**5.2 Global Endemic Areas and Recommended Immunizations/Vaccines for
Travelers**

International travel requirements are relatively straightforward. The
only internationally required vaccination for travel is yellow fever for
travel to and from the countries in the yellow fever endemic zones of
Africa and South America. In general, the African zone is Sub-Saharan
Africa from Senegal and The Gambia on the west coast to Sudan and
Ethiopia on the east coast and as far south as Angola, Zambia, and
Tanzania. In South America, the yellow fever zone includes Panama,
Colombia, Venezuela, Ecuador, Peru, Bolivia, Brazil, Guyana, Suriname,
and French Guyana.

Countries sometimes impose their own vaccination requirements, for
example, Saudi Arabia requires travelers arriving for the Hajj
pilgrimage to Mecca and Medina to have immunizations for meningococcal
meningitis. Flight crew who remain confined to the international airport
need not meet this requirement. Meningococcal vaccination is also
recommended for travelers to the "Meningitis Belt", which runs across
central Africa from The Gambia to Ethiopia, as well as the subcontinent
of India.

Additional vaccinations, however, are often strongly advised, depending
on the area of travel. These include hepatitis A & B, typhoid, polio,
and diphtheria/tetanus. For travel almost anywhere outside North
America, Western Europe, or Australia, the hepatitis A vaccination
series is important, because flight crews are frequently over night in
local hotels and may visit food establishments where sanitation cannot
be assured. Travelers who will have prolonged stays of 30 days or longer
should also consider hepatitis A vaccination. Advisories for Typhoid
fever immunization exist for a similar geographic area. Because of the
potential of diphtheria and polio in Africa, Eastern Europe and all of
Asia (with the exception of Japan), booster immunizations every ten
years are advised. Japanese encephalitis immunization should be
considered for rural travel in the Indian subcontinent as well as rural
Southeast Asia and Indonesia, especially during epidemics.

![](media/image1.jpeg){width="3.125in" height="2.1770833333333335in"}

Culex pipens, one of many mosquito vectors

Extended travel and prolonged layovers in areas at risk for malaria
include the entire tropical world of Central and South America, Africa,
much of Oceana, and southern Asia. Before advising any traveler about
malaria risks you should check the current conditions in the country of
travel by consulting the CDC web site. This site, which has the "Yellow
Book" of international travel diseases online, also lists the
country-specific preferred prophylactic and therapeutic medications for
malaria. Common oral prophylactic medications include mefloquine
(Lariam), doxycycline, Malarone, and chloroquine (Aralen and
Plaquenil). Oral prophylactic medications may be useful, but primary
prevention of mosquito bites is the best course. This includes insect
repellants, primarily DEET (N,N-diethylmetatoluamide) or permethrine,
mosquito netting and window screens. Avoiding mosquito bites will also
prevent yellow fever and dengue. Other vector-borne illness carried by
flies, fleas, mites and ticks include lyme, typhus and onchocerciasis .

The disinsection of aircraft is a controversial topic for two reasons.
First, the basic reason behind disinsection is to kill disease carrying
vectors, primarily mosquitoes, that may be unwanted stowaways. It is
also intended to eliminate agricultural pests. The reasoning behind this
has not been satisfactorily demonstrated as the ability of such vectors
to travel by other means is apparent. The spread of foreign intruders
into North America is evident with the introduction of Asian Tiger
mosquitoes via tires and the South American Fire Ant in agricultural
shipments. Still, disinsection is a requirement for aircraft entering
some countries, but not the United States.

The second issue is the concern over human health when cabins are
sprayed with insecticides. The most commonly used agents are
permethrines. These agents are minimally toxic to humans although
topical allergies are common in plants that manufacture the chemicals.
Permethrines are derived from the chrysanthemum flower and its pyrethrum
components. There are allegations of "total body allergy" and other
somatic complaints due to such exposures, but these claims have not been
verified by objective means.

The most common airborne transmissible disease is influenza. CDC and WHO
conduct a worldwide monitoring program. The flu season is in the winter
of each hemisphere, so by monitoring the southern hemisphere's flu
strains, the next season's potential agents can be predicted for the
northern hemisphere. Using this program, CDC predicts, and vaccine
manufactures make, the annual trivalent vaccine (two influenza A strains
and one influenza B strain) needed for the upcoming season. Such
predictions have been over 90% accurate over the past decade.

Crews should also be advised of the risk of rabies, even in encountering
domestic animals anywhere outside the United States, Canada, Europe, and
Australia. However rabies vaccinations are not needed unless one is
routinely handling domestic and feral animals, or has some reason to be
exposed to bats. Finally, an annual influenza vaccination is strongly
encouraged to prevent morbidity and lost time.

