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Travel Medicine. By Dr. Mona Shawki Moustafa Lecturer of Occupational Health and Industrial Medicine Community Medicine Department Faculty of Medicine-Alexandria University-Egypt. Travel medicine:

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travel medicine

Travel Medicine


Dr. Mona Shawki Moustafa

Lecturer of Occupational Health and Industrial Medicine

Community Medicine Department

Faculty of Medicine-Alexandria University-Egypt

Travel medicine:

It is the branch of medicine that deals with the prevention and management of health problems of international travelers.

The number of people traveling internationally is increasing every year.

According to statistics of the World Tourism Organization, international tourist arrivals in the year 2006 exceeded 846 million

As more people travel and individuals travel more frequently, the specialty of travel medicine becomes more important.

Thus, most clinicians need some basic information to determine the extent of health advice their patients should access prior to their journeys.

International travel can pose various risks to health, depending on the characteristics of both the traveler and the travel.
Morbidity studies suggest that about half of the people from a developed country that stay one month in a developing country will get sick.

Treveler’s diarrhea

Mortality studies indicate that:
  • Cardiovascular disease accounts for most deaths during travel (50-70%).
  • Injury and accident (25%).
  • Infectious disease accounts for about 2.8-4% of deaths during and after return from travel.
Key factors in determining the risks to which travelers may be exposed are:
  • Destination.
  • Duration and season of travel.
  • Purpose of travel.
  • Standards of accommodation and food hygiene.
  • Behavior of the traveler.
  • Underlying health of the traveler.
The durationof the visit may determine whether the traveler may be subjected to marked changes in temperature, humidity, or prolonged exposure to atmospheric pollution and likelihood of exposure to infectious agents which will influence decisions on the need for certain vaccinations or anti-malarial medication.
The purpose of the visit is critical in relation to the associated health risks. (conferences versus holidays)
  • Behavior also plays an important role e.g. going outdoors in the evenings in a malaria-endemic area without taking precautions
Travelers' health is the responsibility of:



Travel Industry.

responsibilities of clinicians
Responsibilities of Clinicians

A clinician should provide the traveler with:

Knowledge that enables them to protect themselves from potential health risks.

Emphasize the importance of a pre-travel consultation and educates the patient that international travel can pose special health risks that should be addressed.


Evaluate the traveler including the medical history, the assessment of the epidemiology of endemic diseases or health risks at the destination, and the behavioral risks that may be taken.

Educate the traveler about importance of having a medical kit during his journey and construct him about its contents.
Provide post-travel medical care. The extent of the care given is personally determined according to condition of traveller and travel circumstances.

Recognize common disease symptoms and syndromes of international travelers.


Travel health advice should be individually tailored to the person.

  • For example, the business traveler to Bangkok, Thailand with underlying heart disease staying at a 5-star resort has different risks from those of the healthy refugee camp worker who will travel throughout northern Thailand on the Cambodian border.
  • Despite their success in preventing disease, vaccines do not fully protect 100% of the recipients.
  • The vaccinated traveler should not assume that there is no risk of catching the disease against which he has been vaccinated.
  • All additional precautions against infection should be followed carefully.
The protective effect of vaccines takes a period of time to be fully developed.
  • The duration varies according to the vaccine, the number of doses required and whether the individual has previously been vaccinated against the same disease.
  • For this reason, travelers are advised to consult a travel medicine clinic or personal physician 4–6 weeks before departure.
choice of vaccines for travel
Choice of vaccines for travel

Vaccines for travelers include:

(1) Vaccines used routinely, particularly for children.

(2) Vaccines that may be advised before travel.

(3) Vaccines that, in some situations, are mandatory.


