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 trimethoprim-sulfamethoxazole one double-strength tablet twice daily or azithromycin (Zithromax) 500 mg once daily.Trimethoprim-sulfamethoxazole should not be given to pregnant women or those with a history of sulfa allergy. Azithromycin should be avoided in those allergic to erythromycin or related antibiotics. An antidiarrheal drug such as diphenoxylate (Lomotil) (PDF) or loperamide (Imodium) 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 Kenya game parks: prophylaxis is recommended for travel to all areas, except Nairobi. Malaria epidemics frequently occur during the rainy season, which begins in April, but transmission occurs year-round. There is little malaria risk in the highlands (above 2500 m) of Central, Eastern, Nyanza, Rift Valley, and Western Provinces. 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, go to the Kenya Malaria Information Service and Roll Back Malaria.

All children should be up-to-date on routine childhood immunizations, as recommended by the American Academy of Pediatrics, prior to international travel. For children less than one year of age or children who are behind in their immunizations, see the accelerated immunization schedule. The following are the recommended vaccinations for Kenya game parks:

Hepatitis A vaccine is recommended for all travelers over age two. 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.

Certain lots of VAQTA were recalled in December 2001 because some prefilled syringes were found not to contain enough antigen. Those who received VAQTA between August 1999 and December 2001 should go to hepatitis A to determine whether or not they may require reimmunization.

Travelers who are less than two years old, are pregnant, or have less than two weeks before departure should receive a single intramuscular dose of gammaglobulin (see hepatitis A for dosage) instead 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 recommended for all travelers greater than nine months of age. The vaccine is required for all travelers greater than one year of age arriving from a yellow-fever-infected country in Africa or the Americas. 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). 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.

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 (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.)

Several cases of African trypanosomiasis (sleeping sickness) have recently been reported among visitors to game parks in East Africa. See Emerging Infectious Diseases for further information. African trypanosomiasis is a potentially fatal parasitic infection transmitted by the bite of the tsetse fly. 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. Also, travelers should avoid riding in the back of open vehicles, since dust may attract tsetse flies, and should take care not to disturb bushes (where tsetse flies rest) during the warmer parts of the day. Insect repellents are ineffective. For further information on personal protection measures, go to Health Canada.

Schistosomiasis may be acquired from exposure to bodies of fresh water. In 1984, acute schistosomiasis developed in a group of 15 American students traveling in Kenya, two of whom became paraplegic from transverse myelitis (inflammation of the spinal cord due to deposition of schistosomal eggs.) (See Acute Schistosomiasis with Transverse Myelitis in American Students Returning from Kenya, MMWR August 10, 1984 / 33(31); 445-7). Swimming and bathing precautions are strongly advised (see below).

Rift Valley Fever reached epidemic levels in late 1997 and early 1998 after torrential rains and severe flooding. Cases were confirmed in the North Eastern, Eastern, Central, and Rift Valley provinces. The outbreak also involved livestock, including sheep, goats, camels and cattle. The disease is generally transmitted by mosquitoes, but may also be acquired by direct contact with infected animals or their tissues. Insect protection measures are essential. (See CDC report "Outbreak of Rift Valley Fever-Kenya and Somalia", January 1998, and "An outbreak of Rift Valley Fever, Eastern Africa, 1997-1998"(PDF). Weekly Epidemiological Record, Vol. 73, 15 1998.)

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)
• Cutaneous and diffuse cutaneous leishmaniasis (transmitted by sandflies)

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.

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 25-35% DEET (N,N-diethyl-3-methylbenzamide) to clothing and exposed skin (but not to the eyes, mouth, or open wounds). For children between 2 and 12 years of age, use preparations containing no more than 10% DEET and apply sparingly. Do not use DEET-containing compounds on children less than two years of age. Preparations containing a higher concentration of DEET carry an increased risk of neurologic toxicity, especially in children. 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.

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.

For an online list of physicians, hospitals, and ambulance services in Kenya, go to the U.S. Embassy website.

Adequate medical services are available in Nairobi.

