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China
Summary of recommendationsMedicationsImmunizations
Recent outbreaksOther infectionsFood and water precautions
Insect and Tick ProtectionSwimming and bathing precautionsGeneral advice
Physicians and hospitalsPharmaciesBlood supply
Medical facilitiesHealth InsuranceOther health information
Traveling with childrenTravel and pregnancyMaps
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Summary of recommendations:

All travelers should visit either their personal physician or a travel health clinic 4-8 weeks before departure.

Malaria: Prophylaxis is recommended for rural areas of Anhui, Guizhou, Hainan, Henan, Hubei, and Yunnan Provinces. Either mefloquine (Lariam), atovaquone/proguanil (Malarone), or doxycycline may be given, except for the western part of Yunnan province along China-Burma border, where mefloquine should not be used due to the risk of mefloquine-resistant malaria.
Vaccinations:

Hepatitis A

Recommended for all travelers

Typhoid

For travelers who may eat or drink outside major restaurants and hotels

Yellow fever

Required for all travelers arriving from a country with risk of yellow fever transmission and for travelers who have been in transit in an airport located in a country with risk of yellow fever transmission. Not recommended otherwise.

Japanese encephalitis

For travelers who may spend a month or more in rural areas and for short-term travelers who may spend substantial time outdoors in rural areas, especially after dusk

Hepatitis B

Recommended for all travelers

Rabies

For travelers spending a lot of time outdoors, or at high risk for animal bites, or involved in any activities that might bring them into direct contact with bats

Measles, mumps, rubella (MMR)

Two doses recommended for all travelers born after 1956, if not previously given

Tetanus-diphtheria

Revaccination recommended every 10 years

Medications

Travelers' diarrhea is the most common travel-related ailment. The cornerstone of prevention is food and water precautions, as outlined below. All travelers should bring along an antibiotic and an antidiarrheal drug to be started promptly if significant diarrhea occurs, defined as three or more loose stools in an 8-hour period or five or more loose stools in a 24-hour period, especially if associated with nausea, vomiting, cramps, fever or blood in the stool. A quinolone antibiotic is usually prescribed: either ciprofloxacin (Cipro)(PDF) 500 mg twice daily or levofloxacin (Levaquin) 500 mg once daily for a total of three days. Quinolones are generally well-tolerated, but occasionally cause sun sensitivity and should not be given to children, pregnant women, or anyone with a history of quinolone allergy. Alternative regimens include a three day course of rifaximin (Xifaxan) 200 mg three times daily or azithromycin (Zithromax) 500 mg once daily. Rifaximin should not be used by those with fever or bloody stools and is not approved for pregnant women or those under age 12. Azithromycin should be avoided in those allergic to erythromycin or related antibiotics. An antidiarrheal drug such as loperamide (Imodium) or diphenoxylate (Lomotil) should be taken as needed to slow the frequency of stools, but not enough to stop the bowel movements completely. Diphenoxylate (Lomotil) and loperamide (Imodium) should not be given to children under age two.

Most cases of travelers' diarrhea are mild and do not require either antibiotics or antidiarrheal drugs. Adequate fluid intake is essential.

If diarrhea is severe or bloody, or if fever occurs with shaking chills, or if abdominal pain becomes marked, or if diarrhea persists for more than 72 hours, medical attention should be sought.

Though effective, antibiotics are not recommended prophylactically (i.e. to prevent diarrhea before it occurs) because of the risk of adverse effects, though this approach may be warranted in special situations, such as immunocompromised travelers.

Malaria in China: malaria occurs in rural parts of Anhui, Guizhou, Hainan, Henan, Hubei, and Yunnan Provinces. Rare cases occur in other rural parts of the country at altitudes less than 1500 m (4921 ft) May–December. There is no malaria risk in urban areas. Some major river cruises may go through malaria-endemic areas in Anhui and Hubei Provinces.

Malaria prevention with either atovaquone/proguanil (Malarone)(PDF) or doxycycline is recommended for the western part of Yunnan Province along the Myanmar border. For Hainan and other parts of Yunnan Province, either mefloquine (Lariam), atovaquone-proguanil (Malarone), or doxycycline may be given. For Anhui, Guizhou, Henan, and Hubei provinces, either atovaquone-proguanil (Malarone), chloroquine, doxycycline, mefloquine, or primaquine may be given.

Mefloquine is taken once weekly in a dosage of 250 mg, starting one-to-two weeks before arrival and continuing through the trip and for four weeks after departure. Mefloquine may cause mild neuropsychiatric symptoms, including nausea, vomiting, dizziness, insomnia, and nightmares. Rarely, severe reactions occur, including depression, anxiety, psychosis, hallucinations, and seizures. Mefloquine should not be given to anyone with a history of seizures, psychiatric illness, cardiac conduction disorders, or allergy to quinine or quinidine. Those taking mefloquine (Lariam) should read the Lariam Medication Guide (PDF). Atovaquone/proguanil (Malarone) is a combination pill taken once daily with food starting two days before arrival and continuing through the trip and for seven days after departure. Side-effects, which are typically mild, may include abdominal pain, nausea, vomiting, headache, diarrhea, or dizziness. Serious adverse reactions are rare. Doxycycline is effective, but may cause an exaggerated sunburn reaction, which limits its usefulness in the tropics. Insect protection measures are essential.

For all other areas with malaria, including river cruises that pass through malaria-endemic provinces, insect protection measures are advised, but malaria medications are not recommended.

Long-term travelers who may not have access to medical care should bring along medications for emergency self-treatment should they develop symptoms suggestive of malaria, such as fever, chills, headaches, and muscle aches, and cannot obtain medical care within 24 hours. See malaria for details. Symptoms of malaria sometimes do not occur for months or even years after exposure.

For further information on malaria in China, including maps showing the risk of malaria in different parts of the country, go to the World Health Organization - Western Pacific Region and the World Health Organization.

Altitude sickness may occur in travelers who ascend rapidly to altitudes greater than 2500 meters. Most roads and towns in Tibet, Qinghai, parts of Xinjiang, and western Sichuan are at altitudes over 3000 meters. Acetazolamide is the drug of choice to prevent altitude sickness. The usual dosage is 125 or 250 mg twice daily starting 24 hours before ascent and continuing for 48 hours after arrival at altitude. Possible side-effects include increased urinary volume, numbness, tingling, nausea, drowsiness, myopia and temporary impotence. Acetazolamide should not be given to pregnant women or those with a history of sulfa allergy. For those who cannot tolerate acetazolamide, the preferred alternative is dexamethasone 4 mg taken four times daily. Unlike acetazolamide, dexamethasone must be tapered gradually upon arrival at altitude, since there is a risk that altitude sickness will occur as the dosage is reduced.

Travel to high altitudes is not generally recommended for those with a history of heart disease, lung disease, or sickle cell disease.

