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• Am J Trop Med Hyg
• v.98(4); 2018 Apr

Centers for Disease Control and Prevention Yellow Book 2018: Health Information for International Travelers

Since its first publication in 1967 as a small pamphlet, the Centers for Disease Control and Prevention’s Health Information for International Travel , more commonly known as the Yellow Book, has blossomed into a 667-page, 7 × 10 inch paperback compendium of detailed, pragmatic, evidence-based recommendations on travel health. Although written first and foremost for clinicians (physicians, nurses, and pharmacists), much or most of the guide will be comprehensible to the lay traveler. Now published every other year ($49.95, University of Oxford Press), the Yellow Book is also available online, as an eBook, and as a mobile app.

The 2018 edition is largely similar to the 2016 edition. A few sections have been dropped (e.g., Perspectives on the Role of the Traveler in the Translocation of Disease, and Fear of Vaccines); others have been added (including Antibiotics in Travelers’ Diarrhea—Balancing the Risks and Benefits; and, in the chapter on Advising Travelers with Specific Needs, a section on Immunocompromised Travelers). Length, at 667 pages, is eight pages longer. The organization of chapters is unchanged.

The chapter on the pretravel consultation, in addition to listing the many topics that must be discussed before international travel, features a number of sections termed Perspectives, including discussions of travelers’ perceptions of risk, prioritizing care for the resource-limited traveler, cost analyses to justify the pretravel consultation, and the pros and cons of travelers self-treating travelers’ diarrhea with antibiotics. This chapter also contains helpful sections on altitude illness; jet lag; motion sickness; food and water precautions; protection against mosquitoes, ticks, and other arthropods; and other salient topics.

Chapter 3, by far the longest chapter in the book, details a number of infectious diseases, from amebiasis to Zika. The country-specific information regarding malaria prophylaxis and yellow fever vaccination is particularly helpful for practicing clinicians who need to make decisions about recommendations during a clinical encounter.

Although the country-specific information on malaria designates each malaria-endemic country’s estimated relative risk of malaria for U.S. travelers as being high, moderate, low, or very low, the relatively brief discussion of factors to take into account when deciding whether to advise the traveler to take a prophylactic medication, as opposed to insect precautions only (pp. 239–240 and p. 374), could be expanded.

A welcome addition in recent years has been the inclusion of 15 country-specific malaria maps and a number of yellow fever maps as well. This chapter also contains a number of historical overviews of selected topics, for example, “A History of Yellow Fever Vaccination Requirements,” “A History of Polio Eradication Efforts,” and “A History of Malaria Chemoprophylaxis,” which are interesting and informative for travel medicine buffs.

Chapter 4 discusses 16 common destinations for tourists and other travelers—this is a relatively recent addition to the Yellow Book—including East African safaris; Peru, including Cusco and Machu Picchu; and Saudi Arabia: Hajj/Umrah Pilgrimage (Cambodia, and Egypt and Nile River Cruses have been removed from the print edition but are available in the online version.) These well-informed sections consist of focused discussion of risks to health at specific destinations.

Chapter 5, Post-Travel Evaluation, discusses general considerations when seeing returned ill travelers and pragmatic discussion of workup of common complaints in returned travelers, including fever, prolonged travelers’ diarrhea, and skin and soft tissue infections.

Chapters 6, 7, and 8 address conveyance and transportation issues, travel with infants and children, and advising travelers with specific needs. Given the increasing numbers of travelers who are elderly and/or have specific medical needs, the topic of travelers with ongoing medical issues is particularly relevant to pretravel providers.

Although the sections on noninfectious threats have become longer in recent years, these sections are still relatively brief, given the importance of noninfectious threats to travelers. The chapter on injury prevention is less than five pages, which is less than 1% of the total length of this book. In defense of editors of the Yellow Book, research showing efficacy of interventions that reduce the risk of noninfectious threats to travelers lags behind research on reducing risk from infectious diseases. Nonetheless, given that the title of the book is Health Information for International Travel , not Health Information on Infectious Threats to International Travelers— and that road traffic injuries alone are the cause of as many as 25% of deaths of travelers—this section could benefit from expanded discussion of epidemiology, contributory factors, and strategies to mitigate risk of road traffic injuries, drowning, falls from height, and other noninfectious threats. Many of the infectious diseases discussed in Chapter 3 are extremely rare in travelers; possibly some of these sections could be shortened to allow expanded discussion of more common threats to travelers, including road traffic injuries. In addition, a section on lesbian, gay, bisexual, and transgender travelers would be a welcome addition.

The Yellow Book remains the best single source of information for clinicians who provide care to international travelers. Its tone is reasoned and reasonable; its implicit level of concern—cautious but not paranoid—is ideal. Increased attention to noninfectious threats to travelers would make it better still.

HENRY M. FEDER, JR., MD, AND KENIA MANSILLA-RIVERA, MD

Am Fam Physician. 2013;88(8):524-530

See related Editor's Note

Related letter: Increase in Reported Malaria Cases Prompts Clarification Regarding Diagnosis and Treatment

Author disclosure: No relevant financial affiliations.

Overall, 3% to 19% of travelers to the developing world will return to the United States with fever or will develop fever within weeks of their return. When evaluating the returning traveler with fever, it is important to know which pretravel immunizations the patient received; which medications he or she took during travel; the likely pathogen exposures during travel; and the incubation interval between travel and onset of fever. A physical examination that includes a search for focal findings may narrow the list of possible infections. Fever compatible with a common illness that occurs in the United States (e.g., mononucleosis) should always be considered. If the patient has fever without a focus and a tropical infection is suspected, malaria, dengue fever, and typhoid fever are common causes. These infections may appear clinically similar, with symptoms of fever, headache, muscle pain, joint pain, and malaise, and decreased white blood cell and platelet counts. Malaria can usually be diagnosed with a thin blood smear. Dengue fever is a clinical diagnosis. Serologic testing for dengue virus immunoglobulin M and G and virus detection tests can be performed to confirm the diagnosis, but are not immediately available. Typhoid fever can usually be diagnosed with a blood, urine, or stool culture.

