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Pakistan



Capital: Islamabad

Time Zone: +5 hours. Daylight saving time: GMT +6 hour from June1 to Sept. 1.
Tel. Country Code: 92
USADirect Tel.: 0
Electrical Standards: Electrical current is 230/50 (volts/hz). European Style Grounding Adaptor Plug. Grounding Adaptor Plugs D, F.


Travel Advisory - Pakistan

Malaria, Japanese encephalitis, and dengue fever occur throughout SE Asia and the Indian sub-Continent. Insect-bite protection is essential. Hepatitis E, spread by contaminated water, is also a threat. There is no vaccine. Pregnant women are at special risk. Take measures, as needed, to purify your water outside of first-class hotels.

Dr. Rose Recommends for Travel to Pakistan


Resource Links

NaTHNaC
World Health Organization
CDC
Travel Health Services
Country Insights
Travel Warnings
Consular Information
Foreign Commonweatlh Office

Embassies

• U.S. Embassy
Diplomatic Enclave, Ramna 5
Islamabad
Tel: [92] (51) 826-161
The Consular Section is located separately in the USAID building
18 Sixth Avenue, Ramna 5
Tel: (51) 824-071

• Canadian Embassy
Diplomatic Enclave
Islamabad
Tel: [92] (51) 227-91-00
E-mail: isbad@dfait-maeci.gc.ca
Website: www.dfait-maeci.gc.ca/islamabad

• British High Commission
Diplomatic Enclave
Ramna 5
Islamabad
Telephone: [92] (51) 201 2000 (Main Switchboard)
Email: visqry.Islamabad@fco.gov.uk (Visa)
Website: www.britishhighcommission.gov.uk/pakistan

Entry Requirements

HIV Test: Test required if staying more than 1 year.

Required Vaccinations: A yellow fever vaccination certificate is required from all travelers older than 1 year arriving from any country in the Yellow Fever Endemic Zones.

Passport Information

Passport/Visa: Pakistan is a parliamentary federal republic in South Asia, with a population of nearly 170 million people. President Pervez Musharraf came to power in October 1999, and was indirectly elected to office in 2002. The political situation is currently in a state of flux. The military continues to play a significant role in the nation’s governance. Pakistan is a developing country, with tourist facilities available in major cities but limited in outlying areas. The infrastructure of the areas of Kashmir and the Northwest Frontier Province was devastated as a result of the October 8, 2005 earthquake and is not yet recovered. Read the Department of State Background Notes on Pakistan for additional information.

ENTRY/EXIT REQUIREMENTS: All U.S. citizens traveling to Pakistan for any purpose are required to have valid U.S. passports and Pakistani-issued visas. Further information on entry requirements can be obtained from the Embassy of Pakistan at:
3517 International Court Avenue, NW, Washington, D.C. 20008; telephone: 202-243-6500; e-mail: info@pakistan-embassy.org ; website: http://www.pakistan-embassy.org/

Travelers may also contact one of the Consulates General of Pakistan in: 

Boston: 20 Chestnut Street, Needham, MA 02492; telephone: (781) 455-8000; fax: (617) 266-6666; email: pakistan@tiac.net

New York: 12 East 65th St., New York, NY 10021; telephone: (212) 879-5800; fax: (212) 517-6987; website: www.pakistanconsulateny.org 

Chicago: 333 North Michigan Ave., Suite 728, Chicago, IL, 60601; telephone: (312) 781-1831; fax: (312) 781-1839; email: parepchicago@yahoo.com

Los Angeles: 10850 Wilshire Blvd., Suite 1100, Los Angeles, CA 90024; telephone: (310) 441-5114; fax: (310) 441-9256; email: info@pakconsulatela.org

Vaccinations: Recommended and Routine

Hepatitis A: Recommended for all travelers >1 year of age not previously immunized against hepatitis A.

