China

Destination overview

China is the world’s second-most populous country (>1.4 billion people) and the fourth largest geographically, behind Russia, Canada, and the United States. Divided into 23 provinces, 5 autonomous regions, 4 municipalities, and 2 Special Administrative Regions, China is home to diverse customs, languages, and topographies (Map 11.3.1.1). The climate varies from tropical in the south to subarctic in the north, with wide variations between regions and seasons.

The long history and varied natural beauty of China can be traced through the country’s 56 UNESCO World Heritage sites, including the Forbidden City and Temple of Heaven, the Great Wall, the Terracotta Warriors of Xi’an, and the spectacular mountainous sanctuaries of the west. Recent additions include Quanzhou, the Emporium of the World in Song-Yuan, Mount Fanjing in southwest China, the archaeological ruins of Liangzhu City in the Yangtze River Delta, the migratory bird sanctuaries along the Bohai Gulf Coast, the Tusi tribal domains in western China, the Ancient Tea Plantations of JingMai Mountain in Pu’er, and the Grand Canal, the oldest (dating back to 468 BCE) and longest (1,794 km; 1,115 miles) man-made canal in the world.

Prior to the COVID-19 pandemic, China had the largest outbound travel market in the world, in terms of the number of trips and total expenditures. In 2019, there were 155 million outbound trips and an additional >145 million inbound visitors. These numbers represent an extraordinary pace of growth, more than tripling since 2010. The pandemic drastically reduced both inbound and outbound travel. After travel restrictions were lifted in January 2023, domestic travel rebounded sharply, reaching 90% of pre-pandemic levels during the first half of the year. Domestic travelers have been visiting the usual tourist destinations, including sightseeing in Beijing and at the Great Wall, touring Shanghai, cruising the Yangtze River, and exploring the Zhangjiajie National Forest Park in Zhejiang Province (see Box 11.3.1.1 for a list of other popular tourist destinations). International travel, both inbound and outbound, has not yet fully recovered but is expected to rebound as international air capacity improves and remaining restrictions on visa requirements and tour groups are lifted.

Aside from tourism, people travel to China for business opportunities, to visit friends and relatives, to study, and to adopt children. These non-tourist travelers might be at greater risk of becoming ill because they may underestimate health hazards, may be less likely to seek pre-travel advice, and may be more likely to stay in local or rural accommodations.

China has the second-largest economy and the second-largest number of billionaires in the world. In 2022, China’s gross national income (GNI) per capita using purchasing power parity method was USD 21,250, slightly above the global GNI per capita of USD 20,593 for the same year. Wide disparities in wealth and development exist between the urban and more rural areas. Health risks vary accordingly.

Box 11.3.1.1

Map 11.3.1.1

Infectious disease risks

Travelers should be up to date on routine childhood vaccinations (diphtheria-tetanus-pertussis, measles-mumps-rubella, and varicella), as well as vaccines that protect children and adults against respiratory illnesses like seasonal influenza and COVID-19. Because of high immunization coverage, China has maintained low rates of measles and rubella transmission since 2020. Due to health risks to unborn fetuses, women of reproductive potential should ensure that they have received rubella vaccine prior to travel. Cases of pertussis and varicella are reported regularly, particularly among young and school-aged children and adolescents.

Vaccine quality and availability in China

China is making considerable advances in vaccine production, working with established pharmaceutical companies in joint ventures or by developing and manufacturing vaccines locally. Although counterfeit and improperly stored vaccines were concerns in the past, China has waged a robust response and these issues are now rare. Availability of some vaccines may be limited. Travelers should not assume they can complete an unfinished vaccination series once in China; thus, all travelers going to China should be up to date with all routine and recommended vaccinations before travel. Circumstances in Hong Kong are different; international vaccines, including routine childhood, COVID-19, and influenza vaccines, are generally available.

