Infectious Diseases Associated with Organized Sports and Outbreak Control

CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care

Infectious Diseases Associated H. Dele Davies, MD, MS, MHCM, FAAP,​a Mary Anne Jackson, MD, FAAP,b​ Stephen G. Rice, MD, PhD, MPH, FAAP,c​ COMMITTEEWith ON INFECTIOUS Organized DISEASES, COUNCIL ON SPORTSSports MEDICINE AND FITNESSand Outbreak Control Participation in organized sports has a variety of health benefits but also has abstract the potential to expose the athlete to a variety of infectious diseases, some of which may produce outbreaks. Major risk factors for infection include skin- to-skin contact with athletes who have active skin infections, environmental

exposures and physical trauma, and sharing of equipment and contact aPediatric Infectious Diseases and Public Health, University of with contaminated fomites. Close contact that is intrinsic to team sports Nebraska Medical Center, Omaha, Nebraska; bInfectious Diseases, Children’s Mercy Kansas City and Department of Pediatrics, School and psychosocial factors associated with adolescence are additional risks. of Medicine, University of Missouri-Kansas City, Kansas City, Missouri; Minimizing risk requires leadership by the organized sports community and cSports Medicine, Jersey Shore University Medical Center and Department of Pediatrics, Robert Wood Johnson Medical School, (including the athlete’s primary care provider) and depends on outlining key Rutgers University, Neptune, New Jersey hygiene behaviors, recognition, diagnosis, and treatment of common sports- Dr Davies was the lead author of the manuscript; Drs Jackson and related infections, and the implementation of preventive interventions. Rice were coauthors of the manuscript with substantial input into content and revision; and all authors approved the final manuscript as submitted.

This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy Introduction of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

The definition of organized sports includes traditional team sports Clinical reports from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external commonly acknowledged as well as other types of sports (‍Table 1). reviewers. However, clinical reports from the American Academy of Participation in organized sports provides the benefits of (‍1) physical Pediatrics may not reflect the views of the liaisons or the organizations activity, by engaging in vigorous exercise, achieving fitness, and or government agencies that they represent. learning athletic skills; (‍2) socialization, by experiencing camaraderie The guidance in this statement does not indicate an exclusive course and learning teamwork and sportsmanship; and (‍3) competition, of treatment or serve as a standard of medical care. Variations, taking ’ into account individual circumstances, may be appropriate. by challenging oneself to perform against others, by striving to All clinical reports from the American Academy of Pediatrics continually improve oneself toward achieving one s full athletic 1 automatically expire 5 years after publication unless reaffirmed, potential, and by learning to win and lose with grace and dignity. revised, or retired at or before that time. Organized sports participation, however, can result in the acquisition of a variety of infectious diseases and conditions. Physical contact To cite: Davies HD, Jackson MA, Rice SG, AAP COMMITTEE among athletes, sharing of equipment (‍such as worn personal ON INFECTIOUS DISEASES, AAP COUNCIL ON SPORTS protective equipment or braces plus towels, drinking vessels, MEDICINE AND FITNESS. Infectious Diseases Associated showers, and locker rooms), and contact with– athletic surfaces (‍mats, With Organized Sports and Outbreak Control. Pediatrics. 2017;140(4):e20172477 artificial turf, dirt, grass, and gym or weight 2room9 equipment) can all be responsible for transmission of infection. ‍ In addition, certain organized sports carry specific additional risks; for example, wrestlers Downloaded from www.aappublications.org/news by guest on October 1, 2021 PEDIATRICS Volume 140, number 4, October 2017:e20172477 From the American Academy of Pediatrics

