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GUIDE TO BRAZIL

HEALTH


BEFORE YOU GO

INSURANCE

If your health insurer doesn't cover you for medical expenses incurred abroad, you'll need to get some extra travel insurance - see the links under www.lonelyplanet.com/subwwway for more information. Find out in advance if your travel insurer will make payments directly to providers or reimburse you later for overseas health expenditures.

RECOMMENDED VACCINATIONS

Since most vaccines don't produce immun­ity until at least two weeks after they're given, visit a physician four to eight weeks before departure. Ask your doctor for an International Certificate of Vaccination (otherwise known as the yellow booklet), which will list all the vaccinations you've received. This is mandatory for countries that require proof of yellow fever vaccin­ation upon entry, but it's a good idea to carry it wherever you travel.

MEDICAL CHECKLIST

Bring medications in their original contain­ers, clearly labeled. A signed, dated letter from your doctor describing your medical conditions and medications (including their generic names) is a good idea. If carrying syringes or needles, carry a physician's let­ter documenting their medical necessity.

INTERNET RESOURCES

There is a wealth of travel-health advice on the Internet. For further information, the Lonely Planet website at www.lonelyplanet.com is a good place to start. The World Health Organization (WHO) publishes a superb book called International Travel and Health, which is revised annually and is available online at no cost ( www.who.int/ith/ ). Another website of general inter­est is the MD Travel Health website at www.mdtravelhealth.com, which provides free, complete travel health recommendations for every country and is updated daily.

It's usually a good idea to consult your government's travel-health website before departure, if one is available:

United States www.cdc.gov/travel/

FURTHER READING

For more detailed information on health matters, see Healthy Travel Central & South America, published by Lonely Planet. If you are traveling with children, Lonely Planet's

IN TRANSIT

Travel with Children provides useful advice. The ABC of Healthy Travel by E Walker et al is another valuable resource.

Deep Vein Thrombosis (DVT)

Blood clots may form in the legs (deep vein thrombosis: DVT) during plane flights, chiefly because of prolonged immobility. The longer the flight, the greater the risk. Though most blood clots are reabsorbed uneventfully, some may break off and travel through the blood vessels to the lungs, where they could cause life-threatening complications.

The chief symptom of DVT is swelling or pain of the foot, ankle or calf, usually but not always on just one side. When a blood clot travels to the lungs, it may cause chest pain difficulty breathing. Travelers with any of these symptoms should seek edical attention immediately.

To prevent the development of DTV on long flights you should walk about the cabin, perform isometric isometric compressions of the leg muscles (ie contract the leg muscles while sitting), drink plenty of fluid, mid avoid alcohol and tobacco.

Jet Lag & Motion Sickness

Jet lag is common when crossing more than five time zones and can result in insomnia, fatigue, malaise or nausea. To avoid jet lag try drinking plenty of (nonalcoholic) fluids and eating light meals. Upon arrival, get exposure to natural sunlight and readjust your schedule (for meals, sleep etc) as soon as possible.

Antihistamines such as dimenhydrin-ate (Dramamine) and meclizine (Antivert, Bonine) are usually the first choice for treat­ing motion sickness. Their main side effect is drowsiness. An herbal alternative is ginger, which works like a charm for some people.

IN BRAZIL

Availabity & Cost of Health Care

For an ambulance in Brazil, call Tel: 192, or an emergency number (listed following).

Good medical care is available in the larger cities, but may be difficult to find in rural areas. Medical care in Brazil may be extremely expensive. Most doctors and hos­pitals expect payment in cash, regardless of whether you have travel-health insurance.

The US embassy website at www.emba ixada-americana.org.br has an extensive list of physicians, dentists, pharmacists, labora­tories and emergency services. If you're pregnant, be sure to check this site before departure to find the name of one or two obstetricians in the area you'll be visiting, just in case.

If you develop a life-threatening med­ical problem, you'll probably want to be evacuated to a country with state-of-the­art medical care. Since this may cost tens of thousands of dollars, be sure you have insurance to cover this before you depart.

You can find a list of medical evacuation and travel insurance companies on the US State Department website at www.travel.state. gov/medical.html.

