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 Democratic Republic of the Congo: 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 (Lariam) 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 the Democratic Republic of the Congo, including a map showing the risk of malaria in different parts of the country, go to the World Health Organization.

The following are the recommended vaccinations for the Democratic Republic of the Congo:

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. A typhoid outbreak was reported from Kinshasa in December 2004 (see "Recent outbreaks" below). Typhoid vaccine 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 greater than one year of age. Though not required, it is also recommended for travelers between 9 and 12 months of age. 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, 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.

Polio immunization is recommended, due to the persistence of polio in sub-Saharan Africa. 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. Side-effects 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.

Meningococcal vaccine is recommended for all travelers. Several meningococcal outbreaks have been reported in recent years (see "Recent outbreaks" below). Meningococcal vaccine has few side-effects. Mild redness at the injection site may occur. Young children may develop transient fever.

Influenza vaccine is recommended for all travelers due to a recent influenza outbreak (see below.) The vaccine may cause soreness at the injection site, low-grade fevers, malaise, and muscle aches. Severe reactions are rare. Influenza vaccine should not be given to pregnant women during the first trimester.

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.

All travelers should be up-to-date on routine immunizations, including

• Tetanus-diphtheria vaccine (recommended for all travelers who have not received a tetanus-diphtheria immunization within the last 10 years.)
• Measles vaccine (measles outbreaks recently reported; vaccine recommended for any traveler born after 1956 who does not have either a history of two documented measles immunizations or a blood test showing immunity. Many adults who had only one vaccination show immunity when tested and do not need the second vaccination. Measles vaccine should not be given to pregnant or severely immunocompromised individuals.)
• Varicella (chickenpox) vaccine (recommended for any international traveler over one year of age who does not have either a history of documented chickenpox or a blood test showing immunity. Many people who believe they never had chickenpox show immunity when tested and do not need the vaccine. Varicella vaccine should not be given to pregnant or immunocompromised individuals.)

Cholera vaccine is not generally recommended, although cholera outbreaks occur frequently (see below), 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 monkeypox, which is a febrile, pustular illness closely related to smallpox, was reported from Bokungu in July 2008, leading to three deaths. In October 2002, an outbreak was reported from Equateur Province (see ProMED-mail; October 25, 2002, and July 11, 2008). In 1996-1997, an outbreak was reported from the Katako-Kombe Health Zone, Kasai Oriental Province, resulting in 88 cases. Between outbreaks, the disease occurs sporadically (see Emerging Infectious Diseases). Monkeypox usually results from contact with infected squirrels or primates, but can also be spread from person to person. Smallpox vaccination protects against monkeypox but is not recommended. See Emerging Infectious Diseases, Health Canada - Monkeypox, and ProMED-mail (March 14, 2002).

Outbreaks of meningococcal disease outbreaks occur regularly in the Democratic Republic of the Congo. Meningococcal vaccine is recommended for all travelers to the Democratic Republic of the Congo. An outbreak was reported in January-February 2008 from Aru district (which neighbors Arua district in Uganda), resulting in 167 cases and 17 deaths as of February 10. The most affected areas included Laybo, Ariwara and Aungba health zones (see the World Health Organization). In January 2007, a meningococcal outbreak occurred in Adi health zone, Province Orientale, in the northeastern part of the country, bordering Uganda. As of March 16, a total of 730 suspected cases and 84 deaths had been identified (see the World Health Organization and ProMED-mail). An outbreak in the winter of 2002-2003 caused 74 confirmed cases and 17 deaths (see The Lancet Infectious Disease). In August 2001, an outbreak was reported from Katana, Bukavu and Idjwi health zones, South-Kivu province, causing 893 cases and 104 deaths as of January 2002 (see the World Health Organization). Meningococcal outbreaks also occurred in the eastern districts in 1997, killing almost 200 people; in Tembo, Bandundu Region in January 1998, leading to more than 30 deaths; and in a military camp in western Kasai beginning in September 1998, resulting in almost 80 deaths.

Cholera outbreaks occur frequently in the Democratic Republic of the Congo. Most of the recent outbreaks have been related to civil disorder and displacement of large populations. In May 2008, a cholera outbreak was reported from North Kivu province, chiefly affecting the health zones of Pinga and Mweso in the upper and forested Masisi North area. In January 2008, cholera outbreaks were reported from Lubumbashi, the capital of Katanga province; from Likasi, a town in Katanga Province; and from the rural area of Bukama, also in Katanga; as of February, the outbreaks were worsening. In January 2008, a cholera outbreak was also reported from a refugee camp in Rutshuru town, north of Goma, which had become a center of heavy fighting between rebels and government forces. In November 2007, cholera outbreaks were reported from Rukwanzi Island in Lake Albert; from the Tchomia health zone within the Ituri district in the northeastern part of the country; and in five refugee camps in the Mugunga area west of Goma, the capital city of North Kivu province in the eastern part of the country. The disease has become endemic in areas surrounding Kivu and Tanganyika lakes in South Kivu Province, where outbreaks have been reported almost continuously, most recently in November 2006 (see the International Federation of Red Cross and Red Crescent Societies).

