Country specific information - RationaleEpidemiological rationale for recommendations
The disease information that follows details the rationale and resources used for the NaTHNaC country specific recommendations.
NaTHNaC monitors and continues to respond to disease outbreaks posting information on the Outbreak Surveillance section of the website and will update country specific recommendations accordingly.
Cholera is considered to represent a potential risk to travellers if:
- a country had reported ≥100 cases to the WHO in at least 3 out of 5 years, 2010 to 2014 inclusive;
- a country had reported an outbreak of ≥1000 cases to the WHO in at least one year, 2010 to 2014 inclusive.
When there had been sporadic or absent reporting to WHO between 2010 and 2014, a consensus opinion was formed based on consideration of available data, and whether the country borders an country endemic for cholera [1,2].
Last updated: September 2016
Review in progress: coming soon
NaTHNaC country specific vaccine recommendations were based on the 2010, the World Health Organization (WHO) “The Global Prevalence of Hepatitis A Virus Infection and Susceptibility publication which classifies countries with different burdens of Hepatitis A disease. For countries with a high burden of hepatitis A disease, the recommendation was for most travellers to receive Hepatitis A vaccine; vaccine was not recommended for low burden countries.
For those countries with a burden of hepatitis A disease classified as “medium” or “low-medium”, two additional factors were considered to assess the need for a vaccine recommendation: sanitation levels in rural populations, and the economic development of that country.
Countries were divided into two groups based on the percentage of the rural population without access to improved sanitation as detailed in the WHO Progress on Drinking Water and Sanitation Report 2014:
(a) < 90% of rural population with access to improved sanitation
(b) ≥ 90% of rural population with access to improved sanitation
(2) Economic Development:
The World Bank classifies economies as low-income, middle-income (subdivided into lower-middle and upper-middle), or high-income based on gross national income (GNI) per capita. Countries with a high GNI per capita were classified as high economic development countries.
Using these additional sanitation and economic factors:
a. for countries with medium or low-medium burden of hepatitis A, high economic development, and ≥ 90% of the rural population with access to improved sanitation vaccine was recommended for some travellers.
b. for all other countries with medium or low-medium burden of Hepatitis A disease, vaccine was recommended for most travellers.
When there had been sporadic, absent or conflicting reports, national authorities were consulted and a consensus opinion was formed based on consideration of any additional available data for that country.
Last updated: August 2015
NaTHNaC vaccine recommendations have been made for countries where 2% or more of the population were known to be persistently infected with the hepatitis B virus (intermediate/high prevalence) [3-5]. When there was limited information about those who are persistently infected with the virus in a country, a consensus opinion was formed based on consideration of the available data.
Last updated: July 2014
Review in progress: coming soon
NaTHNaC country specific vaccine recommendations for meningococcal ACWY have made based on whether a country lies within the meningitis “belt” of sub-Saharan Africa, as defined by the World Health Organization. Additional vaccine recommendations for Saudi Arabia were made in accordance with the requirements of the Ministry of Health of the Kingdom of Saudi Arabia for those who will perform Hajj or Umrah, or undertake seasonal work.
Last updated: April 2014
NaTHNaC monitors the global polio situation, as detailed by the Global Polio Eradication Initiative and World Health Organization, and makes changes to country specific recommendations as new information becomes available.
NaTHNaC recommends that travellers visiting countries where cases of wild type polio have been reported since January 2012 should receive a booster dose of polio-containing vaccine if they have not received one within the past 10 years.
NaTHNaC also recommends that travellers to countries reporting wild type poliovirus in environmental samples in the last year or have reported circulating vaccine derived polio virus usually should receive a booster dose of polio-containing vaccine if they have not received one within the past 10 years.
When an environmental VDPV is reported in a country without human cases, expert advice will be sought to consider immunisation coverage and surveillance and whether a recommendation needs to change.
In addition, some countries have specific polio vaccination and certificate requirements.
Last updated: August 2016
NaTHNaC identified countries where rabies was currently a risk by reviewing data from the World Animal Health Information Database (OIE) 2011- 2012 and where country data was available in 2013. Reports on the Outbreak Surveillance database were reviewed regarding known or presumed cases in indigenous domestic and/or wild animals. Where data was lacking for a country, other verifiable sources were sought including personal communications with the national authorities. Where no or limited data was available, a consensus opinion was formed based upon the best available evidence.
