On March 22, about a week after the coronavirus slowed the sports world to a crawl, a U.S. aircraft carrier in the Pacific Ocean reported its first case of infection. Two weeks later, 150 sailors on the USS Teddy Roosevelt tested positive for the disease and one of those, a hospitalized chief petty officer, died from it. By early May, six weeks after the initial positive test, more than 1,150 sailors—roughly one-quarter of the Roosevelt’s crew—were infected with coronavirus in one of the largest close-quarter spreads in the global outbreak: an epidemic within a pandemic.
In an unsettling twist, many of those who tested positive experienced no symptoms. They represent what medical experts believe to be the most deadly weapon of the coronavirus: asymptomatic spread.
As athletes return to training across the country, some doctors fear that college campuses exhibit similar qualities as the USS Roosevelt: young, seemingly healthy people gathered in close proximity for physical and social interaction—a recipe for a rapid spread of an invisible disease. The asymptomatic individual represents the most significant hurdle in a return to college sports, potentially derailing weeks of forward progress toward an on-time kickoff to the 2020 college football season.
But to combat the virus’s ultimate weapon, there is a solution: testing. Initial and frequent testing is a way to expose—and subsequently isolate—asymptomatic people. However, in varying reopening plans released last week, some universities plan to only initially test athletes experiencing symptoms, and many more do not plan frequent testing during June workouts. The vast majority of medical professionals who spoke to Sports Illustrated for this story are vexed by such plans. Refusing to initially test athletes is a “fool’s errand,” one said, while another described the approach as concerning. Steven Goodman, a professor of epidemiology at Stanford and an avid sports fan, was struck when told about the plans from some schools. “I’ll use an adjective to describe that: surprising,” he says. “You absolutely have to test everybody when they first come back because you have to know if there are any actively infected students. Objectively, they’re taking chances.”
But others say it’s not so easy. The medical community is somewhat split on the practice of testing people without symptoms. In fact, among the general public, doctors don’t recommend people be tested if they aren’t experiencing symptoms. But what about sports? “A lot of people are trying to come up with their best guess,” says Amesh Adalja, a senior scholar at John Hopkins University and an infectious disease physician who sits on the NCAA COVID-19 advisory panel. “I don’t think we’ve come to a consensus in general as a society or even as a task force at the NCAA about what the appropriate amount of testing is needed yet.”
Sports Illustrated spoke to a dozen medical experts across the nation. The list includes several epidemiologists from both the East Coast and the West Coast; three team physicians, one each from the West, Midwest and Southeast; at least two doctors working daily with virus patients; a cardiac specialist whose recent writings in medical journals have sparked another issue entirely; and the NCAA’s chief medical officer, Brian Hainline.
They weighed in on a debate: to test or not to test—and if you do test, how much is appropriate? The dissent among them speaks to the novelty of a disease that the world hasn’t seen since the flu pandemic of 1918. “There is not one best testing practice,” says Hainline. “No one has been through anything like this, unless you’re over 100 years old.”
On Monday, the first day some schools began on-campus training, Marshall University announced that two athletes and a staff member tested positive for coronavirus and were being quarantined.
All three, the school said, are asymptomatic.
Most college reopening plans are similar in terms of sanitation methods, mask-wearing protocols and social distancing guidelines. But they vary greatly in one very important topic: testing. At some schools, like Missouri and Arkansas, athletes will not be tested upon initially arriving on campus unless they are showing symptoms. At others, like LSU, athletes will only receive an antibody (blood) test, which determines if a person has previously contracted the virus—not if they are currently infected. Meanwhile, at Florida and Nebraska, officials plan to administer to athletes upon arrival a polymerase chain reaction test (PCR), the most widely used and reliable diagnostic method in which an administer reaches a prolonged Q tip deep into the nasal cavity for what’s called a nasopharyngeal swab.
Most conferences are issuing only reopening guidelines and suggestions for their members, since most include such sprawling, multi-state footprints. However, the Pac-12 will require initial and weekly virus testing from its schools, commissioner Larry Scott told 247Sports.com. Some are going even a step further. At Tulane, team doctor Greg Stewart is considering a twice-a-week virus test for athletes—a protocol that most if not all schools will follow once full practices and/or the season begin. “We’re making assumptions that all of them are asymptomatic,” Stewart says.
The deeper into the summer and fall, the more efficient and abundant testing becomes—and, as contact increases, the more necessary. There is little to no contact expected in football facilities until an NCAA-approved six-week training camp begins, likely in mid to late July. In the meantime, players will work in small groups, without coaching interaction, lifting weights and cycling through conditioning drills.
