CDC health tips and Malari and Dengue prevention tips

Areas of India with Malaria: All areas throughout country except no malaria in areas >2,000 m (>6,561 ft) in Himachal Pradesh, Jammu, Kashmir, and Sikkim. Present in cities of Delhi and Bombay (Mumbai).
If you will be visiting an area of India with malaria, you will need to discuss with your doctor the best ways for you to avoid getting sick with malaria. Ways to prevent malaria include the following:

• Taking a prescription antimalarial drug
• Using insect repellent and wearing long pants and sleeves to prevent mosquito bites
• Sleeping in air-conditioned or well-screened rooms or using bednets

All of the following antimalarial drugs are equal options for preventing malaria in India: Atovaquone/proguanil, doxycycline, or mefloquine. For detailed information about each of these drugs, see Table 2-23: Drugs used in the prophylaxis of malaria. For information that can help you and your doctor decide which of these drugs would be best for you, please see Choosing a Drug to Prevent Malaria.
Note: Chloroquine is NOT an effective antimalarial drug in India and should not be taken to prevent malaria in this region.
To find out more information on malaria throughout the world, you can use the interactive CDC malaria map. You can search or browse countries, cities, and place names for more specific malaria risk information and the recommended prevention medicines for that area.

Malaria in Province:

Province Name	Malaria in Province	Prophylaxis for this State/Province/District
West Bengal	All areas	Atovaquone/ proguanil, doxycycline, or mefloquine

Malaria in Country:

Country Name	Malaria in Country	Drug Resistance	Malaria Type	Prophylaxis for Areas with Malaria
India	All areas throughout country except no malaria in areas >2,000m (>6,561ft) in Himachal Pradesh, Jammu, Kashmir, and Sikkim. Present in cities of Delhi and Bombay (Mumbai).	Chloroquine	P. vivax 40%, P. falciparum 20-40%, P. malariae and P. ovale 20-40%	Atovaquone/ proguanil, doxycycline, or mefloquine

Malaria Contact for Health-Care Providers
For assistance with the diagnosis or management of suspected cases of malaria, call the CDC Malaria Hotline: 770-488-7788 (M-F, 9 am-5 pm, Eastern time). For emergency consultation after hours, call 770-488-7100 and ask to speak with a CDC Malaria Branch clinician.
A Special Note about Antimalarial Drugs
You should purchase your antimalarial drugs before travel. Drugs purchased overseas may not be manufactured according to United States standards and may not be effective. They also may be dangerous, contain counterfeit medications or contaminants, or be combinations of drugs that are not safe to use.
Halofantrine (marketed as Halfan) is widely used overseas to treat malaria. CDC recommends that you do NOT use halofantrine because of serious heart-related side effects, including deaths. You should avoid using antimalarial drugs that are not recommended unless you have been diagnosed with life-threatening malaria and no other options are immediately available.
For detailed information about these antimalarial drugs, see Choosing a Drug to Prevent Malaria.

More Information About Malaria

Malaria is always a serious disease and may be a deadly illness. Humans get malaria from the bite of a mosquito infected with the parasite. Prevent this serious disease by seeing your health-care provider for a prescription antimalarial drug and by protecting yourself against mosquito bites (see below).
Travelers to malaria risk-areas in India, including infants, children, and former residents of India, should take one of the antimalarial drugs listed in the box above.

Symptoms

Malaria symptoms may include

• fever
• chills
• sweats
• headache
• body aches
• nausea and vomiting
• fatigue

Malaria symptoms will occur at least 7 to 9 days after being bitten by an infected mosquito. Fever in the first week of travel in a malaria-risk area is unlikely to be malaria; however, you should see a doctor right away if you develop a fever during your trip.
Malaria may cause anemia and jaundice. Malaria infections with Plasmodium falciparum, if not promptly treated, may cause kidney failure, coma, and death. Despite using the protective measures outlined above, travelers may still develop malaria up to a year after returning from a malarious area. You should see a doctor immediately if you develop a fever anytime during the year following your return and tell the physician of your travel.

