Contagious diseases in athletes

Contagious diseases in athletes

Cover story

By Dilip R. Patel, MD, and Ralph C. Gordon, MD

As more and more kids participate in recreational and competitivesports, pediatricians must be able to recognize and treat infectious diseasesthat commonly plague athletes and to make sound decisions about when athletesmay resume play.

The contagious diseases that occur in athletic settings range from thecommon to the rare, and from the trivial to the very serious (Table 1).For athletes, the consequences of these maladies may be discontinued participation,sub-par performance, or potentially serious complications resulting fromcontinued physical stress.

This review describes the diseases most commonly transmitted among athletes,explains how they are transmitted, and suggests how transmission can beprevented or minimized. Although not many of these diseases have been conclusivelyshown to be more prevalent in athletes than in non-athletes, general pediatriciansmay still want to ask patients about their athletic activities as part ofkeeping the history current, and to let this information influence theirindex of suspicion when confronting particular symptoms.

Activity, immunity, and susceptibility

Nieman reviewed 629 papers published on the relationship between exerciseand immunology between 1900 and 1995.¹ He noted that acute exerciseof moderate duration and intensity generally affected the immune systemless than more prolonged high-intensity activity, such as running a marathon.During acute physical activity, the immune and hormonal responses of thebody resemble those produced by an acute infection or trauma. Natural killercells, neutrophils, and macrophages are strongly influenced by exercise.

Unlike acute or prolonged high-intensity activity, regular moderate exercisedoes not seem to affect immune function adversely and, in fact, may enhanceit. A hypothetical model for the relationship between athletic activityand infection is depicted in Figure 1.²

Transmission in the athletic setting

As shown in Table 2, infections may spread during the sporting activityitself, in the locker room, or during travel and leisure time.³Several characteristics of athletic settings favor contagion. During contactsports such as wrestling, direct skin contact gives rise to dermatologicinfections. In water sports, the athlete may acquire an infection from anunsanitary swimming pool. Infection may also travel via contaminated equipment,clothing, and towels. The high humidity around showers and in changing roomsfacilitates the spread of many respiratory and fungal infections.³

The modes by which infections are transmitted in competitive athleticsare person-to-person, from a common source, or by the airborne or dropletroute (Table 3).⁴ The most common infection transmitted by directcontact is herpes simplex virus infection. Outbreaks associated with person-to-personspread are often caused by Staphylococcus aureus, group A streptococci,and fungi, and are particularly common in wrestling, basketball, football,rugby, and orienteering (an increasingly popular sport that teaches participantshow to navigate in the out of doors).⁵

The most frequently reported common-source infections are due to enteroviruses.Outbreaks of aseptic meningitis and pleurodynia have been documented infootball and soccer players and are associated with contamination of sharedwater sources and drinking containers.⁴ These episodes have generallyinvolved high school teams in which common-source or person-to-person spreadwas considered the likely mode of transmission.

Epidemics of measles among athletes and spectators have been caused byairborne droplets in the crowded, confined environments of basketball, wrestling,and other sports matches, resulting in the need for mass immunizations andrelocation or cancellation of events.⁶

Acute viral URIs and complications

Upper respiratory tract infections (URIs) are the most common cause ofacute morbidity and time off from play in athletics. Most URIs are causedby rhinoviruses, but coronaviruses have also been implicated, especiallyin athletes 15 to 19 years of age.⁷ In an athletic setting, theseinfections are often transmitted via droplets during person-to-person contactor by direct or indirect contact with contaminated objects or hands. Athletesare more prone to these infections than others because of time spent incrowded gyms.

Various investigators suggest that regular moderate exercise reducesone's relative risk of URIs in comparison to those with a sedentary lifestyle.On the other hand, excessive or long-term endurance activity increases one'srisk.¹ Thus, experts have proposed a J-shaped relationship betweenthe risk of URI and the intensity of physical activity, as depicted in Figure2.⁸

An athlete with an uncomplicated URI and symptoms limited to sneezing,runny nose, and sore throat may be allowed to resume low-intensity sportsparticipation after a rest of a few days. Activity can then gradually increaseto a pre-illness level. The American Academy of Pediatrics (AAP) recommendsthat an athlete with a URI have an individual assessment regarding continuedsports participation,⁹ since studies suggest that athletic performancemay be decreased during such illnesses.⁷ An athlete who has constitutionalsymptoms, such as fever, myalgia, malaise, extreme tiredness, headache,or lymphadenopathy, should refrain from participation in sports until symptomsresolve, or up to one month.¹⁰

