Chapter 4Select DestinationsAsia
China, with >1.3 billion people, is the world’s most populous country and the fourth largest geographically, behind Russia, Canada, and the United States. It shares a border with 14 other countries and has approximately 18,000 km of coastline. China is divided into 23 provinces, 5 autonomous regions, and 4 municipalities. This large landmass is home to diverse topography, languages, and customs. The climate varies from tropical in the south to subarctic in the north, with wide variations between regions and seasons. Natural hazards include typhoons along the southern and eastern seaboards, dust storms in the north, floods, earthquakes, and landslides. Six of the 10 deadliest natural disasters in history occurred in China, including the 1556 Shaanxi earthquake, which is thought to have killed >800,000 people, making it the most lethal earthquake in history. Chinese superstition holds that natural disasters foretell the death of a ruler or the end of a dynasty, and indeed Mao Tse Tung died only 6 weeks after the 1976 Tangshan earthquake, the death toll of which was also in the hundreds of thousands. More recently, devastating earthquakes have struck the western provinces of Sichuan in 2008 and Qinghai in 2010. Torrential rain, floods, and landslides plagued large areas of China in the summer of 2010, as well as drought and dust storms in the north.
China has one of the world’s oldest continuous civilizations, dating back >5,000 years. It has the world’s longest continuously used written language system and is the source of many major inventions, including the “four great inventions of Ancient China”: paper, the compass, gunpowder, and printing. Today, China is considerably more advanced (with the ability to put men in space, for example) and wealthier than many other developing countries, yet rural poverty and underdevelopment are still problems, particularly in the western part of the country.
Approximately 700 million Chinese live in rural areas. Urban areas are growing rapidly, however, and China is now home to many of the world’s largest megacities. Shanghai and Beijing each have ≥20 million inhabitants, and Chongqing, with a metropolitan population >30 million, is the fastest-growing urban center in the world. Rivers play a central role in China’s economy, history, and culture. The Yangtze River basin, stretching 4,000 miles from the Tibetan plateau to the East China Sea near Shanghai, is home to >5% of the world’s population.
In 2010, >55 million tourists visited China, and by 2020, China is widely predicted to be both the largest tourist destination and the largest source of tourists to other countries. China’s long history and varied natural beauty can be traced in its 41 UNESCO World Heritage sites, from the imperial grandeur of the Forbidden City and the Temple of Heaven, to the marvel of the Great Wall, the Terracotta Warriors in Xi’an, and the spectacular mountainous sanctuaries of the west. Popular itineraries often include Beijing and the Great Wall, Xi’an, and the Yangtze River (see Box 4-01 for information specifically about Yangtze River cruises). Other tourist destinations include the following:
- Shanghai and Hong Kong, with their futuristic architecture and East-meets-West mystique
- Lijiang in the province of Yunnan, where many ethnic minorities are concentrated
- Sichuan province, home to China’s iconic symbol, the panda
- Guilin, famous for its uniquely shaped limestone karst mountains that are often featured in Chinese paintings
- Tibet, accessible now by the world’s highest railroad directly to Lhasa, with a maximum altitude of 16,640 ft (5,072 m)
Specialized itineraries are increasingly being offered, including hiking, mountain climbing, village tours, the Silk Road, and other more remote regions. Aside from tourism, increasing numbers of people travel to China to visit friends and relatives, to study, or to adopt children. These groups may be at particularly high risk of illness, because they underestimate their risks, are less likely to seek pre-travel advice, and stay in more local or rural accommodations. People traveling to China to adopt children often worry about the health of the child but neglect their own health.
Box 4-01. Cruising down the Yangtze: what to consider
The Yangtze River is the third longest river in the world and one of the world’s busiest (and most polluted) waterways. Yangtze River cruises are popular with tourists, and there are several heath considerations for this trip:
- At least 1 case of Japanese encephalitis has been documented in a tourist whose 3-week trip to rural and urban China included a Yangtze River cruise, and documented cases are likely to be an underestimate.
- Malaria is not a substantial risk on this itinerary; only insect bite precautions are recommended.
- Schistosomiasis—Schistosoma japonicum—exists in the Yangtze River basin. Swimming is ill-advised.
- Motion sickness is rare on Yangtze cruises, since much of it takes place on a calm reservoir. However, susceptible travelers should carry antiemetic medication.
- Excursions off the boat often involve steep climbs, many stairs, and long walking distances and may not be appropriate for physically infirm tourists.
- Air pollution can be a problem on Yangtze River cruises and can cause eye and throat irritation, as well as respiratory problems in susceptible travelers. September and October are said to be the clearest months.
