travel with tb

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Travel and Tuberculosis

In 1882, the German doctor Robert Koch discovered the bacteria Mycobacterium Tuberculosis which causes Tuberculosis (TB). Despite important advances to cure the disease, TB continues to be a major global health concern – three persons die every minute. The World Health Organization (WHO) has designated March 24 of every year as World Tuberculosis Day in order to raise public awareness of this infection (pulmonary TB being the most contagious) and to highlight the challenges we face to control multi-drug-resistant Tuberculosis (MDR-TB) and extensively drug-resistant TB (XDR-TB).

Air travel and pulmonary tuberculosis

Travellers may recall the 2007 Tuberculosis scare caused by a passenger who travelled by plane to various international destinations including the US, France, Greece, Italy, the Czech Republic, and Canada while he was suspected of having extensively drug-resistant Tuberculosis. Some travellers who flew on the same planes accused him of selfishly putting their lives in danger. It was also the first case where the US Centers for Disease Control and Prevention (CDC) quarantined a person infected with TB. It raised many questions about the risk of contracting TB in an aircraft – as a result of travelling in a confined space for a prolonged period of time – and highlighted how easily infectious diseases can be potentially transmitted through international travel.

The airline industry follows the WHO Tuberculosis and Air Travel guidelines which indicate that people with infectious TB must postpone long distance travel while those with multi-drug-resistant Tuberculosis must postpone all air travel. Some countries have their own DO NOT FLY list at their border services for public health reasons. Quarantine officers from the Public Health Agency of Canada, for example, work in major international airports to prevent infectious diseases and outbreaks. According to the WHO, no active TB case has been identified due to exposure on a commercial aircraft so far. This is because airplanes are built with HEPA (High-Efficiency Particulate Air) filter systems on board which kill germs when air is circulated in the aircraft. Travellers can rest assured that under normal conditions, cabin air is cleaner than the air in most buildings. Furthermore, aircraft ventilation systems are operating as long as the doors are closed even if the plane is on the tarmac. WHO advises ground delays should be kept to a maximum of 30 minutes.

So what are the risks of contracting TB when someone sitting beside you is coughing or sneezing? What precautions can you take to protect yourself?

Tuberculosis is an airborne disease. Symptoms include weight loss, fever, excessive coughing, loss of appetite, fatigue, and night sweats. Sometimes TB may be misdiagnosed as bronchitis or pneumonia. TB becomes infectious when a person with active TB releases the bacteria into the air through coughing or sneezing. Others nearby may breathe the air containing the bacteria into their lungs and become infected. TB is not spread by sharing cutlery, dinner plates, drinking cups, or toilet seats.

The critical steps for controlling and preventing TB are to make sure that persons with active TB get proper and timely treatment. If you have active TB, you'll need to be isolated until the culture test results are negative. Once you are no longer contagious, you can resume your normal activities and travel. To prevent drug resistance to the infection, you need to take the full course of medication for a minimum of 6 months which can take up to one year or more to complete.

As a frontline public health practitioner working directly with TB patients and their families, I often got questions asking: Why did I or a loved one get TB? Can I let my parents / grandparents / child fly back to visit relatives back home? What are the air travel restrictions for people affected by TB? The answer is that persons who have lived in or traveled to areas where TB is endemic, are at greater risk of developing Tuberculosis. Persons can fly back to their home country after their sputum results turn up negative and they follow an established treatment regime.

Income, housing conditions, lack of access to health services, social exclusion and other social determinants of health also play a role in TB infection. For example, data shows how healthy newcomers who have latent TB are at risk of becoming infectious within the first five years of immigrating. Unequal access to employment, education, and wealth distribution are all key factors contributing to physical and psychological stress.

If you are a TB carrier ask your local public health department official who is in charge of infection control, or your treating physician, to issue a letter explaining your health status and confirming that you are fit for travel in case you get asked at the border about your medications.

I hope this information reassures you that there is no need to panic about TB and instead, enjoy your vacation to the fullest.

Download the full tipsheet

For more information, download the full tipsheet below written by Shirley Cheng. Shirley Cheng has over 20 years of public health experience in both Canada and China. She holds a Master of Public Health from the University of Waterloo and a Bachelor of Medical Sciences from West China University of Medical Sciences. Shirley is also an IAMAT Board Member.

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• Disease Prevention Advice

Tuberculosis

Introduction.

• Recommendations

Vaccination

Overview of disease, the illness, further information.

Tuberculosis (TB) is spread through sneezing, coughing or direct, close contact with respiratory secretions from an infected individual. TB can affect any part of the body.

Recommendations for Travellers

If you have concerns regarding potential exposure to tuberculosis during travel please speak to your travel health practitioner for more information.

The vaccine that protects against TB is called the 'BCG' vaccine. In the United Kingdom, routine BCG vaccination for teenagers was discontinued in 2005.

BCG may be required for those who have not previously been vaccinated   , according to the destination and the nature of travel. The vaccine is recommended for those under 16 years of age who are going to live and work with local people for more than three months in an area where the incidence of tuberculosis is high.

Tuberculosis is a bacterial infection due to Mycobacterium tuberculosis . It is spread through respiratory contact (coughs, sneezes from an infected individual) but the disease can affect any part of the body

Tuberculosis is found throughout the world. Areas of particular risk include Africa and Asia. 64% of cases globally are found in 7 countries: India, Indonesia, China, Phillipines, Nigeria, Pakistan and South Africa.

Tuberculosis symptoms are varied and can depend upon the part of the body that has been infected. General symptoms include fever, loss of appetite, weight loss, night sweats and tiredness.

Respiratory tuberculosis can cause persistent, productive cough and may be accompanied by blood-streaked sputum. 

The disease is treatable if diagnosed and treatment is completed. The illness is more severe in children, those with other underlying illness (particularly HIV) and in smokers. Over 95% of deaths from TB occur in developing countries.

Treatment for tuberculosis is with a combination of antibiotics over a minimum of 6 months.

• World Health Organization TB Factsheet

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Tuberculosis and Air Travel: Guidelines for Prevention and Control, Second Edition

The revised guidelines address the concerns about transmission of TB during air travel and provide the following: (i) information on transmission of TB on aircraft; (ii) a summary of the practices adopted for the management of patients with infectious TB associated with air travel, and of commonly encountered diffi culties; (iii) suggestions on practical ways to reduce the risk of exposure to M. tuberculosis on board commercial aircraft, and (iv) guidance on procedures to follow and responsibilities when infectious TB is diagnosed in a patient who has a history of recent air travel, including contact tracing, notifying and screening for possible interventions. It also introduces the revised International Health Regulations, adopted by the World Health Assembly in May 2005, which will enter into force in June 2007, establishing basic rules for international coordination in the detection, investigation, and response to public health risks including the area of communication and information sharing. The guidelines are applicable to all domestic and international airlines worldwide.

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Tuberculosis and Air Travel: Guidelines for Prevention and Control. 3rd edition. Geneva: World Health Organization; 2008.

Tuberculosis and Air Travel: Guidelines for Prevention and Control. 3rd edition.

10 recommendations.

While the following recommendations are provided for guidance and are not legally binding upon States, it is important to note that depending on the particular national context, the same subjects or issues may also be covered by national or international laws or regulations which are legally binding.

In addition, these recommendations should be distinguished from official “temporary recommendations” during a public health emergency of international concern or “standing recommendations” for routine application which may be issued under the International Health Regulations (2005) as noted in Annex 1 . Such IHR recommendations have particular legal consequences as indicated in the Regulations, and are adopted and issued according to specified procedures.

• For travellers

People with infectious or potentially infectious TB should postpone all travel by commercial air transportation 1 of any flight duration until they become non-infectious.

• For physicians

Physicians should inform all infectious and potentially infectious TB patients that they must not travel by air on any commercial flight of any duration until they are sputum smear-negative on at least two occasions (additional steps are required for MDR-TB and XDR-TB, see recommendation 3).

Physicians should inform all MDR-TB and XDR-TB patients that they must not travel by any commercial flight – under any circumstances or on a flight of any duration – until they are proven to be non-infectious (i.e. two consecutive negative sputum-culture results).

Physicians should immediately inform the relevant public health authority when they are aware that an infectious or potentially infectious TB patient intends to travel against medical advice.

Physicians should immediately inform the relevant public health authority when they are aware that an infectious or potentially infectious TB patient may have exceptional circumstances requiring commercial air travel.

Post-travel

Physicians should immediately inform the public health authority when an infectious or potentially infectious TB patient has a history of commercial air travel within the previous three months.

• For public health authorities (see also requirements under the IHR)

Public health authorities aware that a person with infectious or potentially infectious TB is planning to travel via a commercial air carrier should inform the concerned airline and request that boarding be denied.

If an infectious or potentially infectious TB patient has exceptional circumstances that may require commercial air travel, public health authorities should ensure that the airline(s) involved and the national public health authorities at departure, arrival and any transit points have approved the commercial air travel and the procedures for travel.

The public health authority (see section 6.1 ) should promptly contact the airline when an infectious or potentially infectious TB patient is known to have travelled on a commercial flight that may have been of 8 hours duration or longer within the preceding three months in order to obtain the information required for the initial risk assessment (i.e. confirm that the passenger was on the flight and the total flight duration).

The public health authority of the country of diagnosis should carry out a risk assessment based on the specific conditions of the case. If the index case is considered to be infectious or potentially infectious, the public health authorities of all countries involved should be informed (i.e. all countries where the flight(s) departed and landed).

If a contact investigation involves more than one country, national public health authorities of the involved countries should agree on their respective roles and responsibilities (including who will request the passenger manifests from airlines). International bodies such as WHO, the EC, ECDC or others may provide assistance if requested.

The national public health authority that obtained the passenger information from the airline should contact counterpart public health authorities in the appropriate countries and provide them with the relevant information on the source case and the available contact information of all travellers identified as potentially exposed (i.e. those passengers seated in the same row and in the two rows in front of and behind the index case) in their jurisdiction. (See chapter 7 on legal confidentiality and permitted dissemination of such information.)

Public health authorities may follow national policies and guidelines regarding TB contact investigation involving potentially exposed travellers in their jurisdiction (see also Annex 3 for a suggested approach), in accordance with requirements under the IHR.

Public health authorities should be in communication with their national IHR focal point concerning any event that may involve the IHR, including events for which international contact-tracing may be initiated, for assessment of any action that may be required under the IHR and support in facilitating communication.

National and international public health authorities are encouraged to collaborate on a TB and air travel research agenda.

• For airline companies

Airline companies should deny boarding to any person who is known to have infectious or potentially infectious TB as informed by the relevant public health authority.

Airline companies should, in the case of ground delays that last for 30 minutes or longer with passengers on board, ensure that the ventilation system is in operation.

Airline companies should ensure that all their aircraft which recirculate the cabin air are fitted with a filtration system. New aircraft should be fitted with 99.97% efficiency HEPA filters, or an alternative of at least this level of efficiency. The filtration system should be maintained in accordance with the recommendations of the filter manufacturer.

Airline companies should ensure that cabin crew receive adequate training on potential exposure to communicable diseases, in first aid, and in applying universal precautions when there may be exposure to body fluids.

Airline companies should ensure that there are adequate emergency medical supplies aboard all aircraft (including gloves, surgical masks, biohazard disposal bags and disinfectant).

Airline companies should cooperate with national public health authorities in providing as quickly as possible all available contact information requested for contact-tracing of travellers, in accordance with applicable legal requirements including the IHR (see Annex 1 ).

Excluding specially-designated aircraft – air ambulance.

