Conveyance and Transportation Issues

AIR TRAVEL

Nancy M. Gallagher, Karen J. Marienau, Petra A. Illig, Phyllis E. Kozarsky

Travelers often have concerns about the health risks of flying in airplanes. Illness that occurs as a direct result of air travel is uncommon, but the main concerns are—

• •Exacerbations of chronic medical problems due to changes in air pressure, humidity, and oxygen concentration
• •Relative immobility during flights (risk of thromboembolic disease)
• •Close proximity to other passengers with certain communicable diseases
• •Spraying of airplane cabins with insecticides (disinsection) prior to landing in certain destinations

Exacerbation of Chronic Disease

During flight, the aircraft cabin pressure is usually maintained at the equivalent of 1,500–2,500 m (5,000–8,000 ft) above sea level. Most healthy travelers will not notice any effects. However, for travelers with cardiopulmonary diseases (especially those who normally require supplemental oxygen), cerebrovascular disease, anemia, and sickle cell disease, conditions in an aircraft can increase the risk of exacerbations of their underlying conditions. Aircraft cabin air is typically very dry, usually 10%–20% humidity, which can cause dryness of the mucous membranes of the eyes and airways.

People with chronic illnesses, particularly those whose conditions may be unstable, should be evaluated by a physician to ensure they are fit for travel. For those who require supplemental in-flight oxygen, the following must be taken into consideration:

• •Federal regulations prohibit airlines from allowing passengers to bring their own oxygen aboard; passengers requiring in-flight supplemental oxygen should notify the airline at least 72 hours before departure.
• •Information regarding the screening of respiratory equipment (e.g., oxygen canisters or Portable Oxygen Concentrators [POCs]) at airports in the United States and regulations regarding oxygen use on aircraft can be found at www.tsa.gov/travelers/airtravel/.
• •Airlines may not offer in-flight supplemental oxygen on all aircraft or flights; some airlines permit only POCs.
• • Travelers must arrange their own oxygen supply while on the ground, at departure, during layovers, and on arrival. The National Home Oxygen Patients Association provides a brochure, Airline Travel with Oxygen (available at www.homeoxygen.org/airtrav.html) to assist patients who require supplemental oxygen during travel.

Barotrauma during Flight

Air in the middle ear and sinuses, as well as intra-abdominal gas, expands during ascent. Air in the middle ear and sinuses can usually equalize during ascent. More problems occur as the low-pressure air within these spaces needs to be equalized by air that flows in the eustachean tube or sinus passages.

The following suggestions may help avoid potential barotrauma:

• •People with ear, nose, and sinus infections or severe congestion may wish to temporarily avoid flying to prevent pain and injury. This is particularly true for infants and toddlers, in whom obstruction occurs more readily.
• •Oral pseudoephedrine 30 minutes before flight departure or a nonsteroidal anti-inflammatory agent may alleviate symptoms.
• •Travelers sensitive to abdominal bloating should avoid carbonated beverages and foods that can increase gas production.
• •Patients who have had recent surgery, particularly intra-abdominal, neurologic, intrapulmonary or intraocular procedures, should consult with their physicians before flying.

Ventilation and Air Quality

All commercial jet aircraft built after the late 1980s and a few modified older aircraft recirculate 10%–50% of the air in the cabin mixed with outside air. The recirculated air passes through a series of filters 20–30 times per hour. In most newer model airplanes, the recycled air passes through high-efficiency particulate air (HEPA) filters, which capture 99.9% of particles (bacteria, fungi, and larger viruses) between 0.1 and 0.3 microns. Air flow occurs horizontally across the plane in limited bands, and air is not forced up and down the length of the plane.

In-Flight Transmission of Communicable Diseases

Communicable diseases may be transmitted to other travelers during air travel, therefore—

• •Persons who are acutely ill, or still within the infectious period for a specific disease, should be discouraged from traveling.
• •Travelers should be reminded to wash their hands frequently and cover their noses and mouths when coughing or sneezing.

If a passenger with a communicable disease is identified as having flown on a particular flight (or flights), passengers who may have been exposed will be contacted by public health authorities for possible screening or prophylaxis.

For certain communicable diseases, public health authorities will obtain contact information from the airline for potentially exposed travelers so they may be contacted and offered appropriate intervention. To assist in this process, travelers can provide airlines with current contact information such as a telephone number and state of residence. Travel agencies will not share passenger contact information with the airline or public health authorities.

Tuberculosis

Although the risk of transmission of Mycobacterium tuberculosis on board aircraft is low, international TB experts agree that contact investigations for flights >8 hours are warranted when the ill traveler meets WHO criteria for being infectious during flight. The concern is greatest when a person may have flown with a highly resistant strain of TB. People known to have infectious TB should not travel by commercial air (or any other commercial means) until criteria for no longer being infectious are met. State health department TB controllers are valuable resources for advice (www.phf.org/links.htm#State-Health).