Overall, 3% to 19% of travelers to the developing world will have a fever on their return to the United States, or will develop fever within weeks of their return. These travelers may present to family physicians who will face the challenge of diagnosing the cause of fever. With a history, physical examination, and laboratory tests, the etiology of the fever can be established for many of these patients. 1 – 4 Fever compatible with a common illness that occurs in the United States (e.g., mononucleosis) should always be considered. The most common diseases in each geographic region are listed in Table 1 . 5 The GeoSentinel Surveillance Network has 31 clinical sites on six continents that collect data on diseases of returned travelers. 1 From 1997 to 2006, it identified 24,920 travelers who had acquired travel-related diseases, 28% of whom had fever ( Table 2 ) . 1

The greatest challenge for the family physician is to identify the cause of fever without a focus. Table 3 lists the key elements of patient history for evaluating fever in returned travelers, 4 and Table 4 lists the incubation periods for febrile tropical diseases. 5 The physical examination should include a search for focal findings ( Table 5 ) . 6 – 9 Dengue fever, malaria, and typhoid fever are common causes of fever without a focus in patients in whom a tropical infection is suspected. The physical findings with these infections are often nonspecific. 4

The initial laboratory evaluation of the returned traveler with fever and no focus may include only a few laboratory tests ( Table 6 ) . 5 , 10 Malaria can usually be diagnosed with a thin blood smear (utilizing the Giemsa stain). The Wright stain used in the manual differential of the complete blood count is almost as sensitive for detecting malaria parasites as the thin blood smear. 10 Typhoid fever can be diagnosed with blood, urine, or stool cultures positive for Salmonella typhi . Dengue fever is a clinical diagnosis. Serologic testing for dengue virus immunoglobulin M and G and virus detection tests can be performed to confirm the diagnosis, but are not immediately available. 3 – 8 Three vignettes of patients with travel-related fevers are presented below.

A 20-year-old college student spent a semester in rural Brazil. One week after his return, he developed headache, chills, and fever. Prior to traveling, he received typhoid fever and hepatitis A vaccines. He was prescribed mefloquine for malaria prophylaxis, but did not pick up the prescription. On the fifth day of fever, he was seen by his physician; his temperature was 103°F (39.4°C) and findings from an examination were normal. Results of laboratory tests ( Table 6 5 , 10 ) were normal, except for low white blood cell and platelet counts (2,400 per mm 3 [2.4 × 10 9 per L] and 106 × 10 3 per mm 3 [106 × 10 9 per L], respectively). A thin blood smear and blood culture for malaria were negative. Over the next week, his fever and chills continued .

Outcome and Discussion

On the 15th day of fever, the laboratory tests were repeated. This time, the thin blood smear was positive for Plasmodium falciparum malaria, with less than 1% parasitemia. He was treated as an outpatient with atovaquone/proguanil (Malarone) and was afebrile on the third day of therapy.

The patient's history was consistent with malaria or typhoid fever. He had a history of prolonged travel to an area where both diseases were endemic, had not taken malaria prophylaxis, and had a prolonged illness characterized by high fever, chills, malaise, and headache. Malaria should be suspected in patients with spiking fevers, leukopenia, thrombocytopenia, and increased bands who have visited a malaria-endemic area and did not take prophylaxis. 11 Patients with a low parasitemia may need multiple blood smears to produce a positive result. A thin blood smear consists of a Giemsa stain performed on a thin smear of blood that is fixed with alcohol so that the red blood cells remain intact. If the results of the thin blood smear are negative, then a thick blood smear should be performed. A thick blood smear consists of a Giemsa stain performed on dry blood that is not fixed so that the red blood cells lyse. In the developing world, if malaria blood smears cannot be reliably performed, then rapid diagnostic tests that detect specific circulating malaria antigens may be used. 12 , 13

Four species of Plasmodium can infect humans: P. falciparum, Plasmodium vivax, Plasmodium malariae , and Plasmodium ovale . 14 A fifth Plasmodium species, Plasmodium knowlesi , is an emerging human pathogen that may be mistaken microscopically for P. malariae . Infection with P. knowlesi may occur following exposure to macaque monkeys. 15 Malaria is acquired by bites from Anopheles mosquitoes, which are dusk to dawn feeders ( Figure 1 ) . Malaria sporozoites from the mosquito travel to the human liver, where they develop into merozoites and are released in the blood weeks to months later. The merozoites feed on hemoglobin and rupture the red blood cells in 48 hours (for P. falciparum, P. vivax , and P. ovale ) or 72 hours (for P. malariae ). P. vivax and P. ovale can remain latent in the liver for months or years, and P. malariae can remain latent in red blood cells for months or years. When red blood cells rupture, fever spikes occur. If the rupture happens synchronously, then there would be a tertian fever (recurring every third day) or quartan fever (recurring every fourth day). However, red blood cell rupture usually happens asynchronously, and the fever spikes are usually random. 13 , 15 – 17

P. falciparum is the most common species that infects humans and is the only malaria species that causes fulminant disease, due to high parasitemias and the ability to bind to capillaries and clog the microcirculation. Each year there are more than 250 million cases of malaria worldwide. 10 Malaria, human immunodeficiency virus/AIDS, and tuberculosis are the leading infectious causes of deaths in the world; each is responsible for approximately 1 to 2 million deaths annually. 18 Persons living in malaria-endemic countries develop partial immunity; however, if these persons immigrate to the United States, this immunity rapidly wanes. Approximately 18 million U.S. travelers visit malaria-endemic countries each year, and about 1,500 contract malaria. 12 – 17

Findings in patients with P. falciparum malaria often include fever, headache, malaise, arthralgias/myalgias, nausea/vomiting, and abdominal pain. Splenomegaly or jaundice occurs in less than 35% of patients. Laboratory tests may show anemia (29%), thrombocytopenia (45%); white blood cell count of less than 5,000 per mm 3 (5 × 10 9 per L; 26%); elevated bands (85%); positive thin blood smear (99%); and negative thin blood smear with positive thick blood smear (1%). 10 Rarely, P. falciparum can cause severe hemolysis with hemoglobinuria (also called blackwater fever) and dark red urine. 10 , 13

