COMMENTARY

Sports Medicine Docs: Olympics' 'Logistical Nightmare' Mixes Testing, Tracing, Varied Vaccination Statuses

Scott A. Rodeo, MD; Lisa R. Callahan, MD

Disclosures

July 21, 2021

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This transcript has been edited for clarity.

Scott A. Rodeo, MD: Good morning. I'm Scott Rodeo. I'm an orthopedic surgeon at the Hospital for Special Surgery in New York City, and I'm joined by my colleague, Dr Lisa Callahan, to talk about some of the issues related to COVID and the upcoming Olympic Games in Tokyo this summer. Just briefly, I'm a sports medicine orthopedic surgeon. I take care of the New York Giants and I work with USA Swimming, having covered the last four Olympic Games. My colleague, Dr Callahan.

Lisa R. Callahan, MD: Hello, Scott. I have about 20 years of experience working with players in the NBA and the WNBA, also athletes in the NHL, and have several years of experience with USA Basketball. So I think this is a perfect, timely topic for us this morning.

Rodeo: Thank you, Lisa. It's great having you. Lisa has such a tremendous amount of experience with athletes, so we'll be able to address some of the important issues that come up in planning for the Tokyo Olympic Games during this pandemic. There are obviously critically important issues to consider with a worldwide event with individuals from all over the world, and not just athletes but media, spectators, coaches, managers — the whole entourage. What are the burning issues and concerns we should have, Lisa?

Callahan: Scott, I think everybody is pretty up on the news that in the United States we've been really fortunate with the amount of vaccine we have available. We've been able to get a lot of our athletes, coaches, and staff members vaccinated, but not every country has had that opportunity. And so we're going to end up with a situation where we have some competitors and staffs who are highly vaccinated or who've already had infection. We're going to have other people who are COVID naive, who've not been infected and have not been vaccinated. And so it's really logistically interesting to try to figure out how you create a situation where everybody can be as protected as possible. Most of the elite athletes you and I deal with are young, healthy people. If they get COVID, they may not get that sick. Although I have to tell you, I've seen young, healthy athletes who got exposed to COVID and didn't get very sick or maybe didn't get sick at all, and then I've seen others who got really ill. So it's really hard. We can't really predict who will get very sick. I do worry — I think you do, too — about people who have other underlying conditions or people who are older, especially if they haven't been able to be vaccinated. So it will be important for those at the Olympics to remember the mitigation strategies that have proven important in prevention.

Rodeo: So at this point, less than a month away, it'll be hard for an athlete to get vaccinated, but in recent months, we have encouraged our athletes to become vaccinated. What do you tell an athlete who expresses reticence for the vaccine? They're worried about side effects, worried about whether the side effects are going to interrupt their training. How do you educate the athlete to help them understand the risks vs the benefits of vaccination?

Callahan: That's such a timely, good question, and a lot of people have had those questions. The media is a double-edged sword, right? There's lots of information out there. Some of it's correct and good, and some of it may not be correct. And people get their information from all kinds of sources. With social media being so instantaneous, rumors can spread or misinformation can spread. Some of it's accurate, some of it's not so accurate. So that is the background to keep in mind when educating our athletes. I go back to the data and the science, and I look at vaccines over the course of history. A lot of our athletes are young, and so they don't have perspective. But we came of age when we actually got polio vaccines and they don't even know what polio is now. I talk to them a little bit about the history of viruses, the history of vaccinations. One of the big issues for a lot of athletes is they've heard this concept that the vaccines were developed so quickly, and they're worried about that. I explain that this is not as quick as it seems because much of the science was already being developed after prior new coronavirus outbreaks, number one. Number two, we had scientists all over the world working on this at the same time, which is unprecedented. I try to convince them that the development of the vaccines is more a miracle that was forced under the pressure of a pandemic. I talk to them about the science. What are the side effects of the vaccine? What are the risks of the vaccine vs the risks of infection?