Each Brazilian pharmacy has a licensed pharmacist. Most are well supplied. Many medications that require a prescription in the US and Canada are available over the counter in Brazil. If you're taking any medi­cation on a regular basis, be sure you know its generic (scientific) name, since many pharmaceuticals go under different names in Brazil. Droga Raia is a large pharmacy chain; many stores are open 24 hours.

INFECTIOUS DISEASES

Cholera

Cholera is an intestinal infection acquired through ingestion of contaminated food or water. The main symptom is profuse, watery diarrhea, which may be so severe that it causes life-threatening dehydration. The key treatment is drinking oral rehy­dration solution. Antibiotics are also given, usually tetracycline or doxycycline, though quinolone antibiotics such as ciprofloxacin and levofloxacin are also effective.

Cholera sometimes occurs in Brazil, but it's rare among travelers. Cholera vaccine is no longer required, and is in fact no longer available in some countries, including the US, because the old vaccine was relatively ineffective and caused side effects. There are new vaccines that are safer and more effective, but they're not available in many countries and are only recommended for those at particularly high risk.

Dengue

Dengue fever is a viral infection found throughout South America. A large out­break of dengue was reported from the Rio area in early 2002, ultimately affecting al­most 800,000 people. Dengue is transmitted by aedes mosquitoes, which bite preferen­tially during the daytime and are usually found close to human habitations, often indoors. They breed primarily in artificial water containers, such as jars, barrels, cans, cisterns, metal drums, plastic containers and discarded tires. As a result, dengue is especially common in densely populated, urban environments.

Dengue usually causes flulike symptoms, including fever, muscle aches, joint pains, headaches, nausea and vomiting, often followed by a rash. The body aches may be quite uncomfortable, but most cases resolve uneventfully in a few days. Severe cases usually occur in children under the age of 15 who are experiencing their second dengue infection.

There is no treatment for dengue fever except to take analgesics such as acetamin­ophen/paracetamol (Tylenol) and drink plenty of fluids. Severe cases may require hospitalization for intravenous fluids and supportive care. There is no vaccine. The cornerstone of prevention is protection against insect bites.

Hepatitis A

Hepatitis A is the second most common travel-related infection (after traveler's diar­rhea). It's a viral infection of the liver that is usually acquired by ingestion of contaminated water, food or ice, though it may also be acquired by direct contact with infected persons. The illness occurs throughout the world, but the incidence is higher in developing nations. Symptoms may include fever, malaise, jaundice, nausea, vomiting and abdominal pain. Most cases resolve without complications, though hepatitis A occasionally causes severe liver damage. There is no treatment.

The vaccine for hepatitis A is extremely safe and highly effective. If you get a booster six to 12 months later, it lasts for at least 10 years. You really should get it before you go to Brazil or any other developing nation. Because the safety of hepatitis A vaccine has not been established for preg­nant women or children under the age of two, they should instead be given a gamma globulin injection.

Hepatitis B

Like hepatitis A, hepatitis B is a liver in­fection that occurs worldwide but is more common in developing nations. Unlike hepatitis A, the disease is usually acquired by sexual contact or by exposure to infected blood, generally through blood transfusions or contaminated needles. The vaccine is rec­ommended only for long-term travelers (on the road more than six months) who expect to live in rural areas or have close physical contact with the local population. Addi­tionally, the vaccine is recommended for anyone who anticipates sexual contact with the local inhabitants or a possible need for medical, dental or other treatments while abroad, especially if a need for transfusions or injections is expected.

Hepatitis B vaccine is safe and highly ef­fective. A total of three injections, however, are necessary to establish full immunity. Several countries added hepatitis B vaccine to the list of routine childhood immuniza­tions in the 1980s, so many young adults are already protected.

Malaria

Malaria occurs in every South American country except Chile, Uruguay and the Falkland Islands. It's transmitted by mos­quito bites, usually between dusk and dawn. The main symptoms are high spiking fevers, which may be accompanied by chills, sweats, headache, body aches, weakness, vomiting or diarrhea. Severe cases may in­volve the central nervous system and lead to seizures, confusion, coma and death.