Hepatitis B: Recommended for all travelers who might be exposed to blood or bodily fluids from unprotected sex with a high-risk partner; from injecting drug use with shared/re-used needles and syringes; from medical treatment with non-sterile (re-used) needles and syringes; from contact with open skin sores. Recommended for any traveler requesting protection against hepatitis B virus.

Influenza: Vaccination recommended for all travelers >6 months of age who have not received a flu shot in the previous 12 months.

Japanese Encephalitis: Recommended for travelers planning to visit rural farming areas for >4 weeks and under special circumstances, such as a known outbreak of Japanese encephalitis.

Polio: A one-time dose of IPV vaccine is recommended for any traveler >age 18 who completed the primary childhood series but never received an additional dose of polio vaccine as an adult. Available data do not indicate the need for more than a single lifetime booster dose with IPV (Inactivated Polio Vaccine).

Rabies: Recommended for travelers spending time in remote locations, or outdoors in rural areas where there is an increased the risk of animal bites. Pre-exposure vaccination eliminates the need for rabies immune globulin in the event of a high-risk animal bite, but does not eliminate the need for additional treatment with rabies vaccine.

Routine Immunizations: Immunizations against tetanus-diphtheria, measles, mumps, rubella (MMR vaccine) and varicella (chickenpox) should be updated, if necessary, before departure. MMR protection is especially important for any female of childbearing age who may become pregnant.
• The new Tdap vaccine, ADACEL, which also boosts immunity against pertussis (whooping cough) should be considered when a tetanus-diphtheria booster is indicated.

Typhoid: Recommended for all travelers with the exception of short-term visitors who restrict th and cruise passengers.

Yellow Fever: A yellow fever vaccination certificate is required for all travelers >1 year of age arriving from any country in the yellow fever endemic zones. Vaccination is not recommended or required otherwise.

Hospitals / Doctors

Adequate medical care is available in major Pakistani cities, but is limited in rural areas. Facilities in the cities vary in level and range of services, resources, and cleanliness, and Americans may find them below U.S. standards; facilities in rural areas are consistently below U.S. standards.
All travelers should be up-to-date on their immunizations and are advised to carry a medical kit as well as antibiotics to treat travelers’ diarrhea or other infections; they should bring drugs for malaria prophylaxis, if needed according to their itinerary. Travelers who are taking regular medications should carry them properly labeled and in sufficient quantity to last for the duration of their trip; they should not expect to obtain prescription or over-the-counter drugs in local stores or pharmacies in this country—the equivalent drugs may not be available; may be of dubious origin; may be counterfeit, or of unreliable quality.
• Travelers are advised to obtain comprehensive travel insurance with specific overseas coverage. Policies should cover: ground and air ambulance transport, including evacuation to home country; payment of hospital bills; 24-hour telephone assistance.

The U.S. Embassy maintains a listing of doctors and hospitals at:
http://lahore.usconsulate.gov/lahore/img/assets/5816/medical_resources_lahore.pdf

Facilities with high standards of care include:

• Aga Khan University Hospital
Stadium Road
Karachi
Tel: [92] (21) 493-0051
In case of an emergency, call the Emergency Room at Tel: [92] 21 486-1090 and 486-1091, or 493-0051 ext. 1090/1091.
Website: http://www.aku.edu/akuh/index.htm

• Seventh Day Adventist Hospital
Karachi
Tel: [92] (21] 721-8021 to 8024
Private hospital; most specialties; emergency services 24 hours a day. The facility has limited trauma capability.

• Shifa Medical Center
Seovay Arcade
F-11 Markaz
Islamabad
Tel: [92] (51) 222-8231-5
Website: http://www.shifa.com.pk/
24-hour Emergency Room; all specialties.

• Pakistan Institute of Medical Sciences (PIMS)
Islamabad
Tel: (92) 51-6-1170
Pakistan Institute of Medical Sciences is a 600-bed hospital with emergency services available 24 hours a day. The hospital is a major trauma center and a tertiary care center. It is capable of handling major trauma cases.

