1. Infectious Disease in Sports Britt Marcussen, MD Department of Family Medicine University of Iowa

2. UI Sports Medicine 6-0

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4. Influenza Definition: Influenza or “flu” is an infection caused by the influenza viruses. Influenza spreads around the world in seasonal epidemics that result in 250,000 to 500,000 deaths each year (41,000 on average in the US). Occasional pandemics occur when a particularly virulent and contagious strain of flu have been know to cause 50 million deaths.

5. Classification There are three viral types: A/B/C A: The most virulent and responsible for all pandemics thus far. Mutates rapidly B: Not as virulent. Mutates slower. Humans have some baseline immunity. C: Much less common and usually only produces mild symptoms.

6. Influenza Viral Structure Envelope: Contains the glycoprotein's Hemaggutinin (binding) and Neuraminidase (release) and thus the H N classification. Core: contains the RNA that contains the genes for protein coding During viral replication because there are no RNA proofreading enzymes errors in transcription occur, thus altering the surface proteins. These mutations are what is responsible for “antigenic drift”.

7. The typical presentation is fairly rapid onset of fever, chills and body aches. Other symptoms can include HA, cough, nasal congestion and sore throat. You can also get GI symptoms of nausea, vomiting and diarrhea especially in children. None of these clinical symptoms or signs are particularly specific and are common to most of the hundreds of known respiratory viruses Signs and Symptoms

8. Morbidity/Mortality Increased in the young ( 65) and those with other co morbid conditions. Death is usually the result of a secondary infection, usually pneumonia. During pandemics the excess mortality is in younger patient population and is a result of the “cytokine storm” induced by the virus which leads to pulmonary edema and hemorrhage.

9. Transmission Possible mechanism of spread: –Direct transmission from hard surfaces –Direct transmission for large particle contact (up to 1 meter away) –Inhalation of suspended particle (5micrometer)?. The virus can live on hard surfaces up three days and in mucus for up to two weeks!

10. Testing Rapid test for A/B are available and are reasonably accurate (sensitivity 50-70% and specificity of 90-95%). They are most accurate during the first 4-5 days. Test only when results will influence decision making( i.e., hospitalized patients, considering treatment of the individual or contacts/infection control). During outbreaks in patient with typical symptoms no testing is necessary.

11. Treatment Must start within 48 hours! At best decreases the duration of illness by 1-2 days. It is unclear whether treatment decreases the severity of symptoms, complications or mortality.

12. Treatment Agents: Amantidine, rimantidine, oseltamivir (Tamiflu), zanamivir (Relenza). The adamantanes are not currently recommended due to high resistance rates, but this may change! Most healthy adults with no risk factors for complications require no treatment.

13. Treatment High risk groups –Pregnancy up to two weeks postpartum –The young and old ( 65) –Chronic medical conditions (CV/pulmonary disease, renal/hepatic disease, diabetes, immunosuppressed, 19 yo’s or younger on aspirin, obesity/BMI over 30 –Severe disease/pronounce lower respiratory tact symptoms. –Prophylaxis of close contacts is not generally recommended, especially if 48 hours has passed since the time of exposure.

14. Prevention The infectious period starts 24 hour prior to the onset of symptoms and at least for 24 hour after fever abates. Stay home until fever free for 24 hours. For health care workers it’s or 7 days which ever is longer! Patients on antiviral are considered infectious until they have completed at least 4 days of therapy. Surgical masks are recommended for health care workers caring for suspected cases. General Advise: Wash your hands, don’t pick your nose, avoid sick people, eat well, sleep well and avoid stress. Medical offices: Triage/vaccination of staff/masking/designated waiting areas.

15. Vaccination Advised for everyone over 6 months of age. This years vaccine will include H1N1, a seasonal H3N2 and a B component. There are two vaccines available an inactivated injectable form and a live attenuated intranasal form Why everyone: An estimated 85% of the population has and indication for vaccination. People under 50 do get ill and spread infection. We are now able to supply the vaccine.

16. Vaccination Special populations and considerations –One dose if 8 and older, 2 dose 4 weeks apart if 8 and under and did not receive at least one dose of the 2009 H2N1 vaccine plus at least one dose of seasonal flu vaccine previousely. –No nasal vaccine for those under 2 or over 50. Pregnancy, age <19 and on aspirin, lung disease, diabetes, weakend immune system, kidney failure. –No vaccine at all if you have a severe egg allergy, history of Gillain-Barre’ within 6 weeks of previous vaccination. –Multidose vial contains Mercury. –6-35 months get ½ dose. –Avoid Fluviron in those 8 and under due to fever and febrile seizure risk. –If 65 and older consider high dose Fluzone (4x the antigen). Better immune response but ? better protection.

