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Costa Rica
Summary of recommendationsMedicationsImmunizations
Recent outbreaksOther infectionsFood and water precautions
Insect and Tick ProtectionGeneral adviceAmbulance and Emergency Services
Medical facilitiesPharmaciesTraveling with children
Travel and pregnancyMapsEmbassy/Consulate Location
Safety information

 

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Summary of recommendations:

All travelers should visit either their personal physician or a travel health clinic 4-8 weeks before departure.

Malaria: Prophylaxis with chloroquine, Lariam (mefloquine), Malarone (atovaquone/proguanil), doxycyline, or primaquine is recommended for Limon province, but not Limon City.
Vaccinations:

Hepatitis A

Recommended for all travelers

Typhoid

Recommended for all travelers

Hepatitis B

Recommended for all travelers

Yellow fever

Required for travelers arriving from a yellow-fever-infected country in Africa or the Americas (with the exception of Argentina, Panama, and Trinidad and Tobago) and for travelers who have been in transit more than 12 hours in an airport located in a country with risk of yellow fever transmission. Not recommended otherwise.

Measles, mumps, rubella (MMR)

Two doses recommended for all travelers born after 1956, if not previously given

Tetanus-diphtheria

Revaccination recommended every 10 years

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 Costa Rica: prophylaxis is recommended for Limon province, but not Limon City. The risk is greatest in the cantons of Matina and Talamanca.

For many years, the drug of choice has been chloroquine, which is inexpensive and generally well-tolerated. The recommended dosage is 500 mg weekly, starting one-to-two weeks before arrival and continuing through the trip and for four weeks after departure. Chloroquine may cause mild adverse reactions, including gastrointestinal disturbance, headache, dizziness, blurred vision, and itching, but severe reactions are uncommon. Other choices include mefloquine (Lariam), atovaquone/proguanil (Malarone)(PDF), doxycycline, and primaquine. 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. 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. Primaquine may cause hemolytic anemia in those with G6PD deficiency, so a blood test documenting normal G6PD levels must be obtained before starting primaquine. In those with normal G6PD levels, the main side-effect of primaquine is gastrointestinal disturbance, which can be minimized by taking the medication with food. Insect protection measures are essential, as below.

For other parts of the country, where malaria is rare, insect protection measures are advised, but malaria medications are not recommended.

For further information about malaria in Costa Rica, including maps showing the risk of malaria in different parts of the country, go to the World Health Organization and the Pan American Health Organization.

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Immunizations

The following are the recommended vaccinations for Costa Rica.

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. 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.

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.

Yellow fever vaccine is required for travelers arriving from a country in Africa or the Americas with risk of yellow fever transmission, with the exception of Argentina, Panama, and Trinidad and Tobago, and for travelers who have been in transit more than 12 hours in an airport located in a country with risk of yellow fever transmission. The vaccine is not recommended or required otherwise. 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. The vaccine should not in general be given to those who are younger than six months of age, immunocompromised, or allergic to eggs (since the vaccine is produced in chick embryos). It should also not be given to those with a malignant neoplasm and those with a history of thymus disease or thymectomy. Caution should be exercised before giving the vaccine to those who are between the ages of 6 and 8 months, age 60 years or older, pregnant, or breastfeeding. Reactions to the vaccine, which are generally mild, 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.

All travelers should be up-to-date on routine immunizations, including

  • Tetanus-diphtheria vaccine (recommended for all travelers who have not received a tetanus-diphtheria immunization within the last 10 years.)
  • Measles vaccine (recommended for any traveler born after 1956 who does not have either a history of two documented measles immunizations or a blood test showing immunity. Many adults who had only one vaccination show immunity when tested and do not need the second vaccination. Measles vaccine should not be given to pregnant or severely immunocompromised individuals.)
  • Varicella (chickenpox) vaccine (recommended for any international traveler over one year of age who does not have either a history of documented chickenpox or a blood test showing immunity. Many people who believe they never had chickenpox show immunity when tested and do not need the vaccine. Varicella vaccine should not be given to pregnant or immunocompromised individuals.)

