Background Antidoping and medical care delivery programmes are required at all large international multisport events.
Objective To document and critique the novel antidoping and medical care delivery models implemented at the 2nd Summer Youth Olympic Games, Nanjing 2014.
Methods The International Olympic Committee implemented two new models of delivery of antidoping and medical care at the YOG. A review of these models as well as the public health programme and two health educational initiatives in the Cultural and Educational Program was undertaken by the International Olympic Committee.
Results The implementation of the new antidoping model was feasible in the setting of the YOG. The antidoping rules and regulations of the International Olympic Committee were respected. This model enhanced the educational initiative and provided financial as well as human resource savings. The execution of the hospital-based venue model of medical care delivery at the YOG was also feasible in this setting. This model provided a practical infrastructure for the delivery of medical care at multisport events with the goal of providing optimum athlete healthcare. A public health prevention programme was implemented and no public health risks were encountered by the participants or the Nanjing citizens during the YOG. Finally, the implementation of the athlete health educational programmes within the Cultural and Educational Program provided athletes with an opportunity to improve their health and performance.
Conclusions To achieve the goal of protecting athlete health, and of employing effective doping control and education, new alternate models of antidoping and medical care delivery can be implemented.
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Participation in sport has positive benefits on the health and well-being of youth.1 ,2 Through the Youth Olympic Games (YOG), the International Olympic Committee (IOC) promotes physical activity in adolescents.3 The 2nd Summer YOG held in Nanjing, China, in 2014, included 3800 athletes between the ages of 15–18 years from over 200 countries, competing over 12 days in 28 sports and 222 events. One of the main priorities of the IOC is the protection of the ‘clean’ or doping-free athlete from doping in sport. This objective is twofold: protecting the athlete from the deleterious health effects of doping, as well as the protection of the integrity of sport through the promotion of fair play. The protection of athlete health is another top priority for the IOC.4 At the YOG in Nanjing, the IOC introduced two novel models of delivery for antidoping and athlete medical care. The antidoping model for the protection of the clean athlete was implemented by the Nanjing YOG Organizing Committee in partnership with the China Anti-Doping Agency (CHINADA) under the authority and rules of the IOC. The athlete medical care model for the protection of athlete health was also implemented by the Nanjing YOG Organizing Committee medical team under the oversight and guidance of the IOC Medical Commission. In addition, the unique and significant public health risk of Ebola virus disease (EVD) during the time period of the YOG required special planning, programming and monitoring. Finally, the YOG featured an athlete-centred Culture and Education Program (CEP), which delivered health-related programmes among other themed initiatives important for developing athletes.
This paper documents and analyses these new models of antidoping and medical care delivery in a setting of an elite international multidiscipline youth sporting event. A summary of the unique public health risks encountered and the healthcare educational programmes are included to serve as reference for future events.
IOC YOG antidoping programme delivery
The protection of the clean or doping-free athlete is a priority for the IOC and in support of this, the IOC designed and implemented a novel antidoping model at the Nanjing YOG, based on the antidoping rules and regulations of the IOC. The objectives of this novel model were (1) to prioritise prevention through education, (2) to improve efficiency and cost-effectiveness and (3) to assure the integrity of the programme by maintaining the IOC zero tolerance Anti-Doping Policy. After consultation with the World Anti-Doping Agency (WADA), and in collaboration with the Chinese National Anti-Doping Organisation and the Nanjing YOG Organizing Committee, a new model of doping control was implemented at the Nanjing YOG.
IOC YOG antidoping model
In contrast with the conventional model of testing programmes at the Olympic Games, where all postcompetition testing is conducted at each competition venue, all doping control tests carried out during the YOG were centralised in one Doping Control Station in the Youth Olympic Village. Out-of-competition testing started at the opening of the Youth Olympic Village. Athlete notification was coordinated to avoid disruption to training and rest. For postcompetition testing, all medallists were required to register at the doping control desk at the entrance of the Residential Zone of the Youth Olympic Village following their competition. Athletes from the among the medallists, who had been selected for doping control as per the IOC Test Distribution Plan, were then accompanied by a chaperone to the Doping Control Station for testing as per the protocol outlined in the WADA International Standard of Testing.5 There was no notification or testing carried out at the competition venues. Samples were securely transported to the Beijing Anti-Doping Laboratory at regular intervals for analysis. Anti-doping Task Force Meetings, comprised of the members of the IOC Medical Commission Games Group and the local antidoping authorities, were held daily to monitor and facilitate the antidoping programme. Daily visits to the Doping Control Station by IOC Medical Commission personnel were made to provide support and quality control.
