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Information on how to stay safe and healthy abroad. About us.

Note: Malaria maps and specific malaria advice for each country affected by malaria is available on the individual country pages

  • Awareness of Risk
  • Bite prevention
  • Chemoprophylaxis (taking malaria prevention tablets)
  • Diagnosis and treatment
  • Standby  Emergency Treatment for Malaria

Introduction

Malaria is a serious parasite infection that is transmitted by the bite of female mosquitoes. The parasites are microscopic and found in the blood of infected people. There are different types of malaria parasite and although the infection they cause is similar. 'Falciparum' malaria is the one that causes the most severe infection.

  • Malaria can be deadly if untreated.

Symptoms of malaria:

  • usually include a high temperature (fever) accompanied by shivering and sweating
  • are often described as 'flu-like' and can be accompanied by a variety of other symptoms, such as muscle aches, headache or vomiting
  • can be vague, especially in children who may simply be 'out of sorts'

Malaria symptoms can quickly become severe if effective treatment is not started quickly.

  • You must seek urgent medical attention if you become unwell with symptoms suggestive of malaria during, or after a visit to a country with malaria.

You cannot be vaccinated against malaria, but you can protect yourself against this disease using the A , B , C , D approach to prevention as follows:

A = Awareness of risk

Malaria is widespread in many tropical and subtropical countries.

  • if malaria is present, there will also be a map showing the malaria-affected areas in that country at the moment (note that risk areas can change)
  • low risk with additional advice
  • low to no risk

Be aware that the risk of malaria can vary within different parts of the same country, between neighbouring countries, and at different times of year.

Risk for travellers

Every person regardless of their origins who visits a country where malaria is present is at risk of catching malaria.

Increased risk of catching malaria Some groups of people are at increased risk of catching malaria because of the type of travel they are undertaking. These groups include:

  • people who are travelling to visit friends or relatives
  • those planning a longer stay in rural areas 
  • longer term travellers to areas with malaria

Increased risk of developing severe malaria There are also groups of people who are at an increased risk of developing severe malaria if they catch the infection. These include:

  • pregnant women
  • babies and children
  • older people
  • people with conditions that affect the immune system
  • people without a spleen
  • people with certain medical conditions

If you think you fall into any of these categories, you should see a travel health professional for a travel health risk assessment before you travel to a malaria-affected country:

  • they will advise you if you have an increased risk of catching malaria, or of developing serious malaria
  • you may need to take additional measures other than bite prevention to protect yourself, including taking tablets to prevent malaria , even if the risk of malaria is considered to be low

B = Bite Prevention

Protecting yourself against mosquito bites is essential.

  • Reducing the number of bites you receive reduces your chance of developing malaria.

Mosquitoes that transmit malaria typically bite at night, after sunset.

  • There are also day biting mosquitoes that transmit other potentially serious diseases, so make sure you protect yourself against mosquito bites at all times of the day and night.

Take practical measures to avoid mosquito bites including:

  • using good quality insect repellents
  • wearing the right clothing to protect your skin from bites
  • using a mosquito net
  • reducing the number of mosquitos in and around your accommodation

C = Chemoprophylaxis (taking malaria prevention tablets)

Find out the risk of malaria in the country you intend to visit by checking the malaria section on each country page.

  • The malaria section will indicate if you need to take tablets to prevent malaria (antimalarials). 

For countries with a high risk :

  • antimalarial tablets are recommended for everyone
  • bite prevention is recommended for everyone

For countries with a low risk with additional advice:

  • antimalarial tablets are only recommended for those at increased risk of catching malaria, or increased risk of severe malaria

For countries with a low to no risk:

  • malaria outbreaks, if present, are listed in the 'Alerts' section of the country pages

Protecting yourself against mosquito bites is as important as taking antimalarial tablets.  This is because:

  • no antimalarial tablets are 100% effective, but if you take these in addition to preventing mosquito bites, this will significantly reduce your chance of catching malaria
  • antimalarial tablets do not prevent malaria parasites entering your body, but they do help to stop the infection establishing and symptoms developing

There are a range of different types of antimalarial tablets available, and these differ in:

  • how they protect you against malaria
  • how they should be taken
  • their side effects
  • the places in the world where they can be used (because of drug resistance problems, which are different for different drugs)

It is important to discuss the suitability of antimalarial tablets for you with a qualified doctor, nurse or pharmacist.

  • This is to make sure that you can tolerate the recommended tablets and ensure that they are appropriate for your destination(s) .

How to take antimalarial tablets:

You should begin taking antimalarial tablets before arriving in a malaria-risk area as guided by your travel health professional.

  • Some tablets need to start a few days before you travel, whilst others may need to be started a week or more before travel.
  • This means there will be enough antimalarial medication in your system to start preventing infection as soon you arrive in the country.

It is important to take the tablets regularly and as directed – missing tablets can lead to malaria infection.

  • It may be helpful to set an alarm to remind you when to take your tablets.

You must complete the course of tablets even after you have left the malaria area:

  • stopping a course of tablets early, even when you are no longer in a malaria area, can lead to you developing malaria infection if the parasites are already in your body
  • the length of time you have to keep taking the tablets after you leave the malarial area is different for different drugs, and you will be advised about this

In the UK, antimalarial tablets require a prescription, except for:

  • chloroquine , which can be bought from local pharmacies
  • Atovaquone/proguanil (often known as Malarone or Maloff protect) which can be bought from local pharmacies (with some restrictions)

Talk to a pharmacist or travel health professional if you are unsure which antimalarials are most suitable for you or your family.

Further information on the commonly used antimalarial drugs can be found via the following links:

  • atovaquone/proguanil
  • chloroquine
  • doxycycline

D = Diagnosis and prompt treatment

Quick diagnosis and access to prompt treatment for malaria saves lives. The most serious forms of malaria can become life-threatening within 24 hours.

If you think you might have malaria it is very important to seek medical attention urgently.

  • Remember that the symptoms can be vague.
  • Infection can occasionally still develop even if you have taken antimalarial tablets.
  • The most serious form of malaria ('falciparum' malaria) can occur around 6 days after first entering a malaria area and up to 30 days (occasionally longer) after leaving a malaria area.
  • If in doubt, seek medical advice and seek it quickly.

Some types of malaria can develop many months after you have visited a malaria affected country:

  • if you develop a high temperature (fever) between 1 week after first potential exposure and up to 1 year after your return from a country with malaria, you should seek medical attention urgently and tell the doctor that you have been in a malaria risk area.

Emergency Standby Treatment for Malaria

If you are travelling to remote or rural areas of a malaria-risk country where you will be unable to access medical care quickly, or to an area where available medical facilities have limited resources or offer low standards of care, then you may be advised by a travel health professional to carry a course of standby emergency treatment (SBET) for malaria.

  • SBET is not a replacement for taking antimalarial tablets when travelling to a country with a risk of malaria.
  • If you think you may benefit from carrying SBET, you should see a travel health professional for a travel health risk assessment before travelling to a malaria-affected country:

For further information please see the Standby Emergency Treatment for Malaria page.

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Brazil South America

Brazil, South America

Malaria Risk & Vaccination Information

What is the risk of malaria in Brazil?

The risk of Malaria is generally low risk throughout the Amazon basin region in Brazil and this includes Manaus. If travelling to the Amazon in Brazil prescription antimalarial such as Malarone, Doxycycline or Lariam should be taken. For all other areas, including the Iguacu Falls, there is low to no risk and bite avoidance measures should be followed

Please check HERE to see a malaria map of Brazil on fitfortravel (a NHS website).

What Malaria prophylaxis do I need to prevent malaria in Brazil?

If you don't already have a prescription from your Doctor for malaria medication, you can save precious time by using our online consultation service to order the suitable malaria medicines for this region by clicking on the following links. Any of the medicine listed can be recommended for malaria prevention in this region. If you already have a prescription for malaria medicine from your Family Doctor, then you can order the quantity on your prescription(s) on the following links. Travelpharm will supply your prescription, once we receive it from you. When you place your order on one of the links below, please follow the instructions on where to send the prescription.

› Atovaquone and Proguanil 250mg/100mg- Generic Alternative to Malarone

› Malarone Tablets

› Malarone Children's Tablets (for Children under 40kg weight)

› Doxycycline Capsules

› Lariam Tablets (Mefloquine 250mg)

› Maloff Protect Tablets (Atovaquone/Proguanil)

Your online consultation will be reviewed by a Pharmacist Independent Prescriber registered in the UK with the General Pharmaceutical Council. We only dispense genuine UK licensed medicines.

What else can I do to prevent malaria?

For more information and advice on how to prevent malaria, see our How To Avoid Insect & Mosquito Bites page.

Chikungunya virus infection in the Caribbean islands and the Americas

This is a virus passed on by being bitten by infected mosquitos. The incubation period is typically 3–7 days and symptoms include acute onset of fever and joint pain. Other symptoms may include headache, conjunctivitis, nausea/vomiting, or rash. The symptoms usually go within 10 days but in some may last months especially the elderly and people with underlying health issues such as high blood pressure and diabetes.

As this is a virus, there is no medication to prevent or treat the disease and anti-malarial tablets such as Chloroquine will not have an effect on it.

Bite avoidance measures should be taken and followed firmly to reduce the likelihood of being bitten.

The affected mosquitoes tend to bite during the day so wear long-sleeved clothing and trousers wherever possible and ensure that a strong insect repellent is used and reapplied regularly, especially after swimming.

You should also sleep under a mosquito net and if you are staying for a long time or are unsure of the hotel/hostel, it would be advisable to take a battery operated or plug-in mosquito killer for your room to kill any lingering mosquitos.

What Vaccines do I need for Brazil?

Below is a table designed to show you what vaccines are mandatory, recommended or ones to consider when visiting Brazil:

CholeraHepatitis AHepatitis BJapanese EncephalitisMeningitisRabies

TetanusTick-Borne Encephalitis TyphoidYellow Fever CertificateYellow Fever Vaccine

Rec Con Con

Man = Mandatory

Con = Consider

Rec = Recommended

Req = Required if visiting from an area with risk of transmission

Other countries in South America »

Venezuela South America

Belize north america and caribbean, bolivia south america, chile south america.

General Pharmaceutical Council

Passport Health logo

Travel Vaccines and Advice for Brazil

Passport Health offers a variety of options for travelers throughout the world.

Rich with beaches, rain forests, and vibrant urban centers, Brazil offers a wide variety of attractions.

For the adventurous, there are mountains to climb and islands to explore. For the more historically inclined, there are whole settlements from the colonial era that have not been renovated since their construction.

To experience the rich culture of Brazil, it is best to come during the time of Carnaval. Dancers flood the streets showing off sambo rhythms and other aspects of Brazil’s musical fabric. This is not to say Carnaval is the only time to behold such an event. Smaller versions of the festival happen throughout the year, and serve as a perfect window into the country’s heart.

Due to Brazil’s history as a trading port and colony, it is a melting pot of African, European, and Latin American cultures.

Brazil is also home to one of the most diverse ecosystems on the planet, offering an incredible range of flora and fauna. A trip to Brazil is a chance to experience a taste of everything.

On This Page: Do I Need Vaccines for Brazil? Other Ways to Stay Healthy in Brazil Health Notices and Outbreaks in Brazil Do I Need a Visa or Passport for Brazil? What Is the Climate Like in Brazil? Is It Safe to Travel to Brazil? Amazing Rio What Should I Take to Brazil? U.S. Embassy in Brazil

Do I Need Vaccines for Brazil?

Yes, some vaccines are recommended or required for Brazil. The CDC and WHO recommend the following vaccinations for Brazil: typhoid , hepatitis A , polio , yellow fever , chikungunya , rabies , hepatitis B , influenza , COVID-19 , pneumonia , meningitis , chickenpox , shingles , Tdap (tetanus, diphtheria and pertussis) and measles, mumps and rubella (MMR) .

See the bullets below to learn more about some of these key immunizations:

  • Typhoid – Food & Water – Shot lasts 2 years. Oral vaccine lasts 5 years, must be able to swallow pills. Oral doses must be kept in refrigerator.
  • Hepatitis A – Food & Water – Recommended for most travelers.
  • Polio – Food & Water – Due to an increase in cases globally, an additional adult booster is recommended for most travelers to any destination.
  • Yellow Fever – Mosquito – Recommended for all regions except Fortaleza and Recife.
  • Chikungunya – Mosquito – Brazil has the most chikungunya cases of any region globally. Vaccination is recommended.
  • Rabies – Saliva of Infected Animals – Moderate risk country. Vaccine recommended for certain travelers based on destination, activities and length of stay.
  • Hepatitis B – Blood & Body Fluids – Recommended for travelers to most regions.
  • Influenza – Airborne – Vaccine components change annually.
  • COVID-19 – Airborne – Recommended for travel to all regions, both foreign and domestic.
  • Pneumonia – Airborne – Two vaccines given separately. All 65+ or immunocompromised should receive both.
  • Meningitis – Direct Contact & Airborne – Given to anyone unvaccinated or at an increased risk, especially students.
  • Chickenpox – Direct Contact & Airborne – Given to those unvaccinated that did not have chickenpox.
  • Shingles – Direct Contact – Vaccine can still be given if you have had shingles.
  • Polio – Food & Water – Considered a routine vaccination for most travel itineraries. Single adult booster recommended.
  • TDAP (Tetanus, Diphtheria & Pertussis) – Wounds & Airborne – Only one adult booster of pertussis required.
  • Measles Mumps Rubella (MMR) – Various Vectors – Given to anyone unvaccinated and/or born after 1957. One time adult booster recommended.

See the table below for more information:

Specific Vaccine Information

  • Typhoid – Typhoid fever, a bacterial infection caused by Salmonella Typhi, spreads through contaminated food and water sources. Vaccination is recommended for travelers and those at risk, along with maintaining good hygiene and food safety.
  • Hepatitis A – Contagious hepatitis A, caused by the hepatitis A virus (HAV), spreads through contaminated food, water, or close contact. Prevention involves vaccination and practicing good hygiene, particularly when traveling to high-risk areas.
  • Yellow Fever – Yellow fever is a viral disease transmitted by infected mosquitoes, mainly Aedes aegypti and Haemagogus species. Vaccination is a key preventive measure, and the vaccine is highly effective.
  • Chikungunya – Chikungunya, transmitted via mosquito bites, poses a health threat. Prevention involves mosquito bite avoidance and vaccination against the disease.
  • Rabies – Rabies is a deadly viral disease that affects mammals and spreads through the saliva of infected animals, primarily through bites or scratches. Preventing rabies involves vaccinating pets, avoiding contact with wild animals, and seeking immediate medical attention if exposed. The rabies vaccine is a crucial preventive measure that stimulates the immune system to produce antibodies against the virus.
  • Hepatitis B – The hepatitis B virus leads to liver infection through contact with infected fluids. The most effective safeguard is the hepatitis B vaccine, administered in a series of shots that stimulate the body to produce antibodies, providing long-term immunity. It is crucial for infants and those at an increased risk of exposure.
  • Measles, Mumps, Rubella (MMR) – Measles, mumps, and rubella are infectious diseases that can easily spread. Vaccination remains the primary defense against these threats. The MMR vaccine, with its two-dose regimen, is a reliable way to bolster immunity and reduce the risk of infection and outbreaks.

Yellow Fever in Brazil

Most travelers to Brazil should receive the yellow fever vaccine . This includes for travel to Rio de Janeiro, Sao Paulo and Brasilia. Vaccination is generally not recommended for travel to only Fortaleza and Recife.

Malaria in Brazil

Malaria in Brazil is mostly present in more rural areas. Transmission is widespread in Acre, Amapa, Amazonas, Rondonia and Roraima. Maranhao, Mato Grosso and Para have malaria in the regions, but it is rare in urban areas like their capitals. Rural and forested areas of all other states have at least some malaria transmission. No malaria has been reported at Iguacu Falls.

Atovaquone, doxycycline, mefloquine and tafenoquine are recommended for travelers to the region. Malaria parasites in Brazil are resistant to chloroquine. Speak with your travel health specialist to identify which antimalarial is best for your trip and medical history.

Malaria and dengue are present in Brazil. Be sure to take proper precautions to avoid these mosquito-borne diseases. Bring repellents netting and antimalarials, if needed.

Zika virus has been found in Brazil. Some travelers are at an increased risk including women who are pregnant or may become pregnant. Make sure you use repellents and netting where needed.

Visit our vaccinations page to learn more. Travel safely with Passport Health and schedule your appointment today by calling or book online now .

Other Ways to Stay Healthy in Brazil

Prevent bug bites in brazil.

In case of bug bites, cleanse the area, use anti-itch treatments, and resist scratching to prevent infection. Seek medical help for severe reactions or if symptoms of vector-borne diseases emerge post-bite.

Food and Water Safety in Brazil

Abroad, make wise food choices by familiarizing yourself with local cuisine and favoring established restaurants. Frequent hand-washing is crucial, and it’s advisable to steer clear of street food, opting for thoroughly cooked options. A travelers’ diarrhea kit is recommended for travel to all regions throughout the world.

Altitude Sickness in Brazil

When ascending to high altitudes, beware of altitude sickness, which can cause headaches, nausea, and dizziness due to reduced oxygen levels. Preventive measures include gradual ascent, staying hydrated, and possibly using medications like acetazolamide. If symptoms appear, swift descent to lower elevations, rest, and medical evaluation are essential.

