CDC Health Information for International Travelers Geographic Distribution of Potential Health Hazards

NORTH AFRICA
CENTRAL, EAST, AND WEST AFRICA
SOUTHERN AFRICA
NORTH AMERICA
MEXICO AND CENTRAL AMERICA
THE CARIBBEAN
TROPICAL SOUTH AMERICA
TEMPERATE SOUTH AMERICA
EAST ASIA
SOUTHEAST ASIA
SOUTH ASIA
MIDDLE EAST
WESTERN EUROPE
EASTERN EUROPE AND NORTHERN ASIA
AUSTRALIA AND THE SOUTH AND WESTERN PACIFIC

Editor's note: The following information is not a complete medical guide for travelers. Consult with your doctor for specific information related to your needs and your medical history; recommendations may differ for pregnant women, young children, and persons who have chronic medical conditions. Be sure to read the information about all the regions you are planning to visit. The information presented in this section was condensed from the CDC's Health Information for International Travelers 2008, commonly referred to as the Yellow Book. For complete travel health information view CDC's website on the Internet at http://wwwn.cdc.gov/travel or call CDC's toll free voice information system at 1-877-394-8747 .

NORTH AFRICA

Countries: Algeria, Canary Islands, Egypt, Libya, Madeira Islands, Morocco, Tunisia, Western Sahara

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 wide-spread. Vaccine-preventable diseases such as measles, mumps, rubella, and diphtheria persist in the region. More common infections in returned travelers are gastrointestinal: diarrhea (acute and chronic) and occasionally typhoid fever, amebiasis, and brucellosis. Chronic and latent infections in immigrants (and long-term residents) from this region include tuberculosis, schistosomiasis, fascioliasis, hepatitis B and C, intestinal parasites, and echinococcosis.

Vector-borne infections: Many have focal distributions or seasonal patterns. Risk to the usual traveler is low. Vector-borne infections in parts of the region include dengue fever, lymphatic filariasis (especially in the Nile Delta), leishmaniasis (cutaneous and visceral), malaria (risk limited to a few areas), relapsing fever, Rift Valley fever, sand fly fever, Sindbis virus infection, West Nile fever (especially in Egypt), Crimean-Congo hemorrhagic fever, spotted fever due to Rickettsia conorii, and murine typhus.

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, and indigenous wild polio was still present in Egypt in 2005. Other risks include typhoid fever, brucellosis, amebiasis, and fascioliasis (rare in visitors to the area). Intestinal helminths are common in some local populations but rare in short-term travelers.

Airborne and person-to-person transmission: The annual incidence of tuberculosis is estimated to be 50-100/ 100,000 or lower in most countries in the region. Q fever is widespread in livestock-raising areas.

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. Prevalence of chronic hepatitis B carriage is estimated to be 2%-7% in the region; hepatitis C prevalence exceeds 15% in Egypt.

Zoonotic infections: Rabies is endemic in the region. Sporadic cases of human plague are reported, and an outbreak occurred in Algeria in 2003. Sporadic cases and outbreaks of anthrax occur in the region. Avian influenza (H5N1) was found in poultry in 2006; human cases and deaths were reported in Egypt in 2006.

Soil-and water-associated infections: Schistosomiasis is present, especially in the Nile Delta and Valley; it is found focally in other countries. Other risks include lep-tospirosis.

Other hazards: Scorpion stings, snake bites, and a high rate of motor-vehicle accidents and violent injuries occur. Screening of blood before transfusion is inadequate in many hospitals.

CENTRAL, EAST, AND WEST AFRICA

Central Africa: Angola, Cameroon, Central African Republic, Chad, Congo, Democratic Republic of Congo (Zaire), Equatorial Guinea, Gabon, Sudan, Zambia

East Africa: Burundi, Comoros, Djibouti, Eritrea, Ethiopia, Kenya, Madagascar, Malawi, Mauritius, Mayotte, Mozambique, Réunion, Rwanda, Seychelles, Somalia, Tanzania, Uganda

West Africa: Benin, Burkina Faso, Cape Verde, Côte d’Ivoire, The Gambia, Ghana, Guinea, Guinea-Bissau, Liberia, Mali, Mauritania, Niger, Nigeria, Saint Helena, São Tomé and Principe, Senegal, Sierra Leone, Togo

Vector-borne infections are common and widespread and pose a major risk to local residents and travelers. 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, poliomyelitis, and diphtheria persist in the region. The most common cause of systemic febrile illness in travelers to this region is malaria caused by Plasmodium falci-parum. Subacute or chronic infections in immigrants (and long-term residents) from the area include tuberculosis, hepatitis B, HIV, lymphatic filariasis, onchocerciasis, loia-sis, schistosomiasis, echinococcosis, leprosy, and intestinal parasites.

Vector-borne infections: Malaria transmission is intense in many parts of the region, including urban areas, where falciparum malaria, much of it resistant to chloro-quine, predominates. Sporadic cases and outbreaks of yellow fever have occurred in at least 18 of the countries (especially in West Africa) since 2000; outbreaks were reported in 2005 from Guinea, the Sudan, Cöte d’Ivoire, Mali, Senegal, Burkina Faso, and Sierra Leone. All countries in the region are considered to be in the endemic zone, and unvaccinated travelers are at risk for infection. Official reports of yellow fever reflect only a small percentage of all infections. African trypanosomiasis has increased in Africa (it is epidemic in Angola, Democratic Republic of Congo, and the Sudan; and highly endemic in Cameroon, Central African Republic, Chad, Congo, Cöte d’Ivoire, Guinea, Mozambique, Uganda, and Tanzania; low levels are found in most of the other countries), and an increase in travelers has been noted since 2000. Most had exposures in Tanzania and Kenya, reflecting common tourist routes. Trypanosoma brucei gambiense is found in focal areas of western and central Africa; T. b. rhode-siense, which causes more acute illness, is found in east Africa. Vector-borne viral infections include dengue fever, Crimean-Congo hemorrhagic fever, Rift Valley fever, West Nile fever, chikungunya fever, and O’nyong nyong fever. Lymphatic filariasis is present in many areas; onchocercia-sis is widely distributed around river systems, especially in West and Central Africa and as far east as Ethiopia. Another filarial infection, loiasis, is widely distributed in the tropical rain forest, especially in Central and West Africa. Filarial infections are rare in short-term travelers.

The rickettsial infections murine typhus, louse-borne typhus, and African tick bite fever (due to Rickettsia africae) occur in the region. African tick-bite fever has been increasingly recognized in travelers to rural areas. Murine typhus is more common in coastal areas. Tungiasis (penetration of the skin by sand fleas) is widespread in tropical Africa, especially West Africa, including Madagascar.

In 2005-2006, massive outbreaks of chikungunya occurred on island countries in the southwest Indian Ocean (Réunion, Mayotte, Mauritius, and Seychelles). Infections were also imported by returning travelers to Europe (160 imported cases in France alone) and the United States.

Tick-borne relapsing fever is widespread in eastern and central Africa and sporadic elsewhere. Epidemics of louse-borne relapsing fever have occurred in the past but pose little risk to usual travelers. Visceral leishmaniasis is endemic in Ethiopia, Kenya, and Sudan (and has caused large epidemics); it is found in the savanna parts of the region. Cutaneous leishmaniasis is also found in the savanna and in Sudan, Ethiopia, and Kenya. Myiasis transmitted by the tumbu fly can affect travelers.

