Health risks to athletes at olympic and commonwealth games

The separate physical and mental challenges facing an athlete at a major multi-sporting event. The risk of inadvertent adverse analytical findings on drug testing, by an athlete innocently taking a medication or supplement that may be contaminated with a substance which is banned in elite sport. The effect of jet lag and travel fatigue on athletic performance. A summary of the key points for athletes and support staff attending a major multi-sport event and how this may differ from a single sport event. That there is more to consider, by the athlete and staff, than a normal event and preparation is key to an optimum performance. This article should act as a useful and insightful guide to both new and experienced clinicians managing athletes at a major multi-sport Games. The potential pitfalls, and solutions, facing athletes are highlighted and therefore should help in reducing the likelihood of these occurring. Attending a major games as a team or headquarters doctor is a unique experience, unlike any other sporting role, with different pressures experienced across a number of areas. However, the primary role is still to support the health, safety and well-being of not only the athlete, but also their support staff and the wider ‘team behind the team’. The Tokyo 2020 Olympic Games and 2022 Commonwealth Games also had to deal with the issue of COVID-19 and strategies to protect athletes from the infection, which may impact their ability to compete at their optimum, or even at all [1]. The major risk to athletes at a major games, is the ‘win whatever it takes’ attitude [2]. This has several facets: In ‘normal’ circumstances, the athlete is aware of the risk of competing with an injury, both in the short and long-term. In team sports, most are also aware that an injury or illness, that may reduce their performance, will also potentially impact the overall performance of the team. However, in an event such as an Olympic Games, common sense, team performance and self-preservation often get put to one side, especially if the athlete sees this as there one chance of competing at this level and possibly getting a medal. It is up to the athlete’s medical support to make sure that the athlete and coach are in possession of all the facts and risks, in order to make an informed decision. The significance of gaining or losing sponsorship and funding, future career opportunities (media), fame: this is linked to the above. The Olympic Games is, for most athletes, the pinnacle of a sporting career and so they are often willing to consider doing things that they would not normally. This is also true for coaches and, to a certain extent support staff, including doctors. Not only does this encompass competing with an illness or injury (which may take longer to resolve or leave long-lasting disability) but also adopting different strategies, in order to win (or at least get a medal). This may include training longer than normal and reducing time for rest and recovery, which often leads to ‘over-reaching’ and ultimately a worse performance than expected [3]. It may also include the temptation to take supplements to aid performance and recovery, which are not normally taken. No supplement is risk-free and, even though some are batch-tested, may contain substances that are banned in sporting competition. If the athlete undergoes random drug testing, they may then get an unwelcome surprise when the test is positive for a banned substance [4]. Even if this was not intentional, the consequences (under the strict liability rules of the World Anti-Doping Authority [WADA]) can be devastating; disqualification from the competition, stripping of any medals (for the individual and possibly other team members), a ban from the sport, loss of funding, future career opportunities and sponsorship, negative media/social media and a permanent loss of reputation [5]. There are also times when the athlete may be tempted to consciously take a banned substance, in order to gain a competitive advantage, with more severe consequences if caught. This also has potential major consequences for a coach or medical staff, if they are thought to be implicit in the athlete taking a banned substance. A summer Olympic Games is one of the most watched sporting events in the world, across a variety of digital platforms, and with the rise of social media, the exposure to that athlete is higher now than ever before. The psychological pressure to perform is enhanced by the ability of social media to promote or disparage an athlete and therefore athletes may be significantly affected by this, leading to a reduction in performance. The distraction of social media generally may also affect performance and managing exposure to this is challenging; for this reason, many athletes choose to turn off all social media, leading up to, and during competition to reduce this. All these risks are probably higher when there is a ‘home’ games, as the media interest is significantly higher, as well as the fact the athlete feels the need to perform optimally in front of home fans, friends and family. At an ‘away’ games, there are other factors to consider: Many elite athletes are used to travelling to major competition and this is factored into their preparation prior to their event. Long distance travel can negatively affect an athlete (and staff) in a variety of ways. They may be sedentary for several hours which, depending on the distance, may increase the small risk of venous thromboembolism (DVT), especially if the athlete is dehydrated. DVT is common in the general population (1/1000 annually) [6]. Evidence suggests that there is a 2 to 4-fold increased risk of DVT associated with flights lasting more than 10 hours [6]. The causal role of air travel-related factors such as stasis (sitting still), dehydration, cramped seats, and hypobaric hypoxia (less oxygen at altitude) is uncertain but, given the risk-free benefit, all passengers should be well hydrated, wear well-fitting flight compression socks [7] and exercise