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i

CDC
YELLOW BOOK 2018
Health Information for
International Travel
ii
iii

CDC
YELLOW BOOK 2018
Health Information for
International Travel
Editor in Chief Gary W. Brunette, MD, MS

CHIEF MEDICAL EDITOR US DEPARTMENT OF HEALTH AND

Phyllis E. Kozarsky, MD HUMAN SERVICES

PUBLIC HEALTH SERVICE

MEDICAL EDITORS
Clive M. Brown, MBBS, DTM&H
Nicole J. Cohen, MD, MS
Douglas H. Esposito, MD, MPH
Mark D. Gershman, MD
CENTERS FOR DISEASE CONTROL AND
PREVENTION
NATIONAL CENTER FOR EMERGING AND
ZOONOTIC INFECTIOUS DISEASES

Stephen M. Ostroff, MD DIVISION OF GLOBAL MIGRATION AND

Edward T. Ryan, MD QUARANTINE

David R. Shlim, MD ATLANTA, GEORGIA

Richard W. Steketee, MD, MPH
Michelle Weinberg, MD, MPH
Mary Elizabeth Wilson, MD

MANAGING EDITOR
Megan Crawley O’Sullivan, MPH

TECHNICAL EDITOR
1
Ronnie Henry
iv

1
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© Oxford University Press 2017

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above should be sent to the Rights Department, Oxford University Press, at the
address above.

You must not circulate this work in any other form

and you must impose this same condition on any acquirer.

ISSN 0095–3539
ISBN 978–​0–​19–​062861–​1

9 8 7 6 5 4 3 2 1
Paperback printed by LSC Communications, United States of America

Oxford University Press is proud to pay a portion of its sales for this book to the CDC
Foundation. Chartered by Congress, the CDC Foundation began operations in 1995
as an independent, nonprofit organization fostering support for CDC through public-
private partnerships. Further information about the CDC Foundation can be found at
www.cdcfoundation.org. The CDC Foundation did not prepare any portion of this
book and is not responsible for its contents.
v

All CDC material in this publication is in the public domain and may be used and
reprinted without special permission; however, citation of the source is appreciated.

Suggested Citation
Centers for Disease Control and Prevention. CDC Yellow Book 2018: Health Information for
International Travel. New York: Oxford University Press; 2017.

Readers are invited to send comments and suggestions regarding this publication to Gary W.
Brunette, Editor in Chief, Centers for Disease Control and Prevention, Division of Global
Migration and Quarantine (E-03), Travelers’ Health Branch (proposed), 1600 Clifton Road NE,
Atlanta, GA 30333, USA.

Disclaimers
Both generic and trade names (without trademark symbols) are used in this text. In all cases,
the decision to use one or the other was made based on recognition factors and was done for
the convenience of the intended audience. Therefore, the use of trade names and commercial
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References to non-CDC Internet sites are provided as a service to readers and do not
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Notice
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 cont
vi
ents
╇vi

List of Boxes, Figures, Maps, & Tables, by Topicâ•… xiii

List of Mapsâ•… xix
Editorial Staffâ•… xxi
CDC Contributorsâ•… xxi
External Contributorsâ•… xxii
Acknowledgmentsâ•… xxv
Prefaceâ•… xxv
In Memoriam: A Tribute to Alan J. Magillâ•… xxvi

1 Introductionâ•… 1

Introduction to Travel Health & the Yellow Bookâ•… 1

Planning for Healthy Travel: CDC Travelers’ Health Website and Mobile Applicationsâ•… 4
Travel Epidemiologyâ•… 6
Perspectives: WHY GUIDELINES DIFFERâ•… 9
Air Travel Trendsâ•… 13

2 The Pretravel Consultationâ•…

The Pretravel Consultationâ•… 16
16

Perspectives: TRAVELERS’ PERCEPTION OF RISKâ•… 25

Perspectives: PRIORITIZING CARE FOR THE RESOURCE-╉LIMITED TRAVELER╅ 27
Perspectives: THE NEED FOR A COST ANALYSIS TO JUSTIFY THE TRAVEL MEDICINE CONSULTâ•… 30
General Recommendations for Vaccination & Immunoprophylaxisâ•… 32
Interactions among Travel Vaccines & Drugsâ•… 44
Self-╉Treatable Conditions╅ 48
Travelers’ Diarrheaâ•… 48
Perspectives: ANTIBIOTICS IN TRAVELERS’ DIARRHEA—╉BALANCING THE RISKS & BENEFITSâ•… 55
Altitude Illnessâ•… 56
Jet Lagâ•… 62
Motion Sicknessâ•… 64
Respiratory Infectionsâ•… 66
Counseling & Advice for Travelersâ•… 69
Food & Water Precautionsâ•… 69
Water Disinfection for Travelersâ•… 72
Food Poisoning from Marine Toxinsâ•… 77
vi

Protection against Mosquitoes, Ticks, & Other Arthropodsâ•… 81

Sun Exposureâ•… 87
Problems with Heat & Coldâ•… 89
Injury Preventionâ•… 94
Safety & Securityâ•… 99
Animal-╉Associated Hazards╅ 101
Environmental Hazardsâ•… 105
Scuba Divingâ•… 107
Medical Tourismâ•… 110
Discussing Complementary & Integrative Health Approaches with Travelersâ•… 115
Deep Vein Thrombosis & Pulmonary Embolismâ•… 120
Mental Healthâ•… 124
Travel Health Kitsâ•… 126
Perspectives: PHARMACEUTICAL QUALITY & FALSIFIED DRUGSâ•… 131
Obtaining Health Care Abroadâ•… 133
Travel Insurance, Travel Health Insurance, & Medical Evacuation Insuranceâ•… 136

3 Infectious Diseases Related to Travelâ•…

Amebiasisâ•…
139
139

Angiostrongyliasis, Neurologicâ•… 140

Anthraxâ•…
141
B virusâ•… 144
Bartonella Infectionsâ•… 146
Brucellosisâ•…
148
Campylobacteriosisâ•…
149
Chikungunyaâ•…
151
Choleraâ•…
153
Coccidioidomycosisâ•…
156
Cryptosporidiosisâ•…
157
Cutaneous Larva Migransâ•… 159
Cyclosporiasisâ•…
160
Cysticercosisâ•…
161
Dengueâ•…
162
Diphtheriaâ•…
169
Ebola Virus Disease & Marburg Virus Diseaseâ•… 170
Echinococcosisâ•…
173
Escherichia coli, Diarrheagenicâ•… 174
Fascioliasisâ•…
177
Filariasis, Lymphaticâ•… 178
Giardiasisâ•…
179
Hand, Foot, & Mouth Diseaseâ•… 180

viii CONTENTS
╇ix

Helicobacter pyloriâ•… 181

Helminths, Soil-╉Transmitted╅ 182
Hepatitis Aâ•…
183
Hepatitis Bâ•…
187
Hepatitis Câ•…
193
Hepatitis Eâ•…
198
Histoplasmosisâ•…
199
HIV Infectionâ•… 202
Influenzaâ•…
206
Japanese Encephalitisâ•… 214
Legionellosis (Legionnaires’ Disease & Pontiac Fever)â•… 224
Leishmaniasis, Cutaneousâ•… 226
Leishmaniasis, Visceralâ•… 228
Leptospirosisâ•…
230
Lyme Diseaseâ•… 232
Malariaâ•…
233
FOR THE RECORD: A HISTORY OF MALARIA CHEMOPROPHYLAXISâ•… 253
Measles (Rubeola)â•… 256
Melioidosisâ•…
260
Meningococcal Diseaseâ•… 261
Middle East Respiratory Syndrome (MERS)â•… 267
Mumpsâ•…
268
Norovirusâ•…
269
Onchocerciasis (River Blindness)â•… 271
Pertussisâ•…
272
Pinworm (Enterobiasis, Oxyuriasis, Threadworm)â•… 275
Plague (Bubonic, Pneumonic, Septicemic)â•… 276
Pneumococcal Diseaseâ•… 277
Poliomyelitisâ•…
278
FOR THE RECORD: A HISTORY OF POLIO ERADICATION EFFORTSâ•… 283
Q Feverâ•… 286
Rabiesâ•…
287
Perspectives: INTRADERMAL RABIES PREEXPOSURE IMMUNIZATIONâ•… 294
Rickettsial (Spotted & Typhus Fevers) & Related Infections, including
â•… Anaplasmosis & Ehrlichiosisâ•… 297
Rubellaâ•…
303
Salmonellosis (Nontyphoidal)â•… 304
Sarcocystosisâ•…
306
Scabiesâ•…
308
Schistosomiasisâ•…
309
Sexually Transmitted Diseasesâ•… 314
Perspectives: SEX & TOURISMâ•… 317
Shigellosisâ•…
319

CONTENTS ix
x

Smallpox & Other Orthopoxvirus-╉Associated Infections╅ 321

Strongyloidiasisâ•…
323
Taeniasisâ•…
325
Tetanusâ•…
325
Tickborne Encephalitisâ•… 326
Toxoplasmosisâ•…
330
Trypanosomiasis, African (Sleeping Sickness)â•… 331
Trypanosomiasis, American (Chagas Disease)â•… 332
Tuberculosisâ•…
334
Perspectives: TUBERCULIN SKIN TESTING OF TRAVELERSâ•… 340
Typhoid & Paratyphoid Feverâ•… 342
Varicella (Chickenpox)â•… 346
Viral Hemorrhagic Feversâ•… 349
Yellow Feverâ•… 352
FOR THE RECORD: A HISTORY OF YELLOW FEVER VACCINATION REQUIREMENTSâ•… 367
Yersiniosisâ•…
368
Zikaâ•…
369
Yellow Fever & Malaria Information, by Countryâ•… 372

