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Chapter 8
Adising Traelers ith Specific Needs
Chapter 8 - Travelers with Chronic Illnesses (/travel/yellowbook/2012/chapter-8-advising-
travelers-with-specific-needs/travelers-with-chronic-illnesses.htm)
Chapter 8 - Travelers with Disabilities (/travel/yellowbook/2012/chapter-8-advising-travelers-with-
specific-needs/travelers-with-disabilities.htm)
Pregnant Traelers
Madeline Y. Son
OVERVIEW
Since as many as 50% of pregnancies are unplanned, women of reproductive age should consider
maintaining current immunizations during routine check-ups in case an unplanned pregnancy
coincides with a need to travel. Because of the decreased risk to the unborn child, preconceptional
immunizations are preferred to vaccination during pregnancy. A woman should defer pregnancy
for 28 days after receiving live vaccines (such as measles-mumps-rubella or yellow fever)
because of a theoretical risk of transmission to the fetus. However, small studies of women who
received these vaccines unintentionally during pregnancy have not found a definitive link between
the vaccines and poor pregnancy outcomes. Therefore, pregnancy termination is not
recommended after an inadvertent exposure.
According to the American College of Obstetrics and Gynecology, the safest time for a pregnant
woman to travel is during the second trimester, when she usually feels best and is in least danger
of spontaneous abortion or premature labor. A woman in the third trimester should be advised to
defer overseas travel because of concerns about access to medical care in case of problems such as
hypertension, phlebitis, or premature labor. Pregnant women should be advised to consult with
their health care providers before making any travel decisions. Collaboration between travel
health experts and obstetricians is helpful in weighing benefits and risks based on destination and
recommended preventive and treatment measures. Table 8-05 (/travel/yellowbook/2012/chapter-8-
advising-travelers-with-specific-needs/pregnant-travelers.htm#1962) lists relative contraindications to
international travel during pregnancy. In general, pregnant women with serious underlying
illnesses should be advised not to travel to developing countries.
Table 8-05. Potential contraindications to
international travel during pregnanc
OBSTETRIC RISK
FACTORS
GENERAL
MEDICAL RISK
TRAVEL TO POTENTIALLY
HAZARDOUS
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FACTORS DESTINATIONS
History of miscarriage
Incompetent cervix
History of ectopic
pregnancy (ectopic with
current pregnancy should be
ruled out before travel)
History of premature labor
or premature rupture of
membranes
History of or existing
placental abnormalities
Threatened abortion or
vaginal bleeding during
current pregnancy
Multiple gestation in current
pregnancy
Fetal growth abnormalities
History of toxemia,
hypertension, or diabetes
with any pregnancy
Primigravida at age 35
years or 15 years
History of
thromboembolic
disease
Pulmonary
hypertension
Severe asthma or
other chronic lung
disease
Valvular heart disease
(if NYHA class III or
IV heart failure)
Cardiomyopathy
Hypertension
Diabetes
Renal insufficiency
Severe anemia or
hemoglobinopathy
Chronic organ system
dysfunction requiring
frequent medical
interventions
High altitudes
Areas endemic for or
experiencing ongoing outbreaks
of life-threatening foodborne or
insectborne infections
Areas where chloroquine-
resistant Plasmodim
falciparm malaria is endemic
Areas where live virus vaccines
are required or recommended
Abbrevi ati on: NY HA, New Y ork Heart Associ ati on.
PREPARATION FOR TRAVEL DURING PREGNANC
Once a pregnant woman has decided to travel, a number of issues need to be considered before
her departure:
An intrauterine pregnancy should be confirmed by a clinician and ectopic pregnancy excluded
before beginning any travel.
General health insurance policies may or may not provide coverage of pregnancy-related
problems while abroad. Pregnant travelers should inquire about what their health insurance
policies cover and, if needed, obtain a supplemental policy for their trip. Many supplemental
travel insurance policies and prepaid medical evacuation insurance policies do not cover
pregnancy-related problems, so this issue should be clarified before obtaining a policy.
Check medical facilities at the destination. For a woman in the last trimester, medical facilities
should be able to manage complications of pregnancy, toxemia, cesarean sections, and
premature or ill neonates.
Determine beforehand whether prenatal care will be required while abroad and who will
provide it. The pregnant traveler should make sure she does not miss prenatal visits requiring
specific timing.