Food-and water-borne infections: Dysentery and diarrhea are common in local populations; diarrhea in travelers may be caused by bacteria, viruses, and parasites (especially Giardia, Cryptosporidium and Entamoeba his-tolytica). Cholera is sporadic and epidemic. A wave of outbreaks began in West Africa in 2005. Large outbreaks have been re-ported from southern Sudan and Angola in 2006. Risk of hepatitis A is wide-spread; sporadic cases and outbreaks of hepatitis E occur. Polio persists in Nigeria (799 confirmed cases in 2005) and was endemic in Niger in 2005; sporadic cases also occurred in Angola, Cameroon, Chad, Eritrea, Ethiopia, Mali, and Somalia in 2005-2006. Other risks to travelers include typhoid (a large outbreak occurred in the Democratic Republic of the Congo in 2004-2005) and paratyphoid fever, amebiasis, and brucellosis. Dracunculiasis cases were re-ported from nine African countries in 2005, with the highest number of cases in Sudan, Ghana, and Mali, but it is rare in travelers. Intestinal parasites are common in residents in many parts of region but are rare in short-term travelers.

Airborne and person-to-person transmission: The estimated annual incidence rates of tuberculosis (per 100,000) are >100 in all countries and >300 in much of region. Frequent epidemics of serogroup A meningococcal disease occur during the dry sea-son (December through June) in a band of countries from Senegal to Ethiopia. Severe outbreaks have occurred in Burkina Faso, Chad, Mali, Niger, Nigeria, Ethiopia, and the Sudan. Serogroup W135 emerged in Burkina Faso in 2002, causing a large epidemic (13,000 cases). It was the predominant pathogen in 2006 in Kenya, Sudan (W. Darfur camps), and Uganda (Gulu district). Nosocomial and in-trafamilial spread of Ebola occurs in outbreaks (Sudan, Democratic Republic of the Congo, Cöte d’Ivoire, and Gabon). Nosocomial spread of Marburg fever virus (an outbreak occurred in Angola in 2005) and Lassa fever virus has also occurred.

Sexually transmitted and blood-borne infections: The estimated prevalence of HIV in adults (15-49 years) ranges from 1% to 15% in most countries. In most of the region, prevalence of chronic infection with hepatitis B virus exceeds 8%. HTLV-1 is endemic in parts of Central and West Africa. Common causes of genital ulcer disease include chancroid, syphilis, and herpes simplex.

Zoonotic infections: Dogs are the most important source of rabies, which is found throughout the region. A wild rodent is the reservoir host for Lassa fever virus, which is endemic in West Africa; cases have also been documented in the Central African Republic. Echinococcosis is widespread in animal breeding areas. Sporadic cases and outbreaks of anthrax occur in the region (it is hyperendemic in Zambia, Ethiopia, Niger, and Chad and in several countries along the western coast). Monkeypox is found in West and Central Africa, primarily in remote villages in rain forest areas. Plague is enzootic, and sporadic cases and outbreaks occur in humans. (Outbreaks have occurred since 2000 in Madagascar, Malawi, Mozambique, Uganda, and Tanzania.) Ituri District (Oriental Province) in the Democratic Republic of Congo reports about 1,000 cases per year and was the site of an outbreak in 2006. Q fever (airborne spread) is found, especially in West Africa, where livestock breeding is common. Avian influenza (H5N1) was found in poultry in 2006 in Nigeria, Niger, Cameroon, Burkina Faso, Sudan, and Côte d’Ivoire. One human case occurred in Djibouti in 2006.

Soil and water-associated infections: Schistosomiasis due to Schistosoma mansoni and S. haematobium is widespread; S. intercalatum has a more limited distribution (West Africa). Mycobacterium ulcerans (the cause of Buruli ulcer) is most concentrated in West Africa and is increasing in prevalence. Rare cases have occurred in travelers. Leptospirosis (both sporadic cases and outbreaks) occurs in tropical areas. Other risks include mycetoma and histoplasmosis.

Other hazards: Motor vehicle accidents and other injuries, including violent injury with assault rifles and other weapons, and sexual assaults occur. Snake bites and afla-toxin contamination of grains are common, especially in rural areas. Screening of blood before transfusion is inadequate in many hospitals.

SOUTHERN AFRICA

Countries: Botswana, Lesotho, Namibia, South Africa, Swaziland, Zimbabwe

Vector-borne infections are common in parts of the region. Access to clean water and sanitary disposal of waste are highly variable but are poor in some areas (especially some rural areas). Vaccine coverage is high in some populations, but vaccine-preventable diseases, such as measles, mumps, rubella, and diphtheria, persist in parts of the region. Polio reappeared in 2006 in Namibia. More common infections in travelers include gastrointestinal infections, African tick-bite fever, and malaria. Infections in immigrants (and long-term residents from the region) include tuberculosis, HIV, schistosomiasis, and intestinal parasites.

Vector-borne infections: Malaria is present in parts of all countries in the region except Lesotho, although the risk is focal or seasonal in many areas. African tick-bite fever (Rickettsia africae) continues to be common in travelers to the region, especially South Africa, Botswana, Swaziland, Lesotho, and Zimbabwe. Other vector-borne infections include tick-borne relapsing fever, Rift Valley fever, dengue (focal outbreaks but larger areas infested with Aedes aegypti), tick-borne relapsing fever, murine typhus, West Nile fever, and Crimean-Congo hemorrhagic fever. African trypanosomiasis has been reported from Botswana and Namibia in the past. Tungiasis is reported from South Africa.

Food-and water-borne infections: Risk for hepatitis A is high in parts of the region and outbreaks of hepatitis E have been reported. Risk for dysentery and diarrhea is highly variable within the region. Diarrhea in travelers may be caused by bacteria, viruses, and parasites. Other risks for travelers include typhoid and paratyphoid fever and amebiasis. Cholera is sporadic and epidemic (out-breaks in 2004 in South Africa, Swaziland, and Zimbabwe). Intestinal helminths, although common in some local populations, are rare in short-term travelers.

Airborne and person-to-person transmission: The estimated incidence rate of tuberculosis is >300 per 100,000 population in the region.

Sexually transmitted and blood-borne infections: HIV prevalence in antenatal clinics exceeds 25% in many countries in the region; 15%-34% of adults aged 15-49 years are infected. Prevalence of chronic carriage of hepatitis B virus exceeds 8%.

Zoonotic infections: The mongoose is a source of rabies, in addition to domestic dogs and other animals. Plague is enzootic, and sporadic cases and outbreaks have occurred in Botswana, Namibia, and Zimbabwe since 1990. Anthrax is hyperendemic in Zimbabwe, with recent outbreaks in animals and also human cases. Sporadic cases of anthrax have been reported elsewhere in the region.

Soil-and water-associated infections: Focal active areas of schistosomiasis persist (caused by Schistosoma mansoni, S. haematobium, and S. mattheei). Cutaneous larva migrans can occur after exposures on beaches. Lep-tospirosis has caused outbreaks. Histoplasmosis has caused an outbreak in South Africa.

Other hazards: Motor vehicle accidents and violent injury, as well as snake bites occur. Screening of blood before transfusion is inadequate in many hospitals.

NORTH AMERICA

Countries: Canada, Saint Pierre and Miquelon, United States

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

Vector-borne infections: Lyme disease is endemic in northeastern, north central (upper Midwest), and Pacific coastal areas of North America. West Nile fever was first documented in the United States (New York) in 1999 and has since spread throughout continental U.S. and southern Canada. Other vector-borne infections include Rocky Mountain spotted fever, murine typhus, rickettsialpox, St. Louis encephalitis, La Crosse encephalitis, Eastern equine encephalitis, Colorado tick fever, and relapsing fever. Ehr-lichiosis (granulocytic and monocytic) has been reported primarily from the central and eastern thirds of the United States. Sporadic local transmission of dengue has occurred since 1995 in Florida and Texas, and the vector mosquito Aedes aegypti inhabits the southeastern United States. An outbreak of dengue in Hawaii in 2001-2002 was transmitted by Ae. albopictus.

