(Borneo (see Indonesia and Malaysia), Brunei Darussalam, Burma (see Myanmar), Cambodia, China (including Tibet), East Timor, Hong Kong (see China), Indonesia (including Bali and southern Borneo), Japan, Korea, Laos, Macao (see China), Malaysia (Peninsular Malaysia and northern Borneo, including Sarawak and Sabah), Mongolia, Myanmar (formerly Burma), the Philippines, Singapore, Taiwan, Thailand, Tibet (see China), Vietnam)

3.10.1  Disease risks

Food and water-borne diseases including cholera and other watery diarrhoeas, amoebic and bacillary dysentery, typhoid fever and hepatitis A and E. Flukes and intestinal parasites common among the indigenous population.

Malaria endemicity varies greatly but multidrug resistant P.falciparum common and specialist advice about appropriate prophylaxis may be necessary. See individual countries below.

Other arthropod-borne diseases (see Chapter 7) are an important cause of morbidity:

•   Japanese encephalitis - endemic in rural areas; occasional urban outbreaks have been reported.

•   Dengue - urban and rural epidemics occur.

•   Filariasis - rural parts of many countries.

•   Visceral leishmaniasis - recent resurgence in China.

•   Cutaneous leishmaniasis - recently reported from Xinjiang.

•   Plague in Vietnam, Myanmar, Mongolia, Indonesia and China; not usually a risk to tourists.

•   Louse-borne relapsing fever.

•   Lyme disease in some temperate regions.

•   Scrub typhus and tularaemia.

Diseases of close association:

•   Poliomyelitis - Polio eradication activities have rapidly reduced polio transmission in parts of this area. Elimination of polio reported in Brunei, Japan, Korea and Singapore. Transmission interrupted in China and probably interrupted in Indonesia, Laos, Malaysia, Myanmar, Philippines and Thailand. Mongolia no longer reports cases. There remains a focus of polio transmission in the Mekong Delta area of Cambodia and South Vietnam.

•   Meningococcal infection - outbreaks of meningitis have occurred in Mongolia.

•   Tuberculosis - incidence generally high, with some exceptions (such as Japan).

Sexually transmitted and blood-borne infections:

Hepatitis B of high prevalence; HIV endemic and spreading.

Other hazards could include:

•   Schistosomiasis (bilharziasis) endemic in southern Philippines, central Sulawesi (Indonesia) and central Chang Jiang (Yangtze) river basin in China; small foci in Mekong delta in Vietnam.

•   Rabies, snake bites and leeches.

3.10.2  Recommendations for immunisations and malaria chemoprophylaxis (see later chapters for general health precautions)

FOR ALL COUNTRIES Check routine immunisations including tetanus. Immunisation against poliomyelitis, hepatitis A and typhoid, noting that typhoid and/or hepatitis A may be less important for short stays in business or tourist hotels. For longer term travellers, check BCG status and consider immunisation against diphtheria, hepatitis B and, for longer rural travel, rabies. Japanese encephalitis immunisation (for individual countries see below) for rural travel, usually over one month. Less risk in dry seasons. Not recommended for most travellers.

3.10.3  Country by country variations and malaria chemoprophylaxis:

Borneo - see Indonesia and Malaysia

Brunei Darussalam

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas or who have passed through partly or wholly endemic areas within the preceding six days. The countries and areas included in the endemic zones are considered infected areas.

Japanese encephalitis - rural areas only; assume year round transmission.

Malaria: may be slight risk in border areas.

Recommended prophylaxis: none.

Burma - see Myanmar

Cambodia

Yellow fever vaccination certificate required from travellers coming from infected areas.

Japanese encephalitis - consider immunisation for some situations (see 3.10.2 above). Transmission season likely to be May-October.

Malaria risk, predominantly P.falciparum, throughout the year in the whole country except Phnom Penh area and close to Tonle Sap. Malaria does occur in the tourist area of Angkor Wat. P.falciparum highly resistance to chloroquine and resistant to sulphadoxine-pyrimethamine reported. Resistance to mefloquine also reported from western provinces.

Recommended prophylaxis: mefloquine, or doxycycline or atovaquone/proguanil (see 6.5); but mefloquine not suitable for western border areas.

