Travelers' diarrhea is the most common travel-related ailment. The cornerstone of prevention is food and water precautions, as outlined below. All travelers should bring along an antibiotic and an antidiarrheal drug to be started promptly if significant diarrhea occurs, defined as three or more loose stools in an 8-hour period or five or more loose stools in a 24-hour period, especially if associated with nausea, vomiting, cramps, fever or blood in the stool. A quinolone antibiotic is usually prescribed: either ciprofloxacin (Cipro)(PDF) 500 mg twice daily or levofloxacin (Levaquin) (PDF) 500 mg once daily for a total of three days. Quinolones are generally well-tolerated, but occasionally cause sun sensitivity and should not be given to children, pregnant women, or anyone with a history of quinolone allergy. Alternative regimens include a three day course of rifaximin (Xifaxan) 200 mg three times daily or azithromycin (Zithromax) 500 mg once daily. Rifaximin should not be used by those with fever or bloody stools and is not approved for pregnant women or those under age 12. Azithromycin should be avoided in those allergic to erythromycin or related antibiotics. An antidiarrheal drug such as loperamide (Imodium) or diphenoxylate (Lomotil) should be taken as needed to slow the frequency of stools, but not enough to stop the bowel movements completely. Diphenoxylate (Lomotil) and loperamide (Imodium) should not be given to children under age two.

Most cases of travelers' diarrhea are mild and do not require either antibiotics or antidiarrheal drugs. Adequate fluid intake is essential.

If diarrhea is severe or bloody, or if fever occurs with shaking chills, or if abdominal pain becomes marked, or if diarrhea persists for more than 72 hours, medical attention should be sought.

Though effective, antibiotics are not recommended prophylactically (i.e. to prevent diarrhea before it occurs) because of the risk of adverse effects, though this approach may be warranted in special situations, such as immunocompromised travelers.

Malaria in China: prophylaxis is recommended for travel to rural areas of the following provinces: Hainan, Yunnan, Fuijan, Guangdong, Guangxi, Guizhou, Sichuan, Tibet (Xizang) (in the Zangbo River valley only), Anhui, Hubei, Hunan, Jiangsu, Jiangxi, Shandong, and Shanghai. In these provinces, malaria transmission occurs only in rural communities at altitudes less than 1500 meter, and only during warm weather: north of latitude 33° N, July-November; between latitude 25° N and 33° N, May-December; south of latitude 25° N, throughout the year. Prophylaxis is not necessary for cities and popular tourist areas, including Yangtze River cruises.

For prophylaxis in the southern provinces of Hainan and Yunnan, either mefloquine (Lariam), atovaquone/proguanil (Malarone)(PDF), or doxycycline may be given. Mefloquine is taken once weekly in a dosage of 250 mg, starting one-to-two weeks before arrival and continuing through the trip and for four weeks after departure. Mefloquine may cause mild neuropsychiatric symptoms, including nausea, vomiting, dizziness, insomnia, and nightmares. Rarely, severe reactions occur, including depression, anxiety, psychosis, hallucinations, and seizures. Mefloquine should not be given to anyone with a history of seizures, psychiatric illness, cardiac conduction disorders, or allergy to quinine or quinidine. Those taking mefloquine (Lariam) should read the Lariam Medication Guide (PDF). Atovaquone/proguanil (Malarone) is a recently approved combination pill taken once daily with food starting two days before arrival and continuing through the trip and for seven days after departure. Side-effects, which are typically mild, may include abdominal pain, nausea, vomiting, headache, diarrhea, or dizziness. Serious adverse reactions are rare. Doxycycline is effective, but may cause an exaggerated sunburn reaction, which limits its usefulness in the tropics.

For prophylaxis in the other provinces reporting malaria, the drug of choice is chloroquine. The usual dosage is 500 mg once weekly, starting one-to-two weeks before arrival and continuing through the trip and for four weeks after departure. Chloroquine may cause mild adverse reactions, including gastrointestinal disturbance, headache, dizziness, blurred vision, and itching, but severe reactions are uncommon.

Long-term travelers who may not have access to medical care should bring along medications for emergency self-treatment should they develop symptoms suggestive of malaria, such as fever, chills, headaches, and muscle aches, and cannot obtain medical care within 24 hours. See malaria for details. Symptoms of malaria sometimes do not occur for months or even years after exposure.

Insect protection measures are essential.

For further information on malaria in China, including maps showing the risk of malaria in different parts of the country, go to the World Health Organization - Western Pacific Region and the World Health Organization.

Altitude sickness may occur in travelers who ascend rapidly to altitudes greater than 2500 meters. Most roads and towns in Tibet, Qinghai, parts of Xinjiang, and western Sichuan are at altitudes over 3000 meters. Acetazolamide is the drug of choice to prevent altitude sickness. The usual dosage is 125 or 250 mg two or three times daily starting 24 hours before ascent and continuing for 48 hours after arrival at altitude. Possible side-effects include increased urinary volume, numbness, tingling, nausea, drowsiness, myopia and temporary impotence. Acetazolamide should not be given to pregnant women or those with a history of sulfa allergy. For those who cannot tolerate acetazolamide, the preferred alternative is dexamethasone 4 mg taken four times daily. Unlike acetazolamide, dexamethasone must be tapered gradually upon arrival at altitude, since there is a risk that altitude sickness will occur as the dosage is reduced.

Travel to high altitudes is not generally recommended for those with a history of heart disease, lung disease, or sickle cell disease.

Hepatitis A vaccine is recommended for all travelers over one year of age. It should be given at least two weeks (preferably four weeks or more) before departure. A booster should be given 6-12 months later to confer long-term immunity. Two vaccines are currently available in the United States: VAQTA (Merck and Co., Inc.) (PDF) and Havrix (GlaxoSmithKline) (PDF). Both are well-tolerated. Side-effects, which are generally mild, may include soreness at the injection site, headache, and malaise.

Certain lots of VAQTA were recalled in December 2001 because some prefilled syringes were found not to contain enough antigen. Those who received VAQTA between August 1999 and December 2001 should go to hepatitis A to determine whether or not they may require reimmunization.

