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Cambodia



Capital: Phnom Penh

Time Zone: +7 hours.
Tel. Country Code: 855
USADirect Tel.: 1
Electrical Standards: Electrical current is 220/50 or 110/60 (volts/hz). European-Style Adaptor Plug and United Kingdom-Style Adaptor Plug. Grounding Adaptor Plugs C, D.


Travel Advisory - Cambodia

Malaria, Japanese encephalitis, and dengue fever occur throughout SE Asia and the Indian sub-Continent. Insect-bite protection is essential. Hepatitis E, spread by contaminated water, is also a threat. There is no vaccine. Pregnant women are at special risk. Take measures, as needed, to purify your water outside of first-class hotels.

Dr. Rose Recommends for Travel to Cambodia


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Embassies


U.S. Embassy
Phnom Penh


U.S. Citizen Services

American Citizens should call the Embassy as soon as practical in the event of an arrest, death, hospitalization, or other emergency involving a U.S. citizen. In an emergency, Embassy personnel can assist in talking with medical personnel, police, or other officials on behalf of the U.S. citizen and his or her family.

For emergencies during regular office hours (8:00am to 5:00pm, Monday thru Friday) please call +855 23-728-402 / +855 23-728-051 / +855 23-728-234.

In the event of an emergency after hours, please call +855 23-728000.  Press 1 and then 0 to be transferred to the operator.

Entry Requirements

HIV Test: Visa applicants must present a medical certificate. Enforcement of this requirement is inconsistent.

Required Vaccinations: A yellow fever vaccination certificate is required of travelers arriving from infected areas.

Passport Information

Passport/Visa: Cambodia is a poor, developing country with a constitutional monarchy and an elected government. King Norodom Sihamoni is the constitutional monarch and head of state. Elections for Members of the National Assembly were last held in July 2003. Two parties, the CPP and FUNCINPEC, have formed a coalition government, which the CPP dominates. The country has a market economy, with approximately 80 percent of the population of 13.6 million engaged in subsistence farming. The government has good relations with its neighbors despite strains over residual border disputes and other historic antagonisms. The quality of tourist facilities varies widely in Cambodia with the highest standard found in Phnom Penh, Siem Reap, and Sihanoukville. 


 A valid passport and a Cambodian visa are required. Cambodia offers on-line visa processing at http://evisa.mfaic.gov.kh. Tourist and business visas are valid for one month beginning with the date of entry into Cambodia. You may also apply in person at the Cambodian Embassy in Washington, DC  


Tourists and business travelers may also obtain a Cambodian visa at the airports in Phnom Penh, Siem Reap, and at all major border crossings. Both methods of obtaining a Cambodian visa require a passport-sized photograph and a passport that is valid for a minimum of six months beyond the date of entry into Cambodia. A departure tax is charged on all domestic and international flights. This tax must be paid in U.S. dollars. Overseas inquiries may be made at the nearest embassy or consulate of Cambodia. Travelers should note that Cambodia regularly imposes fines of USD 5.00 per day on charges of overstay on an expired visas. Visit the Embassy of the Kingdom of Cambodia web site for the most current visa information.

Vaccinations: Recommended and Routine

Hepatitis A: Recommended for all travelers >1 year of age not previously immunized against hepatitis A.

Hepatitis B: Recommended for all non-immune travelers who might be exposed to blood or body fluids from unsafe/unprotected sexual contact; from injecting drug use; from medical treatment with non-sterile (re-used) needles and syringes, and acupuncture; from unscreened blood transfusions; from contact with open skin sores of another person. Recommended for any traveler requesting protection against hepatitis B.

Influenza: Vaccination recommended for all travelers >6 months of age who have not received a flu shot in the previous 12 months.

Japanese Encephalitis: Recommended for travelers planning to visit rural farming areas for >4 weeks and under special circumstances, such as a known outbreak of Japanese encephalitis.

Rabies: Recommended for travelers spending time in remote locations, or outdoors in rural areas where there is an increased the risk of animal bites. Pre-exposure vaccination eliminates the need for rabies immune globulin in the event of a high-risk animal bite, but does not eliminate the need for additional treatment with rabies vaccine.

