Review
The 2014 FIFA World Cup: Communicable disease risks and advice for visitors to Brazil – A review from the Latin American Society for Travel Medicine (SLAMVI)

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Summary

The next FIFA World Cup will be held in Brazil in June–July 2014. Around 600,000 international visitors and participants (as well over 3 million domestic travelers) are expected. This event will take place in twelve cities. This event poses specific challenges, given its size and the diversity of attendees, including the potential for the transmission of imported or endemic communicable diseases, especially those that have an increased transmission rate as a result of close human proximity, eg, seasonal influenza, measles but also tropical endemic diseases. In anticipation of increased travel, a panel of experts from the Latin American Society for Travel Medicine (SLAMVI) developed the current recommendations regarding the epidemiology and risks of the main communicable diseases in the major potential destinations, recommended immunizations and other preventives measures to be used as a basis for advice for travelers and travel medicine practitioners.

Mosquito-borne infections also pose a challenge. Dengue poses a significant risk in all states, including the host cities. Vaccination against yellow fever is recommended except for travelers who will only visit coastal areas. Travelers visiting high-risk areas for malaria (Amazon) should be assessed regarding the need for chemoprophylaxis. Chikunguya fever may be a threat for Brazil, given the presence of Aedes aegypti, vector of dengue, and the possibility of travelers bringing the virus with them when attending the event. Advice on the correct timing and use of repellents and other personal protection measures is key to preventing these vector-borne infections. Other important recommendations for travelers should focus on preventing water and food-borne diseases such as hepatitis A, typhoid fever, giardiasis and traveler's diarrhea. Sexually transmitted diseases (STD) should be also mentioned and the use of condoms advocated.

This review addresses pre-travel, preventive strategies to reduce the risk of acquiring communicable diseases during a mass gathering such as the World Cup and also reviews the spectrum of endemic infections in Brazil to facilitate the recognition and management of infectious diseases in travelers returning to their countries of origin.

Introduction

The FIFA World Cup is to be held in Brazil for the second time in 2014 (the first occasion was in 1950). Around 600,000 international visitors and participants (as well over 3 million domestic travelers) are expected for the event, which will take place in twelve cities around the country (the largest in South America) between the 12th of June and the 13th of July, 2014. It is a unique opportunity for Brazil to showcase the beauty and diversity of its many tourist attractions (including one the New Seven Wonders of the World, Christ the Redeemer in Rio de Janeiro). While Brazil has successfully hosted a number of large international gatherings, this event poses specific challenges, given its size and the diversity of attendees. This was extensively discussed at the past XVIII International Congress for Tropical Medicine and Malaria, XLVIII Congress of the Brazilian Society of Tropical Medicine and 3rd Latin American Congress of Travel Medicine, which took place in Rio de Janeiro, on September 23–27, 2012, as part of the activities organized by the Latin American Society for Travel Medicine (Sociedad Latinoamericana de Medicina del Viajero, SLAMVI, http://www.slamviweb.org) [1]. 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, eg, seasonal influenza [2], but also tropical diseases that are endemic in Brazil, such as malaria, dengue, leishmaniasis, among others. In addition, such high-profile events may also attract deliberate release of biological or other agents, which should be also considered. For example after the September 11, 2001 terrorist attacks in the United States of America, preparedness and response was raised also in international sports events, such as the Pan-American games, which particularly included enhanced surveillance and rapid detection of terrorist-induced or natural outbreaks for timely intervention to limit exposure and to implement prophylaxis [3], [4], [5]. Then, these are also considerations that should be considered by national health authorities in Brazil in anticipation of the FIFA World Cup 2014.