Infections To Be Aware of in Brazil

  • Chagas disease (American Trypanosomiasis) – Chagas disease, also known as American Trypanosomiasis, is a tropical parasitic infection transmitted by kissing bugs. Preventing Chagas disease involves using repellents and avoiding contacting with the insects.
  • Dengue – According to the CDC, dengue fever, caused by a virus from mosquito bites, manifests through fever, headaches, and severe muscle pain. Preventative measures include using insect repellent and wearing protective clothing. While no specific treatment exists, early medical intervention can mitigate severe complications.
  • Leishmaniasis – The transmission of leishmaniasis primarily occurs through infected sand fly bites, with other routes of transmission possible. Preventing the disease involves minimizing exposure to sand flies. Early detection and treatment can prevent serious symptoms.
  • Schistosomiasis – Schistosomiasis, a prevalent tropical parasitic disease, spreads through contact with contaminated water. To combat it, avoid infected water sources and use protective clothing.
  • Zika – Zika, a virus carried by Aedes mosquitoes, can pose risks, particularly for pregnant women. Preventing Zika requires using mosquito repellent, practicing safe sex, and getting rid of mosquito breeding sites.

Health Notices and Outbreaks in Brazil

  • Oropouche Fever – Amazona and Acre have active Oropouche fever outbreaks. This disease is spread through infected midges (a small fly-like insect) and mosquitoes. Travelers to these regions should use insect repellents. Seek immediate medical care if, while in these areas, you experience high fever, stiff joints, chills or sensitivity to light.

Do I Need a Visa or Passport for Brazil?

As of June 2019, a visa is no longer required for entry to Brazil for stays under 90 days. Proof of a return or onward travel may still be required at entry.

Sources: Embassy of Brazil and U.S. State Department

What Is the Climate Like in Brazil?

Brazil’s climate can vary depending on which region you are visiting.

In the northern parts of the country, the climate is tropical, while in the southern regions the climate is more temperate. Most of the population lives in cooler areas like high altitudes or the coast.

Popular tourist destinations like Rio de Janeiro suffer from an extremely hot climate. Temperatures there are usually above 100 degrees Fahrenheit during the dry season.

In the areas closer to the Amazon rain forest, temperatures higher than 90 degrees Fahrenheit are rare. If you are traveling to cities in the upper region of the Amazon belt like Belem, heavy rainfall is common between December and April.

It is best to study the micro-climate of the region you are visiting while planning a trip to Brazil.

Is It Safe to Travel to Brazil?

U.S. citizens should travel with their passports on them at all times and be prepared to present it to local law enforcement, if necessary.

As a whole, the danger level of Brazil is classified as high. The murder rate if four times that of developed nations, and the crime rate reaches similar numbers. Travelers should remain vigilant at all times. Try not to travel outside of where you are staying after dark.

Do not ever enter the favelas. They are mostly operated by gangs, and are extremely dangerous even for locals. It is best to avoid them completely. If you are planning on going somewhere that is off the beaten path, consult with locals first to find out if it is safe.

Avoid carrying large amounts of money with you. If absolutely necessary, divide it up between several pockets. The efficiency of the police force varies depending on the region. It is imperative that you do not attempt to bribe them for any reason.

Amazing Rio

Avoid mosquitoes and other bugs, insect-borne disease are a threat throughout the world., keep the bugs away with passport health’s repellent options .

Rio de Janeiro is a city in Brazil that is popular for tourists to visit. People go there to see famous landmarks like the Christ the Redeemer statue and Sugarloaf Mountain.

Travelers can also go to the beach at Copacabana, Ipanema, and Leblon to swim, surf and play. Rio de Janeiro is also famous for Carnival, a big party with music, dancing, and colorful parades. Visitors can try different kinds of food like feijoada and churrasco, and drinks like caipirinhas.

At night, there are many bars and clubs to go to, or visitors can have drinks and watch the sunset at the beach. People can also go hiking, biking, or take a jeep tour to explore the city’s parks and natural areas like Tijuca National Park and the Botanical Garden.

Rio de Janeiro has something for everyone and is a great place to experience Brazil’s unique blend of culture and natural beauty.

What Should I Take to Brazil?

Here are some essential items to consider for your trip to Brazil:

  • Medical Supplies – These can be expensive in Brazil. It is important to bring one’s own. Make sure to include anti-diarrheal medication, antimalarials, and basic over the counter aides.
  • Breathable Clothing – The climate of Brazil in the central areas like Rio de Janeiro can be quite hot. Wear clothing that is not too thick, and that you wouldn’t mind sweating in.
  • Warm Clothing – This is advised if traveling to an area south of the Tropic of Capricorn where the climate is more temperate.
  • Documents – Be sure to bring your passport, visa and other forms of identification.
  • Cash – It is safest to operate on a cash-only basis while in Brazil.

U.S. Embassy in Brazil

All Americans visiting Brazil should register online with the U.S. Department of State before departure. This will inform the office of your travel plans within the country and will allow them to reach out in the case of an emergency or evacuation.

Once in Brazil, the information for the U.S. Embassy is:

U.S. Embassy Brasilia SES 801- Avenida das Nacoes, Lote 03 70403-900 – Brasilia, DF Brazil Telephone: 011-55-61-3312-7000 Emergency After-Hours Telephone: 011-55-61-3312-7400 Fax: (61) 3312-7651 Email: [email protected]

Visit the Embassy to Brazil website before departure to confirm correct contact details for the office.

If you have any questions about traveling to Brazil or are wondering what shots you may need for your trip, schedule an appointment with your local Passport Health travel medicine clinic. Call us at or book online now !

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  • Passports, travel and living abroad
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Before you travel check that:

  • your destination can provide the healthcare you may need
  • you have appropriate travel insurance for local treatment or unexpected medical evacuation

This is particularly important if you have a health condition or are pregnant.

Emergency medical number

Call 192 and ask for an ambulance.

Contact your insurance company promptly if you’re referred to a medical facility for treatment.

Vaccinations and health risks

At least 8 weeks before your trip:

  • check the latest vaccination recommendations for Brazil
  • see where to get vaccines and whether you have to pay on the NHS travel vaccinations page

See what health risks you’ll face in Brazil , including:

  • yellow fever
  • chikungunya
  • high UV levels

Altitude sickness is a risk in parts of Brazil. Read more about altitude sickness on TravelHealthPro . 

There is an increase of Dengue in Brazil. Local authorities have declared states of emergency have been introduced in multiple regions of the country, including in Rio de Janeiro State. Dengue is spread by mosquitos, take extra steps to avoid being bitten. Read TravelHealthPro’s Brazil page and information on avoiding insect and tick bites .

The legal status and regulation of some medicines prescribed or bought in the UK can be different in other countries.

If you’re taking medication, bring a prescription or letter from your doctor confirming your need to carry the medication. Bring enough to last your whole trip, as some medicines may not be available locally. Counterfeit drugs can be an issue, so it’s better to travel with your own supplies.

Read best practice when travelling with medicines on TravelHealthPro .

The NHS has information on whether you can take your medicine abroad .

Healthcare facilities in Brazil

Foreign nationals are entitled to emergency medical treatment in Brazilian public hospitals. Public hospitals in Brazil, especially in major cities, tend to be overcrowded and there’s often a long wait for a bed and a lack of medication. Private hospitals will not accept you unless you can show evidence of enough money or insurance to cover your treatment.

FCDO has a list of English-speaking doctors in Brazil .  

There is also guidance on healthcare if you’re living in Brazil .

Travel and mental health

Read FCDO guidance on travel and mental health . There is also mental health guidance on TravelHealthPro .

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Open Access

Peer-reviewed

Research Article

Is Brazil reaching malaria elimination? A time series analysis of malaria cases from 2011 to 2023

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Visualization, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Nucleus of Tropical Medicine, University of Brasilia, Brasilia, Brazil

ORCID logo

Roles Conceptualization, Investigation, Methodology, Supervision, Validation, Writing – review & editing

Affiliation Department of Infection Biology, London School of Hygiene & Tropical Medicine, London, United Kingdom

Roles Conceptualization, Investigation, Methodology, Writing – original draft, Writing – review & editing

Affiliation Faculty of Health Sciences, University of Brasilia, Brasilia, Brazil

Roles Conceptualization, Formal analysis, Investigation, Writing – original draft, Writing – review & editing

Affiliation Health and Environmental Surveillance Secretariat, Ministry of Health, Brasilia, Brazil

Roles Conceptualization, Investigation, Methodology, Supervision, Visualization, Writing – review & editing

Roles Conceptualization, Investigation, Methodology, Supervision, Writing – review & editing

Roles Conceptualization, Formal analysis, Funding acquisition, Investigation, Methodology, Supervision, Validation, Writing – review & editing

Affiliation Evandro Chagas National Institute of Infectious Diseases, Fundação Oswaldo Cruz (Fiocruz), Rio de Janeiro, Brazil

  • Klauss Kleydmann Sabino Garcia, 
  • Seyi Soremekun, 
  • Amanda Amaral Abrahão, 
  • Paola Barbosa Marchesini, 
  • Chris Drakeley, 
  • Walter Massa Ramalho, 
  • André M. Siqueira

PLOS

  • Published: January 31, 2024
  • https://doi.org/10.1371/journal.pgph.0002845
  • Reader Comments

Fig 1

In Brazil, 99% of malaria cases occur in the Amazon region, mainly caused by Plasmodium vivax (~83%) and Plasmodium falciparum ( Pf ) species. Aligned with the Sustainable Development Goals, Brazil aims to eliminate autochthonous malaria by 2035. This study aims to analyse epidemiological patterns of malaria in Brazil to discuss if Brazil is on track to meet malaria control targets. A time-series study was conducted analysing autochthonous malaria new infections notifications in the Brazilian Amazon region from 2011 until June 2023. Descriptive analyses were conducted, along with joinpoint regression and forecast models to verify trend and future behaviour. A total of 2,067,030 malaria cases were reported in the period. Trend analysis indicated a decreasing trend in all malaria infections since late 2017 (monthly reduction = 0.81%, p-value <0.05), while Pf infections have increased progressively since 2015 (monthly increase = 0.46%, p-value <0.05). Forecast models predict over 124,000 malaria cases in 2023 and over 96,000 cases in 2024. Predictions for Pf infections are around 23,900 cases in 2023 and 22,300 in 2024. Cases in indigenous population villages are predicted to reach 48,000 cases in 2023 and over 51,000 in 2024. In gold mining areas it is expected over 21,000 cases in 2023 and over 20.000 in 2024. Malaria elimination in Brazil has advanced over the last decade, but its speed has slowed. The country exhibits noteworthy advancements in the reduction of overall malaria cases. It is imperative, however, to proactively target specific issues such as the incidence raise among indigenous populations and in gold mining areas. Pf infections remain a persistent challenge to control in the country and may require novel measures for containment. Current government supporting actions towards combating illegal goldmining activities and protecting indigenous populations may help malaria control indicators for the following years.

Citation: Garcia KKS, Soremekun S, Abrahão AA, Marchesini PB, Drakeley C, Ramalho WM, et al. (2024) Is Brazil reaching malaria elimination? A time series analysis of malaria cases from 2011 to 2023. PLOS Glob Public Health 4(1): e0002845. https://doi.org/10.1371/journal.pgph.0002845

Editor: Suma Thankamma Krishnasastry, T D Medical College, INDIA

Received: December 5, 2023; Accepted: January 14, 2024; Published: January 31, 2024

Copyright: © 2024 Garcia et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All data used and analysed in the current study are available in the additional file II.

Funding: This work was supported by the Bill & Melinda Gates Foundation (INV-003970 to AMS, URL: https://www.gatesfoundation.org/ ), and by the Brazilian Ministry of Health (BMoH/DECIT/CNPq) - (443148/2019-8 to AMS, URL: https://www.gov.br/saude/pt-br/composicao/sectics/decit ); And by the Higher Education Personnel Improvement Coordination (CAPES) notice 10/2022 (88881.690401/2022-01 to KKSG, URL: https://www.gov.br/capes/pt-br ). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Malaria is an acute febrile infectious disease that is prevalent in tropical regions. Global estimates for the year 2021 indicate approximately 247 million individuals affected worldwide [ 1 ]. In Brazil, malaria is a notifiable disease, and case detection covers the entire country. The Amazon region accounts for 99% of malaria cases [ 2 ]. The main causative agents are Plasmodium vivax and Plasmodium falciparum . P . vivax infections account for around 83% of cases in the Amazon region [ 3 ]. Although transmission of P . malariae occurs, it is relatively low, while P . ovale autochthonous infections do not occur in Brazil. The primary vector responsible for malaria transmission in the Brazilian Amazon region is the Anopheles darlingi mosquito [ 2 ].

Malaria control efforts in Brazil are coordinated by the National Program for the Prevention and Control of Malaria (NMCP), established in 2003 [ 4 ], inside the Brazilian Ministry of Health (BMoH). Currently (2023) it is a Coordination called Malaria Elimination Coordination inside a General Coordination of zoonotic and vector transmitted diseases. The NMCP implements entomological control measures and epidemiological surveillance activities in collaboration with state and municipal health departments. Diagnosis and treatment for malaria are widely available and provided free of charge in Brazil by the Public Health System [ 2 , 5 ]. And in alignment with Sustainable Development Goals (SDG) Brazil aims to eliminate deaths by the disease by 2030, and to eliminate autochthonous malaria by 2035 [ 6 ].

The epidemiological landscape of malaria in Brazil throughout the 20th century witnessed a notable increase in cases. This rise was attributed to the country’s urban expansion, characterized by the construction of roads and agricultural settlements. These developments culminated in a significant population expansion, accompanied by an increased exploitation of the Amazon in the second half of the century [ 7 – 9 ]. In the early 21st century, Brazil recorded over 600,000 malaria cases in 2005, but the incidence has since been on a downward trajectory important exception for the years of 2017 to 2018, with approximately 130,000 cases reported in 2016. Since 2017 the number of cases has been never like 2016 for total cases and P . falciparum [ 10 ].

Despite the NMCP’s endeavours to eliminate the disease, political and structural changes in Brazil’s government and in the BMoH have led to a weakening of the program’s effectiveness since 2016 when NMCP was merged with dengue control program and lost protagonism and strength, and in 2018 is has been transformed in a technical group inside the zoonotic and vector transmitted diseases coordination [ 11 ]. Also, there has been an increase in cases among indigenous population and gold miners, strengthened by the relaxation of environmental protection laws between 2019 and 2022 [ 11 ]. Furthermore, a recent analysis by Laporta et al. (2022) cautioned that the current actions undertaken by the NMCP may not suffice to attain the objective of malaria elimination in the country [ 12 ].

Therefore, this study aims to analyse the recent disease behaviour in the Brazilian Amazon region. The goal is to have a comprehensive understanding of the prevailing conditions to discuss if Brazil is on track to meet malaria control targets.

Ethics statement

This study was exempt from approval by ethics committees, following the guidelines outlined in the Brazilian National Health Council Resolution No. 466/2012, which allows the conduct of studies using public and non-identified data without the need for ethics committee approval.

Study design, site, and population

This study employed a descriptive design with time-series analysis to examine trends in malaria case notifications in the Brazilian Amazon region from 2011 to June 2023.

The study focused on the Brazilian Amazon region, which comprises nine states: Acre, Amazonas, Amapá, Mato Grosso, Maranhão, Pará, Roraima, Rondônia, and Tocantins. This region encompasses 772 municipalities, covering an area of over 5 million km 2 , accounting for approximately 58.9% of the country’s total area. The Sivep-Malaria database includes notifications from all nine states, which had an estimated population of 28.4 million in 2022 [ 13 ].

The study population comprised individuals notified in Sivep-Malaria as new malaria autochthonous infections (filter variables: ID_LVC = 2, and TIPO_LAM = 1 e 2). Autochthonous cases were classified based on their probable place of infection, following guidelines provided by the BMoH [ 14 , 15 ].

Data source and study variables

The data used were non-nominal records obtained from the National Malaria Epidemiological Information System in Brazil (Sivep-Malaria), provided by the Brazilian Ministry of Health (processes #25072.015038/2021-05, #25072.034317/2021-60, #25072.004310/2023-85, and 25072.059125/2023-28). Population data were from the Brazilian Institute of Geography and Statistics (IBGE).

The study analysed the following variables: type of notification (new case or Cure Verification Slide—LVC), date of notifications, laboratory results defining the Plasmodium species, and the local of probable infection (country, state, municipalities) along with type of place of infection (rural area, urban area, gold mining area, indigenous villages).

Statistical analysis

Descriptive analysis involved the summarization of annual malaria case counts. Due to the low proportion of malaria caused by P . malariae and P . ovale , these cases were analysed together with Plasmodium vivax ( Pv ) infections. Similarly, infections of mixed species ( P . falciparum infections along with other species) were categorized together with P . falciparum ( Pf ) infections. Annual Parasitological Incidence (API) was calculated by dividing the total number of new autochthonous cases by the estimated population for each municipality and multiplying it by 1,000 residents (representing the population at risk). Malaria API were further categorized based on the risk stratification provided by the BMoH, classifying API as high-risk (IR ≥ 50 cases per 1,000 residents), medium-risk (IR between 10 and 49.99 cases per 1,000 residents), low-risk (IR between 1 and 9.99 cases per 1,000 residents), and very low-risk (IR < 1 case per 1,000 residents) [ 10 ].

Trend analyses

Malaria trends were described over time using Joinpoint Regression models (JP regression software Version 4.9.1.0) [ 16 ] with Poisson variance to handle uncorrelated but heteroscedastic errors to identify inflection points (joinpoints) and estimate Monthly Percent Changes (MPC) to describe and characterize trends (increase, decrease, or stability) [ 17 ]. The model tests whether a multi-segment line provided a statistically better fit at the 0.05 level to describe the temporal evolution of the data compared to a straight line or a line with fewer segments [ 17 ]. Grid Search methodology was employed to identify the best data suitability for the time-series, and Monte Carlo permutations were used to test and compare different numbers of joinpoints in each model [ 17 , 18 ].