4 Select Destinationsâ•…
Rationale for Select Destinationsâ•… 425
425

Africa & the Middle Eastâ•… 426

East Africa: Safarisâ•… 426
Saudi Arabia: Hajj/╉Umrah Pilgrimage╅ 430
South Africaâ•… 436
Tanzania: Kilimanjaroâ•…
439
The Americas & the Caribbeanâ•… 444
Brazilâ•…
444
Cubaâ•…
449
Dominican Republicâ•… 452
Haitiâ•…
455
Mexicoâ•…
459
Peru: Cusco, Machu Picchu, & Other Regionsâ•… 463
Asiaâ•…
468
Burma (Myanmar)â•… 468
Chinaâ•…
472
Indiaâ•…
478
Nepalâ•…
483
Thailandâ•…
486
Vietnamâ•…
491

x CONTENTS
╇xi

5 Post-╉Travel Evaluation╅
General Approach to the Returned Travelerâ•… 495
495

Fever in Returned Travelersâ•… 499

Persistent Travelers’ Diarrheaâ•… 504
Skin & Soft Tissue Infections in Returned Travelersâ•… 507
Screening Asymptomatic Returned Travelersâ•… 512

6 Conveyance & Transportation Issuesâ•…

Air Travelâ•… 517
517

Cruise Ship Travelâ•… 521

Death during Travelâ•… 527
Taking Animals & Animal Products across International Bordersâ•… 529

7 International Travel with Infants & Childrenâ•…

Traveling Safely with Infants & Childrenâ•… 533
533

Vaccine Recommendations for Infants & Childrenâ•… 541

Travel & Breastfeedingâ•… 546
International Adoptionâ•… 550

8 Advising Travelers with Specific Needsâ•…

Immunocompromised Travelersâ•… 557
557

Travelers with Chronic Illnessesâ•… 571

Pregnant Travelersâ•… 576
Travelers with Disabilitiesâ•… 582
Immigrants Returning Home to Visit Friends & Relatives (VFRs)â•… 584
Health Care Workersâ•… 588
Advice for Air Crewsâ•… 594
Humanitarian Aid Workersâ•… 597
Long-╉Term Travelers & Expatriates╅ 602
Perspectives: MALARIA IN LONG-╉TERM TRAVELERS & EXPATRIATES╅ 607
Last-╉Minute Travelers╅ 611

CONTENTS xi
xi

Special Considerations for US Military Deploymentsâ•… 615

Study Abroad & Other International Student Travelâ•… 621
Travel to Mass Gatheringsâ•… 627
Newly Arrived Immigrants & Refugeesâ•… 629
Wilderness & Expedition Medicineâ•… 636
Work-╉Related Travel╅ 640

Appendicesâ•…645
Appendix A: Promoting Quality in the Practice of Travel Medicineâ•… 645
Appendix B: Travel Vaccine Summary Tableâ•… 649
Indexâ•…
653
Photography Creditsâ•… 667

xii CONTENTS
xi

List of Boxes, Figures, Maps,

& Tables, by Topic

DISEASES, CONDITIONS, & VACCINES

General Travel Health Risks

TABLE 5-​3. Common infections, by incubation period 501
TABLE 5-​4. Common clinical findings and associated infections 502

General Vaccine Information

BOX 2-​1. The Advisory Committee on Immunization Practices (ACIP) 33
TABLE 2-​2. Vaccines to update or consider during pretravel consultations 19
TABLE 2-​5. Recommended and minimum ages and intervals between vaccine doses 38
TABLE 8-​1. Immunization of immunocompromised adults 559
TABLE 8-​2. Immunosuppressive biologic agents that preclude use of live vaccines 566
TABLE B-​1. Travel vaccine summary 650

Acute Mountain Sickness and Altitude Illness

BOX 2-​3. Tips for acclimatization 57
TABLE 2-​7. Risk categories for acute mountain sickness 58
TABLE 2-​8. Ascent risk associated with various underlying medical conditions 59
TABLE 2-​9. Recommended medication doses to prevent and treat altitude illness 60

Deep Vein Thrombosis and Pulmonary Embolism

BOX 2-​10. Venous thromboembolism (VTE) risk factors 121

Dengue
BOX 3-​1. Guidelines for classifying dengue 166
FIGURE 3-​1. Relative sensitivity of detection of dengue virus nucleic acid, antigen, and IgM 168
MAP 3-​1. Dengue risk in the Americas and the Caribbean 163
MAP 3-​2. Dengue risk in Africa and the Middle East 164
MAP 3-​3. Dengue risk in Asia and Oceania 165
TABLE 8-​4. Diseases for which VFR travelers are at increased risk, proposed reasons for risk variance, and
recommendations to reduce risks 586

Dermatologic Conditions
TABLE 5-​5. Ten most common skin lesions in returned travelers, by cause 508

Diarrheal Illnesses
BOX 2-​2. Travelers’ diarrhea definitions 53
TABLE 2-​6. Travelers’ diarrhea treatment recommendations 53
TABLE 8-​4. Diseases for which VFR travelers are at increased risk, proposed reasons for risk variance, and
recommendations to reduce risks 586
xvi

Escherichia coli
TABLE 3-​1. Mechanism of pathogenesis and typical clinical syndrome of Escherichia coli pathotypes 176

Fever
TABLE 5-​1. Illnesses associated with fever presenting in the first 2 weeks after travel 497
TABLE 5-​2. Common causes of fever, by geographic area 500

Hepatitis A
TABLE 3-​2. Vaccines to prevent hepatitis A 185
TABLE 8-​4. Diseases for which VFR travelers are at increased risk, proposed reasons for risk variance, and
recommendations to reduce risks 586

Hepatitis B
MAP 3-​4. Prevalence of hepatitis B virus infection 188
TABLE 3-​3. Interpretation of serologic test results for hepatitis B virus infection 190
TABLE 3-​4. Vaccines to prevent hepatitis B 192
TABLE 8-​4. Diseases for which VFR travelers are at increased risk, proposed reasons for risk variance, and
recommendations to reduce risks 586

Hepatitis C
MAP 3-​5. Prevalence of hepatitis C virus infection 194
TABLE 8-​4. Diseases for which VFR travelers are at increased risk, proposed reasons for risk variance, and
recommendations to reduce risks 586

Hepatitis E
MAP 3-​6. Hepatitis E endemic countries 200
TABLE 8-​4. Diseases for which VFR travelers are at increased risk, proposed reasons for risk variance, and
recommendations to reduce risks 586

HIV
BOX 3-​5. Summary of sexual health recommendations for travelers 318
TABLE 8-​4. Diseases for which VFR travelers are at increased risk, proposed reasons for risk variance, and
recommendations to reduce risks 586
TABLE 8-​1. Immunization of immunocompromised adults 559

Influenza
MAP 3-​7. Distribution of highly pathogenic avian influenza A (H5N1) virus 208
TABLE 3-​5. Recommended dosage and duration of antiviral medications for treatment and prophylaxis of
influenza A and B 212

Injury
FIGURE 2-​2. Leading causes of injury death for US citizens in foreign countries, 2013 & 2014 95
TABLE 2-​13. Recommended strategies to reduce injuries while abroad 96

Japanese Encephalitis
MAP 3-​8. Distribution of Japanese encephalitis 216
TABLE 3-​6. Vaccine to prevent Japanese encephalitis (JE) 217

xiv LIST OF BOXES, FIGURES, MAPS, & TABLES, BY TOPIC

xv

TABLE 3-​7. Risk for Japanese encephalitis (JE), by country 218

TABLE 8-​4. Diseases for which VFR travelers are at increased risk, proposed reasons for risk variance, and
recommendations to reduce risks 586

Malaria
BOX 3-​2. Clinical highlights for malaria 235
BOX 3-​3. What is a reliable supply? 239
BOX 8-​7. Practical advice on malaria prophylaxis for long-​term travelers and expatriates 610
MAP 3-​9. Malaria-​endemic countries in the Western Hemisphere 234
MAP 3-​10. Malaria-​endemic countries in the Eastern Hemisphere 236
MAP 3-​18. Malaria in Bolivia 380
MAP 3-​19. Malaria in Botswana 381
MAP 3-​21. Malaria in Brazil 383
MAP 3-​24. Malaria in Colombia 388
MAP 3-​26. Malaria in Ecuador 392
MAP 3-​28. Malaria in Ethiopia 394
MAP 3-​29. Malaria in India 398
MAP 3-​31. Malaria in Kenya 401
MAP 3-​32. Malaria in Mexico 404
MAP 3-​33. Malaria in Nicaragua 406
MAP 3-​35. Malaria in Panama 409
MAP 3-​37. Malaria in Peru 412
MAP 3-​38. Malaria in South Africa 416
MAP 3-​40. Malaria in Venezuela 421
TABLE 3-​8. Reliable supply regimens for the treatment of malaria 240
TABLE 3-​9. Considerations when choosing a drug for malaria prophylaxis 241
TABLE 3-​10. Drugs used in the prophylaxis of malaria 244
TABLE 3-​11. Half-​lives of malaria chemoprophylaxis drugs 248
TABLE 3-​12. Changing medications as a result of side effects during chemoprophylaxis 250
TABLE 3-​13. Food and Drug Administration recommendations for deferring blood donation in people returning
from malarious areas 251
TABLE 8-​4. Diseases for which VFR travelers are at increased risk, proposed reasons for risk variance, and
recommendations to reduce risks 586
TABLE 8-​6. Differences between CDC recommendations and US military’s use of malaria
chemoprophylaxis 619

Measles
TABLE 2-​4. Recommended intervals between administration of antibody-​containing products and
measles-​containing vaccine or varicella-​containing vaccine 35

Meningitis
MAP 3-​11. Areas with frequent epidemics of meningococcal meningitis 262
TABLE 3-​14. Meningococcal vaccines licensed in the United States 264

LIST OF BOXES, FIGURES, MAPS, & TABLES, BY TOPIC xv

xvi

Rabies
BOX 3-​4. World Health Organization, human rabies case definition 288
TABLE 3-​15. Criteria for preexposure immunization for rabies 290
TABLE 3-​16. Preexposure immunization for rabies 291
TABLE 3-​17. Postexposure immunization for rabies 292

