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 Russia:

Tetanus-diphtheria vaccine is recommended for all adults 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). Cases of diphtheria have been reported among U.S. citizens who have traveled to this area.

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.

Certain lots of VAQTA were recalled in December 2001 because some prefilled syringes were found not to contain enough antigen. Those who received VAQTA between August 1999 and December 2001 should go to hepatitis Ato determine whether or not they may require reimmunization.

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 and cruise passengers. 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. An increased number of animal rabies cases was reported from the Rostov region in June 2007 and the Republic of Udmurtia in December 2006 (see ProMED-mail). In Russia, 22 people died from rabies in 2001, ten of them in the Northern Osetia (Alania) and Dagestan Republics (see EpiNorth).

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.

Japanese encephalitis vaccine is recommended only for long-term (1 month) travelers to rural areas in the far eastern maritime areas south of Khabarousk. The vaccine is also recommended for short-term travelers to this area if they engage in extensive unprotected outdoor activities, especially in the evening. Transmission is by mosquito bites and peaks from July through September.

Japanese encephalitis vaccine (JE-VAX; Aventis Pasteur Inc.) (PDF) is given as a series of three injections on days 0, 7 and 30. If time is short, the third dose may be given on day 14. Mild side effects, including fever, headache, muscle aches, malaise and soreness at the injection site, occur in about 20% of those vaccinated. Serious allergic reactions including urticaria, angioedema, respiratory distress and anaphylaxis are reported in approximately 0.6% of vaccinees and may occur as long as one week after vaccination. Any person who receives the vaccine should be observed in the doctor's office for at least 30 minutes following the injection and should complete the full series at least 10 days before departure. There are no data concerning the safety of Japanese encephalitis vaccine during pregnancy. In addition to vaccination, strict attention to insect protection measures is essential for anyone at risk.

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. The incidence is highest in the Ural region (Udmurtia Republic, Sverdlovsk and Primorsk oblasts), West Siberia (especially Tomsk Oblast), and East Siberia (especially Krasnojarsk krai). 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.

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. 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.

Polio vaccine is generally not recommended for any traveler who completed the recommended childhood immunizations, since polio has not been reported from Russia in recent years. A single dose of inactivated polio vaccine might be considered for extended travel east of the Urals

Cholera vaccine is not generally recommended, even though cholera occurs in Russia, because most travelers are at low risk for infection. Two oral vaccines have recently been developed: Orochol (Mutacol), licensed in Canada and Australia, and Dukoral, licensed in Canada, Australia, and the European Union. These vaccines, where available, are recommended only for high-risk individuals, such as relief workers, health professionals, and those traveling to remote areas where cholera epidemics are occurring and there is limited access to medical care. The only cholera vaccine approved for use in the United States is no longer manufactured or sold, due to low efficacy and frequent side-effects.

Cases of Crimean-Congo hemorrhagic fever are reported annually from the Southern Federal District, chiefly the Rostov, Volgograd, Astrakhan, Stavropol regions, and the Republics of Bashkortostan, Dagestan, Kalmykia, and Ingushetia. The incidence usually peaks in the spring and early summer. The number of cases has been rising, which may be due to insufficient expenditure on measures to control exposure of cattle and other livestock to tick infestation. As of May 2008, it appeared that the number of cases in Stavropol was increasing compared to the same time period in 2007. As of June 2008, the first cases of the year were being reported from the Volgograd and Astrakhan Oblasts. As of July 2008, more than 400 cases had been recorded for Bashkortostan, 61 for Stavropol, and 53 for Rostov (chiefly the Orlov, Martinov, and Zimovnikov districts). For the year 2007, a total of 224 cases weres recorded as of August 6, compared to 191 cases during the same period in 2006. By region, a total of 63 cases were registered in the Republic of Kalmykia (65 in 2006), 53 in the Rostov region (52 in 2006), 58 cases in the Stavropol region (40 in 2006), 28 cases in the Volgograd region (16 in 2006), 19 in the Astrakhan region (15 in 2006), one in the Republic of Karachaevo-Cherkessia (none in 2006), one in the Republic of Ingushetia (none in 2006), and one in the Republic of Dagestan (3 in 2006). In the year 2006, the number of cases in the Southern Federal District was substantially higher than in 2005 and the incidence was highest in the Republic of Kalmykia.

Crimean-Congo hemorrhagic fever is a life-threatening viral infection which is usually transmitted by ticks who have been feeding on infected animals (less commonly by direct contact with infected animals or rarely by exposure to an infected person). Initial symptoms may include fever, muscle aches, backache, joint pains, headaches, dizziness, and light sensitivity. Complications may result from hemorrhage into the skin, intestine, or other sites. Most cases occur in farm workers, who often remove ticks from farm animals without protecting themselves. Most travelers are at low risk. For further information, see ProMED-mail. Tick precautions are recommended for all travelers to southern Russia.

