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Malaria: Cambodia, Laos, Thailand, Vietnam

One of the most commonly asked questions by first-time travellers to Southeast Asia is "Should I take malarials?". It's a simple question, with a complicated answer, best summed up as "it depends". Here's ten pointers that we hope will help you make a more informed decision regarding malarials and travel to Southeast Asia.

Planning categories

Get an idea, get some money, get insurance, get your documents, get your gear, get packing, get the most out of your trip, get talking, get booking, get out alive, get working, 1) talk to a travel doctor..

Malaria is a serious disease which kills over one million people every year , and the best place to start is with a doctor who is a travel specialist. Your local medical practitioner or family doctor may not have the expertise nor experience to give you an accurate opinion on what you should be doing. " Traveller's Medical Centres " are a growing niche which you should avail yourself of.

If you talk to your doctor, mention Asia and they lunge for the prescription book, without even asking where in Asia you are considering going, then you need to get a more informed opinion .

Dengue fever in Southeast Asia

As a casual visitor to Southeast Asia you're fare more likely to contract Dengue fever than malaria. Click here to learn more about the disease including first hand reports from those who have suffered the virus .

Talking of a more informed opinion, we talked to a tropical medicine specialist we've known for years and here's what he had to say:

"Generally travel medical doctors try to individualise it with the patient and their trip, rather than adopt a "cookbook" approach and a risk assessment model works well here. Basically the factors to be considered and discussed with a client enquiring about malaria tabs are: - the country itself and overall level of risk which includes "official" recommendations from organisations e.g.. WHO - areas travelled to within the country (esp urban or rural) as risks will vary here. This includes level of remoteness and access to medical care - duration of travel - season of travel i.e. wet / dry - style of travel - on a spectrum of rock bottom to 5-star. - the client's own compliance with mosquito avoidance measures - the client's own wishes regarding what level of risk is acceptable -- some want to be "covered for everything" whilst some others don't want tablets even if they're going to a high risk area. It's a moveable feast and not cast in stone. For example: - Previous blanket recommendations for needing prophylaxis for anywhere in India were recently relaxed about one to two years ago. However a recent increase in cases amongst tourists in Goa forced a rethink. - there is good evidence that due to climate change, malaria in Kenya is now occurring at higher altitudes (incl. Nairobi!) at areas and elevations previously considered malaria free. I think the main message is that the decision to take or not take malaria prevention needs to be made by the client after consultation with a travel medicine provider. "

Now here's some other points about the disease you should consider.

2) Malarials do not immunise you from malaria

This is a common misconception. To quote the WHO: " No antimalarial prophylactic regimen gives complete protection ". Malarials do not protect you 100% from malaria, rather they give you more time to get to a medical centre where you will still need to seek further medical treatment. This is certainly the case with doxycycline -- one of the more commonly prescribed medications.

3) An ounce of prevention is worth a pound of cure

Listen to your Grandma -- An ounce of prevention is worth a pound of cure . The best way to avoid being afflicted by malaria is to avoid being bitten by mosquitos and there are a number of simple steps one can take to dramatically reduce the chances of being bitten. These include:

a) Use a permethrin impregnated mosquito net b) Use mosquito repellent containing DEET c) Dress sensibly -- wear long pants and sleeves at dawn and dusk. d) Use mosquito coils or other anti-mosquito devices (e.g.., citronella) as a secondary control. e) If you are prone to being bitten, lean towards accommodation that can be sealed up -- air-con with no slatted windows nor open eaves. f) Watch out for rooms with bucket showers/toilets. These tend to have buckets of stagnant water -- a mozzie's beach resort -- in the bathroom. g) Don't sleep naked in a swamp .

4) Prevention protects you from other nasties

Another potentially fatal disease spread by mosquitos is dengue fever . It should be a far bigger concern to travellers than malaria, but as there's no pills to sell to "protect" you from it, you hear far less about it from the medical industry. In following the steps outlined in point 3 above, you'll also protect yourself from dengue fever.

5) The need for malarials is dependent on where you are going

The US Centre for Disease Control (CDC), an organisation which tends to err on the cautious side, suggests the following areas have malaria risks: Cambodia: Risk throughout the country, including risk in the temple complex at Angkor Wat. No risk in Phnom Penh and around Lake Tonle Sap. Laos: Risk throughout the country, except no risk in the city of Vientiane. Thailand: Risk in rural areas that border Cambodia, Laos, and Burma. Risk in Ko Pha Ngan. No risk in cities and no risk in major tourist resorts. No risk in Bangkok, Chiang Mai, Chiang Rai, Pattaya, Phuket and Ko Samui. Vietnam: Rural only, except no risk in the Red River delta and the coastal plain north of the Nha Trang. No risk in Hanoi, Ho Chi Minh City, Da Nang, Nha Trang, Qui Nhon, and Haiphong.

The WHO makes the following recommendations: Cambodia: Throughout the year in the whole country except in Phnom Penh and close around Tonle Sap. Risk within the tourist area of Angkor Wat is limited. Laos: Throughout the year in the whole country except in Vientiane. Thailand: Throughout the year in rural, especially forested and hilly, areas of the whole country, mainly towards the international borders. There is no risk in cities (e.g. Bangkok, Chiang Mai, Pattaya), Samui island and the main tourist resorts of Phuket island. However, there is a risk in some other areas and islands. Vietnam: Malaria risk exists in the whole country, excluding urban centres, the Red River delta, and the coastal plain areas of central Vietnam. High-risk areas are the highland areas below 1 500 m. south of 18?N, notably in the 4 central highlands provinces Dak Lak, Dak Nong, Gia Lai and Kon Tum, Binh Phuoc province, and the western parts of the coastal provinces, Quang Tri, Quang Nam, Ninh Thuan and Khanh Hoa.

6) Malarials can have nasty side effects

There are four main types of malarials which are prescribed for travel to Asia. They are atovaquone/proguanil (brand name Malarone), doxycycline, mefloquine (brand name Larium) and primaquine. While the majority of travellers take these without problem, each of these can have serious side-effects, including:

Atovaquone/proguanil Stomach pain, nausea, vomiting, and headache.

Doxycycline Sun sensitivity, nausea, stomach pain and vaginal yeast infection. More inconvenient than a touch of sunburn is that doxycycline can render the birth-control pill ineffective. If you are using doxycycline and don't have plans for baby travellers on your immediate horizon, then you will need to use alternative birth control measures.

Mefloquine The most common side effects include headache, nausea, dizziness, difficulty sleeping, anxiety, vivid dreams, and visual disturbances. Rarer, more serious side effects include seizures, depression, and psychosis. We've personally seen individuals bearing the brunt of these side effects and would never suggest anyone take this profilactic for travel in Asia.

Primaquine Stomach cramps, nausea, and vomiting. Primaquine can also cause an hemolysis (bursting of the red blood cells) in G6PD deficient persons, which can be fatal.

That all sounds pretty terrible, but then there's the effects of catching malaria which you need to weight these against: Shaking chills, headaches, muscle aches, tiredness, nausea, vomiting, and diarrhoea. May also cause anaemia and jaundice. Infection with one type of malaria, Plasmodium falciparum , if not promptly treated, may cause kidney failure, seizures, mental confusion, coma, and death .

7) Many mosquitos are malarial resistant

Malaria is an adapting disease and certain areas are resistant to some malarials. To again quote from the CDC:

Cambodia The provinces of Preah Vihear, Siemreap, Oddar Meanchey, Banteay Meanchey, Battambang, Pailin, Koh Kong, and Pursat bordering Thailand are mefloquine resistant -- use only atovaquone/proguanil or doxycycline. All other areas you can use atovaquone/proguanil, doxycycline, mefloquine or primaquine. No risk in Phnom Penh and Tonle Sap.

Laos The provinces of Bokeo, Luang Nam Tha, Salavan and Champassak, along with the areas along the Thai and Burmese borders are all mefloquine resistant -- use only atovaquone/proguanil or doxycycline. All other areas you can use atovaquone/proguanil, doxycycline, mefloquine or primaquine. No risk in Vientiane.

Thailand All of Thailand is mefloquine resistant, use only atovaquone/proguanil or doxycycline. No risk in cities and no risk in major tourist resorts. No risk in Bangkok, Chiang Mai, Chiang Rai, Pattaya, Phuket and Ko Samui.

Vietnam The southern and central part of Vietnam, including rural areas of the provinces of Tay Ninh, Song Be, Lam Dong, Ninh Thuan, Khanh Hoa, Dak Lak, Gia Lai, and Kon Tum are all mefloquine resistant -- use only atovaquone/proguanil or doxycycline. All other areas you can use atovaquone/proguanil, doxycycline, mefloquine or primaquine. No risk in Hanoi, Ho Chi Minh City, Da Nang, Nha Trang, Qui Nhon, and Haiphong.

To boil all that down, if you are going to take malarials, don't take mefloquine as it doesn't cover the entirety of any one of the above countries.

8) Malarials are expensive

Purchased in the west, malarials can be very expensive . While we're not suggesting there's any profiteering going on (perish the thought), there is a definate financial incentive for the pharmaceutical industry to convince you to purchase the pills before you leave home. If you're comfortable using generic medication, malarials are far more affordable in Asia than in the west,so consider spending your money in Asia.

9) Chances are you'll be fine

You're far more likely to have a motorbike accident , have your bag stolen or contract dengue fever than you are to come into contact with malaria. While the local population has some degree of inherited resistance to the disease, there are thousands of foreigners living in Asia who have no such resistance. Very very few of these foreigners, who live in Asia for years, take malarials on a regular basis.

10) Our personal experience

For what it's worth, in our over ten years of living and travelling absolutely all over the region, we've: Been involved in three motorcycle accidents Had some piece of luggage stolen at least three times Know of at least half a dozen people who have had dengue fever Have known not a single person who has contracted malaria Have seen two people (including a Travelfish staffer) totally freak out as a result of taking mefloquine.

In conclusion , if you're planning on stopping by just the main tourist hotspots, using repellent and a mosquito net, dressing sensibly and never sleeping naked in a swamp, then chances are you probably don't need to take malarials. On the other hand, if you're planning on spending a lot of time trekking in remote areas and hanging out in border zones, don't plan to use a mosquito net or repellent and almost certainly plan to sleep in a swamp in your birthday suit once or twice, then availing yourself of a course of malarials would be a prudent decision.

One last point -- if you do decide to take malarials, make sure you take the full course of pills. If you cut it short you're contributing to drug resistant strains of malaria and also endangering yourself.

Further reading

Start by contacting a travel doctor and getting their opinion, then try the following websites for more information: CDC Malaria website WHO malaria website

Planning well is an integral part of getting the most out of your trip. Be it picking the right backpack, the right vaccinations or the right country, the simple decisions are often the most important.

Cambodia malaria indicator survey 2020: Implications for malaria elimination

Affiliations.

• 1 Health and Social Development (HSD), Cambodia.
• 2 National Institute of Public Health (NIPH), Cambodia.
• 3 National Malaria Control Program (CNM), Cambodia.
• 4 University Research Co., LLC, (URC) USA.
• 5 AQUITY Global Inc., (AGI) USA.
• PMID: 34532228
• PMCID: PMC8415051

Background: Cambodia has made significant progress in controlling malaria in the past decade. It now aims to eliminate malaria from the country by 2025. It launched the Malaria Elimination Action Framework (MEAF 2016-2020) in 2015 with strong political commitment targeting appropriate interventions on high-risk populations, particularly mobile and migrant groups.

Methods: In 2020, the household-level Cambodia Malaria Survey 2020 (CMS 2020) was conducted with the objective to assess the performance of malaria control activities using the indicators outlined in MEAF 2016-2020. The survey used a cross-sectional probability proportional to size approach drawing 4,000 households from 100 villages across the malaria-endemic districts of the country.

Results: A total of 3,996 households with 17,415 inhabitants were interviewed. Of the surveyed households, 98.4% owned a long-lasting insecticide-treated bednet or hammock (LLIN/LLIHN). However, only 79.5% of these reported sleeping under a net the previous night, with only 45.7% sleeping under an insecticide treated net (ITN). Given that forest visitors are at the highest risk of getting malaria, the survey also targeted this group. Of the forest visitor respondents, 89.3% brought an ITN along and 88.9% reported to have used a net during their forest stay. About 10.8% of forest goers had received a forest kit for malaria prevention from mobile malaria workers the last time they went to the forest. Knowledge about mosquito repellents was high among forest goers (62.5%) but the actual use thereof during the last visit to the forest was low (22%). While awareness about malaria prevention with LLINs remained high among most respondents, knowledge about malaria diagnosis and treatment was not universal. Source of malaria knowledge and its treatment was usually from a household member, followed by a village malaria worker or a primary health care center staff. Of those who had fever during the previous two weeks, 93.6% sought advice or treatment outside the home, and the most commonly reported source for advice or treatment was private providers (39.4%) followed by health center/district hospital (31.3%).