Travelers who are less than one year of age, are pregnant, or have less than two weeks before departure should receive a single intramuscular dose of gammaglobulin (see hepatitis A for dosage) instead of vaccine.

Typhoid vaccine is recommended for all travelers, with the exception of short-term visitors who restrict their meals to major restaurants and hotels, such as business travelers and cruise passengers. It is generally given in an oral form (Vivotif Berna) consisting of four capsules taken on alternate days until completed. The capsules should be kept refrigerated and taken with cool liquid. Side-effects are uncommon and may include abdominal discomfort, nausea, rash or hives. The alternative is an injectable polysaccharide vaccine (Typhim Vi; Aventis Pasteur Inc.) (PDF), given as a single dose. Adverse reactions, which are uncommon, may include discomfort at the injection site, fever and headache. The oral vaccine is approved for travelers at least six years old, whereas the injectable vaccine is approved for those over age two. There are no data concerning the safety of typhoid vaccine during pregnancy. The injectable vaccine (Typhim Vi) is probably preferable to the oral vaccine in pregnant and immunocompromised travelers.

Meningococcal vaccine is recommended for all travelers to Anhui Province, due to a recent outbreak there (see "Recent outbreaks" below). Meningococcal vaccine has few side-effects. Mild redness at the injection site may occur. Young children may develop transient fever.

Japanese encephalitis vaccine is recommended for long-term (1 month) travelers to rural areas or travelers who may engage in extensive unprotected outdoor activities in rural areas, especially in the evening, during shorter trips. At the present time, it should also be considered for any travelers to Henan, Shaanxi, and Shanxi provinces, including Yunching City (see "Recent outbreaks" below). Japanese encephalitis has been reported from all provinces except Xizang (Tibet), Xinjiang, and Qinghai. It is especially prevalent in southern China (an outbreak was reported from Guangdong Province in June 2003). Transmission is from May to September in the north and April to October in the south.

The vaccine (JE-VAX; Aventis Pasteur Inc.) (PDF) is given as a series of three injections on days 0, 7 and 30. If time is short, the third dose may be given on day 14. Mild side effects including fever, headache, muscle aches, malaise and soreness at the injection site occur in about 20% of those vaccinated. Serious allergic reactions including urticaria, angioedema, respiratory distress and anaphylaxis occur in approximately 0.6% of vaccinees and may occur as long as one week after vaccination. Any person who receives the vaccine should be observed in the doctor's office for at least 30 minutes following the injection and should complete the full series at least 10 days before departure. There are no data concerning the safety of Japanese encephalitis vaccine during pregnancy.

Hepatitis B vaccine is recommended for travelers who will have intimate contact with local residents or potentially need blood transfusions or injections while abroad, especially if visiting for more than six months. It is also recommended for all health care personnel. Two vaccines are currently licensed in the United States: Recombivax HB (Merck and Co., Inc.) (PDF) and Engerix-B (GlaxoSmithKline) (PDF). A full series consists of three intramuscular doses given at 0, 1 and 6 months. Engerix-B is also approved for administration at 0, 1, 2, and 12 months, which may be appropriate for travelers departing in less than 6 months. Side-effects are generally mild and may include discomfort at the injection site and low-grade fever. Severe allergic reactions (anaphylaxis) occur rarely.

Rabies vaccine is recommended only for those at high risk for animal bites, such as veterinarians and animal handlers, and for long-term travelers who may have contact with animals and may not have access to medical care. In China, most cases are related to dog bites; a majority are reported from five southern provinces: Guangxi, Hunan, Jiangxi, Guangdong, and Jiangsu (see Emerging Infectious Diseases). A complete preexposure series consists of three doses of vaccine injected into the deltoid muscle on days 0, 7, and 21 or 28. Side-effects may include pain at the injection site, headache, nausea, abdominal pain, muscle aches, dizziness, or allergic reactions.

Any animal bite or scratch should be thoroughly cleaned with large amounts of soap and water and local health authorities should be contacted immediately for possible post-exposure treatment, whether or not the person has been immunized against rabies.

All travelers should be up-to-date on routine immunizations, including

• Tetanus-diphtheria vaccine (recommended for all travelers who have not received a tetanus-diphtheria immunization within the last 10 years.)
• Measles vaccine (recommended for any traveler born after 1956 who does not have either a history of two documented measles immunizations or a blood test showing immunity. Many adults who had only one vaccination show immunity when tested and do not need the second vaccination. Measles vaccine should not be given to pregnant or severely immunocompromised individuals.)
• Varicella (chickenpox) vaccine (recommended for any international traveler over one year of age who does not have either a history of documented chickenpox or a blood test showing immunity. Many people who believe they never had chickenpox show immunity when tested and do not need the vaccine. Varicella vaccine should not be given to pregnant or immunocompromised individuals.)

Polio vaccine is not recommended for any adult traveler who completed the recommended childhood immunizations. In October 2000, the World Health Organization certified that polio had been eradicated from the Western Pacific region, including China. Polio transmission in China appears to have been interrupted since 1994, except for an isolated case reported from Geizi Township, Xunhua County, Haidong Prefecture, Qinghai Province in October 1999. Analysis of the virus recovered from this patient suggests that it was imported from a neighboring country, probably India. No further cases have been reported. (See MMWR for details.)

Cholera vaccine is not generally recommended, even though cholera occurs in China, because most travelers are at low risk for infection. The only cholera vaccine approved for use in the United States has low efficacy and a high incidence of adverse reactions, and is no longer being manufactured or sold. Two oral vaccines have recently been developed but are not yet approved in the United States (see cholera). These vaccines, where available, may be considered for certain high-risk individuals, such as relief workers or health professionals.

Yellow fever vaccine is required for all travelers arriving from a yellow-fever-infected country in Africa or the Americas, but is not recommended or required otherwise. Yellow fever vaccine (YF-VAX; Aventis Pasteur Inc.) (PDF) must be administered at an approved yellow fever vaccination center, which will give each vaccinee a fully validated International Certificate of Vaccination. Yellow fever vaccine should not in general be given to those who are younger than nine months of age, pregnant, immunocompromised, or allergic to eggs. It should also not be given to those with a history of thymus disease or thymectomy.

