THE PHYSICIAN AND SPORTSMEDICINE - VOL 33 - NO. 10 - OCTOBER 2022
Expert Panel Recommends Pertussis Booster
Reported cases of pertussis have reached a 40-year high, according to the Centers for Disease Control and Prevention (CDC) in Atlanta. Pertussis cases have increased from a low of 1,020 in 1976 to more than 19,000 cases in 2004.
Preteens and teens are thought to be most at risk, because protective immunity from early childhood pertussis vaccination wanes 5 to 10 years after the patient's last dose. To address these concerns, the CDC's Advisory Committee on Immunization Practices (ACIP) in June recommended that 11- and 12-year-olds be given newly licensed tetanus, diphtheria, and pertussis (Tdap) boosters to help reduce the number of pertussis cases among adolescents. Previously, a booster containing only tetanus and diphtheria (Td) was recommended for adolescents.
New Vaccines Meet Immunization Needs
The US Food and Drug Administration (FDA) licensed GlaxoSmithKline's Boostrix Tdap vaccine for adolescents in May, and in June it licensed Sanofi Pasteur's Adacel Tdap vaccine. Boostrix is licensed for patients ages 10 through 18, and Adacel is licensed for patients ages 11 through 64. The ACIP also recommended that two additional groups receive the Tdap vaccine: adolescents ages 13 to 18 who missed their age 11 to 12 dose of Td and adolescents ages 11 to 18 who have already been vaccinated with Td.
In a press release from the CDC, Steve Cochi, MD, acting director of the CDC's National Immunization Program, said treatment of pertussis is effective only if given early—often before symptoms are recognized as pertussis. "Therefore, vaccination is the best way to prevent suffering from pertussis," he said. "This recommendation is an important step in reducing this potentially serious disease." Given that pertussis can be a life-threatening disease in infants, Cochi advised parents to vaccinate their children on time: at 2, 4, 6, and 15 to 18 months and between ages 4 and 6.
The ACIP did not make a recommendation for the use of Tdap in adults. The group will consider adult Tdap immunization at a later date to allow members more time to review adult pertussis immunization data.
A Sports Medicine Issue?
A. J. Grove, MD, a pediatrician and sports medicine physician at Columbia Park Medical Group in Andover, Minnesota, says he has noted a number of pertussis outbreaks in his community, including one that involved a girl's hockey team. He says most cases are clustered in the middle school age-group, though some patients have been high school students. "Even this summer we saw sporadic cases, but the disease activity seemed primarily in the winter," he says.
Grove says team members are at risk when a player has pertussis. "Pertussis is highly contagious, with an airborne spread and from contact with nasal secretions," he says. "Teams are in close contact, and sick players often hack and cough on the bench, as well as share water bottles."
When a player is diagnosed as having pertussis, the team should be informed and the teammates tested. Prophylactic treatment may be appropriate for the teammates and household contacts, he says, noting that the larger concern is when a young, active patient who has pertussis puts younger siblings at home at risk.
Observing community pertussis patterns and having a high index of suspicion when a patient has paroxysmal coughing are the keys to diagnosis, Grove says. "If in doubt, I test," he says. Grove says he anticipates that his clinic will adopt the ACIP pertussis booster recommendations quickly as it did for the meningitis vaccine.
When an athlete is diagnosed as having pertussis, Grove usually recommends that he or she stay home during the first 5 days of treatment. Fatigue from the coughing is a concern for many athletes, he says. The usual pharmacologic treatment is 14 days of erythromycin or a 5-day course of azithromycin. "If a patient has more severe disease, I usually go with the erythromycin because it's still the established treatment of choice," Grove says.
Sports Medicine Physicians Feel Katrina's Impact
Physicians, their practices, and their training have all taken a hard hit in the recent Gulf coast hurricanes. A recent analysis by researchers at the University of North Carolina (UNC) at Chapel Hill suggests that 20,000 physicians were affected by Hurricane Katrina and that up to 6,000 may have been displaced.
