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Dr. Flynn: Thoughts on a possible return of the NFL in the age of SARS-CoV-2

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Glossary

Coronavirus - a large family of viruses causing mild to severe upper respiratory symptoms.

SARS-CoV-2 (Sars-coh-vee-too) — a beta-coronavirus, responsible for the 2020 pandemic.

COVID-19 - illness caused by SARS-CoV-2.

COVID-19 test” - an RT-PCR test done on a nasopharyngeal swab to detect viral fragments.

Antigen test - a rapid test done on a nasopharyngeal swab to detect viral surface proteins.

Antibody test -  a blood test to detect antibodies made by the body to combat the virus.

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When the NFL revealed its schedule for the 2020 season with great fanfare on Thursday night, it gave many of us hope for some sense of normalcy in the months to come. We may not know if our summer vacations will happen or if our kids will physically attend school in the Fall, but gosh it was comforting to think that, come hell or high water, the Chiefs are playing the Ravens on Monday Night Football, September 28, 2020.

Unfortunately, nobody knows quite how high the waters may rise by Week 4 of the NFL season. The epidemiologists have used the data and their expert knowledge of pandemics to plot possible courses, but nobody can tell us what the next six to twelve months might hold. Some models predict multiple smaller peaks of infection while others suggest an even larger second wave colliding with an influenza peak and causing devastating further loss of life. Ultimately, these models are only educated guesses - the virus is in charge of the real timeline.

Bedard: When it comes to re-starting sports, get ready for the backlash against the safety-conscious players

I can’t tell you when, or even if, the NFL season will start. There are so many possible scenarios of attempted starts, pauses, or abrupt cancellations. Instead of playing a guessing game, I hope to instead offer you some insight into the unique challenges that professional sports leagues face in returning to business. Before I address the issues, however, I want to make something as clear as the path retired FB James Develin cleared for Patriots running backs — I am NOT rooting against a 2020-2021 NFL season. Believe me, I want football back even more than Tom Brady wants to complete another touchdown pass to Antonio Brown.

Industries across America are trying to figure out how and when to return their employees to the workplace safely.  The major issue the NFL faces is that a football locker room is a particularly high-risk environment for the spread of viruses. Inside a team facility, athletes train together in the weight room and on the field, quarterbacks take snaps from the hands of their centers and linemen grunt as they grapple face-to-face. After their workouts, players head to communal showers and change at side-by-side lockers. When they are not training, NFL athletes are grouped by position in small meeting rooms and eat together in the cafeteria. There’s no social distancing in football.

Even with the most earnest disinfecting techniques, anyone who has been in an NFL locker room has seen viruses spread rapidly through position groups to the team at large. This is most common during the most high-stakes portion of the season from late November until the Super Bowl. Last season, an illness tore through the Patriots locker room Thanksgiving week, prompting veteran safety Devin McCourty to tell reporters “in my 10 years here, this is probably the most guys I've seen be gone with just being sick.” The Packers dealt with an illness during the playoffs and the Chiefs' locker room was also hit with an illness heading into Super Bowl week. These infections were likely common cold viruses that many of those guys had been previously exposed to and yet, still, guys went down left and right. Imagine what would happen with a virus that most of the athletes have never seen before. If the Patriots, Packers and Chiefs were hit by a wave of infection, SARS-CoV-2 would strike more like a tsunami.

The only way for the NFL to safely play a full season is to keep SARS-CoV-2 from infecting anyone in their facilities, and, if there is a breach, to mitigate spread to only within the team involved. In order to keep the virus out, the NFL needs to be able to identify its own cases as rapidly as possible with regular testing of its employees. Testing is also needed outside of NFL walls to understand the level of infection in the general population and, therefore, gauge the risk of players contracting the virus outside of work.

Up until this point, the NFL has adopted a responsible position on testing. NFL lead counsel Jeff Pash told the Associated Press on May 1st, “We don’t want to use a disproportionate number of testing resources if it’s limited. We want to make sure that we’re testing people in an appropriate way if we do it and clear and consistent standards. I think that we very much would take our guidance on that from the medical and public health experts.” Until the US ramps up testing capability for the entire country, the NFL says that they will not use disproportionate resources. If the season was starting today, this would be a no-go. There simply is not enough testing for the NFL or any other league to safely open up next week. Hopefully this is something that they continue to stand by as the season nears.

