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Water Precautions Boiling water is the best method for eliminating infectious agents. There is some debate about how long to boil, but bringing the water to a good boil for at least a minute generally renders it safe to drink. Travellers might consider buying an electric heating coil to boil and purify tap water. Plug adapters and voltage converters may be required.
Carbonated bottled water may be used for brushing teeth and drinking. Carbonation increases the acid in the water and kills bacteria. (Plain bottled water may not be safe, since it can be taken from contaminated sources. Even ice cubes can carry infection.)
Iodine tablets (e.g., Polar Pure, Globaline, Potable-Aqua) purify water. Water may be purified by adding one iodine tablet to a quart of water 30 minutes before drinking it. Adding 50 mg of vitamin C will eliminate the iodine taste and color. Purifying is not effective against parasites such as and Cryptosporidium. Cyclospora Small portable water filters remove parasites and clear murky water without leaving the
chemical taste. They are particularly beneficial for pregnant women and people who cannot take iodine. Filtering does not prevent viruses from passing through. When purchasing a filter, the phrase "EPA Registration" should be printed on the label, indicating that the Environmental Protection Agency has guaranteed its effectiveness. In all cases, do not swim in water that may be contaminated or contain dangerous infectious agents, such as parasites.

Food Precautions Heated food should be hot to the touch and eaten promptly. Beware of sliced fruit that may have been washed in contaminated water. Taking two tablets of Pepto-Bismol four times a day before and during international travel can help prevent many cases of diarrhea. Pepto-Bismol should not be taken for more than three weeks. Bear in mind that both aspirin and Pepto-Bismol share the active ingredient salicylate, many medications interfere with salicylate, and people allergic to aspirin, pregnant women, and those who have ulcers, other bleeding disorders, or gout, should not take Pepto-Bismol without consulting a physician. Children under three and children and adolescents with flu or chicken pox should not take it. Side effects of Pepto-Bismol include ringing in the ears and black stools and tongue.
Prophylactic antibiotic regimens are those that are used to diarrhea while travelling. They are effective but there are many reasons that warrant against their routine use. Taking prophylactic antibiotics can trigger adverse drug reactions, development of superinfections, and can contribute to the widespread bacterial resistance to many antibiotics. Antibiotics are also not effective against parasites or viruses and may give travellers a sense of false security. Prophylactic antibiotics are therefore not recommended unless the traveller has an underlying medical condition or is taking a trip that would be utterly ruined by a change in schedule due to the brief illness. It antibiotics are warranted,
ciprofloxacin is the standard preventive agent.
If diarrhea develops, prevention of dehydration is the most important first step. In severe cases, dehydration can be life threatening, particularly in children. Agitation may be an early symptom. Severe indications include listlessness and a weak pulse. Parents should seek medical help immediately if the child appears to be dehydrated. Don't buy food from street vendors.
Travellers themselves should peel all fresh fruits and vegetables.
Avoid dairy products.
Avoid raw or undercooked meat and fish.

Typhoid Fever
Two basic actions can protect you from Typhoid Fever: 
1. Avoid risky foods and drinks. 
2. Get vaccinated against typhoid fever. 
Typhoid fever is a life-threatening illness caused by the bacterium Salmonella Typhi. Typhoid fever is still common in the developing world, where it affects about 13 million persons each year. 
Typhoid fever is common in most parts of the world except in industrialized regions such as the United States, Canada, western Europe, Australia, and Japan. Therefore, if you are travelling to the developing world, you should consider taking precautions. Over the past 10 years, travellers from the United States to Asia, Africa, and Latin America have been especially at risk. 
If you are travelling to a country where typhoid is common, you should consider being vaccinated against typhoid. Visit a doctor or travel clinic to discuss your vaccination options. 
Remember that you will need to complete your vaccination at least 1 week before you travel so that the vaccine has time to take effect. Typhoid vaccines lose effectiveness after several years; if you were vaccinated in the past, check for a refresher vaccination. Taking antibiotics will not prevent typhoid fever; they only help treat it.

