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Athletes and Risk of Blood Bourne - Hepatitis B Infections Gary Podolsky MD Goals • To review the risk of blood borne infections in athletes. • Discuss the incidence of Hepatitis B • Emphasize the protection given by immunization for Hepatitis B Athletes are be at risk for blood borne infections during sport such as Hepatitis B, Hepatitis C and HIV. Of the three diseases only Hepatitis B can be immunized against. HIV in Sport At present there is no convincing evidence of HIV transmission during sport despite one paper that has since been discounted 1,2 . HIV infection is of similar incidence in athletes compared with the general public. Athletes also remain at risk from activities outside of play, which include unprotected intercourse and intravenous drugs (illicit street drugs as well as anabolic steroids). HIV is important for athletes as well as non-athletes. Education and promotion of preventative measures remains the best way of controlling HIV
Hepatitis CHepatitis C is a disease of the liver caused by blood exposure and transfusions. It is a theoretical risk in sport play since larger quantities of blood or bodily fluids are associated with its transmission. No vaccine exists for its prevention.
Hepatitis B and Sport Hepatitis B is a serious infection of the liver caused by the hepatitis B virus. It can be prevented by vaccination. According to the Centers for Disease Control and Prevention (CDC), in some settings, the hepatitis B virus can be up to 100 times more contagious than the AIDS virus .The hepatitis B virus has been shown in some instances to remain infectious on environmental surfaces for at least a month at room temperature.
How common is Hepatitis B? One in approximately 20 people now has or will someday contract hepatitis B every year in the United States; approximately 240,000 people are infected with hepatitis B. In the US, an estimated 1,000,000 - 1,250,000 people have chronic hepatitis B infection and are potentially infectious to others; this number may be 1/10 th in Canada. Worldwide hepatitis B carriers are increasing and are now estimated to number 2.1 billion of the world's 6.3 billion population. The World Heath Organization has recommended that countries incorporated national Hepatitis B immunization programs and most are doing so. In Canada this is happening at different ages in different provinces (Manitoba immunizes only grade 4 students). This leaves large segments of the population vulnerable to Hepatitis B. At present high school and university students are a group that is not protected from Hepatitis B. Hepatitis B Transmission Hepatitis B is transmitted directly and indirectly through infected body fluids such as blood, semen, and vaginal secretions; the infection can also be picked up through mucous membranes and broken skin. Although Hepatitis B is commonly transmitted by sexual contact, however it can also be picked up through: • Exposure to blood of an infected person through contact sports • Repeatedly sharing an infected person's razor, toothbrush or earrings • Travel to a high-risk area • Use of illicit injectable drugs including anabolic steroids and street drugs • Potentially through contaminated needles used for tattooing or piercing. But still, about one third of those infected do not know the source of their infection High school, University and College students are at risk in several ways: • Approximately 75% of all reported hepatitis B cases occur between the ages of 15 and 39 years More than 80% of acute hepatitis B infections occur among adults. • Risk of exposure to infected blood and body fluids during contact sports • Approximately 45% of the global population lives in high-risk areas. Athletes may travel abroad to high-risk areas as part of their studies or while on school break. • Living in close quarters increases risk of exposure from carriers • Foreign exchange students from highly endemic areas may be carriers • Medical students or other healthcare students may come in contact with infected materials during their course of study • 30% to 60% of new hepatitis B infections in the U.S. are attributed to sexual transmission Strategies used to increase hepatitis B awareness and Prevention 1. American groups have started campus-wide hepatitis B awareness and vaccination programs. 2. Institute a recommendation for hepatitis B vaccination. In Manitoba Publicly funded immunization against Hep B only exists for grade 4 schoolchildren but leaves out High school and University aged students. In support of more attention to this problem for Canadians, the American College Health Association (ACHA) recommends that all college students be vaccinated against hepatitis B. Similarly, the National Collegiate Athletic Association (NCAA) recommends vaccination of all student athletes 3.Institute prematriculation immunization that requires students to be immunized against hepatitis B for students enrolling in the athletic department, health sciences program and any other relevant department .At present Athletic groups are left out of these recommendations in Manitoba as only Health Sciences (Medicine, Nursing, Medical Rehab have this requirement). Previously Medical students were given Hep B immunizations for free. With cutbacks they like all other students must now pay for this. Some Universities in the US require prematriculation immunization of all students regardless of faculty. The Centre for Disease Control (CDC) recommends vaccination of: Everyone aged 0 through 18 years and anyone at high risk for hepatitis B due to behavior or activities, including anyone with more than 1 sexual partner in 6 months (this is an arbitrary definition of promiscuousness). Precautions for Athletes in Contact Sports
