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D Papagiannis, G Rachiotis, A Xanthopoulos, A Simou, C Zilidis, F Triposkiadis, Vaccination practices and influenza in professional football players in Greece, Occupational Medicine, Volume 70, Issue 3, April 2020, Pages 200–202, https://doi.org/10.1093/occmed/kqaa004
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Abstract
There is limited data on vaccination practices for professional footballers globally.
To record vaccination practices employed by medical staff of individual football teams of the Super League Greece, and absenteeism of footballers related to influenza illness.
A brief questionnaire was distributed to chief medical officers (CMOs) of the sixteen teams of the Super League Greece. Participants were asked to report vaccines they recommended for footballers. In addition, the questionnaire included questions on new cases of influenza and absenteeism due to influenza. Descriptive statistics (absolute and relative frequencies) were used for the presentation of the results.
Overall, 87% of the CMOs recommended seasonal influenza vaccine, 62% hepatitis B vaccine and 50% pneumococcal vaccine. Fourteen CMOs (87%) reported that the occurrence of seasonal influenza in the 2016–17 northern hemisphere season ranged from one to five cases, while two medical officers (12%) reported zero workdays lost due to influenza.
Our survey shows considerable variation in vaccination practices of CMOs of the Super League Greece. The results of this survey should stimulate further evaluation of vaccination policy and influenza-related absenteeism in footballers.
There is very limited information about vaccination practices and influenza-related absenteeism in footballers.
Our survey documents considerable variation in the vaccination practices of chief medical officers of the Super League Greece.
The results of this survey should stimulate further investigation of the vaccination practices and influenza-related absenteeism in footballers.
Introduction
Due to the nature of their job, professional footballers must maintain a high level of fitness. Physical interaction with others and engaging in domestic and international travel exposes professional footballers to an increased risk of infectious diseases [1]. Moreover, the high number of players from different parts of the world can expose footballers to diseases that are not endemic in their country of origin. Schwellnus et al. tracked 14 rugby teams and showed that international travel to a foreign location greater than a 5-h time zone difference from the home country was associated with a significant increase in the incidence of all illness, respiratory tract illness, gastrointestinal tract illness and all infective illness [2].
Additionally, it has been pointed out that infectious diseases impact differently on athletes in comparison to the general population [3,–6]. For elite athletes (e.g. football players), even mild diseases that would never cause absenteeism in the general population are critical determinants for their individual performance. According to the ‘open window theory’ athletes are at increased risk of infectious diseases due the impaired immune function following an acute bout of endurance exercise [5,7]. The Union of European Football Associations (UEFA) published official regulations in 2017 and recommended that every footballer must have a complete vaccination record according to the national vaccination program [8]. Nevertheless, there is limited information about vaccination for high-level athletes, especially footballers [3]. The aim of our study was therefore to investigate the vaccination practices of the chief medical officers (CMOs) of all football clubs of Super League Greece. In addition, we sought to draw information on absenteeism due to influenza among footballers.
Methods
A questionnaire was distributed to the CMOs of the sixteen Super League football teams in Greece. They were asked to participate in a telephone interview between December 2017 and February 2018 and report on the vaccines they had recommended for footballers. In addition, the questionnaire included questions on influenza cases (‘Could you please report the cases of influenza among football players of your team during the influenza season 2016–17’) and absenteeism in footballers due to influenza.
The 16 football clubs included players from around the world (total number of players 644; number of players coming from countries other than Greece 205 (32%). All participants gave their informed consent for the participation in the survey, and all responses were anonymized. Descriptive statistics (absolute and relative frequencies) were used for presentation of the results. All analyses were performed using Excel software. The research protocol was approved by the ethics committee of the School of Health Sciences of Technological Educational Institute of Thessaly, number protocol: 1394/1-12-2017.
Results
All invited CMOs (16) participated in the telephone interview survey. The seasonal influenza vaccine was recommended by most medical teams (87%), followed by hepatitis B vaccine (62%) and the pneumococcal vaccine (50%) (Table 1). Vaccination against diphtheria, pertussis and polio was recommended by 12% of CMOs, while vaccination against tetanus and diphtheria was recommended by 31% of CMOs. In addition, 50% of CMOs recommended pneumococcal vaccination, and 25% Hepatitis A vaccine. Measles, mumps and rubella (MMR) and meningococcal ACWY conjugate vaccine were not recommended. Most CMOs (75%) reported that football player absence from the training due to influenza (2016–17 northern hemisphere season) ranged from 1 to 3 days. An absenteeism of 3–5 days was reported by 12% of CMOs. In addition, two CMOs reported zero workdays lost due to influenza. Lastly, most of the participants reported inability to ascertain the past vaccination history of players who came from African countries.
