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Travel Advisory - Myanmar (Burma)
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 Myanmar (Burma)
Canadian diplomatic contacts are handled by the Australian Embassy.
HIV Test: Not required.
Required Vaccinations: Travelers >1 year of age entering the country from an endemic area are required to present a certificate of immunization against yellow fever.
Passport/Visa: Burma (Myanmar) is an underdeveloped agrarian country ruled by an authoritarian military regime. The government suppresses all expression of opposition to its rule.
After a long period of isolation, Burma has started to encourage tourism. Foreigners can expect to pay several times more than locals do for accommodations, domestic airfares, and entry to tourist sites. Tourist facilities in Rangoon (Yangon), Bagan, Ngapali Beach, Inle Lake, and Mandalay are superior to tourist facilities in other parts of the country, where they are limited. Please note that visitors should travel with sufficient cash to cover their expenses for the duration of their visit. Travelers checks and credit cards are not accepted anywhere, and ATM machines are nonexistent in Burma.
ENTRY AND EXIT REQUIREMENTS: The government of Burma strictly controls travel to, from, and within Burma. Since October 1, 2006, Burmese authorities have often prohibited entry or exit at most land border crossings, unless the traveler is part of a package tour group that has received prior permission from the Burmese authorities. A passport and visa are required for entry into Burma. Travelers are required to show their passports with a valid visa at all airports, train stations, and hotels. Security checkpoints are common outside of tourist areas. Burmese authorities rarely issues visas to persons with occupations they deem sensitive, including journalists.
Information about entry requirements as well as other information may be obtained from the Burmese Embassy (Embassy of the Union of Myanmar) 2300 S Street, NW, Washington, DC 20008
The Permanent Burma Mission (Mission of Myanmar) to the U.N.
10 East 77th St., New York, NY 10021, (212-535-1311); fax 212-744-1290.
Vaccinations: Recommended and Routine
Cholera: Recommended for all travelers >1 year of age not previously immunized against hepatitis A.
Hepatitis B: Recommended for all non-immune travelers at potential risk for acquiring this infection. Hepatitis B is transmitted via infected blood or bodily fluids. Travelers may be exposed by needle sharing and unprotected sex; from acupuncture, tattooing or body piercing; when receiving non-sterile medical or dental injections, or unscreened blood transfusions; by direct contact with open skin sores on an infected person. Recommended for long-term travelers, expatriates, and any traveler requesting protection against hepatitis B infection.
Influenza: Vaccination recommended for all travelers >6 months of age who have not received a flu shot in the previous 12 months.
Japanese Encephalitis: The vaccine is recommended for persons living in endemic and epidemic areas and for at-risk travelers planning extended trips to rural areas (arbitrarily defined as 30 days). Persons visiting areas with active epidemic Japanese encephalitis should be considered for vaccination even if their projected stay is less than 30 days. Vaccination for persons staying fewer than 30 days may be considered if they expect unprotected nighttime outdoor exposure in endemic areas.
Polio: A one-time dose of IPV vaccine is recommended for any traveler >age 18 who completed the primary childhood series but never received an additional dose of polio vaccine as an adult. Available data do not indicate the need for more than a single lifetime booster dose with IPV (Inactivated Polio Vaccine).
Rabies: Rabies vaccine is recommended for: persons anticipating an extended stay; for those whose work or activities may bring them into contact with animals; for people going to rural or remote locations where medical care is not readily available; for travelers desiring extra protection.
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.
• In addition to tetanus, all travelers, including adults, should be fully immunized against diphtheria. A booster dose of a diphtheria-containing vaccine (Td or Tdap vaccine) should be given to those who have not received a dose within the previous 10 years.
Note: ADACEL is a new tetanus-diphtheria-pertussis (Tdap) vaccine that not only boosts immunity against diphtheria and tetanus, but has the advantage of also protecting against pertussis (whooping cough), a serious disease in adults as well as children. The Tdap vaccine can be administered in place of the Td vaccine when a booster is indicated.
Typhoid: Recommended for all travelers with the exception of short-term visitors who restrict their meals to hotels or resorts.
Yellow Fever: Travelers >1 year of age entering the country from an endemic area are required to present a certificate of immunization against yellow fever.
Hospitals / Doctors
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 counterfeit; may be of unreliable quality.
• Travelers are advised to obtain comprehensive travel insurance with specific overseas coverage, including air ambulance medevac. In the event of a serious illness or injury that can't be treated locally, every effort should be made to arrange medical evacuation to Bangkok, Thailand.
Routine medical advice and treatment can be obtained in Rangoon and Mandalay, but elsewhere you should not assume that competent advice and treatment will be available.
The best facilities in Yangon include:
• Asia Royal Cardiac and Medical Centre
14 Baho St.
Tel:  (1) 53-8055
Bahosi Medical Centre
Bahosi Housing Complex
Tel:  (1) 212 933
Full range of specialty services; 24-hour emergency room.
