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This is a republication of the CDC guidelines and recommendations for those traveling to Haiti for relief efforts. Go to the CDC website for related information.

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 Announcement
Guidance for Relief Workers and Others Traveling to Haiti for Earthquake Response
This information is current as of today, February 19, 2010 at 15:33 EST

Updated: February 18, 2010

Haiti Earthquake and Travel

Travel Health Warning: Major Earthquake in Port-au-Prince, Haiti - Avoid Nonessential Travel to Haiti

Guidance for U.S. Residents in Haiti

This notice is to advise relief workers and other personnel traveling to Haiti to assist with the humanitarian response following the January 12th earthquake near Port-au-Prince. Conditions in the area remain hazardous, including extensive damage to buildings, roads, and other infrastructure.

Before You Depart for Haiti

Recommended Vaccines

A number of vaccines are recommended for travelers to Haiti. See your doctor before you travel to make sure you have had all necessary vaccines.

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• Routine: Be sure that you are up to date on vaccines such as measles/mumps/rubella (MMR), diphtheria/pertussis/tetanus (DPT), polio, seasonal and H1N1 flu, and varicella. It is especially important to have a current tetanus shot.
• Hepatitis A or immune globulin (IG): Even if your departure is imminent, one dose of hepatitis A vaccine provides adequate short-term protection for healthy people. For long term protection, a second dose is required 6–18 months after the first dose, depending on the brand of vaccine used.

The vaccine recommendations on this page are based on diseases previously observed in Haiti and the possibility for outbreaks in the aftermath of the earthquake. At this time, vaccines for diseases such as polio, cholera, and meningitis are not recommended.

CDC will continue to monitor the situation in Haiti and will revise vaccine recommendations if the situation warrants.

• Typhoid: There are two vaccines available for typhoid prevention. The injectable vaccine may be preferable to the oral vaccine in cases where travel is imminent. The oral vaccine requires refrigeration and 4 tablets taken every other day over one week.
• Hepatitis B: If your departure is imminent, the first in a three-dose series (day 0, 1 month and 6 months) may provide some protection. An accelerated dosing schedule may be used (doses at days 0, 7, and at 21–30 days with a booster at 12 months).
• Rabies: If your activities in Haiti will bring you into contact with animals such as dogs, cats, bats, mongooses or other carnivores, you should consider pre-exposure rabies vaccination, which is a three-shot series (days 0, 7, and 21 or 28) given before travel. Even if you receive pre-exposure vaccination, you will still need immediate medical treatment if you are bitten or scratched by an animal. (See the Animals section for more information.)

Insect-borne Diseases

Malaria

Malaria occurs in all parts of Haiti. Ways to prevent malaria include the following:

• Taking a prescription antimalarial drug
• Using insect repellent and wearing long pants and sleeves to prevent mosquito bites
• Sleeping in air-conditioned or well-screened rooms or using bed nets

No antimalarial drug is 100% protective, so it is important to use all three ways to prevent malaria.

All of the following antimalarial drugs are equal options for preventing malaria in Haiti: Atovaquone/proguanil (Malarone), chloroquine, doxycycline, or mefloquine. Each drug has its own side effects, contraindications, and precautions. You will need to talk to your doctor to decide which of these drugs would be best for you, depending on your current health, medical history, drug allergies, and specific needs. Additional information can be found on the Drugs to Prevent Malaria page.

Malaria is always a serious disease and may be a deadly illness. If you become ill with a fever or flu-like illness either while in Haiti or after you return home (for up to 1 year), you should seek immediate medical attention and should tell the doctor that you have recently been in Haiti.

