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 South Africa: prophylaxis is recommended for travel to low-altitude areas of the Mpumalanga Province (including Kruger Natonal Park), Northern Province, and northeastern KwaZulu-Natal as far south as the Tugela River. Risk is highest from October to May. 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 on malaria in South Africa, including a map showing the risk of malaria in different parts of the country, go to the World Health Organization and Southern Africa Malaria Control.

The following are the recommended vaccinations for South Africa:

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.

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.

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. Most reported in South Africa are from the Eastern Cape province. 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.

Yellow fever vaccine is required for all travelers greater than one year of age arriving from a yellow-fever-infected country in Africa or the Americas or from a country in the endemic zones. 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.

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, despite a recent cholera outbreak, as described 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 alert for paralytic shellfish poisoning was issued in April 2008 for the West Coast of South Africa (north of Cape Point). Shellfish, oysters and abalone from this area should not be collected or consumed until further notice. For details, go to ProMED-mail (April 9, 2008).

Outbreaks of Rift Valley fever, a viral infection that primarily affects domesticated animals but may spread to humans, are periodically reported from South Africa. Between January and June 2008, outbreaks affecting cattle, buffalo, and goats were confirmed in the provinces of Mpumalanga, North West, Gauteng, and Limpopo, leading to 18 human cases. Rift Valley fever is usually transmitted by mosquitoes, but may also be acquired by direct exposure to infected animals or their tissues or by consumption of raw milk. Aerosol transmission has been documented. Most cases occur in those who work with livestock. Initial symptoms may include fever, chills, muscle aches, backache, headache, nausea, vomiting, and light sensitivity. Most people recover uneventfully in four to seven days, but the course may be complicated by loss of vision (retinitis), liver inflammation (hepatitis), kidney failure, excessive bleeding (hemorrhage), inflammation of the brain (encephalitis), or death. Most of the livestock outbreaks in South Africa are not associated with human cases. An outbreak among wild animals in and near the Kruger National Park in February 1999 led to three human cases, all mild. Human outbreaks of Rift Valley fever were also reported in 1974-1976 and 1981. Travelers to affected areas should follow insect protection measures, as below, and avoid direct contact with livestock.

A rabies outbreak was reported from Limpopo and KwaZulu-Natal in 2007, resulting in 42 fatalities in the first nine months of the year. In South Africa, the rabies virus is carried chiefly by dogs, yellow mongooses, black-backed jackals, and bat-eared foxes. See ProMED-mail (September 11, 2007) for details. As above, 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.

An outbreak of paralytic shellfish poisoning was reported in March 2007 among people who had eaten seafood from the coast at Lamberts Bay, apparently caused by a red tide. Until further notice, shellfish harvested from the Cape West coast and False Bay should not be consumed. See ProMED-mail (March 25, 2007) for further information.

An outbreak of myiasis, which is a skin infection caused by the Tumbu fly, was reported from the Northwest Province in February 2006. See ProMED-mail (February 13, 2006) for details.

An outbreak of typhoid fever was reported in September 2005 from Delmas, Mpumalanga, most likely due to contamination of tap water. For further information, see ProMED-mail (September 12 and September 22, 2005). Typhoid vaccine is recommended for all travelers to South Africa.

A cholera outbreak was reported in February 2004 from Nkomazi area, Mpumalanga province, resulting in 179 cases and 5 deaths as of February 11. A much larger outbreak began in August 2000, resulting in 106,159 cases and 232 deaths as of the end of 2001. The outbreak affected the Empangeni area in northern KwaZulu-Natal, made up of the Lower Umfolozi districts, which include Hlabisa and Ngwelezane and the Eshowe/Nkandla area, as well as the lower South Coast mainly in the KwaDukuza/Stanger area and Ugu Region/South Coast. Illness occurred in those using water directly from rivers and dams. Municipal water in KwaZulu-Natal is safe. For further information, go to the World Health Organization. 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 Crimean-Congo hemorrhagic fever was reported in 1996 among workers at an ostrich slaughterhouse in Oudtshoorn, Western Cape Province. Cases of Crimean-Congo hemorrhagic fever occur sporadically in South Africa, chiefly in Karoo, the Western Free State, the Northern Cape and North West province. Most of those affected are farmers, farm laborers, hunters or abattoir workers.

