An outbreak of gastroenteritis was reported late last week among guests at the Bahia Principe Hotel, Río San Juan, province of Espaillat, affecting at least 450 people. Symptoms included vomiting and diarrhea, usually lasting around 24 hours. The cause has not yet been identified, but is probably viral.

A mumps outbreak has been reported from the Maritime Provinces (Nova Scotia, Brunswick, and Prince Edward Island). More than 200 cases have been identified, mostly in teenagers and young adults. A small number of cases have also been reported from Ontario. All travelers born after 1956 should make sure they have had either two documented mumps immunizations or a blood test showing mumps immunity. This does not apply to people born before 1957, who are presumed to be immune. Children greater than 12 months of age should be given two doses of MMR vaccine, separated by one month, before travel to the Maritime Provinces.

An outbreak of cryptosporidiosis, caused by contamination of the municipal water supply, has been reported from Galway, Ireland. Cryptosporidiosis is caused by an intestinal parasite which produces diarrhea and crampy abdominal pain, usually lasting 1-2 weeks. The disease may be especially severe in those with compromised immune systems, such as those infected with HIV. The infection is usually acquired by ingestion of contaminated water, but may also be transmitted by contaminated food and from person-to-person. Local health authorities advise that all water intended for drinking and food preparation, as well as brushing teeth, should be boiled before use.

A dengue fever alert has been declared for all of Paraguay, due to a rising number of cases in the departments of Asunción, Central, Amambay, Alto Paraná, Cordillera, and Guairá. Dengue fever is a flu-like illness sometimes complicated by hemorrhage or shock. The infection is transmitted by Aedes mosquitoes, which bite primarily in the daytime and favor densely populated areas, though they also inhabit rural environments. All travelers to Paraguay should protect themselves from mosquito bites by applying repellent and keeping themselves covered.

The malaria outbreak in Kingston appears to be subsiding, but new cases are still being reported. As of February 3, a total of 280 cases had been identified, including 264 in Kingston (chiefly from the areas of Delacree Park, Denham Town, Tivoli Gardens, Trench Town, and Greenwich), 12 in St. Catherine, 3 in St. Thomas, and one in Clarendon. The Centers for Disease Control has recommended chloroquine prophylaxis for all those staying overnight or longer in Kingston, but not for other travelers, i.e. malaria pills are not necessary for those transiting Kingston on their way to resorts or other areas. By contrast, European authorities have elected not to recommend antimalarial medications at this time. All authorities agree that travelers to Kingston should protect themselves from mosquito bites by applying repellent and keeping themselves covered.

A malaria outbreak has been reported from Kingston, causing 56 cases so far. The Centers for Disease Control has recommended chloroquine prophylaxis for all those staying overnight or longer in Kingston, but not for other travelers, i.e. malaria pills are not necessary for those transiting Kingston on their way to resorts or other areas. By contrast, European authorities have elected not to recommend antimalarial medications at this time. All authorities agree that travelers to Kingston should protect themselves from mosquito bites by applying repellent and keeping themselves covered.

An outbreak of Legionnaires' disease has been reported from the center of Venice, causing 15 cases, none of them fatal. The source of the outbreak has not yet been determined. 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. Any traveler who develops fever, cough, or chest tightness after visiting Venice should seek immediate medical attention.

An increase in the number of cases of Crimean-Congo hemorrhagic fever has been reported from Turkey, especially in Kelkit Valley in the northeastern part of the country. No cases have been reported from popular tourist resorts on the Mediterranean coast. Crimean-Congo hemorrhagic fever is a life-threatening viral infection which is usually transmitted by ticks. All travelers to northeastern Turkey should protect themselves from tick bites by applying repellent and keeping themselves covered. Also, tick checks should be performed at the end of each day.

