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Sri Lanka
Summary of recommendationsMedicationsImmunizations
Recent outbreaksOther infectionsFood and water precautions
Insect and Tick ProtectionGeneral adviceAmbulance and Emergency Services
Medical facilitiesPharmaciesTraveling with children
Travel and pregnancyMapsEmbassy/Consulate Location
Safety 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 except the districts of Colombo, Kalutara, Galle, and Nuwara Eliya.
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 greater than one year of age arriving from a yellow-fever-infected area in Africa or the Americas. Not recommended otherwise.

Japanese encephalitis

For travelers who may spend a month or more in rural areas and for short-term travelers who may spend substantial time outdoors in rural areas, especially after dusk

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 Sri Lanka: prophylaxis is recommended year-round for all areas, except for the districts of Colombo, Galle, Gampaha, Kalutara, Matara, and Nuwara Eliya. A total of 580 cases were reported for the year 2010, representing a 25% increase over 2009. The highest incidence is in Dry Zone districts such as Anuradhapura, Polonnaruwa, Hambanthota, Ampara and the Northern and Eastern Provinces. Either mefloquine (Lariam), atovaquone/proguanil (Malarone)(PDF), or doxycycline may be given. Mefloquine is taken once weekly in a dosage of 250 mg, starting one-to-two weeks before arrival and continuing through the trip and for four weeks after departure. Mefloquine may cause mild neuropsychiatric symptoms, including nausea, vomiting, dizziness, insomnia, and nightmares. Rarely, severe reactions occur, including depression, anxiety, psychosis, hallucinations, and seizures. Mefloquine should not be given to anyone with a history of seizures, psychiatric illness, cardiac conduction disorders, or allergy to quinine or quinidine. Those taking mefloquine (Lariam) should read the Lariam Medication Guide (PDF). Atovaquone/proguanil (Malarone) is a 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 concerning malaria in Sri Lanka, go to Roll Back Malaria, the World Health Organization - South East Asia Region, or the Malaria Journal ("Sri Lanka Malaria Maps", Olivier JT Briet, Dissanayake M Gunawardena, Wim van der Hoek and Felix P Amerasinghe)

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Immunizations

The following are the recommended vaccinations for Sri Lanka:

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 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. The disease occurs throughout the country, except for mountainous areas. Outbreaks have been reported recently from central (Anuradhapura) and northwestern provinces. Transmission occurs from October to January and May to June. For a map of Japanese encephalitis cases in Sri Lanka, go to the World Health Organization — South-East Asia Region.

The recommended vaccine is IXIARO , given 0.5 cc intramuscularly, followed by a second dose 28 days later. The series should be completed at least one week before travel. The most common side effects are headaches, muscle aches, and pain and tenderness at the injection site. Safety has not been established in pregnant women, nursing mothers, or children under the age of two months.

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. In Sri Lanka, most cases of rabies are caused by dog bites. A total of 56, 51, 56, and 59 deaths from rabies were reported from Sri Lanka in 2007, 2008, 2009, and 2010, respectively. A total of 31 deaths were reported for the first nine months of 2011, and 28 deaths in the first nine months of 2012, chiefly from Jaffna, Kegalle, Hambantota and Matara. (For further information, go to Emerging Infectious Diseases and 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.

Polio vaccine is not generally recommended for adult travelers who completed the recommended childhood immunizations, since polio has not been reported from Sri Lanka for several years. A one-time booster of inactivated polio vaccine may be considered for extended travel to rural areas.

Cholera vaccine is not generally recommended, except for relief workers in tsunami-affected areas, 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 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 younger than nine months of age, pregnant, immunocompromised, or allergic to eggs.

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Recent outbreaks

An outbreak of leptospirosis was reported in February 2011 from Anuradhapura (North Central province) after flooding, causing more than 50 cases and at least two deaths. By November 2011, a total of 5930 cases and 78 deaths had been reported nationwide for the year, chiefly from the districts of Kurunegala, Gampaha, Kalutara, and Hambantota. Leptospirosis is acquired by exposure to water contaminated with urine from infected animals. In Sri Lanka, the chief carrier of the disease is rodents; it may also be found in dogs, cattle, pigs, goats, cats, foxes, and deer. Symptoms may include fever, chills, headache, muscle aches, conjunctivitis (pink eye), photophobia (light sensitivity), and rash. Most cases resolve uneventfully, but a small number may be complicated by meningitis, kidney failure, liver failure, or hemorrhage. Outbreaks often occur at times of flooding. Paddy farmers and sugar cane plantation workers are at highest risk. Those who are exposed to water potentially contaminated by animal urine or those engaging in high-risk activities, such as water sports, may consider taking a prophylactic 200 mg dose of doxycycline, either once weekly or as a one-time dose before exposure.

An increased number of cases of leptospirosis was reported from Sri Lanka in 2008, resulting in 4500 cases and 150 deaths by late September. Most of the cases were recorded in paddy farming districts, including Colombo, Gampaha Kalutara, Matale, Kandy, Kurunegala, Matara, Kegalle, Anuradhapura and Ratnapura. In December 2008, a leptospirosis outbreak was reported from the North Western Province, chiefly affecting the Narammala, Pannala and Mawathagama MoH areas of the Kurunegala district. As of December 28, a total of 280 cases and 55 deaths had been described. In September 2007, an outbreak was reported from the Southern Province, resulting in six deaths (see ProMED-mail, Oct. 24, 2003, September 14, 2007; June 6, September 9 and 22, and December 31, 2008; and February 24, 2011) for further information

An outbreak of dengue fever was reported from Sri Lanka in February 2011, causing 17,000 cases and 124 deaths by September. The Colombo district was chiefly affected. A dengue outbreak was reported in February 2009, mainly involving Colombo, Kandy, Matale, Gampaha, Kalutara, Matale, Kegalle, and Kurunegala. By the end of the year, more than 35,000 cases and 345 deaths had been described (see ProMED-mail). An upsurge in dengue cases was reported in early 2010, particularly affecting the cities of Colombo, Jaffna, and Gampaha. By July 2010, more than 22,000 cases had been reported nationwide, including 164 deaths.