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• Cite this Page Tuberculosis and Air Travel: Guidelines for Prevention and Control. 3rd edition. Geneva: World Health Organization; 2008. 10, Recommendations.
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What Is Tuberculosis? Symptoms, Causes, Diagnosis, Treatment, and Prevention

Tuberculosis, or TB, is an infectious disease caused by the bacteria  Mycobacterium tuberculosis . The bacteria spreads through the air from person to person and mainly attacks the lungs, but it can affect other areas of the body, according to the American Lung Association. ( 1 )

The disease has been around for most of human history, becoming particularly deadly at times. In fact, researchers can trace tuberculosis back to early Egypt, more than 5,000 years ago. There is also mention of TB in the biblical books of Deuteronomy and Leviticus under the Hebrew word schachepheth,  and Hippocrates describes it in his writings as "phthisis." ( 2 , 3 )

It’s possible that  M. tuberculosis could have killed more people than any other microorganism. Tuberculosis was an epidemic in industrialized Europe and North America during the 18th and 19th centuries. During those times it was known as "consumption." (2)

The development in the 1940s of streptomycin , the first antibiotic to effectively cure TB, dramatically lowered the number of cases of tuberculosis seen in developed countries, including the United States. (2,3)

Signs and Symptoms of Tuberculosis

The majority of people exposed to the bacteria don’t experience tuberculosis symptoms right away. Instead, the infection may go through three stages:

• Primary TB Infection   This is when the bacteria first enters your body. In many people this causes no symptoms, but others may experience fever or pulmonary symptoms. Most people with a healthy immune system will not develop any symptoms of infection, but in some people the bacteria may grow and develop into an active disease. Most primary TB infections are asymptomatic and followed by a latent TB infection, according to the Centers for Disease Control and Prevention (CDC). ( 4 )
• Latent TB Infection   The bacteria is in your body and can be found through tests, but is not active. During this stage you don’t experience symptoms and can’t spread the disease to others, notes MedlinePlus. ( 5 )
• Active Disease   The TB bacteria are active and multiplying. You’ll feel sick and will be contagious. It’s important to seek immediate treatment to avoid complications and infecting others. (5)

The vast majority of people don’t have a problem because the organism enters their body and is then handled by their immune system, says   Robert Amler, MD , dean of the School of Health Sciences and Practice and vice president for government affairs at New York Medical College in Valhalla, New York.

Tuberculosis is more likely to enter the active phase in people who have acquired the infection recently (in the past two years). It's also more likely to be active among those whose immune systems are weakened as a result of malnutrition, old age, infection with HIV, immunosuppressant drugs, or among people who are on dialysis . (1,5, 6 )

TB can also be caused by the bacteria  Mycobacterium bovis , which lives in animals and can be transmitted to children who drink unpasteurized milk from infected cows. In the United States, cattle are tested for tuberculosis, and most milk is pasteurized, notes the CDC. ( 7 )

Many people with TB won’t know they have it unless they get tested because there won’t be any symptoms from latent TB. About one-quarter of the world's population has latent TB, according to the World Health Organization (WHO). ( 8 ) That’s why it’s important to get screenings if you believe you’ve been exposed to TB.

Once TB becomes active, you’ll begin to notice symptoms. But symptoms may not show up in full force right away. The first thing you may notice is a bad cough that doesn’t go away, or chest pain. These symptoms are easy to dismiss or mistake for another condition, so it’s important to see your doctor if you were diagnosed with latent TB before or have recently been exposed to someone with active TB. (1,5,8)

The symptoms of active tuberculosis include: (5,6, 9 )

• A general sense of being unwell
• Coughing up blood or phlegm
• Trouble breathing
• Loss of weight and appetite
• Night sweats
• Intermittent fever
• Generalized body aches

Learn More About Signs and Symptoms of Tuberculosis

Causes and Risk Factors of Tuberculosis

Tuberculosis is spread through the air, which means you can only get it by breathing contaminated air. If someone who is actively sick talks, coughs, sneezes, or speaks they can spread TB. (1,4)

The bacteria do not live on surfaces, so you can’t get TB by:

• Shaking hands
• Using a toilet
• Sharing drinking glasses or eating utensils
• Touching other surfaces

People with a weakened immune system have the highest risk of getting infected with TB. ( 10 ) “We particularly worry about people with HIV or AIDs because their immune system can be overwhelmed by TB,” says Dr. Amler.

Risk factors for TB include:

• HIV infection
• Homelessness
• Being in jail or prison (where close contact can spread infection)
• Substance abuse
• Taking medication that weakens the immune system
• Kidney disease   and   diabetes
• Organ transplants
• Working in healthcare
• Exposure to air pollution
• Smoking tobacco
• Age, specifically babies, young children, and elderly people

When active tuberculosis is diagnosed in the United States, it's often in a person who has emigrated from or traveled to a country with a much higher rate of TB.

People with a normal, healthy immune system probably don’t have to be worried much about tuberculosis because catching TB is relatively hard, according to   Lee Reichman, MD , professor of medicine and epidemiology and executive director emeritus of the Rutgers Global Tuberculosis Institute in Newark, New Jersey. “There’s a higher chance of catching parasites in Africa than TB,” according to Dr. Reichman. It’s also unlikely you’ll be close enough to inhale the air of someone with TB during travel, he says.

Learn More About Risk Factors for Tuberculosis

How Is Tuberculosis Diagnosed?

Diagnosing tuberculosis can be a complex process. Doctors will first consider a person’s history and the likelihood they were exposed to someone with active disease. Then a series of screenings and tuberculosis tests may be needed in order to confirm TB and decide on a course of treatment.

Since latent TB has no symptoms and fewer bacteria are present, it can only be found through a couple screening tests.

The first test used to find TB is called the tuberculin skin test, also known as the Mantoux test or PPD (purified protein derivative). A solution made from TB bacteria is injected in the top layer of skin on the forearm. The person will then return in 48 or 72 hours to have the injection site examined. If there is a red, raised bump larger than 5 to 15 millimeters, a TB infection could be present. But this test isn’t a perfect science. Sometimes results can be wrong, showing false positives or false negatives. (5, 11 )

A blood test can provide more conclusive results. The interferon gamma release assay (IGRA) test measures the body's immune response to the presence of  M. tuberculosis . The test is done in a lab after a blood sample is drawn.

If initial screenings come back positive, further testing is needed to diagnose active TB. Additional lab tests can determine which strain of TB bacteria a person has and which antibiotics are most effective. Imaging gives more information on where the disease is located and how it’s affecting the body.

Diagnostic tests used for active TB include: (5,11)

• Sputum Samples   Sputum is the mucus that comes up when you cough. Samples of sputum can be directly examined in a lab for   M. tuberculosis .
• Molecular Tests   These can be used to detect the bacteria's genetic material and help identify which antibiotics will work best.
• Biopsy   A biopsy of the lungs, lymph nodes, or other tissues may be cultured to grow the bacteria and make it easier to see under a microscope.

Imaging tests used for active TB include:

• X-Rays   Chest X-rays may be done to look for signs of TB in the lungs.
• Computerized Tomography (CT) Scans   CT scans   may be used to look for TB in the spine or to get better views of the lungs if X-ray images are unclear.
• Magnetic Resonance Imaging (MRI)   An   MRI   of the spine or brain may be done if doctors think the tuberculosis infection has spread to those areas.
• Bone Scans   These can be used to tell the difference between cancerous lesions and those caused by TB.

Learn More About Diagnosing Tuberculosis

Treatment and Medication Options for Tuberculosis

While the disease is still a cause of death in many parts of the world, TB is almost always able to be treated and cured in the United States. But it requires careful adherence to the instructions on how to take medication, in order to eliminate all the bacteria and avoid developing drug resistance, according to the CDC. ( 12 )

TB bacteria takes a long time to be killed off, so treatment can last for six months or longer. People with latent TB will probably only need to take one or two drugs, while those with active TB may need a combination of three to four.

Per the CDC, the most commonly used drugs are: ( 13 )

• Rifapentine
• Moxifloxacin
• Pyrazinamide
• Myambutol (ethambutol)

Remembering to take medicine for such a long period of time can be challenging. One of the biggest worries during TB treatment is people stopping their medication before all the bacteria dies. The leftover bacteria can continue to grow and become resistant to antibiotics. This makes the disease much more dangerous and harder to treat. (12)

Active TB is contagious, making it a public health concern. For that reason, directly observed therapy (DOT) is used to make sure a person is taking their medicine. DOT means a trained healthcare worker provides each dose of medication, watches the patient swallow it, and documents that the medication has been taken.

The Department of Health will be involved until the end of DOT for active TB, according to   Alexea M. Gaffney-Adams, MD , an internist with a subspecialty in infectious disease at Stony Brook Medicine in Stony Brook, New York. “It’s a huge public health risk for someone with active TB to be out in the community not taking medication.”

Learn More About Treatment for TB

Duration of Tuberculosis

A person can have latent TB for years, without having symptoms or becoming sick. But if the bacteria is detected, a course of treatment over three to four months is recommended by the CDC. ( 14 )

Treatment for active TB disease can take six to nine months. It's vital that people with TB disease complete their full course of medication exactly as prescribed. Otherwise, the disease can return and be more resistant to treatment. (13)

Prevention of Tuberculosis

Keeping your immune system healthy and avoiding exposure to someone with active TB is the best way to prevent a TB infection.

Identifying and treating cases of latent TB, before the disease can become active, is also important, particularly in high-risk populations.

To prevent the transmission of tuberculosis in healthcare settings, the CDC’s guidelines recommend that all healthcare personnel be screened for tuberculosis   when they’re hired. ( 15 )

Other steps toward preventing the spread of TB include:

• Improving ventilation in indoor spaces so there are fewer bacteria in the air
• Using germicidal UV lamps to kill airborne bacteria in buildings where there are people at high risk of TB
• Using directly observed therapy (DOT), in which people taking medication for TB are monitored by their healthcare providers, to raise the likelihood of successful treatment

Learn More About Preventing Tuberculosis

Complications of Tuberculosis

If left untreated TB can affect other parts of the body, beyond the lungs. Back pain, joint damage, and liver or kidney problems, can result, as can swelling of the membranes around your brain. Ultimately, untreated TB can be fatal, notes Mayo Clinic. ( 16 )

While most people are able to tolerate the drugs well during treatment, TB medication can lead to some complications, as well. It can be hard on the liver. Doctors will monitor your liver function on regular checkups to make sure you’re not in danger of complications. (5,6,12)

The following symptoms are considered serious side effects and should be reported to your doctor: (5,6,12)

• Loss of appetite
• Nausea or vomiting
• Yellowing of skin or eyes (a sign of liver damage)
• Fever that lasts longer than three days
• Dark-colored urine
• Pain the in the abdominal area
• Tingling in the fingers or toes
• Feeling itchy with no known cause
• Rash on the skin
• Muscle weakness or aching joints
• Changes in vision
• Changes in hearing, like hearing loss or ringing in the ears

Improving your diet, drinking plenty of water, and getting regular exercise can also help your body recover and avoid adding extra strain on the liver.

Learn More About Living With TB and Avoiding Complications

Research and Statistics: Who Gets TB?

Even though you may not hear much about tuberculosis, it’s still a common disease affecting many people around the world. About one-quarter of the world’s population is infected with TB, and most cases occur in Southeast Asia, Africa, and the Western Pacific region. In 2021, an estimated 10.6 million people got sick from the disease and 1.6 million died. (8)

These eight countries made up two-thirds of new TB cases in 2020: (8)

• Philippines
• Democratic Republic of the Congo

Worldwide, tuberculosis is the 13th leading cause of death and it is a leading cause of death for people with an HIV infection. According to the WHO, about 187,000 HIV-positive people died from TB in 2021. (8)

Although the rate of TB in the United States is much lower today, it’s still a concern. According to the CDC, up to 13 million people in the United States may have a latent TB infection. ( 17 ) Without treatment, about 1 in 10 of those people will become sick with TB disease in the future.

The latest data from the CDC shows that a total of 7,174 TB cases were reported in the United States in 2020. ( 18 )

Related Conditions and Causes of Tuberculosis

As mentioned above, certain health conditions increase the risk for TB. They include:

• Inflammatory bowel disease (IBD)

People living with HIV are up to 18 times more likely to develop TB than people without HIV, notes the WHO. (8)

The risk of TB is 2 to 3 times greater in people with diabetes, according to the WHO. ( 19 )

There's also a risk involved with taking certain biologic drugs used to treat autoimmune inflammatory diseases, such as Crohn's disease (an inflammatory bowel disease) or rheumatoid arthritis. Biologic medication that suppresses the immune system can increase the possibility of activating latent TB, according to UpToDate. ( 20 ) So it's important to get tested for TB before you start taking these drugs.

