The Centers for Disease Control and Prevention (CDC) and the Environmental Protection Agency (EPA) recommend using insect repellents to prevent infections transmitted by mosquitoes and ticks. Insect repellents applied to exposed skin should be used in conjunction with other preventive measures such as wearing pants and long-sleeved shirts and avoiding outdoor activities during peak mosquito-biting times. Mosquitoes can transmit diseasecausing pathogens, including Zika, chikungunya, dengue, West Nile, eastern equine encephalitis, and yellow fever viruses, and the malaria parasite. Ticks can transmit the bacteria that cause Lyme disease, the rickettsia that cause Rocky Mountain spotted fever, and viruses such as Powassan virus. Some insect repellents containing EPA-registered active ingredients are listed in Table 1.

Patients who receive pretravel advice can reduce their risk for many travel-related conditions. Vaccines recommended for travelers are reviewed in a separate issue.

Use of insect repellents is strongly recommended by the Centers for Disease Control and Prevention (CDC) and the Environmental Protection Agency (EPA) to prevent infections transmitted by mosquitoes and ticks. Insect repellents applied to exposed skin should be used in conjunction with other preventive measures such as wearing pants and long-sleeved shirts, and avoiding outdoor activities during peak mosquito-biting times. Mosquitoes can transmit Zika, chikungunya, dengue, West Nile, eastern equine encephalitis, and yellow fever viruses, as well as malaria. Ticks can transmit Lyme disease, rickettsial diseases such as Rocky Mountain spotted fever, and viruses such as Powassan virus.

Excessive exposure to ultraviolet (UV) radiation is associated with sunburn, photoaging, and skin cancer. Sunscreens are widely used to reduce these risks, but some questions remain about their effectiveness and safety.

Use of insect repellents is strongly recommended by the CDC and the EPA to prevent Zika virus infection and other mosquito- and tickborne diseases. Mosquitoes can transmit chikungunya, dengue, West Nile, and yellow fever viruses, and malaria. Ticks can transmit Lyme disease and rickettsial diseases such as Rocky Mountain spotted fever.

Patients planning to travel to other countries often ask for information about prevention of diarrhea, malaria, and other travel-related conditions. Vaccines recommended for travelers based on their destination, length of stay, and planned activities were reviewed in a previous issue.

Patients planning to travel to other countries often ask for information about appropriate vaccines and prevention of diarrhea and malaria. More detailed advice for travelers is available from the Centers for Disease Control and Prevention (CDC) at www.cdc.gov/travel. Guidelines are also available from the Infectious Diseases Society of America (IDSA).

Most cases of Lyme disease in the US occur between May and September in the Northeastern, Mid-Atlantic and North Central states.

Patients planning to travel to other countries often ask physicians for information about appropriate vaccines and prevention of diarrhea and malaria. Guidelines are also available from the Infectious Diseases Society of America (IDSA).

Many drugs can cause psychiatric symptoms, but a causal connection is often difficult to establish. Psychiatric symptoms that emerge during drug treatment could also be due to the underlying illness, previously unrecognized psychopathology, or psychosocial factors. The withdrawal of some drugs can cause symptoms such as anxiety, psychosis, delirium, agitation or depression.

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Sunscreens are an important component of photoprotection. A new definition of their effectiveness has been proposed, and some issues have arisen concerning their safety.

An article (Med Lett Drugs Ther 2007; 49:41) on sunscreens in the May 21 issue of The Medical Letter included a statement that if sunscreens and the insect repellent DEET are used together, DEET should be applied first to avoid decreasing the effectiveness of the sunscreen. However, a recent in vitro study in human skin found that sunscreen increases absorption of DEET, especially when DEET is applied first (T Wang and X Gu. J Pharm Pharm Sci 2007; 10:17). Whether this practice could cause clinical toxicity is unclear. Some travel experts recommend applying sunscreen first.