More than 75% of U.S. travelers with malaria do not take adequate prophylaxis. 4 This might be because of the cost or fear of adverse effects, which include insomnia and vivid dreams with mefloquine. Chemoprophylaxis and diethyltoluamide (DEET)-based mosquito repellants are effective in preventing malaria infection. Persons traveling outside of the United States should use repellents that contain 30% to 50% DEET. 19 Current guidelines for the treatment of malaria are available from the Centers for Disease Control and Prevention ( http://www.cdc.gov/malaria ). Chloroquine (Aralen) is the treatment of choice for P. falciparum in areas where there is no resistance. Other medications, such as quinine plus tetracycline or mefloquine, are effective in chloroquineresistant areas. 4 , 10 , 13 , 17

A seven-year-old Pakistani boy born in the United States visited Pakistan for six weeks with his father. Neither the father nor the boy sought pretravel vaccines or prophylaxis. Fourteen days after returning to the United States, the child developed fever (104°F [40°C]) without a focus. On day 6 of the child's fever, the father initiated a 10-day course of amoxicillin using an old prescription. The fever stopped during the course of amoxicillin, but recurred a few days later, prompting a hospital visit .

This case is a good example of how families visiting their homeland may not believe they can get a tropical infection. The child was seen by a physician on the 23rd day of illness; at this time his temperature was 103°F (39.4°C) and findings from an examination were normal. There was no history of diarrhea. Results of laboratory tests, including multiple malaria blood smears, were negative. Stool and urine cultures were negative for other bacterial pathogens; however, his blood culture was positive for S. typhi sensitive to amoxicillin, ciprofloxacin (Cipro), and trimethoprim/sulfamethoxazole (TMP/SMX). The patient was treated with TMP/SMX for 14 days. He was afebrile in 48 hours.

Salmonella infections are usually acquired via the food chain. Had the child been vaccinated against typhoid fever and avoided certain foods/liquids, this infection may not have occurred. 4 When traveling outside the United States, it is usually safe to consume bottled water; hot cooked food; dry food; and fruits and vegetables that can be peeled. Tap water; ice; fresh juices and salads; unpasteurized dairy products; uncooked sauces and toppings; open buffets; and food sold by street vendors should be avoided. 4

Enteric fever includes S. typhi (typhoid fever) and Salmonella paratyphi (paratyphoid fever) infections. Most enteric fever cases worldwide are typhoid fever. As a result of safer water and food, typhoid fever cases in the United States fell from 35,994 cases in 1920 to about 500 cases per year beginning in 1990. Overall, 80% of the cases in 1990 occurred in travelers. Worldwide, 16 million cases of typhoid fever occur annually, resulting in 600,000 deaths. Asia has the greatest disease burden, with 13 million cases. 20 , 21

Patients with typhoid fever present in a similar fashion to those with malaria. After an incubation period of three to 60 days, the first manifestations of typhoid fever are fever and malaise. The fever increases in a stepwise fashion during the first week, then becomes sustained at 102.5°F to 105°F (39.2°C to 40.6°C) for the next week. Associated symptoms include anorexia, vomiting, and abdominal pain. Diarrhea is more likely in children, whereas constipation is more likely in adults; either occurs in less than one-half of patients. Signs of typhoid fever include rose spots, hepatosplenomegaly, and relative bradycardia with fever spikes. Rose spots, which are easily seen in fair-skinned persons, are maculopapular, pink-colored lesions on the trunk that occur in 5% to 30% of patients. Laboratory tests are nonspecific; findings include leukopenia, thrombocytopenia, elevated erythrocyte sedimentation rate/C-reactive protein level, and elevated liver enzyme level. Typhoid fever should be suspected in patients with spiking fever and leukopenia who have visited a typhoid-endemic area and who have not received a typhoid fever vaccination. 21 Blood cultures are positive in 40% to 60% of patients. 20 , 21 Sometimes urine or stool cultures are positive for S. typhi when blood cultures are negative. The most sensitive way to recover S. typhi is by bone marrow culture, but this is rarely used in routine clinical practice. 20 , 21

S. typhi is becoming increasingly resistant to antibiotics. Amoxicillin and TMP/SMX resistance is common, and ciprofloxacin resistance is becoming more common. Alternatives for oral therapy include cefixime (Suprax) or azithromycin (Zithromax). Amoxicillin is associated with a relapse rate of 4% to 8%, which happened to the patient in vignette 2. 20 – 22 Ciprofloxacin is the drug of choice for empiric typhoid fever treatment, unless local fluoroquinolone resistance is high, such as in the Indian subcontinent. In this case, an injectable third-generation cephalosporin should be the empiric antibiotic choice. 5

A 15-year-old male developed fever two days after his return from the Dominican Republic. He also had malaise, body aches, headache, nausea, and abdominal pain. On day 6 of fever, he developed a generalized rash, gingival bleeding, melena, and bloody emesis, and was hospitalized .

On admission, the patient's vital signs were normal except for a temperature of 100.5°F (38.1°C). His physical examination revealed abdominal tenderness, nonpitting leg edema, and petechiae of the palate and legs. Findings on laboratory tests included hemoconcentration (53% hematocrit) and thrombocytopenia (platelet count of 14 × 10 3 per mm 3 [14 × 10 9 per L]). The patient was treated with intravenous fluids and ceftriaxone (Rocephin) for possible meningococcal sepsis. By day 4 of hospitalization, the patient's symptoms had resolved and results of his laboratory tests were normal. Blood smears and cultures for malaria were negative. Results of serologic testing (enzyme-linked immunosorbent assay) for dengue virus immunoglobulin M (IgM) and IgG were positive. The patient had dengue hemorrhagic fever.

