DIPHTHERIA

Pharyngeal or cutaneous diphtheria is caused by toxigenic strains of Corynebacterium diphtheriae bacteria and occasionally by C. ulcerans.

Risk assessment

• EpidemiologyInformation on the occurrence of disease within this country - Diphtheria is known or presumed to occur in this country.
• ExposureInformation on the mode of transmission and factors that may increase disease risk - Travellers may be exposed through the respiratory route, contact with infected objects, or exudate from an infected skin lesion. Those who will be in close contact with the local population are at higher risk.

Risk management

• Travellers should have completed a primary vaccination course according to the UK schedule.
• A booster dose of a diphtheria-containing vaccine should be givenAll travellers in risk categories should receive vaccine to those who have not received a dose within the previous 10 years.

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HEPATITIS A

Hepatitis A is a viral disease that causes inflammation of the liver.

Risk assessment

• EpidemiologyInformation on the occurrence of disease within this country - Hepatitis A is known to occur in this country although the risk to most travellers is considered to be low.
• ExposureInformation on the mode of transmission and factors that may increase disease risk - Hepatitis A is transmitted through contaminated food and water. Travellers who will have access to safe food and water are at low risk. Those at higher risk include travellers visiting friends and relatives, long-term travellers, and those visiting areas of poor sanitation.

Risk management

• Travellers should practice strict food, water and personal hygiene precautions.
• Vaccine may be givenMost travellers at low risk, consider vaccine for those in risk categories to travellers whose planned activities put them at higher risk of exposure (see above).
• Because hepatitis A vaccine is well tolerated and affords long-lasting protection, it may be givenMost travellers at low risk, consider vaccine for those in risk categories to all previously unvaccinated travellers.
• According to UK immunisation guidance, in addition to its indications for travel, vaccine may be givenMost travellers at low risk, consider vaccine for those in risk categories to those with chronic liver disease or haemophilia, men who have sex with men, injecting drug users and those at occupational risk.

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HEPATITIS B

Hepatitis B is a viral disease that causes inflammation of the liver and may lead to chronic complications.

Risk assessment

• EpidemiologyInformation on the occurrence of disease within this country - 8% or more of the population in this country is a carrier of hepatitis B virus (high endemicity).
• ExposureInformation on the mode of transmission and factors that may increase disease risk - Hepatitis B is transmitted via infected blood or bodily fluids. Travellers may be exposed when receiving medical or dental treatment, via direct contact between open skin lesions, or if participating in risk behaviour such as needle sharing, unprotected sex or contact sports. Healthcare workers are at higher risk.

Risk management

• Travellers should avoid contact with blood or bodily fluids. Where contact is unavoidable, appropriate protective precautions should be taken.
• A sterile medical kit should be carried.
• Vaccination should be considered for all adult and child travellers.
• Vaccination should be givenAll travellers in risk categories should receive vaccine to those at risk due to the nature of their activities or occupation (see above).
• Vaccine should also be givenAll travellers in risk categories should receive vaccine to those with chronic kidney failure, liver disease or haemophilia, injecting drug users, men who have sex with men and individuals who change sexual partners frequently.

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RABIES

Rabies is a neurological disease caused by viruses of the Lyssavirus genus.

Risk assessment

• EpidemiologyInformation on the occurrence of disease within this country - Rabies occurs or is presumed to occur in wild and domestic animals (including bats).
• ExposureInformation on the mode of transmission and factors that may increase disease risk - Transmission may occur following contact with the saliva from an infected wild or domestic animal (including bats), most often via a bite or lick to an open wound. Risk of exposure is increased by type of activity (e.g. running, cycling), occupation (e.g. veterinarians) and longer duration of stay. Children are at increased risk as they are less likely to avoid contact with animals and to report a bite or lick.

Risk management

• Travellers should avoid contact with wild or domestic animals.
• Pre-exposure vaccination should be givenAll travellers in risk categories should receive vaccine to adults and children who are:
  • at risk of rabies (see above)
  • travelling to remote areas where medical care is not readily available.
• Following an animal bite, wounds should be thoroughly cleansed and an urgent medical assessment sought, even if the wound appears trivial. Prompt post-exposure treatment is required, even if pre-exposure vaccine has been received.
• Suitable vaccines and immunoglobulin may be in short supply or unavailable in some countries.

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TETANUS

Tetanus is caused by a toxin released from Clostridium tetani bacteria.