Common Questions & Answers

Resources we trust.

• Mayo Clinic: Tuberculosis
• Cleveland Clinic:  Tuberculosis (TB) Test
• American Lung Association: Treating and Managing Tuberculosis
• Centers for Disease Control and Prevention:  TB Testing and Diagnosis
• World Health Organization:  WHO TB Guidelines: Recent Updates

Everyday Health follows strict sourcing guidelines to ensure the accuracy of its content, outlined in our editorial policy . We use only trustworthy sources, including peer-reviewed studies, board-certified medical experts, patients with lived experience, and information from top institutions.

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• Trends in Tuberculosis, 2020.  Centers for Disease Control and Prevention . October 12, 2021.
• Global Tuberculosis Report 2022: TB and Diabetes. World Health Organization . October 14, 2021.
• Patient Education: Disease-Modifying Antirheumatic Drugs (DMARDs) in Rheumatoid Arthritis (Beyond the Basics).  UpToDate.com . August 2022.

• Health Conditions

Is Tuberculosis Contagious and How Is It Spread?

What is tuberculosis?

Tuberculosis (TB) is a serious bacterial infection that primarily affects the lungs and respiratory system, though it can invade any organ. It’s a contagious infection that can be spread in the water droplets of a cough or sneeze.

There are two main types of TB : latent TB infection (LTBI) and active TB disease (sometimes just referred to as TB disease).

Latent TB means you have been infected with TB, but have no symptoms. If you have latent TB, a lung X-ray will not show active disease.

TB disease, however, is characterized by symptoms that include coughing and fever. This type is contagious and dangerous. It can spread from the lungs to other parts of the body.

How is it spread?

TB is spread through the air. The droplets containing the bacteria must be inhaled for the infection to spread from one person to another. This means that being near someone with TB disease when they cough, sneeze, or even talk close to your face for an extended period of time puts you at risk for infection.

Kissing, hugging, or shaking hands with a person who has TB doesn’t spread the disease. Likewise, sharing bed linens, clothes, or a toilet seat isn’t how the disease spreads either.

However, if you’re in close quarters over a period of time with someone who has TB, you could catch the disease from breathing air that’s been saturated with the bacteria.

People living and working with someone who has TB disease are much more likely to become infected than someone in the general public who has a fleeting encounter with someone carrying TB disease.

Who’s at risk for TB?

Exposure to the TB bacteria isn’t always enough to develop the infection. Your body may be able to fight it off.

One of the key factors that raises your risk of becoming infected after exposure is if you have a weakened immune system. You may be at increased risk for TB if you:

• have cancer
• are undergoing cancer treatment
• are taking medications for conditions such as rheumatoid arthritis or Crohn’s disease

TB is also more common in certain parts of the world, including Russia, South America, and Africa. You may be at increased risk if you live in areas with more incidences of TB or if you travel to these areas.

Working in healthcare also raises your TB risk, as does smoking and drug abuse.

If you’ve been infected with the bacteria, you may develop symptoms within a few weeks, or it could be years before you see signs of infection.

How to reduce your risk for TB

Reducing your exposure to people who have active TB is one way to reduce your risk, but this isn’t always possible.

If you’re traveling to a foreign country where TB continues to be a serious public health problem, get up-to-date information about travel warnings or vaccination requirements from the Centers for Disease Control and Prevention .

When traveling to areas with a high prevalence of TB, try to avoid crowded places if possible. Other ways to reduce your exposure include:

• Keeping your room well-ventilated. TB bacteria tend to spread faster in more confined spaces with less outside air.
• Staying home for several weeks or months after you have started TB treatment.

There is a TB vaccine called the Bacillus Calmette-Guerin (BCG) vaccine. It’s not widely used in the United States. It’s more commonly used in countries with a higher rate of TB among babies and children.

If you’re at increased risk for TB, BCG may help reduce your risk.

What are the symptoms of TB?

When symptoms are present, they usually include coughing that lasts for more than a few weeks. The coughs tend to produce phlegm, and it may be flecked with blood at times or be pink, suggesting bleeding and irritation.

Chest pain, especially when breathing deeply or coughing, is also a common symptom.

Other symptoms may include:

• unexplained weight loss
• loss of appetite

If TB has spread to another part of the body, your symptoms may change. An infection that has reached the back, for example, may cause back pain.

What treatments are available?

Once a diagnosis of TB disease is confirmed through TB skin tests , blood tests, and analysis of your sputum, you should begin treatment as soon as possible. Your sputum is the mix of saliva and mucus you cough up when sick.

There are several different medications you may be prescribed based on the type of TB detected. The most frequent combination for active TB includes the antibiotics isoniazid, rifampin, ethambutol, and pyrazinamide.

The course of the drug you take will depend on several factors, such as your age and how far the disease has progressed. But the typical course for TB antibiotics is about six to nine months .

There’s no guarantee that latent TB won’t turn into TB disease, but being proactive about treatment and following through on the entire course of antibiotics may help you recover.

The takeaway

TB is a contagious disease that spreads through the air. Reducing your exposure to people with the condition may help reduce your risk. There’s also a vaccine that may help reduce your risk.

Though it is not in every country, tuberculosis remains one of the top 10 causes of death around the world . If you suspect you’ve developed TB, seek immediate medical help.

How we reviewed this article:

• How TB spreads. (2016). https://www.cdc.gov/tb/topic/basics/howtbspreads.htm
• Mayo Clinic Staff. (2018). Tuberculosis. https://www.mayoclinic.org/diseases-conditions/tuberculosis/symptoms-causes/syc-20351250
• Tuberculosis. (2018). https://www.who.int/news-room/fact-sheets/detail/tuberculosis
• Tuberculosis (TB). (2013). https://www.nationaljewish.org/conditions/tuberculosis-tb

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Website maintenance is scheduled for Saturday, August 17, and Sunday, August 18. Short disruptions may occur during these days.

HOLLY HARTMAN-ADAMS, MD, ROBERT M. GERBO, MD, AND SAIRA GEORGE, MD

This is a corrected version of the article that appeared in print.

Am Fam Physician. 2022;106(3):308-315

Author disclosure: No relevant financial relationships.

Approximately 10 million people worldwide were infected with tuberculosis (TB) in 2019, resulting in 1.4 million deaths. In the United States that same year, there were nearly 9,000 reported cases of TB disease and up to 13 million people were living with latent TB infection (LTBI), which is an asymptomatic, noncommunicable infection caused by Mycobacterium tuberculosis . Without treatment, LTBI will progress to active TB disease in approximately 5% to 10% of affected people. Individuals with symptoms of TB disease warrant testing. The U.S. Preventive Services Task Force recommends testing individuals at increased risk of LTBI with an interferon-gamma release assay or tuberculin skin testing. Because the incidence of LTBI in health care professionals is similar to that of the general population, periodic retesting is not recommended. After a positive test result, chest radiography should be performed and, in patients with suspected pulmonary TB disease, sputum collected for diagnosis. Both suspected and confirmed cases of LTBI and TB disease must be reported to local or state health departments. Preferred treatment regimens for LTBI include isoniazid in combination with rifapentine or rifampin, or rifampin alone for a duration of three and four months, respectively. Treatment of drug-susceptible TB disease includes an eight-week intensive phase with four drugs (isoniazid, rifampin, pyrazinamide, and ethambutol), followed by a continuation phase lasting 18 weeks or more, with two drugs based on susceptibility testing results. Consultation with a TB expert is necessary if there is suspicion or confirmation of drug-resistant TB.

In 2019, approximately 10 million people worldwide were diagnosed with tuberculosis (TB), an infection caused by Mycobacterium tuberculosis , resulting in 1.4 million deaths. 1 In the United States, there were nearly 9,000 reported cases of TB disease in 2019, with up to 13 million people living with latent TB infection (LTBI). 2 Over the past decade, TB incidence in the United States has decreased by 2% to 3% annually, except in 2020 when the incidence was 20% lower compared with 2019. 2 , 3 The COVID-19 pandemic may have affected the reporting of TB incidence in several ways, including underdiagnosis and a true reduction in the incidence of TB. 2

TB is caused by inhalation of respiratory droplets containing M. tuberculosis from a person with active respiratory disease. The M. tuberculosis bacilli multiply in the alveoli and can enter the bloodstream, spreading throughout the body (e.g., brain, larynx, lymph nodes, spine, bone, kidneys). The immune response to TB infection is the formation of granulomas resulting in LTBI. If the immune system cannot control the infection, the bacilli will multiply and progress to TB disease. Without treatment, LTBI will progress to active TB disease in 5% to 10% of affected people. 4 , 5 Risk factors for progression include immunosuppression, diabetes mellitus, intravenous drug use, low body weight, and age younger than five years. 6

Which Clinical Situations Warrant TB Testing?

The Centers for Disease Control and Prevention and the U.S. Preventive Services Task Force recommend testing people who have symptoms of TB disease or are at increased risk of LTBI ( Table 1 ) . 5 – 10

EVIDENCE SUMMARY

Testing should be performed in individuals with symptoms of TB disease and in asymptomatic individuals at increased risk of LTBI and progression to TB disease. 5 Symptoms of TB disease include chronic cough (i.e., lasting three weeks or longer), hemoptysis, chest pain, fever, night sweats, anorexia, fatigue, and unexplained weight loss. People at increased risk include those who were born in, or are former residents of, countries with increased TB prevalence (e.g., immigrants, refugees), those who live or have lived in congregate settings (e.g., homeless shelters, correctional facilities), and people with known exposure to TB disease. 5 – 7 People from sub-Saharan Africa and Southeast Asia are particularly at risk of LTBI. 7 – 9 People at low risk of getting TB should not be tested because of the low positive predictive value of testing in low-risk populations. 5 , 6

Initial testing is recommended for all health care professionals upon hire or preplacement. Repeat testing is recommended only for known exposure or based on risk assessments of the health care facility and setting. 6 The incidence of LTBI in health care professionals is similar to that of the general population because of a substantial decline in the annual national TB rate in 2017 compared with previous decades. 10 A screening questionnaire can be a useful tool in the assessment of health care workers at risk of TB. 11

All suspected and confirmed cases of LTBI and TB disease must be reported to local or state health departments. The health department will assist with diagnostic testing, follow-up, and treatment decisions. 6

What Are the Recommended TB Tests?

Interferon-gamma release assay (IGRA) and tuberculin skin testing (TST) are recommended options in testing for TB in at-risk individuals . 6

IGRA testing requires a blood sample. Two IGRA tests are currently approved for use in the United States: QuantiFERON-TB Gold+ (Qiagen) and T-SPOT.TB (Oxford Immunotec). Both indicate immune sensitization to M. tuberculosis .

TST requires an intradermal injection of 0.1 mL of purified protein derivative and is interpreted 48 to 72 hours later. Induration (not erythema) of 15 mm or more is considered positive in patients without risk factors, 10 mm or more is positive for those at low to intermediate risk of progression to TB disease (e.g., past residence in countries where TB disease is common, diabetes, chronic renal failure, alcohol and intravenous drug use, mycobacteriology laboratory workers, age younger than five years, low body weight), and 5 mm or more is positive for patients at increased risk (e.g., immunocompromised, HIV infection, organ transplants, close contact with someone who has a TB infection, clinical or radiographic evidence of current or prior TB infection). 6 – 9 , 12

Use of TST and IGRA cannot differentiate between LTBI and TB disease or predict the risk of progression from LTBI to TB disease. Chest radiography is indicated when IGRA or TST results are positive.

What Are the Advantages and Disadvantages of TST vs. IGRA?

