Who Vacination Requirments and Health Advice

INTERNATIONAL
TRAVEL AND
HEALTH
VACCINATION REQUIREMENTS
AND HEALTH ADVICE
S o m e useful addresses
WORLD HEALTH ORGANIZATION (WHO)

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Regional Offices W H O Regional Office for Europe

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W H O Regional Office for the Americas the Eastern Mediterranean
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INTERNATIONAL TRAVEL AND HEALTH
The information given in this publication is
valid on the date of issue. It should be kept up to
dale with the notes of amendments published in
the Weekly Epidemiological Record.
Any comments or questions concerning this

publication should be addressed to;
Emerging and Other Communicable

Diseases Surveillance and Control
World Health Organization
1211 Geneva 27. Switzerland
World Wide Web access: http://www.who.ch
WHO Library Cataloguing in Publication Data

International travel and health: vaccination requirements and health advice: situation as on
I January 1998.
1. Communicable disease control 2. Travel 3. Vaccination
ISBN 92 4 158023 2 (NLM Classification; WA 110)
ISSN 0254-296X
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@ World Health Organization 1998

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PRINTED IN SWITZERLAND
97/11588- Atar- 18500
CONTENTS
Page
1. Preface.... .................. ....... 7
2. Vaccination requirements 9
2.1 International Health Regulations 9
2.2 Smallpox 10
2.3 Cholera ... 10
2.4 Yellow fever vaccination certificate 10
3. Country list of vaccination certificate requirements and infor-
mation on the malaria situation 17
4. Geographical distribution of potential health hazards to
travellers 43
4.1 Africa 43
4.2 The Americas 45
4.3 Asia 48
4.4 Europe 51
4.5 Oceania 53
5. Health risks and their avoidance 55
5.1 Incidence of the major diseases that may arise from interna-
tional travel 55
5.2 Hazards related to the environment 55
5.2.1 Travel 55
5.2.3 Altitude 57
5.2.4 Heat and humidity 57
5.2.5 Sun .. 58
5.2.6 Insects 58
5.2.7 Other animals 58
5.2.8 Accidents 60
S3 Risks from food and drink 60
5.3.1 General considerations 60
5.3.2 Diarrhoea 62
5.3.3 Viral hepatitis types A and E .. 63
5.4 Sexually transmitted infections, including HIV (AIDS) 65
5.4.1 Immunization of HIV-infected individuals 66
5.5 Malaria 67
5.5.1 General considerations 67
5.5.2 Protective measures against malaria 71
5.5.3 Stand-by emergency treatment 73
5.5.4 Special groups 73
5.5.5 Special situations - multidrug-resistant malaria 76
5.6 Dengue and dengue haemorrhagic fever 78
5.7 Tuberculosis.... 85
5.8 Vaccinations 85
5.9 Special situations 87
5.9.1 Extended travel 87
5.9.2 Pregnancy 87
5.9.3 Children 88
5.9.4 Chronic diseases and other health problems 88
5.9.5 The disabled.. 89
6. Miscellaneous........................................................................ 91
6.1 Blood transfusion 91
6.2 Medical kit for travellers •
91
6.3 Medical examination after travel 91
6.4 Note for travel organizers 92
Annex 1. Laboratories approved by WHO for the production of
yellow fever vaccine 93
Annex 2. Some relevant WHO publications 94
Indexes 99
LIST OF MAPS Page
Map 1. Yellow fever endemic zone in Africa 14

Map 2. Yellow fever endemic zone in the Americas 15
Map 3. Recommendations for malaria drug prophylaxis by
area - 1998 68-69
1. PREFACE
In recent years there has been a tremendous increase in the number of
people travelling between the various countries of the world, and. in view of
this, it is particularly important that health authorities are kept up to date on
the changing immunization requirements and other prophylactic measures
for travellers intending to go abroad.
There has been an increase not only in the volume but also in the speed of
travel; thus with modern air transport, travellers infected in one country may
still feel quite well when they arrive in another, if they are still only in the
early stages of an illness. In these circumstances, the surveillance and other
precautions taken at ports of arrival are often ineffective. Nowadays, also,
tourists are able to penetrate areas of the world that were previously infre-
quently visited and these places may present hazards for which the inexpe-
rienced tourist is ill prepared.
This booklet is addressed to national health administrations that have the
responsibility for providing advice on the health hazards of international
travel, and to the practising physicians, travel agencies, shipping companies,
airline operators, and other bodies who are called upon to give advice in
individual cases. In addition to summarizing the vaccination requirements of
individual countries, the booklet covers certain health hazards to which the
traveller may be exposed and indicates the areas in which these hazards are
most likely to occur. This is particularly important with malaria, which has
continued to cause serious problems in recent years, it also recommends
precautions that the wise traveller should take when visiting unfamiliar
places.
This booklet focuses essentially on prevention. To a lesser extent, the
epidemiological information it contains may also be used for diagnostic
purposes.
2. VACCINATION REQUIREMENTS
2.1 International Health Regulations
The purpose of the International Health Regulations, adopted by the

Twenty-second World Health Assembly in 1969,' is to help prevent the
international spread of diseases and. in the context of international travel, to
do so with the minimum of inconvenience to the passenger. This requires
international collaboration in the detection and reduction or elimination of
the sources from which infection spreads rather than attempts to prevent the
introduction of disease by legalistic barriers that over the years have proved
to be ineffective. Ultimately, however, the risk of an infective agent becom
ing established in a country is determined by the quality of the national
epidemiological services and, in particular, by the day-to-day national health
and disease surveillance activities and the ability to implement prompt and
effective control measures.
No regulations can be expected to foresee every disease eventuality and, in
certain situations, diseases and conditions other than those covered by the
International Health Regulations may be of concern to national health author
ities and the travelling public. The International Health Regulations obvi
ously cannot refer specifically to diseases that were not known at the time
they were last revised; this is the case with acquired immunodeficiency
syndrome (AIDS). Nevertheless, any requirement for an HIV antibody test
certificate ('' AIDS-free certificate") is contrary to the Regulations, since
Article 81 states that "no health document, other than those provided for in
these Regulations, shall be required in international traffic".
The International Health Regulations are currently being revised in accord-
ance with a resolution adopted by the World Health Assembly in 1995. The
purpose of the revision is to develop Regulations that are adapted to the
present volume of international traffic and trade and take account of current
trends in the epidemiology of communicable diseases, including emerging
disease threats,
Internatıonal Health Regulations (1969):, Third annotated edition. Geneva, World Health
Organization, 1983.79 pp,
10 INTERNATIONAL TRAVEL AND HEALTH
2.2 Smallpox
The eradication of smallpox was confirmed by WHO nearly 20 years

ago. Smallpox vaccination is no longer indicated, and may be danger-
ous to those who are vaccinated and those in close contact with them.
2.3 Cholera
Vaccination against cholera cannot prevent the introduction of the

infection into a country. The World Health Assembly therefore amended
the International Health Regulations in 1973 so that cholera vaccination
should no longer be required of any traveller.
No country requires proof of cholera vaccination as a condition for entry

and the International Certificate of Vaccination no longer provides a spe-
cific space for recording of cholera vaccination. The traditional parenteral
cholera vaccine conveys incomplete, unreliable protection of short duration
and its use. therefore, is not recommended. Two oral cholera vaccines that
provide high-level protection for several months against cholera caused by
Vibrio cholerae O1 have recently become available in a few countries for
use by travellers.
2.4 Yellow fever vaccination certificate'

Urban and jungle yellow fever occur only in parts of Africa and South
America (see maps 1 and 2, pp. 14 and 15). Urban yellow fever is an epi-
demic viral disease of humans transmitted from infected to susceptible
persons by the Aedes aegypti mosquito. Jungle yellow fever is an enzootic
viral disease transmitted among nonhuman primate hosts, and occasionally
to humans, by a variety of mosquito vectors.
A yellow fever vaccination certificate is now the only certificate that
should be required in international travel, and then only for a limited number
of travellers.
Many countries require a valid International Certificate of Vaccination
from travellers arriving from infected areas or from countries with infected
areas, or who have been in transit through those areas. Some countries re-
quire a certificate from all entering travellers, including those in transit.
Although there is no epidemiological justification for this latter requirement.
See also section 5.4.1. Immunization o1 IIIV-intected individuals", p 66.

VACCINATION REQUIREMENTS | |
which is clearly in excess of the International Health Regulations, travellers

may find that it is strictly enforced, particularly for people arriving in Asia
from Africa or South America.
On the other hand, vaccination is strongly recommended for travel out-
side the urban areas of countries in the yellow fever endemic zone (maps I
and 2, pp. 14 and 15), even if these countries have not officially reported the
disease and do not require evidence of vaccination on entry. Practitioners
should note that the actual areas of yellow fever virus activity far exceed the
infected zones officially reported and that, in recent years, fatal cases of
yellow fever have occurred in unvaccinated tourists visiting rural areas
within the yellow fever endemic zone.
The vaccination has almost total efficacy, while the case fatality rate for
the disease is more than 60% in adults who are not immune. Tolerance of the
present vaccine is excellent. The only contraindication to its use. apart from
true allergy to egg protein, is cellular immunodeficiency (congenital or ac-
quired, the latter sometimes being only temporary).
The vaccination certificate is valid only if it conforms with the model
reproduced on pp. 12-13, and if the vaccine has been approved by WHO1
and administered at an approved Yellow Fever Vaccinating Centre.
The period of validity of an international certificate of vaccination against
yellow fever is 10 years, beginning 10 days after vaccination. If a person is
revaccinated before the end of this period, the validity is extended for a
further 10 years from the date of revaccination. If the revaccination is record-
ed on a new certificate, travellers are advised to retain the old certificate for
10 days until the new certificate becomes valid.
For the current list of laboratories approved by WHO for the production of yellow fever
vaccine, see Annex l.page 93.
MODEL OF AN INTERNATIONAL CERTIFICATE OF

VACCINATION OR REVACCINATION AGAINST
YELLOW FEVER
The certificate must be printed in English and French: an additional

language may be added. It must be completed in English or French; an
additional language may be used.
The international certificate of vaccination is an individual certificate. It
should not be used collectively. Separate certificates should be issued for
children; the information should not be incorporated in the mother's certifi-
cate.
An international certificate is valid only if the yellow-fever vaccine used
has been approved by WHO and if the vaccinating centre has been designated
by the national health administration for the area in which the centre is
situated and so recorded with WHO. (See the 1991 WHO publication
Yellow-fever vaccinating centres for international travel.) The date should be
recorded in the following sequence: day. month, year, with the month writ-
ten in letters, e.g.. 8 January 1991.
A certificate issued to a child who is unable to write should be signed by a
parent or guardian. For illiterates, the signature should be indicated by their
mark certified by another person.
Although a nurse may carry out the vaccination under the direct supervi-
sion of a qualified medical practitioner, the certificate must be signed by the
person authorized by the national health administration. The official Stamp of
the centre is not an accepted substitute for a personal signature.
Signature of person vaccinated

Signature de la personne vaccinee
e.g.: 8 January 1991

ex.: 8 janvier 1991
Signature required
(rubber stamp not accepted)
Signature exigee (le cachet
n'est pas suffisant)
Official stomp
Cachet officiel
WHO 881091
VACCINATION REQUIREMENTS 13
INTERNATIONAL CERTIFICATE OF VACCINATION OR REVACCINATION
AGAINST YELLOW FEVER
CERTIFICAT INTERNATIONAL DE VACCINATION OU DE REVACCINATION
CONTRE LA FIEVRE JAUNE
This certificate is v a l i d only if the vaccine used has been approved by the World Health Organization and if the vaccinating centre has been
designated by the health administration for the territory in w h i c h that centre is situated.
The validity of this certificate shall extend tor a period of ten years, beginning ten days after the date of vaccination or in the event of a
revaccination within such period of ten years, from the date of that revaccination.
This certificate must be signed in his own hand by a medical practitioner or other person authorized by the national health administration; his
officient stamp is not an accepted substitute for his signature.
Any amendment of this certificate, or erasure, or failure to complete any part of it may render it invalid
MAP 1. YELLOW FEVER ENDEMIC ZONE IN AFRICA

VACCINATION REQUIREMENTS |S
MAP 2. YELLOW FEVER ENDEMIC ZONE

IN THE AMERICAS
NOTE: The "yellow fever endemic zones" are areas where there is a potential risk
of infection on account of the presence of vectors and animal reservoirs. Some
countries consider these zones as "infected" areas, and require an international
certificate of vaccination against yellow lever from travellers arriving from these
areas. Maps 1 and 2 have therefore heen included for this practical reason. See also
section 2.4. "Yellow lever vaccination Certificate", pp. 10-11.
3. COUNTRY LIST Of VACCINATION CERTIFICATE
REQUIREMENTS AND INFORMATION
ON THE MALARIA SITUATION
Smallpox
No country any longer requires a certificate of vaccination against
smallpox.
Cholera
No country or territory any longer requires a certificate of vaccina-
tion against cholera
Yellow fever
A certificate of vaccination against yellow fever is the only certifi-
cate that should be required for international travel The require-
ments of some countries are in excess of the International Health
Regulations, However, vaticination against yellow fever is strongly
recommended to all travellers Who intend to go to places other than the
major cities in the countries Where the disease occurs in man or
is assumed to be present in primates (see pp, 10-11and maps 1 and
2.pp 14-15).
Malaria
Epidemiological details are given for all countries with malarious
are geographical and seasonal distribution, altitude, predominant
species status of resistance). The recommended chemoprophylactic
regimen is also indicated. The following abbreviations are used
-- = no chemoprophytaxis necessary; CHL = chloroquine; C+P
= chloroquine plus proguanil: MEF = mefloquine; DOX = doxy-
cycline. Important advice on protective measures is given on
pp. 67- 84 and especially on pp. 7 1-73.
AFGHANISTAN ALBANIA
Yellow fever - A yellow fever vaccination Yellow fever - A yellow fever vaccination
is required from travellers com- certificate is required from travellers over
ing from infected areas 1 year of age coming from infected areas.
Malaria - Malaria risk predominantly in
the benign (Plasmodium vivax) from-exists
from May through November below ALGERIA
2000m. Chloroquine resistant P.Faleiparum Yellow fever- A yellow fever vaccination
reported. Recommended prophylexis : C+P certificate is required from travellers over
1 year of age coming from infected areas.
17
Malaria Malaria risk is limited. One small

focus (P. vivax) has been reported in Ihrir ARMENIA
(IIlizi Dept ), but this is isolated and access No vaccination requirements for any inter-
IS DIFFICULT. national traveller.
Recommended prophylaxis : -
Malaria- Malaria risk-exesively in the
benign (P.vivax) from-exists focally in
AMERICAN SAMOA some esatern border areas.
YELLOW fever- A yellow fever vaccination Recommended prophylaxis in risk areas:
certificate is required from travellers over CHL.
AUSTRALIA
ANDORRA Yellow fever - A yellow fever vaccination
No vaccination requirements for any inter- is required from travellers over
national traveller 1 year of age entering Australia within
6 days of having stayed overmight or longer
in an infecred country, as listed in the
ANGOLA Weekly Epidemiological Record.
Yellow fever - A yellow fever vaccination
certificate is required from travellers over AUSTRIA
Malaria - Malaria risk-predominantly in No vaccination requirements for any inter-
national travellers.
the malignant (P. falciparum) from-exist
throughout the year in the whole country.
P. falciparum resistant to chloroquine and AZERBALIAN
sulfadoxine-pyrimethamine reported.
Recommended prophylaxis: MEF No vaccination requirements for any inter-
national traveller.
ANTIGUA AND BARBUDA Malaria - Malaria risk-exclusively in the
benign (P.vivax) from-exist in southern
Yellow fever - A yellow fever vaccination areas as well as in the Khachmas region in
certificate is required from travellers over the north. Sporadie malaria cases reported in
1 year of age coming from infected areas. Baku suburbs.
Recommended prophylaxis in risk areas:
CHL.
ARGENTINA
No vaccination requirements For any inter-
notional traveller. BAHAMAS
Malaria - Malaria risk-inclusively in the Yellow fever- A yellow Fever vaccination
benign (P.vivax) from is low and low and is con-certificate is required from travellers over
fined to rural areas along thc borders with 1 year of age coming from infected areas.
Bolivia (lowlands of Salta and Jujuy prov-
inces) and with Paraguay (lowlands of
Misiones and Corrientes provinees) BAHRAIN
Recommended prophylaxis in risk areas: No vaccination requirements for any inter-
CHL national traveller.
BANGLADESH
Yellow fever - Any person (Including in-
See pp. 10-11 and map 1.p. 14 --nts) who arrives by air or sea without a
COUNTRY LIST OF VACCINATION REQUIREMENTS19
certificate is detained in isolation for a

period of up to 6 days if arriving within BELARUS
6 days of departure from an infected area or No vaccination requirements for any inter-
having been in transit in such an area or national traveller
having come by an aircraft that has been in
an infected area and has not been disin- BELGIUM
sected in accordance with the procedure No vaccination requirements for any inter-
AND formulation laid down in Schedule VI national traveller
of the Bangladesh Aircraft (Public Health)
Rules 1977 (First Amendment) or those BELIZE
recommended by WHO,
The following couturies and areas are re- Yellow fever- A yellow fever vaccination
garded as infected: certificate is required from traveller com-
Africa : Angola, Benin, Burkima, Faso, ing from infected areas.
Burundi, Cameroon, Central African Malaria - Malaria risk P
Republic, Chad, Congo, Cote, d'Ivoire,P. falciparum (5%)-exists in all districts
Democratic Republic of the Congo, Equa- but varies within regions, Risk is highest in
toral Guinea, Ethiopia, Gabon,Gambia, the western and southern regions, No resis-
Ghana, Guinea, Guinea-Bissau, Kenya, tant P. falciparum strains reported.
Liberia, Malawi, Mali, Mauritania, Niger, Recommended prophylaxis in risk areas:
Nigeria, Rwanda, Sao Tome and Principe, CHL.
Senegal, Sierra, Leone, Somalia, Sudan,
(south of 15 N), Togo, Uganda, United BENIN
Republic of Tanzania, Zambia.
America : Belize. Bolivia, Brazil, Yellow fever - A yellow fever vaccination
Colombia, Costa Rica, Equador, French certificate is required from all travellers
Gutania, Guatemala, Guyana, Honduras, over 1 year of age.
Nicaragua, Panama, Peru, Suriname, Malaria - Malaria risk-predominantly in
Trinidad and Tobago, Venezuela, malignant (P. falciparum) form-exists
Note : When a case of yellow fever is throughout the year in the whole coun-
reported from any country that country is try. Chloroquine-resistant P. falciparum
regarded by the government of Bangladesh reported.
as infected with yellow fever and is added Recommended prophylaxis: MEF
to the above list.
BERMUDA
Malaria - Malaria risk exists throughout
the year in the whole country,excluding No vaccination requirements for anr inter-
Dhaka City. P. falciparum highly resistant natinal traveller.
to chloroquine reported in the south-east;
resistance to sulfadoxine-pyrimethamine BHUTAN
also reported.
Yellow fever—A yellow fever vaccination
Recommended prophylaxis C+P; in for- certificate is required from travellers com-
ested areas and south-east, MEF. ing from infected areas.
Malaria - Malaria risk exists throughout
the year in the soutern belt of five
districts: Ghirang, Gaylegphug. Samehi.
BARBADOS Samdrupjongkhar, Shemgang P.falciparum
Yellow Fever - A yellow fever Vaccination resistant to chloroquine and sulfadoxine
certificate is required from travellers over phrymethamine, reported.
1 year of age coming from infected areas. Recommended prophylaxis in risk areas:
C+P
waiver stating that immunization is con-

BOLIVIA traindicated on medical grounds. The fol-
Yellow Fever- A yellow fever vaccination lowing countries or areas are regarded as
certificate is required from travellers com- infected:
ing from infected areas. Vaccination is Africa : Angola,Cameroon Democratic
recommended for incoming travellers from Republic of the Congo, Gabon, Gambia,
non-infected zones visitingrisk areas such Ghana. Guinea, Liberia, Nigeria, Sierra
as the departments of Beni. Cochabamba
Leone, Sudan
and Santa Cruz and the subtropical part of
La Paz Department. America : Colombia, Equador,
Malaria - Malaria risk - predominantly in Peru
the benign (P.vivax) from exist through-- Accination is recommended for trav-
out the year below 2500 m in the depart-
ellers to rural areas in the states of Acre,
ments of Beni, Pando Santa Cruz and Amapa, Amazonas. Goias,Maranhao, Mato
Tarija. and in the provinces of Lacareja, Grosso, Mato Grosso do Sul, Minas Gerais,
Rurenabaque, and North and South Yungas.
in La Paz Department Lower risk exists in Para. Rondonia. Roralma and Tocantins.
Cochabamba and Chuqnisaca. Falciparum
malaria occurs in Pando and Beri, espe- Malaria - Malaria risk - P. vivax (65%),
cially in the localities of Guayaramerfa,
Riberalia and Puerto Rico. P. falciparum P. faliparum (35%) is high throughout
resistant to chloroquine and sulfadoxine- the year in most Iorested areas below
pyrimethamine reported 900 m within the nine states of the ''legal
Recoommended prophylaxis in risk areas: Amazonia" region (Acre, Amapa), Ama-
CHL : in northern departments, MEF. zonas, Maranhao,( western part). Mato
Grosso (northern part), Para except Belem
City), Rondonia. Roraima and Tocantins).
BOSNIA AND HERZEGOVINA Transmission intensity varies from munici-
pality to municipality, but is very high in
Ho vaccination requirements For any Inter- jungle areas of mining tumbering and agri-
national traveller. cultural settlements less than 5 years old
where multi resistant P. falciparum
strains are common (>50%). Intensity of
BOTSWANA transmission is lower in urban areas,even
NO vaccination requirements for any inter- in large cities such as Porto Velho. Boa
national traveller. Vista, Macapa, Manaus,Santarem and
Maraba. In the states outside '"Legal
Malaria - Malaria risk-predominantly in Amazonia", malaria transmission risk is
THE malignant (P. falciparum) form-exists negligible or non-existent.
from November to May/June in thc Recommended prophylaxis in risk areas:
northern parts of the country: Boteti, MEF.
Cbobe, Ngamiland, Okavango, Tutume
districts/subdistricts, Chloropquine resistantBRITISH VIRGIN ISLANDS
P. falciparum reported.
Recommended prophylaxis in risk areas: C+P Mo vaccination requirements for any inter-
national traveller.
BRAZIL
BRUNEI DARUSSALAM
certificate is required from travellers over Yellow Fever-A yellow fever vaccination
9 months of age coming from infected certificate is coming from travellers over
areas, unless they are in possession of a 1 years of age coming infected areas or
COUNTRY LIST OF VACCINATION REQUIREMENTS
21
who have passed through partly or wholly Malaria - Malaria risk-predominantly in

endemic areas within the preceding 6 days. the malignant (P.falciparum from-exists
The countries and areas included in the throughout the year in the whole country
endemic zones (see maps 1 and 2 except in the Phnom Penh area and close
pp. 14—15) are considered as infected around Tonle Sap, Malaria does, however,
occur in the tourist area of Angkor Wat,
P.falciparum highly resistant to chloro-
quine and resistant to sulfadoxine-
BULGARIA pyrimethamine reported. Resistance to
mefloquine reported in western provinces
No vaccination requirements for any inter- Recommended prophylaxis : MEF: in
national traveller. western provinces. DOX.
BURKINA FASO CAMEROON

YELLOW fever - A yellow fever vaccination
CERTIFICATE IS REQUıRED FROM all travellers
certificate is requared from all travellers
over 1 year of age. over 1 year of age:
Malaria - Malaria risk-predominantly in Malaria — Malaria risk-predominantly in
the malignant (P. falciparum-exists the malignant (P. falciparum) form exists
throughout the year in the whole country. throughout the year in the whole conntry.
Resistant to chloroquine reported. P.falciparum resistant to chloroquine a
Recommended prophylaxis: MEF. sulfadoxine-pyrimethamine reported.
Recommended prophylaxis: MEF.
BURMA see MYANMAR

CANADA
No vaccinntion requirements for any inter-
national traveller.
certificate is required from travellers over
CAPE VERDE
Malaria - Malaria risk-predominantly in
the malignant (P. falciparum) from-exists Yellow fever - A yellow fever vaccination
throughout the year in the whole country. certificate is required from travellers ovcr
Resistance to chloroquine reported. 1 year of age coming from countries having
Recommended prophylaxis: MEF notified cases in the last 6 years.
Malaria -Limited malaria risk exists from
September through November in Sao Tiago
Island;
CAMRODIA Recommended prophylaxis: --
certificate is required from travellers com-
ing from inifected areas
CAYMAN ISLANDS
No vaccination requirements for any inter-
ntlional traveller.
See pp. 10-11 and map 1.p 14
v> INTERNATIONAL TRAVEL AND HEALTH
north of latitude 33 N from May to

CENTRAL AFRICAN REPUBLIC December between 33 N and 25 N, and
Yellow fever - A yellow fever vaccination throughout the year south of 25 N.
certificate is required from all travellers
over 1 year of age. CHL : in Hainan and Yunnan, MEF.
the malignant (P. falciparum) form-exists
throughout the year in the whole country. CHRISTMAS ISLAND
Resistance to chloroquine reported. (Indian Ocean)
Recommended prophylaxis: MEF Same requirements as mainland Australia.
CHAD COLOMBIA
Yellow fever - A yellow fever vaccination YELLOW fever - Vaccination is recommend-
certificate is recommended for all travellers ed for travellers who may visit the follow-
over 1 year of age. ing areas considered to be endemic for
Malaria - Malaria risk-predominantly in yellow fever: middle valley of Mag-
the malignant (P falciparum) form-exists dalena river. eastern and western foothills
throughout the year in the whole country. of the Cordillera Oriental from the frontier
Resistance to chloroquine reported. with Ecuador to that with Venezuela.
Recommended prophylaxis: MEF Uraba, foothills of the Sierra Nevada,
estern plains (Orinoqnia) and Amazonia.
Malaria - Malaria risk-P. vivax (66%).
CHILE P.falciparum (34%)-is high throughout the
year in rural/jungle areas below 800 m.
No vaccination requirements for any inter- Transmission occurs in 245 mumcipalines of
national traveller. the regions Uraba-Bajo Cauca Orinoquia-
Pacifico and Amazonio. Transmission inten-
sity varies from department to department.
with the highes risk in Antioquna, Arauca.
CHINA
Caqueta, Choco, Cordoba, Guainia,
Yellow fever - A yellow fever vaccination Guaivare, Meta, Narino, Putumayo and
certificate is required from travellers com- Vichada. Chloroquine-resistant P. falcipa-
ing from infected areas. rum exists in Uraba-Bajo Catica,.Pacifico and
Malaria - Malaria risk-including the ma- Amazonia Lower-intensity transmission oc-
curs in 403 municipalities of the departments
lignant (P. falciparum) form-occurs in of Amazonas. Boyaea Norte de Santander
Hainan and Yunnan, and sporadically in and Vaupes. The other 419 municipalities in
Guangxi, Multidrug resistant P. falciparum 18 departments have no or negligible malaria
has been reported in Hainan and Yunnan transmission risk.
Risk of P.vivax malaria exists in Fujian, Recommended prophylaxis in risk areas;
Guangdong, Guangxi, Guizhou, Hainan, C+P ; in Uraba-Bajo Cauca. Pacifico and
Sichuan. Xinjiang (only along the valley of Amazonia, MEF.
the Yili river). Xixang (only along the valley
the Zangbo river in the extreme south-
east) and Yunnan. Very low malaria risk
(P.vivax only) exists in Anhui. Hubei COMOROS
Hunan, Jiangsu, Jiangzi, Shandong, No vaccination requirements for any inter-
Shanghai and Zhejiang. The risk may be national traveller,
higher in areas of local outbreaks.
Where transmission exists. it occurs Malaria - Malaria risk-predominantly in
below 1500 m from July to November the malignant (P. falciparum) form-exists
COUNTRY LIST OF VACCINATION REQUREMENTS
Throughout the year in the whole country.