A total of 112 personnel were required to implement the antidoping model at the 2014 YOG. A Doping Control Command Center was established by the Nanjing YOG Organizing Committee, consisting of 16 personnel who were responsible for oversight of logistical coordination, doping control, operations and antidoping education. For details of other personnel involved, see table 1.
Doping control station
The Doping Control Station was located adjacent to the Youth Olympic Village Medical Polyclinic. The Doping Control Station was 220 m2 in size and was divided into a reception area, a large waiting room, an educational area, five processing rooms, an operations office and a storage room.
The IOC Test Distribution Plan was designed in consultation with the International Federations. Half of the tests were out-of-competition (unrelated to competition result) and half were postcompetition (within 12 h of competition on selected medallists) with distribution across all sports and most National Olympic Committees. The rationale behind the difference in the Test Distribution Program from 2010 to 2014 was to target sports with historically a higher risk of doping rather than testing all medallists, as was the protocol in 2010. As well, all countries with more than 10 athletes were targeted, ensuring that a minimum of 1 athlete was tested. Additional samples were added as a result of World Record verifications and intelligence testing. More detail can be found in table 2.
Antidoping education programme
A WADA Outreach Program was implemented as part of the YOG CEP.6 An interactive educational booth in the Youth Olympic Village was themed ‘Say No to Doping’, and was staffed by antidoping experts from around the world. In the Doping Control Station, a WADA educational video, a testing procedure chart and a CHINADA educational souvenir were available for athlete education.
Review of the model of antidoping delivery
A review by the IOC Medical Commission Games Group of this new model of antidoping delivery at an international, multisport, youth event was undertaken to evaluate efficacy, feasibility and applicability for future YOG. The review process included three components: (1) interviews and meetings with the various stakeholders involved; (2) document review; and (3) debrief analytical review of the Anti-doping Task Force. Owing to unfamiliarity with the new postcompetition procedures for notification at the Youth Olympic Village instead of at the competition venue, there was some confusion on the first few days among athletes and the National Olympic Committees (NOC), resulting in difficulties in finding some athletes identified in the Test Distribution Plan. This problem was solved through increased education at the NOC Chef de Mission meetings and at competition venues as well as strategically locating the doping control registration desk more prominently at the entrance to the Residential Zone of the Youth Olympic Village.
One concern identified with this model for postcompetition testing was the length of time between the end of competition and the start of the testing procedures. As athletes may have attended celebrations postevent prior to returning to the Youth Olympic Village, a considerable length of time may have elapsed resulting in a late night for some athletes. Another concern identified with this model was unique to the sport of athletics. The IAAF rule on World Record validation states that the first urine produced by the athlete postcompetition must be analysed. Given the time taken to travel from the competition venue, postmedia and victory ceremonies, to the Doping Control Station at the Youth Olympic Village, it could prove problematic for any athlete urgently needing to urinate. This concern, however, was not encountered in Nanjing.
Another concern in using this model at other Games is that if the postcompetition Test Distribution Plan is more comprehensive (identifying athletes for testing beyond the medallists), the implementation of this notification process may be more complex and potentially problematic. Finally, one could question the integrity of the model as athletes could manipulate their urine in the unchaperoned time interval between the end of competition and the start of testing, or use the interval time to metabolise a prohibited substance from their body. While this criticism is hypothetical, this model could be challenged by giving athletes an opportunity to manipulate samples, so should not be universally adopted at major games, but a modified version could be considered at future junior games. Therefore, in light of these challenges, a compromise for future YOGs could be to conduct postcompetition testing in venues where there are already existing suitable doping control facilities using doping control officers who visit the venue for the specific time period to conduct the testing, bringing all necessary equipment with them from the central Doping Control Station.
Despite these challenges, there were several benefits identified of this new model of antidoping delivery. As this model required only one Doping Control Station, all athletes were tested in the same station. This environment provided an opportunity for a more efficient delivery of the antidoping educational programme. Another advantage of having only one Doping Control Station was the significant cost-savings for the local organising committee by not having to create duplicate Doping Control Stations in all competition venues. Human resources costs are also reduced as fewer personnel are required for the delivery of this model. In addition, by using only one Doping Control Station, there is improved consistency in testing procedures, a more simplified chain of custody and an opportunity to design a more efficient Doping Control Station.
IOC YOG medical care delivery model
The delivery of medical care at the YOG presents several challenges. The experience of the 1st Summer YOG in Singapore (2010) underscores the factors that must be taken into consideration in the development of a medical care delivery model at an event of this magnitude and scope.7 Similar challenges have been reported in the Summer Olympic Games8 (box 1).
