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Understanding CDC Travel Health Notices

The U.S. Centers for Disease Control and Prevention (CDC) uses Travel Health Notices (THN) to “inform travelers and clinicians about current health issues that impact travelers’ health, like disease outbreaks, special events or gatherings, and natural disasters, in destinations around the world.”

On April 13, 2022 the CDC announced significant changes to the Travel Health Notices (THN) specific to COVID-19. The structure of the 4 level system will reserve the highest level-'Level 4: Do Not Travel' for only special circumstances such as a healthcare infrastructure collapse or extreme spikes in case counts of COVID-19 levels. This change resulted in 89 countries being removed from the "Level 4: Do Not Travel" list.

CDC Travel Health Notices for Levels 1, 2, and 3 will continue to be based on a 28-day incidence or case counts.

The 4 COVID-19 Travel Health Notice levels are: 

Level 4 – Special Circumstances/Do Not Travel

Level 3 – High Level of COVID-19

Level 2 – Moderate Level of COVID-19

Level 1 - Low Level of COVID-19

Level Unknown: Unknown Level of COVID-19

Read more from the CDC on how COVID-19 Travel Health Notices are determined here .

The CDC's standard (non-COVID-19)  Travel Health Notice system  has 3 levels: 

Warning Level 3 – Avoid all non-essential travel 

Alert Level 2 – Practice Enhanced Precautions 

Watch Level 1 – Practice Usual Precautions 

This standard THN system will remain in use alongside the C OVID-19 specific travel health notices introduced by the CDC in 2020. 

COVID-19 vaccines currently appear as recommended vaccines on CDC Country Information pages . When COVID-19 vaccines were authorized under an Emergency Use Authorization process, they were not listed on Country Imformation pages by the CDC. Now that the COVID vaccines are authorized under general use guidelines per the FDA, they have been added to a list of recommended vaccines on CDC Country pages.

Colleges, universities, and provider organizations consider CDC Travelers Health Notices and other information provided by the CDC (e.g., vaccinations and immunizations) in their evaluation of the relative health and safety of an education abroad location. 

Visit CDC Travelers Health COVID-19 Homepage  

Some other sources are:

• WHO Efficiency of Care
• Global Health Security Index assessment
• Harvard Metrics on Case Rates
• WHO current COVID infection rates/spread 
• Our World in Data Daily Positive Test Rates
• European Centre for Disease Prevention and Control 14-day cumulative number of COVID-19 cases per 100 000
• CIEE Health Risk Index
• ISOS (COVID-19) Impact Rating  

NAFSA Education Abroad Health and Safety  

Crisis Management for Education Abroad

Outbound Immigration and Logistical Considerations for Education Abroad During the COVID-19 Pandemic  

Government Connection: Understanding CDC Travel Health Notices  

Heading Home Healthy is a program supported by Global TravEpiNet , Massachusetts General Hospital and the Centers for Disease Control and Prevention . Our goal is to help travelers stay healthy when they are returning home to visit friends and relatives. We also are working with travel agents and clinicians to help them prepare international travelers to stay healthy.

Malaria and Travelers for U.S. Residents

Quick links.

• Prophylaxis Guidelines for Malaria in “Off-the-Radar” Areas
• Travel to West Africa? Don’t Neglect Malaria Prevention
• Mosquito Repellent Fact Sheet
• Prescribing Information for Malaria Prevention Drugs
• Yellow Book Malaria Section New!
• Blog: CDC Malaria Hotline—When the Caller is Ill Abroad

This information is intended for travelers who reside in the United States. Travelers from other countries may find this information helpful; however, because malaria prevention recommendations and the availability of antimalarial drugs vary, travelers from other countries should consult health care providers in their respective countries. For more health recommendations for international travel, visit the CDC Yellow Book .

Every year, millions of US residents travel to countries where malaria is present. About 2,000 cases of malaria are diagnosed in the United States annually, mostly in returned travelers.

Travelers to sub-Saharan Africa have the greatest risk of both getting malaria and dying from their infection. However, all travelers to countries where malaria is present may be at risk for infection.

Obtain a detailed itinerary including all possible destinations that may be encountered during the trip and check to see if malaria transmission occurs in these locations. The Malaria Information by Country Table  provides detailed information about the specific parts of countries where malaria transmission does or does not occur. It also provides additional information including the species of malaria that occur there, the presence of drug resistance, and the specific medicines that CDC recommends for use for malaria prevention in each country where malaria transmission occurs on CDC’s Malaria maps.

Prevention of malaria involves a balance between ensuring that all people who will be at risk of infection use the appropriate prevention measures, while preventing adverse effects of those interventions among people using them unnecessarily. An individual risk assessment should be conducted for every traveler, taking into account not only the destination country, but also the detailed itinerary, including specific cities, types of accommodation, season, and style of travel. In addition, conditions such as pregnancy or the presence of antimalarial drug resistance at the destination may modify the risk assessment.

More on: Malaria Risk Assessment for Travelers

Based on the risk assessment, specific malaria prevention interventions should be used by the traveler. Often this includes avoiding mosquito bites through the use of repellents or insecticide treated bed nets, and specific medicines to prevent malaria.

More on: Preventing Mosquito Bites While Traveling

If malaria prevention medicines will be needed for the traveler, the  Malaria Information by Country Table lists the CDC-recommended options. For many destinations, there are multiple options available. Factors to consider are the patient’s other medical conditions, medications being taken (to assess potential drug-drug interactions), the cost of the medicines, and the potential side effects.

More on: Tips on Choosing the Right Drug for an Individual Traveler

The Drugs for Malaria Prevention table  provides prescription dosing information for both adults and children.

In some countries (including those with malaria risk), drugs may be sold that are counterfeit (“fake”) or substandard (not made according to United States standards). Such drugs may not be effective. Antimalarial drugs should always be purchased before traveling overseas!

For details and specific warnings, see Counterfeit and Substandard Antimalarial Drugs

This picture shows some things that travelers can use to protect themselves against malaria: malaria pills; insect repellent; long-sleeved clothing; bednet; and flying insect spray. (Not shown, but also protective: air conditioned or screened quarters.)

The interventions used to prevent malaria can be very effective when used properly, but none of them are 100% effective.

Malaria is always a serious disease and may be a deadly illness. Travelers who become ill with a fever or flu-like illness either while traveling in a malaria-risk area or after returning home (for up to 1 year) should seek immediate medical attention and should tell the physician their travel history.

Travelers who are assessed at being at high risk of developing malaria while traveling should consider carrying a full treatment course of malaria medicines with them. Providing this reliable supply of medicine (formerly referred to as standby or emergency self-treatment) will ensure that travelers have immediate access to an appropriate and high quality medicine if they are diagnosed with malaria while abroad. Depending on the medicine they are using for prevention, this could either be atovaquone/proguanil or artemether/lumefantrine.

More on: Malaria Treatment (United States)

Travelers are often surprised to learn that even if they adhered to all of the prevention advice and did not become sick with malaria, recent travel to a place where malaria transmission occurs is an exclusion criterion for blood donation.

More on: Prevention of Blood Transfusion-Associated Malaria

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New! Locally Acquired Cases of Malaria in Florida, Texas, Maryland, and Arkansas

New! Update to Guidance for use of Artemether-Lumefantrine (Coartem®) in Pregnancy for Uncomplicated Malaria New! Discontinuation of CDC’s Distribution of Intravenous Artesunate as Commercial Drug Guidance for Malaria Diagnosis in Patients Suspected of Ebola Infection in the United States -->

See all Malaria Notices

• New! Malaria is a Serious Disease
• New!   La malaria (paludismo) es una enfermedad grave
• How to Report a Case of Malaria
• CDC Yellow Book
• Red Pages: Malaria-endemic areas by country
• Drugs for Prevention
• Choosing a Drug to Prevent Malaria
• Drugs for Treatment in the U.S.
• Frequently Asked Questions (FAQs)
• Blood Banks

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Enabling clinicians to easily find location-based travel health recommendations—is innovation needed?

R. ryan lash.

1 Travelers’ Health Branch, Division of Global Migration and Quarantine, CDC, Atlanta, GA, USA

Allison Taylor Walker

C. virginia lee, regina larocque.

2 Massachusetts General Hospital Travelers’ Advice and Immunization Center, Cox 5, 55 Fruit Street, Boston, MA 02114, USA

3 Harvard Medical School, 10 Shattuck Street, Boston, MA 02115, USA

Sowmya R. Rao

4 Massachusetts General Hospital Biostatistics Center, 50 Staniford Street, Suite 560, Boston, MA 02114, USA

5 Department of Global Health, Boston University, 801 Massachusetts Avenue, Crosstown Center, 3rd Floor, Boston, MA 02118, USA

Edward T. Ryan

Gary brunette, kelly holton, mark j. sotir.

The types of place names and the level of geographic detail that patients report to clinicians regarding their intended travel itineraries vary. The reported place names may not match those in published travel health recommendations, making traveler-specific recommendations potentially difficult and time-consuming to identify. Most published recommendations are at the country level; however, subnational recommendations exist when documented disease risk varies within a country, as for malaria and yellow fever. Knowing the types of place names reported during consultations would be valuable for developing more efficient ways of searching and identifying recommendations, hence we inventoried these descriptors and identified patterns in their usage.

The data analyzed were previously collected individual travel itineraries from pretravel consultations performed at Global TravEpiNet (GTEN) travel clinic sites. We selected a clinic-stratified random sample of records from 18 GTEN clinics that contained responses to an open-ended question describing itineraries. We extracted and classified place names into nine types and analyzed patterns relative to common travel-related demographic variables.

From the 1756 itineraries sampled, 1570 (89%) included one or more place names, totaling 3366 place names. The frequency of different types of place names varied considerably: 2119 (63%) populated place, 336 (10%) tourist destination, 283 (8%) physical geographic area, 206 (6%) vague subnational area, 163 (5%) state, 153 (5%) country, 48 (1%) county, 12 (1%) undefined.

