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 Venezuela: prophylaxis is recommended for Angel Falls and for rural areas in the states of Apre, Amazonas, Barinas, Bolivar, Delta Amacuro, Sucre, and Tachira. In general, the risk of malaria is greatest between February and August, especially after onset of the rainy season in late May. Either mefloquine (Lariam), atovaquone/proguanil (Malarone)(PDF), or doxycycline may be given. Mefloquine is taken once weekly in a dosage of 250 mg, starting one-to-two weeks before arrival and continuing through the trip and for four weeks after departure. Mefloquine may cause mild neuropsychiatric symptoms, including nausea, vomiting, dizziness, insomnia, and nightmares. Rarely, severe reactions occur, including depression, anxiety, psychosis, hallucinations, and seizures. Mefloquine should not be given to anyone with a history of seizures, psychiatric illness, cardiac conduction disorders, or allergy to quinine or quinidine. Those taking mefloquine (Lariam) should read the Lariam Medication Guide (PDF). Atovaquone/proguanil (Malarone) is a recently approved combination pill taken once daily with food starting two days before arrival and continuing through the trip and for seven days after departure. Side-effects, which are typically mild, may include abdominal pain, nausea, vomiting, headache, diarrhea, or dizziness. Serious adverse reactions are rare. Doxycycline is effective, but may cause an exaggerated sunburn reaction, which limits its usefulness in the tropics.

Long-term travelers who will be visiting malarious areas and may not have access to medical care should bring along medications for emergency self-treatment should they develop symptoms suggestive of malaria, such as fever, chills, headaches, and muscle aches, and cannot obtain medical care within 24 hours. See malaria for details. Symptoms of malaria sometimes do not occur for months or even years after exposure.

Insect protection measures are essential.

Malaria prophylaxis is not recommended for Caracas, coastal areas, or Marguerita Island.

For further information about malaria in Venezuela, including maps showing the risk of malaria in different parts of the country, go to the Pan American Health Organization and the World Health Organization.

The following are the recommended vaccinations for Venezuela.

Measles vaccine is 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 (see "Recent outbreaks"). Many adults who had only one vaccination show immunity when tested and do not need the second vaccination. Although measles immunization is usually begun at age 12 months, children between the ages of 6 and 11 months should be given an initial dose of measles vaccine before traveling to Venezuela. If single-antigen measles vaccine is unavailable, MMR should be given. Children greater than 12 months of age should receive two doses of MMR, separated by at least one month, before going to Venezuela. Measles vaccine should not be given to pregnant or severely immunocompromised individuals.

The government of Venezuela recently announced that all Venezuelan nationals and foreign residents living in Venezuela, over the age of six months, who leave Venezuela and travel outside the Americas through international airports or ports, must be in possession of a certificate of vaccination documenting that they have been vaccinated against measles and rubella. Persons without a certificate will be vaccinated on-site. Although this only applies to Venezuelan nationals and foreign residents living in Venezuela, it would be prudent for all travelers to carry documentation of measles and rubella vaccination. For further information, go to Health Canada. A copy of the decree is posted in Spanish at Gaceta Oficial de la Republica Bolivariana de Venezuela.

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.

Yellow fever vaccine is recommended for all travelers greater than nine months of age, except those visiting only Caracas, Valencia, and the northern coastal areas (see the CDC map for details). In recent years, yellow fever has been reported from the states of Amazonas, Bolivar, Zulia, and Tachira, as well as Marguerita Island. A yellow fever outbreak was reported in June 2003 from the Venezuelan-Colombian border (see "Recent outbreaks" below). In September 1999, an unvaccinated California resident died from yellow fever contracted in the rainforests in Amazonas State (see MMWR report).