Dengue

Dengue is a common infection in Haiti. Dengue is a disease caused by a virus transmitted to people by the bite of an infected mosquito. Some important information to know about dengue as you travel to Haiti:

• No vaccine or medications are available to prevent dengue.
• The best way to reduce your risk of dengue is to protect yourself from mosquito bites (see Insects below for more information).
• The mosquitoes that spread dengue usually bite at dusk and dawn but may bite at any time during the day.
• Symptoms and signs are high fever, chills, headache and muscle pain.  Additionally, a faint rash on the trunk and upper arms may appear on the second to third day of illness.
• There are no specific medicines to treat dengue, so treatment is supportive with fever-reducing medicines and fluids.
• You can help control mosquito populations by draining all standing water that you find in open containers left outdoors.
• If you are in the Dominican Republic awaiting entry into Haiti, be aware that dengue is also common there.

Other Infectious Diseases

HIV: Haiti has a high prevalence of HIV infection. To reduce the risk of HIV and other sexually transmitted diseases, always use latex condoms. Healthcare workers should also take the following additional precautions:

• Wear gloves for touching blood and body fluids, mucous membranes, or broken skin and for handling items or surfaces soiled with blood or body fluids.
• Use masks and protective eyewear or face shields to prevent exposure of the mouth, nose, and eyes during procedures that are likely to generate droplets of blood or body fluids.
• Wear gowns or aprons during procedures that are likely to generate splashes of blood or body fluids.

Tuberculosis (TB): Rates of tuberculosis are very high in Haiti.

• If you anticipate giving medical care to or working closely with ill or injured victims or other displaced persons in Haiti, a tuberculin skin test or TST (ideally, a two-step test) is recommended before travel and then 8–10 weeks after return. Your doctor may use a new TB blood test instead of the TST.
• If you have had a negative result on a tuberculin skin test or TB blood test within the past 12 months, you do not need to be tested before going to Haiti.
• If you had a negative TST result >12 months before travel or you have never had a TST, your doctor may do a two-step TST.
• If you have had a positive result on a tuberculin skin test or TB blood test in the past, you do not need to be tested again.
• If you are in contact with known TB patients or persons suspected of having TB, use a personal respiratory protective device (e.g., N-95 respirator).
• Regardless of tuberculin skin test or TB blood test results, any person who develops symptoms of TB during or after deployment should see a doctor immediately. Symptoms of TB can include a bad cough that lasts 3 weeks or longer; pain in the chest; coughing up blood or sputum (phlegm from deep inside the lungs); weakness or fatigue; weight loss; no appetite; chills; fever; and sweating at night.
• Additional information can be found in TB Guidance for Haiti Earthquake Responders.

Anthrax: Anthrax occurs in Haiti and is primarily transmitted by direct contact with infected animals or with contaminated products from infected animals. Cases of cutaneous and gastrointestinal anthrax have been reported among the local population.

• Cutaneous (skin) anthrax infection usually begins as a small sore that develops into a blister. The blister then develops into a skin ulcer with a black area in the center. The sore, blister, and ulcer do not hurt.
• Gastrointestinal anthrax is characterized by flu-like symptoms including fever and tiredness; sore throat, neck swelling, difficulty swallowing; and nausea, loss of appetite, mild to severe vomiting (may be bloody), mild to severe diarrhea (may be bloody), and abdominal pain.

If you develop any of these symptoms, see a healthcare provider immediately.

Leptospirosis: Leptospirosis infection occurs through exposure to soil and water contaminated with urine from infected animals. Symptoms of leptospirosis include high fever, severe headache, chills, muscle aches, and vomiting, and may include jaundice (yellow skin and eyes), red eyes, abdominal pain, diarrhea, or a rash. If the disease is not treated, the patient could develop kidney damage, meningitis (inflammation of the membrane around the brain and spinal cord), liver failure, and respiratory distress. In rare cases death occurs.

Key Items to Bring

There will be almost no infrastructure support available in Haiti for the immediate future. Relief workers, volunteers, and other travelers will need to be self-sufficient.