- Most non-Chinese–speaking tourists will prefer a 4- or 5-star “luxury” cruise. First class on a Chinese tourist boat may not meet expectations for cleanliness, and English may not be spoken.
- Food and water precautions apply, even on a luxury boat.
Although China is now the world’s second-largest economy, in per capita terms income is still below the world average, with wide disparity in wealth and development between rural and urban, as well as east and west. Health risks vary accordingly.
Routine vaccinations should be up-to-date, including tetanus, diphtheria, measles, mumps, rubella, varicella, influenza, and pneumococcal vaccines, as indicated. In addition, hepatitis A and B and typhoid vaccinations are usually recommended. Since the Xinjiang Uygur Autonomous Region borders Pakistan, a polio-endemic country, adults traveling to this region may consider a booster dose of polio vaccine (IPV). Measles and rubella immunity is particularly important, although a massive vaccination campaign begun in September 2010 has decreased the number of reported measles cases, from 131,000 in 2008 to 10,000 in 2011. Nonetheless, a few travelers have made news headlines by triggering outbreaks in their home countries after returning from China. Although limited data exist on rubella in China, it was not part of the national immunization program until 2008, and incidence is believed to be high.
Rabies is a serious problem in China, as in much of Asia, with >3,000 human deaths per year reported in recent years. Mammal bites in any area of China, including urban areas, must be considered high risk for rabies. As international standard rabies immune globulin is generally unavailable, animal bites are often trip-enders, requiring evacuation to Hong Kong, Bangkok, or home for postexposure prophylaxis. Bites are surprisingly common in tourists. For example, dog bites were the most common dermatologic problem seen after China travel in a recent analysis of data from the GeoSentinel Surveillance Network. Rabies risk and prevention should be discussed in pre-travel consultations, and a strategy for dealing with a possible exposure should be developed. Long-term travelers and expatriates living in China should consider the preexposure vaccination series. Travel health insurance, including medical evacuation insurance, should be encouraged (see Chapter 2, Travel Insurance, Travel Health Insurance, & Medical Evacuation Insurance).
Japanese Encephalitis Vaccine
Japanese encephalitis (JE) occurs in all regions except Qinghai, Xinjiang, and Xizang (Tibet) (see Map 3-8 and Table 3-6). China has greatly reduced the incidence of JE through vaccination, and as of 2008, included JE in its expanded national immunization program; however, the disease remains a threat to unimmunized travelers. Although the JE season varies by region, most cases in local residents are reported from June through October. The risk of JE for most travelers to China is low but varies based on season, destination, duration, and activities. Risk is highest among travelers to rural areas during the transmission season. JE vaccine is recommended for travelers who plan to spend ≥1 month in endemic areas during June through October. It should be considered for shorter-term travelers if they plan to travel to rural areas and will have an increased risk for JE virus exposure based on their activities or itineraries, such as spending substantial time outdoors or staying in accommodations without air conditioning, screens, or bed nets. However, rare sporadic cases have occurred on an unpredictable basis in short-term travelers, including in periurban Beijing and Shanghai.
Malaria risk is low for travelers to China, with the exception of those visiting rural parts of southern Yunnan Province or Hainan Island. For these areas, chemoprophylaxis should be considered. Mefloquine resistance in southern Yunnan means that prophylaxis should be given doxycycline or atovaquone-proguanil for travel in this area. For travelers to other regions, the risk is too low to warrant chemoprophylaxis. Rare cases occur in other rural parts of the country at <1,500 m (4,921 ft) from May through December, usually Plasmodium vivax infections, and only insect precautions are recommended.
Other Health Risks
The risk for travelers’ diarrhea appears to be low in deluxe accommodations in China but moderate elsewhere. Usual food and water precautions should apply, and travelers should carry an antibiotic for self-treatment. Since highly quinolone-resistant Campylobacter is a problem in China, azithromycin may be a good choice. Tap water is not safe to drink even in major cities. Most hotels provide bottled or boiled water, and bottled water is easily available. In addition, there have been several well-publicized episodes of contamination of food with pesticides and other substances. Travelers should strictly avoid undercooked fish and shellfish and unpasteurized milk.
Sexually Transmitted Diseases
Sexually transmitted diseases, including syphilis, HIV, gonorrhea, and chlamydia, are a growing problem in China, particularly along the booming eastern seaboard. Travel is associated with loosened inhibitions and increased casual sexual liaisons. In addition to risk-reduction counseling, consider hepatitis B vaccination.
Air pollution is a problem in most major cities in China. There is potential for exacerbation of respiratory conditions, including asthma and chronic obstructive pulmonary disease, and heightened risk for respiratory infections. All travelers should receive influenza vaccine, and susceptible people should also receive pneumococcal vaccination and bring any inhaled medications they may use.
