102 November 2016 Pulse Pulse November 2016 103

travel medicine guide

Tick-borne encephalitis

Recommended

regimen

Alternative regimen

Risk areas

and seasons

Main parasitic hazards

Japanese enceph

Mening/ACWY

Yellow fever

Rabies

Hepatitis B

Tuberculosis

DiptheriaPolio

Cholera

Hepatitis A

Typhoid

Malaria

Destination

Tick-borne encephalitis

Recommended

regimen

Alternative regimen

Risk areas

and seasons

Main parasitic hazards

Japanese enceph

Mening/ACWY

Yellow fever

Rabies

Hepatitis B

Tuberculosis

DiptheriaPolio

Cholera

Hepatitis A

Typhoid

Malaria

Destination

Tick-borne encephalitis

Recommended

regimen

Alternative regimen

Risk areas

and seasons

Main parasitic hazards

Japanese enceph

Mening/ACWY

Yellow fever

Rabies

Hepatitis B

Tuberculosis

DiptheriaPolio

Cholera

Hepatitis A

Typhoid

Malaria

Destination

Tick-borne encephalitis

Recommended

regimen

Alternative regimen

Risk areas

and seasons

Main parasitic hazards

Japanese enceph

Mening/ACWY

Yellow fever

Rabies

Hepatitis B

Tuberculosis

DiptheriaPolio

Cholera

Hepatitis A

Typhoid

Malaria

DestinationAbu Dhabi S R S S S No Le Afghanistan R R S R S S S S C Yes, below 2000m, May-Nov ME or Do or AP PC LeAlbania R S S C S No LeAlgeria S R S S S C Yes, low risk vivax in South W Sh LeAngola R R S R S S S M Yes, high risk ME or DO or AP PC Sh TaAntigua & Barbuda S C No Argentina R S S S S Minimal risk in north & Iguaçu W Armenia R S S S S No WAustralia C S No Austria S No Azerbaijan S R S S S S Low risk SW border Jun-Oct W LeBahamas R S C No Bahrain S R S S C No LeBali R R R S S S C S Minimal risk W Bangladesh R R S R S S S C S Yes, SE and Chittagong Hill Tracts. ME or DO or AP PC Le

Elsewhere, low risk W Barbados S S C No Belarus R S S S S No Belize S R S S S C Low risk W Benin Republic R R S S S S S M S Yes, high risk ME or DO or AP PC Sh LeBermuda S No Bhutan R R S S S S C S Yes, southern districts ME or DO or AP DRF LeBolivia R R S S S S R Yes, high risk in Amazon basin. ME or DO or AP PC

Variable risk on Paraguayan and Argentine borders PC DRF

Borneo R R S S S S S C S Minimal risk coastal areas. Low W risk inland Sabah, Sarawak and ME or DO or AP PC all of Indonesian Kalimantan for high risk groups

Bosnia R S S S S S No LeBotswana R R S S S C High risk Northern half ME or DO or AP PC Sh TaBrazil S R R S S S S High risk in NW half in Amazonia ME or DO or AP PC Sh Le Tc

states. Elsewhere, very low W Brunei R S S S C S Minimal risk W Bulgaria R S S S S No Burkina Faso R R S S S S S M S Yes, high risk ME or DO or AP PC Sh Le TaBurundi R R S S S S M S Yes, high risk ME or DO or AP PC Sh TaCambodia R R S S S S C S Yes North-East area DO or AP PC

Low risk elsewhere with ME or DO or AP PC chemoprophylaxis only for high risk groups (see Travax map) Minimal risk Phnom Pehn, W Angkor Wat, Siem Reap and close to Tonle Sap Lake

Cameroon R R S R R S S S M S Yes, high risk ME or DO or AP PC Sh TaCanada S No Cape Verde Islands R R S S S C Yes, very low risk Aug-Nov W LeCayman Islands S No Central African Rep. R R S R S S S M S Yes, high risk ME or DO or AP PC Sh TaChad R R S R S S S R S Yes, high risk ME or DO or AP PC Sh TaChile R S S S No TcChina (Mainland) S R S S S S C S S Yes, in Yunnan W Sh