• Dr. Arshad Health Associates
No 20, St 1, F-6/3
Islamabad
Tel: [92] 51 282-9666
Cell: [92] 300 5004999
Email hlthline@isb.comsats.net.pk
Website: http://drarshadhealthassociates.com/index.htm
Outpatient services provided for travelers and expatriates.
24-HOUR MOBILE MEDICAL ASSISTANCE. An emergency squad comprising of a team of trained house/emergency doctors andnurses attending to emergencies 24 hours a day, at work place/residence of patients and hotel guests, including all holidays, throughout the year.

• United Christian Hospital, Lahore.
• Khyber Medical Center, Peshawar.

Destination Health Info for Travelers

AIDS/HIV: Pakistan’s first reported case of HIV occurred in1987. Until the late 1990s, most subsequent cases occurred in men who had become infected while living or worked abroad. After 1999, HIV and AIDS cases began to be recorded among Pakistani sex workers, IDUs, and prisoners. Despite a low overall HIV prevalence (0.1%), social and economic conditions in Pakistan – including poverty, low levels of education, and high levels of risk behaviour among IDUs and sex workers –are likely to facilitate the spread of HIV in coming years. Source: www.Avert.org
• The threat of HIV/AIDS should not be a primary concern for the traveler. However, there may be a concern for a subset of travelers who may be exposed to HIV, the virus that causes AIDS, through contact with another person’s body fluids or blood. Although travel has contributed in a general way to the global spread of AIDS, fear of traveling because of this disease is not warranted.
• Transmission of HIV can be prevented by avoiding: sexual contact with a high-risk partner; injecting drug use with shared needles; non-sterile medical injections; unscreened blood transfusions.

Accidents & Medical Insurance: Accidents and injuries are the leading cause of death among travelers under the age of 55 and are most often caused by motor vehicle and motorcycle crashes; drownings, aircraft crashes, homicides, and burns are lesser causes. Important safety rules to follow are 1) Do not drive at night, 2) Do not rent a motorcycle, moped, bicycle, or motorbike, even if you are experienced, and 3) Do not swim alone, at night, or if intoxicated.
• Heart attacks cause most fatalities in older travelers.
• Infections cause only 1% of fatalities in overseas travelers, but, overall, infections are the most common cause of travel-related illness.
• MEDICAL INSURANCE: Travelers are advised to obtain, prior to departure, supplemental travel health insurance with specific overseas coverage. The policy should provide for direct payment to the overseas hospital and/or physician at the time of service and include a medical evacuation benefit. The policy should also provide 24-hour hotline access to a multilingual assistance center that can help arrange and monitor delivery of medical care and determine if medevac or air ambulance services are required.