The Committee on Sports Medicine and Fitness of the American Academy of Pediatrics (AAP) recently released a statement on the risk of infection with human immunodeficiency virus and other blood-borne viral pathogens in the athletic setting. The report appeared in the December 1999 issue of Pediatrics. Athletes can be exposed to blood and bodily fluids during athletic activity. They have a small risk of infection from human immunodeficiency virus, hepatitis B virus and hepatitis C virus. As mentioned earlier it is generally belieed that HIV is not transmissible in sport but this cannot be definitely proven except that there are no well documented cases of this being so. HIV is included for the purpose of the following discussion because of the intence public fears regarding it Sports participation for athletes infected with infectious illnesses and measures that should be taken to lower the risk of infection to other persons in the athletic setting. The Committee on Sports Medicine and Fitness of the American Academy of Pediatrics (AAP) has investigated this problem and made the following recommendations which may assist Sports Physicians in the management of athletes. 1. Athletes with human immunodeficiency virus, hepatitis B virus or hepatitis C virus infection should be allowed to participate in all competitive sports. Sports are important for young people's well being and they should not be held out of sports when there is no risk of transmission. 2. The infection status of patients should be kept confidential . Confidentiality about an athlete's infection with a blood-borne pathogen is necessary to prevent exclusion of the athlete from sports because of inappropriate fear among others in the program. This is difficult to manitain but should be a high priority for coaches, trainers and friends of afflicted athletes. 3. Athletes should not be tested for blood-borne pathogens because they are sports participants . There are no guidelines to screen for participation and this should stay that way. However it is a good idea for individuals to see their own physicians and discuss concerns if the feel they are at high risk. It is impotant for all people to have access to early detection and management of blood borne illnesses yet not be afraid to discuss this because of lack of confidentiality. 4. Physicians should counsel athletes who are infected with human immunodeficiency virus, hepatitis B virus and hepatitis C virus that they have a very small risk of infecting other athletes. These athletes can then consider choosing a sport with a low risk of virus transmission. This will not only protect other participants from infection but also will protect the infected athletes themselves by reducing their possible exposure to blood-borne pathogens other than the one(s) with which they are infected. Wrestling and boxing, a sport opposed by the AAP, probably have the greatest potential for contamination of injured skin by blood. 5. Athletic programs should inform athletes and their families that they have a very small risk of infection, but that the infection status of other players will remain confidential. 6. Physicians and athletic program staff should aggressively promote hepatitis B virus immunization of all persons who may be exposed to athletes' blood. If possible, all athletes should receive hepatitis B virus immunization; more than 95 percent of persons who receive this immunization will be protected against infection. To ensure that athletes respond to the immunization a simple blood test after 3 doses (anti-Hep B surface antigen antibody test) can confirm their immunity which is now believed to be good for life. 7. Coaches and athletic trainers should receive training in first aid and emergency care, and in the prevention of transmission of pathogens in the athletic setting. 8. Coaches and health care team members should teach athletes about the precautions listed above and about high-risk activities that may cause transmission of blood-borne pathogens. Sexual activity and needle sharing during the use of illicit drugs, including anabolic steroids, carry a high risk of viral transmission and are sometimes forgotten as important common ways o get hepatitis B. Athletes should be told not to share personal items, such as razors, toothbrushes and nail clippers, that might be contaminated with blood. The Hepatitis B Virus is very hardy and can survive in the environment on sharps and glass fragments so athletes should avoid any sharp object that has been left alone and possibly contaminated with human bodily fluids. 