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Scientific Data Documentation
Information For International Travelers And Health Professionals

 Simultaneous Administration of Vaccines

 Simultaneous administration of most inactivated vaccines has not resulted in
 impaired antibody responses or increased rates of adverse reactions. Most
 can safely and effectively be given simultaneously at separate sites.
 However, when vaccines commonly associated with local side effects(such as
 cholera, typhoid, and plague vaccines) are given simultaneously, the side
 effects can be accentuated.

 Whenever possible, live viruses not administered on the same day should be
 given at least 30 days apart. Recent studies show that antibody response is
 decreased when yellow fever and cholera are administered within three weeks
 as compared to longer intervals. If under time constraints, the vaccines can
 be given simultaneously or anytime within the 3 week period. When
 considering vaccination under time restraints consider that the yellow fever
 vaccine and documentation are required for certain countries and is strongly
 recommended for those travelers to infected areas. The major benefit of the
 cholera vaccine is for entry into a few countries requiring a certificate.

 The safety and efficacy of hepatitis B vaccine, DPT, and OPV or of hepatitis
 B and yellow fever administered simultaneously is similar to separate
 administrations of the vaccines. However, in cholera and yellow fever the
 antibody response can be lower if administered simultaneously or within 3

 There is little interaction between inactivated vaccines and Immune
 Globulin.  Therefore, IG may be simultaneously administered at different
 sites with an inactivated vaccine.

 However, live attenuated vaccine viruses might not successfully replicate
 and the subsequent antibody response could be diminished when the vaccine is
 given with IG. In general, parenterally administered live vaccines should
 not be given for a least 6 weeks and preferably 3 months after IG
 administration. Two exceptions should be noted.  If IG administration
 becomes necessary after a live vaccine has been given, interference may
 occur, and thus the vaccine may have to be repeated after at least a 3 month
 wait. If IG needs to be administered because of imminent exposure to
 disease, live virus vaccines may be administered simultaneously with IG
 recognizing that vaccine-induced immunity may be compromised. Administration
 should be at different sites. Re- immunization should occur after 3 months
 unless serology confirms antibody production. Note that IG does not
 interfere with either OPV or yellow fever vaccines.
Disease Specific Menu


 Cholera is an acute intestinal infection caused by VIBRIO CHOLERA O-group I.
 The current vaccines have shown a 50% effectiveness in reducing clinical
 illness for 3-6 months after administration, with the greatest effectiveness
 in the first 2 months. It is not routinely recommended for travelers, except
 those traveling to any of the two countries requiring a Certificate of
 Vaccination against cholera. A single dose of vaccine will meet the country
 requirement and should be documented on a Certificate of Vaccination.
 Alternatively, a medical waiver signed by a physician is generally accepted
 by country officials.

 The complete vaccination schedule includes 2 doses of vaccine spaced 1 to 4 or
 more weeks apart. Dosages are age specific.
 For infants 0-6 months of age; the vaccine is not recommended, and a medical
 waiver must be provided for entry to countries requiring a certificate.
 For children 6 months to 4 years of age; .2 ml given subcutaneously or
 For children 5 to 10 years of age; .3 ml given subcutaneously or
 If older than 10 years of age; .5 ml given subcutaneously or intramuscularly.
 .2 ml intradermal dosage for travelers over age 5 may be substituted.

 Booster dosages are the same as the age specific dosages and are spaced every
 6 months.

 Data indicates that simultaneous administration of cholera and yellow fever
 vaccines produces a less-than-normal antibody response. A 3 week minimum
 interval between cholera and yellow fever vaccines is recommended except in
 those cases where both vaccines are required and time constraints exist.
 Then they can be given simultaneously or any time within the three week

 Reactions to the vaccine are: 1-2 days of pain, erythema, and induration at
 the site of injection; fever, malaise, and headache. Serious reactions are
 rare, but if experienced, re-vaccination is not advisable.

 No specific information on the safety of cholera vaccine and pregnancy is
 available, therefore vaccination should be avoided.

 Dengue Fever

 Complications of dengue occur rarely in adults.

 Dengue viruses are transmitted by mosquitoes, who are most active during the
 day.  These vector mosquitoes are found near human habitations and often are
 present indoors.

 There is no vaccine for dengue fever, therefore the traveler should avoid
 mosquito bites by remaining in well screened or air conditioned areas.
 Travlers are advised to use bednets, to bring aerosol insecticides to use
 indoors and to use mosquito repellents on skin and clothing.

 The illness is a flu-like illness characterized by sudden onset, high fever,
 severe headaches, joint and muscle pain, and rash.  The rash appears 3-4
 days after the onset of fever.  Travelers should alert their physician of
 any febrile illnesses occurring within one month after leaving an endemic

 Japanese Encephalitis

 Japanese Encephalitis is a viral disease transmitted by mosquitoes.
 Vaccination should be considered for travelers who plan long-term residence
 in areas experiencing epidemics, such as Japan, Korea, or countries in South
 East Asia, or the Indian subcontinent, especially those who will be
 traveling or living in rural farming areas. The vaccine is presently not
 available in the United States. Persons considered at risk should arrange to
 receive the vaccine at the country of destination. The dosing schedule is
 one shot per week for three weeks.

 Tickborne Encephalitis

 Tickborne encephalitis is a viral infection of the central nervous system.
 Found mainly in Eastern Europe and the Soviet Union, infections are caused
 by tick bites or by consumption of unpasteurized dairy products of cows,
 sheep, or goats. An effective vaccine can be obtained from Immuno, Vienna,
 Austria.  The risk to travelers who do not visit or work in forested areas
 or consume unpasteurized dairy products is apparently low. Insect repellent
 containing N N diethymetatoluamide (deet) should be used by travelers in
 areas of risk.

 Hepatitis A Vaccine

 Hepatitis A, a gastrointestinally transmitted virus of high prevalence in
 developing countries, is prevented through use of Immune globulin (IG). For
 travelers a single dose of IG is recommended if travel is less than 3
 months.  Dosages are weight specific:  for persons under 50 pounds, .5 ml.
 for person weighing 50 to 100 pounds, 1.0 ml.  for persons larger than 100
 pounds, 2.0 ml.

