May be required for ongoing travel to other countries.

There are two types of rabies vaccination:

Pre-exposure vaccination
Usually given in your home country prior to travel.

• Pre-exposure vaccination consists of three injections (given on days 0, 7, and 21 or 28).

Post-exposure vaccination
Given soon after the bite or scratch. It can be life saving.

(i) Those who have not had pre-exposure vaccination:

• Rabies immunoglobulin (RIG) is injected into and around the wound(s)
• Five doses of rabies vaccine are required (given on days 0, 3, 7, 14 and 28).

(ii) Those who have had pre-exposure vaccination:

• Two doses of rabies vaccine are required (given on days 0 and 3).
• Rabies immunoglobulin (RIG) is not required.

• Immediately cleanse the wound with soap and water.
• Let the wound bleed freely.
• Seek medical advice from a qualified source or your assistance company, and notify local health authorities immediately to assess the need for rabies post-exposure vaccination even if you have had pre-exposure vaccination. (THIS CAN BE LIFE SAVING).

IN BRAZIL
Up to 120 cases of human rabies are reported each year and occur nationwide in both rural and urban areas, particularly in the Northeastern states. Although stray dogs are the primary cause of rabies in Brazil, vampire bats have also been known to transmit the disease, especially in the Amazonas region.

In severe cases (10-20%), the diarrhea can cause life-threatening dehydration. Treatment involves oral and/or intravenous fluid replacement and antibiotics, which reduce the volume and duration of diarrhea.

Risk for Travelers
Cholera tends to occur in large epidemics, especially in areas where sanitary conditions have deteriorated, such as refugee camps. With the exception of health and relief workers, cholera is rare in travelers, who usually avoid unsanitary conditions.

Vaccine
A cholera vaccine is available but is rarely recommended. Only 50 percent of those who take the vaccine develop immunity, which lasts for only a few months. This vaccine is not available in the United States.

A new, more effective oral cholera vaccine has been licensed in Europe, Canada, Australia and New Zealand. Medical personnel and relief workers traveling to cholera-infected areas should consider taking this vaccine.

Preventive Measures
If visiting an area infected with cholera, drink only boiled or bottled water, water that has chlorine or iodine, or carbonated beverages. Avoid ice, as it may have been made with unsafe water.

Choose food that has been thoroughly cooked while fresh and is served hot. Avoid street vendors, pre-peeled fruit or salad, fish and shellfish. Fruit that you wash and peel yourself is safe.

CDC Cholera Information

IN BRAZIL
Cholera is present, but the risk to travelers is low.

The Disease
Hepatitis A is a viral disease affecting the liver. It is transmitted person-to-person and by contaminated food and water, especially in areas with poor sanitation and overcrowding.

Symptoms begin 15-50 days after infection and can include fever, chills, weakness, loss of appetite, nausea and/or abdominal discomfort followed by jaundice (yellowing of the skin and eyes). The urine may become dark and the stools pale.

Many people infected with hepatitis A, particularly children, suffer only a mild flu-like illness with no specific symptoms. In other cases the jaundice is severe. Occasionally hepatitis A causes life-threatening liver failure; this is more common in the very young, those with underlying health problems and those over the age of fifty.

Past infection with hepatitis A virus gives life-long immunity and vaccination is not required.

Vaccination
Hepatitis A vaccination should be considered for all non-immune travelers.

• Individual hepatitis A vaccination consists of a series of two injections given on days 0 and after six months. Adequate immunity to hepatitis A develops soon after the first dose. The second dose is necessary to ensure sustained immunity.
• A combined hepatitis A and B vaccine is available in many countries. It requires of a series of three injections given on days 0, 30 and after six months. The first two doses are required before immunity to hepatitis A or B can be assumed. The third dose is necessary to ensure sustained immunity to both diseases.

CDC Hepatitis A Information

The Disease
Schistosomiasis, also known as bilharzia, is a disease caused by parasitic worms that live in freshwater lakes, rivers and rice paddies. The cercariae can penetrate the skin of persons who are wading, swimming, bathing or washing in contaminated water.