China (including Hong Kong and Macao Special Administrative Regions)

Yellow fever vaccination certificate required from travellers coming from infected areas.

Japanese encephalitis in central and southern China, April/May-October; for northern China, the season is shorter. Consider immunisation in certain situations (see 3.10.2 above).

Malaria risk, predominantly P.vivax, below 1,500m in Fujian, Guangdong, Guangxi, Guizhou, Hainan, Sichuan, Xingjjang (only along the valley of the Yili river), Xizang (only along the valley of the Zangbo river in the extreme south) and Yunnan. Very low risk in Anhui, Hubei, Hunan, Jiangsu, Jiangxi, Shandong, Changhai and Zhejiang. Where transmission exists it occurs: north of 33oN, from July to November; between 33ºN and 25ºN, from May to December; and south of 25ºN, throughout the year. Multidrug-resistant P.falciparum present in Hainan and Yunnan.

Recommended prophylaxis: main tourist areas - none; rural risk areas, chloroquine, except for Hainan and Yunnan provinces where mefloquine or doxycycline or atovaquone/proguanil (see 6.5) are the preferred drugs.

East Timor

Malaria risk- predominatly P. falciparum throughout the year in the whole territory. P.falciparum resistant to chloroquine and sulphadoxine pyrimethamine reported.

Recommended prophylaxis: mefloquine or doxycycline or atovaquone/proguanil (see 6.5).

Hong Kong and Macao, Special Administrative Regions of China

Malaria - No risk considered to exist in urban and most rural areas of Hong Kong. No risk in Macao.

Recommended prophylaxis: none.

Indonesia (including Bali and central/southern Borneo)

Yellow fever vaccination certificate required from travellers coming from infected areas. The countries and areas included in the endemic zones are considered by Indonesia as infected areas.

Japanese encephalitis probably year round. Consider immunisation in certain situations (see 3.10.2).

Malaria risk throughout the year in the whole country except in Jakarta Municipality, big cities, and the main tourist resorts of Java and Bali. P.falciparum highly resistant to chloroquine and resistant to sulphadoxine-pyrimethamine reported. P.vivax resistant to chloroquine is also reported in Irian Jaya.

Recommended prophylaxis: for Jakarta, big cities and main resort areas of Java and Bali, none, but remember the slight risk; for other areas, chloroquine plus proguanil. Mefloquine preferred for Irian Jaya.

Japan

Japanese encephalitis immunisation only recommended for rural travel, June-September (or April-October for south (Okinawa)) (see 3.10.2 above).

Korea (Democratic People's Republic of Korea and Republic of Korea)

Japanese encephalitis - immunisation only recommended for rural travel, July-October. (See 3.10.2).

Malaria - limited risk (exclusively P.vivax) in northern Kyunggi Do province.

Recommended prophylaxis: none.

Laos

Yellow fever vaccination certificate required from travellers coming from infected areas.

Japanese encephalitis, presumed season May-October. Immunisation recommended in certain circumstances (see 3.10.2 above).

Malaria risk, predominantly P.falciparum, throughout the year in the whole country except Vientiane. Highly chloroquine resistant P.falciparum reported.

Recommended prophylaxis: mefloquine or doxycycline or atovaquone/proguanil.

Malaysia (Peninsular Malaysia, northern part of Borneo including Sarawak and Sabah)

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas. The countries and areas included in the endemic zones are considered as infected areas.

Japanese encephalitis - year round transmission. Consider immunisation in certain circumstances (see 3.10.2).

Malaria risk limited to small foci in deep hinterland. Urban and coastal areas free from malaria except in Sabah where risk (predominantly P.falciparum) throughout the year. P.falciparum highly resistant to chloroquine and resistant to sulphadoxine-pyrimethamine reported.

Recommended prophylaxis: Peninsular Malaysia and Sarawak - none except for deep forests where chloroquine and proguanil; Sabah - mefloquine; alternatives doxycycline or atovaquone/proguanil (see 6.5); for shorter stays chloroquine plus proguanil is an acceptable alternative, but this regimen provides less protection.

Mongolia

Meningococcal vaccine recommended for longer visits.

Myanmar (formerly Burma)

Yellow fever vaccination certificate required from travellers coming from infected areas. Nationals and residents of Myanmar are required to possess certificates of vaccination on their departure to an infected area.

