(Bolivia, Brazil, Colombia, Ecuador including Galapagos, French Guiana, Guyana, Paraguay, Peru, Surinam, Venezuela including Marguerita island).

3.5.1  Disease risks

Food and water-borne diseases including amoebiasis, diarrhoeal diseases, helminth infections and hepatitis A are common. Bolivia, Brazil, Ecuador, Peru and Venezuela have all reported cholera.

Malaria (P.falciparum, P.malariae and P.vivax) in all countries. The main area of risk is the huge Amazon basin, largely in Brazil but extending into the adjacent countries. The falciparum malaria in the Amazon basin is highly chloroquine resistant.

Other arthropod-borne diseases (see Chapter 7) are an important cause of ill health:

•   Jungle yellow fever in forest areas in all countries except Paraguay, areas west of the Andes, and the north eastern and southern states of Brazil.

•   American trypanosomiasis (Chagas' disease) in most countries.

•   Cutaneous and mucocutaneous leishmaniasis in all countries (the latter increasing in Brazil and Paraguay).

•   Visceral leishmaniasis especially NE Brazil; less frequently in Colombia and Venezuela; rare in Bolivia and Paraguay; not known in Peru.

•   Epidemics of viral encephalitis and dengue fever in some countries

•   Bancroftian lymphatic filariasis is endemic in parts of Brazil, Guyana and Surinam.

•   Onchocerciasis in isolated foci in rural areas of Ecuador, Venezuela and N Brazil.

•   Bartonellosis or Oroya fever (sandfly-borne disease) on arid Western slopes of the Andes (up to 3,000m).

•   Louse-borne typhus in mountain areas of Colombia and Peru.

•   Myiasis

•   Plague - some foci in Bolivia, Brazil, Ecuador and Peru.

•   Relapsing fever.

•   Rocky Mountain spotted fever in Colombia.

Diseases of close association:

•   In 1994, an international commission certified the eradication of endemic wild poliovirus from the Americas. Ongoing surveillance in formerly endemic Central and South American countries confirms that poliovirus transmission remains interrupted.

•   Meningococcal meningitis has occurred in epidemic outbreaks in Brazil.

•   Tuberculosis endemic; incidence particularly high in Bolivia and Peru.

Sexually transmitted and blood-borne infections:

Hepatitis B of intermediate or high prevalence; highly endemic in the Amazon basin; HIV endemic.

Other hazards could include:

•   Schistosomiasis in Brazil, Surinam and north-central Venezuela

•   Rabies, snakes, leeches, dangerous fish and venomous spiders.

•   Rodent-borne hantavirus infection and leptospirosis.

3.5.2  Recommendations for immunisations and malaria chemoprophylaxis (see later chapters for general health precautions)

FOR ALL COUNTRIES Check routine immunisations including tetanus. Immunisation against hepatitis A and typhoid recommended. Immunisation against yellow fever recommended for all countries except Paraguay but see details under individual countries. For longer stays, consider immunisation against diphtheria and hepatitis B and check BCG status; for longer rural travel out of reach of medical attention consider immunisation against rabies.

3.5.3  Country by country variations and malaria chemoprophylaxis:

Bolivia

Yellow fever vaccination certificate required from travellers coming from infected areas. Recommended for incoming travellers from non-infected zones visiting risk areas such as the Departments of Beni, Cochabamba, Santa Cruz, and the sub tropical part of La Paz Department.

Malaria risk (predominantly P.vivax) throughout the year below 2500m in rural areas in several departments. Falciparum malaria occurs in the northern departments bordering Brazil. P.falciparum resistant to chloroquine and sulfadoxine-pyrimethamine reported.

Recommended prophylaxis: for rural areas below 2500m, chloroquine plus proguanil. In the northern borders near to Brazil, mefloquine (or doxycycline or atovaquone/proguanil) is more appropriate, as elsewhere in the Amazon basin.

Brazil

Yellow fever vaccination certificate required from travellers over nine months of age coming from infected areas, unless they are in possession of a waiver stating that immunisation is contraindicated on medical grounds. The following countries or areas are regarded as infected:

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

•   America: Bolivia, Colombia, Ecuador, Peru.

Vaccination is recommended for travellers to endemic areas including rural areas in Acre, Amapa, Amazonas, Goias, Maranhao, Mato Grosso, Mato Grosso do Sul, Pará, and Rondônia, Roraima and Tocantins, and certain areas of Minas Gerais, Parana and Sao Paulo. At present this does not include the tourist areas of Brazilia, Rio, Sao Paulo and Recife, unless outbreaks should occur.

Meningococcal A&C vaccine: consider for those living or working with local people.

Malaria risk throughout the year below 900m in the states of the legal Amazon region, including parts of the cities of Manaus and Porto Velho. P.falciparum highly resistant to chloroquine and resistant to sulfadoxine-pyrimethamine reported.

Recommended prophylaxis: in the 'legal Amazon', mefloquine (or doxycycline or atovaquone/proguanil); alternative chloroquine plus proguanil. Along the eastern seaboard and the arid areas inland from there, no antimalarials needed but travellers should be aware of the small risk.

