Chapter 10 Popular Itineraries The Americas & the Caribbean
Brazil is the fifth largest country in the world and the largest country in South America, occupying nearly half the land area of the continent. With more than 200 million people, Brazil is home to the world’s largest Portuguese-speaking population. It is the world’s eighth largest economy and is classified as an upper-middle-income country. Nearly 85% of Brazilians live in urban areas.
In Brazil, tourism is a growing economic sector; it is the most popular tourist destination in South America, the second most popular in all Latin America. In 2016, more than 6 million international visitors traveled there. Brazil hosted the FIFA World Cup in 2014 and the Summer Olympic and Paralympic Games in 2016. Rio de Janeiro, Brazil’s second-largest city (population >7 million) and most frequently visited tourist destination, is famous for its beaches, landmarks, and annual Carnival festivities. São Paulo, one of the world’s largest cities (>21 million people in the greater metropolitan area), is the economic center of Brazil and the most visited destination for business travel. Brazilians prize many of their major cities, including Salvador, Florianópolis, Fortaleza, Natal, and Recife for their coastlines and regional culture.
The country also boasts a number of UNESCO World Heritage sites. These include Iguaçu National Park in Paraná (home to the largest waterfalls in the Americas); the historic towns of Olinda (Pernambuco), Ouro Preto (Minas Gerais), Salvador (Bahia), and São Luis (Maranhão); the modern capital of Brasília; and natural areas of the Amazon forest, Pantanal Conservation Area (Mato Grosso and Mato Grosso do Sul). The Atlantic forests (Rio de Janeiro and São Paulo) and the archipelago of Fernando de Noronha in the Atlantic Ocean are also World Heritage sites (see Map 10-05).
Map 10-05. Brazil destination map
Travelers to Brazil should be up-to-date on routine vaccines. Hepatitis A vaccination is recommended. Hepatitis B vaccination should be considered for most travelers and is recommended for anyone who could be exposed to blood or other body fluids, including through sexual contact. Consider vaccinating “adventurous eaters” and travelers who stay with friends or relatives, or who visit smaller cities, villages, or rural areas, against typhoid (see Chapter 4, Typhoid & Paratyphoid Fever). The World Health Organization and CDC recommend yellow fever vaccine for travelers going to certain areas of the country (see below for more details). Because of recent yellow fever outbreaks in previously unaffected areas, clinicians must ask patients about their itineraries and potential travel within Brazil and refer to the CDC Travelers’ Health website (www.cdc.gov/travel) for the most recent recommendations.
Vectorborne (including mosquitoborne) diseases are present in many areas of Brazil; these infections are the leading causes of febrile illness among travelers returning from South America. Aedes mosquitoes transmit chikungunya, dengue, and Zika. More detailed information about each of these diseases can be found in Chapter 4. Risk of infection is high in many Brazilian states due to high indices of Aedes infestation. Some vectorborne diseases are new to Brazil: chikungunya was first detected there in 2014, Zika in 2015.
From 2000 through 2015, cases of dengue increased throughout Brazil, with epidemics reported in large cities including Rio de Janeiro and Salvador. In 2016, Brazil recorded 1.4 million probable cases of dengue, approximately 278,000 cases of chikungunya, and 216,000 cases of Zika virus infection. Travelers to Brazil should take measures to protect themselves from mosquito bites (see Chapter 3, Mosquitoes, Ticks & Other Arthropods). Because of the risk of birth defects in infants born to women infected with Zika during pregnancy, women who are pregnant or trying to become pregnant should research the most recent travel recommendations at www.cdc.gov/zika.
Almost all malaria in Brazil occurs in the Amazon Basin, although the mosquito vector is present in much of the country. Plasmodium vivax is the main malaria species, although approximately 12% of cases are caused by P. falciparum. Prophylactic treatment with antimalarial medication is recommended for travelers going to malaria-endemic areas (see Chapter 2, Yellow Fever Vaccine & Malaria Prophylaxis Information, by Country, and Map 2-06).
Mosquitoes transmit the yellow fever virus throughout the Amazon Basin and in forested regions along all major river basins in Brazil, including Iguaçu Falls and as far south as Rio Grande do Sul. Vaccination against this potentially lethal disease is recommended for all travelers aged >9 months going to areas where there is risk of infection (see Chapter 2, Yellow Fever Vaccine & Malaria Prophylaxis Information, by Country).
Tickborne diseases have been identified in Brazil. Caused by the same etiologic agent (Rickettsia rickettsii) as Rocky Mountain spotted fever, these diseases include febre maculosa and Brazilian spotted fever. Travelers should take precautions to avoid flea and tick bites both indoors and outdoors. For more information, see Chapter 3, Mosquitoes, Ticks & Other Arthropods.
