The responsible regulation of combat sports is a difficult task even in normal times. The job becomes particularly challenging during a global pandemic. Following UFC 249 several physicians deeply experienced with combative sports have voiced key information that ringside physicians ought to be aware of and ought to make commissions aware of for events taking place during the Covid-19 outbreak.
Nevada neurologist and President of the Voluntary Anti Doping Association Dr. Margaret Goodman, sports medicine doctor and ringside physician in New York Dr. Sheryl Wulkan and Neurologist and chief ringside physician in Maryland Dr. John Stiller have penned a 6 page letter with key information about Covid-19 that they hope all athletic commissions take into account while operating during these challenging times.
The doctors note they are not speaking on behalf of the various commissions but in the personal capacities as medical doctors. Without being critical about the resumption of events these physicians asked the following questions hoping to improve upon the standard of care under which events operate:
They commented that any limits on discussion of health and safety measures are concerning noting as follows:
If athletes must sign, as part of their contract, a waiver regarding Non-disclosure of concerns surrounding COVID 19 safety protocols, it will be difficult to gather data necessary for epidemiologists, ringside physicians, lawmakers and Commissions to improve their event planning for all contact sports and make them safer in the future.
With respect to their observations of safety protocols in place at UFC 249 particularly focussing on the news that athlete Ronaldo Souza and two of his cornermen tested positive for Covid-19 during fight week leading to his removal from the card they asked the following questions:
- Federal guidelines recommend a two-week downward trend in new Coronavirus cases prior to reopening the state. Florida’s Coronavirus cases have reached a steady state. So, while the athletes and their camps were tested, it is unclear why the Commission did not include in its action plan a statement that required competitors to arrive 14 days prior to the event, or that limited the extent to which athletes and their camps were exposed to friends, family and outside training partners within the same time period.
- The Commission will argue that testing was successful, citing the removal of Mr. Souza from the card once he and his camp tested positive. But Souza and his camp underwent two prior tests that were negative.
- Were the first two tests performed accurately or was the viral load as yet undetectable?
- Were the athletes, television crew, other ancillary personnel and Commission staff aware that positive tests are meaningful, but negative tests mean little?
- Did negative results cause a false sense of security among staff and athletes causing a more lax attitude toward PPE guidelines?
- Did the Commission contact trace with whom the competitors came in contact in the hotel or during their travels to and from the state/venue?
- Could social distancing have been more strictly enforced during the weigh in?
- Could inspectors have respectfully reminded cornermen that some of them were using protective equipment less than effectively?
- What was done to mitigate risk when sending injured athletes to an emergency room likely dealing with COV SARS-2 patients?
- And perhaps most importantly, what contact tracing, if any, will be done by the Commission after the event to determine whether their procedures endorsed adequate protection?
- What if any, was the responsibility of the Commission to other hotel guests when a participant or ancillary staff tested positive?
Lastly the physicians set out the below 14 medical points about Covid 19 they note every athletic commision should be aware of when guiding their decisions about running events at this time:
- The Coronavirus is so named because the spikes on its surface look like a crown. There are many different types of Coronaviruses, one of which causes the common cold. What does COVID 19 mean? COV stands for Coronavirus, ID for infectious disease, and 19, the year the virus was identified.
- The Coronavirus is a zoonotic virus- that means that it’s natural host is an animal. Sometimes viruses mutate or change in ways that allow the virus to infect a new host, such as humans, if /when the appropriate opportunity arises. People have no immune response to a novel virus, since by definition, the human immune system has never before been exposed to this organism.
- All viruses need a host for replication – that’s why social distancing is so important until we can develop a medication to treat the infection or develop a vaccine. What makes this virus so different? It is easily spread, it is infectious 2-3 or more days before infected persons demonstrate symptoms, and the majority of people don’t die, so it doesn’t “burn itself out”. Remember, the virus cannot live outside a host.
- If the majority don’t die, what’s the big deal? We don’t yet fully understand the mechanism by which damage is done to those infected, or whether long term problems can result as a consequence of this disease. It was originally believed that younger individuals didn’t become as sick as older individuals, but the majority of hospitalized patients are in the young adult category, and we are now seeing adults (20-40s) who test positive for antibodies but who do not recall being ill, developing strokes. Children, who were once thought to be immured from this disease are now being hospitalized with rare inflammatory conditions.
- The virus has to get inside a host cell to replicate. For each virus that enters a cell, many new virus particles are released into the host.
- Scientists are looking at many different sites in the virus replication cycle for ways to stop infectivity or to prevent replication.
- Researchers need to make sure medications developed to treat the infection are not only effective, but are unlikely to cause viral mutation with resultant resistance to the treatment. Time is required to develop medications that can ideally interrupt more than one site in the replication cycle, or to develop multiple medications that interrupt the virus’ life cycle at different points.
- A vaccine takes time to develop, but also requires rigorous testing to make sure it is safe. It would be unethical to inoculate otherwise healthy individuals with a vaccine whose side effects were equal to, or worse than the disease.
- Genome tracing (genetic viral tracing) has become a reality. The German government has graciously shared its site GISAID, and information can be uploaded by researchers to nextstrain.org. in order to determine/track which viral strains are present in different areas of the world.
- Epidemiologic models will not be perfect, because we are dealing with the unknown. Epidemiologists use as baseline, knowledge gained from the study of other infectious diseases (1918 flu pandemic, equine influenza North American outbreak 1800s, SARS COV-1, MERS, Ebola). Now that the natural history of the virus is better understood, we can estimate how many people are likely to be infected by a single carrier, and models can be built to determine whether interventions undertaken to contain infectivity are working (harbor in place, masks, social distancing).
- A minimum of 70-80% of the population needs to be immune for herd immunity to occur. The current estimate is that 10-15% of the US population has thus far contracted the virus.
- The purpose of “flattening the curve” is to prevent the overwhelming of public health care/medical resources, and to mitigate worse case scenarios. Those who are being hospitalized with the infection have longer hospital stays than required for most other illnesses, and many require round the clock intensive care. Flattening the curve does not mean we are over the worst of the pandemic. It just means we are moving into the next phase. And the next phase needs to be handled with careful consideration.
- We are beginning to realize that the virus attacks multiple organ systems, not just the lungs. The virus often presents differently in different age groups and in people with multiple medical problems. Individuals may compensate well for several days, and then take a rapid turn for the worse, sometime between days 5-9. Patients who become severely ill usually have underlying conditions, such as high blood pressure, diabetes, obesity, cardiovascular disease, or are immunocompromised. Until proven otherwise, athletes with any of the above conditions should be considered higher risk.
- Hospitals in some regions of the country have been overwhelmed or nearly overwhelmed by the pandemic. There is useful information available from areas that have already been severely affected by COVID-19 and this should be used by ringside physicians when deciding when combat sports events are safe to resume in their localities. For example, if your state or tribal jurisdiction is witnessing a rise or levelling off, but not a drop in hospitalized cases, one should consider whether it is safe to send injured athletes to the local Emergency department, and whether it is reasonable to further burden an overly taxed system for the sake of sport. (resources such as protective equipment, as an example).