Neisseria meningitidis

Meningococcal disease is potentially rapidly fatal, thus rapid identification of close contacts and provision of prophylactic antimicrobials are critical. Antimicrobial prophylaxis should be considered for—

• •household members traveling with a patient,
• •travel companions with close contact, and
• •passengers seated directly next to the ill traveler on flights of >8 hours.

Measles

Most measles cases diagnosed in the United States are imported from countries where measles is endemic.

• •An ill traveler is considered infectious during a flight of any duration if he or she traveled during the 4 days before rash onset through 4 days after rash onset.
• •
  Intervention may prevent or mitigate measles in susceptible contacts if—

  • ○
    MMR vaccine is given within 72 hours of flight exposure or
  • ○
    Immunoglobulin is given within 6 days of flight exposure.
• •International travelers should ensure they are immune to measles prior to travel.

Influenza

Transmission of the influenza virus aboard aircraft has been documented, but data are limited. Transmission is thought to be primarily due to large droplets; therefore, passengers seated closest to the source case are believed to be most at risk for exposure (see the Influenza section in Chapter 2 and www.cdc.gov/flu for more information).

The avian influenza virus (H5N1) has infected hundreds of humans since 1997, primarily associated with direct contact with infected birds or bird products. No cases have yet been associated with air travel. See www.cdc.gov/travel for more general information and up-to-date, specific guidelines for travelers and the airline industry.

Severe Acute Respiratory Syndrome (SARS)

SARS can potentially be transmitted anywhere people are gathered, including aircraft cabins. The last known case of person-to-person transmission occurred in 2003. If SARS were to re-emerge, www.cdc.gov/travel will provide up-to-date information for travelers and flight crews.

Disinsection

To reduce the accidental spread of mosquitoes and other vectors via airline cabins and luggage compartments, a number of countries require disinsection of all inbound flights. WHO and the International Civil Aviation Organization (ICAO) specify two approaches for aircraft disinsection—

• •Spraying the aircraft cabin with an aerosolized insecticide (usually 2% phenothrin) while passengers are on board
• •Treating the aircraft's interior surfaces with a residual insecticide while the aircraft is empty

Some countries use a third method, in which aircraft are sprayed with an aerosolized insecticide while passengers are not on board.

Disinsection is not routinely done on incoming flights to the United States. Although disinsection, when done appropriately, was declared safe by the WHO in 1995, there is still much debate about the safety of the agents and methods used. Guidelines for disinsection have been updated for the revised International Health Regulations (www2a.cdc.gov/phlp/docs/58assembly.pdf). Many countries, including the United States, reserve the right to increase the use of disinsection in case of increased threat of vector or disease spread. An updated list of countries that require disinsection and the types of methods used are available at the U.S. Department of Transportation website: (http://ostpxweb.ost.dot.gov/policy/safetyenergyenv/disinsection.htm).

CRUISE SHIP TRAVEL

Kiren Mitruka

The continued popularity of cruise travel, along with the expansion of cruise itineraries to areas not easily accessible otherwise, promotes the exposure of travelers to multiple global destinations in a short period of time. Passengers and crew from around the world bring together a diversity of cultures, medical risk factors, and health risk behaviors.

• •About 12 million passengers worldwide took a cruise vacation in 2007, a 7% increase over 2006.
• •The North American cruise industry makes up the majority of the global cruise market and since 1980 has had an average annual passenger growth rate of 8.1%.
• •U.S. ports handle about 75% of all embarkations.
• •The Caribbean is the top cruise destination, followed by the Mediterranean, Europe, Alaska, and Mexico.
• •A typical cruise is about 7 days long and includes 3,000 passengers and 1,000 crew members.
• •Approximately 78% of cruise passengers are U.S. residents. About 50 nationalities are represented among crew members, most of whom are from developing countries.

Challenges of Cruise Ship Travel and Infectious Diseases

• •Densely populated, semi-enclosed cruise ship environments may permit repeated and prolonged exposure to communicable diseases, resulting in their transmission between passengers and crew members.
• •Differences in sanitation standards and disease prevalence between seaports may also lead to communicable disease exposure and spread.
• •The risk of acquiring an infectious disease during cruise travel is difficult to quantify due to the diverse activities of crew and passengers, as well as the wide range of potential disease exposures.
• •Senior citizens (an estimated one-third of cruise travelers) and travelers with underlying chronic health problems are at increased risk of illness from infections such as influenza, Legionella, and noroviruses.
• •Early detection and prevention of infectious diseases are important, not only to protect the health of cruise travelers, but also to avoid global dissemination of diseases in home communities through disembarking passengers and crew members.