An outbreak of Legionnaires' disease was reported in July 2007 from the town of Verkhnyaya Pyshma in the Urals region, apparently related to contamination of the hot water supply after routine maintenance in the local thermal plant. Almost 200 suspected cases were identified, including four deaths. See ProMED-mail for details. 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.

More cases of tick-borne encephalitis have been reported in recent years, especially among urban residents, and their severity has been greater. Several factors appear to be responsible, including reduced use of pesticides and acaricides, increased recreational travel to forested areas, and insufficient vaccination of the population at risk. In most years, the incidence is highest in the Ural region (Udmurtia Republic, Sverdlovsk and Primorsk oblasts), West Siberia (especially Tomsk Oblast), and East Siberia (especially Krasnojarsk krai) (see EpiNorth and Eurosurveillance).

For the year 2007, a total of 2124 suspected cases of tick-borne encephalitis (1588 confirmed) had been recorded by August 6, roughly 30% more than during the corresponding period in 2006. The largest numbers of cases (laboratory confirmed in brackets) were recorded in the Krasnoyarsk Krai - 325 (180), the Altay Krai - 118 (43), the Novosibirsk Region - 127 (127), the Perm Krai - 106 (78), the Sverdlovsk Region - 118 (118), the Tomsk Region - 92 (89), the Archangelsk Region - 88 (43), the Kirovskaya Region - 78 (68), the Kemerovo Region - 99 (96), the Tyumen Region - 62 (35), and the Republic of Altay - 56 (46). Cases were also reported from the St. Petersburg region and the Maritime Province (see ProMED-mail, October 24, 2006; June 24 and 28, July 9 and 14, and August 10 and 30, 2007). In July 2007, an outbreak of tick-borne encephalitis related to contaminated goat milk was reported from the Vologda region.

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. The vaccine has been approved for use in many European countries, but not the United States. Tick precautions are strongly advised, as below.

Outbreaks of hemorrhagic fever with renal syndrome (HFRS) occur regularly in Russia, especially in the Privolzhskiy Federal District (chiefly the Mariy El, Bashkortostan, Udmurt, and Tatarstan Republics, which are located within the Privolzhskiy Federal District). The number of cases generally peaks every 3 years. An increased number of cases was reported from Tatarstan in July 2008, affecting the cities of Kazan and Naberejniye Chelni and the districts of Agrizskiy, Almetyevskiy, Leninogorskiy, Nijnekamskiy, Nurlatskiy, Pestrechinskiy, Ribno-Slobodskiy and Tyulaychinskiy, among others. In March 2007, a rise in cases was reported from the Central Federal Region, including the regions of Lipetsk, Voronej, Tambov, and Ryazan. In late 2006, a marked increase was reported from the Republic of Bashkortostan, the Chuvashia and the Orenburg regions, and the Voronezh region in central Russia. Hemorrhagic fever with renal syndrome is caused by a hantavirus and is acquired by exposure to rodent excreta, often by the aerosol route. The infection is not transmitted from person-to-person. Most cases occur in late autumn and early winter, when the rodents move into human dwellings. Cases also occur in the spring and summer, when people go into their gardens and visit the countryside and forests. Most travelers are at low risk for infection.

A measles outbreak was reported in February 2007 from Vyksa, in the Nizhny Novgorod region (see ProMED-mail; March 8, 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. 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 Russia. Measles vaccine should not be given to pregnant or severely immunocompromised individuals.

An outbreak of viral meningitis was reported in August 2006 from the the Khabarovsk territory in the Russian Far East, affecting more than 1400 people, most of them children under 14 years of age. Two different enteroviruses were isolated from patients: echovirus-6 and echovirus-30 (see ProMED-mail, August 30 and September 1, 2006). Echoviruses are spread by direct contact with the respiratory secretions or feces of an infected person. Complications from echovirus infections are rare. 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 hepatitis A was reported in September 2005 from the Nizhniy Novgorod region, chiefly the city of Nizhniy Novgorod (known as Gorky in the Soviet period), especially the Sormovskiy district of the city. Cases were also reported from Balakhna and Dzerzhinsk, to the north and west of Nizhniy Novgorod, respectively. As of late November, more than 2000 people had been affected. The outbreak was thought to be related to delayed repair of a network of waterpipes, though this remains uncertain. See the National Travel Health Network and Centre and ProMED-mail for further information. In June 2005, a hepatitis A outbreak was reported from the southwest district of the Tver region, chiefly the cities of Rzhev, Zubtsov and Olenino. As of late June, almost 700 cases had been reported. See ProMED-mail and National Travel Health Network and Centre for details. Hepatitis A vaccine is recommended for all travelers to Russia.

