How many of you regularly use a towel to wipe off sweat when you go to the gym? More specifically, how many of you place a towel on the bench you use or wipe the equipment down with alcohol after use? Overlooking this simple practice can result in the spread of various infections, including the potentially deadly hepatitis virus. If you think all this is a bit over the top then read on to find out why the carelessness of some sports centres and their users could be jeopardizing your health and the health of your loved ones.

Defining hepatitis and the functions of the liver

Hepatitis is a general term that refers to an inflammation of the liver. The liver is a metabolically active organ which is responsible for many vital functions (Box 1). Healthy living is impossible without a healthy liver – hence the importance of protecting oneself from hepatitis.

(Box 1)

The main functions of the liver

• Bile production and excretion (bile digests fats from the gut in order to be converted into hormones and cell membranes)

• Processing of ingested medication to activate / deactivate it (a fundamentally important function)

• Metabolism of fats, proteins, and carbohydrates

• Enzyme activation / deactivation

• Storage of glycogen, vitamins, and minerals

• Synthesis of plasma proteins, such as albumin, and clotting factors

• Blood detoxification and purification

• Production of clotting factors which control clotting and bleeding

What is inflammation?

The term inflammation is a generic process whereby the body's defence and vascular systems respond to cell injury whenever any foreign particle, “invader” or trauma is inflicted on the body. The ultimate scope of inflammation is to attempt repair and remove the offending “aggressor”. This occurs by means of an intricate and concerted effort involving cells and chemicals called “inflammatory mediators”. A cascade of events unfolds which can, if unchecked, damage the liver cells (hepatocytes) – sometimes permanently and with tragic long term consequences. One such consequence is cirrhosis: a condition where the normal architecture of the liver is lost. Cirrhosis causes excessive scarring both at a microscopic and macroscopic level. A sick liver has limited ability to maintain the above mentioned functions. This results in multiple hospital admissions, time off work, pain, wasting of body tissues and ultimately death. Liver failure can therefore be fatal due to excess unprocessed toxins, malnourishment, mental confusion and high blood pressure in the gut.

What causes hepatitis?

There are many causes of hepatitis, each triggering the above mentioned inflammatory process to various extents depending on the cause, the person's general health and the time taken to diagnose and treat the problem (Box 2).

(Box 2)

Causes of hepatitis

Non-infectious:

• Alcohol (10-35 per cent of heavy drinkers develop hepatitis)

• Ingestion of medication beyond the prescribed dose

• Inflammation of the pancreas (pancreatitis) or gall bladder (cholecystitis)

• Autoimmune hepatitis (a defective defence mechanism induces the body to recognise one's liver as foreign and an unbridled inflammatory process is triggered against the self)

• Non Alcoholic Steato Hepatitis (NASH-a condition associated with diabetes, high cholesterol and obesity; difficult to treat)

Infectious:

• Viruses (namely hepatitis viruses types A, B, C, D, E and F)

• Bacteria

• Fungi

• Parasitic organisms

Box 2 shows that that the causes are broadly classified into infectious and non-infectious. The term infectious implies that it can spread from person to person. Viral hepatitis (especially hepatitis type B) is the most serious cause of infectious hepatitis and this is the one you can easily get from bodily fluids including semen, vaginal secretions, blood, tears, vomit, diarrhoea, saliva and sweat... hence the concerns related to gyms and contact sports. Further evidence of the infectivity of Hepatitis B lies in the fact that you are 100 times more likely to contract the virus when pricked by a used Hepatitis B-contaminated syringe compared to being pricked by an HIV infected syringe.

A breakthrough study

These concerns motivated a team of Turkish scientists to study 70 Olympic wrestlers. Wrestling is by definition a contact sport where sweat is easily and often exchanged between contestants. Cuts with spillage of blood are also likely just as in any other contact sport. The results were a worrying eye-opener. These experts who recently published their paper in the British Journal of Sports Medicine, said that sportsmen who came in contact with others' body fluids, faced an increased risk of infection with the hepatitis B virus (HBV). Although none of the wrestlers had an active HBV infection, the virus was found in nine blood samples (13 per cent) ie they were carriers and potentially contagious. They called for increased testing of sportsmen involved in contact sports.

Researcher Dr Selda Bereket-Yucel added that this showed they had a hidden infection because intense training could suppress their immune system which combats the virus. Dr Bereket-Yucel reiterated that mandatory testing of sportsmen should be introduced for HBV. Dr. James Robson, head of medical services at the Scottish Rugby Union agreed stating that, “It is starting to emerge that hepatitis B is slightly more infectious than previously thought”.

