Brazil Health Risk Overview

Health Risk Rating: Moderate

Travel Health Advice

Routine vaccines for preventable diseases, such as measles/mumps/rubella (MMR) vaccine, diphtheria/pertussis/tetanus (DPT) vaccine, chickenpox (or varicella), poliovirus vaccine, etc. are recommended for all travelers.

Protect against insect bites and insect-borne diseases, such as tick-borne encephalitis or malaria, by using insect repellant and wearing long pants, long sleeve shirts, boots, and hats if possible. See more detailed insect precautions below.

Prevent foodborne illnesses by avoiding undercooked foods and unpasteurized dairy products and washing hands, especially before eating. See more detailed food and beverage precautions below.

A comprehensive pre-travel health consultation with a travel health care provider is recommended for all travelers in order to optimize their health while traveling and to individualize their disease prevention strategies to best mitigate the health risks of any destination.

Immunizations – Required for Entry

The following vaccines are required for travelers entering the country. Some vaccines may only be required for travelers arriving from specific destinations, or those who have previously traveled to specific destinations within a given time period. Travelers are advised to consult with their travel healthcare provider for traveler-specific requirements.

None – There are no immunizations required for entry into Brazil.

The following immunizations are recommended for travel to all destinations.

Routine
Routine vaccines for preventable diseases, such as measles/mumps/rubella (MMR) vaccine, diphtheria/pertussis/tetanus (DPT) vaccine, chickenpox (or varicella), poliovirus vaccine, etc. are recommended for all travelers.

Hepatitis B
Hepatitis B is spread through contact with infected blood, sexual relations, and contact with contaminated needles.

Influenza
All types of Influenza are spread between humans by respiratory droplets through sneezing, coughing, and touching objects contaminated with the virus.

There are 2 types of pre-exposure vaccinations available: Inactivated Influenza Vaccine (IIV), and Live Intranasal Influenza Vaccine (LAIV). IIV is injected into the upper arm or thigh, and LAIV is administered as a nasal spray. Components of the vaccine change yearly, depending on anticipated circulating strains of the virus, which vary by hemisphere. Vaccination is recommended annually for all persons at least 6 months of age, prior to transmission season.
Immunizations – Recommended for this Country

The following are vaccine preventable diseases present in this country. Some travelers may be at an increased risk of exposure to specific diseases. Travelers are advised to consult with their travel healthcare provider for traveler- and itinerary- specific recommendations.

Hepatitis A Virus (HAV)
The Hepatitis A virus is primarily transmitted through contaminated water and food such as shellfish and uncooked vegetables or fruit prepared by infected food handlers. It is also transmitted through person-to-person contact via fecal-oral exposure, or spread through sexual relations, blood transfusions, and needles.

Several pre-exposure vaccination options are available: HAVRIX, VAQTA, TWINRIX (3-dose HepA/HepB combination series), and AVAXIM. The vaccine requires 2 doses, separated by a minimum of 6 months. Ideally, the traveler should complete both doses at least 2 weeks prior to travel. However, if there is insufficient lead time to travel, the first injection should be administered before departure and a booster after 6 months. Once both doses are completed, immunity is considered lifelong.

Typhoid Fever
Typhoid is a bacterial infection spread through the ingestion of contaminated food or water.

Vaccination should be completed 1-2 weeks before travel, depending on the form of the vaccine given. Two forms of the vaccine are available: an inactivated shot (1 dose), and a live oral vaccine (4 capsules given over 8 days). Booster doses of vaccine are needed for ongoing protection. The interval will vary depending on the form of the vaccine and the traveler’s country of vaccination. Vaccination recommendations vary by country, activities, and specific itinerary. Consult a travel health professional for individual advice.

Yellow Fever (YF)
YF is a viral infection spread through the bite of an infected mosquito.

Vaccination is typically recommended for travel to countries where YF is present and transmission is possible. The vaccination recommendations are complex and change frequently to remain up-to-date with the epidemiology of the disease.