CUBA
Resistance to chloroquıne reported.
Recommended prophylaxis : MEF No vaccination requirements for any inter-
national traveller.
CONGO
Yellow fever - A yellow fever vaccination CYPRUS
certificate is required from all travellers No vaccination requirements for any inter-
over 1 year of age. national traveller.
M a l a r i a - Malaria risk-predominantly in
the malignant (P.falciparum) form-exists
throughout the year in the whole country. CZECH REPUBLIC
Resistance to chloroquine reported. No vaccination requirements for any inter-
Recommended prophylaxis : MEF national traveller.
COOK ISLANDS DEMOCRATIC PEOPLE'S

No vaccination requirements for any inter- REPUBLIC OF KOREA
national travellers. No vaccination requirements for any inter-
national traveller.
COSTA RICA
No vaccination requirements for any inter- DEMOCRATIC REPUBLIC
national traveller. OF THE CONGO (formerly ZAIRE)
Malaria - Malaria r i s k - a l m o s t exclusively Yellow fever - A YELLOW FEVER vaccination
in the benign (P. vivax) form-is moderate
throughout the year in the cantons Matima,
Limon and Talamanca (Limon province) and
1 year of age.
Los Chiles(Alajuela Province). L o w e r trans- Miliaria - Malaria risk-predominantly in
mission risk exists 15 cantons in the prov- the malignant (P.falciparum) form-exists
inces of Guanacaste, Alajuela and Heredia. throughout the year in the whole country.
Negligible or no risk of malaria transmission Highly chloroquine-resistant P.falciparum
exists in the other 69 cantons of the country. reported.
Recommended prophylaxis in risk areas: Recommended prophylaxis : MEF,
CHL.
DENMARK
COTE D'TVOIRE No vaccination requirements for any inter-
Yellow fever - A yellow fever vaccination national traveller.
DJIBOUTI
M a l a r i a - Malaria risk- p r e d o m i n a n t l y in
the malignant (P.falciparum) form-exists Yellow fever - A yellow fever vaccination
throughout the year in the whole country. certificate is required from fravellers over
Resistance to chloroquine reported. 1 year of age coming from infected areas.
Recommended prophylaxis : MEF M a l a r i a - Malaria risk-predominantly in
the m a l i g n a n t (P.falciparum) form-exists
CROATIA t h r o u g h o u t the year in the w h o l e country
Chloroquine resistant P.falciparum re-
No vaccination requirements for any inter- ported
national travellerr.
Recommended prophylaxis : MEF
Democratic Republic of the Congo, Equato-
DOMINICA rial Guinea, Ethiopia, Gabon, Gambia,
Yellow fever - A yellow fever vaccination Ghana, Guinea, Guinea-Bissau, Kenya,
certificate is required from traveller, over Lieria, Mali, Niger, Nigeria, Rwanda, Sao
1 year of age coming from infected areas, Tome and Principe, Senegal, Sierra, Leone,
Somalia, Sudan (South of 15 N). Togo,
Uganda, United Republic of Tanzania,
DOMINICAN REPUBLIC Zambia.
No vaccination requirements for any inter- America : Belize, Bolivia, Brazil Co-
national traveller. lombia, Costa Rica, Ecuador, French,
Guiana, Guyana, Panama, Peru, Suriname,
Malaria - Low malaria risk-exclusively in Trniidad and Tobago, Venezuela.
throughout the year especially in rural areas All arrivals from Sudan are required to
of the western provinces such as Monte possess either a vaccination certificate or a
Cristi, Dajabon and Elias Pina. thereofficial location certificate issued by a Sudanese
is no centre stating that they have not
evidence of P.falciparum resistance to any drug. been in Sudan south of 15 N within the
Recommended prophylaxis in risk areas previous 6 days.
CHL Malaria - Malaria risk in the malignant
(P.falciparum) and benign (P.vivax)
form-exists from June through Octob
ECUADOR
El Faiyum area
Yellow Fever - A yellow fever vaccination Recommended prophylaxis in risk areas :
certificate as required from travellers over CHL.
1 year of coming from infected areas.
Malaria - Malaria risk - P.vivax (74%) EL SALVADOR
P.falciparum (26%) high throughout the Yellow fever - A yellow fever vaccination
year in 148 cantons in 19 provinces. There certificate is require from travellers over
are no reports of P.falciparum resistance to 6 months of age coming from infected areas.
chloroquine, except for a few imported Malaria - Very low malaria risk-almost ex-
strains in the Napo and Pastaza river valleys clusively in the benign (P.vivax) form-
Recommended prophylaxis in risk areas: exists throughout the year in Santa Ana
C+ P Province, in rural areas of migratory Influ-
ence from Guatemala.
EGYPT Recommended prophylaxis in risk areas:
Yellow f e v e r - A yellow fever vaccination CHL.
1 year of age coming from infected areas, EQUATORIAL GUINEA
The following countries and areas are re- Yellow fever - A yellow fever vaccination
---ded as infected areas; air passengers in certificate is required from travellers com-
transit coming from these countries or areas
without a certificate will be detained in the ing from infected areas.
precinets of the airport until they resume Malaria - Malaria risk-predominantly in
their journey: the malignant (P.falciparum) form-exists
Africa : Angola, Benin, Burkina Faso, throughout the year in the whole country
Resistance to chloroquine reported.
Burundi, Cameroon, Central African Recommended prophylaxis : MEF.
Republic, Chad, Congo, Cote d'lvoire
See pp. 10-11 and map 2 15 See p.10-11 and map1.p 14

ERITREA FRANCE
certificate is required from travellers com- national traveller.
ing from infected areas.
Malaria - Malaria risk-predominantly in FRENCH GUIANA
the malignant (P.falciparum) form exists Yellow fever - A yellow fever vaccination
throughout the year in the whole country certificate is required from all travellers
below 2000 m. There is no risk in Asmara. over 1 year of age.
Malaria -Malaria risk-predominantly in
the malignant (P. falciparum) form-is high
ESTONIA throughout the year in nine municipalities of
No vaccination requirements for any inter- the territory bordering Brazil (Oiapoque
river valley) and Suriname (Maroni river
national traveller. valley). In the other 13 municipalities trans-
mission risk is low or negligible. High level
ETHIOPIA of multiresistant P.falciparum reported in
areas influenced by Brazilian migration.
Yellow fever - A yellow fever vaccination Recommended prophylaxis risk areas:
certificate is required from travellers over MEF.
Malaria - Malaria risk-predominantly in FRENCH POLYNESIA
the malignant (P.falciparum) form-exists Yellow fever - A yellow fever vaccination
,throughout the year in thewhole country certificate is required from travellers over
below 2000m. Highly chloroquine resistant 1 year of age coming from infected areas.
P.falciparum reported.There is no malaria
risk in Addis Ababa. GABON
Recommended prophylaxis : MEF Yellow fever- A yellow fever vaccination
FALKLAND ISLANDS certificate is required from all travellers
over 1 year of age.
(MALVINAS)
Malaria - Malaria risk- predominantly in
No vaccination requirements for any inter- the malignant (P.falciparum) form-exists
national traveller. throughout the year in the whole country,
Resistance to chloroquine reported:
FAROE ISLANDS Recommended prophylaxis : MEF
national traveller. GAMBIA
Yellow fever- A yellow fever vaccination
FIJI 1 year of age arriving from endemic or in-
Yellow fever - A yellow fever vaccination ------ areas.
certificate is required from travellers over Malaria - Malaria risk-predominantly in
1 year of age coming from infected areas. the malignant (P.falciparum) form-exists
FINLAND Chloroquine-resistant .P falciparum reported,
Recommended prophylaxis : MEF.
national traveller.
See pp 10-11 and map 1.p. 14
GEORGIA GUAM
No vaccination requirements for any inter- No vaccination requirements for any inter-
national traveller. national traveller.
GERMANY GUETAMALA
No vaccination requirements for any inter- Yellow fever - A yellow fever vaccination
national traveller. certificate is required fromtravellers over
1 year of age coming from countries with in-
fected areas.
GHANA Malaria - Malaria risk-predominantly in
the benign (P.vivax) form-exists through-
Yellow fever - A yellow fever vaccination out the year below 1500 m. There is high
certificate is required from travellers. risk in the Departments of Alta Verapaz.
Malaria - Malaria risk-predominantly in Escuinda, Huehuetenango, Peten and
the malignant (P.falciparum) form-exists Quiche, and moderate risk in the Depart-
throughout the year in the whole country. ments of Baja Verapaz, Izabal, Jutiapa,
Resistance to chloroquine reported. Retalhaleu, San Marcos, Suchitepequez and
Reccommended prophylaxis : MEF Zacapa.
Recommended prophylaxis in risk areas : CHL
GIBRALTAR
No vaccination requirements for any inter- GUINEA
national traveller.
1 year of age from infected areas.
GREECE Malaria - Malaria risk predominantly in
Yellow Fever - A yellow fever vaccination the malignant (P. falciparum) form-exists
certificate is required from travellers over throughout the year in the whole country.
6 months of age coming from infected areas Resistance to chloroquine reported.
GREENLAND GUINEA-BISSAU
national traveller. Yellow fever - A yellow fever vaccination
1 year of age coming from infected areas,
and from the following countries:
GRENADA
Africa : Angola, Benin, Burkina, Faso,
Yellow fever - A yellow fever vaccination Burundi, Cape Verde, Central African
certificate is required from travellers over Republic. Chad, Congo, Cote d'lvoire,
1 year of age coming from infected areas. Democratic Republic of the Congo,
Djubiti, Equatorial Guinea, Ethiopia,
Gabon, Gambia. Ghana. Guinea, KENYA,
GUADELOUPE Liberia, Madagaskar, Mali, Mauritima,
Yellow fever - A yellow fever vaccination Mozambique. Niger. Nigeria, Rwanda, Sao,
See pp. 10-11 and map 1.p 14
Tome and Principe, Senegal, Sierra Leone, Malaria - Malaria risk-almost exclusively
Somalia, Togo, Uganda, United Republic in the malignant (P. falciparum) form-ex-
of Tanzania, Zambia ists throughout the year in certain forest areas
in Gros Morne, Hinche, Maissade, Quana.-
America : Bolivia Brazil, Colombia, minthe, Chantal and Jacmel. In the other can-
Ecuaddor, French Guiana, Guyana, Panama,
Peru, Suriname, Venezuela. tons, risk is estimated to be low No P, falci-
parum resistance to Chloroquine reported.
Malaria - Malaria risk-predominantly in Recommended prophylaxis in risk area :
malignant (P.falciparum) form-exists CHL.
Chloroquine resistant P.falciparum reported.
HONDURAS
GUYANA Malaria - Malaria risk-P.vivax (98%)-is
Yellow fever - A yellow fever vaccination high throughout the year in 223 munici-
certificate is required from travellers com- palities. Transmission risk is low in the
ing from infected areas and from the fol- other 7 municipalities, includnig the City
of Tegucigalpa and San Pedro Sula.
lowing countries; Recommended prophylaxis : CHL
Afiica; Angola, Benin, Burkina Faso,
Burundi, Cameroon, Central African
Republic, Chad. Congo, Cote d'ltvoire. HONG KONG SPECIAL
Democratic Republic of the Congo, Gabon, ADMINISTRATIVE REGION
Gambia, Ghana. Guinea, Guinea-Bissau, OF CHINA
Kenya, Liberia, Mali, Niger, Nigeria No vaccination requirements for any inter-
Rwanda, Sao, Tome and Principe, Senegal,
national traveller.
Sierra Leone,Somalia, Togo, Uganda,
United Republic ol Tanzania.; Malaria - Malaria risk is considered not to
exists in urban and most ruralareas.
America : Belize, Bolivia. Brazil, Co- Recommended prophylaxis: --
lombia, Costa Rica, Ecuador, French,
Guiana, Guatemala, Honduras, Nicaragua,
Panama, Peru, Suriname. Venezuela. HUNGARY
Malaria - Malaria risk-P. falciparum national traveller.
(50%) P.vivax (49%)- is high thronghout
the year in all parts of rural areas. Only
Georgtown and New Amsterdam cities area
ICELAND
transmission free. High level of chloro- No vaccination requirements for any inter-
quine-resistant P.falciparum reported. national traveller.
MEF
INDIA
HAITI Yellow Fever - Anyone (except) inlants up
to the age of 6 months arriving by air or
Yellow fever - A yellow fever vaccination sea without a certificate is detained in isola-
certificate is required from travellers com- tion for up to 6 days it that person (i) ar-
ing from infected areas. rives within 6 days of departure from an
infected area, or (ii) has been in such an
area in transit (excepting those passengers
and members of the crew who. while in
See pp. 10-11 and map 2,p. 15 transit through an airport situated in an
Infected area, remained within the airport Malaria - Malaria risk exists throughout
premises during the period of their entire the year in the whole country except in
stay and the Health Officer agrees to such Jakarta Municipality, big cities, and the
exemption, or (iii) has come on a ship that main tourist resorts of Java and Bali.
started from or touched at any port in a P.falciparum highly resistant to chloro-
yellow fever infected area up to 30 days quine and resistant to sulfadoxine-
before its arrival in India, unless such a phrimethamine reported. P.vivax resistant
ship has been disinsected in accordance
with the procedure aid down by WHO, or chloroquine reported in Irian Jaya.
(iv) has come by an aircraft which has been Recommended prophylaxis in risk areas :
in an infected area and has not been disin- C+P in Irian Jaya: M E F .
sected in accordance with the provisions

laid down in thee Indian Aircraft Public IRAN (ISLAMIC REPUBLIC OF)
Health Rules, 1954, or those recommended Yellow fever - A yellow fever vaccination
by WHO. The following countries and is required from travellers com-
areas are regarded as infected : ing from infected areas.
Africa : Angola, Benin, Burkina Faso,
M a l a r i a - Limited risk exists in some areas
Burundi, Cameroon, Central African
Republic, Chad, Congo, Cote d'lvoire, north of the Zagros mountains and in west-
Democratic Republic of the Congo, Equato- ern and south-western regions during the
rial Guinea, Ethiopia, Gabon, Gambia, summer months. Malaria risk exists from
Ghana, Guinea, Guinea-Bissau, Kenya, March through November in the provinces
Liberia, Mali, Niger, Nigerria, Rwanda, Sao of Sistan-Baluchestan, Hormozgan and
Tome and Principe, Senegal, Sierra Leone, Kerman (tropical part). Chloroquine-
Somalia, Sudan, Togo, Uganda, United resistant P. falciparum reported.
Republic of Tanzania, Zambia. Recommended prophylaxis in risk areas:
CHL.: in south east. C+P
America : Bolivia, Brazil, Colombia,
Ecuador, French, Guiana, Guyana. Panama,
Peru. Suriname, Trinidad and Tobago, IRAQ
Venezuela.
Note : When a case of yellow fever is
reported from any country, that country is
regarded by the Government of India as in- ing from infected areas.
fected with yellow feverland is added to the Malaria - Malaria risk-exclusively in the
above list. benign (P.vivax) form-exists from May
through November, principally in areas in
Malaria - Malaria risk exists throughout the North below l500 m (Duhok, Erbil,
the year in the whole country below 2000m. Ninawa, Sulaimaniya and Ta'mim Prov.)
There is no transmission in parts of the but also in Basrah Provinice.
States of H i m a c h a l Pradesh, Jammu and Recommonded prophylaxis : CHL.
Kashmir and Sikkim. Highly chloroquine-
resistant P. falciparum reported.
Recommended prophylaxis : C+P IRELAND
national traveller.
INDONESIA
certificate is required from travellers com- ISRAEL
ing from infected areas. The countries and No vaccination requirements for any inter-
areas included in the endemic zones (see national traveller.
maps 1 and 2 pp. 14-15) are considered by
Indonesia as infected areas.
29
ITALY KUWAIT
No vaccination requirement for any inter- No vaccination requirements for any inter-
JAMAICA KYRGYZSTAN
Yellow fever - A yellow fever vaccination No vaccination requirements for any inter-
certificate is required from travellersnational
over traveller.
LAO PEOPLE'S DEMOCRATIC

JAPAN
REPUBLIC
No vaccination requirement for any inter-
national traveller.
JORDAN Malaria - Malaria risk-predominantly in
Yellow fever - A yellow fever vaccination the malignant (P. falciparum) form-exists
certificate is required from travellers over throughout the year in the whole country
1 year of age coming from infected areas. except in Vientiane; Highly chloroquine-
resistant P.falciparum reported.
KAZAKSTAN Recommended prophylaxis : MEF.
certificate is required from travellers com- LATVIA
ing from infected areas. No vaccination requirements for any inter-
national traveller.
KENYA
certificate is required from travellers over LEBANON
1 year of age coming from infected areas. Yellow fever- A yellow fever vaccination
Malaria - Malaria risk predominantly in certificate is required from travellers com-
the malignant (P.falciparum) form-exists ing from infected areas.
There is normaly little risk in the city of
Nairobi and in the highlands (above LESOTHO
2500 m of Central, Rill Valley, Estern, Yellow fever- A yellow fever vaccination
Nyanza and Western Provinces P. fal- certificate is required from travellers com-
ciparum highly resistant to chloroquine and ing from infected areas.
resistant to sulfadoxine-pyrimethamine re-
ported.
Recommended prophylaxis : MEF LIBERIA
KIRIBATI certificate is required from travellers -
over 1 year of age..
certificate is required from travellers over Malaria - Malaria risk predominantly in
1 year of age coming from infected areas. the malignant (P. falciparum) form-exists
throughout the year in the whole country
See pp. 10-11 and map 1.p 14, P. falciparum highly resistant to chloro-
30
quine and resistant to sulfadoxine-pyri Malaria - Malaria risk-predominantly in

mehamine reported. the malignant (P. falciparum) form-exists
Recommended prophylaxis : MEF. throughout the year in the whole country.
LIBYAN ARAB JAMAH1RIVA quine and resistant to sulfadoxine-pyri-
methnmine reported,
YELLOW fever - A yellow fever vaccination Recommended prophylaxis : MEF.
MALAYSIA
Malaria - Very limited malaria risk-exists
in two small foci in the south-west of the Yellow fever - A yellow fever vaccination
country from February through August. No certificate is required from travellers over
indigenous cases reported in recent years. 1 year of age coming from infected areas.
Recommended prophylaxis. -- The countries and areas included in the en-
demic zones (see maps 1 and 2. pp 14-15)
are considered infected areas.
LIECHTENSTEIN
Malaria - Malaria risk exists only in limi-
No vaccination requirements for any inter- ted foci in the deep hinterland. Urban and
national traveller. coastal areas are from malaria, except
in Sabah, where there is a risk predomi-
LITHUANIA nantly in the malignant (P.falciparum)
form-throughout the year P. falciparum
No vaccination requirements for any inter- resistant to chloroquine and a few cases
national traveller. of parasite resistance to sulfadoxine-
pyrimethamine reported.
LUXEMBOURG Recommended prophylaxis in risk areas:
C+P : in Sabah. MEF.
national traveller.
MALDIVES
MACAO certificate is required from travellers com-
No vaccination requirements for any inter- ing from infected areas.
national traveller.
Malaria - No local malaria transmission
reported since 1983.
MADAGASCAR Recommended prophylaxis :-
certificate is required from travellers com- MALI
ing from, or having been in transit in, areas Yellow fever- A yellow fever vaccination
considered to infected. certificate is required from all travellers
Malaria - Malaria risk-predominantly in over 1 year of age.
throughout the year in the whole country. Malaria - Malaria risk predominantly in
with the highest risk in the coastal areas. the malignant (P. falciparum) form-exists
Resistance to chloroquine reported. throughout the year in the whole country.
Recommended prophylaxis : MEF. Resistance to chloroquine reported.
MALAWI
Yellow fever- A yellow fever vaccination MALTA
ing from infected areas. Yellow fever - A yellow fever vaccination
9 months of age coming from infected

areas indicated on epidemiological MAYOTTE
grounds infants under 9 months of age are (French territorial collectivity)
subject to isolation surveillance if coming No vaccination requirements for any inter-
FROM AN infected area. national traveller.
MARSHALL ISLANDS the malignant (P.falciparum) form-exists
throughout the year.
No vaccination requirements for any inter- Recommended prophylaxis : MEF.
national traveller.
MARTINIQUE MEXICO
Yellow fever- A yellow fever vaccination Yellow fever - A yellow fever vaccination
certificate is required from travellers over certificate is requested from travellers over
1 year of age coming from infected areas.6 months of age coming from infected
areas.
Malaria - Malaria risk almost exclusive-
MAURITANIA ly in the benign (P.vivax) form-exists
Yellow fever - A yellow fever vaccination throughout the year in some r u r a l areas that are
not often visited by tourists. The states most
certificate is required from all travellers affected (in decreasing order of importance)
over 1 year of age except those arriving are; Chiapas, Oaxaca, Sinaloa, Michoacan,
from non-infected area and staying less Nayarit, GuerreroTabasco, Quintana Roo,
than 2 weeks in the country.
Chihuahun Campeche, Hidalgo.
Malaria - Malaria risk-predominantly in Recommended prophylaxis in risk area:.
the malignant (p.falciparum) form-exists CHL.
throughout the year in the whole country,
except in the northern areas: Dakhlet-
Nouadhibou and Tiris-Zemour. In Adrar MICRONESIA
and Inehiri there is malaria risk during the
rainy season (July through October) (FEDERATED STATES OF)
Recommended prophylaxis in risk areas: No vaccination requirements for any inter-
C+P national traveller.
MAURITIUS MONACO
Yellow fever - A yellow fever vaccination No vaccination requirements for any inter-
certificate is required from travellers over national traveller.
The countries and areas included in the en-
demic zones (see maps I and 2. pp, 14-15)
are considered as infected areas. MONGOLIA
Malaria - Malaria risk-exclusively in the national traveller.
bening (P.vivax) form-exists in certain
rural areas.There is no risk on Rodrigues
island.
Recommended prophylaxis : -- MONTSERRAT
national traveller.
See pp. 10-11 and map 1. p. 14
32
areas of Magwe Div. and in Sagaing Div.
MOROCCO P.falciparum highly resistant to chloro-
No vaccination requirements for any inter- quine and resistant to sulfadoxine-pyri-
national traveller. methamine reported P. vivax resistant to
Malaria - Malaria risk exclusively in the chloroquine reported.
benign (P.vivax) form-exists from May to Recommended prophylaxis : MEF
October in certain rural areas of some prov-
inces. Limited form are reported mainly in NAMIBIA
the following provinces (in decresing Yellow Fever - A yellow fever vaccination
order of importance) : Beni Mellal, Taza. certificate is required from travellers com-
Khemisset, Khouribga, Khenifra, Chef- ing from infected areas. The countries, or
chaoueu, Taounate, El Kelaa, Srarhna, parts of countries. Included in the endemic
Settat, and Larache. zones in Africa and South America are
regarded as infected (see maps 1 and 2,
pp. 14-15)
Travellers on scheduled flights that orig-
inated outside the areas regarded as in-
MOZAMBIQUE fected but who have b e e n in transit through
Yellow fever - Ayellow fever vaccination these areas, are not required to posses a
certificate is required from travellers over certificate provided they remained at the
scheduled airport or in the adjacent town
during transit.
Malaria - Malaria risk -predominantly in All passengers whose flights originated
the malignant (P. falciparum) form-exists in infected areas or who have been in transit
throughout the year in the whole country. through these areas on unscheduled flights
P.falciparum highly resistant to chloro- are required to possess a certificate.
quine and resistant to sulfadoxine-pyri- The certificate is not insisted upon in the
methamine reported. case of children under 1 year of age, but
Recommended prophylaxis : MEF such infants may be subject to surveillance.
Malaria - Malaria risk-predominantly
in the malignant (P. falciparum) form-
MYANMAR (formerly BURMA) exsits in the northern regions and in
Orjozondjupa and Omnheke from
certificate is required from travellers com- November to May/June and along the
ing from infected areas. Nationals and resi Kavango and Kunene rivers throughout the
dents of Myanmar are required to possess year. Resistance to chloroquine reported.
Recommended prophylaxis in risk areas :
certificates of vaccination on their departure C+P.
to an infected area.
Malaria - Malaria risk-predominantly in NAURU
commonly below 1000 m (a) throughout Yellow Fever - A yellow fever vaccination
the year in Karen State; (b) from March certificate is required from travellers over
through December in Chin Kachin, Kayah, 1 year of age coming from infected areas.
Mon, Rakhine, and Shan States, Pegu Div-
and Hlegu Hmawbi and Taikky] town- NEPAL
ships of Yungon (formerly Rangoon) Div
Yellow Fever - A yellow fever vaccination
(c) from April through December in the certificate is required from travellers com-
rural areas of Tenasserun Div : (d) from ing from infected areas.
May through December in Irrawadddy Div.
and the rural areas of Mandalay Div : Malaria - Malaria risk-predominantly in
(e) from June through November in the rural the benign (P. vivax) form-exists through-
but the year in rural areas of the Terai risk is low or negligible. No chloroquine-
districts linel forested kills and forest resistant P.falciparum reported.
areas of Dhanukha, Mahorari, Sarlahi, Recommended prophylaxis in risk areas:
Rautahat, Parsa. Rupendehi, Kapil- CHL.
vastu and especially along the Indian bor-
der. Chloroquine-resistant NIGER
P. falciparum
reported.
over 1 year of age and recommended for
travellers leaving Niger.
NETHERLANDS Malaria - Malaria risk-predominantly in
No vaccination requirements for any inter- the malignant (P.falciparum) form-exists
national traveller. throughout the year in the whole country
Chloroquine-resistant P. falciparum re-
ported.
NETHERLANDS ANTILLES Recommended prophylaxis : MEF
Yellow fever - A yellow fever vaccination NIGERIA