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Immunizations

The following are the recommended vaccinations for China:

Hepatitis A vaccine is recommended for all travelers over one year of age. It should be given at least two weeks (preferably four weeks or more) before departure. A booster should be given 6-12 months later to confer long-term immunity. Two vaccines are currently available in the United States: VAQTA (Merck and Co., Inc.) (PDF) and Havrix (GlaxoSmithKline) (PDF). Both are well-tolerated. Side-effects, which are generally mild, may include soreness at the injection site, headache, and malaise.

Certain lots of VAQTA were recalled in December 2001 because some prefilled syringes were found not to contain enough antigen. Those who received VAQTA between August 1999 and December 2001 should go to hepatitis A to determine whether or not they may require reimmunization.

Travelers who are less than one year of age, are pregnant, or have less than two weeks before departure should receive a single intramuscular dose of gammaglobulin (see hepatitis A for dosage) instead of vaccine.

Typhoid vaccine is recommended for all travelers, with the exception of short-term visitors who restrict their meals to major restaurants and hotels, such as business travelers and cruise passengers. It is generally given in an oral form (Vivotif Berna) consisting of four capsules taken on alternate days until completed. The capsules should be kept refrigerated and taken with cool liquid. Side-effects are uncommon and may include abdominal discomfort, nausea, rash or hives. The alternative is an injectable polysaccharide vaccine (Typhim Vi; Aventis Pasteur Inc.) (PDF), given as a single dose. Adverse reactions, which are uncommon, may include discomfort at the injection site, fever and headache. The oral vaccine is approved for travelers at least six years old, whereas the injectable vaccine is approved for those over age two. There are no data concerning the safety of typhoid vaccine during pregnancy. The injectable vaccine (Typhim Vi) is probably preferable to the oral vaccine in pregnant and immunocompromised travelers.

Japanese encephalitis vaccine is recommended for long-term (1 month) travelers to rural areas or travelers who may engage in extensive unprotected outdoor activities in rural areas, especially in the evening, during shorter trips. At the present time, it should also be considered for any travelers to Henan, Shaanxi, and Shanxi provinces, including Yunching City (see "Recent outbreaks" below). Japanese encephalitis has been reported from all provinces except Xizang (Tibet), Xinjiang, and Qinghai. It is especially prevalent in southern China (an outbreak was reported from Guangdong Province in June 2003). Transmission is from May to September in the north and April to October in the south.

For those age 17 or older, the recommended vaccine is IXIARO, given 0.5 cc intramuscularly, followed by a second dose 28 days later. The series should be completed at least one week before travel. The most common side effects are headaches, muscle aches, and pain and tenderness at the injection site. Safety has not been established in pregnant women, nursing mothers, or children under the age of 17. For the vaccination options for those under age 17, go to the Japanese encephalitis section.

Hepatitis B vaccine is recommended for all travelers if not previously vaccinated. Two vaccines are currently licensed in the United States: Recombivax HB (Merck and Co., Inc.) (PDF) and Engerix-B (GlaxoSmithKline) (PDF). A full series consists of three intramuscular doses given at 0, 1 and 6 months. Engerix-B is also approved for administration at 0, 1, 2, and 12 months, which may be appropriate for travelers departing in less than 6 months. Side-effects are generally mild and may include discomfort at the injection site and low-grade fever. Severe allergic reactions (anaphylaxis) occur rarely.

Rabies vaccine is recommended for travelers spending a lot of time outdoors, for travelers at high risk for animal bites, such as veterinarians and animal handlers, for long-term travelers and expatriates, and for travelers involved in any activities that might bring them into direct contact with bats. Children are considered at higher risk because they tend to play with animals, may receive more severe bites, or may not report bites. In China, most cases are related to dog bites; a majority are reported from five southern provinces: Guangxi, Hunan, Jiangxi, Guangdong, and Jiangsu (see Emerging Infectious Diseases). A complete preexposure series consists of three doses of vaccine injected into the deltoid muscle on days 0, 7, and 21 or 28. Side-effects may include pain at the injection site, headache, nausea, abdominal pain, muscle aches, dizziness, or allergic reactions.

Any animal bite or scratch should be thoroughly cleaned with large amounts of soap and water and local health authorities should be contacted immediately for possible post-exposure treatment, whether or not the person has been immunized against rabies.

All travelers should be up-to-date on routine immunizations, including

  • Tetanus-diphtheria vaccine (recommended for all travelers who have not received a tetanus-diphtheria immunization within the last 10 years.)
  • Measles vaccine (recommended for any traveler born after 1956 who does not have either a history of two documented measles immunizations or a blood test showing immunity. Many adults who had only one vaccination show immunity when tested and do not need the second vaccination. Measles vaccine should not be given to pregnant or severely immunocompromised individuals.)
  • Varicella (chickenpox) vaccine (recommended for any international traveler over one year of age who does not have either a history of documented chickenpox or a blood test showing immunity. Many people who believe they never had chickenpox show immunity when tested and do not need the vaccine. Varicella vaccine should not be given to pregnant or immunocompromised individuals.)

Polio vaccine is recommended, because of recent reports of polio near the Pakistan border. Any adult who completed the routine childhood immunizations but never received a booster as an adult should be given a single dose of inactivated polio vaccine. All children should be up-to-date in their polio immunizations and any adult who never completed the initial series of immunizations should do so before departure. Side-effects are uncommon and may include pain at the injection site. Since inactivated polio vaccine includes trace amounts of streptomycin, neomycin and polymyxin B, individuals allergic to these antibiotics should not receive the vaccine.

Cholera vaccine is not generally recommended, even though cholera occurs in China, because most travelers are at low risk for infection. The only cholera vaccine approved for use in the United States has low efficacy and a high incidence of adverse reactions, and is no longer being manufactured or sold. Two oral vaccines have recently been developed but are not yet approved in the United States (see cholera). These vaccines, where available, may be considered for certain high-risk individuals, such as relief workers or health professionals.

Yellow fever vaccine is required for all travelers arriving from a country in Africa or the Americas with risk of yellow fever transmission and for travelers who have been in an airport located in a country with risk of yellow fever transmission, but is not recommended or required otherwise. Yellow fever vaccine (YF-VAX; Aventis Pasteur Inc.) (PDF) must be administered at an approved yellow fever vaccination center, which will give each vaccinee a fully validated International Certificate of Vaccination. Yellow fever vaccine should not in general be given to those who are younger than nine months of age, pregnant, immunocompromised, or allergic to eggs. It should also not be given to those with a history of thymus disease or thymectomy.

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Recent outbreaks

An outbreak of human infections caused by an H7N9 avian influenza A virus, which normally affects only birds, was reported from China in March 2013, causing 136 cases and 65 deaths as of June 2013. More than 30 cases were reported from the city of Shanghai. Cases were also reported from the provinces of Jiangsu, Anhui, Zhejiang, Henan, and Shandong. One case was reported from Beijing. Older males appeared to be particularly affected. Most of the cases occurred in those who had direct contact with poultry or birds in live poultry markets, had visited live poultry markets, or had prepared or cooked freshly slaughtered birds from live poultry markets. Frequent hand-washing was associated with a reduced rate of infection (see Eurosurveillance).

