Injury time

The 2018 FIFA World Cup is nearly upon us. It is a hive of international intermingling seemingly making it a perfect place for the dissemination of communicable disease, be it the classically cited sexually transmitted kind, the exotic Dengue kind, or the new and emerging Zika virus kind. But what about the vast majority of people who tune into the tournament from home on their TV, computer or radio? These people, your patients, are they at risk?


Learning objectives

1. Consider the impact of the World Cup on health

2. Reflect on how ready you and your healthcare system are to the potential healthcare effects of the World Cup

2. Continue the time honoured tradition of poor football puns


Although playing football is generally a healthy activity, watching your favorite side play may have a different effect. The FIFA World Cup is the most viewed sporting event in the world. It can make you experience a range of emotions from euphoria through to misery (or if you don’t like football, include boredom). Winning or hosting the tournament is often associated with a ‘feel-good’ factor, but ultimately only one team can win. Being an England and Coventry City supporter I’m used to disappointment (even with the occasional moments of glory).

One of the most media publicised health concerns of watching football is that of experiencing a heart attack (particularly during penalty shoot-outs). Although there is still some considerable debate, a German study found that viewing a stressful football match more than doubles the risk of an acute coronary event (for men, the incidence was 3.26 times higher than the control period, and for women, it was 1.82 times higher). This was particularly the case for those with known coronary heart disease. On the day the national side played, the highest incidence of events was observed during the first 2 hours after kickoff. In addition, a UK study found that the risk of hospital admission for acute myocardial infarction increased by 25% the day England lost to Argentina in a penalty shoot-out (on 30 June 1998) and the following two days.

But what about the risk of stroke? Interestingly, one study found that the risk of stroke does not seem to increase with watching the national side, whereas a another tudy did find an increase in stroke risk in men but not women when watching a local side. It seems that the WHO video ‘Get hyperemotional – not hypertensive’ should be taken with a pinch of salt. Don’t worry, plenty more bad puns to come.


Questions

How do you feel about some junk-food companies sponsoring the World Cup when there is an association with poor diet and coronary heart disease?

Should healthcare professionals proactively invite men who have known coronary heart disease to discuss the dangers of getting too emotional during the World Cup?


The effects of the World Cup have some quite interesting differences between demographic age groups. One Montreal study revealed teenage boys playing non-organised soccer suffered more severe injuries during the time the World Cup was on and more of their injuries were the results of direct contact with another player during. Although of little consolation, the teenagers did suffer fewer strains/sprains but it seems that the World Cup might be less ‘Bend It Like Beckham’ and more break it like Beckham for boys watching their football idols on TV.

Success at sporting events are also postulated with an increase in birth rate. Although not specific to the World Cup, a last minute goal by Iniesta in the 2009 Champions League Final may have been associated with in 16% increase central Catalonia births in February 2010 (nine months after FC Barcelona’s win in May 2009). 2018 might be ‘From Russia with Love’ for some, but I wonder if the local maternity unit rota organiser is going to consider which members of staff will be placed on-call nine months after England (obviously) score a last minute winner in the final?

Now we change From Russia with Love to From Russia with Blood. One study explored the impact of the 2010 South Africa World Cup on levels of assault attendances in England. Attendances increased by 37.5% on the days that England played and 70.1% of assault attendees were male and aged 18-34 years. Half of those attending were found to have been drinking alcohol before the violence took place. Another study found that special occasion drinking such as televised sports events added approximately 18 units of alcohol per week for both sexes, the greatest impact seen among those aged 25-34 years.

Ambulance call-outs are unsurprisingly high during sporting events. Most call-outs were for men with a mean age of 33 years, three-quarters of them at night. Again, three-quarters were recorded as being due to an assault (including sexual assault). Win, lose or draw, there is also a correlation between the World Cup and domestic abuse. After controlling for day of the week, one study found that domestic abuse rises by 26% when the English national team won or drew, and a 38 percent increase when the national team lost. There may also a carry-over effect, with incidents of domestic abuse 11% higher the day after an England match. This wasn’t the sort of hurt that Baddiel, Skinner & Lightning Seeds were referring to in Three Lions.


Questions

How do you feel about some drinks companies sponsoring the World Cup when there is an association with alcohol and violence?

Should healthcare professionals proactively invite all patients who have been victims of domestic violence to monitor and support during the World Cup?


What about self-harm? A French study found that during the 1998 World Cup there was a significant decline of suicides (-10.3%), this effect being the strongest among men and people aged between 30 and 44. A significant decrease was also observed for the days following French team games (-19.9%). The authors highlight the the sense of belongingness and social integration that national sporting events can create in suicide prevention. It’s worth pointing out that France won the tournament in 1998 and was also the host country.

