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Update April 12, 2024

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Travel Advisory October 19, 2023

Brazil - level 2: exercise increased caution.

Reissued with updates to Country Summary.

Exercise increased caution in Brazil due to  crime . Some areas have increased risk. Read the entire Travel Advisory.

Do not travel to:

• Any areas within 150 km/100 miles of Brazil’s land borders with Venezuela, Colombia, Peru, Bolivia, Guyana, Suriname, French Guiana, and Paraguay due to  crime . (Note: This does not apply to the Foz do Iguacu National Park or Pantanal National Park.)
• Informal housing developments (commonly referred to in Brazil as favelas, vilas, comunidades, and/or conglomerados) at any time of day due to  crime  (see additional information below).
• Brasilia’s administrative regions (commonly known as “satellite cities”) of Ceilandia, Santa Maria, Sao Sebastiao, and Paranoa during non-daylight hours due to  crime  (see additional information below).

Country Summary:   Violent crime, such as murder, armed robbery, and carjacking, is common in urban areas, day and night. Gang activity and organized crime is widespread. Assaults, including with sedatives and drugs placed in drinks, are common. U.S. government personnel are discouraged from using municipal buses in all parts of Brazil due to an elevated risk of robbery and assault at any time of day, and especially at night.

If you decide to travel to Brazil: 

• Be aware of your surroundings.
• Do not physically resist any robbery attempt.
• Do not accept food or drinks from strangers.
• Use caution when walking or driving at night.
• Avoid going to bars or nightclubs alone.
• Avoid walking on beaches after dark.
• Do not display signs of wealth, such as wearing expensive watches or jewelry.
• Be extra vigilant when visiting banks or ATMs.
• Use caution at, or going to, major transportation centers or on public transportation, especially at night. Passengers face an elevated risk of robbery or assault using public, municipal bus transportation throughout Brazil.
• Use increased caution when hiking in isolated areas.
• Enroll in the Smart Traveler Enrollment Program (STEP) to receive Alerts and make it easier to locate you in an emergency.
• Follow the Department of State on Facebook and Twitter .
• Review the Country Security Report for Brazil.
• Prepare a contingency plan for emergency situations. Review the Traveler’s Checklist .
• Visit the CDC page for the latest Travel Health Information related to your travel.

International Borders – Level 4: Do Not Travel

U.S. government personnel are not permitted to travel to areas within 150 km/100 miles of the international land borders with Venezuela, Colombia, Peru, Bolivia, Guyana, Suriname, French Guiana, and Paraguay without advance approval from security officials due to crime. Travel to the Foz do Iguacu National Park and Pantanal National Park is permitted.

Visit our website for Travel to High-Risk Areas .

Informal Housing Developments (commonly known as “Favelas”) – Level 4: Do Not Travel

Do not travel to informal housing developments (commonly referred to in Brazil as favelas, vilas, comunidades, and/or conglomerados), even on a guided tour.  Neither the tour companies nor the police can guarantee your safety when entering these communities.  Even in these communities that the police or local governments deem safe, the situation can change quickly and without notice.  While some informal housing developments have clear boundaries or gates, or even names such as “favela”, “vila”, “comunidade”, or “conglomerado”, other such developments may be less obvious, and may be identified by crowded quarters, poorer conditions, and/or irregular construction.  In addition, exercise caution in areas surrounding these communities, as occasionally, inter-gang fighting and confrontations with police move beyond the confines of these communities.  Except under limited circumstances and with advance approval, U.S. government personnel are not permitted to enter any informal housing developments in Brazil. Read the Safety and Security Section on the  country information page  and consult the maps on the Embassy’s website for further information regarding favelas.

Visit our website for Travel High-Risk Areas .

Brasilia’s Administrative Regions (commonly known as “Satellite Cities”) – Level 4: Do Not Travel

Without advance approval from security officials, U.S. government personnel are not permitted to travel to Brasilia’s Administrative Regions of Ceilandia, Santa Maria, Sao Sebastiao, and Paranoa between the hours of 6:00 p.m. and 6:00 a.m. (non-daylight hours) due to crime.

Embassy Messages

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Quick Facts

Must be valid on the date of entry

One page required for entry stamp

Yes, beginning April 10, 2025

None required, but see Health section

More than 10,000 BR must be declared to Customs

Embassies and Consulates

U.S. Embassy Brasilia SES 801- Avenida das Nacoes, Lote 03 70403-900 - Brasilia, DF Brazil Telephone: 011-55-61-3312-7000 Emergency After-Hours Telephone: 011-55-61-3312-7400 Fax: (61) 3312-7651 Email: [email protected]

Embassy Branch Office in Belo Horizonte Avenida do Contorno, 4520 / 2nd floor – Funcionários 30110-028 Belo Horizonte, MG – Brazil Telephone: +55 (31) 3338-4000 E-mail: [email protected] Emergency After-Hours Telephone: Please contact the U.S. Embassy in Brasilia

Consular Agency in Brasilia’s Consular District Manaus Consular Agency Edificio Atrium, Suite 306 Rua Franco de Sá, 310 69.079-210 Manaus, AM Brazil Telephone: 011-55-92-3611-3333 Emergency After-Hours Telephone: Please contact the U.S. Embassy in Brasilia

U.S. Consulate General Porto Alegre Avenida Assis Brasil, 1889 Passo d' Areia 91010-004 - Porto Alegre, RS Brazil Telephone:  011-55-51-3345-6000 Email:  [email protected]

U.S. Consulate General Recife Rua Goncalves Maia, 163, Boa Vista 50070-125 - Recife, PE Brazil Telephone:  011-55-81-3416-3050 or 011-55-81-3416-3080 Emergency After-Hours Telephone:  011-55-81-3416-3060 or 011-55-81-9916-9470 Email:  [email protected]

Consular Agency in Recife’s Consular District U.S. Consular Agency Fortaleza Avenida Santos Dumont 2828, Aldeota, Suite 708 60150-162- Fortaleza, CE Brazil Telephone: 011-55-85-3223-4902 Emergency After-Hours Telephone: Please contact the U.S. Consulate General in Recife

U.S. Consulate General Rio de Janeiro Avenida Presidente Wilson, 147, Castelo 20030-020, Rio de Janeiro, RJ Brazil Telephone:  011-55-213823-2000 Emergency After-Hours Telephone:  011-55-21-3823-2029 Email:   [email protected]

Consular Agency in Rio de Janeiro’s Consular District U.S. Consular Agency Salvador da Bahia Avenida Tancredo Neves, 1632, Caminho das Arvores Salvador Trade Center-Torre Sul, Room 1401 41820-020 - Salvador, Bahia Brazil Telephone:  011-55-71-3113-2090/2091/2092 Emergency After-Hours Telephone:  Please contact the U.S. Consulate General in Rio de Janeiro: (21) 3823-2029

U.S. Consulate General Sao Paulo Rua Henri Dunant, 500 Chacara Santo Antonio 04709-110 - Sao Paulo, SP Brazil Telephone:  011-55-11-3250-5000 Emergency After-Hours Telephone:  011-55-11-3250-5373 Email:  [email protected]

Destination Description

See the Department of State’s Fact Sheet on Brazil for information on U.S.-Brazil relations.  

Entry, Exit and Visa Requirements

There are no COVID-related entry requirements for U.S. citizens.

Effective midnight on April 10, 2025 , a visa will be required for U.S. citizens to travel to Brazil, regardless of the purpose of travel. For more information about visa requirements, visit the Brazilian government-authorized website, https://brazil.vfsevisa.com

You will need:

• A valid U.S. passport.
• A valid Brazilian visa or e-visa, beginning April 10, 2025 for tourists and currently for all other types of travel.
• Visit the Brazilian government-authorized website to obtain your e-visa: https://brazil.vfsevisa.com

Find a  Brazilian consulate abroad .           

Brazilian law requires any minor who is a Brazilian citizen (even dual nationals who are both U.S. and Brazilian citizens) to have permission from each parent to travel within Brazil or exit the country. When a minor travels with both parents, no written authorization is needed. When the minor travels with only one parent or without either parent, s/he  must have two original written authorization letters from each absent parent  and carry a copy* of the child’s birth certificate or have an annotation in his/her Brazilian passport authorizing travel alone or with only one parent. Brazilian citizen minors without authorization letters and a birth certificate* or an annotated Brazilian passport likely will not be allowed by authorities to pass through immigration or to board a flight departing Brazil.     

The U.S. Embassy and its consulates cannot intervene in Brazilian immigration matters or request that this requirement be waived for U.S. citizen travelers.

Written Authorization Letter:  If the absent parent is in Brazil, written authorization letters must be in Portuguese and notarized by a Brazilian notary. If the absent parent is in the United States or elsewhere outside of Brazil, the authorization must be done at the nearest Brazilian Embassy or Consulate using the form provided by that office. Again, please note that Brazilian law requires two original authorizations for each absent parent. This is important, because Federal Police may request and retain one authorization upon the minor’s entry into Brazil. Authorities may then request the second original document upon the minor’s departure.  Authorizations written in English or executed before a U.S. (or any non-Brazilian) notary public are not accepted by the Brazilian Federal Police.  Similarly, birth certificates issued outside of Brazil that are not  apostilled * and translated by a certified translator may not be accepted.

Brazilian Passport Annotation:  In lieu of carrying authorization letters, parents of dual U.S.-Brazilian citizen minors may instead request an annotation be placed in the minor’s Brazilian passport authorizing the minor to travel with only one parent, or to travel alone or with a third party. This annotation replaces the requirement for written authorization letters until the passport expires. Parents residing in Brazil should contact the Brazilian Federal Police for details on obtaining an annotated passport. Parents residing abroad should contact the nearest Brazilian Embassy or Consulate. The annotated Brazilian passport must not be expired and must be carried along with the minor’s U.S. passport at all times for Brazilian Federal Police to accept it in lieu of an authorization letter. There is no comparable annotation available in U.S. passports.

Children who are not dual citizens of Brazil: Please note that, while Brazilian law related to travel authorization does not explicitly apply to non-citizens of Brazil, Federal Police have, at times, delayed the travel of non-Brazilian minors who lack appropriate authorization from both parents. For this reason, we recommend that families of non-Brazilian minors who may travel through Brazil without one or both parents execute written authorizations (following the instructions in the preceding paragraph) in advance of travel and ensure that the minor, or the minor’s traveling companion, carries the original or notarized copy** of the minor’s birth certificate.

An exemplar of the form used by Brazilian authorities to document parental permission for minors to travel without one or both parents may be found here.

*There is a useful pamphlet published by the Hague Conference called “ The ABCs of Apostilles .” The Brazilian competent authority that issues apostilles is the  Conselho Nacional de Justiça .

**If the birth certificate was issued in Brazil, copies must be notarized by a Brazilian notary. If issued outside of Brazil, copies must be apostilled and translated by a certified translator into Portuguese.

HIV/AIDS Restrictions:  The U.S. Department of State is unaware of any HIV/AIDS entry restrictions for visitors to or foreign residents of Brazil.

Find information on  dual nationality ,  prevention of international child abduction , and  customs regulations  on our websites.

Safety and Security

Crime:  The violent crime rate is high in most Brazilian urban centers. Public transportation, hotel sectors, and tourist areas report high crime rates, but these incidents can happen anywhere and at any time.  Be aware of your surroundings.