Rickettsial and Related Infections

TABLE 3-​18. Classification, primary vector, and reservoir occurrence of rickettsiae known to cause disease
in humans 298
TABLE 8-​4. Diseases for which VFR travelers are at increased risk, proposed reasons for risk variance, and
recommendations to reduce risks 586

Schistosomiasis
MAP 3-​12. Distribution of schistosomiasis 310
TABLE 8-​4. Diseases for which VFR travelers are at increased risk, proposed reasons for risk variance, and
recommendations to reduce risks 586

Sexually Transmitted Diseases

BOX 3-​5. Summary of sexual health recommendations for travelers 318
TABLE 8-​4. Diseases for which VFR travelers are at increased risk, proposed reasons for risk variance, and
recommendations to reduce risks 586

Tickborne Encephalitis
TABLE 3-​19. Tickborne encephalitis (TBE) vaccines licensed in Europe and Russia 329

Tuberculosis
MAP 3-​13. Estimated tuberculosis incidence rates 336
TABLE 3-​20. Estimated proportion of MDR TB cases in high-burden countries 338
TABLE 8-​4. Diseases for which VFR travelers are at increased risk, proposed reasons for risk variance, and
recommendations to reduce risks 586

Typhoid
TABLE 3-​21. Vaccines to prevent typhoid fever 344
TABLE 8-​4. Diseases for which VFR travelers are at increased risk, proposed reasons for risk variance, and
recommendations to reduce risks 586

Varicella (Chickenpox)
TABLE 2-​4. Recommended intervals between administration of antibody-​containing products and
measles-​containing vaccine or varicella-​containing vaccine 35

Yellow Fever
FIGURE 3-​2. Example International Certificate of Vaccination or Prophylaxis (ICVP) 362
FIGURE 3-​3. Medical Contraindication to Vaccination section of the International Certificate of Vaccination
or Prophylaxis (ICVP) 363
MAP 3-​14. Yellow fever vaccine recommendations in Africa 364
MAP 3-​15. Yellow fever vaccine recommendations in the Americas 365

xvi LIST OF BOXES, FIGURES, MAPS, & TABLES, BY TOPIC

xvi

MAP 3-​16. Yellow fever vaccine recommendations in Argentina 376

MAP 3-​17. Yellow fever vaccine recommendations in Bolivia 379
MAP 3-​20. Yellow fever vaccine recommendations in Brazil 382
MAP 3-​23. Yellow fever vaccine recommendations in Colombia 387
MAP 3-​25. Yellow fever vaccine recommendations in Ecuador 391
MAP 3-​27. Yellow fever vaccine recommendations in Ethiopia 393
MAP 3-​30. Yellow fever vaccine recommendations in Kenya 400
MAP 3-​34. Yellow fever vaccine recommendations in Panama 408
MAP 3-​36. Yellow fever vaccine recommendations in Peru 411
MAP 3-​39. Yellow fever vaccine recommendations in Venezuela 420
MAP 3-​41. Yellow fever vaccine recommendations in Zambia 423
TABLE 3-​22. Countries with risk of yellow fever virus (YFV) transmission 353
TABLE 3-​23. Countries with low potential for exposure to yellow fever virus (YFV) 354
TABLE 3-​24. Vaccine to prevent yellow fever 355
TABLE 3-​25. Contraindications and precautions to yellow fever vaccine administration 356
TABLE 3-​26. Countries that require proof of yellow fever vaccination from all arriving travelers 361
TABLE 3-​27. Categories of recommendations for yellow fever vaccination 373
TABLE 8-​4. Diseases for which VFR travelers are at increased risk, proposed reasons for risk variance, and
recommendations to reduce risks 586

Zika
BOX 3-​6. Zika in pregnancy 370

RESOURCES
General Resources
BOX 1-​1. CDC contact information for clinicians 2
BOX 2-​9. About dietary supplements and unproven therapies 116
FIGURE 1-​1. CDC Travelers’ Health website homepage 4
MAP 1-​1. Estimated number of US air travelers received 14
TABLE 1-​1. Estimated number of US air passengers departing to the top 10 destination countries, 2015 14

Insect Avoidance
BOX 2-​4. Maximizing protection from mosquitoes and ticks 82
BOX 2-​5. Bed bugs and international travel 86
BOX 8-​6. Practical advice on personal protective measures for clinicians counseling long-​term travelers
and expatriates 609
FIGURE 2-​1. Sample repellency awareness graphic for skin-​applied insect repellents 84

Pretravel Consultation
BOX 8-​1. Key patient education points for the immunocompromised traveler 570
BOX 8-​2. Pretravel consultation checklist for pregnant travelers 577
TABLE 2-​1. Information necessary for a risk assessment during pretravel consultations 17
TABLE 2-​2. Vaccines to update or consider during pretravel consultations 19
TABLE 2-​3. Major topics for discussion during pretravel consultations 21

LIST OF BOXES, FIGURES, MAPS, & TABLES, BY TOPIC xvii

xvi

Water Treatment
TABLE 2-​10. Comparison of water disinfection techniques 73
TABLE 2-​11. Microorganism size and susceptibility to filtration 74
TABLE 2-​12. Summary of field water disinfection techniques 77

SPECIAL POPULATIONS

Cruise Ship Passengers

BOX 4-​1. Cruising down the Yangtze: what to consider 474
BOX 6-​1. Cruise travel health precautions 525

Health Care Workers

BOX 8-​4. Health care workers in extreme circumstances 589

Immigrants and Migrants

BOX 8-​8. Additional migrant health resources for clinicians 633
TABLE 8-​8. Top 10 countries of birth for newly arriving refugees and immigrants (from overseas locations),
fiscal year 2014 630
TABLE 8-​9. Recommended postarrival laboratory screening tests for immigrants and refugees receiving
medical care in the United States 635

Immunocompromised
TABLE 8-​1. Immunization of immunocompromised adults 559
TABLE 8-​2. Immunosuppressive biologic agents that preclude use of live vaccines 566

Infants and Children

MAP 7-​1. Breastfeeding support group locations 547
TABLE 2-​5. Recommended and minimum ages and intervals between vaccine doses 38

Long-​Term Travelers
BOX 8-​5. Key findings from a review on studies relevant to long-​term travelers and expatriates 608
BOX 8-​6. Practical advice on personal protective measures for clinicians counseling long-​term travelers
and expatriates 609
BOX 8-​7. Practical advice on malaria prophylaxis for long-​term travelers and expatriates 610

Medical Tourists
BOX 2-​6. Guiding principles on medical tourism 112
BOX 2-​7. Patient checklist for obtaining safe dental care during international travel 113
BOX 2-​8. Helpful resources on medical tourism 114

Military
TABLE 8-​5. Differences between military populations and civilian traveling populations 616
TABLE 8-​6. Differences between CDC recommendations and US military’s use of malaria
chemoprophylaxis 619

xviii LIST OF BOXES, FIGURES, MAPS, & TABLES, BY TOPIC

xi

Pregnant Travelers
BOX 8-​2. Pretravel consultation checklist for pregnant travelers 577
BOX 8-​3. Contraindications for travel during pregnancy 578

Returning Travelers
BOX 5-​1. Important elements of a medical history in an ill returned traveler 496
TABLE 5-​1. Illnesses associated with fever presenting in the first 2 weeks after travel 497
TABLE 5-​2. Common causes of fever, by geographic area 500
TABLE 5-​3. Common infections, by incubation period 501
TABLE 5-​4. Common clinical findings and associated infections 502
TABLE 5-​5. Ten most common skin lesions in returned travelers, by cause 508

Students
TABLE 8-​7. Study-​abroad resources 623

Travelers with Chronic Illnesses

TABLE 8-​3. Special considerations for travelers with chronic medical illnesses 573

Travelers Visiting Friends and Relatives

TABLE 8-​4. Diseases for which VFR travelers are at increased risk, proposed reasons for risk variance, and
recommendations to reduce risks 586

List of Maps
DISEASE MAPS
Dengue, the Americas and the Caribbean (Map 3-​1) 163
Dengue, Africa and the Middle East (Map 3-​2) 164
Dengue, Asia and Oceania (Map 3-​3) 165
Hepatitis B (Map 3-​4) 188
Hepatitis C (Map 3-​5) 194
Hepatitis E (Map 3-​6) 200
Influenza, Avian (H5N1) (Map 3-​7) 208
Japanese encephalitis (Map 3-​8) 216
Malaria, Eastern Hemisphere (Map 3-​10) 236
Malaria, Western Hemisphere (Map 3-​9) 234
Malaria, Bolivia (Map 3-​18) 380
Malaria, Botswana (Map 3-​19) 381
Malaria, Brazil (Map 3-​21) 383
Malaria, Colombia (Map 3-​24) 388
Malaria, Ecuador (Map 3-​26) 392

LIST OF MAPS xix

x

Malaria, Ethiopia (Map 3-​28) 394

Malaria, India (Map 3-​29) 398
Malaria, Kenya (Map 3-​31) 401
Malaria, Mexico (Map 3-​32) 404
Malaria, Nicaragua (Map 3-​33) 406
Malaria, Panama (Map 3-​35) 409
Malaria, Peru (Map 3-​37) 412
Malaria, South Africa (Map 3-​38) 416
Malaria, Venezuela (Map 3-​40) 421
Meningococcal meningitis (Map 3-​11) 262
Schistosomiasis (Map 3-​12) 310
Tuberculosis (Map 3-​13) 336
Yellow fever, Africa (Map 3-​14) 364
Yellow fever, the Americas (Map 3-​15) 365
Yellow fever, Argentina (Map 3-​16) 376
Yellow fever, Bolivia (Map 3-​17) 379
Yellow fever, Brazil (Map 3-​20) 382
Yellow fever, Colombia (Map 3-​23) 387
Yellow fever, Ecuador (Map 3-​25) 391
Yellow fever, Ethiopia (Map 3-​27) 393
Yellow fever, Kenya (Map 3-​30) 400
Yellow fever, Panama (Map 3-​34) 408
Yellow fever, Peru (Map 3-​36) 411
Yellow fever, Venezuela (Map 3-​39) 420