Davies et al https://doi.org/10.1542/peds.2017-2477 October 2017 Infectious Diseases Associated With Organized Sports and Outbreak Control 4 140 Pediatrics 2017 ROUGH GALLEY PROOF Pediculosis capitis Pediculosis corporis Pediculosis pubis practicing in close quarters are and safety. Furthermore, because , especially 10,vulnerable11​ to skin pediatricians need to provide , and Escherichia), by infections. ‍ medical clearance to athletes to colicontaminatedShigella food orGiardia water (‍eg, participate in organized sports, Shiga-toxinCryptosporidium producing Athletes should be taught proper the preparticipation physical , species, personal hygiene (‍eg, hand-washing, examination is an opportunity to species, species, showering, and proper laundering– verify that the athlete does not and norovirus, which is further of uniforms and practice clothing 12 15 have a skin condition or infection propagated by the person-to-personNeisseria on a daily or regular basis). ‍ ‍ that could be transmitted to others. meningitidisroute), by respiratory droplet Avoidance of sharing of drinking This visit between the physician (‍eg, influenza, pertussis, vessels (‍water bottles, ladles, and the student athlete allows the , group A streptococcal or cups), mouth guards, towels, primary care pediatrician to deliver pharyngitis, mumps), by airborne braces, batting helmets, personal anticipatory guidance. Ensuring particles (‍eg, varicella, measles), or protective equipment, bars of soap, that immunizations are current per by certain vectors (‍eg, ticks) (‍Table 2). bath sponges, razors or electric recommendations of the Centers In the case of Epstein-Barr virus hair shavers, and– callus trimmers for Disease Control and Prevention, infection, close contact is required is also important2 9 in reducing the Advisory Committee on for transmission, and endemic infectious risk. ‍ ‍ In addition, Immunization Practices, and the disease within adolescent group athletic programs should ensure American Academy of Pediatrics is settings has been reported (‍Table 2). regular (‍daily, weekly, and monthly) important, and pediatric providers Although biologically plausible, cleaning of facilities and equipment should identify and document cases there have been no validated reports (‍eg, weight room,– railings, mats, in which vaccines are refused or of infections from transmission of blocking dummies,16 19 locker rooms, incomplete because of medical bloodborne pathogens, including and showers). ‍ ‍ Those who exemptions (‍eg, serious allergy to hepatitis B, hepatitis C, or HIV manage sports programs and a vaccine component). Coaches and during athletic competitions. facilities should develop a plan for trainers are primarily responsible Nonetheless, the American Academy proper cleaning and maintenance for reviewing and stressing to the of Pediatrics has previously issued of a sanitary sporting environment athlete the key hygiene behaviors specific detailed guidelines for by using guidelines such as those needed to minimize the risk of management of infections spread published by the American20 College obtaining or spreading infection by blood and body fluids, including of Sports Medicine. in organized sports. However, guidance for athletes who are primary care pediatricians can infected with HIV, hepatitis B virus, Special attention should be paid help reinforce such educational or hepatitis C virus, and these will to proper management of blood 21 21 messages. not be reiterated in this statement. and other body fluids. Just as Organisms Associated With hospitals in the United States have Infections in Athletes Transmission of a specific infectious concentrated on preventing hospital- agent may be affected by a variety of associated infections in recent years, psychosocial (‍sexually transmitted the same level of focus on infection An athlete can acquire many infection), physical (‍trauma, prevention and control needs to different infections by participating closed community contact), and be present within the organized in organized sports. The pathogens environmental (‍soil, food, water, sports community, including ï include many that are prominent in vector) factors, especially in an among athletes, parents, coaches, outbreaks typically seen in crowded immunologically na ve population. athletic directors, equipment communities or closed community This policy will be focused on managers, certified athletic trainers, settings or that are facilitated by diagnosis, treatment, and prevention administrators, janitorial staff, team certain exposures specific to the of the most common infections that physicians, facility managers, and sport. may be encountered in the athlete league officials. participating in organized sports, Although the primary care StaphylococcusInfectious pathogens aureus include with an additional focus on factors pediatrician may appear to be those spread by skin contact (‍eg, that are potentially modifiable. peripheral in this athletic milieu Bacillus cereus , group It should be noted that some of of organized sports, leadership A streptococcalTinea skin capitis infections,Tinea the organisms discussed can be from physicians has always corporis Tinea, pedisherpesTinea simplex cruris transmitted in multiple fashions. been welcome and expected virus [HSV], , Transmission of pathogens spread regarding issues of public health , , , by contaminated food or water, by Downloaded from www.aappublications.org/news by guest on October 1, 2021 2 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Davies et al https://doi.org/10.1542/peds.2017-2477 October 2017 Infectious Diseases Associated With Organized Sports and Outbreak Control 4 140 Pediatrics 2017 ROUGH GALLEY PROOF respiratory droplets, and by vectors disease such as bacteremia, septic after indoor association66 67, football68​ are similar to what can be expected51 arthritis, osteomyelitis, myositis, tournaments,​ rugby,​ ‍ and other under nonsporting conditions and fasciitis, and pneumonia56,57​ in up to organized sports. The organism are beyond the scope of this report. 10% of cases. ‍ Other noninvasive can cause localized skin infections Although several of these pathogens forms of disease including impetigo, such as pyoderma, cellulitis, or are summarized in Table 2, detailed staphylococcal ecthyma, pustulosis, impetigo or invasive infections descriptions in this clinical report and folliculitis may also pose a risk such as thrombophlebitis, myositis, are provided only for the organisms for transmission of the organism and sepsis. GABHS has also been transmitted primarily by contact, from those so affected. Players associated with outbreaks of manifesting primarily on the skin, who have preexisting skinS diseases aureus pharyngitis among university and those that are airborne. such as atopic dermatitis may have students (‍median age69 19.5 years) Infections Primarily Spread by chronic colonization with participating in judo. Within Contact Transmission and may be predisposed to recurrent a 15-day period, 12 of 23 club secondary infection. Between 10% members in Tokyo, Japan, presented and 23% of football players or – with sore throat and high fever.