 For prolonged travel or residence in developing countries weight specific
 dosages are given every 5 months.
 for persons less than 22 pounds, .5 ml
 for persons weighing 22 to 50 pounds, 1.0 ml.
 for person weighing 50 to 100 pounds, 2.5 ml.
 for persons larger than 100 pounds, 5.0 ml.

 For traveler requiring repeated IG prophylaxis, screening for total anti-HAV
 antibodies before travel may eliminate the need for IG in those who are

 IG prepared in the United States by the Cohen-Oncley procedure, the standard
 procedure used in U.S. manufactured preparations, carries no risk of
 transmitting HIV, hepatitis B, or Non A Non B hepatitis.

 Pregnancy is not a contraindication to using IG.

 Hepatitis B Vaccine

 The hepatitis B virus is primarily transmitted through activities which
 result in the exchange of blood or blood-derived fluids. Vaccination is
 recommended for health care workers, and long-term travelers to high
 Hepatitis B endemic areas.

 Two hepatitis vaccines are currently available in the United States. A
 vaccine produced from plasma of hepatitis B carriers has been available
 since 1982.  The second vaccine uses recombinant DNA technology - a
 hepatitis B surface antigen is inserted into bakers yeast. The second
 vaccine became available in 1987. Both give comparable immunogenicity and
 efficacy when given in the recommended dosages.

 The primary adult vaccination schedule consists of 3 intramuscular doses of
 either 20ug of plasma-derived vaccine, or 10ug of the recombinant DNA
 vaccine.  The second dose should follow one month later, with the final dose
 6 months after the first. Children may receive either vaccine at a 50% adult
 dosage level spaced on the same schedule.

 Optimal protection is reached after the third dosage. Some protection is
 provided by one or two doses, therefore the vaccination process should be
 initiated, even if it can not be completed before departure.

 The duration of protection and the need for booster doses has not been
 determined. The optimum site of injection in adults is the deltoid muscle,
 vaccination in the buttocks results in a poorer antibody response.

 The major side-effects with the hepatitis B vaccine have been soreness and
 redness at the site of injection. Serious adverse reaction have rarely been
 reported. The production process for the plasma vaccine has been shown to
 inactivate all classes of viruses found in blood including HIV.

 Pregnancy is not a contraindication to the use of the vaccine. Specific data
 is not available on the safety of the vaccine for the developing fetus, but
 because it contains only non-infectious HBsAG particles, administration of
 the vaccine to pregnant women is not considered to constitute a risk to the


      Malaria in humans is caused by one of four protozoan species
 of the genus Plasmodium:  P. falciparum, P. vivax, P. ovale, and
 P. malariae.  All are transmitted by the bite of an infected
 female Anopheles mosquito.  Occasionally transmission occurs by
 blood transfusion or congenitally from mother to fetus.  The
 disease is characterized by fever and flu-like symptoms including
 chills, headache, myalgias, and malaise, which may occur at
 intervals.  Malaria may be associated with anemia and jaundice,
 and P. falciparum infections may cause kidney failure, coma, and
 death.  Deaths due to malaria are preventable.
      Information on malaria risk in specific countries (pp.
 15-60), is derived from various sources including the World
 Health Organization.  While this is the most accurate information
 available at the time of publication, factors which can vary from
 year to year, such as local weather conditions, mosquito vector
 density, and prevalence of infection, can have a marked effect on
 local malaria transmission patterns.

 Risk of Acquiring Malaria

      Malaria transmission occurs in large areas of Central and
 South America, Hispaniola, sub-Saharan Africa, the Indian
 Subcontinent, Southeast Asia, the Middle East, and Oceania.  The
 estimated risk of acquiring malaria varies markedly from area to
 area.  This variability is a function of the intensity of
 transmission in both urban and rural areas within the various
 regions, and also depends on itinerary and time and type of
 travel.  During 1980-1989, 1,834 cases of P. falciparum among
 U.S. civilians were reported to the CDC.  Of these, 1,491 (81%)
 were acquired in sub-Saharan Africa, 136 (7%) were acquired in
 Asia; 105 (6%), were acquired in the Caribbean and South America,
 and 103 (6%), in other parts of the world.  Of the 41 fatal
 infections, 31 were acquired in sub-Saharan Africa.
      Thus, most imported malaria among U.S. travelers was
 acquired in sub-Saharan Africa, even though only an estimated
 90,000 Americans travel to sub-Saharan Africa each year, versus
 an estimated 900,000 American travel to malarious areas of  Asia
 and South America each year.  This disparity in the risk of
 acquiring malaria reflects the fact that travelers to Africa are
 at risk in most rural and many urban areas, and moreover, tend to
 spend considerable amounts of time, including evening and
 nighttime hours, in rural areas where malaria risk is highest.
 Travelers to Asia and South America, however, spend most of their
 time in urban or resort areas where there is limited, if any,
 risk of exposure, and travel to rural areas mainly during daytime
 hours when there is limited risk of infection.
      Estimating the risk of infection for different categories of
 travelers is difficult, even if persons travel or reside
 temporarily in the same general areas within a country.  For
 example, tourists staying in air-conditioned hotels may be at
 lower risk than backpackers or adventure travelers.  Similarly,
 longer-term residents living in screened and air-conditioned
 housing are less likely to be exposed than are missionaries or
 Peace Corps volunteers.

 Checklist for Travelers to Malarious Areas

      The following is a checklist of key issues to be
      considered in advising travelers.
 Risk of malaria
      Travelers should be informed about the risk of malaria
      infection and the presence of drug-resistant P.
      falciparum malaria in their areas of destination.
 Anti-mosquito measures
      Travelers should know how to protect themselves against
      mosquito bites.
      Travelers should be:
   -- Questioned about drug allergies and other
      contraindications for use of drug to prevent malaria.
   -- Advised which drug to use for prophylaxiss, and, if
      chloroquine used, whether Fansidar should be carried for
      presumptive self-treatment.
   -- Advised to use prophylaxis continuously while in malaria-
      endemic area and for four weeks after leaving such areas.
   -- Informed that antimalaria drugs can cause side effects;
      are serious, medical help should be sought promptly and
      use of the drug discontinued.
   -- Warned that they may acquire malaria even if they use
      malaria chemoprophylaxis.

