Destination Background

China, with more than 1.3 billion people, is the most populous country in the world, and the fourth largest geographically, behind Russia, Canada, and the United States. It shares a border with 14 other countries. China is divided into 23 provinces, five autonomous regions, and four municipalities.

This large landmass is home to diverse climates, topography, languages, and customs. China has one of the world’s oldest continuous civilizations, dating back more than 5,000 years. It has the world’s longest continuously used written language system and is the source of many major inventions, including the “four great inventions of Ancient China”: paper, the compass, gunpowder, and printing. Today, China is considerably more advanced (with the ability to put men in space, for example) and wealthier than many other developing countries, yet rural poverty and underdevelopment are still significant problems, particularly in the western part of the country.

About 800 million Chinese live in rural areas. Urban areas are growing rapidly, however, and China is now home to many of the world’s largest megacities. Shanghai and Beijing each have close to 20 million inhabitants, and Chongqing, with a population exceeding 30 million, is the fastest-growing urban center in the world. Rivers play a central role in China’s economy, history, and culture. The Yangtze River basin, stretching 4,000 miles from the Tibetan plateau to the East China Sea near Shanghai, is home to approximately 10% of the world’s population.

In 2006, about 50 million tourists visited China, and by 2020, China is widely predicted to be both the largest tourist destination and the largest source for tourists to other countries. China’s 5,000 years of continuous civilization and varied natural beauty can be traced in its 37 UNESCO World Heritage Sites, from the imperial grandeur of the Forbidden City and the Temple of Heaven to the marvel of the Great Wall, the Terracotta Warriors in Xi’an, and the spectacular mountainous sanctuaries of the west. Popular itineraries often include Beijing and the Great Wall, Xi’an, and the Yangtze River. Other important tourist destinations include:

• Shanghai and Hong Kong, with their futuristic architecture and East-meets-West mystique
• Lijiang and Yunnan, home to many of China’s ethnic minorities, as well as its iconic symbol, the panda
• Guilin, famous for its uniquely shaped limestone Karst mountains that are so often featured in Chinese paintings
• Tibet, accessible now by the world’s highest railroad directly to Lhasa, with a maximum altitude of 16,640 ft  (5,072 m)

Specialized itineraries are increasingly being offered, including hiking, mountain climbing, village tours, the Silk Road, and other more remote regions. Aside from tourism, increasing numbers of people travel to China to visit friends and relatives, to study, or to adopt children. These groups may be at particularly high risk of illness because they underestimate their risks, are less likely to seek pre-travel advice, and stay in more local or rural accommodations. People traveling to China to adopt children often worry about the health of the child but neglect their own travel health safety.

Although China is now the world’s third-largest economy, in per capita terms it is still a low-income country, with wide disparity in income and development between rural and urban and east and west. Health risks vary accordingly.

Immunizations Routine vaccinations should be up-to-date, including tetanus/diphtheria, measles, rubella, varicella, influenza, and pneumococcal vaccines, as indicated. In addition, hepatitis A, hepatitis B, and typhoid vaccinations are usually recommended. Measles immunity is particularly important, as China reports upwards of 100,000 measles cases annually. A few travelers have made news headlines by triggering outbreaks in their own countries on return from trips to China.

Rabies Vaccine
Rabies is a serious problem in China, as in much of Asia, with more than 3,000 human deaths per year reported in recent years. This mortality rate has made rabies, at least officially, the most important infectious disease killer of humans in China. Animal bites in any area of China, including urban areas, must be considered high risk for rabies. As international standard rabies immune globulin is generally unavailable, animal bites are often trip-enders, requiring evacuation to Hong Kong or home for postexposure prophylaxis. Bites are surprisingly common in tourists; dog bites were the most common dermatologic problem seen after China travel in a recent analysis of data from the GeoSentinel Network. Rabies risk and prevention should be discussed in pre-travel consultations, and a strategy for dealing with a possible exposure should be developed.

Japanese Encephalitis Vaccine
Japanese encephalitis (JE) occurs in all regions except Qinghai, Xinjiang, and Xizang (Tibet). Although the JE season varies by region, most human cases are reported from April to October. The risk of JE for most travelers to China is very low but varies based on season, destination, duration, and activities. Risk is highest among travelers to rural areas during the transmission season. JE vaccine is only recommended for travelers who plan to spend a month or longer in endemic areas or shorter-term travelers who plan to spend significant time in rural areas or doing outdoor activities. However, rare sporadic cases have occurred on an unpredictable basis in short-term travelers, including those on Yangtze River cruises or in peri-urban Beijing.

Malaria
 Malaria is very rarely a consideration for travelers to China, with the exception of those visiting rural parts of Anhui, Yunnan, or Hainan Island. For these areas, chemoprophylaxis should be considered; for travelers to other regions, the risk is too low to warrant it. Rare cases occur in other rural parts of the country below 1,500 m (4,921 ft) between May and December, and only insect precautions are recommended.

Other Health Risks

Foodborne Illnesses
The risk for travelers’ diarrhea appears to be low in deluxe accommodations in China, but moderate elsewhere. Usual food and water precautions should apply, and travelers should carry an antibiotic for empiric self-treatment. Tap water is not drinkable even in major cities, except Hong Kong. Most hotels provide bottled or boiled water, and bottled water is easily available. In addition, there have been several well-publicized episodes of contamination of food with pesticides and other substances. Travelers should strictly avoid undercooked fish and shellfish, and unpasteurized milk.

Sexually Transmitted Diseases
 Sexually transmitted diseases, including syphilis, HIV, gonorrhea, and chlamydia, are a growing problem in China, particularly along the booming eastern seaboard. Travel is associated with loosened inhibitions and increased casual sexual liaisons. Aside from risk-reduction counseling, remember hepatitis B vaccination for those who might be at risk.

Air Pollution
Air pollution is a problem in most major cities in China. There is significant potential for exacerbation of respiratory conditions, including asthma and chronic obstructive pulmonary disease (COPD), and heightened risk for respiratory infections. Susceptible travelers should receive influenza and pneumococcal vaccination and bring any inhaled medications they may use.

Medical Care in China
Western-style medical facilities that meet international standards are available in Beijing, Shanghai, and Hong Kong. Some hospitals in other cities have “VIP wards” (gaogan bingfang), which may have English-speaking staff. The standard of care in such facilities is somewhat unpredictable, and cultural and regulatory differences can cause difficulties for travelers. In rural areas, only rudimentary medical care may be available. Hepatitis B transmission from poorly sterilized medical equipment remains a risk outside major centers.

Pharmacies often sell prescription medications over the counter. Such medications have sometimes been counterfeit, substandard, or even contaminated. Travelers should carry all their regular medications in sufficient quantity; if more or other medications are required, it is advisable to visit a reputable clinic or hospital.

Some travelers wish to try traditional Chinese medicine and acupuncture. While most do so uneventfully, there is potential risk from nonsterile acupuncture needles and contamination of traditional medicine products with heavy metals or pharmaceutical agents. Acupressure may be preferable to acupuncture.

Language and Culture
Finally, language will be a problem for many travelers to China. Outside major tourist destinations, English speakers may be rare, and most signage will be in Chinese characters. In general, people are helpful and friendly to tourists, and personal safety is rarely an issue. Cultural sensitivity is essential, however. Chinese will often ask near strangers about their weight, their age, and their income, subjects that are taboo in many Western cultures. Travelers should try to avoid taking offense. In turn, Westerners may offend Chinese by raising their voice, losing their temper, or otherwise bringing conflict into the open. Whatever the problem, patience, firmness, and sensitivity to “face” will almost always work better in China than open confrontation.