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Summary of recommendations:
All travelers should visit either their personal physician or a travel health clinic 4-8 weeks before departure.
Malaria: Prophylaxis with Lariam (mefloquine), Malarone (atovaquone/proguanil), or doxycycline is recommended for rural areas in Sumatra, Sulawesi, Kalimantan and Nusa Tenggara Barat and for all areas in eastern Indonesia (provinces of Papua Indonesia, Irian Jaya Barat, Nusa Tenggara Timur, Maluku, and Maluku Utara). There is no risk in Jakarta, resort areas of Bali, or the island of Java, except for the Menoreh Hills in central Java.
Recommended for all travelers
For travelers who may eat or drink outside major restaurants and hotels
One-time booster recommended for any adult traveler who completed the childhood series but never had polio vaccine as an adult
Required for all travelers greater than one year of age arriving from a yellow-fever-infected area in Africa or the Americas. Not recommended otherwise.
For travelers who may spend a month or more in rural areas and for short-term travelers who may spend substantial time outdoors in rural areas, especially after dusk
Recommended for all travelers
For travelers spending a lot of time outdoors, or at high risk for animal bites, or involved in any activities that might bring them into direct contact with bats
Measles, mumps, rubella (MMR)
Two doses recommended for all travelers born after 1956, if not previously given
Revaccination recommended every 10 years
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) 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.
Rural areas of Kalimantan (Borneo), Nusa Tenggara Barat (includes the island of Lombok), Sulawesi, and Sumatra. All areas of eastern Indonesia (provinces of Irian Jaya Barat, Maluku, Maluku Utara, Nusa Tenggara Timur, and Papua Indonesia). None in Jakarta or resort areas of Bali and Java. Low transmission in rural areas of Java.
Malaria in Indonesia: prophylaxis is not recommended for Jakarta Municipality, major cities (including Bogor, Bandung, Solo, and Surabaya), or the main resort areas of Java and Bali, which are the most common destinations. Prophylaxis is recommended for rural areas of Kalimantan (Borneo), Nusa Tenggara Barat (includes the island of Lombok), Sulawesi, and Sumatra, and for all areas of eastern Indonesia (provinces of Irian Jaya Barat, Maluku, Maluku Utara, Nusa Tenggara Timur, and Papua Indonesia). There is low malaria transmission in rural areas of Java.
For malarious areas in Indonesia, 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 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.
In Indonesia, most transmission occurs after dark in rural, forested areas not frequented by tourists, except in Papua (formerly known as Irian Jaya), where risk is widespread. Over the past few years, a significant increase in malaria has been observed in Central Java Province adjacent to Yogjakarta Province. Antimalarial prophylaxis is recommended for all overnight visitors to these provinces, except for the cities of Semerang and Yogyakarta (see ProMED-mail for details).
Long-term travelers who will be visiting malarious areas and 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 concerning malaria in Indonesia, go to the World Health Organization - South East Asia Region or to the World Health Organization.
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The following are the recommended vaccinations for Indonesia:
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.
Older adults, immunocompromised persons, and those with chronic liver disease or other chronic medical conditions who have less than two weeks before departure should receive a single intramuscular dose of immune globulin (0.02 mL/kg) at a separate anatomic injection site in addition to the initial dose of vaccine. Travelers who are less than one year of age or allergic to a vaccine component should receive a single intramuscular dose of immune globulin (see hepatitis A for dosage) in the place 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.
Polio immunization is recommended, due recent reports of polio in Indonesia (see "Recent outbreaks" below). Any adult who received the recommended childhood immunizations but never had a booster as an adult should be given a single dose of inactivated polio vaccine. All children should be up-to-date in their polio immunizations and any adult who never completed the initial series of immunizations should do so before departure. Side-effects are uncommon and may include pain at the injection site. Since inactivated polio vaccine includes trace amounts of streptomycin, neomycin and polymyxin B, individuals allergic to these antibiotics should not receive the vaccine.
Japanese encephalitis vaccine is recommended for those who expect to spend a month or more in rural areas and for short-term travelers who may spend substantial time outdoors or engage in extensive outdoor activities in rural or agricultural areas, especially in the evening. Japanese encephalitis has been reported in animals from Kalimantan, Bali, Nusa Tenggara, Sulawesi, Mollucas, and West Papua, Lombok. Human cases have been identified on Bali, Java, East Timor, and possibly Lombok. Transmission is by mosquito bites and probably occurs year-round, with peak risk usually from November to March, sometimes in June and July. Increased risk is associated with rainfall, rice cultivation and the presence of pigs.
