Read below for travel health advice on Estonia from the MDtravelhealth channel on Red Planet Travel.
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Summary of recommendations
Most travelers to Estonia will need vaccinations for hepatitis A and typhoid fever, as well as medications for travelers' diarrhea. All travelers should be up-to-date on tetanus-diphtheria vaccination. Other immunizations may be necessary depending upon the circumstances of the trip and the medical history of the traveler, as discussed below. All travelers should visit either a travel health clinic or their personal physician 4-8 weeks before departure.
|Tetanus-diphtheria||For all travelers who have not received a tetanus-diphtheria immunization within the last 10 years.|
|Hepatitis A||Recommended for all travelers|
|Typhoid||For travelers who may eat or drink outside major restaurants and hotels|
|Hepatitis B||Recommended for all travelers|
|Rabies||For travelers at high risk for animal bites or involved in any activities that might bring them into direct contact with bats|
|Measles, mumps, rubella (MMR)||Two doses recommended for all travelers born after 1956, if not previously given|
|Influenza||Recommended for all travelers from November through April|
Travelers' diarrhea is the most common travel-related ailment. The cornerstone of prevention is food and water precautions, as outlined below. All travelers should bring along an antibiotic and an antidiarrheal drug to be started promptly if significant diarrhea occurs, defined as three or more loose stools in an 8-hour period or five or more loose stools in a 24-hour period, especially if associated with nausea, vomiting, cramps, fever or blood in the stool. A quinolone antibiotic is usually prescribed: either ciprofloxacin (Cipro)(PDF) 500 mg twice daily or levofloxacin (Levaquin) 500 mg once daily for a total of three days. Quinolones are generally well-tolerated, but occasionally cause sun sensitivity and should not be given to children, pregnant women, or anyone with a history of quinolone allergy. Alternative regimens include a three day course of rifaximin (Xifaxan) 200 mg three times daily or azithromycin (Zithromax) 500 mg once daily. Rifaximin should not be used by those with fever or bloody stools and is not approved for pregnant women or those under age 12. Azithromycin should be avoided in those allergic to erythromycin or related antibiotics. An antidiarrheal drug such as loperamide (Imodium) or diphenoxylate (Lomotil) should be taken as needed to slow the frequency of stools, but not enough to stop the bowel movements completely. Diphenoxylate (Lomotil) and loperamide (Imodium) should not be given to children under age two.
Most cases of travelers' diarrhea are mild and do not require either antibiotics or antidiarrheal drugs. Adequate fluid intake is essential.
If diarrhea is severe or bloody, or if fever occurs with shaking chills, or if abdominal pain becomes marked, or if diarrhea persists for more than 72 hours, medical attention should be sought.
Though effective, antibiotics are not recommended prophylactically (i.e. to prevent diarrhea before it occurs) because of the risk of adverse effects, though this approach may be warranted in special situations, such as immunocompromised travelers.
The following are the recommended vaccinations for Estonia:
Tetanus - diphtheria vaccine is recommended for all adults who have not received a tetanus-diphtheria immunization within the last 10 years. In the 1990s, a massive diphtheria epidemic occurred in the newly independent states of the former Soviet Union (see CR Vitek and M Wharton, Emerging Infectious Diseases). Cases of diphtheria have been reported among U.S. citizens who have traveled to this area.
Hepatitis A vaccine is recommended for all travelers over one year of age, though the risk of hepatitis A is low. It should be given at least two weeks (preferably four weeks or more) before departure. A booster should be given 6-12 months later to confer long-term immunity. Two vaccines are currently available in the United States: VAQTA (Merck and Co., Inc.) (PDF) and Havrix (GlaxoSmithKline) (PDF). Both are well-tolerated. Side-effects, which are generally mild, may include soreness at the injection site, headache, and malaise.
Older adults, immunocompromised persons, and those with chronic liver disease or other chronic medical conditions who have less than two weeks before departure should receive a single intramuscular dose of immune globulin (0.02 mL/kg) at a separate anatomic injection site in addition to the initial dose of vaccine. Travelers who are less than one year of age or allergic to a vaccine component should receive a single intramuscular dose of immune globulin (see hepatitis A for dosage) in the place of vaccine.
