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Required Vaccinations

No vaccinations are required to enter this country.

Recommended Vaccinations

Routine Immunizations

Your trip is a good occasion for a reminder to keep your routine immunizations updated; more than 80% of adults in industrialized countries have not maintained their immunization status. The following vaccinations are recommended for your protection and to prevent the spread of infectious diseases. 

Tetanus, Diphtheria, Pertussis, Measles, Mumps, Rubella, 
Polio should be reviewed and updated if necessary. Note: Many of these vaccine preventable illnesses are making a resurgence due to non-vaccination, incomplete vaccination, and waning immunity. It is important to keep your routine immunizations up-to-date.
Seasonal influenza
vaccination is recommended for all travellers over 6 months of age, especially for children, pregnant women, persons over 65, and those with chronic health conditions such as asthma, diabetes, lung disease, heart disease, immune-suppressive disorders, and organ transplant recipients. Note: In the northern hemisphere the flu season typically runs from November to April and from April to October in the southern hemisphere. If the flu vaccine is not available at the time of departure, contact your doctor or travel health clinic regarding influenza anti-viral protection.

Pneumococcal vaccine is recommended for persons over the age of 65 and persons of any age suffering from cardiovascular disease, diabetes, renal disorders, liver diseases, sickle cell disease, asplenia, or immuno-suppressive disorders.

Hepatitis A

The Hepatitis A virus (HAV) is primarily transmitted from person to person via the fecal-oral route and through contaminated water and food - such as shellfish, and uncooked vegetables or fruit prepared by infected food handlers.

Risk: The virus is present worldwide, but the level of prevalence depends on local sanitary conditions. HAV circulates widely in populations living in areas with poor hygiene infrastructure. In these areas, persons usually acquire the virus during childhood when the illness is asymptomatic (but still infective to others) or mild, and end up developing full immunity. Large outbreaks in these countries are rare. In contrast, a large number of non-immune persons are found in highly industrialized countries where community wide outbreaks can occur when proper food handling or good sanitation practices are not maintained including in daycare centres, prisons, or mass gatherings.

Symptoms: In many cases, the infection is asymptomatic (persons do not exhibit symptoms). Those with symptoms will usually get ill between 15 to 50 days after becoming infected. Symptoms include malaise, sudden onset of fever, nausea, abdominal pain, and jaundice after a few days. The illness can range from mild to severe lasting from one to two weeks or for several months. Severe cases can be fatal especially in older persons. Most infections are asymptomatic in children under six years of age, but infants and children can continue to shed the virus for up to six months after being infected, spreading the infection to others. Many countries are now including vaccination against Hepatitis A in their childhood vaccination schedules.

Prevention: Practice good personal hygiene, including washing your hands frequently and thoroughly, drink boiled or bottled water, eat well cooked foods, and peel your own fruits.

Vaccination: Recommended for all travellers over 1 year of age.
There are two inactivated vaccines available in Canada and the USA, including a combined Hepatitis A and Hepatitis B vaccine. A combined Hepatitis A and Typhoid Fever vaccine is also available in Canada and Europe. Hepatitis A vaccines confer long term protection and can be given in accelerated schedules. Discuss your options with your healthcare provider if you cannot finish the series prior to your departure. Immune Globulin may be recommended for some last-minute travellers.

Selective Vaccinations

Hepatitis B

The Hepatitis B virus (HBV) can cause acute and chronic liver infections. It is transmitted through infected blood products, unprotected sex, infected items such as needles, razor blades, dental or medical equipment, unscreened blood transfusions, or from mother to child at birth. The virus is present worldwide, but some populations in sub-Saharan Africa, Southeast Asia, Eastern Europe, and the Middle East, as well as indigenous communities are chronic Hepatitis B carriers.

Risk: Travellers getting tattoos or piercing abroad, using drugs intravenously, sharing needles and razor blades, undergoing dental or medical procedures, or having unprotected sex are at risk.

In many cases, the infection is asymptomatic (persons do not exhibit symptoms). Those with symptoms will usually get ill between 30 days and 6 months after becoming infected. Symptoms include fatigue, malaise, nausea, abdominal pain, dark urine, and jaundice. The illness can last several weeks and some adults can become chronic carriers after being infected. Hepatitis B can cause chronic liver infections, cirrhosis of the liver, or liver cancer. Most infections are asymptomatic in children under five years of age but they can become chronic carriers. Many countries are now including vaccination against Hepatitis B in their childhood vaccination schedules. Treatment includes supportive care of symptoms. Some cases of chronic Hepatitis B can be treated with antiretroviral drugs.

Prevention: Avoid getting new piercings or tattoos on your trip and do not share needles or razor blades. If you need medical or dental care abroad, ensure that it is done by a reputable provider. Always practice safe sex.

Vaccination: Hepatitis B vaccination is a routine immunization. If you haven’t been vaccinated, it is recommended for travellers on working assignments in the health care field such as physicians, nurses, laboratory technicians, dentists, or for those working in close contact with the local population such as teachers, aid workers, and missionaries.