For those age 17 or older, the recommended vaccine is IXIARO, given 0.5 cc intramuscularly, followed by a second dose 28 days later. The series should be completed at least one week before travel. The most common side effects are headaches, muscle aches, and pain and tenderness at the injection site. Safety has not been established in pregnant women, nursing mothers, or children under the age of 17. For the vaccination options for those under age 17, go to the Japanese encephalitis section. In addition to vaccination, strict attention to insect protection measures is essential for anyone at risk.
Hepatitis B vaccine is recommended for all travelers if not previously vaccinated. 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 for travelers spending a lot of time outdoors, for travelers at high risk for animal bites, such as veterinarians and animal handlers, for long-term travelers and expatriates, and for travelers involved in any activities that might bring them into direct contact with bats. Children are considered at higher risk because they tend to play with animals, may receive more severe bites, or may not report bites. In Indonesia, rabies is most often transmitted by stray dogs, though cats and monkeys may also be responsible.
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.
Tetanus-diphtheria vaccine is recommended for all travelers who have not received a tetanus-diphtheria immunization within the last 10 years.
Measles-mumps-rubella vaccine: two doses are recommended (if not previously given) for all travelers born after 1956, unless blood tests show immunity. Many adults born after 1956 and before 1970 received only one vaccination against measles, mumps, and rubella as children and should be given a second dose before travel. MMR vaccine should not be given to pregnant or severely immunocompromised individuals.
Cholera vaccine is not generally recommended, except for relief workers, because most travelers are at low risk for infection. Two oral vaccines have recently been developed: Orochol (Mutacol), licensed in Canada and Australia, and Dukoral, licensed in Canada, Australia, and the European Union. These vaccines, where available, are recommended only for 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. The only cholera vaccine approved for use in the United States is no longer manufactured or sold, due to low efficacy and frequent side-effects.
Yellow fever vaccine is required for all travelers arriving from a yellow-fever-infected country in Africa or the Americas or from a country in the endemic zones, 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.
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Several outbreaks of hepatitis A were reported from West Java in November 2011 (see ProMED-mail, November 15,2011). Hepatitis A vaccine is recommended for all travelers to Indonesia.
A leptospirosis outbreak, transmitted by infected rat urine, was reported from Sedayu district in 2009, killing 19 people in the Bantul regency in Java by February 2011 (see ProMED-mail, February 14, 2011). Leptospirosis is transmitted to humans by exposure to water contaminated by the urine of infected animals. Symptoms may include fever, chills, headache, muscle aches, conjunctivitis (pink eye), photophobia (light sensitivity), and rash. Most cases resolve uneventfully, but a small number may be complicated by meningitis, kidney failure, liver failure, or hemorrhage. Those who might be exposed to contaminated water may consider taking a prophylactic 200 mg dose of doxycycline, either once weekly or as a one-time dose.
An outbreak of Legionnaires' disease has been reported among Australians who had vacationed in Bali between August 2010 and June 2011, causing ten confirmed cases. All but one had stayed at the Ramayana Resort and Spa Hotel in Central Kuta (see ProMED-mail, January 15 and 19 and June 11, 2011). Legionnaires' disease is a bacterial infection which typically causes pneumonia but may also involve other organ systems. The disease is usually transmitted by airborne droplets from contaminated water sources, such as cooling towers, air conditioners, whirlpools, and showers. Travelers to Bali who develop fever, cough, chest pain, or difficulty breathing should immediately seek medical attention.
A rabies outbreak related to infected dogs was reported in December 2008 from the southern tip of Bali. The outbreak initially involved Denpasar and Badung districts, but had spread to Kuta, one of the main tourist areas, by February 2009, and had spread throughout the heavily populated southeast and eastern portions of Bali by October 2009. By December 2010, more than 100 confirmed or probable cases, all fatal, had been described. In January 2011, two fatal cases were reported from the Nusa Penida islands, located a short distance from Bali's southeast shore. No cases have been identified within the major cities of Ubud and Gianyar, and only a few on the outskirts of the capital city of Denpasar, but cases have occurred on all sides of these communities. No cases have occurred in tourists. Because the situation is evolving, the Centers for Disease Control advises travelers to take precautions on the entire island. Rabies vaccine and immune globulin may not be available for those who have been bitten, due to local shortages. The nearest facilities that are able to provide reliable post-exposure treatment are in Singapore, Bangkok and Australia. No new cases have been reported since April 2012, raising hopes that the outbreak has been controlled.
