3.1 Europe, including Cyprus and countries of the former USSR

(Albania, Andorra, Armenia, Austria, Azerbaijan, Belarus, Belgium, Bosnia and Herzegovina, Bulgaria, Croatia, Cyprus, Czech Republic, Denmark (with the Faroe Islands), Estonia, Finland, France, Georgia, Ger Norway, Poland, Portugal (with the Azores and Madeira), Romania, Russia, San Marino, Slovakia, Slovenia, Spain (with the Canary Islands), Sweden, Switzerland, Tajikistan, Turkmenistan, Ukraine, Uzbekistan, Yugoslavia (including Kosovo, Montenegro and Serbia)

3.1.1 Disease risks

For much of the area communicable diseases are unlikely to prove a hazard greater than in the UK. The risks may be higher in parts of Eastern Europe, but lack of information makes risk assessment difficult.

Food and water-borne diseases (bacillary dysentery, other diarrhoeas, and typhoid) are most likely to occur in the south-eastern and south-western parts of the area, especially in summer and autumn. The incidence of certain food-borne diseases, eg salmonella and campylobacter infections, is increasing in some countries. Hepatitis A is commoner in the eastern European countries.

Malaria is confined to small foci in Armenia, Azerbaijan, Georgia, Tajikistan and Turkmenistan.

Other arthropod-borne diseases (see Chapter 7) occur of which the most common are:

• Tick-borne encephalitis - mainly in forests and surrounding areas in central and eastern Europe and Scandinavia and across the former USSR to the Pacific coast.
• Lyme disease
• Tick-borne typhus - in Siberia and the Mediterranean
• Japanese encephalitis - in a small area in the far eastern maritime areas of the former USSR neighbouring China
• Murine typhus (endemic) - sporadic cases occur in some countries bordering the Mediterranean littoral
• West Nile Fever - cases sometimes occur in Mediterranean and eastern European countries
• Cutaneous and visceral leishmaniasis and sand fly fever reported from Southern Europe
• Leishmania/HIV co-infection reported from France, Greece, Italy
• Tularaemia in parts of continental Europe.
• Louse-borne relapsing fever in Turkey and areas of the former USSR.
• Tick-borne relapsing fever - foci in Portugal and Spain

Map to show how countries are grouped for pragmatic reasons and the order (by number) in which they appear in the text in Chapter 3.

1. Europe
2. North America, Australia and New Zealand
3. Central America
4. The Caribbean
5. Tropical South America
6. Temperate South America
7. North Africa and Middle East
8. Sub-Saharan and Southern Africa
9. Indian Subcontinent
10. South East Asia and the Far East
11. Pacific islands

Diseases of close association:

• In recent years, Azerbaijan, Belarus, Russia and Ukraine have experienced extensive epidemics of diphtheria. Cases of diphtheria, mostly imported from these three countries, have also been reported in neighbouring countries (Estonia, Finland, Latvia, Lithuania, Poland, the Republic of Moldova).
• All countries are making intense efforts to eradicate polio, and the risk of infection in most countries is very low.
• Tuberculosis rates are increasing in parts of eastern Europe and the former USSR, including drug resistant disease.

Sexually transmitted and blood-borne infections:

Hepatitis B is generally of low prevalence; prevalence higher in the eastern and southern parts of the region. HIV is predominantly in high risk groups, but the risk of all STIs, particularly for young travellers, should not be forgotten.

Other hazards could include:

• Legionnaires' disease - both sporadic cases and clusters of cases associated with holiday hotels and apartments continue to be reported in returning travellers.
• Leptospirosis.
• Rodent-borne haemorrhagic fever with renal syndrome (Hanta virus infection) is now recognised as occurring in some areas in this region.
• Rabies is endemic in wild animals (particularly foxes) in rural areas of northern and eastern Europe and in most countries of southern Europe apart from: Cyprus, Faroe Islands, Finland, Greece, Iceland, Ireland, mainland Italy (except the northern and eastern borders), mainland Norway, mainland Spain (except the N African coast), Sweden, Gibraltar, Malta, Portugal and Monaco.However, the latter country has land borders with France (see 1.9).

Parts of northern Europe can be extremely cold in winter.

3.1.2 Recommendations for immunisations and malaria chemoprophylaxis (see later chapters for general health precautions)

3.1.3 Country by country variations and malaria chemoprophylaxis:

Albania

Yellow fever vaccination certificate required from travellers over one year old coming from infected areas.

Immunisation against poliomyelitis and hepatitis A usually advised.

Armenia

Immunisation against hepatitis A usually advised.

Malaria risk: P.vivax malaria focally in Ararat Valley, from June to October, outside tourist areas.

Recommended prophylaxis: for the risk area only, chloroquine.

Austria

Tick-borne encephalitis vaccine in certain circumstances (see 7.4).

Azerbaijan

Immunisation against hepatitis A and typhoid usually advised.

Malaria risk: P.vivax malaria focally, from June to October.

Recommended prophylaxis: chloroquine.

Belarus

Immunisation against hepatitis A usually advised.

Tick-borne encephalitis vaccine in certain circumstances (see 7.4).

Bosnia

Immunisation against hepatitis A usually advised.

Bulgaria

Immunisation against hepatitis A usually advised.

Croatia

Immunisation against hepatitis A usually advised.

Tick-borne encephalitis vaccine in certain circumstances (see 7.4).

Czech Republic

Immunisation against hepatitis A usually advised.

Tick-borne encephalitis vaccine in certain circumstances (see 7.4).

Estonia

Tick-borne encephalitis vaccine in certain circumstances (see 7.4).

Georgia

Immunisation against hepatitis A usually advised.

Malaria risk: P.vivax malaria focally in rural areas in the south-east, June to October.

Recommended prophylaxis: for those areas only, chloroquine.

Germany

Tick-borne encephalitis vaccine in certain circumstances (see 7.4).

Greece

Yellow fever vaccination certificate required from travellers over six months old coming from infected areas.

Hepatitis A immunisation occasionally advised, eg for those on extensive backpacking holidays where food hygiene might be in doubt.

Herzegovina

Immunisation against hepatitis A usually advised.

Hungary

Tick-borne encephalitis vaccine in certain circumstances (see 7.4).

Kazakhstan

Yellow fever vaccination certificate required from travellers coming from infected areas.

Immunisation against poliomyelitis, hepatitis A and typhoid usually advised.

Kyrgyzstan

Immunisation against poliomyelitis, hepatitis A and typhoid usually advised.

Latvia

Tick-borne encephalitis vaccine in certain circumstances (see 7.4).

Lithuania

Tick-borne encephalitis vaccine in certain circumstances (see 7.4).

Macedonia

Immunisation against hepatitis A usually advised.

Malta

Yellow fever vaccination certificate required from travellers over nine months old coming from infected areas. (If indicated on epidemiological grounds, infants under nine months of age coming from infected areas are subject to isolation or surveillance).

Moldova

Immunisation against hepatitis A usually advised.

Poland

Tick-borne encephalitis vaccine in certain circumstances (see 7.4).

Portugal, with the Azores and Madeira

Yellow fever vaccination certificate required from travellers over one year old coming from infected areas and arriving in or bound for the Azores and Madeira. No certificate is required from passengers in transit at Funchal, Porto Santo and Santa Maria.

Hepatitis A immunisation occasionally advised, eg for those on extensive backpacking holidays where food hygiene might be in doubt.

Romania

Immunisation against hepatitis A usually advised.

Russia

Immunisation against poliomyelitis, hepatitis A and typhoid usually advised for areas east of the Urals.

Japanese encephalitis and Russian spring summer encephalitis - consider immunisation against JE for far eastern maritime areas, south of Khabarousk, July-September.

Tick-borne encephalitis vaccine in certain circumstances (see 7.4).

Slovakia

Immunisation against hepatitis A usually advised.

Tick-borne encephalitis vaccine in certain circumstances (see 7.4).

Slovenia

Immunisation against hepatitis A usually advised.

Tick-borne encephalitis vaccine in certain circumstances (see 7.4).

Tajikistan

Immunisation against poliomyelitis, hepatitis A and typhoid usually advised.

Malaria risk: malaria (mostly P.vivax) patchily distributed, June to October.

Recommended prophylaxis: chloroquine.

Turkmenistan

Immunisation against poliomyelitis, hepatitis A and typhoid usually advised.

Malaria risk: P.vivax from June to October in south-eastern region.

Recommended prophylaxis: in the risk area, chloroquine.

Ukraine

Immunisation against hepatitis A usually advised.

Tick-borne encephalitis vaccine in certain circumstances (see 7.4).

Uzbekistan

Immunisation against poliomyelitis, hepatitis A and typhoid usually advised.

Yugoslavia

Immunisation against hepatitis A usually advised.

3.2 North America, Australia and New Zealand

(Australia, Bermuda, Canada, Greenland, New Zealand, Saint Pierre and Miquelon and the United States of America (with Hawaii))

3.2.1 Disease risks

Communicable diseases are unlikely to prove a hazard greater than that found in the UK.

Malaria is not endemic in these areas.

Other arthropod-borne diseases (see Chapter 7) include various strains of viral encephalitis in some rural areas of Australia (eg Ross River fever) and USA (eg West Nile Virus, St Louis encephalitis).

• Japanese encephalitis confined to islands of Torres Strait and sporadic cases at Cape York Peninsula.
• Lyme disease is endemic in north-eastern, mid-Atlantic and upper Midwest USA, with occasional cases reported from the Pacific north-west.
• Rocky Mountain spotted fever and tularaemia occur occasionally in N America.
• Dengue fever has occurred in northern Australia in recent years; it is endemic in Hawaii and has occurred in South USA.
• Plague in USA.
• Tick-borne relapsing fever in west USA and west Canada.
• Tick and scrub typhus in Queensland, Australia.

Diseases of close association:

• Poliomyelitis has been eliminated in the Americas, Australia and New Zealand.
• Tuberculosis predominantly in certain high risk groups (as in the UK).

Sexually transmitted and blood-borne infections:

• Hepatitis B highly prevalent in certain indigenous groups in N. Canada, Alaska, Greenland, Australia and New Zealand.
• HIV predominantly in high risk groups.