There are two inactivated vaccines available in the Canada and the USA, including a combined Hepatitis A and Hepatitis B vaccine. Both types of vaccines confer long term protection and can be given in accelerated schedules. Discuss your options with your healthcare provider if you cannot finish the series prior to your departure.


Rabies is a viral infection caused by viruses belonging to the Lyssavirus genus. It is a zoonosis (an animal disease that can spread to humans) transmitted through the saliva of infected mammals bites. The infection primarily circulates among domestic and wild animals such as dogs, cats, monkeys, foxes, bats, raccoons, and skunks, although all mammals are at risk. The virus attacks the Central Nervous System targeting the brain and the spinal cord, and if untreated is fatal.

Risk: Rabies is present on all continents except Antarctica. The majority of human infections occur in Asia and Africa. Travellers coming into close contact with domestic animals or wildlife on ecotourism trips, or those undertaking outdoor activities like cave exploring, camping, trekking, and visiting farms or rural areas are at higher risk. Rabies is also an occupational hazard for veterinarians and wildlife researchers. Children are especially vulnerable since they may not report scratches or bites. They should be cautioned not to pet dogs, cats, monkeys, or other mammals. Any animal bite or scratch must be washed repeatedly with copious amounts of soap and water. Seek medical attention immediately.

Symptoms: Usually appear 1 to 3 months or later, although they can appear as early as a few days after being infected. The illness is characterized by fever and pain or a tingling sensation at the wound site. As a result of inflammation to the brain and spinal cord, some patients present with anxiety, hyperactivity, convulsions, delirium, and have a fear of swallowing or drinking liquids, as well as a fear of moving air or drafts. In other patients, muscles become paralysed followed by a coma. Once symptoms are present, most patients die within 1 or 2 weeks.

Prevention: Avoid contact with feral animals or wildlife. Try to anticipate an animal’s actions and always be careful not to make sudden moves or surprise them. If you’ve been bitten by a mammal, wash the wound repeatedly and thoroughly with soap and water. Seek medical attention immediately.

Vaccination: A series of 3 pre-exposure rabies vaccination shots is advised for persons planning an extended stay or on working assignments in remote and rural areas, particularly in Africa, Asia, Central and South America. The pre-exposure series simplifies medical care if you have been bitten by a rabid animal and gives you enough time to travel back from a remote area to seek medical attention. Although this provides adequate initial protection, you will require 2 additional post-exposure doses if you are exposed to rabies. The preferred vaccines for rabies pre-exposure vaccination and post-exposure therapy are HDCV (Human Diploid Cell Rabies vaccine) and PCEC (Purified Chick Embryo Cell vaccine). These two vaccines are interchangeable.

Travellers who have not received the pre-exposure shots need 4 injections (those with compromised immune systems need 5 injections) and the Human Rabies Immune Globulin (HRIG) which is calculated as 20 IU (International Units) per kilo of body weight. HRIG must be injected around the bite site and intramuscularly. In some countries purified Equine Rabies Immune Globulin (ERIG) is used for post-exposure therapy when HRIG is not available. HRIG is in short supply worldwide and is often not available in rural and remote areas.

Note: If you are in a remote area and offered daily rabies injections lasting 14 to 21 days, it may be one of the older animal brain-derived vaccines. We recommend that you do not take them due to serious side effects.

Tick-Borne Encephalitis

Tick-borne Encephalitis is a viral infection caused by one of three tick-borne encephalitis virus (TBEV) subtypes belonging to the Flaviviridae family: Central European, Siberian, and Far Eastern (formerly known as Russian Spring-Summer Encephalitis). It is transmitted to humans through the bite of infected Ixodes ticks found in parts of Europe, Central Asia, and East Asia. Transmission season is usually from March to November.

Risk: Travellers involved in outdoor activities in forested areas are at risk, including campers, hikers, and hunters. Brushing against vegetation or walking in city parks known to have infected ticks can also put a person at risk.

Symptoms: Usually appear 7 to 14 days after being bitten by an infected tick. Symptoms can last up to 8 days and include fever, headache, fatigue, muscle pain, nausea, and loss of appetite. Approximately one-third of patients develop severe symptoms after the first phase of the illness where the virus causes meningitis (attacks the thin lining that surrounds the brain and the spinal cord) and / or encephalitis (swelling of the brain). Second phase symptoms include stiff neck, fever, headache, nausea, aversion to light, confusion, disorientation, drowsiness, behavioural changes, seizures, and paralysis. Some patients may experience long term complications such as memory loss, speech and language problems, mood disorders, epilepsy, fatigue, and motor skill difficulties. Treatment of the acute infection includes supportive care of symptoms.

Prevention: Travellers who engage in hiking, camping, or similar outdoor activities in wooded regions of endemic areas should take measures to prevent tick bites, including applying a DEET-containing repellent to exposed skin and permethrin spray (or solution) to clothing and gear. When hiking in wooded areas, stay in the middle of the trail and avoid tall grasses and shrubs. Wear light coloured clothing, and long shirts and pants tucked into socks. Carefully examine your clothing, gear, and pets for ticks before entering a dwelling.