Because of the lack of contact, some medical experts are advising teams not to test athletes without symptoms. That’s the case in Missouri, as well as LSU. Testing should be based on a team’s “mode of contact” and the prevalence of the virus in the community, says Catherine O’Neal, an infectious disease specialist in Baton Rouge who represents LSU on the SEC’s medical guidance task force. “I’ve seen some schools’ plans and it goes into what’s going to happen when we play a game. Well, we’re not playing games right now,” O’Neal says. “I don’t think the possibility of having an asymptomatic person changes our thought process. We expect it, dealing with young people that we’ll have asymptomatic carriage. You build your plan around being as safe as possible and understand the risk. Testing is just a piece of it.”
For some medical professionals, it is the essential piece, given asymptomatic carriers. The virus is so new that researchers are still uncertain about two important pieces of information: (1) the number of asymptomatic people among those infected and (2) the transmission rate of an asymptomatic person compared to one coughing and sneezing. While the Center for Disease Control and Prevention puts asymptomatic numbers at one-third of those infected worldwide, the numbers vary greatly among the medical community, as high as 50% and as low as 25%. As for transmission, one China study found that 75-80% of infections came from asymptomatic, mildly-symptomatic or pre-symptomatic people. One thing medical experts can agree on: the proportion of those asymptomatic are greater in young people. Even the NCAA’s own guidelines cite the high occurrences of asymptomatic infections “especially in young, healthy Americans.”
Asymptomatic research is a murky subject, partially because the definition of asymptomatic itself is dependent on an individual’s threshold. What one person might describe as a slight cough and mild headache, another person might call a whooping cough and dizzying migraine. For athletes accustomed to playing through pain, identifying and then revealing symptoms becomes even more difficult. Who knows if they’ll be honest, and some may even ignore symptoms subconsciously, says Mark Cullen, another epidemiologist at Stanford who has spent his entire career as a researcher in work-related chronic diseases. “Sometimes it’s not conscious denial,” says Cullen. “We’re tough guys, right? You don’t report little sissy crap—sore throat, fever. Why would we be bother the coach with that crap? Unfortunately, a sore throat or fever could ruin the entire season for a team.”
As a way to help identify asymptomatic or mildly-symptomatic carriers, the NCAA COVID-19 advisory panel recently created a more exhaustive list of symptoms, Hainline says. They include common ailments such as headache, muscle pain and nausea, a trio of conditions that football players might experience after a normal weight-training and conditioning workout.
Late onset symptoms are another worry, too. On average, an infected person’s symptoms may not emerge until five days after they contracted the virus. “To wait until athletes have symptoms, depending on the sport, you’ll be falling behind,” says Jon Drezner, the team physician at the University of Washington. "One of the time periods of highest risk to transmit the virus is the first 42 hours.”
Last week, during a virtual news conference with reporters, Auburn men's basketball coach Bruce Pearl suggested that college athletes’ return to campus this summer was an experimental step in a potential return of the full student body this fall. Are college players glorified guinea pigs?
In fact, doctors say yes. Like it or not, this is seen by the medical community as a trial period when crucial knowledge can be gleaned. “Every university is an experiment. Every state opening up is an experiment,” says Goodman, one of the epidemiologists from Stanford. “If all these colleges are doing this a different way, we need to be studying it and look at these risks. The questions you are asking don’t have good answers, but we could have good answers if we study each of these teams. The most important weapon we have against this epidemic is this information.”
Some of that will come from overseas. While college athletes are some of the first in America to return to their teams, Germany’s Bundesliga soccer league resumed actual competition last month. Under the league’s hygiene plan, players are tested regularly and then quarantined for positive tests. At one point, an entire team was quarantined. More than 20,000 tests for the virus will be carried out on players, coaching staff and other team officials.
When college athletic seasons do begin, Adalja, the infectious disease physician from John Hopkins, expects NCAA conferences and schools to model their in-season plans after those on the professional level. The NHL recently revealed a plan for its postseason in which every player is tested each evening. Big 12 commissioner Bob Bowlsby has suggested that college players could be tested two to three times a week during the season. But in-season testing protocols are a long way from being finalized. Doctors are certain of one thing: the procedures used for contactless June workouts won’t be the same as those used for August camp and September games. “They’ll have to be different,” says Doug Aukerman, a long time athletics physician and associate athletic director at Oregon State who chairs the Pac-12’s medical advisory board. “What they’ll look like is probably too soon to predict.”
