Monday, 11 August 2008

Vaccinations Rio De Janeiro

Summary of recommendations:
The following recommendations are for short-term trips originating in North America or Europe and limited to Rio. For all other trips, please see Brazil (complete). All travelers should visit either their personal physician or a travel health clinic 4-8 weeks before departure.

Vaccinations: Hepatitis A Recommended for all travelers
Typhoid For travelers who may eat or drink outside major restaurants and hotels
Measles, mumps, rubella (MMR) Two doses recommended for all travelers born after 1956, if not previously given
Tetanus-diphtheria Revaccination recommended every 10 years


Medications
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.


Immunizations
The following are the recommended vaccinations for Rio.
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.
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.

Recent outbreaks
An outbreak of dengue fever, a flu-like illness sometimes complicated by hemorrhage or shock, began in January 2002, chiefly affecting the state of Rio de Janeiro. More than 780,000 cases of dengue fever were reported for the year, including 2607 cases of dengue hemorrhagic fever and 145 deaths. See the World Health Organization and ProMED-mail (February 8 and March 1, 8, 15, 22, and 31, 2002) for details. The number of cases declined sharply by April 2002. However, more than 250,000 cases of dengue were reported during the first seven months of 2003. Dengue fever is transmitted by Aedes mosquitoes, which bite primarily in the daytime and favor densely populated areas, though they also inhabit rural environments. No vaccine is available at this time. Insect protection measures are strongly advised, as below.
The largest previous dengue outbreak occurred in 1998, when more then 500,000 people were affected and all urban areas and all but four states/territories were involved. The southeast region was most affected, especially the States of Minas Gerais and Espirito Santo. The number of cases fell in 1999, but has been climbing sharply ever since. In 2000, Brazil reported 210,289 cases of dengue fever, including 40 cases of dengue hemorrhagic fever. In 2001, the number of cases of dengue fever rose to 390,701, and the number of cases of dengue hemorrhagic fever climbed to 675.

Other infections
HIV (human immunodeficiency virus) infection is reported, but travelers are not at risk unless they have unprotected sexual contacts or receive injections or blood transfusions.
Other infections include
• Leptospirosis (mainly urban areas; chief animal hosts are rodents, dogs, pigs, and mice)
• Cutaneous and mucocutaneous leishmaniasis (occurring in suburban areas in Rio de Janeiro and Sao Paulo)
• Visceral leishmaniasis (chiefly in the Northeast) (see Jorge Arias et al., The Reemergence of Visceral Leishmaniasis in Brazil (Emerging Infectious Diseases Vol. 2/No. 2 | April-June 1996)
• Brucellosis (the most common animal source is infected cattle)
For an overview, see Emerging Infectious Diseases--Brazil by Dr. Hooman Momen (Emerging Infectious Diseases Vol. 4./No. 1 January-March 1998).

Food and water precautions
Do not drink tap water unless it has been boiled, filtered, or chemically disinfected. Do not drink unbottled beverages or drinks with ice. Do not eat fruits or vegetables unless they have been peeled or cooked. Avoid cooked foods that are no longer piping hot. Cooked foods that have been left at room temperature are particularly hazardous. Avoid unpasteurized milk and any products that might have been made from unpasteurized milk, such as ice cream. Avoid food and beverages obtained from street vendors. Do not eat raw or undercooked meat or fish, including ceviche. Some types of fish may contain poisonous biotoxins even when cooked. Barracuda in particular should never be eaten. Other fish that may contain toxins include red snapper, grouper, amberjack, and sea bass.
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 accompanied by nausea, vomiting, cramps, fever or blood in the stool. Antibiotics which have been shown to be effective include ciprofloxacin (Cipro), levofloxacin (Levaquin), rifaximin (Xifaxan), or azithromycin (Zithromax). Either loperamide (Imodium) or diphenoxylate (Lomotil) should be taken in addition to the antibiotic to reduce diarrhea and prevent dehydration.
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.