Most sports-related skin infections wrestlers have developed signs5,58​ and60 Diagnosis was made by use of either are spread by contact and have symptoms during outbreaks. ‍ ‍ a rapid streptococcal antigen test or been associated with 10% to 15% Risk factors for infection include skin positive throat culture for GABHS

of time-loss injuries among52 athletes breaks associated58 with turf burns when the clinical presentation at the collegiate level. For this or trauma,​ skin-to-skin contact, was suggestive of pharyngitis.

reason, routine screening of athletes sharing of equipment or clothing5,19,​ 59​ Occasionally, outbreaks of invasive participating in contact sports during (‍towels), and higher BMI. ‍ GABHS disease have been reported

practices and before competitions Although 4% to 23% of athletes have in members70 of high school football is important. The Sports Medicine been found to have colonization with teams,​ likely attributable to sharing Advisory Committee of the National MRSA, high colonization alone does Mofanagement equipment ofand S waterAureus bottles. and GABHS Outbreaks Federation of State High53 School not appear61 sufficient to trigger an Associations (‍NFHS),​ the National outbreak. Wrestling mats, artificial

Collegiate54 Athletic Association turfs, and football training equipment (‍NCAA),​ and the National Athletic55 have been documented19,62,​ 63​ with MRSA Management of MRSA and GABHS Trainers Association (‍NATA) colonization. ‍ ‍ outbreaks has been accomplished have published guidelines for through meticulous focus on hygiene Incidence estimates of MRSA-related screening and when to return to education, good hygiene practices, skin and soft tissue infections in athletic participation for several prompt identification of infected Nebraska student athletes have conditions (‍summarized in Table people, limiting exposure to infected ranged from 11.3 to 20.9 per 10000 3). It is noteworthy that many of people and contaminated surfaces football players and 28.1 to 60.8 the recommendations by these and objects, decontamination of the per 10000 wrestlers from 2008 organizations are more stringent 64 environment, and proper treatment to 2012. Among 190 high school than ordinary infection control and close follow-up of infected football players in northeast Ohio 4,5,​ 7,​ 59,​ 60,​ 69,​ 71​ practices for similar conditions in people. ‍ ‍ ‍ ‍ ‍ Of particular who were managed prospectively which the likelihood of the type importance for management of MRSA with nasal swab cultures, 23% of close bodily contact is not as S aureus outbreaks is screening of players for displayed methicillin-susceptible significant. carriage along with use of topical S Aureus colonization (‍none carried mupirocin for those found to have MRSA). Of the participating athletes, colonization, use of chlorhexidine 10 (‍5.3%) developed skin infections, S aureus washes, and enhancement of Community-acquired methicillin- including 7 with impetigo and 1 with 7,19,​ 72​ personal hygiene practices. ‍ resistant (‍MRSA) is a cause folliculitis barbae during the course Bleach baths (‍Clorox: regular 6.0% of outbreaks of skin infections among of the 2008 season. None of the hypochlorite, 5 mL, added to 1 gallon high school and collegiate athletes cultured specimens65 tested positive of water) used twice weekly reduced participating in contact