 In case of illness
       Travelers should be:
    -- Informed that symptoms of malaria may be mild, and that
       may be mild, and that they should suspect malaria if
       they experience unexplained fever or other symptoms
       such as persistent headaches, muscular aching and
       weakness, vomiting, or diarrhea.
    -- Informed that malaria may be fatal if treatment is de-
       layed.  Medical help should be sought promptly if
       malaria is suspected, and a blood sample should be taken
       and examined for malaria parasites on one or more
    -- Reminded that self-treatment should be taken only if
       prompt medical advice should still be sought as soon as
       possible after self-treatment.

 Special categories
    -- Pregnant women and young children require special
       attention because they cannot use some drugs (mefloquine
       and doxycycline).
   -- Concurrent use of other drugs, e.g. beta-blockers, may be
      a contraindication for use of mefloquine.

 (Adapted from International Travel and Health, World Health
 Organization, Geneva, 1991)

 Drug Resistance

      Resistance of P. falciparum to chloroquine has been
 confirmed or is probable in all countries with P. falciparum
 malaria except the Dominican Republic, Haiti, Central America
 west of the Panama Canal, Egypt, and most countries in the Middle
 East.  In addition, resistance to both chloroquine and FansidarR*
 is widespread in Thailand, Burma, and Cambodia, and the Amazon
 basin area of South America, and resistance has also been
 reported in sub-Saharan Africa.

 *Use of names is for identification only and does not imply
 endorsement by the Public Health Service or the U.S. Department
 of Health and Human Services.

 General Advice for Travelers to Malaria-Endemic Areas

      All travelers to malarious areas of the world are advised to
 use an appropriate drug regimen and personal protection measures
 to prevent malaria; however, travelers should be informed that
 regardless of methods employed, malaria still may be contracted.
 Malaria symptoms can develop as early as 8 days after initial
 exposure in a malaria-endemic area and as late several months
 after departure from a malarious area, after chemoprophylaxis has
 been terminated.  Travelers should understand that malaria can be
 treated effectively early in the course of the disease, but that
 delay of appropriate therapy can have serious or even fatal
 consequences.  Individuals who have the symptoms of malaria
 should seek prompt medical evaluation including thick and thin
 malaria smears as soon as possible.

 Personal Protection Measures

      Because of the nocturnal feeding habits of Anopheles
 mosquitoes, malaria transmission occurs primarily between dusk
 and dawn.  Travelers should take protective measures to reduce
 contact with mosquitoes especially during these hours.  Such
 measures include remaining in well-screened areas, using mosquito
 nets, and wearing clothes that cover most of the body.
 Additionally, travelers should be advised to purchase insect
 repellent before travel for use on exposed skin.  The most
 effective repellents contain N,N diethylmetatoluamide (DEET), an
 ingredient in many commercially available insect repellents.  The
 actual concentration of DEET varies among repellents ranging up
 to 95 percent. rarely children exposed to DEET have had toxic
 encephalopathy.  The possibility of adverse reactions to DEET
 will be minimized if the following precautions are taken:  apply
 repellent sparingly only to exposed skin or clothing; avoid
 applying high-concentration products to the skin; do not inhale
 or ingest repellents or get them into the eyes; avoid applying
 repellents to portions of children's hands that are likely to
 have contact with eyes or mouth; never use repellents on wounds
 or irritated skin; wash repellent-treated skin after coming
 indoors; if suspected reaction to insect repellent occurs, wash
 treated skin and seek medical attention.
        Travelers should use a pyrethrum-containing flying-insect
 spray in living and sleeping areas during evening and nighttime
      Permethrin (PermanoneR) may be sprayed on clothing for
 protection against mosquitoes.

 (Insert Camera-Ready Copy of Malaria map)


      In choosing an appropriate chemoprophylactic regimen before
 travel, persons should consider several factors.  The travel
 itinerary should be reviewed in detail and compared with the
 information on areas of risk within a given country to determine
 whether the traveler will actually be at risk of acquiring
 malaria.  It should be determined whether the traveler will be at
 risk of acquiring chloroquine-resistant P. falciparum malaria.
 In addition, it should be established whether the traveler has
 previously experienced an allergic or other reaction to the
 antimalarial drug of choice and whether medical care will be
 readily accessible during travel.

 Malaria chemoprophylaxis should preferably begin 1-2 weeks before
 travel to malarious areas (except for doxycycline, which can
 begin 1-2 days before).  In addition to assuring adequate blood
 levels of the drug, this allows any potential side-effects to be
 evaluated and treated by the traveler's physician before
 departure.   Chemoprophylaxis should continue during travel in
 the malarious areas and for 4 weeks after leaving the malarious

 Chemoprophylactic Regimens

      Regimen A:  For travel to areas of risk where chloroquine-
 resistant P. falciparum has NOT been reported,  once-weekly use
 of chloroquine alone is recommended.  Chloroquine is usually well
 tolerated.  The few people who experience uncomfortable
 side-effects may tolerate the drug better by taking it with
 meals, or in divided, twice-weekly doses.  As an alternative,
 the related compound hydroxychloroquine may be better tolerated.
 Chloroquine prophylaxis can begin 1-2 weeks before travel to
 malarious areas.  It should be continued weekly during travel in
 malarious areas and for 4 weeks after a person leaves such areas.
 (See table 11a for recommended dosages.)
      Regimen B:  For travel to areas of risk where chloroquine-
 resistant P. falciparum exists, use of mefloquine alone is
 recommended. Mefloquine prophylaxis should begin 1-2 weeks before
 travel to malarious areas.  It should be continued weekly during
 travel in malarious areas and for 4 weeks after a person leaves
 such areeas. (See Table 11a for recommended dosages.)
      Note: In some foreign countries a fixed combination of
 mefloquine and Fansidar is marketed under the name FansimefR.
 Fansimef should not be confused with mefloquine, and it is not
 recommended for prohylaxis of malaria. Alternative to Mefloquine
      Travlers to areas of risk where drug-resistant P. falciparum
 is endemic for whom mefloquine is contraindicated may elect to
 use an alternative regimen, as follows:

      Doxycycline alone taken daily is an alternative regimen for
 short-term travel who are intolerant of mefloquine or for whom
 the drug is contraindicated.  Travelers who use doxycycline
 should be cautioned about the possible side effects as described
 in the section on adverse reactions.  Doxycycline prophylaxis can
 begin 1-2 days before to travel to malarious areas.  It should be
 continued daily during travel in malarious areas and for 4 weeks
 after the  traveler leaves such areas. (See table 11a for
 recommended dosages.)