Only two cases of H7N9 avian influenza were reported in the summer of 2013, but a fresh outbreak began in October 2013. The number of cases rose rapidly in January 2014. As of May 2014, the number of cases in the second wave of H7N9 human infections had reached 423, more than three times as many as in the first wave. The new outbreak particularly affected Zhejiang province. Many cases were also reported from Guangdong and Jiangsu provinces and the Shanghai metropolitan area. One case occurred in a Canadian tourist and another in a traveler from Malaysia. The fatality rate was the same as in the previous H7N9 outbreak, but the virus appeared to spread faster than before. DNA analysis showed that there had been reassortment of genetic material between H7N9 influenza and local H9N2 strains. As of May 2014, new cases of H7N9 avian influenza continued to be reported, but the number appeared to be declining. Sales of live poultry have been suspended in Shanghai, Hong Kong, Guangzhou, and the province of Zhejiang (see Eurosurveillance, the World Health Organization, and ProMED-mail).

Symptoms of human H7N9 influenza may include fever, cough, and shortness of breath, and may progress to severe respiratory illness, in some cases fatal. Laboratory testing conducted so far has shown that the H7N9 viruses are generally sensitive to the two most commonly used anti-influenza drugs, oseltamivir and zanamivir, although resistance to oseltamavir has been reported in severely ill patients shortly after treatment was started.

A few small clusters with possible human-to-human transmission have occurred among family members, but there has been no evidence of sustained human-to-human transmission to date. The World Health Organization does not recommend any travel restrictions for China, but advises that that visitors should avoid poultry farms, or contact with animals in live bird markets, or entering areas where poultry may be slaughtered, or contact with any surfaces that appear to be contaminated with feces from poultry or other animals. Travelers should also wash their hands often with soap and water. Travelers to China who develop fever, cough or shortness of breath should seek immediate medical attention.

In December 2013 and February 2014, three human infections caused by an H10N8 avian influenza A virus, which normally affects only birds, were reported from China. Two of the cases were fatal. The infections appeared to be caused by a new strain which had acquired genetic material from an H9N2 influenza virus and which might have the capacity to replicate efficiently in humans (see ProMED-mail). Health authorities are observing closely for additional cases. One human case of H9N2 avian influenza was reported in December 2008, involving a 2-month old infant living in Guangdong Province in the south.

Seven cases of polio were reported in August-September 2011 from Hotan prefecture, Xinjiang Uygur autonomous region. Genetic sequencing indicates the virus was probably imported from Pakistan. The government responded by mounting a polio immunization campaign (see the World Health Organization). All travelers should be fully immunized against polio. Any adult who completed the routine childhood immunizations but never received a booster as an adult should be given a single dose of inactivated polio vaccine. All children should be up-to-date in their polio immunizations and any adult who never completed the initial series of immunizations should do so before departure.

An outbreak of chikungunya fever, a mosquito-borne illness characterized by fever and incapacitating joint pains, was reported in October 2010 from Dongguan, an industrial city in Guangdong Province, in southern China. As of October 6, a total of 38 cases had been confirmed and an additional 166 people were suspected of having the infection (see ProMED-mail, October 8, 2010). Symptoms of chikungunya fever 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. Insect protection measures are strongly recommended, as described below. Because of the risk of mother-to-child transmission, pregnant women need to take special care to protect themselves from mosquito bites.

An outbreak of hand, foot, and mouth disease was reported in early 2010, causing almost one million cases on the Chinese mainland by end of June, including 537 deaths. More than 90 percent of the cases were caused by enterovirus 71. Quanzhou County in Guangxi Autonomous Region was particularly affected (see ProMED-mail, June 26, 2010). In the first five months of 2012, at least 240 people, mostly children under the age of five, died of hand, foot and mouth disease. In June 2012, an outbreak was reported from Hunan province, causing more than 34,000 cases and 17 deaths (see ProMED-mail, July 15, 2012).

Hand, foot, and mouth disease is characterized by fever, oral blisters, and a rash or blisters on the palms and soles, usually occurring in young children. 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 disease is caused by enteroviruses, which are transmitted by exposure to fecal material from infected individuals. There is no vaccine. The key to prevention is good personal hygiene and scrupulous hand-washing, especially after defecation and before handling food. No travel restrictions are recommended.

A major outbreak of hand, foot, and mouth disease was reported in early 2009, chiefly in rural areas and mostly in young children. The eastern province of Shandong was particularly affected: as of July 2009, the province had reported a total of 85,301 cases and 44 deaths. The central provinces of Henan, Jiangsu, Guangxi, Anhui, Guangdong, Hebei, Hunan, Zhejiang, and Hubei were also involved by the outbreak. Most of the cases were caused by enterovirus 71. A major outbreak caused by enterovirus 71 was also reported in April 2008, particularly involving Anhui province. Cases were also reported from the provinces of Guangdong, Zhejiang, Hebei, Shandong, Hunan, Hubei, Hainan, Henan, Jiangsu, Jiangxi, Shaanxi, Sichuan, Yunnan, and Zhejiang, and in the municipalities of Beijing, Shanghai, and Chongqing. As of June, more than 170,000 cases and at least 36 deaths had been reported, chiefly among infants and young children. The outbreak appeared to be subsiding by June, but additional cases were reported from Fujian Province in October (see the World Health Organization and ProMED-mail). In May 2007, an outbreak of hand, foot, and mouth disease occurred in Linyi city in Shandong province, causing at least three deaths (see ProMED-mail, May 27, 2007). An outbreak between April and July 1998, with many cases complicated by meningitis, encephalitis and acute flaccid paralysis, was apparently caused by enterovirus 71.

The number of measles cases in China has been rising since 1995. A measles outbreak was reported from Heihe province in April-May 2010, causing 280 cases. In February 2008, a measles outbreak was reported from the Xinjiang Uygur Autonomous Region, chiefly affecting those under age four and killing ten people. An increased number of measles cases was reported from Shenzhen (a sub-province of Guangdong province) between January and March 2008, but the incidence appeared to be declining by May. A total of 3650 cases were reported from the city of Guangzhou in southern China during the first 11 months of 2006, the highest number for that period over the past 20 years. Most of the cases occurred in preschool children (ProMED-mail; January 11, 2007 and October 22, 2008).

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, children between the ages of 6 and 11 months should be given an initial dose of MMR vaccine before traveling to China.

An outbreak of pneumonic plague was reported in September 2010 from Laduo, a remote village in southwestern Tibet, causing five cases (see ProMED-mail, September 28, 2010). In August 2009, an outbreak of pneumonic plague occurred in the town of Ziketan in Qinghai Province, a remote area in the northwestern part of China, resulting in 12 cases and three deaths (see the World Health Organization). In September 2008, two cases of pneumonic plague were reported from Linzhi district in southeastern Tibet. Two cases were reported from Gansu in 2007.

