Preparing for potential risks of travel related illnesses:

Cholera is a disease caused as a result of the bacteria Vibrio cholerae. It thrives in areas with poor sanitation and lack of access to safe drinking water. Any consumption of food or drink contaminated by the cholera bacteria can lead to the contraction of the disease. In a few cases, cholera can lead to death if the victim is dehydrated due to loss of fluids and electrolytes. Most international travelers do not get cholera because they do not visit areas with active cholera transmission and usually have good access to safe food and water. Cholera is found in countries around the world but is extremely rare in the United States and other industrialized nations.

Prevention:

A licensed cholera vaccine is available in the United States for adults 18-64 years old. It prevents severe diarrhea caused by the most common types of cholera-causing bacteria and should be administered at least 10 days prior to any potential cholera exposure. The vaccine is not 100% effective. In addition to vaccination, travelers should take steps to reduce their risk by:

• Choosing food and drinks carefully
  • Only eat foods that are cooked and served hot
  • Avoid food that has been sitting on a buffet
  • Eat raw fruits and vegetables only if you have washed them in clean water or peeled them
  • Only drink beverages from factory-sealed containers
  • Avoid ice because it may have been made from unclean water
  • Drink pasteurized milk
• Wash hands carefully
  • Wash hands often with soap and water for 20 seconds, especially after using the bathroom and before eating
  • If soap and water aren’t available, use an alcohol-based hand sanitizer that contains at least 60% alcohol
  • Keep your hands away from your face and mouth

Hepatitis A is a virus that often results in liver disease. Hepatitis A virus is found in the stool and the blood of infected individuals. It is a highly communicable disease. Symptoms appear quickly and could include fever, fatigue, loss of appetite, nausea, vomiting, abdominal pain, dark urine, diarrhea, clay-colored bowel movements, joint pain and jaundice (yellowing of the skin and eyes). You could be infected with hepatitis A if you engage in any of the following:

• Consumption of food or drink contaminated with hepatitis A
• Contact with objects contaminated by the virus followed by direct contact to mouth
• Direct and personal contact with infected individuals
• Sexual intercourse with infected individuals

Hepatitis A is a common disease in countries throughout the world. Anyone who has not been vaccinated or had hepatitis A infection before can get infected. Travelers are more likely to get infected with hepatitis A if they visit rural areas, trek in backcountry areas, or frequently eat or drink in settings of poor sanitation. However, even travelers who stay in urban areas, resorts, or luxury hotels, who wash their hands regularly, and who choose food and drinks carefully have been infected when visiting countries where hepatitis A is common.

Prevention:

The best way to prevent exposure and infection of the virus is to get vaccinated. The vaccine for hepatitis A is extremely effective and has been a routine childhood vaccine since 1996. It is recommended for travelers above the age of 6 months to countries where hepatitis A is prevalent. It is administered in 2 or 3 doses; with a minimum of 1 as soon as possible before you travel. Travelers allergic to a component or are below 6 months of age should be administered a single dosage of immune globulin which provides sufficient protection for up to 2 months depending on the dosage.

Hepatitis B is a virus that causes liver disease. Hepatitis B virus is found in the blood and body fluids of infected people. People infected with hepatitis B can spread it to others. Early symptoms of hepatitis B can include fever, fatigue, loss of appetite, nausea, vomiting, abdominal pain, dark urine, clay-colored bowel movements, joint pain, and jaundice (yellow color in the skin or the eyes). Some infected individuals develop lifelong hepatitis B. The long-term health effects caused by chronic hepatitis B infection can cause people to die early from liver disease and liver cancer. You can be infected with hepatitis B virus if you:

• Have sexual intercourse with an infected partner
• Use of needles, syringes, or drug preparation equipment that are shared with an infected person
• Sharing of personal care items such as razors, toothbrushes, or medical equipment with an infected individual
• Acquire a wound with a sharp instrument or have a needlestick injury in a health care setting
• Direct contact the blood or open sores of an infected individual

Hepatitis B occurs in nearly every part of the world but is more common in some countries in Asia, Africa, South America and the Caribbean. This map shows the worldwide prevalence of hepatitis B virus infection. Although the risk to most travelers is low, medical tourists (people who travel for medical purposes) or people who need emergency medical care while traveling may be more likely to get infected.

Prevention:

Getting vaccinated is the best way to protect against hepatitis B. Hepatitis B is a routine vaccination that most people undergo during infancy in the US at birth. The vaccine has proved to be 90% effective at preventing contraction and has been recommended for infants since 1991. The vaccine is recommended for travelers of all ages with plans to travel to countries where hepatitis B is common.

