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Health & safety

Before you go

Further reading

For more detailed information on health matters, see Healthy Travel Central & South America, published by Lonely Planet. If you are traveling with children, Lonely Planet’s Travel with Children provides useful advice. The ABC of Healthy Travel by E Walker et al is another valuable resource.

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If your health insurer doesn’t cover you for medical expenses incurred abroad, you’ll need to get some extra travel insurance. Find out in advance if your travel insurer will make payments directly to providers or reimburse you later for overseas health expenditures.

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Internet resources

There is a wealth of travel-health advice on the internet. For further information, the Lonely Planet website at www.lonelyplanet.com is a good place to start. The World Health Organization (WHO) publishes a superb book called International Travel and Health, which is revised annually and is available online at no cost (www.who.int/ith/). Another website of general interest is the MD Travel Health website at www.mdtravelhealth.com, which provides free, complete travel-health recommendations for every country and is updated daily.

It’s usually a good idea to consult your government’s travel-health website before departure, if one is available:

Australia www.dfat.gov.au/travel/

Canada ­www.hc-sc.gc.ca/pphb-dgspsp/tmp-pmv/pub_e.html

UK www.doh.gov.uk/traveladvice/index.htm

US www.cdc.gov/travel/

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Medical checklist

Bring medications in their original containers, clearly labeled. A signed, dated letter from your doctor describing your medical conditions and medications (including their generic names) is a good idea. If carrying syringes or needles, take a physician’s letter documenting their medical necessity.

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Recommended vaccinations

Since most vaccines don’t produce immunity until at least two weeks after they’re given, visit a physician four to eight weeks before departure. Ask your doctor for an International Certificate of Vaccination (otherwise known as the yellow booklet), which will list all the vaccinations you’ve received. This is mandatory for countries that require proof of yellow-fever vaccination upon entry, but it’s a good idea to carry it wherever you travel.

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Dangers & annoyances

Brazil receives a lot of bad press about its violence and high crime rate. While undoubtedly sensationalized by the media, many tourists do get robbed while in Brazil, and you’ll want to minimize the risks of becoming a victim. Don’t start your trip by wandering around touristy areas in a jet-lagged state soon after arrival: you’ll be an obvious target. Accept the fact that you might be mugged, pickpocketed or have your bag snatched while you’re in the country. If you carry only the minimum needed for the day (neither too much nor too little), and don’t try to resist thieves, you’re unlikely to come to any real harm. Other tips:

Don’t come to Brazil with jewelry, iPods, expensive watches and other items you’ll worry about.

Don’t dress like a gringo. Avoid wearing baseball caps, shiny sunglasses and black socks (Brazilians, like North Americans, wear white socks with sneakers). Dress down in casual clothes that blend in. Bermuda shorts, T-shirts, a pair of Havaianas and other clothes bought in Brazil are a good choice.

Keep small change handy so you don’t have to flash a wallet to pay bus fare.

Don’t wear a backpack when out ­sightseeing.

Don’t wander around with a camera in view – keep it out of sight. Consider carrying it in a plastic bag from a local store. Disposable cameras are much less worry.

Before arriving in a new place, get a map or at least have a rough idea of the area’s orientation. Use taxis to avoid walking through high-risk areas.

Be alert and walk purposefully. Criminals will hone in on dopey, hesitant, disoriented-looking individuals.

Use ATMs inside buildings. When using any ATM or exchanging money, be aware of those around you. Robbers sometimes watch these places looking for targets.

Check the windows and doors of your room for security, and don’t leave anything valuable lying around. If you consider your hotel to be reliable, place your valuables in its safe and get a receipt.

If you’re suspicious or uneasy about a situation, don’t hesitate to make excuses and leave, change your route, or whatever else is needed to extricate yourself.

Don’t take anything to city beaches except your bathing suit, a towel and just enough money for food and drinks. No camera, no bag, no jewelry.

After dark, don’t walk along empty or nearly empty streets or into deserted parks.

Don’t wander into the favelas (shantytowns) unless you’re with a trustworthy guide who really knows the area.

