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To: Jeffrey Epstein CC[jeevacation©gmail.com] From: Lesley Groff Sent: Wed 11/9/2011 8:25:38 PM Subject: Ivory Coast CDC Health Information Subject: Ivor Coast CDC Health Information From: Date: Wed 9 Nov 2011 15:21:02 -0500 CC: To: Preparing for Your Trip to Cote d'Ivoire Before visiting Cote d'Ivoire, you may need to get the following vaccinations and medications for vaccine- preventable diseases and other diseases you might be at risk for at your destination: (Note: Your doctor or health-care provider will determine what you will need, depending on factors such as your health and immunization history, areas of the country you will be visiting, and planned activities.) To have the most benefit, see a health-care provider at least 4-6 weeks before your trip to allow time for your vaccines to take effect and to start taking medicine to prevent malaria, if you need it. Even if you have less than 4 weeks before you leave, you should still see a health-care provider for needed vaccines, anti-malaria drugs and other medications and information about how to protect yourself from illness and injury while traveling. CDC recommends that you see a health-care provider who EFTA_R1_00870799 EFTA02180900 specializes in Travel Medicine. Find a travel medicine clinic near you. If you have a medical condition, you should also share your travel plans with any doctors you are currently seeing for other medical reasons. If your travel plans will take you to more than one country during a single trip, be sure to let your health-care provider know so that you can receive the appropriate vaccinations and information for all of your destinations. Long-term travelers, such as those who plan to work or study abroad, may also need additional vaccinations as required by their employer or school. Be sure your routine vaccinations are up-to- date. Check the links below to see which vaccinations adults and children should get. Routine vaccines, as they are often called, such as for influenza, chickenpox (or varicella), polio, measles/mumps/rubella (MMR), and diphtheria/pertussis/tetanus (DPT) are given at all stages of life; see the childhood and adolescent immunization schedule and routine adult immunjlitgrnt• Routine vaccines are recommended even if you do not travel. Although childhood diseases, such as measles, rarely occur in the United States, they are still common in many parts of the world. A traveler who is not vaccinated would be at risk for infection. Vaccine-Preventable Diseases Vaccine recommendations are based on the best EFTA_R1_00870800 EFTA02180901 available risk information. Please note that the level of risk for vaccine-preventable diseases can change at any time. Vaccination or Recommendations or Requirements for Vaccine- Disease Preventable Diseases Routine Recommended if you are not up-to-date with routine shots, such as measles/mumps/rubella (MMR) vaccine, diphtheria/pertussis/tetanus (DPT) vaccine, poliovirus vaccine, etc. Hepatitis A or Recommended for all unvaccinated people traveling to immune or working in countries with an intermediate or high globulin (IG) level of hepatitis A virus infection (see map) where exposure might occur through food or water. Cases of travel-related hepatitis A can also occur in travelers to developing countries with "standard' tourist itineraries, accommodations, and food consumption behaviors. Hepatitis B Recommended for all unvaccinated persons traveling to or working in countries with intermediate to high levels of endemic HBV transmission (sire map), especially those who might be exposed to blood or body fluids, have sexual contact with the local population, or be exposed through medical treatment (e.g., for an accident). Tvohoid Recommended for all unvaccinated people traveling to or working in West Africa, especially if staying with friends or relatives or visiting smaller cities, villages, or rural areas where exposure might occur through food or water. Polio Recommended for adult travelers who have received a primary series with either inactivated poliovirus vaccine (IPV) or oral polio vaccine (OPV). They should receive another dose of IPV before departure. For adults, available data do not indicate the need for more than a single lifetime booster dose with WV. Yellow Fever Requirements: Required upon arrival from all countries for travelers ≥1 year of age. Recommendations: Recommended for all travelers ≥9 months of age. Vaccination should be given 10 days before travel and at 10-year intervals if there is on-going risk. Find an authorized U.S. yellow fever vaccination clinic. Menlnoococcal Recommended if you plan to visit countries that imeninaltisl experience epidemics of meningococcal disease during December through June (see map). EFTA_R1_00870801 EFTA02180902 flaDLO Recommended for travelers spending a lot of time • outdoors, especially in rural areas, involved in activities such as bicycling, camping, or hiking. Also recommended for travelers with significant occupational risks (such as veterinarians), for long- term travelers and expatriates living in areas with a significant risk of exposure, and for travelers involved in any activities that might bring them into direct contact with bats, carnivores, and other mammals. Children are considered at higher risk because they tend to play with animals, may receive more severe bites, or may not report bites. Malaria Areas of C6te d'Ivoire with Malaria: All (rnoreinformapjan) If you will be visiting an area of Cote d'Ivoire with malaria, you will need to discuss with your doctor the best ways for you to avoid getting sick with malaria. 