Routine Immunizations: Immunizations against tetanus-diphtheria, measles, mumps, rubella (MMR vaccine) and varicella (chickenpox) should be updated, if necessary, before departure. MMR protection is especially important for any female of childbearing age who may become pregnant.
• The new Tdap vaccine, ADACEL, which also boosts immunity against pertussis (whooping cough) should be considered when a tetanus-diphtheria booster is indicated.

Typhoid: Recommended for all travelers with the exception of short-term visitors who restrict their meals to major restaurants and hotels, such as business travelers and cruise passengers.

Hospitals / Doctors

Medical facilities and services in Cambodia do not meet international standards. Adequate care for basic emergencies is limited in Phnom Penh. Siem Reap, the major tourist attraction of Cambodia, currently has one facility that can provide basic medical care. Medical care outside the capital is almost non-existent. Hospitals are not recommended for anything but immediate stabilization prior to an air medical evacuation or for or minor medical concerns.

All travelers should be up-to-date on their immunizations and are advised to carry a medical kit as well as antibiotics to treat travelers diarrhea or other infections; they should bring drugs for malaria prophylaxis, if needed according to their itinerary. Travelers who are taking regular medications should carry them properly labeled and in sufficient quantity to last for the duration of their trip; they should not expect to obtain prescription or over-the-counter drugs in local stores or pharmacies in this country - the equivalent drugs may not be available; may be of dubious origin; may be counterfeit, or of unreliable quality.

• Travelers are advised to obtain comprehensive travel and medical evacuation insurance with specific overseas coverage. Policies should cover: ground and air ambulance transport, including evacuation to your home country; payment of hospital bills; 24-hour telephone assistance. In the event of a serious illness or injury that can't be treated locally, you should arrange medical evacuation Bangkok or Singapore.


Listing of Hospitals & Clinics in Cambodia


Medical facilities in Phnom Penh used by expatriates and travelers include:


Tropical and Travellers Medical Clinic

2 blocks from the U.S. Embassy


Naga Clinic
#11 Street 254
Phnom Penh
Naga Clinic has a limited facility in Siem Reap.


International SOS 
Phnom Penh

Website: http://www.internationalsos.com./en/about-our-clinics_cambodia_35.htm
Services includr  General Practice, Sports Medicine, Women’s Health, Dermatology, Internal Medicine, Emergency Medicine, Travel Medicine and Dental Care.
international SS provides standards of personalized medical care and assistance to individuals and their families, groups, as well as private sector and non-governmental organizations.


Calmette Hospital
#3 Monivong Boulevard
Phnom Penh

This facility has emergency, surgical, medical and Ob/Gyn departments, a radiology unit, laboratory, central pharmacy and an outpatient.

Calmette Hospital or l'hôpital Calmette, located on Monivong Boulevard in Phnom Penh, is a public hospital managed by Ministry of Health and funded by the Cambodian and French governments. It is considered as Cambodia's flagship health care centre.


Somary Raffles Medical Center (SRMC)
Phnom Penh


Private clinic convenient for travelers and used by expatriates. 24/7 emergency care. SRMC is equipped with the facilities needed to stabilize a critically ill or injured person before evacuation.

Destination Health Info for Travelers

AIDS/HIV: After peaking at approximately 3.3% in 1997-98, HIV prevalence among national adult population in Cambodia has declined to 1.9% in 2003, due in part to a larger decline among young female sex workers compared with those older than 20 years. Husband-to-wife infection is now a major mode of transmission and one-third of all new HIV infections are from mother to child, reports UNAIDS Update, 2005.

• The development of AIDS should not be a primary concern for the traveler. However, there may be a concern for a subset of travelers who may be exposed to HIV, the virus that causes AIDS, through contact with another person’s body fluids or blood. Although travel has contributed in a general way to the global spread of AIDS, fear of traveling because of this disease is not warranted.

• Transmission of HIV can be prevented by avoiding: sexual contact with a high-risk partner; injecting drug use with shared needles; non-sterile medical injections; unscreened blood transfusions.

Accidents & Medical Insurance: Accidents and injuries are the leading cause of death among travelers under the age of 55 and are most often caused by motor vehicle and motorcycle crashes; drownings, aircraft crashes, homicides, and burns are lesser causes.
• Heart attacks cause most fatalities in older travelers.
• Infections cause only 1% of fatalities in overseas travelers, but, overall, infections are the most common cause of travel-related illness.
• MEDICAL INSURANCE: Travelers are advised to obtain, prior to departure, supplemental travel health insurance with specific overseas coverage. The policy should provide for direct payment to the overseas hospital and/or physician at the time of service and include a medical evacuation benefit. The policy should also provide 24-hour hotline access to a multilingual assistance center that can help arrange and monitor delivery of medical care and determine if medevac or air ambulance services are required.