sports, Gforroup MRSA A Streptococcus. S aureus particularly among football players the recurrence rates among children β Streptococcus and wrestlers, and is associated with with community-associated significant morbidity. It manifests Group A -hemolytic infections by 20% compared with primarily as cellulitis or skin (‍GABHS) has been associated control children managed with abscesses but may lead to invasive with outbreaks of skin infections routine hygienic measures, but this Downloaded from www.aappublications.org/news by guest on October 1, 2021 PEDIATRICS Volume 140, number 4, October 2017 3

Davies et al https://doi.org/10.1542/peds.2017-2477 October 2017 Infectious Diseases Associated With Organized Sports and Outbreak Control 4 140 Pediatrics 2017 ROUGH GALLEY PROOF – S aureus 75 77 was not a statistically73 significant resistance of this organism. ‍ ‍ hours after beginning appropriate23 reduction. Screening for Topical mupirocin may be used for oral antimicrobial therapy. Table 3 and GABHS requires knowledge localized and nonbullousS aureus impetigo. summarizes recommendations ofS the of what body sites would have During outbreaks, attempts at aureusNCAA, NFHS, and NATA for return colonization. Nasal,S aureus skin, vaginal, eradication of infections to to competition for patients with and rectal carriage are the primary limit spread may be accomplished infections, including MRSA. – Herpes Gladiatorum and Herpes reservoirs for . In the context by use of topical nasal mupirocin Rugbiorum of sports-related infections, the therapy (‍twice daily for 5 7 days) primary culture sites should be the among people with colonization. – nares and any open skin lesions. However, low-level (‍minimum µ HSV (‍primarily type 1) has been inhibitory concentration, 8 256 identified as a cause of outbreak GABHS screening should be g/mL) and high-level (‍minimum of skin infections among wrestlers performed through vigorous µ inhibitory concentration,S aureus >512 (‍herpes gladiatorum [HG]) and rugby swabbing of a pair of swabs on g/mL) resistance to mupirocin have players (‍herpes rugbiorum [HR]) both tonsils and the posterior been identified in . High-level on numerous occasions, affecting pharynx for rapid antigen detection resistance has been associated with up to 2.6%– of high school and 7.6%

and culture as well as culture of subsequent failure of decolonization. of college84 86 wrestlers in the United States. ‍ ‍ During outbreaks, up to any skin lesions, especially those23 that are oozing or macerated. GABHS typically is susceptible to 34% of all high school wrestlers 87have Measurement of sequential penicillin, and74 this is the usual first- been documented to be infected. streptococcal antibody titers line therapy. An oral macrolide Risk factors for development of may also be used to diagnose a or azalide (‍eg, erythromycin, HG-related cutaneous HSV lesions clarithromycin, or azithromycin) include direct skin-to-skin exposure recent infection, but this is not 74 is acceptable for patients who to opponents with cutaneous recommended for routine use. 84 ± are allergic to penicillin. Duration lesions. There is a range of 4 to Skin abscesses are best managed by of treatment is 10 days, with the 11 days, with an average of 6.80 incision and drainage, with culture exception of –azithromycin, which– 1.70 days from onset of exposure to