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 bednets All of the following antimalarial drugs are equal options for preventing malaria in Cote d' voire:Atovaquone-proguanil, doxycycline, or mefloquine. For detailed information about each of these drugs, see Table 3.11: Drugs usedja_the prophylaxis of malaria. For information that can help you and your doctor decide which of these drugs would be best for you, please see Choosing a Drug to Prevent malaria. Note: Chloroquine is NOT an effective antimalarial drug in Cote d'Ivoire and should not be taken to prevent malaria in this region. EFTA_R1_00870802 EFTA02180903 To find out more information on malaria throughout the world, you can use the interactive CDC malaria map. You can search or browse countries, cities, and place names for more specific malaria risk information and the recommended prevention medicines for that area. Malaria Contact for Health- Care Providers For assistance with the diagnosis or management of suspected cases of malaria, call the CDC Malaria Hotline: 770.488.7788 (14-F, 9 am-5 pm, Eastern time). For emergency consultation after hours, call 770.488.7100 and ask to speak with a CDC Malaria Branch clinician. A Special Note about Antimalarial Drugs You should purchase your antimalarial drugs before travel. Drugs purchased overseas may not be manufactured according to United States standards and may not be effective. They also may be dangerous, contain counterfeit medications or contaminants, or be combinations of drugs that are not safe to use. Halofantrine (marketed as Halfan) is widely used overseas to treat malaria. CDC recommends that you do NOT use halofantrine because of serious heart-related side effects, including deaths. You should avoid using antimalarial drugs that are not recommended unless you have been diagnosed with life- threatening malaria and no other options are immediately available. For detailed information about these antimalarial drugs, see Choosinta Drug to Prevent Malaria. More Information About EFTA_R1_00870803 EFTA02180904 Malaria Malaria is always a serious disease and may be a deadly illness. Humans get malaria from the bite of a mosquito Infected with the parasite. Prevent this serious disease by seeing your health-care provider for a prescription antimalarial drug and by protecting yourself against mosquito bites (SetbelAw). Travelers to malaria risk-areas in Cote d'Ivoire, including infants, children, and former residents of ate d'Ivoire, should take one of the antimalarial drugs listed in the box above. Symptoms Malaria symptoms may include • fever • chills • sweats • headache • body aches • nausea and vomiting • fatigue Malaria symptoms will occur at least 7 to 9 days after being bitten by an infected mosquito. Fever in the first week of travel in a malaria-risk area is unlikely to be malaria; however, you should see a doctor right away if you develop a fever during your trip. Malaria may cause anemia and jaundice. Malaria infections with Plasmodium falciparum, if not promptly treated, may cause kidney failure, coma, and death. Despite using the protective measures outlined above, travelers may still develop malaria up to a year after returning from a malarious area. You should see a doctor immediately if you develop a fever anytime during the year following your return and tell the physician of your travel. EFTA_R1_00870804 EFTA02180905 Items to Bring With You Medicines you may need: • The prescription medicines you take every day. Make sure you have enough to last during your trip. Keep them in their original prescription bottles and always in your carry-on luggage. Be sure to follow security guidelines, if the medicines are liquids. • Antimalarial drugs, if traveling to a malaria-risk area in Cote d'Ivoire and prescribed by your doctor. • Medicine for diarrhea, usually over- the-counter. Note: Some drugs available by prescription in the US are illegal in other countries. Check the US Department of State Consular Information Sheets for the country(s) you intend to visit or the embassy or consulate for that country(s). If your medication is not allowed in the country you will be visiting, ask your health-care provider to write a letter on office stationery stating the medication has been prescribed for you. Other items you may need: • Iodine tablets and portable water filters to purify water if bottled water Is not available. See A Guide to Water Filters, A Guide to Commercially-Bottled Water and Other Beverages, and Safe Food and Water for more detailed information. • Sunblock and sunglasses for protection from harmful effects of UV sun