In China, most human cases of plague are reported from Yunnan and Qinghai provinces. The plague is usually transmitted by the bite of rodent fleas. Less commonly, the disease is acquired by inhalation of infected droplets, which may be coughed into the air by a person with plague pneumonia, or by direct exposure to infected blood or tissues. Most travelers are at low risk for the plague. Those who may have contact with rodents or their fleas should bring along a bottle of doxycycline, to be taken prophylactically if exposure occurs. Those less than eight years of age or allergic to doxycycline may take trimethoprim-sulfamethoxazole instead. To minimize risk, travelers should avoid areas containing rodent burrows or nests, never handle sick or dead animals, and follow insect protection measures, as described below.

The industrial chemical melamine was discovered in infant formula produced in China, as well as in other dairy products produced in China, including frozen yogurt dessert and canned coffee drink, in September 2008. Chinese eggs were also been found to be contaminated. More than 54,000 infants and young children required treatment for kidney stones caused by melamine-contaminated products. At least six infants died. Melamine-contaminated milk products were again found on sale in January 2010. In September 2010, an additional batch of melamine-contaminated powdered milk, which should have been destroyed in 2008, was discovered in at the Jinfulia Dairy Company, based in Yangquan city, Shanxi province. In November 2010, melamine was found in packages of a corn-flavored dairy drink being marketed in Xiangfan, in the central province of Hubei (see the World Health Organization and ProMED-mail). Until further notice, dairy and egg products produced in China should not be consumed. This includes all brands of infant formula; milk or other drinks that contain milk products; foods such as yogurt or ice cream that could be milk-based or contain a large amount of milk or milk products; and any foods or drinks whose labels show they contain milk, milk powder, whey, lactose, casein, or eggs. For further details, go to the CDC and Consumer Reports websites.

Cholera outbreaks are reported sporadically from China. The most recent oubreaks were reported in September 2010 from Mengcheng County in eastern Anhui Province and from a school in Huaian city in Jiangsu Province. In January 2009, an outbreak occurred in Yuxi city in Yunnan Province, causing 47 cases, none fatal. In October 2008, a cholera outbreak occurred in the island province of Hainan in the southern part of the country. In September 2005, an outbreak was reported from Zhejiang Province in the eastern part of the country, resulting in 184 cases, none of them fatal. Cases were also reported from Fujian Province. In 2001, a cholera outbreak occurred in Guandong Province, resulting in 105 cases and no fatalities. Most travelers are at extremely low risk for infection. Cholera vaccine, where available, is recommended only 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. All travelers should carefully observe food and water precautions, as below.

The number of rabies cases is increasing in China, especially in highly populated areas in the southwestern and southern territories. Most cases are related to dog bites, especially on the head and neck. In recent years, more than 2400 people have died from rabies infections annually, chiefly in the Guangxi Zhuang Autonomous Region and the southern provinces of Guizhou, Guangdong, Hunan and Sichuan. An increasing number of rabies cases are also being reported from the central and northern parts of China. An outbreak was reported in June 2009 from Hanzhong City in Shaanxi Province, causing 11 fatalities. The rise appears to be related to the increased popularity of keeping dogs as pets, a decrease in canine vaccination, and a failure to seek treatment after a dog bite. See NATHNAC, ProMED-mail (October 10, 2006; June 12 and July 25, 2007; August 26, 2008; June 7 and September 27, 2009) for further information.

Most travelers are at low risk for rabies. Rabies vaccine is recommended for travelers spending a lot of time outdoors, for travelers at high risk for animal bites, such as veterinarians and animal handlers, for long-term travelers and expatriates, and for travelers involved in any activities that might bring them into direct contact with bats. Children are considered at higher risk because they tend to play with animals, may receive more severe bites, or may not report bites.

An outbreak of dengue fever was reported in September 2010 from Guangdong province, in the southern part of the country. In October 2008, a dengue outbreak occurred in Yunnan Province near the Myanmar border. Another dengue outbreak occurred in Guangdong Province in September 2006 (see ProMED-mail, Sept. 12 and Oct. 24, 2006, and September 21, 2010). Dengue fever is a flu-like illness, sometimes complicated by hemorrhage or shock, transmitted by Aedes mosquitoes, which bite primarily in the daytime and favor densely populated areas, though they also inhabit rural environments. Outbreaks are periodically reported from China, chiefly the provinces of Guangdong, Guangxi, Hainan and Yunnan in the southern part of the country. No vaccine is available at this time. Insect protection measures are strongly advised, as outlined below. For further information on dengue in China, go to the World Health Organization - Western Pacific Region.

A total of 45 human cases of H5N1 avian influenza ("bird flu") have been reported from China since November 2005, of which 28 were fatal.

Since January 2004, outbreaks of avian influenza have been reported from poultry farms in many parts of the country, including the provinces of Guangxi, Hunan, Hubei, Gansu, Shaanxi, Anhui, Shanghai, Guangdong, Zhejiang, Yunnan, Henan, Jiangxi, and Xinjiang Uygar Autonomous Region. The most recent poultry outbreaks were reported from the southwest province of Guizhou in December 2013 and February 2014. The live poultry markets in Beijing have been permanently closed.

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 China should seek immediate medical attention, which may include testing for avian influenza. For further information, go to the World Health Organization, Health Canada, the Centers for Disease Control, and ProMED-mail.

A malaria outbreak was reported from Anhui province in September 2006, resulting in almost 18,000 cases as of September 25 (see ProMED-mail, October 5, 2006). To lower the risk of malaria, a weekly dose of chloroquine is recommended for all travelers to Anhui province during the warm weather months. Insect protections measures, as below, are also advised.

Outbreaks of Japanese encephalitis were reported in August 2006 from the provinces of Henan, Shaanxi, and Shanxi (including Yuncheng City), which share borders in the central part of China (see ProMED-mail). Japanese encephalitis is a life-threatening viral infection which is transmitted by Culex mosquitoes, usually in rural areas. Most infections are asymptomatic, but the virus may spread to the brain, which is frequently fatal. Those who survive may show evidence of mental retardation or other neurological deficits. Japanese encephalitis vaccine is recommended for long-term (1 month) travelers to rural areas or travelers who may engage in extensive unprotected outdoor activities in rural areas, especially in the evening, during shorter trips. At the present time, it should also be considered for any travelers to Henan, Shaanxi, and Shanxi provinces, including Yunching City.

An outbreak of Angiostrongylus meningitis was reported from Beijing in August 2006, caused by undercooked snails. A total of 132 cases were identified, none of them fatal. For further information, go to ProMED-mail (August 23 and October 1, 2006). Angiostrongylus lives as a parasite in a variety of snails and slugs. The symptoms of Angiostrongylus meningitis include fever, headache, stiff neck, and light sensitivity. In most cases, recovery is slow but uneventful. There is no treatment. Snails should never be consumed unless fully cooked.

An outbreak of Streptococcus suis infections was reported in July-August 2005 from Sichuan Province, related to a concurrent outbreak in the pig population. A total of 204 human cases were identified, 38 of them fatal, before the outbreak was controlled in August. 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, subcutaneous hemorrhage, toxic shock, and coma. The incubation period was short and the disease progressed rapidly. 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. For further information, go to the World Health Organization and ProMED-mail.

