Chapter 10 Popular Itineraries Asia
China, the world’s most populous country (>1.3 billion people), is the fourth largest geographically, behind Russia, Canada, and the United States. Divided into 23 provinces, 5 autonomous regions, and 4 municipalities (Map 10-12), it is home to diverse topographies, languages, and customs. The climate varies from tropical in the south to subarctic in the north, with wide variations between regions and seasons.
The long history and varied natural beauty of China can be traced through its 52 UNESCO World Heritage sites, including the Forbidden City and Temple of Heaven, the Great Wall, the terracotta warriors of Xi’an, and the spectacular mountainous sanctuaries of the west. Recent additions include the Tusi tribal domains in western China and the Grand Canal. The oldest (dating back to 468 bce) and longest (1,115 miles; 1,794 km) man-made canal in the world, the Grand Canal, links the cities of Beijing and Hangzho and the island of Gulangyu, a historic pedestrian island settlement off the coast of Xiamen in southeastern China.
In 2017, more than 135 million tourists visited China. Tourism to China has grown at an extraordinary pace over the past decade, although numbers have leveled off slightly in the past few years. Travelers with special interests may go mountain climbing, tour small villages, or travel the Silk Road. More typical travel itineraries include sightseeing Beijing and the Great Wall, touring Shanghai, and cruising the Yangtze River (see Box 10-01 for information about Yangtze River cruises). Other tourist destinations include the following:
- Hong Kong, with its futuristic architecture and East-meets-West mystique
- Lijiang (Yunnan Province), with its many ethnic minorities
- Sichuan Province, home to China’s iconic symbol, the panda
- Guilin, famous for its uniquely shaped limestone karst mountains, featured in paintings
- Tibet, accessible by the world’s highest railroad (maximum elevation 16,640 ft [5,072 m])
- Xi’an, home to China’s army of terracotta soldiers
- Hainan Island, home to tropical beaches and luxury resorts
Aside from tourism, increasing numbers of people travel to China to visit friends and relatives, to study, or to adopt children. These so-called “non-tourists” may be at an increased risk of becoming ill because they underestimate health hazards, are less likely to seek pretravel advice, and are more likely to stay in local or rural accommodations. People traveling to China to adopt often worry about the health of the child but neglect their own.
Map 10-12. China destination map
China is now the world’s second-largest economy but, per capita income is still below the world average, with wide disparity in wealth and development between urban and rural, east and west. Health risks vary accordingly.
Although aggressive efforts are underway to control air pollution (a consequence of rapid economic expansion), many of the most polluted cities in the world are in China; Beijing regularly tops the list. On peak pollution days, the levels of particulate matter (PM) in the air can exceed 40 times the limit considered safe by the World Health Organization (see Chapter 3, Air Quality & Ionizing Radiation). Haze has a negative impact on quality of life and indicates high concentrations of PM2.5, toxic to the respiratory, cardiovascular, and nervous systems.
Short-term exposure to the levels of air pollution in China’s megacities can irritate the eyes and throat. Travelers with underlying cardiorespiratory diseases, including asthma, chronic obstructive pulmonary disease, or congestive heart failure, may find their condition exacerbated. In addition, exposure to high levels of air pollution significantly increases the risk of respiratory tract infections, including sinusitis, otitis, bronchitis, and pneumonia. Children and the elderly are the most vulnerable to these effects.
Regional haze has triggered public anxiety and official concern. To tackle air pollution, a number of policies and measures targeted at reducing emissions and promoting alternative energy production have been implemented. Increased use of natural gas (and restrictions against burning coal) is key to these plans; China’s use of natural gas surged by 19% in 2017, as areas across northern China switched to this relatively clean fossil fuel and away from coal. This enabled those in Beijing and surrounding areas to enjoy many more days with clear, blue skies in the winter of 2017–2018. Other measures have included closing highly polluting factories and moving factories farther away from population centers.
Although surgical-style face masks have become fashionable in the big cities of China, especially Beijing and Shanghai, they afford wearers no protection from air pollution and are not recommended. Properly fitted N95 masks can filter out particulates but not gaseous pollutants and can sometimes actually compound breathing problems, so are not advisable for most people to wear.
Routine vaccinations should be up-to-date, including seasonal influenza. In addition, hepatitis A and B and typhoid vaccinations are recommended. The Xinjiang Uygur Autonomous Region borders Pakistan, a polio-endemic country. Adults traveling to this region who will be working in health care settings, refugee camps, or humanitarian aid settings should be vaccinated against polio, including a single lifetime booster dose of polio vaccine (IPV).
Measles and rubella immunity is particularly important. A massive vaccination campaign begun in September 2010 has decreased the number of reported measles cases; there were, however, still more than 100,000 cases of the disease reported in 2014. 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.