A travel health professional can advise if YF vaccine is indicated for a specific travel itinerary. YF vaccine can be given to most adults and children over 9 months, and should be administered at least 10 days before travel. YF vaccine is considered effective for life; however, there is some uncertainty regarding universal country recognition of this lifetime validity.

Rabies
Rabies is spread through the bite or scratch of an infected animal. All mammals are susceptible, but dogs and other wildlife (particularly bats) are the most common vectors.

A 3-dose pre-exposure rabies vaccine is recommended for long-term travelers and expatriates visiting remote areas. It is also recommended for travelers involved in adventure or outdoor activities in remote areas who could be exposed to bats, dogs, and other mammals and those who might be in direct contact with animals, including in urban areas. Children are at higher risk and have a lower threshold for pre-exposure vaccination. The first dose of the vaccine should be administered at least 21 days before travel.

Influenza Virus (Flu)
Classic, or seasonal, influenza, is a highly contagious respiratory infection, caused by 2 types of virus: A and B. All types of Influenza are spread between humans by respiratory droplets through sneezing, coughing, and touching objects contaminated with the virus.

Hepatitis B Virus (HBV)
Hepatitis B is spread through contact with infected blood, sexual relations, and contact with contaminated needles.

There are several pre-exposure vaccination options available: PEDIARIX (pediatric formulation containing DTaP, HepA/B, and polio vaccines), TWINRIX (3 dose HepA/HepB combination series), ENGERIX-B, RECOMBIVAX HB (3 doses); Heplisav-B (2 doses). The full course of injections is recommended prior to travel. Unvaccinated travelers who have been exposed to HBV should seek medical attention immediately. They should receive a dose of Hep B vaccine within 24 hours of the exposure, and may benefit from treatment with Hep B immunoglobulin as well. Vaccination is routine in the US and many other countries. Previously unvaccinated travelers should consider vaccination for travel to areas with high risk of HBV infection, or if they anticipate needing medical/dental care abroad, being exposed to needles, or engaging in sexual activity.

Meningococcal Disease
Meningococcal disease is spread through contact with the respiratory secretions of an infected person, as well as sharing food and drinks.

Meningococcal conjugate vaccine (MCV4) can be given to all persons at least 2 months of age. Dosing will vary depending on the product and the age of the traveler.
Health Risks

The following are health risks present in the country. Some of these health risks are widespread, while others may only affect travelers in specific areas or those engaging in specific activities. Travelers are advised to consult with their travel healthcare provider for traveler- and itinerary- specific recommendations.

Health Risks

Air Pollution
Air pollution refers to the potentially hazardous mix of particulate matter, chemicals, and other materials that infiltrates the air and causes acute symptoms and chronic conditions. Acute symptoms include itching of the eyes, nose, and throat, as well as wheezing, coughing, shortness of breath, chest pain, headaches, nausea, and upper respiratory infections (bronchitis and pneumonia). Air pollution is increasing in low- and middle- income countries and has become a major concern for travelers.

Travelers with chronic lung conditions such as asthma or chronic obstructive pulmonary disease COPD should consult with their physicians prior to travel to areas with poor air quality, and these populations should reduce outdoor exertion. Elderly travelers and infants are also more at risk for respiratory consequences of exposure to air pollution. All travelers should comply with air pollution advisories. Levels of air pollution will vary by city and region; check current levels prior to travel to appropriately target preventive measures.

Chagas Disease (American trypanosomiasis)
Chagas disease is a parasitic disease caused by the Trypanosoma protozoa. Nonhuman mammals are the primary hosts, and certain species of reduviid insects (kissing bugs) serve as vector. The disease starts with local redness and swelling at the site of inoculation, and progresses through generalized systemic symptoms. Approximately 20-30% of patients will develop cardiac and/or neurologic symptoms.

Chagas disease is spread via inoculation by the reduviid bug through the mucus membranes, broken skin, or the eye. Kissing bugs can reside in buildings made of mud, adobe, or palm thatch, and it is in these habitats that they most often come into contact with humans. Transmission also occurs through blood transfusion, orally, and by ingestion of food or juices contaminated with infected bugs or their feces. Travelers are generally at low risk but those undertaking outdoor activities and ecotourism in endemic countries are at higher risk.

