Mangesh Sawant

Brazil World Cup

Football 2014

Health Advisory

Travelers visiting the 2014 World Cup in Brazil will be most at risk of gastrointestinal illness

and vector borne infections. Researchers have warned of a possible dengue outbreak in Brazil

during the World Cup. The possibility of a large dengue fever outbreak during the World Cup,

capable of infecting visitors and spreading dengue back to their country of origin, depends on a

combination of many factors, including large numbers of mosquitoes, a susceptible population,

and a high rate of mosquito-human contact. Therefore visitors should pay attention to standard

hygienic measures to reduce the risk of gastrointestinal illness and protect themselves against

mosquito and other insect bites.

Riskpro has conducted a risk assessment to identify which infectious diseases present the biggest

risks to travelers visiting Brazil during the tournament and the public health implications after

the travelers’ return to his home country. Riskpro has also developed the current

recommendations regarding the epidemiology and risks of the main communicable diseases and

contaminated food and water based diseases.

Vector Borne Diseases

Diseases spread by mosquitoes such as malaria, dengue and yellow fever are common

throughout Brazil. Mosquitoes that bite during the day can carry serious illnesses like dengue

and yellow fever while night biting mosquitoes can carry malaria. Mosquitoes are attracted by

carbon dioxide, heat and movement. Sand flies can carry diseases such as leishmaniasis and are

most active between dusk and dawn. They also bite in the day if disturbed. There are many

mosquito species; some species bite during daylight hours (e.g. Aedes spp.), and some are bite

from dusk to dawn (e.g. Anopheles spp.).

Malaria Malaria is a serious, potentially fatal illness spread by

night biting mosquitoes. Malaria is a serious febrile

illness caused by infection of red blood cells with

Plasmodium sp. parasites: P. falciparum, P. vivax, P.

ovale and P. malariae. Symptoms usually appear within

in 7-30 days but can take up to one year to develop.

Symptoms include high fevers, shaking chills and flu

like illness. Without treatment, malaria can cause severe

illness and even death. People spending time outdoors

including sleeping outside are at higher risk for malaria.

Anti malarial tablets are recommended if you are going

to any Amazon areas. Travelling on to other South American countries could also put you at risk.

Risk management

Risk depends on the specific location, season of travel, length of stay, activities and type of

accommodation. Anopheles mosquitoes feed predominantly during the hours from dusk to dawn.

No malaria prevention tablets are 100% effective. Taking malaria prevention tablets in

combination with mosquito bite avoidance measures will give substantial protection against

malaria. Travelers should take mosquito bite avoidance measures as mentioned in the report.

Dengue Fever Dengue fever is a major public health concern in Brazil.

Disease incidence and severity have increased in the past

two decades. From 2000 to 2009, 3.5 million cases of

dengue fever were reported Dengue is systemic viral

disease caused by a virus that is spread through an

infected Aedes aegypti mosquito bite. Aedes aegypti

mosquitoes feed predominantly during daylight hours and

are most abundant in urban or peri-urban settings.

Symptoms include fever, headache, nausea, vomiting,

rash, and pain in the eyes, joints and muscles. After a

person is bitten by an infected mosquito the symptoms

can take up to 2 weeks to develop but usually end in a week. In severe cases, symptoms may

include intense stomach pain, repeated vomiting, bleeding from the nose or gums and death. The

mosquito that carries the dengue virus can bite during the day and night. Dengue is not usually

seen at altitudes above 4,500 feet (1,500 meters).

Risk management

There is no vaccination or medication to prevent dengue. A previous dengue illness with one of

the four dengue virus serotypes does not confer immunity to other virus serotypes. Infection with

a second dengue serotype may be a risk factor for the development of dengue haemorrhagic

fever. Travelers should take mosquito bite avoidance measures.

Yellow Fever

Yellow fever is a systemic viral disease and is endemic in

most parts of Brazil. Yellow fever is spread through

mosquito bites. Symptoms take 3–6 days to develop and

include fever, chills, headache, backache, and muscle

aches. About 15% of people who get yellow fever

develop serious illness that can lead to bleeding, shock,

organ failure and sometimes death.

Risk management

Travelers should take mosquito bite avoidance measures. Aedes mosquitoes feed predominantly

during daylight hours. Administration of yellow fever vaccine should take into account both the

certificate requirements under International Health Regulations and the risk of yellow fever at

the destination. The lack of a certificate requirement does not necessarily indicate that there is no

risk of disease

You should receive a yellow card called the International Certificate of Vaccination or

Prophylaxis (ICVP) to prove that you have had yellow fever vaccine. Some countries require all

travelers to show proof of yellow fever vaccination before they can enter the country. Other

countries require proof of vaccination only if travelers have been in a risk area, so if you are

visiting multiple countries, the order of travel may be important.