Elsewhere very low/no risk China (Hong Kong) R S S S No China (Macao) R S S S No Colombia S R S S R Yes, high Eastern half and ME or DO or AP PC Le Ta

coastal areas. Very low around Medellin, W Bogota & Cartagena

Comoros R R S S S S Yes, high risk ME or DO or AP PC LeCongo R R S R S S S M Yes, high risk ME or DO or AP PC Sh TaCongo-Dem. Rep. R R S R S S S M S Yes, high risk ME or DO or AP PC Sh TaCook Islands R S No Costa Rica R S S C Low risk W Le TcCroatia S S No LeCuba R S S S No Cyprus S No LeCzech Republic S S No Djibouti R R S S S S S C Yes, high risk ME or DO or AP PC Sh LeDominican Republic R R S S S S S Yes, high risk along Haitian C P Sh Le

border, variable risk elsewhereDubai S R S S S No Le

East Timor (Timor Leste) R R R S S S C S Yes, high risk ME or DO or AP PC LeEcuador R R S S S S R Yes - high risk coastal provinces and ME or DO or AP PC Tc

on Peru and Colombia borders. Elsewhere low risk W

Egypt R R S S C No El Salvador R R S S S S C Yes, low risk WEquatorial Guinea R R S R R S S S R Yes, high risk ME or DO or AP PC Sh TaEritrea R R S R S S S S S Yes, High risk below 2200 metres, ME or DO or AP PC Sh Le no risk in AsmaraEstonia S S S No Ethiopia R R S R R S S S R S Yes, high risk below 2,000m ME or DO or AP PC Sh

(No risk in Addis Ababa) Falklands (Tristan da C.) No Fiji R R S S S C No Finland S No France S No LeFrench Guiana S R S S M High risk west & south. ME or DO or AP PC Sh Tc

Coast and central inland low risk WFrench Polynesia R S No Gabon R R S R S S S M Yes, high risk ME or DO or AP PC ShGambia R R S S S S R S Yes, high risk ME or DO or AP PC Sh TaGeorgia R S S S S Yes, v. low risk SE villages July-Oct W Germany S No Ghana R R S R S S S M S Yes, high risk ME or DO or AP PC Sh TaGoa R R S R S S S C S Low risk W LeGreece and Islands S S Low risk Evrotas Delta W LeGreenland R S S No Grenada S S C No Guadeloupe S C No Guam R S S S No Guatemala S R S S S S C Yes, low risk below 1500 metres W Guinea R R S R S S S S R S Yes, high risk ME or DO or AP PC Sh TaGuinea Bissau R R S S S S S M S Yes, high risk ME or DO or AP PC Sh TaGuyana S R S S S R Yes, high risk all areas except ME or DO or AP PC Sh

coastal stripHaiti R R S R S S S C Yes, high risk throughout country ME or DO or AP PC Hawaii No Honduras R R S S S S C Yes, risk variable in central and W/C P Le eastern regionsHungary S S No India R R S R S S S C S High risk in east and Assam ME or DO or AP PC Le

Complex central zone W, see Travax & advice Low risk north and south zones W

Indonesia R R S R S S S C S Very low Bali and cities W Risk assess in other areas Usually W (see Travax) High risk in islands to south and ME or Do or AP PC east of Sulawesi

Iran S R S R S S C Yes, rural SE provinces Mar-Nov ME or Do or AP PC Sh LeIraq R R S R R S S S C Yes, v. low risk rural north May-Nov W P Sh LeIsrael R R S S S No LeItaly S No LeIvory Coast R R S R S S S M S Yes, high risk ME or DO or AP PC TaJamaica S R S S C No Japan S S S No ShJordan S S S C No LeKazakhstan S R S S S C S No LeKenya R R S R R S S S R S Yes, high risk ME or DO or AP PC Sh Le Ta

(Nairobi and highlands low risk)Kiribati S R S S S S C No Korea (North) R R S S S S C S Yes, limited risk extreme south W Korea (South) S R S S S S Yes, limited risk extreme north W Kosovo R S S S S No LeKuwait S R S No Kyrgyzstan S R S S S C S Yes, low risk some S & W areas W LeLaos R R S R R S S S C S Minimal risk NE, NW, Vientiane W

Low risk northern two thirds – ME or DO or AP PC chemoprophylaxis for high risk travellers High risk southern third ME or DO or AP PC

Latvia R S S S S No Lebanon S R R S S C No LeLesotho R R S S S S C No ShLiberia R R S S S S S M Yes, high risk ME or DO or AP PC Sh TaLibya S R S S S S C No risk LeLiechtenstein S No Lithuania S S S S S S No Macedonia R S S No LeMadagascar R R R R S S S C Yes, high risk ME or DO or AP PC ShMadeira No Malawi R R S R S S S C Yes, high risk ME or DO or AP PC Sh TaMalaysia S R S S S S S C S Minimal risk coastal areas. Low W PC

risk Sabah & Sarawak ME or DO or AP for high risk groups

Maldives S R S S S C No Mali R R S S S S S M S Yes, high risk ME or DO or AP PC TaMalta and Gozo C No LeMartinique S C No ShMauritania R R S R S S S R S Yes, high risk all year in south ME or DO or AP PC Sh Le