There is no vaccine to prevent against Chagas disease. Avoid sleeping in mud, adobe, or palm thatch buildings. Use bed nets when sleeping outdoors or camping in endemic areas. Avoid unpasteurized juices and eat only well-cooked foods or fruit that can be peeled. Avoid blood transfusions in rural hospitals in endemic areas unless in a life-threatening emergency. Treatment with antitrypanosomal drugs is required for Chagas disease. Seek medical attention if illness is suspected.

Chikungunya
Chikungunya is a viral infection acquired by humans through the bite of an infected mosquito. Chikungunya has been a predominately urban/suburban disease, but expanding development is encouraging spread into more rural areas. Not all infected persons exhibit symptoms, but persons may experience sudden joint pain and fever, as well as headache, rash, and vomiting.

Chikungunya is spread through the bite of an infected Aedes mosquito. Highest risk occurs during the rainy season. The Aedes mosquito is day-biting, with particular activity 2-3 hours after dawn, and from mid-to-late afternoon.

There is no vaccine to prevent against Chikungunya, but taking proper precautions against mosquito and insect bites may help prevent against transmission (see Insect Precautions below). No specific treatment exists for Chikungunya infection, but supportive care can be helpful to ease the symptoms. Seek medical attention if Chikungunya is suspected, as it is important to rule out other treatable or more serious infections that might be present, such as dengue or malaria.

Dengue Fever
Dengue fever is a mosquito-borne viral infection. Symptoms include headache, sudden-onset fever, rash, and joint pain. Some cases progress to severe dengue, when significant bleeding, fluid shifts, and end organ damage can appear.

Dengue fever is spread through the bite of an infected Aedes mosquito. The Aedes mosquito, which carries dengue fever, typically lives indoors in dark, cool places like closets, under beds, bathrooms, and behind curtains, as well as around standing water. Aedes are daytime biters, with highest activity 2-3 hours after dawn and mid-to-late afternoon. Aedes mosquitos are active in both urban and rural environments.

There is no vaccine to prevent dengue fever. Use daytime insect precautions (see Insect Precautions below). Although there is no specific treatment for Dengue Fever, persons with suspected illness should seek medical care for definitive diagnosis. Dengue Fever does not usually require hospitalization; however, close clinical monitoring is needed to allow early intervention if complications occur.

Hepatitis C
Hepatitis C is a viral infection that causes liver disease. Most people do not have symptoms. If symptomatic, people can experience gastrointestinal disturbances, jaundice, dark urine, and fatigue. Chronic disease can cause liver cirrhosis and cancer.

Hepatitis C is spread person-to-person through IV drug use, contaminated needles for tattoos and body piercings, or unsafe medical procedures such as unscreened blood transfusions. Hepatitis C can also be transferred sexually. Travelers are generally at low risk, unless engaging in at-risk behaviors, or suffer a medical event requiring a blood transfusion. Healthcare workers are also at risk.

There is no vaccine to prevent hepatitis C infection. Travelers are advised to avoid IV drug use and sexual contact with high-risk individuals. Avoid receiving blood transfusions in facilities with substandard blood donation and screening procedures. Avoid other procedures that may bring you in contact with contaminated needles, such as tattoos and body piercings. There is effective antiviral treatment for hepatitis C. Travelers should seek medical care for testing and treatment if they suspect infection.

Cutaneous Larva Migrans (CLM)
CLM is one of many soil-transmitted helminthic (parasitic worm) infections that can affect humans worldwide. It is caused by hookworm larvae that penetrate and migrate through the skin. Symptoms include intense itching, with red linear or serpiginous lesions anywhere on the body that has had contact with soil. This rash can last from several weeks to a year.

CLM results from skin penetration by infective larvae of the hookworm. The hookworm eggs are deposited in the soil or sand from the feces of infected dogs and cats, and hatch into larvae. Any direct contact between skin and soil can lead to infection, and the larvae can penetrate swimwear and towels. Travelers are at risk walking barefoot or lying on moist sand or soil in endemic areas.