certificate is required from travellers over Yellow fever - A yellow fever vaccination
6 months of age coming from infected areas. certificate is required from travellers over
NEW CALEDONIA AND Malaria - Malaria risk-predominantly in
DEPENDENCIES the malignant (P. falciparum) form-exists
Cholera - vaccination against cholera is throughout the year in the wbole country
required.Travellers coming from an in Chloroquine-resistant P.falciparum re-
fected area are not given chemoprophy- ported
laxis. but are required to complete a form Recommended prophylaxis : MEF
for use by Health Service.
Yellow fever - A yellow fever vaccination N l U E
1 year of age coming from infected areas. Yellow fever - A yellow fever vaccination
MEW ZEALAND
No vaccination requirements for any inter-NORTHERN MARIANA ISLANDS
national traveller. No vaccination requirements for any inter-
national traveller.
NICARAGUA
NORWAY
YELLOW fever - A yellow fever vaccination
certificate is required from travellers over No vaccination requirements for any inter-
1 year of age coming from infected areas. national traveller.
Malaria - Malaria risk-p.vivax (94%),
P.falciparum (5.5%)- is high throughout the
year in 119 municipalities. In the other
26 municipalities in the departments of
Madriz, Carazo and Masaya, transmission See pp. 10-11 and map 1.p. 14.
34
transmission. A few imported cases of
OMAN falciparum malaria have been reported from
Yellow fever - A yellow fever vaccination San Blas.
certificate is required from travellers com- Recommended prophylaxis in risk areas :
ing from infected areas. CHL.
Malaria - Malaria risk predominantly in
ihr malignant (P.falciparum) form-exists
throughout the year in the whole country, PAPUA NEW GUINEA
except altitudes above 2000m and in Yellow fever - A yellow fever vaccination
desert areas. Chloroquine-resistan P. falci- certificate is required from all travellers over
parum reported. 1 year of age coming from infected areas.
Recommended prophylaxis : C+P
the malignant (P. falciparum) form-exists.
PAKISTAN throughout the year in the whole country
Yellow fever - A yellow fever vaccination below 1800m P.falciparum highly re-
certificate is required from travellers com- sistant to chloroquine and resistant to sul-
fadoxine- pyrimethamine reported. P.vivax
ing from any part of a country in which resistant to chloroquine reported.
yellow fever is endemic infants under
Recommended prophylaxis: MEF.
6 months of age are exempt if the mother's
vaccination certificate show that she was
vaccinated before the birth of the child. The
contries and areas included in the endemic PARAGUAY
zones (see maps 1 and 2. pp. 14-15) are
considered as infected areas. certificate is required from travellers leav-
Maliaria - Malaria risk exists throughout ing Paraguay to go to endemic areas and
the year in the whole country below from travellers coming from endemic areas.
2000m. Chloroquine-resistant P. falci- Malaria - Malaria risk-P.vivax(96%)
parum reported. P.falciparum (4%)- is modarete in certain
Recommended proplaxis : C+P. municipalities of the departments of
Caaguazu, Alto Parana, Amambay and
Canendiyu. In the other 13 departments
PALAU there is no or negligible transmission risk.
Yellow fever A yellow fever vaccination Recommended prophylaxis in risk areas:
certificate is required from all travellers CHL.
over 1 year of age coming from infected
areas of from countries in any part of which
yellow fever is endemic. PERU
PANAMA certificate is required from travellers over
6 mouths of age coming from infected
Yellow fever - A yellow fever vaccination areas and is recommended for those who
certificate is recommended for all travellers intend to visit jungle areas of the country
going to the Province of Darien. below 2300m.
Malaria - Malaria risk-P.vivax (over Malaria - Malaria risk - P.vivax (80%)
87%).P .falciparum (over 12%)- is moder- P.falciparum (20%)-is high in 21 of the
ate throughout the year in only three prov- 33 sanitary regions, including Loreto.
inces. Bocas de Toro in the west and Darien Adre de Dios. Luciano Castilio, Jaen,
and San Blas in the east. In the other six Junin, San Martin, Licayali, Cerro de Pasco,
provinces there is no or negligible risk of Piura. Ayacucho and Tumbes. Transmission
OF p. falciparum is restricted to Luciano

Castillo, Loreto, Jaeri, Piura, San Martin, QATAR
Lumbayeque and Tumbes. Chloroquine- Novaccinationrequirementsf
resistant P.falciparum detected in Piura, national traveller.
Loreto and Luciano Castiilo:
Recommended prophylaxis in risk areas :
C+P in t Luciano Castillo, Loeto Piura
MEF. REPUBLIC OF KOREA
No vaccination requirements for any in
national traveller.
PHILIPPINES
1 year of age arriving within 6 days from REPUBLIC OF MOLDOVA
infected areas. No vaccination requirements for any in
Malaria - Malaria risk exists throughout national traveller.
the year in areas below 600m, axcept in the
provinces of Bohol, Cutanduanes, Cebu
and metropolitan Manila. n-No risk consid-
ered in exist in urban areas or in the plains- REUNION
Chloroquine-resistant P.falciparum re-
ported. Yellow fever - A yellow fever vaccination
1 year of coming from infected areas.
PITCAIRN
Yellow fever -A yellow fever vaccination ROMANIA
certificate is required from travellers over No vaccination requirements for any in
national traveller.
POLAND
RUSSIAN FEDERATION
national traveller.
No vaccination requirements for any in
national traveller.
PORTUGAL
RWANDA
1 year of age coiming from infected areas.
The requirement applies only to travellersYellow fever - A yellow fever vaccination
arriving in or bound for the Azores and certificate is required from all travellers
Madeira.However, no certificate1 yearis re-
of age.
quired from passengers in transit at Funchal, Malaria - Malaria risk-predominantly in
Porto Santa and Santa Maria. the malignant (P.falaciparum) form-exists
throughout the year in thewhole country.
PUERTO RICO
quine and resistant to sulfadoxine-pyri-
methamine reported.
national traveller.
SAINT HELENA SAUDI ARAB1A

1 year of age coming from infected areas. coming from countries, any parts of which
are infected.
SAINT KITTS AND NEVIS Malaria - Malaria risk-predominantly in
Yellow fever - A yellow fever vaccination THE malignsnt (P.falciparum) form-exists
throughout
certificate is required from travellers over the year in most of the Southern
1 year of age coming from infected areas. Region (except in the high altitude areas of
Asii Province) and in certain rural areas of
the Western Region Chloroquine-resistant
SAINT LUCIA P.falciparum reported.
Yellow fever - A yellow fever vaccination Recommended prophylaxis in risk areas : C+P
SENEGAL
SAINT PIERRE AND MIQUELON Yellow fever - A yellow fever vaccination
No vaccination requirements for any inter- certificate is required from travellers comm
national traveller. ing from endemic areas.
SAINT VINCENT AND THE throughout the year in the whole country.
GRENADINES There is less risk from January through
Yellow fever - A yellow fever vaccination June in the central western regions. Resis-
tance to chloroquine reported.
1 year of age coming from infected areas. Recommended prophylaxis : MEF.
SAMOA SEYCHELLES
certificate is required from travellerscertificate
over is required from travellers over
1 year of age coming from infected areas. 1 year of age coming from infected areas or
who have passed from through partly or
endemic areas within the preceding 6 days.
S W MARINO The countries and areas included in the en-
national traveller. are considered as infected areas.
There is no risk of contracting malaria at
yellow fever in Seychelles.
SAO TOME AND P R I C I P E
certificate is required from all travellers SIERRA LEONE
over 1 year of age. Yellow fever - A yellow fever vaccination
certificate is required from travell
Malaria - Mafaria risk-predominantly in ing from infected areas.
throughout the year. Chloroquine-resistant
P.falciparum reported.

Malaria - Malaria risk-predominantly in throughout the year in the whole country.

the malignant (P.falciparum)form-exists Resisntance to chloroquine re
Recommended
throughout the year in the whole country. prophylaxis : MEF.
Resistance to chloroquine reported.
S O U T H AFRICA
SINGAPORE Yellow fever - A yellow fever vaccination
certificate is required from travellers
Yellow fever - A yellow fever vaccination:
certificate is required from travellers over 1 year of age coming from infected areas.
1 year of age coming from infected areas. The countries or ares included in the en-
Certificates of vaccination are requireddemic zone in Africa and the Americas (see
from travellers over 1 year of age who, maps 1 and 2, pp. 14-15) area regarded as
within the proceding 6 days. have been in
infected.
or have passed though any country partly
or wholly endemic for yellow fever. The the malignant (P. falciparum) f o r m - e x i s t s
countries amd areas included in the endemic
zones (see maps 1 and 2. pp 14-15) are throughout the year in the low altitude areas
of the Northern Province, Mpumalanga
considered as infected areas. Province (including the Kruger National
Park) and north-eastern KwaZulu/Natal as
SLOVAKIA Far south as the Tugelu river. Risk is
highest from October to May. Resistance to
Novaccinationrequirementsforanyinter-
chloroquine reported.
national traveller. Recommended prophylaxis in risk areas : C
SLOVENIA
No vaccination requirements for any inter- SPAIN
national traveller.
national traveller.
S O L O M O N ISLANDS
Yellow fever - A yellow fever vaccination SRI LANKA
certificate is required from travellers com- Yellow fever - A yellow fever vaccination
ing from infected areas. certificate is required from travellers over
Maliaria - Malaria risk exists throughout 1 year of age coming from infected areas.
the year except in a few eastern and Malaria - Malaria risk-predominantly in
southern outlying islets. Chloroquine- the benign (P.vivax) form-exists through-
resistant P.falciparum repoerted. out the year whole country excluding
the districts of Colombo, Kalutara and
Nuwara Eliya. Chloroquine-resistant
SOMALIA P.falciparum reported.
Yellow f e v e r - A yellow fever vaccination Recommended prophylaxis : C+P
certificate is required from travellersS com-
UDAN
ing from infected areas. Yellow fever - A yellow fever vaccination
Malaria - Malaria risk-predominantly in certificate is required from
the malignant (P.falciparum) form-exists 1 year of age coming from infected areas.
are considered as infected areas. A
certificate may be required from travellers
SWITZERLAND
leaving Sudan.
Malaria - Malaria risk- predominantly in No vaccination requirements for any inter-
the malignant (P. fafalciparum) form-exists national traveller.
Risk is low and seasonal in the north.It is SYRIAN ARAB REPUBLIC
higher along the Nile south of Lake Nasser Yellow fever - A yellow fever vaccination
and in the central and Southern part of the certificate is required from travellers com-
country. Malaria risk on the Red Sea coast is ing frominfected areas.
very limited Highly chloroquine-resistant
P.falciparum reported. Malaria - Malaria risk-exclusivaly in the
benign (P.vivax) form exists locally along
the northern border especially in the north-
east part of the country from May through
SURINAME October.
Yellow fever - A yellow fever vaccination Recommended prophylaxis in risk areas :
certificate is required from travellers com- CHL.
TAJIKISTAN
Malaria - Malaria risk-predominantly iu
the malignant (P.falciparum) form-is high No vaccination requirements for any inter-
throughout the year in the three southern national traveller.
districts of the country. In Paramaribo City Malaria - Malaria risk-predominantly in
and the other seven coastal districts. trans- the benign (P.vivax) form-exists in some
mission risk is low or negligible. C hloro- central and western areas and particularly in
quine-resistant P.falciparum and some southern border areas. Chloroquine-resis-
quinine resistance reported. tant P.falciparum suspected in some areas.
Recommended prophylaxis in risk areas : Recommended prophylaxis in risk areas :
MEF. CHL.
SWAZILAND THAILAND
Yellow fever - A yellow fever vaccination YelLOW fever - A yellow fever vaccination
certificate is required from travellers com- certificate is required from travellers over
ing from infected areas. 1 year of age coming from infected areas.
demic zones (see map 1 and 2, pp 14-15)
throughout the year in all low void areas are considered as infected areas.
(mainly Big Bend, Mhlume Simunye and Malaria - Malaria risk exists throughout the
Tshaneni) Highly chloroquine-resistant year in rural, especially forested and hil
P. falciparum reported. eas of the whole country mainly towards the
Recommended prophylaxis in risk areas: international borders. There is no risk in cit-
MEF. ies the main tourists resorts (e.g. Bangkok,
Chiangmai, Pauaya, Phuket, Samui) P. falci-
parum highly resistant to chloroquine and
SWEDEN resistant to sulfadoxine-pyrimethamine re-
ported. Resistance to mefloquine and to qui-
No vaccination requirements for any inter- nine reported from areas near the borders
national traveller. with Cambodia and Myanmar.
MEF: in areas near Cambodia and Myanmar
See pp. 10-11 and map 1. p. borders.
14 DOX
COUNTRY LIST OF VACCINATION REQUIREMENTS 39
THE FORMER YOGOSLAV TURKMENISTAN

REPUBLIC OF MACEDONIA Yellow fever - A yellow fever vaccination
No vaccination requirements for any inter- certificate is required from travellers com-
national traveller. ing from endemic areas.
Malaria - anly imported cases of malaria
have been reported during the last 2 years.
TOGO Recommended prophylaxis : --
certificate is reqiured from all travellers
over 1 year of age. TUVALU
Malaria -Malaria risk-predominantly in the No vaccination requirements for any inter
malignant (P.falciparum) form-exists through- national traveller.
out the year in the whole country. Chloro-
quine-resistant P.falciparum reported.
recommended prophylaxis : MEF
UGANDA
TOKELAU certificate is required from travellers over
Same requirements as New Zealand, 1 year of age coming endemic areas.
TONGA the malignant (P. falciparum) form-exists
throughout the year in the whole country
Yellow fever - A yellow fever vaccination including the main towns of Fort Portal.
Tinja, Kampala, Mbale and parts of Kigezi.
1 year of age coming from infected areas.Resistance to chloroquine reported.
TRINIDAD AND TOBAGO
Yellow fever - A yellow fever vaccination UKRAINE
certificat is required from travellers over No vaccimation requirements for any inter-
1 year of age coming from infected areas;
national traveller.
TUNISIA
UNITED ARAB EMIRATES
certificate is required from travellersNo vaccination requirement for any inter-
over
1 year of age coming from infected areas. national traveller.
Malaria - Malaria is not considered to be
risk in the Emirate of Abu Dhabi and the
TURKEY cities of Dubai, Sharjah, Ajman and Umm
No vaccination requirements for any inter- al Qaiwain. There is malaria risk in the
national traveller. foothill areas and valleys ini the moun-
Malaria - Potential malaria risk- exclu- tainous regionss of the northern Emirates.
sively in the benign (P.vaivax) form-exists
from April through Otober in the south-east Recommended prophylaxis in risk areas:C+P
of the country.There is no malaria risk in the
main tourist areas in the west and south-west
of the country.
Recommended prophylaxis in risk areas:CHL.
UNITED KINGDOM (with Channel VENEZUELA

Islands and Isle of Man) No vaccination requirements for any inter-
No vaccination requirements for any inter-national traveller.
national traveller. Malaria - Malaria risk in the benign (P.
vivax) form exists throughout the year
in some rural areas of Apure, Amazonas
UNITED REPUBLIC Of TANZANIA Barinas, Bolivar, Sucre and Tachira states
Yellow fever - A yellow fever vaccination Risk of P.falciparum Malariis restricted to
certificate is required from travellers over municipalities in jungle areas of Amazonas
1 year of age coming from infected areas. (Atabapo), Bolivar (Cedeno, Gran Sabana,
The countries and areas included in the en- Sifontes. Raul Lconi and Sucre) and Delta
Amacuro ( Antonia Diaz, Casacoima and
demic zones (see maps 1 and 2. pp. 14-15)
Pedemales) Isolated cases of chloroquine-
are considered as infected areas.
resistant falciparum malaria reported
Malaria - Malaria risk-predominantly in Recommended prophylaxis : CHL in
the malignant (P. falciparum) form-exists P.vivax risk areas : C+P in P.falciparum
throughout the year in the whole country risk areas.
below 1800 m. P. falciparum highly re-
sistant to chloroquine and resistant to sul-
fadoxine pyrimethamine reported. VIET NAM
Recommended prophylaxis : MEF. Yellow fever - A yellow fever vaccination
UNITED STATES OF AMERICA
Malaria - Malaria risk exists in the whole
No vaccination requirements for any inter- country, excluding urban centres, the Red
national traveller. River delta, and the coastal plains north of
Nha Tang. The risk is generally highest in
the highland areas. Most cases are caused by
URUGUAY P.falciparum, which in most areas is highly
resistant to chloroquine and sulfadoxine-
pyrimethatmine.
national traveller.
Recommended prophylaxis: MEF
UZBEKISTAN VIRGIN ISLANDS (USA)

VANUATU
WAKE ISLAND
No vaccination requirements for any inter- No vaccination requirements for any inter-
Malaria — Malaria risk-predominantly in
the malignant (P.falciparum) form-exists YEMEN
throughout the year in the whole country Yellow fever - A yellow fever vaccination
excluding Futuna Island P. falciparumcertificate is required from travellers over
highly resistant to chloroquine and resistant 1 year of age coming from infected areas.
to sulfadoxine-pyrimethamine reported.
P.vivax resistant chloroquine reported.
Recommended prophylaxis : C+P see pp. 10-11 and map 2. p. 15
COUNTRY LIST OF VACCINATION REQUIREMENTS ii
Malaria - Malaria risk predominantly in Malaria - Malaria risk predominantly in

the malignant (P.falciparum) form-exists the malignant (P.falciparum) form-exists
throughout the year, but mainly from throughout the year in the whole country.
Septmber through February, in the whole Highly chloroquine-resistant P.falciparum
country excluding Aden and airport per- reported.
imeter. Resistance to chloroquine reported. prophylaxis : MEF
Recommended
YUGOSLAVIA
No vaccination requirements inter- ZIMBABWE
national traveller.
ZAIRE see DEMOCRATIC ing from infected areas.
REPUBLIC OF THE CONGO Maliaria - Malaria risk-predominantly in
ZAMBIA from November through June in areas
below 1200 m and throughout the year
Yellow fever - No vaccination require-
ments for any international traveller. in the Zambezi valley. In Harare and
Bulawayo, the risk is negligible. Resistance
to chloroquine reorted.
4. GEOGRAPHICAL DISTRIBUTION OF POTENTIAL
HEALTH HAZARDS TO TRAVELLERS
This section is intended to give a broad indication of the health risks to

which travellers may be exposed in various areas of the world and which they
may not encounter in their usual place of rest
In practice, to identify areas accurately and define the degree of risk Like
in each of them is extremely difficult, if not impossible. For example, viral
hepatitis. A is ubiquitous but the risk of infection varies not only according
to area bill also according to rating habits; hence, there may be more risk
from communal eating in an area of low incidence than from eating in
private home in an area of high incidence. Generalizations may therefore be
misleading, Current efforts to eradicate poliomyelitis worlwide are signifi-
cantly reducing the risk of infection with wild poliovirus in almost all en-
areas.
Another foctor is that tourism is an important source of income for many
countries and to label specific areas as being of high risk for a disease may he
misinterpreted. However, this does not absolve national health administra-
tions from their responsibility to provide an accurate picture of the risks from
communicable diseases that may be encountered in various parts of their
countries.
4.1 Africa
Northern Africa (Algeria, Egypt, Libyan Arab .Jamahiriya. Morocco, and
Tunisia) is characterized by a generally fertile coastal area and a desert
hinterland with oases that are often foci of infections.
The arthropod-borne diseases are unlikely to be a major problem to the
traveller, although Hlariasis ( locallyIn the Nile delta), leishmaniasis.
malaria. relapsing fever. Rift Valley fever, sandly fever, typhus. and West
fevet occur in some areas.
Food-borne and water borne diseases are endemic, the dysenteries and
other diarrhocal diseases being particularly common. Hepatitis A occurs
throughout the area and hepatitis 1Z is endemic in some regions. The typhoid
fevers are common in some areas Alimentary helminthic infections
brucellosis and giardiasis are common. Echinococcosis (hydatid disease)
and sporadic of cholera may occur.
Other hazards. Poliomyelitis eradication efforts in northern Africa ha
successful and virus transmission in most of the area may be inter-
rupted. Egypt is the only country where confirmed cases of poliomyelitis
_ 43 _
were still reported in 1997. Trachoma, rabies (see pp. 58-59), snakes and
scorpions are hazards in certain areas. Schistosomiasis (bilharziasis) is
prevalent both in the Nile delta area and in the Nile valley: it occurs locally
elsewhere in the area.
Sub-Saharan Africa (Angola. Benin. Burkina Faso. Burundi, Cameroon,

Cape Verde, Central African Republic, Chad, Comoros, Congo, Cote
d'lvoire. Democratic Republic of the Congo. Djibouti. Equatorial Guinea.
Eritrea, Ethiopia, Gabon. Gambia, Ghana. Guinea, Guinea-Bissau. Kenya,
Liberia, Madagascar. Malawi. Mali. Mauritania, Mauritius. Mozambique,
Niger. Nigeria, Reunion. Rwanda. Sao Tome and Principe. Senegal.
Seychelles. Sierra Leone. Somalia. Sudan. Togo. Uganda. United Republic
Of Tanzania, Zambia, and Zimbabwe). In this area, entirely within the trop-
ics, the vegetation varies from the tropical rain forests of the west and centre
to the wooded steppes of the east, and from the desert of the north through
the Sahel and Sudan savannas to the moist orchard savanna and woodlands
north and south of the equator.
Many of the diseases listd below occur in localized loci and are confined
to rural areas. They are mentioned so that the international traveller and the
medical practitioner concerned may be aware of the diseases that may occur.
Arthropod-borne diseases are a major cause of morbidity. Malaria occurs
throughout the area, except at over 2600 metres altitude and in the islands of
Reunion and the Seychelles. Various forms of filariasis are widespread;
endemic foci of onchocerciasis (river blindness) exist in all the countries
listed except in the greater pan of Kenya and in Djibouti. Gambia.
Mauritania, Mozambique. Somalia, Zambia. Zimbabwe, and the island
countries of the Atlantic and Indian Oceans. However, onchocerciasis exists
in the island of Bioko. Equatorial Guinea. Both cutaneous and visceral
leishmaniasis may be found, particularly in the drier areas. Visceral
leishmaniasis is epidemic in Eastern and Southern Sudan. Human
trypanosomiasis (sleeping sickness), in discrete foci, is reported from all
countries except Djibouti. Eritrea, Gambia, Mauritania. Niger, Somalia, and
the island countries of the Atlantic and Indian Oceans. The transmission rate
of human trypanosomiasis is high in Sudan and Uganda and very high in
Angola and the Democratic Republic of the Congo, and there is a significant
risk of infection for travellers visiting or working in rural areas. Relapsing
fever and louse-, flea- and tick-borne typhus occur. Natural foci of plague'
have been reported from Angola, the Democratic Republic of the Congo.
Kenya, Madagascar, Mozambique. Uganda, the United Republic of
Tanzania, and Zimbabwe. Tungiasis is widespread. Many viral diseases,
some presenting as severe haemorrhagic fevers, are transmitted by
mosquitos, ticks, sandflies, etc.. which are found throughout this region.
Large outbreaks of yellow fever occur periodically in the unvaccinated
population.
1
A natural focus of plague is a strictly delimited area where ecological conditions ensure
the persistence of plague in wild rodents (and occasionally other animals.) for long periods of
time, and where epizootics and periods of guiescence may alternate.
GEOGRAPHICAL DISTRIBUTION Of HEALTH HAZARDS 45
Food-home and water-borne diseases are highly endemic. Alimentary

helminthic infections, the dysenteries and diarrhoeal diseases, including
giardiasis, the typhoid fevers and hepatitis A and E are widespread. Cholera
is actively transmitted in many countries in this area. Dracunculiasis occurs
in isolated foci. Paragonimiasis (oriental lung fluke) has been reported from
Cameroon. Gabon. Liberia, and most recently from Equatorial Guinea
Echinococcosis (hydatid disease) is widespread in animal-breeding areas.
Other diseases. Hepatitis B is hyperendemic. Poliomyelitis (also a food-
borne or water-borne disease) is probably endemic in most countries except
Cape Verde. Comoros, Mauritius, Reunion and the Seychelles. Schisto-
somiasis (bilharziasis) is present throughout the area except in Cape Verde.
Comoros. Djibouti. Reunion and the Seychelles. Trachoma is widespread.
Among other diseases, certain, frequently fatal, arenavirus haemorrhagic
fevers have attained notoriety, Lassa fever has a virus reservoir in a com-
monly found multimammate rat. Studies have shown that an appreciable res-
ervoir exists in some rural areas, of West Africa, and people visiting these
areas should take particular care to avoid rat-contaminated food or food con-
tainers, but the extent of the disease should not be exaggerated Ebola and
Marburg haemorrhagic fevers are present, but reported only infrequently.
Epidemics of meningococcal meningitis may occur throughout tropical
Africa, particularly in the savanna areas during the dry season.
Other hazards include rabies (see pp. 58-59) and snake bites.
Southern Afiica (Botswana. Lesotho. Namibia, Saint Helena. South Africa.

