vaccine for travel diarrhea

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• Traveler's diarrhea

Gastrointestinal tract

Your digestive tract stretches from your mouth to your anus. It includes the organs necessary to digest food, absorb nutrients and process waste.

Traveler's diarrhea is a digestive tract disorder that commonly causes loose stools and stomach cramps. It's caused by eating contaminated food or drinking contaminated water. Fortunately, traveler's diarrhea usually isn't serious in most people — it's just unpleasant.

When you visit a place where the climate or sanitary practices are different from yours at home, you have an increased risk of developing traveler's diarrhea.

To reduce your risk of traveler's diarrhea, be careful about what you eat and drink while traveling. If you do develop traveler's diarrhea, chances are it will go away without treatment. However, it's a good idea to have doctor-approved medicines with you when you travel to high-risk areas. This way, you'll be prepared in case diarrhea gets severe or won't go away.

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Traveler's diarrhea may begin suddenly during your trip or shortly after you return home. Most people improve within 1 to 2 days without treatment and recover completely within a week. However, you can have multiple episodes of traveler's diarrhea during one trip.

The most common symptoms of traveler's diarrhea are:

• Suddenly passing three or more looser watery stools a day.
• An urgent need to pass stool.
• Stomach cramps.

Sometimes, people experience moderate to severe dehydration, ongoing vomiting, a high fever, bloody stools, or severe pain in the belly or rectum. If you or your child experiences any of these symptoms or if the diarrhea lasts longer than a few days, it's time to see a health care professional.

When to see a doctor

Traveler's diarrhea usually goes away on its own within several days. Symptoms may last longer and be more severe if it's caused by certain bacteria or parasites. In such cases, you may need prescription medicines to help you get better.

If you're an adult, see your doctor if:

• Your diarrhea lasts beyond two days.
• You become dehydrated.
• You have severe stomach or rectal pain.
• You have bloody or black stools.
• You have a fever above 102 F (39 C).

While traveling internationally, a local embassy or consulate may be able to help you find a well-regarded medical professional who speaks your language.

Be especially cautious with children because traveler's diarrhea can cause severe dehydration in a short time. Call a doctor if your child is sick and has any of the following symptoms:

• Ongoing vomiting.
• A fever of 102 F (39 C) or more.
• Bloody stools or severe diarrhea.
• Dry mouth or crying without tears.
• Signs of being unusually sleepy, drowsy or unresponsive.
• Decreased volume of urine, including fewer wet diapers in infants.

It's possible that traveler's diarrhea may stem from the stress of traveling or a change in diet. But usually infectious agents — such as bacteria, viruses or parasites — are to blame. You typically develop traveler's diarrhea after ingesting food or water contaminated with organisms from feces.

So why aren't natives of high-risk countries affected in the same way? Often their bodies have become used to the bacteria and have developed immunity to them.

Risk factors

Each year millions of international travelers experience traveler's diarrhea. High-risk destinations for traveler's diarrhea include areas of:

• Central America.
• South America.
• South Asia and Southeast Asia.

Traveling to Eastern Europe, South Africa, Central and East Asia, the Middle East, and a few Caribbean islands also poses some risk. However, your risk of traveler's diarrhea is generally low in Northern and Western Europe, Japan, Canada, Singapore, Australia, New Zealand, and the United States.

Your chances of getting traveler's diarrhea are mostly determined by your destination. But certain groups of people have a greater risk of developing the condition. These include:

• Young adults. The condition is slightly more common in young adult tourists. Though the reasons why aren't clear, it's possible that young adults lack acquired immunity. They may also be more adventurous than older people in their travels and dietary choices, or they may be less careful about avoiding contaminated foods.
• People with weakened immune systems. A weakened immune system due to an underlying illness or immune-suppressing medicines such as corticosteroids increases risk of infections.
• People with diabetes, inflammatory bowel disease, or severe kidney, liver or heart disease. These conditions can leave you more prone to infection or increase your risk of a more-severe infection.
• People who take acid blockers or antacids. Acid in the stomach tends to destroy organisms, so a reduction in stomach acid may leave more opportunity for bacterial survival.
• People who travel during certain seasons. The risk of traveler's diarrhea varies by season in certain parts of the world. For example, risk is highest in South Asia during the hot months just before the monsoons.

Complications

Because you lose vital fluids, salts and minerals during a bout with traveler's diarrhea, you may become dehydrated, especially during the summer months. Dehydration is especially dangerous for children, older adults and people with weakened immune systems.

Dehydration caused by diarrhea can cause serious complications, including organ damage, shock or coma. Symptoms of dehydration include a very dry mouth, intense thirst, little or no urination, dizziness, or extreme weakness.

Watch what you eat

The general rule of thumb when traveling to another country is this: Boil it, cook it, peel it or forget it. But it's still possible to get sick even if you follow these rules.

Other tips that may help decrease your risk of getting sick include:

• Don't consume food from street vendors.
• Don't consume unpasteurized milk and dairy products, including ice cream.
• Don't eat raw or undercooked meat, fish and shellfish.
• Don't eat moist food at room temperature, such as sauces and buffet offerings.
• Eat foods that are well cooked and served hot.
• Stick to fruits and vegetables that you can peel yourself, such as bananas, oranges and avocados. Stay away from salads and from fruits you can't peel, such as grapes and berries.
• Be aware that alcohol in a drink won't keep you safe from contaminated water or ice.

Don't drink the water

When visiting high-risk areas, keep the following tips in mind:

• Don't drink unsterilized water — from tap, well or stream. If you need to consume local water, boil it for three minutes. Let the water cool naturally and store it in a clean covered container.
• Don't use locally made ice cubes or drink mixed fruit juices made with tap water.
• Beware of sliced fruit that may have been washed in contaminated water.
• Use bottled or boiled water to mix baby formula.
• Order hot beverages, such as coffee or tea, and make sure they're steaming hot.
• Feel free to drink canned or bottled drinks in their original containers — including water, carbonated beverages, beer or wine — as long as you break the seals on the containers yourself. Wipe off any can or bottle before drinking or pouring.
• Use bottled water to brush your teeth.
• Don't swim in water that may be contaminated.
• Keep your mouth closed while showering.

If it's not possible to buy bottled water or boil your water, bring some means to purify water. Consider a water-filter pump with a microstrainer filter that can filter out small microorganisms.

You also can chemically disinfect water with iodine or chlorine. Iodine tends to be more effective, but is best reserved for short trips, as too much iodine can be harmful to your system. You can purchase water-disinfecting tablets containing chlorine, iodine tablets or crystals, or other disinfecting agents at camping stores and pharmacies. Be sure to follow the directions on the package.

Follow additional tips

Here are other ways to reduce your risk of traveler's diarrhea:

• Make sure dishes and utensils are clean and dry before using them.
• Wash your hands often and always before eating. If washing isn't possible, use an alcohol-based hand sanitizer with at least 60% alcohol to clean your hands before eating.
• Seek out food items that require little handling in preparation.
• Keep children from putting things — including their dirty hands — in their mouths. If possible, keep infants from crawling on dirty floors.
• Tie a colored ribbon around the bathroom faucet to remind you not to drink — or brush your teeth with — tap water.

Other preventive measures

Public health experts generally don't recommend taking antibiotics to prevent traveler's diarrhea, because doing so can contribute to the development of antibiotic-resistant bacteria.

Antibiotics provide no protection against viruses and parasites, but they can give travelers a false sense of security about the risks of consuming local foods and beverages. They also can cause unpleasant side effects, such as skin rashes, skin reactions to the sun and vaginal yeast infections.

As a preventive measure, some doctors suggest taking bismuth subsalicylate, which has been shown to decrease the likelihood of diarrhea. However, don't take this medicine for longer than three weeks, and don't take it at all if you're pregnant or allergic to aspirin. Talk to your doctor before taking bismuth subsalicylate if you're taking certain medicines, such as anticoagulants.

Common harmless side effects of bismuth subsalicylate include a black-colored tongue and dark stools. In some cases, it can cause constipation, nausea and, rarely, ringing in your ears, called tinnitus.

• Feldman M, et al., eds. Infectious enteritis and proctocolitis. In: Sleisenger and Fordtran's Gastrointestinal and Liver Disease: Pathophysiology, Diagnosis, Management. 11th ed. Elsevier; 2021. https://www.clinicalkey.com. Accessed May 25, 2021.
• LaRocque R, et al. Travelers' diarrhea: Microbiology, epidemiology, and prevention. https://www.uptodate.com/contents/search. Accessed May 26, 2021.
• Ferri FF. Traveler diarrhea. In: Ferri's Clinical Advisor 2023. Elsevier; 2023. https://www.clinicalkey.com. Accessed April 28, 2023.
• Diarrhea. National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/digestive-diseases/diarrhea. Accessed April 27, 2023.
• Travelers' diarrhea. Centers for Disease Control and Prevention. https://wwwnc.cdc.gov/travel/yellowbook/2020/preparing-international-travelers/travelers-diarrhea. Accessed April 28, 2023.
• LaRocque R, et al. Travelers' diarrhea: Clinical manifestations, diagnosis, and treatment. https://www.uptodate.com/contents/search. Accessed May 26, 2021.
• Khanna S (expert opinion). Mayo Clinic. May 29, 2021.
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Information for Travelers

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Traveller’s Diarrhea and Cholera Vaccine

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Travel vaccines are recommended for people visiting or working in some countries. It is important to talk to your health care provider, or visit a travel clinic at least 6 to 8 weeks before you leave on a trip.

Most travel vaccines are not covered by the provincial Medical Services Plan (MSP), so check with your local travel clinic to find out the cost.

Bring a record of your vaccine history to the travel clinic. It is important to keep a record of the travel vaccines you receive and take this with you on your trip.

What is the traveller’s diarrhea and cholera vaccine?

The vaccine gives you some protection against traveller’s diarrhea and cholera, which are infections caused by 2 types of bacteria.

The vaccine is approved by Health Canada.

Who should get the vaccine?

If you are travelling to or working in Central and South America, the Caribbean, Southeast Asia, Africa, and Eastern or Southern Europe, it may be recommended that you get the vaccine. The travel clinic doctor or nurse will advise if you should receive the vaccine. A booster dose may be required if you continue to travel or work in these areas.

How is the vaccine given?

Traveller’s diarrhea Adults and children 2 years of age and older are given 2 doses of the vaccine to take at home by mouth (orally). A booster dose may be required every 3 months. Please note that this vaccine needs to be refrigerated; bringing the vaccine with you in your travels may be a challenge.

Cholera Adults and children over 6 years of age are given 2 doses of vaccine to take orally at home. A booster dose may be required every 2 years.

Children 2 to 6 years of age are given 3 doses of vaccine to take orally at home. A booster dose may be required every 6 months.

The vaccine will start offering protection about 1 week after taking the last dose.

The travel clinic will provide instructions on how to take the vaccine at home. It is important to follow the instructions.

What are the possible reactions after the vaccine?

Reactions are usually mild and temporary. The most common reactions are stomach pain, diarrhea, nausea and vomiting.

For more information on Reye Syndrome, see HealthLinkBC File #84 Reye Syndrome .

After getting any vaccine there is an extremely rare possibility, less than 1 in a million, of a life-threatening allergic reaction called anaphylaxis. This may include hives, difficulty breathing, or swelling of the throat, tongue or lips. Should this reaction occur, your health care provider is prepared to treat it. Emergency treatment includes administration of epinephrine (adrenaline) and transfer by ambulance to the nearest emergency department. If symptoms develop, call 9-1-1 or the local emergency number.