An outbreak of hand, foot, and mouth disease was reported in April 2008, resulting in more than 24,000 cases and at least 34 deaths as of May 8, chiefly among infants and young children. The outbreak started in Fuyang City in Anhui Province and spread to many other provinces, including Hubei, Guangdong, Guangxi, Hainan, Hunan, Shandong, and Zhejiang. The outbreak was caused by enterovirus 71 (see the World Health Organization and ProMED-mail). In May 2007, an outbreak of hand, foot, and mouth disease occurred in Linyi city in Shandong province, causing at least three deaths (see ProMED-mail, May 27, 2007). Hand, foot, and mouth disease is characterized by fever, oral blisters, and a rash or blisters on the palms and soles, usually occurring in young children. Most cases resolve uneventfully, but a small percentage are complicated by encephalitis (inflammation of the brain), myocarditis (inflammation of the heart muscle), or pulmonary edema (fluid in the lungs). The disease is caused by enteroviruses, which are transmitted by exposure to fecal material from infected individuals. There is no vaccine. The key to prevention is good personal hygiene and scrupulous hand-washing, especially after defecation and before handling food. No travel restrictions are recommended.

A measles outbreak was reported from the Xinjiang Uygur Autonomous Region in February 2008, killing ten people. Most cases occurred in those under age four. The number of measles cases in China has been rising since 1995, reaching an incidence of 10 per 100,000 in 2005. A total of 3650 cases were reported from the city of Guangzhou in southern China during the first 11 months of 2006, the highest number for the that period over the past 20 years. Most of the cases occurred in preschool children (ProMED-mail; January 11, 2007). All travelers born after 1956 should make sure they have had either two documented measles immunizations or a blood test showing measles immunity. This does not apply to people born before 1957, who are presumed to be immune to measles. Although measles immunization is usually begun at age 12 months, children between the ages of 6 and 11 months should be given an initial dose of MMR vaccine before traveling to China.

An increased number of cases of rabies is being reported from China, especially the southern province of Guangdong. Most cases are related to dog bites. In the year 2006, a total of 3215 people died from rabies. In 2007, more than 200 fatalites are being reported each month. The rise appears to be related to the increased popularity of keeping dogs as pets, as well as a failure to seek treatment after a dog bite. See NATHNAC, ProMED-mail (October 10, 2006, and June 12 and July 25, 2007) and AlertNet for further information. Most travelers are at low risk for rabies. Rabies vaccine is recommended only for those at high risk for animal bites, such as veterinarians and animal handlers, and for long-term travelers who may have contact with animals and may not have access to medical care.

A total of 30 human cases of H5N1 avian influenza ("bird flu") have been reported from China since November 2005 (six from Anhui Province, four from Fujian and Hunan Provinces, three from Sichuan and Guangdong Provinces, two each from Guangxi and Jiangsu Provinces, one each from Shanghai and Beijing, and one each from Jiangxi, Hubie, Liaoning, and Xinjiang Uygur Provinces). Twenty of the cases were fatal. Since January 2004, outbreaks of avian influenza have been reported from poultry farms in many parts of the country, including the provinces of Guangxi, Hunan, Hubei, Gansu, Shaanxi, Anhui, Shanghai, Guangdong, Zhejiang, Yunnan, Henan, Jiangxi, and Xinjiang Uygar Autonomous Region. The most recent poultry outbreaks were reported from the Changsha region of Hunan in August 2006, from the Ningxia Hui region and neighbouring Inner Mongolia in October 2006, from Tibet in March 2007, from Guangdong Province in September 2007, from the Xinjiang region and southwestern Tibet in January 2008, from the southwestern province of Guizhou in February 2008, and from Guangdong province in March 2008. The live poultry markets in Beijing have been permanently closed.

Most travelers are at extremely low risk for avian influenza, since almost all human cases have occurred in those who have had direct contact with live, infected poultry, or sustained, intimate contact with family members suffering from the disease. The World Health Organization and the Centers for Disease Control do not advise against travel to countries affected by avian influenza, but recommend that travelers should avoid exposure to live poultry, including visits to poultry farms and open markets with live birds; should not touch any surfaces that might be contaminated with feces from poultry or other animals; and should make sure all poultry and egg products are thoroughly cooked. A vaccine for avian influenza was recently approved by the U.S. Food and Drug Administration (FDA), but produces adequate antibody levels in fewer than half of recipients and is not commercially available. The vaccines for human influenza do not protect against avian influenza. Anyone who develops fever and flu-like symptoms after travel to China should seek immediate medical attention, which may include testing for avian influenza. For further information, go to the World Health Organization, Health Canada, the Centers for Disease Control, and ProMED-mail.

A malaria outbreak was reported from Anhui province in September 2006, resulting in almost 18,000 cases as of September 25 (see ProMED-mail, October 5, 2006). To lower the risk of malaria, a weekly dose of chloroquine is recommended for all travelers to Anhui province during the warm weather months. Insect protections measures, as below, are also advised.

An outbreak of dengue fever was reported in September 2006 from Guangdong Province, in the southern part of the country (see ProMED-mail, Sept. 12 and Oct. 24, 2006). Dengue fever is a flu-like illness, sometimes complicated by hemorrhage or shock, transmitted by Aedes mosquitoes, which bite primarily in the daytime and favor densely populated areas, though they also inhabit rural environments. Outbreaks are periodically reported from China, chiefly the provinces of Guangdong, Guangxi, Hainan and Yunnan in the southern part of the country. No vaccine is available at this time. Insect protection measures are strongly advised, as outlined below. For further information on dengue in China, go to the World Health Organization - Western Pacific Region.