      Chloroquine alone is taken weekly is recommended for
 travelers who can not use mefloquine or doxycycline, especially
 pregnant women and children under 15 kg.

      Proguanil (PaludrineR) is not available commercially in the
 United States.  Limited data suggest that it may be effective in
 East Africa, but not in Thailand, Papua New Guinea, and West
 Africa.  If travelers use proguanil, it should be taken as a
 daily 200 mg. dose (adult) in combination with weekly


      Travelers who elect to use chloroquine (except those with
 histories of sulfonamide intolerance) should be given a treatment
 dose of FansidarR promptly in the event they have a febrile
 illness during their travel when professional medical care is not
 readily available, and they should be aware that this self-
 treatment of a possible malarial infection is only a temporary
 measure and that prompt medical evaluation is imperative.  They
 should continue their weekly chloroquine prophylaxis after
 presumptive treatment with FansidarR.  (See Table 11a for
 recommended dosages for prophylaxis and Table 11b for presumptive
 treatment with Fanidar.)

      Mefloquine should not be used for self-treatment because of
 the frequency of serious side effects (e.g. hallucinations,
 convulsions) which has been associated with therapeutic dosages
 of mefloquine.

 Primaquine:  Prevention of Relapses of Plasmodium vivax and
 Plasmodium ovale.
       P. vivax and P. ovale parasites can persist in the liver
 and cause relapses for as long as 4 years after routine
 chemoprophylaxis is discontinued.  Travelers to malarious areas
 should be alerted to this risk; and if they develop malaria
 symptoms after they leave a malarious area they should report
 their travel history and the possibility of malaria to a
 physician as soon as possible.  Primaquine decreases the risk of
 relapses by acting against the liver stages of P. vivax and P.
 ovale.  Primaquine is administered after the traveler has left an
 endemic area, usually during the last 2 weeks of the period of
 prophylaxis after exposure in an endemic area has ended.

      Since most malarious areas of the world (except Haiti) have
 at least one species of relapsing malaria, travelers to these
 areas have some risk of acquiring either P. vivax or P. ovale.
 Prophylaxis with primaquinem is generally indicated only for
 persons who have had prolonged exposure in malaria-endemic areas,
 e.g., missionaries and Peace Corps volunteers.  Although the
 actual risk to traveler with less intense exposure is difficult
 to define, with the exception of individuals deficient in
 glucose-6-phosphate dehydrogenase (G6PD) (see discussion of
 adverse reactions), most people can tolerate the standard regimen
 of primaquine. (See Table 11a for recommended dosages.)

 Adverse Reactions and Contraindications to Antimalarials

      The frequent or serious side effects of recommended
 antimalarials are discussed below.  In addition, physicians
 should review the prescribing information in standard
 pharmaceutical reference texts and in the manufacturers' package

      Chloroquine and hydroxychloroquine rarely cause serious
 adverse reactions when taken at prophylactic doses for malaria.
 Minor side-effects may occur, such as gastrointestinal
 disturbance, headache, dizziness, blurred vision, and pruritus
 occur, but generally these effects do not require discontinuance
 the drug.  High doses of chloroquine, such as that used to treat
 rheumatoid arthritis, has been associated with retinopathy, but
 this serious side-effect has not been associated with routine
 weekly malaria prophylaxis.  Chloroquine and related compounds
 have been reported to exacerbate psoriasis.  Chloroquine may
 interfere with the antibody response to human diploid cell rabies
 vaccine when it is administrated intradermally.

      Mefloquine has been asociated rarely with serious adverse
 reactions (e.g., hallucination, convulsions) at prophylactic
 dosage, but these reactions are more frequent with the higher
 dosages used in treatment.  Minor side effects observed with
 prohylacitic doses, such as gastrointestinal disturbance and
 dizziness, tend to be transient and self-limited.
      Mefloquine  is not  recommended for use by travelers with a
 know hypersensitivity to mefloquine; children < 15kg. (30 lbs.);
 pregnant women; travelers using beta blockers; travelers involved
 in tasks requiring fine coordination and spatial discrimination,
 such as airline pilots; and travelers with a history of epilepsy
 or psychiatric disorder.
      All studies to date confirm that mefloquine is well
 tolerated when used for prophylaxis; however, monitoring the
 occurrence of severe adverse reactions is important because such
 reactions are possible.  Users of mefloquine prophylaxis, who
 experience seriouss adverse reactions should consult their
 physician, and the reactions should be reported to the Malaria
 Branch, CDC, telephone (404) 488-4046.

      Travelers who use doxycycline should be aware of the
 possibility of photosensitivity, usually manifested as an
 exaggerated sunburn reaction.  The risk of such a reaction can be
 minimized by avoiding prolonged, direct exposure to the sun;
 using sunscreens that absorb long-wave ultraviolet (UVA)
 radiation; and taking the drug in the evening.  In addition,
 doxycycline use is associated with an increased frequency of
 monilial vaginitis.  Gastrointestinal side effects (nausea or
 vomiting ) may be minimized by taking the drug with a meal.
 Tetracyclines are contraindicated in pregnancy and in children <
 8 years of age.
        The use of FansidarR is contraindicated in persons with
 histories of sulfonamide intolerance and in infants under 2
 months of age.
      Proguanil rarely causes adverse reactions at prophylactic
 dosage.  Reported side effects include nausea, vomiting, mouth
 ulcers, and hair loss.
      Primaquine may cause severe hemolysis in G6PD deficient
 individuals.  Before using primaquine, G6PD deficiency should be
 ruled out by appropriate laboratory testing.