The most common illness affecting all crew, tourists and businesspeople
alike, is travelers' diarrhea. In some locations up to 50% of travelers
are afflicted. All persons should be educated in the basics of food
sanitation. Avoid buying food from street venders. Fluids should be in
the form of bottled or carbonated drinks. Vegetables and all meats
should be fully cooked to help prevent travelers' diarrhea. It can be
prevented by limiting intake of unsanitary food and water, but these
precautions are imperfect. Some antibiotics, such as ciprofloxin, reduce
the incidence of travelers' diarrhea, but strains resistant to
ciprofloxin are appearing. Travelers' diarrhea is caused by fecal
contamination involving a multiplicity of agents, including *E. coli,
Salmonella, Vibrio parahaemolyticus, Campylobacter jejuni, and
Yersinia.* It usually responds to symptomatic treatment. Fluid
replenishment is critical. Antidiarrheal agents include loperamide
(Immodium), kaolin/pectin (Kaopectate) and bismuth subsalycilate
(Pepto-Bismol). The bloody diarrhea of *Shigellae dysentery* requires
medical attention. Giardiasis is a major problem for travelers to
countries of the former Soviet Union as well as back country travelers
in North America. Water sanitation rules should be followed to prevent
this; metronidazole (Flagyl®) remains the drug of choice for treatment.

Travelers should carry a small medical kit containing acceptable
medications to treat or prevent such illness, particularly if there are
no crew replacements are readily available. Use of insect repellants,
particularly those containing DEET (for example, OFF), are advised for
outdoor activities in the tropics. Consideration of sexually transmitted
diseases and their prevention must also be addressed. For the tropics,
crews should also be reminded of the use of appropriate sunscreens.
Recreational activities of swimming in freshwater lakes, streams and
canals can be very hazardous due to infectious diseases, pollution and
the occasional crocodile; crews should simply be directed to avoid this
activity. All these can be presented in a pamphlet handed out to crews.
A travel kit recommended by the Consumers' Union includes the following
ideas:

+------------------------------------------+---------------------------+
| **Medications**                          | **First Aid Supplies**    |
+------------------------------------------+---------------------------+
| Antibiotics for diarrhea & respiratory   | Bandages                  |
| infection\*                              |                           |
|                                          | Gauze                     |
| Antibiotic ointment for cuts and         |                           |
| abrasions.                               | Tape                      |
|                                          |                           |
| Hydrocortisone cream for bug bites       | Elastic bandage           |
|                                          |                           |
| Anti-diarrhea drug                       | Sunscreen                 |
|                                          |                           |
| Antihistamine                            | Thermometer               |
|                                          |                           |
| Motion-sickness drugs                    | Spare eyeglasses and      |
|                                          | eyeglass prescription     |
| Analgesic/anti-inflammatory drug         |                           |
|                                          |                           |
| Acetaminophen                            |                           |
|                                          |                           |
| Sleeping medication                      |                           |
|                                          |                           |
| Oral rehydration salts                   |                           |
+------------------------------------------+---------------------------+

\*Subject to physician review.

Outbreaks of illness need surveillance and attention. For an immediate
update, the Centers for Disease Control and Prevention Travelers Health
Advisory, should be consulted on the World Wide Web at **www.cdc.gov.**

In some countries, national health insurance provides care to citizens,
with noncitizens receiving financial billing. It is a good idea for the
traveler to have a list of accessible physicians and health care
providers who are fluent in English, if that is not the local language.
Commercial carriers will have local station managers who are responsible
for coordinating care for flight crew. For charter flights, off-station
landings and layovers, English speaking providers may be identified
through consultations with additional sources such as the local embassy
or consulate, and agencies dealing with travel medicine. Hotel
concierges and some credit card companies may also be an additional
resource. In addition, the U. S. State Department has a web site at
**www.state.gov**.

If there are special environmental demands, flight crews should be
briefed in advance to prepare for extremes of weather and climate or
seasonal changes. For example, crews flying into Saudi Arabia in the
summer should be briefed about specific measures they will need to take
in order to tolerate the extremely hot and dry environment. Arid
conditions will require significantly increased hydration, necessitating
drinking up to a liter of water per hour. Moscow in the late spring is
***puhk*** season, when the cottonwoods inundate the city in a soft,
white snowstorm that is notorious for triggering allergy and asthma
attacks. Very high altitude airports, such as Kennedy Field at La Paz,
Bolivia at over 12,000 ft, will necessitate crew using oxygen to perform
their preflight inspection and during checklist and engine start
procedures, until the cabin is pressurized. Tropical and sunny climates
need sunscreens with an SPF of 15 or higher. Travel guides such as
Fodor's can provide helpful information regarding these issues.

