Diseases prevented by routine vaccination are prevalent in Brazil. Medical practitioners can ensure travelers are current on all routine vaccines (Table 1).

Hepatitis A, transmitted by food, water, or direct person-to-person contact,¹⁶ is characterized by any combination of the following symptoms: fever, anorexia, jaundice, nausea, vomiting, and abdominal pain. Diagnosis typically involves a compatible clinical picture, elevations of hepatic enzyme levels, and detection of IgM antibodies to hepatitis A. Treatment is supportive. Domestic incidence of hepatitis A varies across Brazil and was approximately 7.5 to 11 cases per 100 000 persons during 2000 through 2005.¹⁷The CDC recommends all travelers receive hepatitis A vaccine. The first of the 2-dose series can be administered up to departure, providing most travelers adequate protection. For long-term protection, the second dose should be given after6months. For those suspected of having had illness previously, a serological test for IgG to hepatitis A may be performed prior to vaccination.^16,18Hepatitis B virus is transmitted through blood or other body fluids.¹⁹ Acute hepatitis B virus may cause a febrile illness including nausea, vomiting, rashes, joint pain, and jaundice; chronic infection can lead to liver disease, including cirrhosis and liver cancer.¹⁹ Diagnosis involves recognition of the clinical syndrome along with laboratory evidence for hepatitis B.²⁰ Treatment of acute illness is supportive. The prevalence of chronic carriers of hepatitis B virus in Brazil is 2% to 7%.²⁰ The CDC recommends all travelers to Brazil be vaccinated for hepatitis B.¹⁹ Travelers should have as many doses of the series as possible before travel. An accelerated regimen and a hepatitis A and B combined vaccine are available.^19,21

Typhoid, also a risk for travelers to Brazil, is transmitted via contaminated food or water. Symptoms range from fever to more severe disease that includes abdominal pain, headache, myalgia, nausea, and anorexia.²² Serious complications include intestinal hemorrhage, perforation, or even death.²² Paratyphoid fever is a similar but typically less severe form of typhoid fever. Because many patients present with fever and other nondiagnostic constitutional symptoms, diagnosis is often difficult. Blood, urine, or stool cultures may be positive, but bone marrow cultures, now very rarely done, are most sensitive. If either diagnosis is suspected, patients may be treated with broad-spectrum antibiotics,²² including a quinolone (there may be some resistance to these), azithromycin, or a third-generation cephalosporin until a diagnosis is confirmed.

The CDC recommends typhoid fever vaccine for all travelers to Brazil.²² Two vaccines are licensed: an inactivated injectable vaccine and a live, attenuated vaccine taken orally. Both provide 55% to 70% protection.²³No vaccine is available for paratyphoid fever. Other preventive measures include food and beverage precautions (described in the “Gastrointestinal Illness and Travelers’ Diarrhea” section).²²

Yellow fever virus is transmitted by the bite of an infected mosquito, primarily Aedes orHaemagogusspecies. Yellow fever virus infection is often a symptomatic; when disease occurs it can range from a nonspecific viral syndrome to severe disease with jaundice, multiorgan failure, hemorrhage, and death. Yellow fever should be suspected when an unimmunized traveler returns with fever from an endemic area. Clinicians suspecting yellow fever should contact their state or local health department or call the CDC Arboviral Disease Branch (Table 2). Treatment is exclusively supportive. Yellow fever vaccine is recommended for all travelers 9 months or older traveling to areas within Brazil with risk of yellow fever virus transmission (Figure 1A).^24,25The live, attenuated yellow fever vaccine is rarely associated with serious or fatal adverse events.²⁶ Contraindications include, but are not limited to, age younger than6months, allergy to any vaccine component, and altered immune status.^25-27 Precautions include age 6 to 8 months, age 60 years or older, a symptomatic human immunodeficiency virus infection with moderate immune suppression, pregnancy, and breastfeeding.²⁵ Clinicians should review each traveler’s medical history and itinerary to evaluate risk of yellow fever disease vs risk from vaccine. The online Yellow Fever Vaccination Center Registry lists US clinics authorized to administer vaccine (http://wwwnc.cdc.gov/travel/yellow-fever-vaccination-clinics/search). Clinicians should educate travelers on preventive measures against mosquito bites, including using insect repellents, wearing long-sleeved permethrin-treated clothing, choosing rooms with air conditioning or intact screens, and sleeping under an insecticide-treated bed net.²⁸

Caused by Neisseria meningitidis, meningococcal disease is endemic in Brazil. Meningococcal disease, characterized by headache, fever, stiff neck, nausea, and altered mental status, can result in severe disease and death.²⁹ Outbreaks in Brazil have been primarily due to serotypes B and C.³⁰ Travelers suspected of having meningitis should be treated aggressively with broad-spectrum antibiotic coverage, such as third-generation cephalosporin and vancomycin. Vaccines currently available in the United States are not protective against serogroup B.³⁰ Because N meningitides is transmissible via close contact with respiratory secretions, travelers staying in crowded housing (eg, hostels) may benefit from a meningococcal conjugate vaccine.