Determine beforehand whether blood is routinely screened for HIV and hepatitis B and C at
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the destination. Pregnant travelers should consider the safety of blood transfusions, if needed,
when making plans for international travel. The pregnant traveler should also be advised to
know her blood type, and Rh-negative pregnant women should receive anti-D immune
globulin (a plasma-derived product) prophylactically at about 28 weeks gestation. The
immune globulin dose should be repeated after delivery if the infant is Rh positive.
Determine if the traveler risks influenza on this trip, and recommend influenza vaccine
accordingly.
Determine whether the prevalence of tuberculosis (TB) is high in the destination region and
whether the planned itinerary will put the traveler at risk for TB. If exposure to TB is
determined to be a risk, the pregnant traveler should receive skin testing before and after
travel (see Chapter 3, Tuberculosis (/travel/yellowbook/2012/chapter-3-infectious-diseases-
related-to-travel/tuberculosis.htm) ).
GENERAL RECOMMENDATIONS FOR TRAVEL DURING
PREGNANCY
A pregnant woman should be advised to travel with at least one companion; she should also be
advised that, during her pregnancy, her level of comfort may be adversely affected by traveling.
Table 8-06 (/travel/yellowbook/2012/chapter-8-advising-travelers-with-specific-needs/pregnant-
travelers.htm#1963) lists the most serious risks that pregnant women face during international
travel.
Typical problems of pregnant travelers are the same as those experienced by any pregnant
woman: fatigue, heartburn, indigestion, constipation, vaginal discharge, leg cramps, increased
frequency of urination, and hemorrhoids. During travel, pregnant women can take preventive
measures, including avoiding gas-producing food or drinks before scheduled flights (entrapped
gases can expand at higher altitudes) and periodically moving the legs (to decrease venous stasis).
Pregnant women should always use seatbelts while seated, as air turbulence is not predictable and
may cause significant trauma.
Signs and symptoms that indicate the need for immediate medical attention are vaginal bleeding,
passing tissue or clots, abdominal pain or cramps, contractions, ruptured membranes, excessive
leg swelling or pain, headaches, or visual problems.
Table 8-06. Greatest risks for pregnant
traelers
Motor
ehicle
accidents
Safety belts should be worn whenever possible.
Fasten seatbelts at the pelvic area, not across the lower abdomen. Lap and
shoulder restraints are best.
In most accidents, the fetus recovers quickly from the safety belt
pressure. However, consult a physician even for mild trauma.
Hepatitis
E Hepatitis E is not vaccine preventable and is especially dangerous in
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pregnant women.
As with other enteric infections, pregnant women should be advised that
the best preventive measures are to avoid potentially contaminated water
and food.
Scba
diing Scuba diving should be avoided in pregnancy because of the risk of
decompression syndrome in the fetus.
AIR TRAVEL DURING PREGNANCY
Commercial air travel poses no special risks to a healthy pregnant woman or her fetus. The
American College of Obstetricians and Gynecologists states that women with healthy, single
pregnancies can fly safely up to 36 weeks gestation.
The lowered cabin pressure (kept at the equivalent of 5,0008,000 ft [about 1,5002,400 m])
has minimal effect on fetal oxygenation because of the favorable fetal hemoglobin-oxygen
dynamics. If supplemental oxygen is required during flight because of preexisting medical
conditions, arrangements for oxygen need to be made in advance. Severe anemia, sickle-cell
disease or trait, or history of thrombophlebitis are relative contraindications to flying. Pregnant
women with placental abnormalities or risks for premature labor should avoid air travel.
Airline Policies and Airport Securit
Each airline has policies regarding pregnancy and flying; it is always safest to check with the airline
when booking reservations, because some will require medical forms to be completed. Domestic
travel is usually permitted until the pregnant traveler is in week 36 of gestation, and international
travel may be permitted until weeks 3235, depending on the airline. A pregnant woman should
be advised to carry documentation stating the expected day of delivery, contact information for
her obstetric provider, and her blood type. For pregnant flight attendants and pilots, work-related
air travel is restricted by most airlines by 20 weeks gestation.
To date, airport security radiation exposure is minimal for pregnant women and has not been
linked to an increase in adverse outcomes for unborn children. However, because of early reports
of a possible association of radiation exposure during pregnancy with subsequent increased risk of
childhood leukemia and cancer, a pregnant passenger may request a hand or wand search rather
than being exposed to the radiation of the airport security machines.
General Tips
An aisle seat at the bulkhead will provide the most space and comfort, but a seat over the
wing in the midplane region will give the smoothest ride.
A pregnant woman should be advised to walk every half hour during a smooth flight and flex
and extend her ankles frequently to prevent phlebitis.