Conclusions

The types of place names used by travelers to describe travel itineraries during pretravel consultations were often different from the ones referenced in travel health recommendations. This discrepancy means that clinicians must use additional maps, atlases or online search tools to cross-reference the place names given to the available recommendations. Developing new clinical tools that use geographic information systems technology would make it easier and faster for clinicians to find applicable recommendations for travelers.

The types of names used to describe travel destinations, or place names, and the level of geographic detail with which patients report their intended travel itineraries to clinicians, vary. Some patient itineraries may consist of a single country name; others may report the cities listed on their airline itinerary; and still others may report a detailed itinerary listing specific airports, cities, villages, hotel names and tourist destinations to be visited. When performing individual health risk assessments during pretravel consultations, clinicians must identify travel health risks and recommendations based on the place names in these patient-reported itineraries. One challenge clinicians face is that the patient-reported place names may not match those in published travel health recommendations, making traveler-specific recommendations potentially difficult and time-consuming for clinicians to identify and deliver. More facile and accurate location information could improve the accuracy of recommendations.

To process itinerary descriptions, clinicians usually use a travel medicine reference book or website. 1 – 5 Most published recommendations are at the country level; however, subnational recommendations (e.g. state name, city name) exist when documented disease risk varies within a country, as for malaria and yellow fever. 6 Clinicians need maps detailed enough to locate the travel destinations and described risk areas 7 and have been advised to acquire separate atlases, world maps, or globes to help with this process. 8 To address this need, the CDC Yellow Book has included some country-specific yellow fever and malaria maps enumerating a limited number of subnational places; 6 , 9 however, some users find the CDC maps difficult to use. 10

It has been proposed that incorporating geographic information systems (GIS) technology into clinical decision-support tools could make identifying travel health risks and recommendations easier and faster. 11 Modern GIS-based technologies have been used to create a variety of free Internet-based mapping tools and services, which are rapidly replacing many reference maps and atlases. One of the most popular examples of this technology is Google Maps (Mountain View, CA), which combines a robust place name search service with a detailed map, making it easy to find many types of places all over the world. Anecdotal reports suggest some clinicians regularly use these Internet search and map services to help them interpret travelers’ itineraries, but little is known about how widely such tools have been adopted. An international study suggested that requiring clinicians to rely on their own ability to locate and interpret these numerous mapping resources remains overly burdensome. 12 Knowing the types of places that clinicians are searching for is a necessary first step to solving the recommendation look-up problem.

To better understand the geographic place names clinicians encounter when searching for travel health risk recommendations, we examined previously collected Global TravEpiNet (GTEN) data, which capture patient-reported travel itineraries during pretravel consultations at participating GTEN clinics. We analyzed these free-text itinerary data to classify the types of place names used to describe a traveler’s itinerary during pretravel consultations. The second objective was to summarize types of place names in clinical encounters as compared to those used in CDC’s travel health recommendations. If this comparison found place name types differ between clinical conversations and CDC recommendations, the final objective was to identify new uses for geospatial technology (e.g. place name search services and interactive maps) to assist clinicians in efficiently locating the necessary travel health information.

Data and Methods

Global travepinet patient intake forms.

Global TravEpiNet (GTEN) is a network of travel clinics from across the USA, comprising academic practices, healthcare consortia, health maintenance organizations, pharmacy-based clinics, private practices and public health clinics. 13 Each GTEN clinic uses a standard electronic form to collect demographic and health characteristics, intended travel itineraries, purposes of travel, and pretravel healthcare received on US residents planning international travel. Travelers typically complete the form online before their appointment, and clinicians confirm and may add details during the pretravel consultation. The form captures intended travel itineraries in two ways: (i) a mandatory question that asks users to select one or more places from a list of country names; and (ii) an optional, open-ended, free-text question that allows users to enter ‘additional destination details’. Institutional review boards at all participating GTEN sites have reviewed and approved their participation in the GTEN consortium.

Records containing ‘additional destination details’ were eligible for inclusion in our analysis if submitted to the GTEN system during 12 January 2009–31 December 2016 from clinics with ≥50 such records. A clinic-stratified random sample of these records was taken to balance representation across all clinics and to accommodate the demands of the manual data processing performed. A final sample of records was assembled from two clinic groupings: (i) For clinics that submitted 50–100 eligible records, all eligible records were included in the analysis; and (ii) from each clinic that submitted >100 eligible records, exactly 100 randomly selected records were included.

Classifying Itinerary place names by type

The free-text responses to the ‘additional destination details’ questions were manually processed by two analysts (R. Lash and C. Lee). A Microsoft Access (Microsoft Office 2016, Redmond, WA) relational database with custom data entry forms was created to ensure accuracy and consistency during data processing. The data entry form enabled each analyst to read the free-text response for an individual patient’s itinerary, identify all the place names reported therein, and copy and paste each place name listed into a related place name table for subsequent classification. Free-text place names were classified into one of the following nine types: multi-national area, country, state, county, populated place, tourist destination, physical geographic area, vague subnational area or undefined ( Table 1 ). Online mapping resources (e.g. Google Maps, CIA World Fact Book) were consulted to determine the place name type of any unfamiliar place names. The following assumptions were needed to handle the variation within the unstructured data:

• Locations that are both populated places and administrative areas, such as Singapore and Hong Kong, were classified as the populated place type.
• If a traveler provided a hierarchical place name list, such as ‘Cancun, Quintana Roo, Mexico,’ we interpreted that the traveler was visiting only one destination, ‘Cancun,’ and that the other place names were simply descriptors.
• Country place names were not counted if they had already been reported in the GTEN form’s mandatory country list question.

Unique place names classified as one of nine types

After place names were extracted from the ‘additional destination details’ field, they were classified as one of the nine types of place names listed and defined above.

Microsoft Access was used to generate summary statistics to descriptively analyze place name type variation across different GTEN clinics, as well as the demographic and travel characteristics of the travelers. Microsoft Excel (Microsoft Office 2016, Redmond, WA) was used to create data visualizations.

There were 88 285 records submitted by 25 clinics to the GTEN system during the period of analysis; 35 119 (40%) records contained responses to the ‘additional destination details’ question. Eighteen (72%) of these 25 clinics submitted ≥50 eligible records; 15 of those clinics submitted >100 eligible records (contributing 1500 records to the analysis); and three clinics submitted 50–100 eligible records (contributing 256 records to the analysis), for a final sample size of 1756 records.

The demographic and travel characteristics of the sample were similar to those of all travelers in GTEN. 13 The majority of travel itineraries had durations from 1 day to 4 weeks, with two-thirds being between 8 and 28 days. The most common travel destinations were Africa, the Americas, Southeast Asia and the Western Pacific, with only a small proportion of travelers going to Europe or the Eastern Mediterranean. The most common reasons for travel were leisure (56%), followed by business (17%), and humanitarian service work (17%).

Of all the itineraries sampled, 1570 (89%) included one or more place names in the responses to the ‘additional destination details’ questions, totaling 3366 place names ( Table 2 ). Table 2 shows the frequency of the different types of place names: 2119 (63%) populated place, 336 (10%) tourist destination, 283 (8%) physical geographic area, 206 (6%) vague subnational area, 163 (5%) state, 153 (5%) country and 48 (1%) county. Overall, these data show that the populated place name type (which included city, village or airport) was listed 6 times more often than the tourist destination and 10 times more often than state and country types.

Frequency of different place name types

We assessed whether the overall patterns described above occurred differentially at individual GTEN sites. The total numbers of place names reported per individual GTEN site ranged from 88 to 325. The proportion of each place name type per GTEN site indicated that the populated place name type comprised the largest proportion at each GTEN site, with a median value of 64% (range = 40–86%). This variation did not appear to correlate with any other known characteristics of the GTEN sites.

Figure 1 shows variation in the proportion of place name types across the four levels of travel duration, with populated place being dominant. However, as the duration of the itinerary increased beyond 28 days, the proportion of Populated Place decreased while the proportion of country and multi-national area Area types increased. It is important to note that these class sizes do not represent equal numbers of travelers; there were 204 travelers with itineraries lasting 1–7 days, 1156 travelers with itineraries lasting 8–28 days, 311 travelers with itineraries lasting 29–180 days, and only 85 travelers with itineraries lasting more than 180 days.

Place name type variation by trip duration.

We found that populated place was the most common way for patients to report intended travel itineraries in our analysis, except when the intended trip duration was ≥6 months. This means that there may often be a discrepancy between the place names travelers use to report their travel itineraries and those used by clinicians to identify travel health risks. This discrepancy likely occurs because most travelers report their intended travel itineraries as cities, towns or popular tourist destinations, while most risk assessments and recommendations are reported nationally. As a result, there is subjectivity in how clinicians match risks to their patients’ itineraries and provide travel health recommendations. This subjectivity could be reduced with improved clinical information search tools.

Bauer and Puotinen 11 envisioned that GIS technology could be incorporated into travel medicine to provide improved clinical information search tools. Integrating this technology may increase the accuracy of clinical recommendations by allowing location-specific targeting for subnational recommendations such as malaria prophylaxis and yellow fever vaccination. A tool that incorporates GIS technology could enable travel health clinicians to quickly and easily search global GIS databases of travel-related diseases and disease risks by traveler destination. If such a tool were developed and inserted into existing reference platforms, we propose that it have four components:

• Accurate, specific and up-to-date global health risk and recommendation databases.
• Global place name search capabilities to locate a multitude of place name type descriptions.
• A computer algorithm that can query the database and return location-specific information.
• A user interface that displays this information in a format that clinicians can use and understand without needing to consult additional maps or resources.

The present analysis shows that there is a disconnect between the first and second components of an ideal tool and suggests that GIS-based place name search services could resolve part of this problem. Additionally, adoption of common GIS data standards, extensive user testing and systematic evaluation would be needed to ensure that clinicians’ information needs were being met.

