Travelers' diarrhea is the most common travel-related ailment. The cornerstone of prevention is food and water precautions, as outlined below. All travelers should bring along an antibiotic and an antidiarrheal drug to be started promptly if significant diarrhea occurs, defined as three or more loose stools in an 8-hour period or five or more loose stools in a 24-hour period, especially if associated with nausea, vomiting, cramps, fever or blood in the stool. A quinolone antibiotic is usually prescribed: either ciprofloxacin (Cipro)(PDF) 500 mg twice daily or levofloxacin (Levaquin) (PDF) 500 mg once daily for a total of three days. Quinolones are generally well-tolerated, but occasionally cause sun sensitivity and should not be given to children, pregnant women, or anyone with a history of quinolone allergy. Alternative regimens include a three day course of rifaximin (Xifaxan) 200 mg three times daily or azithromycin (Zithromax) 500 mg once daily. Rifaximin should not be used by those with fever or bloody stools and is not approved for pregnant women or those under age 12. Azithromycin should be avoided in those allergic to erythromycin or related antibiotics. An antidiarrheal drug such as loperamide (Imodium) or diphenoxylate (Lomotil) should be taken as needed to slow the frequency of stools, but not enough to stop the bowel movements completely. Diphenoxylate (Lomotil) and loperamide (Imodium) should not be given to children under age two.

Most cases of travelers' diarrhea are mild and do not require either antibiotics or antidiarrheal drugs. Adequate fluid intake is essential.

If diarrhea is severe or bloody, or if fever occurs with shaking chills, or if abdominal pain becomes marked, or if diarrhea persists for more than 72 hours, medical attention should be sought.

Though effective, antibiotics are not recommended prophylactically (i.e. to prevent diarrhea before it occurs) because of the risk of adverse effects, though this approach may be warranted in special situations, such as immunocompromised travelers.

Malaria in Brazil: prophylaxis 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, where transmission occurs on the periphery. Transmission is greatest in remote jungle areas where mining, lumbering and agriculture occur and which have been settled for less than five years. Malaria risk is negligible outside the states of "Legal Amazonia." For a map showing the risk of malaria in different parts of the country, go to the Pan American Health Organization.

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, insomnia, 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 recently approved 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.

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.

Insect protection measures are essential.

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.

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 those greater than nine months of age traveling to areas in Brazil where yellow fever occurs, which includes the northern part of Espiritu Santo and the western part of Santa Catarina; all areas in the states of Acre, Amapa, Amazones, Goias, Maranhao, Mato Grosso, Mato Grosso do Sol, Minas Gerais, Para, Rondonia, Roraima, and Tocantins; parts of the states of Bahia, Parana, Piaui, Rio Grande do Sul (including the region of Target); the Federal District of Brasilia; and Sao Paulo (see the CDC map for details). A yellow fever alert was issued in January 2008 (see "Recent outbreaks" below). Yellow fever vaccine is recommended for Iguacu Falls, but is not necessary for the coastal cities, including Rio de Janeiro, Sao Paulo, Salvador, Recife, and Fortaleza.

Yellow fever vaccine is required for travelers greater than nine months of age arriving from a yellow-fever-infected country in Africa or the Americas. The vaccine is also required for travelers arriving from

Africa: Angola, Cameroon, Democratic Republic of Congo, Gabon, The Gambia, Ghana, Guinea, Liberia, Nigeria, Sierra Leone, and Sudan.

Americas: Bolivia, Columbia, Ecuador, and Peru.

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 travelers who will have intimate contact with local residents or potentially need blood transfusions or injections while abroad, especially if visiting for more than six months. It is also recommended for all health care personnel. 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 only for those at high risk for animal bites, such as veterinarians and animal handlers, and for long-term travelers who may have contact with animals and may not have access to medical care. 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.