There is no vaccine to prevent against cutaneous larva migrans. Travelers are advised to avoid walking barefoot on beaches or other soil, wash feet after contact with sand, and to always sit on a protective surface to avoid contact between skin and sand or soil. CLM can be treated with anti-helminthic medication and symptomatic care. Seek medical attention if CLM is suspected.

Leishmaniasis
Leishmaniasis is a parasitic disease caused by several species of Leishmania protozoa. Three clinical syndromes result, depending on causative species: cutaneous, mucosal, and visceral (the most severe). Travelers most often are affected by the cutaneous form, usually with ulcerating skin lesions and swollen glands, and experience self-limited disease.

Leishmaniasis is spread through the bite of an infected sandfly. Risk of acquiring the disease is higher among adventure travelers, eco-tourists, missionaries, military personnel, construction workers, and those working outdoors at night or sleeping outdoors.

There is no vaccine to prevent Leishmaniasis. Follow insect precautions (see below), and avoid nighttime outdoor activities if possible. Most sandflies bite from dusk to dawn, but in the Western hemisphere, sandflies bite both day and night. Be aware that the mesh on any protective netting must be of a finer weave than the norm for prevention of mosquito bites. For netting to be effective against sandflies, it must have at least 18 holes per linear inch (2.54 cm). Impregnated nets and screens are most effective. Treatment decisions are multifactorial and can include local wound care and medications.

Malaria
Malaria is caused by a protozoan parasite that lives within red blood cells. Malaria is a very serious and potentially fatal disease. Symptoms include fever, chills, headache, and muscle aches. Vomiting, diarrhea, and abdominal pain also occur. Severe forms of the disease can lead to cerebral malaria, kidney failure, shock, and death.

Malaria is spread through the bite of an infected Anopheles mosquito, which is active between dusk to dawn. Risk varies widely, even within a country, and depends on the traveler’s itinerary, sleeping accommodations, urban vs rural travel, and elevation, among other factors.

There is no vaccine to prevent against malaria. Observe nighttime insect precautions (see below). Malaria prophylaxis medications are often recommended for travel to endemic areas. Consult with a travel health professional for specific advice. Seek medical care immediately if malaria infection is suspected. Treatment with antimalarial medications is effective.

Schistosomiasis (Bilharzia)
Schistosomiasis is a parasitic infection caused by flatworms. Symptoms of initial infection can include skin rash, fever, headache, muscle ache, bloody diarrhea, cough, malaise, and abdominal pain, but many of those infected are asymptomatic. Schistosomiasis can become a chronic illness with varied manifestations if untreated.

Schistosomiasis is spread via larvae that swim in fresh water, and through sexual contact with infected individuals. Travelers become infected by bathing, swimming, boating, or rafting in cercariae-infested waters.

There is no vaccine to prevent against schistosomiasis. Avoid contact with bodies of freshwater in endemic areas. Schistosomiasis cannot be contracted in chlorinated swimming pools or in bodies of salt water. The use of insect repellant may be effective but is unreliable. Travelers who come in contact with bodies of fresh water should wear protective footwear and clothing, and clean their skin with rubbing alcohol and a clean, dry towel. Schistosomiasis can be treated with anti-helminthic medication.

Sexually Transmitted Infections (STIs)
STIs are a concern for travelers worldwide, and are likely underreported as a travel-related infection. STIs are caused by viruses, bacteria, and parasites, the same potential pathogens as are present in the traveler’s home environment. However, certain infections like chancroid, LGV, and Granuloma inguinale are more common in less industrialized countries, and other areas of the world have higher incidence of HIV and Hepatitis B and C than others. Symptoms vary widely depending on the specific infection, and can include both local and systemic symptoms.

STIs are spread between humans by unprotected sexual contact (oral, anal, or vaginal), and skin-to-skin genital contact. Some STIs can also be transmitted through exposure to blood and other bodily fluids. Travelers are at higher risk if engaging in sex with sex workers, traveling for sex tourism, or certain higher risk behaviors. Healthcare workers are at higher risk for certain blood-borne infections.