Pack basic supplies, including

• Food sufficient for the length of your stay.
• Soap and an alcohol-based hand cleaner (containing at least 60% alcohol)
• Insect protection: insect repellent and a bed net.
• Medications: antimalarial pills, medications for the treatment of travelers’ diarrhea (e.g., loperamide and an antibiotic), personal prescriptions (including extras), any preferred over-the-counter medications, and copies of all your prescriptions.
• Oral rehydration salts (ORS) packets for severe diarrhea.
• An extra set of prescription eyeglasses and/or contacts.
• Water purification tablets (iodine or chlorine), bleach, or a water purifier.
• Persons with pre-existing health conditions should consider wearing an alert-bracelet and make sure this information is on a contact card in their wallet or travel documents. A contact card should  include the following information:
• Name and contact information of U.S. family member or close contact.
• Name and contact information of U.S. health-care provider.
• Pre-existing health conditions and treatment.
• Personal protective equipment (PPE): (PDF) safety glasses or goggles, work boots, leather gloves for physical labor, rubber gloves for handling blood or body fluids, surgical masks, hard hat, ear plugs, N-95 respirators for those who are fit-tested.
• Due to severe damage to health facilities and shortages of medical supplies, carry a first aid kit for your own protection. Minimum suggested contents:
• Bandages (roller, adhesive, triangular)
• Sterile gauze pads
• Disposable gloves
• Scissors
• Tweezers
• Cold compress
• Antiseptic wipes
• Antibiotic ointment
• Hydrocortisone ointment  
• Commercial suture/syringe kits to be used by a local health-care provider. These items will require a letter from the prescribing physician on letterhead stationery. Pack these items in checked baggage, since they may be considered sharp objects and confiscated by airport or airline security if packed in carry-on bags.

While in Haiti

Wash your hands often with soap and clean water or use an alcohol-based hand cleaner (with at least 60% alcohol). Clean your hands especially before you eat or prepare food.

Safe Food and Drinks

• Eat foods that are packaged or that are freshly cooked and served hot.
• Do not eat raw and undercooked meats and seafood or unpeeled fruits and vegetables. 
• Drink only bottled, boiled, or chemically treated water and bottled or canned carbonated beverages.  When using bottled drinks, make sure that the seal has not been broken.
• Avoid tap water, fountain drinks, and ice cubes.
• To disinfect your own water: boil for 1 minute or filter the water and add 2 drops of household bleach or ½ an iodine tablet per liter of water.
• Use bottled, boiled, or chemically treated water to wash dishes, brush your teeth, wash and prepare food, or make ice.

Protection Against Insects and Animals

Insects

 Insect-borne diseases such as malaria and dengue are risks in Haiti. Prevent insect bites by:

• Using insect repellent (bug spray) that contains one of the following active ingredients: DEET, picaridin (KBR 3023), Oil of Lemon Eucalyptus/PMD, or IR3535. Always follow the instructions on the label when you use the repellent.
• In general, repellents protect longer against mosquito bites when they have a higher concentration (percentage) of the active ingredient. However, concentrations above 50% do not offer a marked increase in protection time. Products with less than 10% of an active ingredient may offer only limited protection, often no longer than 1-2 hours.
• Wearing lightweight long-sleeved shirts, long pants, and a hat outdoors. For greater protection, clothing may also be sprayed with repellent containing permethrin or another EPA-registered repellent. (Remember: don't use permethrin on skin.)
• Remaining indoors in a screened area or using insect repellent frequently on uncovered skin during the peak biting period for malaria (dusk and dawn) and dengue (any time of day).
• Sleeping in beds covered by a bed net (preferably treated with permethrin), if not sleeping in an air-conditioned or well-screened room.
• Spraying rooms with products effective against flying insects, such as those containing pyrethroid.
• For detailed information about insect repellent use, see Insect and Arthropod Protection.

Animals

Direct contact with animals can spread diseases like rabies or cause serious injury or illness. Displaced animals may revert to the wild and go about in packs. They will also be hungry and may be searching for food and may be more likely to bite. Because you may not have access to appropriate medical care, it is important to prevent animal bites and scratches.