Medical Care Aboard Cruise Ships

Medical facilities on cruise ships can vary, depending on the size of the ship, its itinerary, number of crew and passengers, and the mean age and health status of passengers.

The American College of Emergency Physicians (ACEP) Health Care Guidelines for Cruise Ship Medical Facilities is a consensus report on appropriate facilities and staffing requirements for basic shipboard medical and emergency services, given the recognized limitations of offshore environments. Shipboard health care recommended in these guidelines includes provision of—

• •A medical infirmary with licensed medical staff (physician and registered nurse) on call 24 hours per day
• •One intensive care unit (ICU) room
• •One bed per 1,000 passengers and crew members
• •One isolation room or the capability to isolate patients with communicable diseases
• •Emergency and portable medical equipment, such as a bag valve mask, oxygen tank, endotracheal tube, defibrillator, and a cardiac monitor or external cardiac pacer
• •Medications to handle medical emergencies
• •Basic diagnostic and laboratory supplies for blood chemistry analyses, complete blood counts, urinalyses, chest x-rays, and electrocardiograms (EKGs)
• •A medical record and communication system
• •Health, hygiene, and safety program for medical personnel

Large cruise lines that operate in the United States or are members of Cruise Lines International Organization (CLIA) meet or exceed ACEP guideline standards. However, medical care on these ships should be equated to that of community urgent-care centers, not full-service hospitals. Small ships or those run by independent ship operators may not follow the ACEP guidelines. Therefore, on such ships, medical provisions might not be available onboard.

Primary Health Concerns on Cruise Ships

General

In a retrospective study of four cruise ship medical logs maintained by a major cruiseline, 7,147 new patient visits occurred among 196,171 cruise passengers on 172 voyages.

• •Over half of shipboard infirmary visits are made by passengers over the age of 65.
• •The most common diagnosis was respiratory tract infection (29.1%), followed by injuries (18.2%), seasickness (9.1%), and gastrointestinal (GI) illness (8.9%).
• •An estimated 95% of illnesses seen in cruise ship medical facilities can be treated onboard. However, passengers with serious problems, such as myocardial infarction or cerebrovascular accidents, need to be transferred to shoreside hospitals after stabilization.

Communicable Diseases

Communicable diseases occurring onboard cruise ships are similar to those that occur onshore. Detecting illnesses of public health significance is aided by heightened cruise line surveillance efforts in cooperation with public health authorities, and passenger reporting.

• •The most frequently documented cruise ship outbreaks involve respiratory infections (influenza and Legionella) and gastrointestinal infections (norovirus).
• •In the past decade, clusters of illnesses due to vaccine-preventable diseases other than influenza, such as rubella and varicella (chickenpox), have also been reported.

Respiratory Illnesses

Influenza

• •Outbreaks of influenza A and B can occur year-round, despite seasonality in the destination regions for cruises.
• •Respiratory illness outbreaks usually result from the importation of influenza by embarking passengers and crew; the infection subsequently spreads person to person on the ship.
• •Onboard control measures include isolation, infection control, and antiviral treatment of ill individuals as well as those exposed to the illness.
• •One of the largest and most protracted influenza outbreaks occurred among land- and sea-based tourists to Alaska and the Yukon during the summer of 1998.

Legionnaires' Disease

• •Legionnaires' disease has led to pneumonia outbreaks on multiple occasions, sometimes on consecutive cruises.
• •Although contaminated ships' whirlpool spas and potable water supply systems are the most commonly implicated sources of Legionella outbreaks, exposure to other sources may also occur during port stops.
• •Pinpointing the source of these outbreaks has proved difficult because diagnoses in returned travelers may be delayed and clinical specimens may be unavailable for culture at the time of diagnosis.
• •Culture-based diagnostic tests for cruise travel-associated Legionnaires' disease are of public health importance.
• •Improvements in ship design and standardization of spa and water supply disinfection have reduced the risk of Legionella growth and colonization.

Gastrointestinal (GI) Illnesses

The estimated likelihood of contracting gastroenteritis on an average 7-day cruise is less than 1%. GI illness accounts for fewer than 10% of shipboard passenger infirmary visits. In recent years, outbreaks of gastroenteritis on cruise ships have increased, despite good cruise ship environmental health standards.

