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• Vector-Borne Diseases

Clinical Overview of Epidemic Typhus

• The primary vector of epidemic typhus is the human body louse, with transmission occurring through contact with infected lice feces.
• Epidemic typhus outbreaks are often linked to densely populated environments in situations with limited access to hygienic services.
• Symptoms include fever, headache, rash, and altered mental status. Laboratory confirmation is typically based on serological tests detecting IgG or IgM antibodies.
• Early treatment with doxycycline is crucial to prevent severe complications.

Outbreaks of epidemic typhus are most often associated with the clustering of large populations in situations with limited access to hygienic services, such as those resulting from war or famine, or occurring in refugee camps, prisons, and among persons experiencing homelessness in association with exposure to body lice. However, isolated cases have also been reported in recent years outside of such settings, typically in association with flying squirrels.

The primary vector of epidemic typhus is Pediculus humanus corporis (human body louse). People become infected with Rickettsia prowazekii when they come into contact with the feces or crushed bodies of infected lice on cut or abraded skin. Inhalational exposure of dried louse feces has been reported. R. prowazekii can remain infective in louse feces for up to 100 days. Body lice can proliferate rapidly and spread from person to person through contaminated bedding and clothes. These lice infestations can lead to outbreaks of disease in populations with crowding, such as refugee camps.

In the United States, cases of epidemic typhus have been associated with exposure to flying squirrels or their nests. Fleas and lice carried by the squirrels become naturally infected with R. prowazekii ; however, the exact mechanism of transmission to humans remains unknown.

Clinical characteristics

Signs and symptoms of epidemic typhus usually appear abruptly, 8–16 days following exposure to infected lice. Illness can vary from mild to severe, and can be fatal. Symptoms of acute R. prowazekii infection are generally non-specific and include:

• Fever and chills
• Altered mental status
• Rapid breathing

Delay in treatment with doxycycline may lead to progression of the disease, including neurologic manifestations such as confusion, seizures, or coma, and widespread vasculitis. These symptoms are due to damage to the vascular endothelial cells throughout small blood vessels. Laboratory abnormalities of acute infection may include elevated bilirubin, elevated hepatic transaminases, and thrombocytopenia. Flying squirrel-associated typhus cases are generally less severe, and no fatal cases have been reported.

The rash usually begins 2-3 days after the onset of symptoms. It typically begins as a maculopapular eruption on the trunk and spreads to the extremities, usually sparing the palms of hands and soles of feet. When the disease is severe, petechiae may develop. The rash may be variable among individuals and stage of infection, or may be absent altogether. The presence or morphology of a rash should NOT be relied upon for diagnosis.

Brill-Zinsser Disease

Recrudescent infection with R. prowazekii , called Brill-Zinsser disease, may occur months or years after the initial illness, most often during times of extreme stress or when the immune system is impared. Brill-Zinsser disease is seen in patients who were not treated during their initial infection. The symptoms of Brill-Zinsser disease are similar to those of primary infection, with a rapid onset of chills, fever, headache, and malaise. However, Brill-Zinsser disease is generally milder and is rarely fatal. Patients with Brill-Zinsser disease harbor active R. prowazekii and therefore may pose a risk for reintroduction of the organism and new outbreaks.

Brill-Zinsser disease is not known to occur following infection with other rickettsial pathogens.

Clinical diagnosis

Diagnosis is based on clinical findings and epidemiologic factors, as diagnostic tests are not reliable early in the illness course. Epidemic typhus should be considered in patients with persistent fever, a history of body louse exposure in congregate or other crowded settings, or persons who may have come in contact with flying squirrels or their nests. When treated early, patients may experience a less severe illness and shorter recovery time.

Treatment should never be withheld pending results of diagnostic testing. Epidemic typhus has the potential to spread rapidly among persons living in close quarters, and precautions should be taken to rapidly identify and treat patients and to eliminate body louse infestations.

Clinicians who suspect epidemic typhus should notify their state public health department immediately.

Laboratory confirmation

R. prowazekii can be detected via indirect fluorescent antibody (IFA) test, immunohistochemistry (IHC), polymerase chain reaction (PCR) assay of blood, plasma, or tissue samples, or culture isolation. Serologic tests are the most common means of confirmation and can be used to detect either IgG or IgM antibodies.

Diagnosis is typically confirmed by documenting a four-fold rise in antibody titer between acute and convalescent samples. Acute specimens are taken during the first week of illness and convalescent samples are taken 2–10 weeks later. Detectable levels of IgG or IgM antibodies generally do not appear until 7–10 days after the onset of illness.

Because IgG antibody titers may persist in some individuals for years after the original exposure, only demonstration of recent changes in titers between paired specimens can be considered reliable serological confirmation of an acute epidemic typhus infection. R. prowazekii antigens may cross react with those of R. typhi, and occasionally with R. rickettsii . Persons with Brill-Zinsser disease generally show a rise in IgG but not IgM antibodies to R. prowazekii .

IHC can be used to detect infection with typhus group Rickettsia (including R. prowazekii and R. typhi ) in formalin-fixed tissue samples. PCR of whole blood or tissue can distinguish between infection with R. typhi and R. prowazekii although the sensitivity of these assays vary considerably based on the sample type, timing of sample collection, and the severity of disease. Since epidemic typhus is not common in the United States, testing is not typically available at state and local health departments. Serologic and molecular tests can be performed at the CDC, through submission from state health departments.

Doxycycline is the treatment of choice for suspected cases of acute epidemic typhus and Brill-Zinsser disease in adults and children of all ages.

Recommended dosages of doxycycline:

• Adults over 45 kg (100 lbs): 100 mg twice per day
• Children under 45 kg (100 lbs): 2.2 mg/kg body weight (max dose 100mg) twice per day

Patients should be treated for at least 3 days after the fever subsides and until there is evidence of clinical improvement (usually a minimum of 7–10 days).

Treatment of acute infection with doxycycline may prevent the subsequent development of Brill-Zinsser disease, but definitive data are lacking. Patients with body louse infestations should be treated with delousing gels or creams (pediculicide).

• http://www.cdc.gov/
• http://www.cdc.gov/ncezid
• http://www.cdc.gov/ncezid/dvbd/index.html

Typhus Fevers

Learn about the different types of typhus fevers, how they spread, and how to prevent them.

For Everyone

Health care providers, public health.

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• Section 5 - Perspectives : Testing Travelers for Mycobacterium Tuberculosis Infection
• Section 5 - Yersiniosis

Typhoid & Paratyphoid Fever

Cdc yellow book 2024.

Author(s): Michael Hughes, Grace Appiah, Louise Francois Watkins

Infectious Agent

Transmission, epidemiology, clinical presentation, typhoid fever.

INFECTIOUS AGENT:  Salmonella enterica serotype Typhi

Latin America

Asia (greatest risk for infection is in South Asia)

TRAVELER CATEGORIES AT GREATEST RISK FOR EXPOSURE & INFECTION

PREVENTION METHODS

Follow safe food and water precautions

Typhoid fever is a vaccine-preventable disease

DIAGNOSTIC SUPPORT

Paratyphoid Fever

INFECTIOUS AGENT: Salmonella enterica serotypes Paratyphi A, B, C

Salmonella enterica serotypes Typhi, Paratyphi A, Paratyphi B, and Paratyphi C cause potentially severe and occasionally life-threatening bacteremic illnesses referred to as typhoid fever (for Typhi serotype) and paratyphoid fever (for Paratyphi serotypes), and collectively as enteric fever. Paratyphi B strains are differentiated into 2 distinct pathotypes on the basis of their ability to ferment tartrate: the first pathotype, Paratyphi B, is unable to ferment tartrate and is associated with paratyphoid fever; the second pathotype, Paratyphi B var. L(+) tartrate(+), ferments tartrate and is associated with gastroenteritis typical of nontyphoidal salmonellosis. For more details on nontyphoidal salmonellosis, see the Sec. 5, Part 1, Ch. 19, Nontyphoidal Salmonellosis .

Humans are the only source of the bacteria that cause enteric fever; no animal or environmental reservoirs have been identified. Typhoid and paratyphoid fever are acquired through consumption of water or food contaminated by feces of an acutely infected or convalescent person, or a person with chronic, asymptomatic carriage. Risk for infection is high in low- and middle-income countries with endemic disease and poor access to safe food and water, and poor sanitation. Sexual contact, particularly among men who have sex with men, has been documented as a rare route of transmission.

An estimated 11–21 million cases of typhoid fever and 5 million cases of paratyphoid fever occur worldwide each year, causing an estimated 135,000–230,000 deaths. In the United States during 2016–2018, ≈400 culture-confirmed cases of typhoid fever and 50–100 cases of paratyphoid fever caused by Paratyphi A were reported each year; paratyphoid fever caused by Paratyphi B and Paratyphi C is rarely reported. Approximately 85% of typhoid fever and 92% of paratyphoid fever cases in the United States occur among international travelers; most are in travelers returning from South Asia, primarily Bangladesh, India, and Pakistan. Other high-risk regions for infection include Africa, Latin America, and Southeast Asia; lower-risk regions include East Asia and the Caribbean.

Travelers visiting friends and relatives are at increased risk because they might be less careful with food and water while abroad than other travelers and might not seek pretravel health consultation or typhoid vaccination (see Sec. 9, Ch. 9, Visiting Friends & Relatives: VFR Travel ). Although the risk of acquiring illness increases with the duration of stay, travelers have acquired typhoid fever even during visits of <1 week to countries where the disease is highly endemic (e.g., Bangladesh, India, Pakistan).

The incubation period of both typhoid and paratyphoid infections is 6–30 days. The onset of illness is insidious, with gradually increasing fatigue and a fever that increases daily from low-grade to 102°F–104°F (38°C–40°C) by the third or fourth day of illness. Fever is commonly lowest in the morning, peaking in the late afternoon or evening. Anorexia, headache, and malaise are nearly universal, and abdominal pain, constipation, or diarrhea are common. Diarrhea and vomiting are more common in children than in adults. People also can have dry cough, fatigue, myalgias, and sore throat. Hepatosplenomegaly often can be detected. A transient, maculopapular rash of rose-colored spots can occasionally be seen on the trunk.

The clinical presentation is often confused with malaria. Suspect enteric fever in a person with a history of travel to an endemic area who is not responding to antimalarial medication. Untreated, the disease can last for a month, and reported case-fatality ratios are 10%–30%. By comparison, the case-fatality ratio in patients treated early is usually <1%. Serious complications of typhoid fever occur in 10%–15% of hospitalized patients, generally after 2–3 weeks of illness, and include life-threatening gastrointestinal hemorrhage, intestinal perforation, and encephalopathy. Paratyphoid fever appears to have a lower case-fatality ratio than typhoid fever; however, severe cases do occur.

Typhoid and paratyphoid fever are nationally notifiable diseases in the United States. Clinicians should report cases to their state or local health department. Identification of a domestically acquired case should prompt a public health investigation to prevent other cases.

Blood Culture

Patients with typhoid or paratyphoid fever typically have bacteremia; blood culture is therefore the preferred method of diagnosis. A single culture is positive in only ≈50% of cases, however. Multiple blood cultures increase the sensitivity and might be required to make the diagnosis. Depending on the blood culture system used, cultures might need to be held and observed for up to 7 days before reporting a negative result. Although bone marrow culture is more invasive (and therefore less commonly performed), it increases the sensitivity to ≈80% of cases and is relatively unaffected by previous or concurrent antibiotic use. Stool culture is not usually positive during the first week of illness and has less diagnostic sensitivity than blood culture. Urine culture has a lower diagnostic yield than stool culture.

Rapid Diagnostic Tests

Globally, several commercial rapid diagnostic tests for typhoid fever are available, but their sensitivity and specificity are not optimal. The Widal test measures elevated antibody titers; it is unreliable but widely used in developing countries because of its low cost. Serologic tests do not distinguish acute from past infection or vaccination and lack specificity; thus, blood culture remains the preferred method to diagnose acute infections.

Clinical Diagnosis

Poor sensitivity and specificity of rapid antibody tests and the time it takes to obtain a positive culture mean that the initial diagnosis must often be made clinically. Typhoid and paratyphoid fever are clinically indistinguishable. The combination of risk factors for infection and gradual onset of fever that increases in severity over several days should raise suspicion of enteric fever.

Antibiotic therapy shortens the clinical course of enteric fever and reduces the risk for death. Treatment decisions are complicated by high rates of resistance to many antimicrobial agents, and antimicrobial treatment should be guided by susceptibility testing. A careful travel history can inform empiric treatment choices while awaiting culture results.

Multidrug-Resistant Infection

Established resistance to older antibiotics (e.g., ampicillin, chloramphenicol, trimethoprim-sulfamethoxazole) has led to these agents being recommended only as alternative antibiotics for infections with known susceptibility. Multidrug-resistant (MDR) Typhi with resistance to all 3 of these antibiotics has been present for decades. Regional estimates for MDR Typhi range from 9% in South Asia (2015–2018) to 35%–59% in parts of Africa (2010–2014).

Fluoroquinolones (e.g., ciprofloxacin) are still considered the treatment of choice for fluoroquinolone-susceptible infections in adults. Most Typhi and Paratyphi A infections in the United States are fluoroquinolone-nonsusceptible, however, and most (>90%) have occurred among travelers returning from South Asia. Fluoroquinolone-nonsusceptible infections have been associated with treatment failure or delayed clinical response. Therefore, azithromycin and ceftriaxone, antibiotics with historically low rates of resistance globally, are increasingly being used as empiric treatment for enteric fever.

Extensively Drug-Resistant Infection

In 2017, among all Typhi and Paratyphi A isolates tested by CDC’s National Antimicrobial Resistance Monitoring System (NARMS), <1% were resistant to azithromycin or to ceftriaxone, based on resistance criteria for Typhi. Resistance to both agents is emerging, however. In 2016, an outbreak of extensively drug-resistant (XDR) typhoid fever began in Sindh Province, Pakistan. These XDR Salmonella Typhi isolates are typically resistant to ampicillin, ceftriaxone, chloramphenicol, ciprofloxacin, and trimethoprim-sulfamethoxazole, but susceptible to azithromycin and carbapenem antibiotics.

The first US cases of XDR typhoid fever associated with travel to Pakistan were diagnosed in 2018, and by early 2021 >70 XDR infections had been documented among residents of the United States, including 9 cases among patients who did not travel internationally in the 30 days before illness began. Ceftriaxone resistance also has been identified in Typhi isolates from US travelers returning from Iraq. Additionally, resistance to azithromycin has been identified among Typhi and Paratyphi strains isolated from patients in Bangladesh, Cambodia, India, Nepal, Pakistan, Saudi Arabia, and the United States.

