After a spring without sports, we saw several professional leagues complete their suspended seasons — or start truncated seasons and complete them — in the summer and fall, including MLB, the WNBA, the NBA, the NHL and the NWSL. The NFL and college football are now trying to do the same, with the twin challenges of larger player rosters and a worsening landscape for the COVID-19 pandemic. Meanwhile, the federal government has largely left mitigation to the states, which have had varying responses, from mask mandates and strict lockdowns to denial of the pandemic’s severity and threats to cut funding from counties that have tried to manage the situation on their own.
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The sports leagues that did finish their season ran what amounted to large experiments to see whether specific sets of protocols and higher levels of enforcement could contain the spread of the novel coronavirus enough to keep players playing, minimize outbreaks, and allow the leagues to complete their championships and take in broadcast revenues. Their approaches differed — and aren’t perfectly replicable in the real world — but there are clear lessons that public health officials and politicians can take from these experiments to inform policies going forward, not the least of which is that masks work and more testing is critical to control the virus’s spread.
I asked several experts what we might take away from sports leagues’ successes this year, including Dr. Angela Rasmussen, a virologist and affiliate of the Georgetown Center for Global Health Science and Security; Dr. Jill Weatherhead, Assistant Professor of Infectious Diseases in Tropical Medicine at Baylor College of Medicine; Nathan Grubaugh, Ph.D., Assistant Professor of Epidemiology at the Yale School of Public Health; Dr. Paul Sax, Clinical Director of the Infectious Disease Clinic at Brigham and Women’s Hospital and Professor of Medicine at Harvard Medical School; and Zach Binney, Ph.D., Assistant Professor of Quantitative Theory and Methods at Emory University.
Wear your masks
Just over a year after the SARS-CoV-2 virus first appeared in humans, we have substantial evidence in the scientific literature around the virus that wearing masks reduces transmission rates and reduces the dose of the virus the wearer might receive, so that any infection would be milder or even asymptomatic. A June study of state mandates in the United States found that greater use of face masks was associated with significant declines in the virus’s growth rate. Models estimated lower death rates from 80 percent mask usage than we would have seen even from a strict lockdown, although neither of those policies was enacted and we have now exceeded the projected death total for even 50 percent mask usage.
Bryan Seeley, MLB’s Senior VP and Deputy General Counsel for Investigations, Compliance and Security, oversaw the league’s safety efforts and facility operations this summer and fall, and he put it most bluntly: “The biggest lesson is that mask-wearing indoors is the most important thing you can do to prevent transmission of COVID.” The major sports leagues have all been running various uncontrolled experiments around mask-wearing and testing, but there’s strong evidence that requiring masks in indoor settings dramatically reduces transmission. Binney agrees, saying, “What we’ve learned from MLB and the NFL so far is that testing and masks work.”
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Much of what teams did in their various bubbles this summer and fall can’t be easily replicated in the broader community. Binney points out they aren’t scalable: You just can’t take the bubble model and implement it at even a citywide level, let alone for an entire country. The NBA and the NHL took populations they were pretty sure were infection-free and then put them all into their own versions of “The Truman Show,” with limited and highly managed interactions with anyone who came from outside those bubbles. One thing they did do in those bubbles, however, was require everyone to wear masks. Every epidemiologist I asked pointed to masks, and the rising scientific evidence that masks work, as the main reason we didn’t see outbreaks or even new cases within those bubbles.
“When (the leagues) employed routine testing and very strict protocols of wearing a mask and distancing for all of those connected to the vulnerable population, that showed that it worked,” said Grubaugh. “There was always this doubt, do masks really work? Regardless if it’s real doubt or this fake-news doubt, it’s still doubt that circulates in our communities. Even scientifically, if you go back to the beginning (of the pandemic), there was a lot of debate among scientists if it was legit. It took a while before we were all wearing masks, and it wasn’t known if these cloth masks were effective.” He even points out that increased mask usage has had additional benefits. “Clearly it’s having some effect on influenza too, because in Australia they have almost none of it. It might be one of the lightest flu seasons we would ever have,” which will be of critical importance given how many states are facing imminent or potential shortages of ICU beds.
Masks are also the most easily affordable precautionary option available to civilians, companies and government agencies to slow the spread of COVID-19. Many of the other lessons we can take away from sports leagues’ successful 2020 seasons depend on financial resources that aren’t available to private citizens or small businesses, or even the governments of many developing nations. Masks, however, cost very little; cloth ones are reusable and easily washed; and their usage requires minimal training (yes, it goes over your nose, too).
