Country specific information - Rationale

Epidemiological rationale for recommendations Country specific information - Rationale

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.

Biting insects or ticks

Regional information about biting insects and ticks that transmit infections including African tick bite fever, Chikungunya, Crimean Congo haemorrhagic fever, leishmaniasis, Murray Valley encephalitis Rift Valley fever, Ross River virus, scrub typhus, trypanosomiasis and West Nile virus are included on the "other risk " section of the country information pages where appropriate.

A regional disease risk is included on a country information page, when there are reports of that disease in at least one country of that United Nations standard geographical sub-region according to the World Health Organization, national authorities or other verified sources.

  1. World Health Organization. Distribution of Crimean Congo Haemorrhagic Fever 2015
  2. World Health Organization. Chikungunya countries or areas at risk 2015
  3. Epidemiological update: West Nile virus transmission season in Europe, 2017
  4. Centers for Disease Control. West Nile Virus: Statistics and Maps
  5. Government of Canada: Surveillance of West Nile Virus
  6. World Health Organization. West Nile Virus Fact Sheet
  7. Pan American Health Organization. West Nile Virus
  8. Pan American Health Organization. West Nile Virus: Epidemiological Alerts and Updates
  9. New South Wales Government. Department of Primary Industries. West Nile virus in Australia
  10. World Health Organization. Rift Valley fever fact sheet
  11. Bosworth A et al (2016). Serologic evidence of exposure to Rift Valley fever virus detected in Tunisia. New Microbe and New Infect 2016; 9: 1–7. Accessed 23 July2018.
  12. Fontenille D et al (1998). New Vectors of Rift Valley Fever in West Africa. Emerging infectious diseases. Volume 4, Number 2—June. Accessed 23 July2018
  13.  Nakouné E et al (2016). Rift Valley Fever Virus Circulating among Ruminants, Mosquitoes and Humans in the Central African Republic. PLOS Neglected Tropical Diseases Oct 19;10(10)
  14. World Health Organization. Mapping the distribution of human African trypanosomiasis
  15. Franco JR et al 2017. PLOS Neglected Tropical Diseases. Monitoring the elimination of human African trypanosomiasis: Update to 2014. PLOS Neglected Tropical diseases 11(5). Accessed 23 July2018
  16. World Health Organization. Global Health Observatory data: Leishmaniasis
  17. Gondard M et al. Ticks and Tick-Borne Pathogens of the Caribbean: Current understanding and future directions for more comprehensive surveillance. Frontiers in Cellular and Infection Microbiology. 7;490. 1-16. Accessed 23 July 2018
  18. Xu G et al. A review of the global epidemiology of scrub typhus. PLoS Negl Trop Dis. November 3, 2017. Accessed 23 July 2018
  19. Mackenzie JS et al. The ecology and epidemiology of Ross River and Murray Valley encephalitis viruses in Western Australia: examples of One Health in Action. Trans Roy Soc Trop Med & Hyg 2017. Accessed 23 July 2018

Last Updated: July 2018


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, 2013 to 2017 inclusive;
  • a country had reported an outbreak of ≥1000 cases to the WHO in at least one year, 2013 to 2017 inclusive.

When there had been sporadic or absent reporting to WHO between 2013 and 2017, a consensus opinion regarding risk was formed based on consideration of available data, including Public Health England data on imported cholera cases to the UK and World Health Organization water progress on household drinking water, sanitation and hygiene 2000-2017 [2].

  1. World Health Organization. Weekly epidemiological record: cholera 2017 [Accessed 3 October, 2019]
  2. World Health Organization. Progress on household drinking water, sanitation and hygiene 2000-2017

Last Updated: October 2019


NaTHNaC dengue recommendations are based on the Center for Disease Control review of 2005-2015 data [1]. In addition, a literature review of published data from January 2016 to March 2017 was completed [2-13] and data on travel-associated cases in the UK, 2012-2016, were reviewed. Both reviews focussed on evidence of local mosquito-borne dengue transmission. For part-endemic countries, further sub-national details have been provided where confirmed.