Advantages of TST include less expense and no need for a laboratory. Disadvantages include the need for more than one visit, trained staff to complete testing, and lower specificity and sensitivity. Advantages of IGRA testing include no requirement for a follow-up visit to interpret results and greater sensitivity and specificity. Disadvantages of IGRA testing include cost, and it is not recommended for use in children younger than two years. 32 A comparison of TB tests is discussed in  Table 2 . 12 , 13 , 32  [ corrected ]

TST is performed without laboratory equipment and is less expensive than IGRA testing, although more personnel time is required. Chronic immunosuppressed states and receiving immunizations with live vaccines within four weeks of TST placement may cause a false-negative result. Reliability of TST is dependent on clinician technique and experience. 13

IGRA testing is more convenient for the patient because no return visit is necessary. IGRA test results are objective and not affected by reader variability. IGRA testing is not susceptible to a false-positive result in recipients of the bacillus Calmette-Guérin vaccine, but it does have a false-negative risk similar to that of TST performed in immunosuppressed persons. 12 , 14 For a century, the bacillus Calmette-Guérin vaccine has been used in many parts of the world (i.e., Mexico, South America, Africa, Asia, and Western Europe) in the general population to prevent TB infection. 15 It is also used in special populations in North America, Eastern Europe, and Australia.

How Is TB Disease Distinguished From LTBI?

People with LTBI are asymptomatic. People with TB disease will often have suggestive symptoms, an abnormal result on chest radiography, and a positive sputum smear or culture . Table 3   shows a comparison of LTBI and TB disease . 6

People with LTBI are asymptomatic, noninfectious, and have chest radiography without findings suggestive of TB disease. Those with TB disease are symptomatic and often contagious. Manifestations of TB disease may include respiratory and constitutional symptoms, abnormal results on chest radiography, and positive sputum smear or culture.

In addition to chest radiography, three sputum specimens for acid-fast bacilli smear microscopy, diagnostic nucleic acid amplification test, and cultures are required in patients with suspected pulmonary TB disease. When extrapulmonary TB is suspected, the specimen should be obtained from the site of infection (e.g., lymph node, urine, pleural fluid, cerebrospinal fluid, bone marrow). Additional testing for drug susceptibility is completed on all positive cultures. 12 New methods for whole genome sequencing of M. tuberculosis samples are now widely used in areas of the world with limited resources for laboratory-based culture testing. These tests have similar sensitivity to cultures and provide information about genetic mutations that predict drug resistance. 16

What Are the Standard Treatment Recommendations for LTBI?

There are three preferred regimens for the treatment of LTBI: isoniazid plus rifapentine (Priftin), rifampin alone, or isoniazid plus rifampin. Alternative treatment options involve isoniazid monotherapy . 17 , 18 Table 4   summarizes the preferred and alternative treatment options for LTBI . 14 , 17 , 18 Standard treatment recommendations are modified if a patient has been exposed to someone with drug-resistant TB .

All cases of LTBI and TB disease should be reported to local or state health departments, which can provide valuable resources for contact tracing and support to ensure completion of treatment. Guidelines preferentially recommend three- to four-month drug regimens , all of which include a rifamycin-based medication, rather than the previous standard of six or nine months of monotherapy with isoniazid. 18 The Centers for Disease Control and Prevention recommends initiating treatment of LTBI after excluding the possibility of TB disease. 17 The current treatment guidelines consider the benefits to patients and the public, the complexity of the regimens, potential for toxicity, and costs. Based on these considerations and the quality of evidence, three preferred regimens emerged: (1) 12 weeks of isoniazid plus rifapentine once per week; (2) four months of rifampin once per day; and (3) three months of isoniazid plus rifampin once per day.

Drug-drug interactions, especially with rifampin, may limit the ability to use shorter, preferred options. Alternative regimens use single-drug isoniazid, in a once per day or twice per week dosage for six or nine months. Intermittent regimens must be given under direct observation.

Isoniazid with rifapentine taken once per week for 12 weeks results in better adherence and is as safe and effective in treating LTBI as taking isoniazid once per day for nine months, which has a completion rate of less than 60%. 19 – 22 In patients who have increased risk of progression to TB disease, taking rifampin once per day for four months was not inferior to taking isoniazid monotherapy for nine months because of equivalent effectiveness, improved adherence, and safety. 23

What Is the Standard Treatment Regimen for TB Disease?

Treatment of TB disease is typically done in consultation with the local public health department. Standard treatment for drug-susceptible TB disease includes an eight-week intensive phase with isoniazid, rifampin, pyrazinamide, and ethambutol, and is followed by a three- to four-month continuation phase with isoniazid and rifampin ( Table 5 ) . 24

Empiric treatment of TB disease begins with a regimen of four drugs. The preferred course of therapy for treating adults and children with TB disease known or believed to be drug-susceptible consists of an eight-week intensive phase using isoniazid, rifampin, pyrazinamide, and ethambutol. 24 If susceptibility testing confirms sensitivity of the M. tuberculosis isolate to both isoniazid and rifampin, ethambutol can be stopped, completing the intensive phase with isoniazid, rifampin, and pyrazinamide.

The intensive phase is followed by a four-month continuation phase consisting of isoniazid plus rifampin. 24 Vitamin B 6 (pyridoxine) should be given with isoniazid to people at risk of neuropathy (e.g., pregnant patients; breastfeeding infants; older adults; patients with HIV, diabetes, alcoholism, malnutrition, or chronic renal failure). The preferred frequency of dosing is once per day; however, directly observed therapy five days a week is an acceptable alternative to seven days per week of self-administered therapy.

Baseline and monthly follow-up evaluations are recommended. The results of acid-fast bacilli smears and cultures determine the duration of the continuation phase and, therefore, are critical to appropriate management. Acid-fast bacilli smears and cultures should be obtained monthly until two consecutive specimens are negative. Additional information on monitoring and adverse effects of TB therapy is provided in eTable A .

Interruptions in TB therapy can impact treatment, such as extending the duration. Experience with SARS-CoV-2 infection in patients with LTBI and TB disease remains limited, but it is anticipated that they may have poorer treatment outcomes, especially if TB therapy is interrupted. Patients who have TB should be vaccinated for and follow precautions to be protected from COVID-19 while continuing TB therapy as prescribed. 25

The treatment of drug-resistant isolates of M. tuberculosis is more complex and includes additional molecular and phenotypic diagnostic tests to determine susceptibilities, the use of second-line drugs, and prolonged treatment durations. The World Health Organization recommendations are rapidly changing the modern treatment of TB disease with the use of fluoroquinolones for isoniazid resistance and newer medications such as bedaquiline (Sirturo) or delamanid (Deltyba; not available in the United States) in cases of rifampin resistance. 1 , 26 A TB expert should be consulted when there is suspicion or confirmation of drug-resistant TB disease. 27 Recommendations in special populations (i.e., patients with HIV, extrapulmonary TB, culture-negative pulmonary TB, advanced age, renal or hepatic disease, or who are pregnant or breastfeeding) are beyond the scope of this review.

This article updates previous articles on this topic by Jerant, et al. 28 ; Potter, et al. 29 ; Inge and Wilson 30 ; Hauck, et al. 31 ; and Hartman-Adams, et al. 4

Data Sources: The primary resource used to identify literature was PubMed. Search terms included Mycobacterium tuberculosis , latent tuberculosis infection, TB disease, TST, IGRA testing for TB, and treatment of TB. Essential Evidence Plus and article reference lists were reviewed to identify further sources. The search included meta-analyses and reviews. The Centers for Disease Control and Prevention website was also searched using the terms above. Search dates: July 26, 2021; August 6, 2021; August 22, 2021; January 2, 2022; and May 30, 2022.

World Health Organization. Global tuberculosis report 2021. Accessed May 29, 2022. https://www.who.int/teams/global-tuberculosis-programme/tb-reports/global-tuberculosis-report-2021

Centers for Disease Control and Prevention. Tuberculosis (TB). Data and statistics. Accessed January 4, 2022. https://www.cdc.gov/tb/statistics/default.htm

Deutsch-Feldman M, Pratt RH, Price SF, et al. Tuberculosis - United States, 2020. MMWR Morb Mortal Wkly Rep. 2021;70(12):409-414.

Hartman-Adams H, Clark K, Juckett G. Update on latent tuberculosis infection [published correction appears in Am Fam Physician . 2014; 90(7): 434]. Am Fam Physician. 2014;89(11):889-896.

Bibbins-Domingo K, Grossman DC, Curry SJ, et al.; US Preventive Services Task Force. Screening for latent tuberculosis infection in adults: US Preventive Services Task Force recommendation statement. JAMA. 2016;316(9):962-969.

Centers for Disease Control and Prevention. Core curriculum on tuberculosis: what the clinician should know. 7th ed. 2021. Accessed January 3, 2022. https://www.cdc.gov/tb/education/corecurr/pdf/CoreCurriculumTB-508.pdf

Heartland National TB Center. Screening, diagnosis, and treatment of latent tuberculosis infection (LTBI) in primary care settings. Tips for coding and billing. Accessed January 1, 2022. https://www.heartlandntbc.org/wp-content/uploads/2021/12/Screening_Diagnosis_and_Treatment_of_Latent_Tuberculosis_Infection_LTBI_in_Primary_Care_Settings.pdf

World Health Organization. WHO global lists of high burden countries for tuberculosis (TB), TB/HIV and multidrug/rifampicin-resistant TB (MDR/RR-TB), 2021–2025. Accessed August 23, 2021. https://cdn.who.int/media/docs/default-source/hq-tuberculosis/who_globalhbcliststb_2021-2025_backgrounddocument.pdf?sfvrsn=f6b854c2_9

Cain KP, Benoit SR, Winston CA, et al. Tuberculosis among foreign-born persons in the United States. JAMA. 2008;300(4):405-412.

Sosa LE, Njie GJ, Lobato MN, et al. Tuberculosis screening, testing, and treatment of U.S. health care personnel: recommendations from the National Tuberculosis Controllers Association and CDC, 2019. MMWR Morb Mortal Wkly Rep. 2019;68(19):439-443.

Centers for Disease Control and Prevention. Health care personnel (HCP) baseline individual TB risk assessment. Accessed January 8, 2022. https://www.cdc.gov/tb/topic/infectioncontrol/pdf/healthCareSettings-assessment.pdf

Lewinsohn DM, Leonard MK, LoBue PA, et al. Official American Thoracic Society/Infectious Diseases Society of America/Centers for Disease Control and Prevention clinical practice guidelines: diagnosis of tuberculosis in adults and children. Clin Infect Dis. 2017;64(2):e1-e33.

Kendig EL, Kirkpatrick BV, Carter WH, et al. Underreading of the tuberculin skin test reaction. Chest. 1998;113(5):1175-1177.

Yancey JR, Melchert VE. QuantiFERON-TB Gold+ for the diagnosis of Mycobacterium tuberculosis infection. Am Fam Physician. 2021;103(3):177-178.

Zwerling A, Behr MA, Verma A, et al. The BCG World Atlas: a database of global BCG vaccination policies and practices. PLoS Med. 2011;8(3):e1001012.

Furin J, Cox H, Pai M. Tuberculosis. Lancet. 2019;393(10181):1642-1656.

Centers for Disease Control and Prevention. Tuberculosis (TB). Latent TB infection treatment FAQs for clinicians. June 26, 2018. Accessed January 5, 2022. https://www.cdc.gov/tb/education/FAQforProviders.htm

Sterling TR, Njie G, Zenner D, et al. Guidelines for the treatment of latent tuberculosis infection: recommendations from the National Tuberculosis Controllers Association and CDC, 2020. MMWR Recomm Rep. 2020;69(1):1-11.

Njie GJ, Morris SB, Woodruff RY, et al. Isoniazid-rifapentine for latent tuberculosis infection: a systematic review and meta-analysis. Am J Prev Med. 2018;55(2):244-252.

Sterling TR, Villarino ME, Borisov AS, et al.; TB Trials Consortium PREVENT TB Study Team. Three months of rifapentine and isoniazid for latent tuberculosis infection. N Engl J Med. 2011;365(23):2155-2166.