Let me take myocarditis as a great example because that's been in the news a lot lately. There was a really good study that came out about 3 or 4 months ago that looked at some players from the NFL, the NBA, the NHL, Major League Soccer, baseball, WNBA, and they looked at people who had gotten COVID infection and how many of them had viral-associated myocarditis. Of 789 confirmed infections, there were only five cases of myocarditis. But if you look at the risk for myocarditis with viral infections in general, viral infections are the number-one cause of myocarditis. So we are going to see myocarditis in some people who get a virus, including COVID. The risk for myocarditis with vaccination has been shown with the mRNA vaccines to be extremely low. What I find fascinating is when we give people a vaccine, we're actually not testing them to see if they currently have COVID. Do they have COVID antibodies? Is it possible that vaccine-associated myocarditis is a hypersensitivity response to the vaccine in somebody who's already had COVID or maybe currently has COVID and we don't know it? There are so many questions. What we do know is that the vaccines are very effective and have been critical in getting us to this point in the pandemic battle. We know so much more than we did 15 months ago, but there's so much more we don't know.

Rodeo: That's a good point. It's just not logistically and financially feasible to test all the athletes for myocarditis with cardiac MRI prior to a vaccine, as one example. And you make such an important point about education. One of the most important things we do as physicians with all of our patients is teach. I think the word doctor comes from the Latin word [docere], which means to teach. It's educating your patients, educating your athletes about the risks vs benefits. You make an important point about social media and the issues of myocarditis and the [dural sinus] blood clot risks being higher in females who have gotten the vaccine — another hot topic that gets picked up by our athletes. Those make headlines and social media. How have you been dealing with your female athletes in your specialty practice, where there's been these reports of venous thrombosis more commonly in females?

Callahan: That's a great part of the vaccine debate. I don't know that I have the right answer, but I'll tell you what I have tended to start saying lately, and that is, number one, the vaccines are overall very safe and they're very effective. I believe that choosing vaccination not only helps protect our own health, but that we have a responsibility to the global community to try to help protect everyone. We know that the more people who get vaccinated, the more we're going to drive down the spread of the virus. We're going to drive down new variants of the virus. [Look what has happened lately with young people getting the Delta variant.] I think everybody who's eligible for a vaccine has to really look very carefully at a reason they consider not getting the vaccine. That being said, if you look at the vaccines that had the rare but serious venous blood clots, almost all occurred in women. [So I might encourage a young, healthy woman — my female athletes — more toward a messenger RNA vaccine. If I have a young male athlete who's concerned about the risk for myocarditis, maybe I'll encourage him to get the J&J.] The truth is, the risk for serious illness from COVID is so much greater than the risk for serious side effects from a vaccine. That to me is the take-home message for all the athletes. But I've been having the conversation along gender lines with athletes. The hardest thing is, Scott, we like to get data, and then we like to make recommendations to people based on the things we know. But sometimes we don't know. We have to do the best we can with what we know at the moment.

Rodeo: Yes, we need to continue to follow the data. And luckily, there's a huge international effort to accumulate more data. I think that you made the two important points. Number one, first, these risks — the side effects of the blood clots in females and myocarditis in men — although concerning, they're uncommon. In fact, there's still some question as to whether they're even higher than the normal rate you'd expect from any other vaccine or just in the underlying population. Number two, all that said and all that aside, the risk for illness from COVID is much higher than the risk for these side effects. The next question that comes up then is, "Well, if I'm not vaccinated, how should I be tested? Should I be tested daily at the Olympic Games?" We've had experience with this, you in the NBA, myself in the NFL, with the efficacy in doing testing on a daily basis and PCR testing. But logistically, it's difficult. What would seem to be the optimal testing protocol for athletes at an event of this magnitude?