regularly during the flight. There may also be a temptation to eat the food available on the plane, which may not be in keeping with their normal diet. This may be significant in athletes where weight category is part of the sport. Jet leg is defined as a set of symptoms affecting individuals flying across time zones: fatigue, sleep disturbance, altered appetite, reduced concentration, malaise, altered bowel habit [8]. Dependent on number of time zones crossed rather than length of flight, jet leg occurs when there is desynchrony between normal daily rhythms and the local environment [8]. As the natural daily rhythm is about 25 h, travel in an easterly direction tends to produce the greatest jet lag as it compresses a 24-h day [8, 9]. The biggest dip in sleep time is from days 1 to 4, with recovery around days 5-6. If there is little or no sleep during the flight, then recovery and adaptation is slower. Performance can be affected for up to 7 days; thus, training schedules and time from arrival to competition need to be considered [9]. Travel fatigue and jet lag are separate issues and although the symptoms may be similar, the causes and duration are different. Fatigue is related to the hours spent travelling, as opposed to jet lag, which is related to the time zones and circadian rhythm disruption. Provided there is adequate recovery scheduled post-arrival, travel fatigue will typically subside within 48 h [9]. Normalization of sleep can be aided by having a regular bedtime, avoiding stimulating activities in the evening (phone calls, e-mailing), avoiding caffeine, alcohol, and excess fluid intake. Exposure to blue light in the 2-3 h before bedtime can also affect sleep quality [10]. Many electronic devices (iPads, smartphones) emit a lot of blue light. Downloading an App that helps reduce the blue light may be helpful, but evidence is limited [11]. The air inside the cabin of an aircraft is partly recirculated and partly from outside the plane. The filters used by airlines are extremely efficient, removing microorganisms very effectively [12]. The fact the air is partially recirculated does not therefore increase the infection risk [13]. The main risk is having to sit close to someone who is ill and not being able to distance from them. This was certainly illustrated when flying to the Tokyo Olympics during the COVID-19 pandemic, when the Great Britain (GB) Team were sat in proximity to the general public. The team had been regularly screened and isolated from non-participants leading up to the Games but were then identified as close contacts (due to their seating position) when a member of the public became positive for COVID-19, which had major implications on their ability to train and prepare normally on arrival in Japan. Depending on where a major competition is held, heat and humidity may be major factors to also be aware of. All elite athletes should be well practised at good hydration, with adequate and regular intake. Daily weighing and assessment of urine osmolality are further ways of monitoring good hydration [14]. Although brief daily (up to 20 min) ultraviolet exposure onto bare skin is beneficial to boost levels of Vitamin D, excessive sun exposure carries a risk of sunburn, heat exhaustion and severe dehydration [15]. This not only affects performance but can also lead to severe (and rarely even life-threatening) illness. Therefore, athletes (and staff) are advised to use appropriate and regular sunscreen to bare skin, consider a hat/cap and ensure good hydration. Cooling during training and games can be helped by standing in shaded areas, use of fans and misting sprays, as well as iced towels on the head or back of neck. Hand immersion in iced water has also been shown to be a quick and effective way of cooling [16], although athletes and coaches are often wary of this, particularly if the sport involves holding a stick or racket (although grip is not affected if the hand is not over-cooled). Gastro-intestinal (GI) illness, such as traveller’s diarrhoea, poses a significant risk and is often due to drinking contaminated water [17]. Therefore, athletes are given advice to stick to bottled water, as much as possible. Where bottled water cannot be accessed, water should be boiled and drinking bottles sterilised regularly with a cold-water sterilising solution [18]. Care should also be observed when there is a risk of ingesting contaminated water in competition, such as an artificial Hockey pitch being watered from a contaminated source, or an athlete falling into a water jump in the Steeplechase. Athletes are also warned about avoiding ‘street-food’ which may cause illness, or even trying new foods whilst abroad, which may cause sensitivity. Certain foods should also be viewed with caution, as they may be made or washed with contaminated water, such as salads, ice-cream, ‘homemade’ mayonnaise, pastry icing and shellfish. Food should not be handled by hand, plates should be clean and dry, hot food should be piping hot. Ice in drinks should be avoided. However, simple strategies such as using vinegar and virgin olive oil can help as both have bactericidal activity [19]. Hence, athletes and staff are encouraged to only eat in the village dining areas, where the food and drink has been prepared to a satisfactory standard and is also labelled accurately for its contents in order to reduce the chance of food allergy or sensitivity. Some athletes take a prophylactic antibiotic, whilst abroad, to minimise the risk of a GI infection [20]. Even here, the risk versus benefit needs to be considered, such as side-effects to the antibiotic itself, including thrush or, in the case of ciprofloxacin, the theoretical risk of tendon rupture [21]. There is evidence for the use of probiotics in the prevention of GI infection [22]. Results vary as to actual effectiveness for treatment of diarrhoea illness. Evidence suggests that it can reduce symptom duration, which may be impactful in terms of performance [23]. Any probiotic should ideally be batch-tested and prescribed by a nutritionist, in order to