Outbreaks of Japanese encephalitis were reported in August 2006 from the provinces of Henan, Shaanxi, and Shanxi (including Yuncheng City), which share borders in the central part of China (see ProMED-mail). Japanese encephalitis is a life-threatening viral infection which is transmitted by Culex mosquitoes, usually in rural areas. Most infections are asymptomatic, but the virus may spread to the brain, which is frequently fatal. Those who survive may show evidence of mental retardation or other neurological deficits. Japanese encephalitis vaccine is recommended for long-term (1 month) travelers to rural areas or travelers who may engage in extensive unprotected outdoor activities in rural areas, especially in the evening, during shorter trips. At the present time, it should also be considered for any travelers to Henan, Shaanxi, and Shanxi provinces, including Yunching City.

An outbreak of Angiostrongylus meningitis was reported from Beijing in August 2006, caused by undercooked snails. A total of 132 cases were identified, none of them fatal. For further information, go to ProMED-mail (August 23 and October 1, 2006). Angiostrongylus lives as a parasite in a variety of snails and slugs. The symptoms of Angiostrongylus meningitis include fever, headache, stiff neck, and light sensitivity. In most cases, recovery is slow but uneventful. There is no treatment. Snails should never be consumed unless fully cooked.

A cholera outbreak was reported from Zhejiang Province in the eastern part of the country in September 2005, resulting in 184 cases, none of them fatal. The outbreak was controlled within several weeks. Cases were also reported from Fujian Province. In 2001, a cholera outbreak occurred in Guandong Province, resulting in 105 cases and no fatalities. Most travelers are at extremely low risk for infection. Cholera vaccine, where available, is recommended only for certain high-risk individuals, such as relief workers, health professionals, and those traveling to remote areas where cholera epidemics are occurring and there is limited access to medical care. All travelers should carefully observe food and water precautions, as below.

An outbreak of Streptococcus suis infections was reported in July-August 2005 from Sichuan Province, related to a concurrent outbreak in the pig population. A total of 204 human cases were identified, 38 of them fatal, before the outbreak was controlled in August. Most human cases occurred in adult male farmers or butchers who had direct contact with diseased or dead pigs. Symptoms included high fever, malaise, nausea, and vomiting, followed in severe cases by meningitis, subcutaneous hemorrhage, toxic shock, and coma. The incubation period was short and the disease progressed rapidly. There has been no evidence of person-to-person transmission. No travel restrictions are recommended for China at this time. However, travelers should avoid visiting pig farms in Sichuan Province and should make sure all pork products are thoroughly cooked before consumption. For further information, go to the World Health Organization and ProMED-mail.

An outbreak of meningococcal disease was reported in January 2005 from 11 cities in Anhui Province in eastern China. Most cases occurred in students 13-18 years of age. A smaller number of cases were reported from the provinces of Henan, Hebei, Jiangsu, and Xichuan. The outbreak appeared to have ended by August 2005. Meningococcal vaccine is longer recommended for travelers to China. For further information, go to Health Canada and the National Travel Health Network and Centre (U.K.).

A fresh outbreak of severe acute respiratory syndrome (SARS) was reported from China in April 2004, resulting in nine new cases (seven in Beijing and two in Anhui Province) before the outbreak was declared over in May. Two of those affected were laboratory workers who had been performing research on the SARS virus at the National Institute of Virology. All the others either had close contact with one of the laboratory workers or with a nurse who became ill after caring for one of the researchers. No travel restrictions are recommended for China at this time. For further information, go to the World Health Organization.

The initial SARS outbreak began in Guangdong province in November 2002 and ultimately spread to many other areas, resulting in 5327 cases and 349 deaths before the outbreak was terminated in July 2003 by an aggressive program of contact identification and quarantine. In December 2003, a new case of SARS was reported from Guangdong province, followed in January 2004 by three more cases. All contacts of these patients were promptly quarantined and remained disease-free. No further cases were reported until April 2004, as described above.

The disease appears to be caused by a previously unknown virus belonging to the coronavirus family. The incubation period usually ranges from two-to-seven days, but may be as long as ten days. The first symptom is usually fever, often accompanied by chills, headache, body aches, and malaise. This is typically followed by dry cough and difficulty breathing, at times severe enough to require intubation and mechanical ventilation. The most recent analysis indicates that the overall fatality rate is approximately 15%, ranging from less than 1% in those younger than 25 years old to greater than 50% in those aged 65 years or older.

For further information, go to the SARS pages of the World Health Organization, the Centers for Disease Control, and Health Canada.

An outbreak of measles was reported in April 2004 among children in the United States and Norway who had been adopted in China. A total of 14 cases (ten in the United States and four in Norway) were identified before the outbreak ended. The cases were all traced to a single orphanage, the Zhuzhou Child Welfare Institute in Hunan Province, where a measles outbreak was in progress. On June 2, 2004, the Centers for Disease Control announced that the measles outbreak had been terminated and that adoptions from the orphanage could be resumed. See the Centers for Disease Control for further information. All those who are traveling abroad to adopt children should make sure they have had two documented measles immunizations or a blood test showing measles immunity. This does not apply to people born before 1956, who are presumed to be immune to measles.

An epidemic of hand, foot, and mouth disease complicated by meningitis, encephalitis and acute flaccid paralysis was reported from April through July 1998. The outbreak appeared to have been caused by enterovirus 71. Milder outbreaks of hand, foot, and mouth disease have been reported annually since that time, most recently in the spring of 2002. Most cases have occurred in children. Enteroviruses are transmitted by exposure to contaminated stool (fecal-oral route). Infection may be prevented by frequent handwashing and good personal hygiene.