Hepatitis B vaccine is recommended for all travelers if not previously vaccinated. Two vaccines are currently licensed in the United States: Recombivax HB (Merck and Co., Inc.) (PDF) and Engerix-B (GlaxoSmithKline) (PDF). A full series consists of three intramuscular doses given at 0, 1 and 6 months. Engerix-B is also approved for administration at 0, 1, 2, and 12 months, which may be appropriate for travelers departing in less than 6 months. Side-effects are generally mild and may include discomfort at the injection site and low-grade fever. Severe allergic reactions (anaphylaxis) occur rarely.
Rabies vaccine is recommended only for those at high risk for animal bites, such as veterinarians and animal handlers, for long-term travelers living in areas with a high risk of exposure, and for travelers involved in any activities that might bring them into direct contact with bats. A complete preexposure series consists of three doses of vaccine injected into the deltoid muscle on days 0, 7, and 21 or 28. Side-effects may include pain at the injection site, headache, nausea, abdominal pain, muscle aches, dizziness, or allergic reactions.
Any animal bite or scratch should be thoroughly cleaned with large amounts of soap and water and local health authorities should be contacted immediately for possible post-exposure treatment, whether or not the person has been immunized against rabies.
Measles-mumps-rubella vaccine: two doses are recommended (if not previously given) for all travelers born after 1956, unless blood tests show immunity. Many adults born after 1956 and before 1970 received only one vaccination against measles, mumps, and rubella as children and should be given a second dose before travel. MMR vaccine should not be given to pregnant or severely immunocompromised individuals.
Influenza vaccine is recommended for all travelers during flu season, which runs from November through April. The vaccine may cause soreness at the injection site, low-grade fevers, malaise, and muscle aches. Severe reactions are rare. Influenza vaccine should not be given to pregnant women during the first trimester.
Tick-borne encephalitis vaccine may be considered for long-term travelers who expect to be visiting rural or forested areas from April to October. The incidence of tick-borne encephalitis rose sharply in the late 1990s. In Estonia, most cases are reported from the southwestern part of the country (Pärnumaa, Läänemaa), the northeastern regions (Ida-Virumaa and Lääne-Virumaa counties and the town of Narva), southeastern Estonia (Polvamaa, Tartumaa), and the island of Saaremaa in the west. See the articles in Eurosurveillance at http://www.eurosurveillance.org/ew/2002/020606.asp and http://www.eurosurveillance.org/ew/2005/050630.asp for further discussion. The infection may also be acquired by ingesting unpasteurized dairy products. An outbreak in May-June 2005 was linked to consumption of raw goat milk.
Two vaccines have been developed: TicoVac, also known as FSME Immun (Baxter AG), which is manufactured in Austria, and Encepur (Chiron Behring), which is made in Germany. The vaccines are approved for use in a number of European countries, but not the United States. A full series consists of three doses over a one-year period, which is not practical for most travelers, though limited data indicate that Encepur may be given in an accelerated schedule for faster immunity. Tick precautions, as discussed below, are strongly advised.
Lyme disease is reported from April through October. The greatest risk occurs in Saaremaa, an isolated island off the coast of Estonia. There is also high risk along the Finnish Gulf coast in Harjumaa and Western Virumaa and in Parnumaa and Eastern Virumaa counties. (These are high risk areas for tick-borne encephalitis as well.) For the year 2006, a total 482 cases of Lyme disease occurred in Estonia, including 154 cases (32 percent) from Saaremaa. For further information, see EpiNorth and ProMED-mail (June 23, 2007).
HIV (human immunodeficiency virus) infection is reported, but travelers are not at risk unless they have unprotected sexual contacts or receive injections or blood transfusions.
For a summary of infectious disease statistics, go to EpiNorth (click on EpiData from the menu on the left) or the Estonian Communicable Disease Bulletin.
For a review of helminthic (parasitic) infections in Estonia, go to EpiNorth.
Food and water precautions
Do not drink tap water unless it has been boiled, filtered, or chemically disinfected. Do not drink unbottled beverages or drinks with ice. Do not eat fruits or vegetables unless they have been peeled or cooked. Avoid cooked foods that are no longer piping hot. Cooked foods that have been left at room temperature are particularly hazardous. Avoid unpasteurized milk and any products that might have been made from unpasteurized milk, such as ice cream. Avoid food and beverages obtained from street vendors. Do not eat raw or undercooked meat or fish. Some types of fish may contain poisonous biotoxins even when cooked. Barracuda in particular should never be eaten. Other fish that may contain toxins include red snapper, grouper, amberjack, and sea bass.