Goswami ND, Gadkowski LB, Piedrahita C, et al. Predictors of latent tuberculosis treatment initiation and completion at a U.S. public health clinic: a prospective cohort study. BMC Public Health. 2012;12:468.

Eastment MC, McClintock AH, McKinney CM, et al. Factors that influence treatment completion for latent tuberculosis infection. J Am Board Fam Med. 2017;30(4):520-527.

Menzies D, Adjobimey M, Ruslami R, et al. Four months of rifampin or nine months of isoniazid for latent tuberculosis in adults. N Engl J Med. 2018;379(5):440-453.

Nahid P, Dorman SE, Alipanah N, et al. Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America clinical practice guidelines: treatment of drug-susceptible tuberculosis. Clin Infect Dis. 2016;63(7):e147-e195.

World Health Organization. Tuberculosis and COVID-19. Accessed August 29, 2021. https://www.who.int/teams/global-tuberculosis-programme/covid-19

Dorman SE, Nahid P, Kurbatova EV, et al.; AIDS Clinical Trials Group; Tuberculosis Trials Consortium. Four-month rifapentine regimens with or without moxifloxacin for tuberculosis. N Engl J Med. 2021;384(18):1705-1718.

Zha BS, Nahid P. Treatment of drug-susceptible tuberculosis. Clin Chest Med. 2019;40(4):763-774.

Jerant AF, Bannon M, Rittenhouse S. Identification and management of tuberculosis. Am Fam Physician. 2000;61(9):2667-2678.

Potter B, Rindfleisch K, Kraus CK. Management of active tuberculosis. Am Fam Physician. 2005;72(11):2225-2232.

Inge LD, Wilson JW. Update on the treatment of tuberculosis. Am Fam Physician. 2008;78(4):457-465.

Hauck FR, Neese BH, Panchal AS, et al. Identification and management of latent tuberculosis infection. Am Fam Physician. 2009;79(10):879-886.

• Nolt D, Starke JR. Tuberculosis infection in children and adolescents: testing and treatment. Pediatrics. 2021;148(6):e2021054663.

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Opinion Columnist

’Tis the season for vacations, so let me make my pitch that the best travel is not lounging at a beach resort but rather journeying into a different world. We all need relaxation at times, but nothing beats the thrill of a trip of discovery and the education that comes with it.

Mark Twain once observed that “travel is fatal to prejudice, bigotry and narrow-mindedness.” In that spirit, I’ve long urged young Americans to take gap years before college or junior years abroad . (One high school reader of such an essay, Spencer Cohen , ended up taking a gap year partly in Japan, became an Asia hand and is now a colleague at The Times.)

Still, there are risks, less of violence (the U.S. has more guns than other countries) than of having your passport and credit cards stolen. So I preach both travel and prudence, and on a recent book tour , I found myself often asked about travel advice I had mentioned in my memoir. So let me share a few tips for the vacation season:

1. The most memorable travel often involves encountering something unfamiliar, so consider escaping the herds parading through Paris. Indonesia, Ghana, India, Nepal, Vietnam, Morocco and Bolivia are generally safe, far cheaper than Europe and offer indelible experiences. I’ll never forget venturing deep into the Potosí silver mines in Bolivia, exploring a grim slave castle in Ghana that dispatched prisoners to slavery in America, learning how to use a blowgun while staying with families in their longhouse in Indonesia’s Borneo rainforest. The world awaits us!

2. Some of the places that you find most culturally distant may be right here in the United States. A teenager from an affluent family in the New York or Boston areas would step into a different world by taking a ranch job in Wyoming. And this is the kind of travel that is not only affordable but actually pays for the experience.

3. Be spontaneous. As a law student in 1982, I spent five weeks backpacking through the Middle East and met a couple of Palestinian students on a West Bank bus; I jumped off at their stop and spent a memorable day with them in their refugee camp hearing about their frustrations and dreams (I wrote about reuniting with them last fall). And while on a bus in the Sahara, I accepted an Algerian man’s invitation to visit his village — which turned out to be a warren of underground burrows to protect families from the extreme heat, the most unusual residential architecture I’ve ever seen. In each case, I was with a couple of friends, which made it seem safer to put myself in the company of people I’d just met, and obviously one should be as judicious as one is spontaneous.

4. One occasionally hears that adventurous travel is just for men, but some of the most accomplished foreign correspondents and overseas photographers are women, as are a majority of Peace Corps volunteers. As a man, I don’t face the same risks that women face, but I have seen female travelers — disproportionately from Australia and New Zealand — thriving as they backpack through the most remote places. Some have suggested the purchase of a cheap wedding ring; a $20 band and a fabricated husband can help keep pests away.

5. Carry a decoy wallet. If pickpockets grab it, let them run off — only to discover that it contains just a bit of cash for street purchases, a day pass for the subway and an expired credit card. But do remember to let the pickpockets escape. Years ago, in Lima, Peru, I instinctively jumped a pickpocket who was trying to grab my friend’s decoy wallet, forgetting that he had nothing much in it; next thing I knew we had a melee and a gun was being fired.

6. Carry your passport and valid credit cards and cash in a pouch that loops on your belt and is tucked inside your pants. Travelers often carry travel pouches round their necks under their shirts, but these are visible and sometimes get stolen. While I’ve had bandits make me take off my shoes and socks while searching for cash, nobody has found my pouch in my pants (I dare mention this only because I assume robbers are not big readers of my column).

7. Carry a small cable lock (those for skis are perfect) to lock your bags together so one doesn’t run off while you’re sleeping in a train or on a bench at the train station.

8. Never check a bag for a flight because then it will get lost. That means packing light and taking quick-dry clothes suitable for washing in a hotel sink. I’m fond of travel clothing from a company called Clothing Arts , and I also rely on ultralight backpacking gear such as a tiny Black Diamond or Petzl headlamp that is invaluable when the power goes out.

9. If you’re getting into a taxi or other car in a location that seems at all dubious, use your phone to photograph the license plate before you get in. The driver may wonder if you’ve texted it to a friend. And women can look for female drivers if they exist.

10. My editor doesn’t want me to say anything that might encourage readers to try something dangerous, so I won’t suggest that there is nothing like the view while riding on the top of a train in Sudan . (That was in my dissolute youth, and today I definitely disapprove of riding on top of trains.)

11. People worry about terrorists, but the most likely serious risk is probably a vehicle accident. Motorcycle taxis common in low-income countries can be perilous, while buses and trains are safer (inside trains only!).

12. Now forget all the fears this article has conjured. Go have fun. Travel should be as enjoyable as it is eye-opening. If you take precautions it will be.

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Nicholas Kristof became a columnist for The Times Opinion desk in 2001 and has won two Pulitzer Prizes. His new memoir is “ Chasing Hope: A Reporter's Life .” @ NickKristof

Travel Tips: A Guide for Kidney Patients

For many patients who are on dialysis or have had a kidney transplant, the ability to travel is important to their self-esteem and lifestyle. Working patients may need to attend business meetings or conferences. Older patients may have dreamed of traveling during their retirement. A family event such as a wedding, graduation or family reunion may require travel away from home. At times, emergencies such as illness or a death in the family may require travel.

Is it possible for kidney patients to travel?

Yes, most patients who receive dialysis or have had a kidney transplant can travel safely and continue their treatment while away from home. Of course, you should always consult your doctor before planning to travel. Most doctors encourage travel if the patient's health is stable. Traveling can give a big boost to a patient's morale and sense of well-being.

How should hemodialysis patients begin to plan a trip?

Many dialysis centers have a staff member who is experienced in arranging dialysis treatments away from home (transient dialysis). Some centers will assist patients in making their own arrangements. Ask your social worker or primary nurse if there is such a person at your center.

It is important to start planning at least six to eight weeks in advance. More time should be allowed for popular vacation spots or travel during holidays. Be flexible about the dates for your trip as space in dialysis units may be limited. If you would prefer to have your treatments on specific days and at specific times, let the center know in advance. The unit may not always be able to honor your request, however, because space is limited.

You or your patient travel coordinator may need to contact more than one center in order to find a center that can provide dialysis for you. Check with the center as soon as you arrive to confirm your appointment. You may also want to visit the center and meet the staff so you will feel more comfortable. Before doing this, however, make an appointment with the social worker or nurse manager of the dialysis center you plan to visit.

How will I find a center to dialyze at?

If you plan to visit friends or family out of town, they may be able to give you the name and address of the dialysis center nearest them. Resource publications are available at your center listing dialysis centers around the world that are willing to accept transient dialysis patients. Your social worker or the patient travel coordinator at your center will be able to assist you.

What if I need to travel in an emergency?

Many dialysis centers make every effort to accommodate patients in the event of an emergency such as illness or death of a family member. Dialysis records can be faxed ahead, or you can hand carry them with you.

What information will my transient dialysis center need to safely provide dialysis for me?

Most dialysis centers require the following information in order to assess your health and plan for your treatments with them:

• the dates you need dialysis treatment
• your name, address, etc.
• medical history and recent physical exam reports
• recent lab results
• recent chest x-ray
• your dialysis prescription and 3 to 5 recent treatment records
• dialysis access type
• special needs or dialysis requirements
• information about your general health
• insurance information
• where you will be staying in the area
• a list of the medications you take during treatment and at home.

This information will be sent to your destination center for review. It is important for the doctor and transient center to know as much about you as possible in order to care for your needs while visiting their center. In addition to mailing your records to the center, you should hand carry a copy with you.

How can I be sure about the quality of care I will be getting away from my regular center?

You may want to ask the following questions when making your arrangements for hemodialysis during your trip:

• Does the center reuse dialyzers?
• Does the center reuse bloodlines?
• What is the average treatment length of dialysis at the center?
• Can they provide the treatment time your doctor has prescribed?
• What are the hours and days of operation? Traveling patients often are placed on an evening shift, which could end as early as 7:30 p.m. or as late as 2:00 a.m.
• What types of dialyzers are used?
• Can you use the same type of dialyzer you use at your home center?
• What types of dialysis machine does the center have (conventional, high flux capability)?
• Does the center routinely provide lidocaine?
• Are patients permitted to eat or drink while on dialysis?
• Is an ice machine available for patients?
• Is public transportation available to get to the center?
• How many patients are assigned to each nurse or patient care technician?
• Can you get all the medications you get at your home center during dialysis?

What if I get sick while I am visiting another center?

Don't overdo it! Be realistic when planning activities. Allow enough time to enjoy sightseeing outings and activities without becoming overtired. Also, be sure to watch your diet and fluid intake. Before you begin your trip, you will most likely have a doctor assigned to you by your transient dialysis center. Find out how to contact the doctor when you first arrive. If you do become ill, call the dialysis center or doctor as instructed.

It is possible that a transient patient may require hospitalization. If this should happen to you, your transient doctor is prepared for this possibility and will care for you during your hospital stay. He or she will probably talk to your regular doctor to coordinate your care. You may feel more comfortable to know if this coordination has taken place. Being hospitalized while away from home can be a stressful experience for any patient, and it certainly can change your travel plans. Preparing ahead for this possibility can help make the experience less stressful. The following suggestions may be helpful:

• Make sure your family knows your travel plans.
• Make sure you have important phone numbers with such names as your regular doctor, dialysis center, etc. Have a copy of your medical records with you while traveling.
• Make sure anyone who is traveling with you knows where you keep your records and what your medical needs are.
• Make sure to bring enough of the medications you need to take to last for the entire trip, with enough extra to deal with possible emergencies such as lost luggage or a spill. Also carry written prescriptions just in case.

Is home hemodialysis possible on a trip?

Yes, although most home hemodialysis patients make arrangements for in-center treatments while traveling. Patients who wish to continue doing their own treatment while traveling should check with their dialysis care team about whether they can do home dialysis away from home. Some patients travel with their machines, supplies and portable water treatment equipment. An example would be people who have dialyzed in campsites equipped with hook-ups for electricity.

