cdc travel yellow book

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About the 2020 Yellow Book: Front Matter

Publishing reference.

• Contributors

Acknowledgments

The front matter from the printed edition of CDC Yellow Book 2020: Health Information for International Travel, pages iii-xxvii, is included here.

Editors in Chief

Gary W. Brunette, MD, MS and Jeffrey B. Nemhauser, MD

CHIEF MEDICAL EDITOR

Phyllis E. Kozarsky, MD

Medical Editors

Kristina M. Angelo, DO, MPH&TM Nicole J. Cohen, MD, MS Douglas H. Esposito, MD, MPH Stephen M. Ostroff, MD Edward T. Ryan, MD David R. Shlim, MD Richard W. Steketee, MD, MPH Michelle Weinberg, MD, MPH Mary Elizabeth Wilson, MD

MANAGING EDITOR

Jenique Meekins

TECHNICAL EDITOR

Ronnie Henry

US DEPARTMENT OF HEALTH AND HUMAN SERVICES PUBLIC HEALTH SERVICE CENTERS FOR DISEASE CONTROL AND PREVENTION NATIONAL CENTER FOR EMERGING AND ZOONOTIC INFECTIOUS DISEASES DIVISION OF GLOBAL MIGRATION AND QUARANTINE ATLANTA, GEORGIA OXFORD UNIVERSITY PRESS

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© Oxford University Press 2019

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CIP data is on file at the Library of Congress ISBN 978–0–19–092893–3 (pbk.) ISBN 978–0–19–006597–3 (hbk.) 9 8 7 6 5 4 3 2 1 Paperback and Hardback printed by LSC Communications, United States of America

Oxford University Press is proud to pay a portion of its sales for this book to the CDC Foundation. Chartered by Congress, the CDC Foundation began operations in 1995 as an independent, nonprofit organization fostering support for CDC through public-private partnerships. Further information about the CDC Foundation can be found at www.cdcfoundation.org . The CDC Foundation did not prepare any portion of this book and is not responsible for its contents.

All CDC material in this publication is in the public domain and may be used and reprinted without special permission; however, citation of the source is appreciated.

Suggested Citation

Centers for Disease Control and Prevention. CDC Yellow Book 2020: Health Information for International Travel. New York: Oxford University Press; 2017.

Readers are invited to send comments and suggestions regarding this publication to Gary W. Brunette, Editor-in-Chief, Centers for Disease Control and Prevention, Division of Global Migration and Quarantine), Travelers’ Health Branch (proposed), 1600 Clifton Road NE, Mail Stop E-28, Atlanta, GA 30333, USA.

Disclaimers

Both generic and trade names (without trademark symbols) are used in this text. In all cases, the decision to use one or the other was made based on recognition factors and was done for the convenience of the intended audience. Therefore, the use of trade names and commercial sources in this publication is for identification only and does not imply endorsement by the US Department of Health and Human Services, the Public Health Service, or CDC.

Descriptions of drugs, biologics, or medical products used for an indication not in the approved labeling or packaging (“off-label” uses) do not constitute official HHS approval or endorsement of those products or uses. The uses described in this publication have been identified by subject-matter experts on the basis of published evidence and clinical experience. Clinicians who use a product for an off-label use should be well informed about the product, base its use on firm scientific rationale and sound medical evidence, and maintain records of the product’s use and effects.

References to non-CDC Internet sites are provided as a service to readers and do not constitute or imply endorsement of these organizations or their programs by the US Department of Health and Human Services, the Public Health Service, or CDC. CDC is not responsible for the content of these sites. URL addresses were current as of the date of publication.

Boundaries and labels shown on maps are not necessarily authoritative.

This material is not intended to be, and should not be considered, a substitute for medical, legal, or other professional advice. Treatment for the conditions described in this material is highly dependent on the individual circumstances. While this material is designed to offer accurate information with respect to the subject matter covered and to be current as of the time it was written, research and knowledge about medical, legal, and health issues are constantly evolving, and dose schedules for medications and vaccines are being revised continually, with new side effects recognized and accounted for regularly. Therefore, readers must always check the product information and clinical procedures with the most up-to-date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulation. Oxford University Press and the authors make no representations or warranties to readers, express or implied, as to the accuracy or completeness of this material, including without limitation that they make no representations or warranties as to the accuracy or efficacy of the drug dosages mentioned in the material. The authors and the publishers do not accept, and expressly disclaim, any responsibility for any liability, loss, or risk that may be claimed or incurred as a consequence of the use and/or application of any of the contents of this material.

