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Health

In Bolivia

Infectious Diseases

Hepatitis A

  • Hepatitis A is the second most common travel-related infection (after travelers’ diarrhea). The illness occurs throughout the world, but the incidence is higher in developing nations.
  • It’s a viral infection of the liver that is usually acquired by ingestion of contaminated water, food or ice, or by direct contact with infected persons.
  • Symptoms may include fever, malaise, jaundice, nausea, vomiting and abdominal pain. Most cases resolve without complications, though hepatitis A occasionally causes severe liver damage.
  • There is no treatment.

Dengue Fever

  • Dengue fever is a viral infection found throughout South America. Dengue causes flu-like symptoms, including fever, muscle aches, joint pains, headache, nausea and vomiting, often followed by a rash.
  • The body aches may be quite uncomfortable, but most cases resolve uneventfully in a few days. Severe cases usually occur in children under age 15 who are experiencing their second dengue infection.
  • Dengue is transmitted by Aedes mosquitoes, which bite preferentially during the daytime and are usually found close to human habitation, often indoors. They breed in artificial water containers, such as jars, barrels, cans, cisterns, metal drums, plastic containers and discarded tires.
  • Dengue is most common in densely populated, urban environments.
  • There is no specific antivirus treatment for dengue fever except to take analgesics such as acetaminophen/paracetamol (Tylenol) and drink plenty of fluids. Severe cases may require hospitalization for intravenous fluids and supportive care. There is no vaccine. The cornerstone of prevention is insect control.

Malaria

  • Malaria occurs in nearly every South American country but is rare. It’s transmitted by mosquito bites at night.
  • The main symptom is high spiking fevers, which may be accompanied by chills, sweats, headache, body aches, weakness, vomiting or diarrhea. Severe cases may involve the central nervous system and lead to seizures, confusion, coma and death.
  • Taking malaria pills is strongly recommended for areas below 2500m (8202ft) in the departments of Beni, Santa Cruz and Pando, where the risk is highest, though it is absent in the cities. Falciparum malaria, which is the most dangerous kind, occurs in Beni and Pando.
  • There is a choice of three malaria pills, all of which work about equally well. Mefloquine (Lariam) is taken once weekly in a dosage of 250mg, starting one to two weeks before arrival, and continuing through the trip and for four weeks after return. The problem is that a certain percentage of people (the number is controversial) develop neuropsychiatric side effects, which may range from mild to severe. Stomachache and diarrhea are also common. Atovaquone/proguanil (Malarone) is taken once daily with food, starting two days before arrival and continuing daily until seven days after departure. Side effects are typically mild. Doxycycline is relatively inexpensive and easy to obtain, but it is taken daily and can cause an exaggerated sunburn reaction.
  • For longer trips it’s probably worth trying mefloquine; for shorter trips, Malarone will be the drug of choice for most people.
  • Protecting yourself against mosquito bites is just as important as taking malaria pills, since none of the pills are 100% effective.
  • If you may not have access to medical care while traveling, you should bring along additional pills for emergency self-treatment, which you should take if you can’t reach a doctor and you develop symptoms that suggest malaria, such as high spiking fevers. One option is to take four tablets of Malarone once daily for three days. However, Malarone should not be used for treatment if you’re already taking it for prevention. An alternative is to take 650mg quinine three times daily and 100mg doxycycline twice daily for one week. If you start self-medication, see a doctor at the earliest possible opportunity.
  • If you develop a fever after returning home, see a physician, as malaria symptoms may not occur for months.

Other Infections

  • A number of rare but serious diseases are carried by insects and rodents, such as bartonellosis, Bolivian hemorrhagic fever, Chagas’ disease, leishmaniasis, typhus and the plague. Rabies is also a concern, especially in the southeastern part of the country.
  • Do not attempt to pet, handle or feed any animal. Any bite or scratch by any mammal, should be promptly and thoroughly cleansed with large amounts of soap and water, followed by application of an antiseptic such as iodine or alcohol.
  • The local health authorities should be contacted immediately for possible post-exposure rabies treatment, whether or not you’ve been immunized against rabies. It may also be advisable to start an antibiotic, since wounds caused by animal bites and scratches frequently become infected. Or use one of the newer quinolones, such as levofloxacin (Levaquin), which many travelers carry in case of diarrhea.