It is important to always report serious or unexpected reactions to your health care provider.

Who should not get the vaccine?

Speak with a travel clinic doctor or nurse if you:

• Have had a life-threatening reaction to a previous dose of cholera vaccine, or any component of the vaccine including saccharin; or
• Currently have a fever or stomach illness

Children under 2 years of age should not receive the vaccine.

What is traveller’s diarrhea?

Traveller's diarrhea is frequent, loose, or watery bowel movements usually from eating or drinking contaminated foods or fluids. Symptoms may also include stomach cramps, nausea, vomiting, bloating and feeling unwell. Symptoms can begin suddenly and last 3 to 5 days.

The most common cause of traveller’s diarrhea is food or water contaminated with bacteria called enterotoxigenic E. coli (ETEC). These bacteria are found in the bowel movements (stool) of infected people. People who use the bathroom without proper hand washing can pass the bacteria on to others through food preparation or hand-to-mouth contact. Food can also be contaminated when stool is used as fertilizer, or when contaminated water is used to spray vegetables in market stalls.

What is cholera?

Cholera is a serious and sometimes life-threatening, infection caused by the bacteria Vibrio cholerae . People infected may have no symptoms or only mild diarrhea. However, others can develop very severe, watery diarrhea and vomiting. Without treatment, this can lead to severe dehydration and death.

Like ETEC, cholera bacteria are also found in the stool of infected people and the disease is spread in the same way. In addition, cholera bacteria can live in the water of certain coastal areas, and the disease can be spread by eating raw or undercooked seafood and shellfish.

What other precautions can I take when I am travelling?

It is very important to have good personal hygiene and to take food and drink precautions. For more information, see HealthLinkBC File #41a Health Advice for Travellers .

Mature Minor Consent

It is recommended that parents or guardians and their children discuss consent for immunization. Children under the age of 19, who are able to understand the benefits and possible reactions for each vaccine and the risk of not getting immunized, can legally consent to or refuse immunizations. For more information on mature minor consent see HealthLinkBC File #119 The Infants Act, Mature Minor Consent and Immunization .

For More Information

For a list of travel clinics in B.C., visit the Public Health Agency of Canada: www.canada.ca/en/public-health/services/travel-health/yellow-fever/vaccination-centres-canada-british-columbia.html .

For more information on travel vaccines, see HealthLinkBC File #41c Travel Immunizations for Adults .

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Travellers’ Diarrhea Medicine and Remedies

What is Travellers’ Diarrhea?

Travellers’ diarrhea is the most common illness affecting international travellers. The symptom is so well known that it has earned many nicknames, including “Montezuma’s Revenge”, “Pharaoh’s Revenge,” and “Delhi Belly”. Recent studies show up to 70 percent of travellers will come down with diarrhea symptoms during their trip.

Often, travellers’ diarrhea itself is not an illness. It is usually a symptom of infection like food poisoning or e. coli . The best way to avoid travellers’ diarrhea is to avoid these diseases.

Where Does Travellers’ Diarrhea Occur?

Travellers’ diarrhea can occur anywhere, at home or abroad. Eating at a less clean restaurant or drinking unfiltered water can lead to the symptom. The regions with the highest risk are:

• Latin America
• Middle East

While these regions have an increased risk, travellers’ diarrhea can occur anywhere.

People with a high risk of becoming ill include young adults, immunosuppressed persons, people with chronic diseases such as Crohn’s disease or diabetes, and those who are taking H-2 blockers or antacids that lower the stomach’s ability to kill germs.

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Passport health – travellers’ diarrhea prevention, how does travellers’ diarrhea spread.

Travellers’ diarrhea is caused by eating or drinking contaminated food or water. Most often, the infection is from e. coli , but other diseases like cholera , typhoid or norovirus can cause the symptom. Bacterial infections are responsible for up to 80 percent of travellers’ diarrhea cases.

Most often, these infections spread through a food worker not washing their hands before preparing a meal. Improper sanitation within a kitchen or other similar area can also lead to infection. Fruit, vegetables and other items should be washed with clean water before eating to avoid contamination.

What Are the Symptoms of Travellers’ Diarrhea?

Travellers’ diarrhea can show symptoms just a few hours after exposure. But, they usually appear within one to two days. It is possible to have more than one bout of travellers’ diarrhea during a trip.

The most common symptoms of travellers’ diarrhea are:

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• Passing three or more loose stolls in 24 hours
• An urgent need to defecate
• Abdominal (stomach) cramps
• Fever and/or vomiting

Bacterial diarrhea lasts three to seven days. Viral diarrhea lasts two to three days. Protozoal diarrhea can last months without treatment.

Travellers’ diarrhea kits can help you overcome symptoms quickly. Call or book online now to get yours from a local Passport Health.

How Do I Prevent Travellers’ Diarrhea?

As with many infections, it is easier to prevent travellers’ diarrhea than treat it. Prevention comes in two forms, medication or vaccination and good travel habits.

The PHAC advises travellers to take care when selecting food or drink. Only drink or use safe drinking water. This water should be bottled or filtered. Wash your hands often with sopa and water.

Be sure any food you eat has been cooked well. Peel any fruits or vegetables you may eat and be sure to wash them with clean water. While street food can be tempting, it is best to avoid vendors. Use your hotel conceirge or other services to learn where are the safest and best places to eat in your destination.

Medications like Travelan can help prevent travellers’ diarrhea if exposed. Vaccinations against food- or waterborne infections like typhoid , cholera or hepatitis A are another great form of protection. These vaccines provide the best protectation against their respective diseasese.

How Is Travellers’ Diarrhea Treated?

Most cases of travellers’ diarrhea resolve themselves within a few days. But, travellers don’t have time to wait for the problem to go away.

There are a variety of options available to help fight travellers’ diarrhea when it occurs. These include:

• Antibiotics – These are commonly prescribed for the treatment of travellers’ diarrhea. The specific antibiotic chosen is based on the likelihood a person is infected with an invasive organism, and how resistant the organism is to antibiotics. Both factors are largely determined by the travellers’ destination. For more information on travellers’ diarrhea antibiotics, contact Passport Health, or your local physician.
• Oral Rehydration Tablets – Also known as oral rehydration salts, these will help with keeping a person hydrated during infection.
• Anti-Motility Medications – Are not recommended for use in self-treatment for travellers’ diarrhea. This is due to the risk of side effects and complications.

Various combinations of the above items are available in Passport Health travellers’ diarrhea kits. Call or book online now to get yours .

If the diarrhea continues for more than one or two days after beginning treatment, you may need additional medical care, follow up with a primary care provider.

On This Page: What is Travellers’ Diarrhea? Where Does Travellers’ Diarrhea Occur? How Does Travellers’ Diarrhea Spread? What Are the Symptoms of Travellers’ Diarrhea? How Do I Prevent Travellers’ Diarrhea? How Is Travellers’ Diarrhea Treated?

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GREGORY JUCKETT, M.D.

Am Fam Physician. 1999;60(1):119-124

See related patient information handout on traveler's diarrhea , written by the author of this article .

Common pathogens in traveler's diarrhea include enterotoxigenic Escherichia coli , Campylobacter, Shigella, Salmonella, Yersinia and many other species. Viruses and protozoa are the cause in many cases. Fortunately, traveler's diarrhea can usually be avoided by carefully selecting foods and beverages. Although drug prophylaxis is now discouraged, treatment with loperamide (in the absence of dysentery) and a fluoroquinolone, such as ciprofloxacin (500 mg twice daily for one to three days), is usually safe and effective in adults with traveler's diarrhea. Trimethoprim-sulfamethoxazole and doxycycline are alternatives, but resistance increasingly limits their usefulness. Antibiotic treatment is best reserved for cases that fail to quickly respond to loperamide. Antibiotic resistance is now widespread. Nonabsorbable antibiotics, immunoprophylaxis with vaccines and biotherapeutic microbes that inhibit pathogen infection may eventually supplant antibiotic treatment. In the meantime, azithromycin and new fluoroquinolones show promise as possible replacements for the older agents. Ultimately, the best solution is improvements in sanitary engineering and the development of safe water supplies.

Travel to destinations such as Latin America, Asia, Africa and the Middle East has never been more popular, with over 20 million travelers visiting a less developed country each year. 1 Approximately one third (20 to 50 percent) of travelers to less developed areas of the world become ill from ingesting fecally contaminated food or water. 2 , 3 In 10 to 20 percent of cases, fever and bloody stools (dysentery) occur. 2

Although traveler's diarrhea usually resolves within three to five days (mean duration: 3.6 days), in about 20 percent of persons the illness is severe enough to cause bed confinement and in 10 percent of cases the illness lasts more than one week. 3 , 4 In the very young and the very old, as well as in those who are immunocompromised, traveler's diarrhea can occasionally be life-threatening. It is important to realize, however, that traveler's diarrhea can be minimized by education about ways to prevent the disease. Physicians can do a great deal to ensure that their patients have a safe and enjoyable trip abroad.

Epidemiology

Traveler's diarrhea is defined as three or more unformed stools in 24 hours in a person from an industrialized nation traveling in a less developed country. Unlike in the United States, where most diarrheal disease is viral in origin, in developing countries, bacterial infection is the cause of diarrhea in at least 80 percent of cases. Viral, protozoal or undetermined etiologies account for the remainder of cases. Enterotoxigenic Escherichia coli is the chief pathogen, accounting for 40 to 50 percent of cases. 5 Other common bacterial causes include Campylobacter jejuni , Shigella, Salmonella, Aeromonas and Yersinia species, Plesiomonas shigelloides and Vibrio parahaemolyticus ( Table 1 ) . All of these agents are efficiently spread by the fecal-oral route and, in some cases, such as Shigella infections, a minute inoculum (as few as 10 to 100 organisms) is all that is necessary to produce disease.

Without stool cultures for identifying the pathogen in diarrheal illness, it is easy to confuse the symptoms of traveler's diarrhea with those of food poisoning produced by heat-stable, toxin-forming bacteria such as Staphylococcus aureus and Bacillus cereus or by the heat-labile toxin of Clostridium perfringens . In general, however, preformed toxins (Staphylococcus and Bacillus) produce symptoms within one to six hours, whereas infections (such as from Clostridium) that result in toxin formation in vivo cause symptoms within eight to 16 hours. Most invasive bacterial infections, on the other hand, become symptomatic after 16 hours. 6

Viruses that are responsible for traveler's diarrhea in the tropics include rotavirus and Norwalk agents. Diarrhea caused by viral agents is usually self-limited.

The three major protozoal causes of traveler's diarrhea are Entamoeba histolytica , Giardia duodenalis and Cryptosporidium parvum . Diarrheal disease caused by these organisms is notable for its longer duration and failure to respond to routine antibiotic therapy.

Risk factors for traveler's diarrhea are listed in Table 2 . Persons from a developing region who have relocated to an industrialized country and who then return to their country of origin are also at increased risk, especially since they seldom take precautions. Any “native resistance” is soon lost after relocation and subsequent alteration of the intestinal flora.

Traveler's diarrhea is fundamentally a sanitation failure, leading to bacterial contamination of food and water. It is best prevented through proper sewage treatment and water disinfection. In the absence of these amenities, the next best option is for the educated traveler to take precautions to prevent the disease.

Preventive measures include not drinking tap water, not using ice in beverages (even alcoholic drinks), not eating salads and other forms of raw vegetables, not eating fruits that can't be peeled on the spot and not eating mayonnaise, pastry icing, unpasteurized dairy products and undercooked shellfish.

