9)  234
Malaria, Bolivia (Map 3-​18)  380
Malaria, Botswana (Map 3-​19)  381
Malaria, Brazil (Map 3-​21)  383
Malaria, Colombia (Map 3-​24)  388
Malaria, Ecuador (Map 3-​26)  392



Malaria, Ethiopia (Map 3-​28)  394

Malaria, India (Map 3-​29)  398
Malaria, Kenya (Map 3-​31)  401
Malaria, Mexico (Map 3-​32)  404
Malaria, Nicaragua (Map 3-​33)  406
Malaria, Panama (Map 3-​35)  409
Malaria, Peru (Map 3-​37)  412
Malaria, South Africa (Map 3-​38)  416
Malaria, Venezuela (Map 3-​40)  421
Meningococcal meningitis (Map 3-​11)  262
Schistosomiasis (Map 3-​12)  310
Tuberculosis (Map 3-​13)  336
Yellow fever, Africa (Map 3-​14)  364
Yellow fever, the Americas (Map 3-​15)  365
Yellow fever, Argentina (Map 3-​16)  376
Yellow fever, Bolivia (Map 3-​17)  379
Yellow fever, Brazil (Map 3-​20)  382
Yellow fever, Colombia (Map 3-​23)  387
Yellow fever, Ecuador (Map 3-​25)  391
Yellow fever, Ethiopia (Map 3-​27)  393
Yellow fever, Kenya (Map 3-​30)  400
Yellow fever, Panama (Map 3-​34)  408
Yellow fever, Peru (Map 3-​36)  411
Yellow fever, Venezuela (Map 3-​39)  420


Brazil destination map (Map 4-​5)  445
Burma (Myanmar) destination map (Map 4-​11)  469
China destination map (Map 4-​12)  473
China reference map (Map 3-​22)  386
Cuba destination map (Map 4-​6)  450
Dominican Republic destination map (Map 4-​7)  453
East Africa destination map (Map 4-​1)  427
Hajj destination map (Map 4-​2)  431
Haiti destination map (Map 4-​8)  456
India destination map (Map 4-​13)  479
Kilimanjaro destination map (Map 4-​4)  440
Mexico destination map (Map 4-​9)  460
Nepal destination map (Map 4-​14)  484
Peru destination map (Map 4-​10)  465
South Africa destination map (Map 4-​3)  437
Thailand destination map (Map 4-​15)  488
Vietnam destination map (Map 4-​16)  493


Editorial Staff
Editor in Chief: Gary W. Brunette
Chief Medical Editor: Phyllis E. Kozarsky
Medical Editors: Clive M. Brown, Nicole J. Cohen, Douglas H. Esposito, Mark D. Gershman,
Stephen M. Ostroff, Edward T. Ryan, David R. Shlim, Richard W. Steketee,
Michelle Weinberg, and Mary Elizabeth Wilson
Managing Editor: Megan Crawley O’Sullivan
Technical Editor: Ronnie Henry
Design and Production Editor: Kelly Holton
Editorial Assistant: Kelly Winter
Cartographer: R. Ryan Lash
Assistant Cartographer: C. Virginia Lee

CDC Contributors
Abanyie, Francisca Brooks, John T. Esposito, Douglas H. Green, Michael D.
Abe, Karon Brown, Clive M. Fischer, Marc Griffin, Patricia M.
Alexander, James P. Brunette, Gary W. Fitzgerald, Collette Hall, Aron J.
Ansari, Armin Burdette, Erin Flannery, Brendan Hawley, William A.
Appiah, Grace Burke, Heather Fox, LeAnne M. Hendricks Walters, Kate
Arboleda, Nelson Cantey, Paul T. Francois Watkins, Henry, Ronnie
Arguin, Paul M. Cardemil, Cristina V. Louise K. Herwaldt, Barbara L.
Armstrong, Paige Chen, Tai-​Ho Friedman, Cindy R. Hills, Susan L.
Averhoff, Francisco Chiller, Tom M. Fullerton, Katie Hlavsa, Michele C.
Baggett, Henry C. Choi, Mary Gaines, Joanna Holtzman, Deborah
Bair-​Brake, Heather Chosewood, Casey Galland, G. Gale Hunter, Jennifer C.
Ballesteros, Michael F. Clemmons, Nakia S. Galloway, Renee L. Iwamoto, Martha
Barbre, Kira A. Cochi, Stephen L. Garrison, Laurel E. Jackson, Brendan
Beavers, Suzanne Cohen, Nicole J. Gastañaduy, Paul A. Jentes, Emily S.
Beckman, Michele G. Cope, Jennifer Gee, Jay E. Jones, Jeffrey L.
Benenson, Gabrielle A. Czarkowski, Alan G. Geissler, Aimee L. Judd, Michael C.
Berro, Andre Dhara, V. Ramana Gerber, Susan I. Kersh, Gilbert J.
Blaney, David D. Dubray, Christine Gershman, Mark D. Kharod, Grishma A.
Bowen, Anna Duong, Krista Kornylo Gibbins, John Kitt, Margaret
Bresee, Joseph Ederer, David J. Goodson, James L. Knust, Barbara
Brogdon, William G. Erskine, Stefanie K. Gould, L. Hannah Kozarsky, Phyllis E.

Kroger, Andrew T. Mintz, Eric D. Rabe, Ingrid B. Teshale, Eyasu

Kutty, Preeta K. Montgomery, Susan Raczniak, Gregory A. Tiller, Rebekah
Lebo, Emmaculate J. Montiel, Sonia H. Reef, Susan E. Tiwari, Tejpratap S. P.
Lessa, Fernanda C. Morgan, Oliver W Regan, Joanna J. Traxler, Rita M.
Liang, Jennifer L. Moro, Pedro L. Reyes, Nimia L. Uribe, Carolina
Lippold, Susan A. Morof, Diane F. Reynolds, Megan R. Van Bogaert, Donna
LoBue, Philip Mullan, Robert J. Rollin, Pierre E. Villarino, Margarita E.
Lopez, Adriana S. Mutebi, John-​Paul Russell, Michelle Walker, Allison Taylor
Lopman, Ben Negron, Maria E. Schafer, Ilana J. Wallace, Ryan M.
Lyss, Sheryl Nelson, Christina A. Schmid, D. Scott Wassilak, Steven G. F.
MacNeil, Jessica R. Nelson, Noele P. Schneider, Eileen Waterman, Stephen H.
Mahon, Barbara E. Nguyen, Duc B. Sharp, Tyler M. Watson, John T.
Maloney, Susan A. Nicholson, William L. Shealy, Katherine R. Weinberg, Michelle S.
Marano, Nina Nickels, Leslie Skoff, Tami H. Weinberg, Nicholas
Marin, Mona O’Reilly, Ciara E. Sleet, David A. Weston, Emily J.
Marston, Chung K. Objio, Tina Sobel, Jeremy Winter, Kelly
Martin, Diana L. Paddock, Christopher D. Sotir, Mark J. Wong, Karen K.
Mast, Eric E. Patel, Manisha Staples, J. Erin Workowski, Kimberly
McCollum, Andrea M. Patimeteeporn, Calvin Steele, Stefanie F. Xiao, Lihua
McCotter, Orion Z. Perez-​Padilla, Janice Stoddard, Robyn A. Yeoman, Kristin
McFarland, Jeffrey Peters, Philip J. Stoney, Rhett J. Yoder, Jonathan S.
Mead, Paul S. Petersen, Brett W. Strikas, Raymond A.
Meites, Elissa Piacentino, John Tan, Kathrine R.
Meyer, Sarah A. Powers, Ann M. Tardivel, Kara

External Contributors
Adler, Tina Westat—National Center for Complementary and Integrative Health Clearinghouse,
Rockville, Maryland
Ansdell, Vernon E. University of Hawaii, Honolulu, HI
Atkinson, Gregory Teesside University, Middlesbrough, United Kingdom
Backer, Howard D. California Emergency Medical Services Authority, Sacramento, CA
Barbeau, Deborah Nicolls Tulane University, New Orleans, LA
Barnett, Elizabeth D. Boston University School of Medicine and Boston Medical Center, Boston, MA
Batterham, Alan M. Teesside University, Middlesbrough, United Kingdom
Benenson, Michael W. Armed Forces Research Institute of the Medical Sciences, Bangkok, Thailand (retired)
Boggild, Andrea K. University of Toronto, Toronto, Canada
Borwein, Sarah T. TravelSafe Medical Centre, Hong Kong, China
Carroll, I. Dale The Pregnant Traveler, Spring Lake, MI
Changizi, Roohollah United Family Hospital, subsidiary of United Family Healthcare, Beijing, China
Chen, Lin H. Mount Auburn Hospital—​Travel Medicine Center, Cambridge, MA, and Harvard
Medical School, Boston, MA



Connor, Bradley A. Weill Medical College of Cornell University, New York, NY

DeRomaña, Inés University of California System, Education Abroad Program, Santa Barbara, CA
Ejike-​King, Lacreisha US Food and Drug Administration, US Department of Health and Human Services,
Rockville, Maryland
Fairley, Jessica K. Emory University School of Medicine, Atlanta, GA
Forgione, Michael Keesler Medical Center, Keesler AFB, Mississippi
Freedman, David O. Shoreland, Inc., Milwaukee, WI
Fukuda, Mark Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
Gracia, J. Nadine Office of Minority Health, US Department of Health and Human Services,
Rockville, Maryland
Gushulak, Brian D. Migration Health Consultants, Cheltenham, Canada
Hackett, Peter H. Institute for Altitude Medicine, Telluride, CO, and Altitude Research Center,
University of Colorado Denver School of Medicine, Denver, CO
Hamer, Davidson H. Center for Global Health and Development Boston University; Department of
Global Health, Boston University School of Public Health and Section of Infectious
Diseases, Boston Medical Center, Boston, MA
Henderson, John United Nations consultant, Burma
Hochberg, Natasha S. Section of Infectious Diseases, Boston University School of Medicine, Boston, MA
Hyle, Emily P. Massachusetts General Hospital, Boston, MA
Kain, Kevin C. University of Toronto, Toronto, Canada
Keystone, Jay S. University of Toronto, Toronto, Canada
Kotton, Camille Nelson Massachusetts General Hospital and Harvard University, Boston, MA
LaRocque, Regina C. Massachusetts General Hospital and Harvard Medical School, Boston, MA
Law, Catherine National Center for Complementary and Integrative Health, National Institutes of
Health, Bethesda, MD
Libman, Michael McGill University, Centre for Tropical Disease, Montreal, Canada
Magill, Alan J.* Walter Reed Army Institute of Research, Experimental Therapeutics, Silver
Spring, MD
Neumann, Karl Weill Medical College of Cornell University and New York Presbyterian Hospital/​
Cornell Medical Center, New York, NY
Nilles, Eric J. Division of Health Securities and Emergencies, World Health Organization,
Suva, Fiji
Nord, Daniel A. Divers Alert Network, Durham, NC
Ostroff, Stephen M. Food and Drug Administration, Silver Spring, MD
Parker, Salim Dee Bee Medical Centre, Cape Town, and South African Society of Travel Medicine,
Johannesburg, South Africa
Pedone, Bettina N. Arthur Ashe Student Health & Wellness Center, University of California, Los
Angeles, CA
Pogemiller, Hope University of Minnesota Medical School, Minneapolis, MN
Prinz, Robyn K. US Department of State Bureau of Consular Affairs, Washington D.C.
Rhodes, Gary Center for Global Education, University of California, Los Angeles, CA
Riddle, Mark S. Naval Medical Research Center, Silver Spring, MD
Rosselot, Gail A. Travel Well of Westchester, Inc., Briarcliff Manor, NY
Ryan, Edward T. Massachusetts General Hospital and Harvard University, Boston, MA
Sampson, Dana M. Office of Minority Health, US Department of Health and Human Services,
Rockville, Maryland
Shlim, David R. Jackson Hole Travel and Tropical Medicine, Jackson Hole, WY

* Deceased



Shurtleff, David National Center for Complementary and Integrative Health, National Institutes of
Health, Bethesda, MD
Staat, Mary Allen International Adoption Center, Cincinnati Children’s Hospital Medical Center,
Cincinnati, OH
Taggart, Linda R. University of Toronto, Toronto, Canada
Takiguchi, Rodd Department of Dermatology, Kaiser Permanente, Honolulu, Hawaii
Thompson, Andrew University of Liverpool, Liverpool, United Kingdom
Valk, Thomas H. VEI Inc., Marshall, VA
Van Tilburg, Christopher Providence Hood River Memorial Hospital, Hood River, OR
Wangu, Zoon Department of Pediatric Infectious Diseases, Boston Medical Center, Boston, MA
Wilson, Mary Elizabeth Harvard School of Public Health, Boston, MA
Wu, Henry M. Emory University, Department of Medicine, Atlanta, GA
Youngster, Ilan Children’s Hospital Boston and Harvard University, Boston, MA

All contributors have signed a statement indicating that they have no conflicts of interest with the subject
matter or materials discussed in the document(s) that they have written or reviewed for this book and that the
information that they have written or reviewed for this book is objective and free from bias.



The CDC Yellow Book 2018:  Health Information • Elise Beltrami, Pamela Diaz and Scott
for International Travel editorial team grate- Santibanez for their extensive review of
fully acknowledges all the authors and review- the text.
ers for their commitment to this new edition.
We extend sincere thanks to the following peo-
• Courtney Ware, Aida Sawadogo, Laurie
Dieterich and Crystal Polite for their assis-
ple for their contributions to the production of
tance in preparing the text for publication.
this book:

To stay on the cutting edge of travel health infor- Centers for Disease Control and Prevention
mation, this latest edition of the CDC Yellow Anne Schuchat, MD, Acting Director
Book: Health Information for International Travel National Center for Emerging and Zoonotic
has been extensively revised. The book serves as Infectious Diseases
a guide to the practice of travel medicine, as well Rima Khabbaz, MD, Acting Director
as the authoritative source of US government rec- Division of Global Migration and
ommendations for immunizations and prophy- Quarantine
laxis for foreign travel. As international travel Martin S. Cetron, MD, Director
continues to become more common in the lives of Gary W. Brunette, MD, MS, Chief,
US residents, having at least a basic understand- Travelers’ Health Branch
ing of the medical problems that travelers face Phyllis E. Kozarsky, MD, Expert Consultant,
has become a necessary aspect of practicing med- Travelers’ Health Branch
icine. The goal of this book is to be a comprehen- Megan Crawley O’Sullivan, MPH,
sive resource for clinicians to find the answers to Health Com­munications Specialist,
their travel health–​related questions. Travelers’ Health Branch

Alan J. Magill passed away on September 19, 2015, just days after work began on the CDC Yellow
Book 2018. He was a key figure in the evolution of this publication, serving as an author and medical
editor for three editions. Over the years, he provided invaluable insight and guidance as a singularly
experienced and knowledgeable contributor. The editorial board of the CDC Yellow Book respectfully
dedicate this edition to Alan.

In Memoriam: A Tribute to Alan J. Magill

Alan Magill and I  were asked to become co-╉editors of the Yellow Book at the same time, during the
Conference of the International Society of Travel Medicine in Vancouver, BC, in 2009. The next day
we drove together from Vancouver to the ISTM Executive Board meeting in Whistler, and during that
3-╉hour trip, we discussed how we might revise the Yellow Book to make it more relevant to travel
medicine practitioners. It was one of the more enjoyable conversations of my life.

Whatever Alan was involved in always seemed to go smoother, be more relevant, and even more fun.
At that point in time, Alan was the president-╉elect of the International Society of Travel Medicine. He
would subsequently serve as the president of the American Society of Tropical Medicine and Hygiene,
becoming the first person to be president of both societies. During a 26-╉year career in the US Army
Medical Corps, Alan focused mainly on malaria and leishmaniasis, but his research interests and
projects spanned an extraordinary range, including diagnostics, pharmaceuticals, and vaccine devel-
opment. He carried with him a nagging curiosity about the history of disease, and he often delved into
original sources of research that informed our present practice in new ways. Invariably kind, enthusias-
tic, supportive, tireless, and insightful, Alan improved any project with which he was involved, includ-
ing the Yellow Book.

Upon retiring from the military in 2012, Alan became the Malaria Program Director for the Gates
Foundation, charged with designing a strategy that could lead to the elimination of malaria in the
world. He had already played a large role in helping to shape an international strategy in this regard
when he died suddenly on September 19, 2015, near his home in Seattle, leaving behind his wife
and two daughters, and a devastated string of colleagues and admirers. Although tributes often end
with the words, “He will be missed,” in Alan’s case, we are left wondering what the world has missed
and what might have happened if he had been able to stay with us for many more years. He was
62 years old.

David R. Shlim, MD
Medical Editor of the Yellow Book
Recent Past-╉President of the ISTM

Phyllis E. Kozarsky

TRAVEL HEALTH having a variety of preexisting health concerns

The number of people traveling internation- and conditions. The infectious disease risks that
ally has continued to grow substantially in the travelers face are dynamic—​some travel desti-
past decade. According to the World Tourism nations have become safer, while in other areas,
Organization, there were 1.2 billion worldwide new diseases have emerged and other diseases
international tourist arrivals in 2015, an increase have reemerged.
of 4% from 2013; 50  million more people spent The risk of becoming ill or injured during inter-
a night at an international destination than national travel depends on many factors, such as
in 2014. In 2015, US residents made more than the region of the world visited, a traveler’s age and
73 million trips with at least 1 night outside the health status, the length of the trip, and the diver-
United States. The importance of protecting the sity of planned activities. CDC provides interna-
health of individual travelers, as well as safe- tional travel health information to address the
guarding the health of the communities to which range of health risks a traveler may face, with the
they return, cannot be overstated. International aim of assisting travelers and clinicians to bet-
travel takes on many forms, including tourism, ter understand the measures necessary to pre-
business, study abroad, research, visiting friends vent illness and injury during international travel.
and relatives, ecotourism, adventure, medi- This publication and the CDC Travelers’ Health
cal tourism, mission work, and responding to website (www.cdc.gov/​travel) are 2 primary ave-
international disasters. Travelers are as unique nues of communicating CDC’s travel health
as their itineraries, covering all age ranges and recommendations.



BOX 1-​1.   CDC contact information for clinicians

• After hours/​weekends/​
holidays: 770-​488-​7100
Online parasitic diseases diag-
All topics for clinicians and gen- • State or local health nostic assistance service for
eral public (English and Spanish) departments may be able to laboratorians, pathologists, and
assist: www.cdc.gov/​mmwr/​ other health professionals
• 8 am to 8 pm Eastern, international/​relres.html
M–​F: toll-​free at 800-​CDC-​ • www.cdc.gov/​dpdx/​contact.
INFO (800-​232-​4636) DENGUE html
• E-​mail form: www.cdc.gov/​info
Dengue diagnostic testing
CDC EMERGENCY Diagnostic and treatment
OPERATIONS CENTER • 8 am to 5 pm Atlantic (office assistance
Emergency or urgent patient in Puerto Rico),
M–​F: 787-​706-​2399 • 8 am to 4:30 pm Eastern,
care assistance (Note:This line is
• After hours/​weekends/​ M–​F: 404-​639-​1075
not intended for use by the general
holidays: 770-​488-​7100 • Emergency consultation
• Clinical/​laboratory after hours/​weekends/​
• Available 24 hours per day, guidance: www.cdc.gov/​ holidays: 770-488-​7100, ask
7 days per week: 770-​488-​7100 Dengue/​clinicalLab/​index. for an on-​call clinician in
html Rickettsial Diseases
agents and drugs Assistance with diagnosis or Diagnosis
• Formulary:www.cdc.gov/​ management of suspected cases
Consultation for diagnosis and
laboratory/​drugservice/​ of malaria
reporting suspected cases in
formulary.html • 9 am to 5 pm Eastern, or requiring evacuation to the
• 8 am to 4:30 pm Eastern, M–​F: 770-​488-​7788 or toll-​free United States
M–​F: 404-​639-​3670 at 855-​856-​4713
• After hours/​weekends/​ • 8:30 am to 5:30 pm Eastern,
• Emergency consultation M–​F: 404-​639-​1115
holidays: 770-​488-​7100 after hours/​weekends/​
• E-​mail: drugservice@cdc.gov • Emergency consultation
holidays: 770-488-​7100, ask
after hours/​weekends/​
for a Malaria Branch clinician
CHIKUNGUNYA, JAPANESE holidays: 770-​488-​7100
YELLOW FEVER Requests for ribavirin through
Assistance with diagnostic testing Hotline the Food and Drug Administration
for these diseases and for ques- Assistance with evaluation and (FDA) from Valeant
tions about antibody response to treatment of patients suspected Pharmaceuticals
yellow fever vaccination to have a parasitic disease • Providers should
• 8 am to 4 pm Eastern, request through FDA at
• Division of Vectorborne
Diseases, 8 am to 4:30 pm M–​F: 404-​718-​4745 301-​736-​3400
Mountain, M–​F: 970-​221-​6400 • Emergency consultation after • Simultaneously notify Valeant
hours/​weekends/​holidays: at 800-​548-​5100, ext. 5
• Viral Special Pathogens Branch
can also assist for tickborne 770-​488-​7100, ask for an on-​call (domestic) or 949-​461-​6971
encephalitis, 8:30 am to 5:30 pm clinician in Parasitic Diseases (international)
Eastern, M–​F: 404-​639-​1115 • E-​mail: parasites@cdc.gov


HISTORY AND ROLES OF THE evidence-​based and supported by best practices.

YELLOW BOOK Internal text citations have not been included;
CDC Health Information for International Travel however, a bibliography is included at the end of
(“The Yellow Book”) has been a trusted resource each section for those who would like to obtain
since 1967. Originally, it was a small pamphlet
published to satisfy the International Sanitary
more detailed information. The CDC Travelers’
Health program and the CDC Foundation are
Regulations’ requirements and the International pleased to partner with Oxford University Press,
Health Regulations (IHR), adopted by the World Inc., to publish the 2018 edition. In addition to the
Health Organization (WHO) in 1951 and 1969, printed copy, a searchable, online version of the
respectively; the IHR were completely revised in Yellow Book can be found on the CDC Travelers’
2005. The purpose of the IHR is to ensure maxi- Health website (www.cdc.gov/​yellowbook).
mum security against the international spread of
diseases, with minimum interference with world
travel and commerce. A copy of the current IHR
Questions, comments, and suggestions for CDC
and supporting information can be found on the
Travelers’ Health, including comments about
WHO website (www.who.int/​csr/​ihr/​en).
this publication, may be made through the
In addition to reporting public health events
CDC-​INFO contact center, toll-​free at 800-​CDC-​
of international concern, the United States must
INFO (800-​232-​4636) 8 am to 8 pm Eastern Time
also inform the public about health requirements
(Monday–​Friday, closed on holidays) or by visit-
for entering other countries, such as the neces-
ing www.cdc.gov/​info to submit your question
sity of being vaccinated against yellow fever. The
through an online form.
Yellow Book and the CDC Travelers’ Health web-
site aim to communicate these requirements Pretravel or Post-​travel
under the IHR (2005). Although this publication Clinical Questions
includes the most current available information Since CDC is not a medical facility, clinicians
at the time of printing, requirements can change. needing assistance with preparing patients for
The CDC Travelers’ Health website (www.cdc. international travel should consider referral to a
gov/​travel) may be checked for regularly updated travel clinic or a clinic listed on the International
information to ensure that requirements for inter- Society of Travel Medicine (ISTM) website (www.
national travel are known and met. istm.org).
The Yellow Book is written primarily for clini- Clinicians with post-​ travel health questions
cians, including physicians, nurses, and pharma- regarding their patients may consider referral to
cists. Others, such as people in the travel industry, a clinic listed on the ISTM website, the American
multinational corporations, missionary and vol- Society of Tropical Medicine and Hygiene website
unteer organizations, and individual travelers, can (www.astmh.org), or a medical university with
also find a wealth of information here. specialists in infectious diseases.
This text is authored by subject-​­ matter Because of the complexity of some travel-​
experts from within CDC and outside the related diseases, Box 1-​1 lists contact information
agency. The guidelines presented in this book are for providers needing clinical assistance.

1. United Nations World Tourism Organization. Department of Commerce; 2016 [cited 2016 Mar. 21];
UNWTO World Tourism Barometer, Vol. 14 Available from: http://​travel.trade.gov/​tinews/​archive/​
(March). Madrid: United Nations World Tourism tinews2016/​20160321.asp.
Organization; 2016 [cited 2016 Mar. 2]; Available from: 3. World Health Organization. International Health
http://​www.e-​unwto.org/​toc/​­wtobarometereng/​14/​2. Regulations (2005). Geneva: World Health
2. US Department of Commerce, Office of Travel and Organization; 2008 [cited 2016 Apr. 11]; 2nd: Available
Tourism Industries. 2015 Monthly US Outbound Air from: http://​www.who.int/​ihr/​publications/​
Travel to International Regions. Washington, DC: US 9789241596664/​en/​.




Ronnie Henry

TRAVELERS’ HEALTH WEBSITE provider, and other resources for travelers

The CDC Travelers’ Health website (www.cdc. and clinicians. The home page (Figure  1-​1)
gov/​travel) offers destination-​specific vaccine includes separate portals for travelers and
and travel health recommendations, travel clinicians. Users can also select special popu­
notices, help with finding a travel medicine lations (such as “traveling with children” or

FIGURE 1-​1 .   CDC Travelers’ Health website homepage


“immune-​compromised travelers”) to receive Travel Notices

customized health recommendations. CDC posts travel health notices about disease
outbreaks and international events (such as nat-
Destination Pages ural disasters or mass gatherings) that may affect
The most popular feature of the Travelers’
Health website are the “destination pages,” each
the health of travelers. The notices include infor-
mation about what the situation or health risk is,
with a clinician and traveler view. Destination who is affected, how travelers can protect their
pages provide health recommendations for a health, and links for more information. Travel
particular destination and include the follow- health notices and information about travel
ing information: notice categories can be found at wwwnc.cdc.
• Vaccine and medicine recommendations gov/​travel/​notices.

• Patient counseling information (called “Stay MOBILE APPLICATIONS

Healthy and Safe” on the destination pages CDC has developed 2 mobile applications for
and includes information on preventing travelers, Can I  Eat This? and TravWell, in addi-
foodborne and vectorborne disease and tion to the mobile version of the Yellow Book.
avoiding injuries) All are available for iOS and Android devices and
• Healthy travel packing list can be accessed from wwwnc.cdc.gov/​travel/​page/​
• Travel health notices
• Post-​travel health information Can I Eat This?
CDC’s Can I  Eat This? application helps interna-
tional travelers avoid travelers’ diarrhea by guid-
Information Centers ing their food and drink choices. Travelers select
Resources for clinicians (wwwnc.cdc.gov/​travel/​ the country they are in and answer a few simple
page/​clinician-​information-​center) includes clini- questions about what they are eating or drink-
cal updates on travel medicine–​related topics and ing, and the application will tell them whether
continuing education courses on travel medicine. it is likely to be safe. In addition to helping guide
Resources for travelers (http://​wwwnc.cdc. their on-​the-​spot decisions, Can I  Eat This? also
gov/​travel/​page/​resources-​for-​travelers) provides teaches travelers general principles regarding safe
printable fact sheets that cover over 40 travel food and water. All recommendations are stored
health topics written in plain language for the locally on the user’s device, so no international
international traveler. Topics include travel health data connection is needed to use the application
insurance, jet lag, motion sickness, cruise ship when traveling.
travel, and travel to high altitudes.
Resources for the travel industry (wwwnc. TravWell
cdc.gov/​travel/​page/​travel-​industry-​information-​ CDC’s TravWell is a companion application to the
center) contains guidelines for the air travel and Travelers’ Health destination pages. It allows users
cruise ship industries. It includes information on to build an itinerary and receive destination-​
reporting illnesses and deaths among travelers, specific vaccine and medicine recommendations.
managing ill crew members, and other guidance. For each itinerary, it also generates a customiz-
able, destination-​specific to-​do list and packing
Disease Directory list. TravWell also prompts users to set reminders
The disease directory (wwwnc.cdc.gov/​travel/​ for healthy behaviors, such as taking malaria pro-
diseases) is a list of diseases that may be related phylaxis or getting booster doses of vaccines. It
to travel. It provides a resource on rare as well as also provides users with a place to store electronic
common infections, the risk to travelers, and what copies of health-​related travel documents, such as
travelers can do to prevent them. prescriptions or vaccination records.



Allison Taylor Walker, Regina C. LaRocque, Mark J. Sotir

Travelers are an epidemiologically ­ important of travelers. Often, these studies were conducted
population because of their mobility, their
­ >20  years ago and might be of limited relevance
potential for exposure to diseases outside their to current travelers. Furthermore, these studies
home country, and the possibility that they may use a variety of methodologic designs, each with
carry nonendemic diseases between countries. its own set of strengths and weaknesses, making
International tourist arrivals were 1.2 billion in the findings difficult to compare or combine. They
2015 and are projected to increase to almost 2 bil- have also, for the most part, only examined a few
lion by 2030, so the public health impact of travel key diseases or conditions and have combined
will likely only increase. The destinations of trav- all travelers regardless of destination or purpose
elers are also changing. Increased travel to des- of travel. Many have been single-​clinic or single-​
tinations in Asia (arrivals up 5% from 2014 to destination studies that lead to conclusions that
2015)  and the Middle East (arrivals up 3% from do not apply to groups of travelers with different
2014 to 2015) and anticipated increases in travel local, national, or cultural backgrounds.
to Africa will place more travelers at risk for a vari- A number of factors are relevant to epidemio-
ety of travel-​related conditions, including malaria, logic data on travel-​related diseases and adverse
dengue, measles, and other tropical or vaccine-​ health events. First, the characteristics of the dis-
preventable infections. ease itself must be considered, including mode of
The risk of travel-​related illness varies depend- transmission, incubation period, signs and symp-
ing on destination and traveler characteristics. toms, duration of illness, and diagnostic testing.
Existing information regarding the actual risk for Second, the presence, frequency, seasonality, and
travelers (often expressed as number of events geographic distribution of the disease need to be
per 100,000 travelers) is limited for several rea- assessed; these might change over time because
sons. It is difficult to obtain an accurate numera- of outbreaks, emergence or reemergence in new
tor (number of cases of disease among travelers) areas or populations, successful public health
and denominator (number of travelers overall or interventions, or other factors. Third, travelers
travelers to a specific destination). Many travel- represent a unique subset of people, and their
ers who become infected will have returned to exposures, behaviors, and disease susceptibility
their home countries by the time they develop might differ dramatically from those of the local
symptoms so will not be included in the visited population at a tourist destination.
country’s surveillance data. Similarly, diseases Along with demographic characteristics, addi-
with short incubation periods or brief durations tional travel-​specific factors that should be con-
may have resolved by the time a traveler returns sidered include trip length, destinations (both
home and thus may not be counted in surveil- current and previous), specific travel itineraries,
lance data of the traveler’s country of origin. If the use of preventive measures, and purpose of travel.
illness is mild, the traveler may never seek health Fourth, travelers themselves are a heterogeneous
care, or diagnostic tests may not be performed group, and different subgroups of travelers might
to accurately diagnose the cause. Travelers often have different risks because of activities, behav-
visit multiple locations, and it may be difficult to iors, and other factors during travel. For exam-
determine the location in which the exposure ple, travelers who are visiting friends and relatives
occurred. (VFR travelers) have consistently demonstrated
Frequently quoted studies on the incidence higher proportions of serious febrile illness, par-
of infection in travelers are based on extrapola- ticularly malaria, when compared with other
tions of limited data collected in limited samples types of travelers.


During the past 2 decades, the most rele- malaria prophylaxis. Post-​travel data from the
vant data on travel-​related disease occurrence GeoSentinel network of 53 clinics around the
have come from surveillance of travelers them- world collected from 2007 through 2011 indicate
selves. Data on disease incidence in local popula- that Asia (33%) and sub-​Saharan Africa (27%)
tions may identify the most important diseases to
monitor within a country, but relevance of such
were the most common regions where travel-​
related illnesses were acquired. Malaria, dengue,
data to travelers—​who have different risk behav- enteric fever, spotted-​fever group rickettsioses,
iors, eating habits, accommodations, knowledge chikungunya, and nonspecific viral syndromes
of preventive measures, and activities—​is usually were the most frequent contributors to the acute
limited. Surveillance data that are either focused systemic febrile illness category. Falciparum
on travelers or on illnesses that affect travelers are malaria was most commonly acquired in West
more useful in describing travel-​related disease Africa, while enteric fever was most often con-
patterns and risks. tracted on the Indian subcontinent; leptospi-
Data collected by the Global TravEpiNet rosis, scrub typhus, and murine typhus were
(GTEN) network of pretravel visits in health clin- principally acquired in Southeast Asia. Common
ics across the United States provide a snapshot skin and soft tissue infections, mosquito bites
into the types of travelers seeking pretravel health (often infected), and allergic dermatitis were the
care and their travel practices. Health care pro- most common skin conditions affecting travel-
viders need to understand the epidemiologic fea- ers. Among the more exotic diagnoses, the most
tures of the traveling population to guide their important were hookworm-​ related cutaneous
pretravel recommendations and post-​travel eval- larva migrans, leishmaniasis, myiasis, and tungi-
uations. In examining GTEN data collected from asis. The relative frequency of many diseases var-
2009 through 2011, 13,235 travelers ranged in age ied by travel destination and reason for travel,
from 1 month to 94 years (median 35 years). The and VFR travelers had a disproportionately high
median duration of travel that prompted the pre- prevalence of serious febrile illness (malaria) and
travel evaluation was 14  days, although 22% of low rates of seeking advice before travel (18%).
travelers were taking trips of >28  days, and 3% Only 40% of all ill GeoSentinel travelers reported
of the travelers were taking trips of >6  months. pretravel medical visits.
A total of 75% were traveling to malaria-​endemic Investigations of travel-​related outbreaks can
countries, and 38% were visiting yellow fever–​ also provide data on epidemiologic patterns of
endemic countries. Immunocompromising con- travel-​
related illness. Outbreaks in travelers to
ditions, such as HIV infection and AIDS, organ the Caribbean are a reminder of travel-​associated
transplantation, or receipt of immunocompro- risk of illness. Incidence of chikungunya was eval-
mising medications, were present in 3% of GTEN uated among 102 participants returning from the
travelers. Dominican Republic in 2014. Forty-​ two (41%)
Post-​travel illness surveillance data are col- had evidence of recent chikungunya infection,
lected by the GeoSentinel Global Surveillance and of those, 37 (90%) reported rash or joint pain.
Network, a worldwide data collection and com- Outbreaks in travelers are sentinels to warn the
munication network composed of International international community of prevalent or unrec-
Society of Travel Medicine (ISTM) member ognized illnesses in destination countries. An
travel and tropical medicine clinics. Analyses of outbreak investigation of sarcocystosis in trav-
these data are used to describe the relationships elers returning from Tioman Island, Malaysia, in
between travel and travel-​related illness in spe- 2011–​2012 led to continued monitoring for addi-
cific subpopulations of travelers. A  2013 sum- tional cases and identified asymptomatic infection
mary of GeoSentinel data found that diarrheal, and late presentation. Diseases identified through
systemic, and respiratory illnesses are medical tourism, a booming yet unregulated
the most common diagnoses reported. Another industry, can also highlight local transmission of
study found that >20% of travelers visiting malar- health care–​associated infections. Mycobacterium
ious areas reported inconsistent or no use of abscessus infections in postsurgical wounds of


medical tourists returning from the Dominican advice to their travelers. Clinical networks and
Republic and Venezuela have been reported. surveillance systems provide epidemiologic data
Familiarity with the epidemiology and preva- on new and prevalent global infectious disease
lence of these and other infections, coupled with threats. These data contribute to the evidence
1 demographic information on travelers and their
particular travel details, can help clinicians pro-
base in this growing field and allow for informed
preparation before travel, as well as clinical aware-
vide optimal health-​ related information and ness of travel epidemiology.

1. Adachi K, Coleman MS, Khan N, Jentes ES, Arguin P, 6. Leder K, Torresi J, Libman MD, Cramer JP, Castelli F,
Rao SR, et al. Economics of malaria prevention in Schlagenhauf P, et al. GeoSentinel surveillance of illness
US travelers to West Africa. Clin Infect Dis. 2014 in returned travelers, 2007–​2011. Ann Intern Med. 2013
Jan;58(1):11–​21. Mar. 19;158(6):456–​68.
2. CDC. Malaria surveillance—​United States, 2011. MMWR 7. Millman AJ, Esposito DH, Biggs HM, Decenteceo M,
Surveill Summ. 2013 Nov 1;62(5):1–​17. Klevos A, Hunsperger E, et al. Chikungunya and dengue
3. Esposito DH, Stich A, Epelboin L, Malvy D, Han PV, virus infections among United States community service
Bottieau E, et al. Acute muscular sarcocystosis: an inter- volunteers returning from the Dominican Republic.
national investigation among ill travelers returning from Am J Trop Med Hyg. 2014 Mar. 14;64(6):1336–​41.
Tioman Island, Malaysia, 2011–​2012. Clin Infect Dis. 2014 8. Sharp TM, Pillai P, Hunsperger E, Santiago GA,
Nov 15;59(10):1401–​10. Anderson T, Vap T, et al. A cluster of dengue cases in
4. Harvey K, Esposito DH, Han P, Kozarsky P, Freedman DO, American missionaries returning from Haiti. Am J Trop
Plier DA, et al. Surveillance for travel-​related Med Hyg. 2010 Jan.;86(1):6–​22.
disease—​GeoSentinel Surveillance System, United 9. Sotir M, Freedman D. Basic epidemiology of infec-
States, 1997–​2011. MMWR Surveill Summ. 2013 Jul. tious diseases, including surveillance and reporting.
19;62:1–​23. In: Zuckerman J, Leggat P, Brunette G, editors. Essential
5. LaRocque RC, Rao SR, Lee J, Ansdell V, Yates JA, Travel Medicine. Chichester (UK): John Wiley &
Schwartz BS, et al. Global TravEpiNet: a national Sons; 2015.
consortium of clinics providing care to inter- 10. United Nations World Tourism Organization. UNWTO
national travelers—analysis of demographic Tourism Highlights, 2016 ed. [Internet]. Madrid: World
characteristics, travel destinations, and pre- Tourism Organization; 2016 [cited 2016 Mar. 26].
travel healthcare of high-​risk US international Available from: http://​media.unwto.org/​press-​release/​
­travelers, 2009–2011. Clin Infect Dis. 2012 Feb. 2016-​01-​18/​international-​tourist-​arrivals-​4-​reach-​
15;54(4):455–​62. record-​12-​billion-​2015.


David R. Shlim, Alan J. Magill*

INTRODUCTION and travelers focus on fully validated by national

Numerous international, recommendations for and international authori-
national, and professional immunizations, prophylac- ties. Finally, vast quantities
organizations publish guide- tic medications, and self-​ of unregulated opinions are
lines and recommendations treatment regimens (such as published on the Internet.
that assist travel health provid- those for travelers’ diarrhea). People new to travel medi-
ers in giving the best possible Guidelines come from many cine may not be aware of the
advice to prospective travelers. sources. A regulatory agency decision-​making process
The CDC Yellow Book is one in each country must review or the source information
example of published recom- and approve an application that results in formal rec-
mendations. However, it is from the sponsor of a prod- ommendations from these
quickly apparent to both clini- uct in order for the product organizations.
cians and patients that guide- to be commercially distrib-
lines and recommendations uted. Regulatory authorities Regulatory
differ, sometimes dramatically. review data from prelicen- Authorities
Conflicting messages from sure clinical trials and also Countries typically have
authoritative sources may con- assess the manufacturing a national regulatory
fuse patients and clinicians and process. International orga- authority which acts as
undermine the credibility of the nizations such as the World the government body that
source. It can be unsettling for Health Organization (WHO) approves vaccines and
patients to receive travel med- promote their own sets of drugs. In the United States,
icine advice, vaccines, and an guidelines. At national levels, this is the Food and Drug
antimalarial drug prescription agencies such as CDC make Administration (FDA). For the
from a provider, only to find that recommendations for the vaccines and medications
the recommendations conflict use of approved vaccines and commonly prescribed in a
with what they have obtained medications for travelers. pretravel consultation, pro-
from other sources or even In addition, professional viders are expected to use
heard from other advisors. The organizations may create the products in accordance
skillful travel health provider consensus clinical practice with the product label as
will be able to help the traveler guidelines based on pub- approved by the FDA. The
run this gauntlet of conflicting lished medical literature product label is a valuable
advice by knowing more about and expert opinion. Travel source of information that
why guidelines differ. medicine–​specific subscrip- is accurate at the time it is
tion services use experts to published. Manufacturers
HOW ARE organize and present travel submit a detailed application
GUIDELINES medicine recommendations that undergoes rigorous,
CREATED? for clinicians. However, these multidisciplinary review.
Most guidelines of interest services can use information The approved product label
to travel health providers and sources that may not be reflects the information

* Deceased.




provided by the manufac- US National from their membership.

1 turer in response to the Organizations These practice guidelines
requirements specified by a CDC provides recommen- typically follow an evidence-​
large body of regulatory law dations for travel health and based medicine approach
developed over many years. publishes those recommen- that links recommendations
Since each country has dations in this book. Subject-​ to the strength and quality
different laws and require- matter experts at CDC of the evidence as assessed
ments, approved products review information in their by the committee members.
and their product labels area of expertise and for- The Infectious Diseases
may differ from country to mulate recommendations. Society of America has
country. This difference is For vaccines, the Advisory published a travel medicine
then reflected in the national Committee on Immunization practice guideline that many
guidelines that relate to that Practices (ACIP) develops find useful.
product. written recommendations
for the administration of Peer-​Reviewed
International vaccines, including travelers’ Medical Literature
Organizations vaccines, to children and and Open Sources
Travelers’ health informa- adults in the civilian popu- As experience with a vaccine
tion is provided by WHO’s lation. Recommendations or a drug is acquired over
publication International include age for vaccine the years, these results
travel and health (the “Green administration, number of are often published in the
Book”) and also in the doses and dosing interval, peer-​reviewed medical lit-
WHO International Health and precautions and con- erature. In addition, people
Regulations 2005. The traindications. ACIP, which who use these products gain
Green Book is currently is the only entity appointed experience over time and
out of print; however, WHO by the federal government develop their own opinions
updates factual or evidence-​ to make such recommenda- (“experience-​based medi-
based essential information tions, consists of 15 experts cine”). The data that would
on the International travel in fields associated with be most useful in deciding
and health website (www. immunization who have how to use a vaccine or
who.int/​ith). Countries with been selected to provide medication may not be avail-
less-​developed or nonex- advice and guidance to the able in published reports, so
istent regulatory agencies Department of Health and expert opinion attempts to
often default to the WHO Human Services and CDC interpret available informa-
guidelines, while more-​ on the control of vaccine-​ tion or provide background
developed countries with preventable diseases perspective.
resources devoted to trav­ (Box 2-​1). The use of medications to
elers’ health may be aware treat or prevent disease is up
of the WHO recommenda- Professional to the discretion of the pre-
tions but may not be able Organizations scribing health practitioner.
to reconcile WHO recom- Professional organizations An example is whether
mendations with their own often develop, write, and to provide travelers with
country’s recommendations publish practice guidelines empiric treatment for travel-
in every situation. using committees of experts ers’ diarrhea, and if so, what


medication to recommend antimalarial drugs commer- States, a booster of the

and what course to pre- cially available worldwide, polysaccharide vaccine is

scribe. The travel medicine the process for regulatory recommended after 2 years,
practitioner needs to review approvals varies greatly. but in most European coun-
the available literature to For example, registering a tries, a booster is recom-
keep up with changing anti- new vaccine or antimalarial mended after 3 years. In the
biotic resistance and the drug in the United States is a United States, a packet of
epidemiology of diarrhea in costly and rigorous process. 4 oral typhoid capsules
various destinations. If the market is insufficient is dispensed, whereas in
to justify the expense of Europe, 3 doses are con-
WHY DO registration, then a commer- sidered adequate. The reg-
GUIDELINES cial company may not seek ulatory agencies may have
DIFFER? registration in a particular reviewed the same data and
Guidelines in different coun- country. The standards for drawn different conclusions,
tries and organizations may licensure vary, and what may or they may have reviewed
differ in substantial ways. be sufficient for one regula- different data at separate
Some of the reasons why tory authority may not suffice times and reached different
guidelines differ include for another. For example, conclusions. Regulatory sub-
availability of products in dif- primaquine, an option for missions to various agencies
ferent countries, a different malaria chemoprophylaxis rarely are ready and occur at
cultural perception of risk, in the United States, is not the same time; therefore, the
lack of evidence (or differing registered or commercially data available for review by
interpretations of the same available in Switzerland. each agency may not be the
evidence), and sometimes Atovaquone-​proguanil was same, for legitimate reasons.
just honest differences in available for malaria che-
opinion among experts. moprophylaxis in the United Perception of Risk
Occasionally, public opinion States before many other People from varying back-
may influence recommen- countries. On the other hand, grounds can view the
dations (for example, the a vaccine against tickborne same risk data and come
widespread adverse publicity encephalitis is approved for to different conclusions
about mefloquine that was use and widely available as to the cost and benefit
reported in the media). in many countries, but is of preventing that risk.
not approved by the FDA; For example, national-​
Availability therefore, CDC and ACIP level recommendations
of Products guidelines do not include any to prevent malaria while
Travel health providers recommendations for the traveling to India vary
can only use the products use of this vaccine. widely. Germany does
that are available to them. Even when the same not recommend using
Availability is determined products are available, standard prophylaxis for
by the regulatory approval the recommendations for any travel to an Indian
status of the product and, their use may differ. The destination; standby emer-
to a lesser extent, the mar- injectable capsular polysac- gency treatment (SBET
keting and distribution plan charide typhoid vaccine and or self-​treatment) is the
of the manufacturer. Among the oral typhoid vaccine are recommendation for iden-
the various vaccines and examples. In the United tified risk destinations.




The guidelines in the Lack of Evidence decreased in the past

1 United Kingdom recom- In many cases, limited or decade. In one example of an
mend only awareness and no data are available to effort to harmonize guide-
mosquito bite prevention inform an evidence-​based lines, from 2008 through
as the default recom- assessment. In this setting, 2010, WHO convened an
mendation for more than travel health providers international group of yellow
half the Indian subcon- defer to expert opinion or an fever and travel medicine
tinent, including large extrapolation from limited experts to review available
cities and popular tourist data in conjunction with data on yellow fever virus
destinations in the north expert opinion. In travel transmission. The product
and south, while recom- medicine, it is rare to have of this collaboration was
mending an individual risk actual prospective numer- a country-​specific list of
assessment that is based ator and denominator data yellow fever vaccine recom-
on activities and types of on the risk of any vaccine-​ mendations based on the
travel for consideration preventable diseases in geographic distribution of
of chemoprophylaxis. For travelers. For example, any risk (see Chapter 3, Yellow
some defined higher-​risk data on the risk of hepatitis Fever & Malaria Information,
areas, the recommendation A in travelers would have by Country).
is for standard chemo­ to account for the immu- In summary, the role
prophylaxis for most nization rate with hepatitis of the travel health pro-
travelers, with the option A vaccine. These data are vider is to become more
to consider mosquito avoid- rarely available, and there- sophisticated in his or her
ance for low-​risk travelers. fore, we often rely on histor- understanding of the various
However, CDC recommends ical data that captured few differences in guidelines, in
malaria chemoprophylaxis actual cases. interpreting this informa-
for any Indian destination tion, and in conveying it in
except for some moun- an assured and comforting
tainous areas of northern CAN WE manner to travelers.
states above 2,000 m (6,561 HARMONIZE
ft) as the default recom- GUIDELINES?
mendation for most travel- The complex nature of how BIBLIOGRAPHY
ers, with consideration of we obtain, evaluate, and
1. CDC. Malaria surveillance—
individual risk and benefit. verify data, combined with United States, 2011. MMWR
Is one of these recommen- the fundamental differences Surveill Summ. 2013
dations better than the in risk perception, makes it Nov 1;62(5):1–​17.
others? Not necessarily, as likely that multiple, overlap- 2. CDC. Advisory Committee
the recommendations may ping, and at times conflicting on Immunization Practices
be based on the national (ACIP). Atlanta: CDC; 2014
guidelines will continue to
[cited 2016 Sep. 10]; Available
experience with different exist. However, given the from: http://​www.cdc.gov/​
types of travelers and the international nature of travel vaccines/​acip/​.
risk assessment approach medicine and the exis- 3. Chiodini PL, Field VK, Whitty
of the organization for- tence of the International CJM, Lalloo DG. Guidelines
mulating the national Society of Travel Medicine, for malaria prevention in
guidelines. conflicting guidelines have travellers from the United

3 1

Kingdom. London: Public gc.ca/​collections/​collection_​ America. Clin Infect Dis. 2006

Health England; 2014 [cited 2014/​aspc-​phac/​HP40-​102-​ Dec. 15;43(12):1499–​539.
2016 Sep. 16]. Available 2014-​eng.pdf.

7. World Health Organization.
from: https://​www.gov.uk/​ 5. German Society for Tropical International Health
government/​uploads/​system/​ Medicine and International Regulations (2005).
uploads/​attachment_​data/​ Health Association (DTG). Geneva: World Health
file/​337761/​Guidelines_​for_​ [Recommendations for Organization; 2008 [cited
malaria_​prevention_​in_ malaria prevention]. 2015 2016 June 14]; Available
​travellers_​UK_​PC.pdf. [cited 2016 June 14]; Available from: http://​www.who.int/​ihr/​
4. Committee to Advise on from: http://​www.dtg.org/​ 9789241596664/​en/​index.html.
Tropical Medicine and malaria.html. 8. World Health Organization.
Travel (CATMAT). Canadian 6. Hill DR, Ericsson CD, International Travel and
recommendations for the Pearson RD, Keystone JS, Health. Geneva: World Health
prevention and treatment of Freedman DO, Kozarsky PE, Organization; 2012 (with 2016
malaria. Ottawa: Public Health et al. The practice of travel updates) [cited 2016 June 14];
Agency of Canada; 2014 medicine: guidelines by the Available from: http://​www.
[cited 2016 June 14]. Available Infectious Diseases Society of who.int/​ith/​en/​.
from: http://​publications.

Perspectives sections are written as editorial discussions aiming to add depth and clinical perspective to the official
recommendations contained in the book. The views and opinions expressed in this section are those of the authors and
do not necessarily represent the official position of CDC.

Andre D. Berro

The increased complexity and extent of the global 2015. Map 1-​1 shows the spatial distribution of
aviation network can accelerate the spread of these passengers by destination country. Five
communicable diseases of public health concern. destination countries (Mexico, Canada, United
Recently, air travel has been a factor in the spread of Kingdom, Japan, and China) account for 40% of
Ebola, Middle East respiratory syndrome (MERS), all outbound international air travel from the
and Zika. International airlines connect approxi- United States. Table 1-​1 below shows the volume
mately 40,000 global cities and carry about 3 bil- and proportion of air travelers from the United
lion total passengers per year. Growth in air travel States into each of the top 10 destination coun-
over time reflects a volume growth on established tries in 2015.
routes and a nodal growth where more airports Seasonal trends in travel are discernible from
and cities globally are connected. Understanding year to year; overall outbound travel peaks in the
the overall trends of global air travel can inform the summer and has its nadir in February. Seasonal
response to issues of public health concern and trends also vary by destination. For example,
allow for targeted mitigating measures to limit the although outbound travel volume to Europe
spread of communicable diseases. peaks in June, the volume of passengers to the
About 100  million passengers flew from the Caribbean, Latin America, and sub-​ Saharan
United States to overseas destinations during Africa peaks during December.



MAP 1-​1 .   Estimated number of US air travelers received1

Diio Market Intelligence, Fares and Market Sizes, Global (at www.diio.net).

Table 1-​1. Estimated number of US air passengers departing

to the top 10 destination countries, 2015

Mexico 12,200,000 12.4%

Canada 12,100,000 12.3%

United Kingdom 7,100,000 7.2%

Japan 4,500,000 4.6%

China 3,500,000 3.5%

Dominican Republic 3,100,000 3.1%

Germany 2,800,000 2.8%

Brazil 2,800,000 2.8%

India 2,600,000 2.6%

Italy 2,500,000 2.5%

Other Countries 45,400,000 45.9%

5 1

During 2014, approximately 83% of the US res- passengers per year by 2034. China and the United
idents who traveled overseas did so for vacation States are anticipated to lead the growth volume.
or to visit family and friends and 17% for business. The fastest-​growing routes include those to
US residents traveling abroad made reservations Africa, Asia, and South America; travel to countries
on average 68 days before departure. This period
should allow travelers time to schedule a pretravel
such as the Central African Republic, Ethiopia,
Malawi, Rwanda, Sierra Leone, Tanzania, and
consultation to get recommended vaccinations Uganda, considered to be at high risk for travel-​
and learn about health precautions. related diseases, is expected to double in volume
over the next decade. This growth could lead to
PROJECTIONS increased exposures to communicable diseases.
According to the International Air Transport Public health planners, responders, and cli-
Association (IATA), the combined global volume nicians will need to take these projections into
of inbound and outbound air travel is projected account when developing strategies to prevent
to more than double and reach 7 billion total the spread of communicable diseases of public
health concern through international travel.

1. Chen LH, Wilson ME. The role of the traveler in emerg- 5. International Air Transport Association. FMg DM.
ing infections and magnitude of travel. Med Clin North Global passengers volume based on ticket settlement
Am. 2008 Nov;92(6):1409–​32. data from ARC and IATA. 2015 [cited 2016 Apr. 05].
2. Hui DS, Perlman S, Zumla A. Spread of MERS to 6. Musa EO, Adedire E, Olayinka A, Adeoye O, Adewuyi P,
South Korea and China. Lancet Respir Me. 2015 Waziri N, et al. Epidemiological profile of the Ebola virus
Jun 4;3(7):509–​10. disease outbreak in Nigeria July–​September 2014. Pan
3. International Air Transport Association. Afr Med J. 2014;21(1):331.
100 Years of Commercial Flight | Small World, 7. Musso D. Zika Virus Transmission from French
Big Future. [cited 2016 Mar. 21]; Available from: Polynesia to Brazil (Letter). Emerg Infect Dis. 2015
http://​flying100years.com/​. Oct;21(10).
4. International Air Transport Association. IATA Air 8. US Department of Commerce International Trade
Passenger Forecast Shows Dip in Long-​Term Demand. Administration. Profile of U.S. Resident Travelers
The International Air Transport Association (IATA), Visiting Overseas Destinations: 2014 Outbound. 2014
2015 [updated Nov. 2015; cited 2016 Apr. 5]; Available [cited 2016 Apr. 05]; Available from: http://​travel.trade.
from: http://​www.iata.org/​pressroom/​pr/​Pages/​ gov/​outreachpages/​download_​data_​table/​2014_​
2015-​11-​26-​01.aspx. Outbound_​Profile.pdf.



The Pretravel
Lin H. Chen, Natasha S. Hochberg, Alan J. Magill

The pretravel consultation offers a dedicated time the health beliefs of the traveler. Counseling by
to prepare travelers for the health concerns that trained staff can effectively deliver many mes-
might arise during their trips. The objectives of sages, such as those regarding the need for appro-
the pretravel consultation are: priate immunizations, and malaria risk and
prevention. Familiarity with the traveler’s des-
1. To perform an individual risk assessment.
tination, its culture, infrastructure, and disease
2. To educate the traveler regarding anticipated patterns can assist the travel health advisor in
health risks and methods for prevention. providing more personalized advice.
Travel medicine specialists have in-​ depth
3. To provide immunizations for vaccine-
knowledge of immunizations, risks associated
​preventable diseases and medications for
with specific destinations, and the implications
prophylaxis, self-​treatment, or both.
of traveling with underlying conditions. Therefore,
a comprehensive consultation with a travel med-
THE TRAVEL HEALTH icine expert is indicated for any traveler with a
SPECIALIST complicated health history, special risks (such
The outcome of a pretravel consultation likely as traveling at high altitudes or working in refu-
depends on the fund of knowledge, expertise, and gee camps), or exotic or complicated itinerar-
communication skills of the provider, as well as ies. Those clinicians who wish to be travel health



providers are encouraged to take advantage of health risks at the destination and how to miti-
one of the many travel health educational oppor- gate them. The typical pretravel consultation does
tunities available, join the International Society of not include a physical examination; a separate
Travel Medicine, attend conferences, and obtain appointment with the same or a different pro-
their Certificate in Travel Health. vider may be necessary to assess a person’s fitness
to travel. Because the traveler does not need to be
COMPONENTS OF A PRETRAVEL physically present to receive pretravel education,
Effective pretravel consultations require atten-
pretravel consultations are ideally suited to be
done remotely. In addition, because travel medi-
tion to the health background of the traveler and cine clinics are not available in many communi-
incorporate the itinerary, trip duration, travel pur- ties, remote consultations can give more travelers
pose, and activities, all of which determine health access to the information they need.
risks (Table 2-​1). The pretravel consultation is the Travel health advice should be personal-
major opportunity to educate the traveler about ized, highlighting the likely exposures and also

Table 2-​1. Information necessary for a risk assessment

during pretravel consultations
Health Background

Past medical history • Age

• Sex
• Underlying conditions
• Allergies (especially any pertaining to vaccines, eggs, or latex)
• Medications

Special conditions • Pregnancy (including trimester)

• Breastfeeding
• Disability or handicap
• Immunocompromising conditions or medications
• Older age
• Psychiatric condition
• Seizure disorder
• Recent surgery
• Recent cardiopulmonary event
• Recent cerebrovascular event
• History of Guillain-​Barré syndrome

Immunization history • Routine vaccines

• Travel vaccines

Prior travel experience • Experience with malaria chemoprophylaxis

• Experience with altitude
• Illnesses related to prior travel

Trip Details

Itinerary • Countries and specific regions, including order of countries if >1 country
• Rural or urban

Timing • Trip duration

• Season of travel
• Time to departure




Table 2-​1. Information necessary for a risk assessment

during pretravel consultations (continued)
Reason for travel • Tourism
• Business
• Visiting friends and relatives

2 • Volunteer, missionary, or aid work

• Research or education
• Adventure
• Pilgrimage
• Adoption
• Seeking health care (medical tourism)

Travel style • Independent travel or package tour

• Propensity for “adventurous” eating
• Traveler risk tolerance
• General hygiene standards at destination
• Modes of transportation
• Accommodations (such as tourist or luxury hotel, guest house, hostel or
budget hotel, dormitory, local home or host family, or tent)

Special activities • Disaster relief

• Medical care (providing or receiving)
• High altitude
• Diving
• Cruise ship
• Rafting or other water exposure
• Cycling
• Extreme sports
• Spelunking
• Anticipated interactions with animals

reminding the traveler of ubiquitous risks, such may confront special risks. Recent hospitalization
as injury, foodborne and waterborne infec- for serious problems may lead the advisor to rec-
tions, vectorborne disease, respiratory tract ommend delaying travel. Air travel is contrain-
infections, and bloodborne and sexually trans- dicated for certain conditions, such as <3 weeks
mitted infections. Written information is essen- after an uncomplicated myocardial infarction and
tial to supplement the discussion and highlight <10 days after thoracic or abdominal surgery. The
key advice for travelers. Balancing the cautions travel health provider and traveler should con-
with an appreciation of the positive aspects of sult with the relevant health care providers most
the journey leads to a more meaningful pre- familiar with the underlying illnesses. Other trav-
travel consultation. Attention to the cost of elers with specific risks include travelers who are
recommended interventions may be critical. visiting friends and relatives, long-​term travelers,
Some travelers may not be able to afford all of travelers with chronic illnesses, immunocompro-
the recommended immunizations and medica- mised travelers, pregnant travelers, and travelers
tions, a situation that requires prioritizing inter- with small children. More comprehensive dis-
ventions. (See Perspectives: Prioritizing for the cussion on advising travelers with specific needs
Resource-​Limited Traveler later in this chapter.) is available in Chapter 8. Providers should deter-
mine whether recent outbreaks or other safety
Assess Individual Risk notices have been posted for the traveler’s desti-
Many elements merit consideration in assessing a nation; information is available on the CDC web-
traveler’s health risks (Table 2-​1). Certain travelers site and in various other resources.