Forecast analyses

To predict the future behaviour of malaria against NMCP malaria elimination goals, forecast analysis was performed in R software (version 4.1.1.) [ 19 ] using the forecast [ 20 ] and fpp [ 21 ] packages. The Holt-Winters (HW) prediction model [ 22 , 23 ] was employed, considering key aspects of a time-series such as trend, seasonality, and randomness. The HW method is suitable for short-term forecasts; therefore, monthly counts of autochthonous malaria were used for the following 18 months (July 2023 until December 2024). The time series residuals were analysed to check model’s adequacy.

The forecast model used exponential smoothing and multiplicative or additive seasonality effects. The most appropriate seasonal effect was chosen based on the smallest error presented between the models [ 22 , 23 ]. The exponential smoothing technique of the HW method was employed to analyse the time-series values and estimate likely future outcomes with a 95% confidence interval (CI). The prediction models encompassed all autochthonous malaria cases in the Brazilian Amazon region, as well as specific analyses for P . falciparum infections (mixed infections included), individual states of the Amazon region, indigenous population villages, and gold mining areas.

Spatial analyses

The Qgis software (version 3.18) was utilized to performed descriptive analyses of the geospatial distribution of malaria based on yearly API values. Two spatial analyses were conducted: one for all autochthonous malaria cases and another for autochthonous P . falciparum and mixed infections. The analysis was conducted to describe spatial behaviour through the study period of malaria cases in the Amazon region.

Descriptive analysis

The study period registered a total of 2,067,030 autochthonous new malaria cases. Out of these, 278,483 cases (13.5%) were attributed to P . falciparum and mixed infections, while 1,788,547 cases (86.5%) were caused by P . vivax ( S1 Table ). From 2011 to the end of 2022, Brazil achieved a reduction of over 131,000 autochthonous malaria new cases, resulting in a 50.6% absolute decrease ( S2 Table ).

Regarding the local of infection (urban, rural, indigenous village populations, and gold mining areas): the proportion of cases in rural areas decreased from 67.0% (175,883) in 2011 to 42.2% (54,268) in 2022. Similarly, the proportion of cases in urban areas declined from 14.8% (38,485) in 2011 to 8.2% (10,494) in 2022 ( S2 Table ). Cases infected in indigenous population villages increased from 10.5% (27,359) in 2011 to 30.7% (39,440) in 2022. Infections in gold mining areas rose from 5.9% (15,332) in 2011 to 17.9% (22,965) in 2022.

A total of 418,185 malaria cases were reported in indigenous villages during the study period, of which 25.4% were attributed to P . falciparum and mixed infections. In gold mining areas, there were 152,884 malaria cases, with 13.6% caused by P . falciparum and mixed infections. Also, agriculture-related occupations accounted for most cases (25.9%), the number of cases among gold miners experienced an increase from 3.9% (10,131) in 2011 to 17.3% (22,288) in 2022 ( S2 Table ).

The number of high-risk municipalities decreased from 45 in 2011 to 21 in 2022, reflecting a 46.7% reduction ( S1 and S2 Videos). Similarly, the total number of medium-risk municipalities declined from 81 to 39 (a reduction of 51.9%). While the reduction in number of municipalities regarding risk classifications for P . falciparum infections was more modest, there was an overall decrease in the number of low-risk and very low-risk municipalities. Consequently, one can expected that the number of municipalities capable of eliminating P . falciparum infection increased.

Trend analysis

The trend analysis identified three distinct periods for total number of malaria autochthonous cases. The initial period exhibited a significant and progressive monthly reduction of -1.45% until mid-2016. Subsequently, there was a notable and statistically significant upward trend until the second half of 2017, with a monthly increase of +4.14%. After this period, Brazil experienced a slower rate of reduction (-0.81% monthly) compared to the period between 2011 and 2016 ( Fig 1A ). In contrast to the general behaviour of all malaria autochthonous cases, P . falciparum infections displayed a cases Monthly Percent Change (MPC) increase until the end of 2011 (+4.57%), and then started a strong reduction until late 2015 (-1.98%). Since then, P . falciparum and mixed infection have slowly increased over the months (+0.46%) ( Fig 1B ).

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A) Trend analysis of total number of malaria new cases notified in the Brazilian Amazon region between 2011 and 2023; B) Trend analysis of malaria cases by P . falciparum and mixed infections notified in the Brazilian Amazon region between 2011 and 2023. Source: Sivep-Malaria, Brazilian Ministry of Health.

https://doi.org/10.1371/journal.pgph.0002845.g001

Forecast analysis

The forecast for autochthonous malaria new cases in Brazil predicted a general decrease of annual cases to a total of 124,990 malaria new cases by the end of 2023 and 96,842 by December 2024 ( Fig 2A ). For P . falciparum and mixed infections, the model predicted a general increase to a total of 22,913 new autochthonous cases in 2023 and 22,322 cases in 2024 ( Fig 2B ).

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A) Malaria autochthonous infections in the Brazilian Amazon, forecast for 2023 and 2024; B) Plasmodium falciparum autochthonous infections in the Brazilian Amazon forecast, for 2023 and 2024. Source: Sivep-Malaria, Brazilian Ministry of Health.

https://doi.org/10.1371/journal.pgph.0002845.g002

Individual predictions made for each endemic state showed that the states of Maranhão and Mato Grosso can reach zero autochthonous infections by the end of 2024. The state of Acre is unlikely to present substantial cases reductions, and the states of Roraima, Amazonas, and Amapá may present big increases in cases numbers ( Fig 3 ).

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Source: Sivep-Malaria, Brazilian Ministry of Health.

https://doi.org/10.1371/journal.pgph.0002845.g003

Furthermore, cases in indigenous population villages are predicted to reach 48,001 cases in 2023 and 51,080 in 2024. In gold mining areas it is expected a total of 21,819 in 2023 and 20.015 in 2024 ( Fig 4 ).

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https://doi.org/10.1371/journal.pgph.0002845.g004

Discussions

General scenario.

From 2011 to June 2023, malaria cases in the Amazon region were primarily infections caused by P . vivax , as reported previously [ 24 ]. Brazil has witnessed a decline in malaria cases in the Amazon region, from over 260,000 cases in 2011 to less than 130,000 cases in 2022. However, country level data analysed in this study are insufficient to identify focal problems such as cases increase among indigenous populations villages and gold mining areas.

From 2011 to 2016, Brazil experienced a declining trend in malaria cases, followed by an increase in cases not only within the country but also in the Latin American region in 2017 and 2018 [ 1 ]. Subsequently, Brazil began consistently reducing malaria cases, except for infections caused by P . falciparum , which exhibited a continuous increase for nearly six years after initially decreasing from 2011 to 2015.

Due to the rise in autochthonous P . falciparum infections in early 2019 and the cessation of infection reduction trends since 2016, the forecast for 2023 and 2024 does not indicate progress in controlling P . falciparum infections. The National Plan for Malaria Elimination anticipated fewer than 6,000 P . falciparum cases in 2023 and in 2024 [ 6 ], whereas this study predicts an annual incidence of around 14,000 cases. Consequently, adjustments in P . falciparum control strategies are necessary to reach the stablished goals in 2024, or the goals need revaluation. The upward trend in P . falciparum infections, which persisted until late 2021, signifies a weakening of malaria epidemiological surveillance efforts [ 11 ].

Infections are predominantly observed in rural areas ( S3 Table ), but there was a noticeable increase in infections within indigenous population villages and gold mining areas, particularly after 2016. Although efforts have been made to implement control measures and expand diagnosis and treatment services among indigenous populations and territories, malaria control remains a persistent concern for the NMCP [ 11 ]. The increase of cases in those areas relates to the increase of P . falciparum infections over the latest years. Even though control actions are more likely to impact P . falciparum infections, control actions in those areas have been a challenge in recent years. Also, deforestation activities are common in those areas, and those activities have been proven to influence in the upsurge of P . falciparum infections [ 25 ]. Mainly due to areas and populations social vulnerability (such as difficulties in having access to health services, education, residency, basic sanitation and mainly because of the invasion of their territories by gold miners and other exploitations activities) which makes them highly susceptible to large-scale transmission chains during outbreaks [ 26 ].

Given the escalating trend and the projected increase in cases for 2023 and 2024, it is crucial to pay close attention to this issue and take appropriate measures in indigenous villages and gold mining areas. But there are perspectives that health situation among those populations will improve considering that stronger interest has been shown recently (2023) to protect indigenous populations and to stand against illegal mining and deforestation activities [ 27 ]. These perspectives offer a more favourable outlook for the occurrence of malaria cases among those populations for the following years.

The rise in malaria cases within indigenous population villages can be attributed to the increase in Amazonian deforestation observed in recent years [ 27 ]. Deforestation in the Amazon basin has been linked to the surge in malaria cases in Brazil [ 28 , 29 ], and the country has also witnessed a rise in gold mining activities, which has been associated to increases in malaria incidence [ 30 , 31 ]. Given that many gold mining areas are situated within indigenous territories [ 11 ], it is plausible that deforestation is facilitating the migration of disease-carrying vectors from the forest to indigenous population villages. This migration enhances the vectorial capacity and leads to a higher occurrence of malaria cases among indigenous communities [ 32 , 33 ].

States scenario

The BMoH has an opportunity to develop a comprehensive policy and strategy to eliminate Malaria in the state of Maranhão. This is justified by the fact that a significant number of municipalities in the state have experienced a decline in malaria cases, with a particularly low incidence of P . falciparum infections since 2017.

Although the state of Acre has a substantial proportion of low-risk municipalities, there are still medium-risk areas in the west and east. Strengthening elimination strategies in the low-risk municipalities of Acre may contribute to overall malaria control in the state.

Based on the forecast, it is projected that the state of Amazonas, along with Acre, Roraima, and Pará, will not experience significant reductions in the number of autochthonous malaria infections in 2023. Consequently, these states pose significant challenges in malaria control efforts, as also noted by Laporta et al. [ 12 ]. Therefore, it is recommended to prioritize elimination strategies in Maranhão and in the low-risk municipalities of Mato Grosso.

Although the National Plan of Malaria Elimination, published in 2022 [ 6 ], presented goals to control and eliminate malaria, it did not mention any collaboration with the Environmental Health Surveillance, Workers Health Surveillance, and Public Health Emergencies Surveillance sectors of the BMoH, and also for example other sectors like Environmental Ministry, Mining and Energy Ministry, as they can play a crucial role in strengthening malaria control strategies based in One Health approaches [ 34 ]. Inclusion of those sectors in planning activities can enhance intersectoral strategies for controlling malaria in rural and low-sanitation areas, as well as prevent infections and promote treatment among workers engaged in malaria-prone economic activities. Their involvement is also vital in responding to disease outbreaks. By engaging with these sectors, malaria control measures can be improved in the medium to long term.

Limitations

The predictions utilized in this study are suitable for short-term forecasting and should not be extrapolated to distant scenarios. Also, the time trend and forecast models did not consider the effect of any interventions used by the NMCP over the decades, such as the Malaria supporters’ project [ 35 ]. Therefore, the dynamics of recent scenarios can rapidly change due to governmental interventions aimed at malaria control. For this reason, real outcomes for the year 2024 may differ from the projections presented here after short term structured control measures.

The malaria information system has been effectively employed for the documentation and surveillance of malaria cases since its implementation in the early century [ 4 ], underreporting might be bigger in indigenous villages due to difficulted accessibility from health surveillance teams and among gold miners and gold mining regions due to the sensitive nature of these activities.

Conclusions

Malaria elimination in Brazil has advanced over the last decade but its effect has slowed. The progress seen is due to the control of infections by P . vivax , which is the predominant species in the country, but P . falciparum infections control remains a concern.

While the forecasts presented in this article suggest that Brazil is likely to reduce total annual autochthonous infections by the end of 2024, infections in the states of Amazonas and Roraima are still a challenge, which are connected to the heavy impact of the expansion of gold mining and deforestation activities. Multisectoral efforts to control illegal gold mining activities, deforestation, and to strengthen epidemiological surveillance and assistance in those areas and among indigenous populations are crucial for reducing malaria in those states.

Considering the reductions observed over the last decade, thanks to national efforts to combat malaria, it is anticipated that the years of 2023 to 2026 may yield better results than those achieved between 2019 and 2022. This expectation is also influenced by the current government’s encouragement to implement policies that protect vulnerable populations, promote the health of indigenous communities, and address issues such as deforestation and illegal gold mining. These efforts align with international agendas, such as the Sustainable Development Goals.

Supporting information

S1 checklist. strobe statement—checklist of items that should be included in reports of observational studies..

https://doi.org/10.1371/journal.pgph.0002845.s001

S1 Table. Epidemiological profile by species of infections.

https://doi.org/10.1371/journal.pgph.0002845.s002

S2 Table. Epidemiological profile by year.

https://doi.org/10.1371/journal.pgph.0002845.s003

S3 Table. Cases by place of infection and species of infections.

https://doi.org/10.1371/journal.pgph.0002845.s004

S1 Data. Data repository.

https://doi.org/10.1371/journal.pgph.0002845.s005

S1 Video. Spatial distribution of all autochthonous malaria new infections risk classification in the Brazilian Amazon, 2011–2022.

*Total number of malaria new cases using probable place of infection. Source: Sivep-Malaria, Brazilian Ministry of Health. Data for the year of 2023 is not complete and was not included in the risk classification.

https://doi.org/10.1371/journal.pgph.0002845.s006

S2 Video. Spatial distribution of Plasmodium falciparum and mixed autochthonous infections risk classification in the Brazilian Amazon, 2011–2022.

* Plasmodium falciparum and mixed infections notified by probable place of infection. Source: Sivep-Malaria, Brazilian Ministry of Health. Data for the year of 2023 is not complete and was not included in the risk classification.

https://doi.org/10.1371/journal.pgph.0002845.s007

Acknowledgments

We thank all authors’ contributions. CAPES for allowing the interchange between the Nucleus of Tropical Medicine from the University of Brasília and The London School of Hygiene and Tropical Medicine. And we thank the institutions for providing knowledge and means to develop the research.

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  • v.8; Jan-Dec 2021

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An update on prevention of malaria in travelers

Nelson iván agudelo higuita.

Department of Medicine, Section of Infectious Diseases, University of Oklahoma Health Science Center, 800 Stanton L. Young Blvd., Suite 7300, Oklahoma City, OK 73104, USA

Bryan Pinckney White

Infectious Diseases Clinical Pharmacist, Oklahoma University Medical Center, Oklahoma City, OK, USA

Carlos Franco-Paredes

Department of Medicine, University of Colorado Denver School of Medicine, Aurora, CO, USA

Miranda Ann McGhee

Malaria, a parasitic disease caused by protozoa belonging to the genus Plasmodium , continues to represent a formidable public health challenge. Despite being a preventable disease, cases reported among travelers have continued to increase in recent decades. Protection of travelers against malaria, a potentially life-threatening disease, is of paramount importance, and it is therefore necessary for healthcare professionals to be up to date with the most recent recommendations. The present review provides an update of the existent measures for malaria prevention among travelers.

Introduction

Malaria is a parasitic disease caused by protozoa belonging to the genus Plasmodium . There are four species that exclusively affect humans: Plasmodium falciparum , Plasmodium vivax, Plasmodium ovale, and Plasmodium malariae. Plasmodium species that commonly infect non-human primates can also be responsible for a high proportion of human cases in certain parts of the world as is the case with Plasmodium knowlesi in southeast Asia and Plasmodium simium in Brazil. 1 – 4 All species of malaria are transmitted by the bite of an infective female Anopheles mosquito. Malaria can be also transmitted through blood transfusion, needle sharing, laboratory accidents, organ transplantation, and congenitally from mother to fetus. 5 , 6

Malaria continues to represent a formidable public health challenge. According to the most recent World Malaria Report published in 2020, there were an estimated 229 million cases of malaria worldwide in 2019 with 94% reported from the African region and mostly affecting children younger than 5 years of age. There were an estimated 409,000 deaths globally, with 95% occurring in sub-Saharan Africa. 7 Although there has been progress in reducing the global prevalence and mortality attributable to malaria, the number of cases reported among travelers in the United States (US) has continued to have a stepwise increase of approximately 29.4 cases per year since 1972. 6 A total of 2161 confirmed malaria cases were reported by the Centers for Disease Control and Prevention (CDC) in 2017, a 4% relative increase in confirmed cases compared with 2016 and the highest in 45 years. Most cases originated from West Africa (66.9%) and P. falciparum accounted for the majority of infections (70.5%). Most of the cases of malaria affected travelers who were visiting friends and relatives (VFR traveler) and only about a quarter of US residents with malaria reported taking any form of chemoprophylaxis. There were 27 pregnant women affected, of which 22 were hospitalized. Ten of the pregnant women were US residents, and none took prophylaxis to prevent malaria. 6

Search strategy and selection criteria

We searched PubMed and Google Scholar for articles published up to June 30, 2021 with emphasis in the last 2 decades, using the terms ‘malaria,’ in combination with ‘traveler,’ ‘protection,’ ‘prophylaxis,’ ‘prevention.’ We reviewed these articles, and relevant articles in the references of these articles. Only articles published in English were included.