During an acute viral illness with fever and other constitutional symptoms,athletic performance is significantly compromised by a decrease in strength,maximum oxygen- carrying capacity, endurance, and coordination, and an increasein fatigability. Possible systemic effects of the illness and fever includeincreased heart rate and cardiac effort, predisposition to syncope, impairedlung function, and disordered temperature control.¹⁰ The AAPrecommends that an athlete with fever not participate in sports, since strenuousactivity along with lack of rest, inadequate nutrition, and the emotionalstress of competition may adversely affect the immune system.⁹

Continued physical stress during apparently benign viral illnesses canraise the risk of myocarditis. Myocarditis has been implicated as a causeof sudden death in young athletes in up to 10% of cases.¹¹ Manyathletes continue training in the face of early warning signs such as dyspnea,palpitations, or fatigue. Those of us who care for young athletes need toeducate players on the significance of such symptoms and the need to seekmedical attention if such symptoms develop.

Some researchers suggest that a viral infection should be suspected ifa player exhibits a sudden, unexplained deterioration of athletic performance.¹They advise that continued participation in strenuous activity may leadto "overtraining syndrome"--chronic fatigue, underperformance,and relative immunodeficiency.^12,13 Many athletes with prolongedfatigue have a history of frequent viral infections. Known formerly as post-viralfatigue syndrome, this condition is now considered a self-perpetuating chronicinflammatory response.¹⁴

Infectious mononucleosis

Caused by Epstein-Barr virus, infectious mononucleosis is spread by oralsecretions. It most often affects adolescents and young adults. The clinicalpresentation and general management are no different in athletes than innon-athletes. Athletes seem to return to athletic activity sooner afterthe illness than non-athletes resume their normal lifestyle. This may bepartly because of athletes' strong motivation to return to sports. Generally,it takes three months or more for an athlete to return to his or her pre-illnessperformance level.

Splenomegaly occurs in 50% to 75% of cases of infectious mononucleosis.While an enlarged spleen is more prone to rupture, this is a rare complicationwith an estimated prevalence of less than 0.2%.^7,15 The riskfor splenic rupture is highest between weeks two and four of the illness.Most ruptures occur during non-athletic activities such as defecating andlifting, or spontaneously without direct cause. As there is an increasedrisk of nonimpact or direct impact rupture while participating in sports,however, particularly in contact and collision sports, the athlete shouldrefrain from such sports until complete clinical resolution of the illnessand return of the spleen to normal size--generally at least four weeks fromthe onset of the illness. The athlete should resume activity gradually overa period of several weeks to months depending on ability and sense of well-being.⁷

Blood-borne diseases

Human immunodeficiency virus (HIV) and hepatitis B virus (HBV) infectionsare the blood-borne diseases of greatest concern to parents and athletes,though in fact athletes are at low risk.

HIV infection is transmitted via blood and blood products, semen, vaginaland cervical secretions, breast milk, and amniotic fluid, but is not knownto be transmitted via tears, saliva, sweat, urine, sputum, or respiratorydroplets. It is not acquired by hand-shaking, in swimming pools or communalbath water, or from toilet seats, food, or drinking water. It is also notknown to be spread by contact with potentially contaminated athletic surfaceslike wrestling mats, taping tables, sinks, or other surfaces.¹⁶

The transmission of HIV in athletes requires that there be an infectedathlete with an open bleeding wound; a susceptible individual--that is,an individual with an exposed skin lesion or mucous membrane that couldserve as a portal of entry; and sustained contact between infective materialand the portal of entry.¹⁷ The two documented cases of HIV transmissionduring what might be considered sports activity were between fist fighters.In one instance, transmission from an HIV­positive player occurred whenblood from a nasal hemorrhage was inoculated into a seronegative recipientvia a head laceration. Details of the other case are not known.¹⁸

The risk of an athlete contracting HIV infection during sports is extremelylow. The athlete is more likely to acquire HIV infection during nonathleticactivities, such as unprotected sex or the use of intravenous or intramuscularinjections of illicit drugs or anabolic steroids, than to acquire the diseaseduring any athletic activity.¹⁷ The risk is theoretically higherin contact and collision sports like ice hockey, karate, and football wherea higher likelihood of sustaining bleeding injuries exists; still, the overallrisk of HIV transmission in professional football, for example, was estimatedto be 1 per 85 million game contacts in one study.¹⁸ HIV­positiveathletes benefit tremendously from continued participation in sports andexercise in terms of enhanced immune function and a sense of mental well-being.¹⁹Strenuous physical exertion, however, may adversely affect immune functionin HIV­positive athletes, just as it can in others.

