Dengue fever is endemic in Brazil and each year it reaches epidemic proportions. In 2008, dengue fever is being felt in earnest in Rio de Janeiro, where the epidemic is particularly virulent this year. From the beginning of 2008, and only in the capital, there have been more than 50.000 cases of the disease with 51 people dying as a result. In the whole of the Rio de Janeiro state, more than 75.000 cases and 83 deaths [figures updated on April 15]. The public health system has collapsed and health assistance is precarious. The army has been sent it and field hospitals have been set up.

Most cases are concentrated around the capital, Rio de Janeiro. Of all the main tourist destinations on the state of Rio, only Angra dos Reis should be avoided at all costs, as the outbreak is quite virulent there as well. Paraty, Ilha Grande, Búzios, Cabo Frio and Arraial do Cabo are ok.

The situation is not likely to improve until the end of the rainy season, between June and July. You are strongly advise to reconsider a trip to Rio de Janeiro (the city) until the situation has improved considerably. The fact that famous (and wealthy) people have caught dengue fever in the city should give an indication of the size of the problem.

For more information, you are advised to read the post I wrote a few weeks ago: 10 facts about dengue fever in Brazil

1. Dengue fever is one of the biggest threats to the health of those living in Brazil and of those visiting the country as well.

Dengue hemorrhagic fever can cause death.

2. Dengue fever is spread throughout most of Brazil.

Contrary to what happens with yellow fever, dengue is present both in rural and urban areas. In many places it occurs in the form of epidemics. From January to November 2007 there were 536,519 cases of dengue fever in Brazil. In the entire 2007, there were 1,541 cases of dengue hemorrhagic fever, with 158 deaths. The fight against dengue fever is hindered by precarious hygiene and sanitation standards in most of the country, the insufficient resources made available by the authorities at all levels, and the attitude of part of the population. According to a recent poll, 91% of the population know what needs to be done to erradicate the mosquito than transmits dengue; however, 55% do nothing about it as their neighbours do nothing either.

Google has an online tool that tracks the occurrence of dengue fever cases in Brazil. It can be checked at Dengue trends: Brazil.

3. Cases of dengue fever increase during the rainy season.

The mosquito that transmits dengue fever becomes active with rain and high temperatures. 86% of the cases registered in 2007 occurred between January and May.

4. So far, there is no vaccine against dengue fever.

Primary prevention of dengue fever consists on avoid being bitten by the mosquito that transmits the disease. Cover your exposed skin and your clothes with repellent.

5. Dengue is transmitted through the bite of the Aedes Agypti mosquito.

The fight against dengue is synonym whth the fight against the mosquito. The adult mosquito is middle-sized, dark with white markings on the sides and the upper part of the thorax. It has white rings on its legs. It is found on houses and their vicinities. It needs clean water to deposit its eggs.

6. Dengue fever is not transmitted between humans.

7. There are four serotypes of dengue fever: 1, 2, 3, 4. Type 4 is the only one not found in Brazil.

Update: type 4 has finally made it to Brazil.

8. Two forms of dengue fever are found in Brazil: classic dengue fever and dengue hemorrhagic fever.

On average, symptom manifest between 5 and 6 days after the infection.

The main symptoms of classic dengue fever are high fever (39° to 40°C); severe headache; rashes (bright red on the lower limbs and the chest); muscle and joint pains; nausea and vomiting.

Initially, the symptoms of dengue hemorrhagic fever are the same as those of classic dengue. After the third or fourth day, hemorrhages appear. It the disease is not treated inmmediately, it can lead to the death of the patient.

If symptoms appears, immediate medical care is need – do go to a hospital or health centre.

9. There is no specific treatment for classic dengue fever.
Aspirins should be avoided as they may favour the appearance of hemorrhages. It is important that the patient prevents dehydration through increased oral fluid intake.

Dengue hemorrhagic fever should be trated in hospital.

10. Dengue fever can be caught more than once (although it will never be the same type). Those who have contracted dengue fever in the past should be extra careful as dengue hemorrhagic fever seems to develop almost exclusively on patients that had had classic dengue fever before.

MORE INFORMATION:

Combata a Dengue. Website of the Brazilian Ministry of Health, in Portuguese only. Given the size of the problem and the fact that dengue fever does not discriminate between residents and visitors, one would have expected a more proactive attitude from Brazilian authorities when it came to informing tourists about the risks of dengue fever. I haven’t found any mention of dengue fever on the Brazil Tourism Portal, also belonging to the Brazilian government.

One wonders what are the reasons behind this silence and reaches the conclusion that the authorities want to avoid at all costs associating yet another negative issue to the image of a country already blemished by violence, precarious infrastructures and lack of tourist information. If a blogger with no financial support and the collaboration of a doctor can write a entry like the one you are reading now, why shouldn’t a government be able to do something similar?

The U.S. government’s CDC Dengue Fever Fact Sheet can be consulted for further information in English.

This entry has been entirely written with the medical supervision of dr. Gustavo R. Bonzón, to whom we are grateful for this co-operation. Any mistakes contained in the text are the sole responsibility of the blog.

