Read below for travel health advice on Pakistan from the MDtravelhealth channel on Red Planet Travel.
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Summary of recommendations
Most travelers to Pakistan will need vaccinations for hepatitis A, typhoid fever, and polio, as well as medications for malaria prophylaxis and travelers' diarrhea. Additional immunizations may be necessary depending upon the circumstances of the trip and the medical history of the traveler, as discussed below. Insect repellents are recommended, in conjunction with other measures to prevent mosquito bites. All travelers should visit either a travel health clinic or their personal physician 4-8 weeks before departure.
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.
Malaria in Pakistan: prophylaxis is recommended year-round throughout the country, including cities, except for areas above 2500 m (8202 ft). Risk is greatest after the July-August monsoons. Either mefloquine (Lariam), atovaquone/proguanil (Malarone)(PDF), or doxycycline may be given. Mefloquine is taken once weekly in a dosage of 250 mg, starting one-to-two weeks before arrival and continuing through the trip and for four weeks after departure. Mefloquine may cause mild neuropsychiatric symptoms, including nausea, vomiting, dizziness, insomnia, and nightmares. Rarely, severe reactions occur, including depression, anxiety, psychosis, hallucinations, and seizures. Mefloquine should not be given to anyone with a history of seizures, psychiatric illness, cardiac conduction disorders, or allergy to quinine or quinidine. Those taking mefloquine (Lariam) should read the Lariam Medication Guide (PDF). Atovaquone/proguanil (Malarone) is a combination pill taken once daily with food starting two days before arrival and continuing through the trip and for seven days after departure. Side-effects, which are typically mild, may include abdominal pain, nausea, vomiting, headache, diarrhea, or dizziness. Serious adverse reactions are rare. Doxycycline is effective, but may cause an exaggerated sunburn reaction, which limits its usefulness in the tropics.
Long-term travelers who may not have access to medical care should bring along medications for emergency self-treatment should they develop symptoms suggestive of malaria, such as fever, chills, headaches, and muscle aches, and cannot obtain medical care within 24 hours. See malaria for details. Symptoms of malaria sometimes do not occur for months or even years after exposure.
Insect protection measures are essential.
For further information on malaria in Pakistan, go to Roll Back Malaria, WHO-EMRO Roll Back Malaria, and the World Health Organization - Eastern Mediterranean Region.
The following are the recommended vaccinations for Pakistan:
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 immunization is recommended, due to the persistence of polio in Pakistan, though transmission has been limited mainly to Karachi, southern Sindh (Hyderabad division) and central North West Frontier Province (Kohat, Malakand and Peshawar divisions). Any adult who received the recommended childhood immunizations but never received 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.
Japanese encephalitis vaccine is recommended for those who expect to spend a month or more in rural areas and for short-term travelers who may spend substantial time outdoors or engage in extensive outdoor activities in rural or agricultural areas, especially in the evening. Data for Pakistan are limited, but Japanese encephalitis may be transmitted in the central deltas. Cases have been reported near Karachi. The disease may also occur in the lower Indus Valley.
The recommended vaccine is IXIARO , given 0.5 cc intramuscularly, followed by a second dose 28 days later. The series should be completed at least one week before travel. The most common side effects are headaches, muscle aches, and pain and tenderness at the injection site. Safety has not been established in pregnant women, nursing mothers, or children under the age of two months.
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. More than 5000 human deaths from rabies are reported every year from Pakistan. Most cases in Pakistan are related to dog bites. 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 Pakistan, 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 greater than nine months of age arriving from a yellow-fever-infected country in Africa or the Americas and for travelers who have been in transit more than 12 hours in an airport located in a country with risk of yellow fever transmission, 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 who are younger than nine months of age, pregnant, immunocompromised, or allergic to eggs. It should also not be given to those with a history of thymus disease or thymectomy.
An outbreak of hepatitis A was reported in February 2013 from the district of Swat in northern Pakistan, causing hundreds of cases. In December 2010, a hepatitis A outbreak was reported from Azad Jammu and Kashmir in December 2010, causing at least 150 cases. Both outbreaks were caused by contaminated water supplies. Hepatitis A vaccine is recommended for all travelers to Pakistan.
