AIDS/HIV : Increased cases reported especially from eastern Europe (mainly Romania and Bul-garia) and Russia. Infected blood and contaminated needles and syringes are important sources of infection in these countries. Travelers should consider carrying sterile needles and syringes and should avoid, if possible, blood transfusions and medical injections in these countries. Blood supplies are reportedly screened in Czechoslovakia, Hungary, and Poland, but lack of public health funding may hamper complete screening for AIDS and hepatitis B and C viruses. Travelers should consider evacuation to a European medical facility when surgical care, or blood transfusions, are needed.

Crimean-Congo Hemorrhagic Fever : This is a viral encephalitis transmitted by Hyalomma marginatum ticks. These ticks are most active from April until August, reaching peak feed-ing activity April through May.

Diphtheria : The diphtheria epidemic that started in Moscow in the 1990s and then spread to the Newly Independent States is still a threat. Cases have declined in Russia but are increasing elsewhere. Vaccine control programs, however, are starting to take effect. All travelers to these countries, especially adults, should be fully immunized against diphtheria.

Ehrlichiosis : Cases of human granulocytic ehrlichiosis have been reported from Slovenia and the Netherlands.

European Tick-Borne Encephalitis (TBE) : The tick vector for this disease, Ixodes ricinus (the same tick that transmits Lyme disease), is widely distributed in brushy and forested areas at elevations up to 1,500 meters. TBE occurs in all European countries (especially Austria, Ger-many, Switzerland, the Czech Republic, Hungary, The Balkans, and Eastern Europe) except the Benelux countries and the Iberian Peninsula.

Hemorrhagic Fever with Renal Syndrome (HFRS) : Cases of Hantavirus illness are reported in The Balkans and in eastern Europe. A milder form of HFRS (caused by Puumala virus) occurs in Scandinavia, other European countries, and European Russia. Travelers should avoid contact with rodent urine or rodent feces, which transmit the virus.

Hepatitis : All nonimmune travelers should receive hepatitis A vaccine prior to visiting Spain, Greece, Yugoslavia and the Balkan States, and the eastern European countries, especially Bulgaria, Hungary, and Romania. The hepatitis B carrier rate in the general population of Europe is variable, but is less than 1% in most western European countries. The hepatitis B carrier rate increases to 1%–4% in Spain, Greece, and Eastern Europe. Hepatitis B vaccina-tion should be considered by anyone planning an extended visit to Spain, Greece, the Bal-kan States, and the eastern European countries, especially Bulgaria, Hungary, and Romania.

Leishmaniasis : Cutaneous and visceral leishmaniasis is present in the countries bordering the Mediterranean. Risk areas include Portugal, Spain, southern France, the Naples area, Majorca, the suburbs of Athens, and the Greek Isles. Travelers to these areas should take mea-sures to prevent sandfly bites.

Lyme Disease : Risk of transmission occurs throughout Europe in rural brushy, wooded, and forested areas up to 1,500 meters elevation, especially in Scandinavia, Austria, Switzerland, southern Germany, and northern Italy. The ticks that transmit Lyme disease are most abundant and active April through September. The Lyme disease vaccine made in America is not effective against European strains of borrelia.

Malaria : There is no risk of malaria in western or eastern Europe.

Mediterranean Spotted (Boutonneuse) Fever : Occurs in southern France and in the coastal regions of other Mediterranean countries, and also along the Black Sea coast, in brushy and/or forested areas below 1,000 meters elevation. Peak transmission period is July through September. Disease may be acquired in and around tick-infested houses and terrain, but more than 95% of cases are associated with contact with tick-carrying dogs.

Other Diseases/Hazards : Brucellosis, echinococcosis (southern Europe), Legionnaire’s dis-ease (legionellosis outbreaks have been reported in tourists on package tours to Spain and Naples, Italy; contaminated water probable source), leptospirosis, listeriosis (from contami-nated soft cheeses and meat), tick-borne relapsing fever (risk in rocky, rural livestock areas), and soil-transmitted helminthic infections (roundworm, hookworm, and whipworm infec-tions; reported occasionally in southern Europe). There is a high incidence of yersinia in-fections in Scandinavia from tainted beef. Raw cod (“lutefish”) in Scandinavia may contain the fish tapeworm, Diphyllobothrium latum, a cause of pernicious anemia.

Pertussis (whooping cough) : Reported in the Netherlands. The new strain of Bordetela pertussis bacterium is resistant to a leading vaccine and attacks adults as well as children. Leishmaniasis: Cutaneous and visceral leishmaniasis is present in the countries bordering the Mediterranean. Risk areas include Portugal, Spain, southern France, the Naples area, Majorca, the suburbs of Athens, and the Greek Isles. Travelers to these areas should take mea-sures to prevent sandfly bites.

Rabies : Occurs primarily in wild animals, especially foxes, in many rural areas of Europe. Human cases are infrequent. There is no risk of rabies in Finland, Iceland, Ireland, Sweden, the United Kingdom, Gibraltar, Malta, Monaco, Portugal, and Spain.

Road Safety : Pedestrians should use extra caution when crossing the street in countries where there is left-sided traffic. There is a higher incidence of motor vehicle fatalities in Spain, Por-tugal, Yugoslavia, Greece, and eastern Europe. Seat belts should be worn at all times.

Sandfly Fever and West Nile Fever : Cases reported from Albania and Adriatic area.

Swimmer’s Itch : Widespread increase in cercarial dermatitis has occurred in Central Europe (primarily Germany, Austria, Czech Republic), especially during the hot summer months. The causative cercariae (which penetrate the skin) are found in ponds and lakes that are snail-infested and where ducks are found.

Travelers' Diarrhea : Low risk in most western European countries. Higher risk occurs in Spain, Greece, the Balkans, and eastern Europe, especially Bulgaria, Hungary, and Romania. Travelers to higher risk areas should drink only bottled, boiled, or treated water and avoid undercooked food. A quinolone antibiotic is recommended for the treatment of diarrhea.