and Swaziland) varies physically from the Namib and Kalahari deserts to
fertile plateaux and plains and to the more temperate climate of the southern
coast.
Anhropod-bome diseases such as Crimean-Congo haemorrhagic fever,
malaria, plague, relapsing lever. Rift Valley fever, tick-bite fever, and
typhus-mainly tick-borne-have been reported from most of this area except
Saint Helena, but. apart from malaria in certain areas, they are unlikely to be
a major health problem for the traveller. Trypanosomiasis (sleeping sickness)
may occur in Botswana and Namibia.
Food-borne and water-borne diseases are common in some areas, par-
ticularly amoebiasts and the typhoid fevers. Hepatitis A occurs in this area.
Other diseases. The southern African countries are on the verge of becom-
ing poliomyelitis- free. and the risk of poliovirus infection is now low. Hepa-
titis B is hyperendemic. Schistosomiasis (bilharziasis) is endemic in
Botswana. Namibia, South Africa and Swaziland. Snakes may be a hazard in
some areas.
4.2 The Americas
In 1994, an international commission certified the eradication of endemic

wild poliovirus from the Americas. Ongoing surveillance in formerly en-
demic Central and South American countries confirms that poliovirus trans-
mission remains interrupted.
North America (Bermuda, Canada. Greenland, Saint Pierre and Miquelon,

and the United States of America (with Hawaii)) extends from the Arctic to
the subtropical cays of the southern USA.
The incidence of communicable diseases is such that they are unlikely to
prove a hazard for the international traveller greater than thai found in his or
her own country. There are. of course, health risks, but in general the pre-
cautions required are minimal. Certain diseases occasionally occur, such as
plague, rabies in wildlife including bats'. Rocky Mountain spotted lever,
tularaemia, and arthropod-borne encephalitis. Recently, rodent-borne hanta-
virus has been identified, predominantly in the western states of the USA
and the south-western provinces of Canada. Lyme disease is endemic in the
north-eastern. mid-Atlantic and upper mid-western USA. Occasional cases
have been reported from the Pacific north-west During recent years, the
incidence of certain food-borne diseases, e.g. salmonellosis, has increased in
some regions. Other hazards include poisonous snakes, poison ivy and
poison oak. In the north, a serious hazard is the very low temperature in the
winter
In the USA. proof of immunization against diphtheria, measles, polio-
myelitis, and rubella is now universalis required for entry into school In
addition, the school entry requirements of most states include immunization
against tetanus (49 states), pertussis (44 states), and mumps (42 states).
Mainland Middle America (Belize. Costa Rica, El Salvador. Guatemala.

Honduras. Mexico. Nicaragua, and Panama) ranges from the deserts of the
north to the tropical rain forests of the south-east.
Of the arthropod-borne diseases, malaria and cutaneous and mucocuta-
neous leishmaniasis occur in all eight countries. Visceral leishmaniasis
occurs in Ml Salvador, Guatemala, Honduras and Mexico. Onchocerciasis
(river blindness) is found in two small foci in the south of Mexico and four
dispersed foci in Guatemala. American trypanosomiasis (Chagas disease)
lias been reported to occur in localized foci in rural areas in all eight coun-
tries, Bancroftian filariasis is present in Costa Rica. Dengue fever and
Venezuelan equine encephalitis may occur in all countries.
The food-home and water-borne diseases, including amoebic and bacil-
lary dysenteries and other diarrhoeal diseases, and the typhoid fevers are very
common throughout the area. All countries except Panama reported cases of
cholera in 1996. Hepatitis A occurs throughout the area and hepatitis E has
been reported in Mexico. Helminthic infections are common. Parago-
nimiasis (oriental lung fluke) has been reported in Costa Rica. Honduras and
Panama. Brucellosis occurs in the northern part of the area. Many Salmo-
nella typhi infections from Mexico and Shigella dysenteriae type I infec-
tions from mainland Middle America as a whole have been caused by
drug-resistant enterobacteria.
Other diseases. Rabies in animals (usually dogs and bats! is widespread
throughout the area (see pp. 58-59). Snakes may be a hazard in some areas.
Caribbean Middle America (Antigua and Barbuda. Aruba, Bahamas,
Barbados, British Virgin Islands, Cayman Islands. Cuba, Dominica.
GEOGRAPHICAL DISTRIBUTION OF HEALTH HAZARDS 47
Dominican Republic. Grenada. Guadeloupe, Haiti. Jamaica, Martinique,

Montserrat. Netherlands Antilles. Puerto Rico. Saint Kitts and Nevis. Saint
Lucia. Saint Vincent and the Grenadines. Trinidad and Tobago, Turks and
Caicos Islands, and the Virgin Islands (USA)). The islands, a number of
them mountainous with peaks 1000-2500 m high, have an equable tropical
climate with heavy rain storms and high winds at certain limes of the year.
Of the arthropod-borne diseases, malaria occurs in endemic form only in
Haiti and in parts of the Dominican Republic- Diffuse cutaneous leish-
maniasis was recently discovered in the Dominican Republic, Bancroftian
filariasis occurs in Haiti and some other islands and oilier filariases may
occasionally be found. Human fascioliasis due to Fasciola hepatica is en
demic in Cuba. Outbreaks of dengue fever occur in the area, and dengue
hemorrhagic fever has also occurred. Tularaemia has been reported from
Haiti.
Of the food-borne and water-home diseases, bacillary and amoebic dys-
enteries are common and hepatitis A is reported particularly in the northern
islands. No cases of cholera have been reported in the Caribbean.
Other diseases. Schistosomiasis (bilharziasis) is endemic in the Do-
minican Republic. Guadeloupe. Martinique. Puerto Rico, and Saint Lucia.
in each of which control operations are in progress, and it may also occur
sporadically in oilier islands. Other hazards may occur from spiny sea-
urchins and coelenterates (corals and jellyfish) and snakes. Animal
rabies, particularly in the mongoose, is reported from several islands (see
pp. 58-59).
Tropical South America (Bolivia. Brazil. Colombia. Ecuador, French

Guiana, Guyana, Paraguay, Pern, Suriname. and Venezuela) covers the
narrow coastal strip on the Pacific Ocean, the high Andean range with
numerous peaks 5000-7000 m high, and the tropical rain forests of the
Amazon basin, bordered to the north and south by savanna zones and dry
tropical forest or scrub.
Arthropod-borne diseases are an important cause of ill health in rural
areas. Malaria occurs in all ten countries or areas, as do American trypa-
nosomiasis (Chagas disease) and cutaneous and mucocutaneous leish-
maniasis. There has been an increase of the latter in Brazil and Paraguay.
Visceral leishmaniasis is endemic in north-east Brazil, with foci in other
parts of Brazil, less frequent in Colombia and Venezuela, rare in Bolivia and
Paraguay, and unknown in Peru. Endemic onchocerciasis occurs in isolated
foci in rural areas in Ecuador. Venezuela and northern Brazil. The bites of
blackflies may cause unpleasant reactions. Bancroftian filariasis is endemic
in parts of Brazil. Guyana and Suriname. Plague has been reported in natural
foci (see footnote 1. p. 44) in Bolivia. Brazil. Ecuador and Peru. Among the
arthropod-borne viral diseases, jungle yellow fever may be found in forest
areas in all countries except Paraguay and areas east of the Andes; in Brazil
it is confined to the northern and western slates. Epidemics of viral encepha-
litis and dengue fever occur in some countries of this area. Bartonellosis. or
Oroya fever, a sandfly-borne disease, occurs in and river valleys on the
western slopes of the Andes up to 3000 m. Louse-borne typhus is often

found in mountain areas of Colombia and Peru.
Food-borne and water-borne diseases are common and include amoebisa
sis, diarrhoeal diseases, helminthic infections, and hepatitis A. Paragoni-
miasis (oriental lung fluke) has been reported from Ecuador. Peru and
Venezuela. Brucellosis is common and echinococcosis (hydatid disease)
occurs particularly id Peru. Bolivia. Brazil. Colombia. Ecuador, Peru, and
Venezuela all reported autochthonous cases of cholera in 1996.
Other diseases include rodent-borne arenavirus haemorrhagic fever In
Bolivia and Venezuela, and rodent-borne pulmonary syndrome in Brazil
and Paraguay. Hepatitis B and D (delta hepatitis) are highly endemic in the
Amazon basin. The intestinal form of schistosomiasis (bilharziasis) is found
in Brazil, Suriname, and north-central Venezuela.
Rabies has been reported from many of the countries in this area (see
pp. 58-59).
Meningococcal meningitis occurs in the form of epidemic outbreaks in
Brazil.
Snakes and leeches may be a hazard in some areas.
Temperate South America (Argentina, Chile. Falkland Islands (Malvinas),

and Uruguay). The mainland ranges from the Mediterranean climatic area
of the western coastal strip over the Andes divide on to the steppes and
desert of Patagonia in the south and to the prairies of the north-east.
The arthropod-horne diseases are relatively unimportant except for the
occurrence of American trypanosomiasis (Chagas disease) Outbreaks of
malaria occur in north-western Argentina, and cutaneous leishmaniasis is
also reported from the north-eastern part of the country.
Of the food-borne and water-borne diseases, gastroenteritis ( mainly
salmonellosis) is relatively common in Argentina, especially in suburban
areas and among children below the age of 5 years. Some cases of cholera
were reported from Argentina in 1996. Typhoid fever is not very common in
Argentina but hepatitis A and intestinal parasitosis are widespread, the latter
especially in the coastal region. Taeniasis (tapeworm), typhoid fever, viral
hepatitis, and echinococcosis (hydatid disease) are reported from the other
countries.
Other diseases. Anthrax is an occupational hazard in the three mainland
countries. Meningococcal meningitis occurs in the form of epidemic out-
breaks in Chile. Rodent-borne hantavirus pulmonary syndrome has been
identified in the north-central and south-western regions of Argentina and in
Chile.
4.3 Asia
East Asia (China (including Hong Kong Special Administrative Region).

the Democratic People's Republic of Korea. Japan. Macao. Mongolia, and
the Republic of Korea). The area includes the high mountain complexes, the
peninsula; opisthorchiasis (cat liver fluke) in the Indochina peninsula, the

Philippines and Thailand; and paragonimiasis (oriental long fluke) in most
Countries. Melioidosis can occur sporadically throughout the area.
Other diseases. Hepatitis B is highly endemic. Schistosomiasis (bilharzia-
sis) is endemic in the southern Philippines and in central Sulawesi (Indo-
nesia) and occurs in small foci in the Mekong delta in Viet Nam. The only
known remaining locus of poliovirus transmission is in the Mekong delta
area of Cambodia and southern Viet Nam. Poliovirus transmission has prob-
ably been interrupted in the Lao People's Democratic Republic, Malaysia
and the Philippines, and is very low in Indonesia. Myanmar and Thailand.
Trachoma exists in Indonesia. Myanmar. Thailand and Viet Nam.
Other hazards include rabies (see pp. 58-59), snake bites and leeches.
Middle South Asia (Afghanistan, Armenia, Azerbaijan. Bangladesh. Bhutan.

Georgia, India. Islamic Republic of Iran. Kazakstan, Kyrgyzstan, Maldives
Nepal, Pakistan. Sri Lanka. Tajikistan. Turkmenistan, and Uzbekistan).
Bordered for the most part by high mountain ranges in the north, the area
extends from steppes and desert in the west to monsoon and tropical rain
forests in the east and south.
Arthropod-borne diseases are endemic in all of these countries except for
malaria in Georgia, Kazakstan. Kyrgyzstan, the Maldives. Turkmenistan
and Uzbekistan-There are small foci of malaria in Armenia. Azerbaijan and
Tajikistan, In some of the other countries malaria occurs in urban as well as
rural areas. Filariasis is common in Bangladesh. India and the south-western
coastal belt of Sri Lanka. Sandfly fever is on the increase. A sharp rise in the
incidence of visceral leishmaniasis has been observed in Bangladesh. India
and Nepal, in Pakistan, it is mainly reported from the north (Baltistan).
Cutaneous leishmaniasis occurs in Afghanistan, India (Rajasthan). the
Islamic Republic of Iran, and Pakistan. There are very small foci of cutan-
eous and visceral leishmaniasis in Azerbaijan and Tajikistan. There is evi-
dence that natural foci of plague (see footnote I. p. 44) exist in India and
Kazakstan. An outbreak of plague occurred in India in 1994. Tick-borne
relapsing fever is reported from Afghanistan. India and the Islamic Republic
of Iran, and typhus occurs in Afghanistan and India. Outbreaks of dengue
fever may occur in Bangladesh. India. Pakistan and Sri Lanka, and the
haemorrhagic form has been reported from eastern India and Sri Lanka.
Japanese encephalitis has been reported from the eastern part of the area and
Crimean-Congo haemorrhagic fever from the western part. Another tick-
borne haemorrhagic fever has been reported in forest areas in Karnataka
State in India and in a rural area of Rawalpindi District in Pakistan.
Food-home and water-borne diseases are common throughout the area, in
particular cholera and other watery diarrhoeas, the dysenteries, typhoid fever,
hepatitis A and E. and helminthic infections. Large epidemics of hepatitis E
can occur. Giardiasis is common in the area. Brucellosis and echinococcosis
(hydatid disease) are found in many countries in the area.
Other diseases. Hepatitis B is endemic. A very limited focus of urinary
schistosomiasis (bilharziasis) persists in the south-west of the Islamic
Republic of Iran. Outbreaks of meningococcal meningitis have been re-
ported in India and Nepal. Poliomyelitis eradication activities have begun in
desert and the steppes of the west, and tne various forest zones of the east.
down to the suhtropical forests of the south-east.
Among the arthropod-borne diseases, malaria occurs in China, and in
recent years cases have also been reported from the Korean peninsula.
Although reduced in distribution and prevalence, bancroftian and brugian
filariasis are still reported in southern China. A resurgence of viscera!
leishmaniasis is occurring in China. Cutaneous leishmaniasis has been re-
cently reported from Xinjiang. Uygur Autonomous Region. Plague may be
found in China and Mongolia. Haemorrhagic fever with renal syndrome -
rodent-borne, Korean haemorrhagic fever - is endemic except in
Mongolia, and epidemics of dengue fever and Japanese encephalitis may
occur in some countries. Mite-borne or scrub typhus may be found in
Scrub areas in southern China, certain river valleys in Japan, and in the
Republic of Korea.
Food-borne and water-borne diseases such as the diarrhoeal diseases and
hepatitis A are common in most countries. Hepatitis E is prevalent in west-
ern China. Clonorchiasis (oriental liver fluke) and paragonimiasis (oriental
lung fluke) are reported in China. Japan. Macao and the Republic of Korea,
and fascioiopsiasis (giant intestinal fluke) in China. Brucellosis occurs in
China. Cholera may occur in some countries in this area.
Other diseases. Hepatitis B is highly endemic. The present endemic area of
schistosomiasis (bilharziasis) is in the central Chang Jiang (Yangtze) river ba-
sin in China; active foci no longer exist in Japan. Poliomyelitis eradication
activities have rapidly reduced poliovirus transmission in east Asia. Reli-
able surveillance data indicate that poliovirus transmission has been inter-
rupted in China since 1994. Mongolia also no longer reports cases. Tra-
choma and leptospirosis occur in China. Rabies is.endemic in some countries
(see pp. 58-59). Outbreaks of meningococcal meningitis occur in Mongolia.
Eastern South Asia (Brunei Darussalam. Cambodia. Indonesia, Lao

People's Democratic Republic. Malaysia. Myanmar. the Philippines. Singa-
pore. Thailand, and Viet Nairn. From the tropical rain and monsoon forests
of the north-west, the area extends through the savanna and the dry tropical
forests of the Indochina peninsula, returning to the tropica] rain and mon-
soon forests of the islands bordering the South China Sea.
The arthropod-borne diseases are an important cause of morbidity and
mortality throughout the area. Malaria and filariasis are endemic in many
parts of the rural areas of all the countries or areas-except for malaria in
Brunei Darussalam and Singapore, where normally only imported cases oc-
cur. Foci of plague (see footnote 1. p. 44) exist in Myanmar. Plague also
occurs in Viet Nam. Japanese encephalitis, dengue and dengue
haemorrhagic fever can occur in epidemics in both urban and ratal areas.
Mite-borne typhus has been reported in deforested areas in most countries.
Food-borne and water-borne diseases are common. Cholera and other
watery diarrhoeas, amoebic and bacillary dysentery, typhoid fever and hepa-
titis A and E may occur in all countries in the area. Among helminthic
infections, fascioiopsiasis (giant intestinal fluke) may be acquired in most
countries in the area: clonorchiasis (oriental liver fluke) in the Indochina
all countries in the area, rapidly reducing the risk of infection with wild
poliovirus. However, surveillance data are incomplete and poliovirus trans-
mission should still be assumed to be a risk to travellers in most countries,
especially in the Indian subcontinent. Trachoma is common in Afghanistan
and in parts of India, the Islamic Republic of Iran, Nepal and Pakistan.
Snakes and the presence of rabies in animals ( see pp. 58-59) are hazards in
most of the countries in the area.
Western South Asia (Bahrain. Cyprus, Iraq, Israel. Jordan. Kuwait. Lebanon.
Oman. Qatar. Saudi Arabia, Syrian Arab Republic. Turkey, the United Arab
Emirates, and Yemen ). The area ranges from the mountains and steppes of the
north-west to the large deserts and dry tropical scrub of the south.
The arthropod-borne diseases, except for malaria in certain areas, are not
a major hazard for the traveller. Malaria does not exist in Kuwait and no
longer occurs in Bahrain. Cyprus, Israel, Jordan, Lebanon or Qatar. Its inci-
dence in the Syrian Arab Republic and United Arab Emirates is low. but
elsewhere it is endemic in certain rural areas. Cutaneous leishmaniasis
reported throughout the area: visceral leishmaniasis, although rare through-
out most of the area, is common in central Iraq, in the south-west of Saudi
Arabia, in the north-west of the Syrian Arab Republic. in Turkey (south-east
Anatolia only) and in the west of Yemen. Murine and tick-borne typhus can
occur in certain countries. Tick-borne relapsing fever may occur. Crimean-
Congo) haemorrhagic fever has been reported from Iraq. Limited foci of
onchocerciasis are reported from Yemen.
The food-borne and water-borne diseases are, however, a major hazard in
most countries in the area, The typhoid fevers and hepatitis A exist in all
countries. Dracunculiasis occurs in isolated foci in Yemen. Taeniasis (tape-
worm) is reported from many countries in the area. Brucellosis is reported
from most countries and there are foci of echinococcosis (hydatid disease).
Other diseases. Hepatitis B is endemic- Schistosomiasis (bilharziasis)
occurs in Iraq, Saudi Arabia, the Syrian Arab Republic and Yemen. The risk
of poliovirus infection is low in most countries in the area, with the excep-
tion of Yemen. Trachoma and animal rabies (see pp. 58-59) are found in
many of the countries.
The greatest hazards to pilgrims to Mecca and Medina are heat and water
depletion if the period of the Hajj coincides with the hot season.
4.4 Europe
Northern Europe (Belarus. Belgium. Czech Republic. Denmark (with the

Faroe Islands), Estonia. Finland, Germany. Iceland, Ireland. Latvia.
Lithuania. Luxembourg. Netherlands, Norway, Poland, Republic of
Moldova, Russian Federation. Slovakia. Sweden. Ukraine, and the United
Kingdom (with the Channel Islands and the Isle of Man)). The area encom-
passed by these countries extends from the broadleaf forests and the plains
of the west to the boreal and mixed forest to be found as far east as the
Pacific Ocean.
The incidence of communicable diseases in most parts of the area is such

that they are unlikely to prove a hazard to the international traveller greater
than that found in his or her own country. There are. of course, health risks,
but in most of the area very few precautions are required.
Of the arthropod-borne diseases,, there are very small foci of tick-borne
typhus in east and central Siberia. Tick-borne encephalitis, for which a
vaccine exists, and Lyme disease may occur throughout forested area-
where vector ticks are found. Rodent-borne haemorrhagic fever with renal
syndrome is now recognized as occurring at low endemic levels in this area.
The food-borne and water-borne diseases reported-other than the ubiqui-
tous diarrhoeal diseases-are taeniasis (tapeworm) and trichinellosis in parts
of northern Europe, and diphyllobothriasis (fish tapeworm) from the fresh-
water fish around the Baltic Sea area. Fasciola hepatica infection can occur.
Hepatitis A occurs in the eastern European countries. The incidence of cer-
tain food-borne diseases, e.g. salmonellosis and campylobaeteriosis. is in-
creasing significantly in some countries.
Other diseases. Ail endemic countries in the area are now making intense
efforts to eradicate poliomyelitis. Within the Russian Federation, poliovirus
transmission remains a possibility only in the area of Chechenia. Rabies is
endemic in wild animals (particularly foxes) in rural areas of northern Eu-
rope (see pp. 58-59). In recent years. Belarus, the Russian Federation and
Ukraine have experienced extensive epidemics of diphtheria. Diphtheria
cases, mostly imported from these three countries, have also been reported
from neighbouring countries: Estonia, Finland, Latvia. Lithuania. Poland
and the Republic of Moldova.
A climatic hazard in pan of northern Europe is the extreme cold in winter.
Southern Europe (Albania. Andorra, Austria, Bosnia and Herzegovina.

Bulgaria. Croatia. France, Gibraltar. Greece. Hungary. Italy, Liechtenstein,
Malta. Monaco. Portugal (with the Azores and Madeira). Romania, San
Marino. Slovenia. Spain (with the Canary Islands). Switzerland. The Former
Yugoslav Republic of Macedonia, and Yugoslavia). The area extends from
the broadleaf forests in the north-west and (he mountains of the Alps to
the prairies and. in the south and south-east, the scrub vegetation of the
Mediterranean.
Among the arthropod-borne diseases, sporadic cases of murine and tick-
borne typhus and mosquito-borne West Nile fever occur in some countries
bordering the Mediterranean littoral. Both cutaneous and visceral leish-
maniasis and sandfly fever are also reported from this area. Leishmanial
HIV co-infections have been notified from France. Italy, Portugal and
Spain. Tick-borne encephalitis, for which a vaccine exists. Lyme disease
and rodent-borne haemorrhagic fever with renal syndrome may occur in the
eastern and southern parts of the area.
'The food-borne and water-borne diseases-bacillary dysentery and other
diarrhoeas, and typhoid lever-are more common in the summer and autumn
months, with a high incidence in the south-eastern and south-western parts
of the area. Brucellosis can occur in the extreme south-west and south-east
and echinococcosis (hydatid disease) in the south-east. Fasciola hepatica
infection has been reported from different Countries in this area. Hepatitis A
occurs in the eastern European countries. The incidence of certain food-

home diseases, e.g. salmonellosis and campylobacteriosis, is increasing sig-
nificantly in some countries.
Other diseases. All countries in southern Europe where poliomyelitis was
until recently endemic are conducting eradication activities, and the risk of
infection in most countries is very low. However, a large poliomyelitis out-
break occurred in 1996 in Albania, also affecting Greece and Yugoslavia: it
had been interrupted by the end of 1996. Hepatitis B is endemic in the south-
ern part of Eastern Europe (Albania. Bulgaria and Romania), Rabies in ani-
mals exists in most countries of southern Europe (sec pp. 58-59).
4.5 Oceania
Australia, New Zealand and the Antarctic. In Australia the mainland has
tropical monsoon forests in the north and east, dry tropical forests, savanna
and deserts in the centre, and Mediterranean scrub and subtropical forests in
the south. New Zealand has a temperate climate with the North island char-
acterized by subtropical forests and the South Island by steppe vegetation
and hardwood forests.
International travellers to Australia and New Zealand will, in general, not
be subjected to the hazards of communicable diseases to an extent greater
than that found in their own country.
Arthropod-borne disease (mosquito-borne epidemic polyarthritis and
viral encephalitis) may occur in some rural areas of Australia. Occasional
outbreaks of dengue have occurred in northern Australia in recent years.
Other hazards. Coelentcrates (corals, jellyfish) may prove a hazard to the
sea-bather, and heat is a hazard in the northern and central parts of Australia.
Melanesia and Micronesia-Polynesia (American Samoa. Cook Islands.