Last updated: July 2014
NaTHNaC reviewed available information in order to identify countries where schistosomiasis may pose a risk to travellers. The primary resource used was the World Health Organization (WHO) report on the status of schistosomiasis in endemic countries in 2012 [6,7]. Where reporting was sporadic or absent, consensus expert opinion was formed based on consideration of available data.
NaTHNaC country specific recommendations for Tick-borne encephalitis (TBE) have been based on:
- Cases reported in humans and animals
- Serological data in humans and animals
- TBE virus in identified ticks
- National surveillance and TBE vaccination programmes
In addition, information about habitats, latitudinal, altitudinal limits and proximity to known outbreak areas where used to guide the interpretation of the epidemiological data. Were limited information was available for a country, vaccine recommendations were formed by consensus opinion, based on the most recent available information.
Countries with widespread or localised risk areas considered to have a high risk of TBE infection
Human cases are reported annually, but there is a national vaccination programme: vaccination is recommended for some travellers. For some countries with sparse data, higher risk was assumed due to a country’s existing NaTHNaC classification.
Countries with a low risk of TBE infection and surveillance or unknown surveillance programmes
Sporadic human cases are reported: vaccination is not usually advised, but if being considered specialist advice should be sought.
Countries with a possible risk of TBE infection
No human cases have been reported, but either human sero-survey data or non-human TBE virus circulation has been identified and the country is adjacent to a known risk area: tick bite avoidance is recommended.
Amicizia, D., Domnich, A., Panatto, D., Lai, P.L., Cristina, M.L., Avio, U., Gasparini, R., 2013. Epidemiology of tick-borne encephalitis (TBE) in Europe and its prevention by available vaccines. Hum. Vaccines Immunother. 9, 1163–1171.
Briggs, B.J., Atkinson, B., Czechowski, D.M., Larsen, P.A., Meeks, H.N., Carrera, J.P., Duplechin, R.M., Hewson, R., Junushov, A.T., Gavrilova, O.N., Breininger, I., Phillips, C.J., Baker, R.J., Hay, J., 2011. Tick-borne encephalitis virus, Kyrgyzstan. Emerg. Infect. Dis. 17, 876–879.
Bundesamt für Gesundheit, 2016. Zeckenübertragene Krankheiten. Available at http://www.bag.admin.ch/themen/medizin/00682/00684/06330/ Accessed 14 July 2016
Elyan, D.S., Moustafa, L., Noormal, B., Jacobs, J.S., Aziz, M.A., Hassan, K.S., Wasfy, M.O., Monestersky, J.H., Oyofo, B.A., 2014. Serological evidence of Flaviviruses infection among acute febrile illness patients in Afghanistan. J. Infect. Dev. Ctries. 8, 1176–1180.
Ergünay, K., Saygan, M.B., Aydoğan, S., Litzba, N., Sener, B., Lederer, S., Niedrig, M., Hasçelik, G., Us, D., 2011. Confirmed exposure to tick-borne encephalitis virus and probable human cases of tick-borne encephalitis in Central/Northern Anatolia, Turkey. Zoonoses Public Health 58, 220–227.
EU Commission, 2012. COMMISSION IMPLEMENTING DECISION of 8 August 2012 amending Decision 2002/253/EC laying down case definitions for reporting communicable diseases to the Community network under Decision No 2119/98/EC of the European Parliament and of the Council. Available at https://ec.europa.eu/health/communicable_diseases/early_warning/comm_legislation_en . Accessed 27 April 2017.
European Centre for Disease Prevention and Control, 2012. Epidemiological situation of tick-borne encephalitis in the European Union and European Free Trade Association countries. Stockholm. Available at: http://ecdc.europa.eu/en/publications/Publications/TBE-in-EU-EFTA.pdf. Accessed 27 April 2017.
Folkehelseinstituttet, 2016. Vaksinasjon mot skogflåttencefalitt (TBE). Folkehelseinstituttet. Available at http://www.fhi.no/nyheter/2016/vaksinasjon-mot-skogflattencefalitt-tbe2/ Accessed 25 July 2016.
Hay, J., Yeh, K.B., Dasgupta, D., Shapieva, Z., Omasheva, G., Deryabin, P., Nurmakhanov, T., Ayazbayev, T., Andryushchenko, A., Zhunushov, A., Hewson, R., Farris, C.M., Richards, A.L., 2016. Biosurveillance in Central Asia: Successes and Challenges of Tick-Borne Disease Research in Kazakhstan and Kyrgyzstan. Front. Public Health 4.