Callahan: Boy, Scott, a smarter person than me is going to have to answer that question. What I can say is that we have a good sense now that the PCR testing is pretty reliable. If it's done frequently enough, you're going to catch infection early and have a better chance to keep it from spreading. And so you design a testing program with that goal in mind. The more people who've already had COVID or have been vaccinated, the lower number of infections and rate of spread. If we're looking at a very COVID-naive population, then we're really going to have a bigger issue. I have enormous respect for our colleagues who are going to have to figure out this logistical nightmare, in my opinion, of how you actually do this testing in a methodical, intelligent way. For the Olympics, my feeling is, the more you test, the better, because the more you test, the quicker you're going to catch early infection, the quicker you can isolate that person, the less you're going to allow spread and then hopefully not disrupt the event. We certainly learned in American pro sports this year that you're going to expect some disruptions because you're going to have a positive test that's going to have an impact on the team or the individual performance. But if you catch those early, hopefully you minimize that risk.

Rodeo: I echo your sentiment about our colleagues; you and I won't be in Tokyo. We're going to draw on our experience with our professional teams and Olympic teams in the past. But I too have tremendous respect for our colleagues who will be there trying to manage all of these logistics. I think we have learned, as you said, the more testing, the better, and really on a daily basis is probably your best way to go, because we know you can be infectious and be in the presymptomatic or asymptomatic phase. So that's the tremendous value in daily testing and PCR being the gold standard. The challenge there is just logistics, having been at the Games. It's all the moving around on buses or in the Olympic Village or in the cafeteria. You eat with individuals from all over the world. At the venue, you interact with not just other athletes from around the world, but media, officials, and coaches from around the world. It is really, really challenging. You brought up the important point about the vaccine which is that it's kind of like wearing masks. I wear a mask to protect you. You wear a mask to protect me. Likewise, getting vaccinated is not just to protect the individual, the athlete; you're helping your teammates. An illustrative example we've seen in some sports of late is an athlete who is not vaccinated is then identified by contact tracing as a close contact of a COVID-positive patient, requiring quarantine. Now you hurt your team because you are out in quarantine. For a team sport, that is a tremendous consideration for our athletes. It is one more piece of information that is helping them to make an informed decision about vaccination, because if you're a close contact and you're unvaccinated, now you've got to quarantine and you're out for 7-10 days.

Callahan: One thing, though, that also makes it a conundrum, as far as the testing goes, is that when you test a closed population over and over and over, you're going to have to expect some false positives. Not only are they going to have to set up the original testing, they're going to have to have a very rapid response to any positive test with repeated testing, different platforms. I know it can be done. I know that we've seen it happen in other pro sports leagues this year. People have learned an enormous amount about how well you can do that.

Rodeo: We'll learn a lot, just like the experience from the NFL and the NBA this year. If nothing else, we learned a huge amount from all the data that were available to really learn more about risk mitigation. I have a lot of respect for our colleagues who will be there in Tokyo. The organizing committee I know put in a huge amount of effort into just the logistics of results reporting. What you don't want to get is a positive test back an hour before the Olympic 100-meter final and find out that one of your finalists is positive. It goes back to "an ounce of prevention is better than a pound of cure," ie, in vaccinations and the importance of vaccinations.

Callahan: If you think about it, one of the greatest things about the Olympics is getting together with your colleagues and people from all over the world, other athletes. The level of interaction and intimacy that normally occurs between groups of people at an event like this is really limited now. I think that's a part of the Olympics that the participants will miss. But I think they're going to go through the shared experience in a way that's going to make them feel like they're really making history here.

Rodeo: It's a very interesting point you bring up. The sporting competition part aside, it's the international goodwill, honestly, that's probably the number-one issue or value of the Olympics. You're with these individuals from all over the world. Politics gets put aside, and that will necessarily be a bit different here. What are your thoughts about antigen testing vs PCR? Clearly, nucleic acid testing (PCR) is the gold standard — it takes some logistics — vs so-called rapid tests.

Callahan: Remember, there are some rapid PCR tests and those are pretty good tests. Antigen tests in an asymptomatic population. I just don't know. This would take an epidemiologist and some statisticians and some infectious disease experts to tell us: If you're screening an asymptomatic population and you're using a test with a lower sensitivity, where is the balance between is this good enough vs not? I'd be afraid to even say that any test is better than no test because I'm not sure in this situation that it is. I think it really depends on the population. And if you've got a population that's largely already vaccinated... I don't know the answer. What do you think?