Rabies is an acute, progressive, fatal encephalomyelitis that is endemic in Brazil.³¹ Illness generally occurs after a bite from a rabid mammal; nonbite transmissions are rare but can occur, such as via aerosol from bats in caves.³² The CDC recommends the preexposure vaccination of 3 doses (administered on days0, 7, and 21 or 28) for some travelers, including those who might be in direct contact with bats or stray animals.³¹Review of a traveler’s itinerary may help identify potential exposures, such as a trip that involves handling animals in the Amazon rain forest.³³The CDC does not recommend that travelers begin the 3-dose series if they are unable to complete it before departure. Because preexposure vaccine is not entirely protective³¹ and the disease highly fatal, health care practitioners should educate travelers about animal avoidance and the importance of prompt health care for postexposure prophylaxis and immediate and thorough wound cleaning with soap and water should any bite occur.

Malaria is transmitted by mosquito bites (Anopheles species). Infection, characterized by fever, chills, headache, myalgia, and malaise, can result in severe illness and death.³⁴ Nearly all malaria cases in Brazil occur in the Amazon region, where the 2014 World Cup host cities Cuiaba and Manaus are located (Figure 1A).^24,35

Medical practitioners should advise travelers about malaria chemoprophylaxis based on travel itineraries. Because of widespread chloroquine resistance in Brazil, atovaquone–proguanil hydrochloride (Malarone; GlaxoSmithKline), doxycycline, or mefloquine hydrochloride (Lariam [Roche] and generic) are recommended for chemoprophylaxis.²⁴ Determination of which medication to use is based on age, underlying medical conditions, and cost.³⁴ Travelers should follow the mosquito bite prevention measures detailed in the “Yellow Fever” section. The Department of State (http://www.usembassy.gov) and some travel health insurance companies can assist with identifying local medical services for travelers who develop a fever while traveling. Health care practitioners should inform travelers to urgently seek medical care if they develop fever following travel to a malaria-endemic area. A rapid malaria antigen detection test along with three blood smears at 8-hour intervals should be evaluated for parasites. Assistance in diagnosis and treatment can be obtained from an infectious diseases or tropical medicine clinician, as well as from the CDC malaria branch (Table 2).

Dengue is endemic to Brazil and is transmitted by the bite of a mosquito (primarily Aedesaegypti). Aedes mosquitoes feed during the day and typically live indoors in dark, cool places.³⁶ More than 4 million cases of dengue were reported in Brazil during 1986 through 2006.³⁷ Patients may have a mild, nonspecific febrile syndrome with headache and myalgia, although up to 5% may develop severe, life threatening disease with hemorrhagic signs and symptoms.³⁶ Treatment is supportive; early recognition of severe dengue is critical to reducing morbidity. Neither a vaccine nor chemoprophylaxis is available to prevent dengue. Healthcare practitioners should educate travelers on the mosquito bite prevention measures previously described.

PathogenssuchasEscherichiacoli,Campylobacterspecies,Giardiaspecies, and norovirus are common causes of travelers’ diarrhea.^38,39 A review of ill travelers returning from Brazil between 1997 and 2013 found that gastrointestinal illness accounted for 34% of all diagnoses.⁴⁰Healthcare practitioners should educate travelers on the importance of frequent handwashing with soap and water and use of alcohol-based hand sanitizers to decrease their risk of gastrointestinal illness.^39,41 Other recommended approaches to reduce risk include food and water precautions and the use of nonantimicrobial drugs for prophylaxis.³⁹ Freshly cooked food that is served hot is less likely to be contaminated than foods that have been sitting out. Travelers should avoid raw foods, such as salads, unpeeled fruits, or uncooked vegetables. Tap water may contain viruses, bacteria, or parasites and may be unsafe for drinking, preparing food, or for making ice. Travelers may choose to boil, filter, or otherwise treat water for consumption, although this may not remove chemical contaminants.⁴¹ Choosing unopened, factory-sealed beverages and avoiding ice in drinks may decrease the risk of travelers’ diarrhea.