An outbreak of Legionnaires' disease has been reported from Amsterdam, resulting in 23 confirmed cases, one of them fatal. The source was a cooling tower located next to a former Post Office building (Oosterdokskade) in the east-central part of the city. The cooling tower was taken out of operation on July 11. 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. Any traveler to Amsterdam who develops fever, cough, chest pain, or difficulty breathing should immediately seek medical attention.

An outbreak of malaria has been reported from Great Exuma, affecting 16 people, including one American and one Canadian tourist. No cases have been reported from the other islands. Since malaria does not normally occur in the Bahamas, the situation is expected to be temporary. For the time being, all travelers to Great Exuma should take weekly chloroquine and apply insect repellent to protect themselves from malaria. Symptoms of malaria may include fever, chills, headaches, and muscle aches. Any person who develops these symptoms after travel to the Bahamas should seek immediate medical attention.

An outbreak of mumps has been reported from lower Drave (Drau, Drava) valley in Carinthia, chiefly affecting the provinces of Kärnten (known in English as Carinthia, located in southern Austria), Niederösterreich and Wien (both in northeast Austria). The outbreak apparently began at an Easter festival in Feistritz on the Drave. All travelers born after 1956 should either make sure they have received two doses of MMR or mumps vaccine or have a blood test proving mumps immunity. Many adults born after 1956 and before 1970 received only one vaccination against mumps as children and should be given a second dose before travel. Those born before 1957 are presumed to be immune. Although mumps 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 Austria.

An outbreak of Legionnaires' disease has been reported from Pamplona, in the northern part of Spain. A total of 139 people have been affected so far. The source of the outbreak has not yet been determined. Legionnaires' disease is usually transmitted by airborne droplets from contaminated water sources, such as cooling towers. It is not transmitted from person-to-person.

A polio outbreak has been reported from Namibia, mostly in the Windhoek area. A total of 34 cases are under investigation, of which three have been confirmed. These are the first cases of polio in Namibia since 1996. 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 Namibia.

A cluster of 8 cases of avian influenza (bird flu) has been reported in an extended family from the village of Kubu Sembelang in the Karo district of North Sumatra. This has raised concerns that the virus might now be more capable of passing from human to human. However, DNA analysis indicates that the virus has not mutated. Since the outbreak started more than two years ago, a small number of human cases have been attributed to direct person-to-person spread, typically in a family member caring for an infected relative. There is no evidence at present that the outbreak in North Sumatra has spread beyond the initial family cluster. The World Health Organization (WHO) has not raised its level of pandemic alert. As before, the WHO does not advise against travel to Indonesia or any other country affected with avian influenza, 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 small number of human cases of avian influenza (bird flu) continue to be reported, mostly from Indonesia, Egypt, and China. A single human case has also been reported from Djibouti. No cases have been reported from Viet Nam or Thailand since late last year. Most importantly, there is no evidence that the virus has mutated to become more transmissible from person-to-person. Almost all human cases have occurred in those who have had direct contact with infected poultry. As before, travelers should not hesitate to visit countries affected by avian influenza, but 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 malaria outbreak has been reported from the northeastern state of Assam, causing approximately 500 deaths so far. Malaria prophylaxis is recommended for travel to all parts of India, except for high-altitude areas in the states of Himachal Pradesh, Jammu, Kashmir, and Sikkim. Travelers should also protect themselves from mosquito bites by applying repellent and keeping themselves covered.

A major outbreak of mumps has reported from the state of Iowa, affecting almost a thousand people. A smaller number of cases have been reported from the states of Minnesota, Kansas, Illinois, Nebraska, Wisconsin, Missouri and Oklahoma. Most have occurred in those between the ages of 18 and 25. Mumps is a viral infection which is spread by direct contact with or inhalation of oral or nasal secretions from an infected person. All travelers should make sure they have received mumps vaccine, which is one of the routine childhood immunizations.