Other hazards could include:

In N. America - leptospirosis, hantavirus (mainly in the western states of the USA and SW provinces of Canada); rabies in wildlife (including bats); poisonous snakes; poison ivy, poison oak; very low temperatures in the north in winter.

In Australia and New Zealand - Corals and jelly fish and spines of poisonous fish during sea bathing; snakes and venomous spiders in Australia. Insectivorous and fruit-eating bats in Australia have been found to harbour a rabies-related virus. Heat in northern and central Australia.

3.2.2 Recommendations for immunisations and malaria chemoprophylaxis (see later chapters for general health precautions)

3.2.3 Country by country variations:

Australia

Yellow fever vaccination certificate required from travellers over one year of age entering Australia within six days of having stayed overnight or longer in an infected country, as listed in the WHO Weekly Epidemiological Record.

Japanese encephalitis - consider vaccination only for those going to live or work in Torres Strait Islands.

USA

Proof of immunisation against diphtheria, measles, poliomyelitis and rubella is now universally required for entry into school. Schools in most states also require proof of immunisation against tetanus (49 states), pertussis (44 states),mumps (43 states) and hepatitis B (26 states). Some universities and schools may ask for varicella immunisation.

3.3 Central America

(Belize, Costa Rica, El Salvador, Guatemala, Honduras, Mexico, Nicaragua, Panama)

3.3.1 Disease risks

Food and water-borne diseases including amoebic and bacillary dysentry, other diarrhoeal diseases and typhoid fever are common throughout the area. Hepatitis A occurs throughout the area and hepatitis E has been reported in Mexico. Helminth infections are also common. All countries except Panama have reported cholera in recent years.

Malaria present in all countries - see individual entries below

Other arthropod-borne diseases (see Chapter 7):

• Yellow fever - the South American endemic zone extends into Panama
• Cutaneous and mucocutaneous leishmaniasis in all countries
• Visceral leishmaniasis - El Salvador, Guatemala, Honduras, Mexico and Nicaragua
• Onchocerciasis (river blindness) in two small foci in the south of Mexico and four dispersed foci in Guatemala
• American trypanosomiasis (Chagas' disease) in localised foci in rural areas in all countries
• Dengue fever and Venezuelan equine encephalitis may occur in all countries
• Rocky Mountain spotted fever.

Diseases of close association:

• In 1994, an international commission certified the eradication of endemic wild poliovirus from the Americas. Ongoing surveillance in formerly endemic Central and South American countries confirms that poliovirus transmission remains interrupted.
• Tuberculosis endemic.

Sexually transmitted and blood-borne infections:

Hepatitis B of low prevalence in most countries (intermediate prevalence in Guatemala and Honduras); HIV endemic throughout the area.

Other hazards could include:

• Leptospirosis.
• Rabies in animals (usually dogs and bats).
• Snakes and scorpions in some areas.

3.3.2 Recommendations for immunisations and malaria chemoprophylaxis (see later chapters for general health precautions)

3.3.3 Country by country variations and malaria chemoprophylaxis:

Belize

Yellow fever vaccination certificate required from travellers coming from infected areas.

Malaria risk (predominantly P.vivax) throughout the year.

Recommended prophylaxis: chloroquine.

Costa Rica

Malaria risk (almost exclusively P.vivax) throughout the year in rural areas below 700m in Alajuela, Guanacaste, Limon and Heredia provinces.

Recommended prophylaxis: for the rural areas above only, chloroquine.

El Salvador

Yellow fever vaccination certificate required from travellers over six months of age coming from infected areas.

Malaria risk (almost exclusively P.vivax) throughout the year in Santa Ana province.

Recommended prophylaxis: for the risk area, chloroquine.

Guatemala

Yellow fever vaccination certificate required from travellers over one year of age coming from countries with infected areas.

Malaria risk (predominantly P.vivax) throughout the year below 1,500m in several Departments.

Recommended prophylaxis: chloroquine.

Honduras

Yellow fever vaccination certificate required from travellers coming from infected areas.

Malaria risk (predominantly P.vivax) throughout the year in most areas.

Recommended prophylaxis: chloroquine.

Mexico

Malaria risk (almost exclusively P.vivax) throughout the year largely in rural areas. There is a significant risk of transmission in the states of: Campeche, Chiapas, Guerrero, Michoacan, Oaxaca, Quintana Roo, Sinaloa and Tabasco and moderate risk in the states of Chichuahua, Durango, Hidalgo, Jalisco,Nayarit, Sonora and Veracruz.

Recommended prophylaxis: for the risk areas, chloroquine; in other areas none but bear in mind the remote possibility of malaria.

Nicaragua

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas.

Malaria risk (predominantly P.vivax) throughout the year in most areas.

Recommended prophylaxis: chloroquine.

Panama

Yellow fever vaccination certificate recommended for all travellers going to Chepo Darien and San Blas.

Malaria risk (predominantly P.vivax) throughout the year in three provinces: Bocas de Toro in the west, and Darien and San Blas in the east where chloroquine resistant P.falciparum has been reported. The canal area itself is considered malaria free.

Recommended prophylaxis: for above areas, chloroquine west of the canal; chloroquine plus proguanil east of the canal.

3.4 The Caribbean

(Anguilla, Antigua and Barbuda, Aruba, Bahamas, Barbados, British Virgin Islands, Cayman Islands, Cuba, Dominica, 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)).

3.4.1 Disease risks

Food and water-borne diseases:

Bacillary and amoebic dysentery are common and hepatitis A reported, particularly in the northern islands. No cholera has been reported in recent years.

Biointoxication may occur from raw or cooked fish or shellfish.

Malaria: only in Haiti and the Dominican Republic

Other arthropod-borne diseases (see Chapter 7):

• Outbreaks of dengue fever and some dengue haemorrhagic fever.
• Diffuse cutaneous leishmaniasis recently reported from Dominican Republic.
• Bancroftian filariasis in Haiti and some other islands.
• Other filariases occasionally found.
• Fasciola hepatica endemic in Cuba.
• Yellow fever reported in wildlife in Trinidad.

Diseases of close association:

• In 1994, an international commission certified the eradication of endemic wild poliovirus from the Americas including the Caribbean. Ongoing surveillance in formerly endemic Central and South American countries confirms that poliovirus transmission remains interrupted, although an outbreak of vaccine-derived poliovirus type 1 occurred in the Dominican Republic and Haiti in July 2000.
• Tuberculosis incidence similar to western Europe, although higher in Haiti and the Dominican Republic.

Sexually transmitted and blood-borne infections:

Hepatitis B of low or intermediate prevalence; HIV endemic.

Other hazards could include:

• Schistosomiasis (bilharziasis) in the Dominican Republic, Guadeloupe, Martinique, Puerto Rico and Saint Lucia; may occur sporadically in other islands.
• Spiny sea urchins, corals and jellyfish, snakes and scorpions.
• Animal rabies, particularly in the mongoose, reported from several islands.

3.4.2 Recommendations for immunisations and malaria chemoprophylaxis (see later chapters for general health precautions)

3.4.3 Country by country variations and malaria chemoprophylaxis:

Anguilla, Antigua and Barbuda, Bahamas, Barbados, Dominica

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas.

Dominican Republic

Malaria - low risk throughout the year. Because the malaria is almost exclusively of the more severe falciparum type and still sensitive to chloroquine it is wise for travellers to take prophylaxis.

Recommended prophylaxis: chloroquine.

Grenada, Guadeloupe

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas.

Haiti

Yellow fever vaccination certificate required from travellers coming from infected areas.

Malaria risk (almost exclusively P.falciparum) throughout the year below 300m in suburban and rural areas.

Recommended prophylaxis: chloroquine.

Jamaica

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas.

Netherlands Antilles

Yellow fever vaccination certificate required from travellers over six months of age coming from infected areas.

Saint Kitts and Nevis, Saint Vincent and the Grenadines

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas.

Trinidad and Tobago

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas. Yellow fever vaccination usually advised for visits to rural or forested areas of Trinidad (not for solely city or beach holidays or for Tobago).

3.5 Tropical South America

(Bolivia, Brazil, Colombia, Ecuador including Galapagos, French Guiana, Guyana, Paraguay, Peru, Surinam, Venezuela including Marguerita island).

3.5.1 Disease risks

Food and water-borne diseases including amoebiasis, diarrhoeal diseases, helminth infections and hepatitis A are common. Bolivia, Brazil, Ecuador, Peru and Venezuela have all reported cholera.

Malaria (P.falciparum, P.malariae and P.vivax) in all countries. The main area of risk is the huge Amazon basin, largely in Brazil but extending into the adjacent countries. The falciparum malaria in the Amazon basin is highly chloroquine resistant.

Other arthropod-borne diseases (see Chapter 7) are an important cause of ill health:

• Jungle yellow fever in forest areas in all countries except Paraguay, areas west of the Andes, and the north eastern and southern states of Brazil.
• American trypanosomiasis (Chagas' disease) in most countries.
• Cutaneous and mucocutaneous leishmaniasis in all countries (the latter increasing in Brazil and Paraguay).
• Visceral leishmaniasis especially NE Brazil; less frequently in Colombia and Venezuela; rare in Bolivia and Paraguay; not known in Peru.
• Epidemics of viral encephalitis and dengue fever in some countries
• Bancroftian lymphatic filariasis is endemic in parts of Brazil, Guyana and Surinam.
• Onchocerciasis in isolated foci in rural areas of Ecuador, Venezuela and N Brazil.
• Bartonellosis or Oroya fever (sandfly-borne disease) on arid Western slopes of the Andes (up to 3,000m).
• Louse-borne typhus in mountain areas of Colombia and Peru.
• Myiasis
• Plague - some foci in Bolivia, Brazil, Ecuador and Peru.
• Relapsing fever.
• Rocky Mountain spotted fever in Colombia.

Diseases of close association:

• In 1994, an international commission certified the eradication of endemic wild poliovirus from the Americas. Ongoing surveillance in formerly endemic Central and South American countries confirms that poliovirus transmission remains interrupted.
• Meningococcal meningitis has occurred in epidemic outbreaks in Brazil.
• Tuberculosis endemic; incidence particularly high in Bolivia and Peru.

Sexually transmitted and blood-borne infections:

Hepatitis B of intermediate or high prevalence; highly endemic in the Amazon basin; HIV endemic.

