MD Travel Health - Bolivia - vaccinations, malaria, safety, and other medical advice

Summary You can't Edit

1

Summary of recommendations

Most travelers to Bolivia will need vaccinations for hepatitis A, typhoid fever, and yellow fever, as well as medications for malaria prophylaxis and travelers' diarrhea. Other immunizations may be necessary depending upon the circumstances of the trip and the medical history of the traveler, as discussed below. Insect repellents are recommended, in conjunction with other measures to prevent mosquito bites. All travelers should visit either a travel health clinic or their personal physician 4-8 weeks before departure.

Malaria:Prophylaxis with Lariam (mefloquine), Malarone (atovaquone/proguanil), or doxycycline is recommended for all areas below 2500 m (8202 ft) in the departments of Beni, Chuquisaca, Cochabamba, La Paz, Pando, Santa Cruz, and Tarija, except the city of La Paz.

Vaccinations:

Hepatitis A	Recommended for all travelers
Typhoid	For travelers who may eat or drink outside major restaurants and hotels
Yellow fever	Recommended for the entire departments of Beni, Pando, Santa Cruz, and designated areas of Chuquisaca, Cochabamba, La Paz, and Tarija. Not recommended for areas greater than 2300 m in elevation and all areas not listed above, including the cities of La Paz and Sucre. Required for travelers arriving from a country with risk of yellow fever transmission.
Hepatitis B	Recommended for all travelers
Rabies	For travelers spending a lot of time outdoors, or at high risk for animal bites, or involved in any activities that might bring them into direct contact with bats
Measles, mumps, rubella (MMR)	Two doses recommended for all travelers born after 1956, if not previously given
Tetanus-diphtheria	Revaccination recommended every 10 years

Revisions

Summary of recommendations
Most travelers to Bolivia will need vaccinations for hepatitis A, typhoid fever, and yellow fever, as well as medications for malaria prophylaxis and travelers' diarrhea. Other immunizations may be necessary depending upon the circumstances of the trip and the medical history of the traveler, as discussed below. Insect repellents are recommended, in conjunction with other measures to prevent mosquito bites. All travelers should visit either a travel health clinic or their personal physician 4-8 weeks before departure.
Malaria:Prophylaxis with Lariam (mefloquine), Malarone (atovaquone/proguanil), or doxycycline is recommended for all areas below 2500 m (8202 ft) in the departments of Beni, Chuquisaca, Cochabamba, La Paz, Pando, Santa Cruz, and Tarija, except the city of La Paz.
Vaccinations:
<table class="table table-striped table-hover table-bordered">
<tbody>
<tr>
<td>Hepatitis A</td>
<td>Recommended for all travelers</td>
</tr>
<tr>
<td>Typhoid</td>
<td>For travelers who may eat or drink outside major restaurants and hotels</td>
</tr>
<tr>
<td>Yellow fever</td>
<td>Recommended for the entire departments of Beni, Pando, Santa Cruz, and designated areas of Chuquisaca, Cochabamba, La Paz, and Tarija. Not recommended for areas greater than 2300 m in elevation and all areas not listed above, including the cities of La Paz and Sucre. Required for travelers arriving from a country with risk of yellow fever transmission.</td>
</tr>
<tr>
<td>Hepatitis B</td>
<td>Recommended for all travelers</td>
</tr>
<tr>
<td>Rabies</td>
<td>For travelers spending a lot of time outdoors, or at high risk for animal bites, or involved in any activities that might bring them into direct contact with bats</td>
</tr>
<tr>
<td>Measles, mumps, rubella (MMR)</td>
<td>Two doses recommended for all travelers born after 1956, if not previously given</td>
</tr>
<tr>
<td>Tetanus-diphtheria</td>
<td>Revaccination recommended every 10 years</td>
</tr>
</tbody>
</table>

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Medications You can't Edit

2

Medications

Travelers'diarrhea is the most common travel-related ailment. The cornerstone of prevention is food and water precautions, as outlined below. All travelers should bring along an antibiotic and an antidiarrheal drug to be started promptly if significant diarrhea occurs, defined as three or more loose stools in an 8-hour period or five or more loose stools in a 24-hour period, especially if associated with nausea, vomiting, cramps, fever or blood in the stool. A quinolone antibiotic is usually prescribed: either ciprofloxacin (Cipro)(PDF) 500 mg twice daily or levofloxacin (Levaquin) 500 mg once daily for a total of three days. Quinolones are generally well-tolerated, but occasionally cause sun sensitivity and should not be given to children, pregnant women, or anyone with a history of quinolone allergy. Alternative regimens include a three day course of rifaximin (Xifaxan) 200 mg three times daily or azithromycin (Zithromax) 500 mg once daily. Rifaximin should not be used by those with fever or bloody stools and is not approved for pregnant women or those under age 12. Azithromycin should be avoided in those allergic to erythromycin or related antibiotics. An antidiarrheal drug such as loperamide (Imodium) or diphenoxylate (Lomotil) should be taken as needed to slow the frequency of stools, but not enough to stop the bowel movements completely. Diphenoxylate (Lomotil) and loperamide (Imodium) should not be given to children under age two.

Most cases of travelers' diarrhea are mild and do not require either antibiotics or antidiarrheal drugs. Adequate fluid intake is essential.

If diarrhea is severe or bloody, or if fever occurs with shaking chills, or if abdominal pain becomes marked, or if diarrhea persists for more than 72 hours, medical attention should be sought.

Though effective, antibiotics are not recommended prophylactically (i.e. to prevent diarrhea before it occurs) because of the risk of adverse effects, though this approach may be warranted in special situations, such as immunocompromised travelers.

Malaria in Bolivia: prophylaxis is recommended for all areas below 2500 m (8202 ft). There is no risk in the city of La Paz. The risk is highest in the departments of Beni, Pando, Santa Cruz and Tarija, and in the provinces of Lacareja, Rurenabaque, and North and South Yungas in La Paz Department. Falciparum malaria occurs in Beni and Pando. For a map showing the risk of malaria in different parts of the country, go to the Pan American Health Organization.

Either mefloquine (Lariam), atovaquone/proguanil (Malarone)(PDF), or doxycycline may be given. Mefloquine is taken once weekly in a dosage of 250 mg, starting one-to-two weeks before arrival and continuing through the trip and for four weeks after departure. Mefloquine may cause mild neuropsychiatric symptoms, including nausea, vomiting, dizziness, insomnia, and nightmares. Rarely, severe reactions occur, including depression, anxiety, psychosis, hallucinations, and seizures. Mefloquine should not be given to anyone with a history of seizures, psychiatric illness, cardiac conduction disorders, or allergy to quinine or quinidine. Those taking mefloquine (Lariam) should read the Lariam Medication Guide (PDF). Atovaquone/proguanil (Malarone) is a 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, which are typically mild, may include abdominal pain, nausea, vomiting, headache, diarrhea, or dizziness. Serious adverse reactions are rare. Doxycycline is effective, but may cause an exaggerated sunburn reaction, which limits its usefulness in the tropics.

Long-term travelers who will be visiting malarious areas and may not have access to medical care should bring along medications for emergency self-treatment should they develop symptoms suggestive of malaria, such as fever, chills, headaches, and muscle aches, and cannot obtain medical care within 24 hours. See malaria for details. Symptoms of malaria sometimes do not occur for months or even years after exposure.

Insect protection measures are essential.

For further information about malaria in Bolivia, including a map showing the risk of malaria in different parts of the country, go to the Pan American Health Organization website and the World Health Organization.

Altitude sickness may occur in travelers flying to La Paz, which is 4000 meters above sea level. Acetazolamide is the drug of choice to prevent altitude sickness. The usual dosage is 125 or 250 mg twice daily starting 24 hours before ascent and continuing for 48 hours after arrival at altitude. Possible side-effects include increased urinary volume, numbness, tingling, nausea, drowsiness, myopia and temporary impotence. Acetazolamide should not be given to pregnant women or those with a history of sulfa allergy. For those who cannot tolerate acetazolamide, the preferred alternative is dexamethasone 4 mg taken four times daily. Unlike acetazolamide, dexamethasone must be tapered gradually upon arrival at altitude, since there is a risk that altitude sickness will occur as the dosage is reduced.

Travel to high altitudes is generally not recommended for those with a history of heart disease, lung disease, or sickle cell disease.

Revisions

<categorytext name="Medications">
 
 Medications
 
 
 <a href="/mdtravelhealth/resource/travelers_diarrhea">Travelers'diarrhea</a> is the most common travel-related ailment. The cornerstone of prevention is food and water precautions, as outlined below. All travelers should bring along an antibiotic and an antidiarrheal drug to be started promptly if significant diarrhea occurs, defined as three or more loose stools in an 8-hour period or five or more loose stools in a 24-hour period, especially if associated with nausea, vomiting, cramps, fever or blood in the stool. A quinolone antibiotic is usually prescribed: either <a href="http://www.univgraph.com/bayer/inserts/ciprotab.pdf">ciprofloxacin (Cipro)(PDF)</a> 500 mg twice daily or levofloxacin (Levaquin) 500 mg once daily for a total of three days. Quinolones are generally well-tolerated, but occasionally cause sun sensitivity and should not be given to children, pregnant women, or anyone with a history of quinolone allergy. Alternative regimens include a three day course of <a href="http://www.salix.com/pdf/XifaxanPI.pdf">rifaximin (Xifaxan)</a> 200 mg three times daily or <a href="http://www.pfizer.com/hml/pi's/zithromaxregpi.html">azithromycin (Zithromax)</a> 500 mg once daily. Rifaximin should not be used by those with fever or bloody stools and is not approved for pregnant women or those under age 12. Azithromycin should be avoided in those allergic to erythromycin or related antibiotics. An antidiarrheal drug such as loperamide (Imodium) or diphenoxylate (Lomotil) should be taken as needed to slow the frequency of stools, but not enough to stop the bowel movements completely. Diphenoxylate (Lomotil) and loperamide (Imodium) should not be given to children under age two. 
 Most cases of travelers' diarrhea are mild and do not require either antibiotics or antidiarrheal drugs. Adequate fluid intake is essential. 
 If diarrhea is severe or bloody, or if fever occurs with shaking chills, or if abdominal pain becomes marked, or if diarrhea persists for more than 72 hours, medical attention should be sought. 
 Though effective, antibiotics are not recommended prophylactically (i.e. to prevent diarrhea before it occurs) because of the risk of adverse effects, though this approach may be warranted in special situations, such as immunocompromised travelers. 
 