Animal Hazards: Animal hazards include snakes (cobras, vipers), spiders (black and brown widow), crocodiles, and leeches.

Avian Influenza (Bird Flu):  Avian influenza H5N1 remains a serous threat to the health of all Cambodians and more so for children, who seem to be most vulnerable and are at high risk. There have been 56 cases of H5N1 infection in humans since 2005 and 9 cases in 2014. 


• H5N1 avian influenza is predominantly a disease of birds. The virus does not pass easily from birds to people and does not to pass from person to person (except in very rare cases of close contact with an infected blood relative). 

• The risk to humans from avian influenza is believed to be very low and no travel restrictions are advised, except travelers should avoid visiting animal markets, poultry farms and other places where they may come into close contact with live or dead poultry, or domestic, caged or wild birds and their excretions. In addition, travelers are advised to:

1. Cook poultry and egg dishes thoroughly. (Well-cooked poultry is safe to eat.)

2. Wash hands frequently with soap and water if around poultry.

The World Health Organization (WHO) does not recommend travel restrictions to countries experiencing outbreaks of H5N1 avian influenza in birds, including those countries which have reported associated cases of human infection.

The usual vaccines against influenza are not protective against “bird flu.”

Oseltamivir (Tamiflu) is somewhat effective in the treatment of H5N1 avian influenza. It seems to be effective in some cases, but may fail in others. Recently, resistant strains have been reported. In addition, the dosage and duration of treatment appear to be different in severe H5N1 cases.

Cholera: Although this disease is reported sporadically active, the threat to tourists is relatively low. Cholera is an rare disease in travelers from developed countries. Cholera vaccine is usually recommended only for relief workers or health care personnel who are working in a high-risk endemic area under less than adequate sanitary conditions, or travelers who work or live in remote, endemic or epidemic areas and who do not have ready access to medical care. Canada, Australia, and countries in the European Union license an oral cholera vaccine. The cholera vaccine is not available in the United States.
• The main symptom of more severe cholera is copious watery diarrhea.
• Antibiotic therapy is a useful adjunct to fluid replacement in the treatment of cholera by substantially reducing the duration and volume of diarrhea and thereby lessening fluid requirements and shortening the duration of hospitalization.


A single 1-gm oral dose of azithromycin
 is effective treatment for severe cholera in adults. This drug is also effective for treating cholera in children. 

Crime/Security/Civil Unrest: Terrorism is a threat throughout the world, including South-East Asia. In recent years Cambodian authorities have disrupted a number of attempted bomb plots. The latest incident occurred on 3 January 2009 when three improvised explosive devices (IEDs) were found in two locations in Phnom Penh.
Civil Unrest/Political Tension: The security situation in Cambodia has the potential to deteriorate quickly. You should avoid public gatherings or demonstrations, particularly near political party offices. There is an ongoing dispute between Cambodia and Thailand relating to the land adjacent to the Preah Vihear Temple (Kha Pra Viharn in Thai) located on the border region between Preah Vihear Province in Cambodia and Sisaket Province in Thailand. There were instances of fighting between Cambodian and Thai military troops in October resulting in some injuries and fatalities. The temple is currently closed to tourists.
Crime: Opportunistic crime is common in Cambodia and the frequency of incidents is increasing. Thieves frequently snatch foreigners’ bags and pick-pocketing is a problem in Phnom Penh, Sihanoukville and Siem Reap. Several foreigners have been injured in the course of these incidents, in particular when bags are pulled from passengers on moving motorbike taxis.
There have been recent reports of assaults and armed robberies against foreigners, especially in areas frequented by tourists and expatriate residents, including the Riverfront in Phnom Penh and Sihanoukville (particularly at isolated beaches). You should exercise vigilance when traveling through these areas at all times, but especially after dark. You should limit night time travel around Phnom Penh, Sihanoukville and Siem Reap to well-lit public areas, and travel in groups. At night, travel by car is safer than motorcycle, moto-scooter or cyclo (cycle-rickshaw).
Foreigners have been the target of sexual assault in Cambodia. Due to the high prevalence of HIV/AIDS, victims of sexual assault are strongly encouraged to seek immediate medical assistance.
• Levels of firearm ownership in Cambodia are high and guns are sometimes used to resolve disputes. There have been reports of traffic disputes resulting in violence involving weapons. Foreigners have been threatened with handguns for perceived slights to local patrons in popular Phnom Penh nightclubs and elsewhere.
Banditry and extortion, including by military and police personnel, continue in some rural areas, particularly at night in areas between Snoul, Kratie and Stung Treng in the northeastern provinces.
• Landmines remain a danger in many parts of Cambodia, especially along the border with Thailand. Large areas of rural Cambodia are still contaminated with unexploded ordnance.

