Athletes and team staff members are often required to travel vast distances to compete, putting them at increased risk of acquiring infectious disease during air travel – how can we overcome this?

The coronavirus pandemic has brought to light the risks of infection transmission associated with air travel. In the recent podcast episode #446, BJSM’s Dr. Liam West was joined by Prof. Wayne Derman to discuss the unique challenges posed by airplane travel and how these can be overcome. Prof. Derman is Director and Chair of the Institute of Sport and Exercise Medicine at the Division of Orthopaedic Surgery, Stellenbosch University. He is also Director of the FIFA Medical Centre of Excellence and Co-Director of the South African IOC Research Centre for Injury Prevention and Protection of Health of the Athlete. As an experienced researcher of travel medicine and athlete health, Prof. Derman had several pearls of wisdom to share – listen here:

The consequences of COVID-19 on air travel

Prof. Derman begins the discussion by explaining how travel and movement of people from one geographical region to another is at the very heart of the crisis that we find ourselves in. As a consequence, air travel is completely different now to what it was just over 6 months ago with a whole host of enhanced safety and hygiene methods used at airports and during flights. These range from enhanced social distancing measures and the use of masks and hand sanitisers, to UV sanitisation, thermal screening built into monitoring systems at airports and digital menus on flights.

The 5 ways of infection transmission during air travel

1. Contact
   Contact transmission can either be direct (i.e. person to person) or indirect via a fomite.
2. Droplets
   The spray of droplets during coughing or sneezing can spread infection when inhaled or when landing directly on a mucosal lining or on the eyes.
3. Airborne
   Some infectious agents are aerosol in nature. These small aerosol droplets can remain suspended in the air for longer periods of time and can travel much further, spreading infection as they are inhaled deep into the lungs.
4. Vector borne
   Vectors-borne diseases are illnesses that are transmitted by vectors e.g. a mosquito. Planes are often sprayed before take-off to counter this.
5. Common vehicle
   This refers to infection transmitted through a contaminated source e.g. food/water.

Are athletes at increased risk? 

In a 2012 study co-authored by Prof. Derman, elite athletes travelling to international destinations >5 time zone differences from their home country were found to have a 2–3-fold increased risk of illness.

Why might this be? It is likely that this is due to a combination of intrinsic factors (i.e. the “predisposed athlete”) and extrinsic factors (or external factors).

Intrinsic factors include:

• Transient stress – something which athletes often suffer from around competition.
• Poor sleep – another factor which can be triggered by competition/travel.
• Immune suppression/dysfunction – causes for this can include jet lag, over training or injury e.g. paralympians with spinal cord injury.

Extrinsic factors include:

• Fomites – Prof. Derman explains how the tray table is an area with a particularly high pathogen load, often with 2000+ colony forming units per square inch. Other notable areas include the buttons/metal surrounding drinking fountains at airports which have 1240 colony forming unites per square inch and lavatory flush buttons, overhead airvents and seatbelt buckles which each have around 250 colony forming units per square inch. For comparison, money, phones and home toilet seats have around 5, 27 and 170 colony forming units per square inch respectively.
• Seating allocation – individuals seated in aisle-seats are at higher risk of exposure to infected individuals who may walk along the aisle. Those who remain seated in the window-seats during air travel are at reduced risk – Prof. Derman encourages these individuals to consider wearing compression stockings to reduce the risk of deep vein thrombosis (DVT).

Other extrinsic factors include restricted space in the aircraft, inefficient ventilation/circulation, inefficient cleaning, flight duration, climate & geographical influence

What should clinicians do to combat the risk of travel-related illness?

Prof. Derman first suggests that clinicians should set up briefings for their athletes as an educational endeavor. By presenting athletes with data, they can see the science behind infection control strategies, giving them motivation and reason to partake in good practice. All travelling staff should be encouraged to partake in these educational sessions so that a strong ethos permeates through the whole organisation.

Prof. Derman’s other practical tips include:

• Choosing seats towards the front or back of the plane.
• Staying seated as much as possible whilst taking anti-DVT measures e.g. in-seat exercises.
• Cleaning the surrounding environment (including tray table, overhead airvent and seatbelt buckle) with antimicrobial wipes prior to sitting down. Wipes with ≥60% alcohol have been shown to be most effective at damaging viral structure.
• Wearing a face mask – this has been shown to decrease the number of times an individual touches their face (humans touch their face on average 20 times per hour) and also helps athletes to demonstrate their buy-in.
• Regularly washing hands and practicing good hand hygeine.
• When walking along the aisle, refraining from touching the back of the aisle-seats.
• Avoiding insufficiently warmed food/beverage.
• Staying hydrated by drinking from bottled water, not water fountains.

So, do these strategies work? In a study spanning 7 seasons of the Super Rugby tournament, Prof. Derman and colleagues found that the implementation of a team infection prevention strategy (TIPS) was associated with a 59% reduction in acute illness. To read this key paper, click here.

Finally, for more information on infection control in athletes and managing air travel, check out the following resources:

BJSM Podcast: “How to keep athletes healthy when travelling. David Dunne explains the best strategies.”

Infographic: Useful steps in the prevention of illnesses during international athletics championships

https://bjsm.bmj.com/content/54/4/251

How to manage travel fatigue and jet lag in athletes? A systematic review of interventions.

https://bjsm.bmj.com/content/bjsports/54/16/960.full.pdf

This blog was written by Dr Gautam Menon, a junior doctor with an interest in SEM, based in the UK.