Regularly check your body for ticks and promptly remove using tweezers by grasping the tick's head and mouth parts as much as possible and by pulling perpendicular from the skin. Thoroughly disinfect the bite site with soap and water or alcohol. If travelling in an endemic area, you may want to save the tick in a zip-lock bag or empty container to have it analyzed through your healthcare practitioner.

Vaccination: Recommended if you’re involved in recreational activities in forested areas such as camping and hiking or working in forestry occupations, as well as long term travellers to endemic areas.

A whole-cell inactivated vaccine for adults is available in Canada, and in pediatric and adult formulations in countries where Tick-borne Encephalitis is endemic. Re-vaccination is recommended every 3-5 years depending on your age if you continue to be at risk. This vaccine is not available in the USA. Discuss prevention options with your health care provider or if you cannot complete the series before departure.

Risk is present in forested areas in the western part of the country.

The recommendations for vaccinations outlined above are intended as guidelines only. Your immunization needs depend on your health status, previous immunizations received, and your travel itinerary. Seek further advice from your doctor or travel health clinic.

Health Risks

Air Pollution

Outdoor air pollution (a mix of chemicals, particulate matter, and biological materials that react with each other) contributes to breathing problems, chronic diseases, increased hospitalization, and premature mortality.

Risk: No matter where you travel, you will not be able to escape air pollution since cities and rural areas worldwide are affected by air pollution. Exposure and concentration of pollutants can adversely affect your health. When planning your trip, consider your health status, age, destination, length of trip and season to help you mitigate the effects of air pollution.

Symptoms: Short term symptoms resulting from exposure to air pollution include itchy eyes, nose and throat, wheezing, coughing, shortness of breath, chest pain, headaches, nausea, and upper respiratory infections (bronchitis and pneumonia). It also exacerbates asthma and emphysema. Long term effects include lung cancer, cardiovascular disease, chronic respiratory illness, and developing allergies. Air pollution is also associated with heart attacks and strokes.

Comply with air pollution advisories (ask around and observe what locals are doing) and avoid strenuous activity. If you have asthma or chronic obstructive pulmonary disease (COPD), carry an inhaler, antibiotic, and oral steroid (consult your doctor to see what is best for you). It is recommended that older travellers get a physical exam that includes a stress and lung capacity test prior to departure. Newborns and young children should minimize exposure as much as possible or consider not travelling to areas with poor air quality. Ask your medical practitioner if a face mask is advisable for you.

>> For city and country air pollution levels, see the
World Health Organization.

Sexually Transmitted Infections

Sexually transmitted infections (STIs), also known as Sexually Transmitted Diseases (STDs), are caused by bacteria, viruses or parasites and are transmitted via unprotected sex (oral, anal, or oral) and skin to skin genital contact.

Bacterial infections include Bacterial Vaginosis, Chlamydia, Gonorrhea, Lyphogranuloma venerum (LGV) and Syphilis. Viruses cause Genital Herpes, Hepatitis B, Human Papillomavirus (HPV) and Human Immunodeficiency Virus (HIV). Parasites are responsible for Trichomoniasis and pubic lice.

STIs occur worldwide, but some infections like chancroid, lymphogranuloma vernerum (LGV), and Granuloma Inguinale are more common in less industrialized countries.

Risk: Travellers are at high risk of acquiring STIs if they have unprotected sex outside a monogamous relationship, engage in casual sex, or use the services of sex workers. During travel, some people may be less inclined to follow social mores dictating their behaviour back home and look for adventurous opportunities involving sex. Long term travellers may also be at increased risk due to feelings of loneliness or being homesick.

Travellers should also be aware of sexual tourismand how it spreads STIs. Sexual tourism is travel for the procurement of sex abroad. Travellers participating in this type of exploitive tourism use the services of sex workers or children that are forced to engage in the trade as a result of deceptive practices or are part of human trafficking networks. It’s illegal in many countries and you can be prosecuted in your home country for engaging in sexual exploitation of minors abroad. Sexual violence such as rape or assault can also increase risk of STI.

Symptoms: In many cases you can spread a sexually transmitted infection unknowingly because you are asymptomatic (do not exhibit symptoms). Depending on the infection, symptoms can appear within days or weeks (Chlamydia, Gonorrhea, Genital Herpes), weeks or months (Hepatitis B, Syphilis, HIV) after the initial infection. Common symptoms, which may appear alone or in combination include abnormal genital discharge, burning sensation when urinating, bleeding after intercourse or between periods, rashes and sores in the genital or anal areas, swollen lymph glands in the groin, and sudden fever or appearance of flu-like symptoms.

Note that the sudden or eventual disappearance of symptoms does not mean you are cured from the infection since it can return or manifest itself in different symptoms. Many sexually transmitted infections can be treated with antibiotics (although there is mounting evidence that Gonorrhea is becoming increasingly resistant to antibiotics) or antivirals. If left untreated, infections can lead to infertility, pelvic inflammatory disease, cancer, chronic liver conditions, pregnancy complications, and birth defects.