Tying a ribbon around the faucet and keeping purified bottled water near the sink may serve as memory aids for travelers to remind them not to use tap water, even for tooth brushing. Hot cooked food, fresh bread, dry foods such as crackers, bottled carbonated beverages, coffee, tea and beer are usually safe, provided such food items are not obtained from street vendors. Helpful maxims to keep in mind include “boil it, cook it, peel it or forget it” and the “rule of P's”: food is safe if it is peelable, packaged, purified or piping hot. 3 Careful handwashing, most conveniently achieved with packaged wipes or antiseptic gel, is essential.

Active intervention involves boiling water for three to five minutes (depending on elevation), filtering water or using chlorine bleach (2 drops per quart) or tincture of iodine (5 drops per quart) in the water. Drawbacks with these methods of prevention include the need to allow sufficient time to disinfect the water, clogged filters, chlorine's incomplete effectiveness against some protozoal cysts and iodine's bad taste. 7 Antibiotics (i.e., tetracyclines) added to the water may not destroy resistant bacteria and protozoal cysts. Fortunately, the wide availability of safe bottled water makes these cumbersome interventions unnecessary for all but the most remote destinations.

Drug Prophylaxis

Table 3 summarizes the various drug therapies used for prophylaxis against traveler's diarrhea. Bismuth subsalicylate (Pepto-Bismol), in a dosage of two 262-mg tablets four times a day (taken with meals and in the evening) can prevent traveler's diarrhea. It has been shown to provide a 65 percent protection rate. 8 Bismuth subsalicylate can be taken for up to three weeks. Such long-term use can, however, darken the tongue and stool, produce tinnitus and cause reactions in salicylate-sensitive patients. Bismuth subsalicylate also interferes with the absorption of doxycycline and certain other medications. 8

Compared with bismuth subsalicylate, antibiotic prophylaxis with trimethoprim-sulfamethoxazole (Bactrim DS), in a dosage of 160 mg/800 mg daily, or doxycycline (Vibramycin), in a dosage of 100 mg daily, has been found to provide even better results for up to three weeks. 8 Increasingly, however, resistance to these antibiotics has become such a problem that their routine use is not recommended. For instance, trimethoprim-sulfamethoxazole continues to be effective prophylaxis for summertime travel in inland Mexico, but it is unreliable in many other situations. 2 Although fluoroquinolones such as ciprofloxacin (Cipro) may be the best alternatives to trimethoprim-sulfamethoxazole and doxycycline, resistance to fluoroquinolones is developing too rapidly to justify their continued use for prophylaxis against traveler's diarrhea.

Antibiotic prophylaxis for traveler's diarrhea, always a controversial topic, is now recommended only in specific situations, such as in the seriously immunocompromised patient or the seriously ill patient who would not be able to withstand a diarrheal illness. If antibiotic prophylaxis is used, the antibiotic should only be taken for a three-week period. Other exceptions may include persons who plan short-term critical travel, such as a diplomatic mission, or persons who are unable to practice prevention.

In most people, drug prophylaxis engenders a false sense of security. In addition, drug prophylaxis always carries the remote risk of a potentially life-threatening side effect such as pseudomembranous colitis or Stevens-Johnson syndrome. Nuisance side effects such as vaginal yeast infections and, with doxycycline, photosensitivity, are common. Therefore, the Centers for Disease Control and Prevention recommends preventive measures only and not drug prophylaxis for most travelers. If diarrhea occurs despite precautions, however, a self-treatment contingency plan is reasonable.

Mild traveler's diarrhea can usually be managed with the judicious use of antimotility agents such as loperamide (Imodium A-D), in a dosage of two 2-mg tablets initially, then one tablet after each loose stool (maximum 24-hour dosage: 8 mg). Additionally, a single dose of ciprofloxacin—750 mg; levofloxacin (Levaquin)—500 mg; or ofloxacin (Floxin)—400 mg, usually relieves mild cases of traveler's diarrhea in less than 24 hours. 9

The use of antimotility agents has traditionally been avoided in patients with dysentery, where decreased gut motility would be inadvisable. Moderate to severe traveler's diarrhea, including dysentery, can be empirically treated with a three-day course of a fluoroquinolone such as ciprofloxacin, norfloxacin (Noroxin) or ofloxacin ( Table 4 ) . Loperamide may also be taken if the patient does not have dysentery. Before beginning antibiotic therapy, however, patients should first take a dose of loperamide to see if the antimotility agent stops the diarrhea. Antibiotic therapy should be deferred until it is clear that the diarrheal illness requires antibiotic therapy, since dietary change and stress can cause transient gastrointestinal upset. 2 A single antibiotic dose may be effective for mild traveler's diarrhea, and patients should reassess their condition in 12 hours to determine if further doses are necessary. 10

Ciprofloxacin is not recommended in patients with seizure disorders, in patients who are pregnant and in children under 18 years of age. Children older than two years of age can be given trimethoprim-sulfamethoxazole. Children under two years of age and pregnant women can be treated with an oral rehydration solution. Older children and other adults with traveler's diarrhea also would benefit from oral rehydration, possibly supplemented with salted soda crackers. Commercially available packets of oral rehydration solution can be reconstituted with safe water.

If treatment with a fluoroquinolone fails to resolve the diarrhea, several other diagnostic possibilities should be considered. Protozoal infections and pseudomembranous colitis must be excluded. In addition, infection from an antibiotic-resistant organism is now a third and increasingly probable explanation for continued diarrhea. Azithromycin (Zithromax), in a dosage of 500 mg daily for three days, has been found to be very effective in treating resistant Campylobacter enteritis contracted in Thailand, and its usefulness in other situations of fluoroquinolone resistance merits investigation. 11

Patients should be told to consult a physician if diarrhea does not respond to the planned regimen, especially if high fever or bloody stools are present. Patients should also be warned to avoid over-the-counter anti-diarrheals such as iodochlorhydroxyquinoline (Entero-Vioform), which has been withdrawn from the U.S. market because of its association with myelooptic atrophy. This agent, however, may still be available outside this country.

Public Health Issues

Even with the emphasis now placed on pre-cautionary measures to prevent traveler's diarrhea rather than drug prophylaxis, the treatment of traveler's diarrhea will be increasingly hampered by antibiotic resistance. Multidrug-resistant Shigella and Salmonella strains are now so common that it is only a matter of time until they also become resistant to fluoroquinolones. Some respite may be provided by the most recently developed fluoroquinolones and azithromycin, but eventually a new approach will be necessary.

One future option might be nonabsorbable antimicrobial drugs such as bicozamycin, furazolidone (Furoxone), aztreonam and rifaximin, which have already shown some benefit in the treatment of traveler's diarrhea. Bicozamycin might also be an effective prophylactic agent that would treat only the gastrointestinal tract and, therefore, be more acceptable from the standpoint of safety. 2 Although not yet marketed in the United States, zaldaride, a new type of drug called a calmodulin inhibitor, is a promising treatment. 10

Use of biotherapeutic agents made of microorganisms that suppress pathogenic infection is another option. Lactobacillus casei and Saccharomyces boulardii , a nonpathogenic yeast, have been studied as prophylactic agents in travel scenarios, but the results have been inconsistent. The use of these organisms to treat other types of diarrhea has been encouraging, and improvements in bioengineered forms of these organisms may in the future yield an alternative to antibiotics. 12

Immunoprophylaxis by means of oral vaccines may become a third alternative to systemic antibiotics. Vaccines have already been developed for typhoid, enterotoxigenic E. coli and cholera (the latter two are not yet available in the United States). Shigella and Campylobacter vaccines are in the development stage, and a pediatric rotavirus vaccine has recently been labeled. A combination, or “super,” vaccine could be an effective way to reduce the most common types of traveler's diarrhea. The limiting factor is the vast array of potential pathogens that cannot be included in any single vaccine. 3 , 10

The most sensible, yet most problematic, approach to preventing traveler's diarrhea is to eliminate the basic problem of poor hygiene and water contamination through sanitary engineering, public education and, most importantly, the development of a safe water supply. Unfortunately, much of the developing world is in a “Catch-22” situation: poverty and unclean water hinder the tourism and investment money needed to correct these problems. Progress through international aid and economic development is difficult, but in an increasing number of transitional nations, such as Thailand, economic growth has reduced the country's risk profile in less than a decade. Ultimately, the elimination of poverty, and not new drugs, will resolve the problem of traveler's diarrhea.

Castelli I, Carosi G. Epidemiology of traveler's diarrhea. Chemotherapy. 1995;41(suppl 1):20-32.

DuPont HL, Ericsson CD. Prevention and treatment of traveler's diarrhea. N Engl J Med. 1993;328:1821-7.

Liu LX. Travel medicine part II: malaria, traveler's diarrhea, and other problems. Infect Med. 1993;10:24-8.

Steffen R. Epidemiologic studies of traveler's diarrhea, severe gastrointestinal infections, and cholera. Rev Infect Dis. 1986;8(suppl 2):S122-30.

Layton ML, Bia FJ. Emerging issues in travel medicine. Curr Opin Infect Dis. 1992;5:338-44.

Tauxe RV, Hughes JM. Food-borne disease. In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas and Bennett's Principles and practice of infectious diseases. 4th ed. New York: Churchill Livingstone, 1995:1012–24.

Strum WB. Update on traveler's diarrhea. Postgrad Med. 1988;84(1):163-6.

DuPont HL, Ericsson CD, Johnson PC, Bitsura JA, DuPont MW, de la Cabada FJ. Prevention of traveler's diarrhea by the tablet formulation of bismuth subsalicylate. JAMA. 1987;257:1347-50.

Advice for travelers. Med Lett Drugs Ther. 1998;40(1025):47-50.

Ericsson CD. Travelers diarrhea. Epidemiology, prevention, and self-treatment. Infect Dis Clin North Am. 1998;12:285-303.

Kuschner RA, Trofa AF, Thomas RJ, Hoge CW, Pitarangsi C, Amato S, et al. Use of azithromycin for the treatment of Campylobacter enteritis in travelers to Thailand, an area where ciprofloxacin resistance is prevalent. Clin Infect Dis. 1995;21:536-41.

Elmer GW, Surawicz CM, McFarland LV. Biotherapeutic agents. A neglected modality for the treatment and prevention of selected intestinal and vaginal infections. JAMA. 1996;275:870-6.

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FDA approves new drug to treat travelers’ diarrhea

FDA News Release

The U.S. Food and Drug Administration today approved Aemcolo (rifamycin), an antibacterial drug indicated for the treatment of adult patients with travelers’ diarrhea caused by noninvasive strains of  Escherichia coli ( E. coli ), not complicated by fever or blood in the stool.

"Travelers' diarrhea affects millions of people each year and having treatment options for this condition can help reduce symptoms of the condition," said Edward Cox, M.D., M.P.H., director of the Office of Antimicrobial Products in the FDA’s Center for Drug Evaluation and Research. 

Travelers' diarrhea is the most common travel-related illness, affecting an estimated 10 to 40 percent of travelers worldwide each year. Travelers' diarrhea is defined by having three or more unformed stools in 24 hours, in a person who is traveling. It is caused by a variety of pathogens, but most commonly bacteria found in food and water. The highest-risk destinations are in most of Asia as well as the Middle East, Africa, Mexico, and Central and South America.

The efficacy of Aemcolo was demonstrated in a randomized, placebo-controlled clinical trial in 264 adults with travelers’ diarrhea in Guatemala and Mexico. It showed that Aemcolo significantly reduced symptoms of travelers’ diarrhea compared to the placebo. 