Blood-borne pathogens

Hepatitis B virus

Hepatitis B virus (HBV) infection is endemic to China. Nearly one-third of the 350 million people worldwide infected with HBV reside in China. Although mother-to-child transmission has been virtually eliminated due to successful routine hepatitis B vaccination, a large proportion of infected adults in China remain unaware that they have HBV infection, resulting in potential HBV transmission to the unvaccinated population. The Advisory Committee on Immunization Practices recommends hepatitis B vaccine as part of the routine childhood schedule and for unvaccinated U.S. adults aged 19–59 years; hepatitis B vaccine should be considered for all nonimmune travelers to China.

Enteric infections and diseases

Brucellosis

Brucellosis occurs in pastoral areas of China, primarily among persons involved in livestock production. High-risk provinces include Inner Mongolia, Jilin, Heilongjiang, Shandong, Gansu, Hebei, and Xinjiang. Regardless of destination, travelers should strictly avoid raw or unpasteurized milk and undercooked meat products.

Hepatitis E virus

Hepatitis E virus (HEV) genotype 4 is endemic in China and is usually acquired by drinking contaminated water (e.g., from wells) or eating uncooked/undercooked meats or seafood. Pregnant women in their third trimester are at particular risk for severe disease. Immunosuppressed persons, in particular solid organ transplant recipients receiving immunosuppressive medication, are at risk for chronic infection. Advise travelers to practice good hand hygiene and to adhere to safe food and water precautions (see Food and Water Precautions for Travelers chapter).

Travelers’ diarrhea

The risk for travelers’ diarrhea appears to be low in “luxury” accommodations in China but moderate elsewhere (see Travelers’ Diarrhea and Post-Travel Diarrhea chapter). Travelers should adhere to safe food and water precautions; they should also strictly avoid undercooked fish and shellfish and unpasteurized milk products (see Food and Water Precautions for Travelers chapter). Other than in Hong Kong, tap water is not safe to drink, even in major cities. Most hotels provide boiled or bottled water. Bottled water is readily available at local convenience stores and restaurants.

Typhoid fever

Typhoid fever and paratyphoid fever can be life-threatening diseases (see Typhoid and Paratyphoid Fever chapter). Although typhoid fever is not a significant risk in China’s major urban areas, travelers visiting rural areas, adventure travelers, and travelers visiting friends and relatives should strongly consider receiving the typhoid vaccine (see Adventure Travel and Visiting Friends and Relatives: VFR Travel chapters). Paratyphoid fever can cause similar symptoms and is more common in China. Currently, there is not a vaccine against paratyphoid fever. Multidrug-resistant Salmonella typhi and Salmonella paratyphi have been detected in China. Travelers are advised to adhere to safe food and water precautions (see Food and Water Precautions for Travelers chapter).

Respiratory infections and diseases

Coronavirus disease 2019

All travelers going to China should be up to date with their COVID-19 vaccines.

Influenza

China’s national influenza vaccination technical guidelines recommend the Northern Hemisphere influenza vaccines. Travelers to China are recommended to be up to date using the influenza vaccination offered in their home country before travel. Even when vaccinated, travelers should continue to observe all necessary behavioral precautions to protect themselves from influenza, including frequent hand washing and respiratory etiquette.

Tuberculosis

The World Health Organization (WHO) classifies China as one of the high-burden countries for tuberculosis (TB) transmission. Travelers can become infected through exposure to a person with active Mycobacterium tuberculosis infection. Consuming unpasteurized milk products poses a risk for infection with Mycobacterium bovis, another mycobacterium that can cause disease in people. For long-term travelers or travelers whose itineraries place them at increased risk for exposure, consider pre-departure TB testing with retesting upon their return home (for more details, see Tuberculosis chapter).

Sexually transmitted infections and HIV

Sexually transmitted infections (STIs), including chlamydia, gonorrhea, HIV, and syphilis, are a growing problem in China, particularly along the booming eastern seaboard (see Sex and Travel chapter). Drug-resistant gonorrhea is increasingly prevalent. Travelers should be aware of STI risks and the importance of using condoms when having sex with anyone whose HIV or STI status is unknown. As previously noted, travelers should receive hepatitis B vaccination before travel.

Most cases of mpox occur among adult males, with more than 90% reporting same-sex sexual contact as a risk factor. China has not yet implemented an mpox vaccination prevention strategy. Suspected and confirmed cases are required to be isolated (see Sex and Travel, for more information about mpox).