Cholera vaccine is not recommended. No cases of cholera have been reported since 1997.

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.

Rabies vaccine is not recommended. Only two cases of rabies have been recorded in the last 30 years. For further information, go to Emerging Infectious Diseases.

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Recent outbreaks

Outbreaks of dengue fever have been reported annually from Costa Rica since 1993. An outbreak was reported from Limon province in August 2011, causing approximately 5000 cases. Dengue fever is a flu-like illness which may be complicated by hemorrhage or shock. The disease 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 strongly advised, as outlined below.

An outbreak of malaria was reported in November 2006 from the province of Limon, chiefly the town of Batan on the Caribbean slope. The cases were caused by Plasmodium falciparum, which causes more severe disease and is not generally seen in Costa Rica (see ProMED-mail; November 16, 2006). All travelers to Limon province, except Limon City, should take chloroquine once weekly and follow insect protection measures to prevent malaria.

For the year 2007, more than 26,000 cases and eight deaths were recorded, mainly from the provinces of Guanacaste and Puntarenas, both on the Pacific coast, and the province of Limon on the Caribbean coast. A major dengue outbreak was reported in the summer of 2005, resulting in more than 30,000 cases by late October, chiefly from the central Pacific area and the Atlantic coast. Several cases were identified in American travelers. The outbreak was related to heavy rainfalls, which led to an increase in the mosquito population. Another major outbreak occurred in 2003, when 19,700 people were affected.

An outbreak of an intestinal illness characterized by vomiting, diarrhea, headaches and fever was reported from San Jose in mid-July 2001. More than 2500 people were affected. The outbreak appears to have been related to contamination of the local water supply. The cause of the illness has not been determined, though shigellosis is suspected. Although local authorities have announced that the water supply is now safe, it would be prudent not to drink tap water unless it is boiled, filtered, or chemically disinfected. For further information, see the U.S. Embassy website.

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Other infections

For a detailed weekly update on communicable diseases in Costa Rica, including malaria, dengue fever, cholera, meningococcal meningitis, leptospirosis, and rabies, go to the Ministry of Health (Ministerio de Salud). For an overview of public health in Costa Rica, go to the Pan-American Health Organization.

An outbreak of leptospirosis was reported in 1996 among whitewater rafters in Costa Rica. Leptospirosis is transmitted to humans by exposure to water contaminated by the urine of infected animals. In Costa Rica, the chief animal reservoirs are rats, pigs, goats and cattle. Symptoms may include fever, chills, headache, muscle aches, joint pains, conjunctivitis, and rash. Travelers who participate in activities which place them at risk for leptospirosis, such as swimming, wading, or rafting in potentially contaminated lakes or rivers, should consider taking doxycycline 200 mg once weekly as prophylaxis.

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.

Other infections include

  • Chagas disease (American trypanosomiasis) (rural areas, chiefly Alajuela, Liberia, and Puntarenas; transmitted by reduviid bugs in substandard housing)
  • Cutaneous and mucocutaneous leishmaniasis (occurs chiefly in newly-cleared forest or areas of secondary growth; transmitted by sandflies)
  • Leptospirosis (largest number of cases reported from Limon, Turrialba, San Carlos, and Golfito; most cases have occurred in cattle-raising areas in the northwest; cases also reported among residents of Puerto Limon who have bathed in local streams)
  • Coccidioidomycosis (arid areas)
  • Lymphatic filariasis (small number of cases reported from Puerto Limon)
  • Venezuelan equine encephalitis (transmitted by mosquitoes)
  • Rocky Mountain spotted fever
  • Tick-borne relapsing fever
  • Fascioliasis
  • Paragonimiasis (oriental lung fluke) (rare)

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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. Some types of fish may contain poisonous biotoxins even when cooked. Barracuda in particular should never be eaten. Other fish that may contain toxins include red snapper, grouper, amberjack, sea bass, and a large number of tropical reef fish.