A note on testing

To diagnose SARS-CoV-2 infection, doctors are currently running “COVID 19 tests” on mucous samples from the nasopharynx (obtained through the nose) of patients for fragments of genetic material found inside the virus. There are many brands with varying ability to accurately diagnose COVID-19.

Some tests have a startling number of negative results in patients who actually are infected. Most tests take at least a day for results. Newer antigen tests that detect proteins on the surface of the virus are in development, in fact one test was recently approved by the FDA for emergency use. Benefits of antigen tests are that production can be ramped up very quickly, tests are easily done at the bedside, test kits are inexpensive, and results are available immediately.

The rapid strep test that you get at the doctor’s office is an example of an antigen test. A reliable antigen test would be a great screening tool to use in a place like a locker-room. One final type of test that is currently being studied in MLB is the antibody test, which evaluates a blood sample for immunoglobulin made by the body to combat the virus. As of today, there is unfortunately so much variability in the quality of available antibody tests that they are not accurate enough to confirm prior infection with, recovery from, or immunity to COVID-19. Antibody tests are, however, thought to be accurate enough to evaluate large populations for degree of exposure to the virus. Early results from the MLB study indicate that less than 1% of employees tested have been exposed to SARS-CoV-2, a number much lower than previous population antibody studies.

In mid-April, SnapChat hosted an interview with Dr. Anthony Fauci, Director of the National Institute of Allergy and Infectious Disease at the NIH. Fauci was asked if professional sports seasons were in jeopardy. Fauci, a self-described baseball fan, replied “There’s a way of doing that. Nobody comes to the stadium. Put them in big hotels you know wherever you want to play. Keep the very well surveilled … but have them tested like every week and make sure they don’t wind up infecting each other or their family and let them just play the season out.”

The idea of isolating entire teams and their staffs in a hotel for a five- to seven- month season seems a bit implausible. Even if the NFL could get players to agree to these strict measures, the league would also have to consider isolating all hotel staff and anyone who interacted directly with the team to make the quarantine effective.

MLB All-Star Mike Trout told NBC Sports Network, “I obviously want to play as fast as we can but [being isolated from our families] would be difficult for some guys. What are you going to do with family members? My wife is pregnant. What am I going to do if she goes into labor? Am I going to have to go into quarantine for two weeks after I come back?….Obviously it’s got to be realistic. We can’t just be sitting in a hotel room, just going from the field to the hotel room and not being able to do anything. I think that’s pretty crazy.”

If players are not completely isolated, they should be smart about limiting their contacts outside of work. When Broncos star OLB Von Miller tested positive for SARS-CoV-2 in mid-April, he was shocked. He told reporters, “I’ve been here in Denver for about four weeks now and within those four weeks I probably left the house four times. With all of those four times, I never got out of the car. … So I really just have been taking it seriously, staying at home. Of course, I have had people come in and out like workers, maids, and people who come in and do the plumbing - just everyday stuff, but it was really nothing crazy. I had a cough and here we are.”

Thankfully, Miller has made a full recovery from COVID-19, but going forward, players need to understand that having even a small staff of personal assistants, maids, cooks, and barbers coming in and out of their houses is not isolating. Because we think that patients are most contagious in the days before they are symptomatic, any one of those service providers can innocently and unknowingly bring the risk of infection into their homes. This is probably a good time for guys to start cleaning their own toilets.

Unless you isolate every person who directly interacts with any NFL team and prevent the flow of virus in or out of facilities, there will always be a risk of SARS-CoV-2 infecting someone on the team. Risk is something that NFL athletes and teams are used to dealing with. Players risk injury every time they step on the field. The NFL, however, is not accustomed to the type of risk that a pandemic brings. Here’s an example.

In Week 7 of the 2019 season, Chiefs quarterback Patrick Mahomes lunged forward for a 4th-and-1 quarterback sneak. He got the yard, but under a pile of very large lineman bodies, his patella dislocated. First-time patellar dislocations often require surgery and typically involve over a month of rehabilitation. Mahomes, however, returned to practice one week after his injury and started against the Titans two weeks after that.

Mahomes took a risk. By returning to the practice field only one week after his injury, the young quarterback risked a second, potentially more serious dislocation. The Chiefs took a smaller risk.  By allowing him to return so quickly, they risked losing their franchise player to a potentially season-ending injury should the patella re-dislocate.

The NFL and its teams are used to dealing with individual player risk, mostly as it applies to the future career of that individual player. Mahomes’ patellar dislocation wasn’t going to threaten the knees of any of his teammates or opponents and it certainly wasn’t going to end the NFL season.