Food-and water-borne infections: Outbreaks of diarrhea caused by enterohemorrhagic Escherichia coli 0157:H7 have occurred in many areas and have increased in the past decade. Campylobacter and Salmonella are the most common causes of acute bacterial diarrhea. Giardiasis and cryptosporidiosis occur sporadically and in outbreaks. Outbreaks of diarrhea due to norovirus are increasingly being reported in the United States and Canada.

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 in the United States and Canada, and most of these cases are imported or linked to imported cases.

Sexually transmitted and blood-borne infections: The HIV prevalence in adults aged 15-49 years is estimated to be 0.5% -<1.0% in US, and is 0.1%-<0.5% in Canada.

Zoonotic infections: Rabies is enzootic in bats, raccoons, foxes, and other wild animals. Human cases are rare. Cases of hantavirus pulmonary syndrome have been widely distributed in North America, with the greatest concentration in the western and southwestern United States. Tularemia is found in wide areas of the United States, including Alaska, and Canada, with the greatest number of cases in the central states (Missouri and neighboring states). Outbreaks have occurred on Martha's Vineyard (Massachusetts). Q fever cases occur sporadically, especially in persons having contact with livestock in the western part of the region; a number of outbreaks have been documented in the Maritime provinces, eastern Canada. Plague is enzootic in the western United States, and rare human cases occur, almost 90% from New Mexico, Colorado, Arizona and California, often associated with prairie dogs. Many outbreaks of anthrax in animals were reported in agricultural regions of the US and Canada in 2006; infection in humans is rare.

Soil-and water-associated infections: Coccidioidomy-cosis is endemic in the southwestern United States and can occur in visitors to the area. Its incidence has increased in Arizona and California in recent years. Histo-plasmosis is highly endemic, especially in the Mississippi, Ohio, and St. Lawrence River valleys. Sporadic cases and large outbreaks occur. Hawaii has the highest incidence rate of leptospirosis in the United States, although sporadic cases and outbreaks have occurred elsewhere, primarily in warmer regions or in summer months. Lep-tospirosis is often associated with water recreational activities. Nonhuman schistosomes that cause cercarial dermatitis are widely distributed in freshwater and seawater along the Atlantic, Pacific, and Gulf coasts, and inland lakes.

Other hazards: Violent injury and death related to guns; rates are higher in the United States than in most industrialized countries. Nineteen species of venomous 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.

MEXICO AND CENTRAL AMERICA

Countries: Belize, Costa Rica, El Salvador, Guatemala, Honduras, Mexico, Nicaragua, Panama

Vector-borne infections have focal distributions, and some are seasonal. Access to clean water and sanitary disposal of waste remain limited in many areas, so infections related to fecal contamination of food and water remain common. Levels of vaccine coverage are generally good and improving.

More common infections in travelers to the area include gastrointestinal infections, dengue fever, and myiasis. The risk of malaria is low in most countries; more than half of the cases of malaria in travelers to this region are caused by P. vivax. Chronic or latent infections with late sequelae in immigrants (and long-term residents) include cysticer-cosis, tuberculosis, Chagas’ disease, leishmaniasis, and strongyloidiasis.

Vector-borne infections: Malaria is present in focal areas of all these countries; it remains sensitive to chloro-quine in all areas except for parts of Panama. Risk for travelers is low in most areas. Dengue epidemics have affected most of these countries in the past 5 years. Other vector-borne infections include rickettsial infections (spotted fever and murine typhus) and relapsing fever (tick borne). Foci of active transmission of leishmaniasis (predominantly cutaneous) are present in all countries. West Nile virus has been found in Mexico and may spread in Central America. Localized foci of transmission of Chagas disease exist in rural areas. Risk to the usual traveler is low. Onchocerciasis is endemic in focal areas of Mexico (Oaxaca, Chiapas) and Guatemala; eradication efforts are in progress. Myiasis (primarily botfly) is endemic in Central America.

Food-and water-borne infections: Diarrhea in travelers is common and may be caused by bacteria, viruses, and parasites. Diarrhea caused by enterotoxigenic E. coli predominates, but other bacteria and protozoa (including Giardia, Cryptosporidia, and Entamoeba histolytica) can also cause diarrhea. Risk of hepatitis A is high in many areas; epidemics of hepatitis E have occurred in Mexico. Other infections include brucellosis, typhoid fever, and amebic liver abscess. Nicaragua and Guatemala reported cholera in 2002-2003; however, risk for travelers is low. Gnathostomiasis has increased in Mexico, with many cases being reported from the Acapulco area; infection has been reported in travelers. Intestinal helminth infections are common in some local populations but are rare in visitors to the area. Central nervous system cysticercosis is a common cause of seizures in local residents.

Airborne and person-to-person transmission: The estimated annual incidence rate of tuberculosis per 100,000 population is 25-50 in most of the area, but 50-100 in Guatemala, Nicaragua, and Honduras.

Sexually transmitted and blood-borne infections: The estimated prevalence of HIV in adults is 0.1% -<1%. Incidence of cervical cancer (due to human papillomavirus) is as high as 33/100,000 women.

Zoonotic infections: Rabies is found throughout the region. Anthrax is enzootic throughout the region and can infect humans; this disease is most common in El Salvador, Guatemala, Honduras, and Nicaragua. Cases of hantavirus pulmonary syndrome have been reported from Panama.

Soil-and water-associated infections: Outbreaks of leptospirosis have occurred in travelers to the area (including whitewater rafters in Costa Rica and U.S. troops training in Panama); hemorrhagic pulmonary leptospirosis has occurred in Nicaragua. Sporadic cases and outbreaks of coccidioidomycosis and histoplasmosis have occurred in travelers to area. Risky activities include disturbing soil and entering caves and abandoned mines. Paracoccidioido-mycosis is endemic in parts of Mexico and Central America. Hookworm infections are common in some local populations but rare in travelers. Cutaneous larva migrans occurs in visitors, especially those visiting beaches.

Other hazards: Scorpion and snake bites and motor vehicle accidents occur. Screening of blood before transfusion is inadequate in many hospitals.

THE CARIBBEAN

Countries: Anguilla, Antigua and Barbuda, Aruba, The Bahamas, Barbados, Bermuda, Cayman Islands, Cuba, Dominica, Dominican Republic, Grenada, Guadaloupe, Haiti . Jamaica, Martinique, Montserrat, Netherlands Antilles, Puerto Rico, Saint Kitts and Nevis, Saint Lucia, Saint Martin, Saint Vincent and the Grenadines, Trinidad and Tobago, Turks and Caicos Islands, British Virgin Islands, U.S. Virgin Islands

Access to clean water and levels of sanitation are highly variable in the region. More common infections in travelers include gastrointestinal infections; dengue fever is reported during periods of epidemic activity.

Vector-borne infections: Malaria is endemic in Haiti and is found in focal areas in the Dominican Republic. In 2006, malaria (falciparum) was confirmed in travelers to Great Exuma, Bahamas, and Kingston, Jamaica, areas where malaria transmission typically does not occur. Dengue epidemics have occurred on many of the islands. Most islands are infested with Aedes aegypti, so these places are at risk for introduction of dengue. Lymphatic filariasis has a high prevalence in parts of Haiti; it is endemic in 9 of 13 municipalities in the Dominican Republic and Haiti. Spotted fever due to Rickettsia africae has been acquired in Guadeloupe. Transmission of cutaneous leishmaniasis occurs in the Dominican Republic.

