Read below for travel health advice on Iraq from the MDtravelhealth channel on Red Planet Travel.
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Summary of recommendations
Most travelers to Iraq will need vaccinations for hepatitis A, typhoid fever, and polio, as well as medications for travelers' diarrhea. Malaria prophylaxis is recommended for certain regions, in conjunction with insect repellents and other measures to prevent mosquito bites. Additional 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.
Malaria:Prophylaxis with chloroquine, Lariam (mefloquine), Malarone (atovaquone/proguanil), doxycyline, or primaquine is recommended for for Basrah province and for areas at altitudes below 1500 m (4921 ft) in the provinces of Duhok, Erbil, Ninawa, Sulaimaninya, and Ta'mim
|Hepatitis A||Recommended for all travelers|
|Typhoid||Recommended for all travelers|
|Polio||One-time booster recommended for any adult traveler who completed the childhood series but never had polio vaccine as an adult|
|Yellow fever||Required for all travelers arriving from a yellow-fever-infected area in Africa or the Americas. Not recommended otherwise.|
|Hepatitis B||Recommended for all travelers|
|Rabies||For travelers spending a lot of time outdoors, or 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|
|Tetanus-diphtheria||Revaccination recommended every 10 years|
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 Iraq:
Hepatitis A vaccine is recommended for all travelers over one year of age. It should be given at least two weeks (preferably four weeks or more) before departure. A booster should be given 6-12 months later to confer long-term immunity. Two vaccines are currently available in the United States: VAQTA (Merck and Co., Inc.) (PDF) and Havrix (GlaxoSmithKline) (PDF). Both are well-tolerated. Side-effects, which are generally mild, may include soreness at the injection site, headache, and malaise.
Older adults, immunocompromised persons, and those with chronic liver disease or other chronic medical conditions who have less than two weeks before departure should receive a single intramuscular dose of immune globulin (0.02 mL/kg) at a separate anatomic injection site in addition to the initial dose of vaccine. Travelers who are less than one year of age or allergic to a vaccine component should receive a single intramuscular dose of immune globulin (see hepatitis A for dosage) in the place of vaccine.
Typhoid vaccine is recommended for all travelers. It is generally given in an oral form (Vivotif Berna) consisting of four capsules taken on alternate days until completed. The capsules should be kept refrigerated and taken with cool liquid. Side-effects are uncommon and may include abdominal discomfort, nausea, rash or hives. The alternative is an injectable polysaccharide vaccine (Typhim Vi; Aventis Pasteur Inc.) (PDF), given as a single dose. Adverse reactions, which are uncommon, may include discomfort at the injection site, fever and headache. The oral vaccine is approved for travelers at least six years old, whereas the injectable vaccine is approved for those over age two. There are no data concerning the safety of typhoid vaccine during pregnancy. The injectable vaccine (Typhim Vi) is probably preferable to the oral vaccine in pregnant and immunocompromised travelers.
Polio vaccine is recommended, because of widespread transmission of wild poliovirus in Iraq. Any adult who received the recommended childhood immunizations but never had a booster as an adult should be given a single dose of inactivated polio vaccine. All children should be up-to-date in their polio immunizations and any adult who never completed the initial series of immunizations should do so before departure. Because of ongoing polio transmission, the World Health Organization recently recommended that those visiting for more than four weeks should receive an additional dose of polio vaccine between 4 weeks and 12 months prior to international travel and have the dose documented in the yellow book (International Certificate of Vaccination). Side-effects are uncommon and may include pain at the injection site. Since inactivated polio vaccine includes trace amounts of streptomycin, neomycin and polymyxin B, individuals allergic to these antibiotics should not receive the 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 for travelers spending a lot of time outdoors, for travelers at high risk for animal bites, such as veterinarians and animal handlers, for long-term travelers and expatriates, and for travelers involved in any activities that might bring them into direct contact with bats. Children are considered at higher risk because they tend to play with animals, may receive more severe bites, or may not report bites. 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.
Cholera vaccine is not generally recommended, even though cholera occurs in Iraq (see "Recent outbreaks" below), because most travelers are at low risk for infection. Two oral vaccines have recently been developed: Orochol (Mutacol), licensed in Canada and Australia, and Dukoral, licensed in Canada, Australia, and the European Union. These vaccines, where available, are recommended only for high-risk individuals, such as relief workers, health professionals, and those traveling to remote areas where cholera epidemics are occurring and there is limited access to medical care. The only cholera vaccine approved for use in the United States is no longer manufactured or sold, due to low efficacy and frequent side-effects.
Yellow fever vaccine is required for all travelers arriving from a yellow-fever-infected country in Africa or the Americas, but is not recommended or required otherwise. Yellow fever vaccine (YF-VAX; Aventis Pasteur Inc.) (PDF) must be administered at an approved yellow fever vaccination center, which will give each vaccinee a fully validated International Certificate of Vaccination. Yellow fever vaccine should not in general be given to those younger than nine months of age, pregnant, immunocompromised, or allergic to eggs.