Clinical presentation

The severity of clinical manifestations due to malaria is primarily determined by previous exposures to Plasmodium spp. and the resulting immune status (i.e. premunition). The degree of parasitemia also plays a significant role in the pathogenetic mechanisms of the infection in the microvasculature. The ability of P. falciparum and, to a lesser degree, P. knowlesi to infect most stages of the lifespan of red cells correlates with higher levels of parasitemia and worse outcomes. Reports of life-threatening malaria caused by P. vivax are increasing in certain areas of the world, with thrombocytopenia being a potential marker of severity that requires further validation. 8 , 9 Most travelers are considered non-immune to malaria and symptomatic disease is therefore seen across all age groups. The incubation period is of approximately 2 weeks for malaria caused by P. falciparum , P. knowlesi , and P. vivax . For P. ovale and P. malariae , the incubation period is of about 2–3 weeks and 18–35 days, respectively. 10 – 13 Temperate climate P. vivax ( P. vivax var hibernans ) was of great importance until the middle of last century and was characterized by long incubation periods of up to 8–10 months. Temperate climate P. vivax malaria is still endemic in the Korean peninsula. 14 – 16

The incubation period can also be altered (i.e. prolonged) by agents used for chemoprophylaxis and by antibiotics that are not commonly used to prevent or treat malaria such as rifampin, azithromycin, and ciprofloxacin. 17 – 19 Malaria can present as early as 1 week after the initial exposure and as late as several years after leaving a malaria zone irrespective of chemoprophylaxis use. This is especially true with P. vivax or P. ovale when no liver stage schizonticide is taken as part of prophylaxis. 13 , 18 , 19

The presentation of malaria can be vague and nonspecific. Fever, malaise, headache, chills, and sweats are common but gastrointestinal and respiratory complaints may predominate. Fever in a returning traveler should be considered a medical emergency and expedited evaluation for life-threatening infections is mandatory. Failure to consider the diagnosis of malaria is not infrequent and the diagnosis can be difficult, as fever is not always present during the initial evaluation. If the first blood films are negative, both thick and thin blood films or rapid diagnostics should be repeated twice 8–24 h apart. 13 , 19

There are no pathognomonic physical exam findings for malaria but several variables could be used to predict a higher likelihood of the disease. Splenomegaly, fever, a white blood cell count <10,000 cells/l, platelet count <150,000/μl, hemoglobin <12 g/dl, eosinophils <5%, and hyperbilirubinemia have been associated with parasitemia. 20 , 21 Malaria is a notifiable disease in every state of the United States.

Educating the traveler

The risk of acquiring malaria is determined by a variety of factors inherent to the traveler, itinerary, and the geographic area being visited. The risk assessment should be therefore individualized and ideally occur at least 4–6 weeks before departure.

Malaria is endemic in 90 countries and territories ( Figure 1 ) and its transmission is usually continuous throughout the year in tropical regions and seasonal in temperate zones of the world. The intensity and extent of transmission within a country varies and may be focal. 7 , 22 There are several resources with country-specific data regarding malaria transmission to help clinicians with decision making. It is important to note that despite the great value offered by these resources, reliable data on area-specific risks within a predetermined region/country is difficult to predict 23 and that several professional organizations publish recommendations that differ, sometimes to a great extent. In general, studies have shown that the highest risk of malaria transmission occurs in sub-Saharan Africa and Papua New Guinea. 6 , 24 – 27 Chemoprophylaxis should be therefore prescribed routinely to travelers visiting these regions, Pakistan and India, regardless of whether they will be visiting an urban or rural setting. It is important to note that most, but not all, urban and tourist destinations in southeast Asia, Central and South America do not have sufficient risk of malaria transmission to warrant routine prophylaxis. 27 , 28

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Malaria-endemic countries.

Certain populations are at higher risk of acquiring the disease or suffering from its complications. Immigrants who have settled in developed countries and return to their home countries as VFR travelers are highly vulnerable. 6 , 23 , 26 Some of the factors that affect a VFR’s risk of illness include beliefs that they are immune to diseases that they might have acquired during childhood (e.g. malaria), access and trust of the healthcare (e.g. asylum seekers and new immigrants), lack of awareness of the risks associated with travel, cost, and language barriers among others. 29 , 30 Pregnant women are at high risk of developing potentially fatal complications related to malaria. 31 Women who are pregnant or who are likely to become pregnant should be advised against travel to malaria-endemic zones, as there is no chemoprophylactic regimen that is completely effective (see section 8.2 for more details).

There are many other aspects that need to be considered when determining the risk of acquisition of malaria. These include the length and season of the trip, rural versus urban setting, altitude of the destination, accommodation characteristics, outdoor exposure during night-time hours in locations with considerable exposure to mosquitoes, and adherence to mosquito avoidance precautions and chemoprophylaxis. 23 Travel health practitioners need to inform travelers of the life-threatening nature of malaria infection and the importance of prevention.

Personal protection measures

Anopheles spp. feed mainly between dawn and dusk, and measures to decrease exposure during this time is of paramount importance. Contact with mosquitoes can be reduced by the use of screened accommodations and mosquito bed nets (preferably insecticide impregnated), appropriate application of repellents, and wearing clothes that cover most of the body. 23 , 32 – 34

A wide array of popular devices designed to repel mosquitoes are available on the market. A few examples include coils, candles, and heat-generating devices. The effectiveness of these devices is not supported by robust studies and should therefore be used with the addition of proven measures. 34

In general, topical repellents can be divided into synthetic chemicals and plant-derived essential oils. 35 , 36 The best-known chemical insect repellents are N, N -diethyl- m -toluamide, also known as N, N -diethyl-3-methylbenzamide (DEET), and picaridin. Oil of lemon eucalyptus (OLE) or PMD (chemical name: para-mentahne-3,8 diol), IR3535 [chemical name: 3-( N -butyl- N -acetyl)-aminopropionic acid, ethyl ester], and 2-undecanone are considered either derivatives or synthetic products of natural materials. 33 , 34

The efficacy and duration of protection are subject to factors such as ambient temperature and humidity, degree of perspiration and level of activity, exposure to water and other variables. The degree of protection to a determined species of mosquito or tick varies according to the active ingredient and the duration of protection is proportional to the concentration of the product. 33 , 34 For DEET, picaridin, and IR3535, a concentration of at least 20% and for PMD 30% is recommended. Most repellents can be used on children aged >2 months with the exception of OLE, which should not be used on children aged <3 years. No additional precautions for using registered repellents on children or pregnant or lactating women are otherwise needed. 33 , 34 It is also important to remember that DEET can have an unpleasant odor for some and can dissolve plastic. In addition, the sunscreen and repellent should be used as separate products and the sunscreen should be applied first.

The Environmental Protection Agency reviews and approves repellents based on efficacy and human safety. A repellency awareness graphic is available on the labels of insect repellents. More information is available on the following website: www.epa.gov/insect-repellents/repellency-awareness-graphic .

Chemoprophylactic agents

Please refer to Table 1 for doses and schemes used for the different drugs.

Chemoprophylactic agents in malaria.

CrCl, creatinine clearance; G6PD, glucose-6-phosphate dehydrogenase.

Atovaquone/proguanil

Atovaquone inhibits the parasitic electron transport. Proguanil is metabolized through CYP2C19 to cycloguanil, which acts a parasitic dihydrofolate reductase inhibitor. 37 The drug’s synergistic effect is caused by proguanil’s ability to increase atovaquone activity to collapse the mitochondrial membrane potential. 38 Atovaquone is poorly absorbed, with bioavailability reaching 23% when taken with food. It is extensively protein bound (>99%) and is primarily (94%) hepatically eliminated with limited metabolism. It has a half-life of 55.9 h with multiple doses. 37 Proguanil is extensively absorbed regardless of food with a bioavailability of 60–75%. Approximately 40–60% of proguanil is excreted renally with a half-life of 12–21 h. 38

Studies have shown a 96–100% protection efficacy against P. falciparum . The medication is well tolerated with the most common side effects reported being abdominal pain, nausea, vomiting, and headache. Abbreviated regimens have been examined in an attempt to improve compliance. The doses used for the treatment of malaria (four tablets daily for 3 consecutive days) provides protection against malaria for >4 weeks. A study done in Australia examined the efficacy of this regimen in adults traveling to malaria-endemic areas with low-to-medium risk for up to 4 weeks. Most participants complied with the regimen, although 43.3% reported side effects. No traveler developed malaria, although the study was not designed and did not have the statistical power to determine effectiveness. 39 An observational study designed to detect prophylactic failure with a twice-weekly regimen of atovaquone/proguanil among long-term expatriates (⩾6 months) in West Africa found no cases of malaria. In comparison, the malaria rates were 11.7/1000 person-months in the group taking no prophylaxis, and 2.06/1000 person-months in the group taking weekly mefloquine. 40 Other investigators have examined and concluded that discontinuation of the medication 1 day after return as opposed to the 7 days did not alter efficacy. 41 Despite these promising results, a modified regimen of atovaquone/proguanil needs to be supported by more robust data from clinical trials with a larger sample size and higher-risk destinations. 42

Doxycycline

Doxycycline inhibits protein synthesis by binding to the 30S ribosomal subunit. Doxycycline may also inhibit dihydroorotate dehydrogenase, a mitochondrial enzyme involved in pyrimidine synthesis. 43 Doxycycline is almost completely absorbed in the duodenum with a bioavailability of 95%. Food decreases absorption by 20%. The volume of distribution is 0.7 l/kg with protein binding of 82–93%. It achieves high concentrations in the liver and it is excreted unchanged with 35–60% in the urine and the rest in feces. 44

Doxycycline has an efficacy between 92% and 96% for P. falciparum and 98% for primary P. vivax infection. The most common side effects are photosensitivity, nausea, vomiting, and an increased frequency of vaginal yeast infections. 45 The medication should be taken with at least 8 oz of water while in an upright position and not just before going to bed, to avoid esophagitis. Doxycycline monohydrate or enteric-coated doxycycline hyclate are better tolerated than generic doxycycline hyclate. It is also common practice to prescribe 150 mg of fluconazole for women that intend to use the medication as a standby treatment for vaginal candidiasis. There are insufficient data to make recommendations regarding the interchangeability between doxycycline and minocycline for this indication. Minocycline should be stopped 1–2 days before travel for those taking it chronically and be replaced with doxycycline. The minocycline can be resumed once the course of doxycycline has been completed. 45

The exact mechanism of action is unknown but protein synthesis inhibition has been hypothesized. 46 Mefloquine is well absorbed with a bioavailability of 87–89%. It has high protein binding of 98%, with a mean volume of distribution of 22 l. 47 Mefloquine is metabolized by CYP3A4 into carboxymefloquine, an inactive metabolite. 48 Its terminal half-life is 14–21 days with primarily bile and feces elimination. 47

Controversy has surrounded the use of this agent due to its safety profile. 49 , 50 Mefloquine has been associated with a lengthy list of side effects including gastrointestinal discomfort, headache, and dizziness. More severe neuropsychiatric side effects such as visual disturbances, severe depression leading to suicide, sensory and motor neuropathies, memory deficits, hallucinations, aggression, seizures, psychosis, irreversible vertigo, and encephalopathy have been reported. The US Food and Drug Administration (FDA) issued a black-box warning in 2013 about the risk of neuropsychiatric side effects. In the US, any traveler receiving a prescription for mefloquine must also receive a copy of the FDA medication guide, which can be found at https://www.accessdata.fda.gov/drugsatfda_docs/label/2008/019591s023lbl.pdf . 51 The European Medicines Agency updated the product information and mandated that all European Union members ensure that healthcare professionals are aware and communicate to their patients the risk neuropsychiatric and other adverse events. In addition, it was stipulated that only travelers without a contraindication to the medication receive a prescription and that the traveler carry an alert card at all times. 52

The risk of developing severe or disabling neuropsychiatric side effects ranges from 1/607 to 1/20,000 compared with a rate for chloroquine of 1/1181 to 1/13,600. 50 Mefloquine is contraindicated in the setting of allergy to the medication or related compounds (e.g. quinine) or any excipient. Active or recent history of depression, generalized anxiety disorder, psychosis, schizophrenia, convulsions, cardiac conduction abnormalities and treatment with halofantrine or ketoconazole are also contraindications. 52

Mefloquine is an ideal chemoprophylactic agent for long-term travelers, children, and pregnant women, but due to the potential toxicities, it should be reserved when other agents are contraindicated and for areas with high malaria risk such as sub-Saharan African and parts of Oceania.

Chloroquine and hydroxychloroquine

Chloroquine and hydroxychloroquine’s exact mechanism of action is unknown. They are thought to concentrate in lysosomes and interfere with parasitic processing of hemoglobin. 53 Chloroquine has a bioavailability of 89%. Hydroxychloroquine has a bioavailability of 74%. The pharmacokinetics of these drugs are complex, with a large volume of distribution (greater than 50,000 l has been reported), three-compartment pharmacokinetics, and reported half-lives of over 100 days. They both concentrate in the liver. Approximately 23–38% is excreted unchanged in the urine, 17–18% is excreted as metabolites in the urine, with the remainder being excreted in feces or stored long term in lean tissues. 54

The medication is well tolerated with the most common reported side effects being gastrointestinal disturbances, dizziness, blurred vision, insomnia, and pruritus. The medication can exacerbate psoriasis, and although rare in the doses used for prophylaxis, retinopathy can occur. The medication is safe in pregnancy. 51

The exact mechanism of action of primaquine is unknown. Possible mechanisms are impeding mitochondrial metabolism or oxidative stress. It is rapidly absorbed with a plasma peak in 1–3 h and a volume of distribution of 3 l/kg. It accumulates in the brain, liver, skeletal muscle, lungs, and heart. Primaquine is metabolized into carboxyprimaquine and other metabolites, by oxidases and dehydrogenases. Less than 5% is eliminated unchanged in the urine. 55

Primaquine phosphate has two roles in prevention. It can be used as a causal prophylactic agent against all Plasmodium spp . and for presumptive anti-relapse therapy (PART), also known as terminal prophylaxis, for P. vivax and P. ovale . The dosing should overlap with the blood schizonticide and therefore when chloroquine, doxycycline, or mefloquine are used for primary prophylaxis, primaquine is usually taken during the last 2 weeks of postexposure prophylaxis. When atovaquone–proguanil is used for prophylaxis, primaquine may be taken during the final 7 days of atovaquone–proguanil, and then for an additional 7 days. Primaquine should be given concurrently with the primary prophylaxis medication. However, if that is not feasible, the primaquine course in the form of terminal prophylaxis should still be administered after the primary prophylaxis medication has been completed. 56 Terminal prophylaxis with primaquine (or tafenoquine, see below) is particularly important for long-term travelers returning from highly endemic areas of P. vivax transmission in the Pacific Islands (i.e. Papua New Guinea, Vanuatu, and Solomon Islands) or among those returning from countries that constitute the Horn of Africa.

The efficacy for prophylaxis is considered to be over 85% against P. falciparum and P. vivax and around 95% when used for PART. The most common side effects are abdominal pain, nausea, and vomiting. Severe hemolysis in persons with glucose-6-phosphate-dehydrogenase (G6PD) deficiency and methemoglobinemia can occur. The medication is contraindicated in the setting of G6PD deficiency, nicotinamide dehydrogenase methemoglobin reductase deficiency, pregnancy, known hypersensitivity to primaquine, and illnesses that manifest with tendency for granulocytopenia. A G6PD testing should be performed before use of the medication. 56

Tafenoquine

Tafenoquine’s exact mechanism of action is unknown. Mitochondrial dysfunction leads to Plasmodium spp. death. Absorption is slow and increased with a high-fat meal. It is extensively (>99.5%) protein bound with a volume of distribution of 1600 l. The terminal half-life is 15 days. It is thought to be excreted unchanged, but complete information on excretion is unknown. 57

Tafenoquine succinate is formulated as either a 100 mg or 150 mg tablet. The medication has been approved by the FDA and in Australia for the primary prevention of malaria for persons aged ⩾18 years and for the radical cure of P. vivax in persons older than 16 years of age. 57 – 59 It is important to note that the medication is approved in two separate formulations from two different manufacturers. The 60° Pharmaceuticals manufacture Arakoda ® and Kodatef ® for causal prophylaxis in the US and Australia, respectively. In a partnership with Medicines for Malaria Venture, GlaxoSmithKline (GSK) manufactures Krintafel ® and Kozenis ® for radical cure of P. vivax , also in the US and Australia, respectively. Tafenoquine is also licensed for PART. For P. ovale , tafenoquine can be used off label for radical cure. 60 – 62

Tafenoquine has only been studied for radical cure of P. vivax malaria when used with chloroquine, and the medication should therefore be co-administered with chloroquine only. CDC continues to recommend the off-label use of tafenoquine for radical cure of P. ovale and like with P. vivax , it should be co-administered with chloroquine only.

Tafenoquine has a half-life of approximately 2 weeks allowing weekly administration for primary prophylaxis after a loading dose and one dose when used for radical cure. When used for primary prophylaxis, the medication is taken at a dose of 200 mg daily for 3 days prior to travel, weekly during travel, and then once after return. The last dose should be taken 7 days after the last maintenance dose while in the malaria-endemic area. For the radical cure of P. vivax , the dose is 300 mg once. 57 , 58 The efficacy of the medication for causal prophylaxis varies between 86% and 100%. The malaria recurrence-free rate at 6 months ranges from 62% to 89%. 58

The medication is contraindicated in G6PD-deficient individuals. Quantitative G6PD testing (rather than qualitative, which is usually appropriate for primaquine use) is required, which might logistically be difficult to accomplish for last-minute travelers. 63 , 64 The medication is contraindicated in pregnancy and in breastfeeding women if the infant has G6PD deficiency or if the infant’s G6PD status is unknown. Its safety in children has not been established. 58

Malaria standby emergency treatment (SBET)

The concept describes the self-administration of emergent malaria treatment brought from the country of origin for use when no medical attention is available or for use after the diagnosis has been established. The topic is controversial and the appropriate setting for its use varies according to different national guidelines. 65 There is great variation in the proportion of travelers that appropriately use this strategy as response to the development of fever which is of primordial importance given the life-threatening nature of the disease. 66

For travelers taking chemoprophylaxis and for whom SBET is prescribed, the drug that is being used for chemoprophylaxis should not be used for treatment. Once treatment is completed, chemoprophylaxis should be resumed. If atovaquone/proguanil is being used, it can be resumed immediately after treatment. If another agent is being used, it can be resumed 1 week after completion of treatment. Atovaquone/proguanil and artemether/lumefantrine, two regimens approved in the US, can be used for SBET. Artemether/lumefantrine can be used during pregnancy. 67 , 68 The medications should be bought and taken from the country of origin, given the high rates of counterfeit in malaria-endemic countries. 51 Mefloquine should be avoided for this indication given the potential toxicity. In addition, artemether/lumefantrine should not be used for SBET if mefloquine is being used for chemoprophylaxis. 51 Other regimens such as the combination of doxycycline and quinine require multiple doses which are frequently associated with side effects.