• Stay away from all animals, including dogs and cats. Even animals that look like healthy pets can have rabies or other diseases.
• If you are bitten or scratched, wash the wound well with soap and clean water and seek medical care right away. If you have a povidone-iodine solution (such as Betadine), use that to clean the wound after washing it.
• If you have not received pre-exposure rabies vaccination: You will need shots of rabies immune globulin (or RIG) and 4 shots of rabies vaccine over 1 month.
• If you have received pre-exposure rabies vaccination: You will need two shots of rabies vaccine over 3 days.
• Rabies vaccine and rabies immune globulin are probably not available in Haiti at this time. You will need to have a plan in place to fly to another country for treatment.
• Resist the urge to rescue animals with the intent to bring them home to the United States. Dogs and cats may be infected with rabies but not show signs until several days or weeks after you first encounter them.
• After you return from Haiti, be sure to tell your doctor or state health department if you were bitten or scratched during travel.
• For more information about how to protect yourself from other risks related to animals, see Animal-Associated Hazards. To learn more about Rabies see CDC’s Rabies homepage.

Injury

The risk of injury after an earthquake is high. Hazards such as electrocution from downed power lines and structural damage to buildings and roads all pose a risk. Accidents and violence are documented risks for humanitarian workers and cause more deaths than disease and natural causes. According to the World Health Organization, injuries are among the leading causes of preventable death in travelers.

• The majority of the road network in Haiti is not paved. Haiti is predominately mountainous and has extensive deforestation and soil erosion, making travel over roadways especially hazardous. Exercise extreme care when traveling on roads particularly in rural areas.
• There has been extensive structural damage to buildings in Haiti. Avoid unstable structures if possible.
• Other potential hazards to be aware of in collapsed buildings include standing water from water system breaks, natural gas leaks, airborne smoke and dusk, hazardous materials such as ammonia or leaking fuels, exposure to germs from sewer line breaks, and exposed wiring.
• Use personal protection equipment, such as hard hats and steel-toed boots, if in areas with damaged buildings.

Heat-related Illness

Haiti has a tropical climate throughout the year with average temperatures of 25°C (77°F) to 29°C (84°F). If you are not acclimatized to hot and humid climates you may be at risk for heat-related illnesses such as heat stress, heat exhaustion or even heat stroke*. This is especially true for persons who will be doing physical work in Haiti, even if you are used to exerting yourself. Heat-related illness has been reported in Haiti among the relief workers. Because access to medical care may be limited, it is important to prevent heat-related illness while working in Haiti.

Different types and symptoms of heat-related illness*

• Heat Stress:
• Heat rash
• Heat cramps-muscle contractions in the stomach, arms or legs
• Fainting or light-headedness
• Heat Exhaustion:
• Heavy sweating
• Paleness
• Muscle cramps
• Weakness
• Headache and/or dizziness
• Nausea or vomiting
• Fainting
• Heat Stroke:
• Extremely high body temperature (>103°F, orally)
• Red, hot, and dry skin (no sweating)
• Rapid, strong pulse
• Throbbing headache
• Dizziness
• Nausea
• Confusion
• Unconsciousness

Heat stroke can cause death or permanent disability if emergency treatment is not provided.

Ways to Prevent Heat-related Illness

• Drink plenty of fluids and replace salts and minerals while working in hot weather.  You will need to increase your fluid intake. Don't wait until you're thirsty to drink.
• Wear appropriate clothing and sunscreen.  Clothing should be lightweight, loose, and light-colored to allow maximum air circulation for evaporation yet give protection from the sun. A wide-brimmed hat markedly reduces radiant heat exposure.
• Learn the signs and symptoms of heat-related illness
• When working in the heat, monitor the condition of your co-workers and have someone do the same for you. Heat-related illness can cause a person to become confused or lose consciousness.
• Take more breaks in extreme heat and humidity.  Rest in the shade or a cool area if possible.

