Time Zone: -4 hours. No daylight savings time in 2008.
Tel. Country Code: 1
USADirect Tel.: 1
Electrical Standards: Electrical current is 120/60 (volts/hz). North American Style Adaptor Plug. Grounding Adaptor Plug A.
Travel Advisory - Puerto Rico
Travelers to Central and South America and the Caribbean need to protect themselves against mosquito-transmitted viruses, such as dengue and Zika, as well as nighttime biting mosquitoes in countries where there is the threat of malaria. I recommend all travelers use a combination of DEET or Picaridin repellent on their skin and Permethrin fabric insecticide on their clothing for greater than 99% protection against mosquito and tick bites.
Dr. Rose Recommends for Travel to Puerto Rico
• Canadian Consulate
Tel:  (787) 759 6629
• British Consulate
Tel:  (787) 406 8777
HIV Test: Not required.
Required Vaccinations: None required.
Passport/Visa: Entry requirements for Americans: There is no immigration control for United States citizens arriving from the United States. However, US citizens arriving in Puerto Rico from Central or South America, Bermuda, Canada, Greenland, the West Indies or from Caribbean islands, require proof of United States citizenship such as a birth certificate or naturalisation papers; those arriving from elsewhere should have a United States passport.
Entry requirements for UK nationals: UK passport holders require a valid passport for travel to Puerto Rico. Under the Visa Waiver Permanent Programme (VWP), passports that are endorsed British Citizen do not require a visa for holiday, transit or business purposes providing their passports are machine-readable, the stay does not exceed 90 days and a return or onward ticket is held. Holders of other UK passports do require a visa.
Entry requirements for Canadians: Canadian citizens require a valid passport. No visa is required.
Entry requirements for Australians: Australian citizens qualify for the US Visa Waiver Programme and may stay up to 90 days without a visa provided they have a machine-readable passport.
Entry requirements for South Africans: South Africans must hold a valid passport and a visa for entry to Puerto Rico.
Entry requirements for New Zealanders: New Zealand nationals qualify for the US Visa Waiver Programme provided they have a valid, machine-readable passport and fulfil the other requirements. A visa is then not required for stays of up to 90 days.
Entry requirements for Irish nationals: Irish passport holders qualify for the Visa Waiver Programme if they hold a valid, machine-readable passport, and may stay up to 90 days without a visa.
Passport/Visa Note: All passport holders must have an onward or return ticket and documents necessary for further travel. Entry requirements for Puerto Rico are the same as for the United States of America. When arriving from mainland USA there is no immigration control.
Note: Passport and visa requirements are liable to change at short notice. Travellers are advised to check their entry requirements with their embassy or consulate.
Vaccinations: Recommended and Routine
Hospitals / Doctors
Travelers should be up-to-date on their immunizations and are advised to carry a medical kit as well as antibiotics to treat travelers diarrhea or other infections, Travelers who are taking regular medications should carry them properly labeled and in sufficient quantity to last for the duration of their trip; they should not expect to obtain prescription or over-the-counter drugs in local stores or pharmacies in this country - the equivalent drugs may not be available.
• Travelers are advised to obtain comprehensive travel insurance with specific overseas coverage. Policies should cover: ground and air ambulance transport, including evacuation to home country; payment of hospital bills; 24-hour telephone assistance.
High-level medical care is available in Puerto Rico.
• Ashford Presbyterian Memorial Community Hospital
1451 Avenue Ashford
Tel:  (787) 721-2160
• General Hospital Dr. Ramón Emeterio Betances
Rte. 2, Km 157
Tel:  (787) 735-8001
• Hospital Damas
2213 Ponce Bypass Rd
Tel:  (787] 840-8686
• Hospital Dr. Dominguez
300 Font Martello
Tel:  (787) 852-0505
All of these hospitals have 24-hour emergency rooms.
• University of Puerto Rico School of Medicine
Faculty Practice Plan
Tel:  (787) 758-7910
The Faculty Practice Plan at the University offers a broad array of specialists and sophisticated diagnostic facilities.
• Iturregui Medical Group
Tel:  (787) 768-4278
Offers specialty medical care for travelers.
Destination Health Info for Travelers
AIDS/HIV: The Caribbean has the highest HIV prevalence of any region outside sub-Saharan Africa, particularly in Haiti and the Bahamas, where the prevalence of those living with HIV/AIDS is as high as 3.5%. Puerto Rico is the only Caribbean country apart from Cuba where it is thought that less than 1% of the population is living with HIV.
• The threat of HIV/AIDS should not be a primary concern for the traveler. However, there may be a concern for a subset of travelers who may be exposed to HIV, the virus that causes AIDS, through contact with another person’s body fluids or blood. Although travel has contributed in a general way to the global spread of AIDS, fear of traveling because of this disease is not warranted.