Conclusions: ITN distribution and other malaria prevention interventions have largely benefited the high-risk groups including the forest visitors. Comparing the CMS 2020 results with the 2017 CMS results, it is clear that forest visitors' use of LLIN/LLIHN has improved considerably. However, more needs to be done to ensure forest visitors be protected either through using LLINs or repellents while working and staying in the forest areas. Also, given that sleeping under LLINs has decreased over the past several years among the at-risk populations, the programme will have to develop strategies to ensure that the communities do not lower their guard against malaria as cases further dwindle in malaria prone areas. Heightened awareness amongst the general population will be critical for eliminating malaria in Cambodia without any possibility of malaria re-emergence or re-establishment.

Copyright © 2021 Kheang et al.

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Accelerating malaria elimination in Cambodia: an intensified approach for targeting at-risk populations

Siv sovannaroth.

1 National Center for Parasitology, Entomology and Malaria Control (CNM), Phnom Penh, Cambodia

Pengby Ngor

2 Clinton Health Access Initiative, Phnom Penh, Cambodia

Julia C. Dunn

Michelle k. burbach, sovann peng.

3 Catholic Relief Services, Phnom Penh, Cambodia

4 PSI, Phnom Penh, Cambodia

5 USAID/PMI/URC, Phnom Penh, Cambodia

Giulia Manzoni

6 World Health Organization, Phnom Penh, Cambodia

Jean Olivier Guintran

Luciano tuseo, associated data.

National malaria surveillance data available at https://mis.cnm.gov.kh/ . Intensification Plan data available upon reasonable request to the National Center for Parasitology, Entomology and Malaria Control (CNM), Phnom Penh, Cambodia.

Malaria in Cambodia has decreased by 90.8% between 2010 and 2020, driven by the commitment of the National Center for Parasitology, Entomology and Malaria (CNM) and the achievements of the roll-out of a village malaria worker programme. However, in the first seven months of 2018, CNM identified a 207% increase (11,969 to 36,778) in confirmed malaria cases compared to the same months in the previous year. To address this increase, CNM developed the “Intensification Plan” (IP), implemented between October 2018 and December 2020.

The structure of the IP was summarized, including the selection of sites, the interventions implemented in the selected health facility catchment areas (HFCAs) and the monitoring and evaluation process. Data on IP interventions were collected by CNM and civil society organisations. Data on malaria cases and tests from all HFCAs in Cambodia from January 2018 to December 2020 were sourced from the Cambodia Malaria Information System (MIS) and WHO Malaria Elimination Database. Malaria data from IP HFCAs and non-IP HFCAs was analysed and compared to present the changes in malaria testing and confirmed cases before and during implementation of the IP.

Between October 2018 and December 2020, through the IP 16,902 forest packs and 293,090 long-lasting insecticide treated nets were distributed. In the 45 HFCAs included in the IP, 431,143 malaria tests were performed and 29,819 malaria cases were diagnosed, 5364 (18%) of which were Plasmodium falciparum /mixed cases. During the intervention period, over all HFCAs included in IP, P. falciparum /mixed cases declined from 1029 to 39, a 96.2% decrease, and from 25.4 P. falciparum /mixed cases per HFCA to 0.9. HFCAs not included in IP declined from 468 to 43 cases, a 90.8% decrease, showing that routine malaria activities in Cambodia were also playing an important contribution to malaria control.

Conclusions

Over the course of IP implementation there was a substantial increase in malaria testing and both overall malaria cases and P. falciparum /mixed cases decreased month on month. The initiative yields lessons learned for Cambodia to reach the final stage of elimination as well as for other countries aiming to accelerate their malaria control programmes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12936-022-04234-2.

Cambodia has made significant progress in malaria control over the last decade. Confirmed malaria cases declined from 106,228 to 9771 cases between 2010 and 2020, a 90.8% decrease. Cambodia still accounted for 13.4% of cases in the Southeast Asia region in 2020 [ 1 , 2 ], and has received particular attention from the global malaria community since artemisinin resistance was confirmed in 2008 [ 3 ], requiring continued vigilance and rapid malaria control to ensure resistance does not derail Cambodia’s elimination efforts or spread to other global regions. In 2011, the National Strategic Plan for Malaria Elimination (NSP 2011–2025) was signed by the Prime Minister, setting the ambitious goal of achieving malaria elimination in Cambodia by 2025 [ 4 ].

In Cambodia, from 2010 to 2014 malaria cases reduced by 47% [ 1 ] and malaria-related deaths reduced by 88.1% (151 to 18) [ 5 ]. This decline was attributed to distribution of insecticide-treated nets (ITNs) as well as the high number of tests performed and cases detected through the village malaria worker (VMW) programme, introduced in 2004 [ 6 ]. As malaria cases have decreased in Cambodia, infection has become increasingly focal in hotspots across the country and in populations that are routinely harder to reach and further from points of care [ 3 , 7 , 8 ]. According to the 2013 Cambodia Malaria Indicator Survey, forest-goers (people who work and/or sleep in the forest) and those who travelled had higher odds of malaria infection diagnosed through PCR (odds ratio of 5.8 and 2.3, respectively) [ 9 ]. Forests represent a hot spot for malaria transmission and, therefore, mobile and migrant populations involved in forest activities are at high risk of contracting the disease [ 10 ].

The VMW programme was suspended from 2014 to 2017. The years following 2014 saw a substantial increase in malaria cases, with a particularly large increase of 102% between 2016 and 2017 [ 11 ]. Following the reinstatement of the VMW programme, this increase continued into 2018, culminating in a 207% increase (11,969 to 36,778) in cases January–July 2018 compared to 2017 [ 11 ]. This was likely facilitated by a 35% increase in testing (213,585 to 289,325) between 2017 and 2018 [ 12 ]. The Malaria Elimination Action Framework (MEAF) 2016–2020 [ 1 ], written by the National Center for Parasitology, Entomology and Malaria (CNM), highlighted the implementation of aggressive approaches to reduce malaria in high-risk populations. Informed by the MEAF, to combat this high level of cases, CNM, the Ministry of Health (MoH) and the World Health Organization (WHO) determined that an intensive response was required that targeted hotspots of increased malaria transmission. This plan eventually came to be known as the “Intensification Plan” (IP). The IP took place from October 2018 to December 2020 in 45 health facility catchment areas (HFCAs) across Cambodia.

In this paper, the methods of the Intensification Plan, including objectives, sites, interventions, and M&E through routine data collection and monthly data reviews are presented. Both routine malaria surveillance data and data collected specifically for the IP are used to present the achievements of the IP and analyse change in malaria cases, with a focus on Plasmodium falciparum /mixed infections, both in the IP HFCAs themselves and in comparison to the rest of the country.

Objectives of the Intensification Plan

The IP had two objectives aimed at reducing transmission in the areas of the country with the highest malaria burden: (1) improving programme coordination to ensure full implementation of the country’s Malaria Elimination Action Framework (MEAF) (2016–2020) and (2) implementing aggressive approaches to deploy interventions that would rapidly reduce the parasite reservoir among high-risk populations. The IP focused on reaching forest goers and migrant and mobile populations (MMPs) who may enter the forest for logging or other economic purposes and can stay in the forest for up to 2 weeks on each trip. The first phase of IP (IP1) took place from October 2018 to October 2019. The second phase of IP (IP2) took place from November 2019 to December 2020.

To determine the geographical area of intervention, CNM and partners used MIS data to identify provinces, operational districts (ODs) and villages with the highest reported burden of malaria cases. IP1, seven provinces and nine ODs were selected (Fig.  1 ). In the selected ODs, the 30 highest burden HFCAs were chosen to be included in IP. These 30 HFCAs accounted for 75% of all malaria cases in the country in 2018 and 2019. Sites were reselected at the beginning of IP2; six out of seven provinces remained the same, with one change replacing Preah Vihear for Preah Sihanouk given improvement in the situation in Preah Vihear. 12 ODs with the highest P. falciparum cases (as opposed to malaria cases of any species) were selected and 36 HFCAs within these 12 ODs. These HFCAs represented 77% of P. falciparum cases in the country from January 2018 to June 2019 and was deemed the maximum number of HFCAs that was programmatically feasible to run and manage the intensified activities. Overall, 45 HFCAs were included over the duration of the IP; 21 HFCAs in both IP1 and IP2, 9 HFCAs in IP1 only and 15 HFCAs in IP2 only. The full list of HFCAs included in IP are provided in Additional file 1 : Table S1. CNM used the MIS data and consultations with each HFCA to identify “village hotspots”, areas where at-risk populations of forest-goers resided or transited through. These 141 hotspots (Additional file 1 : Table S1) became the focus geography sites for the IP to conduct interventions. Each site received technical support from CNM, the World Health Organization (WHO), the Clinton Health Access Initiative (CHAI), and from a Civil Society Organization based in the corresponding geographic area, namely Catholic Relief Services, CARE, Population Services International (PSI), University Research Co. (URC).

Selected sites to receive Intensification Plan interventions and number of mobile malaria workers (MMWs) assigned based on identified malaria hotspots

Interventions

Under the primary objective of the IP, implementing ODs were provided additional support from CNM, WHO and CSOs to improve programme coordination and ensure the effective implementation of case management, including high levels of malaria testing, complete treatment for all those diagnosed with malaria, and effective referral for any severe cases. At the beginning of each phase of IP, long-lasting insecticide treated nets (LLINs) were distributed to any households in the target villages that did not have enough (less than one net per 1.8 people). Additional LLINs were then available for continuous distribution over the course of the IP. The IP included additional technical support and supervision from CNM to ODs, verifying optimal coverage of LLINs in the villages with high incidence and ensuring full attendance at VMW monthly meetings. VMWs conducted monthly meetings to set testing targets and refill case management supplies. ODs were encouraged to attend the meetings to review data and coach on performance.

The second objective of the IP was to implement aggressive approaches to target high-risk populations and hasten the decline of P. falciparum cases in the target sites. The main intervention was hiring additional MMWs that were targeted to IP sites and identified hotspots. MMWs were based closer to forested areas where MMPs usually travel and conducted specialized activities focused on forest workers and mobile migrant populations. Performance of MMWs was continuously tracked through monthly VMW/MMW meetings. MMWs also attended several trainings over the course of IP to ensure their knowledge on testing and treating of malaria was up to date and to expand their toolkit (e.g. adding paracetamol and mebendazole to treat those testing negative for malaria). There were also a certain number of MMWs within the targeted sites that were not managed through CNM and the IP, but through the Malaria Consortium [ 13 ]. In the following analyses these MMWs are deemed MMW (Not IP).

Responsibilities of MMW included the following:

• Test: Perform rapid diagnostic tests (RDTs) on all suspected cases according to CNM’s criteria, namely anyone with fever or who had travelled to the forest in the last 1 week.
• Treat: Provide anti-malarial treatment according to national guidelines, including single low dose primaquine (SLDP) for all P. falciparum /mix cases in eligible individuals [ 14 ]. The IP expanded access to SLDP for non-pregnant, non-breastfeeding individuals weighing 20 kg and above, where previously the weight requirement was 50 kg, and actively followed-up with MMWs to ensure all P. falciparum /mix cases had received SLDP.
• Track: Keep complete records of all activities including patient consultations on case reporting forms, active case detection (ACD) activities, questionnaires, and forest pack registries.
• Refer: Refer severe cases to health facilities immediately.
• Malaria knowledge: Attend trainings and routine monthly meetings for VMW/MMW to ensure good knowledge of malaria diagnosis and treatment.
• Work over extended hours especially when forest-goers are active, this means being accessible 24 h if a patient requests a service.
• Active test and treat: Twice a month, travel to malaria hot spots in the forest to conduct ACD.
• Commodity supply: Keep adequate stocks of RDTs and malaria drugs; attend monthly meetings to report stock status, provide paper reports, and replenish stocks.
• Forest pack distribution: Distribute forest packs to target populations. Forest packs included a backpack, information, education and communication/behavior change communication (IEC/BCC) materials, a hammock net, and (added in IP2) insect repellent. Insect repellent top-ups were also available. The first forest pack distribution took place in May 2019.
• Perform IEC/BCC activities: Lead information sessions to educate the community about malaria signs and symptoms, provide health education to patients during consultations, play loudspeaker recordings regularly and display educational posters.
• Offering optional products for negative malaria cases , such as paracetamol for fever reduction and mebendazole for de-worming according to national treatment guidelines (IP2 only).
• Identifying co-travellers: any MMP that testing positive was asked by the MMW for the contact information of their co-travellers. The co-travellers were invited for testing and were provided malaria prevention messages (IP2 only).

For MMWs to perform their responsibilities effectively, the supply chain for RDTs, artemisinin combination therapies (ACTs) (artesunate-mefloquine [ASMQ] and primaquine) and forest packs needed to be improved. At central level, CNM and key partners such as UNOPS, WHO and the implementing CSOs joined together to conduct monthly supply chain meetings to ensure the pipeline of supplies was being accurately forecasted, ordered and distributed timely to subnational levels, in coordination with the Central Medical Stored and subnational partners. The working group also monitored corresponding supplies that MMW need such as weight scales, thermometers, gloves and uniforms for MMW to identify themselves (in IP2).

