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United States



Capital: Washington, DC

Time Zone: -5 hours GMT. Pacific Time is GMT -8, Mountain Time is GMT -7, Central Time is GMT -6, Alaska is GMT -9, and Hawaii is GMT -10.
Tel. Country Code: 1
USADirect Tel.: 1
Electrical Standards: Electrical current is 120/60 (volts/hz). North American Style Adaptor Plug. Grounding Adaptor Plug A.

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CDC
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Travel Warnings
Consular Information
Foreign Commonweatlh Office

Embassies

• Canadian Embassy
501 Pennsylvania Avenue, N.W.
Washington, D.C. 
Tel: [1] (202) 682-1740
Fax: [1] (202) 682-7726
E-mail: wshdc-outpack@dfait-maeci.gc.ca
Website: www.canadianembassy.org/splash

• British Embassy
3100 Massachusetts Avenue, NW
Washington, D.C. 
Tel: [1] (202) 588 6500 (Embassy)
[1] (202) 588 7800 (Consular)
Website: http://www.britainusa.com

Entry Requirements

• Passport/Visa: A passport is required. Travelers should check visa requirements.

• HIV Test: HIV-positive visitors must apply at the U.S. Embassy for a waiver of ineligibility before entry.

• Vaccinations: None required.

Passport Information

Passport/Visa: A single point of access to U.S. visa information is at:http://www.unitedstatesvisas.gov/ This website will connect you to additional, in-depth information found on websites managed by the U.S. State Department and the U.S. Department of Homeland Security.

The US Visa Waiver Program (VWP) allows travelers from many countries holders to visit the U.S. for up to 90 days. The types of journeys that are permissible under the VWP include general travel/tourism, certain types of business and when transitting to another country.
• To find information specific to your country or region, you may also go to the website of your nearest U.S. Embassy or Consulate. Go to:http://www.state.gov/s/cpr/rls/dpl/32122.htm

Travelers may be eligible to be admitted to the United States for 90 days under the Visa Waiver Program. If you wish to work (including on journalism assignments), study, or stay for more than 90 days, you are not eligible for entry under the Visa Waiver Program and you must obtain a visa before traveling. For up-to-date visa information, you should review information contained on a US Government website before deciding whether to seek entry under the Visa Waiver Program or to apply for a visa.

Electronic System for Travel Authorisation (ESTA) 
From Monday 12 January 2009, all passport-holders eligible to travel to the United States under the Visa Waiver Program must obtain approval through ESTA preferably at least three days (or 72 hours) prior to travel to the United States. 

ESTA is a web-based system administered by the United States Government that determines the preliminary eligibility of visitors to travel under the Visa Waiver Program prior to boarding a carrier to the United States. ESTA has been operating on a voluntary basis since 1 August 2008 and is compulsory from 12 January 2009. Travellers who do not have a valid ESTA on or after 12 January 2009 may be denied boarding, experience delayed processing or be denied admission at a United States’ port of entry. 
To obtain a travel authorisation, each family member travelling is required to complete an ESTA application using the online system. The United States government recommends that travellers use the online system no later than three days (72 hours) before departure; applications can be made after that but approval may not be received ahead of travel. 

Visa Waiver Program 
Whether you are staying with family or friends or staying at a hotel, you will need to provide full details of a valid address in the United States when you check in for your flight. A five-digit zip code (post code) is required for all addresses. If you are a permanent resident of the United States, you will be asked for your Alien Registration Number and your country of normal residence. 
Under the US-VISIT program, most visitors to the United States, including those seeking entry under the Visa Waiver Program, are required to have fingerprints scanned by an inkless device and to have a digital photograph taken on arrival. 

With the roll-out of ESTA, it may no longer be necessary for visitors to complete the green paper Form I-94W. Air or ship crew will let you know if it is required. 
Visitors are lawfully present in the United States only up to the date stamped on their Arrival-Departure Record, not the expiration date printed on the visa. If detected, visitors staying beyond the 90-day Visa Waiver Program limit or beyond the date stamped on their Arrival-Departure Record may be arrested and detained for up to seven weeks or more, deported and likely barred from re-entering the United States, possibly for life.

Where children are traveling alone or with one parent/guardian, we recommend you carry a notarised letter of consent for travel signed by the non-traveling parent(s) or guardian. 

The Department of Homeland Security has streamlined the issue of certain short-term non-immigrant visas to people infected with the Human Immunodeficiency Virus (HIV) who are otherwise qualified to enter the United States. 

Travelers with a criminal record (regardless of how minor or how long ago the offence took place) should ensure they seek advice about their visa requirements for entering or transiting the United States as they may be refused entry.

If you have any doubts about whether you are eligible to enter the United States under the Visa Waiver Program, or about visa matters generally, you are strongly advised to contact the nearest Embassy or Consulate of the United States of America about your specific circumstances, well in advance of travel, including if you plan to transit the United States.

