Travelers' diarrhea is the most common travel-related ailment. The cornerstone of prevention is food and water precautions, as outlined below. All travelers should bring along an antibiotic and an antidiarrheal drug to be started promptly if significant diarrhea occurs, defined as three or more loose stools in an 8-hour period or five or more loose stools in a 24-hour period, especially if associated with nausea, vomiting, cramps, fever or blood in the stool. A quinolone antibiotic is usually prescribed: either ciprofloxacin (Cipro)(PDF) 500 mg twice daily or levofloxacin (Levaquin) (PDF) 500 mg once daily, for a total of three days. Quinolones are generally well-tolerated, but occasionally cause sun sensitivity and should not be given to children, pregnant women, or anyone with a history of quinolone allergy. Alternative regimens include a three day course of rifaximin (Xifaxan) 200 mg three times daily or azithromycin (Zithromax) 500 mg once daily. Rifaximin should not be used by those with fever or bloody stools and is not approved for pregnant women or those under age 12. Azithromycin should be avoided in those allergic to erythromycin or related antibiotics. An antidiarrheal drug such as loperamide (Imodium) or diphenoxylate (Lomotil) should be taken as needed to slow the frequency of stools, but not enough to stop the bowel movements completely. Diphenoxylate (Lomotil) and loperamide (Imodium) should not be given to children under age two.

Most cases of travelers' diarrhea are mild and do not require either antibiotics or antidiarrheal drugs. Adequate fluid intake is essential.

If diarrhea is severe or bloody, or if fever occurs with shaking chills, or if abdominal pain becomes marked, or if diarrhea persists for more than 72 hours, medical attention should be sought.

Though effective, antibiotics are not recommended prophylactically (i.e. to prevent diarrhea before it occurs) because of the risk of adverse effects, though this approach may be warranted in special situations, such as immunocompromised travelers.

Malaria in Angola: prophylaxis is recommended for all travelers. Either mefloquine (Lariam), atovaquone/proguanil (Malarone)(PDF), or doxycycline may be given. Mefloquine is taken once weekly in a dosage of 250 mg, starting one-to-two weeks before arrival and continuing through the trip and for four weeks after departure. Mefloquine may cause mild neuropsychiatric symptoms, including nausea, vomiting, dizziness, insomnia, and nightmares. Rarely, severe reactions occur, including depression, anxiety, psychosis, hallucinations, and seizures. Mefloquine should not be given to anyone with a history of seizures, psychiatric illness, cardiac conduction disorders, or allergy to quinine or quinidine. Those taking mefloquine should read the Lariam Medication Guide (PDF). Atovaquone/proguanil (Malarone) is a recently approved combination pill taken once daily with food starting two days before arrival and continuing through the trip and for seven days after departure. Side-effects, which are typically mild, may include abdominal pain, nausea, vomiting, headache, diarrhea, or dizziness. Serious adverse reactions are rare. Doxycycline is effective, but may cause an exaggerated sunburn reaction, which limits its usefulness in the tropics.

Long-term travelers who may not have access to medical care should bring along medications for emergency self-treatment should they develop symptoms suggestive of malaria, such as fever, chills, headaches, and muscle aches, and cannot obtain medical care within 24 hours. See malaria for details. Symptoms of malaria sometimes do not occur for months or even years after exposure.

Insect protection measures are essential.

For further information about malaria in Angola, including a map showing the risk in different parts of the country, go to the World Health Organization and Southern Africa Malaria Control.

The following are the recommended vaccinations for Angola:

Hepatitis A vaccine is recommended for all travelers over one year of age. It should be given at least two weeks (preferably four weeks or more) before departure. A booster should be given 6-12 months later to confer long-term immunity. Two vaccines are currently available in the United States: VAQTA (Merck and Co., Inc.) (PDF) and Havrix (GlaxoSmithKline) (PDF). Both are well-tolerated. Side-effects, which are generally mild, may include soreness at the injection site, headache, and malaise.

