582 SA MEDICAL JOURNAL VOLUME 64 1 OCTOBER 1983

Ultramarathon running and upper

respiratory tract infections
An epidemiological survey

EDITH M. PETERS, E. D. BATEMAN

were more prevalent in the more highly trained athletes who ran
the faster times.
'Summary
Opinions differ as to .whether marathon runners
have an increased susceptibility to upper respiratory Subjects and methods
tract (URT) infections after a race. In an attempt to A randomly selected sample of 170 athletes entered for the 1982
answer this question, we carried out a prospective Two Oceans Marathon (56 km) were asked to complete a
study ofthe incidence of symptoms of URT infections
questionnaire on the day before the race.
in 150 randomly selected runners who took part in
Information requested included training background, running
the 1982 Two Oceans Marathon in Cape Town, and
experience and state of health during the 2 weeks before the race.
compared this with the incidence in individually Each runner was asked to nominate a control subject (of either
matched controls who did not run. Runners were
sex but of similar age) who resided with him/her on a form.
qu'estioned on the day before and 2 weeks after the
Twenty-six subjects failed to do so. Two weeks after completion
race. of the race, 150 of the original 170 subjects were questioned
Symptoms of URT infection occurred in 33,3% of
regarding URT symptoms during the 14-day post-race period,
runners compared with 15,3% of controls, and were
injuries resulting from participation in the race, and the duration
most common in those who achieved the faster race
of muscle stiffness. Twenty runners could not be contacted for
times. The incidence in slow runners was no greater
requestioning. Nine of those questioned who failed to complete
than that in controls. Faster runners also experienced
the race were excluded. The incidence of URT symptoms in the
more musculoskeletal pain during ~md after the
control group during this period was also recorded.
race. These results suggest a relationship between
Those questioned included 145 men and 5 women, ranging in
acute stress and susceptibility to URT infections.
age from 18 to 65 years (98 (65,3%) were aged between 20 and 34
Impairment of one or more local mucosal or general
years, 49 (32,7%) between 35 and 50, 2 under the age of 20 and I
host defences may accountfor this effect
over the age of 55). Of the 124 subjects nominated as controls, 85
were husbands or wives of the runners, 11 were sibs and 28 were
S Air Med J 1983: 64: 582-564.
friends with whom the runners were in frequent contact.
Where relevant, results were analysed in fourfold tables or by
determination of the coefficient of correlation.

In recent years several reports have focused on the effects of

marathon running on health. 1- 6 Most have centred on musculo- Results
skeletal disorders, metabolic changes3 •4 and organ dysfunction,7
but little research has been published on the effect of prolonged Forty-seven (33,3%) of the 141 runners questioned who com-
exercise on host resistance to infection. The suggestion that pleted the race reported URT symptoms during ·the 2-week
'Uberrrainierung' might render athletes more susceptible to post-race period (group I). The rest (group 11) remained
upper respiratory tract (URT) infections was made by Heiss in symptom-free or had no change in symptoms noted before the
1928,8 following an investigation undertaken at the St Moritz race. In contrast, significantly fewer subjects in the control
Winter Olympics. Others have observed that a large proportion groups had URT symptoms (15,3% - x2 = 10,50, P< 0,005).
of runners claim to have had fewer respiratory infections since However, the percentage ofgroup I controls with symptoms was
they started running. 6 In view of this debate we undertook to four times that of the group 11 controls (29,5% v. 7,5%) (Table I).
study the incidence of symptoms of URT infection in a random The frequency ofURT symptoms was inversely related to the
sample ofcompetitors who completed an ultradistance marathon time taken to complete the race (Fig. I), and almost half of the
and in an age-matched control group. The association between faster runners experienced symptoms. Judging from distances
these symptoms and the race performance, training schedule and run in training, it appears that they tended to have trained harder
running experience of each runner was determined. Significantly
more runners than controls experienced symptoms of URT
infections within 2 weeks of completing the race, and symptoms
TABLE I. URT SYMPTOMS IN 124 MATCHED CONTROLS
URT symptoms No symptoms Total
Group I (matched
Department of Medicine and Metropolitan Sport Science with symptomatic
Centre, Department ofPhysiology, University ofCape Town runners) 13 (29,5%) 31 44
EDITH M. PETERS, BA, B. PHYS. ED. HONS, B.SC. (MED.) HONS, S.T.D. 6 (7,5%) 74 80
Group 11
E. D. BATEMAN, M.B. CH.B., D.CH., M.R.C.P.
Total 19 (15,3%) 105 124
Dare received: 30 November )982.
 SA MEDIESE TYDSKRIF DEEL 64 1 OKTOBER 1983 583

