All children should be up-to-date on routine childhood immunizations, as recommended by the American Academy of Pediatrics, prior to international travel. The following are the recommended vaccinations for Germany:

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.

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

Influenza vaccine is recommended for all travelers during flu season, which runs from November through April. Influenza 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 or those allergic to eggs.

Tick-borne encephalitis vaccine may be considered for long-term travelers who expect to be visiting rural or forested areas in the spring or summer. In Germany, the risk for tick-borne encephalitis is greatest in the states of Bavaria and Baden-Wurttemburg in the south. For further information, including a map showing the risk of tick-borne encephalitis (called Fruhsommer-Meningoenzephalitis in German) in different parts of the country, go to the Robert Koch-Insititut. Two vaccines have been developed: TicoVac, also known as FSME Immun (Baxter AG), which is manufactured in Austria, and Encepur (Chiron Behring), which is made in Germany. The vaccines are approved for use in a number of European countries, but not the United States. A full series consists of three doses over a one-year period, which is not practical for most travelers, though limited data indicate that Encepur may be given in an accelerated schedule for faster immunity. Tick precautions, as discussed below, are strongly advised.

A measles outbreak causing more than 50 cases was reported in April 2008. The outbreak was linked to an anthroposophic school in Salzburg, Austria, most of whose students had not been vaccinated against measles (see Eurosurveillance). In October 2007, a measles outbreak was reported from southern Bavaria, chiefly involving residents of the greater Munich area, most of whom had never received measles vaccine (see Eurosurveillance). Between January and June 2007, a measles outbreak was reported from Passau and Rottal-Inn, two districts of Lower Bavaria in southeast Germany sharing a border with Austria. Almost 30% attended a local Montessori school frequented by pupils from the two affected districts and from Austria (see Eurosurveillance). A measles outbreak was also reported in January 2006 from the state of North Rhine Westphalia, chiefly affecting the cities of Duisburg and Mönchengladbach and the district of Wesel. As of June 15, a total of 1452 cases had been identified, mostly in older children and young adults (see Eurosurveillance). A number of other measles outbreaks have recently been reported from the states of Hessen, Bavaria, Lower Saxony, and North Rhine Westphalia. In the previous outbreaks, most cases occurred in children who had not been vaccinated (see Eurosurveillance).

Although the recommendation is to give the first dose of measles vaccine at age 12 months, many German children are not vaccinated until they are two or three years old, resulting in a large susceptible population (see the Pediatric Infectious Disease Journal 2002;21:826-830). All travelers born after 1956 should make sure they have had either two documented MMR or measles immunizations or a blood test showing measles immunity. Those born before 1957 are presumed to be immune. Although measles immunization is usually begun at age 12 months, children between the ages of 6 and 11 months should be given an initial dose of measles or MMR vaccine before traveling to Germany.

The number of cases of tick-borne encephalitis almost doubled from 2004 to 2006 (see Eurosurveillance), reaching 546 cases for the year 2006, the largest number since notification began. This was preceded by a sharp rise in the incidence of tick-borne encephalitis in the late 1990s (see Eurosurveillance). The number of cases fell to 326 in 2007. The disease occurs mainly in southern Germany, chiefly in the federal states of Baden-Wuerttemberg and Bavaria, but also in Thuringia and Hesse. One small risk area is located in Rhineland-Palatinate. Cases have also been recently identified in areas not previously defined as risk areas, such as Saxony, Lower Saxony, Mecklenburg-Western Pomerania, Saxony-Anhalt, and Brandenburg.

Tick-borne encephalitis is a viral infection of the central nervous system transmitted by tick bites, usually after travel to rural or forested areas in the spring or summer. The infection may also be acquired by ingesting unpasteurized dairy products. The disease typically begins as a flu-like illness, including fever, headache, and vomiting, followed by the development of neurologic symptoms. Neurologic damage may be permanent, causing chronic headaches, difficulty concentrating, muscle weakness or loss of balance. Tick-borne encephalitis vaccine should be considered for long-term travelers who expect to be visiting rural or forested areas in the spring or summer, especially in the southern part of the country. The vaccine is available in many European countries, but not the United States. Tick precautions are strongly advised, as below. As above, vaccination against tick-borne encephalitis should be considered for long-term travelers who expect to be visiting rural or forested areas in the spring or summer.

