Listed As Probable

Batman needs rabies vaccination

San Antonio Spur Manu Ginobli caused quite a stir recently when he swatted a bat out of mid-air during a recent game - on Halloween no less: 

I love how the athletic trainer is on the spot with some hand-sanitizer at the end of the clip. That move looks even better now that Ginobli has announced that he had to be vaccinated for rabies.

My initial thought was that the shots seemed like a bit of typical professional sports medical overkill until I read the CDC's page on bats and rabies. The rabies virus is transmitted from infected animals to humans either by bite or more rarely if infected material such as saliva gets into your eyes, nose, mouth, or an open wound. Surely Ginobli would have known whether or not the bat bit him wouldn't he? Not necessarily as apparently bat teeth are so tiny that a bite victim may not even know that his or her skin has been punctured.

Consider this chilling case report:

In February 1995, the aunt of a 4-year-old girl was awakened by the sounds of a bat in the room where the child was sleeping. The child did not wake up until the bat was captured, killed, and discarded. The girl reported no bite, and no evidence of a bite wound was found when she was examined. One month later the child became sick and died of rabies. The dead bat was recovered from the yard and tested--it had rabies.

As the stunned and captured bat was released outside of the arena - which still didn't keep the PETA folks off of Ginobli's back - the bat in question could not be tested, so he prudently opted to get vaccinated. 

Gators "go to extremes" to battle H1N1

Two quotes from this story about H1N1 hitting the Florida Gators football team raise concerns:

"We're trying the best we can, but it's real," Meyer said. "We go to the extremes. They get a separate dorm room for them. They get a separate hotel room for them. They put them right on whatever the flu stuff is. Our guys, our team doctors, they're on it as fast as you can get on it."

Demps, who had a 101-degree temperature, ran four times for 31 yards and a touchdown...Meyer said Sunday that Demps probably shouldn't have played. "Jeff did not look right." Meyer is most concerned about Demps for this week since he was still "on the front end of the flu" (!)

Previous posts about H1N1 discussed H1N1 developing some resistance to anti-virals and the need to lmit their use for treatment and prophylaxis to those with medical conditions that put them at risk for complications. Assuming the coach is talking about anti-virals like Tamiflu and not simply supportive care treatments Should a different standard apply to the #1 team in the nation?

Also, an athlete with a fever should not play or practice (or go to class, hang out in the cafeteria, etc) so as not to expose others to the infection. Maybe, in retaliation for Tennessee coach Lane Kiffin's trash talk about the Gators this summer, Meyer and company decided to smite the Volunteers with swine flu rather than running up the score. Also, exercising with a fever puts the individual at risk for heat illness, dehydration, and exacerbating the infection.

Quick Hitters: TN high school football death, H1N1 gets tougher

A couple of news items that relate to recent posts: 

1. High school football death in East Tennessee. Sullivan South High School football player Jack Logue collapsed during a game due to an apparent cardiac arrest and was pronounced dead later that evening. This is yet another tragic reminder that medical emergencies do occur in youth sports and schools have to make sure their personnel are prepared to respond to them. Sounds like fire department and school first responders on site began CPR and at some point a defibrillator was used but unclear from various reports I've read whether the AED was present on the sidelines or arrived with the EMS vehicle that answered the call. Hopefully all of these decisions, communications, and interventions happened as quickly and optimally as was possible.

The topics of AED availabilty and screening efforts to prevent sudden cardiac death in athletes will be addressed in future posts.

2. Documented resistant H1N1. Our infectious disease experts here at WFUBMC released the following communication (with underlines added by me for emphasis):

On August 14 and 19, 2009, the Centers for Disease Control (CDC) identified oseltamivir resistance in pandemic influenza A (H1N1) isolates from two epidemiologically linked patients in North Carolina. Both developed illness in July while receiving oseltamivir chemoprophylaxis for presumed exposure to an ill person. Their illnesses were mild and resolved without complications. To date, there is no evidence of ongoing transmission of oseltamivir-resistant pandemic influenza A (H1N1) virus. Most circulating virus remains susceptible to oseltamivir and zanamivir, but resistant to amantidine and rimantidine.