China is making considerable advances in vaccination, with the objective of developing their own locally made vaccines or working with established pharmaceutical companies in a joint venture approach. One example is the recent introduction of quadrivalent human papilloma virus (HPV) vaccine. Strong demand has resulted in long waiting lists for this vaccine.
Unfortunately, there have been many issues with counterfeit and improperly stored vaccines. In addition, vaccine shortages are frequent; adult tetanus vaccines, for example, have been out of stock since 2014. Travelers cannot guarantee that they can complete an unfinished vaccination series once in China. Since tetanus vaccines are unavailable, ensure that all travelers going to China are up-to-date with their booster. Hong Kong, by contrast, functions under different rules; international vaccines are in use there and are generally available.
Hepatitis B infection is endemic to China. Nearly one-third of the 350 million people worldwide infected with the hepatitis B virus (HBV) reside in China. Hepatitis B vaccination is recommended for non-immune travelers.
Japanese encephalitis (JE) occurs in all regions except Qinghai, Xinjiang, and Xizang (Tibet) (see Map 4-07 and Table 4-07). China has successfully reduced the incidence of JE through vaccination and, as of 2008, included JE in its expanded national immunization program; however, the disease remains a potential threat to unvaccinated travelers.
Although the JE season varies by region, most cases in local residents occur from June through October. The risk of JE for most travelers to China varies based on season, destination, duration of stay, and activities. Risk is highest among travelers going 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.
Consider JE vaccine for shorter-term travelers (<1 month) planning visits to rural areas, or those at increased risk for JE virus exposure based on anticipated activities or itineraries (e.g., spending substantial time outdoors or staying in accommodations without air conditioning, screens, or bed nets). Sporadic cases have occurred on an unpredictable basis in short-term travelers, including in periurban Beijing and Shanghai. See Chapter 4, Japanese Encephalitis, for more detailed information.
Rabies is a serious problem in China, as in much of Asia. According to the World Health Organization, China has the second highest number of human rabies deaths in the world with more than 2,000 reported per year, every year for the past decade. Mammal bites in any area of China, including urban areas, must therefore be considered high risk for rabies (see Chapter 4, Rabies). As rabies immune globulin is generally unavailable, animal bites are often trip-enders, requiring evacuation to Hong Kong, Bangkok, or home for postexposure prophylaxis.
An analysis of data collected by the GeoSentinel Surveillance Network showed that bites from dogs are surprisingly common in tourists to China (see Chapter 3, Animal Bites & Stings). Include a discussion of rabies risk and prevention during pretravel consultations, and develop a strategy for dealing with possible exposure. Consider providing long-term travelers and expatriates going to live in China with the preexposure vaccination series.
Malaria risk is very low for travelers to China, with the exception of those visiting rural parts of southern Yunnan Province. Consider prophylaxis for travelers to this region and reinforce the importance of mosquito prevention (see Chapter 3, Mosquitoes, Ticks & Other Arthropods). Prescribe doxycycline or atovaquone-proguanil for travel to southern Yunnan, due to known mefloquine resistance (see Chapter 2, Yellow Fever Vaccine & Malaria Prophylaxis Information, by Country).
In 2014, southern China experienced its worst dengue outbreak in decades; Guangdong province reported more than 40,000 cases in just 2 months. Travelers should practice daytime mosquito precautions in the summer months. See Chapter 4, Dengue, for more details on this disease.
Box 10-01. Cruising down the Yangtze River: 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 health considerations for this trip:
- Japanese encephalitis (JE) is a risk; at least 1 case has been documented in a tourist whose 3-week trip to rural and urban China included a Yangtze River cruise.
- Malaria is not a substantial risk, although insect bite precautions are recommended.
- Schistosomiasis—Schistosoma japonicum—exists in the Yangtze River basin; swimming is ill-advised.
- Motion sickness is rare since much of the cruise 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 that may not be accessible for infirm or less physically fit tourists.
- Air pollution on Yangtze River cruises 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 Chinese tourist boats may not meet expectations for cleanliness, and English may not be spoken.
- Food and water precautions apply even on luxury cruises.
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 consider bringing an antibiotic for self-treatment of moderate to severe diarrhea (see Chapter 2, Food & Water Precautions and Travelers’ Diarrhea). 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 Infections
Sexually transmitted infections (STIs), 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 (see Chapter 9, Sex & Travel). Travelers should be aware of STI risks and use condoms when having sex with anyone whose HIV or STI status is unknown. Hepatitis B vaccination before travel should be considered.
Road Traffic Injuries
Traffic in China is often chaotic. The rate of traffic crashes, including fatal ones, is among the highest in the world (see Chapter 8, Road & Traffic Safety). Child safety seats, rear seat belts, and bicycle or motorcycle helmets are rarely seen and not widely available. Traffic crashes, even minor ones, can create major traffic jams and sometimes turn into violent altercations, particularly when foreigners are involved (see Chapter 3, Safety & Security Overseas).
