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Centers for Disease Control and Prevention Yellow Book 2018: Health Information for International Travelers

Since its first publication in 1967 as a small pamphlet, the Centers for Disease Control and Prevention’s Health Information for International Travel , more commonly known as the Yellow Book, has blossomed into a 667-page, 7 × 10 inch paperback compendium of detailed, pragmatic, evidence-based recommendations on travel health. Although written first and foremost for clinicians (physicians, nurses, and pharmacists), much or most of the guide will be comprehensible to the lay traveler. Now published every other year ($49.95, University of Oxford Press), the Yellow Book is also available online, as an eBook, and as a mobile app.

The 2018 edition is largely similar to the 2016 edition. A few sections have been dropped (e.g., Perspectives on the Role of the Traveler in the Translocation of Disease, and Fear of Vaccines); others have been added (including Antibiotics in Travelers’ Diarrhea—Balancing the Risks and Benefits; and, in the chapter on Advising Travelers with Specific Needs, a section on Immunocompromised Travelers). Length, at 667 pages, is eight pages longer. The organization of chapters is unchanged.

The chapter on the pretravel consultation, in addition to listing the many topics that must be discussed before international travel, features a number of sections termed Perspectives, including discussions of travelers’ perceptions of risk, prioritizing care for the resource-limited traveler, cost analyses to justify the pretravel consultation, and the pros and cons of travelers self-treating travelers’ diarrhea with antibiotics. This chapter also contains helpful sections on altitude illness; jet lag; motion sickness; food and water precautions; protection against mosquitoes, ticks, and other arthropods; and other salient topics.

Chapter 3, by far the longest chapter in the book, details a number of infectious diseases, from amebiasis to Zika. The country-specific information regarding malaria prophylaxis and yellow fever vaccination is particularly helpful for practicing clinicians who need to make decisions about recommendations during a clinical encounter.

Although the country-specific information on malaria designates each malaria-endemic country’s estimated relative risk of malaria for U.S. travelers as being high, moderate, low, or very low, the relatively brief discussion of factors to take into account when deciding whether to advise the traveler to take a prophylactic medication, as opposed to insect precautions only (pp. 239–240 and p. 374), could be expanded.

A welcome addition in recent years has been the inclusion of 15 country-specific malaria maps and a number of yellow fever maps as well. This chapter also contains a number of historical overviews of selected topics, for example, “A History of Yellow Fever Vaccination Requirements,” “A History of Polio Eradication Efforts,” and “A History of Malaria Chemoprophylaxis,” which are interesting and informative for travel medicine buffs.

Chapter 4 discusses 16 common destinations for tourists and other travelers—this is a relatively recent addition to the Yellow Book—including East African safaris; Peru, including Cusco and Machu Picchu; and Saudi Arabia: Hajj/Umrah Pilgrimage (Cambodia, and Egypt and Nile River Cruses have been removed from the print edition but are available in the online version.) These well-informed sections consist of focused discussion of risks to health at specific destinations.

Chapter 5, Post-Travel Evaluation, discusses general considerations when seeing returned ill travelers and pragmatic discussion of workup of common complaints in returned travelers, including fever, prolonged travelers’ diarrhea, and skin and soft tissue infections.

Chapters 6, 7, and 8 address conveyance and transportation issues, travel with infants and children, and advising travelers with specific needs. Given the increasing numbers of travelers who are elderly and/or have specific medical needs, the topic of travelers with ongoing medical issues is particularly relevant to pretravel providers.

Although the sections on noninfectious threats have become longer in recent years, these sections are still relatively brief, given the importance of noninfectious threats to travelers. The chapter on injury prevention is less than five pages, which is less than 1% of the total length of this book. In defense of editors of the Yellow Book, research showing efficacy of interventions that reduce the risk of noninfectious threats to travelers lags behind research on reducing risk from infectious diseases. Nonetheless, given that the title of the book is Health Information for International Travel , not Health Information on Infectious Threats to International Travelers— and that road traffic injuries alone are the cause of as many as 25% of deaths of travelers—this section could benefit from expanded discussion of epidemiology, contributory factors, and strategies to mitigate risk of road traffic injuries, drowning, falls from height, and other noninfectious threats. Many of the infectious diseases discussed in Chapter 3 are extremely rare in travelers; possibly some of these sections could be shortened to allow expanded discussion of more common threats to travelers, including road traffic injuries. In addition, a section on lesbian, gay, bisexual, and transgender travelers would be a welcome addition.

The Yellow Book remains the best single source of information for clinicians who provide care to international travelers. Its tone is reasoned and reasonable; its implicit level of concern—cautious but not paranoid—is ideal. Increased attention to noninfectious threats to travelers would make it better still.

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Please note you do not have access to teaching notes, investigating tourist post-travel evaluation and behavioural intention: a cultural intelligence perspective.

Asia Pacific Journal of Marketing and Logistics

ISSN : 1355-5855

Article publication date: 26 February 2021

Issue publication date: 25 October 2021

This paper aims to investigate whether cultural intelligence will influence Chinese tourists’ travel satisfaction, revisit intention and word-of-mouth communication.

Design/methodology/approach

An online survey was conducted to collect data from 614 adult Chinese tourists, who have overseas travel experiences. Then, the Statistics Package for the Social Sciences (SPSS) and the structural equation modelling (SEM) were employed for data analysis.

The findings confirm that cultural intelligence has significant positive impacts on tourist satisfaction, revisit intention and electronic word-of-mouth (eWOM) communication. Additionally, tourist satisfaction significantly affects tourist eWOM communication.

Originality/value

This study provides theoretical and practical contributions regarding the effects of tourist cultural intelligence, especially on tourist post-travel evaluation and behavioural intention, which has been merely investigated in extant tourism research.

• Cultural intelligence
• Chinese tourists
• Tourist satisfaction
• Revisit intention
• Electronic word-of-mouth communication

Zhang, Y. , Shao, W. and Thaichon, P. (2021), "Investigating tourist post-travel evaluation and behavioural intention: a cultural intelligence perspective", Asia Pacific Journal of Marketing and Logistics , Vol. 33 No. 10, pp. 2037-2053. https://doi.org/10.1108/APJML-08-2020-0584

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Cultural Intelligence Matters: Its Effects on Tourist Post-Travel Evaluation and Behavioural Intention: An Abstract

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• Yunen Zhang 4 &
• Wei Shao 4  

Part of the book series: Developments in Marketing Science: Proceedings of the Academy of Marketing Science ((DMSPAMS))

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The prosperity of the international tourism industry implies the need to take a closer look at tourists’ cross-cultural adaptability as which is highly correlated with their overseas travel experiences. Earley and Ang (2003) proposed a concept, cultural intelligence (CQ), to measure one’s cross-cultural adaptability. CQ refers to one’s capabilities to effectively adjust to different cultures (Earley and Ang 2003). Individuals with higher cultural intelligence might alter their ways of thinking and behaving as they understand there are differences between distinct cultures, possess greater cross-cultural knowledge, have a stronger intrinsic motivation to make adjustment, and are able to conduct favourable behaviours based on the host cultural requirement (Ang et al. 2007; Van der Horst and Albertyn 2018). Therefore, this study aims to understand the effect of tourists’ cultural intelligence on their post-travel evaluations and behavioural intentions. The purpose of this study is twofold: first, to explore the relationships between tourist cultural intelligence and satisfaction; and second, to identify the relationships between tourist satisfaction, revisit intention, and electronic word-of-mouth (eWOM) communication.

This study uses an online survey to collect respondents’ information. The sampling units in this research are those Chinese tourists who have overseas travel experiences, given their large population and undeniable influences on the development of the global tourism industry (UNWTO 2019). Statistics package for the social sciences (SPSS) and Analysis of Moment Structures (AMOS) are employed as data analysis methods.

The data analysis results suggest that with higher CQ, Chinese tourists are more likely to be satisfied with, revisit, and say positive things about their overseas destinations. Tourist satisfaction leads to positive eWOM but has no significant impact on revisit intention. Tourist satisfaction also mediates the relationship between CQ and eWOM.