In addition to recognizing the traveler’s char- whether there is sufficient time before travel to
acteristics, health background, and destination-​ complete a vaccine series; the purpose of travel
specific risks, the exposures related to special and specific destination within a country will
activities also merit discussion. For example, inform the need for particular vaccinations. At
river rafting could expose a traveler to schistoso- the same time, the pretravel consultation pres-
miasis or leptospirosis, and spelunking in Central ents an opportunity to update routine vaccines
America could put the traveler at risk of histo- (Table  2-​2). Particular attention should be paid
plasmosis. Flying from lowlands to high-​altitude
areas and trekking or climbing in mountainous
to vaccines for which immunity may have waned
over time or a recent immunocompromising con-
regions introduces the risk of altitude illness. dition (such as after a hematopoietic stem cell
Therefore, the provider should inquire about transplant). Asking the question, “Do you have
plans for specific activities. any plans to travel again in the next 1–​2 years?”
may help the traveler justify an immunization for
Manage Risk this particular trip, such as rabies preexposure or
Immunizations are a crucial component of pre- Japanese encephalitis. Travelers should receive
travel consultations, and the risk assessment a record of immunizations administered and
forms the basis of recommendations for travel instructions to follow up as needed to complete
vaccines. For example, providers should consider a vaccine series.

Table 2-​2. Vaccines to update or consider during pretravel


Routine Vaccines

Haemophilus influenzae No report of travel-​related infection, although organism is ubiquitous.

type b

Hepatitis B Recommended for travelers visiting countries where HBsAg prevalence is ≥2%.
Vaccination may be considered for all international travelers, regardless of destination,
depending upon the traveler’s behavioral risk and potential for exposure as determined by
the provider and traveler.

Human papillomavirus No report of travel-​acquired infection; however, sexual activity during travel may lead
(HPV) to HPV and other sexually transmitted infections.

Influenza Year-​round transmission may occur in tropical areas. Outbreaks have occurred on
cruise ships, and 2009 influenza A (H1N1) illustrated the rapidity of spread via travel.
Novel influenza viruses such as avian influenza H5N1 and H7N9 can be transmitted to
travelers visiting areas with circulation of these viruses.

Measles, mumps, Infections are common in countries and communities that do not immunize children
rubella routinely, including Europe. Outbreaks have occurred in the United States as a result of
infection in returning travelers.

Meningococcal Outbreaks occur regularly in sub-​Saharan Africa in the “meningitis belt” during
the dry season, generally December through June, although transmission may
occur at other times for those with close contact with local populations. Outbreaks
have occurred with Hajj pilgrimage, and the Kingdom of Saudi Arabia requires the
quadrivalent vaccine for pilgrims.




Table 2-​2. Vaccines to update or consider during pretravel

consultations (continued)

Pneumococcal Organism is ubiquitous, and causal relationship to travel is difficult to establish.

2 Polio Unimmunized or underimmunized travelers can become infected with either wild
poliovirus or vaccine-​derived poliovirus. Because the international spread of wild
poliovirus in 2014 was declared a Public Health Emergency of International Concern
under the International Health Regulations, temporary recommendations for
polio vaccination are in place for countries with wild poliovirus circulation for their
residents, long-​term visitors, and international travelers.

Rotavirus Common in developing countries, although not a common cause of travelers’ diarrhea
in adults. The vaccine is only recommended in young children.

Tetanus, diphtheria, Rare cases of diphtheria have been attributed to travel. Pertussis has occurred in
pertussis travelers, recently in adults whose immunity has waned.

Varicella Infections are common in countries that do not immunize children routinely, as in most
developing countries. Naturally occurring disease also occurs later in tropical countries.

Zoster Travel (a form of stress) may trigger varicella zoster reactivation, but causal
relationship is difficult to establish.

Travel Vaccines

Cholera Cases in travelers have occurred recently in association with travel to the Dominican
Republic and Haiti.

Hepatitis A Prevalence patterns of hepatitis A virus infection may vary among regions within a
country, and missing or obsolete data present a challenge. Serologic testing may
be considered in travelers from highly endemic countries since they may already be
immune. Some expert travel clinicians advise people traveling outside the United
States to consider hepatitis A vaccination regardless of their country of destination.

Japanese encephalitis Rare cases have occurred, estimated at <1 case/​1 million travelers to endemic countries.

Rabies Rabies preexposure immunization simplifies postexposure immunoprophylaxis, as

adequately screened immunoglobulin may be difficult to obtain in many destinations.

Tickborne encephalitis Cases have been identified in travelers with an estimated risk of 1/​10,000 person-​
(vaccine not available in months in travelers. Endemic areas are expanding in Europe.
the United States)

Typhoid UK surveillance found the highest risk to be travel to India (6 cases/​100,000 visits),
Pakistan (9 cases/​100,000 visits), and Bangladesh (21 cases/​100,000 visits), although
risk is substantial in many destinations.

Yellow fever Risk occurs mainly in defined areas of sub-​Saharan Africa and the Amazonian
regions of South America. Some countries require proof of vaccination for entry.
For travelers visiting multiple countries, order of travel may make a difference in the

Abbreviation: HBsAg, hepatitis B surface antigen.



Another major focus of pretravel consultations to discuss with their primary care provider how to
for many destinations is the prevention of malaria. plan for treatment and bring necessary medication
Malaria continues to cause substantial morbidity in case of asthma exacerbation. Travelers should
and mortality in travelers. In 2011, the number of be counseled on how they can find reputable med-
US malaria cases reported to CDC was the highest ical facilities at their destination, such as using the
since 1971; therefore, pretravel consultation must ISTM website (www.istm.org) or the American
carefully assess travelers’ risk for malaria and rec- Society of Tropical Medicine and Hygiene website
ommend preventive measures. For travelers going
to malaria-​endemic countries, it is imperative to
(www.astmh.org) to find suitable clinics. Any aller-
gies or serious medical conditions should be iden-
discuss malaria transmission, ways to reduce risk, tified on a bracelet or a card to expedite medical
and recommendations for chemoprophylaxis. care in emergency situations.
Travelers with underlying health conditions The pretravel consultation also provides another
require attention to their health issues as they setting to remind travelers of basic health practices
relate to the destination and activities. For exam- during travel, including frequent handwashing,
ple, a traveler with a history of cardiac disease wearing seatbelts, and using car seats for infants
should carry medical reports, including a recent and children. Topics to be explored are numerous
electrocardiogram. Asthma may flare in a trav- and could be organized into a checklist, placing pri-
eler visiting a polluted city or from physical exer- ority on the most serious and frequently encoun-
tion during a hike; travelers should be encouraged tered issues (Table  2-​3). General issues such as

Table 2-​3. Major topics for discussion during pretravel

Immunizations • Review routine immunizations and those travel immunizations indicated for the specific
itinerary and based on the traveler’s medical history.
• Discuss utility of titers when records are unavailable or unreliable, particularly for
measles, mumps, rubella, and hepatitis A.
• Screen for chronic hepatitis B for people born in countries with HBsAg prevalence ≥2%
(see Map 3-​4).
• Discuss indications for, effectiveness of, and adverse reactions to immunizations.

Malaria • Determine if there is a risk of malaria.

chemoprophylaxis • Discuss personal protective measures.
• Discuss risks and benefits of chemoprophylaxis and recommended choices of
chemoprophylaxis for the itinerary.

Other vectorborne • Define risk of disease in specific itinerary and insect precautions needed.

Respiratory • Discuss areas of particular concern (such as avian influenza in Asia or MERS in the
illnesses Arabian Peninsula).
• Consider influenza treatment for high-​risk travelers.

Travelers’ diarrhea • Recommend strategies to decrease risk of diarrhea.

• Discuss antibiotics for self-​treatment, adjunct medications such as loperamide, and
staying hydrated.

Altitude illness • Determine if the itinerary puts the traveler at risk of altitude illness.
• Discuss preventive measures such as gradual ascent, adequate hydration, and
medications to prevent and treat.




Table 2-​3. Major topics for discussion during pretravel

consultations (continued)
Other • Caution travelers to avoid contact with animals to reduce the potential for bites and
environmental scratches that can transmit rabies.
hazards • Advise travelers to avoid walking barefoot to avoid certain parasitic infections.

2 • Advise travelers to avoid wading or swimming in freshwater where there is risk for
schistosomiasis or leptospirosis.
• Remind travelers to apply sunscreen to skin exposed to the sun.

Personal safety • Discuss precautions travelers can take to minimize risks specific to the trip, such as
traffic accidents, alcohol excess, personal assault, robbery, or drowning.
• Provide information on travel health and medical evacuation insurance.
• Advise travelers to look for security bulletins related to their destination and consider
areas to avoid.

Sexual health • Caution the traveler to avoid activities that can lead to sexually transmitted infections,
and bloodborne unwanted pregnancy, or bloodborne infections.
pathogens • Remind travelers to use condoms if they do have sex.
• Inform travelers who will provide health care overseas what to do in case of needlestick
or bloodborne pathogen exposure.

Disease-​specific • Remind travelers to hand carry medications and supplies.

counseling • Advise travelers to prepare for exacerbations or complications from underlying disease.

Abbreviations: HBsAg, hepatitis B surface antigen; MERS, Middle East respiratory syndrome.

preventing injury and sunburn also deserve men- 50% of the drugs on the shelves) makes it more
tion. Written information is essential to supple- important for travelers to bring quality manu-
ment oral advice and enable travelers to review factured drugs with them from a reliable sup-
the instructions from their clinic visits; educational plier in their own country (see Perspectives:
material is available on the CDC Travelers Health Pharmaceutical Quality & Falsified Drugs later in
webpage (http://​www.cdc.gov/​travel). Advice on this chapter).
self-​treatable conditions may minimize the need Travel health providers need to recognize the
for travelers to seek medical care while abroad and conditions for which the traveler may be at risk
possibly lead to faster return to good health. and educate the traveler about the diagnosis and
treatment of those particular conditions. The keys
Self-​Treatable Conditions to successful self-​treatment strategies are provid-
Despite providers’ best efforts, some travelers will ing a simple disease or condition definition, pro-
become ill. Obtaining reliable and timely medical viding a treatment, and educating the traveler
care during travel can be problematic in many about the expected outcome of treatment. Using
destinations. As a result, prescribing certain med- travelers’ diarrhea as an example, a practitioner
ications in advance can empower the traveler to could provide the following advice:
self-​diagnose and treat common health problems.
With some activities in remote settings, such as • “Travelers’ diarrhea” is the sudden onset of
trekking, the only alternative to self-​treatment abnormally loose, frequent stools.
would be no treatment. Pretravel counseling may
actually result in a more accurate self-​diagnosis
• Most cases will resolve within 2–​5 days, and
symptoms can be managed with loperamide
and treatment than relying on local medical care
or bismuth subsalicylate.
in some areas. In addition, the increasing aware-
ness of substandard and counterfeit drugs in • For diarrhea severe enough to interrupt travel
pharmacies in the developing world (as many as plans, an antibiotic can be prescribed that


3 2

travelers can carry with them (see Travelers’ • Jet lag (see section in this chapter)
Diarrhea section in this chapter).
• Motion sickness (see section in this chapter)
• The traveler should feel better within
6–​24 hours. • Respiratory infections (see section in this
• If symptoms persist for 24–​36 hours despite
self-​treatment, it may be necessary to seek • Skin conditions: skin reactions due to allergic
medical attention. or irritant triggers usually respond to topical
steroids; discomfort from superficial fungal 2
To minimize the potential negative effects of a infections respond to antifungal creams. See
treatment strategy, the recommendations Chapter 5, Skin and Soft Tissue Infections in
should follow a few key points: Returned Travelers.
• Drugs recommended must be safe, well toler- • Urinary tract infections: common among
ated, and effective for use as self-​treatment. many women; carrying an antibiotic for
• A drug’s toxicity or potential for harm, if used empiric treatment may be valuable.
incorrectly or in an overdose situation, should • Vaginal yeast infections: self-​treatment
be minimal. course of patient’s preferred antifungal med-
• Simple and clear directions are critical. ication can be prescribed for women who
Consider providing handouts describing are prone to infections, sexually active, or
how to use the drugs. Keeping the directions who may be receiving antibiotics for other
simple will increase the effectiveness of the reasons (including doxycycline for malaria
strategy. chemoprophylaxis).

The following are some of the most common situ- • Occupational exposure to HIV (see Chapter 8,
ations in which people would find self-​treatment Health Care Workers)
useful. The extent of self-​treatment recommen- • Malaria self-​treatment (see Chapter 3,
dations offered to the traveler should reflect Malaria)
the remoteness and difficulty of travel and the
availability of reliable medical care at the partic- In sum, travelers should be encouraged to carry
ular destination. The recommended self-​treat- a travel health kit with prescription and nonpre-
ment options for each disease are provided in scription medications. Providers should review
the designated section of the Yellow Book or medication lists for possible drug interactions.
discussed below. More detailed information for providers and trav-
elers is given in Chapter  2, Travel Health Kits;
• Travelers’ diarrhea (see section in this chapter) supplementary travel health kit information for
• Altitude illness (see section in this chapter) travelers with specific needs is given in Chapter 8.

1. Freedman DO, Chen LH, Kozarsky P. Medical con- 4. International Society of Travel Medicine. Body of
siderations before travel. N Engl J Med. 2016 July knowledge for the practice of travel medicine—​2012.
21;375:247–​6 0. Atlanta: International Society of Travel Medicine; 2012
2. Hatz CFR, Chen LH. Pre-​travel consultation. [cited 2016 Oct. 1]; Available from: http://​www.istm.org/​
In: Keystone JS, Freedman DO, Kozarsky PE, Connor bodyofknowledge.
BA, Nothdurft HD, editors. Travel Medicine. 3rd ed. 5. LaRocque RC, Rao SR, Lee J, Ansdell V, Yates JA,
Philadelphia: Saunders Elsevier; 2013. pp. 31–​6. Schwartz BS, et al. Global TravEpiNet: a national con-
3. Hill DR, Ericsson CD, Pearson RD, Keystone JS, sortium of clinics providing care to international trav-
Freedman DO, Kozarsky PE, et al. The practice of elers—​analysis of demographic characteristics, travel
travel medicine: guidelines by the Infectious Diseases destinations, and pretravel healthcare of high-​risk US
Society of America. Clin Infect Dis. 2006 Dec international travelers, 2009–​2011. Clin Infect Dis. 2012
15;43(12):1499–​539. Feb 15;54(4):455–​62.



6. Leder K, Chen LH, Wilson ME. Aggregate travel vs. 8. Schwartz BS, Larocque RC, Ryan ET. In the clinic: travel
single trip assessment: arguments for cumulative risk medicine. Ann Intern Med. 2012 Jun 5;156(11):ITC6:1–​16.
analysis. Vaccine. 2012 Mar 28;30(15):2600–​4. 9. Steffen R, Behrens RH, Hill RD, Greenaway C, Leder K.
7. Leder K, Torresi J, Libman MD, Cramer JP, Castelli F, Vaccine-​preventable travel health risks: what is the
Schlagenhauf P, et al. GeoSentinel surveillance of illness evidence—​what are the gaps? J Travel Med. 2015;22(1):1–​12.
in returned travelers, 2007–​2011. Ann Intern Med. 2013 10. Steffen R, Hill DR, DuPont HL. Traveler’s Diarrhea: a
Mar 19;158(6):456–​68. clinical review. JAMA. 2015 Jan 6, 2015;313(1):71–​80.


5 2

David R. Shlim

Travel medicine is based on deaths per 100,000 trekkers, just as the risks of staying
the concept of the reduc- but there is no objective way home are not zero. Even
tion of risk. In the context to determine whether this the act of trying to prevent a
of travel medicine, “risk” risk is high or low. When the risk—​such as yellow fever—​
refers to the possibility of manuscript that reported can lead to a fatal reaction
harm during the course of a this risk of dying while trek- to the vaccine in rare cases.
planned trip. Some risks may king was peer-​reviewed, one Therefore, the goal in travel
be avoidable, and others may reviewer wrote, “You need to and in travel medicine should
not. Vaccine-​preventable emphasize that these data be skillfully managing risk,
diseases may be mostly show how dangerous trek- rather than trying to eliminate
avoidable, depending on the king actually is.” The other risk. The pretravel consul-
risk of the disease and the reviewer wrote, “You should tation is an opportunity to
protective efficacy of the vac- make a point of stating that discuss risks and develop
cine. Non-​disease risks, such these data show how safe plans that minimize these
as motor vehicle accidents trekking is.” risks. Each traveler will have
or drowning, account for a The subjective sense of individual concepts about the
much higher percentage of risk is based on one’s percep- risks and benefits of vaccines,
deaths among travelers than tion of risk (“15 per 100,000 prophylaxis, and behavior
infectious diseases. means it’s dangerous”) and modification.
For many years, travel one’s tolerance for risk (“it Travelers should also
medicine practitioners have may be 15 per 100,000, but consider the psychologi-
felt that if they knew the it’s worth it”). This subjective cal and emotional aspects
statistics for a given risk, sense of risk suffuses the of foreign travel. Culture
they could objectively advise field of travel medicine, but shock can occur on either
travelers about that risk. it is rarely discussed. Some end of a journey: on arrival
However, it has become travelers canceled travel when one encounters an
clear that the perception and plans to Asia because of their entirely strange new world,
tolerance of risk are sub- fear of H5N1 avian influenza, and on return when one’s
jective factors that must be even though the actual risk own world may temporarily
considered when addressing to travelers was virtually appear unfamiliar. Travelers
risks of travel. Travel health zero. Other travelers plan with underlying psychiat-
providers may know statistics to ascend Mount Everest, ric conditions should be
for a given risk, but whether even though the risk of dying cautious when heading out
the risk is considered high during an Everest climb is to a stressful new environ-
or low depends on the per- 1 in 40. ment, particularly if they are
ception of the traveler or the Regardless of the per- traveling alone.
travel medicine provider. For ception and tolerance of risk, Travel medicine providers
example, the risk of dying the hazards associated with should promote the under-
while trekking in Nepal is 15 travel cannot be eliminated, standing of the concept of





commitment, the idea that country with no advanced Travel medicine practi-
certain parts of a journey cardiac services may have tioners should explore their
cannot easily be reversed. a difficult time getting to own perception and tolerance
A person trekking into a definitive medical care. If the of risk, so that they can help
2 remote area may need to traveler has already contem- travelers find their individual
accept that rescue, if avail- plated these concerns and comfort level when making
able at all, may be delayed accepted them, it will be eas- decisions about destinations,
for days. A person who has ier to deal with them if they activities, and prophylactic
a myocardial infarction in a come to pass. measures.

Perspectives sections are written as editorial discussions aiming to add depth and clinical perspective to the official
recommendations contained in the book. The views and opinions expressed in this section are those of the author and do
not necessarily represent the official position of CDC.



Zoon Wangu, Elizabeth D. Barnett
Travelers seen in pretravel health insurance and evacu- the traveler may be denied
clinic consultations often ation insurance before travel entry to the country without
have financial constraints. must also be considered proof of vaccination. Note
Prioritizing immunizations (see Travel Insurance, Travel that travelers who may be
and prophylactic medica- Health Insurance, & Medical staying in a yellow fever–​
tions should be part of an Evacuation Insurance later endemic country only briefly
individualized assessment in this chapter). Clinicians (such as during an airport
based on the travel itinerary, need to understand trav- layover) may still need evi-
efficacy and safety of vac- elers’ financial constraints dence of vaccination to enter
cines and medications, and in order to provide realistic other countries on their
associated costs. Travelers recommendations. The itinerary. In a few specific
must often pay out of pocket variety of insurance plans, circumstances, travelers to
for pretravel care, as many number of travelers without countries that are exporting
health insurance plans do adequate insurance cover- polio may be asked to show
not cover travel immuni- age, and number of student proof of polio vaccination
zations or prophylaxis. As and budget travelers chal- before they are allowed
an example, the estimated lenges even the most savvy to leave those countries if
cost of a US pretravel con- travel medicine clinicians. they have spent >4 weeks in
sultation for a backpacker This section provides guid- the country (see Chapter 3,
planning a 4-​week trip to ance for busy practitioners Poliomyelitis).
West Africa may be as high in prioritizing vaccine and
as $1,400 for the initial con- prophylaxis choices. Routine Vaccines
sultation and vaccinations, All travelers should be
excluding malaria chemo- VACCINES up-​to-​date with routine
prophylaxis. Travelers with Required Vaccines vaccines before interna-
limited budgets may be Only 2 vaccines are required tional travel, regardless of
at higher risk for travel-​ categorically for some destination. The benefits of
associated infections, as travelers: meningococcal vaccines extend beyond the
they often visit remote areas, vaccine for pilgrims travel- travel period, and in many
stay in lower-​grade accom- ing to Mecca during the Hajj cases lifelong immunity is
modations, and are more and yellow fever vaccine for achieved. Routine vaccines
likely to eat local street food. travelers to certain countries are generally associated
Therefore, the cost of dis- in Africa and South America with lower costs, since they
ease (such as malaria) may, (see Chapter 3, Yellow Fever are mass-​produced as part
in many cases, outweigh & Malaria Information, by of the scheduled national
costs of vaccination and Country). If either of these childhood and adult vacci-
prophylaxis. The financial vaccines is required for an nation programs, and many
benefits of obtaining travel itinerary, prioritize it since health insurance plans will





reimburse the patient for duration is short) because advice about preventing
the cost of vaccine admin- of the relatively low efficacy, mosquito bites (see

2 istration. If cost of routine

vaccines is a limitation, a
short duration of protection,
and time needed for onset
Protection against
Mosquitoes, Ticks, & Other
traveler can explore oppor- of protection (≥2 weeks). On Arthropods later in this
tunities for obtaining them the other hand, oral typhoid chapter). Malaria chemopro-
in a health department or vaccine has a longer duration phylaxis, if needed, should
primary care setting, where of protection, and time to be offered based on the
cost may be lower than in a protection is shorter, approxi- risk profile of the traveler,
travel clinic. Prioritize the mately 1 week. taking into account possible
routine vaccines that protect When considering rabies financial burden. The risk
against diseases for which vaccine for resource-​limited of acquiring malaria varies
the traveler is most likely travelers, consider the risk widely, depending on des-
to be at general risk. At this of animal exposure, access tination, accommodations,
time, top priorities for most to local health care, and and activities during travel.
destinations would include availability of rabies immune Malaria risk is decreasing
vaccines against influenza, globulin and rabies vaccine in many countries, and
measles, and hepatitis at the traveler’s destination. up-​to-​date sources of risk
A and B. Travelers who decline pre­ areas in the destination
Some travelers may be exposure immunization country should be used to
immune to the disease for should have a plan of action if advise travelers. Costs asso-
which immunization is being an exposure occurs. In up to ciated with the different
considered. Testing for anti- 37% of locations worldwide, regimens vary widely. For
body concentrations may be rabies vaccine or immune example, based on current
covered by insurance when globulin are available only prices in the United States,
vaccines are not. Testing for sometimes or never. a prophylactic treatment
immunity to diseases such as Review the itinerary in course for a 3-​week trip to a
measles, varicella, and hepati- detail to determine the need malaria-​endemic destination
tis A and B can help determine for Japanese encephalitis would cost $120–​$250
whether vaccination is needed. vaccine. Some travelers may for doxycycline, $50–​$100 for
be able to obtain vaccine at chloroquine, $95–​$120 for
Recommended lower cost outside the United mefloquine, and $200–​$225
Vaccines States. Those who decline for atovaquone-​proguanil
Consider time until depar- vaccine should have a clear (depending on health insur-
ture, risk of disease at the understanding of when and ance and other factors).
destination, effectiveness and how to use insect repellents Atovaquone-​proguanil cost
safety of vaccine, and likeli­ and other measures to pre- may be equivalent to that of
hood of repeat travel. For vent mosquito bites. mefloquine for short trips,
example, parenteral typhoid but mefloquine (or chloro-
vaccine may be less cost-​ MALARIA quine, in the few regions
effective for certain travelers CHEMOPROPHYLAXIS where malaria remains sus-
(especially when depar- Every pretravel consulta- ceptible) will be more cost- ​
tures are imminent and trip tion should include detailed effective for trips lasting ≥2



weeks. Travelers who raise practitioners. All travelers BIBLIOGRAPHY

the question of purchasing can benefit from multiple
1. Adachi K, Coleman MS, Khan N,
antimalarial drugs at their strategies to safeguard Jentes ES, Arguin P, Rao SR, et al.
destination must be advised their health during travel, Economics of malaria prevention
about the risk of inappro- in addition to vaccination in US travelers to West Africa. Clin
Infect Dis. 2014 Jan;58(1):11–​21.
priate, substandard, and and prophylaxis. These
counterfeit medications strategies include follow- 2. Jentes ES, Blanton JD, Johnson KJ,
and discouraged from this ing safety (especially road Petersen BW, Lamias MJ, Robertson
K, et al. The global availability of
practice (see Perspectives: traffic safety) and security
rabies immune globulin and rabies
Pharmaceutical Quality & guidelines, observing sun vaccine in clinics providing indirect
Falsified Drugs later in this protection, avoiding food care to travelers. J Travel Med. 2014
chapter). hazards, and following safe Jan-​Feb;21(1):62–​6.
sex practices. Following 3. Johnson DF, Leder K, Torresi J.
PREVENTIVE insect precautions is essen- Hepatitis B and C infection in inter-
national travelers. J Travel Med. 2013
BEHAVIORS tial to prevent dengue and
Educate about alternative chikungunya viruses and
4. Mangtani P, Roberts JA. Economic
ways to reduce risk, espe- has become especially per-
evaluations of travelers’ vaccina-
cially when immunization is tinent with the emergence of tions. In: Zuckerman JN, Jong EC,
not possible. For example, Zika virus in Latin America. editors. Travelers’ Vaccines. 2nd
advise travelers to avoid ani- Travelers can be reassured ed. Shelton (CT): People’s Medical
mal bites, use insect precau- that the actions they take Publishing House; 2010. pp. 553–​67.
tions, and observe food and to avoid these preventable 5. Steffen R, Connor BA. Vaccines in
water precautions to the best hazards may, in the long travel health: from risk assessment
to priorities. J Travel Med. 2005
of their ability. run, protect against travel-​ Jan-​Feb;12(1):26–​35.
Budget travelers and associated risks that are
6. Wu D, Guo CY. Epidemiology
those who cannot afford more prevalent than are and prevention of hepatitis A in
travel vaccines will continue certain vaccine-​preventable travelers. J Travel Med. 2013
to challenge travel medicine diseases. Nov-​Dec;20(6):394–​9.

Perspectives sections are written as editorial discussions aiming to add depth and clinical perspective to the official
recommendations contained in the book. The views and opinions expressed in this section are those of the authors and
do not necessarily represent the official position of CDC.



Emily P. Hyle, Edward T. Ryan

CLINICAL BENEFITS studies unrelated to travel. ECONOMICS OF

OF THE PRETRAVEL Travel-​related risks fluctuate THE PRETRAVEL
MEDICAL and are affected by evolving ENCOUNTER
ENCOUNTER destination infrastructure and The pretravel encounter
The pretravel medical encoun- economy, advancements in incurs direct costs, including
ter usually consists of 3 disease-​control programs, clinic visit fees (as a compo-
components—​vaccination, pro- and the emergence of infec- nent of a primary care visit
phylaxis, and education—​each tions into new zones. The risk or dedicated specialist visit),
of which is intended to reduce of travel-​related illness is vaccines, and prescribed
the risk of illness during travel. also traveler-​specific. Some drugs, as well as indirect
Vaccination and prophylaxis travelers participate in more costs associated with travel
prevent disease among trav- high-​risk behavior, and some to clinic and missed work.
elers. Fewer data exist on the travelers (such as those who When considering costs
effect of pretravel education are immunocompromised) and other components of
and advice. For example, may be more predisposed to resource use, it is essential
educating travelers on ways infection or complications. to consider the perspective
to limit exposure to foodborne Benefits of a pretravel of who pays and who bene-
and waterborne diseases encounter may also extend fits: the traveler, the health
has not been shown to have beyond the immediate dura- care payer, or society.
a demonstrable effect on the tion of travel, and immunity Economic benefits include
risk of travelers’ diarrhea. resulting from vaccination when the pretravel encoun-
The pretravel encounter can overlap multiple itiner- ter prevents a travel-​related
has more clinical benefit aries. Travelers are known to illness; therefore, costs of
when the risks of acquiring spread extremely contagious the travel-​related illness pre-
a travel-​related illness are infections (such as measles), vented should be considered
greater. Such risks are influ- highly morbid diseases as cost savings. A frequently
enced by regional destination, (such as Middle East respi- overlooked economic aspect
itinerary, travel duration, and ratory syndrome or Ebola), linked to the pretravel medi-
season, but few data quantify and highly drug-​resistant cal encounter is its potential
the risk to travelers. Our best pathogens (such as NDM-​1–​ to reduce the incidence of
data for estimating disease expressing bacteria or multi- many travel-​related illnesses
risk at a destination often drug-​resistant Mycobacterium that have public health impli-
reflect disease prevalence tuberculosis). Reducing impor- cations. The introduction of
among the local population tations of communicable dis- measles or hepatitis A into
and may not correlate with eases by returning travelers a community by a returning
the risk to travelers. Vaccine can have far-​reaching public traveler prompts expensive
efficacy data are also too health implications by dimin- public health and infection-​
often extrapolated from ishing outbreaks. control responses. Such costs



are largely borne by the pub- not only to trace and limit A vaccination, typhoid vacci-
lic health sector and there- ongoing disease transmission nation, and travelers’ diarrhea
fore do not usually appear but also to mitigate the risk strategies. Unfortunately,
in the financial calculus of of establishing environmental many of these analyses were
the individual traveler or the or animal reservoirs in home performed decades ago.

insurance carrier. communities. Such a model A reasonable approach would
could then be used to exam- therefore be to develop mod-
MATHEMATICAL ine the effect of a pretravel eling approaches for major
MODELING FOR encounter on different popu- groups of travel-​related
TRAVEL MEDICINE lations of travelers. Because illnesses, using available
Mathematical modeling only some travelers seek current data regarding the
allows for a comprehensive pretravel evaluation, a model pretravel encounter from
investigation of the value could examine the effect when the GlobalTravEpiNet (GTEN)
of the pretravel medical different percentages of the consortium (see Chapter 1,
encounter. By incorporating traveling population obtain Travel Epidemiology) and
best estimates of bene- pretravel evaluation. other large consortiums.
fits and costs for pretravel A modeling approach can The goals of such analyses
encounters, travel exposures, also be used to perform sen- could include defining core
and travel-​related illness, a sitivity analyses, in which a metrics for pretravel encoun-
model can project possible range of values for a specific ters, improving the value of
outcomes and costs for dif- input parameter is exam- pretravel encounters, and
ferent travelers, exposures, ined in terms of the impact examining where improve-
risks of infection, and effec- on the outcome of interest. ments in pretravel medicine
tiveness of pretravel interven- Sensitivity analyses can evalu- would result in maximally
tions singly or in combination. ate thresholds, or the specific improved patient outcomes
A comprehensive model of value at which a parameter and cost-​effectiveness. These
the pretravel encounter would results in a meaningful separate models could then
examine the range of possible change in clinical outcomes be incorporated into a single
illnesses posed by an itiner- or costs. Uncertain data esti- integrated analysis that would
ary, including those that pres- mates or assumptions are address a comprehensive
ent long after return (such as assessed by using a model in pretravel encounter. Such an
tuberculosis or HIV) or that a similar fashion, investigat- approach will not be easy, but
lead to chronic sequelae (such ing at what values such esti- it is necessary.
as neurologic damage from mates will result in clinically
cerebral malaria, Japanese meaningful changes. Results
encephalitis, or Zika infec- from a pretravel model could BIBLIOGRAPHY
tion). Such a model would highlight where further data
1. Adachi K, Coleman MS, Khan
incorporate the effect of any would be high-​yield and worth N, Jentes ES, Arguin P, Rao SR,
pretravel intervention on investing research dollars. et al. Economics of malaria
mitigating the risk of infection A logical way forward is prevention in US travelers to
while traveling as well as to begin by focusing initial West Africa. Clin Infect Dis.
2014 Jan;58(1):11–​21.
possible side effects of the analyses around a number of
2. Behrens RH, Roberts JA.
intervention. Models should core areas. Studies have been
Economic appraisal of prophy-
incorporate the costs of public published that investigate lactic measures against malaria,
health–​related resources and a specific component of the hepatitis A, and typhoid in trav-
expenditures relating to the pretravel encounter, including ellers. BMJ Clinical Research Ed.
importation of pathogens, malaria prophylaxis, hepatitis 1994 Oct 8;309(6959):918–​22.




3. Ortega-​Sanchez IR, cost-​effectiveness approach. 6. Siegel JE, Weinstein MC,
Vijayaraghavan M, Barskey Clin Microbiol Infect. 2004 Russell LB, Gold MR.

AE, Wallace GS. The economic Aug;10(8):681–​3. Recommendations for report-
burden of sixteen measles out- 5. Reves RR, Johnson PC, ing cost-​effectiveness analyses.
breaks on United States public Ericsson CD, DuPont HL. A JAMA. 1996;276(16): 1339–​41.
health departments in 2011. cost-​effectiveness comparison 7. Van Doorslaer E, Tormans
Vaccine. 2014;32(11):1311–​7. of the use of antimicrobial G, Van Damme P. Cost-​
4. Papadimitropoulos V, agents for treatment or effectiveness analysis of
Vergidis PI, Bliziotis I, Falagas prophylaxis of travelers’ vaccination against hepatitis
ME. Vaccination against diarrhea. Arch Intern Med. A in travellers. J Med Virol.
typhoid fever in travellers: a 1988;148(11):2421–​7. 1994;44(4):463–​9.

Perspectives sections are written as editorial discussions aiming to add depth and clinical perspective to the official
recommendations contained in the book. The views and opinions expressed in this section are those of the authors and
do not necessarily represent the official position of CDC.

Andrew T. Kroger, Raymond A. Strikas

Recommendations for the use of vaccines and immunization issues and the use of specific vac-
other biologic products (such as immune globu- cines. Box 2-​1 provides more information about
lin [IG] products) in the United States are devel- ACIP. This section is based primarily on the ACIP
oped by the Advisory Committee on Immunization General Recommendations on Immunization.
Practices (ACIP) and are harmonized with ACIP Evaluation of people before travel should
liaison organizations including the American include a review and provision of routine vac-
Academy of Pediatrics, the American Academy cines recommended based on age and other indi-
of Family Physicians, the American College of vidual characteristics. Additionally, some routine
Physicians, the American College of Obstetricians vaccines are recommended at earlier ages for
and Gynecologists, and others. Recommendations international travelers. For example, MMR (mea-
voted on by the ACIP are reviewed by the CDC sles-​mumps-​rubella) vaccine is recommended for
director and, if adopted, become official recom- infants aged 6–​11  months who travel abroad to
mendations of the Department of Health and protect them from measles. Recommendations
Human Services/​CDC upon publication in CDC’s for specific vaccines related to travel will depend
Morbidity and Mortality Weekly Report (MMWR). on itinerary, duration of travel, and host factors.
ACIP recommendations are based on scien- Vaccinations against diphtheria, tetanus, pertus-
tific evidence of benefits (disease immunity) and sis, measles, mumps, rubella, varicella, poliomyeli-
risks (vaccine adverse reactions) and, where tis, hepatitis A, hepatitis B, Haemophilus influenzae
few or no data are available, on expert opinion. type b (Hib), rotavirus, human papillomavirus
Recommendations include information on general (HPV), and pneumococcal and meningococcal



BOX 2-​1. The Advisory Committee on Immunization

Practices (ACIP)
In 1964, the Department of Health, and operation of immunization on various policy points, then
Education, and Welfare char-
tered the Advisory Committee on
programs. ACIP is subdivided
into 4 permanent workgroups
the CDC workgroup lead writes
specific content for presentation 2
Immunization Practices (ACIP) that address child/​adoles- to the ACIP at large. When it is
to provide guidance to CDC for cent immunization schedules, difficult to achieve consensus,
making immunization policy. adult immunization schedules, options with plans are developed
Guidance includes scheduling of influenza vaccine, and general and presented to the ACIP at large
vaccine doses, specific risk groups immunization issues. In addition for a vote.
for whom vaccination is recom- to the 4 permanent workgroups, ACIP holds 3 public meetings
mended, and vaccine contraindi- additional workgroups focus on a year during which the various
cations and precautions. particular vaccines. Input into workgroups present content
ACIP is composed of 15 vot- the development of immunization that has been developed and is
ing members selected by the schedules is shared with pro- ready for discussion or voting.
Secretary of Health and Human fessional organizations, includ- Sometimes ACIP members are
Services. The ACIP chair, a con- ing the American Academy of involved in academic vaccine
sumer representative, and 13 Pediatrics, American College of research supported by the phar-
members are balanced among Physicians, American Academy maceutical industry. These mem-
various sectors, including aca- of Family Physicians, American bers must state these conflicts
demic immunology, medicine, College of Obstetricians and and must recuse themselves from
and public health. In addition Gynecologists, and American votes regarding vaccines manu-
to the 15 voting members, the College of Nurse-​Midwives. factured by companies from which
committee includes 8 ex officio ACIP workgroups are led by they receive support. The result
members representing federal a member of ACIP who works in of various discussions and votes
agencies and 35 nonvoting repre- close collaboration with a CDC is an ACIP document published
sentatives of liaison organizations workgroup lead staff member. in CDC’s Morbidity and Mortality
with broad responsibilities for Members of the vaccine pharma- Weekly Report (www.cdc.gov/​
vaccine development, admin- ceutical industry may not serve mmwr), representing the offi-
istration of vaccines to various as workgroup members. The cial policy of the Department of
segments of the population, workgroup develops consensus Health and Human Services.

invasive disease are routinely administered in the most current schedules from the CDC Vaccines and
United States, usually in childhood or adolescence. Immunization website (www.cdc.gov/​vaccines/​
Influenza vaccine is routinely recommended for schedules). The text and many tables of this pub-
all people aged ≥6  months, each year. A  dose of lication present recommendations for the use,
herpes zoster (shingles) vaccine is recommended number of doses, dose intervals, adverse reactions,
for adults aged ≥60 years. If a person does not have precautions, and contraindications for vaccines
a history of adequate protection against these dis- and toxoids that may be indicated for travelers.
eases, immunizations appropriate to age and pre- Recommendations for travelers are not always the
vious immunization status should be obtained, same as routine recommendations. For instance,
whether or not international travel is planned. most adults born after 1956 are recommended to
A visit to a clinician for travel-​related immuniza- receive 1 dose of MMR vaccine; however, interna-
tions should be seen as an opportunity to bring an tional travelers of this age are recommended to
incompletely vaccinated person up-​to-​date on his receive 2 doses. For specific vaccines and toxoids,
or her routine vaccinations. additional details on background, adverse reac-
Both the child and adolescent vaccination tions, precautions, and contraindications, refer to
schedules, and an adult vaccination schedule, are the respective ACIP recommendations (www.cdc.
published annually. Clinicians should obtain the gov/​vaccines/​acip/​index.html).



SPACING OF IMMUNOBIOLOGICS exceed its supply, and providers may have diffi-
culty obtaining vaccines. Information on vaccine
Simultaneous Administration shortages and recommendations can be found on
With some exceptions (such as PCV13 and the CDC Vaccines and Immunization website at
PPSV23, as well as PCV13 and MenACWY-​ D www.cdc.gov/​vaccines/​hcp/clinical-resources/
[Menactra]), all commonly used vaccines can shortages.html.
safely and effectively be given simultaneously (on In some cases, a scheduled dose of vaccine
2 the same day) at separate sites without impairing
antibody responses or increasing rates of adverse
may not be given on time. If this occurs, the dose
should be given at the next visit. However, trav-
reactions. This knowledge is particularly helpful elers may forget to return to complete a series or
for international travelers, for whom exposure to for a booster at the specified time. Available data
several infectious diseases might be imminent. indicate that intervals between doses longer than
Simultaneous administration of all indicated vac- those routinely recommended do not affect sero-
cines is encouraged for people who are the rec- conversion rate or titer when the schedule is com-
ommended age to receive these vaccines and for pleted. Consequently, it is not necessary to restart
whom no contraindications exist. If not admin- the series or add doses of any vaccine because of
istered on the same day, an inactivated vaccine an extended interval between doses. There are
may be given at any time before or after a differ- some exceptions to this rule. Some experts rec-
ent inactivated vaccine or a live-​virus vaccine. ommend repeating the series of oral typhoid vac-
The immune response to an injected or intra- cine if the 4-​dose series is extended to more than
nasal live-​virus vaccine (such as MMR, varicella, 3 weeks. If an extended interval passes between
yellow fever, or live attenuated influenza vac- doses of the preexposure rabies vaccine series,
cines) might be impaired if administered within immune status should be assessed by serologic
28  days of another live-​ virus vaccine (within testing 7–​14 days after the final dose in the series.
30 days for yellow fever vaccine). Whenever pos-
sible, injected live-​virus vaccines administered Antibody-​Containing Blood Products
on different days should be given ≥28 days apart Antibody-​ containing blood products from the
(≥30  days for yellow fever vaccine). If 2 injected United States, such as immune globulin (IG) prod-
or intranasal live-​virus vaccines are not admin- ucts, do not interfere with the immune response
istered on the same day but <28  days apart to yellow fever vaccine and are not believed to
(<30  days for yellow fever vaccine), the second interfere with the response to live typhoid, live
vaccine should be repeated in ≥28 days (≥30 days attenuated influenza, rotavirus, or zoster vac-
for yellow fever vaccine). cines. When MMR and varicella vaccines are
Measles and other live-​ virus vaccines may given shortly before, simultaneously with, or after
interfere with the response to tuberculin skin test- an antibody-​containing blood product, response
ing and the interferon-​γ release assay. Tuberculin to the vaccine can be diminished. The dura-
testing, if otherwise indicated, can be done either tion of inhibition of MMR and varicella vaccines
on the day that live-​virus vaccines are adminis- is related to the dose of IG in the product. MMR
tered or 4–​6 weeks later. Tuberculin skin test- and varicella vaccines either should be adminis-
ing is not a prerequisite for administration of any tered ≥2 weeks before receipt of a blood product
vaccine. Oral typhoid vaccine, a live attenuated or should be delayed 3–​11  months after receipt
bacterial vaccine, has not been associated with of the blood product, depending on the dose and
suppressing the response to tuberculosis testing. type of blood product (Table 2-​4).
IG administration may become necessary for
Missed Doses and Boosters another indication after MMR or varicella vaccines
All vaccines require a primary dose or series have been given. In such a situation, the IG may
to ensure immunity, and some require periodic interfere with the immune response to the MMR
repeat, or booster, doses to maintain immu- or varicella vaccines. Vaccine virus replication and
nity. Occasionally, the demand for a vaccine may stimulation of immunity usually occur 2–​3 weeks


5 3

Table 2-​4. Recommended intervals between administration

of antibody-​containing products and
measles-​containing vaccine or varicella-
​containing vaccine1
Blood transfusion

Red blood cells (RBCs), washed 10 mL/​kg (negligible IgG/​kg) IV None

RBCs, adenine-​saline added 10 mL/​kg (10 mg IgG/​kg) IV 3 months

Packed RBCs (hematocrit 65%)2 10 mL/​kg (60 mg IgG/​kg) IV 6 months

Whole blood (hematocrit 35%–​50%)2 10 mL/​kg (80–​100 mg IgG/​kg) IV 6 months

Plasma/​platelet products 10 mL/​kg (160 mg IgG/​kg) IV 7 months

Botulism immune globulin, intravenous 1.5 mL/​kg (75 mg IgG/​kg) IV 6 months

Cytomegalovirus prophylaxis (CMV IGIV) 150 mg/​kg IV (maximum) 6 months

Hepatitis A (IG), duration of international


≤3-​month stay 0.02 mL/​kg (3.3 mg IgG/​kg) IM 3 months

≥3-​month stay 0.06 mL/​kg (10 mg IgG/​kg) IM 3 months

Hepatitis B prophylaxis (HBIG) 0.06 mL/​kg (10 mg IgG/​kg) IM 3 months

Intravenous immune globulin (IVIG)

Replacement therapy 300–​400 mg/​kg IV 8 months

Immune thrombocytopenic purpura (ITP) 400 mg/​kg IV 8 months

800 mg/​kg IV or 1 g/​kg IV 10 months3

Postexposure measles prophylaxis 400 mg/​kg IV 8 months

(includes immunocompromised people)

Postexposure varicella prophylaxis4 400 mg/​kg IV 8 months

Kawasaki disease 2 gm/​kg IV 11 months

Measles prophylaxis (IG)

Immunocompetent contact 0.5 mL/​kg (80 mg IgG/​kg) IM 6 months

Monoclonal antibody to respiratory 15 mg/​kg IM None

syncytial virus (RSV) F protein (Synagis

Rabies prophylaxis (HRIG) 20 IU/​kg (22 mg IgG/​kg) IM 4 months




Table 2-​4. Recommended intervals between administration

of antibody-​containing products and
measles-​containing vaccine or varicella-
​containing vaccine (continued)

Tetanus (TIG) 250 units (10 mg IgG/​kg) IM 3 months

Varicella zoster immune globulin4 125 units/​10 kg (60–​200 mg IgG/​ 5 months

kg) IM (maximum 625 units)

Abbreviations: IG, immune globulin; IM, intramuscular; IV, intravenous.

Adapted from Table 5, CDC. General recommendations on immunization: recommendations of the Advisory Committee
on Immunization Practices (ACIP). MMWR Recomm Rep. 2011 Jan 28;60(RR-​2):1–​61. Updated with information from
CDC. Prevention of measles, rubella, congenital rubella syndrome, and mumps, 2013: summary recommendations of the
Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2013 Jun 14; 62(RR-​04):1–​34. This table is not
intended for determining the correct indications and dosage for the use of IG preparations. Unvaccinated people may not be
fully protected against measles during the entire recommended interval, and additional doses of IG or measles vaccine may
be indicated after measles exposure. Concentrations of measles antibody in an IG preparation can vary by manufacturer’s
lot. For example, more than a 4-​fold variation in the amount of measles antibody titers has been demonstrated in different
IG preparations. Rates of antibody clearance after receipt of an IG preparation can also vary. Recommended intervals are
extrapolated from an estimated half-​life of 30 days for passively acquired antibody and an observed interference with the
immune response to measles vaccine for 5 months after a dose of 80 mg IgG/​kg. Does not include zoster vaccine. Zoster
vaccine may be given with antibody-​containing products.
Assumes a serum IgG concentration of 16 mg/​mL.
Recommendation adapted from Neunert C, Lim W, Crowther M, Cohen A, Solberg L, Crowther MA. The American Society
of Hematology 2011 evidence-​based practice guideline for immune thrombocytopenia. Blood. 2011;117(16):4190–​207
If varicella zoster immune globulin is not available, IVIG can be used. The recommendation for use of IVIG is based on
best judgment of experts and is supported by reports comparing varicella IgG titers measured in both IVIG and varicella
zoster immune globulin preparations and patients given IVIG and varicella zoster immune globulin. Although licensed IVIG
preparations contain antivaricella antibodies, the titer of any specific lot of IVIG is uncertain, because IVIG is not tested
routinely for antivaricella antibodies. No clinical data demonstrating effectiveness of IVIG for postexposure prophylaxis
of varicella are available. The recommended IVIG dose for postexposure prophylaxis of varicella is 1 dose of 400 mg/​kg,
intravenously (see http://​redbook.solutions.aap.org/​chapter.aspx?sectionid=88187270&bookid=1484).
Contains only antibody to respiratory syncytial virus.

after vaccination. If the interval between adminis- serologic testing indicates antibodies have been
tration of one of these vaccines and the subsequent produced.
administration of an IG preparation is ≥14 days, the When IG is given with the first dose of hepatitis
vaccine need not be readministered. If the interval A vaccine, the proportion of recipients who develop
is <14 days, the vaccine should be readministered a protective level of antibody is not affected, but
after the interval shown in Table 2-​4, unless sero- antibody concentrations are lower. Because the final
logic testing indicates that antibodies have been concentrations of antibody are many times higher
produced. Such testing should be performed after than those considered protective, this reduced
the interval shown in Table 2-​4, to avoid detecting immunogenicity is not expected to be clinically rel-
antibodies from the IG preparation. evant. However, the effect of reduced antibody con-
If administration of IG becomes necessary, centrations on long-​term protection is unknown.
MMR or varicella vaccines can be administered IG preparations interact minimally with other
simultaneously with IG, with the recognition inactivated vaccines and toxoids. Other inacti-
that vaccine-​induced immunity can be com- vated vaccines may be given simultaneously, or
promised. The vaccine should be administered at any time interval before or after an antibody-​
at a body site different from that chosen for the containing blood product is used. However, such
IG injection. Vaccination should be repeated vaccines should be administered at different sites
after the interval noted in Table  2-​ 4, unless from the IG.



VACCINATION OF PEOPLE WITH by drugs or other therapies (cancer chemother-

ACUTE ILLNESSES apy, radiation therapy, prolonged high-​dose corti-
Every opportunity should be taken to provide costeroids). It can also include conditions such as
needed vaccinations. The decision to delay vac- asplenia and chronic renal disease.
cination because of a current or recent acute ill- Determination of altered immunocompetence
ness depends on the severity of the symptoms is important because the incidence or severity of
and their cause. Although a moderate or severe some vaccine-​preventable diseases is higher in
acute illness is sufficient reason to postpone vac-
cination, minor illnesses (such as diarrhea, mild
people with altered immunocompetence. There­
fore, certain vaccines (such as meningococcal
upper respiratory infection with or without low-​ B vaccine, pneumococcal polysaccharide vac-
grade fever, or other low-​grade febrile illness) are cines) are recommended specifically for people
not contraindications to vaccination. with altered immunocompetence. Inactivated
People with moderate or severe acute illness, vaccines may be safely administered to a per-
with or without fever, should be vaccinated as son with altered immunocompetence, although
soon as the condition improves. This precaution response to such vaccines may be suboptimal.
is to avoid superimposing adverse effects from These vaccines may need to be repeated after
the vaccine on underlying illness, or mistakenly immune function has improved. If immunocom-
attributing a manifestation of underlying illness to petence does not improve, the usual doses and
the vaccine. Antimicrobial therapy is not a contra- schedules for inactivated vaccines are recom-
indication to vaccination, with several exceptions: mended. Again, the effectiveness of such vaccina-
tions might be suboptimal.
• Antibacterial agents may interfere with the People with altered immunocompetence may
response to oral typhoid vaccine. be at increased risk for an adverse reaction after
administration of live attenuated vaccines because
• Antiviral agents active against herpesviruses of reduced ability to mount an effective immune
(such as acyclovir) may interfere with the
response to varicella-​containing vaccines. response. Live vaccines should generally be
deferred until immune function has improved. If
• Antiviral agents active against influenza virus immune function does not improve, live vaccines
(such as zanamivir and oseltamivir) may are contraindicated. This is particularly important
interfere with the response to live attenuated when planning to give yellow fever vaccine (see
influenza vaccine. Chapter 3, Yellow Fever). For HIV-​infected people
with mild or moderate immunosuppression, MMR
• Antibiotics may interfere with the response to vaccine is recommended and varicella vaccine
the new oral cholera vaccine.
can be considered. For an in-​depth discussion, see
A physical examination or temperature measure- Chapter 8, Immunocompromised Travelers.
ment is not a prerequisite for vaccinating a per-
son who appears to be in good health. Asking if a VACCINATION SCHEDULING FOR
person is ill, postponing a vaccination for some- LAST-​MINUTE TRAVELERS
one with moderate or severe acute illness, and As noted, for people anticipating imminent travel,
vaccinating someone who does not have contra- most vaccine products can be given during the
indications are appropriate procedures for clinic same visit. Unless the vaccines given are booster
immunizations. doses of those typically given during childhood,
vaccines may require a month or more to induce
ALTERED IMMUNOCOMPETENCE a sufficient immune response, depending on the
Altered immunocompetence is a general term vaccine and the number of doses in the series.
that is often used interchangeably with the terms Some vaccines require more than 1 dose for best
immunosuppression, immunodeficiency, and protection. Recommended spacing should be
a weakened immune system. It can be caused maintained between doses (Table  2-​ 5). Doses
either by a disease (leukemia, HIV infection) or given at less than minimum intervals may induce



Table 2-​5. Recommended and minimum ages and intervals

between vaccine doses1,2

Diphtheria and tetanus toxoids and acellular 2 months 6 weeks 4 weeks

2 pertussis vaccine, pediatric (6 weeks
through 6 years) (DTaP)-​14

DTaP-​2 4 months 10 weeks 4 weeks

DTaP-​3 6 months 14 weeks 6 months5

DTaP-​4 15–​18 months 12 months 6 months5

DTaP-​5 4–​6 years 4 years NA

Haemophilus influenzae type b (Hib)-​16 2 months 6 weeks 4 weeks

Hib-​2 4 months 10 weeks 4 weeks

Hib-​37 6 months 14 weeks 8 weeks

Hib-​4 12–​15 months 12 months NA

Hepatitis A (HepA)-​1 12–​23 months 12 months 6 months5

HepA-​2 ≥18 months 18 months NA

Hepatitis B (HepB)-​14 Birth Birth 4 weeks

HepB-​2 1–​2 months 4 weeks 8 weeks

HepB-​38 6–​18 months 24 weeks NA

Herpes zoster9 ≥60 years 60 years NA

Human papillomavirus (HPV)-​110 11–​12 years 9 years 4 weeks

HPV-​2 2 months after 9 years and 12 weeks

dose 1 4 weeks

HPV-​311 6 months after 9 years and NA

dose 1 24 weeks

Inactivated poliovirus (IPV)-​14 2 months 6 weeks 4 weeks

IPV-​2 4 months 10 weeks 4 weeks

IPV-​3 6–​18 months 14 weeks 6 months5




Table 2-​5. Recommended and minimum ages and intervals

between vaccine doses (continued)

IPV-​412 4–​6 years 4 years NA

Influenza, inactivated13 ≥6 months 6 months14 4 weeks

Influenza, live attenuated13 2–​49 years 2 years 4 weeks

Japanese encephalitis, Vero cell (Ixiaro)-​115 ≥2 months ≥2 months 28 days

Ixiaro-​2 28 days after dose 1 ≥2 months and NA

28 days

Measles, mumps, and rubella (MMR)-​116 12–​15 months 12 months17 4 weeks

MMR-​216 4–​6 years 13 months NA

Meningococcal conjugate (MenACWY-​1)18 11–​12 years 2 months (Menveo) 8 weeks19

or 9 months

MenACWY-​2 16 years 4 months (Menveo) 3–​5 years if at

or 11 months increased risk of
(Menactra) disease19

Meningococcal polysaccharide (MPSV4)-​118 NA 2 years 5 years

MPSV4–​2 NA 7 years NA

Pneumococcal conjugate (PCV)-​16 2 months 6 weeks 4 weeks

PCV-​2 4 months 10 weeks 4 weeks

PCV-​3 6 months 14 weeks 8 weeks

PCV-​4 12–​15 months 12 months NA

Pneumococcal polysaccharide (PPSV)-​1 NA 2 years 5 years

PPSV-​220 NA 7 years NA

Rabies-​1 (preexposure) See footnote 21 See footnote 21 7 days

Rabies-​2 7 days after dose 1 7 days after dose 1 14 days

Rabies-​3 21 days after dose 1 21 days after dose 1 NA

Rotavirus (RV)-​122 2 months 6 weeks 4 weeks




Table 2-​5. Recommended and minimum ages and intervals

between vaccine doses (continued)

RV-​222 4 months 10 weeks 4 weeks

RV-​322 6 months 14 weeks NA

Tetanus and reduced diphtheria toxoids (Td) 11–​12 years 7 years 5 years

Tetanus toxoid, reduced diphtheria toxoid, and ≥11 years 7 years NA

reduced acellular pertussis vaccine (Tdap)23

Typhoid, inactivated (ViCPS) ≥2 years ≥2 years NA

Typhoid, live attenuated (Ty21a) ≥6 years ≥6 years See footnote 24

Varicella (Var)-​116 12–​15 months 12 months 12 weeks25

Varicella (Var)-​2 4–​6 years 15 months NA

Yellow fever ≥9 months26 ≥9 months26 10 years

Adapted from Table 1, CDC. General recommendations on immunization: recommendations of the Advisory Committee on
Immunization Practices (ACIP). MMWR Recomm Rep. 2011 Jan 28;60(RR-​2):1–​61.
Combination vaccines are available. Use of licensed combination vaccines is generally preferred over separate injections
of their equivalent component vaccines (CDC. Combination vaccines for childhood immunization. MMWR Recomm
Rep. 1999 May 14;48[RR-​5]:1–​14.). When administering combination vaccines, the minimum age for administration is the
oldest age for any of the individual components (exception: the minimum age for the first dose of MenHibrix is 6 weeks); the
minimum interval between doses is equal to the largest interval of any of the individual components.
See www.cdc.gov/​vaccines/​schedules for recommended revaccination (booster) schedules.
Combination vaccines containing the HepB component are available (DTaP-​HepB-​IPV, HepA-​HepB). DTaP-​HepB-​IPV
should not be administered to infants aged <6 weeks because of the other components ( DTaP, IPV). HepA-​HepB is not
licensed in the United States for children aged <18 years.
Calendar months.
For Hib and PCV, children receiving the first dose of vaccine at ≥7 months of age require fewer doses to complete the
series (see the current childhood and adolescent immunization schedule at www.cdc.gov/​vaccines).
If PRP-​OMP (Pedvax-​Hib, Merck Vaccine Division) was administered at 2 and 4 months of age, a dose at 6 months of age is
not indicated. The final dose has a minimum age of 12 months.
HepB-​3 should be administered ≥8 weeks after Hep B-​2 and ≥16 weeks after Hep B-​1; it should not be administered
before age 24 weeks.
Herpes zoster (shingles) vaccine is recommended as a single dose for people aged ≥60 years.
Bivalent HPV vaccine is approved for girls/​women aged 10–​26 years. It is recommended to prevent cervical and other anogenital
cancers and precursors for girls/​women aged 11–​26 years. Quadrivalent HPV and 9vHPV vaccines are approved for boys/​men and
girls/​women aged 9–​26 years. They are recommended to prevent cervical and other anogenital cancers, precursors, and genital
warts for girls/​women aged 11–​26 years. They are recommended for boys/​men aged 11–​21 years and high-​risk boys or men
(men who have sex with men, HIV-​positive men, or immunocompromised men) aged 22–​26 years. They may be given to girls aged
9–​10 years to prevent the same diseases, and to boys/​men aged 9–​10 years and 22–​26 years to prevent genital warts.
The third dose of HPV should be administered ≥12 weeks after the second and ≥24 weeks after the first. Dose 3 need not
be repeated if administered ≥16 weeks after dose 1, as long as a minimum interval of 4 weeks is maintained between dose 1
and dose 2 and as long as a minimum interval of 12 weeks is maintained between dose 2 and dose 3.
For people receiving an all-​IPV or all-​OPV series, if the third dose is given after the fourth birthday, a fourth dose is not
needed. For IPV, the next-​to-​last and the last dose must be spaced by 6 months.
Two doses of influenza vaccine are recommended for children aged <9 years who are receiving the vaccine for the first
time, and for certain incompletely vaccinated children (see reference 2).
The minimum age for inactivated influenza vaccine varies by vaccine manufacturer. See package insert for vaccine-​specific
minimum ages.
Ixiaro is approved by the Food and Drug Administration for people aged ≥2 months.
Combination MMR-​varicella (MMRV) can be used for children aged 12 months through 12 years
If an infant 6–​11 months of age is traveling internationally, a dose of MMR is recommended but does not count toward the
2-​dose recommended series. The next dose should be administered at 12–​15 months of age and a minimum of 4 weeks
from the international travel dose.