Factors to be considered in the development of a medical care delivery programme for the Youth Olympic Games7
Large number of participants
A high percentage of foreign delegates and athletes
Multiple events conducted over an extensive time period
Multiple events conducted simultaneously
The relatively young age and inexperience of the competing athletes
Decentralised competition venues
Multiple events in areas of high population density
Medical care delivery model
Taking these factors into consideration, the IOC, in cooperation with the Nanjing YOG Organizing Committee, developed a Medical Care Delivery Model for the 2014 Nanjing YOG. The objective of the Model at the 2nd Summer YOG was to provide medical services for athletes and support personnel while minimising the burden on the healthcare delivery system of the local region.7 As in the antidoping model, the Medical Care Delivery Model was also a novel initiative. In the traditional format of healthcare delivery at large multisport international events, the medical division of the local organising committee organises and manages the medical programme at the training and competition venues, the athlete's village, the main press centre and the official IOC hotels. The Nanjing YOG Organizing Committee utilised a different model by assigning individual local hospitals to be responsible for providing the logistical requirements, equipment, medication and medical staff at specific venues at no cost to the organising committee.
To ensure consistency in healthcare delivery, the Nanjing YOG Organizing Committee developed a Medical Command Centre that was responsible for the setting of minimum standards and personnel training. If required, patients were transferred to the official hospital, the emergency transfer hospital, or the medical clinic at the Youth Olympic Village, depending on the medical severity, the accreditation status of the patient and the location of the venue. Daily meetings were held between the Nanjing YOG Committee Medical team and the IOC Medical Commission to facilitate medical care delivery.
In total, 62 medical stations functioned as field of play urgent care medical clinics in the training and competition venues in addition to the 26 medical clinics functioning in the official hotels. One thousand six hundred and thirty-six personnel were required to implement the medical care model at the YOG. In addition, the Medical Command Centre, under the guidance of the Nanjing YOG Organizing Committee Chief Medical Officer, had a staff of 40 people who were responsible for venue staffing, emergency management and programme supervision. For details, please see table 3. In contrast, at the 1st Summer YOG in Singapore (2010), there were 33 athlete medical rooms and 86 athlete medical posts in the field of play in addition to 55 spectator health stations deployed under the supervision of a staff of 36 comprising the Singapore Medical Services Committee (IOC. Unpublished Report. Singapore 2010 YOG: Report on Medical and Healthcare Services).
During the 2nd Summer YOG, the total number of athlete medical encounters recorded by the Nanjing YOG Organizing Committee Medical Team was 1035 (570 male; 465 female) in a population base of 3800 athletes (27.24 encounters per 100 athletes). In comparison, there were 1337 athlete medical encounters for 3600 athletes (37.14 encounters per 100 athletes) at the 1st Summer YOG in Singapore (2010).6 Athlete injuries accounted for 787 of the total encounters. Of these, 83 were transferred to hospital for further assessment, radiological evaluation (15 CT scan and 34 MRI) and/or hospitalisation. The top three injured body areas were a lower limb (n=408), an upper limb (n=229) and the head/face (n=42). In the Youth Olympic Village Medical Clinic, a total of 123 X-rays, 29 soft tissue ultrasounds and 63 physiotherapy encounters occurred. The injury incidence was highest in judo (7.0/100 athletes), basketball (6.8/100 athletes) and cycling (4.3/100 athletes). In the 2008 Olympic Games in Beijing, athletes in football (31.5/100 athletes) were reported to have the highest incidence of injury followed by taekwondo (27.0/100 athletes) and field hockey (20.4/100 athletes).8 A similar injury pattern occurred in the 2012 Olympic Games in London, with the highest injury incidence occurring in taekwondo (39.0/100 athletes) followed by football and cycling (BMX).9 In Nanjing, two injured athletes required hospitalisation, including a tennis player with a non-contact traumatic atlantoaxial (C1-2) subluxation and a trampoline gymnast who suffered acute spinal shock after a fall from the trampoline onto the floor. Although there were 11 athlete fractures during the YOG, none required hospitalisation. Implementation of the IOC injury and illness surveillance programme in future editions of the summer YOG, as in the winter editions, would improve understanding of the incidence and mechanisms of injuries, and the incidence and nature of illness in this unique elite athlete population.10–12
Of the 1035 total athlete medical encounters, 96 were for respiratory illnesses, 30 were for dental treatments, and 28 for gastrointestinal illnesses and dermatological presentations. Of the dental encounters, seven were referred to the hospital for further treatment. This pattern of illness was expected, as experienced in the 1st Summer YOG in Singapore (2010), where there were 93 respiratory encounters followed by 47 encounters for dermatological presentations and 27 for dental issues.7 There were three athlete hospitalisations for illnesses and one for a YOG ‘Young Ambassador’. The diagnoses included a lower GI bleed, appendicitis, malaria and cellulitis requiring surgical debridement.
