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Thailand
Summary of recommendationsMedicationsImmunizations
Recent outbreaksOther infectionsFood and water precautions
Insect and Tick ProtectionAir pollutionGeneral advice
Ambulance and Emergency ServicesMedical facilitiesTraveling with children
Travel and pregnancyEmbassy/Consulate LocationSafety information

 

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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 Malarone (atovaquone/proguanil) or doxycycline is recommended for rural areas bordering Cambodia, Laos, and Myanmar, including Mae Hong Son. Rare local cases have been reported from Phang Nga and Phuket; insect protection measures but not malaria pills are not recommended for these two areas.
Vaccinations:

Hepatitis A

Recommended for all travelers

Typhoid

For travelers who may eat or drink outside major restaurants and hotels

Yellow fever

Required for all travelers greater than one year of age arriving from a yellow-fever-infected area in Africa or the Americas and for travelers who have been in transit in an airport located in a country with risk of yellow fever transmission. Not recommended or required otherwise.

Japanese encephalitis

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

Hepatitis B

Recommended for all travelers

Rabies

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

Tetanus-diphtheria

Revaccination recommended every 10 years

Medications

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 recent study indicated that, due to the frequency of quinolone-resistant Campylobacter in Thailand, the most effective antibiotic is azithromycin (Zithromax), given either as a single dose of 1 g or a three-day course of 500 mg/day (Clinical Infectious Diseases 2007; 44:338-46). Alternative regimens include a three day course of rifaximin (Xifaxan) 200 mg three times daily or a quinolone antibiotic: 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. 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 diphenoxylate (Lomotil) (PDF) or loperamide (Imodium) 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 Thailand: prophylaxis is recommended for rural, forested areas that border Burma (Myanmar), Cambodia, and Laos. Rare local cases have been reported from Phang Nga and Phuket; malaria pills are not generally recommended for these two areas, but insect protection measures are advised, as below. There is no malaria risk in major tourist resorts or in the cities of Bangkok, Chiang Mai, Chiang Rai, Pattaya, Ko Samui, and Ko Phangan.

Either atovaquone/proguanil (Malarone)(PDF) or doxycycline may be given. 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. The recommended dosage is 100 mg daily, starting one-to-two days before arrival and continuing for four weeks after departure from the malarious area.

Insect protection measures are recommended for all areas reporting malaria, including Phang Nga and Phuket.

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.

Cases of malaria are sometimes reported from the southern part of the country (see "Recent outbreaks"). Because the risk appears to be extremely low, malaria prophylaxis is not generally recommended for travel to the south. However, travelers should be aware that the risk, though small, does exist, and should immediately seek medical attention if they develop fever or other malaria symptoms.

For further information concerning malaria in Thailand, go to the World Health Organization - South-East Asia Region.

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Immunizations

The following are the recommended vaccinations for Thailand:

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. 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.

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 is transmitted by mosquitoes and occurs from May through October in Thailand. The disease is highly prevalent in the north and occurs sporadically in the south. Annual outbreaks have been reported in the Chiang Mai Valley. Sporadic cases have been described in the Bangkok suburbs.

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 Thailand, the chief risk is from dog bites, though cases from cat bites are also reported. 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.

Polio vaccine is not generally recommended for adult travelers who completed the recommended childhood immunizations, since polio has not been reported from Thailand for several years. A one-time booster of inactivated polio vaccine may be considered for extended travel to rural areas.

Cholera vaccine is not generally recommended, though cholera is reported, 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 greater than one year of age arriving from a yellow-fever-infected country in Africa or the Americas and for travelers who have been in transit more than 12 hours in an airport located in a country with risk of yellow fever transmission, 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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Recent outbreaks

Two cases of leptospirosis were reported in Spanish travelers who had visited the Phi Phi islands in September 2013 (see Eurosurveillance). In June 2012, a leptospirosis outbreak was reported from the northeastern part of Surin province, causing 107 confirmed cases and seven deaths (see ProMED-mail, June 26, 2012).