HIV Test: As of August 2008, the U.S. is lifting its travel restrictions for HIV-positive people. Formerly, all HIV-positive visitors had to apply at a U.S. Embassy for a waiver of ineligibility before entry.

The USA has banned entry, travel, and immigration for HIV-positive people for many years. Visitors would be asked to declare any communicable disease of public-health importance. If an Immigration and Naturalization officer suspected HIV or if HIV/AIDS was declared, the officer was permitted to undertake an examination.

For HIV-positive visitors, requirements for entering the United States have been somewhat vague and could change frequently. According to the publication of HIV and Immigrants: A Manual for AIDS Service Providers, the Immigration and Naturalization Service (INS) doesn't require a medical exam for entry into the United States, but INS officials could stop individuals because they look sick or because they are carrying AIDS/HIV medicine.

If an HIV-positive noncitizen applied for a non-immigrant visa, the question on the application regarding communicable diseases was tricky no matter which way it was answered. If the applicant checked "no," INS could deny the visa on the grounds that the applicant committed fraud. If the applicant checks "yes" or the INS suspects the person is HIV-positive, it could deny the visa unless the applicant asks for a special waiver for visitors. This waiver is for people visiting the United States for a short time, to attend a conference, for instance, to visit close relatives, or to receive medical treatment. It could be a confusing situation. 
For up-to-the-minute information, contact AIDSinfo (tel. 800/448-0440 or 301/519-6616 outside the U.S.; www.aidsinfo.nih.gov) or the Gay Men's Health Crisis (tel. 212/367-1000; www.gmhc.org).
Source: Frommer's Travel Guides

Vaccinations: Recommended and Routine

Hepatitis A: All travelers not previously immunized against hepatitis A should consider immunization as a general health precaution.

Hepatitis B: Recommended for all non-immune travelers at potential risk for acquiring this infection. Hepatitis B in the U.S. is transmitted via infected blood or bodily fluids. Travelers may be exposed by needle sharing and unprotected sex. 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.

Routine Immunizations: Immunizations against tetanus-diphtheria, measles, mumps, rubella (MMR vaccine) and varicella (chickenpox) should be updated, if necessary, before visiting this country. The Tdap vaccine, which also boosts immunity against pertussis (whooping cough) should be considered when you are given a tetanus-diphtheria booster.
Measles, mumps, rubella (MMR) immunity is especially important for any female of childbearing age who may become pregnant.
• Note: An outbreak of pertussis affecting 17 children was reported in South Dakota in 2008.

Hospitals / Doctors

Medical care in the United States is of high quality as is the system of emergency medical transport and pre-hospital emergency care that can be accessed by dialing 911 nationwide.
All travelers should be up-to-date on their immunizations and are advised to carry a medical kit to treat minor injuries. 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 drugs in pharmacies in this country - they will need a prescription from a U.S. physician or the equivalent drugs may not be available in this country.
• Travelers are advised to obtain comprehensive travel insurance with specific overseas coverage. Policies should cover: ground and air ambulance transport, including evacuation to home country; payment of hospital bills; 24-hour telephone assistance. A minimum coverage of $500,000 is strongly advised for all visitors. The policy should pay the costs of repatriation back to home country in the event of serious illness or injury that requires on-going care or recovery. Even with insurance, you may be required to pay a deductible in an ER or doctors office. Only emergency cases are treated without prior payment; other treatments may be refused without evidence of insurance or a deposit. Travelers with chronic medical conditions should bring with them copies of pertinent medical records and a list of their medications (by generic name).

Destination Health Info for Travelers

AIDS/HIV: More than 1 million Americans are estimated to be living with HIV, nearly a quarter of whom are not aware of their condition, posing a high risk of further transmission. Newly revised statistics from the CDC indicate that up to 56,000 new infections occur each year. New data indicate that most HIV-infected people (at least 95%) are not spreading the disease; instead, transmission events can be attributed to just 5% of the infected population — or perhaps even less if new infections occur in clusters, with one person infecting several others.
• Although HIV and AIDS affects all sectors of society, the impact has been more serious among some groups than others. In the early years of the epidemic, the most commonly identified vulnerable groups in America were men who have sex with men (MSM), injecting drug users, hemophiliacs and Haitians. Today, HIV continues to infect thousands of gay and bisexual men and injecting drugs users every year, but it has also become a serious problem among the heterosexual African American and the Latino population. (Source: http://www.avert.org/america.htm)
• The prevalence of HIV infection among incarcerated persons in the US is 1.5%; among persons in community settings it is 0.4% (MMWR, June 25, 2010).
• The unselected seroprevalence of HIV infection in urban EDs in the U.S. ranges from 1% to 4%. 
• 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 (not a factor in the U.S.); unscreened blood transfusions (not a factor in the U.S.).
• 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 fluid or blood of another person. Although travel has contributed in a general way to the global spread of AIDS, fear of traveling because of this disease is not warranted.