Never carry any more money than you need for the specific outing you’re on, and keep it discreetly stashed away in a money belt, sock, secret pocket or shoe. But always have enough cash on hand to appease a mugger (R$20 to R$40).

If something is stolen from you, you can report it to the police, but it can be an enormous hassle just to get a police report for your insurance company. The tourist police are the best equipped to deal with foreigners, but are rare outside of Rio.

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Scams & robbery techniques

One of the biggest new scams to hit Brazil in recent years is the hacking into a person’s bank account after he or she uses an ATM machine. There have been many reports of this by travelers throughout Brazil. When withdrawing money, try to use machines inside banks that get a lot of pedestrian traffic and always hide the number pad when you’re inputting your PIN.

Distraction is a common tactic employed by street thieves in Brazil and elsewhere around the world. The aim is to throw potential victims off guard so that they’re easier prey. It may be something as simple as asking you for a cigarette or a light so that you slow down and take your attention off other people around you.

Techniques are continually being developed, and imported or exported across national borders, to relieve the unwary of their belongings. Keep abreast of new scams by talking to other travelers. Theft and security are sources of endless fascination and ­stories.

A classic, revolting distraction method is the ‘cream technique, ’ common the world over, including in Brazil. You’re walking down the street or standing in some public place, when someone surreptitiously sprays a substance on your shoulder, your daypack or anything else connected with you. The substance can be anything from mustard to chocolate or even excrement. An assistant (young or old, male or female) then taps you on the shoulder and amicably offers to clean off the mess…if you’ll just put down your bag for a second. The moment you do this, someone makes off with it in a flash. The golden rule is to ignore any such attempt or offer, and simply endure your mucky state until you can find a safe place, such as your hotel, where you can wash.

There have also been reports of druggings, including spiked drinks. While you’re temporarily unconscious or semiconscious as a result of some noxious substance being slipped into your beverage, you’re powerless to resist thieves. There have even been reported cases of rape in such circumstances. If you start to feel unaccountably dizzy, disoriented, fatigued, or just mentally vacant not long after imbibing, your drink may have been spiked. If you suspect this to be the case, quickly extricate yourself from the situation and get to a safe place – your hotel room.

Exercise extreme caution when someone you don’t know and trust offers you a drink of any kind or even cigarettes, sweets etc. If the circumstances make you suspicious, the offer can be tactfully refused by claiming stomach or other medical problems.

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In transit

Deep Vein Thrombosis (DVT)

Blood clots may form in the legs (deep vein thrombosis; DVT) during plane flights, chiefly because of prolonged immobility. The longer the flight, the greater the risk. Though most blood clots are reabsorbed uneventfully, some may break off and travel through the blood vessels to the lungs, where they could cause life-threatening complications.

The chief symptom of DVT is swelling or pain of the foot, ankle or calf, usually but not always on just one side. When a blood clot travels to the lungs, it may cause chest pain and difficulty breathing. Travelers with any of these symptoms should seek medical ­attention immediately.

To prevent DVT on long flights you should walk about the cabin, perform isometric compressions of the leg muscles (ie contract leg muscles while sitting), drink lots of fluids, and avoid alcohol and tobacco.

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Jet lag & motion sickness

Jet lag is common when crossing more than five time zones and can result in insomnia, fatigue, malaise or nausea. To avoid jet lag try drinking plenty of (nonalcoholic) fluids and eating light meals. Upon arrival, get exposure to natural sunlight and readjust your schedule (for meals, sleep etc) as soon as possible.

Antihistamines such as dimenhydrinate (Dramamine) and meclizine (Antivert, Bonine) are usually the first choice for treating motion sickness. Their main side effect is drowsiness. An herbal alternative is ginger, which works like a charm for some people.

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While you're there

Animal bites

Do not attempt to pet, handle or feed any animal, with the exception of domestic animals known to be free of any infectious disease. Most animal injuries are directly related to a person’s attempt to touch or feed the animal.

Any bite or scratch from a mammal, including bats, 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. One of the newer quinolones, such as levofloxacin (Levaquin), which many travelers carry in case of diarrhea, would be an appropriate choice.