Dengue Fever (DF) and Dengue Hemorrhagic Fever (DHF)

Kay M. Tomashek

Infectious Agent

• Four immunologically related, single positive-stranded RNA viruses known as dengue viruses (DENV-1 through DENV-4) of the genus Flavivirus, family Flaviviridae, are responsible for causing dengue fever (DF) and dengue hemorrhagic fever (DHF).
• Infection with one DENV produces lifelong immunity against reinfection with that one virus and short-term (≤9 months), partial cross-protection against the other three dengue viruses. An individual may be infected up to four times during his or her lifetime.

Mode of Transmission

• Transmission occurs from the bite of an infected Aedes aegypti (rarely Aedes albopictus) mosquito. Mosquitoes first become infected with DENV by feeding on the blood of a dengue-infected person. After the virus replicates for 8–12 days in the mosquito, the mosquito can transmit DENV to many other people.
• Direct person-to-person transmission has not been documented. A few case reports have been published of transmission of DENV through exposure to: dengue-infected blood, organs, or other tissues from blood transfusions; solid organ or bone marrow transplants; needlestick injuries; and mucous membrane contact with dengue-infected blood.

Occurrence

• Dengue infections have been reported in over 100 countries and are widespread in most tropical countries of the South Pacific, Asia, the Caribbean, the Americas, and Africa (Maps 5-1 and 5-2). The geographic spread of dengue infections is similar to that of malaria, but unlike malaria, dengue infections are often found in the urban areas of tropical nations, including Thailand, Singapore, Taiwan, Indonesia, Philippines, India, and Brazil. Because the main risk of exposure for the traveler is in populated urban and residential areas, travelers are advised to consult CDC (www.cdc.gov/ncidod/dvbid/dengue) and WHO www.who.int/topics/dengue/en websites for outbreak information.
• Recently, locally acquired dengue infections have been reported in Texas, Hawaii, and the Middle East.

Risk for Travelers

• Cases of DF and DHF are confirmed every year among travelers returning to the United States. Infection rates (based on antidengue serology) among febrile travelers returning from dengue-endemic areas in the tropics range from 2.9% to 8.0%.
• Dengue was the leading cause of systemic febrile illness among travelers returning from the Caribbean, South America, South Central Asia, and Southeast Asia in a recent study of 17,353 ill travelers seen at GeoSentinel surveillance network clinics. In some case studies, dengue is the second most common cause of hospitalization (malaria is the most common) among travelers returning from the tropics.
• The bite of one infected mosquito can result in infection. The risk of being bitten is highest during the early morning, several hours after daybreak, and in the late afternoon several hours before sunset, because the female mosquito typically feeds (bites) during these hours. However, mosquitoes may feed at any time during the day.
• Published data are limited on the health outcomes associated with dengue infection among pregnant women and the effects of maternal dengue infection on a developing fetus. However, if a pregnant woman has dengue at the time of delivery, the infant can be born with dengue infection or acquire dengue during labor and delivery and then develop the clinical manifestations of DF or DHF. Transplacental transfer of maternal antidengue antibodies (from a previous maternal infection) may place infants at greater risk for DHF with their first dengue infection.

Clinical Presentation

• Dengue should be considered in the differential diagnosis of febrile patients with a history of travel to the tropics in the 2 weeks prior to symptom onset. The incubation period is typically 4–7 days (range 3–14 days).
• Many travelers infected with DENV are asymptomatic, as are about half of people infected with DENV who live in areas where the virus is widespread.
• The clinical manifestations of symptomatic illness range from mild, undifferentiated febrile illness to classic DF or DHF. DF is defined clinically by an acute febrile illness with two or more of the following symptoms: headache, retro-orbital pain, muscle or joint pain, rash, hemorrhagic manifestation, or leucopenia. The rash usually appears as the fever subsides and lasts 2–4 days. The rash is either macular or maculopapular and generalized, often confluent with small patches of normal skin, and it may become scaly and itchy. Other signs and symptoms include flushed facies (usually during the first 24–48 hours), nausea, and vomiting. Approximately 1% of patients with DF develop DHF as the fever subsides (usually 3–7 days following the onset of fever).
• The hallmark of DHF is evidence of vascular leakage. DHF is defined by the presence of all the following symptoms:
  