Avian Influenza A (Bird Flu): 
There have been no cases of avian influenza (bird flu) in the United States.
• The risk to humans from avian influenza is believed to be very low and no travel restrictions are advised, except that overseas travelers to countries where bird flu is endemic 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.


Cholera: 
From 2003 through 2007, Vibrio cholerae serogroup O75 strains possessing the cholera toxin gene were isolated from 6 patients with severe diarrhea, including 3 in Georgia, 2 in Alabama, and 1 in South Carolina. These reports represent the first identification of V. cholerae O75 as a cause of illness in the United States. V. cholerae O75 was isolated from a water sample collected from a pond in Louisiana in 2004. Subsequently, 3 V. cholerae isolates from Louisiana (2 from patients with diarrhea in 2000 and 1 from a water sample collected in 1978) that had been previously reported as serogroup O141 were also discovered to be serogroup O75. 
RESULTS: All 8 patients who were infected with V. cholerae O75 were adults who became ill after consuming seafood; 2 had eaten raw oysters traced back to the Gulf Coast of the United States. All 10 isolates possessed the cholera toxin gene and were susceptible to 10 antimicrobials. 
CONCLUSIONS: The exposure histories suggest that infection can be acquired from consumption of raw oysters from the Gulf Coast. Clinicians and public health authorities should be vigilant for the occurrence of new toxigenic serogroups of V. cholerae that are capable of causing severe diarrhea.
Source: AMEDEO Travel Medicine 24.09.2008
http://www.ncbi.nlm.nih.gov/pubmed/18781876?dopt=Abstract

• 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)


Chickengunya fever: 
Update as of July 2014. The outbreak of chikungunya virus (CHIKV) in the Caribbean region, first reported by the World Health Organization (WHO) in December 2013, continues. Since the initial report, autochthonous (locally acquired) transmission of CHIKV has been reported from several countries and territories in the Caribbean, as well as from mainland North, South and Central America. As of 18 July 2014, there have been 436,568 probable and confirmed cases in the region and at least 26 deaths to date.


On 17 July 2014, the Florida Department of Health confirmed the first locally acquired cases in mainland US, one in Miami Dade County and one in Palm Beach County [2].


Countries and territories in the Caribbean and the Americas that have reported autochthonous transmission so far:

- Aruba

- Anguilla

- Antigua and Barbuda

- Bahamas

- Barbados

- British Virgin Islands

- Cayman Islands

- Costa Rica

- Curacao

- Dominica

- Dominican Republic

- El Salvador

- French Guiana

- Grenada

- Guadeloupe

- Guyana

- Haiti

- Jamaica

- Martinique

- Panama

- Puerto Rico

- Saint-Barthélemy

- Saint Kitts and Nevis

- Saint Lucia

- Saint Martin

- Saint Vincent and the Grenadines

- Sint Maarten

- Suriname

- Trinidad & Tobago

- Turks and Caicos

- United States (US) - See above

- US Virgin Islands

- Venezuela [1, 3, 4, 5].


See a map of the region here.


Several other countries have reported CHIKV infection in travellers returning from one of the affected areas: Bolivia, Bonaire (Netherlands), Brazil, Canada, Chile, Cuba, France (including Tahiti), Greece, Italy, Japan, Mexico, the Netherlands, Nicaragua, Panama, Paraguay, Peru, Spain, Switzerland, Trinidad and Tobago and the US [6].


The two main vectors of CHIKV, Aedes aegypti and Aedes albopictus mosquitoes, are distributed throughout the Caribbean and the Americas so the region is highly susceptible to the introduction and spread of the virus [7]. Autochthonous transmission from an imported viraemic chikungunya case during the summer season in the EU is possible, as the competent vector (Aedes albopictus) is present and the environmental requirements are met during the summer and early autumn in Europe [6].


In symptomatic illness, there is the sudden onset of fever, headache, myalgia and arthralgia. After two to three days, a generalised maculo-papular rash can develop. Most cases recover in three to five days. However, up to 10% of cases experience arthritis, chronic joint pain and fatigue. Complications of CHIKV infection can include hepatitis, myocarditis, neurological and ocular disorders [8]. Treatment is supportive.


Advice for traveller: There is no vaccine or chemoprophylaxis to prevent CHIKV. Travellers to affected areas can reduce their risk of infection by practising insect bite avoidance measures. Aedes mosquitoes are most active during daylight hours. Particular vigilance with bite avoidance should be taken around dawn and dusk.