An increase in the number of hantavirus infections was observed in the first few months of 2007, chiefly in Baden-Württemberg, a federal state in the south-west of Germany. Cases were also reported from Bayern (Bavaria), North-Rhine-Westphalia, Lower Saxony, Hessen, and Mecklenburg Western-Pomerania (see Eurosurveillance). An increased number of cases was also observed in spring 2005, chiefly in several federal states north of the river Main, including Lower Saxony, North-Rhine-Westphalia, Hessen, and Thuringia. Unlike previous years, most infections were acquired in urban areas (see Eurosurveillance). In Germany, the known regions with higher prevalence of human hantavirus infections are Schwäbische Alb in Baden-Württemberg and parts of Unterfranken in Bayern. Hantaviruses cause an illness known as hemorrhagic fever with renal syndrome, characterized by the abrupt onset of fever, chills, weakness, and dizziness, often associated with headache, muscle pains, abdominal pain, and back ache. The main complication is kidney failure. In Germany, the predominant hantavirus is Puumala virus, which is carried by the bank vole (a type of rodent which lives predominantly in forested areas dominated by deciduous trees). The virus is acquired by exposure to rodent excreta, usually by inhalation. Most travelers are at low risk for infection.

In the summer of 2006, wound infections caused by Vibrio vulnificus were reported in three people who had bathed in the Baltic Sea in the state of Mecklenburg-Vorpommernin. All had underlying chronic illnesses, including diabetes mellitus, coronary artery disease, chronic edema, and chronic skin ulcer. Two cases of Vibrio vulnificus wound infections were also reported in Baltic Sea bathers in Mecklenburg-Vorpommernin in the summer of 2003. See Eurosurveillance for details. Wound infections caused by Vibrio species may progress rapidly and be life-threatening, especially in those with compromised immune systems. Those with chronic illnesses or open wounds should avoid swimming in the Baltic Sea during the warm weather months.

An outbreak of H5N1 avian influenza ("bird flu") was reported in March 2006 from a turkey farm in Saxony. Shortly before that, more than a hundred cases of avian influenza were reported among wild swans, ducks, geese, and birds of prey on Ruegen Island in the Baltic Sea, as well as a smaller number of cases in wild birds in other parts of the country. Between June and August, 2007, after more than a year without any new cases, dozens of cases were reported among wild aquatic birds in southern and eastern Germany, as well as an outbreak on two duck farms in Bavaria. In December 2007, three separate outbreaks were reported from poultry farms in Altglobsow (75 km north of Berlin), Bensdorf (85 km west of Berlin), and the state of Brandenburg. In October 2008, an outbreak occurred at a poultry farm in Saxony. No human cases have been reported from Germany 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 areas 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 Ruegen Island 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 trichinellosis, affecting 17 people, was reported among members of an extended family living in the state of Mecklenburg-Vorpommern, eastern Germany, between December 2005 and March 2006. The outbreak was caused by consumption of undercooked pork products from a home-reared pig. See Eurosurveillance for further information. Trichinellosis is rare in Germany, but all pork products should be thoroughly cooked before consumption.

An outbreak of H7N7 avian influenza ("bird flu") was reported in May 2003 from Schwalmtal, a village near the Dutch border in the federal state of North Rhine-Westphalia, Germany. The outbreak appeared to have spread from the Netherlands, where cases of avian influenza were reported earlier in the year. Unlike H5N1 avian influenza, which is highly pathogenic, H7N7 avian influenza poses little risk to humans. Although transmission to humans was reported in the Netherlands, no human cases were seen in Germany. The outbreak was terminated by mass slaughter of poultry. For further information, go to Eurosurveillance.

Bovine spongiform encephalopathy ("mad cow disease") has been identified, but transmission to humans has not been reported to date. At present, the risk of acquiring variant CJD from European beef appears to be extraordinarily low, at most about one in 10 billion servings. The Centers for Disease Control does not advise against eating European beef, but suggests that travelers who wish to reduce their risk may either abstain from beef while in Europe or eat only solid pieces of muscle meat, such as steak, rather than products like sausage or chopped meat that might be contaminated. There is no evidence of any risk from pork, lamb, milk or milk products. For recent updates, go to ProMED-mail.

