Life in the Time of COVID-19

The current world order was determined by a virus. A novel H1N1 influenza virus, often referred to as the Spanish flu, took hold in the trenches of World War I on the German side of the lines. Up to that point, the battle appeared to be dominated by the German army, but the viral illness that targeted younger people raged through the trenches on the German side before hopping the battle lines to affect the Allied troops. The war ended on November 11, 1918, at 1100 hours, marking the end to what had been the deadliest armed conflict in history, but the carnage was just beginning. The new virus was quietly spreading among the troops and exposed populace. The armistice did not end the viral pandemic and likely added to its spread as young soldiers returned home carrying the disease and exposing millions of people en route. The Spanish flu went on to kill between 20 and 40 million people worldwide; a far greater toll than the Great War that helped it gain a foot hold.

COVID-19 is dominating the news and current events. There is new information regarding its spread with each passing hour. Our intercontinental transportation system with daily flights to almost anywhere is a likely culprit and countries are suspending flights to and from affected areas on a daily basis. Several sports medicine meetings have been canceled in the wake. These public health interventions are clearly in our best interest, but the effects are reverberating across the economy, affecting stock markets and manufacturing supply chains. Sport events and other large gatherings can and will play a role in the spread and potential containment of the pending epidemic.

COVID-19 has erupted, like many influenza viruses, in the height of the winter sports tournament season. This peak of the influenza season helps me convince athletes to get their flu shots each fall, but there is no vaccination for COVID-19. Basketball players and fans from 128 colleges and universities are scheduled to descend on 16 different, geographically distributed communities throughout the United States. A single person in a large arena could potentially share the virus with thousands of people; amplifying the spread and sending the virus back to an additional 112 communities, where the fans and athletes alike live in close quarters. A perfect scenario for spreading a deadly disease, not unlike the trenches of WWI.

The Tokyo Marathon was the first major sport event to pull the plug on the competition. Approximately 38,000 runners were scheduled to descend on Tokyo, Japan, where the disease was already starting to gain traction. The economic calculation for large road races suggests that each runner is accompanied by one to three supporters, and in Japan, where marathon racing is a very popular attraction, the potential fan base lining the course is huge. Canceling a large race has enormous economic implications for the host city (Tokyo, in this case, or a March Madness site for NCAA Basketball) and for the event itself. Again, a single competitor or fan has the potential to expose thousands of people, so canceling the Tokyo Marathon was clearly in the interest of world health, despite the economic impact.

Fred Lebow (1932-1994), the first director of the New York City Marathon, often stated the race would never be canceled under any circumstances. Hurricane Sandy proved him wrong. It is critical to understand the potential public health implications of failure to cancel a sporting event or mass gathering in a timely manner. Kudos to the medical team and administration of the Tokyo Marathon for setting precedent and leading the way to reduce the spread of this virus.

What will happen to March Madness, the Frozen 4, the Boston Marathon, numerous state high school tournaments, and other large sporting events remains to be seen. Many feel the virus will go dormant when the snow melts and the seasons change, but the month of March precedes these seasonal changes for much of the United States. COVID-19 going dormant seems wishful thinking to me. We are fortunate in the United States to have the CDC and state public health departments tracking the virus and helping formulate public policy regarding event cancellations, travel restrictions, and quarantine requirements.

Addressing training room and primary care clinic protocols for limiting the spread of the virus is prudent and necessary. Simple precautions for patient care, the decision to mask or not (and who should get them), and limiting exposure for our staff and families are best considered in advance.

The current World Health Organization's (WHO) advice is simple and practical.

WHO recommends the following measures to reduce the general risk of transmission of acute respiratory infections:

• Avoid close contact with people suffering from acute respiratory infections.

• Wash your hands frequently, especially after direct contact with ill people or their environment.

• Avoid unprotected contact with farm or wild animals.

• People with symptoms of acute respiratory infection should practice cough etiquette (maintain distance, cover coughs and sneezes with disposable tissues or clothing, and wash their hands).

  WHO does not recommend any specific health measures, such as isolation, unless travelers experience any symptoms suggestive of acute respiratory illness either during or after traveling, in which case, they are encouraged to seek medical attention and share their travel history with their health care provider.

The outcome of this potential pandemic is yet to be determined. At the time of writing this commentary, there are several new cases in new locations in the Western United States. This includes the city where my daughter and her family live, so the virus has become more personal for me. While spread seems inevitable, a prudent approach to mass gatherings, including sports events and team training rooms, can play a role in the final outcome.