All travelers should bring along an antibiotic and an antidiarrheal drug to be started promptly if significant diarrhea occurs, defined as three or more loose stools in an 8-hour period or five or more loose stools in a 24-hour period, especially if accompanied by nausea, vomiting, cramps, fever or blood in the stool. Antibiotics which have been shown to be effective include ciprofloxacin (Cipro), levofloxacin (Levaquin), rifaximin (Xifaxan), or azithromycin (Zithromax). Either loperamide (Imodium) or diphenoxylate (Lomotil) should be taken in addition to the antibiotic to reduce diarrhea and prevent dehydration.
If diarrhea is severe or bloody, or if fever occurs with shaking chills, or if abdominal pain becomes marked, or if diarrhea persists for more than 72 hours, medical attention should be sought.
Bootleg alcohol in Estonia may contain methanol (wood alcohol), which is highly toxic. See ProMED-mail (Sept. 12, 2001) for details.
Insect and Tick Protection
Wear long sleeves, long pants, and boots, with pants tucked in, when traveling to rural or forested areas. Apply insect repellents containing 25-50% DEET (N,N-diethyl-3-methylbenzamide) or 20% picaridin (Bayrepel) to exposed skin (but not to the eyes, mouth, or open wounds). DEET may also be applied to clothing. Products with a lower concentration of either repellent need to be repplied more frequently. Products with a higher concentration of DEET carry an increased risk of neurologic toxicity, especially in children, without any additional benefit. Do not use either DEET or picaridin on children less than two years of age. For additional protection, apply permethrin-containing compounds to clothing and shoes. Permethrin-treated clothing appears to have little toxicity. Perform a thorough tick check at the end of each day with the assistance of a friend or a full-length mirror. Ticks should be removed with tweezers, grasping the tick by the head. Many tick-borne illnesses can be prevented by prompt tick removal.
Bring adequate supplies of all medications in their original containers, clearly labeled. Carry a signed, dated letter from the primary physician describing all medical conditions and listing all medications, including generic names. If carrying syringes or needles, be sure to carry a physician's letter documenting their medical necessity.Pack all medications in hand luggage. Carry a duplicate supply in the checked luggage. If you wear glasses or contacts, bring an extra pair. If you have significant allergies or chronic medical problems, wear a medical alert bracelet.
Make sure your health insurance covers you for medical expenses abroad. If not, supplemental insurance for overseas coverage, including possible evacuation, should be seriously considered. If illness occurs while abroad, medical expenses including evacuation may run to tens of thousands of dollars. For a list of travel insurance and air ambulance companies, go to Medical Information for Americans Traveling Abroad on the U.S. State Department website. Bring your insurance card, claim forms, and any other relevant insurance documents. Before departure, determine whether your insurance plan will make payments directly to providers or reimburse you later for overseas health expenditures. The Medicare and Medicaid programs do not pay for medical services outside the United States.
Pack a personal medical kit, customized for your trip (see description). Take appropriate measures to prevent motion sickness and jet lag, discussed elsewhere. On long flights, be sure to walk around the cabin, contract your leg muscles periodically, and drink plenty of fluids to prevent blood clots in the legs. For those at high risk for blood clots, consider wearing compression stockings.
Avoid contact with stray dogs and other animals. If an animal bites or scratches you, clean the wound with large amounts of soap and water and contact local health authorities immediately. Wear sun block regularly when needed. Use condoms for all sexual encounters. Ride only in motor vehicles with seat belts. Do not ride on motorcycles.
Ambulance and Emergency Services
For an ambulance in Estonia, call 112 or (372) 697-1500.
Medical care in Estonia is not comparable to that in Western countries, but is improving. For medical emergencies, the main facility is the North-Estonian Regional Hospital (Sütiste str. 19, 13419 Tallinn; information tel. 372 697 1300 (7 AM to 7 PM), reception tel. 372 697-1400, trauma center tel. 372 697-1093, 24-hour emergency tel. 372 697-1500; website http://www.mustamaehaigla.ee). For an outpatient consultation with a specialist at North-Estonian Regional Hospital, call 372 697-1049. For children, the chief facility is the Tallinn Children's Hospital (Tervise str. 28, Tallinn 13419; information tel. 372 697-4113, outpatient treatment tel. 372 697-4222; 372 697-4218, trauma section tel. 372 697-4194, reception tel. 372 697-4141; well-trained physicians; most speak English). For routine care, many expatriates go to the Medicover Swedish-Estonian Medical Center (prepaid health plan; private clinic with offices in Tallinn, Jõhvi,Pärnu, Tartu, Põlva and Võru; see website at http://www.medicover.com/ee/en/en/Default.aspx?TabId=84 for locations).