Noroviruses

• •The increase in gastroenteritis on cruise ships is primarily attributed to noroviruses, also the main cause of acute viral gastroenteritis in the United States.
• •
  Large, consecutive cruise ship outbreaks have resulted from noroviruses, due to their—

  • ○
    low infective dose,
  • ○
    easy person-to-person transmissibility, and
  • ○
    ability to survive routine cleaning procedures.
• •Prompt implementation of disease control measures, such as the isolation of ill persons, strict application of food and water sanitation measures, and disinfection of surfaces with suitable disinfectants, are key to controlling norovirus outbreaks.

Other pathogens

Other known causes of GI illness clusters on cruise ships include food or water contaminated with Salmonella spp., enterotoxigenic Escherichia coli, Shigella spp., Vibrio spp., Staphylococcus aureus, Clostridium perfringens, Cyclospora sp., and Trichinella spiralis.

Vaccine-Preventable Diseases on Cruises

Other than influenza, clusters of rubella and varicella have been investigated on cruises originating in the United States, highlighting the potential global dissemination of vaccine-preventable diseases through cruise travel.

• •During a cruise ship outbreak investigation of rubella, 11% of the crew was found to be acutely infected with or susceptible to rubella and 33% of passengers onboard were women of childbearing age—a high-risk group for congenital rubella syndrome if infected during pregnancy.
• •One investigation of varicella outbreak aboard a cruise ship found that 13% of the crew, most foreign-born from tropical countries, were either acutely infected or susceptible.
• •Vaccine administration to crew members without documented immunity to vaccine-preventable diseases and notification of all passengers at risk for exposure serve as important control measures.

Other Health Concerns

Injuries

• •Are among the most common reasons for passengers to seek medical care on cruise ships.
• •Account for about 18% of passenger infirmary visits.
• •Occurring most frequently on cruise ships include sprains, contusions, and superficial wounds.

Seasickness

• •Is also a common reason for cruise passenger infirmary visits.
• •May not be reduced by the central location of a cabin.
• •See the Motion Sickness section in Chapter 2 for more information.

Exacerbation of Chronic Conditions

• •
  Cruise ship travelers with chronic health conditions may experience complications due to—

  • ○
    Climatic variations
  • ○
    Environmental exposure to pollutants
  • ○
    Changes in diet and physical activity levels
  • ○
    An increased level of stress due to being in an unfamiliar environment
• •Special cruises are available for travelers with certain medical conditions, including persons on dialysis.

Preventive Measures for Cruise Ship Travelers

Due to multiple port visits and potential exposures, cruise ship travelers may be uncertain about which prevention medications, immunizations, and behaviors are appropriate for them and for their itineraries. Pre-travel advice for cruise ship travelers should include a complete review of the health status of the traveler, duration of travel, countries to be visited, and shore side activities. Box 6-1 summarizes recommendations for cruise travelers and health-care providers advising cruise travelers in pre-travel preparation and healthy behaviors during travel.

Box 6-1. Healthy cruise ship travel tips.

Considerations for Health-Care Professionals (During Pre-travel Consultation)

General:

• •Cruise ship itinerary, including planned activities at port stops.
• •Travelers' underlying medical conditions.

Vaccine-preventable diseases:

• •Routine age-specific vaccines.
• •Destination- and activity-specific recommendations or required vaccines. Note: Proof of yellow fever vaccine may be required for entry into certain countries.

Medications based on risk and need:

• •Antimalarial (consider risks at port stops).
• •Antiviral (for travelers at high risk of severe influenza).
• •Motion sickness medication.
• •Antibiotic for travelers' diarrhea.

Documentation:

• •Written summary of medical history-including pertinent diagnostics, such as EKG and chest x-ray, to facilitate overseas medical care should it be required.
• •Vaccines and prescriptions given.

Traveler Pre-Travel Preparations

• •Assess cruise ship medical facilities, sanitation scores, and presence of acute gastroenteritis outbreaks.
• •Cruise ship travelers with chronic diseases, special needs, or those who may require comprehensive medical care during travel should notify the cruise line of special needs before travel (e.g., wheelchair access, oxygen tank, and dialysis needs).
• •Ensure adequate medical insurance coverage for receiving health care overseas and medical evacuation (see the Travel Insurance and Evacuation Insurance section in Chapter 2).

Traveler Precautions During Travel

• •Wash hands often with soap and water. If soap and water are not available, use an alcohol-based gel containing at least 60% alcohol.
• •Practice respiratory hygiene by using a tissue to cover coughs and sneezes.
• •Take food and water precautions by eating foods that are thoroughly cooked and of appropriate temperature.
• •Prevent mosquito and other insect bites by using DEET or picaridin-containing repellents and clothing that provides complete coverage.
• •Use sun protection and drink plenty of water to avoid heat-related illness.
• •Other—avoid excessive alcohol, get plenty of rest, avoid contact with ill persons and report illnesses to cruise staff, and practice safe sex.