Preventive measures focus on decreasing exposure to STI pathogens. Adhere strictly to safe sex practices: use a condom correctly and consistently, or abstain from intercourse, and use an external condom or dental dam for oral exposures. Travelers should pack external and/or internal condoms, as the quality of condoms available in some areas is not reliable. Avoid behavior that increases the risk of contracting an STI such as casual sex with a stranger or a sex worker. Drinking heavily or taking mind-altering drugs will impair judgement and inhibitions during a sexual encounter, increasing the risk of making unsafe choices. Seek medical attention promptly if an STI is suspected.

HIV/AIDS
HIV is a viral infection that affects the body’s immune system, increasing susceptibility to certain infections and other health complications. Untreated, HIV is a fatal infection. The symptoms of HIV infection vary depending on the stage of the disease. Patients can be asymptomatic or only have non-specific symptoms until the infection is very advanced.

HIV is transmitted through contact with blood and other body fluids, and sexual contact. Risk for travelers is generally low and determined more by behaviors than destination. Healthcare workers with clinical or laboratory responsibilities are at higher risk.

There is no vaccine to prevent HIV infection. Travelers can protect themselves by avoiding exposures, engaging in safe sex practices, and using personal protective gear if potential exposure is unavoidable. High risk travelers may consider preexposure prophylaxis. Health care workers should follow standard precautions and assess local availability of (or bring) postexposure prophylaxis. Seek medical care immediately if an exposure occurs. Early treatment with antiviral medications is effective in decreasing transmission.

Helminths – Soil Transmission
Soil-transmitted helminths include the human hookworms Ancylostoma and Necator, and Strongyloides. These helminths penetrate the skin, then migrate through the body through species-dependent pathways to end up settling in the GI tract. Many of those infected have no symptoms. If present, symptoms vary depending on the phase of life cycle within the human host: rash and skin lesions, mild cough, and non-specific gastrointestinal symptoms.

Transmission occurs through skin penetration by infective larvae found in fecally contaminated soil and sand in affected areas, usually when walking barefoot or lying directly on the ground. Transmission is more common in areas with poor sanitary practices. Travelers are at higher risk in moist, jungle environments and along the shoreline of tropical and subtropical beaches.

There is no vaccine to prevent against helminth infection. Travelers are advised to avoid walking barefoot on beaches or other soil, wash feet after contact with sand, and to always sit on a protective surface to avoid contact between skin and sand/soil. Treatment is with anti-helminthic medication and symptomatic care.

Travelers’ Diarrhea
Travelers’ diarrhea (TD) is the most common health problem for travelers, affecting up to 70% of travelers going to developing countries. TD is caused primarily by pathogenic bacteria and less commonly by protozoa or enteric viruses. Symptoms include diarrhea, fever, abdominal pain, nausea, and vomiting. More severe forms of TD include dysentery and diarrhea with blood and mucus present.

TD is transmitted to humans by the ingestion of contaminated food and water. Individuals at higher risk for TD or adverse consequences include adventurous eaters, immunocompromised persons, persons with inflammatory bowel disease or diabetes, and those taking medications that decrease gastric acidity.

There is no vaccine to prevent TD. Following food and beverage precautions may reduce the likelihood of illness (see below). Travelers should carry loperamide for self-treatment of diarrhea and azithromycin to add if diarrhea is severe.

Zika Fever
Zika fever is an acute viral illness within the genus Flavivirus that is spread by the bite of an infected Aedes mosquito. Symptoms include a sudden fever with rash, joint and body pain, headache, and conjunctivitis. Symptoms are usually mild and last from several days to a week. Babies born to women infected with the Zika virus while pregnant, or who become pregnant while infected, are at an increased risk of birth defects, including microcephaly.

Transmission of Zika virus is through the bite of an infected Aedes mosquito. The risk of being bitten is highest in the early morning, several hours after daybreak, and in the mid-to-late afternoons before sunset. The Aedes mosquito, which carries the Zika virus, typically lives indoors in dark, cool places as well as around standing water. Zika can also be transmitted sexually.