 <a href="/mdtravelhealth/resource/malaria">Malaria</a> in Bolivia: prophylaxis is recommended for all areas below 2500 m (8202 ft). There is no risk in the city of La Paz. The risk is highest in the departments of Beni, Pando, Santa Cruz and Tarija, and in the provinces of Lacareja, Rurenabaque, and North and South Yungas in La Paz Department. Falciparum malaria occurs in Beni and Pando. For a map showing the risk of malaria in different parts of the country, go to the <a href="http://www.paho.org/English/HCP/HCT/MAL/maps-cartagena.htm">Pan American Health Organization</a>.
 Either mefloquine (Lariam), <a href="http://us.gsk.com/products/assets/us_malarone.pdf">atovaquone/proguanil (Malarone)(PDF)</a>, or doxycycline may be given. Mefloquine is taken once weekly in a dosage of 250 mg, starting one-to-two weeks before arrival and continuing through the trip and for four weeks after departure. Mefloquine may cause mild neuropsychiatric symptoms, including nausea, vomiting, dizziness, insomnia, and nightmares. Rarely, severe reactions occur, including depression, anxiety, psychosis, hallucinations, and seizures. Mefloquine should not be given to anyone with a history of seizures, psychiatric illness, cardiac conduction disorders, or allergy to quinine or quinidine. Those taking mefloquine (Lariam) should read the Lariam Medication Guide (PDF). Atovaquone/proguanil (Malarone) is a 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, which are typically mild, may include abdominal pain, nausea, vomiting, headache, diarrhea, or dizziness. Serious adverse reactions are rare. Doxycycline is effective, but may cause an exaggerated sunburn reaction, which limits its usefulness in the tropics.
 Long-term travelers who will be visiting malarious areas and may not have access to medical care should bring along medications for emergency self-treatment should they develop symptoms suggestive of malaria, such as fever, chills, headaches, and muscle aches, and cannot obtain medical care within 24 hours. See <a href="/mdtravelhealth/resource/malaria">malaria</a> for details. Symptoms of malaria sometimes do not occur for months or even years after exposure.
 
 Insect protection measures are essential.
 For further information about malaria in Bolivia, including a map showing the risk of malaria in different parts of the country, go to the <a href="http://www.paho.org/English/HCP/HCT/MAL/maps-cartagena.htm">Pan American Health Organization</a> website and the World Health Organization.
 
 <a href="/mdtravelhealth/resource/altitude_sickness">Altitude sickness</a> may occur in travelers flying to La Paz, which is 4000 meters above sea level. Acetazolamide is the drug of choice to prevent altitude sickness. The usual dosage is 125 or 250 mg twice daily starting 24 hours before ascent and continuing for 48 hours after arrival at altitude. Possible side-effects include increased urinary volume, numbness, tingling, nausea, drowsiness, myopia and temporary impotence. Acetazolamide should not be given to pregnant women or those with a history of sulfa allergy. For those who cannot tolerate acetazolamide, the preferred alternative is dexamethasone 4 mg taken four times daily. Unlike acetazolamide, dexamethasone must be tapered gradually upon arrival at altitude, since there is a risk that altitude sickness will occur as the dosage is reduced. 
 Travel to high altitudes is generally not recommended for those with a history of heart disease, lung disease, or sickle cell disease.
 <section name="Medications">
 <sectiontext name="Medications"></sectiontext>
 </section>
</categorytext>

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Immunizations You can't Edit

3

Immunizations

The following are the recommended vaccinations for Bolivia.

Hepatitis A vaccine is recommended for all travelers over one year of age. It should be given at least two weeks (preferably four weeks or more) before departure. A booster should be given 6-12 months later to confer long-term immunity. Two vaccines are currently available in the United States: VAQTA (Merck and Co., Inc.) (PDF) and Havrix (GlaxoSmithKline) (PDF). Both are well-tolerated. Side-effects, which are generally mild, may include soreness at the injection site, headache, and malaise.

Older adults, immunocompromised persons, and those with chronic liver disease or other chronic medical conditions who have less than two weeks before departure should receive a single intramuscular dose of immune globulin (0.02 mL/kg) at a separate anatomic injection site in addition to the initial dose of vaccine. Travelers who are less than one year of age or allergic to a vaccine component should receive a single intramuscular dose of immune globulin (see hepatitis A for dosage) in the place of vaccine.

Typhoid vaccine is recommended for all travelers, with the exception of short-term visitors who restrict their meals to major restaurants and hotels, such as business travelers. It is generally given in an oral form (Vivotif Berna) consisting of four capsules taken on alternate days until completed. The capsules should be kept refrigerated and taken with cool liquid. Side-effects are uncommon and may include abdominal discomfort, nausea, rash or hives. The alternative is an injectable polysaccharide vaccine (Typhim Vi; Aventis Pasteur Inc.) (PDF), given as a single dose. Adverse reactions, which are uncommon, may include discomfort at the injection site, fever and headache. The oral vaccine is approved for travelers at least six years old, whereas the injectable vaccine is approved for those over age two. There are no data concerning the safety of typhoid vaccine during pregnancy. The injectable vaccine (Typhim Vi) is probably preferable to the oral vaccine in pregnant and immunocompromised travelers.

Yellow fever vaccine is recommended for all travelers greater than nine months of age traveling to the following areas east of the Andes Mountains less than 2300 m in elevation: the entire departments of Beni, Pando, Santa Cruz, and designated areas (see map) of Chuquisaca, Cochabamba, La Paz, and Tarija. Not recommended for travelers whose itineraries are limited to areas greater than 2300 m in elevation and all areas not listed above, including the cities of La Paz and Sucre. Yellow fever vaccine is required for all travelers greater than one year of age arriving from a country in Africa or the Americas with risk of yellow fever transmission. Medical waivers must be translated into Spanish and accompany the International Certificate of Vaccination or Prophylaxis (ICVP). Travelers who do not have a valid ICVP will still be allowed to enter Bolivia if they agree to sign an affidavit exempting the Bolivian state from any liability in the event the traveler gets sick with yellow fever within the Bolivian territory. This last option may cause delays at the point of entry. In recent years, yellow fever has been reported from the departments of Beni, Cochabamba, Santa Cruz, and La Paz. For further details on yellow fever in Bolivia, go to the Pan-American Health Organization (PDF).

Yellow fever vaccine (YF-VAX; Aventis Pasteur Inc.) (PDF) must be administered at an approved yellow fever vaccination center, which will give each vaccinee a fully validated International Certificate of Vaccination. Reactions to the vaccine, which are generally mild, may include headaches, muscle aches, and low-grade fevers. Serious allergic reactions, such as hives or asthma, are rare and generally occur in those with a history of egg allergy. The vaccine should not in general be given to those who are younger than nine months of age, pregnant, immunocompromised, or allergic to eggs.

Hepatitis B vaccine is recommended for all travelers if not previously vaccinated. Two vaccines are currently licensed in the United States: Recombivax HB (Merck and Co., Inc.) (PDF) and Engerix-B (GlaxoSmithKline) (PDF). A full series consists of three intramuscular doses given at 0, 1 and 6 months. Engerix-B is also approved for administration at 0, 1, 2, and 12 months, which may be appropriate for travelers departing in less than 6 months. Side-effects are generally mild and may include discomfort at the injection site and low-grade fever. Severe allergic reactions (anaphylaxis) occur rarely.

Rabies vaccine is recommended for travelers spending a lot of time outdoors, for travelers at high risk for animal bites, such as veterinarians and animal handlers, for long-term travelers and expatriates, and for travelers involved in any activities that might bring them into direct contact with bats. Children are considered at higher risk because they tend to play with animals, may receive more severe bites, or may not report bites. In Bolivia, most cases are related to dog bites. A complete preexposure series consists of three doses of vaccine injected into the deltoid muscle on days 0, 7, and 21 or 28. Side-effects may include pain at the injection site, headache, nausea, abdominal pain, muscle aches, dizziness, or allergic reactions.

Any animal bite or scratch should be thoroughly cleaned with large amounts of soap and water and local health authorities should be contacted immediately for possible post-exposure treatment, whether or not the person has been immunized against rabies.

Tetanus-diphtheria vaccine is recommended for all travelers who have not received a tetanus-diphtheria immunization within the last 10 years.

Measles-mumps-rubella vaccine: two doses are recommended (if not previously given) for all travelers born after 1956, unless blood tests show immunity. Many adults born after 1956 and before 1970 received only one vaccination against measles, mumps, and rubella as children and should be given a second dose before travel. MMR vaccine should not be given to pregnant or severely immunocompromised individuals.

Cholera vaccine is not recommended. Cholera is not being reported from Bolivia at this time.

Polio vaccine is not recommended for any adult traveler who completed the recommended childhood immunizations. Polio has been eradicated from the Americas, except for a small outbreak of vaccine-related poliomyelitis in the Dominican Republic and Haiti in late 2000.

Revisions

<categorytext name="Immunizations">
 
 Immunizations
 
 The following are the recommended vaccinations for Bolivia.
 
 <a href="/mdtravelhealth/resource/hepatitis_a">Hepatitis A</a> vaccine is recommended for all travelers over one year of age. It should be given at least two weeks (preferably four weeks or more) before departure. A booster should be given 6-12 months later to confer long-term immunity. Two vaccines are currently available in the United States: <a href="http://www.merck.com/product/usa/pi_circulars/v/vaqta/vaqta_pi.pdf">VAQTA (Merck and Co., Inc.) (PDF)</a> and <a href="http://us.gsk.com/products/assets/us_havrix.pdf">Havrix (GlaxoSmithKline) (PDF)</a>. Both are well-tolerated. Side-effects, which are generally mild, may include soreness at the injection site, headache, and malaise.
 Older adults, immunocompromised persons, and those with chronic liver disease or other chronic medical conditions who have less than two weeks before departure should receive a single intramuscular dose of immune globulin (0.02 mL/kg) at a separate anatomic injection site in addition to the initial dose of vaccine. Travelers who are less than one year of age or allergic to a vaccine component should receive a single intramuscular dose of immune globulin (see <a href="/mdtravelhealth/resource/hepatitis_a">hepatitis A</a> for dosage) in the place of vaccine.
 
 <a href="/mdtravelhealth/resource/typhoid_fever">Typhoid</a> vaccine is recommended for all travelers, with the exception of short-term visitors who restrict their meals to major restaurants and hotels, such as business travelers. It is generally given in an oral form (Vivotif Berna) consisting of four capsules taken on alternate days until completed. The capsules should be kept refrigerated and taken with cool liquid. Side-effects are uncommon and may include abdominal discomfort, nausea, rash or hives. The alternative is an injectable polysaccharide vaccine (Typhim Vi; Aventis Pasteur Inc.) (PDF), given as a single dose. Adverse reactions, which are uncommon, may include discomfort at the injection site, fever and headache. The oral vaccine is approved for travelers at least six years old, whereas the injectable vaccine is approved for those over age two. There are no data concerning the safety of typhoid vaccine during pregnancy. The injectable vaccine (Typhim Vi) is probably preferable to the oral vaccine in pregnant and immunocompromised travelers.
 