Other hazards could include:

• Schistosomiasis in Brazil, Surinam and north-central Venezuela
• Rabies, snakes, leeches, dangerous fish and venomous spiders.
• Rodent-borne hantavirus infection and leptospirosis.

3.5.2 Recommendations for immunisations and malaria chemoprophylaxis (see later chapters for general health precautions)

3.5.3 Country by country variations and malaria chemoprophylaxis:

Bolivia

Yellow fever vaccination certificate required from travellers coming from infected areas. Recommended for incoming travellers from non-infected zones visiting risk areas such as the Departments of Beni, Cochabamba, Santa Cruz, and the sub tropical part of La Paz Department.

Malaria risk (predominantly P.vivax) throughout the year below 2500m in rural areas in several departments. Falciparum malaria occurs in the northern departments bordering Brazil. P.falciparum resistant to chloroquine and sulfadoxinepyrimethamine reported.

Recommended prophylaxis: for rural areas below 2500m, chloroquine plus proguanil. In the northern borders near to Brazil, mefloquine (or doxycycline or atovaquone/proguanil) is more appropriate, as elsewhere in the Amazon basin.

Brazil

Yellow fever vaccination certificate required from travellers over nine months of age coming from infected areas, unless they are in possession of a waiver stating that immunisation is contraindicated on medical grounds. The following countries or areas are regarded as infected:

• Africa: Angola, Cameroon, Democratic Republic of Congo, Gabon, Gambia, Ghana, Guinea, Liberia, Mali, Nigeria, Sierra Leone, Sudan.
• America: Bolivia, Colombia, Ecuador, Peru.

3,53,3

Vaccination is recommended for travellers to endemic areas including rural areas in Acre, Amapa, Amazonas, Goias, Maranhao, Mato Grosso, Mato Grosso do Sul, Pará, and Rondônia, Roraima and Tocantins, and certain areas of Minas Gerais, Parana and Sao Paulo. At present this does not include the tourist areas of Brazilia, Rio, Sao Paulo and Recife, unless outbreaks should occur.

Meningococcal A&C vaccine: consider for those living or working with local people.

Malaria risk throughout the year below 900m in the states of the legal Amazon region, including parts of the cities of Manaus and Porto Velho. P.falciparum highly resistant to chloroquine and resistant to sulfadoxine-pyrimethamine reported.

Recommended prophylaxis: in the 'legal Amazon', mefloquine (or doxycycline or atovaquone/proguanil); alternative chloroquine plus proguanil. Along the eastern seaboard and the arid areas inland from there, no antimalarials needed but travellers should be aware of the small risk.

Colombia

Immunisation against yellow fever recommended for travellers who may travel outside the capital and especially for the following areas: middle valley of the Magdalena river, eastern and western foothills of the Cordillera Oriental from the frontier with Ecuador to that with Venezuela, Uraba, foothills of the Sierra Nevada, eastern plains (Orinoquia) and Amazonia.

Malaria risk, predominantly P.falciparum, throughout the year in many rural areas below 800m of the following regions: Uraba (Antioquia and Choco Dep.), Bajo Cauca-Nechi (Antioquia and Cordoba Dep.), middle valley of the Magdalena river, Catatumbo (Norte de Santander Dep), whole Pacific Coast area, eastern plains (Orinoquia) and Amazonia. P.falciparum highly resistant to chloroquine and resistant to sulfadoxine-pyrimethamine reported.

Recommended prophylaxis: for most areas below 800m, chloroquine plus proguanil; in Amazonia, Pacifico and Uraba, mefloquine (or doxycycline or atovaquone/ proguanil).

Ecuador (including Galapagos)

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas, and recommended for all travellers to the low lands excluding Galapagos.

Malaria risk, roughly half P.falciparum, throughout the year below 1,500m in several provinces. No risk in Guayaquil or Quito. Chloroquine resistant P.falciparum reported. No malaria in Galapagos.

Recommended prophylaxis: chloroquine plus proguanil. In Esmeraldas province mefloquine (or doxycycline or atovaquone/proguanil) preferable.

French Guiana

Yellow fever vaccination certificate required from all travellers over one year of age. Malaria risk, predominantly P.falciparum, throughout the year in the whole country. Resistance to chloroquine reported.

Recommended prophylaxis: mefloquine (or doxycycline or atovaquone/proguanil); alternative, chloroquine plus proguanil.

Guyana

Yellow fever vaccination certificate required from travellers coming from infected areas and from the following countries:

• Africa: Angola, Benin, Burkina Faso, Burundi, Cameroon, Central African Republic, Chad, Congo, Democratic Republic of Congo, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Ivory Coast,Kenya, Liberia, Mali, Niger, Nigeria, Rwanda, Sao Tome and Principe, Senegal, Sierra Leone, Somalia, Tanzania, Togo,Uganda.
• America: Belize, Bolivia, Brazil, Colombia, Costa Rica, Ecuador, French Guiana, Guatemala, Honduras, Nicaragua, Panama, Peru, Surinam, Venezuela.

Yellow fever immunisation recommended for all travellers.

Malaria risk high throughout the year and in all interior regions including the northwest Region and areas along the Pomeroon river. Predominantly chloroquine resistant P.falciparum. Occasional cases in coastal belt.

Recommended prophylaxis: mefloquine (or doxycycline or atovaquone/proguanil); alternative chloroquine plus proguanil.

Paraguay

Yellow fever vaccination certificate required from travellers leaving Paraguay to go to endemic areas and from travellers arriving from endemic areas.

Malaria risk, largely P.vivax, in the Departments of Alto Paraná, Caaguazú, Canendiyú.

Recommended prophylaxis: for these areas only, chloroquine.

Peru

Yellow fever vaccination certificate required from travellers over six months of age coming from infected areas and recommended for those intending to visit areas of the country below 2,300m. Not for Lima, Machu Picchu and Cusco, including Lake Titicaca.

Malaria risk, predominantly P.vivax, throughout the year in almost all rural areas below 1,500m with chloroquine resistant falciparum malaria predominant in the Amazon basin. P.falciparum resistant to sulfadoxine-pyrimethamine also reported.

Recommended prophylaxis: for rural areas below 1,500m, chloroquine plus proguanil; mefloquine (or doxycycline or atovaquone/proguanil) in Amazon basin and swampy area west of the Andes bordering Ecuador.

Surinam

Yellow fever vaccination certificate required from travellers coming from infected areas and recommended for all travellers.

Malaria risk, predominantly P.falciparum, throughout the year in the three southern districts of the country; risk low in Paramaribo City and other coastal areas. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: for risk areas, mefloquine (or doxycycline or atovaquone/proguanil); alternative chloroquine plus proguanil.

Venezuela (including Marguerita Island)

Immunisation against yellow fever recommended for all travellers.

Malaria risk: P.vivax malaria widespread throughout the year in rural areas of: Amazonas, Apure, Barinas, Bolivar, Sucre and Tachira States. Caracas is free of malaria. Falciparum malaria in jungle areas of several provinces. Highly chloroquine resistant P.falciparum reported.

Recommended prophylaxis: chloroquine plus proguanil. None for Caracas, coastal areas or Marguerita Island. Mefloquine (or doxycycline or atovaquone/proguanil) is preferable for the Amazon basin area.

3.6 Temperate South America

(Argentina, Chile, Falkland Islands,Uruguay)

3.6.1 Disease risks

Food and water-borne diseases:

Gastrointestinal infections a risk in rural areas. Gastroenteritis (mainly salmonellosis) relatively common in Argentina, especially suburban areas.Hepatitis A and intestinal parasites reported.

Malaria confined to outbreaks in a few areas of NW Argentina.

Other arthropod-borne diseases (see Chapter 7) relatively unimportant except for American trypanosomiasis (Chagas' disease)

• Cutaneous leishmaniasis in NE Argentina.

Diseases of close association:

• In 1994, an international commission certified the eradication of endemic wild poliovirus from the Americas. Ongoing surveillance in formerly endemic Central and South American countries confirms that poliovirus transmission remains interrupted.
• Meningococcal meningitis outbreaks have occurred in Chile.
• Tuberculosis rates slightly higher than western Europe.

Sexually transmitted and blood-borne infections:

Hepatitis B of low prevalence; HIV generally of low prevalence.

Other hazards could include:

• Animal rabies endemic.
• Rodent-borne hantavirus pulmonary syndrome identified in north-central and SW regions of Argentina and in Chile.

3.6.2 Recommendations for immunisations and malaria chemoprophylaxis (see later chapters for general health precautions)

3.6.3 Country by country variations and malaria chemoprophylaxis:

Argentina

Malaria risk, exclusively P.vivax, confined to the north west area along the borders with Bolivia and Paraguay. The Iguassu Falls area is considered malaria free.

Recommended prophylaxis: for this small area in the NW corner of the country, which will rarely be visited by UK travellers, chloroquine.

3.7 North Africa and the Middle East, including Afghanistan and Turkey

(Afghanistan, Algeria, Bahrain, Egypt, Iran, Iraq, Israel, Jordan,Kuwait, Lebanon, Libya, Morocco, Oman, Qatar, Saudi Arabia, Syria, Tunisia, Turkey, United Arab Emirates, Yemen)

3.7.1 Disease risks

Food and water-borne diseases: particularly the dysenteries and other diarrhoeal diseases, hepatitis A, intestinal helminth infections including taeniasis (tapeworm), brucellosis and giardiasis. Typhoid fever and hepatitis E in some areas. Sporadic cases of cholera. Dracunculiasis in isolated foci in Yemen.

Malaria: limited but variable risk, especially towards the east and south of the area; see country by country guide below.

Other arthropod-borne diseases (see Chapter 7) generally not a major problem:

• Murine (endemic) and tick-borne typhus.
• Cutaneous leishmaniasis.
• Visceral leishmaniasis - central Iraq, SW Saudi Arabia, NW Syria, Turkey (SE Anatolia only) and Yemen.
• Relapsing fever.
• Rift Valley fever.
• Sandfly fever.
• West Nile fever in some areas.
• Crimean-Congo haemorrhagic fever in Iraq.
• Onchocerciasis - limited foci in Yemen.
• Filariasis - locally in the Nile delta.
• Plague foci.