The Publisher is responsible for author selection, and the Publisher and the Author(s) make all editorial decisions, including decisions regarding content. The Publisher and the Author(s) are not responsible for any product information added to this publication by companies purchasing copies of it for distribution to clinicians.

For additional copies, please contact Oxford University Press. Order online at www.oup.com/us .

CDC Contributors

Abe, Karon Acosta, Anna Ali, Ibne Alvarado-Ramy, Francisco Angelo, Kristina Ansari, Armin Anstey, Erica Appiah, Grace Arboleda, Nelson Arguin, Paul M. Baggett, Henry C. Ballesteros, Michael F. Barton Behravesh, Casey Beavers, Suzanne Beckman, Michele G. Benedict, Katherine Benowitz, Isaac Biggs, Holly Blaney, David D. Bonilla, Luis Brogdon, William G. Brooks, John T. Brown, Clive M. Bruce, Beau Brunette, Gary W. Cantey, Paul T. Cardemil, Cristina V. Chatham-Stevens, Kevin Chiller, Tom M. Choi, Mary Joung Clemmons, Nakia S. Cooley, Laura Cope, Jennifer Czarkowski, Alan G. Dionne-Odom, Jodie Dubray, Christine Duong, Krista Kornylo Edelson, Paul Eichwald, John Erskine, Stefanie K. Esposito, Douglas H. Estivariz, Concepcion Fischer, Marc Francois Watkins, Louise K. Friedman, Cindy R. Fry, Alicia Gaines, Joanna Galland, G. Gale Galloway, Renee L. Gastañaduy, Paul A. Gee, Jay E. Geissler, Aimee L. Gerber, Susan I. Gershman, Mark D. Goodson, James L. Goswami, Neela Gould, Carolyn Green, Michael D. Griffin, Patricia M. Hall, Aron J. Hall, Rebecca Ham, David Harris, Aaron Harvey, Pauline Hawley, William A. Healy, Jessica Hendricks Walters, Kate Henry, Ronnie Herwaldt, Barbara L. Hill, Vincent Hills, Susan L. Hinton, Cindy Hlavsa, Michele C. Hughes, Mike Hunter, Jennifer C. Jackson, Brendan Jentes, Emily S. Jones, Jeffrey L. Jungerman, Robynne M. Kersh, Gilbert J. Kharod, Grishma A. Knust, Barbara Kozarsky, Phyllis E. Kroger, Andrew T. Lanzieri, Tatianna Laughlin, Mark Lee, Keun Lessa, Fernanda C. Lindsey, Nichole LoBue, Philip Lopez, Adriana S. Lutgring, Joseph MacArthur, John Maloney, Susan A. Marano, Nina Marin, Mona Marlow, Mariel A. Marston, Chung K. Martin, Diana L. Martin, Stacey McCollum, Andrea M. McCotter, Orion Z. McFarland, Jeffrey McNamara, Lucy Mead, Paul S. Meyer, Sarah A. Mintz, Eric D. Montgomery, Susan Montiel, Sonia H. Moore, Matt Morales, Michelle Morof, Diane F. Moser, Kathleen Mott, Joshua Mounts, Anthony Mullan, Robert J. Mutebi, John-Paul Ncho, Hammad Negron, Maria E. Nelson, Christina A. Nelson, Noele P. Nicholson, William L. Paddock, Christopher D. Park, Benjamin Patel, Manisha Patimeteeporn, Calvin Perez-Padilla, Janice Peters, Philip J. Peterson, Brett W. Powers, Ann M. Rabold, Elizabeth Raczniak, Gregory A. Reef, Susan E. Reyes, Nimia L. Robinson, Candice Roellig, Dawn Roguski, Katherine Rollin, Pierre E. Routh, Janell Roy, Sharon Russell, Michelle Santelli, Ana Carolina Sauber-Schatz, Erin K. Schafer, Ilana J. Schmid, D. Scott Sharp, Tyler M. Shoemaker, Trevor Skoff, Tami H. Sleet, David A. Sotir, Mark J. Spradling, Phil Staples, J. Erin Stauffer, Kendra Stoddard, Robyn A Stoney, Rhett J Straily, Anne Tan, Kathrine R. Tardivel, Kara Teshale, Eyasu Tiller, Rebekah Tiwari, Tejpratap S. P. Uribe, Carolina Vieira, Antonio Villarino, Margarita E. Walker, Allison Taylor Wallace, Ryan M. Wassilak, Steven G. F. Waterman, Stephen H. Watson, John T. Weinberg, Michelle S. White, Stephanie Wien, Simone Winstead, Allison Wong, Karen K. Workowski, Kimberly