Outbreaks of H5N1 avian influenza ("bird flu") were reported in August 2005 from poultry farms in many parts of the country, including Altai Territory, Tiumen Region, Omsk Region, Kurgan Region, Chelyabinsk Region, and Novosibirsk Region. Poultry outbreaks continue to be reported, most recently from the Krasnodar region in September 2007, the Rostov region in December 2007, and the far east region of Primorye in April 2008. No human cases have been reported from Russia 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 does not advise against travel to Russia, but recommends that travelers to affected areas 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 Russia should seek immediate medical attention, which may include testing for avian influenza. It is not recommended that travelers bring along an antiviral medication, such as Tamiflu, or treat themselves. For further information, go to the World Health Organization, Health Canada, the Centers for Disease Control, and ProMED-mail.

The number of cases of meningococcal meningitis in Moscow was approximately twice as great in the year 2003 as it had been the previous year. A total of 273 cases and 24 deaths were reported as of October 2003. Most cases occurred in children. No institutional or family outbreaks were identified. The city health authorities responded by ordering a mass vaccination campaign. As of April 2004, it appeared that the number of cases had significantly fallen. Meningococcal vaccine is no longer recommended for travelers to Moscow. For further information, go to Eurosurveillance, Health Canada, and the National Travel Health Network and Centre.

A small cholera outbreak was reported from Kazan in the Republic of Tatarstan in July 2001. See ProMED-mail (July 31 and August 2, 2001) for details. A previous outbreak occurred in the southern part of the Republic of Dagestan during the first half of October 1998, resulting in eight cases. Cholera vaccine is not recommended for most travelers, as discussed above.

Eight young children in Vladivostok became ill after playing with discarded ampules of smallpox vaccine, which is made from vaccinia virus, not smallpox virus. See Disease Outbreak News (June 20, 2000) for further information.

An increase in the number of cases of pertussis (whooping cough) was reported from St. Petersburg in the 1990s, related to low levels of pertussis immunization among young children. The number of cases appeared to be falling by the end of the decade as vaccination rates improved. For further information, go to EpiNorth.

• Yersiniosis (caused by Yersinia pseudotuberculosis; symptoms include fever and right lower abdominal pain similar to appendicitis; school outbreaks reported due to contaminated food; outbreaks reported in July 2008 at a kindergarten in Krasnoyarsk; in September 2007 among schoolchildren in Noviy Urengoy in western Siberia; in July 2007 from a psychoneurological hostel and a summer camp, both in the Khabarovsk region; and in April 2007 from Megion; see ProMED-mail, May 1, August 3, and October 1, 2007); increased number of cases reported from Novosibirsk in 2006)
• West Nile fever (transmitted by mosquitoes; peak transmission from July through September; occurs in southern Russia, especially the Volgograd and Astrakhan Regions; cases also reported from the Rostov, Krasnodar and Stavrapol Regions; major outbreak reported from the Astrakhan region in September 2005; see Emerging Infectious Diseases)
• Lyme disease (widespread in Russia; increased number of cases reported for the Pskov Region in 2006; for St. Petersburg area, see EpiNorth; for Arkhangelsk province, go to EpiNorth)
• Malaria (reported chiefly from Moscow and neighboring districts; see Roll Back Malaria for further information; malaria prophylaxis not recommended at present)
• Anthrax (sheep outbreak reported in July 2008 from Buryatia in eastern Siberia, causing eight human cases; outbreaks linked to ingestion of meat from privately raised cattle reported in June and July 1998, causing 15 cases and 2 deaths; see ProMED-mail)
• Shigellosis (see ProMED-mail May 10, 2001)
• Brucellosis (chiefly the Caucasian districts; cattle, sheep, and goats are the most common sources of infection;)
• Leptospirosis (high incidence reported in Murmansk region 1995-6 due to outbreak among dogs)
• Epidemic louse-borne typhus
• HIV (human immunodeficiency virus) (travelers not at risk unless they have unprotected sexual contacts or receive injections or blood transfusions)
• Siberian tick typhus (east and central Siberia)
• Tick-borne encephalitis (chiefly the Siberian and Ural regions)
• Tick-borne relapsing fever (southern Russia)
• Trichinellosis (widespread in Russia, most often related to pork products; outbreaks caused by consumption of bear meat reported from Siberia in June 2008, February 2006, and November 2003; outbreak associated with badger meat in February 2004; see ProMED-mail)
• Opisthorchiasis (highest prevalence in the Tyumen, Tomsk, Novosibirsk, and Altay regions; parasitic infection which involves the biliary tract; acquired by eating raw or undercooked fish; causative organism found in the rivers Ob, Irtysh, Dnepr, Donets, Volga, Kama, and Neman; highest incidence along the middle and lower parts of the rivers Irtysh and Ob; see ProMED-mail, May 6 and 29, 2007)
• Astrakhan fever (transmitted by ticks)
• Omsk hemorrhagic fever (tick-borne; forest steppe regions of western Siberia)
• Spotted fever (chiefly the Russian Far East; rickettsial infection, transmitted by ticks; see Emerging Infectious Diseases)
• Powassan virus encephalitis (tick-borne; rare)
• Tularemia (transmitted by ticks; most cases occur in the the Northern, Central, and Western Siberian areas of Russia; especially common among hunters; outbreak reported in August 2007 from the settlement of Berezovo in the Khanti-Mansiysky autonomous region)
• Botulism (cases associated with consumption of dried and smoked fish and with home-tinned vegetables, frequently in the Rostov region and other areas in the southern steppes; also caused by homemade salted and preserved fish in Siberia; see ProMED-mail, November 9, 2006; July 15, 2007; and February 11, May 16, and July 28, 2008)
• Toxocariasis (parasitic infection carried by wild and domestic animals, especially dogs and cats, and shed in their feces; those at greatest risk include young children, veterinarians, hunters, and nursery workers; increase in number of cases reported from Tumen region in 2006; see ProMED-mail, December 5, 2006)
• Dirofilariasis (rare; two human cases reported from the Kirov region in April 2008; see ProMED-mail, April 8, 2008)