In non-IP sites, the national surveillance and case management guidelines were followed. Briefly, standard of care was RDT or microscopy testing of all suspected cases, ACT treatment for all cases ( P. falciparum , Plasmodium vivax and mixed infections), SLDP for P. falciparum /mix cases, and referral to a hospital for any severe cases. VMWs were situated in the highest burden villages, informed by the national stratification (3025 in 2018, 3376 in 2019, 3675 in 2020). All malaria cases from HCs were entered into the MIS at the time of diagnosis and all cases from VMWs were entered on a monthly basis, after the monthly VMW meetings which also served as regular supervision of VMWs.

For the majority of the IP period, radical cure was not available in Cambodia and P. vivax cases were treated with ACT. From November 2019 to December 2020, radical cure was piloted in four provinces, one of which (Kampong Speu) was also included in IP. Over the pilot, any adult male P. vivax cases were referred to the nearest HC and tested for G6PD deficiency. If they were G6PD normal they were treated with 14-day primaquine. All other cases were treated with ACT.

Monitoring and evaluation

Data on malaria testing and cases was routinely entered into the data management system by health centres (HCs), VMWs and MMWs. Each partner involved in IP also collected malaria testing and case data, disaggregated by cadre, in a “CSO Scorecard” to send to CNM and verify against their data, as well as data on IP interventions such as number of forest packs distributed, number of ACD visits and attendance at VMW/MMW monthly meetings. MIS data was compared to CSO Scorecard data and any errors or discrepancies (for example—missing data, more cases than tests, incorrect summation of malaria species to total cases) were clarified with the CSO and corrected in the relevant database. Central CNM staff, with support of WHO and CHAI, analysed the malaria data on a monthly basis (including mapping case data to track any changes in malaria epidemiology). CNM led partner meetings for problem solving and decision making. These “Data Review and Action Meetings” had the goal to provide consistent data review, providing feedback to CSOs and facilitating timely action such as responding to stock outs and flagging HCs/MMWs not performing the target number of outreach visits.

Data analysis

The timeline for data analysis covers pre-IP (January 2018–September 2018), IP1 (October 2018–October 2019) and IP2 (November 2019–December 2020). Data were collated from the CSO Scorecards, the Cambodia Malaria Information System (MIS) and from the WHO Malaria Elimination Database (MEDB) for all HFCAs in Cambodia. This includes IP intervention data (number of MMWs, number of MMW outreach visits, forest packs distributed, LLINs distributed, repellents distributed) and malaria epidemiology data (tests, treatments, cases). Information on forest packs was collected throughout the IP using “MMW Forest Pack questionnaires”. In March 2020, a review of these questionnaires was conducted, providing further information on forest pack distribution during IP.

To analyse whether the IP had been a factor in driving a decline in malaria cases in the implementing HFCAs, the change in P. falciparum /mix cases was compared before and during IP. For this analysis, HFCAs were treated as an IP HFCA if they had been included in any phase of IP (n = 45). Firstly, a segmented interrupted time series was carried out by fitting separate Poisson regression models (log link) to P. falciparum /mix cases in (1) Non-IP HFCAs, (2) IP HFCAs (pre-IP rollout) and (3) IP HFCAs (post-IP rollout). The counterfactual trend for IP HFCAs was extrapolated with the pre-IP intercept and gradient parameters. Secondly, a controlled interrupted time series analysis was carried out by fitting a Poisson regression model to P. falciparum /mix cases in IP HFCAs with fixed terms for month (to account for seasonality), P. falciparum /mix cases in non-IP HFCAs (to control for decline outside of IP) and timepoint interacting with IP Phase (pre/post IP rollout). To account for autocorrelation, standard errors and confidence intervals were calculated with the Newey-West method with a lag of 1. A formula published by Altman and Bland [ 15 ] was used to calculate the statistical significance of the difference between rate ratios. Data analysis was completed and figures prepared using RStudio (v 4.0.2, Vienna, Austria).

To track the deployment of IP interventions and assess epidemiological impact, data was reported to by all health cadres. If monthly data had not been submitted, they were actively followed up by central CNM staff and the responsible CSO. As such, reporting completeness from HCs was 100% over the course of the IP. Data from VMWs and MMWs were collated during monthly meetings. These meetings were tracked via IP surveillance. 788 VMW/MMW meetings out of a possible 893 (88.2%) took place over the course of the IP, attendance was 90.4%. Reporting completeness from VMWs and MMWs was lower than HCs, at 82.2% over the course of IP. There was a drop-off in reporting completeness from VMWs and MMWs between IP1 and IP2, from 96 to 84%.

Intensification Plan interventions

To reinforce the implementation of the interventions, 141 MMWs (one per village) were recruited over the IP, with an average of 8.8 MMWs active per OD. Over the course of the IP 16,902 forest packs and 293,090 LLINs were distributed (Table ​ (Table1). 1 ). The forest-pack survey shows that between May 2019 (when forest packs were distributed) and March 2020 78.7% of MMPs sleeping overnight in the forest had received a forest pack from a MMW; 71.8% of eligible P. falciparum /mix cases received SLDP, increasing from 65.4% in IP1 to 86.7% in IP2. The proportion of correctly treated P. falciparum /mix infections was variable across provinces; from 80.7% in Pursat to 62.1% in Stung Treng.

Malaria cases and interventions over the intensification plan (IP), stratified by IP phase and province

HF: health facility; Pf/mix: Plasmodium falciparum /mixed; SLDP: single low-dose primaquine; MMW: mobile malaria worker; LLIN: long-lasting insecticide treated net

*Patients were eligible for SLDP treatment if they weighed over or equal to 20 kg, weren’t pregnant and weren’t breastfeeding. Data on Pf/mix cases eligible for treatment shows some discrepancies so has not been included

**Insect repellent top-ups were available when MMPs ran out, this is why number of repellents is higher than number of forest packs

Over the course of IP 431,143 malaria tests were performed (Table ​ (Table1), 1 ), the majority of these tests were performed by VMWs (47.4%) and IP MMWs (23.4%) (Fig.  2 ). Between the two phases of IP, testing increased by 101.6% with average tests per HC per month increasing from 366.5 to 571.9. HCs had the highest positivity rate at 16.2%, followed by VMWs (7.2%), MMWs (3.7%) and MMWs not hired through IP (2.4%). Of the total tests conducted during IP, 81,462 (18.9%) were during ACD activities with a test positivity rate (TPR) of 2.5%.

Number of malaria tests performed in intensification plan (IP) health facility catchment areas before and during IP, stratified by health cadre. Total: All tests (cadre disaggregation not available for pre-IP data); HC: health center; MMW (Not IP): mobile malaria workers in IP sites but not managed directly through IP, MMW: mobile malaria workers managed through IP; VMW: volunteer malaria worker. Pre-IP includes IP Phase 1 HFCAs only. IP Phase 1 (30 HFCAs), IP Phase 2 (36 HFCAs)

Malaria epidemiology

Over IP there were 29,819 malaria cases diagnosed, 5817 (19.5%) of which were P. falciparum /mix cases (Fig.  3 ). Between IP1 and IP2 P. falciparum /mix cases decreased by 76.9% (4725 to 1092) and from 12.1 cases per HFCA per month to 2.2. In the 30 IP1 HFCAs, P. falciparum /mix cases decreased from 762 to 284 (62.7%) from October 2018 to October 2019. In the 36 IP2 HFCAs cases decreased from 278 to 23 (91.7%) from November 2019 to November 2020.

Number of Plasmodium falciparum /mix malaria cases (grey bars) and test positivity rate (TPR—red solid line) in intensification plan (IP) health facility catchment areas (HFCAs) over the course of the IP. Left of black dotted line: IP Phase 1 (30 HFCAs); right of black dotted line: IP Phase 2 (36 HFCAs)

Plasmodium falciparum /mix cases decreased on a HFCA level as well as overall (Fig.  4 ). In the first three months of IP1 there were 63.5 P. falciparum /mix cases per IP1 HFCA. This declined to 23.4 in the last three months of IP1 with 15 HFCAs with zero P. falciparum /mix cases in this time. Over IP2, there were 14.8 P. falciparum /mix cases per IP2 HFCA in the first three months of IP2, dropping to 2.25 in the last three months of IP2 and 19 HFCAs with zero P. falciparum /mix cases in those three months.

Number of Plasmodium falciparum /mix malaria cases (red dots) in intensification plan (IP) health facility catchment areas (HFCAs). Left) Beginning of IP (IP1 HFCAs)—October 2018 and Right) End of IP (IP2 HFCAs)—October 2020. Blue polygons: IP operational districts; green polygons: non-IP operational districts

On an OD level, the annual parasite incidence per 1000 people (API) in 2018 was 7.7 in IP ODs and 0.3 in non-IP ODs. By 2020 this had decreased to 0.4 in IP ODs (94.7%) and 0.01 in non-IP ODs (96.4%). Non-IP ODs in the same province as IP ODs saw a greater decrease in API than ODs in other provinces (99.5% and 95.9%, respectively), suggesting a spillover effect of the IP interventions into neighbouring areas, possibly due to the IP interventions targeting MMPs, such as forest-goers, that may spread malaria beyond high transmission areas.

The IP was targeted at the HFCAs with the highest burden of P. falciparum /mix cases in Cambodia in an attempt to hasten the reduction of cases and achieve elimination. Figure  5 shows the cumulative P. falciparum /mix cases from all HFCAs in Cambodia, stratified by whether they are non-IP HFCAs (n = 897) or IP HFCAs (irrespective of IP phase, n = 45). The change in cases over the IP periods (pre and during IP) were quantified by rate ratios (RR). From a controlled interrupted time series analysis, incorporating non-IP HFCAs as a control and adjusting for seasonality, the RR pre-IP was 0.90 (95% CI 0.86–0.93, p  < 0.0001) and during IP was 0.88 (95% CI 0.86–0.89, p  < 0.0001). The difference between the two RRs is not statistically significant ( p  = 0.3). This indicates that, even for controlling for the decline in areas where IP was not carried out, IP areas were experiencing a decline in malaria cases. There is evidence for an acceleration in decline, a reduction in the RR, post-IP but the difference is not statistically significant.

Cumulative number of P. falciparum /mix cases in all health facility catchment areas (HFCAs) in Cambodia. Black dashed line: rollout date of IP. Red: IP HFCAs (n = 45); Blue: Non-IP HFCAs (n = 897). Red dashed line: extrapolated counterfactual from pre-IP model. HFCAs are classified as an IP HFCA if they were included in either/both of Phase 1 or Phase 2

While malaria cases increased by more than 100% from 2016 to 2017, over the course of the Intensification Plan (October 2018 to December 2020) there was a 91.6% decline in malaria cases nationwide [ 11 ] with a 95.7% decline in IP HFCAs alone. Whilst causality between IP interventions and the change in malaria cases cannot be guaranteed, there has been a substantial decline in malaria cases in the IP HFCAs. This decline has been concurrent with a decline in non-IP HFCAs. Results from the statistical analysis indicates that there was a reduction in IP areas on top of the reduction seen in non-IP areas. There is evidence that the rate of malaria decline accelerated post rollout of IP, however there is no statistical difference between the RRs pre and during IP. One interpretation of these results is that whilst IP has not caused a reduction that is faster than in non-IP HFCAs, it has brought the IP HFCAs in line with the already impressive reduction in malaria cases in the rest of the country. Areas that were once struggling with malaria control have received the added boost they required to be in line with national malaria decline. P. falciparum /mix cases remain clustered in mostly the same HFCAs as when IP began, 63.2% of reported P. falciparum /mix cases in 2021, were in HFCAs included in IP. However, the impact of IP in the HFCAs has been sustained after it ended; of the 45 HFCAs included in IP, 17 reported zero P. falciparum /mix cases in 2021 and a further 17 have reported less than five P. falciparum /mix cases.

Evidence from both malaria surveillance and research studies indicate that malaria infection is becoming increasingly focalized in specific populations and that onwards transmission is perpetuated by those deemed “hard-to-reach” [ 16 , 17 ]. The IP took a novel approach to fill this gap by expanding the number of MMWs and targeting their operations towards to the highest burden areas. The increased flexibility of MMWs, both through their base location and through the services they could provide (distributing forest packs, mebendazole and paracetamol) allowed them to access groups of people that were previously missed by HCs and VMWs. Throughout the IP, MMWs contributed 23.4% of tests and 12.7% of malaria cases. Several other operational and research studies have examined the effectiveness of MMW or forest malaria workers (FMWs) in Cambodia, finding similar results that MMWs are able to achieve high testing rates and reach those populations deemed at most risk of malaria infection [ 13 , 18 ]. It is clear that engagement of the target populations, who may be engaging in illegal forest-based activity, is required to ensure these more mobile workers are accepted and trusted [ 18 ].

Whilst the application of new and expanded malaria control interventions was a major advantage of the IP, another focus from CNM was to improve the use of data through monitoring and evaluation. Included in training of HCs, VMWs and MMWs was a particular focus on routine data reporting and how that data would be used to continually monitor performance and rectify issues. The IP initiated a data review and action cycle that brought together CNM and all implementing partners to share and analyse data on a monthly basis. The meeting allowed all parties to share challenges from the field, propose solutions and collectively determining the priorities for the upcoming month. Through this mechanism all partners have transparency, accountability and a shared vision of addressing the most critical and urgent issues. A major achievement of the IP has been to strengthen monitoring, evaluation and response using timely data to ensure interventions are being implemented to reach the forest goer populations in Cambodia. Such a strong focus on M&E resulted in 100% data reporting from the IP health centres.