After Travel

Health-care providers can contribute to healthy cruise ship environments by questioning ill returned travelers about recent cruise vacations and promptly reporting any suspected communicable disease to public health authorities.

Contacts for concerns about illnesses on cruise ships:

• •
  GI illnesses concerns should be directed to CDC Vessel Sanitation Program—

  • ○
    Phone: 800-CDC-INFO (800-232-4636)
  • ○
    E-mail: CDCINFO@cdc.gov
• •Other illnesses suggestive of a communicable disease should be reported to the nearest CDC quarantine station with jurisdiction nearest to the cruise ship's port of arrival.

DEATH DURING TRAVEL

Clare A. Dykewicz, Xiaohong Mao Davis, Carl Lawson

Traveling abroad is an exciting event for many travelers. Fortunately, Americans die only rarely during international travel. Cardiovascular events, followed by injuries, have been the leading cause of deaths; in contrast, infectious diseases other than pneumonias have caused just 1% of deaths. Not surprisingly, injury-related deaths occur at a higher proportion abroad than in the United States (see the Injuries and Safety section in Chapter 2). In a recent review of injury-related deaths in U.S. travelers abroad, the most common causes of death were motor vehicle accidents, homicides, drowning, and suicides. This section provides some highlights regarding recommendations for preventing death during travel and explains regulations on the importation of human remains into the United States.

Recommendations for Preventing Death During Travel Abroad

Cardiovascular Events

• •Persons with known or suspected cardiovascular conditions—such as angina, congestive heart failure, arrhythmias, or hypertension—should refer to the Traveling with Chronic Medical Illnesses section in Chapter 8.
• •Persons with cardiovascular disease (as well as all other travelers) should consider purchasing supplemental insurance such as that covering trip cancellation, health care overseas and medical evacuation. The problem of deep vein thrombosis is receiving greater attention as it relates to travelers; see the Deep Vein Thrombosis and Pulmonary Embolism section in Chapter 2 for a complete review.

Motor Vehicle Injury

• •Travelers should be cautioned about the risks of motor-vehicle injuries during travel, including those caused by unfamiliar road environments, poorly maintained roads, and unavailable passenger restraints. This is especially important for travelers visiting less-developed countries.
• •Travelers should be advised to use seatbelts and child restraints, take mass transportation such as trains and subways whenever possible, avoid road travel at night, avoid drinking and driving, avoid speeding, and wear helmets when riding bicycles, mopeds, and motorcycles (see the Injuries and Safety section in Chapter 2).

Drowning

• •Travelers should be advised that the use of alcohol or illicit drugs may increase the risk of assault or injuries, including drowning. It is advisable for them to swim in areas supervised by a lifeguard if at all possible.
• •Personal flotation devices should be used by adults and children, while operating personal watercraft, and during whitewater boating, waterskiing, and sailboarding.

Homicide

The U.S. Department of State offers the following guidance for reduction of crime, including homicide. Travelers should take the following precautions:

• •Avoid drawing personal attention when traveling by not wearing expensive clothes or jewelry.
• •Carry as little baggage as possible, so movement can be quick and easy.
• •Leave valuables at home, or at least keep them well hidden.
• •Use travelers' cheques and credit cards rather than carrying large quantities of cash.
• •Avoid short cuts, narrow alleys, or poorly lit streets.
• •Do not travel alone at night.
• •Avoid discussing travel plans with strangers.
• •Never attend public demonstrations and civil disturbances.
• •Beware of pickpockets who might jostle or try to distract.
• •Know how to use a local telephone, and have emergency numbers readily available.
• •Give up valuables or car if confronted.
• •Keep hotel doors locked at all times and meet visitors in the lobby.
• •Do not get in an elevator alone with suspicious-looking persons.
• •Do not accept food or drink from strangers.

For detailed information on safety abroad, the State Department's website, Safe Trip Abroad, is extremely helpful (see http://travel.state.gov/travel/tips/safety/safety_1747.html). For additional assistance, U.S. Embassies or Consulates can give assistance or referrals to local services.