Empiric treatment should be guided by the patient’s travel history. For patients with suspected typhoid fever who traveled to Iraq or Pakistan, or who did not travel internationally before their illness began, empirically treat uncomplicated illness with azithromycin, and treat complicated illness with a carbapenem. Ceftriaxone remains an appropriate empiric treatment option for travelers returning from most other countries. Once culture results are available, use susceptibility information to guide treatment. Case reports have suggested that patients with XDR Typhi infection who do not improve on a carbapenem alone might benefit from the addition of a second antibiotic (e.g., azithromycin). Updated information about antimicrobial resistance among isolates from US patients with enteric fever in the United States can be found at the NARMS website .

Cases Unresponsive to Treatment

Patients treated with antimicrobial agents can continue to have fever for 3–5 days, but the maximum temperature generally decreases each day. Patients sometimes feel worse during the first few days after commencing antibiotic treatment. If fever in a person with typhoid or paratyphoid infection does not subside within 5 days of initiating antibiotic therapy, however, consider treatment with alternative antibiotics or begin looking for a persistent focus of infection (e.g., an abscess, or an infection in a bone, joint, or other extraintestinal site).

Relapse, Reinfection & Chronic Carriage

Relapse, reinfection, and chronic carriage also can occur. Relapse occurs in ≤10% of patients 1–3 weeks after clinical recovery, requiring further antibiotic treatment. An estimated 1%–4% of treated patients become asymptomatic chronic carriers (defined as people who excrete the organism in stool for ≥12 months); a prolonged antibiotic course is usually required to eradicate the organism.

Food & Water Precautions

Safe food and water precautions and frequent handwashing, especially before meals, are important in preventing both typhoid and paratyphoid fever (see Sec. 2, Ch. 8, Food & Water Precautions ). Although recommended by the Advisory Committee on Immunization Practices (ACIP), typhoid vaccines are not 100% effective, and a large bacterial inoculum can overwhelm vaccine-induced immunity. Therefore, vaccinated travelers should follow recommended food and water precautions to prevent enteric fever and other infections. No vaccines are available for paratyphoid fever; thus, food and water precautions are the only prevention methods.

Indications

The ACIP recommends typhoid vaccine for travelers going to areas where risk for exposure to Typhi is recognized. Destination-specific vaccine recommendations are available at the CDC Travelers’ Health website. Two typhoid vaccines are licensed for use in the United States: Vi capsular polysaccharide vaccine (ViCPS) (Typhim Vi, manufactured by Sanofi Pasteur) for intramuscular use; and live attenuated vaccine (Vivotif, manufactured from the Ty21a strain of serotype Typhi by PaxVax) for oral use. Both vaccines are unconjugated, which means the polysaccharide antigens are not paired with a protein to elicit a strong response from the immune system. Because these vaccines protect 50%–80% of recipients, remind travelers that typhoid immunization is not 100% effective, and take the opportunity to reinforce safe food and water precautions. Neither vaccine is licensed to prevent paratyphoid fever, although limited data from efficacy trials suggest that the Ty21a vaccine might provide some cross-protection against Paratyphi B.

Newer, protein conjugated Vi vaccines have greater efficacy in children <2 years old and protect people for longer than Vi unconjugated polysaccharide vaccines. Three typhoid Vi conjugate vaccines (TCV) have been licensed in India: Peda Typh (manufactured by Biomed); Typbar-TCV (manufactured by Bharat Biotech); and Zyvac TCV (manufactured by Zydus Cadila). Typbar-TCV also is licensed in Cambodia, Nepal, and Nigeria. Although none of these vaccines are licensed or available in the United States, Tybar-TCV received prequalification from the World Health Organization in 2018. The vaccine is approved for use in people ≥6 months old. In a human challenge study, Typbar-TCV had ≈87% protective efficacy. Interim analysis from a large field study in Nepal has shown Typbar-TCV effectiveness of 81.6% in children after 15 months of follow-up.

Administration

For information on dosage, administration, and revaccination for the 2 typhoid vaccines licensed in the United States, see Table 5-07 . The time required for primary vaccination differs, as do the lower age limits for each.

Table 5-07 Typhoid fever vaccines

Abbreviations: IM, intramuscular; NA, not applicable.

1 Vaccine must be kept refrigerated at 35°F–46°F (2°C–8°C).

2 Capsules should be taken with cool liquid, no warmer than 98.6°F (37°C)

VI Capsular Polysaccharide Vaccine

Primary vaccination with ViCPS consists of one 0.5-mL (25-μg) dose administered intramuscularly ≥2 weeks before travel. The vaccine is approved for use in people ≥2 years old. A dose is recommended every 2 years for those who remain at risk.

Live Attenuated Ty21A Vaccine

Primary vaccination with Ty21a vaccine consists of 4 capsules, 1 taken every other day. The capsules should be kept refrigerated (not frozen), and all 4 doses must be taken to achieve maximum efficacy. Each capsule should be swallowed whole (not chewed) and taken with cool liquid no warmer than 98.6°F (37°C), approximately 1 hour before a meal and ≥2 hours after a previous meal. The manufacturer recommends avoiding alcohol consumption 1 hour before and 2 hours after administration, because alcohol can disintegrate the enteric coating.

Travelers should complete the Ty21a vaccine regimen ≥1 week before potential exposure. The approach for addressing a missed oral vaccine dose or taking a dose late is undefined. Some suggest that minor deviations in the dosing schedule (e.g., taking a dose 1 day late) might not alter vaccine efficacy; no studies have shown the effect of such deviations, however. If travelers do not complete 4 doses as directed, they might not achieve an optimal immune response. The vaccine is approved for use in people ≥6 years old. A booster dose is recommended every 5 years for those who remain at risk.

Adverse Reactions

Adverse reactions most often associated with ViCPS vaccine include headache, injection-site reactions, fever, and general discomfort. Adverse reactions to Ty21a vaccine are rare and mainly consist of abdominal discomfort, diarrhea, fever, headache, nausea, vomiting, and rash. Report adverse reactions to the Vaccine Adverse Event Reporting System at the website or by calling 800-822-7967.

Precautions & Contraindications

Neither the ViCPS nor the Ty21a vaccine should be given to people with an acute febrile illness; in addition, Ty21a is not recommended for use in people with acute gastroenteritis. Live vaccines, including Ty21a vaccine, should not be given to pregnant or immunocompromised people, including those with HIV. No information is available on the safety of the inactivated vaccine (ViCPS) in pregnancy; consider ViCPS for pregnant people when the benefits of vaccination outweigh potential risks (e.g., when the likelihood of exposure to Typhi is high).

The intramuscular vaccine (ViCPS) presents a theoretically safer alternative than the live, oral vaccine (Ty21a) for immunocompromised travelers. The Ty21a vaccine can be administered to household contacts of immunocompromised people; although vaccine organisms can be shed transiently in the stool of vaccine recipients, secondary transmission of vaccine organisms has not been documented. The only contraindication to vaccination with ViCPS vaccine is a history of severe local or systemic reactions after a previous dose.

Theoretical concerns have been raised about the immunogenicity of Ty21a vaccine in people concurrently receiving antimicrobial agents, live vaccines, or immune globulin. The growth of the live Ty21a strain is inhibited in vitro by various antimicrobial agents. The manufacturer advises that vaccination with the Ty21a vaccine should be delayed for >72 hours after the administration of any antimicrobial agent, and antibiotics should not be given to a patient ≤72 hours after the last dose of the Ty21a vaccine.

Ty21a vaccine can be administered simultaneously or at any interval before or after live virus vaccines (e.g., measles-mumps-rubella, oral polio, or yellow fever vaccines). Available data do not suggest that simultaneous administration of live virus vaccines decreases the immunogenicity of the Ty21a vaccine. If typhoid vaccination is warranted, it should not be delayed because of administration of viral vaccines. No data are available on coadministration of the Ty21a vaccine and the oral cholera vaccine (lyophilized CVD 103-HgR [Vaxchora]); taking the first Ty21a vaccine dose ≥8 hours after oral cholera vaccine might decrease potential interference between the vaccines. Simultaneous administration of the Ty21a vaccine and immune globulin does not appear to pose a problem.

CDC website: Typhoid fever and paratyphoid fever

The following authors contributed to the previous version of this chapter: Grace D. Appiah, Michael J. Hughes, Kevin Chatham-Stephens

Bibliography

Browne AJ, Kashef Hamadani BH, Kumaran EAP, Rao P, Longbottom J, Harris E, et al. Drug-resistant enteric fever worldwide, 1990 to 2018: a systematic review and meta-analysis. BMC Med. 2020;18(1):1.

Crump JA. Progress in typhoid fever epidemiology. Clin Infect Dis. 2019;68(Suppl 1):S4–9.

Crump JA, Sjölund-Karlsson M, Gordon MA, Parry CM. Epidemiology, clinical presentation, laboratory diagnosis, antimicrobial resistance, and antimicrobial management of invasive Salmonella infections. Clin Microbiol Rev. 2015;28(4):90137.

Date KA, Bentsi-Enchill A, Marks F, Fox K. Typhoid fever vaccination strategies. Vaccine. 2015;33:C55–61.

Date KA, Newton AE, Medalla F, Blackstock A, Richardson L, McCullough A, et al. Changing patterns in enteric fever incidence and increasing antibiotic resistance of enteric fever isolates in the United States, 2008–2012. Clin Infect Dis. 2016;63(3):322–9.

Effa EE, Lassi ZS, Critchley JA, Garner P, Sinclair D, Olliaro P, Bhutta ZA. Fluoroquinolones for treating uncomplicated typhoid and paratyphoid fever (enteric fever). Cochrane Database Syst Rev. 2011(10):CD004530.

François Watkins LK, Winstead A, Appiah GD, Friedman CR, Medalla F, Hughes MJ, et al. Update on extensively drug-resistant Salmonella serotype Typhi infections among travelers to or from Pakistan and report of ceftriaxone-resistant Salmonella serotype Typhi infections among travelers to Iraq—United States, 2018–2019. MMWR Morb Mortal Wkly Rep. 2020;69(20):618–22.

Jackson BR, Iqbal S, Mahon B. Updated recommendations for the use of typhoid vaccine—Advisory Committee on Immunization Practices, United States, 2015. MMWR Morb Mortal Wkly Rep. 2015;64(11):305–8.

Klemm EJ, Shakoor S, Page AJ, Qamar FN, Judge K, Saeed DK, et al. Emergence of an extensively drug-resistant Salmonella enterica serovar Typhi clone harboring a promiscuous plasmid encoding resistance to fluoroquinolones and third-generation cephalosporins. mBio. 2018;9(1):e00105–18.

Lynch MF, Blanton EM, Bulens S, Polyak C, Vojdani J, Stevenson J, et al. Typhoid fever in the United States, 1999–2006. JAMA. 2009;302(8):859–65.

McAteer J, Derado G, Hughes M, Bhatnagar A, Medalla F, Chatham-Stephens K, et al. Typhoid fever in the US pediatric population, 1999–2015: opportunities for improvement. Clin Infect Dis. 2021; (73)11:e4581–9.

Stanaway JD, Reiner RC, Blacker BF, Goldberg EM, Khalil IA, Troeger CE, et al. The global burden of typhoid and paratyphoid fevers: a systematic analysis for the Global Burden of Disease Study 2017. Lancet Infect Dis. 2019;19(4):369–81.

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Vaccination - Typhoid fever

Vaccination against typhoid fever is recommended if you're travelling to parts of the world where the condition is common.

High-risk areas

Typhoid fever is found throughout the world, but you're more likely to get it in areas where there's poor sanitation and hygiene. 

High-risk areas include:

• the Indian subcontinent
• south and southeast Asia
• South America

Vaccination is strongly recommended if you're going to be staying or working with local people, or if you're going to be staying for prolonged periods in areas where sanitation and food hygiene are likely to be poor.

In the UK, most people who get typhoid fever develop it while visiting India, Pakistan or Bangladesh. It's therefore particularly important that you're vaccinated if you're visiting these countries.

Vaccination against typhoid fever is usually free on the NHS from GP surgeries. Private travel clinics also offer the vaccine for about £30.

Typhoid fever vaccines

In the UK, the 2 main vaccines available to prevent typhoid fever are:

• Vi vaccine – given as a single injection
• Ty21a vaccine – given as 3 capsules to take on alternate days

Combined typhoid and  hepatitis A  injections are also available for people aged 15 or over. Protection against hepatitis A lasts 1 year and protection against typhoid lasts 3 years.

The vaccines work by stimulating your body to create antibodies (infection-fighting proteins) that prevent you getting ill if you become infected with the typhoid bacteria.

But neither typhoid vaccine is 100% effective, so you should always take precautions when eating food and drinking water abroad.

As the Ty21a vaccine contains a live sample of Salmonella typhi bacteria, it isn't suitable for people with a weakened immune system – for example, people with HIV and those receiving certain types of treatment, such as chemotherapy . 

It also isn't usually recommended for children under 5, whereas children can have the Vi vaccine from 2 years of age.

It's unclear whether the Vi and Ty21a vaccines present a risk to pregnant or breastfeeding women. But vaccination should be considered if there's a significant risk of getting typhoid fever.

The typhoid vaccine should ideally be given at least 1 month before you travel, although if necessary it can be given closer to your travel date.

Booster vaccinations are recommended every 3 years if you continue to be at risk of infection with typhoid bacteria.

Side effects of typhoid fever vaccine

After having the typhoid fever vaccine, some people have temporary soreness, redness, swelling or hardness at the injection site.

About 1 in every 100 people have a high temperature.

Less common side effects include:

• abdominal pain
• feeling sick

Severe reactions are rare for both typhoid vaccines.

Read more about routine NHS vaccinations .

Advice for travellers

Whether you have been vaccinated against typhoid or not, it's important to take basic precautions when travelling in countries where typhoid fever is present.

For example:

• only drink bottled water from a bottle that was properly sealed, or water that's been recently boiled
• avoid ice cream and don't have ice in your drinks
• avoid uncooked fruit and vegetables, unless you have washed them in safe water or peeled them yourself
• avoid shellfish, seafood and salads

Read more about safe and healthy holidays on the ABTA website

Page last reviewed: 20 September 2021 Next review due: 20 September 2024

Raj Palraj, M.B.B.S., M.D.

• Infectious Diseases

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9 common questions about vaccines and travel

• Immunizations

Travel does more than just transport you to a different place. It can broaden your perspective, increase your happiness, give you a chance to try new things, boost your creativity and help you recharge. Even planning a trip can be an exciting task. The anticipation of mapping an itinerary and scheduling your must-see attractions can bring a lot of joy and happiness.