There are three main syndromes:
i)Cercarial dermatitis (�gswimmers�h itch): infection of the skin, usually with nonhuman shistosomes
ii)Katayama fever: an autoimmune-like illness causing fever, headache, joint pains, enlarged liver and spleen and raised blood eosinophil count.
iii)Chronic schistosomiasis: caused by the deposition of eggs in the bladder and intestines and local granuloma formation. The chronic infection can cause disease in the liver, intestine, kidneys, lungs, and bladder (including bladder cancer).

Treatment
As the early symptoms are very mild, a blood test for antibodies is the only way to know if a person has been infected. Safe and effective oral drugs are available for the treatment of schistosomiasis.

Risk to Travelers
The countries in which schistosomiasis is most common include Brazil, Egypt and most of sub-Saharan Africa, southern China, the Philippines and South East Asia. Travelers who wade or swim in fresh water in areas with poor sanitation are most at risk. Salt water poses no risk.

Lake Malawi, which borders Malawi, Mozambique and Tanzania, has been the source of many cases of schistosomiasis in recent years. It had previously been thought to be disease free.

Vaccine
There is no vaccine nor are there any drugs to prevent infection.

Preventive measures

• Avoid swimming or wading in fresh water in countries where schistosomiasis occurs.
• The use of soap during bathing reduces the risk of infection, as does a vigorous rubdown with a towel straight after exposure to contaminated water. Do NOT rely on these methods to prevent schistosomiasis.
• Bath water should be heated for five minutes at 50�‹C (122�‹F).
• Water held in a storage tank for at least 48 hours should be safe.

CDC Schistosomiasis Information

IN BRAZIL

Schistosomiasis is present in the Northern and Eastern states from Maranhao to Parana. Although not present in Sao Paulo, many cases have been reported from Bahia and Minas Gerais states, just to the north.

The Disease
Traveler�fs diarrhea is the most common travel-related illness affecting 20 to 50% percent of international travelers. High-risk destinations include the developing countries in Latin America, Africa, the Middle East and Asia.

Travelers�f diarrhea usually occurs within the first week of travel and is mainly caused by the bacterium E coli, which is spread by contaminated food and water. Other bacteria, especially Salmonella, Shigella and Campylobacter account for 5-30%. Viruses (Rotavirus and Clacivirus) and parasites are other causes. Cyclospora is particularly important for travelers to Nepal.

Choosing safe food and water will reduce the risk of developing the disease.

Management of Travelers�f Diarrhea
The main treatment of travelers' diarrhea is to replace lost fluids. Continuously sip clear fluids such as water, soft drink or weak tea. Avoid dairy drinks, alcohol and coffee. Most cases of travelers�f diarrhea will resolve in a one or two days.

Occasionally, intravenous re-hydration is required, especially if there has been significant vomiting or if the diarrhea has been extreme.

Medications
In adults, two main types of medications are used to treat travelers�f diarrhea:

• Drugs to slow the diarrhea (e.g. loperamide ? ImmodiumR, DiamodeR and many generics) Use according to instructions and seek medical attention if there is no improvement within 24-36 hours.
• Antibiotics (e.g. ciprofloxacin ? CiproR and many generics or another quinalone antibiotic) These medications are taken for one to three days and usually significantly shorten the illness; many travelers carry supplies with them. Different antibiotics are given to children. Seek medical attention before giving antibiotics to children.

Obtain medical advice:

• If no improvement is felt after 24-36 hours
• If you develop fever, bloody stools or become lightheaded or dizzy

CDC Travelers' Diarrhea Information

Occasionally, intravenous re-hydration is required, especially if there has been significant vomiting or if the diarrhea has been extreme.

IN BRAZIL
Travelers staying outside of first class hotels and tourist resorts are at high risk for travelers�f diarrhea and other intestinal illnesses.

The Disease
Typhoid fever is a serious infection caused by a species of salmonella bacteria spread by contaminated food or water. Choosing safe food and water will greatly reduce the risk of developing the disease.

The symptoms usually begin seven to 21 days after exposure. The typical feature of the disease is persistent high fevers. While typhoid fever is often called a diarrheal disease, not all patients have diarrhea. Early symptoms are flu-like: body aches and pains, weakness, loss of appetite and a continuous dull headache. A rash with pink spots may appear on the chest and abdomen of some patients. In severe cases, perforation of the bowel can cause severe bleeding or infection in the abdomen, which can be fatal. Paratyphoid is a similar but less severe disease.

