From: Sarah K █████████████████
Sent: Wednesday, November 9, 2011 11:13 PM
To: ███████████
Subject: Re: Ivory Coast CDC Health Information

It looks pretty thorough to me!

On Nov 9, 2011, at 1:11 PM, ██████████ wrote:

I did. Do you think it's what he wants? I =as a bit scared of him today !!

Sent from my =Phone

On Nov 9, 2011, at 5:43 PM, Sarah K ██████████████████████ > wrote:

thanks =es.. did you send this to JE as well?

On Nov 9, 2011, =t 3:21PM, wrote:

Preparing for Your Trip to Cote =1Ivoire

Before visiting Cote 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 =Ilow 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 =evel 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 (DPI) 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 through 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 21 year of age.

Recommendations: Recommended for all =ravelers 29 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)

## Vaccine-Preventable Diseases (cont.)

If you will be visiting an area of Cote 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 °Ste d'Ivoire, including infants, children, =nd former residents of Cote d'Ivoire, should take one of the =ntimalarial drugs listed in the box above.

## A Special Note about =ntimalarial Drugs (cont.)

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.govk , if the medicines =re liquids.

* malaria-risk area in C6te 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 <http://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. air-conditioned or =ell-screened room • and will Bed be nets in malaria-risk treated with areas. =ermethrin, For use if and you =urchasing will not be information, sleeping in an 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 =tems 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.

## A Special Note about =ntimalarial Drugs (cont.)

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

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 H5N1among poultry and/or wild birds, view updates from the =orld Organization for Animal Health =OlE)<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.

Top of =age
Staying Healthy During Your Trip

## A Special Note about =ntimalarial Drugs (cont.)

## 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 3CPA-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 ralaria.

• 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 =ffective against flying insects, such as those containing =yrethroid.

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 rause 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 rubes. If this is not possible, learn how to make water safer to drink.

## Prevent Insect Bites (cont.)

- 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 =ases 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.

Top of =age

After =ou Return Home

If you are not feeling well, =ou should see your doctor and mention that you have recently traveled. =Iso 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 =Ilness. 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 1year), you should seek immediate medical attention and should tell the =hysician your travel history.

## Prevent Insect Bites (cont.)

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

-- =br>**********

**************

The =nformation contained in this communication is confidential, may be attorney-client privileged, may constitute =nside information, and is intended only for the use of the =ddressee. It is the property of Jeffrey Epstein

Unauthorized =se, disclosure or copying of this communication or any part thereof is strictly prohibited and may be =nlawful. If you have received this communication in error, please =otify us immediately by return e-mail or by e-mail to jeevacation@gmail.com, and destroy this communication and all copies thereof, including all =ttachments. copyright -all rights reserved

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