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Afghanistan
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 lower than 2000 meters (6,561 feet) if the travel is during the months of April through December.
Vaccinations:

Hepatitis A

Recommended for all travelers

Typhoid

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

Yellow fever

Required for all travelers arriving from a yellow-fever-infected area in Africa or the Americas. Not recommended otherwise.

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 Afghanistan: prophylaxis is recommended from April to December for all areas, except for altitudes greater than 2000 m (6561 ft). A total of 91 cases of malaria were diagnosed in American soldiers in the year 2011. 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.

An outbreak of malaria was reported from the province of Badghis in December 2002. For details, go to The Lancet Infectious Diseases. For further information on malaria in Afghanistan, go to Roll Back Malaria, WHO-EMRO Roll Back Malaria, and the World Health Organization - Eastern Mediterranean Region.

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Immunizations

The following are the recommended vaccinations for Afghanistan:

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 vaccine is recommended because of the persistence of polio in Afghanistan. Progress towards polio eradication has been slowed by the ongoing civil war. Any adult who completed the routine childhood immunizations but never received 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 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. A rabies outbreak related to rabid dog bites was reported in September 2010 from Titin Valley in Nuristan Province (see ProMED).

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

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

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

Cholera vaccine is not generally recommended, even though cholera is widespread in Afghanistan and outbreaks occur yearly, 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.

Yellow fever vaccine is required for all travelers arriving from a yellow-fever-infected country in Africa or the Americas, but is not recommended or required otherwise. 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. Yellow fever vaccine should not in general be given to those who are younger than nine months of age, pregnant, immunocompromised, or allergic to eggs. It should also not be given to those with a history of thymus disease or thymectomy.

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Recent outbreaks

A measles outbreak was reported in February 2012 from rural western Afghanistan, killing at least 20 children in Ghor and Badghis provinces (see ProMED-mail). All travelers born after 1956 should make sure they have had either two documented measles immunizations or a blood test showing measles immunity. This does not apply to people born before 1957, who are presumed to be immune to measles. 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 Afghanistan.

A fatal case of Crimean-Congo hemorrhagic fever occurred in an American soldier serving in Afghanistan in September 2009. In October 2012, a fatal case was reported from Scotland in a man who had arrived from Kabul. Outbreaks of Crimean-Congo hemorrhagic fever are regularly reported from Afghanistan. In August 2008, five cases, two of them fatal, were reported from Herat (see ProMED-mail; August 27, 2008, and September 19, 2009). An outbreak of acute hemorrhagic fever, compatible with Crimean-Congo hemorrhagic fever, was reported from an isolated village in Gulran district, Herat Province, in June-July 2000. Twenty-seven cases were reported, including 16 deaths (see World Health Organization). In March 1998, an outbreak was reported from the province of Takar in the northeastern part of the country, causing 19 cases and 12 deaths.

Crimean-Congo hemorrhagic fever is a life-threatening viral infection which is usually transmitted by ticks who have been feeding on infected animals (less commonly by direct contact with infected animals or rarely by exposure to an infected person). Initial symptoms may include fever, muscle aches, backache, joint pains, headaches, dizziness, and light sensitivity. Complications may result from hemorrhage into the skin, intestine, or other sites. Most cases occur in farm workers, who often remove ticks from farm animals without protecting themselves. Most travelers are at low risk. Tick precautions, as described below, are recommended for all travelers to Afghanistan.

Cases of polio continue to be reported from Afghanistan. A total of 14 cases were reported nationwide for the year 2013. The first case in Kabul since 2001 was reported in February 2014. For further information on polio in Afghanistan, go to the World Health Organization and NATHNAC. 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 Afganistan.

An cholera outbreak was reported from Kandahar and Zabul provinces in June 2011, causing at least 14 deaths by July. A cholera outbreak in September 2009 caused more than 600 cases nationwide, including Kabul. Local outbreaks were described in the northern province of Samangan and the eastern province of Nangarhar (see ProMED-mail). In October 2008, a cholera outbreak was reported from northern, eastern, and southeastern Afghanistan, chiefly affecting the provinces of Laghman, Nooristan, and Nangarhar in the east; Samangan and Faryab in the north; and Nimruz in the west. In June 2004, a cholera outbreak caused more than 3000 suspected cases and at least eight deaths (see the World Health Organization and ProMED-mail). A cholera outbreak in July 2001 affected more than 4000 people and caused more than 100 deaths. Cases were reported from the northern region (Khulm, Aibak), north-east region (Faizabad, Kunduz), eastern region, southern region and south-east region (see the World Health Organization). An outbreak in August 2000 involved the southern, western and northern regions in the provinces of Kandahar, Badghis and Jawzjan, including Saripul.

The main symptoms of cholera are profuse watery diarrhea and vomiting, which in severe cases may lead to dehydration and death. The disease is usually acquired by drinking water obtained from contaminated local sources, so most travelers are at low risk. Where available, cholera vaccine may be considered for high risk individuals, such as relief workers and health professionals.

An outbreak of typhoid fever was reported from central Ghor province in February 2007 (see ProMED-mail, February 15, 2007). Typhoid vaccine is recommended for all travelers to Afghanistan.