Dengue fever is a flu-like illness which may be 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 essential, as outlined below. For further information, go to the Dengue Alert - World Health Organization and the World Health Organization - South-East Asia Region.

An increase in the number of dengue cases was observed in September 2006, especially in Western Province (see ProMED-mail, September 19, 2006, and February 10 and March 14, 2009). In July 2004, a large dengue outbreak occurred in Sri Lanka, chiefly affecting five cities: Colombo, Kandy, Gampaha, Kalutara and Kurunegala. More than 9000 cases and almost 60 deaths were reported.

Outbreaks of chikungunya fever were reported from the Kuruwita-Erathna area in March 2008 and the Ratnapura District in April 2008, both in Sabaragamuwa province. The outbreak in Ratnapura District reportedly caused 10-15,000 cases as of June. An outbreak was previously reported in November 2006, chiefly affecting the districts of Batticaloa, Colombo, Jaffna, Kalmunai, Mannar, Puttalam, and Trincomalee. Three cases were reported in travelers from the United States and one in a traveler from Japan (see ProMED-mail). Chikungunya fever is a mosquito-borne illness characterized by fever, joint pains, muscle aches, headache, and rash. The disease is almost never fatal, but may be complicated by protracted fatigue and malaise. Rarely, the infection is complicated by meningoencephalitis, which is usually seen in newborns and those with pre-existing medical conditions. Insect protection measures are strongly recommended, as described below. Because of the risk of mother-to-child transmission, pregnant women need to take special care to protect themselves from mosquito bites.

An outbreak of febrile illness that appeared to be caused by chikungunya fever, with some of the cases possibly caused by dengue fever, was reported from the northern war zone in March 2008. Both infections are transmitted by mosquitoes. The outbreak appeared to related to proliferation of mosquitoes due to heavy rains and flooding (see ProMED-mail, April 1, 2008).

An outbreak of hepatitis A was reported in May 2007 from the Gampola area in Central Province, apparently related to contaminated water (see ProMED-mail, May 20, 2007). Hepatitis A vaccine is recommended for all travelers to Sri Lanka.

An outbreak of hand, foot, and mouth disease was reported from Colombo in March 2007, chiefly involving young children. Outbreaks of hand, foot, and mouth disease are generally caused by one of the enteroviruses, which are transmitted by exposure to fecal material from infected individuals. The illness is characterized by fever, oral blisters, and a rash or blisters on the palms and soles. Most cases resolve uneventfully, but a small percentage are complicated by encephalitis (inflammation of the brain), myocarditis (inflammation of the heart muscle), or pulmonary edema (fluid in the lungs). The key to prevention is good personal hygiene and scrupulous hand-washing, especially after defecation and before handling food.

An outbreak of suspected myocarditis of unknown cause was reported in March 2005 from Badulla and Monaragala districts, Uva province. As of late March, the number of cases appeared to be declining. For further information, go to the World Health Organization.

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Other infections

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.

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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 accommodation 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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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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Ambulance and Emergency Services

For an ambulance in Sri Lanka, call 422222.

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Medical facilities

The main teaching and referral facility is the National Hospital (Regent Street, Colombo 8; tel. 941 691111, emergency and trauma unit tel. 941 693184; website http://www.infolanka.com/clinmed). Many travelers obtain medical care from the Apollo Hospital (578 Elvitigala Mawatha Narahenpita, Colombo 5; tel. 94 114 530 000; website http://www.apollocolombo.com), which is operated by a large health care group based in India, or the Asiri Hospital (181 Kirula Road, Colombo 5; tel. 94 11 4523300, 94 11 4524400; contact: Dr. Shiro Gunewardena, tel. 94 11 2867074; website http://www.asirihospitals.com/). All three hospitals provide emergency trauma services.

For a guide to other physicians and hospitals in Sri Lanka, go to the U.S. Embassy website. Acceptable medical care may be difficult to find outside Colombo. Essential medical supplies may not be available. Many doctors and hospitals will expect payment in cash, regardless of whether you have travel health insurance. Serious medical problems will require air evacuation to a country with state-of-the-art medical facilities, usually Thailand or Singapore.

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Pharmacies

The availability of pharmaceuticals is uneven. Many pharmacy staff are not fully trained. Approximately 30% of all pharmaceuticals are dispensed by the State Pharmaceuticals Corporation of Sri Lanka (website http://www.spc.lk/spc.html), which operates pharmacies throughout the 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 (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; 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 (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.

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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)

Americans living in or visiting Sri Lanka are encouraged to register with the nearest U.S. Embassy or Consulate through the State Department's travel registration website and to obtain updated information within Sri Lanka. Americans without internet access may register directly with the nearest U.S. Embassy or Consulate. By registering, you'll make it easier for the Embassy or Consulate to contact you in case of emergency. The U.S. Embassy in located at 210 Galle Road, Colombo 3, Sri Lanka. The Embassy's telephone number during normal business hours Monday through Friday is (94)(11) 244 8007. The after-hours and emergency telephone number is (94)(11) 244-8601. The Consular Section fax number is (94)-(11)-243-6943. The Embassy's Internet address is http://srilanka.usembassy.gov/. The e-mail address for the consular section is consularcolombo@state.gov. The Embassy in Colombo also covers the Republic of Maldives U.S. citizens may register at the Embassy upon arrival in Sri Lanka or via the Embassy's e-mail address.

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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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