An outbreak of botulism has been reported among people who had eaten home-preserved bamboo shoots at a local village Buddhist festival in Baan Luang District, Nan Province. Symptoms included dry mouth, difficulty swallowing, slurred speech, drooping eyelids, double vision, abdominal discomfort, and muscle weakness. Forty people had to be placed on ventilators, but there were no fatalities.

Outbreaks of chikungunya fever, which is transmitted by mosquito bites, have been reported from the southern states of Andhra Pradesh, Maharashtra, and Karnataka. Symptoms 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. There is no vaccine for chikungunya fever. Insect protection measures are strongly recommended.

A large measles outbreak has been reported from the Ukraine, totaling more than 17,000 cases. The outbreak appears to have started in Kiev, but cases have now been reported from all parts of the country. 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, consider giving an initial dose of measles vaccine to children between the ages of 6 and 11 months who will be traveling to the Ukraine.

An outbreak of hand, foot, and mouth disease has been reported from Sarawak state on the island of Borneo, affecting more than 3000 children and causing five deaths. Hand, foot, and mouth disease is a viral infection that is transmitted by exposure to fecal material from infected individuals. Most cases occur in infants and 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). The key to prevention is good personal hygiene and scrupulous hand-washing, especially after defecation and before handling food.

A measles outbreak has been reported from northern Greece, chiefly affecting children and young adults. 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, consider giving an initial dose of measles vaccine to children between the ages of 6 and 11 months who will be traveling to Greece, especially the northern part of the country.

Avian influenza (bird flu) has now spread to a large number of countries in Asia, Europe, and Africa. Cases have been reported among birds in Austria, Azerbaijan, Bulgaria, Cambodia, China, Croatia, Egypt, Germany, Greece, Hong Kong, India, Indonesia, Iran, Italy, Kazakhstan, Malaysia, Mongolia, Nigeria, Romania, Russia, Slovenia, Thailand, Turkey, Ukraine, and Vietnam. A small number of human cases are being identified, but almost all are occurring in those who have had direct contact with live, infected poultry. There is no evidence at present that the virus has acquired the ability to pass easily from person-to-person.

An outbreak of Chikungunya fever, a mosquito-borne illness characterized by fever and incapacitating joint pains, has been reported from Reunion. Transmission has been especially active in the district of Saint-Pierre in the south of the island, particularly in the city of Saint-Louis. Cases have also occurred in the cities of Saint-Denis and Le Port. Symptoms of Chikungunya fever include fever, joint pains, muscle aches, headache, and rash. The disease is rarely fatal, but may be complicated by protracted fatigue and malaise. All travelers to Reunion should use insect repellents and keep themselves covered to prevent mosquito bites.

A total of 18 human cases of avian influenza (bird flu) have now been identified in Turkey. Cases have been reported from nine of the country's 81 provinces, including Ankara. As in other countries, virtually all cases have resulted from direct contact with diseased birds. There has been no evidence of person-to-person transmission. Most travelers are at extremely low risk for avian influenza.

The first two human cases of avian influenza (bird flu) have been reported from Turkey. The cases occurred in a brother and sister living in the rural district of Dogubayazit, in the eastern province of Agri, bordering Iran and Armenia. The district has been placed under quarantine as other possible cases are investigated. 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 countries affected by avian influenza should seek immediate medical attention. It is not recommended that travelers bring along an antiviral medication, such as Tamiflu, or treat themselves.

A rabies outbreak has been reported from rural areas in the northeastern state of Maranhao. The cases appear to have been caused by bites from vampire bats, which proliferated after destruction of local forests. Earlier this year, a rabies outbreak was reported from the neighboring state of Para. Rabies vaccine should be considered for those making extended trips to remote areas in the northeastern and northern regions of Brazil.

The Chinese government has confirmed its first three human cases of avian influenza("bird flu"), two from Anhui Province and one from Hunan Province. Outbreaks of avian influenza have been reported from poultry farms in many parts of the country since January 2004. 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 countries affected by avian influenza should seek immediate medical attention. It is not recommended that travelers bring along an antiviral medication, such as Tamiflu, or treat themselves.

