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Title Page

CDC Yellow Book 2020: Health Information for International Travel
U.S. Centers for Disease Control and Prevention

Editors
CDC Disclaimer and Notice
Contributors
Acknowledgments
Preface
With Gratitude to Phyllis E. Kozarsky
Notices and Disclaimers


Centers for Disease Control and Prevention. CDC Yellow Book 2020: Health Information for International Travel. New York: Oxford University Press 2019. Unbound™ mobile platform © 2000-2020 Unbound Medicine, Inc. All rights reserved.

Editors

Editors in Chief

Gary W. Brunette, MD, MS
Jeffrey B. Nemhauser, MD

Chief Medical Editor

Phyllis E. Kozarsky, MD

Medical Editors

Kristina M. Angelo, DO, MPH&TM
Nicole J. Cohen, MD, MS
Douglas H. Esposito, MD, MPH
Stephen M. Ostroff, MD
Edward T. Ryan, MD
David R. Shlim, MD
Richard W. Steketee, MD, MPH
Michelle Weinberg, MD, MPH
Mary Elizabeth Wilson, MD

Managing Editor

Jenique Meekins

Technical Editor

Ronnie Henry

CDC Disclaimer and Notice

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All CDC material in this publication is in the public domain and may be used and reprinted without special permission; however, citation of the source is appreciated.

Disclaimers
Both generic and trade names (without trademark symbols) are used in this text. In all cases, the decision to use one or the other was made based on recognition factors and was done for the convenience of the intended audience. Therefore, the use of trade names and commercial sources in this publication is for identification only and does not imply endorsement by the US Department of Health and Human Services, the Public Health Service, or CDC.

Descriptions of drugs, biologics, or medical products used for an indication not in the approved labeling or packaging (“off-label” uses) do not constitute official HHS approval or endorsement of those products or uses. The uses described in this publication have been identified by subject-matter experts on the basis of published evidence and clinical experience. Clinicians who use a product for an off-label use should be well informed about the product, base its use on firm scientific rationale and sound medical evidence, and maintain records of the product’s use and effects.

References to non-CDC Internet sites are provided as a service to readers and do not constitute or imply endorsement of these organizations or their programs by the US Department of Health and Human Services, the Public Health Service, or CDC. CDC is not responsible for the content of these sites. URL addresses were current as of the date of publication.

Boundaries and labels shown on maps are not necessarily authoritative.

Notice
This material is not intended to be, and should not be considered, a substitute for medical or other professional advice. Treatment for the conditions described in this material is highly dependent on the individual circumstances. While this material is designed to offer accurate information with respect to the subject matter covered and to be current as of the time it was written, research and knowledge about medical and health issues are constantly evolving, and dose schedules for medications and vaccines are being revised continually, with new side effects recognized and accounted for regularly. Readers must, therefore, always check the product information and clinical procedures with the most up-to-date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulation. Oxford University Press and the authors make no representations or warranties to readers, express or implied, as to the accuracy or completeness of this material, including without limitation that they make no representations or warranties as to the accuracy or efficacy of the drug dosages mentioned in the material. The authors and the publishers do not accept, and expressly disclaim, any responsibility for any liability, loss, or risk that may be claimed or incurred as a consequence of the use and/or application of any of the contents of this material.