Leptospirosis is acquired by exposure to water contaminated by the urine of infected animals. In Thailand, the animal reservoir includes rats and dogs. Outbreaks often occur in between August and November, which is the rainy season, and at times of flooding. Most cases occur in the north and northeast regions of the country (see Emerging Infectious Diseases). 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 may be exposed to contaminated fresh water, such as those on adventure trips, may consider taking a prophylactic 200 mg dose of doxycycline, either once weekly or as a one-time dose.

In September 2006, a leptospirosis outbreak was reported from Nan province in the northern part of the country, related to recent floods (see ProMED-mail; September 12, 2006). A previous outbreak occurred in September-October 1999 in the Khumuang subdistrict, Buriram province, in the northeastern part of the country.

An increased number of malaria cases was reported in April 2011 from Yala Province in the south. Three cases of malaria were reported in late 2005 and early 2006 among travelers to Koh Phangan in the southern part of the country, where malaria is thought to be highly uncommon. See ProMED-mail (May 20, 2006, and April 22, 2011) and Eurosurveillance for further information. In 2002, two cases were reported in German travelers who had visited Khao Sok national park, also in the southern part of the country (see Eurosurveillance). Because the risk appears to be low, malaria prophylaxis is not generally recommended for travel to the southern peninsula. However, travelers should be aware that the risk, though small, does exist, and should immediately seek medical attention if they develop fever or other symptoms suggestive of malaria.

An outbreak of hand, foot, and mouth disease was reported from Thailand in July 2010, including a small outbreak in Phuket. More than 10,000 cases had been described nationwide by September. A small outbreak was reported from Burirum province, in the northeastern part of the country, in July 2012 (see ProMED-mail; September 28, 2010, and July 14 and 15, 2012). Most cases of hand, foot and mouth disease occur in infants and young children, though adults may also be affected. The illness is characterized by fever, oral blisters, and a rash or blisters on the palms and soles. 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). Most cases are caused by enteroviruses, which are transmitted by exposure to fecal material from infected individuals. The key to prevention is good personal hygiene and scrupulous hand-washing, especially after defecation and before handling food.

An outbreak of hand, foot and mouth disease was also reported from Thailand in September 2006 (see ProMED-mail; September 7, 2006).

An outbreak of melioidosis was reported from Thailand in August 2010, causing 1307 cases and six deaths, mostly among farmers in the northeastern part of the country. Three cases of melioidosis were reported in January 2005 among Finnish tourists who had survived the tsunami in December 2004. The tourists had been visiting Khao Lak on the southwest coast of Thailand when the tsunami struck. In October 2012, a case was reported in a Belgian traveler. Melioidosis is caused by a soil bacterium known as Burkholderia pseudomallei, which gains entrance to the body through cuts or other breaks in the skin, leading to pneumonia or wound infections. The infection may progress to septicemia and may be life-threatening, especially in those with compromised immune systems. In Thailand, most cases are reported from the northeastern part of the country, usually in rice farmers during the rainy season. To prevent melioidosis, travelers are advised to wear waterproof gloves and shoes or boots whenever coming into direct contact with soil, especially during the rainy season.

An outbreak of chikungunya fever, a mosquito-borne illness characterized by fever and incapacitating joint pains, was reported in early 2009 from southern Thailand, including Phuket. By late September, more than 42,000 suspected cases had been described and the outbreak had spread to all other regions of the country. The largest number of cases was reported from the southern province of Songkhla, followed by Narathiwat, Pattani, and Yala, also in the south. More than 2000 cases were reported from Phuket, including 31 cases in foreigners. None of the cases were fatal (see ProMED-mail, April 29 and May 15, 2009). 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. In October 2008, a chikungunya outbreak occurred in a village in Narathiwat province, in southern Thailand near the border with Malaysia.

Dengue fever, a flu-like illness sometimes complicated by hemorrhage or shock, is highly prevalent in Thailand. The number of cases usually peaks during the rainy season (ranging from May through November), when mosquitoes proliferate. A total of 26,000 cases and 33 deaths were reported nationwide for the first four months of 2013. A dengue outbreak was reported from Phuket in April 2013, causing more than 300 cases. Dengue is transmitted by Aedes mosquitoes, which bite primarily in the daytime and favor densely populated areas, though they also inhabit rural environments. No vaccine is available at this time. Insect protection measures are strongly advised, as outlined below.

