Travel Medicine

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Travel Medicine

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

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

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• The number of people traveling internationally
  is increasing every year.
• According to statistics of the World Tourism
  Organization, international tourist arrivals in
  the year 2006 exceeded 846 million

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Causes for international travel in the year 2006
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• As more people travel and individuals travel
  more frequently, the specialty of travel medicine
  becomes more important.
• Thus, most clinicians need some basic
  information to determine the extent of health
  advice their patients should access prior to
  their journeys.

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• International travel can pose various risks to
  health, depending on the characteristics of both
  the traveler and the travel.

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• Morbidity studies suggest that about half of
  the people from a developed country that stay one
  month in a developing country will get sick.

Trevelers diarrhea
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• Mortality studies indicate that
• Cardiovascular disease accounts for most deaths
  during travel (50-70).
• Injury and accident (25).
• Infectious disease accounts for about 2.8-4 of
  deaths during and after return from travel.

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• Key factors in determining the risks to which
  travelers may be exposed are
• Destination.
• Duration and season of travel.
• Purpose of travel.
• Standards of accommodation and food hygiene.
• Behavior of the traveler.
• Underlying health of the traveler.

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• The duration of the visit may determine
  whether the traveler may be subjected to marked
  changes in temperature, humidity, or prolonged
  exposure to atmospheric pollution and likelihood
  of exposure to infectious agents which will
  influence decisions on the need for certain
  vaccinations or anti-malarial medication.

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• The purpose of the visit is critical in relation
  to the associated health risks. (conferences
  versus holidays)
• Behavior also plays an important role e.g. going
  outdoors in the evenings in a malaria-endemic
  area without taking precautions

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Planning for healthy travel
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• Travelers' health is the responsibility of
• Clinicians.
• Travelers.
• Travel Industry.

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Responsibilities of Clinicians

• A clinician should provide the traveler with
• Knowledge that enables them to protect themselves
  from potential health risks.

Emphasize the importance of a pre-travel
consultation and educates the patient that
international travel can pose special health
risks that should be addressed.
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Evaluate the traveler including the medical
history, the assessment of the epidemiology of
endemic diseases or health risks at the
destination, and the behavioral risks that may be
taken.
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• Educate the traveler about importance of having a
  medical kit during his journey and construct him
  about its contents.

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• Provide post-travel medical care. The extent
  of the care given is personally determined
  according to condition of traveller and travel
  circumstances.
• Recognize common disease symptoms and
  syndromes of international travelers.

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Travel health advice should be individually
tailored to the person.

• For example, the business traveler to Bangkok,
  Thailand with underlying heart disease staying at
  a 5-star resort has different risks from those of
  the healthy refugee camp worker who will travel
  throughout northern Thailand on the Cambodian
  border.

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Vaccination

• Despite their success in preventing disease,
  vaccines do not fully protect 100 of the
  recipients.
• The vaccinated traveler should not assume that
  there is no risk of catching the disease against
  which he has been vaccinated.
• All additional precautions against infection
  should be followed carefully.

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• The protective effect of vaccines takes a period
  of time to be fully developed.
• The duration varies according to the vaccine, the
  number of doses required and whether the
  individual has previously been vaccinated against
  the same disease.
• For this reason, travelers are advised to consult
  a travel medicine clinic or personal physician
  46 weeks before departure.

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Choice of vaccines for travel

• Vaccines for travelers include
• (1) Vaccines used routinely, particularly for
  children.
• (2) Vaccines that may be advised before travel.
• (3) Vaccines that, in some situations, are
  mandatory.

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Routine vaccination Diphtheria/pertussis/tetanus
(DTP) Hepatitis B (HBV) Haemophilus influenzae
type b (Hib) Measles (MMR) Poliomyelitis (OPV or
IPV)
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Selective use for travelers Cholera Influenza He
patitis A (HAV) Japanese encephalitis Lyme
disease Pneumococcal disease Rabies Tick-borne
encephalitis Tuberculosis (BCG) Typhoid fever
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• Mandatory vaccination
• Yellow fever (for protection of vulnerable
  countries)
• Meningococcal disease (required by Saudi Arabia
  for pilgrims visiting Mecca for the Hajj (annual
  pilgrimage) or for the Umrah.