Dehydration can lead to decreased placental blood flow and hemoconcentration, increasing
risk of thrombosis. Thus, pregnant women should drink plenty of fluids during flights.
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TRAVEL TO HIGH ALTITUDES DURING PREGNANCY
There have been no documented reports of adverse pregnancy outcomes related to high-altitude
exposure during pregnancy. High-altitude destinations, however, often are remote from medical
care in an emergency, and any decision to trek or climb to high altitudes while pregnant should
take into account the uncertainties of being in a remote environment while pregnant and the
unknown possible effects of high altitude on the fetus. Conservative advice for pregnant women is
to avoid altitudes >12,000 ft (3,658 m).
FOODBORNE AND WATERBORNE ILLNESS DURING
PREGNANCY
Pregnant women should be advised of the following:
Adhere strictly to food and water precautions in developing countries, because the
consequences of foodborne and waterborne illness may be more severe than diarrhea and
may have serious sequelae (such as toxoplasmosis or listeriosis).
Boil suspect drinking water to avoid long-term use of iodine-containing purification systems.
Iodine tablets can probably be used for travel up to several weeks, but congenital goiters have
been reported in association with administration of iodine-containing drugs during pregnancy.
Oral rehydration (boiled or bottled water) is the mainstay of therapy for travelers diarrhea.
Bismuth subsalicylate compounds are contraindicated because of the theoretical risks of fetal
bleeding from salicylates and teratogenicity from the bismuth.
The combination of kaolin and pectin may be used, and loperamide should be used only when
necessary.
The combination of kaolin and pectin is no longer readily available in the
United States. The formulation of Kaopectate currently marketed in the
United States uses bismuth subsalicylate as the active ingredient and should
not be given to pregnant women. The formulation marketed in Canada (also
under the trade name Kaopectate) uses attapulgite as the active ingredient.
Attapulgite is most likely safe to use in pregnant women because it adsorbs
bacteria in the gut and does not enter systemic circulation, but it has not been
assigned to a pregnancy category by the Food and Drug Administration.
Formulations of attapulgite are not readily available in the United States.
Updaed Ag 16, 2011
The antibiotic treatment of travelers diarrhea during pregnancy can be complicated.
Azithromycin or an oral third-generation cephalosporin may be the best option for treatment,
if an antibiotic is needed.
MALARIA DURING PREGNANCY
Adise pregnant omen to aoid trael to malaria-endemic areas if possible. Women
who choose to go to areas with malaria can reduce their risk of acquiring malaria by taking
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appropriate malaria chemoprophylaxis and following insect precautions (see Chapter 2, Protection
against Mosquitoes, Ticks, and Other Insects and Arthropods (/travel/yellowbook/2012/chapter-2-
the-pre-travel-consultation/protection-against-mosquitoes-ticks-and-other-insects-and-arthropods.htm) and
Chapter 3, Malaria (/travel/yellowbook/2012/chapter-3-infectious-diseases-related-to-travel/malaria.htm)
). Pregnant women should use insect repellents as recommended for adults sparingly, but as
needed. Pyrethrum-containing house sprays may also be used indoors, if insects are a problem.
Antimalarial Medications
For pregnant women who travel to areas with chloroquine-sensitive Plamodim falcipam
malaria, chloroquine can be taken for malaria chemoprophylaxis, since it has been used for
decades with no documented increase in birth defects. For pregnant women who travel to areas
with chloroquine-resistant P. falcipam, mefloquine should be recommended for
chemoprophylaxis. Evidence suggests that mefloquine prophylaxis causes no significant increase in
spontaneous abortions or congenital malformations when taken during pregnancy. (Updaed
Ocobe 26, 2011)
Because there is no evidence that chloroquine and mefloquine are associated with congenital
defects when used for prophylaxis, CDC does not recommend that women planning pregnancy
wait a specific period of time after their use before becoming pregnant. However, if women or their
health care providers wish to decrease the amount of antimalarial drug in the body before
conception, Table 8-07 (/travel/yellowbook/2012/chapter-8-advising-travelers-with-specific-
needs/pregnant-travelers.htm#1964) provides information on the half-lives of selected antimalarial
drugs. After 2, 4, and 6 half-lives, approximately 25%, 6%, and 2%, respectively, of the drug
remain in the body.
Doxycycline and primaquine are contraindicated for malaria prophylaxis during pregnancy,
because both may cause adverse effects on the fetus. Atovaquone-proguanil is not recommended
for use by pregnant women to prevent malaria because of the lack of safety studies during
pregnancy.
