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Returning to Play: Decisions Should Be Made Based on Local Conditions, Other Factors CHOP Says

Photo by Shelly Atzeni

Should high school sports be played this fall?

(Photo by Shelly Atzeni. Check out more of Atzeni’s work here.)

That is the question facing Pennsylvania leaders – both political and nonpolitical – and school administrators during the current COVID-19 pandemic.

The answer isn’t crystal clear and may depend on the region, the sport being played, and other factors, according to medical experts at the Children’s Hospital of Philadelphia, who were contacted by D9and10sports.com this week.

BACKDROP

Pennsylvania Governor Tom Wolf’s administration has recommended not to have scholastic sports until at least Jan. 1. Some Pennsylvania legislators have pushed back against that recommendation. Parents and players seem to have varying opinions, although the overall sentiment seems to be leaning towards letting them play. And the PIAA last week delayed any decision on what it is going to do about Fall Sports until its Aug. 21 meeting delaying the start of mandatory workouts until at least Aug. 24.

This all came in the wake of the PIAA canceling its basketball and swimming championships in March and then canceling all Spring Sports in April.

Most NCAA Division II and Division III schools have also postponed Fall Sports until the Spring with all championships canceled, and Tuesday, Aug. 11, the Big Ten and Pac-12 Conferences postponed all sports until at least Jan. 1.

CHOP WEIGHS IN

What do the medical experts, one group that hasn’t been heard from a lot in the debate to return-to-play in Pennsylvania, believe?

Nuisance would be a could way to describe it, and one-size-fits-all isn’t the answer.

This is the gist of what CHOP doctors Susan Coffin and Matthew Grady said in a video media conference from a few weeks ago shared with D9and10sports.com by CHOP, in follow-up e-mail questions to both doctors by the site, and in “Return to Play” reference guides for youth sports developed in late spring and early summer by the hospital that is available on the hospital’s website.

“Although no strategy for youth sports can fully eliminate risk of COVID-19 transmission among children, coaching staff, or families, our intention is to provide some practical strategies that can reduce risk and counter the unintended secondary consequences of the pandemic on our children,” a statement on CHOP’s website said.

According to CHOP, its guidance (which can be read in full here) is meant to complement existing recommendations from the CDC to help families make decisions about their child’s participation based on their age, specific sport and the level of play in which they are engaged.

“We cannot throw caution to the wind, but we can make careful judgments based on the best scientific evidence available, guidance from youth sports national governing bodies, and expanding recommendations from public health departments on how to cautiously resume physical activity as safely as possible,” CHOP said on its website.

DECISIONS SHOULD BE MADE AT THE LOCAL LEVEL

One of the major points to come out of all of the information is that much like the reopening of schools, the decision on whether to move forward with sports should be made at the local level.

“Decisions about in-person vs. remote school and sports should be made based on the local information about the amount of viral transmission in your community,” Coffin, a Pediatric Infectious Disease Physician, said in an e-mail. “However, the state is recommending that every county use similar metrics to determine whether it is appropriate to change the way in which schools or sports experiences are delivered.”

In the video interview a few weeks ago, Coffin had made that point with a presentation, which among other things, said that the transmission of the disease “will vary based on disease burden within a local community” and that full sports participation will be safest when “disease burden in communities is lowest.”

When asked in an e-mail to define burden in a community, Coffin said no single metric can completely capture the burden of the disease in a community but did point to the new metrics put forth by the Pennsylvania Department of Health and the Pennsylvania Department of Education.

“We have been advocating tracking at the county level both test positivity rate and the incidence of cases per 100,000 (people),” Coffin said. “The state Department of Health and Department of Education have just issued recommendations about how to decide to move between tiers of in-person vs. remote activities based on these metrics.”

The recommendations set forth by the Department of Health and the Department of Education were for whether schools should resume in-person schooling, do a hybrid schooling system, or do all on-line classes.