Routine vaccination:

Diphtheria/pertussis/tetanus (DTP)

Hepatitis B (HBV)

Haemophilus influenzae type b (Hib)

Measles (MMR)

Poliomyelitis (OPV or IPV)


Selective use for travelers:



Hepatitis A (HAV)

Japanese encephalitis

Lyme disease

Pneumococcal disease


Tick-borne encephalitis

Tuberculosis (BCG)

Typhoid fever


Mandatory vaccination:

  • Yellow fever (for protection of vulnerable countries)
  • Meningococcal disease (required by Saudi Arabia for pilgrims visiting Mecca for the Hajj (annual pilgrimage) or for the Umrah.
The International Health Regulations mandates yellow fever vaccination for two different reasons:

(1) to protect the individual in areas where there is a risk of yellow fever infection.

(2) to protect vulnerable countries from importation of the yellow fever virus.

according to the international measures the world is divided into three zones
According to the international measures, The world is divided into three zones:
  • Infected (endemic) zone.
  • Infectable (receptive) zone.
  • Non-infectable zone.
Infected (endemic) zone:

In this zone, the three requirements for perpetuation of yellow fever are present; the virus, the vector and suitable environmental conditions.

The objective of the control measures is to prevent exportation of the disease and diminish local spread.


Measures applied to infected zone:

  • Ports and airports:

a- should be away from the city.

b-Apply insecticides periodically to control mosquito.

  • The plans: Application of insecticides on planes before leaving.
  • Individuals:
  • Those working in the airport and travelers going outside or entering should have valid vaccination certificate .
  • Cases of yellow fever should not leave the country.
infectable receptive zone
Infectable (receptive) zone:

Between endemic zone and latitude 43N and 43S.

Only the vector and suitable environmental conditions are present, but there is no virus.

  • All planes and ships coming from infected areas should be disinfected on arrival.
  • Only travelers carrying valid vaccination certificates are allowed to enter.

Measures applied to infectable zone:

If travelers were not vaccinated or since less than ten days they should be kept in quarantine to complete the six days
  • Monkeys and apes should be kept in quarantine for seven days.
Non-infectable zone:
  • The area north and south of the latitude 43.
  • In this area, there is no virus, no vector and the environmental conditions are not suitable.
  • Thus, no preventive measures are required.

Yellow fever vaccine

  • 1 dose
  • Protection: 10 years
  • Age range: Minimum age 9 months.

Seek medical advice for infants 6-9 months who are travelling to high risk areas

international certificate of vaccination or prophylaxis icvp for yellow fever
International Certificate of Vaccination or Prophylaxis (ICVP) for Yellow Fever
  • The International Health Regulations allow countries to require proof of vaccination for entry of travelers arriving from certain countries.
  • Travelers arriving without a completed ICVP may be quarantined or refused entry unless submitting to onsite vaccination.
  • Vaccinees should receive a completed ICVP, signed and validated with the center’s stamp where the vaccine was given.
  • This certificate is valid 10 days after vaccination and for a subsequent period of 10 years.
malaria chemoprophylaxis
Malaria chemoprophylaxis
  • Antimalarial drugs are recommended for prophylaxis of non-immune travelers visiting malaria-endemic areas.
  • In areas of chloroquine-sensitive malaria, weekly chloroquine is the drug of choice.
  • In areas where chloroquine-resistant P. falciparum is transmitted, weekly mefloquine or daily doxycycline is recommended.
  • Chemoprophylaxis should be started 1 week before arriving in a malaria-endemic area and continued during travel and for 4 weeks after leaving the area.
responsibilities of travelers
Responsibilities of Travelers
  • Each traveler needs to realize the value of health and the risks that traveling internationally may pose.
  • Every traveler’s responsibility is to weigh the personal risk versus benefits of a particular journey.
Recent studies have shown that a small portion of travelers do not even seek general information about their travel destination.
medical kit and hygiene items
Medical kit and hygiene items
  • Sufficient medical supplies should be carried to meet all needs for the duration of the trip.
  • A medical kit should be carried for all destinations where there may be significant health risks, particularly those in developing countries, and/or where the local availability of specific medications is not certain.
Certain categories of medicine should be carried together with a medical prescription, signed by a physician.
  • Hygiene items should also be carried in sufficient quantity for the entire visit unless their availability at the travel destination is assured. These will include items for dental care, eye care including contact lenses, skin care and personal hygiene.
This kit will include:
  • Basic medicines to treat common ailments.
  • First-aid articles.
  • Special medical items that may be needed by the individual traveler.
Contents of a basic medical kit (First-aid items):
  • Adhesive tape.
  • Antiseptic wound cleanser.
  • Bandages.
  • Emollient eye drops.
  • Insect repellent.
  • Insect bite treatment.
  • Nasal decongestant.
  • Oral re-hydration salts.
  • Scissors and safety pins.
  • Simple analgesic (e.g. Paracetamol).
  • Sterile dressing.
  • Clinical thermometer.

