Communicable Illness Mitigation Strategies for Traveling Elite Sporting Organizations

Abstract

Context:

Transmission of communicable diseases observed in sporting organizations is often preventable. Early detection, isolation, and treatment can significantly diminish time lost. Until recently, there has been a paucity of standardized guidelines outlining feasible, preventable measures to protect both athletes and staff from contagious illnesses. Therefore, the purpose of this narrative was to highlight optimal prevention practices for transmission mitigation, with a particular focus on hygiene activity and travel considerations in professional sporting organizations.

Evidence Acquisition:

Current recommendations from the Centers for Disease Control and Prevention and peer-reviewed journals.

Study Design:

Clinical review.

Level of Evidence:

Level 5.

Results:

Communicable illness prevention strategies begin at the level of sufficient personal hygiene practices. Common area surface cleaning recommendations, including shared equipment sanitization between usage as well as designated equipment use to specific athletes, should be considered to minimize cross-contamination, in particular, for liked-position players. Intelligent design for shared areas can include redistributing the layout of communal spaces, most feasibly, spreading locker designation a minimum distance of 6 ft from one another. Travel considerations can include placing most susceptible passengers closest to window seating, boarding last and exiting first. Team physicians should have knowledge of essential personnel medical histories in an effort to risk stratify staff members and players in the setting of communicable disease.

Conclusion:

Providing a framework for illness management and prevention is important when considering the effects on player health, missed time, performance, and overall cost. Containment of commonly observed communicable illnesses can be optimized with sufficient personal hygiene practices, common area surface cleaning recommendations, intelligent design for shared areas, travel and hotel considerations, as well as appropriate screening tools and isolation techniques.

Strength of Recommendation Taxonomy (SORT):

B.

Amid the COVID-19 global pandemic, hygiene education is of the utmost importance. Illness prevention and containment is a necessary priority, given noninjury-related illness accounts for 12% to 50% of total missed competition participation by elite athletes in major sporting organizations, dependent on population evaluated.^30,31,33,42 During the 2014 and 2018 Olympic Games specifically, team USA had an incidence of approximately 200 illnesses per 1000 registered athletes with 30% of illnesses expected to result in lost time.^34,35,41 Additionally, in Major League Baseball, 14.7% of time missed was attributable to illness during the active seasons from 2011 to 2016. ⁸ While this can account for a significant financial loss due to missed games, there are also likely immeasurable performance detriments involved in playing through illness.

Recent global events emphasize the contagious nature of illness, capable of profound effects within a sporting organization. Musculoskeletal injuries typically remain isolated to the individual athlete, only increasing their personal future injury risk. However, an airborne infectious source can quickly disseminate through an entire organization, elevating athlete and staff risk of harm. Furthermore, secondary risk exists for immediate family members and other close contacts. In Major and Minor League Baseball, the average number of days missed due to illness from 2011 to 2016 was reported as 4.6 days per diagnosis. ⁸ While this may seem insignificant, days can quickly accumulate when several members of a team or organization become infected with a communicable disease. Given the significant burden of contagious illness on the high-performance athlete, the purpose of this clinical commentary is to highlight optimal prevention practices for transmission mitigation, with a particular focus on hygiene activity and travel considerations in professional sporting organizations, and appropriate prevention strategies.

Considerations to Reduce Risk of Contamination and Spread of Illness in the Elite Sport Setting

Facility and Cleaning Equipment Considerations

The primary illness management strategy in any shared facility involves diagnosing conditions early and subsequently, preventing transmission of the illness. Athletic competitions and training facilities, by nature, involve numerous people in relatively small confinement with communal dining, personal hygiene, recreation/meeting spaces, and shared equipment use. Daily hand hygiene (including washing hands with soap or water for at least 20 seconds or use of hand sanitizer with at least 60% alcohol content) ⁴⁶ and appropriate coughing/sneezing technique should be promoted to all athletes as a primary mode of communicable illness prevention. Hand sanitizer should be readily available throughout the kitchen, weight room, training room, restroom, and other shared facilities. Within organizations, this may include meal areas, bath and locker rooms, video review sessions, or player lounge areas. Consistent hand hygiene is encouraged, particularly before meals, after coughing/sneezing, and when utilizing the restroom or touching shared objects. Facial coverings reduce the risk for airborne and droplet transmissible infection and should be used by ill subjects to prevent spread within a facility. ²⁷ Recent studies have found that requiring face mask use in public was associated with a decline in the daily COVID-19 growth rate by 0.9, 1.1, 1.4, 1.7, and 2.0 percentage points in 1 to 5, 6 to 10, 11 to 15, 16 to 20, and 21+ days after mandating, respectively. ²⁵