Acute Mountain Sickness (AMS)/Altitude Illness: The Northern Areas (NAs) of Pakistan have a history of tourism and mountaineering. K2 and Nanga Parbat are two of the 14 peaks in the world over 8,000 meters and are both internationally renowned mountaineering challenges. Most of the highest mountains in Pakistan are located in the Karakoram range, but some high mountains are in Himalaya (the highest of which is Nanga Parbat, globally ranked 9th, 8126 m) and Hindu Kush (the highest of which is Tirich Mir, globally ranked 33rd, 7708 m). See a list of the highest mountains here: http://www.infoplease.com/ipa/A0001771.html
Acute mountain sickness (AMS), also known as altitude illness, is a common malady above 2,400 m (8,000 ft), especially if you do not have a chance to acclimatize by ascending gradually. The prevalence of AMS varies between 15% and 75%, depending on your speed of ascent, altitude gained, sleeping altitude, and individual susceptibility. Acute mountain sickness can progress to high altitude cerebral edema (HACE) or be associated with high altitude pulmonary edema (HAPE). You should intersperse your ascent with rest days and avoid, if possible, increasing your sleeping altitude by more than 1,000 - 1,500 feet each night. To reduce further your risk of AMS, take acetazolamide (Diamox), starting the day prior to beginning your ascent. Acetazolamide is a respiratory stimulant that speeds acclimatization and is about 75% effective. It may also reduce the risk of HAPE.
• Symptoms of AMS include mild to moderate headache, loss of appetite, nausea, fatigue, dizziness and insomnia. Mild AMS usually resolves with rest plus medication for headache and nausea. You can also take acetazolamide to treat mild AMS.
• Under no circumstances should you continue to ascend (especially to a higher sleeping altitude) if you have any persistent symptoms of altitude illness. In the absence of improvement or with progression of symptoms you should descend (at least 500 m) to a lower altitude.
• Dexamethasone (Decadron) is a steroid drug used for treating AMS and HACE. You should carry stand-by treatment doses. You can take dexamethasone together with acetazolamide to treat mild- to moderate-AMS.
• More severe AMS (increasing headache, vomiting, increasing fatigue or lethargy) may indicate the incipient onset of high-altitude cerebral edema (HACE)—recognized by confusion, difficulty with balance and coordination, staggering gait. Start treatment with dexamethasone and descend immediately.
• Increasing dry cough and breathlessness at rest may indicate high altitude pulmonary edema (HAPE). Nifedipine, sildenafil (Viagra), or tadalafil (Cialis) can be used for both the prevention and treatment of HAPE. Dexamethasone and the asthma drug salmeterol (Serevent) also will prevent HAPE.
• Descent, combined with medication (and oxygen, if available) is the best treatment for more severe AMS, HACE or HAPE. Consider helicopter evacuation if the situation is urgent.

Caution: Prior to departing for a high-altitude trip, consult with a physician about the use of medications for preventing/treating altitude illness.
Further advice:
http://www.ismmed.org
http://www.altitudemedicine.org
http://www.basecampmd.com/expguide/highalt.shtml
http://wwwn.cdc.gov/travel/yellowBookCh6-AltitudeIllness.aspx

Avian Influenza (Bird Flu): A cluster of eight suspected human cases of H5N1 avian influenza was reported from the Peshawar area in December 2007. Outbreaks in poultry and birds also reported.
• H5N1 avian influenza is predominantly a disease of birds. The virus does not pass easily from birds to people and does not to pass from person to person (except in very rare cases of close contact with an infected blood relative).
• The risk to humans from avian influenza is believed to be very low and no travel restrictions are advised, except travelers should avoid visiting animal markets, poultry farms and other places where they may come into close contact with live or dead poultry, or domestic, caged or wild birds and their excretions. In addition, travelers are advised to:
1. Cook poultry and egg dishes thoroughly. (Well-cooked poultry is safe to eat.)
2. Wash hands frequently with soap and water if around poultry.

• The World Health Organization (WHO) does not recommend travel restrictions to countries experiencing outbreaks of H5N1 avian influenza in birds, including those countries which have reported associated cases of human infection.

The usual vaccines against influenza are not protective against “bird flu.”
Oseltamivir (Tamiflu) is somewhat effective in the treatment of H5N1 avian influenza. It seems to be effective in some cases, but may fail in others. Recently, resistant strains have been reported. In addition, the dosage and duration of treatment appear to be different in severe H5N1 cases.

Cholera: This disease is active in this country and sporadic cases are reported. In July 2008, 16 confirmed cases of cholera were reported in Punjab Province. Cholera, however, is a rare disease in travelers from developed countries and the cholera vaccine is recommended only for relief workers or health care personnel who are working in a high-risk endemic area under less than adequate sanitary conditions, or travelers who work or live in remote, endemic or epidemic areas and who do not have ready access to medical care. Canada, Australia, and countries in the European Union license an oral cholera vaccine. The cholera vaccine is not available in the United States.
• The main symptom of more severe cholera is copious watery diarrhea.
• Antibiotic therapy is a useful adjunct to fluid replacement in the treatment of cholera by substantially reducing the duration and volume of diarrhea and thereby lessening fluid requirements and shortening the duration of hospitalization.
• A single 1-gm oral dose of azithromycin is effective treatment for severe cholera in adults. This drug is also effective for treating cholera in children. (NEJM:http://content.nejm.org/cgi/content/short/354/23/2452)