Treatment and Management
Malaria must be treated as a medical emergenc in an pregnant traveler. A woman
who has traveled to an area that has chloroquine-resistant strains of P. falcipam should be
treated as if she has illness caused by chloroquine-resistant organisms. The management of
malaria in a pregnant woman should include frequent blood glucose determinations and careful
fluid monitoring (being careful not to give too much intravenous fluid).
Table 8-07. Half-lives of
selected antimalarial drugs
DRUG HALF LIFE
Atovaquone 23 days
Chloroquine Can extend 660 days
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Doxycycline 1224 hours
Mefloquine 23 weeks
Primaquine 47 hours
Proguanil 1421 hours
Pyrimethamine 34 days
Sulfadoxine 69 days
IMMUNIZATIONS FOR PREGNANT TRAVELERS
Risk to a developing fetus from vaccination of the mother during pregnancy is primarily
theoretical. No evidence exists of risk from vaccinating pregnant women with inactivated virus,
bacterial vaccines, or toxoids. The benefits of vaccinating pregnant women usually outweigh
potential risks when the likelihood of disease exposure is high, infection would pose a risk to the
mother or fetus, and the vaccine is unlikely to cause harm.
Table 8-08 (/travel/yellowbook/2012/chapter-8-advising-travelers-with-specific-needs/pregnant-
travelers.htm#1965) is intended for women who may require immunizations during pregnancy.
Pregnant travelers may visit areas of the world where diseases eliminated by routine vaccination
in the United States are still endemic, and therefore may require immunizations before travel.
Table 8-08. Vaccination during pregnanc
VACCINE/IMMUNOBIOLOGIC TYPE USE
Immune globulins, pooled or
hyperimmune
Immune
globulin or
specific
globulin
preparations
If indicated for pre- or
postexposure use. No known risk to
fetus
Vaccination of pregnant women is recommended
Hepatitis B Recombinant
or plasma-
derived
Recommended for women at risk of
infection
Influenza Inactivated
whole virus or
subunit
All people >6 months, including
women who will be or are pregnant
during the flu season (September
March), regardless of trimester, and
women at high risk for pulmonary
complications, regardless of
trimester
1
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TeLunus-dIpILIerIu (Td) ToxoId I IndIcuLed, sucI us Iuck oI prImury
serIes or no boosLer wILIIn pusL 1o
yeurs
TeLunus-dIpILIerIu-perLussIs
(Tdup)
ToxoId,
uceIIuIur
NoL conLruIndIcuLed, buL no duLu ure
uvuIIubIe on suIeLy,
ImmunogenIcILy, und ouLcomes oI
pregnuncy. ACP recommends Td
wIen LeLunus und dIpILIerIu
proLecLIon ure requIred buL Tdup Lo
udd proLecLIon uguInsL perLussIs In
some sILuuLIons. Second or LIIrd
LrImesLer Is preIerred.
HepuLILIs A nucLIvuLed
vIrus
No duLu ure uvuIIubIe on suIeLy In
pregnuncy. Becuuse IepuLILIs A
vuccIne Is produced Irom
InucLIvuLed IepuLILIs A vIrus, LIe
LIeoreLIcuI rIsk oI vuccInuLIon
sIouId be weIgIed uguInsL LIe rIsk oI
dIseuse. ConsIder Immune gIobuIIn
ruLIer LIun vuccIne.
Pregnanc is a Precaution, and Under Normal Circumstances, Vaccination
Should Be Deferred; Vaccine Should Onl Be Given when Benefits Outweigh
Risks
Jupunese encepIuIILIs nucLIvuLed
vIrus
No duLu ure uvuIIubIe on suIeLy In
pregnuncy. PregnunL women wIo
musL LruveI Lo un ureu wIere LIe rIsk
Is IIgI sIouId be vuccInuLed wIen
LIe LIeoreLIcuI rIsks ure ouLweIgIed
by LIe rIsk oI dIseuse.
MenIngococcuI menIngILIs PoIysuccIurIde MenIngococcuI conjuguLe vuccIne
(MenACWY) Is preIerred Ior uduILs;
Iowever, no duLu ure uvuIIubIe on
suIeLy und ImmunogenIcILy In
pregnunL women. MenIngococcuI
poIysuccIurIde vuccIne (MPSVq)
cun be udmInIsLered durIng
pregnuncy II LIe womun Is enLerIng
un epIdemIc ureu. ndIcuLIons Ior
propIyIuxIs ure noL uILered by
pregnuncy; vuccIne Is recommended
In unusuuI ouLbreuk sILuuLIons.
