infectious disease - outbreaks in sports · • most commonly reported infectious disease in sports...
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Infectious Disease Outbreaks In Sports Jennie Johnstone, MD, PhD, FRCPC
Public Health Ontario
St. Joseph’s Health Centre, Toronto
Image credit: Microsoft Clip Art
PublicHealthOntario.ca
Disclosure statement
• I have no conflicts of interests.
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Objectives
• To learn about the common infectious disease outbreaks in sports.
• To identify which infections may occur at the Pan Am/Parapan Am Games.
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INFECTIONS SPREAD VIA CONTACT TRANSMISSION
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Herpes gladiatorum
• Most commonly reported infectious disease in sports in the literature.
• Due to HSV-1 transmitted among athletes, typically wrestlers and rugby players.
• Lesions are typically on head, face and neck.
• Estimated 32% risk of transmission to a sparring partner.
• Risk of transmission increases in the setting of open wounds and abrasions.
Turbeville et al. Am J Sports Med 2006; 34: 1860-1865
Goodman et al. JAMA 1994; 271: 862-867
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Prevention
• HSV in sports thought to be primarily spread via direct contact, but likely some indirect contact.
• Screening of athletes for lesions and removing affected athletes from competition.
• Use of antivirals as prophylaxis during the sporting season to reduce the risk of viral shedding.
• Use of non-abrasive shirts.
• Better cleaning of mats. Anderson Current Sports Medicine Reports 2008; 7: 323-327
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Tinea corporis gladiatorum
• Tinea is a skin rash caused by the fungal group dermatophytes.
• Also called ringworm.
• Labelled according to body site infected: • Tinea capitis
• Tinea cruris (jock itch)
• Tinea pedis (athletes foot)
• Tinea corporis
• Tinea corporis most commonly due to the fungus: Trichophyton tonsurans.
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Diagnosis and treatment
• Hallmark is a circular erythematous scaling patch.
• It spreads centrifugally with central clearing and has an advancing border.
• Diagnosed by doing an KOH examination of the scales from the lesion.
• Treat with topical or oral antifungals.
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Turbeville et al. Am J Sports Med 2006; 34: 1860-1865 Goodman et al. JAMA 1994; 271: 862-867
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Prevention
• Transmission primarily through direct contact. • Indirect contact possible (mats,
headgear).
• Avoid sharing of athletic equipment.
• Better cleaning of mats.
• Screen athletes for lesions and remove affected athletes from competition. • Typically return after 10-15
days on therapy.
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Turbeville et al. Am J Sports Med 2006; 34: 1860 Goodman et al. JAMA 1994; 271: 862-867
Image credit: CDC.gov
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Image credit: CDC.ca, CDC/ Bruno Coignard, M.D.; Jeff Hageman, M.H.S.
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Staphylococcus aureus Skin and Soft Tissue Infection
• Outbreaks of S. aureus skin and soft tissue infections have been longstanding and well described in sports: • Football, basketball, rugby, wrestlers, fencing teams among others.
• Skin trauma appears to be a risk factor.
• Mainly spread via direct contact, but indirect contact implicated in some cases: • Soap
• Towels
• Shared equipment
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Turbeville et al. Am J Sports Med 2006; 34: 1860-1865 Goodman et al. JAMA 1994; 271: 862-867
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Image credit: Kazakova et all. NEJM 2005; 352: 468-475
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Prevention
• Hand hygiene.
• Use clean towels.
• Clean equipment/clothes/towels after every use.
• Shower prior to using communal whirlpool.
• Keep open abrasions/wounds covered.
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CDC Website Kazakova et al. NEJM 2005; 352: 468-475
Image credit: CDC.gov
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Norovirus outbreaks
• Norovirus is a highly contagious pathogen and the leading cause of acute gastroenteritis.
• Common source of outbreaks in hospitals/long-term care homes.
• Norovirus outbreak described at a boy’s basketball tournament in Kentucky.
• In total, 242 persons were infected including 154/573 (27%) of the players (36/52 teams had at least one player infected).
• Spread is by direct and indirect contact.
• Prevention can be promoted by disallowing infected players to play, hand hygiene and improved environmental cleaning.
Humbaugh et al MMWR 2012; 61: 471-472
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Enterovirus infections
• Many outbreaks of aseptic meningitis on football teams due to the enteroviruses Echovirus (5, 9, 16, 24) and Coxsackievirus (B1, B2, B4, B5).
• Usually occur in the summer.
• Enteroviruses are spread via the fecal oral route: • Most commonly, contaminated shared water bottles are implicated, or
contaminated ice in a watercooler.
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Turbeville et al. Am J Sports Med 2006; 34: 1860-1865 Goodman et al. JAMA 1994; 271: 862-867
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Mysterious Outbreak
• 80/140 US athletes who participated in an “Eco-challenge” event in Borneo (Malaysia) developed an acute febrile illness upon return.
• The Borneo Eco-challenge was a multi-sport endurance 10-day race requiring teams of athletes to swim in the Segama River, trek through the jungle, spelunk, climb and mountain bike.
