Author(s): Sarah Borwein, Kate Gaynor

Destination Overview

China, the world’s most populous country (>1.4 billion people), is the fourth largest geographically, behind Russia, Canada, and the United States. Divided into 23 provinces, 5 autonomous regions, 4 municipalities, and 2 Special Administrative Regions (Map 10-12), China is home to diverse customs, languages, and topographies. 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 56 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 Quanzhou; Emporium of the World in Song-Yuan; Mount Fanjing in southwest China; the archeological ruins of Liangzhu City in the Yangtze River Delta; the migratory bird sanctuaries along the coast of the Bohai Gulf; 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.

In 2019, >145 million people visited China, and the number of outbound travelers reached nearly 155 million, 3 times more than in 2010. Tourism in China has grown at an extraordinary pace over the past decade, although the coronavirus disease 2019 (COVID-19) pandemic that began in 2020 has, as everywhere, drastically reduced both inbound and outbound travel. By early 2022, China’s borders remained effectively closed to international tourism; domestic travel, however, had rebounded sharply, reaching (or even exceeding) 2019 levels. Domestic travelers have been flocking to the usual tourist destinations, including sightseeing in Beijing and the Great Wall, touring Shanghai, cruising the Yangtze River, and visiting the Huangshan (Yellow Mountain) site in Anhui Province (see Box 10-02 for a list of other popular tourist destinations).

Aside from tourism, increasing numbers of people travel to China to visit friends and relatives, to study, to adopt children, or to do humanitarian aid work. These non-tourist travelers might be at greater 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 (see Sec. 7, Ch. 5, International Adoption), sometimes neglecting their own health.

China has the world’s second largest economy and more billionaires (658) than any other country in the world. At the same time, per capita income is still below the world average, with wide disparity in wealth and development between the more urban east and the rural west. Health risks vary accordingly.

Infectious Disease Risks

Travelers should be up to date on routine vaccinations, including seasonal influenza vaccine. Travelers also should be current on vaccines against diphtheria-tetanus-pertussis, measles-mumps-rubella, and varicella. China began a massive measles vaccination campaign in September 2010 that has decreased the number of reported measles cases; a brief resurgence occurred during 2013–2015, but high measles vaccination coverage has resulted in historically low numbers of measles cases since 2017. Nonetheless, a few travelers made news headlines by triggering outbreaks in their home countries after returning from China. The reported incidence of rubella has fallen, but availability of data is patchy. Cases of pertussis and varicella occur regularly.

Vaccine Quality & Availability in China

China is making considerable advances in vaccine production, working with established pharmaceutical companies in a joint venture approach or by developing and manufacturing vaccines locally. One example is the recent introduction of the Sinovac-CoronaVac COVID-19 vaccine produced by Sinovac Biotech Ltd., a Chinese biopharmaceutical company based in Beijing.

In the past, counterfeit and improperly stored vaccines were a major issue, but China has waged a robust response to recent vaccine scandals and these issues are now rare, at least in major urban areas. Vaccine shortages are, however, frequent. For example, meningococcal vaccines were in short supply in parts of China during 2017–2018, and as of late 2021, tetanus-diphtheria-pertussis (Tdap) vaccine for adults was not available anywhere on the mainland. Travelers should not assume they can complete an unfinished vaccination series once in China; thus, ensure that all travelers going to China are up to date with routine vaccination series before travel. By contrast, circumstances in Hong Kong are different; international vaccines are in use there and are generally available.

Bloodborne Pathogens

Hepatitis B

Hepatitis B infection is endemic to China (see Sec. 5, Part 2, Ch. 8, Hepatitis B). Nearly one-third of the 350 million people worldwide infected with the hepatitis B virus reside in China. The Advisory Committee on Immunization Practices recommends hepatitis B vaccine for all US adults aged 19–59 years; hepatitis B vaccine should be considered for nonimmune travelers to China.

Enteric Infections & Diseases

Brucellosis

Brucellosis occurs in pastoral areas of China, particularly the northwest. Travelers should strictly avoid raw or unpasteurized milk products and undercooked meat products (see Sec. 5, Part 1, Ch. 3, Brucellosis).

Hepatitis E

Hepatitis E is highly endemic in China and can be acquired by drinking untreated water, eating undercooked meats, or staying in areas with poor sanitation (see Sec. 5, Part 2, Ch. 10, Hepatitis E). Pregnant people in their third trimester are at particular risk for severe disease. Because no routine vaccine is available, advise travelers to practice good hand hygiene and to adhere to safe food and water precautions (see Sec. 2, Ch. 8, Food & Water Precautions).

