Your personal and social behaviors can increase your risk for infection. However, you have the direct ability to modify behavior, improve habits, and decrease risk. One key strategy highlighted throughout is hygiene.
Player Knowledge and Education
Risk Lack of knowledge.
If you are unaware of your risk for athletically acquired infections, you may be missing opportunities to protect yourself and your teammates from these preventable infections.
Participate in preseason athlete health meetings and ask athletic trainers and medical staff for additional information about infection prevention and control protocols in your athletic facility.
Rationale: Athletes are at increased risk for infection for several reasons. Primarily, athletes are often in close quarters and have frequent, close contact with other athletes. Athletic activities often lead to skin abrasions, cuts, and scrapes. Finally, athletes often have inadequate access to clean equipment/facilities and/or simply don’t practice good hand and body hygiene. During just 1 day of training, you will be repeatedly exposed to these risks not only on the court, field, or mats but also in the athletic training room, weight room, and locker room.
You know the cliché—“knowledge is power.” Cliché or not, education is a critical and effective component of infection prevention. In preseason meetings, you should be educated about recognizing and preventing several types of infection, such as skin and soft-tissue infections. One such example, MRSA, is of particular importance. These infections occur commonly among athletes and may produce outbreaks or clusters of infection that consequently impact numerous players.1
Recognize the signs and symptoms of skin infection and present these symptoms to your athletic trainer.
Rationale: You know your body better than anyone, and you know when something might be wrong. So, it’s important that you know of and remain vigilant for early signs of infection. Symptoms of an early infection include but are not limited to a skin lesion with:
Pus or other drainage
These symptoms may also be accompanied by fever, chills, and generalized malaise. Notify your athletic trainer immediately if you develop any of these symptoms.
More specifically, present any concerning issues or symptoms to your athletic trainer immediately if they occur. We’ve spoken to hundreds of athletic trainers, and we know they agree: when in doubt, point it out. Proper diagnosis and prompt treatment could prevent these infections from becoming more severe. The earlier you receive treatment, the less likely the infection will cause serious problems.
Additionally, you should communicate with your athletic trainer about the infection prevention policies that are in place in your athletic facility. These may include but are not limited to protocols regarding hydrotherapy room usage, cut care, laundry services, and hand hygiene. Understanding and abiding by these policies can help you avoid preventable infections.
Notify your athletic trainer when you have vomiting and/or diarrhea.
Rationale: If you have vomiting AND diarrhea, you could potentially have norovirus. Norovirus is the most common cause of outbreaks of acute gastroenteritis in the United States. It is highly contagious and is easily spread from person to person and via aerosols, food, or contact with contaminated environmental surfaces.
Outbreaks among athletes have been documented. For instance, an outbreak of norovirus infections occurred during a football game between Duke and Florida State University. The original source of infection was thought to be turkey sandwiches in box lunches served to the Duke team 50 hours before the game. 50% of the team personnel became ill before and during the game. 11 Florida State players then developed norovirus infection after the game.2
A similar team-to-opposing team transmission occurred in the National Basketball Association (NBA).
Wash your hands thoroughly with soap and water if norovirus is suspected. Norovirus is not inactivated by alcohol-based sanitizers.
Due to the highly contagious nature of norovirus, it is very important that you are transparent with your athletic trainer about your symptoms. Doing so could save all members of your team from missed game time. Your athletic trainers and athletic facility will use special
disinfection strategies when a case of norovirus has been identified. You should do the same. At home, wash your hands frequently and disinfect your bathroom with a bleach or hydrogen peroxide-containing disinfectant.
Recognize the signs of “athlete’s foot” and present these symptoms to your athletic trainer.
Rationale: Tinea pedis or “athlete’s foot” is a fungal infection of the skin, typically between the toes. Athlete’s foot can be easily diagnosed by its appearance, which your athletic trainer will be able to evaluate. Your athletic trainer will likely advise you to apply a topical antifungal cream for 4 weeks. Athlete’s foot should be treated for two reasons. First, the presence of athlete’s foot, and the resulting damage to the skin, can put you at risk for skin infection in the foot and lower leg. Second, athlete’s foot can be spread to other athletes. When an athlete has tinea pedis, the spore-like cells of the fungus are shed on the training floor. Other athletes in the facility can then acquire tinea pedis through contact with that training floor. If untreated, the infection could persist indefinitely.
Recognize the signs of herpes gladiatorum and present these symptoms to your athletic trainer. Know that you are at particularly increased risk for these infections in contact sports, such as wrestling, rugby, and football.
Rationale: Herpes gladiatorum is a viral skin infection caused by the herpes simplex virus (HSV). Most people are familiar with herpes-related cold sores, as almost two-thirds of adults have HSV. HSV is classified into two broad types, HSV-1 and HSV-2. Nearly all reported outbreaks of herpes gladiatorum involve HSV-1, the same virus responsible for nearly 80% of cold sores.
Since the virus gains entry to the body via small breaks in the skin, athletes involved in contact sports are at increased risk. While the majority of outbreaks have been described among wrestlers, transmission between rugby players has also been described (informally called “scrum pox”). The same mechanisms of transmission described above—frequent abrasions and skin-to-skin contact between athletes—put athletes at risk. Sometimes mistaken for other common skin infections, delayed diagnosis contributes to ongoing transmission.
Notify your athletic trainer if you develop flu-like symptoms.
