With the competitive season looming, chiropractor Dr. Alexander JimenezΒ gives insights & examines the current best thinking on vaccination for athletes, and makes recommendations for sports clinicians.
Without doubt, vaccination is one of the greatest triumphs of modern medicine. Many serious diseases that used to routinely maim or kill large numbers of people are no longer a threat. More than that, vaccination can prevent outbreaks of less serious illness, which although not life threatening, are still unpleasant, leading to missed time from work and school.
Anyone with young children or who has travelled extensively abroad will (hopefully) understand that a programme of vaccination is either required or recommended. When it comes to the travelling athlete however, the situation is rather more complex. While the basic vaccinations (eg typhoid, hepatitis etc when travelling to certain regions of the tropics) are of course still required, clinicians will also want to ensure that their athletes stay as well as possible to compete at their full potential. A mild illness that is an inconvenience to a tourist may be a disaster for an athlete focusing on the peak of his/her season!
Sports clinicians may therefore wish to consider extra vaccinations to minimise the risk of more minor conditions. However, this approach raises a whole new set of issues. For example, which additional vaccinations may be use for athletes who regularly travel abroad? What are the possible side effects of these extra vaccinations and how should vaccines be timed to maximise immunity during the competition, while minimising disruption to training in the run up to competition?
There exists some uncertainty about the most appropriate vaccination regimens in athletes among team doctors and other physicians because general public health vaccination guidelines cannot be easily transferred to elite athletes. Complicating factors include the typical circumstances of athletesβ daily life, such as frequent travelling to foreign countries or close contact with teammates and opponents, which might indicate the need for a modification of recommended vaccination schedules. In addition, intense physical activity of training and competition with its possible effects on the immune function can affect decisions about execution and timing of vaccination.
Other complicating factors are that vaccination recommendations are formulated around a public health policy rather than for specific individuals and are likely to change over time(1-3). Also, thereβs the issue of cost effectiveness; the majority of vaccines that are not generally recommended are not recommended because the medical benefit is not regarded sufficiently balanced with the costs if implemented across the whole population. This is despite the fact that they may be potentially beneficial in specific individuals(4,5). Itβs also important to understand that generalised recommendations take no account of the implications of the effects of illness in athletes, which can be far more profound and far reaching than in the general public (see Box 1).
Further reasons as to why athletes are different when it comes to vaccination include the following:
Putting all these factors together, the recommendation is that elite, competitive athletes should be vaccinated more aggressively than the general public(15).
The decision as to which vaccinations are given prior to foreign travel will depend on a number of factors, including the travelΒ destination(s), the nature of the sport and the health/vaccination history of the individual involved. Regardless of these factors however, it is recommended that ALL adult athletes are routinely vaccinated against the following:
1. Tetanus
2. Diphtheria
3. Pertussis (whooping cough)
4. Influenza
5. Hepatitis A and B
6. Measles, mumps and varicella (if immunity is not already proven by a natural infection)
Of these, numbers 1-5 should be given as inactivated vaccines while measles, mumps and varicella (chickenpox) should be given as live vaccines(15). A full discussion on the detailed considerations regarding each and every possible vaccination is beyond the scope of this article (readers are directed to a full and recent review of this topic by Luke and DβHemecourt(15)). However, Table 1 summarises most of the key recommendations.
Timing of vaccinations should be chosen in order to minimise interference with training and competition, and to ensure the immune reaction is not temporarily impaired. Inactivated vaccines generally cause side effects within two days following vaccination. This is in contrast to live vaccinations where the peak of side effects is most likely to occur after 10-14 days when replication of the vaccines is at a maximum. Unless a vaccination needs to be administered urgently, the best time therefore for vaccination is at the onset of resting periods β for example at the beginning of the winter off season.
When a vaccination has to be carried out within a training and/or competition period (eg influenza), there is no major medical problem with training undertaken shortly before or after vaccination. However, it is recommended to vaccinate shortly after a competition in order to make the period of time to the next competition as long as possible. Many vaccinations given via injection can cause local pain and inflammation at the injection site. Clinicians may therefore wish to time vaccine administration so as to not coincide with delayed onset muscle soreness (DOMS) following strenuous exercise.
Dependent on the injection site, some sport- specific impairments may result (for example buttock pain in runners following a gluteal injection). Obviously, it is advisable to use the non-dominant side for injections in unilateral disciplines such as racquet sports. For vaccines that can be administered using either the intramuscular or the subcutaneous route, the intramuscular option seems to be preferable as it yields higher titer rate (more antibody production) and a lower risk of granuloma.