17. Vaccination NNT in Health Adults (Cochrane review) –Under ideal conditions (vaccine match) = 33 –Under usual conditions = 100 –One case of vaccine related Gillian Barre’/million vaccinated. –15/36 studies were industry sponsored. –Vaccine effectiveness under the age of two is not yet established despite the guild lines. –may not need to change from year to year. New DNA vaccine to the inner less variable part of the HA protein shows some promise and -The are over 200 viruses that cause influenza like illness which represent about 90% of the circulating virus each year.

18. Summary of Last Years Flu Season Overall vaccination coverage was 41%, 27% for H1N1. H1N1 was very wide spread peaking in June/July and again in October. Deaths from April 09 to April 10 were approximately 12,470. 9,570 were in the 18-64 year age group! In an average year up to 40,000 deaths will be attributed to flu. Hospitalizations were approximately 274,000 with 160,000 from the 18-64 age group.

19. Summary of Last Years Flu 2009 NEJM 369:1935-1944 –Looked at 272 hospitalized patients –45% were <18; 50% were 18-65 –In a “usual year” 60% of the hospitalized patients will be >65. –New obesity link? 45% of hospitalized patients were obese

20. 1918 Pandemic Prospective Mortality was 10-20% primarily young adults (cytokine storm- massive hemorrhage) WW1 troop movement and close quarters help facilitate the spread 3-6% of the global population died (50-100 million) 500,000 to 700,000 died in the US (more than in the war). In Samoa 90% of the population died. The virus has been identified as an Avian H1N1 virus and sequenced from frozen remains in Alaska and preserved soldiers. Will modern medicine help when this type of stain emerges again? Vaccination/antibiotics/better equipped hospitals.

21. Influenza and Sports Asian Youth Games 2009 (BJSM 2010 44:528-532). –1210 athletes, 810 staff from 43 countries one week after WHO declared H1N1 a pandemic. –All athletes had twice daily temp. recorded –Any athlete with flu like symptoms was tested and if positive placed on medication put in isolation. Close contacts were placed on medication and quarantined. –Masks and thermometers were provided to all athletes and officials. –All confirmed cases of H1N1 were admitted to the Hospital for isolation after “special transport” was arranged. Close contacts were placed on medication and isolated at government quarantine facilities for 7 days. Close contact was defined as 2m for more than one hour. –Temperature scanners were place at strategic locations in the games village. –Medical care was made available 24/7 to all participants family and staff. With hot zone and cold zone triage. All medical staff in the hot zone were required to wear gloves/gowns/N95 masks. Mobile high efficiency air filter systems were installed in the hot zone. –6 cases, 42 quarantined, no event outbreaks were identified.

22. Case: Football team arrives and passes through thermal scans. After arrival 2 team members who did not make the trip due to illness are found to have H1N1. First match is the next day. What do you do?

23. Emergency panel assembles and determines that all are “close contacts”. All 21 team/team personal are screened. 4 are positive, the rest are quarantined.

24. The Athlete and Influenza Athletes may be at higher risk during times of high training load and stress. Athletes may be at higher risk due to close contact with other athletes during training and competition. Athletes may be at higher risk due to there living/travel circumstances Athletes may be at higher risk due to sharing of water bottles towel and other personal items. Good hygiene and infectious control measure should be stressed.

25. The Athlete and Influenza We should do are best to recognizes the typical symptoms of flu in our athletes and staff (i.e., abrupt onset of f/c/HA/cough/ST/rhinnorhea) and treat if appropriate and minimize exposing others. PPV 79-88% Not all need to be seen in the clinic as uncomplicated cases resolve in 3-7 days. Cough and malaise can last several weeks so training loads may need adjusting. We need to be aware of the incubation periods are 1-4 days. Viral shedding occurs for 24 hour prior to symptoms and lasts 5-10 days.

26. Return to Play Must be individualized based on: –Symptom severity Fever/myalgia/severe cough warrant activity limitation (neck check) –Symptom duration/infectious period. –Sport and current demand –Must include monitoring for secondary infection/pneumonia.