• Informal housing developments in Brazil (commonly referred to in Brazil as favelas, vilas, comunidades, and/or satellite cities), even on a guided tour, at any time of day due to crime. Neither the tour companies nor the police can guarantee your safety when entering these areas. Even in favelas that the police or local governments deem safe, the situation can change quickly and without notice. In addition, exercise caution in areas surrounding favelas, as occasionally, inter-gang fighting and confrontations with police move beyond the confines of these communities.
• Brasilia’s administrative regions (commonly known as “satellite cities”) of Ceilandia, Santa Maria, Sao Sebastiao, and Paranoa during non-daylight hours due to crime.
• Any areas within 150 km of Brazil’s land borders with Venezuela, Colombia, Peru, Bolivia, Guyana, Suriname, French Guiana, and Paraguay due to crime. (Note: This does not apply to the Foz do Iguacu National Park or Pantanal National Park.)
• Consider avoiding the use of public, municipal buses in Brazil at any time of day, and especially at night. Crime trends indicate an elevated risk of robbery or assault on public bus systems throughout Brazil. The U.S. government recommends against personnel using public, municipal buses in all parts of Brazil.
• Avoid going to bars or nightclubs alone and avoid leaving with strangers.
• Before going on a date with someone you met on a dating app, tell a loved one who you are meeting, where you are going, and the details of the dating application account.
• Be wary about inviting individuals to your residence. If inviting a new acquaintance to your residence, speak to your door attendant in advance about your invited guest.
• Trust your instincts – if something does not feel right or if you suddenly feel ill, walk away from the situation.
• If you believe you may have been drugged, seek immediate medical attention. Some people can have life-threatening reactions to these drugs. After that, report the crime to local police and contact us at the numbers listed below.
• Traveling Outside Metropolitan Areas After Dark: Travelers are encouraged to organize their trips so that they can travel during daylight hours. Road conditions throughout Brazil can vary widely, and travelers must exercise caution due to debris in the road, horse-drawn carriages, unmarked speed bumps, and other infrastructure deficiencies.
• Armed hold-ups of pedestrians and motorists can happen, including at or near public beaches. Personal belongings, left unattended even for a moment, are often taken. If you are robbed, hand over your personal belongings without resisting. Resisting will increase your risk of injury.
• Carjackings and hold-ups can occur at any time of the day or night, especially at intersections and in tunnels. Some robberies involve individuals robbed at gunpoint and taken to make purchases or to withdraw as much money as possible from one or more ATMs.
• Crime on public transportation occurs.  Registered taxis have red license plates and openly display company information and phone numbers.
• Credit card fraud and ATM scams are common in Brazil. Work closely with your financial institutions to monitor accounts and keep your credit card in view while it is scanned at a point of sale.
• Avoid using ATMs in unfamiliar, secluded, or lightly protected areas. Be aware that criminals often target ATMs and businesses in the early hours of the morning when there are fewer witnesses and law enforcement response times may be delayed. If you opt to use an ATM, select those that are located inside of secure facilities, such as an airport, hospital, bank, or government building. 
• Avoid openly displaying your cell phone.  When using a ride share service or taxi, wait for its arrival in a secure area.
• Avoid large groups or events where crowds have gathered. Public events of any nature, including concerts and sporting events, can unexpectedly turn violent.
• Travel to any areas within 150 km of the international borders with Venezuela, Colombia, Peru, Bolivia, Guyana, Suriname, French Guiana, and Paraguay, except in limited circumstances with the appropriate U.S. Department of State approvals. Individuals with ties to illegal criminal networks operate along Brazilian borders. Travel to the Foz do Iguaçu National Park and Pantanal National Park is permitted.
• Enter any informal housing developments in Brazil (commonly referred to in Brazil as favelas, vilas, comunidades, and/or satellite cities), except in limited circumstances with the appropriate approvals.
• Enter Brasilia’s administrative regions (commonly known as “satellite cities”) of Ceilandia, Santa Maria, Sao Sebastiao, and Paranoa during non-daylight hours.

To reduce the chance of becoming the victim of a crime, in addition to the above recommendations, please review the below precautions:

• Limit the personal belongings you carry with you. Carry your money in your front pockets and limit the number of credit cards you carry. Make copies of all of your personal documents – including your credit cards, license, passport, etc. – and keep them in a safe place. This will be helpful if you lose your documents.
• Do not carry or wear valuable items that will attract the attention of thieves. If you need to wear expensive jewelry or carry a camera, conceal it until you arrive at your destination.
• Be aware of the street environment and avoid contact with those who may be looking for robbery targets. Seek a safer location. Go into a store, bank, or simply cross the street.
• Do not walk on beaches after dark. Assaults are common.
• Use increased caution when hiking in isolated areas, particularly near popular tourist locations in the city of Rio de Janeiro.

Demonstrations  and strikes are common in urban areas, may occur unexpectedly, disrupt transportation, and may escalate into violence.

• Even demonstrations intended to be peaceful can turn confrontational and possibly become violent. 
• Avoid areas around protests and demonstrations. 
• Check local media for updates and traffic advisories.
• Check the website of the Embassy or Consulate nearest you for current information on demonstrations.

International Financial Scams:  See the  Department of State  and the  FBI  pages for information.

Victims of Crime: 

U.S. citizen victims of crime should contact the local authorities to file a Brazilian police report before departing Brazil. In most instances, you can report crimes to the tourist or civil police. U.S. citizens should also inform the nearest U.S. Embassy or Consulate, but local authorities are responsible for investigating and prosecuting the crime.

• Police number - 190
• the U.S. Embassy at 011-55-61-3312-7000
• the U.S. Consulate General in Porto Alegre at 011-55-51-3345-6000
• the U.S. Consulate General in Recife at 011-55-81-3416-3050 or 011-55-81-3416-3080
• the U.S. Consulate General in Rio de Janeiro at 011-55-21-3823-2000
• the U.S. Consulate General in Sao Paulo at 011-55-11-3250-5000

See our webpage on  help for U.S. victims of crime overseas .

• Replace a lost or stolen passport
• Contact relatives or friends with your written consent
• Help you find appropriate medical care
• Assist you in reporting a crime to the police
• Provide an emergency loan for repatriation to the United States and/or limited medical support in cases of destitution
• Help you find accommodation and arrange flights home
• Provide information on  victims' compensation programs in the U.S .
• Provide a list of local lawyers who speak English

The local equivalent to the “911” emergency line in Brazil is divided among four services:

• 190 - Policia (Police)
• 191 - Policia Rodoviaria (on interstate roads)
• 192 - Ambulancia (Ambulance)
• 193 - Bombeiros (Fire Department)

Victims of Domestic Violence or Sexual Assault:  Contact the nearest Embassy or Consulate for assistance after contacting local authorities.

Tourism:  The tourism industry is unevenly regulated, and safety inspections for equipment and facilities are inconsistent. Inquire with property management about the presence and functionality of safety equipment, such as fire alarms and carbon monoxide detectors. Hazardous areas/activities are normally identified with appropriate signage in major urban centers but may not be in other locations. Tourism industry staff may not be trained or certified either by the host government or by recognized authorities in the field. In the event of an injury, appropriate and timely medical treatment is consistently available only in or near major cities. First responders can face delays accessing areas outside of major cities to quickly provide urgent medical treatment. U.S. citizens are encouraged to purchase medical evacuation insurance. See our webpage for more information on insurance providers for overseas coverage

Local Laws & Special Circumstances

Criminal Penalties:  You are subject to local laws. If you violate local laws, even unknowingly, you may be expelled, arrested, or imprisoned. Individuals establishing a business or practicing a profession that requires additional permits or licensing should seek information from the competent local authorities, prior to practicing or operating a business.  

Furthermore, some laws are also prosecutable in the United States, regardless of local law. For examples, see our website on  crimes against minors abroad  and the  Department of Justice  website.

Arrest Notification:  If you are arrested or detained, ask police or prison officials to notify the U.S. Embassy or Consulate immediately. See our  webpage  for further information.

Firearms: Brazil forbids importing, exporting, and possessing firearms without prior authorization of the Brazilian Government. U.S. citizens are subject to arrest and prosecution in Brazil for possession of unauthorized firearms or firearm components anywhere in the country, including airports. This prohibition extends to spent shell casings or ammunition, even if inside luggage during transit, regardless of whether those items were legally purchased in the United States or elsewhere.

Counterfeit and Pirated Goods:  Although counterfeit and pirated goods are prevalent in many countries, they may still be illegal according to local laws. You may also pay fines or have to give them up if you bring them back to the United States. See the  U.S. Department of Justice website  for more information.

Water Hazards:  Many of Brazil’s beaches have very dangerous riptides, even if the water looks safe. Ocean currents and waves are unpredictable, even in popular beaches frequented by tourists. Shark attacks are reported in the waters of some beaches in northeastern Brazil, particularly near Recife. Always observe posted warnings and never swim while under the influence of alcohol. Follow local authorities’ guidance and refrain from swimming alone in areas marked with red warning signs or at beaches where there are no municipal lifeguards or first responder services.

Electricity Blackouts:  Power failures in large urban centers are common and sometimes followed by increased crime. Most tourist hotels are equipped with generators, minimizing the impact of a blackout, but you should remain cautious.

Natural Disasters:  Flooding and mudslides occur throughout the country and can be fatal. Monitor news and weather reports and adhere to municipal advisories before traveling to areas prone to flooding or landslides. Many of Brazil’s larger cities have frequent heavy rainstorms that cause flash flooding and can disrupt traffic.

Customs Restrictions : Contact the Brazilian Embassy in Washington, D.C. or one of Brazil's consulates in the United States for specific information regarding import and export regulations. Please also refer to our  information on customs regulations .

• Brazilian customs authorities may enforce strict regulations concerning temporarily importing or exporting items such as firearms, antiquities, mineral samples, tropical plants, wildlife, medications, and business and communication equipment. 
• In the Amazon region, there is special scrutiny of exporting biological material. People raising, growing, or exporting biological materials without permits can be charged with “biopiracy.”

Faith-Based Travelers:  See our following webpages for details:

• Faith-Based Travel Information
• International Religious Freedom Report  – see country reports
• Human Rights Report  – see country reports
• Hajj Fact Sheet for Travelers
• Best Practices for Volunteering Abroad

LGBTI Travelers:  Brazil does not have legal restrictions on same-sex marriage, relations, or events coordinated by LGBTI organizations. However, according to the 2019 Human Rights Report, violence against lesbian, gay, bisexual, transgender, and intersex (LGBTI) individuals was a serious concern, with local NGOs reporting 297 LGBTI persons were victims of hate killings. See our  LGBTI Travel Information  page and section 6 of our  Human Rights report  for further details.

Travelers Who Require Accessibility Assistance:  Brazilian law prohibits discrimination against persons with physical and mental disabilities in employment, education, and access to health care. However, accessibility to public transportation and the ability to accommodate the needs of physically disabled persons are limited in most areas. 

Students:  See our  Students Abroad  page and  FBI travel tips .

Women Travelers:  See our travel tips for  Women Travelers .

COVID-19 Testing: Brazil is a very large, diverse country with varying medical resources, both private and public, throughout the country. Many private labs perform COVID-19 testing at various prices, typically between $20 and $100.  PCR, serology-based antibody tests, and antigen tests are available.  Turn-around time varies widely depending upon location. Please verify turn-around time with your chosen lab before taking the test.  Express results within 2-4 hours are available in many locations at an increased fee, including in the Guarulhos International Airport in São Paulo and Galeão International Airport in Rio de Janeiro. Testing is available in the private sector without a doctor’s prescription, but a prescription may be required for insurance payment.

