Here Comes Flu Season!

Viruses like the flu can take a team down faster than even the strongest opponent. But education and low-level intervention—along with vigilant prevention techniques—can keep common illnesses from entering the game.

By Guillermo Metz

Guillermo Metz is an Associate Editor at Training & Conditioning.

Training & Conditioning, 12.8, November 2002,

You may nod your head in agreement when you hear someone like San Diego State University Head Athletic Trainer Gary Johnson, MS, ATC, PT, say, “There’s no stopping the flu. Kids are going to get sick.”

Or maybe you concur with David Yeo, PhD, ATC, Head Athletic Trainer at Eastern Connecticut State University when he says, “We do what we can as athletic trainers to prevent these stupid things from happening. I call them stupid because they’re usually 100 percent preventable.”

But, of course, they’re both right. Colds and flus are largely preventable. But even with the best precautions—meticulous hygiene, diet, and rest—they’re sometimes unavoidable.

Collegiate athletes are particularly susceptible. They not only stress their bodies on a daily basis, they generally don’t get the rest they need, they’re immersed in the everyday stresses of college, they don’t always eat as well as they should, and, perhaps most damaging of all, they hang out with each other in very tight quarters. Many of these things you have little or no control over. But there is a tremendous amount athletic trainers can do once an athlete is suffering from the flu.

“I think the athletic trainer has four roles,” says Richard Ray, EdD, ATC, Coordinator of the Athletic Training Program at Hope College. “The first is to provide general health education to groups of athletes about lifestyle choices and hygiene practices that will help stave off a lot of the common illnesses. Another is to deal with individual athletes who present with specific health concerns and provide them with the information they need to make good choices about their own healthcare. The third role is doing low-level healthcare interventions for sick athletes. And the fourth role requires us to recognize those healthcare concerns that need referral and to arrange for those athletes to see a physician or other healthcare provider.”

In this article, athletic trainers and physicians talk about serious yet common viral infections that are often lumped together as the “flu,” as well as the less serious, but equally unpleasant, general cold. While stomach flus aren’t actually related to the flu at all—that term is reserved for infections caused by the influenza virus—they are discussed together here because, at least from an athletic trainer’s point of view, the two viruses are treated similarly.

Keeping athletes healthy starts with educating them on how to take care of themselves. And that starts with your very first meeting with them. “The preseason physical exam is an important health education device,” says Ray. “It allows the physician to have an intervention with an athlete before the season starts. And it ought to be about more than screening athletes to make sure they don’t die on the field.”

Yeo includes a straightforward discussion about preventing colds and flus in his preseason address. “In terms of basic guidelines, there’s nothing new,” he says. “The main preventative steps I hit upon are washing hands, not sharing water bottles, and getting an immunization shot for the flu. And I emphasize the importance of fluids—eight to 12 glasses a day—as well as proper rest and nutrition.”

It’s also important to educate athletes about how viruses spread and how the incubation period works, so they realize that simply avoiding close contact with people who are sick is not enough to stay healthy. Viruses are around us all the time, and friends and teammates may be carrying them without anyone knowing.

“For Norwalk-like viruses [which cause what is commonly referred to as the stomach flu], the time from exposure to active infection can be as little as 10 hours and as much as five days,” says Per Gunnar Brolinson, OD, Team Physician for Virginia Tech. “So, you can be walking around and not be clinically ill but still be carrying the virus. Also, the virus can live on inanimate objects, like a doorknob. And routine cleaning, like vacuuming, won’t rid carpets of the virus for several weeks.

“Obviously, there’s a wide variation in how it affects people,” he continues. “Some people may get little more than some stomach cramps. Others might feel a little nauseated, maybe have an episode or two of diarrhea, and that’s it. And some kids can get very sick, with multiple episodes of vomiting and diarrhea.”

You may also want to give some thought as to how you’re going to present this information to student-athletes. “You need to approach them in a realistic way,” says Ray. “Young people think they’re resistant to all kinds of problems that affect ‘other folks.’ Athletic trainers shouldn’t get too frustrated if a lot of the health education they provide in a team setting falls on deaf ears.

“When providing health education to large groups it helps to have written information and not just the spoken word,” he continues. “So try using tools like posters in the locker room.