Diseases of close association:

• Poliomyelitis - countries reporting polio cases in 1998 and 1999 include: Afghanistan, Egypt, Iraq, Turkey, Syria and Yemen.
• Tuberculosis endemic - most countries have incidence rates higher than in western Europe, particularly Afghanistan, Iraq, Morocco and Yemen.
• Trachoma.
• Meningococcal infection for pilgrims to Saudi Arabia.

Sexually transmitted and blood-borne infections:

Hepatitis B of intermediate prevalence; reported rates of HIV infection low for most countries.

Other hazards could include:

• Schistosomiasis (bilharziasis) especially Nile delta and Nile valley, SW Iran, Iraq, Saudi Arabia, Syria and Yemen.
• Rabies, snakes and scorpions.
• Dehydration and heat exhaustion for pilgrims to Mecca and Medina if the Hajj coincides with the hot season.

3.7.2 Recommendations for immunisations and malaria chemoprophylaxis (see later chapters for general health precautions)

3.7.3 Country by country variations and malaria chemoprophylaxis:

Afghanistan

Yellow fever vaccination certificate required from travellers coming from infected areas.

Malaria risk, predominantly P.vivax,May-November below 2,000m. Chloroquine resistant P.falciparum in the south of the country.

Recommended prophylaxis: chloroquine plus proguanil.

Algeria

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas.

Malaria risk limited to a small focus of P.vivax in Ihrir (Illizi Dept) which is not usually visited by tourists. (Anyone going to this area should be aware of the risk).

Recommended prophylaxis: none.

Egypt

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas. (Air passengers in transit coming from these countries or areas without a certificate will be detained in the precincts of the airport until they resume their journey). The following countries and areas are regarded as infected:

• Africa: Angola, Benin, Burkina Faso, Burundi, Cameroon, Central African Republic, Chad, Congo, Democratic Republic of Congo, Equatorial Guinea, Ethiopia, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Ivory Coast,Kenya, Liberia, Mali, Niger, Nigeria, Rwanda, Sao Tome and Principe, Senegal, Sierra Leone, Somalia, Sudan (south of 15oN), Tanzania, Togo,Uganda, Zambia.
• America: Belize, Bolivia, Brazil, Colombia, Costa Rica, Ecuador, French Guiana, Guyana, Panama, Peru, Surinam, Trinidad and Tobago, Venezuela.

All arrivals from Sudan are required to possess either a vaccination certificate or a location certificate issued by a Sudanese official centre stating that they have not been in Sudan south of 15oN within the previous six days.

Malaria risk: limited risk (P.vivax and P.falciparum) June - October and confined to the El Faiyum area which is 50 miles SW of Cairo and rarely visited by tourists. Recommended prophylaxis: for tourist areas including Nile cruises - none; for the risk area, June - October, chloroquine.

Iran

Malaria risk (P.vivax) in parts of the central, western and south-western regions during the summer months. P.falciparum from March to November more in the south east. In practice this means there is limited risk over much of the country, greater risk in the south and especially the south-east. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: for areas outside the main cities, March-November, chloroquine plus proguanil.

Iraq

Yellow fever vaccination certificate required from travellers coming from infected areas.

Malaria risk, exclusively P.vivax, from May to November in some areas in the north below 1,500m (Duhok, Erbil, Ninawa, Sulaimaniya and Ta'min provinces), and also in Basrah province.

Recommended prophylaxis: for these rural areas in the North and for Basrah, May-November, chloroquine.

Jordan

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas.

Lebanon

Yellow fever vaccination certificate required from travellers coming from infected areas.

Libya

Yellow fever vaccination certificate required from travellers coming from infected areas.

Morocco

Malaria risk: limited risk of P.vivax malaria May-October in some rural areas.

Recommended prophylaxis: none, but remember slight risk.

Oman

Yellow fever vaccination certificate required from travellers coming from infected areas.

Malaria risk: limited risk, including P.falciparum, in rural areas. No transmission in Muscat. Chloroquine resistance reported.

Recommended prophylaxis: for rural areas, chloroquine plus proguanil.

Saudi Arabia

Yellow fever vaccination certificate required from all travellers coming from countries any part of which is infected.

Vaccination requirements for pilgrims to Mecca (Hajj) for 2001:

• Yellow fever: all travellers arriving in Saudi Arabia from countries known to be infected with yellow fever (as shown in the WHO Weekly Epidemiological Record), must present a valid yellow fever vaccination certificate. In the absence of such a certificate an individual will be vaccinated upon arrival and placed under strict surveillance for six days from the day of vaccination or the last date of potential exposure to infection.
• Meningococcal infection: all visitors arriving for 'Umra' or pilgrimage or seasonal work are requested to produce a certificate of vaccination against meningococcal A infection, issued not more than three years and not less than ten days before arrival in Saudi Arabia (but see below).
• Those arriving from countries in the African meningitis belt will be checked at entry points to ensure they are vaccinated. Cases with suspected meningococcal infection will be isolated and contacts put under close supervision. Chemoprophylaxis will be administered to all visitors from these countries to lower the carriage rate among them.
  Source: Ministry of Health, Saudi Arabia.
• NB. The new conjugate meningococcal (MenC)vaccine, which protects only against C strains, and the polysaccharide A&C vaccine give insufficent protection. From 2001, the UK recommends quadrivalent ACWY meningococcal polysaccharide vaccine, which also protects against W135 strains, for protection of pilgrims travelling to Saudi Arabia (see also 8.4.4).

Malaria risk, predominantly P.falciparum, throughout the year in most of the Southern Region (except the high altitude areas of Asir Province) and in certain rural areas of the Western Region. Chloroquine resistance reported.

Recommended prophylaxis: for risk areas, chloroquine plus proguanil.

Syria

Yellow fever vaccination certificate required from travellers coming from infected areas.

Malaria risk, exclusively P.vivax, from May to October along northern border areas, and especially in the north-east.

Recommended prophylaxis: for northern border areas,May-October, chloroquine.

Tunisia

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas.

Turkey

Malaria - potential risk, exclusively P.vivax, March-November in the plain around Adana, Antalya (Side) and SE Anatolia.

Recommended prophylaxis: for most tourist areas, none; for tourist areas along the south coast east of, and including, Side, and for those going to inland SE Turkey from March to November, chloroquine prophylaxis is recommended.

United Arab Emirates

Malaria risk confined to foothill areas and valleys in the mountainous regions of the northern Emirates. Not considered a risk in Abu Dhabi or in the cities of Dubai, Sharjah, Ajman and Umm al Qaiwain.

Recommended prophylaxis: for the northern rural areas of the emirates other than Abu Dhabi, chloroquine plus proguanil.

Yemen

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas.

Malaria risk, predominantly P.falciparum, throughout the year but mainly September-February, except in Aden and the airport perimeter. Chloroquine resistance reported.

Recommended prophylaxis: chloroquine plus proguanil.

3.8 Sub-Saharan and Southern Africa

(Angola, Benin, Botswana, Burkina Faso, Burundi, Cameroon, Cape Verde, Central African Republic, Chad, Comoros, Congo, Democratic Republic of Congo (formerly Zaire), Djibouti, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Ivory Coast,Kenya, Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritania, Mauritius,Mayotte, Mozambique, Namibia, Niger, Nigeria, Reunion, Rwanda, Saint Helena, Sao Tome and Principe, Senegal, Seychelles, Sierra Leone, Somalia, South Africa, Sudan, Swaziland, Tanzania (including Zanzibar), Togo,Uganda, Zaire (see Democratic Republic of Congo), Zambia, Zimbabwe)

3.8.1 Disease Risks

Food and water-borne diseases highly endemic - intestinal helminth infections, the dysenteries and other diarrhoeal diseases including giardiasis, typhoid fevers and hepatitis A and E are widespread. Amoebiasis in southern countries. Cholera in many countries in the area. Dracunculiasis occurs in isolated foci.

Malaria: high transmission rate of P.falciparum in most areas except for the southern tip of the continent. There is no transmission above 3,000m altitude, nor in the islands of Reunion and the Seychelles, Lesotho and St. Helena; there is a little vivax malaria in Mauritius. Malaria in sub-Saharan Africa is highly resistant to chloroquine and the risk to travellers is great. See recommendations for individual countries below.

Other arthropod-borne diseases (see Chapter 7) are a major cause of morbidity in the area:

• Yellow fever - outbreaks occur periodically in unvaccinated populations within the endemic zones (see map on inside back cover). See recommendations for individual countries below.
• Lymphatic filariasis and onchocerciasis widespread.
• Cutaneous and visceral leishmaniasis - particularly drier areas; visceral leishmaniasis is epidemic in eastern and southern Sudan.
• Human trypanosomiasis (sleeping sickness) - small isolated foci in all countries except Djibouti, Eritrea, Gambia, Mauritania, Niger, Somalia, the island countries of the Atlantic and Indian Oceans, Lesotho, Saint Helena, South Africa and Swaziland. Transmission rate is high in north-western Uganda and very high in Angola, Democratic Republic of Congo and Southern Sudan and there is significant risk of infection in travellers visiting or working in rural areas.
• Louse, flea and tick-borne typhus.
• Plague - natural foci reported from Angola,Kenya, Madagascar, Malawi, Mozambique,Uganda, Tanzania, Zambia, Zaire and Zimbabwe and some areas of Southern Africa; not usually a risk for tourists.
• Dengue and many other viral infections transmitted by mosquitoes, ticks, sandflies etc, some presenting as severe haemorrhagic fevers, throughout the region.
• The virus reservoir for Lassa fever (the multimammate rat) exists in some rural areas of West Africa.
• Ebola and Marburg haemorrhagic fevers are present, but reported only infrequently.
• Relapsing fever
• Rift Valley fever.
• West Nile fever.

Diseases of close association:

• Poliomyelitis in most countries except Cape Verde, Comoros, Mauritius, Reunion and the Seychelles. Southern Africa is an emerging poliomyelitis free zone.
• Tuberculosis incidence considered high.
• Meningococcal meningitis - epidemics occur throughout tropical Africa particularly in the savanna in the dry season, which varies from country to country and can be unpredictable.
• Trachoma.

Sexually transmitted and blood-borne infections:

Hepatitis B and HIV infection of high prevalence.