Typhoid and paratyphoid can be cured with antibiotic treatment. Safe vaccinations are available only against typhoid.

Who should be vaccinated?
High-risk areas include the Indian subcontinent and other developing countries in Asia, Africa, Central and South America). Vaccination is particularly recommended for adventurous travelers and for travelers visiting friends and relatives (VFRs). Single trip visitors staying in high quality accommodation are probably at low risk.

Primary vaccination
Primary vaccination and booster doses for typhoid are the same. They can be either:

• A single injection.
• A series of three or four oral capsules taken on alternate days (differs country-to-country).

Booster

• After injected typhoid vaccination (Vi), a booster is required in two years.
• After oral typhoid vaccination (three capsules), a booster is required in one year.
• After oral typhoid vaccination (four capsules), a booster is required in five years.

CDC Typhoid information

IN BRAZIL
There is some typhoid in rural Brazil. However, it is usually of little significance to travelers.

In countries with chloroquine-sensitive malaria, chloroquine is still effective in preventing malaria.

Many countries have chloroquine-resistant malaria, and other drugs (or combinations of drugs) must be taken.

PREVENTING MALARIA

If visiting a malarial area:

• Focus on preventing mosquito bites
• Travelers should take an anti-malarial medication (as these are not 100 percent effective, preventing mosquito bites is still very important)

Appropriate antimalarial medications include:

• Mefloquine (LariamR)
• Doxycycline
• Atovaquone plus proguanil (MalaroneR)

Areas of Brazil have chloroquine-resistant P. falciparum malaria. Present in a large area
There is malaria in

• Most forested areas below 900m within the nine states of the "Legal Amazonia" region: Acre, Amapa, Amazonas, Maranhao (western part), Mato Grosso (northern part), Para (except Belem City), Rondonia, Roraima and Tocantins
• Urban areas in the Amazonia region, including in large cities such as Porto Velho, Boa Vista, Macapa, Manaus, Santarem and Maraba.

• Main cities: Rio de Janeiro, Brasilia and Sao Paulo
• The Iguassu Falls
• The coastal states from the horn to the border with Uruguay

Travelers rarely contract yellow fever, but fatal cases of yellow fever have occurred in some unvaccinated travelers visiting infected areas.

Prevention and Vaccination

• Avoid mosquito bites.
• A safe and effective vaccine is available. A booster dose must be given every ten years.

Travel Restrictions and Vaccination
Many countries require evidence of current yellow fever vaccination before permitting entry. You may need to show proof that you are up-to-date with yellow fever vaccination if:

• The country you are entering requires yellow fever vaccination for all visitors, or
• You have recently visited an infected or endemic country, or
• You have recently visited an infected region of an infected country.

In these cases, a signed and stamped �gWHO Yellow Fever Vaccination Booklet�h is required.

IN BRAZIL

Yellow fever is known to be present in rural areas in the states of Acre, Amapa, Amazonas, Goias, Maranhao, Mato Grosso, Mato Grosso do Sul, Para, Rondonia, Roraima and Tocantins as well as certain areas of Minas Gerais, Parana and Sao Paulo.

Occasionally, a potentially fatal form of dengue called dengue hemorrhagic fever (DHF) occurs. DHF is mostly seen in persons who have been previously infected with dengue ? the fatality rate is about 5%.

Treatment
The symptoms of dengue can be treated with bed rest, fluids, and medications to reduce fever, such as acetaminophen; aspirin and none steroid anti-inflammatory agents such as ibuprofen should be avoided because of their anticoagulant properties.

Prevention
There is no vaccine against dengue fever; wear long sleeves and long pants, and use insect repellents to prevent mosquito bites.

Risk to travelers
Dengue is present in most tropical countries of the South Pacific, Asia, the Caribbean, the Americas and Africa and epidemics have become more common over the last 20 years due to the urbanization of previously rural areas.

Cases of dengue fever are confirmed every year in international travelers visiting infected areas. The risk of acquiring dengue is highest just before sunrise and sunset.

WHO dengue information
CDC dengue information

IN BRAZIL
Dengue is found in the coastal areas, primarily in Rio de Janeiro.

