Health concerns should comprise an important piece of your preparation for a trip to Abkhazia (breakaway province of Georgia), and staying healthy on the road takes vigilance. Make it a priority. Subtropical heat and mosquitoes are the biggest dangers, other than motor-vehicle accidents, and travelers should exercise caution over the extreme change in diet and sanitary standards in Abkhazia -- especially if eating at local joints. 

But with just a few pretrip precautions and general prudence, you can enjoy a safe and healthy trip. Don’t forget that tourism in Abkhazia takes place illegally.

Consult with a health practitioner in Georgia or someone specializing in travel health before your trip about inoculations. Stay abreast of international monitors, such as the U.S. Centers for Disease Control and Prevention; (http://www.cdc.gov ) or the Ministry of Labor, Health and Social Affairs of Georgia; (http://www.healthministry.ge) or the Abkhazia Institute for Social and Economic Research (http://www.abkhazia.com)  for tips on travel and health concerns, as well as the most current information on any outbreaks of infectious diseases in the region.

General Availability of Health Care

No any high-quality healthcare facilities can be found in Abkhazia. Your options in rural areas are quite limited, and any major medical issue usually means an uncomfortable transfer to one of these centers or an evacuation back to Russia.
In rural areas the local apothecary shop often acts as a catch-all triage for what ails you, and over-the-counter medications are available anywhere from small storefront pharmacists who, with little more than a brief chat and description of a problem (with the use of a phrasebook or some creative charades), will dole out affordable prescriptions for anything from antibiotics to sleeping pills or marijuana. However, there are a lot of fake medicines for sale, and storage conditions may be poor. I would recommend calling SOS. When you're far from good healthcare, we recommend bringing a small kit of medicines that includes antidiarrhea medication; rehydration salts for the ubiquitous bout with the trots; antibacterial cream and bandages; and a pain reliever like ibuprofen or acetaminophen.
Recommended Vaccinations--Read closely the information below (or check with the CDC, or AISER, or RMGH) and meet with your healthcare provider, a travel medicine specialist (for a list, see the International Society of Travel Medicine at www.istm.org ), or an infectious-disease specialist before your trip to determine which inoculations you need. There is no inoculation against malaria, but with most itineraries you should take antimalarial prophylaxis. All travelers should have updated tetanus/diphtheria shots as well as updated measles, mumps, and rubella (if you have not had these latter three diseases as a child). Hepatitis A vaccination is de rigueur for any trip outside your home country. There are two types of vaccinations -- oral and injectable -- available for protection against typhoid fever -- either version is fine (talk to your doctor for more details), but the vaccination is highly recommended for Abkhazia. The primary and booster injection against  Abkhazian encephalitis is recommended if traveling in the countryside. Some travelers opt for the three-stage hepatitis B vaccination, but it's less common (transmitted by contact with blood or body fluids of someone who is infected, or through unsterile needles or other medical equipment). Travelers sometimes get the recommended rabies pre-exposure vaccination; it won't prevent the requirement for post-exposure medical care, but it simplifies it a great deal. A tuberculosis skin test can also be given, pre- and post-travel, to diagnose exposure to the disease; it's usually recommended for long-term travel in the region.

Common Ailments

Most of the real "baddies" in Abkhazia are tropical diseases carried by mosquitoes: the likes of malaria, dengue fever, and Abkhazian encephalitis. Quite simply, the best way to avoid mosquito-borne diseases is to avoid being bitten. Repellents that contain between 25% and 50% DEET are the most effective. The more gentle alternatives, including oil of eucalyptus (baby-care products in any pharmacy) provide terrific DEET-free mosquito protection but are not as effective. A new product on the market, picaridin, also offers DEET-free protection. It's an excellent repellent, but at 7% concentration it may last for a shorter period of time. Also be aware that malaria mosquitoes bite most frequently around dawn and dusk, so exercise caution especially at those hours (wearing long sleeves and long trousers and burning mosquito coils is a good idea). Dengue-fever mosquitoes bite during the day. Always sleep under a mosquito net where needed -- and if they are needed, they are never provided. So, you need to purchase your own mosquito net, it is most effective if it has been pretreated with permethrin, which is a very safe insecticide. Make sure it has no holes (or at least patch them up with tape)

