<table><tr><th>From: </th><th></th></tr><tr><td>Sent: </td><td>Wednesday, November 9, 2011 10:43 PM</td></tr><tr><td>To: </td><td></td></tr><tr><td>Subject: </td><td>Re: Ivory Coast CDC Health Information</td></tr></table>

Preparing for Your Trip to Cate &Ivoire

Before visiting Cate d'Ivoire, you may need to =et the following vaccinations and medications for vaccine-preventable =iseases and other diseases you might be at risk for at your =estination: (Note: Your doctor or health-care provider will =etermine what you will need, depending on factors such as your health =nd immunization history, areas of the country you will be visiting, and =fanned activities.)

To have the most benefit, see a =ealth-care provider at least 4-6 weeks before your trip to =flow time for your vaccines to take effect and to start taking medicine =o prevent malaria, if you need it.

Even if you =ave less than 4 weeks before you leave, you should still see a =ealth-care provider for needed vaccines, anti-malaria drugs and other =edications and information about how to protect yourself from illness =nd injury while traveling.

CDC recommends =hat you see a health-care provider who specializes in Travel =edicine. Find a travel medicine clinic near you. If =ou have a medical condition, you should also share your travel plans =ith any doctors you are currently seeing for other medical =easons.

If your travel plans will take =ou to more than one country during a single trip, be sure to let your =ealth-care provider know so that you can receive the appropriate =accinations and information for all of your destinations. Long-term =ravelers, such as those who plan to work or study abroad, may also need =dditional vaccinations as required by their employer or school.

Be sure your routine =accinations are Check the links below to see which vaccinations adults and =hildren should get.

Routine vaccines, as =hey are often called, such as for influenza, chickenpox (or varicella), =olio, measles/mumps/rubella (MMR), and diphtheria/pertussis/tetanus =DPT) are given at all stages of life; see the childhood and adolescent immunization =chedule and routine adult immunization schedule.

Routine vaccines are recommended even if you do not travel. =lthough childhood diseases, such as measles, rarely occur in the United =tates, they are still common in many parts of the world. A traveler who =s not vaccinated would be at risk for infection.

Vaccine-Preventable Diseases

Vaccine recommendations =re based on the best available risk information. Please note that the revel of risk for vaccine-preventable diseases can change at any =ime.

Vaccination or Disease Recommendations =r Requirements for Vaccine-Preventable Diseases

Routine Recommended if you are not =p-to-date with routine shots, such as measles/mumps/rubella (MMR) =accine, diphtheria/pertussis/tetanus (DPT) vaccine, poliovirus vaccine, =tc.

see map) where exposure might occur through food or water. Cases =f travel-related hepatitis A can also occur in travelers to developing =ountries with "standard" tourist itineraries, accommodations, and food =onsumption behaviors.

see map), especially those who might be exposed to blood or body =luids, have sexual contact with the local population, or be exposed =hrough medical treatment (e.g., for an accident).

Typhoid Recommended for all unvaccinated people traveling =o or working in West Africa, especially if staying with friends or =elatives or visiting smaller cities, villages, or rural areas where =xposure might occur through food or water.

Recommended for adult travelers who have received a primary series =ith either inactivated poliovirus vaccine (IPV) or oral polio vaccine =OPV). They should receive another dose of IPV before departure. For =dults, available data do not indicate the need for more than a single =ifetime booster dose with IPV.

Yellow =ever Requirements: Required upon arrival from all countries for =ravelers ≥1 year of age.

Recommendations: Recommended for all =ravelers ≥9 months of age.

Meningococcal (meningitis) Recommended if you plan to =isit countries that experience epidemics of meningococcal disease =uring December through June (see map).

Rabies Recommended for =ravelers spending a lot of time outdoors, especially in rural areas, =nvolved in activities such as bicycling, camping, or hiking. Also =ecommended for travelers with significant occupational risks (such as =eterinarians►,for long-term travelers and expatriates living in areas =ith a significant risk of exposure, and for travelers involved in any =ctivities that might bring them into direct contact with bats, =arnivores, and other mammals. Children are considered at higher risk =ecause they tend to play with animals, may receive more severe bites, =r may not report bites.