External Contributors

The CDC Yellow Book 2020: Health Information for International Travel editorial team gratefully acknowledges all the authors and reviewers for their commitment to this new edition. We extend sincere thanks to the following people for their contributions to the production of this book:

• Kelly M. Winter for serving in the role of managing editor and guiding this edition through the first half of production.
• Elise Beltrami, Nicole Cohen, Rachel Eidex, and Scott Santibanez for their extensive review of the text.
• Maeghan Dessecker, Johanzynn Gatewood, and Calvin Patimeteeporn for their assistance in preparing the text for publication.

To stay on the cutting edge of travel health information, this latest edition of the CDC Yellow Book 2020: Health Information for International Travel has been extensively revised. The book serves as a guide to the practice of travel medicine, as well as the authoritative source of US government recommendations for immunizations and prophylaxis for foreign travel. As international travel continues to become more common in the lives of US residents, having at least a basic understanding of the medical problems that travelers face has become a necessary aspect of practicing medicine. The goal of this book is to be a comprehensive resource for clinicians to find the answers to their travel health–related questions.

Centers for Disease Control and Prevention

Robert R. Redfield, MD, Director

National Center for Emerging and Zoonotic Infectious Diseases

Rima Khabbaz, MD, Director

Division of Global Migration and Quarantine

Martin S. Cetron, MD, Director Gary W. Brunette, MD, MS, Chief, Travelers’ Health Branch Jeffrey B. Nemhauser, MD, Chief Medical Officer, Travelers’ Health Branch Jenique Meekins, Health Communications Specialist, Travelers’ Health Branch

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CDC Yellow Book 17+

Travel health information, unbound medicine, inc., designed for ipad.

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FREE PREVIEW – Experience the 2020 Yellow Book to see the value of having the latest trusted travel information when and where it's needed. **U.S. Government’s Most Current and Trusted Travel Health Guidelines** Preview, Buy, or Sign In using this app. FREE PREVIEW – Experience the Yellow Book to see the value of having trusted travel information when and where it's needed. ABOUT YELLOW BOOK The fully revised and updated 2020 CDC Yellow Book app delivers the U.S. government’s most current travel health guidelines, including pre-travel vaccine recommendations, destination-specific health advice, and easy-to-reference maps, tables, and charts. Authored by a team of the world’s most esteemed travel medicine experts, this app best codifies the U.S. Government’s latest travel guidelines to staying healthy anywhere in the world. Review dedicated topics on emerging infectious disease threats such as Zika, Ebola, and MERS, new cholera vaccine recommendations, updated guidance on the use of antibiotics to treat traveler’s diarrhea, special considerations for unique types of travel (i.e. wilderness expeditions, work-related travel, and studying abroad), and fully revised advice for specific destinations in international travel. FEATURES • Pre-travel vaccinations and preventative care • Destination specific guidelines with sections on Cuba and Burma • Advice for travelers with specific health needs (pregnant women, travelers with chronic illness, etc.) • Practical tips for last minute or resource limited travelers • Recommendations for air crews, humanitarian workers, missionaries, and others who provide care and support overseas • Easy to use reference maps, tables, and charts • Notes for making custom notes and highlights within entries • Full Text Search to find specific topics quickly • "Favorites" for bookmarking important topics EDITOR-IN-CHIEF: Gary W. Brunette Publisher: Oxford University Press Powered by: Unbound Medicine Unbound Privacy Policy: www.unboundmedicine.com/privacy Unbound Terms of Use: https://www.unboundmedicine.com/end_user_license_agreement

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Clarification.