 <a href="/mdtravelhealth/resource/yellow_fever">Yellow fever</a> vaccine is recommended for all travelers greater than nine months of age traveling to the following areas east of the Andes Mountains less than 2300 m in elevation: the entire departments of Beni, Pando, Santa Cruz, and designated areas (see <a href="http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-3-infectious-diseases-related-to-travel/yellow-fever.htm#2854">map</a>) of Chuquisaca, Cochabamba, La Paz, and Tarija. Not recommended for travelers whose itineraries are limited to areas greater than 2300 m in elevation and all areas not listed above, including the cities of La Paz and Sucre. Yellow fever vaccine is required for all travelers greater than one year of age arriving from a country in <a href="http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-3-infectious-diseases-related-to-travel/yellow-fever.htm#1948">Africa</a> or <a href="http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-3-infectious-diseases-related-to-travel/yellow-fever.htm#1948">the Americas</a> with risk of yellow fever transmission. Medical waivers must be translated into Spanish and accompany the International Certificate of Vaccination or Prophylaxis (ICVP). Travelers who do not have a valid ICVP will still be allowed to enter Bolivia if they agree to sign an affidavit exempting the Bolivian state from any liability in the event the traveler gets sick with yellow fever within the Bolivian territory. This last option may cause delays at the point of entry. In recent years, yellow fever has been reported from the departments of Beni, Cochabamba, Santa Cruz, and La Paz. For further details on yellow fever in Bolivia, go to the <a href="http://www.paho.org/English/HVP/HVI/2002_09_%2010_dc.pdf">Pan-American Health Organization (PDF)</a>. 
 Yellow fever vaccine (YF-VAX; Aventis Pasteur Inc.) (PDF) must be administered at an approved yellow fever vaccination center, which will give each vaccinee a fully validated International Certificate of Vaccination. Reactions to the vaccine, which are generally mild, may include headaches, muscle aches, and low-grade fevers. Serious allergic reactions, such as hives or asthma, are rare and generally occur in those with a history of egg allergy. The vaccine should not in general be given to those who are younger than nine months of age, pregnant, immunocompromised, or allergic to eggs. 
 
 <a href="/mdtravelhealth/resource/hepatitis_b">Hepatitis B</a> vaccine is recommended for all travelers if not previously vaccinated. Two vaccines are currently licensed in the United States: <a href="http://www.merck.com/product/usa/pi_circulars/r/recombivax_hb/recombivax_pi.pdf">Recombivax HB (Merck and Co., Inc.) (PDF)</a> and <a href="http://us.gsk.com/products/assets/us_engerixb.pdf">Engerix-B (GlaxoSmithKline) (PDF)</a>. A full series consists of three intramuscular doses given at 0, 1 and 6 months. Engerix-B is also approved for administration at 0, 1, 2, and 12 months, which may be appropriate for travelers departing in less than 6 months. Side-effects are generally mild and may include discomfort at the injection site and low-grade fever. Severe allergic reactions (anaphylaxis) occur rarely.
 
 <a href="/mdtravelhealth/resource/rabies">Rabies</a> vaccine is recommended for travelers spending a lot of time outdoors, for travelers at high risk for animal bites, such as veterinarians and animal handlers, for long-term travelers and expatriates, and for travelers involved in any activities that might bring them into direct contact with bats. Children are considered at higher risk because they tend to play with animals, may receive more severe bites, or may not report bites. In Bolivia, most cases are related to dog bites. A complete preexposure series consists of three doses of vaccine injected into the deltoid muscle on days 0, 7, and 21 or 28. Side-effects may include pain at the injection site, headache, nausea, abdominal pain, muscle aches, dizziness, or allergic reactions. 
 
 Any animal bite or scratch should be thoroughly cleaned with large amounts of soap and water and local health authorities should be contacted immediately for possible post-exposure treatment, whether or not the person has been immunized against rabies.
 
 <a href="/mdtravelhealth/resource/tetanus">Tetanus</a>-<a href="/mdtravelhealth/resource/diphtheria">diphtheria</a> vaccine is recommended for all travelers who have not received a tetanus-diphtheria immunization within the last 10 years.
 
 <a href="/mdtravelhealth/resource/measles">Measles</a>-<a href="/mdtravelhealth/resource/mumps">mumps</a>-<a href="/mdtravelhealth/resource/rubella">rubella</a> vaccine: two doses are recommended (if not previously given) for all travelers born after 1956, unless blood tests show immunity. Many adults born after 1956 and before 1970 received only one vaccination against measles, mumps, and rubella as children and should be given a second dose before travel. MMR vaccine should not be given to pregnant or severely immunocompromised individuals.
 
 <a href="/mdtravelhealth/resource/cholera">Cholera</a> vaccine is not recommended. Cholera is not being reported from Bolivia at this time.
 
 <a href="/mdtravelhealth/resource/polio">Polio</a> vaccine is not recommended for any adult traveler who completed the recommended childhood immunizations. Polio has been eradicated from the Americas, except for a small outbreak of vaccine-related poliomyelitis in the Dominican Republic and Haiti in late 2000.
</categorytext>

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Recent outbreaks of diseases You can't Edit

4

Recent outbreaks

An outbreak of bubonic plague was reported from La Paz department in July 2014, causing one confirmed and three suspected cases in the municipality of Apolo, in the northern part of the region, near the border with Peru. Between June and August 2010, another plague outbreak occurred in northern La Paz department, causing eight cases, three of them fatal. An outbreak involving 26 people, resulting in four deaths, occurred in La Paz from December 1996 to January 1997.

The plague is usually transmitted by the bite of rodent fleas. Most travelers are at extremely low risk. Those who may have contact with rodents or their fleas should bring along a bottle of doxycycline, to be taken prophylactically if exposure occurs. Those less than eight years of age or allergic to doxycycline may take trimethoprim-sulfamethoxazole instead. To minimize risk, travelers should avoid areas containing rodent burrows or nests, never handle sick or dead animals, and follow insect protection measures, as described below.

An outbreak of Bolivian hemorrhagic fever was reported from Beni department in June 2012, causing 13 cases, seven of them fatal, by the end of July. In November 2011, an outbreak was reported among rodents in Beni department, followed by the identification of human cases in Mamore and Itenez provinces in January 2012. An additional human case was reported from Beni in April 2012. Three cases of Bolivian hemorrhagic fever, two of them fatal, were reported in March 2007 from the Mamuja community, 22 km away from Magdalena, in Beni (see ProMED-mail; March 16, 2007; January 29, 2012; and June 29, 2012). In June 2004, two fatal cases were reported from the department of Beni, Itenez Province, localities of Huacareje and Magdalena, in the northeastern part of the country (see the Pan-American Health Organization).

Bolivian hemorrhagic fever is caused by Machupo virus, which is transmitted by exposure to infected rodents. The disease is endemic in Beni department. The illness begins with fever and malaise, followed by abdominal pain, nausea, vomiting, facial swelling, confusion, hemorrhage, and shock. There is no treatment and no vaccine. For further information, see PE Kilgore et al. in Emerging Infectious Diseases.

An outbreak of canine rabies was reported from Bolivia in July 2011, chiefly involving the cities of Santa Cruz, Cochabamba, and Sucre, and leading to four human deaths. For the first half of 2011, the department of Santa Cruz reported the largest number of rabies cases, followed by Cochabamba, Sucre, La Paz, Beni, Potosi, and Tarija. Most cases in Bolivia are related to dog bites (ProMED-mail, July 28 and August 9, 2011). Rabies vaccine is recommended for travelers spending a lot of time outdoors, for travelers at high risk for animal bites, such as veterinarians and animal handlers, for long-term travelers and expatriates, and for travelers involved in any activities that might bring them into direct contact with bats. Any animal bite or scratch should be thoroughly cleaned with large amounts of soap and water and local health authorities should be contacted immediately for possible post-exposure treatment, whether or not the person has been immunized against rabies.

Outbreaks of dengue fever occur regularly in Bolivia. The most recent was reported in early 2011, causing 11,341 probable cases and 27 deaths by April 8, compared to 9000 cases for all of 2010. The departments most affected included Santa Cruz de la Sierra (5727 probable cases, 1404 confirmed cases and 11 deaths), Beni (3269 probable cases, 314 confirmed cases and 14 deaths), and La Paz (993 probable cases, 308 confirmed cases and one death). One of the largest outbreaks in the country's history began in January 2009, resulting in more than 56,000 suspected cases and 25 deaths by the end of April. A majority of the cases occurred in the department of Santa Cruz. Cases were also described in the departments of Beni, Pando and Cochabamba; in the area of Yacuiba on the border with Argentina in the southern department of Tarija; and in Chuquisaca and La Paz. The outbreak subsided with the arrival of winter, but an increased number of cases was reported from Pando in December 2009. As of March 18, 2010, a total of 2586 suspected cases had been reported in Bolivia for the year, with confirmed cases from all provinces except Oruro and Potosi (see the Boliviain Ministry of Health and ProMED-mail). Dengue fever is a flu-like illness sometimes complicated by hemorrhage or shock. The infection is transmitted by Aedes mosquitoes, which bite primarily in the daytime and favor densely populated areas, though they also inhabit rural environments. No vaccine is available at this time. Insect protection measures are recommended, as below.

In November 2008, a dengue outbreak occurred in the city of Cobija, capital of the northern part of the Pando department. In January 2008, an outbreak was reported from central Bolivia after rains and flooding, chiefly affecting the Chapare region in the Cochabamba department. A major dengue outbreak occurred in February 2007, chiefly affecting Santa Cruz de la Sierra and small adjacent cities in the department of Santa Cruz. As of late March, more than 2000 suspected cases had been identified (see the Pan-American Health Organization and ProMED-mail, March 26, 2007). For Bolivia as a whole, a total of 4443 dengue cases were recorded for the year 2005 and a total of 2040 cases for the year 2006.

The government of Bolivia reported 57 suspected cases of yellow fever for the year 2005, of which 16 were confirmed and 7 were fatal. For the first six months of 2004, nine cases of yellow fever, four of them fatal, were identified. Most cases occurred among males over the age of 15 who worked in the countryside. Cases were identified in the municipalities of Palo Alto (2 cases) in the Department of La Paz; and in San Ignacio de Velasco (6) and Yapacani (1), in the Department of Santa Cruz. Another three suspected cases were reported from the Departments of La Paz and Cochabamba. For further information, go to the Pan-American Health Organization and the Ministerio de Salud.