Heinz, F.X., Stiasny, K., Holzmann, H., Grgic-Vitek, M., Kriz, B., Essl, A., Kundi, M., 2013. Vaccination and Tick-borne Encephalitis, Central Europe. Emerg. Infect. Dis. 19, 69–76.
Herpe, B., Schuffenecker, I., Pillot, J., Malvy, D., Clouzeau, B., Bui, N., Vargas, F., Gruson, D., Zeller, H., Lafon, M.E., Fleury, H., Hilbert, G., 2007. Tickborne encephalitis, southwestern France. Emerg. Infect. Dis. 13, 1114–1116.
Hrnjakovic-Cvjetkovic, I., Cvjetkovic, D., Patic, A., Radovanov, J., Kovacevic, G., Milosevic, V., 2016. Tick-borne encephalitis virus infection in humans. Med. Pregl. 69, 93–98.
Kentaro, Y., Yamazaki, S., Mottate, K., Nagata, N., Seto, T., Sanada, T., Sakai, M., Kariwa, H., Takashima, I., 2013. Genetic and biological characterization of tick-borne encephalitis virus isolated from wild rodents in southern Hokkaido, Japan in 2008. Vector Borne Zoonotic Dis. 13, 406–414.
Kim, S.-Y., Yun, S.-M., Han, M.G., Lee, I.Y., Lee, N.Y., Jeong, Y.E., Lee, B.C., Ju, Y.R., 2008. Isolation of tick-borne encephalitis viruses from wild rodents, South Korea. Vector Borne Zoonotic Dis. 8:7–13.
Kuchuloria, T., Imnadze, P., Mamuchishvili, N., Chokheli, M., Tsertsvadze, T., Endeladze, M., Mshvidobadze, K., Gatserelia, L., Makhviladze, M., Kanashvili, M., Mikautadze, T., Nanuashvili, A., Kiknavelidze, K., Kokaia, N., Makharadze, M., Clark, D.V., Bautista, C.T., Farrell, M., Fadeel, M.A., Maksoud, M.A., Pimentel, G., House, B., Hepburn, M.J., Rivard, R.G., 2016. Hospital-Based Surveillance for Infectious Etiologies Among Patients with Acute Febrile Illness in Georgia, 2008-2011. Am. J. Trop. Med. Hyg. 94, 236–242.
Kunze, U., 2016a. Tick-borne encephalitis-still on the map: Report of the 18th annual meeting of the international scientific working group on tick-borne encephalitis (ISW-TBE). Ticks Tick-Borne Dis. 7, 911–914.
Kunze, U., 2016b. The International Scientific Working Group on Tick-Borne Encephalitis (ISW TBE): Review of 17 years of activity and commitment. Ticks Tick-Borne Dis. 7, 399–404.
Markovinović, L., Kosanović Ličina, M.L., Tešić, V., Vojvodić, D., Vladušić Lucić, I., Kniewald, T., Vukas, T., Kutleša, M., Krajinović, L.C., 2016. An outbreak of tick-borne encephalitis associated with raw goat milk and cheese consumption, Croatia, 2015. Infection 44, 661–665.
Mohareb, E., Christova, I., Soliman, A., Younan, R., Kantardjiev, T., 2013. Tick-borne encephalitis in Bulgaria, 2009 to 2012. Euro Surveill. Bull. Eur. Sur Mal. Transm. Eur. Commun. Dis. Bull. 18.
National Institute for Health and Welfare, 2014. Infectious diseases in Finland 2013. Helsinki. Available at https://www.julkari.fi/bitstream/handle/10024/125566/URN_ISBN_978-952-302-194-5.pdf?sequence=1. Accessed 27 April 2017.
Pavlidou, V., Geroy, S., Diza, E., Antoniadis, A., Papa, A., 2007. Epidemiological study of tick-borne encephalitis virus in northern Greece. Vector Borne Zoonotic Dis. 7, 611–615.
Raguet, Couturier, 2016. Étude ALSA(CE)TIQUE 2014-2015. Principaux résultats descriptifs. Santé publique France. Available at http://invs.santepubliquefrance.fr/Publications-et-outils/Rapports-et-syntheses/Maladies-infectieuses/2017/Etude-ALSA-CE-TIQUE-2014-2015.-Principaux-resultats-descriptifs. Accessed 27 April 2017.
