List of Countries

Western Europe

The area is characterized by a low risk for most infectious diseases.

Vector-borne infections: The only malaria cases are “airport” malaria and imported cases. Lyme disease is found in broad areas of Europe in temperate forested areas. Tick-borne encephalitis is found in Austria, Germany, Finland, Sweden, Switzerland, and Denmark (only on island of Bornholm); a few cases have also been reported from Italy, Norway, and France. Leishmaniasis (cutaneous and visceral) is found, especially in countries bordering the Mediterranean, with the highest numbers of cases from Spain, where it is an important opportunistic infection in HIV-infected persons. Relapsing fever (tick-borne) is found in focal areas in Greece, Italy, Portugal, and Spain; sporadic cases may occur elsewhere in region. Murine typhus is more common in warmer areas, especially Mediterranean port cities. Sandfly fever occurs in warmer months in southern Europe, especially in Italy, Spain, Portugal, and Greece. Small numbers of cases of babesiosis have been reported from the region. A number of countries have reported imported cases of chikungunya fever in 2005-2006.

Food- and water-borne infections: Risk of hepatitis A is low (except for Greenland). Outbreaks of salmonellosis, campylobacteriosis, and other food- and water-borne infections occur, but the risk of diarrhea in travelers is low. Brucellosis is found, especially in southern countries on the Mediterranean. Variant Creutzfeldt-Jacob cases have been reported primarily from the United Kingdom, although a few cases have been reported from other countries. Large outbreaks of trichinosis have occurred; outbreaks in France have been linked to horse meat.

Airborne and person-to-person transmission: Measles transmission has been slowed by vaccination programs. The annual incidence rate of tuberculosis per 100,000 population is estimated to be 10-50 for most of the region and less than 10 in Norway and Sweden.

Sexually transmitted and blood-borne infections: The prevalence of HIV in adults is estimated to be 0.3% in this region.

Zoonotic infections: Large outbreaks of tularemia* have occurred in rural areas in several of these countries, including Sweden, Finland, and Spain. Hantaviruses causing hemorrhagic fever with renal syndrome are widespread; Puumala virus, the cause of mild nephropathia epidemica, is found in Scandinavian and western European countries. Rabies is present in many countries in western Europe; human cases are rare. Echinococcosis* due to Echinococcus granulosus is found, especially in Spain and the Mediterranean countries; areas with alveolar echinococcosis (caused by E. multilocularis) have expanded in recent years, with the largest number of cases found in focal areas of France, Germany, and Switzerland. Q fever* (airborne spread) is a common cause of febrile illness (both sporadic cases and outbreaks), especially in rural areas of Spain, southern France, and other Mediterranean countries.

Highly pathogenic avian influenza virus H5N1 has been documented in wild birds or other avian species in many of the countries (at least 10 by August 2006). No human cases have been documented in this region as of fall 2006.

Soil- and water-associated infections: Legionnaires’ disease is sporadic; some outbreaks have involved tourists at resort hotels.

MAP 3-05 Regions - Western Europe

Eastern Europe and Northern Asia

Access to clean water and adequate levels of sanitation are limited in many parts of the region. Vaccine-preventable diseases remain a problem where levels of immunization are low. The public health infrastructure has deteriorated in areas of conflict; political instability has threatened health in some areas. Common infections in travelers include gastrointestinal infections, respiratory infections, and occasionally vector-borne infections. Chronic and latent infections immigrants (and long-term residents) include tuberculosis (including multidrug-resistant TB) and late sequelae of hepatitis B.

Vector-borne infections: Malaria transmission occurs seasonally in focal rural areas of countries in the southernmost part of the region (Azerbaijan, Georgia, Armenia, Tajikistan, Turkmenistan, and Uzbekistan). Tick-borne encephalitis is wide-spread, occurring in warmer months in the southern part of the nontropical forested regions of Europe and Asia. Most intense transmission has been reported in Russia, the Czech Republic, Latvia, Lithuania, Estonia, Hungary, Poland, and Slovenia. Other vector-borne infections include murine typhus, scrub typhus, spotted fever due to Rickettsia sibirica (North Asian spotted fever), rickettsialpox, relapsing fever (more southern parts of region), Crimean-Congo hemorrhagic fever* (in many countries of the region but primarily in persons working with animals or in hospitals), leishmaniasis (cutaneous and visceral, especially in the southern areas of the former Soviet Union), Lyme disease (throughout the former Soviet Union), sandfly fever (in the southern parts of region), West Nile (a large outbreak occurred in Romania in late 1990s), and Japanese encephalitis (transmission occurs in a limited area of far eastern Russia).

Food- and water-borne infections: A high risk of hepatitis A is present in many parts of the region. Sporadic cases of typhoid fever are reported, and outbreaks occur. Outbreaks of hepatitis E have been reported from the southern areas of Russia. Brucellosis is a risk in many areas (annual incidence 50-500 cases per 100,000 population in many parts of the region). Outbreaks of botulism are usually linked to home canned foods. Sporadic cases of fascioliasis occur. A population of 12.5 million is estimated to be at risk for opisthorchiasis in the region (especially Kazakhstan, Russian Federation, Siberia, and Ukraine).

Airborne and person-to-person transmission: The annual incidence rate of tuberculosis per 100,000 population is estimated to be as high as 100-300 in parts of the region. High rates of drug-resistant TB are found in Estonia, Kazakhstan, Latvia, Lithuania, parts of Russia, and Uzbekistan, where rates of drug resistance in newly diagnosed TB patients are as high as 14%. Cases of diphtheria have declined (after the massive outbreak of the 1990s) with improved rates of immunization. Transmission of measles is declining.

Sexually transmitted and blood-borne infections: The prevalence of HIV in adults is estimated to be 1%-<5% in many parts of the region. It has increased rapidly in parts of the Russian Federation; seroprevalence in prison populations is 2-4%. The prevalence of hepatitis B is intermediate (2%-7%) or high (more than 8%) in most of the region. The prevalence of hepatitis C is 1%-2.4% in much of the area (2.5%-9.9% in Romania).

Zoonotic infections: Rabies is widespread in the region and is increasing in some countries. Tularemia* is widespread and occurs in focal outbreaks. Wild rodent plague* is broadly distributed in southern areas of the former Soviet Union; human cases are rare. Sporadic cases and occasional outbreaks of anthrax* are reported. Q fever* is found, especially in cattle-raising areas. Hantaviruses causing hemorrhagic fever with renal syndrome are found in many countries in the region; infection is sporadic and epidemic. Echinococcosis* occurs sporadically in the area.

Highly pathogenic avian influenza virus H5N1 has been documented in wild birds or other avian species in many of the countries (at least 10 by fall 2006). Human cases and deaths were reported from Azerbaijan in 2006.

Soil- and water-associated infections: No endemic transmission of cholera was reported in 2004.

Other hazards: Motor vehicle accidents and injuries related to ongoing conflicts and alcohol abuse occur. Nosocomial transmission of infections is a problem in many areas because of inadequate infection control procedures. Screening of blood before transfusion is inadequate in many hospitals.

MAP 3-06 Regions - Eastern Europe and Northern Asia