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.

The following are the recommended vaccinations for Bulgaria:

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, with the exception of short-term visitors who restrict their meals to major restaurants and hotels, such as business 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.

Hepatitis B vaccine is recommended for travelers who will have intimate contact with local residents or potentially need blood transfusions or injections while abroad, especially if visiting for more than six months. It is also recommended for all health care personnel. Two vaccines are currently licensed in the United States: Recombivax HB (Merck and Co., Inc.) (PDF) and Engerix-B (GlaxoSmithKline) (PDF). A full series consists of three intramuscular doses given at 0, 1 and 6 months. Engerix-B is also approved for administration at 0, 1, 2, and 12 months, which may be appropriate for travelers departing in less than 6 months. Side-effects are generally mild and may include discomfort at the injection site and low-grade fever. Severe allergic reactions (anaphylaxis) occur rarely.

Rabies vaccine is recommended only for those at high risk for animal bites, such as veterinarians and animal handlers, and for long-term travelers who may have contact with animals and may not have access to medical care. 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.

All travelers should be up-to-date on routine immunizations, including

• Tetanus-diphtheria vaccine (recommended for all travelers who have not received a tetanus-diphtheria immunization within the last 10 years.)
• Measles vaccine (recommended for any traveler born after 1956 who does not have either a history of two documented measles immunizations or a blood test showing immunity. Many adults who had only one vaccination show immunity when tested and do not need the second vaccination. Measles vaccine should not be given to pregnant or severely immunocompromised individuals.)
• Varicella (chickenpox) vaccine (recommended for any international traveler over one year of age who does not have either a history of documented chickenpox or a blood test showing immunity. Many people who believe they never had chickenpox show immunity when tested and do not need the vaccine. Varicella vaccine should not be given to pregnant or immunocompromised individuals.)

Influenza vaccine is recommended for all travelers during flu season, which runs from November through April. The vaccine may cause soreness at the injection site, low-grade fevers, malaise, and muscle aches. Severe reactions are rare. Influenza vaccine should not be given to pregnant women during the first trimester.

Polio immunization is not recommended for any adult traveler who completed the recommended childhood immunizations. A small polio outbreak in March-April 2001 was terminated by a mass vaccination campaign (see "Recent outbreaks" below). In June 2002, the World Health Organization certified that polio had been eradicated from the European region.

Four human cases of brucellosis were reported in September 2007 from the villages of Harmanli and Valche pole in the southern part of Bulgaria, near the Greek border, at the same time that dozens of goats and sheeps in the area were found to be infected with the disease. Two human cases were also reported from Bulgaria in 2005. Brucellosis is generally acquired by consumption of unpasteurized dairy products from infected animals or by direct contact with the tissues of infected animals. In the Bulgarian cases, all those involved had direct contact with infected sheep or goats. Brucellosis is uncommon in Bulgaria. Most travelers are at low risk.

A large outbreak of acute gastroenteritis was reported in February 2007 from the Samokov region in western Bulgaria, involving almost 1000 people. Symptoms included nausea, vomiting, abdominal pain, and diarrhea. The outbreak was probably caused by norovirus. See Eurosurveillance for further information. Most norovirus infections resolve uneventfully, although young children, the elderly, and those with chronic medical problems may develop significant dehydration.

An outbreak of mumps was reported in January 2007, starting in the town of Plovdiv in southern central Bulgaria. As of March 18, almost 1000 people had been affected, most of whom were between the ages of 15 and 24. (In Bulgaria, many people in this age group were never immunized against mumps as children or received a relatively ineffective vaccine.) See Eurosurveillance for further information. Mumps is a viral infection which is spread by contact with oral or nasal secretions from an infected person. All travelers born after 1956 should make sure they either have received two doses of mumps vaccine or have a blood test proving immunity to mumps. Travelers born before 1957 are presumed to be immune. Although mumps 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 vaccine before traveling to Bulgaria.

An outbreak of hepatitis A was reported in September 2006 from the Plovdiv region in southern central Bulgaria, chiefly involving the Roma (Gypsy) neighborhoods. As of September 26, more than 1300 cases had been described, mostly in children. The outbreak appeared to be related to poor sanitation and hygiene, including illegal dung hills, a substandard sewage system, and an irregular water supply (see Eurosurveillance and ProMED-mail, Sept. 11 and 26, 2006). Hepatitis A vaccine is recommended for all travelers to Bulgaria.

An outbreak of tularemia has been reported from Bulgaria since 1997, chiefly near the western border with Serbia and Montenegro. The number of cases appeared to decline in 2001 and 2002, but rose again in 2003. The outbreak may be related to changes in ploughing techniques, leading to an increase in the rodent population. See Emerging Infectious Diseases for further information. Most cases of tularemia are acquired from tick bites or from handling the carcass of an infected animal. Tularemia may cause a flu-like illness, pneumonia, or skin ulcers with swollen glands, depending upon how the infection is acquired. Most travelers are at low risk.