Rezza, G., Farchi, F., Pezzotti, P., Ruscio, M., Lo Presti, A., Ciccozzi, M., Mondardini, V., Paternoster, C., Bassetti, M., Merelli, M., Scotton, P.G., Luzzati, R., Simeoni, J., Mian, P., Mel, R., Carraro, V., Zanin, A., Ferretto, R., Francavilla, E., TBE Virology Group, 2015. Tick-borne encephalitis in north-east Italy: a 14-year retrospective study, January 2000 to December 2013. Euro Surveill. Bull. Eur. Sur Mal. Transm. Eur. Commun. Dis. Bull. 20.
Rijksinstituut voor Volksgezondheid en Milieu, 2016. Patiënt ziek door teken-encefalitisvirus Available at http://www.rivm.nl/Documenten_en_publicaties/Algemeen_Actueel/Nieuwsberichten/2016/Pati%C3%ABnt_ziek_door_teken_encefalitisvirus. Accessed 27 April 2017.
Roelandt, S., Suin, V., Riocreux, F., Lamoral, S., Van der Heyden, S., Van der Stede, Y., Lambrecht, B., Caij, B., Brochier, B., Roels, S., Van Gucht, S., 2014. Autochthonous Tick-Borne Encephalitis Virus-Seropositive Cattle in Belgium: A Risk-Based Targeted Serological Survey. Vector-Borne Zoonotic Dis. 14, 640–647.
Schuler, M., Zimmermann, H., Altpeter, E., Heininger, U., 2014. Epidemiology of tick-borne encephalitis in Switzerland, 2005 to 2011. Eurosurveillance 19, 20756.
Statens Serum Institut, 2016. TBE (Tick Borne Encephalitis) - Statens Serum Institut. Available at http://www.ssi.dk/service/sygdomsleksikon/t/tbe.aspx. Accessed 27 April 2017.
Steffen, R., 2016. Epidemiology of tick-borne encephalitis (TBE) in international travellers to Western/Central Europe and conclusions on vaccination recommendations. J Travel Med. 17, 23(4).
Süss, J., 2011. Tick-borne encephalitis 2010: epidemiology, risk areas, and virus strains in Europe and Asia-an overview. Ticks Tick-Borne Dis. 2, 2–15.
Weststrate, A.C., Knapen, D., Laverman, G. D., Schot, B., Prick, J. J., Spit, S. A., Reimerink, J., Rockx, B., Geeraedts, F., 2017. Increasing evidence of tick-borne encephalitis (TBE) virus transmission, the Netherlands, June 2016. Eurosurveillance 22.
Wu, X.-B., Na, R.-H., Wei, S.-S., Zhu, J.-S., Peng, H.-J., 2013. Distribution of tick-borne diseases in China. Parasit. Vectors 6, 119.
Yoshii, K., Mottate, K., Omori-Urabe, Y., Chiba, Y., Seto, T., Sanada, T., Maeda, J., Obara, M., Ando, S., Ito, N., Sugiyama, M., Sato, H., Fukushima, H., Kariwa, H., Takashima, I., 2011. Epizootiological Study of Tick-Borne Encephalitis Virus Infection in Japan. J. Vet. Med. Sci. 73, 409–412.
Last updated: April 2017
There is an increased risk of acquiring tuberculosis in countries where the annual incidence of all forms of tuberculosis (TB) is ≥40 cases per 100,000 population. Further information is available here.
NaTHNaC reviewed the average annual incidence of tuberculosis between 2012 and 2014 from the World Health Organization (WHO).
Some travellers may be recommended to receive BCG vaccination when a country has:
- reported an average annual incidence of tuberculosis of ≥40 cases per 100,000 population in the last five years
- reported an annual incidence of tuberculosis of ≥40 cases per 100,000 population at least once in the last five years
Where no or limited data was available for a country, expert consensus opinion is formed using the best available information. If the annual incidence is presumed to be ≥40 cases per 100,000 population, there is a recommendation for vaccination for some travellers to that country.
Last updated: November 2016
NaTHNaC typhoid vaccine recommendations were based on a review of country specific burden of typhoid disease using available resources [8,9] and Public Health England imported typhoid disease data. Where information was unavailable, the national authorities of a country were contacted for information and a consensus opinion was formed based on consideration of all available data for that country.
Last updated: August 2015
Country specific recommendations are based on collaborations with Public Health England and Centers for Disease Control, Atlanta (Hepatitis A).
First Published : 15 Oct 2015
Last Updated :  27 Apr 2017
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