Soil- and waterborne infections

Schistosomiasis and leptospirosis

Elimination programs for schistosomiasis have been quite successful. Infections are primarily caused by Schistosoma japonicum and are most likely to occur along the Yangtze and Mekong River basins. Current prevalence of S. japonicum in humans and livestock (see Schistosomiasis chapter) is very low. Nevertheless, travelers should avoid freshwater swimming, which also decreases their risk of contracting bacterial infections, including leptospirosis.

Vector-borne diseases

Chikungunya, dengue, and Zika

Most outbreaks of chikungunya, dengue, and Zika in China have been linked to imported cases from elsewhere in Asia, Africa, or South America and spread locally through 2 key vectors: Aedes aegypti and Aedes albopictus. Chikungunya has been reported in China, with recent outbreaks reported in Yunnan, Guangdong, and Zhejiang Provinces. In 2016, 22 cases of Zika were imported to China, including 15 to Guangdong Province. Due to rapid case detection and isolation, along with vector control, no local transmission was reported. Dengue, however, is a significant health risk for travelers (see Dengue chapter). In 2014, China experienced the country’s worst dengue outbreak in decades; Guangdong Province reported >40,000 cases in just 2 months. Dengue epidemics occur in China every 4–6 years, mostly in the southern provinces. Travelers should practice insect-bite precautions during the summer months (see Mosquitoes, Ticks, and Other Arthropods chapter). Due to the moderate climate in southern Yunnan and Hainan Province, insect-bite precautions should be considered year-round.

Japanese encephalitis

China included the Japanese encephalitis (JE) vaccine in the national immunization schedule in 2008 and has successfully reduced the incidence of JE in most of the country. However, the 2018 JE outbreak in Gansu Province, with record high rates of transmission, is a reminder that the vector is still present, and that disease transmission and outbreaks are possible. JE vaccine should be considered for travelers with frequent travel to JE-endemic countries and those who will stay longer than 1 month in China. JE vaccination should also be considered for persons who will stay for a shorter period but plan to spend time in rural areas, participate in outdoor activities, or stay in accommodations without air conditioning, window screens, or bed nets (see Japanese Encephalitis chapter, for more detailed information).

Malaria

In 2021, WHO declared China malaria-free. In the 1940s, China reported >30 million cases of malaria per year. A 70-year eradication campaign progressively reduced numbers. Imported malaria cases still occur, particularly from elsewhere in Southeast Asia. Stopping onward transmission from these imported cases remains a top priority. The risk of malaria transmission in China is very low. Travelers should continue to follow insect-bite precautions to minimize the risk of infection with other vector-borne diseases (see Mosquitoes, Ticks, and Other Arthropods chapter).

Plague

China has a large and complex natural reservoir of Yersinia pestis, the causative pathogen of plague. By the end of 2021, several natural plague foci were identified in 19 provinces in China. Most epizoic and enzootic transmission occurs in parts of Inner Mongolia, Gansu, and Qinghai in the north and in Yunnan, Sichuan, and Tibet in the south. In 2021, a plague death was reported from Inner Mongolia. Plague is rarely seen in tourists but is a risk to campers, hikers, hunters, spelunkers, and others exposed to wild rodents, flea-infested cats, or flea-infested dogs.

Tick-borne encephalitis

Tick-borne encephalitis is endemic in northern and western China, including the mountain areas in Heilongjiang, Jilin, Inner Mongolia, and Xinjiang. Transmission also occurs in southwestern areas in Tibet and Yunnan. Persons who are planning hiking or camping trips from mid-April to July in forested areas are at highest risk. Consider offering vaccination to travelers who have itineraries that will include outdoor activities in forested areas (see Tick-Borne Encephalitis chapter; Box 11.3.1.2). Even among vaccinated travelers, reinforce the importance of taking preventive measures (e.g., wearing long pants tucked into socks, using insect repellent, and regularly checking for ticks).