Travel by roads, especially at night, is dangerous because of poor road conditions, vehicle maintenance, wandering livestock and the risk of crime. You should take precautions, including the use of a helmet and protective clothing when traveling on a motorcycle or motorscooter (even as a passenger).
For further advice, see the bulletin on Overseas Road Safety from Smartraveller: (http://www.smartraveller.gov.au/zw-cgi/view/TravelBulletins/Overseas_Road_Safety).

Public transport, particularly rail, is poorly maintained. You should avoid traveling by trains because of the high risk of accidents.
If travelling beyond the Angkor Wat temple complex to outlying temples in Siem Reap you should exercise caution because of landmines and unexploded ordinance.

Source: http://www.iccwbo.org/ccs/imb_piracy/weekly_piracy_report.asp

Dengue Fever: Endemic at high levels year-round. Increased risk may occur in urban areas. A major outbreak of dengue fever was reported in the summer of 2007 with more fatalities than in all of 2006. Dengue fever is a mosquito-transmitted, flu-like viral illness widespread in Asia. Symptoms consist of sudden onset of fever, headache, muscle aches, and a rash.
• Dengue is transmitted via the bite of an infected Aedes aegypti mosquito. Aedes mosquitoes feed predominantly during daylight hours. All travelers are at risk and should take measures to prevent daytime mosquito bites
. Insect-bite prevention measures include applying a DEET-containing repellent to exposed skin and applying permethrin spray or solution to clothing and gear.
• There is no vaccination or medication to prevent or treat dengue.


Dengue fever maps 


Hepatitis: There is a high risk of hepatitis A in this country. All travelers not previously immunized against hepatitis A should be vaccinated against this disease. Travelers who are non-immune to hepatitis A (i.e. have never had the disease and have not been vaccinated) should take particular care to avoid potentially contaminated food and water. Travelers who will have access to safe food and water are at lower risk. Those at higher risk include travelers visiting friends and relatives, long-term travelers, and those visiting areas of poor sanitation.
• Hepatitis E is endemic with a seroprevalence of 12.8% in the general population. Sporadic cases and outbreaks occur. Transmission of the hepatitis E virus (HEV) occurs primarily through drinking water contaminated by sewage and also through raw or uncooked shellfish. Farm animals may serve as a viral reservoir. In developing countries, prevention of hepatitis E relies primarily on the provision of clean water supplies and overall improved sanitation and hygiene. There is no vaccine.
• Hepatitis B is hyperendemic. The overall hepatitis B (HBsAg) carrier rate in the general population is estimated at >8%. Hepatitis B is transmitted via infected blood or bodily fluids. Travelers may be exposed by needle sharing and unprotected sex; from non-sterile medical or dental injections, and acupuncture; from unscreened blood transfusions; by direct contact with open skin lesions of an infected person. The average traveler is at low risk for acquiring this infection. Vaccination against hepatitis B is recommended for: persons having casual/unprotected sex with new partners; sexual tourists; injecting drug users; long-term visitors; expatriates, and anybody wanting increased protection against the hepatitis B virus.
• Hepatitis C is endemic at high level with a seroprevalence of 4.0% in the general population. Most hepatitis C virus (HCV) is spread either through intravenous drug use or, in lesser-developed countries, through blood contamination during medical procedures. Over 200 million people around the world are infected with hepatitis C - an overall incidence of around 3.3% of the population of the world. Statistically, as many people are infected with HCV as are with HIV, the virus that causes AIDS.