Older adults, immunocompromised persons, and those with chronic liver disease or other chronic medical conditions who have less than two weeks before departure should receive a single intramuscular dose of immune globulin (0.02 mL/kg) at a separate anatomic injection site in addition to the initial dose of vaccine. Travelers who are less than one year of age or allergic to a vaccine component should receive a single intramuscular dose of immune globulin (see hepatitis A for dosage) in the place of vaccine.

Typhoid vaccine is recommended for all travelers. It is generally given in an oral form (Vivotif Berna) consisting of four capsules taken on alternate days until completed. The capsules should be kept refrigerated and taken with cool liquid. Side-effects are uncommon and may include abdominal discomfort, nausea, rash or hives. The alternative is an injectable polysaccharide vaccine (Typhim Vi; Aventis Pasteur Inc.) (PDF), given as a single dose. Adverse reactions, which are uncommon, may include discomfort at the injection site, fever and headache. The oral vaccine is approved for travelers at least six years old, whereas the injectable vaccine is approved for those over age two. There are no data concerning the safety of typhoid vaccine during pregnancy. The injectable vaccine (Typhim Vi) is probably preferable to the oral vaccine in pregnant and immunocompromised travelers.

Yellow fever vaccine is required for all travelers. In Angola, yellow fever is reported from the provinces of Bengo and Luanda, but may occur elsewhere. Yellow fever vaccine (YF-VAX; Aventis Pasteur Inc.) (PDF) must be administered at an approved yellow fever vaccination center, which will give each vaccinee a fully validated International Certificate of Vaccination. The vaccine should not in general be given to those who are younger than nine months of age, pregnant, immunocompromised, or allergic to eggs (since the vaccine is produced in chick embryos). It should also not be given to those with a history of thymus disease or thymectomy. Reactions to the vaccine, which are generally mild, may include headaches, muscle aches, and low-grade fevers. Serious allergic reactions, such as hives or asthma, are rare and generally occur in those with a history of egg allergy.

Meningococcal vaccine is recommended for all travelers, especially if prolonged contact with the populace is likely. An outbreak of meningococcal disease was reported beginning in May 2001, resulting in 332 cases and 30 deaths as of October 10. The provinces chiefly affected were Benguela, Cunene, Luanda, Lunda Sul and Cuando Cubango. See the World Health Organization for details. Previous outbreaks occurred in the provinces of Bi, Malange, Lunda Norte and Huambo in 1998 and in the province of Benguela in 1999. Meningococcal vaccine has few side-effects. Mild redness at the injection site may occur. Young children may develop transient fever.

Polio vaccine is recommended. Several cases of polio were reported from Angola in 2005 (see "Recent outbreaks" below). Any adult who received the recommended childhood immunizations but never had a booster as an adult should be given a single dose of inactivated polio vaccine. All children should be up-to-date in their polio immunizations and any adult who never completed the initial series of immunizations should do so before departure. Adverse reactions to polio vaccine are uncommon and may include pain at the injection site. Since inactivated polio vaccine includes trace amounts of streptomycin, neomycin and polymyxin B, individuals allergic to these antibiotics should not receive the vaccine.

Hepatitis B vaccine is recommended for travelers who will have intimate contact with local residents or potentially need blood transfusions or injections while abroad, especially if visiting for more than six months. It is also recommended for all health care personnel. Two vaccines are currently licensed in the United States: Recombivax HB (Merck and Co., Inc.) (PDF) and Engerix-B (GlaxoSmithKline) (PDF). A full series consists of three intramuscular doses given at 0, 1 and 6 months. Engerix-B is also approved for administration at 0, 1, 2, and 12 months, which may be appropriate for travelers departing in less than 6 months. Side-effects are generally mild and may include discomfort at the injection site and low-grade fever. Severe allergic reactions (anaphylaxis) occur rarely.

Rabies vaccine is recommended only for those at high risk for animal bites, such as veterinarians and animal handlers, and for long-term travelers who may have contact with animals and may not have access to medical care. A complete preexposure series consists of three doses of vaccine injected into the deltoid muscle on days 0, 7, and 21 or 28. Side-effects may include pain at the injection site, headache, nausea, abdominal pain, muscle aches, dizziness, or allergic reactions.