• Plague (most human cases reported from Yunnan and Qinghai provinces; two cases reported from Gansu in 2007; any traveler who might be at risk for exposure to wild rodents or their fleas, which transmit the plague, should bring along a bottle of doxycycline, to be taken if exposure occurs)
• Visceral leishmaniasis (transmitted by sandflies; sporadic cases occur in Xinjiang and western Inner Mongolia in northwestern China and in Fujian province in southeastern China; eradicated elsewhere)
• Cutaneous leishmaniasis (recently reported from Xinjiang, Uygur Autonomous Region)
• Scrub typhus (rural areas in southern China and Tibet; transmitted by chigger bites)
• Hemorrhagic fever with renal syndrome (transmitted by rodents)
• Hepatitis E (northwestern China; transmitted by contaminated food and water)
• Schistosomiasis (central Chang Jiang (Yangtze) river basin; swimming and bathing precautions advised, as below)
• Leptospirosis (animal reservoir includes mice, pigs, rats, buffalo, dogs, and cattle)
• Trachoma (eye infection)
• Brucellosis (rural areas; increasing number of cases, especially from Heilongjiang; prevalence highest in the eastern central provinces of Shanxi, Hebei, and Henan; see ProMED-mail, December 6, 2007)
• Melioidosis (associated with exposure to rice field soil)
• Murine typhus
• Louse-borne typhus (northern China)
• North Asian tick fever (northern China)
• Tick-borne relapsing fever (western China)
• Tick-borne encephalitis (rural and forested areas)
• Crimean-Congo hemorrhagic fever (western China)
• Anthrax (western and northern China)
• Chikungunya fever
• Tularemia
• Q fever
• Lyme disease
• Lung fluke (paragonimiasis)
• Oriental liver fluke (clonorchiasis)
• Giant intestinal fluke (fasciolopsiasis)
• Fish tapeworm (diphyllobothriasis)
• Pork tapeworm (taeniasis)

For further information regarding schistosomiasis and other parasitic infections in China, see Peter Hotez et al., Emerging and Reemerging Helminthiases and the Public Health of China (Emerging Infectious Diseases Vol.3/No.3 July-September 1997)

HIV (human immunodeficiency virus) infection is reported, but travelers are not at risk unless they have unprotected sexual contacts or receive injections or blood transfusions.

Do not drink tap water unless it has been boiled, filtered, or chemically disinfected. Do not drink unbottled beverages or drinks with ice. Do not eat fruits or vegetables unless they have been peeled or cooked. Avoid cooked foods that are no longer piping hot. Cooked foods that have been left at room temperature are particularly hazardous. Avoid unpasteurized milk and any products that might have been made from unpasteurized milk, such as ice cream. Avoid food and beverages obtained from street vendors. Do not eat raw or undercooked meat or fish. Some types of fish may contain poisonous biotoxins even when cooked. Barracuda in particular should never be eaten. Other fish that may contain toxins include red snapper, grouper, amberjack, sea bass, and a large number of tropical reef fish.

All travelers should bring along an antibiotic and an antidiarrheal drug to be started promptly if significant diarrhea occurs, defined as three or more loose stools in an 8-hour period or five or more loose stools in a 24-hour period, especially if accompanied by nausea, vomiting, cramps, fever or blood in the stool. Antibiotics which have been shown to be effective include ciprofloxacin (Cipro), levofloxacin (Levaquin), rifaximin (Xifaxan), or azithromycin (Zithromax). Either loperamide (Imodium) or diphenoxylate (Lomotil) should be taken in addition to the antibiotic to reduce diarrhea and prevent dehydration.

If diarrhea is severe or bloody, or if fever occurs with shaking chills, or if abdominal pain becomes marked, or if diarrhea persists for more than 72 hours, medical attention should be sought.

Wear long sleeves, long pants, hats and shoes (rather than sandals). For rural and forested areas, boots are preferable, with pants tucked in, to prevent tick bites. Apply insect repellents containing 25-50% DEET (N,N-diethyl-3-methylbenzamide) or 20% picaridin (Bayrepel) to exposed skin (but not to the eyes, mouth, or open wounds). DEET may also be applied to clothing. Products with a lower concentration of either repellent need to be repplied more frequently. Products with a higher concentration of DEET carry an increased risk of neurologic toxicity, especially in children, without any additional benefit. Do not use either DEET or picaridin on children less than two years of age. For additional protection, apply permethrin-containing compounds to clothing, shoes, and bed nets. Permethrin-treated clothing appears to have little toxicity. Don't sleep with the window open unless there is a screen. If sleeping outdoors or in an accomodation that allows entry of mosquitoes, use a bed net, preferably impregnated with insect repellent, with edges tucked in under the mattress. The mesh size should be less than 1.5 mm. If the sleeping area is not otherwise protected, use a mosquito coil, which fills the room with insecticide through the night. In rural or forested areas, perform a thorough tick check at the end of each day with the assistance of a friend or a full-length mirror. Ticks should be removed with tweezers, grasping the tick by the head. Many tick-borne illnesses can be prevented by prompt tick removal.

Make sure your health insurance covers you for medical expenses abroad. If not, supplemental insurance for overseas coverage, including possible evacuation, should be seriously considered. If illness occurs while abroad, medical expenses including evacuation may run to tens of thousands of dollars. For a list of travel insurance and air ambulance companies, go to Medical Information for Americans Traveling Abroad on the U.S. State Department website. Bring your insurance card, claim forms, and any other relevant insurance documents. Before departure, determine whether your insurance plan will make payments directly to providers or reimburse you later for overseas health expenditures. The Medicare and Medicaid programs do not pay for medical services outside the United States.

Pack a personal medical kit, customized for your trip (see description). Take appropriate measures to prevent motion sickness and jet lag, discussed elsewhere. On long flights, be sure to walk around the cabin, contract your leg muscles periodically, and drink plenty of fluids to prevent blood clots in the legs. For those at high risk for blood clots, consider wearing compression stockings.

Avoid contact with stray dogs and other animals. If an animal bites or scratches you, clean the wound with large amounts of soap and water and contact local health authorities immediately. Wear sun block regularly when needed. Use condoms for all sexual encounters. Ride only in motor vehicles with seat belts. Do not ride on motorcycles.

For an online directory of physicians and medical facilities in China, go to the U.S. Embassy website. For an overview of health care in China, go to the World Health Organization - Western Pacific Region.