It is generally agreed by major sports medicine organizations and sportsgoverning bodies that HIV­positive athletes should be allowed to participatein all sports, and that routine testing of athletes is not recommended.²⁰The AAP recommends that physicians inform HIV­positive athleteswho want to participate in contact sports of the theoretical risk of transmissionto others and encourage consideration of noncontact sports.²¹ Teamphysicians should advise all athletes of the possibility of HIV­positiveathletes among them while maintaining confidentiality about individual players'HIV status. In isolated instances courts have allowed exclusion of an HIV­positiveathlete from contact sports if reasonable accommodations did not eliminatethe risk of transmission to other athletes, but generally HIV­positiveathletes cannot be excluded from participation solely on the basis of HIVstatus.²²

Hepatitis B virus infection is transmitted similarly to the HIV pathogen,but because HBV is more concentrated in blood, the risk of transmissionis greater. There has been one documented case of HBV transmission betweentwo high school Sumo wrestlers.²⁰ The National Collegiate AthleticAssociation (NCAA) guidelines recommend removal from combative, sustainedclose-contact sports (such as wrestling) of any athlete who develops acuteHBV illness until loss of infectivity is confirmed. Infectivity is indicatedby a positive HBsAg in the blood. Athletes who are asymptomatic but havea positive antigen should probably also be removed from wrestling indefinitely,since transmission, though unlikely, is possible.²³ Routine testingfor HBV is not recommended, but all children and adolescents, athletes andnonathletes alike, should be immunized as specified in the universal immunizationrecommendations.

Preventing transmission of blood-borne infection. Major professionalmedical societies and sports governing bodies have published general guidelinesto minimize the risk of transmission of infection by contact with bloodor other body fluids in athletic settings. These are based on common sense,emphasizing good hygienic practices and universal precautions. Major elementstaken from guidelines published by the NCAA, American Academy of Pediatrics,Canadian Academy of Sports Medicine, American College of Physicians, AmericanMedical Society for Sports Medicine, and the American Academy of SportsMedicine, are listed in Table 4.^{9,16,17,20,21,23}

Vaccine-preventable diseases

Influenza virus infection is a common problem at all ages. While it isgenerally not a serious illness in young athletes, it can cause significantlost practice and play time. College campuses are well-known harbingersof influenza. Epidemics have occurred among athletes as well as spectators.The fear of side effects and the costs associated with vaccination havelimited the immunization of athletes,⁷ but it can be particularlyuseful for children and adolescents participating in winter sports. Thevaccine can be administered pre-season to avoid potential side effects duringthe sports season. Immunization of all players against influenza is a reasonableapproach if supplies of vaccine are adequate.⁷

Measles outbreaks have also been well documented among athletes and spectators,resulting in mass immunizations. Remember that the infectivity period formeasles is early in the illness and until six days after the onset of rash.The currently recommended two-dose vaccination schedule provides protectionto nearly 100% of individuals immunized.

Although tetanus is not spread from person to person, it is an importantpreventable infection that results from contaminated wounds, which are commonamong athletes.

Experts recommend that everyone receive a tetanus and diphtheria toxoid(Td) booster every 10 years. These diseases do still occur. There has beenemergence and spread of diphtheria in the newly independent states of theformer Soviet Union. In the United States between 1991 and 1994, 20 casesof diphtheria and 201 cases of tetanus were reported to the Centers forDisease Control and Prevention (CDC). Data from a serosurvey conducted inMinnesota indicated that 62% of persons 18 to 39 years of age lacked adequateprotection against diphtheria. Another survey found that 15% to 36% of personsage 9 to 13 years lacked immunity against tetanus.²⁴

Approximately 20% of adolescents 11 to 12 years of age remain susceptibleto chickenpox (varicella).²⁴ Vaccination is recommended at age12 months to 12 years as a single dose; two doses separated by 4 to 8 weeksare recommended for those 13 years of age and older. Varicella patientsare infectious until at least six days after the onset of the rash or untilall lesions have dried and crusted.