An outbreak of meningococcal disease was reported in January 2005 from 11 cities in Anhui Province in eastern China. Most cases occurred in students 13-18 years of age. A smaller number of cases were reported from the provinces of Henan, Hebei, Jiangsu, and Xichuan. The outbreak appeared to have ended by August 2005. Meningococcal vaccine is longer recommended for travelers to China. For further information, go to Health Canada and the National Travel Health Network and Centre (U.K.).

A fresh outbreak of severe acute respiratory syndrome (SARS) was reported from China in April 2004, resulting in nine new cases (seven in Beijing and two in Anhui Province) before the outbreak was declared over in May. Two of those affected were laboratory workers who had been performing research on the SARS virus at the National Institute of Virology. All the others either had close contact with one of the laboratory workers or with a nurse who became ill after caring for one of the researchers. No travel restrictions are recommended for China at this time. For further information, go to the World Health Organization.

The initial SARS outbreak began in Guangdong province in November 2002 and ultimately spread to many other areas, resulting in 5327 cases and 349 deaths before the outbreak was terminated in July 2003 by an aggressive program of contact identification and quarantine. In December 2003, a new case of SARS was reported from Guangdong province, followed in January 2004 by three more cases. All contacts of these patients were promptly quarantined and remained disease-free. No further cases were reported until April 2004, as described above.

The disease appears to be caused by a previously unknown virus belonging to the coronavirus family. The incubation period usually ranges from two-to-seven days, but may be as long as ten days. The first symptom is usually fever, often accompanied by chills, headache, body aches, and malaise. This is typically followed by dry cough and difficulty breathing, at times severe enough to require intubation and mechanical ventilation. The most recent analysis indicates that the overall fatality rate is approximately 15%, ranging from less than 1% in those younger than 25 years old to greater than 50% in those aged 65 years or older.

For further information, go to the SARS pages of the World Health Organization, the Centers for Disease Control, and Health Canada.

An outbreak of measles was reported in April 2004 among children in the United States and Norway who had been adopted in China. A total of 14 cases (ten in the United States and four in Norway) were identified before the outbreak ended. The cases were all traced to a single orphanage, the Zhuzhou Child Welfare Institute in Hunan Province, where a measles outbreak was in progress. On June 2, 2004, the Centers for Disease Control announced that the measles outbreak had been terminated and that adoptions from the orphanage could be resumed. See the Centers for Disease Control for further information. 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 1956, who are presumed to be immune to measles.

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Other infections

  • Severe fever with thrombocytopenia virus (life-threatening viral infection transmitted by ticks; causes fever, low platelets, low white blood cell count, and elevated liver enzymes; reported from six rural provinces in northeast and central China in 2011; see Emerging Infectious Diseases and ProMED-mail, February 20, 2013)
  • Visceral leishmaniasis (transmitted by sandflies; sporadic cases occur in Xinjiang and western Inner Mongolia in northwestern China and in Fujian province in southeastern China; eradicated elsewhere)
  • Cutaneous leishmaniasis (recently reported from Xinjiang, Uygur Autonomous Region)
  • Scrub typhus (rural areas in southern China and Tibet; transmitted by chigger bites)
  • Hemorrhagic fever with renal syndrome (transmitted by rodents; outbreak reported from Shandong province in October-December 2011)
  • Hepatitis E (northwestern China; transmitted by contaminated food and water)
  • Schistosomiasis (central Chang Jiang (Yangtze) river basin; swimming and bathing precautions advised, as below)
  • Leptospirosis (animal reservoir includes mice, pigs, rats, buffalo, dogs, and cattle)
  • Trachoma (eye infection)
  • Brucellosis (rural areas; increasing number of cases, especially from Heilongjiang province in northeastern China; outbreak reported among dairy workers in Heilongjiang province in June 2012; prevalence highest in the eastern central provinces of Shanxi, Hebei, and Henan; see ProMED-mail, December 6, 2007, and June 12, 2012)
  • Melioidosis (associated with exposure to rice field soil)
  • Murine typhus
  • Louse-borne typhus (northern China)
  • North Asian tick fever (northern China)
  • Tick-borne relapsing fever (western China)
  • Tick-borne encephalitis (rural and forested areas; most cases occur in the northeastern forest areas of Changbai Mountains in Jilin Province, Daxingán Mountain in Inner Mongolia Province, and Xiaoxingán Mountain in Hei Longjiang Province; reported intermittenly from the forest regions on the northern slope of Tianshan Mountain and the southern slope of the Altai Mountains in Xinjiang Uygur Autonomous Region in northwestern China; sporadic cases in Yunnan (southwestern China) and Tibet)
  • Paratyphoid fever (outbreak reported from Guangxi Zhuang Autonomous Region in south China in October 2010)
  • Crimean-Congo hemorrhagic fever (western China)
  • Anthrax (western and northern China; human outbreaks reported in July 2010 from Gongzhuling City, in August 2011 from Liaoning Province, and in August 2012 from Liaoning Province and Jiangsu Province)
  • Chikungunya fever
  • Tularemia
  • Q fever
  • Lyme disease
  • Lung fluke (paragonimiasis)
  • Oriental liver fluke (clonorchiasis)
  • Giant intestinal fluke (fasciolopsiasis)
  • Fish tapeworm (diphyllobothriasis)
  • Pork tapeworm (taeniasis)

HIV (human immunodeficiency virus) infection is reported, but travelers are not at risk unless they have unprotected sexual contacts or receive injections or blood transfusions.

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Food and water precautions

Do not drink tap water unless it has been boiled, filtered, or chemically disinfected. Do not drink unbottled beverages or drinks with ice. Do not eat fruits or vegetables unless they have been peeled or cooked. Avoid cooked foods that are no longer piping hot. Cooked foods that have been left at room temperature are particularly hazardous. Avoid unpasteurized milk and any products that might have been made from unpasteurized milk, such as ice cream. Avoid food and beverages obtained from street vendors. Do not eat raw or undercooked meat or fish. Some types of fish may contain poisonous biotoxins even when cooked. Barracuda in particular should never be eaten. Other fish that may contain toxins include red snapper, grouper, amberjack, sea bass, and a large number of tropical reef fish.

All travelers should bring along an antibiotic and an antidiarrheal drug to be started promptly if significant diarrhea occurs, defined as three or more loose stools in an 8-hour period or five or more loose stools in a 24-hour period, especially if accompanied by nausea, vomiting, cramps, fever or blood in the stool. Antibiotics which have been shown to be effective include ciprofloxacin (Cipro), levofloxacin (Levaquin), rifaximin (Xifaxan), or azithromycin (Zithromax). Either loperamide (Imodium) or diphenoxylate (Lomotil) should be taken in addition to the antibiotic to reduce diarrhea and prevent dehydration.

If diarrhea is severe or bloody, or if fever occurs with shaking chills, or if abdominal pain becomes marked, or if diarrhea persists for more than 72 hours, medical attention should be sought.