Easter Island. Fiji. French Polynesia. Guam. Kiribati, Marshall Islands,
Micronesia (Federated States of). Nauru. New Caledonia. Niue. Palan. Papua
New Guinea, Samoa. Solomon Islands, Tokelau. Tonga, Tuvalu. Vanuatu,
and the Wallis and Futuna Islands). The area covers an enormous expanse ol
ocean with the larger, mountainous, tropical, and monsoon rain-forest-
covered islands of the west giving way to the smaller, originally volcanic
peaks and coral islands of the east.
Arthropod-borne diseases occur in the majority of the islands. Malaria is
endemic in Papua New Guinea. Solomon Islands and Vanuatu. Filariasis is
widespread but its prevalence varies. Mite-borne typhus has been reported
from Papua New Guinea. Dengue fever, including its haemorrhagic form.
can occur in epidemics in most islands.
Food-home and water-borne diseases, such as the diarrhoeal diseases,
typhoid fever and helminthic infections, are commonly reported Biointoxi-
cation may occur from raw or cooked fish and shellfish. Hepatitis A occurs
in this area.
Other diseases. Hepatitis B is endemic. Poliomyelitis cases have not been
reported from any of these areas for more than live years. Trachoma occurs
in parts of Melanesia Hazards to bathers are the coelenterates, poisonous
fish and sea snakes.
5. HEALTH RISKS AND THEIR AVOIDANCE
5.1 Incidence of the major diseases that may arise from international
travel
Rare but dangerous diseases may sometimes attract attention at the ex-
pense of diseases that are considered trivial but that may often interfere with
travel. Fig. I shows the relative incidence of certain travel-related diseases
in travellers from Europe and North America.
5.2 Hazards related to the environment
5.2.1 Travel
In the age of jet travel, international travellers are subjected to various
forms of stress that may reduce their resistance to disease; crowding, long
hours of waiting, disruption of eating habits, changes in climate and time
zone. These factors may in themselves provoke nausea, indigestion, extreme
fatigue, and insomnia.1
The crossing of several time zones disrupts the sleeping and waking cycle,
producing jet-lag. The lime needed for complete readjustment depends on the
number of zones crossed and may be a week or longer. It is advisable to
schedule some periods of rest in the first few days after arrival. It may also be
useful to lake a short-acting sleeping pill for the first few nights after the
journey. People who have to take medication according to a strict time
schedule (e.g. insulin, contraceptive pill) should seek a doctor's advice.
It should be noted that, with pressurization, the oxygen level and atmo-
spheric pressure in the cabin of an aeroplane flying at an altitude of 12 000 m
are equivalent to conditions found at an altitude of 2000 m (see section
5.2.3).
Travel sickness is very rare in the case of air travel. However, people
travelling by boat-especially small boat-who have no experience of sea
travel would be wise to take supplies of an anti-seasickness drug. Travel-
sickness drugs and other medicines that need to be taken regularly should be
carried as hand baggage rather than as registered luggage.
2
See also section 5.9, "Special situations'', pp. 87-89.
— 55 —
Figure 1. Estimated monthly incidence of health problems per

100 0 0 0 travellers to developing countries
Infections Other problems
any health problem

traveller's diarrhoea (used medication or felt III)
fell III
consulted physician during travel

or on return home
malaria (no chemoprophylaxis, stayed in bed
West Africa) incapacity for work after return
acute febrile respiratory tract Infection
hospitalized abroad
hepatitis A
gonorrhoea
animal bite with rabies risk
hepatitis B (expatriates)
typhoid (India, north and air evacuation
north-west Africa. Peru)
HIV infection
typhoid (other areas)

poliomyelitis, asymptomatic
died abroad
Legionella infection
(Mediterranean)
cholera
paralytic poliomyelitis —
meningococcal disease
Adopted from Steffen R. Lobel HO. Travel medicine. In; Cook GC, ed. Manson's tropi-
cal diseases, 20th ed. London. WB Saunders. 1996. Used by permission of the publisher.
5.2.2 Bathing
Fresh water
Eye, ear. and intestinal infections may be contracted from polluted water.
In the tropics, watercourses, canals, lakes, etc. may be infested with larvae
that can penetrate the skin and cause schistosomiasis (bilharziasis). Bathing
and washing in waters likely to be infested with the snail host of this parasite
or contaminated with human and animal excreta should be avoided. Only
swimming pools containing chlorinated water may be considered safe for
bathing.
Swimming, fishing and walking barefoot in rivers or watery rice paddies,
or on muddy land, may expose travellers to leptospirosis infections, espe-
cially in south-east Asia and the western Pacific regions.
HEALTH RISKS AND THEIR AVOIDANCE 57
"Swimmer's itch" or cercarial dermatitis due to a wide range of trerna-

todes may be acquired in freshwater bodies of both temperate and tropical
zones. These cereariae penetrate the skin and die. causing a localized or
extended cutaneous allergic reaction. Treatment is symptomatic.
Sea water
Bathing in the sea does not in principle involve any risk of communicable
disease. Travellers are nevertheless recommended to ascertain from local
sources whether bathing is permitted and presents any hazards for health.
Jellyfish stings may cause severe pain and skin irritation. In some areas,
bathers should wear shoes as a protection against biting and stinging fish,
coral dermatitis, and poisonous fish, shellfish and sea anemones.
Bare feet
In areas of known risk, footwear should be worn on land as a protection
against ancylostomiasis. strongyloidiasis, certain mycetomas, and tungiasis.
5.2.3 Altitude
Travelling and staying at high altitudes may initially give rise to insomnia
and may be distressing and even dangerous for people with cardiac or pul-
monary conditions. At high altitudes there is a risk of acute pulmonary
oedema and cerebral oedema, winch may produce a sensation of extreme
faintness, accompanied by difficulty in breathing, dizziness, headaches and
vomiting. Gradual adjustment by stages and treatment with diuretics may
sometimes be beneficial. Recovery follows rapidly on return to a lower
altitude.
5.2.4 Heat and humidity

Excessive heat and humidity, or overexertion in these conditions, may lead
to exhaustion from loss of water and sails and to severe heat-stroke requiring
emergency medical attention. Tea and drinks rich in mineral salts (fruit and
vegetable juices, clear soups, etc.) are recommended in cases of exhaustion.
Unless contraindicated, the addition of a little table salt to food or drinks
helps to prevent heat exhaustion, especially during the period of acclimatiza-
tion.
Children and overweight people often suffer from skin irritation (prickly
heat). Fungal skin infections such as tinea pedis (athlete's foot) are often
exacerbated by heat and humidity. Daily showering, loose cotton clothing
and the application of talcum powder to sensitive skin areas will help to
reduce these conditions.
There can be considerable differences between day and night temperatures
at any altitude. It is cool in air-conditioned rooms and aircraft. Sharp con-
trasts in temperature may increase susceptibility to colds, which can be
prevented by dressing appropriately.
5.2.5 Sun
Exposure to the ultraviolet radiation of the sun can produce severe and
very debilitating sun-stroke and sun-burn in light-skinned people. It also
increases the risk of skin cancer. Travellers can protect themselves by wear-
ing adequate clothing and sun-glasses, and using a filter sun cream.
5.2.6 Insects
Many arthropods transmit communicable diseases such as; malaria
(Anopheles mosquitos); yellow fever, dengue and dengue haemorrhagic
lever (Aedes. Haemagogus and Sabethes mosquitos); viral encephalitides
(Culex and Anopheles mosquitos, ticks), including Japanese encephalitis (in
China. India, Japan, Lao People's Democratic Republic, Myanmar. Nepal,
Philippines. Republic of Korea. Sri Lanka. Thailand. Viet Nam); filariasis
(Aedes, Anopheles, Culex and Mansonia mosquitos); onchocerciasis (black-
flies): leishmaniasis (sandflies); African trypanosomiasis (tsetse flies);
American trypanosomiasis or Chagas disease (kissing bugs); plague and
tungiasis (fleas): typhus (fleas, lice, mites, licks): relapsing fever (lice and
ticks); and Lyme disease (Lyme borreliosis) (ticks). The bites and slings of,
and contact with, some arthropods can also cause unpleasant and even dan-
gerous reactions; examples are blister beetles, fleas, mites (chiggers). bed-
bugs, scorpions and spiders. On the other hand, some arthropods can bite and
transmit disease without the victim being aware of the bite.
There is no evidence that the human immunodeficiency virus (HIV),

the causative agent of acquired immunodeficiency syndrome (AIDS).
is transmitted by insects.
An outbreak of plague occurred in India in 1994. In recent years, sporadic

cases have occurred in hunters of wild rodents and in residents of remote
Andean villages living in rat-infested housing.
Measures for the prevention of insect bites are described in Box 5.2, p. 76.
5.2.7 Other animals

Animals in general tend to avoid human beings; but they may attack,
particularly if with their young.
In areas of endemic rabies, domestic dogs and cats should not be petted
and contact with wild animals, especially bats, jackals, foxes, skunks,
raccoons, and mongooses, as well as domestic and wild monkeys, should be
avoided. Travellers should find out which animals are most likely to be
rabies carriers in the area to be visited. In many developing countries, the
dog is the main vector species. WHO regularly collects data on the rabies
situation in its Member States; the latest edition (No. 31) of the WMO docu-
ment World survey of rabies1 includes a list of the 159 Member Stales as-
sessed for the presence or absence of rabies during the year 1995. Because
of the delays in reporting and processing this information, it is currently
impossible to provide more recent data on the rabies situation in the world.2
Travellers should therefore find out from embassies, medical practitioners
or specialized travel clinics the current rabies status of the area they plan to
visit. No animal bite should be ignored, however, and after cleansing of the
wound with antiseptic or soap, a competent opinion should be sought as to
the possibility of rabies in the area.
Pre-exposure immunization may be offered to people who are: (a) working
(even for a short tune) in a rabies-infected country, if their activities may
involve exposure to some special risk; (b) spending time (e.g. 1 month or
more) in a foreign country where rabies is a constant threat; or(c) travelling in
such a country, for any length of time, far away from a major medical centre,
under special conditions (trekking, hiking). Pre-exposure immunization docs
not eliminate the need for prompt administration of rabies prophylaxis follow-
ing contact with a suspect or rabid animal: it simply reduces the number of
vaccine doses required in the post-exposure regimen. Immunoglobulin should
not be used in people who have had pre-exposure immunization.
A booster dose of tetanus toxoid is recommended after an animal bite or
wound and is in any case advisable every ten years under normal conditions.
This precaution is especially important for campers or visitors to rural areas.
Accompanying animals (dogs and for some countries, cats) must be immu-
nized against rabies before they are allowed to cross international frontiers. A
number of rabies-free countries also require a period of quarantine (e.g.. Aus-
tralia, New Zealand. United Kingdom) or a vaccination certificate together
with a positive virus-neutralizing antibody test (e.g.. Finland. Norway. Swe-
den). Before taking an animal abroad, the owner should ascertain the exact
veterinary requirements of the countries of destination and of transit.
Snakes bite and scorpions sting as a defensive reaction, particularly at
night. The wearing of closed shoes or boots, recommended as a protection
against mosquito and other insect bites, is a sensible precaution when walk-
ing outdoors at night in snake-infested areas. Shoes and clothing should be
examined before use-particularly in the morning-as snakes and scorpions
tend to rest in them- Prompt and appropriate treatment of envenomation is
required. Patients should be moved to the nearest medical facility as quickly
and comfortably as possible. Traditional first aid methods (incisions and
suction, tourniquets and compression) are potentially harmful and should
not be used. However, pressure immobilization involving firm but not light
bandaging of the entire bitten limb with a long bandage starting over the site
World survey of rubies No 31 for the year 1995, Geneva. World Health Organization.
1997 (unpublished document WHO/EMC/ZOO/97.1: available on request from Division of
Emerging and other Communicable Diseases Surveillance and Control, World Health Organi-
zation. 1211 Geneva 27. Switzerland).
WHO is now establishing an on-line rabies data-collection system on the World Wide
Web. which should in future provide access to more recent information.
of the bite and incorporating a splint is recommended (especially for hues

By snakes with neurotoxic venoms), but not when local swelling and necro-
sis are present. Electric shock is potentially dangerous and has not proved
beneficial. The most important decision is whether or not to give antivenom.
as this is the only specific treatment. There is convincing evidence that the
benefits of this treatment far outweigh the risk of antivenom reactions.
Antivenom should, however, only be given if its stated range of specificity
includes the species responsible lor the bile. The intravenous route of ad-
ministration is the most effective. There are antivenoms to most snake
poisons, but these may not be readily available in ail areas. Children should
be given the same dose as adults. When required, supportive treatment may
be given.
Leather goods made from inadequately treated skins may contain anthrax
spores and cause serious skin lesions.
In areas where haemorrhagic fevers or plague are endemic, contact with
rodents (mice, rats) should be avoided.
5.2.8 Accidents
Traffic accidents are the leading cause of death among travellers. A traffic
accident in an area that is not well served medically is more likely to be fatal.
Regulations governing traffic and vehicle maintenance vary considerably from
one country to another. Travellers using the roads should find out in advance
about the state of'the roads and the possibilities of fuel supply. In particular.
those hiring vehicles should check carefully the insurance conditions, as well
as the state of the tyres. safety belts, spare wheel, lights, brakes, etc.
5.3 Risks from food and drink
5.3.1 General considerations

"Be careful what you eat" is common advice to travellers, but very few
truly understand its implications. Detailed advice on the general principles
of food safety is of crucial importance to travellers.
Diarrhoea affects an estimated 20-50% of all travellers. It may cause
anything from embarrassment and inconvenience to misery and disruption of
travel and business plans. For vulnerable people it may even be fatal, some-
limes Within a lew hours, if not promptly and effectively treated. Besides
those that cause diarrhoea, other diseases that may be acquired by travellers
from food and water include typhoid and paratyphoid fevers, poliomyelitis.
viral hepatitis A and various parasitic infections.
Contaminated food and drink are the most common sources of these infec-
tions. Table I lists the most important agents of disease that may be present
in contaminated food and water. Careful selection and preparation of food
and drink offer the best protection; unfortunately. the appearance of food is
no guide as to its safety and contaminated food can appear appetizing. Ealing
safely when travelling means not always being able to eat when, where and
what one wishes. The main personal precaution is to consider unpasteurized
HEALTH RISK AND THEIR AVOIDENCE 61
Table 1. Some agents of i m p o r t a n t food-borne diseases

and salient epidemiological features "
Agents Transmission by Examples of some
Multiprification incriminated foods
in food
water food person-
to person
milk, non-bottled drinks and uncooked food, apart from fruit and vegetables
that can be peeled or shelled, as likely to be contaminated and therefore
possibly unsafe. Similarly, dishes containing raw or undercooked eggs, such
as home-made mayonnaise, some sauces (e.g. hollandaise) and some desserts
(e.g. mousses), may be dangerous. Ice-cream from unreliable sources is
frequently contaminated and constitutes a danger. Even with cooked food,
the traveller should ensure that it has been thoroughly and freshly cooked.
i.e.. that it is piping hot. Foods that are cooked in advance need to be held at
a temperature of below 10 °C or above 60 °C to ensure their safety. Cooked
food held at ambient temperatures (15-40 °C) for some time (more than
4-5 hours) constitutes one of the greatest risks of food-borne disease, since
contaminating or surviving bacteria may multiply in it. Unpasteurized milk
should be boiled before it is drunk. Drinking-water should be boiled or
chlorinated and tillered, except if its safety can be ensured. Ice should be
avoided unless made from safe water. Beverages such as wine or beer, hot
tea or coffee, and carbonated soft drinks or fruit juices that are bottled or
otherwise packaged are usually safe to drink. The use of slow-release disin-
fectant agents in water or of filter attachments to domestic taps, if proven to
give safe and reliable disinfection, may be considered.
Travellers should always remember the popular advice: "Cook it, peel it
or leave it." Before travelling, they should make sure their medical kit con-
tains oral rehydration salts (see 5.3.2). If they expect to face situations where
safe drinking-water is not available, they should also lake with them water
disinfectant agents.
At certain times of the year, various species of fish and shellfish contain
poisonous biotoxins even if well cooked. Advice should be sought from lo-
cal public health authorities on these dangerous species.
Where there is no alternative to unsafe food, smaller quantities might
reduce the risk: the gastric acid has some protective effect (hypochlorhydric
and achlorhydric persons are more susceptible). Travellers might also consi-
der missing a meal-many can afford to lose a little weight and it is better to
do so from choice rather than through illness.
The above advice is of particular importance for vulnerable groups, i.e.
infants and children, pregnant women, the elderly, and people with sup-
pressed immune systems.1
5.3.2 Diarrhoea
Diarrhoea is by far the commonest cause of ill health in travellers. No
vaccine is capable of conferring general protection against diarrhoea, which
The advice given in this section on how to cat safety, as well as what to do in case of
diarrhoea, is summarized in a leaflet entitled A guide on safe food for travellers, which is
available in Arabic. English, French. German and Spanish language editions. Public
health authorities, travel agencies, transport companies, and others interested in preventing
travel-related diseases are invited to distribute this leaflet. Packages of 50 copies, or a camera-
ready copy, can be purchased from Distribution and Sales. World Health Organization.
1211 Geneva 27, Switzerland,
has many different causes. A new oral cholera vaccine composed of killed
Vibrio cholerae Ol and B subunit of cholera toxin provides short-term pro-
tection against strains of Escherichia coli that produce heat-labile entero-
toxin (LT), which are one cause of diarrhoea in travellers (see section 2.3,
p. 10). The injectable inactivated whole-cell vaccine against typhoid fever
confers a certain amount of protection, but can have unpleasant side-effects.
However, the new injectable Vi polysaccharide vaccine, given in one
injection, is well tolerated and provides good protection. A booster dose is
recommended every three years, and possibly more often for travellers to
places where conditions of hygiene are poor, Another alternative is to use
the oral live typhoid vaccine, which is effective when given in three oral
doses two days apart. To reduce the risk of infection, travellers must take
great care about what they eat and drink.
Prophylaxis of traveller's diarrhoea with bismuth subsalicylate is imprac-
tical; it is difficult to recommend an effective antibiotic for prophylaxis
without knowing the type and nature of the likely causative agents in the
areas to be visited. Moreover, prophylactic use of antibiotics can lead to the
development of drug resistance in the agents of disease and these drugs are
not without side-effects (including diarrhoea). If used at all. they should be
restricted to adults with medical problems (e.g.. those who take antacids)
spending up to three weeks in areas where clean food and water cannot be
obtained, or when it is important that the travel should not be disrupted (e.g.,
for sporting events, diplomatic missions).
Travellers should be aware of the importance of countering the dehydra-
tion consequent upon diarrhoea by drinking plenty of fluids, preferably a
rehydration fluid containing salt and glucose.1 Dehydration can be danger-
ous at any age but is particularly so in small children. Cholera can cause
extremely rapid and large losses of water and salts through profuse vomiting
and diarrhoea, even in adults. For these cases, oral rehydration to replace salt
and water losses must be particularly quick and abundant; in severe cases
medical care should be sought since intravenous therapy may be required.
Antidiarrhoeal preparations, including antimotility drugs, can provide an
adult with symptomatic relief; however, they can also cause undesirable
side-effects and an authoritative opinion should be sought before they are
used. They should never be used by children. Bacterial dysentery, protozoal
infections and intestinal helminthic infections require specific treatment.
5.3.3 Viral hepatitis types A and E

Hepatitis A. formerly called infectious hepatitis, is the most common
vaccine-preventable infection of travellers. Although the disease is rarely
fatal, most infected persons become quite ill and many are unable to work for
several weeks or months. Hepatitis A may be acquired from faecally con-
laminated food or water, or from direct contact with infected individuals;
1
The recommended a imposition is. tor 1 litre of clean drinking-water (boiled and cooled
before mixing if there is any doubot) 3:5 g sodium chloride; 2.9 g trisodium citrate dihydrate
tor 2.5 g sodium bicarbonate). 1.5 g potassium chloride. 20 g glucose (or 40 g sucrose).
Person-to-person transmission is particularly common between children, and

between sexual partners.
Travellers from industrialized countries are likely to be susceptible to
infection with hepatitis A virus (HAV). and should receive the hepatitis A
vaccine (or immunoglobulin if immediate protection is required) before
travelling to areas outside Australia, Canada, western Europe, Japan. New
Zealand, and the USA. While people travelling to rural areas of developing
countries arc at particularly high risk of infection, most cases actually occur
among people staying in resorts and middle- and upper-level hotels. People
bom and raised in developing countries, and those born before 1945 in in-
dustrialized countries, have usually been infected in childhood, and are
likely to be immune. For such individuals, it may be cost-effective to test for
anti-HAV antibodies in order to avoid unnecessary immunization.
Immunoglobulin has been used for over 40 years to protect against
hepatitis A infection, it is safe and highly effective if given before or
within 14 days of exposure. The protection provided is immediate but
relatively short-lived (approximately one month per ml), so frequent trav-
ellers and those living abroad for prolonged periods require repeated in-
jections.
A safe and highly effective inactivated (killed) HAV vaccine became
available in several European countries in 1992, and widespread distribu-
tion is expected over the next few years. Antibodies induced by the vac-
cine are not delectable until two weeks after administration, but reach
much higher levels than those obtained with immunoglobulin. Ideally,
two doses of vaccine, two weeks to one month apart, should be given be-
fore travel. A double-dose vaccine has also been licensed, which reduces
the first two doses to one. A booster dose given 6-12 months later is rec-
ommended. Such a schedule is expected to provide at least 10 years' pro-
tection. For travellers who seek medical advice less than two weeks before
travelling, a double dose is recommended (two injections, single dose: or
one injection, double dose); this induces antibodies in over 90% of indi-
viduals within 2 weeks, and will almost certainly protect against infection.
Alternatively, a dose of immunoglobulin may be given with the first dose
of vaccine.
Hepatitis E, formerly called enterically transmitted non-A. non-B hepa-
titis, is a water-borne infection, and is found in epidemics and sporadic cases.
The virus has been isolated from hepatitis epidemics in Afghanistan.
Bangladesh, western China. Eritrea. Ethiopia. India. Indonesia, the Islamic
Republic of Iran. Kenya, Mexico, Myanmar. Nepal. Pakistan. Somalia,
Sudan, and the Asian republics of the former USSR. It is probably wide-
spread in Asia, north and sub-Saharan Africa, and the eastern Mediterranean
area. The disease primarily affects young adults, is clinically similar to hepa-
titis A. and docs not lead to chronic disease. However, among women in the
second or third trimester of pregnancy who contract the disease, about
15-20% will die of fulminant hepatitis. There is no vaccine against hepa-
titis E. and immunoglobulin prepared in Europe or the USA does not give
protection. As for many other enteric infections, avoidance of contaminated
food and water is the only effective protective measure.
HEALTH RISKS AND THEIR AVOIDENCE 65
5.4 Sexually transmitted infections, including HIV (AIDS)
An estimated 333 million episodes of curable sexually transmitted infec-

tion (syphilis, gonorrhoea, chlamydial infections and trichomoniasis) occur
annually throughout the world. They are important causes of infertility, ill-
ness and death. None the less, some travellers continue to place themselves
at risk of infection. In a few developed countries, a large proportion of sexu-
ally transmitted infections are now acquired during international travel.
Infection with the human immunodeficiency virus (HIV), which causes
AIDS, is present in virtually all countries of the world and epidemic in many
of them. It is estimated that over 8 million AIDS eases have occurred since
the beginning of the epidemic and that about 23 million men, women and
children are currently infected with HIV (43% of these infections being in
females).
In addition to transmission through sexual intercourse (both heterosexual
and homosexual-anal, vaginal or oral), most of these infections can be
passed on from an infected mother to her unborn or newborn baby, and
some-especially HIV, hepatitis B1 and syphilis-are also transmitted through
blood or blood products2 and contaminated needles.
There is no risk of acquiring any sexually transmitted infection from
casual day-to-day contact at home, at work or socially. People run no risk of
infection when sharing any means of communal transport (e.g. car. train,
bus. aeroplane, boat) with infected persons. There is no evidence that HTV
or other sexually transmitted infections are acquired from insect bites.
Measures for preventing sexually transmitted infections are the same
whether the individual is travelling abroad or not. Intercourse with multiple
partners or with persons who have multiple partners (e.g. male or female
prostitutes) can be dangerous. Do not judge by appearance: most infected
people look healthy and have no symptoms of disease, yet are highly infec-
tious. If in doubt, men should always use a condom, each time, from start to
finish, and women should make sure their partner uses one. Women can also
protect themselves from sexually transmitted infections by using a female
condom-essentially, a vaginal pouch-which is now commercially available
in some countries. Hepatitis B is the only sexually transmitted infection for
which there is a protective vaccine (p. 86).
The bacterial infections (e.g. gonorrhoea, syphilis, chlamydia, chancroid)
can be treated, but there is no single antimicrobial that is effective against
more than one or two of them. Moreover, throughout the world, many of
these bacteria are showing increased resistance to penicillin and other anti-
microbials. For the sexually transmitted viral infections (hepatitis B,1 genital
herpes, genital warts), treatment is inadequate or nonexistent. The same is
true of HIV infection, which in its late stage causes AIDS and is thought to be
invariably Fatal
To reduce the risk of acquiring HIV. hepatitis B.1 syphilis and other infec-
tions from needles and blood, travellers should avoid injecting drugs for
See also section 5.4.2 ''Hepatitis B''. p. 67