Low risk in far northMauritius R S C No W Mayotte R R S C Yes, high risk ME or DO or AP PC LeMexico R R S S S Yes, southern rural areas only W Tc Moldova S R S S S S S No Mongolia S R S S S S No Montenegro R S S S S No LeMontserrat S C No Morocco R R S S S No W LeMozambique R R S R S S S C Yes, high risk ME or DO or AP PC Sh TaMyanmar (Burma) R R S R R S S S C S Yes, Kayin and East Shan state DO or AP PC

Yes, elsewhere ME or DO or AP PC Low/no risk Mandaley & Rangoon W

Namibia R R S R S S S C Yes, NE third only ME or DO or AP PC Sh Elsewhere low risk W

Nepal R R S R S S S C S Vivax risk all year round. Falciparum W Le risk In Western pocket in Terai Neth Antilles S C No Netherlands S No New Caledonia S R S C No New Zealand S No Nicaragua R R S S C Yes, variable risk in north, C P Le Tc

low risk in southNiger R R S R S S S M S Yes, high risk ME or DO or AP PC Sh TaNigeria R R S R R S S S R S Yes, high risk ME or DO or AP PC Sh TaNorway S No Oman S R S S C Sporadic imported risk W Sh LePakistan R R S R R S S S C S Yes, significant below 2000m ME or Do or AP PC PCPanama R R S S S S R Yes, low risk, highest in Darien & W

San Blas Papua New Guinea R R S R S S S C S Yes, high risk below 1800m ME or DO or AP PC Paraguay R R S S S R Low risk W Le TcPeru R R S S S S R Yes, high risk in Amazonian ME or DO or AP PC Le Tc

Loreto Dept. Variable risk SE area bordering C P Brazil & Bolivia, and around Tumbes & Piura

Philippines R R S S S S S C S Very low risk most areas W Low risk Palawan, Tawi Tawi, ME or DO or AP PC Zambales, Zamboanga del Norte for high risk travellers only

Poland S S No Portugal No Puerto Rico R S S S No Sh LeQatar S R S S No LeReunion R S S C No ShRomania S R S S S S S No Russian Federation S R R S S S S S No Rwanda R R S S S S S M S Yes, high risk ME or DO or AP PC Sh TaSabah R R S S S S S C S Minimal risk coastal areas & Kota W

Kinabulu. Low risk inland ME or DO or AP PC for high risk groups

Samoa S R S S C No Sao Tome R R S S S S S Yes, high risk ME or DO or AP PC Sh LeSaudi Arabia S R S S S C S/M Yes SW region, no risk in Jeddah, ME or DO or AP PC Sh Le

Mecca and Taif W Senegal R R S R S S S R S Yes, high risk ME or DO or AP PC Sh TaSerbia R S S S No LeSeychelles R R S C No Sierra Leone R R S R S S S M Yes, high risk ME or DO or AP PC Sh TaSingapore S S C S No Slovakia S S S No Slovenia S S S No Solomon Islands R R S S S S C Yes, high risk ME or DO or AP PC Somalia R R S R R S S S R Yes, high risk ME or DO or AP PC Sh LeSouth Africa S R S R S S S C Yes, NE rim including Kruger ME or DO or AP PC Sh Ta

bordering Zimbabwe, Mozambique and northern Swaziland

Spain No NoSri Lanka R R S S S C S No – imported cases only W St Helena & Ascension S S C No St Kitts & Nevis S C No St Lucia S C No St Vincent & Grenadines S S C No Sudan R R S R S S S R S Yes, high risk but low seasonal ME or DO or AP PC Sh Le in northSouth Sudan R R S R S S S R S Yes, high risk ME or DO or AP PC Sh LeSurinam R R S S S R Yes (except Paramaribo and coast) ME or DO or AP PC Sh LeSwaziland R R S S S S C Yes, high risk, eastern areas ME or DO or AP PC Sh Sweden S No Switzerland S No Syria S R R S S S C No Sh LeTaiwan R S S S S S No Tajikistan R R S S S S S S Yes – variable June-Oct C P

