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Health Information for Travelers to Costa RicaClinician View

 

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Vaccines and Medicines

Prepare travelers to Costa Rica with recommendations for vaccines and medications.

 

  Recommendations Transmission Guidance
Routine vaccines

Recommended for all travelers

varied

Immunization schedules

Hepatitis A

Recommended for most travelers, including those with "standard" itineraries and accommodations

Traveling with Children

Hepatitis A vaccine can be given to infants aged 6-11 months traveling outside the United States; however, hepatitis A vaccine doses administered before 12 months of age are not considered for long-term protection. Immunoglobulin (0.1/mL/kg) injection may be used for protection up to 1 month.

Immune-Compromised Travelers

If trip is in <2 weeks, consider immunoglobulin (0.02/mL/kg) injection in addition to first dose of vaccine.

Fecal-oral route (contaminated food and water)

Person-to-person contact

Hepatitis A (Yellow Book)

Dosing info

Hepatitis B

Consider for most travelers; recommended for those who might be exposed to blood or other body fluids, have sexual contact with the local population, or be exposed through medical treatment (e.g., for an accident).

Contact with blood and other body fluids:

  • Unprotected sex
  • Injection drug use
  • Contaminated transfusions
  • Exposure to human blood
  • Contaminated tattoo and piercing equipment

Hepatitis B (Yellow Book)

Dosing info

Malaria

Advise mosquito avoidance; consider prophylaxis for high-risk patients (e.g., pregnant or immunocompromised). Areas with risk of malaria: Rare local cases in Matina Canton in Limón Province, Sarapiquí Canton in Heredia Province, and Pital District in San Carlos Canton in Alajuela Province. More details.

Bite of infected mosquito (female Anopheles)

Malaria (Yellow Book)

Considerations when choosing a drug for malaria prophylaxis (Yellow Book)

Measles
  • Infants (6 through 11 months old): 1 dose of measles-mumps-rubella (MMR) vaccine before travel. This dose does not count as the first dose in the routine childhood vaccination series.
  • People 12 months old or older, with no evidence of immunity or no written documentation of any doses: 2 doses of MMR vaccine before travel. The 2 doses must be given 28 days apart.
  • People 12 months old or older who have written documentation of 1 dose and no other evidence of immunity: 1 additional dose before travel, at least 28 days after the previous dose.

Airborne

Measles (Rubeola) (Yellow Book)

Rabies

Recommended for the following groups:

  • Travelers involved in outdoor and other activities in remote areas that might bring them into direct contact with bats and other mammals (such as adventure travelers and cavers).
  • Those with occupational risks (such as wildlife professionals and researchers).

Mammal bites (bats and other carnivores). Canine rabies is not present.

Rabies (Yellow Book)

Typhoid

Recommended for most travelers, especially those who are staying with friends or relatives; visiting smaller cities, villages, or rural areas where exposure might occur through food or water; or prone to "adventurous eating"

Traveling with Children

Injectable vaccine is indicated for children aged ≥2 years. Oral vaccine is indicated for children aged ≥6 years.

Immune-Compromised Travelers

Oral typhoid vaccine should not be given to immunocompromised travelers; injectable vaccine is a theoretically safer alternative.

Fecal-oral route (contaminated food and water)

Typhoid (Yellow  Book)

Dosing info (Yellow Book)

Yellow Fever

Required if traveling from a country with risk of YF virus transmission and ≥9 months of age.1 This requirement includes Tanzania and Zambia in the African region; excludes Argentina and Panama in the Americas; and has the following specifications for these countries: Colombia (the entire country except Barranquilla, Cali, Cartagena, Medellín and San Andrés Providencia y Bogotá); Ecuador (applies only to Morona-Santiago, Napo, Orellana, Pastaza, Sucumbíos y Zamora-Chinchipe, and excludes the rest of the country); Paraguay (the entire country except Asunción, the capital); Peru (the entire country except Lima, the capital, Cuzco, Machu Picchu, the Inca Trail, Lambayeque, Tumbes, Piura and Cajamarca); Trinidad and Tobago (the entire country except the urban areas of Port of Spain, and for travelers in transit or whose itineraries are limited to the island of Tobago).

Note: Yellow fever vaccine availability in the United States is currently limited. Travelers may need to schedule appointments well in advance and visit a clinic some distance away. Find the nearest clinic that has vaccine.