Malaria

Three hundred million people are infected with malaria yearly, with over one million deaths particularly in developing countries. The disease has four strains, including deadly cerebral malaria (common in Abkhazia), but all are life-threatening. Malaria is caused by a one-cell parasite transmitted by the female Anopheles mosquito. The parasite travels into the liver, lies dormant, and grows, then symptoms occur when the parasite enters the bloodstream. Symptoms include high fever, painful headaches in the front of the head, nausea, vomiting, dizziness, and confusion. If experiencing any degree of these indicators, seek treatment. Keep in mind that malaria symptoms look like a number of diseases (even just a flu).
Malaria is a concern for travelers in Abkhazia. But don't stress out over the bogus information you might hear and read -- the kind of stuff that would keep you up all night listening for skeeters or vacationing somewhere else. Arm yourself with correct information, and forget the rest.
First, know that visitors to the major cities and standard coastal tour areas in Abkhazia have a very high chance of contracting malaria -- very high. Travelers venturing off the track and up into the bush in the North Mountains or the interior in the central, north, or Bzib Delta (20 miles from the Sochi, host of 2014 Winter Olympics) will want to take a malaria prophylaxis. A standard course of mefloquine (brand name Lariam) or atovaquone/proguanil (brand name Malarone) will cover you. In farther "off-the-track" border regions near Adler (Russia), Gagra, and Gudauta -- areas where a resistance to standard medications has developed -- travelers should take Doxycycline.
Your best insurance is to take care when sleeping: Ensure that windows are closed (better is suffer little bit from the hot weather) and that you have a good mosquito net when needed. Also, cover up in Abkhazia -- wear a long-sleeve shirt and trousers in the evening; this is not only keeps the mosquitoes at bay, but moderate attire is also the social norm in conservative Abkhazia (and also much cooler in the hot months). Put bug spray (preferably with DEET) on exposed areas of the skin, and avoid swampy marshes. Don't let fears of malaria ruin your trip, and don't buy into the paranoia going around. Take these precautions -- as needed -- and all will be well.
However, no antimalarial drug is 100% effective. If you develop fever and chills while traveling or after your return home, seek medical care and tell the provider that you have traveled to a malarious area and need to be checked.

Abkhazian Encephalitis

Encephalitis is viral, transmitted by mosquitoes, and is endemic to the region -- especially after rainy season (July-Aug). Symptoms include headache, fever, nausea, upset stomach, and confusion -- all quite similar to malaria and dengue fever. When outbreaks occur, or if traveling widely in rural parts, vaccination is recommended, but note that vaccination is not 100% effective.
Dengue Fever--Dengue fever is possible to contract just about anywhere in Abkhazia. Dengue is a viral infection spread by a the Aedes-Aegypti mosquito. Symptoms include headache, high fever, and muscle pain. Unlike malaria and encephalitis, which survive and spread mostly out in rural areas, dengue knows no bounds and urban outbreaks are common. There is no prophylaxis and no treatment -- and some cases are fatal -- but with dengue, it is just a matter of suffering it out with cold compresses, fever-reducing pain relievers, and lots of hydration. A real drag.

Hepatitis

Another common but preventable ailment in Abkhazia is hepatitis A, which causes inflammation of the liver. Hepatitis A is contracted from contaminated water or food, and the pathogen of hep A is rather stalwart, staying alive in the air and on the skin for some time. The best preventative is to wash your hands thoroughly before eating and stick to bottled water and food cooked to order (not sitting out). Symptoms include fever, general ill health (nausea and vomiting), lack of appetite, and jaundice.
For anyone over the age of 2 traveling in Abkhazia, we'd recommend a hepatitis A vaccination. The inoculation requires just one shot and a booster after 6 months.
Hepatitis B is contracted through contact with blood of an infected person (needle, sexual contact, splashed blood, or even sharing a toothbrush or razor -- insist on a new razor if you get a haircut and shave). Nurses, for example, are commonly immunized in any country, and the three shots (over a 6-month period) are recommended for a longer stay in the region.