Other hazards could include:

• Tetanus common.
• Schistosomiasis throughout the area except Cape Verde, Comoros, Djibouti, Reunion and the Seychelles, Lesotho, Saint Helena.
• Rabies.
later chapters for general health precautions)

FOR ALL COUNTRIES

Check routine immunisations including tetanus.

Immunisation against poliomyelitis, hepatitis A and typhoid.

Yellow fever immunisation for many countries - risk to the traveller varies with itinerary but immunisation is always advised within the endemic zone (unless travel is exclusively to urban areas at high altitude) and may be mandatory - see individual entries below.

Meningococcal A&C immunisation recommended for longer visits to certain countries (see entries below) especially if backpacking or living or working with local people, or if current outbreaks reported. The risk is greatest in the dry season, but these may vary within a country and from year to year. As a guide, dry season in West Africa is usually between November-May/June. In East Africa, seasons are variable.

For those on longer visits consider immunisation against diphtheria and hepatitis B and check BCG status; for rural visits out of reach of medical attention, consider immunisation against rabies.

Malaria prophylaxis: see individual countries. Unless otherwise indicated, the recommended prophylaxis for Sub-Saharan Africa is mefloquine or doxycycline or atovaquone/proguanil (malarone). For those such as some children and pregnant women unable to take any of these: chloroquine plus proguanil, remembering that this regimen is likely to be less protective than the first-choice recommendations.

3.8.3 Country by country variations and malaria chemoprophylaxis:

Angola

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas and recommended for all travellers.

Meningococcal A&C vaccine in certain circumstances (see recommendations for all countries above).

Malaria risk high in all areas throughout the year. Predominantly P.falciparum. P.falciparum resistant to chloroquine and sulphadoxine-pyrimethamine reported.

Recommended prophylaxis: see 3.8.2 above.

Benin

Yellow fever vaccination certificate required from all travellers over one year of age.

Meningococcal A&C vaccine in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk high in all areas throughout the year. Predominantly P.falciparum. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: see 3.8.2 above.

Botswana

Malaria risk, predominantly P.falciparum, from November to May/June in northern parts of the country: Boteti, Chobe,Ngamiland, Okavango and Tutume districts/subdistricts. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: for the northern half of the country from November to June, chloroquine plus proguanil.

Burkino Faso

Yellow fever vaccination certificate required from all travellers over one year of age.

Meningococcal A&C vaccine in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk high in all areas throughout the year. Predominantly P.falciparum. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: see 3.8.2 above.

Burundi

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas, and recommended for all travellers.

Meningococcal A&C vaccine in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk high in all areas throughout the year. Predominantly P.falciparum. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: see 3.8.2 above.

Cameroon

Yellow fever vaccination certificate required from all travellers over one year of age.

Meningococcal A&C vaccine recommended for northern region in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk very high in all areas throughout the year. Predominantly P.falciparum. P.falciparum resistant to chloroquine and sulphadoxine-pyrimethamine reported.

Recommended prophylaxis: see 3.8.2 above.

Cape Verde

Yellow fever vaccination certificate required from travellers over one year of age coming from countries having notified cases in the last six years; recommended for all travellers.

Malaria prophylaxis: none. Limited risk in Sao Tiago Island, no prophylaxis recommended but remember slight risk if fever occurs.

Central African Republic

Yellow fever vaccination certificate required from all travellers over one year of age. Meningococcal A&C vaccine recommended for northern part in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk high in all areas throughout the year. Predominantly P.falciparum. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: see 3.8.2 above.

Chad

Yellow fever vaccination certificate recommended for all travellers over one year of age (yellow fever is endemic South of 15°N).

Meningococcal A&C vaccine recommended for southern part in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk high in all areas throughout the year. Predominantly P.falciparum. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: see 3.8.2 above.

Comoros

Malaria risk high in all areas throughout the year. Predominantly P.falciparum. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: see 3.8.2 above.

Congo

Yellow fever vaccination certificate required from all travellers over one year of age. Malaria risk high in all areas throughout the year. Predominantly P.falciparum. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: see 3.8.2 above.

Democratic Republic of Congo (formerly Zaire)

Yellow fever vaccination certificate required from travellers over one year of age.

Malaria risk high in all areas throughout the year. Predominantly P.falciparum. Highly chloroquine resistant P.falciparum reported.

Recommended prophylaxis: see 3.8.2 above.

Djibouti

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas and recommended for all travellers.

Meningococcal A&C vaccine in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk high in all areas throughout the year. Predominantly P.falciparum. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: see 3.8.2 above.

Equatorial Guinea

Yellow fever vaccination certificate required from travellers coming from infected areas and recommended for all travellers.

Malaria risk high in all areas throughout the year. Predominantly P.falciparum. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: see 3.8.2 above.

Eritrea

Yellow fever vaccination certificate required from travellers coming from infected areas.

Meningococcal A&C vaccine in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk in all areas under 2,000m throughout the year. Asmara no risk. Predominantly P.falciparum.

Recommended prophylaxis: see 3.8.2 above

Ethiopia

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas and recommended for all travellers.

Meningococcal A&C vaccine recommended in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk, predominantly P.falciparum, in all areas under 2,000m throughout the year. Highly chloroquine resistant P.falciparum reported. No risk in Addis Ababa.

Recommended prophylaxis: see 3.8.2 above.

Gabon

Yellow fever vaccination certificate required from all travellers over one year of age.

Malaria risk high in all areas throughout the year. Predominantly P.falciparum. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: see 3.8.2 above.

Gambia

Yellow fever vaccination certificate required from travellers over one year of age arriving from endemic or infected areas and recommended for all travellers.

Meningococcal A&C vaccine recommended in certain circumstances (see recommendations for all countries (3.8.2) above). Not routinely recommended for tourist visits unless outbreak reported.

Malaria risk high in all areas throughout the year. Predominantly P.falciparum. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: see 3.8.2 above.

Ghana

Yellow fever vaccination certificate required from all travellers.

Meningococcal A&C vaccine recommended for northern area in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk very high in all areas throughout the year. Predominantly P.falciparum. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: see 3.8.2 above.

Guinea

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas and recommended for all travellers.

Meningococcal A&C vaccine recommended in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk high in all areas throughout the year. Predominantly P.falciparum. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: see 3.8.2 above.

Guinea - Bissau

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas and from the following countries:

• Africa: Angola, Benin, Burkina Faso, Burundi, Cape Verde, Central African Republic, Chad, Congo, Democratic Republic of Congo, Djibouti, Equatorial Guinea, Ethiopia, Gabon, Gambia, Ghana, Guinea, Ivory Coast,Kenya, Liberia, adagascar, Mali, Mauritania, Mozambique, Niger, Nigeria, Rwanda, Sao Tome and Principe, Senegal, Sierra Leone, Somalia, Tanzania, Togo,Uganda, Zambia
• America: Bolivia, Brazil, Colombia, Ecuador, French Guiana, Guyana, Panama, Peru, Surinam, Venezuela

and recommended for all travellers.

Meningococcal A&C vaccine recommended in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk very high in all areas throughout the year. Predominantly P.falciparum. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: see 3.8.2 above.

Ivory Coast

Yellow fever vaccination certificate required from all travellers over one year of age.

Meningococcal A&C vaccine recommended for northern areas in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk very high in all areas throughout the year. Predominantly P.falciparum. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: see 3.8.2 above.

Kenya

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas, and recommended for all travellers, except those who confine their visit to a few days in Nairobi city.

Meningococcal A&C vaccine recommended in certain circumstances (see recommendations for all countries (3.8.2) above). Not routinely recommended for tourist visits unless outbreak reported.

Malaria risk very high in most areas throughout the year. The only areas where there is normally little risk are the centre of Nairobi and the highlands (above 2,500m) of Central, Rift Valley, Eastern, Nyanza and Western provinces. Predominantly P.falciparum. P.falciparum highly resistant to chloroquine and resistant to sulfadoxinepyrimethamine reported.

Recommended prophylaxis: see 3.8.2 above.

Lesotho

Yellow fever vaccination certificate required from travellers coming from infected areas.

No malaria risk.

Recommended prophylaxis: none.

Liberia

Yellow fever vaccination certificate required from all travellers over one year of age.

Malaria risk very high in all areas throughout the year. Predominantly P.falciparum. P.falciparum highly resistant to chloroquine and resistant to sulphadoxinepyrimethamine reported.

Recommended prophylaxis: see 3.8.2 above

Madagascar

Yellow fever vaccination certificate required from travellers coming from, or having been in transit in, areas considered to be infected.

Malaria risk in all areas throughout the year, especially in coastal areas. Predominantly P.falciparum. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: see 3.8.2 above

Malawi

Yellow fever vaccination certificate required from travellers coming from infected areas.

Meningococcal A&C vaccine recommended in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk very high in all areas throughout the year. Predominantly P.falciparum. P.falciparum highly resistant to chloroquine and resistant to sulphadoxinepyrimethamine reported.

Recommended prophylaxis: see 3.8.2 above

Mali

Yellow fever vaccination certificate required from all travellers over one year of age (yellow fever is endemic south of 15°N).

Meningococcal A&C vaccine recommended for southern areas in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk high in all areas throughout the year. Predominantly P.falciparum. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: see 3.8.2 above.

Mauritania

Yellow fever vaccination certificate required from all travellers over one year of age, except those arriving from a non-infected area and staying in Mauritania less than two weeks.

Malaria risk, predominantly P.falciparum, throughout the year in all areas except Dakhlet-Nouadhibou and Tiris-Zemour, in the north. Risk in the north confined to the rainy season (Jul-Oct).

Recommended prophylaxis: in risk areas, chloroquine plus proguanil.

Mauritius

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas, considered to be those listed as endemic zones.

Malaria risk, exclusively P.vivax, throughout the year in certain rural areas; not Rodrigues Island.

Recommended prophylaxis: for rural areas, chloroquine. For other areas, remember slight risk if fever occurs.

Mozambique

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas.

Meningococcal A&C vaccine recommended in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk high in all areas throughout the year. Predominantly P.falciparum. P.falciparum highly resistant to chloroquine and resistant to sulphadoxinepyrimethamine reported.

Recommended prophylaxis: see 3.8.2 above.