Aukerman says the Pac-12 advisory group has had “robust discussion” around testing as they pore over data to create conference-wide guidelines for June workouts and beyond. The same goes for the Big Ten, where Chris Kratochvil, a leader in medical research at the University of Nebraska Medical Center, chairs the conference’s task force on emerging diseases. Big Ten medical leaders have settled on a three-stage approach for easing into football, increasing in the frequency of testing with each stage: (1) return to campus, (2) return to practice and (3) return to competition.
But unlike the Pac-12, the league does not plan to require testing, leaving that up to individual programs. “There are a lot of different ways testing can be used and you’re certainly seeing that play out. There are so many variables going into each of those decisions: outbreak in the community, accessibility and the resources to conduct the testing,” Kratochvil says. “It’s going to be very difficult to have a one-size-fits-all policy. We’re so early on in this global pandemic that a month from now we might have some testing modalities we don’t have at this time.”
Current testing has its own problems. That goes even for the PCR test, which can produce false positives by detecting samples of a dead virus, says O’Neal, the Baton Rouge physician. Sometimes, a PCR test is administered too soon after an athlete contracts the virus, returning a negative for a patient that is actually positive. “They’re not 100% perfect,” says Goodman.
Diagnostic tests like PCR are performed in a laboratory and can be returned within hours. There are other, faster testing options, but none as reliable and widespread as the PCR test. With each passing day, however, that’s changing. The strides made in point-of-care testing—those with immediate results at the testing site—have been significant. Just last week, there was a breakthrough in saliva testing, says Hainline, the NCAA’s chief medical officer. Saliva testing could open the door to bulk testing, which is already beginning in some places. Bulk testing allows technicians to test multiple people using one sample. For instance, 20 football players could spit in a sample jar. If the sample turns out negative, all 20 can be cleared. “It could solve some problems around game time,” Hainline says, but there is a problem: the testing is currently about 80% accurate.
The same goes for an antigen point-of-care test that the FDA authorized in early May. The test, administered through a normal nasal swab, is returned quickly, but there is a higher chance of false negatives, so negative results do not rule out infection. An antibody test—a blood sample—isn’t perfect, either. It could actually generate false negatives, returning positives for a different type of coronavirus, one that causes the common cold, not COVID-19. “This disease has put a spotlight on the practice of doing tests without symptoms that correlate to the disease you’re looking for,” O’Neal says. “The concern is the more sensitive your test, if you apply that test to people without symptoms, you’ll find people who have a virus in their nose but don’t have the disease.”
Athletes rights advocates, however, are concerned about the varying college reopening plans. Those include Donna Lopiano, a longtime college administrator who is now president-elect of the Drake Group, an education-first organization of academics. Told that some schools don’t plan to test their athletes once they arrive on campus, Lopiano replied, “That’s nuts!” She believes money plays a part in the issue. On average, a PCR test can cost $100-200 each. To perform a requisite amount of testing on each athlete, prices can soar to more than $400,000, Mountain West commissioner Craig Thompson told SI last month. Lopiano estimates it at as much as $600,000.
A school’s insurance may cover the cost, but like many questions connected to the virus, that’s still unanswered, says Derita Ratcliffe, deputy athletics director at Arkansas who is overseeing the Razorbacks’ reopening. “There is thought right now that those things are going to be covered (by insurance),” she says, “but we don’t have past data that that is the case.”
Athletes from at least one school have expressed enough concern in returning to campus that the university’s student council got involved. The UCLA Student Council, on anonymous complaints from athletes, adopted a resolution last week seeking a series of coronavirus-related protections from political and campus leaders. Ramogi Huma, the president of the National College Players Association and a frequent NCAA critic, believes that more athletes would do the same if they didn’t fear retribution. “When you look at the other multi-billion dollar sports leagues, their plans include a lot of testing,” Huma says. “No surprise... those players have unions. What you’re seeing is the colleges taking advantage of players not having representation.”
Ironically, those at greatest risk are the coaches. More than any other, the virus targets older populations with underlying health issues. “Testing is going to be key in this whole thing,” USC coach Clay Helton says, “because of one area: asymptomatic individuals.”
When most think of coronavirus, the first organ that pops into their mind is likely the lungs. While the virus primarily attacks a human’s ability to breathe, it can leave lasting impacts on the heart.
Drezner, the team physician at the University of Washington and an expert on sports cardiology, is also the deputy editor of the Business Journal of Sports Medicine, where he’s explored the potential effects of the virus on an athlete’s heart. Some hospitalized virus patients—not athletes—have experienced enough heart damage to have Drezner and others concerned. Could the same issues—myocarditis—appear in asymptomatic athletes and those who have recovered from the disease? Even before the virus, myocarditis was responsible for 2-5% of all cardiac deaths in young athletes, Drezner says.