Box 11.3.1.2

Environmental hazards and risks

Air pollution

Rapid economic expansion and industrialization since 1978 has resulted in serious air pollution issues, along with water and soil contamination. To tackle air pollution, China introduced several policies and measures targeted at reducing emissions and promoting alternative energy production. Other measures included closing highly polluting factories, moving factories farther away from population centers, reforestation projects, and promoting the use of electric vehicles. These measures have resulted in a dramatic reduction in air pollution, particularly in fine particulate matter (PM2.5). Although air quality in Beijing has greatly improved overall, air pollution remains a problem in many parts of the country. In 2022, many of the world’s 200 cities with the worst air quality were in China. Hazardous air quality can occasionally occur following large sandstorms originating from southern Mongolia. These sandstorms—which are unpredictable—can blanket Beijing and neighboring provinces with a layer of dust and other air pollutants. Travelers can check the 5-day air quality forecasts.

Short-term exposure to the levels of air pollution in China’s megacities can irritate the eyes and throat. Travelers with cardiovascular or chronic respiratory conditions, children, and older adults are the most likely to be affected by particle pollution exposure. In addition, exposure to high levels of air pollution significantly increases the risk for upper and lower respiratory tract infections, including otitis, sinusitis, bronchitis, and pneumonia.

Even before the COVID-19 pandemic, surgical-style facemasks were commonplace in China’s large cities, especially in Beijing, Hong Kong, and Shanghai. However, facemasks do not provide protection from fine particulate matter in air pollution. Properly fitted N95 masks can filter out these particulates and might be advisable for people determined to engage in outdoor activities at times when air quality is very poor (see Air Quality and Ionizing Radiation During Travel chapter). To reduce daily exposure, many facilities, particularly schools, have installed sophisticated central air-filtering devices and have constructed enclosed sports venues.

Altitude illness

Western China is home to some of the tallest mountains in the world. Some popular destinations are Xining (2,295 m; 7,500 ft), Lijiang (2,418 m; 7,900 ft), Shangri-La (Zhongdian) (3,280 m; 11,000 ft), and Lhasa (3,658 m; 12,000 ft). Advise travelers on the importance of a gradual ascent and taking time to acclimatize to prevent the onset of altitude illness (see High-Altitude Travel and Altitude Illness chapter).

Visitors planning high-altitude travel whose itineraries do not permit gradual acclimatization— or people otherwise known to be at risk for developing acute mountain sickness—should carry their own supply of acetazolamide because availability in China is currently unreliable (see Travel Health Kits chapter).

Animal bites and rabies

An analysis of data collected by the GeoSentinel Surveillance Network indicates that dog bites are common among tourists to China (see Zoonotic Exposures: Bites, Scratches, and Other Hazards chapter). Animal rabies is endemic in China, especially among the free-roaming dog population (see Rabies chapter). Human rabies deaths in China have decreased substantially since peaking in 2007. This decline is mainly attributable to increased public awareness and use of post-exposure prophylaxis. Rabies viruses have also been detected in several wildlife species, including the Chinese ferret badger, raccoon dog, and various bats species. The risk of human rabies exposure remains highest in Hubei, Hunan, Guangxi, and Guizhou Provinces.

Travelers should consider any dog or other mammal bite received anywhere in China, including urban areas, a high risk for rabies infection. Because international-standard rabies immune globulin is often unavailable, animal bites can force travelers to end their trips prematurely, requiring evacuation to Bangkok, Hong Kong, or home, to receive appropriate post-exposure prophylaxis. Younger children are more likely to experience a rabies exposure due to their inherent curiosity about animals. However, everyone is at risk; an American adult citizen died from rabies following a dog bite while traveling in Guangdong Province in 2019. A discussion about the risk of rabies and strategies for dealing with possible exposures should be held during pre-travel consultations. With the recent shortening of the pre-exposure regimen (2 doses, 1 week apart), barriers to pre-exposure rabies vaccination have been considerably reduced. Strongly consider providing travelers to rural communities, long-term travelers, and expatriates going to live in China with the rabies pre-exposure vaccination series. All travelers should also consider purchasing medical evacuation insurance coverage (see Travel Insurance, Travel Health Insurance, and Medical Evacuation Insurance chapter).