Non-athlete healthcare delivery
During the YOG, there were more medical encounters for non-athletes than for athletes. The total number of non-athlete medical encounters was 3243 including members of the IOC (n=91), the NOCs (n=376), the International Federations (n=237), local workforce and volunteers (n=1996) and spectators (n=308). There were 9 hospitalisations for non-athletes and 136 transfers to hospital. In contrast, in the 1st Summer YOG in Singapore (2010), athletes comprised the majority (59.1%) of all medical encounters with non-athlete medical encounters totalling 929.7 While the reason for the increase in non-athlete medical encounters in the 2014 YOG from 2010 YOG is unknown, it is postulated that the difference may be explained by variations in access to healthcare of the workforce and spectators between countries. The top three diagnoses for non-athlete medical encounters include respiratory (n=1018), injury (n=979) and gastrointestinal (n=400). The burden of non-athlete medical care requirements at the YOG underscores the importance of adequate preparation of the healthcare delivery programme to include this population.
Review of the model of medical care delivery
The engagement of local community hospitals provided benefit for the Nanjing YOG Organizing Committee by supplying manpower, equipment, financial resources and infrastructure to assist with the delivery of the medical care programme at the YOG. This delivery model proved to be feasible in a multisport setting. Disadvantages encountered were variations in available equipment and personnel experience between the different medical stations. In addition, due to corporate allegiance, hospital transfers to the sponsor hospital occurred in some instances when transfer to the Youth Olympic Village medical clinic would have been more practical and convenient for the athlete and their support staff.
Public Health Program
International sport events, where athletes and support personnel from around the world attend and live in a village-style environment, have inherent public health risks.13 Consultation with public health authorities prior to the event is essential to ensure adequate preparation for potential infectious disease outbreaks to protect the health and safety of the participants. At the 2nd Summer YOG, 116 local public health personnel were deployed to implement the Public Health Program. To ensure security of the food chain for athlete consumption, a traceable food supply system was developed to monitor food quality from the raw source material to the dining hall.
Prior to the YOG, the IOC and the Nanjing YOG Organizing Committee worked with the Chinese Health authorities to develop a public health strategy and policies for the YOG. This was used to counter the threat of EVD. The WHO advised no restriction to travel to and from the affected countries in West Africa. Programmes were implemented at the YOG to educate all participants, to prevent EVD and to treat any patients suspected of having EVD. Leaflets, posters and thermometers were distributed to all teams. There were twice daily temperature and symptom assessments of all team members from affected West African countries. Owing to the on-going concern regarding infectious diseases with high morbidity and mortality rates in general, and more particularly EVD during the 2nd Summer YOG in Nanjing, China, a decision was taken to exclude athletes from affected countries from competition in contact sports (one judo and one boxing competitor), and also one swimmer, despite the fact they were symptom free. Some delegations from West Africa did not arrive in China due to flight cancellation and one delegation departed following the opening ceremony. Nevertheless, athletes from affected countries did compete at the YOG and there were no cases of EVD. Future organisers of international sport events should work with the WHO and the local health authorities to ensure the protection of public health and also to enable all athletes to compete if safe to do so.
Culture and Education Program
The IOC has a responsibility for young athletes that extends beyond organising sports events. The YOG therefore integrated a unique and comprehensive CEP. All athletes at the YOG were able to participate in a number of activities to help them better understand the importance of a healthy lifestyle and injury prevention,14 as well as the dangers of harassment and abuse in sport, doping, illegal betting and environmental protection, among other topics. Through a variety of fun and interactive activities, workshops and team-building exercises, the CEP gave the athletes the opportunity to learn about five main themes: Olympism, Social Responsibility, Skills Development, Expression, and Well-being and Healthy Lifestyles. An integral part of the latter theme, ‘Well-being and Healthy Lifestyles’, was education on the prevention of injuries, and promotion of safe sport free of harassment and abuse. At the YOG, there were two programmes addressing this theme: ‘Get Set’ and ‘SAFE SPORT’.