Suicide

• •Psychological problems are not uncommon in travelers, and often travel can precipitate problems that had been previously masked. See the Mental Health and Travel section in Chapter 2 for more detailed information. Fortunately, suicide can be prevented. People who are experiencing thoughts of suicide should get help as soon as possible.
• •
  The following signs and symptoms may indicate a person is suicidal:

  • ○
    Withdrawing from friends, family, and society
  • ○
    Anxiety, agitation, inability to sleep, or sleeping much more than usual
  • ○
    Dramatic mood changes
  • ○
    Rage, uncontrolled anger, and seeking revenge
  • ○
    Acting recklessly or engaging in risky activities, seemingly without thinking
  • ○
    Increasing alcohol or drug use
  • ○
    Feelings of hopelessness
  • ○
    Feeling trapped, like there's no way out
  • ○
    Feeling that there is no reason to live and having no sense of purpose in life

When U.S. Citizens Die Abroad

Obtaining U.S. Department of State Assistance

• •Family members of U.S. citizens who die abroad are advised to contact the nearest U.S. Consulate for assistance.
• •In case of emergencies abroad, the Office of Overseas Citizen Services in the Department of State's Bureau of Consular Affairs may be contacted from 8 am to 8 pm Eastern Time, Monday through Friday, by calling 888-407-4747 from the United States or Canada or 202-501-4444 if calling from overseas. For emergency assistance after working hours or on weekends and holidays, call the Department of State Switchboard at 202-647-4000 and ask to speak with the Overseas Citizens Duty Officer.

Importation of Human Remains

General Guidance

Persons wishing to import human remains, including cremated remains, into the United States must obtain clearance from CDC's Division of Global Migration and Quarantine (DGMQ).

• •Clearance can be obtained by presenting copies of the foreign death certificate and if needed, a CDC/DGMQ permit to the CDC Quarantine Station with jurisdiction for the U.S. port of entry.
• •A CDC/DGMQ permit may be needed to import human remains if the deceased is known or suspected to have died from a quarantinable communicable disease.
• •A copy of the foreign death certificate and the CDC/DGMQ permit must accompany the human remains at all times during shipment. The foreign death certificate should state the cause of death and must be translated into English.

The U.S. mortician handling the remains is subject to the regulations of state and local health authorities for interstate and intrastate shipment. The U.S. mortician handling the importation and disposition of the remains will afterwards submit a letter to CDC/DGMQ certifying that the human remains were imported, handled, and disposed of according to the terms of the CDC permit.

Human Remains of a Person Known or Suspected to Have Died from a Quarantinable Communicable Disease

Federal quarantine regulations (42 CFR Part 71) state that the remains of a person who is known or suspected to have died from a quarantinable communicable disease may not be brought into the United States unless the remains are—

• •properly embalmed and placed in a hermetically sealed casket,
• •cremated, or
• •accompanied by a permit issued by the CDC Director.

Quarantinable communicable diseases include cholera; diphtheria, infectious tuberculosis; plague; smallpox, yellow fever; viral hemorrhagic fevers (Lassa, Marburg, Ebola, Congo-Crimean, or others not yet isolated or named); severe acute respiratory syndrome (SARS); and influenza caused by novel or re-emergent influenza viruses that are causing or have the potential to cause a pandemic.

A CDC permit may be required when the remains are not embalmed or cremated, especially if the person is suspected or known to have died from a communicable disease.

• •If a CDC permit is obtained for importation of human remains, CDC may impose additional conditions for importation beyond those listed above.
• •Permits for importation of human remains may be obtained through CDC/DGMQ by calling 866-694-4867 or the CDC Director's Emergency Operation's Center at 770-488-7100.

Human Remains of a Person Who Died of a Nonquarantinable Communicable Disease

Federal regulations also give CDC the authority to restrict the importation of the remains of a person who died of a nonquarantinable communicable disease when necessary to prevent the spread of communicable disease.

Human Remains of a Person Who Died of a Noncommunicable Disease

CDC places no restrictions on the importation of the remains of a person who died of a noncommunicable disease, although other federal, state, or local regulations may apply.

Exportation of Human Remains

CDC places no restrictions on the exportation of human remains outside the United States, although other federal, state, and local regulations may apply. Travelers should also be advised that the requirements of the country of destination must be met. Information regarding these requirements may be obtained from the appropriate foreign embassy or consulate.

TAKING ANIMALS ACROSS INTERNATIONAL BORDERS

G. Gale Galland, Robert J. Mullan, Heather Bair-Brake

Travelers should be advised that CDC restricts the importation of animals that may pose an infectious disease threat to humans. These restrictions apply to some pets, such as dogs and cats, as well as turtles, nonhuman primates, African rodents, birds, civets, bats, and other animals and animal products capable of causing human disease (see www.cdc.gov/yellowbook/AnimalImportation and www.cdc.gov/yellowbook/AnimalFaq).

Upon return, animals taken out of the United States are subject to the same regulations as those entering for the first time. The U.S. Department of Agriculture (USDA) and the U.S. Fish and Wildlife Service (FWS) also have jurisdiction over the importation of some animals. States may have additional restrictions on the importation of animals (see www.agr.wa.gov/FoodAnimal/AnimalHealth/StateVets.htm for additional information).