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Insect bites & stings

To prevent mosquito bites, wear long sleeves, long pants, hats and shoes (rather than sandals). Bring along a good insect repellent, preferably one containing DEET, which should be applied to exposed skin and clothing, but not to eyes, mouth, cuts, 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 the age of 12 should use preparations containing 25% to 35% DEET, which usually last 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 extremely uncommon and generally related to overuse. DEET-containing compounds should not be used on children under the age of two.

Insect repellents containing certain botanical products, including oil of eucalyptus 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 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. Permethrin should not be applied directly to skin.

Don’t sleep with the window open unless there is a screen in the windowframe. If sleeping outdoors or in accommodations that allow entry of mosquitoes, use a bed net, preferably treated with permethrin, with edges tucked in under the mattress. The mesh size should be smaller than 1.5mm. If the sleeping area is not otherwise protected, use a mosquito coil, which will fill the room with insecticide throughout the night. Repellent-impregnated wristbands are not effective.

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Snake bites

Snakes and leeches are a hazard in some areas of South America. In the event of a venomous snake bite, place the victim at rest, keep the bitten area immobilized and move the victim immediately to the nearest medical facility. Avoid tourniquets, which are no longer recommended.

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To protect yourself from excessive sun exposure, you should stay out of the midday sun, wear sunglasses and a wide-brimmed sun hat, and apply sunscreen with SPF15 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 should also drink plenty of fluids and avoid strenuous exercise when the temperature is high.

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Tap water in Brazil is not safe to drink. Vigorous boiling for one minute is the most effective means of water purification. At altitudes greater than 2000m (6500ft), boil for three minutes.

Another option is to disinfect water with iodine pills. Instructions are usually 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 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. Pregnant women, those with a history of thyroid disease, and those allergic to iodine should not drink iodinated water.

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

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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. The key treatment is drinking oral rehydration solution. Antibiotics are also given (tetracycline or doxycycline), though quinolone antibiotics such as ciprofloxacin and levofloxacin are also effective.

Cholera sometimes occurs in Brazil, but it’s rare among travelers. Cholera vaccine is no longer required, and is in fact no longer available in some countries, including the US, because the old vaccine was relatively ineffective and caused side effects. There are new vaccines that are safer and more effective, but they’re not available in many countries and are only recommended for those at particularly high risk.

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Dengue fever is a viral infection found throughout South America. A large outbreak of dengue was reported from the Rio area in early 2002, ultimately affecting almost 800,000 people. Dengue is transmitted by aedes mosquitoes, which bite preferentially during the daytime and are usually found close to human habitations, often indoors. They breed primarily in artificial water containers, such as jars, barrels, cans, cisterns, metal drums, plastic containers and discarded tires. As a result, dengue is especially common in densely populated, urban environments.

Dengue usually causes flulike symptoms, including fever, muscle aches, joint pains, headaches, 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 the age of 15 who are experiencing their second dengue infection.

There is no treatment for dengue fever except to take analgesics such as acetamin-ophen/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 protection against insect bites.

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Hepatitis A

Hepatitis A is the second most common travel-related infection (after traveler’s diarrhea). It’s a viral infection of the liver that is usually acquired by ingestion of contaminated water, food or ice, though it may also be acquired by direct contact with infected persons. The illness occurs throughout the world, but the incidence is higher in developing nations. 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.

The vaccine for hepatitis A is extremely safe and highly effective. If you get a booster six to 12 months later, it lasts for at least 10 years. You really should get it before you go to Brazil or any other developing nation. Because the safety of hepatitis A vaccine has not been established for pregnant women or children under the age of two, they should instead be given a gamma globulin injection.

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Hepatitis B

Like hepatitis A, hepatitis B is a liver infection that occurs worldwide but is more common in developing nations. Unlike hepatitis A, the disease is usually acquired by sexual contact or by exposure to infected blood, generally through blood transfusions or contaminated needles. The vaccine is recommended only for long-term travelers (on the road more than six months) who expect to live in rural areas or have close physical contact with the local population. Additionally, the vaccine is recommended for anyone who anticipates sexual contact with the local inhabitants or a need for medical, dental or other treatments while abroad, especially transfusions or injections.