One of the most important tasks before taking a trip is to make an appointment with a travel medicine specialist. These health care professionals help keep travelers safe and happy before and after their journeys.

Here are answers to common questions about travel medicine:

1. who should make an appointment with a travel medicine specialist.

Anyone planning a trip overseas can benefit from seeing a travel medicine specialist. However, a travel clinic appointment is critical if you are traveling to underdeveloped or developing countries where there's a higher risk of contracting severe communicable illnesses while abroad. It is also important for patients with certain medical conditions that make their immune systems weaker and more vulnerable to infectious diseases.

2. What vaccinations do I need to travel overseas?

All travelers should be vaccinated against the flu and current with COVID-19 vaccines and boosters.

In addition, it's important to complete the adult vaccination schedule that includes vaccinations for:

• Chickenpox (varicella)
• Diphtheria, tetanus and pertussis (DTP)
• Pneumococcal
• Measles, mumps and rubella (MMR)

Additional vaccines may be recommended depending on your travel itinerary. For example, hepatitis A vaccination is recommended if you are traveling to Southeast Asia. During your appointment, we can discuss which vaccines are appropriate for your itinerary.

3. Are there travel destinations that have different vaccination recommendations?

Yes. Infectious diseases thrive in different climates. If you travel to a new climate, you may be exposed to diseases to which you don't have any immunity.

Some infections are more prevalent in tropical settings compared to temperate climates. For example, typhoid and hepatitis A are more common in Southeast Asia because these communicable diseases can be spread through contaminated water. Some areas of Africa and South America have a higher prevalence of yellow fever and malaria, which are mosquito-borne infections.

The Centers for Disease Control and Prevention (CDC) has good information online for travelers for each travel destination.

Recommended vaccines may include:

• Hepatitis A
• Hepatitis B
• Japanese encephalitis
• Yellow fever

4. Can my primary care provider give me travel vaccinations?

It depends on your travel destinations and vaccine recommendations. I recommend starting the conversation with your primary care provider and reviewing the CDC recommendations .

If you have a complex itinerary with multiple countries or are traveling to Southeast Asia or Africa, it's better to make an appointment at the travel clinic. I also would recommend patients with organ transplants and immunocompromising conditions seek travel medicine consultation to reduce the risk of illness during travel. During that appointment, we will review your itinerary, provide necessary vaccinations and discuss ways to prevent mosquito-borne or tick-borne diseases.

5. How long before my trip should I go to the travel clinic?

Plan to have an appointment at least four weeks before you travel. Some vaccines require several weeks for immunity to develop, while others require more than one dose of vaccine for full protection.

If your trip is to an underdeveloped or developing country, you may need to schedule an appointment up to two months in advance to receive a complete set of immunizations. This gives your body time to produce the protective antibodies, so you are well protected when you land at your destination.

6. Can I only go to the travel clinic before I travel?

No. The Travel and Tropical Medicine Clinic is available before or after travel. The team can provide consultative services and treatment if you get sick after you return home.

7. I'm going to an all-inclusive resort. Will I have a lower risk of getting sick?

Maybe, but no traveler should take safety for granted. Even in an all-inclusive resort, knowing how food is prepared or the water supply quality is not possible. Mosquitos and other insects could still be a concern. It's important to take all necessary precautions and follow vaccination recommendations when you travel, regardless of your accommodations.

8. How do I lower my risk of malaria when traveling?

Malaria is a disease caused by a parasite. It's spread to humans through the bites of infected mosquitoes. Prophylactic malaria medications are available and are started before the travel, continued during the stay and for a certain duration after returning home. A travel medicine specialist can review the risks and benefits of all prevention and treatment options.

9. How do I stay healthy while traveling?

Nothing can ruin a trip like illness. Make sure all your vaccinations and boosters are up to date, and get any new vaccinations recommended for your destinations.

Food and water safety is important while traveling. Only eat well-cooked food. Avoid eating from roadside stands and uncooked foods, like salad and raw vegetables. Drink bottled beverages only, including bottled water. This is especially important if you travel in resource-limited regions, such as Southeast Asia or Africa.

Hand hygiene is important at home and overseas. Wash your hands often using soap and hot water. Avoid crowded places, follow respiratory etiquette and consider optional masking. Mosquitos and bugs can transmit parasites and diseases, like yellow fever and malaria. Use mosquito repellents. Mosquito nets may be appropriate in some parts of the world, as well.

As you make travel plans, schedule an appointment with a travel medicine specialist to get the vaccinations and information you need to be healthy and safe on your journey.

Raj Palraj, M.D. , is a physician in Infectious Diseases and Travel and Tropical Medicine in La Crosse , Wisconsin.

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Infections in Returning Travelers

Of the approximately 80 million people who travel from industrialized to developing countries each year, 22% to 64% of travelers report some illness. 1 , 2 The approach to the patient requires knowledge of world geography, the epidemiology of disease patterns in 230 or so countries, and the clinical presentation of a wide spectrum of disorders. 3 Most illnesses are mild, most are self-limited, and many are noninfectious. Up to 10% of travelers may consult a physician during or after a trip, and approximately 1 in 100,000 travelers will die.

The ill travelers that do come to the attention of infectious diseases clinicians are generally either the most seriously ill or are suspected of harboring infectious agents not familiar in their home country. Based on 42,173 ill returned travelers seen by the GeoSentinel Surveillance Network at 53 different clinical sites on six continents, in patients presenting to infectious or tropical diseases specialists after travel to the developing world, specific travel destinations are associated with the probability of the diagnosis of certain diseases. 4 Diagnostic approaches and empirical therapies can be guided by these destination-specific differences. Important region-specific disease occurrence data indicate that febrile illness is most important from Africa and Southeast Asia; malaria is one of the top three diagnoses from every region, yet over the past decade dengue has become the most common febrile illness from every region outside sub-Saharan Africa; in sub-Saharan Africa, rickettsial disease is second only to malaria as a cause of fever; respiratory disease is most important in Southeast Asia and sub-Saharan Africa; and acute diarrhea is disproportionately from South Central Asia. When individual diagnoses are collected into syndrome groups and examined for all regions together, 233 of every 1000 ill returned travelers have a systemic febrile illness, 334 have acute or chronic gastrointestinal infection, 195 have a dermatologic disorder, and 209 have a respiratory disorder.

Travelers who become ill during, or any time up to several months after, a foreign trip will frequently associate that illness with a possible travel-specific cause. This may be the case, but often it is not. Routine disorders are common, and common disorders are common whether actually acquired during travel or at some time after the trip. Thus fever, sore throat, and cervical adenopathy in a college student who returned 2 weeks earlier from a developing country is still more likely to be streptococcal pharyngitis or infectious mononucleosis than diphtheria. Presented with an ill patient with a history of travel, the physician must maintain discipline in making two separate lists of differential diagnoses, the first with the travel history factored in and the second considering the same presenting symptoms and signs as if in any other patient. The approach and workup must then proceed in parallel, with appropriate priority given to the most urgent or the most treatable diagnoses at the top of each list.

In this chapter, travelers are considered to be those returning from short visits to developing countries, and the term does not include immigrants, refugees, and very long-term residents arriving from those countries. Constellations of exposures and clinical presentations highly suggestive of particular diagnoses in returned travelers are shown in Table 324-1 . Highly exotic endemic diseases rarely acquired by travelers are not discussed. Low-frequency illnesses (<20 cases of the 42,173 listed in the “GeoSentinel Surveillance of Illness in Returned Travelers, 2007-2011” 4 ), some potentially serious, were reported, including visceral leishmaniasis, east African trypanosomiasis, scrub typhus, relapsing fever, angiostrongyliasis, botulism, melioidosis, tularemia, hantavirus infection, and infection with Plasmodium knowlesi. No cases of yellow fever, Ebola virus, Lassa fever, Marburg virus, tetanus, polio, anthrax, or plague were reported in this 5-year cohort, thus attesting to their rarity.

TABLE 324-1

Constellations of Exposures and Clinical Presentations Suggestive of Particular Diagnoses in Returned Travelers *

The focus is on the identification of infectious causes of the presenting illness, on travel-associated risk factors, and on manifestations of those diseases that are particular to travelers. Detailed discussions of pathophysiology, spectrum of clinical manifestations, and therapy for each infectious agent are found in the disease-specific chapters of this book. Fever, traveler's diarrhea, and skin problems are the most common presenting illnesses in returned travelers. Eosinophilia is less common but is a frequent source of referral to the infectious diseases specialist.

Epidemiology

Fever occurs in 2% to 3% 5 , 6 , 7 of European or American travelers to the developing world. The proportion of ill returned travelers who present to specialists with a febrile illness is 24%, with variation by region of travel: Americas, 14%; South-Central Asia (includes India), 13%; Southeast Asia, 18%; and sub-Saharan Africa, 43%.

Several large case series from busy tropical disease units indicate malaria to be the cause of the fever in 27% to 42%. 5 , 6 , 7 The other most common tropical diseases specific to returning travelers are dengue, rickettsial disease, typhoid fever, and those caused by enteric pathogens. Less common but important considerations are leptospirosis, chikungunya, acute schistosomiasis, and amebic liver abscess. All of these diseases have widespread distribution in the tropics and need to be considered initially in all febrile travelers. Some may be ruled out quickly based on a detailed travel and exposure history and consultation with relevant information sources on disease distribution. Upper and lower respiratory tract infection, including streptococcal pharyngitis and influenza, as well as urinary tract infections, are cosmopolitan, nontropical febrile disorders that are remarkably common in travelers and should always be considered. In every series from sophisticated referral centers, up to 22% to 25% of those presenting with fever have self-limited illnesses that never have an etiologic diagnosis confirmed. 7 These are mostly viral syndromes caused by one of hundreds of viral agents that exist outside developed countries for which diagnostic tests may not be available anywhere. In many cases, the time and expense of a large panel of viral isolation and serologic assays is not warranted outside the research setting. Fever due to deep venous thrombosis or pulmonary embolism may be related to travel, especially in those with preexisting conditions or underlying coagulopathy. Thromboembolic disease always needs to be considered from the outset but is not discussed further here. 8 , 9

A good patient history is always important in clinical medicine, but nowhere is it as important as in the returning traveler. The cumulative list of infectious agents in 230 separate countries is daunting. A day-by-day travel itinerary, knowledge of risk factors and exposures for the common travel diseases, knowledge of usual incubation periods of those diseases, and knowledge of or access to the known geographic distribution of possible infectious diseases will lead to an appropriately focused workup. 8 , 9 , 10 Much time, expense, and patient discomfort due to sometimes invasive diagnostic tests can be avoided when diagnoses that are not epidemiologically or chronologically possible are eliminated based on the patient history.

The fever pattern and clinical findings by themselves are often nonspecific and overlap greatly between many of the most common tropical infectious diseases. The history should include the key elements detailed in the following sections.

Detailed Travel Itinerary

A travel itinerary should include every locale visited in every country visited, including transit stops. Some individuals are frequent travelers, so all travel for at least the previous 6 months must be considered initially. If the diagnosis remains elusive, a more remote travel history, especially that involving malarious areas, may be sought. The exact date of arrival back in the home country is often crucial to ascertain the last possible exposure date to an exotic pathogen. These details are most efficiently ascertained using a waiting room questionnaire. For example, it is insufficient to know simply that the patient visited Peru. Some parts of Peru are malarious and others are not, only some have risk of yellow fever, high-altitude destinations have little risk of vector-borne disease, and there is no risk of strongyloidiasis along the desert coastal strip.

Chronology of Travel and Illness

This should include the exact dates spent in each locale with respect to the onset of illness. Knowledge of typical incubation periods ( Table 324-2 ) of possible infectious causes is a key tool in narrowing the differential diagnosis. Many agents are simply not biologically possible outside their usual incubation period. Arboviral diseases such as dengue uniformly have short incubation periods. Onset of illness more than 2 weeks after the last possible exposure effectively rules out this class of viral illness. None of the known hemorrhagic fever viruses has a possible incubation longer than 21 days. Long-incubation infections like schistosomiasis cannot present less than several weeks after first possible exposure. Some diseases such as malaria or enteric fever have more variable incubation periods but nevertheless have a typical incubation period during which time the majority of the patients present. A number of diseases, especially those that are arthropod borne, have a strict seasonality whereby transmission stops during either cold or dry weather. Examples would include malaria in nontropical countries such as Korea, Tajikistan, or northern China, as well as Lyme borreliosis or tick-borne encephalitis, all of which completely cease transmission during winter months. GeoSentinel surveillance data indicate that dengue cases in travelers show marked region-specific peaks for Southeast Asia (June, September), South-Central Asia (October), South America (March), and the Caribbean (August, October). 11 , 12

TABLE 324-2

Incubation Periods of Common Travel-Related Infections *

HIV, human immunodeficiency virus.

A detailed dietary history is essential. Budget travel and associated high-risk eating habits predispose to a variety of common enteric pathogens. A history of specific foods associated with known pathogens also should be elicited. This includes unpasteurized dairy products (Brucella, Campylobacter, Salmonella, Mycobacterium tuberculosis), shellfish (vibrios, enteric viruses, viral hepatitis), uncooked beef such as carpaccio and steak tartare ( Toxoplasma, Campylobacter, Escherichia coli O157-H7), undercooked fish such as sushi and ceviche (vibrios, Anisakis, Gnathostoma ), and undercooked pork or game meat (trichinosis). Exposure to fresh water or surface water in recreational or other settings may be associated with schistosomiasis 13 , 14 , 15 or leptospirosis. 16 , 17 A history of exposure to mosquitoes and flies is generally unhelpful, but a history of tick bite (rickettsiae, relapsing fever, tick-borne encephalitis) or tsetse fly bite should be sought in the right setting. Exposures to new sexual partners, 18 , 19 , 20 needles, or blood should be ascertained. Rodent exposure is associated with Lassa fever, hantavirus infection, murine typhus, and rat-bite fever. A history of contact with other sick people is especially important in the post-travel setting. Travelers usually move in groups or with families or companions, all of whom will likely have shared the same exposures.

Immunization History

The immunization history should include exact dates of the last dose of each vaccine received and in some instances whether an adequate primary series was completed in the first place. Most vaccines, with the notable exception of typhoid vaccines, are highly efficacious. Thus, hepatitis A or B, yellow fever, measles, and diphtheria are unlikely diagnoses in those travelers with a substantiated history of adequate and current immunization.