Yellow fever vaccine (YF-VAX; Aventis Pasteur Inc.) (PDF) must be administered at an approved yellow fever vaccination center, which will give each vaccinee a fully validated International Certificate of Vaccination. Yellow fever vaccine should not in general be given to those who are younger than nine months of age, pregnant, immunocompromised, or allergic to eggs. It should also not be given to those with a history of thymus disease or thymectomy. Reactions to the vaccine, which are generally mild, include headaches, muscle aches, and low-grade fevers. Serious allergic reactions, such as hives or asthma, are rare and generally occur in those with a history of egg allergy.

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.

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.)
• 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.)

Cholera vaccine is not generally recommended. Cholera outbreaks have occurred in the past, but no cases were reported for the years 2001 and 2002. Most travelers are at extremely 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.

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.

Dengue fever, a flu-like illness sometimes complicated by hemorrhage or shock, is reported annually in large numbers, especially from the states of Falcon, Zulia, Tachira, Aragua, Carabobo, and Merida Barinas. More than 27,000 cases were reported in the first half of 2008, representing a 17% increase over the same period in 2007. The largest number of cases were reported from Zulia (which borders Colombia), followed by Merida, Lara, and Monagas. More than 200 cases were reported in January 2008 from Margarita Island. For the year 2007, more than 77,000 cases were recorded, almost 100 percent more than in the preceding year. In November 2007, a major outbreak was reported from Maracay (see ProMED-mail; November 6 and December 27, 2007, and January 30 and February 11 and July 7, 2008). Dengue fever 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 are essential, as below.

A small measles outbreak was reported in March 2006, totaling 38 cases as of the end of the month. Cases were reported from the Capital District (15), Miranda (12), Zulia (7), Merida (3) and Carabobo (1). See the Pan-American Health Organization for details. A much larger outbreak occurred in September 2001, resulting in more than 6000 suspected cases, of which more than 2000 were confirmed. The outbreak began in Falcon State and spread to the neighboring State of Zulia, which reported the largest number of cases, as well as fourteen other states. Most cases occurred in children. The outbreak was controlled by a nationwide vaccination campaign. For further information, go to the Centers for Disease Control and EPI Newsletter (PDF). All travelers to Venezuela should make sure they are fully immunized against measles, as above.

Cases of yellow fever are regularly reported from Venezuela. In September-October 2005, seven cases of yellow fever were confirmed in the central state of Portuguesa. In April-May 2005, three cases were reported from Merida State. In October 2004, three cases were identified in the northeastern state of Monagas (two in the municipality of Bolivar and one in Maturin) (see the Pan-American Health Organization). Earlier in 2004, two cases were reported from the municipality of Sucre, Merida State (see the World Health Organization).

In June 2003, a yellow fever outbreak was reported from the Venezuelan-Colombian border, resulting in 34 cases and 14 deaths in Venezuela. Affected areas included the States of Tachira (municipalities of Fernandez, Feo, Libertad and Uribante), Zulia (municipalities of Jesus Maria Semprun, Machiques, Rosario de Perija, Catatumbo, and Jesus E. Lossada) and Portuguesa (municipality of Guanarito). Most of those involved were farm laborers, many of them Colombian nationals who cross the frontier daily for work. The outbreak appeared to have ended by November 2003. For further information, go to EID Weekly Updates and ProMED-mail (August 23, September 2, October 2, and November 11, 2003). In October 1998, a yellow fever outbreak occurred among the Yanomami Indians in Amazonas State, near the border with Brazil. Yellow fever vaccine is recommended for all travelers greater than nine months of age, except those visiting only Caracas, Valencia, and the northern coastal areas.

A localized outbreak of foot-and-mouth disease was reported in June 2001. See ProMED-mail (June 16, 2001) for details. Foot-and-mouth disease poses no risk to humans, but may cause a debilitating illness in cattle, pigs, sheep, and goats, resulting in devastating losses in milk and meat production. Humans may spread the disease if their clothing, shoes, or personal effects become contaminated.