Insect and tick protection
Wear long sleeves, long pants, hats and shoes (rather than sandals). Apply insect repellents containing 25-50% DEET (N,N-diethyl-3-methylbenzamide) or 20% picaridin (Bayrepel) to exposed skin (but not to the eyes, mouth, or open wounds). DEET may also be applied to clothing. Products with a lower concentration of either repellent need to be repplied more frequently. Products with a higher concentration of DEET carry an increased risk of neurologic toxicity, especially in children, without any additional benefit. Do not use either DEET or picaridin on children less than two years of age. For additional protection, apply permethrin-containing compounds to clothing, shoes, and bed nets. Permethrin-treated clothing appears to have little toxicity. Don't sleep with the window open unless there is a screen. If sleeping outdoors or in an accomodation that allows entry of mosquitoes, use a bed net, preferably impregnated with insect repellent, with edges tucked in under the mattress. The mesh size should be less than 1.5 mm. If the sleeping area is not otherwise protected, use a mosquito coil, which fills the room with insecticide through the night.

Swimming and bathing precautions
Avoid swimming, wading, or rafting in bodies of fresh water, such as lakes, ponds, streams, or rivers. Do not use fresh water for bathing or showering unless it has been heated to 150 degrees F for at least five minutes or held in a storage tank for at least three days. Toweling oneself dry after unavoidable or accidental exposure to contaminated water may reduce the likelihood of schistosomiasis, but does not reliably prevent the disease and is no substitute for the precautions above. Chlorinated swimming pools are considered safe.


General advice
Bring adequate supplies of all medications in their original containers, clearly labeled. Carry a signed, dated letter from the primary physician describing all medical conditions and listing all medications, including generic names. If carrying syringes or needles, be sure to carry a physician's letter documenting their medical necessity.Pack all medications in hand luggage. Carry a duplicate supply in the checked luggage. If you wear glasses or contacts, bring an extra pair. If you have significant allergies or chronic medical problems, wear a medical alert bracelet.
Make sure your health insurance covers you for medical expenses abroad. If not, supplemental insurance for overseas coverage, including possible evacuation, should be seriously considered. If illness occurs while abroad, medical expenses including evacuation may run to tens of thousands of dollars. For a list of travel insurance and air ambulance companies, go to Medical Information for Americans Traveling Abroad on the U.S. State Department website. Bring your insurance card, claim forms, and any other relevant insurance documents. Before departure, determine whether your insurance plan will make payments directly to providers or reimburse you later for overseas health expenditures. The Medicare and Medicaid programs do not pay for medical services outside the United States.
Pack a personal medical kit, customized for your trip (see description). Take appropriate measures to prevent motion sickness and jet lag, discussed elsewhere. On long flights, be sure to walk around the cabin, contract your leg muscles periodically, and drink plenty of fluids to prevent blood clots in the legs. For those at high risk for blood clots, consider wearing compression stockings.
Avoid contact with stray dogs and other animals. If an animal bites or scratches you, clean the wound with large amounts of soap and water and contact local health authorities immediately. Wear sun block regularly when needed. Use condoms for all sexual encounters. Ride only in motor vehicles with seat belts. Do not ride on motorcycles.

Ambulance services
For an ambulance in Brazil, call 193.

Physicians and hospitals
For an on-line list of physicians and hospitals, go to the U.S. Embassy website (click on U.S. Citizen Services from the menu at the top). The costs of medical treatment are considerably higher in Brazil than in most parts of the United States for similar care or treatment. Most physicians and hospitals expect payment at time of service.

Medical facilities (reproduced from the U.S. State Dept. Consular Information Sheet)
Medical care is generally good, but it varies in quality, particularly in remote areas, and it may not meet U.S. standards outside the major cities. The Albert Einstein Hospital in Sao Paulo is regularly used by U.S. Government personnel and other expatriates from throughout Brazil. The hospital phone is (55-11) 3747-1301.