There are local customs to be observed, and flight crews should be
specifically briefed, if possible, as to current events and NOTAMS. As
an example, the recent foot and mouth disease outbreak in England
resulted in passengers and crew of commercial airliners being forced to
walk through disinfectant solutions upon arrival at their destination in
some countries. Flight crews should be aware of the local taboos and
sensibilities. Taking multiple copies of a Bible into the People's
Republic of China may be interpreted by the local officials as
impermissible political activity. Likewise, a flight attendant who
brought a large number of computer chips into Egypt in his personal
luggage was arrested by the customs authorities for smuggling as well as
terminated by his company for commercial use of his private carryon
luggage.

![](media/image2.jpeg){width="5.998611111111111in"
height="3.8152777777777778in"}

Bioterrorism drill

Finally, the local political situation should be assessed. Periodically,
the U.S. State Department publishes local threat assessments and risk of
terrorist attack. Certain airports are at much greater risk for
terrorist activity. Corporate plans should be in place and developed for
responding to terrorist attacks and threats, including the rising threat
of bioterrorism. Smallpox vaccinations became available as of January
27, 2003 to first responders and those at risk under the Homeland
Security Act, in recognition of the increased risk of terrorist
activity.

**References:**

CDC, Health Information for International Travel, 2001-2002, U. S.
Department of Health and Human Services, Atlanta, GA, 2001.

Behrens RH. McAdam PWJ, Travel Medicine, Churchill Livingstone, New
York, 1993

Consumer Reports Travel Letter, 19(1), 2003.

Moser RJr, White GL, Lewis-Younger CR, Preparing for expected
bioterrorism attacks, Military Medicine, 166, 5:369-74, 2001.

Parmet AJ, Cimrmancic MA. Operations in Foreign Countries. *In*
Occupational Medicine: State of the Art Reviews: The Aviation Industry,
Kendall Green, Ed., Hanley & Belfus, Philadelphia, 2002, Vol 17, No 2.

**5.2 Global Endemic Areas and Recommended Immunizations/Vaccines for
Travelers**

Describe the most prevalent communicable diseases around the world and
identify endemic areas

Recommended immunizations/vaccines for passengers

Recommended immunizations/vaccines for crew members

Describe the most common acute infectious and non-infectious medical
problems that affect travelers

International travel requirements are relatively straightforward. The
only internationally required vaccination for travel is yellow fever for
travel to and from the countries in the yellow fever endemic zones of
Africa and South America. In general, the African zone is Sub-Saharan
Africa from Senegal and The Gambia on the west coast to Sudan and
Ethiopia on the east coast and as far south as Angola, Zambia, and
Tanzania. In South America, the yellow fever zone includes Panama,
Colombia, Venezuela, Ecuador, Peru, Bolivia, Brazil, Guyana, Suriname,
and French Guyana.

Countries sometimes impose their own vaccination requirements, for
example, Saudi Arabia requires travelers arriving for the Hajj
pilgrimage to Mecca and Medina to have immunizations for meningococcal
meningitis. Flight crew who remain confined to the international airport
need not meet this requirement. Meningococcal vaccination is also
recommended for travelers to the "Meningitis Belt", which runs across
central Africa from The Gambia to Ethiopia, as well as the subcontinent
of India.

Additional vaccinations, however, are often strongly advised, depending
on the area of travel. These include hepatitis A & B, typhoid, polio,
and diphtheria/tetanus. For travel almost anywhere outside North
America, Western Europe, or Australia, the hepatitis A vaccination
series is important, because flight crews are frequently over night in
local hotels and may visit food establishments where sanitation cannot
be assured. Travelers who will have prolonged stays of 30 days or longer
should also consider hepatitis A vaccination. Advisories for Typhoid
fever immunization exist for a similar geographic area. Because of the
potential of diphtheria and polio in Africa, Eastern Europe and all of
Asia (with the exception of Japan), booster immunizations every ten
years are advised. Japanese encephalitis immunization should be
considered for rural travel in the Indian subcontinent as well as rural
Southeast Asia and Indonesia, especially during epidemics.