All (more information)

If you will be visiting an area of C6te d'Ivoire with =alaria, you will need to discuss with your doctor the best ways for you =o avoid getting sick with malaria. Ways to prevent malaria include the =ollowing:

• Taking a prescription =ntimalarial drug

• Using =nsect repellent and wearing long pants and sleeves to prevent mosquito =ites

Sleeping =n air-conditioned or well-screened rooms or using bednets

All of the following antimalarial drugs are equal options for =reventing malaria in Cote d'Ivoire:Atovaquone-proguanil, doxycycline, or mefloquine. For =etailed information about each of these drugs, see Table =-11: Drugs used in the prophylaxis of malaria. For information that =an help you and your doctor decide which of these drugs would be best =or you, please see Choosing a Drug to Prevent Malaria.

Note: Chloroquine is NOT =n effective antimalarial drug in Cote d'Ivoire and should not be =aken to prevent malaria in this region.

To find out more information on malaria throughout the world, =ou can use the interactive CDC malaria map <http://www.cdc.gov/malaria/map/index.html> . You can search or =rowse countries, cities, and place names for more specific malaria risk =nformation and the recommended prevention medicines for that =rea.

Malaria Contact for =ealth-Care Providers For =ssistance with the diagnosis or management of suspected cases of =alaria, call the CDC Malaria Hotline: 770-488-7788 (M-F, 9 am-5 pm, =astern time). For emergency consultation after hours, call 770.488.7100 =nd ask to speak with a CDC Malaria Branch clinician.

A Special Note about =ntimalarial Drugs

You should =urchase your antimalarial drugs before travel. Drugs purchased overseas =ay not be manufactured according to United States standards and may not =e effective. They also may be dangerous, contain counterfeit =edications or contaminants, or be combinations of drugs that are not =afe to use.

Halofantrine (marketed as =alfan) is widely used overseas to treat malaria. CDC recommends that =ou do NOT use =alofantrine because of serious heart-related side effects, including =eaths. You should avoid using antimalarial drugs that are not =ecommended unless you =ave been diagnosed with life-threatening malaria and no other options =re immediately available.

For detailed information =bout these antimalarial drugs, see Choosing a Drug to Prevent Malaria.

More Information About Malaria

Malaria is =lways a serious disease and may be a deadly illness. Humans get malaria =rom the bite of a mosquito infected with the parasite. Prevent this =erious disease by seeing your health-care provider for a prescription =ntimalarial drug and by protecting yourself against mosquito bites (see below).

Travelers to =alaria risk-areas in Cote d'Ivoire, including infants, children, =nd former residents of Cote d'Ivoire, should take one of the =ntimalarial drugs listed in the box above.

Symptoms

Malaria symptoms may include

- chills

- headache

- body =ches

- nausea and =omiting

• Plasmodium falciparum, if not promptly treated, may cause kidney =ailure, coma, and death. Despite using the protective measures outlined =bove, travelers may still develop malaria up to a year after returning =rom a malarious area. You should see a doctor immediately if you =evelop a fever anytime during the year following your return and tell =he physician of your travel.

Items to Bring With You

Medicines you may need:

• The prescription =edicines you take every day. Make sure you have enough to =ast during your trip. Keep them in their original prescription bottles =nd always in your carry-on luggage. Be =ure to follow security =uidelines<icon_out.png> <http://www.tsa.gov/> , if the medicines =re liquids.

	• malaria-risk area in Cote d'Ivoire and prescribed by =our doctor.

	• Medicine for diarrhea, usually =ver-the-counter.

Note: Some drugs available =y prescription in the US are illegal in other countries. Check the US =epartment of State Consular Information =heets<icon_out.png> for the =ountry(s) you intend to visit or the embassy or consulate for that =ountry(s). If your medication is not allowed in the country you will be =isiting, ask your health-care provider to write a letter on office =tationery stating the medication has been prescribed for you.

Other items you may need:

• Iodine tablets and portable water filters to purify water if =ottled water is not available. See A Guide to Commercially-Bottled Water and Other Beverages, =nd Basic Information about Skin Cancer

chttp://wwwnc.cdc.gov/travel/page/safe-food-water.htm> for more =nformation.