 Chemoprophylaxis for Children

      Children of any age can contract malaria.  Consequently, the
 indications for prophylaxis are identical to those described for
 adults.  Mefloquine is not indicated for children <15 kg. (30
 lbs.).  Doxycycline is contraindicated in children <8 years of
 age.  (See recommended dosages in Table 11a.)
      Chloroquine phosphate is manufactured in the United States
 in tablet form only, and tastes quite bitter.  Pediatric doses
 should be calculated carefully according to body weight.
 Pharmacists can pulverize tablets and prepare gelatin capsules
 with calculated pediatric doses.  Mixing the powder in food or
 drink may facilitate the weekly administration of chloroquine to
 children.  Alternatively, chloroquine in suspension is widely
 available overseas.  Parents should calculate the volume to be
 administered, because the concentration of chloroquine base
 varies in different suspensions.


 Prophylaxis During Pregnancy

      Malaria infection in pregnant women may be more severe than
 in non-pregnant women.  In addition, there may be increased risk
 of adverse pregnancy outcomes including prematurity, abortion,
 and stillbirth.  For these reasons, and because chloroquine has
 not been found to have any harmful effects on the fetus when used
 in the recommended doses for malaria prophylaxis, pregnancy is
 not a contraindication to malaria prophylaxis with chloroquine or
 hydroxychloroquine.  However, because no chemoprophylactic
 regimen is completely effective in areas with
 chloroquine-resistant P. falciparum, women who are pregnant or
 likely to become so should avoid travel to such areas.
      Mefloquine should not be used during pregnancy.  Women of
 childbearing potential who are taking mefloquine for malaria
 prophylaxis should take reliable contraceptive precautions for
 the duration of prophylaxis and for two months after the last
 dose of mefloquine.
      Doxycycline is generally contraindicated for malaria
 prophylaxis during pregnancy.  Adverse effects of tetracyclines
 on the fetus include discoloration and dysplasia of the teeth and
 inhibition of bone growth.  In pregnancy therefore, tetracyclines
 would be indicated only if required to treat life threatening
 infections due to multidrug- resistant P. falciparum.

      Proguanil has been widely used for several decades and no
 adverse effects on pregnancy or fetus have been established
      Primaquine should not be used during pregnancy because the
 drug may be passed transplacentally to a G6PD-deficient fetus,
 and cause hemolytic anemia in-utero.  Whenever radical cure or
 terminal prophylaxis with primaquine is indicated during
 pregnancy, chloroquine should be given once a week until
 delivery, at which time the decision to give primaquine may be

 Prophylaxis While Breast-feeding

      Very small amounts of antimalarial drugs are secreted in the
 breast milk of lactating women.  The amount of drug transferred
 is not thought to be harmful to nursing infant; however, more
 information is needed.  Because the quantity of antimalarials
 transferred in breast milk is insufficient to provide adequate
 protection against malaria, infants who require chemoprophylaxis
 should receive the recommended dosages of antimalarials listed in
 Table 11a.

 Malaria Hotline

      Detailed recommendations for the prevention of malaria are
 available 24 hours a day by calling the CDC Malaria Hotline at
 (404) 332-4555.

 Meningococcal Disease

 Vaccination for meningococcal disease is recommended for travelers going to
 the sub-sahara Africa during the dry season. The countries of highest risk
 are Mali, Niger, Chad, Sudan, Ethiopia, Bukina Faso, Benin, Nigeria, and the
 northern parts of Somalia. In addition CDC currently recommends the vaccine
 for all travelers to Saudi Arabia, Nepal, and the Delhi region of India.
 Serogroup A is the most common cause of the epidemics. Meningococcal
 vaccines are chemically defined antigens consisting of purified bacterial
 capsular polysaccharide, each producing serogroup-specific immunity.

 Only one formulation of vaccine is currently available in the United States
 - quadrivalent A/C/Y/W-135 called Menomune is distributed through Connaught.
 No vaccine is available for Serogroup B.

 A one dose subcutaneous injection in the volume specified by the
 manufacturer provides immunity for approximately 3 years. Vaccine response
 rates vary with serogroups and so may be less than effective. Children
 vaccinated before the age of 4 should be re-vaccinated after 2 to 3 years if
 at high risk. Follow the manufacturer's instructions for proper dosing.

 Reaction to the vaccine are infrequent and mild, consisting principally of
 localized erythema that last for 1-2 days. Up to 2% of young children
 develop a fever transiently after vaccination.

 The safety of meningococcal vaccine and pregnancy has not been established.
 It is prudent to avoid the use of the vaccine with pregnant women unless
 there is substantial risk.


 Vaccination against plague is not required by any country as a condition for
 entry. Neither is it recommended except for those who are at particularly
 high risk of exposure because of research or field exposure.

 A 3 dose primary series spaced over about 8 weeks and an additional booster
 dose six months later are available.

 See package insert for dosing information.

 The true protection provided by the vaccine is not known due to the limited


 Mild pain, erythema, and induration at the injection site occur frequently.
 With repeated doses, fever, headache, and malaise are common and more
 severe.  Sterile abscesses occur rarely, but no fatalities or disabling
 complications have been reported.

 In pregnancy only selected vaccinations of exposed persons would be



 Pre-exposure vaccination is not indicated for travelers to large cities or a
 rabies free country.


 Rabies is almost always transmitted by bites which introduce the virus into
 the wound.  Although dogs are the main reservoir of the disease, all warm-
 blooded animal bites should be suspect.


 Do not handle any animals! Any animal bite should receive prompt attention.
 When wounds are thoroughly cleaned with large amounts of soap and water, the
 risk of rabies infection is reduced.  Exposed individuals should receive
 prompt medical attention and advice on post-exposure preventive treatment.
 Upon returning to the U.S. exposed individuals should contact their local
 physician or state health department.



 Schistosomiasis is developed after the larvae of a flat worm has penetrated
 the skin.  The larvae are released into the water from infected snails who
 are the worms host.  The larvae are capable of penetrating unbroken skin.
 Two ingredients are necessary, fresh water and snails.  Brackish water or
 areas of poor sanitation are a contributing factor.  Water treated with
 chlorine or iodine is virtually safe, and salt water poses no risk.


 The traveler cannot distinguish between infested and non-infested water.
 Therefore, swimming in fresh water in rural area should be avoided.  Bath
 water should either be heated to 50 degrees C (122 degrees F) for five min-
 utes or treated with chlorine or iodine as done for drinking water.


 If exposed to suspected water, immediate and vigorous towel drying or appli-
 cation of rubbing alcohol to the exposed areas will reduce the rish of
 infection.  Screening procedures are available for those who suspect
 infection, and schistosomiasis is treatable with drugs.