Applying the results of the Turkish study to other sports

These results can be carried on to other sports or establishments where bodily fluids are liberally and easily disseminated – although more studies with similar findings are necessary to corroborate the advice given. Several of Malta's gyms, aerobic rooms and sports centres are warm and humid despite air-conditioning. Exercise and warm environments causes the skin pores to open and release sweat. The superficial skin layers swell, allowing easy access to any infection spread by direct contact. Viruses can thus “slide” in between cells which usually have no gaps in between when not swollen.

Furthermore, sweaty, hot skin stimulates blood vessels to dilate under the surface of the skin. Any minor cut is therefore more likely to bleed profusely due to the high blood pressure induced by exercise. Those of you who work out or who engage in team sports will know how easy it is to exchange sweat and to sustain minor abrasions or cuts during exercise.

The scientists' conclusions finally confirm what sports doctors have been preaching for many years. We are now beginning to have tangible scientific evidence to justify calls for improving health and safety standards in sports establishments to prevent HBV spreading.

With this in mind, referees, coaches, gym managers and instructors have a duty to remove anyone who is bleeding to prevent them from contaminating other players or gym equipment. Experts concluded that legislation should be in place for all sportsmen at risk to be vaccinated against Hepatitis A, B and tetanus (which can also be transmitted from dirty equipment into broken skin).

How does hepatitis present?

Clinical presentation of infectious hepatitis varies from person to person and depends on the cause. Jaundice (yellow colouration of the skin and white part of the eyes), itching, dark urine and clay coloured stools are common symptoms.

What are the outcomes of hepatitis?

• Complete resolution of the condition, if fortunate

• Becoming an asymptomatic carrier for life… and potentially contagious to others

• Death

• Permanent liver damage which may require a liver transplant

• Development of female breasts in males with male hair loss

• Impotence

• Small testicles

• Mental disorders (depression, memory loss, irritability)

• Internal haemorrhage

• High blood pressure in the gut

• Weight loss

• Susceptibility to infection

• Social marginalisation due to associated stigma

Box 3 lists health and safety advice each sports centre should adhere to. It is important to remember that the country's Health and Safety Act (or equivalent) includes sportsmen and sports premises. It stipulates that basic hygiene standards must be adhered to in order to prevent dissemination of disease. People have a right to exercise in a safe, clean and disease-free environment.

(Box 3)

Health and safety considerations to prevent Hepatitis transmission

• If you know you are infected, it is your responsibility to seek medical advice to determine whether you are fit enough to practise sports. Inform your doctor / coach in confidence.

• In my experience, many people do not deliberately state they have hepatitis. NEVER TAKE ANYONE FOR GRANTED: ASK!

• Check whether your club provides towels. If not, use one at all times to cover equipment and wipe sweat / blood off.

• Ensure that your club has alcohol wipes (or equivalent) to keep the equipment clean.

• Sweat or blood on equipment is potentially infected. Alcohol or bleach will kill any germs present.

• Speak to the manager / instructor if you find blood or sweat on equipment.

• Never allow a sportsman to exercise if he has an open wound. The break in the skin facilitates transfer of infection into the body and also enhances dissemination of infection from the person to others.

• The club should have a dedicated cleaner who checks the premises regularly.

• If you are concerned about a fellow member who may be ill, contact the management immediately.

• It is a myth that some people do not sweat at all. We all do, but to varying extents. Worry more about those who sweat a little as any virus is more likely to be concentrated in their body secretions – and is therefore more contagious- compared to a person who sweats profusely.

• Remember that many other infections such as fungi and bacteria can be transmitted via sweat – hence the huge importance of basic hygiene and use of wipes and towels.

• The premises' licence may be withdrawn if basic health and safety rules are not adhered to.

Local gyms-the situation at present

Malta and Gozo have around two dozen well equipped gyms. Having visited practically all of them, I have to report that sadly very few consistently observe and enforce the towel rule. In the words of a gym instructor, “Members are like babies... you have to keep reminding them”.

Using a towel or wipe is not over the top, a chore or just boring... it can decrease the risk of infection and may be life saving to you and your loved ones. Let your sports complex know about this. Use towels and insist that others do the same!

Dr Mark Xuereb is a psychiatrist and emergency doctor. He has a special interest in sports medicine and psychology.