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Contributors

CDC Contributors

Abe, Karon
Acosta, Anna
Ali, Ibne
Alvarado-Ramy, Francisco
Angelo, Kristina
Ansari, Armin
Anstey, Erica
Appiah, Grace
Arboleda, Nelson
Arguin, Paul M.
Baggett, Henry C.
Ballesteros, Michael F.
Barton Behravesh, Casey
Beavers, Suzanne
Beckman, Michele G.
Benedict, Katherine
Benowitz, Isaac
Biggs, Holly
Blaney, David D.
Bonilla, Luis
Brogdon, William G.
Brooks, John T.
Brown, Clive M.
Bruce, Beau
Brunette, Gary W.
Cantey, Paul T.
Cardemil, Cristina V.
Chatham-Stevens, Kevin
Chiller, Tom M.
Choi, Mary Joung
Clemmons, Nakia S.
Cooley, Laura
Cope, Jennifer
Czarkowski, Alan G.
Dionne-Odom, Jodie
Dubray, Christine
Duong, Krista Kornylo
Edelson, Paul
Eichwald, John
Erskine, Stefanie K.
Esposito, Douglas H.
Estivariz, Concepcion
Fischer, Marc
Francois Watkins, Louise K.
Friedman, Cindy R.
Fry, Alicia
Gaines, Joanna
Galland, G. Gale
Galloway, Renee L.
Gastañaduy, Paul A.
Gee, Jay E.
Geissler, Aimee L.
Gerber, Susan I.
Gershman, Mark D.
Goodson, James L.
Goswami, Neela
Gould, Carolyn
Green, Michael D.
Griffin, Patricia M.
Hall, Aron J.
Hall, Rebecca
Ham, David
Harris, Aaron
Harvey, Pauline
Hawley, William A.
Healy, Jessica
Hendricks Walters, Kate
Henry, Ronnie
Herwaldt, Barbara L.
Hill, Vincent
Hills, Susan L.
Hinton, Cindy
Hlavsa, Michele C.
Hughes, Mike
Hunter, Jennifer C.
Jackson, Brendan
Jentes, Emily S.
Jones, Jeffrey L.
Jungerman, Robynne M.
Kersh, Gilbert J.
Kharod, Grishma A.
Knust, Barbara
Kozarsky, Phyllis E.
Kroger, Andrew T.
Lanzieri, Tatianna
Laughlin, Mark
Lee, Keun
Lessa, Fernanda C.
Lindsey, Nichole
LoBue, Philip
Lopez, Adriana S.
Lutgring, Joseph
MacArthur, John
Maloney, Susan A.
Marano, Nina
Marin, Mona
Marlow, Mariel A.
Marston, Chung K.
Martin, Diana L.
Martin, Stacey
McCollum, Andrea M.
McCotter, Orion Z.
McFarland, Jeffrey
McNamara, Lucy
Mead, Paul S.
Meyer, Sarah A.
Mintz, Eric D.
Montgomery, Susan
Montiel, Sonia H.
Moore, Matt
Morales, Michelle
Morof, Diane F.
Moser, Kathleen
Mott, Joshua
Mounts, Anthony
Mullan, Robert J.
Mutebi, John-Paul
Ncho, Hammad
Negron, Maria E.
Nelson, Christina A.
Nelson, Noele P.
Nicholson, William L.
Paddock, Christopher D.
Park, Benjamin
Patel, Manisha
Patimeteeporn, Calvin
Perez-Padilla, Janice
Peters, Philip J.
Peterson, Brett W.
Powers, Ann M.
Rabold, Elizabeth
Raczniak, Gregory A.
Reef, Susan E.
Reyes, Nimia L.
Robinson, Candice
Roellig, Dawn
Roguski, Katherine
Rollin, Pierre E.
Routh, Janell
Roy, Sharon
Russell, Michelle
Santelli, Ana Carolina
Sauber-Schatz, Erin K.
Schafer, Ilana J.
Schmid, D. Scott
Sharp, Tyler M.
Shoemaker, Trevor
Skoff, Tami H.
Sleet, David A.
Sotir, Mark J.
Spradling, Phil
Staples, J. Erin
Stauffer, Kendra
Stoddard, Robyn A
Stoney, Rhett J
Straily, Anne
Tan, Kathrine R.
Tardivel, Kara
Teshale, Eyasu
Tiller, Rebekah
Tiwari, Tejpratap S. P.
Uribe, Carolina
Vieira, Antonio
Villarino, Margarita E.
Walker, Allison Taylor
Wallace, Ryan M.
Wassilak, Steven G. F.
Waterman, Stephen H.
Watson, John T.
Weinberg, Michelle S.
White, Stephanie
Wien, Simone
Winstead, Allison
Wong, Karen K.
Workowski, Kimberly


External Contributors

Ansdell, Vernon E.

University of Hawaii, Honolulu, HI

Atkinson, Gregory

Teesside University, Middlesbrough, UK

Backer, Howard D.

California Emergency Medical Services Authority, Sacramento, CA

Barbeau, Deborah Nicolls

Tulane University, New Orleans, LA

Barkati, Sapha

McGill University, Centre for Tropical Disease, Montreal, Canada

Barnett, Elizabeth D.

Boston University School of Medicine and Boston Medical Center, Boston, MA

Batterham, Alan M.

Teesside University, Middlesbrough, UK

Boggild, Andrea K.

University of Toronto, Toronto, Canada

Borwein, Sarah T.

TravelSafe Medical Centre, Hong Kong, China

Bozkurt, Taylan

JMS Burn Centers, Inc., Augusta, GA

Bunn, Bill

Medical University of South Carolina; Navistar International Corporation

Carroll, I. Dale

The Pregnant Traveler, Spring Lake, MI

Changizi, Roohollah

United Family Hospital, subsidiary of United Family Healthcare, Beijing, China

Chen, Lin H.