Hepatitis B vaccine is safe and highly effective. A total of three injections, however, is necessary to establish full immunity. Several countries added hepatitis B vaccine to the list of routine childhood immunizations in the 1980s, so many young adults are already protected.

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Malaria occurs in every South American country except Chile, Uruguay and the Falkland Islands. It’s transmitted by mosquito bites, usually between dusk and dawn. The main symptoms are 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 forested areas within the nine states of the ‘Legal Amazonia’ region, including Acre, Amapá, Amazonas, Maranhão (western part), Mato Grosso (northern part), Pará (except Belém city), Rondônia, Roraima and Tocantins, and for urban areas within this region, including the cities of Porto Velho, Boa Vista, Macapá, Manaus, Santarém and Maraba. 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.’ Travelers visiting only the coastal states from the horn to the Uruguay border and Iguaçu Falls do not need prophylaxis.

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 debatable) develop neuro-psychiatric side effects, which may range from mild to severe. Atovaquone/proguanil (Malarone) is a newly approved combination pill taken once daily with food starting two days before arrival and continuing through the trip and for seven days after departure. Side effects are typically mild. Doxycycline is a third alternative, but it may cause an exaggerated sunburn reaction.

In general, Malarone seems to cause fewer side effects than Lariam and is becoming more popular. The chief disadvantage is that it has to be taken daily. For longer trips, it’s probably worth trying Lariam; 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 is 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. Malarone should not be used for treatment, however, if you’re already taking it for prevention. An alternative is to take 650mg of quinine three times daily and 100mg of 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.

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The plague continues to occur among animals in the drier northern and eastern states, from Ceará south to Minas Gerais, but human cases are uncommon. Most occur in Bahia state. The infection is usually transmitted to humans by the bite of rodent fleas, typically when rodents die off. Symptoms include fever, chills, muscle aches and malaise, associated with the development of an acutely swollen, exquisitely painful lymph node, known as a bubo, most often in the groin. Most travelers are at extremely low risk of the plague. But if there’s a chance you will have contact with rodents or their fleas, especially in the above areas, you should bring along a bottle of doxycycline, to be taken prophylactically during periods of exposure. Those less than eight years old or allergic to doxycycline should take trimethoprim-sulfamethoxazole instead. In addition, you should avoid areas containing rodent burrows or nests and never handle sick or dead animals.

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Rabies is a viral infection of the brain and spinal cord that is almost always fatal. The rabies virus is carried in the saliva of infected animals and is typically transmitted through an animal bite, though contamination of any break in the skin with infected saliva may result in rabies. Rabies occurs in all South American countries. In Brazil, most cases are reported from the extreme western Minas Ger­ais state and northeastern areas. Dog bites are the most common cause, but bites from other animals can also lead to rabies. In 2004 several dozen people in the Amazon died from rabies after being bitten by vampire bats.

Rabies vaccine is safe, but a full series requires three injections and is quite expensive. Those at high risk of rabies, such as animal handlers and spelunkers (cave explorers), should certainly get the vaccine. In addition, those at lower risk of animal bites should consider asking for the vaccine if they may be traveling to remote areas and may not have access to appropriate medical care if needed. The treatment for a possibly rabid bite consists of rabies vaccine with rabies immune globulin. It’s effective, but must be given promptly. Most travelers don’t need rabies vaccine.

All animal bites and scratches must be promptly and thoroughly cleansed with large amounts of soap and water and local health authorities contacted to determine whether or not further treatment is necessary.

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Typhoid fever is caused by 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.

Unless you expect to take all your meals in major hotels and restaurants, 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 the age of two.

The drug of choice for typhoid fever is usually a quinolone antibiotic such as ciprofloxacin (Cipro) or levofloxacin (Levaquin), which many travelers carry for treatment of traveler’s diarrhea. However, if you self-treat for typhoid fever, you may also need to self-treat for malaria, since the symptoms of the two diseases may be indistinguishable.