Cases of Crimean-Congo hemorrhagic fever are reported from Pakistan each year, chiefly from June to October and mostly from the province of Balochistan. An increased number of cases was reported from Pakistan in 2012, totalling 38 cases nationwide, 14 of them fatal, in the first nine months of the year. The largest number of cases was reported from Balochistan. Three fatal cases were reported from Punjab province in January 2014. One fatal case was reported from Balochistan in May 2014. A total of 11 cases were reported from a hospital in Khyber-Pakhtunkhwa province in July 2014.
Crimean-Congo hemorrhagic fever is a life-threatening viral infection which is usually transmitted by ticks which have been feeding on infected animals (less commonly by direct contact with infected animals or rarely by exposure to an infected person). Initial symptoms may include fever, muscle aches, backache, joint pains, headaches, dizziness, and light sensitivity. Complications may result from hemorrhage into the skin, intestine, or other sites. Most cases occur in farm workers, who often remove ticks from farm animals without protecting themselves. Most travelers are at low risk. Tick precautions are recommended for all travelers.
An outbreak in October 2010 resulted in 22 confirmed cases (13 from Rawalpindi, 3 from Islamabad, one from Abbottabad and 5 from Balochistan). Three of the cases were fatal (see the World Health Organization and ProMED-mail). Three fatal cases, all occurring in shepherds, were reported from Balochistan province in October 2008. In February 1998, four cases (two of them fatal) were diagnosed in a family in Balochistan province, all of them shepherds.
Leishmaniasis, mainly cutaneous, remains widespread in the Federally Administered Tribal Areas. An outbreak in the rural areas of Mardan district, which began in 2012, was still not controlled as of April 2014. In April 2012, an outbreak was reported from Khyber Pakhtunkhwa, causing more than 800 cases. In January 2002, a leishmaniasis outbreak occurred in the Northwest Frontier Province, causing 5000 cases, chiefly in children under age fifteen (see ProMED-mail (April 29, 2012) and World Health Organization). Cutaneous leishmaniasis is a chronic skin infection transmitted by sandflies. No vaccine is available. Travelers should protect themselves from sandflies by following insect protection measures, as below.
Cases of polio continues to be reported from Pakistan, chiefly from Sindh and the North West Frontier Province. A total of 94 cases were reported nationwide for the year 2013. For further information, go to the World Health Organization. A one-time polio booster is recommended for any adult traveler who received the recommended childhood immunizations but never had polio vaccine as an adult. Children should be fully immunized against polio before traveling to Pakistan.
A measles outbreak was reported in May 2012 from Fata, Khyber-Pakhtunkhwa, and Balochistan, killing 12 children. At around the same time, outbreaks were also reported from Karachi and from North Waziristan. All travelers born after 1956 should make sure they have had either two documented measles immunizations or a blood test showing measles immunity. This does not apply to people born before 1957, who are presumed to be immune to measles. Although measles immunization is usually begun at age 12 months, children between the ages of 6 and 11 months should be given an initial dose of measles or MMR vaccine before traveling to Pakistan.
Outbreaks of dengue fever, a flu-like illness sometimes complicated by hemorrhage or shock, were reported in August 2011 from Punjab province, chiefly affecting Lahore, and from Sindh province, chiefly affecting Karachi. As of September 2011, the number of cases was beginning to rise in Rawalpindi (Punjab province) and Islamabad. Cases were also reported from Khyber Pakhtunkhwa. A dengue outbreak in September 2010 chiefly involved Sindh province, but also affected Punjab (Lahore city), Rawalpindi, Islamabad, and Khyber Pukhtoonkhwa provinces, among other areas. More than 5000 cases were reported from Sindh province by November, including 22 deaths (17 in Karachi and five in other parts of the province). Dengue is transmitted by Aedes mosquitoes, which bite primarily in the daytime and favor densely populated areas, though they also inhabit rural environments. No vaccine is available at this time. Insect protection measures are strongly advised, as outlined below.