Revisions

<categorytext name="Recentoutbreaks">
 
 Recent outbreaks
 
 An outbreak of bubonic <a href="/mdtravelhealth/resource/plague">plague</a> was reported from La Paz department in July 2014, causing one confirmed and three suspected cases in the municipality of Apolo, in the northern part of the region, near the border with Peru. Between June and August 2010, another plague outbreak occurred in northern La Paz department, causing eight cases, three of them fatal. An outbreak involving 26 people, resulting in four deaths, occurred in La Paz from December 1996 to January 1997. 
 The plague is usually transmitted by the bite of rodent fleas. Most travelers are at extremely low risk. Those who may have contact with rodents or their fleas should bring along a bottle of doxycycline, to be taken prophylactically if exposure occurs. Those less than eight years of age or allergic to doxycycline may take trimethoprim-sulfamethoxazole instead. To minimize risk, travelers should avoid areas containing rodent burrows or nests, never handle sick or dead animals, and follow insect protection measures, as described below. 
 An outbreak of Bolivian hemorrhagic fever was reported from Beni department in June 2012, causing 13 cases, seven of them fatal, by the end of July. In November 2011, an outbreak was reported among rodents in Beni department, followed by the identification of human cases in Mamore and Itenez provinces in January 2012. An additional human case was reported from Beni in April 2012. Three cases of Bolivian hemorrhagic fever, two of them fatal, were reported in March 2007 from the Mamuja community, 22 km away from Magdalena, in Beni (see <a href="http://www.promedmail.org">ProMED-mail</a>; March 16, 2007; January 29, 2012; and June 29, 2012). In June 2004, two fatal cases were reported from the department of Beni, Itenez Province, localities of Huacareje and Magdalena, in the northeastern part of the country (see the <a href="http://www.paho.org/English/AD/DPC/CD/eid-eer-01-jul-2004.htm">Pan-American Health Organization</a>). 
 Bolivian hemorrhagic fever is caused by Machupo virus, which is transmitted by exposure to infected rodents. The disease is endemic in Beni department. The illness begins with fever and malaise, followed by abdominal pain, nausea, vomiting, facial swelling, confusion, hemorrhage, and shock. There is no treatment and no vaccine. For further information, see PE Kilgore et al. in Emerging Infectious Diseases.
 An outbreak of canine <a href="/mdtravelhealth/resource/rabies">rabies</a> was reported from Bolivia in July 2011, chiefly involving the cities of Santa Cruz, Cochabamba, and Sucre, and leading to four human deaths. For the first half of 2011, the department of Santa Cruz reported the largest number of rabies cases, followed by Cochabamba, Sucre, La Paz, Beni, Potosi, and Tarija. Most cases in Bolivia are related to dog bites (<a href="http://www.promedmail.org">ProMED-mail</a>, July 28 and August 9, 2011). Rabies vaccine is recommended for travelers spending a lot of time outdoors, for travelers at high risk for animal bites, such as veterinarians and animal handlers, for long-term travelers and expatriates, and for travelers involved in any activities that might bring them into direct contact with bats. Any animal bite or scratch should be thoroughly cleaned with large amounts of soap and water and local health authorities should be contacted immediately for possible post-exposure treatment, whether or not the person has been immunized against rabies.
 Outbreaks of <a href="/mdtravelhealth/resource/dengue_fever">dengue fever</a> occur regularly in Bolivia. The most recent was reported in early 2011, causing 11,341 probable cases and 27 deaths by April 8, compared to 9000 cases for all of 2010. The departments most affected included Santa Cruz de la Sierra (5727 probable cases, 1404 confirmed cases and 11 deaths), Beni (3269 probable cases, 314 confirmed cases and 14 deaths), and La Paz (993 probable cases, 308 confirmed cases and one death). One of the largest outbreaks in the country's history began in January 2009, resulting in more than 56,000 suspected cases and 25 deaths by the end of April. A majority of the cases occurred in the department of Santa Cruz. Cases were also described in the departments of Beni, Pando and Cochabamba; in the area of Yacuiba on the border with Argentina in the southern department of Tarija; and in Chuquisaca and La Paz. The outbreak subsided with the arrival of winter, but an increased number of cases was reported from Pando in December 2009. As of March 18, 2010, a total of 2586 suspected cases had been reported in Bolivia for the year, with confirmed cases from all provinces except Oruro and Potosi (see the Boliviain Ministry of Health and <a href="http://www.promedmail.org">ProMED-mail</a>). Dengue fever is a flu-like illness sometimes complicated by hemorrhage or shock. The infection is transmitted by Aedes mosquitoes, which bite primarily in the daytime and favor densely populated areas, though they also inhabit rural environments. No vaccine is available at this time. Insect protection measures are recommended, as below.
 In November 2008, a dengue outbreak occurred in the city of Cobija, capital of the northern part of the Pando department. In January 2008, an outbreak was reported from central Bolivia after rains and flooding, chiefly affecting the Chapare region in the Cochabamba department. A major dengue outbreak occurred in February 2007, chiefly affecting Santa Cruz de la Sierra and small adjacent cities in the department of Santa Cruz. As of late March, more than 2000 suspected cases had been identified (see the <a href="http://www.paho.org/english/AD/DPC/CD/eid-eer-2007-02-08.htm">Pan-American Health Organization</a> and <a href="http://www.promedmail.org">ProMED-mail</a>, March 26, 2007). For Bolivia as a whole, a total of 4443 dengue cases were recorded for the year 2005 and a total of 2040 cases for the year 2006. 
 The government of Bolivia reported 57 suspected cases of <a href="/mdtravelhealth/resource/yellow_fever">yellow fever</a> for the year 2005, of which 16 were confirmed and 7 were fatal. For the first six months of 2004, nine cases of yellow fever, four of them fatal, were identified. Most cases occurred among males over the age of 15 who worked in the countryside. Cases were identified in the municipalities of Palo Alto (2 cases) in the Department of La Paz; and in San Ignacio de Velasco (6) and Yapacani (1), in the Department of Santa Cruz. Another three suspected cases were reported from the Departments of La Paz and Cochabamba. For further information, go to the <a href="http://www.paho.org/English/AD/DPC/CD/eid-eer-24-jun-2004.htm">Pan-American Health Organization</a> and the Ministerio de Salud.
</categorytext>

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Other Infections You can't Edit

5

Other infections

Hantavirus pulmonary syndrome (life-threatening viral infection characterized by high fevers, fluid in the lungs and respiratory failure; carried by rodents; usually occurs in those whose homes have been infested with rodents or contaminated with rodent excrement; single case reported from San Andres municipality, department of Beni, in June 2011; five confirmed cases from the departments of Cochabamba, Santa Cruz, and Tarija in the first four months of 2010; most travelers at low risk, though case reported in June 2006 in Canadian traveler who had visited farms in Bolivia)
Bartonellosis (Oroya fever) (transmitted by sandflies in arid river valleys on the western slopes of the Andes up to 3000 m)
Cutaneous and mucocutaneous leishmaniasis
Visceral leishmaniasis (reported only from the yungas)
Tick-borne relapsing fever
Trench fever
Brucellosis (the most common animal source is infected cattle; five human cases reported from Potosi in October 2012)
Louse-borne typhus (mountain areas)
Venezuelan equine encephalitis
Mayaro virus disease (transmitted by mosquitoes in tropical forests)
Fascioliasis (sheep-raising areas)
Cholera (outbreaks in past, but no cases reported since 1999)
Foot-and-mouth disease (poses no risk to humans, but may cause a debilitating illness in cattle, pigs, sheep, and goats, resulting in devastating losses in milk and meat production. Humans may spread the disease if their clothing, shoes, or personal effects become contaminated. )

HIV (human immunodeficiency virus) infection is reported, but travelers are not at risk unless they have unprotected sexual contacts or receive injections or blood transfusions.

For in-depth public health information, go to the Pan-American Health Organization. For further information, go to the Ministerio de Salud y Prevision Social and the PAHO Country Office (both in Spanish).

Revisions

<categorytext name="OtherInfections">
 
 Other infections
 
 <ul>
 <li>
 <a href="/mdtravelhealth/resource/hantavirus">Hantavirus pulmonary syndrome</a> (life-threatening viral infection characterized by high fevers, fluid in the lungs and respiratory failure; carried by rodents; usually occurs in those whose homes have been infested with rodents or contaminated with rodent excrement; single case reported from San Andres municipality, department of Beni, in June 2011; five confirmed cases from the departments of Cochabamba, Santa Cruz, and Tarija in the first four months of 2010; most travelers at low risk, though case reported in June 2006 in Canadian traveler who had visited farms in Bolivia)</li>
 <li>
 Bartonellosis (Oroya fever) (transmitted by sandflies in arid river valleys on the western slopes of the Andes up to 3000 m)</li>
 <li>
 <a href="/mdtravelhealth/resource/leishmaniasis">Cutaneous and mucocutaneous leishmaniasis</a>
 </li>
 <li>
 <a href="/mdtravelhealth/resource/leishmaniasis">Visceral leishmaniasis</a> (reported only from the yungas)</li>
 <li>
 <a href="/mdtravelhealth/resource/relapsing_fever">Tick-borne relapsing fever</a>
 </li>
 <li>
 Trench fever
 </li>
 <li>
 <a href="/mdtravelhealth/resource/brucellosis">Brucellosis</a> (the most common animal source is infected cattle; five human cases reported from Potosi in October 2012)</li>
 <li>
 Louse-borne typhus (mountain areas)</li>
 <li>
 Venezuelan equine encephalitis
 </li>
 <li>
 Mayaro virus disease (transmitted by mosquitoes in tropical forests)</li>
 <li>
 Fascioliasis (sheep-raising areas)</li>
 <li>
 <a href="/mdtravelhealth/resource/cholera">Cholera</a> (outbreaks in past, but no cases reported since 1999)</li>
 <li>Foot-and-mouth disease (poses no risk to humans, but may cause a debilitating illness in cattle, pigs, sheep, and goats, resulting in devastating losses in milk and meat production. Humans may spread the disease if their clothing, shoes, or personal effects become contaminated. )</li>
 </ul>
 
 HIV (human immunodeficiency virus) infection is reported, but travelers are not at risk unless they have unprotected sexual contacts or receive injections or blood transfusions.
 For in-depth public health information, go to the <a href="http://www.paho.org/English/DD/AIS/cp_068.htm">Pan-American Health Organization</a>. For further information, go to the Ministerio de Salud y Prevision Social and the <a href="http://www.ops.org.bo/">PAHO Country Office</a> (both in Spanish).
</categorytext>

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Food and Water You can't Edit

6

Food and water precautions

Do not drink tap water unless it has been boiled, filtered, or chemically disinfected. Do not drink unbottled beverages or drinks with ice. Do not eat fruits or vegetables unless they have been peeled or cooked. Avoid cooked foods that are no longer piping hot. Cooked foods that have been left at room temperature are particularly hazardous. Avoid unpasteurized milk and any products that might have been made from unpasteurized milk, such as ice cream. Avoid food and beverages obtained from street vendors. Do not eat raw or undercooked meat or fish, including ceviche.

All travelers should bring along an antibiotic and an antidiarrheal drug to be started promptly if significant diarrhea occurs, defined as three or more loose stools in an 8-hour period or five or more loose stools in a 24-hour period, especially if accompanied by nausea, vomiting, cramps, fever or blood in the stool. Antibiotics which have been shown to be effective include ciprofloxacin (Cipro), levofloxacin (Levaquin), rifaximin (Xifaxan), or azithromycin (Zithromax). Either loperamide (Imodium) or diphenoxylate (Lomotil) should be taken in addition to the antibiotic to reduce diarrhea and prevent dehydration.