SBET alone can be considered if traveling to low malaria transmission areas such as most of southeast Asia and South America. If possible, SBET should only be considered when traveling to remote areas where medical attention is hampered by a lack of medical services, or quality medications and access to a medical evaluation is not readily available within 24 h. 65 It is important to emphasize to the traveler that the development of fever requires immediate evaluation regardless of SBET use.

Vaccines have not been approved for the prevention of malaria among travelers. The RTS,S/AS01 vaccine has been studied in two phase III trials in Africa with ages ranging from 5–17 months. 69 – 71 The largest malaria vaccine trial done in Africa included 15,459 infants and young children and showed that the vaccine prevented 39% of cases of malaria and 29% of cases of severe malaria over a 4-year follow-up period. For those that received four doses, 1774 cases of malaria were prevented for every 1000 children vaccinated. Efficacy waned with time. 69 A recommendation to include the vaccine in the national immunization programs has not been made, and a pilot study is currently underway in Ghana, Kenya, and Malawi. 72 Although vaccines can have a great impact in achieving the goals of malaria eradication, further research is needed to be considered ideal for travelers. 73

Choosing an antimalarial agent for chemoprophylaxis

The choice of a chemoprophylactic agent ( Tables 2 ​ 2 – 4 ) requires consideration of several factors such as the travel destination, layovers, season, length of travel, traveler’s health, potential side effects and medication interactions, preference, and cost.

Cost of malaria chemoprophylaxis for adults for one week of travel, including required pre- and post-travel dosing. Prices obtained from GoodRx ( https://www.goodrx.com/ ).

US, United States.

Advantages and disadvantages of malaria chemoprophylaxis.

G6PD, glucose-6-phosphate dehydrogenase; US, United States.

Drug interactions with malaria chemoprophylaxis agents. 74

B-blockers, beta blockers; US, United States.

P. falciparum has developed resistance to all antimalarials, and knowledge about its geographic distribution is important in decision making. 51 , 75 Resistance to chloroquine was first observed in southeast Asia and South America in the 1950s and subsequently spread to most parts of the world excluding the Caribbean and Central America, west of the Panama Canal. 76 Resistance is the result of a point mutation in the PfCRT protein that localizes to the digestive vacuole of the Plasmodium spp. This results in the inability of chloroquine to concentrate within the digestive vacuole and form complexes with toxic heme moieties that interfere with detoxification mechanisms. 77 – 80

Resistance of P. vivax to chloroquine was documented in 1989 when Australians repatriated from Papua New Guinea failed routine treatment. 81 Subsequent reports from Indonesia, Myanmar, and India corroborated findings. 82 The cause of resistance in P. vivax remains elusive due to the nature of the parasite’s dormant phase in the liver, low parasitemia, and difficulty in distinguishing relapse, recrudescence, and reinfection. 83

Special populations

Infants, children, and adolescents.

Prevention recommendations for malaria in children are similar to that in adults and include assessment of risk based on travel itinerary, education of mosquito avoidance, determination of chemoprophylaxis, and educating parents to seek early medical care if fever develops during or soon after travel. 84 All chemoprophylactic agents used in adults, with the exception of tafenoquine, are available for children. There are several observations to remember: atovaquone/proguanil should not be administered to children weighing less than 5 kg and doxycycline in those younger than 8 years of age. The product’s label should be carefully followed for pediatric dosing of malarial chemoprophylaxis. Due to difficulty in pediatric dosing, pulverizing tablets into specified dosing can be done, with the assistance of a pharmacist. Due to bitter taste, medications can be mixed into or crushed into food. Specific contraindication for use of repellents in children was described earlier in this document.

Pregnancy and breastfeeding

Pregnant women are particularly susceptible to malaria infection due to immunologic changes that occur during pregnancy. P. falciparum can concentrate in the placenta and lead to miscarriage, stillbirth, preterm birth, and low birth weight. 85 – 87 Congenital infection with detectable parasitemia from 24 h to 7 days of life is another important complication. 88 – 90

Pregnant women should be advised not to travel, if at all possible, as no chemoprophylactic regimen is 100% effective. For women that chose to travel to a malaria-endemic region, emphasis on mosquito avoidance measures and chemoprophylaxis should be provided. In the US, malaria chemoprophylaxis in pregnancy is limited to mefloquine and chloroquine.

In some countries, atovaquone/proguanil is used for either treatment or prophylaxis of malaria during pregnancy. Although the available safety data for its use in pregnancy are reassuring, well-established trials are needed before a definite recommendation can be made. 91 , 92 Doxycycline is also used during the first trimester in several European countries if there are compelling reasons for chemoprophylaxis and if no alternative is available. It is important to remember that doxycycline needs to be administered for 4 weeks after return from a malaria-endemic region. 93

In all women of childbearing age, plans for conception during travel should be discussed. All breastfeeding mothers should be counseled that maternal use of chemoprophylaxis does not provide protection to a breastfed infant, as only a limited amount of medication is secreted in the breastmilk. All chemoprophylactic agents can be administered to breastfeeding mothers except primaquine and tafenoquine, unless G6PD deficiency has been excluded in both the mother and newborn.

Immunosuppressed travelers

Immunosuppressed patients, including those with human immunodeficiency virus (HIV), are more likely to develop severe malaria. 22 Immunosuppressed travelers should be provided chemoprophylaxis similarly to those who are immunocompetent, with additional consideration of the possibility of drug interactions.

Interactions with malaria prophylaxis are primarily seen with cancer-related therapies, anti-rejection medications used after transplantation, and medications used to treat HIV ( Table 4 ). Drug interactions related to anti-retrovirals can be checked on the University of Liverpool HIV Drug Interactions website ( https://www.hiv-druginteractions.org/ ). Typical cancer-directed therapies that can result in interactions include the use of tamoxifen with chloroquine that results in an increased risk of retinopathy, increased levels of platinum-based chemotherapies with tafenoquine, and increased levels of methotrexate when used with doxycycline. In those who have undergone transplantation, chloroquine can increase cyclosporine levels. In travelers with HIV, interactions occur primarily with protease-inhibitor-based regimens and with some non-nucleoside reverse-transcriptase inhibitors such as efavirenz, nevirapine, and etravirine. 74 , 94

Long-term travelers

A long-term traveler is a person visiting a malaria-endemic region for longer than 6 months. Long-term travelers represent a high-risk group, as they tend to underuse personal protective equipment and adhere poorly to anti-malaria prophylaxis. 32

Chloroquine has a good safety record for the treatment of rheumatologic conditions, suggesting it can be used for long-term malaria prophylaxis. For long-term use (>5 years) of chloroquine, a baseline eye examination with bi-annual follow up is recommended to screen for potential retinal toxicity. 51 Long-term mefloquine use is shown to be safe. Tolerability has been variable and related to neuropsychiatric events that usually occur early in the course of prophylaxis. 32 , 95 , 96 Atovaquone/proguanil has been used up to a duration of 34 weeks with good tolerability, with diarrhea being the primary side effect. 97

The tolerability of doxycycline was evaluated in a study of 600 military personnel in Cambodia for 1 year and 900 men deployed to Somalia for 4 months. The medication was well tolerated, with gastrointestinal events and photosensitivity being the most common reported side effects. 98 Another study with 228 US Peace Corps volunteers who took doxycycline prophylaxis for an average of 19 months showed a similar side-effect profile. 99 Doxycycline is approved by the FDA for a duration of 4 months. The use of primaquine for up to 52 weeks is safe with mild non-clinically significant methemoglobinemia being the most common side effect. 100

Relapse prevention

PART is an intervention used to eradicate the quiescent liver hypnozoites of P. vivax or P. ovale with medications such as primaquine and tafenoquine. Primaquine is FDA approved at a dose of 0.25 mg/kg (15 mg base) daily for 14 days. 51 The World Health Organization guidelines recommend a higher dose of primaquine (0.5 mg/kg or 30 mg base daily for 14 days) for strains of P. vivax acquired in East Asia and Oceania, 101 and CDC recommends the higher dose regardless of geographic site of acquisition. 51 Tafenoquine should be administered as a single 300 mg dose and it should ideally overlap with blood-stage treatment or the last dose of prophylaxis. If this is not feasible, tafenoquine may be taken as soon as possible afterward. 62

The use of PART is appropriate for travelers that have visited P. vivax -endemic areas, even if P. falciparum is present, and especially for prolonged stays. 50 It is important to remember that if either primaquine or tafenoquine are used as prophylactic agents, PART is not needed.

There are several important caveats with the use primaquine. Adherence to a 14-day course is poor, and life-threatening hemolytic reactions may occur if G6PD deficiency is not recognized. To address the first limitation, two randomized controlled trials in G6PD-normal patients compared a shorter primaquine regimen consisting of 1 mg/kg day for 7 days with high-dose primaquine for 14 days. Both studies showed no difference in efficacy between the 7-day and 14-day course. However, there were more side effects reported in the 7-day arm in one of the studies. 102 , 103

Blood donation

Transfusion-transmitted malaria was first described in the turn of last century and is an important form of transmission in malaria-endemic areas. 104 A recent review concluded that the median worldwide prevalence of malaria parasitemia in healthy blood donors was 10.54% by microscopy, 5.36% by molecular techniques, and 0.38% by rapid diagnostic tests. 105

Storage of blood under refrigeration is deleterious to Plasmodium spp. Refrigeration at 4°C decreases parasitemia rapidly, nonetheless Plasmodium falciparum has been shown to survive in stored whole blood or plasma at this temperature for approximately 18 days and can remain microscopically detectable for up to 28 days when frozen but with diminished infectivity. 106

The incubation period of transfusion-transmitted malaria is longer than mosquito-transmitted malaria which could lead to a lack of suspicion and delay in the diagnosis of the disease; especially in non-endemic regions. 104 A study that examined transfusion-transmitted malaria in the US between 1963 and 1999 found that the median incubation period was 10 days but ranged from 1 to 180 days. 107

As of April of 2020, the FDA recommends that non-resident travelers of an endemic country or those who are residents of an endemic country but have lived in a non-endemic region for more than 3 consecutive years and are returning from malaria-endemic areas defer blood donation for 3 months after arrival as opposed to 1 year as was previously recommended. This group does not necessarily need to defer donation, as pathogen reduction techniques could be used and allow the collection of components from otherwise-eligible donors. For former residents of malaria-endemic regions that have lived in a non-endemic region for less than 3 consecutive years and for people that have been diagnosed with malaria, donation of blood products should be deferred for 3 years, and this recommendation remains unaltered in the most recent update. 108

The prevention of malaria in travelers continues to be challenging. A multitude of factors determine the risk of malaria acquisition among travelers. The knowledge of such factors and the available preventive measures are of vital importance in being able to provide evidence-based recommendations to travelers. This knowledge should not be restricted to specialized travel medicine professionals as a significant percentage of travelers seek attention from general practitioners. It is therefore imperative for practitioners to be familiar with the most recent guidance and available resources (e.g. internet based, specialized travel clinics available in the community, etc.) to be able to provide safe, effective, and affordable care to the traveler.

Authors contributions: Conceptualization, retrieval of articles for review, critical revision of original draft and approval of final manuscript: Nelson I. Agudelo Higuita, Miranda McGhee, Bryan White, Carlos Franco-Paredes

Conflict of interest statement: The authors declare that there is no conflict of interest.

Funding: The authors received no financial support for the research, authorship, and/or publication of this article.

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Contributor Information

Nelson Iván Agudelo Higuita, Department of Medicine, Section of Infectious Diseases, University of Oklahoma Health Science Center, 800 Stanton L. Young Blvd., Suite 7300, Oklahoma City, OK 73104, USA.

Bryan Pinckney White, Infectious Diseases Clinical Pharmacist, Oklahoma University Medical Center, Oklahoma City, OK, USA.

Carlos Franco-Paredes, Department of Medicine, University of Colorado Denver School of Medicine, Aurora, CO, USA.

Miranda Ann McGhee, Department of Medicine, Section of Infectious Diseases, University of Oklahoma Health Science Center, 800 Stanton L. Young Blvd., Suite 7300, Oklahoma City, OK 73104, USA.

The risk of malaria infection for travelers visiting the Brazilian Amazonian region: A mathematical modeling approach

Affiliations.

  • 1 Escola de Matemática Aplicada, Fundação Getúlio Vargas, Rio de Janeiro, Brazil.
  • 2 Setor de Pós-graduação, Pesquisa e Inovação, Centro Universitário Saúde ABC, Fundação do ABC, Santo André, SP, Brazil.
  • 3 Wadsworth Center, New York State Department of Health, Albany, NY, USA.
  • 4 Departamento de Epidemiologia, Faculdade de Saúde Pública, Universidade de São Paulo, São Paulo, SP, Brazil.
  • 5 Superintendência de Controle de Endemias, Secretaria de Estado da Saúde de São Paulo, Araraquara, SP, Brazil.
  • 6 Fundação de Vigilância em Saúde do Amazonas, Manaus, AM, Brazil.
  • 7 Faculdade de Medicina, Universidade de São Paulo e LIM01-HCFMUSP, SP, Brazil.
  • 8 Departamento de Epidemiologia, Faculdade de Saúde Pública, Universidade de São Paulo, São Paulo, SP, Brazil. Electronic address: [email protected].
  • PMID: 32771653
  • PMCID: PMC7578070
  • DOI: 10.1016/j.tmaid.2020.101792

Background: Human mobility between malaria endemic and malaria-free areas can hinder control and elimination efforts in the Amazon basin, maintaining Plasmodium circulation and introduction to new areas.

Methods: The analysis begins by estimating the incidence of malaria in areas of interest. Then, the risk of infection as a function of the duration of stay after t 0 was calculated as the number of infected travelers over the number of arrived travelers. Differential equations were employed to estimate the risk of nonimmune travelers acquiring malaria in Amazonian municipalities. Risk was calculated as a result of the force of the infection in terms of local dynamics per time of arrival and duration of visit.

Results: Maximum risk occurred at the peak or at the end of the rainy season and it was nonlinearly (exponentially) correlated with the fraction of infected mosquitoes. Relationship between the risk of malaria and duration of visit was linear and positively correlated. Relationship between the risk of malaria and the time of arrival in the municipality was dependent on local effects of seasonality.

Conclusions: The risk of nonimmune travelers acquiring malaria is not negligible and can maintain regional circulation of parasites, propagating introductions in areas where malaria has been eliminated.

Keywords: Amazon; Brazil; Malaria risk; Mathematical modeling; Rural settlements.

Copyright © 2020 Elsevier Ltd. All rights reserved.

Publication types

  • Research Support, Non-U.S. Gov't
  • Brazil / epidemiology
  • Plasmodium*
  • Travel-Related Illness*

Grants and funding

  • R01 AI110112/AI/NIAID NIH HHS/United States

Travel vaccination advice

If you're planning to travel outside the UK, you may need to be vaccinated against some of the serious diseases found in other parts of the world.

Vaccinations are available to protect you against infections such as yellow fever , typhoid and hepatitis A .

In the UK, the  NHS routine immunisation (vaccination) schedule protects you against a number of diseases, but does not cover all of the infectious diseases found overseas.

When should I start thinking about the vaccines I need?

If possible, see the GP or a private travel clinic at least 6 to 8 weeks before you're due to travel.

Some vaccines need to be given well in advance to allow your body to develop immunity.

And some vaccines involve a number of doses spread over several weeks or months.

You may be more at risk of some diseases, for example, if you're:

  • travelling in rural areas
  • backpacking
  • staying in hostels or camping
  • on a long trip rather than a package holiday

If you have a pre-existing health problem, this may make you more at risk of infection or complications from a travel-related illness.

Which travel vaccines do I need?

You can find out which vaccinations are necessary or recommended for the areas you'll be visiting on these websites:

  • Travel Health Pro
  • NHS Fit for Travel

Some countries require proof of vaccination (for example, for polio or yellow fever vaccination), which must be documented on an International Certificate of Vaccination or Prophylaxis (ICVP) before you enter or when you leave a country.

Saudi Arabia requires proof of vaccination against certain types of meningitis for visitors arriving for the Hajj and Umrah pilgrimages.

Even if an ICVP is not required, it's still a good idea to take a record of the vaccinations you have had with you.

Find out more about the vaccines available for travellers abroad

Where do I get my travel vaccines?

First, phone or visit the GP practice or practice nurse to find out whether your existing UK vaccinations are up-to-date.

If you have any records of your vaccinations, let the GP know what you have had previously.

The GP or practice nurse may be able to give you general advice about travel vaccinations and travel health, such as protecting yourself from malaria.

They can give you any missing doses of your UK vaccines if you need them.

Not all travel vaccinations are available free on the NHS, even if they're recommended for travel to a certain area.

If the GP practice can give you the travel vaccines you need but they are not available on the NHS, ask for:

  • written information on what vaccines are needed
  • the cost of each dose or course
  • any other charges you may have to pay, such as for some certificates of vaccination

You can also get travel vaccines from:

  • private travel vaccination clinics
  • pharmacies offering travel healthcare services

Which travel vaccines are free?

The following travel vaccines are available free on the NHS from your GP surgery:

  • polio (given as a combined diphtheria/tetanus/polio jab )
  • hepatitis A

These vaccines are free because they protect against diseases thought to represent the greatest risk to public health if they were brought into the country.

Which travel vaccines will I have to pay for?

You'll have to pay for travel vaccinations against:

  • hepatitis B
  • Japanese encephalitis
  • tick-borne encephalitis
  • tuberculosis (TB)
  • yellow fever

Yellow fever vaccines are only available from designated centres .