Prevention: Always practice safe sex. Pack your own male and / or female condoms. Note that condoms obtained abroad may have higher breakage rates, may be expired, or may have been stored in hot or humid places compromising their effectiveness. Use your condom correctly and do not use oil based lubes. If you engage in oral sex use a male condom or dental dam. Keep in mind that birth control methods such as oral contraceptives, injections, IUDs, or diaphragms do not prevent STI transmission, and that condoms aren’t fully effective from infections acquired via skin-to-skin contact like genital herpes.

Avoid behaviour that increases your chances of contracting an STI such as casual sex with a stranger or a sex worker. Drinking heavily or taking mind-altering drugs will impair your judgement and inhibitions during a sexual encounter, putting you at risk of making unsafe choices like not using a condom. If you already practice safe sex, avoid getting tattoos, body piercings, or acupuncture treatments. Also don’t share razors, toothbrushes, or needles. If you have engaged in risky sexual activities or suspect that you may have an STI, visit a healthcare provider immediately. If the results confirm that you have an STI, inform all your sex partners and encourage them to seek medical attention.

Hepatitis B and Human Papillomavirus (HPV) can also be prevented through vaccination.

Note: Some countries continue to have entry restrictions for travellers with HIV / AIDS. Consult your destination country's embassy or consulate to get the latest information. See also HIVTravel for details.


The health risks listed below are of interest to travellers who undertake special activities like adventure travel or ecotourism, long term travellers, visiting friends and family, or those on work assignments abroad. We update our travel health information daily with any new confirmed outbreaks so check back here before your trip for updates. Please note that some infectious diseases are not reported or under reported, preventing us from giving you the full picture of the health risk.

Lyme Disease

Lyme Disease is caused by bacteria belonging to the genus Borrelia transmitted through the bite of infected ticks belonging to the Ixodes genus. Borrelia burgdorferi is the predominant cause of the illness in North America, and Borrelia afzelii and Borrelia garinii in Europe and Asia. Ticks get infected when they feed on deer, birds, and rodents who are reservoirs for the bacteria and spread it to humans typically by nymphs (immature ticks).

Risk: Lyme Disease is present in North America, Europe, and Asia. Travellers involved in outdoor activities in forested areas are at risk, including campers, hikers, and hunters. Brushing against vegetation or walking in city parks known to have infected ticks can also put a person at risk.

Symptoms: Lyme Disease usually progresses in three stages. One of the first symptoms (for approximately 70% to 80% of persons) is a small bump and skin rash at the site of the bite which usually goes away after 1 or 2 days. Anywhere from 3 to 30 days, the rash expands to an encircled red patch (known as Erythema migrans or Bull's Eye rash) which is warm to the touch but not painful or itchy. The rash may produce lesions. Other symptoms include fever, headache, muscle and joint pain, chills, fatigue, and swollen lymph nodes. Contact your healthcare practitioner immediately if you develop symptoms.

If untreated, the illness progresses to the second stage within days or weeks of getting infected. Symptoms include severe headaches, meningitis, swollen joints, skin lesions, heart palpitations, dizziness, persistent fatigue, sleep disturbance, as well as loss of muscle tone in the face (Bell's palsy). Some of these symptoms usually disappear within weeks or months. However, if untreated, the illness will progress to a third stage which includes arthritis and chronic pain, numbness, tingling of hands and feet, and short-term memory loss.

If treated promptly, Lyme Disease usually takes 2 to 4 weeks to cure and includes antibiotics such as doxycycline, amocicillin, or ceftriaxone.

Prevention: Travellers who engage in hiking, camping, or similar outdoor activities in wooded regions of endemic areas should take measures to prevent tick bites, including applying a DEET-containing repellent to exposed skin and permethrin spray (or solution) to clothing and gear. When hiking in wooded areas, stay in the middle of the trail and avoid tall grasses and shrubs. Wear light coloured clothing, and long shirts and pants tucked into socks. Carefully examine your clothing, gear, and pets for ticks before entering a dwelling.

Regularly check your body for ticks and promptly remove using tweezers by grasping the tick's head and mouth parts as much as possible and by pulling perpendicular from the skin. Thoroughly disinfect the bite site with soap and water or alcohol. If travelling in an endemic area, you may want to save the tick in a zip-lock bag or empty container to have it analyzed through your healthcare practitioner. There is no preventive vaccine or medication against Lyme Disease.

>> For Lyme Disease images, life cycle, and distribution maps, see Infection Landscapes.

Lyme Disease is a risk in wooded and brush areas.


Tuberculosis (TB) is an airbone bacterial infection caused by Mycobacterium tuberculosis. TB can be acquired by breathing contaminated air droplets coughed or sneezed by a person nearby who has active Tuberculosis. Humans can also get ill with TB by ingesting unpasteurized milk products contaminated with Mycobacterium bovis, also known as Bovine Tuberculosis. The most common form of the infection is pulmonary TB which affects the lungs. In some cases, the bacteria can also attack the lymphatic system, central nervous system, urogenital area, joints, and bones.