  1. Jentes, E.S. et al. (2016) Evidence-based risk assessment and communication: a new global dengue-risk map for travellers and clinicians. J. Travel Med. 23.
  2. Al-Azraqi, T.A., El Mekki, A.A., Mahfouz, A.A., 2013. Seroprevalence of dengue virus infection in Aseer and Jizan regions, Southwestern Saudi Arabia. Trans. R. Soc. Trop. Med. Hyg. 107, 368–371.
  3. Chinikar, S., Ghiasi, S.M., Shah-Hosseini, N., Mostafavi, E., Moradi, M., Khakifirouz, S., Rasi Varai, F.S., Rafigh, M., Jalali, T., Goya, M.M., Shirzadi, M.R., Zainali, M., Fooks, A.R., 2013. Preliminary study of dengue virus infection in Iran. Travel Med. Infect. Dis. 11, 166–169.
  4. Gonidec, E.L., Maquart, M., Duron, S., Savini, H., Cazajous, G., Vidal, P.-O., Chenilleau, M.-C., Roseau, J.-B., Benois, A., Dehan, C., Kugelman, J., Leparc-Goffart, I., Védy, S., 2016. Clinical Survey of Dengue Virus Circulation in the Republic of Djibouti between 2011 and 2014 Identifies Serotype 3 Epidemic and Recommends Clinical Diagnosis Guidelines for Resource Limited Settings. PLoS Negl. Trop. Dis. 10, e0004755.
  5. Humphrey, J.M., Cleton, N.B., Reusken, C.B.E.M., Glesby, M.J., Koopmans, M.P.G., Abu-Raddad, L.J., 2016. Dengue in the Middle East and North Africa: A Systematic Review. PLoS Negl. Trop. Dis. 10, e0005194.
  6. Jentes, E.S., Lash, R.R., Johansson, M.A., Sharp, T.M., Henry, R., Brady, O.J., Sotir, M.J., Hay, S.I., Margolis, H.S., Brunette, G.W., 2016. Evidence-based risk assessment and communication: a new global dengue-risk map for travellers and clinicians. J. Travel Med. 23.
  7. Kraemer, M.U.G., Sinka, M.E., Duda, K.A., Mylne, A., Shearer, F.M., Brady, O.J., Messina, J.P., Barker, C.M., Moore, C.G., Carvalho, R.G., Coelho, G.E., Bortel, W.V., Hendrickx, G., Schaffner, F., Wint, G.R.W., Elyazar, I.R.F., Teng, H.-J., Hay, S.I., 2015. The global compendium of Aedes aegypti and Ae. albopictus occurrence. Sci. Data 2.
  8. Neumayr, A., Muñoz, J., Schunk, M., Bottieau, E., Cramer, J., Calleri, G., López-Vélez, R., Angheben, A., Zoller, T., Visser, L., Serre-Delcor, N., Genton, B., Castelli, F., Van Esbroeck, M., Matteelli, A., Rochat, L., Sulleiro, E., Kurth, F., Gobbi, F., Norman, F., Torta, I., Clerinx, J., Poluda, D., Martinez, M., Calvo-Cano, A., Sanchez-Seco, M.P., Wilder-Smith, A., Hatz, C., Franco, L., 2017. Sentinel surveillance of imported dengue via travellers to Europe 2012 to 2014: TropNet data from the DengueTools Research Initiative. Eurosurveillance 22.
  9. PAHO, 2017. PAHO WHO | Dengue | PAHO/WHO Data, Maps and Statistics [WWW Document]. (accessed 18.12.17).
  10. ProMED, 2015. DENGUE FEVER - MAURITANIA (03): (NOUAKCHOT) [WWW Document]. ProMED-Mail Post Middle EastNorth Afr. (accessed 5.19.17).
  11. Rezza, G., 2016. Dengue and other Aedes -borne viruses: a threat to Europe? Eurosurveillance 21.
  12. Shi, L., Fu, S., Wang, L., Li, X., Gu, D., Liu, C., Zhao, C., He, J. ’an, Liang, G., 2016. Surveillance of mosquito-borne infectious diseases in febrile travelers entering China via Shenzhen ports, China, 2013. Travel Med. Infect. Dis. 14, 123–130.
  13. van Dodewaard, C.A.M., Richards, S.L., 2015. Trends in Dengue Cases Imported into the United States from Pan America 2001–2012. Environ. Health Insights 9, 33–40.