Outbreaks of Q fever, usually related to sheep, occur periodically in Germany. Most cases occur in those who have had direct contact with infected animals, though outbreaks may involve others in the community, since Q fever is spread by airborne droplets. An outbreak totaling 73 cases was reported from three county districts in North-Rhine Westphalia between December 2000 and May 2001. Several flocks of sheep were identified as the likely source. The infection was probably transmitted by inhalation of infected dust from contaminated afterbirth during the lambing season. See Eurosurveillance for details. A previous outbreak was reported from Rollshausen, a small rural community, in spring 1996, probably originating in a large sheep farm. For an overview of Q fever in Germany, go to Emerging Infectious Diseases.

For disease statistics and updates on recent outbreaks, go to the Epidemiologisches Bulletin (in German).

• Lyme disease (transmitted by ticks)
• Tularemia (uncommon in Germany; three family members infected with tularaemia in late summer 2007 after contact with a dead rabbit in Baden-Wuerttemberg (see Eurosurveillance)); outbreak reported in November 2005 among hare hunters in the Darmstadt-Dieburg district (see Eurosurveillance); between one and five cases reported in most years, with the exception of 15 cases in 2005 and 19 cases in 2007, 11 of them in Baden-Wuerttemberg)
• Brucellosis (low incidence)
• Alveolar echinococcosis (reported from rural areas in the southern part of the country; see Emerging Infectious Diseases for details)
  
• Leptospirosis (occasional cases, especially from the northeastern part of the country; often related to direct contact with infected rats and dogs; see Emerging Infectious Diseases))
• Cowpox infections (sporadic cases, usually related to direct contact with infected cats; see Eurosurveillance)
• 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.

Wear long sleeves, long pants, and boots, with pants tucked in when traveling to rural or forested areas. 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 as close to the skin as possible and pulling straight out. 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 your personal 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 anywhere in Germany, call 112.

For an online list of English-speaking physicians and other medical services in various parts of Germany, go to the U.S. Embassy website.

Good medical care is widely available. Doctors and hospitals may expect immediate payment in cash for health services from tourists and persons with no permanent address in Germany. Most doctors, hospitals and pharmacies do not accept credit cards.

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).

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, and appropriate antibiotics for common childhood infections, such as middle ear infections.

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 or traveling in Germany are encouraged to register with the nearest U.S. Embassy or Consulate through the State Department's travel registration website, http://travelregistration.state.gov, and to obtain updated information on travel and security within Germany. Americans without Internet access may register directly with the nearest U.S. Embassy or Consulate. By registering, American citizens make it easier for the Embassy or Consulate to contact them in cases of emergency.

A new initiative of the American Embassy in Berlin allows all Americans in Germany to obtain automatic security updates and Public Announcements by e-mail. To subscribe to this service, simply send a blank e-mail to GermanyACS@state.gov and put the word SUBSCRIBE on the subject line.

U.S. Embassy Berlin is located at: Neustaedtische Kirchstrasse 4-5; Tel: (49)(30) 238-5174 or 8305-0; the consular section is located at Clayallee 170; Tel: (49)(30) 832-9233; Fax: (49)(30) 8305-1215

U.S. Consulates General are located at:

Duesseldorf: Willi-Becker-Allee 10, Tel: (49)(211) 788-8927; Fax: (49)(211) 788-8938;

Frankfurt: Siesmayerstrasse 21, Tel: (49)(69) 75350; Fax: (49)(69) 7535-2304;

Hamburg: Alsterufer 27/28, Tel: (49)(40) 4117-1351; F ax: (49)(40) 44-30-04;

Leipzig: Wilhelm-Seyfferth-Strasse 4, Tel: (49)(341) 213-8418; Fax: (49)(341) 21384-17 (emergency services only);

Munich: Koeniginstrasse 5, Tel: (49)(89) 2888-0; Fax: (49)(89) 280-9998.

There is also a U.S. consular agency in Bremen located at Bremen World Trade Center, Birkenstockstrasse 15, Tel: (49)(421) 301-5860; Fax: (49)(421) 301-5861.

When calling another city from within Germany, dial a zero before the city code (for example, when calling Berlin from Munich, the city code for Berlin is 030).

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.