More than 200 cases of Q fever have been reported among U.S. military personnel deployed to Iraq since the Iraq war began in 2003. Several of these cases were identified after returning to the U.S. or when they were no longer serving on active military duty. Symptoms of Q fever typically include fever, chills, nausea, headache, and body aches. Complications may include pneumonia, hepatitis, endocarditis (heart valve infection), and infections of the bones and joints. In pregnant women, Q fever may lead to miscarriage. Q fever is primarily a disease of ruminants such as cattle, sheep, and goats, which shed the Q fever bacteria in their body fluids, especially birth products. Humans become infected by inhaling dust or aerosols contaminated by body fluids from infected animals. Transmission may be influenced by hot, dusty conditions and livestock farming practices which may facilitate windborne spread. The disease is not transmitted from person-to-person. Any person with a febrile illness who has traveled to Iraq in the 30 days prior to illness onset should be evaluated for possible Q fever.
A cholera outbreak was reported from central and northern Iraq in August 2008, causing 925 confirmed cases and 11 deaths by December 17. As of late December, the outbreak appeared to be coming under control. In all, the largest number of cases were reported from Babil, Diwanyia, Baghdad, Basra, Kerbala, Najaf, and Muthana. A smaller number of cases were identified in the provinces of Anbar, Maysan, Erbil, Wasit and Diala (see the World Health Organization and ProMED-mail). A much larger outbreak began in Kirkuk province in August 2007, ultimately spreading to 10 out of 18 provinces. A total of 4696 cases were confirmed, including 24 fatalities. Most of the cases were reported from the provinces of Sulaymaniyah, Kirkuk, and Erbil in northeastern Iraq. A small number of cases were also described in Tikrit, Diala, Mosul, Basra, Baghdad, Dahuk, Anbar, and Wasit (see the World Health Organization and ProMED-mail). Most of the cases in this outbreak were relatively mild to moderate. Severe dehydration was uncommon.
The main symptoms of cholera are profuse watery diarrhea and vomiting, which in severe cases may lead to dehydration and death. Most outbreaks are related to contaminated drinking water, typically in situations of poverty, overcrowding, and poor sanitation. Most travelers are at extremely low risk for infection. Cholera vaccine, where available, is recommended only for certain high-risk individuals, such as relief workers, health professionals, and those traveling to remote areas where cholera epidemics are occurring and there is limited access to medical care. All travelers should carefully observe food and water precautions, as below.
In April 2003, a cholera outbreak was reported from Basra, causing more than a thousand cases (see the World Health Organization).
A leishmaniasis outbreak was reported in May 2009 from the southern province of Missan (Maysan), about 350 km south of Baghdad, causing almost 200 cases. In February 2008, a leishmaniasis outbreak occurred in the southern province of Qadisiyah, about 130 km south of Baghdad, causing 212 cases of cutaneous leishmaniasis and 63 cases of visceral leishmaniasis (see ProMED-mail, February 19, 2008, and May 21, 2009). Leishmaniasis is a chronic parasitic infection transmitted by the bites of sandflies. The cutaneous form is manifested by chronic skin lesions which are typically painless, enlarge slowly, and develop central ulceration, often covered with eschar and surrounded by an erythematous, indurated border. The visceral form is characterized by fever, weight loss, anemia, and enlargement of the liver and spleen developing over months to years. Cases of cutaneous leishmaniasis have been reported among U.S. military personnel serving in Iraq, especially in areas near the Iraq-Syria border (e.g. Tall Afar) and the Iraq-Iran border (e.g. Balad Ruz, Kanaquin, Mandali, and Tursaq). For further information, go to MMWR. Insect protection measures are strongly advised, as below.
Two human cases of H5N1 avian influenza ("bird flu") were reported in January 2006 from the northern province of Sulaimaniyah, close to the border with Turkey. The cases, both of them fatal, occurred in a teen-aged girl and her uncle, who had cared for her during her illness. A third case occurred in March 2006. The most recent poultry case was reported from the southern city of Basra in March 2006.
Most travelers are at extremely low risk for avian influenza. The World Health Organization and the Centers for Disease Control do not advise against travel to countries affected by avian influenza, but recommend that travelers should avoid exposure to live poultry, including visits to poultry farms and open markets with live birds; should not touch any surfaces that might be contaminated with feces from poultry or other animals; and should make sure all poultry and egg products are thoroughly cooked. A vaccine for avian influenza was recently approved by the U.S. Food and Drug Administration (FDA), but produces adequate antibody levels in fewer than half of recipients and is not commercially available. The vaccines for human influenza do not protect against avian influenza. Anyone who develops fever and flu-like symptoms after travel to Iraq should seek immediate medical attention, which may include testing for avian influenza. For additional information, go to the World Health Organization, Health Canada, the Centers for Disease Control, and ProMED-mail.