The safety of Aemcolo, taken orally over three or four days, was evaluated in 619 adults with travelers’ diarrhea in two controlled clinical trials. The most common adverse reactions with Aemcolo were headache and constipation. 

Aemcolo was not shown to be effective in patients with diarrhea complicated by fever and/or bloody stool or diarrhea due to pathogens other than noninvasive strains of E. coli and is not recommended for use in such patients. Aemcolo should not be used in patients with a known hypersensitivity to rifamycin, any of the other rifamycin class antimicrobial agents (e.g. rifaximin), or any of the components in Aemcolo.

The FDA granted Aemcolo a Qualified Infectious Disease Product (QIDP) designation. QIDP designation is given to antibacterial and antifungal drug products that treat serious or life-threatening infections under the Generating Antibiotic Incentives Now (GAIN) title of the FDA Safety and Innovation Act. As part of QIDP designation, the Aemcolo marketing application was granted Priority Review under which the FDA’s goal is to take action on an application within an expedited time frame.

The FDA granted approval of Aemcolo to Cosmo Technologies, Ltd.

The FDA, an agency within the U.S. Department of Health and Human Services, protects the public health by assuring the safety, effectiveness, security of human and veterinary drugs, vaccines and other biological products for human use, and medical devices. The agency is also responsible for the safety and security of our nation’s food supply, cosmetics, dietary supplements, products that give off electronic radiation, and for regulating tobacco products.

Related Information

• FDA: Antibiotics and Antibiotic Resistance
• FDA: Combating Antibiotic Resistance
• CDC: Travelers' Diarrhea
• CDC: Managing Travelers’ Diarrhea While Traveling Abroad
• CDC: Yellow Book 2018: Health Information for International Travel – Travelers’ Diarrhea

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Cholera and enterotoxigenic Escherichia coli (ETEC) travellers' diarrhea vaccine: Canadian Immunization Guide

For health professionals

• Previous page
• Part 4 table of contents

Last complete chapter revision (see table of updates ): April 2017

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• Key Information

Epidemiology

Preparations authorized for use in canada, immunogenicity, efficacy and effectiveness.

• Table 1: Immunization schedule for cholera and travellers' diarrhea vaccine, by indication and age

Booster doses and re-immunization

Pregnancy and breastfeeding, persons with chronic diseases, immunocompromised persons, vaccine administration practices, storage and handling requirements, common and local adverse events, contraindications and precautions, selected references, key information (refer to text for details).

• is most often caused by Vibrio cholerae serogroups O1 and O139
• is associated with poor sanitation; generally acquired from contaminated water or food
• if untreated, severe fluid loss can lead to rapid dehydration and hypovolemic shock, which may be life threatening
• accounts for 25% to 50% of travellers' diarrhea (TD)
• is transmitted by contaminated food and, less often, contaminated water
• most episodes are mild and self-limited
• Vaccine efficacy against all cause diarrhea is about 6%. It protects against Vibrio cholera serogroup O1 but does not protect against cholera caused by V. cholerae O139 or other species of Vibrio.
• Following the primary series, protection against cholera lasts for 2 years in persons 6 years of age and older and 6 months in children 2 years to less than 6 years of age. Protection against ETEC travellers' diarrhea may last for 3 months.
• The most commonly reported adverse events following immunization are abdominal pain, diarrhea, nausea and vomiting.
• For protection against cholera: travellers to cholera-endemic countries who may be at significantly increased risk of exposure (for example, humanitarian workers or health care providers working in endemic countries) may benefit from cholera and travellers' diarrhea vaccination.
• For protection against travellers' diarrhea: vaccination with cholera and travellers' diarrhea vaccine is of limited benefit and is not routinely recommended except for high-risk travellers.
• 6 years of age and older: 2 doses orally, 1 to 6 weeks apart
• 2 to less than 6 years of age: 3 doses orally, 1 to 6 weeks apart
• ETEC travellers' diarrhea prevention: 2 doses orally, 1 to 6 weeks apart
• Booster doses may be administered, if indicated. The interval varies with age and indication.
• Oral administration of medicinal products or intake of food or drink should be avoided for 1 hour before and 1 hour after vaccine administration.
• Administration of cholera and travellers' diarrhea vaccine and oral typhoid vaccine should be separated by at least 8 hours.
• Most travellers following the usual tourist itineraries in countries affected by cholera are at extremely low risk of acquiring cholera infection; travellers' diarrhea is usually a mild and self-limited illness. Therefore, this vaccine is reserved for those who are the highest risk of infection only.
• Not all recipients of this vaccine will be fully protected against cholera or travellers' diarrhea.

This chapter update was conducted in collaboration with the Committee to Advise on Tropical Medicine and Travel (CATMAT). Recommendations are based on CATMAT's Statement on Travellers' Diarrhea .

Significant revisions included in this chapter are highlighted in the Table of Updates to the Canadian Immunization Guide.

Disease description

Infectious agent.

Cholera is caused by the toxin-producing bacterium Vibrio cholerae serogroups O1 and O139. V. cholerae serogroup O1 causes the majority of cholera outbreaks and has two biotypes, Classical and El Tor. Each biotype has two serotypes, Inaba and Ogawa. For additional information about Vibrio cholerae refer to the Pathogen Safety Data Sheet.

Enterotoxigenic Escherichia coli (ETEC) is the most common cause of travellers' diarrhea. Many ETEC strains produce a heat-labile enterotoxin that is similar to cholera toxin. For additional information about Escherichia coli refer to the Pathogen Safety Data Sheet.

Humans and contaminated water sources are the main reservoirs of V. cholerae. Humans are the reservoir for ETEC.

Transmission

Cholera is associated with poor sanitation and is generally acquired from contaminated water or food, particularly undercooked or raw shellfish and fish. The incubation period is 2 hours to 5 days and V. cholerae remain in the feces for 7 to 14 days after infection. Transmission from person to person is rare.

ETEC travellers' diarrhea

ETEC is transmitted by contaminated food and, less often, contaminated water. The incubation period is usually 24 to 72 hours and excretion of ETEC may be prolonged.

Risk factors

Travellers at higher risk of cholera infection include those who drink or eat contaminated water or food, in particular undercooked or raw shellfish and fish. Humanitarian relief workers and those visiting areas of high risk with limited access to safe water and food are also at increased risk. The risk of cholera can increase following natural or man-made disasters due to the disruption of water and sanitation systems or the displacement of populations to overcrowded camps. Immunocompromised persons, such as malnourished children or HIV-infected persons, are at greater risk of morbidity if infected.

Travellers' diarrhea

The most important determinants of risk for travellers' diarrhea are the travel destination and the type of travel (for example, five star accommodations vs. backpacking). Factors associated with a higher probability of acquiring travellers' diarrhea include gastric hypochlorhydria, and the relative lack of gut immunity seen in small children. In addition, specific groups of travellers are at an increased risk of serious consequences of travellers' diarrhea:

• persons who are immunosuppressed
• individuals with chronic renal failure
• persons with congestive heart failure
• individuals with insulin-dependent diabetes mellitus
• persons with inflammatory bowel disease.

Spectrum of clinical illness

Cholera presents as profuse, watery diarrhea. If left untreated, severe fluid loss can lead to rapid dehydration and occasionally hypovolemic shock, which may be life threatening. The case fatality rate ranges from 50% or more without treatment to less than 1% among adequately treated patients. The spectrum of disease is wide, with mild and asymptomatic illness occurring more frequently than severe disease. The ratio of symptomatic to asymptomatic cases varies from strain to strain.

Most episodes of travellers' diarrhea are mild and self-limited, although the illness can be debilitating and particularly difficult to manage in remote or unfamiliar surroundings. Some travellers experiencing more severe acute inflammatory gastroenteritis may develop persistent gastrointestinal symptoms, but long term sequelae resulting from non-inflammatory gastroenteritis, such as that caused by ETEC, are very uncommon.

Disease distribution

Incidence and prevalence.

The World Health Organization (WHO) estimates that approximately 3 to 5 million cholera cases occur annually, with up to 120,000 deaths. Cholera is endemic in many countries. Refer to the WHO map of areas reporting cholera outbreaks for additional information.

It is estimated that up to 50% of travellers from developed countries who visit developing countries will have traveller's diarrhea, depending on the destination. The highest rates are seen in Latin America, Africa and the Indian subcontinent, while intermediate rates of 8% to 15% are seen for travellers to China, Russia, the Middle East and southeastern Asia.

In Canada, cholera cases are very uncommon. There have been 30 imported cases of cholera reported between 2008 and 2014. There are no Canadian data on ETEC and travellers' diarrhea.

Recent outbreaks

Since the 19 th century, cholera pandemics have killed millions of people across all continents. In recent years, there has been multiple cholera outbreaks related to mass population movement, especially at times of strife, such as within refugee camps in resource-poor countries. Since 2010, Haiti and the Dominican Republic have been experiencing a cholera epidemic. Since January 2016 outbreaks have increased in East and Southern Africa. For more information, refer to the Travel Health Notices for Cholera .

Cholera and travellers' diarrhea vaccine

• DUKORAL ® (inactivated, oral, travellers' diarrhea and cholera vaccine containing whole cell heat inactivated V. cholerae O1 Inaba classic strain, formalin inactivated V. cholerae O1 Inaba El Tor strain, and heat and formalin inactivated V. cholerae O1 Ogawa classic strain with recombinant non-toxic cholera toxin B subunit), Valneva Sweden AB. (Chol-Ecol-O).

Cholera vaccine

• VAXCHORA ® (live attenuated, oral, cholera vaccine containing lyophilized V. cholerae strain CVD 103-HgR), Emergent Travel Health Inc. (Chol-O)*.

* CATMAT has not yet deliberated on the use of VAXCHORA ® . CATMAT will review this vaccine and the chapter will be updated in due course. For information regarding the use of this vaccine in the interim, please refer to the product monograph available through Health Canada's Drug Product Database .

For complete prescribing information, consult the product leaflet or information contained within the product monograph available through Health Canada's Drug product database .

Refer to Contents of Immunizing Agents Authorized for Use in Canada in Part 1 for a list of vaccines authorized for use in Canada and their contents.

Immunogenicity

Immunological correlates of protection against cholera after oral vaccination have not been identified. There is a poor correlation between serum antibody responses and protection. IgA antibodies produced in the intestine probably mediate protective immunity.

Cholera and travellers' diarrhea vaccine induces intestinal IgA responses in 70% to 100% of vaccinated subjects and serum antibodies have also been detected. A booster dose elicits an anamnestic response indicative of an immune memory. The duration of the immunological memory is estimated to be at least 2 years in adults.

Efficacy and effectiveness

Protection against cholera can be expected approximately 1 week after completion of primary immunization. For cholera, duration of protection is estimated to last for 2 years in persons 6 years of age and older, and 6 months in children 2 years to less than 6 years of age.

Protection against ETEC, if any, can be expected approximately 1 week after completion of primary immunization and may last as long as 3 months.

The pooled results from randomized controlled trials found a pooled RR of 0.94 and no increased benefit for preventing an episode of travellers' diarrhea during travel when comparing immunized individuals to those vaccinated with a placebo. Additionally, these studies found no difference in effect for prevention of travellers' diarrhea related to ETEC when compared to placebo.