Traffic in China is often chaotic, and the rate of accidents, including fatal ones, is among the highest in the world. Driving is on the right side of the road in mainland China but on the left in Hong Kong and Macau. In practice, many people drive down the middle of the road. Child safety seats, rear seat belts, and bicycle or motorcycle helmets are not widely available. Accidents, even minor ones, can create major traffic jams and sometimes turn into violent altercations, particularly when foreigners are involved. China has not signed the convention that created the International Driving Permit, and travelers require a Chinese license to drive in China. For all of these reasons, it is often simpler and safer to hire a local driver than to drive oneself. It is also advisable to avoid driving at night or when weather conditions are bad and not to assume that traffic rules or right-of-way will be respected.
Medical Care in China
Western-style medical facilities that meet international standards are available in Beijing, Shanghai, and Hong Kong. Some hospitals in other cities have “VIP wards” (gaogan bingfang), which may have English-speaking staff. The standard of care in such facilities is somewhat unpredictable, and cultural and regulatory differences can cause difficulties for travelers. In rural areas, only rudimentary medical care may be available. Hepatitis B transmission from poorly sterilized medical equipment remains a risk outside major centers.
Ambulances are not staffed with trained paramedics and often have little or no medical equipment. Therefore, injured travelers may need to take taxis or other immediately available vehicles to the nearest major hospital rather than waiting for ambulances to arrive.
Pharmacies often sell prescription medications over the counter. Such medications have sometimes been counterfeit, substandard, or even contaminated. Travelers should carry all their regular medications in sufficient quantity; if more or other medications are required, it is advisable to visit a reputable clinic or hospital.
Some travelers wish to try traditional Chinese medicine and acupuncture. Although most do so uneventfully, there is a risk of bloodborne and skin infections from acupuncture needles, and traditional medicine products may be contaminated with heavy metals or pharmaceutical agents. Acupressure may be preferable to acupuncture.
Travelers are strongly advised to purchase travel health and medical evacuation insurance before travel. Most hospitals will not directly accept foreign medical insurance, however, and patients will often be expected to pay a deposit before care to cover the expected cost of the treatment.
- CDC. Measles among adults associated with adoption of children in China—California, Missouri, and Washington, July–August 2006. MMWR Morb Mortal Wkly Rep. 2007 Feb 23;56(7):144–6.
- Chen XS, Gong XD, Liang GJ, Zhang GC. Epidemiologic trends of sexually transmitted diseases in China. Sex Transm Dis. 2000 Mar;27(3):138–42.
- Cutfield NJ, Anderson NE, Brickell K, Hueston L, Pikholz C, Roxburgh RH. Japanese encephalitis acquired during travel in China. Intern Med J. 2005 Aug;35(8):497–8.
- Davis XM, MacDonald S, Borwein S, Freedman DO, Kozarsky PE, von Sonnenburg F, et al. Health risks in travelers to China: the GeoSentinel experience and implications for the 2008 Beijing Olympics. Am J Trop Med Hyg. 2008 Jul;79(1):4–8.
- Hills SL, Griggs AC, Fischer M. Japanese encephalitis in travelers from non-endemic countries, 1973–2008. Am J Trop Med Hyg. 2010 May;82(5):930–6.
- Shaw MT, Leggat PA, Borwein S. Travelling to China for the Beijing 2008 Olympic and Paralympic games. Travel Med Infect Dis. 2007 Nov;5(6):365–73.
- Shlim DR, Solomon T. Japanese encephalitis vaccine for travelers: exploring the limits of risk. Clin Infect Dis. 2002 Jul 15;35(2):183–8.
- Tang X, Luo M, Zhang S, Fooks AR, Hu R, Tu C. Pivotal role of dogs in rabies transmission, China. Emerg Infect Dis. 2005 Dec;11(12):1970–2.
- United Nations World Tourism Organization. UNWTO tourism highlights. Madrid: United Nations World Tourism Organization; 2012 [cited 2012 Sep 26]. Available from: http://mkt.unwto.org/en/publication/unwto-tourism-highlights-2012-edition.
- World Health Organization. Measles bulletin: Western Pacific region. Geneva: World Health Organization; 2010 [cited 2012 Sep 26]. Available from: http://www.wpro.who.int/entity/immunization/documents/docs/MeasBulletinVol4Issue1_F840.pdf.
- Zhang J, Jin Z, Sun GQ, Zhou T, Ruan S. Analysis of rabies in China: transmission dynamics and control. PloS One. 2011;6(7):e20891.
- Zhang YZ, Xiong CL, Xiao DL, Jiang RJ, Wang ZX, Zhang LZ, et al. Human rabies in China. Emerg Infect Dis. 2005 Dec;11(12):1983–4.