Risk: Tuberculosis occurs worldwide and commonly spreads in cramped, overcrowded conditions. There is no evidence that pulmonary TB is more easily transmitted in airplanes or other forms of public transportation. Travellers with a compromised immune system, long-term travellers, and those visiting friends and relatives (VFR travellers) in areas where Tuberculosis is endemic are at greater risk. Humanitarian and healthcare personnel working in communities with active TB are also at increased risk. Persons with active TB should not travel.

Symptoms: Persons with active TB have symptoms which include excessive coughing (sometimes with blood), chest pain, general weakness, lack of appetite, weight loss, swollen lymph glands, fever, chills, and night sweats. It can be misdiagnosed for bronchitis or pneumonia. If untreated, active TB can lead to fatalities.

The majority of persons with the illness (90% to 95%) have latent TB infection (LTBI) and do not exhibit any symptoms. The bacteria can remain inactive for many years and the chance of developing active TB diminishes over time.

Tuberculosis treatment involves taking antibiotics for a minimum of 6 months. Drug-resistant TB is a major concern as an increasing number of people are no longer able to be treated with previously effective drugs. Due to misuse of antibiotic therapies, patients can develop multi-drug resistant Tuberculosis (MDR TB). When a second line of antibiotics fail to cure the multi-drug resistant infection, it is known as extensively drug-resistant Tuberculosis (XDR TB).


Prevention: Avoid exposure to people known to who have active Tuberculosis and only consume pasteurized milk products. Travellers at higher risk should have a pre-departure tuberculin skin test (TST) and be re-tested upon their return home. Those at increased risk should also consult their healthcare provider to determine if the Bacillus Calmette-Guérin (BCG) vaccine is recommended.


Tuberculosis is highly endemic and a major public health problem in Romania.

West Nile Virus

The West Nile Virus (WNV) belongs to the Flaviviridae family. It is transmitted to humans and animals through the bite of infected Culex mosquitoes which are active from dusk to dawn. The mosquitoes acquire the virus from feeding on infected birds. Human to human transmission does not occur.

Risk: West Nile Virus is commonly found in North America, Europe, Africa, the Middle East, and west Asia. There is greater risk for long term travellers visiting endemic areas. Older persons and those with a compromised immune system or pre-existing health conditions are also at increased risk of getting ill. Peak transmission occurs during summer months.

Symptoms: The majority of cases are asymptomatic (persons do not exhibit symptoms). Approximately 1 in 5 people have symptoms which include a fever, headaches, nausea, vomiting, muscle aches, including a rash (typically on the torso) and swollen glands. Symptoms usually last a few days to several weeks. More severe symptoms of the illness include high fever, disorientation, tremors, convulsions, paralysis, and coma that can cause neurological damage. Fatalities can occur. The focus for hospitalized patients is supportive treatment of symptoms and prevention of secondary infections.

Prevention: Travellers should take measures to prevent mosquito bites both indoors and outdoors, especially during the daytime. Insect-bite prevention measures include applying a DEET-containing repellent to exposed skin, applying permethrin spray (or solution) to clothing and gear, wearing long sleeves and pants, getting rid of water containers around dwellings and ensuring that door and window screens work properly. There is no preventive medication or vaccine against West Nile Virus for humans.

>> For West Nile Virus images, life cycle, and distribution maps, see Infection Landscapes.

Cases of human West Nile virus have been reported in Romania. For the latest information on West Nile virus outbreaks please go to: <ECDC>. Accessed on October 17, 2014.

Food and Water Safety

Drinking water is chlorinated and has no ill effect on the local population. However, some strains of E. coli (naturally occurring bacteria found in your gastro-intestinal system) may be present in very small concentrations in the local water supply. Some local strains are different than those that you may be used to, and may cause diarrhea in travellers since immunity is not developed as a result of short-term exposure. Using bottled water for the first few weeks will help you adjust and decrease the chance of traveller's diarrhea.

Milk is pasteurized and safe to drink. Butter, cheese, yoghurt, and ice cream are safe.

Local meat, poultry, seafood, vegetables, and fruits are safe to eat.

Chemicals found in food and water

Globalized food production and shipping are making it harder for consumers to know if their food and water is safe. Travellers should be aware that food and water contamination not only occurs through improper food handling or poor hygiene practices. Air, soil, and water pollution resulting from heavy metals, dioxins, pesticides, agro-chemicals, and drugs given to food-production animals, occurs worldwide. IAMAT recommends eating locally sourced foods from reputable growers as much as possible. We will post any new information on outbreaks resulting from environmental contamination on this page. Don’t forget to consult our website before your trip!

Food allergies

Being prepared is important to preventing allergic reactions or anaphylactic shock during your trip.