Antimalarial Prophylaxis or Treatment

If malaria is a possibility, a complete pill-by-pill history of ingestion of antimalarial drugs, including the name and dose of all drugs taken for prophylaxis or treatment, must be obtained. Patients often misunderstand the dosing or timing instructions given at the pretravel visit, or they may have been prescribed an inappropriate drug for their destination. Patients may have been treated with appropriate or inappropriate drugs en route for febrile illnesses. Some very efficacious drugs are not available in the United States, and an international pharmacopeia such as Martindale's may need to be consulted by those unfamiliar with these drugs. A history of appropriate prophylaxis diminishes the possibility of malaria but does not eliminate the need for a malaria thick film, which may be preceded by a malaria rapid card test for any patient legitimately exposed to malaria.

Other Medications Ingested

Travelers who fall ill during travel often self-treat with antibiotics or see a local physician and are prescribed a broad-spectrum antibiotic. Again, an international pharmacopeia may need to be consulted. Recent ingestion of a 1-week course of a quinolone, tetracycline, or cephalosporin may alter the course of the illness or even affect the possibility of certain diagnoses. In particular, malaria may be suppressed by azithromycin, doxycycline, quinolones, or clindamycin.

Physical Examination

Common tropical infections often present as undifferentiated fever without focal findings. However, when a focal finding such as arthritis, meningitis, or pneumonia is present, the differential diagnosis can often be narrowed. Unfortunately, physical findings such as jaundice, hepatomegaly, splenomegaly, and lymphadenopathy occur at least a portion of the time in many of the most common travel-related infections and so are not specific enough to greatly narrow the differential diagnosis. 5 Most imported febrile rash illnesses engender the same differential diagnosis as for nontravelers. However, arbovirus infections, typhoid, rickettsial illness, leptospirosis, measles, early stages of viral hemorrhagic fevers, relapsing fever, and acute African trypanosomiasis should always be kept in mind.

Considerations for the Common Travel-Related Febrile Illnesses

Fever in a traveler returning from a malarious area is an emergency, and the instinctive performance of an immediate malaria smear will prevent unnecessary deaths. A malaria rapid diagnostic test is licensed in the United States for use in clinical laboratories and not at the point of care. The readout for this antigen detection test is Plasmodium falciparum, or non– P. falciparum, or mixed infection. Because it is highly specific, a positive test means immediate treatment is warranted.

The malaria rapid diagnostic test has excellent sensitivity for P. falciparum but may still miss low parasitemias so is not a definitive means to rule out malaria. The sensitivity is poor for non– P. falciparum malaria, which tends to have much lower parasitemias, but non– P. falciparum malaria is not usually life threatening. 21 Thus, a negative test does not rule out malaria and must always be followed by a blood film. Malaria due to P. falciparum is easily treatable if diagnosed early but even with optimum treatment has a mortality rate of 20% or more if treatment is begun only after end-organ complications arise. Smears need to be repeated at least every 12 to 24 hours a minimum of three times to rule out malaria. Rapid deterioration can occur over a period of hours. Patients who are unreliable to care for themselves and have smear-negative results but a high index of suspicion for P. falciparum malaria may need to be admitted for inpatient observation.

Because malaria is overwhelmingly an African disease, with about 80% of all P. falciparum imported into developed countries originating there, 22 , 23 , 24 , 25 suspicion of malaria is especially acute for Africa returnees. Beyond this, trends in the geographic origin of imported malaria cases do not always correlate well with regional transmission patterns because absolute numbers of cases from particular geographic areas may also mirror the intensity of travel to the affected region. Ethnic minority travelers returning home to visit friends and relatives in malarious areas have the highest risk for infection. Resources describing current country-specific malaria microepidemiology should be immediately accessible to those assessing tropical fevers. In general, malaria is a rural disease, but the cities of Africa and India are exceptions.

P. falciparum malaria in nonimmune travelers most commonly has an incubation period of 9 to 14 days, and 90% of cases occur within 1 month of last exposure. Non– P. falciparum malaria in travelers is only rarely life threatening but can present much later after arrival. Incubation periods are prolonged in those taking inadequate or incomplete chemoprophylaxis. Relapses of disease due to Plasmodium vivax or Plasmodium ovale may occur many months after travel in those whose initial attack was clinically silent because of suppressive chemoprophylaxis but in whom terminal prophylaxis with primaquine was not used (see Chapter 276).

The presenting signs and symptoms of imported malaria remain sufficiently protean so as to mimic a number of common tropical or nontropical conditions. 22 , 23 , 24 , 25 No constellation of symptoms or signs differentiates P. falciparum from non– P. falciparum malaria. Classic periodic malarial fever is not a usual manifestation of imported malaria, although when fever does occur in discrete, repeated 48- or 72-hour cycles, the diagnosis is almost certain. The simian malaria parasite P. knowlesi, 26 which is now known to commonly infect humans in Malaysia and throughout Southeast Asia, uniquely has a periodicity of 24 hours. Infected patients have high parasitemias (>1%) with a plasmodium that is morphologically almost identical to Plasmodium malariae . P. malariae typically has a parasitemia of less than 1%. Fever is absent at the exact time of the initial medical assessment in up to 40% of patients with malaria. Respiratory or gastrointestinal symptoms may be predominant. The presence of rash, lymphadenopathy, or leukocytosis indicates another diagnosis. Anemia is uncommon in travelers who present in the early days of their malarial illness. Thrombocytopenia occurs in over 50% and is a reliable if nonspecific indicator of malaria when present.

Many other serious infections are present in malarious areas. The search for malaria should not hamper the simultaneous workup for other pathogens in smear-negative patients. Similarly, semi-immune residents of endemic areas may be mildly parasitemic on a chronic basis with little ill effect, so a positive malaria smear in these patients should not hamper a search for any other clinically suspected infections.

Dengue, transmitted by the day-biting Aedes aegypti mosquito, is an important travel-related problem most notably in heavily visited areas of Southeast Asia, the South Pacific, and Central America and the Caribbean. 11 , 12 Travelers to Thailand seem particularly prone to infection, and dengue is relatively uncommon in Africa but has begun to emerge there. In contrast to many other tropical fevers, it is predominantly an urban infection so that it can even affect upscale business travelers in urban centers. The incubation period is usually 2 to 7 days after the mosquito bite, so many travelers initially become ill while still overseas. The clinical spectrum ranges widely from asymptomatic through a range of clinical manifestations up to the severe myalgia and arthralgia of “breakbone fever” (see Chapter 155). Malaria, other arbovirus diseases including chikungunya fever, leptospirosis, rickettsial disease, measles, or typhoid may present as similar initial findings. However, in cases in which one of several associated rashes manifests ( Fig. 324-1A ), dengue or chikungunya becomes more likely than the other possibilities.

Cutaneous manifestations of some common systemic or widely disseminated diseases.

A, Generalized macular rash of dengue; rash usually appears after 4 or 5 days, but an earlier, faint, flushlike rash also may be present. B, Viral hemorrhagic fever due to yellow fever infection; typical signs of viral hemorrhagic fevers include bleeding from orifices and intravenous sites as well as diffuse petechiae or ecchymoses, especially over pressure points. C, Sepsis due to Vibrio vulnificus infection after ingestion of contaminated shellfish; hemorrhagic bullae are seen in sepsis, envenomation, and autoimmune disease but not with viral hemorrhagic fevers. D, Migratory lesions of infection with Gnathostoma spinigerum after ingestion of uncooked freshwater fish; larvae often leave a mildly hemorrhagic track. E, Faint, papular, highly pruritic dermatitis due to Onchocerca volvulus infection after travel to Sierra Leone; travelers who may not present for a year or more after travel are usually lightly infected and have no ocular manifestation. F, Typical eschar of African tick typhus due to Rickettsia africae; widely disseminated petechial vasculitic lesions are often present as well. G, Verruga peruana due to chronic infection with Bartonella bacilliformis, present only if the patient is not treated for and survives the acute bacteremic phase. H, Painless lesions of cutaneous anthrax; surrounding edema is characteristic, and the base quickly evolves to become totally black and necrotic. I, Spider bite due to Loxosceles laeta; unlike anthrax, spider bites are painful and usually have very irregular borders without significant edema.

A positive tourniquet test is found in up to 50% of patients with classic dengue and in almost all patients with severe dengue with or without hemorrhage, but it is a nonspecific finding that may also be present in leptospirosis. The test is performed by inflating a blood pressure cuff halfway between systolic and diastolic for 5 minutes and, upon release, counting the number of petechiae in a 2.5 × 2.5-cm patch below the cuff. More than 20 petechiae is considered a positive finding.

Polymerase chain reaction testing for viremia is possible only during the first 5 days of illness during the viremic phase and is available at many commercial reference laboratories in the United States. Serologic confirmation must be sent to a reference laboratory. Immunoglobulin M (IgM) is not elevated until 5 or more days after illness onset, but most patients initially present earlier than this. If an IgM sample drawn more than 5 days into illness is negative, a third visit to test for fourfold elevations of immunoglobulin G (IgG) is required. Because most patients will be better by the time results of any confirmatory tests would be available and because treatment is supportive, many clinicians do not seek laboratory confirmation of late-presenting cases. A postviral fatigue lasting up to 6 months may occur.

Chikungunya Fever

Although chikungunya fever, 12 a mosquito-borne alphavirus (chikungunya virus) infection, was first isolated in the early 1950s when it caused epidemics in East Africa and is endemic in tropical Africa and Asia, it has been unknown to most clinicians in the Americas and Europe until reemerging in 2005. Since 2006, with introduction of serology into routine practice, chikungunya virus infection has been identified frequently in travelers after return home from the endemic areas in India, Southeast Asia, and East Africa. Chikungunya virus was introduced to the Caribbean during a large epidemic in 2013 and is now established there. The acute illness resembles dengue but with more prominent joint symptoms. Patients have fever, arthralgia, and sometimes acute arthritis. Rash, which occurs in about 50% of cases, may resemble that seen in dengue and is pruritic and macular or maculopapular. Although acute symptoms usually subside within a week, disabling joint symptoms may persist for months.

Typhoid and Paratyphoid Fever

Typhoid fever is often the most nondescript of the relatively common causes of travel-related fever. 27 , 28 , 29 The incubation period is most often a week but can be as long as 3 weeks. Risk is at least 10 times higher on the Indian subcontinent than anywhere else, but risk exists throughout the tropics in the setting of poor sanitation. In contrast to malaria, dengue, or rickettsial infection, onset is insidious and abnormal physical findings are usually absent. Abdominal discomfort and constipation are common, but diarrhea is frequent enough so as to not rule out the diagnosis. Patients often look and feel particularly unwell, with severe prostration and high, unremitting fever. Leukopenia and thrombocytopenia often occur. Blood cultures are not always positive, but bone marrow cultures increase the yield. Serologic assays, including agglutination and enzyme-linked immunosorbent assay (ELISA), have overall poor sensitivity, especially early in the course, and some lack of specificity in some settings and enjoy poor reputations. However, when present, an unequivocal high titer in a previously naïve traveler provides a more rapid diagnosis than will blood cultures. Up-to-date vaccination against typhoid provides only partial protection against Salmonella typhi and does not protect at all against Salmonella Paratyphi. 30 Because of resistance, fluoroquinolones are no longer an option for empirical treatment in the Indian subcontinent and Southeast Asia, and third-generation cephalosporins or a carbapenem should be used. 27 Increasing data support the use of high-dose oral azithromycin for quinolone-resistant S. typhi . 30

Viral Hepatitis

Incidence rates for travel-related viral hepatitis are likely to have begun a decline as more individuals who had routine childhood hepatitis B vaccine are moving into the traveling population and as more high-risk travelers are receiving long-term protection due to pretravel hepatitis A and B vaccination. 31 Current vaccines do not protect against hepatitis E, which is enterically acquired, 32 or against hepatitis C, which, like hepatitis B, may be acquired overseas after blood transfusion or contact with contaminated syringes, medical equipment, or tattoo and body-piercing implements. Viral hepatitis is a long-incubation infection so that acquisition may not always be readily linked by the patient or the physician to the travel.

Rickettsial Disease

Rickettsial disease is emerging in travelers. 4 , 33 Most of the long list of rickettsial species infecting humans are transmitted by ticks, mites, and fleas. Eschars are seen in most patients with African tick typhus due to Rickettsia africae (see Fig. 324-1F ), 34 Mediterranean spotted fever due to Rickettsia conorii or R. africae and scrub typhus due to Orientia tsutsugamushi infection are the most common travel-related rickettsioses. In a group of 940 travelers to South Africa, 4% of all travelers and 27% of all travelers with flulike symptoms had infection with R. africae. 35 R. africae is the second most common cause of fever in travelers to Africa after malaria and is most prevalent in South Africa itself. Although rickettsial diseases are present in most countries of the world, individual species have restricted geographic distributions (see Chapter 187), which helps in the diagnostic formulation. High fever, headache, leukopenia, and thrombocytopenia are common. Rickettsiae infect endothelial cells and often cause widespread vasculitic-looking lesions. Severe infections may present as disseminated intravascular coagulation and mimic a viral hemorrhagic fever. Because African tick-bite fever and scrub typhus both occur in malarious areas, a thick film is indicated even in febrile patients with pathognomonic skin lesions. Because response to tetracyclines is uniformly prompt and dramatic and the results of serologic tests are slow to return, clinical suspicion and clinical diagnosis are usually relied on. The diagnosis should be reconsidered in those who do not respond within 48 hours of initiation of therapy with doxycycline or tetracycline.

Leptospirosis

Leptospirosis is thought of as an occupational disease and a disease of urban slum dwellers with rodent exposure. In recent years, large leptospirosis outbreaks in adventure travelers and adventure racers such as whitewater rafters, triathletes, and participants in the 2000 Borneo Eco-Challenge race have occurred. 16 Doxycycline prophylaxis is now recommended for both civilians and military personnel who will hike, bike, swim, or raft in tropical environments. 17 The protean clinical manifestations, which include fever, headache, proximal lower extremity myalgia, and abdominal wall pain, are impossible to distinguish clinically from dengue but may also mimic a number of other common tropical infections. Conjunctival suffusion and jaundice occur in a subset and are more common than in the other undifferentiated febrile diseases, although both may occur in relapsing fever. A reliable, rapid IgM dipstick test for leptospirosis is widely available and used. Recognition of possible leptospirosis affects therapy because antibiotic treatment is generally undertaken when the diagnosis is suspected.