Taking malaria pills is strongly recom­mended for forested areas within the nine states of the 'Legal Amazonia' region, in­cluding Acre, Amapa, Amazonas, Maran­hao (western part), Mato Grosso (northern part), Para (except Belem city), Rondonia, Roraima and Tocantins, and for urban areas within this region, including the cities of Porto Velho, Boa Vista, Macapa, Man­aus, Santarem and Maraba. 'I'ransmission is greatest in remote jungle areas where min­ing, lumbering and agriculture occur and which have been settled for less than five years. Malaria risk is negligible outside the states of 'Legal Amazonia.' Travelers visit­ing only the coastal states from the horn to the Uruguay border and Igua4u Falls do not need prophylaxis.

There is a choice of three malaria pills, all of which work about equally well. Me­floquine (Lariam) is taken once weekly in a dosage of 250mg, starting one to two weeks before arrival and continuing through the trip and for four weeks after return. The problem is that a certain percentage of people (the number is debatable) develop neuro-psychiatric side effects, which may range from mild to severe. Atovaquone/ proguanil (Malarone) is a newly approved combin-ation pill taken once daily with food starting two days before arrival and continuing through the trip and for seven days after departure. Side effects are typi­cally mild. Doxycycline is a third alter­native, but it may cause an exaggerated sunburn reaction.

In general, Malarone seems to cause fewer side effects than Lariam and is be­coming more popular. The chief disadvan­tage is that it has to be taken daily. For longer trips, it's probably worth trying Lariam; for shorter trips, Malarone will be the drug of choice for most people.

Protecting yourself against mosquito bites is just as important as taking malaria pills, since none of the pills is 100% effective.

If you may not have access to medical care while traveling, you should bring along additional pills for emergency self­treatment, which you should take if you

can't reach a doctor and you develop symp toms that suggest malaria, such as high spiking fevers. One option is to take tom tablets of Malarone once daily for thrrc days. Mala-rone should not be used tot treatment, however, if you're already taking it for prevention. An alternative is to take 650mg of quinine three times daily and 100mg of doxycycline twice daily for one week. If you start self-medication, see a doctor at the earliest possible opportunity.

If you develop a fever after returning home, see a physician, as malaria symptoms may not occur for months.

Plague

The plague continues to occur among animals in the drier northern and eastern states, from Ceara south to Minas Gerais, but human cases are uncommon. Most occur in Bahia state. The infection is usu­ally transmitted to humans by the bite of rodent fleas, typically when rodents die off Symptoms include fever, chills, mus­cle aches and malaise, associated with the development of an acutely swollen, ex­quisitely painful lymph node, known as a bubo, most often in the groin. Most travel­ers are at extremely low risk of the plague. But if you may have contact with rodents or their fleas, especially in the above areas, you should bring along a bottle of doxycycline, to be taken prophylactically during periods of exposure. Those less than eight years old or allergic to doxycycline should take trim ethoprim-sulfamethoxazole instead. In addition, you should avoid areas containing rodent burrows or nests, never handle sick or dead animals, and follow the guidelines in this chapter for protecting yourself from insect bites.

Rabies

Rabies is a viral infection of the brain and spinal cord that is almost always fatal. The rabies virus is carried in the saliva of in­fected animals and is typically transmitted through an animal bite, though contamin­ation of any break in the skin with infected saliva may result in rabies. Rabies occurs in all South American countries. In Brazil, most cases are reported from the extreme western Minas Gerais state and northeast­ern areas. Dog bites are the most common cause, but bites from other animals can also

lead to rabies. In 2004 several dozen people in the Amazon died from rabies after being bitten by vampire bats.

Rabies vaccine is safe, but a full series requires three injections and is quite ex­pensive. Those at high risk of rabies, such as animal handlers and spelunkers (cave ex­plorers), should certainly get the vaccine. In addition, those at lower risk of animal bites should consider asking for the vaccine if they may be traveling to remote areas and may not have access to appropriate medical care if needed. The treatment for a pos­siblv rabid bite consists of rabies vaccine with rabies immune globulin. It's effective, but must be given promptly. Most travelers don't need rabies vaccine.

All animal bites and scratches must be promptly and thoroughly cleansed with large amounts of soap and water and local health authorities contacted to determine whether or not further treatment is neces­sary.

Typhoid

Typhoid fever is caused by ingestion of food or water contaminated by a species of salmonella known as Salmonella typhi. Fever occurs in virtually all cases. Other symptoms may include headache, malaise, muscle aches, dizziness, loss of appetite, nausea and abdominal pain. Either diarrhea or constipation may occur. Possible com­plications include intestinal perforation, intestinal bleeding, confusion, delirium or (rarely) coma.