Conversely, a study in Tehran found a significant increase in hospital-treated deliberate self-poisoning during the 2014 FIFA World Cup in females but a nonsignificant increase in males. Now it’s worth pointing out here that Iran drew their first tournament game and lost subsequent two, ending up bottom of their group table. They go on to state that preventive and preemptive interventions could be planned in advance of these events. I suppose this is particularly the case if the national side is likely to lose, although I wonder if a loss following an anticipated win would be worse for mental health than an expected loss.

“Some people believe football is a matter of life and death. I’m very disappointed with that attitude. I can assure you it is much, much more important than that.” Bill Shankly former Liverpool manager.


Questions

Despite having this clinical intelligence on how the World Cup will increase the strain on primary care, ambulance services and emergency departments, are you aware of any interventions to mitigate this risk?

How confident are you that the healthcare system in which you work is able to provide preventive interventions and preemptive service provision for the World Cup?


So it seems that watching the World Cup can be dangerous. Eating too many (Diego Mara)doner kebabs might risk coronary heart disease, which is the last thing you want when watching England on penalties. Adding alcohol to the mix you might witness men behaving Chadli and result in things getting very (Lionel) Messi. Some couples might be having unprotected Cesc if there’s a last minute winner while medics will be trying to support Fractures United while the kids are pretending to be David Breakem’. But (Cristiano Ronal)don’t be surprised if people don’t seem their (George) Best if the national team have just lost. Now that’s finally out of my system, please feel free to add your own puns in the comments section.


Summary

Although usually overlooked, there may be scope for healthcare systems preparing for the World Cup. Data already exists which allow us to anticipate potential risks to health. Preemptively inviting in individuals at risk and increasing staff and specialist services at times of vulnerability might be one idea, although in healthcare systems facing perpetual stress this may be wishful thinking. I wonder whether junk-food or alcohol company sponsorship of hospitals would help.


Further resources

Cardiovascular events during World Cup soccer.
https://www.ncbi.nlm.nih.gov/pubmed/18234752

Lack of increase of cerebrovascular events during German World Cup soccer games in 2006.
https://www.ncbi.nlm.nih.gov/pubmed/19252804

It is just a game: lack of association between watching football matches and the risk of acute cardiovascular events.
https://www.ncbi.nlm.nih.gov/pubmed/?term=It+is+just+a+game%3A+lack+of+association+between+watching+football+matches+and+the+risk+of+acute+cardiovascular+events

Admissions for myocardial infarction and World Cup football: database survey.
https://www.ncbi.nlm.nih.gov/pubmed/?term=Admissions+for+myocardial+infarction+and+World+Cup+football%3A+database+survey

An evaluation of the impact of FIFA World Cup on soccer emergency department injuries among Montreal adolescents.
https://www.ncbi.nlm.nih.gov/pubmed/29125217

A matter of life and death: population mortality and football results.
https://www.ncbi.nlm.nih.gov/pubmed/12775788

Barcelona baby boom: does sporting success affect birth rate?
https://www.bmj.com/content/347/bmj.f7387

Effects of the 2010 World Cup football tournament on emergency department assault attendances in England.
https://www.ncbi.nlm.nih.gov/pubmed/?term=Effects+of+the+2010+World+Cup+Football+Tournament+on+Emergency+Department+Assault+Attendances+in+England

Holidays, celebrations, and commiserations: measuring drinking during feasting and fasting to improve national and individual estimates of alcohol consumption.
https://www.ncbi.nlm.nih.gov/pubmed/?term=Holidays%2C+celebrations%2C+and+commiserations%3A+Measuring+drinking+during+feasting+and+fasting+to+improve+national+and+individual+estimates+of+alcohol+consumption

Violence-related ambulance call-outs in the North West of England: A cross-sectional analysis of nature, extent and relationships to temporal, celebratory and sporting events
https://www.ncbi.nlm.nih.gov/pubmed/?term=Violence-related+ambulance+call-outs+in+the+North+West+of+England%3A+A+cross-sectional+analysis+of+nature%2C+extent+and+relationships+to+temporal%2C+celebratory+and+sporting+events

Can the FIFA World Cup Football (Soccer) Tournament Be Associated with an Increase in Domestic Abuse?
http://journals.sagepub.com/doi/abs/10.1177/0022427813494843

Federation Internationale de Football Association (FIFA) 2014 World Cup Impact on Hospital-Treated Suicide Attempt (Overdose) in Tehran.
https://www.ncbi.nlm.nih.gov/pubmed/28612472

Impact of the 1998 football World Cup on suicide rates in France: results from the national death registry.
https://www.ncbi.nlm.nih.gov/pubmed/?term=Impact+of+the+1998+Football+World+Cup+on+Suicide+Rates+in+France%3A+Results+from+the+National+Death+Registry

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