High risk Afghan border in SW ME or Do or AP PCTanzania R R S R S S S S S Yes, high risk ME or DO or AP PC Sh TaThailand S R S S S S S C S Yes, on extreme fringe of DO or AP

international borders Elsewhere W

Tibet S R S S S S C S No Tobago S S S C No TcTogo R R S S S S S M S Yes, high risk ME or DO or AP PC Sh TaTrinidad S S S S No TcTunisia R R S S C No LeTurkey R S S Low risk Mardin province W LeTurkmenistan R S S S S No Uganda R R S R S S S M S Yes, high risk ME or DO or AP PC Sh TaUkraine R R R S S S S No United Arab Emirates S R S S S No LeUruguay R S S C No TcUSA No Uzbekistan R S S S Yes, very low risk extreme SE W LeVanuatu S R S S S S Yes, moderate risk ME or DO or AP PC Venezuela S R S S S R Yes, high risk to south of ME or DO or AP PC LE Tc

Orinoco River Variable/low risk north of Orinoco C P No risk Caracas or Margarita W

Vietnam R R S R S S S C S Minimal risk most areas W Low risk elsewhere with ME or DO or AP PC chemoprophylaxis for high risk groups in Central Highlands (see Travax map)

Virgin Islands S No West Papua R R S R S S S C S Yes, high risk below 1800m ME or DO or AP PC Sh Ta (formerly Irian Jaya) Yemen R R S R S S S C Yes, but no risk in Sana’a City ME or DO or AP PC Sh LeZambia R R S S S S S S Yes, high risk ME or DO or AP PC Sh TaZimbabwe R R S S S S S C Yes, high risk Zambezi valley ME or DO or AP PC Sh Ta

Yes, elsewhere below 1200m ME or DO or AP PC Nov-Jun Negligible risk Harare and W Bulawayo

KeyM = immunisation mandatoryR = immunisation recommended as risk of

infection is substantialS = immunisation sometimes recommended:

– for more than three visits in a one-year period – a stay of more than three months in a rural area – for high-risk occupational groups – for backpackers staying more than one month – when entering the limited geographical risk area for the target disease

C = See Yellow fever, next column

Where S appears for cholera, it indicates that only high-risk travellers, usually healthcare workers in areas of known epidemics, should be immunised.

Vaccination informationTetanusFive tetanus doses are considered protective for life by the DH, although there is no evidence base for this. Travellers at risk of tetanus-prone wounds should be given 10-yearly boosters if they

Not advised in pregnancy but use may be considered in 2nd and 3rd trimesters after careful risk assessment. Children use paediatric tablets.Regimen PCProguanil (Paludrine) 200mg daily plus chloroquine 300mg or 310mg base weekly (=Avloclor 2x250mg). Begin 1 week before travel and continue for 4 weeks after return.Regimen MEMefloquine, 1x250mg tablet weekly. ACMP suggest it is safe in continuous use for at least 3 years. Begin at least 21⁄2 weeks before travel (at least 3 doses before arriving in malarious area). Caution in first trimester but inadvertent use is not an indication for termination. Mefloquine may be considered if planning to conceive in high risk endemic zone after careful risk assessment. In general suggest defer planned pregnancy until 3 months after stopping mefloquine.Regimen CChloroquine 300mg or 310mg base weekly (=Avloclor 2x250mg). Begin 1 week before travel and continue for 4 weeks after return. Regimen PProguanil (Paludrine) 200mg daily. Begin 1-2 days before travel and continue for 4 weeks after return.

is an information service provided by Health Protection Scotland (www.travax.nhs.uk; telephone 0141 300 1130).

NaTHNaC should also be consulted. NaTHNaC and Travax are independently administered and may occasionally differ in the advice offered.

The chart is updated regularly. Readers are advised to use the latest chart only, to ensure that their practice reflects the most recent advice.Travel vaccinations and malaria information authorDr Michael Jones, Consultant in Infectious Diseases, Edinburgh.