Strategies to reduce the risk and mitigate the impact of acquiring communicable diseases during a mass gathering such as the World Cup and the Olympic Games, should include pre-travel consultation, enhanced epidemic intelligence to promptly detect incidents, the provision of standard operating procedures for epidemic response, and training and pre-accreditation of food suppliers to reduce food-borne disease outbreaks [2]. International mass gatherings pose specific challenges not only to implementing control measures due to the mobility of the attendees but also with regard to recognition and management of infectious diseases in travelers returning to their countries of origin. There is a huge commitment to make the event safe for all who visit the country, including authorities and travel medicine experts and practitioners in Brazil [2], [6], [7], [8]. Particularly, during the last three years, then, in order to plan and prepare health system conditions, particularly at the host cities, the Federal Government of Brazil, with the joint action of the Ministry of Health and the Ministry of Sports, installed in May 2011, the Technical Camera of Health (Câmara Temática de Saúde), with the objective to promote interaction between different government sectors, define orientations, strategic projects, responsibilities and goals to attain and also to assess and advise the execution of preparatory actions for the FIFA World Cup 2014 in relation to health [9]. Innovative measures have been even taken regarding the implementation of new health strategies, for example the inclusion of bags with health aid devices and defibrillators for all the players [10].

In anticipation and preparation for the increased travel, to and from Brazil, a panel of experts from the Latin American Society for Travel Medicine (SLAMVI) developed the current recommendations regarding the risk of the main communicable diseases at major potential destinations, particularly the host cities, recommended immunizations and other preventives measures to be used as advice for travelers and travel medicine practitioners, taking in consideration the epidemiology of infectious diseases in the country and its regions, states and cities. These recommendations constitutes a scientific summarized version of an already online report in Spanish of SLAMVI at its website for healthcare professionals (http://www.slamviweb.org/es/home/RECOMENDACIONES%20PARA%20LOS%20VIAJEROS%20A%20LA%20COPA%20MUNDIAL%20DE%20FUTBOL%20BRASIL%202014.pdf) and also for travelers (http://www.slamviweb.org/es/home/Muncial%20de%20Futbol%20Consejos%20para%20Viajeros%20SLAMVI.pdf).

Section snippets

About Brazil

Brazil is the largest country in both South America and the Latin American region. It is the World's fifth largest country, both by geographical area and by population. It is the largest Lusophone country in the World, and the only one in the Americas. Bounded by the Atlantic Ocean on the east, Brazil has a coastline of 7491 km (4655 mi) (Fig. 1). It is bordered on the north by Venezuela, Guyana, Suriname and the French overseas region of French Guiana; on the northwest by Colombia; on the west

Malaria

As a country with a large area in the tropics, includes major zones of malaria and yellow fever transmission, among many other tropical and vector-borne diseases [15], [16]. Malaria is considered endemic in all the states of the north region (Fig. 1) and some municipalities at west of Maranhaõ (northeast region) and Mato Grosso (central west region) (Fig. 1) (Table 1). However, number of cases has been dramatically reduced over the last 8 years, falling from over 600,000 cases in 2005 to less

Immunizations

Currently no vaccines are required by the Government of Brazil on arrival to the country. However, as a general suggestion, all travelers should be up-to-date on their routine vaccines, including hepatitis A, influenza, measles, mumps and rubella [32], but also tetanus, diphtheria, pertussis, pneumococcal and varicella if possible, as not all persons would be candidates for these last two vaccines in many countries [76]. Unfortunately, recent data of travelers to Brazil, eg. from Boston, USA,

Conclusions

As in previous FIFA World Cups, 2014 Brazil will be a major international sporting and cultural event for the host country [81]. Brazil is already a popular tourist destination in Latin America. Healthcare sector administration in Brazil is prepared to deploy medical resources at any stage of the event, and for any unexpected health-compromising events, including but not limited to infectious diseases and mass casualty events [1], [8]. Beyond attention during the World Cup, travelers to Brazil

Conflict of interest

The authors have no conflict of interest to disclose.

Acknowledgment

The authors thank the reviewers and the Editor-in-Chief, Dr. Patricia Schlagenhauf for helpful advice, review and critical comments on the final version of this manuscript.

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