Malaria The world's number one infection. Found in every tropical or subtropical country in the world and in some parts of Eastern Europe. In one 2001 Australian study the risk for travellers was highest in the Pacific region and sub-Saharan Africa (1 in 50 to 1 in 1000), followed by the Indian subcontinent (1 in 1000 to 1 in 12,000); it was lowest in Southeast Asia and South America. (There is no risk in North America, Western Europe, New Zealand, or Australia.) Note: Pregnant women are at higher than average risk for malaria, Initial symptoms are flu-like, also possibly nausea and vomiting. Yellowish skin. Without prompt treatment, can be fatal. Typically develops 10 days to a month following exposure. Symptoms can occur up to a year or more, however, even after careful preventive measures. People who have been in countries with malaria should report fever or other symptoms plus travel information to their physician Immediate treatment is important: Chloroquine in areas where resistance to this drug is low, usually followed by primaquine. Quinine (usually in combination with clindamycin or tetracycline) in chloroquine-resistant regions. Atovaquone/ proguanil (Malarone) in chloroquine-resistant areas if it has not been used for prevention. Derivatives of artemisinin (qinghaosu), including artemether, a traditional Chinese plant remedy. A combination of artesunate and amodiaquine is a promising new regimen.

Yellow Fever Nearly all cases in African countries occur near the equator and in tropical parts of South America. Most cases in moist savanna areas of West and Central Africa in rainy season. Occasional outbreaks in cities and villages in Africa. Lesser extent in any jungle regions. Recent outbreaks in Brazil and Guinea. Yellow Fever rarely infects travellers, but travellers are advised to be vaccinated before travelling to problem areas. Symptoms are usually mild and include headache, fatigue, fever, nausea, vomiting, and constipation. Body temperature usually returns to normal after seven to eight days. If disease goes unrecognized, sufferers may begin to bleed under the skin or from mucous membranes, or vomit material resembling coffee grounds. A further symptom of advanced yellow fever is jaundice (thus, No exact treatment regimen for symptoms. Vaccinations required in African countries near the equator, in tropical parts of South America, and sometimes when outbreaks occur in other areas, or when travellers come from infected areas. Vaccine not usually safe or appropriate for pregnant women, infants, immunocompromised patients, or possibly for elderly people. Nevertheless, if the risk for yellow fever is significant, the vaccination may be warranted in these people.

African sleeping sickness (African Trypanosomiasis) Rural Africa, between latitudes 15 degrees N and 20 degrees S. Symptoms may include fever, chills, headache, fluid accumulation in hands and feet, sleepiness, lethargy, and convulsions. Pentamidine and suramin for early stages. Rimantadine under investigation. Melarsoprol and eflornithine for late stage. Flies attracted to moving vehicles and dark, contrasting colors. Flies not affected by insect repellents.

Dengue Fever Can occur in any tropical or subtropical country. Greater risk in cities than in the country. A large dengue epidemic currently reported spreading across Asia and the Pacific, including Hawaii and Philippines. Large outbreak also has been reported in Brazil. High fever, severe headache, muscle and joint pain, and sometimes vomiting and rash on trunk and upper arms. Disease ends abruptly after three to six days. Patients usually recover, but fatal hemorrhage, can occur and be fatal. Fortunately, this is rare and more likely in someone with a second infection. Treatments include blood transfusions, plenty of fluids, pain killers (aspirin, ibuprofen, or other so-called NSAIDs should not be used). Vaccine is under investigation.

Tuberculosis A few reports of TB in airline passengers exposed to TB during long flight. High rates of TB are found in Mexico, China, Hong Kong, Taiwan, Central America, Philippines, Vietnam, India, Haiti, and South Korea. Coughing, weight loss, fever, night sweats. Isoniazid or two months of rifampin plus pyrazinamide. BCG vaccine available for children in developing countries. Not routinely used for travellers. Consider screening children who return from developing countries.