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Yellow fever

Yellow fever is a life-threatening viral infection transmitted by mosquitoes in forested areas. The illness begins with flulike symptoms, which may include 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 travelers to Brazil, except those visiting only Rio de Janeiro, São Paulo, the central eastern area to the coast, and the coastal areas south of São Luís. Major outbreaks have recently been reported from Minas Gerais state, and additional cases occur elsewhere. Fatal cases of yellow fever among travelers who failed to get vaccinated are periodically reported. For an up-to-date map showing the distribution of yellow fever in Brazil, go to the Centers for Disease Control (CDC) website at ­www.cdc.gov/travel/diseases/maps/yellowfever_map2.htm.

Proof of vaccination is required from all travelers arriving from a yellow fever–infected country in Africa or the Americas.

Yellow fever vaccine is given only in approved yellow fever vaccination centers, which provide validated International Certificates of Vaccination. 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.

Taking measures to protect yourself from mosquito bites is an essential part of preventing yellow fever.

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This is a parasitic infection acquired by skin exposure to contaminated fresh water; it occurs in almost all states of the Northeast and two states (Minas Gerais and Espírito Santo) in the Southeast. When traveling in these areas, you should avoid swimming, wading, bathing or washing in bodies of fresh water, including lakes, ponds, streams and rivers. Salt water and chlorinated pools carry no risk of schistosomiasis.

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This has been reported from various areas, including northwestern Paraná state and northern Rio de Janeiro state. Most cases have been related to contaminated water supplies. Pregnant women should be particularly careful to avoid drinking unfiltered water, since toxoplasmosis may cause severe fetal illness. In nonpregnant people with normal immune systems, most cases of toxoplasmosis clear uneventfully.

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Chagas’ disease

This parasitic infection is transmitted by triatomine insects (reduviid bugs), which inhabit crevices in the walls and roofs of substandard housing in South and Central America. In Brazil, the disease has been eliminated in every state except Bahia and Tocantins through an aggressive program of insecticide spraying. The triatomine insect lays its feces on human skin as it bites, usually at night. A person becomes infected when they unknowingly rub the feces into the bite wound or any other open sore. Chagas’ disease is extremely rare in travelers. If you sleep in a poorly constructed house, especially one made of mud, adobe or thatch, however, you should be sure to protect yourself with a bed net and a good insecticide.

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Leishmaniasis occurs in the mountains and jungles of all South American countries except for Chile, Uruguay and the Falkland Islands. The infection is transmitted by sand flies, which are about one-third the size of mosquitoes. In Brazil, leishmaniasis has been reported from suburban areas in Rio de Janeiro and São Paulo. Most cases are limited to the skin, causing slowly growing ulcers over exposed parts of the body. The more severe type of leishmaniasis, which disseminates to the bone marrow, liver and spleen, occurs mainly in the Northeast. Leishmaniasis may be particularly severe in those with HIV. There is no vaccine. To protect yourself from sand flies, follow the same precautions as for mosquitoes, except that netting must be made of a finer mesh (at least 18 holes per 2.54cm or to the linear inch).

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Hantavirus pulmonary syndrome

A rapidly progressive, life-threatening infection, hantavirus is acquired through exposure to the excretions of wild rodents. Most cases occur in those people who live in rodent-infested dwellings in rural areas. In Brazil, hantavirus infections are reported from the states of Minas Gerais, Santa Catarina and São Paulo.

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This is a parasite that infects the liver, usually in people who work with sheep. Echinococcus infections occur chiefly in the southernmost part of the country.

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Brucellosis is an infection of domestic and wild animals that may be transmitted to humans through animal contact or by consumption of unpasteurized dairy products from infected animals. In Brazil, most human cases are related to infected cattle. Symptoms include fever, malaise, depression, loss of appetite, headache, muscle aches and back pain. Complications may include arthritis, hepatitis, meningitis and endocarditis (heart-valve infection).

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This is a parasitic infection that is typically acquired by eating contaminated watercress grown in sheep-raising areas. Early symptoms may include fever, nausea, vomiting and painful enlargement of the liver.

