There are no compulsory vaccinations required to enter the country from Europe or North America (although you may need a yellow fever certificate entering from another South American country), but certain precautions should be taken, especially if you’re staying for any length of time or visiting more remote regions. Taking out travel insurance is vital, and you should be especially aware of HIV and dengue fever, a significant problem in Rio during the Brazilian summer (Dec–April). But you should not let health issues make you unduly paranoid – if you need it, good medical care is available cheaply for all but the most serious of problems.
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Pharmacies and medical treatment
Most standard drugs are available in pharmacies (farmácias), which you’ll find everywhere – no prescriptions are necessary. A pharmacy will also give injections (unless you’ve already had one, you’ll need a tetanus jab if you get bitten by a dog) and free medical advice, and they’re a good first line of defence if you fall ill.
If you are unlucky enough to need medical treatment in Brazil, forget about the public hospitals – as a foreigner, you have virtually no chance of getting a bed unless you have an infectious disease, and the level of health care offered by most is appalling. You can get good medical and dental care privately: North Americans will think it fairly inexpensive, Europeans used to state-subsidized health care will not. A doctor’s visit will cost on average US$40–75; drugs are relatively cheap. Hotels in big cities will have lists of English-speaking doctors; ask for a médico. Outside the larger centres, you will probably have to try out your Portuguese. Any Brazilian doctor will also understand – although not necessarily speak – Spanish.
Food and water
Many diseases are directly or indirectly related to impure water and contaminated food, and care should be taken in choosing what to eat and drink.
You should, of course, take particular care with seafood, especially shellfish – don’t eat anything that’s at all suspicious. Fruit and salad ingredients should be washed in bottled or purified water or, preferably, peeled. Ultimately, you are going to run some risks with food, so if you’re going to enjoy your stay to the full, you can’t be too paranoid.
Even in the most remote towns and villages mineral water (água mineral), either sparkling (com gás) or still (sem gás), is easily available and cheap. To avoid dehydration be sure to drink plenty of non-alcoholic liquids, always carry a bottle of water on long trips, and check that the seal on any bottled water you use is intact.
As with food, it’s difficult to be on guard all the time whilst drinking; fruit juices are often diluted with water, and ice is rarely made with filtered water outside a smart hotel. It is not realistic to restrict all water intake to mineral water, but if you are sensible you can at least minimize risk.
A serious disease you should guard against is Chagas’ disease, which is endemic in parts of the Northeast and the Amazon. Although it is difficult to catch, it can lead to serious heart and kidney problems that appear up to twenty years after infection. The disease is carried in the faeces of beetles that live in the cracks of adobe walls, so if sleeping in an adobe hut, make sure nothing can crawl into your hammock; either use a mosquito net or sling the hammock as far from walls as you can. The beetle bites and then defecates next to the spot: scratching of the bite will rub in the infected faeces, so before scratching a bite that you know wasn’t caused by a mosquito, bathe it in alcohol. If you are infected, you will have a fever for a few days that will then clear up as if nothing untoward happened. Though the disease can be treated in its early stages, it becomes incurable once established. If you travel through a Chagas area and get an undiagnosed fever, have a blood test as soon as possible afterwards.
Dengue fever, a viral disease transmitted by mosquito bites, is increasingly common in all Brazilian cities save the extreme south of the country. Rio has been particularly badly affected in recent years, as the spectacular incompetence of its city government has allowed the mosquito problem to get out of hand. It is highly seasonal, peaking in the southern hemisphere summer (Dec–April). The symptoms are debilitating rather than dangerous: light but persistent fever, tiredness, muscle and joint pains, especially in the fingers, and nausea and vomiting. It is easily treatable, but you will feel pretty grim for a week or so. It is much more widespread than any other disease in urban areas, and is currently the focus of much educational and preventive work by the Brazilian government. The same precautions against mosquito bites outlined in the section on malaria above apply here. The difference is that the dengue mosquito comes out during the day rather than at night. Be cautious in urban environments around anything that could act as a water retainer and thus as a mosquito breeding ground: drainage channels, old oil drums and tyres, abandoned lots, swampy areas in general.
There is one dangerous form of dengue, hemorraghic dengue, which kills hundreds of people a year in Brazil. Tourists tend not to get it, since you almost always need to have had a previous attack of dengue to be vulnerable to it. It is particularly dangerous to children. The body’s immune system is provoked to attack itself by the dengue virus, resulting in internal bleeding that can quickly get out of hand. If dengue-like symptoms are accompanied by bleeding from the nose and ears or highly bloodshot eyes, get yourself to a private hospital fast. Even if you are unlucky enough to get it, in the vast majority of cases getting timely treatment will mean a few days in hospital is all that’s needed for complete recovery. You will feel very weak and should take things easy for a couple of weeks after you leave hospital, however.