For detailed statistics regarding many infectious diseases, go to EpiNorth (click on EpiData from the menu on the left).

For a review of the epidemiological situation in the Russian Federation in 2001, go to EpiNorth. For a review of tick-and animal-borne infections in the Republic of Karelia, go to EpiNorth.

All travelers to the Urals and Western Siberia regions are strongly urged to read Medical Information on the website of the U.S. Consulate General in Yekaterinburg.

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.

Thousands of people are poisoned every year by contaminated, illegal alcohol. Do not drink any alcoholic beverage unless known to be produced by a reputable manufacturer.

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. 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.

In Moscow and most other areas, call 03 for a public ambulance. In general, the private ambulances are better equipped and respond faster. For a guide to these services, see the U.S. consular websites listed below.

Physicians and hospitals

For a guide to physicians, clinics, hospitals, and emergency services in Moscow, St. Petersburg, and Yekaterinburg (Urals and Western Siberia), go to the U.S. consular websites for those cities.

In general, medical care is below Western standards. Many facilities are poorly equipped. Essential medications and supplies may not be available. Elective surgery requiring blood transfusions should not be performed in Russia, due to uncertainties concerning the blood supply. Travelers to remote regions should bring a supply of sterile, disposable syringes, with a doctor's note explaining their necessity. 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.

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 or traveling in Russia are encouraged to register with the nearest U.S. Embassy or Consulate through the State Department's travel registration website, https://travelregistration.state.gov, and to obtain updated information on travel and security within Russia. 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's consular section is located in Moscow at Novinskiy Bulvar 19/23; The Embassy's switchboard is 7 (095) 728-5000, American Citizen Service's tel: (7) (095) 728-5000, after-hours emergencies: (7) (095) 728-5000, fax: (7) (095) 728-5084, email: consulmo@state.gov, and website: http://www.usembassy.ru.

U.S. Consulates General are located in:

St. Petersburg

15 Ulitsa Furshtadtskaya, St. Petersburg 191028 Tel: (7) (812) 331-2600 Fax: (7) (812) 331-2646 Email: acsstpete@state.gov. Website: http://www.stpetersburg-usconsulate.ru/

Vladivostok

32 Ulitsa Pushkinskaya, Vladivostok 690001 Tel: (7) (4232) 30-00-70 Fax: (7) (4232) 30-00-91 After-hours emergencies: (7) (4232) 71 00 67 E-mail: conssect@gin.ru Website: http://vladivostok.usconsulate.gov

Yekaterinburg

Ulitsa Gogolya 15a, 4th floor, Yekaterinburg 620151; Tel: (7) (343)379-3001 Fax: (7) (343) 379-4515 After-hours emergencies: (7) 8 902 84 16653 Email: consulyekat@state.gov Website: http://www.usa.ural.ru

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.