Western-style medical facilities with international staffs are available in Beijing, Shanghai, Guangzhou and a few other large cities. Many other hospitals in major Chinese cities have so-called VIP wards (gaogan bingfang). These feature reasonably up-to-date medical technology and physicians who are both knowledgeable and skilled. Most VIP wards also provide medical services to foreigners and have English-speaking doctors and nurses. Most hospitals in China will not accept medical insurance from the United States, with the exception of the following hospitals, which are on the BlueCross BlueShield worldwide network providers - overseas network hospitals(http://www.fepblue.org/wasite/wabenefits/wa-benefitsoverseas04.html): Hong Kong Adventist Hospital, Beijing United Family Hospital, Beijing Friendship Hospital, International Medical Center in Beijing, and Peking Union Medical Center. Travelers will be asked to post a deposit prior to admission to cover the expected cost of treatment. Hospitals in major cities may accept credit cards for payment. Even in the VIP/Foreigner wards of major hospitals, however, American patients have frequently encountered difficulty due to cultural and regulatory differences. Physicians and hospitals have sometimes refused to supply American patients with complete copies of their Chinese hospital medical records, including laboratory test results, scans, and x-rays. All Americans traveling to China are strongly encouraged to buy foreign medical care and medical evacuation insurance prior to arrival. Travelers who want a list of modern medical facilities in China can access that information at the Embassy's website. Ambulances do not carry sophisticated medical equipment, and ambulance personnel generally have little or no medical training. Therefore, injured or seriously ill Americans may be required to take taxis or other immediately available vehicles to the nearest major hospital rather than waiting for ambulances to arrive. In rural areas, only rudimentary medical facilities are generally available. Medical personnel in rural areas are often poorly trained, have little medical equipment or availability to medications. Rural clinics are often reluctant to accept responsibility for treating foreigners, even in emergency situations.

Foreign-operated medical providers catering to expatriates and visitors are available in China.

SOS International, Ltd., operates modern medical and dental clinics and provides medical evacuation and medical escort services in Beijing, Nanjing, Tianjin and Shekou, as well as 24hr Alarm Centers in Beijing and Shanghai. Through clinics in Beijing (24 hours), Tianjin, Nanjing and Shekou, SOS offers international standard family practice services, emergency medical services and a range of clinical services.

The emergency assistance services SOS offers through alarm centers in Hong Kong, Shanghai and Beijing compliment their clinics. Each Alarm Center provides 24-hour hotline services to all our global members when they are in China. Any problem from lost luggage to a serious medical condition can be reported to the alarm center, where multilingual coordinators and doctors are on duty to respond to all manners of emergencies.

To provide these services, SOS has developed an external network of hospitals, airlines and local authorities with whom they work to deliver a fast and efficient response. These services also support the many remote site medical staff, equipment and facilities that SOS provides to clients.

For medical emergencies anywhere in mainland China, Americans can call the SOS International, Ltd., 24-hour Alarm Center in Beijing at telephone (86-10) 6462-9100 or in Shanghai at (86-21) 6295-0099 for advice and referrals to local facilities. SOS International Alarm Centers can also be contacted in Hong Kong at telephone (852) 2428-9900 and in the United States at (215) 245-4707. For a full list of SOS locations and phone numbers, consult the SOS website at http://www.internationalsos.com .

*Beijing United Family Hospital and Clinics ("BJU") is the first and remains the only foreign-invested full service international standard 50 bed hospital operating in Beijing, China. BJU was opened in 1997 by Chindex International, an American company, which in 2002 was awarded the US Secretary of State's Award for Corporate Excellence. BJU offers the full range of specialties including Family Practice, Internal Medicine, Surgery, Obstetrics/Gynecology, Pediatrics, Dentistry, Psychiatry and Physiotherapy, in addition to a 24 hour Emergency Room staffed solely by Expatriate Staff Specialists. These Physicians are all board qualified (or equivalent) in their respective fields and include specialties such as Anesthesiology, and Intensive Care Medicine. Additionally, staff are fluent in not only English, but also a wide range of languages including French, German, Japanese, Spanish, Swedish, and Finnish to name a few.

Facilities include 2 Operating Theatres, international standard 5 star LDRP birthing suites, Neonatal ICU, a 4-bed Adult ICU, General Inpatient facilities, and standard support services such as Digital Radiology, Ambulance services, Pharmacy, Laboratory and a 24 hour on-site Blood Bank with emergency blood pre-screened to the American Blood Bank standard.

Bayley Jackson Beijing Medical Center #7 Ritan Dong Lu, Chaoyang District, Beijing 100020 ( 8610) 8562-9998 Fax: (8610) 8562-3497 email: info@bjhealthcare.com Website: www.bjhealthcare.com

Beijing United Family Hospital and Clinics #2 Jiang Tai Lu, Chaoyang District, Beijing 100016 (8610) 6433-3960 Fax: (8610) 6433-3963 Emergency Hotline: (8610) 6433-2345 Website: www.bjunited.com .cn

Beijing United Family Clinic - Shunyi Pinnacle Plaza, Unit # 818, Tian Zhu Real Estate Development Zone, Shunyi District, 101312 (8610) 8046-5432 Fax: (8610) 8046-4383

Peking Union Medical Hospital 1 Shui Fu Yuan, Dong Cheng Distict, Beijing 100730 Tel: 010-6529-6114 (registration); 010-6529-7292 (information); 010-6529-5284 (24 hours) Modern Facilities with English speaking staff. Separate ward for foreign patients.

World Link Shanghai Clinics. Expatriate doctors and imported vaccines.

Portman Clinic: Shanghai Center #203 W, 1376 Nanjing Xi Lu, 200040 Tel: 6279-7688. For appointments: 6279-8678 Fax: 6279-7698

Hong Qiao Clinic: Mandarin City Unit 30, 788 Hong Xu Lu, 201103 Tel: 6405-5788; Fax: 6405-3587

GlobalDoctor, Ltd., has opened clinics staffed by English-speaking doctors within the VIP wards of government-run hospitals in Chengdu, Nanjing, and Beijing. GlobalDoctor can be reached by telephone from China at 86-10-8456-9191 or on the Internet at http://www.eglobaldoctor.com/.