If diarrhea is severe or bloody, or if fever occurs with shaking chills, or if abdominal pain becomes marked, or if diarrhea persists for more than 72 hours, medical attention should be sought.

Revisions

<categorytext name="FoodandWater">
 
 Food and water precautions
 
 Do not drink tap water unless it has been <a href="/mdtravelhealth/resource/water_purification">boiled, filtered, or chemically disinfected</a>. Do not drink unbottled beverages or drinks with ice. Do not eat fruits or vegetables unless they have been peeled or cooked. Avoid cooked foods that are no longer piping hot. Cooked foods that have been left at room temperature are particularly hazardous. Avoid unpasteurized milk and any products that might have been made from unpasteurized milk, such as ice cream. Avoid food and beverages obtained from street vendors. Do not eat raw or undercooked meat or fish, including ceviche. 
 All travelers should bring along an antibiotic and an antidiarrheal drug to be started promptly if significant diarrhea occurs, defined as three or more loose stools in an 8-hour period or five or more loose stools in a 24-hour period, especially if accompanied by nausea, vomiting, cramps, fever or blood in the stool. Antibiotics which have been shown to be effective include <a href="http://www.univgraph.com/bayer/inserts/ciprotab.pdf">ciprofloxacin (Cipro)</a>, levofloxacin (Levaquin), <a href="http://www.salix.com/pdf/XifaxanPI.pdf">rifaximin (Xifaxan)</a>, or <a href="http://www.pfizer.com/hml/pi's/zithromaxregpi.html">azithromycin (Zithromax)</a>. Either loperamide (Imodium) or diphenoxylate (Lomotil) should be taken in addition to the antibiotic to reduce diarrhea and prevent dehydration. 
 If diarrhea is severe or bloody, or if fever occurs with shaking chills, or if abdominal pain becomes marked, or if diarrhea persists for more than 72 hours, medical attention should be sought. 
</categorytext>

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Insect Tick Protection You can't Edit

7

Insect and Tick Protection

Wear long sleeves, long pants, hats and shoes (rather than sandals). For rural and forested areas, boots are preferable, with pants tucked in, to prevent tick bites. Apply insect repellents containing 25-50% DEET (N,N-diethyl-3-methylbenzamide) or 20% picaridin (Bayrepel) to exposed skin (but not to the eyes, mouth, or open wounds). DEET may also be applied to clothing. Products with a lower concentration of either repellent need to be repplied more frequently. Products with a higher concentration of DEET carry an increased risk of neurologic toxicity, especially in children, without any additional benefit. Do not use either DEET or picaridin on children less than two years of age. For additional protection, apply permethrin-containing compounds to clothing, shoes, and bed nets. Permethrin-treated clothing appears to have little toxicity. Don't sleep with the window open unless there is a screen. If sleeping outdoors or in an accommodation that allows entry of mosquitoes, use a bed net, preferably impregnated with insect repellent, with edges tucked in under the mattress. The mesh size should be less than 1.5 mm. If the sleeping area is not otherwise protected, use a mosquito coil, which fills the room with insecticide through the night. In rural or forested areas, perform a thorough tick check at the end of each day with the assistance of a friend or a full-length mirror. Ticks should be removed with tweezers, grasping the tick by the head. Many tick-borne illnesses can be prevented by prompt tick removal.

Revisions

<categorytext name="InsectTickProtection">
 
 Insect and Tick Protection
 
 Wear long sleeves, long pants, hats and shoes (rather than sandals). For rural and forested areas, boots are preferable, with pants tucked in, to prevent tick bites. Apply <a href="/mdtravelhealth/resource/insect_repellents">insect repellents</a> containing 25-50% DEET (N,N-diethyl-3-methylbenzamide) or 20% picaridin (Bayrepel) to exposed skin (but not to the eyes, mouth, or open wounds). DEET may also be applied to clothing. Products with a lower concentration of either repellent need to be repplied more frequently. Products with a higher concentration of DEET carry an increased risk of neurologic toxicity, especially in children, without any additional benefit. Do not use either DEET or picaridin on children less than two years of age. For additional protection, apply permethrin-containing compounds to clothing, shoes, and bed nets. Permethrin-treated clothing appears to have little toxicity. Don't sleep with the window open unless there is a screen. If sleeping outdoors or in an accommodation that allows entry of mosquitoes, use a bed net, preferably impregnated with insect repellent, with edges tucked in under the mattress. The mesh size should be less than 1.5 mm. If the sleeping area is not otherwise protected, use a mosquito coil, which fills the room with insecticide through the night. In rural or forested areas, perform a thorough tick check at the end of each day with the assistance of a friend or a full-length mirror. Ticks should be removed with tweezers, grasping the tick by the head. Many tick-borne illnesses can be prevented by prompt tick removal. 
</categorytext>

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General Advice You can't Edit

8

General advice

Bring adequate supplies of all medications in their original containers, clearly labeled. Carry a signed, dated letter from the primary physician describing all medical conditions and listing all medications, including generic names. If carrying syringes or needles, be sure to carry a physician's letter documenting their medical necessity.Pack all medications in hand luggage. Carry a duplicate supply in the checked luggage. If you wear glasses or contacts, bring an extra pair. If you have significant allergies or chronic medical problems, wear a medical alert bracelet.

Make sure your health insurance covers you for medical expenses abroad. If not, supplemental insurance for overseas coverage, including possible evacuation, should be seriously considered. If illness occurs while abroad, medical expenses including evacuation may run to tens of thousands of dollars. For a list of travel insurance and air ambulance companies, go to Medical Information for Americans Traveling Abroad on the U.S. State Department website. Bring your insurance card, claim forms, and any other relevant insurance documents. Before departure, determine whether your insurance plan will make payments directly to providers or reimburse you later for overseas health expenditures. The Medicare and Medicaid programs do not pay for medical services outside the United States.

Pack a personal medical kit, customized for your trip (see description). Take appropriate measures to prevent motion sickness and jet lag, discussed elsewhere. On long flights, be sure to walk around the cabin, contract your leg muscles periodically, and drink plenty of fluids to prevent blood clots in the legs. For those at high risk for blood clots, consider wearing compression stockings.

Avoid contact with stray dogs and other animals. If an animal bites or scratches you, clean the wound with large amounts of soap and water and contact local health authorities immediately. Wear sun block regularly when needed. Use condoms for all sexual encounters. Ride only in motor vehicles with seat belts. Do not ride on motorcycles.

Revisions

<categorytext name="GeneralAdvice">
 
 General advice
 
 Bring adequate supplies of all medications in their original containers, clearly labeled. Carry a signed, dated letter from the primary physician describing all medical conditions and listing all medications, including generic names. If carrying syringes or needles, be sure to carry a physician's letter documenting their medical necessity.Pack all medications in hand luggage. Carry a duplicate supply in the checked luggage. If you wear glasses or contacts, bring an extra pair. If you have significant allergies or chronic medical problems, wear a medical alert bracelet. 
 Make sure your health insurance covers you for medical expenses abroad. If not, supplemental insurance for overseas coverage, including possible evacuation, should be seriously considered. If illness occurs while abroad, medical expenses including evacuation may run to tens of thousands of dollars. For a list of travel insurance and air ambulance companies, go to Medical Information for Americans Traveling Abroad on the U.S. State Department website. Bring your insurance card, claim forms, and any other relevant insurance documents. Before departure, determine whether your insurance plan will make payments directly to providers or reimburse you later for overseas health expenditures. The Medicare and Medicaid programs do not pay for medical services outside the United States.
 Pack a personal <a href="/mdtravelhealth/resource/medical_kit">medical kit</a>, customized for your trip (see description). Take appropriate measures to prevent <a href="/mdtravelhealth/resource/motion_sickness">motion sickness</a> and <a href="/mdtravelhealth/resource/jet_lag">jet lag</a>, discussed elsewhere. On long flights, be sure to walk around the cabin, contract your leg muscles periodically, and drink plenty of fluids to prevent <a href="/mdtravelhealth/resource/deep_vein_thrombosis">blood clots</a> in the legs. For those at high risk for blood clots, consider wearing compression stockings.
 Avoid contact with stray dogs and other animals. If an animal bites or scratches you, clean the wound with large amounts of soap and water and contact local health authorities immediately. Wear sun block regularly when needed. Use condoms for all sexual encounters. Ride only in motor vehicles with seat belts. Do not ride on motorcycles. 
</categorytext>

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Ambulance You can't Edit

9

Ambulance and Emergency Services

Ambulance services in Bolivia are not dependable. A taxi may get you faster to the emergency room than an ambulance. For an emergency in La Paz, call SAMI ambulance (tel. 706-1656, -57, 279-9911) or go directly to the Clinica del Sur emergency room (Hernando Siles Ave. corner, Calle 7 – OBRAJES, tel. 278-4001, -02, -03). In Cochabamba, call the MEDICAR Emergency Ambulance Service (tel. 453-3222) or go to the emergency room of Centro Medico Boliviano Beluga (Antezana St. between Venezuela and Paccieri N-O455, tel. 422-9407, 425-0928, 423-1403). In Santa Cruz, call the Clinica Foianini ambulance at 336-2211 or go to the Clinica Foianini emergency room at Av. Irala 468 (tel. 336-6001, -02, -03, -04).

Medical Facilities You can't Edit

10

Medical facilities

Medical care in the larger cities is generally adequate for routine problems, but the quality is highly variable. In rural areas, good medical care may be entirely unobtainable. For non-emergency medical problems, you can find the names of physicians, dentists, hospitals, and laboratories on the U.S. Embassy website at http://lapaz.usembassy.gov/english/consular/medicalresources.htm. Many travelers go to the High Altitude Pathology Institute Clinica IPPA (Av. Saavedra 2302, La Paz; tel. 591-2-224-5394; website http://www.altitudeclinic.com), which specializes in high altitude disease and other travel-related illnesses. Many doctors and hospitals expect payment in cash, regardless of whether you have travel health insurance. Serious medical problems will require air evacuation to a country with state-of-the-art medical facilities.

Pharmacies You can't Edit

11

Pharmacies

Most medications are available, but some are not manufactured according to international standards. Not all pharmacies are staffed by trained personnel. Make sure all pharmaceuticals that you buy are made by international drug companies with established reputations and that the pharmacy is staffed by a pharmacist, not just a clerk. In La Paz, the following pharmacies are generally reliable:

Carlos V (Mercurio Bldg, 6 de Agosto/Cordero St; P.O.C. Dra. Luz Clavijo de Salamanca; tel. 243-0490)
Gloria (Av. Garcia Lanza/Calle 16, Achumani; P.O.C. Dra. Gloria Helguero; tel. 271-1501/271-3030)

Blood Supply You can't Edit

12

Blood supply

Screening for hepatitis B, hepatitis C, and Chagas disease remains inadequate. More than one in ten blood donors is paid, a relatively high number (blood from voluntary donors is generally thought to be safer). Transfusions in Bolivia should be avoided if at all possible.