This research contributes to the existing literature on cultural intelligence by extending its research context to tourism research. To add, this study is the first to identify that tourist cultural intelligence is an important antecedent of tourist post-travel evaluations and behaviours, which are the two most important tourism research topics. This study suggests outbound tourists to acquire more knowledge about the host cultures of their destinations for gaining a more satisfying travel experience. Moreover, Local travel agents and government are suggested to strengthen visitors’ cultural attachment and enhance cultural influence power, which is an essential index for measuring national soft power (Ning 2018).

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Zhang, Y., Shao, W. (2022). Cultural Intelligence Matters: Its Effects on Tourist Post-Travel Evaluation and Behavioural Intention: An Abstract. In: Allen, J., Jochims, B., Wu, S. (eds) Celebrating the Past and Future of Marketing and Discovery with Social Impact. AMSAC-WC 2021. Developments in Marketing Science: Proceedings of the Academy of Marketing Science. Springer, Cham. https://doi.org/10.1007/978-3-030-95346-1_196

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Independent Travel to Moscow and St. Petersburg

My wife and I have traveled independently to many European countries and, after reading many of the comments in this forum, feel like we may be able to do so in Moscow and St. Petersburg as well, although we feel somewhat less comfortable than the other countries where we have traveled in Europe.

My biggest question is how much we will miss by visiting the main sites without a tour guide. In the other European countries we have visited on our own we have been comfortable and satisfied with the level of knowledge we have gained by studying and visiting on our own, although we believe a tour guide or tour company in any country would normally be able to provide greater insight than visiting a site on our own, but about in Moscow and St. Petersburg?

Any thoughts would be appreciated.

Unless you speak at least some Russian and read the alphabet it would be difficult without a guide. Very few signs in English especially in Moscow. Also not too many people speak English there.

I visited St Petersburg last Autumn for a protracted period , and did not find it anymore daunting than any other European city . As Ilja says , learning the Cyrillic alphabet is a big plus . I also found that it was fairly easy to grasp . It will , among other things , enable you to read signs with relative ease . I would answer the main part or your question ( about tour guides ) thus - I am not enamored of tour guides or tours. While I only use a tour under duress ( A sites rules prohibiting an independent visit - ie Glasgow School of Art , Municipal House in Prague , etc ) . Doing your own preparation and homework is the best way , in my opinion . My wife and I ventured through St Petersburg with nary a concern ,and made two day trips outside of the central district ( one was twenty five miles away , and no English speakers in sight ) Figuring out the logistical details , did not present any difficulties . While I never use tours , I am an inveterate eavesdropper , have done so many times , and find , that on balance , the information that they impart is fairly elementary . If you want greater detail , they are unlikely to supply it . I also prefer to go at my own pace , not being rushed and being able to dwell on things that most other visitors barely give a passing glance . If you are interested , let me know . I would be happy to provide you with information that will enable you to travel independently

Thank you, Steven. I am encouraged by your comments and feel the same way you do about tour groups. We are very much willing to prepare in advance and learn the basics of the Cyrillic alphabet to help us have a better experience.

I would be very interested in learning more about your experience in Russia and receiving any additional information you can provide on independent travel there, starting perhaps with obtaining the visa.

I am not opposed to hiring a private or small group guide for a specific site or for a day trip outside St Petersburg and Moscow, but, like you said, I much prefer the freedom of staying at places as long or short as I want and seeing the sites that interest me most. For example, neither my wife nor I are big into shopping, yet most tour itineraries leave afternoon time for just that. Not interested!

Please provide whatever you may feel would be helpful for us.

Russ , I see you are quite near San Francisco - you can start by looking at the VISA procedure , it's fairly straightforward . Since there is a consulate in San Francisco - look here http://www.consulrussia.org/eng/visa-sub1.html

And here - http://ils-usa.com/main.php

Having always traveled independently, we thought we could do a better job than any tour. How misguided (pun intended) we were. Now that we have had the experience of having someone native to the area walk us around and explain things through a personal perspective we realize how much we missed. For St. Petersburg I highly recommend http://www.peterswalk.com/tours.html . This is not a traditional guided tour, but an opportunity to receive some orientation to the area as well as insight into the "Russian soul". I think if you did this upon arrival the rest of your time would be much more meaningful. We really liked the http://www.pushka-inn.com . The location is superb (just around the corner from the Hermitage square), the rooms lovely, the included breakfast at the restaurant next door ample and overall an excellent value. We used this company to get our visa: https://www.passportvisasexpress.com/site/san_francisco_customer_service Note that it costs about the same for a 3-year visa as a one-year, and you never know if you might want to return within that more extended window of time. It is not cheap, so factor that into your planning.

If you like traveling without a guide in other countries and find this satisfying, the same will be true in Moscow and St. Petersburg. Of course it's not either/or - you can certainly take a guided walk or boat tour, for instance.

I cannot emphasize enough the importance of learning Cyrillic if you're going on your own. The book I used was Teach Yourself Beginner's Russian Script, which was great. It breaks down the alphabet into letters that are the same as English, letters that look the same but are pronounced differently, etc. It's out of print, but you can get used copies on Amazon: http://www.amazon.com/Teach-Yourself-Beginners-Russian-Script/dp/0071419861/ref=sr_1_2?ie=UTF8&qid=1459701143&sr=8-2&keywords=teach+yourself+russian+script

Russia is indeed a bit more "foreign" than say, Italy. However, in Moscow and St. Petersburg, I found enough English to be able to get by. Many restaurants had English menus and/or English speaking staff, for instance. This was most emphatically not true in Vladimir and Suzdal (two cities in the Golden Ring outside Moscow). I went with my sister, a Russian speaker, and if she hadn't been there, I would have been in big trouble. So, if you want to see places outside these two big cities, use a guided tour (even if just for that part). Also, Moscow and St. Petersburg are huge cities. Coming from New York, I wasn't intimidated, but those not used to a megacity may not be so cavalier (even I found them overwhelming at times, especially Moscow).

I found both Lonely Planet and Rough Guide to be helpful, and both to have various errors. Look at both, buy whichever one has a more recent edition, and then be prepared to have to discard some of the advice therein. Also, these places change more quickly than places in Western Europe. Be very careful of outdated advice. For instance, I was there in 2001 and 2010, so I won't give you any specifics on getting a visa - that changes constantly.

Just as a teaser, two things I saw and loved that I doubt would be included in any escorted tour are the Gorky House in Moscow (an Art Nouveau wonder) and the Sheremyetov Palace in St. Petersburg (it's now a museum of musical instruments, and the decor is amazing, particularly in the Etruscan Room).

Thanks for all the good advice. Any additional thoughts are welcomed.

One of history's seminal works pertaining to Russian history and culture and a MUST for anyone contemplating a visit or simply interested , is this fine work from 1980 - http://www.amazon.com/Land-Firebird-The-Beauty-Russia/dp/096441841X

This is about you and not about Petersburg. Do you like guided tours? We don't and didn't find that a guide added to our experience in China where we did hire private guides mostly for the logistics; it was easy to have someone drive us places. But once at a site, we didn't need the guide. I felt the same way about our 9 nights in Petersburg. We did hire a guide for the trip to the Catherine Palace again for the ease of logistics for us Olds. Here is our visit: https://janettravels.wordpress.com/2016/01/23/an-easy-trip-to-the-catherine-palace/ There are also snapshots of the Church on Spilled Blood in this photo journal. Having someone pick us up at the apartment and get us in without line ups and shepherd us through the palace steering clear of the tour groups was lovely. But we didn't need commentary because we can read and prepare.