See also section 6.1. "Blood transfusion'' p. 91
nonmedical purposes, and particularly any type of needle-sharing. Medical

injections using unsterilized equipment are also a possible source of infec-
tion. If an injection is essential, the traveller should try to ensure that the
needles and syringes come from a sterile package or have been sterilized
properly by steam or boiling water for 20 minutes. Patients under medical
care who require frequent injections (e.g. diabetics) should carry sufficient
sterile needles and syringes for the duration of their trip and a doctor's
authorization for their use.
Unsterile dental and surgical instalments, needles used in tattooing and
acupuncture, ear-piercing devices, and other skin-piercing instruments can
likewise transmit infection. If a blood transfusion is essential, the traveller
should request blood that has been screened for HIV. hepatitis Bl and
syphilis.
Some countries have adopted HIV/AIDS-related entry restrictions and
people who are infected with HIV should consult their personal physician for
a detailed assessment and advice prior to travel- WHO has taken the position
that there is no public health justification for entry restrictions that dis-
criminate solely on the basis of a persons HIV status (see also p. 9).
5.4.1 Immunization of HIV-infected individuals

Yellow fever. Yellow fever vaccine is recommended for travel to countries
designated as yellow fever endemic zones (pp. 14-15). However, it is re-
cognized that the risk of yellow fever infection for international travellers is
low. particularly for those who limit their travel to urban areas.
Yellow fever vaccine is recommended for HIV-seropositive individuals
who are asymptomatic. There is insufficient evidence to permit a definitive
statement on whether administration of yellow fever vaccine poses a risk for
symptomatic HIV-infected persons, and the issue is currently under investi-
gation. Any adverse reactions to yellow fever vaccine occurring in HIV-
positive individuals should be reported to WHO.
Since yellow fever is transmitted by mosquitos. the risk of infection can
be reduced by taking general measures to prevent or reduce mosquito bites.
including avoiding being outdoors at dusk and in the early evening, wearing
long trousers and long-sleeved shirts, using mosquito repellents on exposed
skin, and sleeping in screened rooms or under netting (p. 76).
Childhood immunization Available experience suggests that the likelihood

of successful immunization is reduced in some HIV-infected children but
that the risk of serious adverse effects remains low. Consequently, in coun-
tries where the target diseases of the Expanded Programme on Immunization
(EPI) are considered a problem, asymptomatic HIV-infected children
should be immunized according to standard schedules. This also applies to
children with clinical (symptomatic) AIDS, with the exception of BCG vac-
cine, which is safe for use in those with symptomless HIV infection, but
should not be used in those who have symptoms.
See also section 5.4.2 "Hepatitis B''. p. 67

5.4.2 Hepatitis B
Hepatitis B is highly endemic in all of Africa, much of .South America.
Eastern Europe, the eastern Mediterranean area, south-east Asia. China, and
the Pacific Islands except Australia. New Zealand and Japan. In most of
these areas, 5-15% of the population are chronically infected carriers of the
hepatitis B virus (HBV). and in some areas may also carry the hepatitis D
virus (delta hepatitis), which may lead to severe liver damage. Adults infec-
ted with HBV usually acquire acute hepatitis B and recover, but 5—10%
develop the chronic carrier state. Infected children rarely develop acute dis-
ease, but 25-90% become chronic carriers. Approximately 25% of carriers
will die from cirrhosis or primary liver cancer.
Hepatitis B may be transmitted to visitors and expatriate residents in en-
demic areas in a number of ways. Sexual transmission is highly efficient, as
is percutaneous transmission from needle-sharing, blood transfusion, injec-
tions or other invasive procedures with unsterile medical or dental equip-
ment, traditional medical procedures such as acupuncture, or tattooing.
Medical personnel working in endemic areas are at especially high risk.
Child-to-child transmission is very common.
Hepatitis B vaccines produced from plasma or by recombinant DNA tech-
nology (usually in yeast) are available and are safe and effective. Three
doses of vaccine constitute the complete series; the first two doses are usually
given one month apart, with the third dose 1-12 months later. Immunization
will provide protection for at least 10 years. Because of the prolonged incu-
bation period of hepatitis B. protection will be afforded to most travellers
even if only the first dose is given prior to travel, provided that the subse-
quent doses arc given upon return. Prevaccination screening to determine
immune status is generally not cost-effective in people from industrialized
countries, but may be in people from developing counties who have a high
probability of having had asymptomatic infection during childhood.
Hepatitis B vaccine is strongly recommended for:
• all health care personnel:

• frequent travellers to endemic areas:
• persons living in endemic areas for more than 6 months;
• young children who will be in day-care or residential settings with other
children in endemic areas:
• travellers likely to engage in sexual or needle-sharing activities while abroad:
• travellers who may need to undergo medical or dental procedures
while abroad.
S.5 Malaria
5.5.1 General considerations
Malaria is a common and serious tropical disease. It is a protozoan infec-
tion transmitted by mosquitos biting mostly between sunset and sunrise.
MAP 3. RECOMMENDATIONS FOR MALARIA DRUG PROPHYLAXIS BY AREA - 1998 69
Recommendations concerning prophylaxis see Table 2 for dosages/regimens; see Table 3 for contraindications, see Box 5.3 for prophylaxis
Zone : Characteristics (for details by country, see yellow pages) of pregnant women, see Tables 4 and 5 for stand-by emergency treatment)
Risk generally low and seasonal, no risk in many areas (for example urban prophylaxis: chloroquine
areas) P falciparum absent or sensitive to chloroquine. or (in case of very low risk no prophylaxis
Low risk in most areas. Chloroquine alone will protect against P was prophylaxis: chloroquine + proguanil Protection from
B Chloroquine With proguanil will give some p r o t e c t s against P.falctpaium or: (in case of very low risk no prophylaxis mosquito bites
and may alleviate the disease if it occurs despite prophylaxis should be the rule
in all stiuatios
even when
Risk high in most areas of thus zone in Africa, except In some high-altitude- prophylaxis: first choice - meftoquine prophylaxis is
areas Risk low in most areas of this zone in Asia and America but high in second choice - chloroquine + proguanil for details, see yellow pages taken
parts of the Amazon basin (colonization and mining areas) Resistance to border areas Cambodia/Myanmar/Thailand -doxycycline
Sulfadoxine-pyrimethamine common in zone C in W Asia variable in zone C or : ( in case of very low risk) no prophylaxis
in Afrika and America.
Human malaria is caused by four species of Plasmodium: Plasmodium

falciparum, P. vivax, P. ovale and P. malariae. Each year many travellers
fall ill with malaria while visiting countries where the disease is endemic
More than 10 000 fall ill on return to their home countries. About 1% of
patients with P. falciparum infection die. Most of these deaths could be
prevented by earlier diagnosis and adequate treatment.1
The malaria situation is gelling worse in many areas, and prevention and
treatment of falciparum malaria are becoming more difficult because resist
ance of P. falciparum to antimalarial drugs is increasing and becoming
more widespread. Resistance of P. vivax to chloroquine has been reported
from Irian Jaya. Myanmar. Papua New Guinea and Vanuatu. However, poor
compliance with prophylactic regimens remains the major reason for
malaria in travellers.
In many countries of Asia, the eastern Mediterranean area, and South
America where there is malaria, the main urban areas are free of transmis
sion of the disease, although this is not necessarily true of their outskirts or
of main urban areas in Africa and India. While there is usually less risk of
malaria at altitudes greater than 1500 metres, the disease can occur in
favourable climatic conditions at altitudes up to almost 3000 metres. The
risk of infection may also vary according to the season, being highest at (the
end of the rainy season. There may be no risk in many tourist destinations in
South-East Asia and Latin America. Travellers to countries where malaria
transmission is heterogeneous should investigate the risk of malaria in the
specific zones that they will be visiting. If they cannot obtain specific infor
mation before travelling, they are recommended to assume uniform high
malaria risk throughout the country.
Authorities in endemic countries are requested to provide WHO regularly
with information on the malaria situation in those countries. Although
the data provided arc not always complete, they are used by WHO to update
the information given in this publication and to give an indication of areas of
the world where malaria may be contracted and details concerning its pre
vention. A map (Map 3) showing the distribution of malaria in the world
appears on pp. 68-69.
5.5.2 Protective measures against malaria

Four principles of malaria protection should receive the attention of
travellers and their advisers: (1) be aware of the risk; (2) avoid being bitten
by mosquitos; (3) take chemoprophylaxis where appropriate; and (4) seek
early diagnosis and treatment.
' For details of the management of uncomplicated malaria, including indications for
antimalarial drug use. dosages, adverse reactions and contraindications, see Management of
uncomplıcated malaria and the use of antimatarial drugs for the protection of travellers, Geneva.
World Health Organization. 1996 (unpublished document WHO/MAL/96.1075; available on
request from Malaria Control. World Health Organization. 1211 Geneva 27. Switzerland).
1. Be aware of the risk. All travellers to malarious areas need to he aware of

the risk of malaria infection, and how they can best protect themselves
and urgently seek medical advice if they get a lever (Box 5.1, p. 75).
Travellers staying overnight in rural areas may be at highest risk.
2. Avoid being bitten by mosquitos. All travellers should be told that pro-
tection from biting mosquitos is their first line of defence against
malaria. Practical measures for protection are described in Box 5.2. p. 76.
3. Take chemoprophylaxis where appropriate. The correct dosage regimen
of the most appropriate antimalarial drug(s) (if any) for the place of visit
should be prescribed (Map 3. yellow pages, and Table 2. pp. 79-80).
Prophylactic antimalarial regimens should be started one week before
travel or, in the case of proguanil or doxycycline. the day before travel.
Drugs should then be taken with unfailing regularity throughout the period
spent in the area of malaria risk, and continued for 4 weeks after leaving the
area. Drugs should be taken with food and swallowed with plenty of water.
Adverse reactions attributed to malaria chemoprophylaxis are common.
Most of these are minor and do not affect the activities of the traveller.
However, the risk associated with the drug should be weighed against
the risk of malaria, especially falciparum malaria. Chemoprophylaxis
should not be prescribed in the absence of malaria risk.
Some drugs are contraindicated in certain groups and individuals (see
Table 3. p. 81. Box 5.3. p. 77, and Box 5.4, p. 78). Severe adverse
reactions during prophylaxis with amodiaquine or sulfadoxine-
pyrimethamine have led to their deletion from the list of drugs
recommended by WHO for prophylaxis. Mefloquine prophylaxis should
preferably be started 2-3 weeks before departure, so that side-effects can
be detected before travel and possible alternatives considered.
4. Seek early diagnosis and treatment. Both travellers and doctors should be
aware that no antimalarial prophylactic regimen gives complete pro-
tection. Falciparum malaria, which can be fatal, must always be suspected
if fever, with or without other symptoms, develops at any time between
one week after the first possible exposure to malaria and two months (or
even later in rare cases) after the last possible exposure. The most impor-
tant factors that determine the survival of patients with falciparum
malaria are early diagnosis and appropriate treatment. The symptoms of
falciparum malaria may not be easy to recognize. It is important, therefore,
that the possibility of malaria is considered in all cases of unexplained
fever that starts after the seventh day of stay in an endemic area.
Before taking drugs for emergency treatment, anyone suspecting ma-
laria should, whenever possible, promptly seek medical attention and
insist that a blood sample is taken and examined microscopically for
malaria parasites. If malaria is suspected but no facilities are easily ac-
cessible for blood examination, treatment should be started. If no para-
sites are found in the first blood film, but symptoms persist, a scries of
blood samples should be taken and examined at 6-12-hour intervals.
P. vivax and P. ovale can remain quiescent in the liver for many months.
Relapses caused by the persistent liver forms may appear months, and
rarely 1-2 years, after exposure. Relapses can be treated symptomatically
with chloroquine and further relapses prevented by a course of primaquine,
which destroys any remaining parasites in the liver. The normal adult dose
of primaquine is (5 mg of base per day for 14 days, but in patients with
known or suspected glucose-6-phosphate dehydrogenase (G6PD) defi-
ciency (e.g. those of Mediterranean origin), expert medical advice should
be sought since the drug may cause haemolysis in G6PD-deficient patients.
Blood infection with P. malariae may be present for many years, but it is
not lethal and is easily cured by standard doses of chloroquine.
5.5.3 Stand-by emergency treatment

Most travellers will be able to obtain prompt medical attention when
malaria is suspected. However, a minority at risk of infection may be unable
to seek such care within 24 hours of the onset of symptoms, particularly if
they are in an isolated location Ear from competent medical services. In such
cases, it is advised that prescribers issue antimalarial drugs to be carried by
the travellers for self-administration ("stand-by emergency treatment").
The choices of stand-by emergency treatments in relation to the drugs
used for prophylaxis are given in Table 4, p. 82.
People prescribed stand-by emergency medication should be given precise
instructions on the recognition of symptoms, the treatment regimen
(Table 5, pp. 83-84), possible side-effects and the action to be taken in the
event of drug failure. They should be made aware that self-treatment is a first-
aid measure, and that they should seek medical advice as soon as possible.
Halofantrine is no longer recommended for stand-by treatment following
reports that it can result in prolongation of Q-T intervals and ventricular
dysrhythmias in susceptible individuals. These changes may be accentuated
if halofantrine is taken with other antimalarial drugs that can decrease myo-
cardial conduction.
5.5.4 Special groups

Some groups of travellers are at special risk of serious consequences if
they become infected with malaria. Foremost among these groups are preg-
nant women and young children.
1. Pregnant women. WHO advises pregnant women not to travel on
vacation to areas where transmission of chloroquine-resistant
P. falciparum occurs. Malaria in a pregnant woman increases the risk of
maternal death, neonatal death, miscarriage, and stillbirth. Medical help
should be sought immediately if malaria is suspected, and treatment with
an effective antimalarial drug must always be given.
To prevent malaria, if travel cannot be avoided, great care must be taken
to avoid mosquito bites (Box 5.2), and in the few areas where
P. falciparum can be expected to be 100% sensitive to chloroquine, pro-
phylaxis with chloroquine alone may be used. In areas of chloroquine
resistance, prophylaxis with chloroquine plus proguanil is recommended

during the first three months of pregnancy. Cumulative evidence from
women inadvertently given mefloquine chemoprophylaxis during preg-
nancy and from clinical trials has not shown embryotoxic or teratogenic
effects. Mefloquine may therefore be given during the second and third
trimesters. Data concerning use during the first trimester are limited.
Other drugs are either dangerous to the fetus or insufficiently investi-
gated to be prescribed for prophylaxis in pregnancy. In non-pregnant
women of childbearing potential, mefloquine or doxycycline can be
given, but pregnancy should be avoided for three months after complet-
ing prophylaxis in the case of mefloquine, and for one week in the case
of doxycycline. In the case of unplanned pregnancy, malaria chemo-
prophylaxis is not considered an indication for pregnancy termination.
2. Children. WHO advises against taking babies and young children on
holiday to malarious areas, in particular where there is transmission
of chloroquine-resistant P. falciparum. Children are at special risk
since they can rapidly become seriously ill with malaria. Fever in a child
returning from a malarious area should be considered to be due to
malaria until proved otherwise. Every attempt must be made to seek
prompt medical help, even if stand-by treatment is given. If travel is
unavoidable, babies and children should be well protected against mos-
quito bites and receive malaria prophylaxis (Box 5.4). it is sometimes
difficult to give an adequate prophylactic dose of a drug because of the
small amount required and lack of paediatric formulations.
3. Long-term travellers. The recommendations given throughout this section
are applicable only to non-immune travellers visiting malarious areas for
up to one month, which includes most travellers. Long-term travellers
staying in malarious areas should follow the recommendations of this
booklet for the first month of residence, after which they should follow
local medical advice. The risk of serious side-effects associated with
taking long-term prophylactic chloroquine and proguanil is low. How-
ever, twice-yearly screening for the detection of early retinal changes
should be performed in anyone who has taken 300 mg of chloroquine
weekly for over five years and requires further prophylaxis (screen after
three years if daily doses of 100 mg have been taken). If changes are
observed, an alternative drug should be prescribed. Data indicate no in-
creased risk of serious side-effects with long-term use of mefloquine.
The risk of serious side-effects from prolonged use of doxycycline is not
yet known. Mefloquine and doxycycline should be reserved for those at
greatest risk of infection (see Map 3).
4. Frequent travellers. Some travellers, such as members of aircraft crews,

make frequent short slops in endemic areas over a prolonged period of
lime. Such travellers may eventually choose to reserve chemoprophy-
laxis for high-risk areas only. However, they should maintain rigorous
self-protection against mosquito bites and be prepared for an attack of
malaria: they should always carry a course of antimalarials for stand-by
BOX 5.1
Checklist for prescribers
Travellers to areas of malaria risk should:
1. Be aware of the risk
• Be informed about the risk of malaria infection (see country list in
yellow pages and Map 3). Pregnant women and parents taking young
children should question the necessity of their trip.
2. Avoid being bitten by mosquitos
• Be informed how to protect themselves against mosquito bites (see
Box 5.2).
3. Take chemoprophylaxis where appropriate
• Be questioned about drug allergies and contraindications for drug use.
If intolerance is suspected, ask the patient to start prophylactic drugs early
(e.g. 2-3 weeks before departure) and check the outcome before travel.
• Be informed how to take the prescribed antimalarial drug (a) for pro-
phylaxis (drugs should always be taken with food and water) and/or
(b) for stand-by emergency treatment (see Map 3 and Tables 2.4 and 5)
and of the importance of maintaining complete compliance.
• Be informed that prophylaxis must be continued for 4 weeks after
they leave the malarious area, whether they return to their home country
or move to a malaria-free area in the tropics.
• Be informed that some antimalarial drugs can cause serious side-
effects and that medical help should be sought promptly if these occur (see
Table 3). If a serious side-effect occurs, the patient should stop taking the
drug and seek medical advice on an alternative drug. Mild nausea, occa-
sional vomiting or loose stools should not prompt discontinuation of pro-
phylaxis, but medical advice should be sought if symptoms persist.
4. Seek early diagnosis and treatment
• Be warned that they may contract malaria despite taking antimalarial
prophylaxis.
• Be informed that malaria can kill if treatment is delayed. Medical help
must be sought prompdy if a febrile illness occurs. A blood sample should
be taken and examined for malaria parasites on one or more occasions.
• Be informed that initial symptoms of malaria may often be mild, and
that malaria should be suspected if, one week after entry into an endemic
area, they suffer unexplained fever with or without other symptoms such
as headache, muscular aching and weakness, vomiting, diarrhoea, and
cough. Prompt medical advice must be sought.
• Be reminded that antimalarial drugs for stand-by emergency treat-
ment should be taken only when prompt medical help is not available.
They should complete the treatment course and resume antimalarial pro-
phylaxis 7 days after the first treatment dose (Tables 4 and 5).
• Be aware that if they have had. or have been suspected of ha\ing.
malaria while staying in an endemic area, and have been treated or have
used stand-by treatment, they should see a doctor for a check-up after
returning home.
BOX 5.2
Protection against mosquito bites
The following measures are effective in reducing the risk of mosquito bites:
1. Apply insect repellent to exposed skin between dusk and dawn when
malaria mosquitos commonly bite. Choose one containing either N.N-
diethyl-m-toluamide (deet) or dimethyl phthalate. Repeated applica-
tions may be required every 3-4 hours, especially in hot and humid
climates. The manufacturers' recommendations for use must not be
exceeded, particularly with small children.
2. Stay, if possible, in a well-constructed and well-maintained building
with screens over doors and windows; if no screens are available,
windows and doors should be closed at sunset.
3. If accommodation allows entry of mosquitos. use a mosquito net
over the bed, with edges tucked in under the mattress, and ensure
that the net is not torn and that there are no mosquitos inside: it is
preferable to use nets impregnated with permethrin or deltamethrin.
4. Use anti-mosquito sprays or insecticide dispensers (mains or battery
operated) containing pyrethroids. or burn pyrethroid mosquito coils
in bedrooms at night.
emergency treatment, seek immediate medical care in case of fever, and

take self-treatment if prompt medical help is not available.
5.5.5 Special situations - multidrug-resistant malaria

In areas of Thailand near the borders with Cambodia and Myanmar,
P. falciparum infections do not respond to treatment with chloroquine or
sulfadoxine-pyrimethamine. and sensitivity to quinine is reduced. Treatment
failures of over 50% with mefloquine are also being reported. A similar
situation is reported from western Cambodia.
In these situations, chemoprophylaxis with doxycycline is recommended
along with rigorous use of personal protection measures. Doxycycline
should be taken daily, according to the schedule given in Table 2, with copi-
ous volumes of water to prevent possible oesophageal irritation. Light-
skinned people need to protect themselves from sunlight since the drug may
induce photosensitivity. Experience with use of this drug for long-term
chemoprophylaxis, i.e. over 4-6 months, is limited.
Doxycycline is contraindicated in pregnant women and children under the
age of 8 years. There is no prophylactic regimen that is both effective and
safe for these groups in areas of multidrug-resistant malaria. It is advised,
therefore, that pregnant women and young children should avoid entering
these malarious areas.
BOX 5.3
Advice to be given by prescribers to pregnant women and women
of childbearing potential"
Pregnant women
1. Malaria in a pregnant woman increases the risk of maternal death,
miscarriage- stillbirth and low birth weight with associated risk of
neonatal death.
2. Do not go to a malarious area unless absolutely necessary,
3. Be extra diligent in using measures to protect against mosquito bites,
4. Take and comply with chloroquine and proguanil prophylaxis. In
areas with chloroquine-resistant P. falciparum, chloroquine and
proguanil should be taken during the first three months of preg-
nancy; mefloquine prophylaxis may be taken from the fourth month
of pregnancy onwards.
5. Do not take doxycycline prophylaxis.
6; Seek medical help immediately if malaria is suspected, and take emer-
gency stand-by treatment (quinine is the drug of choice) only if no
medical help is immediately available. Medical help must still be
sought as soon as possible alter stand-by treatment.
Non-pregnant women of childbearing potential

1. Both mefloquine and doxycycline prophylaxis may be taken, but
pregnancy should be avoided during the period of drug intake and
for three months after mefloquine and one week alter doxycycline
prophylaxis is stopped.
2. If pregnancy occurs during antimalarial prophylaxis (except with
chloroquine and proguanil). information about the possible effects
of the drugs on the newborn infant should be given by the woman's
doctor. However, in the case of unplanned pregnancy, malaria
chemoprophylaxis is not considered an indication for pregnancy ter-
mination.
• See also section 5.9.2, p. 87.
The national authorities in Thailand recommend a combination of

mefloquine plus artesunate or artemether as the first-line treatment in areas
of highly mefloquine-resistant malaria. When these drugs are not available,
infections with P. falciparum acquired on the Thailand/Cambodia and
Thailand/Myanmar borders may be treated with a total dose of 25 mg/kg
mefloquine, given as 15 mg/kg initially followed by 10 mg/kg 6-8 hours
later, or with oral quinine. 10 mg/kg of body weight every 8 hours for
7 days, plus oral tetracycline. 500 mg every 8 hours for 7 days, if full com-
pliance is obtained.
BOX 5.4
Advice to be given by prescribers to the parents of young children
1. Children can rapidly die from malaria.
2. Do not take babies or young children to a malarious area unless abso-
lutely necessary.
3. Protect children against mosquito bites. Mosquito nets for cots and
small beds are available. Keep babies as much as possible under
mosquito nets between dusk and dawn.
4. Give prophylaxis to breast-fed as well as to bottle-fed babies, since
they are not protected by the mothers' prophylaxis.
5. Chloroquine and proguanil may be given safely to babies and young
children. For administration, drugs may be crushed and mixed with
jam, banana or similar foods. Syrup formulations are available for
certain drugs, but have shorter shelf-lives in tropical areas.
•
6. Do not give sulfadoxine-pyrimethamine or sulfalene-pyrimethamine

to babies under 2 months of age.
7. Do not give doxycycline prophylaxis to children below 8 years of age.
8. Keep all antimalarial drugs out of the reach of children and store in
childproof containers. Chloroquine is particularly toxic to children if
the recommended dose is exceeded.
9. Seek medical help immediately if a child develops a febrile illness.
The symptoms of malaria in children may not be typical and so
malaria should always be suspected. In infants, malaria should be
suspected even in non-febrile illness.
5.6 Dengue and dengue haemorrhagic lever
Dengue, and its complications, dengue haemorrhagic fever (DHF) and

dengue shock syndrome (DSS), are the most important arbovirus diseases in
the world today.
Dengue viruses are transmitted to humans by mosquitos, especially Aedes
aegypti, a species that is well adapted to life in tropical urban environments.
Unlike most malaria vectors, this species preferentially feeds on humans
during the day. frequently enters homes to rest and feed, and breeds in water
that is stored or collects around human dwellings. As a result. A. aegypti has
invaded urban, suburban and rural settings throughout many parts of the
tropics. Consequently, travellers to tropical countries, especially in south-
east Asia and Latin America, may be at risk of dengue infection. At present.
(text continues on p. 85)

HEALTH RISKS AND THEIR AVOIDENCE 79
Table 2. Drug regimens for chemoprophylaxis
For recommendations according to the areas visited and to the age and other per-
sonal characteristics of travellers, see Table 3. Map 3, Boxes and t e x t
Prophylactic schedules for children s h o u l d be based on w e i g h t .
Chloroquine (common trade names: Aralen, Avloclor. Nivaquine, Resochin)

The recommended prophylactic regimen is 5 mg base/kg weekly. The following
table is based on the administration o1 the commonly used tablets containing
either 100 mg or 150 mg base.
Number of tablets/week
Weight
(kg) Age (years) 100 mg base 150 mg base
5-6 < 4 months 0.25 0.25
7-10 4-11 months 0,5 05