About 1,270 of the affected physicians were residents in training. The two New Orleans medical schools—Tulane University and Louisiana State University—enrolled about 1,300 medical students who have been moved to other schools in the region. "We don't know what this is going to mean to healthcare; we've never had to deal with something like this before," said Thomas C. Ricketts, MD, deputy director for policy analysis at UNC's Cecil G. Sheps Center for Health Services Research. The initial findings of the report were announced in a press release from UNC.
To gauge how the hurricane affected the families and practices of sports medicine physicians, THE PHYSICIAN AND SPORTSMEDICINE contacted by e-mail several who live in and near the affected areas. Here are the responses of those who have been able to reply.
Thomas K. Bond, MD, chief of sports medicine, Section of Family Medicine, Louisiana State University, New Orleans. This is the first time I've been able to check my e-mail since we evacuated. Although we lost our home and medical practice, my wife and I, along with our 6-month-old son, Thomas, remain positive and determined to rebuild. I'm currently working with the Federal Emergency Management Agency (FEMA) providing medical services to the people south of New Orleans. It has been absolutely the most amazing medical experience of my career, and I'll have plenty of stories, once things return to normalcy. I'm making arrangements to temporarily move our fellowship program to Lafayette so our fellow can complete the year.
Matt McQueen, MD, family practice physician, Ochsner Clinic Foundation, Lakeview Family Practice, New Orleans. I was recalled to active military duty a couple weeks prior to the storm, and I feel blessed that I have a viable job. Likewise, we had all our affairs in order as the result of Reserve Readiness. I had prepared a couple evacuation tubs with photos and important documents ready to go, and had copies of some things with me.
My wife and kids evacuated to the Florida panhandle and are living with my mother. My kids had to enroll in the Walton County public schools. The immense caring and efforts of the folks in Walton County and Santa Rosa Beach are truly commendable.
Our home was in Metairie, and apparently remained dry and intact. Though we have not been back just yet, we've had neighbors and friends inspect it. Our neighbors just across the street were not so lucky, as two lost roofs and suffered major internal rain damage.
My office building was likewise very unlucky. Located just a quarter mile from the flooded side of the 17th Street levee breech, it was flooded to the first floor and may have other damage, as well. More important are the homes of our patients and community in Lakeview and to the east, whose homes are the ones you saw flooded to the ceilings. It's hard to imagine the thousands of these homes that will have to be razed, and the lost jobs, displaced friends, and on and on.
Our main Ochsner hospital and clinic, and many of the other satellites, are up and running. When folks finally get to come home, most of our medical services will be there to greet them. This was a truly incredible feat.
Robert K. Collins, MD, director, John C. Longest Student Health Center, Mississippi State University, Mississippi State, Mississippi. Living in the northern part of Mississippi, we were without power 14 hours at home and did not lose power at the clinic. We have had an influx of evacuees from the coastal parts of Mississippi and Louisiana. Many are here until they can get living quarters (trailers) on the coast. Many of our students had family move in with them. All have needs. Many are in denial; some are resigned. We have started physical therapy on patients who had surgery prior to Katrina. We have removed sutures on others from before and after the storm. We have several athletes who have lost everything, and within the bounds of the National Collegiate Athletic Association are helping them with things they lost.
Personally, we are doing well. I have a godchild who, with her two dogs, is living with my wife and me and attending our high school. Hers was washed away with all of her belongings.
F. Clarke Holmes, MD, sports medicine physician, University Sports Medicine, Jackson, Mississippi. By the time Katrina reached the Jackson area, it was still a category 1 hurricane. The damage in our area involved power outages, 2 to 4 days for most, phone outages, and a moderate amount of trees uprooted with associated roof and vehicle damages. We were very lucky when compared with the Mississippi Gulf coast.
My clinic never closed. I volunteered at clinics near a major Jackson shelter and provided orthopedic care to evacuees. We are providing free sports medicine physicals to high school and college student-athletes who have relocated to our area.