Travelers’ diarrhea usually resolves within 48 hours.³⁹ Ill travelers should maintain a high intake of nonalcoholic fluids to prevent dehydration and avoid dairy products. The effectiveness of a singledose or 3 days of antibiotic therapy with a fluoroquinolone or azithromycin, along with over-the-counter loperamide hydrochloride to ease symptoms, iswell established for self-treatment. Bismuth subsalicylate, the active ingredient in Pepto-Bismol (Procter & Gamble), is a nonantimicrobial drug useful for mild travelers’ diarrhea if it has not been used for prophylaxis. Health care practitioners should review a traveler’s medical history as those taking anticoagulants, probenecid, or methotrexate and travelers with aspirin allergy, renal insufficiency, and gout should avoid taking bismuth subsalicylate.³⁹

If travelers’ diarrhea does not resolve, is not responsive to self-treatment, or is accompanied by high fever or bloody diarrhea, travelers should immediately seek medical attention. Because travelers’ diarrhea leads to fluid and electrolyte loss, oral rehydration salts should be considered if diarrhea and/or vomiting occur. Both bismuth subsalicylate and rehydration salts are widely available at stores and pharmacies.³⁹

Leishmaniasis is caused by the protozoan parasite Leishmania species, spread primarily through the bite of infected sand flies.⁴² It has rarely been seen in travelers returning from Brazil.⁴⁰ The most common form of leishmaniasis in travelers is a dermatologic infection called cutaneous leishmaniasis, which is characterized by skin lesions that may develop weeks or months after infection as small papules or nodular plaques, progressing to ulcers that may scale or crust (Figure 2). No vaccines or drugs are available to prevent leishmaniasis; healthcare practitioners should educate travelers on vector prevention practices, such as those described in the yellow fever section. Diagnosis usually involves identification of the parasites in a skin biopsy. A number of treatment regimens are available depending on the species identified. See Table 2 for medical practitioner resources.

Schistosomiasis is caused by Schistosoma species parasites. Infection occurs when the larval form penetrates the skin, typically when a person swims or bathes infresh water.⁴³ Brazil is endemic for schistosomiasis, and outbreaks have been reported, including one in the 2014 World Cup site of Belo Horizonte.⁴⁴ Patients with acute schistosomiasis (Katayama syndrome) may have fever, headache, myalgia, diarrhea, painful hepatomegaly or splenomegaly, and respiratory symptoms.⁴⁵ Diagnosis is confirmed by microscopic identification of parasite eggs in stool or urine or by serological testing. Serological testing should be done at least 3 months following exposure. Referral to someone with expertise in treating schistosomiasis is recommended (Table 2).^43,45

Leptospirosis is a bacterial infection transmitted through breaks in the skin or through conjunctiva and mucous membranes via contact with urine or reproductive fluids from infected animals or by contact with water or soil contaminated by these fluids.⁴⁶ Symptoms include an acute febrile illness with headache (potentially severe with retroorbital pain and photophobia), which can progress to severe disease (Weil disease). Diagnosis is typically based on clinical recognition of the often biphasicillness. Blood, urine, or spinal fluid cultures may yield results, along with serological testing. Nucleic acid amplification (polymerase chain reaction) may also be available.⁴⁶ Treatment includes antibiotics such as penicillins and tetracyclines (Table 2).

Dermatologic issues are common among travelers to Brazil.⁴⁰Wearing appropriate clothing and using insect repellent can limit insect bites.²⁸ The use of high–UV protection factor (UV protection factor >30) sunscreen and clothing is recommended to prevent sunburn.⁴⁷

Bed bugs (Cimex lectularius) are common worldwide; infestations can occur in hotels.^28,48 Travelers who see evidence of bed bugs, such as blood spotting on bed linens or the bugs themselves (reddish brown, 1-7mmlong) should request alternate lodging.²⁸

Cutaneous larva migrans, known as hookworm, is transmitted via contaminated soil or sand and has been documented in travelers to Brazil.^40,49,50 Infected travelers may have a creeping eruption (Figure 2). Most often, skin on the foot and buttocks is affected. Larva migrans can be treated by using albendazole or ivermectin.^50,51 Travelers can reduce their risk of infection by wearing shoes and using barriers (eg, towels) when sitting on the ground.⁵⁰ Various treatment regimens exist, most notably oral albendazole or ivermectin.

Tungiasis is caused by the flea Tunga penetrans. These parasites become embedded in the epidermis, where they mature and produce eggs until their death up to 5 weeks later (Figure 2). Because the fleas remain partially extruded from the skin, pathogens can enter through the break in the skin. The periungual regions of the toes are the preferred penetration site of T penetrans, but they can penetrate skin anywhere on the body.⁵² Tungiasis is common in impoverished areas of Brazil.⁵³Wearing closed-toe shoes may limit exposure; treatment requires extraction of the parasite.

A systematic review of studies of travel-associated sexual behavior calculated a pooled prevalence of 20.4% for casual sex, of which 49.4% is unprotected.⁵⁴ Health care practitioners should advise travelers to avoid unprotected sex with new partners while traveling. Condoms can decrease risk and should be purchased prior to departure to ensure they are of sufficient quality. Assessment of a traveler with a suspected sexually transmitted disease includes screening for others such as human immunodeficiency virus and hepatitis B.