Adjustingto Altitude You can't Edit

13

Adjusting to high altitude

(reproduced from the U.S. Embassy in La Paz)

Approximately 25% of people experience an unpleasant period of acclimatization after they arrive in La Paz. This usually lasts for a few days, until the body adjusts to the altitude. Normal adjustment symptoms include mild headache, lack of energy and appetite, mild nausea, dizziness, lightheadedness, and insomnia. Symptoms that may indicate that you need urgent medical care include severe fatigue, a severe headache, shortness of breath (especially if it continues at rest), vomiting, onset of a cough, lack of coordination, and confusion. If you are experiencing these symptoms, please call the Health Unit during office hours or the Duty Nurse after hours.

To ease your adjustment to high altitude, we recommend the following:

Take Diamox 125mg by mouth twice a day for two days before the flight and for three days after arrival. If you are severely allergic to sulfa, you may find Ginkgo Biloba to be helpful. Dexamethasone may also be prescribed.
Drink plenty of fluids. Water, Gatorade, Koolaid, and herbal teas (sweetened) are especially helpful. Avoid drinking alcoholic, caffeinated, and carbonated drinks for one week. Allow fizzy drinks to go flat before drinking.
Eat frequent, small, carbohydrate-loaded meals (pasta, potatoes, rice, and non-chocolate candy). Avoid eating heavy, high fat meals, especially at night.
Limit your activities for the first few days. Avoid doing a lot of walking or lifting. Children and young athletic adults are more likely to develop serious complications, so guard them against over-activity until they are well adapted. On the other hand, lying down and resting too long may actually increase the headache.
Medications: Take two tablets of Tylenol, with a full glass of water, every four hours for headache. Camomille (manzanilla) and coca tea may help alleviate nausea.
Avoid drugs such as alcohol, sleeping pills, and narcotics that can interfere with your breathing. Avoid "soroche remedies" such as "Coramine" and "Micoren." These can increase adjustment symptoms. Avoid smoking for a week.
Avoid eating or drinking contaminated food or water. Do not drink the water from the faucet! Drink only bottled or distilled water. Don't eat raw fruits or vegetables that you have not treated with a bleach solution. Order your meats well-done and served hot.

Revisions

<categorytext name="AdjustingtoAltitude">
 
 Adjusting to high altitude
 
 (reproduced from the U.S. Embassy in La Paz)
 Approximately 25% of people experience an unpleasant period of acclimatization after they arrive in La Paz. This usually lasts for a few days, until the body adjusts to the altitude. Normal adjustment symptoms include mild headache, lack of energy and appetite, mild nausea, dizziness, lightheadedness, and insomnia. Symptoms that may indicate that you need urgent medical care include severe fatigue, a severe headache, shortness of breath (especially if it continues at rest), vomiting, onset of a cough, lack of coordination, and confusion. If you are experiencing these symptoms, please call the Health Unit during office hours or the Duty Nurse after hours.
 
 To ease your adjustment to high altitude, we recommend the following:
 Take Diamox 125mg by mouth twice a day for two days before the flight and for three days after arrival. If you are severely allergic to sulfa, you may find Ginkgo Biloba to be helpful. Dexamethasone may also be prescribed. Drink plenty of fluids. Water, Gatorade, Koolaid, and herbal teas (sweetened) are especially helpful. Avoid drinking alcoholic, caffeinated, and carbonated drinks for one week. Allow fizzy drinks to go flat before drinking. Eat frequent, small, carbohydrate-loaded meals (pasta, potatoes, rice, and non-chocolate candy). Avoid eating heavy, high fat meals, especially at night. Limit your activities for the first few days. Avoid doing a lot of walking or lifting. Children and young athletic adults are more likely to develop serious complications, so guard them against over-activity until they are well adapted. On the other hand, lying down and resting too long may actually increase the headache. Medications: Take two tablets of Tylenol, with a full glass of water, every four hours for headache. Camomille (manzanilla) and coca tea may help alleviate nausea. Avoid drugs such as alcohol, sleeping pills, and narcotics that can interfere with your breathing. Avoid "soroche remedies" such as "Coramine" and "Micoren." These can increase adjustment symptoms. Avoid smoking for a week. Avoid eating or drinking contaminated food or water. Do not drink the water from the faucet! Drink only bottled or distilled water. Don't eat raw fruits or vegetables that you have not treated with a bleach solution. Order your meats well-done and served hot. 
 <section name="AdjustingtoAltitude">
 <sectiontext name="AdjustingtoAltitude"></sectiontext>
 </section>
</categorytext>

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High Altitude You can't Edit

14

High-altitude health risks

(reproduced from the U.S. State Dept. Consular Information Sheet)

Prior to departing the U.S. for high-altitude locations over 10,000 feet above sea level, such as La Paz, travelers may wish to discuss the trip with their personal physician and request information on specific recommendations concerning medication and lifestyle tips at high altitudes.

Official U.S. Government travelers to La Paz are provided with the following information: The altitude of La Paz is over 13,000 feet (4,000 meters) above sea level. The altitude alone poses a serious risk of illness, hospitalization, and even death, if you have a medical condition that affects blood circulation or breathing. The State Department's Office of Medical Services does not allow any official U.S. Government travelers to visit La Paz if they have any of the following:

- Sickle cell anemia or sickle cell trait: 30 percent of persons with sickle cell trait are likely to have a crisis at elevations of more than 8,000 feet.

- Heart disease: A man 45 years or older, or a woman 55 years or older, who has two of the following risk factors (hypertension, diabetes, cigarette smoking, or elevated cholesterol) should have a stress EKG and a cardiological evaluation before the trip.

- Lung disease: Anyone with asthma and on maximum dosage of medication for daily maintenance, or anyone who has been hospitalized for asthma within the last year should not come to La Paz.

All people, even healthy and fit persons, will feel symptoms of hypoxia (lack of oxygen) upon arrival at high altitude. Most people will have increased respiration and increased heart rate. Many people will have headaches, difficulty sleeping, lack of appetite, minor gastric and intestinal upsets, and mood changes. To help prevent these complications:

- Consider taking acetazolamide (Diamox) 125 mg. twice a day, starting two days before traveling, on the day of the trip, and two to three days after arriving at high altitude. This medication inhibits the enzyme carbonic anhydrase, has a slight diuretic effect, and stimulates respiration. It is available only by prescription in the U.S. Pregnant women and nursing mothers cannot take Diamox. If you have a severe allergy to sulfa, you may not be able to take Diamox.

- Avoid alcohol and smoking for at least one week after arrival in La Paz.

- Limit physical activity for the first 36 to 48 hours after arrival in La Paz.

For those with diabetes, only the blood glucose meter called One Touch II works properly at altitudes over 6,000 feet. Other models give incorrect readings of blood sugar levels.

Revisions

<categorytext name="HighAltitude">
 
 High-altitude health risks
 
 (reproduced from the U.S. State Dept. Consular Information Sheet)
 Prior to departing the U.S. for high-altitude locations over 10,000 feet above sea level, such as La Paz, travelers may wish to discuss the trip with their personal physician and request information on specific recommendations concerning medication and lifestyle tips at high altitudes. 
 Official U.S. Government travelers to La Paz are provided with the following information: The altitude of La Paz is over 13,000 feet (4,000 meters) above sea level. The altitude alone poses a serious risk of illness, hospitalization, and even death, if you have a medical condition that affects blood circulation or breathing. The State Department's Office of Medical Services does not allow any official U.S. Government travelers to visit La Paz if they have any of the following: 
 - Sickle cell anemia or sickle cell trait: 30 percent of persons with sickle cell trait are likely to have a crisis at elevations of more than 8,000 feet. 
 - Heart disease: A man 45 years or older, or a woman 55 years or older, who has two of the following risk factors (hypertension, diabetes, cigarette smoking, or elevated cholesterol) should have a stress EKG and a cardiological evaluation before the trip. 
 - Lung disease: Anyone with asthma and on maximum dosage of medication for daily maintenance, or anyone who has been hospitalized for asthma within the last year should not come to La Paz. 
 All people, even healthy and fit persons, will feel symptoms of hypoxia (lack of oxygen) upon arrival at high altitude. Most people will have increased respiration and increased heart rate. Many people will have headaches, difficulty sleeping, lack of appetite, minor gastric and intestinal upsets, and mood changes. To help prevent these complications: 
 - Consider taking acetazolamide (Diamox) 125 mg. twice a day, starting two days before traveling, on the day of the trip, and two to three days after arriving at high altitude. This medication inhibits the enzyme carbonic anhydrase, has a slight diuretic effect, and stimulates respiration. It is available only by prescription in the U.S. Pregnant women and nursing mothers cannot take Diamox. If you have a severe allergy to sulfa, you may not be able to take Diamox. 
 - Avoid alcohol and smoking for at least one week after arrival in La Paz. 
 - Limit physical activity for the first 36 to 48 hours after arrival in La Paz. 
 For those with diabetes, only the blood glucose meter called One Touch II works properly at altitudes over 6,000 feet. Other models give incorrect readings of blood sugar levels. 
 <section name="HighAltitude">
 <sectiontext name="HighAltitude"></sectiontext>
 </section>
</categorytext>

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Health Advice La Paz You can't Edit

15

Health advice for La Paz

(reproduced from the U.S. Embassy in La Paz)

La Paz is the highest capital city in the world and a wonderful place to visit. However, sudden ascent to La Paz's 10,000 to 13,000 feet can cause some problems for even healthy people. Please carefully read the following advice before coming to La Paz.

Anyone with high blood pressure, diabetes, angina, heart disease, anemia, hemaglobinopathies (e.g., sickle cell disease and trait), significant obesity, asthma, or emphysema must see their physician for clearance to come to altitude. Those with respiratory infections such as severe colds, bronchitis, or pneumonia should delay travel to La Paz until they have recovered. Pregnant women should consider delaying travel until after delivery or they should ascend gradually to altitude.

All visitors who fly into La Paz should take medication to prevent altitude sickness. The La Paz Health Unit frequently admits visitors to local hospitals for treatment of Acute Mountain Sickness, but rarely has to admit a visitor who is taking prophylaxis. Make sure your visit to La Paz is as productive as possible by taking a medication that will help you adjust to altitude quickly. Ask your doctor for a prescription. Acetazolamide (Diamox) is the drug of choice. The prophylactic dose for adults is 125mg twice a day, beginning 24 hours before coming to La Paz until two days after arrival. Children over the age of five should take 5mg/Kg of body weight every 12 hours. Acetazolamide is a sulfa-based medication and should not be taken by anyone with a severe sulfa allergy. It is also contraindicated in pregnancy. Common side effects include numbness and tingling of hands and feet and frequent urination. These symptoms are minor, short-lived and occur to show you that the medicine is working. If you cannot take Diamox due to a sulfa allergy, dexamethasone (4mg every 12 hours) is a good alternative.