Two cases of yellow fever have been reported from the central state of Portuguesa. Yellow fever vaccine is recommended for all travelers to Venezuela, except those visiting only Caracas, Valencia, and the northern coastal areas.

An outbreak of hepatitis A has been reported from the Nizhniy Novgorod region, chiefly the city of Nizhniy Novgorod (known as Gorky in the Soviet period). Cases have also been reported from Balakhna and Dzerzhinsk, to the north and west of Nizhniy Novgorod, respectively. More than 2000 people have been affected. The outbreak is thought to be related to delayed repair of a network of waterpipes, though this remains uncertain. Hepatitis A vaccine is recommended for all travelers to Russia.

Because of the occurrence of new cases of malaria among travelers to the Punta Cana resort area, the Centers for Disease Control has reinstituted its recommendation that all travelers to La Altagracia Province, which includes Punta Cana, should take malaria drugs.

A new case of malaria has been reported in a traveler to Bavaro Beach, indicating that there is still a low degree of malaria risk in resort areas at the eastern end of the island. The Centers for Disease Control and Health Canada no longer recommend malaria prophylaxis for resort areas, whereas French and British authorities continue to recommend weekly chloroquine for all travelers to the Dominican Republic.

Outbreaks of avian influenza ("bird flu") have been reported from poultry farms in Turkey and Romania. No human cases have been reported from these countries to date. 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 countries affected by avian influenza, 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 countries affected by avian influenza should seek immediate medical attention. It is not recommended that travelers bring along an antiviral medication, such as Tamiflu, or treat themselves.

An outbreak of dengue fever has been reported from Singapore, affecting more than 10,000 people. Dengue fever is a flu-like illness which is sometimes complicated by hemorrhage or shock. The infection 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. All travelers to Singapore should protect themselves from mosquito bites by applying insect repellent and keeping themselves covered.

An outbreak of Japanese encephalitis has been reported from Nepal, chiefly the western, mid-western and far-western regions of the country. Japanese encephalitis is a life-threatening viral infection transmitted by Culex mosquitoes, which breed in ground pools, especially flooded rice fields, and bite primarily after dusk. Japanese encephalitis vaccine is not recommended for all travelers to Nepal, but is advised for those who will be visiting rural areas for more than one month or who may engage in extensive unprotected outdoor activities in rural areas, especially in the evening, during shorter trips. All travelers to Nepal should protect themselves from mosquito bites by applying insect repellent and keeping themselves covered.

An outbreak of Japanese encephalitis has been reported from the northern Indian state of Uttar Pradesh, chiefly among young children and others living in rural areas. Japanese encephalitis is a life-threatening viral infection transmitted by Culex mosquitoes, which breed in ground pools, especially flooded rice fields, and bite primarily after dusk. Japanese encephalitis vaccine is not recommended for all travelers to Uttar Pradesh, but is advised for those who will be visiting rural areas for more than one month or who may engage in extensive unprotected outdoor activities in rural areas, especially in the evening, during shorter trips. All travelers to India should protect themselves from mosquito bites by applying insect repellent and keeping themselves covered.

A yellow fever outbreak has been reported from the region of Fouta Djalon. Four cases and three deaths have been reported from Mamou, which acts as an important transport hub in the country, and three cases and one death have been reported from Dalaba, which is 50 km from Mamou. Yellow fever is a life-threatening viral infection which is transmitted by mosquitoes. Yellow fever vaccine is recommended for all travelers to Guinea.

Cholera outbreaks have been reported from a number of West African countries, including Burkina Faso, Guinea, Guinea-Bissau, Mali, Mauritania, Liberia, Niger, and Senegal. Cholera vaccine is not generally advised, since most travelers at low risk for infection. Two oral vaccines have recently been developed but are not yet approved in many countries, including the United States. Where available, cholera vaccine may be considered 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.