Respiratory Illness

Travelers spend long periods in confined spaces and tend to meet many different people during the course of their trip. Acute respiratory tract infections occur in 10% to 20% of all travelers, with rates as high as 1,261 per 100,000 travelers for a 1-month stay in a developing country. For all ill returning travelers seen at GeoSentinel Surveillance Network sites, 7.8% were diagnosed with respiratory tract infection, with almost half of these being lower respiratory tract infections such as pneumonia or atypical pneumonia. 36

Respiratory diseases are second only to gastrointestinal infections as a cause of morbidity in travelers. In outbreaks of infections on cruise ships, respiratory tract infections constitute the most common diagnosis. 37 Influenza is the most common vaccine-preventable disease of travelers, with an incidence rate of approximately 1%. One fourth or more of all cases of legionellosis are associated with travel in the previous 2 weeks, and rates appear to be increasing. Risk factors include stays at large air-conditioned resort hotels or spas and cruise ship travel. 38 Acute histoplasmosis can be seen after brief excursions into caves anywhere in the Americas, and travel-related coccidioidomycosis is reported. 39 Tuberculosis is a clear risk in those who spend longer periods in very high-risk countries and especially those who are doing medical or aid work. 40 , 41 Pulmonary infiltrates and symptoms may be seen during the migratory phases of helminthiases such as schistosomiasis, strongyloidosis, hookworm infestation, and ascariasis. Hemorrhagic pneumonitis may be seen with leptospirosis. Q fever should be sought in those with animal exposure. Workup should be guided by clinical and radiologic findings.

Initial Office Approach to the Febrile Patient

The first priority is assessment for dangerous or immediately life-threatening disease, such as when hemorrhagic manifestations are apparent. If the patient has the appropriate exposures for a viral hemorrhagic fever, he or she needs to be immediately isolated and public health authorities contacted. None of the isolatable hemorrhagic fever viruses have incubation periods exceeding 3 weeks. Arenavirus infection, whether from West Africa (Lassa virus) or South America (Junin, Machupo, Guanarito viruses), should be treated with ribavirin. Most also recommend treating Crimean-Congo hemorrhagic fever with ribavirin. 42 Other rare hemorrhagic fevers of travelers such as Rift Valley fever, yellow fever, dengue hemorrhagic fever, and Ebola hemorrhagic fever need to be supported with the best possible intensive care. 43 Meningococcemia and rickettsial infection present as purpuric lesions, and bacterial sepsis and severe malaria are serious but treatable causes of hemorrhage owing to disseminated intravascular coagulation. Any febrile patient with altered sensorium or any other evidence of end-organ damage consistent with malaria and in whom P. falciparum malaria is a possibility should receive empirical therapy for malaria regardless of the result of a blood film. The smear is often negative in advanced disease because of sequestration of parasites in capillary beds.

In the patient who is not severely ill but who has an undifferentiated fever without any localizing symptoms or signs, three blood films, if epidemiologically indicated, are the first priority. At the same time, other mandatory diagnostic tests in the workup of every tropical fever include blood cultures (for enteric fever), complete blood cell count with differential and platelets, liver function tests, urinalysis, and a chest radiograph. The blood film may also diagnose bartonellosis, acute trypanosomiasis, and relapsing fever. Leukopenia militates away from common bacterial infections and toward dengue, typhoid, brucellosis, rickettsial disease, or acute human immunodeficiency virus (HIV) infection. Thrombocytopenia is indicative of malaria, dengue, or brucellosis. Eosinophilia may indicate early migratory stages of a number of helminths (see later). Liver function test results will be consistently abnormal in viral hepatitis or toxin damage and variably abnormal in leptospirosis, rickettsial disease (including Q fever), relapsing fever, yellow fever, amebic abscess, brucellosis, typhoid, hemorrhagic fever, and dengue. An indirect benefit of chest radiography is the finding of an elevated right hemidiaphragm in many patients with amebic liver abscess.

The second wave of diagnostic testing is driven by any abnormalities that emerge from initial test results. In the absence of enlightening abnormalities, additional serologic studies may need to be obtained based on travel itinerary, incubation periods, and known exposures, as discussed previously. HIV infection and its complications, syphilis, and tuberculosis should be sought at this stage if there is any suggestive exposure at all. After ruling out potentially serious as well as potentially treatable infections by history, physical examination, and routine laboratory work, and especially if patient financial resources are limiting, the clinician must then decide whether to wait 48 to 72 hours before serology and sophisticated diagnostic studies are pursued. Because up to 25% of all febrile illnesses in returning travelers are self-limited viral syndromes, a patient who was highly febrile and quite toxic looking at initial assessment is quite often perfectly well 48 hours later with no intervention. Reasonable clinical and local laboratory experience and confidence are required for this approach, but from the patient standpoint it is the most desirable course. At a minimum, acute serum should be stored for possible later use. If the patient is stable, has no laboratory abnormalities and no clinical evidence of end-organ damage, and has a reliable companion, he or she may be followed as an outpatient during the clinical evolution and the appropriate workup pursued according to any ensuing clinical findings.

Oral ciprofloxacin is sometimes given as empirical therapy for the slightest chance of typhoid fever because of the ease of treatment and the difficulty making the diagnosis. However, quinolone-resistant typhoid and paratyphoid fever are now predominant in the Indian subcontinent and Southeast Asia, where much of the travel-related enteric fever originates. Thus, in this situation, if clinical suspicion is high, the patient may need to be admitted for parenteral therapy. Empirical therapy for malaria without a positive blood film is appropriate if clinical evidence of cerebral dysfunction or any other end-organ damage consistent with malaria is present. Otherwise, examination of these patients and of serial blood smears over several days by someone with appropriate experience will generally lead to the parasitologic diagnosis of malaria, when present. 44 Expertise is rarely so far away as to compromise patient care, although empirical therapy with co-artemether or atovaquone-proguanil is generally well tolerated. However, empirical treatment will necessarily eliminate any possibility of making a species diagnosis if the patient, in fact, does have malaria. After empirical treatment, the clinician is then probably obligated to a course of primaquine, a potentially toxic drug, to cover the possibility that the antecedent infection was due to relapsing ( P. vivax or P. ovale ) malaria.

Febrile patients who present initially with focal symptoms or signs should have a more directed workup that takes into consideration appropriate disease distribution, incubation period, and possible exposures. Altered mental status or other central nervous system deficits are present as nonspecific sequelae of many systemic infections. However, appropriate itinerary, exposure, and incubation periods for the following less common infections should be sought: Japanese encephalitis, rabies, West Nile virus, tick-borne encephalitis, African trypanosomiasis, angiostrongyliasis, gnathostomiasis, and, in recent Hajj pilgrims to Mecca, meningococcal infection. 45

Diarrhea in Travelers

Acute traveler's diarrhea.

Diarrhea is by far the most common cause of illness during travel, affecting up to 60% of travelers to some high-risk destinations. South Asia is by far the highest-risk region for traveler's diarrhea. 46 The most frequent cause of traveler's diarrhea is enterotoxigenic E. coli (6% to 70%). Other types of E. coli (especially enteroaggregative E. coli ), 47 , 48 Salmonella, Shigella, and Campylobacter each account for 5% to 15%. Vibrio parahaemolyticus is related to shellfish ingestion and is seen almost exclusively in Asia. Protozoa account for less than 5%; and in adults, norovirus or, rarely, rotavirus may be detected. 49 , 50 , 51 However, norovirus outbreaks aboard cruise ships are increasingly recognized. About 30% of diarrheal episodes remain unexplained, but many are likely due to enteroaggregative E. coli.

Bacterial diarrhea generally manifests as the abrupt onset of uncomfortable, crampy diarrhea. 52 , 53 Fever, nausea, or vomiting, if present, further increase the likelihood of a bacterial cause. In contrast, protozoal diarrhea (most often due to Giardia lamblia or Entamoeba histolytica ) begins gradually, with loose stools occurring in distinct episodes and gradually becoming more disabling over 1 to 2 weeks. In protozoal diarrhea, medical care usually is not sought immediately because of the low-grade nature of the symptoms. Because most traveler's diarrhea is bacterial, many travelers are instructed to self-treat with quinolone antibiotics and are told to seek medical assistance if diarrhea does not resolve after 3 to 5 days of treatment. 51 , 52 , 53 , 54

Classic traveler's diarrhea is defined as three or more unformed stools per day, although a syndrome of nonclassic traveler's diarrhea with fewer stools but with accompanying symptoms is defined by some. Travelers may vary in their own definition of what is an abnormal bowel pattern, and this needs to be established with the patient in a quantitative way at the outset. Returned travelers with acute diarrhea of a few days' duration who have not yet had a course of quinolone antibiotic can be prescribed an empirical course without any workup or stool culture. Toxic patients with bloody diarrhea should have a wet prep of stool and an immediate sigmoidoscopic examination to look for amebic trophozoites. Nonresponders at 36 to 48 hours should then have stool specimen sent for performance of bacterial culture, ova and parasite testing, acid-fast bacilli testing (to detect Cryptosporidium and Cyclospora ), Giardia enzyme-linked immunosorbent assay (ELISA) or immunofluorescence assay, Entamoeba ELISA, and Clostridium difficile toxin assay. Vibrio cultures usually require a special request. Quinolone-resistant Campylobacter is increasing worldwide and is prevalent in Southeast Asia, so an empirical course of azithromycin can be given while awaiting culture if the patient is still moderately ill. 53 Rifaximin has been approved for traveler's diarrhea due to E. coli. 54 Because of the difficulty in making the diagnosis of giardiasis, an empirical course of tinidazole is often given in practice to those with subacute symptoms and a negative workup. Reactive arthritis (formerly Reiter's syndrome) is an occasional sequela of enteritis due to Shigella or Campylobacter.

Persistent Diarrhea in the Traveler

Two percent of those with traveler's diarrhea go on to develop chronic diarrhea lasting a month or more. These patients' disorders can be extremely frustrating to deal with because diagnosis is most often elusive despite extensive diagnostic testing. 55 Clearly, some undiscovered enteric pathogens remain. A number of limited studies indicate that the incidence of postinfective irritable bowel syndrome at 6 months after an acute episode of traveler's diarrhea may range from 4% to 32%. The true incidence of this syndrome is not clear, and ancillary contributing factors and possible preemptive interventions are still being investigated. 56 Appropriate studies, in addition to those already listed, include HIV serology, 5-hydroxyindoleacetic acid (5-HIAA) levels, thyroid function tests, serum calcium, testing for malabsorption, anti– Saccharomyces cerevisiae antibody/antineutrophil cytoplasmic antibody serologic studies for inflammatory bowel disease, antigliadin/antiendomysial/antitransglutamase antibodies for celiac disease, and upper and lower endoscopy with all aspirates and biopsy samples examined carefully for a parasitic cause. G. lamblia, Strongyloides stercoralis, Cryptosporidium parvum, and Cyclospora cayetanensis are occasional infectious causes of persistent diarrhea and may be discovered only after invasive workup. Serology for S. stercoralis, Schistosoma mansoni, or E. histolytica is indicated when exposure to these agents may have occurred. Intestinal biopsy almost always yields nonspecific findings, although cases of tropical or nontropical sprue are occasionally discovered or an initial diagnosis of inflammatory bowel disease made. In many patients, the etiology of the frequently found nonspecific villus blunting is unclear. This syndrome has often been termed tropical enteropathy or postinfective tropical malabsorption and is believed to be the residual damage caused by an initial bacterial or other insult. A temporary luminal disaccharidase deficiency may occur. Diarrhea may persist for months before resolving. In the absence of definitive diagnosis in patients with chronic traveler's diarrhea, symptomatic treatment with loperamide is indicated. Elimination diets with restriction of lactose, fructose, gluten, and fat are sometimes of benefit. Those with preexisting irritable bowel syndrome may have it unmasked by travel and frequently have exacerbations during or after travel. Tegaserod, alosetron, antispasmodics, or other appropriate medication for the underlying disease may be needed. 56 , 57 , 58 , 59

Skin Problems

The proportion of ill returned travelers who present to infectious and tropical diseases specialists who have a dermatologic problem is 20%, with variation by region of travel ( Fig. 324-2 ). The most common skin-related diagnoses are cutaneous larva migrans (9.8% of all skin diagnoses), insect bites including superinfected bites (15%), skin abscess (7.7%), and allergic reaction (5.5%). Dengue (3.4%), leishmaniasis (3.3%), myiasis (2.7%), and the rickettsial spotted-fever diseases (1.5%) are other important reasons for presentation. Arthropod-related skin diseases accounted for 31% of all skin diagnoses. 60 , 61 Ulcerative lesions of travelers include leishmaniasis, mycobacterial disease, deep mycoses, and, rarely, anthrax. Rickettsial diseases frequently include black eschars at the site of the arthropod bite. Loiasis, 62 gnathostomiasis, 63 and cysticercosis present as painless subcutaneous nodules. Arthropod bites and infestations such as scabies, fleas, lice, and mites present similarly as in nontropical environments. Onchocerciasis presents as an intensely pruritic, evanescent papular rash. 64 , 65 Varicella, measles, or other childhood exanthems occur in nonimmune travelers and should not be forgotten in the quest for exotic diagnoses. Seabather's eruption (sometimes called “sea lice”) is a pruritic papular rash notable for being distributed only on skin covered by the patient's bathing suit. 66 Larval sea anemones become trapped by the fabric while the patient is swimming. The indurated erythematous chancre of Trypanosoma rhodesiense infection (see Chapter 279) should not be overlooked. 67 Arboviral eruptions usually present as acute febrile illnesses and not as predominant rash illnesses. HIV infection and sexually transmitted diseases should always be considered as a cause of exanthems and ulcerative lesions.

Some common diseases of travelers with pathologic effects localized to circumscribed areas of the skin and underlying tissue.

A, Painless ulcer with a clean base in a traveler to Peru with New World cutaneous leishmaniasis due to Leishmania braziliensis. B, More nodular and inflammatory lesions with crusting but only slight ulceration in a traveler to Afghanistan, which is more characteristic of Old World cutaneous leishmaniasis due to Leishmania major. C, Painless nasal perforation, which is often the earliest manifestation of mucocutaneous leishmaniasis due to metastatic spread of L. braziliensis from an earlier cutaneous lesion. D, Cutaneous larva migrans or creeping eruption due to the canine hookworm Ancylostoma caninum. E, Furuncular myiasis due to Dermatobia hominis (botfly). Patients often report a sense of movement inside; note tiny hole for the respiratory spicule of the botfly. F, D. hominis larva after migration to surface when the respiratory spicule was blocked with petroleum jelly. G, Characteristic multilesion presentation of African furuncular myiasis due to Cordylobia anthropophaga (tumbu fly). H, Phytophotodermatitis in a traveler to Ecuador after application of a lime juice–containing mixture by a shaman during a native ceremony; the same effect is seen when common tropical cocktails are spilled on sun-exposed areas. Pigmented lesions may take weeks to resolve. I, Tropical pyomyositis in a traveler to the Amazon. Pyomyositis due to deep staphylococcal infection is common in moist, warm climates and is characterized by brown pus as the muscle fibers dissolve. Initial lesions are characterized by exquisitely painful, localized erythematous areas overlying the affected muscle.