Mount Auburn Hospital—Travel Medicine Center, Cambridge, MA, and Harvard Medical School, Boston, MA

Chimiak, James M.

Divers Alert Network, Durham, NC

Connor, Bradley A.

Weill Medical College of Cornell University, New York, NY

DeRomaña, Inés

University of California System, Education Abroad Program, Santa Barbara, CA

Ejike-King, Lacreisha

US Food and Drug Administration, US Department of Health and Human Services, Rockville, MD

Fairley, Jessica K.

Emory University School of Medicine, Atlanta, GA

Florez-Arango, Jose F.

Biomedical Informatics, College of Medicine, Texas A&M Health Science Center, College Station, TX

Forgione, Michael

Keesler Medical Center, Keesler AFB, Mississippi

Franco-Paredes, Carlos

Division of Infectious Diseases, University of Colorado at Denver, School of Medicine, Aurora, CO; Hospital Infantil de México Federico Gómez, Mexico City, Mexico

Freedman, David O.

Shoreland, Inc., Milwaukee, WI

Gracia, J. Nadine

Office of Minority Health, US Department of Health and Human Services, Rockville, MD

Hackett, Peter H.

Institute for Altitude Medicine, Telluride, CO, and Altitude Research Center, University of Colorado Denver School of Medicine, Denver, CO

Hamer, Davidson H.

Center for Global Health and Development Boston University; Department of Global Health, Boston University School of Public Health and Section of Infectious Diseases, Boston Medical Center, Boston, MA

Henao-Martinez, Andres

Division of Infectious Diseases, University of Colorado at Denver, School of Medicine, Aurora, CO

Henderson, John

United Nations consultant, Burma

Hochberg, Natasha S.

Section of Infectious Diseases, Boston University School of Medicine, Boston, MA

Javed, Uzma

Office of American Citizens Services

Kain, Kevin C.

University of Toronto, Toronto, Canada

Kayden, Stephanie

Harvard Humanitarian Initiative, Cambridge, MA; Harvard Medical School, Boston, MA; Brigham and Women’s Hospital, Boston, MA

Keystone, Jay S.

University of Toronto, Toronto, Canada

Kotton, Camille Nelson

Massachusetts General Hospital and Harvard University, Boston, MA

LaRocque, Regina C.

Massachusetts General Hospital and Harvard Medical School, Boston, MA

Law, Catherine

National Center for Complementary and Integrative Health, National Institutes of Health, Bethesda, MD

Levi, Matt

CHI Franciscan Health, Tacoma, WA

Libman, Michael

McGill University, Centre for Tropical Disease, Montreal, Canada

McDevitt, Sue Ann

New York, NY

Neumann, Karl

Weill Medical College of Cornell University and New York Presbyterian Hospital/ Cornell Medical Center, New York, NY

Nilles, Eric J.

Harvard Humanitarian Initiative, Cambridge, MA; Harvard Medical School, Boston, MA; Brigham and Women’s Hospital, Boston, MA

Nord, Daniel A.

Divers Alert Network, Durham, NC

Norton, Scott

Children’s National Medical Center, Washington, DC

Parker, Salim

Dee Bee Medical Centre, Cape Town; South African Society of Travel Medicine, Johannesburg, South Africa

Pogemiller, Hope

University of Minnesota Medical School, Minneapolis, MN

Rhodes, Gary

Center for Global Education, University of California, Los Angeles, CA

Riddle, Mark S.

Naval Medical Research Center, Silver Spring, MD

Rosselot, Gail A.

Travel Well of Westchester, Briarcliff Manor, NY

Ryan, Edward T.

Massachusetts General Hospital and Harvard University, Boston, MA

Sampson, Dana M.

Office of Minority Health, US Department of Health and Human Services, Rockville, MD

Shlim, David R.

Jackson Hole Travel and Tropical Medicine, Jackson Hole, WY

Shurtleff, David

National Center for Complementary and Integrative Health, National Institutes of Health, Bethesda, MD

Staat, Mary Allen

International Adoption Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH

Taggart, Linda R.

University of Toronto, Toronto, Canada

Thompson, Andrew

University of Liverpool, Liverpool, UK

Valk, Thomas H.

VEI Inc., Marshall, VA

Van Tilburg, Christopher

Providence Hood River Memorial Hospital, Hood River, OR

Waggoner, Jesse

Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA

Wanat, Karolyn

Medical College of Wisconsin, Milwaukee, WI

Wangu, Zoon

Department of Pediatric Infectious Diseases, Boston Medical Center, Boston, MA

Weinberg, Nicholas

Geisel School of Medicine, Dartmouth College, Hanover, NH

Wilson, Mary Elizabeth

Harvard School of Public Health, Boston, MA

Wu, Henry M.