Health Certificates

• •CDC regulations do not require general health certificates for animals (including dogs or cats) entering the United States
• •Health certificates may be required for entry into some states
• •Health certificates may be required by airlines for pet travel
• •Travelers should check with officials in their state of destination and with the airline prior to the travel date

Dogs

Dogs are subject to inspection and may be denied entry into the United States if they have evidence of an infectious disease that can be transmitted to humans. If a dog appears to be ill, further examination by a licensed veterinarian at the owner's expense may be required before entry.

Unless a dog is being imported from a country considered “rabies-free” by the World Health Organization (see Table 2-16), it must be accompanied by a valid rabies vaccination certificate that includes the following information:

• •The breed, sex, age, color, markings, and other identifying information
• •A vaccination date at least 30 days before importation
• •A vaccination date reflecting that the dog was at least 3 months of age at the time of vaccination
• •The vaccination expiration date (if not shown, the date of vaccination must be within 12 months of date of importation)
• •The signature of a licensed veterinarian

A dog not accompanied by a current rabies vaccination certificate may be admitted provided the importer completes a confinement letter agreeing to the following:

• •Dogs must be kept confined at a place of the owner's choosing, including their home until proper rabies vaccination is obtained. Confinement is defined as isolation away from other animals and people except for contact necessary for the dog's care. If the dog is allowed out of its enclosure, the owner must muzzle the dog and use a leash.
• •The dog must be vaccinated within 4 days of arrival at its destination and remain in confinement for at least 30 days after the date of vaccination.
• •The dog may not be sold or transferred from the responsibility of the importer during the time of confinement.
• •A copy of the confinement agreement (Form CDC 75.37) can be found on the CDC website at www.cdc.gov/yellowbook/ConfinementAgreement.
• •Puppies <3 months of age are not considered old enough for rabies vaccination. Puppies <3 months of age may be admitted provided the importer completes a confinement agreement, vaccinates the animal at 3 months of age, and keeps the animal in confinement for at least 30 days after vaccination.
• •Routine rabies vaccination of dogs is recommended in the United States and required by most state and local health authorities.
• •Check with state authorities at the final destination to determine the local requirements for rabies vaccination.
• •All pet dogs arriving in the state of Hawaii and the territory of Guam, even from the U.S. mainland, are subject to locally imposed quarantine requirements. For more information, consult http://hawaii.gov/hdoa/ai/aqs/info or call 808-483-7151 (Hawaii), or see http://k9.gov.gu/or call 671-475-1426 (Guam).

Cats

• •Cats are subject to inspection at ports of entry and may be denied entry into the United States if they have evidence of an infectious disease that can be transmitted to humans. If a cat appears to be ill, further examination by a licensed veterinarian at the owner's expense may be required at the port of entry.
• •Cats are not required to have proof of rabies vaccination for importation into the United States.
• •States may require rabies vaccination for cats, so it is a good idea to check with state and local health authorities at the final destination.
• •All pet cats arriving in the state of Hawaii and the territory of Guam, even from the U.S. mainland, are subject to locally imposed quarantine requirements. For more information, consult http://hawaii.gov/hdoa/ai/aqs/info or call 808-483-7151 (Hawaii), or see http://k9.gov.gu/or call 671-475-1426 (Guam).

Other Animals, Animal Products, and Vectors

Nonhuman Primates (Monkeys, Apes, etc.)

• •
  Nonhuman primates can transmit a variety of serious diseases to humans, including Ebola and tuberculosis. Nonhuman primate entry into the United States is restricted, see—

  • ○
    www.cdc.gov/yellowbook/AnimalFaq
  • ○
    www.cdc.gov/yellowbook/Primates
• •Nonhuman primates may only be imported into the United States by a CDC registered importer and only for scientific, educational, or exhibition purposes. Nonhuman primates may not be imported as pets.
• •All nonhuman primates are considered endangered or threatened and require additional permits issued by FWS for import. More information is available at www.fws.gov/le/Travelers/TipsforTravelers.htm.
• •Nonhuman primates that leave the United States may only return through a registered importer and only if they are imported for science, education, or exhibition.

Turtles

• •
  Turtles can transmit Salmonella to humans, and because small turtles are often kept as pets, restrictions apply to their importation. More information is available at—

  • ○
    www.cdc.gov/yellowbook/AnimalFaq
  • ○
    www.cdc.gov/yellowbook/FederalRegs42CFR71
• •An individual may import no more than six viable turtle eggs or six live turtles with a carapace (shell) length of less than 4 inches.
• •Seven or more turtles may be imported with permission from CDC and only for scientific, educational, or exhibition purposes.
• •CDC has no restrictions on the importation of live turtles with a carapace length ≥4 inches. Check with USDA or U.S. Fish and Wildlife regarding additional requirements to import turtles.