In March 2006, outbreaks were reported from Orientale, Katanga, and Maniema provinces (see Health Action in Crises). In January 2006, an outbreak was reported from South Kivu province, chiefly affecting the Uvira and Fizi territories (see the International Federation of Red Cross and Red Crescent Societies). An outbreak began in October 2005 in the eastern part of the country around Lake Tanganyika, caused by local residents drinking unpurified water from the lake (see ProMED-mail; March 3, 2006). In June 2003, an outbreak was reported from the provinces of Sud Kivu, Katanga, and Kasai Oriental (mostly in the Tsilingue area), resulting in 13,452 cases and 380 deaths (see the World Health Organization). An outbreak beginning in November 2001 led to more than 7000 cases and 500 deaths as of April 2002 (see the World Health Organization). In early 1998, an outbreak in the provinces of Katanga, Nord-Kivu, Sud-Kivu and Orientale resulted in more than 13,000 cases and almost 800 deaths. In April 1997, an outbreak occurred among Rwandan refugees living in temporary camps, causing more than 1500 deaths.

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.

An outbreak of Ebola hemorrhagic fever was reported from the province of Kasai Occidental in September 2007, resulting in 26 confirmed cases, 21 of them fatal. The outbreak was declared over in November. Those at greatest risk for Ebola include household contacts of an infected person, health care providers, and those participating in funeral rites, which usually involve close contact with the body of the deceased. Most travelers are at low risk. No travel restrictions are recommended for the DRC at this time. For further information, go to the World Health Organization. The last Ebola outbreak occurred in Kikwit in 1995, resulting in 244 deaths.

A measles outbreak was reported in May 2007 from the Malemba-Nkulu territory in northern Katanga region, resulting in about 3500 cases and more than 150 deaths (see ProMED-mail, June 1, 2007). In March 2006, a measles outbreak was reported from the four eastern provinces (Maniema, Kasai Oriental, Bandundu, and Bas-Congo) (see Health Action in Crises). All travelers born after 1956 should make sure they have had either two documented measles immunizations or a blood test showing measles immunity. This does not apply to people born before 1957, who are presumed to be immune. Children greater than 12 months of age should be given two doses of MMR vaccine, separated by one month, before travel to the DRC. Although measles immunization is usually begun at age 12 months, children between the ages of 6 and 11 months should be given an initial dose of measles or MMR vaccine before departure.

A total of 32 cases of polio were reported from the Democratic Republic of the Congo in the first ten months of 2007, chiefly from Equateur, Orientale, and Bandundu provinces (see the World Health Organization). Two additional cases were reported in 2008. All travelers to the Democratic Republic of the Congo should make sure they are fully immunized against polio.

An outbreak of suspected pneumonic plague was reported in September 2006 from four health zones in Haut-Uele district, Oriental province, in the northeastern part of the country. As of early November, a total of 1174 suspected cases and 50 deaths had been described. See the World Health Organization for further information. In June 2006, an outbreak of suspected pneumonic plague was reported from Ituri district, Oriental province, resulting in 144 cases and 22 deaths of June 19. Suspected cases of bubonic plague were also identified (see the World Health Organization and Doctors Without Borders).

Bubonic plague, which is the more common form of the disease, is transmitted by the bite of rodent fleas. The infection is characterized by fever, chills, muscle aches, and malaise, associated with the development of an acutely swollen, exquisitely painful lymph node, known as a bubo, near the site of the flea bite. Pneumonic plague, which is transmitted by infected droplets coughed into the air by an infected person, is much less common than bubonic plague, but much more contagious. Symptoms include rapid onset of fever, chills, headache, body aches, weakness, dizziness, and chest discomfort, followed by cough, increasing chest pain, and difficulty breathing. Most travelers are at low risk for the plague. There is no vaccine at present. Those who may have contact with anyone suffering from pneumonic plague, or with rodents or their fleas, should bring along a bottle of doxycycline, to be taken prophylactically if exposure occurs. Those less than eight years of age or allergic to doxycycline may take trimethoprim-sulfamethoxazole instead. To minimize risk, travelers should avoid areas containing rodent burrows or nests, never handle sick or dead animals, and follow insect protection measures, as described below.

