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 Cuba.

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. 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 Cuba, rabies is caused by contact with wild animals (especially the small Indian mongoose), bats, and dogs. 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.

All travelers should be up-to-date on routine immunizations, including

• Tetanus-diphtheria vaccine (recommended for all travelers who have not received a tetanus-diphtheria immunization within the last 10 years.)
• Measles vaccine (recommended for any traveler born after 1956 who does not have either a history of two documented measles immunizations or a blood test showing immunity. Many adults who had only one vaccination show immunity when tested and do not need the second vaccination. Measles vaccine should not be given to pregnant or severely immunocompromised individuals. Measles has not been reported in Cuba since 1994.)
• Varicella (chickenpox) vaccine (recommended for any international traveler over one year of age who does not have either a history of documented chickenpox or a blood test showing immunity. Many people who believe they never had chickenpox show immunity when tested and do not need the vaccine. Varicella vaccine should not be given to pregnant or immunocompromised individuals.)

Polio vaccine is not recommended for any adult traveler who completed the recommended childhood immunizations. Polio has been eradicated from the Americas, except for a small outbreak of vaccine-related poliomyelitis in the Dominican Republic and Haiti in late 2000.

Cholera vaccine is not recommended. Cholera outbreaks are not reported from the Caribbean.

The Department of State alerts U.S. citizens to the quarantine measures imposed by the Government of Cuba in response to the 2009-H1N1 pandemic that may affect travel to Cuba. This Travel Alert expires on January 7, 2010.

In April 2009, Cuba implemented a policy that allows it to quarantine arriving passengers who exhibit fever or flu-like symptoms. Although the overall percentage of U.S. citizens being quarantined remains low, the nature of the selection process makes it almost impossible to predict when a traveler may be placed into quarantine.

Cuba has reported confirmed cases of H1N1 and has quarantined the cases, including foreign travelers and residents, until their recovery. Cuban authorities screen travelers coming into Cuba by asking them to fill out a questionnaire regarding their current health status. If travelers are identified as being ill with flu-like symptoms in the airport, they may be evaluated by local medical personnel with the potential for treatment and quarantine at a Cuban hospital. The Government of Cuba directs that individuals staying or residing in Cuba, including diplomats, who are exhibiting flu-like symptoms, report to the hospital where they are normally treated. If the hospital suspects that the individual may have H1N1, they will be immediately quarantined for treatment.

Please note that the U.S. Department of State usually cannot interfere with the rights of other countries to screen airline passengers entering or exiting their countries, nor can it influence the number of days in quarantine.Because these outbreak-related delays, which could include several days of quarantine (the standard period is six days), may affect planned activities and lead to unexpected costs, CDC strongly recommends that travelers consider purchasing travel insurance.U.S. citizens are reminded that the U.S. government imposes restrictions on travel to Cuba. For further information, please see our Consular Specific Information for Cuba...

A major outbreak of dengue fever was reported in July 2006 from Cerro, Playa, Centro Habana (Central Havana), Arroyo Naranjo, and Santiago de Cuba. The outbreak peaked in September and October and appeared to be coming under control by November. Another major outbreak occurred from November 2001 through March 2002, involving Havana and other areas and resulting in about 3000 cases. The outbreak was terminated by an aggressive program of mosquito control. Dengue fever is a flu-like illness which may be complicated by hemorrhage or shock. The disease is transmitted by Aedes mosquitoes, which bite primarily in the daytime and favor densely populated areas, though they also inhabit rural environments. No vaccine is available at this time. Insect protection measures, as below, are recommended when dengue outbreaks occur.

A small number of cases of West Nile virus infection have been reported (see ProMED-mail).

Leptospirosis was reported at epidemic levels in 1994. The incidence has decreased significantly since then, but the disease persists.

An outbreak of viral meningoencephalitis began in 1995 and extended into early 1996.

Fascioliasis may be acquired by eating contaminated watercress grown in sheep-raising areas.

Brucellosis may be acquired from infected pigs.

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.

For in-depth public health information, go to the Pan-American Health Organization (in English) or Infomed (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, including ceviche. 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, sea bass, and a large number of tropical reef 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, 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 an on-line listing of hospitals and other health institutions in Cuba, go to Infomed (in Spanish). For travel health services, many travelers go to Clinica Central Cira Garcia (Calle 20 No. 4101 esquina Ave 41, Playa, Ciudad de la Habana; tel. 537-2042811 to 14).

The Cuban government has established a for-profit health system for foreigners called Servimed (tel. 07/24-01-41 or 42), which is entirely separate from the free, not-for-profit system that takes care of Cuban citizens. There are more than 40 Servimed health centers across the island, offering primary care as well as a variety of specialty and high-tech services. If you’re staying in a hotel or other accommodation, the usual way to access the system is to ask the manager for a physician referral. Many of the physicians are well-trained, but supplies and bed space are often inadequate. Life-threatening medical problems will generally require air evacuation to a country with state-of-the-art medical facilities.

There are special pharmacies for foreigners, also run by the Servimed system, but all Cuban pharmacies are notoriously short on supplies, including pharmaceuticals. Be sure to bring along adequate quantities of all medications you might need, both prescription and over-the-counter. Also, be sure to bring along a fully-stocked medical kit.

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 Infomed).

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" above), because diarrhea can be especially dangerous in this age group. 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 Infomed). 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.

The U.S. Interests Section (USINT) represents American citizens and the U.S. Government in Cuba, and operates under the legal protection of the Swiss government. The Interests Section staff provides the full range of American citizen and other consular services. U.S. citizens who travel to Cuba are encouraged to contact and register with the American Citizen Services section. USINT staff provide briefings on U.S.-Cuba policy to American individuals and groups visiting Cuba. These briefings or meetings can be arranged through USINT's Public Diplomacy office.

The Interests Section is located in Havana at Calzada between L and M Streets, Vedado; telephone (537) 33-3551 through 33-3559. Hours are Monday through Thursday, 8:30 a.m. to 5:00 p.m., and Friday, 8:30 a.m. to 4:00 p.m. After hours and on weekends, the number is 33-3026 or 66-2302. Should you encounter an emergency after normal duty hours, call these numbers and request to speak with the duty officer.

U.S. citizens who register at the U.S. Interests Section in Havana may obtain updated information on travel and security within the country. There is no access to the U.S. Naval Base at Guantanamo Bay from within Cuba. Consular issues for Guantanamo Bay are handled by the U.S. Embassy in Kingston, Jamaica. For further information on Guantanamo Bay, please contact the U.S. Embassy in Kingston at telephone (876) 929-5374.

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.