Clarification on all the bad reviews. The info is great and if you live in the developing world and see patients it is invaluable. Great info without a WiFi. It is a trial version. It lists all the topics you can see with a subscription. I think people just want everything for free nowadays. It’s a great app.

Developer Response ,

Thank you for taking the time to write this thoughtful review. We are so glad to hear you find this to be a valuable resource.

Not really a preview

I don’t think any reasonable man would call this a “Preview.” Once you waste your time and data downloading the app, you will ONLY have access to a “water disinfection for travelers” document. If you want to know what the app contains and how it functions you’ll have to pay $30 or just go to the CDC website where it’s free.

We appreciate your feedback. The current Preview version offers 11 available entries in the "Contents" section and 46 available entries within the "Topics" section to aid in a user's decision whether to purchase. Purchasing an account unlocks the remaining content and also grants the ability to add Favorites and Notes so that you can easily return to entries that are important. Also, once the content has been synced to your device, it is accessible without an internet connection. These perks set the mobile app apart from accessing the content online.

Don’t waste your time - go to CDC instead

Complete waste of time. The “previews” are no such thing and nearly all information is behind a $30 paywall. Don’t bother with this cash grab. Go to the CDC website where all the information is available freely. It is disgraceful that a public health info resource like this that is already paid for by taxpayers and donations *and* that has all the info for free on the CDC website is being sold here for a hefty profit. Absolutely shameful behavior. A minor convenience fee of $1-$3 or so would be perfectly fine, but present cost is criminal.

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CDC Yellow Book: A Vital Resource for International Travelers

Written by a team of CDC experts on the forefront of travel medicine, the Yellow Book provides a user-friendly, vital resource for those in the business of keeping travelers healthy abroad. 

The 2018 edition, released this week, serves as the U.S. government’s most current health guidelines and information for international travelers, including pre-travel vaccine recommendations, destination-specific advice, and easy-to-reference maps, tables and charts.

The 2018 Yellow Book includes important travel medicine updates, including:

• The latest information about emerging infectious disease threats such as Zika, Ebola and MERS
• New cholera vaccine recommendations
• Updated guidance on the use of antibiotics in the treatment of travelers’ diarrhea
• Special considerations for unique types of travel, such as wilderness expeditions, work-related travel and study abroad
• Destination-specific recommendations for popular itineraries, including new sections for travelers to Cuba and Burma

Learn more about the 2018 edition of the Yellow Book on CDC’s website. Order the 2018 edition online through Oxford University Press here .

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On the Bookshelf — CDC Health Information for International Travel (Yellow Book)

Published on Jun 21, 2016

The Pretravel Consultation

The pretravel consultation offers a dedicated time to prepare travelers for the health concerns that might arise during their trips. The objectives of the pretravel consultation are to:

• Perform an individual risk assessment.
• Communicate to the traveler anticipated health risks.
• Provide risk management measures, including immunizations, malaria prophylaxis, and other medications as indicated.

The Travel Medicine Specialist

Travel medicine specialists have in-depth knowledge of immunizations, risks associated with specific destinations, and the implications of traveling with underlying conditions. Therefore, a comprehensive consultation with a travel medicine expert is indicated for all travelers, and is particularly important for those with a complicated health history, special risks (such as traveling at high altitudes or working in refugee camps), or exotic or complicated itineraries. Clinicians who wish to be travel medicine providers are encouraged to join the International Society of Travel Medicine (ISTM) and consider specialty training and certification.