Eosinophilia

In addition to parasitic causes, peripheral blood eosinophilia may be associated with a variety of dermatologic, immunologic, inflammatory, neoplastic, and idiopathic causes. Returning travelers and long-term residents of tropical countries are as prone to nonparasitic causes of eosinophilia as is the general population, and these must be considered when obtaining a history and initiating a diagnostic workup in a returned traveler. Schistosomiasis and strongyloidiasis are the most common parasitic causes of significant eosinophilia in returning travelers, and serology should be sent on every traveler with potential exposure to either. 68 , 69

Eosinophilia is a reaction to a tissue-invasive helminth, with its intensity being proportional to the degree of tissue invasion. During the initial larval migration phase after a new infection with a specific parasite (e.g., hookworm), there may be an intense eosinophilia (up to 5000/mm 3 ). Weeks or months later, when the mature adults reside in the intestine with only minimal tissue contact, eosinophilia will be mild or absent. Although eosinophilia is not seen in protozoan infection, local eosinophilic infiltrates exceptionally occur in areas of the intestinal tract penetrated by E. histolytica, G. lamblia, or Cystoisospora belli.

Although most laboratory reports express the eosinophil count as a percentage of the total white blood cell count, this practice can make it difficult to follow serial determinations in an individual patient. The absolute eosinophil count can be calculated easily and ranges from 0 to 350/mm 3 (mean, 120/mm 3 ). Because the list of helminths inducing eosinophilia ( Table 324-3 ) is extensive, and because many of the parasitologic and serologic techniques required for specific diagnosis are laborious and expensive, a well-obtained epidemiologic history is needed to narrow the differential diagnosis down to a manageable size. Some helpful physical findings are dermatitis (onchocerciasis, cutaneous larva migrans, larva currens); migratory swellings (loiasis, gnathostomiasis); wheezing or cough ( Strongyloides, hookworm, Ascaris, or Schistosoma larvae in the lung); hemoptysis (Paragonimus); hepatomegaly (Toxocara, Echinococcus); lymphedema (filariasis); facial edema and myositis (trichinosis); subcutaneous mass (cysticercosis); meningeal signs (angiostrongyliasis, gnathostomiasis); and abdominal tenderness (angiostrongyliasis, anisakiasis, fascioliasis).

TABLE 324-3

Parasitic Causes of Eosinophilia

The examination of stools for ova and parasites is the first step and, unfortunately, this crucial diagnostic procedure is dependent on the expertise of the individual laboratory. A concentration technique should be used and at least three separate stools examined. Eggs are produced only by mature adult worms, so stool examinations will be negative during the initial larval migratory phase of intestinal helminths for up to 6 weeks after exposure. Strongyloides eggs hatch while still in the intestine, and Baermann concentration or agar plate cultures are indicated if suspicion is high. Because most anthelmintic drugs only work on adult worms and not immature larvae, empirical therapy for a traveler with eosinophilia soon after return is of no benefit.

The following ancillary procedures are indicated when epidemiologically appropriate 70 or when dictated by specific symptoms: day and night blood concentrations (filariasis); skin snips (onchocerciasis); rectal snips or scrapings (schistosomiasis); urine concentration (schistosomiasis); duodenal aspirate (strongyloidiasis); sputum tests for ova and parasites (migrating larvae, Strongyloides, Paragonimus ); and biopsy of any abnormal lesions. Serology is available for many of the common helminthic infections but is hampered by lack of standardization and broad cross-reactivity among many helminth species. Nevertheless, an unequivocally elevated parasite-specific serum IgG level can be extremely helpful when positive in the setting of a previously naïve traveler with a history of exposure to only one or a few specific parasites. Schistosomiasis and strongyloidiasis are the two most common causes of parasitic eosinophilia. Stool and more invasive examination is often negative, and diagnosis often depends on positive serology.

The detection of one parasitic infection does not preclude the presence of another. All individuals should complete the diagnostic workup that is clinically and epidemiologically indicated. Similarly, all treated patients should be observed to be certain that both infection and eosinophilia have resolved. An anomalous exacerbation of the eosinophilia may occur for 2 to 3 weeks after treatment as parasites die and release their antigens. Eosinophilia may not totally resolve for 6 months or more after adequate treatment of the inciting helminth, but no response whatsoever for a month or more after treatment may be a sign of inadequate response to treatment.

Screening for Asymptomatic Infection

Completely asymptomatic returned travelers may present with a request to be checked for possible tropical disease. The limited number of available cost-effectiveness studies have yet to show significant benefit to this approach on a population basis. 71 , 72 , 73 Neither a clinic visit nor any nondirected laboratory screening of returned very short-term travelers is indicated. Exceptions are those with known discrete high-risk exposure events in situations conducive to transmission of specific agents. This would include testing for HIV and other sexually transmitted infections, a purified protein derivative skin test or interferon-γ release assay, or Schistosoma serology. For those who have spent 6 months or more under any conditions in a developing country, a purified protein derivative skin test or interferon-γ release assay is the highest priority even without a specific exposure. For those living under harsher conditions, any abnormalities found on a complete physical examination, including a dermatologic assessment, that would lead to specific laboratory testing should be sought first. For general screening, a stool sample for ova and parasite testing and an eosinophil count are used by most. Serologic studies for schistosomiasis, filarial infection, and strongyloidiasis are often performed but should be strictly limited to those with extended travel to a known endemic area for each pathogen tested for. Those with new sexual partners should be screened for HIV and sexually transmitted infections at an appropriate interval after last potential exposure. Malaria smears are not indicated in asymptomatic travelers, even those with a remote history of malaria exposure during the travel, but primaquine treatment for those at risk for later relapse of disease due to P. vivax or P. ovale is indicated.

Key References

The complete reference list is available online at Expert Consult.

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Die Ständige Impfkommission (STIKO) hat nach dem Infektionsschutzgesetz (IfSG) den gesetzlichen Auftrag, Empfehlungen zur Durchführung von Schutzimpfungen in Deutschland zu geben. Neben Standardimpfempfehlungen für die gesamte Bevölkerung oder für bestimmte Altersgruppen spricht sie Impfempfehlungen für Menschen mit besonderen Indikationen aus. Die STIKO empfiehlt in Zusammenarbeit mit der Deutschen Gesellschaft für Tropenmedizin, Reisemedizin und Globale Gesundheit e.V. (DTG) Reiseimpfungen zum individuellen Schutz Reisender mit einem Expositionsrisiko gegenüber bestimmten impfpräventablen Erkrankungen und um den Import von Infektionserregern in das bereiste Land oder bei Rückreise nach Deutschland zu verhindern. Reiseimpfberatungen sind die optimale Gelegenheit, um den individuellen Impfstatus zu überprüfen und mögliche Impflücken auch bei den Standardimpfungen zu schließen.

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Empfehlungen der STIKO und der DTG e.V. zu Reiseimpfungen, Epid Bull 14/2024

Antworten auf häufig gestellte Fragen (FAQ)

Wie ergänzt die neue veröffentlichung zu reiseimpfempfehlungen die bisherigen stiko -empfehlungen.

Die Reiseimpfempfehlungen der STIKO wurden bislang allgemein gehalten. Da Fernreisen, ausbildungs- oder berufsbedingte Auslandsaufenthalte zunehmen und die Reise- und Impfmedizin immer komplexer wird, hat die STIKO beschlossen, ihre Empfehlungen zu Reiseimpfungen zu konkretisieren. Hierfür wurde 2019 die Arbeitsgruppe "Reiseimpfungen" etabliert, um offene Fragestellungen in diesem Themenbereich evidenzbasiert nach STIKO -Methodik aufzuarbeiten. Nach Erweiterung der Arbeitsgruppe durch eine Kooperation mit der deutschen Gesellschaft für Tropenmedizin, Reisemedizin und Globale Gesundheit ( DTG ) wurden die Empfehlungen erstmals in Form der 4. Aktualisierung im April 2022 gemeinsam veröffentlicht.

Zu den von der STIKO und der DTG empfohlenen Reiseimpfungen gehören aktuell die Impfungen gegen Cholera, COVID-19 , FSME , Gelbfieber, Hepatitis A und B, Influenza, Japanische Enzephalitis, Meningokokken der Serogruppen ACWY, Poliomyelitis, Tollwut und Typhus. Impfungen gegen diese Erkrankungen werden in den erstmals am 8. April 2021 erschienenen Empfehlungen der Ständigen Impfkommission ( STIKO ) zu Reiseimpfungen ausführlich besprochen. Sie umfassen allgemeine Aspekte bei der reisemedizinischen Beratung, berücksichtigen Besonderheiten für bestimmte Personengruppen und geben einen orientierenden Überblick über Epidemiologie und Risikofaktoren einer Übertragung von impfpräventablen Erkrankungen. Eine ausführliche Darstellung zugelassener Reiseimpfstoffe mit den jeweiligen Impfschemata und Indikationsstellungen sowie eine Ländertabelle ermöglichen einen umfassenden Überblick über die im jeweiligen Land zu berücksichtigenden Erkrankungen.

Die Empfehlungen sollen der Ärzteschaft als Hilfestellung für eine Reiseimpfberatung dienen. Die Empfehlungen der STIKO zu Reiseimpfungen werden fortlaufend aktualisiert; Änderungen im Jahresverlauf können online eingesehen werden ( https://doi.org/10.25646/8156) und sind durch blaue Randmarkierungen gekennzeichnet. In der jährlich im ersten Quartal erscheinenden Printausgabe sind die Aktualisierungen des zurückliegenden Jahres enthalten.

Da das Infektionsrisiko je nach aktuellem Impfstatus, Reiseland, Art und Dauer der Reise, Saison, geplanten Aktivitäten sowie möglicher vorbestehender Grunderkrankungen individuell unterschiedlich ist, ist eine reisemedizinische Beratung vor einer Reise ins Ausland zu empfehlen. Die STIKO , die DTG und auch das Robert Koch-Institut führen keine individuellen Beratungen zu Impfungen durch, auch nicht zu Reiseimpfungen. Hierfür stehen spezialisierte niedergelassene Ärzt:innen sowie Tropeninstitute und teilweise Gesundheitsämter zur Verfügung. Informationen über aktuelle gesundheitliche Risiken im Reiseland finden sich auf den Internetseiten des Auswärtigen Amtes ( www.auswaertiges-amt.de/de/ReiseUndSicherheit/reise-gesundheit ).

Stand: 20.06.2022

Was ist neu bei den Empfehlungen der STIKO und der DTG zu Reiseimpfungen?

Die am 8. April 2021 erstmalig von der STIKO veröffentlichten und seither regelmäßig aktualisierten Reiseimpfempfehlungen der STIKO und der DTG sollen Impfärzt:innen eine Hilfestellung bei der Beratung und Anwendung von Reiseimpfungen bieten. Zusätzlich zu den bisherigen STIKO -Empfehlungen enthalten sie z. B. Hintergrundinformationen in Form von allgemeinen Aspekten bei der reisemedizinischen Beratung. Außerdem widmet sich ein Kapitel ausführlich den Impfungen bei besonderen Risikogruppen; zu beachtende Besonderheiten werden für die folgenden Gruppen aufgeführt: Schwangere, Stillende, Kleinkinder, ältere Reisende, Reisende mit Grunderkrankungen, Migrant:innen, die Freund:innen oder Verwandte im Ausland besuchen, Personen mit Langzeitaufenthalt und Katastrophenhelfer:innen.

Im Kapitel „Anmerkungen zu einzelnen Impfungen“ werden die impfpräventablen Erkrankungen ausführlich dargestellt, wobei neben der Indikation für die Impfung ein Überblick über die Epidemiologie und die Übertragbarkeit der Infektion nach Reiserückkehr gegeben wird. Die aktuell in Deutschland zugelassenen Impfstoffe werden hinsichtlich Wirksamkeit und Sicherheit besprochen und ihre Anwendung in Form von Impftabellen anschaulich abgebildet, ggf. zusätzlich eine mögliche Anwendung in Form von Kombinationsimpfstoffen.

Länderspezifische Reiseimpfungen werden in Form einer alphabetisch sortierten Ländertabelle dargestellt, die einen ersten Überblick gibt und bereits differenziert, für welche Impfung eine Nachweispflicht bzw. eine Empfehlung bei bestimmten Risiken oder bei allen Reisenden besteht. Mit den Reiseimpfempfehlungen der STIKO und der DTG ist eine umfassende Reiseimpfberatung möglich, die sowohl individuelle Voraussetzungen des Reisenden einschließlich evtl. Vorerkrankungen und besonderer gesundheitlicher Risiken ( z.B. Medikamenteneinnahme) als auch Reiseroute, Reisedauer und Reisestil berücksichtigen sollte.

Wo kann man sich reisemedizinisch beraten lassen?

Da das Infektionsrisiko je nach aktuellem Impfstatus, Reiseland, Art und Dauer der Reise, Saison, geplanten Aktivitäten sowie möglicher vorbestehender Grunderkrankungen individuell unterschiedlich ist, ist eine reisemedizinische Beratung vor einer Reise ins Ausland zu empfehlen.

Die STIKO , die DTG und auch das Robert Koch-Institut führen keine individuellen Beratungen zu Impfungen durch, auch nicht zu Reiseimpfungen. Hierfür stehen spezialisierte niedergelassene Ärztinnen und Ärzte sowie Tropeninstitute und teilweise Gesundheitsämter zur Verfügung. Informationen über aktuelle gesundheitliche Risiken im Reiseland finden sich auf den Internetseiten des Auswärtigen Amtes .

Stand: 24.05.2023

Weitere Informationen

• Reiseassoziierte Infektionskrankheiten
• Liste der tropenmedizinischen Institutionen in Deutschland
• Auswärtiges Amt: Reise und Sicherheitshinweise
• Hinweise zur Kostenübernahme

Stand: 04.04.2024

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Das Robert Koch-Institut ist ein Bundesinstitut im Geschäftsbereich des Bundesministeriums für Gesundheit

© Robert Koch-Institut

Alle Rechte vorbehalten, soweit nicht ausdrücklich anders vermerkt.

Fit For Flight

The #1 app for travel wellness.

Relax. Move. Power Up!

Don´t be that person. The one who doesn´t move enough. The one contributing to an annual cost exceeding $50 Bn. The one with pain and poor blood flow. 

Fit For Flight 2.1 has the tools for you. Tailored Functional Training exercises, Mndfulness, Yoga, Breathing Exercises, Automated Training Programs, CBT based Fearless Flying…

Join the movement! Users in well above 100 countries and growing rapidly.