You certainly don't need a guide for the Hermitage (we spent 4 days there), the Russian Museum, the Kazan Cathedral or Church on Spilled Blood or the Faberge Museum. We enjoyed a number of self guided walking tours including a couple from Rick Steves guidebooks. We took the canal cruise suggested by RS that had an English commentator. I would not take one without that as you will be totally clueless. The commentator was not all that good but at least we had some idea what we were seeing. So for people like us who like to do our own thing and can read a guidebook and don't particularly like to be led about, a tour is not needed. If you enjoy tour groups, then go for it. Petersburg is easy to negotiate. It helps if you can read the cyrillic alphabet and it is also useful to have the google translate ap on your phone. We found ourselves translating packages in grocery stores with it and the occasional museum sign or menu. I have one food I need to avoid and so it was handy to have the translator to talk with waiters (I could either show them the sentence, or play it for them or play it to myself and then repeat it to the waiter -- that all worked well)

Dear Russ, I cannot help you with Moscow, but about four years ago, my husband and I went to St Petersburg on our own. But, we did use a private guide for 4 half days. We both feel that our guide absolutely made our trip (we stayed 6 or 7 nights). We used a company owned by Tatyana Chiurikova, www.tour-stpetersburg.com I cannot say enough good things about her and our experience. I emailed her and we worked out a schedule/ sights that was tailored to our interests. She also offered some recommendations, which we took. The guide will meet you at your hotel. And frequently, at certain places, with the guide, we were able to skip the long entrance lines. We had an half day driving tour of the city (car, driver, & guide). You are taken to & go in places such as Peter & Paul Fortress, some of the cathedrals, etc. We had a half day with the guide at the Hermitage which ensured that we would see the major sights there. And, of course, you can stay after your guide leaves or return another day. Also, we had the guide for Peterhof (a must & go by boat) and Catherine's Palace. I hope that you will go to the website. As I said, our guide made our trip. I am positive that we would have missed quite a bit on our own everyday. And I'm sure we would have wasted a lot of time trying to get to various place.This was the best of both worlds, a guide where needed and plenty of time on our own. Whatever you do, I'm sure that you will love St Petersburg! Ashley

I am curious about the lines as we encountered no lines on our trip -- but it was in September. We got tickets for the Hermitage at machines and skipped those lines and our guide for the Catherine Palace which was our only guided experience (as noted before, chosen for the logistics of getting there) had arranged tickets and we didn't have a line, but then we also didn't see lines. We did not find lines at any other site.

Both Moscow and St Petersburg I've done on my own, that is together with the Dear Partner. I can't remember any problem getting where we wanted to go. The Metro systems are well signed, and with a little exercise and patience you can recognize the station names. With a good map and a good guide - we had the Rough Guides - that part of the logistics is solved. The language is a major problem, but the usual tricks of pointing, looking helpless, and making a joke of it all do wonders. I would hate to be led by a guide, but for others it is a comfortable thought.

We also did both cities on our own. I found the DK Eyewitness guide for Moscow has the best map. I used the one from our library (kept the book at home). Took the smaller RS book for St. Petersburg ( his book on northern cities). His map and restaurant ideas were all good. We also downloaded the Google maps in our Android Samsung tablets/phones for both cities and then could get directions to any place we typed in. The blue ball guided us everywhere. I'm sure we missed somethings by not having a guide, but we just enjoy walking around and getting a sense of a place. If you like art, The Hermitage is great. We went 3 times and still missed alot. In St. Peterburg we stayed at the 3 Mosta which we loved (quite and not far from the Church of Spilled Blood.) We also loved the Georgian food in both cities. There's a great Georgian restaurant near the 3 Mosta hotel. We're now in Belarus- very scenic. Enjoy your trip!!

This topic has been automatically closed due to a period of inactivity.

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Apartment for new years location evaluation.... - Moscow Forum

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Apartment for new years location evaluation....

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Getting ready to book my new years hotel, what do you guys think of this place:

LikeHome Paveletsky Serviced Apartments

The price is right and they can take 3 guests, which is essential. My primary concern is location, and privacy if we want to bring back guests. Proximity to Red Square is important but will probably only be there on NYE night, so otherwise how do you consider this area? Paveletskaya.

Thanks as always to everyone helping me, I like to go and reply to other travel posts after I post here. :)

Hi Braveheart,

Paveletskaya is quite good location and your apartments will be really close to the metrostation. On the other side you will be too close to Railway station that means a lot of people around. Anyway there are a lot of cafe and restaurants near from your place.

If you rent apartmnets that means (usually) that you can bring as many guests there as you want. Just be sure you won't be too noisy to disturb local people who live in the house.

http://guyssquared.com

Thanks again!

Maybe this is too late, but I hope it reaches you.

I would strongly recommend against the Likehome apartments, and I mean VERY strongly recommend against them.

When it came to finding the place, we could see the building in the description on hotels.com but couldn't enter.

The staff from Likehome sent the manager down to find us, to lead the way. He took us about 10 minutes away to another building which looked like a projects/housing estate block of flats (which while Approaching the building, we had a little laugh about the possibility of it being this one).

I'm a pretty big guy, and not afraid of many situations, but we ended up RUNNING from the place, and I'll tell you why. Please bear in mind that this is meant to be a constructive review of the place, and everything is fact.

Firstly as we walked up to the building through a quite eerie park, the front door was almost hanging off. We entered, and in front of us was a lift, and with no exaggeration it looked like the building should have been deserted, and perhaps from a horror film. The pungent smell of urine on the inside of the building wasn't very appealing either.

we walked towards the lift. as we did the door opened and 3 young people staggered out of it, quite obviously on drugs. They could barely walk or speak. As they stumbled towards us holding on to the rail, one of the guys jackets opened to reveal a handgun which he was trying to secure into a holster. Now I'm not a big fan of guns at the best of times even in a controlled environment, but when they are in the hands of drugged up teenagers I'm even more wary of them.

We immediately refused to stay there, and the manager called the office and put us through to the reservations manager. We had a long conversation with them and they said they would still charge us despite not staying there.

It was only when we asked them that if THEY had booked somewhere based on the pictures and description in an advert, and then were shown something entirely different, that they understood and agreed not to charge us (as I say we are still in Moscow, and are yet to see if they will keep their word on this).

Luckily the drugged up teenagers with the gun weren't to be seen once we had had this conversation, but as it was now dark, we ran through the park and got to the high street. We booked another hotel, and even though its cost us a fortune, we would much rather we were safe.

Be careful, and if you need any advice, let me know.

Wow... Good to know! Thanks! I actually changed the reservation anyway.

Hotels are best! That's my 2 cents worth. Man what a horror story. AIM.

This topic has been closed to new posts due to inactivity.

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How to Phone and Send Post from Moscow

To be omnipresent in Moscow you’ll need wi-fi or cellular phone capabilities. It’s better to get a local SIM card to avoid high roaming costs. The best one is from Megafon, who offers “Mezhdunarodny” tarif with cheap calls abroad and inexpensive fast speed LTE (4G) internet (get a prepaid 3 gig pack for 10 eur). They also have lots of additional options you’d need to switch on to save money, so check out their English-language website. One thing to keep in mind is that all Russian cell phone operators have slightly higher tariffs if you travel outside of the city where you bought your SIM. So check out their roaming tariffs and buy the SIM in the region you’ll spend most of your time in or switch on the cheaper roaming options.

How to phone from Moscow

The phone code of Moscow is 495. If you phone inside Moscow , you should just dial the 7-digit number. If you phone to another country , dial 8, wait for a long tone, dial 10 (for international access), then the code of the country, of the city, and the phone number you need. If you phone to another town in Russia , dial 8, wait for a long tone, and then dial the code of the city, followed by the local phone number. If you phone to a mobile phone , which doesn't have a direct Moscow number, dial 8, wait for a long tone, and then dial the number (for example, 910 555-5555).  

Using Public Phones  

Most of the pay phones require a phonecard, which you can buy at any metro station's ticket office. Each phone has an instruction in English on the display and you can change the language of it by pressing the button "L". The telephone card - Tele`fonnaya `Karta - can be for 20 units (minutes) - 60 R ($2) or 50 units (one hour) - 105 R ($4). The public phones are usually located near or inside all metro stations and at the other popular places. It's possible to use those public phones for international calls too, but it's very expensive, better consider the options below.