The full breakdown can be found here, but the recommendations said that counties with an average seven-day incident rate of under 10 AND a PCT positivity rate of less than five percent are considered to have a “low” level of community transmission, while counties with an average seven-day incident rate of 10 to 99 OR a PCT positivity rate of between five percent and less than 10 percent are considered to a have a “medium” level of community transmission. Counties with an average seven-day incident rate of 100 or more of a PCT positivity rate of over 10 percent are considered “substantial” level of community transmission.

CHOP developed a pyramid to show how activities should be scaled based on the disease burden, or amount of circulating COVID-19 cases, within in a community.

The bottom of the pyramid represents a high disease burden (red) while the top is low disease burden (or green) of circulating infections in a community, as reported by local and state health departments.

According to the pyramid, games should only be contested during low community infections, while during a medium (or yellow) community infections outbreak, small-group training with a subset of team and coaches should be conducted. During a high outbreak, only individual training apart from the team should be conducted.

As of this week, nine of the 17 counties that include at least a portion of a school district that plays in District 9 or District 10 are in the Commonwealth-defined “low-risk” category for reopening schools while eight are in the the “moderate-risk: category for reopening schools. All nine of the counties considered to be “low-risk” house District 9 schools – only two counties that house school building in District 9, Clearfield and Butler, are in the “moderate-risk”, while Warren County – home to District 10 schools Warren, Youngsville, and Eisenhower – and Venango County – home to District 10 schools Rocky Grove, Oil City, and Franklin – are the only counties that have District 10 schools that appear in the “low-risk” counties list. Crawford County was considered “low-risk” for the week ending July 31 but “moderate-risk” for the week ending Aug. 7.

Even in areas where community infection is a little bit higher, Grady, a Sports Medicine Pediatrician at CHOP, said certain sports could still take place.

“Some activities naturally social distance,” Grady said. “Playing tennis or playing golf can start even when the community infection rates are a little bit higher as long as people are staying apart.”

Grady said as community infection rates start coming down, athletes can get closer and closer, but schools and teams must understand that if infection rates begin to spike then shutting down competitions and even practices may have to take place.

“As the community risk goes down, then we can feel a little more comfortable taking more risks with our athletes, so the higher risk is going to be close contact, training, and then eventually, a local play if local play has lower rates of infection,” Grady said in the media conference a few weeks ago. “Then we can look to go into regional play, but we would want to try to stay in regions where the local community risks are about the same. So, we’ll have to be monitoring. The tricky part about this is if we have a spike in infection in the area then we actually may have to go backward and go from training where we’re close together to potentially training further apart.”

TYPE OF SPORT COULD PLAY A ROLE

Community burden is only one factor that should be taken into consideration, according to the CHOP doctors.

The type of sport being contested may also play a role.

Some sports – like football and basketball – may expose athletes to a higher level of risk than in-person school, while others – like baseball and soccer – may not increase the level of risk from what children will be facing with in-person school, according to Grady.

“When in school, the exposure to classmates that occurs in a sports setting may be greater (for example in close sports like football or basketball) or may be not different (outdoor distanced sports like baseball and soccer) than exposure in the classroom,” Grady said. “So, sports may or may not change the risk depending on the nature of the sport.”

That point was also made in the guiding principles to returning to sports that Coffin talked about during the media conference a few weeks ago.

“Sports with greater and more frequent inter-athlete contact are higher risk than ‘no-to-lower’ contact sports,” Coffin said.

During the e-mail interview, Grady again emphasized the particular sport could play a role when inter-school competition is added to the equation.

“Some of this depends on the nature of the sport,” Grady said. “The risk of transmission between baseball players on opposite teams seems to be very low. We do not have any data with American football, but since players are much closer, the risk should be higher.”

Grady said one known is that when games are against other teams, that makes the circle of people those athletes come into contact with bigger and thus increases risk.

“Playing against other teams also means coming in contact with a bigger circle,” Grady said. “Games against other teams, especially with close contact, will have more risk.”

Grady again pointed to community rates of transmission playing a key role as to whether sporting competitions between schools could be contested.

“Game play against other teams will depend on community risk levels,” Grady said. “As community rates go down, playing teams in communities with similar infection rates is preferred.”