Crimean-Congo Hemorrhagic Fever: Crimean-Congo hemorhagic fever (CCHF) is reported to occur in border areas. CCHF is caused by a virus and is transmitted by tick bites or exposure to blood or secretions from infected animals or humans. Anyone who has visited this country and is suffering from a fever, headache, chills, muscle aches, vomiting, red rash (which does not fade when pressed under glass), bleeding on the roof of the mouth, or any other unexplained symptoms should seek medical advice immediately. Risk is seasonal, associated with periods of high tick activity (usually March through September, but seasonal patterns may occur) and increases in tick and rodent host populations.

Dengue Fever: Pakistan reports 287 cases of dengue in August 2008. An outbreak of dengue fever was also reported from Karachi in August 2007, resulting in more than 1500 suspected cases and 11 deaths. A smaller outbreak was reported from Lahore in October 2007. Dengue fever is a mosquito-transmitted, flu-like viral illness widespread in the Indian sub-Continent. Symptoms consist of sudden onset of fever, headache, muscle aches, and a rash. A syndrome of hemorrhagic shock can occur in severe cases.
• Dengue is transmitted via the bite of an infected Aedes aegypti mosquito. Aedes mosquitoes feed predominantly during daylight hours. All travelers are at risk and should take measures to prevent daytime mosquito bites. Insect-bite prevention measures include applying a DEET-containing repellent to exposed skin and applying permethrin spray or solution to clothing and gear.
• There is no vaccination or medication to prevent or treat dengue.

Hepatitis: All travelers not previously immunized against hepatitis A should be vaccinated against this disease. Travelers who are non-immune to hepatitis A (i.e. have never had the disease and have not been vaccinated) should take particular care to avoid potentially contaminated food and water. Travelers who will have access to safe food and water are at lower risk. Those at higher risk include travelers visiting friends and relatives, long-term travelers, and those visiting areas of poor sanitation.
• Hepatitis E is endemic. Explosive waterborne epidemics of hepatitis E have occurred in Islamabad, Karachi, Sargodha and elsewhere throughout this country. Transmission of the hepatitis E virus (HEV) occurs primarily through drinking water contaminated by sewage and also through raw or uncooked shellfish. Farm animals may serve as a viral reservoir. In developing countries, prevention of hepatitis E relies primarily on the provision of clean water supplies and overall improved sanitation and hygiene. There is no vaccine.
• Hepatitis B is hyperendemic. The overall hepatitis B (HBsAg) carrier rate in the general population is estimated at >8%. Hepatitis B is transmitted via infected blood or bodily fluids. Travelers may be exposed by needle sharing and unprotected sex; from non-sterile medical or dental injections, and acupuncture; from unscreened blood transfusions; by direct contact with open skin lesions of an infected person. The average traveler is at low risk for acquiring this infection. Vaccination against hepatitis B is recommended for: persons having casual/unprotected sex with new partners; sexual tourists; injecting drug users; long-term visitors; expatriates, and anybody wanting increased protection against the hepatitis B virus.
• Hepatitis C is endemic at high level with a prevalence of 2.4% in the general population. Most hepatitis C virus (HCV) is spread either through intravenous drug use or, in lesser-developed countries, through blood contamination during medical procedures. Over 200 million people around the world are infected with hepatitis C - an overall incidence of around 3.3% of the population of the world. Statistically, as many people are infected with HCV as are with HIV, the virus that causes AIDS.

Influenza: Influenza is transmitted from November through March. Flu vaccine is recommended for travelers over age 6 months.