The average distance covered in training in preparation for the

race was 1062,7 km, the average number of weeks spent in
_ Symptomatic training was 12,87 and the average run per week was 75,9 km.
40 . r=0,995 D Asymptomatic The most prevalent symptom after the race was a sore throat,
followed by nasal symptoms, including a running nose and/or
p<O,Ol
(f) 35 excessive sneezing (Table Ill). A cough was less common and
.... only 3 subjects developed fever in conjunction with one or more
~ 30 of the URT symptoms. Of the total number of symptoms
c reported by 47 runners (78), 37 (47%) lasted for longer than 7
::J

-....
.... 25

o 20
days, 26 (33%) lasted between 4 and 7 days, 7 (9%) lasted between
1 and 3 days, and only 8 (10%) were trivial, lasting less than 1 day.
In an attempt to include only patients with infective coryza, nasal
<ll symptoms in persons with a recent history of allergic rhinitis
.0 15
E
::J
42% were excluded. Subjects reporting fever without accompanying
URT symptoms were also excluded. Cold cures and antipyretics
Z 10
were taken by 13 patients (28%) and antibiotic treatment was
5 administered to 1.
19%
o
<4h 4h-4h30 4h30-5h 5h-5h30 5h30-6h
TABLE Ill. NATURE AND DURATION OF URT SYMPTOMS
Race time (hours) Duration of symptoms
Fig. 1. Distribution of symptomatic and asymptomatic runners
Symptoms < 1 day 1-3 d 4-7 d >7d Total
according to time taken to complete the race (N = 141). Sore throat 6 2 12 12 32
Nasal symptoms 1 5 8 14 28
Cough 1 5 9 15
(Fig. 2). There was no difference between runners in groups I Fever plus URT
and II with respect to age, previous running experience (gauged symptoms 1 2 3
from the number of years each runner had been running), the
Total 8 7 26 37 78
number of weeks spent in training for the race, or personal
satisfaction with the race time achieved. A significant but weaker
association was also found between symptoms and high training
distance per week (Table ll). All runners experienced stiffness after the race. In 31% it
lasted only 1 day, in 52% between 2 and 3 days and in 17% for
more than 3 days.
6
• • • Unusually severe musculoskeletal pain experienced during or
after the race was reported by 48 subjects (32%) (Table IV), and
those who subsequently developed URT symptoms reported a
....
(f)
significantly higher percentage of injuries (P < 0,01). The most
::J common site of pain was the knee (18%), and in 4 subjects this

-2 <ll
5 prevented completion of the race. Since most of the injuries were
self-diagnosed, their specific nature was not established.
E
<ll
<.)
eu 4- Discussion
a::
Several factors might account for the significantly higher
r=0,4705 • • incidence of symptoms of URT infection in runners in the
p < 0,01 • immediate post-race period.
3 Symptoms might be nonspecific or functional and not represent
viral or bacterial infection but merely reflect the athlete's
0 40 80 120 160 preoccupation with health. Several aspects of this study make
these explanations unlikely. Athletes are usually concerned
Training distance (km! week)
about minor symptoms before and not after races, and only those
whose symptoms occurred or worsened after the race were
Fig. 2. Relationship between distance run in training and time included. In 80% of affected runners the symptoms lasted for
taken to complete the race for total sample (N = 141).
more than 3 days, suggesting an infective origin. Attempts were
made to exclude runners with previously known allergic symp-
toms. Nevertheless, a study including virological and bacterio-
TABLE 11. URT SYMPTOMS IN RELATION TO TRAINING
logical investigation is necessary to determine the true incidence
DISTANCE PER WEEK BEFORE RACE' of infection. The fact that symptoms were four times more frequent
in the controls of the infected group than in the controls of the
Symptomatic Asymptomatic
asymptomatic runners provides further evidence of true infec-
<65 km/wk 9 36 l P < 0,01
tion. It is possible that in some cases the control subjects
were the source of infection, but the order in which subject and
>65 km/wk 38 56 ~ control developed symptoms was not recorded. In any event, it is
·N = 139 (2 subjects tailed to provide details). clear that symptoms occurred three times more commonly in
runners than in their matched controls.
584 SA MEDICAL JOURNAL VOLUME 64 1 OCTOBER 1983

TABLE IV. ANALYSS OF SITES OF PAIN DURING OR AFTER A 56 km RACE

Total
Symptomatic (URT) Asymptomatic group Failed to complete (150
group (47 subjects) (94 subjects) race (9 subjects) subjects)
Knee 11 12 4 27
Ankle 3 3
Hip 2 1 3
Foot 1 1
Achilles tendon 2 2
'Shin splints' 1 2 3
Strained or 'pulled' leg
muscles 5 3 8
Tendonitis in other sites 1 1
Total No. of injuries 22 (47%) 22 (23%) 4 (44%) 48 (32%)