  • Research the common foods of your destination country and talk to your health practitioner about your travel plans.
  • Pack the medications you need to prevent an adverse reaction like antihistamines or epinephrine injectors with refills.
  • Find a reputable doctor or hospital prior to your trip in case of an emergency. Carry your IAMAT Traveller Clinical Record outlining your food allergies so that healthcare providers abroad are aware of your condition. 
  • If you’re grocery shopping abroad, read labels and be aware of packaging that does not list ingredients. Note that in many countries there are no or weak food labelling regulations and some products may be partially labelled.
  • Tell others about your food allergy. Carry a personalized translated card detailing your allergies to show restaurant waiters, grocery store clerks, or food vendors. SelectWisely offers a wide range of professionally translated cards.

Traveller’s Diarrhea

The term Traveller's Diarrhea is used to describe gastro-intestinal infections affecting travellers caused by ingesting bacteria, viruses, and protozoa. These micro-organisms are found worldwide and are typically transmitted from person to person via the fecal-oral route – an infected person who does not practice proper hand or body hygiene passes on the infection to another person when handling food and water. Traveller's Diarrhea is the most common illness among travellers.

Risk: Traveller’s Diarrhea can happen when:

  • Eating raw, undercooked, unwashed, or improperly handled meat, poultry products, dairy products, fruits, vegetables, shellfish, and seafood.
  • Drinking contaminated water or beverages.
  • Inadvertently ingesting fecal matter, protozoa eggs, or viruses by touching the mouth with dirty or improperly washed hands.
  • Eating out in restaurants, from buffets, or from street vendors where food handling and hygienic practices are not followed properly.

Prevention: The golden rule to prevent gastro-intestinal infections is: Boil it, Cook it, Peel it, or Forget it! However, it’s not just about what you eat, it’s also important to consider where you eat. It’s not always easy to know if a restaurant or food vendor follows proper food handling and hygienic practices (properly cleaning cutting boards, utensils, sink to wash hands, refrigeration). Be cautious of food that has been stored uncovered, has been improperly refrigerated, or has been standing out for a long time, such as buffets.

More information on Food and Water Safety:
>> How To Prevent Traveller's Diarrhea [PDF]
>> How To Prevent Food and Water Illnesses [PDF]
>> How To Prevent Illness by Washing Your Hands [PDF]
>> 24 World Food and Climate Charts

>> Guide to Healthy Travel

Approximately 85% of Traveller’s Diarrhea is caused by bacteria. Symptoms involving bacterial infections generally appear within hours of eating contaminated food or water and can last 3 to 7 days. Typical symptoms include diarrhea, abdominal pain, nausea, general weakness, headache, low fever, and possible vomiting. Severe cases can cause dehydration.

The following are common bacteria causing food and water illnesses in travellers:
Enterotoxigenic Escherichia coli (ETEC)
– Commonly known as ‘E. coli’ and responsible for the majority of Traveller’s Diarrhea cases. The illness is associated with contaminated food and water. Symptoms appear 1 to 3 days after infection. Treatment includes supportive care of symptoms and in severe cases antibiotics are prescribed.

Campylobacter jejuni– Associated with contaminated water, undercooked poultry, unpasteurized milk. Symptoms appear 1 to 7 days after being infected and can last 2 to 3 weeks without treatment. Some patients also have bloody diarrhea. Post-infection complications can lead to Guillain-Barré Syndrome, where the immune system attacks the nerves and causes paralysis, or irritable bowel syndrome. Treatment includes antibiotics.

Salmonella enteritidis
– Associated with eggs, poultry, meat, raw fruits and vegetables. Symptoms usually appear 1 to 3 days after infection and can last up to 7 to 14 days. Infected persons can become asymptomatic carriers and shed the bacteria for weeks or months, becoming the source of infection for others through poor hygiene practices. Treatment includes supportive care of symptoms. Salmonella typhi is the cause of Typhoid Fever.

Shigellosis – Associated with contaminated food and water and caused by one of four Shigella species that spreads as a result of unsanitary conditions, contaminated food and water, and overcrowded living conditions. Symptoms usually last 4 to 7 days. The illness may progress to bloody diarrhea with mucous and the constant urge to pass stools. Shigella bacteria can be shed from your gastro-intestinal system for up to 3 months after symptoms disappear. Treatment includes antibiotics.

Vibrio cholera, Vibrio parahaemolyliticus, Vibrio vulnificus
– Associated with contaminated water, raw or undercooked fish and shellfish and causes Cholera, an acute gastro-intestinal infection. Risk to travellers is low and vaccination is advised only for medical and rescue personnel working in endemic areas. The infection can lead to severe dehydration and death in undernourished persons or those with compromised immune systems or kidneys.  Vibrio vulnificus has caused septicemia (blood poisoning) in persons with liver disorders.


Approximately 5% of Traveller’s Diarrhea is caused by viruses. A person can become ill when touching contaminated surfaces with the virus (railings, door knobs), shaking hands, or coming into close contact with an infected person and then touching your mouth and eyes.

The most common viruses causing food and water illnesses in travellers are:
– Associated with outbreaks at large gatherings or on cruise ships. The illness is also caused by contaminated water and foods like salads, clams, and oysters. Symptoms can appear 10 hours to 2 days after infection and include nausea, vomiting, abdominal pain, diarrhea, and sometimes fever and dehydration. The illness usually last 1 to 4 days and treatment includes supportive care of symptoms.