PneumococcuI PoIysuccIurIde TIe suIeLy oI pneumococcuI
(PPVz) vuccIne durIng LIe II rsL
LrImesLer oI pregnuncy Ius noL been
evuIuuLed, uILIougI no udverse
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een hae been epoed afe
inadeen accinaion ding
pegnanc. Women ih chonic
dieae, moke, and
immnoppeed omen hold
conide accinaion.
Polio, inaciaed Inaciaed
i
Indicaed fo cepible pegnan
omen aeling in endemic aea
o in ohe high-ik iaion.
Rabie Inaciaed
i
Indicaion fo poepoe
pophlai no aleed b
pegnanc. If ik fo epoe o
abie i banial, peepoe
pophlai ma alo be indicaed.
Tphoid (ViCPS) Polacchaide If indicaed fo ael o endemic
aea
Tphoid (T21a) Lie baceial No daa ae aailable on afe in
pegnanc; heoeical ik ei,
becae i i a lie-aenaed
accine.
Yello fee Lie
aenaed
The afe of YF accinaion in
pegnanc ha no been died in a
lage popecie ial. If ael i
naoidable and he ik fo YFV
epoe oeigh he accinaion
ik, a pegnan oman hold be
accinaed. If he ik fo
accinaion oeigh he ik fo
YFV epoe, a pegnan oman
hold be ied a medical aie o
flfill healh eglaion. If a
pegnan oman i accinaed, he
infan hold be monioed afe
bih fo eidence of congenial
infecion and ohe poible adee
effec eling fom YF
accinaion. Pegnanc ma
inefee ih he immne epone
o YF accine; heefoe, eologic
eing o docmen a poecie
immne epone o he accine
hold be conideed (ee Chape
3, Yello Fee
(/ael/ellobook/2012/chape-
3-infecio-dieae-elaed-o-
ael/ello-fee.hm) fo moe
deail).
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Pregnanc is a Contraindication to Vaccination; Vaccine Should Not Be
Administered to Pregnant Women
Tuberculosis (BCG) Attenuated
mycobacterial
Contraindicated due to theoretical
risk of disseminated disease. Skin
testing for tuberculosis exposure
before and after travel is preferable
when the risk of possible exposure is
high.
Measles-mumps-rubella Live
attenuated
virus
Contraindicated. Vaccination of
susceptible women should be part of
postpartum care. Unvaccinated
women should delay travel to
countries where measles is endemic
until after delivery. Unvaccinated
pregnant women with a documented
exposure to measles should receive
immune globulin within 6 days to
prevent illness.
Human papillomavirus Recombinant
quadrivalent
Contraindicated. The vaccine has
not been causally associated with
adverse outcomes of pregnancy;
however, additional information is
needed for further
recommendations. Pregnancy
testing is not needed before
vaccination.
Varicella Live
attenuated
virus
Contraindicated. Vaccination of
susceptible women should be
considered postpartum.
Unvaccinated pregnant women
should consider postponing travel
until after delivery, when the
vaccine can be given safely.
Influenza Live
attenuated
virus,
including
intranasal
preparations
Contraindicated during pregnancy;
postpartum and breastfeeding
mothers may receive live attenuated
virus vaccines.
Abbrevi ati ons: ACIP, Advi sory Commi ttee on Immuni zati on Practi ces; BCG, Baci l l us Cal mette-Guri n; Y F, yel l ow
fever; Y FV, yel l ow fever vi rus.
Starti ng wi th the 201011 i nfl uenza season, most i nfl uenza vacci nes wi l l offer protecti on agai nst both seasonal
and H1N1 i nfl uenza vi rus strai ns.
TRAVEL HEALTH KITS FOR PREGNANT WOMEN
1
1
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Additions and substitutions to the usual travel health kit (see Chapter 2, Travel Health Kits
(/travel/yellowbook/2012/chapter-2-the-pre-travel-consultation/travel-health-kits.htm) ) need to be made
during pregnancy. Talcum powder, a thermometer, oral rehydration salt packets, prenatal
vitamins, a topical antifungal agent for vaginal yeast, acetaminophen, and a sunscreen with a high
SPF should be included. Women in the third trimester may be advised to carry a blood-pressure
cuff and urine dipsticks and be trained to use this equipment to check for hypertension,
proteinuria, and glucosuria, any of which would require prompt medical attention. Antimalarial
and antidiarrheal self-treatment medications should be evaluated individually, depending on the
travelers itinerary and her health history. Medications should only be used after consultation with
a physician.