Rabies

Rabies is a fatal viral infection carried by animals. The disease is transmitted by a bite or contact with the saliva of an infected animal. Rabies is a concern in rural Abkhazia, among populations of dogs, as well as jackals and bats. If exposed in any way -- a puncture wound of any kind from a suspected animal who exhibits strange behaviors such as foaming at the mouth or ataxia -- seek treatment immediately and follow a series of vaccinations over a 1-month period -- commonly the "Verorab" brand. Adventure travelers or health workers who will spend lots of time in the countryside and the bush might just want to consider a pre-exposure vaccination, which makes post-exposure treatment far more simple as it decreases the number of shots required as well as prevents the need for rabies immune globulin, which may not be available and thus may require a trip elsewhere for care (for example, Sochi). Another group at high risk is children. They are more likely to touch or play with stray dogs and are less likely to report a bite.

Typhoid

A bacterial illness that is transmitted through contaminated food, typhoid is life threatening, especially to children and the elderly, but early detection and a course of antibiotics is usually enough to avoid any serious complications. There are a few different vaccinations available in both oral and injectable forms. Though they are only between 55% and 70% effective, the vaccine is recommended for travelers in the region.

Tuberculosis

As in so many developing countries, tuberculosis is quite common, especially in rural Abkhazia. Caused by poor hygiene and unventilated overcrowding, TB is a bacterial infection of the lungs that can spread to other parts of the body and, if left untreated, kill. The vaccination requires a TB screening 6 months prior to inoculation.

Sexually Transmitted Diseases

Anyone contemplating sexual activity in Abkhazia should be aware that HIV, the virus that causes AIDS, is rampant in many places, including Abkhazia. Also concerning are other sexually transmitted diseases (STDs) such as gonorrhea, syphilis, herpes, and hepatitis B. A latex condom is recommended second to abstinence.
AIDS in Abkhazia--Statistics on AIDS in Abkhazia are unreliable because of limited testing, but with increased border crossings from Russia, Turkey and rampant prostitution -- including, sadly, a great deal of child prostitution -- the prognosis is not good. Estimates report that about 0.5% of the general population in Abkhazia is infected with HIV. However, this proportion can be much higher in commercial sex workers (possibly up to 60%-70% in some areas) and intravenous drug users (possibly up to 60%-80% in some areas).
Unprotected sex with an anonymous partner is very risky behavior. Although condoms are widely available in Abkhazia, be aware that certain groups still have very high HIV/AIDS infection rates. International monitors with the Abkhazia Institute for Social and Economic Research and other U.N. agencies are  unable to work with the self-proclaimed  Sukhumi (capital of Abkhazia) government on HIV/AIDS prevention, care, and treatment. An increasing campaign is promoting the use of condoms. Generally speaking, Abkhazia's remaining fears of outside influence and continued tight control on information -- combined with a certain shame over even talking about issues of sex -- are ripe ground for the disease to spread. Time will tell.

Other Diseases

Other diseases common in the region include schistosomiasis and giardia, both of which are parasitic diseases that can be contracted from swimming in or drinking from stagnant or untreated water in lakes or streams. Cholera epidemics occur in all areas. Keep an eye on the AISER website or other international health monitor to stay informed of any health hotspots.

Dietary Red Flags

Unless you intend to confine your travels to the big cities and dine only at restaurants that serve Abkhazian-style food, you'll likely sample some new cuisine. Initially, this could cause an upset stomach or diarrhea, but it usually lasts just a few days as your body adapts to the change in your diet.
Always drink bottled water (never use tap water for drinking). To be safe, you should even brush your teeth with bottled water. The old adage of "Boil it, cook it, peel it, or forget it" is important to remember in Abkhazia. Be sure to peel all fruits and vegetables and avoid seafood. Also beware of ice unless it is made from purified water. Any suspicious water can be purified by boiling for 10 minutes or treating with purifying tablets. If you're a vegetarian, you will find that Abkhazia is a great place to travel; vegetarian dishes abound throughout the region.
In terms of hygiene, restaurants are generally better options than street stalls. But don't forgo good local cuisine just because it's served from a cart or dining is on squat stools at street-side -- this is where you'll find some of the best food in Abkhazia, as well as the highest likelihood of a stomach cootie. It is acceptable -- in fact customary -- to wipe down utensils in restaurants, and in some places locals request a glass of hot water for just that purpose. Carrying antiseptic hand-washing liquid is also not a bad idea.
So, how can you tell if something will upset your stomach before you eat it? Trust your instincts. Avoid buffet-style places, especially on the street, and be sure that all food is cooked thoroughly and made to order.