• Schistosomiasis (swimming and bathing precautions strongly advised)
• Marburg fever (reported in 1975)
• Tick-borne relapsing fever
• African tick bite fever (reported among travelers to the Bongani Game Reserve on the southern border of Krueger National Park; see ProMED-mail April 10, 2002 for details)
• West Nile fever (transmitted by mosquitoes)
• Brucellosis (the most common animal source is infected cattle)
• Anthrax (outbreaks reported from the Northern Cape province in March 2008 and from the North West province in 2002)

Plague has not been reported in recent years, but foci persist in the rodent population. The plague is usually transmitted by the bite of rodent fleas. Less commonly, the disease is acquired by inhalation of infected droplets, which may be coughed into the air by a person with plague pneumonia, or by direct exposure to infected blood or tissues. Most travelers are at low risk for the plague. Those who may have contact 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.

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.

For statistical information regarding many infectious diseases, go to the Department of Health website.

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. 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.

Good medical care is available at private clinics in the major urban areas and in the vicinity of game parks, but may be difficult to obtain elsewhere. The Travel Doctor Group (TVMC), which is based in Australia, has clinics in most major cities, including Bloemfontein, Cape Town, Durban, George, Johannesburg (Roosevelt Park, Sandton, Morningside), Nelspruit, Port Elizabeth, Pretoria (Hatmed and Menlyn), Richards Bay, Secunda, Somerset West, Springs, Stellenbosch, Vanderbiljpark, and Vereeniging. See their website at www.traveldoctor.co.za for addresses and phone numbers. In Durban, medical care for travelers is also provided by the SAA-Netcare Travel Clinic, located in the Medicross Medical Centre in Pinetown (corner of Old Main and Meller Rds; ph. 031-7093070). Pharmacies are well-supplied. Many 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).

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.

International travel should be avoided by pregnant women with underlying medical conditions, such as diabetes or high blood pressure, or a history of complications during previous pregnancies, such as miscarriage or premature labor. For pregnant women in good health, the second trimester (18–24 weeks) is probably the safest time to go abroad and the third trimester the least safe, since it's far better not to have to deliver in a foreign country.

Before departure, make sure you have the names and contact information for physicians, clinics, and hospitals where you can obtain emergency obstetric care if necessary. In general, pregnant women should avoid traveling to countries which do not have modern facilities for the management of premature labor and other complications of pregnancy.

As a rule, pregnant women should avoid visiting areas where malaria occurs. 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 malarious areas 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.

Strict attention to food and water precautions is especially important for the pregnant traveler because some infections, such as listeriosis, have grave consequences for the developing fetus. Additionally, many of the medications used to treat travelers' diarrhea may not be given during pregnancy. Quinolone antibiotics, such as ciprofloxacin (Cipro) and levofloxacin (Levaquin), should not be given because of concern they might interfere with fetal joint development. Data are limited concerning trimethoprim-sulfamethoxazole, but the drug should probably be avoided during pregnancy, especially the first trimester. Options for treating travelers' diarrhea in pregnant women include azithromycin and third-generation cephalosporins. For symptomatic relief, the combination of kaolin and pectin (Kaopectate; Donnagel) appears to be safe, but loperamide (Imodium) should be used only when necessary. Adequate fluid intake is essential.

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 in or visiting South Africa are encouraged to register at the Consular Section of the nearest U.S. consulate and obtain updated information on travel and security within South Africa. The U.S. Embassy is located at 877 Pretorius Street, Arcadia in Pretoria, telephone (27-12) 431-4000 (from South Africa 012-431-4000), fax (27-12) 431-5504 (from South Africa 012-431-5504). The U.S. Embassy web site is http://usembassy.state.gov/pretoria/.

The U.S. Consulate General in Johannesburg provides most consular services for Americans in the Pretoria area. The Consulate General in Johannesburg is located at No. 1 River Street (corner of River and Riviera Road ), Killarney, Johannesburg, telephone (27-11) 644-8000 (from South Africa 011-644-8000), fax (27-11) 646-6916 (from South Africa (011-646-6916). Its consular jurisdiction includes Gauteng, Mpumalanga, Limpopo, NorthWest, and Free State provinces.

The Consulate General in Cape Town is located at Broadway Industries Center, Heerengracht, Foreshore, telephone (27-21) 421-4280 (from South Africa 021-421-4280), fax (27-21) 425-3014 (from South Africa 021-425-3014). Its consular jurisdiction includes Western Cape, Eastern Cape, and Northern Cape provinces.

The Consulate General in Durban is located at the Old Mutual Building, 31st floor, 303 West Street, telephone (27-31) 305-7600 (from South Africa 031-305-7600), fax (27-31) 305-7691 (from South Africa 031-305-7691). Its consular jurisdiction includes KwaZulu-Natal Province.

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.