Influenza: Influenza is transmitted year-round in the tropics. The flu vaccine is recommended for all travelers over age 6 months.

Insects: All travelers should take measures to prevent both daytime and nighttime insect bites. Insect-bite prevention measures include a DEET-containing repellent applied to exposed skin, insecticide (permethrin) spray applied to clothing and gear, and use of a permthrin-treated bednet at night while sleeping.

Japanese Encephalitis (JE): Sporadic cases occur throughout the year, primarily in rural areas, but occasionally near or within urban areas. The peak transmission season is May to November.
The Centers for Disease Control and Prevention (CDC) recommends JE vaccination for travelers spending more than 30 days in an endemic environment, or less than 30 days in areas with epidemic transmission. However, the use of an arbitrary cutoff cannot protect all travelers. Advance knowledge of trip details, accommodation and purpose, as well as local geography, is warranted to give adequate advice. Is travel occurring during the peak transmission season? In general, travelers to rural areas (especially where there is pig rearing and rice farming) should be vaccinated if the duration of their trip exceeds 3 to 4 weeks. They may consider vaccination for trips of shorter duration if more intense exposure is anticipated, especially during unprotected outdoor activities in the evening.
In addition:
• Vaccination is advised for expatriates living in this country.
• Japanese encephalitis is transmitted by Culex mosquitoes that bite primarily from dusk to dawn. All travelers should take measures to prevent mosquito bites, especially in the evening and during the night. Insect-bite prevention measures include applying a DEET-containing repellent to exposed skin, applying permethrin spray or solution to clothing and gear, and sleeping under a permethrin-treated bednet at night.

Geographic Distribution of Japanese Encephalitis:
http://gamapserver.who.int/mapLibrary/Files/Maps/Global_JE_ITHRiskMap.png

Malaria: Risk is widespread year-round throughout this country, but in the main tourist areas, including Phnom Penh and the Angkor temple complex, the risk is low. Malaria is endemic at high levels in forested areas along the borders, moderate levels in central areas, and low levels from Tonle Sap Lake through Phnom Penh and down the Mekong River to the Vietnamese border. There is increased risk in mountainous and rural areas. Falciparum malaria accounts for an estimated 90% of cases. Mefloquine-resistant falciparum malaria is common, especially near the Thai-Cambodian border.


Malaria map for Cambodia


Malaria is transmitted via the bite of an infected female Anopheles mosquito. Anopheles mosquitoes feed predominantly during the hours from dusk to dawn. All travelers should take measures to prevent evening and nighttime mosquito bites. Insect-bite prevention measures include applying a DEET-containing repellent to exposed skin, applying permethrin spray or solution to clothing and gear, and sleeping under a permethrin-treated bednet. DEET-based repellents have been the gold standard of protection under circumstances in which it is crucial to be protected against insect bites that may transmit disease. Nearly 100% protection can be achieved when DEET repellents are used in combination with permethrin-treated clothing.
NOTE: Picardin repellents (20% formulation, such as Sawyer GoReady or Natrapel 8-hour) are now recommended by the CDC and the World Health Organization as acceptable non-DEET alternatives to protect against malaria-transmitting mosquito bites. Picaridin is also effective and ticks and biting flies.
• You should consider the diagnosis of malaria if you develop an unexplained fever during or after being in this country.
• Long-term travelers who may not have access to medical care should bring along medications for emergency self-treatment should they develop symptoms suggestive of malaria, such as fever, chills, headaches, and muscle aches, and cannot obtain medical care within 24 hours.


Marine Hazards: Stingrays, jellyfish, sea snakes and several species of poisonous fish are common in the coastal waters and are potential hazards to unprotected swimmers.