We believe that our analysis is the first of its kind in travel medicine, though analogous research has already been conducted in tourism and hospitality research with similar results. Hwang et al. 14 studied the phone call transcripts from an Illinois state tourism information call center to understand the way domestic travelers use location to search for travel information (e.g. tourist activities, hotels), an important question for informing how tourist destination websites are designed. Consistent with our analysis, the authors classified the place name types reported in travelers’ queries as either the state, region within the state, county or city. They found that cities were the most frequent place name type used, with 83% of the single-destination searches and 75% of the multidestination searches using cities, while counties were the least common and states the second-least common name types. Similar research was done on a sample of Internet search queries to study travelers’ accommodation searches. This study found that cities were again the most common type of place name used, and they were used four times more frequently than country and state names. 15 This tourism and hospitality research appears to corroborate our findings that travelers use city names to structure their travel itineraries.

Our analysis has some limitations. Because the ‘additional destination detail’ question on the GTEN form is optional and users are not given any specific instructions on what type of information to put in, little is known about why some forms contain more detailed destination information and others do not. Similarly, because both the patient and the clinician are able to enter information into the intake form, it is difficult to associate patterns in the data with the information-seeking behavior of either the patient or the clinician. An additional limitation is the specificity of existing travel recommendations. Due to variations in laboratory and surveillance capacity internationally, data are not available to define areas of subnational disease transmission.

We believe our analysis is a first step toward providing clinicians with the detailed and helpful information they need to provide more targeted travel health recommendations to their patients, based on the geographic travel locations their patients describe. The time-consuming process clinicians currently go through could be made less burdensome by developing GIS-based clinical decision-support tools that incorporates innovative and increasingly common GIS technology, such as travel health recommendations formatted as GIS databases, place name search services and interactive web maps.

Acknowledgments

Members of the Global TravEpiNet Consortium (in alphabetical order) are George M. Abraham, Saint Vincent Hospital (Worcester, MA); Salvador Alvarez, Mayo Clinic (Jacksonville, FL); Vernon Ansdell and Johnnie A. Yates, Travel Medicine Clinic, Kaiser Permanente (Honolulu, HI); Elisha H. Atkins, Chelsea HealthCare Center (Chelsea, MA); Holly K. Birich and Dagmar Vitek, Salt Lake Valley Health Department (Salt Lake, Utah); John Cahill, Travel and Immunization Center, St. Luke’s-Roosevelt (New York, NY); Lin Chen, Mount Auburn Hospital (Cambridge, MA); Bradley A. Connor, New York Center for Travel and Tropical Medicine, Cornell University (New York, NY); Roberta Dismukes, Jessica Fairley, Phyllis Kozarsky, Henry Wu, Emory TravelWell, Emory University (Atlanta, GA); Ronke Dosunmu, JourneyHealth (Maywood, NJ); Jeffrey A. Goad and Edith Mirzaian, International Travel Medicine Clinic, University of Southern California (Los Angeles, CA); Nelson Iván Agudelo Higuita, University of Oklahoma Health Sciences Center, Oklahoma City, OK; Karl Hess, Hendricks Pharmacy International Travel Clinic, Claremont, CA; Noreen A. Hynes, Johns Hopkins Travel and Tropical Medicine, Division of Infectious Diseases, Johns Hopkins School of Medicine (Baltimore, MD); Frederique Jacquerioz and Susan McLellan, Tulane University (New Orleans, LA); Jenn Katsolis, Jacksonville Travel Clinic-St. Vincents (Jacksonville, FL); Paul Kelly, Bronx Lebanon Medical Center (New York, NY); Mark Knouse, Keystone Travel Medicine, Lehigh Valley Health Network (Allentown, PA); Jennifer Lee, Northwestern Medical Group-Travel Medicine, Northwestern Memorial Hospital (Chicago, IL); Daniel Leung, Brian Kendall, and DeVon Hale, International Travel Clinic, University of Utah (Salt Lake City, UT); Alawode Oladele and Hanna Demeke, DeKalb County Board of Health Travel Services-DeKalb North and Central-T.O. Vinson Centers (Decatur, GA); Alawode Oladele and Althea Otuata, DeKalb County Board of Health Travel Services-DeKalb East (Decatur, GA); Roger Pasinski and Amy E. Wheeler, Revere HealthCare Center (Revere, MA); Adrienne Showler, Laura Coster, and Jessica Rosen, Infectious Diseases and Travel Medicine, Georgetown University (Washington, DC); Brian S. Schwartz, Travel Medicine and Immunization Clinic, University of California (San Francisco, CA); William Stauffer and Patricia Walker, HealthPartners Travel Medicine Clinics (St. Paul, Minnesota); and Joseph Vinetz, Travel Clinic, Division of Infectious Diseases, Department of Medicine, University of California-San Diego School of Medicine (La Jolla, CA). An earlier version of this work was presented as a poster at the 15th Conference of the International Society of Travel Medicine, Barcelona, Spain. Also, an earlier version of this manuscript was included in R. Lash’s doctoral dissertation entitled ‘Geocoding of Place Names for Collecting, Mapping, Managing, and Communicating Public Health Information,’ Department of Geography, University of Georgia, and we would like to thank the members of that dissertation committee for their constructive comments. The views expressed in this paper are solely those of the authors and do not represent those of CDC, the US government, or any other entity the authors may be affiliated with.

This work was supported by Centers for Disease Control and Prevention (Grants U19CI000514, U01CK000175 and U01CK000490).

Conflict of interest: None to declare.

Author Contributions

CHRISTOPHER SANFORD, MD, MPH, ADAM MCCONNELL, MD, AND JUSTIN OSBORN, MD

Am Fam Physician. 2016;94(8):620-627

Patient information : See related handout on tips for international travel .

Author disclosure: No relevant financial affiliations.

Key components of the pretravel consultation include intake questions regarding the traveler's anticipated itinerary and medical history; immunizations; malaria prophylaxis; and personal protection measures against arthropod bites, traveler's diarrhea, and injury. Most vaccinations that are appropriate for international travelers are included in the routine domestic immunization schedule; only a few travel-specific vaccines must also be discussed. The most common vaccine-preventable illnesses in international travelers are influenza and hepatitis A. Malaria prophylaxis should be offered to travelers to endemic regions. Personal protection measures, such as applying an effective insect repellent to exposed skin and permethrin to clothing and using a permethrin-impregnated bed net, should be advised for travelers to the tropics. Clinicians should offer an antibiotic prescription that travelers can take with them in case of traveler's diarrhea. Additional topics to address during the pretravel consultation include the risk of injury from motor vehicle crashes and travel-specific risks such as altitude sickness, safe sex practices, and emergency medical evacuation insurance.

Data show that 1.1 billion persons crossed an international border in 2014, and this number is projected to increase to 1.8 billion persons in 2025. 1 Tourism is increasing in both high- and low-income destinations, and is the first- or second-largest source of revenue in 20 of the 48 least developed countries. 2

WHAT'S NEW ON THIS TOPIC: THE PRETRAVEL CONSULTATION

Pregnant women and women of childbearing age who are trying to conceive should postpone travel to Zika-endemic areas. If they do visit these areas, they should be vigilant about arthropod avoidance measures. Because Zika is also transmitted by sex, men who visit Zika-endemic areas should use condoms with pregnant sex partners.

Only a minority of international travelers—36% in one study—seek pretravel counseling; of those, 60% see a primary care clinician, 10% see a travel subspecialist, and 30% turn to friends and family. 3 Although research supports some portions of the pretravel encounter (e.g., malaria prophylaxis, immunizations), the benefit of counseling on other topics (e.g., motor vehicle crashes, safe sex) has not yet been demonstrated. 4

Although consulting a clinician is beneficial to patients at any time before international travel, pretravel visits should ideally occur at least six weeks before departure to maximize benefit of immunizations and other preventive measures. The pretravel consultation is likely to be particularly useful in those visiting low-income nations.

Table 1 outlines the recommended components of the pretravel consultation, 5 , 6 and Table 2 provides resources for clinicians who provide pretravel services. Physicians who perform pretravel consultations only occasionally or who have minimal training in travel medicine may want to refer complex cases to a clinician experienced in travel medicine.

The assessment should include dates of travel, anticipated itinerary, planned activities, mode of travel, and reason for travel. Additionally, clinicians should inquire about the traveler's acceptance level for health risks and budget for health care expenditures.

A full medical history should be elicited from the traveler, including immunization records, medications, allergies, and medical conditions. Certain conditions, if uncontrolled, may increase health risks in travelers and include congestive heart failure, hypertension, seizures, diabetes mellitus, and mental illness. Clinicians may recommend against particular trips or activities if they exceed the traveler's physical abilities or if there is a specific contraindication. Persons who have had a myocardial infarction or coronary artery bypass within the previous two weeks, or a complicated myocardial infarction within the previous six weeks, 7 are thought to be at higher risk of cardiovascular events when flying. Prior use of antimalarials and any adverse effects experienced should be recorded. Physicians should ask women about pregnancy status and birth control method, if applicable.

Selected travel hazards and risk reduction strategies are included in Table 3 . 8 – 12

Noninfectious Risks

The most common cause of death in nonelderly international travelers is motor vehicle crashes, which account for 18% to 24% of deaths in all travelers. Deaths from motor vehicle crashes are markedly more common in low-income nations. Other common causes of death in travelers include violence (e.g., homicide, suicide) and drowning. 13 , 14

Immunization-Preventable Diseases

eTable A summarizes immunizations recommended for international travelers. Live vaccines should be avoided in travelers who are pregnant or immunocompromised.