Surface cleaning should be regular (at least once per day), and contact time should be adequate, allowing at least 1 minute and up to 2 to 3 minutes drying time to optimize effectiveness. ¹³ Shared equipment should be sanitized between usages with optimal practices including a disinfection step as well as 45 minutes of uninterrupted air-drying. ³⁸

Possible disinfectant tools include microfiber cloths with quaternary ammonium salts, ultraviolet germicidal radiation, as well as adjunctive electrostatic sprayers with vaporized hydrogen peroxide to provide a quick and effective disinfecting and decontaminating method in small or large spaces and on portable objects.^6,22 Solutions must be approved by the Environmental Protection Agency and water soluble in nature. Sprayer devices include roller carts, portable cordless backpacks, as well as handheld devices. Handheld tanks of 8 to 33 oz disinfect in a range of 6000 to 13,000 ft² (depending on which brand) in less than 30 minutes. ¹⁰ One-gallon tanks for roller/backpack units sanitize in a range of 18,000 to 54,000 ft² in approximately 1 hour. Portable handheld sprayers can be used to decontaminate buses and airplane spaces such as vents, overhead areas, handles, seats, and lavatories. Consideration for hotel rooms is another possibility, though likely already utilized by most, if not all institutions. Application in facility centers should target high traffic areas daily. Consideration can also be given to products that provide a chemical barrier for lasting protection on environmental surfaces, described as effective between 30 and 90 days.^14,16,36,43 This substance is normally applied after the primary disinfection steps listed earlier.

Density of people is a known risk factor for communicable illness spread by droplet and contact transmission. ⁴⁴ Where possible, large congregations should be limited in communal dining areas, locker rooms, and meeting rooms. Shared areas ideally should be optimized via intelligent design, spacing locker room arrangements as one example, shown in Table 1. Furthermore, distribution of specific athlete lockers can be individualized to minimize exposure. For example, if 2 athletes are roommates at baseline, and thus exposed to one another regularly both inside and outside of the facility, placing their lockers next to one another makes logical and strategic sense. On the contrary, like role/position players, like 2 quarterbacks, for example, should be spaced from one another. If both subsequently become ill, teams may not have an alternative person to play that position.

Table 1.

Specific techniques for intelligent design of shared communal space in elite athlete sporting facilities

Spreading lockers a minimum distance from one another

Emphasis of spacing of athletes of similar role/position

Redistributing layout of communal spaces

HVAC (heating, ventilation, and air-conditioning) system with fortified air filtration and cleaning element

Minimize communal buttons and taps within the facility through electronic door systems, taps, and soap dispensers

Designate equipment use to specific athletes or subgroups of athletes, to minimize cross-contamination

Readily available hand sanitation and masks in areas of the facility most traveled

Buffet style dining should be avoided if individualized meals can be provided to avoid increased contact points. If unavoidable, servers should distribute food and utensils. In a recent experiment conducted by Japanese broadcasting company NHK in consultation with science experts, the potential spread of coronavirus infection by contact was demonstrated through fluorescent paint where one contaminated individual was capable of spread to all other individuals in a half-hour interval, observable on the faces of 3 of 10 people. ¹ It should also be noted a similar principle would apply to any illness with evidence of contact transmission.

Finally, screening is a crucial aspect of containment. Daily symptom screens and temperature checks should be considered beyond COVID-19 in an effort to promote early identification, efficient isolation, and ultimately spread prevention. Symptomatic players and staff members should not be present in athletic facilities until a medical evaluation has been conducted. Rapid PCR (polymerase chain reaction) testing tools may also be considered for diagnostic management of patients who present with respiratory ailments of a potentially infectious etiology. Pathogen identification may provide an effective way forward in early management. Various testing tools return results rapidly (approximately 1 hour) and are associated with decreased antibiotic use, reduced length of hospitalization courses, as well as increased detection rate with particular attention to influenza.^5,29 It should be noted that utilizing these machines in an athletic facility would require laboratory designation status, a process that varies state by state.

Travel Considerations

Traveling brings with it risk of illness. Schwellnus et al ³⁹ noted a higher incidence of illness in athletes after international travel to a foreign country with a 5-hour or greater time difference that returns to baseline on return to the home country. With any major travel, the goal is to minimize contact points with other individuals and areas of possible pathogen transmission, in addition to maximizing ventilation. With any travel plans, passengers should try to avoid eating during plane/bus travel when possible, with meal planning before or after travel as a most appropriate strategy.