Diarrhoea, dysentery and giardia
Diarrhoea is something everybody gets at some stage, and there’s little to be done except drink a lot (but not alcohol) and bide your time. You should also replace salts either by taking oral rehydration salts or by mixing a teaspoon of salt and eight of sugar in a litre of purified water. You can minimize the risk by being sensible about what you eat, and by not drinking tap water anywhere. This isn’t difficult, given the extreme cheapness and universal availability of soft drinks and água mineral, while Brazilians are great believers in herbal teas, which often help alleviate cramps.
If your diarrhoea contains blood or mucus, the cause may be dysentery or giardia. With a fever, it could well be caused by bacillic dysentery and may clear up without treatment. If you’re sure you need it, a course of antibiotics such as tetracyclin or ampicillin (travel with a supply if you are going off the beaten track for a while) should sort you out, but they also destroy “gut flora” that help protect you. Similar symptoms without fever indicate amoebic dysentery, which is much more serious, and can damage your gut if untreated. The usual cure is a course of metronidazole (Flagyl), an antibiotic that may itself make you feel ill, and should not be taken with alcohol. Similar symptoms, plus rotten-egg belches and farts, indicate giardia, for which the treatment is again metronidazole. If you suspect you have any of these, seek medical help, and only start on the metronidazole (750mg three times daily for a week for adults) if there is definitely blood in your diarrhoea and it is impossible to see a doctor.
Wherever you go, protection against hepatitis A is a sensible precaution. The disease is transmitted through contaminated water and food, resulting in fever and diarrhoea, and it can also cause liver damage. Gammaglobulin injections, one before you go and boosters every six months, are the standard protection. If you plan to spend much time in Amazônia or the Northeast, or if you know that you will be travelling rough, it’s well worth protecting yourself. If you have had jaundice, you may well have immunity and should have a blood test to see if you need the injections. A newer vaccine – Havrix – is very effective and lasts for up to ten years.
HIV and AIDS
Brazil has a relatively high number of people with AIDS and HIV. There are many reasons for this: a scandalous lack of screening of either blood donors or supplies in the 1980s; the level of gay sex between Brazilian men, among whom bisexuality is common; the popularity of anal sex, not least among heterosexual couples; and the sharing of needles among drug users in large cities. But Brazil has been a world leader in dealing with the epidemic. It faced down international drug companies in the late 1990s with the threat that they would independently manufacture AIDS drugs – with the result that all HIV-positive Brazilians now receive free anti-retroviral medicines in a programme that has become a global model for developing countries. Brazil also has some of the funniest and most imaginative safe-sex campaigns anywhere, particularly in evidence during Carnaval.
A straightforward understanding of the disease and how it is transmitted is the best defence. Firstly, HIV is not evenly distributed throughout Brazil. A majority of HIV carriers are concentrated in the big cities. As anywhere else, sex with a prostitute is a high-risk activity. The situation with blood and blood products has now improved enormously, but in remoter parts of the country, especially the Amazon, make sure that if you have an injection it is with a needle you see being removed from its packaging. Finally, use a condom. Only a tiny minority of sexually active Brazilian men carry them as a matter of course. They are widely available in pharmacies, where you should ask for a camisinha.
Malaria is endemic in northern Brazil, and anyone intending to travel in Amazônia should take precautions very seriously. You are safe if you are only visiting cities and towns, where intensive campaigns keep malarial mosquitoes at a distance, and if your visit will be restricted to Manaus, Santarém and Belém you can forego prophylaxis. Mosquitoes are also not a problem on river journeys, since the breezes keep them off, and they are much less common in black-water river systems – such as the River Negro, where jungle lodges around Manaus are concentrated – where malaria is rare.
If you will be sleeping in a rural area anywhere else in the Amazon, however, it is a good idea to take precautions. In recent years, rates have climbed as mosquitoes have become more resistant to insecticides and drugs, and a few unwary tourists die avoidably every year. Southern Pará state and much of rural Rondônia state are the riskiest areas for malaria. However, with simple precautions you can minimize the chances of getting it even in highly malarial areas, and, properly treated, a dose of malaria should be no worse than a severe bout of flu. But make no mistake – unless you follow the precautions outlined here, and take malaria prophylaxis when appropriate, malaria can kill.