ROUTINE VACCINES

In general, the diseases on the routine domestic immunization schedule are more common in travelers than are the travel-specific illnesses; hence, travelers should be up to date on the routine vaccines recommended by the Advisory Committee on Immunization Practices. The most common vaccine-preventable illnesses in international travelers are influenza and hepatitis A. The influenza season is between April and September in the southern hemisphere, and it occurs year-round in locations near the equator. Immunization for influenza should be advised when available. Hepatitis A, transmitted by contaminated food and water, is ubiquitous in low-income nations, and the vaccine is appropriate for all travelers older than one year. 15

TRAVEL-SPECIFIC VACCINES

Travel-specific immunizations include those for typhoid fever, 16 yellow fever, Japanese encephalitis, rabies, and cholera. Travelers may be required to show proof of vaccination for yellow fever to enter or return from nations within endemic regions (tropical Africa and tropical South America). Physicians should document yellow fever vaccination on travelers' International Certificate of Vaccination or Prophylaxis (“yellow card,” as approved by the World Health Organization). An example of the vaccine certificate is available at http://www.who.int/ihr/IVC200_06_26.pdf?ua=1 . If travelers have a contraindication to the yellow fever immunization, clinicians should write a letter of exemption or complete the waiver section of the vaccine certificate; these are generally accepted at international borders. Travelers to Saudi Arabia for the annual hajj and umrah (Muslim pilgrimage) are required to show proof of immunization for meningococcal meningitis.

Protection Against Insects and Other Arthropods

Personal protection measures.

It is important to stress to travelers that taking antimalarials does not negate the need for personal protection measures ( Table 4 17 ) , which guard against malaria and numerous other arthropod-borne diseases (e.g., dengue fever, a common illness in most tropical countries). 18 , 19

Insect repellent should be applied to exposed skin. The most effective insect repellents contain 20% to 50% diethyltoluamide (DEET) 20 , 21 or 20% picaridin. Other effective insect repellents are oil of lemon eucalyptus (PMD) and IR3535. Insect repellent should not be applied onto or under clothing. Regular reapplication is important.

Applying permethrin to clothing markedly increases protection against insect bites. 22 , 23 Travelers to malaria-endemic regions should sleep under a bed net impregnated with permethrin unless there is air-conditioning. Wearing long sleeves and pants offers additional protection. The vector for malaria is the female Anopheles mosquito, which feeds at dusk, nighttime, and dawn; minimizing time outdoors during these times will reduce risk. IR3535 does not provide adequate protection against Anopheles mosquitoes and should not be used in malaria-endemic areas.

MALARIA PROPHYLAXIS

Travelers to endemic regions should receive malaria prophylaxis. 24 , 25 The choice of prophylactic medication ( Table 5 20 , 26 ) should be based on whether the patient is going to an area with chloroquine-sensitive or chloroquine-resistant malaria, whether there could be potential adverse effects or interactions with the patient's medical conditions or other medications, the convenience of dosing schedule, and the cost. A summary of countries where malaria is endemic and prophylaxis recommendations from the Centers for Disease Control and Prevention are available at http://www.cdc.gov/malaria/travelers/country_table/a.html . Recommendations from the World Health Organization are available at http://www.who.int/ith/2015-ith-chapter7.pdf?ua=1 .

Regions where chloroquine-sensitive malaria is endemic include Mexico and Central America (west of the Panama Canal), and the island of Hispaniola (Haiti and the Dominican Republic). Options for prophylaxis in these regions are chloroquine (Aralen) and hydroxychloroquine (Plaquenil). Potential adverse effects of these medications include blurred vision, headache, nausea, and vomiting. Hydroxychloroquine may be better tolerated than chloroquine. Primaquine may be used for prophylaxis in areas affected primarily by Plasmodium vivax malaria.

The options for travelers to chloroquine-resistant regions (including most of South America, Asia, and Africa) are doxycycline, atovaquone/proguanil (Malarone), and mefloquine; these agents are equally effective. Doxycycline, which is taken daily, is relatively inexpensive. Potential adverse effects include nausea, photosensitivity, vaginal yeast infections, and esophageal ulceration. Atovaquone/proguanil, also a daily medication, is the most expensive option but has the lowest incidence of adverse effects. Mefloquine, taken weekly, is well-tolerated by most patients, but has a U.S. Food and Drug Administration boxed warning because of its neurologic and psychiatric adverse effects. In some areas of Southeast Asia, malaria is resistant to mefloquine, and doxycycline or atovaquone/proguanil should be used. Antimalarials should not be purchased in low-income nations because there is a high risk of counterfeit, adulterated, or expired medications.

ZIKA VIRUS INFECTION

Zika virus infection is primarily transmitted by mosquitoes, but it can also be sexually transmitted. Since May of 2015, this disease has spread to Mexico and essentially every country in Central and South America and the Caribbean. Risk of microcephaly in the newborn if a woman is infected in the first trimester of pregnancy has been estimated at 1% to 13%. Pregnant women should avoid travel to areas with Zika transmission. Men who live in or visit a Zika-endemic area should use a condom or abstain from sex with a pregnant partner for the remainder of the pregnancy. 27 , 28

Traveler's Diarrhea

Traveler's diarrhea (TD) is by far the most common infection in international travelers, with a rate of 30% to 70% depending on destination and season of travel. The risk is highest in the first two weeks of travel and slowly declines thereafter. 29 Taking medications that reduce gastric acidity, including proton pump inhibitors and antacids, significantly increases the risk of TD. 10 Other risk factors include younger age, diabetes, and immunosuppression.

The etiology of TD is bacterial in 80% to 90% of cases; the remainder are caused by viral or protozoan organisms. Bacterial and viral TD usually present as the sudden onset of loose stools, cramping, and nausea. Other manifestations may include abdominal pain, fever, vomiting, and bloody stools. TD caused by protozoan organisms, such as Giardia , tends to have a more insidious onset and a longer duration of symptoms. 30

Traditional advice (e.g., avoiding food from street stands, tap water, raw foods, and ice) has not been shown to reduce the incidence of TD. 31 Hand washing reduces risk by 30%; alcohol-based hand sanitizer also significantly reduces risk. 32

Prophylactic antibiotics are not routinely recommended. For patients at particularly high risk, taking bismuth subsalicylate (Pepto-Bismol; two tablets four times daily for the duration of the trip) reduces risk by 50% to 65%. 20 , 33 Possible adverse effects of bismuth subsalicylate include a black tongue and dark stool, and contraindications include aspirin allergy, renal insufficiency, breastfeeding, and concurrent use of anticoagulants. There is insufficient evidence for the use of probiotics to prevent TD.

The primary supportive treatment for TD is rehydration. However, in general, TD is not dehydrating, except for in persons who are very young or old or who have chronic illnesses. If dehydration occurs, travelers can rehydrate with most fluids, including water, juice, soda pop, or tea.

Loperamide (Imodium) is a safe and effective antimotility agent that can be used with or without antibiotics. It should be avoided in persons with warning signs, such as blood in the stool or fever, and in children younger than six years. Diphenoxylate is an alternative antimotility agent.

Without treatment, TD usually lasts three to seven days. A short course of antibiotics usually shortens symptom duration to six to 24 hours. 34 , 35 Fluoroquinolones are effective for self-treatment of TD in Africa and Latin America. One regimen is ciprofloxacin taken as one 500-mg tablet followed by a second 500-mg tablet 12 hours later. However, a macrolide, such as azithromycin (Zithromax; 500 mg daily for one to three days or one 1,000-mg tablet [higher incidence of nausea]) is more effective in South and Southeast Asia because of the high prevalence of TD caused by fluoroquinolone-resistant Campylobacter . Given the recent warning by the U.S. Food and Drug Administration regarding adverse effects of fluoroquinolones, 36 clinicians may consider prescribing a macrolide for self treatment of TD regardless of destination. Rifaximin (Xifaxan), an antibiotic with minimal systemic absorption, can be used as a preventive medication (200 mg once or twice daily) or as treatment (200 mg three times daily for three days). It is not approved by the U.S. Food and Drug Administration for TD prophylaxis.

Because TD is usually self-limited, and antibiotics have potential adverse effects, a course of carry-along antibiotics should be prescribed for the patient to use only if needed. To reduce the risk of creating drug-resistant bacteria, antibiotics should be taken only for severe diarrhea. 37

Travelers with TD who develop syncope, dehydration, or symptoms lasting more than one week should seek medical care. Studies show that 3% to 17% of TD cases may result in chronic postinfectious irritable bowel syndrome; the risk increases with multiple bouts of TD. 38 , 39

Emergency Medical Evacuation Insurance

Emergent medical evacuation from a low-income nation can cost $50,000 to $75,000 or more. Emergency medical evacuation insurance is particularly important for older travelers, for those with chronic medical conditions, and for those engaged in high-risk activities, such as high-altitude climbing. Travelers can visit https://www.squaremouth.com/ to compare travel insurance options, including medical and emergency evacuation insurance.

Travelers with Chronic Medical Conditions

Persons with most medical conditions can travel without restriction, but additional advance preparation may be necessary. Medical conditions should be stable before travel, and patients requiring frequent medical interventions should postpone travel to low-income nations.

Travelers who have chronic medical conditions should carry a list of their medications and physician contact information. Medications should be transported in carry-on, not checked, luggage and remain in the labeled containers in which they were dispensed from the pharmacy. Travelers who have diabetes should accept somewhat higher than usual glucose values during travel days to avoid hypoglycemia. Those requiring oxygen should contact the airline several weeks in advance to arrange for oxygen during flights. The Federal Aviation Administration does not allow passengers to carry their own oxygen tanks; battery-powered portable oxygen concentrators approved by the Department of Transportation may be used. Travelers who have a significant history of cardiac events should travel with a recent electrocardiogram.

Pregnant Women

Most airlines allow pregnant women to fly until 36 weeks of gestation. Pregnant women should not scuba dive because of the potential risk of decompression sickness in the fetus and fetal malformations. 40

Data Sources: We searched PubMed, the Cochrane Database of Systematic Reviews, Essential Evidence Plus, AHRQ Evidence Reports, and BMJ Clinical Evidence. Key words: travel medicine, immunizations, malaria prophylaxis, traveler's diarrhea, motor vehicle injuries, pretravel consultation. Search dates: May and September 2015, and June 2016.

note: This review updates previous articles by Bazemore and Huntington , 26 Lo Re and Guzman , 41 and Dick . 42

World Travel and Tourism Council. http://www.wttc.org . Accessed June 2015.