“And it’s really important that the advice is acted on in some practical way. If I stand up at a preseason meeting and tell the athletes to drink lots of water and to weigh in and out before and after practice, I then have to have a scale and weight chart in the locker room and water at practice. You’ve got to follow up with practical things that allow the athletes to comply with the advice you’re giving them.”

The other part of any discussion with athletes about preventing the flu and related illnesses is the importance of coming to you at the earliest sign of trouble. Which means they have to trust that you will actually be able to do something for them and won’t needlessly keep them out of the game.

“There’s really no substitute for having a certain level of trust between the athlete and athletic trainer,” says Ray. “If the athlete trusts the athletic trainer to make a good, well thought-out judgment about whether they ought to play that takes into account the athlete’s goals and objectives, then those athletes are more likely to come to the athletic trainer and confide in him or her. If those circumstances don’t exist, then you’re going to have a lot more athletes hiding things.

“We encourage athletes to come to us at the earliest signs of any problem,” he continues, “because sometimes we have interventions that can shorten the duration of their illness. Also, there are some ailments that if you don’t find out about them until much later, there’s not much you can do. And some things, like meningitis, are much more serious than they first appear. For all these reasons, it’s good to catch things early so you can follow the course of the disease, and that really helps inform your referral decision.”

Athletic trainers will be perceived as trustworthy if they talk with student-athletes in terms they can relate to. “We educate our athletes from the standpoint of performance as opposed to potentially life-threatening or health-related issues,” says Mike Goforth, MS, ATC/L, Head Athletic Trainer at Virginia Tech. “They seem to listen more when you talk about their performance suffering as opposed to their getting sick or ill, because they all think they’re invincible. But if you start talking about how some of these illnesses will compromise their performance, they’ll want to come to you or to a physician immediately to try to counteract that.”

“I think it comes down to trust, and it comes down to communication,” says Yeo. “I tell athletes at the beginning of the season that I’m paid to have them in the line-up. And I do that to the best of my abilities. But I tell them, ‘I can help you most by having you communicate with me what’s going on with your body and with your health, and then having you follow my directions.’

“Sometimes that’s not an easy message to get across,” he continues. “Some athletes feel they’re taking on a badge of honor by playing with illness. Athletes will hide it, they will deny, they will lie, and you have to be observant of people who aren’t acting fully healthy. Anybody who I observe coughing, blowing their nose every two seconds, or to be very malaised or tired is obviously not completely healthy, and I will want to evaluate them further, whether they’ve come to me or not.”

Whether you observe an athlete sniffling and sneezing on the field or someone comes to you complaining of flu-like symptoms, it’s time to put on your physician hat. While athletic trainers aren’t MDs, there’s still a lot you can do for a sick athlete while staying well within licensure and practice guidelines.

“A huge percentage, probably a third, of the cases we see in the typical college or high school training room are non-orthopedic problems—just general health concerns,” says Ray. “The athletic trainer has some responsibility to manage some of those on his or her own—I’m talking about the real simple stuff that they’re well-trained to do. Every sore throat, ear ache, or rash doesn’t have to get shipped off to the doctor right away.

“But an athletic trainer needs to act within the scope of his or her education, training, and license,” he adds. “The minute they get outside any of those three, they’re at risk of legal liability problems. That’s just as true in treating an illness as it is when treating an ankle sprain. It takes experience to know what you can handle and what you can’t handle.”

As a general guideline for when an athletic trainer should refer athletes to a physician Brolinson suggests this: “Any ailment that the athlete, coach, or athletic training staff feels will significantly impact an athlete’s ability to train or compete is something that I, as a physician, want to see.

“It obviously depends on the symptoms that are involved,” he continues, “but if someone has a persistent fever, and by that I mean a fever greater than 101 degrees orally that doesn’t respond in a period of 24 to 48 hours to the usual antipyretic measures, that’s obviously somebody a doctor should see.”

Athletes, unless they’re too sick to move, will have one thought on their minds while they’re sitting there with the thermometer hanging out of their mouths: “Can I still play?”

“I think it’s very important to have return-to-play criteria that have been jointly developed by the athletic trainer and the team physician,” says Ray. “The team physician has to have medical control over the athletic program, and return-to-play decisions are a huge part of that. So, when we have kids who are sick with the flu, our physician will tell me, ‘it’s when the athlete has this and this that he or she can go back to this level of activity.’