rays. See Basic Information about Skin Cancer for more information. EFTA_R1_00870805 EFTA02180906 • Antibacterial hand wipes or alcohol-based hand sanitizer containing at least 60% alcohol. • To prevent insect/mosquito bites, bring: o Lightweight long- sleeved shirts, long pants, and a hat to wear outside, whenever possible. o Flying-insect spray to help clear rooms of mosquitoes. The product should contain a pyrethroid Insecticide; these insecticides quickly kill flying insects, including mosquitoes. o Bed nets treated with permethrin, if you will not be sleeping in an air- conditioned or well- screened room and will be in malaria-risk areas. For use and purchasing information, seeInsecticide Treated Bed Nets on the CDC malaria site. Overseas, permethrin or another insecticide, deltamethrin, may be purchased to treat bed nets and clothes. See other suggested over-the- counter medications and first aid items for a travelers' health ht. Note: Check the Air Travel section of the Transportation Security Administration website for the latest Information about airport screening procedures and prohibited items. Too of Page Other Diseases Found in West Africa Risk can vary between countries within this region and also within a EFTA_R1_00870806 EFTA02180907 country; the quality of in- country surveillance also varies. The following are disease risks that might affect travelers; this Is not a complete list of diseases that can be present. Environmental conditions may also change, and up to date information about risk by regions within a country may also not always be available. Dengue, filariasis, leishmaniasis and gncnocerciasig (river blindness) are other diseases carried by insects that also occur in West Africa. African trvoanosomiasis (African sleeping sickness' has Increased In Africa (it is epidemic in Angola, Democratic Republic of the Congo, and the Sudan; and highly endemic in Cameroon, Central African Republic, Chad, Congo, Cote d'Ivoire, Guinea, Mozambique, Uganda, and Tanzania; low levels are found in most of the other countries), and an increase in travelers has been noted since 2000. Most had exposures in Tanzania and Kenya, reflecting common tourist routes. protecting yourself against insect bites will help to prevent these diseases. Schictosomiasis a parasitic infection, can be contracted in fresh water in this region. Do not swim in fresh water (except in well-chlorinated swimming pools) in these countries. Polio outbreaks were reported in several previously polio-free countries in Central, Eastern, and Western Africa beginning in 2003. Polio is still endemic in Nigeria. Travelers to rural areas of West Africa may be exposed to Lassa virus, which is spread through contact with rat urine or EFTA_R1_00870807 EFTA02180908 droppings. People can be exposed to Lassa virus by inhaling tiny particles of these excretions in the air, especially if they stay in traditional dwellings. Travelers should avoid contact with rats and should not stay in dwellings that may be infested with rats. Human-to•human transmission of the disease has been described. proper safety precautions should be followed to prevent human-to-human transmission from Infected people. Highly pathogenic avian influenza (H5N1) has been found in poultry populations in several countries in Africa. Avoid all direct contact with birds, including domestic poultry (such as chickens and ducks) and wild birds, and avoid places such as poultry farms and bird markets where live birds are raised or kept. For a current list of countries reporting outbreaks of H5N1 among poultry and/or wild birds, view updates from the World Organization for Animal Health (OIF) and for total numbers of confirmed human cases of H5N1 virus by country see the World Health Organization (WHO) Avian Influenza website. Many countries in this region have high Incidence rates of tuberculosis and high HIM prevalence rates. TOD Of Page Staying Healthy During Your Trip Prevent Insect Bites Many diseases, like malaria and Ongmg, are spread through Insect bites. One of the best protections is to prevent insect bites by: EFTA_R1_00870808 EFTA02180909 • Using Insect repellent (bug spray) with 30%- 50% DEET. Picaridin, available in 7% and 15% concentrations, needs more frequent application. There is less information available on how effective picaridin is at protecting against all of the types of mosquitoes that transmit malaria. • Wearing long-sleeved shirts, long pants, and a hat outdoors. • Remaining indoors in a screened or air- conditioned area during the peak biting period for malaria (dusk and dawn). • Sleeping in beds covered by nets 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 Arthrop_od Protection. Prevent Animal Bites and Scratches Direct contact with animals can spread diseases like rabies or cause serious injury or illness. It is important to prevent animal bites and scratches. • Be sure you are up to date with tetanus vaccination. • Do not touch or feed any animals, including dogs and cats. Even animals that look like healthy pets can have rabies or other diseases. • Help children stay safe by supervising them carefully