Cases of acute eosinophilic pneumonia, a potentially fatal lung disease of unknown cause, were reported in December 2004 among military personnel deployed in or near Iraq. No infectious disease or common environmental factor could be identified. Two of 18 cases were fatal. For further information, see AF Shorr et al, "Acute Eosinophilic Pneumonia Among US Military Personnel Deployed in or Near Iraq; Journal of the American Medical Association. 2004; 292: 2997-3005.
An outbreak of hepatitis E was reported in September 2004 from Sadr City in Baghdad and from Mahmudiya, a town 56 km (35 miles) south of Baghdad. Hepatitis E is transmitted by consumption of fecally contaminated water. Pregnant women are particularly susceptible. Outbreaks typically occur when basic sanitation is not maintained, as has occurred at present.
More than thirty cases of Q fever have been reported in U.S. military personnel, chiefly among those serving in the northern part of the country. Several of the cases had atypical manifestations, including acute cholecystitis and acute respiratory distress syndrome. See Emerging Infectious Diseases and EID for further information.
Schistosomiasis may be contracted by swimming in bodies of fresh water. Swimming and bathing precautions are advised, as below.
HIV (human immunodeficiency virus) infection is reported, but travelers are not at risk unless they have unprotected sexual contacts or receive injections or blood transfusions.
Other infections include
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.
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.
Insect and Tick Protection
Wear long sleeves, long pants, hats and shoes (rather than sandals). For rural and forested areas, boots are preferable, with pants tucked in, to prevent tick bites. Apply insect repellents containing 25-50% DEET (N,N-diethyl-3-methylbenzamide) or 20% picaridin (Bayrepel) to exposed skin (but not to the eyes, mouth, or open wounds). DEET may also be applied to clothing. Products with a lower concentration of either repellent need to be repplied more frequently. Products with a higher concentration of DEET carry an increased risk of neurologic toxicity, especially in children, without any additional benefit. Do not use either DEET or picaridin on children less than two years of age. For additional protection, apply permethrin-containing compounds to clothing, shoes, and bed nets. Permethrin-treated clothing appears to have little toxicity. Don't sleep with the window open unless there is a screen. If sleeping outdoors or in an accommodation that allows entry of mosquitoes, use a bed net, preferably impregnated with insect repellent, with edges tucked in under the mattress. The mesh size should be less than 1.5 mm. If the sleeping area is not otherwise protected, use a mosquito coil, which fills the room with insecticide through the night. In rural or forested areas, 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.
To prevent sandfly bites, follow the same precautions as for mosquito bites, except that netting must be finer-mesh (at least 18 holes to the linear inch) since sandflies are smaller.
Swimming and bathing precautions
Avoid swimming, wading, or rafting in bodies of fresh water, such as lakes, ponds, streams, or rivers. Do not use fresh water for bathing or showering unless it has been heated to 150 degrees F for at least five minutes or held in a storage tank for at least three days. Toweling oneself dry after unavoidable or accidental exposure to contaminated water may reduce the likelihood of schistosomiasis, but does not reliably prevent the disease and is no substitute for the precautions above. Chlorinated swimming pools are considered safe.
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.
In general, the private clinics in Baghdad provide better care than the public facilities, but at a higher price. Most expatriates go to either Al-Hayat Hospital (52 Street, Karada), Al-Rahebat (Karada Inside Street, Karada), or Karkh Hospital for Surgery. None of the private hospitals have emergency rooms.
Medical care is extremely limited. Many hospitals are not operational and shortages of essential supplies are common. Those with serious medical problems should be evacuated to a country with state-of-the art medical facilities. However, because the Baghdad International Airport has limited operations for security reasons, air evacuation may be difficult or impossible to arrange. For medical evacuation from Iraq, call American Air Ambulance (website http://www.americanairambulance.com; email firstname.lastname@example.org; hotline 800-863-0312 or 941-536-2002 in the United States). For further information on medical facilities in Iraq, go to the U.S. Embassy website.
Most expatriates use either Al-Shaiklee Pharmacy, located on al-Kindi Street in the Kindi area of the Karkh Municipality (ph. 5413811), or Hunnudi Pharmacy, located on Karada Inside Street (ph. 7190989).
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)
The Travel Warning on Iraq urges U.S. citizens to defer travel to Iraq. However, U.S. citizens living or traveling in Iraq despite that Warning 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 Iraq. 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. U.S. citizens may also register with the consular section of the U.S. Embassy in Iraq located in the International Zone and obtain updated information on travel and security within Iraq. U.S. citizens may register with the Embassy via their e-mail address email@example.com, telephone 1-240-553-0584 x5340 or5635 (this number rings in Baghdad), or the Embassy's website at http://iraq.usembassy.gov or http://baghdad.usembassy.gov. Their after hours number is 1-914-822-5473.
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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