Any animal bite or scratch should be thoroughly cleaned with large amounts of soap and water and local health authorities should be contacted immediately for possible post-exposure treatment, whether or not the person has been immunized against rabies.

Tetanus-diphtheria vaccine is recommended for all travelers who have not received a tetanus-diphtheria immunization within the last 10 years.

Measles-mumps-rubella vaccine: two doses are recommended (if not previously given) for all travelers born after 1956, unless blood tests show immunity. Many adults born after 1956 and before 1970 received only one vaccination against measles, mumps, and rubella as children and should be given a second dose before travel. MMR vaccine should not be given to pregnant or severely immunocompromised individuals.

Cholera vaccine is not generally recommended, even though cholera outbreaks are reported, because most travelers are at low risk for infection. Two oral vaccines have recently been developed: Orochol (Mutacol), licensed in Canada and Australia, and Dukoral, licensed in Canada, Australia, and the European Union. These vaccines, where available, are recommended only for high-risk individuals, such as relief workers, health professionals, and those traveling to remote areas where cholera epidemics are occurring and there is limited access to medical care. The only cholera vaccine approved for use in the United States is no longer manufactured or sold, due to low efficacy and frequent side-effects.

An outbreak of mass bromide poisoning, probably caused by contaminated salt, was reported in November 2007 from the Cacuaco municipality, Luanda Province, Angola. Almost 500 people were affected. See the World Health Organization for further information.

A massive cholera outbreak was reported from Angola in March 2006, resulting in more than 62,000 cases and more than 2500 deaths by the end of the year. The outbreak began in the poorest sections of Luanda, then spread throughout the city and to 16 out of 18 provinces (all but Lunda Sul and Moxico). Approximately 45% of the cases were reported from Luanda, 17% from Benguela, and 8% from Malange. The outbreak appeared to be waning in September and October, but the number of cases began to rise again in early November with the arrival of the rains. Cases continued to be reported from many parts of the country through 2007. A surge in cholera cases was reported in March 2008 after widepread flooding, chiefly affecting the southern provinces of Cunene and Huila. Almost a thousand cases were also reported from Luanda Province. For further information, go to ProMED-mail, the World Health Organization, Doctors Without Borders, AlertNet, IRIN, and the International Red Cross.

The main symptoms of cholera are profuse watery diarrhea and vomiting, which in severe cases may lead to dehydration and death. Most outbreaks are related to contaminated drinking water, typically in situations of poverty, overcrowding, and poor sanitation. Most travelers are at extremely low risk for infection. Cholera vaccine, where available, is recommended only for certain high-risk individuals, such as relief workers, health professionals, and those traveling to remote areas where cholera epidemics are occurring and there is limited access to medical care. All travelers should carefully observe food and water precautions, as below.

Seven cases of polio were reported in June-August 2005, representing the first cases of polio in Angola since 2001. The government responded by initiating a nationwide polio vaccination campaign. See the World Health Organization for further information. No cases were reported in 2006, but ten new cases were reported during the first eight months of 2007 and five were recorded during the first five months of 2008, all in the Luanda area(see the the World Health Organization). A one-time polio booster is recommended for any adult traveler who received the recommended childhood immunizations but never had polio vaccine as an adult. Children should be fully immunized against polio before traveling to Angola. In early 1999, a polio epidemic occurred in Luanda and neighboring regions of Bengo province. Most cases occurred in children under age 5. The outbreak was related to the movement of large numbers of displaced persons to overcrowded, unhygienic areas as a result of the ongoing civil war.

An outbreak of Marburg virus hemorrhagic fever was reported in March 2005 from Uige Province in northern Angola. In retrospect, the outbreak probably began in October 2004. Cases were also reported among residents of other provinces in northwestern Angola, but most of these appear to have been acquired in Uige Province. A total of 374 cases were identified, of which 329 were fatal. Most occurred in children less than five years old. The outbreak ended in late July. For further information, go to the World Health Organization and the International Federation of Red Cross and Red Crescent Societies.