Japanese encephalitis (JE) is a sickness spread through mosquito bites. Its symptoms usually take around 5-15 days to develop and could include fever, headache, vomiting, confusion, and difficulty moving. Symptoms that develop later include swelling around the brain and coma. JE is a serious disease that could be fatal. Travelers who go to Asia are at risk for getting Japanese encephalitis (See map). For most travelers the risk is extremely low but depends on where you are going, the time of year, your planned activities, and the length of the trip. You are at higher risk if you are traveling to rural areas, will be outside frequently, or will be traveling for a long period of time.  In mild climates in northern Asia the risk for JE is greater in the summer and fall. In tropical and subtropical areas, there is a risk year-round.

Prevention:

In addition to bug bite prevention, travelers may choose to get vaccinated against JE. There is one JE vaccine available in the US. It is approved for use in individuals older than 2 months of age. The JE vaccine is administered in two doses, spaced 28 days apart. Individuals 18 to 65 years of age can shorten this buffer period to seven days and all must finish the last dose at least a week before travel. A third dose should ideally be taken if the person has taken the 2-dose primary vaccine a year or more as they risk re-exposure.

Malaria results from a parasite that is spread by mosquitoes. Symptoms appear between 7 to 3 days but in a few cases can take up to a year to display fully. These could include high fevers, chills and flu. If not treated, Malaria can result in severe illness or even death. The mosquitoes that spread malaria are found in Africa, Central and South America, parts of the Caribbean, Asia, Eastern Europe, and the South Pacific (See maps: Eastern Hemisphere and Western Hemisphere). Travelers going to these countries may get bit by mosquitoes and get infected. About 2,000 cases of malaria are diagnosed in the United States annually, mostly among returned travelers.

Prevention:

There is no vaccine for malaria. Travelers can safeguard themselves by preventing mosquito bites and taking medication to protect against malaria. There are six different malaria medications available. The one that’s right for you depends on your trip and other factors. Depending on the medicine, individuals will have to start taking it several days before the trip as well as during and after. Consultation with a doctor is a must. If bitten by mosquitoes, avoid itching the bites and apply hydrocortisone cream to reduce irritation.

Meningococcal disease is a result of bacteria called Neisseria meningitidis. This disease is communicable through direct personal contact like kissing, sharing living spaces etc. Individuals with this disease require immediate medical attention and symptoms vary depending on the type of illness. Some common symptoms of meningococcal meningitis include headaches, sudden fever and a stiff neck as well as nausea, vomiting, confusion and heightened sensitivity to light. Symptoms may present differently in children and infants. The bacteria that cause this disease may also infect the blood and cause septicemia. The symptoms of this include chills, fatigue, vomiting, severe aches and pains, diarrhea, dark rash, and rushed breathing. This disease can also lead to death in a few cases in as little as a few hours. Anyone can get meningococcal disease, but people who live or travel to certain areas of the world are more likely to get it. The “meningitis belt” of sub-Saharan Africa has the highest rates of meningococcal disease in the world. The disease is more common in this part of Africa during the dry season (December through June). Travelers who spend a lot of time with local populations in the meningitis belt, especially during outbreaks of meningococcal disease, are more likely to get this disease. Participants in the Hajj or Umrah pilgrimages in Saudi Arabia are also more likely to get sick.

Prevention:

A vaccine is the best way to protect yourself from the meningococcal disease. There are two types of meningococcal vaccines available in the United States:

• Meningococcal ACWY (MenACWY) vaccine
• Serogroup B meningococcal (MenB) vaccine
• MenACWY is a routine vaccination administered to 11–12-year-olds followed up by a booster shot at 16. MenB is administered to teens and young adults at 16-18 years old. Depending on the travel plans, younger children and adults may also need a MenACWY and those vaccinated previously might require a booster shot.  It takes a buffer period of 7-10 days after vaccination to enable maximum protection against the disease. Consult with a doctor to get your personalized recommendation.

Rabies is a fatal disease caused by a virus that spreads through the saliva of infected animals. All mammals are susceptible to rabies. People typically get rabies from licks, bites, or scratches from infected dogs and other animals such as bats, foxes, raccoons, and mongooses. Rabies impacts the central nervous system, ultimately resulting in brain disease and death. Once symptoms of rabies make themselves known, the disease is nearly always fatal, making prevention paramount. Rabid dogs are a problem in many countries around the world, including most of Africa, Asia, and parts of Central and South America. Although any mammal can transmit rabies, dog bites are how most travelers get rabies. Factors that may increase a traveler’s chances of rabies infection include:

• Camping or exploring caves (spelunkers)
• Working with animals (veterinarians, animal handlers, field biologists, or laboratory workers handling animal specimens)
• Long-term travelers and expatriates
• Children are more likely to get infected because they often play with animals and may not report bites.

Rabies in dogs is rare in the United States, Australia, Canada, Japan, and most European countries.