Dengue Fever: 
University of Florida mosquito researchers have reported that the dengue virus has retureds to the state in 2009 after more than 50 years. By November 2009, 20 cases of locally transmitted dengue had been confirmed in Key West. Monroe County officials have issued a health alert and launched an education campaign urging residents to eliminate water sources in and around their homes where mosquitoes can breed. The last big dengue epidemic in Florida was in 1934 and left more than 25,000 Floridians ill. Researchers do not expect this outbreak to reach beyond Monroe County.
Outside of Key West, there is minimal risk for dengue fever outbreaks in the southern continental United States. Dengue has been detected six times in the last 25 years in south Texas (1980-2004) and there have been dengue outbreaks in Hawaii (2001-02) where 40 confirmed cases were reported (39 on Maui and 1 case on Kauai). 
• Dengue is transmitted via the bite of an infected Aedes aegypti or Aedes albopictus mosquito. Aedes mosquitoes feed predominantly during daylight hours. All travelers who are at risk 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


Food & Water Safety: 
There is very low risk of food- and drink-related illness nationwide. Tap water is potable. Sporadic cases of food-borne illness, usually due to salmonella or campylobacter, are reported. Undercooked or raw eggs, and undercooked chicken, are often the source of these outbreaks, usually confined to institutions, such as nursing homes, or to gatherings, such as picnics. In 2009, products made with contaminated peanut butter caused cases of salmonellosis, but major national brands of jarred peanut butter found in grocery stores have not been among the products recalled. 
Outbreaks of diarrhea caused by enterohemorrhagic Escherichia coli O157:H7 have occurred in many areas and have increased in the past decade. Hemolytic uremic syndrome (HUS) may result from this infection. E. coli O157:H7 bacteria are usually transmitted by contaminated, undercooked hamburger meat, dairy products, and fruit juice. 
• Campylobacter and salmonella are the most common causes of acute bacterial diarrhea. In 2007, in the State of Kansas, at least 87 people became ill with campylobacter gastroenteritis after drinking raw, unpasteurized milk or cheese made by the milk. Health officials warned the public to be aware of the health risks of consuming raw milk.
Campylobacteriosis is an intestinal infection caused by a group of different Campylobacter bacteria. Infection often causes diarrhea, fever, abdominal pain, nausea, headache, and muscle pain. It is most often seen in outbreaks related to food especially undercooked chicken, unpasteurised milk and contaminated water.
• Gastroenteritis, due to Vibrio species, salmonella, or campylobacter, has been reported after the consumption of contaminated oysters in Louisiana, Maryland, North Carolina, Florida, and Mississippi. Vibrio cholera infections, transmitted by contaminated shellfish (crab, shrimp, raw oysters), have occurred sporadically along the Gulf of Mexico (Texas, Louisiana).
• In the United States, Cryptosporidium is the leading cause of reported recreational water-associated outbreaks of diarrhea. Cryptosporidium infection is transmitted by the faecal-oral route and results from the ingestion of Cryptosporidium oocysts through the faecally contaminated water or food or through direct person-to-person or animal-to-person contact. 
• Mexican cheese, imported to California, has transmitted listeriosis. 
• Ciguatera fish poisoning is occasionally reported from Hawaii and Florida.


Food-Borne Disease: 
The Oklahoma Health Department (September 2010) has reported an outbreak of salmonellosis that involves 3 counties and which may extend into 2 other states. The department is monitoring the outbreak of a similar strain of Salmonella identified in Iowa and Nebraska. So far, they have not been able to identify sources or possible sources of the bacterial disease, and there is not enough information yet to suggest a food that people should avoid.
Note: Poultry and/or eggs are often identified as the source of food-borne outbreaks of salmonellosis.


Giardiasis: 
This parasitic infection occurs primarily in wilderness areas of the Rocky Mountains and the Pacific Northwest, but the distribution of risk, nationwide, is not clearly defined. Campers and hikers are advised to boil or filter drinking water obtained from lakes, streams, or ponds. Outbreaks of giardiasis (and cryptospordiosis) have occurred from occasional breakdowns in municipal water treatment plants.


Hantavirus Pulmonary Syndrome: 
Sporadic cases of Hantavirus Pulmonary Syndrome (HPS), a severe cardio-pulmonary illness first identified in 1993 in the southwestern United States, continue to occur. HPS has now been identified in 24 states. New Mexico, Arizona, and California have the most cases, but HPS has also been reported in Rhode Island. Transmission of the virus is through aerosolized rodent urine or secondary aerosolization of dried rodent excreta.


Hepatitis: 
There is low risk nationwide of hepatitis A, but there is an increased incidence in the states of Alaska, Arizona, California, New Mexico, Nevada, Oklahoma, Oregon, South Dakota, Utah, Washington, and Idaho, which have hepatitis A rates >20 per 100,000. Community outbreaks account for most cases nationwide. Travelers who are non-immune to hepatitis A (i.e. have never had the disease and have not been vaccinated) should consider vaccination as a general health precaution. Hepatitis A is transmitted through contaminated food and water and can be transmitted through sexual contact. 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 at a low level with 1% to 5% of the general population seropositive for antibodies to the hepatitis E virus (HEV). The incidence of human cases of acute, clinically apparent hepatitis E in the U.S. is unknown but thought to be rare. Sporadic cases may be underdiagnosed or underreported. (Anti-HEV antibodies are also found in human and swine populations in other industrialized countries.) 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.
• The hepatitis B (HBsAg) carrier rate in the general population is <2% nationwide, but up to 3.1% of Alaskan natives are chronic carriers of the hepatitis B virus. 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 very low levels in the general population. All blood and blood products in the U.S. are screened for hepatitis viruses and HIV. Carriers of the hepatitis C antibody are usually injecting drug users (IDUs) or people who received contaminated blood transfusions many years ago.