9. The AAP committee also recommends that the following precautions be taken in sports with direct body contact and sports in which an athlete's blood or other bodily fluids may contaminate the skin or mucous membranes of other participants or staff members of the athletic program: 10. Athletes should cover existing cuts, abrasions, wounds or other areas of broken skin with a covering dressing before and during participation. Caregivers must also cover their own damaged skin to prevent transmission of infection to or from an injured athlete. 11. Disposable, water-impervious vinyl or latex gloves should be worn to avoid contact with blood or other bodily fluids visibly tinged with blood and any object contaminated with these fluids. Hands should be cleaned with soap and water or an alcohol-based antiseptic handwash as soon as gloves are removed. 12. Athletes with active bleeding should be removed from competition immediately and bleeding should be stopped. Wounds should be cleaned with soap and water or skin antiseptics. Wounds should be covered with an occlusive dressing that remains intact during further play before athletes return to competition. 13. Athletes should be told to report injuries and wounds in a timely fashion before or during competition. Minor cuts or abrasions that are not bleeding do not require interruption of play but can be cleaned and covered during scheduled breaks. During breaks, if an athlete's equipment or uniform is wet with blood, the equipment should be cleaned and disinfected and the uniform should be replaced. 14. Equipment and playing areas contaminated with blood should be cleaned and disinfected with an appropriate germicide. The decontaminated equipment or area should be in contact with the germicide for at least 30 seconds. The area may be wiped with a disposable cloth after the minimum contact time or be allowed to air dry. Each sport should have a policy that covers this. Proper cleaning policies should be upheld and not substituted because of time, convience, or cost. 15. Emergency care should not be delayed because gloves or other protective equipment is not available . If the caregiver does not have appropriate protective equipment, a towel may be used to cover the wound until a location off the playing field is reached and gloves can be obtained. Some providers will carry a hankerchief in their pocket and will give this to the bleeding player to put preassure on a wound. This preparation helps eliminate the need for the provider to be unneccessarily in contact with blood while still functioning to correct the problem. During this time saving moment providers can put on their gloves (from the other pocket). 16. Breathing bags and oral airways should be available for giving resuscitation . Mouth to mouth resuscitation is recommended only if this equipment is not available. 17. Equipment handlers, laundry personnel and janitorial staff should also be trained in the proper procedures for handling washable or disposable materials contaminated with blood. Post Exposure to Blood and Bodily Fluids On or Off the Field Additionally in the event of a very likely or suspected blood or bodily fluid exposure an immediate referral to an emergency department is recommended. In the case of hepatitis B transmission an Immune globulin prepared to protect against Hepatitis B may be given. This gives temporary protection for someone who is susceptable (has not been immunized for Hepatitis B) and will prevent them from developing the disease. More contraversial is the treatment of Post exposure Prophylaxis for Human Immune Deficiencey Virus (HIV, AIDS). For many high risk situations the drugs to fight HIV are given to people suspected of a high risk transmission to kill off any invading viruses before they infect a new person. This still remains controversial since these medications are expensive and cause significant side effects and the risk of HIV in sport is still felt to be very small. This is an area where each sport should discuss with their Medical Director on a plan of action if an athete does have a significant exposure. Off the field many coaches and those working with young female athletes should similarly know about Rape crisis lines and how to access services immediately. Unprotected sexual intercourse represents another high risk of Hepatitis B. In addition to the psychological, criminal and physical stress it is important to remember that the same measures to prevent HIV and Hepatitis B may be applied here ofeten with a narrow margin of available time. These women require specialized professional help which is available through major emergency departments. Summary In conclusion blood borne contacts are infrequent in sport but may happen. Unfortunately many athletes may also be unaware that they are infected so that all contacts must be viewed with suspicion and to assume the worst. By taking "universal precautions" athletes can ensure they can minimize risks of exposure.