Test, trace, isolate, repeat
The other major lesson from the three major men’s leagues that completed seasons in 2020 was the value of extremely frequent testing. The NBA tested players in its bubble every day and MLB tested Tier 1 personnel, a level that included players and on-field staff, every other day. This intense testing regimen allowed leagues to implement a “test, trace, isolate” protocol, where each positive test result leads to a contact-tracing effort to identify possible exposures and the isolation of anyone who tests positive until they’re no longer contagious. This isn’t a new response to pandemics, but it is easier today with the technology available.
“This is actually something that has been in place as a useful epidemiologic tool for hundreds of years,” Rasmussen said. “You identify people as early as possible who are sick. In this case we would do that through PCR (polymerase chain reaction) testing. In the past it’s been done by people becoming symptomatic,” which isn’t as useful here because COVID-19 can be spread by infected people who are asymptomatic, “but in our case we have a very sensitive PCR test, or the less sensitive antigen test, to identify positive cases and isolate them.
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“Then you have contact tracers who find out who that person in isolation has been around, and in contact with, and you put them in quarantine and then keep them there until they’re tested. If they become positive you trace their secondary contacts. Right now, unfortunately, we’re not in a place where we could implement that because we don’t have enough testing capacity, there’s too much community transmission, and there’s no way at this point — we had nearly 200,000 cases yesterday in the U.S. and we’re still on a steep upward trajectory — that we have enough contact tracers to implement something like that.”
“Testing alone is not a strategy, but testing with other protocols can be a strategy,” Grubaugh said. “The good news for schools is that it shows that if you have some level of testing, which is hard to do, and follow these really strict protocols you can keep them safe. People will get infected in the community and there will be cases outside of the school.” CDC guidelines for school closures lean heavily on whether the disease is spreading within the school, or if the transmission is happening outside of the school, so schools’ ability to capture new cases and isolate them before there is community spread in the building is key to their power to stay open.
“The good thing is that frequent testing as a strategy for mitigation is actually a great idea, even though the White House outbreaks give it a bad name,” Sax said. “And even though the rapid antigen tests are not as sensitive as the PCR tests, that doesn’t mean they’re useless. It would be so transformative to apply the resources that sports teams have to schools, or to make it easier for hospital workers to come to work. That’s the big lesson. If you have a regular testing program in place, any outbreaks that occur, you can respond to them quickly and snuff them out.”
Sports leagues have funding for frequent testing, and a strong financial incentive to test frequently; without the tests, they would have experienced outbreaks that threatened to end their seasons. The resources for this quantity of testing are not available to schools, for example — though they should be, if we want to keep schools open even as nonessential businesses close in a second wave of lockdowns. One bit of good news on that front came from the NBA’s partnership with Grubaugh’s group at Yale, as they developed and clinically validated a new test, SalivaDirect, that the NBA helped fund. The scientists were able to work with the testers to use some of the same saliva collected from NBA players to test the SalivaDirect product and ensure it was as accurate as the existing saliva PCR test as well as the brain-tickling nasopharyngeal test. The test is now available in over 30 labs in 19 states and costs $25 or less.
Sax also pointed out that there are already inequities in testing the populace. “In places like Wellesley (a wealthy suburb of Boston that is 81 percent White and only 3 percent Black) there’s plenty of testing, but in poorer sections (of Boston) it’s harder.” Professional sports teams have the money to execute a test-trace-isolate regimen, and universities might as well, but local or state governments either don’t have the funds or won’t commit them to the endeavor.
On inconclusive tests, Justin Turner and misinformation
Every epidemiologist I asked had the same general reaction to Justin Turner returning to the field after he’d been told he tested positive — it was irresponsible. MLB declined to suspend or otherwise punish Turner for his extremely poor judgment, even though there have now been nine positive cases within the Dodgers organization. Turner was a risk to anyone who came within a few feet of him — at times he wasn’t wearing a mask, either — and needed to self-isolate as soon as he learned that his second test had come back positive, rather than putting MLB security in the impossible spot of having to choose between letting him run amok on the field or putting themselves at risk by physically stopping him.
What the incident did reveal, however, was the need for protocols that anticipate less-likely scenarios, like what to do if a player’s (or student’s, or employee’s) initial test comes back inconclusive. This is possible with the most common PCR tests, which target two different places on the virus’s genome and must detect both to return a positive result. (There’s also a third control test that looks for human DNA, so you can’t try to use your cat’s saliva instead.) There are newer tests, including SalivaDirect, that only target one part of the viral DNA and thus only return positive or negative results for the virus’ presence.