World Tourism Organization Network. http://step.unwto.org/content/tourism-and-poverty-alleviation-1 . Accessed June 27, 2015.

Hamer DH, Connor BA. Travel health knowledge, attitudes and practices among United States travelers. J Travel Med. 2004;11(1):23-26.

Talbot EA, Chen LH, Sanford C, et al. Travel medicine research priorities: establishing an evidence base. J Travel Med. 2010;17(6):410-415.

Travel and Tropical Medicine Manual . St. Louis, Mo.: Elsevier; 2016.

Pottinger PS, Sanford CA. Travel and adventure medicine. Med Clin North Am. 2016;100(2):xvii-xviii.

Aerospace Medical Association. http://www.asma.org . Accessed Feb. 2016.

Sanford C. Urban medicine: threats to health of travelers to developing world cities. J Travel Med. 2004;11(5):313-327.

Paulozzi LJ, Ryan GW, Espitia-Hardeman VE, Xi Y. Economic development's effect on road transport-related mortality among different types of road users. Accid Anal Prev. 2007;39(3):606-617.

Ehiri JE, Ejere HO, Magnussen L, Emusu D, King W, Osberg JS. Interventions for promoting booster seat use in four to eight year olds traveling in motor vehicles. Cochrane Database Syst Rev. 2006;1:CD004334.

Vivancos R, et al. Foreign travel associated with increased sexual risk-taking, alcohol and drug use among UK university students. Int J STD AIDS. 2010;21(1):46-51.

Kahn SR, Lim W, Dunn AS, et al. Prevention of VTE in nonsurgical patients. 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 suppl):e195S-e226S.

Cortés LM, et al. Recommendations for water safety and drowning prevention for travelers. J Travel Med. 2006;13(1):21-34.

Tonellato DJ, et al. Injury deaths of US citizens abroad. J Travel Med. 2009;16(5):304-310.

Innis BL, Snitbhan R, Kunasol P, et al. Protection against hepatitis A by an inactivated vaccine. JAMA. 1994;271(17):1328-1334.

Anwar E, Goldberg E, Fraser A, et al. Vaccines for preventing typhoid fever. Cochrane Database Syst Rev. 2014;1:CD001261.

Yates J. Advice for protection against mosquitoes and ticks [editorial]. Am Fam Physician. 2015;91(11):754-755.

Alpern JD, et al. Personal protection measures against mosquitoes, ticks, and other arthropods. Med Clin North Am. 2016;100(2):303-316.

Hill DR, et al.; Infectious Diseases Society of America. The practice of travel medicine. Clin Infect Dis. 2006;43(12):1499-1539.

Brunette GW, Kozarsky PE, Cohen NJ. CDC Health Information for International Travel 2016 . New York, NY: Oxford University Press; 2016.

Schoepke A, et al. Effectiveness of personal protection measures against mosquito bites for malaria prophylaxis in travelers. J Travel Med. 1998;5(4):188-192.

Banks SD, et al. Insecticide-treated clothes for the control of vector-borne diseases. Med Vet Entomol. 2014;28(suppl 1):14-25.

Rowland M, Durrani N, Hewitt S, et al. Permethrin-treated chaddars and top-sheets. Trans R Soc Trop Med Hyg. 1999;93(5):465-472.

Schlagenhauf P, Weld L, Goorhuis A, et al. Travel-associated infection presenting in Europe (2008–12) [published correction appears in Lancet . 2015;15(3):263]. Lancet Infect Dis. 2015;15(1):55-64.

Lüthi B, Schlagenhauf P. Risk factors associated with malaria deaths in travellers: a literature review. Travel Med Infect Dis. 2015;13(1):48-60.

Bazemore AW, Huntington M. The pretravel consultation. Am Fam Physician. 2009;80(6):583-590.

Johansson MA, et al. Zika and the risk of microcephaly [published ahead of print May 25, 2016]. N Engl J Med . http://www.nejm.org/doi/full/10.1056/NEJMp1605367 . Accessed June 30, 2016.

CDC. Zika virus. http://www.cdc.gov/zika/ . Accessed June 13, 2016.

Kollaritsch H, Paulke-Korinek M, Wiedermann U. Traveler's diarrhea. Infect Dis Clin North Am. 2012;26(3):691-706.

Ortega YR, Adam RD. Giardia. Clin Infect Dis. 1997;25(3):545-549.

Steffen R, Tornieporth N, Clemens SA, et al. Epidemiology of travelers' diarrhea: details of a global survey. J Travel Med. 2004;11(4):231-237.

Henriey D, et al. Does the use of alcohol-based hand gel sanitizer reduce travellers' diarrhea and gastrointestinal upset?. Travel Med Infect Dis. 2014;12(5):494-498.

Ericsson CD. Nonantimicrobial agents in the prevention and treatment of traveler's diarrhea. Clin Infect Dis. 2005;41(suppl 8):S557-S563.

De Bruyn G, Hahn S, Borwick A. Antibiotic treatment for travellers' diarrhoea. Cochrane Database Syst Rev. 2000;3:CD002242.

Heather CS. Travellers' diarrhoea. BMJ Clin Evid . April 30, 2015. http://clinicalevidence.bmj.com/x/systematic-review/0901/overview.html . April 30, 2015. Accessed September 20, 2015.

U.S. Food and Drug Administration. FDA advises restricting fluoroquinolone antibiotic use for certain uncomplicated infections; warns about disabling side effects that can occur together. http://www.fda.gov/Drugs/DrugSafety/ucm500143.htm . Accessed August 29, 2016.

Kantele A, Lääveri T, Mero S, et al. Antimicrobials increase travelers' risk of colonization by extended-spectrum betalactamase-producing Enterobacteriaceae. Clin Infect Dis. 2015;60(6):837-846.

Nair P, et al. Persistent abdominal symptoms in US adults after short-term stay in Mexico. J Travel Med. 2014;21(3):153-158.

Connor BA, Riddle MS. Postinfectious sequelae of travelers' diarrhea. J Travel Med. 2013;20(5):303-312.

Stewart BT, et al. Road traffic and other unintentional injuries among travelers to developing countries. Med Clin North Am. 2016;100(2):331-343.

Lo Re V, Gluckman SJ. Travel immunizations. Am Fam Physicians. 2004;70(1):89-99.

Dick L. Travel medicine: helping patients prepare for trips abroad. Am Fam Physicians. 1998;58(2):383-398.

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India Traveler View

Travel health notices, vaccines and medicines, non-vaccine-preventable diseases, stay healthy and safe.

• Packing List

After Your Trip

Be aware of current health issues in India. Learn how to protect yourself.

Level 1 Practice Usual Precautions

• Updated   Global Measles April 26, 2024 Many international destinations are reporting increased numbers of cases of measles. Destination List: Afghanistan, Angola, Armenia, Azerbaijan, Benin, Burkina Faso, Burundi, Cameroon, Central African Republic, Chad, Côte d'Ivoire (Ivory Coast), Democratic Republic of the Congo, Djibouti, Equatorial Guinea, Ethiopia, Gabon, Ghana, India, Indonesia, Kazakhstan, Kyrgyzstan, Lebanon, Liberia, Libya, Malaysia, Mauritania, Nepal, Niger, Nigeria, Pakistan, Philippines, Qatar, Republic of South Sudan, Republic of the Congo, Romania, Russia, Senegal, Somalia, Sri Lanka, Sudan, Syria, Tajikistan, Timor-Leste (East Timor), Togo, Turkey, United Arab Emirates, Uzbekistan, Yemen, Zambia

⇧ Top

Check the vaccines and medicines list and visit your doctor at least a month before your trip to get vaccines or medicines you may need. If you or your doctor need help finding a location that provides certain vaccines or medicines, visit the Find a Clinic page.

Routine vaccines

Recommendations.

Make sure you are up-to-date on all routine vaccines before every trip. Some of these vaccines include

• Chickenpox (Varicella)
• Diphtheria-Tetanus-Pertussis
• Flu (influenza)
• Measles-Mumps-Rubella (MMR)

Immunization schedules

All eligible travelers should be up to date with their COVID-19 vaccines. Please see  Your COVID-19 Vaccination  for more information. 

COVID-19 vaccine

Cholera is  presumed to be present  in India. Cholera is rare in travelers.  Certain factors  may increase the risk of getting cholera or having severe disease ( more information ). Avoiding unsafe food and water and washing your hands can also help prevent cholera. Avoiding unsafe food and water and washing your hands can also help prevent cholera.

Vaccination may be considered for children and adults who are traveling to areas of active cholera transmission.

Cholera - CDC Yellow Book

Hepatitis A

Recommended for unvaccinated travelers one year old or older going to India.

Infants 6 to 11 months old should also be vaccinated against Hepatitis A. The dose does not count toward the routine 2-dose series.

Travelers allergic to a vaccine component or who are younger than 6 months should receive a single dose of immune globulin, which provides effective protection for up to 2 months depending on dosage given.

Unvaccinated travelers who are over 40 years old, immunocompromised, or have chronic medical conditions planning to depart to a risk area in less than 2 weeks should get the initial dose of vaccine and at the same appointment receive immune globulin.

Hepatitis A - CDC Yellow Book

Dosing info - Hep A

Hepatitis B

Recommended for unvaccinated travelers younger than 60 years old traveling to India. Unvaccinated travelers 60 years and older may get vaccinated before traveling to India.

Hepatitis B - CDC Yellow Book

Dosing info - Hep B

Japanese Encephalitis

Recommended for travelers who

• Are moving to an area with Japanese encephalitis to live
• Spend long periods of time, such as a month or more, in areas with Japanese encephalitis
• Frequently travel to areas with Japanese encephalitis

Consider vaccination for travelers

• Spending less than a month in areas with Japanese encephalitis but will be doing activities that increase risk of infection, such as visiting rural areas, hiking or camping, or staying in places without air conditioning, screens, or bed nets
• Going to areas with Japanese encephalitis who are uncertain of their activities or how long they will be there

Not recommended for travelers planning short-term travel to urban areas or travel to areas with no clear Japanese encephalitis season. 

