Friday, July 29, 2016

Patients Going to Rio Olympics? Here's the Advice You Should Give

The 2016 Summer Olympics begin in Rio de Janeiro on August 5. Travelers to the Olympics face unique health risks. Martin Cetron, MD, director of the Division of Global Migration and Quarantine at the Centers for Disease Control and Prevention (CDC), answers questions about counseling patients who are traveling to the 2016 Summer Olympics.


Medscape: What vaccines do travelers to Brazil need?

Martin Cetron, MD: All travelers should be current on routine immunizations, including an annual influenza vaccine. Most travelers should also be vaccinated against hepatitis A and typhoid. Some travelers should consider hepatitis B vaccination, particularly if they may be at high risk (engage in risky sex, get tattoos, or use injection drugs). Those who are likely to have contact with animals should consider the rabies vaccine. Most of the Olympic Games will be held in and around Rio, where there is no risk for yellow fever or malaria, but some of the soccer venues are in cities where these diseases can be acquired. Depending on their itineraries, some travelers may need yellow fever vaccine or malaria prophylaxis (Figure 2).

Figure 2. Areas of Brazil associated with mosquito-borne diseases.

Medscape: What other health risks do travelers face in Brazil?

Dr Cetron: Broadly, the three most common categories of health risks are (1) foodborne and waterborne diseases, primarily travelers' diarrhea; (2) vector-borne diseases such as Zika; and (3) threats to safety and security.


Medscape: Do you recommend prescribing antibiotics so that travelers can self-treat diarrhea?

Dr Cetron: Travelers' diarrhea is among the most predictable travel-related illnesses. Travelers can avoid it by choosing only bottled drinks and eating only food that is cooked and served hot. Adults and older children may wish to treat mild to moderate diarrhea symptoms with antimotility agents such as loperamide or bismuth subsalicylate. Antibiotics can be reserved for more severe symptoms, but travelers may appreciate having them available so that they don't miss a crucial event. A single dose of 500 mg ciprofloxacin is standard treatment.

Medscape: What about swimming? A recent news report said that the beaches are contaminated with raw sewage.

Dr Cetron: Some recreational water around Rio has been found to be contaminated with sewage. Travelers should look for recreational water areas that the government has classified as suitable (própria in Portuguese), cover cuts with waterproof bandages, and try to avoid swallowing water. Note that schistosomiasis is also a risk in Brazil, so travelers should not swim in fresh water (lakes and rivers). A chlorinated pool is probably safest.

Medscape: Does CDC have any resources that I can offer my patients to help them avoid foodborne and waterborne disease?

Dr Cetron: I thought you'd never ask! Yes, CDC has two useful mobile apps for iPhone and Android. The first is called Can I Eat This? and it guides travelers through a series of questions to help them make safe food and beverage choices. CDC's app TravWell is a healthy-travel planning app that offers vaccine recommendations and a travel-health packing list. CDC also has printable infographics that show examples of safer and riskier choices (Figure 3).

Figure 3. Safe food and drink choices.


Medscape: What should I tell patients about Zika?

Dr Cetron: Most Zika virus infections are asymptomatic; when symptoms develop, they are usually mild and last only a few days. Many people might not realize that they have been infected. However, Zika virus infection during pregnancy can cause microcephaly and other neurologic abnormalities. There may also be a link between Zika and Guillain-Barré syndrome.

Medscape: What can travelers do to prevent vector-borne diseases?

Dr Cetron: Travelers can reduce their risk by preventing mosquito bites. They can wear long-sleeved shirts and long pants and stay in accommodations that are air conditioned. People going to the Olympics should also use an EPA-registered insect repellent that includes DEET, picaridin, IR3535, oil of lemon eucalyptus, or para-menthane-diol. Because Zika can also be transmitted sexually, travelers should use condoms or abstain from sex while in an area with ongoing Zika virus transmission. Travelers with a pregnant partner should use condoms or not have sex during pregnancy, even after returning from Rio (Figure 4).

Figure 4. Protection from Zika during and after the summer Olympics.

Medscape: My patients who are traveling are healthy, young, and not pregnant or planning to become pregnant. They don't perceive any risk from Zika. How can I convey the need to take precautions?

Dr Cetron: Tell your patients that even if they don't become sick, they can infect local mosquito populations after returning home. Infected people are viremic for about a week, and if they are bitten by mosquitos back at home, they can transmit the Zika virus to those mosquitos, which can then infect other people. Even if they do not feel sick, travelers returning to the United States from Brazil should take steps to prevent mosquito bites for 3 weeks (a 2-week incubation period plus 1 week of active viremia). This will prevent them from infecting mosquitoes in the United States with Zika. To prevent sexual transmission, men should use condoms or abstain from sex for 8 weeks after leaving (6 months if they become symptomatic). Women should wait at least 8 weeks after travel before trying to conceive.


Medscape: My patients are worried about their safety, even in such tourist destinations as Copacabana and Ipanema. What should I recommend?

Dr Cetron: As with any international mass gathering, US travelers may be targets for criminals. Advise travelers not to travel at night, to avoid questionable areas, and to travel with a companion. If your patients drink alcohol, advise them to do so in moderation. Drunk people are more likely to hurt themselves or other people, engage in risky sex, or get arrested. More information on safe travel to mass gatherings is available at Travel to Mass Gatherings.

Medscape: This question comes up very often: What should travelers do with their passports while in Brazil? Should they carry their passports with them at all times?

Dr Cetron: No. Travelers should carry a photocopy of their passport and entry stamp but leave the actual passport securely in the hotel. Travelers should also carry contact information for the nearest US embassy or consulate in Brazil.

Medscape: What other safety tips do you have for people going to Rio for the Olympics?

Dr Cetron: Like in any other big city, travelers should not wear expensive clothing or jewelry. Keep hotel doors locked, and store valuables in secure areas. If possible, travelers should choose hotel rooms on the second through the sixth floors. A room on the first floor of a hotel may provide easier access for criminals. Rooms on the seventh floor or above may be difficult to escape in the event of a fire.

Dr Martin Cetron is the director of the Division of Global Migration and Quarantine at the US Centers for Disease Control and Prevention. Dr Cetron holds faculty appointments in the Division of Infectious Disease at the Emory University School of Medicine and the Department of Epidemiology at Rollins School of Public Health. His primary research interests are global health and migration, with a focus on health disparities, emerging infections, tropical diseases, and vaccine-preventable diseases, particularly in mobile populations.

Susan Yox, RN, EdD; Martin Cetron, MD

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