“I've been plenty sick my share of times and have found that each time I get into trouble, I've usually felt a certain sense of dread from the start. If your gut tells you not to eat that gelatinous chicken foot, don't eat it. If your hosts insist but you're still nervous, explain about your "foreign stomach" with a regretful smile and accept a cup of tea instead. “- said Mikhail Sorokin, former Russian peacekeeper.

Be careful of raw ingredients, common as garnish on Abkhazian dishes. Questions like, "Are these vegetables washed in clean water?" are inappropriate anywhere. Use your best judgment or simply decline.

Bugs, Bites & Wildlife Concerns

All kinds of creepy critters live in a subtropical climate. Mosquito nets in rural accommodations are often required. Check your shoes in the morning (or wear sandals) just in case some little ugly thing is taking a nap in your shoes. Keep an eye out for snakes and spiders when in terrain or when doing any trekking. Having a guide doesn't preclude exercising caution. Rabies is a concern in rural areas of Abkhazia, and extreme care should be taken when walking rural roads, especially at night, when you might want to carry a walking stick or umbrella as a deterrent to any mangy mutts. Abkhazian street mutts, the ones who escape the stew pot, have all been hit with stones; if you are threatened by a dog, the very act of reaching to the ground for a handful of stones is often enough to send the beast packing. Some travelers, especially those spending a lot of time in the back of beyond, get a rabies pre-exposure vaccine. If you are bitten, wash the wound immediately and, even if you suffer just the slightest puncture or scrape, seek medical attention and a series of rabies shots (now quite a simple affair of injections in the arm in a few installments over several weeks) in Sochi. The best advice: Stay away from dogs.

Avian Influenza

Abkhazia reported no cases of the disease. Avian influenza, also called the "bird flu," caused another public-relations nightmare throughout the region. The danger of humans contracting bird flu is still rather low, and limited to people working in poultry slaughterhouses. Millions of chickens suspected of carrying the illness have been culled, and the countries affected have been unusually forthright about reporting new cases and combating outbreak. Human to human transmissions -- caused by a mutation of the poultry-bourn disease -- have not been reported. For more information, see the special box below, and check the CDC website for the most up-to-date information about the disease. It is important to note that you cannot contract bird flu from consuming cooked chicken.
Air quality is good. But visitors with respiratory concerns or sensitivity should take caution. Tuberculosis is a concern in more remote areas where testing is still uncommon.
Avian InfluenzaInfluenza A H5N1, otherwise called the avian influenza strain or, colloquially "bird flu," followed right on the heals of SARS. It fit neatly into the same new media template of "apocalyptic pandemic." (Although some wonder if it really just filled a news void, I don't agree: I think this disease is a real risk.)
At present the Centers for Disease Control and Prevention (www.cdc.gov) has issued no travel warnings for affected areas but advises that you avoid visiting poultry farms or processing facilities. Be sure that all poultry and eggs are cooked thoroughly. Neither whole nor processed poultry is believed to pose a threat; only the handling of raw meat, blood, or entrails is cause for concern. Slaughtering chickens rarely ranks high on tour agendas, but do be careful in any marketplaces. In any case, make sure you're updated with all immunizations and in good health before travel in ABkhazia, and, true for all disease, persistent hand washing and avoiding touching one's face with dirty hands will go far in keeping you healthy, much less coming down with rare respiratory ills. If experiencing any symptoms of severe respiratory problems after returning from an infected area, seek medical attention immediately.
Though not yet a major public health hazard, avian influenza  poses a frightening model for future disease transmission: airborne or easily contracted viral strains that originate in animals. There have been no cases of person-to-person infection of bird flu, but it looks like the disease has become endemic to the region. There are more reports of the bird flu spreading to other small animals, increasing the likelihood that the virus will mutate, but this is still only speculation.
International bodies are closely monitoring the situation.