Chagas disease is still reported from Venezuela, mostly from the northern half of the country. The infection is usually transmitted by triatomine insects, which infest substandard human dwellings, but a school outbreak apparently caused by contaminated fruit juice was recently reported (see ProMED-mail, December 26, 2007). Transmission has been effectively controlled in recent years through an aggressive program of insecticide house-spraying and improvements in rural housing.

Venezuelan equine encephalitis reached epidemic levels in 1995 after unusually heavy rainfalls, especially in the states of Zulia, Lara, Falcon, Yaracuy, Carabobo, and Trujillo in the northwestern part of the country. The greatest incidence was reported among the Wayuu population. Cases still occur, but in smaller numbers, chiefly in the west between the Guajira peninsula and the Catatumbo River.

Venezuelan hemorrhagic fever is reported. An outbreak occurred in 1989-1991, followed by occasional cases since that time in the Guanarito area. The infection appears to be related to rodent exposure.

Hepatitis D has been reported among Amerindians in villages southwest of Maracaibo.

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.

Other infections include

• Cutaneous, mucocutaneous, and visceral leishmaniasis (rural foci throughout the country; most intense transmission occurs in west central areas; recent increase in Aragua State)
• Brucellosis (the most common animal source is infected cattle)
• Tick-borne relapsing fever
• Schistosomiasis (isolated foci in the north-central part of the country, including the Federal District (but not Caracas) and the states of Aragua, Carabobo, Guarico, and Miranda)
• Onchocerciasis (rural foci at elevations up to 1000 m in the northeastern, north-central, and southern parts of the country)
• Kyasanur forest disease (reported in Guanarito)
• Fascioliasis (sheep-raising areas)
• Eastern equine encephalitis
• Paragonimiasis (rare)
• Coccidioidomycosis (occurs rarely in arid areas)
• Mayaro virus disease (semirural areas in central Venezuela; see Emerging Infectious Diseases and ProMED-mail, April 28,2001)
• West Nile virus (identified in birds)

For in-depth public health information, go to the Pan-American Health Organization. For further information, go to the Ministerio de Salud (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, 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 Venezuela, call 171, but service is variable. For a private ambulance, which is more reliable, call ServiMedic Venezuela at 0212 395 27 03; e-mail: servimedicvzla@telcel.net.ve.

Good medical care is available at private clinics in Caracas and other major cities. Many travelers go to one of the following:

• Clínica El Avila (6th transversal with Av. San Juan Bosco, Altamira Norte; tel. 276-1111; U.S. Embassy Medical Advisor: Dr. Ronald Stern (Internal Med./Hematology/Oncology); tel. 276-1984; 264-7120; 264-7340 fax; beeper 731-5111 clave 4481; emergency room tel. 276-1013; 276-1014)
• Centro Médico Docente La Trinidad (Carretera towards El Hatillo in La Trinidad (“Av. Intercomunal La Trinidad”) La Trinidad; tel. 949-6411 (M-F 8 AM - 6 PM only); U.S. Embassy Medical Advisor, Dr. Raul Isturiz (Internal Medicine); tel. 949-6339 (appts); 949-6290 direct; 941-8187/5078; emergency room tel. 949-6291; 949-6369)
• Instituto Médico La Floresta (Av. Principal de la Floresta and Fco. Miranda, La Floresta; tel. 209-6222; 209-6122; U.S. Embassy Medical Advisor, Dr. Jean Desenne (Internal Medicine/Hematology); tel. 284-2656; 986-5683; beeper 731-0711 clave 7301; emergency room 209-6368; 209-6369)
• Policlínica Metropolitana (Calle A-1, Caurimare; tel. 908-0100; 908-0229; U.S. Embassy Medical Advisor, Dr. David Gentili (Internal Med./Critical Care Specialist); tel. 908-0330; 908-0590; 908-0594 Intensive Care Unit; emergency room tel. 908-0430, 908-0431, 908-4444)

Most doctors and hospitals will expect payment in cash, regardless of whether you have travel health insurance. Some private facilities accept credit cards. For an online list of other physicians, dentists, and health care providers, most of whom speak English, go to the U.S. Embassy website. Public hospitals are free, but essential supplies may be lacking and the quality of care may be substandard. Adequate medical care may be difficult to find in rural areas. Serious medical problems will require air evacuation to a country with state-of-the-art medical facilities.

