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.

All children should be up-to-date on routine childhood immunizations, as recommended by the American Academy of Pediatrics, prior to international travel. For children less than one year of age or children who are behind in their immunizations, see the accelerated immunization schedule. The following are the recommended vaccinations for Serbia:

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.

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.

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.

An outbreak of hepatitis A was reported from Nis and surrounding areas in southeastern Serbia in December 2007, resulting in more than 700 cases. The outbreak appeared to have been caused by person-to-person transmission, rather than a point source (see Eurosurveillance). Outbreaks of hepatitis A also occurred in the Nis vicinity in 1987, 1994, and 2003. Hepatitis A vaccine is recommended for all travelers to Serbia.

An outbreak of measles was reported from northern Serbia in January 2007, resulting in 121 suspected cases (78 confirmed) as of March 12 (see Eurosurveillance). 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, consider giving an initial dose of measles vaccine to children between the ages of 6 and 11 months who will be traveling to Serbia. Measles vaccine should not be given to pregnant or severely immunocompromised individuals.

An outbreak of meningitis was reported from Kosovo in July 2006, resulting in 878 cases as of September 13, chiefly in children and teenagers. The outbreak appeared to be caused by an enterovirus. Enteroviruses are spread by direct contact with the respiratory secretions or feces of an infected person. No travel precautions are recommended at this time except for careful attention to hand washing and personal hygiene, especially after using the toilet, before eating, and after changing diapers. The chief symptoms of meningitis are fever, severe headache, stiff neck, sensitivity to bright light, drowsiness or confusion, and nausea and vomiting. Anyone who develops these symptoms should immediately seek medical attention. See Eurosurveillance and ProMED-mail (August 19 and 30, 2006) for further information.

An outbreak of tularemia began in November 2001, resulting in 170 confirmed cases as of February 5, 2002. Most cases have been identified in rural areas, chiefly in the Lipjlan, Ferijaz and Pristine municipalities. No fatalities have been reported to date. For further information, go to the World Health Organization. A previous outbreak in 1999-2000, which resulted in 327 confirmed cases, was caused by contamination of food and water by infected rodents. Most cases were characterized by fever, sore throat, and swollen glands (cervical adenopathy). For further information, go to Emerging Infectious Diseases.

An outbreak of Crimean-Congo hemorrhagic fever was reported from the southwestern part of Kosovo in June 2001. As of June 29, a total of 18 cases had been confirmed. For details, go to the World Health Organization. Sporadic cases of Crimean-Congo hemorragic fever are reported each year from Kosovo. Tick precautions, as discussed below, are recommended.

• Trichinellosis (may be acquired from salami, sausage, or other meats, especially pork products, if not fully cooked)
• Brucellosis (low incidence; cattle, sheep, and goats are the most common sources of infection)
• Tick-borne encephalitis (rural and forested areas in the spring and summer; sporadic cases reported near Belgrade)
• 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, 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 Serbia, call 94 or, from a cell phone, call 011-94. Staffing and equipment may not be up to Western standards. In large parts of rural Serbia, ambulance service may be entirely unavailable.

Medical care is limited. Many physicians in Serbia are well-trained, but hospitals and clinics may lack equipment and supplies. For an acute emergency, the best options are the Military Medical Academy (Vojno Medicinska Akademija) (Centar Za Dijalizu Crnotravska 17, 11000 Belgrade; emergency department tel. 266-2516; urgent care center tel. 266-2755 ext 31157 or 31532; website http://www.vma.mod.gov.yu) and the Emergency Centre (Pasterova 2, 11000 Belgrade; tel. 361-8444). For routine health care in Belgrade, many travelers go to one of the following private clinics:

• Bel Medic (three locations: Bel Medic General Hospital, Koste Jovanovica 87; tel. 309-1000, mobile 381 (0)65 309 1000; Bel Medic Outpatient Clinic; Viktora Igoa 1, tel. 306-5888, 306-6999, mobile 381 (0)63 206 602; Bel Medic General Practice, Vladimira Popovica 10, tel. 309-1000, mobile 381 (0)65 309 1000; website http://www.belmedic.com)
• BeoKlinika (Vojvode Stepe 323; tel. 3970-666, 3970-999; website www.beoklinika.co.yu)
• Anlave Clinic (Majora Branka Vukosavljevica 114, Novi Beograd, Bezanijska kosa; tel. 2271-944; 3175-929; website http://www.anlave.co.yu)
• Klinika Petkovic (Maglajska 19; tel. 667-078; 2662-777)

For a list of other physicians and clinics, go to the U.S. Embassy or the Australian Embassy websites. Most 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.

In Kosovo, medical care is extremely limited. Military field hospitals will treat only emergency cases and only if space is available.

In Serbia, most essential medications and basic supplies are available in privately-owned pharmacies. For a 24-hour pharmacy in Belgrade, many travelers go to one of the following:

• Prvi Maj (Kralja Milana 9; tel 324-0533)
• Prima Pharmacy (Nemanjina 2; tel. 361-0999)

In Kosovo, many medications are in short supply.

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.

Americans living in or traveling in Serbia are encouraged to register with the nearest U.S. Embassy of Consulate through the State Department’s travel registration website, and to obtain updated information on travel and security with Serbia. 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 case of emergency. The U.S. Embassy in Belgrade is located at 50 Kneza Milosa Street. The Embassy and consular section telephone number is 381-11-3619-344, and the same number should be used for after hour emergencies. The Consular Section fax number is 381-11-3615-989. The website is http://belgrade.usembassy.gov/...

Americans living in or traveling in Kosovo 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 on travel and security with Kosovo. 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 case of emergency. U.S. citizens are encouraged to register at the U.S. Office in Pristina and obtain updated information on travel and security in Kosovo. At this time the U.S. Office in Pristina provides only emergency services to American citizens. The U.S. Embassy in Skopje, Macedonia provides all routine consular services such as passport and visa processing. The U.S. Office is located at 30 Nazim Hikmet St. in the Dragodan area of Pristina. The telephone number is (381) 38-549-516, e-mail: consularpristina@state.gov. The website is http://pristina.usmission.gov/.

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.