Travelers’ Diarrhea and Foodborne Infections
Travelers should take food and water precautions throughout Brazil (see Chapter 2, Food & Water Precautions). Travelers’ diarrhea is the most common travel-related ailment; consuming raw fruits and/or vegetables or unpasteurized dairy products, or patronizing street vendors, increases the risk for foodborne infections. Oral rehydration salts are available from public health clinics and in almost all pharmacies in Brazil. Clinicians may prescribe an antibiotic for self-treatment of moderate to severe diarrhea (see Chapter 2, Travelers’ Diarrhea).
SEXUALLY TRANSMITTED INFECTIONS
In Brazil, condoms are distributed free of charge by the government and are available in health clinics, tourist service centers, and other distribution points in many cities. Male condoms are available throughout Brazil in pharmacies, convenience stores, and large supermarkets; female condoms are also available in some locations. Travelers, particularly those at high risk for acquiring HIV infection (men who have sex with men, for example) may wish to discuss preexposure prophylaxis with their health care provider (www.cdc.gov/hiv/prep).
Peak influenza circulation occurs from April through September in most of Brazil but may occur throughout the year in tropical areas. CDC recommends seasonal influenza vaccination at least 2 weeks before travel and also pneumococcal vaccination for the elderly and younger adults with chronic medical conditions.
A number of fungal diseases are endemic to parts of Brazil. Inhaled fungal spores typically present in the soil (paracoccidioidomycosis, histoplasmosis, cryptococcosis, and coccidioidomycosis) cause respiratory illness and occasionally more severe disease such as meningitis or bone infections (see the sections on Histoplasmosis and Coccidioidomycosis in Chapter 4). Travelers should beware of bat guano in caves, and exercise caution before disturbing soil, particularly if contaminated by bird or bat feces.
Outbreaks of leptospirosis have occurred in urban areas in Brazil following heavy flooding (see Chapter 4, Leptospirosis). Travelers participating in recreational water activities are at increased risk, particularly after heavy rainfall.
Most Brazilian states have eliminated Chagas disease (American trypanosomiasis) through insecticide spraying for the vector. Although the risk is extremely low, travelers and ecotourists staying in poor-quality housing may be at higher risk for this disease. Outbreaks have been associated with consuming foods or beverages containing açaí, an Amazonian fruit eaten throughout Brazil. Oral transmission occurs when people consume açaí contaminated with triatomines—the bloodsucking insects that transmit the etiologic agent of Chagas disease (Trypanosoma cruzi)—or their feces (see Chapter 4, American Trypanosomiasis).
Schistosoma spp. are parasites found in freshwater lakes and rivers in many states of Brazil, especially in the northeast. Swimming, bathing, and wading in fresh, unchlorinated water can result in schistosomiasis (see Chapter 4, Schistosomiasis). Swimming or bathing in saltwater (oceans or seas) is not a source of infection.
Both cutaneous and visceral leishmaniasis occur in Brazil and are most common in the Amazon and northeast regions (see Chapter 4, Cutaneous and Visceral Leishmaniasis). The risk is highest from dusk to dawn because the sand fly vector typically feeds (bites) at night and during twilight hours. Ecotourists and adventure travelers might have an increased risk, but even short-term travelers in endemic areas have developed leishmaniasis.
Preexposure rabies vaccination is recommended for travelers with extended itineraries, particularly children and those planning trips into rural areas. For shorter stays, rabies vaccination is recommended for adventure travelers, those who may be exposed to animals occupationally, and those staying in locations >24 hours away from access to rabies immune globulin (see Chapter 4, Rabies).
Tuberculosis is prevalent in Brazil, but short-term travelers are not considered high risk for infection unless visiting specific crowded environments. Travelers who anticipate prolonged exposure to people with TB (i.e., those whose travel plans include spending time in clinics, hospitals, prisons, or homeless shelters) should have a tuberculin skin test or TB blood test before leaving the United States. If the pretravel test is negative, travelers should undergo repeat testing 8–10 weeks after returning from Brazil. For more information, see Chapter 4, Tuberculosis.
Other Health and Safety Risks
As in many foreign countries, motor vehicle accidents in Brazil are a leading cause of injury and death of US travelers (see Chapter 8, Road & Traffic Safety). Road conditions in Brazil differ significantly from those in the United States, and driving at night can be dangerous. The national toll-free number for emergency roadside assistance (193) is in Portuguese only. It is illegal to drive after drinking alcohol, even small quantities. Seatbelt use is mandatory, and motorcyclists are required to wear helmets.