Table 2-​5. Recommended and minimum ages and intervals

between vaccine doses (continued)
Infants aged 2–​18 months. Routine vaccination with HibMenCY –​TT (MenHibrix) or Menveo (4-​dose primary series) is
recommended for infants aged 2–​18 months who are at increased risk for meningococcal disease. The first dose of either
vaccine may be administered as early as age 6 weeks. The fourth dose may be administered as late as age 18 months.
Infants and children who received Hib-​MenCY-​TT and are traveling to areas with high endemic rates of meningococcal
disease such as the African “meningitis belt” are not protected against serogroups A and W-​135 and should receive a
quadrivalent meningococcal vaccination before travel.
People aged 9 months through 55 years. People aged 9 months through 55 years at increased risk for meningococcal
disease should receive Menveo or Menactra. Infants aged 9–​23 months are recommended to receive a 2-​dose primary
series with a dosing interval of 12 weeks.
People aged ≥56 years. Menomune is the only licensed meningococcal vaccine for adults aged ≥56 years and is
immunogenic in older adults. For adults who have received a conjugate meningococcal vaccine previously, limited data
demonstrate a higher antibody response after a subsequent dose of a conjugate vaccine compared with a subsequent
dose of Menomune. For meningococcal vaccine-​naïve people aged ≥56 years who anticipate requiring a single dose
of meningococcal vaccine (such as travelers and people at risk as a result of a community outbreak), Menomune is
preferred. For people now aged ≥56 years who were vaccinated previously with a meningococcal conjugate vaccine
and are recommended for revaccination or for whom multiple doses are anticipated (such as people with asplenia and
microbiologists), a conjugate vaccine is preferred.
Revaccination with meningococcal vaccine is recommended for people previously vaccinated who remain at high risk for
meningococcal disease. MenACWY is preferred for revaccinating people aged 2–​55 years (CDC. Prevention and control of
meningococcal disease. Recommendations of the Advisory Committee on Immunization Practices [ACIP]. MMWR Recomm
Rep. 2013 Mar 22;62[RR-​2]:1–​28.).
A second dose of PPSV is recommended for people aged ≥65 years who received a first dose at an age <65 years
and at a 5-​year minimum interval. A second dose is also recommended for people aged <65 years at highest risk for
serious pneumococcal infection and those who are likely to have a rapid decline in pneumococcal antibody concentration
(CDC. Updated recommendations for prevention of invasive pneumococcal disease among adults using the 23-​valent
pneumococcal polysaccharide vaccine [PPSV23]. MMWR Recomm Rep. 2010;59[34]:1102–​6.).
There is no minimum age for preexposure immunization for rabies (CDC. Human rabies prevention—​United States,
2008: recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep. 2008 May
The first dose of RV must be administered by 14 weeks and 6 days of age. The vaccine series should not be started at ≥15
weeks of age. The final dose in the series should be administered by age 8 months, 0 days. If Rotarix rotavirus vaccine is
administered at 2 and 4 months of age, a dose at 6 months of age is not indicated.
Only 1 dose of Tdap is recommended. Subsequent doses should be given as Td. Children aged 7–​10 years who are not fully
vaccinated against pertussis and for whom no contraindication to pertussis vaccine exists should receive a single dose of Tdap.
If additional doses of tetanus and diphtheria toxoid-​containing vaccines are needed, then children aged 7–​10 years should
be vaccinated according to catch-​up guidance, with Tdap preferred as the first dose. Tdap vaccine, when indicated, should
be administered regardless of the interval since the last dose of Td vaccine. For management of a tetanus-​prone wound,
the minimum interval after a previous dose of any tetanus-​containing vaccine is 5 years. A dose of Tdap is recommended for
pregnant women, preferably at 27–​36 weeks’ gestation, regardless of history of previous Tdap vaccination.
Oral typhoid vaccine is recommended to be administered 1 hour before a meal with a cold or lukewarm drink
(temperature not to exceed body temperature—​98.6°F [37°C]) on alternate days, for a total of 4 doses.
The minimum interval from Var-​1 to Var-​2 for people beginning the series at ≥13 years of age is 4 weeks.
Yellow fever vaccine may be administered to children aged <9 months in certain situations (CDC. Yellow fever
vaccine: recommendations of the Advisory Committee on Immunization Practices [ACIP]. MMWR Recomm Rep. 2010
Jul 30;59[RR-​7]:1–​27.).

lower antibody response than if given according shorter than the recommended minimum is dis-
to the recommended schedule. Intervals between couraged. Table  2-​5 lists the minimum age and
doses longer than those routinely recommended minimum interval between doses for vaccines
do not decrease the immune response when the routinely recommended in the United States.
schedule is completed. Consequently, it is not Because some travelers visit their health
necessary to restart the series or add doses of any care providers at the last minute before depar-
vaccine because of an extended interval between ture, studies have been performed to deter-
doses, with the exceptions mentioned previously mine whether accelerated scheduling is
(oral typhoid vaccine and rabies vaccine). If a trav- adequate. This concern is primarily the case
eler needs yellow fever vaccination to meet a coun- for hepatitis B vaccine or the combined hep-
try requirement under the International Health atitis A  and B vaccine. An accelerated sched-
Regulations, the yellow fever vaccine is not con- ule for combined hepatitis A  and B vaccine
sidered valid until 10 days after administration. has been approved by the Food and Drug
Administration of a vaccine earlier than the Administration (FDA). It is unclear what level
recommended minimum age or at an interval of protection any given traveler will have if he



or she does not complete a full series of multi- an allergy should receive the vaccine. No recom-
dose vaccination. mended vaccine contains penicillin or penicillin
derivatives. Some vaccines (MMR vaccine, inac-
ALLERGY TO VACCINE tivated polio vaccine [IPV], hepatitis A  vaccine,
COMPONENTS some hepatitis B vaccines, some influenza vac-
Vaccine components can cause allergic reac- cines, rabies vaccine, varicella vaccine, and small-
tions in some recipients. These reactions can be pox vaccine) contain trace amounts of neomycin
2 local or systemic and can include anaphylaxis or
anaphylactic-​like responses. The vaccine compo-
or other antibiotics; the amount is less than would
normally be used for the skin test to determine
nents responsible can include the vaccine anti- hypersensitivity. However, people who have expe-
gen, animal proteins, antibiotics, preservatives rienced anaphylactic reactions to this antibiotic
(such as thimerosal), or stabilizers (such as gela- generally should not receive these vaccines. Most
tin). The most common animal protein allergen is often, neomycin allergy is a contact dermatitis—​
egg protein in vaccines prepared by using embry- a manifestation of a delayed-​type (cell-​mediated)
onated chicken eggs (influenza and yellow fever immune response rather than anaphylaxis. A his-
vaccines). People with a history of egg allergy who tory of delayed-​type reactions to neomycin is not
have experienced only hives after exposure to egg a contraindication to receiving these vaccines.
should receive influenza vaccine. Any licensed Thimerosal, an organic mercurial compound
influenza vaccine that is otherwise appropri- in use since the 1930s, has been added to cer-
ate for the recipient’s age and health status may tain immunobiologic products as a preservative.
be used. Thimerosal is present at preservative concentra-
People who report having had reactions to tions in multidose vials of some brands of vaccine.
egg involving symptoms other than hives, such Receiving thimerosal-​ containing vaccines has
as angioedema, respiratory distress, lighthead- been postulated to lead to induction of allergy.
edness, or recurrent emesis, or who required However, there is limited scientific evidence for
epinephrine or another emergency medical inter- this assertion. Allergy to thimerosal usually con-
vention, may similarly receive any licensed influ- sists of local delayed-​type hypersensitivity reac-
enza vaccine that is otherwise appropriate for the tions. Thimerosal elicits positive delayed-​ type
recipient’s age and health status. If a person has hypersensitivity patch tests in 1%–​18% of people
a severe egg sensitivity or has a positive skin test tested, but these tests have limited or no clinical
to yellow fever vaccine but the vaccination is rec- relevance. Most people do not experience reac-
ommended because of their travel destination-​ tions to thimerosal administered as a component
specific risk, desensitization can be performed of vaccines, even when patch or intradermal tests
under direct supervision of a physician experi- for thimerosal indicate hypersensitivity. A  local-
enced in the management of anaphylaxis. In such ized or delayed-​type hypersensitivity reaction to
circumstances, both yellow fever and influenza thimerosal is not a contraindication to receipt of a
vaccines should be administered in an inpatient vaccine that contains thimerosal.
or outpatient medical setting. Vaccine adminis- Since mid-​ 2001, vaccines routinely recom-
tration should be supervised by a health care pro- mended for infants have been manufactured
vider who is able to recognize and manage severe without thimerosal as a preservative. Additional
allergic reactions. A previous severe allergic reac- information about thimerosal and the thimerosal
tion to any vaccine, regardless of the component content of vaccines is available on the FDA web-
suspected of being responsible for the reaction, is site (www.fda.gov/​cber/​vaccine/​thimerosal.htm).
a contraindication to future receipt of the vaccine.
Some vaccines contain a preservative or trace REPORTING ADVERSE EVENTS
amounts of antibiotics to which people might AFTER IMMUNIZATION
be allergic. Providers administering the vaccines Modern vaccines are extremely safe and effective.
should carefully review the prescribing informa- Benefits and risks are associated with the use of
tion before deciding if the rare person with such all immunobiologics—​no vaccine is completely


3 4

effective or completely safe for all recipients. The method of administration of injectable vac-
Adverse events after immunization have been cines depends in part on the presence of an adju-
reported with all vaccines, ranging from frequent, vant in some vaccines. The term adjuvant refers
minor, local reactions to extremely rare, severe, to a vaccine component distinct from the anti-
systemic illness, such as that associated with yel- gen, which enhances the immune response to the
low fever vaccine. Adverse events following spe- antigen. Vaccines containing an adjuvant (DTaP,
cific vaccines and toxoids are discussed in detail DT, HPV, Td, Tdap, pneumococcal conjugate, Hib,
in each ACIP statement. In the United States,
clinicians are required by law to report selected
hepatitis A, hepatitis B) should be injected into a
muscle mass, because administration subcutane-
adverse events occurring after vaccination with ously or intradermally can cause local irritation,
any vaccine in the recommended childhood induration, skin discoloration, inflammation, and
series. In addition, CDC strongly recommends granuloma formation. Detailed discussion and
that all vaccine adverse events be reported to recommendations about vaccination of people
the Vaccine Adverse Event Reporting System with bleeding disorders or receiving anticoagu-
(VAERS), even if a causal relation to vaccination is lant therapy are available in the ACIP general rec-
not certain. VAERS reporting forms and informa- ommendations on immunization.
tion are available electronically at www.vaers.hhs. Routes of administration are recommended
gov, or they may be requested by telephone: 800-​ by the manufacturer for each immunobio-
822-​7967 (toll-​
free). Clinicians are encouraged logic. Deviation from the recommended route of
to report electronically at https://​vaers.hhs.gov/​ administration may reduce vaccine efficacy or
esub/​step1. increase local adverse reactions. Detailed recom-
mendations on the route and site for all vaccines
INJECTION ROUTE AND have been published in ACIP recommendations; a
INJECTION SITE compiled list of these publications is available on
Injectable vaccines are administered by intra- the CDC website at www.cdc.gov/​vaccines/​hcp/​
muscular, intradermal, and subcutaneous routes. acip-​recs (also see Table B-​1 in Appendix B).

1. CDC. General recommendations on immuniza- PCV13 and PPSV23 vaccines: recommendations of
tion: recommendations of the Advisory Committee on the Advisory Committee on Immunization Practices
Immunization Practices (ACIP). MMWR Recomm Rep. (ACIP). MMWR Morb Mortal Wkly Rep. 2015 Sep
2011 Jan 28;60(2):1–​6 4. 4;64(64):944–​7.
2. CDC. Updated recommendations for use of tetanus 6. Kretsinger K, Broder KR, Cortese MM, Joyce MP, Ortega-​
toxoid, reduced diphtheria toxoid, and acellular Sanchez I, Lee GM, et al. Preventing tetanus, diphtheria,
pertussis (Tdap) vaccine in adults aged 65 years and and pertussis among adults: use of tetanus toxoid,
older—​Advisory Committee on Immunization Practices reduced diphtheria toxoid and acellular pertussis vac-
(ACIP), 2012. MMWR Morb Mortal Wkly Rep. 2012 Jun cine recommendations of the Advisory Committee on
29;61(25):468–​70. Immunization Practices (ACIP) and recommendation
3. Cohn AC, MacNeil JR, Clark TA, Ortega-​Sanchez IR, of ACIP, supported by the Healthcare Infection Control
Briere EZ, Meissner HC, et al. Prevention and control Practices Advisory Committee (HICPAC), for use of
of meningococcal disease: recommendations of the Tdap among health-​care personnel. MMWR Recomm
Advisory Committee on Immunization Practices Rep. 2006 Dec 15;55(RR-​17):1–​37.
(ACIP). MMWR Recomm Rep. 2013 Mar 22;62(2):1–​28. 7. McLean HQ, Fiebelkorn AP, Temte JL, Wallace GS,
4. Grohskopf LA, Sokolow LZ, Olsen SJ, Bresee JS, Broder CDC. Prevention of measles, rubella, congenital rubella
KR, Karron RA, et al. Prevention and control of sea- syndrome, and mumps, 2013: summary recommen-
sonal influenza with vaccines: recommendations of dations of the Advisory Committee on Immunization
the Advisory Committee on Immunization Practices—​ Practices (ACIP). MMWR Recomm Rep. 2013 Jun
United States, 2013–​2014. MMWR Recomm Rep. 2015 14;62(RR-​0 4):1–​34.
Aug 7;64(30):818–​25. 8. Nuorti JP, Whitney CG, CDC. Prevention of pneumo-
5. Kobayashi M, Bennett NM, Gierke R, Almendares coccal disease among infants and children—​use of 13-​
O, Moore MR, Whitney CG, et al. Intervals between valent pneumococcal conjugate vaccine and 23-​valent



pneumococcal polysaccharide vaccine: recommen- Reporting System (VAERS). Vaccine. 2015 Aug

dations of the Advisory Committee on Immunization 26;33(36):4398–​4 05.
Practices (ACIP). MMWR Recomm Rep. 2010 Dec 10. Staples JE, Gershman M, Fischer M, CDC. Yellow fever
10;59(RR-​11):1–​18. vaccine: recommendations of the Advisory Committee
9. Shimabukuro TT, Nguyen M, Martin D, DeStefano on Immunization Practices (ACIP). MMWR Recomm
F. Safety monitoring in the Vaccine Adverse Event Rep. 2010 Jul 30;59(RR-​7):1–​27.

Ilan Youngster, Elizabeth D. Barnett

Vaccines and medications are prescribed fre- to yellow fever and mumps components, com-
quently in pretravel consultations, and potential pared with responses following separate vaccina-
interactions between vaccines and medications, tion with MMR and yellow fever vaccines 30 days
including those already taken by the traveler, apart. (See “Simultaneous Administration” in
must be considered. The importance of this Yellow Fever section, Chapter 3.) A single study
topic is highlighted by a study identifying poten- suggested that in adults, concomitant adminis-
tial drug–​drug interactions with travel-​ related tration of the 13-​valent pneumococcal conjugate
medications in 45% of travelers using chronic vaccine with the trivalent inactivated influenza
medications. Although a comprehensive list of vaccine results in lower immunogenicity to the
interactions is beyond the scope of this section, PCV13 components. However, the clinical signifi-
some of the more serious interactions of com- cance of this observation is uncertain, as responses
monly used travel-​related vaccines and medica- still met FDA criteria of noninferiority. In infants
tions are discussed here. given PCV13 and inactivated influenza vaccine
concomitantly, the risk of fever and febrile seizure
is slightly increased. However, this risk must be
INTERACTIONS BETWEEN weighed against the need for both vaccines before
VACCINES travel and the time available to separate them.
In general, concomitant administration of mul-
tiple vaccines, including live attenuated immu-
nizations, is safe and effective. Administering a
live-​virus vaccine within 4 weeks after adminis-
tration of another live-​virus vaccine can decrease Live Attenuated Oral Typhoid and
immunogenicity to the second administered vac- Cholera Vaccines
cine. This observation has given rise to the rec- Live attenuated vaccines should generally be
ommendation that live-​virus vaccines should be avoided in immunocompromised travelers, includ-
administered the same day or ≥4 weeks apart. ing those who are taking immunomodulators,
If the 4-​week span is not achievable, the second calcineurin inhibitors, cytotoxic agents, antimetab-
vaccine may be administered sooner to afford olites, and high-​dose steroids (see Table 8-​1).
some protection, but it should be readminis- Antimicrobial agents may be active against
tered ≥4 weeks later if the traveler is at continued the vaccine strain in the oral typhoid and cholera
risk. A  study examining concurrent administra- vaccines and may prevent an adequate immune
tion of the yellow fever vaccine with the measles-​ response to the vaccine. Therefore, oral typhoid
mumps-​rubella (MMR) vaccine in 12-​month-​old or cholera vaccine should not be given to peo-
children showed slightly reduced immunogenicity ple taking antibacterial agents. Vaccination with


5 4

oral typhoid vaccine should be delayed for >72 combination to treat people with uncomplicated
hours after the administration of any such agent. Plasmodium falciparum malaria), potentially
Parenteral typhoid vaccine may be a more appro- causing fatal prolongation of the QTc interval.
priate choice for these people. Live attenuated Lumefantrine should therefore be avoided or used
oral cholera vaccine should not be given to peo- with caution in patients taking mefloquine pro-
ple who have received oral or parenteral antibi- phylaxis. Although no conclusive data are availa­
otics within 14 days prior to vaccination. There is ble with regard to coadministration of mefloquine
no parenteral cholera vaccine currently available,
and no killed oral cholera vaccines are licensed in
and other drugs that may affect cardiac conduc-
tion, mefloquine should be used with caution
the United States. or avoided in patients taking antiarrhythmic or
Chloroquine and atovaquone-​ proguanil at β-​blocking agents, calcium-​ channel blockers,
doses used for malaria chemoprophylaxis may be antihistamines, H1-​blocking agents, tricyclic anti-
given concurrently with the oral typhoid vaccine. depressants, selective serotonin reuptake inhibi-
Data from an older formulation of the CVD 103-​ tors (SSRIs), or phenothiazines. Mefloquine may
HgR oral cholera vaccine suggest that the immune also lower plasma levels of a number of anticon-
response to the vaccine may be diminished when vulsants, such as valproic acid, carbamazepine,
it is given concomitantly with chloroquine. Live phenobarbital, and phenytoin; concurrent use of
attenuated oral cholera vaccine should be given mefloquine with these agents should be avoided.
at least 10 days before beginning antimalarial pro- In general, mefloquine should be avoided in trav-
phylaxis with chloroquine, although a study in elers with a history of seizures, mood disorders
children using the oral cholera vaccine suggested or psychiatric disease. Mefloquine can also lead
no decrease in immunogenicity when given with to increased levels of calcineurin inhibitors and
atovaquone-​proguanil. mTOR inhibitors (tacrolimus, cyclosporine A,
and sirolimus). Potent CYP3A4 inhibitors such
Rabies Vaccine as macrolides (azithromycin, clarithromycin,
Concomitant use of chloroquine may reduce the erythromycin), azole antifungals (ketoconazole,
antibody response to intradermal rabies vaccine voriconazole, posaconazole and itraconazole),
administered for preexposure vaccination. The SSRIs ( fluoxetine, sertraline, fluvoxamine), (anti­
intramuscular route should be used for people retroviral protease inhibitors (ritonavir, lopinavir,
taking chloroquine concurrently. (Currently, intra- darunavir, atazanavir, saquinavir), and cobici-
dermal administration of rabies vaccine is not stat (available in a combination with elvitegravir)
approved in the United States.) may increase the levels of mefloquine, increasing
the risk for QT prolongation. CYP3A4 inducers
INTERACTIONS BETWEEN such as efavirenz, nevirapine, etravirine, rifampin,
ANTIMALARIALS AND SELECTED rifabutin, St John’s wort and glucocorticoids may
OTHER DRUGS reduce plasma concentrations of mefloquine, and
This section describes some of the more com- concurrent use should be avoided. Concurrent
monly encountered drug interactions. Any time use of mefloquine with the direct-​acting protease
a new medication is prescribed, clinicians should inhibitors boceprevir and telaprevir used to treat
check for any interactions and inform the traveler hepatitis C should also be avoided. The newer
of the potential risk. direct-​
acting protease inhibitors (grazoprevir,
paritaprevir, simeprevir) are believed to be asso-
Mefloquine ciated with fewer drug–​drug interactions, but as
Mefloquine may interact with several catego- safety data are lacking, alternatives to mefloquine
ries of drugs, including other antimalarial drugs, could be considered pending additional data.
drugs that alter cardiac conduction, and anti-
convulsants. Mefloquine is associated with Chloroquine
increased toxicities of the antimalarial drug lume- Chloroquine may increase risk of prolonged QTc
fantrine (available in the United States in fixed interval when given with other QT-​prolonging



agents (such as sotalol, amiodarone, and lume- reverse transcriptase inhibitors nevirapine, etra-
fantrine), and the combination should be avoided. virine, and efavirenz, resulting in decreased levels
The antiretroviral rilpivirine has also been shown of atovaquone-​proguanil. Despite the potential
to prolong QTc, and coadministration should be for interactions, atovaquone-​proguanil is well tol-
avoided. Chloroquine inhibits CYP2D6; when erated in most patients receiving these antivirals
given concomitantly with substrates of this and is the preferred antimalarial for short-​term
enzyme (such as metoprolol, propranolol, fluoxe- travel. Cimetidine and fluvoxamine interfere with
2 tine, paroxetine, flecainide), increased monitoring
for side effects may be warranted. Chloroquine
the metabolism of proguanil and should therefore
be avoided.
absorption may be reduced by antacids or kaolin;
≥4 hours should elapse between doses of these Doxycycline
medications. Concomitant use of cimetidine and Phenytoin, carbamazepine, and barbiturates may
chloroquine should be avoided, as cimetidine can decrease the half-​life of doxycycline. Patients on
inhibit the metabolism of chloroquine and may anticoagulants may need to reduce their antico-
increase drug levels. CYP3A4 inhibitors such as agulant dose while taking doxycycline because of
ritonavir, ketoconazole, and erythromycin may its ability to depress plasma prothrombin activity.
also increase chloroquine levels, and concomitant Absorption of tetracyclines may be impaired by bis-
use should be avoided. Chloroquine inhibits bioa- muth subsalicylate, preparations containing iron,
vailability of ampicillin, and 2 hours should elapse and antacids containing calcium, magnesium, or
between doses. Chloroquine is also reported to aluminum; these preparations should not be taken
decrease the bioavailability of ciprofloxacin and within 3 hours of taking doxycycline. Doxycycline
methotrexate. Chloroquine may increase digoxin may interfere with the bactericidal activity of pen-
levels; increased digoxin monitoring is warranted. icillin, so these drugs, in general, should not be
Use of chloroquine could possibly also lead to taken together. Doxycycline has no known interac-
increased levels of calcineurin inhibitors and tion with antiretroviral agents, but concurrent use
should be used with caution. may lead to increased levels of calcineurin inhibi-
tors and mTOR inhibitors (sirolimus).
Tetracycline, rifampin, and rifabutin may reduce
plasma concentrations of atovaquone and should
not be used concurrently with atovaquone-​
proguanil. Metoclopramide may reduce bioavail-
ability of atovaquone; unless no other antiemetics Azithromycin
are available, this antiemetic should not be used Close monitoring for side effects of azithromy-
to treat the vomiting that may accompany use cin is recommended when azithromycin is used
of atovaquone at treatment doses. Atovaquone-​ with nelfinavir. Increased anticoagulant effects
proguanil should not be used with other medica- have been noted when azithromycin is used with
tions that contain proguanil. Patients on warfarin warfarin; monitoring prothrombin time is rec-
may need to reduce their anticoagulant dose or ommended for people taking these drugs con-
monitor their prothrombin time more closely while comitantly. Additive QTc prolongation may occur
taking atovaquone-​proguanil, although coadmin- when azithromycin is used with the antimalarial
istration of these drugs is not contraindicated. artemether, and concomitant therapy should be
The use of novel oral anticoagulants (dabiga- avoided. Drug interactions have been reported
tran, rivaroxaban and apixaban) is not expected with macrolides and antiretroviral protease inhib-
to cause significant interactions, and their use itors, as well as efavirenz and nevirapine, and
has been suggested as an alternative in patients can increase risk of QTc prolongation, though a
in need of anticoagulation. Atovaquone-​proguanil short treatment course is not contraindicated for
may interact with the antiretroviral protease those without an underlying cardiac abnormal-
inhibitors ritonavir, darunavir, atazanavir, indina- ity. Concurrent use with macrolides may lead to
vir, and lopinavir, in addition to the nonnucleoside increased levels of calcineurin inhibitors.



Fluoroquinolones These agents should not be taken within 30 min-

Increase in the international normalized ratio has utes of acetazolamide.
been reported when levofloxacin and warfarin are
used concurrently. Concurrent administration of Dexamethasone
ciprofloxacin and antacids that contain magne- Dexamethasone interacts with multiple classes of
sium or aluminum hydroxide may reduce bioa- drugs. Using this drug to treat altitude illness may,
vailability of ciprofloxacin. Ciprofloxacin decreases however, be life-​saving. Interactions may occur
clearance of theophylline and caffeine; theophyl-
line levels should be monitored when ciprofloxacin
with dexamethasone and the following drugs and
drug classes: macrolide antibiotics, anticholines-
is used concurrently. Ciprofloxacin and other fluo- terases, anticoagulants, hypoglycemic agents, iso-
roquinolones should not be used with tizanidine. niazid, digitalis preparations, oral contraceptives,
Sildenafil should not be used in patients on cip- and phenytoin.
rofloxacin, as concomitant use is associated with
increased rates of adverse effects. Fluoroquinolones DRUG INTERACTIONS IN
have no known interaction with antiretroviral PATIENTS ON HIV MEDICATIONS
agents, but concurrent use may increase levels of Patients with HIV can be a challenge in the pre-
calcineurin inhibitors and fluoroquinolone levels, travel consultation (See Chapter 8, Immunocom­
and use should reflect renal function. promised Travelers). A  study in Europe showed
that as many as 29% of HIV-​positive travelers do
Rifaximin not disclose their disease and medication sta-
Rifaximin is not absorbed in appreciable amounts tus when seeking pretravel advice. Antiretroviral
by intact bowel, and no clinically significant drug medications have multiple drug interactions,
interactions have been reported to date with especially through activation or inhibition of
rifaximin. CYP3A4 and CYP2D6. There are several reports
of antimalarial treatment failure and prophy-
laxis failure in patients on protease inhibitors and
INTERACTIONS WITH DRUGS both nucleoside and nonnucleoside reverse tran-
USED FOR TRAVEL TO HIGH scriptase inhibitors, whereas entry and integrase
ALTITUDES inhibitors are not a common cause of drug–​drug
Acetazolamide interactions with commonly administered travel-​
Acetazolamide produces alkaline urine that can related medications. A  number of the poten-
increase the rate of excretion of barbiturates and tial interactions are listed above, and 2 excellent
salicylates and may potentiate salicylate toxic- resources for HIV medication interactions can
ity, particularly if taking a high dose of aspirin. be found at www.hiv-​druginteractions.org and at
Decreased excretion of dextroamphetamine, anti- www.aidsinfo.nih.gov.
cholinergics, mecamylamine, ephedrine, mexile-
tine, or quinidine may also occur. Hypokalemia INTERACTIONS WITH
caused by corticosteroids may be potentiated by HERBAL OR NUTRITIONAL
concurrent use of acetazolamide. Acetazolamide SUPPLEMENTS
should not be given to patients taking the anticon- As many as 30% of travelers take herbal or nutri-
vulsant topiramate, as concurrent use is associ- tional supplements, and many consider them
ated with increased toxicity. Increased monitoring to be of no clinical relevance, and will not dis-
of cyclosporine, tacrolimus, and sirolimus is war- close their use unless specifically asked during
ranted if these drugs are given with acetazol- the pretravel consultation. Special attention
amide. Concurrent administration of metformin should be given to supplements that activate or
and acetazolamide should be done with caution inhibit CYP2D6 or CYP3A4 like ginseng, hyper-
as there may be an additive risk for lactic acido- icum, St. John’s wort and grapefruit extract.
sis. Acetaminophen and diclofenac sodium form Coadministration with medications that are
complex bonds with acetazolamide in the stom- substrates of CYP2D6 or 3A4 should be avoided
ach’s acidic environment, impairing absorption. (chloroquine, mefloquine, macrolides).



1. Frenck RW Jr, Gurtman A, Rubino J, Smith W, van on the immune response to yellow fever vaccine and a
Cleeff M, Jayawardene D, et al. Randomized, controlled combined vaccine against measles, mumps and rubella.
trial of a 13-​valent pneumococcal conjugate vaccine Vaccine. 2011 Aug 26;29(37):6327–​34.
administered concomitantly with an influenza vac- 5. Nielsen US, Jensen-​Fangel S, Pedersen G, Lohse N,
cine in healthy adults. Clin Vaccine Immunol. 2012 Pedersen C, Kronborg G, et al. Travelling with HIV: a
Aug;19(8):1296–​303. cross sectional analysis of Danish HIV-​infected patients.

2 2. Jabeen E, Qureshi R, Shah A. Interaction of antihyper-

tensive acetazolamide with nonsteroidal anti-​inflam-
matory drugs. J Photochem Photobiol B. 2013 Aug
Travel Med Infect Dis. 2014 Jan-​Feb;12(1):72–​8.
6. Ridtitid W, Wongnawa M, Mahatthanatrakul W,
Raungsri N, Sunbhanich M. Ketoconazole increases
5;125:155–​63. plasma concentrations of antimalarial mefloquine in
3. Kollaritsch H, Que JU, Kunz C, Wiedermann G, Herzog C, healthy human volunteers. J Clin Pharm Ther. 2005
Cryz SJ Jr. Safety and immunogenicity of live oral cholera Jun;30(3):285–​9 0.
and typhoid vaccines administered alone or in combina- 7. Stienlauf S, Meltzer E, Kurnik D, Leshem E, Kopel
tion with antimalarial drugs, oral polio vaccine, or yellow E, Streltsin B, et al. Potential drug interactions
fever vaccine. J Infect Dis. 1997 Apr;175(4):871–​5. in travelers with chronic illnesses: a large retro-
4. Nascimento Silva JR, Camacho LA, Siqueira MM, Freire spective cohort study. Travel Med Infect Dis. 2014
Mde S, Castro YP, Maia Mde L, et al. Mutual interference Sep-​Oct;12(5):499–​5 04.

Self-​Treatable Conditions
Bradley A. Connor

Travelers’ diarrhea (TD) is the most predictable symptoms and collectively account for approxi-
travel-​related illness. Attack rates range from 30% mately 10% of diagnoses in longer-​term travelers.
to 70% of travelers, depending on the destination What is commonly known as “food poisoning”
and season of travel. Traditionally, it was thought involves the ingestion of preformed toxins in food.
that TD could be prevented by following simple In this syndrome, vomiting and diarrhea may both
recommendations such as “boil it, cook it, peel it, be present, but symptoms usually resolve sponta-
or forget it,” but studies have found that people neously within 12 hours.
who follow these rules may still become ill. Poor
hygiene practice in local restaurants is likely the INFECTIOUS AGENTS
largest contributor to the risk for TD. Bacteria are the most common cause of TD.
TD is a clinical syndrome that can result from Overall, the most common pathogen is enterotoxi-
a variety of intestinal pathogens. Bacterial patho- genic Escherichia coli, followed by Campylobacter
gens are the predominant risk, thought to account jejuni, Shigella spp., and Salmonella spp. Entero­
for up to 80%–​90% of TD. Intestinal viruses usually aggregative and other E. coli pathotypes are also
account for at least 5%–​8% of illnesses, although commonly found in cases of TD. There is increas-
improved diagnostics may increase recognition ing discussion of Aeromonas spp., Plesiomonas
of norovirus infections in the future. Infections spp., and newly recognized pathogens (Acrobacter,
with protozoal pathogens are slower to manifest Larobacter, enterotoxigenic Bacteroides fragilis) as



potential causes of TD as well. Viral diarrhea can plumbing or latrines, the amount of stool con-
be caused by a number of pathogens, including tamination in the environment will be higher
norovirus, rotavirus, and astrovirus. and more accessible to flies. Inadequate electri-
Giardia is the main protozoal pathogen cal capacity may lead to frequent blackouts or
found in TD. Entamoeba histolytica is a relatively poorly functioning refrigeration, which can result
uncommon cause of TD, and Cryptosporidium is in unsafe food storage and an increased risk for
also relatively uncommon. The risk for Cyclospora disease. Lack of safe water may lead to contami-
is highly geographic and seasonal:  the most
well-​known risks are in Nepal, Peru, Haiti, and
nated foods and drinks prepared with such water;
inadequate water supply may lead to shortcuts in
Guatemala. Dientamoeba fragilis is a flagellate cleaning hands, surfaces, utensils, and foods such
occasionally associated with diarrhea in trav- as fruits and vegetables. In addition, handwashing
elers. Most of the individual pathogens are dis- may not be a social norm and could be an extra
cussed in their own sections in Chapter  3, and expense; thus there may be no handwashing sta-
persistent diarrhea in returned travelers is dis- tions in food preparation areas. In destinations
cussed in Chapter 5. in which effective food handling courses have
been provided, the risk for TD has been demon-
OCCURRENCE strated to decrease. However, even in developed
The most important determinant of the caus- countries, pathogens such as Shigella sonnei have
ative organism and risk for TD is travel destina- caused TD linked to handling and preparation of
tion. The world is generally divided into 3 grades food in restaurants.
of risk: low, intermediate, and high.
• Low-​risk countries include the United States, CLINICAL PRESENTATION
Canada, Australia, New Zealand, Japan, and Bacterial and viral TD presents with the sud-
countries in Northern and Western Europe. den onset of bothersome symptoms that can
range from mild cramps and urgent loose stools
• Intermediate-​risk countries include those to severe abdominal pain, fever, vomiting, and
in Eastern Europe, South Africa, and some bloody diarrhea, although with norovirus vom-
Caribbean islands. iting may be more prominent. Protozoal diar-
rhea, such as that caused by Giardia intestinalis or
• High-​risk areas include most of Asia, the
Middle East, Africa, Mexico, and Central and E. histolytica, generally has a more gradual onset
South America. of low-​grade symptoms, with 2–​5 loose stools per
day. The incubation period between exposure and
RISK FOR TRAVELERS clinical presentation can be a clue to the etiology:
TD occurs equally in male and female travelers
• Bacterial toxins generally cause symptoms
and is more common in young adult travelers within a few hours.
than in older travelers. In short-​term travelers,
bouts of TD do not appear to protect against • Bacterial and viral pathogens have an incuba-
future attacks, and >1 episode of TD may occur tion period of 6–​72 hours.
during a single trip. A cohort of expatriates resid-
• Protozoal pathogens generally have an incu-
ing in Kathmandu, Nepal, experienced an aver- bation period of 1–​2 weeks and rarely present
age of 3.2 episodes of TD per person in their in the first few days of travel. An exception
first year. In more temperate regions, there may can be Cyclospora cayetanensis, which can
be seasonal variations in diarrhea risk. In south present quickly in areas of high risk.
Asia, for example, much higher TD attack rates
are reported during the hot months preceding Untreated bacterial diarrhea usually lasts 3–​7 days.
the monsoon. Viral diarrhea generally lasts 2–​3  days. Protozoal
In environments in warmer climates where diarrhea can persist for weeks to months without
large numbers of people do not have access to treatment. An acute bout of gastroenteritis can lead


to persistent gastrointestinal symptoms, even in causes blackening of the tongue and stool and may
the absence of continued infection (see Chapter 5, cause nausea, constipation, and rarely tinnitus.
Persistent Travelers’ Diarrhea). This presentation BSS should be avoided by travelers with aspirin
is commonly referred to as postinfectious irrita- allergy, renal insufficiency, and gout, and by those
ble bowel syndrome. Other postinfectious sequelae taking anticoagulants, probenecid, or methotrex-
may include reactive arthritis and Guillain-​Barré ate. In travelers taking aspirin or salicylates for
syndrome. other reasons, the use of BSS may result in salicy-
late toxicity. BSS is not generally recommended for
children aged <12 years; however, some clinicians
For travelers to high-​risk areas, several approaches use it off-​label with caution to avoid administer-
may be recommended that can reduce, but never ing BSS to children with viral infections, such as
completely eliminate, the risk for TD. These varicella or influenza, because of the risk for Reye
include instructions regarding food and beverage syndrome. BSS is not recommended for children
selection, using agents other than antimicrobial aged <3  years or pregnant women. Studies have
drugs for prophylaxis, using prophylactic anti- not established the safety of BSS use for periods >3
biotics, and carefully washing hands with soap weeks. Because of the number of tablets required
where available. Carrying small containers of and the inconvenient dosing, BSS is not commonly
alcohol-​based hand sanitizers (containing ≥60% used as prophylaxis for TD.
alcohol) may make it easier for travelers to clean The use of probiotics, such as Lactobacillus
their hands before eating when handwashing is GG and Saccharomyces boulardii, has been stud-
not possible. No vaccines are available for most ied in the prevention of TD in small numbers
pathogens that cause TD, but travelers should of people. Results are inconclusive, partially
refer to the Cholera, Hepatitis A, and Typhoid & because standardized preparations of these bac-
Paratyphoid Fever sections in Chapter  3 regard- teria are not reliably available. Studies are ongo-
ing vaccines that can prevent other foodborne ing with prebiotics to prevent TD, but data are
or waterborne infections to which travelers are insufficient to recommend their use. There have
susceptible. been anecdotal reports of beneficial outcomes
after using bovine colostrum as a daily prophy-
Food and Beverage Selection laxis agent for TD. However, commercially sold
Care in selecting food and beverages can minimize preparations of bovine colostrum are marketed
the risk for acquiring TD. See the Food & Water as dietary supplements that are not Food and
Precautions section later in this chapter for CDC’s Drug Administration (FDA) approved for med-
detailed food and beverage recommendations. ical indications. Because no data from rigorous
Although food and water precautions continue clinical trials demonstrate efficacy, there is insuf-
to be recommended, travelers may not always be ficient information to recommend the use of
able to adhere to the advice. Furthermore, many of bovine colostrum to prevent TD.
the factors that ensure food safety, such as restau- Although not available in the United States, a
rant hygiene, are out of the traveler’s control. cholera vaccine (Dukoral) that provides partial
protection against enterotoxigenic E. coli is avail-
Nonantimicrobial Drugs able in some other countries. Several clinical tri-
for Prophylaxis als of new vaccines against TD pathogens are in
The primary agent studied for prevention of TD, progress.
other than antimicrobial drugs, is bismuth sub-
salicylate (BSS), which is the active ingredi- Prophylactic Antibiotics
ent in adult formulations of Pepto-​Bismol and Although prophylactic antibiotics can prevent
Kaopectate. Studies from Mexico have shown that some TD, the emergence of antimicrobial resis-
this agent (taken daily as either 2 oz of liquid or 2 tance has made the decision of how and when
chewable tablets 4 times per day) reduces the inci- to use antibiotic prophylaxis for TD difficult.
dence of TD by approximately 50%. BSS commonly Controlled studies have shown that diarrhea



attack rates are reduced by 90% or more by the use and helps the traveler feel better more quickly.
of antibiotics. The prophylactic antibiotic of choice Travelers should remember to use only bever-
has changed over the past few decades as resis- ages that are sealed, treated with chlorine, boiled,
tance patterns have evolved. Fluoroquinolones or are otherwise known to be purified. For severe
have been the most effective antibiotics for the fluid loss, replacement is best accomplished with
prophylaxis and treatment of bacterial TD patho- oral rehydration solution (ORS) prepared from
gens, but increasing resistance to these agents packaged oral rehydration salts, such as those
among Campylobacter and Shigella species glob-
ally limits their potential use. Alternative consid-
provided by the World Health Organization. ORS
is widely available at stores and pharmacies in
erations include azithromycin and rifaximin, a most developing countries. ORS is prepared by
nonabsorbable broad-​spectrum antibiotic. adding 1 packet to the indicated volume of boiled
At this time, prophylactic antibiotics should not or treated water—​generally 1 liter. Travelers may
be recommended for most travelers. Prophylactic find most ORS formulations to be relatively unpal-
antibiotics afford no protection against nonbacte- atable due to their saltiness. In mild cases, rehy-
rial pathogens and can remove normally protec- dration can be maintained with any palatable
tive microflora from the bowel, increasing the risk liquid (including sports drinks), although overly
of infection with resistant bacterial pathogens. sweet drinks, such as sodas, can cause osmotic
Travelers may become colonized with extended-​ diarrhea if consumed in quantity.
spectrum β-​lactamase (ESBL)–​producing bac-
teria, and this risk is increased by exposure to Antimotility Agents
antibiotics while abroad. Additionally, the use Antimotility agents provide symptomatic relief
of antibiotics may be associated with allergic or and are useful therapy in TD. Synthetic opi-
adverse reactions, and prophylactic antibiotics ates, such as loperamide and diphenoxylate,
limit the therapeutic options if TD occurs; a trav- can reduce frequency of bowel movements and
eler relying on prophylactic antibiotics will need therefore enable travelers to ride on an airplane
to carry an alternative antibiotic to use if severe or bus. Loperamide appears to have antisecre-
diarrhea develops despite prophylaxis. The risks tory properties as well. The safety of loperamide
associated with the use of prophylactic antibi- when used along with an antibiotic has been well
otics should be weighed against the benefit of established, even in cases of invasive pathogens;
using prompt, early self-​treatment with antibiot- however, acquisition of ESBL-​producing patho-
ics when moderate to severe TD occurs, shorten- gens may be more common when loperamide
ing the duration of illness to 6–​24 hours in most and antibiotics are coadministered. Antimotility
cases. Prophylactic antibiotics may be considered agents alone are not recommended for patients
for short-​term travelers who are high-​risk hosts with bloody diarrhea or those who have diarrhea
(such as those who are immunosuppressed) or and fever. Loperamide can be used in children,
who are taking critical trips (such as engaging in a and liquid formulations are available. In practice,
sporting event) without the opportunity for time however, these drugs are rarely given to small chil-
off in the event of sickness. dren (aged <6 years).

TREATMENT Antibiotics are effective in reducing the duration
Oral Rehydration Therapy of diarrhea by about a day in cases caused by bac-
Fluids and electrolytes are lost during TD, and terial pathogens that are susceptible to the par-
replenishment is important, especially in young ticular antibiotic prescribed. However, there are
children or adults with chronic medical illness. In concerns about adverse consequences of using
adult travelers who are otherwise healthy, severe antibiotics to treat TD. Travelers who take anti-
dehydration resulting from TD is unusual unless biotics may acquire resistant organisms such as
vomiting is prolonged. Nonetheless, replacement ESBL-​producing organisms, resulting in poten-
of fluid losses remains an adjunct to other therapy tial harm to travelers—​particularly those who are


immunosuppressed or women who may be prone trials and clinical experience. The best regimen for
to urinary tract infections—​and the possibility of azithromycin treatment may also be a single dose
introducing these resistant bacteria into the com- of 1,000 mg, but side effects (mainly nausea) may
munity. In addition, there is concern about the limit the acceptability of this large dose. Giving
effects of antibiotic use on travelers’ microbiota azithromycin as 2 divided doses on the same day
and the potential for adverse consequences such may limit this adverse event.
as Clostridium difficile infection as a result. These Because of the competing concerns of effective
2 concerns have to be weighed against the conse-
quences of TD and the role of antibiotics in short-
treatment of TD episodes and a desire to avoid
the potential negative consequences of antibiotic
ening the acute illness and possibly preventing use, consensus guidelines have been developed
postinfectious sequelae (see Chapter 5, Persistent by the International Society of Travel Medicine to
Travelers’ Diarrhea). address this (Box 2-​2 and Table 2-​6). See the next
The effectiveness of a particular antimicrobial section in this chapter for more information on
drug depends on the etiologic agent and its antibi- the risks and benefits of antiobiotic use for TD.
otic sensitivity. As empiric therapy or to treat a spe-
cific bacterial pathogen, first-​line antibiotics have Treatment of TD Caused
traditionally been the fluoroquinolones, such as by Protozoa
ciprofloxacin or levofloxacin. Increasing microbial The most common parasitic cause of TD is Giardia
resistance to the fluoroquinolones, especially among intestinalis, and treatment options include met-
Campylobacter isolates, may limit their usefulness in ronidazole, tinidazole, and nitazoxanide (see
many destinations, particularly South and Southeast Chapter  3, Giardiasis). Although cryptosporidio-
Asia, where both Campylobacter infection and fluo- sis is usually a self-​limited illness in immunocom-
roquinolone resistance is prevalent. Increasing flu- petent people, nitazoxanide can be considered as
oroquinolone resistance has been reported from a treatment option. Cyclosporiasis is treated with
other destinations and in other bacterial pathogens, trimethoprim-​ sulfamethoxazole. Treatment of
including in Shigella and Salmonella. In addition, amebiasis is with metronidazole or tinidazole, fol-
the use of fluoroquinolones has been associated lowed by treatment with a luminal agent such as
with tendinopathies and the development of C. dif­ iodoquinol or paromomycin.
ficile infection. FDA warns that the potentially seri-
ous side effects of fluoroquinolones may outweigh Treatment for Children
their benefit in treating uncomplicated respiratory Children who accompany their parents on trips to
and urinary tract infections; however, because of the high-​risk destinations can contract TD as well, with
short duration of therapy for TD, these side effects elevated risk if they are visiting friends and family.
are not believed to be a significant risk. Causative organisms include bacteria responsible
A potential alternative to fluoroquinolones for TD in adults as well as viruses including noro-
is azithromycin, although enteropathogens with virus and rotavirus. The main treatment for TD in
decreased azithromycin susceptibility have been children is ORS. Infants and younger children with
documented in several countries. Rifaximin has TD are at higher risk for dehydration, which is best
been approved to treat TD caused by noninvasive prevented by the early initiation of oral rehydra-
strains of E. coli. However, since it is often difficult tion. Empiric antibiotic therapy should be consid-
for travelers to distinguish between invasive and ered if there is bloody or severe watery diarrhea or
noninvasive diarrhea, and since they would have evidence of systemic infection. In older children
to carry a backup drug in the event of invasive and teenagers, treatment recommendations for
diarrhea, the overall usefulness of rifaximin as TD follow those for adults, with possible adjust-
empiric self-​treatment remains to be determined. ments in the dose of medication. Among younger
Single-​dose regimens are equivalent to mul- children, macrolides such as azithromycin are
tidose regimens and may be more convenient considered first-​line antibiotic therapy, although
for the traveler. Single-​dose therapy with a fluo- some experts now use short-​course fluoroquino-
roquinolone is well established, both by clinical lone therapy (despite its not being FDA-​approved


3 5

Table 2-​6. Travelers’ diarrhea treatment recommendations

Therapy of mild travelers’ diarrhea

• Antibiotic treatment is not recommended in patients with mild travelers’ diarrhea.

• Loperamide or BSS may be considered in the treatment of mild travelers’ diarrhea.

Therapy of moderate travelers’ diarrhea

• Antibiotics may be used to treat cases of moderate travelers’ diarrhea.

• Fluoroquinolones may be used to treat moderate travelers’ diarrhea.
• Azithromycin may be used to treat moderate travelers’ diarrhea.
• Rifaximin may be used to treat moderate travelers’ diarrhea.
• Loperamide may be used as adjunctive therapy for moderate to severe travelers’ diarrhea.
• Loperamide may be considered for use as monotherapy in moderate travelers’ diarrhea.

Therapy of severe travelers’ diarrhea

• Antibiotics should be used to treat severe travelers’ diarrhea.

• Azithromycin is preferred to treat severe travelers’ diarrhea.
• Fluoroquinolones may be used to treat severe, nondysenteric travelers’ diarrhea.
• Rifaximin may be used to treat severe, nondysenteric travelers’ diarrhea.
• Single-​dose antibiotic regimens may be used to treat travelers’ diarrhea.

BOX 2-​2. Travelers’ diarrhea definitions

Mild (acute): diarrhea that is Moderate (acute): diarrhea Severe (acute): diarrhea that
tolerable, is not distressing, and that is distressing or is incapacitating or completely
does not interfere with planned interferes with planned prevents planned activities; all
activities. activities. dysentery is considered severe.

for this indication in children) for travelers aged diaper rash on their buttocks in response to the
<18 years. Rifaximin is approved for use in children liquid stool. Barrier creams, such as zinc oxide
aged ≥12 years. or petrolatum, could be applied at the onset
Breastfed infants should continue to nurse on of diarrhea to help prevent and treat rash.
demand, and bottle-​fed infants can continue to Hydrocortisone cream is the best treatment for
drink formula. Older infants and children should an established rash. More information about diar-
be encouraged to eat and may consume a regular rhea and dehydration is discussed in Chapter  7,
diet. Children in diapers are at risk for developing Traveling Safely with Infants & Children.

1. Black RE. Epidemiology of travelers’ diarrhea and rel- galacto-​oligosaccharide mixture in reducing travellers’
ative importance of various pathogens. Rev Infect Dis. diarrhoea. Eur J Clin Nutr. 2010 Feb;64(2):146–​52.
1990 Jan-​Feb;12 Suppl 1:S73–​9. 3. DuPont HL, Ericsson CD, Farthing MJ, Gorbach S,
2. Drakoularakou A, Tzortzis G, Rastall RA, Gibson Pickering LK, Rombo L, et al. Expert review of the evi-
GR. A double-​blind, placebo-​controlled, random- dence base for prevention of travelers’ diarrhea. J Travel
ized human study assessing the capacity of a novel Med. 2009 May-​Jun;16(3):149–​6 0.


4. Farthing M, Salam MA, Lindberg G, Dite P, Khalif I, Salazar-​ 7. Raja MK, Ghosh AR. Laribacter hongkongensis: an
Lindo E, et al. Acute diarrhea in adults and children: a emerging pathogen of infectious diarrhea. Folia
global perspective. J Clin Gastroenterol. 2013 Jan;47(1):12–​20. Microbiol (Praha) 2014 Jul;59(4):341–​7.
5. Kantele A, Lääveri T, Mero S, Vilkman K, Pakkanen S, 8. Riddle MS, DuPont HL, Connor BA. ACG clinical guide-
Ollgren J, et al. Antimicrobials increase travelers’ risk line: diagnosis, treatment, and prevention of acute
of colonization by extended-​spectrum betalactamase-​ diarrheal infections in adults. Am J Gastroenterol 2016
producing Enterobacteriaceae. Clin Infect Dis. 2015 Mar May;111(5):602–​22.
15;60(6):837–​46. 9. Shlim DR. Looking for evidence that personal hygiene
2 6. Kendall ME, Crim S, Fullerton K, Han PV, Cronquist AB,
Shiferaw B, et al. Travel-​associated enteric infections
precautions prevent travelers’ diarrhea. Clin Infect Dis.
2005 Dec 1;41(Suppl 8):S531–​5.
diagnosed after return to the United States, Foodborne 10. Steffen R, Hill DR, DuPont HL. Traveler’s diarrhea: a
Diseases Active Surveillance Network (FoodNet), clinical review. JAMA. 2015 Jan 6;313(1):71–​80.
2004–​2009. Clin Infect Dis. 2012 Jun;54 Suppl 5:S480–​7.



Mark S. Riddle, Bradley A. Connor

For the last 30 years, ran- the benefits appear to out- spread of resistance with the
domized controlled trials weigh the risks. More recently, health benefits of antibiotic
have consistently and clearly there has been concern that treatment of TD. Although the
demonstrated that antibiot- antibiotics used by travelers role of travelers in the trans-
ics slightly but significantly might result in significant location of infectious disease
shorten the duration of changes in the host microbi- and resistance cannot be
illness and alleviate the ome as well as the acquisition ignored, the ecology of ESBL-​
disability associated with of multidrug-​resistant bac- PE infections is complex and
travelers’ diarrhea (TD). teria. Multiple observational includes environmental, diet,
Treatment with an effective studies have found that peo- immigration, and local noso-
antibiotic shortens the aver- ple who travel (in particular comial transmission dynam-
age duration of a TD episode to regions of Asia), develop ics. ESBL-​PE infections are
by about a day, and if the TD, and take antibiotics are an emerging health threat,
traveler combines an antibi- at incrementally increas- and addressing this complex
otic with an antimotility agent ing risk for colonization problem will require multiple
such as loperamide, the with extended-​spectrum strategies.
duration is shortened even β-​lactamase–​producing How, then, to prepare a
further. Emerging data on the Enterobacteriaceae (ESBL-​ traveler with a prescription
potential long-​term health PE). The effect of coloniza- for empiric self-​treatment
consequences of TD, such tion on the average traveler before a trip? There needs
as irritable bowel syndrome, appears limited; carriage is to be a conversation with
dyspepsia, and chronic con- most often transient but does the traveler about the multi-
stipation, might suggest a persist in a small percentage level (individual, community,
benefit of early antibiotic of those who are colonized. global) risks of travel, travel-
therapy given the association However, international travel ers’ diarrhea, preventing TD
between more severe and by a household member is through hand hygiene and
longer disease and risk of associated with ESBL colo- careful selection of foods
postinfectious consequences. nization among US children, and beverages, and antibiotic
Although these clinical which suggests that there treatment. Reserving antibi-
results are impressive, anti- may be larger public health otics for moderate to severe
biotics, like any drug, are not consequences from acquiring TD should be emphasized
without consequences. Each ESBL-​PE during travel. strongly, and using antimo-
of the antibiotics commonly The challenge that we face tility agents alone may be
used to treat TD have side as providers and travelers suggested for mild TD.
effects, but these are gener- is how to balance the risk of Elderly travelers or those
ally mild and self-​limiting, and colonization and the global with recurrent urinary tract





infections may be at higher colonization, nonantibiotic be challenged by the anxiety-​

risk of health consequences chemoprophylactic strat- provoking onset of that first

2 as a result of ESBL-​PE col-

onization. At a minimum
egies, such as the use of
bismuth subsalicylate, may
abdominal cramp in some-
times austere and incon-
these travelers should be decrease both the acute and venient settings. Providing
made aware of this risk, post-​travel risk concerns. prospective travelers with
and should be counseled to Strengthening the resilience clear written guidance about
convey their travel exposure of the host microbiota to pre- TD prevention and step-​by-​
history to their treating vent infection and unwanted step instructions about how
providers if they become ill colonization, as with the use and when to use medica-
after travel. Though further of prebiotics or probiotics, tions for TD is crucial (see
studies are needed (and are promising potential previous section, Travelers’
many are underway), a strategies but need further Diarrhea).
rational approach is advised investigation.
to decrease exposure by Finally, we must be cog-
using single-​dose regimens nizant of the fact that we BIBLIOGRAPHY
and selecting an antibiotic expect the traveler to be the 1. Islam S, Selvarangan R, Chohan
agent that minimizes micro- diagnostician, practitioner, R, Chappell JD, McHenry R,
biome disruption and risk and patient when it comes to Dighe A, et al. Antibiotic-
​resistant Enterobacteriaceae col-
of colonization. Additionally, managing TD. For even the
onization in healthy children in
as travel and untreated TD most astute traveler, making the United States. Open Forum
increase the risk of ESBL-​PE such learned decisions can Infect Dis. 2015;2(Suppl 1):73.

Perspectives sections are written as editorial discussions aiming to add depth and clinical perspective to the official
recommendations contained in the book. The views and opinions expressed in this section are those of the authors and
do not necessarily represent the official position of CDC.

Peter H. Hackett, David R. Shlim

The high-​ altitude environment exposes trav- the most hypoxemia; day trips to high altitude
elers to cold, low humidity, increased ultravio- with return to low altitude are much less stress-
let radiation, and decreased air pressure, all of ful on the body. Typical high-​altitude destina-
which can cause problems. The biggest con- tions include Cusco (11,000 ft; 3,300 m), La Paz
cern, however, is hypoxia. At 10,000 ft (3,000 m), (12,000 ft; 3,640 m), Lhasa (12,100 ft; 3,650 m),
for example, the inspired PO2 is only 69% of Everest Base Camp (17,700 ft; 5,400 m), and
sea-​level value. The magnitude of hypoxic stress Kilimanjaro (19,341 ft; 5,895 m).
depends on altitude, rate of ascent, and duration The human body adjusts very well to moder-
of exposure. Sleeping at high altitude produces ate hypoxia, but requires time to do so (Box 2-​3).