DESTINATION AND REFERENCE MAPS

Brazil destination map (Map 4-​5) 445
Burma (Myanmar) destination map (Map 4-​11) 469
China destination map (Map 4-​12) 473
China reference map (Map 3-​22) 386
Cuba destination map (Map 4-​6) 450
Dominican Republic destination map (Map 4-​7) 453
East Africa destination map (Map 4-​1) 427
Hajj destination map (Map 4-​2) 431
Haiti destination map (Map 4-​8) 456
India destination map (Map 4-​13) 479
Kilimanjaro destination map (Map 4-​4) 440
Mexico destination map (Map 4-​9) 460
Nepal destination map (Map 4-​14) 484
Peru destination map (Map 4-​10) 465
South Africa destination map (Map 4-​3) 437
Thailand destination map (Map 4-​15) 488
Vietnam destination map (Map 4-​16) 493

xx LIST OF MAPS
xxi

Editorial Staff
Editor in Chief: Gary W. Brunette
Chief Medical Editor: Phyllis E. Kozarsky
Medical Editors: Clive M. Brown, Nicole J. Cohen, Douglas H. Esposito, Mark D. Gershman,
Stephen M. Ostroff, Edward T. Ryan, David R. Shlim, Richard W. Steketee,
Michelle Weinberg, and Mary Elizabeth Wilson
Managing Editor: Megan Crawley O’Sullivan
Technical Editor: Ronnie Henry
Design and Production Editor: Kelly Holton
Editorial Assistant: Kelly Winter
Cartographer: R. Ryan Lash
Assistant Cartographer: C. Virginia Lee

CDC Contributors
Abanyie, Francisca Brooks, John T. Esposito, Douglas H. Green, Michael D.
Abe, Karon Brown, Clive M. Fischer, Marc Griffin, Patricia M.
Alexander, James P. Brunette, Gary W. Fitzgerald, Collette Hall, Aron J.
Ansari, Armin Burdette, Erin Flannery, Brendan Hawley, William A.
Appiah, Grace Burke, Heather Fox, LeAnne M. Hendricks Walters, Kate
Arboleda, Nelson Cantey, Paul T. Francois Watkins, Henry, Ronnie
Arguin, Paul M. Cardemil, Cristina V. Louise K. Herwaldt, Barbara L.
Armstrong, Paige Chen, Tai-​Ho Friedman, Cindy R. Hills, Susan L.
Averhoff, Francisco Chiller, Tom M. Fullerton, Katie Hlavsa, Michele C.
Baggett, Henry C. Choi, Mary Gaines, Joanna Holtzman, Deborah
Bair-​Brake, Heather Chosewood, Casey Galland, G. Gale Hunter, Jennifer C.
Ballesteros, Michael F. Clemmons, Nakia S. Galloway, Renee L. Iwamoto, Martha
Barbre, Kira A. Cochi, Stephen L. Garrison, Laurel E. Jackson, Brendan
Beavers, Suzanne Cohen, Nicole J. Gastañaduy, Paul A. Jentes, Emily S.
Beckman, Michele G. Cope, Jennifer Gee, Jay E. Jones, Jeffrey L.
Benenson, Gabrielle A. Czarkowski, Alan G. Geissler, Aimee L. Judd, Michael C.
Berro, Andre Dhara, V. Ramana Gerber, Susan I. Kersh, Gilbert J.
Blaney, David D. Dubray, Christine Gershman, Mark D. Kharod, Grishma A.
Bowen, Anna Duong, Krista Kornylo Gibbins, John Kitt, Margaret
Bresee, Joseph Ederer, David J. Goodson, James L. Knust, Barbara
Brogdon, William G. Erskine, Stefanie K. Gould, L. Hannah Kozarsky, Phyllis E.
xxi

Kroger, Andrew T. Mintz, Eric D. Rabe, Ingrid B. Teshale, Eyasu

Kutty, Preeta K. Montgomery, Susan Raczniak, Gregory A. Tiller, Rebekah
Lebo, Emmaculate J. Montiel, Sonia H. Reef, Susan E. Tiwari, Tejpratap S. P.
Lessa, Fernanda C. Morgan, Oliver W Regan, Joanna J. Traxler, Rita M.
Liang, Jennifer L. Moro, Pedro L. Reyes, Nimia L. Uribe, Carolina
Lippold, Susan A. Morof, Diane F. Reynolds, Megan R. Van Bogaert, Donna
LoBue, Philip Mullan, Robert J. Rollin, Pierre E. Villarino, Margarita E.
Lopez, Adriana S. Mutebi, John-​Paul Russell, Michelle Walker, Allison Taylor
Lopman, Ben Negron, Maria E. Schafer, Ilana J. Wallace, Ryan M.
Lyss, Sheryl Nelson, Christina A. Schmid, D. Scott Wassilak, Steven G. F.
MacNeil, Jessica R. Nelson, Noele P. Schneider, Eileen Waterman, Stephen H.
Mahon, Barbara E. Nguyen, Duc B. Sharp, Tyler M. Watson, John T.
Maloney, Susan A. Nicholson, William L. Shealy, Katherine R. Weinberg, Michelle S.
Marano, Nina Nickels, Leslie Skoff, Tami H. Weinberg, Nicholas
Marin, Mona O’Reilly, Ciara E. Sleet, David A. Weston, Emily J.
Marston, Chung K. Objio, Tina Sobel, Jeremy Winter, Kelly
Martin, Diana L. Paddock, Christopher D. Sotir, Mark J. Wong, Karen K.
Mast, Eric E. Patel, Manisha Staples, J. Erin Workowski, Kimberly
McCollum, Andrea M. Patimeteeporn, Calvin Steele, Stefanie F. Xiao, Lihua
McCotter, Orion Z. Perez-​Padilla, Janice Stoddard, Robyn A. Yeoman, Kristin
McFarland, Jeffrey Peters, Philip J. Stoney, Rhett J. Yoder, Jonathan S.
Mead, Paul S. Petersen, Brett W. Strikas, Raymond A.
Meites, Elissa Piacentino, John Tan, Kathrine R.
Meyer, Sarah A. Powers, Ann M. Tardivel, Kara

External Contributors
Adler, Tina Westat—National Center for Complementary and Integrative Health Clearinghouse,
Rockville, Maryland
Ansdell, Vernon E. University of Hawaii, Honolulu, HI
Atkinson, Gregory Teesside University, Middlesbrough, United Kingdom
Backer, Howard D. California Emergency Medical Services Authority, Sacramento, CA
Barbeau, Deborah Nicolls Tulane University, New Orleans, LA
Barnett, Elizabeth D. Boston University School of Medicine and Boston Medical Center, Boston, MA
Batterham, Alan M. Teesside University, Middlesbrough, United Kingdom
Benenson, Michael W. Armed Forces Research Institute of the Medical Sciences, Bangkok, Thailand (retired)
Boggild, Andrea K. University of Toronto, Toronto, Canada
Borwein, Sarah T. TravelSafe Medical Centre, Hong Kong, China
Carroll, I. Dale The Pregnant Traveler, Spring Lake, MI
Changizi, Roohollah United Family Hospital, subsidiary of United Family Healthcare, Beijing, China
Chen, Lin H. Mount Auburn Hospital—​Travel Medicine Center, Cambridge, MA, and Harvard
Medical School, Boston, MA

xxii EXTERNAL CONTRIBUTORS

xxii

Connor, Bradley A. Weill Medical College of Cornell University, New York, NY

DeRomaña, Inés University of California System, Education Abroad Program, Santa Barbara, CA
Ejike-​King, Lacreisha US Food and Drug Administration, US Department of Health and Human Services,
Rockville, Maryland
Fairley, Jessica K. Emory University School of Medicine, Atlanta, GA
Forgione, Michael Keesler Medical Center, Keesler AFB, Mississippi
Freedman, David O. Shoreland, Inc., Milwaukee, WI
Fukuda, Mark Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
Gracia, J. Nadine Office of Minority Health, US Department of Health and Human Services,
Rockville, Maryland
Gushulak, Brian D. Migration Health Consultants, Cheltenham, Canada
Hackett, Peter H. Institute for Altitude Medicine, Telluride, CO, and Altitude Research Center,
University of Colorado Denver School of Medicine, Denver, CO
Hamer, Davidson H. Center for Global Health and Development Boston University; Department of
Global Health, Boston University School of Public Health and Section of Infectious
Diseases, Boston Medical Center, Boston, MA
Henderson, John United Nations consultant, Burma
Hochberg, Natasha S. Section of Infectious Diseases, Boston University School of Medicine, Boston, MA
Hyle, Emily P. Massachusetts General Hospital, Boston, MA
Kain, Kevin C. University of Toronto, Toronto, Canada
Keystone, Jay S. University of Toronto, Toronto, Canada
Kotton, Camille Nelson Massachusetts General Hospital and Harvard University, Boston, MA
LaRocque, Regina C. Massachusetts General Hospital and Harvard Medical School, Boston, MA
Law, Catherine National Center for Complementary and Integrative Health, National Institutes of
Health, Bethesda, MD
Libman, Michael McGill University, Centre for Tropical Disease, Montreal, Canada
Magill, Alan J.* Walter Reed Army Institute of Research, Experimental Therapeutics, Silver
Spring, MD
Neumann, Karl Weill Medical College of Cornell University and New York Presbyterian Hospital/​
Cornell Medical Center, New York, NY
Nilles, Eric J. Division of Health Securities and Emergencies, World Health Organization,
Suva, Fiji
Nord, Daniel A. Divers Alert Network, Durham, NC
Ostroff, Stephen M. Food and Drug Administration, Silver Spring, MD
Parker, Salim Dee Bee Medical Centre, Cape Town, and South African Society of Travel Medicine,
Johannesburg, South Africa
Pedone, Bettina N. Arthur Ashe Student Health & Wellness Center, University of California, Los
Angeles, CA
Pogemiller, Hope University of Minnesota Medical School, Minneapolis, MN
Prinz, Robyn K. US Department of State Bureau of Consular Affairs, Washington D.C.
Rhodes, Gary Center for Global Education, University of California, Los Angeles, CA
Riddle, Mark S. Naval Medical Research Center, Silver Spring, MD
Rosselot, Gail A. Travel Well of Westchester, Inc., Briarcliff Manor, NY
Ryan, Edward T. Massachusetts General Hospital and Harvard University, Boston, MA
Sampson, Dana M. Office of Minority Health, US Department of Health and Human Services,
Rockville, Maryland
Shlim, David R. Jackson Hole Travel and Tropical Medicine, Jackson Hole, WY