Food-and waterborne infections: Risk of diarrheal illness varies greatly by island. Risk of diarrhea and hepatitis A is high, especially on the island of Hispaniola, where an outbreak of typhoid fever occurred in 2003. An outbreak of eosinophilic meningitis caused by Angiostrongylus can-tonensis occurred in travelers to Jamaica. Intestinal helminths are common in local populations on some islands but are rare in short-term travelers.

Airborne and person-to-person transmission: The annual incidence of tuberculosis is estimated to exceed 300 per 100,000 population in Haiti and is 50-100 per 100,000 population in the Dominican Republic. The rates are substantially lower on other islands.

Sexually transmitted and blood-borne infections: The prevalence of HIV infection is estimated to be 4.5% in Haiti (1.8%-7% in pregnant women) and greater than 2% in the Dominican Republic. The prevalence of chronic infection with hepatitis B is moderate (2%-7%) in Haiti and Dominican Republic, but <2% on most of the islands. Seroprevalence of HTLV-I/II is reported to be as high as 5%-14% on some islands.

Zoonotic infections: Anthrax is hyperendemic in Haiti but has not been reported on most of the other islands.

Soil-and water-associated infections: Cutaneous larva migrans is a risk for travelers with exposures on beaches. Endemic foci of histoplasmosis are found on many islands, and outbreaks have occurred in travelers. Lep-tospirosis is common in many areas and poses a risk to travelers engaged in recreational freshwater activities. Foci of schistosomiasis have been active in the past in the Dominican Republic, Puerto Rico, and other islands, but pose little risk to travelers.

Other hazards: Outbreaks of ciguatera poisoning, which results from eating toxin-containing reef fish have occurred on many islands. Injury from motor vehicle accidents (including from motorized scooters) is a risk for travelers. Screening of blood before transfusion is inadequate in hospitals on many islands.

TROPICAL SOUTH AMERICA

Countries: Brazil, Colombia, Ecuador, French Guiana, Galápagos Islands, Guyana, Paraguay, Peru, Suriname, Venezuela

More common infections in travelers include dengue, gastrointestinal infections, and malaria. Chronic or latent infections in immigrants (and long-term residents) include tuberculosis, schistosomiasis, leishmaniasis, Chagas’ disease, cysticercosis, and intestinal helminth infections, including strongyloidiasis.

Vector-borne infections: Malaria is widely distributed, but the risk to travelers is low in most areas. Vivax malaria predominates in many areas. Dengue outbreaks have increased in the past decade, and infections occur in travelers. Yellow fever causes sporadic cases and outbreaks. Cases have been reported since 2000 from Bolivia, Brazil, Colombia, Ecuador, Peru, and Venezuela. Aedes aegypti infests all these countries, including urban areas, placing them at risk for introduction of yellow fever (and dengue). Fatal yellow fever has occurred in unvaccinated travelers. Other vector-borne infections include rickettsial infections (murine typhus and spotted fever due to Rickett-sia rickettsii and R. felis), relapsing fever (the tick-borne form is widely distributed; the louse-borne form occurs primarily in the highlands of Bolivia and Peru), and Venezuelan encephalitis. Oropouche fever is a common arboviral infection, especially in the Amazon basin. Leishmaniasis has increased in recent years; foci of transmission of cutaneous leishmaniasis are found throughout the region; visceral leishmaniasis is found primarily in Brazil. American trypanosomiasis (Chagas’ disease) has been widespread in poor, rural areas, but transmission has been interrupted or slowed in many areas (e.g., Brazil) through eradication programs. Onchocerciasis is endemic in focal areas of Brazil, Colombia, Ecuador, and Venezuela; eradication efforts are in progress. Bartonellosis is found in the mountain valleys of Peru (largest endemic focus), Ecuador, and southwestern Colombia (at altitudes of 600-2800 meters). Lymphatic filariasis is endemic in Guyana and in focal areas of Brazil and in parts of northeastern South America. Myiasis occasionally occurs in travelers.

Food-and waterborne infections: Gastrointestinal infections in travelers are caused by bacteria, viruses, and parasites. Hepatitis A risk is widespread. Cholera was widespread in South America in the 1990s; only Brazil, Colombia, and Ecuador reported infections in 2005. Typhoid fever, brucellosis, and amebic liver abscesses are occasionally seen in travelers. Fascioliasis is highly endemic in some areas, especially in Bolivia, Ecuador, Peru, and Venezuela, but risk is low for the usual traveler. Paragonimiasis is endemic in Ecuador and Peru and occurs sporadically in other countries; infections are rare in the usual traveler.

Airborne and person-to-person transmission: The annual incidence rate of tuberculosis per 100,000 is estimated to be 100-300 in Peru, Ecuador, Bolivia, and Guyana and 50-100 or less in the rest of the region. Multi-drug resistance has been a problem, especially in Peru and Ecuador, where the rate of multidrug resistance is 3%-6% among new cases. Leprosy is highly endemic in some focal areas (e.g., high prevalence in the Amazon and parts of the Andes). Prevalence in Brazil was 46 per 100,000 population in 2004.

Sexually transmitted and blood-borne infections: Prevalence of HIV in adults is estimated to be 0.1% -<1% in most of the region, but the prevalence is higher in Guyana and Suriname (1%-<5%). The prevalence of chronic infection with hepatitis B exceeds 8% in Peru, northern Brazil, and southern Colombia and Venezuela and is 2%-7% in the rest of the region. Hepatitis D has caused epidemics of fulminant hepatitis in the Amazon Basin. HTLVI is found especially in areas adjacent to the Caribbean, including Colombia, Venezuela, Surinam, Guyana, and Brazi

Zoonotic infections: Rabies is found throughout the region; vampire bats transmit infection in some areas and have been responsible for outbreaks of human rabies in Peru, Venezuela, and Brazil. Hantavirus pulmonary syndrome caused by hantaviruses with rodent reservoirs has been documented in Bolivia, Brazil, and Paraguay; these viruses may be more widely distributed. Other rodent-associated viruses include Machupo virus, which causes sporadic infections in rural northeastern Bolivia, and Guanarito virus in Venezuela. Plague has been reported from Bolivia, Brazil, Ecuador, and Peru since 1990 (most cases are from Peru). Echinococcosis is endemic in cattle-grazing areas of Ecuador and other countries; the risk to travelers is low.

Soil-and water-associated infections: Endemic foci of schistosomiasis (Schistosoma mansoni) are found in Brazil, Venezuela, and Suriname. Buruli ulcer (Mycobacterium ulcerans) is endemic in French Guyana; a few cases have been reported from other countries (e.g., Peru and Suriname). Risk of leptospirosis is widespread in tropical areas; outbreaks have followed flooding. Histoplasmosis has been reported from all countries in the region, and paracoccidioidomycosis is endemic throughout the area, with the highest transmission in Peru, Ecuador, Colombia, and Brazil. Coccidioidomycosis is more focal in distribution with endemic areas in Brazil, Colombia, Paraguay, and Venezuela.

Other hazards: Venomous snake bites, injury from motor vehicle accidents, and high altitude-related illness in the Andes occur. Screening of blood before transfusion is inadequate in many hospitals.

TEMPERATE SOUTH AMERICA

Countries: Argentina, Chile, Easter Island, Falkland Islands, South Georgia, South Sandwich Islands, Uruguay, Bolivia

The overall risk for infections is low for most travelers to the area. Gastrointestinal infections are a risk, especially in rural areas. Chronic and latent infections in immigrants (and long-term residents) include cysticercosis, Chagas’ (from remote acquisition), echinococcosis, soil-associated fungal infections , and intestinal helminth infections.