Emory University, Department of Medicine, Atlanta, GA

Youngster, Ilan

Children’s Hospital Boston and Harvard University, Boston, MA

All contributors have signed a statement indicating that they have no conflicts of interest with the subject matter or materials discussed in the document(s) that they have written or reviewed for this book and that the information that they have written or reviewed for this book is objective and free from bias.

Acknowledgments

The CDC Yellow Book 2020: Health Information for International Travel editorial team gratefully acknowledges all the authors and reviewers for their commitment to this new edition. We extend sincere thanks to the following people for their contributions to the production of this book:

  • Kelly M. Winter for serving in the role of managing editor and guiding this edition through the first half of production.
  • Elise Beltrami, Nicole Cohen, Rachel Eidex, and Scott Santibanez for their extensive review of the text.
  • Maeghan Dessecker, Johanzynn Gatewood, and Calvin Patimeteeporn for their assistance in preparing the text for publication.

Preface

To stay on the cutting edge of travel health information, this latest edition of the CDC Yellow Book: Health Information for International Travel has been extensively revised. The book serves as a guide to the practice of travel medicine, as well as the authoritative source of US government recommendations for immunizations and prophylaxis for foreign travel. As international travel continues to become more common in the lives of US residents, having at least a basic understanding of the medical problems that travelers face has become a necessary aspect of practicing medicine. The goal of this book is to be a comprehensive resource for clinicians to find the answers to their travel health–related questions.

Centers for Disease Control and Prevention
Robert R. Redfield, MD, Director

National Center for Emerging and Zoonotic Infectious Diseases
Rima Khabbaz, MD, Director

Division of Global Migration and Quarantine
Martin S. Cetron, MD, Director
Gary W. Brunette, MD, MS, Chief, Travelers’ Health Branch
Jeffrey B. Nemhauser, MD, Chief Medical Officer, Travelers’ Health Branch
Jenique Meekins, Health Communications Specialist, Travelers’ Health Branch

With Gratitude to Phyllis E. Kozarsky

Descriptive text is not available for this image


Phyllis E. Kozarsky, MD,
is the longest serving member of the Travelers’ Health Branch at the Centers for Disease Control and Prevention (CDC). More than 25 years ago, she came to the branch, bringing with her extensive experience in travel medicine and infectious diseases. Over the years, Phyllis has helped elevate the quality of the work performed by branch epidemio­logists, public health advisors, medical officers, and communicators thanks to her generously shared clinical insight. Phyllis has also served as an editor of CDC’s Yellow Book since 1999. Yellow Book 2020 will be her final one as Chief Medical Editor, and it is to her great legacy and contribution to travel medicine that we gratefully and fondly dedicate this edition.

It is difficult to imagine the field of travel medicine without Phyllis Kozarsky. A wealth of knowledge and critical judgment in all areas of travel medicine—she really is one of the best in the world—Phyllis is remarkably humble and naturally reticent by nature, qualities that have prevented many of the members of our community from fully appreciating the key role she has played in developing this specialty. In 1991, after helping to create the International Society of Travel Medicine (ISTM), she then managed the organization for several years until it gained its footing. She was also instrumental in creating ISTM’s Certificate of Travel Health exam. An infectious disease specialist, Phyllis started and ran the travel medicine clinic at Emory University in Atlanta, while simultaneously serving as a stable and knowledgeable presence in the travel medicine section of the CDC.

David R. Shlim, MD

When I think of Phyllis Kozarsky, it is her big beautiful smile and her willingness to pitch in and work as part of a team to solve problems that first come to mind.

Phyllis shaped travel medicine as it exists today. Masterful in bringing evidence to practice and policy, she led efforts to define a core body of knowledge for the specialty. She then developed the examination that awards clinicians who pass it, a certificate recognizing their expertise, according to internationally established standards. She has provided crucial support to the GeoSentinel surveillance network and the Global TravEpiNet (GTEN) consortium, and translated the data each provides into sensible guidance for travel medicine practitioners. Her many experiences—as a professor in an academic institution, as an expert consultant in CDC’s Division of Global Migration and Quarantine, and her work with industry—have provided Phyllis with the multiple perspectives she uses to develop her sound, workable recommendations.

Practical, pragmatic, resourceful, deeply knowledgeable, and highly connected to colleagues throughout the world, Phyllis has a deft touch when dealing with controversial and complicated issues. Her many publications include guidelines and useful advice for common as well as emerging problems, including Zika and Ebola. She has written about vulnerable populations and business and corporate travelers. She has communicated information to the public through interviews and other media outlets, and as Chief Medical Editor for multiple editions of the Yellow Book, Phyllis has reached the global community of travel medicine practitioners.