Influenza: 
Influenza is transmitted from November through March. Flu vaccine is recommended for travelers over age 6 months.

• Read more from the CDC: http://www.cdc.gov/h1n1flu
• Tracking influenza H1N1 cases: http://www.cdc.gov/h1n1flu/update.htm


Legionnaires' Disease: 
Outbreaks have occurred on cruise ships departing U.S. ports. Disease transmission often related to being in or near shipboard whirlpool spas.


Leishmaniasis: 
Transmission of this disease has been reported in southern Texas. Travelers should take measures to avoid insect (sandfly) bites.


Leptospirosis: 
Reported most frequently from Hawaii and Puerto Rico although sporadic cases and outbreaks have occurred elsewhere, primarily in warmer regions or in summer months. Most transmission occurs from immersion in freshwater streams or in association with recreational surface water sports.


Lyme Disease: 
Lyme disease occurs in the the Northeast (from Maryland to Maine), the Middle Atlantic states, the upper Midwest (Wisconsin and Minnesota), and the northern Pacific Coast region (Oregon and northern California). The number of reported Lyme disease cases in Maryland nearly doubled in 2007 from the previous year, although this may have been due to better reporting. Peak transmission season runs from April to October. Lyme disease is transmitted by Ixodes ticks mostly in wooded or brushy areas, although transmission can also occur in the backyards of homes.
Lyme disease risk map here:http://www.cdc.gov/MMWR/preview/mmwrhtml/rr4807a2.htm
• All travelers who engage in hiking, camping, or similar outdoor activities in rural wooded regions of endemic areas should take measures to prevent tick bites. Tick-bite prevention measures include applying a DEET-containing repellent to exposed skin and permethrin spray or solution to clothing and gear.
• A single 200-mg dose of doxycycline is effective in preventing Lyme disease in someone who has just been bitten by an infected tick. (http://content.nejm.org/cgi/content/abstract/345/2/79).


Malaria: 
There is no indigenous malaria in the U.S. Of the approximately 1500 imported cases of malaria reported annually in the United States, almost two thirds are due to P. falciparum and almost one third from P. vivax; cases caused by P. ovale and P. malariae are rare. In 2006, six deaths from malaria were reported in the U.S. Imported P. falciparum malaria occurs almost exclusively in persons receiving no chemoprophylaxis or inadequate chemoprophylaxis. Most imported cases of malaria are not in tourists but in immigrants and their children who have returned to the country of their family’s origin to visit friends and relatives (so-called VFR travelers) and have foregone chemoprophylaxis. (Source: NEJM Aug 7, 2008.)
Each year, several hundred cases of late-onset P. vivax or P. ovale malaria occur in returned travelers who adhered to their prescribed regimen of chloroquine, atovaquone-proguanil (Malarone), mefloquine (Lariam), or doxycycline. Such late relapses do not occur in P. falciparum and P. malariae infections (which have no hypnozoite stage) or in travelers taking primaquine prophylaxis.

• Coartem, a drug composed of both artemether and lumefantrine, which was approved by the U.S. Food and Drug Administration in April 2009, is now available in pharmacies in the U.S. for the treatment of acute, uncomplicated malaria infections in adults and children weighing at least five kilograms (approximately 11 pounds). 

Guidelines for the treatment of malaria in the U.S. are here:
http://www.cdc.gov/malaria/pdf/treatmenttable.pdf


Marine Hazards/Injuries: Swimming related hazards include jellyfish, spiny sea urchins, and sharp coral. Sea snakes are found in the waters of Hawaii which is the only state in the U.S. that has sea snakes. The venom is highly toxic and mortality is 25% in untreated cases. In severe envenomations, symptoms can occur within 5 minutes, but typically evolve over 8 hours. It is possible that the victim may not have been aware of the bite, since there is little or no pain on envenomation.
Symptoms include anxiety, muscle aching, salivation and a sensation of tongue swelling, followed by nausea, vomiting, muscle spasms, ascending paralysis, ocular palsy and sometimes loss of vision. Respiratory collapse may ensue, and the need for intubation and mechanical ventilation should be anticipated. Sea snake antivenom should be administered in all actual and suspected cases.
• A sea snake bite is always a medical emergency, even if the victim does not appear ill.
• You must get the victim to an emergency room, as fast as possible.
• En route, hold the bite site below the rest of the body, while keeping the victim as still as possible.
• Apply a broad pressure bandage over the bite about as tight as an elastic wrap to a sprained ankle. This will slow the spread of the venom through the lymph system. Make sure that arterial circulation is not cut off, by making sure fingers or toes stay pink and warm.
• Never cut open a sea snake bite and try to suck venom from the victim.
• Sea snake toxin is not inactivated by changes in temperature or pH. Application of ice, hot packs, or vinegar only wastes time.
Read more: http://emedicine.medscape.com/article/771804-overview

Ciguatera poisoning occurs and can result from eating coral reef fish such as grouper, snapper, sea bass, jack, and barracuda. The ciguatoxin is not destroyed by cooking. 