of the wound for identification of is indicated78 for80 5 days. Local 81 83 development of skin lesions. Most causative agent and antimicrobial mupirocin ‍ ‍ or retapamulin ‍ ‍ outbreaks (‍96%) occur on the ventral susceptibility pattern along with ointment may be useful for surface of the body, with up to three- empirical antibiotic coverage pending limiting person-to-person spread quarters of the cases occurring culture results. Antibiotic choices of nonbullous impetigo and for on areas in direct contact when shouldS aureus be guided by knowledge of eradicating localized GABHS disease. wrestlers are engaged in the lock-up the local patterns of susceptibility Guidelines from the NCAA, NFHS, and position (‍head, face, and neck). Other Sof aureus , especially local rates NATA for whenS aureus the infected athlete body areas frequently involved are of MRSA. Methicillin-susceptible can return to competition for both the extremities16 (‍42%) and trunk typically is treated GABHS and are summarized (‍28%). HSV conjunctivitis (‍5%) β with oral penicillinase-resistant Preventionin Table 3. of S Aureus and GABHS and blepharitis87 have also been -lactam drugs, such as a first- or Outbreaks reported. Between 25% and 40% second-generation cephalosporin. of patients with HG and HR will For patients who are allergic to develop constitutional symptoms

penicillin, or if MRSA is a significant Prevention of infections caused including fever,85, chills,87​ sore throat, consideration, the alternatives are by MRSA and GABHS is achieved and headaches. ‍ There are data trimethoprim-sulfamethoxazole, primarily through good hygiene associating acquired antibody to HSV

doxycycline, or clindamycin22 for practices, not sharing equipment type 1 infection with protection from susceptible isolates. Doxycycline and water bottles, limiting acquiring HG,84 but the association is can be used safely in children ages exposure to infected people and Hveryerpes weak. Outbreak and High-Altitude 2 years and older when given contaminated surfaces and objects, Skiing for durations less than 2 weeks. decontamination of the environment, Trimethoprim-sulfamethoxazole and prompt identification, proper

should not be used as a single agent treatment, and close4,5,​ 7,​ 59,​ follow-up60,​ 69,​ 71​ of High-altitude skiing also has been in the initial treatmentStreptococcus of cellulitis infected people. ‍ ‍ ‍ ‍ ‍ Athletes associated with relapses of orofacial because of the possibility it is with GABHS pharyngitis or skin herpes, presumably because of caused by group A infections should not return to solar UV radiation exposure, with and the possibility of intrinsic competitive sports for at least 24 a median onset of 3.5 days after Downloaded from www.aappublications.org/news by guest on October 1, 2021 4 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Davies et al https://doi.org/10.1542/peds.2017-2477 October 2017 Infectious Diseases Associated With Organized Sports and Outbreak Control 4 140 Pediatrics 2017 ROUGH GALLEY PROOF ’ 88 exposure (‍strong evidence). of a physician s written statement HSV type 1 immunoglobulin G Although sunscreen with a sun indicating that their condition is seronegative at the beginning of the protection factor of 15 was shown noninfectious, and (‍3) cleaning camp and had postcamp serologic to prevent experimental UV light- of wrestling mats with a freshly testing performed, none developed induced reactivation of herpes prepared solution of household detectable immunoglobulin M against 89 94 – labialis compared with placebo,​ it bleach (‍1 quarter cup of bleach HSV type 1 or HSV type 2. However, has not been shown to influence the in 1 gallon of water) applied for a there is need for a detailed risk

