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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. PublicHealthOntario.ca 2 1 4/29/2015 Objectives • To learn about the common infectious disease outbreaks in sports. • To identify which infections may occur at the Pan Am/Parapan Am Games. PublicHealthOntario.ca 3 Image credit: Public Health Ontario, 2012 PublicHealthOntario.ca 4 2 4/29/2015 Image credit: Public Health Ontario, 2012 PublicHealthOntario.ca 5 INFECTIONS SPREAD VIA CONTACT TRANSMISSION PublicHealthOntario.ca 6 3 4/29/2015 Image credit: Medscape.com PublicHealthOntario.ca 7 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 PublicHealthOntario.ca 8 4 4/29/2015 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 PublicHealthOntario.ca 9 Image credit: UpToDate.com PublicHealthOntario.ca 10 5 4/29/2015 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. PublicHealthOntario.ca Image credit: UpToDate.com 11 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. PublicHealthOntario.ca Turbeville et al. Am J Sports Med 2006; 34: 1860-1865 Goodman et al. JAMA 1994; 271: 862-867 12 6 4/29/2015 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 PublicHealthOntario.ca 13 Image credit: CDC.ca, CDC/ Bruno Coignard, M.D.; Jeff Hageman, M.H.S. PublicHealthOntario.ca 14 7 4/29/2015 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 PublicHealthOntario.ca 15 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 PublicHealthOntario.ca 16 8 4/29/2015 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 PublicHealthOntario.ca 17 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 PublicHealthOntario.ca 18 9 4/29/2015 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 PublicHealthOntario.ca 19 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 PublicHealthOntario.ca 20 10 4/29/2015 • 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 PublicHealthOntario.ca PublicHealthOntario.ca 21 Image credit: CDC.gov 22 11 4/29/2015 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 PublicHealthOntario.ca 23 DROPLET SPREAD PublicHealthOntario.ca 24 12 4/29/2015 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 PublicHealthOntario.ca 25 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 PublicHealthOntario.ca 26 13 4/29/2015 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 PublicHealthOntario.ca 27 AIRBORNE INFECTIONS PublicHealthOntario.ca 28 14 4/29/2015 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 PublicHealthOntario.ca 29 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 PublicHealthOntario.ca 30 15 4/29/2015 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 PublicHealthOntario.ca 31 INFECTIOUS DISEASES NOT DIRECTLY LINKED TO SPORTS PublicHealthOntario.ca 32 16 4/29/2015 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 PublicHealthOntario.ca 33 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 PublicHealthOntario.ca 34 17 4/29/2015 Most Likely? PublicHealthOntario.ca 35 Most Likely?* • Foodborne illness • Sexually transmitted infections • Respiratory-viral infections • Measles? *My opinion only PublicHealthOntario.ca 36 18 4/29/2015 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. PublicHealthOntario.ca 37 Questions? PublicHealthOntario.ca 38 19