Vaccination is a cornerstone of infection prevention efforts. Several highly transmissible and potentially serious infections can be reliably prevented among athletes and players using safe and effective vaccines. Vaccination provides temporary or lifelong immunity against specific infections and is a mainstay of infection prevention practices. Immunity is effective and long-lasting for some infections such as hepatitis A and B, while it provides incomplete or short protection for other infections such as influenza. Vaccination prevents infections through two mechanisms. First, vaccinated individuals have increased protection. Second, community or herd immunity reduces transmission risk when a high enough proportion of a population has been immunized. Thus, vaccination in the population setting actually protects unimmunized individuals.
While standard childhood vaccination schedules provide protection into adolescence and early adulthood, some persons may have inadvertently or deliberately missed critical vaccinations, or immunity may have waned with time leaving individuals at risk for infection. Reviewing vaccination history, testing for protective antibodies, and then undertaking catch up or revaccination is a reasonable strategy to prevent infections within teams—both for the individual athlete and for the entire team. While standard childhood and adult catch-up immunization schedules are subject to both national and local variability, vaccination should be considered against the pathogens listed in Table 5.3
Valuable methods for minimizing the impact of vaccine-preventable illnesses on athlete health include (1) developing a reliable system to assess the vaccination status of athletes and support staff and (2) implementing strategies to ensure both standard and selected additional vaccinations have been provided.
Develop a policy about immunizations for vaccine-preventable diseases (influenza, pertussis, meningococcus, measles, mumps, and chicken pox) in players and team personnel.
Several highly transmissible and potentially serious infections can be easily prevented among athletes using safe vaccines: influenza, Bordetella pertussis
(pertussis or “whooping cough”), meningococcal meningitis, measles, mumps, and chicken pox. An example of a policy for vaccine-preventable diseases is included in Appendix 1D
. Vaccine Information Sheets (VISs) for influenza vaccine, tetanus-diphtheria-acellular pertussis (Tdap) vaccine, meningococcal vaccine, measles-mumps-rubella (MMR) vaccine, and chicken pox vaccine are provided by the Advisory Committee on Immunization Practices (ACIP) and should be reviewed prior to vaccine administration (www.cdc.gov/vaccines/acip/index.html
Provide influenza vaccination to prevent influenza (the “flu”).
Provide influenza vaccination to all players and staff annually.
Track compliance with influenza vaccination among players and staff.
Rationale: Influenza is a common and partially preventable respiratory infection that is readily transmitted from person to person. Influenza infection significantly reduces respiratory capacity and athletic performance even in players with relatively mild infections. A small but important percentage of young and otherwise healthy individuals who acquire influenza may develop severe infections that require hospitalization and, occasionally, intensive care.
Vaccination is the most effective method to prevent flu. Influenza vaccines have proven benefits that are important for athletes and teams. Most importantly, players who receive influenza vaccines are less likely to have fever or influenza-like illness, are less likely to miss practice and games, and are less likely to spread influenza to teammates
It is important to recognize, however, that numerous viruses can cause “influenza-like illness”; thus, vaccination will not prevent all episodes of influenza-like illness. This fact should be emphasized when players or skeptics complain “I received influenza vaccine, and I got the flu anyway.” We are including specific educational materials regarding facts and myths about the benefits and safety of influenza vaccination in Appendix 1E
Vaccination is the most effective method to prevent flu.
From a team perspective, vaccinated players who are exposed to influenza are less likely to spread the virus and are, thus, less likely to cause a locker room-wide outbreak that could potentially devastate a team. Thus, immunization has benefits for individual players and the team.
We continue to believe the best and most effective approach is to require that all players receive influenza vaccination. This approach is now widely used in most hospitals in the United States. We acknowledge, however, that this approach may not be feasible in some settings without union, parent, and/or player approvals. Compliance among athletes is typically low, between 20% and 30%. However, some programs have achieved much higher rates of compliance (even up to 90%) through highly visible and active campaigns.
Vaccination can be given intranasally or via intramuscular (IM) injection. In 2017, the ACIP recommended against the use of the intranasal formulation (a live attenuated vaccine) due to lack of efficacy against the common H1N1 influenza strain. However, the intranasal vaccine was reintroduced and approved by the ACIP for the 2018 season (and beyond) following a change in the H1N1 component.5
We welcome the reintroduction of the intranasal vaccine, as it provides a method for overcoming one of the key excuses for not receiving a vaccine—the injection or “shot.” Similarly, egg allergies are no longer sufficient to prevent receipt of the vaccine, as egg-free formulations now exist. Injections can be given using either trivalent (covers three types of flu) or quadrivalent (covers four types of flu) vaccine.
Mandate that all athletic trainers and team medical staff receive annual influenza vaccination.
Most US healthcare institutions now require that all healthcare workers receive annual influenza vaccination.6
Requiring that team healthcare providers, including athletic trainers and team physicians, receive annual influenza vaccination leads to two benefits. First, it helps improve the “culture of safety” by providing an outward and visible demonstration of the importance of influenza prevention. Second, as athletic trainers have regular close contact with players, immunized athletic trainers are unlikely to spread influenza from one player to another during their routine work and activities.
Hepatitis A and Hepatitis B
Provide vaccine to prevent hepatitis A and hepatitis B infections.
Ensure athletes have been vaccinated against hepatitis A and B.
Rationale: Hepatitis A and hepatitis B are viral infections that can cause serious liver damage. Hepatitis A is an acute illness acquired by ingestion of contaminated food. Hepatitis B can be an acute and/or chronic disease that is acquired from exposure to contaminated blood (eg, a needle stick).