The incubation period of Marburg fever ranges from 5-to-10 days. Initial symptoms may include fever, chills, and muscle aches, followed by the appearance of a rash. Nausea, vomiting, chest pain, sore throat, abdominal pain, and diarrhea may occur. Complications may include jaundice, confusion, shock, hemorrhage, and multi-organ failure.

Transmission of Marburg virus, which is closely related to Ebola virus, is thought to require direct contact with blood or body fluids from infected persons. Those at greatest risk include health care workers and family members of those affected. Those who care for Marburg patients should wear protective gowns, gloves, and masks, as well as eye protection or a face shield. To date, no foreign nationals, except those involved in direct patient care, have been infected. Most travelers appear to be at extremely low risk. No travel restrictions are advised for Angola at this time.

African trypanosomiasis (sleeping sickness) is reported. The disease is transmitted by the bite of tsetse flies. Transmission is highest in rural areas in the northern part of the country, including the provinces of Uige and Cuanze Norte. The best means of prevention is to avoid areas infested with tsetse flies, which are usually known to local inhabitants. Travelers at risk should wear long sleeves and long pants of medium weight fabric in neutral colors that blend with the environment. Insect repellents are ineffective. For further information on personal protection measures, go to Health Canada.

Schistosomiasis may be acquired by swimming, wading, rafting or bathing in contaminated fresh water. Swimming and bathing precautions are advised (see below).

HIV (human immunodeficiency virus) infection is reported, but travelers are not at risk unless they have unprotected sexual contacts or receive injections or blood transfusions.

Other infections include

• Dengue fever (flu-like illness sometimes complicated by hemorrhage or shock; transmitted by mosquitoes)
• Lymphatic filariasis
• Onchocerciasis
• Rift Valley fever
• Tick-borne relapsing fever
• Plague (not reported in humans in recent years, but foci persist in the rodent population; any traveler at risk for exposure to wild rodents or their fleas, which transmit the plague, should bring along a bottle of doxycycline, to be taken prophylactically if exposure occurs)

Do not drink tap water unless it has been boiled, filtered, or chemically disinfected. Do not drink unbottled beverages or drinks with ice. Do not eat fruits or vegetables unless they have been peeled or cooked. Avoid cooked foods that are no longer piping hot. Cooked foods that have been left at room temperature are particularly hazardous. Avoid unpasteurized milk and any products that might have been made from unpasteurized milk, such as ice cream. Avoid food and beverages obtained from street vendors. Do not eat raw or undercooked meat or fish. Some types of fish may contain poisonous biotoxins even when cooked. Barracuda in particular should never be eaten. Other fish that may contain toxins include red snapper, grouper, amberjack, and sea bass.

All travelers should bring along an antibiotic and an antidiarrheal drug to be started promptly if significant diarrhea occurs, defined as three or more loose stools in an 8-hour period or five or more loose stools in a 24-hour period, especially if accompanied by nausea, vomiting, cramps, fever or blood in the stool. Antibiotics which have been shown to be effective include ciprofloxacin (Cipro), levofloxacin (Levaquin), rifaximin (Xifaxan), or azithromycin (Zithromax). Either loperamide (Imodium) or diphenoxylate (Lomotil) should be taken in addition to the antibiotic to reduce diarrhea and prevent dehydration.

If diarrhea is severe or bloody, or if fever occurs with shaking chills, or if abdominal pain becomes marked, or if diarrhea persists for more than 72 hours, medical attention should be sought.

