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Q&A Transcript | Covid Update: Return to Play Webinar

The following is a transcript of the Q&A resource utilized during the Friday webinar titled Covid Update: Return to Play and Special Topics in Sports. More than 500 registered for the discussion with USCAH physicians Dr. Jim Borchers, Dr. Chad Asplund and Dr. Doug Aukerman. 

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I have some athletes who got the booster and subsequently tested positive via PCR. Is there any validity to a false positive due to the booster?
The NBA and NFL are using the CT levels on the PCR tests. The higher the CT value the lower viral load. NBA using CT level of 32 as “negative test” NFL is using CT of 30, but that is also test dependent. So it is possible to get a “false” positive or inconclusive PCR test

With the recommendation of 5-day isolation, we're understanding this as a 5-day isolation and testing at day 6. Dr. Borchers, you mention testing on day 5, is that what we should be doing?
Day of positive test is Day 0 with isolation on days 1-5.

If possible touch on unvaccinated close contacts and quarantine guidelines. Currently NCAA recommends quarantine if there was close contact by an unvaccinated individual if they are close contact with a positive person.
Unvaxxed or incompletely vaxxed close contacts should quarantine at home for 5 days and then may resume contact with others if wearing a well-fitting mask. It is also recommended that they get tested on day 5.

What are your thoughts on a gradual return to play protocol after getting out of isolation? How many days should that protocol take before fully practicing?
It depends on vax status, which will dictate to some extent severity of disease and amount of virus, fitness of the athlete going into isolation/quarantine and he length of isolation/quarantine. For a vaxxed or boosted fit athlete with a time out less than 7 days they can return back to play. If unfit but fully vaxxed, will likely need a 1-3 day return to play. If unfit and unvaxxed or out > 7 days, full transition period is recommended.

Is it more likely that an unvaccinated Covid positive athlete would test positive on Day 5/6?  Should we just not test them and have them mask till day 10
Yes, unvaxxed will likely remain positive past day 9-10. 

Do you have a good graduated return to play protocol? I have been using the BJSM paper but it is 17 days from positive. I am worried that since they reduced isolation days is there a reduced RTP protocol?
We have a generic 1-3 day and a 7-day protocol. Essentially it should start with light aerobic activity and then move towards gradual return of sport specific activities. Speed of progress through the progression can be fairly athlete specific.

Is there still any recommendation on getting a POST COVID physical exam in athletes who have minimal to no symptoms?
Athletes should have a medical evaluation - that could be done by an athletic trainer. If they have no symptoms, they will likely have a normal exam. The focus is really on how do they handle the return to play process. Those that struggle or are unable to return or progress, will need more evaluation (possibly cardiac or pulmonary testing).

What’s the recommendation with positive PCR tests at day 10-11?
Once you get past 10 days, you are no longer consider infectious. The previous guideline on why not to test unvaxxed people for 90 days is that many people will still test positive after the 10-day period (mostly true in unvaxxed or incompletely vaxxed)

As many of us highly encourage our SAs to get boosted, especially if they are more than 6 months out from being fully vaccinated, when would we be able to consider them as being boosted as it applies to CDC Covid protocols for quarantine and isolation?
2 weeks after vaccination/booster shot, they would be considered fully boosted

Do all athletes still need a medical evaluation post Covid prior to return to play? Asymptomatic and symptomatic?
Athletes should have a medical evaluation - that could be done by an athletic trainer. If they have no symptoms, they will likely have a normal exam. The focus is really on how do they handle the return to play process. Those that struggle or are unable to return or progress, will need more evaluation (possibly cardiac or pulmonary testing).

How long is this wave expected to last? I’m hearing around 2 more weeks.
Omicron is expected to peak nationwide in next 2 weeks, but there will be some geographic variability

Would any of these recommendations to allow back unmasked on day 6 change if the team is mostly unvaccinated?
Think we addressed this, but I would not recommend allowing unmasked athletes back before the end of the full 10-day window.