Approximately 1000 cases of plague, usually bubonic, are reported each year from Ituri District, which is one of the most active areas in the world for plague transmission. In February 2005, an outbreak of pneumonic plague was also reported among diamond mine workers in Zobia, Bas-Uele district, Oriental province, in the northern part of the country, resulting in 130 cases and 57 deaths (see the World Health Organization and Health Canada).

An outbreak of hepatitis E was reported from Equateur Province in July 2006, resulting in 341 cases and 13 deaths by October (see ProMED-mail, October 18, 2006). Hepatitis E is a viral infection of the liver transmitted by contaminated food or water. The fatality rate is particularly high in pregnant women. There is no vaccine or treatment.

An outbreak of typhoid fever was reported from Kinshasa between September 2004 and January 2005, resulting in 42,564 cases as of January 11, including 696 cases of peritonitis and 214 deaths. Most cases occurred in the suburbs of Kimbanseke, Kikimi, Masina and Ndjili, which had already been affected by a major outbreak of E.coli in May 2004. The typhoid outbreak appears to have been related to unsanitary drinking water. For further information, go to the World Health Organization.

An outbreak of influenza was reported from Kinshasa in January-February 2003, resulting in more than 20,000 cases and 170 deaths. A previous influenza outbreak was reported in October 2002 from Bosobolo, Gbadolite, Gemena, and Karawa health areas in Equateur Province, causing more than 5000 cases and more than 700 deaths. Influenza vaccine is recommended for all travelers to the Democratic Republic of the Congo. For further information, go to the World Health Organization.

African trypanosomiasis (sleeping sickness) is occurring in increasing numbers due to civil war, population displacement, and a breakdown in public health systems (see ProMED-mail). Most cases are reported from Equateur and Bandundu. The disease is transmitted by the bite of tsetse flies. Travelers to rural areas are at risk for infection. 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.

Marburg fever has been reported in Watsa Zone in the northeastern part of the country, chiefly among gold miners. The most recent outbreak, which began in May 1999 and continued through September 2000, was localized to Durba, Province Orientale, and linked to the gold mine there. A total of 154 cases were identified, most of them fatal. Approximately half the cases occurred in miners and half in those who had close contact with someone already infected. The outbreak ended when the mine was closed. See the DG Bausch, "Marburg Hemorrhagic Fever Associated with Multiple Genetic Lineages of Virus" (NEJM 2006; 355:909-919) for further information.

Schistosomiasis is frequently observed in expatriates who have been swimming, wading, rafting, or bathing in contaminated fresh water. A recent study from Belgium showed that a majority of the cases occurring in expatriates had been acquired in Lake Katebe or Lake Wasela, which are the upstream and downstream parts of a large artificial lake complex on the upper course of the Lualaba river, the lake Nzilo (formerly Lake Delcommune). The lake complex is situated northeast from the main Kolwezi mining sites in south Katanga. Most of the other infections were acquired after bathing in Kalemie, Lake Tanganyika (North Katanga province) or the northern shore of Lake Kivu, near Goma. Bobandana Bay, east of Goma city, has been a well-known focus of schistosomiasis since colonial times. See Eurosurveillance for further information. 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
• Crimean-Congo hemorrhagic fever (chiefly among those who work with livestock)
• Rift Valley Fever
• Tick-borne relapsing fever
• Brucellosis (low incidence)

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.

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. In rural or forested areas, perform a thorough tick check at the end of each day 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.

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 the 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.

Medical facilities are limited and medications are in short supply. Many expatriates use the Centre Privé d'Urgences (CPU) (corner of Avenue du Commerce and Avenue Bas-Congo; Starcel: 20875 or 20876). The CPU has the best equipped emergency room in the country, but requires a quarterly or annual membership fee. Costs are high for non-members. You may wish to contact the CPU upon arrival. 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.

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.

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 the Democratic Republic of the Congo.

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 the Democratic Republic of the Congo. 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.

Americans living or traveling in Congo-Kinshasa are encouraged to register with the nearest U.S. Embassy or Consulate through the State Department's travel registration website, https://travelregistration.state.gov, and to obtain updated information on travel and security within Congo-Kinshasa. Americans without Internet access may register directly with the nearest U.S. Embassy or Consulate. By registering, American citizens make it easier for the Embassy or Consulate to contact them in case of emergency. The U.S. Embassy is located at 310 Avenue des Aviateurs, tel. 243-081-225-5872 (do not dial the zero when calling from abroad). Entrance to the Consular Section of the Embassy is on Avenue Dumi, opposite the Ste. Anne residence. The Consular Section of the Embassy may be reached at tel. 243-081-884-6859 or 243-081-884-4609; fax 243-081-301-0560 (do not dial the first zero when calling from abroad). Cellular phones are the norm, as other telephone service is often unreliable.

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.