* Deceased

EXTERNAL CONTRIBUTORS xxiii

xvi

Shurtleff, David National Center for Complementary and Integrative Health, National Institutes of
Health, Bethesda, MD
Staat, Mary Allen International Adoption Center, Cincinnati Children’s Hospital Medical Center,
Cincinnati, OH
Taggart, Linda R. University of Toronto, Toronto, Canada
Takiguchi, Rodd Department of Dermatology, Kaiser Permanente, Honolulu, Hawaii
Thompson, Andrew University of Liverpool, Liverpool, United Kingdom
Valk, Thomas H. VEI Inc., Marshall, VA
Van Tilburg, Christopher Providence Hood River Memorial Hospital, Hood River, OR
Wangu, Zoon Department of Pediatric Infectious Diseases, Boston Medical Center, Boston, MA
Wilson, Mary Elizabeth Harvard School of Public Health, Boston, MA
Wu, Henry M. Emory University, Department of Medicine, Atlanta, GA
Youngster, Ilan Children’s Hospital Boston and Harvard University, Boston, MA

All contributors have signed a statement indicating that they have no conflicts of interest with the subject
matter or materials discussed in the document(s) that they have written or reviewed for this book and that the
information that they have written or reviewed for this book is objective and free from bias.

xxiv EXTERNAL CONTRIBUTORS

xv
Acknowledgments
The CDC Yellow Book 2018: Health Information
for International Travel editorial team grate-
fully acknowledges all the authors and review-
ers for their commitment to this new edition.
We extend sincere thanks to the following peo-
ple for their contributions to the production of
this book:
Preface
To stay on the cutting edge of travel health infor-
mation, this latest edition of the CDC Yellow
Book: Health Information for International Travel
has been extensively revised. The book serves as
a guide to the practice of travel medicine, as well
as the authoritative source of US government rec-
ommendations for immunizations and prophy-
laxis for foreign travel. As international travel
continues to become more common in the lives of
US residents, having at least a basic understand-
ing of the medical problems that travelers face
has become a necessary aspect of practicing med-
icine. The goal of this book is to be a comprehen-
sive resource for clinicians to find the answers to
their travel health–​related questions.
• Elise Beltrami, Pamela Diaz and Scott
Santibanez for their extensive review of
the text.
• Courtney Ware, Aida Sawadogo, Laurie
Dieterich and Crystal Polite for their assis-
tance in preparing the text for publication.
Centers for Disease Control and Prevention
Anne Schuchat, MD, Acting Director
National Center for Emerging and Zoonotic
Infectious Diseases
Rima Khabbaz, MD, Acting Director
Division of Global Migration and
Quarantine
Martin S. Cetron, MD, Director
Gary W. Brunette, MD, MS, Chief,
Travelers’ Health Branch
Phyllis E. Kozarsky, MD, Expert Consultant,
Travelers’ Health Branch
Megan Crawley O’Sullivan, MPH,
Health Com­munications Specialist,
Travelers’ Health Branch
xvi

Alan J. Magill passed away on September 19, 2015, just days after work began on the CDC Yellow
Book 2018. He was a key figure in the evolution of this publication, serving as an author and medical
editor for three editions. Over the years, he provided invaluable insight and guidance as a singularly
experienced and knowledgeable contributor. The editorial board of the CDC Yellow Book respectfully
dedicate this edition to Alan.

In Memoriam: A Tribute to Alan J. Magill

Alan Magill and I were asked to become co-╉editors of the Yellow Book at the same time, during the
Conference of the International Society of Travel Medicine in Vancouver, BC, in 2009. The next day
we drove together from Vancouver to the ISTM Executive Board meeting in Whistler, and during that
3-╉hour trip, we discussed how we might revise the Yellow Book to make it more relevant to travel
medicine practitioners. It was one of the more enjoyable conversations of my life.

Whatever Alan was involved in always seemed to go smoother, be more relevant, and even more fun.
At that point in time, Alan was the president-╉elect of the International Society of Travel Medicine. He
would subsequently serve as the president of the American Society of Tropical Medicine and Hygiene,
becoming the first person to be president of both societies. During a 26-╉year career in the US Army
Medical Corps, Alan focused mainly on malaria and leishmaniasis, but his research interests and
projects spanned an extraordinary range, including diagnostics, pharmaceuticals, and vaccine devel-
opment. He carried with him a nagging curiosity about the history of disease, and he often delved into
original sources of research that informed our present practice in new ways. Invariably kind, enthusias-
tic, supportive, tireless, and insightful, Alan improved any project with which he was involved, includ-
ing the Yellow Book.

Upon retiring from the military in 2012, Alan became the Malaria Program Director for the Gates
Foundation, charged with designing a strategy that could lead to the elimination of malaria in the
world. He had already played a large role in helping to shape an international strategy in this regard
when he died suddenly on September 19, 2015, near his home in Seattle, leaving behind his wife
and two daughters, and a devastated string of colleagues and admirers. Although tributes often end
with the words, “He will be missed,” in Alan’s case, we are left wondering what the world has missed
and what might have happened if he had been able to stay with us for many more years. He was
62 years old.

David R. Shlim, MD
Medical Editor of the Yellow Book
Recent Past-╉President of the ISTM
1
1
Introduction
INTRODUCTION TO TRAVEL
HEALTH & THE YELLOW BOOK
Phyllis E. Kozarsky
TRAVEL HEALTH
The number of people traveling internation-
ally has continued to grow substantially in the
past decade. According to the World Tourism
Organization, there were 1.2 billion worldwide
international tourist arrivals in 2015, an increase
of 4% from 2013; 50 million more people spent
a night at an international destination than
in 2014. In 2015, US residents made more than
73 million trips with at least 1 night outside the
United States. The importance of protecting the
health of individual travelers, as well as safe-
guarding the health of the communities to which
they return, cannot be overstated. International
travel takes on many forms, including tourism,
business, study abroad, research, visiting friends
and relatives, ecotourism, adventure, medi-
cal tourism, mission work, and responding to
international disasters. Travelers are as unique
as their itineraries, covering all age ranges and
INTRODUCTION TO TRAVEL HEALTH & THE YELLOW BOOK
having a variety of preexisting health concerns
and conditions. The infectious disease risks that
travelers face are dynamic—​some travel desti-
nations have become safer, while in other areas,
new diseases have emerged and other diseases
have reemerged.
The risk of becoming ill or injured during inter-
national travel depends on many factors, such as
the region of the world visited, a traveler’s age and
health status, the length of the trip, and the diver-
sity of planned activities. CDC provides interna-
tional travel health information to address the
range of health risks a traveler may face, with the
aim of assisting travelers and clinicians to bet-
ter understand the measures necessary to pre-
vent illness and injury during international travel.
This publication and the CDC Travelers’ Health
website (www.cdc.gov/​travel) are 2 primary ave-
nues of communicating CDC’s travel health
recommendations.
1
2
BOX 1-​1. CDC contact information for clinicians
1 CDC-​INFO NATIONAL
CONTACT CENTER
All topics for clinicians and gen-
eral public (English and Spanish)
• 8 am to 8 pm Eastern,
M–​F: toll-​free at 800-​CDC-​
INFO (800-​232-​4636)
• E-​mail form: www.cdc.gov/​info
CDC EMERGENCY
OPERATIONS CENTER
Emergency or urgent patient
care assistance (Note:This line is
not intended for use by the general
public.)
• Available 24 hours per day,
7 days per week: 770-​488-​7100
CDC DRUG SERVICE
Distribution of special biologic
agents and drugs
• Formulary:www.cdc.gov/​
laboratory/​drugservice/​
formulary.html
• 8 am to 4:30 pm Eastern,
M–​F: 404-​639-​3670
• After hours/​weekends/​
holidays: 770-​488-​7100
• E-​mail: drugservice@cdc.gov
CHIKUNGUNYA, JAPANESE
ENCEPHALITIS, TICKBORNE
ENCEPHALITIS, AND
YELLOW FEVER
Assistance with diagnostic testing
for these diseases and for ques-
tions about antibody response to
yellow fever vaccination
• Division of Vectorborne
Diseases, 8 am to 4:30 pm
Mountain, M–​F: 970-​221-​6400
• Viral Special Pathogens Branch
can also assist for tickborne
encephalitis, 8:30 am to 5:30 pm
Eastern, M–​F: 404-​639-​1115
2 INTRODUCTION
• After hours/​weekends/​
holidays: 770-​488-​7100
• State or local health
departments may be able to
assist: www.cdc.gov/​mmwr/​
international/​relres.html
DENGUE
Dengue diagnostic testing
assistance
• 8 am to 5 pm Atlantic (office
in Puerto Rico),
M–​F: 787-​706-​2399
• After hours/​weekends/​
holidays: 770-​488-​7100
• Clinical/​laboratory
guidance: www.cdc.gov/​
Dengue/​clinicalLab/​index.
html
MALARIA HOTLINE
Assistance with diagnosis or
management of suspected cases
of malaria
• 9 am to 5 pm Eastern,
M–​F: 770-​488-​7788 or toll-​free
at 855-​856-​4713
• Emergency consultation
after hours/​weekends/​
holidays: 770-488-​7100, ask
for a Malaria Branch clinician
PARASITIC DISEASES (OTHER
THAN MALARIA)
Hotline
Assistance with evaluation and
treatment of patients suspected
to have a parasitic disease
• 8 am to 4 pm Eastern,
M–​F: 404-​718-​4745
• Emergency consultation after
hours/​weekends/​holidays:
770-​488-​7100, ask for an on-​call
clinician in Parasitic Diseases
• E-​mail: parasites@cdc.gov
DPDx
Online parasitic diseases diag-
nostic assistance service for
laboratorians, pathologists, and
other health professionals
• www.cdc.gov/​dpdx/​contact.
html
RICKETTSIAL DISEASES
Diagnostic and treatment
assistance
• 8 am to 4:30 pm Eastern,
M–​F: 404-​639-​1075
• Emergency consultation
after hours/​weekends/​
holidays: 770-488-​7100, ask
for an on-​call clinician in
Rickettsial Diseases
VIRAL HEMORRHAGIC FEVERS
Diagnosis
Consultation for diagnosis and
reporting suspected cases in
or requiring evacuation to the
United States
• 8:30 am to 5:30 pm Eastern,
M–​F: 404-​639-​1115
• Emergency consultation
after hours/​weekends/​
holidays: 770-​488-​7100
Treatment
Requests for ribavirin through
the Food and Drug Administration
(FDA) from Valeant
Pharmaceuticals
• Providers should
request through FDA at
301-​736-​3400
• Simultaneously notify Valeant
at 800-​548-​5100, ext. 5
(domestic) or 949-​461-​6971
(international)
Another random document with
no related content on Scribd:
 A Killing Play