  How to communicate with the outside world?

First, you can phone from the hotel or hostel you're staying in. Usually hotels charge much more than it really costs, so it's not a very good idea. If you live in an apartment, the price would be around 20R ($0.7) a minute if the call goes through MGTS local provider (it will, in most cases). You can also go to the Tverskaya ulitsa, 7 (central telegraph, opened 24 hours) or to another telegraph office . You can order a telephone call or send a fax anywhere. A call to Western Europe is around 20 roubles (0.7$) a minute. For some reason, there are no special 'budget call centers' in Moscow as in some other countries. Another way to phone abroad is to make a collect phone call . In this case, you will not pay for the phone call, but the party you're phoning to will. You can do it by dialing AT&T access number in Moscow (755-5042 or 747-3323), dialing the number you wish to reach, waiting for an operator to answer (English-speaking only) and telling him / her you'd like to make a free phone call to this number. You will need to repeat the number again to the operator, then you'll be connected, the person you're phoning to will be asked if he's willing to pay a phonecall from Russia, and voila. The cheapest way to phone abroad , is to use a special telephone card for IP-telephoning . You can use these cards from any phone in Moscow, even public ones. Just dial the Moscow access number written on the card, switch to the tone mode (usually a * (star) button), dial your PIN and then the number you're calling. There are many companies selling those cards, such as Comstar (Maxicard) or Rinotel, besides they have an English-language menu to explain you what to do while calling. Those cards can be bought either directly from the providers or easier from the telecom shops (sa`lon s`vyazi - usually next to metro stations -- the places where cell phones and accessories are sold). Regarding the prices, IP-cards from MTU cost 150 R ($5) and one minute of speaking with US, Canada, Western Europe costs $0.2. Even if you're calling from a public phone, the phonecall will cost you the same $0.2, plus $0.07 a minute you'll have to pay for the payphone.

You can also buy phonecards online , this way you will be able to use your card instantly. WayToRussia.Net together with MasterBell offers this service to our readers through Way to Russia Budget Phonecards shop. The rates are $0.10 per minute if you call from Moscow abroad, and $0.02 per minute if you call from USA to Russia. The quality is perfect if you use the card from Russia or USA, but don't buy it if you intend to use it in a European country.

Here's a list of some IP telephony providers in Moscow. Rinotel. Address: Sofiyskaya embankment, #30/3, (zamoskvorechie area, south center, metro Tretyakovskaya). Phone: 792-5404, fax 792-5405, internet: www.rinotel.ru e-mail: [email protected] | Comstar. Address: Dmitrovsky pereulok, #3, build. 1. Contacts: tel 956-0000, fax 956-0707, internet: http://www.comstar.ru/  

Using Mobile Phones in Moscow

All the operators have the same level of service and about the same prices: about $0.20 for a minute of a local call (incoming or outcoming), and $0.15 mobile to a mobile. Megafon offers calls to Europe and USA for only $0.35 / minute if you subscribe to one of their contract plans (starts from $35 US / month with 200 minutes included). Normally, you will be able to subscribe for a short period of time, because there are no 1-year minimum term contracts in Russia -- you can usually cancel with 1 month notice. To subscribe, you just can go to any telecom shop (there are many), pay a set-up fee ($30-$90) and a deposit $35-$40 which will directly go on your account, and you'll have a new SIM card and phone number. Just make sure your mobile isn't blocked by another provider. Once subscribed, if you want to add money to your account, you can buy a top-up card, which is sold in most shops.

Sending the Post in Russia

If you want to send something by post from Russia, you can do it either through the government post service or a courier service - the difference is the price and speed. State post service. The government post system in the whole Russia is unexpensive, not quality enough and slow, either if you send it inside or outside of Russia. Besides, sometimes the letters don't come at all. It'll be ok in the most cases with the parcels though.

How to send it. You should buy the post stamps at a post office, which you can find by Pochta sign. Post offices usually work monday - friday from 9.00 to 19.00 and saturday - 9.00 to 17.00, sunday is day off. The stamps you need to send a letter to Western Europe will cost around 12 R ($0.5). For that price your letter will arrive in 2-4 weeks. You can send your letter or postcard by putting them at any of the light blue post boxes on the streets or directly at the post office (better). Sending an average (around 500gm) parcel costs around $15 A more secure option is to go directly to the main post office of Moscow - Tsentralny Telegraph (Central Telegraph), it's on Tverskaya ulitsa, #7. It'll cost around $3 to send a letter from there and it'll take 2 weeks for it to arrive.

Courier services. It costs about $50 US to send a letter with a major courier service (see contacts below) from Russia to Europe, and about $70 US to the USA. It should take about 1 to 3 business days to arrive. DHL Express. Address: 8 Marta Ul., #14. Contacts: tel 956-1000, 961-1000, fax 974-2105 internet: http:// www.dhl.ru    Federal Express . Address: Aviatsionny pereulok, #8/17. Contacts: tel 234-3400, fax 234-9942. email: [email protected] internet: http://www.fedex.com    TNT. Address: Svobody Ul., #31. Contacts: tel 797-2777, fax 797-2778, email: [email protected] internet: http://www.tnt.com    UPS. Address: Bolshoi Tishinsky pereulok, #8, build. 2. Contacts: tel 961-2211. fax 254-4015. internet: http://www.ups.com  

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• Section 11 - Persistent Diarrhea in Returned Travelers
• Section 11 - Perspectives : Delusional Parasitosis

Dermatologic Conditions

Cdc yellow book 2024.

Author(s): Karolyn Wanat, Scott Norton

Fever & Rash

Skin lesion morphology, miscellaneous skin infections.

Skin and soft tissue problems, including rashes, are among the most frequent medical concerns of returned travelers. Several large reviews of dermatologic conditions in returned travelers have shown that cutaneous larva migrans, insect bite reactions, and bacterial infections (often superimposed on insect bites) represent the most common skin problems identified during posttravel medical visits ( Table 11-12 ).

Clinicians can use several approaches to diagnose and manage skin conditions in returned travelers. One useful approach is to consider whether the condition is accompanied by an elevated temperature. Few travelers’ dermatoses are accompanied by fever, which could indicate a systemic infection, usually viral or bacterial, that requires prompt attention. A second consideration is the geographic and exposure elements of the travel history. A third consideration is the morphology of the lesions noted on physical examination. The most successful approach combines all 3 considerations supported by laboratory confirmation from cultures, serology, skin biopsy, or microscopy if required or indicated. Box 11-02 includes essential elements of the assessment of returned travelers presenting with skin problems.

Many dermatologic problems in returned travelers represent a flare of an existing condition, perhaps because of interruption in the usual treatment regimen while away from home. Other skin disorders might coincide with travel or appear shortly thereafter but are unrelated to travel itself.

Table 11-12 Most common causes of skin lesions in returned travelers

Source: Modified from Lederman ER, Weld LH, Elyazar IR, von Sonnenburg F, Loutan L, Schwartz E, et al. GeoSentinel Surveillance Network. Dermatologic conditions of the ill returned traveler: an analysis from the GeoSentinel Surveillance Network. Int J Infect Dis. 2008;12(6):593–602.

Box 11-02 Assessing returned travelers presenting with skin problems: essential elements

Pertinent past medical history.

• Systemic diseases and chronic conditions, including preexisting skin conditions
• Current medications and allergies

HISTORY OF THE PRESENT ILLNESS

• Time of onset of lesions (during or after travel)
• Associated symptoms: fever, pain, pruritus

TRAVEL HISTORY

• Location and duration of travel
• Exposure history: freshwater, marine water, insects, animals, plants, occupational and recreational exposures, sexual and other human contact exposures
• Companion travelers with similar findings
• Vaccination status
• Adherence to standard travel precautions (e.g., safe food and water precautions, insect bite precautions)
• Medications taken during travel (could provide adequate prophylaxis for certain conditions or might have cutaneous side effects)

PHYSICAL EXAMINATION

• Shape of skin lesions (e.g., macules, nodules, papules, plaques, ulcers)
• Number, pattern, and distribution of lesions
• Location of lesions: exposed versus unexposed skin surfaces

Many illnesses fall into the category of fever with a rash. Consider the following infections in the differential diagnosis of febrile travelers with rashes: cytomegalovirus, enteroviruses (e.g., coxsackievirus, echovirus), Epstein-Barr virus, hepatitis B virus, histoplasmosis, leptospirosis, measles, syphilis, and typhus. Fever and rash in returned travelers are most often, though not exclusively, due to viral infections.