Rotavirus – Particularly affects children less than 5 years old and is also associated with contaminated food and water. Symptoms appear 1 to 3 days after being infected and include vomiting, diarrhea, fever, abdominal pain, and headache. Dehydration and body limpness are characteristics of this illness which typically lasts 4 to 8 days. Vaccination is recommended for children. Treatment includes supportive care of symptoms for both children and adults.

Approximately 10% of Traveller’s Diarrhea is caused by protozoa. In addition to contaminated food and water, these one-celled microscopic organisms are also transmitted to humans by swallowing contaminated water from lakes, rivers, fountains, ponds, and other bodies of water or accidentally swallowing soil or sand containing protozoa eggs. Typical symptoms include abdominal pain and cramps, diarrhea, bloating, nausea, lack of appetite, fatigue, headache, and light fever. Prolonged infection causes dehydration and weight loss.

The most common protozoa causing food and water illnesses in travellers are:
Amoebiasis – Caused by Entamoeba histolytica protozoa. The majority of cases are asymptomatic (persons do not exhibit symptoms). Those who do exhibit symptoms usually develop them 2 to 4 weeks after being infected. Amoebic Dysentery is the more severe form of the illness where patients develop fever and blood in their stools. In rare cases, the protozoa can cause lesions in the liver. Treatment includes taking medication belonging to the nitroimidazole family of drugs.

Cryptosporidiosis –The infection, commonly referred to as ‘Crypto’, is primarily caused by Cryptosporidium hominis protozoa. The illness is associated with contaminated food or water, including swimming pools and other water bodies. Some people are asymptomatic (do not exhibit symptoms). Those who do exhibit symptoms usually develop them 2 to 10 days after being infected. Some patients may also have a cough, recurring headache, dizziness, eye pain, and joint pain. The illness can trigger irritable bowel syndrome and inflammatory bowel diseases. Symptoms usually disappear after 1 to 2 weeks as the protozoa are shed through feces. Treatment includes anti-protozoal medication or antibiotics.

Cyclosporiasis – Caused by the Cyclospora cayetanensis protozoa and associated with fresh produce like berries and lettuce. Symptoms usually appear 2 to 7 days after infection. Some patients may develop fever after a few days. The diarrhea may come and go throughout the duration of the illness which can last from 2 to 12 weeks if untreated. The infection tends to be seasonal for reasons yet unknown and disinfecting agents like chlorine do not seem to kill the protozoa. Treatment includes taking antibiotics.   

Giardiasis–Caused by Giardia intestinalis protozoa and associated with contaminated food and water. Symptoms usually appear 1-2 weeks after infection. The symptoms usually disappear 2-4 weeks later as the protozoa are shed through feces. Treatment includes taking medication belonging to the nitroimidazole family of drugs. Treatment includes taking medication belonging to the nitroimidazole family of drugs.

Foodborne Toxins

Another source of gastro-intestinal illness are foodborne toxins produced by bacterial spores that germinate on food – particularly meat, poultry, salads, baked goods, and dairy products – that is improperly stored or refrigerated, usually standing at room temperature for a prolonged period of time.Symptoms can appear within hours of ingesting contaminated food and include abdominal pain, diarrhea, nausea, and vomiting. The infection usually lasts 1 or 2 days and treatment includes supportive care of symptoms. Antibiotics are not recommended.

Common foodborne toxins affecting travellers include:
Clostridium perfringens – Associated with meat and poultry and is the most important agent causing food poisoning in industrialized countries. Symptoms appear within 6 to 24 hours after ingestion.

Staphylococcus aureus – Associated with creamy desserts, custards, meats, and baked goods. Enterotoxins are transmitted via unsanitary practices by infected persons. Symptoms appear within 30 minutes to 8 hours after ingestion.

Clostridium botulinum – Associated with improperly canned food, lightly preserved vegetables, salted fish, and meats. Symptoms usually appear within 12 to 48 hours and include nausea, vomiting, blurred and double vision, paralysis of respiratory and motor muscles that may progress rapidly.

Seafood and Shellfish Poisoning

Seafood and shellfish poisoning occurs as a result of eating marine food products contaminated with naturally occurring toxins in sea water. Travellers are at risk in any country as a result of the availability of these products (fresh or frozen) around the world.

The most common seafood and shellfish related illnesses in travellers are:
Ciguatera Fish Poisoning – Occurs when toxins created by dinoflagellate micro-organisms are passed up the marine food chain and bio-accumulate in large fish like barracuda, grouper, red snapper, moray eel, amberjack, parrotfish, hogfish, sturgeonfish, kingfish, coral trout, and sea bass. The toxins are not destroyed through cooking, smoking, or freezing, they are odorless and tasteless, and do not alter the appearance of the fish. For information on symptoms and prevention, see Ciguatera Fish Poisoning

Scombroid Poisoning – Results from improper handling and refrigeration of fish containing high levels of natural occurring histidine (amino acid in protein). Contamination with bacteria will convert histidine to histamine causing symptoms similar to allergic reactions, which occur very rapidly and include headache, abdominal cramps, diarrhea, itching, flushed face, dry mouth, heart palpitations, difficulty breathing. Symptoms rarely last over 8 to 12 hours. Scombroid poisoning affects fish from the Scombridae family: Tuna, mackerel, skipjack, and bonito. It can also affect other species such as herring, bluefish, sardine, anchovy, amberjack, and mahi-mahi. Treatment includes taking anti-histamines and supportive care of symptoms. Treatment in severe cases may include anti-inflammatory steroids and epinephrine related medication.