Last Updated: December 2017

Hepatitis A

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”, the additional factor of sanitation levels in rural populations was considered to assess the need for a vaccine recommendation.

Vaccine was recommended for some travellers to a country, if the percentage of the rural population with access to improved sanitation was ≥ 80% as detailed in the WHO Progress on Drinking Water and Sanitation Report 2015.

All other countries with medium or low-medium burden of Hepatitis A disease, where the access to improved sanitation was < 80%, vaccine was recommended for most travellers.

When there had been sporadic, absent or conflicting reports, confirmed recent outbreaks, or return traveller case reports, national authorities were consulted and a consensus opinion was formed based on consideration of any additional available data for that country.

  1. Public Health England. Laboratory reports of hepatitis A infections in England and Wales, 2017. Health Protection Report. 2018;12(27)
  2. Travel-associated hepatitis A in Europe, 2009 to 2015. Euro Surveillance. 2018;23(22)

Last Updated: May 2019

Japanese encephalitis

NaTHNaC country specific recommendations are based on the World Health Organization reported cases in 2013 to 2017 [1]. In addition, a literature review focussing on national ministry of health vaccine and mosquito control programmes reports, serological surveys and traveller case reports was completed [2- 20].

Where no or limited data was available, NaTHNaC worked with Public Health England to form a consensus opinion based upon the best available evidence.

  1. World Health Organization vaccine-preventable diseases: monitoring system 2018 global summary.
  2. Bulletin of the World Health Organization. Estimated global incidence of Japanese encephalitis: a systematic review. Volume 89, Number 10, October 2011
  3. Centers for Disease Control MMWR June 2017: JE surveillance and immunization- Asia and Western Pacific Regions 2016
  4. Padbidri VS et al. A serological survey of arbovrial diseases among the human population of the Andaman and Nicobar Islands, India. Southeast Asian J Trop Med Public Health. 2002 Dec;33(4):794-800.
  5. Lindquist L. Recent and historical trends in the epidemiology of Japanese encephalitis and its implications for risk assessment in travellers. J Travel Med 2018 May 1;259 suppl_1): S3-S9.
  6. Fen Y et al, Distribution of Mosquitoes and Mosquito-Borne Viruses along the China-Myanmar Border in Yunnan Province. Jpn J Infect. Dis 65 (3), 215-221, 2012.
  7. Hills SL et al. Japanese encephalitis in Travelers from Non-Endemic Countries 1973-2008. Am. J. Trop. Med. Hyg., 2010; 82(5), pp. 930–936.
  8. Zhang H et al. Epidemiologic Survey of Japanese Encephalitis Virus Infection, Tibet, China, 2015. Emerg Infect Dis. 2017 Jun; 23(6).
  9. World Health Organization Strategic Advisory Group of Experts. Working Group Background Paper on Japanese Encephalitis Vaccines.1 October 2014.
  10. Wesley de Jong et al. Endemic and emerging acute virus infections in Indonesia: an overview of the past decade and implications for the future. Critical Reviews in Microbiology, 44:4, 487-503 (2018). 
  11. Pavli A, Maltezou HC. Travel-acquired Japanese encephalitis and vaccination considerations. J Infect Dev Ctries 2015; 9(9):917-924.
  12. Im J et al. Protecting children against Japanese encephalitis in Bali, Indonesia. The Lancet 2018, Volume 391, Issue 10139, Pages 2500-2501.
  13. Bae W et al. Changes of Epidemiological Characteristics of Japanese Encephalitis Viral Infection and Birds as a Potential Viral Transmitter in Korea. J Korean Med Sci. 2018 Feb 26; 33(9): e70.
  14. Dong-Woo L et al. Epidemiology of Japanese encephalitis in South Korea, 2007–2010. International Journal of Infectious Diseases 2012 Vol 16(6), e448-e452.
  15. Kumar K et al. Japanese encephalitis in Malaysia: An overview and timeline. Acta Tropica 2018 Vol 185, 219-229.
  16. Oo PM et al. A Large Outbreak of Japanese Encephalitis in Rakhine State, Myanmar: Implication for Vaccine Policy. Outbreak, Surveillance and Investigation Reports 2016, Vol 9 (2), 8-16.
  17. Pant DK et al. Spatio-temporal epidemiology of Japanese encephalitis in Nepal, 2007-2015. PLoS One. 2017; 12(7): e0180591.
  18. Darwish MA et al. A sero epidemiological survey for certain arboviruses (Togaviridae) in Pakistan. Trans R Soc Trop Med Hyg 1983; 77 (4):442-5.
  19. Wang H, Liang G. Epidemiology of Japanese encephalitis: past, present, and future prospects. Ther Clin Risk Manag. 2015;11:435-48.
  20. Nitatpattana N et al. Change in Japanese Encephalitis Virus Distribution, Thailand. 2008; Nov 14 (11):1762-1765.