Traveling with Children

Age <6 months is a contraindication, and age 6–8 months is a precaution.

Immune-Compromised Travelers

Contraindicated in patients with severe immune suppression.

Bite of infected mosquitoes

Yellow Fever (Yellow Book)

Routine vaccines

Recommendations

Recommended for all travelers

Transmission

varied

Guidance

Hepatitis A

Recommendations

Recommended for most travelers, including those with "standard" itineraries and accommodations

Transmission

Fecal-oral route (contaminated food and water)

Person-to-person contact

Guidance

Hepatitis A (Yellow Book)

Dosing info

Traveling with Children

Hepatitis A vaccine can be given to infants aged 6-11 months traveling outside the United States; however, hepatitis A vaccine doses administered before 12 months of age are not considered for long-term protection. Immunoglobulin (0.1/mL/kg) injection may be used for protection up to 1 month.

Immune-Compromised Travelers

If trip is in <2 weeks, consider immunoglobulin (0.02/mL/kg) injection in addition to first dose of vaccine.

Hepatitis B

Recommendations

Consider for most travelers; recommended for those who might be exposed to blood or other body fluids, have sexual contact with the local population, or be exposed through medical treatment (e.g., for an accident).

Transmission

Contact with blood and other body fluids:

  • Unprotected sex
  • Injection drug use
  • Contaminated transfusions
  • Exposure to human blood
  • Contaminated tattoo and piercing equipment
Guidance

Hepatitis B (Yellow Book)

Dosing info

Malaria

Recommendations

Advise mosquito avoidance; consider prophylaxis for high-risk patients (e.g., pregnant or immunocompromised). Areas with risk of malaria: Rare local cases in Matina Canton in Limón Province, Sarapiquí Canton in Heredia Province, and Pital District in San Carlos Canton in Alajuela Province. More details.

Transmission

Bite of infected mosquito (female Anopheles)

Guidance

Measles

Recommendations
  • Infants (6 through 11 months old): 1 dose of measles-mumps-rubella (MMR) vaccine before travel. This dose does not count as the first dose in the routine childhood vaccination series.
  • People 12 months old or older, with no evidence of immunity or no written documentation of any doses: 2 doses of MMR vaccine before travel. The 2 doses must be given 28 days apart.
  • People 12 months old or older who have written documentation of 1 dose and no other evidence of immunity: 1 additional dose before travel, at least 28 days after the previous dose.
Transmission

Airborne

Guidance

Measles (Rubeola) (Yellow Book)

Rabies

Recommendations

Recommended for the following groups:

  • Travelers involved in outdoor and other activities in remote areas that might bring them into direct contact with bats and other mammals (such as adventure travelers and cavers).
  • Those with occupational risks (such as wildlife professionals and researchers).
Transmission

Mammal bites (bats and other carnivores). Canine rabies is not present.

Guidance

Rabies (Yellow Book)

Typhoid

Recommendations

Recommended for most travelers, especially those who are staying with friends or relatives; visiting smaller cities, villages, or rural areas where exposure might occur through food or water; or prone to "adventurous eating"

Transmission

Fecal-oral route (contaminated food and water)

Guidance

Typhoid (Yellow  Book)

Dosing info (Yellow Book)

Traveling with Children

Injectable vaccine is indicated for children aged ≥2 years. Oral vaccine is indicated for children aged ≥6 years.

Immune-Compromised Travelers

Oral typhoid vaccine should not be given to immunocompromised travelers; injectable vaccine is a theoretically safer alternative.

Yellow Fever

Recommendations

Required if traveling from a country with risk of YF virus transmission and ≥9 months of age.1 This requirement includes Tanzania and Zambia in the African region; excludes Argentina and Panama in the Americas; and has the following specifications for these countries: Colombia (the entire country except Barranquilla, Cali, Cartagena, Medellín and San Andrés Providencia y Bogotá); Ecuador (applies only to Morona-Santiago, Napo, Orellana, Pastaza, Sucumbíos y Zamora-Chinchipe, and excludes the rest of the country); Paraguay (the entire country except Asunción, the capital); Peru (the entire country except Lima, the capital, Cuzco, Machu Picchu, the Inca Trail, Lambayeque, Tumbes, Piura and Cajamarca); Trinidad and Tobago (the entire country except the urban areas of Port of Spain, and for travelers in transit or whose itineraries are limited to the island of Tobago).