Vector-borne infections: Limited areas of malaria risk are found in Argentina. Dengue outbreaks have occurred in Argentina since 1997, and Aedes aegypti infests the country as far south as Buenos Aires. An outbreak occurred on Easter Island (Chile) in 2002. Other vector-borne infections include bartonellosis (limited to the slopes of the Andes in Chile), tick-borne relapsing fever (reported from northern Argentina and Chile), murine typhus, and spotted fever due to Rickettsia rickettsii (reported from Argentina). Leishmaniasis (both cutaneous and mucocutaneous) is endemic in northern Argentina and may be present in Uruguay. Programs to eradicate American try-panosomiasis (Chagas’ disease) have reduced or interrupted active transmission in many areas.

Food- and water-borne infections: Risk of hepatitis A is moderate to high in parts of the region. Diarrhea in travelers is caused by bacteria, viruses, and parasites. Typhoid fever outbreaks have occurred in Chile in the past, and sporadic infections occur in the region. Typhoid fever, amebic abscesses, and brucellosis can be acquired by travelers. Fascioliasis occurs sporadically, but travelers are at low risk.

Airborne and person-to-person transmission: The annual incidence of tuberculosis is estimated to be 25-50 per 100,000 population in most of region, but lower in Chile. Influenza outbreaks peak in May-August.

Sexually transmitted and blood-borne infections: The estimated prevalence of HIV infection in adults is low (0.1%-<1%). Foci of high endemicity of HTLV-I are found in Argentina and Chile.

Zoonotic infections: Q fever (airborne spread) is common in areas where livestock are raised; frequent outbreaks have been noted in Uruguay. Rabies is present in the region. Anthrax is enzootic in Argentina. Sporadic cases of hantavirus pulmonary syndrome (Andes virus; rodent reservoir host) have been reported from Argentina and Chile. Argentine hemorrhagic fever caused by Junin virus (rodent reservoir) is found in an agricultural area of Argentina. Risk to travelers is low.

Soil- and water-associated infections: Histoplasmosis is endemic in Uruguay and parts of Venezuela. Coccidio-idomycosis is found in focal areas of Argentina and Chile; paracoccidioidomycosis is highly endemic in Uruguay and in parts of Argentina and sporadic elsewhere. Sporotricho-sis is highly endemic in Uruguay and sporadic elsewhere. Hookworm infections are endemic in warm, wet areas but are rare in travelers. Leptospirosis is a risk in warmer months.

Other hazards: Screening of blood prior to transfusion is inadequate in many hospitals.

EAST ASIA

Countries: China, Hong Kong SAR, Japan, Macau SARI, Mongolia, North Korea, South Korea, Taiwan

Risk of infection is highly variable in the region. Access to clean water and good sanitary facilities are limited in many rural areas, especially in China and Mongolia. Respiratory infections (etiology often undefined) are common in travelers to the region. Chronic and latent infections in immigrants (and long-term residents) include tuberculosis, complications from chronic hepatitis B (and also hepatitis C) infection, schistosomiasis, liver flukes, paragonimiasis (lung flukes), and strongyloidiasis.

Vector-borne infections: Malaria is found in focal areas of China and North and South Korea. Japanese encephalitis (JE) is found in wide areas of China and Japan and focally in Korea. Transmission of malaria and JE is seasonal in many areas. Reported infections in travelers are rare. Other vector-borne infections include dengue, which has caused outbreaks in mainland China, Hong Kong, and Taiwan; spotted fever caused by Rickettsia sibirica (China, Mongolia); murine typhus; Oriental spotted fever caused by R. japonica (Japan); rickettsialpox (Korea); scrub typhus (especially in China, Korea, and Japan); tick-borne encephalitis (in forested regions northeastern China and in South Korea); visceral and cutaneous leishmaniasis (in rural China); lymphatic filariasis (in focal coastal areas of China and South Korea); and Crimean-Congo hemorrhagic fever (in western China).

Food- and water-borne infections: Risk of diarrhea is highly variable within the region. Diarrhea in travelers may be caused by bacteria, viruses, and parasites. Risk of hepatitis A is high in some areas (excluding Japan), especially in rural areas of China and Mongolia. Outbreaks of hepatitis E have been reported in China. Cases of cholera were reported from China in 2004; most of the cases reported from Japan in 2004 were imported (55 of 66). Sporadic cases of anisakiasis are reported from Korea and Japan. Brucellosis is found, especially in sheep-raising regions of China and Mongolia (annual incidence >500 per 100,000 population in Mongolia). Paragonimiasis is endemic in China (an estimated 20 million are infected) and still occurs in Korea. Liver flukes (causing clonorchia-sis and fascioliasis) are endemic in the region (in 2004 the infected population in China was estimated to be 15 million), but risk to usual traveler is low.

Airborne and person-to-person transmission: The estimated annual incidence of tuberculosis per 100,000 population is 100-300 in China, Mongolia, and North Korea; 25-50 in Japan; and 50-100 in South Korea. High rates of multidrug-resistant tuberculosis are found in parts of China (3%-6% overall in new cases and as high as 10% in some areas). Outbreaks of SARS occurred in mainland China, Hong Kong, and Taiwan in 2003. Measles remains endemic in the region, and infection has occurred in adopted children from China and in travelers to the region. In tropical areas, influenza may occur during all months of the year.

Sexually transmitted and blood-borne infections: The prevalence of HIV in adults is low (0.1%-<0.5%) in most of the region, but a much higher prevalence is found in focal areas in southern China. Hepatitis B is highly endemic among adults in the region, excluding Japan. Prevalence of chronic infection exceeds 8% in many areas. Prevalence of hepatitis C is 10% or higher in Mongolia; 2.0%-2.9% in mainland China and Taiwan, and slightly lower in the rest of the region. A high prevalence of HTLV-I is found focally in the southern islands of Japan.

Zoonotic infections: Rabies is widespread in China (not Hong Kong) and Mongolia. In 2005, a reported 2545 people died from rabies in China; outbreaks in 2006 have led to mass killings of dogs. Rates of rabies vaccine coverage in pet dogs have been low. Highly pathogenic avian influenza (H5N1) continues to cause outbreaks in domestic and wild bird populations and has caused human cases and deaths in Hong Kong and China. Highly pathogenic H5N1 was also found in bird populations in Japan and South Korea in 2003-2004. Cases of human plague are reported most years from China and Mongolia. Hantaviruses causing hemorrhagic fever with renal syndrome are a major health threat in China and the Republic of Korea, primarily affecting residents of rural areas in late fall and early winter. Risk to the usual traveler is low. Anthrax is enzootic in China and Mongolia, and sporadic infection is reported in the rest of the region. Tularemia occurs in China and Japan and is found especially in northern parts of region. Echinococcosis is endemic in rural areas of China and Mongolia.

In 2005 a large outbreak of human Streptococcus infection caused 215 cases (66 laboratory confirmed) in Sichuan, China. Infection occurred in farmers ex-posed to backyard pigs during slaughter.

Soil-and water-associated infections: Schistosomiasis (Schistosoma japonicum) is present in focal areas in China, especially in the Yangtze River basin. An estimated 60 million people live in at-risk areas. Leptospirosis is a risk, especially in tropical areas of China and South Korea. Cutaneous larva migrans is common in warm coastal areas. Cases of histoplasmosis have been reported.

Other hazards: Injury from motor vehicle accidents and venomous snake bites occur. Screening of blood before transfusion is inadequate in many hospitals in the region.

SOUTHEAST ASIA

Countries: Brunei, Burma (Myanmar), Cambodia, Indonesia, Laos, Malaysia, Philippines, Singapore, Thailand, Timor-Leste (East Timor), Vietnam

More common infections in travelers to the area include dengue fever, respiratory infections, and diarrheal infections. Chronic and latent infections in immigrants (and long-term residents) include tuberculosis, late complications of hepatitis B infection, intestinal helminth infections (including strongyloidiasis), and other helminth infections, such as paragonimiasis, opisthorchiasis, and clonorchiasis.

