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 Spain:

Hepatitis A vaccine is recommended for extended travel to rural areas where food hygiene is questionable. 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.

Travelers who require protection against hepatitis A and are less than two years old, are pregnant, or have less than two weeks before departure should receive a single intramuscular dose of gammaglobulin (see hepatitis A for dosage) instead of vaccine.

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.

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.

An outbreak of an uncommon infectious disease, probably tick-related lymphadenopathy, was reported from Spain in August 2008. For details, go to ProMED-mail, August 11, 2008.

A measles outbreak was reported in February 2008 from the town of Algeciras in the south of Spain, causing 57 confirmed cases by April (see Eurosurveillance). A measles outbreak was reported from Barcelona in the last quarter of 2006, affecting 213 people by January 31, 2007, and from Madrid in February 2006, resulting in 59 cases as of March 16 (see Eurosurveillance and ProMED-mail; January 11 and 22, 2007). 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. Children who are 12 months or older should receive a total of 2 doses of MMR vaccine, separated by at least 28 days. Children between the ages of 6 and 11 months should be given a single dose of measles or MMR vaccine before travel to Spain. Measles vaccine should not be given to pregnant or severely immunocompromised individuals.

An outbreak of tularemia occurred between June and December 2007 in a rural area in the province of Palencia and in the provincial capital city of León in the province of Castilla y Leon, located in the northern part of Spain. A total of 507 cases were laboratory-confirmed. About one-third occurred in farm workers or people whose jobs involved contact with the environment, such as gardeners, rangers, and lake and reservoir maintenance staff. About one-quarter were caused by direct contact with rodents (see Eurosurveillance and ProMED-mail, August 11, 2007). A previous tularemia outbreak was reported from Castilla y Leon in November-December 1997, apparently related to the handling of infected hares (see Eurosurveillance). The 1997 outbreak resulted in 534 cases. Tularemia may be acquired by direct contact with infected animals, by mosquito or tick bites, or by inhalation. Symptoms may include fever, swollen glands, and skin lesions. Severe cases may be complicated by pneumonia or sepsis.

An outbreak of mumps was reported in August 2006 from Navarra, in northern Spain, following a local festival. As of February 2007, more than 1300 cases had been identified and new cases were still being reported. See Eurosurveillance and ProMED-mail (January 11, 2007) for further information. All travelers born after 1956 should make sure they have had either two doses of MMR or mumps vaccine or a blood test showing mumps immunity. Those born before 1957 are presumed to be immune. Children who are 12 months or older should receive a total of 2 doses of MMR 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 MMR vaccine.

An increase in the number of cases of viral meningitis was reported from the Autonomous Region of Madrid during the first nine months of 2006, chiefly affecting those under 15 years of age (see Eurosurveillance). Two deaths were recorded. Most cases were caused by enteroviruses. An increase was also observed in other regions of Spain. Viral meningitis is a mild illness which is spread by direct contact with the respiratory secretions or feces of an infected person. No travel precautions are recommended 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.

An outbreak of Legionnaires' disease was reported in June 2006 from Pamplona in north Spain, affecting 149 people as of June 14. Most of the cases occurred close to the city center. The source of the outbreak has not been confirmed, though four cooling towers in the area tested positive for Legionella and have been closed. See NATHNAC, Eurosurveillance, and ProMED-mail (June 5, 2006) for details. A much larger outbreak occurred in Murcia in July 2001, chiefly affecting the the northern neighborhoods of the city. A total of 420 cases were confirmed, including four deaths. The source of the outbreak was never determined. See the World Health Organization, Eurosurveillance, and ProMED-mail (October 17, 2001) for details. An outbreak linked to two contaminated cooling towers was reported from Zaragoza in June and July 2004, affecting at least 30 people. A separate outbreak related to a contaminated cooling tower occurred in the municipalities of Vic and Gurb (Central Region of Catalonia) in October and November 2005, causing 55 cases (see Eurosurveillance). Legionnaires' disease is a bacterial infection which typically causes pneumonia but may also involve other organ systems. The disease is usually transmitted by airborne droplets from contaminated water sources, such as cooling towers, air conditioners, whirlpools, and showers. Legionnaires' disease is not transmitted from person-to-person. For further information on Legionaires' disease among travelers to Spain, go to the European Working Group on Legionella Infections.

An outbreak of rubella was reported from the autonomous region of Madrid during the first weeks of 2005. Most cases occurred in young adults of foreign origin, chiefly from Latin America. For further information, go to Eurosurveillance. All travelers to Spain should make sure they have been vaccinated against rubella, which is one of the routine childhood immunizations.

Four cases of variant Creutzfeldt-Jakob disease (CJD) has been identified in Spain. The disease is acquired by eating beef from cows with a related infection known as bovine spongiform encephalopathy (mad cow disease). 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.