In the public healthcare system, each Brazilian state has its own COVID-19 testing plan. We recommend that you  contact local/state authorities for more information.  Typically, a COVID-19 test is ordered by an emergency room physician and then sent to a public lab. Turnaround time is much slower and can take up to seven days, but tests are generally free.  Information on testing sites and procedures is available through the  official app of the Ministry of Health.

COVID-19 Vaccines: The COVID-19 vaccine is available for U.S. citizens to receive in Brazil once they register with the public Unified Health System (SUS) . According to the Ministry of Health, available vaccines include AstraZeneca/Oxford (Fiocruz), CoronaVac (Butantan), Janssen (Johnson & Johnson), and Pfizer (BioNTech). For more information on local availability of COVID-19 vaccines, please see the Brazilian Ministry of Health’s website and also contact local health authorities .  

For emergency services in Brazil, dial 192.

Ambulance services are not present throughout the country or are unreliable in most areas except in state capitals and other large cities. 

We do not pay medical bills.  Be aware that U.S. Medicare/Medicaid does not apply overseas. Most hospitals and doctors overseas do not accept U.S. health insurance. 

Medical Insurance:  Make sure your health insurance plan provides coverage overseas. Most care providers overseas only accept cash payments. See  our webpage  for more information on overseas insurance coverage. Visit the  U.S. Centers for Disease Control and Prevention  for more information on type of insurance you should consider before you travel overseas.

We strongly recommend supplemental insurance to cover medical evacuation.

If traveling with prescription medication, check with the  Government of Brazil  to ensure the medication is legal in Brazil. Always carry your prescription medication in original packaging, along with your doctor’s prescription. 

Vaccinations:  Be up-to-date on all  vaccinations  recommended by the U.S. Centers for Disease Control and Prevention.

Though the yellow fever vaccine is not required to enter Brazil, travelers wishing to be vaccinated should consider receiving it prior to travel, as local supplies are limited. Please note that the yellow fever vaccine should be administered ten days prior to travel for it to be effective.

Also note that, while yellow fever vaccine is not required to enter Brazil, some neighboring countries (French Guiana, Suriname, Guyana, Bolivia, and Paraguay) do require travelers with recent entries in Brazil to show proof of yellow fever vaccination.

All travelers to the country are advised to carry documentation, such as a vaccination card, that they have been appropriately vaccinated for yellow fever.

The following diseases are prevalent in Brazil:

• Chikungunya
• Leishmaniasis
• Travelers' diarrhea
• Tuberculosis
• Schistosomiasis

In recent years, outbreaks of these diseases have also been detected in certain areas of Brazil:

• Yellow fever

Elective Surgery : Although Brazil has many elective/cosmetic surgery facilities that are on par with those found in the United States, the quality of care varies widely. If you plan to undergo surgery in Brazil, make sure that emergency medical facilities are available and professionals are accredited and qualified. Some “boutique” plastic surgery operations offer luxurious facilities but are not hospitals and are unable to handle emergencies. 

Visit the  U.S. Centers for Disease Control and Prevention  website for information on Medical Tourism, the risks of medical tourism, and what you can do to prepare before traveling to Brazil.

Non-traditional Medicine: Several U.S. citizens have died while seeking medical care from non-traditional “healers” and practitioners in Brazil. Ensure you have access to licensed emergency medical facilities if seeking such services.

Further health information:

• World Health Organization
• U.S. Centers for Disease Control and Prevention  (CDC)

Travel and Transportation

Public Transportation:  Consider avoiding the use of public, municipal buses in Brazil at any time of day, and especially at night. Crime trends indicate an elevated risk of robbery or assault on public bus systems throughout Brazil. The U.S. government recommends against personnel using public, municipal buses in all parts of Brazil.

Public buses are one of the main modes of inter-city road travel. Buses can range (depending on route and price) from luxurious and well-maintained to basic and mechanically unsound. Bus hijacking can occur at random.

Road Conditions and Safety:  Driving on Brazil's roads poses significant risks. Poor driving skills, bad roads, and high-density traffic make road travel more hazardous than in the United States. Road maintenance is inadequate in many areas and some long-distance roads through the Amazon forest are impassable much of the year due to flooding. 

Apart from toll roads, which generally have their own services, roadside assistance is available only sporadically and informally through local mechanics. The fastest way to summon assistance in an emergency anywhere in the country is to dial 193, a universal number staffed by local fire departments. This service is in Portuguese only.

Traffic Laws:  Travelers planning on staying for more than 180 days should obtain an Inter-American Driving Permit to carry with their valid U.S. license if they plan to drive in Brazil. Such permits can be obtained through AAA or other sources. Please note:

• Everyone in the vehicle must wear a seatbelt. Brazilian federal law requires child seats for all children under the age of 7 ½. From age 7 ½ years to 10, children must only ride in the back seat.
• Drivers must yield the right of way to cars on their right. Compliance with stop signs is rarely enforced, so many motorists treat them as yield signs. It is common for drivers to turn or cross one or more lanes of traffic without warning.
• Drivers often flash their lights or wave their hand out the window to signal other drivers to slow down. 
• Pedestrian crossings are only observed in some places, such as Brasilia. 
• Drivers must have their daytime running lights on during the day and headlights on at night on Federal Highways.
• Under Brazil’s Lei Seca (“Dry Law”),  you cannot operate a vehicle with any measurable blood-alcohol level. Checkpoints are often set up in urban areas, and randomly chosen drivers are required to perform a breathalyzer test. Those in violation are subject to legal penalties and having their vehicle impounded. 

See our  Road Safety page  for more information. Visit the website of Brazil’s  national tourist office  and  national authority responsible for road safety . 

Aviation Safety Oversight:  The U.S. Federal Aviation Administration (FAA) has assessed the government of Brazil’s Civil Aviation Authority as being in compliance with International Civil Aviation Organization (ICAO) aviation safety standards for oversight of Brazil’s air carrier operations. Further information may be found on the  FAA’s safety assessment page .

Maritime Travel:  Mariners planning travel to Brazil should also check for  U.S. maritime advisories and alerts .  Information may also be posted to the   U.S. Coast Guard homeport website , and the  NGA broadcast warnings .

For additional travel information

• Enroll in the  Smart Traveler Enrollment Program (STEP)  to receive security messages and make it easier to locate you in an emergency.
• Call us in Washington, D.C. at 1-888-407-4747 (toll-free in the United States and Canada) or 1-202-501-4444 (from all other countries) from 8:00 a.m. to 8:00 p.m., Eastern Standard Time, Monday through Friday (except U.S. federal holidays).
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Travel Restrictions to Prevent the Spread of Disease

Credit: David Snyder

Disease is just a flight away. To protect America’s health, CDC partners with the Department of Homeland Security to prevent the spread of serious contagious diseases during travel. CDC uses a Do Not Board list to prevent travelers from boarding commercial airplanes if they are known or suspected to have a contagious disease that poses a threat to the public’s health. Sick travelers are also placed on a Lookout list so they will be detected if they attempt to enter the United States by land or sea. These tools can be used for anyone who poses a threat to the public’s health.

Local and state public health officials can request CDC’s assistance if a person who poses a public health threat intends to travel. CDC helps ensure these people do not travel while contagious.

Placing people on the lists

The criteria for adding people to the Do Not Board and Lookout lists are

• not  aware of diagnosis or not  following public health recommendations, or
• Likely to travel on a commercial flight involving the United States or travel internationally by any means; or
• Need to issue travel restriction to respond to a public health outbreak or to help enforce a public health order.

Criteria number one plus one of the three subsets must be met for a person to be placed on the Do Not Board and Lookout lists.

Credit: David Heaberlin

Once a person is placed on these lists, airlines will not issue a boarding pass to the person for any commercial flight within, arriving to, or departing from the United States.

The Do Not Board and Lookout lists have been used for people with suspected or confirmed infectious tuberculosis (TB), including multidrug-resistant tuberculosis (MDR-TB), and measles. During 2020-2022, CDC used these authorities to restrict travel of people with COVID-19 and close contacts who were recommended to quarantine. These authorities were also used for mpox during 2022. Travel restrictions can also be used for other suspected or confirmed contagious diseases that could pose a public health threat during travel, including viral hemorrhagic fevers such as Ebola.

Preventing people with contagious diseases from traveling also helps to make sure they get or continue medical treatment, such as for infectious tuberculosis.

Taking people off the lists

Once public health authorities confirm a person is no longer contagious, the person is removed from the lists (typically within 24 hours). Also, CDC reviews the records of all persons on the lists every two weeks to determine whether they are eligible for removal.

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COVID-19: Brazil simplifies measures for entry of travelers

Proof of vaccination or a negative rest result may now suffice.

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Published on 13/09/2022 - 15:07 By Pedro Peduzzi - Brasília

Click to listen:.

Per national sanitary body Anvisa, travelers are now only required to meet some of the requirements for entry into the national territory.

For instance, visitors may choose to only procure proof of vaccination or a test with a negative result, when arriving in Brazil.

The new rules are already in force and must be observed by travelers and operators in air, waterway, and land transportation.

Anvisa adds that the recommendation is reiterated by the World Health Organization (WHO), which stresses that the “policies for testing and quarantine should be reviewed regularly” to ensure they are lifted when no longer necessary.

Despite the move, Anvisa reinforces the alert from the WHO on the need for alternatives for unvaccinated people, such as a COVID-19 test.

Translation: Fabrício Ferreira -  Edition: Nádia Franco

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Coronavirus Updates

Cdc says travel is safe for fully vaccinated people, but opposes nonessential trips.

Rachel Treisman

The Centers for Disease Control and Prevention updated its domestic travel guidance for fully vaccinated people on Friday, lifting certain requirements while continuing to advise mitigation measures like mask-wearing and hand-washing. Angus Mordant/Bloomberg via Getty Images hide caption

The Centers for Disease Control and Prevention updated its domestic travel guidance for fully vaccinated people on Friday, lifting certain requirements while continuing to advise mitigation measures like mask-wearing and hand-washing.

The Centers for Disease Control and Prevention has updated its domestic travel guidance for fully vaccinated people, lifting certain testing and self-quarantine requirements and recommending precautions like wearing a mask and avoiding crowds. But health officials continue to discourage nonessential travel, citing a sustained rise in cases and hospitalizations.

The CDC updated its website on Friday to reflect the latest scientific evidence, writing that "people who are fully vaccinated with an FDA-authorized vaccine can travel safely within the United States."

The announcement comes less than a month after the CDC first released updated guidance about gatherings for fully vaccinated people, which it described as a "first step" toward returning to everyday activities.

Air Travel Is Opening Up Again, But That Doesn't Mean The Pandemic Is Over

The CDC considers someone fully vaccinated two weeks after they receive the last dose of vaccine. Those individuals will no longer need to get tested before or after travel unless their destination requires it, and do not need to self-quarantine upon return.

The new guidance means, for example, that fully vaccinated grandparents can fly to visit their healthy grandkids without getting a COVID-19 test or self-quarantining as long as they follow other recommended measures while traveling, according to CDC Director Rochelle Walensky.

Those measures include wearing a mask over their nose and mouth, staying 6 feet from others and washing their hands frequently. Masks are required on all planes traveling into, within or out of the U.S., under an executive order issued by President Biden.

But Walensky, speaking at a White House COVID-19 Response Team briefing on Friday, nonetheless discouraged all nonessential travel, citing a continued increase in the seven-day average of cases and hospitalizations.

