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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http://www.publichealthontario.ca/

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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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PublicHealthOntario.ca 4

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Image credit: Public Health Ontario, 2012


INFECTIONS SPREAD VIA CONTACT TRANSMISSION

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PublicHealthOntario.ca 7 Image credit: Medscape.com


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


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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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


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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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


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Image credit: Youtube.com, Pittsburgh Penguins confirmed the diagnosis Sunday


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).


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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


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


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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Infectious Disease - Outbreaks In Sports · • Most commonly reported infectious disease in sports...

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