African Rodents and Civets

• •
  To reduce the risk of introducing monkeypox and the SARS-coronavirus, live African rodents and civets, as well as potentially infectious products made from these animals, may not be imported into the United States. More information is available at—

  • ○
    www.cdc.gov/ncidod/monkeypox/embargoqa.htm
  • ○
    http://edocket.access.gpo.gov/2003/03-27557.htm
• •Exceptions may be made for scientific, exhibition, or educational purposes with a valid permit issued by CDC.
• •African rodent and civet products that have been processed in a way to render them noninfectious do not require CDC permission for importation; however, these items should be accompanied by a statement indicating how they have been treated to render them noninfectious.

Birds from Countries with Highly Pathogenic Avian Influenza (H5N1)

• •To reduce the risk of introducing highly pathogenic avian influenza (HPAI) H5N1 into the United States, CDC restricts the importation of birds and unprocessed bird products from countries where HPAI H5N1 has been confirmed in poultry (see www.cdc.gov/flu/avian/outbreaks/embargo.htm).
• •Current details on the countries affected by the CDC restrictions may be found at www.cdc.gov/flu/avian/outbreaks/embargo.htm.
• •These restrictions are subject to change at any time, depending on the current situation regarding the geographic range of this disease in birds and other animals, and the virus' transmissibility.
• •USDA maintains similar restrictions. The CDC and USDA import restrictions allow U.S.-origin pet birds to return following quarantine for 30 days at a USDA facility. CDC and USDA allow import of processed bird products that have been rendered noninfectious. These products must be accompanied by a USDA permit and government certification confirming that the products were treated according to USDA requirements.

Bats

• •Bats have been shown to be reservoirs of many viruses that can infect humans, including rabies virus, Nipah virus, SARS-coronavirus, and others. To reduce the risk of introducing these viruses, the importation of all live bats requires a permit from CDC.
• •Because they may be endangered species, bats also require additional permits issued by FWS. The applications for a CDC import permit for these animals can be found at www.cdc.gov/yellowbook/bats.

Other Animals, Trophies, Animal Products, and Vectors

• •
  Certain live animals, hosts, or vectors of human disease, including insects, biological materials, tissues, and other unprocessed animal products, may pose an infectious disease risk to humans and be restricted from entry.

  • ○
    For example, goatskin souvenirs (such as goatskin drums) from Haiti have been associated with human anthrax cases, and CDC restricts these items from entry into the United States.
  • ○
    Potentially infectious nonhuman primate trophies may be imported only with a permit issued by CDC and must be taken to a USDA-licensed taxidermist for processing. More information on import restrictions for nonhuman primate trophies may be found at www.cdc.gov/od/ohs/biosfty/IP_NHP_Guidance013004.pdf.
• •In some circumstances, restricted items may be admitted with a permit from CDC for scientific, educational or exhibition purposes (see www.cdc.gov/od/eaipp/).

Measures at Ports of Entry

The goal of these restrictions is to prevent the importation into the United States of communicable diseases transmissible from animals to humans or other animals. Persons who violate these requirements may be subject to criminal and/or civil penalties. For additional information regarding importation of these animals, travelers should be advised to contact CDC, Attention: Division of Global Migration and Quarantine, Mailstop E03, Atlanta, Georgia 30333 (404-639-3441), or visit www.cdc.gov/yellowbook/AnimalFaq.

Travelers planning to import horses, ruminants, swine, poultry, birds, and dogs used for handling livestock should be advised to contact the USDA Animal Plant Health Inspection Service (301-734-8364) or at www.aphis.usda.gov regarding additional requirements.

Travelers planning to import fish, reptiles, spiders, wild birds, rabbits, bears, wild members of the cat family, or other wild or endangered animals should be advised to contact FWS (800-358-1949) or at www.fws.gov/le.

Traveling Abroad with a Pet

Travelers planning to take a companion animal to a foreign country should be advised to meet the entry requirements of the country of destination and transportation guidelines of the airline. To obtain this information, travelers should contact the country's embassy in Washington, D.C., or the nearest consulate (see www.state.gov/s/cpr/rls/fco/).

There are several ways to travel with a companion animal. The animal may be allowed in the cabin if it meets certain size and weight restrictions, may be checked in with luggage, or may be placed into cargo. Travelers intending to bring their pets onboard with them should check with the airline for space and size/weight restrictions. For the health of the animal, pets are allowed to travel in checked luggage or cargo only if weather conditions permit. The airline will be able to help determine the best dates and times for traveling with pets.