What to do if you develop signs of heat-related illness

• Stop all activity, and sit in a shaded area or cool place>
• Slowly drink plenty of water, juice or other nonalcoholic beverage
• Cool down by soaking clothes with water if possible or spraying or sponging with water and fanning the body
• Seek medical attention if symptoms of heat exhaustion or heat stroke are observed

To learn more about heat-related illness, see:

• Extreme Heat: A Prevention Guide to Promote Your Personal Health and Safety http://www.emergencycdc.gov/disasters/extremeheat/heat_guide.asp        
• Temperature Extremes http://wwwnc.cdc.gov/travel/yellowbook/2010/chapter-2/problems-with-heat-and-cold.aspx 
• Sunburn http://wwwnc.cdc.gov/travel/yellowbook/2010/chapter-2/sunburn.aspx
• NIOSH Safety and Health Topic: Heat Stress http://www.cdc.gov/niosh/topics/heatstress/

Exposure to Human Remains

Human remains may contain blood-borne viruses and diarrhea-causing bacteria. Relief workers who are handling remains should take precautions to avoid being exposed to these organisms.

• Protect your face from splashes of body fluids and fecal material by using a plastic face shield or a combination of eye protection and surgical mask. In extreme situations, a cloth tied over the nose and mouth can be used to block splashes.
• Protect your hands from direct contact with body fluids and from injuries that break the skin by using a combination of a cut-proof inner layer glove and a latex (or similar) outer layer.
• Wash your hands with soap and water or with an alcohol-based hand cleaner immediately after you remove the gloves.
• Protect your feet and ankles against sharp debris by wearing foot wear that covers the entire foot and has thick soles.
• Give prompt care—including immediate cleansing with soap and water, and a tetanus booster if indicated—to anyone who is injured during work with human remains.  

For more extensive information about working with human remains after a disaster, see the Interim Health Recommendations for Workers who Handle Human Remains After a Disaster fact sheet.

Psychological/Emotional Difficulties

As a first responder or relief worker, you may encounter extremely stressful situations, such as witnessing a tremendous loss of life, serious injuries, missing and separated families, and destruction of whole areas. It is important to recognize that these experiences may cause you psychological or emotional difficulties.

Some Common Normal Reactions to a Disaster

• Profound sadness, grief, and anger.
• Not wanting to leave the scene until the work is finished.
• Trying to override stress and fatigue with dedication and commitment.
• Denying the need for rest and recovery time.

Ways to Help Manage Your Stress

• Limit on-duty work time to no more than 12 hours per day.
• Rotate work assignments between high stress and lower stress functions.
• Drink plenty of water and eat healthy snacks and energy foods.
• Take frequent, brief breaks from the scene when you are able.
• Keep an object of comfort with you such as a family photo, favorite music, or religious material.
• Stay in touch with family and friends.
• Pair up with another responder so that you can monitor one another’s stress.

To learn about mental health resources, see:

• Self-Care Tips for Stress
• Download Podcasts on stress management for first responders: Stress Management for Emergency Responders - What Responders Can Do
• NIOSH: Traumatic Incident Stress: Information for Emergency Response Workers
• NIOSH: Estrés por sucesos traumáticos: Información para el personal de Emergencia

After You Come Home

If you are not feeling well, you should see your doctor and mention that you have recently returned from response and relief work in Haiti. Also tell your doctor if you were bitten or scratched by an animal while traveling.

Symptoms of malaria can develop up to one year after travel, so be alert for fever or flu-like symptoms.

Approximately one-third of aid workers report depression shortly after returning home, and more than half of returned aid workers have reported feeling predominantly negative emotions on returning home, even though many reported that their time overseas was positive and fulfilling. You might want to see a mental health professional to help you adjust back into your home environment.

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