Other Diseases/Hazards: Anthrax (may be associated with eating infected buffalo meat)
• Chikungunya fever (regionally endemic, with outbreaks; acute Chikungunya fever typically lasts a few days to several weeks; may be confused with dengue or malaria)
• Clonorchiasis (Oriental liver fluke infection; acquired from undercooked freshwater fish; symptoms include fever, chills, epigastric pain, tender hepatomegaly, diarrhea, and mild jaundice)
• Echinococcosis
• Fasciolopsiasis (Giant intestinal fluke; acquired through eating contaminated aquatic plants, such as water chestnuts, or drinking untreated water infested with trematode cercaria)
• Filariasis (endemic; current levels unclear)
• Gnathostomiasis (larvae may be found in raw or undercooked meat, e.g., freshwater fish, chicken, snails, frogs, pigs, or in contaminated water. Rarely, larvae penetrate the skin of individuals who are exposed to contaminated meat or water) Any organ system can be involved, but the most common manifestation of infection is localized, intermittent, migratory swelling in the skin and subcutaneous tissues.
• Leptospirosis (humans may be infected through direct contact with urine of infected animals, or through contact with contaminated water or soil)
• Melioidosis (contact with contaminated soil and water, especially in agricultural fields; symptoms include wound infections or life-threatening pneumonia)
• Plague
• Scrub typhus
• Soil-transmitted helminthic diseases (ascariasis, hookworm disease, strongyloidiasis)
• Opisthorchiasis (liver fluke disease; human infection occurs through consumption of pickled, raw, or poorly cooked fish that contain the developing worms known as metacercariae; Infection most frequently occurs in Thailand, Cambodia; Laos, and southeast Asia as a result of the cultural preference for raw fish cuisine)

Rabies: Sporadic cases of human rabies are reported countrywide and the risk of human rabies is increased in rural areas. Stray and sometimes viscous dogs are the main source of human rabies, but monkeys can also carry the disease. Pre-exposure rabies vaccine is recommended for travel longer than 3 months, for shorter stays in rural when travelers plan to venture off the usual tourist routes and where they may be more exposed to the stray dog population; when travelers desire extra protection; or when they will not be able to get immediate medical care.
• All animal bite wounds, especially from a dog, should be thoroughly cleansed with soap and water and then medically evaluated for possible post-exposure treatment, regardless of your vaccination status. Pre-exposure vaccination eliminates the need for rabies immune globulin, but does not eliminate the need for two additional booster doses of vaccine. Even if rabies vaccine was administered before travel, you will need a 2-dose booster series of vaccine after the bite of a rabid animal.

Schistosomiasis: Risk is present year-round, especially along the Mekong and Mun Rivers and in Battambang Province. Schistosomiasis is transmitted through exposure to freshwater streams, rivers or lakes during activities such as wading, swimming, and bathing. Schistosoma larvae, released from infected freshwater snails, penetrate intact skin to establish infection. All travelers should avoid swimming, wading, or bathing in freshwater lakes, ponds, or streams. There is no risk in chlorinated swimming pools or in seawater.

Travelers' Diarrhea: Outside of hotels and resorts, we recommend that you boil, filter or purify all drinking water or drink only bottled water or other bottled beverages and do not use ice cubes. Avoid unpasteurized milk and dairy products. Do not eat raw or undercooked food (especially meat, fish, raw vegetables—these may transmit intestinal parasites, as well as bacteria). Peel all fruits.
• Good hand hygiene reduces the incidence of travelers’ diarrhea by 30%.
• A quinolone antibiotic, or azithromycin, combined with loperamide (Imodium), is recommended for the treatment of diarrhea. Diarrhea not responding to antibiotic treatment may be due to a parasitic disease such as giardiasis, amebiasis, or cryptosporidiosis.
• Seek qualified medical care if you have bloody diarrhea and fever, severe abdominal pain, uncontrolled vomiting, or dehydration.

Tuberculosis: Tuberculosis is highly endemic in Cambodia with an annual occurrence was greater than or equal to 40 cases per 100,000 population. Tuberculosis (TB) is transmitted following inhalation of infectious respiratory droplets. Most travelers are at low risk. Travelers at higher risk include those who are visiting friends and relatives (particularly young children), long-term travelers, and those who have close contact, prolonged contact with the local population. There is no prophylactic drug to prevent TB. Travelers with significant exposure should have PPD skin testing done to evaluate their risk of infection.

Typhoid Fever: Typhoid fever is the most serious of the Salmonella infections. Typhoid vaccine is recommended by the CDC for all people traveling to or working in Cambodia, especially if visiting smaller cities, villages, or rural areas and staying with friends or relatives where exposure might occur through food or water. Current vaccines against Salmonella typhi are only 50-80% protective and do not protect against Salmonella paratyphi, the cause of paratyphoid fever. (Paratyphoid fever bears similarities with typhoid fever, but the course is generally more benign.) Travelers should continue to practice strict food, water and personal hygiene precautions, even if vaccinated.