11-14 1-2 075 0.5
15-18 3-4 1 0.75
19-24 5-7 1.25 1
25-35 8-10 2 1
36-50 11-13 2.5 2
50+ 14+ 3 2
Note: Some authorities recommend a total weekly dose of 10 mg/kg divided into 6 daily
doses, i.e. an adult dose of 100 mg base daily for 6 days per week
Proguanil (common trade name: Paludrine)

The recommended prophylactic regimen is 3 m g / k g daily in combination with
chloroquine. The following table applies to tablets containing 100 mg proguanil
hydrochloride.
Weight Age Numbers of tablets/day

years
5-8 < 8 months 0.25

9-16 8 months- 3 years 0.5
17-24 4-7 0 75
25-35 8-10 1
36-50 11-13 1.5
50+ 14+ 2
Note. In some countries, a combination tablet containing 100 mg chloroquine base + 200 mg
proguanil hydrochloride is available, which may improve compliance in adults.
Table 2 (continued)
Mefloquine (common trade names: Lariam, Mephaquin)

The following regimens relate to the commonly used tablet containing 250 mg
base to be taken for prophylaxis at a single weekly dose of 5 m g / k g Patients
prescribed the formulation available in the USA containing 228 mg base (i.e,
250 mg mefloquine hydrochloride) should take the same number of tablets but will
receive a slightly lower weekly dose of the drug in terms of base.
Weight Age Number of tablets/week

(kg) (years)
<5 < 3 months Not recommended

5-6 3 months 0.25
7-8 4-7 months 0.25
9-12 8-23 months 0.25
13-16 2-3 0.33
17-24 4-7 0.5
26-35 8-10 0 75
36-50 11-13 1
50+ 14+ 1
Doxycycline (common trade name. Vibramycin)

The prophylactic dose is 1.5 mg salt/kg daily, given as tablets or capsules con-
taining 100 mg doxycycline salt as hyclate or hydrochloride. Doxycycline is mainly
recommended for high risk areas where resistance to mefloquine exists (see sec-
tion 5.5.5). It may also be an alternative in high risk areas with high levels of
chloroquine resistance for persons unable to tolerate mefloquine.
Weight (kg)
(years)
< 25 < 8 Contraindicated

25-35 8-10 0.5
36-50 11-13 075
50+ 14+ 1
Table 3. Special considerations in malaria prophylaxis and stand-by
emergency treatment 1
Group Recommendation
People with known or suspected allergies If history of allergy to sulfa drugs, antimalarials such
or a previous history of adverse reactions as sulfadoxine-pyrimethamine and sulfalene-pyri-
meihamine should not be taken.
If history of allergy or other severe reaction to meflo-

quine or related compounds (quinine, quinidine).
mefloquine should not be prescribed for prophylaxis.
If history of severe pruritus after chloroquine treat-

ment, use an alternative drug to chloroquine for pro-
phylaxis.
• Doxycycllne may cause skin photosensitivity and

should not be prescribed tor people likely to be ex-
posed to prolonged direct sunlight. Those who are
sensitive should use a highly protective sunscreen
and avoid prolonged direct sunlight or switch to
another prophylactic drug.
People with chronic illness • People with chronic illness should seek individual
medical advice.
• Chloroquine should not be taken by people with a

family history of epilepsy
• Chloroquine should not be prescribed for people with

a history of generalized psoriasis
• Mefloquine should not be taken by people with a his-

tory of epilepsy or psychiatric disorders.
People taking other drugs and vaccines Mefloquine and other related compounds (e.g qui-
nine, quinidine and chloroquine) may be given con-
comitantly only under dose medical supervision
because of possible additive cardiac toxicity
The co-administration of-mefloquine with anti-arrhyth-

mic agents. B-adrenergic blocking agents, calcium
channel blockers, antihistamines including H-block-
ing agents, tricyclic antidepressants and phenothia-
zines might contribute to the prolongation of Q-T,. in-
tervals However, in the tight of information currently
available, co-administration of mefloquine with such
drugs is not contraindicated.
Vaccination with live bacterial vaccines, such as oral

live typhoid vaccines, should be completed at least
3 days before the first prophylactic dose of mefloquine
'Further information on adverse reactions, drug interractions and contrindications is given in the manifacturer's
prescribing information provided with the product.
82 I N T E R N A T I O N A L T R A V E L AND H E A L T H
Table 3 (continued)
Group Recommendation
People who develop serious side-effects to Stop taking the drug and seek immediate medical
an antimalarial attention; this applies in particular to neurological or
psychological disturbances after mefloquine and to
rashes after treatment with sulfa-derived antimalarials.
People who vomit Vomiting of antimalarials given for therapy is less likely
if fever is first lowered with antipyretics A second full
dose should be given to patients who vomit less than
30 minutes after receiving the drug If vomiting occurs
30-60 minutes alter a dose, an additional half-dose
should be given Vomiting together with diarrhoea may
lead to treatment failure due to poor drug absorption.
People involved in tasks requiring fine Mefloquine prophylaxis should not be given. After
coordination and spatial discrimination mefloquine treatment, caution should be exercised
(e.g. air crews) with regard to drying and operating machinery, ana
piloting aircraft should be avoided, since dizziness,
disturbances of balance and neuropsychiatry reac-
tions have been reported during and up to 3 weeks
after the use of this drug. Chloroquine may cause
blurring of vision and dizziness in some people; those
affected should switch. to another prophylactic drug
Table 4. Choice of stand-by t r e a t m e n t a c c o r d i n g to c h e m o p r o p h y l a c t i c r e g i m e n
Prophylactic region Stand-by treatment
none • chloroquine (zone A. see Map 3)

• sulfa/pyrimethamine combination (zone B (see Map 3)
and Africa south of the Sahara only)
• mefloquine. 15 mg/kg
• quinine
chloroquine alone or with proguanil • sulfa/pyrimethamine combination (zone B (see Map 3)

and Africa south of the Sahara only)
• mefloquine. 15 mg/kg
• quinine
mefloquine • sulfa/pyrimethamine combination (Africa south of the

Sahara only)
• quinine
• quinine + doxycycline/tetracycline. for 7 days
doxycycline • mefloquine, 25 mg/kg

• quinine + tetracycline, for 7 days
Table 5. Drug regimens for stand-by emergency t r e a t m e n t
Treatment schedules for children should be based on weight.
Chloroquine (common trade names: Aralen. Avloclor, Nivaquine. Resochin)

The total dose is 25 mg base/kg over 3 days. The following table is based on the
administration of the commonly used tablets containing either 100 mg or 150 mg
base. If formulations of other strengths are used, the doses should be adjusted
accordingly
Number of tablets
Weight Age
(kg) (years) 100 mg base 160 mg base
Day 1 Day 2. Day 3 Day 1 Day 2 Day 3
5-6 <4 months 0-5 0.5 0.5 0.5 0.25 0.25

7-10 4-11 months 1 1 0.5 0,5 0.5 0.5
11-14 1-2 1-5 1.5 0.5 1 1 0.5
15-18 3-4 2 2 as 1 1 1
19-24 5-7 2.5 2.5 1 1 5 1 5 1
25-35 8-10 3-5 3.5 2 25 2.5 1

36-50 11-13 5 5 2.5 3 3 2
50+ 14+ 6 6 3 4 4 2
Sulfadoxine/pyrimethamine or sulfalene/pyrimethamine (common trade

names Fansidar for sulfadoxine/pyrimethamine. Metakelfin for sulfalene/
pyrimethamine)
The following recommendations are for single-dose treatment with tablets con-
taining 500 mg sulfadoxine or sulfalene plus 25 mg pyrimethamine.
Weight Age Number of tablets

(kg) (years)
5-6 2-3 months 0.25
7-10 4-11 months 0.5

11-14 1-2 0.75
15-18 3-4 1
19-29 5-9 1.5
30-39 10-11 2
40-49 12-13 2.5
50+ 144 3
Table 5 (continued)
Mefloquine (common trade names; Lariam. Mephaquin)

Single-dose (15 mg base/kg) or split-dose (25 mg base/kg) treatment is rec-
ommended depending on the extent of mefloquine resistance in the area con-
cerned The following regimens are based on tablets containing 250 mg
mefloquine base. The mefloquine formulation available in the USA. which contains
250 mg hydrochloride (equivalent to 228 mg mefloquine base), can be used ac-
cording to the same regimens as regards the number of tablets, but the daily
doses in terms of base will be slightly lower than recommended
Number of tablets
Split dose
Weight Age
(years)
(kg)
Single dose Dose 1 Dose 2
<5 < 3 months Not recommended

5-6 3 months 0.25 0.25 0.25
7-8 4-7 months 0.5 0.5 0.25
9-12 8-23 months 075 0.75 0.5
13-16 2-3 T 1 0.5
17-24 4-7 1.5 1.5 1
25-35 8-10 2 2 1.5
36-50 11-13 3 3 2
51-59 14-15 3.5 3.5 2
60+ 15+ 4 4 2
* Split dose (|25 mg base). areas with resistance to mefloquine nuch as neat the Thailand/Carnbodia border. The
split dose is given as 15 mg base/kg on Day 1 followed by a second dose of 10 mg b a s e / k g - 2 4 hours later.
* Single dose (15 mg base/kg) areas not affected by significant resistance to mefloquine.
Not recommended because data for this weight/age group are limited.
Quinine
Since many different tablet formulations of quinine salts are available, the follow-
ing regimens are given in terms only of mg base/kg The most common formula-
tions are various strengths of quinine hydrochloride, quinine dihvdfochloride and
quinine sulfate, containing 82%, 82% and 82.6% quinine base respectively
(a) Areas where parasites are sensitive to quinine:
quinine 8 mg base/kg orally 3 times daily for 7 days
(b) Areas of high levels of resistance to quinine:

quinine 8 mg base/kg orally 3 times daily for 7 days, accompanied by
either doxycycline 100 mg salt daily for 7 days (not in children under 8 years of
age and not in pregnancy)
or tetracycline 250 mg salt 4 times daily for 7 days (not in children under
8 years of age and not in pregnancy).
there is no protective vaccine for dengue, so travellers must rely on prevent-

ing mosquito bites to combat infection. In addition to taking the precautions
suggested in Box 5.2. p. 76, travellers should use insect repellents or mos-
quito coils during daylight hours.
Anyone suspected of being infected with dengue, especially with
haemorrhagic manifestations, should seek medical assistance immedi-
ately. If untreated or inappropriately treated, DHF and DSS have a high
case-fatality rate; appropriate clinical management can reduce the rate to
under 5%.
5.7 Tuberculosis
Air travel has sometimes been associated with the spread of Mycobacte-
rium tuberculosis infection. Over the past 5 years, investigations of sev-
eral instances of transmission of tuberculosis to passengers and crew have
concluded that the risk of contracting the disease on board an aircraft is no
greater than in other confined spaces. However, an association was found
between the transmission of M. tuberculosis and (1) the infectiousness of
the index patient as expressed by a positive sputum smear, (2) flight time
of more than 8 hours, and (3) the passenger's seating proximity to the
index patient.
To prevent exposure of others to tuberculosis during air travel, persons
known to have infectious tuberculosis should travel by private transport or
should at least have become sputum smear negative before travelling. If an
infectious patient is known to have travelled on an aircraft, health depart-
ments and airlines should collaborate to inform passengers seated in the
same cabin area as the patient. These passengers should undergo a medical
examination and lake adequate preventive measures if so recommended by
the examining physician.
5.8 Vaccinations
Travellers can be immunized against a certain number of diseases. The

duration of the protection conferred by immunization varies. It is possible to
determine the person's immune status beforehand, but if there is any doubt it
is usually more convenient to give complete primary vaccination or a
booster, as appropriate.
A distinction should be made between vaccinations required by countries
by law for entry to their territory, vaccinations recommended by WHO for
general protection against certain diseases, and other vaccinations which
may be advisable in certain circumstances (Table 6). A vaccination plan
should be established, taking into account the traveller's destination, overall
state of health and current immune status, the duration and type of travel,
and the time available.
Table 6. C o m p r e h e n s i v e list of v a c c i n a t i o n s
Table 6 (continued)
Indicated for people travelling in endemic areas. Does not pre-

vent transmission mission by carrier. To ensure long-lasting immunity
a booster dose may be required in your childeren.
Women who f a i l to serconvrt after initial injection need to be

prevaccinated Available combined
(MMR) vaccine to be given after 15 months of age.
Only available as MMR vaccine (see above)
pending on season and destination in the tropics influenza

can occur throughout the year,in the southern hemisphere, the
season of greatest artwity is April September and in the north-
ern hemisphere: November-February.Elderly poople and these
with high-risk medical conditions preparing to travel to areas
where influenza may be active should review then influenza
vaccination histories. If they were not vaccinated during the
previous season, they should consist influenzavaccination
before travel.
Indicated for high risk occupations and situations in endemic

areas (see section 5.2.7) Serum should be checked for antibody
level 1 month after 3rd dose.
5.9 Special situations
5.9.1 Extended travel

The recommendations given for short trips are usually valid but not al-
ways adequate for extended travel. Each ease should be examined individu-
ally. Special vaccinations (Table 6) may be needed in some circumstances.
The duration of travel and itinerary must be taken into account when ma-
laria prophylaxis is prescribed. Transmission of the disease may follow a
seasonal cycle and, in areas where it is not continuous, it may be possible for
the traveller to do without prophylaxis for a period.
5.9.2 Pregnancy
Travel is not generally contraindicated during pregnancy, but there arc
some risks: in particular, travel to malarious areas should be avoided if at all
possible. Air travel is not recommended in the last month of pregnancy and
until the seventh day after delivery. For safety reasons, airlines restrict the
acceptance for international flights of women over 36 weeks pregnant.
Administration of killed or inactivated vaccines, toxoids and polysaccha-

rides is authorized during pregnancy. Live vaccines are generally contra-
indicated. The risks and benefits should nevertheless be examined in each
individual case. Vaccination against yellow fever is permitted after the sixth
month of pregnancy when justified epidemiologically. Oral immunization
against poliomyelitis is not contraindicated.
The antimalarial drugs chloroquine. proguanil and quinine may be given
to pregnant women. Sulfadoxine-pyrimethamine. sulfalene-pyrmethamine.
mefloquine, doxycycline and halofantrine are contraindicated during
pregnancy. For the use of antimalarial drugs during pregnancy, see Box 5.3,
p. 77. and pp. 73-74.
5.9.3 Children
Children usually adapt better to time and climate changes than adults.
However, their resistance to illness is lower. A child can be overcome by
acute dehydration within a few hours.
Air travel can sometimes cause discomfort to infants, who become dis-
tressed by the changes in cabin pressure. They should be given a bottle to
help overcome the problem. Air travel is not recommended for infants of less
than seven days old or for premature babies.
For children with sensitive skins, prickly heat can be alleviated by the use
of talcum powder, daily bathing and loose cotton clothing (see section 5.2.4).
Some vaccines can be administered in the first few days of life (BCG, oral
poliomyelitis vaccine, hepatitis A and B). Other vaccines (diphtheria/tetanus/
pertussis, diphtheria/tetanus, inactivated poliomyelitis vaccine) should not be
given before 6 weeks of age. Children can receive yellow fever vaccine from
6 months of age. Below that age, it is all the more important to ensure protec-
tion against mosquitos (see Box 5.2. p. 76). Special attention must be given to
all children who have not been immunized against measles at the appropriate
time. Measles is still common in many countries and travel in densely popu-
lated areas may favour transmission. For infants travelling to countries where
measles is endemic, a dose of measles vaccine may be given at 6 months of
age. However, children who receive the first dose at 6, 7, or 8 months should
receive a second dose at 9 months or as soon as possible thereafter.
Malaria prophylaxis is important for children, Chloroquine. proguanil and
quinine may be safely given to infants (see Table 2. p. 79). The prevention
of exposure is vitally important, especially as it is relatively easy to protect
small children by using suitable mosquito nets.
5.9.4 Chronic diseases and other health problems

Neither chronic disease nor advanced age is an absolute contraindication
for travel. People suffering from chronic diseases or taking immuno-
suppressive medication should seek the advice of their doctor. Drugs and
medicines should be kept at hand so as to avoid the risk of an accidental
break in medication.
Hot climates can exacerbate diseases of the cardiovascular and digestive

systems, but may alleviate rheumatic pain and chronic infections of the up-
per respiratory tract.
Contraindications for air travel include cardiac failure, recent myocardial
infarction or stroke, angina pectoris or chest pain a! rest, rhythm disorders
(e.g. paroxysmal tachycardia, left ventricular heart block, atrial fibrillation),
uncontrolled arterial hypertension of more than 200 mmHg (27kPa) systolic
pressure, severe anaemia, sickle-cell anaemia, acute mental disorders, epi-
lepsy, pneumothorax, and any serious and acute contagious disease. Pas-
sengers with a pacemaker should be made aware of the possibility of induc-
tion currents on board (from radar and electronic devices) and should take
appropriate precautions. Passengers with rheumatism, arthritis, varicose veins
and swollen legs are likely to experience discomfort on long-haul flights.
It is particularly important that travellers with a chronic illness should ob-
tain information on the medical facilities available in the country to be visited
5.9.5 The disabled

A physical disability is not a contraindication for travel. The airlines have
regulations on conditions of travel for handicapped or disabled people who
need to be accompanied.
6- MISCELLANEOUS
6.1 Blood transfusion
The decision to transfuse blood or blood products must be based on a

careful assessment indicating that transfusion is necessary to save life or
prevent major morbidity. Blood transfusion should not be the first consider-
ation during the management of patients with acute haemorrhage, because
blood volume replacement is initially more urgent than red cell replacement.
Accurate diagnosis, adequate oxygenation and volume replacement with
plasma substitutes (crystalloids and colloids), and prompt and meticulous
surgical care may obviate the need for blood transfusion.
Blood that has not been obtained from carefully selected donors or that
has not been appropriately tested for infectious agents should not be trans-
fused, other than in the most exceptional life-threatening situations.
6.2 Medical kit for travellers
It is always useful to carry a disinfectant and dressings that can be applied

easily. For travel to certain areas, sun creams, mosquito repellents, anti-
malarial drugs and oral rehydration salts are also basic necessities. Travellers
should consult a doctor as to whether they should take antibiotics or anti-
diarrhoea! preparations with them.
Travellers contemplating a protracted stay in a remote location should
consult someone who is competent to advise them on the content of their
medical kit. If it is likely to be necessary to administer a vaccination or other
drug by injection, disposable syringes and needles for this purpose should
be carried.
6.3 Medical examination after travel
A medical examination is unnecessary after a short trip with no problems,

or if the traveller has only suffered a trivial ailment (traveller's diarrhoea,
cold). Patients with chronic diseases should nevertheless consult their doctor
for a check-up. Medical examination is essentia) if fever, diarrhoea, vomit-
ing, jaundice, urinary disorders, or skin or genital infections occur in the
weeks following return from travel.
A medical examination is advisable after a long stay abroad. Some dis-
eases do not develop immediately but may appear some time later when the
traveller has resumed normal activities: the commonest of these are malaria,
amoebic dysentery, viral hepatitis, typhoid and paratyphoid fevers, sexually
transmitted diseases, intestinal parasitoses (e.g.. giardiasis), schistosomiasis

(Bilharziasis), filariasis, leishmaniasis, trachoma, trypanosomiasis, and
typhus. Travellers who fall ill on their return must inform their doctor of their
trip without fail. Medical practitioners must always bear in mind that their
patients may have been travelling recently and may have contracted an un-
usual disease. This is especially true for malaria, which may strike months or
even years after the traveller has left the endemic area. Special attention
should be paid to tuberculosis.
6.4 Note for travel organizers
Travel free of health problems is in the interest of travel organizers and

employers as well as travellers.
Travel agencies are encouraged to give their clients objective information
on the hazards related to travel and their avoidance. Awareness of vaccina-
tion requirements usually prompts travellers to seek medical advice. When
no vaccinations are required, travellers are all too often ill-informed of the
risks to which they may be exposed (including malaria).
Airlines and shipping companies that carry travellers to countries where
malaria is endemic should ensure that their passengers are informed of the
presence of the disease.
Travel organizations should be able to provide information on the medical
facilities available at travel destinations (distance to the nearest hospital,
facilities for evacuation in case of accident or emergency). When the destina-
tion is remote from any health care centre, the travel organizer should be
able to provide specific products such as vaccines and antirabies or antivenom
sera.
During the past decade, outbreaks of legionnaires' disease have occurred
in some groups of tourists staying at certain hotels. This disease can present
as a respiratory illness and may be severe and even fatal. The vehicle of
infection is usually water: air-conditioning systems and showers have been
implicated. Measures such as chlorination of water supplies can prevent
infection, against which travellers have no other means of protection.
Codes of practice and recommendations on the application of specific
procedures for the monitoring and safety of food and water have been es-
tablished by such bodies as the International Air Transport Association and
the International Civil Aviation Organization. These recommendations are
brought to the attention of airlines and international hotel groups. The Joint
FAO/WHO Codex Alimentarius Commission has so far drawn up some
25 codes of hygienic practice and/or technology in respect of different food
products.1 Some countries maintain extensive food surveillance activities at
the national level. Travel organizations should ascertain whether these codes
and recommendations are followed in the countries with which they arc
concerned.
1
These are available upon request from national Codex Contact Points or from the Chief.
Joint FAO/WHO Food Standards Programme, Food ant! Agriculture Organization of the United
Nations, Via delle Terme di Caracalla, l-00100 Rome. Italy.
ANNEX 1
LABORATORIES APPROVED BY WHO FOR THE

PRODUCTION OF YELLOW FEVER VACCINE
Bio-Manguinhos
Oswado Cruz Foundation
Rio de Janeiro
Brazil
Evans Medical
Liverpool
England
Pasteur-Merieux Sera and Vaccines
Lyon
France
Robert Koch Institute
Berlin
Germany
Institute of Poliomyelitis and Viral Encephalitides

Moscow
Russian Federation
Pasteur Institute
Dakar
Senegal
Connaught Laboratories Inc.
Swiftwater
Pennsylvania
United States of America
Vaccinations carried out with yellow lever vaccine produced by labora-
tories no longer on the list remain valid until the normal expiry dale of the
International Certificate of Vaccination or Revaccination against Yellow
Fever,
93
ANNEX 2
SOME RELEVANT WHO PUBLICATIONS
International travel
International Health Regulations (1969): third annotated edition. 1983.
79 pages, index.
Ports designated in application of the International Health Regulations.
Situation as on 1 April 1992. 1992. 40 pages.
Yellow-fever vaccinating centres for international travel. Situation as on
1 January 1991. 1991. 88 pages.
International medical guide for ships. 2nd ed. 1988. 376 pages.
Sanitation and water quality

Guide to ship sanitation, by Vincent B. Lamoureux. 1967. reprinted 1987.
119 pages.
Guide to sanitation in tourist establishments, by J. A. Salvato, jr. 1976.
J 29 pages.
Guide to hygiene and sanitation in aviation, by J. Bailey. Second edition.
1977. 162 pages.
Environmental sanitation in European tourist areas. Report on a Working
Group. Montpellier. 1978. 1980. 33 pages (EURO Reports and Studies.
No. 18).
Basic sanitation technologies suitable for smaller European communities.
Report on a WHO Working Group. Rennes, France. 1978. 1982.
25 pages (EURO Reports and Studies. No. 34).
Guide to simple sanitary measures for the control of enteric diseases.
by S. Rajagopalan; with a section on food sanitation by M. A. Shiffman.
1974. 103 pages.
Guidelines for drinking-water quality, 2nd ed. Volume 1. Recom-
mendations, 1993. x + 188 pages. Volume 2. Health criteria and other
supporting information. 1996. xvi + 973 pages. Volume 3. Surveillance
and control of community supplies. 1998. xii + 238 pages.
Food safety
Guide to shellfish hygiene, by P. C. Wood. 1976. 80 pages (WHO Offset
Publication, No. 31).
— 94 —
SOME RELEVANT WHO PUBLICATIONS 95
Paralytic shellfish poisoning, by B. W. Halstead in collaboration with