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RELATED POSTS:
dengue fever alert: state of Bahia (2009)
Dengue fever epidemic in Rio (2008)
Dengue fever in Natal (2008)

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In the face of continuing misinformation on the current yellow fever situation in Brazil, I’ve dedicated some time to gather together a few facts about the crisis. The following text has been written by me and it is based on reliable Brazilian sources (listed at the end of the entry). Hope it clarifies all the doubts you might have.

1. There hasn’t been a new outbreak of yellow fever in Brazil insofar as yellow fever is endemic in the country.
2. There have been no cases of yellow fever in areas of Brazil where the disease wasn’t present before.
3. Yellow fever is only present in rural areas. Since 1942 there are no cases of yellow fever in the towns and cities of Brazil.
4. Only those visiting risk areas need to get vaccinated against yellow fever.
5. Tourists visiting risk-free areas do not need to take the vaccine. The vaccine has a series of well-documented side effects.
6. For the vaccine to be effective, it needs to be taken at least 10 days prior to travel.
7. NEW: Brazilian authorities are not asking at the moment for an International Certificate of Vaccination Against Yellow Fever regardless of where the passenger comes from.
8. Yellow fever is transmitted through a mosquito bite.
9. The main symptoms of yellow fever are: fever, muscle pain, headache, shivers, nausea or vomiting. Symptoms appear between three and six days after becoming infected.
10. Treatment of yellow fever is supportive only. There is no specific medication to treat yellow fever. Victims of yellow fever need to be treated in hospital.

1. There has not been a new outbreak of yellow fever in Brazil insofar as yellow fever is endemic in the country. Cases are recorded every single year.

- in 2000: 85 cases, resulting in 40 deaths;
- in 2001: 41 cases, resulting in 22 deaths;
- in 2002: 15 cases, resulting in 6 deaths;
- in 2003: 64 cases, resulting in 23 deaths;
- in 2004: 5 cases, resulting in 3 deaths;
- in 2005: 3 cases, resulting in 3 deaths;
- in 2006, 2 cases, resulting in 2 deaths;
- in 2007, 6 cases, resulting in 5 deaths.

In recent years the number of cases of yellow fever had decreased considerably. The number of cases recorded in the first three weeks of 2008 outnumbers the figures for the last four years together. Yellow fever seems to be back in force in 2008.

2. There have been no cases of yellow fever in areas of Brazil where the disease wasn’t present before. The cases registered in 2008 were of people who were not vaccinated and got infected in risk areas.

3. Yellow fever is only present in rural areas. Since 1942 there are no cases of yellow fever in the towns and cities of Brazil. The measures taken by Brazilian authorities aim at preventing the reappearence of urban yellow fever. For that to happen, someone would have to be bitten my a mosquito in a rural area. That person would then travel to an urban area, and would be bitten again by another mosquito that would, from then on, carry the yellow fever virus.

4. Only those visiting risk areas need to get vaccinated against yellow fever.
The Brazilian authorities have recently changed their advice. Previously, they divided the country in four different areas (risk areas, potential risk areas, transition areas and risk-free areas). Now the split is much more simple, just the two areas: risk areas and risk-free areas. ONLY those travelling to risk areas should be vaccinated.

• risk areas. Those where yellow fever is endemic and the virus is at large in rural areas. The states included in this group are Acre, Amazonas, Amapá, Distrito Federal (Brasilia), Goiás, Maranhão, Mato Grosso, Mato Grosso do Sul, Minas Gerais, Pará, Rondônia, Roraima and Tocantins. In December 2008 there were new additions to the list: the western part of the states of Paraná (including the area of the Iguassu Falls), Piaui, Santa Catarina and São Paulo. The western part of the state of Rio Grande do Sul as well as Porto Alegre and part of its metropolitan area are included too.
• risk-free areas. Areas where there have been no cases recorded and the likelihood of them happening is null. This area includes the entire Brazilian coast from Rio Grande do Sul up to Piaui (both states included). The state of Espírito Santo and the south of the state of Bahia are now declared risk-free.

5. Tourists visiting risk-free areas do not need to take the vaccine. The vaccine has a series of well-documented side effects.
Suddenly, everyone wants to get vaccinated against yellow fever, regardless of whether they are planning to visit risk zones or not. All vaccines have side effects, and the vaccine against yellow fever is no exception. Getting vaccinated for the sake of it is being discouraged.

6. For the vaccine to be effective, it needs to be taken at least 10 days prior to travel.
In Brazil at least, people embarking on trips to risk areas are taking the vaccine as they are about to begin their journey. You need to take the vaccine at least 10 days before you begin your journey to risk areas. The vaccine is valid for ten years. You should *not* get a booster before the end of that 10-year period.