Namibia

Yellow fever vaccination certificate required from travellers coming from, or transitting on unscheduled flights through, infected areas. Travellers on scheduled flights which have transitted through infected areas are exempt provided they remained at the scheduled airport or adjacent town. A certificate is not insisted on for children under one year, but such infants may be subject to surveillance. The countries, or parts of countries, included in the endemic zones in Africa and South America are regarded as infected.

Meningococcal A&C vaccine recommended for north of country in certain circumstances. Not routinely recommended for tourist visits unless outbreak reported (see recommendations for all countries (3.8.2) above).

Malaria risk, predominantly P.falciparum, in northern regions (approximately one third of the country) from November to June and along the Kavango and Kunene rivers (the northern border) throughout the year. Resistance to chloroquine reported.

Recommended prophylaxis: chloroquine plus proguanil for northern area November-June, year round in extreme north.

Niger

Yellow fever vaccination certificate required from all travellers over one year of age and recommended for travellers leaving Niger. (Yellow fever is endemic south of 15°N).

Meningococcal A&C vaccine recommended for southern area in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk high in all areas throughout the year. Predominantly P.falciparum. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: see 3.8.2 above.

Nigeria

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas, and recommended for all travellers

Meningococcal A&C vaccine recommended for visits to northern part of the country in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk very high throughout the year in the whole country. Predominantly P.falciparum. Chloroquine resistance reported.

Recommended prophylaxis: see 3.8.2 above.

Reunion

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas.

No malaria risk.

Recommended prophylaxis: none.

Rwanda

Yellow fever vaccination certificate required from all travellers over one year of age.

Meningococcal A&C vaccine recommended in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk high in all areas throughout the year. Predominantly P.falciparum. P.falciparum highly resistant to chloroquine and resistant to sulphadoxinepyrimethamine reported.

Recommended prophylaxis: see 3.8.2 above.

Saint Helena

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas.

Sao Tome and Principe

Yellow fever vaccination certificate required from all travellers over one year of age.

Malaria risk, predominantly P.falciparum, in all areas throughout the year. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: see 3.8.2 above.

Senegal

Yellow fever vaccination certificate required from travellers coming from endemic areas and recommended for all travellers.

Meningococcal A&C vaccine recommended for southern part of the country in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk high in all areas throughout the year. Predominantly P.falciparum. Chloroquine resistance reported.

Recommended prophylaxis: see 3.8.2 above.

Seychelles

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas or who have passed through partly or wholly endemic areas within the preceding six days. The countries and areas in the endemic zones are considered as infected areas.

No malaria risk.

Recommended prophylaxis: none.

Sierra Leone

Yellow fever vaccination certificate required from travellers coming from infected areas, and recommended for all travellers.

Malaria risk very high in all areas throughout the year. Predominantly P.falciparum. Chloroquine resistance reported.

Recommended prophylaxis: see 3.8.2 above.

Somalia

Yellow fever vaccination certificate required from travellers coming from infected areas, and recommended for all travellers.

Meningococcal A&C vaccine recommended in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk high in all areas throughout the year. Predominantly P.falciparum. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: see 3.8.2 above.

South Africa

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas. The countries or parts of countries included in the endemic zone in Africa and the Americas are regarded as infected.

Malaria risk, predominantly P.falciparum, throughout the year in low altitude areas of the northern and eastern Transvaal and eastern Natal as far south as the Tugela river (sixty miles north of Durban). At times of heavy rainfall this area may get larger and transmission rates may increase. Resistance to chloroquine reported.

Recommended prophylaxis: for risk areas (which are in the north eastern part of the country and include Kruger National Park), see 3.8.2 above.

Sudan

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas. The countries and areas included in the endemic zone are considered as infected. A certificate may be required from travellers leaving Sudan. Recommended for all travellers (yellow fever is endemic south of 12°N).

Meningococcal A&C vaccine recommended in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk high in all areas throughout the year. Predominantly P.falciparum. Highly chloroquine resistant P.falciparum reported.

Risk on the Red Sea coast is very limited, and that in the north and beside Lake Nasser is limited.

Recommended prophylaxis: see 3.8.2 above

Swaziland

Yellow fever vaccination certificate required from travellers coming from infected areas.

Malaria risk, predominantly P.falciparum, throughout the year in all low veld areas (mainly Big Bend, Mhlume, Simunye and Tshaneni). These are in the eastern half of the country. Highly chloroquine resistant P.falciparum reported.

Recommended prophylaxis: see 3.8.2 above.

Tanzania (including Zanzibar)

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas, regarded as those listed as endemic zones, and recommended for all travellers.

Meningococcal A&C vaccine recommended in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk very high throughout the year in all areas under 1,800m. Predominantly P.falciparum. P.falciparum highly resistant to chloroquine and resistant to sulphadoxine-pyrimethamine reported.

Recommended prophylaxis: see 3.8.2 above.

Togo

Yellow fever vaccination certificate required from all travellers over one year of age (yellow fever is endemic south of 15°N).

Meningococcal A&C vaccine recommended in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk high in all areas throughout the year. Predominantly P.falciparum. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: see 3.8.2 above.

Uganda

Yellow fever vaccination certificate required from travellers over one year of age coming from endemic areas and recommended for all travellers.

Meningococcal A&C vaccine recommended in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk very high throughout the year in the whole country including the main towns and cities. Predominantly P.falciparum. Chloroquine resistance reported.

Recommended prophylaxis: see 3.8.2 above.

Zaire - see Democratic Republic of Congo

Zambia

The western area is within the yellow fever belt; vaccination recommended for all travellers.

Meningococcal A&C vaccine recommended in certain circumstances (see recommendations for all countries (3.8.2) above).

Malaria risk high in all areas throughout the year. Predominantly P.falciparum. Highly chloroquine resistant P.falciparum reported.

Recommended prophylaxis: see 3.8.2 above.

Zimbabwe

Yellow fever vaccination certificate required from travellers coming from infected areas.

Meningococcal A&C vaccine recommended (May-October) in certain circumstances (see recommendations for all countries (3.8.2) above). Not routinely recommended for tourist visits unless outbreak reported.

Malaria risk, predominantly P.falciparum, from November to June in areas below 1,200m and throughout the year in the Zambezi valley. In Harare and Bulawayo the risk is negligible. Resistance to chloroquine reported.

Recommended prophylaxis: for the Zambezi valley, see 3.8.2 above. For other infected areas, chloroquine plus proguanil.




3.9 Indian Subcontinent

(Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, Sri Lanka)

3.9.1 Disease Risks

Food and water-borne diseases including cholera and other watery diarrhoeas, the dysenteries, typhoid fever, giardia and helminth infections.Hepatitis A very common. Large outbreaks of hepatitis E can occur.

Malaria present in all countries, except virtually eradicated from the Maldives.

Other arthropod-borne diseases endemic (see Chapter 7):

• Filariasis - common in Bangladesh, India and SW coastal belt of Sri Lanka
• Sandfly fever - increasing.
• Visceral leishmaniasis - sharp increase in Bangladesh, India and Nepal; also present in north Pakistan (Baltistan).
• Cutaneous leishmaniasis - India (Rajasthan) and Pakistan.
• Dengue - epidemics in Bangladesh, India (haemorrhagic in East), Pakistan and Sri Lanka (also haemorrhagic form).
• Japanese encephalitis occurs in much of the subcontinent. The risk is highest during and just after the rainy season.
• Plague - some natural foci in the area.
• Tick-borne and louse-borne relapsing fever and scrub typhus reported from India.

Diseases of close association:

• Polio eradication activities are as yet incomplete. Polio should still be assumed to be a risk to travellers.
• Meningococcal meningitis - outbreaks have occurred in Nepal.
• Tuberculosis incidence high.
• Trachoma in India, Nepal and Pakistan.

Sexually transmitted and blood-borne infections:

Hepatitis B of intermediate prevalence; HIV becoming more widespread.

Other hazards could include:

• Snakes.
• Rabies.

3.9.2 Recommendations for immunisations and malaria chemoprophylaxis (see later chapters for general health precautions)

FOR ALL COUNTRIES

Check routine immunisations including tetanus.

Immunisation against poliomyelitis, hepatitis A and typhoid.

For longer term travellers, check BCG status, and consider immunisation against diphtheria, hepatitis B and rabies.

For rural travel, usually for more than one month, particularly during and just after the rainy seasons, consider immunisation against Japanese encephalitis (see individual countries for risk). The vaccine is not necessary for the majority of travellers to the Indian subcontinent.

3.9.3 Country by country variations and malaria chemoprophylaxis:

Bangladesh

Yellow fever - any person (including infants) who arrives by air or sea without a yellow fever certificate is detained in isolation for a period of up to six days if arriving within six days of departure from an infected area or having been in transit in such an area, or having come by an aircraft that has been in an infected area and has not been disinsected in accordance with the procedure and formulation laid down in Schedule VI of the Bangladesh Aircraft (Public Health) Rules 1977 (First Amendment) or those recommended by WHO.

The following countries and areas are regarded as infected:

• Africa: Angola, Benin, Burkina Faso, Burundi, Cameroon, Central African Republic, Chad, Congo, Democratic Republic of Congo, Equatorial Guinea, Ethiopia, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Ivory Coast,Kenya, Liberia, Malawi, Mali, Mauritania, Niger, Nigeria, Rwanda, Sao Tome and Principe, Senegal, Sierra Leone, Somalia, Sudan (south of 15oN), Tanzania, Togo,Uganda, Zambia.
• America: Belize, Bolivia, Brazil, Colombia, Costa Rica, Ecuador, French Guiana, Guatemala, Guyana, Honduras, Nicaragua, Panama, Peru, Surinam, Trinidad and Tobago, Venezuela.

Note: when a case of yellow fever is reported from any country, that country is regarded by the Government of Bangladesh as infected with yellow fever and is added to the above list.

Japanese encephalitis probably widespread but few data are available.

Malaria risk throughout the year in the whole country excluding Dhaka city. Risk highest along the northern and eastern borders and in the South East (Chittagong Hill Tracts). P.falciparum highly resistant to chloroquine reported in the south-east and resistant to sulphadoxine-pyrimethamine reported from these latter areas.

Recommended prophylaxis: chloroquine plus proguanil; mefloquine (or doxycycline or atovaquone/proguanil) is appropriate for anyone visiting forested areas in the south east (including the Chittagong Hill Tracts).