| Vaccines from the Hellenic national immunization program recommended to the football players . | Yes . | No . |
|---|---|---|
| . | n (%) (total = 16) . | n (%) (total = 16) . |
| Diphtheria, Tetanus, Pertussis, Polio (TdapIPV) | 2 (12) | 14 (88) |
| Tetanus, Diphtheria (Td-adult) | 5 (31) | 11 (69) |
| Pneumococcal | 8 (50) | 8 (50) |
| Seasonal influenza | 1 (87) | 2 (13) |
| Hepatitis-B | 10 (62) | 6 (38) |
| Hepatitis-A | 4 (25) | 12 (75) |
| Measles–Mumps–Rubella | 16 (100) | |
| Meningitis ACWY | 16 (100) |
| Vaccines from the Hellenic national immunization program recommended to the football players . | Yes . | No . |
|---|---|---|
| . | n (%) (total = 16) . | n (%) (total = 16) . |
| Diphtheria, Tetanus, Pertussis, Polio (TdapIPV) | 2 (12) | 14 (88) |
| Tetanus, Diphtheria (Td-adult) | 5 (31) | 11 (69) |
| Pneumococcal | 8 (50) | 8 (50) |
| Seasonal influenza | 1 (87) | 2 (13) |
| Hepatitis-B | 10 (62) | 6 (38) |
| Hepatitis-A | 4 (25) | 12 (75) |
| Measles–Mumps–Rubella | 16 (100) | |
| Meningitis ACWY | 16 (100) |
| Vaccines from the Hellenic national immunization program recommended to the football players . | Yes . | No . |
|---|---|---|
| . | n (%) (total = 16) . | n (%) (total = 16) . |
| Diphtheria, Tetanus, Pertussis, Polio (TdapIPV) | 2 (12) | 14 (88) |
| Tetanus, Diphtheria (Td-adult) | 5 (31) | 11 (69) |
| Pneumococcal | 8 (50) | 8 (50) |
| Seasonal influenza | 1 (87) | 2 (13) |
| Hepatitis-B | 10 (62) | 6 (38) |
| Hepatitis-A | 4 (25) | 12 (75) |
| Measles–Mumps–Rubella | 16 (100) | |
| Meningitis ACWY | 16 (100) |
| Vaccines from the Hellenic national immunization program recommended to the football players . | Yes . | No . |
|---|---|---|
| . | n (%) (total = 16) . | n (%) (total = 16) . |
| Diphtheria, Tetanus, Pertussis, Polio (TdapIPV) | 2 (12) | 14 (88) |
| Tetanus, Diphtheria (Td-adult) | 5 (31) | 11 (69) |
| Pneumococcal | 8 (50) | 8 (50) |
| Seasonal influenza | 1 (87) | 2 (13) |
| Hepatitis-B | 10 (62) | 6 (38) |
| Hepatitis-A | 4 (25) | 12 (75) |
| Measles–Mumps–Rubella | 16 (100) | |
| Meningitis ACWY | 16 (100) |
Discussion
This study found that influenza vaccination was frequently recommended by team CMOs. Notably, Signorelli and colleagues in a survey among Italian footballers reported an average influenza vaccination rate of 40% [3]. Hepatitis B vaccine was also frequently recommended. In contrast, Hepatitis A vaccine was only recommended by 25% of medical teams. ‘Vaccinating against hepatitis A and B as well as seasonal influenza is recommended because high-level athletes’ immune system is likely to be more vulnerable due to fatigue.’ [4] However, it should be emphasized that an Australian sero-prevalence study reported that the prevalence of markers of past hepatitis B infection among football players was no different to that in the population of blood donors [9]. Of note, recommended MMR or the meningococcal vaccines were not recommended by any CMOs. The risk of a meningococcal outbreak spreading due to participation in a sporting event is low [10], and while it could be assumed that footballers have been vaccinated against MMR during childhood, this information is not discernible in our data set; an area. deserving further investigation given the current measles outbreaks in Europe.
In this study, most teams reported footballers’ absence from group activities for at least 1–3 days due to influenza, an important point as the Greek Super League operates from August to May during the northern hemisphere season.
Our results are subject to several limitations. The cross-sectional design of our study precludes attribution of cause and effect. In addition, the study was questionnaire based and information bias may have occurred. Furthermore, we have investigated the vaccine recommendation by clubs’ CMOs and not actual vaccination coverage among players. Lastly, we acknowledge the fact that a part of ‘influenza-related absenteeism’ could be attributed to influenza like illness. Nevertheless, the present study presents some advantages; we report on flu-related absenteeism on footballers, and in addition, we have reported on the immunization practices in football teams related to a variety of vaccine-preventable diseases. In conclusion, our survey documents considerable variation in practice in Greek Super League CMOs. This finding may reflect the absence of national/international guidelines on vaccination of footballers. Nevertheless, our results contribute to the current body of knowledge and provide novel insights about immunization practices in footballers.
Acknowledgements
The authors of this study would like to thank the medical staff of the sixteen clubs of Super League Greece for their valuable collaboration in completing the research.
Competing interests
None declared.