![](media/image1.jpeg){width="3.125in" height="2.1770833333333335in"}

Culex pipens, one of many mosquito vectors

Extended travel and prolonged layovers in areas at risk for malaria
include the entire tropical world of Central and South America, Africa,
much of Oceana, and southern Asia. Before advising any traveler about
malaria risks you should check the current conditions in the country of
travel by consulting the CDC web site. This site, which has the "Yellow
Book" of international travel diseases online, also lists the
country-specific preferred prophylactic and therapeutic medications for
malaria. Common oral prophylactic medications include mefloquine
(Lariam), doxycycline, Malarone, and chloroquine (Aralen and
Plaquenil). Oral prophylactic medications may be useful, but primary
prevention of mosquito bites is the best course. This includes insect
repellants, primarily DEET (N,N-diethylmetatoluamide) or permethrine,
mosquito netting and window screens. Avoiding mosquito bites will also
prevent yellow fever and dengue. Other vector-borne illness carried by
flies, fleas, mites and ticks include lyme, typhus and onchocerciasis .

The disinsection of aircraft is a controversial topic for two reasons.
First, the basic reason behind disinsection is to kill disease carrying
vectors, primarily mosquitoes, that may be unwanted stowaways. It is
also intended to eliminate agricultural pests. The reasoning behind this
has not been satisfactorily demonstrated as the ability of such vectors
to travel by other means is apparent. The spread of foreign intruders
into North America is evident with the introduction of Asian Tiger
mosquitoes via tires and the South American Fire Ant in agricultural
shipments. Still, disinsection is a requirement for aircraft entering
some countries, but not the United States.

The second issue is the concern over human health when cabins are
sprayed with insecticides. The most commonly used agents are
permethrines. These agents are minimally toxic to humans although
topical allergies are common in plants that manufacture the chemicals.
Permethrines are derived from the chrysanthemum flower and its pyrethrum
components. There are allegations of "total body allergy" and other
somatic complaints due to such exposures, but these claims have not been
verified by objective means.

The most common airborne transmissible disease is influenza. CDC and WHO
conduct a worldwide monitoring program. The flu season is in the winter
of each hemisphere, so by monitoring the southern hemisphere's flu
strains, the next season's potential agents can be predicted for the
northern hemisphere. Using this program, CDC predicts, and vaccine
manufactures make, the annual trivalent vaccine (two influenza A strains
and one influenza B strain) needed for the upcoming season. Such
predictions have been over 90% accurate over the past decade.

Crews should also be advised of the risk of rabies, even in encountering
domestic animals anywhere outside the United States, Canada, Europe, and
Australia. However rabies vaccinations are not needed unless one is
routinely handling domestic and feral animals, or has some reason to be
exposed to bats. Finally, an annual influenza vaccination is strongly
encouraged to prevent morbidity and lost time.

The most common illness affecting all crew, tourists and businesspeople
alike, is travelers' diarrhea. In some locations up to 50% of travelers
are afflicted. All persons should be educated in the basics of food
sanitation. Avoid buying food from street venders. Fluids should be in
the form of bottled or carbonated drinks. Vegetables and all meats
should be fully cooked to help prevent travelers' diarrhea. It can be
prevented by limiting intake of unsanitary food and water, but these
precautions are imperfect. Some antibiotics, such as ciprofloxin, reduce
the incidence of travelers' diarrhea, but strains resistant to
ciprofloxin are appearing. Travelers' diarrhea is caused by fecal
contamination involving a multiplicity of agents, including *E. coli,
Salmonella, Vibrio parahaemolyticus, Campylobacter jejuni, and
Yersinia.* It usually responds to symptomatic treatment. Fluid
replenishment is critical. Antidiarrheal agents include loperamide
(Immodium), kaolin/pectin (Kaopectate) and bismuth subsalycilate
(Pepto-Bismol). The bloody diarrhea of *Shigellae dysentery* requires
medical attention. Giardiasis is a major problem for travelers to
countries of the former Soviet Union as well as back country travelers
in North America. Water sanitation rules should be followed to prevent
this; metronidazole (Flagyl®) remains the drug of choice for treatment.

Travelers should carry a small medical kit containing acceptable
medications to treat or prevent such illness, particularly if there are
no crew replacements are readily available. Use of insect repellants,
particularly those containing DEET (for example, OFF), are advised for
outdoor activities in the tropics. Consideration of sexually transmitted
diseases and their prevention must also be addressed. For the tropics,
crews should also be reminded of the use of appropriate sunscreens.
Recreational activities of swimming in freshwater lakes, streams and
canals can be very hazardous due to infectious diseases, pollution and
the occasional crocodile; crews should simply be directed to avoid this
activity. All these can be presented in a pamphlet handed out to crews.
A travel kit recommended by the Consumers' Union includes the following
ideas:

+------------------------------------------+---------------------------+
| **Medications**                          | **First Aid Supplies**    |
+------------------------------------------+---------------------------+
| Antibiotics for diarrhea & respiratory   | Bandages                  |
| infection\*                              |                           |
|                                          | Gauze                     |
| Antibiotic ointment for cuts and         |                           |
| abrasions.                               | Tape                      |
|                                          |                           |
| Hydrocortisone cream for bug bites       | Elastic bandage           |
|                                          |                           |
| Anti-diarrhea drug                       | Sunscreen                 |
|                                          |                           |
| Antihistamine                            | Thermometer               |
|                                          |                           |
| Motion-sickness drugs                    | Spare eyeglasses and      |
|                                          | eyeglass prescription     |
| Analgesic/anti-inflammatory drug         |                           |
|                                          |                           |
| Acetaminophen                            |                           |
|                                          |                           |
| Sleeping medication                      |                           |
|                                          |                           |
| Oral rehydration salts                   |                           |
+------------------------------------------+---------------------------+

\*Subject to physician review.

Outbreaks of illness need surveillance and attention. For an immediate
update, the Centers for Disease Control and Prevention Travelers Health
Advisory, should be consulted on the World Wide Web at **www.cdc.gov.**

In some countries, national health insurance provides care to citizens,
with noncitizens receiving financial billing. It is a good idea for the
traveler to have a list of accessible physicians and health care
providers who are fluent in English, if that is not the local language.
Commercial carriers will have local station managers who are responsible
for coordinating care for flight crew. For charter flights, off-station
landings and layovers, English speaking providers may be identified
through consultations with additional sources such as the local embassy
or consulate, and agencies dealing with travel medicine. Hotel
concierges and some credit card companies may also be an additional
resource. In addition, the U. S. State Department has a web site at
**www.state.gov**.

If there are special environmental demands, flight crews should be
briefed in advance to prepare for extremes of weather and climate or
seasonal changes. For example, crews flying into Saudi Arabia in the
summer should be briefed about specific measures they will need to take
in order to tolerate the extremely hot and dry environment. Arid
conditions will require significantly increased hydration, necessitating
drinking up to a liter of water per hour. Moscow in the late spring is
***puhk*** season, when the cottonwoods inundate the city in a soft,
white snowstorm that is notorious for triggering allergy and asthma
attacks. Very high altitude airports, such as Kennedy Field at La Paz,
Bolivia at over 12,000 ft, will necessitate crew using oxygen to perform
their preflight inspection and during checklist and engine start
procedures, until the cabin is pressurized. Tropical and sunny climates
need sunscreens with an SPF of 15 or higher. Travel guides such as
Fodor's can provide helpful information regarding these issues.

There are local customs to be observed, and flight crews should be
specifically briefed, if possible, as to current events and NOTAMS. As
an example, the recent foot and mouth disease outbreak in England
resulted in passengers and crew of commercial airliners being forced to
walk through disinfectant solutions upon arrival at their destination in
some countries. Flight crews should be aware of the local taboos and
sensibilities. Taking multiple copies of a Bible into the People's
Republic of China may be interpreted by the local officials as
impermissible political activity. Likewise, a flight attendant who
brought a large number of computer chips into Egypt in his personal
luggage was arrested by the customs authorities for smuggling as well as
terminated by his company for commercial use of his private carryon
luggage.

![](media/image2.jpeg){width="5.998611111111111in"
height="3.8152777777777778in"}

Bioterrorism drill

Finally, the local political situation should be assessed. Periodically,
the U.S. State Department publishes local threat assessments and risk of
terrorist attack. Certain airports are at much greater risk for
terrorist activity. Corporate plans should be in place and developed for
responding to terrorist attacks and threats, including the rising threat
of bioterrorism. Smallpox vaccinations became available as of January
27, 2003 to first responders and those at risk under the Homeland
Security Act, in recognition of the increased risk of terrorist
activity.

**References:**

CDC, Health Information for International Travel, 2001-2002, U. S.
Department of Health and Human Services, Atlanta, GA, 2001.

Behrens RH. McAdam PWJ, Travel Medicine, Churchill Livingstone, New
York, 1993

Consumer Reports Travel Letter, 19(1), 2003.

Moser RJr, White GL, Lewis-Younger CR, Preparing for expected
bioterrorism attacks, Military Medicine, 166, 5:369-74, 2001.

Parmet AJ, Cimrmancic MA. Operations in Foreign Countries. *In*
Occupational Medicine: State of the Art Reviews: The Aviation Industry,
Kendall Green, Ed., Hanley & Belfus, Philadelphia, 2002, Vol 17, No 2.