Outbreaks of dengue fever are reported annually from Karachi, usually in the late summer and early fall. An outbreak in August 2008 caused 287 cases and four deaths as of October. A larger outbreak in August 2007 led to more than 1500 suspected cases and 11 deaths, and an outbreak in October 2006 caused more than a thousand cases and 29 deaths. A dengue outbreak was reported in September 2009 from Haripur district, North-West Frontier Province. In November 2008, an outbreak was reported from Lahore, causing more than 1000 cases. A dengue outbreak was also reported from Lahore in October 2007. For details, see ProMED-mail, October 16 and 24 and November 15, 2006; October 1 and November 5, 2007; August 26, October 28, and November 24, 2008, September 28, 2009, and September 6, 2010.
Cholera outbreaks occur regularly in Pakistan. An outbreak was reported from Khyber Pakhtunkhwa in August 2011 and from Sindh in September 2011. A total of 99 confirmed cases were reported in October 2010 from the flood-affected provinces of Sindh, Punjab, and Khyber Pakhtunkhwa (see the World Health Organization). Cholera outbreaks were also reported in September 2009 from the village Garah Aashiq of Tehsil Parova; in July 2009 from the Dera Ismail Khan district in the North-West Frontier Province and from camps set up for internally displaced persons at Mardan, Nowshera, and Charsadda, also in North-West Frontier Province; in October 2008 from the Swat mountain district in the North-West Frontier Province; in September 2008 among those who had fled from the Bajaur region in northwestern Pakistan, a haven for Al-Qaeda and Taliban fighters along the Afghan border; in June 2008 from the city of Rawalpindi, in Punjab province; and in May 2008 from Mirpur Khas, a district of Sindh province.
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.
A cluster of eight human cases of H5N1 avian influenza ("bird flu"), two of them fatal, was reported from the Peshawar area in December 2007. Four of those affected were brothers. Three of the four contracted the infection from their brothers, rather than infected poultry, but there was no evidence of person-to-person transmission in the wider community. Outbreaks of avian influenza have been reported among poultry and other birds in many parts of Pakistan since April 2006, chiefly from the North West Frontier province, particularly the Abbottabad and Mansehra area. The most recent outbreaks were reported from the Karachi area (Sindh province) in February 2008 and from the North West Frontier province in June 2008.
Most travelers are at extremely low risk for avian influenza, since almost all human cases in other countries have occurred in those who have had direct contact with live, infected poultry, or sustained, intimate contact with family members suffering from the disease. The Centers for Disease Control and the World Health Organization 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 Pakistan should seek immediate medical attention, which may include testing for avian influenza. For further information, go to the World Health Organization, Health Canada, the Centers for Disease Control, and ProMED-mail.
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.
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.
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.
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.
Many barbers in Pakistan carry HIV or hepatitis virus. Travelers should visit only those beauty and hairdressing shops that have been issued a No Objection Certificate (NOC), which indicates that the applicant has had negative blood tests for HIV and hepatitis viruses (see ProMED-mail, December 15, 2006).
Ambulance and Emergency Services
Reliable ambulance service is not generally available in Pakistan. Ambulances are few and may not be staffed by trained medical personnel. In case of medical emergency, you should arrange immediate transport to the emergency room of one of the facilities below.
For Western-style medical care, the best facilities are the Aga Khan University Hospital in Karachi (Stadium Road, PO Box 3500, Karachi 74800, tel: 92-21-4930051; website: http://www.aku.edu/akuh/index.htm; member of the international networks of the Massachusetts General Hospital and the New York-Presbyterian Hospital, two leading U.S. hospitals), Doctors' Hospital in Lahore, and Shifa International Hospital in Islamabad (Sector H-8/4, Islamabad; tel. 444680132; website http://www.shifa.com.pk/; 24-hour emergency room). For pediatric emergencies, go to the Children's Hospital at the Pakistan Institute of Medical Sciences (G-8/3, Islamabad; tel. 9260450; Outpatient/Emergency Unit: 2201-2). For outpatient care, another option is Dr. Arshad Health Associates (No 20, St 1, F-6/3, Islamabad; tel. 92 51 2829666, 287686; cell 92 300 5004999; email firstname.lastname@example.org).
For a guide to physicians and other hospitals in Pakistan, go to the U.S.Embassy website. The quality of medical care is extremely uneven. Outside major cities, good medical care may be difficult or impossible to find. Most doctors and hospitals will expect payment in cash, regardless of whether you have travel health insurance, and many will require pre-payment. Serious medical problems will require air evacuation to a country with state-of-the-art medical facilities.
