Chapter 117. Health Advice for International Travel (Part 3)

Rabies Domestic animals, primarily dogs, are the major transmitters of rabies in developing countries (Chap. 188). Several studies have shown that the risk of rabies posed by a dog bite in an endemic area translates into 1–3.6 cases per 1000 travelers per month of stay. Countries where canine rabies is highly endemic include Mexico, the Philippines, Sri Lanka, India, Thailand, and Vietnam. The three vaccines available in the United States provide 90% protection. Rabies vaccine is recommended for long-stay travelers, particularly children, and persons who may be occupationally exposed to rabies in endemic areas. Even after receipt of a...
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Chapter 117. Health Advice for International Travel (Part 3) Chapter 117. Health Advice for International Travel (Part 3) Rabies Domestic animals, primarily dogs, are the major transmitters of rabies indeveloping countries (Chap. 188). Several studies have shown that the risk ofrabies posed by a dog bite in an endemic area translates into 1–3.6 cases per 1000travelers per month of stay. Countries where canine rabies is highly endemicinclude Mexico, the Philippines, Sri Lanka, India, Thailand, and Vietnam. Thethree vaccines available in the United States provide >90% protection. Rabiesvaccine is recommended for long-stay travelers, particularly children, and personswho may be occupationally exposed to rabies in endemic areas. Even after receiptof a preexposure rabies vaccine series, two postexposure doses are required.Travelers who have had the preexposure series will not require rabies immuneglobulin (which is often unavailable in developing countries) if they are exposedto the disease. Prevention of Malaria and Other Insect-Borne Diseases It is estimated that more than 30,000 American and European travelersdevelop malaria each year (Chap. 203). The risk to travelers is highest in Oceaniaand sub-Saharan Africa (estimated at 1:5 and 1:50 per month of stay, respectively,among persons not using chemoprophylaxis); intermediate in malarious areas onthe Indian subcontinent and in Southeast Asia (1:250–1:1000 per month); and lowin South and Central America (1:2500–1:10,000 per month). Of the more than1000 cases of malaria reported annually in the United States, 90% of those due toPlasmodium falciparum occur in travelers returning or immigrating from Africaand Oceania. VFRs are at the highest risk of acquiring malaria. With theworldwide increase in chloroquine- and multidrug-resistant falciparum malaria,decisions about chemoprophylaxis have become more difficult. In addition, thespread of malaria due to primaquine- and chloroquine-resistant strains ofPlasmodium vivax has added to the complexity of treatment. The case-fatality rateof falciparum malaria in the United States is 4%; however, in only one-third ofpatients who die is the diagnosis of malaria considered before death. Several studies indicate that fewer than 50% of travelers adhere to basicrecommendations for malaria prevention. Keys to the prevention of malariainclude both personal protection measures against mosquito bites (especiallybetween dusk and dawn) and malaria chemoprophylaxis. The former measuresinclude the use of DEET-containing insect repellents, permethrin-impregnatedbed-nets and clothing, screened sleeping accommodations, and protective clothing.A new insect repellent containing picaridin as an active ingredient appears to bequite efficacious and is available in the United States only in low-concentrationformulations that require frequent reapplications. Thus, in regions whereinfections such as malaria are transmitted, DEET products (25–50%) arerecommended, even for children and infants >2 months of age. Personal protectionmeasures also help prevent other insect-transmitted illnesses, such as dengue fever(Chap. 189). Over the past decade, the incidence of dengue has increased,particularly in the Caribbean region, Latin America, and Southeast Asia. Denguevirus is transmitted by an urban-dwelling mosquito that bites primarily at dawnand dusk. Table 117-2 lists the currently recommended drugs of choice forprophylaxis of malaria, by destination. Table 117-2 Malaria Chemosuppressive Regimens According toGeographic Areaa Geographic Area Drug of Alternatives Choice Central America (north Chloroquine Mefloquineof Panama), Haiti, Dominican DoxycyclineRepublic, Iraq, Egypt, Turkey,northern Argentina, and Atovaquone/proguanilParaguay South America Mefloquine Primaquineincluding Panama (except Doxycyclinenorthern Argentina andParaguay); Asia (including Atovaquone-Southeast Asia); Africa; and proguanil (Malarone)Oceania Thai-Myanmar and DoxycyclineThai-Cambodian borders Atovaquone- proguanil (Malarone) a See CDCs Health Information for International Travel 2005–2006.Note: See also Chap. 203.