All travelers should avoid touching all animals, including pet dogs and cats and wild animals such as monkeys. Rabies vaccine is recommended for travelers spending a lot of time outdoors, for travelers at high risk for animal bites, such as veterinarians and animal handlers, for long-term travelers and expatriates, and for travelers involved in any activities that might bring them into direct contact with bats. Children are considered at higher risk because they tend to play with animals, may receive more severe bites, or may not report bites. In Indonesia, rabies is most often transmitted by stray dogs, though cats and monkeys may also be responsible.
A rabies outbreak was reported in March 2012 from the southwest district of Maluku province. Rabies outbreaks were reported in 2010 from Nias (26 deaths for the year), West Maluku Tenggara (20 deaths) and East Maluku Tenggara (28 deaths). In February 2008, a rabies outbreak was reported from Flores Island (East Maluku Tenggara). Up to one quarter of the dogs on Flores Island have not been vaccinated against rabies (see the Centers for Disease Control and ProMED-mail; February 15, November 9, and December 7, 2008, September 30 and October 16, 2009, July 22, 2011, and March 6, 2012). Rabies outbreaks were also reported from Flores Island in 2000 and from Sulawesi in 2005.
An increased number of cases of typhoid fever was reported in April-July 2009 among travelers from Hong Kong who had visited Indonesia. More than half of those affected had stayed in Surabaya, Indonesia's second largest city. For further information, go to the Hong Kong Information Services Department. 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.
A total of 193 human cases of H5N1 avian influenza ("bird flu"), 161 of them fatal, have been reported from Indonesia since July 2005. According to the World Health Organization, the H5N1 virus is considered firmly entrenched in poultry throughout much of Indonesia. Unless the outbreak is urgently controlled, more human cases can be expected.
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 Indonesia 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.
Outbreaks of dengue fever, a flu-like illness sometimes complicated by hemorrhage or shock, occur regularly in Indonesia. More than 100,000 cases were recorded nationwide for the year 2008. Six cases were reported in Japanese travelers who had visited Bali in February-March 2010. Dengue is transmitted by Aedes mosquitoes, which bite primarily in the daytime and favor densely populated areas, though they also inhabit rural environments. In Indonesia, peak transmission usually occurs from May to July, though the disease is observed year-round. No vaccine is available at this time. The cornerstone of prevention is insect protection measures, as outlined below.
The most recent dengue outbreaks were reported in November 2010 from West Nusatenggara; in September 2010 from Central Jakarta; in March 2010 from Malang regency, East Java; in February 2010 from Bali, from Bekasi, West Java, and from Kediri, East Java; in January 2010 from Jakarta, from Jember regency, East Java, and from Balikpapan, East Kalimantan; in December 2009 from West Kutai regency, East Kalimantan; in November 2009 from North Sumatra; in April 2009 from Jakarta; in March 2009 from West Java; in February 2009 from Banten province, from Mamuju District, West Sulawesi Province, and from Pacitan Regency, East Java; in January 2009 from Bone Regency, South Sulawesi, and from East Kalimantan; in December 2008 from Riau province; in November 2008 from Banyumas Regency, Central Java; in October 2008 from Central Sulawesi, from Batam City (Riau Province), and from Aceh (northern Sumatra); in August 2008 from Tanjungbalai city in North Sumatra; in June 2008 from the city of Jakarta and from Sikka regency, East Nusa Tenggara; in May 2008 from Bali, causing almost 400 cases; in April 2008 from East Kalimantan, Borneo; in February 2008 from central Java, resulting in more than 2300 cases and at least 37 fatalities; and in December 2007 from Jepara (Java), Jombang (central Java), East Java, East Kalimantan (Borneo), South Sulawesi, and North Sulawesi. In January 2007, a dengue outbreak was reported from Bali, but travelers appeared to be at low risk, since most cases were occurring in densely populated areas far from the main tourist centers (see ProMED-mail, May 21, 2007).
A dengue outbreak was reported in January 2006 from the Bantul regency, which is next to the ancient city of Yogyakarta, a popular tourist destination. A major dengue outbreak occurred in early 2004, affecting all 30 provinces and causing almost 60,000 cases and more than 600 deaths, chiefly in Java (especially DKI Jakarta), Jawa Barat, Jawa Tengah and Jawa Timur (see the World Health Organization). An unusually large number of cases was reported in 1998, possibly due to climatic changes related to El Nino. For further information on dengue in Southeast Asia, go to the World Health Organization - South-East Asia Region.