Japanese encephalitis - presumed season May-October. Consider immunisation in certain circumstances (see 3.10.2).

Malaria risk, predominantly P.falciparum, below 1,000 m

a.  throughout the year in Karen State;

b.  from March to December in Chin, Kachin, Kayah, Mon, Rakhine, and Shan States, Pegu Div., and Hlegu, Hmawbi, and Taikkyi townships of Yangon (formerly Rangoon) Div.;

c.  from April to December in rural areas of Tenasserim Div.;

d.  from May to December in Irrawaddy Div. and the rural areas of Mandalay Div.;

e.  from June to November in the rural areas of Magwe Div., and in Sagaing Div.

P.falciparum highly resistant to chloroquine and resistant to sulfadoxine-pyrimethamine reported. P.vivax resistant to chloroquine reported.

Recommended prophylaxis: chemoprophylaxis is needed throughout Myanmar. For most of the country, mefloquine or doxycycline or atovaquone/proguanil. Doxycycline or atovaquone/proguanil on the Thai border.

Philippines

Yellow fever vaccination certificate required from travellers over one year of age arriving within six days from infected areas.

Japanese encephalitis - probably year round. Consider immunisation in certain circumstances (see 3.10.2).

Malaria risk throughout the year in rural areas below 600m, except for the provinces of Bohol, Catanduanes, Cebu and metropolitan Manila. The risk is low in the provinces of Aklan, Biliran, Camiguin, Capiz, Guimaras, Iloilo, Leyte del sur, Northern Samar, and Sequijor. Negligable risk in urban areas and the plains. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: for rural areas other than the four areas listed above, chloroquine plus proguanil; for other areas none, but be aware of the risk.

Singapore

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas. Certificates of vaccination are required from travellers over one year of age who, within the preceding six days, have been in or have passed through any country partly or wholly endemic for yellow fever. The countries and areas included in the endemic zones are considered as infected areas.

No malaria risk.

Recommended prophylaxis: none.

Taiwan

Japanese encephalitis - rural areas only, April-October. Consider immunisation in certain circumstances (see 3.10.2).

No malaria risk.

Recommended prophylaxis: none.

Thailand

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas. The countries and areas included in the endemic zones are considered as infected areas.

Japanese encephalitis - highest risk May-October. Consider immunisation in certain circumstances (see 3.10.2).

Malaria - no risk in cities nor in the main tourist resorts (such as Bangkok, Chiangmai, Pattaya, Phuket, Samui). Elsewhere there is malaria risk throughout the year. The risk is very low in the central plain, greater in forested and hilly areas of the country, especially in the areas bordering Myanmar, Laos and Cambodia. P.falciparum is highly resistant to chloroquine and sulphadoxine-pyrimethamine, and at the Myanmar and Cambodian borders also shows resistance to mefloquine and quinine.

While the city of Chiangmai is malaria-free, tourists commonly visit forested areas near the Myanmar border where there is a risk if they are there for an evening or night; some tourist hotels in NW Thailand are also very close to the forest. However, the combination of limited risk and resistance to several antimalarials means that most tourists will be advised not to take chemoprophylaxis; they must be made aware of the risk and that they must urgently seek prompt diagnosis and treatment in the event of fever during or up to a year after their visit.

Recommended prophylaxis: Bangkok and main tourist areas, none. Day visits to forested areas, none but be aware of the risk. Longer stays in rural areas with forests, and in border areas with Laos, Myanmar or Cambodia, doxycycline or atovaquone/ proguanil.

Vietnam

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas.

Japanese encephalitis - Hanoi city and rural areas, highest risk May-October (see recommendations for all countries (3.10.2)).

Malaria risk, predominantly P.falciparum, in the whole country except urban centres, the Red River Delta, and coastal plains north of Nha Trang. High-risk areas are the two southernmost provinces of the country, Ca Mau and Bac Lieu, and the highland areas below 1,500m south of 18ºN. P.falciparum highly resistant to chloroquine and resistant to sulphadoxine-pyrimethamine reported.

Recommended prophylaxis: mefloquine or doxycycline or atovaquone/proguanil in the risk areas.