Shellfish Poisoning – Associated with the algal blooms (red tides) occurring in temperate and tropical areas. Oysters, clams, cockles, mussels, scallops, crabs, and lobsters filter or ingest toxins produced by dinoflagellates micro-organisms. There are four different illnesses associated with shellfish poisoning:

  1. Diarrheic shellfish poisoning can occur hours or days after eating contaminated shellfish. Symptoms include abdominal pain, nausea, vomiting, and diarrhea. Recovery occurs within 2 to 3 days and treatment includes supportive care of symptoms.
  2. Neurotoxic shellfish poisoning can occurs 1 to 6 hours after ingestion. Symptoms include nausea, vomiting, diarrhea, reversal of hot and cold temperature sensation, and involuntary muscle movement. Recovery occurs within 2 to 3 days and includes supportive care of symptoms.
  3. Paralytic shellfish poisoning can occur 30 minutes after eating contaminated shellfish. Symptoms include nausea, numbness of face arms and legs, headache, loss of coordination and dizziness. In severe cases respiratory failure and paralysis may lead to death.
  4. Amnesic shellfish poisoning can occur within 24 hours of ingestion and include nausea, vomiting, abdominal pain, and diarrhea. Within 48 hours, symptoms include headache, seizures, muscle weakness or paralysis, and disorientation. Permanent short-term memory loss has been observed, and in severe cases can lead to coma or death. Treatment includes supportive care of symptoms.

Puffer (Fugu) Fish Poisoning – Caused by a tetrodotoxin accumulating mainly in the liver, intestines and ovaries of puffer fish, ocean sunfish, globe fish, and porcupine fish. Symptoms appear between 6 and 20 hours and include nausea, abdominal pain, diarrhea, vomiting, profuse sweating, salivation, headache, hypothermia, heart palpitation. Neurological symptoms include numbness, loss of coordination, tremors, and paralysis. The illness can also cause respiratory failure and approximately 60% of patients die. Treatment involves supportive care of symptoms and may include cholinesterase inhibitors (anti-poisoning agents).

Travel and Mental Health

Travel is enjoyable, but there is no doubt that it can be stressful. Even if you don't have a prior history of mental illness, travel stress, mood changes, anxiety and other mental health concerns can unexpectedly affect you and potentially disrupt your trip. Studies show that psychiatric emergencies are the leading cause for air evacuations along with injuries and cardiovascular disease.

Factors Affecting Mental Health During Travel

Your mental and physical health prior to, and during, a trip determines how well you will cope with travel stress. Consider the following:

  • Tiredness, lack of sleep.
  • Major life events occurring prior to travel such as a birth, death, wedding, divorce, moving, or serious illness.
  • Difficult home or professional life; experiencing recent emotional exhaustion or financial strain.
  • Being lonely; prone to depression and anxiety.
  • Having pre-existing psychiatric, behavioural, neurological disorders; memory or cognitive deficits.
  • Dependence on, or misuse, of psychoactive substances.
  • Using medications that have psychiatric or neurological side effects (some anti-retrovirals and anti-malarials).
  • Type and length of travel; adventure, business, leisure, emergency aid work, missions.
  • Travel destination; travelling to politically unstable or war-torn areas, returning to a place where psychological trauma occurred.

Mental Health Abroad

Mental illness is an under recognized public health concern and travellers often have difficulty accessing adequate emergency psychiatric care abroad. While some countries are leading the way in mental healthcare and treatment, 30% of countries do not have a budget dedicated to mental health and 64% do not have any mental health legislation or it's outdated.

Accessibility to a psychiatrist varies from more than 10 per 100,000 to fewer than 1 per 300,000 people. Almost 70% of psychiatric beds are in mental hospitals rather than general hospitals or in integrated community care facilities.*

Persons with mental health concerns have the additional burden of dealing with stigma ? negative attitudes and behaviour towards their illness. Prejudice and discrimination towards mental illness may determine the type of medical care you will receive abroad.

* World Health Organization: Mental Health, Human Rights and Legislation Framework.

Download My Travel and Mental Health Checklists

What's inside:

  • Tips for coping with travel stress.
  • Tips for travellers with no prior history of mental illness.
  • Tips for travelling with medications.
  • Tips for travellers with:
    • Mood disorders (depression, bipolar disorder)
    • Anxiety disorders (panic attacks, phobias, obsessive compulsive disorders, posttraumatic stress disorder)
    • Psychotic disorders (acute situational psychosis, schizophrenia)
    • Substance dependence

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