CDC data indicate that each year approximately 140,000 persons in theUnited States are infected with hepatitis A virus (HAV).²⁴ Thehighest rate of disease occurs among persons 5 to 14 years of age. Mosthepatitis A is spread via person- to-person transmission. Adolescents whoare likely to visit endemic areas should receive the hepatitis A vaccine.A person with HAV infection is contagious until one week after the onsetof the illness or jaundice, if the illness is mild.

It is important to assess the immunization status of all athletes duringthe preparticipation evaluation and to see that required vaccines are administeredaccording to general guidelines for the age group (Table 5).

Skin diseases

Contagious skin infections are common in athletes. NCAA data indicatethat skin infections are associated with at least 10% of time-loss injuriesin wrestling. Several factors predispose athletes to skin infections.^2,25These include perspiration during physical activity, maceration of the skin,cuts and abrasions, and direct contact with skin lesions. Infections tendto affect areas of natural occlusion such as the groin, and areas coveredwith bulky equipment. Infections may also be transmitted by contact withcontaminated mats, equipment, and uniforms. The warm, humid environmentaround pools and showers promotes growth of many organisms, particularlyfungi.

Impetigo. The most common etiologic agent for impetigo is Streptococcuspyogenes (group A b-hemolytic streptococcus or GABHS), which causes nonbullouslesions. Less frequently, bullous impetigo is caused by S aureus. The infectionis spread via direct skin contact with infected skin or contaminated surfaces,such as mats or athletic equipment. Inoculation occurs at sites of skinbreakdown because of friction, pressure, or trauma. Areas affected by dermatitisare predisposed to infection. The lesions are highly contagious during theweeping phase and sometimes for up to 10 days later. In some cases, streptococcalinfection is acquired from a player with pharyngitis or nasopharyngeal colonization.Staphylococci can infect normal skin, while GABHS must colonize the skinfor several days before clinical infection is evident. Wrestlers, swimmers,and gymnasts are particularly vulnerable, but outbreaks of staphylococcaland streptococcal skin infections have also been reported in football, basketball,and rugby players.⁷

Impetigo is treated most effectively with systemic antibiotics effectiveagainst both S pyogenes and S aureus. These include amoxicillin-clavulanate,clarithromycin, azithromycin, clindamycin, dicloxacillin, cephalexin, andcloxacillin. Topical treatment with mupirocin resolves the lesions but maynot eradicate the organisms colonizing the skin. Athletes with active lesionsof impetigo should not participate in contact or water sports and shouldnot share equipment or towels.⁷ Since active lesions are highlycontagious, all lesions must be healed before allowing participation incontact sports. This may take up to 10 days of treatment.

Folliculitis, furuncles, and carbuncles. Infection of the hair folliclecan cause folliculitis, furunculosis, or abscess formation due to S aureus,and in some cases Gram-negative organisms, particularly Pseudomonas aeruginosa.Coalescence of furuncles leads to the development of carbuncles. These lesionsmost commonly affect the neck, buttocks, and axillary areas of the skinand require incision and drainage in addition to antibiotics.

The infection caused by P aeruginosa, commonly known as hot-tub folliculitis,frequently occurs in athletes and others who use hot tubs, Jacuzzis, andswimming pools. The lesions commonly affect axillae, breasts, and buttocks.Inadequate chlorination of water is considered a predisposing factor. Hot-tubfolliculitis usually resolves spontaneously in seven to 10 days, but someindividuals develop fever, malaise, and lymphadenopathy and may need treatmentwith an antibiotic such as ciprofloxacin, which can be used in patientsover 18 years of age.²⁶

Superficial folliculitis often responds to topical agents such as benzoylperoxide applied twice daily for five days, but abscesses may require incisionand drainage along with systemic antibiotics. Nasal and skin carriage ofS aureus can lead to recurrent infections. Application of mupirocin to nares,and longer treatment with systemic antibiotics, including rifampin, hasbeen satisfactorily used to treat the carrier state.