Dengue fever should be suspected in patients with spiking fevers and leukopenia who have visited a dengue-endemic area. 23 – 25 The history of travel has to be within 14 days. The incubation period is typically four to eight days (range of three to 14 days). Dengue fever is transmitted by the day-biting Aedes mosquito ( Figure 2 ) . Four different serotypes of dengue virus (DENV 1, DENV 2, DENV 3, and DENV 4) exist. Infection and immunity to one serotype may predispose to more serious disease if infected with another serotype. Dengue is an arbovirus; the more than 500 arboviruses are transmitted by the bites of mosquitoes, ticks, and sand flies. Dengue virus is in the Flavivirus genus, which includes West Nile and yellow fever viruses. Dengue fever is endemic in more than 100 tropical countries, with 40% of the world's population. The global incidence of dengue infection is 50 to 100 million cases each year, resulting in 500,000 hospitalizations and 12,500 deaths. 23 – 25 A few hundred U.S. travelers develop dengue fever each year. 23 , 24 , 26 – 29 The clinical presentations of dengue and yellow fever are similar, except yellow fever is often associated with hyperbilirubinemia and clinical jaundice. Globally, yellow fever infects about 200,000 persons each year and is fatal in about 30,000. Yellow fever is rare in returned U.S. travelers, with about one case reported every five years. 30

Patients with dengue fever may be asymptomatic or may have a mild undifferentiated febrile illness. Classic dengue fever lasts fewer than seven days. Symptoms include fever, retro-orbital headache, muscle or joint pain, fine maculopapular rash, nausea, and vomiting. In about 1% of patients, dengue fever is severe and manifests as dengue hemorrhagic fever or dengue shock syndrome. 23 Dengue hemorrhagic fever is defined by the triad of hemorrhagic manifestations, thrombocytopenia, and plasma leakage (increased hematocrit level, hypoproteinemia, or effusions). The mortality rate in dengue shock syndrome can be 10% to 20%. 28 , 29 Dengue shock syndrome is characterized by a narrow pulse pressure (less than 20 mm Hg) or hypotension. Dengue hemorrhagic fever and dengue shock syndrome do not occur with the first dengue infection, but may occur on reinfection with a different dengue serotype. 23 , 25 , 28 Antibodies from the first infection may inhibit an adequate antibody response to the second infection. Infants born with their mother's antibodies to one serotype can develop dengue hemorrhagic fever or dengue shock syndrome if infected with another serotype. 23 , 24 , 26 – 29

Laboratory tests for a suspected case of dengue fever include a complete blood count evaluating for leukopenia, thrombocytopenia, and an increased hematocrit level. A tourniquet test involves inflating the blood pressure cuff midway between systolic and diastolic for five minutes. Having more than 20 petechiae per inch of skin is a positive result and can be used to diagnose increased capillary fragility or thrombocytopenia. Dengue fever is usually confirmed by at least a fourfold increase in reciprocal IgG dengue antibody titers in acute/convalescent serum samples. The presence of dengue-specific IgM antibodies is presumptive evidence of acute dengue infection. The most important treatment for dengue fever is bed rest and adequate hydration. Affected patients should avoid aspirin and nonsteroidal anti-inflammatory drugs because of their anticoagulant properties. 23 , 24 , 26 – 29 For prevention, there is no medication prophylaxis or vaccine available. The best prevention method is to reduce or avoid mosquito bites by using repellents (containing 30% to 50% DEET 19 ), wearing protective clothing, and using bed nets. 23

Data Sources: A PubMed search was completed using the key words malaria, dengue, typhoid, and fever in travelers. Also reviewed were the following journals over the past 15 years: Clinical Infectious Diseases, Lancet Infectious Diseases, New England Journal of Medicine, Morbidity and Mortality Weekly Report , and Emerging Infectious Diseases . Search dates: January 2011 through September 2011.

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Wilson ME. Post-travel evaluation: fever in returned travelers. In: Brunett GW, ed., Centers for Disease Control and Prevention. Health Information for International Travel 2012: The Yellow Book . New York, NY: Oxford University Press; 2012. http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-5-post-travel-evaluation/fever-in-returned-travelers.htm . Accessed February 12, 2013.

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Freedman DO. Clinical practice. Malaria prevention in short-term travelers. N Engl J Med . 2008;359(6):603-612.

Fraser IP, Cserti CM, Dzik WH. Case record of the Massachusetts General Hospital. Case 32–2006. A 3-year-old girl with fever after a visit to Africa. N Engl J Med . 2006;355(16):1715-1722.

World Health Organization. The top 10 causes of death. http://who.int/mediacentre/factsheets/fs310/en/index.html . Accessed May 29, 2013.

Fradin MS, Day JF. Comparative efficacy of insect repellents against mosquito bites. N Engl J Med . 2002;347(1):13-18.

Connor BA, Schwartz E. Typhoid and paratyphoid fever in travellers. Lancet Infect Dis . 2005;5(10):623-628.

Bhutta ZA. Current concepts in the diagnosis and treatment of typhoid fever. BMJ . 2006;333(7558):78-82.

Frenck RW, Nakhla I, Sultan Y, et al. Azithromycin versus ceftriaxone for the treatment of uncomplicated typhoid fever in children. Clin Infect Dis . 2000;31(5):1134-1138.

Centers for Disease Control and Prevention. Dengue. http://www.cdc.gov/dengue/ . Accessed May 21, 2013.

Wilder-Smith A, Schwartz E. Dengue in travelers. N Engl J Med . 2005;353(9):924-932.

Mangold KA, Reynolds SL. A review of dengue fever: A resurging tropical disease. Pedr Emerg Care . 2013;29(5):665-669.

Gubler DJ. Dengue and dengue hemorrhagic fever. Clin Microbiol Rev . 1998;11(3):480-496.

Kalayanarooj S, Vaughn DW, Nimmannitya S, et al. Early clinical and laboratory indicators of acute dengue illness. J Infect Dis . 1997;176(2):313-321.

Kautner I, Robinson MJ, Kuhnle U. Dengue virus infection: epidemiology, pathogenesis, clinical presentation, diagnosis, and prevention. J Pediatr . 1997;131(4):516-524.

Johnston V, Stockley JM, Dockrell D, et al.; British Infection Society and the Hospital for Tropical Diseases. Fever in returned travellers presenting in the United Kingdom: recommendations for investigation and initial management. J Infect . 2009;59(1):1-18.

Gershman M, Staples JE. Infectious diseases related to travel: yellow fever. In: Brunett GW, ed., Centers for Disease Control and Prevention. Health Information for International Travel 2012: The Yellow Book . New York, NY: Oxford University Press; 2012. http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-3-infectious-diseases-related-to-travel/yellow-fever.htm . Accessed February 15, 2013.