Polio

The Xinjiang Uygur Autonomous Region borders Pakistan, a polio-endemic country. Adults traveling to this region who will be working in health care facilities, humanitarian aid settings, or refugee camps should be vaccinated against polio, including a single lifetime booster dose of polio vaccine as an adult (see Sec. 5, Part 2, Ch. 17, Poliomyelitis).

Travelers’ Diarrhea

The risk for travelers’ diarrhea (see Sec. 2, Ch. 6, Travelers’ Diarrhea) appears to be low in so-called “luxury” accommodations in China but moderate elsewhere. Travelers should adhere to safe food and water precautions, and strictly avoid undercooked fish and shellfish and (as noted previously) unpasteurized milk (see Sec. 2, Ch. 8, Food & Water Precautions).

Other than in Hong Kong, tap water is not safe to drink, even in major cities. Most hotels provide boiled or bottled water, and bottled water is readily available.

Typhoid Fever

Typhoid fever is not a significant risk in China’s major urban areas. Consider vaccinating travelers planning visits to rural areas, adventure travelers, and travelers visiting friends and relatives. Advise them to adhere to safe food and water precautions.

Respiratory Infections & Diseases

Coronavirus Disease 2019

Located in central China at the confluence of the Han and Yangtze rivers, Wuhan is a city of 11 million people and a major travel hub accessible by air, land, and water. On December 31, 2019, Chinese officials reported to the World Health Organization (WHO) an outbreak of unusual pneumonia cases linked to a seafood market there. The outbreak spread globally, and on March 11, 2020, WHO officially declared COVID-19 a pandemic.

In response to the outbreak, officials in China combined a swift and stringent lockdown of Wuhan and Hubei Province, with public health messaging, widespread testing, contact tracing, and isolation of all cases and quarantine of contacts. They also built several brand new, full-service COVID-19 hospitals within a matter of days, and established a network of fangcang (makeshift) hospitals in public venues (e.g., convention centers, sports stadiums).

Patients with mild illness were isolated in these newly established facilities, thereby reducing the risk of infecting household members. Confirmed or suspected cases were required to be seen at a small number of government- designated fever clinics. Indoor mask-wearing was strictly enforced. Tracking mobile phone applications assigned users a color-coded QR code based on their risk for infection. A green QR code became mandatory for entry into many facilities including stores, restaurants, and public transportation.

All travelers going to China should be up to date with their COVID-19 vaccines.

Tuberculosis

China remains moderately endemic for tuberculosis (TB). Travelers can become infected through exposure to a person with active Mycobacterium tuberculosis infection. Consuming unpasteurized milk products poses a risk for infection with Mycobacterium bovis, another mycobacterium that can cause TB disease in people. For long-term travelers or travelers whose itineraries place them at increased risk for exposure, consider predeparture TB testing with retesting upon their return home. For more details, see Sec. 5, Part 1, Ch. 22, Tuberculosis, and Sec. 5, Part 1, Ch. 23, . . . perspectives: Testing Travelers for Mycobacterium tuberculosis Infection.

Sexually Transmitted Infections & HIV

Sexually transmitted infections (STIs), including chlamydia, gonorrhea, HIV, and syphilis, are a growing problem in China, particularly along the booming eastern seaboard. Drug-resistant gonorrhea is increasingly prevalent. Make travelers aware of STI risks and the importance of using condoms when having sex with anyone whose HIV or STI status is unknown. As previously noted, travelers also should receive hepatitis B vaccination before travel.

Soil- & Waterborne Infections

Schistosomias & Leptospirosis

Although eradication programs have been quite successful, schistosomiasis (see Sec. 5, Part 3, Ch. 20, Schistosomiasis), primarily due to Schistosoma japonicum, continues to be reported in various areas, including the Yangtze and Mekong River basins. Advise travelers to avoid freshwater swimming, which also decreases their risk of contracting the bacterial illness, leptospirosis (Sec. 5, Part 1, Ch. 10).

Vectorborne Diseases

Chikungunya & Dengue

Chikungunya has been reported in China, but the level of risk is not well quantified. Dengue, however, is known to be a more significant health risk (see Sec. 5, Part 2, Ch. 4, Dengue). In 2014, China experienced its worst dengue outbreak in decades; Guangdong province reported >40,000 cases in just 2 months. Dengue epidemics occur in China every 4–6 years, mostly in the southern provinces. Travelers should practice insect bite precautions during the summer months (see Sec. 4, Ch. 6, Mosquitoes, Ticks & Other Arthropods).

