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 Turkey: prophylaxis is recommended for the provinces of Adana, Adryaman, Batman, Bingol, Bitlis, Diyarbakar, Elazig, Gaziantep, Hakkari, Hatay, Icel, Kahraman Maras, Kilis, Mardin, Mus, Osmaniyeh, Sanliurfa, Siirt, Sirnak, and Van, chiefly in the south and southeastern parts of the country. Peak transmission occurs from May to October. The drug of choice is chloroquine, taken once weekly in a dosage of 500 mg, starting one-to-two weeks before arrival and continuing through the trip and for four weeks after departure. Chloroquine may cause mild adverse reactions, including gastrointestinal disturbance, headache, dizziness, blurred vision, and itching, but severe reactions are uncommon. Insect protection measures are advised for areas of malaria risk.

There is no malaria risk on typical cruise itineraries or on Incerlik U.S. Air Force Base

For further information on malaria in Turkey, including a map showing the risk of malaria in different parts of the country, go to the World Health Organization and the World Health Organization.

The following are the recommended vaccinations for Turkey:

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 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.

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.

Cholera vaccine is not recommended. Cholera is not being reported from Turkey at this time.

Polio immunization is not recommended for any adult traveler who completed the recommended childhood immunizations. In June 2002, the World Health Organization certified that polio had been eradicated from the European region.

An outbreak of Crimean-Congo hemorrhagic fever (CCHF) was reported in May 2008 from the central Anatolian and eastern Anatolian provinces (Tokat, Corum, Sivas, Amasya, Yozgat and Gumushane), resulting in 27 deaths by late June. At least five cases occurred in health care providers (see ProMED-mail). Crimean-Congo hemorrhagic fever is a life-threatening viral infection which is usually transmitted by ticks (less commonly by direct contact with infected animals or by exposure to an infected person). In Turkey, most cases are reported from the eastern provinces of Tokat, Yozgat, and Sivas (see Emerging Infectious Diseases). The ticks in Istanbul reportedly do not carry the disease. 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. Tick precautions, as described below, are strongly recommended for all travelers to northeast Turkey. Hospital patients with Crimean-Congo hemorrhagic fever should be isolated using barrier nursing techniques.

In June 2007, an increase in the number of cases of Crimean-Congo hemorrhagic fever was reported from the Black Sea and Central Anatolia regions (see ProMED-mail; June 10, 2007, and May 8 and 22, 2008). An increase was also observed in the first seven months of 2006, resulting in 242 confirmed cases and 20 deaths as of August 4. Six provinces in Kelkit Valley in northeastern Turkey were the most affected (Tokat, Sivas, Gümüshane, Amasya, Yozgat and Corum provinces). One of the fatal cases occurred in a health care worker who acquired the infection while treating CCHF patients in Corum province. No cases were reported from popular tourist resorts on the Mediterranean coast. For further information, go to the World Health Organization, Eurosurveillance, ProMED-mail, and NATHNAC.

An outbreak of typhoid fever was reported in March 2007 from the village of Bascatak in the province of Mus in eastern Turkey (see ProMED-mail; March 16, 2007). Typhoid vaccine is recommended for all travelers to Turkey, with the exception of short-term visitors who restrict their meals to major restaurants and hotels, such as business travelers and cruise passengers.

An outbreak of H5N1 avian influenza ("bird flu") was reported from Turkey in January 2006, resulting in 12 human cases, four of them fatal. The fatalities all occurred in children from the town of Dogubayazit in the eastern province of Agri, near the Iranian border. As in other countries, virtually all cases resulted from direct contact with diseased birds. There was no evidence of person-to-person transmission. No human cases have been reported since early 2006. The most recent poultry outbreaks were reported in March 2008 from a village near Ipsala in Edirne province, in the western part of the country near the border with Greece; in February 2008 from the village of Yenicam, Sakarya province, in the northwest of the country; and in January 2008 from the Zonguldak and Samsun provinces in the northern Black Sea region.

Most travelers are at extremely low risk for avian influenza. The World Health Organization and the Centers for Disease Control do not advise against travel to countries affected by avian influenza, but recommend that travelers should avoid exposure to live poultry, including visits to poultry farms and open markets with live birds; should not touch any surfaces that might be contaminated with feces from poultry or other animals; and should make sure all poultry and egg products are thoroughly cooked. A vaccine for avian influenza was recently approved by the U.S. Food and Drug Administration (FDA), but produces adequate antibody levels in fewer than half of recipients and is not commercially available. The vaccines for human influenza do not protect against avian influenza. Anyone who develops fever and flu-like symptoms after travel to Turkey should seek immediate medical attention, which may include testing for avian influenza. For a map showing the current distribution of avian influenza in Turkey, go to the European Commission Joint Research Centre. For additional information, go to the World Health Organization, Health Canada, the Centers for Disease Control, and ProMED-mail.

A cluster of E. coli O157 infections was reported in July-August 2005 among Scottish tourists who had stayed in coastal resorts of the southwest province of Mugla and the southern province of Antalya. A total of 10 confirmed and 5 suspected cases were identified. The source of infection was not determined. For further information, go to Eurosurveillance. E. coli O157 frequently causes bloody diarrhea and may lead to kidney failure. Any traveler to Turkey who develops bloody diarrhea should immediately seek medical attention.

A tularemia outbreak was reported from western Turkey (Edirne Province) in May 2005. The outbreak appeared to be related to drinking water from a contaminated spring. For further information, go to ProMED-mail.

An outbreak of Salmonella infections was reported among travelers to southwestern Turkey in the summer of 1999. Most had stayed in the town of Alanya in the Antalya region.

