Page 1 of 4SPECIAL REPORT: Brazil: Health Concerns for Olympic Attendees

Brazil: Health Concerns Surrounding Olympic Training and Venues Point to the Need for Early Planning for AttendeesExecutive SummaryRecent media stories have put coastal waters in Brazil in the spotlight, as reported elevated levels of viral and bacterial contamination hazardous to human health are believed potentially to impact visitors and athletes of the 2016 Summer Olympic Games. International health officials, however, are reluctant to issue mandated testing of the water; the World Health Organization (WHO) released “guidelines,” and the International Olympic Committee (IOC) stated that it will not conduct testing without an official WHO recommendation. In addition to waterborne health risks, Brazil has been embattled with mosquito-borne illnesses in 2015, with more than 746,000 cases of dengue reported, representing a 236-percent increase over 2014.

Potential Health Threats in BrazilLongstanding issues regarding pollutants and contaminants known to endanger human health in Brazilian inland and coastal waters have sparked some anxiety among 2016 Olympic participants and coaches. For example, recent media reports detailing the illnesses of 13 US Rowers participating in the World Junior Rowing Championships have garnered much attention. The team physician reportedly suspected pollution in the lake where the competition took place outside of Rio de Janeiro as the source of the team’s poor health. Multiple participants from other boating teams also reported illnesses; however, event officials stated that the case numbers of various reported illnesses in proportion to the number of participants in the event fell within an expected range. In an independent analysis in July, the Associated Press reported high levels of viruses and bacteria, largely from human sewage, in many of the Olympic and Paralympic water venues.

Despite the assertions by Brazilian health officials that water pollutants would be cleaned by 80 percent prior to January 2015, high levels of contamination remain, increasing participants’ concerns about exposure to infectious disease.

Although the WHO has encouraged testing the Rio de Janeiro area waters for viruses and other contaminants, the globally recognized health authority has fallen short of officially recommending mandatory testing. The IOC has stated that until the WHO makes an official declaration on the need for testing for viruses, only bacterial testing – the only requirement by Brazilian law – will be routine. Although the acute illnesses suffered recently by the US team could have been due to other exposures to gastrointestinal pathogens, the ailments serve to highlight the broad health-related issues visitors may face in the Rio de Janeiro area.

Key JudgmentsContinuous monitoring for health concerns at Olympic venue sites is key to mitigating health risk:

• Waterborne contamination can be avoided by swimming in chlorinated pools.

• Pre-trip immunizations given in advance of travel may protect against some illnesses.

• Food and water safety measures can reduce many common types of illness.

• Insect bite precautions may reduce the risk of many common vector-borne health threats.

• Events such as the Olympics increase health risks due to population surges and global travel.

Aug. 20, 2015

SPECIAL REPORT: Brazil: Health Concerns for Olympic AttendeesPage 2 of 4

The root cause of illnesses in those training or participating in trials calls to light the need for adequate understanding of the health risks that may be faced in the area, especially as disputes between Games officials and critics of the water pollution escalate. Contaminants found in the waters, including fecal coliforms 10 times the acceptable limit per Brazilian regulations; multi-drug resistant Klebsiella sp.; various adenoviruses capable of causing respiratory and gastrointestinal illness; rotavirus, a significant digestive pathogen; and multiple other infectious disease-generating pathogens, all of which pose health concerns for residents, athletes participating in training or the Games, and visitors for the 2016 Olympics who may partake in beach or water activities.

As polluted open-water exposure cannot officially be ascertained as the direct cause of illnesses among US and other national athletes earlier this year, food and water concerns are speculated as the next most probable cause. Travelers to Brazil may be exposed to a range of pathogens with the potential for causing disease in humans from drinking water, in foods that are uncooked and not served hot and fresh, and by poor hygienic practices of those preparing or serving food.

Other health risks in the area include mosquito-borne diseases, particularly dengue fever and chikungunya. As of July 27, the Ministry of Health in Brazil reported more than 48,000 suspected cases of dengue in Rio

de Janeiro – more than was reported in all of 2014. Officials stated one potential cause for the increase in cases was varying circulating strains of the dengue sub-type; however, breeding areas, such those inadvertently created by construction sites, for the vector that carries dengue virus plague the area, especially as preparations for the Summer Games continue. Chikungunya, a rising problem in northern and northeastern Brazil, has not been shown to be epidemic in Rio de Janeiro, and despite one case of related Zika virus having been found in June of 2015, this vector-borne threat has yet to emerge as a significant concern in the city. Data is still young on these diseases, and it is difficult to ascertain what potential risks for August of 2016 may look like. With adequate control measures, insect-spraying efforts, and reduction of breeding sites, the risk may be reduced. However, a lack of action by officials could increase health concerns.