To prevent the high-altitude headache that 50% of all new arrivals experience, take one aspirin (325mg) every four hours, starting shortly before you arrive, for a total of three doses. Drink plenty of non-alcoholic and non-caffeinated fluids (fruit juices or water) on the airplane. You will have fewer adjustment symptoms if you are well hydrated when you arrive. If you have a meal choice on the plane, chose a high-carbohydrate/low-fat meal (usually pasta). Digestion takes oxygen and a high fat meal is harder to digest.

Once you arrive in La Paz, take it easy. Avoid doing a lot of walking or lifting. Don t plan on exercising for several weeks. Drink plenty of fluids. Water, Gatorade, Koolaid, and herbal teas (sweetened) are especially helpful. Eat frequent, small, carbohydrate-loaded meals (pasta, potatoes, rice, and non-chocolate candy). Avoid eating heavy, high fat meals, especially at night.

Visitors to La Paz frequently develop severe bacterial diarrhea, often requiring hospitalization. Be smart! Don' t drink the tap water. Don' t eat salads or other raw fruits and vegetables. Order your meats well done and served hot. And don' t eat food from sidewalk vendors.

For more information on altitude adjustment go to www.high-altitude-medicine.com

Revisions

<categorytext name="HealthAdviceLaPaz">
 
 Health advice for La Paz 
 
 (reproduced from the U.S. Embassy in La Paz) 
 La Paz is the highest capital city in the world and a wonderful place to visit. However, sudden ascent to La Paz's 10,000 to 13,000 feet can cause some problems for even healthy people. Please carefully read the following advice before coming to La Paz.
 Anyone with high blood pressure, diabetes, angina, heart disease, anemia, hemaglobinopathies (e.g., sickle cell disease and trait), significant obesity, asthma, or emphysema must see their physician for clearance to come to altitude. Those with respiratory infections such as severe colds, bronchitis, or pneumonia should delay travel to La Paz until they have recovered. Pregnant women should consider delaying travel until after delivery or they should ascend gradually to altitude. 
 All visitors who fly into La Paz should take medication to prevent altitude sickness. The La Paz Health Unit frequently admits visitors to local hospitals for treatment of Acute Mountain Sickness, but rarely has to admit a visitor who is taking prophylaxis. Make sure your visit to La Paz is as productive as possible by taking a medication that will help you adjust to altitude quickly. Ask your doctor for a prescription. Acetazolamide (Diamox) is the drug of choice. The prophylactic dose for adults is 125mg twice a day, beginning 24 hours before coming to La Paz until two days after arrival. Children over the age of five should take 5mg/Kg of body weight every 12 hours. Acetazolamide is a sulfa-based medication and should not be taken by anyone with a severe sulfa allergy. It is also contraindicated in pregnancy. Common side effects include numbness and tingling of hands and feet and frequent urination. These symptoms are minor, short-lived and occur to show you that the medicine is working. If you cannot take Diamox due to a sulfa allergy, dexamethasone (4mg every 12 hours) is a good alternative. 
 To prevent the high-altitude headache that 50% of all new arrivals experience, take one aspirin (325mg) every four hours, starting shortly before you arrive, for a total of three doses. Drink plenty of non-alcoholic and non-caffeinated fluids (fruit juices or water) on the airplane. You will have fewer adjustment symptoms if you are well hydrated when you arrive. If you have a meal choice on the plane, chose a high-carbohydrate/low-fat meal (usually pasta). Digestion takes oxygen and a high fat meal is harder to digest. 
 Once you arrive in La Paz, take it easy. Avoid doing a lot of walking or lifting. Don t plan on exercising for several weeks. Drink plenty of fluids. Water, Gatorade, Koolaid, and herbal teas (sweetened) are especially helpful. Eat frequent, small, carbohydrate-loaded meals (pasta, potatoes, rice, and non-chocolate candy). Avoid eating heavy, high fat meals, especially at night. 
 Visitors to La Paz frequently develop severe bacterial diarrhea, often requiring hospitalization. Be smart! Don' t drink the tap water. Don' t eat salads or other raw fruits and vegetables. Order your meats well done and served hot. And don' t eat food from sidewalk vendors. 
 For more information on altitude adjustment go to www.high-altitude-medicine.com
</categorytext>

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Health Advice Santa Cruz You can't Edit

16

Health advice for Santa Cruz

(reproduced from the U.S. Embassy in La Paz)

CITY: SANTA CRUZ

COUNTRY: BOLIVIA

ALTITUDE: 400 meters

HEALTH CONCERNS:

Although most visitors remain healthy during their stay in Santa Cruz, bacterial enteritis (including salmonella, typhoid, and cholera), hepatitis, tuberculosis, intestinal parasites, hantavirus, dengue, and rabies are important health concerns. In the areas surrounding Santa Cruz (but not within the city), yellow fever and malaria are two common mosquito-borne diseases.HEALTH PRECAUTIONS:

Water is not potable at the tap. Drink only bottled water and avoid adding ice to your drinks. Eat only fruits and vegetables that can be peeled or cooked.

Apply mosquito repellent if you notice the presence of mosquitoes or if you have traveled to areas outside of Santa Cruz. If you will be traveling to surrounding areas for several days, consider taking medication for malaria prophylaxis (chloroquine, doxycycline, or mefloquine). Make sure that your yellow fever vaccination is current (valid for 10 years).

Do not approach stray animals. In addition to other risks, stray animals may have rabies.

MEDICAL RESOURCES:

Clinica Foianini is a 35-bed hospital with a well-equipped emergency room, operating room, and intensive care unit. The emergency room is staffed 24 hours a day by a surgeon and a pediatrician, each specialized in emergency care. The hospital also has an ambulance service that can be reached at telephone # 362211...

In case of an emergency, go directly to Clinica Foianini's emergency room, Av. Irala #468... Depending on the type of emergency, go to the hospital by private vehicle or taxi, call the Roving Patrol (tel. # 423369), or call the Clinica Foianini Ambulance Service (tel. # 362211)

TRAVEL TO LA PAZ:

Approximately 25% of people experience an unpleasant period of acclimatization (Acute Mountain Sickness) after they arrive in La Paz. Occasionally, this acclimatization can result in serious complications. Individuals with hypertension, diabetes, angina pectoris, asthma, emphysema, and blood diseases (like sickle cell disease and trait) should see their physician for clearance to come to altitude. If you have a respiratory illness, delay your arrival until improved.

All adults and children over the age of five traveling to La Paz should take the drug Diamox (acetazolamide) twice a day, beginning on the day of the flight and continuing for three days after arrival until improved. Diamox significantly reduces, and in most cases prevents, the symptoms of Acute Mountain Sickness. Diamox, however, contains sulfa and cannot be taken by those allergic to sulfa. Common side effects include numbness and tingling of hands and feet and frequent urination.

Revisions

<categorytext name="HealthAdviceSantaCruz">
 
 Health advice for Santa Cruz 
 
 (reproduced from the U.S. Embassy in La Paz) 
 CITY: SANTA CRUZ 
 COUNTRY: BOLIVIA 
 ALTITUDE: 400 meters
 HEALTH CONCERNS:
 Although most visitors remain healthy during their stay in Santa Cruz, bacterial enteritis (including salmonella, typhoid, and cholera), hepatitis, tuberculosis, intestinal parasites, hantavirus, dengue, and rabies are important health concerns. In the areas surrounding Santa Cruz (but not within the city), yellow fever and malaria are two common mosquito-borne diseases.HEALTH PRECAUTIONS:
 Water is not potable at the tap. Drink only bottled water and avoid adding ice to your drinks. Eat only fruits and vegetables that can be peeled or cooked.
 Apply mosquito repellent if you notice the presence of mosquitoes or if you have traveled to areas outside of Santa Cruz. If you will be traveling to surrounding areas for several days, consider taking medication for malaria prophylaxis (chloroquine, doxycycline, or mefloquine). Make sure that your yellow fever vaccination is current (valid for 10 years).
 Do not approach stray animals. In addition to other risks, stray animals may have rabies.
 MEDICAL RESOURCES:
 Clinica Foianini is a 35-bed hospital with a well-equipped emergency room, operating room, and intensive care unit. The emergency room is staffed 24 hours a day by a surgeon and a pediatrician, each specialized in emergency care. The hospital also has an ambulance service that can be reached at telephone # 362211...
 In case of an emergency, go directly to Clinica Foianini's emergency room, Av. Irala #468... Depending on the type of emergency, go to the hospital by private vehicle or taxi, call the Roving Patrol (tel. # 423369), or call the Clinica Foianini Ambulance Service (tel. # 362211)
 TRAVEL TO LA PAZ:
 Approximately 25% of people experience an unpleasant period of acclimatization (Acute Mountain Sickness) after they arrive in La Paz. Occasionally, this acclimatization can result in serious complications. Individuals with hypertension, diabetes, angina pectoris, asthma, emphysema, and blood diseases (like sickle cell disease and trait) should see their physician for clearance to come to altitude. If you have a respiratory illness, delay your arrival until improved.
 All adults and children over the age of five traveling to La Paz should take the drug Diamox (acetazolamide) twice a day, beginning on the day of the flight and continuing for three days after arrival until improved. Diamox significantly reduces, and in most cases prevents, the symptoms of Acute Mountain Sickness. Diamox, however, contains sulfa and cannot be taken by those allergic to sulfa. Common side effects include numbness and tingling of hands and feet and frequent urination.
</categorytext>

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Travel with children You can't Edit

17

Traveling with children

Make sure you have the names and contact information for qualified medical personnel in Bolivia before you go abroad (see the U.S. Embassy website).

In general, the recommendations for infants and young children are the same as those for adults, except that certain vaccines and medications should not be administered to this age group. Most importantly, yellow fever vaccine is not approved for use in those under age nine months. Unless there is an extraordinary need to do so, children less than nine months of age should not be brought to areas where yellow fever occurs.

The recommendations for malaria prophylaxis are the same for young children as for adults, except that (1) dosages are lower; and (2) doxycycline should be avoided. DEET-containing insect repellents are not advised for children under age two, so it's particularly important to keep children in this age group well-covered to protect them from mosquito bites.

Food and water precautions, which are recommended for all travelers, must be strictly followed at all times, because diarrhea is especially dangerous in this age group and because the vaccines for hepatitis A and typhoid fever are not approved for children less than two years of age.

All children should be up-to-date on routine childhood immunizations, as recommended by the American Academy of Pediatrics. Children who are 12 months or older should receive a total of 2 doses of MMR (measles-mumps-rubella) vaccine, separated by at least 28 days, before international travel. Children between the ages of 6 and 11 months should be given a single dose of measles vaccine. MMR vaccine may be given if measles vaccine is not available, though immunization against mumps and rubella is not necessary before age one unless visiting a country where an outbreak is in progress. Children less than one year of age may also need to receive other immunizations ahead of schedule (see the accelerated immunization schedule).