Vector-borne infections: Dengue fever is hyperendemic in the region, and epidemics are common; cases occur in travelers to the region. Malaria is found in focal areas (primarily rural) in all these countries (except Brunei and Singapore), especially in rural areas. Japanese encephalitis is widely distributed in the region and is hyperendemic in some areas; risk is seasonal in some countries. Scrub typhus is a common cause of fever in the region. Other vector-borne infections include murine typhus, chikungunya virus, and relapsing fever. Foci of transmission of lymphatic filariasis are found throughout the area, with the exception of some of the Indonesian islands.

Food-and water-borne infections: Risk of hepatitis A is widespread in the region. Risk of diarrhea caused by bacteria, viruses, and parasites is high in parts of the area. An outbreak of polio (more than 300 virus-confirmed cases) occurred in Indonesia in 2005 after importation of the virus from Nigeria. Campylobacter infections are especially common in Thailand and are often resistant to fluo-roquinolones. Amebic liver abscesses, typhoid fever, and brucellosis occur. Isolates of Salmonella causing typhoid fever may be resistant to multiple drugs, including the flu-oroquinolones. Cholera epidemics have been common in the past; cases were reported from Cambodia, Malaysia, and the Philippines in 2004. Outbreaks of hepatitis E have been reported from the region (Indonesia and Burma). Cysticercosis is especially common in Indonesia. Gnathostomiasis is endemic in region and especially common in Thailand. Intestinal helminth infections are common in some rural areas; risk to the usual traveler is low. Opisthorchiasis, clonorchiasis, fasciolopsiasis, and paragonimiasis are endemic in parts of the region (especially Laos and Burma).

Airborne and person-to-person transmission: The annual incidence rate of tuberculosis per 100,000 population is estimated to be more than 300 in Cambodia and 100-300 in the rest of the region. Measles transmission persists in the region, although vaccination coverage is improving in some countries. SARS outbreaks occurred in the region (especially in Singapore and Vietnam) in 2003. Influenza infections can occur throughout the year in tropical areas.

Sexually transmitted and blood-borne infections: The prevalence of HIV in adults is 1%-<5% in Thailand, Burma (Myanmar), and Cambodia and <1% in the rest of the region. Higher prevalences may be found in specific populations. The prevalence of hepatitis B chronic carriage exceeds 8% in many parts of region. The prevalence of chronic hepatitis C is 1%-2.4%. Chancroid is a common cause of genital ulcer disease.

Zoonotic infections: Rabies is common in the region, and travelers are at risk for exposure to rabid animals, especially dogs. Highly pathogenic avian influenza (H5N1) has been found in poultry populations in most countries of the region. Human cases and deaths have been reported in Thailand, Vietnam, Indonesia, and Cambodia. In 2006, the virus continued to spread in poultry populations in Indonesia. Anthrax is hyperendemic in Burma; sporadic cases occur in much of the rest of the region. An outbreak of Nipah virus, with a probable reservoir in fruit bats and documented transmission to humans from pigs, occurred in Malaysia (1998–1999) and in Singapore (after contact with pigs imported from Malaysia). Cases of human plague have been reported since 1990 from Indonesia, Laos, Burma, and Vietnam.

Soil-and water-associated infections: Schistosomiasis caused by S. japonicum is found in the Philippines and Indonesia (Sulawesi [Celebes]); caused by S. mekongi in Cambodia and Laos; and caused by S. malayensis in peninsular Malaysia. Leptospirosis is common in tropical areas and has been reported in travelers to the area. Melioidosis is a common cause of community-acquired sepsis, especially in rural areas of Thailand; it is also common in Cambodia, Laos, and Vietnam. Cases have in-creased in 2004 in Singapore. Infection in travelers is rare. Penicilliosis marneffei is found in Southeast Asia and is a common opportunistic infection in HIV-infected patients, especially in Thailand. Rare cases have been reported in travelers to the region. Cutaneous larva migrans is common on warm coastal areas.

Other hazards: Snake bites and motor vehicle accidents occur. Screening of blood before transfusion is inadequate in many hospitals.

SOUTH ASIA

Countries: Afghanistan, Bangladesh, Bhutan, British Indian Ocean Territory, India, Maldives, Nepal, Pakistan, Sri Lanka

More common infections in travelers are gastrointestinal infections (including acute bacterial diarrhea and amebic disease), typhoid fever, and malaria. Chronic and latent infections in immigrants (or long-term residents) include tuberculosis, cysticercosis, visceral leishmaniasis, lymphatic filariasis, echinococcosis, and intestinal helminths. Primary varicella may be seen in adults, as childhood infection is less common in tropical areas.

Vector-borne infections: Malaria is widespread in areas at altitudes lower than 2000 meters and is found in the Terai and Hill districts of Nepal at altitudes lower than 1200 meters. Dengue fever has caused epidemics in all these countries except Nepal. Japanese encephalitis transmission occurs widely in lowland areas of the region (except for Afghanistan). Severe outbreaks occurred in India in 2005. Transmission is seasonal. Focal areas of transmission of visceral leishmaniasis are present in rural India, Pakistan, Nepal, and Bangladesh. Major epidemics of visceral leishmaniasis have occurred in eastern India (especially Assam and Bihar states). Cutaneous leishma-niasis is present in Afghanistan, (where it has infected US troops); India; and Pakistan. Lymphatic filariasis is endemic in large areas of India, Sri Lanka, and Bangladesh. Other vector-borne infections include scrub typhus, murine typhus, epidemic typhus (in remote, cooler areas), relapsing fever, sandfly fever, spotted fever due to R. conorii (especially in India), Kyasanur Forest disease (tick-borne; Karnataka State, India, and Pakistan), and Crimean-Congo hemorrhagic fever (in Pakistan and Afghanistan). In 2005–2006, an outbreak of chikungunya affected thousands of persons in India.

Food-and water-borne infections: Hepatitis A is widespread, and risk to travelers is high. Large outbreaks of hepatitis E have occurred in Bangladesh, India, Nepal, and Pakistan. Typhoid and paratyphoid fever (increasingly resistant to multiple antimicrobial agents) occur sporadically and in outbreaks and can affect travelers to the region. Amebic infections are common and can cause liver abscesses. Indigenous wild polio was present in 2005-2006 in India, Pakistan, and Afghanistan; cases from Bangladesh and Nepal were confirmed in 2005-2006. Cyclospora infections have been reported, especially from Nepal. Cholera outbreaks have occurred frequently in the region, especially in Bangladesh and India. Cysticercosis is found, especially in India. Paragonimiasis is endemic in India (Manipur province). Gnathostomiasis has caused sporadic cases and outbreaks.

Airborne and person-to-person: The annual incidence rates of tuberculosis per 100,000 population are estimated to be higher than 300 in Afghanistan and 100-300 in most of the rest of the region. Measles occurs in the region and can be a source of infection for unvaccinated travelers.

Sexually transmitted and blood-borne infections: The prevalence of HIV in adults is less than 1% in most of the region but is rising rapidly in some populations in India (seroprevalence higher than 5% in some antenatal clinics). The prevalence of chronic infection with hepatitis B is 2%-7% in most of the region.

Zoonotic infections: Rabies is common in the region and poses a risk to travelers. Q fever is widespread. Anthrax is endemic in much of the region, and cases occur sporadically. Plague is endemic in India, and outbreaks have occurred. Echinococcosis is highly endemic in focal rural areas. An outbreak of Nipah virus (encephalitis) occurred in Bangladesh in early 2004, and person-to-person spread may have occurred. Macaques throughout the region are infected with B virus (Herpes). Highly pathogenic avian influenza (H5N1) has been found in poultry populations in India and Pakistan.

