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For stays in areas with very low rates of malaria transmission, some authorities — notably, in Europe — advise that only a standby drug be carried for self-treatment, to be taken in the event that symptoms suggestive of malaria occur and there is no access to competent medical care or to a facility in which a competent assessment of a blood smear for malaria can be performed within 6 to 12 hours. This strategy is especially attractive for long-stay travelers. A full course of atovaquone–proguanil or artemether–lumefantrine is recommended. In the United States, the CDC recommends continuous prophylaxis, as noted above, for travelers at risk but also suggests that treatment doses of these drugs may be carried for the treatment of confirmed malaria in areas where appropriate drugs for treatment may be unavailable or where there is concern about substandard or counterfeit medication.

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Yellow fever vaccine is necessary for personal protection during travel to some tropical countries in South America and sub-Saharan Africa where the acquisition of yellow fever is a risk. Separately, under the 2005 International Health Regulations (IHR), yellow fever vaccination may also be required for travelers arriving in countries where there is no local transmission of yellow fever from countries where yellow fever is endemic. That way, competent vector mosquitoes in the receiving country will be protected from acquiring and transmitting the virus. A specialized travel medicine clinic or a medical facility designated by the Centers for Disease Control and Prevention (CDC) as a yellow fever vaccination center is best situated to interpret nuanced requirements and recommendations, and referral to such a facility is recommended (). Neither yellow fever vaccine nor any other vaccine is currently required for readmission to the United States. First doses of yellow fever vaccine, but not booster doses, have been associated with rare but severe or fatal adverse events (overall rate, 1 event per 250,000 doses); the risk is highest among persons over the age of 60 years and increases with advancing age.


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During the medical appointment that precedes international travel, a structured and sequenced approach () is the most efficient way for the physician and other clinicians to address the necessary preventive and educational interventions. An individualized risk assessment that takes into consideration the exact place-by-place itinerary and factors that are particular to the prospective traveler should be performed first. Immunizations, malaria considerations, and travelers’ diarrhea should be covered next. Since appropriate behavior by the traveler can substantially reduce the risk of many specific travel-related health and safety problems, the remainder of the consultation should consist of education about behavioral and self-treatment strategies (). Protection against insects and strategies for ensuring the safety of food and water are the most important. It is advisable to provide printed instructions (in lay language) because many of these measures will be initiated much later, at the traveler’s destination, and time constraints may preclude detailed discussion in the office. Individual risk factors vary greatly, and not all travelers to a given country will receive the same pretravel recommendations.