  
  • fever or recent history of fever lasting 2–7 days,
  • any hemorrhagic manifestation,
  • thrombocytopenia (i.e., platelet count <100,000/mm³), and
  • evidence of increased vascular permeability (i.e., hemoconcentration, pleural or abdominal effusion, hypoalbuminemia, or hypoproteinemia).
• Thrombocytopenia can occur with classic DF and does not by itself indicate DHF.
• Dengue Shock Syndrome (DSS) is defined as a syndrome in any case patient who meets the criteria for DHF and has hypotension, narrow pulse pressure (≤20 mm Hg), or frank shock.

Treatment

• No specific therapeutic agents exist for dengue infections.
• Encourage bed rest and maintenance of fluids to prevent dehydration.
• Control fever with acetaminophen. Headache, back pain and muscle aching may be so severe as to require narcotics. Aspirin (acetylsalicylic acid), aspirin-containing drugs, and other nonsteroidal anti-inflammatory drugs (e.g., ibuprofen) should be avoided because of their anticoagulant properties. Aspirin and other salicylates should be especially avoided in children due to the association with Reye syndrome.
• Ask patients to watch for warning signs of DHF or DSS as fever declines 3–7 days after onset of symptoms. Instruct patients to go to the hospital if they have any of the following warning signs: abrupt change from fever to hypothermia, severe abdominal pain, persistent vomiting, bleeding, difficulties breathing, or altered mental status (e.g., irritability, confusion, lethargy).
• Prompt and judicious administration of intravenous fluids in patients with DHF or DSS can improve outcomes. In patients with DHF or DSS, hospitalization with close monitoring of vital signs, fluid balance, and hematologic parameters (i.e., hematocrit, platelet count) is indicated, as well as additional supportive measures.

Preventive Measures for Travelers

• Neither vaccine nor drugs for preventing infection are available.
• Travelers should be advised to take measures to avoid being bitten by Aedes mosquitoes. These preventive measures include the following:
  
  
  • Select accommodations with well-screened windows or air-conditioning when possible. Aedes mosquitoes typically live indoors and are often found in dark, cool places such as in closets, under beds, behind curtains, and in bathrooms. A traveler should be advised to use insecticides to get rid of mosquitoes in these areas.
  • Wear clothing that adequately covers the arms and legs, especially during the early morning and late afternoon.
  • Apply insect repellent to both skin and clothing (e.g., permethrin). The most effective repellents contain DEET (N,N-diethylmetatoluamide) (see the Protection Against Mosquitoes, Ticks, and Other Insects and Arthropods section in Chapter 2).
  • For long-term travelers, empty and clean or cover any standing water that can be mosquito-breeding sites in your accommodation (e.g., water storage barrels).

Other items you may need:

• Iodine tablets and portable water filters to purify water if bottled water is not available. See A Guide to Water Filters, A Guide to Commercially-Bottled Water and Other Beverages, and Safe Food and Water for more detailed information.
• Sunblock and sunglasses for protection from harmful effects of UV sun rays. See Basic Information about Skin Cancer for more information.
• Antibacterial hand wipes or alcohol-based hand sanitizer containing at least 60% alcohol.
• To prevent insect/mosquito bites, bring:
  
  
  • Lightweight long-sleeved shirts, long pants, and a hat to wear outside, whenever possible.
  • Flying-insect spray to help clear rooms of mosquitoes. The product should contain a pyrethroid insecticide; these insecticides quickly kill flying insects, including mosquitoes.
  • Bed nets treated with permethrin, if you will not be sleeping in an air-conditioned or well-screened room and will be in malaria-risk areas. For use and purchasing information, see Insecticide Treated Bed Nets on the CDC malaria site. Overseas, permethrin or another insecticide, deltamethrin, may be purchased to treat bed nets and clothes.