Cholera

  • Cholera is an intestinal infection acquired through ingestion of contaminated food or water. The main symptom is profuse, watery diarrhea, which may be so severe that it causes life-threatening dehydration.
  • Cholera sometimes occurs in Bolivia, but it’s rare among travelers.
  • A cholera vaccine is no longer required. There are effective vaccines, but they’re not available in many countries and are only recommended for those at particularly high risk.
  • The key treatment is drinking oral rehydration solution. Antibiotics are also given, usually tetracycline or doxycycline, though quinolone antibiotics such as ciprofloxacin and levofloxacin are also effective.

Yellow Fever

  • Yellow fever is a life-threatening viral infection transmitted by mosquitoes in forested areas. Taking measures to protect yourself from mosquito bites is an essential part of preventing yellow fever.
  • The illness begins with flu-like symptoms, such as fever, chills, headache, muscle aches, backache, loss of appetite, nausea and vomiting. These symptoms usually subside in a few days, but 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 the cases.
  • There is no treatment except for supportive care.
  • Yellow fever vaccine is strongly recommended for all those visiting areas where yellow fever occurs, which includes the departments of Beni, Cochabamba, Santa Cruz and La Paz. For the latest information on which areas in Bolivia are reporting yellow fever, see the website of Centers for Disease Control & Protection (CDC; www.cdc.gov).
  • Proof of vaccination is required from all travelers arriving from a yellow fever–infected country in Africa or the Americas.
  • The yellow-fever vaccine is given only in approved yellow fever vaccination centers, which provide validated International Certificates of Vaccination (yellow booklets). The vaccine should be given at least 10 days before any potential exposure to yellow fever, and remains effective for approximately 10 years.
  • Reactions to the vaccine are generally mild and may include headaches, muscle aches, low-grade fevers, or discomfort at the injection site. Severe, life-threatening reactions have been described but are extremely rare. In general the risk of becoming ill from the vaccine is far less than the risk of becoming ill from yellow fever, and you’re strongly encouraged to get the vaccine.

Typhoid Fever

  • Typhoid fever is caused by the ingestion of food or water contaminated by a species of salmonella known as Salmonella typhi.
  • Fever occurs in virtually all cases. Other symptoms may include headache, malaise, muscle aches, dizziness, loss of appetite, nausea and abdominal pain. Either diarrhea or constipation may occur. Possible complications include intestinal perforation, intestinal bleeding, confusion, delirium or (rarely) coma.
  • A typhoid vaccine is a good idea. It’s usually given orally, but is also available as an injection. Neither vaccine is approved for use in children under age two.
  • It is not a good idea to self-treat for typhoid fever as the symptoms may be indistinguishable from malaria. If you show symptoms for either, see a doctor immediately – treatment is likely to be a quinolone antibiotic such as ciprofloxacin (Cipro) or levofloxacin (Levaquin).

Women's Health

There are English-speaking obstetricians in Bolivia, listed on the US Embassy website (http://bolivia.usembassy.gov/uploads/images/eOd9_kCdEz0Za_pollKATw/PHYSICIANSLIST1.pdf). However, medical facilities will probably not be comparable to those in your home country. It’s safer to avoid travel to Bolivia late in pregnancy, so that you don’t have to deliver there.

If pregnant, you should avoid travel to high altitudes. The lower oxygen levels that occur at high altitudes can slow fetal growth, especially after the 32nd week. Also it’s safer not to visit areas where yellow fever occurs, since the vaccine is not safe during pregnancy.

If you need to take malaria pills, mefloquine (Lariam) is the safest during pregnancy.