The IP focused on the reduction of P. falciparum /mix malaria cases. Due to the nationwide reduction in these cases, P. vivax is now the dominant malaria species in Cambodia, 86.5% of total cases in 2020 [ 11 ], and is targeted for elimination by 2025. In this analysis we have focused on P. falciparum /mix cases, however, from October 2018 to October 2020 P. vivax cases in the 45 IP HFCAs also decreased by 84.9%. Ensuring effective case management, vector control and universal access to care is not malaria species specific. As such, interventions such as those included in the IP are necessary for P. vivax elimination as well as P. falciparum . Following a pilot in 2019, radical cure for P. vivax through primaquine treatment was scaled-up nationwide in December 2020. The strengthening of the VMW programme through programmes such as IP will support other interventions, such as radical cure, through well-trained VMWs and a strong data collection pathway.

The implementation of IP faced several operational challenges. Delays in procurement of repellents meant that the distribution of forest packs happened after May 2019, and repellents were only distributed as part of IP2. While IEC/BCC messages were recorded and distributed on loudspeakers for MMWs to play in the forest, more effort is required to measure the impact of IEC/BCC activities and how they can be better targeted in future programmes. Given the transient nature of MMP and often illegal activities conducted in the forest, it can be difficult to reach the target population with IEC messages. The rainy season in remote areas may have caused data to be delayed in entering into MIS where it was captured in the following month, which can prevent timely analysis and response during these periods. Finally, as with all health programmes, the emergence of the COVID-19 pandemic at the beginning of 2020 impacted the implementation of both routine and IP malaria programmes. For example, in-person meetings with VMWs and MMWs were adapted to COVID-19 measures (e.g. solo instead of group meetings, held in open spaces) and health workers in some areas were reassigned from malaria to COVID activities (e.g. testing and quarantine). CNM applied mitigation measures in accordance with the national guidance on COVID-19 issued by the Royal Government of Cambodia and took steps to limit the exposure of health personnel to COVID-19 including procurement of personal protective equipment and reducing subnational travel [ 19 ]. Another limitation of the analysis is the potential impact that COVID-19 may have had on malaria transmission and epidemiology. Cambodia closed its borders in March 2020 and inter-province travel was restricted. This could have impacted malaria transmission due to reduced travel between high-risk areas. However, as there were very few reported COVID cases over the course of 2020 in Cambodia, travel did not seem to be severely impacted and this has not been treated as a significant factor to explain malaria decline. There was also a brief reduction in malaria testing between March and April, however testing remained above pre-pandemic levels. In the analysis presented here how malaria cases changed over the course of the IP, and in comparison to areas not included in IP, has been described. However, causality between IP and decline in malaria cases cannot be guaranteed as other factors, such as climate, have not been included in the analysis.

CNM initially aimed to achieve elimination of P. falciparum by 2020, however this has now been extended to 2023 [ 3 ]. Valuable lessons were learned from the IP which will be applied to achieve this goal, namely the importance of targeting forest-based populations and the importance of the VMW/MMW cadre. At the end of 2020, CNM, technically supported by WHO, are implementing a programme known as “last mile”, reinforcing foci management activities to accelerate malaria elimination [ 20 , 21 ]. Based on the vulnerability and receptivity of active foci, additional interventions are implemented. This includes targeted drug administration and intermittent preventive treatment for at-risk populations, as well as weekly fever screening of village-based populations and LLIN/LLIHN distribution. In addition, continuing to support routine malaria case management and surveillance remains essential in achieving elimination. CNM, WHO and CSOs will continue to work to build capacity of health staff at all levels, as well as implementing strong financial management and operational planning to ensure all activities, both routine and one-off, are implemented on time and to the highest standard.

Through population-targeted activities and routine use of malaria surveillance data P. falciparum /mix cases declined by 97.4% (1029 to 27) between October 2018 and October 2020 in the 45 IP HCs. CNM will continue to focus on capacity building for HCs, VMWs and MMWs to determine malaria hotspots as well as fostering collaboration with HCs and local authorities to better track and target MMPs to provide preventive and treatment services. Vector control and raising awareness of malaria prevention and treatment to MMPs and forest goers are continuing priorities for the last mile of malaria elimination in Cambodia.

Acknowledgements

The authors are grateful to the staff from the respective Provincial Health Districts, Operational Districts, Health Centres participating in the intensification plan. Village Malaria Workers and Mobile Malaria Workers who conducted the package of interventions deserve appreciation. The authors also acknowledge the United Nations Office for Project Services (UNOPS) for their contributions to financial management and procurement.

Abbreviations

Author contributions.

SS, HR, MB, GM, JOG, LT conceived and designed the interventions; SS, SP, SM, KS implemented the interventions. SS, PN, SP, SM, KS, VK carried out data collection, data entry and data cleaning. SS, MB, VK, JD conceptualized the manuscript and designed the analysis. VK and JCD carried out the analysis. SS, MB, VK, JCD drafted the manuscript. All authors reviewed and edited the manuscript. All authors read and approved the final manuscript.

Funding for the Intensification Plan was provided by the Global Fund to Fight AIDS, Tuberculosis and Malaria. This work was supported, in part, by the Bill and Melinda Gates Foundation [Grant Number INV-002736]. Under the grant conditions of the Foundation, a Creative Commons Attribution 4.0 Generic License has already been assigned to the Author Accepted Manuscript version that might arise from this submission. The findings and conclusions contained within are those of the authors and do not necessarily reflect positions or policies of the Bill & Melinda Gates Foundation. The funders had no role in the study design, data collection, data analysis, interpretation or writing the manuscript.

Availability of data and materials

Declarations.

Not applicable.

The authors declare no competing interests.

Publisher's Note

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• Section 2 - Interactions Between Travel Vaccines & Drugs
• Section 2 - Travelers’ Diarrhea

Yellow Fever Vaccine & Malaria Prevention Information, by Country

Cdc yellow book 2024.

Author(s): Mark Gershman, Rhett Stoney (Yellow Fever) Holly Biggs, Kathrine Tan (Malaria)

The following pages present country-specific information on yellow fever (YF) vaccine requirements and recommendations, and malaria transmission information and prevention recommendations. Country-specific maps are included to aid in interpreting the information. The information in this chapter was accurate at the time of publication; however, it is subject to change at any time due to changes in disease transmission or, in the case of YF, changing entry requirements for travelers. Updated information reflecting changes since publication can be found in the online version of this book and on the Centers for Disease Control and Prevention (CDC) Travelers’ Health website. Recommendations for prevention of other travel-associated illnesses can also be found on the CDC Travelers’ Health website .

Yellow Fever Vaccine

Entry requirements.

Entry requirements for proof of YF vaccination under the International Health Regulations (IHR) differ from CDC’s YF vaccination recommendations. Under the IHR, countries are permitted to establish YF vaccine entry requirements to prevent the importation and transmission of YF virus within their boundaries. Certain countries require proof of vaccination from travelers arriving from all countries ( Table 5-25 ); some countries require proof of vaccination only for travelers above a certain age coming from countries with risk for YF virus transmission. The World Health Organization (WHO) defines areas with risk for YF virus transmission as countries or areas where YF virus activity has been reported currently or in the past, and where vectors and animal reservoirs exist.

Unless issued a medical waiver by a yellow fever vaccine provider, travelers must comply with entry requirements for proof of vaccination against YF.

WHO publishes a list of YF vaccine country entry requirements and recommendations for international travelers approximately annually. But because entry requirements are subject to change at any time, health care professionals and travelers should refer to the online version of this book and the CDC Travelers’ Health website for any updates before departure.

CDC Recommendations

CDC’s YF vaccine recommendations are guidance intended to protect travelers from acquiring YF virus infections during international travel. These recommendations are based on a classification system for destination-specific risk for YF virus transmission: endemic, transitional, low potential for exposure, and no risk ( Table 2-08 ). CDC recommends YF vaccination for travel to areas classified as having endemic or transitional risk (Maps 5-10 and 5-11 ). Because of changes in YF virus circulation, however, recommendations can change; therefore, before departure, travelers and clinicians should check CDC’s destination pages for up-to-date YF vaccine information.

Duration of Protection

In 2015, the US Advisory Committee on Immunization Practices published a recommendation that 1 dose of YF vaccine provides long-lasting protection and is adequate for most travelers. The recommendation also identifies specific groups of travelers who should receive additional doses, and others for whom additional doses should be considered (see Sec. 5, Part 2, Ch. 26, Yellow Fever ). In July 2016, WHO officially amended the IHR to stipulate that a completed International Certificate of Vaccination or Prophylaxis is valid for the lifetime of the vaccinee, and YF vaccine booster doses are not necessary. Moreover, countries cannot require proof of revaccination (booster) against YF as a condition of entry, even if the traveler’s last vaccination was >10 years ago.

Ultimately, when deciding whether to vaccinate travelers, clinicians should take into account destination-specific risks for YF virus infection, and individual risk factors (e.g., age, immune status) for serious YF vaccine–associated adverse events, in the context of the entry requirements. See Sec. 5, Part 2, Ch. 26, Yellow Fever , for a full discussion of YF disease and vaccination guidance.

Table 2-08 Yellow fever (YF) vaccine recommendation categories 1

Malaria prevention.

The following recommendations to protect travelers from malaria were developed using the best available data from multiple sources. Countries are not required to submit malaria surveillance data to CDC. On an ongoing basis, CDC actively solicits data from multiple sources, including WHO (main and regional offices); national malaria control programs; international organizations; CDC overseas offices; US military; academic, research, and aid organizations; and the published scientific literature. The reliability and accuracy of those data are also assessed.

If the information is available, trends in malaria incidence and other data are considered in the context of malaria control activities within a given country or other mitigating factors (e.g., natural disasters, wars, the coronavirus disease 2019 pandemic) that can affect the ability to control malaria or accurately count and report it. Factors such as the volume of travel to that country and the number of acquired cases reported in the US surveillance system are also examined. In developing its recommendations, CDC considers areas within countries where malaria transmission occurs, substantial occurrences of antimalarial drug resistance, the proportions of species present, and the available malaria prophylaxis options.

Clinicians should use these recommendations in conjunction with an individual risk assessment and consider not only the destination but also the detailed itinerary, including specific cities, types of accommodations, season, and style of travel, as well as special health conditions (e.g., pregnancy). Several medications are available for malaria prophylaxis. When deciding which drug to use, consider the itinerary and length of trip, travelers’ previous adverse reactions to antimalarials, drug allergies, medical history, and drug costs. For a thorough discussion of malaria and guidance for prophylaxis, see Sec. 5, Part 3, Ch. 16, Malaria .

Afghanistan

Entry requirements : None

CDC recommendations : Not recommended

• All areas <2,500 m (≈8,200 ft) elevation (April–December)
• Chloroquine
• P. vivax  (primarily)
• P. falciparum (less commonly)
• Atovaquone-proguanil, doxycycline, mefloquine, tafenoquine 3

Other Vaccines to Consider

See Health Information for Travelers to Afghanistan

Entry requirements : Required for travelers ≥1 year old arriving from countries with risk for YF virus transmission 1

No malaria transmission

See Health Information for Travelers to Albania

Entry requirements : Required for travelers ≥9 months old arriving from countries with risk for YF virus transmission; this includes >12-hour airport transits or layovers in countries with risk for YF virus transmission. 1

See Health Information for Travelers to Algeria

American Samoa (US)

See Health Information for Travelers to American Samoa

See Health Information for Travelers to Andorra

Entry requirements : Required for arriving travelers  ≥9 months old

CDC recommendations : Recommended for all travelers ≥9 months old

• P. falciparum (primarily)
• P. malariae , P. ovale , and P. vivax (less commonly)

See Health Information for Travelers to Angola

Anguilla (U.K.)

See Health Information for Travelers to Anguilla (U.K.)

See Health Information for Travelers to Antarctica

Antigua and Barbuda

Entry requirements : Required for travelers ≥1 year old arriving from countries with risk for YF virus transmission this includes >12-hour airport transits or layovers in countries with risk for YF virus transmission. 1

See Health Information for Travelers to Antigua and Barbuda

CDC recommendations : Recommended for travelers ≥9 months old going to Corrientes and Misiones Provinces. Generally not recommended for travel to Formosa Province or to designated areas of Chaco, Jujuy, and Salta Provinces. Not recommended for travel limited to provinces and areas not listed above.

Related Maps

Map 2-01 Yellow fever vaccine recommendations for Argentina & neighboring countries

See Health Information for Travelers to Argentina

See Health Information for Travelers to Armenia

Entry requirements : Required for travelers ≥9 months old arriving from countries with risk for YF virus transmission; this includes >12-hour airport transits or layovers in countries with risk for YF virus transmission. 1 Entry will be denied if a valid vaccination certificate cannot be provided.

See Health Information for Travelers to Aruba

Entry requirements : Required for travelers ≥1 year old arriving from countries with risk for YF virus transmission; this includes >12-hour airport transits or layovers in countries with risk for YF virus transmission. 1 Travelers arriving from the Galápagos Islands of Ecuador are exempt from this requirement.