Poliomyelitis (Polio) Most developing countries in Africa, Asia, Latin American, the Middle East, India and neighboring regions, and most of the new independent countries of the former Soviet Union, including Albania. In 2001, cases reported Haiti, and the Dominican Republic. Symptoms in small children can be mild and flu-like. More likely to be serious in older children and adults. In such cases symptoms include severe fever, headache, stiff neck and back, deep muscle pain, or odd sensations. Can lead to paralysis, sometimes only in certain muscles. Can be fatal. Treatments are available only for symptoms. Universal immunization with vaccine required. Booster needed for adults travelling to developing country. Inactivated polio vaccine (eIPV) preferred. Travellers not previously immunized should receive three doses of injectable vaccine at intervals of one to three months. If departure is imminent, travellers should have a single dose at home and booster shots at appropriate intervals abroad.

Hepatitis A Worldwide. Highest risk in developing nations, particularly where cholera and typhoid are prevalent. Nausea and vomiting, decreased appetite, itching, extreme fatigue, jaundice, fever, and abdominal pain. Serious complications are rare, but recovery may take months. No specific treatment for acute hepatitis. Stop all medications except as approved by physician. Abstain from alcohol and sexual contact. Avoid dehydration and becoming over tired. Keep own eating and cooking utensils separate from others. Two vaccines are available as well as combination vaccine for hepatitis A and B. Vaccination recommended for travel to any nation where risk is intermediate or high. Immunity from vaccine may develop more slowly in elderly people. Vaccination recommended four weeks before travel. Immune globulin used for children under two years.

Pregnant Travellers (Pregnancy while Travelling)

In general, travel should not have a harmful effect on your pregnancy if you are healthy and have an uncomplicated pregnancy. It is usually recommended, however, that you not travel during the last 4 to 6 weeks of pregnancy. 

If you plan to travel to a developing country or remote area of the world where medical care may not be immediately available, you should discuss the risks with your obstetrician and a knowledgeable travel medicine provider, since special risks exist for those persons who travel internationally while pregnant. Some infections are more severe in pregnancy (for example, malaria and hepatitis) and some immunizations and medications that are needed to prevent or treat specific diseases (e.g., antimalarials and antidiarrheal agents) may be harmful to the fetus. You should not travel if you cannot take crucial immunizations or antimalaria drugs or if you have complicated medical needs (for instance, a high-risk pregnancy, a history of spontaneous abortions, expecting multiple births). 

Visit your obstetrician and a travel medicine provider well in advance of your planned date of departure. This will give your medical providers time to assess your health care needs and to administer any necessary medications and immunizations. You should discuss any possible reasons not to travel; travel-related risks and strategies for prevention; potential complications of pregnancy and when to seek medical assistance; and insurance coverage. Discuss the need for medical coverage for pregnancy, labor, and delivery; travel health insurance; and emergency medical evacuation insurance. Many insurance plans do not cover pregnant women overseas, and many plans have gestation cutoff dates for travel beyond which they will not cover delivery out of the area. 

Before leaving on your trip, you should have a clear plan on how to deal with obstetrical complications and emergencies that might occur during travel. It is essential that you obtain the names of reliable physicians in the cities you will be visiting (preferably physicians who speak your native language) and the name and location of the preferred medical facility. Carry a copy of your medical and obstetrical records (including blood type and Rh) in case of an emergency. 

You should also carry a travel kit of medical and first aid items; see "Packing a Medical Kit.” Additional items you should consider packing include: prenatal vitamins, antifungal for vaginal yeast infections, talcum powder, sunscreen with high SPF, and acetaminophen (rather than aspirin). Antimalarial medications and self-treatment for traveller's diarrhea should be included if recommended by your physician. A blood pressure cuff and urine dipsticks for use in the third trimester may also be advised. 

Immunizations and Medications

Immunizations and medications can reduce the risk of certain infections and are especially important if you are travelling to areas where the risk for those infections is high. However, some vaccines and medications may be harmful to you and your developing fetus. Your physician and a knowledgeable travel medicine practitioner will help assess the benefits and risks of these medications/immunizations, as well as the risks of not taking them. 

It is generally preferable not to receive any vaccines during the first 3 months of pregnancy.