Note: Yellow fever vaccine availability in the United States is currently limited. Travelers may need to schedule appointments well in advance and visit a clinic some distance away. Find the nearest clinic that has vaccine.

Transmission

Bite of infected mosquitoes

Guidance

Yellow Fever (Yellow Book)

Traveling with Children

Age <6 months is a contraindication, and age 6–8 months is a precaution.

Immune-Compromised Travelers

Contraindicated in patients with severe immune suppression.

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Non-Vaccine-Preventable Diseases

The following diseases are possible risks your patients may face when traveling in Costa Rica. This list is based on our best available surveillance data and risk assessment information at the time of posting. It is not a complete list of diseases that may be present in a destination. Risks may vary within different areas of a destination.

 

  Guidance Patient Education Notes

Vectorborne

Chagas disease (American Trypanosomiasis)
  • Risk to travelers is extremely low
  • Higher risk if staying in poor-quality housing
  • Spread by the feces of triatomine bugs (also known as reduviid bugs or “kissing” bugs), not the bug bite
Dengue
  • Mosquitoes carrying dengue bite during the day and night, both indoors and outdoors, and often live around buildings
  • Leading cause of febrile illness among travelers returning from the Caribbean, South America, and South and Southeast Asia
Zika
  • We do not have accurate information on the current level of risk. There may be delays in detection and reporting of new outbreaks.
  • Because Zika is a cause of severe birth defects, CDC recommends pregnant women and couples trying to become pregnant within the next 3 months work with their health care providers to carefully consider the risks and possible consequences of travel to areas with risk of Zika.

Vectorborne

Chagas disease (American Trypanosomiasis)

Guidance
Patient Education
Notes
  • Risk to travelers is extremely low
  • Higher risk if staying in poor-quality housing
  • Spread by the feces of triatomine bugs (also known as reduviid bugs or “kissing” bugs), not the bug bite

Dengue

Guidance
Patient Education
Notes
  • Mosquitoes carrying dengue bite during the day and night, both indoors and outdoors, and often live around buildings
  • Leading cause of febrile illness among travelers returning from the Caribbean, South America, and South and Southeast Asia

Zika

Guidance
Patient Education
Notes
  • We do not have accurate information on the current level of risk. There may be delays in detection and reporting of new outbreaks.
  • Because Zika is a cause of severe birth defects, CDC recommends pregnant women and couples trying to become pregnant within the next 3 months work with their health care providers to carefully consider the risks and possible consequences of travel to areas with risk of Zika.

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Patient Counseling

Counsel your patients on actions they can take on their trip to stay healthy and safe.

Eat and drink safely

Industrialized country—no special precautions. Counsel travelers visiting rural or remote areas that are served by unregulated water sources (such as private wells) to take special precautions to ensure the safety of their drinking water.

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Prevent bug bites

Counsel travelers to be diligent in insect precautions:

  • Cover exposed skin.
  • Use an appropriate insect repellent. (see below)
  • Use permethrin-treated clothing and gear (such as boots, pants, socks, and tents). Travelers can buy pre-treated clothing and gear or treat them at home. Treated clothing remains protective after multiple washings. Permethrin should NOT be used directly on skin.
  • Stay and sleep under in air-conditioned or screened rooms.
  • Use a bed net if sleeping area is exposed to the outdoors.
More Information on Insect Repellents

DEET (concentration of 20% or more) is the only insect repellent shown to be effective against ticks. However, several EPA-registered active ingredients provide reasonably long-lasting protection against mosquitoes:

  • DEET (chemical name: N,N-diethyl-m-toluamide or N,N-diethyl-3-methyl-benzamide): Concentrations above 50% show no additional protective benefit.
  • Picaridin (KBR 3023 [Bayrepel] and icaridin outside the United States; chemical name: 2-(2-hydroxyethyl)-1-piperidinecarboxylic acid 1-methylpropyl ester): Must be reapplied more often than DEET.
  • Oil of lemon eucalyptus (OLE) or PMD (chemical name: para-menthane-3,8-diol), the synthesized version of OLE. “Pure” oil of lemon eucalyptus (essential oil) is not the same product; it has not undergone similar testing for safety and efficacy, is not registered with EPA as an insect repellent, and is not covered by this recommendation.
  • IR3535 (chemical name: 3-[N-butyl-N-acetyl]-aminopropionic acid, ethyl ester).
  • 2-undecanone

Products with <10% active ingredient may offer only limited protection (1–2 hours).