See Health Information for Travelers to Australia

See Health Information for Travelers to Austria

See Health Information for Travelers to Azerbaijan

Azores (Portugal)

See Health Information for Travelers to Azores

Bahamas, The

Entry requirements : Required for travelers ≥1 year old arriving from countries with risk for YF virus transmission; this includes >12-hour airport transits or layovers in countries with risk for YF virus transmission. 1

See Health Information for Travelers to The Bahamas

See Health Information for Travelers to Bahrain

Entry requirements : Required for travelers ≥1 year old arriving from countries with risk for YF virus transmission; this includes airport transits or layovers in countries with risk for YF virus transmission. 1

• Districts of Chittagong Hill Tract (Bandarban, Khagrachari, and Rangamati); and the following districts: Chattogram (Chittagong) and Cox’s Bazar (in Chattogram [Chittagong] Division); Mymensingh, Netrakona, and Sherpur (in Mymensingh Division); Kurigram (in Rangpur Division); Habiganj, Moulvibazar, Sunamganj, and Sylhet (in Sylhet Division)
• No malaria transmission in Dhaka (the capital)
• P. falciparum (90%)
• P. vivax (10%)
• P. malariae  (rare)

See Health Information for Travelers to Bangladesh

Entry requirements : Required for travelers ≥1 year old arriving from countries with risk for YF virus transmission. 1 Travelers arriving from Guyana or Trinidad & Tobago are exempt from this requirement, unless an outbreak is occurring.

See Health Information for Travelers to Barbados

See Health Information for Travelers to Belarus

See Health Information for Travelers to Belgium

• Rare transmission
• No malaria transmission in Belize City or on islands frequented by tourists (e.g., Ambergris Caye)
• P. vivax (primarily)
• None (insect bite precautions / mosquito avoidance only) 4

See Health Information for Travelers to Belize

Entry requirements : Required for all arriving travelers ≥9 months old

• P. falciparum  (primarily)
• P. malariae ,  P. ovale,  and  P. vivax  (less commonly)

See Health Information for Travelers to Benin

Bermuda (U.K.)

See Health Information for Travelers to Bermuda (U.K.)

• Rare cases in rural areas <1,700 m (≈5,500 ft) elevation in districts along the southern border shared with India
• P. falciparum  (less commonly)
• None (insect bite precautions and mosquito avoidance only) 4

See Health Information for Travelers to Bhutan

Entry requirements : Required for travelers ≥1 year old arriving from countries with risk for YF virus transmission. 1

CDC recommendations : Recommended for travelers ≥9 months old going to areas <2,300 m (≈7,550 ft) elevation, east of the Andes Mountains: the entire departments of Beni, Pando, Santa Cruz, and designated areas in the departments of Chuquisaca, Cochabamba, La Paz, and Tarija. Not recommended for travel limited to areas >2,300 m (≈7,550 ft) elevation and any areas not listed above, including the cities of La Paz (administrative capital) and Sucre (constitutional [legislative and judicial] capital).

• All areas <2,500 m (≈8,200 ft) elevation
• No malaria transmission in La Paz (administrative capital)
• P. vivax  (99%)
• P. falciparum  (1%)
• Atovaquone-proguanil, doxycycline, mefloquine, primaquine 5 , tafenoquine 3

Map 2-02. Yellow fever vaccine recommendations for Bolivia & neighboring countries

See Health Information for Travelers to Bolivia

See Health Information for Travelers to Bonaire

Bosnia and Herzegovina

See Health Information for Travelers to Bosnia and Herzegovina

Entry requirements : Required for travelers ≥1 year old arriving from countries with risk for YF virus transmission; this includes transits through countries with risk for YF virus transmission. 1

• Districts/ subdistricts of Bobirwa, Boteti, Chobe (including Chobe National Park), Ghanzi, Mahalapye, Ngamiland (Ngami), North East (including its capital, Francistown), Okavango, Serowe/ Palapye, and Tutume
• Rare cases or sporadic foci of transmission in districts/ subdistricts of Kgalagadi North, Kgatleng, Kweneng, and Southern
• No malaria transmission in Gaborone (the capital)
• P. malariae ,  P. ovale , and  P. vivax  (less commonly)
• Districts/subdistricts of Bobirwa, Boteti, Chobe (including Chobe National Park), Ghanzi, Mahalapye, Ngamiland (Ngami), North-East (including its capital, Francistown), Okavango, Serowe/Palapye, and Tutume: Atovaquone-proguanil, doxycycline, mefloquine, tafenoquine 3
• Areas with rare cases or sporadic foci of transmission: no chemoprophylaxis recommended (insect bite precautions and mosquito avoidance only) 4

See Health Information for Travelers to Botswana

CDC recommendations : Recommended for travelers ≥9 months old going to the states of Acre, Amapá, Amazonas, Distrito Federal (including the capital city, Brasília), Espírito Santo,* Goiás, Maranhão, Mato Grosso, Mato Grosso do Sul, Minas Gerais, Pará, Paraná,* Piauí, Rio de Janeiro (including the city of Rio de Janeiro and all coastal islands),* Rio Grande do Sul,* Rondônia, Roraima, Santa Catarina,* São Paulo (including the city of São Paulo and all coastal islands),* Tocantins, and designated areas of Bahia*. Vaccination is also recommended for travelers going to Iguaçu Falls. Not recommended for travel limited to any areas not listed above, including the cities of Fortaleza and Recife *In 2017, in response to a large YF outbreak in multiple eastern states, CDC expanded its vaccination recommendations for travelers going to Brazil. The expanded YF vaccination recommendations for these states are preliminary. For updates, refer to the CDC Travelers’ Health website.

• All areas in the states of Acre, Amapá, Amazonas, Rondônia, and Roraima
• Present in the states of Maranhão, Mato Grosso, and Pará, but rare cases in their capital cities (São Luis [capital of Maranhão], Cuiabá [capital of Mato Grosso], Belém [capital of Pará])
• Rural and forested areas in the states of Espírito Santo, Goiás, Minas Gerais, Mato Grosso do Sul, Piauí, Rio de Janeiro, São Paolo, and Tocantins
• No malaria transmission in the cities of Brasília (the capital), Rio de Janeiro, or São Paolo
• No malaria transmission at Iguaçu Falls
• P. vivax  (90%)
• P. falciparum  (10%)
• Areas with rare cases: No chemoprophylaxis recommended (insect bite precautions and mosquito avoidance only) 4
• Map 2-03 Yellow fever vaccine recommendations for Brazil & neighboring countries
• Map 2-04 Malaria prevention in Brazil

See Health Information for Travelers to Brazil

British Indian Ocean Territory; includes Diego Garcia (U.K.)

See Health Information for Travelers to British Indian Ocean Territory (U.K.)

• No human malaria
• Rare transmission of P. knowlesi 6 in primarily forested or forest-fringe areas
• P. knowlesi 6 (100%)
• None (insect bite precautions and mosquito avoidance only) 4

See Health Information for Travelers to Brunei

See Health Information for Travelers to Bulgaria

Burkina Faso

Entry requirements : Required for all arriving travelers ≥9 months old

CDC recommendations : Recommended for all travelers ≥9 months old.

• P. malariae ,  P. ovale , and  P. vivax (less commonly)

See Health Information for Travelers to Burkina Faso

Burma (Myanmar)

• All areas <1,000 m (≈3,300 ft) elevation, including Bagan
• Rare transmission in areas >1,000 m (≈3,300 ft) elevation
• Chloroquine and mefloquine
• P. vivax (60%)
• P. falciparum (40%)
• P. knowlesi 6 , P. malariae , and P. ovale (rare)
• Areas <1,000 m (≈3,300 ft) elevation in the regions of Bago and Tanintharyi, and in the states of Kachin, Kayah, Kayin, and Shan: Atovaquone-proguanil, doxycycline, tafenoquine 3
• Areas <1,000 m (≈3,300 ft) elevation in all other areas: Atovaquone-proguanil, doxycycline, mefloquine, tafenoquine  3
• Areas >1,000 m (≈3,300 ft) elevation: No chemoprophylaxis recommended (insect bite precautions and mosquito avoidance only)  4

See Health Information for Travelers to Burma (Myanmar)

Entry requirements : Required for all arriving travelers ≥9 months old.

CDC recommendations : Recommended for all travelers ≥9 months old.

See Health Information for Travelers to Burundi

• Present throughout the country
• No (or negligible) malaria transmission in the cities of Phnom Penh (the capital) and Siem Reap
• No (or negligible) malaria transmission at the main temple complex at Angkor Wat
• P. vivax (80%)
• P. falciparum (20%)
• P. knowlesi 6 (rare)
• Atovaquone-proguanil, doxycycline, tafenoquine 3

See Health Information for Travelers to Cambodia

Entry requirements : Required for all arriving travelers ≥1 year old.

See Health Information for Travelers to Cameroon

See Health Information for Travelers to Canada

Canary Islands ( Spain )

See Health Information for Travelers to Canary Islands (Spain)

• No indigenous cases reported since 2018
• Previously, rare cases on Santiago (São Tiago) Island and Boa Vista Island
• Previously, chloroquine
• Previously, P. falciparum (primarily)

See Health Information for Travelers to Cape Verde

Cayman Islands (U.K.)

See Health Information for Travelers to Cayman Islands (U.K.)

Central African Republic

Entry requirements : Required for all arriving travelers ≥9 months old .

See Health Information for Travelers to Central African Republic

Entry requirements : Required for travelers ≥9 months old arriving from countries with risk for YF virus transmission. 1

CDC recommendations : Recommended for travelers ≥9 months old going to areas south of the Sahara Desert. Not recommended for travel limited to areas in the Sahara Desert.

See Health Information for Travelers to Chad

See Health Information for Travelers to Chile

Entry requirements : Required for travelers ≥9 months old arriving from countries with risk for YF virus transmission; this includes >12-hour airport transits or layovers in countries with risk for YF virus transmission. 1 Travelers with itineraries limited to Hong Kong Special Administrative Region (SAR) or Macao SAR are exempt from this requirement.

See Health Information for Travelers to China

Christmas Island (Australia)

See Health Information for Travelers to Christmas Island (Australia)

Cocos (Keeling) Islands (Australia)

See Health Information for Travelers to Cocos (Keeling) Islands (Australia)

Entry requirements : Required for travelers ≥1 year old arriving from Angola, Brazil, Democratic Republic of the Congo, or Uganda; this includes >12-hour airport transits or layovers in any of these countries.

CDC recommendations : Recommended for all travelers ≥9 months old except as follows. Generally not recommended for travel limited to the cities of Barranquilla, Cali, Cartagena, or Medellín. Not recommended for travel limited to areas >2,300 m (≈7,550 ft) elevation, the archipelago department of San Andrés and Providencia, or the city of Bogotá (the capital).

• All areas <1,700 m (≈5,600 ft) elevation
• No malaria transmission in the cities of Bogotá (the capital), Cartagena, or Medellín
• P. falciparum  (50%)
• P. vivax  (50%)

Map 2-05 Yellow fever vaccine recommendations for Colombia & neighboring countries

See Health Information for Travelers to Colombia

• P. malariae and P. vivax (rare)

See Health Information for Travelers to Comoros

Congo, Republic of the (Congo-Brazzaville)

Entry requirements : Required for all arriving travelers ≥9 months old.

See Health Information for Travelers to Congo, Republic of the

Cook Islands (New Zealand)

See Health Information for Travelers to Cook Islands (New Zealand)

Entry requirements : Required for travelers ≥9 months old arriving from countries with risk for YF virus transmission. 1 Included in this requirement are travelers arriving from Tanzania and Zambia, and designated areas of: Colombia (the entire country, except the cities of Barranquilla, Bogotá, Cali, Cartagena, and Medellín, and the archipelago department, San Andrés and Providencia); Ecuador (the provinces of Morona-Santiago, Napo, Orellana, Pastaza, Sucumbíos, and Zamora-Chinchipe, and excluding the rest of the country); Paraguay (the entire country, except the city of Asunción); Peru (the entire country, except the cities of Cusco and Lima, the regions of Cajamarca, Lambayeque, Piura, and Tumbes, and the highland tourist areas of Machu Picchu and the Inca Trail); Trinidad & Tobago (the entire country, except the urban areas of Port of Spain; travelers with itineraries limited to the island of Tobago, and travelers with airport transits or layovers are also exempt from this requirement). Travelers arriving from Argentina and Panama are exempt from this requirement.