Rodeo: You bring up an important point, which is that for any test, it depends on your pretest suspicion. If you have a very low prevalence in that population — young, otherwise healthy individuals, vaccinated — that impacts what test you use and the underlying specificity and sensitivity of that test. And you need to marry that with just logistics, cost, results management. When do you test? In the morning? In the evening? These athletes have busy schedules between training, resting, media, performing. It's going to be a logistical challenge for the organizers and each delegation and each team will have to manage that the best way for them. Everybody's on amazingly different schedules. I remember that at the Olympic Village, people are coming and going at all hours. Some compete in the morning. Some finals don't end until 11:00 PM or midnight, and the athletes get back to the village at 1:00 and you're eating dinner at 1:00 AM. Very different schedules. All those logistics need to be figured into and married with the science and the data.

Callahan: In pro sports, a lot of times you've got the players who are the regular rotation players, but then you've got the other guys sitting on the bench who can step in if somebody gets hurt or somebody gets sick or somebody has a positive test. At the Olympics, you're not sending those extra people. One false-positive test or one true-positive test is just going to have a tremendous domino effect.

Rodeo: That's exactly right. In swimming, there are only two individuals per event. To make an Olympic team is frankly as hard or harder than medaling in the Olympics. We leave people home who could possibly medal, and when someone's sick, there's no substitute, obviously.

Rodeo: In the NBA and the NFL, we've used these wearable devices for contact tracing. My understanding is that the International Olympic Committee is giving athletes a smartphone with an app, which may not be quite as effective or feasible as these wearable devices. What are your thoughts on how to contact-trace with this huge number of people? Contact tracing is complex. It takes human and financial resources. There are probably more questions than answers in this area as well.

Callahan: It's a daunting task when you're taking people from different countries, people who speak different languages, people who have different cultural backgrounds, people with different vaccination rates, and you're bringing them all into this kind of an event. I think the contact tracing could be fascinating, which is, again, why I think you've really got to do pretty regular testing, because the more vaccinations you have, the more positives you prevent, and the more positives you prevent, the more contact tracing you prevent. I don't know what you do when you've got a medal round and somebody tests positive, and they're playing a team from another country. It's like I said earlier: It's going to take somebody smarter than me to figure that part out.

Rodeo: That's exactly my concern as well. Again, it goes back to vaccines, because if you're unvaccinated and contact tracing identifies you as a close contact, you're stuck. You have this necessary, mandatory quarantine. Whereas if you're vaccinated, many now will say that you don't need to have that quarantine. So, again, back to the ounce of prevention being better than a pound of cure.

Callahan: Remember, in the United States, we're incredibly fortunate. Our resources are so much more than some other countries'. I really hope that other countries are going to have an opportunity for their delegations to be vaccinated.

Scott, I wanted to say one other thing before we go. Like you just said, we have a lot of questions right now. We have more questions than answers. But if you think back to the 2016 Olympics, when we were in Rio, we dealt with Zika then. Infectious diseases are here to stay. Hopefully this is the last pandemic in our lifetime, but it won't be the last time we see infectious diseases affecting an international event. So I'm hopeful that we take all the lessons that come out of this and we really learn and we apply them so that we get better and better at managing these. And I know we all are hoping that by the time we get back to the next Olympics, COVID is in our rearview mirror and hopefully we'll have more knowledge about mitigation of risk for illness.

Rodeo: Totally agree. And it's not just in international sports; all of our national and international medical societies broadly have recognized the importance of learning lessons from this experience. How can we be better prepared next time around? The international community dealt with SARS-1 in 2003-2004, then the Middle Eastern respiratory syndrome several years later, and now this. What lessons have we learned? How do we do better next time? How do we be better prepared? Because you're right — there will be another pandemic, whether that's next year or in 5 years or 15 years. We don't know. But the risk is there. Well, thank you so much.

Callahan: It was great getting to catch up with you a little bit this way.

Rodeo: It was fun. I enjoyed it. I learned a lot from you, as always. Thank you for sharing your expertise and experience.

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