There is no vaccine to prevent Zika virus infection. Prevention is primarily accomplished by avoiding the bites of infected Aedes mosquito. Adhere strictly to daytime insect precautions (see below). Travelers who are pregnant or are planning to become pregnant, or sexual partners of those who may become pregnant, should consult with their healthcare provider and determine the level of risk for microcephaly or other birth defects before traveling to areas with confirmed Zika virus activity, and after their return. Treatment for Zika fever is primarily supportive.

Rocky Mountain Spotted Fever (RMSF)
RMSF is a tick-borne infection caused by a species of rickettsial bacteria. Symptoms include fever, headache, chills, muscle pain, and a spotted rash that typically presents itself several days after the onset of fever. It can be fatal if not treated within the first few days of infection.

Rocky Mountain Spotted Fever is spread through the bite of an infected tick. Those engaging in outdoor activities in wooded or high vegetation areas are at increased risk of exposure to ticks.

There is no vaccine to prevent against RMSF. To avoid bites, adhere to the insect precautions detailed below, with particular attention to tick avoidance. Infected, individuals should seek medical attention. They can be treated with antibiotics and supportive care.

Melioidosis
Melioidosis infection is caused by Burkholderia bacteria found in soil and water. Acute symptoms include fever, cough, chest pain, and shortness of breath. Localized skin infections also occur, as well as systemic forms of infection. Melioidosis can be fatal.

Melioidosis is spread through direct contact with sources, usually water and soil, that are contaminated with the bacterium. Transmission occurs primarily through direct inoculation through the skin, contamination of wounds, and inhalation and aspiration, most often in the setting of recent rains, floods, or severe weather events. Ecotourists, adventure travelers, and persons working in agriculture, mining, and construction are at risk.

There is no vaccine to prevent melioidosis. Avoid contact with pools of standing water, soil, or mud in endemic areas. Wear long pants, boots, and gloves if in contact with soil or an area of standing water. Clean wounds thoroughly and use an antiseptic cleanser. Seek medical care promptly if melioidosis infection is suspected for antibiotic treatment and other effective care.

Marine Hazards
Marine hazards are varied and include exposures to challenging tides and currents, hazards of watersports and boating, as well as contact with plants and animals that can injure humans. Most commonly seen in travelers are envenomation or stings from jellyfish, sea urchins, certain corals, stonefish, sting rays, and sea urchins.

Travelers should seek out and heed posted warnings and refrain from bathing or other aquatic activities at unmarked, unpatrolled beaches.

Snakebites
Snakebites are an important cause of morbidity and mortality for rural populations in tropical and subtropical areas. Risk of snakebites exists in areas with dense vegetation or rock formation, and snakes are more active in warm weather. Despite this prevalence in resident populations, travelers rarely experience snakebites. Symptoms of snakebites depend on the degree of envenomation, which varies based on species of snake, the volume of venom injected (many bites from venomous snakes are dry), and the weight and size of the victim.

Avoid close contact with snakes and do not attempt to handle them. Back away if a snake is disturbed and wait for it to move away. When hiking or trekking in a high risk country, travelers should wear boots and long pants, avoid tall grass if possible, walk slowly, and use a stick ahead to beat the vegetation. Do not reach into holes or cracks between rocks. Sleep under a bed net when camping. Use a flashlight if walking after dark. Seek medical attention immediately after any snakebite. Immediate first aid includes keeping the victim calm and quiet, and immobilizing the limb involved.

Lymphatic Filariasis
Lymphatic filariasis is caused by several species of filarial worms which target the lymphatic system, causing a variety of symptoms. A longer-term chronic infection can cause swelling of body parts and thickening of the skin known as elephantiasis.

Larvae of these worm species are transmitted to humans through the bite of several species of mosquitos. Biting can occur night or day depending on the vector species. Short term travelers are at low risk. Longer term travelers such as humanitarian workers, missionaries, and military personnel in endemic areas are at higher risk.