Revisions

<categorytext name="Travelwithchildren">
 
 Traveling with children
 
 Make sure you have the names and contact information for qualified medical personnel in Bolivia before you go abroad (see the U.S. Embassy website). 
 In general, the recommendations for infants and young children are the same as those for adults, except that certain vaccines and medications should not be administered to this age group. Most importantly, <a href="/mdtravelhealth/resource/yellow_fever">yellow fever</a> vaccine is not approved for use in those under age nine months. Unless there is an extraordinary need to do so, children less than nine months of age should not be brought to areas where yellow fever occurs.
 The recommendations for <a href="/mdtravelhealth/resource/malaria">malaria</a> prophylaxis are the same for young children as for adults, except that (1) dosages are lower; and (2) doxycycline should be avoided. DEET-containing insect repellents are not advised for children under age two, so it's particularly important to keep children in this age group well-covered to protect them from mosquito bites.
 
 <a href="/mdtravelhealth/resource/food_water">Food and water precautions</a>, which are recommended for all travelers, must be strictly followed at all times, because diarrhea is especially dangerous in this age group and because the vaccines for <a href="/mdtravelhealth/resource/hepatitis_a">hepatitis A</a> and <a href="/mdtravelhealth/resource/typhoid_fever">typhoid fever</a> are not approved for children less than two years of age.
 All children should be up-to-date on routine childhood immunizations, as recommended by the <a href="http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5751a5.htm">American Academy of Pediatrics</a>. Children who are 12 months or older should receive a total of 2 doses of MMR (measles-mumps-rubella) vaccine, separated by at least 28 days, before international travel. Children between the ages of 6 and 11 months should be given a single dose of measles vaccine. MMR vaccine may be given if measles vaccine is not available, though immunization against mumps and rubella is not necessary before age one unless visiting a country where an outbreak is in progress. Children less than one year of age may also need to receive other immunizations ahead of schedule (see the accelerated immunization schedule). 
</categorytext>

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Travel and pregnancy You can't Edit

18

Travel and pregnancy

International travel should be avoided by pregnant women with underlying medical conditions, such as diabetes or high blood pressure, or a history of complications during previous pregnancies, such as miscarriage or premature labor. For pregnant women in good health, the second trimester (18–24 weeks) is probably the safest time to go abroad and the third trimester the least safe, since it's far better not to have to deliver in a foreign country.

Before departure, make sure you have the names and contact information for physicians, clinics, and hospitals where you can obtain emergency obstetric care if necessary (see the U.S. Embassy website). In general, pregnant women should avoid traveling to countries which do not have modern facilities for the management of premature labor and other complications of pregnancy.

Yellow fever vaccine, which consists of live virus, should not in general be given to pregnant women. Unless absolutely necessary, pregnant women should not travel to areas where yellow fever occurs.

Pregnant women should also avoid areas where malaria is transmitted. Malaria may cause life-threatening illness in both the mother and the unborn child. None of the currently available prophylactic medications is 100% effective. If travel to malarious areas is unavoidable, insect protection measures must be strictly followed at all times. The recommendations for DEET-containing insect repellents are the same for pregnant women as for other adults. Of the currently available drugs for malaria prophylaxis, Mefloquine (Lariam) may be given if necessary in the second and third trimesters, but should be avoided in the first trimester. There are no data regarding the safety of atovaquone/proguanil (Malarone) during pregnancy, so the drug should be avoided pending further information. Doxycycline may interfere with fetal bone development and should not be given during pregnancy.

Strict attention to food and water precautions is especially important for the pregnant traveler because some infections, such as listeriosis, have grave consequences for the developing fetus. Additionally, many of the medications used to treat travelers' diarrhea may not be given during pregnancy. Quinolone antibiotics, such as ciprofloxacin (Cipro) and levofloxacin (Levaquin), should not be given because of concern they might interfere with fetal joint development. Data are limited concerning trimethoprim-sulfamethoxazole, but the drug should probably be avoided during pregnancy, especially the first trimester. Options for treating travelers' diarrhea in pregnant women include azithromycin and third-generation cephalosporins. For symptomatic relief, the combination of kaolin and pectin (Kaopectate; Donnagel) appears to be safe, but loperamide (Imodium) should be used only when necessary. Adequate fluid intake is essential.

Travel to altitudes greater than 4000 meters (13,100 feet) should be avoided during pregnancy. During the third trimester and during high-risk pregnancies, travel should be limited to altitudes less than 2500 meters (8200 feet).

For a detailed discussion of managing pregnancy in Bolivia, go to the U.S. Embassy website.

Revisions

<categorytext name="Travelandpregnancy">
 
 Travel and pregnancy
 
 International travel should be avoided by pregnant women with underlying medical conditions, such as diabetes or high blood pressure, or a history of complications during previous pregnancies, such as miscarriage or premature labor. For pregnant women in good health, the second trimester (18–24 weeks) is probably the safest time to go abroad and the third trimester the least safe, since it's far better not to have to deliver in a foreign country.
 Before departure, make sure you have the names and contact information for physicians, clinics, and hospitals where you can obtain emergency obstetric care if necessary (see the U.S. Embassy website). In general, pregnant women should avoid traveling to countries which do not have modern facilities for the management of premature labor and other complications of pregnancy. 
 
 <a href="/mdtravelhealth/resource/yellow_fever">Yellow fever</a> vaccine, which consists of live virus, should not in general be given to pregnant women. Unless absolutely necessary, pregnant women should not travel to areas where yellow fever occurs.
 Pregnant women should also avoid areas where <a href="/mdtravelhealth/resource/malaria">malaria</a> is transmitted. Malaria may cause life-threatening illness in both the mother and the unborn child. None of the currently available prophylactic medications is 100% effective. If travel to malarious areas is unavoidable, insect protection measures must be strictly followed at all times. The recommendations for DEET-containing insect repellents are the same for pregnant women as for other adults. Of the currently available drugs for malaria prophylaxis, Mefloquine (Lariam) may be given if necessary in the second and third trimesters, but should be avoided in the first trimester. There are no data regarding the safety of atovaquone/proguanil (Malarone) during pregnancy, so the drug should be avoided pending further information. Doxycycline may interfere with fetal bone development and should not be given during pregnancy.
 Strict attention to <a href="/mdtravelhealth/resource/food_water">food and water precautions</a> is especially important for the pregnant traveler because some infections, such as listeriosis, have grave consequences for the developing fetus. Additionally, many of the medications used to treat travelers' diarrhea may not be given during pregnancy. Quinolone antibiotics, such as ciprofloxacin (Cipro) and levofloxacin (Levaquin), should not be given because of concern they might interfere with fetal joint development. Data are limited concerning trimethoprim-sulfamethoxazole, but the drug should probably be avoided during pregnancy, especially the first trimester. Options for treating travelers' diarrhea in pregnant women include azithromycin and third-generation cephalosporins. For symptomatic relief, the combination of kaolin and pectin (Kaopectate; Donnagel) appears to be safe, but loperamide (Imodium) should be used only when necessary. Adequate fluid intake is essential. 
 Travel to altitudes greater than 4000 meters (13,100 feet) should be avoided during pregnancy. During the third trimester and during high-risk pregnancies, travel should be limited to altitudes less than 2500 meters (8200 feet).	
 For a detailed discussion of managing pregnancy in Bolivia, go to the U.S. Embassy website.
</categorytext>

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Maps You can't Edit

19

Maps

Helpful maps are available in the University of Texas Perry-Castaneda Map Collection and the United Nations map library. If you have the name of the town or city you'll be visiting and need to know which state or province it's in, you might find your answer in the Getty Thesaurus of Geographic Names.

Embassy You can't Edit

20

Embassy/Consulate Location

(reproduced from the U.S. State Dept. Consular Information Sheet)

Americans living or traveling in Bolivia are encouraged to register with the U.S. Embassy in La Paz, the Consular Agency in Santa Cruz or Cochabamba, or through the State Department's travel registration website, https://travelregistration.state.gov/, and to obtain updated information on travel and security within Bolivia. Americans without Internet access may register directly with the U.S. Embassy or Consular Agency. By registering, American citizens make it easier for the Embassy or Consular Agency to contact them in case of emergency. The U.S. Embassy is located at 2780 Avenida Arce in La Paz; telephone (591-2) 2433-812 during business hours 8:30 a.m.-5:30 p.m., or (591-2) 2430-251 for after-hours emergencies; fax (591-2) 2433-854; Internet http://bolivia.usembassy.gov/. Questions should be directed to the email address consularlapaz@state.gov. The U.S. Consular Agencies in Santa Cruz and Cochabamba, which are open weekday mornings from 9: 00 a.m. – 12:00 noon, excluding U.S. and Bolivian holidays. The Consular Agency in Santa Cruz is located at 146 Avenida Roque Aguilera (Tercer Anillo); telephone (591-3) 351-3477, 351-3479, or 351-3480; fax (591-3) 351-3478. The Consular Agency in Cochabamba is located at Avenida Oquendo 654, Torres Sofer, room 601; telephone (591-4) 411-6313; fax (591-4) 425 -6714.

Revisions

<categorytext name="Embassy">
 
 Embassy/Consulate Location
 
 (reproduced from the U.S. State Dept. Consular Information Sheet)
 Americans living or traveling in Bolivia are encouraged to register with the U.S. Embassy in La Paz, the Consular Agency in Santa Cruz or Cochabamba, or through the <a href="https://travelregistration.state.gov">State Department's travel registration website</a>, https://travelregistration.state.gov/, and to obtain updated information on travel and security within Bolivia. Americans without Internet access may register directly with the U.S. Embassy or Consular Agency. By registering, American citizens make it easier for the Embassy or Consular Agency to contact them in case of emergency. The U.S. Embassy is located at 2780 Avenida Arce in La Paz; telephone (591-2) 2433-812 during business hours 8:30 a.m.-5:30 p.m., or (591-2) 2430-251 for after-hours emergencies; fax (591-2) 2433-854; Internet http://bolivia.usembassy.gov/. Questions should be directed to the email address consularlapaz@state.gov. The U.S. Consular Agencies in Santa Cruz and Cochabamba, which are open weekday mornings from 9: 00 a.m. – 12:00 noon, excluding U.S. and Bolivian holidays. The Consular Agency in Santa Cruz is located at 146 Avenida Roque Aguilera (Tercer Anillo); telephone (591-3) 351-3477, 351-3479, or 351-3480; fax (591-3) 351-3478. The Consular Agency in Cochabamba is located at Avenida Oquendo 654, Torres Sofer, room 601; telephone (591-4) 411-6313; fax (591-4) 425 -6714. 
</categorytext>

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21

Safety information

For information on safety and security, go to the U.S. Department of State, United Kingdom Foreign and Commonwealth Office, Foreign Affairs Canada, and the Australian Department of Foreign Affairs and Trade.

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