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Insect and Tick Protection

Wear long sleeves, long pants, hats and shoes (rather than sandals). For rural and forested areas, boots are preferable, with pants tucked in, to prevent tick bites. Apply insect repellents containing 25-50% DEET (N,N-diethyl-3-methylbenzamide) or 20% picaridin (Bayrepel) to exposed skin (but not to the eyes, mouth, or open wounds). DEET may also be applied to clothing. Products with a lower concentration of either repellent need to be repplied more frequently. Products with a higher concentration of DEET carry an increased risk of neurologic toxicity, especially in children, without any additional benefit. Do not use either DEET or picaridin on children less than two years of age. For additional protection, apply permethrin-containing compounds to clothing, shoes, and bed nets. Permethrin-treated clothing appears to have little toxicity. Don't sleep with the window open unless there is a screen. If sleeping outdoors or in an accomodation that allows entry of mosquitoes, use a bed net, preferably impregnated with insect repellent, with edges tucked in under the mattress. The mesh size should be less than 1.5 mm. If the sleeping area is not otherwise protected, use a mosquito coil, which fills the room with insecticide through the night. In rural or forested areas, perform a thorough tick check at the end of each day with the assistance of a friend or a full-length mirror. Ticks should be removed with tweezers, grasping the tick by the head. Many tick-borne illnesses can be prevented by prompt tick removal.

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Swimming and bathing precautions

Avoid swimming, wading, or rafting in bodies of fresh water, such as lakes, ponds, streams, or rivers. Do not use fresh water for bathing or showering unless it has been heated to 150 degrees F for at least five minutes or held in a storage tank for at least three days. Toweling oneself dry after unavoidable or accidental exposure to contaminated water may reduce the likelihood of schistosomiasis, but does not reliably prevent the disease and is no substitute for the precautions above. Chlorinated swimming pools are considered safe.

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General advice

Bring adequate supplies of all medications in their original containers, clearly labeled. Carry a signed, dated letter from the primary physician describing all medical conditions and listing all medications, including generic names. If carrying syringes or needles, be sure to carry a physician's letter documenting their medical necessity.Pack all medications in hand luggage. Carry a duplicate supply in the checked luggage. If you wear glasses or contacts, bring an extra pair. If you have significant allergies or chronic medical problems, wear a medical alert bracelet.

Make sure your health insurance covers you for medical expenses abroad. If not, supplemental insurance for overseas coverage, including possible evacuation, should be seriously considered. If illness occurs while abroad, medical expenses including evacuation may run to tens of thousands of dollars. For a list of travel insurance and air ambulance companies, go to Medical Information for Americans Traveling Abroad on the U.S. State Department website. Bring your insurance card, claim forms, and any other relevant insurance documents. Before departure, determine whether your insurance plan will make payments directly to providers or reimburse you later for overseas health expenditures. The Medicare and Medicaid programs do not pay for medical services outside the United States.

Pack a personal medical kit, customized for your trip (see description). Take appropriate measures to prevent motion sickness and jet lag, discussed elsewhere. On long flights, be sure to walk around the cabin, contract your leg muscles periodically, and drink plenty of fluids to prevent blood clots in the legs. For those at high risk for blood clots, consider wearing compression stockings.

Avoid contact with stray dogs and other animals. If an animal bites or scratches you, clean the wound with large amounts of soap and water and contact local health authorities immediately. Wear sun block regularly when needed. Use condoms for all sexual encounters. Ride only in motor vehicles with seat belts. Do not ride on motorcycles.

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Physicians and hospitals

For an online directory of physicians and medical facilities in China, go to the U.S. Embassy website. For an overview of health care in China, go to the World Health Organization - Western Pacific Region.

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Pharmacies

Quality control of pharmaceuticals is poor. Fake or contaminated drugs are a major problem. Travelers should avoid using medications purchased in China.

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Blood supply

An outbreak of hepatitis C infections related to unsterilized needles was reported in November-December 2011 from the eastern province of Anhui and the neighboring central province of Henan. In February 2012, an outbreak of hepatitis C related to reused needles was reported from Guangdong Province (see ProMED-mail). Transfusions and injections should be avoided in China if at all possible.

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Medical facilities

(reproduced from the U.S. State Dept. Consular Information Sheet)

Western-style medical facilities with international staffs are available in Beijing, Shanghai, Guangzhou and a few other large cities. Many other hospitals in major Chinese cities have so-called VIP wards (gaogan bingfang). These feature reasonably up-to-date medical technology and physicians who are both knowledgeable and skilled. Most VIP wards also provide medical services to foreigners and have English-speaking doctors and nurses. Most hospitals in China will not accept medical insurance from the United States, with the exception of the following hospitals, which are on the BlueCross BlueShield worldwide network providers - overseas network hospitals(http://www.fepblue.org/wasite/wabenefits/wa-benefitsoverseas04.html): Hong Kong Adventist Hospital, Beijing United Family Hospital, Beijing Friendship Hospital, International Medical Center in Beijing, and Peking Union Medical Center. Travelers will be asked to post a deposit prior to admission to cover the expected cost of treatment. Hospitals in major cities may accept credit cards for payment. Even in the VIP/Foreigner wards of major hospitals, however, American patients have frequently encountered difficulty due to cultural and regulatory differences. Physicians and hospitals have sometimes refused to supply American patients with complete copies of their Chinese hospital medical records, including laboratory test results, scans, and x-rays. All Americans traveling to China are strongly encouraged to buy foreign medical care and medical evacuation insurance prior to arrival. Travelers who want a list of modern medical facilities in China can access that information at the Embassy's website. Ambulances do not carry sophisticated medical equipment, and ambulance personnel generally have little or no medical training. Therefore, injured or seriously ill Americans may be required to take taxis or other immediately available vehicles to the nearest major hospital rather than waiting for ambulances to arrive. In rural areas, only rudimentary medical facilities are generally available. Medical personnel in rural areas are often poorly trained, have little medical equipment or availability to medications. Rural clinics are often reluctant to accept responsibility for treating foreigners, even in emergency situations.

Foreign-operated medical providers catering to expatriates and visitors are available in China.

SOS International, Ltd., operates modern medical and dental clinics and provides medical evacuation and medical escort services in Beijing, Nanjing, Tianjin and Shekou, as well as 24hr Alarm Centers in Beijing and Shanghai. Through clinics in Beijing (24 hours), Tianjin, Nanjing and Shekou, SOS offers international standard family practice services, emergency medical services and a range of clinical services.

The emergency assistance services SOS offers through alarm centers in Hong Kong, Shanghai and Beijing compliment their clinics. Each Alarm Center provides 24-hour hotline services to all our global members when they are in China. Any problem from lost luggage to a serious medical condition can be reported to the alarm center, where multilingual coordinators and doctors are on duty to respond to all manners of emergencies.

To provide these services, SOS has developed an external network of hospitals, airlines and local authorities with whom they work to deliver a fast and efficient response. These services also support the many remote site medical staff, equipment and facilities that SOS provides to clients.