Injury prevention: ‘Get Set’
The ‘Get Set’ programme is an educational app for handheld devices on injury prevention in sport. This app was created for the 2nd Summer YOG through collaboration between the IOC, the Oslo Sports Trauma Research Center and several International Federations. The main aim of the app was to translate research, which has documented that structured warm-up exercises can reduce the risk of injuries by over 50%,15–17 into an accessible, understandable and user-friendly format.
In the CEP venue, a booth was installed hosting the app as a part of an injury prevention activity. The athletes could learn about the concept of injury prevention in their sport, try out and download the app, as well as practice injury prevention exercises in the booth under the supervision of an expert. In the app, all exercises were presented through videos, supported by short descriptions on how to perform the exercise correctly. Furthermore, exercises were presented with variations and with three levels of difficulty, to keep challenging the athlete as he/she progressed. At the same time, the exercises were designed to be carried out with a minimum of equipment, to make them safe and easy to implement in all environments. The app includes injury prevention exercises for all the 28 summer sports, as well as exercises targeting specific body parts. ‘Get Set’ is available for free on iOS and Android, in several languages (http://www.olympic.org/news/make-sure-your-body-is-ready-for-exercise-with-get-set/235461).
SAFE SPORT: ‘healthy body image’ and ‘sexual harassment and abuse’
The IOC also developed a ‘SAFE SPORT’ booth in the CEP venue to address the issues of healthy body image and sexual harassment and abuse in sport (Relative Energy Deficiency in Sport, RED-S).18 ,19 The sexual harassment and abuse in sport component included a short introduction animation with links to background information on the topic (http://www.olympic.org/sha) and a series of nine video clips of approximately 4 min duration including interactive modules (http://sha.olympic.org). Both components were available in six languages (English, French, Spanish, German, Russian and Mandarin). The aims of these components were (1) to increase knowledge of the athlete's right to safe sport and to develop athlete's and coaches’ capacity to respond to risks; (2) to promote leadership on athlete protection in the Olympic Movement; and (3) to stimulate policy development in International Federations and National Olympic Committees. In total, 1512 visitors to the SAFE SPORT booth completed an online survey evaluating the tools (table 4).
The 2nd Summer YOG in Nanjing, China, 2014, provided an opportunity for the IOC to develop, implement and evaluate two novel models of antidoping and healthcare delivery. Implementation of these models in a large multisport international event proved to be feasible. Utilisation of these models provided financial and logistical advantages for the Nanjing YOG Organizing Committee that can be realised by the organising committees of similar events. These new models upheld the rules of the IOC, maintained the integrity of the programme objectives and respected athlete health and fair play. Improvements to both programmes should be considered, based on the analysis of this experience. Future editions of the YOG and other international multisport events of similar scope and size can implement these new models to benefit from the IOC experience.
What are the new findings?
A single doping control station model of antidoping programme delivery at an international multisport youth event is feasible.
Enhanced educational opportunities and significant cost savings can be realised by this model of antidoping programme delivery.
Community hospital-based venue support at the Youth Olympic Games was a feasible model of healthcare delivery at a sporting event of this scope and size.
Communicable diseases can pose a significant risk to the health of all participants and a detailed, strategic plan for the implementation of prevention measures and a management plan during the Games, developed in cooperation with Public Health Authorities, is therefore required well in advance.
Implementation of athlete health education programmes in international youth sporting events can complement competitive programming.
How might it impact on clinical practice in the near future?
An antidoping programme delivering a single doping control station design can be implemented at future international multisport youth events.
A hospital-based venue support model of medical care delivery may be utilised in future large multisport events to help defray the financial burden of organising committees.
Organisers of sporting events should work with WHO and local Public Health officials to develop a strategic plan in case of an outbreak of serious infectious disease.
Future organisers of large youth sporting events should include athlete health education programmes to improve the athletes’ understanding of the benefits of injury prevention programmes and to promote safe sport free of harassment and abuse.
The authors appreciate the cooperation of all members of the Nanjing Youth Olympic Medical and Antidoping teams for their vital role in the delivery of the healthcare and the antidoping programme during the 2nd Summer Youth Olympic Games.
Contributors MM, RB and SG were involved in the substantial contributions to conception and design, data collection, interpretation of results, drafting and revising the manuscript, and final approval of the version to be published. NA was involved in the substantial contributions to conception and design, data collection, interpretation of results, final approval of the version to be published. GL and JM were involved in the substantial contributions to acquisition of data and final approval of the version of the manuscript to be published. TS was involved in the substantial contributions to conception and design, data collection, interpretation of results, drafting and revising the manuscript and final approval of the version to be published. XH, XY were involved in the substantial contributions to conception and design, data collection, interpretation of results, drafting the manuscript and final approval of the version to be published.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
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