Natural disasters

In the last few decades, China has experienced earthquakes, heat waves, droughts, forest and grassland fires, hailstorms, red tides, sandstorms, and torrential rains resulting in damaging landslides. Typhoons and storm surges occur regularly along the southern and eastern seaboard.

The heat wave in the summer of 2023 in Eastern China was close to the longest and hottest on record, creating an influx of emergency room visits for heat stroke. Air conditioning may not be reliable in all locations. Travelers, particularly those with existing chronic cardiovascular conditions, are strongly encouraged to reduce outdoor activities and increase fluid intake during prolonged periods of excessive heat (see Heat and Cold Illness in Travelers chapter). An earthquake struck the western province of Sichuan in 2009, killing more than 90,000 persons and causing devastating damage to schools, homes, and businesses. Less severe and minor earthquakes are common in China; in 2023, a 5.5 magnitude earthquake occurred near the city of Dezhou, about 300 km south of Beijing. Advise U.S. citizen travelers to enroll with the Department of State’s Smart Traveler Enrollment Program (STEP); STEP will provide travelers with information and alerts from local U.S. embassies or consulates about disasters, safety, and security issues at their destination.

Wet markets

“Wet markets” are common throughout China and many other parts of Asia. The term “wet market” is a generic one, encompassing many types of marketplaces selling perishable goods; some sell only fruits and vegetables, while others sell live animals that are slaughtered on-site after purchase.

Because the exotic animal trade has been banned in China, most wet markets do not sell wild or exotic animals. However, smuggling of animals (e.g., pangolins) is highly profitable and can be difficult to control. Travelers should avoid visiting markets selling live animals due to the risk of zoonotic disease spill-over (i.e., spread of animal diseases to humans), such as coronaviruses and avian influenza.

Safety and security

Crime

In major cities, expansive video security systems have been established, resulting in low rates of violent crime, thefts, and pickpocketing. However, various forms of scams and fraud, targeting foreign businesses and tourists, can and do occur. Travelers should remain vigilant and avoid responding to emails from unknown contacts as well as giving out sensitive information to unfamiliar sources.

Political unrest

Travelers should be aware of and avoid involvement in protests and flare-ups of unrest in places as diverse as Hong Kong, Tibet, and Xinjiang. Travelers also should avoid public criticism of the Communist Party or the government. More information about political and religious activity can be found on the U.S. Department of State travel website.

Traffic-related injuries

Traffic in China can be chaotic. The rate of traffic crashes, including fatal ones, is among the highest in the world (see Injury and Death During Travel chapter). Traffic accidents are one of the leading causes of death in China for children 6–18 years of age. Traffic crashes, even minor ones, can create major traffic jams and sometimes turn into violent altercations, particularly when foreign travelers are involved (see Safety and Security Overseas chapter).

China has not signed the convention that created the International Driving Permit and requires travelers to have a Chinese license to drive. Recent regulations have allowed foreign travelers to obtain a temporary (≤3 months) driver’s license if they possess a valid overseas driver’s license, have a notarized copy translated into Chinese, and attend lessons on Chinese road safety regulations. Persons must be at least 18 years of age to legally drive in China.

Driving is on the right side of the road in mainland China and Taiwan but on the left side in Hong Kong and Macau. Advise travelers to avoid driving at night or when weather conditions are bad. Also, ensure that they do not assume that traffic rules are the same everywhere or that right-of-way will be respected. Despite national seat belt legislation being in effect since 2004, seat belt use is inconsistent, and rear seat belts are often unavailable. The use of child safety seats has recently become mandatory. For all these reasons, travelers should strongly consider hiring a local driver or using public transportation rather than driving themselves. Travelers should take care when opening the door of a taxi or private vehicle, to avoid hitting cyclists or pedestrians.

Despite the best efforts of municipal governments and green-developers, most of the urban centers in China are not yet pedestrian-friendly. As a pedestrian, travelers should defer right-of-way to vehicles and double-check at intersections for oncoming traffic before crossing, regardless of the traffic signals.