• Legionnaires' disease (has been reported among travelers returning from Turkey; see European Working Group on Legionella Infections)
• Cutaneous leishmaniasis (increasing incidence)
• Visceral leishmaniasis (southeast Anatolia only)
• Tick-borne relapsing fever
• Louse-borne relapsing fever
• Brucellosis (especially prevalent in the poor eastern regions)
• Anthrax
• Fascioliasis (sheep liver fluke disease)

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, including 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, hats and shoes (rather than sandals). 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, shoes, and bed nets. Permethrin-treated clothing appears to have little toxicity. Don't sleep with the window open unless there is a screen. If sleeping outdoors or in an accomodation that allows entry of mosquitoes, use a bed net, preferably impregnated with insect repellent, with edges tucked in under the mattress. The mesh size should be less than 1.5 mm. If the sleeping area is not otherwise protected, use a mosquito coil, which fills the room with insecticide through the night.

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 a public ambulance in Turkey, call 112. For a private ambulance in Istanbul, call the International Hospital at 0212-663-3000 or Vehbi Koc Foundation American Hospital at 0212 311 20 00 -1. For a private ambulance in Ankara, call Bayindir Hospital at 0312-287-9000 (English may not be spoken).

The quality of medical care is highly variable, but modern health care is available in the new, private hospitals in Ankara and Istanbul. In Ankara, many travelers go to Mesa Hospital (Mesa Hastanesi), which offers a broad range of specialty and emergency services and has been accredited by the Joint Commission International (Yasam Caddesi No:5 Sogütözü, Ankara; tel. 90 (312) 292 99 00; website http://www.mesahastanesi.com.tr/en_default.aspx). In Istanbul, many expatriates go to the International Hospital (82 Yesilkoy 34800, Istanbul; ph. 90-212-663-3000; website http://www.internationalhospital.com.tr/english/hqs_ukas.asp), which has been accredited by the Health Quality Service (HQS) in the United Kingdom and is a member of the New York-Presybyterian International Network. The Acibadem Medical Group, which is affiliated with Harvard Medical International and has been accredited by the Joint Commission International, operates four hospitals and a number of outpatient clinics in Istanbul (see website at http://www.acibadem.com.tr/English/AcibademSaglikMerkezleri.asp for locations). The Memorial Health Group, also accredited by the Joint Commission International, operates one hospital and two outpatient clinics in Istanbul (see website at http://www.memorial.com.tr/eng/iletisim.php for locations). The Vehbi Koc Foundation American Hospital (Güzelbahçe Sokak, No: 20 Nişantaşı, İstanbul, tel. 90 212 311 20 00; website http://www.amerikanhastanesi.com.tr/kurum.aspx?r=6485; accredited by the Joint Commission International) offers 24-hour ambulance service to the hospital.

Outpatient care for travelers is available at the Marmara University Travel Medicine Clinic, which is affiliated with the Marmara University Academic Hospital (Volkan Korten MD, Nuh Kuyusu Cad. No: 88, Baglarbasi, Istanbul; ph. 90-216-651-0000; website http://abone.turk.net/travmed), and the German Hospital Universal Hospitals Group (Chengiz Uzun MD, Siraselviler Cd No 119 Taksim 80060, Istanbul; ph. 90-212-293-2150; website http://almanhastanesi.com.tr). For a list of other physicians, dentists, and hospitals in Turkey, go to the U.S. Embassy (see menu on the left). Good medical care may be difficult to find in the smaller cities and elsewhere. Many doctors and hospitals will expect payment in cash, regardless of whether you have travel health insurance. Life-threatening medical problems may require air evacuation to a country with state-of-the-art medical facilities.

Quality control of pharmaceuticals is regulated by the Turkish government. Certain medications may be difficult to obtain in Turkey. Pharmacies are staffed by a pharmacist and one or more supervisors, who have less training than a pharmacist. If you have questions about a medication, be sure to speak to the pharmacist, not a supervisor. Many medications that require a prescription in other countries are available over-the-counter in Turkey. Certain controlled medications are sold with a red or green prescription. Most pharmacies are open 6 days a week and closed on Sundays. In each neighborhood, there is one pharmacy that is "on duty" and open 24 hours. When closed, each pharmacy displays the name of the nearest open pharmacy in its window.

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).

The recommendations for malaria prophylaxis are the same for young children as for adults, except that the dosages of chloroquine are 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. The U.S. State Department recommends medical evacuation for its personnel who will be giving birth.

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.

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 once a 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 or traveling in Turkey 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 Turkey. 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 Ankara is at 110 Ataturk Boulevard, tel: (90)(312) 455-5555, fax (90)(312) 468-6131. Visa information is available at (90)(312) 468-6110. The Internet address is http://ankara.usembassy.gov. Non-emergency e-mail messages about consular matters may be sent through the website.

The U.S. Consulate General in Istanbul is located at Kaplicalar Mevkii Sokak No. 2, 34460, Istinye, Sariyer, tel: (90) (212) 335-9000, fax (90) (212) 335-9102. Istanbul-specific information can also be accessed via the Consulate's website http://www.usconsulate-istanbul.org.tr/. Non-emergency e-mail messages about consular matters may be sent to email: ca_istanbul@state.gov.

The U.S. Consulate in Adana is located at Girne Bulvari No. 212, Guzelevler Mahallesi, Yuregir, Adana, Turkey. tel: 90)(322) 346-6262, fax (90)(322) 346-7916.

The U.S. Consulate in Izmir can be reached at (90)(232) 464-8755.

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.