For a guide to other physicians, clinics, and hospitals in Estonia, go to the U.S. Embassy website. Many physicians in Estonia are well-trained, but hospitals and clinics often lack equipment and supplies. Many doctors and hospitals will expect payment in cash, regardless of whether you have travel health insurance. Serious medical problems will require air evacuation to a country with state-of-the-art medical facilities.
There is good quality control of pharmaceuticals in Estonia, comparable to that in other EU member states. Medications may be sold only in a licensed pharmacy, called "apteek". Over the last several years, a number of large pharmacy chains have emerged, including Apteek1 (http://www.apteek1.ee/) and Apotheka (http://www.apotheka.ee)(see websites for locations). Tõnismäe Apteek (Tõnismägi 5, Tallinn) is open 24 hours. Hospital pharmacies are not permitted to sell drugs to the general public. See the World Health Organization for further information.
Traveling with children
Before you leave, make sure you have the names and contact information for physicians, clinics, and hospitals where you can obtain emergency medical care if needed.
All children should be up-to-date on routine childhood immunizations, as recommended by the American Academy of Pediatrics. Children who are 12 months or older should receive a total of 2 doses of MMR (measles-mumps-rubella) vaccine, separated by at least 28 days, before international travel. Children between the ages of 6 and 11 months should be given a single dose of measles vaccine. MMR vaccine may be given if measles vaccine is not available, though immunization against mumps and rubella is not necessary before age one unless visiting a country where an outbreak is in progress. Children less than one year of age may also need to receive other immunizations ahead of schedule (see the accelerated immunization schedule).
When traveling with young children, be particularly careful about what you allow them to eat and drink (see food and water precautions), because diarrhea can be especially dangerous in this age group and because the vaccines for hepatitis A and typhoid fever, which are transmitted by contaminated food and water, are not approved for children under age two.
Be sure to pack a medical kit when traveling with children. In addition to the items listed for adults, bring along plenty of disposable diapers, cream for diaper rash, oral replacement salts, and appropriate antibiotics for common childhood infections, such as middle ear infections.
Travel and pregnancy
International travel should be avoided by pregnant women with underlying medical conditions, such as diabetes or high blood pressure, or a history of complications during previous pregnancies, such as miscarriage or premature labor. For pregnant women in good health, the second trimester (18–24 weeks) is probably the safest time to go abroad and the third trimester the least safe, since it's far better not to have to deliver in a foreign country.
Before departure, make sure you have the names and contact information for physicians, clinics, and hospitals where you can obtain emergency obstetric care if necessary. In general, pregnant women should avoid traveling to countries which do not have modern facilities for the management of premature labor and other complications of pregnancy.
Strict attention to food and water precautions is especially important for the pregnant traveler because some infections, such as listeriosis, have grave consequences for the developing fetus. Additionally, many of the medications used to treat travelers' diarrhea may not be given during pregnancy. Adequate fluid intake is essential.
Helpful maps are available in the University of Texas Perry-Castaneda Map Collection and the United Nations map library. If you have the name of the town or city you'll be visiting and need to know which state or province it's in, you might find your answer in the Getty Thesaurus of Geographic Names.
(reproduced from the U.S. State Dept. Consular Information Sheet)
Americans living or traveling in Estonia are encouraged to register with the nearest U.S. Embassy or Consulate through the State Department's travel registration website, https://travelregistration.state.gov, and to obtain updated information on travel and security within Estonia. Americans without Internet access may register directly with the nearest U.S. Embassy or Consulate. By registering, American citizens make it easier for the Embassy or Consulate to contact them in case of emergency. The U.S. Embassy in Tallinn is located at Kentmanni 20, telephone (372) 668-8100; fax (372) 668-8267; emergency cell phone (011)(372) 509-2129 (if dialed from the U.S., and 509-2129 if dialed from within Estonia). The Embassy's home page on the Internet is at http://estonia.usembassy.gov.
For information on safety and security, go to the U.S. Department of State, United Kingdom Foreign and Commonwealth Office, Foreign Affairs Canada, and the Australian Department of Foreign Affairs and Trade.
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