Additional information on medical providers specializing in treating foreigners for general medical, dental and orthodontic problems are available at http://www.usembassy-china.org.

The Department of State strongly urges Americans to consult with their medical insurance company prior to traveling abroad to confirm whether their policy applies overseas and if it will cover emergency expenses such as a medical evacuation. U.S. medical insurance plans seldom cover health costs incurred outside the United States unless supplemental coverage is purchased. Further, U.S. Medicare and Medicaid programs do not provide payment for medical services outside the United States. However, many travel agents and private companies offer insurance plans that will cover health care expenses incurred overseas, including emergency services such as medical evacuations.

When making a decision regarding health insurance, Americans should consider that many foreign doctors and hospitals require payment in cash prior to providing service and that a medical evacuation to the U.S. may cost well in excess of $50,000. Uninsured travelers who require medical care overseas often face extreme difficulties. When consulting with your insurer prior to your trip, ascertain whether payment will be made to the overseas healthcare provider or if you will be reimbursed later for expenses you incur. Some insurance policies also include coverage for psychiatric treatment and for disposition of remains in the event of death.

Two private emergency medical assistance firms, SOS International, Ltd., and Medex Assistance Corporation, offer medical insurance policies designed for travelers. Both of these companies have staff in China who can assist in the event of a medical emergency.

SOS International, Ltd. Beijing Clinic address: Building C, BITIC Leasing Center No. 1 North Road, Xingfu Sancun, Sanlitun, Chaoyang District, Beijing 100027 Beijing SOS International Clinic, telephone: (86-10) 6462-9112, Fax (86-10) 6462-9111.

For medical emergencies, please telephone the SOS International Alarm Center at (86-10) 6462-9100 from anywhere in Mainland China. From Hong Kong: (852) 2528-9900. From the U.S.: 1-215-245-4707. These phone lines are answered 24 hours by SOS International Alarm Center personnel. For information on purchasing health or travel insurance from SOS International, please telephone (1-800) 523-8930 ( 8:30 a.m. to 4:30 p.m. Eastern Time, Monday through Friday) in the U.S. or visit http://www.intsos.com/ on the Internet or e-mail: china.marketing@internationalsos.com .

SOS members calling with a medical emergency should first telephone the Alarm Center in Beijing at (86-10)6462-9100.

MEDEX Assistance Corporation 871 Poly Plaza Beijing 100027 Toll Free Number from China to U.S.: 10811-800-527-0218 Email: info@medexassist.com (Baltimore, Maryland) U.S. telephone: (1-800) 537-2029 or (1-410) 453-6300 (24 hours) Emergencies (members only): (1-800) 527-0218 or (1-410) 453-6330 Web site: http://www.medexassist.com/

Medex members calling with a medical emergency should call Medex-Emergency in China at telephone (86-10) 6595-8510.

Other Evacuation Insurance Options:

Heathrow Air Ambulance Heathrow is an air evacuation service with offices in the United States and England. Travelers can pre-arrange air evacuation insurance and other emergency travel assistance. This service also has a business plan to assist foreigners who lack travel insurance. Heathrow Air Ambulance Service,

15554 FM, Suite 195 Houston, TX. 77095-2704. Office telephone 1-800-513-5192. Office fax 1-832-934-2395. E-mail: info@heathrowairambulance.com

Useful information on medical emergencies abroad, including overseas insurance programs, is provided in the Department of State's Bureau of Consular Affairs brochure, Medical Information for Americans Traveling Abroad, available via the Bureau of Consular Affairs home page.

Most roads and towns in Tibet, Qinghai, parts of Xinjiang, and western Sichuan are situated at altitudes over 10,000 feet. Travelers in these areas should seek medical advice in advance of travel, allow time for acclimatization to the high altitude, and remain alert to signs of altitude sickness. Reuse or poor sterilization practices are problems in China, contributing to transmission of diseases such as Hepatitis, which is endemic in China. In order to protect themselves from blood and other tissue borne disease such as Hepatitis and HIV, travelers should always ask doctors and dentists to use sterilized equipment and be prepared to pay for new syringe needles in hospitals or clinics. Tuberculosis is endemic in China. Air pollution is also a significant problem throughout China. Travelers should consult their doctor prior to travel and consider the impact seasonal smog and heavy particulate pollution may have on them. Travelers are advised to consult the CDC's travelers' health website at: http://www.cdc.gov/travel/eastasia.htm prior to departing for China.

Alcoholics Anonymous can be reached in Beijing at telephone (86-10) 139-1138-9075, e-mail: Beijingfellows@yahoo.com . On the Internet, http://members.cox.net/mppowers1/aa-china3.html lists AA meeting locations and contact information for other cities in China. Visit the U.S. Embassy web page in advance of travel to China for additional contact numbers. There is an Al-Anon chapter in Beijing that can be reached at (86-10) 6940-3935. Information on vaccinations and other health precautions may be obtained from the Centers for Disease Control and Prevention's hotline for international travelers at 1-877-394-8747; fax -888-232-3299, or via the CDC's Internet site at http://www.cdc.gov/ . For information about outbreaks of infectious diseases abroad consult the World Health Organization's website at http://www.who.int/en . Further health information for travelers is available at http://www.who.int/ith.

LifeLine Shanghai is a community-based, confidential hotline providing emotional support and information to Shanghai's expatriate community. HOTLINE: (86 21) 6279-8990

Some areas of China frequented by Americans, notably Yunnan Province, are prone to earthquakes. Coastal areas of Hainan, Guangdong, Fujian, and Zhejiang provinces are subject to typhoons during the summer rainy season. General information about natural disaster preparedness is available via the Internet from the U.S. Federal Emergency Management Agency (FEMA) at http://www.fema.gov. Travelers should check weather conditions for cities and areas in China prior to departure. Winter weather and summer typhoons often cause the closure of airports in some parts of the country.

Before you leave, make sure you have the names and contact information for physicians, clinics, and hospitals where you can obtain emergency medical care if needed (see the U.S. Embassy website).