A yellow fever outbreak was reported in January 2008, resulting in 40 confirmed cases and 21 deaths by April. A majority of the cases occurred in Goias State, but cases were also described in Mato Grosso do Sul, Mato Grosso, Parana, and the Federal District. A monkey outbreak of yellow fever, which frequently precedes the appearance of human cases, was reported from Goias in December 2007 and from Mato Grosso in January 2008. In March 2008, the state of Sao Paulo issued a yellow fever alert for the Grande and Parana River region after two monkeys in that area died from the disease. 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 all travelers to the northern part of Espiritu Santo and the western part of Santa Catarina; all areas in the states of Acre, Amapa, Amazones, Goias, Maranhao, Mato Grosso, Mato Grosso do Sol, Minas Gerais, Para, Rondonia, Roraima, and Tocantins; parts of the states of Bahia, Parana, Piaui, Rio Grande do Sul (including the region of Target); the Federal District of Brasilia; and Sao Paulo. Insect protection measures, as described below, are also strongly advised.

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. A major dengue outbreak was reported in the first quarter of 2008, causing a national total of 120,570 cases as of March 28, including 647 cases of dengue hemorrhagic fever and 48 deaths. The State of Rio de Janeiro was particularly affected: more than 120,000 cases, including at least 103 deaths, were reported as of April 30 (see the World Health Organization). Outbreaks were also reported from the states of Rio Grande do Norte (particularly affecting the region of the Grande Natal), Bahia, Sergipe, and Para (in the metropolitan region of Belem). 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.

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 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.

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. An outbreak was reported in July 2006 from 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 (August 21, 2007).

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 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.

An outbreak of toxoplasmosis was reported from Santa Isabel do Ivai in northwestern Parana state in January 2002. The outbreak was caused by unfiltered, municipally treated water. See Emerging Infectious Diseases and ProMED-mail (January 12, 2002) 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 for details. Because toxoplasmosis may cause severe fetal illness, pregnant women traveling to Brazil should make sure they do not drink unfiltered water.

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.

Cases of "caterpillar plague" were reported from the Amazon delta region between 1983 and 1985 and from southern Brazil in 1995. The disease is 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. The adult and pupal forms are harmless.

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

• 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)
• 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)
• Visceral leishmaniasis (chiefly in the Northeast; increased number of cases reported from Mato Grosso state between November 2007 and January 2008; see ProMED-mail, January 25, 2008, and Jorge Arias et al., The Reemergence of Visceral Leishmaniasis in Brazil (Emerging Infectious Diseases Vol. 2/No. 2 | April-June 1996)
• 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)
• 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)
• Oropouche fever (chiefly in Para State, mainly in Belem and neighboring areas; 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 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)
• Mayaro virus disease (Amazon region)
• Hepatitis D (upper Amazon river basin along the Purus and Jurua rivers)
• Venezuelan equine encephalitis
• Eastern equine encephalitis
• Brazilian spotted fever (almost 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; 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)

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.

Do not drink tap water unless it has been boiled, filtered, or chemically disinfected. Do not drink unbottled beverages or drinks with ice. Do not eat fruits or vegetables unless they have been peeled or cooked. Avoid cooked foods that are no longer piping hot. Cooked foods that have been left at room temperature are particularly hazardous. Avoid unpasteurized milk and any products that might have been made from unpasteurized milk, such as ice cream. Avoid food and beverages obtained from street vendors. Do not eat raw or undercooked meat or fish, including ceviche. Some types of fish may contain poisonous biotoxins even when cooked. Barracuda in particular should never be eaten. Other fish that may contain toxins include red snapper, grouper, amberjack, and sea bass.

All travelers should bring along an antibiotic and an antidiarrheal drug to be started promptly if significant diarrhea occurs, defined as three or more loose stools in an 8-hour period or five or more loose stools in a 24-hour period, especially if accompanied by nausea, vomiting, cramps, fever or blood in the stool. Antibiotics which have been shown to be effective include ciprofloxacin (Cipro), levofloxacin (Levaquin), rifaximin (Xifaxan), or azithromycin (Zithromax). Either loperamide (Imodium) or diphenoxylate (Lomotil) should be taken in addition to the antibiotic to reduce diarrhea and prevent dehydration.

If diarrhea is severe or bloody, or if fever occurs with shaking chills, or if abdominal pain becomes marked, or if diarrhea persists for more than 72 hours, medical attention should be sought.

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

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.

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."

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; (2) Malarone is not recommended for children weighing less than 25 pounds; and (3) 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).

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.

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.

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:

Recife: 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.

Rio de Janeiro: 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.

Sao Paulo: 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.

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.