Systemic Viral Infections & Illnesses

Chikungunya.

A virus transmitted by Aedes spp. mosquitoes, chikungunya has caused major outbreaks of illness in southeast Africa, the Americas and the Caribbean, and South Asia (see Sec. 5, Part 2, Ch. 2, Chikungunya ). The rash associated with chikungunya resembles that of dengue (discussed next), but hemorrhage, shock, and death are rare with chikungunya. A major distinguishing feature of chikungunya is its associated arthritis, arthralgia, or tenosynovitis that can persist for months, particularly in older adults. As with dengue, serologic testing is available for diagnosis. After ruling out dengue, treat arthritis with nonsteroidal anti-inflammatory drugs (NSAIDs).

Dengue is caused by 1 of 4 strains of dengue viruses (see Sec. 5, Part 2, Ch. 4, Dengue ). The disease is transmitted by Aedes spp. mosquitoes often found in urban areas, and its incidence continues to increase. Disease is characterized by abrupt onset of high fever, frontal headache (often accompanied by retro-orbital pain), and myalgia. A widespread but faint macular rash interrupted by islands of uninvolved pallid skin commonly becomes evident 2–4 days after illness onset. A petechial rash might be found in classic and severe dengue.

Diagnostic methods include antigen and antibody detection tests, and PCR assays. A positive IgM serology helps support the diagnosis. Treatment is supportive; avoid NSAIDs, which can increase the risk of bleeding in patients with dengue.

Acute retroviral syndrome can present as a flulike syndrome including fever, generalized lymphadenopathy, malaise, and a generalized skin eruption. Acute HIV infection–associated skin findings are often nonspecific and present as pink to deeply red macules or papules or as a morbilliform eruption, but urticarial and pustular lesions also have been described. Oral ulcers might be present.

Zika is a flavivirus transmitted by Aedes mosquitoes. It caused major outbreaks in the Western Hemisphere beginning in 2015 (see Sec. 5, Part 2, Ch. 27, Zika ). Sexual transmission has been documented for months after infection. The course of the illness is generally subclinical or mild, characterized by arthralgia, conjunctivitis, fever, lymphadenopathy, and a morbilliform (“maculopapular”) rash. In pregnant people, Zika infection can cause fetal loss or fetal microcephaly and neurological damage. Zika-associated Guillain-Barré syndrome also has been reported after infection. Infection is usually diagnosed by using molecular diagnostics and serologic testing. Treatment involves supportive care.

Systemic Bacterial Infections & Illnesses

Meningococcemia.

Invasive Neisseria meningitidis disease occurs worldwide and often is associated with outbreaks, especially in the meningitis belt of sub-Saharan Africa (see Sec. 5, Part 1, Ch. 13, Meningococcal Disease ). Meningococcemia is characterized by acute onset of fever and petechiae that often expand into purpuric macules and patches, commonly accompanied by hypotension and multiorgan failure. Rapid diagnosis and immediate treatment can be lifesaving.

Rickettsioses

African tick-bite fever.

Rickettsia africae , the bacteria responsible for African tick-bite fever (South African tick typhus), is transmitted by the bite of a hard tick ( Hyalomma spp.). Travelers who hike and camp outdoors or who are on safari are particularly at risk for this disease, a frequent cause of fever and rash in southern Africa (see Sec. 5, Part 1, Ch. 18, Rickettsial Diseases ).

Disease is characterized by fever and an eschar at the site of the tick bite. The eschar, or tache noire, is a mildly painful black necrotic lesion with a red rim. Several lesions might be present because people often suffer multiple tick bites. Within a few days, patients develop a fine petechial or papular rash, associated with localized lymphadenopathy. Diagnosis is usually made through clinical recognition and is confirmed by serologic testing. Treatment is doxycycline.

Other rickettsial infections (e.g., Mediterranean spotted fever, rickettsialpox, scrub typhus) might present with eschars or maculopapular, vesicular, or petechial rashes. Each has distinctive geographic or epidemiologic exposure risks.

Rocky Mountain Spotted Fever

Rocky Mountain spotted fever (RMSF) is a tickborne rickettsial disease that is more severe than the other spotted fevers. RMSF occurs in North America (the United States and Mexico) and parts of Central and South America, but it is uncommon in travelers. Nevertheless, because of its potential severity and the need for early treatment, consider RMSF when evaluating patients with fever and rash.

Most patients with RMSF develop a rash 3–5 days after illness onset. The typical rash of RMSF begins on the ankles and wrists and spreads centrally and to the palms and soles. The rash commonly starts as a blanching maculopapular eruption that becomes petechial, although in some patients it begins with petechiae. Doxycycline is the treatment of choice.

Bacterial Skin Infections

Bacterial skin infections occur most frequently when the skin’s surface has been interrupted, often by abrasions, bites, or minor scratches, particularly when maintaining good hygiene is difficult. Common organisms responsible are Staphylococcus aureus and Streptococcus pyogenes . Resulting infections are collectively called pyodermas (Greek for “pus skin”) and can present as cellulitis and erysipelas, ecthyma (ulcers or open sores), folliculitis, furuncles (also called abscesses or boils), impetigo, and lymphangitis.

Cellulitis & Erysipelas

Cellulitis and erysipelas manifest as red, warm, edematous areas that might start at the site of a minor injury or opening in the skin, or without an obvious underlying suppurative focus. Unlike cellulitis, erysipelas tends to be raised, with a clear line of demarcation at the edge of the lesion due to involvement of superficial lymphatics, and is more likely to be associated with fever. Cellulitis, erysipelas, and lymphangitis are usually caused by β-hemolytic streptococci. S. aureus (including methicillin-resistant strains), and gram-negative aerobic bacteria also can cause cellulitis.

Furunculosis

People whose skin or nasal mucosa is colonized with S. aureus are at risk for recurrent folliculitis or furunculosis. Boils can continue to occur weeks or months after a traveler returns; if associated with S. aureus , treatment usually involves a decolonization regimen with nasal mupirocin and a skin wash with an antimicrobial skin cleanser. Some decolonization protocols advise similar treatment for household members and close contacts.

Many travelers who develop boils when abroad mistakenly attribute the tender lesions to spider bites. Outside a few endemic areas, however, necrotizing spider bites are extremely rare. The lesions in these cases are far more likely to be abscesses caused by methicillin-resistant S. aureus and should be treated accordingly.

Impetigo is another common bacterial skin infection, especially in children in the tropics, and is caused by S. aureus or S. pyogenes . Impetigo is a highly contagious superficial skin infection that generally appears on the arms, legs, or face as golden or “honey-colored” crusting formed from dried serum. Streptococcal impetigo is usually what causes the classic crust seen in the mid-face of children. Staphylococcal impetigo often appears in body folds, especially the axillae, and might present as delicate pustules.

Use soap and water for local cleansing of bacterial skin infections. A topical antibiotic, preferably mupirocin, also can be used; bacitracin zinc and polymyxin sulfate (often in combination) are an alternative. Topical antibiotic ointments widely available in other countries contain neomycin (a known, common cause of acute allergic contact dermatitis) or gentamicin. Other “triple cream” type products available for purchase in low- and middle-income countries often contain ultra-potent steroids that can interfere with the healing of common infections and have their own side effects. In many low- and middle-income countries, an application of gentian violet or potassium permanganate is the treatment of choice for impetigo.