There are two kinds of malaria in Brazil: falciparum, which is more serious but less common, and vivax. Both are transmitted by anopheles mosquitoes, which are most active at sunrise and for an hour or so before sunset. Even in very malarial areas, only around five percent of anopheles are infected with malarial parasites, so the more you minimize mosquito bites, the less likely you are to catch it. Use insect repellent: the most commonly used in Brazil is Autan, often in combination with Johnson’s Baby Oil to minimize skin irritation. The most effective mosquito repellents – worth looking out for before you leave home – contain DEET (diethyl toluamide). DEET is strong stuff, so follow the manufacturers’ instructions, particularly with use on children. If you have sensitive skin, a natural alternative is citronella or, in the UK, Mosi-guard Natural, made from a blend of eucalyptus oils (though still use DEET on clothes and nets). Wear long-sleeved shirts and trousers, shoes and socks during the times of day when mosquitoes are most active. Sleep under a sheet and, crucially, use a mosquito net. Nets for hammocks (mosqueteiro para rede) are reasonable and easily available in Amazonian cities and towns. Mosquito coils also help keep the insects at bay.
When taking preventive tablets it’s important to keep a routine and cover the period before and after your trip with doses. Doctors can advise on which kind to take. As resistance to chloroquin-based drugs increases, mefloquin, which goes under the brand name of Lariam, has become the recommended prophylactic for most travellers to Brazil. This has very strong side effects, and its use is controversial.
Malaria has an incubation period of around two weeks. The first signs of malaria are remarkably similar to flu – muscle pains, weakness and pain in the joints, which will last for a day or two before the onset of malaria fever proper – and may take months to appear: if you suspect anything go to a hospital or clinic immediately. You need immediate treatment and a blood test to identify the strain. Malaria treatment is one public-health area where Brazil can take some credit. Dotted in malarial parts of the Amazon are small malaria control posts and clinics, run by the anti-malaria agency SUCAM – ask for the posto da SUCAM. They may not look like much, but the people who staff them are very experienced and know their local strains better than any city specialist. Treatment in a posto is free, and if you do catch malaria you should get yourself taken to one as quickly as possible; don’t shiver in your hammock and wait for it to pass. It often does, but it can also kill. If in a city and you get the same symptoms (a fever and the shakes), make sure you get a blood test right away; you’ll get your results in a few hours, and quick diagnosis is vital. Remember that the incubation period means that the symptoms may only appear after you return home – make sure to tell your doctor where you’ve been if you get a fever shortly after your return home.
Malaria is a much more serious issue for a child. We specifically recommend avoiding the state of Rondônia other than Porto Velho, rural Acre and Amapá and southern Pará if you are travelling with children.
Getting a yellow fever vaccination, which offers protection for ten years, is recommended if you’re going to Amazônia, Goiás or Mato Grosso. This viral disease is transmitted by mosquitoes and can be fatal, but is extremely rare even in places where it is endemic. Symptoms include headache, fever, abdominal pain and vomiting, and though victims may appear to recover, without medical help they may suffer from bleeding, shock and kidney and liver failure. While you’re waiting for help, it is important to keep the fever as low as possible and prevent dehydration.
In the Amazon
Given the remoteness of many parts of the Amazon and the prevalence of insects and snakes, health care takes on a special significance. If you are trekking through forest or savanna, long trousers are a good idea, and it is vital to wear good boots that protect your ankles from snake bites, chiggers (mites) and scorpions. You should never trek alone.
Snakes are timid and, unless you’re unlucky, only attack if you step on them. Many of the most poisonous snakes are tiny, easily able to snuggle inside a shoe or a rucksack pocket. Always shake out your hammock and clothes, keep rucksack pockets tightly closed and take special care when it rains, as snakes, scorpions and other nasty beasties quite sensibly head for shelter in huts. If you do get bitten by a snake, try to kill it for identification – but only if this can easily be done. Use a shoelace or a torn piece of shirt wound round the limb with a stick as a tourniquet, which you should repeatedly tighten for twenty seconds and then release for a minute, to slow down the action of the poison. Contrary to popular belief, cutting yourself and sucking out blood will do you more harm than good. It goes without saying that you should get yourself to a doctor as soon as possible. If you are well off the beaten track, health posts in the nearest town may have serum, but you must know the type of snake involved.
Due to the humidity, any cut or wound gets infected very easily. Always clean cuts or bites with alcohol or purified water before dressing. As a general rule, leave all insects alone and never handle them. Even the smallest ants, caterpillars and bees can give you nasty stings and bites, and scorpions, large soldier ants and some species of bee will give you a fever for a day or two as well.