Last Updated: February 2019


NaTHNaC malaria recommendations follow current Public Health England malaria prevention guidelines for travellers from England, Wales and Northern Ireland [1]. 

  1. Public Health England. Guidelines for malaria prevention in travellers from the UK


NaTHNaC country information pages include measles as a risk in all countries. All travellers should have received two measles containing vaccines in their lifetime or be immune because of measles disease, even if the country is declared by the World Health Organization to have eliminated measles.


Last Updated: October 2019

Meningococcal meningitis

NaTHNaC country specific vaccine recommendations for meningococcal ACWY have been made if a country lies within the extended meningitis “belt” of sub-Saharan Africa, as defined by the World Health Organization. Additional vaccine recommendations for Saudi Arabia are made in accordance with the annual requirements of the Ministry of Health of the Kingdom of Saudi Arabia for those who will perform Hajj, Umrah or undertake seasonal work.

  1. World Health Organization. Epidemic meningitis control in countries in the African meningitis belt, 2018.
    Weekly Epidemiological Record, 5 April 2019. 94, 14/15: 179–188
  2. World Health Organization. Meningococcal meningitis. 18 February 2018

Last Updated: April 2019

Middle East respiratory syndrome coronavirus

NaTHNaC country specific recommendations for countries with a known risk of Middle East respiratory syndrome coronavirus (MERS-CoV) is based on cases reported globally to the World Health Organization (WHO). Recommendations for countries with a presumed risk of MERS-CoV is based on expert opinion and proximity to a country with reported cases.

Last Updated: July 2017


NaTHNaC monitors the global polio situation, as detailed by the Global Polio Eradication Initiative (GPEI) and World Health Organization (WHO), and makes changes to country specific recommendations as new information becomes available.

NaTHNaC recommends that all travellers should receive a booster dose of polio-containing vaccine if they have not received one within the past 10 years if visiting:

  • countries considered by the WHO to be infected with wild polio virus (WPV) and/or a circulating vaccine derived polio virus (cVDPV) with the potential risk of international spread. (Note: there are additional temporary vaccination recommendations and a certificate requirement under International regulations (IHR) for some travellers to these countries).
  • countries considered by the WHO as no longer infected with either WPV or cVDPV, but which remain vulnerable to re-infection.
  • countries not included in either of these WHO categories, but considered at risk according to Global Polio Eradication Initiative.

When an environmental cVDPV 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.

  1. World Health Organization. Global Polio Eradication Initiative. Public Health Emergency Status. Temporary Recommendations to Reduce International Spread of Polio Virus
  2. World Health Organization. IHR Emergency Committee. IHR Emergency Committee concerning ongoing events and context involving transmission and international spread of poliovirus.

Last Updated: December 2018


NaTHNaC worked with Public Health England to identify countries where rabies was currently a risk by reviewing data from the World Animal Health Information Database (OIE) 2015- 2017 and where country data was available in 2018. 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. Updates to these recommendations are made as required based on additional information as it becomes available.

Last Updated: May 2019


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 [1,2]. Where reporting was sporadic or absent, consensus expert opinion was formed based on consideration of available data.