"While we believe that fully vaccinated people can travel at low risk to themselves, CDC is not recommending travel at this time due to the rising number of cases," Walensky said.

CDC Director Fears 'Impending Doom' If U.S. Opens Too Quickly

She said that while vaccinated people can do more things safely, most Americans are not yet fully vaccinated. Those who are not must have a negative test 1-3 days before they travel under CDC guidance. They must either get tested 3-5 days after they return and self-quarantine for 7 days, or self-quarantine for 10 days with no test.

Walensky said on Monday that there is more travel occurring now than throughout the pandemic, including the winter holidays. She acknowledged that people have been looking to get away over spring break or take advantage of what they perceive as a "relative paucity in cases," and she said the country was seeing an uptick in cases as a result.

"The thing that's different this time is that we actually have it in our power to be done with the scale of the vaccination," she said. "And that will be so much slower if we have another surge to deal with as well."

The U.S. is already seeing an uptick in domestic travel, and many Americans are looking to book trips in the coming months in what experts described to NPR as a sign of "clear pent up demand for travel."

As the country's supply of COVID-19 doses has grown, so has Biden's goal for the number of shots in arms during his first 100 days, doubling the target to 200 million by the end of this month. Many states have already expanded eligibility to all adults or are set to do so in the coming weeks, well ahead of the president's May 1 deadline.

According to NPR's vaccine tracker , 16.9% of the U.S. population is fully vaccinated, and 30% has had at least one dose. Researchers estimate that 70% to 85% of the country would need to have immunity for COVID-19 to stop spreading through communities.

International travel restrictions remain

The CDC is not lifting travel restrictions barring the entry of most non-U.S. citizens from places including China, Brazil, South Africa and parts of Europe. It will continue to require airline passengers entering the U.S. to get a test within three days of their departure and show proof of a negative result before boarding.

The travel industry has been pushing for some of these restrictions to end. A group of 26 organizations sent a letter to White House COVID-19 czar Jeffrey Zients urging the federal government "to partner with us to develop, by May 1, 2021, a risk-based, data-driven roadmap to rescind inbound international travel restrictions."

While Some Spring Breakers Swarm Beaches, Many Stay Home, Dreaming Of Summer Travel

"To be clear, at this time, we do not support removal or easing of core public health protections, such as the universal mask mandate, inbound international testing requirement, physical distancing or other measures that have made travel safer and reduced transmission of the virus," they wrote. "However, the data and science demonstrate that the right public health measures are now in place to effectively mitigate risk and allow for the safe removal of entry restrictions."

Travel and tourism have taken a considerable hit because of the pandemic with industry groups noting that overseas travel to the U.S. declined by 81% in 2020, causing billions of dollars in losses. Without lifting international travel bans, the U.S. Travel Association estimates that some 1.1 million American jobs will not be restored and billions in spending will be lost by the end of the year.

"Fortunately, enough progress has been made on the health front that a rebound for domestic leisure travel looks possible this year, but that alone won't get the job done," Roger Dow, the association's president and CEO, said in a statement . "A full travel recovery will depend on reopening international markets, and we must also contend with the challenge of reviving business travel."

Fauci Expects Surge In Vaccinations To Keep A 4th Coronavirus Wave At Bay

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How travel brought two covid variants to the U.S., according to the CDC

The agency says the cases demonstrate the need for testing both before and after travel, along with other measures..

On Dec. 29, 2020, the United States discovered its first known case of a highly contagious coronavirus variant , first identified in the United Kingdom, in a Colorado man with no travel history. The man’s lack of prior travel meant the more deadly version of covid-19 was already spreading in the United States, leaving Americans wondering how it got here.

“It didn’t teleport across the Atlantic,” William Hanage, a Harvard University epidemiologist, told the New York Times at the time.

And as news reports of the initial case of the variant (known as B.1.1.7) broke that week, a separate case of that variant boarded a flight from London to Dallas. We now know this because of Centers for Disease Control and Prevention reports released Wednesday about the first detected travel-linked cases of two coronavirus variants.

The agency detailed in one case study how a 61-year-old passenger infected with the B.1.1.7 variant boarded a Dallas-bound flight Dec. 31 despite being symptomatic for covid-19. In another case study, the agency outlined how a traveler from Brazil became the first known U.S. case of the variant identified in Brazil (P.1).

As variants spread, countries pursue new round of travel restrictions

While the first documented case of B.1.1.7 in the United States was one of community spread, the first known P.1 case in the U.S. was identified in a traveler.

The CDC detailed that travel case in a report released Wednesday which said the P.1 variant, which experts suspect can reinfect individuals who already had covid-19 , arrived on an early January flight to Minnesota from southwestern Brazil. The infected traveler was hospitalized in Minnesota 14 days after exposure to the virus, and no secondary cases were confirmed by the CDC, despite dozens of close contacts of the traveler being tested for the variant, including hospital staff, according to the report. The agency said it did not contact trace the flight’s passengers because 19 days had passed since the patient’s flight.

In the case of the variant found in the U.K., the passenger flying from London to Dallas on Dec. 31 had tested negative for the coronavirus as required via a rapid antigen test three days before traveling, the report said. But the traveler developed nasal congestion the day before travel and more severe symptoms after landing in the United States. The traveler was permitted to fly the 10 hours to Texas despite disclosing congestion on a preflight health survey and subsequently tested positive for the coronavirus in the United States on Jan. 2. Upon arrival on New Year’s Eve, the traveler stayed in a hotel overnight before an eight-hour drive to Corpus Christi, Tex., that saw five road stops for food and gas.

The agency did not detail any confirmed cases linked to that traveler, and it did not contact trace the flight’s passengers, this time because 12 days had passed since travel. It remains unclear which airline either passenger traveled with.

“As part of the contact investigation, Texas DSHS shared the patient’s flight information with the CDC El Paso Quarantine Station on January 11,” the CDC report said. “Because 12 days had passed since the flight, CDC did not initiate an aircraft contact investigation; however, CDC later provided an informational notification to the states because of the variant case.”

The case studies demonstrate how travel can facilitate the spread of covid-19 variants across the globe, the CDC said, and shows the need for restrictions like testing both before and after travel, as well as self-quarantine and physical distancing.

Variants mean the coronavirus is here to stay — but perhaps as a lesser threat

It also shows that the new U.S. requirements for all entrants to present a negative coronavirus test taken within three days of departure can falter, such as in the U.K. traveler’s case, by allowing rapid tests, which can miss early cases of covid-19. The report notes that the passenger’s initial rapid test, which was required for U.K. travel to the U.S. at the time, had “the potential for false-negative results” because of the timing of the test.

The CDC also stated that “predeparture testing should be considered one component of a comprehensive travel risk management strategy” that includes testing both before and after travel along with mask-wearing, distancing, hand-washing, self-monitoring for symptoms, and a period of self-quarantine after travel.

The CDC has not responded to request for clarification on what its typical practice is for contact tracing airplane exposure to a confirmed coronavirus variant case. On its website, the agency says it is responsible for contact investigations involving flights to the U.S. or between states, and that timing of the reported cases can vary greatly.

“Sometimes CDC is notified about a sick traveler while the plane is still in the air or shortly after the plane has landed,” the CDC website states . “However, in most cases CDC is notified when a sick traveler seeks treatment at a medical facility. These notifications can be made days, weeks, or even months after the travel.”

More than 2,500 confirmed cases of the B.1.1.7 variant and 13 cases of the P.1 variant have now been found in the United States through randomly performed genome sequencing of samples, which the CDC says does not represent the total number of variant cases in the United States — the actual total is probably higher. The variant identified in South Africa (B.1.351), which is also more contagious, was discovered in South Carolina in late January in two unrelated people with no travel history, and the U.S. has confirmed at least 65 cases of that variant since then, according to the CDC.

The state with the most reported cases of coronavirus variants is Florida, which has confirmed more than 500, according to the CDC. Second is Michigan, with more than 400 confirmed variant cases, and third is California, with more than 200. The primary variant found in all three states was B.1.1.7.

“CDC recommends that people avoid travel at this time,” the CDC says on its website. “However, for those who must travel, additional measures have been put in place to increase safety; especially as COVID-19 variants spread around the world.”

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CDC Updates COVID Travel Guidance for 120 Countries Ahead of Summer

Images By Tang Ming Tung / Getty Images

Key Takeaways

• The Centers for Disease Control and Prevention has updated its COVID travel guidance for more than a hundred countries.
• The CDC classifies travel to each country by level of COVID-19 risk.
• Infectious disease experts say it's relatively safe to travel internationally now, provided you're vaccinated and avoid high-risk countries.

The Centers for Disease Control and Prevention (CDC) has issued new COVID-19 travel guidelines for more than 120 countries.

The updated advice offers detailed information on specific countries for travelers who are vaccinated and for those who aren't. The CDC specifically assigns risk levels to each country based on the number of cases per 100,000 people.

To use the new guidance , travelers can search by the name of the country they’re interested in visiting and then learn whether its COVID-19 risk is very high, high, moderate, low, or unknown.

The CDC also offers detailed advice on what to do to stay safe in that particular country, broken down by whether you’re vaccinated or unvaccinated.

The new guidance arrives as COVID-19 cases dip to low levels previously seen at the start of the pandemic in March 2020.  As vaccination increases and cases drop, travel among Americans is picking up speed.

Just days after the CDC's updated guidance, the Transportation Security Administration (TSA) announced that it screened more than 2 million passengers on the same day for the first time since March 2020.

What the Risk Levels Mean

The CDC divides up countries based on four levels of risk.

Level 4: Very High Risk

Countries that are classified as very high-risk have more than 500 new cases per 100,000 people over the past 28 days. The CDC recommends against traveling to these countries, which currently include Brazil, India, and Iraq.

Level 3: High Risk

These countries have 100 to 500 cases per 100,000 residents. The CDC specifically recommends avoiding nonessential travel to these countries—including Mexico, Russia, and Iran—for people who are unvaccinated.

Level 2: Moderate Risk

Level 2 countries have 50 to 99 cases per 100,000, and currently include Finland, Cambodia, and Kenya. The CDC suggests that people who are unvaccinated and at increased risk of severe illness from COVID-19 avoid these countries.

Level 1: Low Risk

Level 1 countries are nations with less than 50 COVID-19 cases per 100,000 people, and include Australia, Israel, and Singapore. The agency still recommends that you get vaccinated before you travel to one of them.

What This Means For You

The CDC breaks down which countries are considered high and low risk for travel right now. If you decide to travel internationally, first check the risk level of the country you’re interested in visiting, and don’t forget to wear a mask on your journey.

Is International Travel Safe Right Now?

Infectious disease experts say your safety depends on your vaccination status. “For a fully vaccinated individual, international travel is low-risk,” infectious disease expert  Amesh A. Adalja, MD , senior scholar at the Johns Hopkins Center for Health Security, tells Verywell.

“If you’re fully vaccinated, I think international travel is OK,” Thomas Russo, MD , professor and chief of infectious disease at the University at Buffalo in New York, tells Verywell. “But one should be a little more cognizant of countries that have variants of concern, like India.”

While Russo says that “the consequences for fully vaccinated individuals might not be as bad” as they would be for those who aren't vaccinated, there is still a chance that they can bring the variants back home after traveling. “We’re trying to minimize importing those strains,” he says.

But there are “issues related to air travel in general,” Stanley Weiss, MD , professor of medicine at the Rutgers New Jersey Medical School, tells Verywell. “There is the issue of yourself and those near you, in screening areas, waiting areas, and on the plane."