An athlete with only superficial folliculitis may be allowed to returnto sports once treatment is initiated and all lesions are securely covered.When there is an abscess, the lesion must be covered and have no exudate,and the athlete must have received antibiotic treatment for at least threedays before returning to play.²⁷

Acne mechanica is not an infection; however, it is useful to recognizeand distinguish it from folliculitis and other bacterial skin infections.It causes a follicular eruption that occasionally progresses to cysts andnodules. Predisposing factors are friction, pressure, occlusion, and heat.Acne mechanica is prevalent in football players in areas covered by padsand helmets, and also among wrestlers, dancers, and weight lifters.^28,29The lesions commonly involve the back, neck, shoulders, and face and shouldbe differentiated from acne vulgaris. In the majority of cases, acne mechanicaresolves when the offending mechanism is removed. A change of uniform andregular washing and scrubbing with soap and water is recommended. For selectedcases, consider treatment with topical clindamycin.

Hidradenitis suppurativa is an infection of the apocrine glands, primarilyaffecting the axillae and, in some cases, the genital region. It resultsin the formation of multiple furuncles, ulcers, sinuses, and abcesses. Organismscultured include S aureus, streptococci, Escherichia coli, Proteus mirabilis,and P aeruginosa. Treatment is difficult and may require consultation witha dermatologist. It includes long-term use of systemic antibiotics and localcare of abscesses. Extensive exudative lesions are considered legitimatecause for disqualifying an athlete from contact sports such as wrestling.^27,30

Warts. Infection of skin caused by human papillomavirus (HPV) is commonlyknown as warts. Different HPV types can cause the common wart (verruca vulgaris),plantar wart (weight-bearing wart), flat wart, and condyloma acuminata (genitalor venereal wart). Transmission is by direct skin-to-skin contact, autoinoculation,or contact with contaminated fomites. Because the virions are most abundantearly in the course of infection, the lesions are most contagious at thisstage. Infection is common during the teen years.

Plantar warts tend to be the most painful and disabling for the athlete.Infection can be acquired from contaminated mats, equipment, and clothing.Because calluses are more susceptible than normal skin, gymnasts, footballplayers, and wrestlers are commonly affected. Swimming in public pools alsoseems to be a contributing factor for plantar warts.

Spontaneous resolution is common in healthy athletes in six months totwo years; and only a few persist for more than five years. Since the presenceof warts may result in disqualification of the athlete from contact sportslike wrestling, treatment is often warranted (Table 6). Salicylic acid paintor plaster and cryotherapy are the preferred modes of treatment for commonand plantar warts. The lesions must be completely and securely covered beforeparticipation in contact sports may resume. If lesions are extensive andcannot be covered adequately, the athlete may not be allowed to participatein contact sports.²⁷

Molluscum contagiosum is caused by poxvirus. The lesions are highly contagiousand are spread by direct contact, contaminated fomites, or autoinoculation.The infection is transmitted by person-to-person contact and in gyms andswimming pools, and is common in swimmers and wrestlers. Lesions are benignand usually resolve spontaneously over six to nine months. Curettage iscurative, as is topical application of cantharidin 0.7%, salicylic or lacticacid, or tretinoin 0.025%. Application of liquid nitrogen to lesions forsix to nine seconds is another option. Athletes should avoid sharing bathsor towels. A lesion-free period of about four months is generally consideredevidence of cure. Lesions must be removed before a meet or tournament, andsolitary lesions must be covered as stated in the NCAA wrestling guidelines.²⁷

Herpes simplex virus (HSV) type 1 is the cause of herpes gladiatorum,reported in wrestlers, and of scrum pox in rugby players.³ Theinfection is highly contagious and spreads by direct contact. While transmissionvia fomites is questionable, HSV can be transmitted in the saliva of asymptomaticathletes. A number of outbreaks in contact sports have been documented.Systemic antiviral treatment initiated early in the course of the infection(within six days of onset) may diminish its acuity and duration. For adolescentsand adults, acyclovir, famciclovir, and valacyclovir are valid treatmentoptions. If there is inadequate response to this treatment or if the eyesare involved, consider consultations with infectious disease and ophthalmologyexperts.

NCAA wrestling rules state that athletes with acute primary infectionmust be free of active lesions and on systemic antiviral treatment for atleast three days; and must have no systemic symptoms prior to wrestling.For recurrent infection, the lesions must be dry and covered, and the athleteon appropriate treatment for at least three days before a tournament. Wrestlerswith a history of severe recurrent herpes labialis or gladiatorum are candidatesfor season-long prophylaxis with acyclovir.²⁷

Fungal infections. Various dermatophytes can infect the skin, nails,and hair. Fungal infections of the skin are common among athletes becauseof increased moisture from sweat, occlusive footwear, shared towels, contaminatedlocker room floors, and the breakdown of skin. Superficial fungal infectionsare spread by direct contact, fomites, and autoinoculation.