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Also known as river blindness, onchocerciasis is caused by a roundworm that may invade the eye, leading to blindness. The infection is transmitted by black flies, which breed along the banks of rapidly flowing rivers and streams. In Brazil, onchocerciasis is reported among the indigenous Yanomami population living along the Venezuelan border, as well as in nearby tribes and non-Indians visiting the area. Most cases occur near swift-flowing streams in densely forested highlands.

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Venezuelan equine encephalitis

Transmitted by mosquitoes and causing brain inflammation, this form of encephalitis occurs sporadically.

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‘Caterpillar plague’

Cases 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.

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As with most parts of the world, HIV infection occurs throughout Brazil. You should never assume, on the basis of someone’s background or appearance, that they’re free of this or any other sexually transmitted disease. Be sure to use a condom for all sexual encounters.

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Availability & cost of health care

For an ambulance in Brazil, call 192, or an emergency number (listed following).

Good medical care is available in the larger cities, but may be difficult to find in rural areas. Medical care in Brazil may be extremely expensive. Most doctors and hospitals expect payment in cash, regardless of whether you have travel-health insurance.

The US embassy website at www.embaixada-americana.org.br has an extensive list of physicians, dentists, pharmacists, laboratories and emergency services. If you’re pregnant, be sure to check this site before departure to find the name of one or two obstetricians in the area you’ll be visiting, just in case.

The Einstein Hospital (emergencies 55-11-3747 0200, ambulance & air ambulance 0xx11-3747 1000/1100; Av Albert Einstein 627, Morumbi) in São Paulo is used by expatriates throughout Brazil, including US government personnel. English is also spoken at Hospital Sírio-Libânes (information 0xx11-2344 8877, ambulance 0xx11-826 0111 or 926 0400; Rua da Adma Jafet 91, Bela Vista) in São Paulo.

If you develop a medical emergency while in Rio, you can call Hospital Samaritano (0xx21-2537 9722; Rua Bambina 98, Botafogo), Clínica São Vicente (0xx21-2529 4422; Rua João Borges 204, Gávea), Hospital Ipanema (0xx21-3111 2300; Rua Antônio Parreiras 67, Ipanema),Miguel Couto Hospital (0xx21-2274 2121; Av Bartolomeu Mitre 1108, Gávea) or Pró-Cardíaco (information 0xx21-2537 4242, ambulance 0xx21-2527 6060; Rua General Polidoro 192, Botafogo) – the latter specializes in cardiac ­emergencies.

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. You can find a list of medical-evacuation and travel-insurance companies on the US State Department website at www.travel.state.gov/medical.html.

Each Brazilian pharmacy has a licensed pharmacist. Most are well supplied. Many medications that require prescriptions in the US are available over the counter in Brazil. If you’re taking medication on a regular basis, be sure you know its generic (scientific) name, since many pharmaceuticals go under different names in Brazil. Droga Raia is a large pharmacy chain; many stores are open 24 hours.

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Traveler’s diarrhea

Traveler’s diarrhea is defined as the passage of more than three watery bowel actions within 24 hours, plus at least one other symptom such as fever, cramps, nausea, vomiting or feeling generally unwell. In over 80% of cases, traveler’s diarrhea is caused by a bacteria and therefore responds promptly to treatment with antibiotics. Treatment with antibiotics will depend on your situation – how sick you are, how quickly you need to get better, where you are etc.

To prevent diarrhea, avoid tap water unless it has been boiled, filtered or chemically disinfected (iodine tablets); be wary of dairy products that may contain unpasteurized milk; and be highly selective when eating food from street vendors.

Treatment consists of staying well hydrated. Drink plenty of fluids, preferably an oral rehydration solution like Gastrolite. Coconut water, which is loaded with electrolytes, is also good for rehydration. Antibiotics such as Norfloxacin, Ciprofloxacin or Azithromycin will kill the bacteria quickly.

Loperamide is just a ‘stopper’ and doesn’t get to the cause of the problem. It can be helpful, for example, on a long bus ride. Don’t take Loperamide if you have a fever or blood in your stools. Seek medical attention quickly if you do not respond to an appropriate antibiotic.

If diarrhea is bloody, persists for more than 72 hours or is accompanied by fever, shaking chills or severe abdominal pain, you should seek medical attention.

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