E. J. Schantz. 1984. 60 pages (WHO Offset Publication. No. 79).
Control of foodborne nematode infections. Report of a WHO Study Group,
WHO Technical Report Series, No. 849. 1995. viii + 157 pages."
Mass catering, by R. II. G, Charles. 1983. x + 70 pages (WHO Regional
Publications, European Series, No. 15).
Health surveillance and management procedures for food-hand ling per-
sonnel WHO Technical Report Series, No. 785, 1989. 47 pages.
Safe food for travellers (leaflet).
Communicable diseases
The management and prevention of diarrhoea, Practical guidelines.
3rd ed. 1993. v + 50 pages.
The rational use of drugs in the management of acute diarrhoea in
children. 1990. 75 pages.
Guidelines for cholera control. 1993. vi + 61 pages.
Cholera: basic facts for travellers (leaflet).
Prevention and control of yellow fever in Africa. 1986. v + 94 pages.
Vector resistance to pesticides. Fifteenth report of the WHO Expert Com-
mittee on Vector Biology and Control. WHO Technical Report Series.
No. 818. 1992. v + 6 2 pages.
A global strategy for malaria control. 1993. x + 30 pages.
Implementation of the global malaria control strategy. Report of a WHO
Study Group. WHO Technical Report Series. No. 839, 1993.
v + 57 pages.
Management of severe and complicated malaria. Practical guidelines.
1991. vi + 56 pages.
Practical chemotherapy of malaria. Report of a WHO Scientific Group.
WHO Technical Report Series, No. 805. 1990. 141 pages.
Malaria chemoprophylaxis regimens for travellers. Weekly epidemiological
record. 68(51): 377-383 (1993).
Drug alert: halofantrine. Change in recommendations for use. Weekly epi-
demiological record, 68(37): 269-270 (1993).
Development of recommendations for the protection of short-stay travel-
lers to malaria endemic areas: Memorandum from two WHO Meetings.
Reprinted from Bulletin of the World Health Organization. 66(2):
177-196 (1988).
Vector control for malaria and other mosquito-borne diseases. Report of a
WHO Study Group. WHO Technical Report Series. No. 857. 1995. vi +
91 pages.
Vector control: methods for use by individuals and communities, prepared

by Jan A. Rozendaal. 1997. xiii + 412 pages.
Epidemiology, prevention and control of legionellosis: Memorandum from
a WHO Meeting. Bulletin of the World Health Organization. 68(2):
155-164(1990).
Dengue haemorrhagic fever: diagnosis, treatment, prevention and control.
2nd ed. 1997. viii + 84 pages.
WHO Expert Committee on Rabies. Eighth report. WHO Technical
Report Series, No. 824, 1992. 90 pages.
Management of patients with sexually transmitted diseases. Report of a
WHO Study Group. WHO Technical Report Series, No. 810, 1991.
110 pages.
Sixth report of the WHO Expert Committee on Venereal Diseases and
Treponematoses. WHO Technical Report Series, No. 736, 1986.
141 pages.
Control of sexually transmitted diseases. 1985. 110 pages.
WHO model prescribing information: drugs used in sexually transmitted
diseases and HIV infection. 1995. 97 pages.
Prevention of sexual transmission of human immunodeficiencv virus. WHO
AIDS Scries. No. 6. i 990. iii + 27 pages.
Guidelines on sterilization and disinfection methods effective against
human immunodeficiency virus (HIV). 2nd ed. WHO AIDS Series,
No. 2. 1989. iv + 11 pages.
AIDS in Africa. A manual for physicians, by P. Piot et al. 1992.
133 pages.
AIDS: images of the epidemic. 1994. x + 142 pages.
Control of Chagas disease. Report of a WHO Expert Committee. WHO
Technical Report Series. No. 811. 1991. 101 pages.
Control of the leishmaniases. Report of a WHO Expert Committee. WHO
Technical Report Series. No. 793, 1990. 158 pages.
Control and surveillance of African trypanosomiasis. Report of a WHO
Expert Committee. WHO Technical Report Series, in press.
Lymphatic filariasis: the disease and its control. Fifth report of the WHO
Expert Committee on Filariosis, WHO Technical Report Series,
No. 821. 1992. 77 pages.
Onchocerciasis and its control. Report of a WHO Expert Committee on
Onchocerciasis Control. WHO Technical Report Series. No. 852. 1995.
111 pages.
Sixth report of the Joint FAO/WHO Expert Committee on Brucellosis.
WHO Technical Report Series. No. 740. 1986. 132 pages.
SOME RELEVANT WHO PUBLICATIONS 97
Prevention and control of intestinal parasitic infections. Report of a WHO

Expert Committee. WHO Technical Report Series, No. 749. 1987.
86 pages.
File control of schistosomiasis. Second report of the WHO Expert Com-
mittee. WHO Technical Report Series. No. 830. 1993. vii + 86 pages.
WHO model prescribing information: drugs used in parasitic diseases.
2nd ed. 1995. 146 pages.
La dermatite cercarienne en Europe: un probleme de sante publique
nouveau? by L de Gentile et al. Bulletin of the World Health Organiza-
tion, 74(2): 159-163 (1996) (article in French, summary in English).
INDEX OF COUNTRIES AND TERRITORIES
Afghanistan. 17.50.51.64 Christmas Island (Indian Ocean). 22
Albania, 17.52.53 Colombia, 22, 47. 48
Algeria, 17. 43 Comoros, 22.44, 45
American Samoa, 18. 53 Congo, 23, 44
Andorra. 18.52 Cook Islands. 23,53
Angola. 18.44 Costa Rica. 23.46
Antarctic. 53 Cote d'lvoire.23.44
Antigua and Barbuda. 18. 46 Croatia. 23.52
Argentina. IK. 48 Cuba. 23. 46. 47
Armenia, 18. 50 Cvprus.23,51
Aruba. 46 Czech Republic. 23.51
Australia, 18,53.59.64.67
Democratic People's Republic of Korea,
Austria. 18. 52 23.48
Azerbaijan. 18. 50 Democratic Republic of the Congo, 23. 44
AZores. 35. 52 Denmark, 23, 51
Bahamas. 18.46 Djibouti. 23. 44.45
Bahrain. 18.51 Dominica. 24,46
Bangladesh. 18. 50, 64 Dominican Republic. 24, 47
Barbados, 19,46
Belarus, 19.51,52 Easter Island. 53
Belgium, 19.51 Ecuador. 24. 47. 48
Belize. 19.46 Egypt. 24.43
Ellice Islands see Tuvalu
Benin. 19,44 El Salvador. 24.46
Bermuda. 19,46 Equatorial Guinea. 24.44. 45
Bhutan. 19.50 Eritrea, 25,44.64
Bolivia. 20. 47 48 Estonia. 25. 51.52
Bosnia and Herzegovina, 20. 52 Ethiopia. 25. 44. 64
Botswana. 20. 45
Brazil. 20.47. 48 Falkland Islands (Malvinas). 25. 48
British Virgin Islands. 20. 46 Faroe Islands. 25. 51
Brunei Darussalam, 20.49 Fiji. 25. 53
Bulgaria. 21.52.53 Finland. 25. 51. 52. 59
Burkina Faso. 21. 44 France. 25, 52
Burma see Myanmar French Guiana, 25. 47
Burundi. 21. 44 French Polynesia. 25. 53
Cambodia. 21.49. 50. 69.76. 77. 84
Cameroon. 21,44,45 Gabon. 25.44,45
Canada. 21.46, 64 Gambia. 25. 44
Canary Islands, 52 Georgia. 26. 50
Germany. 26. 51
Cape Verde. 21.44.45 Ghana. 26. 44
Cayman Islands, 21. 46 Gibraltar. 26. 52
Central African Republic. 22. 44 Gilbert Islands see- Kiribati
Chad. 22, 44 Greece. 26. 52. 53
Channel Islands. 40. 51 Greenland. 26, 46
Chile. 22,48 Grenada. 26. 47
China. 22. 48. 49. 58. 64. 67
101 —
Guadeloupe. 26. 47 Mauritania, 31.44

Guam. 26. 53 Mauritius. 31. 44. 45
Guatemala, 26,46 Mayotte. 31
Guinea. 26,44 Mexico. 31. 46. 64
Guinea-Bissau. 26. 44 Micronesia (Federated States of"). 31. 53
Guyana. 27. 47 Moldova see Republic Of Moldova
Monaco, 31, 52
Haiti. 27. 47 Mongolia. 31.48.49
Hawaii. 46 Montserrat 31.47
Honduras, 27, 46 Morocco. 32. 43
Hong Kong Special Administrative Mozambique. 32, 44
Region of China, 27.48 Myanmar. 32.49, 50. 58. 64.69.71. 76, 77
Hungary. 27. 52
Namibia. 32.45
Iceland. 27. 51 Nauru. 32, 53
India. 27, 50. 51.58,64, 71 Nepal. 32. 50, 51.58. 64
Indonesia. 28.49. 50.64 Netherlands. 33. 51
Iran (Islamic Republic of). 28. 50. 51, 64 Netherlands Antilles. 33. 47
Iraq. 28. 51 New Caledonia and Dependencies. 33. S3
Ireland. 28.51 New Hebrides see Vanuatu
Isle of Matt, 40. 51 New Zealand. 33, 53. 59. 64. 67
Israel. 28. 51 Nicaragua, 33, 46
Italy. 29. 52 Niger. 33, 44
Ivory Coast see Cote d'lvoire Nigeria, 33, 44
Jamaica 29. 47 Niuc.33.53
Japan. 29,48. 49, 58. 64. 67 Northern Mariana Islands. 33
Jordan, 29, 51 Norway. 33,51.59
Oman. 34. 51
Kazakstan. 29, 50
Kenya, 29.44. 64 Pakistan, 34, 50, 51.64
Kiribati. 29. 53 Palau, 34, 53
Korea see Democratic People's Republic Panama.34. 46
of Korea; Republic of Korea Papua New Guinea. 34, 53.71
Kuwait. 29. 51 Paraguay, 34.47
Kyrgyzstan, 29.50 Peru. 34.47. 48
Philippines. 35.49.50.58
Lao People's Democratic Republic. 29.
49. 50, 58 Pitcaim. 35
Latvia, 29.51,52 Poland. 35, 51.52
Lebanon. 29.51 Portugal. 35. 52
Lesotho, 29. 45 Puerto Rico, 35. 47
Liberia. 29. 44. 45 Qater. 35.51
Libyan Arab Jamahiriya, 30, 43
Liechtenstein, 30, 52 Republic of Korea, 35,48.49.58
Lithuania. 30. 51.52 Republic of Moldova. 35. 51. 52
Luxembourg. 30, 51 Reunion. 35. 44,45
Romania, 35. 52. 53
Macao. 30. 48. 49 Russian Federation. 35. 51. 52
Macedonia see The Former Yugoslav Rwanda 35.44
Republic of Macedonia
Madagascar. 30.44 Saint Helena. 36, 45
Madeira, 35, 52 Saint Kitts and Nevis. 36,47
Malawi. 30. 44 Saint Lucia. 36. 47
Malaysia, 30.49.50 Saint Pierre and Miquelon, 36.46
Maldives, 30.50 Saint Vincent and the Grenadines. 36.47
Mali. 30. 44 Samoa, 36, 53
Malta. 30. 52 San Marino. 36, 52
Marshall Islands. 31.53
Martinique. 31. 47 Sao Tome and Principe. 36. 44
Saudi Arabia, 36, 51
INDEX OF COUNTRIES AND TERRITORIES 103
Senegal, 36.44 Turkmenistan. 39. 50
Seychelles. 44, 45 Turks and Caicos Islands. 47
Sierra Leone, 36, 44 Tuvalu. 39.53
Singapore. 37. 49
Slovakia, 37. 51 Uganda 39.44
Slovenia. 37. 52 Ukraine. 39, 51.52
Solomon Islands. 37. 53 United Arab Emirates. 39. 51
Somalia. 37,44.64 United Kingdom. 40. 51.59
South Africa,. 37.45 United Republic of Tanzania. 40. 44
Spain. 37. 52 United Slates of America. 40. 46. 64
Sri Lanka, 37. 50. 58 Upper Volta See Burkina Faso
Sudan. 37.44.64
Uruguay, 40,48
Suriname. 38.47,48
Swaziland. 38, 45 USSR, Former. 64 see also individual
Sweden. 38. 51.59 countries
Switzerland, 38. 52 Uzbekistan.40.50
Syrian Arab Republic. 38. 51 Vanuatu. 40, 53. 71
Venezuela. 40. 47. 48
Tajikistan. 38. 50 Viet Nam. 40, 49. 50. 58
Tanzania set United Republic of Virgin Islands (USA). 40. 47
Tanzania,
Thailand. 38.49. 50. 58.69. 76, 77. 84 Wake Island. 40
The Former Yugoslav Republic of Wallis and Futuna Islands, 53
Macedonia. 39.52
Togo, 39. 44 Yemen. 40. 51
Tokelau. 39, 53 Yugoslavia. 41. 52, 53
Tonga. 39. 53
Trinidad and Tobago. 39.47 Zaire see Democratic Republic of the Congo
Zambia. 41.44
Tunisia. 39. 43 Zimbabwe. 41.44
Turkey. 39. 51
SUBJECT INDEX
Accidents, 60
Acquired immunodeficiency syndrome (AIDS), 9. 58, 65-66
Aedes mosquitos. 58. 78
Airlines. 7.90
Altitude, 57
American trypanosomiasis. 46. 47. 48, 58
Amoebiasis and amoebic dysentery. 45, 46.47. 48, 91
Ancylostomiasis. 57
Animals. 58-60
Anopheles mosquitos. 58
Anthrax. 48. 60
Autidiarrhoeal drugs, 63
Antimalarial drugs. 69-84
Antivenom. 60
Arenavirus haemorrhagic fevers. 45. 48
Arthropod-borne diseases. 43. 44. 45.46. 47.48. 49. 50. 51. 52. 53. 58
Ascaris lumbricoides. 61
Athlete's foot. 57
Bacillary dysentery. 46. 47, 49. 52
Bacillus cereus food infection. 61
Bartonellosis, 47
Bats, 46. 58
BCG vaccine. 66. 86. 88
Bedbugs. 58
Bilharziasts see Schistosomiasis
Bites, 56, 57. 58, 59. 72. 73. 76. 78
see also Leeches. Snakes
Blackflies.47. 58
Blister beetles. 58
Blood transfusion, 91
Borreliosis, 58
Brucellosis. 43, 46. 48.49.50. 51.52. 61
Campylobacter jejuni, 52. 53, 61
Cats. 58, 59
Cerearial dermatitis. 57
Chagas disease. 46. 47. 48. 58
Chancroid. 65
Chemoprophylaxis. antimalarial. 69-84
Chiggers. 58
Children, 62. 63. 74.78.88
Chlamydia, 65
Cholera, control. 10,62-63
geographical distribution. 43. 45.46.47. 48. 49. 50
vaccination certificate, international requirements. 10, 17
national requirements. 17
vaccine. 10,63.86
See also Diarrhoeal diseases
Chronic diseases. 88-89
Clonorchiasis. 49.61
Clostridium botulinum, 61
104 —
SUBJECT INDEX
Clostridium perfringens. 61
Coelenterates. 47. 53
Cold, 46. 52. 57
Condoms. 65
Contraceptive pill, 55
Contraindications for air travel, 87, 88
Cora] dermatitis. 57
Corals. 47,53.57
Crimean-Conga haemorrhagic fever. 45, 50. 51
Cryptosporidium parvum. 61
Culex mosquitos. 58
Dehydration. 57, 63
Dengue and dengue haemorrhagic fever. 46. 47. 49. 50. 53, 58, 78, 85
Diabetics, 66
Diarrhoeal diseases, 43.45. 46.48.49. 50, 52. 53. 56. 60. 62-63
Diphtheria. 46. 52. 86. 88
Diphyllobothriasis, 52
Disabled persons. 89
Disinfectant agents, 62
Dogs. 46. 58. 59
Draeuneuliasis. 45, 51
Dysenteries. 43,45.47. 49. 50. 52. 63. 91
Ear infections. 56
Ebola fever. 45
Echinococcosis. 43. 45. 48, 50, 51 52
Eggs.61.62
Encephalitis 46. 47. 49. 50. 52. 58. 87
Entamoeba histolytica, 61
Escherichia coli, 61
Lye infections. 56
Fascioliasis. 47. 52.61
Fasciolopsiasis, 49
Fatigue. 55
Fever, arenavirus haeraorrhagic, 45. 48
dengue, 46,47.49. 50. 53,58, 78, 85
Ebola, 45
haemorrhagic. 44. 45. 47. 48, 49. 50. 51. 52. 53. 58. 60. 78. 85
Korean haemorrhagic, 49
Lassa, 45
Marburg, 45
Oroya, 47
relapsing, 43,44.45. 50. 51. 58
Rift Valley,43,45
sandfly. 43.44, 50. 52
typhoid and paratyphoid. 43,45. 46. 48. 49. 50. 51. 52, 53. 56. 60. 86. 9
undulant see Brucellosis
West Nile. 43. 52
yellow. 10-15. 17,44,47,58.66,86; 88
Filariasis. 43, 44, 46. 47. 49. 50. 53. 58. 92
Fish and fish poisoning. 52.53,57.61.62
Fish tapeworm. 52
Fleas, 44, 58
Flute infections, 46, 43,49
Food-borne diseases. 43. 45. 46. 47.48. 49, 50. 51. 52. 53. 60-64
Foxes. 52,58
Fruits. 61. 62
Gastroenteritis. 48
Giardiasis. 43, 45, SO; 92
Gonorrhoea, 56, 65
Guinea-worm infection see Dracunculiasis
Giardia lamblia. 61
Haemagogus mosquitos, 58
Haemorhagic fevers. 44. 45, 47. 4X. 49, 50. 51, 52, 53. 58, 60, 78. 85
Haji. 51
Hamavirus, 46
Health administrations, 7. 9, 43
Heat and heat exhaustion, 51. 57
Helminthic infections. 43.45. 46. 48. 49.50. 53. 61.63
see also individual infections
Hepatitis, 43. 45.46. 47. 48, 49. 50, 51. 52. 53. 50. 61. 63-64. 65. 67, 86. 88. 91
Herpes, 65
Honey, 61
Human immunodeficiency virus (HIV), 9. 52. 56. 58. 65-66.86
Humidity, 57
Hydatid disease see Echinococcosis
Ice. 62
Ice-cream, 61. 63
Immunization see Vaccinations
Immunoglobulin. 59. 64, 85
Influenza, 87
Insects, 58
see also Arthropod-borne diseases
Insomnia. 55, 57
Insulin. 55
International Air Transport Association, 92
International Civil Aviation Organization. 92
International Health Regulations. 9. 10. 17
Intestinal parasitosis. 48. 92
Jackals. 58
Japanese encephalitis. 49, 50. 58. 87
Jellyfish. 47. 53.57
Jet-lag, 55
Kit. medical. 91
Korean haemorrhagic fever. 49
Lassa fever. 45
Leather and skins. 60
Leeches. 48. 50
Legionnaires' disease. 92
Leishmaniasis, 43. 44.46.47. 48. 49.50.51.52.58,92
Leptospirosis, 49, 56
Listeria monocytogenes, 61
Louse-borne infections. 44. 48. 58
Lyme disease. 46. 52, 58
Malaria. 56. 58. 67-84. 88, 91. 92
chemoprophylaxis. 69-84, 88
geographical distribution. 43. 44 45. 46. 17, 48. 49. 50. 53
risk by country or territory. 17-41
Mansonia mosquitos, 58
Marburg fever, 45
Mayonnaise. 62
Measles. 46. 86.88
SUBJECT INDEX
Meat. 61
Melioidosis. 50
Meningococcal meningitis. 45,48. 49. 50. 87
Milk. 61, 62
Mite-borne infections. 49. 53.58
Mongooses. 47. 58
Monkeys, 58
Mosquitos. 52. 58. 71.72. 73. 76. 78
Mumps. 46. 87
Mycetomas. 57
Mycobacterium bovis. 61
Mycobacterium tuberculosis. 85
Norwalk agents. 61
Oedema, acute pulmonary. 57
cerebral. 57
Onchocerciasis. 44. 46.47. 51. 58
Opisthorchiasis, 50,61
Oral rehydration, 63. 91
Oroya lever. 47
Paragonimiasis. 45. 46. 48,49. 61
Parasitosis, intestinal. 48. 92
Paratyphoid fever see Typhoid and paratyphoid fevers
Pertussis. 46. 86. 88
Plague, 44,45. 46. 47. 49. 50. 58.60
Plasmodia, drug resistance, 68-69. 71. 76-77
see also individual countries
Poison ivy. 46
Poison oak, 46
Poliomyelitis. 43, 45.46.49. 50.51. 52. 53. 56. 60. 86. 88
Polyarthritis, mosquito-borne epidemic. 53
Pregnancy. 62, 73-74. 76. 77. 84. 87-88
Prickly heat, 57. 88
Quarantine, 59
Rabies, 44.45,46. 47.48. 49. 50. 51. 52. 56. 58. 59, 87
Rabies-free countries, 5$-^)
Raccoons, 58
Rats. 45. 58. 60
Rehydration fluid, 63
Relapsing fever. 43.44. 45, 50. 51. 58
Rice. 61
Rift Valley fever. 43.45
River blindness see Onchocerciasis
Rocky Mountain spotted fever. 46
Rotavirus. 61
Rubella. 46. 87
Subethes mosquitos, 58
Salads, 61
Salmonella (non-typhe). 61
Salmonella typhi and paratyphi, 46. 61
see also Typhoid and paratyphoid fevers
Salmonellosis. 46.48.52
Sandfly fever. 43. 44. 50. 52
Sausage, 61
Schistosomiasis. 44. 45, 47.48. 49. 50, 51. 56. 92
Scorpions. 44. 58. 59
Sea anemones, 57
Seasickness, 55
Sea-urchins. 47
Sexually transmitted diseases, 65-67
Shellfish. 53, 57. 61. 62
Shigella spp, 46, 61
Shipping companies. 7
Skin cancer, 58
Skin lesions. 60
Skunks, 58
Sleeping pill. 55
Sleeping sickness see Trypanosomiasis
Smallpox vaccination certificate no longer required. 10, 17
Snakes. 44,45,46. 47. 48.50. 53. 59
Spiders. 58
Staphylococcus aureus, 61
Strongyloidiasis. 57
Sun-stroke, 58
Swimming and bathing. 53, 56. 57
Syphilis. 65. 66
Taeniasis (tapeworm), 48, 52. 61
Tetanus immunization. 46. 59, 86. 88
Tick-bite lever, 45
Tick-borne infections. 44.45. 50.51. 52. 58
Tinea pedis. 57
Toxoplasma gondii, 61
Trachoma. 44, 45. 49. 50. 51, 53. 92
Transfusion, blood. 91
Travel agencies. 7, 92
Travel sickness. 55
Trichinellosis. 52, 61
Trichomoniasis. 65
Trichuris ırichiura, 61
Trypanosomiasis. 44. 45.46.47, 48. 58. 92
Tsetse fly. 58
Tuberculosis. 85. 86. 92
Tularaemia, 46, 47
Tungiasis.44.57. 58
Typhoid and paratyphoid fevers. 43. 45. 46. 48.49, 50, 51, 52. 53. 56. 60, 86. 91
Typhus. 43.44, 45.48.49. 50. 51. 52. 53. 58. 92
Vaccination certificates, international requirements. 7. 9-13
national requirements. 17-41
Vaccinations. 10-11. 66. 85. 88
Vegetables, 61. 62
Venereal diseases see Sexually transmitted diseases
Venezuelan equine encephalitis. 46
Vibrio cholerae see Cholera
Vibrio parahaemolyicus. 61
Vibrio vulnificus, 61
Water and water-borne diseases. 43. 45. 46, 47. 48. 49. 50. 51. 52, 53, 56, 57, 60, 62, 92
Weil's disease see Leptospirosis
West Nile fever. 43. 52
Yellow fever, geographical distributor, 10. 14-15.44.47
revaccination, 11, 12-13
vaccination certificate, international requirements. 10-13. 17. 66
national requirements. 17-41
vaccine, 11.66.86.88,93
Yersinia enterocolitica, 61
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INTERNATIONAL

WORLD HEALTH ORGANIZATION (WHO)

Telephone: (41 22) 791 21 11

Regional Offices W H O Regional Office for Europe

Telephone 1 (202)974 3000 Tele; (20 3) 48-300 90, 48-300 96/97

Any comments or questions concerning this

Emerging and Other Communicable

World Wide Web access: http://www.who.ch

WHO Library Cataloguing in Publication Data

@ World Health Organization 1998

LIST OF MAPS Page

Map 1. Yellow fever endemic zone in Africa 14

The purpose of the International Health Regulations, adopted by the

The eradication of smallpox was confirmed by WHO nearly 20 years

Vaccination against cholera cannot prevent the introduction of the

No country requires proof of cholera vaccination as a condition for entry

2.4 Yellow fever vaccination certificate'

See also section 5.4.1. Immunization o1 IIIV-intected individuals", p 66.

which is clearly in excess of the International Health Regulations, travellers

MODEL OF AN INTERNATIONAL CERTIFICATE OF

The certificate must be printed in English and French: an additional

Signature of person vaccinated

e.g.: 8 January 1991

MAP 1. YELLOW FEVER ENDEMIC ZONE IN AFRICA

MAP 2. YELLOW FEVER ENDEMIC ZONE

Malaria Malaria risk is limited. One small

certificate is detained in isolation for a

waiver stating that immunization is con-

who have passed through partly or wholly Malaria - Malaria risk-predominantly in

BURKINA FASO CAMEROON

BURMA see MYANMAR

north of latitude 33 N from May to

Throughout the year in the whole country.

COOK ISLANDS DEMOCRATIC PEOPLE'S

See pp. 10-11 and map 2 15 See p.10-11 and map1.p 14

sected in accordance with the provisions

LAO PEOPLE'S DEMOCRATIC

quine and resistant to sulfadoxine-pyri Malaria - Malaria risk-predominantly in

9 months of age coming from infected

Yellow fever - A yellow fever vaccination NIGERIA

OF p. falciparum is restricted to Luciano

SAINT HELENA SAUDI ARAB1A

See pp. 10-11 and map 1. p. 14

Malaria - Malaria risk-predominantly in throughout the year in the whole country.

THE FORMER YOGOSLAV TURKMENISTAN

UNITED KINGDOM (with Channel VENEZUELA

UZBEKISTAN VIRGIN ISLANDS (USA)

Malaria - Malaria risk predominantly in Malaria - Malaria risk predominantly in

This section is intended to give a broad indication of the health risks to

Sub-Saharan Africa (Angola. Benin. Burkina Faso. Burundi, Cameroon,

Food-home and water-borne diseases are highly endemic. Alimentary

Southern Afiica (Botswana. Lesotho. Namibia, Saint Helena. South Africa.

4.2 The Americas

In 1994, an international commission certified the eradication of endemic

North America (Bermuda, Canada. Greenland, Saint Pierre and Miquelon,

Mainland Middle America (Belize. Costa Rica, El Salvador. Guatemala.

Dominican Republic. Grenada. Guadeloupe, Haiti. Jamaica, Martinique,

Tropical South America (Bolivia. Brazil. Colombia. Ecuador, French

western slopes of the Andes up to 3000 m. Louse-borne typhus is often