It's been a year since the first case of novel coronavirus was detected in the United States, and while much has been learned about the too-often fatal respiratory disease COVID-19, "we still don't know what we don't know." That's according to Dr. Susannah Briskin, a pediatric sports medicine specialist at University Hospital in Cleveland, who coauthored return-to-sports guidelines for the American Academy of Pediatrics, and has been updating them every 30 days with new information from evolving medical literature and news reports. AB senior editor Paul Steinbach asked Briskin to assess the progress youth sports and the sports world at large has made during the pandemic.
How did you come to get involved in the AAP's efforts?
I am currently serving on the Council on Sports Medicine and Fitness. I'm an elected executive committee member, and when COVID started rolling out they asked for somebody to volunteer. And seeing as I was sitting in my living room twiddling my thumbs, not seeing patients, it seemed like a good way to contribute.
What's the process?
I'm not an infectious disease expert. I'm a sports medicine physician. I have general infectious disease knowledge, but I'm dependent on other people to review my recommendations. The majority of our recommendations are based off of what's written in the current literature and recommendations that the CDC and World Health Organization have made, as well as other governing bodies. And then whatever I write up is reviewed by other people, including pediatric infectious diseases specialists. In particular, we're trying to review literature on how COVID-19 has impacted sports. We're constantly pulling the literature and reviewing what's available, trying to look at transmission rates within sports. What are the known risk factors? Looking at situations where there have been team outbreaks or tournament outbreaks that have been published and trying to figure out what we can learn from this and what recommendation we can make to try to mitigate risk in the best possible way.
Were you curious or concerned about an emerging pandemic and what its impact might be?
Oh, yeah. Absolutely. The nature of being a physician is you worry about other people's health and wellbeing. But I don't think anybody back in January 2020 could have predicted how we're living now.
Has any one thing about COVID-19 alarmed you?
The risk with kids is certainly less than the risks in adults, so nothing has really taken me aback in terms of the severity. What is more surprising or, I think, concerning is that a majority of recent reports have had to do with the increased spread as we move to indoor sports. A lot of the cases that have been published have been around ice hockey. And for us, what's challenging is you're stuck with somebody else's publication and trying to determine, okay, where was the transmission in this group? Was the transmission on the ice during hockey? Was the transmission because all the kids were sitting on the bench next to each other? Did they all have a shared locker room? Did the families have a pizza party at somebody's house afterward? It's hard to pinpoint exactly when the transmission occurred. But I think that's pretty reflective of what's going on in the community. If you talk to people who contract COVID-19 and try to get them to pinpoint where they got it from, most people can't do that. You really don't know. So the hardest thing about our situation is we're trying to make recommendations to keep sports as safe as possible, but we're stuck looking at the current literature that's rolling out slowly to help us determine, "Is there anything more we could be doing?"
Was the rush to return to sports outpacing available literature?
Well, the problem is you can't have literature without sports starting up. All the initial guidance is based on what we know we should be doing in the community in terms of hand-washing, sanitizing equipment, spacing out as much as possible, and masking whenever possible. Really, you're stuck with applying the community guidelines to the sports setting and then watching and waiting and seeing what happens. So, I think a 30-day review is an appropriate amount of time to have guidelines updated. I don't feel like the guidelines are coming out too slowly, because if you put them out any faster, there would be no new literature to review, and we're still doing it often enough that we have the ability to impact sports within the same season, because typically the seasons go on for much longer than 30 days.
We've seen schedule disruptions in college football and now basketball. Do you ever feel like maybe we shouldn't be playing sports at all?
It's a good question. I think it is really dependent on where you live, because obviously the community rate of infection and things such as hospital and ICU utilization should all be impacting how we choose to spend our time outside of the house. So, I think it's really a community-based decision. The reality is we're still being impacted at the youth sports level from a scheduling perspective. I'm in Cleveland, and so the majority of sports have now moved indoors, and even at the high school level, we're constantly seeing teams cancel or reschedule games — due to somebody in quarantine or somebody ill or a team deciding they don't want to travel and have an overnight because of risks associated with it. Youth sports are for sure impacted in a similar way that you may see at the college level.
State high school associations have categorized certain sports as being higher risk than others. Should some sports return to action at a different pace than others? And should an infected athlete's return timeline depend on their given sport?
Anybody who has contracted COVID should absolutely see a physician prior to returning to any sport — contact or otherwise — to determine if it's safe for them to return. We always recommend a visit with a pediatrician prior to returning to sport, and the purpose of that is really for cardiac screening. Those individuals should undergo a thorough history and physical exam to figure out what signs and symptoms they have as a result of COVID, and then the physician can determine if any further workup is needed because of concern for potential impact on the cardiac system. In my mind, it doesn't really matter if you play tennis or if you play football, you still need to see a physician prior to returning to sport. From the perspective of the high school athletic associations, the risk level is really determined based on contact, time spent in contact and location of the sport. We know sports played outdoors are safer than sports played indoors. We know that sports with a high degree of contact and in close proximity, such as wrestling, probably carry a greater risk than a sport like indoor soccer, where the time spent face to face with somebody else is less. You're really thinking about indoor versus outdoor, contact versus non-contact — those are the main things that are going to impact risk for COVID transmission. I think if people are signing up their children for sports, they need to understand what risk is associated and make sure that they understand that certain sports are a greater risk than others.
Can youths as a demographic present a particular challenge when it comes to adherence to mitigation protocols?