Children aged ≤10 years must be seated in the back seat. Brazilian federal law requires infants up to 1 year of age to use rear-facing car seats, children 1–4 years of age to use forward-facing car seats, and children 4–7.5 years of age to use booster seats. Anyone traveling with small children should bring their own car or booster seats, in the event they are limited or unavailable.
Travelers to Brazil should familiarize themselves with climatic conditions at their destinations before travel. Temperatures >104°F (40°C) are common from October through January in some Brazilian cities (see Chapter 3, Extremes of Temperature).
Poisonous snakes are hazards in many locations in Brazil, although deaths from snakebites are rare (see Chapter 3, Animal Bites & Stings). Counsel travelers to seek immediate medical attention any time a bite wound breaks the skin or if a snake sprays venom into their eyes. In some areas of the country, specific antivenins are available; being able to identify the snake species may prove critical to delivery of optimal medical care. The national toll-free number for intoxication and poisoning assistance is 0800-722-6001 (in Portuguese only).
Travel in Brazil is generally safe, although crime remains a problem in urban areas and has spread to rural areas. The incidence of crime against tourists is higher in areas surrounding beaches, hotels, nightclubs, and other tourist destinations (see Chapter 3, Safety & Security Overseas). Drug-related violence has resulted in clashes with police in tourist areas. Political demonstrations may disrupt public and private transportation. Encourage travelers to register to receive Department of State advisories for alerts in areas they plan to visit (https://step.state.gov/step/). Several Brazilian cities have established specialized police units whose job is to patrol areas frequented by tourists.
HEALTH CARE IN BRAZIL
Quality health care is available in most sizable Brazilian cities. Brazilian public health services are free. Foreign visitors can seek treatment in the emergency care network of Brazil’s public health system, known as the Unified Health System or by its acronym, SUS, or through private facilities. The toll-free emergency number for ambulance services throughout Brazil is 192. The Brazilian Ministry of Health provides information in Portuguese for international visitors (http://portalms.saude.gov.br/saude-para-voce/saude-do-viajante/durante-sua-estadia), including a list of reference hospitals for mass events in Brazil.
Brazil has a growing number of private clinics that cater to international clientele and offer medical procedures using advanced technologies (see Chapter 9, Medical Tourism). Travel to Brazil for cosmetic surgery, assisted reproductive technology, or other elective medical procedures has increased in recent years, becoming a major part of the medical industry there. Although Brazil has many cosmetic surgery facilities on par with those found in the United States, quality of care can (and does) vary widely. Instruct patients seeking cosmetic surgery or other elective procedures to do their research and to make sure that emergency medical facilities are available at their clinic of choice.
- Gaines J, Sotir MJ, Cunningham TJ, Harvey KA, Lee CV, Stoney RJ, et al. Health and safety issues for travelers attending the World Cup and Summer Olympic and Paralympic Games in Brazil, 2014 to 2016. JAMA Intern Med. 2014 Aug;174(8):1383–90.
- Jentes ES, Poumerol G, Gershman MD, Hill DR, Lemarchand J, Lewis RF, et al. The revised global yellow fever risk map and recommendations for vaccination, 2010: consensus of the Informal WHO Working Group on Geographic Risk for Yellow Fever. Lancet Infect Dis. 2011 Aug;11(8):622–32.
- Malaria Atlas Project. The spatial limits of Plasmodium vivax malaria transmission map in 2010 in Brazil. 2010 [cited 2016 Sep 23]. Available from: www.map.ox.ac.uk/explore/countries/BRA/.
- Nobrega AA, Garcia MH, Tatto E, Obara MT, Costa E, Sobel J, et al. Oral transmission of Chagas disease by consumption of acai palm fruit, Brazil. Emerg Infect Dis. 2009 Apr;15(4):653–5.
- Oliveira-Ferreira J, Lacerda MV, Brasil P, Ladislau JL, Tauil PL, Daniel-Ribeiro CT. Malaria in Brazil: an overview. Malar J. 2010 Apr 30;9:115.
- Teixeira MG, Siqueira JB Jr, Ferreira GL, Bricks L, Joint G. Epidemiological trends of dengue disease in Brazil (2000–2010): a systematic literature search and analysis. PLoS Negl Trop Dis. 2013 Dec 19;7(12):e2520.
- Wilson ME, Chen LH, Han PV, Keystone JS, Cramer JP, Segurado A, et al. Illness in travelers returned from Brazil: the GeoSentinel experience and implications for the 2014 FIFA World Cup and the 2016 Summer Olympics. Clin Infect Dis 2014 May;58(10):1347–56.