7. Brazilian authorities are NOT asking at the moment for an International Certificate of Vaccination Against Yellow Fever regardless of where the passenger comes from.
Not long ago the certificate was being asked to passengers coming from a series of countries. That is no longer the case, at least for the time being. The official document from the Brazilian authorities stating a certificate is not needed is here: Certificado Internacional de Vacinação (see paragraph 3, unfortunately in Portuguese only). Basically, the certificate was only asked to passengers coming from countries where there was yellow fever, countries that were a potential threat to other countries. Anvisa (the Brazilian state agency responsible for disease control) states in the document that right now there are no countries posing a threat of spreading yellow fever. Anvisa also states in the document that if the risk should reappear, an alert would be issued.

8. Yellow fever is transmitted through a mosquito bite.
You can’t catch yellow fever from a fellow human being. In the rural areas, the Haemagogus mosquito is the carrier of the yellow fever virus. In urban areas, it is the notorious Aedes aegypti mosquito, responsible as well for transmitting dengue fever to humans.

9. The main symptoms of yellow fever are: fever, muscle pain, headache, shivers, nausea or vomiting. Symptoms appear between three and six days after becoming infected.
In 15% of the cases symptoms can include also jaundice, bleeding and a series of complications. Yellow fever symptoms are very similar to those of dengue fever. For that reason, the diagnosis can only be confirmed after a series of lab tests.

10. Treatment of yellow fever is supportive only. There is no specific medication to treat yellow fever. Victims of yellow fever need to be treated in hospital.

VERY IMPORTANT: the medical information contained on this entry has been put together with responsible care. However, I am no health professional, and medical advice must be sought from doctors and other health professionals.

SOURCES:
On the Portal da Saúde from the Brazilian Ministry of Health up-to-date information on the yellow fever crisis can be found (in Portuguese only). There is a page in English, hidden under a subdomain at the same site, with basic information on yellow fever – but no specific mention to the current crisis (Febre amarela).

In Tourist Support Recommendations: Vaccines from the Brazilian Tourism portal there are general recommendations from the Brazilian authorities to tourists travelling to the country.

The US’s CDC is essential reading too: Yellow Fever in Brazil.

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RELATED POSTS:
10 facts about dengue fever in Brazil

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UPDATE: Ten facts about yellow fever in Brazil

Yellow fever has hit the headlines once again. The Brazilian authorities have re-issued a health alert for visitors coming to Brazil and intending to visit certain regions of the country where yellow fever is endemic. The recent deaths of a handful of people in Goiania and Brasilia have provoked a sudden rush to the health centres.

The basic facts about yellow fever in Brazil remain the same:

1. It is strongly recommended that people visiting the states of Acre, Amazonas, Amapá, Distrito Federal, Goiás, Maranhão, Mato Grosso, Mato Grosso do Sul, Pará, Rondônia, Roraima and Tocantins be vaccinated against yellow fever.

2. Additional areas of potential risk have been identified in the western areas of the states of Santa Catarina, Paraná (including the area around Iguassu Falls), Piauí, São Paulo and on the southern part of the state of Bahia. No cases of yellow fever have been recorded on these areas but visitors are advised to get the vaccine.

3. Any other part of the country not included above is risk-free. The popular tourist destinations where there is no risk of catching yellow fever and, therefore, no need to get the vaccine, include:

State of ALAGOAS: Maceió, Maragogi, the Rota Ecológica and the rest of the state.
State of BAHÍA: Salvador, Morro de São Paulo, Praia do Forte. For the southern coast of the state (Porto Seguro, Arraial d’Ajuda, Trancoso, Caraíva) the vaccine is recommended.
State of CEARÁ: Fortaleza, Canoa Quebrada, Jericoacoara and the rest of the state.
State of PARAÍBA: João Pessoa and the rest of the state.
State of PARANÁ: Ilha do Mel and the rest of the coast of the state.
State of PERNAMBUCO: Recife, Olinda, Porto de Galinhas, Fernando de Noronha and the rest of the state.
State of RÍO DE JANEIRO: Río de Janeiro, Paraty, Ilha Grande, Búzios, Arraial do Cabo, Cabo Frío and the rest of the coast of the state.
State of SANTA CATARINA: Bombinhas, Camboriu, Florianópolis and the rest of the coast of the state.
State of SÃO PAULO: Santos, Guarujá, Ilhabela, Ubatuba and the rest of the coast of the state.
State of SERGIPE: Aracaju and the rest of the state.
State of RIO GRANDE DO NORTE: Natal, Pipa and the rest of the state.

The latest information can be found on the Brazilian Health Minister website: Ministério da Saúde. As usual in Brazil, the information contained on the Ministry’s homepage is only in Portuguese.

However, a reader of this blog has reported the existence of a website of the same Ministry, but under a different subdomain (and with no link from the Ministry’s homepage) with information in English on yellow fever: Febre amarela (I certainly can’t see how a visitor to the Ministry’s webpage would find their way to the page in English). The information contained here is of a general nature and does not relate specifically to the current crisis, as does the Portuguese-only information of the homepage. So, those wanting to read more about yellow fever in English can do so at the link provided; those wanting to find out information in English on the current crisis, will be left waiting.

Yellow fever is a serious disease. If in doubt, get the vaccine. You should do so at least 10 days prior to travel.