Included in Fit For Flight…

Tailored Programs

Let us help you to arrive at your destination with a fresh mind and body. It´s simple! Just enter the length of your flight and your target and we´ll remind you when it´s time to take action. 

At the beginning of a flight you may want to wind down. When you get close to your destination you may want to power up and increase your energy level. Or maybe you just need to focus? Don´t worry – we have got you covered either way…

Yoga´s benefits on your mental and physical well being has been proven for ages. Let´s see what our flight specific Yoga Flow sessions can do for you.

Fearless Flying

18% of all passengers feel a discomfort while flying. Our Fearless Flying section helps your mind to focus on other things while flying and hopefully even smile!

How you breathe determines the state of your body and mind. We promise you the most mesmerising app breathing experience there is on the market today! Keep calm, keep focus.

Functional Training

”Sitting is the new smoking”. Our movements are carefully designed for an in-flight environment and will keep you feel fresher, reduce aches and pains, increase your blood flow and reduce the risk of DVT

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”For me, having a mindful flight is top priority. I feel a slight anxiety when I fly and I need to focus on other things. For me Fit For Flight´s automated and tailored mind programs works wonders.”

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”My mind needs to be sharp and open the moment I arrive at my destination. The customers make their decisions in split seconds, and consequently my mind needs to act even faster than that.”

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Retired re-traveller

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[email protected]

When pups fly: BARK Air, the world's first airline for dogs, take first flight

Bark air says that it has taken the 'white glove experience typical of a human’s first-class experience and redirected all that pampering to pooches.' that experience comes at a cost..

The first jet charter company in the world in which every passenger is a VIP (very important pup) is now off the ground.

BARK Air , launched by dog toy company BARK in partnership with a jet charter service, is a luxury airline for man's best friend that transports dogs of all sizes along with their owners “in comfort and in style,” CEO Matt Meeker said in a video provided by Reuters that takes the public behind the scenes of the new airline.

"We’re here to revolutionize flying for dogs," says BARK Air's website.

Tickets sold out for BARK Air's first flight , which took off at 4 p.m. ET from New York, headed to Los Angeles. And flights are filling fast for the month of June.

Here's what you need to know about the new airline, including how much flights cost.

Learn more: Best travel insurance

Dogs take first Bark Air flight

BARK Air shared details of the company's first flight on Thursday in an Instagram post.

"Right now, at an altitude of 30,000 feet, there is a flight filled with dogs. Unlike any flight before it, these dogs are not merely an afterthought, nor are they treated as cargo or a burden to the crew and fellow travelers. Here, dogs are the foremost priority," the company posted.

BARK Air continued to say that the effort took 10 years, "but we are finally confident that we can provide all dogs with the air travel experience they deserve: one that puts them first."

One user commented that "this really is the pawfect flight!" Another said: "We woof to see this."

BARK Air's prices aren't cheap

Pet owners can expect to pay $8,000 for a one-way international flight and $6,000 one way for a domestic flight that covers both them and their dog.

For now, routes will serve the New York City metro area via Westchester County Airport (HPN), with flights to the Los Angeles area via Van Nuys (VNY) and London, England via Biggin Hill (BQH), according to BARK Air's website.

What to expect flying BARK Air

The company says that it has taken the “white glove experience typical of a human’s first-class experience and redirected all that pampering to pooches.”

Meeker said that the airlines caters everything to the dog, "trying to lower their anxiety and their stress, so they have the most comfortable, fear-free experience on an airplane."

Food and water are provided for the pooches, and there's "even a spa treatment that happens in air," Meeker said.

BARK Air says that a concierge will learn a dog's temperament and sensitivities before the flight for the best placement on the plane. Dogs will not be caged or on leashes but will be free to sit on the seat, their human, a bed or wherever comfortable, the company says.

There are designated areas before flights for dogs to go potty and emergency pads will be available during flights.

How many dogs can fit on a flight?

Each flight fits 15 dogs and their humans, according to BARK AIR's website, but it never sells more than 10 tickets per flight. Space while flying is important to how animals roam, the company says.

Though there are additional tickets available if more than one human needs to accompany a dog, kids are not allowed to fly BARK Air. Each passenger must be at least 18 years old.

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Amazon’s Top-rated Travel Pants Are 58% Off for Memorial Day — Shop the 16 Best Deals From $9

They’re all under $50.

Travel + Leisure

The warm weather is finally here. It has us planning vacations that call for dresses, tanks, bikinis, and other clothes that bear more skin. Shorts are the obvious bottom option but don’t forget to grab a new pair of pants — the most versatile, easy-to-wear style for travel . If you run hot, you might not consider pants a 12-months-of-the-year piece of clothing, but there is a range of breathable, lightweight, and stylish pants to choose from, and many of them are on sale for under $50 during Amazon’s Memorial Day sale . 

When shopping for the best travel pants, consider the shape you want. Women can choose from leggings , joggers , wide legs , and capris that can be dressed up or down and are comfy to wear while on the go. There are equally cool styles for men, some with an active flare and others with a refined look. Amazon’s top-rated pants will keep you stylish in pictures, plus they also come in handy for chilly planes, offer sun protection, and are dressy for a nice dinner. Keep reading for 16 of the best Memorial Day deals on travel pants at Amazon now.

Baleaf Women's Quick-dry Hiking Pants 

Amazon's top-selling hiking pants are currently over 30 percent off. These pants are beloved by shoppers because they have a cool look and are made to keep you comfortable. With a drawstring waist and adjustable cords at the cuff, their fit is relaxed and easy. This pair of travel-friendly pants also offers UV protection and is quick-drying and water-resistant. Plus, there are a ton of options — lengths tall, regular, and petite, plus 20 colors and a range of sizes from XS to 3XL.

Libin Women's Cargo Joggers

Another popular hiking option is this pair of cargo pants. With joggers, you’ll have a polished silhouette with the comfort of sweatpants. Adding to the put-together look are the anti-wrinkle fabric and cuffed ankle. Five pockets, all with either zipper or hook-and-loop closures are handy to keep your goods secure. One shopper who bought the pants for a long-haul flight wrote, “I tried them out on a shorter domestic flight last week and they were perfect. Comfortable on the plane, soft elastic waistband, breathable fabric. I especially like the elastic ankles because it keeps the pant-leg from hitting the floor in public restrooms at airports and on the planes.” And, of course, they added that the pants are “cute, too!”

Under Armour Women’s HeatGear High No-slip Waistband Ankle Leggings

Under Armour leggings for under $20, almost 60 percent off the original price? This is a run, don’t walk, quickly-add-to-cart situation. Leggings are another style I personally love to travel in since they are comfortable and more polished than looser sweat styles. As a compression legging, this has a second-skin feel that’s super light, wicks sweat, and dries fast. The no-slip waistband and ergonomic flatlock seams keep comfort front and center. It also has a side drop-in pocket, my favorite for storing my iPhone when jet-setting. 

The Gym People Women’s Lightweight Jogger Pants

As the no. 1 best-seller in women’s activewear leggings at Amazon, The Gym People jogger is a must-try. A smooth, wide waistband is always appreciated, especially when it's flattering and offers a bit of tummy control. The jogger is also crafted in a soft, stretch fabric that allows for easy movement. This review from a buyer who purchased the pants in three colors sold me: “They are perfect for traveling. They roll up well and don’t wrinkle that much. They wash and wear well. They are so comfortable and you can dress them up with a nicer shirt or wear them with T-shirts.” Choose from any of the neutral or bright 22 shades. 

Anrabess Women’s Linen High-waist Wide-leg Pants

This pair of linen pants is packed with style for an easy upgrade to your travel look. From the elastic self-tie waist down to the flowy leg opening, you'll look effortlessly chic. These features also make this comfy pair of pants versatile and easy to dress up with a tucked-in tank and heels, or go casual with a tee and low-profile sneakers. “I bought multiple pairs for an overseas trip, and they were perfect,” one five-star reviewer shared . “I was able to use them for work and sightseeing. They were so comfortable and lightweight, easy to pack for travel.”

Santiny Women’s Drawstring Jogger Pants 

Joggers are personally some of my favorite pants to travel in. I love their sleek and flattering silhouette, which pairs nicely with a hoodie for a long flight and a tank for sightseeing. This top-selling pair also doubles as workout pants for those who love to exercise while away. Deep pockets are ready to hold essentials like phones, keys, and your wallet, while the soft, four-way stretch will feel good against the skin. A drawstring elastic waistband and a cuffed ankle lend a personalized fit that will stay put no matter your activity. From running in a new city to lounging in an airport, you’ll easily fall in love with this jogger. 

Eddie Bauer Women's Rainier Capris

Capris are back, a trend that many might find surprising. What makes the style excellent for travel is that the short length is less bulky and a whole lot cooler than long pants, yet offers more coverage than shorts. This very popular capri from Eddie Bauer is made for the outdoors with two-way stretch, a water-repellent finish, and UPF 50+ sun protection. This packable pair also has hems finished with adjustable bungees for the freedom to change up the look. For hiking adventures or overnight campouts, this pair is a must-own. 

Lnx Women’s High-waist Wide-leg Linen Pants

Linen is an ideal material for summer travel since it’s naturally breathable and lightweight. This option on sale on Amazon has a cute high-waisted, cropped silhouette, which makes it easy to pair with tanks and tees and comfy-to-walk in sneakers and sandals. One customer said these were perfect to go from beach to dinner, while another five-star reviewer found them in search of comfy yet stylish pants for long travel: “The mid-rise waist has a perfect amount of give and [is] flattering to the figure. They look dressy enough to wear with a nice top but have the comfort and roomy feel of wearing sweatpants.”

G Gradual Women’s 7/8 Stretch Ankle Sweatpants

Another very popular option on Amazon is this pair of athletic sweatpants. Currently the no. 1 best-seller in women’s golf pants , this pair will support you along the golf course, with a comfortable silhouette and an adjustable elastic waistband. What I particularly like about this pair is the cropped 7/8 ankle length. It's not only stylish but will look good with your athletic golf shoes, sandals on vacation, or your easy-to-slip-on and off-travel shoes. I suspect that whether you buy these for golf or travel, you will probably also end up lounging at home in them, too — yet another perk.

Briggs New York Women’s Super Stretch Millennium Pull-on Career Pant

While work pants are great for work travel, they also can double as a dressy bottom on vacation. This pull-on pant has a smoothing panel along the waist along with slimming solution technology, for an ultra-flattering look. Crafted with a stretch fabric, this on-sale pant comes in great color options from go-to black to an easy-to-mix into your wardrobe gravity blue. One shopper even shared that they keep their shape. “I bought these specifically for travel and they were perfect. Great fit and comfortable elastic waist. Although they are ‘stretchy,’ they did not stretch out and lose their shape, even after several days of wearing. I will definitely buy another pair.”

Unionbay Men's Rainier Lightweight Comfort Travel Tech Chino Pants

Anyone traveling to sunny locales should consider pants like these that are made for the climate. This lightweight pant has it all — they’re quick-drying and water-resistant, and the fabric has UPF 50 protection. Stretch fabrication also allows for ease of movement. Plus, you can secure your belongings with mesh-lined pockets, leg pockets, and zipper closure pockets. From a graphic tee and walkable sandals for the day to a polo and dress shoes for the night, these pants will get a ton of wear on all your travels. 

Lee Men's Extreme Comfort Canvas Cargo Pant

Canvas pants are great for travel because they are comfortable yet have a polished and refined look. With a straight leg, this pair is super versatile to wear with sneakers, oxfords, or sandals. The canvas fabric also contains stretch, combined with the flexible waistband, it’s ideal for long travel days. “So comfortable," one shopper wrote . “These pants are versatile and comfortable. The sizing is accurate. [I’ve] worn them for travel, hiking, layering — you name it. They can be easily dressed up. Bought them in two colors and might buy more!”

Rdruko Men's Casual Lightweight Quick-dry Hiking Pants

Whether traveling by plane, train, or car, these are comfortable pants are made for a long day of sitting. At the same time, when you are ready to get up and get moving, they're flexible with an elastic waist and stretch. The fabric is also durable and quick drying if your movement takes you on a long hike on a hot day. Another great feature is its side zippered pockets that securely store what you need.

Amazon Essentials Men's Classic Fit Stretch Golf Pant 

The number one golf pants for men on Amazon is currently on sale for under $10. Made in a performance fabric with moisture-wicking properties, this is an optimal pair for the course, especially in the summer heat. Off the green, they still work as comfortable pants with a classic fit. Also worth noting, especially in terms of traveling, is their versatility and the fact that they don’t wrinkle easily, as reviewers mention. 

Linlon Men’s Quick Dry Zip-off Cargo Hiking Pants

For men who love options or prefer shorts, these convertible pants are a two-for-one style thanks to their zip-off legs. The ability to go from pants to shorts makes this an excellent purchase for hikers who would appreciate the ability to cool off their legs mid-excursion. Quick drying, water-repellent fabric with UPF 50+ sun protection makes these pants excellent for outdoor activities. And reviewers also mention how easily packable they are, too.  

Amazon Essentials Men's Classic Fit Wrinkle-resistant Flat-front Chino Pants

The best-seller in men’s casual pants on Amazon , these pants are wrinkle-resistant — perfect for travel. A tailored design with a flat front waist, front slant pockets, and button-through back pockets keeps the look classic and flexible to go from day to night. The fact that they are machine washable also makes them great for travel, and easy to keep clean and wear more than once. This Amazon chino pant is now on sale for under $10 and is available in a variety of inseam options to get the best fit. 

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• Ihr Reiseziel

Es ist ganzjährig sehr warm. Die Durchschnittstemperaturen in Bangkok betragen 25,7 °C im Dezember und 30,1 °C im April. Von November bis Februar ist es trocken und sehr warm, von März bis Mai ist es heiß. Die Hauptniederschläge fallen von Mai bis Oktober.

Reisezeiten

November bis März (und Mai bis August für Nordthailand und die Ostküste Südthailands)

Einreisevorschrift

Für alle Reisende, die aus einem akuten Gelbfiebergebiet kommen, ist eine Gelbfieberimpfung vorgeschrieben. Ausgenommen sind Kinder unter 9 Monaten. Eine Auffrischimpfung gegen Gelbfieber wird von der WHO nicht mehr empfohlen. Unbedingt die Einreisbestimmungen des Reiselandes prüfen, inwieweit diese Empfehlung übernommen wurde.

>> Gelbfieberländer

Hier werden bis zu fünf aktuelle Meldungen zu diesem Land angezeigt. Weitere Meldungen finden Sie hier .

