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 the Philippines: prophylaxis is recommended for all rural areas below 600 m (1969 ft), except on Bohol Island, Borocay Island, Catanduanes Island, and Cebu Island. Subic Bay is a risk area. No risk is considered to exist in Manila and other urban areas. 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.

There is no malaria risk in metropolitan Manila and other urban areas. There is also thought be no malaria risk in the plains or at altitudes above 600 m.

For further information on malaria in the Philippines, go to the World Health Organization - Western Pacific Region (includes maps which show the risk of malaria in different parts of the country) and Roll Back Malaria.

The following are the recommended vaccinations for Philippines:

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.

Japanese encephalitis vaccine is recommended only for long-term (1 month) travelers to rural areas or travelers who may engage in extensive unprotected outdoor activities in rural areas, especially in the evening, during shorter trips. Japanese encephalitis is transmitted by mosquito bites and is thought to occur on all islands. Outbreaks have been reported in Nueva Ecija, Luzon, and Manila. The vaccine (JE-VAX; Aventis Pasteur Inc.) (PDF) is given as a series of three injections on days 0, 7 and 30. If time is short, the third dose may be given on day 14. Mild side effects including fever, headache, muscle aches, malaise and soreness at the injection site occur in about 20% of those vaccinated. Serious allergic reactions including urticaria, angioedema, respiratory distress and anaphylaxis occur in approximately 0.6% of vaccinees and may occur as long as one week after vaccination. Any person who receives the vaccine should be observed in the doctor's office for at least 30 minutes following the injection and should complete the full series at least 10 days before departure. There are no data concerning the safety of Japanese encephalitis vaccine during pregnancy. In addition to vaccination, strict attention to insect protection measures is essential for anyone at risk.

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 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. In May 2001, a man died of rabies in a London hospital after being bitten during a dog fight in the Philippines. See Eurosurveillance for details. In the Philippines, most cases result from dog bites, though bites from monkeys and other wildlife may also be responsible. The risk of rabies is particularly high in the Bicol region and in Iloilo Province (see ProMED-mail). 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, even though cholera occurs in the Philippines, because most travelers are at low risk for infection. Two oral vaccines have recently been developed: Orochol (Mutacol), licensed in Canada and Australia, and Dukoral, licensed in Canada, Australia, and the European Union. These vaccines, where available, are recommended only for high-risk individuals, such as relief workers, health professionals, and those traveling to remote areas where cholera epidemics are occurring and there is limited access to medical care. The only cholera vaccine approved for use in the United States is no longer manufactured or sold, due to low efficacy and frequent side-effects.

An outbreak was reported from the Paco and San Andres areas of Manila in September 1996.

Polio immunization is recommended. Between March and July, 2001, three cases of poliomyelitis were reported from the Philippines. See the Centers for Disease Control for details. Any adult who received the recommended 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.

Yellow fever vaccine is required for all travelers over one year of age 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.

Outbreaks of typhoid fever are frequently reported from the Philippines. In November 2008, a suspected outbreak was reported from the towns of Real and Infanta, Quezon province. In March 2008, a typhoid outbreak was reported from Iloilo City, the capital of Iloilo province in the Western Visayas region. In February 2008, an outbreak was reported from Calamba City in Laguna province, about 30 miles south of Manila, resulting in almost 2000 cases by March. Also in February, an outbreak was reported from a mountain town in the eastern part of the province of Nueva Vizcaya, located in the Cagayan Valley region on Luzon. In January 2008, typhoid outbreaks were reported from a remote village in the municipality of Bayombong, capital of Nueva Vizcaya province, and from the village of Kisulad in the province of Davao del Sur. In April 2007, a typhoid outbreak occurred in the city of Zamboanga on the island of Mindanao, resulting in over 40 cases and at least one death. The outbreak was attributed to contaminated water from shallow tube wells. In November 2006, an outbreak was reported from the province of Agusan del Sur on the island of Mindanao, affecting almost 500 people (see ProMED-mail). Typhoid vaccine is recommended for all travelers to the Philippines.

Cholera outbreaks occur regularly in the Philippines. The most recent were reported in January 2009 from Ticao Island, Masbate, Bicol; in November 2008 from the settlement of Tagoloan in southern Misamis Oriental; in September 2008 from Pangasinan province on the island of Luzon; and in August 2008 from two tribal communities in Palimbang, Sultan Kudarat. In September 2005, a cholera outbreak was reported from the province of Catanduanes in the Bicol region in September 2005, closely following an outbreak in Caramoan, Camarines Sur (see ProMED-mail; October 8, 2005). 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 capillariasis, a parasitic infection which causes severe intestinal inflammation, was reported in November 2007 from several villages in the town of Zamboanga del Norte. The outbreak was caused by consumption of freshwater fish and shrimp from the nearby rivers of Siayan. For further information, go to ProMED-mail (November 13, 2007).

A rabies outbreak related to unvaccinated dogs was reported in September 2007 from Bauang, La Union Province, causing three deaths. A rise in the number of rabies cases caused by bites from stray dogs was reported from Iloilo Province in January-February 2007 (see ProMED-mail; February 9 and September 18, 2007). Rabies vaccine is recommended 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. 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.