Encourage patients to use repellents and reapply only as instructed. If sunscreen is also needed, they should apply sunscreen first and repellent second. Encourage them to follow package directions for using repellent on children and avoid applying to their hands, eyes, and mouth.

For more detailed information, visit the Yellow Book: Protection against Mosquitoes, Ticks, & Other Insects & Arthropods

Additional Resources

Traveling with Children

Counsel parents to protect their children with similar precautions to those recommended for adults.

Most insect repellents are safe for use on children. The American Academy of Pediatrics recommends ≤30% DEET for use on children >2 months. Products containing OLE should not be used on children aged <3 years. EPA does not recommend any additional precautions for using registered repellents on children.

For parents of infants <2 months of age, encourage the use of a carrier draped with mosquito netting with an elastic edge for a tight fit to protect against biting insects.

Children should not handle repellents. Instead, adults should apply repellents to their own hands first, then gently spread on the child’s exposed skin. They should avoid applying directly to children’s hands.

Immune-Compromised Travelers

Vectorborne infections can be severe in immunocompromised patients. Urge patients to rigidly adhere to insect precautions.

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Stay safe outdoors

Advise travelers to exercise caution during outdoor activities. Important tips include dressing appropriately for the climate (such as loose, lightweight clothing in hot climates and warm layers in cold climates), staying hydrated, avoiding overexposure to the sun, and practicing safe swimming habits. To avoid infection while swimming, travelers should not swallow water when swimming and avoid contact with water that may be contaminated from poor sanitation.

Encourage travelers to learn basic first aid and CPR before travel, especially if they will be traveling to remote areas where medical assistance may not be accessible. Help them assemble a travel health kit.

Additional Resources:

Sunburn
Problems with Heat & Cold

Traveling with Children

Advise parents to minimize sun exposure for children. Infants under 6 months have thinner, more sensitive skin, and therefore require additional protection from the sun. Sunscreen is recommended for use on children above 6 months of age; physical precautions such as seeking shade and wearing protective clothing are recommended for infants under 6 months of age, as well as minimal use of sunscreen on exposed areas (e.g., face and hands).

Travelers with children should never leave children unattended while swimming, and should be advised of the risk of infection from swimming in and/or swallowing contaminated water.

Parents should also be advised to avoid contact with potentially contaminated soil. Children should wear protective footwear and should play on a sheet or towel instead of directly on the ground.

Chronic Disease

Advise travelers to remain hydrated while engaging in outdoor activities.

Also advise travelers to avoid potentially contaminated water. They should exercise extreme caution while swimming in fresh, untreated water.

Immune-Compromised Travelers

Advise immunocompromised travelers not to swim in fresh, untreated water.

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Keep away from animals

Counsel travelers to be cautious around all animals.

  • Travelers should avoid touching, petting, handling, or feeding animals, including pets.
  • Arthropods such as spiders and scorpions can pose a stinging risk, and travelers should exercise care in environments where these creatures are likely to be present.
  • Stress the urgency of treating suspected and probable rabies infection by:
    • Washing the wound immediately with soap and clean water.
    • Seeking medical attention as soon as possible.
  • Travelers at risk for rabies should consider medical evacuation insurance, since postexposure prophylaxis may not be available at the destination.
Additional Resources

Animal-Associated Hazards (YB)
Rabies (YB)
Criteria for Preexposure Immunization for Rabies (YB)
Protection against Mosquitoes, Ticks, & Other Insects & Arthropods (YB)

 

Traveling with Children

  • Counsel families to avoid all stray or unfamiliar animals.
  • Children are at increased risk for animal-associated injuries. They are more likely to suffer severe injuries to the neck or head.
  • Children should be encouraged to tell adults about all contact with animals.
  • Families should consider purchasing medical evacuation insurance, since postexposure prophylaxis may not be available at the destination.
Additional Resources

Traveling Safely with Children & Infants (YB)

Visiting Friends or Family

Domestic animals may not be vaccinated for rabies in developing countries. Urge VFR travelers to avoid even family pets.