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11 Posttravel Evaluation

• Published: March 2023
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Chapters in this section include: 1. General Approach to the Returned Traveler 2. Rapid Diagnostic Tests for Infectious Diseases 3. Perspectives: Screening Asymptomatic Returned Travelers 4. Fever in the Returned Traveler 5. Antimicrobial Resistance 6. Respiratory Infections 7. Persistent Diarrhea in Returned Travelers 8. Skin & Soft Tissue Infections 9. Perspectives: Delusional Parasitosis 10. Sexually Transmitted Infections 11. Newly Arrived Immigrants, Refugees & Other Migrants

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Post travel feedback form

We hope you had a nice time on your trip and that you will give us another chance to help you. please share your experience if you have travelled with us..

1 minute to complete

Eligibility

The Post travel feedback form is available to all customers who have traveled with the company within the last six months.

Questions for Post travel feedback form

How was your flight?

What is your destination?

How convenient was the travel from origin to destination?

How comfortable was the accommodation at your destination?

How would you rate the quality of the service we provided overall? (e.g., booking, transfers, etc.)

Is there anything else that you would like to add regarding this session or any aspect of our service in general?

Forms Similar to Post travel feedback form

• Travel feedback form
• Holiday feedback form
• Trip feedback form

Here are some FAQs and additional information on Post travel feedback form

Who is the post-travel feedback form for, the post travel feedback form is specially meant for travel agencies who are looking for ways to improve their services., how do you write a feedback for a trip, if you have had a recent trip, you can drop in your feedback about the trip either on your social media, or the travel agency’s social media profiles or even drop them a testimonial in their feedback forms., what are the benefits of a tour evaluation form, a tour evaluation form helps in evaluating the strengths and weaknesses of the services and it helps in providing actionable insights to scale their services., how to measure the overall satisfaction of my customers after the travel, you can measure the overall satisfaction of your customers, you can ask them to share their views about your services as a testimonial or ask them to fill the post-travel feedback form., how can i improve my travel agency, you can improve your travel agency by actively engaging with your customers, by actively engaging with people of your industry and by constantly upgrading and updating your services., want to use this template, loved by people at home and at work.

What's next? Try out templates like Post travel feedback form

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• Caring for Yourself and Others
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• DPDM Features
• Alphabetical Index of Parasitic Diseases
• Clinical Overview
• Laboratory Information
• CDC Bottle Bioassay
• Epi Info Vector Surveillance Application
• Chagas Disease: Optimizing Care for Pregnant Women and Children
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Clinical Overview of Parasitic Diseases

At a glance.

CDC offers a number of services for health professionals.

Clinical Management Advice for Confirmed or Suspected Cases of Parasitic Diseases

Pre- and post-travel evaluation, parasitic disease diagnosis, drugs for parasitic diseases.

Subject matter experts from the Division of Parasitic Diseases and Malaria are available on a 24-hour, 7 day-a-week basis to assist health professionals with diagnosis and treatment of parasitic diseases that are potentially life threatening.

Health care providers in need of assistance with diagnosis or management of parasitic disease cases other than malaria should call one of the CDC Parasitic Diseases Hotlines below. Information about risk factors, diagnosis, treatment, prevention, and control of parasitic diseases is available on CDC's Parasites website.

Hotlines for Parasitic Disease Cases (not including Malaria)

Phone Number

Emergency, after-hours hotline

770-488-7100

For malaria cases, health professionals should call one of the following CDC Malaria Hotlines. Guidance for diagnosis and treatment of malaria is also available at CDC's Malaria website .

Hotlines for Malaria

Information on pre-travel general advice, including parasitic diseases, can be found on CDC's Travelers' Health website and can be used to assist international travelers prepare for their trip.

DPDx: Laboratory Identification of Parasites of Public Health Concern provides information to health professionals on the identification and diagnosis of parasites. DPDx also contains parasite-specific information that may prove useful.

Some drugs used to treat parasitic diseases are not approved (licensed) by the U.S. Food and Drug Administration (FDA) for sale in this United States since their demand in this country is so low and seeking approval is not cost effective for the drug manufacturers.

However, to allow treatment of patients with an unlicensed drug product, FDA may permit the use of a drug or biological product under an Investigational New Drug (IND) application. An IND application includes a protocol for the clinical use of the unlicensed drug and must be submitted for review to FDA and permitted to proceed before any agents are released under IND status. CDC maintains protocols with IND status for some drugs to ensure that they are available in the United States when needed.

The following anti-parasitic drugs can be obtained from CDC's Drug Service (CDC Drug Service, Scientific Resources Program, telephone 404-639-3670):

• Diethylcarbamazine (DEC)
• Melarsoprol

Information on Specific Parasites

Health care providers who wish to obtain more information on a particular parasite can consult the Division of Parasitic Diseases and Malaria A–Z Index of Parasitic Diseases .

Accredited Continuing Medical Education (CME)

Courses are designed to educate clinicians about parasitic disease in the United States.

These courses will present an opportunity to think critically about diagnosis and treatment of less common parasitic diseases.

Course lessons will cover the following:

• Basic epidemiology
• Disease manifestations
• Laboratory diagnosis
• Clinical evaluation
• Treatment options
• Patient scenarios

More on: Continuing Medical Education Course Offerings

A parasite is an organism that lives on or in a host organism and gets its food from or at the expense of its host.

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Travel Health

International travel can increase the risk for various illnesses. Below are resources and guidance materials for healthcare professionals regarding travelers’ health.

Current Travel Health Notices

Please see the CDC website for current travel health notices.

• CDC Travel Health Notices

Pre-Travel Consultation

A pre-travel consultation balances the health of the traveler (the traveler's age, underlying health conditions, medications, and immunization history) with the details of the planned trip (the season of travel, itinerary, duration, and planned activities).

Clinical Guidelines

• PDPH Clinical Guidance for Pre-Travel Consultations
• Infectious Diseases Society of America Clinical Guidelines for Pre-Travel Consultations

Travel Vaccines

Depending on the traveler’s destination, your patient may need additional vaccines different from the routine immunizations recommended for children and adults. These special immunizations may include vaccines for typhoid, yellow fever, rabies, or Japanese encephalitis.

• A list of travel vaccine clinics
• A quick reference for administering or prescribing travel-related vaccines.