For medical emergencies anywhere in mainland China, Americans can call the SOS International, Ltd., 24-hour Alarm Center in Beijing at telephone (86-10) 6462-9100 or in Shanghai at (86-21) 6295-0099 for advice and referrals to local facilities. SOS International Alarm Centers can also be contacted in Hong Kong at telephone (852) 2428-9900 and in the United States at (215) 245-4707. For a full list of SOS locations and phone numbers, consult the SOS website at http://www.internationalsos.com .

*Beijing United Family Hospital and Clinics ("BJU") is the first and remains the only foreign-invested full service international standard 50 bed hospital operating in Beijing, China. BJU was opened in 1997 by Chindex International, an American company, which in 2002 was awarded the US Secretary of State's Award for Corporate Excellence. BJU offers the full range of specialties including Family Practice, Internal Medicine, Surgery, Obstetrics/Gynecology, Pediatrics, Dentistry, Psychiatry and Physiotherapy, in addition to a 24 hour Emergency Room staffed solely by Expatriate Staff Specialists. These Physicians are all board qualified (or equivalent) in their respective fields and include specialties such as Anesthesiology, and Intensive Care Medicine. Additionally, staff are fluent in not only English, but also a wide range of languages including French, German, Japanese, Spanish, Swedish, and Finnish to name a few.

Facilities include 2 Operating Theatres, international standard 5 star LDRP birthing suites, Neonatal ICU, a 4-bed Adult ICU, General Inpatient facilities, and standard support services such as Digital Radiology, Ambulance services, Pharmacy, Laboratory and a 24 hour on-site Blood Bank with emergency blood pre-screened to the American Blood Bank standard.

Bayley Jackson Beijing Medical Center #7 Ritan Dong Lu, Chaoyang District, Beijing 100020 ( 8610) 8562-9998 Fax: (8610) 8562-3497 email: info@bjhealthcare.com Website: www.bjhealthcare.com

Beijing United Family Hospital and Clinics #2 Jiang Tai Lu, Chaoyang District, Beijing 100016 (8610) 6433-3960 Fax: (8610) 6433-3963 Emergency Hotline: (8610) 6433-2345 Website: www.bjunited.com .cn

Beijing United Family Clinic - Shunyi Pinnacle Plaza, Unit # 818, Tian Zhu Real Estate Development Zone, Shunyi District, 101312 (8610) 8046-5432 Fax: (8610) 8046-4383

Peking Union Medical Hospital 1 Shui Fu Yuan, Dong Cheng Distict, Beijing 100730 Tel: 010-6529-6114 (registration); 010-6529-7292 (information); 010-6529-5284 (24 hours) Modern Facilities with English speaking staff. Separate ward for foreign patients.

World Link Shanghai Clinics. Expatriate doctors and imported vaccines.

Portman Clinic: Shanghai Center #203 W, 1376 Nanjing Xi Lu, 200040 Tel: 6279-7688. For appointments: 6279-8678 Fax: 6279-7698

Hong Qiao Clinic: Mandarin City Unit 30, 788 Hong Xu Lu, 201103 Tel: 6405-5788; Fax: 6405-3587

GlobalDoctor, Ltd., has opened clinics staffed by English-speaking doctors within the VIP wards of government-run hospitals in Chengdu, Nanjing, and Beijing. GlobalDoctor can be reached by telephone from China at 86-10-8456-9191 or on the Internet at http://www.eglobaldoctor.com/.

Additional information on medical providers specializing in treating foreigners for general medical, dental and orthodontic problems are available at http://www.usembassy-china.org.

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Health Insurance

(reproduced from the U.S. State Dept. Consular Information Sheet)

The Department of State strongly urges Americans to consult with their medical insurance company prior to traveling abroad to confirm whether their policy applies overseas and if it will cover emergency expenses such as a medical evacuation. U.S. medical insurance plans seldom cover health costs incurred outside the United States unless supplemental coverage is purchased. Further, U.S. Medicare and Medicaid programs do not provide payment for medical services outside the United States. However, many travel agents and private companies offer insurance plans that will cover health care expenses incurred overseas, including emergency services such as medical evacuations.

When making a decision regarding health insurance, Americans should consider that many foreign doctors and hospitals require payment in cash prior to providing service and that a medical evacuation to the U.S. may cost well in excess of $50,000. Uninsured travelers who require medical care overseas often face extreme difficulties. When consulting with your insurer prior to your trip, ascertain whether payment will be made to the overseas healthcare provider or if you will be reimbursed later for expenses you incur. Some insurance policies also include coverage for psychiatric treatment and for disposition of remains in the event of death.

Other Evacuation Insurance Options:

Heathrow Air Ambulance Heathrow is an air evacuation service with offices in the United States and England. Travelers can pre-arrange air evacuation insurance and other emergency travel assistance. This service also has a business plan to assist foreigners who lack travel insurance. Heathrow Air Ambulance Service,

15554 FM, Suite 195 Houston, TX. 77095-2704. Office telephone 1-800-513-5192. Office fax 1-832-934-2395. E-mail: info@heathrowairambulance.com

Useful information on medical emergencies abroad, including overseas insurance programs, is provided in the Department of State's Bureau of Consular Affairs brochure, Medical Information for Americans Traveling Abroad, available via the Bureau of Consular Affairs home page.

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Other health information

(reproduced from the U.S. State Dept. Consular Information Sheet)

Most roads and towns in Tibet, Qinghai, parts of Xinjiang, and western Sichuan are situated at altitudes over 10,000 feet. Travelers in these areas should seek medical advice in advance of travel, allow time for acclimatization to the high altitude, and remain alert to signs of altitude sickness. Reuse or poor sterilization practices are problems in China, contributing to transmission of diseases such as Hepatitis, which is endemic in China. In order to protect themselves from blood and other tissue borne disease such as Hepatitis and HIV, travelers should always ask doctors and dentists to use sterilized equipment and be prepared to pay for new syringe needles in hospitals or clinics. Tuberculosis is endemic in China. Air pollution is also a significant problem throughout China. Travelers should consult their doctor prior to travel and consider the impact seasonal smog and heavy particulate pollution may have on them. Travelers are advised to consult the CDC's travelers' health website at: http://www.cdc.gov/travel/eastasia.htm prior to departing for China.

Alcoholics Anonymous can be reached in Beijing at telephone (86-10) 139-1138-9075, e-mail: Beijingfellows@yahoo.com . On the Internet, http://members.cox.net/mppowers1/aa-china3.html lists AA meeting locations and contact information for other cities in China. Visit the U.S. Embassy web page in advance of travel to China for additional contact numbers. There is an Al-Anon chapter in Beijing that can be reached at (86-10) 6940-3935. Information on vaccinations and other health precautions may be obtained from the Centers for Disease Control and Prevention's hotline for international travelers at 1-877-394-8747; fax -888-232-3299, or via the CDC's Internet site at http://www.cdc.gov/ . For information about outbreaks of infectious diseases abroad consult the World Health Organization's website at http://www.who.int/en . Further health information for travelers is available at http://www.who.int/ith.