Japanese encephalitis - CDC Yellow Book

Japanese Encephalitis Vaccine for US Children

CDC recommends that travelers going to certain areas of India take prescription medicine to prevent malaria. Depending on the medicine you take, you will need to start taking this medicine multiple days before your trip, as well as during and after your trip. Talk to your doctor about which malaria medication you should take.

Find  country-specific information  about malaria.

Malaria - CDC Yellow Book

Considerations when choosing a drug for malaria prophylaxis (CDC Yellow Book)

Malaria information for India.

Cases of measles are on the rise worldwide. Travelers are at risk of measles if they have not been fully vaccinated at least two weeks prior to departure, or have not had measles in the past, and travel internationally to areas where measles is spreading.

All international travelers should be fully vaccinated against measles with the measles-mumps-rubella (MMR) vaccine, including an early dose for infants 6–11 months, according to  CDC’s measles vaccination recommendations for international travel .

Measles (Rubeola) - CDC Yellow Book

Rabid dogs are commonly found in India. However, if you are bitten or scratched by a dog or other mammal while in India, rabies treatment is often available. 

Consider rabies vaccination before your trip if your activities mean you will be around dogs or wildlife.

Travelers more likely to encounter rabid animals include

• Campers, adventure travelers, or cave explorers (spelunkers)
• Veterinarians, animal handlers, field biologists, or laboratory workers handling animal specimens
• Visitors to rural areas

Since children are more likely to be bitten or scratched by a dog or other animals, consider rabies vaccination for children traveling to India. 

Rabies - CDC Yellow Book

Recommended for most travelers, especially those staying with friends or relatives or visiting smaller cities or rural areas.

Typhoid - CDC Yellow Book

Dosing info - Typhoid

Yellow Fever

• Arrive within 6 days of leaving an area with risk for YF virus transmission, or
• Have been in such an area in transit (exception: passengers and members of flight crews who, while in transit through an airport in an area with risk for YF virus transmission, remained in the airport during their entire stay and the health officer agrees to such an exemption), or
• Arrive on a ship that started from or touched at any port in an area with risk for YF virus transmission ≤30 days before its arrival in India, unless such a ship has been disinsected in accordance with the procedure recommended by the World Health Organization (WHO), or
• Arrive on an aircraft that has been in an area with risk for YF virus transmission and has not been disinsected in accordance with the Indian Aircraft Public Health Rules, 1954, or as recommended by WHO.
• Africa: Angola, Benin, Burkina Faso, Burundi, Cameroon, Central African Republic, Chad, Congo, Côte d’Ivoire, Democratic Republic of the Congo, Equatorial Guinea, Ethiopia, Gabon, The Gambia, Ghana, Guinea, Guinea-Bissau, Kenya, Liberia, Mali, Mauritania, Niger, Nigeria, Rwanda, Senegal, Sierra Leone, South Sudan, Sudan, Togo, Uganda
• Americas: Argentina, Bolivia, Brazil, Colombia, Ecuador, French Guiana, Guyana, Panama, Paraguay, Peru, Suriname, Trinidad & Tobago (Trinidad only), Venezuela

Yellow Fever - CDC Yellow Book

Avoid contaminated water

Leptospirosis

How most people get sick (most common modes of transmission)

• Touching urine or other body fluids from an animal infected with leptospirosis
• Swimming or wading in urine-contaminated fresh water, or contact with urine-contaminated mud
• Drinking water or eating food contaminated with animal urine
• Avoid contaminated water and soil

Clinical Guidance

Avoid bug bites.

Chikungunya

• Mosquito bite
• Avoid Bug Bites

Crimean-Congo Hemorrhagic fever

• Tick bite 
• Touching the body fluids of a person or animal infected with CCHF
• Mosquito bite

Leishmaniasis

• Sand fly bite
• An infected pregnant woman can spread it to her unborn baby

Airborne & droplet

Avian/bird flu.

• Being around, touching, or working with infected poultry, such as visiting poultry farms or live-animal markets
• Avoid domestic and wild poultry
• Breathing in air or accidentally eating food contaminated with the urine, droppings, or saliva of infected rodents
• Bite from an infected rodent
• Less commonly, being around someone sick with hantavirus (only occurs with Andes virus)
• Avoid rodents and areas where they live
• Avoid sick people

Tuberculosis (TB)

• Breathe in TB bacteria that is in the air from an infected and contagious person coughing, speaking, or singing.

Learn actions you can take to stay healthy and safe on your trip. Vaccines cannot protect you from many diseases in India, so your behaviors are important.

Eat and drink safely

Food and water standards around the world vary based on the destination. Standards may also differ within a country and risk may change depending on activity type (e.g., hiking versus business trip). You can learn more about safe food and drink choices when traveling by accessing the resources below.

• Choose Safe Food and Drinks When Traveling
• Water Treatment Options When Hiking, Camping or Traveling
• Global Water, Sanitation and Hygiene | Healthy Water
• Avoid Contaminated Water During Travel

You can also visit the Department of State Country Information Pages for additional information about food and water safety.

Prevent bug bites

Bugs (like mosquitoes, ticks, and fleas) can spread a number of diseases in India. Many of these diseases cannot be prevented with a vaccine or medicine. You can reduce your risk by taking steps to prevent bug bites.

What can I do to prevent bug bites?

• Cover exposed skin by wearing long-sleeved shirts, long pants, and hats.
• Use an appropriate insect repellent (see below).
• Use permethrin-treated clothing and gear (such as boots, pants, socks, and tents). Do not use permethrin directly on skin.
• Stay and sleep in air-conditioned or screened rooms.
• Use a bed net if the area where you are sleeping is exposed to the outdoors.

What type of insect repellent should I use?

• FOR PROTECTION AGAINST TICKS AND MOSQUITOES: Use a repellent that contains 20% or more DEET for protection that lasts up to several hours.
• Picaridin (also known as KBR 3023, Bayrepel, and icaridin)
• Oil of lemon eucalyptus (OLE) or para-menthane-diol (PMD)
• 2-undecanone
• Always use insect repellent as directed.

What should I do if I am bitten by bugs?

• Avoid scratching bug bites, and apply hydrocortisone cream or calamine lotion to reduce the itching.
• Check your entire body for ticks after outdoor activity. Be sure to remove ticks properly.

What can I do to avoid bed bugs?

Although bed bugs do not carry disease, they are an annoyance. See our information page about avoiding bug bites for some easy tips to avoid them. For more information on bed bugs, see Bed Bugs .

For more detailed information on avoiding bug bites, see Avoid Bug Bites .

Some diseases in India—such as dengue, Zika, filariasis, and leishmaniasis—are spread by bugs and cannot be prevented with a vaccine. Follow the insect avoidance measures described above to prevent these and other illnesses.

Stay safe outdoors

If your travel plans in India include outdoor activities, take these steps to stay safe and healthy during your trip.

• Stay alert to changing weather conditions and adjust your plans if conditions become unsafe.
• Prepare for activities by wearing the right clothes and packing protective items, such as bug spray, sunscreen, and a basic first aid kit.
• Consider learning basic first aid and CPR before travel. Bring a travel health kit with items appropriate for your activities.
• If you are outside for many hours in heat, eat salty snacks and drink water to stay hydrated and replace salt lost through sweating.
• Protect yourself from UV radiation : use sunscreen with an SPF of at least 15, wear protective clothing, and seek shade during the hottest time of day (10 a.m.–4 p.m.).
• Be especially careful during summer months and at high elevation. Because sunlight reflects off snow, sand, and water, sun exposure may be increased during activities like skiing, swimming, and sailing.
• Very cold temperatures can be dangerous. Dress in layers and cover heads, hands, and feet properly if you are visiting a cold location.

Stay safe around water

• Swim only in designated swimming areas. Obey lifeguards and warning flags on beaches.
• Practice safe boating—follow all boating safety laws, do not drink alcohol if driving a boat, and always wear a life jacket.
• Do not dive into shallow water.
• Do not swim in freshwater in developing areas or where sanitation is poor.
• Avoid swallowing water when swimming. Untreated water can carry germs that make you sick.
• To prevent infections, wear shoes on beaches where there may be animal waste.

Schistosomiasis and leptospirosis, infections that can be spread in fresh water, are found in India. Avoid swimming in fresh, unchlorinated water, such as lakes, ponds, or rivers.

Keep away from animals

Most animals avoid people, but they may attack if they feel threatened, are protecting their young or territory, or if they are injured or ill. Animal bites and scratches can lead to serious diseases such as rabies.

Follow these tips to protect yourself:

• Do not touch or feed any animals you do not know.
• Do not allow animals to lick open wounds, and do not get animal saliva in your eyes or mouth.
• Avoid rodents and their urine and feces.
• Traveling pets should be supervised closely and not allowed to come in contact with local animals.
• If you wake in a room with a bat, seek medical care immediately. Bat bites may be hard to see.

All animals can pose a threat, but be extra careful around dogs, bats, monkeys, sea animals such as jellyfish, and snakes. If you are bitten or scratched by an animal, immediately:

• Wash the wound with soap and clean water.
• Go to a doctor right away.
• Tell your doctor about your injury when you get back to the United States.

Consider buying medical evacuation insurance. Rabies is a deadly disease that must be treated quickly, and treatment may not be available in some countries.

Reduce your exposure to germs

Follow these tips to avoid getting sick or spreading illness to others while traveling:

• Wash your hands often, especially before eating.
• If soap and water aren’t available, clean hands with hand sanitizer (containing at least 60% alcohol).
• Don’t touch your eyes, nose, or mouth. If you need to touch your face, make sure your hands are clean.
• Cover your mouth and nose with a tissue or your sleeve (not your hands) when coughing or sneezing.
• Try to avoid contact with people who are sick.
• If you are sick, stay home or in your hotel room, unless you need medical care.