Killed vaccines and toxoids may be given during pregnancy but should be avoided during the first 3 months of pregnancy. However, if you will be pregnant during the influenza season, you should receive injectable influenza vaccine, which can be given during any trimester. 
In general, you should not be vaccinated with "live" viral vaccines (such as measles, mumps, and rubella vaccines or varicella vaccine) at any time while you are pregnant. An exception is yellow fever vaccine, which may be given but only to individuals who are at high risk of contracting the disease and who cannot avoid travel to the area of risk. (The safety of yellow fever vaccine in pregnancy has not been established.) 
Avoid becoming pregnant for at least 28 days after receiving measles, mumps, rubella, varicella, or yellow fever vaccine.
Medications for traveller's diarrhea should be included in your medical kit. You should carry loperamide and an antibiotic prescribed by your physician for self-treatment of traveller's diarrhea—ask your physician how and when you should self-treat for diarrhea.

Antimalarial medication and personal protection measures against insect bites (see "Insect Precautions") are mandatory for pregnant women, because malaria carries a greater risk to pregnant women and their fetuses. Some antimalarials are effective and safe in pregnancy, and your physician can prescribe the right medication for your destination.

Carry any current medications with you at all times, not in your checked luggage. Make sure you have sufficient quantities for your trip. If you are bringing prescriptions, ask to have them written for generic name medications and not brand or trade names, which may not be available at your destination. 

Food and Water Precautions

You should adhere strictly to food and water precautions while travelling and at your destination in order to reduce the risk of traveller's diarrhea (as well as viral diseases caused by hepatitis A and E). See "Food and Beverage Precautions." Severe traveller's diarrhea (TD) can lead to premature labor and shock. It is important to stay hydrated and to use ORS (oral rehydration salts), as instructed, if you develop traveller's diarrhea (TD). Follow the same guidelines as those for non-pregnant travellers.

Most experts now consider azithromycin the antibiotic treatment of choice for TD in pregnancy. The quinolones (such as norfloxacin, ciprofloxacin, and ofloxacin) are not considered safe in pregnancy; likewise, tetracycline and doxycycline should not be used in pregnancy. Loperamide is thought to be safe during pregnancy but should be used sparingly due to lack of data. Bismuth salicylate (Pepto-Bismol) should not be used in pregnancy because of risk of bleeding and risk to the fetus. 

Air travel

Airlines generally prohibit pregnant women from flying during the final month of pregnancy, so be sure you inquire about restrictions before buying your ticket. If you plan to fly any time during the last 3 months of your pregnancy, carry a letter from your obstetrician indicating your due date, in case airline officials need confirmation. 

During travel, stretch and do leg exercises while seated; if possible, walk every 2 hours. Seat belts should be worn low around the pelvis. Drink extra fluids (for example, a glass of water every hour if possible). Avoid alcoholic and caffeinated beverages because these drinks act as diuretics (they increase urine output). On long trips, wear support hose or surgical support stockings (if advised to do so by your physician). They can help prevent ankle, foot, and leg swelling and discomfort. 

Avoid air travel with an infant less than 2 weeks of age, as newborns are quite sensitive to changes in atmospheric pressure. 

Other Precautions

Sun - Use topical sunscreens regularly to avoid excessive facial pigmentation (discoloration) from exposure to sunlight. 

Insects - Remember to use personal protection measures against insect bites, especially mosquitoes, since malaria carries a greater risk to pregnant women and their fetuses. Wear long-sleeved clothing and use bednets (when appropriate) that have been treated with a substance called permethrin, an insecticide. 

Two types of insect repellent have been shown to be effective when used in appropriate concentrations: those containing either DEET or picaridin. Picaridin can be used by pregnant women but should not be applied directly to the abdomen. DEET has been shown in 1 study to be safe in the second and third trimesters of pregnancy when used at concentrations of 20% or lower, but the use of DEET in the first trimester has not been well studied. (It is important to keep in mind that any risk of DEET must be balanced against the high risk of potentially life-threatening insect-borne infections such as malaria and dengue.) 

With both DEET and picaridin, the duration of effectiveness increases as the concentration of repellent increases. Therefore, if extensive exposure is anticipated, apply the repellent more frequently since lower concentrations are often used in pregnancy. 