Injection into the deltoid muscle is preferred if possible, although other muscle sites are possible. Regardless, it is important that the athlete is sitting or lying, and the muscle is completely relaxed. Studies indicate that the use of longer needles (25 mm) and a fast speed of injection/ withdrawal of the needle (1-2 seconds) are associated with less pain(37). Also, an angle of injection of 90 degrees may also help reduce pain in intramuscular injections.
Syncopes or collapses following vaccination are uncommon but may occur; some studies on influenza vaccination suggest the frequency of syncope in younger athletes to be around 1%(38). However, the syncope itself may be less important than secondary injuries caused by the collapse such as skull fracture and cerebral haemorrhage. Given that the majority of syncopes (80 %) occur within 15 min of vaccine administration, it is recommended that athletes are observed for a period of 15-30 minutes following vaccination. This recommendation may be particularly important for endurance athletes because there are indications that, in these athletes, vasovagally-induced syncopes are more frequent(39).
The recommended vaccination schedules for disease prevention will be dependent on the previous vaccination record and disease history of the athlete in question. Also, some schedules are dependent of the type/brand of vaccines used and recommendations may also differ according to public health policy in each country. Readers are directed to the summary given by Luke and DβHemecour(15); there are also some excellent downloadable resources on the US Centre for Disease Control and Prevention (CDC) β www.cdc.gov/vaccines/ schedules/hcp/adult.html.
The vaccination requirements for elite athletes are not the same as that for the general public. Not only are these athletesΒ potentially exposed to more disease pathogens as a result of international travel, even the mildest episode of illness that would be barely noticeable to most of us can be devastating for elite athletic performance. For these reasons, sports clinicians and doctors should take a much more aggressive approach to vaccination of their athletes. Together with steps to reduce exposure and the correct vaccination techniques and timing, clinicians can maximise the potential of their athletes to perform at all times of year across all regions of the globe.
References
1. World Health Organization. WHO vaccinepreventable
diseases: monitoring system. 2012
global summary 2013. www.who.int/
immunization_monitoring/data/data_subject/
en/index.html accessed 5th Feb 2017
2. Sta¨ndige Impfkommission (STIKO).
Empfehlungen der Sta¨ndigen Impfkommission
(STIKO) am Robert Koch-Institut. Epi Bull.
2012;283β10
3. Centers for Disease Control and Prevention.
General recommendations on immunizationβ
recommendations of the Advisory Committee
on Immunization Practices (ACIP). MMWR
Recomm Rep. 2011;60:1β64
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12. Lancet. 1990;336:1315
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17. www.nhs.uk/Conditions/Lymedisease/Pages/Introduction.aspx#symptoms accessed Feb 2017
18. J Infect Dis 1999;180(3):900β3
19. Ann N Y Acad Sci 2003;990: 295β30
20. J Infect Dis 1984;150(4):480β8
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25. Centers for Disease Control and
Prevention. Epidemiology and prevention of
vaccine-preventable diseases. The pink
book:course textbook. 12th ed.; 2012.
26. World Health Organisation. Poliomyelitis;
2014. www.who.int/topics/poliomyelitis/en/
27. Clin Exp Rheumatol. 2001;19:724β6
28. JAMA. 1997;278:551β6
29. Clin Infect Dis. 2004;38:771β9
30. Travel Med. 1998;5:14β7
31. Cochrane Database Syst Rev.
2014;1:CD001261
32. Curr Opin Infect Dis. 2012;25:489β99
33. Drugs. 2013;73:1147β55
34. Hum Vaccin Immunother. 2014;10:995β1007
35. Popul Health Metr. 2013;11:17.
36. Vaccine. 2009;27(Suppl 2):B51β63
37. Arch Dis Child. 2007;92:1105β8
38. Vaccine. 2013;31:6107β12
39. Prog Cardiovasc Dis. 2012;54:438β44
Professional Scope of Practice *
The information herein on "Vaccination: Is Defense The Best Attack" is not intended to replace a one-on-one relationship with a qualified health care professional, or licensed physician, and is not medical advice. We encourage you to make your own healthcare decisions based on your research and partnership with a qualified healthcare professional.
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Our information scope is limited to Chiropractic, musculoskeletal, physical medicines, wellness, contributing etiological viscerosomatic disturbances within clinical presentations, associated somatovisceral reflex clinical dynamics, subluxation complexes, sensitive health issues, and/or functional medicine articles, topics, and discussions.
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Dr. Alex Jimenez DC, MSACP, CCST, IFMCP*, CIFM*, ATN*
email: coach@elpasofunctionalmedicine.com
Licensed in: Texas & New Mexico*
Dr. Alex Jimenez DC, MSACP, CIFM*, IFMCP*, ATN*, CCST
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