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• The International Health Regulations mandates
  yellow fever vaccination for two different
  reasons
• (1) to protect the individual in areas where
  there is a risk of yellow fever infection.
• (2) to protect vulnerable countries from
  importation of the yellow fever virus.

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According to the international measures, The
world is divided into three zones

• Infected (endemic) zone.
• Infectable (receptive) zone.
• Non-infectable zone.

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• Infected (endemic) zone
• In this zone, the three requirements for
  perpetuation of yellow fever are present the
  virus, the vector and suitable environmental
  conditions.
• The objective of the control measures is to
  prevent exportation of the disease and diminish
  local spread.

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Yellow fever endemic zone
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Measures applied to infected zone

• Ports and airports
• a- should be away from the city.
• b-Apply insecticides periodically to
  control mosquito.
• The plans Application of insecticides on planes
  before leaving.
• Individuals
• Those working in the airport and travelers going
  outside or entering should have valid vaccination
  certificate .
• Cases of yellow fever should not leave the
  country.

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Infectable (receptive) zone

• Between endemic zone and latitude 43N and 43S.
• Only the vector and suitable environmental
  conditions are present, but there is no virus.
• All planes and ships coming from infected areas
  should be disinfected on arrival.
• Only travelers carrying valid vaccination
  certificates are allowed to enter.

Measures applied to infectable zone
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• If travelers were not vaccinated or since less
  than ten days they should be kept in quarantine
  to complete the six days
• Monkeys and apes should be kept in quarantine for
  seven days.

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• Non-infectable zone
• The area north and south of the latitude 43.
• In this area, there is no virus, no vector and
  the environmental conditions are not suitable.
• Thus, no preventive measures are required.

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Yellow fever vaccine

• 1 dose
• Protection 10 years
• Age range Minimum age 9 months.
• Seek medical advice for infants 6-9 months who
  are travelling to high risk areas

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International Certificate of Vaccination or
Prophylaxis (ICVP) for Yellow Fever

• The International Health Regulations allow
  countries to require proof of vaccination for
  entry of travelers arriving from certain
  countries.
• Travelers arriving without a completed ICVP may
  be quarantined or refused entry unless submitting
  to onsite vaccination.
• Vaccinees should receive a completed ICVP, signed
  and validated with the centers stamp where the
  vaccine was given.
• This certificate is valid 10 days after
  vaccination and for a subsequent period of 10
  years.

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Malaria chemoprophylaxis

• Antimalarial drugs are recommended for
  prophylaxis of non-immune travelers visiting
  malaria-endemic areas.
• In areas of chloroquine-sensitive malaria,
  weekly chloroquine is the drug of choice.
• In areas where chloroquine-resistant P.
  falciparum is transmitted, weekly mefloquine or
  daily doxycycline is recommended.
• Chemoprophylaxis should be started 1 week before
  arriving in a malaria-endemic area and continued
  during travel and for 4 weeks after leaving the
  area.

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Levels of concern at destination
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Responsibilities of Travelers

• Each traveler needs to realize the value of
  health and the risks that traveling
  internationally may pose.
• Every travelers responsibility is to weigh the
  personal risk versus benefits of a particular
  journey.

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• Recent studies have shown that a small portion of
  travelers do not even seek general information
  about their travel destination.

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Medical kit and hygiene items

• Sufficient medical supplies should be carried to
  meet all needs for the duration of the trip.
• A medical kit should be carried for all
  destinations where there may be significant
  health risks, particularly those in developing
  countries, and/or where the local availability of
  specific medications is not certain.

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• Certain categories of medicine should be carried
  together with a medical prescription, signed by a
  physician.
• Hygiene items should also be carried in
  sufficient quantity for the entire visit unless
  their availability at the travel destination is
  assured. These will include items for dental
  care, eye care including contact lenses, skin
  care and personal hygiene.

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• This kit will include
• Basic medicines to treat common ailments.
• First-aid articles.
• Special medical items that may be needed by the
  individual traveler.

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• Contents of a basic medical kit (First-aid
  items)
• Adhesive tape.
• Antiseptic wound cleanser.
• Bandages.
• Emollient eye drops.
• Insect repellent.
• Insect bite treatment.
• Nasal decongestant.
• Oral re-hydration salts.
• Scissors and safety pins.
• Simple analgesic (e.g. Paracetamol).
• Sterile dressing.
• Clinical thermometer.