There are specific contraindications and adverse events associated with yellow fever vaccine. A

careful risk assessment should be made before administration and specialist advice sought as

appropriate.

Precautions against Mosquito Bites

General

Cover exposed skin by wearing long sleeved shirts, long pants and hats.

Use an appropriate insect repellent as directed.

Always follow product directions and reapply as directed

If you are also using sunscreen, apply sunscreen first and insect repellent second.

Use permethrin treated clothing and gear (such as boots, pants, socks, and tents). You can buy

pre-treated clothing:

Treated clothing remains protective after multiple washings. See the product

information to find out how long the protection will last.

Do not use permethrin directly on skin.

Take particular care at times when mosquitoes are most likely to bite: dusk and dawn and from

April until October.

Avoid areas where mosquitoes are likely to be found, i.e. near water including ponds, outdoor

swimming pools, lakes and marshes.

Spray onto exposed skin whenever you are in an area where mosquitoes may be present.

If in areas where mosquitoes are likely wear long sleeves, long trousers, socks and closed

shoes to minimize skin exposure.

Mosquito bites can be reduced by air conditioning, insect proof screens on windows and doors

and spraying the room with insecticide.

Some day biting mosquitoes also transmit infections, so reducing bites at any time is a sensible

precaution.

Empty containers of standing water near where you are staying to prevent mosquito eggs from

hatching.

Use area repellents if there are mosquitoes in your room.

Avoid unnecessary exposure (including while travelling and when sleeping) in infested areas.

Try to stay in air conditioned accommodation as this reduces the number of insects in your

room. Mesh screening on doors and windows also helps, but is not as effective as good air

conditioning. Plug-in devices (vaporizers) release an insecticide mist, but you need an

appropriate adapter plug for the country you are visiting

Screening and mosquito nets

Travelers staying in accommodation without screening should sleep under a net to avoid

being bitten at night.

Mesh size in mosquito bed nets should be no larger than 1.5 mm.

Contact insecticides will kill insects landing on the net and therefore increase the

effectiveness.

Other preventative measures

A systemic review demonstrated that mosquito coils can decrease bites by repelling and

killing mosquitoes. Coils which contain synthetic insecticide should only be used in well

ventilated areas and may be useful for some travelers.

Use a bed net if the area where you are sleeping is exposed to the outdoors.

Clothing

Wear loose fitting, light colored clothes (insects can reach skin through tight clothing), long

trousers and long sleeves. Don’t go barefoot.

Malaria mosquitoes are most active after dark, so it’s important to cover up in the evenings in

malaria risk regions.

In tick infested areas avoid shorts/skirts and tuck trousers into socks to stop ticks crawling up

your legs

Travelers to areas with a risk of dengue fever infection should cover up during the day if

possible, as the Aedes spp. mosquitoes that transmit dengue fever bite during the day.

To avoid bites wear clothing that covers as much of the body as possible such as long sleeved

clothing and long trousers.

Mosquitoes may bite through thin clothing, so spray an insecticide or repellent on them.

Insect repellents should also be used on exposed skin

Insect Bites

Bugs, including bedbugs, fleas, lice and mites can also spread disease. For example; fleas can

spread plague, some mites carry typhus (a flu like illness with a rash) and the kissing bug in

South America carries a parasite that causes a serious illness called Chagas disease (also called

American trypanosomiasis). Reduviid bugs, the vectors of American trypanosomiasis inhabit

cracks in the walls and roofs or buildings constructed from mud or thatch in Latin America. For

many diseases spread by insects, avoiding bites is the only way to prevent them. Places like

jungles and swamps may be highly infested with insects. It is almost impossible to completely

avoid bites but by reducing the number of times you are bitten you will reduce your risk of being

infected. Some diseases in Brazil such as dengue, leishmaniasis, and Chagas disease are spread

by bugs and cannot be prevented with a vaccine. Follow the insect avoidance measures described

to prevent these and other illnesses. You can reduce your risk by taking steps to prevent bug

bites.

What should I do if I am bitten by bugs?

Avoid scratching bug bites and apply hydrocortisone cream or calamine lotion to reduce

the itching.

Check your entire body for ticks after outdoor activity. Be sure to remove ticks properly.

Removing ticks

Ticks need to be removed from the skin carefully with tweezers or special tick removers. Grasp

the tick near to the skin and steadily pull it out. Be careful not to crush the tick’s body or squeeze

its stomach contents into the bite site.

Insect Repellents

Advice for travelers

Follow the manufacturer’s instructions carefully.

Apply directly to any exposed areas of skin.

Use a cream/lotion or spray repellent on your hands and then rub onto your face.