I think anybody in the teenage years or anybody who's at the point where they're more likely to do things on their own is hard to control. What I tell everybody is that it also has to do with the parents. We can have coaches and athletic directors and state associations mandate as much as possible on the field or court to keep things safe, but if the team leaves from a competition and they all go to somebody's house for a postgame meal, it completely washes away the benefit of all the separating that we're working on creating. You really need people to be compliant with the recommendations off the court and field in terms of keeping distance, not spending time with people who don't live in your home, wearing a mask and washing your hands in order to give people the best chance of staying healthy. I think as time goes on, we'll start to see more data coming out about how teams are getting infected. But, like I said, pinpointing exactly how the infections occur is hard, because the athletes tend to hang out with other athletes, and then you don't know if they're transmitting it while they're at practice or if they're transmitting it at a team sleepover.
Are you worried about potential fatalities in the sports world?
I think there's low likelihood of COVID-related fatality because of all of the measures that are currently in place — especially at the college and professional levels — for evaluating athletes post-diagnosis. But I don't think any athlete or anybody else is completely protected from a COVID-related fatality. And I honestly think that the bigger issue in the youth sports world is if there's a youth athlete who gets it, then the likelihood of infecting somebody else in their house is pretty significant. You have to think about other people, because those youth athletes are taking it home, and their parents may be high risk or they may have a grandparent who lives in the house who may be high risk. That's really where we start to think more about the potential for a COVID-related fatality — that tree of spread that could happen so quickly.
Would a fatality shock people into shutting sports down?
Hard to say. I think the sports world started up pretty fast and furious as soon as it was given permission. I think putting the brakes on the sports world is very hard, because it's something people want to participate in. They want their kids to be active. They want their kids to be social. Parents themselves want to get out of the house and do something that breaks up the monotony of the usual routine we all have at this point.
How is the sports word doing? Is one sports entity handling this any better than others?
I think that's really hard. I don't know if I could assign a grade. The reality is each different professional sports organization has faced different challenges, and I think they've all done the absolute best that they can to try to create protocols to keep people safe, but also to try to keep the game going.
Are empty stadiums better than stadiums filled to 25 percent capacity?
I think any situation where you can be outside and maximize spacing between people is really the best way to minimize spread, but a lot of it also has to do with what's going on in the community. If you have a high rate of community spread and there's a high rate of hospitalizations and ICU usage, and things are filling up, then probably doing everything you can to minimize people being around each other outside their home is going to be incredibly important for the safety of the community. I think it really is a geographic issue.
Can limiting attendance to well-spaced groups be effective?
I always wonder about that, right? Let's say you're allowed to bring in a group of four. So, out of that group of four, do all of those people live together? They can't guarantee that whoever they're giving the tickets to that those people are actually all members of the same household. That's really what you want. Obviously, people being outside is more beneficial than being in an indoor stadium, but I still think there's risk if there are groups of four sitting outside and they're all right on top of each other, and they're eating and drinking unmasked, and they're not from the same household. The risk of spread is present even in that scenario.
Is there anything about COVID you would like to know more about, even after we gain control of it?
I think we're still trying to untangle the short-term effects of the disease, let alone understand the long-term effects. I think we're probably looking at a future where not everybody gets vaccinated, so we may be in a situation where we are still dealing with unvaccinated individuals for some time. So, I don't think coping with COVID-19 is going away anytime soon for everybody, but we certainly all hope that the situation improves enough that we regain some normalcy, and that the majority of people do well with vaccination and can move forward and feel confident that they are well-protected.
What about mitigating the economic impacts of COVID-19?
If you're really thinking about things from a business perspective, probably the one thing that I'm really trying to dedicate some time to locally is making sure that facilities and leagues pay attention to the current recommendations. Like I said, this is a moving target, and there is an active business side to sports at all levels, not just the professional level. Thinking about things from a money-making standpoint, obviously, facilities and leagues want to stay open, but I don't think they're necessarily all requiring or recommending the latest in safety measures. I think it's to their disadvantage in the long run, because the reality is if they're not recommending or requiring the latest in safety recommendations, I think we will see a greater number of people fall sick and potentially see facilities having to close or leagues needing to shut down because of the spread of COVID-19. I would much prefer leagues and facilities be proactive about instituting safety measures in an effort to not only keep people healthy, but also to increase the likelihood of sports continuing.
How would you rate enforcement of safety measures so far?
That's really what I'm dealing with here locally from the perspective of just even wearing a mask. We have some facilities that aren't mandating spectators wear masks and space out. It's written everywhere and people are informed of it, but nobody's actually enforcing it at facilities. So, I think one thing is facilities need to have some foresight and think about the fact that they need to have somebody enforcing with the spectators that they are masked appropriately and they are spaced appropriately, because it's the only way we're going to help slow the spread. And the same goes with the youth athletes. In some places, masking is required and other places it's not, but making sure there's compliance with whatever the current local recommendations are. They need to not only be communicated, but somebody needs to enforce these rules and regulations. And that's certainly an issue that I'm seeing not being addressed appropriately on a day-to-day basis here.
How do you communicate your updated guidelines to people who need to see them?
Media releases are sent out once the guidelines are approved, and then I get swarmed with interviews.
This article originally appeared in the January | February 2021 issue of Athletic Business with the title "Physician assesses COVID risks in youth sports." Athletic Business is a free magazine for professionals in the athletic, fitness and recreation industry. Click here to subscribe.