Summary of recommendations:
All travelers should visit either their personal physician or a travel health clinic 4-8 weeks before departure.
Malaria: Prophylaxis with Lariam, Malarone, or doxycycline is recommended for the states of Acre, Amapa, Amazonas, Maranhao (western part), Mato Grosso (northern part), Para (except Belem City), Rondonia, Roraima, and Tocantins, and for urban areas within these states, including the cities of Porto Velho, Boa Vista, Macapa, Manaus, Santarem, and Maraba.
Vaccinations: Hepatitis A Recommended for all travelers
Typhoid For travelers who may eat or drink outside major restaurants and hotels
Yellow fever Recommended for the northern part of Espiritu Santo and the western part of Santa Catarina; all areas in the states of Acre, Amapa, Amazones, Goias, Maranhao, Mato Grosso, Mato Grosso do Sol, Minas Gerais, Para, Rondonia, Roraima, and Tocantins; parts of the states of Bahia, Parana, Piaui, Rio Grande do Sul; the Federal District of Brasilia; and Sao Paulo. Required for travelers arriving from a yellow-fever-infected area in Africa or the Americas.
Hepatitis B For travelers who may have intimate contact with local residents, especially if visiting for more than 6 months
Rabies For travelers who may have direct contact with animals and may not have access to medical care
Measles, mumps, rubella (MMR) Two doses recommended for all travelers born after 1956, if not previously given
Tetanus-diphtheria Revaccination recommended every 10 years
Travelers' diarrhea is the most common travel-related ailment. The cornerstone of prevention is food and water precautions, as outlined below. All travelers should bring along an antibiotic and an antidiarrheal drug to be started promptly if significant diarrhea occurs, defined as three or more loose stools in an 8-hour period or five or more loose stools in a 24-hour period, especially if associated with nausea, vomiting, cramps, fever or blood in the stool. A quinolone antibiotic is usually prescribed: either ciprofloxacin (Cipro)(PDF) 500 mg twice daily or levofloxacin (Levaquin) (PDF) 500 mg once daily for a total of three days. Quinolones are generally well-tolerated, but occasionally cause sun sensitivity and should not be given to children, pregnant women, or anyone with a history of quinolone allergy. Alternative regimens include a three day course of rifaximin (Xifaxan) 200 mg three times daily or azithromycin (Zithromax) 500 mg once daily. Rifaximin should not be used by those with fever or bloody stools and is not approved for pregnant women or those under age 12. Azithromycin should be avoided in those allergic to erythromycin or related antibiotics. An antidiarrheal drug such as loperamide (Imodium) or diphenoxylate (Lomotil) should be taken as needed to slow the frequency of stools, but not enough to stop the bowel movements completely. Diphenoxylate (Lomotil) and loperamide (Imodium) should not be given to children under age two.
Most cases of travelers' diarrhea are mild and do not require either antibiotics or antidiarrheal drugs. Adequate fluid intake is essential.
If diarrhea is severe or bloody, or if fever occurs with shaking chills, or if abdominal pain becomes marked, or if diarrhea persists for more than 72 hours, medical attention should be sought.
Though effective, antibiotics are not recommended prophylactically (i.e. to prevent diarrhea before it occurs) because of the risk of adverse effects, though this approach may be warranted in special situations, such as immunocompromised travelers.
Malaria in Brazil: prophylaxis is recommended for the states of Acre, Amapa, Amazonas, Maranhao (western part), Mato Grosso (northern part), Para (except Belem City), Rondonia, Roraima, and Tocantins, and for urban areas within these states, including the cities of Porto Velho, Boa Vista, Macapa, Manaus, Santarem, and Maraba, where transmission occurs on the periphery. Transmission 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." For a map showing the risk of malaria in different parts of the country, go to the Pan American Health Organization.