Re-apply regularly, especially after swimming and in hot, humid countries, as sweating

reduces effectiveness.

Don’t swallow repellent.

Don’t put apply to cuts, grazes or broken/irritated skin.

Wash hands after applying.

If you are using sunscreen, put it on first.

Sunscreen containing repellent is not recommended.

Leptospirosis

Leptospirosis is another environmental, zoonotic and water borne concern given the fact that this

disease is highly endemic, reported in Brazil, counts for almost 20,000 cases between 2007 and

2011. The disease has been associated with swimming, wading, kayaking and rafting in

contaminated lakes and rivers. As such it is a recreational hazard for travelers who participate in

outdoor sports in addition to consuming contaminated food and beverages

Be aware of the risk and avoid exposure to contaminated water where possible

All cuts, scratches and open skin lesions should be covered with waterproof plasters.

Do not swallow or drink water that could be infected

Washing and showering after possible exposure may be helpful

Food and Water Safety

Eating contaminated food and drinking contaminated water can cause illnesses such as hepatitis

A, typhoid fever, and travelers’ diarrhea. Beware of food from street vendors, ice in drinks, and

other foods and drinks that may be contaminated.

Traveler’s diarrhea

Traveler’s diarrhea and food borne diseases are highly common and prevalent. TD is acquired

primarily through the consumption of contaminated food or water. Traveler's diarrhea can be

caused by bacteria, parasites or viruses. The risk of TD is associated with the water, sanitation,

and hygiene environment and practices in specific destinations as well as the handling and

preparation of food in restaurants in developed countries. Poor hygiene practice in local

restaurants is likely the largest contributor to the risk for TD.

Inadequate electrical capacity may lead to frequent blackouts or poorly functioning refrigeration

which can result in unsafe food storage and an increased risk for disease. Inadequate water

supplies can lead to the absence of sinks for hand washing by restaurant staff as well as direct

contamination of foods such as fruits and vegetables washed in contaminated water. Poor

training in handling and preparation of food may lead to cross contamination from meat and

inadequate disinfection of food preparation surfaces and utensils. Drinking contaminated water is

the most common cause of acquiring traveler's diarrhea.

The following methods or products help reduce exposure to contaminated water.

Boiling water is the best method for eliminating infectious organisms

Avoid eating foods or drinking beverages purchased from street vendors or other

establishments where unhygienic conditions are present

Avoid eating raw or undercooked meat and seafood

If handled properly well cooked and packaged foods usually are safe. Tap water, ice,

unpasteurized milk and dairy products are associated with increased risk for TD. Safe

beverages include bottled carbonated beverages, hot tea or coffee, beer, wine and water

boiled or appropriately treated with iodine or chlorine

The best means of preventing TD is education regarding food and beverage selection

with the goal that the traveler avoid the consumption of high risk products

People often discuss the importance of care in selecting "safe" foods and beverages for

consumption

Water should be bottled and sealed, or boiled. Alcohol is OK, but ice cubes are not.

Eat and drink safely

Unclean food and water can cause travelers' diarrhea and other diseases. Reduce your risk by

sticking to safe food and water habits.

Eat

• Food that is cooked and served hot

• Hard cooked eggs

• Fruits and vegetables you have washed in clean water or peeled yourself

• Pasteurized dairy products

• Freshly cooked food such as soup or stir fry

• Canned food

• Food in sealed packs

• Fresh bread

Don't Eat

• Food served at room temperature

• Food from street vendors

• Raw or soft cooked (runny) eggs

• Raw or undercooked (rare) meat or fish

• Unwashed or unpeeled raw fruits and vegetables

• Unpasteurized dairy products

• ”Bushmeat” (monkeys, bats, or other wild game)

• Salads

• Uncooked fruits and vegetables, unless they have been washed in safe water

• Fresh or cooked food that has be allowed to stand at room temperature in warm environments or that has been exposed to flies such as in an open buffet

• Raw or undercooked meat, shellfish or seafood

• Food from street traders unless it is has been recently prepared and is served hot on clean crockery

• Raw fruit and vegetables unless you wash and peel them yourself

• Food left exposed to flies.

• Reheated food – especially fish, meat or rice.

• Takeaways and street food – unless thoroughly cooked in front of you.

• Unpasteurised milk, cheese, ice cream and other dairy products.

Drink

• Water that has been disinfected

• Ice made with bottled or disinfected water

• Carbonated drinks

• Hot coffee or tea

• Pasteurized milk

• Commercially sealed beverages in cans or bottles and served unopened such as carbonated drinks and drinks made with boiled water and served steaming hot such as coffee and tea are generally safe.