Minor skin abscesses often respond to incision and drainage without the need for antibiotics. Oral or parenteral antibiotics might be required if the skin infection is deep, expanding, extensive, painful, or associated with systemic symptoms (e.g., fever). Consider antibiotic resistance if the condition does not respond to empiric therapy. Bites and scratches from animals (both domestic and wild) can be the source of unusual gram-negative organisms and anaerobic bacteria; appropriate treatment might require care from specialists who can obtain bacterial cultures, prescribe focused antibiotic therapy, and perform surgical debridement, as needed (see Sec. 4, Ch. 7, Zoonotic Exposures: Bites, Stings, Scratches & Other Hazards ).

Linear Lesions

Cutaneous larva migrans.

Cutaneous larva migrans, a condition in which the skin is infested with the larval stage of cat or dog hookworm ( Ancylostoma spp.), manifests as an extremely pruritic, serpiginous, linear lesion (see Sec. 5, Part 3, Ch. 4, Cutaneous Larva Migrans). The migrating larvae advance relatively slowly in the skin’s uppermost layers. A deeper lesion that resembles urticarial patches and that progresses rapidly might be due to larva currens (running larva), caused by cutaneous migration of filariform larva of Strongyloides stercoralis (see Sec. 5, Part 3, Ch. 21, Strongyloidiasis).

Lymphocutaneous or Sporotrichoid Spread of Infection

Lymphocutaneous or sporotrichoid spread of infection occurs when organisms ascend proximally along superficial cutaneous lymphatics, producing raised, cordlike, linear lesions. Alternatively, this condition can present as an ascending chain of discontinuous, sometimes ulcerated nodules (termed nodular lymphangitis) that occur after primary percutaneous inoculation of certain pathogens. Causative pathogens can be bacterial (e.g., Francisella tularensis ; atypical Mycobacterium spp. [such as M. marinum after exposure to brackish water or rapidly growing Mycobacteria after pedicure footbaths]; Nocardia spp.), parasitic (e.g., Leishmania spp., particularly those responsible for causing Western Hemisphere leishmaniasis), or fungal (e.g., Coccidioides spp., Sporothrix ).

Phytophotodermatitis & Other Noninfectious Exposures

Phytophotodermatitis is a noninfectious condition resulting from the interaction of natural psoralens, most common in the juice of limes, and ultraviolet A radiation from the sun. The result is the equivalent of an exaggerated sunburn that creates a painful line of blisters, after which asymptomatic hyperpigmented lines appear that can take weeks or months to resolve.

Long linear lesions caused by cnidarian envenomation (e.g., stings from the tentacles of jellyfish and the Portuguese man o’ war [ Physalia physalis ]), often resemble phytophotodermatitis. Another common, but self-evident, cause of an itchy, often blistering eruption, is acute contact dermatitis due to black henna. In places where temporary tattooing is practiced, paraphenylenediamine is added to red or brown henna to make a longer-lasting pigment, black henna. Travelers who receive temporary tattoos using black henna (rather than the red or brown), are at risk for developing a cutaneous reaction to paraphenylenediamine.

Macular Lesions

Macules and patches (flat lesions) are common, often nonspecific, and frequently due to drug reactions or viral exanthems. Purpura are typically macular, and any purpuric lesion associated with fever could indicate a life-threatening emergency (e.g., meningococcemia).

Coronavirus Disease 2019

Some patients with coronavirus disease 2019 (COVID-19), particularly young children and young adults, develop a condition known as COVID toes. The condition is characterized by the sudden onset of painful, dusky red macules and patches, typically on the plantar aspect of the distal phalanges of ≥1 toes. Clinically and histologically, COVID toes resembles conditions known as chilblains (a cold weather injury) or lupus pernio (a skin finding in some patients with systemic lupus erythematosus). Although an epidemiologic link with the COVID-19 pandemic seems apparent, viral, molecular, and serologic studies have not confirmed a causal relationship. Nevertheless, young travelers who develop this medical condition warrant further evaluation for COVID-19.

Leprosy / Hansen’s Disease

Leprosy frequently presents with hypopigmented or erythematous patches that are hypoesthetic to pin prick and associated with peripheral nerve enlargement. Newly diagnosed leprosy cases occur almost exclusively in immigrants arriving from low- or middle-income countries where the disease is endemic. Diagnosis is made by skin lesion biopsies. The National Hansen’s Disease Clinical Center in Baton Rouge, Louisiana, provides consultations ([email protected]; 800-642-2477).

Lyme Disease

Lyme disease is caused by the spirochete Borrelia burgdorferi sensu lato (see Sec. 5, Part 1, Ch. 11, Lyme Disease ). Endemic to temperate latitudes in North America, Asia, and Europe, the bacteria that causes Lyme disease is transmitted through the bite of infected hard ticks, genus Ixodes .

Infected travelers present with ≥1 large erythematous patch (erythema migrans). If ≥1 lesion is present, the first lesion to appear is where the tick bite occurred; subsequent lesions are due to secondary, probably hematogenous, spread of Borrelia , not multiple tick bites. Erythema migrans often is described as targetoid, but central clearing or red-and-white bands do not occur with every case. The lesions generally are asymptomatic. Pruritus, if present, is usually intermittent and very mild. Lesions that are severely or persistently pruritic are unlikely to be erythema migrans.

Tinea (ringworm) is caused by a variety of superficial fungi (e.g., Microsporum , Trichophyton ). Typical lesions appear as expanding, red, raised rings, with an area of central clearing. Diagnostic methods include fungal culture, microscopy (prepare skin scraping samples using a 10% solution of potassium hydroxide [KOH]), and PCR. Treatment usually involves several weeks’ application of a topical antifungal (e.g., clotrimazole, ketoconazole, miconazole, terbinafine) or a course of an oral antifungal (e.g., fluconazole, griseofulvin, terbinafine). Nystatin-based topical agents are ineffective.

For recalcitrant tinea infections associated with international travel, consider obtaining culture for species identification. Prolonged courses of higher dose oral antifungals might be needed to treat severe or recurrent infections caused by emerging resistant Trichophyton species.

Topical medications that combine an antifungal agent with a potent corticosteroid (e.g., betamethasone, clobetasol) are available in many countries; caution travelers against their use. Adverse events associated with steroid-containing antifungal preparations include longer-lasting infections; more extensive spread of the infection over large areas of the body; invasion of the fungal pathogen into the deeper skin layers; unusual presentation of infection (making diagnosis more challenging); and severe redness and burning.

Tinea Versicolor

Caused by several species of the fungus Malassezia (e.g., M. furfur [previously Pityrosporum ovale ], M. globosa ), tinea versicolor is characterized by abundant, asymptomatic, round to oval skin patches. Lesions are often 1–3 cm in diameter, but dozens of lesions can coalesce to form a “map-like” appearance on the upper chest and back. Affected skin typically has a dry or dusty surface. Lesions can be skin-colored, slightly hypopigmented, or slightly hyperpigmented ( versicolor means “changed color”), but all lesions on a person have a uniform color.

Tinea versicolor can be diagnosed in various ways. A clinical diagnosis often is based on the appearance of the lesions. Under the light of a Wood ultraviolet lamp, the lesion produces a subtle yellowish-green hue, corroborating the diagnosis. Microscopic examination using a KOH preparation can be confirmatory.

Topical azoles (e.g., clotrimazole cream, ketoconazole shampoo used as a body wash), selenium sulfide shampoo, or topical zinc pyrithione are recommended treatments. Systemic azoles (e.g., fluconazole) can be used for infections that are severe, relapsing, or recalcitrant to first-line therapies. In many countries, the most common treatment is Whitfield ointment (salicylic acid 3% and benzoic acid 6%, mixed in a vehicle such as petrolatum). Oral griseofulvin and oral terbinafine are ineffective against Malassezia .

Nodular & Subcutaneous Lesions

Gnathostomiasis.