Responsibilities of the Travel Industry

  • Travel agencies, tour operators, air and cruise lines should learn about the basics of travel medicine as it affects the areas of the world where their customers are traveling.
  • Their respnsibilities are:
  • Consult travelers about health risks and preventive actions they should take. (such as the presence of malaria or the fact that vaccinations may be beneficial).
  • Provide resources in travel medicine.
mode of travel
Mode of travel

The mode of travel is an integral part of the travel experience.

According to the World Tourism Organization, of the 846 million international tourist arrivals in 2006, air transport represented 45% of arrivals and marine transport accounted for 7%.

travel by air1
Travel by air

The volume of air traffic has risen steeply in recent years.

Moreover, the number of long-distance flights has increased.

According to the International Civil Aviation Organization, the passenger traffic is projected to double between 2006 and 2020.

Air travel, in particular over long distances, exposes passengers to a number of factors that may have an effect on their health and well-being.

Health risks associated with air travel can be minimized if the traveler plans carefully and takes some simple precautions before, during and after the flight.

cabin air pressure
Cabin air pressure
  • Although aircraft cabins are pressurized, cabin air pressure at cruising altitude is lower than air pressure at sea level.
  • As a consequence, less oxygen is taken up by the blood (hypoxia) and gases within the body expand.
  • The effects of reduced cabin air pressure are usually well tolerated by healthy passengers.
Passengers with certain medical conditions, particularly heart and lung disease and blood disorders such as anemia (in particular sickle cell anemia), may not tolerate this reduced oxygen level (hypoxia) very well.
  • Some of these passengers are able to travel safely if arrangements are made with the airline for the provision of an additional oxygen supply during flight.
gas expansion
Gas expansion
  • As the aircraft climbs, the decreasing cabin air pressure causes gases to expand.
  • Similarly, as the aircraft descends, the increasing pressure in the cabin causes gases to contract.
Gas expansion during the climb causes air to escape from the middle ear and the sinuses, usually without causing problems( “popping” sensation in the ears).
  • As the aircraft descends, air must flow back into the middle ear and sinuses in order to equalize pressure differences. If this does not happen, the ears or sinuses may feel as if they are blocked and pain can result.
  • Swallowing, chewing or yawning (“clearing the ears”), a short forceful expiration against a pinched nose and closed mouth (Valsalva maneuver).
  • Take a decongestant before you get on the airplane, (particularly if suffering from a common cold or swollen sinuses).
  • For infants, feeding or giving a pacifier (dummy) to stimulate swallowing.
cabin humidity and dehydration
Cabin humidity and dehydration

The humidity in aircraft cabins is low (less than 20%).

Low humidity may cause skin dryness and discomfort of the eyes, mouth, nose and exposed skin but presents no risk to health.

Use a skin moisturizing lotion, nasal saline, and spectacles rather than contact lenses.

  • Ozone is a form of oxygen occurs in the upper atmosphere and may enter the aircraft cabin together with the fresh air supply.
  • In older aircraft, it was found that the levels of ozone in cabin air could sometimes lead to irritation of the lungs, eyes and nasal tissues.
  • Ozone is broken down by heat and most ozone is removed by the compressors (in the aircraft engines) that provide pressurized air for the cabin.
motion sickness
Motion sickness

Travelers by air rarely suffer from motion (travel) sickness except in the case of severe turbulence.