Japanese Encephalitis

Japanese encephalitis (JE) occurs in all regions of China except Qinghai, Xinjiang, and Xizang (Tibet) (see Table 5-13). China has successfully reduced the incidence of JE through vaccination and, as of 2008, included JE in its expanded national immunization program; JE remains a potential threat to unvaccinated travelers, however.

Although JE season varies by region, most cases occur in local residents during June–October. In addition to season of travel, the risk to travelers depends on their activities, destination, and duration of stay. JE vaccine is recommended for travelers planning to spend ≥1 month in endemic (mainly rural) areas during June–October, when risk for transmission is greatest.

Consider vaccinating shorter-term travelers (<1 month) who plan to visit rural areas, and travelers at increased risk for JE virus exposure based on anticipated activities or itineraries (e.g., those spending substantial time outdoors or staying in accommodations without air conditioning, mosquito nets, or window screens). Sporadic JE cases have occurred on an unpredictable basis in short-term travelers, including in peri-urban Beijing and Shanghai. See Sec. 5, Part 2, Ch. 13, Japanese Encephalitis, for more detailed information.

Malaria

In the 1940s, China reported >30 million cases of malaria per year. A 70-year eradication campaign progressively reduced numbers, and in 2021, WHO declared China malaria-free. Travelers should still follow insect bite precautions, however, because of the risk for infection with other vectorborne diseases (see Sec. 4, Ch. 6, Mosquitoes, Ticks & Other Arthropods).

Plague

Plague outbreaks occur sporadically in the northern and southwestern areas of the country (see Sec. 5, Part 1, Ch. 15, Plague). Plague is rarely seen in tourists but is a risk to campers, hikers, hunters, spelunkers, and others exposed to wild rodents or flea-infested cats and dogs.

Tick-Borne Encephalitis

Tick-borne encephalitis (TBE) is present in northeastern parts of China and is a risk during March–November. Consider recommending TBE vaccination for travelers engaging in outdoor activities (e.g., camping, hiking) in endemic areas (see Sec. 5, Part 2, Ch. 23, Tick-Borne Encephalitis). Even among vaccinated travelers, reinforce the importance of taking preventive measures (e.g., wearing long pants tucked into socks, using insect repellent, regularly checking for ticks).

Environmental Hazards & Risks

Air Pollution

Rapid economic expansion and industrialization since 1978 has resulted in serious air pollution issues, along with water and soil contamination, that peaked in 2013. Regional haze triggered public anxiety and official concern, leading to the Air Pollution and Control Plan, which was implemented in 2013; subsequently a series of other initiatives to control soil, water, and plastic waste pollution began.

To tackle air pollution, China introduced several policies and measures targeted at reducing emissions and promoting alternative energy production. Increased use of natural gas and restrictions against burning coal are key to these plans. Other measures included closing highly polluting factories, moving factories farther away from population centers, afforestation projects (planting trees in areas where there had been no trees before), and promoting the use of electric vehicles. These measures have resulted in a dramatic reduction in air pollution, particularly in fine particulate matter (PM2.5).

Once renowned for its toxic haze, Beijing is no longer among the 10 most polluted cities in the world. Nonetheless, pollution remains a problem in many parts of the country; and China still accounts for over half of the world’s 200 most polluted cities. In the spring of 2021, several large sandstorms originating in southern Mongolia blanketed eastern China in hazardous dust. These sandstorms are unpredictable and are likely to continue. Travelers can check 5-day air quality forecasts.

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, might find their condition exacerbated. In addition, exposure to high levels of air pollution significantly increases the risk for upper and lower respiratory tract infections, including otitis, sinusitis, bronchitis, and pneumonia. Children and older people are most vulnerable.

Even before the COVID-19 pandemic, surgical- style facemasks were fashionable in China’s large cities, especially Beijing, Hong Kong, and Shanghai; facemasks provide wearers no protection from air pollution, however. Properly fitted N95 masks can filter out particulates and might be advisable for people determined to engage in outdoor exercise at times when air quality is very poor (see Sec. 4, Ch. 3, Air Quality & Ionizing Radiation). Many facilities, particularly schools, have installed sophisticated central air-filtering devices and constructed enclosed sports venues.

Altitude Illness

Western China is home to some of the tallest mountains in the world. Some popular destinations are Xining (2,295 m; ≈7,500 ft), Lijiang (2,418 m; ≈7,900 ft), Shangri-La (3,280 m; ≈11,000 ft), and Lhasa (3,658 m; ≈12,000 ft). Preparation and gradual ascent to acclimatize are the mainstays travelers should follow to prevent the onset of altitude illness (see Sec. 4, Ch. 5, High Elevation Travel & Altitude Illness).