Hepatitis B, HIV and Hepatitis C can all kill. At present there is only a immunization to protect against Hepatitis B. Hepatitis B is still more common than, more infectious and kills more people than HIV yet Hepatitis B is still under appreciated as a risk to young adults.
In many areas of the world Hepatitis B is much more common and even easier to acquire so that athlete travelers are recommended to have their immunizations before they depart.
Many teenagers and young adults are susceptible to hepatitis B and may be at the highest risks for this infection. It is very important that they understand the potential risk of this infection from the above high risk activities. Athletes, parents and coaches need to consider routinely immunizing against Hepatitis B. Unfortunately this is not covered by all Public Health Plans so interested people must pay for this vaccine themselves.
The cost benefit ratio is high enough to merit this but the choice should remain the families since they bear the costs.
Hepatitis B is also a safe vaccine and accusations by antivaccinationist groups about its causing a number of diseases (diabetes, multiple sclerosis and autism among a multitude of others) have proven false and negated by the overwhelming body of scientific studies maintaining that it is safe. There is nothing controversial about using Hepatitis B vaccines except the issue of who should pay for it - government or individual.
For Hepatitis C and HIV the only preventative measure at present is avoidance of contact.
ON LINE REFERENCES: American College health Association http://www.acha.org/projects_programs/hepbfaqs.cfm A short movie on Hep B and Sports is available at: http://www.acha.org/projects_programs/hepB.cfm Physician and Sports Medicine http://www.physsportsmed.com/issues/1996/08_96/nb_hepb.htm American Family Physician http://www.findarticles.com/p/articles/mi_m3225/is_5_61/ai_61432714 Rape crisis centres in Manitoba http://www.casac.ca/avcentres/rccs_mb.htm Klinic Community Health Centre (Manitoba Counseling Services) CDC WHO • Torre D, Sanpietro C, Ferraro G et al. Transmission of HIV-1 infection via sports industry Lancet 335:1105,1990 • Calabrere L, La Perriere A: Human Immunodeficiency virus infection, exercising, and athletics. Sports Med 15:1-7,1993. 3. Centers for Disease Control and Prevention. Epidemiology & Prevention of Vaccine-Preventable Diseases. January 1995:143-162. 4. Centers for Disease Control and Prevention. 1998 guidelines for treatment of sexually transmitted diseases. MMWR. 1998;47(RR-1): 101-104. 5. American Medical Association. Prevention, Diagnosis, and Management of Viral Hepatitis. A Guide for Primary Care Physicians. January 1995:1-21. 6. Brookman RR, Koff RS, Schaffner W, et al. Critical issues surrounding hepatitis B vaccination for adolescents: a roundtable. J Adolesc Health. 1995;17:208-233. 7. American College Health Association. Recommendations for an institutional prematriculation immunization requirement. ACHA Guidelines. May 1995. 8. National Collegiate Athletic Association. Hepatitis B immunization recommended for intercollegiate student athletes. NCAA Sports Sciences. Spring 1996:1-4. 9. Hepatitis Control Report. ACIP expands hepatitis B recommendation and VFC coverage to all children ages 0-18. Bala Cynwyd, Pa:Precision Media Works;1997:2-8. 10. McQuillan GM, Townsend TR, Fields HA, et al. Seroepidemiology of hepatitis B virus infection in the United States:1976 to 1980. Am J Med. 1989;87(suppl 3A):5S-10S. 11 .Centers for Disease Control and Prevention. Recommendations for preventing transmission of human immunodeficiency and hepatitis B virus to patients during exposure-prone invasive procedures. MMWR. 1991;40(RR-8):1-9.
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