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Sudan
Summary of recommendationsMedicationsImmunizations
Recent outbreaksOther infectionsFood and water precautions
Insect and Tick ProtectionSwimming and bathing precautionsGeneral advice
Medical facilitiesTraveling with childrenTravel and pregnancy
MapsEmbassy/Consulate LocationSafety information

 

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Summary of recommendations:

All travelers should visit either their personal physician or a travel health clinic 4-8 weeks before departure.

Malaria: Prophylaxis with Lariam (mefloquine), Malarone (atovaquone/proguanil), or doxycycline is recommended for all areas.
Vaccinations:

Hepatitis A

Recommended for all travelers

Typhoid

Recommended for all travelers

Yellow fever

Recommended for all areas south of the Sahara Desert. Not recommended for the city of Khartoum. Required for travelers arriving from a country with risk of yellow fever transmission.

Meningococcus

Recommended for all travelers

Polio

One-time booster recommended for any adult traveler who completed the childhood series but never had polio vaccine as an adult

Hepatitis B

Recommended for all travelers

Rabies

For travelers spending a lot of time outdoors, or at high risk for animal bites, or involved in any activities that might bring them into direct contact with bats

Measles, mumps, rubella (MMR)

Two doses recommended for all travelers born after 1956, if not previously given

Tetanus-diphtheria

Revaccination recommended every 10 years

Medications

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) 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 Sudan: prophylaxis is recommended for all travelers. Risk is lowest in the northern part of the country and higher along the Nile south of Lake Nasser and in the central and southern part of the country. Malaria risk on the Red Sea coast is very limited. 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 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 Sudan, including a map showing the risk of malaria in different parts of the country, go to Roll Back Malaria and WHO-EMRO Roll Back Malaria.

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Immunizations

The following are the recommended vaccinations for Sudan:

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

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

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

Yellow fever vaccine is recommended for all travelers greater than nine months of age going to areas south of the Sahara Desert (see map). The vaccine is not recommended for travelers whose itineraries are limited to areas in the Sahara Desert Desert and the city of Khartoum (see map). The vaccine is required for travelers greater than nine months of age arriving from a country in Africa or the Americas with risk of yellow fever transmission. Proof of immunization may also be required for travelers leaving Sudan.

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 six months of age, immunocompromised, or allergic to eggs (since the vaccine is produced in chick embryos). It should also not be given to those with a malignant neoplasm and those with a history of thymus disease or thymectomy. Caution should be exercised before giving the vaccine to those who are between the ages of 6 and 8 months, age 60 years or older, pregnant, or breastfeeding. 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 a recent nationwide polio outbreak (see "Recent outbreaks" below). Any adult who received the recommended childhood immunizations but never had a booster as an adult should be given a single dose of inactivated polio vaccine. All children should be up-to-date in their polio immunizations and any adult who never completed the initial series of immunizations should do so before departure. 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 travelers, especially if prolonged contact with the populace is likely (see "Recent outbreaks" below). Meningococcal vaccine has few side-effects. Mild redness at the injection site may occur. Young children may develop transient fever.

Hepatitis B vaccine is recommended for all travelers if not previously vaccinated. 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 for travelers spending a lot of time outdoors, for travelers at high risk for animal bites, such as veterinarians and animal handlers, for long-term travelers and expatriates, and for travelers involved in any activities that might bring them into direct contact with bats. Children are considered at higher risk because they tend to play with animals, may receive more severe bites, or may not report bites. A complete preexposure series consists of three doses of vaccine injected into the deltoid muscle on days 0, 7, and 21 or 28. Side-effects may include pain at the injection site, headache, nausea, abdominal pain, muscle aches, dizziness, or allergic reactions.

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

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

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

Cholera vaccine is not generally recommended, despite a recent cholera outbreak (see "Recent outbreaks"), 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.

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Recent outbreaks

A cholera outbreak was reported from South Sudan in May 2014, causing almost 900 cases and at least 27 deaths by the end of the month. 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. The outbreak in South Sudan was related to the ongoing civil war, in particular to poor sanitation in overcrowded refugee camps. 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.

In May 2010, a cholera outbreak was reported from Northern Bahr el Ghazal State. A major cholera outbreak was reported in June 2008 from southern Sudan, resulting in over 9000 cases and at least 44 deaths by September. The number of cases started to increase again in November after flooding. In February 2006, a major cholera outbreak started in Yei and Juba in southern Sudan and spread rapidly to six out of ten states. By April 2006, the outbreak had spread to the northern part of the country. As of late August, almost 25,000 cases and more than 700 deaths had been identified. A majority of the cases occurred in the states of Khartoum and North Kordofan. Cases were also reported from the states of White Nile, South Darfur, South Kordofan, Kassala, Red Sea, Al Gezira and River Nile. See the World Health Organization, Health Action in Crises, AlertNet, and the International Federation of Red Cross and Red Crescent Societies for further information. In August 2006, cholera outbreaks were also reported from camps for internally displaced persons (IDPs) in the western Sudanese region of Darfur, as well as urban areas. In September 2006, a cholera outbreak was reported from Mornay in western Darfur, a small village which had been flooded with refugees.

