Yellow Fever & Malaria Information, by Country

Travelers' Health: Travel Safe, Travel Smart

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Mark Gershman, Emily S. Jentes, Theresa Sommers, J. Erin Staples (YELLOW FEVER) Kathrine R. Tan, Paul M. Arguin, Stefanie F. Steele (MALARIA)

The following pages present country-specific information on yellow fever vaccine requirements and recommendations and malaria transmission information and prophylaxis recommendations. Reference maps of 13 countries are included within the country-specific list to aid in interpreting the recommendations. The information was accurate at the time of publication; however, this information is subject to change at any time as a result of changes in disease transmission or, in the case of yellow fever, changing country entry requirements. Updated information, reflecting changes since publication, can be found in the online version of this book (www.cdc.gov/yellowbook) and on the CDC Travelers’ Health website (www.cdc.gov/travel).

Yellow Fever

Yellow fever vaccination recommendations have changed substantially since the 2010 edition of CDC Health Information for International Travel. From 2008 through 2010, CDC, the World Health Organization (WHO), and other yellow fever and travel medicine experts reviewed available data and revised the criteria and maps that describe the risk of yellow fever virus (YFV) transmission. Based on the review, updated recommendations have been made for Argentina, Brazil, Colombia, Democratic Republic of the Congo, Ecuador, Eritrea, Ethiopia, Kenya, Panama, Paraguay, Peru, São Tomé and Príncipe, Somalia, Tanzania, Trinidad and Tobago, Venezuela, and Zambia (see the country-specific information in this section and Maps 3-18 and 3-19).

The review process also resulted in the creation of 3 categories of recommendations regarding yellow fever vaccination. See Table 3-25 for definitions of these recommendation categories. Note: The format of the yellow fever maps (Maps 3-18 and 3-19) has been revised to depict vaccination recommendations rather than yellow fever risk.

Ultimately, the clinician’s decision whether or not to vaccinate any traveler must take into account the traveler’s risk of being infected with YFV, country entry requirements, and individual risk factors for serious adverse events after yellow fever vaccination (such as age and immune status). For a thorough discussion of yellow fever and guidance for appropriate vaccination, see the Yellow Fever section earlier in this chapter.

Malaria

The recommendations for malaria prevention have also been extensively updated since the 2010 edition and now include estimates of malaria risk to US travelers. These estimates are based on numbers of malaria cases reported in US travelers and the estimated volume of travel to these countries. In some instances, the risk may be low because the actual intensity of transmission is low in that country. In other instances, significant malaria transmission may occur only in small focal areas of the country where US travelers seldom go. Thus, even though the risk for the average traveler to that country may be low, the risk for the rare traveler going to the areas with higher transmission intensity will be higher. For some countries rarely visited by US travelers, insufficient information exists to make a risk estimate. Information about malaria species present in each country is based on the best available data from multiple sources.

Several medications are available for malaria chemoprophylaxis. When deciding on which drug to use, clinicians should consider the specific itinerary, length of trip, cost of the drugs, previous adverse reactions to antimalarials, drug allergies, and medical history.

For a thorough discussion of malaria and guidance for appropriate prophylaxis, see the Malaria section earlier in this chapter.

Table 3-25. Categories of recommendations for yellow fever vaccination

YELLOW FEVER VACCINATION CATEGORY	RATIONALE FOR RECOMMENDATION
Recommended	Vaccination recommended for all travelers ≥9 months of age to areas with endemic or transitional yellow fever risk, as determined by persistent or periodic YFV transmission.
Generally not recommended	Vaccination generally not recommended in areas where the potential for YFV exposure is low, as determined by absence of reports of human yellow fever and past evidence suggestive of only low levels of YFV transmission. However, vaccination might be considered for a small subset of travelers who are at increased risk for exposure to YFV because of prolonged travel, heavy exposure to mosquitoes, or inability to avoid mosquito bites.
Not recommended	Vaccination not recommended in areas where there is no risk of YFV transmission, as determined by absence of past or present evidence of YFV circulation in the area or environmental conditions not conducive to YFV transmission.

Abbreviation: YFV, yellow fever virus.

Display only:

Brazil

Yellow Fever

Requirements: None

Recommendations:
Recommended for all travelers ≥9 months of age going to the following areas: the entire states of Acre, Amapá, Amazones, Distrito Federal (including the capital city of Brasília), Goiás, Maranhão, Mato Grosso, Mato Grosso do Sul, Minas Gerais, Pará, Rondônia, Roraima, Tocantins, and designated areas (see Map 3-19) of the following states: Bahia, Paraná, Piauí, Rio Grande do Sul, Santa Catarina, and São Paulo. Vaccination is also recommended for travelers visiting Iguassu Falls. Update: The Brazil Ministry of Health has recently expanded the list of municipalities for which yellow fever vaccination is recommended in the four southeastern states of São Paulo, Paraná, Santa Catarina, and Rio Grande do Sul. For details, see In the News: Yellow Fever in Brazil.
Not recommended for travelers whose itineraries are limited to areas not listed above, including the cities of Fortaleza, Recife, Rio de Janeiro, Salvador, and São Paulo (see Map 3-19).

Malaria

Areas with malaria: States of Acre, Amapá, Amazonas, Mato Grosso, Para, Rondonia, Roraima, Tocantins, and the western part of Maranhaõ. Also present in urban areas, including cities such as Boa Vista, Macapa, Manaus, Maraba, Porto Velho, and Santarem. Rare cases in Belem. No transmission at Iguassu Falls.

Estimated relative risk of malaria for US travelers: Low

Drug resistance^c: Chloroquine

Malaria species: P. vivax 75%, P. falciparum 25%.

Recommended chemoprophylaxis: Atovaquone-proguanil, doxycycline, or mefloquine. Belem City: Mosquito avoidance only.

FOOTNOTES:
^aThe official WHO list of countries with risk of YFV transmission can be found in Table 3-21. Proof of yellow fever vaccination should be required only if traveling from a country on the WHO list, unless otherwise specified. The following countries, containing only areas with low potential for exposure to YFV, are not on the WHO list: Eritrea, São Tomé and Príncipe, Somalia, Tanzania, Zambia.
^bThis risk estimate is based largely on cases occurring in US military personnel who travel for extended periods of time with unique itineraries that likely do not reflect the risk for the average US traveler.
^cRefers to P. falciparum malaria unless otherwise noted.
^dAn elevation of 2,300 m is equivalent to 7,546 ft.
^ePrimaquine can cause hemolytic anemia in people with glucose-6-phosphate dehydrogenase (G6PD) deficiency. Patients must be screened for G6PD deficiency before starting primaquine.