These are the “General Guidelines for Illness Prevention in Athletes,” published by the International Olympic Committee (IOC).
Our last article was all about how regular exercise, ranging from moderate to intense, boosts immunity to strengthen the body’s natural defense system against infection. Research has proven this throughout the past century, and it is true for most people.
On one hand, the “open window” hypothesis of workout-induced immune suppression is more controversial. Researchers previously observed temporary reductions of lymphocytes following intense workouts. Lymphocytes are types of leukocytes (white blood cells) that are fundamentally important to the immune system. A more recent review from 2018 suggested that workouts may actually be causing immune cells to move to peripheral tissues, enhancing immune regulation and surveillance in parts of the body vulnerable to infection, such as the gut and lungs.
On the other hand, elite athletes who are either vigorously training or have just completed a highly competitive event are at particular risk. There is no doubt that normal training benefits the immune system… But sustained stress and overexertion can make a professional athletes more vulnerable to bacterial and viral infection.
In the midst of intermittent cold and flu seasons, viral outbreaks, and busy competition calendars, athletes can be exposed to infectious diseases in may ways. They may train in public places, share equipment and facilities, interact with different people during competitions, and travel as teams or individuals. In 2016, the International Olympic Committee published a consensus statement with guidelines for the prevention of illness in athletes, and it is also useful for coaches, trainers, medical staff, and team support…
International Olympic Committee’s General Guidelines for Illness Prevention in Athletes
1. Behavioural, lifestyle and medical strategies
A variety of behavioural, lifestyle and medical intervention strategies have been advocated to reduce the risk of illness in the athlete.
These include advice to athletes, measures taken by medical staff and the athlete support team.
Athletes are advised to:
i. Minimise contact with infected people, young children, animals and contagious objects;
ii. Avoid crowded areas and shaking hands and minimise contact with people outside the team and support staff;
iii. Keep at distance to people who are coughing, sneezing or have a ‘runny nose’, and when appropriate wear (or ask them to wear) a disposable mask;
iv. Cough or sneeze on to the elbow and not on the hands—always clean the hands and nose after sneezing or coughing;
v. Wash hands regularly and effectively with soap and water, especially before meals, and after direct contact with potentially contagious people, animals, blood, secretions, public places and bathrooms;
vi. Use disposable paper towels and limit hand to mouth/nose contact when suffering from upper respiratory symptoms or gastrointestinal illness (putting hands to eyes and nose is a major route of viral self-inoculation);
vii. Carry insect repellent, antimicrobial foam/cream or alcohol-based hand washing gel with them;
viii. Not to share drinking bottles, cups, cutlery, towels, etc, with other people;
ix. Choose beverages from sealed bottles, avoid raw vegetables and undercooked meat, wash and peel fruit before eating, while competing or training abroad;
x. Wear enough covered clothing (covering the arms and legs) during training sessions when travelling in tropical areas, particularly at dusk and dawn;
xi. Wear open footwear when using public showers, swimming pools and locker rooms in order to avoid dermatological diseases;
xii. Adopt strategies that facilitate good quality sleep such as strategic napping during the day and correct sleep hygiene practices at night;
xiii. Avoid excessive drinking and binge drinking of alcohol as this impairs immune function for several hours, particularly after strenuous training or competition;
xiv. Practice the principles of safe sex and use condoms.
Medical staff taking care of athletes is advised to consider the following:
i. Develop, implement and monitor illness prevention guidelines for athletes and medical and administrative support staff;
ii. Screening for airway inflammation disturbances (asthma, allergy and other inflammatory airway conditions);
iii. Identify the high-risk athletes and take full preventative precautions during high-risk training or competition periods;
iv. Arrange for single room accommodation during tournaments for athletes with heavy competition load or known susceptibility to respiratory tract infections, or high performance priority athletes;
v. Consider protecting the airways of athletes from being directly exposed to very cold (<0°C) and dry air during strenuous exercise by using a facial mask;
vi. Adopt measures to reduce the risk of illness associated with international travel;
vii. Update athletes vaccines needed at home and for foreign travel and take into consideration that influenza vaccines take 5–7 weeks to take effect, intramuscular vaccines may have a few small side effects, vaccinations are performed preferably out of season and avoid vaccinating just before competitions or if symptoms of illness are present;
viii. Update administrative and support staff vaccines needed at home and for foreign travel;
ix. Consider zinc lozenges (>75 mg zinc/day; high ionic zinc content) at the onset of upper respiratory symptoms, as there is some evidence that the number of days with illness symptoms can be reduced.