The higher incidence of symptoms is probably more correctly
attributable to one or both of the following factors: (i) the
impairment ofgeneral host resistance to infection resulting from
the extreme stress and fatigue of running an ultramarathon; or
(ii) the physical effects of cold and dry air on local mucosal
defences.
Acute stress is recognized as a cause of increased susceptibility
to oropharyngeal infection. Normal oral flora may become
invasive and herpes simplex virus may be reactivated during
stress. 9 The observed immunological effects of stress in man
include a decreased T -cell response to mitogens, impaired
lymphocyte cytotoxicity and impairment of function of neutro-
phils and cells of the macrophage-phagocytic series. Some of
these changes may be mediated by the alterations in adrenal or
pituitary hormone levels which are known to occur. 9
To date no consistent immunological abnormality has been
observed in marathon runners. Green el al. 6 in a study of trained
marathon runners found normal leucocyte phagocytosis and
killing, normal levels of serum immunoglobins, and no changes
in C3, C4, properdin factor B, ratio of T and B lymphocytes in
peripheral blood, or lymphocyte responses to mitogens. These
functions were, however, not studied immediately after a mara-
thon race. Nordic skiers tested before and after completion of a
50 km race had low levels of salivary IgA, which fell further after
the race. An increase in the percentage of B lymphocytes and a
decrease in proportions of null (non-T, non-B) lymphocytes
were noted in these subjects. lo
In our study the role of stress is supported by the finding that
the faster runners experienced more symptoms. These runners
are subjected to greater stress arising from their own competi-
tiveness and because running at a faster pace demands a higher
oxygen consumption per minute. Their subjection to greater
physical stress is further reflected in the higher incidence of
musculoskeletal pain and injury in this group. It is of interest
that the shorter duration of the race did not compensate for these
effects. In contrast, the incidence of infective symptoms in the
slower runner was no greater than that in the controls. It is also
apparent that susceptibility to infection increased although the
faster runners were better prepared for the race. It is even
possible that overtraining affected some runners.
Local damage to URT mucous membranes may result from
their drying and cooling during mouth breathing. Mouth
breathing is demanded by the increased minute ventilation
during submaximal exercise, and as this occurs continuously for
4-5 hours during an ultramarathon, marathon running may
result in greater damage to mucous membranes than other
sporting activities. Besides the fall in IgA already mentioned,
mucosal effects might include changes in the physical properties
of the protective mucous layer, impaired mucociliary clearance
and macrophage function, and changes in the amount or
function of other substances protecting the mucosal surfaces,
e.g. lysozyme and interferon. I I The question whether the general
or local impairment of defences accounts for the apparent
increase in URT infections remains a topic for future research. It
is evident, however, that competitive ultramarathon running, in
common with other challenging human endeavours, is associated
with a degree of stress that leads to physical disorders in a
significant proportion of participants. The long-term significance
of these negative effects is not known, but judging by the
increasing popularity of marathon running it appears that they
do not appear to lessen the satisfaction provided by these events.
REFERENCES
I. Bunch TW. Blood test abnormalities in runners. Mayo Clin Proe 1980; 55:
Il3-Il7.
2. Kaufman DA, Swenson EW, FenceI J, Lucas A. Pulmonary function in
marathon runners. Med Sci Sports Exere 1978; 6: 114-117.
3. Adner MM, Castelli WP. Elevated high-density lipoprotein levels in marathon
runners. ]AMA 1980; 243: 534-536.
4. Riley WJ, Pyke FS, Robem AD, England JF. The effect of long-distance
running on some biochemical variables. Clin Chim Aaa 1975; 65: 83-89.
5. Mandalaki T, Dessypris A, Lonizou C, Bossinakou I, PanayolOpoulou C,
Antonopoulou A. Marathon run: l. Effects on blood coagulation and fibrino-
Ivsis. Thromb Haemost 1977; 37: 444-450.
6. Green RL, Kaplan SS, Rabin BS, Stanitski CL, Zdziarski U. Immune
function in marathon runners. Ann Allergy 1981; 47: 73-75.
7. Dancaster CP, Whereat SJ. Renal function in marathon runners. S Afr Med]
1971; 45: 547-551.
8. Heiss F. Unfalft'erhiilUng beim Sport. Schomdorf: K. Hoffman, 1971: 17-19.
9. Solomon GF, Armkraut AA. P ycboneuroendocrinological effects in immune
response. Annu Rev MierobiolI981; 35: 155-184.
10. Legwold G. Cross country ~kiers may be susceptible to RTs. Physician Sports
Med 1982; 10: 42.
11. McNab PC, Tomasi TB. Host defence mechanisms at mucosal surfaces. Annll
Rn· MicrobiolI98I; 35: 477-496.