More than 48,000 cases of dengue fever, 27 of them fatal, were reported from Thailand in the first nine months of 2011, chiefly in the central region. Provinces most affected included Krabi, Samut Sakhon, Satun, Songkhla, Ratchaburi, Nakhon Pathom, Nakhon Sawan, Chon Buri and Trat. An outbreak was reported from the island of Phi Phi in August 2011, causing 20 cases, some of them in tourists. In September 2011, an outbreak of a febrile illness, possibly dengue, was reported from the Karenni refugee camp in Mae Hong Song. More than 86,000 cases of dengue fever and at least 100 deaths were reported nationwide for the first nine months of 2010. Most of the cases were reported from the Northeastern provinces, followed by the Central, Southern and Northern regions. An outbreak was reported from the island of Phuket, causing almost 700 cases by November 2010. Dengue outbreaks were reported from Buri Ram province and from the northeastern province of Surin in September 2010, from the northeastern province of Ubon Ratchathani in August 2010, from Nakhon Ratchasima province in July 2010, and from Pattani province in May 2010. In June 2009, a dengue outbreak was reported from the region of Mae Hong Son, causing 155 cases. The dengue reports by province and region are available from the Thailand Ministry of Public Health dengue surveillance website at http://203.157.15.4/surdata/disease.php?ds=66 for dengue fever, http://203.157.15.4/surdata/disease.php?ds=26 for dengue hemorrhagic fever, and http://203.157.15.4/surdata/disease.php?ds=27 for dengue shock syndrome. While the URL links go to webpages in the Thai language, if one goes to the central column of the page, there are links to the data files by years, with 2552 representing 2009. Clicking on the year will then provide a link to download the respective files for dengue fever reports by province and region, dengue hemorrhagic fever reports by province and region, and dengue shock syndrome reports by province and region).

For the year 2008, there were more than 91,000 cases of dengue fever nationwide, including 99 deaths. Koh Samet, Koh Mun, and Koh Kodi were particularly affected. A dengue outbreak was reported from Rayong Province in August 2008, causing almost 1400 cases and two deaths. For the first nine months of 2007, more than 40,000 dengue cases were reported nationwide, including 47 deaths. The number of dengue cases appeared to rise earlier than usual in 2007, due to early, heavy rains. A dengue outbreak was reported from Phuket in August 2007, resulting in 110 cases and at least two deaths by November. In May 2007, an outbreak was reported from Trat province, 400 km southeast of Bangkok on the Cambodian border, and in the southernmost provinces along the Malaysian border. In August 2006, the provinces of Kamphaeng Phet, Nakhon Sawan, Phichit and Uthai Thani were declared dengue "alert zones" by the Ministry of Public Health because of a large number of cases (more than a thousand) being reported from these provinces (see Thailand Ministry of Public Health). A dengue outbreak was reported from Surin Province in July 2006 and from Ampur Mae Sareang in June 2006. Earlier in the year, a dengue outbreak was reported from Chaiyaphum Province. In April 2002, a unusually large number of cases was reported among travelers to southern Thailand, especially the island of Koh Pha Ngan.

An increased number of cholera cases has been reported from the northeastern part of Thailand, due to the consumption of raw cockles, poorly prepared som tam, and fast food. A cholera outbreak was reported from Pattani province in southern Thailand in November 2009 and was ongoing as of January 2010. An outbreak was reported in June 2007 among Burmese migrant workers and in a Burmese refugee camp in Tak province, which shares a long border with Burma (see ProMED-mail, August 4 and 10 and October 30, 2007; February 5, 2010). As above, cholera vaccine is not recommended for most travelers.

Four cases of Legionnaires' disease were reported in December 2006 among guests who had stayed at a hotel in Patong Beach, Phuket, Thailand. See Eurosurveillance for further information. 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. Legionnaires' disease is not transmitted from person-to-person.