Clinical Evaluation Tools

• CDC Yellow Book
• A free clinical tool that guides clinicians through preparing a US traveler for a safe and healthy international trip. It is based on the recommendations of the CDC Yellow Book.

Screening the Returned Traveler

Although some illnesses may begin during travel, others may occur weeks, months, or even years after return. A history of travel (particularly any travel within the past six months) should be part of the routine medical history for every ill patient. A travel history, particularly of the previous six months, should be part of every routine medical history. Recommendations will depend upon travel destination, duration of travel, immunization history, various medication regimens, activities, and personal history of exposure. Clinicians can also refer patients to qualified specialists versed in travel medicine or infectious disease to ensure appropriate post-travel medical care is provided.

• PDPH Infectious Disease Considerations for Patients with History of Travel
• Fever in Returned Travelers
• Screening Asymptomatic Patients
• Persistent Travelers' Diarrhea
• CDC Post-Travel Evaluation Guide
• Georgia Department of Public Health Travel Clinical Assistant (provides post-travel clinical information on travel-related diseases)

Health Education Materials

• PDPH Travel Clinic List for Patients
• CDC Mobile Applications for Travelers
• CDC Travel Health Resources for Clinicians
• CDC Destination-Specific Health Considerations

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• Post Travel Survey

A Post-Travel Survey is a form template designed to collect feedback and evaluate the travel experience of customers. It includes questions about various aspects of the travel, such as customer service, accommodations, transportation, attractions visited, and overall satisfaction. This survey is valuable for travel agencies, tour operators, hotels and accommodation providers, online travel agencies, and event planners, as it helps them make improvements, enhance customer experiences, and tailor their offerings to meet the expectations of travelers. By gathering feedback through this survey, organizations and service providers can gain valuable insights to optimize their services and ensure customer satisfaction.

Jotform, a user-friendly and drag-and-drop online form builder, offers the Post-Travel Survey template as part of its Form Builder product. With Jotform, travel industry professionals can easily create and customize this survey to suit their specific needs. The ease of use and customization options of Jotform make it a convenient tool for gathering feedback and enhancing customer experiences. Additionally, Jotform's capability to collect e-signatures ensures that necessary consent forms or agreements can be obtained seamlessly. Overall, Jotform provides travel agencies and service providers with a reliable and efficient solution for conducting post-travel surveys and improving their offerings based on valuable customer feedback.

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A market research survey is a questionnaire used by companies to collect information about their customers and their market. Here's a quick market research form that focuses on a few demographic statistics. This survey form will ask for the respondents' age, gender, household income, and educational attainment. The survey format is multiple-choice, giving your respondents an easy way of completing it in a few minutes. Use this market research template and use the collected submission data to your advantage. If you want to create your survey from scratch, you can get started with the survey maker now!Use our free Market Research Survey template for your business — it’s easy to customize, fast to set up, and perfect for collecting info from your customers and fans. Simply add your company logo, change the text and colors, and you’re on your way! If you’d like to embed this survey on your website, you can sync it to a website builder. If you’re looking to collect more information than the Market Research Survey provides, you can use our Form Builder to add more fields. Collect all of the data you need to make decisions with a free Market Research Survey.

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Survey Templates

If you want to improve your upcoming event, you can get suggestions from participants by using this event satisfaction survey template. This sample feedback form allows gathering overall satisfaction by categorizing the event services. These categories are location, content, price, speakers, organization.

An Online Interview Questionnaire Form is a form template designed to help organizations gather important information from their interviewees.

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Customers satisfaction is important for every business and to determine that you need to survey your customers. This restaurant survey form is designed for this purpose. This restaurant evaluation form let your customers rate or evaluate the quality of your services, this includes food quality, overall service quality, cleanliness, order accuracy, speed of service and others. To deliver the highest level of service, this restaurant review form will help you easily understand your customers and their tastes based on their feedback. So if you own a restaurant and you want the quickest and hassle-free to collect feedback, this restaurant review template free is all you need!

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HR departments can use this free Exit Interview Form to conduct exit interviews online. Customize the form and share via email to quickly collect employee feedback.

Product Survey Form

A product feedback form is a good way to gauge how well (or bad) you're doing as a company. With this product survey form sample, a variety of commonly asked questions are readily available for you to use. This product survey form will ask your respondents how long they have been using your products/services, their impression on how you compete with other competitors, their satisfaction about the products/services you offer and a couple more that's related to the overall experience they had.

Customer Feedback Survey

Great tool to capture customers concerns on products and services used

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Demographic Survey

Here is a simple demographic survey template that you can use to determine your market or to make any other research. With this demographic form for research, you can gather gender, age, education, household income and interests of the form's respondents. Use this demographics form template to start your survey now! Or, simply make your own online surveys from scratch!

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Product Customer Feedback Form 

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Make the teachers happy by attending to their needs and listening to their feedback by using this Teacher Satisfaction Survey. This form template contains all the required questions when building a survey.

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About Survey Templates

Surveys are the perfect way to gauge customer, employee, or even just public opinion about your brand. Get started the easy way: select a free online survey template from Jotform. We have all the survey and reporting tools to find and collect helpful data. It's perfect when you need to understand customer demographics, or when you need to conduct a market research survey. Select from one of our pre-made sample survey forms or make your own survey from scratch in just minutes. Once you have selected a survey template, use the Jotform builder to design, format and customize your survey form. Try one of our free online survey form templates today!

You can also check out our ready-to-use questionnaire templates prepared for a variety of use cases which allows you to customize your online questionnaire with our drag-and-drop Form Builder.

Frequently Asked Questions

1) what are survey templates.

Survey templates are ready-made sample surveys with built-in questions. Instead of creating a survey from scratch, you can use a template as a starting point, then customize it with your own specific questions, branding elements, and more.

2) Where can I find survey templates?

You can find many survey templates online for free! Jotform’s survey templates are all available in our form templates library. Not only are they free, but they’re totally customizable with our no-code, drag-and-drop form builder, so you don’t have to switch between platforms to find a survey template, customize it, and share it with your audience!

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Jotform offers a wide variety of survey templates for different industries and use cases, including surveys for HR, marketing, products, customer satisfaction, and more. Plus, we have a great selection of employee and education surveys, with everything from polls and assessment forms to motivation and feedback forms.