Bhutan

Yellow fever vaccination certificate required from travellers coming from infected areas.

Meningococcal A&C vaccine recommended for all visits longer than a few days.

Japanese encephalitis may occur in the south, but few data are available.

Malaria risk throughout the year in the southern belt of five districts: Chirang, Gaylegphug, Samchi, Samdrupjongkhar and Shemgang. P.falciparum resistant to chloroquine and sulphadoxine-pyrimethamine reported.

Recommended prophylaxis: for risk areas in the southern districts, chloroquine plus proguanil.

India

Yellow fever - anyone (except infants up to the age of six months) arriving by air or sea without a yellow fever certificate is detained in isolation for up to six days if that person

1. arrives within six days of departure from an infected area, or
2. has been in such an area in transit (excepting those passengers and members of crew who, while in transit through an airport situated in an infected area, remained within the airport premises during their entire stay and the Health Officer agrees to such exemption), or
3. has come on a ship that started from or touched at any port in a yellow fever infected area up to 30 days before its arrival in India, unless such a ship has been disinsected in accordance with the procedure laid down by WHO, or
4. has come by an aircraft which has been in an infected area and has not been disinsected in accordance with the provisions laid down in the Indian Aircraft Public Health Rules, 1954, or those recommended by WHO.

The following countries and areas are regarded as infected:

• Africa: Angola, Benin, Burkina Faso, Burundi, Cameroon, Central African Republic, Chad, Congo, Democratic Republic of Congo, Equatorial Guinea, Ethiopia, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Ivory Coast,Kenya, Liberia, Mali, Niger, Nigeria, Rwanda, Sao Tome and Principe, Senegal, Sierra Leone, Somalia, Sudan, Tanzania, Togo,Uganda, Zambia.
• America: Bolivia, Brazil, Colombia, Ecuador, French Guiana, Guyana, Panama, Peru, Surinam, Trinidad and Tobago, Venezuela.

Note: when a case of yellow fever is reported from any country, that country is regarded by the Government of India as infected with yellow fever and is added to the above list.

Japanese encephalitis risk highest in central and north east India in the summer and autumn and in parts of the rural south all year round (see recommendations for all countries above).

Malaria risk throughout the year in the whole country below 2,000m. Urban transmission occurs. No transmission in certain parts of the states of Himachal Pradesh, Jammu and Kashmir, and Sikkim. Predominantly P.vivax, but P.falciparum is also important and mixed infections often occur. Highly chloroquine resistant P.falciparum reported.

Recommended prophylaxis: chloroquine plus proguanil except in mountain areas.

Maldives

Yellow fever vaccination certificate required from travellers coming from infected areas.

Malaria prophylaxis: none - malaria eradicated.

Nepal

Yellow fever vaccination certificate required from travellers coming from infected areas.

Meningococcal A&C vaccine recommended for all visits longer than a few days.

Japanese encephalitis occurs in the lowlands only, usually July-December (see recommendations for all countries).

Malaria risk, predominantly P.vivax, throughout the year in rural areas of the Terai districts (incl. forested hills and forest areas) of Dhanukha, Mahotari, Sarlahi, Rautahat, Bara, Parsa, Rupendehi,Kapilvastu, and especially along the Indian border. These are the lowland and foothill areas towards the southern border of the country and include the Chitwan National Park. No risk in Kathmandu. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: in risk areas, chloroquine plus proguanil.

Pakistan

Yellow fever vaccination certificate required from travellers coming from any part of a country in which yellow fever is endemic; infants under six months of age are exempt if the mother's vaccination certificate shows that she was vaccinated before the birth of the child. The countries and areas included in the endemic zones are considered as infected areas.

Japanese encephalitis may occur in the central area and outside Karachi, but few data available.

Malaria risk throughout the year in the whole country below 2,000m. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: chloroquine plus proguanil.

Sri Lanka

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas.

Japanese encephalitis can occur in lowland areas, especially northern and central provinces, usually October-January, but possibly also May-June (see 3.9.2).

Malaria risk, predominantly P.vivax, throughout the year in the whole country excluding the districts of Colombo,Kalutara and Nuwara Eliya. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: chloroquine plus proguanil. None in Colombo and districts listed.




3.10 South East Asia and the Far East

(Borneo (see Indonesia and Malaysia), Brunei Darussalam, Burma (see Myanmar), Cambodia, China (including Tibet), East Timor, Hong Kong (see China), Indonesia (including Bali and southern Borneo), Japan,Korea, Laos, Macao (see China), Malaysia (Peninsular Malaysia and northern Borneo, including Sarawak and Sabah), Mongolia, Myanmar (formerly Burma), the Philippines, Singapore, Taiwan, Thailand, Tibet (see China), Vietnam)

3.10.1 Disease risks

Food and water-borne diseases including cholera and other watery diarrhoeas, amoebic and bacillary dysentery, typhoid fever and hepatitis A and E. Flukes and intestinal parasites common among the indigenous population.

Malaria endemicity varies greatly but multidrug resistant P.falciparum common and specialist advice about appropriate prophylaxis may be necessary. See individual countries below.

Other arthropod-borne diseases (see Chapter 7) are an important cause of morbidity:

• Japanese encephalitis - endemic in rural areas; occasional urban outbreaks have been reported.
• Dengue - urban and rural epidemics occur.
• Filariasis - rural parts of many countries.
• Visceral leishmaniasis - recent resurgence in China.
• Cutaneous leishmaniasis - recently reported from Xinjiang.
• Plague in Vietnam, Myanmar, Mongolia, Indonesia and China; not usually a risk to tourists.
• Louse-borne relapsing fever.
• Lyme disease in some temperate regions.
• Scrub typhus and tularaemia.

Diseases of close association:

• Poliomyelitis - Polio eradication activities have rapidly reduced polio transmission in parts of this area. Elimination of polio reported in Brunei, Japan,Korea and Singapore. Transmission interrupted in China and probably interrupted in Indonesia, Laos, Malaysia, Myanmar, Philippines and Thailand. Mongolia no longer reports cases. There remains a focus of polio transmission in the Mekong Delta area of Cambodia and South Vietnam.
• Meningococcal infection - outbreaks of meningitis have occurred in Mongolia.
• Tuberculosis - incidence generally high, with some exceptions (such as Japan).

Sexually transmitted and blood-borne infections:

Hepatitis B of high prevalence; HIV endemic and spreading.

Other hazards could include:

• Schistosomiasis (bilharziasis) endemic in southern Philippines, central Sulawesi (Indonesia) and central Chang Jiang (Yangtze) river basin in China; small foci in Mekong delta in Vietnam.
• Rabies, snake bites and leeches.

3.10.2 Recommendations for immunisations and malaria chemoprophylaxis (see later chapters for general health precautions)

FOR ALL COUNTRIES

Check routine immunisations including tetanus.

Immunisation against poliomyelitis, hepatitis A and typhoid, noting that typhoid and/or hepatitis A may be less important for short stays in business or tourist hotels.

For longer term travellers, check BCG status and consider immunisation against diphtheria, hepatitis B and, for longer rural travel, rabies.

Japanese encephalitis immunisation (for individual countries see below) for rural travel, usually over one month. Less risk in dry seasons. Not recommended for most travellers.

3.10.3 Country by country variations and malaria chemoprophylaxis:

Borneo - see Indonesia and Malaysia

Brunei Darussalam

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas or who have passed through partly or wholly endemic areas within the preceding six days. The countries and areas included in the endemic zones are considered infected areas.

Japanese encephalitis - rural areas only; assume year round transmission.

Malaria: may be slight risk in border areas.

Recommended prophylaxis: none.

Burma - see Myanmar

Cambodia

Yellow fever vaccination certificate required from travellers coming from infected areas.

Japanese encephalitis - consider immunisation for some situations (see 3.10.2 above). Transmission season likely to be May-October.

Malaria risk, predominantly P.falciparum, throughout the year in the whole country except Phnom Penh area and close to Tonle Sap. Malaria does occur in the tourist area of Angkor Wat. P.falciparum highly resistance to chloroquine and resistant to sulphadoxine-pyrimethamine reported. Resistance to mefloquine also reported from western provinces.

Recommended prophylaxis: mefloquine, or doxycycline or atovaquone/proguanil (see 6.5); but mefloquine not suitable for western border areas.

China (including Hong Kong and Macao Special Administrative Regions)

Yellow fever vaccination certificate required from travellers coming from infected areas.

Japanese encephalitis in central and southern China, April/May-October; for northern China, the season is shorter. Consider immunisation in certain situations (see 3.10.2 above).

Malaria risk, predominantly P.vivax, below 1,500m in Fujian, Guangdong, Guangxi, Guizhou, Hainan, Sichuan, Xingjjang (only along the valley of the Yili river), Xizang (only along the valley of the Zangbo river in the extreme south) and Yunnan. Very low risk in Anhui, Hubei, Hunan, Jiangsu, Jiangxi, Shandong, Changhai and Zhejiang.Where transmission exists it occurs: north of 33oN, from July to November; between 33°N and 25°N, from May to December; and south of 25°N, throughout the year. Multidrug-resistant P.falciparum present in Hainan and Yunnan.

Recommended prophylaxis: main tourist areas - none; rural risk areas, chloroquine, except for Hainan and Yunnan provinces where mefloquine or doxycycline or atovaquone/proguanil (see 6.5) are the preferred drugs.

East Timor

Malaria risk- predominatly P. falciparum throughout the year in the whole territory. P.falciparum resistant to chloroquine and sulphadoxine pyrimethamine reported.

Recommended prophylaxis: mefloquine or doxycycline or atovaquone/proguanil (see 6.5)

Hong Kong and Macao, Special Administrative Regions of China

Malaria - No risk considered to exist in urban and most rural areas of Hong Kong. No risk in Macao.

Recommended prophylaxis: none.

Indonesia (including Bali and central/southern Borneo)

Yellow fever vaccination certificate required from travellers coming from infected areas. The countries and areas included in the endemic zones are considered by Indonesia as infected areas.

Japanese encephalitis probably year round. Consider immunisation in certain situations (see 3.10.2).