There is no vaccine against Lymphatic filariasis. Use daytime and nighttime insect precautions (see below). There are medications to treat the disease, but treatment can be complex. Seek medical care if infection is suspected.

Plague
Plague is a bacterial disease that can lead to 3 forms of disease: bubonic plague affecting the lymph nodes, septicemic plague in the bloodstream, and pneumonic plague affecting the lungs. Symptoms will vary depending on which form of the disease is present, and can include, fever, swollen and painful lymph nodes, abdominal pain, pneumonia, and bleeding.

The plague is typically spread through the bite of infected rodent fleas. It is sometimes spread through the inhalation of infected animal secretions, or by handling infected animal tissue. Rarely, person-to-person spread can occur if pneumonic plague is present. Risk to travelers is generally low. Hikers, campers, hunters, and persons exposed to wild rodents in endemic areas are at higher risk.

There is no vaccine to prevent against the plague. Measures should be taken to prevent against contact with rodents and other potentially infected animals. Prevent flea bites with insect repellant and protective clothing. Travelers should avoid crowds and coughing persons in areas where pneumonic plague has been reported. Those who may have had contact with an infected person, rodent, or other animal should receive antibiotic prophylactic treatment. Infected persons need immediate antibiotic treatment due to the high risk of death.

Onchocerciasis (River Blindness)
Onchocerciasis is a parasitic disease caused by infection with a filarial worm. It is widespread in river basins. Once it is settled in humans, the worms form nodules in the skin and migrate through skin and eye tissues. Many cases are asymptomatic, and symptoms may only manifest after 9-24 months after exposure. Skin rash, itching, eye lesions, and bumpy skin are the typical symptoms. Eye involvement can lead to blindness.

Onchocerciasis is spread through the bite of an infected blackfly. Blackflies bite during the day, with highest activity at dawn and dusk. They are found near fast-moving bodies of water like rivers and streams. Adventure travelers, humanitarian workers, missionaries, and military personnel are at higher risk of being exposed to blackflies.

There is no vaccine against Onchocerciasis. Follow daytime insect precautions to reduce blackfly bites (see below). Treatment with the anti-helminthic medication Ivermectin is effective, but may be required for 10 years or more given the longevity of adult worms in the human body.

Hantavirus Infection
Hantavirus Infection is a zoonosis associated with rodents. There are multiple different hantaviruses circulating worldwide, but they divide into 2 groups, each group causing a distinct clinical syndrome: the European and Asian group of viruses causes hemorrhagic fever with renal syndrome (HFRS), and the American group causes hantavirus cardiopulmonary syndrome (HCPS). HFRS begins with fever, muscle aches, nausea, and headache, and progresses to blood and renal system involvement. HCPS is more severe and progresses to heart and lung complications leading to respiratory failure and shock. Case fatality of HCPS ranges from 25-40%.

Hantavirus is spread through the inhalation of contaminated rodent waste matter. Person-to-person transmission can occur but is rare. Those at risk include agricultural workers, campers, trekkers, and those sleeping on the ground or staying in rodent-infested cabins.

A vaccine for 1-2 strains of hantavirus is available in China and Korea, but the cost limits its use. No other vaccine is currently in use. Limit contact with rodents and their droppings in affected areas. Hantavirus progresses quickly, even with treatment. Those affected by hantavirus should receive immediate hospital care.

Tuberculosis (TB)
TB is caused by infection with the Mycobacterium tuberculosis bacteria. Over 95% of cases occur in developing countries, and infection is strongly associated with poverty, overcrowding, and malnutrition. TB infection can be latent, with no symptoms, for many years. The most common clinical presentation of active TB is pulmonary TB, with symptoms of cough, night sweats, weight loss, bloody sputum, and fatigue.

Tuberculosis is spread through contact with the respiratory secretions of an infected person. It can also be acquired by eating unpasteurized dairy products in areas where the bovine form of TB is endemic.