Avoid sharing body fluids

Diseases can be spread through body fluids, such as saliva, blood, vomit, and semen.

Protect yourself:

• Use latex condoms correctly.
• Do not inject drugs.
• Limit alcohol consumption. People take more risks when intoxicated.
• Do not share needles or any devices that can break the skin. That includes needles for tattoos, piercings, and acupuncture.
• If you receive medical or dental care, make sure the equipment is disinfected or sanitized.

Know how to get medical care while traveling

Plan for how you will get health care during your trip, should the need arise:

• Carry a list of local doctors and hospitals at your destination.
• Review your health insurance plan to determine what medical services it would cover during your trip. Consider purchasing travel health and medical evacuation insurance.
• Carry a card that identifies, in the local language, your blood type, chronic conditions or serious allergies, and the generic names of any medications you take.
• Some prescription drugs may be illegal in other countries. Call India’s embassy to verify that all of your prescription(s) are legal to bring with you.
• Bring all the medicines (including over-the-counter medicines) you think you might need during your trip, including extra in case of travel delays. Ask your doctor to help you get prescriptions filled early if you need to.

Many foreign hospitals and clinics are accredited by the Joint Commission International. A list of accredited facilities is available at their website ( www.jointcommissioninternational.org ).

In some countries, medicine (prescription and over-the-counter) may be substandard or counterfeit. Bring the medicines you will need from the United States to avoid having to buy them at your destination.

Malaria is a risk in India. Fill your malaria prescription before you leave and take enough with you for the entire length of your trip. Follow your doctor’s instructions for taking the pills; some need to be started before you leave.

Select safe transportation

Motor vehicle crashes are the #1 killer of healthy US citizens in foreign countries.

In many places cars, buses, large trucks, rickshaws, bikes, people on foot, and even animals share the same lanes of traffic, increasing the risk for crashes.

Be smart when you are traveling on foot.

• Use sidewalks and marked crosswalks.
• Pay attention to the traffic around you, especially in crowded areas.
• Remember, people on foot do not always have the right of way in other countries.

Riding/Driving

Choose a safe vehicle.

• Choose official taxis or public transportation, such as trains and buses.
• Ride only in cars that have seatbelts.
• Avoid overcrowded, overloaded, top-heavy buses and minivans.
• Avoid riding on motorcycles or motorbikes, especially motorbike taxis. (Many crashes are caused by inexperienced motorbike drivers.)
• Choose newer vehicles—they may have more safety features, such as airbags, and be more reliable.
• Choose larger vehicles, which may provide more protection in crashes.

Think about the driver.

• Do not drive after drinking alcohol or ride with someone who has been drinking.
• Consider hiring a licensed, trained driver familiar with the area.
• Arrange payment before departing.

Follow basic safety tips.

• Wear a seatbelt at all times.
• Sit in the back seat of cars and taxis.
• When on motorbikes or bicycles, always wear a helmet. (Bring a helmet from home, if needed.)
• Avoid driving at night; street lighting in certain parts of India may be poor.
• Do not use a cell phone or text while driving (illegal in many countries).
• Travel during daylight hours only, especially in rural areas.
• If you choose to drive a vehicle in India, learn the local traffic laws and have the proper paperwork.
• Get any driving permits and insurance you may need. Get an International Driving Permit (IDP). Carry the IDP and a US-issued driver's license at all times.
• Check with your auto insurance policy's international coverage, and get more coverage if needed. Make sure you have liability insurance.
• Avoid using local, unscheduled aircraft.
• If possible, fly on larger planes (more than 30 seats); larger airplanes are more likely to have regular safety inspections.
• Try to schedule flights during daylight hours and in good weather.

Medical Evacuation Insurance

If you are seriously injured, emergency care may not be available or may not meet US standards. Trauma care centers are uncommon outside urban areas. Having medical evacuation insurance can be helpful for these reasons.

Helpful Resources

Road Safety Overseas (Information from the US Department of State): Includes tips on driving in other countries, International Driving Permits, auto insurance, and other resources.

The Association for International Road Travel has country-specific Road Travel Reports available for most countries for a minimal fee.

For information traffic safety and road conditions in India, see Travel and Transportation on US Department of State's country-specific information for India .

Traffic flows on the left side of the road in India.

• Always pay close attention to the flow of traffic, especially when crossing the street.
• LOOK RIGHT for approaching traffic.

Maintain personal security

Use the same common sense traveling overseas that you would at home, and always stay alert and aware of your surroundings.

Before you leave

• Research your destination(s), including local laws, customs, and culture.
• Monitor travel advisories and alerts and read travel tips from the US Department of State.
• Enroll in the Smart Traveler Enrollment Program (STEP) .
• Leave a copy of your itinerary, contact information, credit cards, and passport with someone at home.
• Pack as light as possible, and leave at home any item you could not replace.

While at your destination(s)

• Carry contact information for the nearest US embassy or consulate .
• Carry a photocopy of your passport and entry stamp; leave the actual passport securely in your hotel.
• Follow all local laws and social customs.
• Do not wear expensive clothing or jewelry.
• Always keep hotel doors locked, and store valuables in secure areas.
• If possible, choose hotel rooms between the 2nd and 6th floors.

To call for emergency services while in India, dial 100 or, from a mobile phone, 112. Write these numbers down to carry with you during your trip.

Learn as much as you can about India before you travel there. A good place to start is the country-specific information on India from the US Department of State.

Healthy Travel Packing List

Use the Healthy Travel Packing List for India for a list of health-related items to consider packing for your trip. Talk to your doctor about which items are most important for you.

Why does CDC recommend packing these health-related items?

It’s best to be prepared to prevent and treat common illnesses and injuries. Some supplies and medicines may be difficult to find at your destination, may have different names, or may have different ingredients than what you normally use.

If you are not feeling well after your trip, you may need to see a doctor. If you need help finding a travel medicine specialist, see Find a Clinic . Be sure to tell your doctor about your travel, including where you went and what you did on your trip. Also tell your doctor if you were bitten or scratched by an animal while traveling.

If your doctor prescribed antimalarial medicine for your trip, keep taking the rest of your pills after you return home. If you stop taking your medicine too soon, you could still get sick.

Malaria is always a serious disease and may be a deadly illness. If you become ill with a fever either while traveling in a malaria-risk area or after you return home (for up to 1 year), you should seek immediate medical attention and should tell the doctor about your travel history.

For more information on what to do if you are sick after your trip, see Getting Sick after Travel .

Map Disclaimer - The boundaries and names shown and the designations used on maps do not imply the expression of any opinion whatsoever on the part of the Centers for Disease Control and Prevention concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Approximate border lines for which there may not yet be full agreement are generally marked.

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The Pretravel Consultation

The pretravel consultation offers a dedicated time to prepare travelers for the health concerns that might arise during their trips. The objectives of the pretravel consultation are to:

• Perform an individual risk assessment.
• Communicate to the traveler anticipated health risks.
• Provide risk management measures, including immunizations, malaria prophylaxis, and other medications as indicated.

The Travel Medicine Specialist

Travel medicine specialists have in-depth knowledge of immunizations, risks associated with specific destinations, and the implications of traveling with underlying conditions. Therefore, a comprehensive consultation with a travel medicine expert is indicated for all travelers, and is particularly important for those with a complicated health history, special risks (such as traveling at high altitudes or working in refugee camps), or exotic or complicated itineraries. Clinicians who wish to be travel medicine providers are encouraged to join the International Society of Travel Medicine (ISTM) and consider specialty training and certification.

Components of a Pretravel Consultation

Effective pretravel consultations require attention to the health background of the traveler and incorporate the itinerary, trip duration, travel purpose, and activities, all of which determine health risks (Table 2-1 ). The pretravel consultation is the major opportunity to educate the traveler about health risks at the destination and how to mitigate them. The typical pretravel consultation does not include a physical examination; a separate appointment with the same or a different provider may be necessary to assess a person’s fitness to travel. Because travel medicine clinics are not available in some communities, primary care physicians should seek guidance (by phone or other communication, if available) from travel medicine specialists to address areas of uncertainty.

Travel health advice should be personalized, highlighting the likely exposures and also reminding the traveler of ubiquitous risks, such as injury, foodborne and waterborne infections, vectorborne disease, respiratory tract infections, and bloodborne and sexually transmitted infections. Balancing the cautions with an appreciation of the positive aspects of the journey leads to a more meaningful pretravel consultation. Attention to the cost of recommended interventions may be critical. Some travelers may not be able to afford all of the recommended immunizations and medications, a situation that requires prioritizing interventions. (See Prioritizing Care for the Resource-Limited Traveler later in this chapter.)

Assess Individual Risk

Many elements merit consideration in assessing a traveler’s health risks (Table 2-1 ). Certain travelers may confront special risks. Recent hospitalization for serious problems may lead the travel health provider to recommend delaying travel. Air travel is contraindicated for certain conditions, such as <3 weeks after an uncomplicated myocardial infarction and <10 days after thoracic or abdominal surgery. The travel health provider and traveler should consult with the relevant health care providers most familiar with the underlying illnesses. Other travelers with specific risks include travelers who are visiting friends and relatives, long-term travelers, travelers with small children, travelers with chronic illnesses, immunocompromised travelers, and pregnant travelers. More comprehensive discussion on advising travelers who have additional health considerations is available in Chapter 5. Providers should determine whether recent outbreaks or other safety notices have been posted for the traveler’s destination; information is available on the CDC and US Department of State websites, and in various other resources.

In addition to recognizing the traveler’s characteristics, health background, and destination-specific risks, the exposures related to special activities also merit discussion. For example, river rafting could expose a traveler to schistosomiasis or leptospirosis, and spelunking in Central America could put the traveler at risk of histoplasmosis. Flying from lowlands to high-altitude areas and trekking or climbing in mountainous regions introduces the risk of altitude illness. Therefore, the provider should inquire about plans for specific leisure, business, and health care–seeking activities.