Tinea pedis (athlete's foot) is the most common fungal infection of theskin among athletes. A dermatophid or id reaction often occurs with athlete'sfoot, appearing as dyshydrotic eczema with pruritic vesicles or annularplaques on the hands; therefore, if dermatitis on the hands is recognized,the feet should be examined carefully. Tinea corporis outbreaks have beenreported in wrestling. Tinea capitis and barbae are transmitted via directcontact and by sharing of hats, caps, combs, and brushes. Infection of theskin generally responds well to topical antifungal treatment, while infectionof the hair shaft requires systemic antifungals (Table 7).

NCAA guidelines stipulate that an athlete must have received topicaltreatment for at least three days for skin lesions and two weeks of systemictreatment for scalp lesions in order to participate.²⁷ Wrestlerswith extensive and active lesions should be excluded. Lesions must be coveredin the following fashion: First wash the lesions with selenium sulfide orketoconazole shampoo; follow with an application of naftifine gel or cream(Naftin) or terbinafine cream (Lamisil); then cover the lesions with a gas-permeabledressing such as Op-Site or Bioclusive, followed by ProWrap and stretchtape. Dressings should be changed after each match so that lesions can airdry.²⁷

Pediculosis is caused by Pediculus humanus and can affect the head (peduculosiscapitis) or the body (pediculosis corporis). Infection in the genital area(pediculosis pubis) is usually caused by Phthirus pubis and is commonlyknown as "crabs." Transmission occurs through person-to-personcontact and the sharing of hairbrushes, caps, or clothes. Once it has beendiagnosed, clothing and bedding should be changed, laundered, and driedin hot temperatures. Contacts should be examined. Pediculosis is treatedwith topical application of permethrin 1% cream rinse (Nix), pyrethrin shampoo(RID), or 1% lindane shampoo. Athletes must have received complete treatmentand have been examined for evidence of cure before being allowed to participatein contact sports.²⁷

Scabies is caused by the human mite Sarcoptes scabiei. Transmission usuallyrequires direct human contact, but occasionally female mites survive twoor three days in fomites and may transmit the infestation. Scabies is highlycontagious and can be spread by casual contact. Humans are the only reservoirsof S scabiei. Close contacts should be treated, and clothes and beddingchanged and laundered thoroughly. Topical application of 5% permethrin (Elimite),lindane lotion 1% , or crotamiton 10% (Eurax) for 48 hours is effective.Alternatively, in some cases oral ivermectin (Stromectol) in a single dosehas been used effectively, but there is little experience with this approach.²⁷

Preventing the spread of skin diseases from one infected athlete to othersshould be a primary goal of any athletic program. Before participation incontact sports, particularly those with sustained direct skin-to-skin contactsuch as wrestling, all athletes should be thoroughly examined for any skinlesions, including in the pubic area and scalp. According to NCAA wrestlingguidelines, the presence of a communicable skin disease shall be full andsufficient reason for disqualification of an athlete from wrestling.^27,30Open wounds and skin conditions that cannot be adequately covered are alsoconsidered legitimate cause for disqualification from practice and competitionin wrestling and other contact sports. The AAP recommends that any athletewho has an infectious skin disease (boils, herpes, impetigo, scabies, molluscum,and so on) not participate in gymnastics exercises on mats, martial arts,or other collision, contact, or limited contact sports while contagious.⁹Regardless of the sport, all equipment, mats, and common areas, such aslocker rooms, should be cleaned thoroughly and routinely.

Other diseases

Various other diseases can be transmitted from athlete to athlete.

Enteroviral infections are spread via oral-oral and fecal-oral routes.Epidemics are common during the summer and fall, and patients may presentwith a variety of syndromes in almost any system of the body. For example,enteroviruses can cause vesicular lesions to appear on hands and feet andin the mouth. Their importance in aseptic meningitis was mentioned earlier.

Gastroenteritis. The Norwalk virus, rotaviruses, and bacterial infectionsby Salmonella, Shigella, Campylobacter, Yersinia, and E coli are commoncauses of diarrhea. Person-to-person and common-source spread is known tooccur in athletic settings.