“That said,” he continues, “there’s a rule of thumb for respiratory infections: if the symptoms are below the neck and don’t resolve five to 15 minutes after stopping exercising, then they shouldn’t play. Whereas if symptoms are above the neck they probably can.”

In the absence of a diagnosed illness, the athlete may provide the best guide. “If they come in and are running a 100-degree fever, that’s one thing,” says Johnson. “But if their temperature’s normal, and they’ve seen a doctor and there’s nothing terribly wrong with them, if they want to practice I’ll often let them.

“Among the things I’ll look at in those cases is their schedule,” he says. “Is there a game tomorrow or the next day that they have to practice for? If so, I’d probably let them do it. But if they don’t have a game, I might say, ‘Hey, let’s just take a day or two here to get you better. That’s not really going to affect your ability to prepare for your next competition.’”

In August 2002, Brolinson and Goforth were confronted with an outbreak of Norwalk-like virus that quickly spread to over half the Virginia Tech football team, as well as some of the coaching, athletic training, and support staff. “We were right in the middle of our two-a-days,” recalls Goforth, “and one of the things we were most concerned about was heat illness. We talk about acclimatization, and we felt our kids were acclimatized, but two of the biggest negators are fatigue and illness. And here our kids couldn’t eat for about 48 hours and they’re up at night vomiting and having diarrhea. Then we’re asking them to be well in about 48 hours and train at a high level.

“So Coach Beamer altered practices and actually canceled a day and a half,” he continues. “And the next practice with the whole team, we scaled way back as far as padding and what we had them do. So, we were able to escape a lot of those problems, like heat illness.”

Randy Oravetz, ATC, Director of Sports Medicine at Florida State University, recalls once having to make similar decisions during a big game. “We played a bowl game a few years back where we had a few athletes suffering from the flu and some athletes with a stomach bug,” he says. “It was the last game of some of these guys’ careers, so we tried to give them a chance to play. You have to look at things like the temperature and the humidity, the amount of exertion, what kind of sickness, how long they’ve been sick, those types of things. And we’ll make those decisions with our physician.”

For the not-so-serious cases, there’s plenty you as an athletic trainer can do for a sick athlete. Like most athletic trainers, Johnson has some basic over-the-counter medicines he keeps on hand, which he’ll hand out to athletes after checking their records for any contraindications and logging the medicines in their files. But he’ll also talk with sick athletes about what they can take and what they should stay clear of.

“There are a lot of different medicines out there,” Johnson says, “whether they’re the traditional Western medicines or nontraditional herbal remedies. Our athletes are sometimes tested for some common substances, like pseudoephedrine. So, at those times, if an athlete’s sick, we’ll remind them that they can’t take certain medications. And I make sure they’re taking the right dose. I make a point of saying, ‘Take it like it says on the bottle. More is not always better.’

“The biggest thing you have to be concerned about with the stomach flu is dehydration,” Johnson adds. “So, you want to make sure they’re getting a lot of fluids and get them to see a doctor, even if they’re not running a fever, because there are prescription drugs to help ease diarrhea and vomiting beyond what something like Imodium can do.

The other thing is they’re probably not eating very much, so you can put them on what’s called a BRAT diet—bananas, rice, apple sauce, and toast—things that won’t upset the stomach. And then you have to bring them back slowly. Once their diarrhea and vomiting have stopped and they’re well hydrated, and after a few days of eating normally, and if their energy is up, they can start to go full speed.”

Brolinson stresses the importance of taking it slow on their return. “Once they’re afebrile and the muscle aches and pains are starting to resolve, then some gentle exercise is appropriate,” he says. “It might be as simple as spending 20 or 30 minutes doing some light stretching and taking a walk. Pool exercises are good, too. Not necessarily swimming but just getting in the pool and walking or doing some deep-water jogging.”

In addition to treating an athlete who’s sick, you also have to consider how to keep him or her from spreading the bug to teammates. As the Virginia Tech case points out, that’s no easy feat. Often, by the time you realize you have an infectious situation, it’s already affected several people. And athletes aren’t in close contact only when they train and compete. They also tend to hang out and live together—all in very small, overly populated quarters.