Recommendations for Use

Children (2 to 17 years of age) and adults (18 years of age and older)

Vaccination with cholera and travellers' diarrhea vaccine is of limited benefit and is not routinely recommended for most travellers. However, short-term travellers at high risk for health complications or serious inconvenience from travellers' diarrhea may find that the potential benefits of the vaccine based on their personal values and preferences, coupled with a low likelihood of adverse events may outweigh the burden of their risk. These include individuals:

• for whom a brief illness cannot be tolerated (i.e., elite athletes, some business or political travellers);
• with increased susceptibility to TD (e.g., due to achlorhydria, gastrectomy, history of repeated severe TD, young children > 2 years);
• who are immunosuppressed due to HIV infection with depressed CD4 count or other immunodeficiency states;
• with chronic illnesses for whom there is an increased risk of serious consequences from TD (e.g., chronic renal failure, congestive heart failure, insulin dependent diabetes mellitus, inflammatory bowel disease).

For travellers, prevention of cholera or travellers' diarrhea relies primarily on taking meticulous care in the choice of food and water supply and in the use of good hygienic measures, rather than on immunization. A detailed, travel related risk assessment should be made to determine which travellers are most likely to benefit from vaccination.

Cholera and travellers' diarrhea vaccine is not recommended in children less than 2 years of age because efficacy has not been studied in this age group.

Indications for cholera and travellers' diarrhea vaccine to prevent travellers' diarrhea are further limited because:

• The overall protection provided by cholera and travellers' diarrhea vaccine against travellers' diarrhea is expected to be approximately 6%.
• Most episodes of travellers' diarrhea are mild and self-limited.
• Therapeutic options (oral rehydration, dietary management, anti-motility and antibiotic treatment) are available if prevention fails.
• Vaccinated travellers may have a false sense of security and may not be as strict in observing food and water precautions.

Table 1 summarizes the schedule for cholera and ETEC travellers' diarrhea immunization, by age.

Refer to additional information contained within the product monograph available through Health Canada's Drug product database .

Table 1 summarizes the schedule for booster doses of cholera and travellers' diarrhea vaccine, by age.

An optimal booster dose or interval has not been established; however, if indicated based on ongoing risk assessment:

• For children 2 years to less than 6 years of age: a booster dose may be offered every 6 months.
• For people 6 years of age and older: a booster dose may be offered every 2 years; a complete primary series (2 doses) may be offered if the last dose was received more than 5 years previously.

Cholera and travellers' diarrhea vaccine may provide short-term protection (approximately 3 months) against ETEC diarrhea; therefore, if the traveller will be at ongoing risk, booster doses may be considered. An optimal booster dose or interval has not been established; however, if there is an ongoing risk:

• For people 2 years of age and older - a booster dose may be offered every 3 months.

Vaccination of Specific Populations

Cholera and travellers' diarrhea vaccine has not been studied in pregnant or breastfeeding women. Administration of this vaccine to pregnant women may be considered in high-risk situations only, such as an outbreak, after evaluation of the benefits and risks. This vaccine may be given to breastfeeding women.

Refer to Immunization in Pregnancy and Breastfeeding in Part 3 for additional information about vaccination of women who are pregnant or breastfeeding.

Cholera and travellers' diarrhea vaccine may be considered for prevention of travellers' diarrhea in persons with chronic illnesses such as, chronic renal failure, congestive heart failure, insulin-dependent diabetes mellitus, and inflammatory bowel disease, for whom there is an increased risk of serious consequences from travellers' diarrhea. However, vaccine benefits have not been studied in these specific groups.

Refer to Immunization of Persons with Chronic Diseases in Part 3 for additional information about vaccination of people with chronic diseases.

Cholera and travellers' diarrhea vaccine has not been studied in immunocompromised persons. Immunocompromised persons, including HIV-infected persons, may be immunized with cholera and travellers' diarrhea vaccine; however, the antibody response may be suboptimal. When considering immunization of an immunocompromised person with cholera and travellers' diarrhea vaccine, consultation with the individual's attending physician may be of assistance. For complex cases, referral to a physician with expertise in immunization or immunodeficiency is advised.

Refer to Immunization of Immunocompromised Persons in Part 3 for additional information about vaccination of people who are immunocompromised.

Cholera and travellers' diarrhea vaccine consists of a single dose vial of vaccine and a sachet of sodium hydrogen carbonate effervescent buffer granules.

Vaccine reconstitution

Cholera and travellers' diarrhea vaccine and buffer solution should be prepared according to the manufacturers' guidelines.

Route of administration

Cholera and travellers' diarrhea vaccine is for oral administration only. It can be self-administered.

Refer to Vaccine Administration Practices in Part 1 for additional information about pre-vaccination and post-vaccination counselling, vaccine preparation and administration technique, and infection prevention and control.

Concurrent administration of vaccines

The administration of cholera and travellers' diarrhea vaccine and oral typhoid vaccine capsules should be separated by at least 8 hours. There is no known interaction between cholera and travellers' diarrhea vaccine and other commonly used travel vaccines, such as hepatitis A, hepatitis B, meningococcal and yellow fever vaccines, although data are limited.

Refer to Timing of Vaccine Administration in Part 1 for additional information about concurrent administration of vaccines.

Serologic testing

Serologic testing is not recommended before or after receiving cholera and travellers' diarrhea vaccine.

Cholera and travellers' diarrhea vaccine should be stored at +2°C to +8°C and should not be frozen. The vaccine can be stored at room temperature (less than +25°C) for up to 2 weeks on one occasion only, before opening. The buffer sachet may be stored at room temperature. If the vaccine and buffer mixture is not used immediately, it can be stored at room temperature (less than +25°C) for up to 2 hours.

Refer to Storage and Handling of Immunizing Agents in Part 1 for additional information and recommendations.

Safety and Adverse Events

In a clinical trial, the most commonly reported adverse events following immunization with cholera and travellers' diarrhea vaccine were: abdominal pain (16%), diarrhea (12%), nausea (4%) and vomiting (3%). These events are most likely due to the bicarbonate buffer used with the vaccine, since they occurred with similar frequency when vaccine and buffer, or buffer alone, were given.

Less common and serious or severe adverse events

Anaphylaxis following vaccination with cholera and travellers' diarrhea vaccine may occur but is very rare.

Globally over 7 million vaccine doses have been distributed. Events such as paraesthesia, dyspnea, urticaria, pruritus, angioedema, gastroenteritis, lymphadenitis, influenza-like syndrome and hypertension have been reported very rarely (less than 1 per 10,000 doses distributed), and no causal relation has been established.

Guidance on reporting Adverse Events Following Immunization (AEFI)

Vaccine providers are asked to report, through local public health officials, any serious or unexpected adverse event temporally related to vaccination. An unexpected AEFI is an event that is not listed in available product information but may be due to the immunization, or a change in the frequency of a known AEFI.

Refer to Reporting Adverse Events Following Immunization (AEFI) in Canada and Adverse events following immunization in Part 2 for additional information about AEFI reporting.

Cholera and travellers' diarrhea vaccine is contraindicated in people with a history of anaphylaxis after previous administration of the vaccine, or proven immediate or anaphylactic hypersensitivity to any component of the vaccine or its container. Refer to Contents of Immunizing Agents Available for Use in Canada in Part 1 for a list of vaccines available for use in Canada and their contents.

Administration of cholera and travellers' diarrhea vaccine should be postponed in persons with moderate or severe acute illness or acute gastrointestinal illness. Persons with minor acute illness, with or without fever, may be vaccinated.

Refer to Contraindications, Precautions and Concerns in Part 2 for additional information.

Drug-drug and drug-food interactions

Oral administration of medicinal products or intake of food or drink should be avoided for 1 hour before and 1 hour after cholera and travellers' diarrhea vaccine administration. Food or drink may increase acid production in the stomach and impair the effect of the vaccine.

• Ahmed T, Bhuiyan TR, Zaman K, Qadri F. Vaccines for preventing enterotoxigenic Escherichia coli (ETEC) diarrhoea. The Cochrane Library. 2011.
• American Academy of Pediatrics. In: Pickering LK, Baker CJ, Kimberlin DW, et al. (editors). Red Book: 2009 Report of the Committee on Infectious Diseases. 28th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009.
• Centers for Disease Control and Prevention. Health Information for International Travel 2016. The Yellow Book. Accessed January 2017. Available from: https://wwwnc.cdc.gov/travel/page/yellowbook-home-2014
• Committee to Advise on Tropical Medicine and Travel (CATMAT). Statement on travellers' diarrhea 2015. Accessed March 2016. Available from: https://www.canada.ca/en/public-health/services/catmat/statement-travellers-diarrhea.html
• Valneva Sweden AB. Product Monograph - DUKORAL®. December 2015.
• Public Health Agency of Canada. 2014. Notifiable Diseases On-Line. Accessed January 2017. Available from: http://diseases.canada.ca/notifiable/charts?c=yl
• Pitzinger B, Steffen R, Tschopp A. Incidence and clinical features of traveler's diarrhea in infants and children. Pediatr Infect Dis J 1991;10(10):719-23.
• Scerpella EG, Sanchez JL, Mathewson III JJ, et al. Safety, immunogenicity, and protective efficacy of the whole-cell/recombinant B subunit (WC/rBS) oral cholera vaccine against travelers' diarrhea. J Travel Med 1995;2(1):22-7.
• Steffen R. Epidemiologic studies of travelers' diarrhea, severe gastrointestinal infections, and cholera. Rev Infect Dis 1986;8 (Suppl 2):S122-30.
• World Health Organization. International and travel health, 2015. Chapter 6 - Vaccine preventable diseases and vaccines. Accessed July 2015. Available from: http://www.who.int/ith/ITH_chapter_6.pdf?ua=1
• World Health Organization. Cholera, 2006. Wkly Epidemiol Rec 2007;82:273–84.

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Health Risks To Be Aware Of When Traveling To India

W here do you start with a country as vast as India? From its mountainous north to its tropical south — with scorching deserts and countless mega cities in between — you could spend a lifetime here and barely scratch the surface. It's a must-see destination for all travelers and one that begs to be explored beyond well-known tourist hotspots like the Taj Mahal . But you'd be forgiven for feeling an ounce of trepidation, given the number of health-related scare stories you may have heard from other visitors. Here's the thing — yes, you need to familiarize yourself with the risks of a trip to India before you travel. Still, it certainly doesn't mean you can't do so safely.

Let's take hygiene and sanitation first. The standards in India, in some regions, are not as high as you'd expect from mainland Europe or Australia, but there are plenty of ways to arm yourself with protection during your trip. Vaccines, for one, are super important here. And then there's personal hygiene, not to mention educating yourself on the risks of altitude sickness and air pollution, depending on where in India you'll be exploring. To help get the ball rolling, book an appointment with your doctor at least eight weeks before you jet off — they'll be able to provide ample travel advice tailored specifically to you. But for now, here are some of the most important health risks to consider before you explore the many wonders of India.

Read more: Dangerous European Destinations To Skip On Your Next Trip

Get Yourself Up To Date With These Vaccines

Many of the vaccines here will have been given to you as a child, but it's possible that one could have slipped through the net, or you may need a booster shot. You likely had 2 doses of the chickenpox vaccine at 12 months and 4 years old, but if you didn't, get yourself up to date — a new variant (clade 9) has been detected in India. Diphtheria, tetanus, and pertussis are also present in the country. As a baby, you probably had three shots of the combined vaccine and three boosters as a child. If you didn't, get 1 shot before heading to India and a booster dose every 10 years thereafter. Make sure you're fully vaccinated against measles, mumps, rubella (MMR) and polio, too. The MMR vaccine should have been given to you in 2 shots — at 12 months and 4 years old. And the polio vaccine comes in four doses — usually given at two months, four months, six months, and four years old.

