The Summer Olympics and Zika: Tips and Recommendations to Prevent Transmission

By Michael D. Holzer MD, MPH&TM, National Travel Medicine Medical Director | 05/10/2016

Travel Health Recommendations for Travel to Rio de Janeiro, Brazil for the 2016 Summer Olympics and Paralympics


Background

The 2016 Summer Olympics will take place in Rio de Janeiro from August 5-21 and the Paralympic Games from September 7-18. The majority of the events are in Rio de Janeiro, but soccer matches will also be played in Brasilia, Sao Paulo, Belo Horizonte, Salvador and Manaus. It has been estimated that around 500,000 people will come from all over the world to Rio de Janeiro for the games.

Recommended Vaccines

  • Hepatitis A

    • Recommended for all travelers
    • Transmission = contaminated food and water
    • 2 shot series each separated by at least 6 months, but first shot will provide protection for at least 6 months
  • Influenza

    • Recommended for all travelers who have not received the 2015-2016 flu vaccine
    • Risk in Rio and most of Brazil is all year round, and increased risk due to large gatherings during Olympics
    • All flu vaccine in the United States will expire on June 30 and therefore no flu vaccine will be available in the US in July/Early August
  • Typhoid Fever

    • Recommended for most travelers, especially for adventurous eaters or those travelling to rural areas
    • Transmission = contaminated food and water
    • Two options for vaccine
      • Injectable lasts 2 years
      • Oral - lasts 5 years
  • Routine Vaccines

    • All travelers should be up to date with their routine vaccines. These includes
    • Tetanus, Diphtheria and Pertussis (Tdap)
    • Measles, Mumps and Rubella (MMR)
    • Varicella (Chicken pox)
  • Yellow Fever

    • Transmission = infected mosquitos
    • There is NO yellow fever virus transmitted in Rio de Janeiro, so travelers who plan to only stay in Rio should not get the vaccine
    • Travelers planning to go to other areas of Brazil, including but not limited to Iguazu Falls and the Amazon are at risk of getting yellow fever and should get the vaccine unless contraindicated. The yellow fever vaccine would also be recommended for most travelers attending soccer matches in Manaus, Brasilia, and Belo Horizonte. Please refer to the Yellow Fever Map.
    • Yellow fever vaccine is only available at state authorized yellow fever vaccine centers, such as Concentra's Travel Health Centers

Malaria

  • There is NO malaria in Rio de Janeiro, Sao Paulo, Belo Horizonte, Brasilia or Salvador
  • There is also no malaria at Iguazu Falls
  • There is malaria in Manaus and entire amazon as well as other areas of Brazil (refer to Malaria Map of Brazil)
  • Transmission = Infected mosquitos
  • Prevention
  • Medications (There is no vaccine to prevent malaria)
    • See a travel health specialist to determine which anti-malarial medication is the best choice for you
    • Insect precautions as below from sunset to sunrise

Zika

Background

Zika virus was first identified in Africa in 1947 and up until 2007, sporadic infections occurred in at least 12 countries in Africa and SE Asia. Given its cross-reaction in commonly used dengue antibody tests, misdiagnosis as mild dengue has most likely led to underreporting of Zika virus infection. Since early 2015, the largest outbreak ever was first discovered in Brazil and subsequently to most other countries in Central and South America and the Caribbean. While most Zika infections result in either no or very mild symptoms, Zika infections during pregnancy can be passed to fetus causing microcephaly and other birth defects and poor pregnancy outcomes. There have also been reports of increased rates of Guillain-Barre' syndrome (GBS), an auto-immune disease that attacks the nervous system, in individuals with Zika infection. Symptoms of GBS include weakness of both arms and legs but in severe cases can involve the lungs requiring mechanical ventilation. Most people fully recover from GBS. GBS is a rare complication of many infections including the flu.
  • How is Zika transmitted?

    The virus is transmitted by bite of an infected Aedes mosquito, most commonly Aedes aegypti. This is the same mosquito that transmits yellow fever, dengue, and chikungunya which are diseases that are also found in Brazil. These mosquitos bite during the day, with peak biting times being the first 2-3 hours after dawn and mid-late afternoon. Zika may also be sexually transmitted from a male to his sexual partners. There have not been any documented cases of a woman sexually transmitting the virus to sexual partners. For more information, refer to travel recommendations below.
  • What are the symptoms?

    Approximately, 1 of 5 people who become infected has symptoms. The incubation period is approximately 3-14 days. The majority of cases are very mild and self-limited and last less than a week. Severe disease resulting in hospitalization is very uncommon. The most common symptoms are:
    • Rash
    • Joint and muscle pain
    • Fever
    • Conjunctivitis (red eyes)
    • Headache
  • What is the treatment?