Weiss points out that you can be exposed to COVID for long periods of time on international flights. And there's “a considerable period of time” where everyone may not always be masked.

Ultimately, “the decision to take an international trip currently is really a risk/benefit consideration that is dependent upon one's own risk tolerance,” Prathit Kulkarni, MD , assistant professor of medicine in infectious diseases at Baylor College of Medicine, tells Verywell.

He recommends being mindful of the risk level of the country you’re interested in visiting. “If it is possible to defer a trip to a country with very high transmission currently until transmission slows down a bit, that is likely preferred,” Kulkarni says.

It’s important to keep in mind that “you may not be able to get reasonable healthcare if you get sick” while visiting a higher risk area, John Sellick, DO , an infectious disease expert and professor of medicine at the University at Buffalo in New York, tells Verywell.

Adalja agrees. “Traveling to a very high-risk area, even when fully vaccinated, probably is not going to be a very fun trip if a country is spiraling out of control because of COVID-19 cases and hospitals in crisis,” he says.

How to Stay Safe When You Travel

“Sometimes there are extenuating circumstances necessitating travel; In this case, prevention steps are the best way to reduce risk,” Kulkarni says. That includes wearing a mask in the airport and on the plane and practicing good hand hygiene, Sellick adds.

Be aware, too, that you may have to get tested or quarantine—even if you’re fully vaccinated—because of regulations in place in other countries, Adalja says.

Weiss recommends bringing extra masks along for the trip and keeping a spare on you at all times. “You need enough with you to enable you to change them,” he says.

Overall, public health experts stress the importance of getting vaccinated before you travel. “It’s the most important thing you can do,” Russo says.

The information in this article is current as of the date listed, which means newer information may be available when you read this. For the most recent updates on COVID-19, visit our coronavirus news page .

Centers for Disease Control and Prevention. How CDC determines the level for COVID-19 travel health notices .

Centers for Disease Control and Prevention. COVID-19 travel recommendations .

Centers for Disease Control and Prevention. Trends in number of COVID-19 cases and deaths in the US reported to CDC, by state/territory .

Transportation Security Administration. TSA surpasses 2 million daily travelers screened .

By Korin Miller Miller is a health and lifestyle journalist with a master's degree in online journalism. Her work appears in The Washington Post, Prevention, SELF, Women's Health, and more.

Hunting for COVID-19 in the Rain Forest of Brazil

CDC experts went to Brazil in February 2021 to investigate the second COVID-19 wave. They went to a remote community called Parintins along the Amazon River. Here is a riverside community in the Amazon. Photo by Juliana de Fatima da Silva/CDC

Manaus, BRAZIL — The first wave of  COVID-19  overwhelmed the health system in Manaus, the capital of Amazonas, Brazil’s largest state.

The second wave, which started in December 2020, was even worse. By January 2021, there weren’t enough hospital beds, medicine, or oxygen for those who needed it. The situation was dire, according to the governor of Amazonas, Wilson Miranda Lima, who pleaded for urgent medical assistance. “This second wave has hit us with colossal force,” he said in a January 25 letter to the international community, donors, and non-governmental organizations.

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CDC sent a team of Portuguese-speaking epidemiologists and laboratory experts to Brazil. Their goal was to learn what was fueling the rapid spread of COVID-19 and conduct a public health investigation.

One of the first to arrive in Manaus , in January 2021, was Roberto Jorge Freire Esteves, MD, an epidemiologist from CDC’S South America Regional Office in Brasilia. The city was in a lockdown phase. “The normally vibrant streets were empty, and people were staying indoors,” he said.

When Atlanta-based Juliana de Fatima da Silva, MD, arrived a few weeks later, on February 20, 2021, the outbreak was out of control and spreading quickly. “The situation was very concerning,” she said.

“Everyone we met had one or multiple stories to share about colleagues or family members who had succumbed to COVID-19. We wanted to understand what role the emerging variant played in that scenario,” she said.

As they prepared for their tasks, the team faced many logistics challenges, including getting personal protective equipment, testing supplies, and a team to a community where they could begin the investigation.

“We had to act fast and overcome several hurdles to carry out the investigation in the middle of this ravaging surge,” says Dr. Freire Esteves. “And we could not have achieved that without the strong support from CDC headquarters and the U.S. Mission to Brazil.”

Drs. Juliana de Fatima da Silva (left) and Roberto Jorge Freire Esteves (right) stand near a U.S. Air Force plane used during a COVID-19 outbreak investigation in remote parts of Brazil. Photo by Juliana de Fatima da Silva/CDC

After meeting with local health officials, the team planned a journey to the remote city of Parintins, located on an island in the middle of the Amazon rain forest.

Map illustrating cities Manaus and Parintins in Brazil, the Amazonas State, the Amazon river, and the Amazon rain forest

You get there only by plane or a 24-hour boat ride. The team loaded research and testing supplies on a boat that only carried cargo. The U.S. Embassy secured a U.S. Air Force plane to fly the team to and from Parintins, to support the investigation in partnership with the health department.

There the team went to the houses of recently diagnosed people to interview and test their families to find out whether a new strain of coronavirus (referred to as P.1.) was fueling the new outbreak.

In less than 72 hours, CDC and local partners talked to and tested 90 people. Fifty-four tested positive for SARS CoV-2, the virus that causes COVID-19. Of the 45 samples that underwent genetic sequencing, 31 (or 69 percent) had P.1.

“We worked very hard to empower local and state health authorities to take ownership of the samples, data, and process,” said Dr. Freire Esteves. “We really wanted to demonstrate the value of partnering with CDC and this was central to ensuring that. We did not want to be perceived as taking over.”

“This truly was a whole-of-US-Government effort,” said Dr. Juliette Morgan, regional director for CDC’s South America Regional Office in Brasilia. “We needed every bit of support we could find to get people and supplies on the ground in Parintins.”

Residents had limited access to COVID-19 tests , Dr. da Silva said. “They were grateful for the health department and CDC teams who were coming to their homes to offer rapid antigen tests.”

Juliana de Fatima da Silva holds a COVID-19 rapid test. The team took photos of every test result to double check afterwards if the patient was negative or positive. This is one of those tests – it’s negative. Photo by Juliana de Fatima da Silva/CDC

CDC epidemiologists and local health department staff gather in Parintins, Brazil, before going house to house to interview residents and offer free COVID-19 tests. Photo by Roberto Jorge Freire Esteves/CDC

Parintins Health Department staff were trained on how to collect a sample for COVID-19 test. Photo by Juliana de Fatima da Silva/CDC

A local health department team member prepares to collect samples from a family. Photo by Roberto Jorge Freire Esteves/CDC

Juliana de Fatima da Silva (left) and members of the local health department in Parintins, Brazil go to houses to test residents for COVID-19. Photo by Juliana de Fatima da Silva/CDC

A team member in the backyard of a Parintins home makes sure blood samples are dry before they are packed up for the journey back to the laboratory in Manaus, Brazil. Photo by Juliana de Fatima da Silva/CDC

CDC epidemiologist and Parintins health staff went to a local hospital to review the facility and identify contacts of other patients in the study that had been hospitalized. Photo by Roberto Jorge Freire Esteves/CDC

Engaging CDC experts helped the team solve problems efficiently and effectively. “Working directly with authorities in the state of Amazonas was critical,” said Dr. Freire Esteves. “We are grateful to our colleagues at the State Health Surveillance Foundation and the Municipal Health Department of Parintins for inviting CDC to participate. It really was an all hands on deck situation and without having an epidemiologist on the ground early to see what was happening in Amazonas state, we would not have known how dire the situation was and how CDC’s experts could help local authorities mitigate the spread.”

Analyses of the investigation in Parintins is ongoing, but it is clear that the P.1. variant spread rapidly.

Routine Monitoring Reveals COVID-19 Surge in Brazil

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Brazil’s Actions and Reactions in the Fight against COVID-19 from January to March 2020

Ana szylovec.

1 Institute of Global Health, University of Geneva, 1211 Geneva, Switzerland; [email protected] (B.N.C.); [email protected] (H.T.N.); [email protected] (A.F.); [email protected] (L.R.)

Isis Umbelino-Walker

2 Athena Institute, Faculty of Science, VU University Amsterdam, 1081 HV Amsterdam, The Netherlands; [email protected]

Brittany Nicole Cain

Hoi tung ng, antoine flahault, liudmila rozanova, associated data.

Data sharing not applicable. No new data were created or analyzed in this study. Data sharing is not applicable to this article.

The outbreak of the novel coronavirus SARS-CoV-2 and the disease it causes, COVID-19, which emerged in 2019, was identified by the World Health Organization as a public health emergency of international concern. Brazil actively responded to contain the virus. This case study aims to examine Brazil’s response to COVID-19 by investigating the country’s actions and reflecting upon the outcomes throughout January and March 2020. The data collection strategy included gathering data from the country’s intergovernmental organization’s official website, epidemiological bulletins, and news reports, guided by intersectoral and interdisciplinary themes. Although the highest incidence rates were in the most rich and populated region in Brazil, it was the poorest region that had the highest case fatality rate. Nevertheless, Brazil took several non-pharmaceutical measures to control and mitigate the spread of the virus. However, the strategy seems to have failed to consider regional and social inequalities. The actions of the health minister were undermined by a conflicting discourse between the minister and the president. The outbreak of COVID-19 added an extra burden on the country’s healthcare system and the existing economic crises; exacerbated the inherent social, political, and economic challenges; and exposed the country’s contradictions.

1. Introduction

On 31 December 2019, the World Health Organization (WHO) was alerted to a cluster of pneumonia patients in Wuhan City, Hubei Province of China. On 7 January 2020, a novel coronavirus was identified as the cause of pneumonia. The virus was then named SARS-CoV-2 and the coronavirus disease was titled COVID-19 [ 1 ]. Epidemiological evidence shows that there was a human-to-human transmission of SARS-CoV-2. The virus was identified in environmental samples from a live animal market in Wuhan, and some human cases were epidemiologically linked to this market. However, the precise zoonotic origin is still uncertain [ 2 ]. On 30 January, the WHO declared the outbreak to be a public health emergency of international concern (PHEIC). With more than 118,000 cases in 114 countries, and 4291 deaths as of 11 March, the WHO announced that COVID-19 is characterized as a pandemic, the first caused by a coronavirus. The WHO called on all countries to activate and scale up their emergency response mechanisms, and remarked on the importance of balancing between protecting health, minimizing economic and social disruption, and respecting human rights [ 3 ].

Developing countries, which have limited fiscal and monetary capacity, face unique challenges not only in having the resources to respond to the pandemic but also in dealing with the consequences that go beyond health impacts. Brazil, in particular, as a continental country, presents great social, economic, and structural disparities within the country. In addition, before the pandemic, the country was already facing economic and political crises. Despite that, Brazil has a history of being an active actor in international cooperation for health [ 4 ]. The Brazilian leadership can be exemplified with the establishment of a strategic mass vaccination program, the effective HIV/AIDS program, leadership in the fight against tuberculosis, and more recently, the detection and containment of the congenital Zika virus syndrome emergency [ 5 ].

Following the announcements made by the WHO, Brazil actively prepared for the pandemic of COVID-19. On 22 January, the Ministry of Health (MoH) established an Emergency Operations Centre (COE) to coordinate actions and prepare the health system to respond to possible cases. The Centre was composed of three main institutions: Fiocruz (Oswald Cruz Foundation—Fundação Oswald Cruz), Anvisa (Brazilian Health Regulatory Agency—Agência Nacional de Vigilância Sanitária) and the Pan American Health Organization (PAHO). The COE led the technical capacity to respond to the pandemic in the country and Latin America by training health professionals and providing test and clinical practice guidelines [ 6 ].

