Accepted Manuscript

Football fever in Russia: Infectious disease risks and the FIFA world cup 2018

Natalia Pshenichnaya, Eskild Petersen, Dipti Patel, Philippe Gautret, Patricia

Schlagenhauf

PII: S1477-8939(18)30145-5
DOI: 10.1016/j.tmaid.2018.06.010
Reference: TMAID 1282

To appear in: Travel Medicine and Infectious Disease

Received Date: 12 June 2018

Accepted Date: 12 June 2018

Please cite this article as: Pshenichnaya N, Petersen E, Patel D, Gautret P, Schlagenhauf P, Football
fever in Russia: Infectious disease risks and the FIFA world cup 2018, Travel Medicine and Infectious
Disease (2018), doi: 10.1016/j.tmaid.2018.06.010.

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EDITORIAL

Football fever in Russia: infectious disease risks and the FIFA World Cup 2018

Natalia Pshenichnaya1, Eskild Petersen2, Dipti Patel3 , Philippe Gautret4, Patricia Schlagenhauf 5

1. Department of Infectious Diseases, Rostov State Medical University, Rostov-on-Don,

Russia; Department of infectious Diseases and Parasitology, Rostov Scientific Research
Institute of microbiology and parasitology, Rostov-on-Don, Russia.
Corresponding author: natalia-pshenichnaya@yandex.ru

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2. Institute for Clinical Medicine, University of Aarhus, Denmark and Department of
Infectious Diseases, The Royal Hospital, Muscat, Oman.
3. National Travel Health Network and Centre (NaTHNaC), UCLH NHS Foundation Trust,

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London NW1 2PG, UK
4. Aix Marseille Univ, IRD, AP-HM, SSA, VITROME, IHU-Méditerranée Infection, Marseille,
France

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5. University of Zurich Centre for Travel Medicine, WHO Collaborating for Travellers’
Health, Department of Public Health, Institute for Epidemiology, Biostatistics and
Prevention, Hirschengraben 84, 8001 Zurich, Switzerland

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The World Cup 2018 (from June 14th to July 15th) will be held in Russia in 11 host cities
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(Moscow, St. Petersburg, Kaliningrad, Kazan, Nizhny Novgorod, Rostov-on-Don, Samara,
Saransk, Sochi, Volgograd, and Yekaterinburg) that span a vast geographic area with a
wide range of different climatic conditions (Table 1) and some infectious disease risks.
Over three million people will participate in this mass gathering event. Sunburn, heat-
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related and cosmopolitan illnesses can be expected. Infections will most likely not pose
major hazards for teams, fans and spectators but this editorial considers possible risks
from an epidemiological perspective and suggests some preventative measures to
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mitigate the risk of infection.

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Mass Gatherings (MGs) including sporting events have been associated with injuries (1)
and with infectious disease outbreaks, notably in the context of religious MGs like the
Hajj pilgrimage where cholera, bacterial meningitis and upper-tract respiratory
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infections outbreaks were reported [2]. High crowd densities, non-compliance with
hygiene rules or inadequate sanitation may lead to enhanced transmission of infectious
disease agents among attendees with a potential for globalization given the
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international component of the event. Outbreaks of gastrointestinal infections, influenza,

measles and mumps have been reported in the setting of large open-air music festivals
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where faecal–oral and person-to-person transmissions of pathogens have resulted from

non-compliance with basic hygiene rules, inadequate sanitation, and insufficient
vaccination coverage [3]. Visitors attending sporting events in urban areas like the FIFA
world cup in Russia face a possible risk of gastrointestinal infections. It is recommended
to drink bottled water and to observe food hygiene (eat well-cooked food and peel fruit)
and observe hand hygiene measures. Pre-travel hepatitis A vaccination and carriage of
loperamide in case of diarrhoea are recommended.
A review of outbreaks at large sport events including the Summer and Winter Olympics,
FIFA world cup and the EURO football cup from 1984 through 2015 found little evidence
for infection outbreaks with the exception of 36 cases of influenza among participants to
the Winter Olympiad in Salt Lake City in 2002 and a small outbreak of gastrointestinal
disease affecting a single team during the pre-race sailing competition in Brazil in 2015,
prior to the 2016 Olympics [4]. More recently, the Pyeong Ghang 2018 Winter Olympiad
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may have been have been hindered by a norovirus outbreak days before the events
commenced. This outbreak affected mainly security staff for the games rather than
athletes or visitors [5].