An outbreak of yellow fever, a life-threatening viral infection transmitted by mosquitoes, was reported in October 2013 from West and South Kordofan states, causing 44 suspected cases, including 14 deaths, by December. Some of the cases were laboratory-confirmed (see the World Health Organization). In November 2012, a yellow fever outbreak was reported from Darfur, causing 849 suspected cases, including 171 deaths, as of January 2013. Most of the cases were reported from Central, South, and West Darfur (see the World Health Organization and ProMED-mail). Yellow fever vaccine is strongly recommended for all travelers to Sudan. Insect protection measures (see below) are also essential.

In November 2005, a yellow fever outbreak was reported from South Kordofan State, chiefly affecting Abu Gebiha, Rashad, Dilling, Kadugli, and Talodi. As of December 19, a total of 583 cases and 144 deaths had been identified. See the World Health Organization and the WHO Country Office in Sudan for details. A previous yellow fever outbreak was reported in May 2003 from the Imatong and Ikotos districts, Torrit county, in the southeastern part of the country, causing 178 cases and 27 deaths as of May 27. For further information, go to Emerging Infectious Diseases and the World Health Organization. Yellow fever vaccine is recommended for all travelers to Sudan.

A polio outbreak was reported from South Sudan in September 2013, causing two cases in Northern Bahr el Ghazal State and one in Eastern Equatoria State. A polio outbreak in early 2009 caused 11 cases, chiefly in the southern part of the country, though two cases were reported from the north (in Khartoum and Port Sudan). A polio outbreak which began in May 2004 resulted in 105 cases as of January 2005 (see the World Health Organization). The outbreak appeared to have been controlled by August 2005, but a new case was reported in October 2007, which may have spread from neighboring Chad. A one-time polio booster is recommended for any adult traveler who received the recommended childhood immunizations but never had polio vaccine as an adult. Children should be fully immunized against polio before traveling to the Sudan.

An outbreak of hepatitis E was reported in January-February 2014 from the El Sareif locality in North Darfur, causing 2572 cases and 34 deaths. The most affected areas were the villages of Abuseniena and Umjamina, where displaced people have settled. In May 2013, a hepatitis E outbreak occurred in two refugee camps in North Darfur. In November 2012, a hepatitis E outbreak was reported from four Maban County refugee camps in South Sudan (Doro, Gendrassa, Jamam, and Yusuf Batil), causing more than 5000 cases and more than 100 deaths by February 2013. In May 2004, a hepatitis E outbreak was reported from Darfur, resulting in 6861 suspected cases and 87 deaths by September. Most of the deaths occurred in pregnant women, who are particularly susceptible to hepatitis E. Hepatitis E is transmitted by consumption of fecally contaminated water. Outbreaks typically occur when basic sanitation is not maintained, as has occurred during the present crisis. For further information, go to ProMED-mail and the World Health Organization.

An outbreak of visceral leishmaniasis (kala-azar) was reported from southern Sudan in October 2009, starting in the states of Upper Nile and Jonglei and spreading to to the states of Eastern Equatoria and Unity. The counties of Old Fangak and Ayod were particularly affected. As of October 2011, more than 18,000 cases and 720 deaths had been reported. A major outbreak of visceral leishmaniasis was also reported from southern Sudan in November 2002, which was attributed to lack of access to health care due to the ongoing civil war. An outbreak was reported from Al Qadarif state in April 2011, causing more than 5550 cases (see ProMED-mail, November 10 and 17, 2002; November 7, 2009; August 8 and October 9, 2010; and April 11, 2011, and The Lancet Infectious Diseases). Leishmaniasis is a parasitic infection transmitted by sandflies. In its visceral form, the disease is characterized by fever, weight loss, anemia, and enlargement of the liver and spleen developing over months to years. The infection is widespread in the eastern and southern parts of the country. There is no vaccine. Insect protection measures, as below, are strongly recommended.

A measles outbreak was reported from Unity State in southern Sudan in January 2011, causing 95 cases and four deaths, mostly in Mayom County. A measles outbreak was also reported from southern Sudan in August 2008, killing at least 22 people. The hardest-hit area was Maiwut County in the northeastern Upper Nile state (see ProMED-mail, August 22, 2008, and January 20, 2011). All travelers born after 1956 should make sure they have had either two documented MMR or measles immunizations or a blood test showing measles immunity. Those born before 1957 are presumed to be immune. 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 traveling to Sudan.