BOX 2-​3. Tips for acclimatization

• Ascend gradually, if possible. extra day for acclimatization • Participate in only mild
Avoid going directly from low every 3,300 ft (1,000 m). exercise for the first 48 hours.
altitude to more than 9,000 ft • Consider using acetazolamide • Having a high-​altitude
(2,750 m) sleeping altitude in
1 day. Once above 9,000 ft
to speed acclimatization, if
abrupt ascent is unavoidable.
exposure at more than 9,000 ft
(2,750 m) for 2 nights or more, 2
(2,750 m), move sleeping • Avoid alcohol for the first within 30 days before the trip,
altitude no higher than 1,600 ft 48 hours. is useful.
(500 m) per day, and plan an

The process of acute acclimatization to high Some common destinations such as the ones
altitude takes 3–​ 5  days; therefore, acclima- mentioned above require rapid ascent by airplane
tizing for a few days at 8,000–​9,000 ft (2,500–​ to >3,400 meters and thus place travelers in the
2,750 m) before proceeding to a higher altitude high-​risk category (see Table  2-​7). Chemopro­
is ideal. Acclimatization prevents altitude ill- phylaxis may be necessary for these travelers, in
ness, improves sleep, and increases comfort and addition to 2–​4  days of acclimatization before
well-​being, although exercise performance will going higher. In some cases, such as Cuzco and La
always be reduced compared with low altitude. Paz, the traveler can descend to altitudes much
Increase in ventilation is the most important lower than the airport to sleep.
factor in acute acclimatization; therefore, respi-
ratory depressants must be avoided. Increased CLINICAL PRESENTATION
red-​cell production does not play a role in acute Altitude illness is divided into 3 syndromes: acute
acclimatization. mountain sickness (AMS), high-​altitude cerebral
edema (HACE), and high-​ altitude pulmonary
Inadequate acclimatization may lead to altitude
illness in any traveler going to 8,000 ft (2,500 m) Acute Mountain Sickness
or higher, and sometimes even at lower altitude. AMS is the most common form of altitude illness,
Susceptibility and resistance to altitude illness affecting, for example, 25% of all visitors sleeping
are genetic traits, and no simple screening tests above 8,000 ft (2,500 m) in Colorado. Symptoms
are available to predict risk. Risk is not affected by are similar to those of an alcohol hangover: head-
training or physical fitness. Children are equally ache is the cardinal symptom, sometimes accom-
susceptible as adults; people aged >50 years have panied by fatigue, loss of appetite, nausea, and
slightly lower risk. How a traveler has responded occasionally vomiting. Headache onset is usually
to high altitude previously is the most reliable 2–​12 hours after arrival at a higher altitude and
guide for future trips if the altitude and rate of often during or after the first night. Preverbal chil-
ascent are similar, but this is not infallible. Given dren may develop loss of appetite, irritability, and
certain baseline susceptibility, risk is largely influ- pallor. AMS generally resolves with 12–​48 hours of
enced by the altitude, rate of ascent, and exertion acclimatization.
(see Table  2-​7). Creating an itinerary that will
avoid any occurrence of altitude illness is difficult High-​Altitude Cerebral Edema
because of variations in individual susceptibility, HACE is a severe progression of AMS and is rare; it
as well as in starting points and terrain. The goal is most often associated with HAPE. In addition to
for the traveler may not be to avoid all symptoms AMS symptoms, lethargy becomes profound, with
of altitude illness but to have no more than mild drowsiness, confusion, and ataxia on tandem gait
illness. test, similar to alcohol intoxication. A person with


Table 2-​7. Risk categories for acute mountain sickness


Low • People with no prior history of altitude illness and ascending to Acetazolamide
less than 9,000 ft (2,750 m) prophylaxis generally

2 • People taking ≥2 days to arrive at 8,200–​9,800 ft (2,500–​3,000 m),

with subsequent increases in sleeping elevation less than 1,600 ft
(500 m) per day, and an extra day for acclimatization every 3,300 ft
not indicated.

(1,000 m)

Moderate • People with prior history of AMS and ascending to 8,200–​9,200 ft Acetazolamide
(2,500–​2,800 m) or higher in 1 day prophylaxis would be
• No history of AMS and ascending to more than 9,200 ft (2,800 m) beneficial and should
in 1 day be considered.
• All people ascending more than 1,600 ft (500 m) per day (increase
in sleeping elevation) at altitudes above 9,900 ft (3,000 m), but with
an extra day for acclimatization every 3,300 ft (1,000 m)

High • History of AMS and ascending to more than 9,200 ft (2,800 m) in Acetazolamide
1 day prophylaxis strongly
• All people with a prior history of HAPE or HACE recommended.
• All people ascending to more than 11,400 ft (3,500 m) in 1 day
• All people ascending more than 1,600 ft (500 m) per day (increase
in sleeping elevation) above 9,800 ft (3,000 m), without extra days
for acclimatization
• Very rapid ascents (such as less than 7-​day ascents of Mount

Abbreviations: AMS, acute mountain sickness; HACE, high-​altitude cerebral edema; HAPE, high-​altitude pulmonary edema.

HACE requires immediate descent; death can high-​altitude medical issues before undertaking
ensue within 24 hours of developing ataxia, if the high-​altitude travel (see Table  2-​8). The risk for
person fails to descend. new ischemic heart disease in previously healthy
travelers does not appear to be increased at high
High-​Altitude Pulmonary Edema altitudes. Patients with asthma, hypertension,
HAPE can occur by itself or in conjunction with atrial arrhythmia, and seizure disorders that are
AMS and HACE; incidence is 1 per 10,000 ski- well controlled at low altitude generally do well at
ers in Colorado and up to 1 per 100 climbers at high altitude. All patients with OSA should receive
more than 14,000 ft (4,270 m). Initial symptoms acetazolamide; those with mild to moderate OSA
are increased breathlessness with exertion, and may do well without their CPAP machines, while
eventually increased breathlessness at rest, asso- those with severe OSA should avoid altitude travel
ciated with weakness and cough. Oxygen or unless given supplemental oxygen in addition to
descent is life-​saving. HAPE can be more rapidly their CPAP. People with diabetes can travel safely
fatal than HACE. to high altitudes, but they must be accustomed
to exercise and carefully monitor their blood glu-
Preexisting Medical Problems cose. Diabetic ketoacidosis may be triggered by
Travelers with medical conditions, such as heart altitude illness and may be more difficult to treat
failure, myocardial ischemia (angina), sickle cell in those on acetazolamide. Not all glucose meters
disease, any form of pulmonary insufficiency or read accurately at high altitudes.
preexisting hypoxemia, or obstructive sleep apnea Most people do not have visual problems at
(OSA) should consult a physician familiar with high altitudes. However, at very high altitudes



Table 2-​8. Ascent risk associated with various underlying

medical conditions

Children and adolescents Infants <6 weeks old Sickle cell anemia

Elderly people Compensated heart failure Severe–​very severe chronic obstructive
Sedentary people Morbid obesity pulmonary disease
Mild obesity Cystic fibrosis (FEV1 30%–​50% Pulmonary hypertension with
Well-​controlled asthma predicted) pulmonary artery systolic pressure
Diabetes mellitus Poorly controlled arrhythmia >60 mm Hg
Coronary artery disease Poorly controlled asthma Unstable angina
following revascularization Poorly controlled hypertension Decompensated heart failure
Mild chronic obstructive Moderate chronic obstructive High-​risk pregnancy
pulmonary disease pulmonary disease Cystic fibrosis (FEV1 <30% predicted)
Low-​risk pregnancy Severe obstructive sleep apnea Recent myocardial infarction or stroke
Mild–​moderate obstructive Stable angina (<90 days)
sleep apnea Nonrevascularized coronary Untreated cerebral vascular aneurysms
Controlled hypertension artery disease or arteriovenous malformations
Controlled seizure disorder Sickle cell trait Cerebral space-​occupying lesions
Psychiatric disorders Poorly controlled seizure disorder
Neoplastic diseases Cirrhosis
Mild pulmonary hypertension
Radial keratotomy surgery

Abbreviations: FEV1, forced expiratory volume in 1 s.

some people who have had radial keratotomy descend ≥300 m, and symptoms will rapidly abate.
may develop acute farsightedness and be unable Alternatively, supplemental oxygen at 2 L per min-
to care for themselves. LASIK and other newer ute will relieve headache quickly and resolve AMS
procedures may produce only minor visual distur- over hours, but it is rarely available. People with
bances at high altitudes. AMS can also safely remain at their current alti-
There are no studies or case reports of harm to tude and treat symptoms with nonopiate analge-
a fetus if the mother travels briefly to high altitudes sics and antiemetics, such as ondansetron. They
during pregnancy. However, it may be prudent to may also take acetazolamide, which speeds accli-
recommend that pregnant women do not stay at matization and effectively treats AMS, but is better
sleeping altitudes higher than 10,000 ft (3,048 m). for prophylaxis than treatment. Dexamethasone
In addition, the pregnancy should be verified as is more effective than acetazolamide at rapidly
low risk and the mother in good health. The dan- relieving the symptoms of moderate to severe
gers of having a pregnancy complication in remote, AMS. If symptoms are getting worse while the
mountainous terrain should also be discussed. traveler is resting at the same altitude, or in spite
of medication, he or she must descend.
HACE is an extension of AMS characterized
DIAGNOSIS AND TREATMENT by neurologic findings, particularly ataxia, con-
Acute Mountain Sickness/​ fusion, or altered mental status. HACE may also
High-​Altitude Cerebral Edema occur in the presence of HAPE. People developing
The differential diagnosis of AMS/​ HACE HACE in populated areas with access to medical
includes dehydration, exhaustion, hypoglyce- care can be treated at altitude with supplemen-
mia, hypothermia, or hyponatremia. Focal neu- tal oxygen and dexamethasone. In remote areas,
rologic symptoms, or seizures, are rare in HACE descent should be initiated in any person sus-
and should lead to suspicion of an intracranial pected of having HACE. If descent is not feasible
lesion or seizure disorder. Patients with AMS can because of logistical issues, supplemental oxygen


or a portable hyperbaric chamber in addition to or high-​altitude medical clinic, for example) may
dexamethasone can be lifesaving. not need to descend to lower elevation and can
be treated with oxygen at the current elevation. In
High-​Altitude Pulmonary Edema the field setting, where resources are limited and
Although the progression of decreased exercise there is a lower margin for error, nifedipine can be
tolerance, increased breathlessness, and breath- used as an adjunct to descent, oxygen, or portable
lessness at rest is almost always recognizable as hyperbaric therapy. A  phosphodiesterase inhibi-
2 HAPE, the differential diagnosis includes pneu-
monia, bronchospasm, myocardial infarction, or
tor may be used if nifedipine is not available, but
concurrent use of multiple pulmonary vasodila-
pulmonary embolism. Descent in this situation tors is not recommended.
is urgent and mandatory, and should be accom-
plished with as little exertion as is feasible for Medications
the patient. If descent is not immediately possi- In addition to the discussion below, recommen-
ble, supplemental oxygen or a portable hyper- dations for the usage and dosing of medications
baric chamber is critical. Patients with mild to prevent and treat altitude illness are outlined
HAPE who have access to oxygen (at a hospital in Table 2-​9.

Table 2-​9. Recommended medication doses to prevent and

treat altitude illness

Acetazolamide AMS, HACE Oral 125 mg twice a day; 250 mg twice a day if >100 kg
prevention Pediatrics: 2.5 mg/​kg every 12 h

AMS treatment1 Oral 250 mg twice a day

Pediatrics: 2.5 mg/​kg every 12 h

Dexamethasone AMS, HACE Oral 2 mg every 6 h or 4 mg every 12 h

prevention Pediatrics: should not be used for prophylaxis

AMS, HACE Oral, IV, IM AMS: 4 mg every 6 h

treatment HACE: 8 mg once, then 4 mg every 6 h
Pediatrics: 0.15 mg/​kg/​dose every 6 h up to 4 mg

Nifedipine HAPE prevention Oral 30 mg SR version every 12 h, or 20 mg SR version

every 8 h

HAPE treatment Oral 30 mg SR version every 12 h, or 20 mg SR version

every 8 h

Tadalafil HAPE prevention Oral 10 mg twice a day

Sildenafil HAPE prevention Oral 50 mg every 8 h

Salmeterol HAPE prevention2 Inhaled 125 µg twice a day

Abbreviations: AMS, acute mountain sickness; HACE, high-​altitude cerebral edema; HAPE, high-​altitude pulmonary edema;
IM, intramuscular; IV, intravenous; SR, sustained release.
Acetazolamide can also be used at this dose as an adjunct to dexamethasone in HACE treatment, but dexamethasone
remains the primary treatment for that disorder.
Should not be used as monotherapy and should only be used in conjunction with oral medications.



ACETAZOLAMIDE effect on systemic blood pressure. Tadalafil, 10 mg

Acetazolamide prevents AMS when taken before twice a day, during ascent can prevent HAPE and
ascent and can speed recovery if taken after is being studied for treatment. When taken before
symptoms have developed. The drug works by ascent, gingko biloba, 100–​120 mg twice a day,
acidifying the blood, which causes an increase was shown to reduce AMS in adults in some trials,
in respiration and arterial oxygenation and thus but it was not effective in others, probably due to
aids acclimatization. An effective dose that min- variation in ingredients. Ibuprofen 600 mg every
imizes the common side effects of increased uri-
nation and paresthesias of the fingers and toes is
8 hours was recently found to help prevent AMS,
although it was not as effective as acetazolamide.
125 mg every 12 hours, beginning the day before However, it is over-​the-​counter, inexpensive, and
ascent and continuing the first 2 days at altitude, well-​tolerated.
or longer if ascent continues. Allergic reactions to
acetazolamide are uncommon. As a nonantimi- PREVENTION OF SEVERE
crobial sulfonamide, it does not cross-​react with ALTITUDE ILLNESS
antimicrobial sulfonamides. However, it is best OR DEATH
avoided by people with history of anaphylaxis to The main point of instructing travelers about alti-
any sulfa. People with history of severe penicillin tude illness is not to eliminate the possibility of
allergy have occasionally had allergic reactions to mild illness but to prevent death or evacuation.
acetazolamide. The pediatric dose is 5 mg/​kg/​day Since the onset of symptoms and the clinical
in divided doses, up to 125 mg twice a day. course are sufficiently slow and predictable, there
is no reason for anyone to die from altitude illness,
DEXAMETHASONE unless trapped by weather or geography in a situ-
Dexamethasone is effective for preventing and ation in which descent is impossible. Three rules
treating AMS and HACE and prevents HAPE as well. can prevent death or serious consequences from
Unlike acetazolamide, if the drug is discontinued at altitude illness:
altitude before acclimatization, mild rebound can
occur. Acetazolamide is preferable to prevent AMS
• Know the early symptoms of altitude illness,
and be willing to acknowledge when they are
while ascending, with dexamethasone reserved for
treatment, as an adjunct to descent. The adult dose
is 4 mg every 6 hours. An increasing trend is to use • Never ascend to sleep at a higher altitude
dexamethasone for “summit day” on high peaks when experiencing symptoms of altitude
such as Kilimanjaro and Aconcagua, in order to pre- illness, no matter how minor they
vent abrupt altitude illness. seem.

NIFEDIPINE • Descend if the symptoms become worse

while resting at the same altitude.
Nifedipine prevents HAPE and ameliorates it as
well. For prevention, it is generally reserved for For trekking groups and expeditions going into
people who are particularly susceptible to the remote high-​altitude areas, where descent to a
condition. The adult dose for prevention or treat- lower altitude could be problematic, a pressuriza-
ment is 30 mg of extended release every 12 hours, tion bag (such as the Gamow bag) can be benefi-
or 20 mg every 8 hours. cial. A foot pump produces an increased pressure
of 2 lb/​in2, mimicking a descent of 5,000–​6,000 ft
OTHER MEDICATIONS (1,500–​1,800 m) depending on the starting alti-
Phosphodiesterase-​5 inhibitors can also selec- tude. The total packed weight of bag and pump is
tively lower pulmonary artery pressure, with less about 14 lb (6.5 kg).


1. Bartsch P, Swenson ER. Acute high-​altitude illnesses. Society consensus guidelines for the prevention and
N Engl J Med. 2013 Oct 24;369(17):1666–​7. treatment of acute altitude illness. Wilderness Environ
2. Hackett P. High altitude and common medical con- Med. 2010 Jun;21(2):146–​55.
ditions. In: Hornbein TF, Schoene RB, editors. High 7. Luks AM, Swenson ER. Medication and dosage con­
Altitude: an Exploration of Human Adaptation. siderations in the prophylaxis and treatment of high-​
New York: Marcel Dekker; 2001. p. 839–​85. altitude illness. Chest. 2008 Mar;133(3):744–​55.

2 3. Hackett PH, Roach RC. High altitude cerebral edema.

High Alt Med Biol. 2004 Summer;5(2):136–​46.
8. Maggiorini M, Brunner-​La Rocca HP, Peth S, Fischler
M, Bohm T, Bernheim A, et al. Both tadalafil and dexa-
4. Hackett PH, Roach RC. High-​altitude medicine and methasone may reduce the incidence of high-​altitude
physiology. In: Auerbach PS, editor. Wilderness pulmonary edema: a randomized trial. Ann Intern Med.
Medicine. 6th ed. Philadelphia: Mosby Elsevier; 2012. 2006 Oct 3;145(7):497–​5 06.
p. 2–​32. 9. Pollard AJ, Murdoch DR. The High Altitude Medicine
5. Johnson TS, Rock PB, Fulco CS, Trad LA, Spark Handbook. 3rd ed. Abingdon, UK: Radcliffe Medical
RF, Maher JT. Prevention of acute mountain sick- Press; 2003.
ness by dexamethasone. N Engl J Med. 1984 Mar 10. Pollard AJ, Niermeyer S, Barry P, Bartsch P, Berghold F,
15;310(11):683–​6. Bishop RA, et al. Children at high altitude: an interna-
6. Luks AM, McIntosh SE, Grissom CK, Auerbach PS, tional consensus statement by an ad hoc committee of
Rodway GW, Schoene RB, et al. Wilderness Medical the International Society for Mountain Medicine, March
12, 2001. High Alt Med Biol. 2001 Fall;2(3):389–​4 03.

Gregory Atkinson, Ronnie Henry, Alan M. Batterham, Andrew Thompson

RISK FOR TRAVELERS new time zone, some people may prefer to anchor
Jet lag results from a mismatch between a per- their sleep–​wake schedule to time of day at home
son’s circadian (24-​hour) rhythms and the time as much as is practical. Thereby, the total “bur-
of day in the new time zone. When establishing den” of jet lag resulting from the short round trip
risk, clinicians should first determine how many is minimized.
time zones the traveler will cross and what the
discrepancy will be between time of day at home CLINICAL PRESENTATION
and at the destination. During the first few days Jet-​lagged travelers typically experience the fol-
after a flight to a new time zone, a person’s circa- lowing symptoms after a flight across >3 time
dian rhythms are still “anchored” to time of day at zones:
home. Rhythms then adjust gradually to the new
time zone. A useful web-​based tool for world time • Poor sleep, including difficulty initiating
zone travel information can be found at:  www. sleep at the usual time of night (after east-
timeanddate.com/​worldclock/​converter.html. If ward flights), early awakening (after westward
≤3 time zones are being crossed, the risk of signif- flights), and fractionated sleep (after flights in
icant jet lag is likely to be negligible. either direction)
Many people traveling over >3 time zones for
a vacation accept the risk of jet lag as a transient
• Poor performance in physical and mental
tasks during the new daytime
and mild inconvenience, while other people who
are traveling on business or to compete in athletic • Negative feelings such as fatigue, headache,
events desire clear advice on prophylactic mea- irritability, anxiety, inability to concentrate,
sures and treatments. If ≤2 days are spent in the and depression


3 6

• Gastrointestinal disturbances and decreased homeopathy, aromatherapy, and acupressure

interest in, and enjoyment of, meals have no scientific basis.

These symptoms are difficult to distinguish from

Hypnotic Medications
the general fatigue resulting from international
Prescription medications like temazepam, zolp-
travel itself, as well as from other travel factors
idem, or zopiclone may reduce sleep loss during
such as the hypoxia in the aircraft cabin.
and after travel but do not necessarily help resyn-
TREATMENT chronize circadian rhythms or improve overall jet
lag symptoms. The lowest effective dose of a short-​
Since light and social contacts influence the tim-
to medium-​acting compound should be prescribed
ing of internal circadian rhythms, a traveler who
for the initial few days, bearing in mind the adverse
is staying in the time zone for >2 days should try
effects of these drugs. Taking hypnotics during a
to follow the local people’s sleep–​wake habits as
flight should be considered with caution because
much as possible and as quickly as possible. This
the resulting immobility could increase the risk of
approach can be supplemented with the following
deep vein thrombosis. Alcohol should not be used
information on specific treatments.
by travelers as a sleep aid because it disrupts sleep
Light and can provoke obstructive sleep apnea.
Exposure to bright light can advance or delay
human circadian rhythms depending on when it Melatonin and Melatonin-​Receptor
is received relative to a person’s body clock time. Analogs
Consequently, schedules have been formulated Melatonin is secreted at night by the pineal gland
for proposed “good” and “bad” times for exposure and is probably the most well-​known treatment
to light after arrival in a new time zone (www.caa. for jet lag. Melatonin delays circadian rhythms
co.uk/​ Passengers/​B efore-​y ou-​f ly/​Am-​I -​f it-​to-​ when taken during the rising phase of body tem-
fly/​Health-​information-​for-​passengers/​Jet-​lag/​). perature (usually the morning) and advances
After flights that cross a large number of time rhythms when ingested during the falling phase
zones, the proposed best circadian time for expo- of body temperature (usually the evening). These
sure to light immediately after the flight may actu- effects are opposite to those of bright light. The
ally be when it is still dark in the new time zone, instructions on most melatonin products advise
which raises the question of whether exposure to travelers to take it before nocturnal sleep in the
supplementary light from a “light box” is helpful. new time zone, irrespective of number of time
Unfortunately, to date, only 1 small randomized zones crossed or direction of travel. Studies pub-
controlled trial on supplementary bright light for lished in the mid-​1980s indicated a substantial
reducing jet lag has been conducted. No clinically benefit of melatonin (just before sleep) for reduc-
relevant effects of supplementary light on jet lag ing overall feelings of jet lag after flights. However,
symptoms were detected after a flight across 5 subsequent larger studies did not replicate the
time zones going west. earlier findings. Melatonin is considered a dietary
supplement in the United States and is not reg-
Diet and Physical Activity ulated by the Food and Drug Administration.
Dietary interventions do not reduce jet lag Therefore, the advertised concentration of mela-
symptoms. Because gastrointestinal distur- tonin has not been confirmed for most melatonin
bance is a common symptom, smaller meals products on the market, and the presence of con-
before and during the flight might be better tol- taminants in the product cannot be ruled out.
erated than larger meals. Caffeine and physical Ramelteon, a melatonin-​receptor agonist, is an
activity may be used strategically at the desti- FDA-​approved treatment for insomnia. A dose of
nation to ameliorate any daytime sleepiness, 1 mg taken just before bedtime can decrease sleep
but little evidence indicates that these inter- onset latency after eastward travel across 5 time
ventions reduce overall feelings of jet lag. Any zones. Higher doses do not seem to lead to further
purported treatments that are underpinned by improvements, and the effects of the medication


on other symptoms of jet lag and the timing of cir- fatigue compared with the comparator group and
cadian rhythms are not as clear. improved aspects of health-​related behavior such
as physical activity, snacking, and sleep quality but
Combination Treatments not other measures of sleep (latency, duration, use
Multiple therapies to decrease jet lag symp- of sleep-​related medication).
toms may be combined into treatment packages. In conclusion, there is still no “cure” for jet lag.
Although marginal gains from multiple treatments Counseling should focus on the factors that are
2 may aggregate, evidence from robust randomized
controlled trials is lacking for most of these treat-
known, from laboratory simulations, to alter cir-
cadian timing. Nevertheless, more randomized
ment packages. One treatment package offer- controlled trials of treatments prescribed before,
ing tailored advice via a mobile application was during, or after transmeridian flights are needed
piloted recently to be used over several months before the clinician can provide robust, evidence-​
of frequent flying. Participants reported reduced based advice.

1. Atkinson G, Batterham AM, Dowdall N, Thompson A, 6. Thompson A, Batterham AM, Jones H, Gregson W, Scott
Van Drongelen A. From animal cage to aircraft cabin: an D, Atkinson G. The practicality and effectiveness of
overview of evidence translation in jet lag research. Eur supplementary bright light for reducing jet-​lag in elite
J Appl Physiol. 2014 Dec;114(12):2459–​68. female athletes. Int J Sports Med. 2013 Jul;34(7):582–​9.
2. Herxheimer A. Jet lag. BMJ Clin Evid. 2014 Apr 29. 7. Van Drongelen A, Boot CR, Hlobil H, Twisk JW, Smid T,
3. Herxheimer A, Petrie KJ. Melatonin for the preven- Van der Beek AJ. Evaluation of an mHealth intervention
tion and treatment of jet lag. Cochrane Database of aiming to improve health-​related behavior and sleep
Systematic Reviews 2002, Issue 2. Art. No.: CD001520. and reduce fatigue among airline pilots. Scand J Work
Environ Health. 2014 Nov;40(6):557–​68.
4. Sack RL. Clinical practice. Jet lag. N Engl J Med. 2010 Feb
4;362(5):440–​7. 8. Waterhouse J, Reilly T, Atkinson G. Jet-​lag. Lancet. 1997
Nov 29;350(9091):1611–​6.
5. Samuels CH. Jet lag and travel fatigue: a comprehensive
management plan for sport medicine physicians and 9. Waterhouse J, Reilly T, Atkinson G, Edwards B. Jet
high-​performance support teams Clin J Sport Med. 2012 lag: trends and coping strategies. Lancet. 2007 Mar
May;22(3):268–​73. 31;369(9567):1117–​29.

Stefanie K. Erskine

RISK FOR TRAVELERS 50 years are less susceptible to motion

Motion sickness is the term attributed to physi- sickness.
ologic responses to motion by sea, car, train, air,
and virtual reality immersion. Given sufficient
• Sex—​women are more likely to have motion
sickness, especially when pregnant, menstru-
stimulus all people with functional vestibular
ating, or on hormones.
systems can develop motion sickness. However,
people vary in their susceptibility. Risk factors • Race/​ethnicity—​Asians may be more suscep-
include the following: tible to motion sickness than Europeans.
• Age—​children aged 2–​12 years are espe- • Migraines—​people who get migraine head-
cially susceptible, but infants and toddlers aches are more prone to motion sickness,
are generally immune. Adults older than especially during a migraine.


5 6

• Medication—​some prescriptions can worsen • Adding distractions—​controlling breathing,

the nausea of motion sickness. listening to music, or using aromatherapy
scents such as mint or lavender. Flavored loz-
CLINICAL PRESENTATION enges may also help.
Travelers suffering from motion sickness
commonly exhibit some or all of the following
• Using acupressure or magnets is advocated
by some to prevent or treat nausea, although
• Nausea
scientific data on efficacy of these interven-
tions for preventing motion sickness are 2
• Vomiting/​retching
• Sweating • Gradually exposing oneself to continuous or
repeated motion sickness triggers. Most peo-
• Cold sweats ple, in time, notice a reduction in motion sick-
ness symptoms.
• Excessive salivation
Nonpharmacologic treatments for preventing
• Hyperventilation and treating motion sickness can be effective with
• Increased sensitivity to odors few adverse side effects (see Prevention above).
However, these measures can be time-​consuming
• Loss of appetite and unpleasant for travelers. Many patients will
• Headache prefer medication.
Before deciding which medications to pre-
• Drowsiness scribe, consider factors such as individual sus-
• Warm sensation ceptibility and type, magnitude, and duration of
potential stimuli. Medications to treat motion
• General discomfort sickness are most effective when taken before
PREVENTION A primary side effect of most efficacious med-
Nonpharmacologic interventions to prevent or
ications used for motion sickness is drowsiness,
treat motion sickness include the following:
along with other drug-​specific side effects. Some
• Being aware of and avoiding situations that medications may interfere with or delay accli-
tend to trigger symptoms. mation to the offending movement. Because
gastric stasis can occur with motion sickness,
• Optimizing position to reduce motion or parenteral delivery may be advantageous.
motion perception—​for example, driving a
Antihistamines are the most frequently used
vehicle instead of riding in it, sitting in the
and widely available medications for motion sick-
front seat of a car or bus, sitting over the wing
ness; non-​sedating ones appear to be less effec-
of an aircraft, holding the head firmly against
tive. Antihistamines commonly used for motion
the back of the seat, and choosing a window
sickness include cinnarizine (not currently avail-
seat on flights and trains.
able in the United States), cyclizine, dimenhydri-
• Reducing sensory input—​lying prone, shut- nate, meclizine, and promethazine (oral and
ting eyes, sleeping, or looking at the horizon. suppository). Other common medications used
to treat motion sickness are anticholinergics such
• Maintaining hydration by drinking water, as scopolamine (hyoscine, oral, intranasal, and
eating small meals frequently, and limiting
transdermal), antidopaminergic drugs (such as
alcoholic and caffeinated beverages.
prochlorperazine), metoclopramide, sympathomi-
• Avoiding smoking—​even short-​term cessa- metics, and benzodiazepines. Clinical trials have
tion reduces susceptibility to motion sickness. not shown that ondansetron, a drug commonly


used as an antiemetic in cancer patients, is effec- sickness in children. Caregivers should be

tive in the prevention of nausea associated with reminded to always ask a physician, pharma-
motion sickness. cist, or other clinician if they have any questions
When recommending any of these medica- about how to use or dose antihistamines in chil-
tions to travelers, providers should make sure that dren before they administer the medication.
patients understand the risks and benefits, pos- Oversedation of young children with antihista-
sible undesirable side effects, and potential drug mines can be life-​threatening.
2 interactions. Travelers may consider trying the
medication before travel to see what effect it has
Scopolamine can cause dangerous adverse
effects in children and should not be used;
on them. prochlorperazine and metoclopramide should be
used with caution in children.
Medications in Children
For children aged 2–​ 12  years, dimenhydrinate Medications in Pregnancy
(Dramamine), 1–​1.5 mg/​kg per dose, or diphen- Drugs with the most safety data regarding
hydramine (Benadryl), 0.5–​1 mg/​kg per dose up the treatment of the nausea of pregnancy are the
to 25 mg, can be given 1 hour before travel and logical first choice. Alphabetical scoring of the
every 6 hours during the trip. Because some chil- safety of medications in pregnancy may not be
dren have paradoxical agitation with these medi- helpful, and clinicians should review the actual
cines, a test dose should be given at home before safety data or call the patient’s obstetric provider
departure. for suggestions. Web-​based information may be
Antihistamines are not approved by the found at the websites www.Motherisk.org and
Food and Drug Administration to treat motion www.Reprotox.org.

1. Golding JF, Gresty MA. Pathophysiology and treatment of 5. Shupak A, Gordon CR. Motion sickness: advances
motion sickness. Curr Opin Neurol. 2015 Feb;28(1):83–​8. in pathogenesis, prediction, prevention, and treat-
2. Murdin L, Golding J, Bronstein A. Managing motion ment. Aviat Space Environ Med. 2006 Dec;77(12)
sickness. BMJ. 2011 Dec 2;343:d7430. :1213–​23.

3. Priesol AJ. Motion sickness. Deschler DG, editor. 6. Zhang L, Wang J, Qi R, Pan L, Li M, Cai Y. Motion sick-
Waltham MA: UpToDate; 2012. ness: current knowledge and recent advance.
CNS Neurosci Ther. 2016 Jan;22(1):15–​24.
4. Schmäl F. Neuronal mechanisms and the treat-
ment of motion sickness. Pharmacology. 2013

Regina C. LaRocque, Edward T. Ryan

Respiratory infection is a leading cause of seeking are rare. Clinicians must inquire about history of
medical care in returning travelers. Respiratory travel when evaluating a patient for respiratory
infections occur in up to 20% of all travelers, infections.
which is almost as common as travelers’ diarrhea.
Upper respiratory infection is more common than INFECTIOUS AGENT
lower respiratory infection. In general, the types Viral pathogens are the most common cause
of respiratory infections that affect travelers are of respiratory infection in travelers; causative
similar to those in nontravelers, and exotic causes agents include rhinoviruses, respiratory syncytial



virus, influenza virus, parainfluenza virus, human including respiratory tract inflammation, exac-
metapneumovirus, measles, mumps, adenovirus, erbations of asthma and chronic obstructive pul-
and coronaviruses. Clinicians also need to con- monary disease (COPD), impaired lung function,
sider novel viral causes of respiratory infection in bronchitis, and pneumonia. Certain travelers have
travelers, including Middle East respiratory syn- a higher risk for respiratory tract infection, includ-
drome (MERS) coronavirus and highly pathogenic ing children, the elderly, and people with comorbid
avian influenza viruses. Respiratory infection pulmonary conditions such as asthma and COPD.
due to viral pathogens may predispose to bacte-
rial sinusitis, bronchitis, or pneumonia. Bacterial
The risk for tuberculosis among most travelers
is low (see Chapter 3, Tuberculosis).
pathogens are less common but can include
Streptococcus pneumoniae, Mycoplasma pneumo­ DIAGNOSIS
niae, Haemophilus influenzae, and Chlamydophila Identifying a specific etiologic agent, especially
pneumoniae. Coxiella burnetii and Legionella pneu­ in the absence of pneumonia or serious disease,
mophila can also cause outbreaks and sporadic is not always clinically necessary. If indicated, the
cases of respiratory illness. following methods of diagnosis can be used:

RISK FOR TRAVELERS • Molecular methods are available to detect

a number of respiratory viruses, including
Reported outbreaks are usually associated with
influenza virus, parainfluenza virus, adenovi-
common exposure in hotels and cruise ships or
rus, human metapneumovirus, and respira-
among tour groups. A  few pathogens have been
tory syncytial virus, and for certain nonviral
associated with outbreaks in travelers, including
influenza virus, L.  pneumophila, and Histoplasma
capsulatum. The peak influenza season in the tem- • Rapid tests are also available to detect some
perate Northern Hemisphere is December through pathogens such as respiratory syncytial virus,
February. In the temperate Southern Hemisphere, influenza virus, L. pneumophila, and group
the peak influenza season is June through August. A Streptococcus.
Travelers to tropical zones are at risk all year.
Exposure to an infected person from another hemi-
• Microbiologic culturing of sputum and blood,
although insensitive, can help identify a caus-
sphere, such as on a cruise ship or package tour, can
ative respiratory pathogen.
lead to an outbreak of influenza at any time or place.
Air-​pressure changes during ascent and descent • Special consideration should be given to
of aircraft can facilitate the development of sinus- diagnosing patients with suspected MERS
itis and otitis media. Direct airborne transmission (www.cdc.gov/​coronavirus/​mers/​interim-​
aboard commercial aircraft is unusual because guidance.html) or highly pathogenic avian
recirculated air passes through a series of filters, influenza (www.cdc.gov/​flu/​avianflu/​severe-​
and cabin air generally circulates in limited areas potential.htm)
within the aircraft. Despite this, influenza, tuber-
culosis, measles, and other diseases have resulted CLINICAL PRESENTATION
from transmission in aircraft. Transmission may Most respiratory tract infections, especially those
occur via several pathways, including direct phys- of the upper respiratory tract, are mild and not
ical contact, fomites, direct droplet spread, and incapacitating. Upper respiratory tract infections
suspended small particles. Intermingling of large often cause rhinorrhea or pharyngitis. Lower
numbers of people in locations such as airports, respiratory tract infections, particularly pneu-
cruise ships, and hotels can also facilitate trans- monia, can be more severe. Lower respiratory
mission of respiratory pathogens. tract infections are more likely than upper respi-
The air quality at many travel destinations may ratory tract infections to cause fever, dyspnea, or
be poor, and exposure to sulfur dioxide, nitrogen chest pain. Cough is often present in either upper
dioxide, carbon monoxide, ozone, and particulate or lower tract infections. People with influenza
matter is associated with a number of health risks, commonly have acute onset of fever, myalgia,


headache, and cough. At present, MERS should makes it problematic to decide whether to pre-
be considered in travelers who develop fever scribe travelers a neuraminidase inhibitor for self-​
and pneumonia within 14  days after traveling treatment. This practice should probably be limited
from countries in or near the Arabian Peninsula. to travelers with a specific underlying condition
Certain other patients with illness following con- that may predispose them to severe influenza.
tact with a confirmed or suspected MERS case, or Specific situations that may require medical
with health care facilities with MERS transmis- intervention include the following:
2 sion, should also be evaluated.
Practitioners should be aware that regions
• Pharyngitis without rhinorrhea, cough, or
other symptoms that may indicate infection
associated with MERS may expand or change
with group A Streptococcus.
(www.cdc.gov/​coronavirus/​mers). H5N1 and
H7N9 should be considered in patients with new-​ • Sudden onset of cough, chest pain, and fever
onset severe acute respiratory illness requiring that may indicate pneumonia (or pulmonary
hospitalization when no alternative etiology has embolism), resulting in a situation where the
been identified and if the patient has recently traveler may be sick enough to seek medical
(within 10 days) been to a country with recently care right away.
confirmed human or animal cases of H5N1 (www.
• Travelers with underlying medical conditions,
such as asthma, pulmonary disease, or heart
or H7N9 (www.cdc.gov/​flu/​avianflu/​h7n9/​case-​
disease, who may need to seek medical care
definitions.htm) or has had close contact with an
earlier than otherwise healthy travelers.
ill person who has traveled to these areas in the
last 10  days. It should also be noted that highly
pathogenic avian influenza A  H5 virus has now PREVENTION
been reported in wild birds and domestic poultry Vaccines are available to prevent a number of
in the United States. Pulmonary embolism should respiratory diseases, including influenza, S. pneu­
be considered in the differential diagnosis of trav- moniae infection, H.  influenzae type B infection
elers who present with dyspnea, cough, or pleu- (in young children), pertussis, diphtheria, vari-
risy and fever, especially those who have recently cella, and measles. Unless contraindicated, trav-
been on long car or plane rides. elers should be vaccinated against influenza and
be up-​to-​date on other routine immunizations.
TREATMENT Preventing respiratory illness while traveling may
Affected travelers are usually managed similarly not be possible, but common-​sense preventive
to nontravelers, although travelers with progres- measures include the following:
sive or severe illness should be evaluated for ill-
nesses specific to their travel destinations and
• Minimizing close contact with people who
are coughing and sneezing.
exposure history. Most respiratory infections are
due to viruses, are mild, and do not require spe- • Frequent handwashing, either with soap and
cific treatment or antibiotics. Self-​treatment with water or alcohol-​based hand sanitizers (con-
antibiotics during travel can be considered for taining ≥60% alcohol) when soap and water
higher-​risk travelers who develop symptoms of are not available.
lower respiratory tract infections, such as those
who have chronic bronchitis and who have been
• Using a vasoconstricting nasal spray immedi-
ately before air travel, if the traveler has a pre-
instructed by their providers to take an antibiotic
existing eustachian tube dysfunction, may help
for exacerbations. A  respiratory-​spectrum fluo-
lessen the likelihood of otitis or barotrauma.
roquinolone such as levofloxacin or a macrolide
such as azithromycin may be prescribed to the Appropriate infection control measures should
traveler for this purpose before travel. be used while managing any patient with a respi-
The rate of influenza among travelers is not ratory infection (www.cdc.gov/​flu/​professionals/​
known. The difficulty in self-​diagnosing influenza infectioncontrol).



1. Benkouiten S, Charrel R, Belhouchat K, Drali T, 6. Jennings L, Priest PC, Psutka RA, Duncan AR, Anderson
Nougairede A, Salez N, et al. Respiratory viruses and T, Mahagamasekera P, et al. Respiratory viruses in air-
bacteria among pilgrims during the 2013 Hajj. Emerg line travellers with influenza symptoms: Results of an
Infect Dis. 2014 Nov.;20(11):1821–​7. airport screening study. J Clin Virol. 2015 Jun;67:8–​13.
2. Camps M, Vilella A, Marcos MA, Letang E, Munoz J, 7. Leder K, Sundararajan V, Weld L, Pandey P, Brown G,
Salvado E, et al. Incidence of respiratory viruses among Torresi J. Respiratory tract infections in travelers: a
travelers with a febrile syndrome returning from tropical
and subtropical areas. J Med Virol. 2008 Apr;80(4):711–​5.
review of the GeoSentinel surveillance network. Clin
Infect Dis. 2003 Feb 15;36(4):399–​4 06. 2
3. Foxwell AR, Roberts L, Lokuge K, Kelly PM. 8. Leder K, Torresi J, Libman MD, Cramer JP, Castelli F,
Transmission of influenza on international flights, May Schlagenhauf P, et al. GeoSentinel surveillance of illness
2009. Emerg Infect Dis. 2011 Jul;17(7):1188–​94. in returned travelers, 2007–​2011. Ann Intern Med. 2013
4. Freedman DO, Weld LH, Kozarsky PE, Fisk T, Robins R, Mar 19;158(6):456–​68.
von Sonnenburg F, et al. Spectrum of disease and rela- 9. Luna LK, Panning M, Grywna K, Pfefferle S, Drosten C.
tion to place of exposure among ill returned travelers. N Spectrum of viruses and atypical bacteria in interconti-
Engl J Med. 2006 Jan 12;354(2):119–​30. nental air travelers with symptoms of acute respiratory
5. German M, Olsha R, Kristjanson E, Marchand-​Austin infection. J Infect Dis. 2007 Mar 1;195(5):675–​9.
A, Peci A, Winter AL, et al. Acute respiratory infections 10. Mangili A, Gendreau MA. Transmission of infectious
in travelers returning from MERS-​CoV-​affected areas. diseases during commercial air travel. Lancet. 2005 Mar
Emerg Infect Dis. 2015 Sep.;21(9):1654–​6. 1218;365(9463):989–​9 6.

Counseling & Advice for Travelers

Patricia M. Griffin, Michele C. Hlavsa, Jonathan S. Yoder

Contaminated food and water often pose a risk pathogens. (Some fish harvested from tropical
for travelers. Many of the infectious diseases asso- waters can transmit toxins that survive cook-
ciated with contaminated food and water are ing; see Food Poisoning from Marine Toxins sec-
caused by pathogens transmitted via the fecal–​oral tion in this chapter.) In areas where hygiene and
route. Swallowing, inhaling aerosols of, or coming sanitation are inadequate or unknown, travelers
in contact with contaminated water, including should avoid consuming salads, uncooked veg-
natural freshwater, marine water, or the water in etables, unpasteurized fruit juices, unpasteur-
inadequately treated swimming pools, water play- ized milk, or cheese made from unpasteurized
grounds (splash parks or splash pads), or hot tubs milk. Raw fruits that are eaten unpeeled (such as
and spas can transmit pathogens that can cause strawberries) should be avoided, and fruits that
diarrhea, vomiting, or infection of the ears, eyes, are eaten peeled (such as bananas and mangoes)
skin, or the respiratory or nervous system. should be peeled by the person who eats them.
Produce should be washed under safe running
FOOD water or soaked in water that has been purified,
Travelers should be advised to select food with and then rinsed with safe water just before eat-
care. Raw food is especially likely to be contami- ing (see Water Disinfection for Travelers section
nated. Raw or undercooked meat, fish, and shell- in this chapter). It is safest to eat only food that
fish can carry various intestinal and systemic is fully cooked and served hot. Always refrigerate



perishable cooked food within 2 hours (1 hour WATER

at temperatures >90°F [32°C]). Cooked food that
has been stored should be thoroughly reheated Drinking Water and
before serving. Eggs should be thoroughly cooked, Other Beverages
whether they are served alone or used in sauces. In many parts of the world, particularly where
Consumption of food and beverages obtained water treatment, sanitation, and hygiene are
from street vendors has been associated with an inadequate, tap water may contain disease-​

2 increased risk of illness.

Travelers should wash their hands with soap
causing agents, including viruses, bacteria, and
parasites, or chemical contaminants such as
and water before preparing food, before eating, after lead. As a result, tap water in some places may
using the bathroom or changing diapers, before and be unsafe for drinking, preparing food and bev-
after caring for someone who is ill, and after con- erages, making ice, cooking, and brushing teeth.
tact with animals or their environments. If soap Infants, young children, pregnant women, the
and water are not available, use an alcohol-​based elderly, and people whose immune systems are
hand sanitizer (with ≥60% alcohol) and wash hands compromised ( for example, because of HIV, che-
with soap and water as soon as they become avail- motherapy, or transplant medications) may be
able. Hand sanitizer is not very effective against especially susceptible to illness.
Cryptosporidium or norovirus and does not work Travelers should avoid drinking or putting into
well when hands are visibly dirty or greasy. their mouths tap water unless they are reasonably
The safest way to feed an infant aged <6 months certain it is safe. Many people choose to disinfect
is to breastfeed exclusively. If the infant is fed for- or filter their water when traveling to destina-
mula prepared from commercial powder, the tions where safe tap water may not be available.
powder should be reconstituted with hot water at Tap water is not sterile and should not be used for
a temperature of ≥158°F (≥70°C). This precaution sinus or nasal irrigation or rinsing, including use
will kill most pathogens with which the infant for- in neti pots and for ritual ablution (see Chapter 4,
mula may have been contaminated during man- Saudi Arabia:  Hajj/​Umrah Pilgrimage), unless it
ufacturing or through handling after opening. To is disinfected. Tap water should never be used
ensure that the water is hot enough, travelers to clean or rinse contact lenses. Water contami-
should prepare formula within 30 minutes after nated with toxins or chemicals will not be made
boiling the water (see the Water Disinfection for safe by boiling or disinfection.
Travelers section later in this chapter). The pre- In areas where tap water may be unsafe, only
pared formula should be cooled to a safe tem- commercially bottled water from an unopened,
perature for feeding ( for example, by placing the factory-​sealed container or water that has
bottle upright in a bath of safe water and safe ice been adequately disinfected should be used for
[see below], keeping the bath water below the nip- drinking, preparing food and beverages, mak-
ple ring) and used within 2 hours of preparation. ing ice, cooking, and brushing teeth. (See Water
Bottles and nipples should be washed and then Disinfection for Travelers later in this chapter for
sterilized (in boiling water or in an electric steril- proper disinfection techniques.)
izer). Travelers may wish to pack enough formula Beverages made with boiled water and served
for their trip because manufacturing standards steaming hot (such as tea and coffee) are gener-
vary widely around the world. ally safe to drink. When served in unopened, fac-
Travelers should be advised not to bring per- tory-​sealed cans or bottles, carbonated beverages,
ishable seafood from high-​risk areas back to the commercially prepared fruit drinks, water, alco-
United States. For example, cholera has occurred holic beverages, and pasteurized drinks gener-
in people who ate crab that had been brought into ally can be considered safe. Because water on the
the United States from Latin America by travelers. outside of cans and bottles may be contaminated,
Moreover, travelers should not assume that food they should be wiped clean and dried before open-
and water aboard commercial aircraft are safe; ing or drinking directly from the container.
they may be obtained in the country of departure, Beverages that may not be safe for consump-
where hygiene and sanitation may be inadequate. tion include fountain drinks or other drinks made



with tap water and iced drinks. Because ice might concentrations are not adequately maintained.
be made from contaminated water, travelers in Travelers at increased risk for legionellosis, such
areas with unsafe tap water should request that as the elderly and those with immunocompro-
beverages be served without ice. mising conditions, may choose to avoid entering
or walking near higher-​risk areas such as hot tubs
Recreational Water and spas (see Chapter 3, Legionellosis). Travelers
Pathogens that cause gastrointestinal, respira- should avoid pools, water playgrounds, and hot
tory, skin, ear, eye, and neurologic illnesses can
be transmitted by contaminated recreational
tubs or spas where bather limits are not enforced
or where the water is cloudy. Additional guid-
water in inadequately treated pools, water play- ance can be found at www.cdc.gov/​healthywater/​
grounds (splash pads or spray parks), or hot swimming.
tubs and spas or in freshwater or marine water. To protect their health in oceans, lakes, and
Recreational water contaminated by human rivers, travelers should try not to swim or wade
feces from swimmers, sewage, animal waste, (1)  near storm drains; (2)  in water that may be
or wastewater runoff can appear clear but still contaminated with sewage, human or animal
contain disease-​causing infectious or chemical feces, or wastewater runoff; (3)  in lakes or riv-
agents. Ingesting even small amounts of such ers after heavy rainfall; 4)  in freshwater streams,
water can cause illness. To protect other peo- canals, and lakes in schistosomiasis-​ endemic
ple, children and adults with diarrhea should areas of the Caribbean, South America, Africa,
not enter recreational water. Infectious patho- and Asia (see Chapter  3, Schistosomiasis); (5)  in
gens, such as Cryptosporidium, can survive for water that might be contaminated with urine
days even in well-​maintained pools, water play- from animals infected with Leptospira (see
grounds, and hot tubs and spas. Chapter 3, Leptospirosis); or (6) in warm seawater
Maintaining proper pH and free chlorine or when they have wounds. A traveler with an open
bromine concentration is necessary to prevent wound should stay out of the water if the wound
transmission of most infectious pathogens in is not covered with a water-​occlusive bandage.
water in pools, water playgrounds, and hot tubs To help prevent a rare but fatal infection caused
and spas. If travelers would like to test recre- by Naegleria fowleri (www.cdc.gov/​parasites/​
ational water prior to use, CDC recommends pH naegleria), a parasite found in warm freshwater
7.2–​7.8 and a free available chlorine concentration around the world, travelers should prevent water
of at least 3 ppm in hot tubs and spas and at least from entering the nose by holding the nose shut
1 ppm in pools and water playgrounds (or a free or wearing a nose clip when swimming, diving, or
available bromine concentration of at least 4 ppm participating in similar activities in warm fresh-
in hot tubs and spas and at least 3 ppm in pools water (including lakes, rivers, ponds, hot springs,
and water playgrounds). Test strips may be pur- or locations with water warmed by discharge
chased at most superstores, hardware stores, and from power plants and industrial complexes), and
pool supply stores. Pseudomonas, which can cause avoid digging in or stirring up sediment, especially
“hot tub rash” or “swimmer’s ear,” and Legionella in warm water. This infection has also been linked
(see Chapter  3, Legionellosis) can multiply in to use of contaminated tap water for sinus and
hot tubs and spas in which chlorine or bromine nasal irrigation.

1. Cartwright RY, Colbourne JS. Cryptosporidiosis and 3. CDC. Naegleria fowleri—​Primary amebic meningo-
hotel swimming pools—​a multifaceted challenge. Water encephalitis (PAM). Atlanta, GA: CDC; 2012 [updated
SciTechnol: Water Supply. 2002 Jan 2(3):47–​54. Sep. 24, 2015; cited 2016 Apr. 15]; Available from: www.
2. CDC. Drinking water: camping, hiking, travel. cdc.gov/​parasites/​naegleria/​index.html.
Atlanta: CDC; 2012 [cited 2016 Apr. 15]; Available 4. CDC. Legionellosis resource site. Atlanta: CDC; 2013
from: www.cdc.gov/​healthywater/​drinking/​travel/​ [cited 2016 Apr. 15]; Available from: www.cdc.gov/​
index.html legionella/​index.html.



5. CDC. Notes from the field: primary amebic meningo- 8. Eberhart-​Phillips J, Besser RE, Tormey MP, Koo D, Feikin
encephalitis associated with ritual nasal rinsing—​St. D, Araneta MR, et al. An outbreak of cholera from food
Thomas, US Virgin Islands, 2012. MMWR Morb Mortal served on an international aircraft. Epidemiol Infect.
Wkly Rep. 2013 Nov 15;62(45):903. 1996 Feb;116(1):9–​13.
6. CDC. Otitis externa: Swimmer’s ear. Atlanta: CDC; 9. Finelli L, Swerdlow D, Mertz K, Ragazzoni H, Spitalny
2016 [updated May 4, 2016; cited 2016 Apr. 15]; K. Outbreak of cholera associated with crab brought
Available from: www.cdc.gov/​healthywater/​swimming/​ from an area with epidemic disease. J Infect Dis. 1992
swimmers/​rwi/​ear-​infections.html. Dec;166(6):1433–​5.

2 7. CDC. Pseudomonas dermatitis/​folliculitis: Hot tub rash.

Atlanta: CDC; 2016 [updated May 4, 2016; cited 2016
10. Yoder JS, Straif-​Bourgeois S, Roy SL, Moore TA, Visvesvara
GS, Ratard RC, et al. Primary amebic meningoencephali-
Apr. 15]; Available from: www.cdc.gov/​healthywater/​ tis deaths associated with sinus irrigation using contami-
swimming/​swimmers/​rwi/​rashes.html. nated tap water. Clin Infect Dis. 2012 Nov;55(9):e79–​85.

Howard D. Backer

RISK FOR TRAVELERS most developing countries do not recycle plas-

Waterborne disease is a risk for international tic bottles. All international travelers, especially
travelers who visit countries that have poor long-​term travelers or expatriates, should become
hygiene and inadequate sanitation, and for wil- familiar with and use simple methods to ensure
derness visitors who rely on surface water in safe drinking water. Several methods are scalable
any country, including the United States. The and some can be improvised from local resources,
list of potential waterborne pathogens is exten- allowing adaptation to disaster relief and refugee
sive and includes bacteria, viruses, protozoa, and situations. Table 2-​10 compares benefits and lim-
parasitic helminths. Most of the organisms that itations of different methods.
can cause travelers’ diarrhea can be waterborne.
Where treated tap water is available, most trav-
elers’ intestinal infections are probably trans-
mitted by food, but aging or inadequate water
treatment infrastructure may not effectively dis- Heat
infect water or maintain water quality during Common intestinal pathogens are readily inac-
distribution. Where untreated surface or well tivated by heat. Microorganisms are killed in a
water is used and there is no sanitation infra- shorter time at higher temperatures, whereas
structure, the risk of waterborne infection is high. temperatures as low as 140°F (60°C) are effective
Microorganisms with small infectious doses (such with a longer contact time. Pasteurization uses
as Giardia, Cryptosporidium, Shigella, Escherichia this principle to kill foodborne enteric patho-
coli O157:H7, and norovirus) can even cause ill- gens and spoilage-​causing organisms at tempera-
ness through recreational water exposure, via tures between 140°F (60°C) and 158°F (70°C), well
inadvertent water ingestion. below the boiling point of water (212°F [100°C]).
Bottled water has become the convenient Although boiling is not necessary to kill com-
solution for most travelers, but in some places it mon intestinal pathogens, it is the only easily
may not be superior to tap water. Moreover, the recognizable end point that does not require a
plastic bottles create an ecological problem, since thermometer. All organisms except bacterial


3 7

Table 2-​10. Comparison of water disinfection techniques


Heat • Does not impart additional taste or color • Does not improve taste, smell, or appearance
• Single step that inactivates all enteric of source water
pathogens • Fuel sources may be scarce, expensive, or
• Efficacy is not compromised by contaminants
or particles in the water as for halogenation
and filtration
• Does not prevent recontamination during
Filtration • Simple to operate • Adds bulk and weight to baggage
• Requires no holding time for treatment • Many filters do not reliably remove viruses
• Large choice of commercial product designs • Channeling of water or high pressure can
• Adds no unpleasant taste and often improves force microorganisms through the filter
taste and appearance of water • More expensive than chemical treatment
• Can be combined with halogens to remove or • Eventually clogs from suspended particulate
kill all pathogenic waterborne microbes matter and may require some field
maintenance or repair
• Does not prevent recontamination during

Halogens • Inexpensive and widely available in liquid or • Impart taste and odor to water
(chlorine, tablet form • Flexible dosing requires understanding of
iodine) • Taste can be removed by simple techniques principles
• Flexible dosing • Iodine is physiologically active, with potential
• Equally easy to treat large and small volumes adverse effects
• Will preserve microbiologic quality of stored • Not readily effective against Cryptosporidium
water oocysts
• Efficacy decreases with low water
temperature and decreasing water clarity
• Corrosive and stains clothing

Chlorine • Low doses have no taste or color • Volatile and sensitive to sunlight: do not
dioxide • Simple to use and available in liquid or expose tablets to air, and use generated
tablet form solutions rapidly
• More potent than equivalent doses of chlorine • No persistent residual concentration, so does
• Effective against all waterborne pathogens not prevent recontamination during storage

Ultraviolet • Imparts no taste • Requires clear water

(UV) • Portable devices now available • Does not improve taste or appearance
• Effective against all waterborne pathogens of water
• Extra doses of UV can be used for added • Relatively expensive (except solar)
assurance and with no side effects • Requires batteries or power source
• Solar UV exposure (SODIS) also provides • Cannot know if devices are delivering
substantial benefit required UV doses
• No persistent residual concentration, so does
not prevent recontamination during storage

spores, which are rarely waterborne enteric boil should be adequately disinfected; however, if
pathogens, are killed in seconds at boiling tem- fuel supplies are adequate, travelers may wish to
perature. In addition, the time required to heat boil for 1 minute to allow for a margin of safety.
the water from 60°C to boiling works toward Although the boiling point decreases with alti-
heat disinfection. Any water that is brought to a tude, at common terrestrial travel elevations it



is still above temperatures required to inactivate Progressively finer levels of filtration known as
enteric pathogens. ultrafiltration, nanofiltration, and reverse osmo-
If no other means of water treatment is avail- sis can remove particles of 0.01, 0.001, and 0.0001
able, a potential alternative to boiling is to use tap µm, respectively. All of these filters can remove
water that is too hot to touch, which is probably viruses. Nanofiltration will remove organic mol-
at a temperature between 131°F (55°C) and 140°F ecules, while reverse osmosis will remove mon-
(60°C). This temperature may be adequate to kill ovalent salts, thus achieving desalination. One
2 pathogens if the water has been kept hot in the
tank for some time. Travelers with access to elec-
new portable filter design incorporates hollow
fiber technology, which is a cluster of tiny tubules
tricity can bring a small electric heating coil or a with variable pore sizes that can achieve nano-
lightweight beverage warmer to boil water. filtration and remove virus-​size particles. These
are now available in various designs at reason-
Filtration and Clarification able prices, including hand-​pump, gravity drip,
Portable hand-​pump or gravity-​drip filters with and drink through. All are effective, although
various designs and types of filter media are drink-​through is least practical due to the nega-
commercially available to international travel- tive pressure required for flow. The high price and
ers. Filter pore size is the primary determinant of slow output of small hand-​pump reverse-​osmosis
a filter’s effectiveness, but microorganisms also units prohibit use by land-​based travelers; how-
adhere to filter media by electrochemical reac- ever, they are survival aids for ocean voyagers, and
tions. Microfilters with “absolute” pore sizes of 0.1–​ larger powered devices are used for military and
0.4 µm are usually effective to remove cysts and refugee situations. Microfilters that commonly
bacteria but may not adequately remove viruses, use ceramic, synthetic fiber, compressed carbon,
which are a major concern in water with high lev- or large-​pore hollow-​fiber filter elements are suf-
els of fecal contamination (Table 2-​11). Filters that ficient to remove bacteria and protozoan cysts in
claim Environmental Protection Agency (EPA) water with low levels of contamination (wilder-
designation of water “purifier” undergo company-​ ness water with little human and animal activ-
sponsored testing that has demonstrated removal ity), but hollow-​fiber filters with ultrafiltration or
of 106 bacteria, 104 (9,999 of 10,000) viruses, and nanofiltration should be used for water with high
103 Cryptosporidium oocysts or Giardia cysts. levels of human and animal activity in the water-
(EPA does not independently test the validity of shed. A 2-​step process of halogen (see below) and
these claims.) microfiltration can also assure virus removal.