• Trichinellosis (outbreak reported in January 2007, caused by consumption of home-made sausage (chorizo) made from the meat of two wild boars (jabalí) killed on a private hunt held in Castile and León; see Eurosurveillance)
• Anthrax (chiefly the communities of Castilla-La Mancha, Aragon, Castilla y Leon, and Estremadura)
• Brucellosis (incidence declining in most areas, but remains significant in Andalusia, Castille-La Mancha, Aragon, Castille-Leon, and Extremadura)
• Q fever
• Echinococcosis (hydatid cyst disease) (chiefly Guadalajara, Soria, Segovia, and Caceres)
• Mediterranean spotted fever (mainly Andalusia, Castilla-La Mancha, Castilla y Leon, Cataluna, and Estremadura)
• Visceral leishmaniasis (especially AIDS patients; chief reservoir is dogs)
• Tick-borne relapsing fever
• Rabies (no recent human cases, but reported in insectivorous bats; any person who has contact with a bat should contact local health authorities for rabies prophylaxis; rabies also reported in dogs, cats, and horses in the Spanish towns of Ceuta and Melilla in North Africa; see Eurosurveillance for details)
• Toscana virus (common cause of aseptic meningitis between May and October; see Emerging Infectious Diseases)
• Scorpion stings
• Black widow spider bites
  

For further information, see Weekly Epidemiological Record, 1996.

For disease statistics and updates on recent outbreaks, go to the Boletin Epidemiologico Semanal (in Spanish).

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.

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.

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 general emergencies in Spain, call 112. For ambulance services, call the following numbers:

Samur - 092
Uvimovil - 061
Ambulances Cruz Roja - 91 522 2222
Ambulancias Sasu - 91 355 1039

For an on-line guide to physicians, hospitals, and emergency medical services in Spain, go to the United States Embassy website.

Good medical care is available in both Spain and Andorra. The Department of State strongly urges Americans to consult with their medical insurance companies prior to traveling abroad to confirm whether their policy applies overseas and if it will cover emergency expenses such as a medical evacuation. U.S. medical insurance plans seldom cover health costs incurred outside the United States unless supplemental coverage is purchased. Further, U.S. Medicare and Medicaid programs do not provide payment for medical services outside the United States. However, many travel agents and private companies offer insurance plans that will cover health care expenses incurred overseas, including emergency services such as medical evacuations.

When making a decision regarding health insurance, Americans should consider that many foreign doctors and hospitals require payment in cash prior to providing service and that a medical evacuation to the United States may cost well in excess of $50,000. Uninsured travelers who require medical care overseas often face extreme difficulties, whereas travelers who have purchased overseas medical insurance have found it to be life saving when a medical emergency has occurred. When consulting with your insurer prior to your trip, please ascertain whether payment will be made to the overseas healthcare provider or if you will be reimbursed later for expenses that you incur. Some insurance policies also include coverage for psychiatric treatment and for disposition of remains in the event of death.

Useful information on medical emergencies abroad, including overseas insurance programs, is provided in the Department of State’s Bureau of Consular Affairs brochure, Medical Information for Americans Traveling Abroad, available via the Bureau of Consular Affairs home page.

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 in or visiting Spain or Andorra are encouraged to register at the Consular Section of the U.S. Embassy in Madrid or at the U.S. Consulate General in Barcelona, where they may obtain updated information on travel and security within Spain or Andorra.

The U.S. Embassy in Madrid, Spain, is located at Serrano 75; telephone (34)(91) 587-2200, and fax (34)(91) 587-2303. U.S. citizens who register in the Consular Section at the U.S. Embassy, Consulate General, or one of the Consular Agency listed below can obtain updated information on travel and security within Spain or Andorra. Additional information is available through the U.S. Embassy’s Internet homepage at http://madrid.usembassy.gov/.

The U.S. Consulate in Barcelona is located at Paseo Reina Elisenda 23-25; telephone (34)(93) 280-2227 and fax (34)(93) 205-5206. Visitors to Barcelona can access additional information from the Consulate General’s web page at http://barcelona.usconsulate.gov/.

There are six Consular Agencies in Spain, which provide limited services to American Citizens, but are not authorized to issue passports.

Fuengirola near Malaga, at Avenida Juan Gomez Juanito #8, Edificio Lucia 1C, 29640, Fuengirola, telephone (34)(952) 474-891 and fax (34)(952) 465-189, hours 10:00 a.m. to 1:00 p.m.;

La Coruna, at Canton Grande 6, telephone (34)(981) 213-233 and fax (34)(981 22 28 08), hours 10:00 a.m. to 1:00 p.m.;

Las Palmas, at Edificio Arca, Calle Los Martinez de Escobar 3, Oficina 7, telephone (34)(928) 222-552 and fax (34)(928) 225-863, hours 10:00 a.m. to 1:00 p.m.;

Palma de Mallorca, Edificio Reina Constanza, Porto Pi, 8, 9-D, 07015 Palma de Mallorca, Spain. Telephone (34)(971) 40-3707 or 40-3905 and fax (34)(971) 40-3971. Hours 10:30 a.m. to 1:30 p.m.; Seville, at Paseo de Las Delicias 7, telephone (34)(954) 231-885 and fax (34)(954) 232-040, hours 8:30 a.m. to 1:30 p.m.;

Valencia, at Doctor Romagosa #1, 2-J, 46002, Valencia telephone (34)(96)-351-6973 and fax (34)(96) 352-9565, hours 10:00 a.m. to 1:00 p.m.

For Andorra, please contact the U.S. Consulate in Barcelona.

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.