Either mefloquine (Lariam), atovaquone/proguanil (Malarone)(PDF), or doxycycline may be given. Mefloquine is given once weekly in a dosage of 250 mg, starting one-to-two weeks before arrival and continuing through the trip and for four weeks after departure. Side-effects, which are typically mild, may include nausea, vomiting, dizziness, insomnisa, and nightmares. Rarely, severe reactions occur, including depression, anxiety, psychosis, hallucinations, and seizures. Mefloquine should not be given to anyone with a history of seizures, psychiatric illness, cardiac conduction disorders, or allergy to quinine or quinidine. Those taking mefloquine (Lariam) should read the Lariam Medication Guide (PDF). Atovaquone/proguanil (Malarone) is a recently approved combination pill taken once daily with food starting two days before arrival and continuing through the trip and for seven days after departure. Malarone may cause abdominal pain, nausea, vomiting, headache, diarrhea, or dizziness, though usually mild. Serious adverse reactions are rare. Doxycycline is effective, but may cause an exaggerated sunburn reaction, which limits its usefulness in the tropics.
Long-term travelers who will be visiting malarious areas and may not have access to medical care should bring along medications for emergency self-treatment should they develop symptoms suggestive of malaria, such as fever, chills, headaches, and muscle aches, and cannot obtain medical care within 24 hours. See malaria for details. Symptoms of malaria sometimes do not occur for months or even years after exposure.
Insect protection measures are essential.
Travelers visiting only the coastal states from the horn to the Uruguay border and Iguacu Falls do not need prophylaxis.
For further information about malaria in Brazil, go to the World Health Organization.
The following are the recommended vaccinations for Brazil.
Hepatitis A vaccine is recommended for all travelers over one year of age. It should be given at least two weeks (preferably four weeks or more) before departure. A booster should be given 6-12 months later to confer long-term immunity. Two vaccines are currently available in the United States: VAQTA (Merck and Co., Inc.) (PDF) and Havrix (GlaxoSmithKline) (PDF). Both are well-tolerated. Side-effects, which are generally mild, may include soreness at the injection site, headache, and malaise.
Older adults, immunocompromised persons, and those with chronic liver disease or other chronic medical conditions who have less than two weeks before departure should receive a single intramuscular dose of immune globulin (0.02 mL/kg) at a separate anatomic injection site in addition to the initial dose of vaccine. Travelers who are less than one year of age or allergic to a vaccine component should receive a single intramuscular dose of immune globulin (see hepatitis A for dosage) in the place of vaccine.
Typhoid vaccine is recommended for all travelers, with the exception of short-term visitors who restrict their meals to major restaurants and hotels, such as business travelers and cruise passengers. It is generally given in an oral form (Vivotif Berna) consisting of four capsules taken on alternate days until completed. The capsules should be kept refrigerated and taken with cool liquid. Side-effects are uncommon and may include abdominal discomfort, nausea, rash or hives. The alternative is an injectable polysaccharide vaccine (Typhim Vi; Aventis Pasteur Inc.) (PDF), given as a single dose. Adverse reactions, which are uncommon, may include discomfort at the injection site, fever and headache. The oral vaccine is approved for travelers at least six years old, whereas the injectable vaccine is approved for those over age two. There are no data concerning the safety of typhoid vaccine during pregnancy. The injectable vaccine (Typhim Vi) is probably preferable to the oral vaccine in pregnant and immunocompromised travelers.
Yellow fever vaccine is recommended for all those greater than nine months of age traveling to areas in Brazil where yellow fever occurs, which includes the northern part of Espiritu Santo and the western part of Santa Catarina; all areas in the states of Acre, Amapa, Amazones, Goias, Maranhao, Mato Grosso, Mato Grosso do Sol, Minas Gerais, Para, Rondonia, Roraima, and Tocantins; parts of the states of Bahia, Parana, Piaui, Rio Grande do Sul (including the region of Target); the Federal District of Brasilia; and Sao Paulo (see the CDC map for details). A yellow fever alert was issued in January 2008 (see "Recent outbreaks" below). Yellow fever vaccine is recommended for Iguacu Falls, but is not necessary for the coastal cities, including Rio de Janeiro, Sao Paulo, Salvador, Recife, and Fortaleza.
Yellow fever vaccine is required for travelers greater than nine months of age arriving from a yellow-fever-infected country in Africa or the Americas. The vaccine is also required for travelers arriving from
Africa: Angola, Cameroon, Democratic Republic of Congo, Gabon, The Gambia, Ghana, Guinea, Liberia, Nigeria, Sierra Leone, and Sudan.
Americas: Bolivia, Columbia, Ecuador, and Peru.