Even if you do your own treatment, it is important to know where the closest dialysis center is where you could go for assistance. Let the center know when you will be in the area, and ask if they would be willing to provide medical assistance if needed. Carry complete medical information with you. Remember that most dialysis and equipment companies have toll-free numbers for assistance 24 hours a day. Carry these numbers with you.

What should peritoneal dialysis patients know about traveling?

Traveling is often easier for peritoneal dialysis patients because they are not dependent on the availability of a dialysis unit. Peritoneal dialysis patients still need to plan ahead and arrange for back-up medical care for their trips, as do hemodialysis patients. Typically, this would mean contacting a dialysis center in the area where you will be and asking if they would be available should a problem arise. The center may request a copy of your medical records in advance. In any case, you should always carry a copy of your records with you as well.

CAPD patients should carry enough supplies for the length of the trip, plus some extra supplies in case of problems. It may also be possible to arrange for delivery of supplies to your destination for longer stays. Make sure these supplies have arrived before you leave on your trip. CAPD patients also need to plan for adequate clean space where they may do their exchanges while traveling.

APD patients who plan to travel for one week or longer can arrange for supplies to be delivered to their destination. Smaller cycler machines are now available, which are easy to carry on airplanes and to use in hotel rooms, campers, etc.

Is it possible to travel if you are active on a transplant waiting list?

Yes. Simply inform your transplant coordinator about your travel plans. The coordinator will help you decide whether to be "on hold" during the trip or whether you would be able to return within a reasonable amount of time if a kidney became available. Arrange to be contacted in the event a kidney becomes available.

What should diabetic patients know about traveling?

Since the unexpected may happen during a trip and meals may be delayed, you should carry glucose tablets and appropriate snacks, such as low-potassium juice boxes or hard candy, to treat low blood sugar. It's a good idea to travel with a "brown-bag" lunch or a packaged nutritional supplement in case of delays. Managing your diabetes can be made simpler by having insulin, syringes and blood glucose monitoring supplies handy.

Will my insurance cover treatment during travel?

If Medicare is your primary insurance coverage, Medicare will pay for 80 percent of your treatment costs within the U.S. and its territories. You will be responsible for the remaining 20 percent not covered by Medicare. If you have secondary insurance, it may cover this 20 percent. However, you may have to pay this 20 percent "up front" and bill your insurance later. Check with the transient center about their policy on this. Most state Medicaid programs will not pay for treatment outside of your home state.

If you have commercial insurance as your primary insurance, you may need to request a letter from your insurance company stating they will pay for your treatment at the transient dialysis center. Some commercial insurance will pay for dialysis outside of the U.S. Transient dialysis centers will often call and verify this coverage themselves. Be sure to allow enough planning time to make these arrangements.

A doctor's fee may also be charged by the transient dialysis center. Be sure to ask what portion of this charge will be your responsibility.

Further information

Where can I get more information?

Following is a list of other resources you may find helpful:

• Easy Access to National Parks, by Sierra Club Books, available at bookstores or order from the Sierra Club at 1-800-935-1056.
• Management of Diabetes During Intercontinental Travel, available free from The Diabetic Traveler, P.O.. Box 8223 RW, Stamford, CT 06905; (203) 327-5832.
• "The List," a comprehensive list of international dialysis centers accepting transient patients. Available from Dialysis & Transplantation, 7628 Densmore Ave., Van Nuys, CA 91406-2088. (Most dialysis centers have a copy.)
• Also available are companies that specialize in vacation and travel planning for dialysis patients, such as cruises, foreign travel, and wilderness travel. Camps are available for dialysis and transplant patients (both adults and children). Contact your local National Kidney Foundation office for more information and a directory of camps. Your health care team can also give you more information about these options.

Don't forget!

• Hand carry essential medical information, your medicines and other medical supplies in case of the unexpected, such as lost luggage.
• Bring enough of your medications to last for your entire trip, with enough extra to deal with possible emergencies. Also carry written prescriptions just in case.
• If you need extra assistance boarding a plane or train, inform personnel when you check in so they can give you special instructions.
• If you are planning to travel by plane or train, make arrangements for any special meals such as low-salt, low-fat or diabetic, at the time you make your reservations.
• When making a hotel reservation, you can request a first-floor room or a handicapped-accessible room, if stairs or distances are a problem.
• If you use a travel agent, tell the agent about any special needs you may have, such as special meals, accessible rooms, and assistance while changing planes. The agent can also advise you about special considerations regarding safe transport of dialysis supplies while traveling to foreign countries.

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• Section 11 - Rapid Diagnostic Tests for Infectious Diseases
• Section 11 - Fever in the Returned Traveler

Perspectives : Screening Asymptomatic Returned Travelers

Cdc yellow book 2024.

Author(s): Michael Libman, Sapha Barkati

Deciding to Screen

Screening for nonparasitic infections, screening for parasitic infections, long-term travelers & expatriates.

Except for coronavirus disease 2019 (COVID-19), CDC has no official guidance or recommendations for screening asymptomatic international travelers in the absence of specific risk factors for infectious diseases. Nevertheless, screening travelers returning from developing countries represents a substantial portion of the activity of many travel health and tropical medicine clinics.

The scientific literature on the clinical utility and cost effectiveness of screening asymptomatic travelers is sparse. Asymptomatic travelers can harbor many infections acquired during travel, some of which have the potential to cause serious sequelae or have public health implications. In some cases, these will include pathogens rarely found in the traveler’s country of origin. US medical practitioners might have little familiarity with these travel-associated diseases, and specific diagnostic tests might not be readily available or will require expertise in their proper interpretation.

The decision to screen an asymptomatic person for travel-acquired pathogens depends on their exposure history, itinerary, type of travel, and the public health implications of identifying infection. Screening healthy short-term travelers for infectious diseases other than COVID-19, especially people who do not report a particular exposure, is usually not necessary. On the other hand, consider obtaining specific tests for long-term travelers (e.g., adventure travelers, expatriates, humanitarian aid workers, missionaries, travelers visiting friends and relatives) who might have prolonged or heavy exposure to epidemiologically relevant pathogens with potential for long-term consequences. A traveler’s exposure history might be unreliable or not predictive of infection, however, and the value of a detailed itinerary can be limited by incomplete information. Finally, the type of travel might not provide a practical assessment of risk.

For the long-term traveler on hiatus from a continuing assignment abroad, the periodic travel health consultation offers the clinician a chance to screen for infectious diseases, conduct a general health evaluation, and to review health behaviors, malaria prophylaxis, and vaccination status. Promote and reinforce primary prevention by discussing behavioral or other risk factors that could predispose the traveler to ill health (e.g., exposures to contaminated food and drink, arthropods, and freshwater sources; drug use; high-risk sex). The usual recommendations for a periodic health exam, which might include screening for cardiovascular disorders, diabetes, hypertension, and malignancy, also apply.

Benefit & Risk of Screening Asymptomatic Travelers

Before scheduling screening tests for asymptomatic returned travelers, evaluate the sensitivity and specificity of the test, and the risk and cost to the patient. The low prevalence of tropical infections in asymptomatic travelers will heavily influence the positive predictive value of the screening tests, leading to an increased likelihood of false-positive results. As a result, the asymptomatic traveler could be subjected to further investigations, generating greater costs, anxiety, and other possible harms related to diagnostic follow-up, creating complex considerations of benefit versus risk.

Screening traditionally has been viewed as a secondary prevention intervention, that is, an attempt to identify occult illnesses or health risks. Cost effectiveness of screening depends on the disease of interest, potential outcomes associated with the disease both for the individual traveler and the public’s health, and whether an early intervention could reduce morbidity or mortality. One exception regarding asymptomatic screening is newly arrived immigrants and refugees; for recommendations regarding these individuals see Sec. 11, Ch. 11, Newly Arrived Immigrants, Refugees & Other Migrants .

Arboviruses

Chikungunya & dengue.

Screening for chikungunya and dengue in asymptomatic travelers typically is not recommended because there are no specific treatments for infection once identified. Travelers concerned about the risk for complications after a secondary dengue infection sometimes request screening. The absolute risk elevation is minimal, however, and generally there is no specific intervention. The exception are children 9–16 years old living in dengue-endemic areas; Dengvaxia vaccine is a prevention option for those presenting with laboratory-confirmed previous dengue infection (see Sec. 5, Part 2, Ch. 4, Dengue ).

The prevalence of Zika virus infection in many countries has decreased dramatically since 2017; as a result, the likelihood of a false-positive test result has increased. Moreover, Zika virus IgM antibody persists months after infection, making it difficult to determine the date of infection, which is crucial information for judging the risk in a pregnant person. Nonetheless, remain vigilant for the potential reemergence of Zika, and review screening guidelines for travelers, including pregnant people and their partners (see Sec. 5, Part 2, Ch. 27, Zika , and CDC's  Zika for Healthcare Providers  website).

Coronavirus Disease 2019

The COVID-19 pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus, has had vast health, social, and economic effects. The emergence of variants makes the evolution of this pandemic unpredictable. As the pandemic progresses, guidance for populations and travelers evolve, as do requirements and recommendations for crossing international borders. For patients who test positive for SARS-CoV-2 after international travel, consider prioritizing specimens for whole genome sequencing, as applicable.

Sexually Transmitted Infections & Bloodborne Pathogens

High rates of sexual activity with new partners, including sex workers, have been documented in overseas backpackers, military personnel, expatriate workers, and people doing volunteer work. Of concern are the low rates of reported condom use. Moreover, travelers might engage in other high-risk activities (e.g., getting a tattoo or piercing, using injection or intranasal drugs, receiving medical or dental care). Returning travelers with acute hepatitis B, hepatitis C, HIV, monkeypox, or syphilis infection pose public health risks and might be hesitant to volunteer a relevant exposure history.

A detailed questionnaire on risk factors for sexually transmitted infections and bloodborne pathogens is recommended for all travelers; always consider screening according to published guidelines. Screening people with relevant exposures should include HIV and syphilis serologic tests, and nucleic acid amplification testing for chlamydia and gonorrhea in urine and at sites of contact (e.g., pharynx, rectum). For travelers with an identified specific risk factor (e.g., blood exposure, condomless sex) who have not been previously vaccinated against hepatitis B virus (HBV), perform HBV testing; hepatitis C virus (HCV) testing also is indicated. Test all travelers born between 1945 and 1965 for HCV if not previously tested.

Tuberculosis

The incidence of tuberculosis (TB) infection related to travel is difficult to estimate. Those with a history of work in high-prevalence settings (e.g., health care institutions, refugee camps) merit screening. Pretravel and posttravel tuberculin skin testing (TST) can require as many as 4 visits to a health care provider—2 pretravel visits for a 2-step test, and 2 posttravel visits after potential exposure. The TB screening process can be simplified by using the interferon-γ release assay (IGRA), which is more expensive but less likely to yield false-positive results in people who received a previous bacillus Calmette-Guérin (BCG) vaccination.

Studies assessing IGRA use for serial testing demonstrated large variations in the rate of conversion and reversion. Fully investigate any positive TST or IGRA result, assess symptoms suggestive of active TB disease, and obtain a chest x-ray. For more information, see Sec. 5, Part 1, Ch. 23, . . . perspectives: Testing Travelers for Mycobacterium tuberculosis Infection .

Travelers often are most concerned about the possibility of an occult parasitic infection (see also Sec. 11, Ch. 9,. . . perspectives: Delusional Parasitosis ). Unfortunately, the literature shows that patient questionnaires and common laboratory testing used to screen for parasitic diseases have poor sensitivity and specificity. Studies have shown that even an exhaustive risk-factor history in asymptomatic patients is unable to reliably detect those who would or would not have evidence of parasitic infection. Physical examination is equally unrevealing.