The athlete support team can consider adopting nutritional measures to maintain robust immunity in athletes, including the following:
i. Introduce personalised nutrition programmes to avoid deficiencies of essential micronutrients;
ii. Encourage athletes to ingest carbohydrate during and after exercise and to ingest both carbohydrate and protein after exercise;
iii. Measure and monitor the vitamin D status of athletes and supplement if required;
iv. Consider advising athletes to ingest probiotic such as Lactobacillus probiotics on a daily basis;
v. Consider advising athletes on the regular consumption of fruits and plants, polyphenol supplements (eg, quercetin), or foodstuffs (eg, non-alcoholic beer and green tea) that may reduce risk of illness.
2. Training and competition load management
There is evidence that poor load management with ensuing maladaptation can be a significant risk factor for acute illness and overtraining. However, data are limited to a few select sports and athlete populations, and this, combined with the unique nature of different sports, make it difficult to provide sport-specific guidelines for load management. However, the following general recommendations can be made:
i. Very high loads can have either positive or negative influences on risk of illness in athletes, with the athlete’s level of competition (elite), load history (chronic load) and intrinsic risk factor profile being important;
ii. Athletes should have a detailed individualised training and competition plan, including postevent recovery measures (encompassing nutrition and hydration, sleep, and psychological recovery);
iii. The training load is monitored using measurements of external and internal load;
iv. Training load is managed by adopting the following principles:
a. Changes in training load should be individualised as there are large intraindividual and interindividual variances in the timeframe of response and adaptation to load;
b. Changes in training load should be in small increments, with data (from the injury literature) indicating that weekly increments should be <10%;
v. The competition load is monitored and managed;
vi. Variation in an athlete’s psychological stressors should guide the prescription of training and/or competition loads;
vii. It is recommended that coaches and support staff schedule adequate recovery, particularly after intensive training periods, competitions and travel, including nutrition and hydration, sleep and rest, active rest, relaxation strategies and emotional support;
viii. Sports governing bodies have the responsibility to consider the competition load, and hence the health of the athletes when planning their event calendars. This requires increased coordination between single-sport and multisport event organisers, and the development of a comprehensive calendar of all international sports events.
3. Psychological load management
Psychological load (stressors) such as negative life event stress and daily hassles can significantly increase the risk of illness in athletes. Clinical practical recommendations centre on reducing state-level stressors and educating athletes, coaches and support staff in proactive stress management, and comprise the following:
i. Developing resilience strategies that help athletes understand the relationship between personal traits, negative life events, thoughts, emotions and physiological states, which, in turn, may help them minimise the impact of negative life events and the subsequent risk of illness;
ii. Educating athletes in stress management techniques, confidence building and goal setting, optimally under supervision of a sport psychologist, to help minimise the effects of stress and reduce the likelihood of illness;
iii. Reducing training and/or competition loads and intensities to mitigate risk of illness for athletes who appear unfocused as a consequence of negative life events or ongoing daily hassles;
iv. Implementing periodical stress assessments (eg, hassle and uplift scale, LESCA) to inform adjustment of athletes’ training and/or competition loads. An athlete who reports high levels of daily hassle or stress could likely benefit from reducing the training load during a specified time period to prevent potential fatigue, illness or burnout.
4. Measuring and monitoring for early signs and symptoms of illness, over-reaching and overtraining
The use of sensitive measures to monitor an athlete’s health can lead to early detection of symptoms and signs of illness, early diagnosis and appropriate intervention. Athletes’ innate tendency to continue to train and compete despite the existence of physical complaints or functional limitations, particularly at the elite level, highlight the pressing need to use appropriate illness monitoring tools. It is recommended that:
i. Ongoing illness (and injury) surveillance systems should be implemented in all sports;
ii. Athletes be monitored, using sensitive tools, for subclinical signs of illness such as non-specific symptoms and signs, or selected special investigations;
iii. Athletes be monitored for overt symptoms and signs of illness;
iv. Athletes be monitored for early symptoms and signs of over-reaching or overtraining;
v. Illness monitoring should be ongoing, and long enough to detect early indicators of illness particularly during alterations in training load, travel and competitions.
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