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Responsibilities of the Travel Industry

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

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Mode of travel

• The mode of travel is an integral part of the
  travel experience.
• According to the World Tourism Organization, of
  the 846 million international tourist arrivals in
  2006, air transport represented 45 of arrivals
  and marine transport accounted for 7.

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Travel by air
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Travel by air

• The volume of air traffic has risen steeply in
  recent years.
• Moreover, the number of long-distance flights
  has increased.
• According to the International Civil Aviation
  Organization, the passenger traffic is projected
  to double between 2006 and 2020.

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• Air travel, in particular over long distances,
  exposes passengers to a number of factors that
  may have an effect on their health and
  well-being.
• Health risks associated with air travel can be
  minimized if the traveler plans carefully and
  takes some simple precautions before, during and
  after the flight.

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Factors that may affect the health and well-being
of air travelers
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Cabin air pressure

• Although aircraft cabins are pressurized, cabin
  air pressure at cruising altitude is lower than
  air pressure at sea level.
• As a consequence, less oxygen is taken up by the
  blood (hypoxia) and gases within the body expand.
  
• The effects of reduced cabin air pressure are
  usually well tolerated by healthy passengers.

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• Passengers with certain medical conditions,
  particularly heart and lung disease and blood
  disorders such as anemia (in particular sickle
  cell anemia), may not tolerate this reduced
  oxygen level (hypoxia) very well.
• Some of these passengers are able to travel
  safely if arrangements are made with the airline
  for the provision of an additional oxygen supply
  during flight.

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Gas expansion

• As the aircraft climbs, the decreasing cabin air
  pressure causes gases to expand.
• Similarly, as the aircraft descends, the
  increasing pressure in the cabin causes gases to
  contract.

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• Gas expansion during the climb causes air to
  escape from the middle ear and the sinuses,
  usually without causing problems( popping
  sensation in the ears).
• As the aircraft descends, air must flow back
  into the middle ear and sinuses in order to
  equalize pressure differences. If this does not
  happen, the ears or sinuses may feel as if they
  are blocked and pain can result.

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• Prevention
• Swallowing, chewing or yawning (clearing the
  ears), a short forceful expiration against a
  pinched nose and closed mouth (Valsalva
  maneuver).
• Take a decongestant before you get on the
  airplane, (particularly if suffering from a
  common cold or swollen sinuses).
• For infants, feeding or giving a pacifier (dummy)
  to stimulate swallowing.

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Cabin humidity and dehydration

• The humidity in aircraft cabins is low (less
  than 20).
• Low humidity may cause skin dryness and
  discomfort of the eyes, mouth, nose and exposed
  skin but presents no risk to health.
• Use a skin moisturizing lotion, nasal saline,
  and spectacles rather than contact lenses.

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Ozone

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

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

• Request a seat in the mid-section of the cabin.
• Keep eyes fixed on the horizon and avoid rapid
  head movements. Sleep if you are able to.

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• Keep the motion sickness bag, provided at each
  seat, readily accessible.
• Consult doctor or travel medicine physician about
  medication.
• Avoid drinking alcohol during the flight and for
  the 24 hours before travel.

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Immobility, circulatory problems and deep vein
thrombosis (DVT)

• Prolonged immobility can lead to pooling of blood
  in the legs, causing leg swelling, stiffness and
  discomfort and may lead deep vein thrombosis or
  DVT.
• According to WHO, the risk of DVT approximately
  doubles after long flights (gt 4 hours) and also
  with other forms of travel where travelers are
  exposed to prolonged seated immobility and with
  multiple flights within a short period.

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Jet lag

• The symptoms caused by the disruption of the
  bodys internal clock and circadian rhythms it
  controls.
• Disruption occurs when crossing multiple time
  zones.

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Jet lag may lead to

• Indigestion and disturbance of bowel function.
• General malaise.
• Daytime sleepiness and difficulty in sleeping at
  night.
• Reduced physical and mental performance.
• Disturbance for travelers who take medication
  according to a strict timetable (e.g. insulin,
  oral contraceptives).

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General measures to reduce the effects of jet lag
Jet lag cannot be prevented

• Rest before departure, and during the flight.
• Eat light meals and limit consumption of alcohol.
  