  • Request a seat in the mid-section of the cabin.
  • Keep eyes fixed on the horizon and avoid rapid head movements. Sleep if you are able to.
Keep the motion sickness bag, provided at each seat, readily accessible.
  • Consult doctor or travel medicine physician about medication.
  • Avoid drinking alcohol during the flight and for the 24 hours before travel.
immobility circulatory problems and deep vein thrombosis dvt
Immobility, circulatory problems and deep vein thrombosis (DVT)
  • Prolonged immobility can lead to pooling of blood in the legs, causing leg swelling, stiffness and discomfort and may lead “deep vein thrombosis” or DVT.
  • According to WHO, the risk of DVT approximately doubles after long flights (> 4 hours) and also with other forms of travel where travelers are exposed to prolonged seated immobility and with multiple flights within a short period.
jet lag
Jet lag

The symptoms caused by the disruption of the body’s “internal clock” and circadian rhythms it controls.

Disruption occurs when crossing multiple time zones.

jet lag may lead to
Jet lag may lead to:
  • Indigestion and disturbance of bowel function.
  • General malaise.
  • Daytime sleepiness and difficulty in sleeping at night.
  • Reduced physical and mental performance.
  • Disturbance for travelers who take medication according to a strict timetable (e.g. insulin, oral contraceptives).
general measures to reduce the effects of jet lag

Jet lag cannot be prevented

General measures to reduce the effects of jet lag:
  • Rest: before departure, and during the flight.
  • Eat light meals and limit consumption of alcohol.
  • Caffeine should be limited to normal amounts.
Try to create the right conditions when preparing for sleep.
  • Short-acting sleeping pills.
  • Melatonin (available in some countries).
psychological aspects
Psychological aspects

Travel by air is not a natural activity for humans and many people experience some degree of psychological difficulty when flying.

The main problems encountered are:

  • Stress.
  • fear of flying.
  • Air Rage.

These may occur together or separately at different times before and during the period of travel.

aircraft disinsection
Aircraft disinsection

Disinsection is a public health measure that is mandated by the current International Health Regulations.

Many countries require disinsection of aircraft (to kill insects) arriving from countries in order to:

  • Pevent diseases that are spread by insects (e.g. malaria and yellow fever)
  • Protect agriculture e.g. Australia and New Zealand.
Countries where disinsection generally takes place include those in Latin America, the Caribbean, Australia, and the South Pacific regions.
medical assistance on board
Medical assistance on board

Airlines are required to provide:

  • Minimum levels of medical equipment on aircraft.
  • Train all cabin crew on first aid.

Equipment carried on a typical international flight would include:

  • One or more first-aid kits, to be used by the crew.
A medical kit, normally to be used by a doctor or other qualified person, to treat in-flight medical emergencies.
  • An automated external defibrillator (AED) to be used by the crew in case of cardiac arrest.
contraindications to air travel
Contraindications to air travel

Travel by air is normally contraindicated in the following cases:

  • Infants less than 7 days old.
  • Women after the 36th week of pregnancy (after 32nd week for multiple pregnancies) and until seven days after delivery.

Contraindications to air travel (cont)

Those suffering from:

  • Angina pectoris or chest pain at rest.
  • Serious or acute infectious disease.
  • Decompression sickness after diving.
  • Increased intracranial pressure due to hemorrhage, trauma or infection
  • Infections of the sinuses, ear or nose, particularly if the Eustachian tube is blocked.
contraindications to air travel cont
Contraindications to air travel (cont)
  • Recent myocardial infarction and stroke.
  • Recent surgery or injury.
  • Severe chronic respiratory disease, and unresolved pneumothorax.
  • Sickle-cell disease.
  • Psychotic illness, except when fully controlled.
travel by sea1
Travel by sea
  • The passenger shipping industry has expanded considerably in recent decades.
  • In 2006, 11.7 million passengers worldwide traveled on cruise ships.
  • Cruise itineraries include all continents including areas that are not easily accessible by other means of travel.
  • The average duration of a cruise is about 7 days, but cruise voyages can last from several hours to several months (e.g. round-the world cruises).
travel by sea2
Travel by sea
  • The revised International Health Regulations (2005) address health requirements for ship operations and construction.
  • There are global standards regarding ship and port sanitation and disease surveillance, as well as response to infectious diseases.
  • Guidance is given on provision of safe water and food, on vector and rodent control, and on waste disposal.
travel by sea3
Travel by sea