LifeLine Shanghai is a community-based, confidential hotline providing emotional support and information to Shanghai's expatriate community. HOTLINE: (86 21) 6279-8990

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Traveling with children

The industrial chemical melamine has been discovered in infant formula produced in China. If you are traveling to China and are planning to bring your infant or child, be sure to carry any needed formula or other milk products with you. Do not use any milk products produced in China.

Before you leave, make sure you have the names and contact information for physicians, clinics, and hospitals where you can obtain emergency medical care if needed (see the U.S. Embassy website).

All children should be up-to-date on routine childhood immunizations, as recommended by the American Academy of Pediatrics. Children who are 12 months or older should receive a total of 2 doses of MMR (measles-mumps-rubella) vaccine, separated by at least 28 days, before international travel. Children between the ages of 6 and 11 months should be given a single dose of measles vaccine. MMR vaccine may be given if measles vaccine is not available, though immunization against mumps and rubella is not necessary before age one unless visiting a country where an outbreak is in progress. Children less than one year of age may also need to receive other immunizations ahead of schedule (see the accelerated immunization schedule).

The recommendations for malaria prophylaxis are the same for young children as for adults, except that (1) dosages are lower; and (2) doxycycline should be avoided. DEET-containing insect repellents are not advised for children under age two, so it's especially important to keep children in this age group well-covered to protect them from mosquito bites.

When traveling with young children, be particularly careful about what you allow them to eat and drink (see food and water precautions), because diarrhea can be especially dangerous in this age group and because the vaccines for hepatitis A and typhoid fever, which are transmitted by contaminated food and water, are not approved for children under age two. Baby foods and cows' milk may not be available in developing nations. Only commercially bottled milk with a printed expiration date should be used. Young children should be kept well-hydrated and protected from the sun at all times.

Be sure to pack a medical kit when traveling with children. In addition to the items listed for adults, bring along plenty of disposable diapers, cream for diaper rash, oral replacement salts, and appropriate antibiotics for common childhood infections, such as middle ear infections.

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Travel and pregnancy

International travel should be avoided by pregnant women with underlying medical conditions, such as diabetes or high blood pressure, or a history of complications during previous pregnancies, such as miscarriage or premature labor. For pregnant women in good health, the second trimester (18–24 weeks) is probably the safest time to go abroad and the third trimester the least safe, since it's far better not to have to deliver in a foreign country.

Before departure, make sure you have the names and contact information for physicians, clinics, and hospitals where you can obtain emergency obstetric care if necessary (see the U.S. Embassy website). In general, pregnant women should avoid traveling to countries which do not have modern facilities for the management of premature labor and other complications of pregnancy.

As a rule, pregnant women should avoid visiting areas where malaria occurs. Malaria may cause life-threatening illness in both the mother and the unborn child. None of the currently available prophylactic medications is 100% effective. Mefloquine (Lariam) is the drug of choice for malaria prophylaxis during pregnancy, but should not be given if possible in the first trimester. If travel to malarious areas is unavoidable, insect protection measures must be strictly followed at all times. The recommendations for DEET-containing insect repellents are the same for pregnant women as for other adults.

Strict attention to food and water precautions is especially important for the pregnant traveler because some infections, such as listeriosis, have grave consequences for the developing fetus. Additionally, many of the medications used to treat travelers' diarrhea may not be given during pregnancy. Quinolone antibiotics, such as ciprofloxacin (Cipro) and levofloxacin (Levaquin), should not be given because of concern they might interfere with fetal joint development. Data are limited concerning trimethoprim-sulfamethoxazole, but the drug should probably be avoided during pregnancy, especially the first trimester. Options for treating travelers' diarrhea in pregnant women include azithromycin and third-generation cephalosporins. For symptomatic relief, the combination of kaolin and pectin (Kaopectate; Donnagel) appears to be safe, but loperamide (Imodium) should be used only when necessary. Adequate fluid intake is essential.

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Maps

Helpful maps are available in the University of Texas Perry-Castaneda Map Collection and the United Nations map library. If you have the name of the town or city you'll be visiting and need to know which state or province it's in, you might find your answer in the Getty Thesaurus of Geographic Names.

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Embassy/Consulate Location

(reproduced from the U.S. State Dept. Consular Information Sheet)

Americans living in or visiting China are encouraged to register at the Consular Section of the U.S. Embassy in China and obtain updated information on travel and security within China.

Beijing: The U.S. Embassy in China is located at 2 Xiu Shui Dong Jie, Beijing 100600, telephone:

(86-10) 6532-3431, 6532-3831, and after-hours: (86-10) 6532-1910; fax (86-10) 6532-4153. The U.S. Embassy web site address is http://www.usembassy-china.org.cn .cn/ and the e-mail address is AmCitBeijing@state.gov . The Embassy consular district includes the following provinces/regions of China: Beijing, Tianjin, Shandong, Shanxi, Inner Mongolia, Ningxia, Shaanxi, Qinghai, Xinjiang, Hebei, Henan, Hubei, Hunan, and Jiangxi.

Chengdu: The U.S. Consulate General in Chengdu is located at Number 4, Lingshiguan Road, Section 4, Renmin Nanlu, Chengdu 610041, telephone: (86-28) 558-3992, 555-3119; fax (86-28) 8558-3520 and the e-mail address is ACSchengdu@state.gov; after-hours (86-0) 13708001422. This consular district includes the following provinces/regions of China: Guizhou, Sichuan Xizang (Tibet), and Yunnan, as well as the municipality of Chongqing.

Guangzhou: The U.S. Consulate General in Guangzhou is located at Number 1 South Shamian Street, Shamian Island 200S1, Guangzhou 510133; telephone: (86-20) 8121-8418; after-hours:

(86-)139-0229-3169; fax: (86-20) 8121-8428 and the e-mail address is GuangzhouACS@state.gov . This consular district includes the following provinces/regions of China: Guangdong, Guangxi, Hainan, and Fujian.

Shanghai: The Consular Section of the U.S. Consulate General in Shanghai is located in the Westgate Mall, 8 th fl, 1038 Nanjing Xi Lu, Shanghai 200031 telephone: (86-21) 3217-4650, ext. 2102, 2013, or 2134; after-hours: (86-21) 6433-3936; fax: (86-21) 6217-2071; e-mail address: shanghai_acs@yahoo.com . This consular district includes the following provinces/regions of China: Shanghai, Anhui, Jiangsu, and Zhejiang.

Shenyang: The U.S. Consulate General in Shenyang is located at No. 52, 14th Wei Road, Heping District, Shenyang 110003, telephone: (86-24) 2322-1198, 2322-0368; after-hours: (86-0) 13704019790; fax (86-24) 2322-2374 and the e-mail address is ShenyangACS@state.gov . This consular district includes the following provinces/regions of China: Liaoning, Heilongjiang, and Jilin.

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Safety information

For information on safety and security, go to the U.S. Department of State, United Kingdom Foreign and Commonwealth Office, Foreign Affairs Canada, and the Australian Department of Foreign Affairs and Trade.

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