Risk assessment

• EpidemiologyInformation on the occurrence of disease within this country - Tetanus bacteria are found worldwide.
• ExposureInformation on the mode of transmission and factors that may increase disease risk - Tetanus bacteria are present in soil and manure and may be introduced through open wounds such as a puncture wound, burn or scratch.

Risk management

• Travellers should thoroughly clean all wounds and seek appropriate medical attention
• Travellers should have completed a primary vaccination course according to the UK schedule.
• A booster dose should be givenAll travellers in risk categories should receive vaccine to travellers whose last dose of a tetanus-containing vaccine was given more than 10 years ago, and who will not have ready access to medical care; even if they have received five doses previously.

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TICK-BORNE ENCEPHALITIS

Tick-borne encephalitis (TBE) is a viral disease affecting the central nervous system. View a map showing risk areas for countries in Europe here (587KB GIF).

Risk assessment

• EpidemiologyInformation on the occurrence of disease within this country - There is a risk of TBE in some areas of the country below 1,400m. The area most affected is the mountain forest zone of the Krym Republic (the Crimea). The transmission season varies, however, ticks are most active during early spring to late autumn (March to November).
• ExposureInformation on the mode of transmission and factors that may increase disease risk - TBE is transmitted to humans via the bite of an infected Ixodes tick. Travellers are at risk via exposure to ticks during outdoor activities in areas of vegetation (gardens, parks, forest fringes, meadows and marshes) below 1,400m. Cases of TBE may also occur following ingestion of unpasteurised milk products.

Risk management

• Travellers should take tick bite avoidance measures during outdoor activities.
• Travellers should check themselves for ticks and be aware of effective tick removal methods.
• Travellers should not eat or drink unpasteurised milk products.
• TBE vaccine may be givenMost travellers at low risk, consider vaccine for those in risk categories to travellers whose planned activities put them at risk (see above).

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TUBERCULOSIS

Tuberculosis (TB) is caused by the bacteria Mycobacterium tuberculosis.

Risk assessment

• EpidemiologyInformation on the occurrence of disease within this country - The annual occurrence of TB was greater than or equal to 40 cases per 100,000 population in 2005.
• ExposureInformation on the mode of transmission and factors that may increase disease risk - TB is transmitted following inhalation of infectious respiratory droplets. Most travellers are at low risk. Travellers at higher risk include healthcare workers, those who are visiting friends and relatives (particularly young children), long-term travellers, and those who have close contact with an infected individual. HIV-positive travellers and those with impaired immunity are also at higher risk.

Risk management

• The pre-travel visit is an opportunity to ensure that children in defined risk categories under 16 years of age are vaccinated with BCG according to current UK guidance (see resource below).
• Travellers should avoid close contact with individuals known to have infectious pulmonary TB.
• BCG vaccine should be considered for previously unvaccinated, tuberculin skin test negative individuals, under 16 years of age, who are going to live for more than 3 months in this country.
• Healthcare workers should take appropriate infection control precautions. BCG vaccine should be givenAll travellers in risk categories should receive vaccine to healthcare workers under 35 years of age. This recommendation is irrespective of duration of stay.
• There are specific contraindications (e.g. impaired immunity) and adverse events associated with BCG vaccine (see Green Book chapter in resources below). A careful risk assessment should be made before administration and specialist advice sought as appropriate.
• Travellers who are in the risk groups described and who do not receive BCG vaccine should be considered for pre-travel and post-travel testing for exposure to tuberculosis.
• Travellers who suspect that they may have been exposed to tuberculosis should receive an appropriate medical evaluation.

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TYPHOID

Typhoid fever is a systemic disease caused by Salmonella Typhi bacteria.

Risk assessment

• EpidemiologyInformation on the occurrence of disease within this country - Typhoid fever is known or presumed to occur in this country.
• ExposureInformation on the mode of transmission and factors that may increase disease risk - Typhoid is transmitted through contaminated food and water. Travellers who will have access to safe food and water are likely to be at low risk. Those at higher risk include travellers visiting friends and relatives, young children, long-term travellers, and those visiting areas of poor sanitation.

Risk management

• Travellers should practice strict food, water and personal hygiene precautions even if vaccinated.
• Most travellers are at low risk and do not need vaccination.
• Vaccine may be givenMost travellers at low risk, consider vaccine for those in risk categories to travellers whose planned activities put them at higher risk (see above). Current vaccines against Salmonella Typhi are only 50-80% protective and do not protect against Salmonella Paratyphi. Previous typhoid illness does not confer reliable immunity.

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MALARIA

There is no risk of malaria in this country.