• Transmission of HIV can be prevented by avoiding: sexual contact with a high-risk partner; injecting drug use with shared needles; non-sterile medical injections; unscreened blood transfusions.
Accidents & Medical Insurance: Accidents and injuries are the leading cause of death among travelers under the age of 55 and are most often caused by motor vehicle and motorcycle crashes; drownings, aircraft crashes, homicides, and burns are lesser causes.
• Heart attacks cause most fatalities in older travelers.
• Infections cause only 1% of fatalities in overseas travelers, but, overall, infections are the most common cause of travel-related illness.
• MEDICAL INSURANCE: Travelers are advised to obtain, prior to departure, supplemental travel health insurance with specific overseas coverage. The policy should provide for direct payment to the overseas hospital and/or physician at the time of service and include a medical evacuation benefit. The policy should also provide 24-hour hotline access to a multilingual assistance center that can help arrange and monitor delivery of medical care and determine if medevac or air ambulance services are required.
Dengue Fever: The number of dengue fever cases in Puerto Rico markedly increased in 2007. Up to 300 cases were reported in the first week of August alone which is a rate more than double seen in the previous year. (Source: ProMED-mail August 2007) The highest incidence in Puerto Rico is reported in the vicinity of Yanes. Dengue fever is a mosquito-transmitted, flu-like viral illness widespread in the Caribbean. Symptoms consist of sudden onset of fever, headache, muscle aches, and a rash. A syndrome of hemorrhagic shock can occur in severe cases.
• Dengue is transmitted via the bite of an infected Aedes aegypti mosquito. Aedes mosquitoes feed predominantly during daylight hours. All travelers are at risk and should take measures to prevent daytime mosquito bites. Insect-bite prevention measures include applying a DEET-containing repellent to exposed skin and applying permethrin spray or solution to clothing and gear. There is no vaccination or medication to prevent or treat dengue.
• A dengue fever map is at: http://www.nathnac.org/ds/c_pages/documents/dengue_map.pdf
Update 2009: Dengue is a mosquito-borne viral disease that affects 40% of the population of the world. Nearly four million U.S. citizens live in dengue-endemic areas; the most affected population resides in Puerto Rico. Data from a dengue surveillance system were used to describe all suspected cases reported in Puerto Rico in 2007. Rates of infection per 10,000 residents were calculated by age, sex, and residence. Rates and clinical outcomes were compared with those from outbreaks in 1994-1995 and 1998. In 2007, 10,508 suspected cases were reported; 52.5% persons were hospitalized, 31.8% reported hemorrhage, 2.2% had dengue hemorrhage fever, and 44 died. The overall incidence of laboratory-positive dengue was 8.6 infections per 10,000 population. Rates were highest among persons 10-14 years of age (19.0), followed by persons 15-19 years of age and infants. United States citizens residing in Puerto Rico are at risk of acquiring dengue. Data suggest that the severity is worsening, and persons 10-19 years of age and infants continue to be most affected.
Sorce: Am J Trop Med Hyg. 2009 Sep;81(3):467-74.
Hepatitis: All travelers not previously immunized against hepatitis A should be vaccinated against this disease. Travelers who are non-immune to hepatitis A (i.e. have never had the disease and have not been vaccinated) should take particular care to avoid potentially contaminated food and water. Travelers who will have access to safe food and water are at lower risk. Those at higher risk include travelers visiting friends and relatives, long-term travelers, and those visiting areas of poor sanitation.
• Hepatitis E may be endemic but levels are unclear. Sporadic cases may be underdiagnosed or underreported. Transmission of the hepatitis E virus (HEV) occurs primarily through drinking water contaminated by sewage and also through raw or uncooked shellfish. Farm animals, such as swine, and also deer and wild boar, may serve as a viral reservoirs. (HEV is one of the few viruses which has been shown to be transmitted directly from animals through food.) In developing countries, prevention of hepatitis E relies primarily on the provision of clean water supplies and overall improved sanitation and hygiene. There is no vaccine.
• The overall hepatitis B (HBsAg) carrier rate in the general population is estimated at 3.8%. Hepatitis B is transmitted via infected blood or bodily fluids. Travelers may be exposed by needle sharing and unprotected sex; from non-sterile medical or dental injections, and acupuncture; from unscreened blood transfusions; by direct contact with open skin lesions of an infected person. The average traveler is at low risk for acquiring this infection. Vaccination against hepatitis B is recommended for: persons having casual/unprotected sex with new partners; sexual tourists; injecting drug users; long-term visitors; expatriates, and anybody wanting increased protection against the hepatitis B virus.