Table 2-​11. Microorganism size and susceptibility to filtration


Viruses 0.03 Not specified (optimally 0.01, ultrafiltration)

Enteric bacteria (such as Escherichia coli) 0.5 × 3.0–​8.0 0.2–​0.4 (microfiltration)

Cryptosporidium oocyst 4–​6 1 (microfiltration)

Giardia cyst 6.0–​10.0 × 8.0–​15.0 3.0–​5.0 (microfiltration)

Nematode eggs 30 × 60 Not specified; any microfilter

Schistosome larvae 50 × 100 Not specified; any microfilter


5 7

Filters made from ceramic clay or simple sand world. Other chlorine-​ containing compounds
and gravel (slow sand or biosand) filters are suc- such as calcium hypochlorite and sodium
cessfully used for households in developing coun- dichloroisocyanurate, available in granular or
tries. Gravel and sand filters can be improvised tablet formulation, are also effective for water
in remote or austere situations when no other treatment. An advantage of halogens is flexible
means of disinfection is available. dosing that allows use by individual travelers,
Coagulation-​flocculation (CF) removes sus- small or large groups, or communities.
pended particles that cause a cloudy appear-
ance and bad taste and do not settle by gravity;
Given adequate concentrations and length
of exposure (contact time), chlorine and iodine
this process removes many but not all micro- have similar activity and are effective against
organisms. CF is easily applied in the field. bacteria and viruses (www.cdc.gov/​safewater/​
Alum—​an aluminum salt that is widely used effectiveness-​on-​pathogens.html). Giardia cysts
in food, cosmetic, and medical applications—​ are more resistant to halogens; however, field-​
or one of several other natural substances is level concentrations are effective with longer
added to the water and stirred. The clumped contact times. For this reason, dosing and con-
particulates that form are allowed to settle, centrations of halogen products are targeted to
then poured through a coffee filter or fine cloth the cysts. Some common waterborne parasites,
to remove the sediment. Tablets or packets of such as Cryptosporidium, are poorly inactivated
powder that combine flocculent and hypochlo- by halogen disinfection at practical concentra-
rite disinfection are available (products include tions, even with extended contact times.
Chlor-​floc and PUR Purifier of Water [Proctor Chemical disinfection may be supplemented
and Gamble—​for humanitarian use, not sold with filtration to remove resistant oocysts from
commercially]). CF removes most microorgan- drinking water. Cloudy water contains sub-
isms but should not be used as the sole means stances that will neutralize disinfectant, so it will
of disinfection. It also improves the effective- require higher concentrations or contact times
ness of filtration by causing microorganisms, or, preferably, clarification through settling, CF, or
including viruses, to clump with larger parti- filtration before disinfectant is added.
cles, facilitating their removal. Both chlorine and iodine are available in liquid
Granular-​ activated carbon (GAC) purifies and tablet form. Because iodine has physiologic
water by adsorbing organic and inorganic chem- activity, WHO recommends limiting iodine water
icals and most heavy metals, thereby improving disinfection to a few weeks. Iodine use is not
odor, taste, and safety. GAC is a common compo- recommended for people with unstable thyroid
nent of household and field filters. It may trap but disease or known iodine allergy. In addition, preg-
does not kill organisms. In field water treatment, nant women should not use iodine to disinfect
GAC is best used after chemical disinfection to water over the long term because of the poten-
remove disinfection byproducts as well as the tial effect on the fetal thyroid. Pregnant travelers
taste of iodine and chlorine (see Halogens below). who have other options should use an alternative
means such as heat, chlorine, or filtration.
Some prefer the taste of iodine to chlorine, but
Chemical Disinfection
neither is appealing in doses often recommended
HALOGENS for field use. The taste of halogens in water can be
The most common chemical water disinfec- improved by:
tants are halogens, mainly chlorine and iodine,
although bromine has similar qualities. Sodium • Reducing concentration and increasing
hypochlorite, the active ingredient in com- contact time;
mon household bleach, is the primary disinfec-
tant promoted by CDC and the World Health
• Or, following contact time,
Organization Safe Water System at a 1.5% con- > Running water through a filter containing
centration for household use in the developing activated carbon or



> Adding a 25mg tablet of vitamin C, a tiny turbidity, because suspended particles can shield
pinch of powdered ascorbic acid, or a microorganisms from UV rays.
small amount of hydrogen peroxide.
Solar Irradiation and Heating
IODINE RESINS UV irradiation by sunlight in the UVA range can
Iodine resins transfer iodine to microorganisms substantially improve the microbiologic quality
that come into contact with the resin but leave lit- of water and may be used in austere emergency
2 tle iodine dissolved in the water. The resins have
been incorporated into various filter designs
situations. Recent work has confirmed the effi-
cacy and optimal procedures of the solar disin-
available for field use. Most contain a 1-​µm cyst fection (SODIS) technique. Solar disinfection is
filter, which should effectively remove protozoan not effective on turbid water. If the headlines in
cysts. Few models are sold in the United States a newspaper cannot be read through the bottle
because of inconsistent test results. of water, then the water must be clarified before
solar irradiation is used. Under cloudy weather
SALT (SODIUM CHLORIDE) ELECTROLYSIS conditions, water must be placed in the sun for 2
Passing a current through a simple brine salt solu- consecutive days.
tion generates oxidants, including hypochlorite,
which can be used to disinfect microbes. This Silver and Other Products
technique has been engineered into a pocket-​ Silver ion has bactericidal effects in low doses,
sized, battery-​powered product, which is com- and some attractive features include lack of
mercially available. color, taste, and odor, and the ability of a thin
coating on the container to maintain a steady,
CHLORINE DIOXIDE low concentration in water. Silver is widely used
Chlorine dioxide (ClO2) can kill most waterborne by European travelers as a primary drinking
pathogens, including Cryptosporidium oocysts, at water disinfectant. In the United States, silver
practical doses and contact times. Tablets and liq- is approved only for maintaining microbiologic
uid formulations are available to generate chlo- quality of stored water because its concentration
rine dioxide in the field for small-​quantity water can be strongly affected by adsorption onto the
treatment. Although extensive data show the effi- surface of the container, and there has been lim-
cacy of chlorine dioxide in municipal and indus- ited testing on viruses and cysts. Silver is avail-
trial systems, fewer data are available to show able alone or in combination with chlorine in
the efficacy of small-​quantity treatment compa- tablet formulation.
rable to other halogens—​mainly concentrations Several other common products, includ-
achieved and contact time required. ing hydrogen peroxide, citrus juice, and potas-
sium permanganate have antibacterial effects
Ultraviolet (UV) Light in water and are marketed in commercial prod-
UV light kills bacteria, viruses, and Cryptos­ ucts for travelers. None have sufficient data to
poridium oocysts in water. The effect depends recommend them for primary water disinfection
on UV dose and exposure time. Portable battery-​ at low doses in the field.
operated units that deliver a metered, timed dose
of UV are an effective way to disinfect small quan- THE PREFERRED TECHNIQUE
tities of clear water in the field. Larger units with Tables 2-​10 and 2-​12 summarize advantages and
higher output are available where a power source disadvantages of field water disinfection tech-
is available. These units have limited effectiveness niques and their bacteriological efficacy. It is
in water with high levels of suspended solids and advisable to test a method before travel.



Table 2-​12. Summary of field water disinfection techniques


Heat + + + + +

Filtration + +/​–​1 + + +

Halogens + + +2 –​ +/​–​3
Chlorine dioxide + + + + +

Most filters make no claims for viruses. Hollow-​fiber filters with ultrafiltration pore size and reverse osmosis are effective.
Require higher concentrations and contact time than for bacteria or viruses.
Eggs are not very susceptible to halogens, but risk of waterborne transmission is very low.

1. Backer H. Field water disinfection. In: Auerbach PS, edi- 6. Sobsey MD, Stauber CE, Casanova LM, Brown JM,
tor. Wilderness Medicine. 6th ed. Philadelphia: Mosby Elliott MA. Point of use household drinking water
Elsevier; 2012. pp. 1324–​59. filtration: a practical, effective solution for provid-
2. Backer H, Hollowell J. Use of iodine for water disinfec- ing sustained access to safe drinking water in the
tion: iodine toxicity and maximum recommended dose. developing world. Environ Sci Technol. 2008 Jun
Environ Health Perspect. 2000 Aug;108(8):679–​84. 15;42(12):4261–​7.

3. Bielefeldt AR. Appropriate and sustainable water 7. Swiss Federal Institute of Aquatic Science
disinfection methods for developing communities. and Technology. SODIS method. Dübendorf,
In: Buchaman K, editor. Water Disinfection. New York Switzerland: Swiss Federal Institute of Aquatic Science
City: Nova Science 2011. pp. 41–​75. and Technology; 2012 [cited 2016 Sep. 21]; Available
from: www.sodis.ch/​methode/​index_​EN.
4. CDC. Safe water systems for the developing world: a
handbook for implementing household-​based water 8. World Health Organization. Boil water. Technical
treatment and safe storage projects. Atlanta: CDC, 2000 Brief. WHO; 2015 [cited 2016 Mar. 13]; Available
[cited 2016 Sep 19]. Available from: http://​www.cdc.gov/​ from: http://​apps.who.int/​iris/​bitstream/​10665/​
safewater/​pdf/​sws-​for-​the-​developing-​world-​manual.pdf. 155821/​1/​WHO_​F WC_​W SH_​15.02_​eng.pdf ?ua=1.

5. Clasen T, Roberts I, Rabie T, Schmidt W, Cairncross 9. World Health Organization. Guidelines for drinking-​
S. Interventions to improve water quality for pre- water quality. WHO; 2011 [cited 2016 Mar. 13]; Available
venting diarrhoea. Cochrane Database Syst Rev. from: http://​apps.who.int/​iris/​bitstream/​10665/​4 4584/​
2006;(3):CD004794. 1/​9789241548151_​eng.pdf.


Vernon E. Ansdell

Seafood poisoning from marine toxins is an CIGUATERA FISH POISONING

underrecognized hazard for travelers, particu- Ciguatera fish poisoning occurs after eating reef
larly in the tropics and subtropics. Furthermore, fish contaminated with toxins such as cigua-
the risk is increasing as a result of factors such as toxin or maitotoxin. These potent toxins origi-
climate change, coral reef damage, and spread of nate from Gambierdiscus toxicus, a small marine
toxic algal blooms. organism (dinoflagellate) that grows on and



around coral reefs. Dinoflagellates are ingested but may be delayed for up to 30 hours. Sym­
by herbivorous fish. The toxins produced by ptoms include:
G.  toxicus are then modified and concentrated
as they pass up the marine food chain to car- • Gastrointestinal: diarrhea, nausea, vomiting,
and abdominal pain.
nivorous fish and finally to humans. Ciguatoxins
are concentrated in fish liver, intestines, roe, • Cardiovascular: bradycardia, heart block,
and heads. hypotension.
2 G.  toxicus may proliferate on dead coral
reefs more effectively than other dinoflagel- • Neurologic: paresthesias, weakness, pain in
the teeth or a sensation that the teeth are
lates. The risk of ciguatera is likely to increase as
loose, burning or metallic taste in the mouth,
more coral reefs deteriorate because of climate
generalized itching, sweating, and blurred
change, ocean acidification, construction, and
vision. Cold allodynia (abnormal sensation
nutrient runoff.
when touching cold water or objects) has
been reported as characteristic, but there
Risk for Travelers can be acute sensitivity to both hot and cold.
Ciguatera poisoning is underrecognized and
Neurologic symptoms usually last a few days
underreported; up to 50,000 cases occur globally
to several weeks but may persist for months
every year. The incidence in travelers to highly
or even years.
endemic areas has been estimated as high as
3 per 100. Ciguatera is widespread in tropical • Neuropsychiatric: fatigue, general malaise,
and subtropical waters, usually between the lat- insomnia.
itudes of 35°N and 35°S; it is particularly com-
The overall death rate from ciguatera poison-
mon in the Pacific and Indian Oceans and the
ing is <0.1% but varies according to the toxin
Caribbean Sea. The incidence and geographic
dose and availability of medical care to deal
distribution of ciguatera poisoning are increas-
with complications. The diagnosis of ciguat-
ing. Newly recognized areas of risk include the
era poisoning is based on the characteristic
Canary Islands, the eastern Mediterranean,
signs and symptoms and a history of eating
and the western Gulf of Mexico. Medical prac-
species of fish that are known to carry ciguat-
titioners must be aware that cases of ciguatera
era toxin. Fish testing can be done by the Food
fish poisoning acquired by travelers in endemic
and Drug Administration (FDA) in their labora-
areas may present in nonendemic (temperate)
tory at Dauphin Island. There is no readily avail-
areas. In addition, cases of ciguatera fish poison-
able test for ciguatera toxins in human clinical
ing are seen with increasing frequency in nonen-
demic areas as a result of the increasing global
trade in seafood products.
Fish that are most likely to cause ciguatera poi- Prevention
soning are large carnivorous reef fish, such as bar- Travelers can take the following precautions to
racuda, grouper, moray eel, amberjack, sea bass, prevent ciguatera fish poisoning:
or sturgeon. Omnivorous and herbivorous fish
such as parrot fish, surgeonfish, and red snapper
• Avoid or limit consumption of reef fish.
can also be a risk. • Never eat high-​risk fish such as barracuda or
moray eel.
Clinical Presentation • Avoid the parts of the fish that concentrate
Ciguatera poisoning may cause gastrointestinal, ciguatera toxin: liver, intestines, roe, and head.
cardiovascular, neurologic, and neuropsychiat-
ric illness. The first symptoms usually develop Remember that ciguatera toxins do not affect the
within 3–​6 hours after eating contaminated fish texture, taste, or smell of fish, and they are not



destroyed by gastric acid, cooking, smoking, freez- there may be respiratory compromise, malig-
ing, canning, salting, or pickling. nant arrhythmias, and hypotension requiring
hospitalization. There are no long-​term sequelae.
Treatment Diagnosis is usually clinical. A clustering of cases
There is no specific antidote for ciguatoxin or mai- helps exclude the possibility of true fish allergy.
totoxin poisonings. Symptomatic treatment may
include gabapentin or pregabalin (neuropathic Prevention
symptoms), amitriptyline (chronic paresthesias,
depression, and pruritus), fluoxetine (chronic
Fish contaminated with histamine may have a
peppery, sharp, salty, taste or “bubbly” feel but will
fatigue), and nifedipine or acetaminophen (head- usually look, smell, and taste normal. The key to
aches). Intravenous mannitol has been reported prevention is to make sure that the fish is prop-
in uncontrolled studies to reduce the severity and erly iced or refrigerated at temperatures <38°F
duration of neurologic symptoms, particularly if (<3.3°C), or immediately frozen after it is caught.
given within 48 hours of the appearance of symp- Cooking, smoking, canning, or freezing will not
toms. It should only be given to hemodynamically destroy histamine in contaminated fish.
stable, well-​hydrated patients.
After recovering from ciguatera poisoning, Treatment
patients may want to avoid any fish, nuts, alcohol, Scombroid poisoning usually responds well to
or caffeine for at least 6 months as they may cause antihistamines (H1-​ receptor blockers, although
a relapse in symptoms. H2-​receptor blockers may also be of benefit).


Scombroid, one of the most common fish poison- Several forms of poisoning may occur after ingest-
ings, occurs worldwide in both temperate and ing toxin-​containing shellfish, such as filter-​
tropical waters. The illness occurs after eating feeding bivalve mollusks (such as mussels, oysters,
improperly refrigerated or preserved fish contain- clams, scallops, and cockles), gastropod mollusks
ing high levels of histamine, and often resembles a (such as abalone, whelks, and moon snails), or
moderate to severe allergic reaction. crustaceans (such as Dungeness crabs, shrimp,
Fish typically associated with scombroid have and lobsters). The toxins originate in small marine
naturally high levels of histidine in the flesh and organisms (dinoflagellates or diatoms) that are
include tuna, mackerel, mahi mahi (dolphin fish), ingested and are concentrated by shellfish.
sardine, anchovy, herring, bluefish, amberjack,
and marlin. Histidine is converted to histamine Risk for Travelers
by bacterial overgrowth in fish that has been Contaminated (toxic) shellfish may be found in
improperly stored after capture. Histamine and temperate and tropical waters, typically during or
other scombrotoxins are resistant to cooking, after phytoplankton blooms, also called harmful
smoking, canning, or freezing. algal blooms (HABs). One example of a HAB is the
Florida red tide caused by Karenia brevis.
Clinical Presentation
Symptoms of scombroid poisoning resemble Clinical Presentation
an acute allergic reaction and usually appear Poisoning results in gastrointestinal and neu-
10–​60 minutes after eating contaminated fish. rologic illness of varying severity. Symptoms
They include flushing of the face and upper body typically appear 30–​ 60 minutes after ingest-
(resembling sunburn), severe headache, palpita- ing toxic shellfish but can be delayed for several
tions, itching, blurred vision, abdominal cramps, hours. Diagnosis is usually one of exclusion and
and diarrhea. Untreated, symptoms usually resolve is typically made clinically in patients who have
within 12 hours but may last up to 48 hours. Rarely, recently eaten shellfish.




Paralytic shellfish poisoning (PSP) is the most Diarrheic shellfish poisoning (DSP) is caused
common and most severe form of shellfish poi- by eating shellfish contaminated with toxins
soning. PSP is caused by eating shellfish contam- such as okadaic acid. It occurs worldwide, and
inated with saxitoxins. These potent neurotoxins outbreaks have been reported from China, Japan,
are produced by various dinoflagellates. A  wide Scandinavia, France, Belgium, Spain, Chile,
range of shellfish may cause PSP, but most cases Uruguay, Ireland, the United States, and Canada.
2 occur after eating mussels or clams.
PSP occurs worldwide but is most common
Most cases result from eating toxic bivalve
mollusks such as mussels and scallops. Symptoms
in temperate waters, especially off the Pacific usually occur within 2 hours of eating contami-
and Atlantic Coasts of North America, includ- nated shellfish and include chills, diarrhea, nau-
ing Alaska. Cases have also been reported from sea, vomiting, and abdominal pain. Symptoms
countries such as the Philippines, China, Chile, usually resolve within 2–​3  days. No deaths have
Scotland, Ireland, New Zealand, and Australia. been reported.
Symptoms usually appear 30–​60 minutes after
eating toxic shellfish and include numbness and AMNESIC SHELLFISH POISONING
tingling of the face, lips, tongue, arms, and legs. Amnesic shellfish poisoning (ASP) is a rare form of
There may be headache, nausea, vomiting, and shellfish poisoning caused by eating shellfish con-
diarrhea. Severe cases are associated with inges- taminated with domoic acid, produced by the dia-
tion of large doses of toxin and clinical features tom Pseudonitzchia spp. ASP has been reported
such as ataxia, dysphagia, mental status changes, from Canada, Scotland, Ireland, France, Belgium,
flaccid paralysis, and respiratory failure. The case-​ Spain, Portugal, New Zealand, Australia, and Chile.
fatality ratio is dependent on the availability of Toxic mussels, scallops, razor clams, and crusta-
modern medical care, including mechanical ven- ceans were responsible in those outbreaks.
tilation. The death rate may be particularly high In most cases, gastrointestinal symptoms
in children. such as diarrhea, vomiting, and abdominal pain
develop within 24 hours of eating toxic shellfish,
NEUROTOXIC SHELLFISH POISONING followed by headache, memory loss, and cognitive
Neurotoxic shellfish poisoning (NSP) is caused by impairment. In severe cases there may be hypo-
eating shellfish contaminated with brevetoxins tension, arrhythmias, ophthalmoplegia, coma,
produced by the dinoflagellate K. brevis. NSP has and death. Survivors may have severe antero-
been reported from the southeastern coast of the grade, short-​term memory deficits.
United States, the Gulf of Mexico, the Caribbean,
and New Zealand. Prevention
NSP usually presents 30 minutes to 3 hours Shellfish poisoning can be prevented by avoiding
after eating toxic shellfish. Most cases present potentially contaminated shellfish. This is partic-
with gastroenteritis accompanied by minor neu- ularly important in areas during or shortly after
rologic symptoms resembling mild ciguatera algal blooms, which may be locally referred to as
poisoning or mild paralytic shellfish poisoning. “red tides” or “brown tides.” Travelers to devel-
A syndrome known as aerosolized red tide respi- oping countries should avoid eating all shellfish,
ratory irritation (ARTRI) occurs when aerosolized because they also carry a high risk of viral and
brevetoxins are inhaled in sea spray. This has been bacterial infections. Marine shellfish toxins can-
reported in association with a red tide (K. brevis not be destroyed by cooking or freezing.
bloom) in Florida. It can induce bronchoconstric-
tion and may cause acute, temporary respiratory Treatment
discomfort in healthy people. People with asthma Treatment is symptomatic and supportive. Severe
may experience more severe and prolonged respi- cases of paralytic shellfish poisoning may require
ratory effects. mechanical ventilation.



1. Ansdell V. Food-​borne illness. In: Keystone JS, Freedman 6. Isbister GK, Kiernan MC. Neurotoxic marine poisoning.
DO, Kozarsky PE, Connor BA, Nothduft HD, editors. Lancet Neurol. 2005 Apr;4(4):219–​28.
Travel Medicine. 3rd ed. Philadelphia: Saunders 7. Palafox NA, Buenoconsejo-​Lum LE. Ciguatera fish poi-
Elsevier; 2013. pp. 425–​32. soning: review of clinical manifestations. J Toxicol Toxin
2. Chan TY. Ciguatera fish poisoning in East Asia and Rev. 2001 May;20(2):141–​6 0.
Southeast Asia. Marine Drugs. 2015 Jun 2;13(6):3466–​78. 8. Schnorf H, Taurarii M, Cundy T. Ciguatera fish poison-
3. Chan TY. Characteristic features and contributory fac-
tors in fatal ciguatera fish poisoning—​implications for
ing: a double-​blind randomized trial of mannitol ther-
apy. Neurology. 2002 Mar 26;58(6):873–​80. 2
prevention and public education. Am J Trop Med Hyg. 9. Sobel J, Painter J. Illnesses caused by marine toxins. Clin
2016 Apr;94(4):704–​9. Infect Dis. 2005 Nov 1;41(9):1290–​6.
4. Dickey RW, Plakas SM. Ciguatera: a public health per- 10. Stewart I, Lewis RJ, Eaglesham GK, Graham GC, Poole S,
spective. Toxicon. 2010 Aug 15;56(2):123–​36. Craig SB. Emerging tropical diseases in Australia. Part 2.
5. Hungerford JM. Scombroid poisoning: a review. Toxicon. Ciguatera fish poisoning. Ann Trop Med Parasitol. 2010
2010 Aug 15;56(2):231–​43. Oct;104(7):557–​71.

John-​Paul Mutebi, William A. Hawley, William G. Brogdon

Vaccines or prophylactic drugs are available GENERAL PROTECTIVE

to protect against some vectorborne diseases MEASURES
such as yellow fever, Japanese encephalitis, and Avoid outbreaks. To the extent possible, travel-
malaria; however, travel health practitioners ers should avoid known foci of epidemic disease
should advise travelers to use repellents and transmission. The CDC Travelers’ Health website
other general protective measures against bit- provides updates on regional disease transmission
ing arthropods. The effectiveness of malaria pro- patterns and outbreaks (www.cdc.gov/​travel).
phylaxis is variable, depending on patterns of Be aware of peak exposure times and
drug resistance, bioavailability, and compliance places. Exposure to arthropod bites may be
with medication, and no similar preventive mea- reduced if travelers modify their patterns or loca-
sures exist for other mosquitoborne diseases tions of activity. Although mosquitoes may bite at
such as dengue, chikungunya, Zika, and West any time of day, peak biting activity for vectors of
Nile encephalitis, or tickborne diseases such as some diseases (such as dengue, Zika, and chikun-
Lyme borreliosis, tickborne encephalitis, and gunya) is during daylight hours. Vectors of other
relapsing fever. diseases (such as malaria) are most active in twi-
The Environmental Protection Agency (EPA) light periods (dawn and dusk) or in the evening
regulates repellent products in the United States. after dark. Avoiding the outdoors or taking pre-
CDC recommends that consumers use repel- ventive actions (such as using repellent) during
lent products that have been registered by EPA. peak biting hours may reduce risk. Place also mat-
EPA registration indicates the materials have ters; ticks and chiggers are often found in grasses,
been reviewed and approved for both efficacy woodlands, or other vegetated areas. Local health
and human safety when applied according to the officials or guides may be able to point out areas
instructions on the label. with increased arthropod activity.



Wear appropriate clothing. Travelers can Insecticides and spatial repellents. More
minimize areas of exposed skin by wearing long-​ spatial repellent products are becoming com-
sleeved shirts, long pants, boots, and hats. Tucking mercially available. These products, containing
in shirts, tucking pants into socks, and wearing active ingredients such as metofluthrin and alle-
closed shoes instead of sandals may reduce risk. thrin, augment aerosol insecticide sprays, vapor-
Repellents or insecticides, such as permethrin, can izing mats, and mosquito coils that have been
be applied to clothing and gear for added protec- available for some time. Such products can help
2 tion. (Additional information on clothing is below.)
Check for ticks. Travelers should inspect them-
to clear rooms or areas of mosquitoes (spray aero-
sols) or repel mosquitoes from a circumscribed
selves and their clothing for ticks during outdoor area (coils, spatial repellents). Although many of
activity and at the end of the day. Prompt removal these products appear to have repellent or insec-
of attached ticks can prevent some infections. ticidal activity under particular conditions, they
Showering within 2 hours of being in a tick-​infested have not yet been adequately evaluated in peer-​
area reduces the risk of some tickborne diseases. reviewed studies for their efficacy in preventing
Bed nets. When accommodations are not ade- vectorborne disease. Travelers should supplement
quately screened or air conditioned, bed nets are the use of these products with repellent on skin or
essential in providing protection and reducing dis- clothing and using bed nets in areas where vector-
comfort caused by biting insects. If bed nets do not borne diseases are a risk or biting arthropods are
reach the floor, they should be tucked under mat- noted. Since some products available internation-
tresses. Bed nets are most effective when they are ally may contain pesticides that are not registered
treated with a pyrethroid insecticide. Pretreated, in the United States, it may be preferable for trav-
long-​lasting bed nets can be purchased before elers to bring their own. Insecticides and repel-
traveling, or nets can be treated after purchase. lent products should always be used with caution,
Effective, treated nets may also be available in des- avoiding direct inhalation of spray or smoke.
tination countries. Nets treated with a pyrethroid Optimum protection can be provided by
insecticide will be effective for several months if applying the repellents described in the fol-
they are not washed. Long-​lasting pretreated nets lowing sections to clothing and to exposed
may be effective for much longer. skin (Box 2-​4).

BOX 2-​4. Maximizing protection from mosquitoes

and ticks
To optimize protection against clothing but provide shorter mosquitoes bite mainly
mosquitoes and ticks and reduce duration of protection from dawn to dusk.
the risk of diseases they transmit: (same duration as on skin) > Malaria, West Nile, and
and must be reapplied after Japanese encephalitis
• Wear a long-​sleeved shirt, long
laundering. vector mosquitoes bite
pants, and socks.
mainly from dusk to dawn.
• Treat clothing with permethrin • Apply lotion, liquid, or spray
> Use common sense.
or purchase pretreated repellent to exposed skin.
Reapply repellents as
clothing. • For Mosquitoes protection wanes and
> Permethrin-​treated > Ensure adequate mosquitoes start to bite.
clothing will retain repellent protection during times
activity through multiple of day when mosquitoes • For Ticks
washes. are most active. > Check yourself daily (your
> Repellents used on skin > Dengue, yellow fever, Zika, entire body) and remove
can also be applied to and chikungunya vector attached ticks promptly.


3 8

REPELLENTS FOR USE ON SKIN OLE, PMD, IR3535, and 2-undecanone as “biope-

AND CLOTHING sticide repellents,” which are either derived from
CDC has evaluated information published in or are synthetic versions of natural materials.
peer-​reviewed scientific literature and data avail-
able from EPA to identify several types of EPA-​ Repellent Efficacy
registered products that provide repellent activity Published data indicate that repellent efficacy
sufficient to help people reduce the bites of dis- and duration of protection vary considerably
ease-​carrying mosquitoes. Products containing
the following active ingredients typically provide
among products and among mosquito and tick
species. Product efficacy and duration of pro-
reasonably long-​lasting protection: tection are also markedly affected by ambient
temperature, level of activity, amount of per-
• DEET (chemical name: N,N-​diethyl-​m-​tolua-​ spiration, exposure to water, abrasive removal,
mide or N,N-​diethyl-​3-​methyl-​benzamide).
and other factors. In general, higher concen-
Products containing DEET include, but
trations of active ingredient provide longer
are not limited to, Off !, Cutter, Sawyer, and
duration of protection, regardless of the active
ingredient. Products with <10% active ingre-
• Picaridin (KBR 3023 [Bayrepel] and dient may offer only limited protection, often
icaridin outside the US; chemical name: 1–​2 hours. Products that offer sustained-​release
2-​(2-​hydroxyethyl)-​1-​piperidinecarboxylic or controlled-​release (microencapsulated) for-
acid 1-​methylpropyl ester). Products mulations, even with lower active ingredient
containing picaridin include, but are not concentrations, may provide longer protection
limited to, Cutter Advanced, Skin So Soft Bug times. Studies suggest that concentrations of
Guard Plus, and Autan (outside the US). DEET above approximately 50% do not offer
a marked increase in protection time against
• Oil of lemon eucalyptus (OLE) or PMD mosquitoes; DEET efficacy tends to plateau at
(chemical name: para-​menthane-​3,8-​diol),
a concentration of approximately 50%. CDC rec-
the synthesized version of OLE. Products
ommends using products with ≥20% DEET on
containing OLE and PMD include, but
exposed skin to reduce biting by ticks that may
are not limited to, Repel and Off !
spread disease.
Botanicals. This recommendation refers
Recommendations are based on peer-​
to EPA-​registered products containing
reviewed journal articles and scientific stud-
the active ingredient OLE (or PMD).
ies and data submitted to regulatory agencies.
“Pure” oil of lemon eucalyptus (essential
People may experience some variation in pro-
oil not formulated as a repellent) is not
tection from different products. Regardless of
recommended; it has not undergone
what product is used, if travelers start to get
similar, validated testing for safety and
insect bites they should reapply the repellent
efficacy and is not registered with EPA as
according to the label instructions, try a differ-
an insect repellent.
ent product, or, if possible, leave the area with
• IR3535 (chemical name: 3-​[N-​butyl-​N-​acetyl]-​ biting insects.
aminopropionic acid, ethyl ester). Products Ideally, repellents should be purchased
containing IR3535 include, but are not limited before traveling and can be found online or in
to, Skin So Soft Bug Guard Plus Expedition hardware stores, drug stores, and supermar-
and SkinSmart. kets. A  wide variety of repellents can be found
in camping, sporting goods, and military surplus
• 2-undecanone (chemical name: methyl stores. When purchasing repellents overseas,
nonyl ketone). The product BioUD contains
look for the active ingredients specified above
on the product labels; some names of products
EPA characterizes the active ingredients DEET available internationally have been specified in
and picaridin as “conventional repellents” and the list above.



protection factor (SPF) of sunscreens when

DEET-​containing insect repellents are used after
a sunscreen is applied. Products that combine
sunscreen and repellent are not recommended,
because sunscreen may need to be reapplied
more often and in larger amounts than needed for
the repellent component to provide protection
2 from biting insects. In general, the recommen-
dation is to use separate products, applying sun-
screen first and then applying the repellent. Due
to the decrease in SPF when using a DEET-​con-
taining insect repellent after applying sunscreen,
travelers may need to reapply the sunscreen more

Repellents and Insecticides for Use

on Clothing
Clothing, hats, shoes, bed nets, jackets, and camp-
ing gear can be treated with permethrin for
added protection. Products such as Permanone
FIGURE 2-​1 .   Sample repellency awareness and Sawyer, Permethrin, Repel, and Ultrathon
graphic for skin-​applied insect repellents1 Permethrin Clothing Treatment are registered
with EPA specifically for use by consumers to
Image from: www.epa.gov/​insect-​repellents/​
treat clothing and gear. Alternatively, clothing pre-
treated with permethrin is commercially avail­
able, marketed to consumers in the United States
Repellency Awareness Graphic as Insect Shield, BugsAway, or Insect Blocker.
The Environmental Protection Agency (EPA) Permethrin is a highly effective insecticide,
allows companies to apply for permission to acaricide and repellent. Permethrin-​ treated
include a new repellency awareness graphic on clothing repels and kills ticks, chiggers, mosqui-
the labels of insect repellents that are applied toes, and other biting and nuisance arthropods.
to the skin (Figure  2-​1). The graphic helps con- Clothing and other items must be treated 24–​48
sumers easily identify the time a repellent is hours in advance of travel to allow them to dry.
effective against mosquitoes and ticks. EPA As with all pesticides, follow the label instructions
reviews products that apply to use the graphic when using permethrin clothing treatments.
to ensure that their data meet current testing Permethrin-​ treated materials retain repel-
protocols and standard evaluation practices. Use lency or insecticidal activity after repeated laun-
of this graphic by manufacturers is voluntary. dering but should be retreated, as described on
For more information, visit www.epa.gov/​insect-​ the product label, to provide continued protec-
repellents/​repellency-​awareness-​graphic tion. Clothing that is treated before purchase
is labeled for efficacy through 70 launderings.
Repellents and Sunscreen Clothing treated with the other repellent prod-
Repellents that are applied according to label ucts described above (such as DEET) provides
instructions may be used with sunscreen with protection from biting arthropods but will not last
no reduction in repellent activity; however, lim- through washing and will require more frequent
ited data show a one-​third decrease in the sun reapplications.


5 8

Precautions when Using Insect poison-​control center should be called for fur-

Repellents ther guidance, if feasible. Travelers seeking health
Travelers should take the following precautions: care because of the repellent should take the
repellent to the doctor’s office and show the doc-
• Apply repellents only to exposed skin or cloth- tor. Permethrin should never be applied to skin
ing, as directed on the product label. Do not but only to clothing, bed nets, or other fabrics as
apply repellents under clothing. directed on the product label.
• Never use repellents over cuts, wounds, or
Children and Pregnant Women
irritated skin.
Most repellents can be used on children aged
• When using sprays, do not spray directly >2 months. Protect infants aged <2 months from
on face—​spray on hands first and then mosquitoes by using an infant carrier draped with
apply to face. Do not apply repellents to mosquito netting with an elastic edge for a tight
eyes or mouth, and apply sparingly around fit. Products containing OLE specify that they
ears. should not be used on children aged <3  years.
Other than the safety tips listed above, EPA does
• Wash hands after application to avoid acci-
dental exposure to eyes or ingestion. not recommend any additional precautions for
using registered repellents on children or on preg-
• Children should not handle repellents. nant or lactating women.
Instead, adults should apply repellents
to their own hands first, and then gently Useful Links
spread on the child’s exposed skin. Avoid
applying directly to children’s hands. After • Insect Repellents: Use and Effectiveness
returning indoors, wash your child’s treated (EPA): http://​cfpub.epa.gov/​oppref/
skin and clothing with soap and water or ​insect/​
give the child a bath. • Using Insect Repellents Safely (EPA):
• Use just enough repellent to cover exposed
skin or clothing. Heavy application and using-insect-repellents-safely-and-effectively
saturation are generally unnecessary • FAQ: Insect Repellent Use and Safety (CDC):
for effectiveness. If biting insects do not www.cdc.gov/​westnile/​faq/​repellent.html
respond to a thin film of repellent, apply a
bit more. • Choosing and Using Insect Repellents
(National Pesticide Information
• After returning indoors, wash repellent-​ Center): http://​npic.orst.edu/​ingred/​ptype/​
treated skin with soap and water or repel.html
bathe. Wash treated clothing before
wearing it again. This precaution may
vary with different repellents—​check the BED BUGS
product label. There has been a recent resurgence in bed bug
infestations worldwide, particularly in developed
If a traveler experiences a rash or other reac- countries. Although bed bugs do not transmit
tion, such as itching or swelling, from an insect diseases, their bites may be a nuisance. Travelers
repellent, the repellent should be washed off can take measures to avoid bed bug bites and
with mild soap and water and its use discon- avoid transporting them in luggage and clothing
tinued. If a severe reaction has occurred, a local (Box 2-​5).



BOX 2-​5. Bed bugs and international travel

A recent resurgence in bed bug can produce strong allergic reac- • Keep suitcases closed when
infestations worldwide, partic- tions and considerable emotional they are not in use and try to
ularly in developed countries, stress. keep them off the floor.

2 is thought to be related to the

increase in international travel, PROTECTIVE MEASURES
• Remove clothing and personal
items (such as toiletry bags
pest control strategy changes in AGAINST BED BUGS and shaving kits) from the
travel lodgings, and insecticide Travelers should be encouraged to suitcase only when they are
resistance. Bed bug infestations take the following precautions to in use.
have been increasingly reported avoid or reduce their exposure to • Carefully inspect clothing and
in hotels, theaters, and any loca- bed bugs: personal items before returning
tions where people congregate, them to the suitcase.
even in the workplace, dormito- • Inspect the premises of hotels
• Keep in mind that bed bug
or other sleeping locations
ries, and schools. Bed bugs eggs and nymphs are very
for bed bugs on mattresses,
may be transported in luggage small and can be easily
box springs, bedding, and
and on clothing. Transport of overlooked.
furniture, particularly built-​in
personal belongings in contami-
furniture with the bed, desk, Prevention is by far the most
nated transport vehicles
and closets as a continuous effective and inexpensive way to
is another means of spread of
structural unit. Travelers who protect oneself from these pests.
these insects.
observe evidence of bed bug The costs of ridding a personal
Bed bugs are small, flat
activity—​whether it be the bugs residence of these insects are
insects that are reddish-​brown in
themselves or physical signs considerable, and efforts at control
color, wingless, and range from
such as blood-​spotting on are often not immediately suc-
1 to 7 mm in length. Although bed
linens—​should seek alternative cessful even when conducted by
bugs have not been shown
lodging. professionals.
to transmit disease, their bites

1. Barnard DR, Xue RD. Laboratory evaluation of spp.—​a literature review. Travel Med Infect Dis. 2013
mosquito repellents against Aedes albopictus, Nov-​Dec;11(6):374–​411.
Culex nigripalpus, and Ochlerotatus triseria­ 5. Montemarano AD, Gupta RK, Burge JR, Klein K. Insect
tus (Diptera: Culicidae). J Med Entomol. 2004 repellents and the efficacy of sunscreens. Lancet. 1997
Jul;41(4):726–​3 0. Jun 7;349(9066):1670–​1.
2. Fradin MS, Day JF. Comparative efficacy of insect repel- 6. Murphy ME, Montemarano AD, Debboun M, Gupta
lents against mosquito bites. N Engl J Med. 2002 Jul R. The effect of sunscreen on the efficacy of insect
4;347(1):13–​8. repellent: a clinical trial. J Am Acad Dermatol. 2000
3. Goodyer LI, Croft AM, Frances SP, Hill N, Moore SJ, Aug;43(2 Pt 1):219–​22.
Onyango SP, et al. Expert review of the evidence base 7. Pages F, Dautel H, Duvallet G, Kahl O, de Gentile L,
for arthropod bite avoidance. J Travel Med. 2010 Boulanger N. Tick repellents for human use:
May-​Jun;17(3):182–​92. prevention of tick bites and tick-​borne diseases.
4. Lupi E, Hatz C, Schlagenhauf P. The efficacy of repel- Vector Borne Zoonotic Dis. 2014 Feb;14(2):
lents against Aedes, Anopheles, Culex and Ixodes 85–​93.



Vernon E. Ansdell, Rodd Takiguchi

Increased exposure to ultraviolet (UV) radia- carcinoma, squamous cell carcinoma, and mela-
tion occurs near the equator, during summer
months, at high elevation, and between 10 am
noma. Repeated exposure to sunlight in the eyes
can also result in ocular pterygium formation, cat-
and 4 pm. Reflection from the snow, sand, and aracts, and macular degeneration.
water increases exposure, a particularly import-
ant consideration for snow skiing, beach activi- PREVENTION
ties, swimming, and sailing. In addition, several
Avoid Overexposure to the Sun
common medications may cause photosensitiv-
Sun exposure is the most preventable risk fac-
ity reactions:
tor for skin cancer, including melanoma. Staying
• Acetazolamide indoors or seeking shade between 10 am and
4 pm is very important in limiting exposure to UV
• Amiodarone rays, particularly UVB rays. The intensity of UV
• Antibiotics ( fluoroquinolones, sulfonamides, rays varies seasonally, peaking at the solstice, and
and tetracyclines) gets stronger at the equator and at high altitudes.
Be aware that sunburn and sun damage can occur
• Diuretics ( furosemide, hydrochlorothiazide) even on cloudy days. Sunburn can occur in a fair-​
• Nonsteroidal anti-​inflammatory drugs skinned person after as little as 10–​15 minutes
(celecoxib, ibuprofen, ketoprofen, naproxen, of unprotected sun exposure. Tanning beds and
piroxicam) sun lamps are also carcinogenic and should be
• Sulfonylureas (glipizide, glyburide)
Medical conditions such as connective tissue Protective Clothing
diseases, polymorphous light eruption, rosacea, Wide-​brimmed hats, long sleeves, and long pants
and vitiligo can increase sun sensitivity. Alcohol protect against UV rays. Tightly woven cloth-
consumption can lead to behavioral changes ing and darker fabrics provide additional pro-
that increase the risk of sunburn. tection. High-​UPF (ultraviolet protection factor
Both UVA rays (320–​400  nm) and UVB rays >30) clothing is recommended for travelers at
(290–​320  nm) are carcinogenic. UVA rays are increased risk of sunburn or with a history of skin
present throughout the day and can pass through cancer. This type of clothing contains colorless
window glass. UVA rays cause premature aging of compounds, fluorescent brighteners, or treated
the skin and are primarily responsible for drug-​ resins that absorb UV rays. Sunglasses that pro-
related phototoxicity and photoallergic reactions. vide 100% protection against both UVA and UVB
UVB rays are most intense from 10 am to 4 pm, are radiation are strongly recommended.
blocked by window glass, and are most responsi-
ble for sunburn. Sunscreens
Serious burns are painful, and the skin may Sun protection factor (SPF) defines the extra pro-
be red, tender, swollen, and blistered. These sun- tection against UVB rays that a person receives
burns may be accompanied by fever, headache, by using a sunscreen. Although higher-​SPF sun-
itching, and malaise. Cumulative overexposure screens provide more protection than lower-​SPF
to the sun leads to premature aging of the skin, sunscreens, SPF is not linear. An SPF 30 sun-
including wrinkling and age spots, as well as an screen does not offer twice the protection of SPF
increased risk for skin cancer, including basal cell 15. Sunscreens with at least an SPF of 15 and


that offer protection from both UVA and UVB • Apply to all exposed areas, including the ears,
rays (labeled “broad-​spectrum SPF”) are recom- scalp, back of the neck, tops of the feet, and
mended for best protection. backs of the hands.
Physical sunscreens contain titanium diox-
ide or zinc oxide, inorganic molecules that are • Use a lip balm or lipstick with broad-​spectrum
confined to the stratum corneum and reflect SPF ≥15.
and scatter both visible and UV light. They are • Reapply every 2 hours and after sweat-
2 effective, broad-​spectrum sunscreens that pro-
tect against both UVA and UVB radiation. With
ing, swimming, or towel-​drying (even on
cloudy days).
the advent of nanotechnology, these products
no longer cause an opaque white film on the • The FDA requires that all sunscreens retain
skin and have become cosmetically accept- their original strength for at least 3 years.
able for widespread use. They are recom- Always check the expiration date and discard
mended for people who burn easily or who take all expired product.
medications that may cause photosensitivity • Sunscreens should be applied to the skin
reactions. before insect repellents. (Note: DEET-​con-
Chemical sunscreens absorb rather than taining insect repellents may decrease the
reflect UV radiation. A  combination of chem- SPF of sunscreens by one-​third. Sunscreens
ical agents is recommended to provide broad-​ may increase absorption of DEET through
spectrum protection against UVA and UVB rays. the skin.)
The Food and Drug Administration (FDA) rec-
ommends using sunscreen with 15 SPF or higher • Avoid products that contain both sunscreens
regularly and as directed. and insect repellents, because sunscreen may
Travelers should consider the following need to be reapplied more often and in larger
key points regarding physical and chemical amounts than the repellent.
• Choose a broad-​spectrum sunscreen with Travelers with sunburn should maintain hydra-
≥15 SPF to ensure adequate UVA and UVB tion and stay in a cool, shaded, or indoor
protection. environment. Topical and oral nonsteroidal
anti-​inflammatory drugs decrease skin redness
• For UVA protection, look for the following if used before or soon after sun exposure and
active ingredients: zinc oxide, titanium diox-
may relieve symptoms such as headache, fever,
ide, avobenzone, ecamsule, oxybenzone,
and local pain. Pain is usually most intense 6–​48
dioxybenzone, or sulisobenzone.
hours after sun exposure, and skin usually peels
• Select a waterproof or water-​resistant prod- 4–​7  days later. Topical steroids are of limited
uct. Waterproof sunscreens confer approxi- benefit, and systemic steroids appear to be inef-
mately 80 minutes of protection in the water, fective in alleviating pain. Cool compresses, col-
and water-​resistant products offer 40 minutes loidal oatmeal baths, moisturizing creams, and
of protection. topical aloe vera gel may relieve symptoms. Oral
diphenhydramine may relieve itching. If blisters
• Apply to dry skin 15 minutes to one-​half hour occur, they should be left intact to promote
before exposure to the sun.
faster healing. Open erosions should be coated
• At least 1 oz (2 tablespoons or enough to fill with petroleum jelly and covered with sterile
a shot glass) of sunscreen is needed to cover gauze to decrease the risk of infection. If infec-
the exposed areas of the body. Most people tion occurs, oral antibiotics may be necessary. In
only apply 25%–​50% of the recommended severe cases of sunburn, dehydration and hypo-
amount of sunscreen, which decreases the volemia may occur, presenting with severely
achieved SPF. inflamed or reddened skin, disorientation,



dizziness or fainting, nausea, chills, high fever, rehydration and narcotic analgesics for pain
and headache. Hospitalization for intravenous relief may be required in these extreme cases.

1. Gu X, Wang T, Collins DM, Kasichayanula S, Burczynski 4. Krakowski AC, Kaplan LA. Exposure to radiation from
FJ. In vitro evaluation of concurrent use of commercially the sun. In: Auerbach PS, editor. Wilderness Medicine.
available insect repellent and sunscreen preparations.
Br J Dermatol. 2005 Jun;152(6):1263–​7.
6th ed. Philadelphia: Mosby Elsevier; 2012. pp. 294–​313.
5. McLean DI, Gallagher R. Sunscreens. Use and misuse. 2
2. Han A, Maibach HI. Management of acute sunburn. Am Dermatol Clin. 1998 Apr;16(2):219–​26.
J Clin Dermatol. 2004;5(1):39–​47. 6. Wang SQ, Stanfield JW, Osterwalder U. In vitro assess-
3. Henry WL, Steven QW. The Skin Cancer ments of UVA protection by popular sunscreens avail-
Foundation’s Guide to Sunscreens New York: Skin able in the United States. J Am Acad Dermatol. 2008
Cancer Foundation; 2012 [cited 2016 Dec;59(6):934–​42.
Sep. 22]; Available from: www.skincancer. 7. Wang SQ, Tooley IR. Photoprotection in the era
org/​prevention/​sun-​protection/​sunscreen/​ of nanotechnology. Semin Cutan Med Surg. 2011
the-​skin-​cancer-​foundations-​guide-​to-​sunscreens. Dec;30(4):210–​3.

Howard D. Backer, David R. Shlim

International travelers encounter environments behaviors are more important. The major means
that may include extremes of climate to which the of heat dissipation are radiation while at rest
traveler is not accustomed. Exposure to heat and and evaporation of sweat during exercise, both
cold can result in serious injury or death. Travelers of which become minimal with air temperatures
should investigate climate extremes that they will above 95°F (35°C) and high humidity.
face during their journey and prepare with proper The major organs involved in temperature reg-
clothing, knowledge, and equipment. ulation are the skin, where sweating and heat
exchange take place, and the cardiovascular sys-
PROBLEMS ASSOCIATED WITH tem, which must increase blood flow to shunt heat
A HOT CLIMATE from the core to the surface, while meeting the
metabolic demands of exercise. Cardiovascular
Risk for Travelers status and conditioning are the major physiologic
Many of the most popular travel destinations are variables affecting the response to heat stress at
tropical or desert areas. Travelers who sit on the all ages. Many chronic illnesses limit tolerance to
beach or by the pool and do only short walking heat and predispose to heat illness, including car-
tours incur minimal risk of heat illness. Those who diovascular disease, extensive skin disorders or
do strenuous hiking, biking, or work in the heat scarring that limits sweating, diabetes, and renal
are at risk, especially travelers coming from cool disease.
or temperate climates who are not in good physi- In addition to environmental conditions and
cal condition and are not acclimatized to the heat. intensity of exercise, dehydration is the most
important predisposing factor in heat illness.
Clinical Presentations Dehydration also reduces exercise performance,
PHYSIOLOGY OF HEAT INJURIES decreases time to exhaustion, and increases inter-
Tolerance to heat depends largely on physiologic nal heat load. Temperature and heart rate increase
factors, unlike cold environments where adaptive in direct proportion to the level of dehydration.


Sweat is a hypotonic fluid containing sodium boundary shared with heat stroke. Transient
and chloride. Sweat rates commonly reach 1 L mental changes, such as irritability, confusion, or
per hour and may even exceed this level, which irrational behavior may be present in heat exhaus-
results in substantial fluid and sodium loss. tion, but major neurologic signs such as seizures
or coma indicate heat stroke or hyponatremia.
MINOR HEAT DISORDERS Body temperature may be normal or mildly to
Heat cramps are painful muscle contractions fol- moderately elevated.
2 lowing exercise. They begin an hour or more after
stopping exercise and most often involve heav-
Most cases can be treated with supine rest in the
shade or other cool place and oral water or fluids
ily used muscles in the calves, thighs, and abdo- containing glucose and salt; subsequently, sponta-
men. Rest and passive stretching of the muscle, neous cooling occurs, and patients recover within
supplemented by commercial rehydration solu- hours. An oral solution for treating heat exhaus-
tions or water and salt, will rapidly relieve symp- tion can be made by adding one-​fourth to one-​half
toms. Water with a salty snack is sufficient. An teaspoon of table salt (or two 1-​g salt tablets) to
oral salt solution can be made by adding one-​ 1 L of water plus 4–​6 teaspoons of sugar. To fur-
fourth to one-​half teaspoon of table salt (or two ther improve taste, add one-​quarter cup of orange
1-​g salt tablets) to 1 L of water. To improve taste, juice or 2 teaspoons of lemon juice. Commercial
add a few teaspoons of sugar and/​or orange juice sports-​electrolyte drinks are also effective. Plain
or lemon juice. water plus salty snacks may be more palatable
Heat syncope is sudden fainting that occurs in and equally effective. Subacute heat exhaustion
unacclimatized people while standing in the heat may develop over several days and is often mis-
or after 15–​20 minutes of exercise. Consciousness diagnosed as “summer flu” because of findings of
rapidly returns to normal when the patient is weakness, fatigue, headache, dizziness, anorexia,
supine. Rest, relief from heat, and oral fluids are nausea, vomiting, and diarrhea. Treatment is as
sufficient treatment. described for acute heat exhaustion.
Heat edema is mild swelling of the hands and
feet (more frequent in women) during the first EXERCISE-​ASSOCIATED HYPONATREMIA
few days of heat exposure. It resolves sponta- Hyponatremia (low sodium [salt] levels in the
neously and should not be treated with diuretics, blood) occurs in both endurance athletes and
which may delay heat acclimatization and cause recreational hikers, likely due to replacement of
dehydration. fluids with excessive amounts of water. The kid-
Prickly heat (miliaria or heat rash) manifests as neys fail to correct the excess water because of
small, red, raised itchy bumps on the skin caused the influence of inappropriate amounts of anti-
by obstruction of the sweat ducts. It resolves spon- diuretic hormone that act on the kidney to cause
taneously, aided by avoiding continued sweating retention of water and loss of sodium. Loss
and relief from heat. It is best prevented by wear- of sodium through sweat also contributes to
ing light, loose clothing and avoiding heavy, con- hyponatremia.
tinuous sweating. In the field setting, altered mental status
with normal body temperature and a history of
MAJOR HEAT DISORDERS large volumes of water intake suggest hypona-
HEAT EXHAUSTION tremia. The vague and nonspecific symptoms
Most people who experience acute collapse or are the same as those described for hyponatre-
other symptoms associated with exercise in the mia in other settings, including anorexia, nau-
heat are suffering from heat exhaustion—​ the sea, emesis, headache, muscle weakness, lethargy,
inability to continue exertion in the heat. The confusion, and seizures. Symptoms of heat
presumed cause of heat exhaustion is loss of exhaustion and early hyponatremia are similar.
fluid and electrolytes, but there are no objective Hyponatremia can be distinguished from other
markers to define the syndrome, which is a spec- heat illnesses by persistent alteration of men-
trum ranging from minor complaints to a vague tal status without elevated temperature, delay



in onset of major neurologic symptoms (confu- Early symptoms are similar to those of heat
sion, seizures, or coma), or deterioration up to exhaustion, with confusion or change in personal-
24 hours after cessation of exercise and removal ity, loss of coordination, dizziness, headache, and
from heat. In organized events, measurement of nausea that progress to more severe symptoms.
serum sodium should be used to diagnose hypo- A presumptive diagnosis of heat stroke is made in
natremia and guide treatment. Gaining weight or the field when people have elevation of body tem-
failure to lose weight increases risk of symptom- perature (hyperpyrexia) and marked alteration of
atic hyponatremia.
The recommendation to force fluid intake
mental status, including delirium, convulsions,
and coma. Body temperatures in excess of 106°F
during prolonged exercise and the attitude that (41°C) can occur in heat stroke; even without a
“you can’t drink too much” are major contributors thermometer, people will feel hot to the touch. If a
to exercise-​associated hyponatremia. Prevention thermometer is available, a rectal temperature is
includes drinking only enough to relieve thirst. the safest and most reliable way to check the tem-
During prolonged exercise (>12 hours) or heat perature of someone who may have heat stroke;
exposure, supplemental sodium should be taken. an axillary temperature may give a reasonable
Most sports-​electrolyte drinks do not contain suf- estimation.
ficient amounts of sodium to prevent hyponatre- In the field, immediately institute cooling mea-
mia; on the other hand, salt tablets often cause sures by these methods:
nausea and vomiting. For hikers, food is the most
efficient vehicle for salt replacement. Trail snacks
• Maintain the airway if victim is unconscious.
should include not just sweets, but salty foods • Move to the shade or a cool place out of the sun.
such as trail mix, crackers, and pretzels.
If hyponatremia is suspected along with neu-
• Use evaporative cooling: remove excess cloth-
ing to maximize skin exposure, spray tepid
rologic symptoms in the absence of hyperther-
water on the skin, and maintain air move-
mia or other diagnoses, restrict fluid. In conscious
ment over the body by fanning. Alternatively,
patients who can tolerate oral intake, salty snacks
place cool or cold wet towels over the body
may be given with sips of water or a solution of
and fan to promote evaporation.
concentrated broth (2–​4 bouillon cubes in 1/​2 cup
of water). Obtunded patients may require hyper- • Apply ice or cold packs to the neck, axillas,
tonic saline. groin, and as much of the body as possible.
Vigorously massage the skin to limit constric-
tion of blood vessels and prevent shivering,
which will increase body temperature.
Heat stroke is an extreme medical emergency
requiring aggressive cooling measures and hos- • Immerse the person in cool or cold water,
pitalization for support. Heat stroke is the only such as a nearby pool or natural body of
form of heat illness in which the mechanisms for water or bath—​an ice bath cools fastest.
thermal homeostasis have failed, and the body Always attend and hold the person while in
does not spontaneously restore the temperature the water.
to normal. As a result of uncontrolled fever and
circulatory collapse, organ damage can occur in
• Encourage rehydration for those able to take
oral fluids.
the brain, liver, kidneys, and heart. Damage is
related to duration as well as peak elevation of Heat stroke victims usually have significant dehy-
body temperature. The onset of heat stroke may dration, so intravenous or oral fluid replace-
be acute (exertional heat stroke), which can affect ment is indicated. Heat stroke is life threatening,
healthy people who are exercising in the heat, or and many complications may occur in the first
gradual (nonexertional heat stroke, also referred 24–​48 hours, including liver or kidney damage
to as classic or epidemic), which occurs from pas- and abnormal bleeding. Most victims require hos-
sive heat exposure in those with chronic illness. pital intensive care management. If evacuation to


a hospital will be delayed, monitor closely for sev- advantage over plain water. However, for those
eral hours for temperature swings. exercising many hours in heat, salt replacement is
recommended. Eating salty snacks or lightly salt-
Prevention of Heat Disorders ing mealtime food or fluids is the most efficient
HEAT ACCLIMATIZATION way to replace salt losses. Salt tablets, when swal-
Heat acclimatization is a process of physiologic lowed whole, may cause gastrointestinal irrita-
adaptation to a hot environment that occurs in tion and vomiting but may be better tolerated if
2 both residents and visitors. The result of acclimati-
zation is increased sweating with less salt content,
2 tablets are dissolved in 1 L of water. Urine vol-
ume and color are a reasonable means to monitor
and decreased energy expenditure with lower rise fluid needs.
in body temperature for a given workload. Only
partial adaptation occurs by passive exposure to PROBLEMS ASSOCIATED WITH
heat. Full acclimatization, especially cardiovas- A COLD CLIMATE
cular response, requires 1–​2 hours of exercise in
Risk for Travelers
the heat each day. Most acclimatization changes
Travelers do not have to be in an arctic or high-​
occur within 10 days, provided a suitable amount
altitude environment to encounter problems with
of daily exercise. After this time, only increased
the cold. Humidity, rain, and wind can produce
physical fitness will result in further exercise toler-
hypothermia even with temperatures around 50°F
ance. Decay of acclimatization occurs within days
(10°C). Even in a temperate climate, a traveler
to weeks if there is no heat exposure.
in a small boat that overturns in cold water can
PHYSICAL CONDITIONING AND rapidly become hypothermic. However, reports
ACCLIMATIZATION of severe hypothermia in international travel-
ers are rare. Many high-​altitude destinations are
Higher levels of physical fitness improve exercise
not wilderness areas, and villages offer an escape
tolerance and capacity in heat, but not as much as
from extreme weather. In Nepal, trekkers almost
acclimatization. If possible, travelers should accli-
never experience hypothermia except in the rare
matize before leaving by exercising ≥1 hour daily
instance in which they get lost in a storm.
in the heat. If this is not possible before depart-
ing, limit exercise intensity and duration during
the first week of travel in a hot climate. It is a good Clinical Presentations
idea to conform to the local practice in most hot HYPOTHERMIA
regions and avoid strenuous activity during the Hypothermia can be defined as having a core
hottest part of the day. body temperature below 95°F (35°C). When peo-
ple are faced with an environment in which they
CLOTHING cannot keep warm, they first feel chilled, then
Clothing should be lightweight, loose, and light-​ begin to shiver, and eventually stop shivering
colored to allow maximum air circulation for as their metabolic reserves are exhausted. Body
evaporation yet give protection from the sun. temperature continues to decrease, depending
A  wide-​brimmed hat markedly reduces radiant on the ambient temperatures. As the core tem-
heat exposure. perature falls, neurologic functioning decreases
until almost all hypothermic people with a core
FLUID AND ELECTROLYTE REPLACEMENT temperature of 86°F (30°C) or lower are coma-
During exertion, fluid intake improves perfor- tose. The record low core body temperature in
mance and decreases the likelihood of illness. an adult who survived is 56°F (13°C). Travelers
Reliance on thirst alone is not sufficient to pre- headed to a cold climate should ask questions
vent mild dehydration, but forcing a person who and research clothing and equipment. Modern
is not thirsty to drink water creates the potential clothing, gloves, and particularly footwear have
danger of hyponatremia. During mild to moder- greatly decreased the chances of suffering cold
ate exertion, electrolyte replacement offers no injury in extreme climates. Cold injuries occur


3 9

more often after accidents, such as avalanches Once frostbite has occurred, little can be done
or unexpected nights outside, than during nor- to reverse the changes. Therefore, taking great
mal recreational activities. care to prevent frostbite is crucial. Frostbite is
Travelers engaging in recreational activities or usually graded like burns. First-​degree frostbite
working around cold water face a different sort of involves reddening of the skin without deeper
risk. Immersion hypothermia can render a person damage. The prognosis for complete healing is vir-
unable to swim or keep floating in <15 minutes. In tually 100%. Second-​degree frostbite involves blis-
these cases, a personal flotation device is critical,
as is knowledge about self-​rescue and righting a
ter formation. Blisters filled with clear fluid have a
better prognosis than blood-​tinged blisters. Third-​
capsized boat. degree frostbite represents full-​thickness injury to
The other medical conditions associated with the skin and possibly the underlying tissues. No
cold affect mainly the skin and the extremities. blister forms, the skin darkens over time and may
These can be divided into nonfreezing cold inju- turn black. If the tissue is completely devascular-
ries and freezing injuries ( frostbite). ized, amputation will be necessary.
Frostbitten skin is numb and appears whitish
NONFREEZING COLD INJURY or waxy. The generally accepted method for treat-
Nonfreezing cold injuries include trench foot ing a frozen digit or limb is through rapid rewarm-
(immersion foot), pernio (chilblains), and cold ing in water heated to 104°F–​108°F (40°C–​42°C).
urticaria. Trench foot is caused by prolonged The frozen area should be completely immersed
immersion of the feet in cold water (32°F–​59°F; in the warm water. A thermometer is needed to
0°C–​15°C). The damage is mainly to nerves and ensure the water is kept at the correct tempera-
blood vessels, and the result is pain that is aggra- ture. Rewarming can be associated with severe
vated by heat and a dependent position of the pain, so analgesics can be given if needed. Once
limb. Severe cases can take months to resolve. the area is rewarmed, it must be safeguarded
Unlike the treatment for frostbite, immersion foot against freezing again. It is better to keep digits
should not be rapidly rewarmed, which can make frozen a little longer and rapidly rewarm them,
the damage much worse. than to allow them to thaw out slowly or to thaw
Pernio are localized, inflammatory lesions that and refreeze. A  cycle of freeze-​thaw-​refreeze is
occur mainly on the hands and with exposure devastating to tissue and can lead to amputation.
to only moderately cold weather. The bluish-​red Once the area has rewarmed, it can be exam-
lesions are thought to be caused by prolonged, ined. If blisters are present, note whether they
cold-​induced vasoconstriction. As with trench extend to the end of the digit. Proximal blisters
foot, rapid rewarming should be avoided, as it usually mean that the tissue distal to the blister
makes the pain worse. Nifedipine may be an effec- has suffered full-​thickness damage. For treatment,
tive treatment. avoid further mechanical trauma to the area and
Cold urticaria involves the formation of local- prevent infection. In the field, wash the area thor-
ized or general wheals and itching. It is not the oughly with a disinfectant such as povidone-​
absolute temperature that induces this form of iodine, put dressings between the toes or fingers
urticaria but the rate of change of temperature in to prevent maceration, use fluffs (expanded gauze
the skin. sponges) for padding, and cover with a roller gauze
bandage. These dressings can safely be left on for
FREEZING COLD INJURY up to 3 days at a time. By leaving the dressings on
Frostbite is the term that is used to describe tissue longer, the traveler can preserve what may be lim-
damage from direct freezing of the skin. Modern ited supplies of bandages. Prophylactic antibiotics
equipment and clothing have decreased the risk are not needed in most situations.
of frostbite resulting from adventure tourism, In the rare situation in which a foreign trav-
and frostbite occurs mainly during an accident, eler suffers frostbite and can be evacuated to an
severe unexpected weather, or as a result of poor advanced medical setting within 24–​ 72 hours,
planning. there may be a role for thrombolytics, such as


prostacyclin and recombinant tissue plasmino- Once the patient has reached a definitive med-
gen activator. If you are managing frostbite in the ical setting, there should be no rush to do surgery.
first 72 hours, you should consult someone with The usual time from injury to surgery is 4–​5 weeks.
expertise in frostbite as soon as possible. The risks Technetium (Tc)-​ 99 scintigraphy and magnetic
and benefits of using these drugs should be care- resonance imaging can be used to help define the
fully considered in each patient. Beyond 72 hours extent of the damage. Once the delineation between
after thawing, these interventions are probably not dead tissue and viable becomes clear, surgery that
2 beneficial. preserves the remaining digits can be planned.