• Present in the provinces of Alajuela and Limón
• Rare to no transmission in other parts of the country
• P. falciparum (86%)
• P. vivax (14%)
• Alajuela and Limón Provinces: Atovaquone-proguanil, chloroquine, doxycycline, mefloquine, tafenoquine 3
• All other areas: None (insect bite precautions and mosquito avoidance only) 4

See Health Information for Travelers to Costa Rica

Côte d'Ivoire (Ivory Coast)

See Health Information for Travelers to Côte d'Ivoire

See Health Information for Travelers to Croatia

See Health Information for Travelers to Cuba

Curaçao, Netherlands

See other recommended vaccines and medicines for travelers to Curaçao

See Health Information for Travelers to Cyprus

See Health Information for Travelers to Czech Republic

Democratic Republic of the Congo (Congo-Kinshasa)

CDC recommendations : Recommended for all travelers ≥9 months old

See Health Information for Travelers to Democratic Republic of the Congo

See Health Information for Travelers to Denmark

• P. falciparum (60–70%)
• P. vivax (30–40%)
• P. ovale (rare)

See Health Information for Travelers to Djibouti

See Health Information for Travelers to Dominica

Dominican Republic

Entry requirements : Required for travelers ≥1 year old arriving from the following states in Brazil: Espírito Santo, Mina Gerais, Rio de Janeiro, São Paulo; this includes >12-hour airport transits or layovers in any of these states

• Primarily in the provinces near the border with Haiti, and the provinces (including resort areas) of La Altagracia, San Cristóbal, San Juan, and Santo Domingo
• In the Distrito Nacional, city of Santo Domingo (the capital), primarily in the La Ciénaga and Los Tres Brazos areas
• Rare transmission in other provinces
• P. falciparum  (100%)
• Provinces near the border with Haiti, and the provinces (including resort areas) of La Altagracia, San Cristóbal, San Juan, and Santo Domingo: Atovaquone-proguanil, chloroquine, doxycycline, mefloquine, tafenoquine 3
• All other areas: No chemoprophylaxis recommended (insect bite precautions and mosquito avoidance only) 4

See Health Information for Travelers to Dominican Republic

Easter Island (Chile)

Entry requirements : Easter Island has not stated its YF vaccination certificate requirements

See Health Information for Travelers to Easter Island (Chile) .

Ecuador, including the Galápagos Islands

Entry requirements : Required for travelers ≥1 year old arriving from Brazil, Democratic Republic of the Congo, or Uganda; this includes >12-hour airport transits or layovers in any of these countries .

CDC recommendations : Recommended for travelers ≥9 months old going to areas <2,300 m (≈7,550 ft) elevation, east of the Andes Mountains, in the provinces of Morona-Santiago, Napo, Orellana, Pastaza, Sucumbíos, Tungurahua,* and Zamora-Chinchipe. Generally not recommended for travel limited to areas <2,300 m (≈7,550 ft) elevation, west of the Andes Mountains, in the provinces of Esmeraldas,* Guayas, Los Ríos, Manabí, Santa Elena, Santo Domingo de los Tsáchilas, and designated areas in the provinces of Azuay, Bolívar, Cañar, Carchi, Chimborazo, Cotopaxi, El Oro, Imbabura, Loja, and Pichincha. Not recommended for travel limited to areas >2,300 m (≈7,550 ft) elevation, the cities of Guayaquil or Quito (the capital), or the Galápagos Islands *CDC recommendations differ from those published by WHO .

• Areas <1,500 m (≈5,000 ft) elevation in the provinces of Carchi, Cotopaxi, Esmeraldas, Morona-Santiago, Orellana, Pastaza, and Sucumbíos
• Rare cases <1,500 m (≈5,000 ft) in all other provinces
• No malaria transmission in the cities of Guayaquil or Quito (the capital)
• No malaria transmission on the Galápagos Islands
• P. vivax  (85%)
• P. falciparum  (15%)
• Transmission areas in the provinces of Carchi, Cotopaxi, Esmeraldas, Morona-Santiago, Orellana, Pastaza, and Sucumbíos: Atovaquone-proguanil, doxycycline, mefloquine, tafenoquine 3
• All other areas with reported malaria transmission: No chemoprophylaxis recommended (insect bite precautions and mosquito avoidance only) 4

Map 2-06 Yellow fever vaccine recommendations for Ecuador & neighboring countries

See Health Information for Travelers to Ecuador .

See Health Information for Travelers to Egypt .

El Salvador

See Health Information for Travelers to El Salvador .

Equatorial Guinea

• P. malariae, P. ovale , and P. vivax  (less commonly)

See Health Information for Travelers to Equatorial Guinea .

CDC recommendations : Generally not recommended for travel to the regions of: Anseba, Debub (also known as South or Southern Region), Gash Barka, Ma’ekel (also known as Ma’akel or Central Region), or Semenawi K’eyih Bahri (also known as Northern Red Sea Region). Not recommended for travel to any areas not listed above, including the Dahlak Archipelago.

• All areas <2,200 m (≈7,200 ft) elevation
• No malaria transmission in Asmara (the capital)
• P. falciparum  (80–85%)
• P. vivax (15–20%)
• P. malariae and P. ovale (rare)

Map 5-10 Yellow fever vaccine recommendations for Africa

See Health Information for Travelers to Eritrea .

See Health Information for Travelers to Estonia .

Eswatini (Swaziland)

Entry requirements : Required for travelers ≥9 months old arriving from countries with risk for YF virus transmission; this includes airport transits or layovers in countries with risk for YF virus transmission. 1

• Eastern areas bordering Mozambique and South Africa, including the entire region of Lubombo and the eastern half of Hhohho, Manzini, and Shiselweni Regions
• P. malariae , P. ovale , and  P. vivax  (less commonly)

See Health Information for Travelers to Swaziland .

CDC recommendations : Recommended for all travelers ≥9 months old except as follows. Generally not recommended for travel limited to the regions of Afar or Somali.

• All areas <2,500 m (≈8,200 ft) elevation, except none in Addis Ababa (the capital)
• P. falciparum  (80%)
• P. vivax  (20%)
• P. malariae and P. ovale  (rare)

Map 2-07 Yellow fever vaccine recommendations for Ethiopia & neighboring countries

See Health Information for Travelers to Ethiopia .

Falkland Islands (Islas Malvinas), UK Overseas Territory (also claimed by Argentina)

See Health Information for Travelers to Falkland Islands (Islas Malvinas) .

Faroe Islands (Denmark)

See Health Information for Travelers to Faroe Islands (Denmark) .

See Health Information for Travelers to Fiji .

See Health Information for Travelers to Finland .

See Health Information for Travelers to France .

French Guiana

• Areas associated with gold mining, primarily the communes near the border with Brazil and Suriname, especially Régina and Saint-Georges-de-l’Oyapock; also, the communes of Kourou, Matoury, and Saint-Élie
• No malaria transmission in coastal areas west of Kourou
• No malaria transmission in Cayenne City (the capital)
• P. falciparum (15%)

See Health Information for Travelers to French Guiana (France) .

French Polynesia, including the Society Islands [Bora-Bora, Moorea & Tahiti]; Marquesas Islands [Hiva Oa & Ua Huka]; and Austral Islands (Tubuai & Rurutu), France

See Health Information for Travelers to French Polynesia (France) .

• P. malariae , P. ovale , and P. vivax  (less commonly)

See Health Information for Travelers to Gabon .

Gambia, The

See Health Information for Travelers to The Gambia .

See Health Information for Travelers to Georgia .

See Health Information for Travelers to Germany .

• P. malariae,   P. ovale, and   P. vivax (less commonly)

See Health Information for Travelers to Ghana .

Gibraltar (U.K.)

See Health Information for Travelers to Gibraltar (U.K.) .

• Rare, local transmission in agricultural areas, associated with imported malaria (May–November)
• No malaria transmission in tourist areas
• Not applicable
• P. vivax  (100%)

See Health Information for Travelers to Greece .

Greenland (Denmark)

See Health Information for Travelers to Greenland (Denmark) .

See Health Information for Travelers to Grenada .

Guadeloupe (including Marie-Galante, La Désirade & Îles des Saintes)

See Health Information for Travelers to Guadeloupe .

Guam (U.S.)

See Health Information for Travelers to Guam (U.S.) .

• Primarily in the departments of Alta Verapaz, Escuintla, Izabal, Petén, and Suchitapéquez
• Few cases reported in other departments
• No malaria transmission in the cities of Antigua or Guatemala City (the capital)
• No malaria transmission at Lake Atitlán
• P. vivax (99%)
• P. falciparum  (1%)
• Departments of Alta Verapaz, Escuintla, Izabal, Petén, and Suchitapéquez: Atovaquone-proguanil, chloroquine, doxycycline, mefloquine, primaquine 5 , tafenoquine 3
• Other areas with reported malaria transmission: No chemoprophylaxis recommended (insect bite precautions and mosquito avoidance only) 4

See Health Information for Travelers to Guatemala .

Entry requirements : Required for travelers ≥1 year old arriving from countries with risk for YF virus transmission. 1 Required for all arriving travelers from all countries if traveler is ≥9 months of age and arriving at Ahmed Sékou Touré International Airport in Conakry.

See Health Information for Travelers to Guinea .

Guinea-Bissau

See Health Information for Travelers to Guinea-Bissau .

Entry requirements : Required for travelers ≥1 year old arriving from countries with risk for YF virus transmission; this includes >4-hour airport transits or layovers in countries with risk for YF virus transmission. 1

• Rare cases in the cities of Georgetown (the capital) and New Amsterdam
• All areas (except the cities of Georgetown and New Amsterdam): Atovaquone-proguanil, doxycycline, mefloquine, tafenoquine 3
• Cities of Georgetown and Amsterdam: No chemoprophylaxis recommended (insect bite precautions and mosquito avoidance only) 4

See Health Information for Travelers to Guyana .

• All (including Labadee, also known as Port Labadee)
• P. falciparum (99%)
• P. malariae  (rare)
• Atovaquone-proguanil, chloroquine, doxycycline, mefloquine, tafenoquine 3

See Health Information for Travelers to Haiti .

Entry requirements : Required for travelers 1-60 years old arriving from countries with risk for YF virus transmission; this includes >12-hour airport transits or layovers in countries with risk for YF virus transmission. 1

• Throughout the country and on the island of Roat á n and other Bay Islands
• No malaria transmission in the cities of San Pedro Sula or Tegucigalpa (the capital)
• P. vivax (93%)
• P. falciparum  (7%)
• Atovaquone-proguanil, chloroquine, doxycycline, mefloquine, tafenoquine 3

See Health Information for Travelers to Honduras .

Hong Kong Special Administrative Region, China

See Health Information for Travelers to Hong Kong SAR (China) .

See Health Information for Travelers to Hungary .

See Health Information for Travelers to Iceland .

• Arrive within 6 days of leaving an area with risk for YF virus transmission, or
• Have been in such an area in transit (exception: passengers and members of flight crews who, while in transit through an airport in an area with risk for YF virus transmission, remained in the airport during their entire stay and the health officer agrees to such an exemption), or
• Arrive on a ship that started from or touched at any port in an area with risk for YF virus transmission ≤30 days before its arrival in India, unless such a ship has been disinsected in accordance with the procedure recommended by the World Health Organization (WHO), or
• Arrive on an aircraft that has been in an area with risk for YF virus transmission and has not been disinsected in accordance with the Indian Aircraft Public Health Rules, 1954, or as recommended by WHO.
• Africa: Angola, Benin, Burkina Faso, Burundi, Cameroon, Central African Republic, Chad, Congo, Côte d’Ivoire, Democratic Republic of the Congo, Equatorial Guinea, Ethiopia, Gabon, The Gambia, Ghana, Guinea, Guinea-Bissau, Kenya, Liberia, Mali, Mauritania, Niger, Nigeria, Rwanda, Senegal, Sierra Leone, South Sudan, Sudan, Togo, Uganda
• Americas: Argentina, Bolivia, Brazil, Colombia, Ecuador, French Guiana, Guyana, Panama, Paraguay, Peru, Suriname, Trinidad & Tobago (Trinidad only), Venezuela
• Throughout the country, including the cities of Bombay (Mumbai) and New Delhi (the capital)
• No malaria transmission in areas >2,000 m (≈6,500 ft) elevation in Himachal Pradesh, Jammu and Kashmir, or Sikkim
• P. vivax (50%)
• P. falciparum (>40%)

See Health Information for Travelers to India .

• All areas of eastern Indonesia (the provinces of Maluku, North Maluku, East Nusa Tenggara, Papua, and West Papua), including the town of Labuan Bajo and the Komodo Islands in the Nusa Tenggara region
• Rural areas of Kalimantan (Borneo), West Nusa Tenggara (includes the island of Lombok), Sulawesi, and Sumatra
• Low transmission in rural areas of Java, including Pangandaran, Sukabumi, and Ujung Kulon
• No malaria transmission in the cities of Jakarta (the capital) or Ubud
• No malaria transmission in the resort areas of Bali or Java, the Gili Islands, or the Thousand Islands (Pulau Seribu)
• Chloroquine ( P. falciparum and P. vivax )
• P. falciparum (60%)
• P. vivax (40%)

See Health Information for Travelers to Indonesia .

• Previously, March-November in rural areas of Fars Province, Sistan-Baluchestan Province, and southern, tropical parts of Hormozgan and Kerman Provinces.
• Recent outbreaks in Sistan-Baluchestan Province near the border with Pakistan.
• P. vivax (90%)
• Sistan-Baluchestan Province along the border with Pakistan: Atovaquone-proguanil, doxycycline, mefloquine, tafenoquine 2
• All other areas with previous transmission: No chemoprophylaxis recommended (insect bite precautions and mosquito avoidance only) 4

See Health Information for Travelers to Iran .

See Health Information for Travelers to Iraq .

See Health Information for Travelers to Ireland .

See Health Information for Travelers to Israel, including the West Bank and Gaza .