Outbreaks of chikungunya fever, a mosquito-borne illness characterized by fever and incapacitating joint pains, have occurred regularly in Indonesia in recent years. The most recent were reported from East Jakarta in May 2012; from West Java in January 2012; from West Sumatra and Central Java in October 2011; from Lampung and Bangka-Belitung provinces and from South Kalimantan regency in Banjar (Borneo) in February 2010; from south Sumatra in April 2009 and again in December 2009; from Banyumas regency in Central Java in March 2009; from Madiun Regency in East Java and from Indragiri Hulu Regency, Riau (Sumatra) in January 2009; from Central Java in November-December 2008; from Pajagalan Village, Garut Regency, West Java, from Pauh subdistrict, Kota Padang of West Sumatra, from Pangke village in Kepulauan Riau province, and from Riau Province, Sumatra in October 2008; from Bali in July 2008; from Makmur City in Sulawesi in May 2008 (mixed with cases of dengue fever); from Sukoharjo District in Central Java between January and April 2008; from the Jepara Regency (Central Java), from Bandarlampung and Padang City (Sumatra), and from Brebes and Pekalongan (Central Java) in December 2007; from East Java in November 2007; from Bandarlampung in May 2007; and from Bekasi in March 2007. In April 2005, an outbreak occurred in West Lombok. In July of the same year, an outbreak occurred in Tangerang. In December 2003 and January 2004, outbreaks were reported from East Java and Central Java. In December 2002, an outbreak was reported from West Java, spreading to West Timor and Central Sulawesi. See ProMED-mail for details.
Symptoms of chikungunya fever include fever, joint pains, muscle aches, headache, and rash. The disease is almost never fatal, but may be complicated by protracted fatigue and malaise. Rarely, the infection is complicated by meningoencephalitis, which is usually seen in newborns and those with pre-existing medical conditions. Insect protection measures are strongly recommended, as described below. Because of the risk of mother-to-child transmission, pregnant women need to take special care to protect themselves from mosquito bites.
A cholera outbreak was reported from West Papua in April 2008, causing at least 170 fatalities. Cholera outbreaks were reported from the Jayawijaya and Yahukimo regencies in Irian Jaya in April 2006, from Ciomas subdistrict, Bogor, West Java province in May 2006, and from the highlands region of Wamena in the far east of Indonesia, also in May 2006. See ProMED-mail (May 1 and 5, 2006) and Doctors Without Borders for further information. The main symptoms of cholera are profuse watery diarrhea and vomiting, which in severe cases may lead to dehydration and death. Most outbreaks are related to contaminated drinking water, typically in situations of poverty, overcrowding, and poor sanitation. 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.
A measles outbreak was reported in February 2006 from the southern part of Papua, a province in the far east of Indonesia. See Doctors Without Borders for further information. All travelers born after 1956 should make sure they have had either two documented measles immunizations or a blood test showing measles immunity. Those born before 1957 are presumed to be immune. Although measles immunization is usually begun at age 12 months, consider giving an initial dose of measles vaccine to children between the ages of 6 and 11 months who will be traveling to Indonesia.
An outbreak of polio was reported in May 2005, resulting in a total of 303 cases. The outbreak began in West Java and Banten Provinces on the island of Java, then spread to Central Java, East Java, and Jakarta provinces on Java, as well as Lampung, North Sumatra, South Sumatra, Aceh, and Riau provinces on the island of Sumatra. In addition, a polio outbreak caused by the attenuated virus found in oral polio vaccine was reported from Madura Island, East Java province. These are the first cases of polio seen in Indonesia since 1995. The government responded by initiating a massive nationwide immunization campaign. The outbreak appears to be declining. Only two cases were reported during the first four months of 2006. See Polio Eradication website, NATHNAC, and the World Health Organization for further information. A one-time polio booster is recommended for any adult traveler who received the recommended childhood immunizations but never had polio vaccine as an adult. Children should be fully immunized against polio before traveling to Indonesia.
An anthrax outbreak was reported in March 2011 from Karangmojo village in Boyolali, Central Java. In April 2010, an outbreak occurred in Tenrigangkae village, Mandai township, Maros regency in South Sulawesi. In October 2005, an anthrax outbreak was reported from a village near Bogor, West Java, resulting in six deaths and possibly affecting as many as 65 people. The outbreak was related to the consumption of infected goat meat. For further information, go to the U.S. Embassy website. Almost all cases of anthrax occur in those who work directly with farm animals. Most travelers are at low risk.