Prevention:

In addition to practicing good animal safety, some travelers should get vaccinated against rabies. Rabies vaccine is administered to people at high risk of rabies to protect them should they be exposed. People at high risk of exposure to rabies should be offered a pre-exposure rabies vaccination. For pre-exposure protection, 3 doses of rabies vaccine are recommended. People who may be repeatedly susceptible to rabies virus should receive periodic testing for immunity, and booster doses may be necessary. Rabies vaccine can prevent rabies if given to a person after they have had an exposure, before symptoms appear. Anyone who has been bitten by an animal suspected to have rabies or has been exposed to it should clean the wound and visit a medical professional immediately regardless of vaccination status.

Tickborne encephalitis is a viral disease that affects the central nervous system. The virus is found across many parts of Europe and Asia and typically spreads to humans either through the bite of an infected tick or through consumption of unpasteurized dairy products from infected livestock (goats, sheep, or cows). The disease is not known to spread from person to person, except for an infected pregnant mother passing it to her fetus. Tickborne encephalitis infection is most common from April through November, when ticks are most active. Travelers whose plans include camping, hiking, and hunting are more likely to be exposed to the virus. Although most people who get infected with tickborne encephalitis do not get sick, symptoms can be serious and sometimes deadly. Possible symptoms include:

• Fever
• Aches
• Loss of appetite
• Headache
• Nausea/vomiting
• Swelling of brain and/or spinal cord
• Confusion or sensory disturbances

Prevention

Currently, the best way to protect against tickborne encephalitis is to prevent tick bites and avoid unpasteurized dairy products. Ticks are found in grassy, brushy, wooded areas, or on animals. Spending time in these kinds of areas can bring you in contact with ticks. If you do plan on being in areas where ticks are active, you can reduce the risk of being bitten by doing the following:

• Avoiding walking directly through tall grass and brush
• Use an EPA-registered insect repellent
• Treat clothing and gear with permethrin
• Check clothing and gear (and pets!) for ticks when returning indoors
• Shower right after being outdoors

Typhoid fever and paratyphoid fever are similar diseases caused by the bacteria Salmonella Typhi. Salmonella Paratyphi bacteria cause paratyphoid fever. It is a communicable disease. It can be contracted when an infected person uses the bathroom and does not wash their hands. The bacteria can remain on their hands and subsequently contaminate everything that the person touches, including any food and drinks. In countries with poor sanitation, the water used to rinse and prepare food and beverages can also be contaminated with these bacteria. Travelers who consume foods or drinks contaminated with these bacteria are susceptible to the disease. Typhoid fever and paratyphoid fever cause similar symptoms. People with these diseases usually have a fever that may go as high as 103–104°F (39–40°C). They also may exhibit weakness, stomach pain, headache, diarrhea or constipation, cough, and loss of appetite. Some people have a rash of flat, rose-colored spots.  Internal bleeding and death may occur but are rare.

Prevention:

Two typhoid vaccines are available in the US currently:

• Pill vaccine. People 6 years+ can take the pill vaccine. All four pills (1 pill every other day) must be taken at least a week before travel.
• Shot vaccine. People 2 years+ can receive the shot vaccine. One shot (or a booster shot) must be taken at least 2 weeks before travel.

Unfortunately, neither the typhoid pills nor shot can offer complete protection against infection (50%-80%) and both lose effectiveness over time. Also, there isn’t a vaccine that prevents paratyphoid fever. For these reasons, it is very important that you also take the following steps to prevent typhoid:

Choose food and drinks carefully

• Only eat foods that are cooked and served hot
• Avoid food that has been sitting open on a buffet
• Eat raw fruits and vegetables only if they have been washed in clean water or peeled
• Only consume beverages from factory-sealed containers
• Avoid ice as it may have been made from unclean water
• Only consume pasteurized milk

Wash your hands

• Wash hands frequently with soap and water for 20 seconds, especially after using the bathroom and before eating
• If soap and water aren’t available, use an alcohol-based hand sanitizer that contains a minimum of 60% alcohol
• Keep your hands away from your face and mouth

Yellow fever is a disease caused by a type of virus that is spread through mosquito bites. Symptoms take about 3–6 days to develop and include fever, chills, headache, backache, and muscle aches. Around 15% of people who contract yellow fever develop serious illnesses that could lead to bleeding, shock, organ failure, and sometimes even death. Travelers to certain parts of South America and Africa are at risk for yellow fever.

Prevention:

In addition to avoiding mosquito bites, travelers may be required or recommended the yellow fever vaccine. Yellow fever vaccine is a live vaccine containing a weakened, live yellow fever virus. It is administered as a single shot. A single dose provides lifelong protection for most people. Yellow fever vaccine is provided only at designated vaccination centers. After receiving the vaccine, you will be given an “International Certificate of Vaccination or Prophylaxis” (ICVP, also called the “yellow card”). You will need this card as proof of vaccination to be able to enter certain countries. If you don’t have it, you might be required to get yellow fever vaccine upon entering the country or be forced to wait for up to 6 days to ensure that you are not infected. Do not donate blood for 14 days after vaccination as there stands a risk of passing vaccine virus to others during that period.