Electronic bicycles and bike-sharing

Electronic bicycles (E-bikes) provide a low-cost mode of transportation and are popular in China. A driver’s license is not required. However, since 2019, all E-bikes must be registered. Registration requirements vary by municipality. Because E-bikes have no engine noise, pedestrians might not readily identify an oncoming E-bike, and crashes and injuries have increased. A 2020 law requiring helmet use for riders of motorcycles and E-bikes resulted in a shortage of available helmets. Helmet use on E-bikes remains inconsistent.

Bike-sharing has increased substantially during the last several years in major municipalities, including Beijing, Chengdu, Guangzhou, Shanghai, and Tianjin. Several bike-sharing companies exist in the same market, each requiring a smartphone app linked to a local phone number. If able to access the apps, travelers should check the brakes, steering column, and seat stability when selecting a shared bicycle. Bicycle helmets are not required but are advisable. Travelers should consider bringing their own motorcycle or bicycle helmets.

Availability and quality of medical care

Strongly encourage travelers to invest in travel health insurance, including medical evacuation insurance coverage (see Travel Insurance, Travel Health Insurance, and Medical Evacuation Insurance chapter). Many hospitals do not accept foreign medical insurance, and patients are expected to pay a deposit to cover the anticipated cost of treatment before care is delivered. Many major cities, including Beijing, Guangzhou, Hong Kong, Shanghai, and Shenzhen, have medical facilities that meet international standards. Hospitals in other cities might have “VIP wards” (gaogan bingfang) with English-speaking staff. The standard of care in such facilities is somewhat unpredictable, however, and cultural and regulatory differences can cause difficulties for travelers. In rural areas, rudimentary medical care might be all that is available.

Blood and blood product safety

The blood supply is heavily regulated and generally deemed safe. Since implementation of the 1998 Blood Donation Law, all blood and blood products must be tested before transfusion in medical institutes to ensure safety. Due to low blood donation rates, however, supply can be limited, especially for rare types, including Rhesus negative blood. Large regional variations exist in the blood supply, with acute shortages more likely in Western China. RhoGAM is available in Hong Kong, and recently in Shenzhen under a new program permitting drugs and medical equipment already marketed in Hong Kong to be used in the Guangdong-Hong Kong-Macau “Greater Bay Area” after approval. Hepatitis B and hepatitis C virus transmission from poorly sterilized medical equipment remains a risk in remote areas.

Emergency medical services

Emergency medical services are scarce in many parts of China, most acutely in rural areas (see Injury and Death During Travel chapter). In major cities, 2 types of ambulances are available: general ambulances and ambulances that carry more advanced medical equipment. No recognized paramedic profession exists in China, and ambulances might be staffed instead with doctors or nurses with variable levels of training. In many rural areas, rather than waiting for an ambulance to arrive, injured travelers should strongly consider taking a taxi or other immediately available vehicle to the nearest major hospital.

Medical tourism

Most people who choose to try traditional Chinese remedies do so uneventfully, albeit while accepting some risk. Remind travelers that acupuncture needles can be a source of blood-borne and skin infections; acupressure might be preferable. Herbal medicine products can be contaminated with heavy metals or pharmaceutical agents. Advise travelers about the dangers of possible interactions with their regular prescription medications.

Prior to the COVID-19 pandemic, China was experiencing an influx of patients from high-income countries seeking treatment not available or licensed in their home countries (see Medical Tourism chapter). International medical tourism to China has not yet recovered post-pandemic.

Pharmacies

Pharmacies often sell prescription medications over the counter, but these can be counterfeit, substandard, or contaminated. Advise travelers to bring all their regular medications in sufficient quantity. If travelers need more or other medications, recommend that they visit a reputable clinic or hospital. The U.S. Embassy or expatriates may be able to offer city-specific advice. China allows travelers to bring controlled medications into the country in quantities “reasonable for personal use” (see Traveling with Prohibited or Restricted Medications chapter). Especially for controlled medications, travelers are expected to carry a copy of the written prescription with them and, whenever possible, a signed note from the prescribing physician written on letterhead stationery. A copy of the prescription may be kept by customs or at tourist inspection site officials. Custom officials may hold and request high customs duties for medications sent to China from overseas, even if the medications are for personal use.

Acknowledgements

The following authors contributed to the previous version of this chapter: Roohallah Changizi and Kate Gaynor.