1. Armstrong LE, Casa DJ, Millard-​Stafford M, Moran DS, 5. Freer L, Imray CHE. Frostbite. In: Auerbach PS, editor.
Pyne SW, Roberts WO. American College of Sports Wilderness Medicine. 6th ed. Philadelphia: Mosby
Medicine position stand. Exertional heat illness during Elsevier; 2012. pp. 181–​201.
training and competition. Med Sci Sports Exerc. 2007 6. Hadad E, Rav-​Acha M, Heled Y, Epstein Y, Moran DS.
Mar;39(3):556–​72. Heat stroke: a review of cooling methods. Sports Med.
2. Bennett BL, Hew-​Butler T, Hoffman MD, Roger sIR, 2004;34(8):501–​11.
Rosner MH, Wilderness Medical Society. Wilderness 7. Lipman GS, Eifling KP, Ellis MA, Gaudio FG, Otten EM,
Medical Society practice guidelines for treatment Grissom CK, et al. Wilderness Medical Society practice
of exercise-​associated hyponatremia: 2014 update. guidelines for the prevention and treatment of heat-​
Wilderness Environ Med. 2014 Dec;25(4 Suppl):S30–​42. related illness: 2014 update. Wilderness Environ Med.
3. Cauchy E, Cheguillaume B, Chetaille E. A controlled 2014 Dec;25(4 Suppl):S55–​65.
trial of a prostacyclin and rt-​PA in the treatment of 8. O’Brien KK, Leon LR, Kenefick RW. Clinical manage-
severe frostbite. N Engl J Med. 2011 Jan 13;364(2): ment of heat-​related illnesses. In: Auerbach PS, editor.
189–​9 0. Wilderness Medicine. 6th ed. Philadelphia: Mosby
4. Epstein Y, Moran DS. Extremes of temperature Elsevier; 2012. pp. 232–​8.
and hydration. In: Keystone JS FD, Kozarsky PE, 9. Rogers IR, Hew-​Butler T. Exercise-​associated hypona-
Connor BA, Nothdurft HD, editor. Travel Medicine. tremia: overzealous fluid consumption. Wilderness
Philadelphia: Saunders Eslevier; 2013. pp. 381–​9 0. Environ Med. 2009 Summer;20(2):139–​43.

David A. Sleet, David J. Ederer, Michael F. Ballesteros

According to the World Health Organization In 2013 and 2014, an estimated 1,670 US citi-
(WHO), injuries are among the leading causes of zens died from nonnatural causes, such as injuries
death and disability in the world, and they are the and violence, while in foreign countries (exclud-
leading cause of preventable death in travelers. ing deaths occurring in the wars in Iraq and
An estimated 18%–​24% of deaths among travelers Afghanistan). Motor vehicle crashes—​not crime
in foreign countries are caused by injuries, com- or terrorism—​are the number 1 killer of healthy
pared with only 2% of deaths caused by infectious US citizens living, working, or traveling overseas.
diseases. Contributing to the injury toll while In 2013 and 2014, 456 Americans died in road traf-
traveling are unfamiliar and perhaps risky envi- fic crashes abroad (27% of nonnatural deaths).
ronments, differences in language and communi- Another 350 were victims of homicide (21%), 286
cations, less stringent product safety and vehicle committed suicide (17%), and 220 drowned (13%)
standards, unfamiliar rules and regulations, and a (Figure 2-​2).
carefree holiday or vacation spirit leading to more If a traveler is seriously injured in a foreign
risk-​taking behavior. country, emergency care may not be available


5 9





























FIGURE 2-​2 .   Leading causes of injury death for US citizens in foreign countries, 2013 & 20141,2
Data from US Department of State. Death of US citizens abroad by non-​natural causes. Washington, DC: US Department of
State; 2016 [cited 2016 Mar. 24]. Available from: http://​travel.state.gov/​content/​travel/​english/​statistics/​deaths.html.
Excludes deaths of US citizens fighting wars in Afghanistan or Iraq, and deaths that were not reported to the nearest US
Embassy or Consulate.

or acceptable by US standards. Trauma cen- deaths were related to motorcycle use in these
ters capable of providing optimal care for seri- countries. The reported rate of motorbike inju-
ous injuries are uncommon outside urban areas ries in Bermuda is much higher in tourists than
in many foreign destinations. Travelers should in the local population, and the rate is highest
be aware of the increased risk of certain injuries among those aged 50–​59  years. Motor vehicle
while traveling or residing abroad, particularly rentals for tourists in Bermuda and some other
in developing countries, and be prepared to take small Caribbean islands are typically limited to
preventive steps. motorbikes, possibly contributing to the higher
rates of motorbike injuries. Loss of vehicular con-
ROAD TRAFFIC INJURIES trol, unfamiliar equipment, and inexperience with
Globally, an estimated 3,300 people, including 720 motorized 2-​wheelers contribute to crashes and
children, are killed each day in road traffic crashes injuries, even at speeds <30 miles per hour.
involving cars, buses, motorcycles, bicycles, Road traffic crashes are common among for-
trucks, and pedestrians. Annually, 1.24  million eign travelers for a number of reasons:  lack of
are killed and 20–​50  million are injured in traf- familiarity with the roads, driving on the opposite
fic crashes—​a number likely to double by 2030. side of the road, lack of seat belt use, the influence
Although only 53% of the world’s vehicles are in of alcohol, poorly made or maintained vehicles,
developing countries, more than 90% of road traf- travel fatigue, poor road surfaces without shoul-
fic casualties occur in these countries. ders, unprotected curves and cliffs, and poor vis-
According to US Department of State data, ibility due to lack of adequate lighting. In many
road traffic crashes are the leading cause of injury developing countries, unsafe roads and vehicles
deaths to US citizens while abroad (Figure  2-​2). and an inadequate transportation infrastructure
Motorcycle use is a risk factor for road traffic contribute to the traffic injury problem. In many
crashes; in 2013 and 2014, approximately 20% of of these countries, motor vehicles often share the
road traffic deaths while abroad involved motor- road with vulnerable road users such as pedestri-
cycles. Road deaths per million trips are highest ans, bicyclists, and motorcycle users. The mix of
in Thailand and Vietnam, and most American traffic including cars, buses, taxis, rickshaws, large


trucks, and even animals increases the risk for International Road Travel (www.asirt.org) and
crashes and injuries. Make Roads Safe (www.makeroadssafe.org)
Strategies to reduce the risk of traffic injury have useful safety information for international
are shown in Table  2-​ 13. The Association for travelers, including road safety checklists and

Table 2-​13. Recommended strategies to reduce injuries

2 while abroad

Road Traffic Crashes

Lack of seat belts Always use safety belts and child safety seats. Rent vehicles with seat belts; when possible,
and child safety ride in taxis with seat belts and sit in the rear seat; bring child safety seats and booster
seats seats from home for children to ride properly restrained.

Driving hazards When possible, avoid driving at night in developing countries; always pay close attention to
the correct side of the road when driving in countries that drive on the left.

Country-​specific Check the Association for Safe International Road Travel website for driving hazards or
driving hazards risks by country (www.asirt.org).

Motorcycles, Always wear helmets (bring a helmet from home, if needed). When possible, avoid driving
motorbikes, and or riding on motorcycles or motorbikes, including motorcycle and motorbike taxis. Traveling
bicycles overseas is a bad time to learn to drive a motorcycle or motorbike.

Alcohol-​impaired Alcohol increases the risk for all causes of injury. Do not drive after consuming alcohol, and
driving avoid riding with someone who has been drinking. Penalties can be severe overseas.

Cellular Do not use a cellular telephone or text while driving. Many countries have enacted laws
telephones banning cellular telephone use while driving, and some countries have made using any kind
of telephone, including hands-​free, illegal while driving.

Taxis or hired Ride only in marked taxis, and try to ride in those that have safety belts accessible. Hire
drivers drivers familiar with the area.

Bus travel Avoid riding in overcrowded, overweight, or top-​heavy buses or minivans and avoid riding in
mountainous terrains, at night, and with a drinking or distracted bus driver.

Pedestrian Be alert when crossing streets, especially in countries where motorists drive on the left side
hazards of the road. Walk with a companion or someone from the host country.

Other Tips

Airplane travel Avoid using local, unscheduled aircraft. If possible, fly on larger planes (>30 seats), in good
weather, during the daylight hours, and with experienced pilots.Children <2 years should sit
in a child safety seat, not on a parent’s lap. Whenever possible, parents should travel with a
safety seat for use before, during, and after a plane ride.

Drowning Avoid swimming alone or in unfamiliar waters. Wear life jackets while boating or during
water recreation activities.

Burns In hotels, stay below the 6th floor to maximize the likelihood of being rescued in a fire. Bring
your own smoke alarm.



country-​specific driving risks. The Department in developing countries where building codes do
of State has safety information useful to interna- not exist or are not enforced, there are no smoke
tional travelers, including road safety and security alarms, there is no access to emergency services,
alerts, international driving permits, and travel and the fire department’s focus is on putting
insurance (www.travel.state.gov). out fires rather than on fire prevention or victim
WATER AND AQUATIC INJURIES In 2013 and 2014, an estimated 50 US citi-
In 2013 and 2014, drowning accounted for 13%
of all deaths of US citizens abroad. Although risk
zens abroad were killed in aircraft crashes.
Travel by local, lightweight aircraft in many
factors have not been clearly defined, these deaths countries can be risky. Travel on unscheduled
are most likely related to unfamiliarity with local flights, in small aircraft, at night, in inclement
water currents and conditions, inability to swim, weather, and with inexperienced pilots carries
and the absence of lifeguards on duty. Rip cur- the highest risk.
rents can be especially dangerous, as are sea ani- Before flying with children, parents and care-
mals such as urchins, jellyfish, coral, and sea lice. givers should check to make sure that their child
Alcohol also contributes to drowning and boating restraint system is approved for use on an air-
mishaps. craft. This approval should be printed on the sys-
Drowning is often the leading cause of injury tem’s information label or on the device itself. The
death to US citizens visiting countries where Federal Aviation Administration (FAA) recom-
water recreation is a major activity, such as Fiji, mends that a child weighing <20 pounds use a
the Bahamas, Jamaica, and Costa Rica. Young rear-​facing child restraint system. A forward-​fac-
men are particularly at risk of head and spinal ing child safety seat should be used for children
cord injuries from diving into shallow water, and weighing 20–​40 pounds. FAA has also approved a
alcohol is a factor in some cases. harness-​type device for children weighing 22–​44
Boating can be a hazard, especially if boaters pounds.
are unfamiliar with the boat, do not know proper
boating etiquette or rules for watercraft naviga- TRAVEL TIPS
tion, or are new to the water environment in a Health care providers, vendors of travel services,
foreign country. In 2013 and 2014, maritime acci- and travelers themselves should consider the
dents resulted in 16 deaths to healthy Americans following:
abroad. Many boating fatalities result from inex- • Travelers may wish to purchase special travel
perience or failure to wear lifejackets. health and medical evacuation insurance if
Scuba diving is a frequent pursuit of travelers their destinations include countries where
in coastal destinations. The death rate among all there may not be access to good medical
divers worldwide is thought to be 15–​20 deaths care (see the Travel Insurance, Travel Health
per 100,000 divers per year. Travelers should Insurance, & Medical Evacuation Insurance
either be experienced divers or dive with a reli- section later in this chapter).
able dive shop and instructors. See the Scuba
Diving section later in this chapter for a more • Adventure activities, such as mountain
detailed discussion about diving risks and pre- climbing, skydiving, whitewater rafting,
ventive measures. dune-​buggying, kayaking, skiing, and snow-
boarding are popular with travelers. The
lack of rapid emergency trauma response,
OTHER UNINTENTIONAL inadequate trauma care in remote loca-
INJURIES tions, and sudden, unexpected weather
In 2013 and 2014, other unintentional injuries
changes that compromise safety and ham-
such as aviation incidents, drug-​ related inci-
per rescue efforts can delay care and reduce
dents, natural disasters, and deaths classified as
“other unintentional injuries” (including fires and
falls) accounted for 19% of deaths to healthy US • Travelers should avoid using local, unsched-
citizens abroad. Fires can be a substantial risk uled, small aircraft and refrain if possible from


flying in bad weather and at night. If avail- own smoke alarm. Two escape routes
able, choose larger aircraft (>30 seats), as they from buildings should always be identified.
are more likely to have undergone more strict Crawling low under smoke and covering
and regular safety inspections. Larger aircraft one’s mouth with a wet cloth are helpful in
also provide more protection in the event escaping a fire. Families should agree on a
of a crash. For country-​specific airline crash meeting place outside the building in case a
events, see www.airsafe.com. fire erupts.
2 • When traveling by air with young chil- • Improperly vented heating devices may cause
dren, consider bringing a child safety seat poisoning from carbon monoxide. Carbon
approved for use on an aircraft, helmets if monoxide (CO) at the back of boats near the
considering riding bicycles or motorbikes, engine can be especially dangerous. Travelers
and life preservers if travelers will be in may want to carry a personal CO detector
the water. that can sound an alert in the presence of
this lethal gas.
• To prevent fire-​related injuries, travelers
should select accommodations no • Travelers should consider learning basic
higher than the sixth floor ( fire ladders first aid and CPR before travel overseas
generally cannot reach higher than the with another person. Travelers should bring
sixth floor). Hotels should be checked for a travel health kit, which should be cus-
smoke alarms and preferably sprinkler tomized to the anticipated itinerary and
systems. Travelers may want to bring their activities.

1. Balaban V, Sleet DA. Pediatric travel injuries: risk, 6. Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K.
prevention, and management. In: Kamat DM, Fischer Global and regional mortality from 235 causes of death
PR, editors. American Academy of Pediatrics Textbook for 20 age groups in 1990 and 2010: a systematic analysis
of Global Child Health. 2nd ed. Elk Grove Village, for the Global Burden of Disease Study 2010. Lancet.
IL: American Academy of Pediatrics; 2015. 2012 Dec 15;380(9859):2095–​128.
2. Ederer D, Parker E, Sleet DA. Motorcycle helmets as a 7. Sherry MK, Mossallam M, Mulligan M, Hyder AA,
vaccine: CDC and Asia Injury Prevention Foundation Bishai D. Rates of intentionally caused and road
Partner in Cambodia and Uganda. CDC’s Division of crash deaths of US citizens abroad. Inj Prev. 2015
Global Health Protection; 2014 [cited 2016 Sep. 29]; Apr;21(e1):e10–​4.
Spring 2014, Issue 14. Available from: www.cdc.gov/​ 8. US Department of Commerce. 2015 US travel and
globalhealth/​healthprotection/​fieldupdates/​pdf/​dghp-​ tourism statistics. Washington, DC: US Department
field-​updates-​2014-​spring.pdf. of Commerce; 2016 [cited 2016 Sep. 29]; Available
3. Guse CE, Cortes LM, Hargarten SW, Hennes HM. from: http://​travel.trade.gov/​outreachpages/​outbound.
Fatal injuries of US citizens abroad. J Travel Med. 2007 general_​information.outbound_​overview.asp.
Sep-​Oct;14(5):279–​87. 9. US Department of State. Tips for traveling abroad.
4. Lawson CJ, Dykewicz CA, Molinari NA, Lipman H, Washington, DC: US Department of State; 2012 [cited
Alvarado-​Ramy F. Deaths in international travelers 2016 Sep. 22]; Available from: https://​travel.state.gov/​
arriving in the United States, July 1, 2005 to June 30, content/​passports/​en/​go/​checklist.html.
2008. J Travel Med. 2012 Mar-​Apr;19(2):96–​103. 10. World Health Organization. WHO global status
5. Li G, Pressley JC, Qiang Y, Grabowski JG, Baker SP, report on road safety 2015. Geneva: World Health
Rebok GW. Geographic region, weather, pilot age, and Organization; 2015 [cited 2016 Sep. 22] Available from
air carrier crashes: a case-​control study. Aviat Space http://​www.who.int/​violence_​injury_​prevention/​road_​
Environ Med. 2009 Apr;80(4):386–​9 0. safety_​status/​2015/​en/​.




Robyn K. Prinz, Ronnie Henry

Violence is a leading worldwide public health to receive updated information about safety and
problem and a growing concern of US citi-
zens traveling, working, or residing abroad.
security conditions and messages about emergent
threats while they are abroad. The governments of
International terrorism and crime are risks any- the United Kingdom, Canada, and Australia also
where in the world, but international travelers have excellent websites with safety and security
operating in an unfamiliar environment face par- information for travelers.
ticular hurdles. Travelers may not have access to
networks of friends or family to assist them. Local CRIME
government responses to problems may be differ- One of the most common threats to the safety of
ent from what US residents expect, or an effective US citizens abroad comes from criminal activity.
local government may not exist to respond at all. Travelers to foreign countries are viewed by many
Language barriers, unexpected costs, or different criminals as wealthy, naïve targets, who are inex-
cultural mores can also complicate what happens perienced, unfamiliar with the culture, and inept
in an emergency. The best way for US residents at seeking assistance if victimized. Traveling in
going overseas to manage their risk is to prepare high-​poverty areas or regions of civil unrest, using
before they travel. Travelers should research con- alcohol or drugs, and traveling in unfamiliar envi-
ditions at their destination to learn what risks ronments at night increase the likelihood that a
they are likely to face and have a plan to mitigate traveler will be the victim of crime.
those risks while they are abroad. Travelers should take the time to research crime
trends and patterns at their destination through
RESEARCH AND PREPARATION the Overseas Security Advisory Council at www.
Travelers need information to make good deci- osac.gov. Strategies for avoiding becoming the vic-
sions about risks while traveling and to make tim of a crime overseas are, for the most part, the
plans to deal with those risks. The Department same common-​sense habits that people should fol-
of State’s Bureau of Consular Affairs publishes low everywhere, but the following actions should
comprehensive information on safety and secu- be stressed with international travelers:
rity concerns for every independent nation,
along with basic advice for safe travel anywhere,
• Limit travel at night, travel with a companion,
and vary routine travel habits.
at http://​travel.state.gov. More information can
also be found at individual embassy and consul- • Do not wear expensive clothing or
ate websites, all of which can be found at www. accessories.
usembassy.gov. The Department of State also
publishes travel alerts and travel warnings that
• Avoid accommodations on the ground floor
or immediately next to the stairs, and lock all
focus on emergent or chronic safety issues in
doors and windows.
countries around the world. They encourage all
US citizens to avoid travel to areas with major • Take only recommended and safe modes of
threats to safety and security. Travelers should local transportation.
take these warnings seriously as they cover areas
where security threats and instability severely
• If confronted in a robbery, give up all valu-
ables and do not resist attackers. Resistance
limit the help the US government can offer to its
can escalate to violence and result in injury
citizens in those areas.
or death.
Travelers should enroll with the Department of
State’s Smart Traveler Enrollment Program (STEP) Victims of a crime overseas should contact the
before leaving on their trip. This will allow them nearest US embassy, consulate, or consular agency.



The Department of State can help replace a stolen aware of surroundings and adopting protective
passport, contact family and friends, obtain appro- measures.
priate medical care, explain the local criminal jus-
tice process, and connect victims of crime with OTHER ISSUES
available resources. However, they do not have the Just as important as learning about safety and
legal authority to conduct a criminal investigation security conditions at a traveler’s destination
and prosecution. country is to learn about legal differences that
may cause problems for US citizens. Many coun-
tries have weapons laws that are much stricter
International terrorism is also a threat to US cit- than those in the United States, such that a sin-
izens abroad. The Department of State main- gle loose bullet in a suitcase can lead to arrest and
tains a worldwide caution addressing this threat possible jail time. Some countries prohibit certain
on its consular affairs website. Terrorist groups religious activities or the possession of religious
continue to plan attacks against Western inter- literature. Prescription medications that are com-
ests in multiple regions, including Europe, Asia, monly used in the United States may be illegal
Africa, and the Middle East. These attacks may in another country. Some countries do not have
employ a wide variety of tactics, including sui- the same free speech protections as those in the
cide operations, assassinations, kidnappings, United States, and statements made in public or
hijackings, and bombings. Possible targets online can lead to arrest or detention. These and
include high-​ profile sporting events, public other legal differences can be researched online at
transportation systems, residential areas, busi- the Department of State website.
ness offices, hotels, clubs, restaurants, places Since travelers may become the victim of a
of worship, schools, shopping malls, and other crime, regardless of the precautions they take,
tourist destinations where US citizens gather in they should have plans for what they will do
large numbers. in an emergency. Travelers should make pho-
Although terrorism is a worldwide threat tocopies of their travel documents and leave
and can be a major cause of concern to travel- a copy with a friend or relative at home along
ers, it should be seen in context. In 2014, 24 pri- with a detailed itinerary and contact informa-
vate US citizens were killed in terrorist attacks tion if possible. They should also have the con-
overseas, 8 were injured, and 3 were kidnapped. tact information for the nearest US embassy or
Although threats of this type cannot be totally consulate where they are traveling. Many medi-
eliminated, travelers can lower the chance cal insurance programs, including Medicare and
they will be a victim through knowledge and Medicaid, will not pay for medical treatment
planning: overseas. Travelers should ensure they have ade-
quate medical coverage before going overseas. If
• Look out for unattended packages or bags in their current insurance does not cover their trip
public places and other crowded areas.
abroad, they should consider additional insur-
• Be cautious of unexpected packages. ance that can pay for their medical expenses
abroad or help return them to the United States
• When packing, choose clothing that does if that becomes necessary. For more infor-
not identify one as a tourist (such as T-​shirts
mation, see Travel Insurance, Travel Health
emblazoned with the US flag or logos of the
Insurance, & Medical Evacuation Insurance in
traveler’s local sports team).
this chapter.
• Try to blend in with the locals.
These strategies incorporate the same defensive
Department of State Consular Affairs
alertness and good judgment that people should
use to keep safe from crime at home or abroad. • Know Before You Go: http://​travel.state.gov/​
Awareness is key—​ taking precautions to be content/​passports/​english/​go.html



• Alerts and Warnings: http://​travel.state. • US Citizen Deaths Overseas: http://​travel.

gov/​c ontent/​passports/​en/​alertswarnings. state.gov/​content/​travel/​english/​statistics/​
html deaths.html
• Country Information: http://​travel.state. Federal Bureau of Investigation, Crime Statistics:
gov/​content/​passports/​english/​country. https://​ucr.fbi.gov
Overseas Security Advisory Council:  www.
osac.gov 2

Heather Bair-​Brake, Ryan M. Wallace, G. Gale Galland, Nina Marano

HUMAN INTERACTION booster vaccination in the previous 5–​10  years

WITH ANIMALS: A RISK FACTOR (see Chapter  3, Tetanus). Travel health provid-
FOR INJURY AND ILLNESS ers should assess a traveler’s need for pre​expo-
Animals, even those in close association with sure rabies immunization (see Chapter 3, Rabies).
humans, such as dogs, can attack if they feel While traveling, people should never try to pet,
threatened, are protecting their young or terri- handle, or feed unfamiliar animals (whether
tory, or are injured or ill. Travelers should be aware domestic or wild, even in captive settings such
that attacks by domestic animals are far more as game ranches or petting zoos), particularly in
common than attacks by wildlife, and secondary areas where rabies is endemic. Young children
infections of wounds may result in serious illness should be watched closely around unfamiliar ani-
or death. This section will cover the most com- mals as they are more likely to be bitten and to
mon routes of transmission of illness and injury sustain more severe injuries from animal bites.
from animals and insects. However, most animals
can transmit infection by more than one route. Management
This section provides examples of high-​priority To prevent infection, all bite and scratch wounds
diseases and injuries from animals and refers the should be promptly cleaned with soap and water,
reader to other sections for more detailed descrip- and the wound should be promptly debrided by
tions of the specific diseases. a health care professional if necrotic tissue, dirt,
or other foreign materials are present. Often, a
BITES AND SCRATCHES course of antibiotics is appropriate after dog or cat
Bites from certain mammals frequently encoun- bites or scratches as these can lead to local or sys-
tered during foreign travel, such as monkeys, dogs, temic infections. Wound care is especially import-
bats, and rodents, can present a risk for serious ant for exposures where rabies or tetanus is a
infection. These animals’ saliva can be so heav- concern. Travelers who might have been exposed
ily contaminated with pathogens that a bite may to rabies should contact a health care provider as
not even be necessary to cause infection if saliva soon as possible for advice about rabies postex-
enters a preexisting cut or scratch or mucous posure prophylaxis (PEP). Travelers who received
membrane. their most recent tetanus toxoid–​containing vac-
cine >5 years previously, or who have not received
Prevention ≥3 doses of tetanus toxoid–​containing vaccines,
Before departure, travelers should have a cur- may require a dose of tetanus toxoid–​containing
rent tetanus vaccination or documentation of a vaccine (Tdap, Td, or DTaP).



DOGS AND CATS University Viral Immunology Center (www2.gsu.

Although travelers may assume that most dogs edu/​~wwwvir).
and cats are pets and therefore safe to interact
with, more rabies cases in humans occur because RODENTS
of bites from free-​roaming dogs and cats than Wild rodents are unlikely to have rabies; however,
from any other animals in the world. Rabies infec- rodent bites and scratches can transmit rat-​bite
tions in dogs and cats may be difficult to detect, fever, Salmonella, lymphocytic choriomeningitis
2 particularly early in the onset of clinical signs.
Rabies also cannot be definitively diagnosed in a
virus, and monkeypox. Each rodent bite or scratch
needs to be evaluated on a case-​by-​case basis to
live animal. Travelers who are bitten or scratched determine the need for treatment.
by dogs or cats should promptly clean the wound
and seek medical care. To further mitigate the risk STINGS AND ENVENOMATIONS
of exposure to rabies, unfamiliar dogs should be Snakes
avoided, and travelers should avoid the tempta- Poisonous snakes are hazards in many locations,
tion to adopt a stray dog from abroad. although deaths from snakebites are uncommon.
Snakebites usually occur in areas where dense
BATS human populations coexist with dense snake
Like any other wild animal, bats, whether sick or populations, such as Southeast Asia, sub-​Saharan
healthy, may bite if handled. Any suspected or doc- Africa, and tropical areas in the Americas.
umented bite or scratch from a bat anywhere in
the world should be considered a rabies risk, and PREVENTION
the traveler should be evaluated for rabies PEP. It Common sense is the best precaution. Most
is not possible to tell if a bat has rabies without snakebites result from startling, handling, or
laboratory confirmation; however, any bat that is harassing snakes. Therefore, all snakes should be
active by day, is found where bats are not usually left alone. Travelers should be aware of their sur-
seen ( for example, indoors or outdoors in areas roundings, especially at night and during warm
near humans), or is unable to fly is far more likely weather when snakes tend to be more active. For
to be rabid. People may not know when they have extra precaution, when practical, travelers should
been bitten by a bat, as most bats have tiny teeth, wear heavy, ankle-​high or higher boots and long
and not all wounds are apparent. Furthermore, pants when walking outdoors in areas possibly
because bat bites rarely cause much trauma, inhabited by venomous snakes.
people may trivialize the bite and not seek care.
Travelers should seek medical advice even in the MANAGEMENT
absence of an obvious bite wound if they wake up Travelers should be advised to seek immedi-
to find a bat in the room or see a bat in the room ate medical attention any time a bite wound
of an unattended child or other person who could breaks the skin or when snake venom is ejected
not reliably report a bite. into their eyes or other mucous membranes.
Immobilization of the affected limb and applica-
MONKEYS tion of a pressure bandage that does not restrict
After a monkey bite or scratch, travelers should blood flow are recommended first aid measures
be advised to thoroughly clean the wound and while the victim is moved as quickly as possi-
seek medical care immediately to be evaluated for ble to a medical facility. Incision of the bite site
possible rabies and herpes B PEP. Macaque bites and tourniquets that restrict blood flow to the
can transmit herpes B virus, a virus related to the affected limb are not recommended. Specific
herpes simplex viruses (see Chapter  3, B virus). therapy for snakebites is controversial and
Additional information and photos of macaques should be left to the judgment of local emer-
can be found at the website for the National gency medical personnel. Specific antivenoms
B Virus Resource Center at the Georgia State are available for some snakes in some areas, so



trying to ascertain the species of snake that bit seen or recognized at the time of injury. In such
the victim may be critical. cases, treatment is based on the injury. Symptoms
of venomous injuries can range from mild swell-
Insects and Other Arthropods ing and redness at the site to more severe symp-
Bites and stings from spiders and scorpions can toms, such as difficulty breathing or swallowing,
be painful and can result in illness and death, chest pain, or intense pain at the site of the sting,
particularly among infants and children. Other for which immediate medical treatment should
insects and arthropods, such as mosquitoes and
ticks, can transmit infections. See the Protection
be sought. Management will vary according to
the severity of symptoms and can include medi-
against Mosquitoes, Ticks, & Other Arthropods cations, such as diphenhydramine, steroids, pain
section earlier in this chapter. medication, and antibiotics.

Marine Animals OTHER HAZARDS

Most marine animals are generally harmless Travelers should be aware that animals do not
unless threatened. Most injuries are the result have to be sick or appear sick to be a risk to
of chance encounters or defensive maneuvers. humans. Some animals such as poultry, reptiles,
Resulting wounds have many common charac- and goats carry human pathogens as normal gut
teristics: bacterial contamination, foreign bodies, flora. Other animals, such as rodents, bats, and
and occasionally venom. Venomous injuries from nonhuman primates, can be subclinical carriers
marine fish and invertebrates are increasing with of pathogens.
the popularity of surfing, scuba diving, and snor-
keling. Most species responsible for human inju- Bats
ries, including stingrays, jellyfish, stonefish, sea Viral infections such as rabies and viral hemor-
urchins, and scorpionfish, live in tropical coastal rhagic fevers can be transmitted from bats to peo-
waters. ple. Histoplasmosis is a fungal infection that may
be associated with bat droppings. Exposure to
PREVENTION bats can occur during adventure activities such
Travelers should be advised to maintain vigilance as caving or spelunking and can include muco-
while engaging in recreational water activities. sal or cutaneous exposure to bat saliva or drop-
Prevention is the best defense: pings, in addition to bites and scratches. A recent
example of an indirect exposure is an imported
• Avoid contact. This may be difficult in condi- case of Marburg fever in a tourist who had vis-
tions of poor visibility, rough water, currents,
ited a “python cave” inhabited by bats in western
and confined areas.
Uganda. This case illustrates the risk of acquiring
• Do not attempt to feed, handle, tease, or diseases from indirect contact with cave-​dwelling
annoy marine animals. bats. This same cave was the source of a fatal case
of Marburg hemorrhagic fever in a Dutch tourist
• Wear protective clothing, such as protective in 2008.
Bats should never be handled. If a traveler
• Try to find out which animals may be encoun- touches a bat or if infectious material (such as
tered at the destination and learn about their saliva) from a bat gets into the eyes, nose, mouth,
characteristics and habitats before engaging or a wound, the traveler should wash the affected
in recreational water activities. area thoroughly and seek medical advice immedi-
ately. Travelers should be discouraged from going
MANAGEMENT into caves or mines that have bat infestations. If
In case of injury, identifying the species involved travelers will be entering densely populated bat
can help determine the best course of treatment. habitats, they should wear protective equipment
Signs and symptoms may not appear for hours and clothing ( face shield, respirator, gloves). Dirty
after contact, or the animal may not have been clothing should be removed and washed as soon



as possible after leaving the cave. If travelers, par- choriomeningitis, Lassa fever, tickborne enceph-
ticularly adventure travelers, know they will enter- alitis, poxvirus, tularemia, and bartonellosis (see
ing high-​density bat habitats or plan on having Chapter 3) should be included in the list of pos-
direct contact with bats or other rabies reservoir sible diagnoses.
species, preexposure rabies vaccination should be
considered. Birds
Both ill and asymptomatic birds have been asso-
2 Rodents
Rodents carry a variety of viral, bacterial, and par-
ciated with cases of highly pathogenic avian
influenza in humans. When traveling in an area
asitic agents that may pose a threat to human where outbreaks of avian influenza have been
health. Human exposure can occur directly by a reported, travelers should avoid contact with
bite or scratch or indirectly by exposure to sur- live poultry (such as chickens, ducks, geese,
faces or water contaminated with urine or feces. pigeons, turkeys, and quail) or any wild birds
Rodents can also be reservoirs for vectorborne and should avoid settings where avian influenza
infections carried by fleas, ticks, and mites. A  (H5N1 or H7N9)–​ infected poultry may be
Wild rodents should never be handled. present, such as commercial or backyard poul-
Travelers should avoid places that have evidence try farms and live poultry markets. Other patho-
of rodent infestation and should avoid contact gens from birds may infect humans through
with rodent feces. Travelers should not eat or infected feces or by aerosol. These cause dis-
drink anything that is suspected to be contami- eases such as histoplasmosis (see Chapter  3,
nated by rodent feces or urine. Histoplasmosis), salmonellosis (see Chapter  3,
Travelers who were exposed to rodents or who Salmonellosis [Nontyphoidal]), psittacosis, and
have a history of flea or tick bites or mite infes- avian mycobacteriosis.
tation may develop febrile illness shortly after Travelers should not eat uncooked or under-
exposure and should be evaluated by a clinician. cooked poultry or poultry products, including
Depending on the history and symptoms, dis- dishes that contain uncooked eggs or poultry
eases such as plague, leptospirosis, hantavirus, blood. Travelers should wash their hands if they
rickettsial infections, Lyme disease, lymphocytic come in contact with bird feces.

1. Callahan M. Bites, stings and envenoming injuries. age of global travel: a review of travel-​and trade-​associ-
In: Keystone JS, Freedman DO, Kozarsky PE, Connor ated rabies events—​United States, 1986–​2012. Zoonoses
BA, Nothdurft HD, editors. Travel Medicine. 3rd ed. Public Health. 2014 Aug;61(5):305–​16.
Philadelphia: Saunders Elsevier; 2013. pp. 413–​24. 7. Meerburg BG, Singleton GR, Kijlstra A. Rodent-​borne
2. Cohen JI, Davenport DS, Stewart JA, Deitchman S, diseases and their risks for public health. Crit Rev
Hilliard JK, Chapman LE. Recommendations for pre- Microbiol. 2009;35(3):221–​70.
vention of and therapy for exposure to B virus (cer- 8. Pan American Health Organization. Rabies. In: Acha
copithecine herpesvirus 1). Clin Infect Dis. 2002 Nov PN, Szyfres B, editors. Zoonoses and Communicable
15;35(10):1191–​203. Diseases Common to Man and Animals. 3rd ed.
3. Diaz JH. The global epidemiology, syndromic classifica- Washington, DC: Pan American Health Organization;
tion, management, and prevention of spider bites. Am J 2003. pp. 246–​76.
Trop Med Hyg. 2004 Aug;71(2):239–​5 0. 9. Smith KE, Dunn JR, Castrodale L, Daly R, Wohrle R,
4. Gibbons RV. Cryptogenic rabies, bats, and the ques- Journal of the American Veterinary Medical Association.
tion of aerosol transmission. Ann Emerg Med. 2002 Compendium of measures to prevent disease associ-
May;39(5):528–​36. ated with animals in public settings, 2013. J Am Vet Med
5. Gold BS, Dart RC, Barish RA. Bites of venomous snakes. Assoc. 2013 Nov 1;243(9):1270–​88.
N Engl J Med. 2002 Aug 1;347(5):347–​56. 10. World Health Organization. WHO Expert Consultation
6. Lankau EW, Cohen NJ, Jentes ES, Adams LE, Bell TR, on rabies. World Health Organ Tech Rep Ser.
Blanton JD, et al. Prevention and control of rabies in an 2005;931:1–​88.



Armin Ansari, Suzanne Beavers

AIR smoke-​free places in 201 countries, visit www.

Air pollution has decreased in many parts of the
world, but it is worsening in certain industrial-
tobaccocontrollaws.org/​legislation. 2
izing countries. Polluted air can be difficult or
• As much as possible, look for lodging with
working smoke and carbon monoxide
impossible to avoid, but the risk to healthy short-​
term travelers is most likely low. People with pre-
existing heart and lung disease, children, and Travelers to areas where air pollution is reported
older adults are at higher risk. to be high might inquire about the advisability of
Travelers should be familiar with the air quality wearing face masks. CDC has no recommenda-
at their destination. The AirNow website (http://​ tions regarding the use of face masks for travelers.
airnow.gov/​) provides information about the One small study in Beijing showed that wear-
effects of particulate matter and ozone, as well as ing a valved dust respirator appeared to mitigate
links to international air quality sites. Historical the effects of air pollution on blood pressure and
data on outdoor air pollution in urban areas are heart rate. However, it should be noted that the
available from the World Health Organization respirators used in the study had better filtration
at http://​gamapserver.who.int/​gho/​interactive_​ than the surgical masks commonly worn in some
charts/​phe/​oap_​exposure/​atlas.html. countries. The decision to wear a mask should be
Travelers should also limit exposure to indoor left to the traveler’s discretion.
air pollution and carbon monoxide. Possible
sources of indoor air pollutants include cooking
or combustion sources (such as kerosene, coal,
Extensive water damage after hurricanes or
wood, or animal dung). Major sources of indoor
floods can lead to mold contamination in build-
carbon monoxide include gas ranges and ovens,
ings. Travelers may visit flooded areas overseas
unvented gas or kerosene space heaters, and
as part of emergency, medical, or humanitarian
coal-​or wood-​burning stoves. Another import-
missions. Mold is a more serious health hazard
ant source of indoor air pollution is secondhand
for people who are immunocompromised or have
smoke produced from smoking tobacco.
respiratory problems. To prevent exposure that
Travelers to countries where air pollution may
could result in adverse health effects from dis-
be a problem should consider the following:
turbed mold, people should adhere to the follow-
• For people with preexisting conditions such ing recommendations:
as asthma, chronic obstructive pulmonary
disease, and heart disease, limit strenuous
• Avoid areas where mold contamination is
or prolonged outdoor activity, particularly
in cities. • If the traveler will be working in a moldy
environment (such as on a medical or
• For long-​term travelers and expatriates, humanitarian mission), use personal protec-
consider investing in an indoor air filtration
tive equipment (PPE), such as gloves, gog-
gles, and a fit-​tested N95 respirator or higher.
• Avoid indoor areas with high levels of indoor These travelers should take sufficient PPE
air pollutants such as tobacco smoke. For with them, as these may be scarce in the
additional information on tobacco laws and countries visited.



• Keep hands, skin, and eyes clean and free and monitor the situation, access requirements
from mold-​contaminated dust. and travel advisories change. The Department of
State recommends against all unnecessary travel
• Review the CDC guidance, Mold Prevention to areas designated by the Japanese government.
Strategies and Possible Health Effects in the For up-​to-​date information or any travel adviso-
Aftermath of Hurricanes and Major Floods ries, see the Department of State’s information for
(www.cdc.gov/​mmwr/​preview/​mmwrhtml/​ Japan (http://​travel.state.gov/​content/​passports/​
2 rr5508a1.htm), which provides recommenda-
tions for dealing with mold in these settings.
In most countries, areas of known radioactive
contamination are fenced or marked with signs.
RADIATION Any traveler seeking long-​term (more than a few
Natural background radiation levels can vary sub- months) residence near a known or suspected
stantially from region to region, but these varia- contaminated area should consult with staff of the
tions are not a health concern. Travelers should nearest US embassy and inquire about any adviso-
be aware of regions known to have been contam- ries regarding drinking water quality or purchase
inated with radioactive materials, such as the of meat, fruit, and vegetables from local farmers.
areas surrounding the Chernobyl nuclear power Radiation emergencies are rare events. In case of
plant in Ukraine and the Fukushima Daiichi such an emergency, however, travelers should fol-
nuclear power plant in Japan. low instructions provided by local authorities. If
The Chernobyl plant is located 100 km (62 such information is not forthcoming, US travelers
miles) northwest of Kiev. The 1986 accident con- should seek advice from the nearest US embassy
taminated regions in 3 republics—​ Ukraine, or consulate.
Belarus, and Russia—​but the highest radioactive Natural disasters (such as floods) may also dis-
ground contamination is within 30 km (19 miles) place industrial or clinical radioactive sources. In
of Chernobyl. all circumstances, travelers should exercise cau-
The Fukushima Daiichi plant is located 240 km tion when they encounter unknown objects or
(150 miles) north of Tokyo. After the accident in equipment, especially if they bear the basic radi-
2011, the area within a 20-​km (32-​mile) radius of ation tri-​foil symbol or other radiation signs (see
the plant was evacuated, and Japanese authorities www.remm.nlm.gov/​radsign.htm for examples).
also advised evacuation from locations farther Travelers who encounter a questionable object
away to the northwest of the plant. As Japanese should not touch or move the object and should
authorities continue to clean the affected areas notify local authorities.

1. Ansari A. Radiation threats and your safety: a guide to 5. Guarnieri M, Balmes JR. Outdoor air pollution and
preparation and response for professionals and commu- asthma. Lancet. 2014;383(9928):1581–​92.
nity. Boca Raton (FL): Chapman & Hall/​CRC; 2009. 6. Langrish JP, Mills NL, Chan JK, Leseman DL, Aitken RJ,
2. Brandt M, Brown C, Burkhart J, Burton N, Cox-​Ganser J, Fokkens PH, et al. Beneficial cardiovascular effects of
Damon S, et al. Mold prevention strategies and possible reducing exposure to particulate air pollution with a
health effects in the aftermath of hurricanes and major simple facemask. Part Fibre Toxicol. 2009;6:8.
floods. MMWR Recomm Rep. 2006 Jun 9;55(RR-​8):1–​27. 7. Nuclear Emergency Response Headquarters,
3. Brook RD, Rajagopalan S, Pope CAr, Brook JR, Government of Japan. Report of Japanese Government
Bhatnagar A, Diez-​Roux AV, et al. Particulate matter to IAEA Ministerial Conference on Nuclear Safety: the
air pollution and cardiovascular disease: An update accident at TEPCO’s Fukushima nuclear power stations.
to the scientific statement from the American Heart 2011 [cited 2016 Sep. 19]. Available from: http://​japan.
Association. Circulation. 2010 Jun 1;121(21):2331–​78. kantei.go.jp/​kan/​topics/​201106/​iaea_​houkokusho_​
4. Eisenbud M, Gesell TF. Environmental e.html
Radioactivity: from Natural, Industrial, and Military 8. Scientific Committee on the Effects of Atomic
Sources. 4th ed. San Diego Academic Press; 1997. Radiation. Annex J: exposure and effects of the


0 17

Chernobyl accident. In: Sources and Effects of Ionizing to tobacco smoke: a report of the Surgeon General.
Radiation. New York: United Nations; 2000. pp. 451–​556. Atlanta, GA: U.S. Department of Health and Human
9. Shofer S, Chen TM, Gokhale J, Kuschner WG. Outdoor Services, Centers for Disease Control and Prevention,
air pollution: counseling and exposure risk reduction. Coordinating Center for Health Promotion, National
Am J Med Sci. 2007 Apr;333(4):257–​6 0. Center for Chronic Disease Prevention and Health
Promotion, Office on Smoking and Health; 2006 [cited
10. US Department of Health and Human Services. 2016 Sep. 22]; Available from: www.ncbi.nlm.nih.gov/​
The health consequences of involuntary exposure books/​NBK44324/​.

Daniel A. Nord, Gregory A. Raczniak

Published estimates report anywhere from one-​ a physical examination to assess their cardiovas-
half to 4  million people who participate in rec- cular fitness. This may include an electrocardio-
reational diving in the United States, and many gram and exercise treadmill test.
travel to tropical areas of the world to dive. Divers Health care workers providing travel medicine
can face a variety of medical challenges, but examinations for divers should also remind their
because dive injuries are generally rare, few clini- patients of preventive actions they can take before a
cians are trained in their diagnosis and treatment. dive. Every dive should begin with identifying poten-
Therefore, the recreational diver must be able to tial hazards (such as weather and water conditions,
assess potential risks before diving, recognize the planned depth and bottom time, environment),
signs of injury, and find qualified dive medicine assessing these hazards and the associated risk, and
help when needed. making decisions about acceptable risk. The diver
should be able to implement controls to eliminate
PREPARING FOR DIVE TRAVEL or reduce the risk (by using correct and well-​main-
Planning for dive-​related travel should take into tained protective equipment, for example), make
account any recent changes in health, including sure the dive is supervised, and ensure that medical
injuries or surgery, and medication use. Respiratory care is available in the event of an emergency.
diseases (such as asthma or chronic obstructive
pulmonary disease), disorders that affect central DIVING DISORDERS
nervous system higher function and conscious-
ness (such as seizures) or the peripheral nervous Barotrauma
system (such as diabetic or autonomic neuropa- EAR AND SINUS
thy), mental health dysfunction (such as anxiety, Ear barotrauma is the most common injury in
claustrophobia, or substance abuse), cardiovascu- divers. On descent, failure to equalize pressure
lar disease that limits physical exertion, and preg- changes in the middle ear space creates a pres-
nancy raise special concerns about diving fitness. sure gradient across the eardrum. This pressure
Special mention must be made regarding car- change must be controlled through proper equal-
diovascular fitness. Diving should be considered ization techniques to avoid bleeding or fluid accu-
a potentially strenuous activity that can make mulation in the middle ear and avoid stretching or
substantial demands on the cardiovascular sys- rupture of the eardrum and the membranes cov-
tem. People with known risk factors for coronary ering the windows of the inner ear. Symptoms of
artery disease, including but not limited to abnor- barotrauma include the following:
mal lipid profile, elevated blood pressure, diabe-
tes, and smoking history, who wish to either begin
• Pain
a dive program or continue diving should undergo • Tinnitus (ringing in the ears)


• Vertigo (dizziness or sensation of spinning) frequently tracks under the skin (subcutane-
ous emphysema) or into the tissue around the
• Sensation of fullness larynx, sometimes precipitating a change in
• Effusion ( fluid accumulation in the ear) voice characteristics.

• Decreased hearing • Gas rupturing the alveolar walls can enter

the pulmonary capillaries and pass via the
Paranasal sinuses, because of their relatively nar-
2 row connecting passageways, are especially sus-
ceptible to barotrauma, generally on descent.
pulmonary veins to the left side of the heart,
where it is distributed according to rel-
ative blood flow, resulting in arterial gas
With small changes in pressure (depth), symp- embolism (AGE).
toms are usually mild and subacute but can be
exacerbated by continued diving. Larger pres- While mediastinal or subcutaneous emphy-
sure changes, especially with forceful attempts at sema may resolve spontaneously, pneumotho-
equilibration (such as the Valsalva maneuver), can rax generally requires specific treatment to
be more injurious. Additional risk factors for ear remove the air and reinflate the lung. AGE is
and sinus barotrauma include the following: a medical emergency, requiring urgent inter-
vention with hyperbaric oxygen recompression
• Use of solid earplugs treatment.
• Medications (such as decongestants) Lung overinflation injuries from scuba div-
ing can range from dramatic and life threaten-
• Ear or sinus surgery ing to mild symptoms of chest pain and dyspnea.
• Nasal deformity or polyps Although pulmonary barotrauma is relatively
uncommon in divers, prompt medical evalua-
• Chronic nasal and sinus disease that inter- tion is necessary, and evidence for this condi-
feres with equilibration during the large tion should always be considered in the presence
barometric pressure changes encountered of respiratory or neurologic symptoms following
while diving a dive.
A diver who may have sustained ear or sinus baro-
trauma should discontinue diving and seek med- Decompression Illness
ical attention. Decompression illness (DCI) describes the dys-
baric injuries (such as AGE) and decompres-
PULMONARY sion sickness (DCS). Because the 2 diseases are
A scuba diver must reduce the risk of lung over- considered to result from separate causes, they
pressure problems by breathing normally and are described here separately. However, from a
ascending slowly when breathing compressed clinical and practical standpoint, distinguish-
gas. Overinflation of the lungs can result if a scuba ing between them in the field may be impossi-
diver ascends toward the surface without exhal- ble and unnecessary, since the initial treatment
ing, which may happen, for example, when a nov- is the same for both. DCI can occur even in divers
ice diver panics. During ascent, compressed gas who have carefully followed the standard decom-
trapped in the lung increases in volume until the pression tables and the principles of safe diving.
expansion exceeds the elastic limit of lung tis- Serious permanent injury or death may result
sue, causing damage and allowing gas bubbles to from either AGE or DCS.
escape into 3 possible locations:
• Gas entering the pleural space can cause lung Gas entering the arterial blood through ruptured
collapse or pneumothorax.
pulmonary vessels can distribute bubbles into
• Gas entering the space around the heart, the body tissues, including the heart and brain,
trachea, and esophagus (the mediasti- where they can disrupt circulation or damage ves-
num) causes mediastinal emphysema and sel walls. The presentation of AGE ranges from


0 19

minimal neurologic symptoms to dramatic symp- • Unusual fatigue

toms that require immediate attention. Common
signs and symptoms include the following: • Dizziness
• Numbness • Weakness
• Weakness • Personality changes
• Tingling • Loss of bowel or bladder function
• Dizziness • Staggering, loss of coordination, or tremors 2
• Blurred vision • Paralysis
• Chest pain • Collapse or unconsciousness
• Personality change or difficulty thinking
• Bloody sputum The risk of developing decompression sickness is
• Paralysis or seizures increased when divers are exposed to increased
altitude too soon after a dive. The cabin pressure
• Loss of consciousness of commercial aircraft may be the equivalent
In general, any scuba diver who surfaces uncon- of 6,000–​8,000 ft (1,829–​2,438 m). Thus, divers
scious or loses consciousness within 10 minutes should avoid flying or an altitude exposure >2,000
after surfacing should be suspected to have AGE. ft (610 m) for:
Intervention with basic life support is indicated, • ≥12 hours after surfacing from a single
including the administration of the highest frac- no-​decompression dive
tion of oxygen, followed by rapid evacuation to a
hyperbaric oxygen treatment facility. • ≥18 hours after repetitive dives or multiple
days of diving
DECOMPRESSION SICKNESS • 24–​48 hours after a dive that required
Breathing air under pressure causes excess inert decompression stops
gas (usually nitrogen) to dissolve in body tissues
These recommended preflight surface intervals
and can saturate these tissues. The amount of
do not eliminate risk of DCS, and longer surface
gas dissolved is proportional to and increases
intervals will further reduce this risk.
with depth and time. As the diver ascends back
to the surface, the excess dissolved gas must be
cleared through respiration via the bloodstream.
Depending on the amount dissolved and the
Recreational divers should dive conservatively
rate of ascent, some gas can supersaturate tis-
and well within the no-​decompression limits
sues, where it separates from solution to form
of their dive tables or computers. Risk factors
bubbles, interfering with blood flow and tissue
for DCI are primarily dive depth, dive time, and
oxygenation and causes the following signs and
rate of ascent. Additional factors such as repet-
itive dives, strenuous exercise, dives to depths
• Joint aches or pain >60 ft (18 m), altitude exposure soon after a
dive, and certain physiological variables also
• Numbness or tingling increase risk. Divers should be cautioned to stay
• Mottling or marbling of skin hydrated and rested and dive within the limits
of their training. Diving is a skill that requires
• Coughing spasms or shortness of breath training and certification and should be done
• Itching with a companion.


TREATMENT OF DIVING help decide if recompression is needed, provide

DISORDERS the location of the closest recompression facil-
Definitive treatment of DCI begins with early rec- ity, and help arrange patient transport. DAN can
ognition of symptoms, followed by recompression also be contacted for routine, nonemergency con-
with hyperbaric oxygen. A  high concentration sultation by telephone at 919-​684-​2948, exten-
(100%) of supplemental oxygen is recommended. sion 6222, or by accessing the DAN website (www.
Surface-​level oxygen given for first aid may relieve diversalertnetwork.org).
2 the signs and symptoms of DCI and should be
administered as soon as possible. Divers are often
Travelers who plan to scuba dive may want
to ascertain whether recompression facilities are
dehydrated, either because of incidental causes, available at their destination before embarking on
immersion, or DCI itself, which can cause capil- their trip.
lary leakage. Administration of isotonic glucose-​
free intravenous fluid is recommended in most HAZARDOUS MARINE LIFE
cases. Oral rehydration fluids may also be help- The oceans and waterways are filled with crea-
ful, provided they can be safely administered ( for tures and, although some are capable of wound-
example, if the diver is conscious and can main- ing and poisoning, most marine animals are
tain his or her airway). The definitive treatment of generally harmless unless threatened. Most inju-
DCI is recompression and oxygen administration ries are the result of chance encounters or defen-
in a hyperbaric chamber. sive maneuvers. Resulting wounds have many
Divers Alert Network (DAN) maintains 24-​hour common characteristics:  bacterial contamina-
emergency consultation and evacuation assis- tion, foreign bodies, and occasionally venom. See
tance at 919-​684-​9111 (collect calls are accepted). the Animal-​Associated Hazards section earlier in
DAN will help with managing the injured diver, this chapter for prevention and injury manage-
ment recommendations.