• Caffeine should be limited to normal amounts.

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• Try to create the right conditions when preparing
  for sleep.
• Short-acting sleeping pills.
• Melatonin (available in some countries).

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Psychological aspects

• Travel by air is not a natural activity for
  humans and many people experience some degree of
  psychological difficulty when flying.
• The main problems encountered are
• Stress.
• fear of flying.
• Air Rage.
• These may occur together or separately at
  different times before and during the period of
  travel.

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Important measures to be taken in air flights
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Aircraft disinsection

• Disinsection is a public health measure that
  is mandated by the current International Health
  Regulations.
• Many countries require disinsection of
  aircraft (to kill insects) arriving from
  countries in order to
• Pevent diseases that are spread by insects (e.g.
  malaria and yellow fever)
• Protect agriculture e.g. Australia and New
  Zealand.

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• Countries where disinsection generally takes
  place include those in Latin America, the
  Caribbean, Australia, and the South Pacific
  regions.

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Medical assistance on board

• Airlines are required to provide
• Minimum levels of medical equipment on aircraft.
• Train all cabin crew on first aid.
• Equipment carried on a typical international
  flight would include
• One or more first-aid kits, to be used by the
  crew.

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• A medical kit, normally to be used by a doctor or
  other qualified person, to treat in-flight
  medical emergencies.
• An automated external defibrillator (AED) to be
  used by the crew in case of cardiac arrest.

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Contraindications to air travel

• Travel by air is normally contraindicated in the
  following cases
• Infants less than 7 days old.
• Women after the 36th week of pregnancy (after
  32nd week for multiple pregnancies) and until
  seven days after delivery.

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Contraindications to air travel (cont)

• Those suffering from
• Angina pectoris or chest pain at rest.
• Serious or acute infectious disease.
• Decompression sickness after diving.
• Increased intracranial pressure due to
  hemorrhage, trauma or infection
• Infections of the sinuses, ear or nose,
  particularly if the Eustachian tube is blocked.

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Contraindications to air travel (cont)

• Recent myocardial infarction and stroke.
• Recent surgery or injury.
• Severe chronic respiratory disease, and
  unresolved pneumothorax.
• Sickle-cell disease.
• Psychotic illness, except when fully controlled.

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Travel by Sea
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Travel by sea

• The passenger shipping industry has expanded
  considerably in recent decades.
• In 2006, 11.7 million passengers worldwide
  traveled on cruise ships.
• Cruise itineraries include all continents
  including areas that are not easily accessible by
  other means of travel.
• The average duration of a cruise is about 7 days,
  but cruise voyages can last from several hours to
  several months (e.g. round-the world cruises).

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Travel by sea

• The revised International Health Regulations
  (2005) address health requirements for ship
  operations and construction.
• There are global standards regarding ship and
  port sanitation and disease surveillance, as well
  as response to infectious diseases.
• Guidance is given on provision of safe water and
  food, on vector and rodent control, and on waste
  disposal.

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Travel by sea

• According to International Labor Organization
  Convention
• Concerning Health Protection and Medical Care
  for Seafarers (1987), vessels carrying more than
  100 crew members on an international voyage of
  three days or longer must provide a physician for
  care of the crew.

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Travel by sea

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

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Health hazards for traveling by sea
I. Communicable diseases Gastroenteritis.
Respiratory infections. II. Non-communicable
diseases.
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Communicable diseasesGastrointestinal disease

• The viral gastroenteritis is highly infectious
  and can spread in food or water or from person to
  person.
• In an outbreak on a cruise ship in 1998, more
  than 80 of the 841 passengers were affected.

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• Factors that have contributed to outbreaks
  include
• Contaminated bunkered water, inadequate
  disinfection of water.
• Potable water contaminated by sewage on ship.
• Poor design and construction of storage tanks for
  potable water.
• Deficiencies in food handling, preparation and
  cooking.
• Use of seawater in the galley.

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Influenza and other respiratory tract infections

• Respiratory tract infections are frequent among
  cruise-ship travelers.
• Risk of exposure to influenza viruses in regions
  of the world where influenza is not in seasonal
  circulation, particularly if the group contains
  travelers from areas of the world where influenza
  viruses are in seasonal circulation.
• Crew members who serve passengers may become
  reservoirs for influenza infection.