Malaria risk throughout the year in the whole country except in Jakarta Municipality, big cities, and the main tourist resorts of Java and Bali. P.falciparum highly resistant to chloroquine and resistant to sulphadoxine-pyrimethamine reported. P.vivax resistant to chloroquine is also reported in Irian Jaya.

Recommended prophylaxis: for Jakarta, big cities and main resort areas of Java and Bali, none, but remember the slight risk; for other areas, chloroquine plus proguanil. Mefloquine preferred for Irian Jaya.

Japan

Japanese encephalitis immunisation only recommended for rural travel, June-September (or April-October for south (Okinawa)) (see 3.10.2 above).

Korea (Democratic People's Republic of Korea and Republic of Korea)

Japanese encephalitis - immunisation only recommended for rural travel, July-October. (See 3.10.2).

Malaria - limited risk (exclusively P.vivax) in northern Kyunggi Do province.

Recommended prophylaxis: none.

Laos

Yellow fever vaccination certificate required from travellers coming from infected areas.

Japanese encephalitis, presumed season May-October. Immunisation recommended in certain circumstances (see 3.10.2 above).

Malaria risk, predominantly P.falciparum, throughout the year in the whole country except Vientiane. Highly chloroquine resistant P.falciparum reported.

Recommended prophylaxis: mefloquine or doxycycline or atovaquone/proguanil.

Malaysia (Peninsular Malaysia, northern part of Borneo including Sarawak and Sabah)

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas. The countries and areas included in the endemic zones are considered as infected areas.

Japanese encephalitis - year round transmission. Consider immunisation in certain circumstances (see 3.10.2).

Malaria risk limited to small foci in deep hinterland. Urban and coastal areas free from malaria except in Sabah where risk (predominantly P.falciparum) throughout the year. P.falciparum highly resistant to chloroquine and resistant to sulphadoxinepyrimethamine reported.

Recommended prophylaxis: Peninsular Malaysia and Sarawak - none except for deep forests where chloroquine and proguanil; Sabah - mefloquine; alternatives doxycycline or atovaquone/proguanil (see 6.5); for shorter stays chloroquine plus proguanil is an acceptable alternative, but this regimen provides less protection.

Mongolia

Meningococcal vaccine recommended for longer visits.

Myanmar (formerly Burma)

Yellow fever vaccination certificate required from travellers coming from infected areas. Nationals and residents of Myanmar are required to possess certificates of vaccination on their departure to an infected area.

Japanese encephalitis - presumed season May-October. Consider immunisation in certain circumstances (see 3.10.2).

Malaria risk, predominantly P.falciparum, below 1,000 m

1. throughout the year in Karen State;
2. from March to December in Chin,Kachin,Kayah, Mon, Rakhine, and Shan States, Pegu Div., and Hlegu, Hmawbi, and Taikkyi townships of Yangon (formerly Rangoon) Div.;
3. from April to December in rural areas of Tenasserim Div.;
4. from May to December in Irrawaddy Div. and the rural areas of Mandalay Div.;
5. from June to November in the rural areas of Magwe Div., and in Sagaing Div.

P.falciparum highly resistant to chloroquine and resistant to sulfadoxinepyrimethamine reported. P.vivax resistant to chloroquine reported.

Recommended prophylaxis: chemoprophylaxis is needed throughout Myanmar. For most of the country, mefloquine or doxycycline or atovaquone/proguanil. Doxycycline or atovaquone/proguanil on the Thai border.

Philippines

Yellow fever vaccination certificate required from travellers over one year of age arriving within six days from infected areas.

Japanese encephalitis - probably year round. Consider immunisation in certain circumstances (see 3.10.2).

Malaria risk throughout the year in rural areas below 600m, except for the provinces of Bohol, Catanduanes, Cebu and metropolitan Manila. The risk is low in the provinces of Aklan, Biliran, Camiguin, Capiz, Guimaras, Iloilo, Leyte del sur, Northern Samar, and Sequijor. Negligable risk in urban areas and the plains. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: for rural areas other than the four areas listed above, chloroquine plus proguanil; for other areas none, but be aware of the risk.

Singapore

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas. Certificates of vaccination are required from travellers over one year of age who, within the preceding six days, have been in or have passed through any country partly or wholly endemic for yellow fever. The countries and areas included in the endemic zones are considered as infected areas.

No malaria risk.

Recommended prophylaxis: none.

Taiwan

Japanese encephalitis - rural areas only, April-October. Consider immunisation in certain circumstances (see 3.10.2).

No malaria risk.

Recommended prophylaxis: none.

Thailand

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas. The countries and areas included in the endemic zones are considered as infected areas.

Japanese encephalitis - highest risk May-October. Consider immunisation in certain circumstances (see 3.10.2).

Malaria - no risk in cities nor in the main tourist resorts (such as Bangkok, Chiangmai, Pattaya, Phuket, Samui). Elsewhere there is malaria risk throughout the year. The risk is very low in the central plain, greater in forested and hilly areas of the country, especially in the areas bordering Myanmar, Laos and Cambodia. P.falciparum is highly resistant to chloroquine and sulphadoxine-pyrimethamine, and at the Myanmar and Cambodian borders also shows resistance to mefloquine and quinine.

While the city of Chiangmai is malaria-free, tourists commonly visit forested areas near the Myanmar border where there is a risk if they are there for an evening or night; some tourist hotels in NW Thailand are also very close to the forest. However, the combination of limited risk and resistance to several antimalarials means that most tourists will be advised not to take chemoprophylaxis; they must be made aware of the risk and that they must urgently seek prompt diagnosis and treatment in the event of fever during or up to a year after their visit.

Recommended prophylaxis: Bangkok and main tourist areas, none.Day visits to forested areas, none but be aware of the risk. Longer stays in rural areas with forests, and in border areas with Laos, Myanmar or Cambodia, doxycycline or atovaquone/ proguanil.

Vietnam

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas.

Japanese encephalitis - Hanoi city and rural areas, highest risk May-October (see recommendations for all countries (3.10.2)).

Malaria risk, predominantly P.falciparum, in the whole country except urban centres, the Red River Delta, and coastal plains north of Nha Trang. High-risk areas are the two southernmost provinces of the country, Ca Mau and Bac Lieu, and the highland areas below 1,500m south of 18°N. P.falciparum highly resistant to chloroquine and resistant to sulphadoxine-pyrimethamine reported.

Recommended prophylaxis: mefloquine or doxycycline or atovaquone/proguanil in the risk areas.




3.11 Pacific Islands

(American Samoa, Cook Islands, Easter Island, Fiji, French Polynesia (Tahiti), Guam, Kiribati, Marshall Islands, Micronesia (Federated States of), Nauru, New Caledonia, Niue, Palau, Papua New Guinea, Samoa, Solomon Islands, Tokelau, Tonga, Trust Territory of the Pacific Islands, Tuvalu, Vanuatu and the Wallis and Futuna Islands)

3.11.1 Disease risks

Food and water-borne diseases:

Diarrhoeal diseases, typhoid fever, helminth infections and hepatitis A. Biointoxication may occur from raw or cooked fish or shellfish.

Malaria - endemic in Papua New Guinea, the Solomon Islands, and Vanuatu. Not in fiji nor in islands to the north, to French Polynesia and Easter Island in the east and to New Caledonia in the south (ie present in Melanesia, but absent from Polynesia and Micronesia due to absence of the vector mosquito).

Other arthropod-borne diseases (see Chapter 7):

• Filariasis - widespread but variable prevalence
• Dengue and dengue haemorrhagic fever - epidemics can occur in most islands
• Japanese encephalitis reported in the past from some islands including Guam, Saipan and recently from Papua New Guinea.
• Ross River fever
• Scrub typhus, mainly Papua New Guinea.

Diseases of close association:

• Poliomyelitis - poliomyelitis cases have not been reported from any of these areas for more than five years.
• Tuberculosis - variable incidence throughout the region - higher in Papua New Guinea.

Sexually transmitted and blood-borne infections:

Hepatitis B of intermediate to high prevalence and HIV reported.

Other hazards could include:

For sea bathers, corals, jellyfish, poisonous fish and sea snakes.

3.11.2 Recommendations for immunisations and malaria chemoprophylaxis (see later chapters for general health precautions)

FOR ALL COUNTRIES

Check routine immunisations including tetanus.

Immunisation against poliomyelitis, hepatitis A and typhoid.

For long term travellers, consider immunisation against diphtheria and hepatitis B and check BCG status.

3.11.3 Country by country variations and malaria chemoprophylaxis:

Fiji

Yellow fever vaccination certificate required from travellers over one year of age entering Fiji within ten days of having stayed overnight or longer in infected areas.

French Polynesia (Tahiti)

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas.

Kiribati

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas.

Nauru

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas.

New Caledonia and dependencies

Yellow fever vaccination certificate required from travellers over one year old coming from infected areas.

Cholera - vaccination against cholera is not required. Travellers coming from an infected area are not given chemoprophylaxis, but are required to complete a form for use by the Health Service.

Niue

Yellow fever vaccination certificate required from travellers over one year old coming from an infected area.

Palau

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas or from countries in any part of which yellow fever is endemic.

Papua New Guinea

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas.

Malaria - high risk, predominantly P.falciparum, throughout the year in the whole country below 1,800m. P.falciparum highly resistant to chloroquine and resistant to sulphadoxine-pyrimethamine reported.

Recommended prophylaxis: mefloquine or doxycycline or atovaquone/proguanil, or if these contra-indicated, maloprim plus chloroquine.

Japanese encephalitis - probably year-round risk. Consider immunisation for visits over one month to rural areas.

Samoa

Yellow fever vaccination certificate required from travellers over one year old coming from infected areas.

Solomon Islands

Yellow fever vaccination certificate required from travellers coming from infected areas.

Malaria - high risk throughout the year except in some eastern and southern outlying islets. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: mefloquine or doxycycline or atovaquone/proguanil, or if these contra-indicated, maloprim plus chloroquine.

Tonga

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas.

Vanuatu

Malaria - low to moderate risk, predominantly P.falciparum, throughout the year in the whole country. P.falciparum highly resistant to chloroquine and resistant to sulphadoxine-pyrimethamine reported.

Recommended prophylaxis: mefloquine or doxycycline or atovaquone/proguanil, or if these contra-indicated, maloprim plus chloroquine.