Environmental Hazards

Altitude Sickness

  • Altitude sickness may develop in those who ascend rapidly to altitudes greater than 2500m (8100ft). In Bolivia this includes La Paz (altitude 4000m). The risk increases with faster ascents, higher altitudes and greater exertion.
  • Symptoms may include headache, nausea, vomiting, dizziness, malaise, insomnia and loss of appetite. Severe cases may be complicated by fluid in the lungs (high-altitude pulmonary edema) or swelling of the brain (high-altitude cerebral edema).
  • Being physically fit offers no protection.
  • Those who have experienced altitude sickness in the past are prone to future episodes.
  • The best treatment for altitude sickness is descent. If you are exhibiting symptoms, do not ascend. If symptoms are severe or persistent, descend immediately.
  • To protect yourself against altitude sickness, take 125mg or 250mg acetazolamide (Diamox) twice or three times daily, starting 24 hours before ascent and continuing for 48 hours after arrival at altitude. Possible side effects include increased urinary volume, numbness, tingling, nausea, drowsiness, myopia and temporary impotence. Acetazolamide should not be given to pregnant women or anyone with a history of sulfa allergy.
  • For those who cannot tolerate acetazolamide, the next best option is 4mg dexamethasone taken four times daily, best with medical supervision. Unlike acetazolamide, dexamethasone must be tapered gradually on arrival at altitude if taken for longer than 10 days, since there is a risk that altitude sickness will occur as the dosage is reduced. Dexamethasone is a steroid, so it should not be given to diabetics or anyone for whom steroids are contraindicated. A natural alternative is gingko, which helps some people.
  • When traveling to high altitudes, it’s also important to avoid overexertion, eat light meals and abstain from alcohol.
  • If your symptoms are more than mild or don’t resolve promptly, see a doctor immediately. Altitude sickness should be taken seriously; it can be life-threatening.

Insect Bites & Stings

  • To prevent mosquito bites, wear long sleeves, long pants, hats and shoes (rather than sandals).
  • Don’t sleep with the window open unless there is a screen.
  • If sleeping outdoors or in accommodations that allow entry of mosquitoes, use a fine-mesh bed net, preferably treated with permethrin, with edges tucked in under the mattress. If the sleeping area is not protected, use a mosquito coil, which will fill the room with insecticide through the night.
  • Bring along a good insect repellent, preferably one containing DEET, which should be applied to exposed skin and clothing, but not to eyes, mouth, wounds or irritated skin. Products containing lower concentrations of DEET are as effective, but for shorter periods of time.
  • In general, adults and children over 12 should use preparations containing 25% to 35% DEET, which usually lasts about six hours. Children between two and 12 years of age should use preparations containing no more than 10% DEET, applied sparingly, which will usually last about three hours. Neurologic toxicity has been reported from DEET, especially in children, but appears to be rare and related to overuse. DEET-containing compounds should not be used on children under age two.
  • Insect repellents containing certain botanical products, including eucalyptus oil and soybean oil, are effective but last only 1½ to two hours. DEET-containing repellents are preferable for areas where there is a high risk of malaria or yellow fever. Products based on citronella and repellent-impregnated wristbands are not effective.
  • For additional protection you can apply permethrin to clothing, shoes, tents and bed nets. Permethrin treatments are safe and remain effective for at least two weeks, even when items are laundered, but do not apply it directly to skin.

Snake Bites

In Bolivia there are two families of poisonous snakes:

  • vipers (including rattlesnakes)
  • coral snakes

It is extremely rare to be bitten by a venomous snake, but in the event that it does occur place the victim at rest, keep the bitten area immobilized and move the victim to the nearest medical facility immediately.

Avoid tourniquets, which are no longer recommended.

Water

Bottled mineral water is cheap and freely available. Use it for everything and if you are going anywhere remote take a good supply with you.

Ground water has been polluted by mining in many areas of the altiplano, and some cities, such as Trinidad, are known for having a toxic water supply that will have you regretting that little sip out of the tap in the middle of the hot sweaty Amazonian night. Should you find yourself desperate, thirsty and with nowhere to buy water, then try the following:

Boiling Vigorous boiling for one minute is the most effective means of water purification. At altitudes greater than 2000m (6500ft), boil for three minutes.

Purification pills Disinfect water with iodine pills such as Globaline, Potable-Aqua and Coghlan’s, available at most pharmacies. Instructions are enclosed and should be carefully followed. Or you can add 2% tincture of iodine to one quart or liter of water (five drops to clear water, 10 drops to cloudy water) and let it stand for 30 minutes. If the water is cold, longer times may be required. The taste of iodinated water may be improved by adding vitamin C (ascorbic acid). Iodinated water should not be consumed for more than a few weeks.

Filters Filters with smaller pores (reverse osmosis filters) provide the broadest protection, but they are relatively large and are readily plugged by debris. Those with larger pores (microstrainer filters) are ineffective against viruses, although they remove other organisms. Manufacturers’ instructions must be carefully followed.