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.

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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 accomodation 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.

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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.

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Ambulance and Emergency Services

For a medical emergency in Costa Rica, call Red Cross Ambulance at 911, 128, or 221-5818. For a private ambulance, call Clinica Biblica at 257-0466. For a pediatric emergency, call Hospital Nacional de Ninos at 222-0122. The best-equipped ambulances are called “unidad avanzada.”

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Medical facilities

Good medical care is available in San Jose, but may be limited elsewhere. Most travelers go to one of the private hospitals, usually Hospital Clinica Biblica (Calle central y primera, Avenidas 14 16, Apartado 1307-1000, San José; tel. 506-522-1000; website http://www.clinicabiblica.com) or Hospital Cima San Jose (located 500 m west of the tollbooths on Prospero Fernández Freeway; tel. 506-208-1000; emergency tel. 506-208-1144; website http://www.hospitalsanjose.net; affiliated with Baylor University Medical Center, Dallas, Texas). Both are relatively small, but include a 24-hour emergency room, an intensive care unit, surgical and maternity services, CAT scan and MRI, and a 24-hour pharmacy. Both accept a number of U.S. health insurance plans. For a list of physicians, dentists, and other hospitals, go to the U.S. Embassy website at http://sanjose.usembassy.gov/medical.html. Most doctors and hospitals will 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.

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Pharmacies

Most prescription and over-the-counter medications are available in San Jose (many that require a prescription in North America are available over-the-counter). Most pharmacies are well-supplied and the quality is generally reliable. The Fischel pharmacies are well-regarded (main branch across from the main post office in San José, tel. 223-0909; branches around San José and in Heredia, Alajuela, Cartago and Puntarenas). For a 24-hour pharmacy, go to one of the private hospitals above or the Farmacia del Este in San Pedro (tel. 253-5121).

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Traveling with children

Before you leave, make sure you have the names and contact information for physicians, clinics, and hospitals where you can obtain emergency medical care if needed (see the U.S. Embassy website).

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).

The recommendations for malaria prophylaxis are the same for young children as for adults, except that the dosage of chloroquine is lower. DEET-containing insect repellents are not advised for children under age two, so it's especially important to keep children in this age group well-covered to protect them from mosquito bites.

When traveling with young children, be particularly careful about what you allow them to eat and drink (see food and water precautions), because diarrhea can be especially dangerous in this age group and because the vaccines for hepatitis A and typhoid fever, which are transmitted by contaminated food and water, are not approved for children under age two. Baby foods and cows' milk may not be available in developing nations. Only commercially bottled milk with a printed expiration date should be used. Young children should be kept well-hydrated and protected from the sun at all times.

Be sure to pack a medical kit when traveling with children. In addition to the items listed for adults, bring along plenty of disposable diapers, cream for diaper rash, oral replacement salts, and appropriate antibiotics for common childhood infections, such as middle ear infections.

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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.

As a rule, pregnant women should avoid visiting areas where malaria occurs. 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, chloroquine must be taken once a week and 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.

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.

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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.

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Embassy/Consulate Location

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

The Department of State invites American citizens to register their travel on the Internet-Based Registration System (IBRS) on line at: http://travelregistration.state.gov/ibrs/ or http://travel.state.gov. IBRS provides a convenient means for American citizens traveling or residing overseas to provide important contact data, useful in the event of emergencies, and to instantly receive up-to-the-minute travel and safety information for the regions or countries on their travel itineraries, on the website or through optional email lists. Even American citizens who have registered previously but did not do it using the IBRS online program may now wish to register online to update their records. U.S. citizens may also register in person at the Embassy, which is located in Pavas, San Jose, and may be reached at (506) 519-2000; the extension for the Consular Section is 2453. The Embassy is open Monday through Friday, and is closed on Costa Rican and U.S. holidays. For emergencies arising outside normal business hours, U.S. citizens may call (506) 220-3127 and ask for the duty officer.

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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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