1. Brubakk AO, Neuman TS, Bennett PB, Elliott DH. 5. Sheffield P, Vann RD. Flying after recreational diving,
Bennett and Elliott’s Physiology and Medicine of Diving. workshop proceedings of the Divers Alert Network
5th ed. London: Saunders; 2003. 2002 May 2. Durham, NC: Divers Alert Network;
2. Dear G, Pollock NW. DAN America Dive and Travel 2004 [cited 2016 Sep. 22]; Available from: http://​
Medical Guide. 5th ed. Durham, NC: Divers Alert www.diversalertnetwork.org/​research/​projects/​fad/​
Network; 2009. workshop/​FADWorkshopProceedings.pdf.

3. Moon RE. Treatment of decompression illness. In: Bove 6. US Navy Diving Manual Revision 6 Change A. Publication
AA, Davis JC, editors. Bove and Davis’ Diving Medicine. Number SS521-​AG-​PRO-​010 0910-​LP-​106-​0957. 2011
4th ed. Philadelphia: WB Saunders; 2004. pp. 195–​223. [cited 2016 Mar, 16]; Revision 6 [Available from: http://​
4. Neuman TS, Thom SR. Physiology and medicine of hyper- Frontmatter_​index.pdf.
baric oxygen therapy. Philadelphia, PA: Saunders; 2008.

Duc B. Nguyen, Joanna Gaines

Medical tourism is the term commonly used to providers from a similar culture, or to receive a
describe people traveling outside their home procedure or therapy not available in their coun-
country for medical treatment. Patients may pur- try of residence. In the United States, medical
sue medical care abroad for a variety of reasons, tourism generally refers to people traveling to less-​
such as decreased cost, a preference for care from developed countries for medical care. Medical



tourism is a worldwide, multibillion-​dollar phe- measures to control their spread in the United
nomenon that is expected to grow substantially States.
in the next 5–​10  years. Studies have estimated Several outbreaks of infectious disease have
that hundreds of thousands of medical tourists been documented among medical tourists after
travel from the United States annually. Little reli- their return to the United States. Recent examples
able epidemiologic data on medical tourism exist, include nontuberculous mycobacteria infections
but ongoing case reports and outbreaks of infec- among patients who had cosmetic surgery in the
tions serve as a reminder that medical tourism is
not without risks.
Dominican Republic and Q fever among patients
who received sheep cell injections in Germany.
Common categories of procedures that US Patients who experience complications after
travelers pursue during medical tourism trips receiving medical care overseas should inform
include orthopedic surgery, cosmetic surgery, their providers of their travel history and their
cardiology (cardiac surgery), oncologic care, medical history, but may lack adequate docu-
and dentistry. Common destinations include mentation of the care they received. Some may be
Thailand, Mexico, Singapore, India, Malaysia, reluctant to share such information if they have
Cuba, Brazil, Argentina, and Costa Rica. The had complications.
type of procedure and the destination need to
be considered when reviewing the risk of travel PRETRAVEL ADVICE
for medical care. FOR MEDICAL TOURISTS
Most medical tourists pay for their care at Patients who travel for medical reasons should
time of service, and rely on private companies consult a travel medicine specialist in the United
or medical concierge services to identify for- States for advice tailored to individual health
eign health care facilities. These companies may needs, preferably ≥4–​6 weeks before travel. In
not require accreditation of foreign providers, addition to regular considerations for healthy
track patient outcome data, or maintain formal travel related to their destination, medical tour-
medical record security policies. Some health ists should consider the additional risks asso-
insurance companies and large employers have ciated with surgery and travel, either while
formed alliances with overseas hospitals to con- being treated or while recovering from treat-
trol health care costs, and several major medi- ment. Flying and surgery both increase the risk
cal schools in the United States have developed of blood clots and pulmonary emboli. Air pres-
joint initiatives with overseas providers, such as sure in most commercial aircraft is equivalent
the Harvard Medical School Dubai Center, the to the pressure at an altitude of approximately
Johns Hopkins Singapore International Medical 6,000–​8,000 ft (1,829–​2,438 m). Patients should
Center, and the Duke-​ National University of not travel for 10  days after chest or abdomi-
Singapore. nal surgery to avoid risks associated with this
change in pressure. The American Society of
RISKS ASSOCIATED Plastic Surgeons advises people who have had
WITH MEDICAL TOURISM cosmetic procedures of the face, eyelids, or
Medical tourism has been associated with compli- nose, or who have had laser treatments, to wait
cations, including infections caused by antibiotic-​ 7–​10 days before flying. Patients are also advised
resistant strains of bacteria not commonly seen to avoid typical vacation activities such as sun-
in the United States. Patients who are considering bathing, drinking alcohol, swimming, and tak-
seeking medical care overseas should be aware ing long tours or engaging in strenuous activities
of this risk. It is wise for travelers to bring home or exercise after surgery. The Aerospace Medical
outer packaging and package inserts from medi- Association has published medical guidelines
cations they receive or purchase abroad. Health for airline travel that provide useful informa-
care providers should be vigilant for the possi- tion on the risks of travel with certain medical
bility of resistant infections among patients who conditions (www.asma.org/​asma/​media/​asma/​
have traveled for medical procedures and take Travel-​Publications/​paxguidelines.pdf ).



GUIDANCE FOR TRAVELERS entities include Joint Commission International,

SEEKING MEDICAL DNV International Accreditation for Hospitals, and
CARE ABROAD the International Society for Quality in Health Care,
Several professional organizations have developed which have lists of standards that facilities need
guidance that includes questions useful for travel- to meet to be accredited. However, using a facil-
ers when discussing medical or dental care abroad, ity that is accredited does not guarantee a lack of
either with the facility providing the care or with complications, similar to any hospital or proce-
2 the group facilitating the trip. When considering
a trip overseas for medical care, travelers should
dure performed in the United States. Similarly, the
American Dental Association provides informa-
be aware of the guiding principles developed by tional documents, including “Traveler’s Guide to
the American Medical Association (Box 2-​6). The Safe Dental Care,” through the Global Dental Safety
American College of Surgeons (ACS) issued a sim- Organization for Safety and Asepsis Procedures
ilar statement on medical and surgical tourism (Box 2-​7). Although this guidance was not devel-
with the additional recommendation that travel- oped for medical tourists, it provides useful infor-
ers obtain a complete set of medical records before mation for travelers to consider when selecting a
returning home to ensure that details of their care facility or planning a trip for medical or dental care.
are available to providers in the United States, These guides indicate the types of questions that
which helps facilitate continuity of care and proper people considering travel for medical care should
follow-​up if needed. ACS also recommends that discuss with their regular health care provider.
prospective medical tourists use facilities that are Additional resources exist to assist both providers
internationally accredited. Examples of accrediting and prospective medical tourists (Box 2-​8).

BOX 2-​6. Guiding principles on medical tourism1

The American Medical Association bodies (such as the Joint (g) Access to physician licensing
advocates that employers, Commission International or and outcome data, as well
insurance companies, and other the International Society for as facility accreditation and
entities that facilitate or promote Quality in Health Care). outcomes data, should be
medical care outside the United (d) Before travel, local follow-​up arranged for patients seeking
States adhere to the following care should be coordinated medical care outside the
principles: and financing should be United States.
arranged to ensure continuity (h) The transfer of patient medical
(a) Medical care outside the United
of care when patients return records to and from facilities
States must be voluntary.
from medical care outside the outside the United States
(b) Financial incentives to travel
United States. should be consistent with
outside the United States for
(e) Coverage for travel outside Health Insurance Portability
medical care should not limit
the United States for medical and Accountability Action
the diagnostic and therapeutic
care must include the costs of (HIPAA) guidelines.
alternatives that are offered to
necessary follow-​up care upon (i) Patients choosing to travel
patients or restrict treatment
return to the United States. outside the United States
or referral options.
(f) Patients should be informed of for medical care should be
(c) Patients should be referred
their rights and legal recourse provided with information about
for medical care only to
before agreeing to travel the potential risks of combining
institutions that have been
outside the United States for surgical procedures with long
accredited by recognized
medical care. flights and vacation activities.
international accrediting

From American Medical Association. New AMA Guidelines on Medical Tourism. Chicago: AMA; 2008.



BOX 2-​7. Patient checklist for obtaining safe dental

care during international travel1
Before you leave: If the answers to any of the aster- • Is sterile (or boiled) water used

• Visit your dentist for a check-​

up to reduce the chances you
isked (*) items below are “No,”
you should have reservations
about the office’s infection control
for surgical procedures?** (In
areas where drinking water
is unsafe, the water also may
will have a dental emergency.
standards. If the answer to a two-​ cause illness if used for dental
• See a health care provider to
star item (**) is “No,” consider treatment.)
receive any needed vaccinations,
making a swift but gracious exit.
medications, and advice related Upon arriving at the office, observe
When making the appointment,
to your travel destination. the following:
ask the following:
When seeking treatment for a den- • Is the office clean and neat?
• Do you use new gloves for each
tal emergency during your trip: • Do staff wash their hands, with
soap, between patients?**
• Consult hotel staff or the • Do you use an autoclave (steam
• Do they wear gloves for all
American Embassy or sterilizer) or dry heat oven
consulate for assistance in to sterilize your instruments
• Do they clean and disinfect
finding a dentist. between patients?**
or use disposable covers
• If possible, consider • Do you sterilize your
on surfaces touched during
recommendations from handpieces (drills)?* (If not, do
Americans living in the you disinfect them?)**
area or from other trusted • Do you use new needles for
sources. each patient?**

Excerpt from Organization for Safety and Asepsis Procedures. Traveler’s guide to safe dental care. Annapolis,
MD: Organization for Safety and Asepsis Procedures; 2001. Available from: http://​www.osap.org/​?page=TravelersGuide.

Many websites that market directly to trav- TRANSPLANT TOURISM

elers provide information on medical tourism. One of the newer and more controversial forms
These sites may not include comprehensive of medical tourism is “transplant tourism,” which
details on the qualifications or certifications of is travel for the purpose of receiving an organ or
a facility or provider. Furthermore, local stan- stem cell purchased from an unrelated donor for
dards for facility accreditation and provider transplant or receiving other biomaterial (cell,
certification can vary. The ACS recommends tissue) from nonhuman species (xenotransplan-
that patients considering treatment abroad tation). Xenotransplantation is regulated differ-
seek care from providers certified in their spe- ently among countries; no scientific evidence
cialties through a process that is equivalent to supports its therapeutic benefit, and adverse
that established by the member boards of the events have been reported. Additionally, several
American Board of Medical Specialties. ACS, studies of medical tourism identified potential
American Society of Plastic Surgeons, and problems that travelers and clinicians need to
the International Society of Aesthetic Plastic be aware of when considering transplantation
Surgery all accredit overseas physicians. Again, overseas:  the donor and the procedures lacked
however, the traveler should realize that accred- documentation, most patients received fewer
itation does not ensure a good outcome, and immunosuppressive drugs than is current prac-
travelers should be encouraged to do as much tice in the United States, and most patients did
research as possible on a health care facility they not receive antibiotic prophylaxis. In 2004, to
are considering using. protect vulnerable populations from becoming



BOX 2-​8. Helpful resources on medical tourism

• Aerospace Medical Association procedures abroad: www. Find-​a-​surgeon tool helps
guidelines for airline travel surgery.org/​consumers/​ identify a surgeon: www.isaps.
provide useful information on consumer-​resources/​ org/​find-​a-​surgeon

2 the risks of travel with certain

medical conditions: www.asma.
• Joint Commission
International list of its
org/​asma/​media/​asma/​Travel-​ procedures-​abroad accredited facilities outside
Publications/​paxguidelines.pdf • American Society of Plastic of the United States: www.
• American Academy of Surgeons (ASPS). The jointcommissioninternational.
Orthopaedic Surgeons Bulletin, dangers of plastic surgery org/​JCI-​Accredited-​
July 2007, discusses safety tourism: www.plasticsurgery. Organizations/​
issues that patients should org/​articles-​and-​galleries/​ • Organization for Safety
consider: www.aaos.org/​news/​ dangers-​of-​plastic-​surgery-​ and Asepsis Procedures.
bulletin/​jul07/​cover1.asp tourism.html Traveler’s guide to safe
• American Academy of • American Society of Plastic dental care: www.osap.org/​
Orthopaedic Surgeons Surgeons’ Find-​a-​surgeon tool ?page=TravelersGuide
discusses liability implications helps identify ASPS member • World Health Organization.
of medical tourism: www.aaos. surgeons in the United Guiding principles on human
org/​news/​aaosnow/​feb08/​ States and overseas: www1. cell, tissue and organ
managing7.asp plasticsurgery.org/​find_​a_​ transplantation: www.who.
• American College of Surgeons. surgeon int/​transplantation/​Guiding_​
Statement on medical and • European Commission. Cross-​ PrinciplesTransplantation_​
surgical tourism: www.facs. border care policy: http://​ WHA63.22en.pdf
org/​fellows_​info/​statements/​ ec.europa.eu/​health/​cross_​ • US Department of States:
st-​65.html border_​care/​policy/​index_​ Your Health Abroad https://​
• American Society for Aesthetic en.htm travel.state.gov/​content/​
Plastic Surgery. Guidelines • International Society for passports/​en/​go/​health.
for patients seeking cosmetic Aesthetic Plastic Surgery’s html#healthy.html

victims of transplant tourism, the World Health these activities to be prohibited. In view of those
Assembly Resolution 57.18 encouraged mem- events, the World Health Organization revised
ber countries to “take measures to protect the the Guiding Principles on Human Cell, Tissue
poorest and vulnerable groups [the donors] and Organ Transplantation and released those
from ‘transplant tourism’ and the sale of tis- revised principles in March 2009. These guide-
sues and organs.” A meeting in 2008 in Istanbul lines emphasize that cells, tissues, and organs
addressed the issue of transplant tourism and should only be donated freely without any form
organ trafficking, which resulted in a call for of financial incentive.

1. Budiani-​Saberi DA, Delmonico FL. Organ trafficking 3. Mathers AJ, Hazen KC, Carroll J, Yeh AJ, L. CH, Bonomo
and transplant tourism: a commentary on the RA, et al. First clinical cases of OXA-​48-​producing
global realities. Am J Transplant. 2008 May;8(5): carbapenem-​resistant Klebsiella pneumoniae in the
925–​9. United States: the "menace" arrives in the new world.
2. Chen LH, Wilson ME. The globalization of healthcare: J Clin Microbiol. 2013 Feb;51(2):680–​3.
implications of medical tourism for the infectious 4. Merion RM, Barnes AD, Lin M, Ashby VB, McBride V,
disease clinician. Clin Infect Dis. 2013 Dec;57(12): Ortiz-​Rios E, et al. Transplants in foreign countries
1752–​9. among patients removed from the US transplant



waiting list. Am J Transplant. 2008 Apr;8(4 Pt 2): multi-​resistant bacterial infection. Clin Infect Dis. 2011
988–​9 6. Jul 1;53(1):49–​56.
5. Organ Procurement and Transplantation Network, 9. Schnabel D, Gaines J, Nguyen DB, Esposito DH,
Scientific Registry of Transplant Recipients. United Ridpath A, Yacisin K, et al. Notes from the field:
States organ transplantation annual data report, rapidly growing nontuberculous Mycobacterium
2011. Rockville (MD): US Department of Health and wound infections among medical tourists
Human Services; 2012 [cited 2016 Sep. 22]; Available undergoing cosmetic surgeries in the Dominican
from: http://​srtr.transplant.hrsa.gov/​annual_​reports/​ Republic—​multiple states, March 2013–​February
6. Reed CM. Medical tourism. Med Clin North Am. 2008
2014. MMWR Morb Mortal Wkly Rep. 2014 Mar
7;63(9):201–​2. 2
Nov;92(6):1433–​46, xi. 10. US Department of Health and Human Services. 2007
7. Robyn MP, Newman AP, Amato M, Walawander M, annual report of the US Organ Procurement and
Kothe C, Nerone JD, et al. Q Fever outbreak among trav- Transplantation Network and the Scientific Registry
elers to Germany who received live cell therapy—​United of Transplant Recipients: transplant data 1997–​2006.
States and Canada, 2014. MMWR Morb Mortal Wkly Rockville, MD: US Department of Health and Human
Rep 2015 Oct;64(38):1071–​3. Services; 2007 [cited 2016 Sep. 22]; Available from:
8. Rogers BA, Aminzadeh Z, Hayashi Y, Paterson DL. ar_​archives.htm.
Country-​to-​country transfer of patients and the risk of

Catherine Law, Tina Adler, David Shurtleff

Travelers often ask their health care providers TRAVEL-​RELATED AILMENTS

about the use of complementary or integrative AND COMPLEMENTARY HEALTH
health approaches for travel-​ related illnesses APPROACHES
and conditions. This should come as no surprise,
Malaria Prophylaxis and Treatment
given that many people—​approximately 1 in 3
Americans—​report using products or practices ARTEMISIA ( ARTEMISIA ANNUA L. OR
that have origins outside of conventional med- SWEET WORMWOOD) AND QUININE
icine to complement treatment for a variety of Standard treatments for malaria in most of the
medical conditions or to promote general well- world depend on plant derivatives. Quinine from
ness. Some of these approaches for travel-​related the cinchona tree (Cinchona spp.) may be used
health problems are promoted widely in adver- in combination with other antimalarial medica-
tising or discussed on the Internet. However, lit- tions to treat malaria. There is no evidence that
tle of this information is supported by research quinine prevents malaria. Travelers should not
evidence, and some of it is misleading or false. attempt to use quinine to self-​treat or prevent
This section focuses on what scientifically credi- malaria. An important component of the anti-
ble research says about some of the herbal rem- malarial drug artemether-​ lumefantrine comes
edies, dietary supplements (see Box 2-​9), and from artemisinin, isolated from the qinghao
other complementary health approaches fre- plant (Artemisia annua). Consumer websites and
quently suggested for travel-​related ailments and news stories have claimed that using the herb
hazards. artemisia alone may prevent malaria, but studies



BOX 2-​9. About dietary supplements and

unproven therapies
• The Food and Drug contamination. Analyses of recalls and safety

2 Administration (FDA) regulates

dietary supplements, but the
regulations are different and
supplements sometimes find
differences between labeled
and actual ingredients.
alerts: www.fda.gov/​Food/​
generally less strict than those For example, an herbal htm.
for prescription or over-​the-​ supplement may not contain • Unproven therapies are
counter drugs. Learn more at the correct plant species, discussed in this section only
https://​nccih.nih.gov/​health/​ or the amounts of the for educational purposes and
supplements/​wiseuse.htm. ingredients may be lower or are not recommended for
• Two major safety concerns higher than the label states. use. The Centers for Disease
about dietary supplements • Consult the FDA’s safety Control and Prevention (CDC)
are potential drug advisories to learn the endorses only FDA-​approved
interactions and product latest regarding product therapies.

show it does not. The World Health Organization earth, will protect against or treat the Zika virus.
recommends against using artemisia plant mate- There is no evidence that any of these products
rial in any form (including tea) for treating or pre- can prevent or treat Zika virus infection. For more
venting malaria. The use of artemisia alone has information see Chapter 3, Zika.
contributed to the increase in malaria parasites
resistant to artemisinin. Recommended drugs Travelers’ Diarrhea Prevention
used to prevent and treat malaria are described and Treatment
in Chapter 3, Malaria. PROBIOTICS
Probiotics are often suggested to help prevent trav-
VITAMIN AND MINERAL SUPPLEMENTS elers’ diarrhea (TD). Research on their use in treat-
Limited research suggests that when children with ing acute infectious diarrhea is generally positive.
malaria are nutritionally deficient, supplements Results from studies on preventing TD are mixed
of vitamin A  and zinc may help lower their fever but encouraging. Given current data, it must be
and blood levels of the malaria parasite; however, assumed that effects of probiotics in any given
there is no evidence that vitamin A or zinc prevent study are specific to the strain or strains tested.
malaria infection. Vitamin A is fat soluble, and large The US Food and Drug Administration (FDA) has
or frequent doses may accumulate in the body and not approved any health claims for probiotics.
cause acute or chronic toxicity. High intake of vita- In healthy people, probiotics usually have only
min A has been linked to birth defects. Taking beta-​ minor side effects, if any. For more information
carotene, a precursor of vitamin A, has been linked see “Nonantimicrobial Drugs for Prophylaxis” in
to an increased risk of lung cancer and cardiovas- the Travelers’ Diarrhea section in this chapter.
cular disease in some smokers. Zinc supplements
can interact with several types of medications. GOLDENSEAL
Anyone taking high levels of zinc should be mon- Goldenseal is an herb that has been touted as a
itored for adverse health effects. treatment for a variety of ailments. No high-​qual-
ity research on goldenseal for TD has been con-
Zika Prophylaxis and Treatment ducted. Studies show that goldenseal inhibits
Consumer websites and online videos are claiming, cytochrome P450 enzymes, raising concerns that
without credible evidence, that herbs or other prod- it may increase the toxicity or alter the effects of
ucts, such as activated charcoal or diatomaceous many commonly used drugs.



ACTIVATED CHARCOAL appear to be safe when used as directed. However,

There is no solid evidence to support claims that ginkgo may increase the risk of bleeding in some
activated charcoal helps with TD, bloating, stom- people and interact with certain conventional
ach cramps, or gas. The side effects of activated medications, including anticoagulants. In addi-
charcoal have not been well documented but tion, studies by the National Toxicology Program
were mild when it was tested on healthy people. showed that rodents developed tumors after
Warning: Children should not be given acti- being given a ginkgo extract for up to 2 years.
vated charcoal for diarrhea and dehydration. It
may absorb nutrients, enzymes, and antibiotics VITAMIN E
in the intestine and mask the severity of fluid loss. Only one small study has investigated vitamin E,
in combination with other antioxidants, for alti-
GRAPEFRUIT SEED EXTRACT tude illness, and the results were negative. Taking
Claims that grapefruit seed extract can prevent supplements of vitamin E, a fat-​soluble vitamin,
bacterial foodborne illnesses are unfounded and has been linked to an increased risk of hemor-
not supported by research. rhagic stroke. They also have the potential to
interact with several types of medications, includ-
Altitude Illness Prevention and ing statins, niacin, and warfarin.
There is little, if any, evidence that dietary or Motion Sickness Prevention
herbal supplements help prevent or treat altitude and Treatment
illness (often referred to as mountain sickness). ACUPRESSURE AND MAGNETS
Using acupressure or magnets is advocated
COCA by some to prevent or treat motion sickness.
Coca tea has been used for altitude illness, but However, research does not support the use of
there is no strong evidence on whether it works or acupressure or magnets for this purpose.
has adverse effects. It will result in a positive drug
test for cocaine metabolites. For more informa- GINGER
tion see Chapter 4, Peru: Cusco, Machu Picchu, & Although some studies have shown that ginger
Other Regions. may ease pregnancy-​related nausea and vomiting,
there is no strong evidence that ginger helps with
GARLIC motion sickness. Several studies have found no
There is no evidence supporting claims that garlic evidence of harm from taking ginger during preg-
helps reduce altitude illness. Garlic supplements nancy, but it’s uncertain whether ginger is always
appear safe for most adults. Possible side effects safe for pregnant women; women should always
of taking garlic include breath and body odor, talk with their health care provider before trying
heartburn, and upset stomach. Some people have any dietary supplements during pregnancy, espe-
allergic reactions to garlic. Short-​term use of most cially if traveling overseas. In some people, gin-
commercially available garlic supplements poses ger can have mild side effects such as abdominal
only a limited risk for causing herb–​drug interac- discomfort. Research has not definitely shown
tions, including interfering with the effectiveness whether ginger interacts with medications, but
of the HIV drug saquinavir. concerns have been raised that it might inter-
act with anticoagulants. The effect of using gin-
GINKGO BILOBA ger supplements with common over-​the-​counter
Results from several small studies of ginkgo for drugs for motion sickness (such as dimenhydri-
preventing altitude illness show conflicting, but nate [Dramamine]) is unknown.
mostly negative, results. Whether these differ-
ences relate to the different preparations used PYRIDOXINE (VITAMIN B6)
in these studies cannot be determined. Products While The American Congress of Obstetrics and
made from standardized ginkgo leaf extracts Gynecology’s 2015 Practice Bulletin Summary



recommends pyridoxine alone or in combination may help with insomnia, but it has not been
with doxylamine as a safe and effective treatment established whether they are effective for jet lag.
for nausea and vomiting associated with preg-
nancy, there is no evidence supporting claims that OTHER
pyridoxine prevents or alleviates motion sickness. There is very little evidence that aromather-
Excessive use of pyridoxine supplements can apy, chamomile, or valerian help with insomnia.
affect nerve function. None have significant side effects, but cham-
omile can cause allergic reactions. Kava is also
advertised for sleep but good research on kava
There is no evidence supporting claims that for insomnia is lacking. More importantly, kava
homeopathic products prevent or alleviate supplements have been linked to a risk of severe
motion sickness. liver damage.
For more information see the Jet Lag section
Jet Lag/​Sleep Problems in this chapter.
Colds and Flu
Melatonin supplements may help with sleep prob-
lems caused by jet lag. Travelers report having less ZINC
jet lag on eastward and westward flights when Zinc supplements taken orally may reduce the
given melatonin compared with placebo. In a 2007 duration of a cold. Zinc, particularly in large
clinical practice guideline, the American Academy doses, can have side effects including nausea and
of Sleep Medicine supported using melatonin to diarrhea. The intranasal use of zinc can cause
reduce jet lag symptoms and improve sleep after anosmia (loss of sense of smell), which may be
traveling across >1 time zone. A systematic litera- long-​lasting or permanent. In 2009, the FDA
ture review suggested taking 0.5–​5 mg of melatonin warned consumers to stop using several intrana-
appeared to be effective for easing jet lag. sal zinc products that had been linked to cases
Before recommending melatonin, consider the of anosmia.
• People with epilepsy or who take an oral anti- Nasal saline irrigation, such as with neti pots, may
coagulant should never use melatonin with- be useful and safe for chronic sinusitis. However,
out medical supervision. even in places where tap water is safe to drink,
• Melatonin supplements appear to be safe for people should use only sterile or distilled water
most people when used short-​term; less is for nasal irrigation to avoid the risk of introduc-
known about their long-​term safety. ing waterborne pathogens. Nasal saline irrigation
may help relieve the symptoms of acute upper
• Melatonin should not be taken early in the respiratory tract infections, but the evidence is not
day, as it may cause sleepiness and delay definitive.
adaptation to local time.
• The amount of melatonin in products and
the dosages recommended on labels can vary Taking vitamin C supplements regularly may
significantly. slightly reduce the duration and severity of colds
in some people. Vitamin C supplements appear
Side effects from melatonin are uncommon but safe, even at high doses.
can include drowsiness, headache, dizziness, or
Probiotics might reduce susceptibility to colds or
RELAXATION TECHNIQUES other upper respiratory tract infections and the
Relaxation techniques, such as progressive relax- length of the illnesses, but the quality of the evi-
ation and mindfulness-​ based stress reduction, dence is low or very low.



OTHER there is no evidence that they are effective.

There is no strong evidence that echinacea, gar- Experts recommend against using any insect
lic, Chinese herbs, oil of oregano, or eucalyptus repellents or pesticides on clothing or luggage.
essential oil prevent or treat colds, or that the Instead, travelers should be encouraged to fol-
homeopathic product Oscillococcinum prevents low steps to detect and avoid bed bugs, such as
or treats influenza or influenzalike illness. inspecting their mattress and keeping their lug-
gage off the floor or bed. A guide for the public,
Other Common or Travel-​Related
How to Find Bed Bugs, is available at www.epa.
gov/​bedbugs/​how-​find-​bed-​bugs. Information
HEPATITIS C is also available on CDC’s website at www.cdc.
Herbal supplements should never be used to treat gov/​parasites/​bedbugs. For more information
hepatitis C outside of well-​designed, randomized see Box 2-​5.
clinical trials. A  randomized clinical trial found
no evidence of benefit from silymarin (an extract Sunscreens
from milk thistle seeds) in patients with chronic Skin cancer is the most common type of cancer
hepatitis C.  In addition, a systematic review of in the United States. Experts recommend using
10 randomized clinical trials found no firm evi- a broad-​spectrum sunscreen, limiting your sun
dence of efficacy of any herbal supplements for exposure, and wearing protective clothing to pro-
hepatitis C. Two of the trials studied a single herb tect against sunburns and to possibly lower the
or herbal ingredient; the others studied different risk of skin cancer. There are many “natural” sun-
compounds made from herbs. screen products available online, recipes for mak-
ing your own, and advice on consuming dietary
VAGINAL INFECTIONS AND URINARY TRACT supplements or drinking teas to protect against
INFECTIONS sun damage. Sunscreens are promoted as contain-
Probiotics have been studied for treating vagi- ing aloe vera and green tea, among other natural
nal or urinary tract infections, but there is not ingredients, but studies have not proven that any
enough supporting evidence to suggest that they herbal product or dietary supplement, including
are helpful. aloe, beta carotene, selenium, or epigallocatechin
gallate (EGCG), an extract in green tea, reduce the
Insect Protection: Botanical risk of skin cancer or sun damage. For more infor-
Repellents mation see Sun Exposure in this chapter.
Laboratory-​based studies found that botanicals, Homeopathic Vaccines
including citronella products, worked for shorter There is no credible scientific evidence or plausible
periods than products containing DEET. For peo- scientific rationale to support claims that certain
ple wishing to use botanicals, CDC recommends homeopathic products (sometimes called nosodes
Environmental Protection Agency (EPA)–​ regis- or homeopathic immunizations) are effective
tered products containing oil of lemon eucalyp- substitutes for conventional immunizations. For
tus (OLE), such as the products Repel and Off ! more information see General Recommendations
Botanicals. for Vaccination & Immunoprophylaxis in this
There are no high-​quality studies on the effec- chapter.
tiveness or safety of neem oil for preventing
mosquito bites. Neem oil is used in agricultural Untested Therapies in Other
insecticide products and promoted on some web- Countries
sites for human use. CDC does not recommend traveling to other
countries for untested medical interventions or
BED BUGS to buy medications that are not approved in the
Essential oils and other natural products are United States. For more information see Medical
marketed for travelers to repel bed bugs, but Tourism in this chapter.



TALKING TO TRAVELERS ABOUT Federal agencies, such as the National Center for
COMPLEMENTARY HEALTH Complementary and Integrative Health (NCCIH),
APPROACHES offer evidence-​based resources (nccih.nih.gov/​
Given the vast number of complementary or inte- health/​providers) to help you and your patients
grative interventions and the wealth of potentially have a meaningful discussion about complemen-
misleading information about them that can be tary approaches.
found on the Internet, discussing the use of these
2 approaches with patients may seem daunting.
However, it is important to be proactive, as sur-
The authors thank Dr.  John Williamson of
veys show that many patients are reluctant to NCCIH for his scientific review and Ms. Karen
raise the topic with their health care providers. Kaplan and Ms. Patricia Andersen of Westat for
their editorial assistance.

1. Hao Q, Lu Z, Dong BR, Huang CQ, Wu T. Probiotics for 7. Mathie RT, Frye J, Fisher P. Homeopathic
preventing acute upper respiratory tract infections. Oscillococcinum® for preventing and treating influenza
Cochrane Database Syst Rev. 2011 Sep 7(2):CD006895. and influenza-​like illness. Cochrane Database of Syst
2. Hemilä H, Chalker E. Vitamin C for preventing and Rev. 2015 (1):CD001957.
treating the common cold. Cochrane Database Syst Rev. 8. Schwenger EM, Tejani AM, Loewen PS. Probiotics
2013 Jan 31(1):CD000980. for preventing urinary tract infections in adults and
3. Karsch-​Völk M, Barrett B, Kiefer D, Bauer R, Ardjomand-​ children. Cochrane Database of Syst Rev. 2015 Dec
Woelkart K, Linde K. Echinacea for preventing and 23(12):CD008772.
treating the common cold. Cochrane Database of Syst 9. Wang C, Lü L, Zhang A, Liu C. Repellency of selected
Rev. 2014 (2):CD000530. chemicals against the bed bug (Hemiptera:
4. King D, Mitchell B, Wlilliams CP, Spurling GK. Saline Cimicidae). J Econ Entomol. 2013 Dec;106(6):2522–​9.
nasal irrigation for acute upper respiratory tract 10. World Health Organization. Global Malaria
infections. Cochrane Database Syst Rev. 2015 Apr Programme. WHO position statement:
20(4):CD006821. effectiveness of non-​pharmaceutical forms of
5. Lissiman E, Bhasale AL, Cohen M. Garlic for the com- Artemisia annua L. against malaria. WHO; 2012
mon cold. Cochrane Database of Syst Rev. 2014 Nov [cited 2016 Sep. 22]; Available from: http://​www.
11(11):CD006206. who.int/​malaria/​diagnosis_​treatment/​position_​
6. Liu J, Manheimer E, Tsutani K, Gluud C. Medicinal herbs l.pdf ?ua=1.
for hepatitis C virus infection. Cochrane Database of
Syst Rev. 2001 Oct 23(4):CD003183.


Nimia L. Reyes, Michele G. Beckman, Karon Abe

Deep vein thrombosis (DVT) is a condition in DVT, PE, or both. VTE is often recurrent, and long-​
which a blood clot develops in the deep veins, most term complications, such as postthrombotic syn-
commonly in the lower extremities. A part of the drome after a DVT or chronic thromboembolic
clot can break off and travel to the lungs, causing a pulmonary hypertension after a PE, are frequent.
pulmonary embolism (PE), which can be life threat- People traveling for extended periods of time
ening. Venous thromboembolism (VTE) refers to may be at increased risk for DVT/​PE because



they have prolonged limited mobility. More than regard to duration of travel and period of observa-
300 million people travel on long-​distance flights tion after travel. Estimates of travel-​related VTE
each year. An association between VTE and air incidence vary because of differences between
travel was first reported in the early 1950s, and studies in duration of travel, measured outcome,
since then, long-​distance air travel has become period of observation after the flight, and the pop-
more common, leading to increased concerns ulations observed.
about travel-​related VTE. In general, the overall incidence of travel-​

related VTE is low. Two studies reported that
the absolute risk of VTE for flights >4 hours is 1
Virchow’s classic triad for thrombus formation is in 4,656 flights and 1 in 6,000 flights. People who
venous stasis, vessel wall damage, and the hyper- travel on long-​distance flights are generally health-
coagulable state. Prolonged cramped sitting ier and therefore are at lower risk for VTE than the
during long-​distance travel interferes with venous general population. Five prospective studies that
flow in the legs and causes venous stasis. Seat-​ assessed the incidence of DVT among travelers
edge pressure on the popliteal area may contrib- at low to intermediate risk for VTE after travel
ute to vessel wall damage as well as venous stasis. >8 hours yielded an overall incidence of VTE of
Coagulation activation may result from an inter- 0.5%, while the incidence of symptomatic VTE
action between cabin conditions (such as hypo- was 0.3%.
baric hypoxia) and individual risk factors for VTE.
Studies of the pathophysiologic mechanisms ASSOCIATION WITH TRAVEL
for the increased risk of VTE after long-​distance Numerous studies have examined the associa-
travel have not produced consistent results, but tion between travel, particularly air travel, and
venous stasis appears to play a major role; other VTE with varying results due to differing study
factors specific to air travel may increase coagula- methods. Outcomes ranged from asymptomatic
tion activation, particularly in travelers with pre- DVT to symptomatic DVT/​PE and to severe or
existing risk factors for VTE. fatal PE. Asymptomatic DVT is estimated to be
5-​to 20-​fold more common than symptomatic
INCIDENCE events, is of uncertain clinical significance, and
The annual incidence of VTE in the general pop- often resolves spontaneously. Definitions of long-​
ulation has been estimated at 0.1% but is higher distance travel ranged from flight duration >3
in subpopulations with risk factors for VTE (Box hours to >10 hours (most >4 hours). The period
2-​10). The actual incidence of travel-​related VTE of observation after the flight ranged from hours
is difficult to determine, since there is no national after landing to ≥8 weeks (most 4 weeks).
surveillance for VTE and no consensus on the Overall, these studies indicate that long-​dis-
definition of travel-​related VTE, particularly in tance air travel may increase a person’s risk for

BOX 2-​10. Venous thromboembolism (VTE) risk factors

General risk factors for VTE • Pregnancy and the • Serious medical illness
include the following: postpartum period (such as congestive heart
• Thrombophilia (such as failure or inflammatory bowel
• Older age (increasing risk after
factor V Leiden mutation or disease)
age 40)
antiphospholipid syndrome) or • Recent surgery, hospitalization,
• Obesity (BMI ≥30 kg/​m2)
a family history of VTE or trauma
• Estrogen use (hormonal
• Previous VTE • Limited mobility
contraceptives or hormone
• Active cancer
replacement therapy)



VTE by 2-​to 4-​fold. However, published results • The most common signs or symptoms of
from these studies vary; some studies found that acute PE include unexplained shortness of
long-​distance travel increased the risk of VTE, breath, pleuritic chest pain, cough or hemop-
and others either found no definitive evidence tysis, and syncope.
that it increased the risk of VTE or found that it
increased the risk only if ≥1 additional risk factors
were present.
Imaging studies are needed for diagnosis:
A similar increase in risk is also seen with other
modes of travel, such as car, bus, or train, implying • Duplex ultrasonography is the standard imag-
that the increase in risk is caused mainly by pro- ing procedure for diagnosis of DVT.
longed limited mobility rather than by the cabin
environment. The risk is the same for economy-​
• Computed tomographic pulmonary angio­
graphy is the standard imaging procedure for
class and business-​class travel. The risk increases
diagnosis of PE. Ventilation-​perfusion scan is
with increasing travel duration and with preexist-
the second-​line imaging procedure.
ing risk factors for VTE. The risk decreases with
time after air travel and returns to baseline by 8
weeks; most air travel–​related VTE occurs within
Anticoagulants are the medications most com-
the first 1–​2 weeks after the flight.
monly used to treat DVT or PE. Bleeding can be a
RISK FACTORS complication of anticoagulant therapy.
Most travel-​related VTE occurs in travelers with The most frequently used injectable antico-
preexisting risk factors for VTE (Box 2-​10). The agulants are unfractionated heparin, low molec-
combination of air travel with preexisting individ- ular weight heparin (LMWH), and fondaparinux.
ual risk factors may have a synergistic effect on the Oral anticoagulants include warfarin, dabigatran,
risk for VTE. Some studies have shown that 75%–​ rivaroxaban, apixaban, and edoxaban.
99.5% of those who developed travel-​related VTE It is critical that patients who are at increased
had ≥1 preexisting risk factor; one study showed risk be evaluated with enough time prior to
that 20% had ≥5 risk factors. For travelers without departure so that travelers understand how to
preexisting risk factors, the risk of travel-​related take the medication and the health provider can
VTE is low. However, a person may not be aware evaluate whether there are any potential adverse
that he or she has a risk factor such as inherited effects of the combination of these medications
thrombophilia. with others that the travel health provider has
For air travelers, height appears to be an addi- prescribed.
tional risk factor. Risk of travel-​ related VTE
increases with height <1.6 m (5 ft, 3 in). Airplane PREVENTIVE MEASURES
seats are higher than car seats and cannot be FOR LONG-​DISTANCE
adjusted to a person’s height; therefore, shorter TRAVELERS
people who travel by air may experience seat-​edge The American College of Chest Physicians pub-
pressure to the popliteal area. Risk of travel-​related lished the 9th edition of their Antithrombotic
VTE also increases with height >1.9 m (6 ft, 3 in), Therapy and Prevention of Thrombosis Evidence-​
possibly because taller travelers have less leg room. Based Clinical Practice Guidelines in February
2012. Recommendations for long-​distance trav-
CLINICAL PRESENTATION elers (considered grade 2C:  weak recommenda-
Signs and symptoms of DVT/​PE are nonspecific: tion, low-​or very low-​quality evidence) are the
• Typical signs or symptoms of DVT in the
extremities include pain or tenderness, 1. For long-​distance travelers at increased risk
swelling, increased warmth in the affected of VTE (Box 2-​10), frequent ambulation, calf
area, and redness or discoloration of the muscle exercise, and sitting in an aisle seat if
overlying skin. feasible are suggested.



2. For long-​distance travelers at increased risk 6-​fold increase in risk. Aisle seats are reported to
of VTE (Box 2-​ 10), use of properly fitted, have a protective effect, compared with window
below-​knee graduated compression stockings or middle seats, probably because travelers are
(GCS) providing 15–​30 mm Hg of pressure at freer to move around.
the ankle during travel is suggested. For all GCS are indicated for long-​distance travelers
other long-​distance travelers, use of GCS is at increased risk. GCS appear to reduce asymp-
not recommended. tomatic DVT in travelers and are generally well
3. For long-​distance travelers, the use of aspi-
rin or anticoagulants to prevent VTE is not
Global use of anticoagulants for long-​distance
recommended. travel is not indicated. Pharmacologic prophy-
laxis for long-​distance travelers at particularly
There is no evidence for an association between
high risk should be decided on an individual
dehydration and travel-​ related VTE and no
basis. In cases where the potential benefits of
direct evidence that drinking plenty of nonalco-
pharmacologic prophylaxis outweigh the pos-
holic beverages to ensure adequate hydration
sible adverse effects, anticoagulants rather
or avoiding alcoholic beverages has a protec-
than antiplatelet drugs (such as aspirin) are
tive effect. Therefore, while maintaining hydra-
tion is reasonable and unlikely to cause harm, it
cannot be recommended specifically to prevent
travel-​related VTE.
There is evidence that immobility while fly- 1. General measures for long-​distance travelers:
ing is a risk for VTE and indirect evidence that a. Calf muscle exercises
maintaining mobility may prevent VTE. In view b. Frequent ambulation
of the role of venous stasis in the pathogenesis of c. Aisle seating when feasible
travel-​related VTE, it would be reasonable to rec- 2. Additional measures for long-​distance travel-
ommend frequent ambulation and calf muscle ers at increased risk of VTE:
exercises for long-​distance travelers. a. Properly fitted below-​knee GCS
Compared with aisle seats, window seats in b. Anticoagulant prophylaxis only in partic-
one study were reported to increase the general ularly high-​risk cases where the potential
risk of VTE by 2-​fold, while obese travelers had a benefits outweigh the risks

1. Aryal KR, Al-​Khaffaf H. Venous thromboembolic com- of thrombosis, 9th ed: American College of Chest
plications following air travel: what’s the quantitative Physicians evidence-​based clinical practice guidelines.
risk? A literature review. Eur J Vasc Endovasc Surg. 2006 Chest. 2012 Feb;141(2 Suppl):e195S–​226S.
Feb;31(2):187–​99. 7. Schobersberger W, Schobersberger B, Partsch H.
2. Bartholomew JR, Schaffer JL, McCormick GF. Air travel Travel-​related thromboembolism: mechanisms
and venous thromboembolism: minimizing the risk. and avoidance. Expert Rev Cardiovasc Ther. 2009
Cleve Clin J Med. 2011 Feb;78(2):111–​20. Dec;7(12):1559–​67.
3. Chandra D, Parisini E, Mozaffarian D. Meta-​analy- 8. Schreijer AJ, Cannegieter SC, Caramella M, Meijers
sis: travel and risk for venous thromboembolism. Ann JC, Krediet RT, Simons RM, et al. Fluid loss does not
Intern Med. 2009 Aug 4;151(3):180–​9 0. explain coagulation activation during air travel. Thromb
4. Eklof B, Maksimovic D, Caprini JA, Glase C. Air travel-​ Haemost. 2008 Jun;99(6):1053–​9.
related venous thromboembolism. Disease-​a-​month 9. Schreijer AJ, Cannegieter SC, Doggen CJ, Rosendaal
: DM. 2005 Feb-​Mar;51(2-​3):200–​7. FR. The effect of flight-​related behaviour on the risk of
5. Gavish I, Brenner B. Air travel and the risk of thrombo- venous thrombosis after air travel. Br J Haematol. 2009
embolism. Intern Emerg Med. 2011 Apr;6(2):113–​6. Feb;144(3):425–​9.

6. Kahn SR, Lim W, Dunn AS, Cushman M, Dentali 10. Watson HG, Baglin TP. Guidelines on travel-​related
F, Akl EA, et al. Prevention of VTE in nonsurgical venous thrombosis. Br J Haematol. 2011 Jan;152(1):
patients: antithrombotic therapy and prevention 31–​4.



Thomas H. Valk

International travel is stressful. Stressors vary to nontravelers. In order of decreasing frequency,

2 some extent with the type of travel; short-​term
tourist travel likely offers the least stress and fre-
diagnoses in this population were schizo-
phrenia, alcohol abuse, anxiety reactions, and
quent travel and expatriation the most. Given the depression.
stressors of travel, preexisting psychiatric disor-
ders can recur, latent or undiagnosed problems
• Quigley et al. studied repatriations over
a 2-​year period (2010–​2012) comparing
can become apparent, and new problems can
American-​sponsored college students study-
arise. In addition, short-​term travelers may suf-
ing abroad with American-​sponsored cor-
fer from anxiety and aggravated depressive symp-
porate business travelers and expatriates.
toms triggered by jet lag, fatigue, and work or
They found a 23-​times higher rate of repatri-
family pressures. Remaining aware of these issues
ation because of mental health problems for
is important for providers when evaluating the
the student population. In this population of
ill patient who may have trouble distinguishing
repatriated students, in order of decreasing
physical and psychological problems after travel.
frequency, diagnoses were mood disorders,
personality disorders, substance abuse, eat-
OCCURRENCE IN TRAVELERS ing disorders, and schizophrenia or other psy-
Incidence data based on population surveys of
chotic disorders.
travelers are nonexistent. Data from clinical pop-
ulations include the following:
• Patel et al. conducted a study of urgent repa- AND MENTAL HEALTH
triation of British diplomats and found that
11% of medical evacuations were “nonphys-
Any pretravel consultation should include a
ical,” or psychological in nature. Using the
mental health screening, especially for those
authors’ data, an overall incident rate of 0.34%
planning extended travel or residence in a for-
for psychological evacuations occurred for
eign country. Since travel medicine specialists
their population. Of these, 41% were for some
rarely have mental health credentials, a full men-
form of depression.
tal health inquiry with mental status examina-
• Another study examined psychiatric evacu- tion and a psychiatric review of symptoms would
ations over a 5-​year period in the US Foreign not be practicable. Rather, a brief inquiry aimed
Service population from 1982 through 1986. at eliciting previously diagnosed psychiatric dis-
Using an unpublished estimate of the popula- orders should be undertaken. To introduce this
tion served in this study, an overall incidence portion of the consultation and to elicit the most
rate of 0.16% for psychiatric evacuations cooperation, the practitioner could enumerate
occurred. Of these, fully 50% were for sub- the following facts:
stance abuse or affective disorder. Mania and
hypomanic states accounted for 2.8% of these
• International travel is stressful for everyone
and has been associated with the emergence
or reemergence of mental health problems.
• Streltzer studied psychiatric emergencies in • The availability of culturally compatible men-
travelers to Hawaii and estimated a rate of
tal health services varies widely.
0.22% for tourists and 2.25% for transient trav-
elers (those arriving in Hawaii with no imme- • Laws regarding the use of illicit substances
diate plans to leave) versus a rate of 1.25% for can be severe in some countries.



The practitioner can then ask about factors that is always wise to carry medications in their
might indicate a mental health problem: original containers, along with a letter from
the prescribing physician indicating that the
• Any previously treated or diagnosed psy- medications have been prescribed for medical
chiatric disorders and the type of treatment
reasons. Even with these precautions, prob-
involved (inpatient, outpatient, medications)
lems may still occur at customs.
• Current treatment for any psychiatric disor- • Psychotropic medication refills: Obtaining
ders and their nature
these medications while living overseas can 2
• Current or past use of illicit substances be problematic, as availability or even legal-
ity of the medication varies from country to
• Any diagnosis of substance use disorder, or country. Again, a check with the country’s
suggestion from medical service providers,
embassy may be helpful, as would a check
friends, or family that the traveler might be
with a reputable in-​country pharmacy or
using alcohol or other substances to excess
health care provider.
• Any immediate family history of serious men- • Measuring drug levels: Locating laboratory
tal health problems
facilities for the determination of lithium lev-
In general, any history of inpatient treatment, psy- els or for other mood-​stabilizing medications
chotic episode, violent or suicidal behavior, affec- may be challenging and should be investi-
tive disorder (including mania, hypomania, or gated prior to travel. High ambient tempera-
major depression), any treatment for substance tures and increased sweating could lead to
use problems, and any current treatments would lithium toxicity, even on the same dose.
warrant further evaluation by a mental health
professional, preferably one who has had some
• Mefloquine: In general, patients with mental
health issues should not be prescribed meflo-
experience in problems relating to international
quine for malarial chemoprophylaxis because
travel. On occasion, the patient’s mental status
of its potential for neuropsychiatric side
upon examination may be notably abnormal,
effects. Please see the discussion of meflo-
which would also warrant a referral.
quine in Chapter 3, Malaria.
Other issues that may be encountered and
should be addressed during the pretravel consul- • Alcoholics Anonymous (AA) and Narcotics
tation include the following: Anonymous (NA) meetings: Currently sober
patients with substance use disorders should
• Availability of culturally compatible mental consider seeking out AA and NA meetings,
health treatment in the destination country
depending upon their length of stay and sta-
for long-​term travelers or expatriates.
bility of their sobriety. AA and NA maintain,
• Customs regulations: Traveling through cus- by country, lists of such meetings on their
toms with medications for personal use can websites, although availability can change.
be problematic in countries where those Language of meetings should also be checked.
medications are prohibited. What substances
are prohibited in any given country varies.
• Evacuation insurance: Travelers with mental
health problems should consider travel health
Stimulants frequently used for attention defi-
and medical evacuation insurance that does
cit disorders, such as amphetamine or meth-
not exclude psychiatric evacuations for emer-
ylphenidate, may be problematic, along with
gencies when abroad.
narcotics. This list is not exhaustive, and trav-
elers should check with the host country’s
embassy if anything is questionable. A health POST-​TRAVEL MENTAL
care provider or pharmacist in the desti- HEALTH ISSUES
nation country may also be able to provide Travel health practitioners may be in a unique
guidance about medication restrictions. It position to inquire about traumatic experiences


a traveler might have had that may lead to acute • Changes in mood or cognition associated
stress disorder (ASD) or posttraumatic stress dis- with the event can include diminished inter-
order (PTSD). Travelers exposed to life-​threaten- est in activities, inability to experience pos-
ing events, such as disaster relief workers or war itive emotions, or an inability to remember
correspondents, may experience subclinical or significant details of the event.
outright ASD or PTSD.
If the traveler has had such experiences, clini- • Arousal symptoms can include difficulty
2 cians should inquire about possible symptoms: sleeping or concentrating, irritability, or an
exaggerated startle response.
• Reexperiencing the event can include recur-
rent, intrusive recollections, distressing As symptoms of PTSD may occur months or even
dreams of the event, and feeling as if the event years after an event, education about the pos-
is happening again. sibility of having such symptoms in the future is
worthwhile. If there is any concern about a possi-
• Avoidance symptoms can include avoiding ble reaction to a traumatic event, referral to a psy-
thoughts, feelings, activities, places, or people chiatrist is warranted.
that lead to memories of the event.

1. American Psychiatric Association. Diagnostic and 6. Quigley RL, Copeland R. Mental health and study
Statistical Manual of Mental Disorders. 5th ed. abroad: incidence and mitigation strategies. Oral
Arlington, VA: American Psychiatric Association; 2013. presentation at: 13th Conference of the International
2. Benedek DM, Wynn GH. Clinical manual for manage- Society of Travel Medicine; 2013 May 19-​23; Maastricht,
ment of PTSD. Arlington, VA: American Psychiatric The Netherlands.
Publishing, Inc.; 2011. 7. Streltzer J. Psychiatric emergencies in travelers to
3. Feinstein A, Owen J, Blair N. A hazardous profes- Hawaii. Compr Psychiatry. 1979 Sep-​Oct;20(5):
sion: war, journalists, and psychopathology. Am J 463–​8.
Psychiatry. 2002 Sep;159(9):1570–​5. 8. Valk TH. Psychiatric medical evacuations within
4. Liese B, Mundt KA, Dell LD, Nagy L, Demure B. Medical the Foreign Service. Foreign Serv Med Bull. 1988;268:
insurance claims associated with international business 9–​11.
travel. Occup Environ Med. 1997 Jul;54(7):499–​5 03. 9. Valk TH. Psychiatric disorders of travel In: Keystone JS,
5. Patel D, Easmon CJ, Dow C, Snashall DC, Seed PT. Freedman DO, Kozarsky PE, Connor BA, Nothdurft HO,
Medical repatriation of British diplomats resident over- editors. Travel Medicine. 3rd ed. Philadelphia: Saunders
seas. J Travel Med. 2000 Mar-​Apr;7(2):64–​9. Elsevier; 2013. pp. 439–​48.

Kelly Winter

Regardless of the destination, all international A travel health kit can help to ensure travelers
travelers should assemble and carry a travel have supplies they need to:
health kit. The contents of a travel health kit
should be tailored to the traveler’s needs, type
• Manage preexisting medical conditions and
treat any exacerbations of these conditions.
and length of travel, and destinations. Kits can be
assembled at home or purchased at a local store, • Prevent illness and injury related to
pharmacy, or online. traveling.


2 17

• Take care of minor health problems as they exceed size limits. Exceptions are made for cer-
occur. tain medical reasons; check the Transportation
Security Administration for US outbound and
By bringing medications from home, travelers inbound travel (call toll-​free at 866-​289-​9673 M–​F
avoid having to purchase them at their destina- 8 am to 11 pm, weekends and holidays 9 am to
tion. See Perspectives: Pharmaceutical Quality & 8 pm, or e-​mail TSA-​ContactCenter@dhs.gov) and
Falsified Drugs later in this chapter for informa- the embassy or consulate of the destination coun-
tion about the risks associated with purchasing
medications abroad. Even when the quality of
try for their restrictions.
medications is reliable, medications people are SUPPLIES FOR PREEXISTING
used to taking at home may be sold under differ- MEDICAL CONDITIONS
ent names or with different ingredients and dos- Travelers with preexisting medical conditions
age units in other countries, presenting additional should carry enough medication for the dura-
challenges. tion of their trip and an extra supply, in case
the trip is extended for any reason. If additional
TRAVELING WITH MEDICATIONS supplies or medications would be needed to
All medications should be carried in their original manage exacerbations of existing medical con-
containers with clear labels, so the contents are ditions, these should be carried as well. The cli-
easily identified. The patient’s name and dosing nician managing a traveler’s preexisting medical
regimen should be on each container. Although conditions should be consulted for the best plan
many travelers prefer placing medications into of action (see Chapter 8, Travelers with Chronic
small containers or packing them in daily-​dose Illnesses).
containers, officials at ports of entry may require People with preexisting conditions, such as
proper identification of medications. diabetes or allergies, should consider wearing
Travelers should carry copies of all prescrip- an alert bracelet and making sure this informa-
tions, including their generic names and pref- tion (in English and preferably translated into
erably translated into the local language of the the local language of the destination) is on a
destination. For controlled substances and card in their wallet and with their other travel
injectable medications, travelers should carry a documents.
note from the prescribing clinician or from the
travel clinic on letterhead stationery. Translating GENERAL TRAVEL HEALTH
the letter into the local language of the destina- KIT SUPPLIES
tion and attaching this translation to the original Although the following is not a comprehensive
document may prove helpful if the document is list, basic items that should be considered for a
needed during the trip. Some countries do not travel health kit are listed below. See Chapter  8
permit certain medications. If there is a question for additional suggestions that may be useful in
about these restrictions, particularly regarding planning the contents of a kit for travelers with
controlled substances, travelers should con- specific needs.
tact the embassy or consulate of the destination
country. Prescription Medications
A travel health kit is useful only when it is eas- and Supplies
ily accessible. It should be carried with the traveler
at all times (such as in a carry-​on bag), although
• Medications taken on a regular basis at
sharp objects must remain in checked luggage.
Travelers should make sure that any liquid or gel-​ • Antibiotic for self-​treatment of moderate to
based items packed in the carry-​on bags do not severe diarrhea1

For factors to consider when deciding whether to use an antibiotic for self-​treatment of moderate to severe travelers’ diarrhea,
see Perspectives: Antibiotics in Travelers’ Diarrhea, earlier in this chapter.



• Medication to prevent malaria, if needed • Treatment for upper respiratory tract

• Medication to prevent or treat altitude illness, > Antihistamine
if needed
> Decongestant, alone or in combination
• Prescription glasses/​contact lenses (consider with antihistamine
packing an extra pair of each in case lenses > Cough suppressant or expectorant
are damaged) > Cough drops
2 • Epinephrine auto-​injectors2 (such as an • Anti–​motion sickness medication
EpiPen 2-​Pak), especially if history of severe
allergic reaction or anaphylaxis; smaller-​dose
• Mild sedative or sleep aid
packages are available for children • Saline eye drops
• Diabetes testing supplies and insulin • Saline nose drops or spray
• Needles or syringes, if needed for injectable Basic First Aid Items
medication. Needles and syringes can be
difficult to purchase in some locations, so • Disposable latex-​free gloves (≥2 pairs)
take more than what is needed for the length
of the trip. (These items will require a letter
• Adhesive bandages, multiple sizes
from the prescribing clinician on letterhead • Gauze
• Adhesive tape
• Medical alert bracelet or necklace • Antiseptic wound cleanser
Over-​the-​Counter Medications • Cotton swabs
• Medications taken on a regular basis at • Antifungal and antibacterial spray or
home creams
• Treatment for pain or fever (one or more of • 1% hydrocortisone cream
the following, or an alternative):
> Acetaminophen • Anti-​itch gel or cream for insect bites
and stings
> Aspirin
> Ibuprofen • Aloe gel for sunburns
• Treatment for stomach upset or diarrhea: • Moleskin or molefoam for blister prevention
> Antidiarrheal medication (such as lopera- and treatment
mide [Imodium] or bismuth subsalicylate
• Digital thermometer
> Packets of oral rehydration salts for • Tweezers 3
> Mild laxative • Scissors 3
> Antacid • Safety pins
Injectable epinephrine and antihistamines should always be carried on one’s person, including during air, sea, and land travel,
for immediate treatment of a severe allergic reaction. Travelers with a history of severe allergic reactions should consider
bringing along a short course of oral steroid medication (prescription required from doctor) and antihistamines as additional
treatment of a severe allergic reaction.
If traveling by air, travelers should pack these sharp items in checked baggage, since they could be confiscated by airport or
airline security if packed in carry-​on bags. Small bandage scissors with rounded tips may be available for purchase in certain
stores or online.