Murine Typhus: 
Murine typhus, an acute febrile illness caused by Rickettsia typhi, is distributed worldwide. Mainly transmitted by the fleas of rodents, it is associated with cities and ports where urban rats are abundant. In the United States, cases are concentrated in suburban areas of Texas and California. Contrary to the classic rat-flea-rat cycle, the most important reservoirs of infection in these areas are opossums and cats. The cat flea, Ctenocephalides felis, has been identified as the principal vector. In Texas, murine typhus cases occur in spring and summer, whereas, in California, cases have been documented in summer and fall. Most patients present with fever, and many have rash and headache. Serologic testing with the indirect immunofluorescence assay is the preferred diagnostic method. Doxycycline is the antibiotic of choice and has been shown to shorten the course of illness.


Other Diseases/Hazards: 
• Angiostrongyliasis (human angiostrongyliasis caused by Angiostrongylus cantonensis, a rat lungworm, with a widespread occurrence in the Americas: from the southern United States to northern Argentina. Human infections are acquired by ingestion of raw or undercooked snails, slugs, or frogs, prawns, or contaminated vegetables that contain the infective larvae of the worm. The human infection is established through the ingestion of third-stage larvae when water or food is contaminated with the mucous secretions eliminated by the intermediate host or when a small mollusc is accidentally ingested. Acute abdominal disease may develop with severe inflammatory and thrombotic lesions in the intestines. Inflammation in the intestinal wall probably prevents the elimination of larvae in faeces and the diagnosis relies upon histopathological examination of surgical specimens obtained in the most severe cases when surgical treatment for the correction of intestinal perforations or obstruction is required; Angiostrongylus cantonensis is the most common cause of eosinophilic meningitis in humans after ingestion of raw or inadequately cooked intermediate hosts or food contaminated with infective third-stage larvae.)
• Many outbreaks of anthrax in animals were reported in agricultural regions of the US and Canada in 2006; infection in humans is rare.
• Coccidioides immitis is a pathogenic fungus that resides in the soil in certain parts of the southwestern United States, northern Mexico, and a few other areas in the Western Hemisphere. It, along with its relative Coccidioides posadasii, can cause a disease called coccidioidomycosis (Valley Fever), and it is a rare cause of meningitis, mostly in immunocompromised persons. 
• Paragonimiasis (human infections with the lung fluke Paragonimus westermani). Paragonamiasis has rarely been reported from North America as a zoonosis caused by Paragonimus kellicotti. Only 7 autochthonous cases of paragonimiasis have been previously reported from North America. Three patients with proven or probable paragonimiasis with unusual clinical features were seen at a single medical center in Missouri during an 18-month period in 2009. These patients acquired their infections after consuming raw crayfish from rivers in Missouri. Physicians should consider the possibility that patients who present with cough, fever, hemoptysis, and eosinophilia may have paragonimiasis.
• Plague is enzootic in the western United States, and rare human cases occur, almost 90% from New Mexico, Colorado, Arizona and California, often associated with prairie dogs. 
• Snakebites: Nineteen species of venomous snakes inhabit North America; the highest bite rates are found in southern states and southwestern desert states. Treatment with snake anti-venom may be required. 
• Tularemia is found in wide areas of the United States, including Alaska, and Canada, with the greatest number of cases in the central states (Arkansas, Missouri, Oklahoma and neighboring states). Outbreaks have occurred on Martha’s Vineyard (Massachusetts). Most persons with tularemia acquire the infection from tick bites or mosquito bites, or from contact with infected mammals, particularly rabbits. In 2009, 2 residents of Fairbanks, Alaska were diagnosed with tularemia, contracted by handling sick snowshoe hares. 
Sporadic cases in the United States have been associated with contaminated drinking water.
• Typhoid fever: Most cases of typhoid fever in the U.S. are imported, primarily by travelers who have visited friends and relatives in the Indian subcontinent. These cases may be resistant to the fluoroquinolone antibiotics. Note: the typhoid vaccine is no more than 75% protective nor is it effective against paratyphoid fever. 