As substantial progress and knowledge over the actions taken to control this unprecedented pandemic are needed, it is imperative to understand how developing countries respond to this global sanitary emergency. This case study aims to examine Brazil’s response to COVID 19 by investigating the country’s actions and reflecting upon the outcomes during January and March 2020.

2. Methodology

This is a single case study with an intrinsic design [ 7 ]. The unit of analysis is Brazil’s response to COVID 19 and is defined by the beginning of the country’s first measure to tackle the pandemic. Data collection involved unobtrusive measures—such as official (inter)governmental statements, legislation, and statistical information from official websites—and secondary data—such as epidemiological bulletins and news reports—that covered the study’s timeframe between January and March 2020. The first data points used and reproduced in this case study date to 22 January 2020, while the last data points date to 15 April 2020. Thus, the study was built in concomitance with the events, hence its peculiar “real-time” character. Much has happened in terms of data and outcomes, since the pandemic continues to unfold.

An intersectoral and interdisciplinary theme guided the data collection and the data analysis process. The guiding themes comprised the non-pharmaceutical measures taken, as well as the economic and social consequences of the pandemic in the country that are related to COVID 19. The analytical approach simply consisted of the description and analysis of the data. This strategy seemed appropriate since it enabled it to gain an understanding of the dynamics of this contemporary event, the pandemic in the Brazilian setting, within its real-life context.

3. Findings

3.1. case presentation, 3.1.1. brazil’s context.

The Federative Republic of Brazil is the largest and most populous country in Latin America and is home to 210 million inhabitants. The country is composed of the partnerships of states, municipalities, and the federal district. They are all autonomous under the terms of the Constitution [ 8 ]. Although the country is unified, that does not mean that it is homogeneous. Brazil has several types of social inequalities, not only limited by factors, such as race or social position, but also regional differences.

The disparities between regions are historically rooted, and they shape the country, politically and economically [ 9 ]. Table 1 summarizes the indicators regarding the distribution of the population, GDP, and sanitation by region and state, and the human development index (HDI). The indicators display the inequalities between the regions. For instance, the southeast has a human development index (HDI) of 0.794 [ 10 ]. It is the most populated region, housing 42% of the Brazilian population, with 22% residing in the state of São Paulo only [ 11 , 12 ]. The area is responsible for more than 50% of the GDP and employs 45% of Brazil’s labor force [ 10 , 12 ]. In contrast, the north has an HDI of 0.730 [ 10 ], and it is the second less populated region in the country, with 8.77% Brazilians living there [ 12 ]. The differences in access to clean water between regions, states, and municipalities are also consistent with the country’s health conditions and are directly linked to the country’s social inequality. For instance, in the north, 57% of the population have access to clean water and only 10.5% have access to sewage collection service, while in the southeast, these indicators correspond to 91% and 79.2%, respectively [ 13 ].

Human development index (HDI), GDP, population, and sanitation indicators by region and state.

HDI: Human Development Index; GDP: Gross Domestic Product. Data in bold refers to the region’s of Brazil.

Besides the socio-economic differences, the country also has a diverse climate. It extends from equatorial in the north and northeast, to subtropical in the centre-west and southeast, and temperate in the south.

Brazil also occupies the position of the 5th largest country, with a GDP of 1.91 trillion dollars. The services sector represented 76% of the Brazilian GDP in 2019, while the industrial and agricultural sectors represent 21% and 4%, respectively [ 14 ]. Despite an average economic growth of 4.5% during the 2006–2010 period and 2.8% during the 2011–2013 period, since 2014, Brazil has been facing economic crises. The origin of the economic crises was multifaceted and encompassed the decrease of commodities and issues of corruption and political uncertainties. This scenario limited the government’s ability to implement necessary fiscal reforms, leading to a decrease in consumption as well as investor confidence. During 2015–2016 the country faced a GDP contraction of 3.6% and 3.4%, respectively. However, since 2017, the country has shown signs of a slow recovery [ 9 ]. Although the unemployment rate in Brazil is around 11%, almost half of the working population (41%) is in informality and deprived of working rights [ 12 ].

3.1.2. Brazil’s Health System

The Brazilian tax-based health system, known as the Unified Health System (SUS), was created in 1990, soon after establishing health as a right in the Constitution in 1988. The system was built based on the principles of universality, integrity, and equity, guaranteeing access to health for the entire population [ 15 ]. The system is decentralized, which grants independence for municipalities and states to carry out their healthcare policies with the support of the federal government. Thus, tripartite and bipartite intergovernmental commissions count on the participation of the federal government, states, and municipalities for decision making related to health policies [ 15 , 16 ]. The private sector may participate in the SUS on a complementary basis [ 15 ]. Therefore, the health services in Brazil have two faces, the public and private.

During the recession period, in addition to rising unemployment, inflation, poverty, and budget cuts that directly affected social programs, Brazil’s healthcare system reported delays in staff payment, lack of equipment and medicine, and increased demand for health services. In 2018, to restore fiscal sustainability, the government adopted Constitutional Amendment 95/2016, freezing public spending until 2026. This measure directly impacted the health of Brazil, since it made it impossible to increase investments in this sector [ 17 ].

In general, public health services’ spatial distribution follows the historical trends of inequalities within the country [ 9 ]. Medium and high complexity equipment, such as Intensive Care Unit (ICU) beds and ventilators, remained concentrated mainly in capitals, metropolitan areas, and in a few regional centers. For instance, the southeast region has 53.4% of the total number of ICU beds in Brazil, while the north has 5.2% [ 18 , 19 ]. This scenario refers to equipment and human resources, where most of the intensive doctors, 57%, work in the southeast, while 3% work in the north [ 18 ]. Moreover, these disparities are further exacerbated when contrasting the amount of ICU beds available in the private sector. SUS holds 44% of the total ICU beds in the country, while the private’s sector has 56%, showing a disproportion, since only 24.6% of Brazilians own private insurance [ 20 ]. Figure 1 shows the number of hospital beds (a) and healthcare professionals (b) per 100,000 people in all Brazilian states, emphasizing the difference between states and regions [ 21 ].

Map of Brazil, elaborated by the authors, with the distribution of healthcare resources by state: ( a ) Hospital Beds per 100,000 people ranging from 1.56 (light blue) to 2.85 (dark blue) ( b ) Healthcare Professionals (doctors and nurse) per 100,000 people ranging from 1.4 (light blue) to 5.69 (dark blue). Brazilian states acronym are: Acre (AC), Alagoas (AL), Amapá (AM), Amazonas (AP), Bahia (BA), Ceará (CE), DistritoFederal (DF), EspíritoSanto (ES), Goiás (GO), Maranhão (MA), MatoGrosso (MT), MatoGrossodoSul (MS), MinasGerais (MG), Pará (PA), Paraíba (PB), Paraná (PR), Pernambuco (PE), Piauí (PI), RiodeJaneiro (RJ), RioGrandedoNorte (RN), RioGrandedoSul (RS), Rondônia (RO), Roraima (RR), SantaCatarina (SC), SãoPaulo (SP), Sergipe (SE) and Tocantins (TO).

3.1.3. Epidemiological Situation

In March 2020, Brazil had had the first 30 days after the first case of COVID-19, which was confirmed on 26 February 2020. According to the Ministry of Health (MoH), until the end of March, the country confirmed 5717 cases and 201 deaths (Case Fatality ~3.5%; Incidence Rate ~2.7 per 100,000 people—the incidence coefficient per 100,000 inhabitants was calculated by the authors considering the IBGE (Instituto Brasileiro de Geografia e Estatistica—Brazilian Institute of Geography and Statistics) population projections for 2020 [ 8 ]). Most of the cases were concentrated in the southeast region (3406; 59.6%), followed by the northeast (875; 15.3%), south (672; 11.8%), centre-west (470; 8.2%), and north (294; 5.1%). More than half of the cases were concentrated in the states of São Paulo (40.9%) and Rio de Janeiro (708; 12.4%) [ 22 ]. The concentration of cases in the richest region was mainly due to (I) a high aerial network, which imported the first cases of COVID-19 from Italy; and (II) the population density, facilitating the dissemination of the virus.

The incidence rate followed a different trend, placing the southeast region at first with 3.9 per 100,000 population, followed by the centre-west (~2.9/100,000) and south (~2.2/100,000). Among the states, the Federal District had the highest incidence coefficient, with approximately 11 cases per 100,000 inhabitants. São Paulo had the second highest (~5.1/100,000), followed by Acre (~4.8/100,000), Ceará (~4.3/100,000), Amazonas (~4.2/100,000), and Rio de Janeiro (4.1/100,000) [ 8 , 18 ]. The two main factors that can explain this difference are the high mobility flow between national or international regions affected by the new coronavirus and containment measures adopted by the states.

The southeast region had the majority of deaths (161 deaths; case fatality ~4.7%), while the northeast had the second highest case fatality rate (2.5%) with 22 deaths. The south, centre-west, and north regions had nine, five, and four deaths, respectively [ 22 ]. Figure 2 shows the distribution of incidence per 100,000 people and case fatality rate per state.

Map of Brazil with the distribution of COVID-19 cases and fatalities by state, elaborated by the authors: ( a ) Incidence of COVID-19 cases per 100,000 people ranging from 0.37 (light green) to 11.01 (dark green); ( b ) Case fatality (%) ranging from 0.00% (light green) to 22.22% (dark green). Brazilian states acronym are: Acre (AC), Alagoas (AL), Amapá (AM), Amazonas (AP), Bahia (BA), Ceará (CE), DistritoFederal (DF), EspíritoSanto (ES), Goiás (GO), Maranhão (MA), MatoGrosso (MT), MatoGrossodoSul (MS), MinasGerais (MG), Pará (PA), Paraíba (PB), Paraná (PR), Pernambuco (PE), Piauí (PI), RiodeJaneiro (RJ), RioGrandedoNorte (RN), RioGrandedoSul (RS), Rondônia (RO), Roraima (RR), SantaCatarina (SC), SãoPaulo (SP), Sergipe (SE) and Tocantins (TO).

The fatality rate per case highlights the fragility of the health system in the northeast and the pressure that the health system in the southeast was facing. For instance, Piauí (PI), even though it did not have a high incidence rate, presented a high case fatility rate. According to the MoH, more than 80% of the fatalities had at least one associated risk factor, with heart disease being the main one, followed by diabetes, pneumopathies, and neurological diseases. Moreover, approximately 85% of the cases were people over 60 years old [ 23 ].

The MoH established two risk groups: (I) people with health conditions and (II) health professionals. Individuals who were most at risk were over 60 years old, had severe or decompensated heart diseases, had pneumopathies, were immunosuppressed, had chronic kidney diseases in advanced stages (3, 4, 5), were diabetics, and were pregnant women. The government also identified health care professionals as a major concern because of the role they play in responding to the health emergency and because of the increasing numbers of confirmed cases among them due to lack of personal protective equipment (PPE). In a hospital in São Paulo, for instance, 348 employees were diagnosed with COVID-19, which corresponded to 2% of the employees in that hospital [ 23 ].