Gnathostomiasis is a nematode infection primarily occurring in equatorial Africa, along the Pacific coast of Ecuador and Peru, in parts of Mexico, and in Southeast Asia. Infection results from eating raw or undercooked freshwater fish, amphibians, or reptiles. Infected travelers experience transient, migratory, subcutaneous, pruritic, and painful nodules that can occur weeks or even years after exposure. Symptoms are due to migration of the nematode through the body; central nervous system involvement is possible. Eosinophilia is common, and serologic tests are available for diagnosis. Treat cutaneous gnathostomiasis with albendazole or ivermectin.

Caused by Loa loa , a deerfly-transmitted nematode, loiasis occasionally occurs in long-term travelers living in rural equatorial Africa. Infected travelers present with transient, migratory, subcutaneous, painful, or pruritic nodules (called Calabar swellings) produced by adult nematode migration through the skin. Rarely, the worm can be observed crossing the conjunctiva or eyelid. Peripheral eosinophilia is common.

Loiasis can be diagnosed by finding microfilariae in blood collected during daytime; because microfilaremia might be indetectable, however, serologic testing is useful. Treatment is complicated, and consultation with an expert is required for nearly all cases. Two medications are required to control both the larval microfilariae and the adult filariae; the most common regimen includes use of both albendazole and diethylcarbamazine (DEC).

Due to relative contraindications for DEC use in patients with onchocerciasis, special management considerations are warranted for travelers who visited areas endemic for both loiasis and onchocerciasis. Treating loiasis with ivermectin can cause adverse neurological side effects. For additional details regarding contraindications to use of DEC and ivermectin (and a recommendation to consult a specialist in tropical diseases for management advice and support), see Sec. 5, Part 3, Ch. 9, Lymphatic Filariasis , and Sec. 5, Part 3, Ch. 17, Onchocerciasis / River Blindness ).

In sub-Saharan Africa, myiasis is caused by a skin infestation with the larva of the tumbu fly, also known as the mputsi fly ( Cordylobia anthropophaga and related species). In the Western Hemisphere, larva of the botfly ( Dermatobia hominis ) cause furuncular myiasis; the botfly’s range extends from central Mexico to the northern half of South America. Solitary or multiple painful nodules resembling a furuncle might be present; each lesion holds only a single larva. The center of the lesion has a small punctum through which the larva both breathes and expels waste.

More mature larvae sometimes exit on their own to pupate, or can be gently squeezed out of nodules. Extracting larva can be difficult; obstructing the breathing punctum as a first step can be helpful and is easily achieved by applying an occlusive dressing or covering (e.g., a bottle cap filled with petroleum jelly), for several hours. Removal might require minor incision, carefully performed to avoid puncturing the larval body, after which newly vacant cavity should be flushed with sterile water. Treatment for secondary infection and appropriate prophylaxis for tetanus also could be required.

Tungiasis is a skin infestation caused by adult female sand fleas ( Tunga penetrans ). Gestating females burrow into the usually thick skin on the sole of the foot or around the toes. Most people with tungiasis have multiple lesions. Individual lesions have a strikingly uniform appearance with a round, 5 mm diameter, white, slightly elevated surface. In the center of the lesion, a minute, frequently black, opening is present, through which the embedded flea breathes, eliminates waste, and eventually extrudes eggs. Clustered lesions can appear as crusty, dirty, or draining plaques, which are typically itchy, painful, and continue to expand as the uterus of the sand flea fills with eggs.

Treatment includes extracting the burrowed fleas, empirical antibiotics for secondary bacterial infection, and appropriate prophylaxis for tetanus, if required. In many countries, extraction is performed at home using a heat-sterilized needle to pluck out the mature flea with eggs.

Papular Lesions

Arthropod bites.

Arthropod bites are probably the most common cause of papular lesions. Biting arthropods include bed bugs, fleas, headlice, midges, mosquitoes, and sandflies. Itching associated with arthropod bites is due to hypersensitivity reactions to proteins and other components in arthropod saliva.

Individual bites usually appear as small (4–10 mm diameter) edematous, pink to red papules with a gentle “watch-glass” profile. The center of many bites will have a small, subtle break in the epidermis where the arthropod’s mouth parts entered the surface of the skin. The pink to red color generally does not extend beyond the elevated part of the lesion, and often a subtle pale hypovascular surrounding halo is apparent.

Lesions are almost invariably quite pruritic; scratching will often excoriate or erode the skin’s surface. Such bites are vulnerable to secondary bacterial infections, usually with Staphylococcus spp. or Streptococcus spp. Many types of arthropods produce bite reactions with characteristic shapes, patterns, and distributions. For example, bites from bed bugs and fleas often appear as scattered clusters of discrete red papules on unclothed surfaces of the body.

Scabies infestation usually manifests as a generalized or regional pruritic papular rash with erythema, abundant excoriations, and secondarily infected pustules (see Sec. 5, Part 3, Ch. 19, Scabies ). Scabies generally has regional symmetry and most commonly involves the volar wrists and finger web spaces. Most boys and men with scabies will have nodular lesions on the scrotum and penis. Scabies burrows are short, delicate, linear lesions involving just the most superficial part of the epidermis; they are pathognomonic but can be difficult to detect.

Other Papular Lesions

Many other conditions present as widespread, extremely pruritic eruptions, often with numerous fine, slightly elevated, somewhat indistinct papules. Examples include acute allergic contact dermatitis (perhaps due to plants) and photosensitive dermatitis (often associated with photosensitizing medications, e.g., doxycycline). Onchocerciasis (specifically onchocercal dermatitis due to microfilaria migrating through the skin) can occur in expatriates living in endemic areas in sub-Saharan Africa and manifests as a generalized pruritic, papular dermatitis (see Sec. 5, Part 3, Ch. 17, Onchocerciasis / River Blindness ). Swimmer’s itch (cercarial dermatitis) and hookworm folliculitis are extremely itchy eruptions composed of papules on skin surfaces exposed to fresh water and fecally contaminated soils, respectively.

Ulcerative Lesions

Skin ulcers form when a destructive process damages or erodes the epidermis, the skin’s superficial layer, and then enters the dermis, the skin’s deeper, more leathery layer. The most frequent causes of acute (duration <1 month) cutaneous ulcers are the common pyogenic bacteria, staphylococci and streptococci. These create well-demarcated, shallow ulcers with sharp borders and are known as bacterial or common ecthyma; treatment is described earlier in this chapter.

Cutaneous anthrax produces a large, surprisingly painless edematous swelling. The surface develops a shallow ulcer that progresses into a necrotic black eschar. Nearly all cases of travel-associated anthrax are cutaneous and result from exposure to live cattle, goats, or sheep, or from handling unprocessed products made from animal hides or wool (see Sec. 5, Part 1, Ch. 1, Anthrax ).

Buruli Ulcer

Buruli ulcer is a rare infection in travelers caused by Mycobacterium ulcerans , a freshwater bacterium found most commonly in equatorial Africa (especially Ghana and Nigeria) and in the Australian state of Victoria. Buruli ulcers typically start as edematous nodules that arise at sites of minor skin injury. The nodules ultimately break down into expanding invasive wounds. Tropical ulcer has a similar clinical presentation but is exceptionally painful. Unlike Buruli ulcer, tropical ulcer likely represents a polymicrobial bacterial infection, including some mycobacteria.

Cutaneous Leishmaniasis

The main areas of risk for cutaneous leishmaniasis (CL) are Africa’s northeastern quadrant, Latin America, south and central Asia, the Mediterranean coastal areas, and the Middle East (see Sec. 5, Part 3, Ch. 14, Cutaneous Leishmaniasis ). The Leishmania parasite is transmitted by the bite of an infected sandfly, and CL lesions start as localized, typical insect bite reactions. Lesions then evolve slowly over several weeks into shallow ulcers with raised margins, resembling a broad, shallow, volcanic caldera; the ulcer’s surface can be covered by a dried crust or a raw, fibrinous coat. In the absence of secondary bacterial infection, ulcers are generally painless.