The CDC also recommends that everyone over 6 months get the flu vaccine yearly, and those over 50, or those with a weakened immune system, should have the shingles vaccine. You must be protected against both illnesses in India — more than 1 million cases of shingles are recorded here yearly, and the country's peak flu season coincides with what's considered the best time to visit India — October to May.

These Additional Jabs Are Also Recommended

Traveling to exotic, new places is one of life's ultimate pleasures, but it brings with it the risk of new diseases. First up is cholera — thought to be present in India and spread through dirty water or contaminated food. The vaccine is given as a drink in two doses, each taken a week apart. Japanese encephalitis is next — this rare but dangerous infection is spread by mosquitoes, with outbreaks in India typically occurring during the rainy season — from May to October. If you're traveling during this time, especially if you'll be staying in rural areas, consider this two-dose vaccine for peace of mind.

You should also protect yourself from typhoid fever, especially if you plan to stay with friends or relatives. It's spread through unclean water and food and is especially prevalent in rural parts of the country. Two types of vaccine are available for typhoid — one in pill form (four pills taken every other day) or a shot vaccine. Both should be given at least two weeks before traveling.

Ensure your doses of Hepatitis A and B are up to date, too. Each is spread in similar ways, whether that's contaminated food or drink, having sex with an infected person, or sharing needles with one. Both vaccines are routine and given to children in the U.S., but as an adult traveling to India, you should get the combined vaccine as a booster shot to make sure you're still protected.

Keep Away From All Animals

Do you love to pet every dog, stroke every cat, and take pictures of every monkey you see? Well, this isn't advised in India. In fact, it will increase your risk of contracting certain diseases. Animal bites and wounds can play host to a whole load of these — cellulitis and fasciitis are just some examples common in India, with both almost always requiring strong antibiotics for treatment.

What's more, India has the highest number of reported cases of rabies in the world — a rare but serious infection that's usually fatal once symptoms appear. Rabid dogs are often the problem here, but you can get rabies from any infected animal if it bites you, scratches you, or licks a wound on your body. It all sounds terrifying, but there are easy ways to stay safe. 

First, steer clear of all animals, including those cute-looking monkeys at temples. Second, get the pre-exposure vaccine before traveling — this is two doses (one given seven days after the other), and a third dose is needed within three years if you continue to visit high-risk areas. It'll protect you from a rabies infection for a little while (if you've been exposed to the virus), giving you time to reach a hospital in India for the two-dose post-exposure vaccine. Depending on where you are in the country, this may be difficult to come by. So, having a medical evacuation insurance policy covering emergency travel to receive it can give you peace of mind.

Consider Your Malaria Risk

You've probably heard about malaria — a serious flu-like illness caused by a parasite that infects certain types of mosquitoes. Whether you'll need extra special medication depends on where your adventures in India are taking you and when you plan to travel. Most regions are low-risk — malaria has been found in cities like Mumbai and Delhi. Still, most cases occur in West Bengal, Jharkhand, Chhattisgarh, Gujarat, Madhya Pradesh, and Odisha. There's also a higher risk if you're traveling to India during its monsoon season (June to September), when hot temperatures, heavy rains, and a risk of flooding bring more mosquitoes.

Make sure to have a strong insect repellent on hand, and wear long, loose-fitted clothing to avoid being bitten. But if you're going to high-risk areas, get prescription antimalarials, too. Some of these tablets will need to be taken before your trip, during your travels, and after you get back — your doctor can help you determine which medication is best for you.

Another mosquito-borne illness to be aware of is Dengue — it's become more common in India over recent years. The mosquitos that carry it are often found in urban areas, but there's no vaccine. This means using a strong insect repellent, sleeping under a mosquito net, and covering your skin is your best defense. Dengue can cause nausea, vomiting, headache, and joint and muscle pain, but not everyone infected will feel sick.

Prepare For Diarrhea

One key symptom across many of the illnesses we've spoken about already is (the dreaded) diarrhea. While you can "get the runs" from anywhere in the world, "Delhi belly" is fairly common for visitors to India. From a 24-hour bout of loose stools to a full-on episode of travelers' diarrhea (TD) or giardiasis, the risk is exceptionally high here. You have a 60% chance of getting TD during a two-week trip. It's usually caused by eating or drinking contaminated foods or liquids, so it pays to be vigilant at all times.

Washing your hands as often as possible or using an antibacterial gel (when running water isn't available) can help protect you from germs. But you'll also want to avoid drinking tap water (even when brushing your teeth) and always ask for drinks without ice when you're out and about. Stick to filtered, boiled, or bottled water wherever you can. Oh, and when it comes to eating at restaurants or from food stalls in India, say no to anything that's been reheated, not to mention seafood and meat, which can also pose real risks if they're not fresh. Steering clear of raw, unpeeled fruit and veg is a good idea, too. If you're concerned about getting diarrhea while you're away, bring along some anti-diarrhea medication and oral rehydration salts, which can help relieve symptoms and give you peace of mind.

Protect Yourself From COVID-19

Sorry — it's likely you're a bit fed up hearing about this virus and the three-year-long global emergency it caused. Nevertheless, it's another jab you should consider getting before you make your way to India. True, there are no COVID-19 testing requirements to enter the country — you don't even need to prove you're vaccinated — but it's a good idea to make sure you're covered should you become infected while you're out there. Why? India is so densely populated. 

Despite being one-third the size of the U.S., it has four times the population, which increases the likelihood of virus transmission. Daily cases in the country are indeed low at this time. Still, the virus appears to circulate during specific seasons — India's last spike saw a total of 12,193 people infected with COVID-19 on April 21, 2023. With all this in mind, it's better to be safe than sorry, so do your part to stay protected from the illness. The CDC recommends everyone over the age of 5 get one dose of an updated COVID-19 vaccine yearly, especially those traveling internationally.

Air Quality Is A Huge Problem

With its sumptuous mix of traditions, stunning architecture, and jaw-dropping landscapes, India is a real sight to behold. But if you're planning a trip here, you'll want to think carefully about the time of year you visit. Perhaps more so than any other country in the world, India has an air quality problem, thanks to many of its mega-cities with dangerous pollution levels , especially during the annual "pollution season" — from October to December.

If you need any more convincing, the air quality index in Delhi hit 500 in November 2023. For context, this is the highest measurement the index will go to and is 100 times the limit deemed healthy by the World Health Organisation (WHO). Thick smog covering the capital, brought on by car emissions, construction, and farmers burning their fields during the crop planting season, has forced schools to shut and all but non-essential construction work to be paused in the past. Avoiding India's urban areas may help, but beware that air quality is a real problem in rural settings, too.

To properly take in the sights and smells of this wondrous country, you're much better off timing your trip outside of the pollution season. But if you must travel at this time, take plenty of precautions. You'll want to bring multiple face masks and avoid going outside wherever possible, especially if you have a preexisting health condition like asthma or chronic lung disease.

Beware Of Altitude Sickness

Frankly, India is ginormous — you'd need years, perhaps decades, to explore every ounce of its captivating land mass. For this reason, some travelers choose to visit the country in sections, organizing trips to and from India over the course of many years. But if this holiday sees you planning to take in all that the north has to offer — a word of caution. The high-elevation Himalayan areas that are both stunningly beautiful and have a perfect climate during India's summertime can also bring on the symptoms of altitude sickness. We're talking about places like the home of the 14th Dalai Lama — Dharamshala, mountainous Manali, the hill resort of Shimla, and spiritual Rishikesh.

But what exactly is altitude sickness? It's when your body doesn't have time to adjust to lower oxygen levels in the atmosphere. You're looking for the tell-tale signs of a headache, nausea and vomiting, a loss of appetite, fatigue (even when resting), trouble sleeping, and dizziness. To fight altitude sickness , make sure you ascend gradually and give yourself time to acclimate to your surroundings. If your symptoms worsen, especially at rest, you should descend slowly. Planning on taking a hiking or trekking excursion in the Himalayas? Your doctor can advise you on how to physically prepare for trips to high altitudes , including using a preventative altitude sickness treatment, such as acetazolamide. But if you notice troublesome symptoms on this medication, follow the safety guidance above.

Protect Yourself From The Sun

Regardless of the time of year, you're visiting India, you need to be careful when it comes to sun exposure. In Mumbai, for example, the UV Index (UVI) has been recorded as 8.2, which falls under the high-risk category — meaning you should avoid direct sunlight wherever possible, especially in the middle of the day. This is particularly important during the summer months (March to May) and where elevation is high, such as in the Himalayan areas in the north.

Other ways to stay as safe as possible are using a high-SPF sunscreen and reapplying it every two hours to protect yourself from sunburn . Wear loose, lightweight clothing and a sun hat to ward off heat-related illnesses like heat stroke . Steering clear of any physical activity when temperatures are high is also advised. So, too, is drinking plenty of water often and eating small, regular meals throughout the day.

Be Aware Of Sexually Transmitted Infections (STIs)

Arming yourself with protection against STIs is always a good idea, whether you're exploring new sights abroad or going about your normal routine at home. But make sure you stay extra vigilant during your trip to India — especially if you're a member of a high-risk population group, such as someone who's transgender, a man who has sex with men, or a female sex worker. Why? In 2019, it was found that 2.3 million people in India were living with HIV, especially in areas such as Manipur, Mizoram, and Nagaland. Compare this with 1.2 million people living with HIV in the U.S.

None of this is anything to worry about, though — you just need to be sensible and follow all the same general advice as you would at home. First off — don't have unprotected sex. If you do choose to have sex while in India, make sure you use latex condoms correctly. Second, don't share any needles, including needles used for getting a new tattoo, a piercing, or health therapies like acupuncture. Lastly, don't inject drugs. HIV can be spread through each of these means via bodily fluids, such as saliva, blood, and semen. Not to mention other STIs that can be contracted in similar ways, including chlamydia, gonorrhea, and syphilis.

Get Pre-Travel Advice, Even If Visiting People You Know

Are you jetting off to India to visit relatives or old friends? Chances are you're counting down the days until you're reunited with your loved ones. But before you hop on a flight, make sure you've checked in with a doctor. While your trip to India may technically be a return to your homeland, it's just as important for you to be made aware of the health risks at play, if not more so. For instance, you might be staying in a rural area not set up properly for tourists — somewhere that doesn't have a hospital or medical facilities nearby. Or maybe you'll be eating all of your meals with local family members who don't have adequate running water or the same sanitation measures you're used to when it comes to preparing food.

Even if you think it's a waste of time, book an appointment with your doctor at least eight weeks before you travel anyway. It can give you peace of mind that you're up to date with all the necessary vaccines, are aware of the risks you might be facing, and have all the right precautions in place should something go wrong.

Read the original article on Explore .

• Travel Insurance

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Travel Insurance For South Africa: Everything You Need To Know

Updated: Apr 30, 2024, 1:13pm

Table of Contents

Featured Partners

Do I Need Travel Insurance for South Africa?

What does travel insurance for south africa cover, frequently asked questions (faqs).

Tourism is on the rise in South Africa according to the local government , with more than four million tourists visiting the nation in the first half of 2023 alone. Australians form a sizable chunk of those numbers, with an estimated 125,000 Australians touring the country each year pre-pandemic.

With travel still high on the agenda for many Australians, that figure is expected to rise in the coming years.

If you’re considering a trip to South Africa, you’ll want to purchase travel insurance. Our guide explains everything you need to know.