Wear long sleeves, long pants, hats and shoes (rather than sandals). For rural and forested areas, boots are preferable, with pants tucked in, to prevent tick bites. Apply insect repellents containing 25-50% DEET (N,N-diethyl-3-methylbenzamide) or 20% picaridin (Bayrepel) to exposed skin (but not to the eyes, mouth, or open wounds). DEET may also be applied to clothing. Products with a lower concentration of either repellent need to be repplied more frequently. Products with a higher concentration of DEET carry an increased risk of neurologic toxicity, especially in children, without any additional benefit. Do not use either DEET or picaridin on children less than two years of age. For additional protection, apply permethrin-containing compounds to clothing, shoes, and bed nets. Permethrin-treated clothing appears to have little toxicity. Don't sleep with the window open unless there is a screen. If sleeping outdoors or in an accomodation that allows entry of mosquitoes, use a bed net, preferably impregnated with insect repellent, with edges tucked in under the mattress. The mesh size should be less than 1.5 mm. If the sleeping area is not otherwise protected, use a mosquito coil, which fills the room with insecticide through the night. After a day outdoors in rural or forested areas, perform a thorough tick check with the assistance of a friend or a full-length mirror. Ticks should be removed with tweezers, grasping the tick by the head. Many tick-borne illnesses can be prevented by prompt tick removal.

To protect yourself against tsetse flies, which transmit African trypanosomiasis (sleeping sickness), you should wear long sleeves and long pants of medium weight fabric in neutral colors that blend with the environment. Also, you should avoid riding in the back of open vehicles, since dust may attract tsetse flies, and take care not to disturb bushes (where tsetse flies rest) during the warmer parts of the day. Insect repellents are ineffective against tsetse flies.

Avoid swimming, wading, or rafting in bodies of fresh water, such as lakes, ponds, streams, or rivers. Do not use fresh water for bathing or showering unless it has been heated to 150 degrees F for at least five minutes or held in a storage tank for at least three days. Toweling oneself dry after unavoidable or accidental exposure to contaminated water may reduce the likelihood of schistosomiasis, but does not reliably prevent the disease and is no substitute for the precautions above. Chlorinated swimming pools are considered safe.

Bring adequate supplies of all medications in their original containers, clearly labeled. Carry a signed, dated letter from your primary physician describing all medical conditions and listing all medications, including generic names. If carrying syringes or needles, be sure to carry a physician's letter documenting their medical necessity. Pack all medications in hand luggage. Carry a duplicate supply in the checked luggage. If you wear glasses or contacts, bring an extra pair. If you have significant allergies or chronic medical problems, wear a medical alert bracelet.

Make sure your health insurance covers you for medical expenses abroad. If not, supplemental insurance for overseas coverage, including possible evacuation, should be seriously considered. If illness occurs while abroad, medical expenses including evacuation may run to tens of thousands of dollars. For a list of travel insurance and air ambulance companies, go to Medical Information for Americans Traveling Abroad on the U.S. State Department website. Bring your insurance card, claim forms, and any other relevant insurance documents. Before departure, determine whether your insurance plan will make payments directly to providers or reimburse you later for overseas health expenditures. The Medicare and Medicaid programs do not pay for medical services outside the United States.

Pack a personal medical kit, customized for your trip (see description). Take appropriate measures to prevent motion sickness and jet lag, discussed elsewhere. On long flights, be sure to walk around the cabin, contract your leg muscles periodically, and drink plenty of fluids to prevent blood clots in the legs. For those at high risk for blood clots, consider wearing compression stockings.

Avoid contact with stray dogs and other animals. If an animal bites or scratches you, clean the wound with large amounts of soap and water and contact local health authorities immediately. Wear sun block regularly when needed. Use condoms for all sexual encounters. Ride only in motor vehicles with seat belts. Do not ride on motorcycles.

There are a small number of adequate medical facilities in Luanda, and virtually none elsewhere. Many expatriates go to Clinica Sagrada Esperança (Avenida Mortella – Mohamed, Ilha de Luanda; ph. 222-309360 or 309034) or Medigroup/Clinica da Mutamba (Rua Pedro Felix Machado, 10-12, Luanda; ph. 393783/395283), which provide 24-hour emergency services as well as routine medical care. The main inpatient facility is Americo Boavida Hospital (Av. Hoji Ya Henda, Luanda; ph. 244-380117, 380118, 380119), which offers dialysis services. For a guide to other physicians, hospitals, clinics, and pharmacies in Luanda, go to the U.S. Embassy website. Most doctors and hospitals will expect payment in cash, regardless of whether you have travel health insurance. Serious medical problems will require air evacuation to a country with state-of-the art medical facilities.