 Typhoid Fever


 Salmonella typhi, the organism which causes typhoid fever, is transmitted
 through contaminated food and water.


 By drinking only bottled or boiled water and eating only cooked food, a
 traveler lowers the risk of infection.

 Currently available vaccines have been shown to protect 70- 90% of the
 recipients.  Therefore, even vaccinated travelers should be cautious in
 selecting their food and water.

 The primary series of vaccine consists of two shots, spaced at least 4 weeks
 apart.  A booster dose given every 3 years provides continued protection for
 repeated exposure. If there is insufficient time for two doses a month
 apart, an accelerated schedule of three shots a week apart may be
 administered.  It is recognized that the accelerated schedule is less
 effective.  A primary series need never be repeated.


 Symptoms of typhoid include fever, headaches, malaise, anorexia, and consti-
 pation more often than diarrhea.  Seek medical assistance immediately for
 appropriate antibiotic treatment.

 Yellow Fever

 Yellow fever is a viral disease. Vaccines are available only through
 approved yellow fever vaccination centers designated by state health
 departments. Call your state and local health departments to find the center
 closest to you.

 One dose of .5 ml of vaccine may be administered to anyone over 9 months of
 age. A booster of equal amount may be given every 10 years. Infants under 4
 months must not be immunized.

 Persons with a hypersensitivity to eggs should not be given the vaccine.
 Persons able to eat eggs or egg products can receive the vaccine. Efforts
 should be made to obtain a medical waiver for persons hypersensitive to the
 vaccine. A physicians letter clearly stating the contraindication to the
 vaccine, has been acceptable to some governments. It should be written on
 letterhead stationary and bear the stamp used by a health department or
 official immunization center to validate the International Certificate of
 Vaccination. Also check embassies or consulates for waiver of requirements

 Reactions occur in less than 5% of those vaccinated for yellow fever. They
 are generally mild, for example, headaches, low-grade fevers, myalgia, or
 other minor symptoms.

 Patients with immunosuppression, including AIDS, leukemia, lymphoma,
 generalized malignancy, etc. or those patients using corticosteroids,
 alkylating drugs, antimetabolites, or radiation should not receive the

 Simultaneous Administration of yellow fever vaccine and other live virus
 vaccines have not caused inhibition of the yellow fever vaccine. If live
 viruses are not given concurrently, 4 weeks should be allowed to lapse
 between sequential vaccinations. Simultaneous administration of cholera and
 yellow fever vaccines has produced a lower-than-normal antibody response to
 both vaccines. There is no data of interference between yellow fever and
 typhoid, paratyphoid, typhus, plague, rabies, or Japanese encephalitis.

 Pregnancy is not a contraindication to yellow fever vaccine. However,
 specific information is not available concerning the adverse effects of
 yellow fever vaccine and the developing fetus. If possible avoid
Vaccinations and Pregnancy

 Live Virus Vaccines

 Live attenuated-virus vaccines are not generally given to pregnant women or
 to those likely to become pregnant within 3 months of receiving the vaccine.
 For the MMR vaccine, pregnancy is a contraindication. Only with a
 substantial risk of exposure to natural infection of the disease should
 either yellow fever or OPV be given to pregnant women . If given during
 pregnancy, waiting until the second or third trimester minimizes concerns
 over teratogenicity. The risk of teratogenicity from live rubella vaccine is
 small, with no evidence of congenital rubella syndrome in infants born to
 mothers who inadvertently were vaccinated during pregnancy. For
 poliomyelitis OPV is recommended over IPV when immediate protection is

 MMR and OPV vaccines can safely be administered to children of pregnant
 women in spite of viral shedding. To date the evidence shows no risk to the
 developing fetus.

 Inactivated Vaccines

 There is no convincing evidence of risk to fetus from inactivated viral or
 bacterial vaccines, or toxoids administered to pregnant women. These
 include:  hep B, rabies, cholera, typhoid, plague, meningococcal,
 pneumococcal, and the adult formulation of the Td toxoid. If immunization is
 considered, the risk and probability of contracting the disease should be
 weighed against benefits and complication from administering the vaccine.
 Unimmunized pregnant women who may deliver under non-hygienic circumstances
 should receive two properly spaced doses of Td, preferably during the last
 two trimesters. Incompletely immunized women should complete the three dose
 series. Those immunized more than 10 years ago should receive a booster

 For IG there is no known risk to the fetus from passive immunization of
 pregnant women.

Vaccinations of Children Less Than 2 Years of Age

 The vaccine information in this section is presented in alphabetical order
 by disease.

 Cholera vaccine is of questionable benefit to travelers of any age. It is
 not recommended in children less than 6 months old. Breast-feeding is
 protective against cholera. For other infants careful preparation of formula
 and food from safe water and foodstuffs should protect non-breast-fed

 Diphtheria, tetanus, and pertussis is endemic in developing countries, and
 therefore may put the infant at greater risk than in the U.S. Optimum
 protection in the first year of life is achieved with three doses of DTP
 administered normally. Infants traveling should have received 3 doses of
 DTP, the first dose at 6-8 weeks of age, and the next two doses at 4-8 week
 intervals. A forth dose, generally 6-12 months after the third dose
 maintains protection. For infants at imminent risk, reducing the interval
 between the third and forth doses of the primary series to six months may be
 considered.  One dosage by its self affords little protection, while two
 doses provide some protection. Parents must note that less than the 3
 recommended doses of DTP puts a child at greater risk of infection. If
 traveling for extensive periods, travelers may wish to receive the remaining
 doses of the vaccine at the recommended intervals while abroad.

 Hepatitis B vaccine should be considered for infants and children who will
 live 6 months or more in smaller cities and rural areas of developing
 countries where hep B is endemic, and who will be in contact with the local
 population. This is especially true when the local children have open skin
 lesions such as impetigo, scabies, scratched insect bites, or when any risk
 of exposure to blood from the local population occurs.

 Immune globulin is recommended for infants and children traveling outside
 the usual tourist routes if they will be eating food and water in settings
 of questionable sanitation.