Fast Cover Travel Insurance

On Fast Cover’s Secure Website

Medical cover

Unlimited, 24/7 Emergency Assistance

Cancellations

Unlimited, (Trip Disruption $50,000)

Key Features

25-Day Cooling Off Period, Australian Based Call Centre, 4.6 Star Product Review Rating

Cover-More Travel Insurance

On Cover-more’s secure website

Unlimited, with a $2000 limit to dental

Yes, amount chosen by customer

Southern Cross Travel Insurance

Medical Cover

Including medical treatment, doctors’ visits, prescribed medication, specialist treatment & medical transport costs

$2,500 with option to increase to unlimited

Yes, Australians should purchase travel insurance for South Africa. While not a legal requirement to enter the country, it is highly recommended from the Australian government—especially for medical care.

The standard of medical facilities in South Africa can vary by region, but medical facilities are generally of a much lower standard than Australia. In fact, many regional hospitals only provide basic facilities, meaning you may have to be relocated in order to receive the right medical attention.

There is no shared healthcare agreement between Australia and South Africa, which makes travel insurance even more essential. If you need to be transferred by air evacuation to a major city in order to receive treatment, and you don’t have travel insurance, you’ll likely face a hefty bill out of your own pocket.

As Smartraveller advises all Australians, if you can’t afford travel insurance, you can’t afford to travel.

Vaccinations to Consider for Your Trip to South Africa

There is a high risk of certain diseases in South Africa, so it is worth making sure your vaccinations are up to date before you travel and taking any preventative measures with you, such as medications.

This can help reduce your chances of needing to seek medical attention.

There is a risk of Hepatitis A and B throughout South Africa, so vaccinations for Australian travellers are recommended. There is also a moderate risk for most travellers of typhoid, so a vaccination is also recommended if you are travelling to smaller cities, villages and rural areas.

Malaria is present throughout the country, so it could be a good idea to equip yourself with malaria tablets before you travel.

It is essential that you consult a medical practitioner regarding your need for vaccinations before you travel to South Africa, especially as some medical conditions can predispose travellers to certain infections.

When purchasing a travel insurance policy for South Africa, you will have the option to choose a basic policy or a comprehensive policy. A basic policy is cheaper , but may turn out to be more expensive in the long run if you aren’t covered for the things you need.

While a basic policy will usually cover medical needs, it may not provide cover for things such as lost luggage and cancellations (or, if it does, will provide it at a much lower claim level).

That’s why a comprehensive policy is highly recommended for travel to South Africa, as you will receive cover for stolen items, lost luggage, delays and more, in addition to medical and emergency dental care.

Smartraveller asks Australians to exercise a high degree of caution due to the threat of violent crime in South Africa, which includes robbery and carjacking.

The government website warns that opportunistic criminals will target travellers at the approaches to tourist-hotspot Kruger National Park, at well-known resorts, and on public transport.

Additionally, as ATM and credit card fraud are common crimes in South Africa, a comprehensive policy can be the more financially sound choice to give you peace of mind.

Going on a Safari?

South Africa is a popular tourist region for many reasons, including wildlife safaris. If you wish to partake in a safari or a game walk—walking with wild animals and a professional guide—you will need to ensure that these activities are covered in your policy’s list of included sports and activities.

If they are not, you will not receive cover for anything that occurs during the safari.

However, your policy may offer the option for you to choose an ‘adventure pack’ at an additional cost, which can include many activities that aren’t covered in the standard offering.

This can also include hiking or trekking to certain altitudes.

It’s important to consider which activities you may be participating in during your trip to South Africa in order to ensure you have the appropriate coverage, and purchase an additional add-on if necessary.

What Travel Insurance Won’t Cover

Your travel insurance policy won’t cover anything that is set out in its exclusions, as per the product disclosure statement (PDS). This could include certain sports and activities (such as a safari), or travel to certain regions in South Africa due to safety.

While each travel insurance policy differs on the fine-print, it is standard for most policies not to cover:

• Cancellations due to ‘disinclination to travel’, being if you change your mind about your holiday;
• Accidents or injuries that occur when not following the appropriate safety guidance or official guidelines;
• Intoxicated behaviour, including recreational drugs;
• Any illegal activity.

Be sure to carefully read the PDS of your policy so you know exactly what you can and cannot claim on your trip to South Africa.

Is it safe to travel to South Africa?

Smartraveller recommends that Australians exercise a high degree of caution when travelling to South Africa, due to the threat of violent crime. This includes armed robbery, mugging, carjacking, credit card theft, and more.

There is a higher risk of violent crime in major cities after dark, or during “rolling blackout” periods.

For these reasons (and more), Smartraveller urges Australians to take out a travel insurance policy before travelling to South Africa.

Do Australians need a visa for South Africa?

No, Australians do not need a visa for South Africa if they are visiting for tourism for stays of up to 90 days.

Where can I buy travel insurance for South Africa?

Most Australian travel insurance providers will cover Aussies wanting to head abroad to South Africa. When shopping around for a policy, you will be able to choose your destination when you request a quote. If there is no option to choose South Africa, this would be a clear indicator that the insurance provider does not provide policies to this region.

At the time of writing, a few of our top picks for comprehensive travel insurance cover South Africa, including Allianz and Cover-More .

Travel insurance providers can revoke the issuing of new policies to certain destinations at any time, especially if Smartraveller changes the alert warning for a country to ‘Do Not Travel’.

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Sophie Venz is an experienced editor and features reporter, and has previously worked in the small business and start-up reporting space. Previously the Associate Editor of SmartCompany, Sophie has worked closely with finance experts and columnists around Australia and internationally.

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Uganda Traveler View

Travel health notices, vaccines and medicines, non-vaccine-preventable diseases, stay healthy and safe.

• Packing List

After Your Trip

There are no notices currently in effect for Uganda.

⇧ Top

Check the vaccines and medicines list and visit your doctor at least a month before your trip to get vaccines or medicines you may need. If you or your doctor need help finding a location that provides certain vaccines or medicines, visit the Find a Clinic page.

Routine vaccines

Recommendations.

Make sure you are up-to-date on all routine vaccines before every trip. Some of these vaccines include

• Chickenpox (Varicella)
• Diphtheria-Tetanus-Pertussis
• Flu (influenza)
• Measles-Mumps-Rubella (MMR)

Immunization schedules

All eligible travelers should be up to date with their COVID-19 vaccines. Please see  Your COVID-19 Vaccination  for more information. 

COVID-19 vaccine

Areas of active cholera transmission are  localized  to Kayunga (last case reported 3-6 months ago), Mbale (last case reported in the past 3 months), and Namayingo (last case reported 6-9 months ago) in Uganda. Cholera is rare in travelers.  Certain factors  may increase the risk of getting cholera or having severe disease ( more information ). Avoiding unsafe food and water and washing your hands can also help prevent cholera.

Vaccination may be considered for children and adults who are traveling to areas of active cholera transmission.

Cholera - CDC Yellow Book

Hepatitis A

Recommended for unvaccinated travelers one year old or older going to Uganda.

Infants 6 to 11 months old should also be vaccinated against Hepatitis A. The dose does not count toward the routine 2-dose series.

Travelers allergic to a vaccine component or who are younger than 6 months should receive a single dose of immune globulin, which provides effective protection for up to 2 months depending on dosage given.

Unvaccinated travelers who are over 40 years old, immunocompromised, or have chronic medical conditions planning to depart to a risk area in less than 2 weeks should get the initial dose of vaccine and at the same appointment receive immune globulin.

Hepatitis A - CDC Yellow Book

Dosing info - Hep A

Hepatitis B

Recommended for unvaccinated travelers younger than 60 years old traveling to Uganda. Unvaccinated travelers 60 years and older may get vaccinated before traveling to Uganda.

Hepatitis B - CDC Yellow Book

Dosing info - Hep B

CDC recommends that travelers going to Uganda take prescription medicine to prevent malaria. Depending on the medicine you take, you will need to start taking this medicine multiple days before your trip, as well as during and after your trip. Talk to your doctor about which malaria medication you should take.

Find  country-specific information  about malaria.

Malaria - CDC Yellow Book

Considerations when choosing a drug for malaria prophylaxis (CDC Yellow Book)

Malaria information for Uganda.

Cases of measles are on the rise worldwide. Travelers are at risk of measles if they have not been fully vaccinated at least two weeks prior to departure, or have not had measles in the past, and travel internationally to areas where measles is spreading.

All international travelers should be fully vaccinated against measles with the measles-mumps-rubella (MMR) vaccine, including an early dose for infants 6–11 months, according to  CDC’s measles vaccination recommendations for international travel .

Measles (Rubeola) - CDC Yellow Book

Meningitis (Meningococcal disease)

Recommended for travelers 2 months old or older traveling to  areas of Uganda  that are part of the meningitis belt during the dry season.

Meningococcal disease - CDC Yellow Book

Meningitis Belt Map

Rabid dogs are commonly found in Uganda. If you are bitten or scratched by a dog or other mammal while in Uganda, there may be limited or no rabies treatment available. 

Consider rabies vaccination before your trip if your activities mean you will be around dogs or wildlife.

Travelers more likely to encounter rabid animals include

• Campers, adventure travelers, or cave explorers (spelunkers)
• Veterinarians, animal handlers, field biologists, or laboratory workers handling animal specimens
• Visitors to rural areas

Since children are more likely to be bitten or scratched by a dog or other animals, consider rabies vaccination for children traveling to Uganda. 

Rabies - CDC Yellow Book

Recommended for most travelers, especially those staying with friends or relatives or visiting smaller cities or rural areas.

Typhoid - CDC Yellow Book

Dosing info - Typhoid

Yellow Fever

Required for all arriving travelers ≥1 year old.

Recommended for all travelers ≥9 months old.

Yellow Fever - CDC Yellow Book

• Avoid contaminated water

Leptospirosis

How most people get sick (most common modes of transmission)

• Touching urine or other body fluids from an animal infected with leptospirosis
• Swimming or wading in urine-contaminated fresh water, or contact with urine-contaminated mud
• Drinking water or eating food contaminated with animal urine
• Avoid contaminated water and soil

Clinical Guidance

Schistosomiasis

• Wading, swimming, bathing, or washing in contaminated freshwater streams, rivers, ponds, lakes, or untreated pools.

Avoid bug bites

African sleeping sickness (african trypanosomiasis).

• Tsetse fly bite 
• Avoid Bug Bites

African Trypanosomiasis

African Tick-Bite Fever

African Tick-bite fever

Chikungunya

• Mosquito bite

Crimean-Congo Hemorrhagic fever

• Tick bite 
• Touching the body fluids of a person or animal infected with CCHF
• Mosquito bite
• An infected pregnant woman can spread it to her unborn baby
• Avoid animals
• Touching infected animals (including bats and primates) or their body fluids
• Touching body fluids (blood or sweat) from an infected person
• Touching objects contaminated with the body fluids of a person infected with Ebola or Marburg virus
• Avoid sick people
• Avoid animals and areas where they live

Ebola virus

Marburg Hemorrhagic Fever

Marburg virus

Rift Valley Fever

• Touching blood, body fluids, or tissue of infected livestock

Rift Valley fever

Airborne & droplet

• Breathing in air or accidentally eating food contaminated with the urine, droppings, or saliva of infected rodents
• Bite from an infected rodent
• Less commonly, being around someone sick with hantavirus (only occurs with Andes virus)
• Avoid rodents and areas where they live

Tuberculosis (TB)

• Breathe in TB bacteria that is in the air from an infected and contagious person coughing, speaking, or singing.