A tetanus outbreak was reported in January 2005 from tsunami-affected areas in Indonesia, including Banda Aceh, Meulaboh, and Sigli. As of January 15, a total of 67 cases had been identified. According to Médecins Sans Frontières (Doctors Without Borders), "People are becoming infected when they search for corpses or useful objects in the rubble left by the tsunami. Wounds on their arms and legs can become infected by the tetanus bacteria when they walk through the mud. Since the disease has an incubation period of between two and 60 days, most cases are only starting to show up now. The fear is that many more people will develop the disease in days and weeks to come." A tetanus booster is recommended for all adults who haven't had a tetanus shot within the last 5 years. For further information, go to Médecins Sans Frontières.
Outbreaks of Chikungunya fever, a mosquito-borne illness characterized by fever and incapacitating joint pains, have recently been reported from Indonesia. In December 2002, an outbreak was reported from West Java, spreading to West Timor and Central Sulawesi. In December 2003 and January 2004, outbreaks were reported from East Java and Central Java. In April 2005, an outbreak occurred in West Lombok. In July of the same year, an outbreak occurred in Tangerang. See ProMED-mail for details. The disease is rarely fatal, but may be complicated by protracted fatigue and malaise.
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Murine typhus, which is transmitted by fleas, has been reported in travelers returning from Indonesia. In April 2008, two cases were reported in Japanese travelers who had visited Bali (see ProMED-mail, April 10 and 21, 2008, and P. Parola et al., Emerging Infectious Diseases, vol. 4 no. 4, Oct-Dec 1998).
Bubonic plague was reported in six people from the village of Sulorowo in Pasuruan district, East Java, in 1997. This was the first cluster of human plague in Indonesia since 1970. Travelers should avoid areas containing rodent burrows or nests, never handle sick or dead animals, and follow insect protection measures, as described below.
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.
Other infections include
- Hepatitis E (transmitted by contaminated food or water)
- Schistosomiasis (Schistosoma japonicum reported from central Sulawesi; avoid swimming, wading, or bathing in bodies of fresh water, such as lakes, rivers, or streams)
- Anthrax (declining incidence; occurs in cows, carabaos, and horses; human cases reported from West Nusa Tenggara, East Nusa Tenggara, West Java, and Central Java; outbreaks reported from Pappa subdistrict, Patalassang district, in Takalar regency, South Sulawesi in May 2013, from Sabu Raijua District, East Nusa Tenggara, in August 2011, and from the town of Gowa in South Sulawesi in June 2009)
- Brucellosis (reported from West Java; see ProMED-mail)
- Lymphatic filariasis (see the World Health Organization - South-East Asia Region for further information; increased number of cases reported from Jambi in early 2007; see ProMED-mail, January 24, 2007)
- Scrub typhus (rural areas; transmitted by chigger bites)
- Filariasis (scattered cases)
- Fasciolopsiasis (giant intestinal fluke)
- Cyclosporiasis (parasitic intestinal infection; outbreak reported among microbiologists at scientific meeting in Bogor in September 2001; see Emerging Infectious Diseases)
For detailed information concerning the incidence of malaria, dengue fever, and many other infectious diseases, go to the Ministry of Health website.
For a country health profile of Indonesia, go to the World Health Organization.
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Food and water precautions
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.
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Insect and Tick Protection
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.
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Bring adequate supplies of all medications in their original containers, clearly labeled. Carry a signed, dated letter from the primary physician describing all medical conditions and listing all medications, including generic names. If carrying syringes or needles, be sure to carry a physician's letter documenting their medical necessity.Pack all medications in hand luggage. Carry a duplicate supply in the checked luggage. If you wear glasses or contacts, bring an extra pair. If you have significant allergies or chronic medical problems, wear a medical alert bracelet.
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.
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Ambulance and Emergency Services
Indonesia does not have a nationwide emergency phone number or ambulance service, such as "911" in the United States. Many hospitals have their own ambulances, but staffing and equipment may not be comparable to that in Western nations and response time may be slow. Because of traffic congestion and poor road conditions, ambulance transport may take hours. The following hospitals offer ambulance service:
- R.S. MMC Kuningan: call 527-3473
- R.S. Medistra: call 521-0200
- R.S. Pondok Indah: call 750-2322
- R.S. Graha Medika: call 530-0887-9
Those staying in Indonesia for prolonged periods should identify private ambulance services in their area.