Bacterial gastroenteritis in a symptomatic person is highly contagious.Athletes should avoid potentially contaminated food, water, and ice, andshould wash their hands thoroughly and frequently. Continued participationin sports is generally guided by clinical resolution and well-being.

Infectious conjunctivitis can be caused by viruses or bacteria. Infectionis spread by direct contact or contaminated hands leading to autoinoculation.Respiratory spread can also occur from droplets. A bacterial etiology isuncommon after 5 years of age, but self-limited viral infections can bedifficult to differentiate from bacterial conjunctivitis, which requiresappropriate topical antibiotics. Any conjunctivitis in an athlete is consideredcontagious until symptoms have resolved. On occasion, sports participationis allowed once treatment is initiated. The spread of pathogens can be minimizedwith frequent hand-washing.

Streptococcal pharyngitis caused by group A b-hemolytic streptococci(Streptococcus pyogenes) is spread by contact with a person who has pharyngealstreptococcal infection. Transmission of GABHS infection, including majoroutbreaks, can occur in classrooms and on athletic teams, via respiratorysecretions. The infection is not contagious after a patient has received24 hours of specific antimicrobial treatment. Thus, participation in activitieswith a potential for droplet spread should be restricted for 24 hours afterthe initiation of therapy.^23,27

Tuberculosis. The increased incidence of tuberculosis in recent yearsmandates vigilance to contain its spread. Pulmonary tuberculosis causedby Mycobacterium tuberculosis is an airborne infection. Children youngerthan 12 years of age do not usually transmit the disease; the small sizeof their pulmonary lesions minimizes expulsion of bacilli. High-risk adolescentathletes, such as those living in an inner city and those who are recentimmigrants, should be tested for tuberculosis. Tuberculosis in most adultand adolescent patients is not contagious after a few weeks of treatment.Participation in sports depends on their overall well-being; no specificrecommendations are available.

Sexually transmitted diseases, including HIV and HBV, are rarely transmittedduring athletic activity proper, but they may be transmitted during thetravel and leisure time of athletes. The respect and admiration that manyathletes have for their coaches and trainers can facilitate education aboutprevention of transmission. Such issues as the dangers of having unprotectedsex and the importance of using condoms should be discussed. Whether athletesas a group engage in more high-risk health behaviors than non-athletes remainscontroversial.

Otitis externa, known as "swimmer's ear," is not transmittedfrom athlete to athlete but deserves mention because it is quite common.It is primarily the result of sustained retention of moisture in the earcanal.³¹ Frequent cleaning and use of ear drops erodes cerumen,which acts as a natural water repellent. The moist canal becomes a breedingground for infection, most commonly with P aeruginosa. Inadequately chlorinatedwater is a contributing factor, as is the frequency and depth of head submersion;the condition is more common among divers than swimmers. Young athletesshould be educated to avoid frequent cleaning and the use of ear drops andto keep the ear canals as dry as possible. Treatment options include topicalVosol 2% solution and ciprofloxacin otic drops. Ideally, the athlete shouldabstain from water sports until acute infection is resolved, but returnto competition is allowed within three days of starting treatment.

Put the accent on prevention

Prevention of the transmission of infection in sports and decisions regardingcontinued participation must consider the risk to the athlete, the riskto team members and personnel, and the risk to spectators.⁴ Preparticipationevaluations provide an excellent opportunity for education of the athleteas well as of parents or other family members regarding potential infections.Athletic trainers, coaches, and other officials should be similarly educatedand familiar with the principles of good hygiene, universal precautions,and first aid. The immunization status of the athlete should be well documented;no athlete should be permitted to play without proof of receipt of all appropriatevaccinations.

Make sure that all measures to prevent exposure to blood and other bodyfluids in the sports setting are being implemented, and that all potentiallycontagious diseases are diagnosed and treated promptly. Finally, reportall communicable diseases to the public health department.

DR. PATEL is Associate Professor of Pediatrics, Division of AdolescentMedicine and Sports Medicine, Department of Pediatrics, Kalamazoo Centerfor Medical Studies, Michigan State University, Kalamazoo.

DR. GORDON is Professor of Pediatrics, Division of Pediatric InfectiousDiseases, Department of Pediatrics, Kalamazoo Center for Medical Studies,Michigan State University, Kalamazoo.

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