Football World Cup 2014 Health Advisory if you are traveling to South America and Brazil. Original created by my colleagues at Riskpro

1. Mangesh Sawant
Brazil World Cup
Football 2014
Health Advisory

2. 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.

3. 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.

4. 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

5. 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

6. 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.

7. 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

8. 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.

9. 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.

10. 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)

11. 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.

13. 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.

14. 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.

15. 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

16. Be Safe
Stay Safe