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Absolutely! As mentioned above, Jotform’s drag-and-drop form builder is the ultimate tool to customize your survey templates in a matter of minutes. You can adjust fonts and colors, drag and drop form fields, drop in logos and images, and so much more. Plus, feel free to sync with our 100-plus integrations — like Google Drive or Dropbox — to add extra functionality to your survey or include it in your existing workflows.

5) How can I use a survey template?

To use a survey template, just select the template you want to use and edit it according to your needs. With Jotform, simply navigate to our Survey Templates page and choose the right one for you. Click Use Template , then use our drag-and-drop Form Builder to customize it and share it with others, all from one place. Responses will automatically be sent to your Jotform Inbox, and you can analyze your data in Jotform Tables and Jotform Report Builder.

6) Can I create my own survey template?

Yes, you can build your own survey from scratch. Navigate to Jotform’s Form Builder, click Create Form , then Start from Scratch . From there, you can add questions and widgets to create the perfect survey template to use as needed.

7) Are survey templates free to use?

Depending on where you source them, some survey templates are free, and some you’ll need to pay for. Jotform’s 1,000-plus survey templates will always be 100 percent free. You’ll just need to upgrade to a paid plan to increase the limit on the number of submissions you receive.

8) How many questions are typically included in a survey template?

Make sure your respondents don’t get “survey fatigue” before they even start taking your survey! The tricky part about this question is that there’s no exact answer — it depends on a number of factors, like who your audience is, what information you need, and what your purpose is. In general, a survey should never take longer than 10 minutes, which means that 5–10 questions is usually a safe range.

9) How do I choose the right survey template for my needs?

Before you choose a survey template, you need to define your research objectives. This can be done by doing a deep dive into your product, service, or team and pinpointing specific topics you want to gather more data on. Once you’ve done this, you can search for survey templates related to your research objective and find one that most closely matches your needs.

10) Can survey templates be used for both online and offline surveys?

Sometimes, you need to be offline to conduct market research or surveys in the field — that’s why finding survey tools that work offline is a game-changer. Jotform Mobile Forms allows you to create, edit, and fill out forms from any location and on any device, and even collects data offline to be populated later once you connect back to the internet. Don’t let spotty cell reception stop you from collecting the survey data you need!

11) What are the benefits of using a survey template?

Using a survey template can cut down on the time you would otherwise spend building a survey from scratch, so that you can spend more time collecting responses and analyzing data to make better business decisions. On top of that, survey templates provide great inspiration for the kinds of questions you should be asking, as well as the format of those questions (multiple choice, yes/no, fill-in-the-blank, etc.).

12) Can survey templates be used for different industries and sectors?

Survey templates can be used across every industry and sector! Whether you’re collecting employee feedback, reaching out to customers about a potential new product, or simply just polling your friends for fun, there’s a survey template for you.

13) How do I modify a survey template to suit my specific requirements?

To modify a survey template to suit your specific needs, you can customize it with your own text, images, branding, and more. Jotform makes this easy with our drag-and-drop form builder. Simply replace our questions with your own, add new fields, switch up the survey colors and fonts, include your logo, and more. Then share it through email, a link, or a QR code, or embed it on your website.

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Please note you do not have access to teaching notes, investigating tourist post-travel evaluation and behavioural intention: a cultural intelligence perspective.

Asia Pacific Journal of Marketing and Logistics

ISSN : 1355-5855

Article publication date: 26 February 2021

Issue publication date: 25 October 2021

This paper aims to investigate whether cultural intelligence will influence Chinese tourists’ travel satisfaction, revisit intention and word-of-mouth communication.

Design/methodology/approach

An online survey was conducted to collect data from 614 adult Chinese tourists, who have overseas travel experiences. Then, the Statistics Package for the Social Sciences (SPSS) and the structural equation modelling (SEM) were employed for data analysis.

The findings confirm that cultural intelligence has significant positive impacts on tourist satisfaction, revisit intention and electronic word-of-mouth (eWOM) communication. Additionally, tourist satisfaction significantly affects tourist eWOM communication.

Originality/value

This study provides theoretical and practical contributions regarding the effects of tourist cultural intelligence, especially on tourist post-travel evaluation and behavioural intention, which has been merely investigated in extant tourism research.

• Cultural intelligence
• Chinese tourists
• Tourist satisfaction
• Revisit intention
• Electronic word-of-mouth communication

Zhang, Y. , Shao, W. and Thaichon, P. (2021), "Investigating tourist post-travel evaluation and behavioural intention: a cultural intelligence perspective", Asia Pacific Journal of Marketing and Logistics , Vol. 33 No. 10, pp. 2037-2053. https://doi.org/10.1108/APJML-08-2020-0584

Emerald Publishing Limited

Copyright © 2021, Emerald Publishing Limited

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Article • 9 min read

The MoSCoW Method

Understanding project priorities.

By the Mind Tools Content Team

(Also Known As MoSCoW Prioritization and MoSCoW Analysis)

You probably use some form of prioritized To-Do List to manage your daily tasks. But what happens when you're heading up a project that has various stakeholders, each of whom has a different opinion about the importance of different requirements? How do you identify the priority of each task, and communicate that to team members, stakeholders and customers alike?

This is when it's useful to apply a prioritizing tool such as the MoSCoW method. This simple project-management approach helps you, your team, and your stakeholders agree which tasks are critical to a project's success. It also highlights those tasks that can be abandoned if deadlines or resources are threatened.

In this article, we'll examine how you can use the MoSCoW method to prioritize project tasks more efficiently, and ensure that everyone expects the same things.

What Is the MoSCoW Method?

The MoSCoW method was developed by Dai Clegg of Oracle® UK Consulting in the mid-1990s. It's a useful approach for sorting project tasks into critical and non-critical categories.

MoSCoW stands for:

• Must – "Must" requirements are essential to the project's success, and are non-negotiable. If these tasks are missing or incomplete, the project is deemed a failure.
• Should – "Should" items are critical, high-priority tasks that you should complete whenever possible. These are highly important, but can be delivered in a second phase of the project if absolutely necessary.
• Could – "Could" jobs are highly desirable but you can leave them out if there are time or resource constraints.
• Would (or "Won't") – These tasks are desirable (for example, "Would like to have…") but aren't included in this project. You can also use this category for the least critical activities.