BIBLIOGRAPH
1. ACOG Committee on Obstertic Practice. Committee opinion: number 264, December 2001.
Air travel during pregnancy. Obstet Gynecol. 2001 Dec;98(6):11878.
2. American College of Obstetricians and Gynecologists. ACOG Committee Opinion.
Immunization during pregnancy. Obstet Gynecol. 2003 Jan;101(1):20712.
3. Barish RJ. In-flight radiation exposure during pregnancy. Obstet Gynecol. 2004
Jun;103(6):132630.
4. Bia FJ. Medical considerations for the pregnant traveler. Infect Dis Clin North Am. 1992
Jun;6(2):37188.
5. Bilukha OO, Rosenstein N. Prevention and control of meningococcal disease.
Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR
Recomm Rep. 2005 May 27;54(RR-7):121.
6. Boice JD, Miller RW. Childhood and adult cancer after intrauterine exposure to ionizing
radiation. Teratology. 1999 Apr;59(4):22733.
7. CDC. Guidelines for vaccinating pregnant women, Advisory Committee on Immunization
Practices. Atlanta: CDC; 1998 [updated 2007 May; cited 2010 Oct 26]. Available from:
http://www.cdc.gov/vaccines/pubs/downloads/b_preg_guide.pdf
(http://www.cdc.gov/vaccines/pubs/downloads/b_preg_guide.pdf) .
8. CDC. Guiding principles for development of ACIP recommendations for vaccination during
pregnancy and breastfeeding. MMWR Morb Mortal Wkly Rep. 2008 May 30;57(21):580.
9. CDC. Human rabies preventionUnited States, 1999. Recommendations of the Advisory
Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 1999 Jan 8;48(RR-
1):121.
10. CDC. Revised ACIP recommendation for avoiding pregnancy after receiving a rubella-
containing vaccine. MMWR Morb Mortal Wkly Rep. 2001 Dec 14;50(49):1117.
11. CDC. Typhoid immunization: recommendations of the Advisory Committee on Immunization
Practices (ACIP). MMWR Morb Mortal Wkly Rep. 1994;43(RR-14):17.
12. Cetron MS, Marfin AA, Julian KG, Gubler DJ, Sharp DJ, Barwick RS, et al. Yellow fever
vaccine. Recommendations of the Advisory Committee on Immunization Practices (ACIP),
2002. MMWR Recomm Rep. 2002 Nov 8;51(RR-17):111.
13. Fiore AE, Shay DK, Broder K, Iskander JK, Uyeki TM, Mootrey G, et al. Prevention and
control of influenza: recommendations of the Advisory Committee on Immunization
Practices (ACIP), 2008. MMWR Recomm Rep. 2008 Aug 8;57(RR-7):160.
14. Fiore AE, Uyeki TM, Broder K, Finelli L, Euler GL, Singleton JA, et al. Prevention and
control of influenza with vaccines: recommendations of the Advisory Committee on
Immunization Practices (ACIP), 2010. MMWR Recomm Rep. 2010 Aug 6;59(RR-8):162.
15. GlaxoSmithKline. Malarone (atovaquone and proguanil hydrochloride) tablets and pediatric
tablets prescribing information. Research Triangle Park, NC: GlaxoSmithKline; 2009.
Available from: http://us.gsk.com/products/assets/us_malarone.pdf.
16. Marin M, Guris D, Chaves SS, Schmid S, Seward JF. Prevention of varicella:
06/02/12 Pregnant Travelers - Chapter 8 - 2012 Yellow Book - Travelers' Health - CDC
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Page cr eat ed: July 01 , 2 01 1
Page last updat ed: Oct ober 2 6, 2 01 1
Page last r ev iewed: July 01 , 2 01 1
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recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR
Recomm Rep. 2007 Jun 22;56(RR-4):140.
17. Mast EE, Margolis HS, Fiore AE, Brink EW, Goldstein ST, Wang SA, et al. A comprehensive
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18. Watson JC, Hadler SC, Dykewicz CA, Reef S, Phillips L. Measles, mumps, and rubella
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Chapter 8 - Travelers with Chronic Illnesses (/travel/yellowbook/2012/chapter-8-advising-
travelers-with-specific-needs/travelers-with-chronic-illnesses.htm)
Chapter 8 - Travelers with Disabilities (/travel/yellowbook/2012/chapter-8-advising-travelers-with-
specific-needs/travelers-with-disabilities.htm)