Most pharmacists are not adequately trained. Many of the pharmaceuticals are made in Pakistan, often in collaboration with major international drug companies, but the quality is not known. American-brand medications may be difficult to find.
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 (see the U.S. Embassy website).
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).
The recommendations for malaria prophylaxis are the same for young children as for adults, except that (1) dosages are lower; and (2) doxycycline should be avoided. DEET-containing insect repellents are not advised for children under age two, so it's especially important to keep children in this age group well-covered to protect them from mosquito bites.
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. Baby foods and cows' milk may not be available in developing nations. Only commercially bottled milk with a printed expiration date should be used. Young children should be kept well-hydrated and protected from the sun at all times.
Be sure to pack a medical kit when traveling with children. In addition to the items listed for adults, bring along plenty of disposable diapers, cream for diaper rash, oral replacement salts, and appropriate antibiotics for common childhood infections, such as middle ear infections.
Travel and pregnancy
Due to the risk of malaria, pregnant women should avoid traveling to Pakistan. Malaria may cause life-threatening illness in both the mother and the unborn child. None of the currently available prophylactic medications is 100% effective. Mefloquine (Lariam) is the drug of choice for malaria prophylaxis during pregnancy, but should not be given if possible in the first trimester. If travel to malarious areas is unavoidable, insect protection measures must be strictly followed at all times. The recommendations for DEET-containing insect repellents are the same for pregnant women as for other adults.
Strict attention to food and water precautions is especially important for the pregnant traveler because some infections, such as listeriosis, have grave consequences for the developing fetus. Additionally, many of the medications used to treat travelers' diarrhea may not be given during pregnancy. Quinolone antibiotics, such as ciprofloxacin (Cipro) and levofloxacin (Levaquin), should not be given because of concern they might interfere with fetal joint development. Data are limited concerning trimethoprim-sulfamethoxazole, but the drug should probably be avoided during pregnancy, especially the first trimester. Options for treating travelers' diarrhea in pregnant women include azithromycin and third-generation cephalosporins. For symptomatic relief, the combination of kaolin and pectin (Kaopectate; Donnagel) appears to be safe, but loperamide (Imodium) should be used only when necessary. Adequate fluid intake is essential.
Helpful maps are available in the University of Texas Perry-Castaneda Map Collection and the United Nations map library. If you have the name of the town or city you'll be visiting and need to know which state or province it's in, you might find your answer in the Getty Thesaurus of Geographic Names.
(reproduced from the U.S. State Dept. Consular Information Sheet)
American citizens living in or visiting Pakistan are encouraged to register at the Consular Section of the U.S. Embassy or Consulate in Pakistan and obtain updated information on travel and security within Pakistan. They are located at the following addresses:
-- The U.S. Embassy in Islamabad is located at Diplomatic Enclave, Ramna 5, telephone (92-51) 2080-0000; consular section telephone (92-51) 2080-2700, fax (92-51) 282-2632, website http://islamabad.usembassy.gov/.
-- The U.S. Consulate General in Karachi, located at 8 Abdullah Haroon Road, closed its public operations indefinitely due to security concerns. U.S. citizens requiring emergency assistance should call the consular section in Karachi. The telephone is (92-21) 568-5170 (after hours: 92-21-568-1606), fax (92-21) 568-0496, website http://karachi.usconsulate.gov/.
-- The U.S. Consulate in Lahore is located on 50-Empress Road Sharah-E-Abdul Hamid Bin Badees, (Old Empress Road) near Shimla Hill Rotary, telephone (92-42) 636-5530, fax (92-42) 636-5177, website http://lahore.usconsulate.gov/. Email address: email@example.com.
-- The U.S. Consulate in Peshawar is located at 11 Hospital Road, Cantonment, Peshawar, telephone (92-91) 279-801 through 803, fax (92-91) 276-712, web site http://Peshawar.usconsulate.gov/.
The normal workweek in Pakistan is Monday through Saturday, with a half-day worked on Friday. The U.S. Embassy and consulates are open Monday through Thursday, with a half-day on Friday.
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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