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Reduce your exposure to germs

People who are ill should not travel. Urge travelers to practice hand hygiene and sneeze into a tissue or their sleeve.

Traveling with Children

Scrupulous attention should be paid to washing bottles, pacifiers, teething rings, and toys that fall to the floor or are handled by others; water used to clean these items should be potable.

Parents should be particularly careful to wash hands after changing diapers.

Immune-Compromised Travelers

Attention to hand hygiene is the best protection against gastroenteritis in immunocompromised travelers. Hands should be washed after contact with public surfaces.

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Avoid sharing body fluids

Counsel travelers on the risks of diseases associated with the exchange of saliva, blood, vomit, semen, urine, and feces.

Travelers should:

  • Use a latex condom correctly every time they engage in sex (vaginal, anal, and oral-genital).
  • Not inject drugs.
  • Limit alcohol consumption.
  • Not have tattoos, piercings, or other procedures that use needles (acupuncture) unless the needles are packaged new or sterilized.
  • Ensure that medical and dental equipment is sterile or disinfected if seeking care.
Additional Resources:
HIV & AIDS (YB)
Hepatitis B (YB)
Hepatitis C (YB)
Medical Tourism (YB)

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Know how to get medical care while traveling

Travelers should plan for how to obtain health care during their trip, should the need arise.

Discuss supplemental travel health insurance and medical evacuation insurance, and consider helping the traveler obtain an extra month of prescriptions for any needed medications.

Traveling with Children

Adults traveling with children should be counseled about the signs and symptoms of dehydration and the proper use of oral rehydration salts (ORS), and when to seek medical care.

Chronic Disease

Give patients comprehensive documentation that they should take with them that outlines their medical conditions:

  • A letter, printed on office letterhead, explaining the patient’s current medical condition(s).
  • All medication that you have prescribed for the patient (include generic names).
  • A list of equipment the patient needs to manage his/her condition.

Help patients who have chronic conditions develop a health plan for their trip:

  • Instruct how to manage minor problems or exacerbations.
  • Research medical facilities at the destination that are equipped to handle the condition and give the patient contact information for these facilities.
  • Reinforce the importance of medical evacuation insurance, particularly for patients traveling to rural or developing areas.

Extended Stay/Study Abroad

People spending prolonged periods abroad are at increased risk of illness and injury that requires local medical care. Emphasize the need for these travelers to buy travel health and medical evacuation insurance.

Immune-Compromised Travelers

Give patients comprehensive documentation that they should take with them that outlines their medical conditions:

  • A letter, printed on office letterhead, explaining the patient’s current medical condition(s).
  • All medication that you have prescribed for the patient (include generic names).
  • A list of equipment the patient needs to manage his/her condition.

Help patients develop a health plan for their trip:

  • Instruct how to manage minor problems or exacerbations.
  • Research medical facilities at the destination that are equipped to handle the condition and give the patient contact information for these facilities.
  • Reinforce the importance of medical evacuation insurance, particularly for patients traveling to rural or developing areas.

Visiting Friends or Family

Consider whether patients are likely to use risky or unproven traditional medicines at the destination. Discuss any potential risks of traditional therapies.

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Select safe transportation

Motor vehicle crashes are the #1 killer of healthy US citizens in foreign countries.

Most recommendations for safe transportation are basic and could be considered common sense. However, travelers often do not think about the importance of being aware and careful when walking, riding, driving, or flying.

In many places cars, buses, large trucks, rickshaws, bikes, pedestrians, and even animals share the same lanes of traffic, increasing the risk for crashes.

Counsel travelers to think about transportation options before they arrive, especially if they will be driving in Costa Rica.

Medical Evacuation Insurance

If your patient is seriously injured, emergency care may not be available or may not meet US standards. Trauma care centers are uncommon outside urban areas. Encourage patients to purchase medical evacuation insurance.

Some basic reminders to review with your patients:

  • Choose safe vehicles and avoid motorbikes when possible.
  • Wear a seatbelt or a helmet at all times.
  • Do not drive after drinking alcohol or ride with someone who has been drinking.
  • Avoid driving at night; street lighting in certain parts of Costa Rica may be poor.
  • If they will be driving, remind them to get any driving permits and insurance they may need. It is recommended to get an International Driving Permit (IDP).
  • Avoid using local, unscheduled aircraft, and fly on larger planes (more than 30 seats) when possible.
Helpful Resources

Road Safety Overseas (Information from the US Department of State): Includes tips on driving in other countries, International Driving Permits, Auto Insurance, and other resources.