Most cases of Lyme disease in North America occur between May and September. In 2005, 12 states (CT, DE, ME, MD, MA, MI, NH, NJ, NY, PA, VA, WI) reported about 95% of all the Lyme disease in the US, but some cases occurred in all states except AR, CO, HI, MS, MT and OK. New guidelines for treatment of Lyme disease have been published.

Patients planning to travel to other countries often ask physicians for information about immunizations and prevention of diarrhea and malaria. More detailed advice for travelers is available from the Centers for Disease Control and Prevention at 877-FYI-TRIP (877-394-8747) or www.cdc.gov/travel.

Many patients planning to travel seek advice about prevention of malaria. No drug is 100% effective for this indication; travelers should be told to take other protective measures as well. Malaria in pregnancy is particularly serious for both mother and fetus; prophylaxis is indicated if travel cannot be avoided. Countries with a risk of malaria are listed in the table on page 102. Some countries with endemic malaria transmission may not have malaria in the most frequently visited major cities and rural tourist resorts.

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Picaridin (KBR 3023), which has been used as an insect repellent for years in Europe and Australia (Autan Repel, and others), is now available in the US in 7% solution as Cutter Advanced (Spectrum Brands). The US Centers for Disease Control and Prevention (CDC) is recommending it as an alternative to DEET.

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Lyme disease in North America is caused by the spirochete Borrelia burgdorferi, which is transmitted to humans by Ixodes scapularis or pacificus ticks. These ticks may also carry other pathogens; coinfection with Babesia microti or Anaplasma phagocytophilum (formerly Ehrlichia) has been reported.1 In 2001 and 2002, 12 states (CT, DE, ME, MD, MA, MI, NH, NJ, NY, PA, RI, WI) reported about 95% of all the Lyme disease in the US, but cases occurred in all states except HI, MT and OK. Most Lyme disease in North America occurs between May and September.

Patients planning to travel to other countries often ask physicians for advice about immunizations and prevention of diarrhea and malaria. More detailed advice for travelers is available from the Centers for Disease Control (CDC) at 877-FYI-TRIP (877-394-8747) or www.cdc.gov/travel. Recommendations for the treatment of parasitic diseases are available in the public reading room of The Medical Letter's web site.

Insect repellents have been used on the skin for many years, primarily to prevent mosquito bites, which transmit malaria, West Nile virus infection, and various types of encephalitis. With increased concern about Lyme disease in recent years, skin and clothing repellents are now also recommended for protection against ticks. This review describes the effectiveness of the most widely used repellents DEET and permethrin , as well as some alternatives, and a new product called picaridin that may be available soon. The safety of these products is also discussed. The review concludes with an overall assessment of safety and efficacy and a recommendation on how to achieve the best protection.

Many drugs can cause psychiatric symptoms, but a causal connection is often difficult to establish. Psychiatric symptoms that emerge during drug treatment may also be due to the underlying illness, previously unrecognized psychopathology, or psychosocial factors. The withdrawal of some drugs can cause symptoms such as anxiety, psychosis, delirium, agitation or depression.

Patients planning to travel to other countries often ask physicians for advice about immunizations and prevention of diarrhea and malaria. More detailed advice for travelers is available from the CDC at 877-FYI-TRIP (877-394-8747) or www.cdc.gov/travel.

Patients planning to travel to other countries often ask physicians for advice about immunizations and prevention of diarrhea and malaria. More detailed advice for travelers is available from the CDC at 877-FYI-TRIP (877-394-8747) or www.cdc.gov/travel.

Patients planning to travel to other countries often ask physicians for advice about immunizations and prevention of diarrhea and malaria. Legal requirements for entry and epidemiological conditions in different countries vary from time to time, often unpredictably, but some reasonable recommendations can be made. More detailed information is available in Health Information for International Travel, published annually by the Centers for Disease Control (CDC), which can be obtained from the Superintendent of Documents, US Government Printing Office, Washington, DC 20402. Up-to-date automated information is available by telephone from the CDC (404-332-4559).

Insect repellents have been used on the skin for many years, primarily to prevent mosquito bites. With recent increased concern about Lyme disease, skin and clothing repellents are now also recommended for protection against ticks.