A total of 25 human cases of H5N1 avian influenza ("bird flu"), 17 of them fatal, have been reported from Thailand. The first twelve cases were reported in January-February 2004, at the time of the initial avian influenza outbreaks in Thailand and other Asian countries. New poultry outbreaks were reported in July 2004, followed by five additional human cases in September-October, 2004. Five more human cases were reported between October and December, 2005. No human or avian cases were reported in the first half of 2006, but fresh poultry outbreaks and three additional human cases were reported between July and September 2006. The most recent poultry outbreaks were reported from the northern province of Phichit in September 2007 and again in January 2008; from Nakhon Sawan province, also in January 2008; from Sukhothai province in October 2008; and from Uthai Thani province in November 2008.

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 Centers for Disease Control does not advise against travel to Thailand, but recommends 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 Thailand should seek immediate medical attention, which may include testing for avian influenza. For further information, go to the World Health Organization, the Centers for Disease Control, and ProMED-mail.

An outbreak of botulism was reported in March 2006 among people who had eaten home-preserved bamboo shoots at a local village Buddhist festival in Baan Luang District, Nan Province. A total of 163 people were affected. Symptoms included dry mouth, dysphagia, dysarthria, ptosis, diplopia, abdominal discomfort, and muscle weakness. Forty people required intubation, but there were no fatalities. For further information, go to the World Health Organization and the Centers for Disease Control. Another botulism outbreak was reported in June 2006, affecting more than 50 people in the northern province of Phayao who had eaten raw deer meat. See Global Health for details.

Toxic jellyfish stings were reported to have killed two tourists swimming off the coast of Koh Phangan in August 2002. Three years before that, a fatal jellyfish sting was reported off Koh Samui in the Gulf of Siam. In general, the time of highest risk for jellyfish stings is the evening, when they come to the surface.

HIV disease has reached epidemic levels in Thailand. Most cases result from heterosexual transmission. HIV infection is common in prostitutes of both sexes.

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Other infections

  • Zika virus infections (mosquito-borne viral infection, usually mild; symptoms may include fever, headache, red eyes, rash, muscle aches, and joint pains; case reported in a traveler from Germany in November 2013; see Eurosurveillance)
  • Streptococcus suis infections (northern Thailand; often acquired by eating Larb and Lu Mu, which are meat salads made with raw pork and raw pork blood; for the year 2010, 23 cases and 5 fatalities reported in Phetchabun province; three cases reported from Lampang province; cases also reported from Phetchabun and Nakhon Sawan provinces)
  • Gnathostomiasis (acquired by eating raw or undercooked freshwater fish; chief symptom is intermittent, migratory swellings under the skin, sometimes associated with joint pains, muscle pains, or gastrointestinal symptoms; symptoms may not begin until months after exposure)
  • Vibrio parahemolyticus (intestinal infection similar to cholera; numbers increasing rapidly over the last several years)
  • Scrub typhus (deforested areas; transmitted by chigger bites; marked by thick black scab at the site of the initial bite and rash which starts on the trunk; also causes fever, headache, sweating, pink-eye, swollen glands)
  • Murine typhus (case reported in April 2011 in a Japanese traveler who had visited northern Thailand)
  • Spotted fever rickettsioses (reported from Sangkhlaburi District on the Myanmar border; trasnmitted by ticks)
  • Schistosomiasis (acquired by exposure to contaminated water; incidence declining)
  • Hepatitis E (transmitted by contaminated food or water; particularly dangerous for pregnant women)
  • Eosinophilic meningitis (caused by roundworm; acquired by eating contaminated food; chief symptoms are headache, neck stiffness, numbness and tingling)
  • Chikungunya fever (transmitted by mosquitoes; causes fever and incapacitating joint pains; rarely fatal but may be complicated by protracted fatigue and malaise)

A recent study of febrile illnesses along the Thai-Myanmar border showed that the most frequent documented causes were malaria and leptospirosis. Other common diagnoses included rickettsial infections, dengue fever, and typhoid. For further information, go to the American Journal of Tropical Medicine and Hygiene (74(1), 2006, pp. 108-113).