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Non-communicable diseases

• Because of temperature and weather
  variations, changes in diet and physical
  activities, and generally increased levels of
  stress compared with life at home, the cruise
  ship traveler particularly the elderly traveler
  may experience worsening of existing chronic
  health conditions.
• Cardiovascular events are the most common cause
  of mortality on cruise ships.
• Motion sickness can occur, especially on smaller
  vessels.

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Environmental health risks
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Environmental health risks

• Travel may involve major changes in
• Altitude.
• Temperature.
• Humidity.
• Exposure to microbes, animals and insects.
• Recreational water hazards.

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Recreational water

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

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Recreational Water Hazards

• Drowning injury.
• Physiological
• -Chilling leading to coma death.
• -Thermal shock leading to cramps cardiac
  arrest.
• -Decompression sickness in divers.
  
• -Acute exposure to heat ultraviolet
  radiation.
• -Cumulative exposure to sun (skin cancer
  cataract).

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Recreational water hazards

• Infection
• Ingestion or inhalation of or contact with
• pathogenic micro-organisms.
• Poisoning toxicities
• - Ingestion or inhalation or contact with
  chemically
• contaminated water.
• - Stings or bites of venomous animals.
• Injuries and accidents.

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Prevention of recreational water hazards

• Adequate environmental monitoring for
  recreational water activities.
• Provide health information to recreational water
  users.
• Avoiding areas with visible algae concentrations.

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

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

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• Wearing adequate lifejackets when boating.
• local hazard warning notices.
• Emergency services access.
• Beach cleaning.
• Solid waste management.

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Insects and disease vectors

• Vectors play an essential role in the
  transmission of many infectious diseases.
• Many insect vectors are involved in the life
  cycle and transmission of diseases as mosquitoes,
  bloodsucking flies, ticks, and aquatic snails.

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Protection against vectors

• Travelers may protect themselves from
  mosquitoes and other vectors by using
• Protective clothing
• Insect repellents
• Insecticide-treated curtains and bed-nets
• Mosquito coils
• Aerosol insecticide sprays

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

• They constitute significant risk in many
  countries, particularly developing countries

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Accidents constitute special risk for travelers
in developing countries because

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

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• Travelers can reduce the possibility of accidents
  through
• Travelers, both drivers and pedestrians, should
  be extremely attentive and careful on the roads.
• Have full insurance cover for medical treatment
  of both illness and injuries.
• Carry an international driving license as well
  as your national driving license.

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• Obtain information on the regulations governing
  traffic and vehicle maintenance, and on the state
  of the roads, in the countries to be visited.
• Before renting a car, check the state of its
  parts.

• Know the informal rules of the road in some
  countries.
• Be particularly vigilant in a country where the
  traffic drives on the opposite side of the road
  to that used in your country of residence.

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• Do not drive on unfamiliar roads
• Do not use motorcycle, bicycle or tricycle.
• Do not drive after drinking alcohol.
• Drive within the speed limit at all times.
• Always wear a seat belt where these are
  available.
• Beware of wandering animals.

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• First-aid courses.
• First-aid equipment, a communications device, and
  equipment that will add visibility to themselves
  and/or their vehicles (e.g., reflecting vest)
• Protective clothing should be worn when riding on
  motorbikes.
• Bringing child seats is advisable.
• Children lt12 years of age should ride in the
  back seat.

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Intentional Injuries (violence)
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• Violence and collective violence are leading
  worldwide public health problems and are growing
  concerns of travelers.
• The 20th century was one of the most violent
  periods in history.

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

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Risk factors for violence

• Destinations where
• 1. Government is unstable, even for short periods
  of time.
• 2. Recent coups have taken place.
• 3. Marked social inequality.
• 4. Rapid demographic changes.
• 5. Government is under control by a single group
  that identifies itself by a particular ethnic
  background or religious fundamentalism.

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Important tips to reduce risk of violence against
travelers

• Education about and greater awareness of regions
  of the world where political and civil unrest are
  present are important for all travelers.
• Be alert to muggings
• Avoid overcrowded trains, buses and minibus
  taxis.
• Avoid isolated beaches and other remote areas.