An outbreak of dengue fever has been reported from Calcutta, affecting the affluent as well as the poorer neighborhoods. Dengue fever is a flu-like illness which is sometimes complicated by hemorrhage or shock. The infection 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. All travelers to Calcutta and other parts of India should protect themselves from mosquito bites by applying insect repellent and keeping themselves covered.

A cluster of E. coli O157 infections has been reported among Scottish tourists who stayed in coastal resorts of the southwest province of Mugla and the southern province of Antalya. The source of infection has not been determined. E. coli O157 frequently causes bloody diarrhea and may lead to kidney failure. Any traveler to Turkey who develops bloody diarrhea should immediately seek medical attention.

The outbreak of meningococcal disease in Anhui Province appears to have ended. Meningococcal vaccine is no longer recommended for travelers to China.

An outbreak of Streptococcus suis infections has been reported from Sichuan Province, related to a concurrent outbreak in the pig population. 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, bleeding under the skin, toxic shock, and coma. 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.

The first human case of avian influenza ("bird flu") has been reported from Indonesia. The individual lived in Tangerang, Banten Province. Other possible cases are under investigation. 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 Indonesia, 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 Indonesia should seek immediate medical attention, which may include testing for avian influenza.

Cases of dengue fever have been reported among American travelers who visited Jaco in late May and June. The Costa Rican Ministry of Health has responded by improving surveillance and mosquito control measures. Dengue outbreaks are reported annually from Costa Rica. Dengue fever is a flu-like illness which may be complicated by hemorrhage or shock. The disease 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. Travelers to Costa Rica should protect themselves from mosquito bites by applying insect repellent and keeping themselves covered.

The outbreak of meningococcal disease in New Delhi has been declared over. Meningococcal vaccine is no longer recommended for travelers to New Delhi.

A malaria outbreak has been reported from the northeastern state of Assam, affecting more than 10,000 people and causing at least 25 deaths. The outbreak appears to be related to heavy rains, which amplified the mosquito population. Previously, malaria outbreaks were reported from Assam in the summers of 2001 and 2002. All travelers to India should protect take either Lariam (mefloquine), Malarone, or doxycycline as malaria prophylaxis, and should protect themselves from mosquito bites by applying insect repellent and keeping themselves covered.

An outbreak of Ebola hemorrhagic fever has been reported from Etoumbi and Mbomo, Cuvette Ouest region. At least three other Ebola outbreaks have occurred in the Cuvette Ouest region since December 2001. Ebola virus is usually spread by direct contact with secretions from infected persons, typically in the home, at a funeral, or in a health care facility. Travelers to the Congo should refrain from visiting households possibly affected by Ebola and should not participate in funeral rites, which usually involve close contact with the body of the deceased. Those who care for Ebola patients should wear protective gowns, gloves, and masks, as well as eye protection or a face shield. Travelers should also avoid eating meat from wild animals, especially primates, which may be sold in markets as "bushmeat".

The Centers for Disease Control has lifted its recommendation that visitors to Punta Cana should take malaria prophylaxis. The outbreak was terminated by an intensive program of mosquito control. No cases of malaria have been reported among travelers to Punta Cana since early January.

No cases of malaria have been reported among visitors to the Punta Cana resort area since early January. Health Canada has withdrawn its recommendation that travelers to Punta Cana should take chloroquine to prevent malaria, but still advises the use of personal protective measures, including insect repellents, to reduce the likelihood of mosquito bites. The Centers for Disease Control continues to recommend weekly chloroquine for all travelers to Punta Cana and other areas in La Altagracia Province.

An outbreak of meningococcal disease has been reported from Delhi, resulting in 111 cases and 15 deaths as of May 6. Most cases have occurred in young adults, and most have been reported from Old Delhi. Meningococcal infections are spread person-to-person by exposure to secretions from the nose or throat, and may lead to meningitis, marked by the abrupt onset of fever, headache, stiff neck, and lethargy, frequently with a rash. Pending further information, meningococcal vaccine is recommended for all travelers to Delhi, especially if close contact with the local populace is likely.