On November 28, 2002, there was a car bomb attack on a hotel in Mombasa, Kenya, in which 15 people were killed, and an unsuccessful attempt to shoot down an Israeli charter plane departing Mombasa. These incidents have highlighted the continuing threat posed by terrorism in East Africa and the capacity of terrorist groups to carry out attacks. U.S. citizens should be aware of the risk of indiscriminate attacks on civilian targets in public places, including tourist sites and other sites where Westerners are known to congregate, especially in the coastal region.

Successful presidential and parliamentary elections were held in December 2002 with minimum reports of violence.

Travelers should maintain security awareness at all times and avoid public gatherings and street demonstrations.

The area near Kenya's border with Somalia has been the site of a number of incidents of violent criminal activity, including kidnappings. In a late 1998 attack by armed bandits at a resort in the Lamu district near the border with Somalia, U.S. citizens were identified as specific targets, although none were present. There are some indications of ties between Muslim extremist groups, including Osama Bin Laden's al Qaeda organization, and these roving groups of Somali gunmen. Recent information about possible targeting of Americans for kidnapping or assassination in this same area has heightened the Embassy's concern. In March 1999, a U.S. citizen was killed, reportedly by a Somali national, on the Somali side of the border area.

Some sparsely populated rural areas of Kenya, principally in the North, experience recurrent, localized incidents of violent cattle rustling, counter-raids, ethnic conflict, tribal or clan rivalry, and armed banditry. During the past several years, incidents have occurred in the Keiro Valley, Northern Rift Valley sections of Laikipia and Nakuru Districts, and other areas north of Mount Kenya. A number of incidents have also occurred near the game parks or lodges north of Mwingi, Meru, and Isiolo frequented by tourists. The precise areas tend to shift with time. For these reasons, U.S. citizens who plan to visit Kenya are urged to take basic security precautions to maximize their safety. Travel to northern Kenya should be undertaken with at least two vehicles to ensure a backup in the case of a breakdown or other emergency.

Villagers in rural areas are very suspicious of all strangers. There have been several incidents of violence against Kenyan and foreign adults in rural areas who are suspected of stealing children. U.S. visitors to rural areas should be aware that close contact with children, including taking their pictures or giving them candy, can be viewed with deep alarm and may provoke panic and violence. Adoptive parents traveling with their adopted child should exercise particular caution and are urged to carry complete copies of their adoption paperwork with them at all times.

On August 7, 1998, terrorists bombed the U.S. Embassy in Nairobi, killing 213 people and injuring many more in and around the Embassy. The U.S. Embassy subsequently relocated to a different location.

While in a foreign country, U.S. citizens may encounter road conditions that differ significantly from those in the United States. The information below concerning Kenya is provided for general reference only and may not be totally accurate in a particular location or circumstance.

Safety of public transportation: poor
Urban road conditions/maintenance: poor
Rural road conditions/maintenance: poor
Availability of roadside assistance: poor

In Kenya, one drives on the left side of the road, which can be very disorienting to those not accustomed to it. Excessive speed, unpredictable local driving habits and manners, poor vehicle maintenance, and the lack of basic safety equipment on many vehicles are daily hazards on Kenyan roads. When there is a heavy traffic jam either due to rush hour or because of an accident, drivers will drive across the median strip and drive directly toward oncoming traffic. There are often fatal accidents involving long-distance, inter-city buses, or local buses. Also, vehicle travel outside major cities at night should be avoided due to the poor road and street light conditions, and the threat of banditry.

During the rainy season, many unpaved roads are passable only with four-wheel drive vehicles with high clearance. Severe storms and heavy rains in late 1997 and early 1998 led to extensive flooding and critical damage to roads and bridges, making travel and communications difficult in many parts of the country. Although the government repaired many of the damaged roads and bridges, some are still impassable. Travelers are urged to consult with the U.S. Embassy in Nairobi and local officials regarding road conditions.

For additional general information about road safety, including links to foreign government sites, see the Department of State, Bureau of Consular Affairs' website at http://travel.state.gov/road_safety.html. For specific information concerning Kenyan driving permits, vehicle inspection, road tax and mandatory insurance, contact the Kenyan National Tourist Organization offices in New York at telephone 212-486-1300 or in California at telephone 310-274-6635.