Components of a Pretravel Consultation

Effective pretravel consultations require attention to the health background of the traveler and incorporate the itinerary, trip duration, travel purpose, and activities, all of which determine health risks (Table 2-1 ). The pretravel consultation is the major opportunity to educate the traveler about health risks at the destination and how to mitigate them. The typical pretravel consultation does not include a physical examination; a separate appointment with the same or a different provider may be necessary to assess a person’s fitness to travel. Because travel medicine clinics are not available in some communities, primary care physicians should seek guidance (by phone or other communication, if available) from travel medicine specialists to address areas of uncertainty.

Travel health advice should be personalized, highlighting the likely exposures and also reminding the traveler of ubiquitous risks, such as injury, foodborne and waterborne infections, vectorborne disease, respiratory tract infections, and bloodborne and sexually transmitted infections. Balancing the cautions with an appreciation of the positive aspects of the journey leads to a more meaningful pretravel consultation. Attention to the cost of recommended interventions may be critical. Some travelers may not be able to afford all of the recommended immunizations and medications, a situation that requires prioritizing interventions. (See Prioritizing Care for the Resource-Limited Traveler later in this chapter.)

Assess Individual Risk

Many elements merit consideration in assessing a traveler’s health risks (Table 2-1 ). Certain travelers may confront special risks. Recent hospitalization for serious problems may lead the travel health provider to recommend delaying travel. Air travel is contraindicated for certain conditions, such as <3 weeks after an uncomplicated myocardial infarction and <10 days after thoracic or abdominal surgery. The travel health provider and traveler should consult with the relevant health care providers most familiar with the underlying illnesses. Other travelers with specific risks include travelers who are visiting friends and relatives, long-term travelers, travelers with small children, travelers with chronic illnesses, immunocompromised travelers, and pregnant travelers. More comprehensive discussion on advising travelers who have additional health considerations is available in Chapter 5. Providers should determine whether recent outbreaks or other safety notices have been posted for the traveler’s destination; information is available on the CDC and US Department of State websites, and in various other resources.

In addition to recognizing the traveler’s characteristics, health background, and destination-specific risks, the exposures related to special activities also merit discussion. For example, river rafting could expose a traveler to schistosomiasis or leptospirosis, and spelunking in Central America could put the traveler at risk of histoplasmosis. Flying from lowlands to high-altitude areas and trekking or climbing in mountainous regions introduces the risk of altitude illness. Therefore, the provider should inquire about plans for specific leisure, business, and health care–seeking activities.

Communicate Risk

Once destination-specific risks for a particular itinerary have been assessed by the provider, they should be clearly communicated to the traveler. The process of risk communication is a 2-way exchange of information between the clinician and traveler, in which they discuss potential health hazards at the destination and the effectiveness of preventive measures, with the goal of improving understanding of risk and promoting more informed decision making. Risk communication is among the most challenging aspects of a pretravel consultation, because travelers’ perception of and tolerance for risk can vary widely. For a more detailed discussion, see Perspectives : Travelers’ Perception of Risk in this chapter.

Manage Risk

Immunizations are a crucial component of pretravel consultations, and the risk assessment forms the basis of recommendations for travel vaccines. For example, providers should consider whether there is sufficient time before travel to complete a vaccine series; the purpose of travel and specific destination within a country will inform the need for particular vaccinations. At the same time, the pretravel consultation presents an opportunity to update routine vaccines (Table 2-2 ). Particular attention should be paid to vaccines for which immunity may have waned over time or following a recent immunocompromising condition (such as after a hematopoietic stem cell transplant). Asking the question, “Do you have any plans to travel again in the next 1–2 years?” may help the traveler justify an immunization for travel over a number of years rather than only the upcoming trip, such as rabies preexposure or Japanese encephalitis. Travelers should receive a record of immunizations administered and instructions to follow up as needed to complete a vaccine series.

Another major focus of pretravel consultations for many destinations is the prevention of malaria. Malaria continues to cause substantial morbidity and mortality in travelers. Since 1973, the annual number of US malaria cases reported to CDC has shown an increasing trend; therefore, pretravel consultation must carefully assess travelers’ risk for malaria and recommend preventive measures. For travelers going to malaria-endemic countries, it is imperative to discuss malaria transmission, ways to reduce risk, recommendations for prophylaxis, and symptoms of malaria.