Communicate Risk

Once destination-specific risks for a particular itinerary have been assessed by the provider, they should be clearly communicated to the traveler. The process of risk communication is a 2-way exchange of information between the clinician and traveler, in which they discuss potential health hazards at the destination and the effectiveness of preventive measures, with the goal of improving understanding of risk and promoting more informed decision making. Risk communication is among the most challenging aspects of a pretravel consultation, because travelers’ perception of and tolerance for risk can vary widely. For a more detailed discussion, see Perspectives : Travelers’ Perception of Risk in this chapter.

Manage Risk

Immunizations are a crucial component of pretravel consultations, and the risk assessment forms the basis of recommendations for travel vaccines. For example, providers should consider whether there is sufficient time before travel to complete a vaccine series; the purpose of travel and specific destination within a country will inform the need for particular vaccinations. At the same time, the pretravel consultation presents an opportunity to update routine vaccines (Table 2-2 ). Particular attention should be paid to vaccines for which immunity may have waned over time or following a recent immunocompromising condition (such as after a hematopoietic stem cell transplant). Asking the question, “Do you have any plans to travel again in the next 1–2 years?” may help the traveler justify an immunization for travel over a number of years rather than only the upcoming trip, such as rabies preexposure or Japanese encephalitis. Travelers should receive a record of immunizations administered and instructions to follow up as needed to complete a vaccine series.

Another major focus of pretravel consultations for many destinations is the prevention of malaria. Malaria continues to cause substantial morbidity and mortality in travelers. Since 1973, the annual number of US malaria cases reported to CDC has shown an increasing trend; therefore, pretravel consultation must carefully assess travelers’ risk for malaria and recommend preventive measures. For travelers going to malaria-endemic countries, it is imperative to discuss malaria transmission, ways to reduce risk, recommendations for prophylaxis, and symptoms of malaria.

Travelers with underlying health conditions require attention to their health issues as they relate to the destination and activities. For example, a traveler with a history of cardiac disease should carry medical reports, including a recent electrocardiogram. Asthma may flare in a traveler visiting a polluted city or from physical exertion during a hike; travelers should be encouraged to discuss with their primary care provider how to plan for treatment and bring necessary medication in case of asthma exacerbation. Travelers should be counseled on how to obtain travel medical insurance and how they can find reputable medical facilities at their destination, such as using the ISTM website ( www.istm.org ), the American Society of Tropical Medicine and Hygiene website ( www.astmh.org ), or the State Department Travel website ( https://travel.state.gov/content/travel/en/international-travel/before-you ...). Any allergies or serious medical conditions should be identified on a bracelet or a card to expedite medical care in emergency situations.

The pretravel consultation also provides another setting to remind travelers of basic health practices during travel, including frequent handwashing, wearing seatbelts, using car seats for infants and children, and safe sexual practices. Topics to be explored are numerous and could be organized into a checklist, placing priority on the most serious and frequently encountered issues (Table 2-3 , Box 2-1 ). General issues such as preventing injury and sunburn also deserve mention. Written information is essential to supplement oral advice and enable travelers to review the instructions from their clinic visits; educational material is available on the CDC Travelers Health webpage ( www.cdc.gov/travel ). Advice on self-treatable conditions may minimize the need for travelers to seek medical care while abroad and possibly lead to faster return to good health.

Self-Treatable Conditions

Despite providers’ best efforts, some travelers will become ill. Obtaining reliable and timely medical care during travel can be problematic in many destinations. As a result, prescribing certain medications in advance can empower the traveler to self-diagnose and treat common health problems. With some activities in remote settings, such as trekking, the only alternative to self-treatment would be no treatment. Pretravel counseling may result in a more accurate self-diagnosis and treatment than relying on local medical care in some areas. In addition, the increasing awareness of substandard and counterfeit drugs in pharmacies in the developing world makes it more important for travelers to bring quality manufactured drugs with them from a reliable supplier in their own country (see Chapter 6, Perspectives : Avoiding Poorly Regulated Medicines and Medical Products during Travel ).

Travel health providers need to recognize the conditions for which the traveler may be at risk, and educate the traveler about the diagnosis and treatment of those conditions. The keys to successful self-treatment strategies are providing a simple disease or condition definition, providing a treatment, and educating the traveler about the expected outcome of treatment. Using travelers’ diarrhea as an example, a practitioner could provide the following advice:

• “Travelers’ diarrhea” is the sudden onset of abnormally loose, frequent stools.
• Most cases will resolve within 2–5 days, and symptoms can be managed with loperamide or bismuth subsalicylate.
• For diarrhea severe enough to interrupt travel plans, an antibiotic can be prescribed that travelers can carry with them (see Travelers’ Diarrhea section in this chapter).
• The traveler should feel better within 6–24 hours.
• If symptoms persist for 24–36 hours despite self-treatment, it may be necessary to seek medical attention.

To minimize the potential negative effects of a self-treatment strategy, the recommendations should follow a few key points:

• Drugs recommended must be safe, well tolerated, and effective for use as self-treatment.
• A drug’s toxicity or potential for harm, if used incorrectly or in an overdose situation, should be minimal.
• Simple and clear directions are critical. Consider providing handouts describing how to use the drugs. Keeping the directions simple will increase the effectiveness of the strategy.

The following are some of the most common situations in which people would find self-treatment useful. The extent of self-treatment recommendations offered to the traveler should reflect the remoteness and difficulty of travel and the availability of reliable medical care at the destination. The recommended self-treatment options for each disease are provided in the designated section of the Yellow Book or discussed below.

• Travelers’ diarrhea ( Chapter 2 , Travelers’ Diarrhea)
• Altitude illness ( Chapter 3 , High-Altitude Travel & Altitude Illness)
• Jet lag ( Chapter 8 , Jet Lag)
• Motion sickness (Chapter 8, Motion Sickness )
• Respiratory infections ( Chapter 11 , Respiratory Infections)
• Skin conditions such as allergic reactions or superficial fungal infections ( Chapter 11 , Skin & Soft Tissue Infections)
• Urinary tract infections: common among many women; carrying an antibiotic for empiric treatment may be valuable
• Vaginal yeast infections: self-treatment course of patient’s preferred antifungal medication can be prescribed for women who are prone to infections, sexually active, or who may be receiving antibiotics for other reasons (including doxycycline for malaria chemoprophylaxis)
• Occupational exposure to HIV (Chapter 9, Health Care Workers , Including Public Health Researchers and Laboratorians)
• Malaria self-treatment (see Chapter 4 , Malaria)

In sum, travelers should be encouraged to carry a travel health kit with prescription and nonprescription medications. Providers should review medication lists for possible drug interactions. More detailed information for providers and travelers is given in Chapter 6, Travel Health Kits; supplementary travel health kit information for travelers with specific needs is given in Chapter 5.

Box 2-1. Summary of sexual health recommendations for travelers

Before travel.

• Obtain recommended vaccinations, including those that protect against sexually transmitted infections.
• Get recommended tests for HIV and treatable STDs. Be aware of STD symptoms in case any develop.
• Check condom packaging and expiration dates.
• Review local laws about sexual practices and obtain contact information for medical and law enforcement services.
• If pregnant or considering pregnancy, review whether Zika virus infection is a risk at destination.

During Travel

• Use good judgment in choosing consensual adult sex partners.
• Use condoms consistently and correctly to decrease the risk of HIV and STDs.
• If indicated, be prepared to start taking medications for HIV postexposure prophylaxis or unintended pregnancy within 72 hours after a high-risk sexual encounter.
• Never engage in sex with a minor (<18 years old), child pornography, or trafficking activities in any country.
• Report suspicious activity to US and local authorities as soon as it occurs.

After Travel

• To avoid exposing sex partners at home, see a clinician to get recommended tests for HIV and treatable STDs.

Bibliography

• Freedman DO, Chen LH, Kozarsky P. Medical considerations before travel. N Engl J Med. 2016 July 21;375:247–60.
• Hatz CFR, Chen LH. Pre-travel consultation. In: Keystone JS, Freedman DO, Kozarsky PE, Connor BA, Nothdurft HD, editors. Travel Medicine. 3rd ed. Philadelphia: Saunders Elsevier; 2013. pp. 31–6.
• Hill DR, Ericsson CD, Pearson RD, Keystone JS, Freedman DO, Kozarsky PE, et al. The practice of travel medicine: guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2006 Dec 15;43(12):1499–539.
• International Society of Travel Medicine. Body of knowledge for the practice of travel medicine—2012. Atlanta: International Society of Travel Medicine; 2012 [cited 2018 Feb 18]. Available from: www.istm.org/bodyofknowledge .
• Kozarsky PE, Steffen R. Travel medicine education—what are the needs? J Travel Med. 2016 Jul 4;23(5).
• Leder K, Chen LH, Wilson ME. Aggregate travel vs. single trip assessment: arguments for cumulative risk analysis. Vaccine. 2012 Mar 28;30(15):2600–4.   [PMID:22234265]
• Leder K, Torresi J, Libman MD, Cramer JP, Castelli F, Schlagenhauf P, et al. GeoSentinel surveillance of illness in returned travelers, 2007–2011. Ann Intern Med. 2013 Mar 19;158(6):456–68.   [PMID:23552375]
• Schwartz BS, Larocque RC, Ryan ET. In the clinic: travel medicine. Ann Intern Med. 2012 Jun 5;156(11):ITC6:1–16.   [PMID:22665823]
• Steffen R, Behrens RH, Hill RD, Greenaway C, Leder K. Vaccine-preventable travel health risks: what is the evidence—what are the gaps? J Travel Med. 2015;22(1):1–12.
• Riddle MS, Connor BA, Beeching NJ, DuPont HL, Hamer DH, Kozarsky P, et al. Guidelines for the prevention and treatment of travelers’ diarrhea: a graded expert panel report. J Travel Med. 2017 Apr 1;24(suppl_1):S57–S74.

Lin H. Chen, Natasha S. Hochberg

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