reduce the risk of an adverse analytical finding on drug testing. Good hand hygiene (washing hands before/after meals and/or toileting) is now standard practice for all athletes and staff, especially since the COVID-19 pandemic. Regular cleaning of shared areas and implements is now also a regular practice. Other strategies for reducing the risk of Upper Respiratory Tract Infections (URTI) that are commonly used include using over-the-counter cold prevention sprays, such as Coldzyme [24], turning off air-conditioning in hotels, when possible, and opening windows to increase fresh air circulation. If symptoms occur, there is variable evidence for the benefit of high dose Vitamin C in shortening the duration of an URTI [25]. Zinc lozenges used within 24-hours of the onset of symptoms may reduce the duration of common cold symptoms but have no role in prevention [26]. Zinc Lozenges should be taken as soon as symptoms start [26]. As with any medication for elite athletes, they should be sourced from a batch tested or pharmaceutical grade product. There has been considerable research looking at the negative effects of poor oral hygiene on athletic performance and the increased risk of both local and systemic infection [27]. As such, athletes are strongly advised to at least an annual dental review, brush teeth twice daily with fluoride-containing toothpaste, avoid sugary drinks, excessive carbohydrate snacks and acidic food, and consider rinsing the mouth after meals with Chlorhexidine-containing mouthwash. Superficial skin abrasions are commonplace, particularly on arms and legs in certain sports, particularly with artificial pitches and surfaces. Outdoor pitches may also be contaminated with ‘dirty’ water and/or other player’s bodily fluids and often hot and humid climates, infection can be rapid and severe. Therefore, cuts and abrasions should be thoroughly cleaned immediately with sterile water/saline and covered with antiseptic barrier cream and/or a clean dressing. Any signs of infection should be quickly treated with either a broad spectrum topical (cream) or oral antibiotic [28]. There are several different biting vectors that carry a variety of diseases, especially if a major Games is overseas. The key strategy is to reduce the exposure to the biting vectors. The mainstay of prevention is the use of insect repellent on the skin and clothing. This should contain at least 20% N,N-diethyl-meta-toluamide. Stronger versions are available but can cause skin irritation and clothing disintegration. In some countries, the risk of Malaria is also present, although most major games try to avoid such areas. Again, the main advice is to avoid getting bitten, by wearing appropriate clothing and using other simple preventative measures. Chemoprophylaxis may also be indicated. The actual medication will depend on the area, but all may have significant side-effects which may impact performance and athletes will often try and avoid taking these [29, 30]. Athletes travelling abroad have the potential to being exposed to all infections of the usual traveller, which makes ensuring that all athletes are vaccinated (and boosted) against common infections important. This includes diphtheria, tetanus, polio, MMR, Hepatitis A, Meningitis C and Typhoid [31]. All athletes and staff are also potentially at risk from contracting Hepatitis B and C, especially when travelling abroad. The main risk (similar to the general public) is via sexual contact [32]. There is also a risk of potential contamination if an athlete has to receive a blood transfusion in an emergency situation [32]. As such, all athletes and staff are encouraged to be vaccinated against Hepatitis B. The risk of transmission of blood-borne pathogens in sport is, thankfully, very rare. There are no well-documented reports of HIV, hepatitis C virus, or hepatitis D virus transmission during sport [33]. Athletes are also regularly given sexual health advice whilst competing in a major multi-sport event, as there may be sexual contact with individuals who are already carrying a sexually transmitted infection, such as Chlamydia, or possibly athletes who are infected with HIV. For this reason, free condoms are readily available in the athlete village Polyclinic. For the Tokyo summer Olympics, Beijing winter Olympics and Birmingham Commonwealth Games, there was the issue of COVID-19 to contend with [2]. This brought its own unique challenges for both athletes and supporting staff. The main aim was to ensure that all athletes and staff were fully vaccinated against COVID-19, to not only reduce the risk of contracting the infection but also reduce the severity, duration, and long-term sequelae. The dilemma for an individual who refused vaccination included not being allowed to travel to the host country at all. For the Tokyo Olympic Games, any asymptomatic individual testing positive on arrival was automatic isolation in a hotel for 14 days and any close contacts isolated in the team environment. This obviously had a significantly negative impact on the ability to acclimatise, train and/or compete, as well as their mental health, and so Team GB took significant steps in trying to ensure that no travelling athletes or staff tested positive on arrival, by advising anyone travelling to isolate from friends, family, and general public, as much as possible, for two weeks prior to travel. All travellers were also regularly tested prior to boarding the flight. Anyone testing positive was then held back from flying until they were negative and asymptomatic. Thankfully, no Team GB athletes or staff tested positive on arrival in Japan. Unfortunately, some delegates were identified as close contacts on the flight, for those members of the public on the same flight who tested positive on arrival and therefore had to isolate in the team environment for several days. This proved to be a major organisational to ensure that the athletes were able to sleep and eat and travel training in but still able to prepare as normally as possible. 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