  1. World Health Organization. Status of Schistosomiasis endemic countries 2012. [Accessed 8 October 2015]
  2. World Health Organization. Weekly Epidemiological Record, 89, 21-28, 2014. Schistosomiasis: number of people receiving preventive chemotherapy in 2012. [Accessed 8 October 2015]
  3. Reliefweb, WHO to provide medical aid for outbreak of snail fever, 23 July 2018. [Accessed 25 July 2018].

Last Updated: July 2018

Tick-borne encephalitis

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.

  1. 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.
  2. 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.
  3. Bundesamt für Gesundheit, 2016. Zeckenübertragene Krankheiten. Accessed 14 July 2016
  4. 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.
  5. 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.
  6. 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. Accessed 27 April 2017.
  7. 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. Accessed 27 April 2017.
  8. Folkehelseinstituttet, 2016. Vaksinasjon mot skogflåttencefalitt (TBE). Folkehelseinstituttet. Accessed 25 July 2016.
  9. 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.
  10. 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.
  11. 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.
  12. 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.
  13. 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.
  14. 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.
  15. 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.
  16. 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.
  17. 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.
  18. 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.
  19. 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.
  20. National Institute for Health and Welfare, 2014. Infectious diseases in Finland 2013. Helsinki. Accessed 27 April 2017.
  21. 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.
  22. Raguet, Couturier, 2016. Étude ALSA(CE)TIQUE 2014-2015. Principaux résultats descriptifs. Santé publique France. Accessed 27 April 2017.
  23. 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.
  24. Rijksinstituut voor Volksgezondheid en Milieu, 2016. Patiënt ziek door teken-encefalitisvirus. Accessed 27 April 2017.
  25. 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.
  26. Schuler, M., Zimmermann, H., Altpeter, E., Heininger, U., 2014. Epidemiology of tick-borne encephalitis in Switzerland, 2005 to 2011. Eurosurveillance 19, 20756.
  27. Statens Serum Institut, 2016. TBE (Tick Borne Encephalitis) - Statens Serum Institut. Accessed 27 April 2017.
  28. 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).
  29. 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.
  30. 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.
  31. 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.
  32. 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 2016 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 

Some travellers may be recommended to receive BCG vaccination when the risk of MultiDrug Resistant- TB (MDR-TB) is considered as high in countries with high rates of MDR-TB according to the WHO Global tuberculosis report 2017

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: August 2018


NaTHNaC typhoid vaccine recommendations were based on a review of country specific burden of typhoid disease using available resources [1-4] 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.

For those countries with typhoid disease incidence classified as “medium” the additional factor of sanitation levels in rural populations was considered to assess the need for a vaccine recommendation [1,5].

Vaccine was recommended for some travellers to a country, if the percentage of the rural population with access to improved sanitation was ≥ 80% as detailed in the WHO Progress on Drinking Water and Sanitation Report 2015. All other countries with “medium” disease incidence, where the access to improved sanitation was < 80%, vaccine was recommended for most travellers.

  1. Burden of typhoid fever in low-income and middle-income countries: a systematic, literature-based update with risk-factor adjustment. Mogsdale V, Maskery B, Ochiai Rl et al, 2015. The Lancet Global Health Oct; 2(10):e570-80.
  2. Crump JA, Luby SP, Mintz ED. The global burden of typhoid fever. Bulletin of the World Health Organisation, May 2004, 82(5), 346-353
  3. Antillion M et al, 2018. The burden of typhoid fever in low- and middle-income countries: A meta-regression approach. PLOS Neglected Tropical Disease; February 27, 2017, 1-21.
  4. Global Trends in Typhidal Salmoellosis: A Systematic Review. Als D, Radhakrishnan A, Arora P et al, 2018. Am. J. Trop. Med. Hyg., 99 (Suppl 3), 10-19.
  5. World Health Organization. Progress on Drinking Water and Sanitation Report 2015. 

Last Updated: December 2018

Country specific recommendations are based on collaborations with Public Health England

First Published :   15 Oct 2015
Last Updated :   03 Oct 2019

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