Travelers with underlying health conditions require attention to their health issues as they relate to the destination and activities. For example, a traveler with a history of cardiac disease should carry medical reports, including a recent electrocardiogram. Asthma may flare in a traveler visiting a polluted city or from physical exertion during a hike; travelers should be encouraged to discuss with their primary care provider how to plan for treatment and bring necessary medication in case of asthma exacerbation. Travelers should be counseled on how to obtain travel medical insurance and how they can find reputable medical facilities at their destination, such as using the ISTM website ( www.istm.org ), the American Society of Tropical Medicine and Hygiene website ( www.astmh.org ), or the State Department Travel website ( https://travel.state.gov/content/travel/en/international-travel/before-you ...). Any allergies or serious medical conditions should be identified on a bracelet or a card to expedite medical care in emergency situations.

The pretravel consultation also provides another setting to remind travelers of basic health practices during travel, including frequent handwashing, wearing seatbelts, using car seats for infants and children, and safe sexual practices. Topics to be explored are numerous and could be organized into a checklist, placing priority on the most serious and frequently encountered issues (Table 2-3 , Box 2-1 ). General issues such as preventing injury and sunburn also deserve mention. Written information is essential to supplement oral advice and enable travelers to review the instructions from their clinic visits; educational material is available on the CDC Travelers Health webpage ( www.cdc.gov/travel ). Advice on self-treatable conditions may minimize the need for travelers to seek medical care while abroad and possibly lead to faster return to good health.

Self-Treatable Conditions

Despite providers’ best efforts, some travelers will become ill. Obtaining reliable and timely medical care during travel can be problematic in many destinations. As a result, prescribing certain medications in advance can empower the traveler to self-diagnose and treat common health problems. With some activities in remote settings, such as trekking, the only alternative to self-treatment would be no treatment. Pretravel counseling may result in a more accurate self-diagnosis and treatment than relying on local medical care in some areas. In addition, the increasing awareness of substandard and counterfeit drugs in pharmacies in the developing world makes it more important for travelers to bring quality manufactured drugs with them from a reliable supplier in their own country (see Chapter 6, Perspectives : Avoiding Poorly Regulated Medicines and Medical Products during Travel ).

Travel health providers need to recognize the conditions for which the traveler may be at risk, and educate the traveler about the diagnosis and treatment of those conditions. The keys to successful self-treatment strategies are providing a simple disease or condition definition, providing a treatment, and educating the traveler about the expected outcome of treatment. Using travelers’ diarrhea as an example, a practitioner could provide the following advice:

• “Travelers’ diarrhea” is the sudden onset of abnormally loose, frequent stools.
• Most cases will resolve within 2–5 days, and symptoms can be managed with loperamide or bismuth subsalicylate.
• For diarrhea severe enough to interrupt travel plans, an antibiotic can be prescribed that travelers can carry with them (see Travelers’ Diarrhea section in this chapter).
• The traveler should feel better within 6–24 hours.
• If symptoms persist for 24–36 hours despite self-treatment, it may be necessary to seek medical attention.

To minimize the potential negative effects of a self-treatment strategy, the recommendations should follow a few key points:

• Drugs recommended must be safe, well tolerated, and effective for use as self-treatment.
• A drug’s toxicity or potential for harm, if used incorrectly or in an overdose situation, should be minimal.
• Simple and clear directions are critical. Consider providing handouts describing how to use the drugs. Keeping the directions simple will increase the effectiveness of the strategy.

The following are some of the most common situations in which people would find self-treatment useful. The extent of self-treatment recommendations offered to the traveler should reflect the remoteness and difficulty of travel and the availability of reliable medical care at the destination. The recommended self-treatment options for each disease are provided in the designated section of the Yellow Book or discussed below.