A case of polio has been confirmed in an 18-month-old child in Giri Jaya village, Sukabumi district, West Java. This is the first case of polio seen in Indonesia since 1995. A number of other possible cases have been identified and are under investigation. The government has responded by initiating a massive nationwide immunization campaign. 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.

A polio outbreak has been reported from six governorates in Yemen. These are the first polio cases reported from Yemen since 1996. The government has responded by starting a nationwide immunization campaign. 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.

An outbreak of cryptosporidiosis has been reported among visitors to Auchingarrich Wildlife Centre in Perthshire, Scotland, in the northeastern part of the country. At least one case has been identified in a non-Scottish visitor. Cryptosporidiosis is caused by an intestinal parasite, which produces abdominal discomfort and diarrhea, typically lasting 1-2 weeks. Most cases resolve uneventfully.

An outbreak of Chagas disease has been reported from Santa Catarina in southern Brazil, an area frequented by international tourists. More than 90% of those affected consumed sugar cane juice (garapa) from a single establishment, Kiosk Barracao da Penha 2, between the municipalities of Navegantes and Pen-ha, on the side of the BR-101 highway by Kilometer 111. Anyone who consumed sugar cane juice from this establishment in February or March, 2005, should seek immediate medical attention.

An outbreak of Marburg hemorrhagic fever has been reported from Uige Province in northern Angola. As of March 23, a total of 102 cases had been identified, of which 95 were fatal. Initial symptoms of Marburg fever may include fever, chills, and muscle aches, followed by the appearance of a rash. Complications may include jaundice, confusion, shock, hemorrhage, and kidney failure.

Transmission of Marburg virus, which is closely related to Ebola virus, is thought to require direct contact with blood or body fluids from infected persons. Those at greatest risk include health care workers and family members of those affected. Those who care for Marburg patients should wear protective gowns, gloves, and masks, as well as eye protection or a face shield. To date, no foreign nationals, except those involved in direct patient care, have been infected. Most travelers appear to be at extremely low risk. Travelers who have visited Angola should seek immediate medical attention if they develop a fever within 10 days of leaving the country. No travel restrictions are advised for Angola at this time.

An outbreak of meningococcal disease has been reported from Chad, particularly the districts of Bongor and Moissal. Meningococcal infections are spread person-to-person by exposure to secretions from the nose or throat. The most feared complication is meningitis, marked by the abrupt onset of fever, headache, stiff neck, and lethargy, frequently with a rash. If not treated promptly, usually with penicillin, the infection may lead to coma and death. Meningococcal vaccine is recommended for all travelers to Chad.

An outbreak of probable measles has been reported from 12 Local Government Areas (LGAs) of Adamawa state. Measles outbreaks have also been reported recently from the states of Gombe, Jigawa, Kaduna, Kano, and Kebbi. 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, consider giving an initial dose of measles vaccine to children between the ages of 6 and 11 months who will be traveling to Nigeria.

An outbreak of meningococcal disease has been reported from 11 cities in Anhui Province in eastern China. Meningococcal infections are spread person-to-person by exposure to secretions from the nose or throat. The most feared complication is meningitis, marked by the abrupt onset of fever, headache, stiff neck, and lethargy, frequently with a rash. If not treated promptly, usually with penicillin, the infection may lead to coma and death. Meningococcal vaccine should be considered for all travelers to Anhui Province, especially those who expect to be in close contact with the local population.

At least 12 human cases of avian influenza (bird flu) have occurred in Viet Nam since the middle of December. Nine have been fatal. Most travelers appear to be at extremely low risk, since almost all 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 Viet Nam, 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. Anyone who develops fever and flu-like symptoms after travel to Viet Nam should seek immediate medical attention, which may include testing for avian influenza.