Travel by Plane

While flight ventilation is superior to many alternative forms of transportation, air travel continues to pose an infection transmission risk due to the long duration of close contact to individuals who may be carrying transmissible illness. In 2018, Hertzberg et al ¹⁹ demonstrated that there is approximately a 6% risk to passengers seated within the 2 rows of infected individual(s) while only a 2% risk to passengers seated beyond 2 rows when using the conservatively low transmission rate of 0.0045. Highest risk of disease transmission was associated with flight times of greater than 8 hours. From a ventilation perspective, the most hazardous time on a plane is during taxiing when the vents are turned off. ⁹ Therefore, all vents should be open and cleaned with alcohol wipes before the team enters the plane. While taxiing, it is ideal if coughs and sneezes are avoided or covered during this period of decreased ventilation. If necessary, it is recommended to sneeze or cough directly into a tissue, or if not readily available, into the elbow. ¹² Frequent filter changes by the appropriate aircraft maintenance staff is encouraged. Ideally, sick staff and media should not travel with the team. It is worth noting, that amid the COVID-19 pandemic, masks should be worn by all passengers during all forms of travel as per Centers for Disease Control and Prevention current guidelines. “At-risk” passengers should prioritize sitting nearest windows, with highest reported ventilation and air movement while also minimizing points of contact from flight attendants as well as others walking up and down the aisle^19,47,48; an extensive flight seating structure is included in Figure 1. COVID-19 vaccination status and natural immunity should be taken into consideration for this strategic seating assignment and risk stratification. Flight attendant health and hygiene should be emphasized with strict policy forbidding any ill flight attendants, given the abundance of contact with passengers. Ties and lanyards should be tucked in. Hand sanitizer should be easily accessible and used frequently, particularly when serving an ill player. Hydration should be available for players.

Figure 1.

Charter plane (A) distribution and (B) recommendations for traveling elite sporting groups by risk of infection.

Travel by Bus

Buses are also a high-risk environment for infectious disease spread. In January 2020, an asymptomatic woman who had recently been to Wuhan, China took a bus with 66 other passengers for a ride-time of 50 minutes each way. Of the 66 passengers in the vehicle, 24 were infected with COVID-19. An additional study based in the United Kingdom found that male bus drivers were more likely to die from COVID-19 than the average citizen, at a rate of 26.4 deaths per 100,000 men compared with 9.9 deaths per 100,000 men, respectively. ¹¹

Bus driver health and hygiene should be ensured with strict policy forbidding sick or symptomatic bus drivers. Buses should be cleaned with Environmental Protection Agency–approved cleaning solutions between uses. ⁷ Windows should be open, weather permitting, to maximize ventilation. Window seating should be maximized. Ideally, ill passengers should travel in separate vehicles. If unavoidable, placing ill players first in the back of the bus nearest windows with maximal airflow in the opposite direction of movement might be most logical, though there are insufficient data to support this hypothesis currently. Ill passengers should wear a mask if unable to travel separately. Hydration should be encouraged throughout travel with individual water bottles.

Hotel Accommodations

Hotel cleaning practices should be verified before occupation. Ideally, teams should use private entrances and separate elevators with blocks of rooms clustered on one floor to minimize exposure to others. Should sharing of hotel rooms be necessary due to limited resources, strategic assignment of roommates, so that one athlete who has immunity through natural disease or vaccination is placed with a susceptible individual, is recommended as this approach likely offers most protection to both parties. Room temperature should be set at 70°F. ² In 2019, Kormuth et al ²¹ demonstrated that while moderate humidity may not directly affect the longevity of the influenza virus, it does make virus particles heavier, precipitating out of the air and making for a plausible means for decreased airborne transmission. Evidence is scarcer as it pertains to nonlaboratory settings, though Reiman et al ³⁷ conducted a study comparing surface and air level concentrations of influenza A virus in 2 active preschool classrooms, finding decreased levels of viral particles in the humidified room over the nonhumidified one. Thus, consideration should be given to filling bathtubs and sinks to increase humidity levels. Finally, water and nutritional supplements/snacks should be available on arrival. Turndown service avoidance may be considered to diminish points of contact and exposure to an unknown individual who may be shedding virus.

Personnel Considerations

Team physicians should have knowledge of essential personnel medical histories in an effort to risk stratify staff members and players in the setting of any communicable disease. Age and relative comorbidities, including significant cardiopulmonary disease, immunosuppression, chronic kidney or liver disease, hypertension, obesity, and prior strokes/coagulopathy issues, are all pertinent medical history. Furthermore, if players or staff members live with individuals who may be high risk, this should be identified, and counseling should be offered by the team physician.