He began to study music with C. G. Müller, for Beethoven’s works

made him decide that he wanted to know more. He also was taught
by Theodore Weinlig, the cantor or singer of St. Thomas’ school. At
sixteen, he wrote a play which had so tragic a plot that he killed off
forty-two of the characters, and afterwards said, he had to bring
some back as ghosts to wind up the drama, for there were no
characters left alive! His drama reading made him exaggerate
tragedy in his own play! After this he wrote a sonata, a polonaise and
a symphony, in classic style, performed in 1833.
In 1830 there had been a political revolution in Germany and it
greatly impressed the young man for he was an independent thinker
in politics as well as in music.
He visited Vienna in 1832 but he found it so appreciative of
Hérold’s opera Zampa and Strauss’ waltzes that he could not bear it
and left almost immediately. He was much like Beethoven in
disposition for he was quick to anger and kind in great gusts, and
could be most agreeable to his friends.
 His Early Operas

He had gone to Vienna with his symphony but showed it to no one;

it is said that Mendelssohn saw it but forgot about it. Here he wrote
the poem and some poor music for an opera Die Hochzeit (The
Wedding) which he tore up the next year.
Then off to Prague went he (1832), and wrote his first libretto, for
you must remember he did not go to people like Metastastio or
Molière for his libretto but wrote his own. Had he not been a
composer he certainly would have been a literary man. In fact, he
was, for he wrote more pamphlets and books than many a writer!
Yet, he showed his real genius as a composer.
But he was so poor now that he was glad to get a job as a chorus
master at the mean salary of 10 florins ($5) a month! It was here he
wrote the opera Die Feen (The Fairies) a wildly romantic work, after
which he returned again to Leipsic. For the first time he heard
Wilhelmine Schroeder-Devrient sing, whose marvelous talent
influenced him all his life. In 1834 as a conductor of a troupe with
headquarters in Magdeburg, he tried to produce his second opera the
tragic Das Liebesverbot (Forbidden Love), modeled after
Shakespeare’s Measure for Measure; but it was so badly given that it
was a dismal failure. The second was like Bellini and Auber, both of
whom he admired and it was too early in his life (twenty-one) to
show new ways of composing.
Soon he went to Königsberg, where (1836) he married Wilhelmina
Planer, a young actress whom he met in the theatre, and he spent the
year trying to get his Magdeburg troupe out of difficulties. Later he
was given a post in Riga.
While at Riga his duty was to lead orchestral concerts, at many of
which Ole Bull the Norwegian violinist played, here too, he read
Rienzi of Bulwer-Lytton, the English writer, and wrote a libretto and
opera on the showy model of Meyerbeer. He said himself that it “out-
Meyerbeered Meyerbeer.” Leaving hastily, debts and all, with Rienzi
in his hand, he went to Paris (the goal of all composers) in a sailing
vessel, with his new wife and a dog named Robber, stopping over in
England. The trip took four long perilous weeks. From the sailors he
learned the story of the Flying Dutchman, which he afterwards used
in his opera of that name.
We wish we could tell you the whole story of this gale-tossed,
unhappy mariner, the Flying Dutchman, and how at last he found
happiness and relief from storms and troubles of life by finding his
mate in the maiden Senta. You will love the music and the story
which is woven about Senta in the beautiful ballad bearing her name.
In this opera, Wagner first used the leit-motif or leading theme
(particularly in the overture) which he used as we use a name or
description of a person, idea or thing, except that he used them in
music instead of in words. For example, when Senta comes in to the
story, either as someone’s thought or as a person, or when she is
spoken of, her theme is heard, woven into the music. So it is when
Siegfried appears in the operas of the Ring of the Nibelungen, you
hear the Siegfried theme; when the Gold is mentioned, you hear the
Gold theme; or if the Giants appear, their theme is heard,—so it is
with the Dragon and everything connected with the story. You hear
in some form, their name plates, as it were, and so by listening, you
can follow just what is going on through the music. This is one of the
things that Wagner developed, though Gluck and others had
attempted to use it.
During his stay in Paris, he had a struggle for existence and did
everything possible to gain a livelihood, while striving to get a
hearing for his compositions. He wrote, in his misery, the Faust
Overture, the first work to win recognition.
He went to see Meyerbeer on his way to Paris, for Meyerbeer was
very popular and his approval could have aided poor Richard. Some
say Meyerbeer helped him and others say he did not. Wagner gained
little from him. Even when he first went to see Liszt, who later
became his best friend, it is said that Liszt snubbed him. Wagner
never stopped writing his theories for the papers, and a hot-headed
young scribbler he was! Yet withal he submitted the story of The
Flying Dutchman to the director of the Paris Opera House who
rejected it as an opera, but gave the story to Dietsch, the conductor,
to write the music. This did not daunt Wagner, who, after a defeat,
worked harder or his next task. So he wrote another Flying
Dutchman, story and music and orchestration in seven weeks!
 However, luck began to favor him, and Rienzi (1842) was accepted
by the Dresden Opera and was so successful that he became
conductor in Dresden, which saved him for a while from money
worries, and The Flying Dutchman, which had gone begging so long,
was loudly demanded. Strange to say, this wonderful legend did not
succeed, for the people missed the little tricks of Meyerbeer and they
could not understand the flowing music in new form. Wagner was
very disappointed for the story was one of the old German (Teuton)
legends and he thought the German people would love it.
Later, however, Spohr gave it with great success at Cassel, and won
Wagner’s gratitude for his understanding and kindness.
Now comes Tannhäuser, an entrancing legend which inspired him
to study more deeply into the Teutonic legends. This he produced in
Dresden, and other German cities played it later. Everything became
topsy-turvy in the musical and political world. Wagner was writing
fiery things about freedom in music and politics, nothing to amount
to much, but enough to rouse his enemies, who became hateful and
hissed Tannhäuser,—calling it nerve-killing, distressing music
without melody. How could anyone fail to find melody in Oh Thou
Sublime Sweet Evening Star, the Pilgrim’s Chorus, the Venusburg
music and the colorful overture with themes of the whole opera? Yet
music affects people this way when it is new in structure. “There is
no melody” is said today when the so-called modern music is played.
This should make us stop and listen carefully and look back on what
happened to the writers of the past when they dared differ from the
crowd. Perhaps calling your attention to this will make you listen
with open ears and open minds to the new, which so soon becomes
the familiar.
So Wagner, while conducting other operas in Dresden, began on
Lohengrin and finished it in 1847. But he was impetuous and his
written articles irritated the people. His ideas were fiery and his
musical speech so odd, that even Schumann, who was very
sympathetic, only partially understood him or his music. However he
did say that Wagner would have a great influence on German opera,
but Mendelssohn, after hearing Tannhäuser, only liked the second
finale. Even his friend Madame Devrient, though she loved and
admired him, said: “You are a man of genius but you write such
eccentric stuff, it is hardly possible to sing it.”
 Never did Wagner feel that he was at fault, so great was his faith in
his ideas of doing away with arias, of not having stopping places in
an opera, just to begin some other song, and of making the words
equally important to the music.
 The Nibelungen Ring