reactivation88 rate among high-altitude minimum contact time of 15 seconds benefit analysis of using valacyclovir Mskiersanagement. of HG and HR at least daily26 and preferably between for prophylaxis in wrestlers who are Outbreaks matches. NCAA, NFHS, and NATA Mseronegativeolluscum C ontagiosumfor herpes. guidelines for when the infected athlete can return to competition are There is strong evidence that prompt summarized in Table 3. Prevention of HG and HR Outbreaks Molluscum contagiosum is a identification and 3 to 8 days of common, benign viral skin infection isolation of infected wrestlers during presenting as skin-colored papules primary outbreaks of HG and HR that develop a central umbilication with suspension of competition Athletes with a history of recurrent as they age. Molluscum contagiosum can help contain outbreaks in more HG, HR, or herpes labialis should 87,90,​ 91​ affects 5% to 11% of children than 90% of cases. ‍ ‍ Diagnosis be considered for suppressive 95 0 to 16 years of age and most involves a combination of clinical antiviral therapy. There is strong commonly affects the trunk, face, and recognition and may be coupled with evidence that nucleoside analogues extremities. Molluscum contagiosum cell culture, histologic examination, or (‍valacyclovir) can suppress recurrent is mostly asymptomatic but may rapid diagnostic tests such as direct outbreaks of herpes. In a study present with pain, itching, redness, or fluorescent antibody staining, enzyme involving 42 male wrestlers aged 13 occasionally bacterial superinfection. immunoassay, or polymerase chain to 31 years in Minnesota combining Outbreaks of molluscum contagiosum reaction (‍PCR) of vesicular lesion double-blind randomization have most often been described scrapings in complex, lingering, or followed by an open enrollment 26 in association with exposure to unclear cases. Valacyclovir, 500 onto treatment, participants with – swimming in public pools and mg, every day or twice a day for 7 recurrent HG were treated during 3,95​ 97 underlying eczema. ‍ ‍ Other days, when given within 24 hours the first half of the season with either factors associated with infection of symptoms onset, has been shown 500 mg of valacyclovir or placebo include young age (‍highest incidence to shorten the duration of time until and in the second half with 1000 mg in children younger than 14 years), HSV PCR clearance from lesions of of valacyclovir. The 500 and 1000 mg ∼ living in close proximity, skin-to- adolescent and adult wrestlers with doses of valacyclovir suppressed skin contact, sharing of fomites, and recurrent HG by 21% (‍from 8.1 recurrence of outbreaks among 3,98​ residence in tropical climates. ‍ days with placebo92 to 6.4 days with 100% (‍7 out of 7 and 12 out of 12) of Management of Molluscum valacyclovir). Wrestlers receiving participants whose last recurrence Outbreaks valacyclovir should be advised about was more than 2 years before. the importance of good hydration to However, the doses were slightly minimize the risk of nephrotoxicity. less successful among those with Resolution of uncomplicated Competitors often do not recognize recurrences within 2 years (‍11 out molluscum contagiosum typically or may deny possible infection. As a of 14 and 23 out of 25, respectively), occurs spontaneously in 6 to

result, efforts to reduce transmission with better93 results with the 1000 mg 12 months, although complete should include (‍1) examination of dosing. resolution of lesions can take up wrestlers and rugby players for to 4 years. Although no regimen vesicular or ulcerative lesions on Similarly, in a Minnesota study has proven highly successful, exposed areas of their bodies and of 332 male wrestlers 13 to 20 10% potassium hydroxide and around their mouths or eyes before years of age who participated at a cryotherapy with liquid nitrogen practice or competition by a person 28-day wrestling camp, once-a-day have been used to treat lesions familiar with the appearance of prophylactic valacyclovir (‍1000 that occur in locations that are mucocutaneous infections (‍including mg) starting 1 week before camp cosmetically bothersome to HSV, herpes zoster, and impetigo), and continuing throughout camp patients or for patients with (‍2) excluding athletes with these reduced the incidence of clinical underlying skin conditions such as lesions from competition until all HG outbreaks by 87%. Among eczema. Both forms of treatment lesions are fully crusted or production 55 of these wrestlers who were appear to have similar efficacy in Downloaded from www.aappublications.org/news by guest on October 1, 2021 PEDIATRICS Volume 140, number 4, October 2017 5