Lifestyle Considerations

Nutrition

Nutritional choices supporting immune function should be optimized, including omega 3s, flavonoids, fiber, vitamin C, vitamin D, and zinc, as directed by the team dietician in collaboration with the team physician. Vitamin C in higher doses was evaluated by Hemilä et al. ¹⁷ The pooled rate ratio of common cold infections in the included studies was 0.50 (95% CI: 0.35-0.69) in favor of the vitamin C group. Accordingly, the results suggest that vitamin C supplementation may be beneficial for some subjects undergoing heavy exercise who have problems with frequent upper respiratory infections. Martineau et al ³² conducted a randomized, double-blind, placebo-controlled trial of supplementation with vitamin D₃ or vitamin D₂ and the relationship with incidence of acute respiratory tract infection. Vitamin D supplementation reduced the risk of acute respiratory tract infection among all participants (adjusted odds ratio 0.88, 95% CI: 0.81-0.96; P for heterogeneity <0.001). Zinc supplementation and its relationship to respiratory illness duration was also studied in a randomized blinded placebo-controlled trial showing mean, overall duration of cold symptoms was shorter in the zinc group relative to placebo. ²⁴ More specifically, cough (3.1 vs 6.3 days, P = 0.001) and nasal discharge (4.1 vs 5.8 days, P = 0.025) were shorter in duration, and patients in the zinc group had decreased total severity scores for all symptoms (2.7 vs 5.4, P = 0.002). Finally, zinc combined with vitamin C was also studied by Maggini et al, ²⁶ who showed that vitamin C plus zinc was found to be significantly more efficient than placebo at reducing rhinorrhea over a 5-day course of treatment. However, a recent randomized controlled trial found no difference in symptom duration among patients with COVID-19 on high-dose zinc, vitamin C, zinc plus vitamin C, and placebo regimens. ⁴⁵

It is worth noting that these supplements were studied using specific dosages and frequencies as it pertains to illness incidence and duration; therefore, close attention should be paid to this aspect. Along those lines, the US Preventative Service Task Force found insufficient evidence to recommend for or against the use of a general multivitamin in the general population, ¹⁸ with limited evaluation for at-risk subgroups.

Smoking

Smoking and its relationship with infectious disease has been previously established and should be avoided in professional sporting organizations.^15,20 Increased vulnerability to infection has been suggested with marijuana use; in particular, the role cannabinoids play in suppressing an inflammatory response and immunity can minimize resistance to infectious agents. ²⁰ Furthermore, cigarette smoking has been linked to hindered ability to phagocytose bacteria in the lungs, increased alveolar macrophage expression, which can destroy the alveolar lining, and the secretion of significantly fewer pro-inflammatory cytokines necessary in mounting an immediate immune response.^4,28,40

Sleep

Minimizing sleep debt and attempting to mitigate the risks associated with large volumes of travel should be prioritized. Immune-boosting effects have been noted with adequate amounts/quality of sleep.^3,23 Some examples cited include increased extravasation of T cells and their redistribution to lymph nodes, as well as promoted interactions between antigen-presenting cells and T helper cells, thereby enhancing immunological memory formation. ³ Screening athletes for basic sleep conditions, and supporting high-risk athletes with appropriate resources (pulmonary specialists or physicians with focus in sleep medicine) is recommended. Sleep apnea screening should be considered based on clinical presentation.

Vaccination

Players and staff members should receive personalized, disease-specific education and appropriate vaccinations, when indicated. COVID-19 vaccination status and natural immunity should be taken into consideration for strategic risk-stratification planning. Influenza vaccinations should strongly be encouraged annually, if not required. Maintaining detailed and up-to-date vaccination records can provide a quick reference for risk stratification and planning purposes.

Conclusion

The current circumstances, albeit devastating and tragic, present invaluable information to practitioners with a unique opportunity to drive change with a captive audience. This opportunity for reflection enhances our ability to prepare our athletes for the future. Beyond the current COVID-19 pandemic, illnesses will continue to burden sporting populations. Providing a set of guidelines, that can feasibly be implemented for this specific demographic, has invaluable, practical implications. Containment of commonly observed communicable illnesses can be optimized with sufficient personal hygiene practices, common area surface cleaning recommendations, intelligent design for shared areas, travel and hotel considerations, as well as appropriate screening tools and isolation techniques.