There has been an increase in armed banditry in or near many of Kenya's national parks and game reserves, particularly the Samburu, Leshaba, and Masai Mara game reserves. In response, the Kenya Wildlife Service and police have taken some steps to strengthen security in the affected areas, but the problem has not been eliminated. Travelers who do not use the services of reputable travel firms or knowledgeable guides or drivers are especially at risk. Safaris are best undertaken with a minimum of two vehicles so that there is a backup in case of mechanical failure or other emergency. Camping alone is always risky.

Local tap water is not potable. Sealed bottled water is safe to drink, and it can be purchased in hotels, restaurants, and grocery stores.

Kenya Telephone and Telegraph has discontinued its "collect call" facility. 1-800 numbers cannot be accessed from Kenya. Use of international long-distance calling cards is very limited in Kenya. International long-distance costs from Kenya are significantly higher than corresponding long-distance rates in the United States. Several local companies offer computer Internet access, including an hourly rate basis. Many hotels have facsimile machines, but they often limit their access to guests; some facsimile services are also available at office supply shops. Travelers are urged to consider their method of maintaining contact with family and friends when making their pre-travel preparations.

U.S. citizens visiting or resident in Kenya are encouraged to register with the U.S. Embassy, where they may obtain updated information on travel and security in Kenya. Security updates are e-mailed to all registered Americans on a monthly basis. American citizens may complete a registration form on-line at http://kenya.usembassy.gov/wwwhcop.html or may request one by contacting the Embassy by phone at (254)(20)363-6000 or email at kenya_acs@state.gov. Biographic information,passport data, and itinerary may be faxed directly to the consular section at (254)(20)363-6410.

The Embassy is located on United Nations Avenue, Gigiri, Nairobi, Kenya; telephone (254)(20)363-6000; facsimile (254)(20)363-6410. In the event of an after-hours emergency, the Embassy duty officer may be contacted at (254)(20)363-6170. The Embassy's international mailing address is P.O. Box 606 Nairobi, Kenya. Mail using U.S. domestic postage may be addressed to Unit 64100, APO AE 09831. The Embassy home page is http://kenya.usembassy.gov.

This Travel Warning is being issued to inform American citizens that the Department of State has lifted the authorized departure status of non-emergency employees and family members at the U.S. Embassy in Nairobi, Kenya. However, the Department continues to alert U.S. citizens to ongoing safety and security concerns in Kenya. This supersedes the Travel Warning of May 16, 2003.

The Department of State has rescinded the authorized departure of non-emergency employees and family members of the U.S. Embassy in Kenya. However, due to ongoing security concerns, the Department continues to urge Americans to defer all non-essential travel to Kenya at this time. The Department recommends that private American citizens in Kenya evaluate their personal security situation in light of the current terrorist threat and consider departure from the country as one option to ensure their safety.

The U.S. Government continues to receive indications of terrorist threats in the region aimed at American and western interests, including civil aviation. The government of Kenya might not be able to prevent such attacks.

The threat to aircraft by terrorists using shoulder-fired missiles continues in Kenya, including Nairobi. Terrorism poses a continuing threat in East Africa. Terrorist actions may include suicide operations, bombings, or kidnappings. U.S. citizens should be aware of the risk of indiscriminate attacks on civilian targets in public places including tourist sites and locations where westerners are known to congregate, as well as commercial operations associated with U.S. or western interests.

American citizens in Kenya should remain vigilant, particularly in public places frequented by foreigners such as hotels, shopping malls, restaurants, and churches, and should also avoid demonstrations and large crowds. In particular, there is an increased threat against westerners in the capital, Nairobi, and the coastal region.

U.S. citizens who remain in Kenya despite this Travel Warning should consult the Department of State’s Consular Information Sheet for Kenya, the East Africa Public Announcement, and the Worldwide Caution Public Announcement, which are available via the Internet at travel.state.gov. American citizens may obtain up-to-date information on security conditions by calling 1-888-407-4747 toll-free in the United States, or 317-472-2328 from overseas.

U.S. citizens visiting or resident in Kenya are encouraged to register with the U.S. Embassy. Security updates are e-mailed to all registered Americans monthly. American citizens may complete a registration form on-line at http://usembassy.state.gov/nairobi/wwwhcon3.html or may request one by email at: kenya_acs@state.gov. American citizens living or traveling in Kenya may contact the U.S. Embassy in Nairobi at 363-6000 during normal business hours; after-hours phone numbers are 363-6170 and 0722-514-246.