Dear Editor:
We were delighted to read the recent work by Boden and colleagues4 that presented data on nontraumatic fatalities occurring in American football players competing at the high school and collegiate level in the United States, and the effectiveness of the National Collegiate Athletic Association (NCAA) policies surrounding exertional heat stroke (EHS) and exertional sickling (ES) on reducing fatal events. The meticulous overview of the causes of death and the associated rates and incidence provides clinicians employed in these settings data to inform action-oriented policies and procedures to mitigate risk of catastrophic injuries and fatal outcomes. Despite the thoroughness of the data presented by the authors over a 20-year reporting period, a few points of contention exist that warrant further discussion.
Presently, the analyses fail to account for when the heat acclimatization policy would be enforced, and capture deaths occurring outside of these regulatory periods. The authors concluded that the NCAA heat acclimatization policies implemented in 2003 have not significantly reduced EHS-related fatalities among collegiate American football players.4 We acknowledge that EHS remains a significant issues at both the collegiate and high school levels, and specific to the collegiate level, the instances of nontraumatic exertional fatalities (including EHS) that continue to occur during out-of-season conditioning3 warrant immediate attention to ensure proper medical oversight of these conditioning sessions, and to rid the sport of unorthodox, unscientific, and unsafe conditioning practices. Over the reporting period examined by Boden et al,4 8 EHS-related fatalities were reported; 2 occurred prior to the implementation of the 2003 heat acclimatization policy and 6 occurred afterwards. The authors concluded that there were no differences in incidence or rate of EHS-related fatalities before and after the 2003 heat acclimatization policy was implemented, however, only 2 of the 6 post-policy EHS-related fatalities occurred during the time frame in which the 2003 policy would have been enforced. This also assumes that the institution was in fact enforcing said policy at the time of the death, which would further influence the interpretation of these findings. We encourage the authors to separate these data and report on nontraumatic exertional fatalities occurring during in-season (including preseason) practice sessions and out-of-season conditioning sessions. This revised methodology would allow for a more thorough understanding of the context in which these fatalities are occurring. Presenting data on sport-related fatalities during out-of-season conditioning sessions within collegiate athletes allows for increased scrutiny in how these sessions are structured, managed, and regulated and should be a driving force for instituting systemic changes to optimize health and safety that are athlete-centered.
Further, it is unclear as to why the authors decided to use the 2003 NCAA heat acclimatization policy as the demarcation to determine effectiveness of reducing EHS-related fatalities at the high school level. It was not until 2009 that the consensus document on heat acclimatization among secondary school athletics was published,5 and to the best of our knowledge, it was not until 2011 that any state within the United States instituted a state-wide mandate requiring member schools to abide by any form of heat acclimatization. The 2003 NCAA heat acclimatization policy differs, albeit to a limited extent, than to which the 2009 high school recommendations were written. We have previously reported1,2 that, as of the 2016-2017 high school academic year, only 7 states required the respective member high schools to meet all heat acclimatization guidelines put forth in 2009.5 However, it must be acknowledged that these 7 states instituted these changes at varying points in time. Therefore, examining the efficacy of a policy on reducing risk using a singular time point occurring prior to the initiation of change at the high school level is inappropriate. Recently, Kerr et al7 conducted an in-depth analysis of the incidence of exertional heat illness (EHI) before and after the implementation of state-level heat acclimatization policies and found a 55% reduction in EHI risk when accounting for the point in time where each state made individual changes to their heat acclimatization policies. Cooper et al6 also examined the effectiveness of heat policy revisions in the state of Georgia, where the findings showed a reduction in EHI incidence rates of 35% to 100% depending on the wet-bulb globe temperature category observed. While Kerr et al8 and Cooper et al6 did not evaluate fatalities related to heat acclimatization, these investigations provide a more accurate understanding of the effect of heat acclimatization policies on EHI risk mitigation among high school athletics, compared with the 2003 NCAA heat acclimatization policy, which is only specific to collegiate athletics.
The epidemiological data that has been previously reported by Boden and colleagues in this and previous work have been critical to advancing our understanding, and the authors should be commended for publishing such meticulous work. Our suggestions here only aim to consider looking at the data in alternative ways to maximize the knowledge gained from the research being conducted. The continued efforts investigating the factors involved surrounding sport-related fatalities is applauded, as it is vital for informing action-oriented and evidence-based decisions that promote the health and safety of athletes. It is imperative that all stakeholders involved in high school and collegiate sports (eg, administrators, coaches, sports medicine professionals, strength and conditioning staff) approach their respective roles and responsibilities with the student athlete’s health and safety at the forefront of any decisions that are made. Unless we take an athlete-centered approach, we will continue to see preventable deaths occur. To use the famous quote, “With great power comes great responsibility,” a phrase with origins dating back to the French National Convention held in May 1793,7 we make the notion that those in positions of power, influence, and authority have the responsibility to act on behalf of the lives they impact. To ignore this would be a blatant disregard to human life.
William M. Adams, PhD, ATC
Greensboro, North Carolina, USA
Samantha E. Scarneo-Miller, PhD, ATC
Morgantown, West Virginia, USA
Rebecca L. Stearns, PhD, ATC
Douglas J. Casa, PhD, ATC, FNAK, FACSM, FNATA
Mansfield, Connecticut, USA
Footnotes
Declaration of Conflicting Interests: The authors have declared that there are no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
Contributor Information
William M. Adams, Greensboro, North Carolina, USA.
Samantha E. Scarneo-Miller, Morgantown, West Virginia, USA.
Douglas J. Casa, Mansfield, Connecticut, USA.
References
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