An outbreak of acute hemorrhagic conjunctivitis caused by coxsackievirus A24v was reported from southern Sudan, affecting thousands of people. Symptoms include Symptoms subconjunctival hemorrhage ("pink-eye"), foreign-body sensation, light sensitivity, and discharge, and usually resolve within 1-2 weeks. Treatment is symptomatic. The key to prevention is good personal hygiene and scrupulous hand-washing. See the Centers for Disease Control for further information.

An outbreak of Rift Valley fever was reported in November 2007 from Gazeera, Kassala, Khartoum, River Nile, Sinnar, and White Nile states in central and eastern Sudan, resulting in 698 cases and 222 deaths as of January 15, 2008. A majority of the cases occurred in Gazeera state. As of January, the outbreak appeared to be subsiding. No new cases have been reported since January 5, 2008 (see the World Health Organization and ProMED-mail; November 3, 2007). Rift Valley fever is a viral infection that primarily affects domesticated animals. The disease is usually transmitted by mosquitoes or by direct exposure to infected animals or their tissues, but may also be acquired by consumption of raw milk. Aerosol transmission has been documented. Most cases occur in those who work with livestock. The incubation period ranges from two to six days. 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. Travelers to affected areas should follow insect protection measures, as below, and avoid direct contact with livestock.

Outbreaks of meningococcal disease occur regularly in Sudan. The most recent outbreak was reported from South Sudan in June 2013, causing 196 cases and 13 deaths (see ProMED-mail, June 6, 2013). An outbreak which began in January 2007, affecting 9 out of 10 states in southern Sudan, caused more than 11,000 suspected cases and more than 700 deaths by April, chiefly in the counties of Aweil West, Juba, Mundri East, Rumbek, Tonj South, Wulu and Yirol. At about the same time, a smaller outbreak in northern Sudan caused 775 cases and 43 deaths (see the World Health Organization and ProMED-mail, January 26, February 3 and 13, and April 17 and 28, 2007). In November 2006, a meningococcal outbreak in Greater Yei County, Central Equatorial State of South Sudan, resulted in 231 suspected cases and 16 deaths (see the World Health Organization). The largest recent outbreak began in January 2006, causing almost 6000 suspected cases and more than 400 deaths. The outbreak reached epidemic levels in the states of West Darfur, Blue Nile, Gedarif, Kassala, South Kordofan and North Kordofan in the north, and Warab and Northern and Western Bahr-el Ghazal in the south. See the World Health Organization and Health Action in Crises for details. At about the same time, a smaller outbreak was reported from IDP camps in Zallingi, West Darfur State (see the World Health Organization). In March 2005, a meningococcal outbreak was reported from Sarf Omra, Kabkabia locality, North Darfur State, resulting in 71 suspected cases and five deaths (see the World Health Organization). In February 2005, an outbreak was reported from Blue Nile (199 cases), Gedarif (22 cases) and Khartoum States (29 cases) (see the World Health Organization). An epidemic that began in December 1998 caused 22,000 cases and 1600 deaths. Meningococcal vaccine is recommended for all travelers to Sudan.

Several outbreaks of H5N1 avian influenza ("bird flu") have been reported since May 2006 from poultry farms in the Sudan, most recently from Juba, Central Equatoria state, in September 2006. No human cases have been reported to date. Most travelers are at extremely low risk for avian influenza, since almost all human cases in other countries have occurred in those who have had direct contact with live, infected poultry, or sustained, intimate contact with family members suffering from the disease. The World Health Organization and the Centers for Disease Control do not advise against travel to countries affected by avian influenza, but recommend that travelers to affected areas should avoid exposure to live poultry, including visits to poultry farms and open markets with live birds; should not touch any surfaces that might be contaminated with feces from poultry or other animals; and should make sure all poultry and egg products are thoroughly cooked. A vaccine for avian influenza was recently approved by the U.S. Food and Drug Administration (FDA), but produces adequate antibody levels in fewer than half of recipients and is not commercially available. The vaccines for human influenza do not protect against avian influenza. Anyone who develops fever and flu-like symptoms after travel to the Sudan should seek immediate medical attention, which may include testing for avian influenza. For further information, go to the World Health Organization, Health Canada, the Centers for Disease Control, and ProMED-mail.

An outbreak of dengue fever was reported from the south Kordofan region of central Sudan in October 2005. See Alertnet for further information. Dengue fever is a flu-like illness which is sometimes complicated by hemorrhage or shock. The infection is transmitted by Aedes mosquitoes, which bite primarily in the daytime and favor densely populated areas, though they also inhabit rural environments. No vaccine is available at this time. Insect protection measures are strongly advised, as outlined below.