The cost of travel vaccines that are not available on the NHS will vary, depending on the vaccine and number of doses you need.

It's worth considering this when budgeting for your trip.

Other things to consider

There are other things to consider when planning your travel vaccinations, including:

  • your age and health – you may be more vulnerable to infection than others; some vaccines cannot be given to people with certain medical conditions
  • working as an aid worker – you may come into contact with more diseases in a refugee camp or helping after a natural disaster
  • working in a medical setting – a doctor, nurse or another healthcare worker may require additional vaccinations
  • contact with animals – you may be more at risk of getting diseases spread by animals, such as rabies

If you're only travelling to countries in northern and central Europe, North America or Australia, you're unlikely to need any vaccinations.

But it's important to check that you're up-to-date with routine vaccinations available on the NHS.

Pregnancy and breastfeeding

Speak to a GP before having any vaccinations if:

  • you're pregnant
  • you think you might be pregnant
  • you're breastfeeding

In many cases, it's unlikely a vaccine given while you're pregnant or breastfeeding will cause problems for the baby.

But the GP will be able to give you further advice about this.

People with immune deficiencies

For some people travelling overseas, vaccination against certain diseases may not be advised.

This may be the case if:

  • you have a condition that affects your body's immune system, such as HIV or AIDS
  • you're receiving treatment that affects your immune system, such as chemotherapy
  • you have recently had a bone marrow or organ transplant

A GP can give you further advice about this.

Non-travel vaccines

As well as getting any travel vaccinations you need, it's also a good opportunity to make sure your other vaccinations are up-to-date and have booster vaccines if necessary.

Although many routine NHS vaccinations are given during childhood, you can have some of them (such as the MMR vaccine ) as an adult if you missed getting vaccinated as a child.

There are also some extra NHS vaccinations for people at higher risk of certain illnesses, such as the flu vaccine , the hepatitis B vaccine and the BCG vaccine for tuberculosis (TB) .

Your GP can advise you about any NHS vaccinations you might need.

Find out about NHS vaccinations and when to have them

Page last reviewed: 16 March 2023 Next review due: 16 March 2026

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Travel safely to Brazil with Passport Health's travel vaccinations and advice.

Travel Vaccines and Advice for Brazil

Passport Health offers a variety of options for travellers throughout the world.

Rich with seasides, rainforests, and vibrant urban centers, Brazil offers a wide variety of attractions.

For the adventurous, there are mountains to climb and islands to explore. For the more historically inclined, there are whole settlements from the colonial era that have not been renovated since their construction.

To experience the rich culture of Brazil, it is best to come during the time of Carnaval. Dancers flood the streets showing off sambo rhythms and other aspects of Brazil’s musical fabric. This is not to say Carnaval is the only time to behold such an event. Smaller versions of the festival happen throughout the year, and serve as a perfect window into the country’s heart.

Due to Brazil’s history as a trading port and colony, it is a melting pot of African, European, and Latin American cultures.

Brazil is also home to one of the most diverse ecosystems on the planet, offering an incredible range of flora and fauna. A trip to Brazil is a chance to experience a taste of everything.

On This Page: Do I Need Vaccines for Brazil? Yellow Fever in Brazil Do I Need a Visa or Passport for Brazil? What is the Climate Like in Brazil? How Safe is Brazil? Seaside in Brazil What Should I Take To Brazil? Embassy of the United Kingdom in Brazil

Do I Need Vaccines for Brazil?

Yes, some vaccines are recommended or required for Brazil. The National Travel Health Network and Centre and WHO recommend the following vaccinations for Brazil: hepatitis A , typhoid , yellow fever , rabies and tetanus .

See the bullets below to learn more about some of these key immunisations:

  • Hepatitis A – Food & Water – Recommended for most travellers to the region, especially if unvaccinated.
  • Typhoid – Food & Water – Jab lasts 3 years. Oral vaccine lasts 5 years, must be able to swallow pills. Oral doses must be kept in refrigerator.
  • Yellow Fever – Mosquito – Required if travelling from a Angola or the Democratic Republic of the Congo. Recommended for all regions except: Fortaleza, Recife, Rio de Janeiro, Salvador, and São Paulo
  • Rabies – Saliva of Infected Animals – High risk country. Vaccine recommended for long-stay travellers and those who may come in contact with animals.
  • Tetanus – Wounds or Breaks in Skin – Recommended for travellers to most regions, especially if not previously vaccinated.

See the tables below for more information:

A yellow fever vaccination is not required to enter Brazil, but is highly recommended. See the yellow fever section below.

Malaria and dengue are present in Brazil. Be sure to take proper precautions to avoid these mosquito-borne diseases. Bring repellents netting and antimalarials, if needed.

Zika virus has been found in Brazil. Some travellers are at an increased risk including women who are pregnant or may become pregnant. Ensure you use repellents and netting where needed.

Visit our vaccinations page to learn more. Travel safely with Passport Health and schedule your appointment today by calling or book online now .

Yellow Fever in Brazil

Brazil has been the site of multiple yellow fever outbreaks in the past few years. The most recent outbreak started in December 2016 and is still ongoing.

Yellow fever vaccination is highly recommended for travellers to:

  • Espirito Santo
  • Rio de Janeiro

Do I Need a Visa or Passport for Brazil?

Visas are not required for tourist purposes in Brazil. Other types of visas are required. Passports must be valid for at least six months. Proof of yellow fever vaccination may be required if you are travelling from a region where yellow fever is present.

Immigration authorities may request proof of sufficient funds, return travel or similar items upon entry.

Sources: Embassy of Brazil and GOV.UK

What is the Climate Like in Brazil?

Brazil’s climate can vary depending on which region you are visiting.

In the northern parts of the country, the climate is tropical, whilst in the southern regions the climate is more temperate. Most of the population lives in cooler areas like high altitudes or the coast.

Popular tourist destinations like Rio de Janeiro suffer from an extremely hot climate. Temperatures there are usually above 38 degrees during the dry season.

In the areas closer to the Amazon rainforest, temperatures higher than 32 are rare. If you are travelling to cities in the upper region of the Amazon belt like Belem, heavy rainfall is common between December and April.

It is best to study the microclimate of the region you are visiting whilst planning a trip to Brazil.

How Safe is Brazil?

Be sure to travel with your passports on your person at all times and be prepared to present it to local law enforcement, if necessary.

As a whole, the danger level of Brazil is classified as high. The murder rate if four times that of developed nations, and the crime rate reaches similar numbers. Travellers should remain vigilant at all times. Try not to travel outside of where you are staying after dark.

Do not ever enter the favelas. They are mostly operated by gangs, and are extremely dangerous even for locals. It is best to avoid them completely. If you are planning on going somewhere that is off the beaten path, consult with locals first to find out if it is safe.

Avoid carrying large amounts of money with you. If necessary, divide it up between several pockets. The efficiency of the police force varies depending on the region. It is imperative that you do not attempt to bribe them for any reason.

Amazing Rio

Rio de Janeiro is a city in Brazil that is popular for tourists to visit. People go there to see famous landmarks like the Christ the Redeemer statue and Sugarloaf Mountain.

Travelers can also go to the beach at Copacabana, Ipanema, and Leblon to swim, surf and play. Rio de Janeiro is also famous for Carnival, a big party with music, dancing, and colorful parades. Visitors can try different kinds of food like feijoada and churrasco, and drinks like caipirinhas.

At night, there are many bars and clubs to go to, or visitors can have drinks and watch the sunset at the beach. People can also go hiking, biking, or take a jeep tour to explore the city’s parks and natural areas like Tijuca National Park and the Botanical Garden.

Rio de Janeiro has something for everyone and is a great place to experience Brazil’s unique blend of culture and natural beauty.

What Should I Take To Brazil?

Here are some essential items to consider for your trip to Brazil:

  • Medical Supplies – These can be expensive in Brazil. It is important to bring one’s own. Ensure to include antidiarrhoeal medication, antimalarials, and basic over the counter aides.
  • Breathable Clothing – The climate of Brazil in the central areas like Rio de Janeiro can be quite hot. Wear clothing that is not too thick, and that you wouldn’t mind sweating in.
  • Warm Clothing – This is advised if travelling to an area south of the Tropic of Capricorn where the climate is more temperate.
  • Documents – Be sure to bring your passport, visa and other forms of identification.
  • Cash – It is safest to operate on a cash-only basis whilst in Brazil.

Embassy of the United Kingdom in Brazil

If you are in Brazil and have an emergency (for example, been attacked, arrested or someone has died) contact the nearest consular services. Contact the embassy before arrival if you have additional questions on entry requirements, safety concerns or are in need of assistance.

British Embassy Brasilia Quadra 801 – Conjunto K – Lote 08 Av. das Nações – Asa Sul CEP 70408-900 Brasilia Brazil Telephone: +55 (61) 3329 2300 Emergency Phone: +55 61 3329 2300 Fax: +55 (61) 3329 2369 Contact Form: Click Here

If you have any questions about travelling to Brazil or are wondering which jabs you may need for your trip, schedule an appointment with your local Passport Health travel medicine clinic. Ring us up at or book online now !

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Brazil Travel Health Information

Read below for travel health advice on Brazil from the MDtravelhealth channel on Red Planet Travel.

Page Sections

Medications

Immunizations

  • Recent outbreaks of diseases
  • Other Infections
  • Food and Water
  • Insect Tick Protection
  • Swimming and Bathing
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Are you a doctor or medical professional with knowledge of the situation in Brazil  Why not apply to contribute to this page? You will get a link and referrals to your clinic from this site.

Summary You can't Edit

Summary of recommendations

Most travelers to Brazil will need vaccinations for hepatitis A , typhoid fever , and yellow fever , as well as medications for travelers' diarrhea . Many will require malaria prophylaxis , in conjunction with insect repellents and other measures to prevent mosquito bites. Additional immunizations may be necessary depending upon the circumstances of the trip and the medical history of the traveler, as discussed below. All travelers should visit either a travel health clinic or their personal physician 4-8 weeks before departure.

Malaria:Prophylaxis with Lariam (mefloquine), Malarone (atovaquone/proguanil), 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:

Medications You can't Edit

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) 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: malaria transmission occurs in the states of Acre, Amapá, Amazonas, Mato Grosso, Para, Rondonia, Roraima, Tocantins, and the western part of Maranhaõ, as well as urban areas, including cities such as Boa Vista, Macapa, Manaus, Maraba, Porto Velho, and Santarem. Rare cases are reported from Belem. There is no malaria transmission at Iguassu Falls. Transmission is greatest in remote jungle areas where mining, lumbering and agriculture occur and which have been settled for less than five years. For a map showing the risk of malaria in different parts of the country, go to the Pan American Health Organization .

For all ares with malaria transmission, except Belem city, 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 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.

Insect protection measures are essential.

For Belem city, insect protection measures are advised, but malaria medications are not recommended.

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.

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.

Immunizations You can't Edit

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 travelers greater than nine months of age going to the following areas: all areas of Acre, Amapá, Amazonas, Distrito Federal (including the capital city of Brasília), Goiás, Maranhão, Mato Grosso, Mato Grosso do Sul, Minas Gerais, Pará, Rondônia, Roraima, and Tocantins, and designated areas (see map ) of the following states: Bahia, Paraná, Piauí, Rio Grande do Sul, Santa Catarina, and São Paulo. Vaccination is also recommended for travelers visiting Iguacu Falls. Vaccination is not recommended for travel to the following coastal cities: Rio de Janeiro, São Paulo, Salvador, Recife, and Fortaleza. For information on risk in specific municipalities, please see the Brazilian Ministry of Health yellow fever risk area search portal (in Portuguese).

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 all travelers if not previously vaccinated. 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 for travelers spending a lot of time outdoors, for travelers at high risk for animal bites, such as veterinarians and animal handlers, for long-term travelers and expatriates, and for travelers involved in any activities that might bring them into direct contact with bats. Children are considered at higher risk because they tend to play with animals, may receive more severe bites, or may not report bites. 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.

Recent outbreaks of diseases You can't Edit

Recent outbreaks

Multiple outbreaks of Chagas disease have recently been reported from the northern Brazilian states of Para, Amazonas, and Amapa, related to consumption of local fruit juices, mainly those made from the berries of the acai and bacaba palms, which have been contaminated by triatomid bugs, which transmit the disease. The most recent were reported in October 2012 from the city of Abaetetuba, in the interior of Para state; in August 2012 from Abaetetuba municipality, in the northeast of Para state; in January 2010 from the municipality of Santa Isabel do Rio Negro in Amazonas; and in November 2009 from a district of Belem, Para state. Both were probably related to the consumption of acai. In July 2006, an outbreak occurred in Santarem township in western Para state, apparently caused by contaminated bacaba wine. In March 2005, an outbreak of Chagas disease was reported from Santa Catarina in the southern part of the country, an area frequented by international tourists. The outbreak was related to a single roadside stand, which was serving sugar cane juice (garapa) which had been contaminated by feces from triatomid bugs left on the sugar cane. Travelers should beware of consuming homemade juice or wine in Brazil, especially from roadside stands. For further information, go to CDR Weekly and ProMED-mail .

An outbreak of toxoplasmosis was reported from Cuiaba, Brazil, in October 2011, causing 30 cases. The source of the outbreak was not determined, but most outbreaks of toxoplasmosis, which are rare, are related to drinking contaminated water. In January 2002, a toxoplasmosis outbreak occurred in Santa Isabel do Ivai in northwestern Parana state, caused by unfiltered, municipally treated water. See Emerging Infectious Diseases and ProMED-mail (January 12, 2002, and October 9, 2011) for further information. In northern Rio de Janeiro state, the water supplies have been contaminated with toxoplasma oocysts and drinking unfiltered water increases the risk of becoming infected (see Emerging Infectious Diseases). Because toxoplasmosis may cause severe fetal illness, pregnant women traveling to Brazil should make sure they do not drink unfiltered water.

An outbreak of visceral leishmaniasis was reported from Ipanema (Minas Gerais) between September 2009 and January 2010. Leishmaniasis is a parasitic infection transmitted by sandfly bites. Dogs are the chief reservoir. In Brazil, visceral leishmaniasis occurs chiefly in the Northeast. An increased number of human and canine cases were reported from Mato Grosso state in 2008. Four cases were reported from the Federal District in 2008, all in Sobradinho; see ProMED-mail , January 25 and November 30, 2008, and February 11, 20102, and Jorge Arias et al., The Reemergence of Visceral Leishmaniasis in Brazil (Emerging Infectious Diseases Vol. 2/No. 2 | April-June 1996). Travelers to affected areas should follow insect precautions , as below.

An increased number of cases of meningococcal meningitis was reported from the state of Bahia in December 2009 and again in December 2011. Details are limited. Pending further information, all travelers to Bahia should receive meningococcal vaccine prior to departure.

An outbreak of Oropouche fever was reported in August 2009 from the municipalitiy of Mazagao in the southern part of the state of Amapa. More than 650 cases were identified (see ProMED-mail , August 8, 2009). Oropouche fever is a viral infection transmitted by biting midges. Symptoms may include fever, headache, rash, and joint and muscle pains, lasting up to seven days. Outbreaks occur chiefly in Para State, mainly in Belem and neighboring areas. The disease is also reported from other Amazonian states, including Amazonas, Amapa, Acre, Rondônia, and Tocantins, as well as non-Amazonian states, including Maranhao in northeastern Brazil and Tocantins in central Brazil. Outbreaks were reported in April–May 2003 in Vila Sansao and Vila Paulo Fontelles in the municipality of Parauapebas, and in July–August 2004 in Vila Tapara in the municipality of Porto de Moz, all in Para State (see Emerging Infectious Diseases). Insect protection measures are recommended for all travelers to Brazil.

A yellow fever outbreak was reported in January 2008, causing 45 confirmed cases and 25 deaths as of June 2008. A majority of the cases occurred in Goias State. Cases were also described in Mato Grosso do Sul, Mato Grosso, Parana, Para, Sao Paulo State, and the Federal District. Following that, two human yellow fever cases were reported in the state of Sao Paulo near the ecologic reserve of Jatai, specifically in the rural areas of Luiz Antonio and Sao Carlos. Additionally, there were two cases of human yellow fever reported from rural areas in central west Parana State (in the rural area of Laranjal). Between December 2008 and April 2009, 20 human cases of yellow fever, nine of them fatal, occurred in the state of Rio Grande do Sul on the southern tip of the country (see the Brazilian Ministry of Health in Portuguese). Between February and April 2009, 28 cases and 11 deaths were reported from Sao Paulo State (municipalities of Itatinga, Sarutaiá, Buri, and Piraju) (see the Brazilian Ministry of Health in Portuguese). In February 2009, a case was reported from Minas Gerais. For further information, go to ProMED-mail and the Centers for Disease Control.

Yellow fever is a life-threatening viral infection which is transmitted by mosquitoes. Initial symptoms may include fever, chills, headache, muscle aches, backache, loss of appetite, nausea and vomiting, which usually subside in three or four days. However, after initial improvement, approximately one person in six enters a second, toxic phase characterized by recurrent fever, vomiting, listlessness, jaundice, kidney failure, and hemorrhage, leading to death in up to half of cases. There is no treatment except for supportive care. Yellow fever vaccine is recommended for travelers to all areas of Acre, Amapá, Amazonas, Distrito Federal (including the capital city of Brasília), Goiás, Maranhão, Mato Grosso, Mato Grosso do Sul, Minas Gerais, Pará, Rondônia, Roraima, Tocantins, and designated areas of the following states: northwest and west Bahia, central and west Paraná, southwest Piauí, northwest and west central Rio Grande do Sul (including the state capital city of Porto Alegre), far west Santa Catarina, and north and west São Paulo. Insect protection measures , as described below, are also strongly advised. For a map of yellow fever risk in Brazil, go to the CDC website.