Japanese Encephalitis (JE): Low risk, mostly confined to areas near Karachi and the Indus Delta, June through January.
The Centers for Disease Control and Prevention (CDC) recommends JE vaccination for travelers spending more than 30 days in an endemic environment, or less than 30 days in areas with epidemic transmission. However, the use of an arbitrary cutoff cannot protect all travelers. Advance knowledge of trip details, accommodation and purpose, as well as local geography, is warranted to give adequate advice. Is travel occurring during the peak transmission season? In general, travelers to rural areas (especially where there is pig rearing and rice farming) should be vaccinated if the duration of their trip exceeds 3 to 4 weeks. They may consider vaccination for trips of shorter duration if more intense exposure is anticipated, especially during unprotected outdoor activities in the evening. Vaccination is advised for expatriates living in this country.
• Japanese encephalitis is transmitted by night-biting Culex mosquitoes. All travelers should take measures to prevent mosquito bites, especially in the evening and overnight. Insect-bite prevention measures include applying a DEET-containing repellent to exposed skin, applying permethrin spray or solution to clothing and gear, and sleeping under a permethrin-treated bednet.


Leishmaniasis: Cutaneous leishmaniasis occurs sporadically in the urban and semirural areas at the margin of the deserts, especially in the west, in Baluchistan. In 2002 Northwest Frontier Province reported 5000 cases of cutaneous leishmaniasis in Kurram Agency and other Agencies of the Province. The epidemiological pattern suggests transmission (man to man) through the sandfly vector with no animals hosts involved.
• Visceral leishmaniasis occurs primarily in northern areas (northern Punjab Province and the Northwest Frontier Province), at elevations between 2,000 and 6,000 meters. Travelers to these regions should protect themselves against sandfly bites. The most intense sandfly-biting activity is April through October. The parasites that cause leishmaniasis are transmitted by the bite of the female phlebotomine sandfly. Sandflies bite mostly in the evening and at night. They breed in ubiquitous places: in organically rich, moist soils (such as found in the floors of rain forests), animal burrows, termite hills, and in the cracks and crevices in stone or mud walls, and earthen floors, of human dwellings.
• All travelers should take measures to prevent sandfly bites. Insect-bite prevention measures include applying a DEET-containing repellent to exposed skin, permethrin (spray or solution) to clothing and gear, and sleeping under a permethrin-treated bednet.

Malaria: Malaria is endemic country-wide at elevations below 6,500 feet (2,000 meters), including the cities and urban areas. The greatest risk of malaria is in the Punjab, especially after the rainy season, July through August. The Himalaya region in the north is risk-free. Prophylaxis with atovaquone/proguanil (Malarone), mefloquine (Lariam), doxycycline or primaquine (G6-PD test required) is recommended for travel in endemic areas.

A malaria map is located on the Fit for Travel website (www.fitfortravel.nhs.uk) which is compiled and maintained by experts from the Travel Health division at Health Protection Scotland (HPS). Go to www.fitfortravel.nhs.uk and select Malaria Map from the Pakistan page on the Destinations menu.

Malaria is transmitted via the bite of an infected female Anopheles mosquito. Anopheles mosquitoes feed predominantly during the hours from dusk to dawn. All travelers should take measures to prevent evening and nighttime mosquito bites. Insect-bite prevention measures include applying a DEET-containing repellent to exposed skin, applying permethrin spray or solution to clothing and gear, and sleeping under a permethrin-treated bednet. DEET-based repellents have been the gold standard of protection under circumstances in which it is crucial to be protected against insect bites that may transmit disease. Nearly 100% protection can be achieved when DEET repellents are used in combination with permethrin-treated clothing.
NOTE: Picardin repellents (20% formulation, such as Sawyer GoReady or Natrapel 8-hour) are now recommended by the CDC and the World Health Organization as acceptable non-DEET alternatives to protect against malaria-transmitting mosquito bites. Picaridin is also effective and ticks and biting flies.
• You should consider the diagnosis of malaria if you develop an unexplained fever during or after being in this country.
• 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.