Dengue fever, a flu-like illness sometimes complicated by hemorrhage or shock, is highly prevalent throughout the Philippines. Transmission usually peaks from June through November but, in recent years, a significant number of cases have been reported year-round. Almost 20,000 cases were reported during the first eight months of 2008, of which 195 were fatal, including 37 deaths in Metro Manila. The most recent outbreaks were reported in August 2008 from Calasiao, Pangasinan; in July 2008 from the province of Negros Oriental; in June 2008 from Caloocan City in Metro Manila and from the province of Negros Occidental; in March 2008 from Ilocos Norte; in February 2008 from Negros Oriental and Zamboanga City; in January 2008 from Bacoor, Cavite, and from Valenzuela City; in December 2007 from the Mountain Province and Antique Province; in November 2007 from the province of Capiz; in October 2007 from Aklan; in September 2007 from Cebu Province (ongoing as of February 2008); in August 2007 from Laguna and Iloilo City; in July 2007 from Caraga Region; in June 2007 from Hinoba-an town in southern Negros Occidental; in May 2007 from Bangui in Ilocos Norte, northern Philippines, and Cabantian and Sasa in Davao City in the south; in March 2007 from Bukidnon province; and in January 2007 from the National Capital Region (especially Malabon, Navotas and Quezon City) and from Bayugan town, Agusan del Sur Province.

Dengue is transmitted by Aedes mosquitoes, which bite primarily in the daytime and favor densely populated areas, though they also inhabit rural environments. An unusually large number of cases was reported in 1998, possibly related to climatic changes due to El Nino. Fewer cases were reported in 1999 and 2000, but the numbers began to rise again in 2001. See the World Health Organization for details. No vaccine is available at this time. Insect protection measures are strongly advised, as below. For further information on dengue in the Philippines, go to the World Health Organization - Western Pacific Region.

A measles outbreak was reported in October 2008 from Moises Padilla, Negros Occidental, and was controlled as of January 2009. In July 2007, a measles outbreak was reported from Basilan province in Mindanao, eventually spreading to Zamboanga City. A measles vaccination program was interrupted by military conflicts in Basilan province (see ProMED-mail, July 25, 2007, and January 15, 2009). 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 MMR or measles vaccine before traveling to the Philippines.

An outbreak of meningococcal infections was reported in January 2005 from Baguio City and the Cordillera Region in the island of Luzon. In retrospect, the outbreak probably began in September 2004. As of July 2005, a total of 376 cases had been identified, including 81 deaths. Meningococcal vaccine is recommended for all travelers to Baguio City and the Cordillera Region, especially if close contact with the populace is likely. For details, go to the World Health Organization and NATHNAC.

A small outbreak of severe acute respiratory syndrome (SARS) was reported from the Philippines, chiefly the Manila area, in May 2003, resulting in ten cases and two deaths. The outbreak was limited to a single person who acquired her infection in Toronto, her family members, and the medical staff who cared for her. The outbreak was promptly contained. No travel restrictions are recommended. For further information, go to the World Health Organization and the Centers for Disease Control.

• Schistosomiasis (southern Philippines; caused by Schistosoma japonicum; acquired by exposure to water colonized by infected snails; swimming and bathing precautions advised, as below; see the Bulletin of the World Health Organization)
• Heterophyiasis (reported from Bukidnon, a landlocked province on the island of Mindanao; small bowel infection caused by tiny intestinal flukes; acquired by eating raw or undercooked fresh water fish; causes abdominal cramps and diarrhea; make sure all fish are thoroughly cooked; see ProMED-mail, September 27, 2006)
• Leptospirosis (high incidence noted in the Davao Region in June 2008; see ProMED-mail, June 26, 2008)
• Hepatitis E
• Scrub typhus (rural areas; transmitted by chigger bites)
• Murine typhus
• Chikungunya fever (transmitted by mosquitoes)
• Lymphatic filariasis (found throughout the Philippines)
• Capillariasis (highly prevalent)
• Lung fluke (paragonimiasis)
• Giant intestinal fluke (fasciolopsiasis)
• Cat liver fluke (opisthorchiasis)
• Strongyloides
• Sea snakes (may be highly venomous, well-camouflaged, and highly aggressive; found in coastal waters, lakes and rivers; anti-venom may not be readily available)
• Corals, jellyfish, sharks, and sea urchins (avoid unmarked, unpatrolled beaches)

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.

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.

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.

There is no national ambulance service in the Philippines. For an ambulance in Manila, call St. Luke’s Hospital at (011-63-2) 722-6161, 723-0101, or 723-0199.

High-quality medical care is available in Manila, but may be difficult to locate elsewhere. Many expatriates go to St. Luke’s Hospital (279 E. Rodriguez Avenue, Quezon City, tel. (011-63-2) 722-6161, 723-0101, 723-0199; website http://www.stluke.com.ph/; 24-hour emergency room with ambulance services; accredited by the Joint Commission International; member of the international networks of the Massachusetts General Hospital and the New York-Presbyterian Hospital, two leading U.S. hospitals). Another option is the Makati Medical Center (2 Amorsolo Street, Makati City, tel. (011-63-2) 815-9911, 892-5544; website http://www.makatimed.ph/). For a comprehensive guide to health care in the Philippines, including lists of doctors and hospitals, go to the U.S. Embassy website. Most hospitals will require a downpayment at the time of admission. In some cases, public and private hospitals have withheld lifesaving medicines and treatments for non-payment of bills. Hospitals may refuse to discharge patients or release important medical documents until the bill has been paid in full. Life-threatening medical problems may 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 (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).

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 (see the U.S. Embassy website). 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 the Philippines are encouraged to register with the Consular Section of the U.S. Embassy in the Philippines and obtain updated information on travel and security within the Philippines. The U.S. Embassy is located at: 1201 Roxas Boulevard; Manila, Philippines tel. (63)(2) 528-6300. The Consular American Citizen Services (ACS) section's fax number is (63)(2) 522-3242 and the ACS web page is at http://philippines.usembassy.gov.

The U.S. Consular Agency in Cebu provides limited services for U.S. citizens. The Consular Agency address is: Business Office, Waterfront Hotel; Lahug, Cebu City, tel. (63) (32) 231-1261.

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.