In March 2002, an unvaccinated Texas man died from yellow fever after a 6-day fishing trip on the Rio Negro west of Manaus in the state of Amazonas. In 1996, a Tennessee resident died from yellow fever contracted during a nine-day trip along the Rio Negro and Amazon rivers. Yellow fever has also been reported from the states of Amapa, Goias, Maranhao, Mato Grosso, Minas Gerais, Para, Roraima, Sao Paulo, and Tocantins. For further details on yellow fever in Brazil, go to the Pan-American Health Organization (PDF).
Yellow fever vaccine (YF-VAX; Aventis Pasteur Inc.) (PDF) must be administered at an approved yellow fever vaccination center , which will give each vaccinee a fully validated International Certificate of Vaccination. Reactions to the vaccine, which are generally mild, include headaches, muscle aches, and low-grade fevers. Serious allergic reactions, such as hives or asthma, are rare and generally occur in those with a history of egg allergy. The vaccine should not in general be given to those who are younger than nine months of age, pregnant, immunocompromised, or allergic to eggs.
Hepatitis B vaccine is recommended for travelers who will have intimate contact with local residents or potentially need blood transfusions or injections while abroad, especially if visiting for more than six months. It is also recommended for all health care personnel. Two vaccines are currently licensed in the United States: Recombivax HB (Merck and Co., Inc.) (PDF) and Engerix-B (GlaxoSmithKline) (PDF). A full series consists of three intramuscular doses given at 0, 1 and 6 months. Engerix-B is also approved for administration at 0, 1, 2, and 12 months, which may be appropriate for travelers departing in less than 6 months. Side-effects are generally mild and may include discomfort at the injection site and low-grade fever. Severe allergic reactions (anaphylaxis) occur rarely.
Rabies vaccine is recommended only for those at high risk for animal bites, such as veterinarians and animal handlers, and for long-term travelers who may have contact with animals and may not have access to medical care. Rabies vaccine should also be considered for those making extended trips to remote areas in the northeastern and northern regions of the country, where most cases occur. In the past, most cases of rabies in Brazil were related to dog bites in urban areas. However, since 2004, most have been transmitted by bats in rural parts of the states of Pará and Maranhão (see "Recent outbreaks" below). A complete preexposure series consists of three doses of vaccine injected into the deltoid muscle on days 0, 7, and 21 or 28. Side-effects may include pain at the injection site, headache, nausea, abdominal pain, muscle aches, dizziness, or allergic reactions.
Any animal bite or scratch should be thoroughly cleaned with large amounts of soap and water and local health authorities should be contacted immediately for possible post-exposure treatment, whether or not the person has been immunized against rabies.
Tetanus-diphtheria vaccine is recommended for all travelers who have not received a tetanus-diphtheria immunization within the last 10 years.
Measles-mumps-rubella vaccine: two doses are recommended (if not previously given) for all travelers born after 1956, unless blood tests show immunity. Many adults born after 1956 and before 1970 received only one vaccination against measles, mumps, and rubella as children and should be given a second dose before travel. MMR vaccine should not be given to pregnant or severely immunocompromised individuals.
Cholera vaccine is not generally recommended. Only seven cases were reported for the year 2001 and none in 2002. Most travelers are at extremely low risk for infection. Two oral vaccines have recently been developed: Orochol (Mutacol), licensed in Canada and Australia, and Dukoral, licensed in Canada, Australia, and the European Union. These vaccines, where available, are recommended only for high-risk individuals, such as relief workers, health professionals, and those traveling to remote areas where cholera epidemics are occurring and there is limited access to medical care. The only cholera vaccine approved for use in the United States is no longer manufactured or sold, due to low efficacy and frequent side-effects.
In November 1998, a cholera outbreak was reported from Cortez municipality in the region of Mata-Sul, Pernambuco State, in the northeastern part of the country. The source of infection was thought to be the Rio Sirinhaem, which supplies 80% of the water used by the population. Another outbreak occurred in the municipality of Paranagua, Parana State, in March 1999.
Polio vaccine is not recommended for any adult traveler who completed the recommended childhood immunizations. Polio has been eradicated from the Americas, except for a small outbreak of vaccine-related poliomyelitis in the Dominican Republic and Haiti in late 2000.