Mary E. Wilson, MD

A clade of scholars currently focuses on virtual or counterfactual history. So let us ask, hypothetically, “What if in the late 1980’s there would have been no Phyllis Kozarsky at Emory University to collaborate mainly with the CDC in the project for the 1991 Atlanta Travel Medicine Conference?” The simple answer is that there would have been no meeting, and the International Society of Travel Medicine (ISTM) would not have been founded!

Over the decades, Phyllis has continued to contribute as a top leader in crucial projects whenever needed, forging compromises and building bridges. On the surface, soft as velvet, but—when necessary—convincing colleagues with hard facts and her little smile, up to the final success. Phyllis has been one of the main travel medicine achievers in many functions both inside and outside the CDC and the ISTM.

Robert Steffen, MD

Few others in my experience have Phyllis Kozarsky’s common sense and wisdom, two of her strongest personal qualities. Wise beyond her years, she is also a caretaker: a compassionate, thoughtful and nurturing individual, always sensitive to the needs of others, an excellent team player and peacemaker. She has never sought the limelight in terms of her work with ISTM, preferring instead to be in the background, letting others take credit even when she was very much involved in the work and its accomplishments. She preferred to be, as I saw it, ‘the power behind the throne.’ She has carved out her many successes with a quiet determination.

Phyllis is a remarkably bright, innovative leader in the field of travel medicine. A visionary, not a follower, her accomplishments are a testament to her desire to make the world a better place. Her tremendous interpersonal skills have made her an effective, innovative leader in the field of travel medicine and a beloved friend.

Jay S. Keystone, MD

Phyllis Kozarsky has played a critical role in defining, nurturing, and holding to high standards the field of travel medicine. Her depth of expertise is unsurpassed, but more importantly, she has been amazingly adept at linking the fields of clinical medicine and public health. She has facilitated countless connections, bringing together disparate groups, topics, and nations. With regard to CDC’s Yellow Book, Phyllis’ input has ensured it has remained the authoritative travel medicine reference, enabling countless providers to render outstanding care and advice. We will miss her knowledge, counsel, wit and graciousness as she steps down as Chief Medical Editor.

Edward T. Ryan, MD

I have known my friend and colleague Dr. Phyllis Kozarsky for over 25 years and I cannot think of a single person who has had as much influence on the field of travel medicine as she has. An advocate for public and professional education in travel medicine, Phyllis was a founding member of the International Society of Travel Medicine (ISTM), served as its first Secretary Treasurer, and organized its first conference in 1991; she chaired its first Professional Education Committee and created the ISTM Certification Examination. She has also served as editor of the premier textbook in travel medicine. Her accomplishments—clinical, educational and organizational—set her apart from virtually everyone else in the field. And matched by her accomplishments and intelligence (perhaps even exceeding them) are her warmth, compassion and generosity of spirt, her kindness, empathy and true respect of others.

Bradley A. Connor, MD

The CDC Yellow Book first appeared in 1967. Originally a thin pamphlet, it presented to readers some specific provisions of the International Health Regulations.

For the last 11 editions (over the past 20 years), Phyllis Kozarsky has guided the transformation of the Yellow Book into the comprehensive travel medicine reference by which all other sources of travel medicine information are now judged. Its guidelines and recommendations articulate the evidence-base in the US-context as determined by the CDC and its various advisory bodies. And while a number of other national and international resources are available, experienced clinicians outside the United States continue to refer to the Yellow Book as a mandatory pillar of consultation for all matters of clinical decision support to safeguard the health of their travelers.

Phyllis, who directed her own travel clinic at Emory University where she had an enviable publication record as a Professor of Medicine, has been steadfast in ensuring that the Yellow Book be written primarily for practicing clinicians. Over the years, she assembled a cadre of expert co-editors and contributors from outside the agency (mainly experts from GeoSentinel and ISTM) who themselves had day-to-day experience in the practice of travel medicine, helping make each edition come to life.

Phyllis’ vision and soft-spoken subject-matter mastery—combined with her dogged diligence up until the last possible publication deadline—has allowed her to bring together experts from inside and outside the CDC. Experts who craft language that provides readers with a comprehensive understanding of a topic, and a best-possible, very practical solution to any clinical scenario that might walk into the travel clinic. The qualifications for Phyllis’ successor should simply include the attributes mentioned in this dedication piece; one should ask for no more and no less.

David O. Freedman, MD

Notices and Disclaimers

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