See other suggested over-the-counter medications and first aid items for a travelers' health kit.
Note: Check the Air Travel section of the Transportation Security Administration website for the latest information about airport screening procedures and prohibited items.

Staying Healthy During Your Trip

Prevent Insect Bites

Many diseases, like malaria and dengue, are spread through insect bites. One of the best protections is to prevent insect bites by:

• Using insect repellent (bug spray) with 30%-50% DEET. Picaridin, available in 7% and 15% concentrations, needs more frequent application. There is less information available on how effective picaridin is at protecting against all of the types of mosquitoes that transmit malaria.
• Wearing long-sleeved shirts, long pants, and a hat outdoors.
• Remaining indoors in a screened or air-conditioned area during the peak biting period for malaria (dusk and dawn).
• Sleeping in beds covered by nets treated with permethrin, if not sleeping in an air-conditioned or well-screened room.
• Spraying rooms with products effective against flying insects, such as those containing pyrethroid.

For detailed information about insect repellent use, see Insect and Arthropod Protection.

Prevent Animal Bites and Scratches

Direct contact with animals can spread diseases like rabies or cause serious injury or illness. It is important to prevent animal bites and scratches.

• Be sure you are up to date with tetanus vaccination.
• Do not touch or feed any animals, including dogs and cats. Even animals that look like healthy pets can have rabies or other diseases.
• Help children stay safe by supervising them carefully around all animals.
• If you are bitten or scratched, wash the wound well with soap and water and go to a doctor right away. 
• After your trip, be sure to tell your doctor or state health department if you were bitten or scratched during travel.

For more information about rabies and travel, see the Rabies chapter of the Yellow Book or CDC's Rabies homepage. For more information about how to protect yourself from other risks related to animals, see Animal-Associated Hazards.

Be Careful about Food and Water

Diseases from food and water are the leading cause of illness in travelers. Follow these tips for safe eating and drinking:

• Wash your hands often with soap and water, especially before eating.  If soap and water are not available, use an alcohol-based hand gel (with at least 60% alcohol).
• Drink only bottled or boiled water, or carbonated (bubbly) drinks in cans or bottles.  Avoid tap water, fountain drinks, and ice cubes.  If this is not possible, learn how to make water safer to drink.
• Do not eat food purchased from street vendors.
• Make sure food is fully cooked.
• Avoid dairy products, unless you know they have been pasteurized.

Diseases from food and water often cause vomiting and diarrhea. Make sure to bring diarrhea medicine with you so that you can treat mild cases yourself.

Avoid Injuries

Car crashes are a leading cause of injury among travelers. Protect yourself from these injuries by:

• Not drinking and driving.
• Wearing your seat belt and using car seats or booster seats in the backseat for children.
• Following local traffic laws.
• Wearing helmets when you ride bikes, motorcycles, and motor bikes.
• Not getting on an overloaded bus or mini-bus.
• Hiring a local driver, when possible.
• Avoiding night driving.

Prevent Altitude Illness and Sunburn

If you visit the Himalayan Mountains, ascend gradually to allow time for your body to adjust to the high altitude, which can cause insomnia, headaches, nausea, and altitude illness. If you experience these symptoms descend to a lower altitude and seek medical attention. Untreated altitude illness can be fatal.
Use sunblock rated at least 15 SPF, especially at high altitudes, where the risk of sunburn is greater.

Other Health Tips

• To avoid infections such as HIV and viral hepatitis do not share needles for tattoos, body piercing, or injections.
• To reduce the risk of HIV and other sexually transmitted diseases always use latex condoms.
• To prevent fungal and parasitic infections, keep feet clean and dry, and do not go barefoot, especially on beaches where animals may have defecated.