In light of these events, the North Carolina Division of Public Health reminds clinicians of the following: 

• Antiviral chemoprophylaxis should be used judiciously to decrease opportunities for development of antiviral resistance.
  • Chemoprophylaxis for prevention of illness in healthy children or adults following exposure to ill persons is not indicated.
  • Antiviral chemoprophylaxis may be considered for persons at higher risk from complications due to influenza or for some health care workers with an exposure to influenza secondary to inadequate personal protective equipment.
  • Careful observation for symptoms following an exposure combined with early treatment if symptoms develop could be an appropriate alternative to chemoprophylaxis in some settings, and could reduce the potential for oseltamivir resistance.
  • Development of symptoms while receiving prophylaxis does not necessarily indicate antiviral resistance. 
• Healthy patients with uncomplicated illness need not be treated with antivirals.

This new resistance is a not so gentle reminder that all of us, even those involved in athletics, need to be good stewards when it comes to anti-viral medication use so that these remedies will remain effective when they are really needed by the sickest/most vulnerable of people.

Are athletic teams above the law when it comes to H1N1?

Texas Rangers pitcher Vicente Padilla is the first athlete in US major pro sports to be diagnosed with H1N1 (swine) flu. He is recovering and expected to pitch this week. Several other Rangers have been ill with flu like symptoms. A Pacific Coast League baseball game was postponed due to an influenza illness that hit several of the Portland Beavers. The interesting aspect of this story and H1N1 in general for me starts with this quote from Texas assistant general manager Thad Levine:

"We've been medicating our players. We would use the same medication and the same kind program to rehabilitate them and they've all shown improvement. Those are the positive signs."

Consider the CDC recommendations on anti-viral use for H1N1:

Many patients who have had novel influenza (H1N1) virus infection, but who are not in a high-risk group have had a self-limited respiratory illness similar to typical seasonal influenza. For most of these patients, the benefits of using antivirals may be modest. Therefore, testing, treatment and chemoprophylaxis efforts should be directed primarily at persons who are hospitalized or at higher risk for influenza complications.

H1N1 is already resistant to one of the two main classes of anti-viral medications. As in the case of bacteria, overuse of the currently effective drugs zanamivir and oseltamivir could potentially train the virus to develop resistance to them as well.

In addition to resistance, availability of these drugs could be an issue if as in past major flu epidemics the first mild wave is followed by a more severe wave this fall according to UPMC and other experts:

It is less clear whether there would be sufficient supplies for a more severe pandemic if the currently stockpiled antivirals were used much more broadly than for treatment, such as for widespread prophylaxis (ie, prevention of infection).

As mentioned in my post about Methicillin Resistant Staph Aureus, athletic teams especially at the highest professional level have been know to overuse medications. This is a result of the "do everything just in case" mentality. It isn't clear if if the Rangers are "medicating" their players - who would all be classified as low risk for developing complications from the illness - with anti-virals for treatment and prevention but I would not be at all surprised if that is indeed the case. We in sports and sports medicine need to step back and get some perspective about our place in society. Certainly concern about the availability of a few players for a handful of days does not supercede the national need to limit resistance and save supplies.

Another interesting question is when should a game be cancelled due to illness? Apparently as in the case of the PCL postponement clubs can make a case to the league who then renders the decision. Teams can come to an agreement with each other as in the case of the Georgetown-Colgate football game this past fall. Georgetown made the case that enough team members were sick with norovirus that not only were the Hoyas unfairly weakened but also that traveling to Colgate would have put the hosts at significant risk.

 

HIV Soccer Scares

Not the good kind of "high five". 6 soccer players from the English Premier League apparently are nervously awaiting HIV test results after finding out that a female soccer groupie recently discovered she had contracted the virus. 

And one of the transvestites, Andre Albertini, who Ronaldo brought back to his apartment last year has died of complications from Acquired Immune Deficiency Syndrome. For his sake I hope Ronaldo really did send them packing once he realized they weren't women. 

Both incidents once again demonstrate that counseling about sexual activity and other risk behaviors needs to be a part of a good sports physical

Bravo to the English Premier League for partnering with Grassroots Soccer in its fight against HIV in Africa. Hopefully the involved EPL players get good news on their test results and celebrate their good fortune by making a contribution to this cause. Click here to make your own donation.

NFL MRSA Lawsuit

Joe Jurevicius is suing the Cleveland Browns, their physicians, and the Cleveland Clinic over the MRSA infection that complicated his recovery from knee surgery.

The lawsuit alleges that physicians Anthony Miniaci and Richard Figler failed to warn Jurevicius that therapy equipment was not always sanitized at the team's training facility in suburban Berea.