Hepatitis A vaccine became available in the United States in 1996 but was not widely used prior to 2006 when it became part of the standard vaccines administered to American children. However, many young adults did not receive this vaccination in childhood and thus remain vulnerable to acquiring hepatitis A.
In light of the above, it is not surprising that outbreaks of hepatitis A continue to occur even though the overall incidence of hepatitis A has declined. A large and persistent outbreak of hepatitis A began in San Diego in 2015 and continued into 2017.7
Cases linked to this outbreak have occurred in multiple states including Arizona, Indiana, Michigan, Colorado, and Tennessee. The average age of 3421 cases reported in 2017 was 40 years; two-thirds of the affected individuals were men. Over 25,000 cases were reported between November 2016 and September 2019, contributing to 15,500 hospitalizations and 259 deaths.8
Due to these outbreaks, the United States Centers for Disease Control and Prevention (CDC) supports the use of hepatitis A vaccine after known or possible exposure to a single case of hepatitis A. Some experts have recommended vaccination in athletes involved in close-contact sports “because this disease typically leads to months of reduced physical performance and [because] hepatitis A can be easily transferred to teammates and opponents.”9
Another aspect of hepatitis A risk is international travel. For example, the CDC recommends that travelers to most Central American, South American, and Southeast Asian destinations receive vaccination against hepatitis A, as the virus can be acquired via contaminated food or water regardless of where you are eating or staying. Specific recommendations for specific destinations can be found at wwwnc.cdc.gov/travel/destinations/list
Hepatitis B vaccine became part of routine childhood immunizations in the United States in 1991. Outbreaks are more likely to occur in locations where health care is provided. More specifically, these outbreaks occur because of poor, unsafe, and sometimes illegal activities during invasive medical procedures (eg, hemodialysis, surgical centers, injections) (www.cdc.gov/hepatitis/outbreaks/healthcarehepoutbreaktable.htm
). The CDC reported 23 outbreaks of hepatitis B related to health care from 2008 through 2017; 18 occurred in long-term care facilities and 5 occurred in medical settings such as dental clinics, outpatient oncology clinic, surgical center, and two pain clinics. See Chapter 4 for additional information about safe injection practices to prevent the risk of hepatitis B transmission
Hepatitis B is more contagious than hepatitis C or HIV. Transmission has occurred in contact sports, such as among members of a Japanese sumo wrestling club,10
during American football,11
and among cross-country runners in Sweden.12
Vaccinate all athletic trainers and team medical personnel against hepatitis B.
Document that all athletic trainers and team medical personnel have been vaccinated against hepatitis B.
The risk of transmission due to high-risk exposures to blood infected with hepatitis B is approximately 33% (one in three). Vaccination is highly effective in reducing this risk to near zero, is long-lasting, and is safe.13
In fact, healthcare facilities that do not offer the hepatitis B vaccine to employees have been sued for negligence.14
Therefore, most medical facilities require hepatitis B vaccination as a requirement for employment.
Based on previous discussions with athletic trainers, we believe the vast majority of athletic trainers and team physicians are already vaccinated against hepatitis B. In the event that
athletic trainers or team physicians have not been vaccinated against hepatitis B, we recommend they receive the vaccination series. We also recommend documenting the vaccination status for each athletic trainer and physician. This requirement is especially important for new staff members.
Provide vaccine to prevent pertussis infection (“whooping cough”).
Ensure all athletes have completed recommended DTaP series.
Rationale: Pertussis is widely and erroneously believed to be a rare disease of infants and children. In fact, pertussis is common. An estimated 2 million Americans acquire pertussis each year. Pertussis causes an illness that typically manifests as cough (often prolonged) with or without fever. During the second phase of illness, cough due to pertussis can be so severe that it leads to vomiting (ie, paroxysms of cough leading to posttussive vomiting). Among children, the illness often causes a characteristic “whooping” sound or “whooping cough.”
Vaccination is the key strategy to prevent infection with pertussis. The ACIP currently recommends that children in the United States receive five doses of the diphtheria-tetanus-pertussis (DTaP) vaccine: 2 months, 4 months, 6 months, 15 to 18 months, and 4 to 6 years old.15
Ensure athletes have received at least one dose of Tdap.
Provide the Tdap vaccine in place of standard tetanus when indicated.
The ACIP recommends that children in the United States receive one dose of Tdap vaccine at age 11 or 12 years.16
“Acellular” refers to the fact that the immune response is triggered by immunogenic proteins, toxins, and other cellular components and is not due to an intact bacterium. As such, pertussis vaccine cannot and does not cause pertussis.
As this recommendation is relatively recent, most adult athletes will not have received a dose. As a result, adult athletes should receive a dose of Tdap. If the athlete is unsure if he or she has received Tdap, the CDC recommends providing a booster. Furthermore, if a player requires a tetanus booster due to an injury that requires sutures, the Tdap can be given instead of the standard tetanus booster.
The fact that immunization for pertussis in childhood does not produce durable immunity in adults is widely underappreciated. While infants have more severe infections, adolescents and adults actually account for >60% of cases in the vaccination era.17
Because immunity induced by pertussis vaccine characteristically declines with time, adults who were vaccinated during childhood can and do become infected with B. pertussis
. For example, 40% of previously immunized adults contract pertussis after exposure to infected children.18
Though unlikely to cause death, adults with pertussis often have prolonged, significant illnesses. Pertussis infection regularly results in unnecessary doctor visits, unnecessary use of antibiotics, and most importantly from a team perspective, increased absenteeism from work.19
Several studies have demonstrated that the majority of adults with pertussis missed between 7 to 10 days of work20
; 10% to 16% of adults with pertussis missed more than a month of work.21,22,23,24
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