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The MLB operations manual for 2020 did not include any protocols for handling a player whose test came back inconclusive, which was tantamount to an assumption that the player was not infected. In Turner’s case, it was especially unlikely that he would have been infected because he was within the playoff bubble. The epidemiologists I interviewed had diverse views on how MLB handled the situation in real time, but agreed the protocols should have anticipated this possibility. “The protocol not having anything for an inconclusive is a failure,” Binney said. “It wouldn’t have been crazy for the protocol to say we rerun that sample or a new sample ASAP and make a decision after that.” (Binney also said he didn’t see a problem with Turner staying in the game after the inconclusive test, just that the lack of a protocol was a problem.)
“I do recall if a player was had a suspected exposure, they were going to be quarantined,” said Rasmussen. “I would imagine an inconclusive test would also cause them to be quarantined.” She went on to point out that we are dealing with a parallel epidemic of misinformation, so that many people are simply not armed with the facts they might need to make better decisions: “The pandemic has become so politicized, at this point there are people who will not believe the settled science about viral infection or about this particular virus, and we’ve seen that all over the country with people refusing to wear masks, etc.”
The torrent of false information about COVID-19 online is inescapable; on Twitter, there is a substantial subculture of self-styled experts who think they see something that epidemiologists don’t, arguing that masks don’t work (they do) or that the virus is harmless (it’s harmful, causing not just death in about 2.2 percent of known cases, but also long-term damage to many other sufferers) or that it’s all a hoax (please, if you think this, log off the internet for a while). Rasmussen expressed the hope that the Biden administration will help work to re-establish public faith in science and the advice of scientists so that we can improve compliance with mask mandates and guidelines for physical distancing.
Lessons beyond sports
The successes of a number of leagues in completing their seasons offer clear guides both for public policymakers and individuals. Masks work to slow transmission, and mask mandates reduce case rates. The three states with the highest rates of cases per million population, Iowa and the Dakotas, had no mask mandates until this past week; Nebraska, Idaho and Tennessee also lack statewide mandates and are in the top ten for case rate. Iowa, Nebraska, South Dakota and Idaho all rank in the bottom ten in test rates, and none of these states have hired many contact tracers relative to other states. We know test-trace-isolate works from the leagues’ efforts this summer, but no jurisdiction can do this without widespread testing and contact tracing, which requires a significant financial commitment (one that the federal government can and should help fill).
Major League Baseball had to modify its own protocols multiple times in response to changing conditions, especially how quickly positive test results piled up in the Marlins and Cardinals outbreaks. They moved to more rapid testing, and shut each team down when testing showed more positives even as they were preparing to clear some players (who had tested negative) to return from quarantine. After the second outbreak, they tightened mask mandates and saw more voluntary cooperation from players and staff. From the Cardinals outbreak to Justin Turner testing positive during the last World Series game, the league went over 50 days without a positive test.
Rasmussen also offers advice that seems especially relevant as we head into the holidays and colder weather: “People like to focus on one intervention to reduce risk. Risk reduction is additive. You don’t need to bleach your produce or any of your groceries! Just wash your hands. Be outside of an enclosed space if possible, or ventilate. You need to also physically distance, wear a mask, avoid crowds, and especially avoid crowds that you’ll be around a long period of time or where there’s shouting or singing or physical exertion going on.” She mentioned that she’ll be doing a Zoom Thanksgiving this year rather than risk exposing her parents to the virus, a fact that has attracted vitriol on social media when she’s stated it before.
Dr. Rasmussen also underscored the importance of imposing our own bubbles or “pods” so we can reduce community transition. Test, trace, isolate is only feasible when the infection and case rates are low enough, which may only be possible now with a second wave of lockdowns — which, while politically challenging, are authorities’ best tool for avoiding ICU overload, and can bring case levels down to the point where contact tracing becomes possible again.
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“One thing we’ve been talking about for the public in general is to limit the number of people you interact with on a day-to-day basis,” Weatherhead said. “It’s much less risky to have interactions with the same neighbor over and over rather than seeing new people each week.
“Once you are positive, you need to be isolated and stay in isolation, and there shouldn’t be an exception. Every time you’re around people you have the risk of transmitting to somebody. Everybody has to buy in that it’s your responsibility as an individual to do your part. That’s the only way we can have these activities. The only way we can have the sports we all want so badly and are craving so much is if everyone follows the rules.”
You can substitute schools, or concerts, or travel for “sports” in that last sentence and the statement still holds: We can’t have nice things if we refuse to fulfill our responsibilities to ourselves, our family members and our neighbors to wear masks, physically distance and limit our interactions outside the home. Sports leagues have given us valuable information, and in the NBA’s case directly funded an inexpensive and accurate new PCR test, to help public health officials better fight this pandemic. Those officials need to do their part, and we need to do ours as well.
(Top photo: Randy Litzinger / Icon Sportswire via Getty Images)