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Medical services are limited. Most expatriates go to either International SOS or Global Doctor, which offer 24-hour emergency as well as routine care. International SOS has locations in Jakarta, Balikpapan, and Bali: JL Puri Sakti No. 10 Cipete, Jakarta Selatan, Jakarta, ph. 62 21 750 5980, 750 6001; PKT Office, Jalan Pupuk Raya 54, Balikpapan, ph. 62 542 765966; Pt. Abhaya Eka Astiti, Klinik SOS Medika, Jalan Bypass Ngurah Rai 505 X, Kuta 80361, Bali, Indonesia 80361, ph. 62 361 710 544. Global Doctor is located in South Jakarta at Jl. Patimura 15 Kebayoran Baru, South Jakarta; ph. 021-723-1121. Only Indonesian doctors are allowed to treat patients in Indonesian medical facilities. However, International SOS has an expatriate consultant physician on the premises most of the time and Global Doctor offers telemedicine appointments with a consultant in Perth.
For a cardiac emergency, many people go to Pusat Jantung Nasional (National Cardiac Center) (Jl. Letjen S. Parman Kav. 87; Jakarta Barat; ph. 568-4085, 568-4093). If hospital admission is necessary for non-cardiac problems, options include R.S. MMC Kuningan (Jl. H.R. Rasuna Said Kav. C21, Kuningan, South Jakarta; ph.021 520-3435/45) and R.S. Medistra (Jl. Jend. Gatot Subroto Kav. 59, South Jakarta, ph. 021 5210200), both of which have 24-hour emergency rooms and their own ambulance services. However, most expatriates prefer to be transferred to a country with state-of-the-art medical facilities, usually Singapore or Australia, for serious medical problems.
For a guide to other physicians and health facilities in Indonesia, go to the U.S. Embassy website. Routine medical care is available in major cities, but not elsewhere. Many doctors and hospitals will expect payment in cash, regardless of whether you have travel health insurance.
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There are many well-supplied pharmacies ("apotik") in Indonesia, including a number of chains, such as Century Healthcare (website http://www.apotikcentury.com/), Guardian Pharmacies (based in Malaysia), and Apotik Melawai. Do not buy medications from street vendors.
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Traveling with children
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.
Because of a recent polio outbreak, all children traveling to Indonesis should be fully immunized against polio. 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; and (2) 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.
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Travel and pregnancy
International travel should be avoided by pregnant women with underlying medical conditions, such as diabetes or high blood pressure, or a history of complications during previous pregnancies, such as miscarriage or premature labor. For pregnant women in good health, the second trimester (18–24 weeks) is probably the safest time to go abroad and the third trimester the least safe, since it's far better not to have to deliver in a foreign country.
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. 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.
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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.
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(reproduced from the U.S. State Dept. Consular Information Sheet)
Americans living in or visiting Indonesia are encouraged to register at the Consular Section of the U.S. Embassy in Indonesia and obtain updated information on travel and security within Indonesia. The U.S. Embassy is located in Jakarta at Medan Merdeka Selatan 5; telephone: (62)(21) 3435-9000; fax (62)(21) 385-7189. The U.S. Embassy website is http://jakarta.usembassy.gov. The consular section can be reached by e-mail at firstname.lastname@example.org. U.S. citizens can register online at http://jakarta.usembassy.gov/consular/onlinereg.html. To subscribe to the U.S. Embassy Emergency Notification System, please register at http://jakarta.usembassy.gov/consular/Mailwarden.html
The U.S. Consulate General in Surabaya is at Jalan Raya Dr. Sutomo 33; telephone: (62)(31) 568-2287/8; fax (62)(31) 567-4492; e-mail: email@example.com. The consulate should be the first point of contact for Americans needing assistance who are present or residing in the Indonesian provinces of: East and Central Java, Yogyakarta, Nusa Tenggara Timor, Nusa Tenggara Barat, all of Sulawesi North and South Maluku.
There is a Consular Agency in Bali at Jalan Hayam Wuruk 188, Denpasar, Bali; telephone: (62)(361) 233-605; fax (62)(361) 222-426; e-mail: firstname.lastname@example.org. The U.S. Consulate in Surabaya is an alternate contact for American citizens in Bali.
The U.S. Consulate in Medan closed in May 1996. American citizens needing assistance in Sumatra should contact the U.S. Embassy in Jakarta.
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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.
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