Tick-borne encephalitis (TBE) and Borreliosis (Lyme disease) are frequently reported
infections in Russia and transmission areas include the regions of the host cities of the
World Cup games. According to an ECDC assessment (6), Russia reports over 6000 cases
of borreliosis each year and circa 2000 cases of TBE annually. Risk exists in most
Northwesterly areas (including St. Petersburg) and from the Kaliningrad Oblast in the

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west to Khabarovsk Kray in the east. High risk exists in Ural Region and the West
Siberia. A low urban risk of TBE exists in St. Petersburg, Kaliningrad, and Saransk, with
some risk in forested suburbs; no risk exists in Moscow or suburbs (7). Transmission

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activity is high from June onwards during the period of the Wold Cup games. TBE
subtypes in Russia are: the Siberian subtype (TBEV-SiB), the Far Eastern subtype
(TBEV-FE) and the European sub-type (TBEV-Eu). Currently available TBE vaccines in

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Europe are considered to confer some degree of cross-protection against the TBEV-SiB
and TBEV-FE sub-types. Up to 11 different tick species have been implicated in
transmission but the most common vector is Ixodes ricinus. Insecticide-impregnated
clothing and, to lesser extent, repellents provide protection against ticks. Vaccination is

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not generally recommended for typical World Cup travellers as the risk is higher for
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visitors to rural areas with activities such as hiking and camping. If football fans do
intend to add on such activities, TBE vaccination can be considered but the availability
of the vaccine in an issue for several of the participating World Cup countries.
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Sexually transmitted infections

HIV is estimated to be present in more than 1% of the adult population in Leningrad
Oblast (capital of Oblast is Saint-Peterburg) and more southern areas from Samara to
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Irkutsk regions, compared to less than 1% in most EU countries. Russia is country with
lower intermediate hepatitis B endemicity and intermediate hepatitis C endemicity [6].
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All travelers should avoid unprotected sex. Increased awareness is recommended

regarding safe sex, condom use and body fluid/blood precautions. Hepatitis B
vaccination is desirable.
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Rare Risks
Often visitors will take the opportunity to make excursions into the countryside and
thus exposure to other, often rare infections should also be considered.
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Tuberculosis incidence in Russia is 25 to 100 cases per 100,000 population. According

to the World Health Organisation, this is a high burden of multidrug-resistant TB.
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A moderate risk of rabies exists throughout the country. Visitors to Russia should avoid
animal contact and dog, other terrestrial mammals (including fox, cat, raccoon, dog,
marten, and wolf), and bat bites or scratches should be taken seriously, the wound
thoroughly washed with water and soap and post-exposure prophylaxis should be
sought, even in those already immunized. Anti-rabies post-exposure prophylaxis is
available in every city of Russia free of charge (6).
West Nile Fever risk exists in the Southern, Central and North-Western parts of Russia
and also in Siberia. It occurs more frequently in Astrakhan, Saratov, and Volgograd
oblasts in the period from May to November. Evening and night-time arthropod bite
precautions are recommended for those with significant outdoor exposure.
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A low risk of Crimean-Congo hemorrhagic fever exists and is limited to Southern and
North Caucasian federal districts, mainly in Stavropol Krai, Kalmykiya and Rostov
Oblasts. Transmission is significant from April through September, with peak activity
from May through June (7). Tick precautions are recommended in green areas (suburbs,
parks, gardens).

A very low risk of Hantavirus (hemorrhagic fever with renal syndrome HFRS) exists in
Kaliningrad, Samara, Saint-Peterburg, Saransk. A low risk of HFRS exist in rural areas
of the same regions and also in the surburbs of Moscow, Sochi, Nizhniy Novgorod,

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Volgograd. Travellers, especially campers, should avoid inadequately ventilated
buildings and forested areas harboring rodent excreta, which may become aerosolized.

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In addition to the infectious disease risks already mentioned, those advising football
fans should re-iterate the need for them to be up to date with the routine vaccination
courses recommended in their home country [8]. These vaccinations, for

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example, include the measles, mumps and rubella (MMR) vaccine and diphtheria-
tetanus-polio vaccine. While the risk of these vaccine preventable diseases is generally
considered to very low, the pre-travel consultation provides an ideal opportunity to
“catch up” and update vaccination schedules, and also to advise on additional vaccines

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for those who may be at increased risk of a vaccine preventable illness due to their
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lifestyle choice, or pre-existing illness. Of particular importance however is the MMR
vaccine; outbreaks of measles have been reported in the Moscow region in 2018 [9], and
there continues to be spread of measles across Europe related to the sub-optimal
vaccination coverage in many countries [9]. Concerns regarding measles transmission
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during international football championships endure [10], and reflect the on-going
challenges of vaccine uptake. Moreover, the travel health practitioner is ideally placed
to help improve coverage by opportunistically vaccinating those football fans who had
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previously missed out on the vaccine.