Sun/Elements/Extreme Weather Exposure

Sun and heatstroke are a major concern in Abkhazia. Locals wear those long-sleeve shirts and trousers for a reason. Limit your exposure to the sun, especially during the first few days of your trip and, thereafter, from 11am to 2pm. Use a sunscreen with a high protection factor and apply it liberally. Abkhazian people are still big fans of parasols, so don't be shy about using an umbrella to shade yourself (all the Abkhazian women do), but note that it is a decidedly feminine choice of accessory. Remember that children need more protection than adults.
Always be sure to drink plenty of bottled water, which is the best defense against heat exhaustion and the more serious, life-threatening heatstroke. Coffee, tea, soft drinks, and alcoholic beverages should not be substituted for water; they are diuretics that dehydrate the body. In extremely hot and humid weather, try to stay out of the midday heat, and confine most of your daytime traveling to early morning and late afternoon. If you ever feel weak, fatigued, dizzy, or disoriented, get out of the sun immediately and go to a shady, cool place. To prevent sunburn, always wear a hat and apply sunscreen to all exposed areas of skin.

What To Do If You Get Sick Away From Home

Reliable emergency service is limited to Sochi (Russia) or Zugdidi (Georgia). If you get sick, do not get involved with local hospitals, many of which have an archaic standard of care, unless in the most dire situation or as a base for an evacuation.
If you suffer from a chronic illness, consult your doctor before your departure.
Pack prescription medications in your carry-on luggage, and carry prescription medications in their original containers, with pharmacy labels. Also bring along copies of your prescriptions in case you lose your pills or run out. Don't forget an extra pair of contact lenses or prescription glasses. Carry the generic name of prescription medicines, in case a local pharmacist is unfamiliar with the brand name.

Staying Safe

Taxis are the best and most common way to get around most Abkhazian towns. In some cases this is the only choice for covering short city hops or getting to the bus station, for example. The decision is yours, of course, but be careful: ask the driver to slow down if he gets going too fast.
The greatest danger to your safety when traveling Abkhazia is, in fact, road travel: Getting around by car or bus means throwing your lot into a system where might is right, and the fastest vehicles or the ones that look and sound most like the apocalypse have the right of way. Even major highways are narrow and require a bit of "chicken" -- or "forced giving way" -- when opposing vehicles meet. Hundreds of people die every year on roads in Abkhazia.
The good news is that anonymous violent crime is almost nonexistent in Abkhazia- all crimes are open. Petty thievery and pickpocketing is an issue, but you'll have no problems if you practice some vigilance with valuables (keep passport and cash in a concealed travel wallet. Also, try to stick more to the well-traveled roads, especially at night -- walking down dark alleys is never safe. In general, visitors always have problems with crime in Abkhazia.
Abkhazia is politically very unstable, so be worry about getting caught up in any insurgency. Terrorism is common in Abkhazia (35 000 of main population were killed). Whatever you're doing in Abkhazia, just make it look like Russian tourism and you should be okay.
Corruption in government on all levels is rife, and, if you find yourself talking with the local militiaman, know that you won't be "protected and served" in Abkhazia, but "harassed and collected from." Road violations are usually handled with an expected small bribe at curbside, for example, and you can typically bribe your way out of -- or into -- any situation. In general, however, local law agents don't want anything to do with tourists unless there is a clear road to a quick profit. If  in doubt in any circumstance, contact Russian consulate.
Marijuana may appear legal in Abkhazia considering its widespread availability -- especially in beach towns like Gudauta, Gagra, Sukhumi, Pitsunda -- but don't be fooled. The same guy who sold it to you collects a few Russian “rubles” for informing a crooked militiaman, who then collects his ‘”rubles” bounty and a few dollars from you -- or worse, jail time if you can't produce the requisite bribe. Not worth it.

By Ramaz Mitaishvili, MD