Soil-and water-associated infections: Leptospirosis is common, especially in tropical areas.

Other hazards: There may be a risk for snake bites, injury from motor vehicle accidents, and injury related to ongoing conflicts. Screening of blood before transfusion is inadequate in many hospitals.

MIDDLE EAST

Countries: Bahrain, Cyprus, Iran, Iraq, Israel, Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, Syria, Turkey, United Arab Emirates, Yemen

Common infections in travelers are gastrointestinal infections. Chronic and latent infections in immigrants (and long-term residents) include tuberculosis, echinococcosis, cutaneous leishmaniasis, and brucellosis.

Vector-borne infections: Malaria is present in focal areas of Iran, Iraq, Oman, Saudi Arabia, Syria, Turkey, and Yemen. Epidemic dengue activity occurred in Saudi Arabia and Yemen in 2002. Cutaneous leishmaniasis is widespread and common, especially in countries bordering the Mediterranean.

Transmission of visceral leishmaniasis occurs focally in Turkey, Iraq, Saudi Arabia, and Syria. Other vector-borne infections include murine typhus, spotted fever due to R. conorii, tick-borne encephalitis (in Turkey), Crimean-Congo hemorrhagic fever (in Iran, Iraq, and the Arabian peninsula) (an outbreak occurred in Turkey in 2006), tick-borne relapsing fever, sandfly fever, and West Nile fever. Lymphatic filariasis and onchocerciasis are endemic in focal areas of Yemen.

Food- and water-borne infections: Risk of hepatitis A is high in many parts of the area; typhoid fever occurs sporadically and in outbreaks. Outbreaks of hepatitis E have been reported in Iran and Jordan. An outbreak of polio (478 virus-confirmed cases) occurred in Yemen in 2005 following importation of poliovirus from Nigeria. Cholera was reported from Iran and Iraq in 2004. Brucellosis is widespread and common in parts of the region.

Airborne and person-to-person transmission: Pilgrims to the Hajj (Saudi Arabia) have acquired meningococcal infections caused by serotypes A and W-135, as well as influenza infections. The annual incidence of tuberculosis per 100,000 population is estimated to be 100-300 in Iraq, 50-100 in Yemen and 25-50 in most of the rest of the region. Measles continues to be reported from the region.

Sexually transmitted and blood-borne infections: The prevalence of hepatitis B chronic infection is >8% in Saudi Arabia and 2%-7% in much of the rest of the region. The prevalence of HIV is estimated to be lower than 0.5% throughout the region.

Zoonotic infections: Anthrax is enzootic in Turkey, and sporadic cases occur in most of the region except for Oman. Rabies is widespread in the region. Endemic foci of plague have been identified in the region in the past. Q fever is common in most countries in the region. Echinococcosis is endemic in many rural areas. Outbreaks of oropharyngeal tularemia have been reported from Turkey. Brucellosis is common in Syria (annual incidence of >500 per 100,000 population) and has an incidence of 50-500 cases per 100,000 population in most of the rest of the region.

Highly pathogenic H5N1 influenza virus has been found in poultry in Turkey, Iraq, and Israel. Human cases and deaths were confirmed in Iraq and Turkey in 2006.

Soil-and water-associated infections: Schistosomiasis has been found in focal areas in Saudi Arabia, Yemen, Iraq, and Syria.

Other hazards: Motor vehicle accidents, intentional injuries, and injuries related to ongoing conflicts occur. Snake and scorpion bites are an additional hazard. Screening of blood before transfusion is inadequate in many hospitals.

WESTERN EUROPE

Countries: Andorra, Austria, Azores, Belgium, Denmark, Faroe Islands, Finland, France, Germany, Gibraltar, Greece, Greenland, Holy See, Iceland, Ireland, Italy, Liechtenstein, Luxembourg, Malta, Monaco, Netherlands, Norway, Portugal, San Marino, Spain, Sweden, Switzerland, United Kingdom

The area is characterized by a low risk for most infectious diseases.

Vector-borne infections: The only malaria cases are “airport” malaria and imported cases. Lyme disease is found in broad areas of Europe in temperate forested areas. Tick-borne encephalitis is found in Austria, Germany, Finland, Sweden, Switzerland, and Denmark (only on island of Bornholm); a few cases have also been reported from Italy, Norway, and France. Leishmaniasis (cutaneous and visceral) is found, especially in countries bordering the Mediterranean, with the highest numbers of cases from Spain, where it is an important opportunistic infection in HIV-infected persons.

Relapsing fever (tick-borne) is found in focal areas in Greece, Italy, Portugal, and Spain; sporadic cases may occur elsewhere in region. Murine typhus is more common in warmer areas, especially Mediterranean port cities. Sandfly fever occurs in warmer months in southern Europe, especially in Italy, Spain, Portugal, and Greece. Small numbers of cases of babesiosis have been reported from the region. A number of countries have reported imported cases of chikungunya fever in 2005-2006.

Food-and water-borne infections: Risk of hepatitis A is low (except for Greenland). Outbreaks of salmonellosis, campylobacteriosis, and other food-and water-borne infections occur, but the risk of diarrhea in travelers is low. Brucellosis is found, especially in southern countries on the Mediterranean. Variant Creutzfeldt-Jacob cases have been reported primarily from the United Kingdom, although a few cases have been reported from other countries. Large outbreaks of trichinosis have occurred; outbreaks in France have been linked to horse meat.

Airborne and person-to-person transmission: Measles transmission has been slowed by vaccination programs. The annual incidence rate of tuberculosis per 100,000 population is estimated to be 10-50 for most of the region and less than 10 in Norway and Sweden.

Sexually transmitted and blood-borne infections: The prevalence of HIV in adults is estimated to be 0.3% in this region.

Zoonotic infections: Large outbreaks of tularemia have occurred in rural areas in several of these countries, including Sweden, Finland, and Spain. Hantaviruses causing hemorrhagic fever with renal syndrome are wide-spread; Puumala virus, the cause of mild nephropathia epidemica, is found in Scandinavian and western European countries. Rabies is present in many countries in western Europe; human cases are rare. Echinococcosis due to Echinococcus granulosus is found, especially in Spain and the Mediterranean countries; areas with alveolar echi-nococcosis (caused by E. multilocularis) have expanded in recent years, with the largest number of cases found in focal areas of France, Germany, and Switzerland. Q fever (airborne spread) is a common cause of febrile illness (both sporadic cases and outbreaks), especially in rural areas of Spain, southern France, and other Mediterranean countries. Highly pathogenic avian influenza virus H5N1 has been documented in wild birds or other avian species in many of the countries (at least 10 by August 2006). No human cases have been documented in this region as of fall 2006.

Soil-and water-associated infections: Legionnaires’ disease is sporadic; some outbreaks have involved tourists at resort hotels.

EASTERN EUROPE AND NORTHERN ASIA

Countries: Albania, Armenia, Azerbaijan, Belarus, Bosnia and Herzegovina, Bulgaria, Croatia, Czech Republic, Estonia, Georgia, Hungary, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, Macedonia, Moldova, Montenegro, Poland, Romania, Russia, Serbia, Slovakia, Slovenia, Tajikistan, Turkmenistan, Ukraine, Uzbekistan

Access to clean water and adequate levels of sanitation are limited in many parts of the region. Vaccine-preventable diseases remain a problem where levels of immunization are low. The public health infrastructure has deteriorated in areas of conflict; political instability has threatened health in some areas. Common infections in travelers include gastrointestinal infections, respiratory infections, and occasionally vector-borne infections. Chronic and latent infections immigrants (and long-term residents) include tuberculosis (including multidrug-resistant TB) and late sequelae of hepatitis B.