Although making predictions is notoriously inaccurate, it is very likely that the
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upcoming FIFA World Cup in Russia will not dramatically change the usual safe profile
of large international sporting events regarding infectious disease risks. Nevertheless,
visitors to Russia should visit their travel medicine advisors prior to travel and clinicians
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seeing ill-returned travellers should consider the epidemiology of infection in Russia in

their differential diagnoses.
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References
1. Ahmed QA, Memish ZA.
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From the madding crowd to mass gatherings-religion, sport, culture and public
health.
Travel Med Infect Dis. 2018 Jun 4. pii: S1477-8939(18)30131-5. doi:
10.1016/j.tmaid.2018.06.001
2. Abubakar I, Gautret P, Brunette GW, Blumberg L, Johnson D, Poumerol G, et al.
Global perspectives for prevention of infectious diseases associated with mass
gatherings. Lancet Infect Dis 2012;12:66–74.
3. Botelho-Nevers E, Gautret P. Outbreaks associated to large open air festivals,
including music festivals, 1980 to 2012. Euro Surveill. 2013 Mar
14;18(11):20426
4. Gautret P, Steffen R. Communicable diseases as health risks at mass gatherings
other than Hajj: what is the evidence? Int J Infect Dis. 2016 Jun;47:46-52.
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5. Sheridan [http://www.healthmap.org/site/diseasedaily/article/multiple-
outbreaks-threaten-2018-winter-olympics-21418
6. European Centre for Disease Prevention and Control. Mass gathering event –
FIFA World Cup, Russia 2018 – 28 May 2018; Stockholm, 2018
7. Pshenichnaya, Natalia, Malgorzata Paul, Alexander Erovichenkov. Chapter 17,
"Eastern Europe." In Infectious Diseases: A Geographic Guide (Petersen, Chen,
Schlagenhauf Eds) Wiley (2017): 235-256.
8. NaTHNaC. World Cup: Russia 2018 available at
https://travelhealthpro.org.uk/news/319/world-cup-russia-2018 [accessed 7

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June 2018]
9. European Centre for Disease Prevention and Control. Rapid risk assessment: Risk
of measles transmission in the EU/EEA. 21 March 2018. [Accessed 7 June March

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2018]
10. Eberhardt KA, Vinnemeier CD, Dehnerdt J, Rolling T, Steffen R, Cramer JP.
Travelers to the FIFA world cup 2014 in Brazil: Health risks related to mass

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gatherings/sports events and implications for the Summer Olympic Games in Rio
de Janeiro in 2016.
Travel Med Infect Dis. 2016 May-Jun;14(3):212-20. doi:
10.1016/j.tmaid.2016.05.014

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Table 1. Climate in 2018 FIFA World Cup Cities in Russia
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2018 FIFA World Cup Climate (Summer months)*

Cities
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Moscow Humid continental climate (Köppen

climate classification Dfb) with warm, sometimes hot or
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humid summers. The average daily temperature in June 22 °C

(72 °F), in July - 27 °C (81 °F). but during heat waves, which
can occur anytime from May to September, daytime temperature
highs often top 30 °C (86 °F) for 1-2 weeks.
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Saint-Peterburg Humid continental climate (Dfb by Köppen). Warm, humid and

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short summers.
The average daily temperature in June 19 °C (66 °F), in July -
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20 °C (68 °F).

Kazan Humid continental climate (Dfb by Köppen) with warm, often dry
summers. In June temperature is 21 °C (70 °F). The warmest
month is July with daily mean temperature near 25 °C (77 °F).

Ekaterinburg Humid continental climate (Dfb by Köppen), summer is quite

warm. In June temperature is 17 °C (63 °F). July is the warmest
month of the year. The average temperature is 20 °C (68 °F). The
hottest temperatures are 35-38 °C (95-100 °F).
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Volgograd Humid continental climate with hot summers (Dfa by Köppen).
The average temperature in June 28 °C (82 °F) and in July 31 °C
(88 °F)

Nizhny Novgorod Humid continental climate (Dfb by Köppen) similar to the climate
in Moscow. The average temperature in June 21 °C (70 °F) and in
July 25 °C (77 °F)

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Rostov-on-Don Humid continental climate (Dfa by Köppen) The summers are
warm and sunny. June temperatures average +26 °C (79 °F). July
- 29 °C (84 °F).

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Samara Humid continental climate (Dfb by Köppen). The summers are

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enough warm. The average temperature in June 23 °C (73 °F) and
in July 27 °C (81 °F).

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Sochi Humid subtropical climate (Cfa by Köppen). July and August are
the warmest months, with average temperatures around 27–28 °C
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(81–82 °F) during the day. In June the average daily temperature is
around 25 °C (77 °F).
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Saransk Humid continental climate ((Dfb by Köppen) with moderately

hot summer. The average daily temperature in June 23 °C (73 °F)
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and in July 28 °C (82 °F)

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Kaliningrad Humid continental climate ((Dfb by Köppen) with mild summers

and frequent showers and thunderstorms.
Summer is predominantly warm but hot at times (with temperature
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reaching as high as +30–+35 °C (86–95 °F) at least once per year)

with plenty of sunshine interspersed with heavy rain. The average
daily temperature in June 23 °C (73 °F) and in July 28 °C (82
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°F) The average daily temperature in June 15 °C (60 °F) and in

July 18 °C (66 °F)
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*Average daily temperature was taken from https://pogoda.365c.ru