Avoid perfume and bright colored clothing. Avoid outdoor activity during times when mosquitoes are most active and likely to feed. Mosquitoes that can cause malaria most often feed from dusk to dawn. The mosquitoes that can carry dengue fever ("breakbone fever") feed during the daytime, especially in the early morning hours and late afternoon to dusk. Ask your travel health provider to discuss the risks at your planned destination. 

Altitude - Do not snow ski or trek at high altitudes (greater than 6,000 feet; 1,800 meters), especially in remote areas. 

Water sports - It is not advisable to water ski, jet ski, or scuba dive while pregnant. 

Heat - Avoid hot tubs, saunas, and vigorous exercise, especially in hot and humid climates, because a rise in your body temperature may harm the developing fetus. 

Breastfeeding and Travel

If you are breastfeeding, you should try to maintain a regular schedule while travelling (as much as possible), avoid disruptions to sleep and meals, and drink plenty of fluids (avoiding caffeine and alcohol). 

In general, you can receive all necessary vaccines while breastfeeding, as indicated by your medical needs/ history and itinerary. (However, there is no data on the use of the newly approved intranasal influenza vaccine in the nursing mother.) Rubella vaccine virus may be transmitted through breast milk but does not usually affect the infant (and if it does, the infection is well tolerated). It is not known if VZV is excreted in breast milk. 

Your infant should be immunized according to the recommended schedule/itinerary. However, the infant cannot be immunized at birth for some infections (yellow fever, measles, meningococcal meningitis) and this must be taken into consideration when making the decision to travel to areas where these infections may be a risk. Remember that immunizations and medications that you receive do not offer protection to your baby, even if these medications are excreted in breast milk to some degree.

Mefloquine and chloroquine are considered safe for malaria prevention while breastfeeding. Your infant does not receive protection against malaria through your breast milk while you are taking antimalarial medications, so he/she will also need malaria prophylaxis. Insect precautions are also important for both you and your child. Neither DEET nor picaridin should be used while breastfeeding, due to a lack of data. See "Insect Precautions.” 

Observe safe food and water precautions while travelling to avoid traveller's diarrhea. See "Food and Beverage Precautions.” If you do develop traveller's diarrhea (TD) you can continue to breastfeed but it is important to increase your fluid intake. "See traveller's Diarrhea" for information on self-treatment of TD.

   It is sensible to carry a small, straightforward medical kit. A kit should include:

Aspirin or paracetamol (acetaminophen in the US) - for pain or fever.

Antihistamine (such as Benadryl) - useful as a decongestant for colds and allergies, to ease the itch from insect bites or stings and to help prevent motion sickness. There are several antihistamines on the market, all with different pros and cons (eg a tendency to cause drowsiness), so it's worth discussing your requirements with a pharmacist or doctor.

Antihistamines may cause sedation and interact with alcohol so care should be taken when using them.
Antibiotics - useful if you're travelling well off the beaten track, but they must be prescribed and you should carry the prescription with you.

Loperamide (eg Imodium) or Lomotil for diarrhoea; prochlorperazine (eg Stemetil) or metaclopramide (eg Maxalon) for nausea and vomiting.

Rehydration mixture - for treatment of severe diarrhoea; this is particularly important if travelling with children.

Antiseptic such as povidone-iodine (eg Betadine) for cuts and grazes.

Multivitamins - especially for long trips when dietary vitamin intake may be inadequate.

Calamine lotion or aluminium sulphate spray (eg Stingose spray) to ease irritation from bites and stings.

Bandages and Band-aids - for minor injuries. 
Scissors, tweezers and a thermometer (note that mercury thermometers are prohibited by airlines).

Insect repellent, sunscreen, chap stick and water purification tablets.

Cold and flu tablets and throat lozenges. Pseudoephedrine hydrochloride (Sudafed) may be useful if flying with a cold to avoid ear damage.

A couple of syringes and needles, in case you need injections in a country with medical hygiene problems. Ask your doctor for a note explaining why they have been prescribed. 

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