Most commonly, a stool examination is performed, typically microscopy. Several molecular assays are commercially available to detect a panel of bacterial, viral, and parasitic pathogens. In some cases, these panels are more sensitive than traditional testing methods, and even asymptomatic people often are found to harbor pathogens. The clinical implications of asymptomatic carriage, sometimes at a low level, are unknown for most of these agents, and the risks and benefits of treatment are not well studied. Serologic tests typically are more sensitive for parasitic infections; some have performance limitations related to specificity, but are often preferred for screening asymptomatic travelers.

For questions about parasites and screening for parasitic infections, see the CDC parasites website or contact the CDC .

Travelers often are concerned about “worms,” by which they usually mean intestinal helminths (see Sec. 5, Part 3, Ch. 13, Soil-Transmitted Helminths ). Infections of travelers with large burdens of the common nematodes (e.g., Ascaris , hookworm, Trichuris ) are rare, however. Questioning returning expatriates infected with intestinal helminths has disclosed no attributable symptoms compared with uninfected controls. The life cycles of almost all helminths preclude any real risk of ongoing person-to-person transmission from asymptomatic hosts in high-income countries; helminths generally have a natural lifespan of months to a few years, which ensures eventual spontaneous clearance. In addition, low-intensity infections are of limited clinical importance, though in rare cases aberrant migration of Ascaris spp. can result in clinical disease. The exception to this is Strongyloides stercoralis .

Strongyloidiasis

For Strongyloides infections, serious complications are well known, nonspecific symptoms can easily be overlooked, duration of carriage after infection is unlimited due to its autoinfection cycle, and the original burden of infection is irrelevant (see Sec. 5, Part 3, Ch. 21, Strongyloidiasis ). Specific types of immune suppression (e.g., corticosteroid therapy, hematologic malignancy, hematopoietic stem cell transplant, human T-lymphotropic virus type 1 [HTLV-1] infection, solid organ transplant) are risk factors for developing a potentially lethal hyperinfection syndrome or disseminated strongyloidiasis. The COVID-19 pandemic has prompted widespread, urgent dexamethasone use, which could lead to an increased risk for severe strongyloidiasis in exposed travelers and migrants.

Consider screening for strongyloidiasis in select high-risk travelers with potential skin exposure to human feces, usually a result of walking barefoot in areas without proper sanitation facilities. Unfortunately, the sensitivity of stool-based biomolecular and parasitological methods is low. Molecular detection of helminths is more sensitive and specific compared to microscopy, but sensitivity is still insufficient for screening purposes. Moreover, molecular techniques are not widely available outside the reference laboratory and research setting. Serologic methods are often required, as discussed elsewhere in this chapter.

Schistosomiasis

There is no evidence to demonstrate that the low-burden Schistosoma infections typically found in travelers lead to the types of complications found in endemic areas (e.g., liver fibrosis, malignancy). Nevertheless, the possibility of complications cannot be entirely ruled out, particularly in people who have more intense exposures (see Sec. 5, Part 3, Ch. 20, Schistosomiasis ). Even brief exposures to freshwater lakes and rivers in known endemic areas in Africa are associated with substantial seroconversion rates. In addition, complications due to ectopic egg migration occasionally can occur in light infections and without warning.

Consider serologic screening in asymptomatic travelers who bathed or swam in freshwater canals, lakes, or rivers in areas endemic for schistosomiasis. Other types of fresh water (e.g., adequately chlorinated swimming pools) carry minimal exposure risk because they do not support the larval parasitic forms. Screening becomes most sensitive only 8–10 weeks after potential exposure and is useful only in those who have not been infected with a schistosome previously. Schistosoma antigens (e.g., circulating anodic antigen [CAA]) can be detected in blood and urine in active infection and can be used to monitor cure after treatment, but sensitivity in asymptomatic travelers is not well studied, and these tests are not widely available.

Interpreting traditional tests for the parasites that cause schistosomiasis and strongyloidiasis can be challenging. Urine and stool examination for Schistosoma spp. and stool examination for Strongyloides lack sensitivity, particularly in low-burden infection; thus, serologic testing has been advocated as the best screening tool. Problems inherent to serologic screening include expense, lack of easy availability, and lack of standardization. Serologic tests often are designed to maximize sensitivity, typically at the expense of specificity. Unfortunately, specificity is almost impossible to define. Seropositivity in the absence of direct pathogen detection is common, and its clinical significance can be difficult to determine.

Fortunately for patients with schistosomiasis (or strongyloidiasis), treatment is easy and effective; for people deemed at risk of strongyloidiasis who require immediate immunosuppression, consider empiric treatment. The common antihelminthic agents used for short-course therapy (e.g., albendazole, ivermectin, praziquantel) have excellent safety profiles. Be aware, however, that rare but severe adverse events can occur when using certain antihelminthics in patients who have occult, unsuspected co-infection with other parasites. Of note, albendazole can cause increased intracranial pressure with focal signs, seizures, and retinal damage in people infected with Taenia solium ; diethylcarbamazine can provoke ocular damage in people infected with Onchocerca ; and ivermectin can cause encephalopathy in people infected with Loa loa .

Reports of travelers with late complications from asymptomatic filarial infections are virtually nonexistent, and filarial screening (blood or skin snips for microfilaria) is generally not recommended for asymptomatic travelers.

Other Helminthic Infections

Helminth parasitic infections rarely seen in returning travelers include fascioliasis, neurocysticercosis, and paragonimiasis, among others. Screening asymptomatic travelers for these infections is generally not appropriate. Primary care providers should refer patients to an infectious disease specialist when biological, clinical, or radiologic abnormalities increase suspicion for these infections. Intestinal helminths (e.g., Ascaris , Enterobius , hookworms, Strongyloides , Trichuris ) rarely cause severe illness in travelers. Other than for Strongyloides in select high-risk travelers, screening is not recommended for intestinal helminth infections.

Blood- & Tissue-Dwelling

No justification can be made for screening most asymptomatic travelers for malaria, whether by blood film, molecular methods, or serologic tests. No available tests can detect the latent hepatic forms (hypnozoites) of Plasmodium vivax or P. ovale . Remind travelers to seek evaluation for unexplained fever and to notify practitioners of international travel within the past 12 months.

Immigrants with frequent and regular exposure to malaria might gradually develop partial immunity, which can result in low-level parasitemia with minimal symptoms. Immigrants from malaria-endemic areas might later recrudesce with more severe illness, but this phenomenon is rare in non-immigrant travelers. Of note, in rare cases, travelers compliant with prophylaxis might still acquire malaria; often they will present with low parasitemia infections, and their symptoms can manifest after ending prophylaxis. In these cases, testing asymptomatic travelers is generally inadequately sensitive and not recommended. Rather, advise travelers to remain vigilant for symptoms, particularly unexplained fever.

Trypanosomiasis

Occult trypanosomiasis in asymptomatic travelers (as opposed to immigrants) appears to be extremely rare. Screening tests (e.g., molecular diagnostics, serology) are of unknown value. Consider Trypanosoma cruzi testing for travelers who lived for >6 months in rustic housing (e.g., shelters with mud walls and thatched roofs) in endemic areas of Latin America, especially if they report having seen triatomine bugs inside their dwelling. Also consider testing in people who received blood products in an endemic area, or in travelers with clinical manifestations compatible with acute Chagas disease (see Sec. 5, Part 3, Ch. 25, American Trypanosomiasis / Chagas Disease ).

East African trypanosomiasis has affected travelers but typically causes acute symptoms. West African trypanosomiasis generally is not reported in travelers. Refer patients to an infectious disease specialist when these infections are suspected based on biological, clinical, or radiologic abnormalities.

Treat symptomatic intestinal protozoa infections, particularly Entamoeba histolytica which can cause severe disease and ectopic infections (e.g., liver abscess). Except for E. histolytica infection (which is only rarely asymptomatic), the finding of pathogenic protozoa in asymptomatic patients is of questionable significance.

The most common protozoa found in asymptomatic travelers are Blastocystis and Giardia species. History of exposure to contaminated food or water has poor predictive value. No evidence suggests that asymptomatic carriers are likely to develop symptoms later, and the medications used to treat these protozoa can have adverse effects. In theory, asymptomatic carriers pose a public health risk, but transmission by asymptomatic travelers appears to be rare. In addition, stool microscopy for protozoa is expensive, not very sensitive, not highly reproducible, and many laboratories have limited expertise; thus, screening is not recommended unless evidence of onward transmission is present.

Microscopy cannot distinguish Entamoeba histolytica from E. dispar . Differentiation requires further specimen collection and testing. Studies reveal that most travelers with Entamoeba on microscopy are carrying E. dispar . Antigen testing for E. histolytica and Giardia (among others) is fairly reliable but lacks the potential to screen for all intestinal parasites with a single test, and only some antigen tests are able to differentiate E. histolytica from E. dispar .

Commercial molecular methods to screen stool specimens for multiple pathogens simultaneously typically include several protozoa, generally with better sensitivity than microscopy. These assays also can specifically distinguish potentially pathogenic E. histolytica from nonpathogenic amoebae. They offer rapid turnaround times and, although costs remain high, these assays are increasingly being used in returned travelers with suspected protozoal infections. Some of these panels detect organisms for which pathogenicity remains controversial, (e.g., Blastocystis and Dientamoeba ). Identifying these pathogens can lead to patient anxiety and unnecessary treatment; thus, screening asymptomatic travelers for intestinal protozoa is not routinely recommended.

General Guidelines

Eosinophilia.

Screening for eosinophilia is a common test because it is quick, universally available, and theoretically of value in detecting invasive helminths, if not protozoa. Multiple studies have shown, however, that testing for eosinophilia has poor sensitivity for identifying parasitic infections; the low prevalence of infection in asymptomatic travelers means that the positive predictive value is poor, and the finding of eosinophilia can lead to an extensive and often fruitless search for a cause, generating patient anxiety and high costs. Many cases of eosinophilia resolve spontaneously, possibly because of infection with nonpathogenic organisms or a noninfectious cause (e.g., allergy, drug reaction). Repeat eosinophil counts after several weeks or months before embarking on an extensive investigation.

A recent study in travelers and migrants showed that those with helminthic infection (as compared to other diagnoses) had much higher eosinophil counts. Counts can be highly variable, though, even within a single day, and are suppressed by endogenous or exogenous steroids. Using absolute eosinophil counts, rather than eosinophils as a percentage of leukocytes, is more reproducible and predictive.

Duration of Travel & Other Risk Factors

Table 11-08 and the following traveler classification scheme provide general guidelines for screening asymptomatic returned travelers for imported infections.

Table 11-08 Considerations for screening asymptomatic travelers

Abbreviations: CBC, complete blood count; COVID-19, coronavirus disease 2019; CRP, C-reactive protein; HBV, hepatitis B virus; HCV, hepatitis C virus; NAAT, nucleic acid amplification test; TB, tuberculosis; TST, tuberculin skin test; IGRA, interferon-γ release assay

1 Recommendation might change with the evolution of the pandemic. Refer to the updated recommendations available from: www.cdc.gov/coronavirus/2019-ncov/travelers/international-travel/index.html .

All Travelers

See guidance regarding international travel and posttravel COVID-19 testing .

Short-Term Travelers

Screening asymptomatic short-term (<3–6 months) travelers is usually low-yield and should be directed by specific risk factors revealed in the history. A history of prolonged (>2 weeks) digestive symptoms during travel can suggest protozoal infection. Consider serologic testing of travelers who bathed or swam in unchlorinated freshwater sources in regions with known schistosomiasis risk, especially sub-Saharan Africa.

In addition, consider serology testing for Strongyloides in select high-risk travelers who have skin exposure to soil likely to be contaminated with human feces, usually individuals with a history of frequently walking barefoot outdoors. Obtain a sexual history; screen for sexually transmitted and bloodborne infections, if warranted. Zika virus testing for asymptomatic travelers (including pregnant people) with potential exposure is generally not recommended (see Sec. 5, Part 2, Ch 27, Zika ). Consider TB screening for those returning from work in health care or other high-risk settings.