• Symptoms included fever, chills, muscle aches, headache, conjunctival injection.
• No-one died and there were no severe manifestations.
• Diagnosis??? Sejvar et al. Emerging Infect Dis 2003; 9: 702-707
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• Leptospirosis is a zoonotic infection due to bacteria (spirochetes).
• Rodents are the most important reservoirs.
• Human infection results from exposure to environmental exposures (water/soil contaminated with urine).
• Present in temperate and tropical regions.
• Several outbreaks Leptospirosis outbreaks described in triathlons.
Morgan et al Clin Infect Dis 2002; 34: 1593 Brockman et al BMC Infect Dis 2010; 10: 91
Sejvar et al. Emerging Infect Dis 2003; 9: 702-707
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Bloodborne pathogens: HBV, HCV, HIV
• Rarely associated with sports outbreaks.
• One outbreak of Hepatitis B virus (HBV) in sumo wrestlers in a high school club.
• Important to be vaccinated against HBV and cover open wounds, but transmission of bloodborne pathogens is unlikely.
Kashiwagi et al. JAMA 1982; 248: 213-214
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DROPLET SPREAD
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Influenza and other Respiratory Viruses
• Respiratory infections are the most common infectious health problem to occur during mass gatherings.
• Numerous examples of influenza-like-illness outbreaks at sporting functions and on sports teams.
• MERS (and other novel respiratory illnesses) should be considered but unlikely.
McCloskey et al. Lancet 2014; 383: 2083-2089 Goodman et al. JAMA 1994; 271: 862-867
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Group A Streptococcus
• No reports of invasive GAS outbreaks.
• Found the following: • GAS pharyngitis outbreak in a judo club.
• GAS skin infection and pharyngitis on a varsity football team.
• GAS pharyngitis outbreak in a high school football team.
• No specific recommendations exist to prevent spread of GAS in sports teams other than education and awareness.
Aoki et al. J Inefect Chemother 2014; 20: 190-193
Glezen et al. Lancet 1972; 300: 301-303 Manning et al. Emerg Infect Dis 2005; 11: 146-149
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Mumps
• Recent mumps outbreak affecting at least 15 NHL players and 2 referees.
• Though to have started with the Anaheim Ducks.
• Spread through droplets.
• Prevented by vaccination.
• Mumps outbreak on a high school football team previously described.
• Increasingly common on college campuses; further varsity sports outbreaks could well occur.
CDC website
Goodman et al. JAMA 1994; 271: 862-867
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Image credit: Youtube.com, Pittsburgh Penguins confirmed the diagnosis Sunday
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AIRBORNE INFECTIONS
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Measles
• One of the most contagious infectious diseases.
• Spread via airborne route.
• Responsible for at least 4 outbreaks after athletic events in domed stadiums.
• A problem during the Vancouver 2010 Olympics: • 3 co-primary cases, exposed individuals in downtown Vancouver.
• Led to 82 cases.
• Best prevention is to be vaccinated.
Turbeville et al. Am J Sports Medicine 2006; 34: 1860-1865 BCCDC Website
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Chickenpox
• Uncommon.
• One report of a university team game postponement due to an outbreak of chickenpox on the team.
• Best prevention is to ensure immunity (prior infection or vaccination).
Goodman et al. JAMA 1994; 271: 862-867
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Tuberculosis
• Uncommon; one report of a TB outbreak in a professional basketball team in Montevideo, Uruguay.
• Involved 6 members of the team (all living in the same basketball clubhouse).
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Coitinho C et al. Eur Respir J 2014; 43: 900-903
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INFECTIOUS DISEASES NOT DIRECTLY LINKED TO SPORTS
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Vector Born Illnesses • Dengue:
• A concern for the 2014 World Cup in Brazil (Olympics too?).
• St. Louis Encephalitis:
• An outbreak caused re-scheduling of all football, wrestling and basketball to daytime.
• Malaria a concern for the 2010 World Cup in South Africa.
• Potential for West Nile Virus at Pan Am/Parapan Am?
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Hay S. Nature 2013; 503: 439 Goodman et al. JAMA 1994; 271: 862
Mantero et al. Euro Surveill 2014; 19: 1
Image credit: "CulexNil". Wikimedia Commons - http://commons.wikimedia.org/wiki/File:CulexNil.jpg#/media/File:CulexNil.jpg
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Other Infections at Mass Gatherings
• Sexually transmitted infections.
• Foodborne illness: • Paradoxically, during Beijing 2008 Olympics, gastrointestinal illness
reduced by 40% compared to previous year.
• Thought to be due to enhancements of food safety and hygiene leading up to the Olympics.
McCloskey et al. Lancet 2014; 383: 2083-2089
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Most Likely?
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Most Likely?*
• Foodborne illness
• Sexually transmitted infections
• Respiratory-viral infections
• Measles?
*My opinion only
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Conclusions
• Sports related outbreaks of infectious diseases are common.
• Infections that spread via contact, droplet and airborne routes have been described.
• Infections commonly associated with mass gatherings should also be considered at the Pan Am/Parapan Am Games in Toronto 2015.
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Questions?
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