Other Diseases/Hazards: Anthrax (cutaneous form, usually from contact with infected animals), b
• Brucellosis (human cases associated with occupational exposure to livestock and consumption of unpasteurized dairy products)
• Crimean-Congo hemorrhagic fever (transmitted by ticks; sporadic outbreaks occur)
• Chikungunya fever (rare outbreaks occur)
• Dracunculiasis (focally endemic in NW Frontier, Punjab, Sind Provinces)
• Echinococcosis
• Filariasis (Bancroftian filariasis occurs in the southern Indus delta)
• Leptospirosis (rare in humans)
• Indian tick typhus (also called boutonneuse fever, reported sporadically)
• Melioidosis (sporadic cases)
• Sandfly fever (highly endemic below 1,800 meters elevation; risk is higher in nondesert areas of Pakistan)
• West Nile fever (mosquito-transmitted; absent during winter)
• Typhus (both murine and scrub typhus occur)

Poliomyelitis (Polio): Polio continues to be transmitted in Pakistan. In June 2008, 7 cases were reported, mostly in Sindh province. All travelers shouls be fully immunized. A one-time dose of IPV vaccine is recommended for any traveler >age 18 who completed the primary childhood series but never received an additional dose of polio vaccine as an adult.

Rabies: Rabies is considered a public health problem in many rural and periurban areas. WHO estimates that 2000–10,000 deaths due to rabies occur annually.
Pre-exposure rabies vaccine is recommended for travel longer than 3 months, for shorter stays in rural when travelers plan to venture off the usual tourist routes and where they may be more exposed to the stray dog population; when travelers desire extra protection; or when they will not be able to get immediate medical care.
• All animal bite wounds, especially from a dog, should be thoroughly cleansed with soap and water and then medically evaluated for possible post-exposure treatment, regardless of your vaccination status. Pre-exposure vaccination eliminates the need for rabies immune globulin, but does not eliminate the need for two additional booster doses of vaccine. Even if rabies vaccine was administered before travel, you will need a 2-dose booster series of vaccine after the bite of a rabid animal.

Travelers' Diarrhea: High risk. Although urban areas usually have water treatment facilities, central distribution systems, and public taps, none of the water in Pakistan should be considered potable. Piped water supplies are frequently untreated and may be grossly contaminated. Outside of hotels and resorts, we recommend that you boil, filter or purify all drinking water or drink only bottled water or other bottled beverages and do not use ice cubes. Avoid unpasteurized dairy products. Do not eat raw or undercooked food, especially meat, fish, raw vegetables. Peel all fruits.
• Good hand hygiene reduces the incidence of travelers’ diarrhea by 30%.
• A quinolone antibiotic, or azithromycin, combined with loperamide (Imodium), is recommended for the treatment of diarrhea. Diarrhea not responding to antibiotic treatment may be due to a parasitic disease such as giardiasis, amebiasis, or cryptosporidiosis.
• Seek qualified medical care if you have bloody diarrhea and fever, severe abdominal pain, uncontrolled vomiting, or dehydration.

Tuberculosis: Tuberculosis is highly endemic in Pakistan with an annual occurrence was greater than or equal to 40 cases per 100,000 population. Tuberculosis (TB) is transmitted following inhalation of infectious respiratory droplets. Most travelers are at low risk. Travelers at higher risk include those who are visiting friends and relatives (particularly young children), long-term travelers, and those who have close contact, prolonged contact with the local population. There is no prophylactic drug to prevent TB. Travelers with significant exposure should have PPD skin testing done to evaluate their risk of infection.

Typhoid Fever: Highly endemic, with cases reported almost daily in Islamabad. Typhoid is the most serious of the Salmonella infections. Typhoid vaccine is recommended for all people traveling to or working in Central Asia and the Indian sub-continent, especially if visiting smaller cities, villages, or rural areas and staying with friends or relatives where exposure might occur through food or water. Current vaccines against Salmonella typhi are only 50-80% protective and do not protect against Salmonella paratyphi, the cause of paratyphoid fever. (Paratyphoid fever bears similarities with typhoid fever, but the course is generally more benign.) Travelers should continue to practice strict food, water and personal hygiene precautions, even if vaccinated.