The overall yield of screening increases for longer-stay (>3–6 months) travelers. The emphasis should be on those with the longest stays and the most problematic sanitary conditions or other exposures. In some cases, employers require certain tests, partly for liability reasons. Performing stool examinations mostly provides psychological reassurance. Consider obtaining serologic testing for schistosomiasis and strongyloidiasis in people with recent or remote travel histories to endemic areas and who report some level of risk.

A complete blood count with white blood cell differential and eosinophil counts, liver transaminases, creatinine, and C-reactive protein are usually the basic set of tests performed. Interpret results cautiously; abnormalities might trigger further testing. Zika virus testing for asymptomatic travelers with potential exposure, including pregnant people, is generally not recommended outside of a recognized outbreak. Limit TST or IGRA testing to travelers who worked in a health care or similar setting or who had intimate and prolonged contact with residents of a highly TB-endemic area for ≥6 months. Only perform other screening based on exceptional exposures or knowledge about local outbreaks.

The following authors contributed to the previous version of this chapter: Michael Libman, Sapha Barkati

Bibliography

Baaten GG, Sonder GJ, van Gool T, Kint JA, van den Hoek A. Travel-related schistosomiasis, strongyloidiasis, filariasis, and toxocariasis: the risk of infection and the diagnostic relevance of blood eosinophilia. BMC Infect Dis. 2011;11:84.

Casacuberta-Partal M, Janse JJ, van Schuijlenburg R, de Vries JJC, Erkens MAA, Suijk K, et al. Antigen-based diagnosis of Schistosoma infection in travellers: a prospective study. J Travel Med. 2020;27(4):1–9.

Centers for Disease Control and Prevention. International travel during COVID-19; 2020. Available from: www.cdc.gov/coronavirus/2019-ncov/travelers/international-travel-during-covid19.html .

Centers for Disease Control and Prevention. Zika virus for health care providers; 2022. Available from: www.cdc.gov/zika/hc-providers .

MacLean JD, Libman M. Screening returning travelers. Infect Dis Clin North Am. 1998;12(2):431–43.

Overbosch FW, van Gool T, Matser A, Sonder GJB. Low incidence of helminth infections (schistosomiasis, strongyloidiasis, filariasis, toxocariasis) among Dutch long-term travelers: A prospective study, 2008–2011. PLoS ONE. 2018;13(5):e0197770.

Salzer HJF, Rolling T, Vinnemeir CD, Tannich E, Schmiedel S, Addo MM, et al. Helminthic infections in returning travelers and migrants with eosinophilia: diagnostic value of medical history, eosinophil count and IgE. Travel Med Infect Dis. 2017;20:49–55.

Smith BD, Morgan RL, Beckett GA, Falck-Ytter Y, Holtzman D, Teo CG, et al. Recommendations for the identification of chronic hepatitis C virus infection among persons born during 1945–1965. MMWR Recomm Rep. 2012;61(RR-4);1–18.

Soonawala D, van Lieshout L, den Boer MA, Claas EC, Verweij JJ, Godkewitsch A, et al. Post-travel screening of asymptomatic long-term travelers to the tropics for intestinal parasites using molecular diagnostics. Am J Trop Med Hyg. 2014;90(5):835–9.

US Preventive Services Task Force. Final recommendation statement. Hepatitis C: screening; 2022. Available from: www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/hepatitis-c-screening .

Weinbaum CM, Williams I, Mast EE, Wang SA, Finelli L, Wasley A, et al. Recommendations for identification and public health management of persons with chronic hepatitis B virus infection. MMWR Recomm Rep. 2008;57(RR-8):1–20.

Yansouni CP, Merckx J, Libman MD, Ndao M. Recent advances in clinical parasitology diagnostics. Curr Infect Dis Rep. 2014;16(11):434.

. . . perspectives chapters supplement the clinical guidance in this book with additional content, context, and expert opinion. The views expressed do not necessarily represent the official position of the Centers for Disease Control and Prevention (CDC).

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What to know.

It’s important to plan ahead to get the shots required for all countries you and your family plan to visit.

Before you travel

Protect your child and family when traveling in the United States or abroad by:

• Getting the shots required for all countries you and your family plan to visit during your trip
• Making sure you and your family are up-to-date on all routine U.S. vaccines
• Staying informed about travel notices and alerts and how they can affect your family's travel plans

Avoid getting sick or coming back home and spreading the disease to others.

Vaccinate at least a month before you travel

See your doctor when you start to plan your trip abroad. It's important to do this well in advance.

• Your body needs time to build up immunity.
• You may need several weeks to get all the doses of the vaccine.
• Your primary doctor may not stock travel vaccines. Visit a travel medical clinic .
• You'll need time to prepare for your pre-travel appointment .
• If the country you visit requires a yellow fever vaccine , only a limited number of clinics have the vaccine and will probably be some distance from where you live. You must get it at least 10 days before travel.

Find out which vaccines are recommended or required for the countries you plan to visit .

Time-saving Tip‎

Last-minute travelers.

When traveling to another country be aware your doctor may not carry a travel vaccine and you may have to visit a medical clinic.

Many travel vaccines require multiple shots or take time to become fully effective. But some multiple-dose vaccines (like hepatitis A) can still give you partial protection after just one dose. Some can also be given on an "accelerated schedule," meaning doses are given in a shorter period of time.

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5 Tips for Traveling With Type 2 Diabetes

Managing type 2 diabetes is an everyday job. That means that even as you travel, you have to take steps to keep your blood sugar under control. Health’s Type 2 Diabetes Advocate Alysse Dalessandro is an expert traveler. She explains what she does to manage her diabetes even when she is away from home.

I’m sitting in a chair with the wooden arms squeezing my thighs. There’s a smell of antiseptic in the air. My nerves are completely wrecked. I should be at home packing for my first cruise, but instead, I am at the doctor’s office waiting to pee in a cup. I came in just the day before for a full physical, but only so my insurance would completely cover the visit. I just needed a prescription for motion sickness patches—I feel fine.

“You have diabetes,” the doctor tells me. An A1C over 10 confirms the diagnosis, and a urine test will confirm which type of diabetes I have. The frequent trips to the bathroom in the middle of the night, the way my mouth feels painfully dry when I wake up, the sudden unexplained weight loss—it turns out those were all symptoms of diabetes .

“Can I still go on the cruise tomorrow?” is among the first questions I ask the doctor. He looks back at me, shocked. He explains that if it’s type 2 diabetes , I can go on the cruise armed with new medications, a blood glucose meter, and a strict order to not drink any alcohol or touch a dessert.

At that moment, managing type 2 diabetes may have been completely foreign to me, but with the diagnosis came a realization: Your life can change at any moment. I decided in that doctor’s office I would not let diabetes rule my life. I left that office with a renewed sense of purpose. I was determined to make memories and challenge myself with new experiences while I still could.

On that cruise, I explored the ocean floor in a submarine, went cave tubing, and ziplined, all for the first time. As I was soaring through the jungle in Belize, I couldn’t help but wonder if my fear would’ve held me back from this experience just a week earlier. Traveling with diabetes on that first trip after my diagnosis had its complications, but it also fueled me.

More than eight years later, I am a content creator sharing my experiences as a plus-size queer person traveling with type 2 diabetes to thousands of folks across social media. I don’t take vacations as a break from a desk job—it’s my job to travel and explore new places. One week I am hiking Giant’s Causeway in Northern Ireland, and the next week I am looking up at Juliet’s balcony in Verona, Italy.

I don’t have all the answers, but having visited nearly 30 countries in the past eight years, I have learned some things along the way that I hope will help others with diabetes who want to travel.

1. Consider Wearing a Continuous Glucose Monitor 

Before that first cruise, my doctor handed me a paper schedule of when I should check my blood glucose levels . I had to bring my blood glucose meter, needles, test strips, and sharps container with me to every meal as I tracked the numbers on that paper schedule. While I was armed with more information than before my diagnosis, this was certainly not the best way for me to monitor my blood glucose levels. I realized I wanted something more efficient.

For the past four years, I have been wearing a continuous glucose monitor (CGM). This has absolutely transformed my experience traveling with diabetes. My CGM tracks my blood glucose levels by using a sensor attached to my arm and sends the readings to an app on my phone via Bluetooth.

Dylan Furlano / Photo courtesy Alysse Dalessandro

Using a CGM takes the guesswork out of traveling with diabetes. Instead of getting a snapshot of my numbers a few times throughout the day with finger pricks, I am able to see what my numbers are at any time, even what they were when I was sleeping. Data are power when you have diabetes. I use this information to look for trends.

I love that at 30,000 feet in the air, I can still get a reading and make an informed decision when the flight attendant says, “Chicken or pasta?”

2. Pack Extras 

If there’s one thing I’ve learned while traveling over the past four years, it’s to expect the unexpected: Always buy the travel insurance, and pack extra! Now, by pack extra, I don’t mean pack three pairs of jeans for a weekend trip to Mexico “just in case.” I am referring specifically to the supplies you use to manage your diabetes.

I got my first CGM in early 2020, and a few months later, with travel still mostly shut down, I decided to go on a 50+ hour road trip to Yellowstone National Park. I left with a fresh CGM on my arm that would last me the next 14 days. Although this was a lot of driving, we planned to do most of it over the course of a week, and it did not even occur to me to pack an extra CGM in my bag just in case.

Well, luck would have it that as I pulled into a parking spot in Cheyenne, Wyoming, more than 1,200 miles from home, I accidentally caught my CGM on my seatbelt, and it fell off. I spent the next few hours on the phone trying to get my prescription transferred to the one pharmacy in the entire state of Wyoming that had my CGM in stock. This whole snafu added hours to an already long day of driving.

If your insurance or budget allows it, make sure you have devices and medications beyond the length of your trip. Better safe than stranded in Wyoming, unable to track your blood glucose levels.

3. Maintain Your Medication Schedule 

If you have traveled between Asia and the United States, then you already know what it feels like to switch your days and nights. My recent trip had me leaving my hometown in Cleveland on a Friday morning and arriving in Bali on a Monday morning. By the time I finally arrived, I didn’t know what time or day it was.

I did not want to take more than or less than my recommended daily and nightly medications during this cross-continent flight. I set alarms for the length of time between what would be my “breakfast” and “dinner” medications rather than basing it off the time at home or the time at my destination.

I also decided to bring protein-dense snacks that didn’t require refrigeration so that if the inflight meals did not align with the time I needed to take my medications with food, I could still stay on schedule.

4. Be Mindful of Your Meals

Speaking of meals, traveling makes it a lot more challenging to plan your meals. I personally love the spontaneity of travel meals, but my diabetes isn’t always on board. It’s also not as easy to plan when your next meal might be, especially if you are traveling with a guide or group.

Even as a seasoned traveler, I can still mess up the timing of my meals . Before a recent evening transatlantic flight, I ate a snack at the airport and took my dinner medications. I figured that, as with most transatlantic flights, the dinner service would occur as soon as the flight reached a cruising altitude.

Over three hours later, it was almost midnight, and the dinner cart still loomed far down the aisle. My CGM alarms rang out loudly and flashed red as my blood glucose levels dipped into dangerous territory. I rang my flight attendant call button and asked for two emergency glasses of orange juice. That flight was a scary reminder to always keep my snacks for lows close by and ask about meal times rather than assume.

5. Drink Water

Access to clean drinking water should be a basic human right, but traveling to certain parts of the world will show you how inaccessible this vital resource can be. I have seen how quickly my body and blood glucose levels react when I don’t drink enough water.

Places with higher elevations or hotter temperatures require an even greater water intake . This is even more important for people with diabetes, who can become dehydrated more quickly.

Some people with diabetes also cannot cool their bodies as quickly, and being in places near the Equator like Colombia, I was absolutely feeling these side effects.  

Final Thoughts

Going on a cruise just one day after receiving my diagnosis has set the tone for my current life traveling with diabetes. There are certainly times when I am scared or uncertain, but I have learned to be more aware of what’s going on in my body. I have also learned to better advocate for myself and educate others about diabetes management while traveling.

Centers for Disease Control and Prevention. Managing Diabetes in the Heat .

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