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.

Malaria in Kyrgyz Republic: frequent border crossings between neighboring countries with malaria poses a small risk of malaria transmission in the southern and western parts of the country along the borders of Tajikistan and Uzbekistan. Insect protection measures are advised for these areas, but not malaria pills. There is no malaria transmission in Bishkek at this time.

For further information on malaria in the Kyrgyz Republic, go to the World Health Organization.

The following are the recommended vaccinations for Kyrgyz Republic:

Tetanus-diphtheria vaccine is recommended for all travelers who have not received a tetanus-diphtheria immunization within the last 10 years. In the 1990s, a massive diphtheria epidemic occurred in the newly independent states of the former Soviet Union (see CR Vitek and M Wharton, Emerging Infectious Diseases).

Hepatitis A vaccine is recommended for all travelers over one year of age. An increase in the number of cases of hepatitis A was reported from southern Kyrgyzstan in September 2004. The vaccine 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.

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 the Kyrgyz Republic, the chief source of rabies is wild animals, chiefly wolves and foxes, who then spread the disease to stray dogs and cats. 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.

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 generally not recommended for any traveler who completed the recommended childhood immunizations, since polio has not been reported from the Kyrgyz Republic in recent years. A single dose of inactivated polio vaccine might be considered for extended travel to rural areas.

Cholera vaccine is not recommended. Cholera is not being reported from the Kyrgyz Republic at this time.

An outbreak of brucellosis was reported from the Naryn region in December 2008, causing more than 400 cases. The Kyrgyz Republic has one of the highest rates of brucellosis in the world. The most affected regions are Jalal-Abad, Talasskoe, Norinskoe [Naryn], and Issik Kulsoe (see ProMED-mail, January 2 and February 1, 2009). Brucellosis is an infection of domestic and wild animals that may be transmitted to humans through direct animal contact or by consumption of unpasteurized dairy products from infected animals. Cattle, goats, and sheep are the most common source of infection. The incubation period usually ranges from one to four weeks. Symptoms may include fever, malaise, depression, loss of appetite, headache, muscle aches, and back pain. Complications may include arthritis, hepatitis, endocarditis, and meningitis. Infection may be short-lived or last for years. Prevention depends upon avoidance of unpasteurized dairy products and limiting contact with potentially infected animals and their bodily fluids.

An increase in the number of cases of malaria was reported from Bishkek and the Chuysk region during the first eight months of 2006. As of September 1, a total of 209 cases had been recorded (161 in Bishkek city, 21 in Batken, 22 in Jalalabad, 3 in Issik-Kul, and one case each in Osh and Narin.) The epicenter of the outbreak appeared to be the Ala-Archinsk reservoir in the Chuysk region. Most cases occurred in migrants from the southern part of the country, where malaria is endemic. For the year 2007, a total of 52 cases were reported as of August 8, most of them occurring in the new residential areas of Bosogo, Olmo and Kalys-Ordo, located close to the reservoir. See AlertNet and ProMED-mail (June 24 and July 24, 2006; July 17 and August 15, 2007) for further information.

Outbreaks of anthrax are regularly reported from the Kyrgyz Republic, usually from the oblasts of Jalal-Abad and Osh in the southwestern part of the country, followed by the provinces of Batken and Chuy. The most recent outbreak was reported in July and August 2009 from Aksi district of Jalal-Abad. Before that, anthrax outbreaks were reported in September 2008 from the Jalal-Abad Oblast and the Batken Oblast (to the west of Osh), and in June and July 2008 from the Aravan region and Osh region in Osh Oblast and from the Suzak region and Nooken region in Jalal-Abad Oblast. Cases were also reported in 2008 from the Chuysk region and the Talass region. The annual nationwide total of human cases was 41 in 2005, 15 in 2006, 23 in 2007, and 47 in 2008. See ProMED-mail for further information. Anthrax usually occurs in those handling infected animals or their products, including hides, hair, wool, or flesh. Spores are introduced through a break in the skin, leading to a small raised area on the skin which ulcerates and turns black. When untreated, the illness may be complicated by high fevers, swelling of the area around the ulcer, enlargement of the regional lymph nodes, infection of the bloodstream, and death. However, the cure rate is high when appropriate antibiotics are given. Most travelers are at low risk.

• Tick-borne encephalitis
• Cutaneous leishmaniasis (transmitted by sandflies)

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.

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 Bishkek, call 103 (city ambulance) or 151 (commercial ambulance).

Medical care is extremely limited. Many expatriates go to the Medical Associates Clinic (Hyatt Regency Bishkek, 191 Sovetskaya, room 113; ph. 680262, 985745; All doctors speak English and are Western-trained), the German-Kyrgyz Medical Center (94/1 Akhunbaev St., Institute of Oncology, 1st Radiological Corps, Bishkek; tel. (312) 512197, 511797; e-mail al bakell@elcat.kg; English-speaking professor is available), or the VIP Clinic (110 Kievskaya Street, Bishkek, 720001, Sagymbaev Marat Akimovich, Chief Physician, Tazabekova Osipa Tabakelovna, Deputy Chief Physician, tel. (office) 996-312-621063; (home) 312-661 310; 24 hours duty telephone/ambulance: 996-312-660-356/228-992; reception: 996-312-663549 or 21-69-37 or 66-19-01; English speakers available). For a guide to other physicians, dentists, hospitals and clinics in the Kyrgyz Republic, 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.

Most pharmaceuticals are imported from the Russian Federation and other countries in the former Soviet Union. Quality is monitored by the Department of Drug Supply and Medical Equipment, but may not be comparable to drugs produced in Western countries. The choice of medications may be limited. Pharmacies recommended by the U.S. Embassy include the following (all in Bishkek):

• Prestige (95a Kievskaia Street; tel. 621-462)
• Neman (139 Moskovskaia street/ T. Moldo street; ph. 622-937; or 8 Manas Ave/Bokonbaeva street; tel. 216-792)
• Central Pharmacy (340 Frunze street; tel. 681-005)

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 the dosage of chloroquine is lower. 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.

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. If travel to malarious areas is unavoidable, chloroquine must be taken each week and 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.

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 the Kyrgyz Republic are encouraged to register at the Consular Section of the U.S. Embassy and obtain updated information on travel and security in the Kyrgyz Republic. The U.S. Embassy in Bishkek is located at 171 Prospect Mira, 720016 Bishkek, Kyrgyz Republic. The phone number is 996-312-551-241, fax: 996-312-551-264, and website: http://www.usemb-bishkek.rpo.at.

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.