The "o"s in MoSCoW are just there to make the acronym pronounceable.

Terms from Clegg, D. and Barker, R. (1994). ' CASE Method Fast-Track: A RAD Approach ,' Amsterdam: Addison-Wesley, 1994. Copyright © Pearson Education Limited. Reproduced with permission.

People often use the MoSCoW method in Agile Project Management . However, you can apply it to any type of project.

MoSCoW helps you manage the scope of your project so that it isn't overwhelmingly large. It is particularly useful when you're working with multiple stakeholders, because it helps everyone agree on what's critical and what is not. The four clearly labeled categories allow people to understand a task's priority easily, which eliminates confusion, misunderstanding, conflict, and disappointment.

For example, some project management tools sort tasks into "high-," "medium-," and "low-" priority categories. But members of the team might have different opinions about what each of these groupings means. And all too often, tasks are labeled "high" priority because everything seems important. This can put a strain on time and resources, and ultimately lead to the project failing.

Using the MoSCoW Method

Follow the steps below to get the most from the MoSCoW method. (This describes using MoSCoW in a conventional "waterfall" project, however the approach is similar with agile projects.)

Step 1: Organize Your Project

It's important that you and your team fully understand your objectives before starting the project.

Write a business case to define your project's goals, its scope and timeline, and exactly what you will deliver. You can also draw up a project charter to plan how you'll approach it.

Next, conduct a stakeholder analysis to identify key people who are involved in the project and to understand how its success will benefit each of them.

Step 2: Write out Your Task List

Once you understand your project's objectives, carry out a Gap Analysis to identify what needs to happen for you to meet your goals.

Step 3: Prioritize Your Task List

Next, work with your stakeholders to prioritize these tasks into the four MoSCoW categories: Must, Should, Could, and Would (or Won't). These conversations can often be "difficult," so brush up on your conflict resolution, group decision making and negotiating skills beforehand!

Rather than starting with all tasks in the Must category and then demoting some of them, it can be helpful to put every task in the Would category first, and then discuss why individual ones deserve to move up the list.

Step 4: Challenge the MoSCoW List

Once you've assigned tasks to the MoSCoW categories, critically challenge each classification.

Be particularly vigilant about which items make it to the Must list. Remember, it is reserved solely for tasks that would result in the project failing if they're not done.

Aim to keep the Must list below 60 percent of the team's available time and effort. The fewer items you have, the higher your chance of success.

Try to reach consensus with everyone in the group. If you can't, you then need to bring in a key decision-maker who has the final say.

Step 5: Communicate Deliverables

Your last step is to share the prioritized list with team members, key stakeholders and customers.

It's important that you communicate the reasons for each categorization, particularly with Must items. Encourage people to discuss any concerns until people fully understand the reasoning.

Zhen is a project manager for a large IT organization. She's working with a team of designers, marketers and developers to redesign a large corporate client's website.

At the initial meeting, each group has strong opinions about which tasks are most important to the project's success, and no one wants to give up their "high priority" objective.

For example, the marketing team is adamant that the new website should gather visitors' personal information, for use in future marketing campaigns.

Meanwhile, the designers are arguing that, while this is important, the site may be more successful if it had a professionally produced streaming video. They also want a feed streaming onto the website's home page from the client's social networking accounts.

The developers counter that the current prototype design won't translate well onto mobile devices, so the top priority is retrofitting the site so people can view it on these.

Zhen can see that, while each priority is important, they're not all critical to the project's success. She decides to use the MoSCoW method to help the group reach consensus on which task is truly "mission critical."

She starts with a key question: "If I came to you the night before rollout and the following task was not done, would you cancel the project?" This question helped everyone in the group drill down to the project's most important priority.

The group finally agreed on the following priorities:

• Must – The retrofit website must be easily viewable on mobile devices.
• Should – There should be a social networking stream included.
• Could – There could be a streaming video on the site to help users.
• Would – Personal information would be gathered for future marketing efforts, but not on this occasion.

The MoSCoW method helped everyone agree on what was truly important for the project's final success.

The MoSCoW method is a simple and highly useful approach that enables you to prioritize project tasks as critical and non-critical. MoSCoW stands for:

• Must – These are tasks that you must complete for the project to be considered a success.
• Should – These are critical activities that are less urgent than Must tasks.
• Could – These items can be taken off the list if time or resources are limited.
• Would – These are tasks that would be nice to have, but can be done at a later date.

The benefit of the MoSCoW approach is that it makes it easy for team members and key stakeholders to understand how important a task is for a project's success.

Apply This to Your Life

Try using the MoSCoW method to prioritize your daily tasks. Look at what you completed at the end of the day. Did prioritizing enable you to get more done?

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After Travel Tips

You may get infected during travel but not have symptoms until you get home. If you recently traveled and feel sick, particularly if you have a fever, talk to your healthcare provider, and tell them about your travel.

Contact your healthcare provider if you feel sick

Contact your healthcare provider if you feel sick after your trip. Sharing the following information may help your healthcare provider identify possible diseases or infections:

• Your vaccination history.
• Where you traveled.
• Your reasons for traveling.
• Your travel activities, including swimming, hiking, etc.
• The timeframe of your vacation.
• Where you stayed, such as hotels, family or friends’ homes, hostels, or tents.
• What you ate and drank.
• Animals you had close contact with or touched.
• If you have any injuries, scratches, or bug bites.
• Health care or medications you received during your trip.
• Close contact with other people, including sexual encounters.
• If you got any tattoos or piercings.

If your healthcare provider has trouble determining why you are feeling sick, you may want to ask to speak with an infectious disease doctor or travel medicine specialist. Find a clinic for a travel medicine specialist.

Long-term Travelers

Long-term travelers, such as expatriate workers, Peace Corps volunteers, or missionaries, have a greater risk of getting infected, sometimes without symptoms, during travel. If you are a long-term traveler, consider having a thorough medical exam or interview with your healthcare provider after you return to the United States.

More Information:

• The Post Travel Evaluation in CDC Yellow Book
• Long-Term Travelers & Expatriates in CDC Yellow Book
• Screening Asymptomatic Returned Travelers in CDC Yellow Book

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