Parasitic infectionsShort-term travellers staying in good conditions are usually at low risk of acquiring parasitic infections. Schistosomiasis is common and potentially serious. Leishmaniasis and trypanosomiasis are less common but potentially lethal. Expatriates in remote areas at risk of other rare diseases are not shown in this chart.Sh = schistosomiasis. Travellers should avoid swimming in freshwater lakes and rivers in endemic areas.

are going to poorer countries in Africa, Asia and South America where specific immunoglobulin may be unavailable.Polio All travellers should have completed the British vaccination schedule for polio immunisation in childhood or as adults. Yellow fever⦁ An international certificate of vaccination may be required for those entering from, or transiting through airports in YF endemic countries where C, S, R or M appears indicated in the yellow fever column. For details consult CDC Yellow Book at tinyurl.com/lnxngfwt ⦁ M = Mandatory generally indicates that all travellers aged >9 months should carry an international certificate of vaccination. Country specific ages are indicated on the CDC web site above.⦁ Although WHO has indicated that one yellow fever vaccination protects for life numerous countries have not incorporated this into their recommendations. A complete list of country certificate requirements is available at http://www.who.int/ith/2016-ith-annex1.pdfInformation source and updatesThis chart is based on information from the UK TRAVAX website and other databases. TRAVAX

Regimen WNo chemoprophylaxis but be aware of risk. Avoid mosquito bites and carry standby treatment if going to be far from medical facilities.Regimen DODoxycycline, 1 tablet of 100mg daily. Begin 1-2 days before travel and continue for 4 weeks after return. Not for children or pregnant women. Be aware of oesophageal ulceration, photosensitivity and very rare intracranial hypertension risk. Take with food, but not milk (37% reduction in AUC) and avoid ingestion in late evening. Regimen DRFIn the alternative regimen column, DRF is Drug-Resistant-Falciparum regimen. DRF = ME or DO or APPrimaquineCausal prophylactic for use in travellers for whom other anti-malarials are contra-indicated after excluding G6PD deficiency. 5-10% poor response rate due to CYP450 metabolic defect. Active against all species. Adult dose 30mg daily. Start 1-2 days before departure and continue for 7 days after return.

Ta = African trypanosomiasis (sleeping sickness). Transmitted by tse-tse flies, and a risk in some African game parks and rural areas. Travellers should use insect repellents, close windows if fly swarms approach and seek medical attention for any signs of infection around bites one to three weeks later.Tc = South American trypanosomiasis (Chagas’ disease). Transmitted by reduvid bugs that feed at night and reside in the thatch and crevices of rural dwellings. Travellers should avoid sleeping in huts.Le = Leishmaniasis. Transmitted by sandflies in arid areas (including Mediterranean coastal areas), mostly at night. Travellers should use insecticide-impregnated mosquito nets and insect repellent.

Key to malaria prophylaxis regimensRegimen APAtovaquone-proguanil, one 250/100mg tablet daily. Begin 1-2 days before departure, continue whilst in malarial area and for 7 days after return. Advisory Committee on Malaria Prophylaxis suggest AP is safe in continuous use for at least 1 year and possibly longer.

Weight Chloroquine Mefloquine Age in kg ProguanilUnder 6.0 0.125 adult dose not term to ¼ tablet recommended 12 weeks6.0 to 9.9 0.25 adult dose 0.25 adult dose 3 months to ½ tablet ¼ tablet 11 months10.0 to 15.9 0.375 adult dose 0.25 adult dose 1 year to ¾ tablet ¼ tablet 3 years 11 months16.0 to 24.9 0.5 adult dose 0.5 adult dose 4 years to 1 tablet ½ tablet 7 years 11 months25.0 to 44.9 0.75 adult dose 0.75 adult dose 8 years to 1½ tablets ¾ tablet 12 years 11 months45kg and over Adult dose Adult dose 13 years 2 tablets 1 tablet and overDoxycycline only above 12 years and the adult dose is given

Children’s doses of antimalarial prophylactics Specialist adviceFor advice on complex itineraries and other queries, use the following helplines:Birmingham 0121 424 0357/ 3354/2357 Edinburgh, Western General Hospital 0131 537 2822National Travel Health Network and Centre (Monday to Friday, 9am-12pm, 2pm-4.30pm) 0845 602 6712 (local call rate)

For malaria advice:Malaria Reference Laboratory 020 7636 3924 (health professionals only)Birmingham 0121 424 0357/ 3354/2357 Edinburgh 0131 537 2822Glasgow 0141 300 1130Liverpool 0151 708 9393 Oxford 01865 225 214

Children’s doses Paediatric atovaquone-proguanil (62.5/25mg)

Weight in kg Number of tabletsdaily 5-10 ½ paediatric tablet (ACMP recommendation but off licence)11-20 1 paediatric tablet21-30 2 paediatric tablets31-40 3 paediatric tabletsAbove 40 1 adult tablet

Although every effort is made to ensure that information in these pages is correct, the compilers and Pulse cannot accept responsibility for the consequences of errors. © PULSE 2016

Updated: November 2016