An outbreak of hepatitis E was reported in February 2007 from Laghman province in the eastern part of Afghanistan (see ProMED-mail, February 26, 2007). Hepatitis E virus is usually transmitted by contaminated drinking water. Symptoms may include fever, jaundice, malaise, nausea, vomiting, and abdominal pain. The illness usually resolves without complications, but may lead to fulminant hepatitis in pregnant women, resulting in a 15-20% fatality rate. There is no vaccine for hepatitis E. Tap water in Afghanistan should not be consumed unless purified.

Outbreaks of H5N1 avian influenza ("bird flu") were reported in February 2007 from turkey farms in the provinces of Nangarhar and Kunar in the northeastern part of the country. In March 2007, outbreaks were reported from the Shah Shahid area of Kabul and the southern province of Kandahar. 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 Centers for Disease Control and the World Health Organization do not advise against travel to countries affected by avian influenza, but recommend that travelers 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 Afghanistan 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 cutaneous leishmaniasis began in the mid-1990s and has been worsening. A number of cases have occurred in U.S. and U.K. military personnel. The outbreak is particularly severe in Kabul, where 65,000 cases were reported for the year 2009. An outbreak was reported from Khosan district of Herat province in October 2010. Cutaneous leishmaniasis is a chronic skin infection transmitted by sandflies, chiefly from May to October. The problem has been exacerbated by the ongoing war and by the lack of access to effective drugs. A small number of cases of visceral leishmaniasis, which causes fever, weight loss, anemia, and enlargement of the liver and spleen, have also been reported, including two cases in U.S. soldiers. Insect protection measures are strongly advised, as below. For further information, go to the World Health Organization, MMWR, Emerging Infectious Diseases, and The Lancet Infectious Diseases.

An outbreak of diphtheria was reported from the Zhare Dasht resettlement camp in Kandahar province, southern Afghanistan, in June 2003. As of August 9, a total of 50 cases and three deaths had been identified. Most cases occurred in children, including all three fatalities. For further information, go to the World Health Organization and ProMED-mail (August 9, 2003).

An outbreak of pertussis was reported in January 2003 from Khwahan district, the provincial capital of Badakhshan, in northeastern Afghanistan. As of January 8, a total of 115 cases and 17 deaths had been identified. For further information, go to the World Health Organization.

An outbreak of malaria was reported from the province of Badghis in December 2002, after the malaria season would have been expected to have ended. For further information, go to The Lancet Infectious Diseases.

An outbreak of acute watery diarrheal syndrome was reported in July 2002, resulting in 6691 cases, including 3 deaths in Kabul. Three cases were confirmed as cholera. For more information, go to the World Health Organization.

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Other infections

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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, sea bass, and a large number of tropical reef fish.

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

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

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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.

To prevent sandfly bites, follow the same precautions as for mosquito bites, except that netting must be finer-mesh (at least 18 holes to the linear inch) since sandflies are smaller.

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Swimming and bathing precautions

Because of the risk of leptospirosis, which is transmitted by exposure to water contaminated by the urine of infected animals, you should avoid swimming, wading, or rafting in bodies of fresh water, such as lakes, ponds, streams, or rivers. Toweling oneself dry after unavoidable or accidental exposure to contaminated water may reduce the likelihood of becoming infected, but does not reliably prevent the disease.

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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

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

Well-equipped medical facilities are few and far between throughout Afghanistan. European and American medicines are available in limited quantities and may be expensive or difficult to locate. There is a shortage of basic medical supplies. Basic medicines manufactured in Iran, Pakistan, and India are available, but their reliability can be questionable. Several western-style private clinics have opened in Kabul: the DK-German Medical Diagnostic Center (www.medical-kabul.com), Acomet Family Hospital (www.afghancomet.com), and CURE International Hospital (ph. 079-883-830) offer a variety of basic and routine-type care; Americans seeking treatment should request American or Western health practitioners.

Afghan public hospitals should be avoided. Individuals without government licenses or even medical degrees often operate private clinics; there is no public agency that monitors their operations. Travelers will not be able to find Western-trained medical personnel in most parts of the country outside of Kabul, although there are some international aid groups temporarily providing basic medical assistance in various cities and villages. For any medical treatment, payment is required in advance. Commercial medical evacuation capability from Afghanistan is limited and could take days to arrange. Even medevac companies that claim to service the world may not agree to come to Afghanistan. Those with medevac insurance should confirm with the insurance provider that it will be able to provide medevac assistance to this country...

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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.

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). In view of a recent pertussis outbreak, it is particularly important that all children be fully immunized against this disease.

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

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.

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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)

U.S. citizens living or traveling in Afghanistan are encouraged to register with the Consular Section of the U.S. Embassy in Kabul through the State Department’s travel registration website, https://travelregistration.state.gov, and to obtain updated information on travel and security within Afghanistan. U.S. citizens may also register with the consular section online by visiting the Embassy's web site at http://usembassy.state.gov/afghanistan/. Americans without internet access may register in person at the U.S. Embassy in Kabul. By registering, American citizens make it easier for the Embassy to contact them in case of emergency. The Embassy provides no visa services, but does perform emergency and routine passport and citizens services. The U.S. Embassy is located at Great Masood Road, also known as Bebe Mahro (Airport) Road, Kabul, telephone number: 93-20-230-0436. Fax number (93-20) 230-1364.

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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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