An outbreak of Q fever pneumonia was reported from Botevgrad in May 2004, probably related to a dust storm which occurred at the beginning of the month. Most of those affected reported no direct contact with animals. For further information, see Eurosurveillance. Q fever outbreaks occur regularly in Bulgaria. The incidence of the disease rose steadily through the 1990s, due to a marked increase in the number of goats (which carry the disease), closer contact between goats and their owners, and increased consumption of raw goat milk and its products. Q fever is usually acquired through inhalation of aerosols produced by goat excrement and bodily fluids, meaning direct animal contact is not necessary to become infected.

Three cases of polio, apparently imported from the Indian subcontinent, were reported in March-April 2001 among Roma (gypsy) children. The outbreak was terminated by a mass vaccination campaign. See the World Health Organization, Centers for Disease Control, and Eurosurveillance for details.

• Crimean-Congo hemorrhagic fever (most cases occur in eastern Bulgaria; chiefly affects livestock workers; most cases transmitted by tick bites, though may be transmitted person-to-person; outbreak reported in March-April 2008 from the municipality of Gotse Delchev in Blagoevgrad district, an area bordering Greece and Macedonia; see Eurosurveillance and Emerging Infectious Diseases)
• Tick-borne encephalitis (rural and forested areas in the spring and summer; tick precautions recommended)
• Lyme disease (tick-borne infection which causes fever, headache, joint pains, body aches, and malaise, usually in association with an expanding red rash, often pale in the center; may be complicated by arthritis, meningitis, encephalitis, Bells palsy, or cardiac involvement if not treated in early stages; tick precautions recommended for travel to rural and forested areas, especially during warm weather months)
• HIV (human immunodeficiency virus) infection (travelers not at risk unless they have unprotected sexual contacts or receive injections or blood transfusions)

Tap water is generally safe to drink in major cities, but water quality is variable in rural areas. If in doubt, do not drink tap water unless it has been boiled, filtered, or chemically disinfected. 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, including red snapper, grouper, amberjack, and sea bass.

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

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

Wear long sleeves, long pants, and boots, with pants tucked in. 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 and shoes. Permethrin-treated clothing appears to have little toxicity. 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.

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.

For an ambulance in Bulgaria, call 150, but response time may be slow. For a true emergency, call a taxi and ask to be taken to Pirogov (the best hospital for emergency cases) if you are in Sofia, or to the emergency unit of the local regional hospital if you are in the country.

Bulgarian physicians are often well-trained, but most hospitals and clinics, especially in village areas, are not well-equipped. Most physicians work in government-owned hospitals and clinics. The best hospital for emergencies is Pirogov - National Institute for Emergency Medical Services (21 Totleben Blvd, Sofia; tel. 915-4411). For private medical care, many expatriates go to the Vita Hospital (9, Dragovitza Street, Sofia 1505; tel. 943-4398; 846-5376; 960-4950; website http://www.vita.bg/indexen.php; major credit cards accepted). For guide to physicians, clinics, and other hospitals in Bulgaria, go to the U.S. Embassy website. 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.

Quality control of pharmaceuticals is generally in accord with EU standards. Most pharmacies are well-supplied, though not all medications available in North America and Western Europe are obtainable in Bulgaria. The largest pharmacy chain is Sofia Pharmacies AD (see website at http://www.apteka.bg/index_en.xsp for locations). For further information on pharmaceuticals in Bulgaria, go to the World Health Organization.

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).

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.

Be sure to pack a medical kit when traveling with children. In addition to the items listed for adults, bring along plenty of disposable diapers, cream for diaper rash, oral replacement salts, and appropriate antibiotics for common childhood infections, such as middle ear infections.

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

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

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. 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.

American citizens living in or visiting Bulgaria are encouraged to register at the Consular Section of the U.S. Embassy in Bulgaria and obtain updated information on travel and security within Bulgaria. The U.S. Embassy in Sofia is located at 1 Saborna St. (formerly 1 a. Stamboliyski boulevard); tel. (359)(2) 980-5241; fax: (359)(2) 981-8977. The Consular Section of the Embassy is located at 1 Kapitan Andreev St. In Sofia; tel. (359)(2) 963-1391; fax (359)(2) 963-2859. The embassy's website address is http://bulgaria.usembassy.gov/. Questions regarding consular services may be directed via email to: niv_sofia@state.gov (for non-immigrant visa matters); iv_sofia@state.gov (for immigrant visa matters); and acs_sofia@state.gov (for American Citizen Services matters).

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.