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Food and water precautions

Tap water in Thailand should not be consumed unless it has been boiled, filtered, or chemically disinfected. In the major cities, water comes from water purification plants, but may be contaminated due to inadequate sewage facilities. This is especially common during times of flooding.

Avoid unpasteurized milk and any products that might have been made from unpasteurized milk, such as ice cream. Fruits and vegetables should not be eaten unless they have been peeled or cooked. Foods that have been cooked but left at room temperature, such as buffets, should be avoided, as well as raw or undercooked meat or fish. Do not buy food or beverages from street vendors.

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), and 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 reapplied 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. 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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Air pollution

Air pollution may be a significant health problem in Bangkok and Chiang Mai. Travelers with respiratory or cardiac conditions and those who are elderly or extremely young are at greatest risk for complications from air pollution, which may include cough, difficulty breathing, wheezing, or chest pain. The risk may be minimized by staying indoors, avoiding outdoor exercise, and drinking plenty of fluids.

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General advice

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. 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.

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Ambulance and Emergency Services

For a public ambulance in Thailand, call 1669. Response time is usually 10 minutes in cities and 30 minutes in rural areas. For a private ambulance in Bangkok, call 66-2-667-2999 (Bumrungrad International Hospital) or 66-2-712-7007 (Samitivej Hospital).

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Medical facilities

Excellent medical care is available in Bangkok. Many physicians have been trained in the United States and other Western countries and many speak English. Outside Bangkok, medical care may be variable, and it may be difficult to find an English-speaking physician.

Many expatriates go to one of the following, all of which provide 24-hour emergency care:

  • Global Doctor Clinic (Sumait Premmanisakul MD, Medical Director; G Floor, Holiday Inn Silom, Bangkok; ph. 66-2236-8444, mobile 661 8379957, email sumait@globaldoctorclinic.com; consultation by appointment or walk-in; also house calls; all medications made by international drug companies; most major credit cards accepted)
  • Bumrungrad International Hospital (33 Sukhumvit 3 (Soi Nana Nua), Wattana, Bangkok 10110; ph. 66-2-667-1000 - general, 667-2999 - emergency; website http://www.bumrungrad.com)
  • Samitivej Hospital (133 Sukhumvit 49, Vadhana, Bangkok 10110; ph. 66-2-392-0011 - general, 712-7007 - emergency; website http://www.samitivejhospital.com)
  • BNH Hospital (9/1 Convent Rd, Silom, Bangkok; ph. 66-2-686-2700; website http://www.BNHhospital.com; also offers an international travel clinic)

For infectious diseases, travelers can also go to the Thai Travel Clinic at the Hospital for Tropical Diseases, Mahidol University (420/6 Rajvithi Rd, Rajthewi Bangkok 10400; ph. 66-23549100 x1420, x1225; website www.thaitravelclinic.com)

For a guide to physicians and other hospitals in Thailand, go to the Welcome to Thailand document (Appendix K) on the U.S. Embassy website. Many doctors and hospitals will expect payment in cash, regardless of whether you have travel health insurance. Life-threatening medical problems may require air evacuation to a country with state-of-the-art medical facilities.

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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.

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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Embassy/Consulate Location

(reproduced from the U.S. State Dept. Consular Information Sheet)

Americans living in or visiting Thailand are encouraged to register, either online, or in person at the Consular Section of the U.S. Embassy in Bangkok or the U.S. Consulate General in Chiang Mai. At both locations, updated information on travel and security in Thailand is available. The Consular Section of the U.S. Embassy is located at 95 Wireless Road in Bangkok; the U.S. mailing address is APO AP 96546-0001. The central switchboard number is (66-2) 205-4000; the American Citizen Services Unit number is (66-2) 205-4049; and the fax number is (66-2) 205-4103. The web site for the U.S. Embassy is http://bangkok.usembassy.gov. American citizens can register online via the web site. Questions regarding American Citizens Services can be submitted by E-mail to acsbkk@state.gov. The U.S. Consulate General in Chiang Mai is located at 387 Wichayanond Road; the U.S. mailing address is Box, C, APO AP 96546. The telephone number is (66-53) 252-629, and the fax number is (66-53) 252-633.

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Safety information

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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