An outbreak of hepatitis E was reported from Darfur in May 2004, resulting in 6861 suspected cases and 87 deaths by September 17. A majority of the cases were reported from West Darfur state. Most of the deaths occurred in pregnant women, who are particularly susceptible to hepatitis E. Hepatitis E is transmitted by consumption of fecally contaminated water. Outbreaks typically occur when basic sanitation is not maintained, as has occurred during the present crisis. For further information, go to the World Health Organization.

An outbreak of shigellosis was reported in May 2004 from North Darfur in the Abu Shoak Internally Displaced Persons (IDP) camp, resulting in 1340 cases of bloody diarrhea with 11 deaths as of June 30. For further information, go to the World Health Organization.

An outbreak of Ebola hemorrhagic fever was reported in May 2004 from Yambio County in Western Equatoria, south Sudan, resulting in 17 cases and seven deaths before the outbreak ended in late June. Prior outbreaks were reported in 1976 and 1979. Ebola is a life-threatening viral infection that is generally acquired by direct contact with the blood or body fluids of infected persons. Those at greatest risk 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. No travel restrictions are recommended for the Sudan at this time. For further information, go to the World Health Organization and the Weekly Epidemiological Record.

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Other infections

African trypanosomiasis (sleeping sickness) is being reported in rising numbers. The disease is transmitted by the bite of tsetse flies and occurs mainly in rural lakeshore areas. Travelers to rural areas in the southern part of the country, where transmission is very high, are at greatest risk for infection. See the World Health Organization and West African Trypanosomiasis Resurging in Southern Sudan(CDC/NCID Vol. 6/No. 5/Sept-Oct 1997). 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.

An outbreak of louse-borne relapsing fever was reported from Rumbek county in southern Sudan in April 1999.

Outbreaks of Ebola hemorrhagic fever were reported in 1976 and 1979.

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

  • Schistosomiasis (approximately 2 million inhabitants affected; occurs throughout the country; highest prevalence in the state of North Kordofan; increased number of cases reported from South Darfur in May 2014; acquired by swimming, wading, or bathing in contaminated fresh water; see swimming and bathing precautions below)
  • Lymphatic filariasis
  • Onchocerciasis
  • Rift Valley fever (chiefly among persons in close contact with livestock)
  • Brucellosis (the most common animal source is infected cattle)
  • Dengue fever (reported from the northeastern part of the country; flu-like illness sometimes complicated by hemorrhage or shock; transmitted by mosquitoes)
  • Anthrax (outbreak of cutaneous anthrax reported from Western Bahr al-Ghazal state in March 2011, resulting in 83 cases by July; see ProMED-mail)

For further information on infectious diseases in the Sudan, go to the the WHO Country Office in Sudan.

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Food and water precautions

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.

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Insect and Tick Protection

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.

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Swimming and bathing precautions

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.

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General advice

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.

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Medical facilities

Medical care is extremely limited in Khartoum and virtually non-existent elsewhere. Essential medications and supplies may not be available. For a guide to physicians and dentists in Khartoum, go to the U.S. Embassy website. Most private clinics are open in the evenings, usually from 6 to 9 PM, except for Fridays and/or Sundays. 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.

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Traveling with children

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

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

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

The recommendations for malaria prophylaxis are the same for young children as for adults, except that (1) dosages are lower; and (2) 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.

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Travel and pregnancy

Because of the risk of malaria and yellow fever, pregnant women should not in general travel to the Sudan. 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.

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Maps

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.

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Embassy/Consulate Location

(reproduced from the U.S. State Dept. Consular Information Sheet)

There are no consular officers resident in Sudan. The U.S. Embassy's ability to provide consular services, including emergency assistance, is severely limited. U.S. citizens traveling to Sudan are encouraged to register with the U.S. Embassy in Khartoum and to obtain updated information on travel and security in Sudan. American travelers to southern Sudan are also encouraged to register with the U.S. Embassy in Nairobi, Kenya. The Embassy in Sudan is located at Sharia Ali Abdul Latif, Khartoum. The mailing address is P.O. Box 699, Khartoum. The telephone number is (249)183-774-701 (0183-774-701 inside Sudan ); fax (249)183-774-137 (0183-774-137 inside Sudan ). The workweek in Khartoum is Sunday through Thursday.

The Embassy in Kenya 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 Village Market, 00621 Nairobi, Kenya. Mail using U.S. domestic postage may be addressed to Unit 64100, APO AE 09831, USA.

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Safety information

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.

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