• unprotected sex,
• needle sharing during IV drug abuse, or
• unsafe blood or medical/dental instruments.

Prevention:

• Always use new condoms (preferably brought from your home country).
• IV drug users should not share needles.
• In healthcare settings, make sure that needles and syringes are new.
• Call International SOS or your corporate medical department if you are hospitalized or before having a blood transfusion.

Avoid street vendors; the standard of hygiene may be low and the food may not be fresh. Milk and other dairy products should be pasteurized.

Rio de Janeiro and Campinas have good private and public (university) hospitals that provide reasonable care but would not be suitable for critical patients and complicated cases. The better hospitals include: Hospital Barra D'Or, Hospital Copa D'Or, and Clinica Sao Vicente.

Other large cities in Brazil also have small private hospitals providing reasonable services; however, because well-trained ancillary staff and sufficient medical equipment cannot be guaranteed, these hospitals are not recommended. Outside of the major cities, medical care in Brazil can be poor and unreliable.

Private ambulance services are also available:

Sao Paulo
The Albert Einstein Hospital is a private hospital with an excellent emergency department; it can dispatch ambulances.

Rio de Janeiro
Difficult traffic conditions in Rio may delay an ambulance arriving in time; it is best to take a taxi or other private transport to the hospital. Samaritano Hospital has four basic life support ambulances that are available 24 hours. The ambulance personnel speak only Portuguese.

Campinas
Ambulances are not well equipped; therefore, take a taxi or private transport to the hospital. Centro Medico de Campinas hospital provides an ambulance service; call (192).

Since brand names vary, know the generic (chemical) names of your medications.

It is always advisable to bring an adequate supply of prescription and other medications from your home country. Check the expiration date on all medications.

However, major hospitals such as Albert Einstein Hospital and Hospital Sirio-Libanes in Sao Paulo, and Hospital Barra D'Or, Hospital Copa D'Or, Clinica Sao Vicente and Hospital Samaritano in Rio, use a special test known as PCR to ensure the safety of blood transfusions.

If possible, avoid blood transfusions; they can transmit diseases, and immune reactions can vary from minor to life-threatening. If a blood transfusion is recommended and circumstances permit, seek a second opinion from SOS or your health advisor.

Incidents of crime against tourists tend to be greater in areas surrounding discotheques, bars, nightclubs and other similar establishments. Travelers should avoid walking downtown and in business areas after hours. They should also avoid surrounding hillside favelas or slums where there may be a danger of drug-gang violence. Be aware that fireworks often signal a drug shipment arrival. In addition, travelers should stay away from the North Zone of the city and Copacabana�fs Lido section, both of which are frequented by streetwalkers and muggers. Beachfront bicycle and jogging lanes are crowded, but generally safe during mornings, evenings and weekends. Most of the attacks have occurred in Copacabana but the biggest increase has been seen in Santa Teresa. The following areas have been identified as "high crime" areas: Avenida Atlantica, between Postos 3 and 6; Avenida Rio Branco; Lapa; Santa Teresa and Vista Chinesa.

An increase in street crime involving guns has been noted in Sao Paulo. Petty theft is common in the center of Sao Paulo and around major hotels. In addition, thefts involving carry-on luggage and briefcases that have been placed on the floor, sometimes only for a moment, have been reported at Guarulhos International Airport. Travelers should be especially vigilant and take the necessary precautions at this and other Brazilian airports. Since traffic is heavy, Sao Paulo is not conducive to bicycle riding or jogging.

If Brazilian officials ask for excessive tips or bribes, pretend that you do not understand. The kidnapping-for-ransom industry primarily targets wealthy Brazilian families, and the threat to foreign travelers is low.

Travelers should also avoid all protests, rallies and demonstrations due to the potential for violence.

If you must drive, however, observe the following guidelines: drive on the right and, whenever possible, travel by day. Driving at night can be hazardous because of poor lighting and the sometimes erratic behavior of truck and bus drivers. Always keep the doors locked and windows rolled up to within two inches of the top frame. Travelers should also exercise extreme caution when driving in the cities. City drivers sometimes disregard red lights and other traffic signs. You must have your own driver�fs license to drive in Brazil. It is also advisable to obtain an international driving permit, which is available through national motoring organizations.