When Brolinson and Goforth realized what they had on their hands this past August, they did their best to contain it. “We actually went out and bought several of each of the items on the BRAT diet,” says Goforth, “and when someone came in here sick we’d give them a bag with those foods to take home with them. We didn’t want them going into the dining hall.”

At Florida State, Oravetz and his staff implement containment measures as part of daily procedure. “During football two-a-days we have 105 athletes running around who are always touching things,” he says. “So we try to cut down on the use of towels—we use paper towels a lot. Also, we cut the nozzles off the water bottles we use, so they have to shoot the water into their mouths rather than suck on them. And we have what we call an open-door policy. We prop as many doors open as possible so there’s not a lot of people touching door handles, which is a good way for viruses to spread.”

Good housekeeping is critical to preventing the spread of illness-causing germs. At Virginia Tech, the recent rash of athletes fighting a stomach virus forced Goforth to implement some tough precautions in his athletic training room.

“We were on a strict cleaning schedule,” he says. “Basically, if we were here 14 hours a day, we tried to clean at least once each of those 14 hours—all hard surfaces, all tables. As a staff, we tried to wash our hands as much as possible, especially after any exposure to an athlete.

“And the other thing,” says Goforth, “is trying to limit the number of places where you’re seeing these athletes. We tried to limit our exposure to the virus to the training room and the physicians’ offices and kept those as clean as possible. We only had two staff members come down with this out of about 20 who work in here.”

More dramatic measures are another option. The staff of the Salt Lake City Polyclinic, the main medical center for the 2002 Winter Olympics, prophylactically treated those in close contact with affected athletes to great success.

“You have to figure out what the risk is of transferring, in this case influenza, to other members of the team, and that’s related to the degree of contact,” says Mark Elstad, MD, who was the Medical Director of the Polyclinic, and is Medical Director of the Medical Intensive Care Unit at Salt Lake Veteran’s Affairs Medical Center, and Associate Professor of Medicine and Director of the Utah Airway Disorder Center at the University of Utah. “In general, if the contact is going to be like a family living together in a house, then the recommendation is if one of them gets sick then the rest should consider getting the prophylaxis. But if everyone lives in different dorms or houses and they just get together to practice and play, then it’s probably not warranted.

“We found a couple of outbreaks among teams or individuals who work together,” adds Elstad, “and essentially what we did is recommend mass vaccinations for everyone else in those groups. In the teams that received the vaccine, there were no new cases of flu that developed. So, I think that you can make the argument that when you have a team traveling and living together and one player comes down with influenza, it might be reasonable to vaccinate the entire team.”

So, while the flu (stomach or respiratory) and colds are often unavoidable, the steps you take before the bug hits your campus and while it’s spreading can make all the difference as to how long it sticks around. And that can make all the difference between a mild annoyance and a full-blown epidemic.

Sidebar: Olympic-Style Prevention
There are few athletic events that carry more importance for athletes than the Olympics. There are also few athletic events where you have so many athletes from all over the world in one place at one time. And that’s a recipe for disaster when you’re talking about infectious diseases like the flu.

At the 2002 Winter Olympics, Mark Elstad, MD, wasn’t anybody’s team physician. But, as Medical Director of the Salt Lake City Polyclinic, he was given the huge responsibility of preventing and treating illnesses. Just as with athletic trainers at any college or university, his first goal was to get the athletes and their coaches to trust him enough to come to the Polyclinic at the first signs of feeling ill.

“We talked with all the athletes and their coaches at the beginning of the Games,” says Elstad. “We told them what we had to offer, which was that we could identify anyone who had the flu.

“We were set up to take nasal washings from anyone who came in with a runny nose,” he continues. “Using rapid detection techniques we could make a specific diagnosis of either influenza or one of several other viral syndromes. Our idea was that if we could identify people who had the flu, we could first treat them with antivirals, and second, we might be able to suggest prophylaxis to people who were in close proximity. For example, teams who might all live and train together.”

Elstad found, even beyond his expectations, that athletes came to him at the earliest sign of discomfort. “Before it started, we thought that the team physicians would want to just give antibiotics to anyone who got sick,” he says. “But it turns out they came to us a lot and asked us our advice. I think that’s because we offered this kind of testing and the team physicians and athletes realized that we had a reasonable chance of figuring out what was wrong with them before it got out of hand.”