China has not signed the convention that created the International Driving Permit, and travelers require a Chinese license to drive. 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. It is 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. For all of these reasons, it is often simpler and safer to hire a local driver than to drive oneself.
Electronic bicycles (E-bikes) are popular and do not have to be registered. They often travel in pedestrian and bicycle lanes as well as with traffic. Because there is no engine noise, it can be challenging for pedestrians to identify an oncoming E-bike. Motor vehicles and E-bikes often drive without lights, making night travel dangerous.
Five of the 10 deadliest natural disasters in history have occurred in China. Natural hazards include dust storms in the north and typhoons along the southern and eastern seaboards. Torrential rain, floods, and landslides occur on a regular basis, most recently in the summer of 2017. Earthquakes cause significant death and destruction. The 1556 Shaanxi earthquake—thought to have killed more than 800,000 people—is the most lethal earthquake ever recorded and one of the 10 deadliest natural disasters. More recently, devastating earthquakes struck the western provinces of Sichuan in 2008 and Qinghai in 2010.
High Elevation Travel
Western China is home to some of the highest mountains in the world. Some popular destinations are Lhasa (3,658 m), Shangri-La (3,280 m), Lijiang (2,418 m), and Xining (2,295 m). Preparation and gradual ascent to acclimatize are the mainstays travelers should follow to prevent the onset of altitude illness (see Chapter 3, High-Altitude Travel & Altitude Illness).
Travelers who cannot ascend gradually—or who develop acute mountain sickness (AMS)—should carry their own supply of acetazolamide; it is not available in China. Dexamethasone, a prevention for AMS and high-altitude pulmonary and cerebral edema (HAPE and HACE, respectively), is reportedly available in China. Similarly, nifedipine (as a prevention and treatment for HAPE) is reportedly available. The quality and ready availability of either of these drugs is unknown.
Vitamin D Deficiency
Vitamin D deficiency is a major issue in the northern provinces of China, where smog blocks out sunlight, leading to inadequate vitamin D absorption, even in the summer months. To decrease the risk of osteomalacia and osteoporosis in travelers spending more than 6 months in China, prescribe vitamin D supplementation.
MEDICAL CARE IN CHINA
Strongly encourage travelers to invest in travel health insurance, including medical evacuation insurance coverage (see Chapter 6, Travel Insurance, Travel Health Insurance & Medical Evacuation Insurance). Most hospitals do not accept foreign medical insurance, and patients are expected to pay a deposit to cover the expected cost of the treatment before care is delivered. Western-style medical facilities that meet international standards are available in Beijing, Shanghai, and Hong Kong.
Hospitals in other cities may have “VIP wards” (gaogan bingfang) with English-speaking staff. The standard of care in such facilities is somewhat unpredictable, however, and cultural and regulatory differences can cause difficulties for travelers. In rural areas, only rudimentary medical care may be available. Hepatitis B virus 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; rather than waiting for an ambulance to arrive, injured travelers may be better off taking a taxi or other immediately available vehicle to the nearest major hospital. Pharmacies often sell prescription medications over the counter; these may be counterfeit, substandard, or even contaminated. Travelers should bring all their regular medications in sufficient quantity. If more or other medications are required, visiting a reputable clinic or hospital is advised.
Most who wish to try traditional Chinese remedies do so uneventfully, although not without accepting some risk. Remind travelers that acupuncture needles may be a source of bloodborne and skin infections; acupressure may be preferable to acupuncture. Herbal medicine products may be contaminated with heavy metals or pharmaceutical agents.
Currently China is witnessing an influx of patients coming from Africa seeking treatment not available in their home countries. There is also a growing market of patients coming from more developed countries looking for as-yet unapproved experimental treatments (see Chapter 9, Medical Tourism).
- 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.
- United Nations World Tourism Organization. UNWTO tourism highlights. Madrid: United Nations World Tourism Organization; 2012 [cited 2016 Sep 24]. Available from: http://mkt.unwto.org/en/publication/unwto-tourism-highlights-2012-edition.
- World Health Organization. Hepatitis B surveillance and control. WHO; [updated 2016 July; cited 2016 Sep 24]. Available from: www.who.int/mediacentre/factsheets/fs204/en/.
- World Health Organization. Measles bulletin: Western Pacific region. Geneva: World Health Organization; 2010 [cited 2016 Sep 24]. Available from: www.wpro.who.int/entity/immunization/documents/docs/MeasBulletinVol4Issue1_F840.pdf.
- Xia J, Min L, Shu J. Dengue fever in China: an emerging problem demands attention. Emerg Microbes Infect. 2015 Jan;4(1):e3.
- 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.