For the year 2007, a total of six human cases were reported from four states: Amazonia, Para, Roraima, and Goias (Jatai township). Monkey outbreaks were reported from nine states: Goias, Tocantins, Minas Gerais, Mato Grosso, South Mato Grosso, South Rio Grande, Piaui, the Federal District, and North Rio Grande (see ProMED-mail ). In July 2006, the first yellow fever death in three years was reported from the western state of Mato Grosso. In January 2003, a yellow fever outbreak was reported from Minas Gerais State, resulting in a total of 58 cases by the end of the year. All cases occurred in a localized rural area of San Lucas, in the regional municipality of Diamantina, and in the neighboring cities of Serro, Alvorada, Sabinopolis and Guanhaes in the valley of Jequitinhonha. In addition, four isolated cases were reported the state of Mato Grosso during 2003 (see Pan-American Health Organization , the World Health Organization , Health Canada, ProMED-mail, and the Brazilian Ministry of Health in Portuguese).

A yellow fever outbreak was previously reported from Minas Gerais State in the first three months of 2001, resulting in 32 cases and 16 deaths. Eleven cities in the center-west region were involved. Although a majority of those affected resided in urban areas, all had been exposed to the jungle, where the infection was acquired. None had received yellow fever vaccine prior to becoming infected. In early 2000, a yellow fever outbreak was reported from Chapada Dos Veadeiros National Park in the State of Goias, ultimately spreading to other parts of the country. Before that, an outbreak was reported from the island of Marajo in the State of Para from 1998 through 1999. See EPI Newsletter (PDF) and the World Health Organization for further information.

Outbreaks of dengue fever , a flu-like illness sometimes complicated by hemorrhage or shock, occur regularly in Brazil. As of January-February 2011, outbreaks were being reported from the states of Amazonas, Acre, Ceara, Minas Gerais, Espirito Santo, Parana, Rio de Janeiro, Sao Paulo, Alagoas, Rio Grande do Sul, and Rio Grande do Norte. As of March-April 2011, outbreaks were being reported from the states of Amazonas, Parana, Ceara, Rio Grande do Norte, Sao Paulo, Rio de Janeiro, Alagoas, Paraiba, Bahia, Paribo, Piaui, Pernambuco, Acre, Minas Gerais, Mato Grosso do Sul, Sergipe, and Para. As of May-June 2011, outbreaks were being reported from the states of Alagoas, Rio Grande do Norte, Minas Gerais, Ceara, Bahia, Parana, Rio de Janeiro, Mato Grosso do Sul, and Sao Paulo. As of July-August 2011, outbreaks were being reported from the states of Alagoas, Ceara, Parana, and Sao Paulo. 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.

A major dengue outbreak was reported in 2010, causing more than 900,000 cases and 592 deaths by November. More than two-thirds of the cases occurred in six states: Sao Paulo and Minas Gerais in the southeastern region, Mato Grosso do Sul and Goias in the mid-western region, and Acre and Rondonia in the northern region. A total of 27,885 dengue cases and 39 deaths were registered in the state of Rio de Janeiro for the first 11 months of 2010, compared to 12,403 cases and 12 deaths for the same period in 2009. As of October and November 2010, dengue outbreaks were being reported from Amazonas, Goiania, Sao Paulo, Alagoas, Piaui, Campinas, Cearas, and Goias. As of August and September 2010, dengue outbreaks were occurring in the states of Roraima, Sao Paulo, Parana, Goias, Espirito Santo, Minas Gerais, Mato Grosso, and Pernambuco. As of June and July 2010, outbreaks were occurring in the states of Roraima, Sao Paulo, Alagoas, Espirito Santo, Rio Grande do Sul, Minas Gerais, Pernambuco, and Rio de Janeiro. As of March and April 2010, outbreaks were occurring in the states of Sao Paulo, Minas Gerais, Parana, Mato Grosso, Mato Grosso do Sul, Rio Grande do Sul, Acre, Roraima, Alagoas, and Goias, and in the Federal District. Dengue outbreaks were reported from the state of Rondonia in January 2010, from Rondonia, Mato Grosso, and Mato Grosso do Sul in December 2009, from the states of Ceara and Rio Grande do Sul in September 2009, and from the state of Parana in August 2009.

A major dengue outbreak was reported in the first half of 2008. The State of Rio de Janeiro was particularly affected, resulting in almost 250,000 cases and at least 181 deaths by the end of the year (see the World Health Organization and ProMED-mail ). Outbreaks were also reported from the states of Rio Grande do Norte (particularly affecting the region of the Grande Natal), Ceara, Bahia, Sergipe, Pernambuco, Minas Gerais, and Para (in the metropolitan region of Belem). For the year 2007, a total of 559,954 cases were reported, including 158 deaths. This represented an increase of approximately 200,000 cases compared to 2006, mostly attributable to epidemics in Mato Grosso do Sul (along the border with Bolivia and Paraguay, countries which also suffered dengue epidemics this year), Parana, Rio de Janeiro and Pernambuco. Outbreaks were also reported from Ceara, Sao Paulo, Maranhao, Amazonas, Piaui, Goias, Alagoas, Paraiba, and Rio Grande do Norte. For the year 2006, a total of 346,550 cases and 67 deaths were recorded nationwide, including an outbreak in Ribeirao Preto (Sao Paulo State) that resulted in more than 3000 cases. Compared to 2005, the number of cases rose in Rio and in the states of Recife, Sao Paulo, and Rio Grande do Norte. A major dengue outbreak 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. A large outbreak also occurred in 1998, when more then 500,000 people were affected and all urban areas and all but four states/territories were involved.

An increased number of cases of Mycobacterium fortuitum infections after breast implants was reported in January 2009 from Campinas and Indaiatuba, both in the state of Sao Paulo. An outbreak of M.fortuitum infections after breast implants was also reported from Campinas in 2004. The U.S. State Department advises that "Plastic and other elective/cosmetic surgery is a major medical industry in Brazil. While Brazil has many plastic surgery facilities that are on par with those found in the United States, two U.S. citizens died and one was left in vegetative state from complications following plastic surgery in the past year. U.S. citizens should make sure when arranging such surgery that emergency medical facilities are available, as some "boutique" plastic surgery operations offer luxurious facilities, but are not hospitals and are therefore unable to deal with unforeseen emergencies. Several U.S. citizens have also died while visiting non-traditional healers outside of urban areas."

An increased number of malaria cases caused by Plasmodium vivax was reported for Sao Paulo, Brazil, in the first few months of 2007. Because the overall risk of malaria remains quite low, malaria prophylaxis is not recommended for travelers to Sao Paulo. However, all visitors to Brazil should protect themselves from mosquito bites by applying insect repellent and keeping themselves covered, as below. For further information, go to NATHNAC.

A measles outbreak was reported in January 2007 from Bahia State, Brazil, resulting in 47 cases (see ProMED-mail ). All travelers born after 1956 should make sure they have had either two documented MMR or measles immunizations or a blood test showing measles immunity. Those born before 1957 are presumed to be immune. Although measles immunization is usually begun at age 12 months, children between the ages of 6 and 11 months should be given an initial dose of measles or MMR vaccine before traveling to Brazil.

An outbreak of human rabies was reported in October 2005 from rural areas in the northeastern state of Maranhao, causing 23 fatal cases. The outbreak was caused by bites from vampire bats, which proliferated after destruction of local forests. Vampire bats are about the size of a human thumb. In March 2004, a rabies outbreak caused by vampire bats was reported from the city of Portel in the northern state of Pará, resulting in 15 confirmed cases, all of them fatal. The bat attacks occurred mainly during the months of September and October 2003. Most of the affected persons were living in the rural area around the Acuti Pereira River. In May 2004, a vampire bat-related rabies outbreak was reported from Viseu municipality, also in Pará state, causing six deaths. See the Pan-American Health Organization , NATHNAC, Emerging Infectious Diseases, and Eurosurveillance for further information.

An outbreak of diphyllobothriasis , a parasite acquired by eating raw or undercooked fish, was reported from Sao Paulo and Rio in April 2005. One case was identified in a Dutch traveler who had recently visited Brazil. Symptoms of diphyllobothriasis may include abdominal discomfort and diarrhea, sometimes complicated by anemia. In the Brazilian outbreak, most cases appeared to be related to the consumption of raw salmon. Other cases in Brazil have been linked to sushi and sashimi. See ProMED-mail andEmerging Infectious Diseases for further information.

Cases of hantavirus pulmonary syndrome are reported annually from Brazil, mostly from June through August. Cases are reported from all states except those in the northeastern part of the country, with the largest number reported from the states of Parana, Minas Gerais, Sao Paulo, Mato Grosso, Santa Catarina and Rio Grande do Sul. In the year 2009, fatal cases were reported from Rio Grande do Sul in February and from Parana in July. In the first six months of 2008, a total of 34 cases were identified, of which 17 were fatal. In May-August 2004, an outbreak was reported from the Federal District and from the State of Goiás, resulting in 17 cases and nine deaths from the Federal District and four cases and two deaths from the State of Goiás. Hantavirus pulmonary syndrome is a life-threatening infection which is acquired through exposure to the excretions of wild rodents. The outbreak in 2004 may have been related to an unusually long and intense rainy season (from November to March), leading to an abundance of food for wild rodents. For further information, go to the Pan-American Health Organization and ProMED-mail (June 1, 2003, June 12, 2004, and July 17, 2004, and July 8, 2007). Most travelers are at low risk.

Other Infections You can't Edit

Other infections

Plague continues to be reported from Brazil, but is uncommon. A total of four cases were recorded in 1998 and six in 1999, all from Bahia state. The plague is usually transmitted by the bite of rodent fleas. Most travelers are at extremely low risk. Those who may have contact with rodents or their fleas should bring along a bottle of doxycycline , to be taken prophylactically if exposure occurs. Those less than eight years of age or allergic to doxycycline may take trimethoprim-sulfamethoxazole instead. To minimize risk, travelers should avoid areas containing rodent burrows or nests, never handle sick or dead animals, and follow insect protection measures , as described below.

Schistosomiasis occurs in almost all states of the Northeast and two states (Minas Gerais and Espirito Santo) in the Southeast. Swimming and bathing precautions are advised, as below.

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

  • Cutaneous and mucocutaneous leishmaniasis (occurring in suburban areas in Rio de Janeiro and Sao Paulo; has spread recently to the states of Bahia in the northeast, Mato Grosso in the center, and Santa Catarina south of Rio de Janeiro; see ProMED-mail , May 8, 2007)
  • Brazilian purpuric fever (caused by Hemophilus aegypti; reported in children in the states of Sao Paulo and Pirana in the 1980's)
  • Leptospirosis (mainly urban areas; chief animal hosts are rodents, dogs, pigs, and mice)
  • Sporotrichosis (fungal skin infection; frequently transmitted by scratches or bites from infected cats; see Emerging Infectious Diseases)
  • Brucellosis (the most common animal source is infected cattle; outbreak reported among slaughterhouse workers in Parana in February 2014; see ProMED-mail )
  • Echinococcus (especially in the southernmost part of the country)
  • Fascioliasis (sheep-raising areas)
  • Lymphatic filariasis (mainly in the metropolitan area of Recife, Pernambuco)
  • Onchocerciasis (reported among the indigenous Yanomami population living along the Venezuelan border, as well as in nearby tribes and non-Indians visiting the area; associated with swift-flowing streams in densely forested highlands)
  • Mayaro virus disease (mosquito-borne viral infection which occurs in the Amazon region; increased number of cases reported from Manaus in 2011; symptoms include fever, headache, body aches, and joint pains; joint pains may be incapacitating and may last for months, but life-threatening complications are rare; case reported in a French traveler to the Amazon in January 2010)
  • Hepatitis D (upper Amazon river basin along the Purus and Jurua rivers)
  • Venezuelan equine encephalitis
  • Eastern equine encephalitis
  • Brazilian spotted fever (identical to Rocky Mountain spotted fever; transmitted by ticks; found chiefly in the states of Sao Paulo and Minas Gerais; also reported from Rio, Espirito Santo, and the southern state of Santa Catarina; cases reported recently from Itaipava, a popular mountain resort next to Rio; two fatal cases reported from Paulinia, Sao Paulo, in August 2012; three cases reported from Piracicaba city in September 2012; fatal case reported in February 2014 from the region of Pampulha in Belo Horizonte, Minas Gerais state; three fatal cases reported from Piracicaba, Sao Paulo, in the first five months of 2014; see ProMED-mail )
  • Lyme disease (Sao Paulo, Rio Grande do Norte, and Santa Catarina states)
  • Melioidosis (northeastern Brazil; see Emerging Infectious Diseases)
  • Paracoccioidomycosis
  • Angiostrongylus meningitis (two cases reported in March 2007 from Espirito Santo; both cases probably related to ingestion of slugs; see ProMED-mail ; April 14, 2007)
  • " Caterpillar plague " (reported from the Amazon delta region between 1983 and 1985 and from southern Brazil in 1995; caused by contact with the larvae (caterpillars) of the butterfly Lamonia achelous, which secrete venom through their skins; the illness is characterized by high fever, bleeding from the nose and ears, kidney failure, and death; the caterpillar is found from December through March)

Chagas disease (American trypanosomiasis) transmission has been eliminated in every state except Bahias and Tocantins through an aggressive program of insecticide spraying.

For an overview, see Emerging Infectious Diseases--Brazil by Dr. Hooman Momen (Emerging Infectious Diseases Vol. 4./No. 1 January-March 1998).

For in-depth public health information, go to the Pan-American Health Organization .

Food and Water You can't Edit

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.

Insect Tick Protection You can't Edit

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 accommodation 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.

To prevent sandfly bites, follow the same precautions as for mosquito bites, except that netting must be finer-mesh (at least 18 holes to the linear inch) since sandflies are smaller.

Swimming and Bathing You can't Edit

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 You can't Edit

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 You can't Edit

Ambulance and Emergency Services

For a public ambulance anywhere in Brazil, call 192 . For a private ambulance in Sao Paulo, call the Albert Einstein Hospital at 3747-1000 or 3747-1100 or the Samaritan Hospital at 3824-5000 or 3824-0022. For a private ambulance in Rio, call Copacabana at 2257-3848 or Pró-Cardíaco (private cardiac hospital) at 2527-6060. For a private ambulance in Brasilia, call Vida Ambulance at 3248-3030.

Medical Facilities You can't Edit

Medical facilities

Good medical care is available in the major cities. In Sao Paulo, the Albert Einstein Hospital is regularly used by U.S. Government personnel and other expatriates (Av. Albert Einstein, 627/701 - Morumbi - São Paulo - SP - CEP 05651-901 - tel. 55-11-3747-1301 or 1233; website http://www.einstein.br/ingles; offers broad range of state-of-the-art specialty services). Another option in Sao Paulo is the Samaritan Hospital (Hospital Samaritano - Rua Conselheiro Brotero, 1486 - Higienópolis - São Paulo - SP - CEP 01232-010; tel. (11) 3821-5300; website http://www.samaritano.com.br/). Both are accredited by the Joint Commission International and the Consortium for Brazilian Accreditation. Travelers in Sao Paulo can also receive quality care at FreireZaini MT (Rua Mairinque, 267 - Vila Mariana -SP CEP 04037-020 - SP; tel. 5511 55753632).

In Rio, many expatriates go to Hospital Samaritano (Rua Bambina 98, Botafogo; tel. 2537-9722) or Pró-Cardíaco, which specializes in cardiac care but offers other specialty services (Rua Dona Mariana 219, Botafogo; tel. 2537-4242, ambulance tel. 2527-6060; website http://www.procardiaco.com.br/). In Curtiba, medical care for travelers is provided by Travel Clin, which includes both an internist and a pediatrician (Rua da Paz, 195 conj. 319, Alto Da XV, Curitiba-PR, CEP 80060-160; ph. 55-41-3019-2474 (afternoons); email [email protected]; website http://www.travelclin.com.br). In Fortaleza, 24-hour medical care is provided by SAT Emergencia Medicas (Av. Senador Virgílio Távora 2225 Aldeota - Fortaleza 60170-251 Fortaleza-CE; ph. 55-85-4009-0909; website www.gruposat.com.br).

For a guide to other physicians and hospitals, go to the U.S. Embassy website (click on U.S. Citizen Services from the menu at the top). Medical facilities outside the major cities may vary in quality. 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.

The U.S. State Department advises that "Plastic and other elective/cosmetic surgery is a major medical industry in Brazil. While Brazil has many plastic surgery facilities that are on par with those found in the United States, two U.S. citizens died and one was left in vegetative state from complications following plastic surgery in the past year. U.S. citizens should make sure when arranging such surgery that emergency medical facilities are available, as some "boutique" plastic surgery operations offer luxurious facilities, but are not hospitals and are therefore unable to deal with unforeseen emergencies. Several U.S. citizens have also died while visiting non-traditional healers outside of urban areas."

Pharmacies You can't Edit

Most Brazilian pharmacies are well-supplied. Each is staffed by a licensed pharmacist. Many medications that require a prescription in Europe and North America are available over-the-counter in Brazil. Droga Raia is a large, reputable pharmacy chain; many stores are open 24 hours (see their website at http://www.drogaraia.com.br/ for locations).

Travel with children You can't Edit

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.

The recommendations for malaria prophylaxis are the same for young children as for adults, except that (1) dosages are lower; and (2) doxycycline should be avoided. DEET-containing insect repellents are not advised for children under age two, so it's particularly important to keep children in this age group well-covered to protect them from mosquito bites.

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 You can't Edit

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.

Pregnant women should also avoid areas where malaria is transmitted. Malaria may cause life-threatening illness in both the mother and the unborn child. None of the currently available prophylactic medications is 100% effective. If travel to malarious areas is unavoidable, insect protection measures must be strictly followed at all times. The recommendations for DEET-containing insect repellents are the same for pregnant women as for other adults. Of the currently available drugs for malaria prophylaxis, Mefloquine (Lariam) may be given if necessary in the second and third trimesters, but should be avoided in the first trimester. There are no data regarding the safety of atovaquone/proguanil (Malarone) during pregnancy, so the drug should be avoided pending further information. Doxycycline may interfere with fetal bone development and should not be given during pregnancy.