The Association for International Road Travel has country-specific Road Travel Reports available for most countries for a minimal fee.

Encourage your patients to look up the information provided under Travel and Transportation on US Department of State's country-specific information for Costa Rica.

 

Traveling with Children

Counsel parents of children to bring their own car or booster seats from home and use them according to the same guidelines they follow here in the United States.

Parents will need to choose vehicles that have seatbelts in order to properly secure the car or booster seat. 

Also remind parents that they should use FAA-approved car or booster seats when flying in aircraft.

Extended Stay/Study Abroad

Patients who will be living or studying abroad may be considering purchasing a bicycle, vehicle, or motorbike. Counsel them to make sure they have the appropriate permits and insurance.

Remind students that crashes involving in-country travel are a major cause of injury to people studying abroad, so they need to be diligent about finding and using safe modes of travel. (Refer to guidance on traveler pages of the website.)

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Maintain personal security

Travelers should be reminded on how to protect their personal safety during travel, regardless of their destination. 

The US Department of State has an extensive website with safety information for international travelers, travel alerts and warnings, and country-specific information. Travelers should be directed to the Department of State resources for information and tips on safe travel.

Stay abreast of current events, particularly those that could pose a safety or health problem for travelers. You can also receive updates on new travel alerts and warnings from the US Department of State by subscribing to their RSS feeds.

Traveling with Children

Because of concerns about illegal transport of children across international borders, if only 1 parent is traveling with the child, he or she may need to carry custody papers or a notarized permission letter from the other parent. Children should also carry their own identifying information and contact numbers, in case family members become separated.

Chronic Disease

Americans have been arrested for possessing prescription drugs, particularly tranquilizers and amphetamines that they purchased legally elsewhere. Some countries have laws against possession of certain prescription drugs that are legal in the United States.

Travelers should check with the embassy of Costa Rica to make sure any required medications are not considered to be illegal.

Extended Stay/Study Abroad

Students are at risk for heavy drinking. Counsel students on alcohol and drug safety abroad. Emphasize the need to understand and abide by local drug and alcohol laws.

Guide patients to the Students Abroad website from the US Department of State, which has excellent information and resources specifically for study-abroad travel.

Immune-Compromised Travelers

Americans have been arrested for possessing prescription drugs, particularly tranquilizers and amphetamines that they purchased legally elsewhere. Some countries have laws against possession of certain prescription drugs that are legal in the United States.

Travelers should check with the embassy of Costa Rica to make sure any required medications are not considered to be illegal.

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Healthy Travel Packing List

Remind your patients to pack health and safety items. Use the Healthy Travel Packing List for Costa Rica for a list of health-related items they should consider packing.

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Travel Health Notices

Stay aware of current health issues in Costa Rica in order to advise your patients on additional steps they may need to take to protect themselves.

Watch Level 1, Practice Usual Precautions

  • Global Measles Outbreak Notice June 10, 2019 Measles is in many countries and outbreaks of the disease are occurring around the world. Before you travel internationally, regardless of where you are going, make sure you are protected fully against measles.

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Advising Returning Travelers

Although some illnesses may begin during travel, others may occur weeks, months, or even years after return. A history of travel, particularly within the previous 6 months, should be part of the routine medical history for every ill patient. A newly returned, ill international traveler should be preferentially evaluated by a physician versed in travel-related illness.

Here are two professional medical organizations that provide directories of travel clinics throughout the United States:

Malaria is always a serious disease and may be a deadly illness. Any patient presenting with a fever after traveling in a malaria-risk area during the last year should be evaluated immediately using the appropriate diagnostic tests for malaria. Malaria, especially P. falciparum, requires urgent intervention as clinical deterioration can occur rapidly and unpredictably.

For more information on advising patients after international travel, see Yellow Book Chapter 5: Post-Travel Evaluation.

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Map Disclaimer - The boundaries and names shown and the designations used on maps do not imply the expression of any opinion whatsoever on the part of the Centers for Disease Control and Prevention concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Approximate border lines for which there may not yet be full agreement are generally marked.

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