While working at Lohengrin he had started his studies of the

Icelandic and Germanic Saga, the Nibelungenlied. These tales
changed under his pen into the story of Siegfried, which he wove into
the trilogy known as The Nibelungen Ring or Trilogy with a
Prologue, as he called it, and as we call it now—The Tetralogy (in
four parts).
The four dramas of the Ring of the Nibelung are:
(1) The Rhine Gold (Das Rheingold)
(2) Valkyrie (Die Walküre)
(3) Siegfried
(4) The Twilight of the Gods (Die Götterdämmerung)
Many things happen in these tales but it takes the four to tell the
one big story:
Alberich the wicked Nibelung, a gnome, in his greed steals the gold
from the Rhine Maidens who were guarding it, hidden in the Rhine.
They tell him that the one who fashions a ring out of the gold will
rule the world, but must forego love. Alberich makes the ring but
Wotan the god of the gods wrests it from him. During the drama
various people secure the Ring but it had been cursed by Alberich
and brings disaster to all who get it. Finally the very gods themselves
are doomed to destruction, and Brünnhilde the oldest of the
Valkyries, the daughters of Wotan, returns the stolen treasure to the
waters of the Rhine.
The Wizard has painted in magnificent music the great Rhine
River, flowing across the stage; the fire surrounding Brünnhilde until
she is rescued by the valiant Siegfried, who knows no fear; Valhalla
the home of the gods; the hunt in which Siegfried drinks from the
magic horn of memory; and his funeral pyre into which Brünnhilde
casts herself and her horse carrying the ring which she has taken
from Siegfried’s finger back to the Rhine Maidens from whence it
came.
The scenes are gigantic and so is the music. Wagner, with his
ideals for freedom and the betterment of humanity, used these
legends as a cloak to cover his personal opinions which would have
been looked upon as anarchism if he had not used such clever and
artistic symbols. In Alberich’s greed for the gold, is hidden Wagner’s
ideas of the Government’s greed for power against which he had
fought so strenuously. Another lesson is that anyone possessing the
gold is denied love, showing that greed kills human feelings.
Because the Opera at Dresden did not use the things he liked, he
rebelled openly against the popular political and musical ideas; he
was banished and went to Zürich, Switzerland. Here he wrote more
fiery literature and made more enemies and a few friends, and the
enmity he stirred up against himself delayed his success. He hoped
for a better state of political life in order to write freer and more
beautiful music.
While he was in Zürich, Liszt, in Vienna, produced Lohengrin with
success. It was given to celebrate Goethe’s birthday (1850), before a
brilliant audience, and now Wagner’s fame seemed sure, though his
“pockets were empty.” Lohengrin’s success was slow in Germany, as
it took about nine years to reach Berlin and Dresden. It was thought
to be without melody! Can you hear Lohengrin’s song to the Swan,
the Wedding March or the Prelude? Listen to it in your mind’s ear or
auralize it! Wagner’s themes were so marvelously interwoven and he
did such amazing things with his orchestra, that it was difficult for
people to unravel the torrential new music. They were not prepared
for endless music flowing on like speech, suiting the music to the
word and not stopping the action to show off the singer’s skill. What
Gluck tried to do, Wagner did. His operas were music dramas
because the action or drama was his first thought.
For fifteen years in exile, he gave himself to literary work and
composition. He had ample time now to write of his musical theories
and his feelings about life.
Soon, London called him to lead the Philharmonic Society, which
he did during the time he was completing Valkyrie and sketching
Siegfried. He tried to interest the English in Beethoven and others
whom he loved, but of little avail. The people preferred the delightful
delicacy of Mendelssohn to the solidity of Beethoven. So here again
he made more enemies than friends, and his bitter pen did not help
to smooth things over. By the time he left London, he had finished
the Valkyrie.
 In this great music drama, he tells the story of Siegmund and
Sieglinda, Brünnhilde and the Valkyries who carried the dead
warriors from the battle fields on their saddles to Valhalla. You hear
in the galloping music of the Ride of the Valkyries and the Fire
Music and Love Song of the first act, such music as never was written
by anyone but Wagner! Oh, it is a wonderful legend, explaining itself,
in Wagner’s own poems and with the short music name tags (leit-
motifs) which are enlarged and turned around and intermingled with
other name tags and which stand out beautifully when you know how
to listen.
 Tristan and Isolde and Meistersinger

While in Zürich, Wagner met the merchant Otto Wesendonck,

whose beautiful and poetic wife Wagner loved dearly. She was a great
influence in his life and they were friends for many years. It was
during his friendship that he started the love drama of Tristan and
Isolde.
In 1859 he finished the love drama which tells of Tristan and the
lovely Queen of Ireland and how they drank the love potion and how
they loved and were separated. A noble story with some of the most
grippingly beautiful music ever written!
But with this masterpiece of masterpieces completed, he could get
nobody to produce it. Everyone said it was impossible to sing it, and
we know even today that it takes very special musical gifts and few
can do it well. For it is quite true that Wagner, with all his theories
about composition, thought little of the singer’s throat muscles and
more of what he wanted to say.
Poor Wagner was disconsolate! He could not get his works
performed and he was still prevented from returning to Germany,
the country he loved. So off he went to Paris and there Tannhäuser
failed utterly after three terrible, turbulent, horrible performances,
which almost ended in riots, no doubt planned ahead by his enemies.
But to offset this disaster, he was allowed to return home and
everyone rejoiced in his arrival. No doubt his treatment in Paris
softened the German heart.
Not long after this Wagner and his wife separated and some years
later in 1871, he married Cosima Liszt, who had been the wife of
Hans von Bülow.
After Wagner conducted opera on a tour through Russia, Hungary,
Bohemia (Czecho-Slovakia) and many German cities, Ludwig II,
King of Bavaria, sent for Wagner and offered him an income, and
from this time on Wagner composed without financial worries. He
was commissioned in 1865 to complete The Ring, and Tristan and
Isolde was performed by Hans von Bülow.
 Again political intrigues and his enemies drove him to Switzerland,
and after Tristan and Isolde was given and while he was in
Switzerland, he completed The Ring and Die Meistersinger, the most
beautiful comic opera in the world, which was also produced by von
Bülow in Munich, June 21st, 1868. And now we fulfill our promise to
you, which we made in Chapter VIII about the Meistersinger:
Walther von Stolzing, a young knight, falls in love at first sight
with Eva the beautiful daughter of Pogner, the goldsmith of
Nüremberg, who has promised her to the winning singer in the
coming Festival of the Mastersingers. Beckmesser, the old town
clerk, counts on winning as he also loves Eva. As Walther does not
belong to the music guild, he has to pass the examination.
Beckmesser gives him so many bad marks for not keeping the
committee’s rules that he is not admitted.
But Hans Sachs, the greatest Meistersinger of all, the town
cobbler, thought Walther a beautiful singer even though he broke
musical laws and the very freedom and the new loveliness in his
music charmed him.
In the evening when Walther and Eva try to run away, Beckmesser
decides to serenade Eva. Hans Sachs, cobbling shoes in his doorway
interrupts Beckmesser’s ludicrous serenade with a jolly song, in
which he marks all Beckmesser’s mistakes with his hammer, just as
Beckmesser had marked Walther’s. The neighborhood is aroused,
confusion follows, Beckmesser gets a beating and Hans Sachs slips
Eva and Walther into his own house.
Next day Walther sings a song to Hans which he has dreamed and
Hans writes it down. Beckmesser comes in and finding the words
steals them, sure he could win if he sang a song of Hans Sachs.
Beckmesser fails miserably and Sachs calls on Walther to sing it.
Here he sings Walther’s Prize Song, which wins the approval of the
Meistersingers, and the prize—lovely Eva.
Here we get a splendid idea of what Wagner felt about new music,
for in the Meistersinger he tried to picture the jealousies of
composers, who condemned the beauty of his inspiration and new
ideas and methods.
Never was there an opera more delightful for young people, who
love the melodies and charming pictures of medieval Nüremberg.
 Bayreuth

About this time the Valkyrie and Rhinegold had been given at the
Court Theatre in Munich (1869–1870). The King gave up his plan to
build a new theatre for these stupendous works, which needed
special machinery because of the elaborate stage effects. Wagner
insisted that scenery was as important as the words and music. So he
started to build, by general subscription over all Europe, a theatre at
Bayreuth. He succeeded so well that not only did Europe contribute
but America, too, and groups of people banded together to collect
money for it. Wagner was now the fashion and finally the new opera
house opened August 13th, 1876, with The Ring, for he had finished
Die Götterdämmerung the year before.
Artistically it was successful but not financially. If his pen had been
dipped in honey and not in bitters, he would have won his public
more easily, but he seemed unable to be diplomatic. So off he went to
London and other places to conduct concerts to make money to pay
the debts of his new theatre. Later he wrote the Festival March, for
the Philadelphia Centennial (1876), which helped financially.
The people were divided into two camps,—those for Wagner, and
those against him. So strong was the feeling, that during the 1880’s,
in Germany, signs in cafés read: “It is forbidden to discuss religion or
Wagner”! The proprietors wished to save their chairs and china
which the fists of their patrons would destroy.
 Parsifal

During this time he was at work on Parsifal, a drama in music as

serious as oratorio yet with the most thrilling stage effects and
richness of music. Parsifal, Tristan and Isolde, The Ring and Die
Meistersinger are to every other opera what a plum pudding is,
compared to a graham cracker. In fact, all Wagner’s late music
dramas are like plum puddings, so rich and compact are they.
Parsifal was produced in 1882 in Bayreuth and was not given
again for six years. Later it was the occasion for yearly pilgrimages to
Bayreuth, as if to a shrine. It is so long that it takes the better part of
an afternoon and evening to perform it, yet you sit enraptured before
its gripping spell of beauty and holiness.
In 1903 the musical world was startled by the first performance in
America of Parsifal, as Wagner, in his will, had forbidden a stage
performance outside of Bayreuth. It was covered by copyright until
1913, which was supposed to have protected it from performance.
Heinrich Conried, director of the Metropolitan Opera Company in
New York City, in his eagerness for novelties, disregarded the
master’s wish, and mounted an elaborate production under the
direction of Alfred Hertz. This so offended the Wagner family that
they refused to allow anyone who had taken part in that performance
to appear in Bayreuth.
Bayreuth became a Mecca, to which pilgrims went every other
year, to attend the festivals. After the World War, Wagner’s family
turned to America for help to continue these festivals, interrupted by
the war, as the Wizard himself had done, when building his theatre.
In 1924 his son, Siegfried, visited America, conducted some
symphony concerts and secured funds to carry on the festivals.
Parsifal is a combination of three legends—of which one is the
Parsifal of our old friend the Minnesinger Wolfram von Eschenbach
(1204). (Chapter VIII.)
It is the story of the Redemption of Mankind, told in symbols with
great beauty of poetry, music and scenery. It is certain to fill you with
religious fervor, for it reaches the depths of your soul and raises you
above the things of the earth. Amfortas, the guardian of the Holy
Grail, whose wound represents the suffering of mankind, hears the
mystic voice of his father, Titurel, who tells him that not until a
sinless one comes with pity in his heart will the wound be healed.
Parsifal, “the guileless fool,” is his redeemer.
The year following the first production of Parsifal Wagner’s health
began to fail and he went to Venice where he died suddenly in 1883.
He was buried with fitting honors at Bayreuth which always honors
the memory of the Great Master of German Opera.
Here is a picture of Wagner in the words of his brother-in-law:
“the double aspect of this powerful personality was shown in his face;
the upper part beautiful with a vast ideality, and lighted with eyes
which were deep and severe, gentle or malicious, according to the
circumstances; the lower part wry and sarcastic. A mouth cold and
calculating and pursed up, was cut slantingly into a face beneath an
imperious nose, and above a chin which projected like the menace of
a conquering will.”
 How the Wizard Changed Opera