• Sealed bottled water produced by a recognized international manufacturer

Don’t Drink

• Tap or well water

• Ice made with tap or well water

• Drinks made with tap or well water (such as reconstituted juice)

• Unpasteurized milk

• Fountain drinks

• Fruit juices (if sold by a street vendor)

Precautions

Wash

Wash your hands before handling food

Wash and sanitize all surfaces and equipment used for food preparation

Protect kitchen areas and food from insects, pests and other animals

Always wash your hands before eating or preparing food. It is also important to remember

to wash your hands after using the bathroom, changing diapers or having contact with

animals or sick people.

Separate raw and cooked food

Separate raw meat, poultry and seafood from other foods

Use separate equipment and utensils such as knives and cutting boards for handling raw

foods

Store food in containers to avoid contact between raw and prepared foods

Cook thoroughly

Cook food thoroughly especially meat, poultry, eggs and seafood

Bring foods like soups and stews to boiling to make sure that they have reached 70°C. For

meat and poultry, make sure that juices are clear, not pink. Ideally, use a thermometer

Reheat cooked food thoroughly

Keep food at safe temperatures

Do not leave cooked food at room temperature for more than 2 hours

Refrigerate promptly all cooked and perishable food (preferably below 5°C)

Keep cooked food piping hot (more than 60°C) prior to serving

Do not store food too long even in the refrigerator

Do not thaw frozen food at room temperature

Use safe water and raw materials

Use safe water or treat it to make it safe

Select fresh and wholesome foods

Choose foods processed for safety such as pasteurized milk

Wash fruits and vegetables especially if eaten raw

Use ice made only from purified or disinfected water.

What can travelers do to protect themselves?

Consider purchasing travel health and medical evacuation insurance.

Get vaccinated

Take anti malarial meds

Eat and drink safely

Prevent bug bites

Keep away from animals

Reduce your exposure to germs

Travelers who sleep outdoors or who stay in poorly constructed housing are at greatest

risk. Therefore take necessary precautions

Travelers should be advised to avoid outdoor activities especially from dusk to dawn

Talk to your doctor about which medicine is best for you.

Emergency

If you need emergency medical help dial 192 to ask for an ambulance. Foreigners are entitled to

emergency medical treatment in Brazil’s public hospitals, but the public health system,

especially in big cities, tends to be crowded. Private hospitals will not treat you unless you have

proof that you can pay. Remember to contact your insurance and medical assistance company

promptly if you are admitted to a clinic or hospital. Both public and private health facilities in

remote regions may be very basic.

When you get back

There is a possibility that returning travelers will export communicable diseases for example

vector borne diseases such as dengue and introduce them to their country of residence. During

the World Cup travelers to Brazil may encounter Brazil endemic infections that could be

diagnosed after returning to their countries of origin. If you have any symptoms such as fever, flu

like illness or persistent diarrhea you should seek immediate medical advice. Make sure your

doctor knows you have been to South America. If you travelled to malarial areas an urgent

malaria test must be arranged. This is important even if you took anti malarial tablets and have

been home for a while.

If you are not feeling well after your trip you may need to see a doctor. Be sure to tell your

doctor about your travel, including where you went and what you did on your trip. Also tell your

doctor if you were bitten or scratched by an animal while traveling. Malaria is always a serious

disease and may be deadly. If you become ill with a fever either while traveling in a malaria risk

area or after you return home (for up to 1 year), you should seek immediate medical attention

and should tell the doctor about your travel history.

Conclusion

The health risks whilst travelling to Brazil will vary between individuals and many issues need to

be taken into account such as planned activities, length of stay and the general health of the

traveler. Many of the problems experienced by travelers cannot be prevented by vaccinations and

so other preventive measures need to be taken; for example, consumption of safe food and water

and protection from sun exposure and insect bites.

There is potential for transmission of imported or endemic communicable diseases, especially

those that have an increased transmission rate as a result of close proximity of multiple

asymptomatic but infected individuals. Limited food borne outbreaks due to bacterial and viral

infections are expected. The risk to be affected by gastrointestinal illness will be reduced by

standard hygienic measures. Recently aiming to prevent food borne illnesses during the 2014

FIFA World Cup, Brazil has developed a risk based evaluation tool able to assess and grade

Brazilian food services in cities that will host football matches. This tool has been used by the

Brazilian sanitary surveillance officers during the inspection of facilities where food services.

Riskpro recommends that all travelers attending the 2014 FIFA World Cup take routine health

precautions.

Manoj Jain Managing Director Riskpro Email: manoj.jain@riskpro.in

Mangesh Sawant Senior Vice President Security Consulting & Risk Management Riskpro Email: mangesh.sawant@riskpro.in

www.riskpro.in

Be Safe Stay Safe