Support is provided by the claims of an expert witness, infectious disease specialist Dr. Bonnie Bock from nearby Newport Beach, CA:

"Sterile techniques were not at all times used at the Browns training facility," she said. "Therapy devices commonly used by multiple Browns players were not properly maintained, disinfected or cleaned, if at all at the Browns training facility."

MRSA skin infections really started hitting football players in the early to middle part of this decade. For whatever reason, a community version of this formerly hospital only bug developed and football athletes were a prime target due to their physical contact, open wounds such as turf burns, living in close quarters, and probably less than ideal general hygeine. No specific pattern has defitely emerged as far as which positions are more likely to get it or where the source is despite some reports that have identified turf, pads, locker room or gym equipment, hot tubs, or other colonized players as culprits. An eye opening report about the outbreak that struck the 2003 St. Louis Rams noted that the players received antibiotics at a rate 10x higher than the average man their age which certainly may have helped the fittest and most resistant bacteria to survive and prosper in professional locker rooms.

By 2007 the sports medicine community started to get a handle on how to lower the attack rate of MRSA. A nice article by Benjamin et al in describes how simple hygiene measures such as washing hands, not sharing personal gear, cleaning and covering any open wounds, and cleaning equipment with a mixture of water and bleach make the most sense. While there is probably no way to know where Jurevicius' MRSA ultimately came from, the Browns may have trouble defending themselves from this suit if they did not have a simple policy like this in place by last year.

At the same time, the locker room and gym are never going to be in Dr. Bock's words "sterile" unless we start treating them like operating rooms.

This type of litigation may be what is now driving many orthopedic surgeons to screen community patients for MRSA prior to outpatient surgery. Pre-treating these people in addition to employing the usual sterile precautions in the O.R. may not necessarily help and certainly contributes to further antibiotic resistance. 

   

Maybe the Browns should sue Braylon Edwards for not warning them about his hands.

Red Card For Stupidity

Not sure but this may be the first case of threatening a biological attack as a way to trash talk or intimidate an opponent:

"Hector Reynoso has been provisionally banned from appearing in Copa Libertadores games for his Mexican club Chivas Guadalajara, after he spat and expectorated mucus from his nostrils in the direction of an Everton de Chile player during the sides' 1-1 draw, and then told him he had Swine 'Flu."

You stay classy Hector. This is the type of guy who makes bomb jokes in the airport security line. Makes me long for the good old days of the playful throat-slashing gesture .

Upon further review, however, it does not appear that the South American hosts were entirely blameless in the incident:

"Guadalajara players had complained that they were being taunted throughout the game by their Everton counterparts about carrying the disease, and also that they had been publicly mocked by shoppers when they attended a local shopping mall."

Consider yourselves all booked in the game of life. Maybe rather than handing out suspensions the CSF should require everyone involved in the match to volunteer some time in an indigent health clinic or infectious disease ward.

When Pigs Fly (Or Sneeze)

The medical advisory board of the Alabama High School Athletic Association has taken the dramatic step of suspending high school sports in the state until at least next week due to the swine flu outbreak in the US.

Tough to criticize this decision as the way to deal with infectious disease oubreaks is to act early and decisively with widespread precautions (from immunizations to hand washing) that keep a bug from ever building any momentum. Limiting the number of large gatherings where people in close proximity might be more likely to transmit the virus via coughs and sneezes can certainly help. A delay in the high school sports schedule is also certainly a microscopic issue when compared to the big picture of world health.

On the other hand, why limit sporting gatherings but allow people without masks to ride on buses and planes, gather in theaters and shopping malls, etc. I suppose the medical advisory council to the AHSAA could make the argument that they are doing the right thing and it is up to those in charge of other civic areas to do so as well. They can also point to the fact that at least some schools have been closed and athletic events in Mexico have been either cancelled or played in closed stadiums. Others could argue that Alabama is raising the hysteria level as there has yet to be even one confirmed case in the state.

In the end it is tough to quibble with a safety first mentality and taking infectious disease prevention seriously. I certainly hope these brave medical advisory folks in Alabama never have to make this decision during football season! I also wish that the public that is so concerned over this virus would pay as much attention to other health and safety issues that are far more likely to impact themselves or their families by funding PE classes, hiring a certified athletic trainer at all high schools, and placing AEDs at all athletic events.