When Athletes Share Infections

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The Checkup

When parents of young athletes reel off their kids’ sports-related health issues, they usually think of sprains, broken bones and concussions. Infectious diseases may not even make the list.

But to pediatricians, the close contact and casual equipment give and take that are often components of team bonding can also be a breeding ground for infection. A new clinical report released Monday by the American Academy of Pediatrics focuses on how to prevent and control outbreaks of infectious diseases in organized sports.

“All kinds of things travel through the teams,” said Dr. Stephen G. Rice, who is starting his 43rd season as a high school team doctor. Adolescents can often be “sort of sloppy about sharing water bottles, equipment, sometimes even helmets,” said Dr. Rice, the director of sports medicine at Jersey Shore University Medical Center and one of the authors of the report.

Dr. H. Dele Davies, professor of pediatric infectious diseases and public health at the University of Nebraska Medical Center, and the lead author on the clinical report, said that he wants to emphasize to parents that “participation in sports is a good thing, we want their children to participate, we just want to keep them safe.”

An important role for the medical practitioner, Dr. Rice said, is talking to the athletes about hygiene and cleanliness. It’s important at the sports physical, as well as for the team doctor, the coach and the school.

Dr. Mary Anne Jackson, the director of infectious disease and professor of pediatrics at Children’s Mercy Hospital in Kansas City, and an author of the report, said that those sports physicals need to be done well, and done by the adolescent’s regular doctor. The visit should be an opportunity to discuss the importance of good personal hygiene, including reminders about not sharing water bottles or sports equipment, about cleaning your footwear and changing your socks, and making sure your feet are clean and dry before you put on those socks.

For the patient and family, Dr. Davies said, the sports physical is “a great opportunity to ask, what are some infectious risks and what can I do to manage that.” And for the practitioner, it’s an opportunity to do some anticipatory guidance, he said, telling the athlete, for example, “if you see any lesion on your skin, notify your trainer.”

On sports teams, infections can be transmitted in several ways. “The most common involve close contact,” Dr. Davies said. Skin infections can be transmitted directly, especially in wrestling, rugby and football. They can also be transmitted via mats or floors, shared towels, or communal use of such equipment as callus cutters or soccer shin guards.

So it’s important to follow infection control practices. That includes thorough hand-washing, that basic building block of hospital infection control, not sharing water bottles or equipment or towels, and properly and regularly cleaning mats and floors and surfaces.

Any team sport can bring kids into close enough contact for the spread of infectious diseases that travel by respiratory and airborne routes, so athletes must be up-to-date on all the recommended immunizations. Athletes who travel may have contact with other athletes from other areas, and “increasingly across the country, we know there are underimmunized pockets where you may more readily have transmission of highly infectious agents like measles,” Dr. Jackson said. Some kids will play against athletes from other countries, who may not all be immunized to the same standards recommended here.

The most infectious of these vaccine-preventable diseases include the ones that children should all be immunized against from early childhood, such as measles, chickenpox and whooping cough. Everyone should also get the annual flu shot and the meningitis vaccine, which is recommended at 11 to 12 years of age, with a booster at 16. All of these diseases can spread rapidly in a close team environment.

And then there are the sports that bring athletes into closer physical contact with one another, especially wrestling and rugby, but also football, basketball and others. Wrestling and rugby are sufficiently well-known for skin-to-skin transfer that there are herpes virus skin infections actually named for them, Herpes gladiatorum, and Herpes rugbiorum (also known as “scrum pox”). “Herpes can shut down a whole team,” Dr. Rice said; wrestlers need “regular skin checks before tournaments,” looking for herpes, impetigo and ringworm, and treating problems so the athletes can compete. Prophylactic medications can help prevent herpes recurrences.

Among bacterial skin infections, community-acquired methicillin-resistant Staphylococcus aureus, or MRSA, has caused many infections among high school and college athletes. MRSA has been a major issue in professional sports as well, particularly football, with several N.F.L. teams having had to deal with outbreaks. These skin infections can be extremely serious, as can streptococcal skin infections, so identifying and treating the lesions is really important for the individual athlete’s health, as well as for containing possible spread.

Athletes are also vulnerable to fungal skin infections, like Tinea corporis, or ringworm, not to mention athlete’s foot (Tinea pedis) and jock itch (Tinea cruris), two fungal infections whose popular names also reflect their tendency to hang around locker rooms. The fungal pathogens can be transmitted directly, skin to skin, but also by towels and contaminated surfaces.

Infection control for athletes goes beyond attention to personal hygiene; the school and the athletic staff have to be scrupulous about cleaning equipment and the locker room and the weight room. In wrestling and gymnastics, it’s about cleaning the mats; in football, about the tackling dummies; and in every sport, it’s about clean surfaces in the locker room, from floors to showers.

When outbreaks do occur, the close contact of team members means that they have to be addressed as quickly as possible. Dr. Rice recalled an outbreak of scabies on a high school wrestling team. A parent meeting was called immediately, he said, for that very evening, and “we called all the pharmacies and made sure they had adequate medication on hand.” They didn’t want any delay while each child saw his own doctor, he said, so “I actually wrote prescriptions, I didn’t want them to have to wait.”

Finally, every team and every venue needs to understand universal precautions, that is, that blood and body fluids need to be treated as potentially infectious. “We start teaching from kindergarten, if it’s wet and not yours, don’t touch it,” Dr. Jackson said.

“There are a lot of great, great things about athletic participation,” Dr. Rice said, like exercise, socialization, teamwork and the challenges of competition. Infection control is meant to keep athletes safe so they can enjoy these benefits.