	• Lightweight long-sleeved shirts, long pants, and a hat to wear =utside, whenever possible.

• Flying-insect spray to help clear rooms of mosquitoes. The =roduct should contain a pyrethroid insecticide; these insecticides =uickly kill flying insects, including mosquitoes.

• Bed nets treated with =ermethrin, if you will not be sleeping in an air-conditioned or =ell-screened room and will be in malaria-risk areas. For use and =urchasing information, seelnsecticide Treated Bed Nets on the CDC malaria site. =verseas, permethrin or another insecticide, deltamethrin, may be =urchased to treat bed nets and clothes.

See other suggested over-the-counter medications and first aid =terns for a travelers' health kit.

Note: =heck the Air Travel =ection<icon_out.png> of the Transportation Security =dministration<icon_out.png> website =or the latest information about airport screening procedures and =rohibited items.

Top of =age

Other Diseases Found in West Africa

Risk can vary between countries within this region =nd also within a country; the quality of in-country surveillance also =aries.

The following are disease risks =hat might affect travelers; this is not a complete list of diseases =hat can be present. Environmental conditions may also change, and up to =ate information about risk by regions within a country may also not =lways be available.

filariasis, leishmaniasis, and onchocerciasis (river blindness) are other =iseases carried by insects that also occur in West Africa. African trypanosomiasis (African sleeping =ickness) has increased in Africa (it is epidemic in Angola, =emocratic Republic of the Congo, and the Sudan; and highly endemic in =ameroon, Central African Republic, Chad, Congo, Cote d'Ivoire, =uinea, Mozambique, Uganda, and Tanzania; low levels are found in most =f the other countries►, and an increase in travelers has been noted =ince 2000. Most had exposures in Tanzania and Kenya, reflecting =ommon tourist routes. Protecting yourself against insect =ites will help to prevent these diseases.

Schistosomiasis, a parasitic infection, can be =ontracted in fresh water in this region. Do not swim in fresh water =except in well-chlorinated swimming pools) in these countries.

Polio outbreaks were reported in several =reviously polio-free countries in Central, Eastern, and Western Africa =eginning in 2003. Polio is still endemic in Nigeria.

Travelers to rural areas of West Africa may be exposed =o Lassa virus, which is spread through contact =ith rat urine or droppings. People can be exposed to Lassa virus by =nhaling tiny particles of these excretions in the air, especially if =hey stay in traditional dwellings. Travelers should avoid contact with =ats and should not stay in dwellings that may be infested with rats. =uman-to-human transmission of the disease has been described. Proper safety precautions should be =ollowed to prevent human-to-human transmission from infected =eople.

Highly pathogenic avian =nfluenza (H5N1) has been found in poultry populations in several =ountries in Africa. Avoid all direct contact with birds, including =omestic poultry (such as chickens and ducks) and wild birds, and avoid =laces such as poultry farms and bird markets where live birds are =aised or kept. For a current list of countries reporting =utbreaks of H5N1 among poultry and/or wild birds, view updates from the =orld Organization for Animal Health =OIE)<icon_out.png>, and for total numbers =f confirmed human cases of H5N1 virus by country see the World Health Organization (WHO) Avian Influenza =ebsite<icon_out.png>.

Many countries in this region have high incidence rates =f tuberculosis <http://wwwnc.cdc.gov/travel/yellowBookCh4- TB.aspx> and high HIV prevalence rates.

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Staying Healthy During Your Trip

Prevent Insect Bites

Many diseases, like malaria and dengue, are spread through insect bites. One of =he best protections is to prevent insect bites by:

• Using insect repellent (bug spray) with 30%-50% DEET. Picaridin, =vailable in 7% and 15% concentrations, needs more frequent application. =here is less information available on how effective picaridin is at =rotecting against all of the types of mosquitoes that transmit =alaria.

• Wearing =ong-sleeved shirts, long pants, and a hat outdoors.

• Remaining indoors in a =creened or air-conditioned area during the peak biting period for =alaria (dusk and dawn).