Unless you expect to take all your meals in major hotels and restaurants, typhoid vaccine is a good idea. It's usually given orally, but is also available as an injection. Neither vaccine is approved for use in chil­dren under the age of two.

The drug of choice for typhoid fever is usually a quinolone antibiotic such as ciprofloxacin (Cipro) or levofloxacin (Le­vaquin), which many travelers carry for treatment of traveler's diarrhea. However, if you self-treat for typhoid fever, you may also need to self-treat for malaria, since the symptoms of the two diseases may be in­distinguishable.

Yellow Fever

Yellow fever is a life-threatening viral in­fection transmitted by mosquitoes in for­ested areas. The illness begins with flulike symptoms, which may include fever, chill, headache, muscle aches, backache, loss of appetite, nausea and vomiting. These symp­toms usually subside in a few days, but one person in six enters a second, toxic phase characterized by recurrent fever, vomiting, listlessness, jaundice, kidney failure, and hemorrhage, leading to death in up to half of the cases. There is no treatment except for supportive care.

Yellow fever vaccine is strongly rec­ommended for all travelers to Brazil, ex­cept those visiting only Rio de Janeiro, Sao Paulo, the central eastern area to the coast, and the coastal areas south of Sao Luis. Major outbreaks have recently been reported from Minas Gerais state and ad­ditional cases occur elsewhere. Fatal cases of yellow fever among travelers who failed to get vaccinated are periodically reported. For an up-to-date map showing the distri­bution of yellow fever in Brazil, go to the Centre for Disease Control (CDC) web­site at www.cdc.gov/travel/diseases/maps/yellowfever_map2.htm.

Proof of vaccination is required from all travelers arriving from a yellow fever­infected country in Africa or the Americas.

Yellow fever vaccine is given only in ap­proved yellow fever vaccination centers, which provide validated International Cer­tificates of Vaccination. The vaccine should be given at least 10 days before any poten­tial exposure to yellow fever and remains effective for approximately 10 years. Reac­tions to the vaccine are generally mild and may include headaches, muscle aches, low­grade fevers or discomfort at the injection site. Severe, life-threatening reactions have been described but are extremely rare. In general, the risk of becoming ill from the vaccine is far less than the risk of becoming ill from yellow fever, and you're strongly encouraged to get the vaccine.

Taking measures to protect yourself from mosquito bites is an essential part of preventing yellow fever.

Other Infectious Diseases

style="font-weight:bold;">Sehistosomiasis , which is a parasitic infection acquired by skin exposure to contaminated fresh water, occurs in almost all states of the Northeast and two states (Minas Gerais and Espirito Santo) in the Southeast. When traveling in these areas, you should avoid swimming, wading, bathing or washing in bodies of fresh water, including lakes, ponds, streams and rivers. Salt water and chlorin­ated pools carry no risk of schistosomiasis.

style="font-weight:bold;">Toxoplasmosis has been reported from vari­ous areas, including northwestern Parana state and northern Rio de Janeiro state. Most cases have been related to contaminated water supplies. Pregnant women should be particularly careful to avoid drinking unfil­tered water, since toxoplasmosis may cause severe fetal illness. In nonpregnant people with normal immune systems, most cases of toxoplasmosis clear uneventfully.

style="font-weight:bold;">Chagas' disease is a parasitic infection that is transmitted by triatomine insects (redu­viid bugs), which inhabit crevices in the walls and roofs of substandard housing in South and Central America. In Brazil, the disease has been eliminated in every state except Bahia and Tocantins through an aggressive program of insecticide spray­ing. The triatomine insect lays its feces on human skin as it bites, usually at night. A person becomes infected when they un­knowingly rub the feces into the bite wound or any other open sore. Chagas' disease is extremely rare in travelers. If you sleep in a poorly constructed house, especially one made of mud, adobe or thatch, however, you should be sure to protect yourself with a bed net and a good insecticide.