Gun-related deaths, a significant public health problem, are higher in the United States than in any other industrialized country. About 30,000 firearm deaths occur annually: 17,000 from suicides; 12,000 from homicides, often gang- and drug-related; and almost 1,000 from accidents. Another 70,000 people sustain wounds of variable severity. Nearly half of these deaths occurred in people under the age of 35.
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Neglected Infections of Poverty in the United States of America
Peter J. Hotez
Department of Microbiology, Immunology, and Tropical Medicine, The George Washington University and Sabin Vaccine Institute, Washington, D.C., United States of America
Abstract
In the United States, there is a largely hidden burden of diseases caused by a group of chronic and debilitating parasitic, bacterial, and congenital infections known as the neglected infections of poverty. Like their neglected tropical disease counterparts in developing countries, the neglected infections of poverty in the US disproportionately affect impoverished and under-represented minority populations. The major neglected infections include the helminth infections, toxocariasis, strongyloidiasis, ascariasis, and cysticercosis; the intestinal protozoan infection trichomoniasis; some zoonotic bacterial infections, including leptospirosis; the vector-borne infections Chagas disease, leishmaniasis, trench fever, and dengue fever; and the congenital infections cytomegalovirus (CMV), toxoplasmosis, and syphilis. These diseases occur predominantly in people of color living in the Mississippi Delta and elsewhere in the American South, in disadvantaged urban areas, and in the US–Mexico borderlands, as well as in certain immigrant populations and disadvantaged white populations living in Appalachia. Preliminary disease burden estimates of the neglected infections of poverty indicate that tens of thousands, or in some cases, hundreds of thousands of poor Americans harbor these chronic infections, which represent some of the greatest health disparities in the United States. Specific policy recommendations include active surveillance (including newborn screening) to ascertain accurate population-based estimates of disease burden; epidemiological studies to determine the extent of autochthonous transmission of Chagas disease and other infections; mass or targeted treatments; vector control; and research and development for new control tools including improved diagnostics and accelerated development of a vaccine to prevent congenital CMV infection and congenital toxoplasmosis.

• Citation: Hotez PJ (2008) Neglected Infections of Poverty in the United States of America. PLoS Negl Trop Dis 2(6): e256. doi:10.1371/journal.pntd.0000256


Rabies: 
The only reported case of human rabies in the US in 2007 was from Minnesota; the likely source of rabies was a bat.
During 2000 - 2006, a total of 24 human rabies cases were reported in the United States, 19 of which were acquired indigenously. Almost all cases of human rabies in the United States are transmitted by bats. These bites are usually unnoticed. Any person who discovers bats in their sleeping quarters require rabies vaccination because of unnoticed exposure. 
Dog and cat rabies in the U.S. has essentially been eliminated through state-mandated vaccination programs, but with some exceptions. In 2009, Point Pleasant Beach, New Jersey reported an outbreak of rabies in a town which is home to an estimated 300 stray cats. One person was bitten by a rabid cat, was was successfully treated with prophylactic rabies vaccine.
The number of cases of animal rabies, however, is increasing. Raccoon rabies is endemic in the southeastern and Middle Atlantic states and is increasing in the northeastern United States. Rabid raccoons are a threat in Central Park in New York City, with increased number of raccoon rabies reported in 2010. In northcentral and southcentral United States, and California, skunk rabies predominates. Along the U.S.-Mexican border, rabies transmitted by dogs and coyotes is a potential threat to humans. In Alaska, the arctic and red fox are primarily infected. Bats anywhere in the United States should be considered potentially rabid. 
Travelers should seek immediate treatment for any unprovoked animal bite, particularly bites from a raccoon, fox, skunk, or bat. Other wild animals that sometimes, but rarely transmit rabies include groundhogs, wolves, bobcats, cattle, horses, and black bears (hampsters, squirrels, mice are excepted). No cases of wild animal rabies have been reported from the states of Washington, Idaho, Utah, Nevada, or Colorado.
• 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.
Reminder: In the United States human rabies is most likely to result from contact with bats, raccoons, skunks, foxes and coyotes.
• The State of Hawaii is the only state in the U.S. that is rabies-free.

ProMED Dec 2009: With the identification of 3 raccoons with rabies in Manhattan's 
Central Park in recent months -- 2 during the past week -- the Health 
Department is cautioning New Yorkers to stay away from raccoons, 
skunks, bats, stray dogs and cats and other wild animals that can 
carry rabies. The recent cluster of findings suggests that rabies is 
being transmitted among raccoons in the park. The Health Department 
is increasing surveillance efforts to determine the extent of the problem.

Raccoons are the most commonly reported rabid animal in New York 
City. Rabid raccoons are a relatively common occurrence in the Bronx, 
and many were found in Staten Island in 2006 and 2007. In Queens and 
Manhattan, rabid raccoons have historically been rare, and rabid 
raccoons have never been seen in Brooklyn. Bats with rabies have also 
been found in all 5 boroughs. So far this year [2009], 20 rabid 
animals have been identified in New York City: 14 raccoons from the 
Bronx, 4 raccoons from Manhattan, one raccoon from Queens and one bat 
from Staten Island.