 MMR vaccine should be administered to all children 15 months of age or
 older.  For earlier departure to areas of high risk, vaccines may be
 administered as follows: Children 12-14 months of age may receive MMR before
 their departure without need for re-vaccination; at ages 6-11 months a
 single dose of single measles antigen vaccine (without mumps and rubella)
 may be given before departure, with re-vaccination of the MMR vaccine coming
 at 15 months, and if required as early as 12 months. Infant less than 6
 months of age are protected by maternally derived antibodies. The risk of
 serious disease from Mumps and rubella is so small that no vaccination is
 required before 12 months. For Meningococcal vaccine effectiveness of the
 vaccine in children is dependent upon the child's age when the vaccine is
 administered. Protection against certain strains of the bacteria may not be
 effective in children vaccinated between 3 months and 2 years. Vaccination
 before 3 months of age has little effectiveness against the disease. The
 vaccine may be safely given to infants with the understanding that it may be
 less effective than in adults.

 OPV is the vaccine of choice for all infants and children if there are no
 contraindications to the vaccine. Inactivated poliovirus vaccine is also
 available. Children traveling to endemic areas should receive at least 3
 doses of OPV at intervals of at least 6-8 weeks. A forth dose may be given
 if at least 6 weeks have elapsed since the third dose. If travel is to occur
 before a child is 6 weeks old, a dose of OPV should be administered prior to
 travel.  The dose of OPV given before 6 weeks of age should not be counted
 as part of the primary series. Children traveling to endemic areas should
 complete the 3 dose primary series abroad with doses at 4 week intervals.
 Children with only partial immunity should complete the primary series if
 they remain in a high risk area.

 For plague vaccine children under 1 year of age, dose 1 is .2 ml; dose 2 is
 .04 ml and spaced 4 or more weeks later. A third dose of .04 ml follows the
 second by 3-6 months. Give 2 booster doses of .02-.04 ml 6 months apart,
 then one booster every 1-2 years. For children between 1 and 4 years of age,
 dose 1 is .4 ml; dose two is .08 ml spaced 4 weeks later. A third dose of
 .08 ml follows the second by 3-6 months. Give 2 booster doses of .04-.08 ml
 6 months apart, then one booster every 1-2 years.

 For typhoid fever breast feeding is likely to protect infants. Careful
 preparation of formula and food from safe water should protect
 non-breast-fed infants. Typhoid fever vaccine is recommended for children
 older than 2 years of age traveling to areas where there is questionable

 Yellow Fever vaccine should not be administered to any infant under 4 months
 of age. Immunization of children 4-6 months old should be considered only
 under very unusual circumstances. (Consult CDC at 303-221-6400.) It may be
 administered to infants 6-9 months if traveling to areas of risk and when a
 high level of protection against mosquito bites is not possible. Infants 9
 months or older should be vaccinated if they are traveling to or living in
 areas of South America or Africa where yellow fever infection is officially

 General Vaccinations-Recommended for Adult Travelers

 All adult travelers should have their polio and tetanus immunizations up to
 date. Tetanus should be boosted every ten years. If the traveler completed
 in the past a primary polio series of either OPV or IPV, they should receive
 one additional dose of OPV or IPV before most travel. This is due to the
 higher risk of exposure to "wild" polio virus found abroad. This is strongly
 advised for travelers to less developed countries.

 Persons who are unvaccinated or who do not know their polio vaccination
 history should take 2 shots of inactivated polio virus vaccine at least a
 month apart for protection prior to travel.

 If less than four weeks are available before protection is needed a single
 dose of OPV or IPV is recommended. There is a slightly higher rate of
 vaccine induced polio in adults than in children following OPV. This is most
 often associated with persons who either have no prior immunization or are
 unknowingly immunodeficient.

 Persons who receive less than a full primary course of OPV or IPV should
 complete the required doses for the primary series regardless of the time
 interval since the last dose. The vaccine should be of the type previously
 received. No serious side effects for IPV have been documented, however
 since IPV contains trace amounts of streptomycin and neomycin, person with a
 history of anaphylactic reaction following administration of those
 antibiotics should not receive IPV.

 Travelers should be immune to measles. Most people born before 1957 have
 natural immunity. Those born after 1957 should be immune either by
 documented history of disease or history of vaccination.

 Healthy travelers over 65 may benefit from the flu shot taken during the flu

Food and Water

 General Risks

 Contaminated food and drink are the major sources of stomach or intestinal
 illness while traveling. Intestinal problems due to poor sanitation are
 found in far greater numbers outside the United States. The information
 under food and water precautions can help prevent infection to many of these



 In areas of poor sanitation only the following beverages may be safe to drink:
 -         Boiled or bottled water
 -         Hot beverages made with boiled water, such as coffee or tea.
 -         Canned or bottled carbonated beverages.
 -         Beer and Wine.
 Ice and drinking containers should also be considered as contaminated. It is
 safer to drink from a can or bottle of beverage than to drink from a
 questionable container. Water on the surface of beverage container may also
 be contaminated. Therefore beverage containers should be dry and the area to
 contact the mouth should be wiped clean.

 Where water is contaminated, the traveler should avoid brushing their teeth
 with tap water.

Treatment of Water

 Boiling is by far the most reliable method to make water safe to drink. From
 a vigorous boil allow the water to cool to room temperature - do not add
 ice. At higher altitudes allow water to boil for a few minutes or use
 chemical disinfectants. Adding a pinch of salt or pouring water from one
 container to another will improve the taste.

 Chemical disinfection can be achieved with either iodine or chlorine, with
 iodine providing greater disinfection in a wider set of circumstances. For
 disinfection with iodine use either tincture of iodine or tetraglycine
 hydroperiodide tablets, such as, Globaline, Potable-Aqua, and others. These
 disinfectants can be found in sporting good stores and pharmacies. Read and
 follow the manufacturer's instructions. If the water is cloudy then strain
 it through a clean cloth, and double the number of disinfectant tablets
 added. If the water is very cold, either warm it or allow increased time for
 disinfectant to work.

 CDC makes no recommendation as to the use of any of the portable filters on
 the consumer market due to the lack of independently verified results to
 their efficacy.

 As a last resort, water that is uncomfortably hot to touch may be safe for
 drinking and brushing teeth after it is allowed to cool to room temperature.