According to International Labor Organization Convention:

“Concerning Health Protection and Medical Care for Seafarers” (1987), vessels carrying more than 100 crew members on an international voyage of three days or longer must provide a physician for care of the crew.


Travel by sea

  • These regulations do not apply to passenger vessels and ferries sailing for less than three days, even though the number of crew and passengers may exceed 1000.
  • The contents of the ship’s medical chest must be in accordance with the international agreements for ocean-going trade vessels but there are no special requirements for additional drugs for passenger ships.
health hazards for traveling by sea
Health hazards for traveling by sea

I. Communicable diseases:


Respiratory infections.

II. Non-communicable diseases.


Communicable diseasesGastrointestinal disease

  • The viral gastroenteritis is highly infectious and can spread in food or water or from person to person.
  • In an outbreak on a cruise ship in 1998, more than 80% of the 841 passengers were affected.
Factors that have contributed to outbreaks include:
  • Contaminated bunkered water, inadequate disinfection of water.
  • Potable water contaminated by sewage on ship.
  • Poor design and construction of storage tanks for potable water.
  • Deficiencies in food handling, preparation and cooking.
  • Use of seawater in the galley.
influenza and other respiratory tract infections
Influenza and other respiratory tract infections
  • Respiratory tract infections are frequent among cruise-ship travelers.
  • Risk of exposure to influenza viruses in regions of the world where influenza is not in seasonal circulation, particularly if the group contains travelers from areas of the world where influenza viruses are in seasonal circulation.
  • Crew members who serve passengers may become reservoirs for influenza infection.
non communicable diseases
Non-communicable diseases

Because of temperature and weather variations, changes in diet and physical activities, and generally increased levels of stress compared with life at home, the cruise ship traveler – particularly the elderly traveler – may experience worsening of existing chronic health conditions.

  • Cardiovascular events are the most common cause of mortality on cruise ships.
  • Motion sickness can occur, especially on smaller vessels.
environmental health risks1
Environmental health risks

Travel may involve major changes in:

  • Altitude.
  • Temperature.
  • Humidity.
  • Exposure to microbes, animals and insects.
  • Recreational water hazards.
recreational water
Recreational water

Include costal waters, fresh water lakes, rivers, swimming pools and spas.


Recreational Water Hazards

  • Drowning & injury.
  • Physiological:

-Chilling leading to coma & death.

-Thermal shock leading to cramps & cardiac arrest.

-Decompression sickness in divers.

-Acute exposure to heat & ultraviolet radiation.

-Cumulative exposure to sun (skin cancer & cataract).


Recreational water hazards:

  • Infection:

Ingestion or inhalation of or contact with

pathogenic micro-organisms.

  • Poisoning & toxicities:
  • - Ingestion or inhalation or contact with chemically
  • contaminated water.
  • - Stings or bites of venomous animals.
  • Injuries and accidents.
prevention of recreational water hazards
Prevention of recreational water hazards
  • Adequate environmental monitoring for recreational water activities.
  • Provide health information to recreational water users.
  • Avoiding areas with visible algae concentrations.

4. Travelers should be advised to wear protective gloves and footwear and avoid contact with corals and other marine animals.

  • Public education regarding hazards & safe behaviors.
  • Regulations that discourage unsafe behaviors (e.g. exceeding recommended boat loadings).
  • Trained lifeguards.
  • Availability of resuscitation facilities.