Tick-Borne Diseases: 
Lyme disease occurs in the Middle Atlantic states, the Northeast, the upper Midwest, and the northern Pacific Coast region (See above). 
• Babesiosis occurs in the northeast U.S., especially in the Nantucket region, and was recently reported in Wisconsin. A new Babesia strain has appeared in Washington State. 
• Human monocytic ehrlichiosis occurs in the south-central and southeastern United States. In the USA, there were 17 confirmed cases of Ehrlichiosis in Tennessee in 2010, compared with 14 for the same period last year.
Note: Ehrlichiosis is caused by rickettsia-like bacteria that are transmitted by bite of ticks. Symptoms usually appear 5 to 10 days after a person is bitten. Possible symptoms can be fever, headache, fatigue, muscle aches, nausea, vomiting, diarrhea, cough, joint pains or rash. The disease can even cause confusion or death. Wearing long-sleeved clothing and using insect repellants may prevent tick bites.

• Murine typhus (Texas), also called fleaborne or endemic typhus, is a rickettsial disease caused by the organism Rickettsia typhi. Another organism, R. felis, may also play a role in causing murine typhus. Rickettsiae are a type of bacteria. Most of the murine typhus cases in Texas occur in South Texas from Nueces County southward to the Rio Grande Valley, but a few cases are reported in other parts of the state each year.

• Human granulocytic anaplasmosis (formerly called human granulocytic human granulocytic ehrlichiosis - http://www.aldf.com/Anaplasmosis.shtml) is reported from Minnesota, Wisconsin, California, and the northeastern United States. 
• Other tick-borne infections include Rocky Mountain spotted fever (occurs mostly in the Southeast), Colorado tick fever (Western U.S.), tickborne relapsing fever (Western U.S.), tularemia (see above), tick paralysis (Western states and Pacific coast) and Q fever (can also be caused by inhalation).

• Travelers who engage in hiking, camping, or similar outdoor activities in rural wooded regions of endemic areas should take measures to prevent tick bites. Tick-bite prevention measures include applying a DEET-containing repellent to exposed skin and permethrin spray or solution to clothing and gear.
• A single 200-mg dose of doxycycline is effective in preventing Lyme disease if taken within 72 hours of being bitten by an infected tick. (Reference:http://content.nejm.org/cgi/content/abstract/345/2/79). Doxycycline may also prevent ehrlichiosis, but no studies document this.


Viral Encephalitis (other than West Nile virus): 
St. Louis encephalitis (SLE), named for the city where the first cases were recognized in 1933, is the most common variety of viral encephalitis in the United Statyes. It occurs along the Gulf Coast, in the Ohio and Mississippi Valleys, Florida, and the Western States. Most people who are infected with the SLE virus never show any outward symptoms. Those who do exhibit symptoms face a very serious threat to life. As many as 30% of elderly patients infected with SLE die. The agent that causes St. Louis encephalitis is a virus, thus antibiotic treatments are not effective. There is no vaccine for the virus and (like all viruses) there is no cure.
• Eastern equine encephalitis (also a mosquito-borne disease with a fatality rate up to 60%) occurs in the eastern and north-central U.S. and Canada. From 2004 to 2006, Massachusetts recorded a total of 13 cases with 6 deaths. Most cases were in the southeastern part of the state, a habitat of the C.melanura mosquito.
• Western equine encephalitis (a milder disease with a fatality rate of 3%) is endemic in central and western U.S. and in Canada. Viral encephalitis is commonly spread by culex mosquitoes, but the Aedes albopictus mosquito (“Asian tiger mosquito”) is also known to transmit encephalitis viruses.
Travelers can reduce their risk of illness by 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. There are no vaccines against these particular viruses.


West Nile Fever:  Update 2014. 
An outbreak of the West Nile virus in California's Orange County in 2014 has infected more than 90 people so far this year [2014], 7 times as many as were diagnosed in all of 2013, and public health experts say the region's prolonged drought may be a factor. Not only has the number of human infections reported in the Souther California county since January [2014] dwarfed the 12 cases documented for all of 2013, but the prevalence of West Nile in birds, which harbor the virus, and in the mosquitoes transmitting it has also spiked.

West Nile virus (WNV) was first reported in the United States in 1999 in the New York City area, where 59 people were hospitalized. In 2002, almost 3,000 cases of WNV encephalitis were reported in the United States, but in 2004 the total number of cases declined to 741. The virus has spread nationwide, with California now reporting the most cases (394). Illinois also has reported an increase in WNV. Most cases of WNV occur in the mid- to late-summer and fall.
West Nile virus has three different effects on humans. The first is an asymptomatic infection; the second is a mild febrile syndrome termed West Nile Fever; the third is a neuroinvasive disease termed West Nile meningitis or encephalitis that may be fatal. In infected individuals the ratio between the three states is roughly 110:30:1 The more severe outcomes of WNV infection are associated with advancing age. People younger than age 50 rarely develop neurological complications. 
• West Nile virus is transmitted by Culex mosquitoes, which bite from dusk to dawn. Travelers can reduce their risk of illness by applying a DEET-containing repellent  (such as Ultrathon) to exposed skin, applying permethrin spray or solution to clothing and gear, and sleeping under a permethrin-treated bednet at night. There is no vaccine.