Special techniques are necessary to confirm CL diagnosis. In travelers, pathogen speciation often is necessary to determine whether the lesion is strictly cutaneous and self-healing or will require treatment with medication (oral, topical, or intravenous) or possibly cryotherapy or heat therapy. Refer to the Centers for Disease Control and Prevention (CDC) webpage or call or email the CDC for recommendations on diagnosis and treatment (404-718-4745; [email protected]).

Spider Bites

Necrotizing spider bites are usually caused by recluse spiders, the most common culprit being Loxosceles reclusa , the brown recluse, found in the south-central United States. The Mediterranean recluse spider ( Loxosceles rufescens ), native to regions around the Mediterranean Sea and the Near East, resembles the brown recluse. L. rufescens has become a widespread “tramp” species giving it a large, nearly worldwide distribution; it bites only rarely and has venom of low toxicity. Many studies have shown that outside a few endemic areas, most alleged spider bites are, in fact, methicillin-resistant S. aureus infections and should be treated accordingly.

Uncommon Causes

A less common cause of skin ulcers is cutaneous diphtheria ( Corynebacterium diphtheriae ). On several island groups in the southwestern Pacific, Haemophilus ducreyi causes nonvenereal cutaneous ulcers. Trypanosoma brucei rhodesiense , the causative agent of African trypanosomiasis, can produce a chancre at the bite site of the transmitting tsetse fly ( Glossina spp.). Several sexually transmitted infections (e.g., syphilis [ Treponema pallidum ], chancroid [ H. ducreyi ]), also can ulcerate the skin.

Bite-Associated

Wound infections after cat and dog bites are caused by a variety of microorganisms including S. aureus , α-, β-, and γ-hemolytic streptococci, several genera of gram-negative organisms, and several anaerobes. Pasteurella multocida infection classically occurs after cat bites but also can occur after dog bites. Patients lacking spleens are at particular risk for severe cellulitis and sepsis due to Capnocytophaga canimorsus after dog bites. Management of cat and dog bites includes consideration of rabies postexposure prophylaxis (see Sec. 5, Part 2, Ch. 18, Rabies ), as well as tetanus immunization and antibiotic prophylaxis. Avoid primary closure of puncture wounds and dog bites to the hand.

Antibiotic prophylaxis after dog bites is controversial, although most experts treat patients lacking spleens prophylactically with amoxicillin-clavulanate. Consider antibiotic prophylaxis of cat bites (P. multocida) with amoxicillin-clavulanate or a fluoroquinolone for 3–5 days.

Monkey bite management includes wound care, tetanus immunization, rabies postexposure prophylaxis, and consideration of antimicrobial prophylaxis. Bites and scratches from Old World macaque monkeys showing no signs of illness have been associated with fatal encephalomyelitis due to B virus infection in humans (see Sec. 5, Part 2, Ch. 1, B Virus ); valacyclovir is the recommended postexposure prophylaxis for high-risk macaque exposure.

Water-Associated

Skin and soft tissue infections (SSTI) can occur after exposure to fresh, brackish, or salt water, particularly if the skin’s surface is compromised. Skin trauma (e.g., abrasions or lacerations sustained during swimming or wading, bites or stings from marine or aquatic creatures, puncture wounds from fishhooks) can result in waterborne infections.

The most virulent SSTIs associated with marine and estuarine exposures are due to Vibrio vulnificus and related non-cholera Vibrio. For freshwater exposures, Aeromonas hydrophila is the most dangerous pathogen. A variety of skin and soft tissue manifestations can occur in association with these infections, including abscess formation, cellulitis, ecthyma gangrenosum, and necrotizing fasciitis.

Pending identification of a specific organism, treat acute infections related to aquatic injury with an antibiotic that provides both gram-positive and gram-negative coverage (e.g., fluoroquinolone or third-generation cephalosporin).

Mycobacterium marinum

M. marinum lives in brackish water. Infection can occur on skin surfaces injured by minor abrasions or shallow puncture wounds; typical locations include knees, shins, and the dorsal surfaces of hands and feet where water-associated minor trauma occurs most commonly.

Patients often describe divergent healing patterns after minor water-associated injury—areas that were injured but not infected heal quickly, whereas areas that were injured and infected with M. marinum go on to develop the irregularly bordered, expanding, multinodular violaceous plaques characteristic of this infection. Treatment with antimycobacterial agents for weeks to months is required because lesions do not resolve spontaneously. Occasionally, lymphocutaneous or sporotrichoid spread of infection (see the discussion earlier in this chapter) can occur, resulting in proximal movement of lesions along superficial lymphatics.

Pseudomonas aeruginosa

So-called “hot tub folliculitis” can occur after using inadequately disinfected swimming pools or hot tubs. Folliculitis (tender or pruritic folliculocentric red papules, papulopustules, or nodules) typically develops 8–48 hours after exposure to water contaminated with Pseudomonas aeruginosa . Usually, several dozen discrete lesions occur on skin surfaces submerged in the infectious water. Most patients have malaise, some have low-grade fever. The condition is self-limited to 2–12 days; typically, no antibiotic therapy is required.

Shewanella , a genus of motile gram-negative bacilli found in warm marine waters worldwide, causes SSTIs that clinically and epidemiologically resemble V. vulnificus infections. Patients, often those with chronic liver disease, can develop sepsis and multiple organ failure. Migrants crossing the Mediterranean with prolonged exposure of their feet and legs to contaminated seawater have developed Shewanella infection.

Necrotizing Vibrio vulnificus skin infections can occur when contaminated brackish or saltwater, or the juices or drippings from contaminated raw or undercooked seafood, contact open wounds. Infections also happen from consuming Vibrio -contaminated shellfish. The illness is especially severe in people with underlying liver disease and can manifest as a dramatic cellulitis with hemorrhagic bullae and severe sepsis. In general, infections caused by these organisms can be more severe in immunosuppressed people.

The following authors contributed to the previous version of this chapter: Karolyn A. Wanat, Scott A. Norton

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Ticket prices for the Trans-Siberian Railway also depend on the current ruble exchange rate.

Is the Trans-Siberian Railway expensive?

Before starting on your Trans-Siberian Railway adventure you naturally want to know what the entire trip will cost. Although this sounds like a simple question, it is pretty difficult to answer. The Trans-Siberian Railway price of travel depends on the following factors:

• Which travel class do I want to use? The price for a first class ticket is about three times the price of a 3rd class ticket
• Am I willing to buy the tickets myself and assume responsibility for the organisation of the trip?
• How many stopovers do I want to make? The more breaks, the higher the total price.
• What sort of accommodation do I want? Will it be a luxury hotel or will a hostel dormitory be sufficient?
• What tours and excursions would I like to go on?
• What is the current exchange rate for rubles?

Basically, everything from a luxury to a budget holiday is available. If you buy yourself a 3rd Class nonstop ticket at the counter, a few hundred Euros will cover the price. All you will experience is a week on the Trans-Siberian train and will see nothing of the cities on the way. There is, however, any amount of room for upward expansion. Everyone makes different choices about which aspects they are willing to spend money on. I personally prefer to save money on accommodation and railcar class, visit as many cities and do as many trips as possible. To enable better classification of your travel expenses I have contrasted two typical traveler types. In the third column you can calculate the total cost of your own journey on the Trans-Siberian Railway. Please keep in mind that these are only rough estimations and not exact prices.

The all-in costs seem fairly high at first. However, they cover everything and it is quite a long journey taking four weeks. Many people forget to consider that when looking at the list. We should also deduct the running costs for food and leisure at home. I think most visitors to this page will classify themselves somewhere between the two categories, that is around the € 2,000 – € 2,500 range. When comparing these prices with other travel packages, you get the impression that it is hardly worthwhile travelling individually on the Trans-Siberian Railway. Please keep in mind that most packages last no more than 14 days and you are herded like cattle through the most beautiful locations.

If you spend less time on the Trans-Siberian Railway you will, of course, pay less. I chose this particular travel length because I prefer not to do things by halves. If you fulfill your dream of travelling on the Trans-Siberian Railway, enjoy it and don’t rush things. But it’s up to you, of course. Try playing around with the form a bit to find the appropriate price for your trip.

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