• Travelers’ diarrhea ( Chapter 2 , Travelers’ Diarrhea)
• Altitude illness ( Chapter 3 , High-Altitude Travel & Altitude Illness)
• Jet lag ( Chapter 8 , Jet Lag)
• Motion sickness (Chapter 8, Motion Sickness )
• Respiratory infections ( Chapter 11 , Respiratory Infections)
• Skin conditions such as allergic reactions or superficial fungal infections ( Chapter 11 , Skin & Soft Tissue Infections)
• Urinary tract infections: common among many women; carrying an antibiotic for empiric treatment may be valuable
• Vaginal yeast infections: self-treatment course of patient’s preferred antifungal medication can be prescribed for women who are prone to infections, sexually active, or who may be receiving antibiotics for other reasons (including doxycycline for malaria chemoprophylaxis)
• Occupational exposure to HIV (Chapter 9, Health Care Workers , Including Public Health Researchers and Laboratorians)
• Malaria self-treatment (see Chapter 4 , Malaria)

In sum, travelers should be encouraged to carry a travel health kit with prescription and nonprescription medications. Providers should review medication lists for possible drug interactions. More detailed information for providers and travelers is given in Chapter 6, Travel Health Kits; supplementary travel health kit information for travelers with specific needs is given in Chapter 5.

Box 2-1. Summary of sexual health recommendations for travelers

Before travel.

• Obtain recommended vaccinations, including those that protect against sexually transmitted infections.
• Get recommended tests for HIV and treatable STDs. Be aware of STD symptoms in case any develop.
• Check condom packaging and expiration dates.
• Review local laws about sexual practices and obtain contact information for medical and law enforcement services.
• If pregnant or considering pregnancy, review whether Zika virus infection is a risk at destination.

During Travel

• Use good judgment in choosing consensual adult sex partners.
• Use condoms consistently and correctly to decrease the risk of HIV and STDs.
• If indicated, be prepared to start taking medications for HIV postexposure prophylaxis or unintended pregnancy within 72 hours after a high-risk sexual encounter.
• Never engage in sex with a minor (<18 years old), child pornography, or trafficking activities in any country.
• Report suspicious activity to US and local authorities as soon as it occurs.

After Travel

• To avoid exposing sex partners at home, see a clinician to get recommended tests for HIV and treatable STDs.

Bibliography

• Freedman DO, Chen LH, Kozarsky P. Medical considerations before travel. N Engl J Med. 2016 July 21;375:247–60.
• Hatz CFR, Chen LH. Pre-travel consultation. In: Keystone JS, Freedman DO, Kozarsky PE, Connor BA, Nothdurft HD, editors. Travel Medicine. 3rd ed. Philadelphia: Saunders Elsevier; 2013. pp. 31–6.
• Hill DR, Ericsson CD, Pearson RD, Keystone JS, Freedman DO, Kozarsky PE, et al. The practice of travel medicine: guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2006 Dec 15;43(12):1499–539.
• International Society of Travel Medicine. Body of knowledge for the practice of travel medicine—2012. Atlanta: International Society of Travel Medicine; 2012 [cited 2018 Feb 18]. Available from: www.istm.org/bodyofknowledge .
• Kozarsky PE, Steffen R. Travel medicine education—what are the needs? J Travel Med. 2016 Jul 4;23(5).
• Leder K, Chen LH, Wilson ME. Aggregate travel vs. single trip assessment: arguments for cumulative risk analysis. Vaccine. 2012 Mar 28;30(15):2600–4.   [PMID:22234265]
• Leder K, Torresi J, Libman MD, Cramer JP, Castelli F, Schlagenhauf P, et al. GeoSentinel surveillance of illness in returned travelers, 2007–2011. Ann Intern Med. 2013 Mar 19;158(6):456–68.   [PMID:23552375]
• Schwartz BS, Larocque RC, Ryan ET. In the clinic: travel medicine. Ann Intern Med. 2012 Jun 5;156(11):ITC6:1–16.   [PMID:22665823]
• Steffen R, Behrens RH, Hill RD, Greenaway C, Leder K. Vaccine-preventable travel health risks: what is the evidence—what are the gaps? J Travel Med. 2015;22(1):1–12.
• Riddle MS, Connor BA, Beeching NJ, DuPont HL, Hamer DH, Kozarsky P, et al. Guidelines for the prevention and treatment of travelers’ diarrhea: a graded expert panel report. J Travel Med. 2017 Apr 1;24(suppl_1):S57–S74.

Lin H. Chen, Natasha S. Hochberg

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