Most pharmacies are well-supplied, but some prescription medications that are sold in the United States may not be available in Venezuela. Many travelers go to one of the following:

• Auto Farmacia (Avenida Principal, Las Mercedes; tel. 993-9251)
• Farmacia Las Rosas, CA. (Santa Rosa de Lima; open 24 hrs; tel. 991-3435)
• La Farmacia (Central Integral, Santa Rosa de Lima; open 24 hrs; tel. 993-2674; 993-3286)
• Farmacia Gitutto (Avenida Orinoco, Las Mercedes; tel. 993-4161)
• Farmacia Hotel Tamanaco (Las Mercedes; tel. 991-4510)

Make sure you have the names and contact information for qualified medical personnel in Venezuela before you go abroad (see the U.S. Embassy website).

In general, the recommendations for infants and young children are the same as those for adults, except that certain vaccines and medications should not be administered to this age group. Most importantly, yellow fever vaccine is not approved for use in those under age nine months. Unless there is an extraordinary need to do so, children less than nine months of age should not be brought to areas where yellow fever occurs.

The recommendations for malaria prophylaxis are the same for young children as for adults, except that (1) dosages are lower; (2) Malarone is not recommended for children weighing less than 25 pounds; and (3) doxycycline should be avoided. DEET-containing insect repellents are not advised for children under age two, so it's particularly important to keep children in this age group well-covered to protect them from mosquito bites.

Food and water precautions, which are recommended for all travelers, must be strictly followed at all times, because diarrhea is especially dangerous in this age group and because the vaccines for hepatitis A and typhoid fever are not approved for children less than two years of age.

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).

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.

Yellow fever vaccine, which consists of live virus, should not in general be given to pregnant women. Unless absolutely necessary, pregnant women should not travel to areas where yellow fever occurs.

Pregnant women should also avoid areas where malaria is transmitted. 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, 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. Of the currently available drugs for malaria prophylaxis, Mefloquine (Lariam) may be given if necessary in the second and third trimesters, but should be avoided in the first trimester. There are no data regarding the safety of atovaquone/proguanil (Malarone) during pregnancy, so the drug should be avoided pending further information. Doxycycline may interfere with fetal bone development and should not be given during 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. 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.

U.S. citizens living in or visiting Venezuela are strongly encouraged to register on line at https://travelregistration.state.gov and check the Embassy website at http://embajadausa.org.ve to obtain updated information on travel and security within Venezuela. The U.S. Embassy is located at Calle Suapure and Calle F, Colinas de Valle Arriba, Caracas. The Embassy is open from 8 am to 5 pm, Monday-Friday, telephone (58)(212) 975-6411. In case of an after-hours emergency, callers should dial (58)(212) 975-9821.

Direct consular office phone lines are as follows: (58)(212) 975-9234 (preferably afternoons) for information on applications for U.S. passports, Reports of Birth, registration, or other U.S. citizenship and passport matters; (58)(212) 975-9777 to report injury, death, destitution, imprisonment, or other matters of an emergency nature involving a U.S. citizen in Venezuela. The American Citizens Services section fax number is (58)(212) 975-8991. Additional information is also available at the Embassy's Internet website at: http://caracas.usembassy.gov/.

A part-time consular agent in Maracaibo provides services for U.S. citizens in western Venezuela. The agent is available to the public every Monday from 8:15 am to 12:15 pm, at the Centro Venezolano Americano del Zulia (CEVAZ), Calle 63 No. 3E-60, Maracaibo; telephone (58)(0261) 791-1436 or 791-1980.

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.