Learn actions you can take to stay healthy and safe on your trip. Vaccines cannot protect you from many diseases in Uganda, so your behaviors are important.

Eat and drink safely

Food and water standards around the world vary based on the destination. Standards may also differ within a country and risk may change depending on activity type (e.g., hiking versus business trip). You can learn more about safe food and drink choices when traveling by accessing the resources below.

• Choose Safe Food and Drinks When Traveling
• Water Treatment Options When Hiking, Camping or Traveling
• Global Water, Sanitation and Hygiene | Healthy Water
• Avoid Contaminated Water During Travel

You can also visit the Department of State Country Information Pages for additional information about food and water safety.

Prevent bug bites

Bugs (like mosquitoes, ticks, and fleas) can spread a number of diseases in Uganda. Many of these diseases cannot be prevented with a vaccine or medicine. You can reduce your risk by taking steps to prevent bug bites.

What can I do to prevent bug bites?

• Cover exposed skin by wearing long-sleeved shirts, long pants, and hats.
• Use an appropriate insect repellent (see below).
• Use permethrin-treated clothing and gear (such as boots, pants, socks, and tents). Do not use permethrin directly on skin.
• Stay and sleep in air-conditioned or screened rooms.
• Use a bed net if the area where you are sleeping is exposed to the outdoors.

What type of insect repellent should I use?

• FOR PROTECTION AGAINST TICKS AND MOSQUITOES: Use a repellent that contains 20% or more DEET for protection that lasts up to several hours.
• Picaridin (also known as KBR 3023, Bayrepel, and icaridin)
• Oil of lemon eucalyptus (OLE) or para-menthane-diol (PMD)
• 2-undecanone
• Always use insect repellent as directed.

What should I do if I am bitten by bugs?

• Avoid scratching bug bites, and apply hydrocortisone cream or calamine lotion to reduce the itching.
• Check your entire body for ticks after outdoor activity. Be sure to remove ticks properly.

What can I do to avoid bed bugs?

Although bed bugs do not carry disease, they are an annoyance. See our information page about avoiding bug bites for some easy tips to avoid them. For more information on bed bugs, see Bed Bugs .

For more detailed information on avoiding bug bites, see Avoid Bug Bites .

Stay safe outdoors

If your travel plans in Uganda include outdoor activities, take these steps to stay safe and healthy during your trip.

• Stay alert to changing weather conditions and adjust your plans if conditions become unsafe.
• Prepare for activities by wearing the right clothes and packing protective items, such as bug spray, sunscreen, and a basic first aid kit.
• Consider learning basic first aid and CPR before travel. Bring a travel health kit with items appropriate for your activities.
• If you are outside for many hours in heat, eat salty snacks and drink water to stay hydrated and replace salt lost through sweating.
• Protect yourself from UV radiation : use sunscreen with an SPF of at least 15, wear protective clothing, and seek shade during the hottest time of day (10 a.m.–4 p.m.).
• Be especially careful during summer months and at high elevation. Because sunlight reflects off snow, sand, and water, sun exposure may be increased during activities like skiing, swimming, and sailing.
• Very cold temperatures can be dangerous. Dress in layers and cover heads, hands, and feet properly if you are visiting a cold location.

Stay safe around water

• Swim only in designated swimming areas. Obey lifeguards and warning flags on beaches.
• Practice safe boating—follow all boating safety laws, do not drink alcohol if driving a boat, and always wear a life jacket.
• Do not dive into shallow water.
• Do not swim in freshwater in developing areas or where sanitation is poor.
• Avoid swallowing water when swimming. Untreated water can carry germs that make you sick.
• To prevent infections, wear shoes on beaches where there may be animal waste.

Schistosomiasis, a parasitic infection that can be spread in fresh water, is found in Uganda. Avoid swimming in fresh, unchlorinated water, such as lakes, ponds, or rivers.

Keep away from animals

Most animals avoid people, but they may attack if they feel threatened, are protecting their young or territory, or if they are injured or ill. Animal bites and scratches can lead to serious diseases such as rabies.

Follow these tips to protect yourself:

• Do not touch or feed any animals you do not know.
• Do not allow animals to lick open wounds, and do not get animal saliva in your eyes or mouth.
• Avoid rodents and their urine and feces.
• Traveling pets should be supervised closely and not allowed to come in contact with local animals.
• If you wake in a room with a bat, seek medical care immediately. Bat bites may be hard to see.

All animals can pose a threat, but be extra careful around dogs, bats, monkeys, sea animals such as jellyfish, and snakes. If you are bitten or scratched by an animal, immediately:

• Wash the wound with soap and clean water.
• Go to a doctor right away.
• Tell your doctor about your injury when you get back to the United States.

Consider buying medical evacuation insurance. Rabies is a deadly disease that must be treated quickly, and treatment may not be available in some countries.

Reduce your exposure to germs

Follow these tips to avoid getting sick or spreading illness to others while traveling:

• Wash your hands often, especially before eating.
• If soap and water aren’t available, clean hands with hand sanitizer (containing at least 60% alcohol).
• Don’t touch your eyes, nose, or mouth. If you need to touch your face, make sure your hands are clean.
• Cover your mouth and nose with a tissue or your sleeve (not your hands) when coughing or sneezing.
• Try to avoid contact with people who are sick.
• If you are sick, stay home or in your hotel room, unless you need medical care.

Avoid sharing body fluids

Diseases can be spread through body fluids, such as saliva, blood, vomit, and semen.

Protect yourself:

• Use latex condoms correctly.
• Do not inject drugs.
• Limit alcohol consumption. People take more risks when intoxicated.
• Do not share needles or any devices that can break the skin. That includes needles for tattoos, piercings, and acupuncture.
• If you receive medical or dental care, make sure the equipment is disinfected or sanitized.

Know how to get medical care while traveling

Plan for how you will get health care during your trip, should the need arise:

• Carry a list of local doctors and hospitals at your destination.
• Review your health insurance plan to determine what medical services it would cover during your trip. Consider purchasing travel health and medical evacuation insurance.
• Carry a card that identifies, in the local language, your blood type, chronic conditions or serious allergies, and the generic names of any medications you take.
• Some prescription drugs may be illegal in other countries. Call Uganda’s embassy to verify that all of your prescription(s) are legal to bring with you.
• Bring all the medicines (including over-the-counter medicines) you think you might need during your trip, including extra in case of travel delays. Ask your doctor to help you get prescriptions filled early if you need to.

Many foreign hospitals and clinics are accredited by the Joint Commission International. A list of accredited facilities is available at their website ( www.jointcommissioninternational.org ).

In some countries, medicine (prescription and over-the-counter) may be substandard or counterfeit. Bring the medicines you will need from the United States to avoid having to buy them at your destination.

Malaria is a risk in Uganda. Fill your malaria prescription before you leave and take enough with you for the entire length of your trip. Follow your doctor’s instructions for taking the pills; some need to be started before you leave.

Select safe transportation

Motor vehicle crashes are the #1 killer of healthy US citizens in foreign countries.

In many places cars, buses, large trucks, rickshaws, bikes, people on foot, and even animals share the same lanes of traffic, increasing the risk for crashes.

Be smart when you are traveling on foot.

• Use sidewalks and marked crosswalks.
• Pay attention to the traffic around you, especially in crowded areas.
• Remember, people on foot do not always have the right of way in other countries.

Riding/Driving

Choose a safe vehicle.

• Choose official taxis or public transportation, such as trains and buses.
• Ride only in cars that have seatbelts.
• Avoid overcrowded, overloaded, top-heavy buses and minivans.
• Avoid riding on motorcycles or motorbikes, especially motorbike taxis. (Many crashes are caused by inexperienced motorbike drivers.)
• Choose newer vehicles—they may have more safety features, such as airbags, and be more reliable.
• Choose larger vehicles, which may provide more protection in crashes.

Think about the driver.

• Do not drive after drinking alcohol or ride with someone who has been drinking.
• Consider hiring a licensed, trained driver familiar with the area.
• Arrange payment before departing.

Follow basic safety tips.

• Wear a seatbelt at all times.
• Sit in the back seat of cars and taxis.
• When on motorbikes or bicycles, always wear a helmet. (Bring a helmet from home, if needed.)
• Avoid driving at night; street lighting in certain parts of Uganda may be poor.
• Do not use a cell phone or text while driving (illegal in many countries).
• Travel during daylight hours only, especially in rural areas.
• If you choose to drive a vehicle in Uganda, learn the local traffic laws and have the proper paperwork.
• Get any driving permits and insurance you may need. Get an International Driving Permit (IDP). Carry the IDP and a US-issued driver's license at all times.
• Check with your auto insurance policy's international coverage, and get more coverage if needed. Make sure you have liability insurance.
• Avoid using local, unscheduled aircraft.
• If possible, fly on larger planes (more than 30 seats); larger airplanes are more likely to have regular safety inspections.
• Try to schedule flights during daylight hours and in good weather.

Medical Evacuation Insurance

If you are seriously injured, emergency care may not be available or may not meet US standards. Trauma care centers are uncommon outside urban areas. Having medical evacuation insurance can be helpful for these reasons.

Helpful Resources

Road Safety Overseas (Information from the US Department of State): Includes tips on driving in other countries, International Driving Permits, auto insurance, and other resources.

The Association for International Road Travel has country-specific Road Travel Reports available for most countries for a minimal fee.

Traffic flows on the left side of the road in Uganda.

• Always pay close attention to the flow of traffic, especially when crossing the street.
• LOOK RIGHT for approaching traffic.

Maintain personal security

Use the same common sense traveling overseas that you would at home, and always stay alert and aware of your surroundings.

Before you leave

• Research your destination(s), including local laws, customs, and culture.
• Monitor travel advisories and alerts and read travel tips from the US Department of State.
• Enroll in the Smart Traveler Enrollment Program (STEP) .
• Leave a copy of your itinerary, contact information, credit cards, and passport with someone at home.
• Pack as light as possible, and leave at home any item you could not replace.

While at your destination(s)

• Carry contact information for the nearest US embassy or consulate .
• Carry a photocopy of your passport and entry stamp; leave the actual passport securely in your hotel.
• Follow all local laws and social customs.
• Do not wear expensive clothing or jewelry.
• Always keep hotel doors locked, and store valuables in secure areas.
• If possible, choose hotel rooms between the 2nd and 6th floors.

Healthy Travel Packing List

Use the Healthy Travel Packing List for Uganda for a list of health-related items to consider packing for your trip. Talk to your doctor about which items are most important for you.

Why does CDC recommend packing these health-related items?

It’s best to be prepared to prevent and treat common illnesses and injuries. Some supplies and medicines may be difficult to find at your destination, may have different names, or may have different ingredients than what you normally use.

If you are not feeling well after your trip, you may need to see a doctor. If you need help finding a travel medicine specialist, see Find a Clinic . Be sure to tell your doctor about your travel, including where you went and what you did on your trip. Also tell your doctor if you were bitten or scratched by an animal while traveling.

If your doctor prescribed antimalarial medicine for your trip, keep taking the rest of your pills after you return home. If you stop taking your medicine too soon, you could still get sick.

Malaria is always a serious disease and may be a deadly illness. If you become ill with a fever either while traveling in a malaria-risk area or after you return home (for up to 1 year), you should seek immediate medical attention and should tell the doctor about your travel history.

For more information on what to do if you are sick after your trip, see Getting Sick after Travel .

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