Rationale: Flu-like symptoms typically include the sudden onset of fever, chills, myalgias, headache, cough, loss of appetite, and a generalized feeling of weakness. These symptoms can be caused by different viral infections, but influenza should be suspected during the “flu season,” especially when flu levels are high in your area. Your athletic trainer may want to have you tested for influenza and other respiratory viruses. If you test positive for influenza, you can be treated with oseltamivir to shorten the duration of the symptoms. As importantly, your athletic trainer can initiate a layered response to help prevent you from spreading the flu to other teammates.
Risk Poor team culture.
Become an infection prevention champion to improve the “culture” of infection prevention and accountability.
As an athlete, you are well aware of how team culture affects performance, and likely, the final outcome of a game, match, or competition. Just as you, your teammates, and
coaches try to build a culture of athletic excellence, you can and need to create a “culture” of quality in infection prevention. Accountability is a key component of both your culture of athletic excellence and the culture of quality in infection prevention.
Who do you identify as a leader in your team? Are you the leader? Leaders play a critical role in developing team culture. In quality improvement initiatives, leaders are often labeled as “champions.” Infection prevention champions serve as role models for effective infection prevention practices and hold other members of the team accountable. In order to be an infection prevention champion, you must be familiar with specific infection prevention policies used at the facilities and integrate them into your daily routine. What can you do to lead the way?
Infection prevention champions serve as role models for effective infection prevention practices and hold other members of the team accountable.
Here is a list of suggested actions that will demonstrate to your teammates that you are committed to creating a safe environment and upholding a culture of quality:
Shower immediately after practice
Don’t use whirlpools with open wounds
Perform hand hygiene in the weight room
Get up-to-date with recommended vaccinations
By adhering to these recommendations, you can motivate and stimulate others to embrace and follow good infection prevention practices (Figure 2.2
). Lead by example! You also can effectively reeducate and remind teammates who violate infection prevention principles by positively motivating them to change their behaviors. For example, teammates are less likely to enter a whirlpool with open wounds if they see you, a leader on your team, adhering to team-based protocols and good practices.
Figure 2.2 Infection prevention champions model behavior for other athletes.
Risk Poor hygiene.
As in any athletic endeavor, focusing on the fundamentals is critical to success. Hygiene is a fundamental component of health and one that you can directly control. This subsection includes specific strategies to help you improve and maintain your hygiene through hand washing, showering, and using appropriate strategies for hair removal, as necessary. You have a responsibility to yourself and your teammates to adhere to these strategies!
Showering After Athletic Participation
Risk Factors Body cleanliness (or lack thereof). Body contact (skin to skin). Skin contact with contaminated items or surfaces.
Figure 2.4 Cycle of transmission and infection in athletes.
Immediately shower after practice to decrease your risk of infection and bacterial transmission from player to player and from player to environment. Encourage your teammates to do the same.
Rationale: You will be exposed to MRSA and other pathogens during athletic participation. Humans are the natural reservoirs for MRSA, meaning that we are the agent by which the bacteria are spread and the source for MRSA in the environment. Showering after practice decreases the risk of MRSA infection because it removes the bacteria from the skin. As with hand hygiene, this intervention stops the infection cycle for you. More specifically, showering after practice can remove MRSA and other pathogens acquired during practice.
You will be exposed to MRSA and other pathogens during athletic participation.
Removal of these bacteria decreases risk of infection in two ways. First, with fewer bacteria present, the risk of infection in compromised skin is decreased in the short term. Second, removing bacteria will prevent long-term colonization on the skin. Colonization means that a person carries the bacteria on their skin without showing signs of infection. However, colonization increases the risk of infection in the long term. That is, the germ is present and ready to cause trouble when an opportunity occurs later on (eg, a subsequent scratch or cut).
As above, showering decreases risks associated with new
acquisition of a pathogen like MRSA. Showering will also decrease risks for athletes who are already colonized. A recent study showed that 13% of US collegiate athletes are colonized with MRSA without showing signs of infection.3
In other words, on a 50-member team, nearly 7 players are silently colonized
with MRSA. The study also demonstrated that players with MRSA colonization were 7.3 times more likely to experience a subsequent MRSA infection. In comparison, only 2% of people in the general American public carry the bacteria on their skin. So, to relate to the hypothetical team we described above, that means that out of 50 people, only 1 person would be silently colonized with MRSA. Showering after practice improves skin health and decreases the risk that MRSA (or some other germ) will enter a skin abrasion, even if the MRSA is already on the skin.
Finally, showering after practice will decrease the risk of secondary transmission to your teammates both by direct contact (primary transmission) and through contamination of the environment (secondary transmission). By reducing the amount of MRSA on the skin, you will reduce the amount of MRSA in the environment. This intervention will reduce contamination of a training facility and athletic environment, ultimately protecting other athletes from contamination as well.
REMEMBER—contact with MRSA is inevitable in team settings. MRSA exposure increases the risk of subsequent infection as well, particularly in the setting of skin abrasions and cuts acquired through athletic participation. Simple interventions can help you decrease this risk.
Do not use bar soap present in the shower. Use soap dispensers that utilize prepackaged liquid soap in the shower.
Bar soap has previously been implicated as a potential source of MRSA transmission. Specifically, sharing bar soap was associated with MRSA infections during an outbreak among football players and in an outbreak in a prison.4
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