INDOOR VS. OUTDOOR COULD MAKE A DIFFERENCE

The guiding principles document also states that the location of the activity – indoor vs. outdoor – could play a role.

“Outdoor activities appear to be lower risk than prolonged indoor activities,” Coffin said reading from the guiding principles.

Grady, during the media conference, also emphasized indoor vs. outdoor activities.

“As Dr. Coffin mentioned, outdoor transmission seems to be lower than indoor transmission,” Grady said. “Having our training start outdoors would be more helpful than starting indoors, and that could even be for things like basketball we could use outdoor courts to do some spacing as opposed to an indoor (court).”

LENGTH OF EXPOSURE, DISTANCE TRAVELED SHOULD BE CONSIDERED

Additional factors for increased risk, according to the guiding principles, include the length of time a person is exposed to the virus and whether or not the person touches their face after touching an infected surface, like a ball.

“The risk for individual COVID-19 infection increases with prolonged exposure (at least 10 to 15 minutes) to an infected person (through close contact) or direct contact with a COVID-19 contaminated object and subsequent self-inoculation by touching eyes, nose, mouth with contaminated hands,” Coffin read from the list of the guiding principles.

Distance traveled to an event also could play a role.

“Longer distance travel for games may increase spread between regions, particularly during periods of higher regional disease burden,” the guiding principles said.

HOW MUCH CONTACT HAVE ATHLETES HAD

In the e-mail interview, Coffin also said that each person’s risk of becoming infected or passing infection to another is strongly linked to the contacts they have with other people.

“If a child has been having very few out-of-the-house contacts in the past and then resumes both schools and sports, they will have a dramatic increase in their potential risk of becoming infected or spreading infection,” Coffin said.

According to Coffin, that increased risk can be mitigated by students/athletes only rejoining the activities when viral activity is very low, and by continuing to adhere closely to all prevention measures.

SUGGESTIONS TOWARD MAKING SPORTS SAFER

A couple of suggestions made by the guiding principles included a “quaranteam” approach and a risk-based approach to returning to play.

The “quaranteam” approach would be a group of athletes committing to the same safe principles in daily life to minimize risk of COVID-19 transmission with the team.

“This can reduce risk for transmission within teams and across sports leagues,” the guiding principles said.

Grady said this could be achieved by athletes committing to a contract – possibly no different than any other team rules – to keep their “circle” relatively small.

“We’re relying on everyone on the team to protect each other,” Grady said. “This idea of the ‘quaranteam’ is that everyone would agree that I won’t come to practice if I have symptoms, and I’m going to try to keep my bubble of who I’m interacting with relatively small so that they don’t accidentally bring the infection to the team. We’re relying on everyone getting together and making a pact with each other that they’re going to do their best to limit infection.”

Grady said athletes could be asked to sign a form acknowledging these rules.

“We developed a little youth sports COVID compact,” Grady said. “(It’s) where we’re asking people to sign a form that each person on the team understands their responsibilities as a teammate and then collectively the team agrees to try to adhere to these principles as best as possible.”

According to Grady, the “quaranteam” approach needs to be more than just about checking for symptoms.

“We know this infection has been very tricky to manage because you can be asymptomatic and then be potentially infectious and the symptoms can come a day or two later,” Grady said. “So, it’s not going to be perfect if we screen only for symptoms. We do want athletes to try to minimize the risk outside of the sport setting. So temperature-check taking alone isn’t ideal as a way of prevention.”

The risk-based approach to the resumption of team activities can allow coaches and leagues to adapt activities as needed based on the degree of disease burden and risk in communities, according to the guiding principles.