style="font-weight:bold;">Leishmaniasis occurs in the mountains and jungles of all South American countries ex­cept for Chile, Uruguay and the Falkland Is­lands. The infection is transmitted by sand flies, which are about one-third the size of mosquitoes. In Brazil, leishmaniasis has been reported from suburban areas in Rio de Janeiro and Sao Paulo. Most cases are limited to the skin, causing slowly growing ulcers over exposed parts of the body. The more severe type of leishmaniasis, which disseminates to the bone marrow, liver and spleen, occurs mainly in the Northeast. Leishmaniasis may be particularly severe in those with HIV. There is no vaccine. To protect yourself from sand flies, follow the same precautions as for mosquitoes, except that netting must be made of a finer mesh (at least 18 holes per 2.54cm or to the linear inch).

style="font-weight:bold;">Hantavirus pulmonary syndrome is a rapidly progressive, life-threatening infection that is acquired through exposure to the excretions of wild rodents. Most cases occur in those people who live in rodent-infested dwellings in rural areas. In Brazil, hanta virus infections are reported from the states of Minas Gerais, Santa Catarina and Sao Paulo.

Echinococcus is a parasite that infects the liver, usually in people who work with sheep. Echinococcus infections occur chiefly in the southernmost part of the country.

Brucellosis is an infection of domestic and wild animals that may be transmitted to hu­mans through direct animal contact or by consumption of unpasteurized dairy prod­ucts from infected animals. In Brazil, most human cases are related to infected cattle. Symptoms may include fever, malaise, de­pression, loss of appetite, headache, muscle aches and back pain. Complications may include arthritis, hepatitis, meningitis and endocarditis (heart-valve infection).

style="font-weight:bold;">Fascioliasis is a parasitic infection that is typically acquired by eating contaminated watercress grown in sheep-raising areas. Early symptoms may include fever, nau­sea, vomiting and painful enlargement of the liver.

style="font-weight:bold;">Onchocerciasis (river blindness) is caused by a roundworm that may invade the eye, lead­ing to blindness. The infection is transmitted by black flies, which breed along the banks of rapidly flowing rivers and streams. In Bra­zil, onchocerciasis is reported among the indigenous Yanomami population living along the Venezuelan border, as well as in nearby tribes and non-Indians visiting the area. Most cases occur near swift-flowing streams in densely forested highlands.

style="font-weight:bold;">Venezuelan equine encephalitis which is transmitted by mosquitoes and causes brain inflammation, occurs sporadically.

Cases of 'caterpillar plague' were reported from the Amazon delta region between 1983 and 1985 and from southern Brazil in 1995. The disease is caused by contact with the larvae (caterpillars) of the butterfly Lamo­nia achelous, which secrete venom through their skins. The illness is characterized by high fever, bleeding from the nose and ears, kidney failure and death. The caterpillar is found from December through March. The adult and pupal forms are harmless.

style="font-weight:bold;">HIV/AIDS is a big problem in Brazil. An estimated 600,000 Brazilians carry the virus. Be sure to use condoms for all sexual encounters.

TRAVELER'S DIARRHEA

To prevent diarrhea, avoid tap water un­less it has been boiled, filtered or chem­ically disinfected (iodine tablets); only eat fresh fruits and vegetables if they are cooked or peeled; be wary of dairy prod­ucts that may contain unpasteurized milk; and be highly selective when eating food from street vendors.

If you develop diarrhea, be sure to drink plenty of fluids, preferably an oral rehy­dration solution containing lots of salt and sugar. A few loose stools don't require treat­ment, but it you start having more than four or five stools a day you should start taking an antibiotic (usually a quinolone drug) and an antidiarrheal agent (such as loperamide).

If diarrhea is bloody, persists for more than 72 hours or is accompanied by fever, shaking chills or severe abdominal pain, you should seek medical attention.

ENVIRONMENTAL HAZARDS

Animal Bites

Do not attempt to pet, handle or feed any animal, with the exception of domestic animals known to be free of any infectious disease. Most animal injuries are directly related to a person's attempt to touch or feed the animal.

Any bite or scratch from a mammal, including bats, should be promptly and thoroughly cleansed with large amounts of soap and water, followed by application of an antiseptic such as iodine or alcohol. The local health authorities should be contacted immediately for possible post­exposure rabies treatment, whether or not you've been immunized against rabies. It may also be advisable to start an antibi­otic, since wounds caused by animal bites and scratches frequently become infected. One of the newer quinolones, such as levo­floxacin (Levaquin), which many travelers carry in case of diarrhea, would be an ap­propriate choice.