When Wagner reached his full power, he composed drama rather

than opera in the old sense.
His music explained the words and action and expressed the state
of mind of the character.
The melodies are used very much like the theme in a sonata. These
leit-motifs (leading motives) are usually carried, as we told you, in
the weavings of his wonderful orchestral webs. This theme or leit-
motif or name tag, is tossed from instrument to instrument in
numberless entrancing ways. Sometimes he uses a flickering theme
for flames as in the fire music of The Valkyrie or glorious chimes or
trumpetings as in Parsifal to cast a holy spell; but, whatever he uses,
he charms and holds you spellbound.
He combines the counterpoint of the 16th century masters, with a
most modern feeling for harmony, inherited from the classic
Germans. He used harmony in a new way with a freedom it never
before had reached, and pointed the way for modern composers of
today.
As the Wizard, Wagner throws a glamor over the most mystic
happening, as when Siegmund, in Die Valkyrie, withdraws the
Sword from the tree; or in the most commonplace fact as when Eva
tells Hans Sachs that she has a nail in her shoe. In The
Meistersinger, you can always tell that he is making fun of
Beckmesser, because his name tag shows him to be petty and
ridiculous.
Although Wagner’s music is rich, very clear to us and beautiful, in
his day it seemed complicated and discordant, because of its great
volume and sonority, the result of the perfect part-writing.
For the first time, he makes the brasses of equal importance to the
string and wind instruments. It is thrilling to hear the trombones and
his beautiful use of trumpets. He used many of Berlioz’s ideas in
muffling horns and added new instruments, too, among them, the
bass clarinet and the English horn (cor anglais), which is a tenor
oboe and not a horn at all!
 Wagner had a beautiful way of dividing up the parts for violins and
other instruments into smaller choirs which answered each other
and with which he could get special effects. For example, the Prelude
of Lohengrin is probably the nearest thing in shimmering music to
what the angels must play, so heavenly is it. Here he divides the
violins into many parts and it is far more beautiful than if they all
played the same thing. Thus, he gave more value to the instruments
and greatly improved the orchestra.
His preludes in which you hear the leading motives or name tags,
are a table of contents for what follows.
Wagner did not use tricks of decoration like Meyerbeer nor did he
give show-off pieces for his singers’ benefit. His idea was to use
sincere musical speech to tell the story and not one bit did he care
how hard the singer worked to carry out his idea.
Wagner, above all, was a dramatist, choosing lofty and noble
themes of heroic and ideal subjects in which his imagination could
play. He loved the sublime and the great spectacle.
The chief interest of Wagner’s opera is in the orchestra which
carries the theme webs. He used neither the folk song in its simple
beauty nor accepted classic arias which could be taken out and sung.
His song is often declaimed and appears not to sing with the
orchestra, for the voices are used as instruments and not to show off
vocal skill. Yet, Liszt was quick to take out from the operas and
transcribe for piano the Fire Music, the Ride of the Valkyrie and
many others which we now sing and whistle.
Finally, Wagner by his example has given courage to the man of
ideas, if he will believe in himself and work without ceasing.
 CHAPTER XXVI
More Opera Makers—Verdi and Meyerbeer to Our Day

After reading about the feats of the Wizard it is not surprising that he
had many followers,—those who openly claimed to take him for an
example, and others who did not realize how much they received
from him and would not like to have been called his followers!
 Verdi—The Grand Old Man of Italy

After following the Italian methods of writing opera and having

become a very famous composer, Verdi received inspiration from
Wagner in the last three or four years of his very long life. He was
much loved and it is difficult to tell whether it was his operas or his
beautiful character which prompted the affection. He was called “the
Grand Old Man of Italy.” A national hero was he, and the Italians’
idol. Praise and flattery did not make him proud but spurred him to
work through trouble and good fortune, and so he became one of the
greatest opera writers. He was born a few months after Wagner, in
the village of Roncole near Parma, and his life was interesting, for he
lived at the time when opera was popular and was going through the
Wagner upheaval which spread all over Europe.
He had a unique chance to make opera more important in Italy,
and succeeded in giving it a new impetus, even though in the
beginning his popular things followed popular patterns.
 Verdi and the Organ grinder

Giuseppe Verdi (1813–1901) was the son of an innkeeper and, as a

little boy, showed marked musical talent. He was a good obedient
little fellow, but always rather melancholy in character and never
joined the village boys in their noisy amusements. “One thing only
could rouse him from his habitual indifference, and that was the
occasional passing through the village of an organ grinder. To the
child, who in after years was to afford an inexhaustible repertory to
those instruments for half a century all over the world, this was an
irresistible attraction. He could not be kept indoors, and would
follow the strolling player as far as his little legs could carry him.”
(Grove’s Dictionary.)
Who has not heard the Miserere from Il Trovatore played, all out
of tune, by an Italian organ grinder who sends a little monkey around
with a cup to gather in the pennies? We remember an organ grinder
in San Francisco who ground out the Miserere. Each year or two that
we returned there were more of the notes missing. Ten years later,
the performance was quite “toothless” and sounded very funny.
All his life, Verdi kept a little spinet that his father bought for him
in 1820. We see him then, at seven, deep in musical study and at ten
he was the organist of Roncole, going to school in Busseto, a nearby
town. One night when he was walking the three miles to go back to
Busseto after church, the poor little fellow was so weary that he
missed the road and fell into a canal, narrowly escaping death! Is it
not splendid that his village appreciated his talent and gave him a
scholarship which made it possible for him to go to Milan to continue
his musical studies!
 His Operas

He did not compose an opera until 1839 when his Oberto in the
style of Bellini was produced in Milan with such success that he
received orders to write three more from which he gained much
good-will and fame.
It must have been a thrilling time for opera writers, because
Wagner was composing, too, and you know the great excitement he
caused. Amidst this interesting whirl of opinion, Verdi wrote one of
the operas ordered by the Milan director, and during this time he
was sorely stricken by the deaths of his wife and two lovely children.
Besides this, his opera failed and in his discouragement the poor
young man made up his mind to give up composition. However, a
rare good friend coaxed him back to his work after a little rest, and
he produced his successful Nebucco (Nebuchadnezzar) (1842), I
Lombardi the next year and his well known Ernani (1844). In this,
his first period, he used as models, Bellini and men of his type, not
writing anything startlingly new.
In his second period he wrote operas nearly as fast as we write
school compositions, and among the famous things are Rigoletto
(1851), Il Trovatore, La Traviata (story from Dumas’ Camille or
Dame aux Camelias), (1853), and The Masked Ball (1859). Ernani
and Rigoletto are founded on stories by Victor Hugo. The first
performance of La Traviata in Venice was a failure due more to the
performers, than to the opera itself which still crowds opera houses
of the world.
The greatest opera of his third period is Aida (1871), one of Verdi’s
masterpieces. An opera on an Egyptian subject was ordered by the
Khedive of Egypt for the opening of the Italian Opera House in Cairo,
for which Verdi received $20,000. Mariette Bey a famous
Egyptologist made the first sketch in order to give the right local
atmosphere to the libretto. Curiosity ran so high that every seat was
sold before the first night and it was a great success. Think how
electrified the audience must have been by the tenor solo, “Celeste
Aida,” one of Caruso’s greatest successes; by the realistic Nile scene;
the voice of the priestess in the mammoth Egyptian temple, and the
famous march with trumpets made specially for it!
Dear old lovable Verdi was a wise man as well as an accomplished
composer. He used more modern methods in Aida to hold audiences
who were hearing about Wagner and his startling innovations.
Other operas of this third period were La Forza del Destino and
one given at the Paris Grand Opera, Don Carlos, which was not up to
his standard. Until this time he showed great mechanical skill and a
sense of color and melody. The great singers have revelled in the
operas of his second period. In our day Marcella Sembrich, Nellie
Melba, Frieda Hempel, Luisa Tetrazzini, Amelita Galli-Curci,
Florence Macbeth and many others have sung the coloratura,—frilly,
soaring, gymnastic-singing, still very popular. However in Aida,
Verdi departed much from the usual, and people said that he was
copying Wagner, because they didn’t know the difference between
the influences which change a person’s ways, and imitation.
So he deserted the old models, Auber, Meyerbeer and Halévy for
something more substantial, his deeper and gigantically conceived
Aida. James Wolfe of the Metropolitan Opera said of the bigness of
this work as produced at the Metropolitan Opera House in New
York: “I have played before audiences of 30,000 in arenas in Mexico.
I am so at home in the opera that I do cross-word puzzles waiting for
my cue, and yet at the Metropolitan when I first played the King in
Aida with its flaming music, its hundreds of people and its scores of
horses, I was over-awed and frightened!”
After this, Verdi’s splendid mass, The Requiem, was written for the
death of the Italian hero Manzoni. In it he approaches the German
school in depth and seriousness, veering away from the emptiness of
Italian writing.
In his last efforts he seems definitely influenced by Wagner; for,
with his Otello and Falstaff we find a new Verdi, surpassing in form
and sincere melody anything that he had done. He was very
fortunate to have Arrigo Boito, his friend, to write librettos based on
Shakespeare’s Othello and Merry Wives of Windsor. When Falstaff
was given in New York (1925) a young American baritone, Lawrence
Tibbet, in the rôle of Ford, flashed into fame.