RECOMMENDED SAFE BEHAVIORS

CHOP developed some recommended safe behaviors including:

  • No sharing personal items such as towels, water bottles, and razors
  • Use frequent hand hygiene, including before and after play, during practice and during play as rules allow
  • For athletes with COVID-19-like symptoms or high-risk exposure in their household or who have had close contact with infected individuals (even if asymptomatic), prohibit return to play for at least 10 days, regardless of the test result, due to uncertain reliability of PCR testing in children. That athlete should return to play only after completing 10 days of quarantine and at least three days without fever
  • Mandate a daily self-assessment of symptoms and maintain a strongly enforced sick policy
  • Avoid face touching whenever possible, use hand sanitizer before and after putting on helmets, mouth guards, etc.
  • Distance whenever possible during practice, while on sidelines and in the locker room
  • Commit to your “quaranteam” – have athletes sign the “Return to Youth Sports COVID-19 Compact

“We’re going to try to limit sharing personal items, especially water,” Grady said during the media conference. “We can do frequent hygiene before and after practice, and, if there are opportunities, between practice or games to do hand hygiene, we can do that. Then we want to make sure there are monitoring systems in place where we’re making sure that if there has been exposure to individuals who have COVID or likely have COVID that our players self-quarantine and get evaluated by a physician or other provider.”

MASKS, OTHER MEASURES IMPORTANT

Because scholastic and youth sports include more than just young people – coaches, referees, parents, grandparents, etc. – making sure that current guidelines involving mask-wearing and other measures is also important, the doctors said.

“I think we’ve found that our data suggests that using masks, especially for adults, has been helpful to for decreasing risk,” Grady said. “ And I would like to think of masks as a public health policy not as a political statement. Coaches who aren’t breathing hard and aren’t exercising certainly can keep a mask on the entire time. We know from athletes that may be a challenge. So we may be only doing that when we’re really close to full play. But for coaches interacting, certainly masking is a possibility.”

According to Grady, coaches and adults need to understand that there is the risk of infection between them and kids and vice-versa.

“I think coaches and adults who are participating with youth sports need to recognize that they potentially could infect kids as well as kids infect them,” Grady said. “It seems to be most of our transmission has been for adults to kids than the other way around. So I would say the things they could do to prevent infection are very important as well. And we would like them to try to make sure that they are participating in doing good hygiene and social distancing.”

Coffin said she understands that the question around masks is a really tough one for athletes because with greater and great exertion it is difficult to keep them on but that doesn’t mean it shouldn’t be tried.

“We’re all part of a larger public health community, and there are public health guidelines that need to be taken into consideration and followed,” Coffin said. “As risk falls in your region, so too will the guidance around mask use in public places. So, you’ll be needing to incorporate those principles into how you approach your team.”

TAKING SIMPLE PRECAUTIONS BOTH IN COMMUNITIES AND IN SPORTS CAN LEAD TO GREATER CHANCE TO STAY HEALTHY

Coffin said the more a community takes simple precautions the more chance that community has in being able to conduct any activity, including sports, safely.

“I think the more that our whole community becomes accustomed to applying their own personal strategies to reduce risk through distancing and mask use, removing themselves from activities if they’re sick, and cleaning one’s hands, you have a much greater (chance) of being able to participate and remain healthy throughout whatever activity you choose to do,” Coffin said. “It’s all about what you can do to lower your risk.”

Coffin used going to the beach as an example.

“You can go to the beach and be perfectly safe if you travel alone or travel in a single car or (in a) car with one other person if you choose to keep your mask on when you’re not in the water, if you put yourself in a spot on the beach where it’s not crowded, and avoid the boardwalk when it’s crowded,” Coffin said. “Conversely, you could have a very risky day at the beach if you didn’t follow those sorts of precautions.”

D9and10sports.com also reached out to UPMC Hospital in Pittsburgh, the Cleveland Clinic, and Johns Hopkins Medicine in Baltimore.

UPMC said it believes the return-to-play issue is “more of a public health issue best addressed by public health authorities.”

“UPMC advises individual athletes and their parents but isn’t creating policy on this for the overarching population,” Allison Hydzik, Manager of Media Relation for the University of Pittsburgh Schools of Health Sciences/UPMC, said in an e-mail.

Jenna Homrock, Corporate Communication for the Cleveland Clinic, said to her knowledge the Cleveland Clinic has not put together any guidelines to return to play, while Johns Hopkins did not return an e-mail.

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