• Conversations with Brazilians, as with other Latin Americans, may take place at a much closer physical distance than travelers are accustomed to in their home countries.
• Avoid making the sign of thumb and forefinger forming a circle with other fingers pointing up, known as the �gokay" sign in some nations; it has an obscene meaning.
• If entertained in a home, flowers and a thank you note sent the following day are appropriate. Do not send purple flowers, as this signifies mourning.
• Brazilians shake hands when greeting and leaving.
• A souvenir from the visitor's home country is an acceptable gift of appreciation.
• Casual clothing is acceptable.
• The Catholic Church is an important part of Brazilian society.

• Both men and women shake hands when meeting and departing.
• Women will often exchange kisses with one another by placing their cheeks together and kissing the air.
• The pace of negotiations may be slow; developing a personal relationship is important.
• The best time to call a Brazilian executive is between 1000-1200 and 1500-1700.
• Business is usually not discussed during a meal and will only begin after coffee is served.
• Business dress for women is important and should be conservative. Manicured nails are also considered very important.

• Mon-Fri: 0830-1730.

• It is customary to tip 10% for most services.
• Gas station attendants, barbers, and restaurant servers receive tips regularly.
• Parking assistants expect around BRL1.
• Taxi drivers do not expect tips; however, many people typically round up the fare as a tip.

Small change is in short supply in Brazil. It is helpful to request small bills when changing money and to ask first if the seller has change before making a purchase with a large bill.

• On international flights:
  • Departing from Belem Airport, Belo Horizonte (Tancredo Neves), Brasilia International Airport, Curitiba (Afonso Pena Airport), Fortaleza (Printo Martins International Airport), Manaus (Brigadeiro Eduardo Gomes International Airport), Natal, Porto Alegre, Rio de Janeiro (Galeao Airport), Salvador and Sao Paulo (Guarulhos International Airport): USD36
  • All other airports: USD30
• On Domestic flights:
  • Departing from Belem Airport, Brasilia International Airport, Curitiba (Afonso Pena Airport), Fortaleza (Printo Martins International Airport, Manaus (Brigadeiro Eduardo Gomes International Airport), Natal, Porto Alegre and Salvador: USD4 or BRL9.15
  • Departing from Belo Horizonte (Tancredo Neves), Rio de Janeiro (Galeao Airport), Sao Paulo (Guarulhos International Airport): USD4 or BRL8.25
  • All other airports: USD3 or BRL7.20

• It is customary to tip 10% for most services.
• Gas station attendants, barbers, and restaurant servers receive tips regularly.
• Parking assistants expect around BRL1.
• Taxi drivers do not expect tips; however, many people typically round up the fare as a tip.

• On international flights:
  • Departing from Belem Airport, Belo Horizonte (Tancredo Neves), Brasilia International Airport, Curitiba (Afonso Pena Airport), Fortaleza (Printo Martins International Airport), Manaus (Brigadeiro Eduardo Gomes International Airport), Natal, Porto Alegre, Rio de Janeiro (Galeao Airport), Salvador and Sao Paulo (Guarulhos International Airport): USD36
  • All other airports: USD30
• On Domestic flights:
  • Departing from Belem Airport, Brasilia International Airport, Curitiba (Afonso Pena Airport), Fortaleza (Printo Martins International Airport, Manaus (Brigadeiro Eduardo Gomes International Airport), Natal, Porto Alegre and Salvador: USD4 or BRL9.15
  • Departing from Belo Horizonte (Tancredo Neves), Rio de Janeiro (Galeao Airport), Sao Paulo (Guarulhos International Airport): USD4 or BRL8.25
  • All other airports: USD3 or BRL7.20

Winters on the other hand, June to August, are cooler, and temperatures average in the 20�‹s C (upper 60�‹s and 70�‹s F). In the Northeast, temperatures are similar to those of Rio, but a tropical breeze keeps the humidity down. Further south, winter temperatures can dip into the lower teens C (50�‹s F). Some areas even see a bit of snow. In the valley of the Amazon, humidity is high and rainfall heavy, but temperatures remain steady all year, between 27�‹C and 32�‹ C (81�‹F and 90�‹F.)