2 19

• Elastic/​compression bandage wrap for translated into the local language of the
sprains and strains destination)

• Triangular bandage to wrap injuries and to • Documentation of preexisting conditions,

make an arm or shoulder sling such as diabetes or allergies (in English and
preferably translated into the local language
• For travel in remote areas, consider a com- of the destination)
mercial suture kit
• First aid quick reference card
• Health insurance, supplemental travel health
insurance, medical evacuation insurance, and
travel insurance information (carry contact
Supplies to Prevent Illness or Injury information for all insurance providers and
copies of claim forms)
• Antibacterial hand wipes or an alcohol-​
based hand sanitizer, containing ≥60% • Contact card to be carried with the trav-
alcohol eler at all times, including street addresses,
phone numbers, and e-​mail addresses of the
• Insect repellents for skin and clothing (see following:
the Protection against Mosquitoes, Ticks,
& Other Arthropods section earlier in this
> Family member or close contact remain-
ing in the United States
chapter for recommended types)
> Health care provider(s) at home
• Bed net (if needed, for protection against > Place(s) of lodging at the destination(s)
insect bites while sleeping) > Hospitals or clinics (including emergency
services) in your destination(s)
• Sunscreen (≥15 SPF with UVA and UVB > US embassy or consulate in the destina-
tion country or countries
• Water purification tablets (if visiting remote See the Obtaining Health Care Abroad section
areas, camping, or staying in areas where
later in this chapter for information about how to
access to clean water is limited)
locate local health care and embassy or consulate
• Latex condoms contacts.
• Ear plugs
• Personal safety equipment (such as child Commercial medical kits are available for a
safety seats and bicycle helmets) wide range of circumstances, from basic first aid
to advanced emergency life support. For more
Documents adventurous travelers, a number of companies
Travelers should carry the following documents produce advanced medical kits and will even
and leave a copy of these documents with a family customize kits based on specific travel needs. In
member or close contact who will remain in the addition, specialty kits are available for managing
United States, in case of an emergency. diabetes, dealing with dental emergencies, and
handling aquatic environments. Many pharmacy,
• Proof of vaccination on an International grocery, retail, and outdoor sporting goods stores,
Certificate of Vaccination or Prophylaxis
as well as online retailers, sell their own basic
(ICVP) card or medical waiver (if vaccina-
first aid kits. Travelers who choose to purchase a
tions are required)
preassembled kit should review the contents of
• Copies of all prescriptions for medications, the kit carefully to ensure that it has everything
eye glasses/​contacts, and other medical sup- needed. Additional items may be necessary and
plies (including generic names and preferably can be added to the purchased kit.



1. Goodyer L. Travel medical kits. In: Keystone JS, 3. Rose SR, Keystone JS. Chapter 2, trip preparation.
Freedman DO, Kozarsky PE, Connor BA, Nothdurft HD, In: Rose SR, Keystone JS, editors. International Travel
editors. Travel Medicine. 3rd ed. Philadelphia: Saunders Health Guide. 2016 online ed. Northampton: Travel
Elsevier; 2013. pp. 63–​6. Medicine, Inc; 2016.
2. Harper LA, Bettinger J, Dismukes R, Kozarsky PE.
Evaluation of the Coca-​Cola company travel health kit.

2 J Travel Med. 2002 Sep-​Oct;9(5):244–​6.



Michael D. Green
The quality of medicines and surveillance methods. Before international
available outside the United Recent survey studies of departure, travel health care
States should not always be antimicrobial drug quality providers should alert trav-
taken for granted. In many in Africa and Southeast elers to the dangers of coun-
countries, national drug Asia revealed that 9%–​41% terfeit and substandard drugs
regulatory authorities lack failed quality specifications. and provide suggestions on
the resources to effectively Previous reports have shown how to avoid them.
monitor drug quality and that global estimates of drug
keep poor-​quality pharma- counterfeiting range from 1% HOW TO AVOID
ceuticals off the market. of sales in developed coun- COUNTERFEIT
These poor-​quality drugs tries to >10% in developing DRUGS WHEN
include falsified (the prod- countries. In specific regions TRAVELING
uct’s identity or source is in Africa, Asia, and Latin The best way to avoid coun-
falsely represented), coun- America, chances of pur- terfeit drugs is to reduce
terfeit (a product bearing an chasing a counterfeit drug the need to purchase medi-
unauthorized representation may be >30%. cations abroad. Anticipated
of a registered trademark), Since counterfeit drugs amounts of medications for
and substandard (a medicine are not made by the legiti- chronic conditions (such
not conforming to the spec- mate manufacturer and are as hypertension, sinusitis,
ifications set by an accepted produced under unlawful arthritis, and hay fever),
pharmacopeia) medications. circumstances, toxic con- medications for gastro-
Poor-​quality medicines also taminants or lack of proper enteritis (such as travelers’
include products that are ingredients may cause diarrhea), and prophylactic
not stored correctly, such serious harm. For example, medications for infectious
that high temperature and the active pharmaceutical diseases (such as malaria)
humidity can alter the chemi- ingredient may be completely should all be purchased
cal composition. These drugs lacking, present in small before traveling. Purchasing
are an international problem quantities, or substituted by these drugs via the Internet
contributing to illness, tox- a less-​effective compound. In is not recommended, since
icity, drug resistance, and addition, the wrong inactive the source of the medicines
death. Although this prob- ingredients (excipients) can is always questionable. The
lem exists on a worldwide contribute to poor drug dis- traveler should also be aware
scale, reliable global esti- solution and bioavailability. that other health-​related
mates of its prevalence are As a result, a patient may not items such as medical
scarce because consensus respond to treatment or may devices, mosquito nets, and
is lacking on harmonized have adverse reactions to insect repellents could also
international definitions unknown substituted or toxic be counterfeit, falsified, or
of poor-​quality medicines ingredients. substandard.




Before departure, travel- States is available on the the brand, batch num-
ers should do the following: Department of State’s web- ber, and expiration date.
site at www.state.gov/​s/​cpr/​ Sometimes a wary con-
• Obtain all medicines rls/​dpl/​32122.htm. sumer will prompt the
2 and other health-​related
items needed for the trip
If travelers run out and seller into supplying qual-
require additional medica- ity medicine.
in advance. Prescriptions tions, they should take steps
written in the United to ensure the medicines they
• Be familiar with medi-
States usually cannot be cations. The size, shape,
buy are safe:
filled overseas, and over-​ color, and taste of coun-
the-​counter medicines • Obtain medicines from terfeit medicines may
may not be available in a legitimate pharmacy. be different from the
many foreign countries. Patients should not buy authentic. Discoloration,
Checked baggage can get from open markets, street splits, cracks, spots, and
lost; therefore, travelers vendors, or suspicious-​ stickiness of the tablets or
should pack as much as looking pharmacies; they capsules are indications
possible in a carry-​on bag should request a receipt of a possible counter-
and bring extra medicine when making the pur- feit. These defects may
in case of travel delays. chase. The US embassy also indicate improper
may be able to help find storage. Travelers should
• Make sure medicines a legitimate pharmacy in keep examples of authen-
are in their original the area. tic medications to com-
containers. If the drug pare if they purchase the
is a prescription, the • Do not buy medicines that same brand.
patient’s name and dose are substantially cheaper
regimen should be on the than the typical price. • Be familiar with the
container. Although generics are packaging. Different color
usually less expensive, inks, poor-​quality print
• Bring the “patient pre- many counterfeit brand or packaging material,
scription information” names are sold at prices and misspelled words are
sheet. This sheet provides substantially lower than clues to counterfeit drugs.
information on common the normal price for that Travelers should keep an
generic and brand particular brand. example of packaging for
names, use, side effects, comparison and observe
precautions, and drug • Make sure the medicines the expiration date.
interactions. are in their original pack-
ages or containers. If trav- If the authentic packaging
Many countries have restric- elers receive medicines as is not available or if you are
tions on medicines (including loose tablets or capsules not familiar with the brand,
over-​the-​counter medica- supplied in a plastic bag compare the distinguishing
tions) entering their borders. or envelope, they should features of the package with
Check with the embassies ask the pharmacist to that of the insert or blister
of your destination countries see the container from pack. For example, batch/​
for prohibited items. A listing which the medicine was lot numbers, manufacturing
of foreign embassies and originally dispensed. The date, and expiration date
consulates in the United traveler should record should match.



USEFUL WEBSITES Traveling and cbp-​advises-​travelers-​

General Information Customs Guidelines entry-​regulations-
about Counterfeit Researching what travelers ​pertaining
Drugs can pack and bring back into
the United States, especially
• CDC: wwwnc.cdc.
for travelers with disabilities 1. Gaurvika ML, Nayyar JG, Bremen JG,
gov/​travel/​page/​ Herrington JE. The global pandemic
and medical conditions, is
counterfeit-​medicine of falsified medicines: laboratory
helpful in preparing for travel. and field innovations and policy
• World Health • Transportation Security perspectives. Am J Trop Med Hyg
Organization: www. 2012 Jun;92(6 suppl):2–​7.
Administration: www.tsa.
who.int/​mediacentre/​ 2. Institute of Medicine. Countering
factsheets/​fs275/​en the problem of falsified and substan-
travelers-​disabilities-​and-​ dard drugs. Washington, DC: The
• Food and Drug medical-​conditions National Academics Press; 2013 Feb.
Administration: www.fda.
• Customs and Border 3. World Health Organization.
Medicines: counterfeit medicines
Protection: www.
ucm170314.htm [ fact sheet no. 275]. Geneva: World
cbp.gov/​newsroom/​ Health Organization; 2012 [cited
• US Pharmacopeia: www. local-​media-​release/​ 2016 Sep. 22]; Available from: www.
usp.org/​worldwide 2015-​04-​22-​000000/​ who.int/​mediacentre/​factsheets/​

Perspectives sections are written as editorial discussions aiming to add depth and clinical perspective to the official
recommendations contained in the book. The views and opinions expressed in this section are those of the author and
do not necessarily represent the official position of CDC.


Carolina Uribe

The quality and availability of medical care abroad does not usually cover emergency evacuation or
may be variable. Before departure, travelers the costs of altered itineraries. Travelers may pur-
should consider how they would access health chase specific policies to cover these expenses,
care during their trip should a medical problem or understanding that such policies often do not
emergency arise. Travelers may seek medical care cover expenses related to preexisting conditions.
for a variety of reasons, ranging from minor infec- Supplemental medical insurance plans acquired
tions and care for chronic conditions to major ill- before travel will often enable access to local pro-
ness or injury. viders in many countries through a 24-​hour emer-
Some insurance plans cover emergency health gency hotline (see Travel Insurance, Travel Health
care, but travelers should check with their carri- Insurance, & Medical Evacuation Insurance sec-
ers to confirm what coverage is offered and what tion later in this chapter).
requirements exist. At a minimum, travelers may In addition to identifying quality health care,
need to provide copies of bills and invoices to ini- travelers, especially those with chronic or compli-
tiate reimbursement. Emergency health coverage cated medical issues, should know the names of



their chronic conditions and allergies, their blood Membership is free, although donations are
type, and current medications (including generic suggested. Search for clinics at www.iamat.
names), ideally in the local language. Travelers org/​doctors_​clinics.cfm.
should also wear medical identification jewelry
(such as a MedicAlert bracelet), if appropriate.
• The Joint Commission International (JCI) aims
to improve patient safety through accredita-
There are a number of cellular telephone appli-
tion and certification of health care facilities.
cations that enable travelers to download their
2 medical records, medications, EKG, and other
information so that it is accessible if needed.
For a list of facilities accredited through JCI,
see www.jointcommissioninternational.org/​
LOCATING HEALTH • Embassies and consulates in other countries,
CARE PROVIDERS AND hotel doctors, and credit card companies
FACILITIES ABROAD (especially those with special privileges) may
Before going abroad, travelers should identify also provide information.
health care providers and facilities at their destina-
tion. This is especially true for travelers with preex-
• A number of countries or national travel med-
icine societies have websites related to travel
isting or complicated medical issues. Travelers who
medicine that provide access to clinicians,
require regular dialysis need to arrange appoint-
including the following:
ments at an adequate clinical site. Similarly, preg-
nant travelers should identify reliable health
> Canada:  Health Canada (www.phac-​aspc.
gc.ca and travel.gc.ca)
facilities. More choices are generally available in
urban areas than in rural or remote areas.
> Great Britain:  National Travel Health
Network and Centre (www.nathnac.org)
The following list of resources will help iden-
and British Global and Travel Health
tify health care providers and facilities around
Association (www.bgtha.org)
the world. CDC does not endorse any particu-
lar provider or medical insurance company, and
> South Africa:  South African Society of
Travel Medicine (www.sastm.org.za)
accreditation does not necessarily ensure a good
outcome. If travelers are likely to seek health care
> Australia: Travel Medicine Alliance (www.
abroad, they should be encouraged to thoroughly
research health care facilities in the area.
> China:  International Travel Healthcare
Association (http://​en.itha.org.cn)
• The Department of State (www.usembassy. • Travelers also may consider contracting
gov) can help travelers locate medical services
with one of a number of private companies
and notify friends, family, or employer of an
that provide physician services abroad as
well as medical evacuations. One example is
• The Department of State also maintains a International SOS, which operates through-
list of travel medical insurance providers at out the world. Provider locations and details
travel.state.gov/​content/​passports/​en/​go/​ may be found at www.internationalsos.com.
• The International Society of Travel Medicine Travelers should evaluate their health before
maintains a directory of health care profes-
travel to ensure that they are healthy enough
sionals with expertise in travel medicine in
for their itinerary and should avoid travel if they
more than 80 countries. Search these clinics
become ill before or during their trip. Travelers
at www.istm.org.
may be reluctant to postpone or cancel a trip
• The International Association for Medical when ill because of their financial investment in
Assistance to Travelers maintains a network a trip, among other factors. However, some air-
of physicians, hospitals, and clinics that lines check for visibly sick passengers in the wait-
have agreed to provide care to members. ing area and during boarding. If a passenger looks



visibly ill, the airline may prohibit that person need for a blood transfusion. Not all countries
from boarding. have accurate, reliable, and systematic screening
Encouraging travelers, especially those with of blood donations for infectious agents, which
chronic or complicated health conditions, to pur- increases the risk of transfusion-​related trans-
chase trip cancellation insurance, which will pro- mission of disease. Travelers in developing coun-
tect some or all of the investment in a trip, may tries should receive a blood transfusion only in
increase compliance with this recommendation. life-​or-​death situations. Although it is difficult to


ensure access to safe blood, travelers can take a
few measures to increase their chances of having
PHARMACEUTICALS a safe blood transfusion in the event of a medical
The quality of drugs and medical products abroad emergency:
cannot be guaranteed, as they may not meet reg-
ulated standards or could be counterfeit (see
• If a blood transfusion is required, travelers
should make every effort to ensure that the
Perspectives: Pharmaceutical Quality & Falsified
blood has been screened for transmissible
Drugs earlier in this chapter). To minimize risks
diseases, including HIV. Although this is dif-
associated with substandard drugs and pharma-
ficult to do at the point of service, travelers
ceuticals, travelers should
who plan ahead—​especially those with med-
• Bring with them all the medicines that they ical conditions that might require transfu-
think they will need, including pain relievers sions—​and locate medical services before
and antidiarrheal medication. traveling will increase their chances of obtain-
ing higher-​quality care abroad.
• Insist that a new needle and syringe be used
when receiving an injection. Travelers who • Travelers may consider registering with
know beforehand that they will require injec- agencies such as the Blood Care Foundation
tions during their trip can bring their own that attempt to rapidly deliver reliable
injection supplies (see the Travel Health Kits blood products to members while abroad
section earlier in this chapter). (www.bloodcare.org.uk/​blood-​transfusions-​
• Carry an epinephrine autoinjector, if needed,
in carry-​on luggage. Include a letter from the All travelers should consider being immunized
prescribing physician that explains the allergy against hepatitis B virus before travel, especially
and a copy of the prescription. those who travel frequently to developing coun-
tries, those whose itinerary indicates spending
BLOOD SAFETY a prolonged period in developing countries, and
A medical emergency abroad, such as a motor those whose activities (such as adventure travel)
vehicle accident or trauma, could result in the put them at higher risk for serious injury.

1. Kolars JC. Rules of the road: a consumer’s guide for from: http://​www.who.int/​mediacentre/​factsheets/​
travelers seeking health care in foreign lands. J Travel fs275/​en/​.
Med. 2002 Jul-​Aug;9(4):198–​201. 3. World Health Organization. Blood safety [ fact sheet
2. World Health Organization. Medicines: spurious/​falsely-​ no. 279]. Geneva: World Health Organization; 2014
labelled/​falsified/​counterfeit (SFFC) medicines [ fact [updated July 2016 cited 2016 Sep. 22]; Available
sheet no. 275]. Geneva: World Health Organization; 2012 from: http://​www.who.int/​mediacentre/​factsheets/​
[updated January 2016 cited 2016 Sep. 22]; Available fs279/​en/​.




Rhett J. Stoney
Severe illness or injury abroad may result in a finan- • Exclusions regarding psychiatric emergencies
cial burden on travelers. Although planning for
every possible contingency is impossible, travelers
• Exclusions for injuries related to terrorist
attacks, acts of war, or natural disasters
can reduce the cost of a medical emergency by con-
sidering the purchase of a specialized insurance pol- • Whether preauthorization is needed for treat-
icy for their trip, regardless of whether or not they ment, hospital admission, or other services
have a domestic health insurance plan. There are
3 types of policies:  travel insurance, travel health
• Whether a second opinion is required before
obtaining emergency treatment
insurance, and medical evacuation insurance. These
insurance policies can be purchased before a trip to • Whether there is a 24-​hour physician-​backed
provide coverage in the event of an illness or injury support center
and may be of particular importance to travelers
with chronic medical conditions. Basic accident or PAYING FOR HEALTH
travel insurance may even be required for travelers SERVICES ABROAD
with certain itineraries. For example, cruise ships Medical care abroad usually requires cash or credit
have medical staff on board, but treatment may not card payment at the point of service, regardless of
be included in passengers’ ticket costs. In this case, whether the traveler has insurance coverage in his
those traveling by cruise ship may want to consider or her home country. Additionally, the existence
a specialized insurance policy. of nationalized health care services in a given des-
tination does not ensure that nonresidents will be
DOMESTIC HEALTH INSURANCE covered. This could result in a large out-​of-​pocket
AND OVERSEAS TRAVEL expenditure of perhaps thousands of dollars.
Some health insurance carriers in the United A  discussion of insurance options is an import-
States may cover emergencies that occur while ant part of any pretravel consultation. In addition
traveling abroad. Travelers should examine their to covering costs of treatment or medical evacu-
coverage and itinerary to determine which med- ation, the travel health insurer can also assist in
ical services, if any, will be covered abroad and organizing and coordinating care and keeping rel-
the level of supplemental insurance needed. The atives informed. This is especially important when
following is a list of characteristics to consider: the traveler is severely ill or injured and requires
medical evacuation. Although all travelers should
• Exclusions for treating exacerbations of pre- consider insurance, it is particularly important
existing medical conditions
for travelers who plan extended travel outside
• The company’s policy for “out-​of-​network” the United States, have underlying health condi-
services tions, or plan to participate in high-​risk activities
on their trip, especially if the destination is remote
• Coverage for complications of pregnancy or lacks high-​quality medical facilities. Regardless
(or for a neonate, especially if the newborn
of which insurance option (or options) is (are)
requires intensive care)
selected for a trip, when paying out-​of-​pocket for
• Exclusions for high-​risk activities such as sky- care overseas, travelers should obtain copies of all
diving, scuba diving, and mountain climbing bills and receipts and, if necessary, contact a US


3 17

consular officer, who can assist US citizens with • Emergency medical transport to facilities that
transferring funds from the United States. are equivalent to those in the home country
or to the home country itself (repatriation)
Travel insurance protects the financial invest- • Any specific medical services that may apply
ment in a trip, including lost baggage and trip to their circumstances, such as coverage of
cancellation. Travelers may be more likely to high-​risk activities
avoid travel when sick if they know their financial
investment in the trip is protected. Depending on
Even if an insurance provider is selected carefully,
travelers should be aware that unexpected delays
the policy, travel insurance may or may not cover in care may still arise, especially in remote desti-
medical expenses abroad, so travelers need to nations. In special circumstances, travelers may
carefully research the coverage offered to deter- be advised to postpone or cancel international
mine if additional travel health and medical evac- trips if the health risks are too high.
uation insurance is needed.
HEALTH AND MEDICAL The following resources, although not all-​inclu-
EVACUATION INSURANCE sive, provide information about purchasing travel
Travel health insurance and medical evacuation health and medical evacuation insurance:
insurance are both short-​term supplemental pol-
icies that cover health care costs on a trip and are • Department of State (www.travel.state.gov)
relatively inexpensive. Many commercial compa-
• International Association for Medical
nies offer travel health insurance, which may be Assistance to Travelers (www.iamat.org)
purchased separately or in conjunction with med-
ical evacuation insurance. Frequent travelers may • American Association of Retired Persons
consider purchasing annual policies or even poli- (www.aarp.org) ( for information about
cies that will provide coverage for repatriation to Medicare supplement plans, see below)
one’s home country.
Although travel health insurance will cover SPECIAL CONSIDERATIONS FOR
some health care costs abroad, the quality of care TRAVELERS WITH UNDERLYING
may be inadequate, and medical evacuation from MEDICAL CONDITIONS
a resource-​poor area to a hospital where definitive Travelers with underlying medical conditions
care can be obtained may be necessary. The cost should discuss any concerns with the insurer
of evacuation can exceed $100,000. In such cases, before departure. In a study of international trav-
medical evacuation insurance would cover the cost elers with travel health insurance claims, only
of transportation to a facility where adequate care two-​thirds of claims were fully met. Preexisting ill-
can be provided. Medical evacuation companies ness and poor documentation were the main rea-
may have better resources and experience in some sons for refusal. Travelers with medical conditions
parts of the world than others; travelers may want should choose a medical assistance company
to ask about a company’s resources in a given area, that allows them to store their medical his-
especially if planning a trip to remote destinations. tory before departure, so it can be accessed any-
The traveler should scrutinize all policies before pur- where. Travelers should carry a letter from their
chase, looking for those that provide the following: health care provider listing their medical condi-
tions and current medications (including their
• Arrangements with hospitals to guarantee generic names), written in the local language if
payments directly
possible. Those with cardiac disease should carry
• Assistance via a 24-​hour physician-​backed a copy (paper or electronic) of their most recent
support center (critical for medical evacua- ECG. They should also pack all medications in
tion insurance) their original bottles, checking beforehand with


the destination’s embassy to ensure that none are Before travel:

considered illegal in the destination country.
• Scrutinize the traveler’s domestic health
insurance policy to see what medical services
SPECIAL CONSIDERATIONS FOR may or may not be covered abroad.
The Social Security Medicare program does not • Consider travel, travel health, and medical
provide coverage for medical costs outside the evacuation insurance.
2 United States, except in limited circumstances.
Some Medigap (Medicare supplement insurance)
• Locate medical services in areas that the trav-
eler plans to visit and carry this information
plans may provide limited coverage for emergency
with them on their trip.
care abroad. As with all travelers, Medicare bene-
ficiaries should examine their coverage carefully During travel:
and supplement it with additional travel health
insurance, as needed.
• Carry copies of insurance policy identity
cards, including any supplemental insur-
ance purchased for a trip, and insurance
The following checklist can guide an insurance • Retain copies of all bills and receipts for medi-
discussion before travel. cal care received abroad.

1. American Association of Retired Persons, Education and 4. Leggat PA, Leggat FW. Travel insurance claims
Outreach. Overview of Medicare supplemental insur- made by travelers from Australia. J Travel Med. 2002
ance. Washington, DC: American Association of Retired Mar-​Apr;9(2):59–​65.
Persons; 2010 [cited 2016 Mar. 8]; Available from: http://​ 5. Teichman PG, Donchin Y, Kot RJ. International
www.aarp.org/​health/​medicare-​insurance/​info-​10-​2008/​ aeromedical evacuation. N Engl J Med. 2007 Jan
overview_​medicare_​supplemental_​insurance.html. 18;356(3):262–​70.
2. Centers for Medicare and Medicaid Services. Medicare 6. US Department of State. Insurance Providers for
coverage outside the United States. Baltimore: CMS; Overseas Coverage. Washington, DC: US Department
2016 [cited 2016 Mar. 8]; Available from: https://​www. of State; 2016 [cited 2016 Sep. 22]; Available from:
medicare.gov/​Pubs/​pdf/​11037.pdf. https://​travel.state.gov/​content/​passports/​en/​go/​
3. Leggat PA, Carne J, Kedjarune U. Travel insurance and health/​insurance-​providers.html.
health. J Travel Med. 1999 Dec;6(4):243–​8.


3 19

Infectious Diseases
Related to Travel
Jennifer R. Cope

INFECTIOUS AGENT immunocompromised, or receiving corticoste-

The protozoan parasite Entamoeba histolytica, roids; associations with diabetes and alcohol use
possibly other Entamoeba spp. have also been reported.


oral route, either directly by person-​ to-​ Most patients have a gradual illness onset days or
person contact (such as by diaper-​changing or weeks after infection. Symptoms include cramps,
sexual practices) or indirectly by eating or drink- watery or bloody diarrhea, and weight loss and
ing fecally contaminated food or water. may last several weeks. Occasionally, the para-
site may spread to other organs (extraintestinal
EPIDEMIOLOGY amebiasis), most commonly the liver. Amebic
Amebiasis is distributed worldwide, particularly in liver abscesses may be asymptomatic, but most
the tropics, most commonly in areas of poor san- patients present with fever and right upper quad-
itation. Long-​term travelers (duration >6 months) rant abdominal pain, usually in the absence of
are significantly more likely than short-​term trav- diarrhea.
elers (duration <1  month) to develop E.  histo­
lytica infection. Immigrants and refugees from DIAGNOSIS
these areas are also at risk. People at higher risk Microscopy does not distinguish between E.  his­
for severe disease are those who are pregnant, tolytica (known to be pathogenic), E. bangladeshi,


E. dispar, and E. moshkovskii. E. dispar and E. mos­ or tinidazole should be followed by treatment
hkovskii have historically been considered non- with iodoquinol or paromomycin. Asymptomatic
pathogenic, but evidence is mounting that patients infected with E.  histolytica should also
E.  moshkovskii can cause illness; E.  bangladeshi be treated with iodoquinol or paromomycin,
has only recently been identified, so its pathogenic because they can infect others and because 4%–​
potential is not well understood. More specific 10% develop disease within a year if left untreated.
tests such as EIA or PCR are needed to confirm the
diagnosis of E.  histolytica. Additionally, serologic PREVENTION
tests can help diagnose extraintestinal amebiasis. Food and water precautions (see Chapter 2, Food
& Water Precautions) and hand hygiene. Avoid
For symptomatic intestinal infection and extrain-
fecal exposure during sexual activity.

testinal disease, treatment with metronidazole CDC website: www.cdc.gov/​parasites/​amebiasis

1. Choudhuri G, Rangan M. Amebic infection 4. Lachish T, Wieder-​Finesod A, Schwartz E.
in humans. Indian J Gastroenterol. 2012 Amebic Liver Abscess in Israeli Travelers: A
Jul;31(4):153–​62. Retrospective Study. Am J Trop Med Hyg. 2016
2. Cordel H, Prendki V, Madec Y, Houze S, May 4;94(5):1015–​9.
Paris L, Bouree P, et al. Imported amoebic 5. Shimokawa C, Kabir M, Taniuchi M, Mondal D,
liver abscess in France. PLoS Negl Trop Dis. Kobayashi S, Ali IK, et al. Entamoeba moshkovskii is
2013;7(8):e2333. associated with diarrhea in infants and causes diarrhea
3. Heredia RD, Fonseca JA, Lopez MC. Entamoeba and colitis in mice. J Infect Dis. 2012 Sep 1;206(5):744–​51.
moshkovskii perspectives of a new agent to be con- 6. Ximenez C, Moran P, Rojas L, Valadez A, Gomez A,
sidered in the diagnosis of amebiasis. Acta Trop. 2012 Ramiro M, et al. Novelties on amoebiasis: a neglected
Sep;123(3):139–​45. tropical disease. J Glob Infect Dis. 2011 Apr;3(2):166–​74.

LeAnne M. Fox, Francisca Abanyie

Angiostrongylus cantonensis, rat lungworm, a Most described cases have occurred in Asia and
nematode parasite. the Pacific Basin (such as in parts of Thailand,
Taiwan, mainland China, the Hawaiian Islands,
TRANSMISSION and other Pacific Islands); however, cases have
Various species of rats are the definitive hosts of been reported in many areas of the world, includ-
the parasite, known as the rat lungworm. Rats can ing the Caribbean.
infect only snails and slugs, which are the inter-
mediate hosts. Transmission to humans occurs CLINICAL PRESENTATION
by consuming infected snails or slugs or contam- Incubation period is typically 1–​ 3 weeks but
inated raw produce or vegetable juices. Infective ranges from 1  day to >6 weeks. A.  cantonensis is
larvae have also been found in freshwater shrimp, considered the most common infectious cause
crabs, and frogs. of eosinophilic meningitis in humans. Common



manifestations include headache, photophobia, corticosteroids to limit inflammation. No antihel-

stiff neck, nausea, vomiting, fatigue, and body minthic drugs have been proven to be effective in
aches. Abnormal skin sensations (such as tingling treatment.
or painful feelings) are more common than in
other types of meningitis. A low-​grade fever might PREVENTION
be noted. Symptoms are usually self-​limited but Food and water precautions, particularly:
may persist for weeks or months. Severe cases can
be associated with paralysis, blindness, or death.
• Avoid eating raw or undercooked snails, slugs,
and other possible hosts.
DIAGNOSIS • Eat raw produce, such as lettuce, only if it
Typically presumptive, on the basis of clinical and
epidemiologic criteria in people with otherwise
has been thoroughly washed or treated with
bleach. Such measures might provide some
unexplained eosinophilic meningitis. PCR testing protection but may not eliminate the risk.
of cerebrospinal fluid is available from CDC (www.
cdc.gov/​dpdx; 404-​718-​4745; parasites@cdc.gov).
• Wear gloves (and wash hands) if snails or
slugs are handled.
Serum antibody testing may be available in refer-
ence laboratories. CDC website: www.cdc.gov/​parasites/
The larvae die spontaneously and supportive care
usually suffices, including analgesics for pain and

1. Chotmongkol V, Sawadpanitch K, Sawanyawisuth K, Angiostrongylus cantonensis infection in Hawaii: clinical
Louhawilai S, Limpawattana P. Treatment of eosin- characteristics and potential exposures. Am J Trop Med
ophilic meningitis with a combination of prednis- Hyg. 2011 Oct;85(4):685–​9 0.
olone and mebendazole. Am J Trop Med Hyg. 2006 3. Wang QP, Lai DH, Zhu XQ, Chen XG, Lun ZR.
Jun;74(6):1122–​4. Human angiostrongyliasis. Lancet Infect Dis. 2008
2. Hochberg NS, Blackburn BG, Park SY, Sejvar JJ, Effler PV, Oct;8(10):621–​30.
Herwaldt BL. Eosinophilic meningitis attributable to

Kate Hendricks Walters, Rita M. Traxler, Chung K. Marston

INFECTIOUS AGENT meat, hides, wool, or items made with those

Aerobic, gram-​ positive, encapsulated, spore-​ products, such as drum heads or wool cloth-
forming, nonmotile, nonhemolytic, rod-​ shaped ing. Anthrax  has  a variety of presentations—​
bacterium Bacillus anthracis. cutaneous, gastrointestinal, injection, inhalation,
and meningitis—​and most are synonymous with
TRANSMISSION their mode of transmission. The exception is men-
Worldwide, most B.  anthracis is transmitted by ingitis, which may complicate any of the other
direct contact with B.  anthracis–​infected ani- types. It may also occur with no obvious portal of
mals, their carcasses, or contaminated products entry, in which case it is called primary anthrax
from infected animals. Such products include meningitis.


Introducing spores through the skin can life-​threatening or fatal disease is possible: cases
result in cutaneous anthrax; abrasion of the of cutaneous (4), gastrointestinal (1), and inhala-
skin increases susceptibility. Eating meat from tion (3) anthrax have been reported among peo-
infected animals can result in gastrointestinal ple who have handled, played, or made drums or
anthrax. Since 2000, injecting, and possibly smok- who have been in the same place as people partic-
ing and snorting, heroin has been associated with ipating in these activities.
B.  anthracis soft-​tissue infections in intravenous Severe soft tissue infections, including cases
drug users in northern Europe. Inhaling spores with sepsis and systemic infection, have been
aerosolized during work with contaminated reported in drug users in northern Europe and are
materials such as hides or wool can result in inha- suspected to be due to recreational use of heroin
3 lation anthrax.
Anthrax in humans is not generally considered
contaminated with B.  anthracis spores. No asso-
ciated cases have been identified in people who
to be contagious; person-​to-​person transmission have not taken heroin. To date, no heroin has been
of cutaneous anthrax has rarely been reported. found to be contaminated with B. anthracis spores.
Inhalation exposure was historically associ-
EPIDEMIOLOGY ated with the industrial processing of hides or
Anthrax is a zoonotic disease that primarily affects wool (hence, “woolsorters’ disease”). However,
herbivores such as cattle, sheep, goats, antelope, in more recent decades it has also resulted from
and deer, which become infected by ingesting bioterrorism. Occasional anthrax cases have
contaminated vegetation, water, or soil; humans occurred in the United States and elsewhere in
are generally incidental hosts. Anthrax is most which the exposure source remains unidentified.
common in agricultural regions in Central and
South America, sub-​Saharan Africa, Central and CLINICAL PRESENTATION
Southwestern Asia, and Southern and Eastern Cutaneous anthrax usually develops 1–​ 7  days
Europe. Although outbreaks occur most years in after exposure, but incubations as long as 17 days
livestock and wild herbivores in the United States have been reported. Before antimicrobial ther-
and Canada, human anthrax is now rare in both of apy, almost a quarter of patients with cutane-
these countries. ous anthrax died. The case-​fatality ratio is <2%
Worldwide, the most commonly reported form with antimicrobial therapy. Cutaneous anthrax
(95%–​99%) of anthrax in humans is cutaneous is characterized by localized itching followed by
anthrax. Outbreaks of cutaneous and gastrointes- the development of a painless papule, which turns
tinal anthrax have been associated with handling vesicular and enlarges, ulcerates, and develops
infected animals and butchering and consuming into a depressed black eschar within 7–​10  days
meat from those animals. Most of these outbreaks of the initial lesion. The head, neck, forearms,
are reported from endemic areas of Asia and Africa. and hands are the most commonly affected sites.
A single case of travel-​associated anthrax has Edema usually surrounds the lesion, sometimes
been reported. In 2006, a case of cutaneous anthrax with secondary vesicles, hyperemia, and regional
was reported in a woman who traveled with a lymphadenopathy. Patients may have malaise and
small group of tourists to Namibia, Botswana, and headache; about a third are febrile.
South Africa. Although she had no direct contact Gastrointestinal anthrax usually develops 1–​
with animals, another group member handled 1 7  days after consumption of contaminated meat;
or more animal carcasses and shortly afterward however, incubations as long as 16 days have been
helped her clean an abrasion on her finger, which reported. More than half of cases die if untreated;
was later the site of the anthrax lesion. with treatment, the case-​ fatality ratio is <40%.
Additional cases have occurred from play- There are 2 main types, oropharyngeal and intes-
ing or handling drums made with contaminated tinal. Fever and chills are usual with either. The
goat hides that were imported from anthrax-​ oropharyngeal type is characterized by severe
endemic countries. Although the risk of acquir- sore throat, difficulty swallowing, swelling of the
ing anthrax from these drums appears to be low, neck, and regional lymphadenopathy; airway



compromise can occur. Symptoms of the intestinal diagnosis. Confirmatory testing, including iso-
type include nausea, vomiting, and diarrhea, which late identification, antigen detection in tissues,
may be bloody; marked ascites may develop. Shock or quantitative serology, should be performed in
and death may occur within 2–​5 days of onset. the United States by the state health department
Cases of anthrax in injection drug users usually or Laboratory Response Network laboratories, or
develop within 1–​4  days of exposure; more than internationally by the relevant national reference
a quarter of the confirmed cases die. Cases pres- laboratory. Guidelines for collecting and submit-
ent with severe soft tissue infection manifested ting clinical specimens for testing and algorithms
by swelling, erythema, and excessive bruising at for laboratory diagnosis can be found at www.cdc.
the injection site; pain may be less than would be gov/​anthrax/​lab-​testing/​index.html. Specimens
anticipated for the degree of swelling. In approx-
imately a third of cases, the localized symptoms
for culture should be collected before initiating
antimicrobial therapy. Anthrax is a nationally
are accompanied by signs of sepsis. notifiable disease.
Inhalation anthrax usually develops within a Diagnostic procedures for inhalation anthrax
week after exposure, but the incubation period include thoracic imaging studies to detect a wid-
may be prolonged (up to 2 months). Fatality ratios ened mediastinum or pleural effusion. Unless
before 2001 were 90%; since then, they have been contraindicated, lumbar puncture should be per-
45%. Initially, most patients have constitutional formed to rule out meningitis in all patients with
symptoms such as fever, chills, and fatigue, which systemic illness.
may be accompanied by cough, making inhala-
tion anthrax difficult to distinguish from influ- TREATMENT
enza and community-​acquired pneumonia. This Naturally occurring localized or uncomplicated
is often described as the prodromal period. Over cutaneous anthrax can be treated with 7–​10 days
the next day or so, chest pain develops in about of a single oral antimicrobial agent. First-​ line
half of patients, and nonthoracic complaints such agents include ciprofloxacin or an equivalent flu-
as nausea, vomiting, headache, and diaphoresis oroquinolone or doxycycline; clindamycin is an
develop in approximately one-​third. Upper respi- alternative, as are penicillins if the isolate is peni-
ratory tract symptoms occur in only a quarter cillin susceptible.
of patients, and myalgias are rare. Altered men- Treatment recommendations for systemic dis-
tal status or shortness of breath generally brings ease are available at wwwnc.cdc.gov/​eid/​article/​
patients to the attention of the medical establish- 20/​2/​13-​0687_​intro. Additional recommendations
ment and heralds the fulminant phase of illness. to prevent or treat anthrax in pregnant, post-
Anthrax meningitis may develop from hema- partum, and lactating women are available at
togenous spread of any of the clinical forms wwwnc.cdc.gov/​eid/​article/​20/​2/​13-​0611_​intro.
of anthrax, or it may occur alone; half of all
reported cases are sequelae of cutaneous anthrax. PREVENTION
Although anthrax meningitis is usually fatal, sur- The CDC published updated recommendations
vival is significantly more likely if the patient in 2010 for preexposure use of anthrax vaccine
receives multiple antimicrobials that include a and for postexposure management of previously
bactericidal agent. unvaccinated people (www.cdc.gov/​ mmwr/​
preview/​mmwrhtml/​rr5906a1.htm). Vaccination
DIAGNOSIS against anthrax is not recommended for travelers.
Laboratory diagnosis depends on bacterial cul- To prevent anthrax, travelers should:
ture and isolation of B. anthracis; detection of bac-
terial DNA, antigens, or toxins; or detection of a
• Avoid direct or indirect contact with car-
casses of animals in anthrax-​endemic regions.
host immune response to B.  anthracis. Anthrax
lethal toxin can be detected in acute-​phase serum, • Not eat meat from animals that were not
while serologic testing of host antibody responses inspected by health officials and found to be
requires acute-​and convalescent-​phase sera for healthy at the time of slaughter.


• Not import animal products, trophies, or • USADA regulations at www.aphis.usda.gov/​

souvenirs from anthrax-​endemic regions aphis/​ourfocus/​importexport
that are prohibited by either the CDC or the
United States Department of Agriculture
• World Organisation for Animal Health (OIE)
Terrestrial Animal Health Code at www.
(USDA). A map of endemic areas can be found
at www.cdc.gov/​anthrax/​specificgroups/​
Animal-​hide drum owners or players should
No tests are available to determine if animal prod-
report any unexplained fever or new skin lesions
ucts are free of contamination with B.  anthracis
to their health care provider and describe any
3 spores. Additional information regarding import
regulations may be found in the following
recent contact with animal-​hide drums.
CDC website: www.cdc.gov/​anthrax
• Chapter 6, Taking Animals & Animal Products
across International Borders

1. Bales ME, Dannenberg AL, Brachman PS, Kaufmann 6. Hanczaruk M, Reischl U, Holzmann T, Frangoulidis
AF, Klatsky PC, Ashford DA. Epidemiologic response D, Wagner DM, Keim PS, et al. Injectional anthrax in
to anthrax outbreaks: field investigations, 1950–​2001. heroin users, Europe, 2000–​2012. Emerg Infect Dis. 2014
Emerg Infect Dis. 2002 Oct;8(10):1163–​74. Feb;20(2):322–​3.
2. CDC. Anthrax contamination of Haitian goatskin 7. Hendricks KA, Wright ME, Shadomy SV, Bradley JS,
products. MMWR Morb Mortal Wkly Rep. 1981 July Morrow MG, Pavia AT, et al. Centers for disease control
17;30(27):338. and prevention expert panel meetings on prevention
3. CDC. Gastrointestinal anthrax after an animal-​hide and treatment of anthrax in adults. Emerg Infect Dis.
drumming event—​New Hampshire and Massachusetts, 2014 Feb;20(2).
2009. MMWR Morb Mortal Wkly Rep. 2010 Jul 8. Meaney-​Delman D, Zotti ME, Creanga AA, Misegades
23;59(28):872–​7. LK, Wako E, Treadwell TA, et al. Special considerations
4. Eurosurveillance editorial team. Probable for prophylaxis for and treatment of anthrax in preg-
human anthrax death in Scotland. Euro Surveill. nant and postpartum women. Emerg Infect Dis. 2014
2006;11(8):E060817.2. Feb;20(2).

5. Griffith J, Blaney D, Shadomy S, Lehman M, Pesik 9. Van den Enden E, Van Gompel A, Van Esbroeck M.
N, Tostenson S, et al. Investigation of inhalation Cutaneous anthrax, Belgian traveler. Emerg Infect Dis.
anthrax case, United States. Emerg Infect Dis. 2014 2006 Mar;12(3):523–​5.

D. Scott Schmid

INFECTIOUS AGENT B virus is commonly found among macaques, a

Macacine herpesvirus I, or B virus, is an envel- genus of Old World monkeys.
oped, double-​ stranded DNA virus in the fam-
ily Herpesviridae, genus Simplexvirus. B virus is TRANSMISSION
also commonly referred to as herpes B, monkey Transmission is typically caused by bites or
B virus, herpesvirus simiae, and herpesvirus B. scratches from an infected macaque but may also



occur through contact with body fluids or tissues National B Virus Resource Center at Georgia
of an infected macaque. A single case of human-​ State University. Detection of viral DNA by B
to-​human spread has been documented, in which virus PCR from clinical specimens is the stan-
a woman became infected through direct contact dard for diagnosis of infection. Detection of
with the lesions of her infected spouse. B virus–​specific antibodies in serum is also diag-
nostic. Culture is generally unsuccessful as the
EPIDEMIOLOGY virus is unlikely to remain viable during tran-
Macaques are the natural reservoir for B virus sit or after being frozen and thawed. For more
infection. No other primates are known to information, see www2.gsu.edu/​ ~wwwvir/​
carry any risk of B virus infection unless they index.html.
have become infected by contact with infected
macaques. Although B virus infections in TREATMENT
macaques are usually asymptomatic or cause For any suspected exposure, immediate first
only mild disease, approximately 70% of untreated aid is crucial. The wound should be cleansed
infections in humans are fatal. People at risk by thoroughly washing and scrubbing the area
for B virus infection are veterinarians, laboratory with soap, concentrated detergent solution,
workers, and others who have close contact with povidone-​iodine, or chlorhexidine and water.
Old World macaques or monkey cell cultures, The wound should then be irrigated with
but infections in humans are rare. Since B virus running water for 15–​20 minutes. For urine
was identified in 1932, fewer than 50 cases of splashes to the eyes, repeated flushes of the
human infection have been documented. eyes should be performed for 15 minutes with
sterile saline solution or water. Specimens for
CLINICAL PRESENTATION diagnostic testing should not be obtained
Disease onset typically occurs within 1 month from wound sites before washing because
of exposure, although the actual incubation doing so may force virus more deeply into
period can be as short as 3–​7  days. The first the wound.
signs of disease typically include influenza- Antiviral therapy is recommended as postex-
like symptoms ( fever, headache, myalgias) and posure prophylaxis in high-​risk exposures (see
sometimes vesicular lesions near the expo- www.cdc.gov/​herpesbvirus/​firstaid-​treatment.
sure site. Localized neurologic symptoms such html). When recommended, the first choice of
as pain, numbness, or itching may occur near drug for postexposure prophylaxis is valacyclovir
the wound site. Lymphadenitis, lymphangi- and an alternative is acyclovir. If B virus infection
tis, nausea, vomiting, and abdominal pain is diagnosed, treatment consists of intravenous
may also occur. Spread of the infection to the acyclovir or ganciclovir, depending on whether
central nervous system (CNS) causes acute CNS symptoms are present.
ascending encephalomyelitis. Most patients
with CNS involvement die despite antivi- PREVENTION
ral therapy and supportive care, and those Adhering to laboratory and animal facility pro-
who survive usually suffer serious neurologic tocols will reduce the risk of B virus transmis-
sequelae. Respiratory failure associated with sion among laboratory workers. Visitors to parks
ascending paralysis is the most common cause and other tourist destinations (such as certain
of death. religious temples) with free-​roaming macaques
should avoid contact with the animals (including
DIAGNOSIS feeding or petting them).
In the United States, diagnostic testing of
human specimens is performed only at the CDC website: www.cdc.gov/​herpesbvirus


1. CDC. Notice to readers: occupational safety and health (Cercopithecine herpesvirus 1). Clin Infect Dis. 2002 Nov
in the care and use of nonhuman primates. MMWR 15;35(10):1191–​203.
Recomm Rep. 2003;52(38):920. 4. Health NIfOSa. Hazard ID 5—​C ercopithicine
2. Chosewood LC WD. Section VIII–​Agent summary herpesvirus 1 (B virus) infection resulting from
statements. In: Chosewood LC WD, editor. Biosafety ocular exposure. Atlanta: CDC; 1999 [cited 2016
in microbiological and biomedical laboratories. 5th ed. Sep. 21]. Available from: http://​www.cdc.gov/​niosh/​
Washington, DC: US Department of Health and Human docs/​9 9-​100/​.
Services; 2009. pp. 205–​8. 5. Veterinarians NAoSPH. Compendium of mea-
3. Cohen JI, Davenport DS, Stewart JA, Deitchman S, sure to prevent disease associated with animals

Hilliard JK, Chapman LE, et al. Recommendations in public settings, 2009. MMWR Recomm Rep.
for prevention of and therapy for exposure to B virus 2009;58(RR-​0 5):1–​15.

Christina A. Nelson

INFECTIOUS AGENT populations that do not have access to proper

Gram-​negative bacteria in the genus Bartonella. hygiene, such as refugees and the homeless.
Human illness is primarily caused by Bartonella Carrión disease has limited geographic distribu-
henselae (cat-​ scratch disease [CSD]), B.  quin­ tion; transmission occurs in the Andes Mountains
tana (trench fever), and B.  bacilliformis (Carrión at 1,000–​ 3,000 m (3,281–​
9,843 ft) elevation in
disease). A  variety of Bartonella spp. can cause Peru, Colombia, and Ecuador; sporadic cases
culture-​negative endocarditis; other clinical syn- have also been reported in Bolivia, Chile, and
dromes due to Bartonella spp. have also been possibly Guatemala. Most cases are reported in
reported. For example, in 2007, a newly recog- Peru. Short-​term travelers to endemic areas are
nized species of Bartonella (B.  rochalimae) was likely at low risk.
identified in a traveler with fever and splenomeg-
aly who had visited Peru. CLINICAL PRESENTATION
CSD typically manifests as a papule or pustule at
TRANSMISSION the inoculation site and enlarged, tender lymph
B. henselae is contracted through scratches from nodes that develop proximal to the inoculation site
domestic or feral cats, particularly kittens. Direct 1–​3 weeks after exposure. B. henselae infection may
transmission to humans by the bite of infected cat also cause prolonged fever, follicular conjunctivitis,
fleas is likely but has not yet been proven. B. quin­ neuroretinitis, or encephalitis. Trench fever symp-
tana is transmitted by the human body louse. toms include fever, headache, transient rash, and
B.  bacilliformis is transmitted by infected sand bone pain (mainly in the shins, neck, and back).
flies (genus Lutzomyia). Some Bartonella spp. can cause subacute
endocarditis, which is often culture-​n egative.
EPIDEMIOLOGY Bacillary angiomatosis (caused by B.  henselae
CSD and trench fever are distributed worldwide. or B. quintana) and peliosis hepatis (caused by
In the United States, CSD is more common in B. henselae) occur primarily in people infected
children, and the incidence peaks from August with HIV. Bacillary angiomatosis may present
through January. Trench fever typically occurs in as skin, subcutaneous, or bone lesions.


4 17

Carrión disease has 2 distinct phases: an acute TREATMENT

phase (Oroya fever) characterized by fever, myal- Most cases of CSD eventually resolve without
gia, headache, and anemia and an eruptive phase treatment, but a small percentage of people will
(verruga peruana) characterized by red-​to-​purple develop disseminated disease with severe com-
nodular skin lesions. plications. The use of antibiotics to shorten the
course of disease is debated, although azith-
DIAGNOSIS romycin speeds the decrease in lymph node
CSD can be diagnosed clinically in patients with volume.
typical presentation and a compatible expo- Various antibiotics are effective against
sure history. Serology can confirm the diagnosis, Bartonella infections, and regimens including
although cross-​reactivity may limit interpretation
in some circumstances. B.  henselae may also be
agents such as tetracyclines, fluoroquinolones,
trimethoprim-​sulfamethoxazole, rifampin, and
detected by PCR or culture of lymph node aspi- aminoglycosides have been used. Recommended
rates by using special techniques. regimens and duration of treatment vary by clin-
Trench fever can be diagnosed by serology or ical disease.
blood culture for B.  quintana. PCR may also aid
the diagnosis of disseminated Bartonella infec- PREVENTION
tions when performed by clinical laboratories Avoid rough play with cats, particularly strays
using validated methods. Endocarditis caused and kittens, to prevent scratches. This is espe-
by Bartonella spp. can be diagnosed by elevated cially important for immunocompromised peo-
serology of the patient and by PCR or culture of ple. Wash hands promptly after handling cats.
excised heart valve tissue. Protect against bites of sand flies and body lice
Oroya fever is typically diagnosed via blood (see Chapter  2, Protection against Mosquitoes,
culture or direct observation of the bacilli in Ticks, & Other Arthropods). Flea control for cats
peripheral blood smears, though sensitivity of is also important.
these methods is low. PCR and serologic testing
may also aid diagnosis. CDC website: www.cdc.gov/​bartonella

1. Bass JW, Freitas BC, Freitas AD, Sisler CL, Chan DS, 4. Fournier PE, Thuny F, Richet H, Lepidi H, Casalta JP,
Vincent JM, et al. Prospective randomized double blind Arzouni JP, et al. Comprehensive diagnostic strategy
placebo-​controlled evaluation of azithromycin for treat- for blood culture-​negative endocarditis: a prospec-
ment of cat-​scratch disease. Pediatr Infect Dis J. 1998 tive study of 819 new cases. Clin Infect Dis. 2010 Jul
Jun;17(6):447–​52. 15;51(2):131–​4 0.
2. Eremeeva ME, Gerns HL, Lydy SL, Goo JS, Ryan ET, 5. Maguina C, Gotuzzo E. Bartonellosis. New and old.
Mathew SS, et al. Bacteremia, fever, and splenomegaly Infect Dis Clin North Am. 2000 Mar;14(1):1–​22, vii.
caused by a newly recognized Bartonella species. N Engl 6. Rolain JM, Brouqui P, Koehler JE, Maguina C,
J Med. 2007 Jun 7;356(23):2381–​7. Dolan MJ, Raoult D. Recommendations for treatment
3. Florin TA, Zaoutis TE, Zaoutis LB. Beyond cat scratch of human infections caused by Bartonella species.
disease: widening spectrum of Bartonella henselae infec- Antimicrob Agents Chemother. 2004 Jun;48(6):
tion. Pediatrics. 2008 May;121(5):e1413–​25. 1921–​33.



Maria E. Negron, Rebekah Tiller, Grishma A. Kharod

INFECTIOUS AGENT marrow, or other clinical specimen is performed,

Facultative, intracellular, gram-​ negative cocco- the laboratory must be informed that Brucella
bacilli; known human pathogens include Brucella is suspected, as the culture takes longer to grow
abortus, B. melitensis, B. suis, and B. canis. and laboratory personnel require additional per-
sonnel protective equipment when handling
cultures. A serum agglutination test is the most
Most commonly through consumption of unpas- common serologic approach, but other serol-
teurized dairy products or undercooked meat ogy assays (including ELISA) and PCR have been
from infected animals and direct contact with used to make a diagnosis. Brucellosis is a nation-
infected animals, especially those that have ally notifiable disease.
recently given birth. Since wildlife can be reser-
voirs for Brucella spp., hunting can be a risk for TREATMENT
exposure as well. Brucella can enter the body via Doxycycline, rifampin, trimethoprim-​ sulfame-
skin wounds, mucous membranes, or inhalation. thoxazole, fluoroquinolones, aminoglycosides,
Person-​to-​person transmission is rare. and other agents have been used in various com-
binations for a minimum of 6–​8 weeks. If bacte-
EPIDEMIOLOGY ria localize in organs and tissues and cause focal
High-​risk regions include the Mediterranean infection, surgical drainage could be indicated.
Basin, South and Central America, Eastern Late diagnosis or inappropriate therapy can result
Europe, Asia, Africa, and the Middle East. In these in chronic disease or relapse.
areas, brucellosis is primarily enzootic in cattle,
sheep, and goat populations, as well as feral swine. PREVENTION
Avoid unpasteurized dairy products and under-
CLINICAL PRESENTATION cooked meat. Wear protective equipment when
Incubation period is usually 2–​4 weeks (range, dressing or butchering wild animals potentially
5  days to 5  months). Initial presentation is non- infected with Brucella spp. In clinical microbi-
specific, including fever, muscle aches, fatigue, ology laboratories, if Brucella spp. is suspected,
headache, and night sweats. Focal infections are culture isolates should be handled under BSL-​3
common and can affect most organs in the body. conditions.

DIAGNOSIS CDC website: www.cdc.gov/​brucellosis

Blood culture is the diagnostic gold standard, but
is not always positive. If culture of blood, bone

1. Al Dahouk S, Nockler K. Implications of laboratory 3. Arnow PM, Smaron M, Ormiste V. Brucellosis in a group
diagnosis on brucellosis therapy. Expert Rev Anti Infect of travelers to Spain. JAMA. 1984 Jan 27;251(4):505–​7.
Ther. 2011 Jul;9(7):833–​45. 4. Memish ZA, Balkhy HH. Brucellosis and international
2. Ariza J, Bosilkovski M, Cascio A, Colmenero JD, Corbel travel. J Travel Med. 2004 Jan-​Feb;11(1):49–​55.
MJ, Falagas ME, et al. Perspectives for the treatment of 5. Organization WH. Brucellosis. Geneva: World Health
brucellosis in the 21st century: the Ioannina recommen- Organization; 2012 [cited 2016 Sep. 21]. Available from:
dations. PLoS Med. 2007 Dec;4(12):e317. http://​www.who.int/​zoonoses/​diseases/​brucellosis/​en/​.


4 19

6. Pappas G, Papadimitriou P, Akritidis N, Christou L, of raw camel milk. Travel Med Infect Dis. 2016
Tsianos EV. The new global map of human brucellosis. May-​Jun;14(3):255–​6 0.
Lancet Infect Dis. 2006 Feb;6(2):91–​9. 8. Yousefi-​Nooraie R, Mortaz-​Hejri S, Mehrani M,
7. Rhodes HM, Williams DN, Hansen GT. Invasive human Sadeghipour P. Antibiotics for treating human brucello-
brucellosis infection in travelers to and immigrants sis. Cochrane Database Syst Rev. 2012;10:Cd007179.
from the Horn of Africa related to the consumption

Aimee L. Geissler, Barbara E. Mahon, Collette Fitzgerald
INFECTIOUS AGENT ( frequently bloody), abdominal pain, fever, and
Infection is caused by gram-​ negative, spiral-​ occasionally nausea and vomiting. More severe
shaped microaerophilic bacteria of the family illness can occur, including dehydration, blood-
Campylobacteriaceae. Most infections are caused stream infection, and symptoms mimicking acute
by Campylobacter jejuni; at least 18 other species, appendicitis or ulcerative colitis. People with cam-
including C. coli, also cause infection. C. jejuni and pylobacteriosis are at increased risk for postinfec-
C. coli are carried normally in the intestinal tracts tious complications, including reactive arthritis
of many domestic and wild animals. (2%–​5% of patients), irritable bowel syndrome
(9%–​ 13%), and Guillain-​ Barré syndrome (GBS)
TRANSMISSION (0.1%). C.  jejuni is the most frequently observed
The major modes of transmission include eat- antecedent bacterial infection in cases of GBS;
ing contaminated foods (especially undercooked symptoms usually begin 1–​3 weeks after the onset
chicken and foods contaminated by raw chicken), of Campylobacter enteritis.
drinking contaminated water or milk (unpasteur-
ized milk, most commonly), and having contact DIAGNOSIS
with animals, particularly farm animals such as Diagnosis is traditionally based on isolation of the
cows and chickens, as well as domestic cats and organism from stool specimens or rectal swabs by
dogs. Campylobacter can also be transmitted from using selective media incubated under reduced
person to person by the fecal-​oral route. oxygen tension at 42°C (107.6°F) for 72 hours.
Visualization of motile and curved, spiral, or S-​
EPIDEMIOLOGY shaped rods by stool phase-​contrast or dark-​field
Campylobacter is a leading cause of bacterial diar- microscopy can provide rapid presumptive evi-
rheal disease worldwide; in the United States, it dence for Campylobacter enteritis. A stool specimen
is estimated to cause 1.3 million human illnesses should be collected during the acute phase of the
every year. Campylobacter is the most common diarrheal illness and before antibiotic treatment is
laboratory-​confirmed enteric pathogen reported initiated. Because the organism is fastidious, a delay
in travelers returning to the United States from in transporting the specimen will affect the viabil-
every region of the world. The risk of infection is ity of Campylobacter spp. A  laboratory may reject
highest in travelers to Africa and South America, stool samples without preservative that are in tran-
especially in areas with poor restaurant hygiene sit for more than 2 hours. If transport and process-
and inadequate sanitation. The infectious dose is ing are not possible within 2 hours of stool sample
small; <500 organisms can cause disease. collection, s