* Sleeping in beds covered by nets treated with permethrin, if not =leeping in an air-conditioned or well-screened room.

* Spraying rooms with products =effective against flying insects, such as those containing =ytrethroid.

For detailed information about =nsect repellent use, see Insect and Arthropod Protection.

Prevent Animal Bites and Scratches

Direct contact with animals can spread diseases like rabies or =ause serious injury or illness. It is important to prevent animal bites =nd scratches.

• Be sure you are up to date =ith tetanus vaccination.

• Do not touch or feed any animals, including dogs and cats. Even =nimals that look like healthy pets can have rabies or other =iseases.

• Help =hildren stay safe by supervising them carefully around all =nimals.

• If you are =itten or scratched, wash the wound well with soap and water and go to a doctor right away.

• After your trip, be sure to =ell your doctor or state health department if you were bitten or =cratched during travel.

For more =nformation about rabies and travel, see the Rabies chapter of the Yellow Book or CDC's =abies homepage. For more information about how to protect yourself =rom other risks related to animals, seeAnimal-Associated Hazards.

Be Careful about Food and Water

Diseases =rom food and water are the leading cause of illness in travelers. =ollow these tips for safe eating and drinking:

• Wash your hands often with soap and water, especially before =ating. If soap and water are not available, use an alcohol-based =and gel (with at least 60% alcohol).

• Drink only bottled or boiled water, or carbonated (bubbly) drinks =n cans or bottles. Avoid tap water, fountain drinks, and ice =ubes. If this is not possible, learn how to make water safer to drink.

• Do not eat food purchased from street vendors.

• Make sure food is fully =ooked.

• Avoid =airy products, unless you know they have been pasteurized.

Diseases from food and water often cause vomiting and diarrhea. =ake sure to bring diarrhea medicine with you so that you can treat mild rases yourself.

Avoid Injuries

Car crashes are a leading cause of injury among travelers. Protect yourself =rom these injuries by:

	- Not =rinking and driving.

• Wearing =our seat belt and using car seats or booster seats in the backseat for =hildren.

• Following =ocal traffic laws.

• Wearing =elmets when you ride bikes, motorcycles, and motor bikes.

* Not getting on an overloaded =us or mini-bus.

* Hiring a =ocal driver, when possible.

	- Avoiding night driving.

Other Health Tips

• To avoid =nfections such as HIV and viral hepatitis do not share needles for =attoos, body piercing, or injections.

• To reduce the risk of HIV and other sexually transmitted diseases =lways use latex condoms.

• To prevent fungal and parasitic infections, keep feet clean and =ry, and do not go barefoot, especially on beaches where animals may =ave defecated.

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After =ou Return Home

If you are not feeling well, =ou should see your doctor and mention that you have recently traveled. =lso tell your doctor if you were bitten or scratched by an animal while =raveling.

If you have visited a =alaria-risk area, continue taking your antimalarial drug for 4 weeks =doxycycline or mefloquine) or seven days (atovaquone/proguanil) after =eaving the risk area.

Malaria is always a serious disease and may be a deadly =llness. If you become ill with a fever or flu-like illness =ither while traveling in a malaria-risk area or after you return home =for up to 1 year), you should seek immediate medical attention and should tell the =hysician your travel history.

Important =ote: This document is not a complete medical guide for =ravelers to this region. Consult with your doctor for specific =nformation related to your needs and your medical history; =ecommendations may differ for pregnant women, young children, and =ersons who have chronic medical conditions.

Top of =age <http://wwwnc.cdc.gov/travel/destinations/ivory-coast.htm#top>

Map Disclaimer - The boundaries =nd names shown and the designations used on maps do not imply the =xpression of any opinion whatsoever on the part of the Centers for =isease Control and Prevention concerning the legal status of any =ountry, territory, city or area or of its authorities, or concerning =he delimitation of its frontiers or boundaries. Approximate border =ines for which there may not yet be full agreement are generally =arked.

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On Nov 9, 2011, at 2:53 PM, Jeffrey Epstein =rote:

find out about disease shots for ivory coast. =asseck tells me malaria is there

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