Traveling with children
Make sure you have the names and contact information for qualified medical personnel in Brazil before you go abroad (see the U.S. Embassy website).
In general, the recommendations for infants and young children are the same as those for adults, except that certain vaccines and medications should not be administered to this age group. Most importantly, yellow fever vaccine is not approved for use in those under age nine months. Unless there is an extraordinary need to do so, children less than nine months of age should not be brought to areas where yellow fever occurs.
Food and water precautions, which are recommended for all travelers, must be strictly followed at all times, because diarrhea is especially dangerous in this age group and because the vaccines for hepatitis A and typhoid fever are not approved for children less than two years of age.
All children should be up-to-date on routine childhood immunizations, as recommended by the American Academy of Pediatrics. Children who are 12 months or older should receive a total of 2 doses of MMR (measles-mumps-rubella) vaccine, separated by at least 28 days, before international travel. Children between the ages of 6 and 11 months should be given a single dose of measles vaccine. MMR vaccine may be given if measles vaccine is not available, though immunization against mumps and rubella is not necessary before age one unless visiting a country where an outbreak is in progress. Children less than one year of age may also need to receive other immunizations ahead of schedule (see the accelerated immunization schedule).


Travel and pregnancy
International travel should be avoided by pregnant women with underlying medical conditions, such as diabetes or high blood pressure, or a history of complications during previous pregnancies, such as miscarriage or premature labor. For pregnant women in good health, the second trimester (18–24 weeks) is probably the safest time to go abroad and the third trimester the least safe, since it's far better not to have to deliver in a foreign country.
Before departure, make sure you have the names and contact information for physicians, clinics, and hospitals where you can obtain emergency obstetric care if necessary (see the U.S. Embassy website). In general, pregnant women should avoid traveling to countries which do not have modern facilities for the management of premature labor and other complications of pregnancy.
Yellow fever vaccine, which consists of live virus, should not in general be given to pregnant women. Unless absolutely necessary, pregnant women should not travel to areas where yellow fever occurs.
Strict attention to food and water precautions is especially important for the pregnant traveler because some infections, such as listeriosis, have grave consequences for the developing fetus. Additionally, many of the medications used to treat travelers' diarrhea may not be given during pregnancy. Quinolone antibiotics, such as ciprofloxacin (Cipro) and levofloxacin (Levaquin), should not be given because of concern they might interfere with fetal joint development. Data are limited concerning trimethoprim-sulfamethoxazole, but the drug should probably be avoided during pregnancy, especially the first trimester. Options for treating travelers' diarrhea in pregnant women include azithromycin and third-generation cephalosporins. For symptomatic relief, the combination of kaolin and pectin (Kaopectate; Donnagel) appears to be safe, but loperamide (Imodium) should be used only when necessary. Adequate fluid intake is essential.

Maps
Helpful maps are available in the University of Texas Perry-Castaneda Map Collection and the United Nations map library. If you have the name of the town or city you'll be visiting and need to know which state or province it's in, you might find your answer in the Getty Thesaurus of Geographic Names.

2 comments:

Tim said...

We have found that the best and easiest way to protect travel is the Air Rescue Card by Travel Assist Network. They bring you home if you need an Air Ambulance. Their webiste is www.travelassistnetwork.com

Zithromax Side Effects said...

My name is Wesley Brown and i would like to show you my personal experience with Zithromax.

I am 45 years old. Have been on Zithromax for 2 days now. I took this drug (generic azithro 500 mg bid) to get rid of an 2+ week old sinus infection that did not clear with decongestants and antihistamines. The drug made a substantial difference within 2 days. I'm a physician and needed to return to work, and the tiredness was just excessive, so I stopped the drug after 48-72 hours. The infection did not return. I would take this drug again if I needed to kill off an infection. I don't expect to feel good all the time. If a drug is making me healthy in a particular way, it's up to me to weigh that benefit against the cost of side effects.

I have experienced some of these side effects -
Fatigue. I just didn't want to move or get out of bed while on the drug; it was a bit hard to figure out that this was an effect of the medication rather than the sinusitis. Otherwise I was fine.

I hope this information will be useful to others,
Wesley Brown