    There is no specific treatment for Zika. Treatment is supportive and includes hydration, rest and analgesics. NSAIDS (such as ibuprofen and Naprosyn) and Aspirin should be avoided unless dengue is ruled out (due to possible bleeding complications associated with dengue) as the presentation and area of risk are similar.
  • Travel Recommendations for pregnant women, women trying to become pregnant, and their male partners

    • For the prevention of possible Zika associated complications with pregnancy in a pregnant female
      • Pregnant women should not go to the Olympics/Paralympics
        • If must go, consult with a travel health specialist 4-6 weeks prior to leaving
      • Male partners of pregnant women who attend Olympics
        • should use condoms or do not have sex (vaginal, anal, or oral) during the pregnancy
    • For the prevention of possible Zika associated complications with pregnancy in a non-pregnant female
      • Couples in which a man had confirmed Zika virus infection or clinical illness consistent with Zika virus disease should consider using condoms or abstaining from sex for at least 6 months after onset of illness.
      • Couples in which a man traveled to the Olympics/Paralympics or any other area with active Zika virus transmission but did not develop symptoms of Zika virus disease should consider using condoms or abstaining from sex for at least 8 weeks after departure from the area.
      • Women with Zika Virus disease should wait at least 8 weeks from symptom onset before attempting conception.
      • Women who travel to the Olympics/Paralympics or other areas with active Zika transmission should wait until at least 8 weeks after the last date of exposure before attempting conception.
    • All travelers to Brazil for the Olympics/Paralympics should use insect precautions as described below, but even more important for the individuals above
  • How can Zika be prevented?

  • There is no vaccine currently available to prevent Zika. Avoiding being bitten by mosquitoes is the best way to prevent Zika and other insect borne diseases. For Zika (as well as dengue, chikungunya and yellow fever) daytime insect precautions and personal protection measures should be followed. This includes, but not limited to:
    • Using an insect repellant containing DEET (25-50%) or picaridin (20%) which are safe in pregnancy.
    • Long pants/long sleeves during biting times.
    • Staying in air conditioned and/or places with window and door screens.
    • Treat clothing and gear with permethrin, including permethrin treated bed net, if not sleeping in a well screened and/or air conditioned room.

    Other Health Risks

    • Food and waterborne illnesses - Hepatitis A, Typhoid, Travelers' Diarrhea

      • Avoid tap water, ice cubes, unpasteurized dairy products, street food, unwashed or unpeeled fruits and vegetables
      • Despite travel health advice, rates of travelers' diarrhea has not significantly changed
      • Your travel health specialist can equip you with an antibiotic to take to self-treat travelers' diarrhea
    • Sexually Transmitted Diseases - HIV, Hepatitis B, Gonorrhea, Chlamydia, Syphilis, Zika, Others

      • Many travelers indulge in activities they do not normally do back at home or to a much greater extent due to anonymity, increased alcohol consumption and/or drugs
      • High risk sexual activities, including sex without a condom, may increase, especially when alcohol or drugs are involved
      • If there is a possibility that you may engage in sex while abroad, carry condoms that were purchased from a reliable source, drink in moderation, and avoid drugs
    • Other Insect borne disease - Dengue and Chikungunya

      • These 2 diseases are spread by the same mosquito that transmits yellow fever and Zika
      • Symptoms are often more severe than Zika
      • Prevention is the same as for Zika, except these diseases are not sexually transmitted
    • Animal Bites - Rabies

      • Transmission = any mammal with fur is capable of transmitting rabies, but especially dogs
      • If develop the symptoms of rabies it is essentially 100% fatal
      • Prevention is by avoiding being bitten
      • If bitten or scratched, wash wound with soap/water and betadine if available and seek immediate medical care at a hospital that has Rabies Immune Globulin (RIG)
      • There is an expensive 3 shot vaccine series over 3-4 weeks that is available and would preclude an individual from needing to obtain RIG. RIG may be difficult to obtain if not in one of the larger Brazilian cities.
    • Injury and Accidents

      • According to the CDC, motor vehicle crashes are the #1 killer of healthy US citizens in foreign countries
      • Brazil has one of the highest road fatality rates in the world
      • Always wear a seat belt, avoid travelling at night, and do not drink and drive

    There are other health risks depending on your itinerary, activities, and medical history. Travelers planning to attend the Olympics or Paralympics should seek the advice of a travel health specialist four to six weeks prior to departure. Your travel health specialist will provide:

    • Recommended vaccines
    • Prescriptions to prevent or self-treat common travel-related illnesses
    • Health and safety counseling tailored to your specific itinerary, activities, and medical history