Download Infectious Disease - Outbreaks In Sports

4/29/2015
Infectious Disease
Outbreaks In Sports
Jennie Johnstone, MD, PhD, FRCPC
Public Health Ontario
St. Joseph’s Health Centre, Toronto
Image credit: Microsoft Clip Art
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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Image credit: Public Health Ontario, 2012
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INFECTIONS SPREAD VIA CONTACT
TRANSMISSION
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Image credit: Medscape.com
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Herpes gladiatorum
Image credit: Wikimedia Commons - http://commons.wikimedia.org/wiki/File:USMC10881.jpg#/media/File:USMC-10881.jpg
• 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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Image credit: UpToDate.com
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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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Image credit: UpToDate.com
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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.
Image credit: UpToDate.com
• 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.
Image credit: CDC.gov
Turbeville et al. Am J Sports Med 2006; 34: 1860
Goodman et al. JAMA 1994; 271: 862-867
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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
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
Image credit: Wikimedia Commons - http://commons.wikimedia.org/wiki/File:St.louis_rams_textlogo.png#/media/File:St.louis_rams_textlogo.png
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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.
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.
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.
Image credit: disha1056.com
• 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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Image credit: CDC.gov
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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.
Image credit: ©iStockphoto.com/Yuri Arcurs
• 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.
Image credit: Youtube.com, Pittsburgh
Penguins confirmed the diagnosis Sunday
CDC website
Goodman et al. JAMA 1994; 271: 862-867
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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).
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 rescheduling 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?
Image credit: "CulexNil". Wikimedia Commons http://commons.wikimedia.org/wiki/File:CulexNil.jpg#/media/File:CulexNil.jpg
Hay S. Nature 2013; 503: 439
Goodman et al. JAMA 1994; 271: 862
Mantero et al. Euro Surveill 2014; 19: 1
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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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