The Bacillus Calmette-Guérin (BCG) vaccine has historically been used at birth in most developing countries to prevent against TB. Results in adults have varied with effectiveness of between 0-80 percent. It is not recommended for travelers. The BCG vaccine is also reported to interfere with TB testing in some cases. Individuals who anticipate prolonged exposure to TB areas should undergo the tuberculin skin test (TST) or interferon-y release assay (IGRA) both before leaving the US and 8-10 weeks after returning from travel. Treatment for TB is complex; seek medical care for concerns of TB infection.

Leptospirosis
Leptospirosis is caused by a spirochete organism acquired through contact with contaminated freshwater, soil, or tissues of infected animals. Leptospirosis can be a serious illness and potentially fatal. Symptoms include fever, headache, muscle aches, red eyes, and gastrointestinal disturbance, which can then progress to meningitis, kidney or liver failure, and mental status changes.

Leptospirosis is transmitted to humans through contact with contaminated freshwater, soil, or tissues of infected animals. The organisms access the body through skin lesions, intact mucus membranes, or waterlogged skin. Travelers at highest risk are those going to areas with flooding, or who will be swimming, wading, kayaking, or rafting in contaminated fresh water. It is also a potential risk for travelers around animals, like humanitarian aid workers, adventure travelers, and animal caretakers. Areas with poor sanitation can also harbor leptospirosis.

There is no vaccine to prevent against leptospirosis. Preventive measures include avoidance of potentially contaminated soil, mud, and water (particularly bodies of freshwater), as well as animal tissues or urine. Wear boots and cover any cuts or abrasions if wading through water. Follow food and water precautions (see below). Travelers with unavoidable contact with contaminated water or soil may benefit from pre-exposure prophylaxis with doxycycline. This is currently recommended for outdoor adventure travelers engaging in high risk activities, as well as for persons in areas of recent flooding. Leptospirosis can be treated with antibiotics. Seek medical care if infection is suspected.

Medical Facilities and Services
Medical facilities in major cities meet international standards, have well-trained professionals, and adequate supplies. Rural medical clinics usually do not have sufficient resources to meet international standards or provide quality care. Serious illnesses and injuries usually require medical evacuation to major cities. Medical facilities may expect cash payment in advance, even in cases of emergency. Ambulance services employed by public hospitals tend to be unreliable; private hospitals offer more consistent services. Traffic in major cities can reduce ambulance response times considerably.

Food and Water Safety
Tap water in Brazil is generally not considered potable. Avoid eating raw or undercooked meat, poultry, seafood, or eggs. Avoid eating unwashed or unpeeled fruits/vegetables, fruits/vegetables that have been washed with contaminated water, unpasteurized dairy products, and bush or game meat. Avoid eating food that is not properly refrigerated or cooled, or that has been left standing and uncovered. Avoid eating leafy or uncooked vegetables and salads.

Only drink water that has been filtered or boiled, or has come in a sealed bottle. Avoid drinking any well water unless you can verify its quality. Do not drink beverages that contain ice unless you can confirm that the ice is from purified water. Do not drink unpasteurized milk or juice, or anything mixed with contaminated water. Hot coffee or tea is usually safe to drink.

Wash hands with soap or use an alcohol-based hand sanitizer prior to eating. Do not use tap water to brush teeth unless you can verify the quality of the water. Avoid sharing beverages or utensils with others.

Insect Precautions
Use insect repellent: DEET 20 – 30% or Picaridin 20% on exposed skin. Re-apply per manufacturer’s directions.

Avoid scented soaps, hair products, deodorants, perfumes, and shaving products.
Wear long sleeves and pants tucked into socks. Wear neutral colors (beige, light gray). Always wear shoes, both indoors and outdoors.
Treat outer clothing with permethrin.
Remove any containers holding water, both inside and outside any building.

Avoid insect exposure using additional various methods depending on the insect:

For nighttime flying insects, sleep under bed nets, preferably insecticide impregnated.
For ticks, hike in the middle of the trail and avoid tall grasses and shrubs, use a tarp when sitting on grass, perform regular tick checks on your body and clothing.
For other insect vectors, avoid direct contact with animals, and avoid overcrowded, unsanitary conditions to reduce risk of exposure to body lice, mites, fleas, and rodents.