Italy (including Holy See [Vatican City])

See Health Information for Travelers to Italy .

See Health Information for Travelers to Jamaica .

See Health Information for Travelers to Japan .

See Health Information for Travelers to Jordan .

Entry requirements : Required for travelers arriving from countries with risk for YF virus transmission; this includes airport transits or layovers in countries with risk for YF virus transmission. 1

See Health Information for Travelers to Kazakhstan .

CDC recommendations : Recommended for all travelers ≥9 months old except as follows. Generally not recommended for travel limited to: the city of Nairobi (the capital); the counties of the former North Eastern Province (Mandera, Wajir, and Garissa); or the counties (except Taita-Taveta) of the former Coast Province (Kilifi, including the city of Malindi; Kwale; Lamu; Mombasa, including the city of Mombasa; Tana River) .

• All areas (including game parks) <2,500 m (≈8,200 ft) elevation, including the city of Nairobi (the capital)
• Map 2-08 Yellow fever vaccine recommendations for Kenya & neighboring countries
• Map 2-09 Malaria prevention in Kenya

See Health Information for Travelers to Kenya .

Kiribati (formerly Gilbert Islands), includes Tarawa, Tabuaeran (Fanning Island), and Banaba (Ocean Island)

See Health Information for Travelers to Kiribati .

See Health Information for Travelers to Kosovo .

See Health Information for Travelers to Kuwait .

See Health Information for Travelers to Kyrgyzstan .

• All, except in Vientiane (the capital) where there is no transmission
• P. vivax (55%)
• P. falciparum (45%)
• P. knowlesi 6 , P. malariae, and P. ovale (rare)
• Areas bordering Burma (the provinces of Bokeo and Luang Namtha), Cambodia; Thailand (the provinces of Champasak and Salavan); and Vietnam: Atovaquone-proguanil, doxycycline, tafenoquine 3
• All other areas with malaria transmission: Atovaquone-proguanil, doxycycline, mefloquine, tafenoquine 3

See Health Information for Travelers to Laos .

See Health Information for Travelers to Latvia .

See Health Information for Travelers to Lebanon .

See Health Information for Travelers to Lesotho .

See Health Information for Travelers to Liberia .

See Health Information for Travelers to Libya .

Liechtenstein

See Health Information for Travelers to Liechtenstein .

See Health Information for Travelers to Lithuania .

See Health Information for Travelers to Luxembourg .

Macau Special Administrative Region, China

See Health Information for Travelers to Macau SAR (China) .

• All; except in Antananarivo (the capital) where malaria transmission is rare
• P. ovale and P. vivax (less commonly)
• All areas (except the city of Antananarivo): Atovaquone-proguanil, doxycycline, mefloquine, tafenoquine 3
• Antananarivo: No chemoprophylaxis recommended (insect bite precautions and mosquito avoidance only) 4

See Health Information for Travelers to Madagascar .

Madeira Islands (Portugal)

See Health Information for Travelers to Madeira Islands (Portugal) .

See Health Information for Travelers to Malawi .

• No indigenous cases of human malaria since 2017
• Zoonotic transmission of simian malaria occurs in rural, forested areas
• No malaria transmission in other areas, including Kuala Lumpur (the capital), in Penang State, on Penang Island, or in George Town (capital of Penang State)
• P. knowlesi 6 (primarily)
• Previously, P. falciparum , P. malariae , P. ovale , and P. vivax
• In rural, forested areas: atovaquone-proguanil, doxycycline, mefloquine, tafenoquine 3

See Health Information for Travelers to Malaysia .

See Health Information for Travelers to Maldives .

See Health Information for Travelers to Mali .

See Health Information for Travelers to Malta .

Marshall Islands

See Health Information for Travelers to Marshall Islands .

See Health Information for Travelers to Martinique (France) .

• All; except in the regions of Dakhlet Nouadhibou and Tiris Zemmour where there is no transmission

See Health Information for Travelers to Mauritania .

See Health Information for Travelers to Mauritius .

Mayotte (France)

See Health Information for Travelers to Mayotte (France) .

• Chiapas and southern part of Chihuahua state
• Rare in the states of Campeche, Durango, Nayarit, Quintana Roo, Sinaloa, Sonora, and Tabasco
• No malaria transmission along the U.S.–Mexico border
• Chiapas and southern part of Chihuahua state: Atovaquone-proguanil, chloroquine, doxycycline, mefloquine, primaquine 5 , tafenoquine 3
• All other areas with malaria transmission: No chemoprophylaxis recommended (insect bite precautions and mosquito avoidance only) 4

Map 2-10 Malaria prevention in Mexico

See Health Information for Travelers to Mexico .

Micronesia, Federated States of (including Chuuk, Kosrae, Pohnpei & Yap)

See Health Information for Travelers to Micronesia, Federated States of .

See Health Information for Travelers to Moldova .

See Health Information for Travelers to Monaco .

See Health Information for Travelers to Mongolia .

See Health Information for Travelers to Montenegro .

Montserrat, United Kingdom

See Health Information for Travelers to Montserrat (U.K.) .

See Health Information for Travelers to Morocco .

See Health Information for Travelers to Mozambique .

• In the regions of Kavango (East and West), Kunene, Ohangwena, Omaheke, Omusati, Oshana, Oshikoto, Otjozondjupa, and Zambezi
• Rare in other parts of the country
• No malaria transmission in Windhoek (the capital)
• Kavango (East and West), Kunene, Ohangwena, Omaheke, Omusati, Oshana, Oshikoto, Otjozondjupa, and Zambezi: Atovaquone-proguanil, doxycycline, mefloquine, tafenoquine 3

See Health Information for Travelers to Namibia .

See Health Information for Travelers to Nauru .

• Throughout the country in areas <2,000 m (≈6,500 ft) elevation
• No malaria transmission in Kathmandu (the capital) or on typical Himalayan treks
• P. falciparum (<10%)

See Health Information for Travelers to Nepal .

Netherlands

See Health Information for Travelers to The Netherlands .

Netherlands Antilles (Bonaire, Curaçao, Saba, St. Eustasius, and St. Maarten)

Entry requirements : See Bonaire, Curaçao, Saba, St. Eustasius, and St. Maarten for yellow fever information.

• See Bonaire, Curaçao, Saba, St. Eustasius, and St. Maarten for malaria information.

New Caledonia (France)

Entry requirements : Required for travelers ≥1 year old arriving from countries with risk for YF virus transmission; this includes >12-hour airport transits or layovers in countries with risk for YF virus transmission. 1 In the event of an epidemic threat to the territory, a specific vaccination certificate may be required.

See Health Information for Travelers to New Caledonia (France) .

New Zealand

See Health Information for Travelers to New Zealand .

• Región Autónoma Atlántico Norte (RAAN) and Región Autónoma Atlántico Sur (RAAS)
• Rare cases in the departments of Boaco, Chinandega, Estelí, Jinotega, León, Matagalpa, and Nueva Segovia
• No malaria transmission in Managua (the capital)
• P. falciparum  (20%)
• Región Autónoma Atlántico Norte (RAAN) and Región Autónoma Atlántico Sur (RAAS): Atovaquone-proguanil, chloroquine, doxycycline, mefloquine, tafenoquine 3

See Health Information for Travelers to Nicaragua .

See Health Information for Travelers to Niger .

CDC recommendations : Recommended for all travelers ≥9 months old.  

See Health Information for Travelers to Nigeria .

Niue (New Zealand)

See Health Information for Travelers to Niue (New Zealand) .

Norfolk Island (Australia)

See Health Information for Travelers to Norfolk Island (Australia) .

North Korea

• Southern provinces
• P. vivax (100%)
• Atovaquone-proguanil, chloroquine, doxycycline, mefloquine, primaquine 5 , tafenoquine 3

See Health Information for Travelers to North Korea .

North Macedonia

See Health Information for Travelers to North Macedonia .

Northern Mariana Islands (U.S.), includes Saipan, Tinian, and Rota Island

See Health Information for Travelers to Northern Mariana Islands (U.S.) .

See Health Information for Travelers to Norway .

Entry requirements : Required for travelers ≥9 months old arriving from countries with risk for YF virus transmission, with the addition of Rwanda and Tanzania; this includes >12-hour airport transits or layovers in countries with risk for YF virus transmission. 1

• Rare sporadic transmission after importation only
• Previously, P. falciparum and P. vivax

See Health Information for Travelers to Oman .

• All areas (including all cities) <2,500 m (≈8,200 ft) elevation

See Health Information for Travelers to Pakistan .

See Health Information for Travelers to Palau .

CDC recommendations : Recommended for travelers ≥9 months old going to all mainland areas east of the Canal Zone including Darién Province, the indigenous provinces (comarcas indígena) of Emberá and Kuna Yala (also spelled Guna Yala), and areas of the provinces of Colón and Panamá, east of the Canal Zone. Not recommended for travel limited to the Canal Zone; areas west of the Canal Zone; Panama City (the capital); Balboa district (Pearl Islands) of Panamá Province; or the San Blas Islands of Kuna Yala Province.

• The provinces of Bocas del Toro, Chiriquí, Colón, Darién, Panamá, and Veraguas
• The indigenous provinces (comarcas indígena) of Emberá, Kuna Yala (also spelled Guna Yala) and Ngäbe-Buglé
• No malaria transmission in the province of Panamá Oeste, in the Canal Zone, or in Panama City (the capital)
• Chloroquine (east of the Panama Canal)
• P. vivax (97%)
• P. falciparum  (3%)
• Darién, Emberá, Kuna Yala, and eastern Panamá Provinces : Atovaquone-proguanil, doxycycline, mefloquine, primaquine 5 , tafenoquine 3
• Bocas del Toro, Chiriquí, Colón, Veraguas, and Ngäbe-Buglé Provinces : Atovaquone-proguanil, chloroquine, doxycycline, mefloquine, primaquine 5 , tafenoquine 3
• Map 2-11 Yellow fever vaccine recommendations for Panama & neighboring countries
• Map 2-12 Malaria prevention in Panama

See Health Information for Travelers to Panama .

Papua New Guinea

• Chloroquine (both P. falciparum and P. vivax )
• P. falciparum (75%)
• P. vivax (25%)

See Health Information for Travelers to Papua New Guinea .

Entry requirements : Required for travelers ≥1 year old arriving from Bolivia, Brazil, Peru, or Venezuela; this includes this includes >24-hour transits or layovers in those countries 1

CDC recommendations : Recommended for all travelers ≥9 months old except as follows. Generally not recommended for travel limited to the city of Asunción (the capital).

See Health Information for Travelers to Paraguay .

CDC recommendations : Recommended for travelers ≥9 months old going to areas <2,300 m (≈7,550 ft) elevation in the regions of Amazonas, Cusco, Huánuco, Junín, Loreto, Madre de Dios, Pasco, Puno, San Martín, and Ucayali, and designated areas of Ancash (far northeast), Apurímac (far north), Ayacucho (north and northeast), Cajamarca (north and east), Huancavelica (far north), La Libertad (east), and Piura (east). Generally not recommended for travel limited to the following areas west of the Andes: the regions of Lambayeque and Tumbes, and designated areas of Cajamarca (west-central), and Piura (west). Not recommended for travel limited to areas >2,300 m (≈7,550 ft) elevation, areas west of the Andes not listed above, the city of Lima (the capital), and the highland tourist areas (the city of Cusco, the Inca Trail, and Machu Picchu).

• All areas of the country <2,500 m (≈8,200 ft) elevation, including the cities of Iquitos and Puerto Maldonado, and only the remote eastern areas in the regions of La Libertad and Lambayeque
• No malaria transmission in the following areas: Lima Province; the cities of Arequipa, Ica, Moquegua, Nazca, Puno, or Tacna; the highland tourist areas (the city of Cusco, Machu Picchu, Lake Titicaca); along the Pacific Coast
• Map 2-13 Yellow fever vaccine recommendations for Peru & neighboring countries
• Map 2-14 Malaria prevention in Peru

See Health Information for Travelers to Peru .

Philippines

• Palawan and Mindanao Islands
• No malaria transmission in metropolitan Manila (the capital) or other urban areas
• P. falciparum (85%)
• P. vivax (15%)

See Health Information for Travelers to Philippines .

Pitcairn Islands (U.K.)

See Health Information for Travelers to Pitcairn Islands (U.K.) .

See Health Information for Travelers to Poland .

See Health Information for Travelers to Portugal .

Puerto Rico (U.S.)

See Health Information for Travelers to Puerto Rico (U.S.) .

See Health Information for Travelers to Qatar .

Réunion (France)

See Health Information for Travelers to Réunion (France) .

See Health Information for Travelers to Romania .

See Health Information for Travelers to Russia .

CDC recommendations : Generally not recommended for travel to Rwanda.

See Health Information for Travelers to Rwanda .

Saba, Netherlands

See Health Information for Travelers to Saba .

Saint Barthelemy, France

Saint helena, united kingdom.

Entry requirements : Required for travelers ≥1 year old arriving from countries with risk for YF virus transmission. 1 *For YF vaccine entry requirements and recommendations and malaria prevention information for Ascension Island and Tristan da Cunha archipelago, see: UNITED KINGDOM (including CHANNEL ISLANDS, ISLE OF MAN, ASCENSION ISLAND & TRISTAN DA CUNHA ARCHIPELAGO)

See Health Information for Travelers to Saint Helena (U.K.) .