A large outbreak of tetanus has been reported among tsunami survivors in Sumatra. A tetanus booster is recommended for all travelers to tsunami-affected areas in any country if the last tetanus immunization was 5 years ago or more. All wounds should be thoroughly cleansed with soap and water.

An outbreak of a meningococcemia-like illness has been reported from Baguio City. A total of 33 cases and 19 deaths have been identified to date, eight of which have been confirmed by blood cultures as meningococcal infections. Pending further information, meningococcal vaccine is recommended for all travelers to Baguio City. There is no travel advisory against travel to the Philippines.

Two cases of malaria have been reported in American travelers to Punta Cana (La Altagracia Province) and San Francisco de Macoris (Duarte Province). At least two additional cases have been reported in European travelers to Punta Cana. Prophylaxis with chloroquine is now recommended for all travelers to La Altagracia Province, including the Punta Cana area, and Duarte Province, as well as personal protection measures to prevent mosquito bites. The CDC advises that, if these recommendations are followed, the risk of malaria is extremely low, and does not advise any change in travel plans.

An outbreak of hepatitis A has been reported among German tourists who had stayed at a particular hotel by the Red Sea. Any traveler to Egypt who develops symptoms of hepatitis A, which may include fever, malaise, jaundice, nausea, vomiting, and abdominal pain, should immediately seek medical attention. Immunization against hepatitis A is recommended for all trips to Egypt.

An outbreak of viral meningitis has been reported from Puerto Rico, chiefly the southern part of the country (Patillas, Arroyo, Santa Isabel, Salinas, and Guayama), though cases have been reported elsewhere. Most cases have occurred in young children. The outbreak has been caused by echovirus 30, which does not in general lead to serious illness. All cases have resolved uneventfully. No travel precautions are recommended except for careful attention to hand washing and personal hygiene.

Three deaths from avian influenza (bird flu) have been reported from Viet Nam, two from Ha Tay province in the north and one from Hau Giang province in the south. These human cases have occurred at the same time that new outbreaks of avian influenza are being reported from poultry farms throughout the country. Almost all human cases of avian influenza have occurred in those who have had direct contact with live, infected poultry. Most travelers appear to be at extremely low risk. As a precaution, travelers to Viet Nam should avoid exposure to live poultry, including visits to poultry farms and open markets with live birds, and should make sure all poultry and egg products are thoroughly cooked. There is no advisory against travel to Viet Nam.

New outbreaks of avian influenza (bird flu) have been reported from poultry farms in China, Thailand, Viet Nam, and Indonesia. No new human cases have been reported. Almost all human cases of avian influenza have occurred in those who have had direct contact with live, infected poultry. Most travelers appear to be at extremely low risk. As a precaution, travelers to Southeast Asia should avoid exposure to live poultry, including visits to poultry farms and open markets with live birds, and should make sure all poultry and egg products are thoroughly cooked. There is no advisory against travel to Southeast Asia.

Two cases of Japanese encephalitis, a life-threatening viral infection transmitted by mosquitoes, usually in rural areas, have been reported from Hong Kong. The cases appear to be unrelated. There is no evidence at present of an outbreak. No special precautions are recommended for travel to Hong Kong at this time. Specifically, Japanese encephalitis vaccine is not recommended for travel to Hong Kong.

A measles outbreak has been reported from Distrito Federal, Estado de Mexico, and Hidalgo. 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.

Four new cases of severe acute respiratory syndrome (SARS) have been reported from China. Two of the cases occurred in laboratory workers who had been performing research with the SARS virus. The other two cases occurred in people who had been caring for one of the laboratory workers after she became ill. There is no evidence that the SARS virus has reentered the general population. No travel advisories have been issued for China at this time.

An outbreak of measles has been reported among adoptees from the Zhuzhou Child Welfare orphanage in the Hunan Province of China. 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 1957, who are presumed to be immune to measles.