The supply of pharmaceuticals is limited. All travelers should bring along an adequate supply of all medications which might be necesssary for the duration of their stay in Angola.

Before you leave, make sure you have the names and contact information for physicians, clinics, and hospitals where you can obtain emergency medical care if needed (see the U.S. Embassy website).

All children should be up-to-date on routine childhood immunizations, as recommended by the American Academy of Pediatrics. Children who are 12 months or older should receive a total of 2 doses of MMR (measles-mumps-rubella) vaccine, separated by at least 28 days, before international travel. Children between the ages of 6 and 11 months should be given a single dose of measles vaccine. MMR vaccine may be given if measles vaccine is not available, though immunization against mumps and rubella is not necessary before age one unless visiting a country where an outbreak is in progress. Children less than one year of age may also need to receive other immunizations ahead of schedule (see the accelerated immunization schedule).

Because yellow fever vaccine is not approved for use in children less than nine months of age, children in this age group should not in general be brought to Angola.

The recommendations for malaria prophylaxis are the same for young children as for adults, except that (1) dosages are lower; (2) Malarone is not recommended for children weighing less than 25 pounds; and (3) doxycycline should be avoided. DEET-containing insect repellents are not advised for children under age two, so it's especially important to keep children in this age group well-covered to protect them from mosquito bites.

When traveling with young children, be particularly careful about what you allow them to eat and drink (see food and water precautions), because diarrhea can be especially dangerous in this age group and because the vaccines for hepatitis A and typhoid fever, which are transmitted by contaminated food and water, are not approved for children under age two. Baby foods and cows' milk may not be available in developing nations. Only commercially bottled milk with a printed expiration date should be used. Young children should be kept well-hydrated and protected from the sun at all times.

Be sure to pack a medical kit when traveling with children. In addition to the items listed for adults, bring along plenty of disposable diapers, cream for diaper rash, oral replacement salts, and appropriate antibiotics for common childhood infections, such as middle ear infections.

Because of the risk of malaria and yellow fever, pregnant women should not in general travel to Angola. Yellow fever vaccine is not approved for use during pregnancy, because it contains live virus. Malaria may cause life-threatening illness in both the mother and the unborn child. None of the currently available prophylactic medications is 100% effective. Mefloquine (Lariam) is the drug of choice for malaria prophylaxis during pregnancy, but should not be given if possible in the first trimester. If travel to areas with malaria and yellow fever is unavoidable, insect protection measures must be strictly followed at all times. The recommendations for DEET-containing insect repellents are the same for pregnant women as for other adults.

Helpful maps are available in the University of Texas Perry-Castaneda Map Collection and the United Nations map library. If you have the name of the town or city you'll be visiting and need to know which state or province it's in, you might find your answer in the Getty Thesaurus of Geographic Names.

U.S. citizens are encouraged to register with and obtain updated information on travel and security from the Consular Section of the U.S. Embassy in Luanda located at the Casa Inglesa Complex, Rua Major Kanhangula No. 132/135, tel. 244-2-371-645 or 396-727; fax 244-2-390-515. The Embassy is located on Rua Houari Boumedienne in the Miramar area of Luanda, P.O. Box 6468, tel. 244-2-447-028/445-481/446-224; 24-hour duty officer 244-92-404-209; fax 244-2-446-924. The Consular section may be contacted by e-mail at consularluanda@state.gov or at luandaconsular@yahoo.com . Further information on travel to Angola is also located on the Embassy website at http://usembassy.state.gov/angola.

For information on safety and security, go to the U.S. Department of State, United Kingdom Foreign and Commonwealth Office, Foreign Affairs Canada, and the Australian Department of Foreign Affairs and Trade.