around all animals. EFTA_R1_00870809 EFTA02180910 • If you are bitten or scratched, wash the wound well with soap and water and go to a doctor right away. • After your trip, be sure to tell your doctor or state health department if you were bitten or scratched during travel. For more information about rabies and travel, see the Rabies chapter of the Yellow Book or CDC's Rabies homepacte. For more Information about how to protect yourself from other risks related to animals, seeAnimal- Associated Hazards. Be Careful about Food and Water Diseases from food and water are the leading cause of illness In travelers. Follow these tips for safe eating and drinking: • Wash your hands often with soap and water, especially before eating. If soap and water are not available, use an alcohol- based hand gel (with at least 60% alcohol). • Drink only bottled or boiled water, or carbonated (bubbly) drinks in cans or bottles. Avoid tap water, fountain drinks, and Ice cubes. If this is not possible, learn how to make water safer to drink. • Do not eat food purchased from street vendors. • Make sure food is fully cooked. • Avoid dairy products, unless you know they have been pasteurized. Diseases from food and water often cause vomiting and diarrhea. Make sure to bring diarrhea medicine with you so EFTA_R1_00870810 EFTA02180911 that you can treat mild cases yourself. Avoid Injuries Car crashes are a leading cause of imury among travelers. Protect yourself from these injuries by: • Not drinking and driving. • Wearing your seat belt and using car seats or booster seats in the backseat for children. • Following local traffic laws. • Wearing helmets when you ride bikes, motorcycles, and motor bikes. • Not getting on an overloaded bus or mini- bus. • Hiring a local driver, when possible. • Avoiding night driving. Other Health Tips • To avoid infections such as HIV and viral hepatitis do not share needles for tattoos, body piercing, or injections. • To reduce the risk of HIV and other sexually transmitted diseases always use latex condoms. • To prevent fungal and parasitic infections, keep feet clean and dry, and do not go barefoot, especially on beaches where animals may have defecated. Teo Of Page After You Return Home If you are not feeling well, you should see your doctor and mention that you have recently traveled. Also tell your doctor if you were bitten or scratched by an animal while traveling. EFTA_R1_00870811 EFTA02180912 If you have visited a malaria- risk area, continue taking your antimalarial drug for 4 weeks (doxycycline or mefloquine) or seven days (atovaguone/proguanil) after leaving the risk area. 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 traveling in a malaria-risk area or after you return home (for up to 1 year), you should seek Immediate medical attention and should tell the physician your travel history. Important Note: This ocument is not a complete medical guide for travelers o this region. Consult with our doctor for specific nforrnation related to your eeds and your medical history; recommendations may differ for pregnant omen, young children, and persons who have chronic medical conditions. Top of Page Map Disclaimer - The boundaries and names shown and the designations used on maps do not imply the expression of any opinion whatsoever on the part of the Centers for Disease Control and Prevention concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Approximate border lines for which there may not yet be full agreement are generally marked. iize: M L XL page wage EFTA_R1_00870812 EFTA02180913 lark and share his to... tes o.us )ok ) Bookmarks MyWeb nail updates Kt Us: s for Disease Control and Prevention 1600 Clifton Rd a, GA 30333 DC-INFO (800-232.4636) 888) 232-6348 ours of Operation 8am-8pm ET/Monday-Friday I Holidays D@cdc.gov Email page Print page Bookmark and share Add this to... Favorites Del.icio.us Digg Facebook Google Bookmarks Yahoo MyWeb Get email updates Page created: February 22, 2011 Page last updated: November 03, 2011 Page last reviewed: September 29, 2011 Content source: Centers for Disease Control and Prevention National Center for Emerging and Zoonotic Infectious Diseases (NCEZID) Division of Global Migration and Quarantine (DGMQ) Travelers' HealthAll CDC Topics Search The CDC Search Button On Nov 9, 2011, at 2:53 PM, Jeffrey Epstein wrote: find out about disease shots for ivory coast. rasseck tells me malaria is there *********************************************************** The information contained in this communication is confidential, may be attorney-client privileged, may constitute inside information, and is intended only for the use of the addressee. It is the property of Jeffrey Epstein Unauthorized use, disclosure or copying of this EFTA_R1_00870813 EFTA02180914 communication or any part thereof is strictly prohibited and may be unlawful. If you have received this communication in error, please notify us immediately by return e-mail or by e-mail to jeevacation(d\gmail.com, and destroy this communication and all copies thereof, including all attachments. copyright -all rights reserved EFTA_R1_00870814 EFTA02180915