08.04.2024 - Timor Leste: Chikungunya Ausbruch

Chikungunya Fälle Der mehrmonatige Ausbruch des Chikungunya-Virus hält weiterhin an und gefährdet die Bewohner von Timor-Leste (Osttimor): Bis Ende März 2024 wurden in Timor-Le... weiter lesen

02.04.2024 - Welt: Chikungunya Fallzahlen in 2023

Die Gesundheitsbehörde ECDC berichtet in ihrem aktuellen Disease Report über die folgenden Chikungunya-Fallzahlen (CHIKVD) in 2023: >> Afrika>> Asien>> Mittel- und ... weiter lesen

11.03.2024 - Thailand: Über 17.700 Dengue Fälle in 2024

Dengue Fälle in 2024 . Die Zahl der Dengue-Patienten in Thailand hat in diesem Jahr bereits 17.783 Fälle erreicht. Dies ist mehr als das Doppelte als im Vorjahreszeitraum 2023. Die Krank... weiter lesen

27.02.2024 - Thailand: 73 ZIKA Fälle in 2024

ZIKA-Fälle Das thailändische Büro für Epidemiologie meldet für das Jahr 2024 bislang 73 Zika-Virus-Fälle und keine Todesfälle in 19 Provinzen Thailand... weiter lesen

18.02.2024 - Thailand: Über 13.000 Dengue-Fälle in 2024

Dengue Fälle . Die Zahl der Dengue-Fieber-Fälle ist weiter am steigen: In diesem Jahr wurden bisher insgesamt 13.126 Fälle gemeldet, darunter 12 Todesfälle. Dies entspricht ein... weiter lesen

E-Mail Benachrichtigung

Sie erhalten eine Nachricht von uns, sobald sich die Impfempfehlungen, Hinweise oder aktuellen Meldungen für "Ihr" Reiseziel ändern oder aktualisiert werden.

Impfempfehlung

Für alle Reisenden:

• Diphtherie  
• Hepatitis A

Für Reisende, die besonderen Risiken ausgesetzt sind:

• Hepatitis B bei engen sozialen Kontakten und Langzeitaufenthalten
• Typhus bei mangelhaften hygienischen Verhältnissen
• Tollwut für Trekkingreisen und bei Langzeitaufenthalten in ländlichen Gebieten
• Poliomyelitis  bei Trekkingreisen, mangelhaften hygienischen Verhältnissen und Langzeitaufenthalten
• Masern für alle Kinder
• Japanische Enzephalitis von Mai bis Oktober in ländlichen Gebieten. Impfempfehlung nach WHO: Bei Übernacht-Aufenthalten von mindestens 2 Wochen, speziell in ländlichen Regionen
• Dengue für Reisende, die schon eine Dengue-Infektion hatten

Ein erhöhtes Infektionsrisiko ohne Impfmöglichkeit besteht u.a. für:

• Darminfektionen
• Bilharziose

  Eine individuelle reisemedizinische Beratung sollte idealerweise sechs Wochen vor der geplanten Reise wahrgenommen werden, damit sinnvolle und erforderliche Impfungen rechtzeitig ausgewählt werden können.

>>    Telefonische Reiseberatung

>>     Reise-Fragebogen - Impfberatung

Thailand ist ein Malarialand . Für Reisende besteht ein regionales Infektionsrisiko:

a) Geringes Risiko in den Grenzgebieten der Nordhälfte, inkl. der Touristengebiete im Goldenen Dreieck sowie der Südhälfte des Landes (inkl. Küsten), im Khao Sok National Park und auf den meisten Inseln, z.B. Ko Chang, Ko Mak, Ko Phangan, Ko Tao.

b) Die zentralen Gebiete in der Nordhälfte des Landes, Bangkok, Chanthaburi, Chiang Mai, Chiang Rai, Pattaya, Phuket, Samet, Ko Samui und Inseln der Krabi Provinz gelten als malariafrei.

Anteil von Plasmodium falciparum , dem Erreger der gefährlichen Malaria tropica , ca. 23%.

Medikamentöse Prophylaxe:

I) In den benannten Risikogebieten a) wird die Mitnahme von Atovaquon / Proguanil (Malarone®) als Notfallmedikament empfohlen.

II) Eine Malariaprophylaxe oder die Mitnahme eines Notfallmedikamentes (Stand-By-Therapie) ist für die aufgeführten Gebiete (b) zur Zeit nicht erforderlich.

Die konkrete Auswahl der Anti-Malaria-Mittel, deren individuelle Anpassung sowie Nebenwirkungen bzw. Unverträglichkeit mit anderen Medikamenten sollten vor der Reise mit einem Reisemediziner abgestimmt werden.

>> Medikamentöse Prophylaxe

>> Reisemedizinische Beratung

Eine Expositionsprophylaxe (z.B. imprägniertes Moskitonetz und hochwirksamer Mückenschutz ) sollte auf jeden Fall durchgeführt werden.

Welches Moskitomittel und welches -netz eignet sich für Thailand? Hier finden Sie weitere Infos:

>> Imprägniertes Moskitonetz >> Hochwirksames Mückenmittel >> Kleidung / Socken mit Insektenschutz >> Schlaf-Inletts mit Insektenschutz

Botschaft Botschaft der Bundesrepublik Deutschland 9 South Sathorn Road, Bangkok 10120 Tel.: 0066 2 - 2879000 Fax: 0066 2 - 2871776 E-Mail: [email protected] URL: http://www.bangkok.diplo.de

Reiseapotheke

Häufige Reise-Erkrankungen und kleinere Verletzungen sollten Sie auf Ihrer Reise mit einer gut ausgestatteten Reiseapotheke selbst behandeln können. So empfehlen sich auf jeden Fall wirksame Anti-Mücken-Mittel , Mittel gegen Fieber, Schmerzen und Durchfall , Desinfektionsmittel, Pflaster und Verbandsmaterial sowie Sonnenschutzmittel . Weitere Medikamente können sinnvoll sein - dies sollten Sie mit einem reisemedizinisch erfahrenen Arzt besprechen.

Weitere Informationen sowie eine Checkliste für Ihre Reiseapotheke finden Sie hier:

>> Reiseapotheke

Müssen Sie auch während Ihrer Reise Medikamente einnehmen , sollten Sie diese in ausreichender Menge in Ihrem Handgepäck mitführen. Dabei ist - je nach Medikament - bei der Einreise eventuell auch eine Bestätigung über die Notwendigkeit der Einnahme dieser Medikamente notwendig. Diese erhalten Sie von Ihrem behandelnden Arzt.

Gelbfieberländer

Eine Bescheinigung, auf der eine gültige Gelbfieber-Impfung , nachgewiesen wird (Impfpass), ist bei der Einreise aus den folgenden Ländern erforderlich:

Angola - Äquatorial-Guinea - Argentinien - Äthiopien - Benin - Bolivien - Brasilien - Burkina Faso - Burundi - Ecuador - Elfenbeinküste - Französisch Guayana - Gabun - Gambia - Ghana - Guinea - Guinea-Bissau - Guyana - Kamerun - Kenia - Kolumbien - Kongo, Republik - Kongo, demokratische Republik - Liberia - Mali - Mauretanien - Niger - Nigeria - Panama - Paraguay - Peru - Senegal - Sierra Leone - Sudan - Surinam - Togo - Trinidad & Tobago - Tschad - Uganda - Venezuela - Zentralafrikanische Republik

Hygiene & Essen

Wenn Sie ein paar einfache Regeln zur Hygiene beachten, bleiben Sie von zahlreichen Krankheiten verschont: Vor dem Essen und nach der Toilette immer Hände waschen - am besten mit eigener Seife - und keine benutzten Handtücher zum Abtrocknen verwenden. Als Trinkwasser oder Wasser zum Zähneputzen benutzen Sie idealerweise in Flaschen abgefülltes Mineralwasser oder abgekochtes Wasser. Da bis zu 50% aller Fernreisenden an Durchfall , erkranken, sollten Sie sich beim Essen an die folgende Regel halten:

Boil it, cook it, peel it or forget it - Koche es, brate es, schäle es oder vergiss es!

>> Essen und Trinken auf Reisen

Mückenschutz

Je weniger Stiche, desto geringer ist Ihr Infektionsrisiko! Schützen Sie sich mit ein paar einfachen Maßnahmen:

• Verwenden Sie auf unbedeckter Haut ein wirksames Moskitomittel - passend zu Ihrem Reiseziel. >> Hochwirksame Mittel
• Wenn Sie auf Ihrer Reise nicht nur in klimatisierten Räumen übernachten, schlafen Sie unter einem Moskitonetz. >> Auswahl Moskitonetz
• Wollen Sie sich auch unterwegs vor lästigen Moskitos schützen, tragen Sie möglichst lange, helle Kleidung. In Risikogebieten sollten Sie imprägnierte oder stichfeste Kleidung tragen. >> Kleidung mit Mückenschutz
• Wählen Sie Ihren Schlafplatz sorgfältig aus: Wenn Sie nicht sicher sind, ob die Matratze oder Bettwäsche evtl. Bettwanzen, Zecken oder Flöhe beherbergen, empfiehlt sich die Verwendung eines insektenabweisenden Schlaf-Inletts. >> Anti-Insekt-Inlett / -Schlafsack

>> Schutz vor Insektenstichen

Sonnenschutz

Aufgrund der erhöhten UV-Strahlung am Reiseziel besteht ein Risiko für Sonnenbrand und andere UV-Schäden. Schützen Sie sich und Ihre evtl. mitreisenden Kinder daher gut vor der Sonne und vermeiden Sie so einen Sonnenbrand: Benutzen Sie Sonnenschutzmittel mit hohem Lichtschutzfaktor (LSF/SPF 30-50) auf der unbedeckten Haut. Tragen Sie wenn möglich UV-geschätzte, hautbedeckende Kleidung, eine Kopfbedeckung sowie eine Sonnenbrille. Insbesondere Kinder sollten sich zwischen 12-15:00 Uhr im Schatten aufhalten und nicht direkt der Sonne ausgesetzt sein. Wissenschaftliche Studien haben ergeben, dass das Hautkrebs-Risiko umso höher ist, je öfter die Haut vor dem 18. Lebensjahr durch Sonnenbrände geschädigt wurde. Auf die empfindliche Haut von Kindern sollten Sie daher besonders achten.

>> Sonne, Strand und Meer

>> Kinder & Sonne

Vorsicht Tiere!

Die meisten Tiere gehen Menschen aus dem Weg - wenn sie sich aber bedroht fühlen, die Tiere ihren Nachwuchs oder Territorium schützen oder verletzt oder krank sind, können sie auch angreifen. Tierbisse und Kratzer können dann zu schweren Krankheiten wie Tollwut führen. Befolgen Sie daher diese Tipps, um sich zu schützen:

• Berühren oder füttern Sie keine Tiere, die Sie nicht kennen.
• Lassen Sie die Tiere keine offenen Wunden lecken und achten Sie darauf keinen tierischen Speichel in Ihre Augen oder Mund zu bekommen.
• Vermeiden Sie Nagetiere und ihren Urin und Kot.
• Grundsätzlich können viele Tiere eine gesundheitliche Bedrohung darstellen, seien Sie aber bei Hunden, Fledermäuse, Affen, sowie Quallen und Schlangen besonders vorsichtig.
• Werden Sie von einem Tier gebissen oder gekratzt, waschen Sie die Wunde mit Seife und sauberem Wasser aus. Gehen Sie anschließend sofort zu einem Arzt. Berichten Sie auch Ihrem Arzt in Ihrem Heimatland über Ihre Verletzung, wenn Sie von Ihrer Reise wieder zurückkommen.

Sollten Sie mit Kindern reisen, ist es wichtig, dass Ihre Kinder die oben beschriebenen Regeln beachten und dass sie Ihnen über die kleinste Bissverletzung sofort berichten müssen. 

>> Tollwut - häufige Fragen & Antworten (FAQs)

>> Kinder & Tiere

Nach der Reise

Sollten Sie sich nach Ihrer Reise nicht wohl fühlen oder Fieber bekommen, suchen Sie sofort einen Arzt auf. Beschreiben Sie Ihrem Arzt, wann Sie wohin gereist sind und was Sie auf Ihrer Reise getan haben (Aktivitäten, Verletzungen, Essen und Trinken, Kontakt mit Tieren oder Körperflüssigkeiten, Baden in Binnengewässern etc).

Ihre reisemedizinische Beratung – bequem von zu Hause

Lassen Sie sich bequem von zu Hause von erfahrenen Fachärzten des CRV - Centrum für reisemedizinische Vorsorge* beraten und fordern Sie Ihre reisemedizinische Beratung jetzt einfach online an:

Für Ihre individuelle Beratung steht Ihnen online ein Fragebogen zur schriftlichen Reiseberatung  (empfohlene Impfungen und Vorsorgemaßnahmen für Ihr Reiseziel) zur Verfügung. Zur Beantwortung Ihrer reisemedizinischen Fragen können Sie auch einen Telefontermin mit einem Facharzt vereinbaren. 

Oder finden Sie einen stationären Arzt in Ihrer Nähe: Über die Arztsuche der KBV – Kassenärztlichen Bundesvereinigung, können Sie Ärzte in der Nähe eines gewünschten Ortes suchen sowie über den Terminservice der KBV einen Arzttermin vor Ort buchen. 

. *      CRV – Centrum für reisemedizinische Vorsorge ist eine Firmierung der Praxis Dr. med. Andrea Gontard.

**    Sie werden bei Betätigung des Buttons auf die Seite des vom CRV - Centrum für reisemedizinische Vorsorge* betriebenen Internetangebots weitergeleitet.

***  Sie werden bei Betätigung des Buttons auf die Seite des von der KBV – Kassenärztliche Bundesvereinigung betriebenen Internetangebots weitergeleitet.

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Scrub typhus in india, 23 jul 2014.

A seasonal (monsoon) increase in scrub typhus has been reported in the state of Himachal Pradesh. To date, 137 cases have been recorded throughout the state with rural areas most affected. The worst affected area is Bilaspur district, with 29 confirmed cases. Thirty six cases have required admission to hostpital for treatment and 69 have received treatment at hospital in Tanda.

The health department has recommended the distribution of material among the general public to raise awareness of the symptoms and treatment of scrub typhus. Health institutions across the state have been recommended to adequately stock doxycycline and azithromycin for treatment of scrub typhus.

Advice for Travellers

Scrub typhus is transmitted by infected ticks. Travellers should take precautions against tick bites including the use of insect repellents on the skin and clothes and covering the skin as much as possible (long sleeves and long trousers tucked into socks).

The skin should be inspected daily for ticks and any ticks seen removed by grasping the tick as near to the skin surface as possible and applying gentle traction (without twisting).

• Further information on insect bite avoidance .

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