Peter King interviewed Dr. Fauci over the weekend and during the course of their discussion, King posed a theoretical situation for the upcoming season involving Mahomes. “I take it that teams have to be willing to say, If Patrick Mahomes tests positive on a Saturday night, he’s got to disappear for two weeks.”

“Absolutely, absolutely,” Fauci responded. “It would be malpractice in medicine to put him on the field. Absolutely.”

In this fictitious scenario, if Mahomes is symptom-free and wants to play, there is probably very little risk to his personal health. But the risk to the team and, by extrapolation, the NFL’s season, is enormous. To put Mahomes on the field during the time that he is likely infectious would risk spread to his own teammates and any of their opponents.

During a pandemic, individual player health is directly tied to league health.

So, where does the NFL go from here? The league appears to be planning for the show to go on while incorporating contingencies for every possible path the virus might take. The first task is planning for team facilities to open. So far, the NFL has repeatedly expressed a commitment to fairness in the way that it opens team facilities. NFL lead counsel Jeff Pash told reporters: “We’re going to treat all 32 teams the same way. We’ll do it in a way that does preserve competitive equity.” As training camp nears, the league may find it challenging to maintain their commitment.

In his MMQB column this week, Albert Breer hinted that cracks may already be forming in the NFL’s competitive equity pledge. “In a memo to teams last week, the league laid out a plan to start reopening facilities, with a desire to start Phase I of the plan on May 15 (which would allow no more than 50% of team employees, up to a total of 75, to return to work, and no players outside of those rehabbing).” With multiple states still under stay-at-home orders, a May 15th opening date would leave some teams unable to return to their facilities.

Breer went on to share a discussion that he had with basketball insider, Chris Mannix about the NBA’s decision to open training facilities where stay-at-home orders had been relaxed." Mannix said that basketball teams talked big about keeping things even, from team to team, weeks ago. And when push came to shove over the last couple of weeks, the NBA decided going forward with it as states started to reopen wasn’t logical.” I guess we’ll see what happens if push comes to shove for the NFL this week.

The good news for the NFL is that they have the luxury of some time to observe and prepare. The NBA is already opening some facilities and MLB owners are reportedly set to bring a proposal to their players’ association targeting a return near July 4th. The NFL can wait and see how other professional sports leagues navigate these uncharted waters. Two and a half months from now, when the NFL hopes to open training camps, the world could look very different.

While no experts know which course the virus will take, other viruses in the same betacoronavirus family typically see a drop in transmissibility in the summer months with a steady increase in the Fall, peaking from December through February. SARS-CoV-2, however, may not naturally follow that pattern of a Summer hiatus because most of our immune systems have never seen it before. If the number of infections in the general population does drop significantly in the next couple of months, NFL athletes and employees will have a lower risk of becoming infected. In fact, if the number of cases drops low enough, stadiums may even be able to host small numbers of socially-distanced fans for games. Of course, if the virus surges instead of receding, the risk will be significantly higher.

By mid-July, there is good reason to hope that we will be much better equipped to monitor our population for infections, trace contacts, and manage small outbreaks. An increase in testing capacity would also free up tests to screen NFL athletes and staff regularly. How regularly? Since everyone tests negative the day before they test positive, it would be great to have daily testing but highly impractical. Testing two or three times per week may be a reasonable compromise, but I would yield to the public health experts on that. As we improve our ability to test for SARS-CoV-2, doctors are also getting better at treating patients. New treatments and possibly even prophylactic medications to prevent infection in exposed patients could really change our management. When a vaccine becomes available, that will, of course, be the ultimate game-changer.

At the end of the day, athletes have to feel safe taking the field. I see the irony there - what NFL athlete is ever truly safe when they step on the turf? The difference here is obviously that infection with a deadly virus isn’t on the list of expected risks that athletes consider when they sign up to play. Every player will approach the risk differently. Some players are already training in groups despite social distancing orders. Others are sheltering at home with their families and training on equipment ranging anywhere from a set of dumbbells to a lined field in the backyard. These athletes all face the very real threat that returning to football will risk their own health as well as the health of their families. When the time comes, the stadiums are lit, and all possible safety measures are in place, athletes will have to decide — is it worth it?

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Dr. Jessica Flynn is a sports medicine physician at Lahey Hospital and Medical Center in Burlington, MA. She writes about injuries in professional sports on her blog, DocFlynn.com. You can follow her on Twitter @jessdeede.

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