Tap Water

Tap water in Bolivia is not safe to drink! Buy bottled water!

Sunburn & Heat Exhaustion

To protect yourself from excessive sun exposure:

  • Stay out of the midday sun.
  • Drink plenty of fluids.
  • Avoid strenuous exercise in high temperatures.
  • Wear sunglasses.
  • Wear a wide-brimmed sun hat.
  • Apply sunscreen with SPF 15 or higher, with both UVA and UVB protection. Sunscreen should be generously applied to all exposed parts of the body approximately 30 minutes before sun exposure and should be reapplied after swimming or vigorous activity.

Travelers' Diarrhea

You are almost certain to get a bout at some stage, but you can put it off for as long as possible by observing some simple rules.

  • Avoid tap water unless it has been boiled, filtered or chemically disinfected (with iodine tablets).
  • Only eat fresh fruits or vegetables if peeled or cooked.
  • Be wary of dairy products that might contain unpasteurized milk.
  • Be highly selective when eating food from street vendors. If it looks, smells or tastes iffy, don’t eat it!
  • If you develop diarrhea, be sure to drink plenty of fluids, preferably an oral rehydration solution containing lots of salt and sugar. A few loose stools doesn’t require treatment but if you start having more than four or five stools a day you should start taking an antibiotic (usually a quinolone drug) and an antidiarrheal agent (such as loperamide).
  • If diarrhea is bloody, or persists for more than 72 hours, or is accompanied by fever, shaking chills or severe abdominal pain, you should seek medical attention.

Availability & Cost of Healthcare

  • Good medical care is available in the larger cities, but may be difficult to find in rural areas.
  • Many doctors and hospitals expect payment in cash, regardless of whether you have travel health insurance. Note that a taxi may get you to the emergency room faster than an ambulance.
  • If you develop a life-threatening medical problem, you’ll probably want to be evacuated to a country with state-of-the-art medical care. Since this may cost tens of thousands of dollars, be sure you have insurance to cover this before you depart.
  • Bolivian pharmacies offer most of the medications available in other countries. In general it’s safer to buy pharmaceuticals made by international manufacturers rather than local companies.
  • Buy the brand name prescribed by your doctor, not the generic-brand drugs that may be offered at lower prices. These medications may be out of date or have no quality control from the manufacturer.

Online Resources

Your government’s travel health website can also be helpful:

Before You Go

The only required vaccine for Bolivia is yellow fever, and that’s only if you’re arriving from a yellow fever–infected country in Africa or the Americas. However, a number of other vaccines are recommended, such as hepatitis A, rabies, tetanus/diphtheria and typhoid.

Since most vaccines don’t produce immunity until at least two weeks after they’re applied, visit a physician four to eight weeks before departure. Ask your doctor for an International Certificate of Vaccination, containing a list of your vaccinations.

Bring medications in their original containers, clearly labeled, and a signed, dated letter from your physician describing all medical conditions and medications. If carrying syringes or needles, carry a physician’s letter documenting their medical necessity.

Insurance

  • If your health insurance does not cover you for medical expenses abroad, consider supplemental insurance. Check the Travel Insurance section of Lonely Planet's website (www.lonelyplanet.com/travel-insurance) for more information.
  • Find out in advance if your insurance plan will make payments directly to providers or reimburse you later for overseas health expenditures. Most private-practice providers in Bolivia expect cash payment and should provide receipts for your insurance company claims and reimbursement.
  • Credit cards are usually not accepted for medical services.

Medical Checklist

  • acetaminophen (Tylenol) or aspirin
  • acetazolamide (Diamox) for altitude sickness
  • adhesive or paper tape
  • antibacterial ointment (eg Bactroban) for cuts and abrasions
  • antibiotics
  • antidiarrheal drugs (eg loperamide)
  • antihistamines (for hay fever and allergic reactions)
  • anti-inflammatory drugs (eg ibuprofen)
  • bandages, gauze, gauze rolls
  • DEET-containing insect repellent for the skin
  • iodine tablets (for water purification)
  • oral rehydration salts
  • permethrin-containing insect spray for clothing, tents and bed nets
  • pocket knife
  • scissors, safety pins, tweezers
  • sun block
  • steroid cream or cortisone (for poison ivy and other allergic rashes)
  • syringes and sterile needles
  • thermometer