Although some of the participants in the Summer Games of 2016 may be unable to avoid the health threats that polluted waters pose, tourists and spectators planning on attending any of the Olympic trials, training, or games may be able to prevent and/or mitigate many of the hazards. Avoiding areas of known contamination and high levels of bacteria and/or viruses may significantly reduce digestive, respiratory, and more serious illnesses. Swimming only in well-chlorinated pools will markedly reduce

Dengue Fever Incidence in Brazil, 2014 Dengue Fever Incidence in Brazil, 2015

Page 3 of 4SPECIAL REPORT: Brazil: Health Concerns for Olympic Attendees

exposure to many potential diseases. If reportedly contaminated areas cannot be avoided, ensuring that no polluted water is inhaled or swallowed and thoroughly cleansing exposed skin with soap and clean water may reduce risk. Food and water precautions such as drinking only from sealed, bottled water that is name brand and eating only food that is served very hot and fresh, as well as eating fresh fruits and vegetables that you peel yourself – avoiding salad and fruit bars – will reduce the risk of food- or waterborne illnesses. Taking thorough insect bite precautions by covering exposed skin with lightweight, loose-fitting, lightly colored clothing and using products containing DEET on exposed skin may provide protection against mosquitoes and other hazardous insects. Use of a mosquito net over bedding at night if there is no air conditioning or if rooms are exposed to the outside may also help prevent bites. Although the mosquitoes that carry dengue are known to be “day-biters,” other species of mosquitoes and insects may pose risks at night. Monitoring for new health outbreak information from a trusted source, as well as knowing where local health facilities are located nearby, is advisable in the event of illness or injury. Not all medical facilities accept travel health insurance or have multilingual staff. Researching in advance which facility may be optimal will reduce anxiety and frustration in the event of acute need for medical care.

With continued pressure from participating nations in the 2016 Summer Olympics to better test the waters for dangerous pathogens, more information and guidance for coaches, athletes, and spectators will be needed. It is unlikely that the waters can be significantly cleaned, given that most of the contamination is secondary to raw sewage discharge into the local waterways; an effective method of correcting such pollution would require investing in and correcting an infrastructure concern that has beleaguered Rio de Janeiro for a long time. Knowledge of the specific viruses or bacteria in the water, as well as the levels of contamination, would aid in decision-making regarding health risk mitigation for the Games. Those potentially exposed would then be able to take enhanced precautions and monitor for specific symptoms, relaying exposure risk to a medical provider should they become ill. However, a lack of funding for viral testing has been cited by Brazilian health authorities as the reason for omitting enhanced water quality research and testing. Renewed funding may provide enhanced testing measures.

Further concerns include dengue, which has been a threat that has waxed and waned in the greater Rio de Janeiro area for many years, but is markedly more pronounced in other areas of Brazil (see map above). It is likely that the threat will continue into and through 2016 at a relatively stable rate. While chikungunya and Zika virus may not be as prominent in Rio de Janeiro, their presence in other states has been steadily growing and is not expected to decline significantly before next year’s Summer Games for those travelers with an extended itinerary. Visitors to the games may be exposed to these vector-borne diseases should they travel to other areas of Brazil with heightened risk of these viruses. With the influx of global travelers, especially next summer, other spikes of disease activity are likely to occur, and travelers should remain vigilant around surveillance of disease presence and risk in their respective areas of travel. Spikes in epidemic activity of many various diseases occur throughout Brazil, and although the Health Ministry has excellent reporting and surveillance measures in place, visitors should understand infrastructure limitations to cope with preventive measures and their potential risk of exposure.

ConclusionTravelers participating in or attending the pre-game events and/or the 2016 Summer Olympics and Paralympics should be aware of the myriad health concerns the venue areas are facing. Education regarding pre-travel immunizations, precautions for food, water, and insect bites, and ensuring an understanding of the local health resources are vital to ensure a healthy experience. Ongoing issues of pollution in the waters in and near the venue sites may pose additional health risks that require enhanced precautions. While a consensus regarding water quality testing has yet to be reached, public pressure from attendees through media outlets may encourage expanded testing, as well as increased clean-up efforts as the events draw closer.

Further information regarding health, safety, and security at the 2016 Summer Olympic and Paralympic Games in Brazil will continue to be provided as the event draws nearer. For information regarding medical or security assistance during the 2016 event, please contact assistance@ijet.com. For in-depth reporting or analysis on the event or venue sites, please contact assessments@ijet.com, and for in-depth health considerations, please contact health@ijet.com.

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