• Shwe Gon Dine Specialist Centre
7 East Shwe Gon Dine Road
Tel:  544 128
• Myanmar International SOS Limited
The New World Inya Lake Hotel
37 Kaba Aye Pagoda Road
Tel:  (1) 667 879
Fax:  (1) 667 866
The best facilities In Mandalay include:
• Mandalay General Hospital
Chan Aye Tha Zan Township
Tel:  39001 (952) 390002 (952) 39005
• Palace Specialist Centre
71st Street between 28th-29th Street
Chan Aye Tha Zan Township
Tel:  (2] 36128
Travelers should be aware that the U.S. Embassy often evacuates its personnel to Bangkok, Thailand, in lieu of using local Burmese hospitals.
Destination Health Info for Travelers
AIDS/HIV: After first appearing in the mid-to-late 1980s, HIV became increasingly common in Myanmar. HIV/AIDS is widespread among high-risk populations, such as prostitutes and illegal drug users.
• When HIV is transmitted through unprotected sex in Asia, it is often from commercial sex. More people in Asia engage in sex work (either as a client or a worker), than any other type of behavior that can carry a high risk of HIV infection. High levels of HIV infection have been documented among sex workers and their clients in Asian countries; in South and South East Asian countries outside India, it is thought that sex workers and their clients accounted for almost half of people living with HIV in 2006.
• Injecting drug use (IDU) is a major driving factor in the spread of HIV throughout Asia. There is often an overlap between communities of IDUs and communities of sex workers in Asia, as those who sell sex may do it to fund a drug habit, or they may have become involved in sex work first before turning to drug use.
• Sex between men accounted for some of the earliest recorded cases of HIV in Asia, and transmission through this route is still a prominent feature of many countries epidemics. Most men who have sex with men (MSM) in Asia do not identify themselves as gay because of cultural norms that discourage homosexuality; in some cases they may even be heads of families, with children. This means that MSM can serve as a bridge for HIV to spread into the broader population. HIV outbreaks are becoming evident among MSM in Cambodia, China, Nepal, Pakistan, Thailand and Vietnam. (Source: www.Avert.org)
• 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.
• The threat of HIV/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 the body fluids of another person or their 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.
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 (vipers, cobras), centipedes, scorpions, and black widow spiders. Other possible hazards include crocodiles, pythons, and large, aggressive lizards, all abundant in and near Burma’s swamps and rivers, and leopards, wildcats, and bears, all found in the hilly regions of the country.
Avian Influenza A (Bird Flu): In December 2007, the World Health Organization (WHO) confirmed Burma’s first (nonfatal) human case of avian influenza in a remote area of eastern Shan State. In early 2006 and throughout 2007, brief avian influenza outbreaks resulted in the death of domestic poultry and some wild birds.
• Avian influenza A (H5N1) 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 influenza A (H5N1) in birds, including those countries which have reported associated cases of human infection. To date, no cases of avian influenza A (H5N1) illness have been identified among short-term travelers visiting countries affected by outbreaks among poultry or wild birds.
The usual vaccines against influenza are not protective against bird flu. Oseltamivir (Tamiflu) is somewhat effective in the treatment of avian influenza A (H5N1). 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 cases.
Cholera: This disease is reported sporadically active in this country. Cholera is a rare disease in travelers from developed countries. Cholera vaccine is 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.
Cholera vaccine is 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. (NEJM:http://content.nejm.org/cgi/content/short/354/23/2452)
Dengue Fever: Highly endemic. Cases in April and May 2007 were nearly double what they were in 2006 and nearly 1000 cases a week were reported through July 2007. The peak infection rate usually occurs during the wetter months, May through October. Dengue occurs countrywide, but predominates in urban areas.
Dengue fever is a mosquito-transmitted, flu-like viral illness occurring in South East Asia. Symptoms consist of sudden onset of fever, headache, muscle aches, and a rash. A syndrome of hemorrhagic shock can occur in severe cases.
• 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.
A dengue fever map is at: http://www.nathnac.org/ds/c_pages/documents/dengue_map.pdf
Filariasis: Bancroftian and Malayan filariasis (mosquito-borne) are highly endemic in rural and urban areas. All travelers should take measures to prevent insect (mosquito) bites.
Hepatitis: 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 but levels are unclear. Documented outbreaks have occurred; sporadic cases may be underdiagnosed or underreported. Transmission of the hepatitis E virus (HEV) occurs primarily through drinking water contaminated by sewage and also through raw or uncooked shellfish. Farm animals, such as swine, and also deer and wild boar, may serve as a viral reservoirs. (HEV is one of the few viruses which has been shown to be transmitted directly from animals through food.) 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 with a prevalence of 5.6% 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: There is the risk of insect-transmitted diseases in this country. You should take measures to prevent insect-bites, especially in rural areas below 5,000 ft. elevation. For maximum protection, apply a DEET-containing repellent to exposed skin (30%–50% concentration recommended), apply permethrin spray or solution to your clothing and gear, and sleep under a permethrin-treated bednet (if available).