 To avoid illness food should be selected with care. All raw food is subject
 to contamination, particularly in areas of poor sanitation. Questionable
 foods are: salads, uncooked vegetables and fruit, unpasteurized milk and
 milk products, raw meat, or shellfish. If you peal fruit yourself it is
 generally safe. Food that has been cooked and is still hot is generally

 For infants less than 6 months of age, breast feed or give powdered
 commercial formula prepared with boiling water.

 Some normally edible fish are not safe even when cooked. Tropical reef fish,
 red snapper, amberjack, grouper, sea bass, and barracuda can become toxic at
 unpredictable times. Highest risk areas include the islands of the West
 Indies, Pacific and Indian Oceans.

Travelers Diarrhea

 Travelers diarrhea is a syndrome characterized by a twofold or greater
 increase in the frequency of unformed bowel movements. Symptoms include
 cramps, nausea, bloating, fever, urgency, and malaise. Episodes begin
 abruptly with increased frequency when traveling to areas of higher risk,
 such as, the developing countries of Africa, the Middle East, Asia, or Latin
 America. Risk of infection increases by type of eating establishment - from
 lower risk in private homes, to high risk for food from street vendors.

 TD is slightly more common in young adults than in older people, with no
 difference between males and females. Td is usually acquired through
 ingestion of fecally contaminated food and water.

 TD lasts from 3 to 7 days but sometimes longer. Rarely is it life


 There are four possible approaches to preventing TD - meticulous attention
 to food and beverage preparation, immunization, use of nonantimicrobial
 medication, and preventive antibiotic drugs. CDC does not recommend the use
 of antibiotics or other medications as they can cause additional problems
 themselves. Instead, careful selection of food and water is encouraged. If
 illness occurs the use of such products as Lomotil or Immodium should be
 sufficient for most travelers. It is not to be used by anyone with a high
 fever or blood in their stools.


 If symptoms do not resolve after using these preparations, antimicrobial
 drugs such as doxycycline, and trimethoprim/sulfamethoxazole (TMP/SMX for
 short) can shorten the length of sickness. Consult your physician
 prescription and dose schedules.

 Oral fluids should be administered to suffers of diarrhea. Fruit juices
 suitable for drinking, soft drinks preferably without caffeine, and salted
 crackers are advised. Avoid dairy products, and all beverages that contain
 water of questionable quality.

 It is important for the traveler to consult a physician about treatment of
 diarrhea in children and infants, because many of the drugs mentioned are
 not recommended for them. The greatest risk for children and especially
 infants is dehydration. Prevention of dehydration through administration of
 soups, thin porridges, and other safe beverages is advised. If bloody
 diarrhea, moderate dehydration, fever in excess of 102 F degrees, or
 persistent vomiting occurs seek immediate medical help.

 As with all diseases it is best to consult a physician rather than attempt
 self-medication, especially for pregnant women and children. If diarrhea is
 severe or does not resolve within a few days, or a fever occurs with
 shaking, or if there is dehydration, travelers should seek medical help.


 CDC is authorized to distribute at no cost the book Health Information for
 International Travel as well as other related materials to physicians,
 public health care workers, travel agencies, and units of the Federal

 International Certificate of Vaccination may be ordered for officially
 designated vaccination centers by calling the superintendent of documents at
 202-783-3238. The cost is $2.00 each or $14.00 per 100. The form number is
 PHS-731 #017-001-004405. The address of the Superintendent of Documents is
 U.S. Government Printing Office, Washington, DC 20402. All previous editions
 of this document are valid and may be used without problem.

 If you do not qualify to receive our publications free, you can purchase the
 pamphlet Health Information for International Travel.

 You may purchase a current copy of the Health Information for International
 Travel document, H.H.S. Publication number (CDC) 88-8280, from the
 Superintendent of documents, U.S. Government Printing Office, Washington,
 D.C. 20402, telephone number 202-783-3238. Please include a check or money
 order for $4.75.

 Acquired Immunodeficiency Syndrome or AIDS is the severest manifestation of
 the human immunodeficiency virus (HIV). The incubation period for AIDS may
 be long, up to several years. Currently there is no vaccine, and no cure for

 AIDS is found on every continent, with over 125 countries reporting, but
 actual cases far exceeding reported information. With the global
 distribution of HIV, risk of infection is behaviorally based rather than
 geographically related. The international traveller should know about the
 transmission and prevention of HIV infection, as well as the complications
 of travel for persons with HIV infection.

 HIV infection is preventable, as its transmission is not through casual
 contact, air, food, or water routes; contact with inanimate objects; through
 mosquitoes or other arthropod vectors. The use of any means of public travel
 by people infected with HIV does not pose a risk of HIV infection to other
 passengers. HIV is transmitted through sexual intercourse - heterosexual or
 homosexual with an infected person; use of unsterilized syringes and
 needles, (e.g. drug use, acupuncture, or tattooing); through blood or blood
 components; and perinatally from an infected pregnant mother.

 Travelers should avoid sexual encounters with any one thought to be infected
 with HIV or whose HIV infection status is unknown. Avoid sexual encounters
 with intravenous drug users, people with multiple sexual partners, including
 prostitutes either male or female. Condoms may decrease but not eliminate
 the risk of transmission.

 Do not use drugs intravenously or share needles for any reason. Needles must
 be sterile, preferably disposable, and prepackaged in a sealed, single unit
 container. Diabetics or other people requiring frequent injections should
 carry a supply of syringes and needles to last the entire stay abroad.

 Unlike the US, Japan, Canada, Australia, and western European countries
 where mandatory testing procedures have greatly reduced the risk of HIV
 infection, blood and blood products available in less-developed countries
 may not be formally tested for HIV contamination. Locally produced blood
 clotting factor concentrates and blood from the native population should not
 be used unless tested by appropriately-trained technicians using reliable
 tests. US produced IG that follows the Food and Drug Administrations
 procedures is safe from HIV.

 Recently, several countries have established serological screening of
 incoming passengers to detect either AIDS or HIV antibodies. Travelers
 testing positive are refused entry. With one or two exceptions these tests
 are only being done on travelers staying in a country greater than 3 months.
 The testing requirements for individual countries can be obtained by calling
 the appropriate Consulate office in Washington, D.C.

This page last reviewed: Thursday, January 28, 2016
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