High school football and other sports were cancelled statewide for 1 week, and many of the teams we cover also postponed their games for an additional week. The college that I'm team physician for postponed its opening football game. I also serve as team physician for an Atlanta Braves minor league affiliate, and it cancelled its entire final homestand. My medical group kept several of our nonessential employees home from work due to gas shortages and power outages.
Obviously, Hurricane Katrina has affected my life in many ways these past few weeks, but not in a catastrophic fashion. I simply feel lucky to have been spared from a major disaster and hope that I can continue to help whose needs are much greater than mine.
CDC Launches Concussion Prevention Initiative
"It's better to miss one game than the whole season" is the theme of a new education initiative about concussion and second impact syndrome from the Centers for Disease Control and Prevention (CDC) in Atlanta. About 300,000 sports- and recreation-related concussions occur nationwide each year, and many happen during high school games, drills, and practices.
A free "Heads' Up: Concussion in High School Sports" kit designed for coaches includes posters, a concussion guide, concussion fact sheets for parents and athletes in English and Spanish, a clipboard sticker, a wallet card, and an educational video to share with parents, students, and school staff. The video shows the consequences that one family faced when an athlete's parents were inadequately informed and failed to recognize the importance of taking their child to a doctor for follow-up care. The kit can be ordered or downloaded on the Web at https://www.cdc.gov/ncipc/tbi/Coaches_Tool_Kit.htm.
The CDC's prevention approach is twofold. First, coaches, school staff, and parents should learn how to recognize the signs and symptoms of concussion in students. All injured athletes should be withheld from play until cleared by a medical professional. Coaches should teach safe play and insist that safety equipment be properly used. Teachers can help by letting the coach know if a student-athlete's grades suddenly fall. School personnel should be sure that injury information is shared between coaches as the athletes move into the next season's sports. Sideline preparations should include a specific plan to manage concussions.
Second, athletes should be taught to take head impacts and bumps seriously and to report all head injuries promptly. Players should know the symptoms of concussion and tell the coach if they observe out-of-character behavior in another player. Athletes should play in an atmosphere that encourages incident reporting. High school students should be aware that symptoms of a concussion may develop weeks later, even if the injury seemed minor at the time, and that taking enough time to recover from injuries is far more important than achieving a varsity letter.
Organizations participating with the CDC in this initiative include the American Academy of Pediatrics, the American College of Sports Medicine, the National Athletic Trainers' Association, the National Federation of State High School Associations, and 11 other partners.
Patricia D. Mees
NFHS Issues Infectious Skin Disease Policy
The sports medicine advisory committee of the National Federation of State High School Associations (NFHS) recently updated its communicable disease policy, which previously focused solely on guarding against blood-borne pathogens.
According to a press release from the NFHS, the updated policy now includes information on infectious skin diseases and preventing student-athlete transmission with a universal hygiene protocol for all sports. Jerry Diehl, NFHS assistant director and liaison to the sports medicine advisory committee, said blood-borne pathogens aren't less of a concern, but that infectious skin diseases such as methycillin-resistant Staphylococcus aureus have become more of a problem.
According to the new policy, a guardian, athletic trainer, and coach should be notified of any lesion before the athlete participates in competition or practice. The lesion must be evaluated by a healthcare provider before the athlete returns to competition. The policy also suggests that the athlete's teammates be evaluated for the potential spread of infection, particularly in contact sports. Healthcare providers are advised to follow return-to-play recommendations that have been published by the NFHS or state or local associations.
The NFHS's new universal hygiene protocol advises athletes in all sports to:
•Shower immediately after competition or practice,
•Wash all workout clothing after practice,
•Wash personal gear, such as knee pads, periodically,
•Avoid sharing towels or other personal hygiene products with others, and
•Refrain from cosmetic shaving.
More information about the revisions to the NFHS communicable disease policy can be found on the organization's Web site at https://www.nfhs.org.