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• Keep items of value out of sight and do not carry
  large sums of money on your person.
• Use taxis from authorized ranks only.
• Avoid driving at night and never travel alone.

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• Park in well-lit areas and do not pick up
  strangers.
• Employ the services of a local guide or local
  driver when traveling to remote areas.
• Vehicle hijacking.

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Personal security

• To reduce any risk of mugging travel in groups,
  avoid remote areas after dark, carry an alarm or
  an anti-personnel spray (may be illegal in some
  countries), wear modest clothing, do not display
  wealth.

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• Many areas are not safe to wander around at
  night, including those that look safe by
  daylight.
• While driving, consider locking your car doors at
  stopping points especially at night in isolated
  areas.

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• Be aware of political unrest. Get up to date
  information from a Foreign Office on line. Do not
  rely on information from local residents.
• In some countries, producing cameras, tape
  recorders etc. in sensitive areas such as near
  airports and railway stations can result in
  arrest on suspicion of spying.

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

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

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More common infections in returned travelers are
gastrointestinal

• Diarrhea (acute and chronic) and occasionally
  typhoid fever, amebiasis, and brucellosis.
• Chronic and latent infections in immigrants
  (and long-term residents) from this region
  include tuberculosis, schistosomiasis,
  fascioliasis, hepatitis B and C, intestinal
  parasites, and echinococcosis.

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• Vector-borne infections
• Many have focal distributions or seasonal
  patterns.
• Risk to the usual traveler is low.
• e.g. dengue fever, lymphatic filariasis,
  leishmaniasis, malaria (risk limited to a few
  areas), relapsing fever, Rift Valley fever, West
  Nile fever
• Food- and water-borne infections
• These infections, which are common in travelers
  to this region, include dysentery and diarrhea
  caused by bacteria, viruses, and parasites.
• Risk for hepatitis A is high throughout the
  region.
• Hepatitis E and cholera have caused focal
  outbreaks.

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• Sexually transmitted and blood-borne infections
• HIV prevalence (in adults 15-49 years) is
  estimated to be 0.1- 0.5 or lower.
• Chancroid is a common cause of genital ulcers.
• Chronic hepatitis B carriage, hepatitis CV.

• Zoonotic infections
• Rabies is endemic in the region.
• Sporadic cases of human plague and anthrax.
• Avian influenza (H5N1) was found in poultry
  and human cases
• and deaths.

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• Airborne and person-to-person transmission
• Tuberculosis (incidence 50-100/100,000 or lower
  in most countries).
• Soil- and water-associated infections
• Schistosomiasis is present. Other risks include
  leptospirosis.
• Other hazards
• Scorpion stings, snake bites
• high rate of motor-vehicle accidents.
• Screening of blood before transfusion is
  inadequate.

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America
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North America

• Good sanitation and clean water are available in
  major urban areas and most rural areas.
• Many vector-borne infections are found in focal
  areas and can pose a risk to travelers,
  especially adventure travelers to rural areas.
• In temperate areas these infections occur during
  the summer months.
• Levels of immunization are high in most areas.
• Poliomyelitis has been eradicated.

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• Vector-borne infections
• Lyme disease is endemic
• Other vector-borne infections include Rocky
  Mountain spotted fever and relapsing fever.
• Sporadic local transmission of dengue.

• Food- and water-borne infections
• Outbreaks of diarrhea caused by
  enterohemorrhagic E-coli, Campylobacter and
  Salmonella are the most common causes of acute
  bacterial diarrhea.
• Outbreaks of noroviral diarrhea are increasing.

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Airborne and person-to-person transmission

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

• Sexually transmitted and blood-borne infections
• The HIV prevalence in adults aged 15-49 years is
  estimated to be 0.5 -lt1.0 in USA.

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• Zoonotic infections
• Rabies is enzootic in bats, raccoons, foxes, and
  other wild animals.
• Plague is enzootic in the western United States
• Many outbreaks of anthrax in animals were
  reported in agricultural regions of the US and
  Canada in 2006.
• Human cases are rare .
• Other hazards
• Violent injury and death related to guns rates
  are higher in the United States than in most
  industrialized countries.
• Snakes inhabit North America the highest bite
  rates are found in southern states and
  southwestern desert states.
• Tick paralysis is most often reported from
  western Canada and the northwestern United States.

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Thank YouWish you a safe travel