Colombia

Immunisation against yellow fever recommended for travellers who may travel outside the capital and especially for the following areas: middle valley of the Magdalena river, eastern and western foothills of the Cordillera Oriental from the frontier with Ecuador to that with Venezuela, Uraba, foothills of the Sierra Nevada, eastern plains (Orinoquia) and Amazonia.

Malaria risk, predominantly P.falciparum, throughout the year in many rural areas below 800m of the following regions: Uraba (Antioquia and Choco Dep.), Bajo Cauca-Nechi (Antioquia and Cordoba Dep.), middle valley of the Magdalena river, Catatumbo (Norte de Santander Dep), whole Pacific Coast area, eastern plains (Orinoquia) and Amazonia. P.falciparum highly resistant to chloroquine and resistant to sulfadoxine-pyrimethamine reported.

Recommended prophylaxis: for most areas below 800m, chloroquine plus proguanil; in Amazonia, Pacifico and Uraba, mefloquine (or doxycycline or atovaquone/ proguanil).

Ecuador (including Galapagos)

Yellow fever vaccination certificate required from travellers over one year of age coming from infected areas, and recommended for all travellers to the low lands excluding Galapagos.

Malaria risk, roughly half P.falciparum, throughout the year below 1,500m in several provinces. No risk in Guayaquil or Quito. Chloroquine resistant P.falciparum reported. No malaria in Galapagos.

Recommended prophylaxis: chloroquine plus proguanil. In Esmeraldas province mefloquine (or doxycycline or atovaquone/proguanil) preferable.

French Guiana

Yellow fever vaccination certificate required from all travellers over one year of age.

Malaria risk, predominantly P.falciparum, throughout the year in the whole country. Resistance to chloroquine reported.

Recommended prophylaxis: mefloquine (or doxycycline or atovaquone/proguanil); alternative, chloroquine plus proguanil.

Guyana

Yellow fever vaccination certificate required from travellers coming from infected areas and from the following countries:

•   Africa: Angola, Benin, Burkina Faso, Burundi, Cameroon, Central African Republic, Chad, Congo, Democratic Republic of Congo, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Ivory Coast, Kenya, Liberia, Mali, Niger, Nigeria, Rwanda, Sao Tome and Principe, Senegal, Sierra Leone, Somalia, Tanzania, Togo, Uganda.

•   America: Belize, Bolivia, Brazil, Colombia, Costa Rica, Ecuador, French Guiana, Guatemala, Honduras, Nicaragua, Panama, Peru, Surinam, Venezuela.

Yellow fever immunisation recommended for all travellers.

Malaria risk high throughout the year and in all interior regions including the north-west Region and areas along the Pomeroon river. Predominantly chloroquine resistant P.falciparum. Occasional cases in coastal belt.

Recommended prophylaxis: mefloquine (or doxycycline or atovaquone/proguanil); alternative chloroquine plus proguanil.

Paraguay

Yellow fever vaccination certificate required from travellers leaving Paraguay to go to endemic areas and from travellers arriving from endemic areas.

Malaria risk, largely P.vivax, in the Departments of Alto Paraná, Caaguazú, Canendiyú.

Recommended prophylaxis: for these areas only, chloroquine.

Peru

Yellow fever vaccination certificate required from travellers over six months of age coming from infected areas and recommended for those intending to visit areas of the country below 2,300m. Not for Lima, Machu Picchu and Cusco, including Lake Titicaca.

Malaria risk, predominantly P.vivax, throughout the year in almost all rural areas below 1,500m with chloroquine resistant falciparum malaria predominant in the Amazon basin. P.falciparum resistant to sulfadoxine-pyrimethamine also reported.

Recommended prophylaxis: for rural areas below 1,500m, chloroquine plus proguanil; mefloquine (or doxycycline or atovaquone/proguanil) in Amazon basin and swampy area west of the Andes bordering Ecuador.

Surinam

Yellow fever vaccination certificate required from travellers coming from infected areas and recommended for all travellers.

Malaria risk, predominantly P.falciparum, throughout the year in the three southern districts of the country; risk low in Paramaribo City and other coastal areas. Chloroquine resistant P.falciparum reported.

Recommended prophylaxis: for risk areas, mefloquine (or doxycycline or atovaquone/proguanil); alternative chloroquine plus proguanil.

Venezuela (including Marguerita Island)

Immunisation against yellow fever recommended for all travellers.

Malaria risk: P.vivax malaria widespread throughout the year in rural areas of: Amazonas, Apure, Barinas, Bolivar, Sucre and Tachira States. Caracas is free of malaria. Falciparum malaria in jungle areas of several provinces. Highly chloroquine resistant P.falciparum reported.

Recommended prophylaxis: chloroquine plus proguanil. None for Caracas, coastal areas or Marguerita Island. Mefloquine (or doxycycline or atovaquone/proguanil) is preferable for the Amazon basin area.