Wearing adequate lifejackets when boating.

  • local hazard warning notices.
  • Emergency services & access.
  • Beach cleaning.
  • Solid waste management.
insects and disease vectors
Insects and disease vectors
  • Vectors play an essential role in the transmission of many infectious diseases.
  • Many insect vectors are involved in the life cycle and transmission of diseases as mosquitoes, bloodsucking flies, ticks, and aquatic snails.
protection against vectors
Protection against vectors:

Travelers may protect themselves from mosquitoes and other vectors by using:

  • Protective clothing
  • Insect repellents
  • Insecticide-treated curtains and bed-nets
  • Mosquito coils
  • Aerosol insecticide sprays
traffic accidents are the most frequent cause of death among travelers

Traffic accidents are the most frequent cause of death among travelers.

They constitute significant risk in many countries, particularly developing countries


Accidents constitute special risk for travelers in developing countries because:

  • Traffic laws are limited or are inadequately enforced.
  • Traffic mix is more complex than that in developed countries and involves different vehicles, animal-drawn vehicles and other conveyances, plus pedestrians, all sharing the same road space
  • Roads may be poorly constructed and maintained
  • Road signs and lighting are inadequate.
  • Poor driving habits.
  • Lack of familiarity with the roads.

Travelers can reduce the possibility of accidents through :

Travelers, both drivers and pedestrians, should be extremely attentive and careful on the roads.

Have full insurance cover for medical treatment of both illness and injuries.

Carry an international driving license as well as your national driving license.


Obtain information on the regulations governing traffic and vehicle maintenance, and on the state of the roads, in the countries to be visited.

  • Before renting a car, check the state of its parts.
  • Know the informal rules of the road; in some countries.
  • Be particularly vigilant in a country where the traffic drives on the opposite side of the road to that used in your country of residence.

Do not drive on unfamiliar roads

  • Do not use motorcycle, bicycle or tricycle.
  • Do not drive after drinking alcohol.
  • Drive within the speed limit at all times.
  • Always wear a seat belt where these are available.
  • Beware of wandering animals.
First-aid courses.
  • First-aid equipment, a communications device, and equipment that will add visibility to themselves and/or their vehicles (e.g., reflecting vest)
  • Protective clothing should be worn when riding on motorbikes.
  • Bringing child seats is advisable.
  • Children <12 years of age should ride in the back seat.
Violence and collective violence are leading worldwide public health problems and are growing concerns of travelers.

The 20th century was one of the most violent periods in history.

Rates of violent deaths in low to middle-income countries are more than 3 times those in higher-income countries, although there are great variations within countries, depending on regional demographic differences.
risk factors for violence
Risk factors for violence

Destinations where:

1. Government is unstable, even for short periods of time.

2. Recent coups have taken place.

3. Marked social inequality.

4. Rapid demographic changes.

5. Government is under control by a single group that identifies itself by a particular ethnic background or religious fundamentalism.

important tips to reduce risk of violence against travelers
Important tips to reduce risk of violence against travelers
  • Education about and greater awareness of regions of the world where political and civil unrest are present are important for all travelers.
  • Be alert to muggings
  • Avoid overcrowded trains, buses and minibus taxis.
  • Avoid isolated beaches and other remote areas.
Keep items of value out of sight and do not carry large sums of money on your person.
  • Use taxis from authorized ranks only.
  • Avoid driving at night and never travel alone.

Park in well-lit areas and do not pick up strangers.

  • Employ the services of a local guide or local driver when traveling to remote areas.
  • Vehicle hijacking.
personal security
Personal security
  • To reduce any risk of mugging travel in groups, avoid remote areas after dark, carry an alarm or an anti-personnel spray (may be illegal in some countries), wear modest clothing, do not display wealth.
Many areas are not safe to wander around at night, including those that look safe by daylight.
  • While driving, consider locking your car doors at stopping points especially at night in isolated areas.
Be aware of political unrest. Get up to date information from a Foreign Office on line. Do not rely on information from local residents.
  • In some countries, producing cameras, tape recorders etc. in sensitive areas such as near airports and railway stations can result in arrest on suspicion of spying.
north africa
North Africa

Access to clean water and sanitary disposal of waste are limited in many areas, so infections related to fecal contamination of food and water remain common and widespread.