Dr Aukerman, based on your assessment, do you intend to allow athletes out of isolation prior to day 10 without a negative test on/after day 6?
Not to participate without a mask in close proximity to others.

All post positive isolation cases require a medical examination for whether day 5 or full 10 days of isolation before initiating a RTP. And shouldn’t all still be symptom free for 2-3 days before initiating a RTP protocol.
Last week CDC said symptoms improving and fever free x  24 hours. This week’s guidance said symptoms improved and fever free x 24 hours (loss of smell/taste may last longer)

What's considered "minimal standard of care" post-COVID positive for 'Return to Play'? Are we still recommending EKG, Bloodwork, Echocardiograms etc?
Asymptomatic or mild symptoms do not require cardiac clearance prior to return to play. Moderate may (should have a medical evaluation) and severe (hospitalized) should definitely have cardiac evalhttps://www.amssm.org/Content/pdf-files/COVID19/NCAA_COVID-18-AUG-2021.pdf

During days 6-10 should mask wearing be for outdoor student athletes as well?
If you are outdoors, and are vaxxed/boosted, I think for sport-specific activities you could go unmasked, but should still mask for meetings, travel, social activities.

Would you recommend a PCR over antigen test for unvaccinated individuals who were exposed?
PCR is more specific and will identify these individuals earlier.

Do all these recommendations apply to middle school and high school athletes? Or are there separate recommendations in regards to RTP and examinations post-covid?
They apply to all levels. But it is OK to be a bit more conservative with middle and high school athletes.

If we start looking at spring sports, where close contact is limited for some positions...is it necessary to mask for activity if they don't test?  For example, a pitcher is standing on the mound by himself.
Outdoor in spring will be less risk - there may be more tolerance for the situation you pose for not requiring masking

Working at a college, coaches want a written policy on return to play from covid. How can we portray that everyone will have a different return to play protocol, while maintaining good rapport with players and coaches?
I think the guidelines and recommendations are just that. I think educating the coaches/administrators about the individual nature of this disease may be helpful. Also, try to educate coaches that athlete A may be able return at day 5, athlete B may not be able to return at Day 7

If tests aren't available for testing on day 5/6, what types of masks are available/acceptable to use for activity?
KN95 or well-fitting surgical masks are the best. If cloth it should be at least two layers and again cover nose/mouth

For mild case I am currently using cardiac maneuvers such as Valsalva and hand grip squeeze to tease out subtle cardiovascular pathology with history taking. Any other recommendations for especially since we are moving away from widespread EKG and echo use in  the mild cases to pick up myocarditis. Or should we take an approach to tell coaches and patients that there is a risk and we just have to monitor?
Those are excellent clinical maneuvers to try to tease out subtle pathology. Latest guidance: https://www.amssm.org/Content/pdf-files/COVID19/NCAA_COVID-18-AUG-2021.pdf

Asymptomatic or mildly symptomatic athletes don’t require cardiac testing for return to play

According to the NCAA Sports Science Release last night, they have redefined Fully Vaccinated to mea?
NCAA guidance states:

  • Within two months of having completed the primary series of the Johnson & Johnson vaccine (one dose).
  • Within five months of having completed the primary series of the mRNA Pfizer vaccine or within six months of having completed the primary series of the mRNA Moderna vaccine (two doses for both).
  • Who have received a booster vaccine if they are beyond two months of the Johnson & Johnson vaccine or beyond five or six months of the mRNA Pfizer or Moderna vaccine, respectively.

In regards to the booster, should athletes that test positive, should there be a waiting period after testing positive to receiving the booster?
If they are asymptomatic and fever free, there doesn’t need to be a waiting period. It should be 5 months since last immunization date

What are your thoughts on someone with antibodies (tested with blood test) but is considered unvaccinated or someone who has already had covid. Any different handling those athletes?
It is unclear how long the antibodies will last from a natural infection, it is probably closer to 120 days. Previous infection plus vaccination is recommended.

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