If antibody and PCR tests conclude that an athlete has or has had the virus, they may need more serious heart evaluations, including an EKG. Those schools not testing their athletes initially run the risk of missing what could be a potential life-threatening heart issue, a concerning factor for Aukerman, the Oregon State team doctor leading the Pac-12’s reopening plan. “If we’re not going to test, you’d need to consider doing an EKG on every single one of them,” he says.
Not every doctor sees it like that. In Baton Rouge, O’Neal says that there is no evidence of asymptomatic, healthy athletes developing cardiac disease. Drezner acknowledges that the research is still a ways from over. Question marks linger. Think of the virus as a puzzle, with this as just another small piece. Experts are a long way from finding its rightful place, and they’re even farther away from completing the puzzle.
UCLA coach Chip Kelly has just as many questions as the doctors themselves. He has several players from near hotspots, including Seattle and New York.“We’ve got to test the kids when they first get back,” he says, “and then is it biweekly testing or once-a-week testing? That’s a huge question mark in my mind. Until you get a national testing program that can be brought to scale, how do we do this? And are we taking away tests that people are in need of? How are we to say in the college football community, ‘Well, we need the test.’”
The aforementioned testing inaccuracies aside, there are other issues to consider when administering multiple tests to athletes so early in the evolution of the disease, none more important than the accessibility of tests. For example, O’Neal says she’s in a constant state of worry that her hospital’s supply may run dry. In Nebraska, Kratochvil says there are only three circumstances in which a person is administered a test: (1) someone who arrives at the hospital experiencing symptoms; (2) first-responders fighting the virus on the front lines; and (3) random bulk testing to determine unidentified cases.
There are other considerations before testing frequently or even initially. At NCAA headquarters, Hainline believes that acquiring a team’s baseline through initial testing can produce a false sense of security. His main worry are athletes who produce a false negative because they’ve only contracted the disease a day earlier. “Testing everyone coming in is not perfect,” he says, but what if an athlete is exposed a day later? A player might test negative on a Monday and contract the virus during a house party on a Tuesday. “It’s when they leave your facility that you’ve got to really be careful,” Georgia athletic director Greg McGarity says.
At Houston, TJ Meagher, an associate athletic director overseeing the Cougars’ reopening, says a message will be drilled into athletes: "If you don’t make responsible decisions, you put the team at risk." But will that work? Some are skeptical. “Did you see Lake of the Ozarks (pool party videos)?” says Lopiano. “You tell me whether those kids are going to stay in the dorm at night.”
Kratochvil, the Big Ten’s COVID-19 task force chair, is a seasoned physician who’s been on the front lines of the pandemic as the executive director of the Nebraska Global Center for Health Security. In February, virus victims from the Diamond Princess cruise ship were transported, quarantined and treated at his facility. He saw people arrive who have no symptoms, yet tested positive. Kratochvil was the first medical expert to speak of another ship, the USS Roosevelt, in the same context as college athletics. “Some of those considerations found there are not terribly different in what we see in athletics,” he says.
A vaccine would quell the fear of asymptomatics and basically end the argument over testing, but it’s months or even years away, experts say. Vaccine projections of 12-18 months are a best-case scenario. Adalja, the physician from John Hopkins, believes a vaccine won’t arrive until January 2022. Developing a vaccine is historically a multi-year process, involving lengthy trial-and-error hurdles and mass production barriers, a “herculean” effort to overcome in less than 18 months, says Cullen, the former Yale and current Stanford epidemiologist.
Cullen is amazed at how soon colleges are welcoming back athletes to their campus and believes that short-term economic gains will be destroyed by long-term economic failures. He concedes that his approach is one of caution, shaped by decades of studying infectious diseases. He’s the doctor who referred to a school’s decision not to initially and frequently test athletes as a fool’s errand. “No testing is just bizarre,” he says. “We need to be realistic that we’re dealing with a rather formidable opponent. That’s the way coaches have to think about it. On the Stanford schedule, Notre Dame is always the toughest game. This is going to be a hell of a lot tougher than Notre Dame. This is a very tough opponent and a season-long opponent—on the bench, in the locker room, on the field and in the dorms the entire season.”
Sometimes the opponent is all together invisible. Try tackling a ball carrier you can’t see. “This virus has thrown many, many nasty little twists, but far and away the nastiness of its twists is its ability to spread from asymptomatic people,” Cullen says. “You wait for someone to have a fever or demonstrative cough, you’ve waited three days too long.”