Vaccine-preventable diseases such as measles, mumps, rubella, and diphtheria persist in the region.


More common infections in returned travelers are gastrointestinal:

Diarrhea (acute and chronic) and occasionally typhoid fever, amebiasis, and brucellosis.

Chronic and latent infections in immigrants (and long-term residents) from this region include tuberculosis, schistosomiasis, fascioliasis, hepatitis B and C, intestinal parasites, and echinococcosis.

Vector-borne infections:
  • Many have focal distributions or seasonal patterns.
  • Risk to the usual traveler is low.
  • e.g. dengue fever, lymphatic filariasis, leishmaniasis, malaria (risk limited to a few areas), relapsing fever, Rift Valley fever, West Nile fever

Food- and water-borne infections:

  • These infections, which are common in travelers to this region, include dysentery and diarrhea caused by bacteria, viruses, and parasites.
  • Risk for hepatitis A is high throughout the region.
  • Hepatitis E and cholera have caused focal outbreaks.
Sexually transmitted and blood-borne infections:
  • HIV prevalence (in adults 15-49 years) is estimated to be 0.1- 0.5% or lower.
  • Chancroid is a common cause of genital ulcers.
  • Chronic hepatitis B carriage, hepatitis CV.
  • Zoonotic infections:
  • Rabies is endemic in the region.
  • Sporadic cases of human plague and anthrax.
  • Avian influenza (H5N1) was found in poultry and human cases
  • and deaths.
Airborne and person-to-person transmission:
  • Tuberculosis (incidence: 50-100/100,000 or lower in most countries).

Soil- and water-associated infections:

  • Schistosomiasis is present. Other risks include leptospirosis.

Other hazards:

  • Scorpion stings, snake bites
  • high rate of motor-vehicle accidents.
  • Screening of blood before transfusion is inadequate.
north america
North America
  • Good sanitation and clean water are available in major urban areas and most rural areas.
  • Many vector-borne infections are found in focal areas and can pose a risk to travelers, especially adventure travelers to rural areas.
  • In temperate areas these infections occur during the summer months.
  • Levels of immunization are high in most areas.
  • Poliomyelitis has been eradicated.
Vector-borne infections:
  • Lyme disease is endemic
  • Other vector-borne infections include Rocky Mountain spotted fever and relapsing fever.
  • Sporadic local transmission of dengue.
  • Food- and water-borne infections:
  • Outbreaks of diarrhea caused by enterohemorrhagic E-coli, Campylobacter and Salmonella are the most common causes of acute bacterial diarrhea.
  • Outbreaks of noroviral diarrhea are increasing.

Airborne and person-to-person transmission:

  • Outbreaks and cases of pertussis have been increasing for more than a decade.
  • The incidence of tuberculosis is low (about 5/100,000 population).
  • Numbers of measles cases have declined and most of these cases are imported or linked to imported cases.

Sexually transmitted and blood-borne infections:

  • The HIV prevalence in adults aged 15-49 years is estimated to be 0.5% -<1.0 in USA.
Zoonotic infections:
  • Rabies is enzootic in bats, raccoons, foxes, and other wild animals.
  • Plague is enzootic in the western United States
  • Many outbreaks of anthrax in animals were reported in agricultural regions of the US and Canada in 2006.
  • Human cases are rare .

Other hazards:

  • Violent injury and death related to guns; rates are higher in the United States than in most industrialized countries.
  • Snakes inhabit North America; the highest bite rates are found in southern states and southwestern desert states.
  • Tick paralysis is most often reported from western Canada and the northwestern United States.