COVID-19 arrived in Brazil at the same period of its flu season, which began in mid-April until early September. Similar trends to influenza were expected by the MoH due to the agglomeration related to the winter season. In the south, which has a temperate climate, the peak usually happens in June and July. In the north, due to the rainy season, the biggest peak happens in March and April. Other regions presented an intermediary situation with less evident peaks during the winter [ 23 ].

Brazil’s laboratory capacity to perform tests for COVID-19 was considered insufficient by the ministry itself, leading to a number of cases being underreported. The network of Central Public Health Laboratories (Lacens), Fiocruz Institute and Evandro Chagas, was able to do 6700 tests a day [ 23 ]. Several models were developed to estimate the number of cases in the country. According to the mathematical model, based on the SIR model for disease spread and minimum t-norm, made by the Federal University of Pelotas (2020), the number of confirmed cases of COVID-19 in Brazil was 10,394 on 31 March 2020. In contrast, only 5717 were confirmed by the MoH at the end of March [ 24 ].

A different model, adapted from the Microscopic Markov Chain Approach (MMCA) metapopulation mobility model [ 21 ], considered the mobility and the demographical data for each municipality to capture the spread of COVID-19 [ 25 ]. As a result, the model, which did not include imported international cases, generated an indicator for each municipality, expressed by the risk of contracting the virus through local transmission [ 26 ]. The city of São Paulo, which held the index case, had a prediction of 0.04673% risk on 26 March, meaning that 46.73 people for every 100,000 individuals might be infected, either manifesting symptoms or not. The number of confirmed cases on the same date was 1052, which resulted in an incidence rate of 8.21 people for each 100,000 during the month of March [ 27 ]. On 26 March, the city reported 4621 suspected cases of COVID-19, waiting for testing confirmation [ 27 ]. Even though it seems the predictions overestimated the number of cases compared to the number of confirmed cases, they also showed the cities’ lack of ability to test for SARS-Cov-2.

Considering the fact that the ministry did not consider socio-economic characteristics in their reports and the high level of inequality between and within states in Brazil, there was a demand for mathematical models or analyses that include social vulnerability, mainly related to living conditions. Coelho et al. classified municipalities based on their vulnerability. The model considered urban indicators in education, health, and income distribution, highlighting the inequality between the north and south of the country. Their study showed that the regions in the north and north-east were more vulnerable to COVID-19 when compared to the other regions [ 19 ].

Brazil faced great challenges during the first three months of this unprecedented pandemic given the country’s social-economic context, the epidemiological situation-early transmission phase, and the concomitant period of the flu season-and the health system conditions. This scenario highlighted the complexity of the response needed to the new coronavirus in Brazil. Figure 3 shows the evolution of cases in Brazil from 20 January to 31 March as well as the measures implemented by the Ministry of Health discussed in the “Non-Pharmaceutical Measures” session.

Timeline with measures taken by the Ministry of Health (grey) and the WHO (red) on the left with the evolution of accumulate cases of COVID-19 on the right.

3.2. Management and Outcome

3.2.1. non-pharmaceutical measures.

The Emergency Operations Centre (COE), after its creation, developed the “National Contingency Plan for Human Infection with the new COVID-19 Coronavirus,” which established three levels of response: alert, imminent danger, and public health emergency of national importance (PHENI). Each level of response defined the role of the institutions which make up the national healthcare system. On 3 February, Brazil declared the last level of response (PHENI) to allow the mission of repatriating 34 Brazil citizens living in Wuhan [ 6 ].

To assist the crisis, the Ministry of Health (MoH) announced the anticipation of influenza’s vaccination campaign. Vaccinations started on 23 March instead of the second half of April as was typically the case [ 28 ]. On 27 February, they declared that the campaign would be targeted to vaccinate the most vulnerable population, including children, elderly people, health professionals, and pregnant women. Their goal was to facilitate the differential diagnosis between COVID-19 and influenza and reduce the number of people seeking healthcare.

On 14 March, the MoH issued a publication providing recommendations on non-pharmaceutical intervention measures to be adopted by Brazilian cities and states to reduce the possibility of transmission of the virus [ 29 ]. In general, the MoH recommended promoting personal and public hygiene; the isolation of people with symptoms for 14 days; and the use of personal protective equipment for patients and health professionals. According to the publication, the MoH categorized COVID-19 cases into the local transmission and community transmission [ 29 ]. The former refers to the occurrence of a domestic case with an epidemiological link to a confirmed case, while the latter refers to a case without such a link. With this categorization, depending on the pandemic development and healthcare services capacity of a specific region, the MoH suggested respective non-pharmaceutical intervention measures for cities and states to contain the pandemic better.

Regarding areas with local transmission, apart from general personal and public hygiene, measures were focused on vulnerable groups, social contact restriction, patient referral procedure, and the reduction of unnecessary mass events. Regarding areas with community transmission, the MoH suggested social distancing measures for companies and education institutions (e.g., the use of virtual meetings, flexible working hours). It also provided recommendations for healthcare services, which included daily monitoring on COVID-19 cases, and quarantine measures to be adopted when reaching 80% of Intensive Care Unit (ICU) bed occupancy to ensure the necessary capacity needed for the pandemic response [ 29 ]. Despite the MoH’s general recommendation for municipalities and states, they may act differently in accordance with their capacity.

Starting from 17 March, several municipalities declared a state of emergency, such as Rio de Janeiro [ 30 ], followed by São Gonçalo and Guapimirim on 18 March [ 31 ]. On 19 March, the state Rio Grande do Sul prohibited interstate transport between itself and other Brazilian states to restrict travel [ 32 ]. On 20 March, Brazil’s Senate approved a presidential decree to declare the state of emergency at a national level. Under this measure, the government could waive fiscal targets and free up budget resources to combat the pandemic [ 33 ]. The MoH also declared on the same date the recognition of community transmission of COVID-19 throughout the national territory [ 34 ].

With 291 confirmed cases and the first death reported on 17 March, Brazil partially closed its border with Venezuela starting on 18 March for 15 days [ 35 ]. Health Minister Luiz Henrique Mandetta commented that Venezuela as a country was no longer able to provide healthcare. Hence, such measures were taken to alleviate the influx of Venezuelans overburdening Brazil’s health services. There was controversy over this measure, as the country did not close its border with other countries, which had more confirmed cases than Venezuela. Later on 19 March, Brazil also closed its land borders with Argentina, Bolivia, Colombia, French Guyana, Paraguay, Peru, and Suriname for 15 days to prevent the spread of the coronavirus [ 36 ]. On the same day, foreigners from several European and Asia Pacific countries were also restricted from entering the country by air for 30 days [ 37 ]. Starting from 22 March, a similar restriction also applied to Uruguay [ 38 ] and all foreigners entering Brazil over water [ 39 ] or air [ 40 ].

The MoH defended and advised social distance based on the recommendation of WHO to avoid the collapse of the healthcare system in Brazil. As such, all states were expected to adopt respective non-pharmaceutical measures aiming to help contain the pandemic; however, they were not legally biding to do so. In March, states such as Distrito Federal (11 March) and São Paulo (24 March) declared social distancing measures, but there were still some states that had not adopted them yet. The differences in the healthcare capacity between regions posed a challenge to the federal government. To cope with the pandemic, the Brazilian federal government installed measures to maintain enough healthcare inputs such as: personal tests, healthcare workforce, protective equipment (PPE), and hospital equipment (ICU beds and ventilators) [ 23 ].

On 24 March, it was reported that the Ministry of Health would expand the testing distribution to 22 million. Two types of tests were either purchased or donated. The first test was an RT-PCR test. This test identifies the virus while it is present in the body, and is typically used for patients hospitalized with severe symptoms. The second test consisted of serological assays. These respond to a reaction of the immune system to the virus, and they were typically used for healthcare workers at an increased risk of coming in contact with SARS-CoV-2 because of their close contact with patients. [ 41 ]. Brazil also established public–private partnerships aiming to guarantee the production of these tests [ 23 ].

To mobilize the health workforce to respond to the emergency situation for outpatients and hospital services, the MoH established the Strategic Action “O Brasil Conta Comigo” on 31 March, calling for health care professionals. The objective of the Strategic Action was registering and training health care professionals to combat the pandemic. Under this, all health professionals qualified to work in the national territory must register with the MoH through their respective professional councils. Training in the form of distance courses was provided to health professionals [ 42 ].

The MoH had been purchasing and redistributing PPE for the region to guarantee resources for the entire country. Most of the resources were allocated according to the region’s needs. Therefore, around 39% of all resources were in the southeast, followed by the northeast (28%), north (11%), and south (9%) [ 41 ]. On 17 March, the Chamber of Deputies approved the measure of prohibiting the export of health-related products necessary to contain the virus to prevent their shortage in the domestic market. Such products include PPE, such as latex gloves, goggles, and surgical masks, and hospital equipment, such as hospital beds and multi-parameter monitors [ 43 ].

In March, the MoH stated that Brazil’s health system would collapse by the end of April [ 44 ]. For instance, the shortage of hospital beds was worrying. Under the collaboration with Fiocruz, in March, the institution started to build a 200-bed hospital of intensive and semi-intensive care for COVID-19 patients [ 6 ]. States also built campaign hospitals, such as Rio de Janeiro [ 45 ] and São Paulo, which transformed a soccer stadium into a hospital [ 46 ].

Through all measures implemented by the Ministry of Health, the federal government aimed to reduce the transmission of COVID-19 by promoting technical information to the states, monitoring available resources, and researching existing questions. The government also recognized the gap between announcing resources’ availability and making them feasible for the states. Consequently, the recommendation for the states and municipalities was to implement the “extended social distancing until the health inputs and teams are available in sufficient quantity, in order to promote, with security, the transition to the strategy of selective social distancing” [ 23 ] (p.20). Until 31 March, no technical recommendations were provided by the MoH related to people living in poor living conditions, such as in favelas and those without access to water, and indigenous Brazilian communities.

3.2.2. Economy

The scenario of uncertainty produced by the COVID-19 pandemic in the world economy was also evident in Brazil’s economy, which previously presented a gradual resumption of growth. These uncertainties are reflected in a dollar appreciation of +15.4% and a drop on the stock market of −35.8% and S&P500 of −24% on the financial market. In March, these impacts caused Brazil to break many records in its economy. Among them, the highest dollar price since the creation of the real coin and the highest number of circuit breakers (four) in one week on the stock exchange. The devaluation of Brazilian companies on the financial market also represented macroeconomic expectations, which followed the same trend [ 47 ].

The Institute of Applied Economic Research (IPEA) predicted a significant drop in economic activity during March. Brazil was expected to go through a recession in the first half of 2020. Although in the first quarter, the prediction was only a 0.2% reduction in the economy, compared to the previous three months, in the second quarter, they forecasted a fall of 2.13% in GDP [ 47 ]. In March, the central bank of Brazil (Bacen) predicted for the total economic growth of 2020, a fall from 2.2% to −0.48% [ 48 ]. This fall was mainly due to the increase in domestic costs, international shocks in the national economy, and a decreased in consumption.

The domestic costs related to the pandemic can be classified into direct and indirect costs. Among the indirect costs, there were the consequences of the COVID-19 containment measures, such as the decreased supply of services due to isolation measures. Among the direct costs were the loss of labor force—related to increased mortality—sick leave—due to COVID-19—and the government increasing spending on the health sector. International shocks refer to the reduction of capital flows and the world economy’s slowdown, which impacted exports and imports [ 47 ].