Saint Kitts (Saint Christopher) & Nevis

See Health Information for Travelers to Saint Kitts and Nevis .

Saint Lucia

See Health Information for Travelers to Saint Lucia .

Saint Martin, France

Saint pierre and miquelon (france).

See Health Information for Travelers to Saint Pierre and Miquelon (France) .

Saint Vincent and the Grenadines

See Health Information for Travelers to Saint Vincent and the Grenadines .

Samoa (formerly Western Somoa)

See Health Information for Travelers to Samoa (formerly Western Samoa) .

See Health Information for Travelers to San Marino .

São Tomé and Príncipe

CDC recommendations : Generally not recommended for travel to São Tomé and Príncipe.

See Health Information for Travelers to São Tomé and Príncipe.

Saudi Arabia

• Asir and Jazan (also spelled Jizan) Regions near the Yemen border only
• No malaria transmission in the cities of Jeddah, Mecca, Medina, Riyadh (the capital), or Ta’if
• P. vivax (rare)

See Health Information for Travelers to Saudi Arabia .

See Health Information for Travelers to Senegal .

See Health Information for Travelers to Serbia .

See Health Information for Travelers to Seychelles .

Sierra Leone

Entry requirements : Required for all arriving travelers.

See Health Information for Travelers to Sierra Leone .

See Health Information for Travelers to Singapore .

Sint Eustatius, Netherlands

Entry requirements : Required for travelers ≥6 months old arriving from countries with risk for YF virus transmission. 1

See Health Information for Travelers to Sint Eustatius .

Sint Maarten, Netherlands

See Health Information for Travelers to Sint Maarten .

See Health Information for Travelers to Slovakia .

See Health Information for Travelers to Slovenia .

Solomon Islands

• P. vivax (70%)
• P. falciparum (30%)
• P. ovale (<1%)

See Health Information for Travelers to Solomon Islands .

CDC recommendations : Generally not recommended for travel to the regions of Bakool, Banaadir, Bay, Galguduud, Gedo, Hiiraan (also spelled Hiran), Lower Juba (also known as Jubbada Hoose), Middle Juba (also known as Jubbada Dhexe), Lower Shabelle (also known as Shabeellaha Hoose), or Middle Shabelle (also known as Shabeellaha Dhexe). Not recommended for travel to areas not listed above.

• P. vivax (5–10%)

See Health Information for Travelers to Somalia .

South Africa

• Along the border with Mozambique and Zimbabwe
• KwaZulu-Natal Province: uMkhanyakude District; the districts of King Cetshwayo and Zululand (few cases) Limpopo Province: the districts of Mopani and Vhembe; the districts of Capricorn, Greater Sekhukhune, and Waterberg (few cases)
• Mpumalanga Province: Ehlanzeni District
• Kruger National Park
• KwaZulu-Natal Province (uMkhanyakude District); Limpopo Province (the districts of Mopani and Vhembe); Mpumalanga Province (Ehlanzeni District); and Kruger National Park: Atovaquone-proguanil, doxycycline, mefloquine, tafenoquine 3
• All other areas with malaria transmission (including the districts of King Cetshwayo and Zululand in KwaZulu-Natal Province, and the districts of Capricorn, Greater Sekhukhune, and Waterberg in Limpopo Province): No chemoprophylaxis recommended (insect bite precautions and mosquito avoidance only) 4

Map 2-15 Malaria prevention in South Africa

See Health Information for Travelers to South Africa .

South Georgia & the South Sandwich Islands, UK Overseas Territory (also claimed by Argentina)

Entry requirements : South Georgia & the South Sandwich Islands has not stated its YF vaccination certificate requirements.

See Health Information for Travelers to South Georgia and the South Sandwich Islands (U.K.) .

South Korea

Entry requirements : Required if traveling from a country with risk of YF virus transmission and ≥1 year of age. 1

• Limited to the months of March– December in rural areas in the northern parts of the provinces of Inch’ŏn (also spelled Incheon), Kangwŏn (also spelled Gangwon), and Kyŏnggi (also spelled Gyeonggi), including the demilitarized zone (DMZ)
• Atovaquone-proguanil, chloroquine, doxycycline, mefloquine, primaquine 5 , or tafenoquine 3

See Health Information for Travelers to South Korea .

South Sudan

See Health Information for Travelers to South Sudan .

See Health Information for Travelers to Spain .

See Health Information for Travelers to Sri Lanka .

CDC recommendations : Recommended for travelers ≥9 months old going to areas south of the Sahara Desert. Not recommended for travel limited to areas in the Sahara Desert or the city of Khartoum (the capital).

See Health Information for Travelers to Sudan .

• Primarily in Sipaliwini District, near the border with French Guiana
• Limited transmission in Brokopondo, Marowijne, and Para (near the border with French Guiana)
• No malaria transmission in the districts along the Atlantic Coast or in Paramaribo (the capital)
• Sipaliwini District near the border with French Guiana: Atovaquone-proguanil, doxycycline, mefloquine, tafenoquine 3
• All other areas with malaria transmission: No chemoprophylaxis recommended (insect bite precautions / mosquito avoidance only) 4

See Health Information for Travelers to Suriname .

See Health Information for Travelers to Sweden .

Switzerland

See Health Information for Travelers to Switzerland .

See Health Information for Travelers to Syria .

See Health Information for Travelers to Taiwan .

• No indigenous cases reported since 2014
• Previously, P. vivax (90%)
• Previously, P. falciparum  (10%)

See Health Information for Travelers to Tajikistan .

CDC recommendations : Generally not recommended for travel to Tanzania.

• All areas below 1,800 m (≈5,900 ft) elevation
• P. malariae and P. ovale (less commonly)

See Health Information for Travelers to Tanzania .

• Primarily the provinces that border Burma, Cambodia (few cases in Buri Ram Province), and Malaysia (few cases in Satun Province) Also, the provinces of Phitsanulok and Ubon Ratchathani (bordering Laos), and Surat Thani (especially in the rural forest and forest-fringe areas of these provinces)
• Rare to few cases in other parts of Thailand, including the cities of Bangkok (the capital), Chiang Mai, and Chiang Rai, or on the islands of Koh Pha Ngan, Koh Samui, or Phuket
• No malaria transmission on the islands of Krabi Province (Ko Lanta, Koh Phi, Koh Yao Noi, Koh Yao Yai) or in Pattaya City
• P. falciparum (<20%)
• Provinces that border Burma, Cambodia (except Buri Ram Province), and Malaysia (except Satun Province); the provinces of Phitsanulok, Ubon Ratchathani, and Surat Thani: Atovaquone-proguanil, doxycycline, tafenoquine 3
• All other areas with malaria transmission (including the provinces of Buri Ram and Satun): No chemoprophylaxis recommended (insect bite precautions and mosquito avoidance only) 4

Map 2-16 Malaria prevention in Thailand

See Health Information for Travelers to Thailand .

Timor-Leste

• Rare cases; outbreak in Indonesia border area in mid-2020
• Previously, P. falciparum (50%)
• Previously, P. vivax (50%)
• Previously, P. malariae  and  P. ovale  (each <1%)

See Health Information for Travelers to Timor-Leste (East Timor) .

See Health Information for Travelers to Togo .

Tokelau (New Zealand)

See Health Information for Travelers to Tokelau (New Zealand) .

See Health Information for Travelers to Tonga .

Trinidad and Tobago

CDC recommendations : Recommended for travelers ≥9 months old going to densely forested areas on Trinidad. Not recommended for cruise ship passengers, airplane passengers in transit, or travel limited to Tobago.

See Health Information for Travelers to Trinidad and Tobago .

See Health Information for Travelers to Tunisia .

See Health Information for Travelers to Turkey .

Turkmenistan

See Health Information for Travelers to Turkmenistan .

Turks and Caicos Islands (U.K.)

See Health Information for Travelers to Turks and Caicos Islands (U.K.) .

See Health Information for Travelers to Tuvalu .

See Health Information for Travelers to Uganda .

See Health Information for Travelers to Ukraine .

United Arab Emirates

See Health Information for Travelers to United Arab Emirates .

United Kingdom (including Channel Islands, Isle of Man, Ascension Island & Tristan Da Cunha Archipelago)

See Health Information for Travelers to United Kingdom .

United States of America

See Health Information for Travelers to United States .

See Health Information for Travelers to Uruguay .

See Health Information for Travelers to Uzbekistan .

• P. vivax (75%–90%)
• P. falciparum (10-25%)

See Health Information for Travelers to Vanuatu .

Entry requirements : Required for travelers ≥1 year old arriving from Brazil; this includes >12-hour airport transits or layovers in Brazil

CDC recommendations : Recommended for all travelers ≥9 months old except as follows. Generally not recommended for travel limited to the Distrito Capital or the states of Aragua, Carabobo, Miranda, Vargas, or Yaracuy. Not recommended for travel limited to areas >2,300m (≈7,550 ft) elevation in the states of Mérida, Táchira, or Trujillo; the states of Falcón or Lara; Margarita Island; or the cities of Caracas (the capital) or Valencia .

• All areas <1,700 m (≈5,600 ft) elevation and Angel Falls
• P. vivax (75%)
• P. falciparum  (25%)

Map 2-17 Yellow fever vaccine recommendations for Venezuela & neighboring countries

See Health Information for Travelers to Venezuela .

• Rural areas only. Rare cases in the Mekong and Red River Deltas
• None in the cities of Da Nang, Hai Phong, Hanoi, Ho Chi Minh City (Saigon), Nha Trang, and Quy Nhon.
• P. falciparum (65%)
• P. vivax (35%)
• Provinces of Bình Dương, Bình Phước, Đắk Lắk, Đắk Nông, Gia Lai, Khánh Hòa, Kon Tum, Lâm Đồng, Ninh Thuận, Tây Ninh: Atovaquone-proguanil, doxycycline, tafenoquine 3
• All other areas with malaria transmission (except Mekong and Red River Deltas): Atovaquone-proguanil, doxycycline, mefloquine, tafenoquine 3
• Mekong and Red River Deltas: No chemoprophylaxis recommended (insect bite precautions / mosquito avoidance only) 4

See Health Information for Travelers to Vietnam .

Virgin Islands, British

See Health Information for Travelers to Virgin Islands, British .

Virgin Islands, U.S.

See Health Information for Travelers to Virgin Islands, U.S. .

Wake Island, U.S.

See Health Information for Travelers to Wake Island .

• All areas <2,000 m (≈6,500 ft) elevation
• No malaria transmission in Sana’a (the capital)

See Health Information for Travelers to Yemen .

Entry requirements : Required for travelers ≥1 year of age arriving from countries with risk for YF virus transmission; this includes >12-hour airport transits or layovers in countries with risk for YF virus transmission. 1

CDC recommendations : Generally not recommended for travel to North-Western Province or Western Province. Not recommended for travel to any areas not listed above.

See Health Information for Travelers to Zambia .

See Health Information for Travelers to Zimbabwe .

1 Current as of November 2022. This is an update of the 2010 map created by the Informal WHO Working Group on the Geographic Risk of Yellow Fever.

2 Refers to Plasmodium falciparum malaria, unless otherwise noted.

3 Tafenoquine can cause potentially life-threatening hemolysis in people with glucose-6-phosphate-dehydrogenase (G6PD) deficiency. Rule out G6PD deficiency with a quantitative laboratory test before prescribing tafenoquine to patients.

4 Mosquito avoidance includes applying topical mosquito repellant, sleeping under an insecticide-treated mosquito net, and wearing protective clothing (e.g., long pants and socks, long-sleeve shirt). For additional details on insect bite precautions, see Sec. 4, Ch. 6, Mosquitoes, Ticks & Other Arthropods.

5 Primaquine can cause potentially life-threatening hemolysis in people with G6PD deficiency. Rule out G6PD deficiency with a quantitative laboratory test before prescribing primaquine to patients.

6 P. knowlesi is a malaria species with a simian (macaque) host. Human cases have been reported from most countries in Southwest Asia and are associated with activities in forest or forest-fringe areas. P. knowlesi has no known resistance to antimalarials.

Yellow Fever Maps

2 In 2017, the Centers for Disease Control and Prevention (CDC) expanded its YF vaccination recommendations for travelers going to Brazil because of a large YF outbreak in multiple states in that country. Please refer to the CDC  Travelers’ Health website for more information and updated recommendations.

3 YF vaccination is generally not recommended for travel to areas where the potential for YF virus exposure is low. Vaccination might be considered, however, for a small subset of travelers going to these areas who are at increased risk for exposure to YF virus due to prolonged travel, heavy exposure to mosquitoes, or inability to avoid mosquito bites. Factors to consider when deciding whether to vaccinate a traveler include destination-specific and travel-associated risks for YF virus infection; individual, underlying risk factors for having a serious YF vaccine–associated adverse event; and destination entry requirements.

The following authors contributed to the previous version of this chapter: Mark D. Gershman, Emily S. Jentes, Rhett J. Stoney (Yellow Fever) Kathrine R. Tan, Paul M. Arguin (Malaria)

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