All children should be up-to-date on routine childhood immunizations, as recommended by the American Academy of Pediatrics. Children who are 12 months or older should receive a total of 2 doses of MMR (measles-mumps-rubella) vaccine, separated by at least 28 days, before international travel. Children between the ages of 6 and 11 months should be given a single dose of measles vaccine. MMR vaccine may be given if measles vaccine is not available, though immunization against mumps and rubella is not necessary before age one unless visiting a country where an outbreak is in progress. Children less than one year of age may also need to receive other immunizations ahead of schedule (see the accelerated immunization schedule).

The recommendations for malaria prophylaxis are the same for young children as for adults, except that (1) dosages are lower; (2) Malarone is not recommended for children weighing less than 25 pounds; and (3) doxycycline should be avoided. DEET-containing insect repellents are not advised for children under age two, so it's especially important to keep children in this age group well-covered to protect them from mosquito bites.

When traveling with young children, be particularly careful about what you allow them to eat and drink (see food and water precautions), because diarrhea can be especially dangerous in this age group and because the vaccines for hepatitis A and typhoid fever, which are transmitted by contaminated food and water, are not approved for children under age two. Baby foods and cows' milk may not be available in developing nations. Only commercially bottled milk with a printed expiration date should be used. Young children should be kept well-hydrated and protected from the sun at all times.

Be sure to pack a medical kit when traveling with children. In addition to the items listed for adults, bring along plenty of disposable diapers, cream for diaper rash, oral replacement salts, and appropriate antibiotics for common childhood infections, such as middle ear infections.

Before departure, make sure you have the names and contact information for physicians, clinics, and hospitals where you can obtain emergency obstetric care if necessary (see the U.S. Embassy website). In general, pregnant women should avoid traveling to countries which do not have modern facilities for the management of premature labor and other complications of pregnancy.

As a rule, pregnant women should avoid visiting areas where malaria occurs. Malaria may cause life-threatening illness in both the mother and the unborn child. None of the currently available prophylactic medications is 100% effective. Mefloquine (Lariam) is the drug of choice for malaria prophylaxis during pregnancy, but should not be given if possible in the first trimester. If travel to malarious areas is unavoidable, insect protection measures must be strictly followed at all times. The recommendations for DEET-containing insect repellents are the same for pregnant women as for other adults.

Strict attention to food and water precautions is especially important for the pregnant traveler because some infections, such as listeriosis, have grave consequences for the developing fetus. Additionally, many of the medications used to treat travelers' diarrhea may not be given during pregnancy. Quinolone antibiotics, such as ciprofloxacin (Cipro) and levofloxacin (Levaquin), should not be given because of concern they might interfere with fetal joint development. Data are limited concerning trimethoprim-sulfamethoxazole, but the drug should probably be avoided during pregnancy, especially the first trimester. Options for treating travelers' diarrhea in pregnant women include azithromycin and third-generation cephalosporins. For symptomatic relief, the combination of kaolin and pectin (Kaopectate; Donnagel) appears to be safe, but loperamide (Imodium) should be used only when necessary. Adequate fluid intake is essential.

Helpful maps are available in the University of Texas Perry-Castaneda Map Collection and the United Nations map library. If you have the name of the town or city you'll be visiting and need to know which state or province it's in, you might find your answer in the Getty Thesaurus of Geographic Names.

Americans living in or visiting China are encouraged to register at the Consular Section of the U.S. Embassy in China and obtain updated information on travel and security within China.

Beijing: The U.S. Embassy in China is located at 2 Xiu Shui Dong Jie, Beijing 100600, telephone:

(86-10) 6532-3431, 6532-3831, and after-hours: (86-10) 6532-1910; fax (86-10) 6532-4153. The U.S. Embassy web site address is http://www.usembassy-china.org.cn .cn/ and the e-mail address is AmCitBeijing@state.gov . The Embassy consular district includes the following provinces/regions of China: Beijing, Tianjin, Shandong, Shanxi, Inner Mongolia, Ningxia, Shaanxi, Qinghai, Xinjiang, Hebei, Henan, Hubei, Hunan, and Jiangxi.

Chengdu: The U.S. Consulate General in Chengdu is located at Number 4, Lingshiguan Road, Section 4, Renmin Nanlu, Chengdu 610041, telephone: (86-28) 558-3992, 555-3119; fax (86-28) 8558-3520 and the e-mail address is ACSchengdu@state.gov; after-hours (86-0) 13708001422. This consular district includes the following provinces/regions of China: Guizhou, Sichuan Xizang (Tibet), and Yunnan, as well as the municipality of Chongqing.

Guangzhou: The U.S. Consulate General in Guangzhou is located at Number 1 South Shamian Street, Shamian Island 200S1, Guangzhou 510133; telephone: (86-20) 8121-8418; after-hours:

(86-)139-0229-3169; fax: (86-20) 8121-8428 and the e-mail address is GuangzhouACS@state.gov . This consular district includes the following provinces/regions of China: Guangdong, Guangxi, Hainan, and Fujian.

Shanghai: The Consular Section of the U.S. Consulate General in Shanghai is located in the Westgate Mall, 8 th fl, 1038 Nanjing Xi Lu, Shanghai 200031 telephone: (86-21) 3217-4650, ext. 2102, 2013, or 2134; after-hours: (86-21) 6433-3936; fax: (86-21) 6217-2071; e-mail address: shanghai_acs@yahoo.com . This consular district includes the following provinces/regions of China: Shanghai, Anhui, Jiangsu, and Zhejiang.

Shenyang: The U.S. Consulate General in Shenyang is located at No. 52, 14th Wei Road, Heping District, Shenyang 110003, telephone: (86-24) 2322-1198, 2322-0368; after-hours: (86-0) 13704019790; fax (86-24) 2322-2374 and the e-mail address is ShenyangACS@state.gov . This consular district includes the following provinces/regions of China: Liaoning, Heilongjiang, and Jilin.

For information on safety and security, go to the U.S. Department of State, United Kingdom Foreign and Commonwealth Office, Foreign Affairs Canada, and the Australian Department of Foreign Affairs and Trade.