The fact that the region most affected by COVID-19 is also the region responsible for most of the country’s GDP and economic activity [ 49 ] put pressure on Brazil to adopt daily countercyclical macroeconomic measures [ 47 ]. Thus, despite the constitutional amendment 95, establishing a freeze on government spending, the ministry of economics announced extraordinary credits for different sectors to not be computed by the amendment. Besides the health sector, the sectors most affected by the COVID-19 pandemic were the services sector, except for services that are considered essential, and the informal labor sector, which contains 41% of the Brazilian labor force [ 47 ].

In order to respond to the prospects of increased unemployment and falling income, the government adopted a monetary policy of “reducing interest and compulsory rates and measures to expand credit with the temporary relaxation of prudential rules” [ 47 ] (p. 2). In March, different fiscal measures adopted by Brazil reached R$ 280.1 billion and aimed at reducing the impact on income, employment, production, and companies, as well as increasing social protection. Table 2 summarizes all the fiscal measures.

Summary of the fiscal measures adopted by the government due to COVID-19.

R$ 46 billion (~9.01 billion USD) was put aside for the elderly population. Workers were supported with R$ 32.8 billion (~6.4 billion USD) through the anticipation of social benefits, while 45 billion (~8.8 billion USD) was made available to workers in the informal sector. The government allowed workers to access their social benefits if they take sick leave over 15 days due to the coronavirus. Other efforts included putting aside R$77.7 billion (~15.21 billion USD) to benefit companies in general and investing R$19.9 billion (~3.9 billion USD) into the SUS. The government has also offered to assist states and cities with R$ 50.6 billion (~9.91 billion USD) by delaying the deadline for them to pay their debts to the federal government, passing on financial resources, and offering loan credits. In order to decrease the spending in the health sector, the government decided to reduce to zero the tax to imported hospital products until the end of the year and to exempt IPI (Industrialized Products Tax) temporarily for goods needed to fight COVID-19 [ 47 , 50 ].

3.2.3. Social and Political Disruption/Media Coverage

Health Minister Luiz Henrique Mandetta tried to implement WHO’s recommendations and learn from the international experience. Although the Ministry of Health remained consistent in its approach to slowing the spread of COVID-19, the main critique over its actions lies over the impracticalities of adopting these measures in a country surrounded by inequalities [ 9 ]. The socially vulnerable population did not have the conditions to adequately self-isolate while living in overcrowded slums and having job positions that cannot be done from home. Moreover, the lack or absence of sanitation made it even harder to regularly follow the recommendation of washing hands. Furthermore, the fragile economic situation of this community mades it difficult to purchase basic hygiene supplies. Fiocruz and civil society led a movement to draw authorities and society’s attention on this problem [ 51 ]. However, until 31 March, social vulnerability was not included as an indicator on any of the epidemiological bulletins, and no epidemiological model predictions had been made of how the virus would spread in such circumstances, therefore hampering the country’s ability to take adequate and urgent measures [ 52 ].

In addition to the country’s complex social situation, there were also discrepancies between the Ministry of Health’s recommendations and measures and the presidency. Mandetta’s voice was overshadowed by President Jair Bolsonaro, who called COVID-19 a “fantasy” and accused the media of promoting hysteria over the population by its constant coverage of the subject. President Bolsonaro received backlash after mingling with supporters following his return from a trip with the United States’ President Donald Trump, in which more than 20 members of the trip tested positive for COVID-19 [ 53 ]. Although the president took a more severe angle by announcing that protestors should reconsider protesting the National Congress and Supreme Federal Court to support a more authoritarian government, he then sent them a WhatsApp message congratulating demonstrators for protesting in support of his ideology [ 54 ]. Bolsonaro, after having been tested three times for COVID-19, refused to make his results public until 31 March [ 55 ].

President Bolsonaro seemed to be more concerned about the economy than the serious health threat that COVID-19 presents. The president’s official pronouncements from 24 March called COVID-19 a “little cold.” [ 56 ]. His announcements contradicted several of the MoH’s measures and recommendations and escalated the tensions between Bolsonaro and Mandetta. For instance, Bolsonaro defended the use of chloroquine and extolled its suspected positive effects. In contrast, Mandetta emphasized that further studies were still needed to understand the medicine’s full effects. Another controversial position that the president took was the call for vertical isolation, where only the most vulnerable population should remain isolated. The MoH, on the contrary, reinforced the need to standardize isolation measures in the country when necessary. The minister’s opinion was supported by most of the scientific and medical community [ 57 , 58 , 59 ]. These frictions within the executive power put the minister’s position at risk, and the president threatened to fire him.

Bolsonaro also presented a clash with several governors and mayors who installed restrictive measures for the circulation of people in an attempt to reduce the spread of the disease [ 60 ]. The president advocated a relaxation of the social isolation measures implemented in the states. This dispute with governors led the president to promote propaganda called “Brazil cannot stop” to encourage the population to return to their regular social and economic activities. However, the Ministry of Justice prevented the government from promoting this propaganda, claiming that the campaign incites behaviors that are not based on technical guidelines [ 61 ]. Nevertheless, there were some states that chose to remain faithful to Bolsonaro’s position and refused to adopt measurements of social distancing [ 62 ].

This split between the powers was also reflected in the population. A poll conducted in São Paulo revealed that Brazilians’ overwhelming majority supported strict measures to slow the spread of COVID-19 [ 63 ]. The president’s refusal to take COVID-19 as a serious threat caused Brazilians to protest against his inaction by banging pans from their home’s window [ 53 ]. Although he was voted into office on the promise to boost Brazil’s economy, the people were much more concerned about the health threat COVID-19 posed. A petition was signed for more over than 1 million people asking the parliament to impeach the president [ 64 ]. Moreover, several political leaders sent an open letter to the president, asking him to resign [ 65 ]. Despite this, a part of the population was active on the streets in organized protests to support the president’s statements [ 66 ]. There was much controversy over the reluctance of certain groups to take restrictive care during this time. One church refused to close its doors, which was supported by President Bolsonaro [ 63 ]. Some 1500 prisoners escaped a semi-open prison in São Paulo after learning they will not be released for the holidays, and visits would be restricted [ 67 ].

The corporate side was also polarized. Although some companies helped either by donating money or supplies, most of the business side was against social distancing measures [ 68 , 69 ]. A Brazilian businessman stated that although Brazil would mourn those who die from COVID-19, Brazil should not shut down businesses, because he believed this would have a more significant impact on Brazilians than the spread of COVID-19 [ 70 ]. This argument proved to be fallacious. Even though the economic recession in Brazil, indeed, could contribute to deteriorating health conditions and increasing mortality, the investment in health and social protection addresses those issues, especially with regards to the most vulnerable populations, highlighting the need to strengthen health and social security [ 71 ].

Besides the internal conflicts, the COVID-19 pandemic also escalated some diplomatic tension between Brazil and China. The geopolitical dispute was initiated by a tweet from Eduardo Bolsonaro—son of the president and federal deputy—comparing the Chinese late response to communicate the virus emerging to the Chernobyl accident and, ultimately, blaming China for the pandemic. The tweet caused discomfort with the Chinese ambassador in Brazil, who demanded that the deputy and the Brazilian chancellor apologize to the Chinese government. After this event, several other members of the government started blaming China, calling COVID-19 the Chinese virus. However, other Brazilian politicians condemned their actions [ 72 ].

Brazil demonstrated internal and external tensions during January and March while trying to respond to the threat that COVID-19 posed to the pursuit of recovering the economic growth and, at the same time, the collapse of the health system. The debate and actions taken during this period were permeated by the historical and sociological inequalities inherent to the country and also by the polarized (geo)politics debates and positions on the issue.

4. Discussion

Once the WHO announced information related to COVID-19, Brazil reacted quickly to contain the pandemic in the country. Measures adopted since the establishment of the COE increased the healthcare system’s capacity to respond to the health emergency in collaboration between different sectors. At the same time, the arrival of the novel coronavirus in the country also exacerbated the inherent social, political, and economic challenges. For instance, although the highest incidence rates were in the most rich and populated region in Brazil, it was the poorest region that had the highest fatality rates. Furthermore, it exposed the contradictions of this continental country.

In response to the pandemic, the MoH recommended various non-pharmaceutical measures. They included a range of actions, from promotion and prevention to pandemic surveillance and coordination of healthcare resources and personnel. Those measures were aimed to avoid the collapse of a health system that has been underfinanced since 2014. On top of this, there were issues of different health capacities between regions as well as differences in health access between those with and without private health insurance.

One of the central contradictions of the measures proposed by the MoH was the classification of the risk groups. While the minister defined just the health professional and people with health conditions as at risk, the people living in poor conditions and the traditional communities remained without any guidelines. Social status, from January to March, was not considered in any of the epidemiological bulletins. The social distancing measures may have had the worst effect on the workers that needed the coming and going to guarantee their earnings. The restrictions may have harmed those living in the slums. With schools closing, these communities may have became even more overcrowded, putting at risk the population in these areas.

The biggest challenge that the country was facing was economical due to economic crises inherited since 2014. Nevertheless, the Ministry of Economy adopted several fiscal measures that englobe mainly helping companies and workers and assisting the poorest and the informal sector. Moroever, the federal government also repassed financial resources to the health sector to respond to the COVID-19 pandemic. Tackling social protection and the health sector can help increase health coverage and reduce the pandemic’s impact. However, given the uncertain scenery, it was unknown whether these measures would be enough and how long Brazil could sustain them.

Economic and political disruptions further exacerbated this alarming scenario. The absence of a coherent discourse between the president and the Ministry of Health, governors, and mayors caused political insecurity and confusion. The minister tried to steer the country towards the technical advice but was undermined by his president. These frictions and conflicting information resulted in polarization in all clusters in Brazilian society, from the top-level government to the ordinary citizen. This duality of visions hampered the containment of the virus in the country, since it brought forth difficulties in the compliance with health policies measures recommended in fighting the virus.

The main limitations of this research lay in its design. Although the real-time case study approach allowed to grasp a unique perception of the unfolding of the pandemic in Brazil, it also constrained and limited data collection. Moreover, external validity is low, and the study does not draw generalizations. It would be beneficial to investigate this period of the pandemic in Brazil from a different theoretical perspective, for instance, health equity perspective in public health governance, to contrast with the thematic analytical approach of this study.

5. Conclusions

This case study reported, in real-time, the dynamics of the COVID-19 pandemic in Brazil by exposing the outcomes from an intersectoral and interdisciplinary point of view. It seems that the COVID-19 pandemic posed unique challenges for developing countries. From January to March, Brazil’s experience showed that this pandemic crisis exacerbated political, social, and economic challenges that the country was already facing. However, Brazil also reaffirmed its leadership and coordination capacity, especially in fiscal and economic measures. This case study pointed to the need to include vulnerable populations and traditional communities while drawing emergency measures. Moreover, this case study exposed the importance of unified leadership when responding to a health crisis, including civil societies, the public sector, the private sector, government, and international organizations. More research is needed to continue the evaluation of Brazil’s response as well as the effect of the measures that were implemented (or not).

Acknowledgments

The authors thank Antoine Flahault and Liudmila Rozanova for their supervision and orientation. The authors also thank Claudia Codeço and the reviewer for technical feedback.

Author Contributions

Conceptualization, A.S. and I.U.-W.; project administration, A.S. supervision, A.F. and L.R.; visualization, A.S.; writing—original draft preparation. A.S., I.U.-W., B.N.C., and H.T.N.; writing—review and editing, A.S. and I.U.-W. All authors have read and agreed to the published version of the manuscript.

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Data availability statement, conflicts of interest.

The authors declare no conflict of interest.

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