Strict attention to food and water precautions is especially important for the pregnant traveler because some infections, such as listeriosis and toxoplasmosis, 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 You can't Edit

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 .

Embassy You can't Edit

Embassy/Consulate Location

(reproduced from the U.S. State Dept. Consular Information Sheet)

Americans living in or visiting Brazil are encouraged to register at the Consular Section of the U.S. Embassy or Consulates in Brazil and obtain updated information on travel and security within Brazil. The U.S. Embassy is located in Brasilia at Avenida das Nacoes, Lote 3, telephone 011-55-61-321-7272, after-hours telephone 011-55-61-321-8230; web site at http//www.embaixada-americana.org.br. Consular Section public hours are 8:00 a.m.-12:00 noon and 1:30 p.m.-4:00 p.m., Monday through Friday except Brazilian and American holidays. There are consulates in the following cities:

Rua Goncalves Maia 163, telephone 011-55-81-3421-2441, after-hours telephone 011-55-3421-2641; web site at http://www.consulado-americano.org.br. Consular Section public hours are 8:00am-12noon and 1:00pm-4:00pm Monday through Friday except Brazilian and American holidays.

Avenida Presidente Wilson 147, telephone 011-55-21-2292-7117, after-hours 011-55-21-2220-0489; web site at http://www.consulado-americano-rio.org.br. Consular Section public hours are 8:30am-11:00am and 1:00pm-3:00pm, Monday through Friday except Brazilian and American holidays.

Rua Padre Joao Manoel 933, telephone 011-55-11-3081-6511, after-hours telephone 011-55-113064-6355; web site at http://www.amcham.com.br/consulate. Consular Section public hours are 8:30am-11:00am, Monday through Friday and 2:00pm-3:30pm Monday, Wednesday, and Friday except Brazilian and American holidays.

There are Consular Agencies in:

Belem: Rua Oswaldo Cruz 165; telephone 011-55-91-242-7815.

Manaus: Rua Recife 1010, Adrianopolis; telephone 011-55-92-633-4907.

Salvador da Bahia: Rua Pernambuco, 51, Pituba; telephone 011-55-71-345-1545 and 011-55-71-345-1548.

Forteleza: The Instituto Cultural Brasil-Estados Unidos (IBEU), Rua Nogueira Acioly 891, Aldeota; telephone 011-55-85-252-1539.

Porto Alegre: The Instituto Cultural Brasil-Norteamericano, Rua Riachuelo, 1257, Centro; telephone 011-55-512-225-2255.

Safety Information You can't Edit

Safety information

For information on safety and security, go to the U.S. Department of State, United Kingdom Foreign and Commonwealth Office, Foreign Affairs Canada , and the Australian Department of Foreign Affairs and Trade .

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Check out our page on Brazil for information on how to get there, accommodation, video and reviews.

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  • R. Padre Anchieta Full Details R. Padre Anchieta, 481 - Vila Povoa, Uberlândia - MG, 38411-106, Brazil Directions +55 34 3217-0001 http://www.pleni.med.br/
  • Av. do Contorno Full Details Av. do Contorno, 4480 - Funcionários, Belo Horizonte - MG, 30110-090, Brazil Directions +55 31 3223-3636

Hotels near Brazil

  • Pousada Recanto do Araguaia Located next to the famous Araguaia River, Pousada Recanto do Araguaia offers private barbecue facilities, a swimming pool and games room. It offers free Wi-Fi and private parking.
  • Pousada Aquarius Offering an outdoor pool and a restaurant, Pousada Aquarius is located at Toberi port, 100 metres from Rio Araquaia river. Free WiFi access is available in public areas.
  • Casa Verde Offering an outdoor pool, Casa Verde is located in Aruanã. The accommodation will provide you with a TV and air conditioning. There is a full kitchen with a microwave and an oven. Shared bathrooms also come with a shower.
  • Pousada Canoeiros Just 50 metres from Araguaia River, Pousada Canoeiros offers an outdoor pool, sports court, sauna and games area. It also provides a bar, restaurant and free Wi-Fi in public areas.
  • Pousada Águas Quentes Offering an outdoor pool, Pousada Águas Quentes is located in Barra do Garças. Free WiFi access is available and a daily breakfast is included. Parque das Águas Quentes waterpark is 40 metres away.
  • Hotel Pousada Tropical Just 1 block from Rio das Garças river, this hotel offers breakfast, a compact outdoor pool, gym and 24-hour reception. Rooms have air conditioning, free Wi-Fi and free parking. Rooms at Hotel Pousada Tropical provide a TV, telephone and minibar.
  • Odara Araguaia Offering an outdoor pool, 24-hour front desk, and a restaurant, Odara Araguaia is located in Barra do Garças. Free WiFi access is available. These air conditioned rooms are stylishly decorated with pastel colours and marble floors.
  • Esplanada Palace Hotel Centrally located in Barra do Garças, Esplanada Palace offers a rich buffet breakfast with cakes and hot meals. It features air-conditioned rooms, free Wi-Fi and a 24-hour reception. Private parking is free.
  • Tawfiq´s Palace Hotel Located in Barra do Garças city centre, this hotel offers air-conditioned rooms with free Wi-Fi and free parking. A 24-hour reception and buffet breakfast are available. Rooms at Tawfiq´s Palace Hotel provide a TV and a minibar.
  • Pousada Sinhá Offering an outdoor pool, Pousada Sinhá is located in the city of Goiás. Free WiFi access is available. At Pousada Sinhá you will find a 24-hour front desk and a garden. Other facilities offered at the property include a games room.

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Accommodation near Brazil

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Fond Doux Plantation & Resort is a 19th century eco-friendly boutique resort situated amidst a 250-yr. old traditional working plantation.

The plantation resort features fifteen private and comfortable cottages, two onsite restaurants, spa, gift shop, wedding gazebo, triple cascading pool and hiking trails.

Fond Doux Plantation & Resort is located within the UNESCO World Heritage site and is minutes away from the island’s main attractions.

It offers an authentic Saint Lucian experience to vacationers who wish to experience the real St. Lucia

  • Samfi Gardens No info yet.. Please go to this page and enter some.

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Brazil Healthy Travel Packing List

Pack items for your health and safety.

  • You may not be able to purchase and pack all of these items, and some may not be relevant to you and your travel plans. Talk to your doctor about which items are most important for you.
  • This list is general and may not include all the items you need. Check our Traveler Information Center for more information if you are a traveler with specific health needs, such as travelers who are pregnant, immune compromised, or traveling for a specific purpose like humanitarian aid work.
  • Remember to pack extras of important health supplies in case of travel delays.

Prescription medicines

  • Your prescriptions
  • Travelers' diarrhea antibiotic
  • Suture/syringe kit Kit is for use by local health care provider & requires a letter from your doctor on letterhead stationery
  • Altitude sickness medicine
  • Medicine to prevent malaria

Medical supplies

  • Glasses Consider packing spare glasses in case yours are damaged
  • Contact lenses Consider packing spare contacts in case yours are damaged
  • Needles or syringes (for diabetes, for example) Requires a letter from your doctor on letterhead stationery
  • Suture kit Kit is for use by local health care provider & requires a letter from your doctor on letterhead stationery
  • Diabetes testing supplies
  • Epinephrine auto-injectors (EpiPens)
  • Medical alert bracelet or necklace

Over-the-counter medicines

  • Antihistamine
  • Motion sickness medicine
  • Cough drops
  • Cough suppression/expectorant
  • Decongestant
  • Medicine for pain and fever Examples: acetaminophen, aspirin, or ibuprofen
  • Mild laxative
  • Mild sedative or other sleep aid
  • Saline nose spray

Supplies to prevent illness or injury

  • Hand sanitizer or wipes Alcohol-based hand sanitizer containing at least 60% alcohol or antibacterial hand wipes
  • Water purification tablets See CDC recommendations: Water Disinfection .
  • Water purification tablets May be needed if camping or visiting remote areas
  • Insect repellent Select an insect repellent based on CDC recommendations: Avoid Bug Bites
  • Permethrin Permethrin is insect repellent for clothing. It may be needed if you spend a lot of time outdoors. Clothing can also be treated at home in advance.
  • Bed net For protection against insect bites while sleeping
  • Sunscreen (SPF 15 or greater) with UVA and UVB protection. See Sun Exposure .
  • Sunglasses and hat Wear for additional sun protection. A wide brim hat is preferred.
  • Personal safety equipment Examples: child safety seats, bicycle helmets
  • Latex condoms

First-aid kit

  • 1% hydrocortisone cream
  • Antifungal ointments
  • Antibacterial ointments
  • Antiseptic wound cleanser
  • Aloe gel For sunburns
  • Insect bite treatment Anti-itch gel or cream
  • Bandages Multiple sizes, gauze, and adhesive tape
  • Moleskin or molefoam for blisters
  • Elastic/compression bandage wrap For sprains and strains
  • Disposable gloves
  • Digital thermometer
  • Scissors and safety pins
  • Cotton swabs (Q-Tips)
  • Oral rehydration salts
  • Health insurance documents Health insurance card (your regular plan and/or supplemental travel health insurance plan) and copies of claim forms
  • Proof of yellow fever vaccination If required for your trip, take your completed International Certificate of Vaccination or Prophylaxis card or medical waiver
  • Copies of all prescriptions Make sure prescriptions include generic names. Bring prescriptions for medicines, eye glasses/contacts, and other medical supplies.
  • Family member or close contact remaining in the United States
  • Health care provider(s) at home
  • Lodging at your destination
  • Hospitals or clinics (including emergency services) in your destination
  • US embassy or consulate in the destination country or countries

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Exit Notification / Disclaimer Policy

  • The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website.
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IMAGES

  1. areas of malaria transmission in Brazil, accordingly to Annual

    fit for travel malaria brazil

  2. Brazil: Travel Vaccines & Health Advice

    fit for travel malaria brazil

  3. Yellow Fever Vaccine & Malaria Prevention Information, by Country

    fit for travel malaria brazil

  4. Malaria Information for Travellers: Know This Before Leaving Home

    fit for travel malaria brazil

  5. Brazil

    fit for travel malaria brazil

  6. Fit For Travel Malaria Map

    fit for travel malaria brazil

COMMENTS

  1. Brazil Malaria Map

    Map showing extent of malaria risk in Brazil.

  2. Brazil

    Vaccinations and malaria risk. Review both the Vaccination and Malaria sections on this page to find out if you may need vaccines and/or a malaria risk assessment before you travel to this country. If you think you require vaccines and/or malaria risk assessment, you should make an appointment with a travel health professional:

  3. Malaria

    Malaria is a serious parasite infection that is transmitted by the bite of female mosquitoes. The parasites are microscopic and found in the blood of infected people. There are different types of malaria parasite and although the infection they cause is similar. 'Falciparum' malaria is the one that causes the most severe infection.

  4. Brazil

    Brazil. Due to heavy rainfall, the state of Rio Grande do Sul is experiencing significant flooding. Travel by land may be dangerous in flood zones, and the healthcare infrastructure has been damaged in many areas. There is an increased risk of waterborne and vector-borne diseases in the flood-affected areas. Avoid contact with floodwater, as it ...

  5. Brazil South America

    Brazil, South America. Malaria Risk & Vaccination Information. What is the risk of malaria in Brazil? The risk of Malaria is generally low risk throughout the Amazon basin region in Brazil and this includes Manaus. If travelling to the Amazon in Brazil prescription antimalarial such as Malarone, Doxycycline or Lariam should be taken.

  6. NewsDetail

    16 May 2017. The malaria advice and map for Brazil and Peru have recently been updated. This is following consideration by the Scottish Malaria Advisory Group after an extensive trawl of the available data. In Brazil malaria risk is highest in the Amazon regions (Acre, Amazonas, Roraima) and Amapa. There is low to no risk in all other areas.

  7. Travel Vaccines and Advice for Brazil

    Passport Health - Travel Vaccines for Brazil. Overall rating: 4.9 stars - 15 reviews. ★★★★★. "Helpful and Efficient". "Our time frame was very short as we had not got our immunizations before we left NZ. Passport Health was able to assist us with this immediately and gave a very thorough review of what was essential for ...

  8. Malaria

    Malaria in humans is caused by protozoan parasites of the genus Plasmodium, including Plasmodium falciparum, P. malariae, P. ovale, and P. vivax. In addition, zoonotic forms have been documented as causes of human infections and some deaths, especially P. knowlesi, a parasite of Old World (Eastern Hemisphere) monkeys, in Southeast Asia.

  9. Health

    See what health risks you'll face in Brazil, including: yellow fever. dengue. chikungunya. high UV levels. Altitude sickness is a risk in parts of Brazil. Read more about altitude sickness on ...

  10. Maps & Travel Medicine

    Reprint of malaria map from Health Information for International Travel 1974 (CDC 1974) View Larger Figure. For many years, CDC Yellow Book included World Health Organization global malaria maps, which generally followed the above design style. Small size and lack of labels made these maps difficult to interpret for specific travel itineraries.

  11. Malaria Prevention in Brazil

    Malaria is a serious concern for travelers in certain regions of Brazil, and understanding the risks and preventive measures is crucial. In this comprehensive guide, we will delve into key aspects of malaria prevention to ensure a safe and informed travel experience. Assessing Malaria Risks in Brazil Brazil, with its diverse landscapes and tropical climate, […]

  12. The Risk of Malaria Infection for Travelers Visiting the Brazilian

    1. Background. Malaria is a frequently imported, life-threatening tropical disease in international travelers from malaria-free to malaria-endemic regions [1-4].Globalization has increased the number of international travelers who travel for tourism, business, or visits with friends and families from industrialized countries to geographical destinations that have a high risk of malaria ...

  13. Is Brazil reaching malaria elimination? A time series analysis of

    In Brazil, 99% of malaria cases occur in the Amazon region, mainly caused by Plasmodium vivax (~83%) and Plasmodium falciparum (Pf) species. Aligned with the Sustainable Development Goals, Brazil aims to eliminate autochthonous malaria by 2035. This study aims to analyse epidemiological patterns of malaria in Brazil to discuss if Brazil is on track to meet malaria control targets. A time ...

  14. An update on prevention of malaria in travelers

    Introduction. Malaria is a parasitic disease caused by protozoa belonging to the genus Plasmodium.There are four species that exclusively affect humans: Plasmodium falciparum, Plasmodium vivax, Plasmodium ovale, and Plasmodium malariae.Plasmodium species that commonly infect non-human primates can also be responsible for a high proportion of human cases in certain parts of the world as is the ...

  15. The risk of malaria infection for travelers visiting the Brazilian

    Background: Human mobility between malaria endemic and malaria-free areas can hinder control and elimination efforts in the Amazon basin, maintaining Plasmodium circulation and introduction to new areas. Methods: The analysis begins by estimating the incidence of malaria in areas of interest. Then, the risk of infection as a function of the duration of stay after t 0 was calculated as the ...

  16. Brazil

    With >210 million people, Brazil is home to the world's largest Portuguese-speaking population. The world's eighth largest economy, Brazil is classified as an upper-middle-income country. Nearly 85% of Brazilians live in urban areas. Brazil is the most popular tourist destination in South America, and the second most popular in all Latin ...

  17. Travel vaccination advice

    The GP or practice nurse may be able to give you general advice about travel vaccinations and travel health, such as protecting yourself from malaria. They can give you any missing doses of your UK vaccines if you need them. Not all travel vaccinations are available free on the NHS, even if they're recommended for travel to a certain area.

  18. Travel Vaccines and Advice for Brazil

    Advice. Travellers'. Diarrhoea. Prevention. Rich with seasides, rainforests, and vibrant urban centers, Brazil offers a wide variety of attractions. For the adventurous, there are mountains to climb and islands to explore. For the more historically inclined, there are whole settlements from the colonial era that have not been renovated since ...

  19. Yellow Fever Vaccine & Malaria Prevention Information, by Country

    CDC Yellow Book 2024. Preparing International Travelers. Author (s): Mark Gershman, Rhett Stoney (Yellow Fever) Holly Biggs, Kathrine Tan (Malaria) The following pages present country-specific information on yellow fever (YF) vaccine requirements and recommendations, and malaria transmission information and prevention recommendations.

  20. MD Travel Health

    Summary of recommendations. Most travelers to Brazil will need vaccinations for hepatitis A, typhoid fever, and yellow fever, as well as medications for travelers' diarrhea.Many will require malaria prophylaxis, in conjunction with insect repellents and other measures to prevent mosquito bites. Additional immunizations may be necessary depending upon the circumstances of the trip and the ...

  21. NaTHNaC

    NaTHNaC - Country List - TravelHealthPro COUNTRY INFORMATION is a webpage that provides comprehensive and up-to-date information on travel health risks and recommendations for over 200 countries. Whether you are travelling to Peru, Bali, Romania, Uganda or any other destination, you can find useful factsheets, vaccine advice, malaria prevention tips, outbreak alerts and more on this webpage.

  22. Yellow Fever Vaccine & Malaria Prevention Information, by Country

    CDC Yellow Book 2024. Author (s): Mark Gershman, Rhett Stoney (Yellow Fever) Holly Biggs, Kathrine Tan (Malaria) The following pages present country-specific information on yellow fever (YF) vaccine requirements and recommendations, and malaria transmission information and prevention recommendations. Country-specific maps are included to aid in ...

  23. Brazil Healthy Travel Packing List

    Check our Traveler Information Center for more information if you are a traveler with specific health needs, such as travelers who are pregnant, immune compromised, or traveling for a specific purpose like humanitarian aid work. Remember to pack extras of important health supplies in case of travel delays. Prescription medicines. Your prescriptions