Vector-borne infections: Malaria transmission occurs seasonally in focal rural areas of countries in the southern-most part of the region (Azerbaijan, Georgia, Armenia, Tajikistan, Turkmenistan, and Uzbekistan). Tick-borne encephalitis is wide-spread, occurring in warmer months in the southern part of the nontropical forested regions of Europe and Asia. Most intense transmission has been reported in Russia, the Czech Republic, Latvia, Lithuania, Estonia, Hungary, Poland, and Slovenia. Other vector-borne infections include murine typhus, scrub typhus, spotted fever due to Rickettsia sibirica (North Asian spotted fever), rickettsialpox, relapsing fever (more southern parts of region), Crimean-Congo hemorrhagic fever (in many countries of the region but primarily in persons working with animals or in hospitals), leishmaniasis (cutaneous and visceral, especially in the southern areas of the former Soviet Union), Lyme disease (throughout the former Soviet Union), sandfly fever (in the southern parts of region), West Nile (a large outbreak occurred in Romania in late 1990s), and Japanese encephalitis (transmission occurs in a limited area of far eastern Russia).

Food-and water-borne infections: A high risk of hepatitis A is present in many parts of the region. Sporadic cases of typhoid fever are reported, and outbreaks occur. Outbreaks of hepatitis E have been reported from the southern areas of Russia. Brucellosis is a risk in many areas (annual incidence 50-500 cases per 100,000 population in many parts of the region). Outbreaks of botulism are usually linked to home canned foods. Sporadic cases of fascioliasis occur. A population of 12.5 million is estimated to be at risk for opisthorchiasis in the region (especially Kazakhstan, Russian Federation, Siberia, and Ukraine).

Airborne and person-to-person transmission: The annual incidence rate of tuberculosis per 100,000 population is estimated to be as high as 100-300 in parts of the region. High rates of drug-resistant TB are found in Estonia, Kazakhstan, Latvia, Lithuania, parts of Russia, and Uzbekistan, where rates of drug resistance in newly diagnosed TB patients are as high as 14%. Cases of diphtheria have declined (after the massive outbreak of the 1990s) with improved rates of immunization. Transmission of measles is declining.

Sexually transmitted and blood-borne infections: The prevalence of HIV in adults is estimated to be 1%-<5% in many parts of the region. It has increased rapidly in parts of the Russian Federation; seroprevalence in prison populations is 2-4%. The prevalence of hepatitis B is intermediate (2%-7%) or high (more than 8%) in most of the region. The prevalence of hepatitis C is 1%-2.4% in much of the area (2.5%-9.9% in Romania).

Zoonotic infections: Rabies is widespread in the region and is increasing in some countries. Tularemia is widespread and occurs in focal outbreaks. Wild rodent plague is broadly distributed in southern areas of the former Soviet Union; human cases are rare. Sporadic cases and occasional outbreaks of anthrax are reported. Q fever is found, especially in cattle-raising areas. Hantaviruses causing hemorrhagic fever with renal syndrome are found in many countries in the region; infection is sporadic and epidemic. Echinococcosis occurs sporadically in the area. Highly pathogenic avian influenza virus H5N1 has been documented in wild birds or other avian species in many of the countries (at least 10 by fall 2006). Human cases and deaths were reported from Azerbaijan in 2006.

Soil- and water-associated infections: No endemic transmission of cholera was reported in 2004.

Other hazards: Motor vehicle accidents and injuries related to ongoing conflicts and alcohol abuse occur. Noso-comial transmission of infections is a problem in many areas because of inadequate infection control procedures. Screening of blood before transfusion is inadequate in many hospitals.

AUSTRALIA AND THE SOUTH AND WESTERN PACIFIC

Countries: American Samoa, Australia, Christmas Island, Cocos (Keeling) Islands, Cook Islands, Fiji, French Polynesia, Guam, Kiribati, Marshall Islands, Micronesia, Nauru, New Caledonia, New Zealand, Niue, Norfolk Island, Northern Mariana Islands, Palau, Papua New Guinea, Pitcairn Islands, Samoa, Solomon Islands, Tahiti, Tokelau, Tonga, Tuvalu, Vanuatu, Wake Island, Wallis and Futuna

Risk of infection is highly variable within the region. The risk of food and water-borne infections is low in most of Australia and New Zealand; immunization coverage is also generally high in those countries. Vector-borne infections and gastrointestinal infections are common in travelers to other islands.

Vector-borne infections: Malaria is transmitted on Papua New Guinea, Vanuatu, and the Solomon Islands. Dengue has caused recurring epidemics on many of the islands and in northern Australia. Japanese encephalitis (JE) is found in Papua New Guinea and the Torres Strait and far northern Australia. JE infections have occurred in the western Pacific islands (e.g., Guam). Lymphatic filari-asis is widely distributed on many of the Pacific islands, including American Samoa, Cook Islands, Fiji, French Polynesia, Kiribati, Niue, Samoa, Tonga, Tuvalu, Vanuatu, and Wallis and Futuna. Other vector-borne infections include scrub typhus (in northern Australia and Papua New Guinea and on some of the western and southern islands), murine typhus, spotted fever due to Rickettsia australis (Queensland tick typhus), and Murray Valley encephalitis (recurring epidemics are re-ported, especially in southeastern Australia; rare cases occur in Papua New Guinea). Ross River fever (epidemic polyarthritis) causes sporadic cases and outbreaks in Australia and on a number of the Pacific islands.

Food- and water-borne infections: Risk of hepatitis A is high on many of the Pacific islands. Gastrointestinal infections due to bacteria, viruses, and parasites (including Entamoeba histolytica) have been common on some of the islands, including Papua New Guinea. Typhoid fever is uncommon in Australia; outbreaks have occurred on some of the islands. Cases of eosinophilic meningitis due to Angiostrongylus cantonensis have been reported from many of the islands. Occasional cases of cholera occur in Australia.

Airborne and person-to-person transmission: The annual incidence of tuberculosis per 100,000 population is estimated to be 100-300 for the Pacific islands, and 0-25 for the rest of the region. The influenza transmission season in Australia typically occurs April through September. Periodic outbreaks of measles have occurred on islands with inadequate immunization coverage.

Sexually transmitted and blood-borne infections: The prevalence of HIV in adults is 0.1%-<0.5% in most of the region; it is higher (1%-<5%) in Papua New Guinea and some of the Pacific islands. The prevalence of chronic infection with hepatitis B is 8% on many of the Pacific islands. The prevalence of hepatitis C is 1%-2.4% in most of the area.

Zoonotic infections: Sporadic cases and outbreaks of Q fever occur in Australia (rarely in New Zealand). Most of the islands are reported to be rabies free, although bat rabies exists in some of these areas. Fatal cases of Hendra virus (closely related to Nipah virus) infection occurred in Australia in 1994. Fruit bats, widely distributed in Australia and the South Pacific, may be the natural host.

Soil- and water-associated infections: Buruli ulcer (caused by Mycobacterium ulcerans) increased in incidence in Australia in the 1990s, with the development of new foci on Phillip Island and in a district southwest of Melbourne. Most cases are in Victoria and Queensland. Cases of melioidosis have been reported from Papua New Guinea, Guam, and Australia; risk may exist on other islands. Leptospirosis is common on some of the islands. Sporadic cases of histoplasmosis have been documented. Hookworm infections and strongyloidiasis are common on some of the Pacific Islands.

Other hazards: High attack rates of ciguatera poisoning from eating large reef-dwelling fish have been reported on some of the islands. Venomous snakes and spiders are a risk in many areas. Screening of blood before transfusion is inadequate in hospitals on many of the islands.