Insect Bites & Stings

To prevent mosquito bites, wear long sleeves, long pants, hats and shoes (rather than sandals). Bring along a good insect repellent, preferably one containing DEET, which should be applied to exposed skin and clothing, but not to eyes, mouth, cuts, wounds or irritated skin. Product containing lower concentrations of DEET are as effective, but for shorter periods of time in general, adults and children over the age of 12 should use preparations containing 25% to 35% DEFT, which usually last about six hours. Children between two and 12 years of age should use preparations containing no more than 10% DEFT, applied sparingly, which will usually last about three hours. Neurologic toxicity has been reported from DEET, especially in children, but appears to be extremely uncommon and gener­ally related to overuse. DEET-containing compounds should not be used on children under the age of two.

Insect repellents containing certain bo­tanical products, including oil of eucalyp­tus and soybean oil, are effective but last only 1'/z to two hours. DEET-containing repellents are preferable for areas where there is a high risk of malaria or yellow fever. Products based on citronella are not effective.

For additional protection, you can apply permethrin to clothing, shoes, tents and bed nets. Permethrin treatments are safe and remain effective for at least two weeks, even when items are laundered. Permethrin should not be applied directly to skin.

Don't sleep with the window open unless there is a screen in the windowframe. If sleeping outdoors or in accommodations that allow entry of mosquitoes, use a bed net, preferably treated with permethrin, with edges tucked in under the mattress. The mesh size should be smaller than 1.5mm. If the sleeping area is not otherwise protected, use a mosquito coil, which will fill the room with insecticide throughout the night. Repellent-impregnated wrist­bands are not effective.

Snake Bites

Snakes and leeches are a hazard in some areas of South America. In the event of a venomous snake bite, place the victim at rest, keep the bitten area immobilized and move the victim immediately to the nearest medical facility. Avoid tourniquets, which are no longer recommended.

Sun

To protect yourself from excessive sun ex­posure, you should stay out of the midday sun, wear sunglasses and a wide-brimmed sun hat, and apply sunscreen with SPF15 or higher, with both UVA and UVB protection. Sunscreen should be generously applied to all exposed parts of the body approximately 30 minutes before sun exposure and should be reapplied after swimming or vigorous activity. Travelers should also drink plenty of fluids and avoid strenuous exercise when the temperature is high.

Water

Tap water in Brazil is not safe to drink. Vigorous boiling for one minute is the most effective means of water purification. At altitudes greater than 2000m (6500ft), boil for three minutes.

Another option is to disinfect water with iodine pills. Instructions are usually enclosed and should be carefully followed. Or you can add 2% tincture of iodine to one quart or liter of water (five drops to clear water, 10 drops to cloudy water) and let stand for 30 minutes. If the water is cold, longer times may be required. The taste of iodinated water may be improved by add­ing vitamin C (ascorbic acid). Iodinated water should not be consumed for more than a few weeks. Pregnant women, those with a history of thyroid disease, and those allergic to iodine should not drink iodi­nated water.

A number of water filters are on the market. Those with smaller pores (reverse osmosis filters) provide the broadest pro­tection, but they are relatively large and are readily plugged by debris. Those with somewhat larger pores (microstrainer filters) are ineffective against viruses, al­though they remove other organisms. Manufacturers' instructions must be care­fully followed.

TRAVELING WITH CHILDREN

In general, children under the age of nine months should not be brought to areas where yellow fever occurs, since the vac­cine is not safe in this age group.

When traveling with young children, be particularly careful about what you allow them to eat and drink, because diarrhea can be especially dangerous in this age group and because the vaccines for hepatitis A and typhoid fever are not approved for use in children who are under the age of two years.

The two main malaria medications, Lar­iarn and Malarone, may be given to chil­dren, but insect repellents must be applied in lower concentrations.

TRAVELING WHILE PREGNANT

You can find an English-speaking obstetri­cian near your location in Brazil by going to the US embassy website at www.emb ixada-americana.org.br . However, medical facilities will probably not be comparable to those in your home country. It's safer to avoid travel to Brazil late in pregnancy, so that you don't have to risk delivering there.

If pregnant, it's preferable to avoid areas where yellow fever occurs, since the vaccine is not safe during pregnancy.

For malaria prevention, mefloquine (Lariam) is the safest during pregnancy.