• Until recently, DEET-based repellents have been the gold standard against mosquito and tick bites. The CDC and the World Health Organization now recommend 20% picaridin as an effective DEET alternative. You can achieve nearly 100% bite protection by using a properly-applied DEET or picaridin skin repellent and wearing permethrin-treated clothing.
Japanese Encephalitis (JE): Japanese encephalitis is widespread in both rural and urban areas of this country. Repeated outbreaks have been reported in Shan State. Increased transmission occurs during the monsoon season, from May to November, but sporadic cases occur year-round, countrywide.
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. Vaccination is advised for expatriates living in this country.
• Japanese encephalitis is transmitted by night-biting Culex mosquitoes. All travelers should take measures to prevent mosquito bites, especially in the evening and overnight. 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.
Malaria: There is a high risk of malaria in Myanmar and there has been a recent sharp increase in the number of malaria cases reported along the Thai/Myanmar border in Burmese refugees. Malaria occurs countrywide with the greatest risk of transmission during the wetter months, May through December. Malaria is most prevalent in forested foothill areas below 1,000 meters elevation. There is less malaria in the plains and urban areas. Malaria risk is present in all cities except Rangoon and the urban centers of Mandalay, Magwe, Pegu, and Sagaing. Falciparum malaria accounts for 86% of cases. There is widespread occurrence of chloroquine-resistant falciparum malaria in this country. Multidrug-resistant malaria is reported along the Thai-Burmese border.
• Prophylaxis with atovaquone/proguanil (Malarone), doxycycline or primaquine is recommended. There is a high rate of mefloquine-resistant falciparum malaria in this country. See CDC map (below).
A malaria map is located on the Fit for Travel website (www.fitfortravel.nhs.uk), which is compiled and maintained by experts from the Travel Health division at Health Protection Scotland (HPS). Go to www.fitfortravel.nhs.uk and select Malaria Map from the Burma (Myanmar) page on the Destinations menu or A-Z Index.
An up-dated CDC map showing the geographic distribution of mefloquine-resistant malaria in South East Asia is at: http://wwwn.cdc.gov/travel/yellowBookCh4-Malaria.aspx#648
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, sea wasps, cones, jellyfish, spiny sea urchins, and anemones are common in the coastal waters and are potentially hazardous to unprotected or careless swimmers.
Other Diseases/Hazards: Anthrax
• Brucellosis (usually from consumption of unpasteurized dairy products)
• Helminthic infections (ascariasis and hookworm disease are highly endemic in urban and rural areas)
• Paragonimiasis (lung fluke disease; presumed endemic in small foci in rural areas)
• Leishmaniasis (low risk; sand-fly-borne, probably visceral type, reported historically)
• Typhus (louse-borne; may occur in northern upland provinces; murine typhus-flea-borne; scrub typhus, mite-borne; risk elevated in grassy rural areas)
Poliomyelitis (Polio): Poliomyelitis has been reported in this country since 2003. New cases are currently being reported in 2010 from Rakhine Province. Polio is transmitted through contaminated food and water. Those at higher risk of exposure include travelers visiting friends and relatives, those in direct contact with an infected person, long-term travellers, and those visiting areas of poor sanitation. All travelers to this country should be fully immunized.
• A one-time dose of IPV vaccine is recommended for any traveler >age 18 who completed the primary childhood series but never received an additional dose of polio vaccine as an adult. Available data do not indicate the need for more than a single lifetime booster dose with IPV (Inactivated Polio Vaccine).
Rabies: Sporadic cases of human rabies are reported countrywide. All animal bites or scratches, especially from a dog, should be thoroughly cleansed with soap and water and immediate medical attention sought. Although rabies is rare among tourists, there is risk. No one should pet or pick up any stray animals. All children should be warned to avoid contact with unknown animals. Pre-exposure rabies vaccine is recommended for: persons anticipating an extended stay; for those whose work or activities may bring them into contact with animals; for people going to rural or remote locations where medical care is not readily available; for travelers desiring extra protection. Children are considered at higher risk because they tend to play with animals and may not report bites.
• Pre-exposure vaccination eliminates the need for rabies immune globulin, but does not eliminate the need for two additional booster doses of vaccine. Prompt medical evaluation and treatment of any animal bite is essential, regardless of vaccination status. Note: If adequate rabies treatment is not available locally, medical evacuation is advised to a facility that can provide treatment.
Travelers' Diarrhea: Potable water is almost nonexistent in Burma. Rural water supplies usually are grossly contaminated and urban water supplies invariably are subject to contamination. Local dairy products are considered unsafe. Local fruits and vegetables should be scrubbed and soaked in a chlorine or iodine solution before consumption. 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 dairy products. Do not eat raw or undercooked food, especially meat, fish, raw vegetables. 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 Burma 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 (with the exception of short-term visitors who restrict their meals to hotels or resorts) traveling to or working in Asia, 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.