Visitors planning high elevation travel whose itineraries do not permit gradual acclimatization— or people otherwise known to be at risk for developing acute mountain sickness (AMS)—should carry their own supply of acetazolamide, because it is not reliably available in China. Dexamethasone, used to both prevent and treat AMS and high-altitude cerebral edema, and to potentially prevent high-altitude pulmonary edema (HAPE), reportedly is available in China. Similarly, nifedipine (as a prevention and treatment for HAPE) reportedly is available. The quality and ready availability of either of these drugs is unknown; thus, as with acetazolamide, travelers should carry a personal supply in a travel health kit.

Animal Bites & Rabies

An analysis of data collected by the GeoSentinel Surveillance Network showed that dog bites are surprisingly common among tourists to China. In addition, in China (as in much of Asia) rabies remains a serious problem. Animal rabies is endemic in China and might even be increasing, especially in the dog population. Thus, travelers should consider any dog or other mammal bite received anywhere in China, including urban areas, a high risk for rabies infection (see Sec. 5, Part 2, Ch. 18, Rabies).

Because international-standard rabies immune globulin is often unavailable, animal bites can be trip-enders, requiring evacuation to Bangkok, Hong Kong, or home, to receive appropriate postexposure prophylaxis (PEP). Rabies is a particular risk for younger children, who are more likely to approach animals and less likely to report bites or scratches. Incorporate a discussion of rabies risk and prevention during pretravel consultations, and develop a strategy with travelers for dealing with possible exposures, including purchasing medical evacuation insurance coverage (see Sec. 6, Ch. 1, Travel Insurance, Travel Health Insurance & Medical Evacuation Insurance). Consider providing long-term travelers and expatriates going to live in China with the rabies preexposure vaccination series.

Human rabies deaths in China peaked at 3,300 cases in 2007 and decreased to 290 cases in 2019; the decline in human rabies deaths is mainly attributable to widespread use of PEP and public PEP awareness.

Natural Disasters

Five of the 10 deadliest natural disasters in history have occurred in China. In the last few decades, almost every type of major hazard except volcanic eruption has hit China, including cold waves, droughts, earthquakes, forest and grassland fires, hailstorms, heat waves, red tides, sandstorms, and torrential rains resulting in debris flows and landslides. Typhoons and storm surges occur regularly along the southern and eastern seaboards.

Earthquakes cause significant death and destruction. For instance, devastating earthquakes struck the western provinces of Qinghai in 2010 and Sichuan in 2019. Advise US citizen travelers to enroll with the Department of State’s Smart Traveler Enrollment Program (STEP; https://step.state.gov/step); STEP will provide travelers with information and alerts from local US embassies or consulates about disasters, safety, and security issues at their destination.

Vitamin D Deficiency

Vitamin D deficiency is a major issue in the northern provinces of China, where (despite the progress in reducing air pollution noted previously) smog blocks out sunlight, leading to inadequate vitamin D absorption even during the summer months. To decrease the risk of osteomalacia and osteoporosis in travelers spending >6 months in China, prescribe vitamin D supplementation.

Wet Markets

So-called “wet markets” are common throughout China, south Asia, and southeast Asia. The term wet market is a generic one, encompassing many types of marketplaces selling perishable goods; some sell only fruit and vegetables, but others sell live animals that are slaughtered on-site after purchase. Most do not sell wild or exotic animals, and the tendency to lump all wet markets together has fueled Sinophobia related to the origins of the COVID-19 pandemic.

The exotic animal trade has been banned in China, but smuggling of animals (e.g., pangolins) is highly profitable and difficult to control. A coordinated international response will be required to curb the exotic animal trade. Travelers should avoid visiting markets selling live animals because these have been linked with many zoonotic outbreaks, including monkeypox and severe acute respiratory syndrome (SARS). Avian influenza transmission is another reason for travelers to avoid live animal markets.

Safety & Security

Crime

Rates of violent crime are low in China, but minor theft, pickpocketing, and various forms of scams and fraud do occur, especially in densely populated and more heavily touristed areas. Scams targeting foreign businesses also have been reported. Travelers should remain vigilant about their personal belongings, and avoid responding to emails from, or giving out sensitive information to, unknown sources.

Political Unrest

Travelers should be aware of and avoid involvement in protests and flare-ups of unrest in places as diverse as Hong Kong, Tibet, and Xinjiang Province. Travelers also should avoid public criticism of the Communist Party or the government. The internet is censored, and many widely used social media sites might be unavailable.