• Hepatitis C is endemic a prevalence of 1.9% in the general population. Most hepatitis C virus (HCV) is spread either through intravenous drug use or, in lesser-developed countries, through blood contamination during medical procedures. Over 200 million people around the world are infected with hepatitis C - an overall incidence of around 3.3% of the population of the world. Statistically, as many people are infected with HCV as are with HIV, the virus that causes AIDS.
Leptospirosis: Leptospirosis is difficult to distinguish from dengue fever without laboratory confirmation. Sporadic cases/clusters of leptospirosis occur in Puerto Rico, but laboratory confirmation is rare. Jaundice, elevated BUN, hyperbilirubinemia, anemia, and leukocytosis were associated with leptospirosis. Male sex, walking in puddles, rural habitation, and owning horses were independently associated with leptospirosis. The correct diagnosis is important because leptospirosis requires antibiotic treatment, whereas dengue, a viral illness, requires supportive care only.
Source: Acta Trop. 2005 Oct;96(1):36-46.
Marine Hazards: Swimming related hazards include jellyfish, spiny sea urchins, and coral.
• Ciguatera poisoning is prevalent and can result from eating coral reef fish such as grouper, snapper, sea bass, jack, and barracuda. The ciguatoxin is not destroyed by cooking.
• Scuba Diving-Hyperbaric Chamber Referral: Divers Alert Network (DAN) maintains an up-to-date list of all functioning hyperbaric chambers in North America and the Caribbean. DAN does not publish this list, since at any one time a given chamber may be non-functioning, or its operator(s) may be away or otherwise unavailable. Through Duke University, DAN operates a 24-hour emergency phone line for anyone (members and non-members) to call and ask for diving accident assistance. Dive medicine physicians at Duke University Medical Center carry beepers, so someone is always on call to answer questions and, if necessary, make referral to the closest functioning hyperbaric chamber. In a diving emergency, or for the location of the nearest decompression chamber, call 919-684-8111.
Other Diseases/Hazards: Bancroftian filariasis (mosquito-borne) may be a threat, but the risk is low. Intestinal helminthic infections (ancylostomiasis, ascariasis, strongyloidiasis, and trichuriasis) are reported.
Rabies: Low risk. The last case of human rabies was reported in 2003. All unprovoked dog, mongoose or wild animal bites must be medically evaluated for possible post-exposure treatment. Rabies vaccination is not routinely recommended for travel to Puerto Rico.
Schistosomiasis: Risk of intestinal schistosomiasis is focally present throughout Puerto Rico. Seventeen of 79 municipalities tested have seroprevalence rates averaging 10%. The highest exposure (seroprevalence) rates occur around Jayuya (38.5%) and Naguabo. Schistosomiasis is a parasitic flatworm infection of the intestinal or urinary system caused by one of several species of Schistosoma. Schistosomiasis is transmitted through exposure to contaminated water while wading, swimming, and bathing. Schistosoma larvae, released from infected freshwater snails, penetrate intact skin to establish infection.
• All travelers should avoid swimming, wading, or bathing in freshwater lakes, ponds, or streams. There is no risk in chlorinated swimming pools or in seawater.
Travelers' Diarrhea: Low to moderate risk. In urban and resort areas, the hotels and restaurants generally serve reliable food and potable water. Outside of hotels and resorts, we recommend that you filter or purify all drinking water or drink only bottled water or other bottled beverages and do not use ice cubes. Avoid unpasteurized milk and dairy products. Do not eat raw or undercooked meat or fish. Peel all fruits.
• Wash your hands with soap or detergent, or use a hand sanitizer gel, before you eat. Good hand hygiene reduces the incidence of travelers’ diarrhea by 30%.
• A quinolone antibiotic, azithromycin, or rifaximin (Xifaxin), combined with loperamide (Imodium), is recommended for the treatment of diarrhea. Diarrhea not responding to antibiotic treatment may be due to a parasitic disease such as giardiasis, amebiasis, or cryptosporidiosis.
• Seek qualified medical care if you have bloody diarrhea and fever, severe abdominal pain, uncontrolled vomiting, or dehydration.
Typhoid Fever: Typhoid fever is the most serious of the Salmonella infections. Typhoid vaccine is recommended by the CDC for all people (with the exception of short-term visitors who restrict their meals to hotels or resorts) traveling to or working in the Caribbean and West Indies, especially if visiting smaller cities, villages, or rural areas and staying with friends or relatives where exposure might occur through food or water. Current vaccines against Salmonella typhi are only 50-80% protective and do not protect against Salmonella paratyphi, the cause of paratyphoid fever. (Paratyphoid fever bears similarities with typhoid fever, but the course is generally more benign.) Travelers should continue to practice strict food, water and personal hygiene precautions, even if vaccinated.