Traffic-Related Injuries

Traffic in China is often chaotic. The rate of traffic crashes, including fatal ones, is among the highest in the world (see Sec. 8, Ch. 5, Road & Traffic Safety). Traffic crashes, even minor ones, can create major traffic jams and sometimes turn into violent altercations, particularly when foreign travelers are involved (see Sec. 4, Ch. 11, Safety & Security Overseas).

China has not signed the convention that created the International Driving Permit and requires travelers to have a Chinese license to drive. Recent regulations have allowed foreign travelers to obtain a temporary (≤3 months) driver’s license, if they have a valid overseas driver’s license and a notarized copy translated into Chinese; in addition, travelers are required to attend lessons on Chinese road safety regulations.

Driving is on the right side of the road in mainland China and Taiwan, but on the left in Hong Kong and Macau. If travelers choose to drive, advise them to avoid driving at night or when weather conditions are bad, and to not assume that traffic rules or rights-of-way will be respected. Despite national seatbelt legislation being in effect since 2004, seatbelt use is inconsistent, and rear seatbelts often are unavailable. Use of child safety seats recently become mandatory. For all these reasons, travelers likely will find it safer and simpler to hire a local driver or to use public transportation than to drive themselves. Travelers should take care when opening the door of a taxi or private vehicle, to avoid hitting cyclists or pedestrians.

Electronic Bicycles

Electronic bicycles (E-bikes) are popular in China and do not have to be registered. E-bike riders often travel in pedestrian and bicycle lanes as well as with traffic. Because E-bikes have no engine noise, pedestrians might not readily identify an oncoming E-bike. Motor vehicles and E-bikes often drive without lights, making night travel dangerous. Bicycle helmets are rarely worn in China; a new 2020 law requiring helmet use for riders of motorcycles and E-bikes has resulted in a shortage of available helmets.

Availability & Quality of Medical Care

Strongly encourage travelers to invest in travel health insurance, including medical evacuation insurance coverage (see Sec. 6, Ch. 1, Travel Insurance, Travel Health Insurance & Medical Evacuation Insurance). Many hospitals do not accept foreign medical insurance, and patients are expected to pay a deposit to cover the anticipated cost of treatment before care is delivered. Many major cities, including Beijing, Guangzhou, Hong Kong, Shanghai, and Shenzhen have medical facilities that meet international standards. Hospitals in other cities might 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, rudimentary medical care might be all that is available.

Blood & Blood Product Safety

Hepatitis B and hepatitis C virus transmission from poorly sterilized medical equipment remains a risk in remote areas. The blood supply is heavily regulated and generally deemed safe, but is very limited, especially for rare types, including Rhesus negative blood; hospitals usually have only a few units of blood on hand. Rhogam legally is available only in Hong Kong, and recently in Shenzhen, under a new program permitting drugs and medical equipment already marketed in Hong Kong to be used in the Guangdong–Hong Kong–Macau “Greater Bay Area” after approval.

Emergency Medical Services

Emergency medical services are scarce in many parts of China, most acutely in rural areas. In major cities, 2 types of ambulance are available: general ambulances and ambulances that carry more advanced medical equipment. No recognized paramedic profession exists in China, and ambulances might be staffed instead with doctors or nurses with variable levels of training. In many rural areas, rather than waiting for an ambulance to arrive, injured travelers might be better off taking a taxi or other immediately available vehicle to the nearest major hospital.

Medical Tourism

Most people who choose to try traditional Chinese remedies do so uneventfully, albeit not without accepting some risk. Remind travelers that acupuncture needles can be a source of bloodborne and skin infections; acupressure might be preferable. Herbal medicine products can be contaminated with heavy metals or pharmaceutical agents.

China is currently witnessing an influx of patients coming from Africa seeking treatment not available in their home countries. Medical tourists from high-income countries looking for as-yet unapproved experimental treatments are also a growing market (see Sec. 6, Ch. 4, Medical Tourism).

Pharmacies

Pharmacies often sell prescription medications over the counter, but these can be counterfeit, substandard, or contaminated (see Sec. 6, Ch. 3, . . . perspectives: Avoiding Poorly Regulated Medicines & Medical Products During Travel). Advise travelers to bring all their regular medications in sufficient quantity. If travelers need more or other medications, recommend that they visit a reputable clinic or hospital. China allows travelers to bring controlled medications into the country in quantities “reasonable for personal use.” Especially for controlled medications, travelers are expected to carry a copy of the written prescription with them and, whenever possible, a signed note from the prescribing physician written on letterhead stationery.