Davies et al https://doi.org/10.1542/peds.2017-2477 October 2017 Infectious Diseases Associated With Organized Sports and Outbreak Control 4 140 Pediatrics 2017 ROUGH GALLEY PROOF tonsurans

children, but cryotherapy may be , Trichophytonaccounting for rubrum more than In contrast, 200 mg of itraconazole associated with postinflammatory Trichophyton80% of cases, mentagrophytesbut it may also be was found to be superior to 250 hyperpigmentation99,100​ or, uncommonly, causedT tonsurans by 113, and114​ mg of terbinafine when given for 7 scarring. ‍ Imiquimod was not T mentagrophytes . ‍ days respectively in terms of clinical shown to be of benefit compared Microsporum (‍ primarily),canis response rates when administered119 to T capitis with placebo in randomized101,102​ , and adolescents and adults. controlled trials. ‍ Open-label have also 103,104​ T capitis For , the traditional and observational studies ‍ been isolated in high rates during treatment in children had been oral indicate that cantharidin can be an outbreaks of (‍ringworm) griseofulvin, 10 mg/kg per day, effective treatment of molluscum among high school wrestlers in microsize formulation, given once contagiosum; however, in 1 small a wrestling boarding school in 109,115,​ 116​ daily for 6 to 8 weeks, although randomized controlled trial of 29 Turkey. ‍ These organisms doses of griseofulvin as high as 20 patients, the improvement seen with have been isolated frequently from to 25 mg/kg per day have been cantharidin, although greater than individual skin lesions and from 120 108,109​ used. Terbinafine, 125 or 250 mg with placebo, was not found to be Mwrestlinganagement mats of. T Corporis‍ and 100 (‍adjusted for age), given for 2 to 8 statistically significant. Guidelines T Capitis Outbreaks weeks, has recently been shown to from the NCAA, NFHS, and NATA for have efficacy that is at least as good, when the infected athlete can return – with fewer adverse effects and fewer to competition for molluscum are Both skin-based and oral medications 116,121​ 123 T corporis T capitis recurrences. ‍ ‍ Cochrane Preventionsummarized of in M Tableolluscum 3. are available for the treatment of reviews have concluded that 4 weeks Contagiosum Outbreaks , but is managed of terbinafine was equivalent to exclusively with oral medications, 124,125​ 8 weeks of griseofulvin. ‍ often with simultaneous application Similarly, oral fluconazole given for Given the known associations of of topical treatment to the scalp 4 weeks had similar efficacy molluscum contagiosum, the best (‍because of the need for hair T corporis to oral griseofulvin given for method of prevention would involve follicle penetration). Skin-based 126,127​ 6 weeks,​ ‍ although at least 1 avoiding of skin-to-skin contact preparations for include study revealed the efficacy to be low with people known to have lesions but are not limited to azole 128 for both regimens. Itraconazole (‍covering lesions), not sharing towels creams (‍clotrimazole, econazole, given for 2 weeks is also similar in and other fomites, and limiting ketoconazole, oxiconazole), efficacy to 6 weeks of griseofulvin, exposure to swimming pools that allylamine creams and gels (‍1% whereas terbinafine and itraconazole have recently been associated with gel of terbinafine and butenafine), appear to have similar efficacy for knownTinea Infections outbreaks. and hydroxypyridone (‍ciclopirox) 124 treatment periods of 2 to 3 weeks. preparations. Although these all T corporis T capitis However, terbinafine, itraconazole, are reasonably effective, some and fluconazole are significantly and infections preparations in some studies more expensive than griseofulvin. have been reported more demonstrate superior cure rates. For Furthermore, griseofulvin appears to frequently among high school example, terbinafine emulsion gel Microsporum T corporis T be superior for infections attributable wrestlers and judo practitioners has a mycological cure rate superior ’ capitis to certain species of , (‍ gladiatorum and to that of ketoconazole cream (‍94% – which may require 4 weeks gladiatorum) than among versus 69%, respectively) with T8, 105​corporis112 117 duration or more of therapy with other athletes. ‍ ‍‍ Studies of the similar adverse events rates. 122,129,​ 130​ terbinafine and itraconazole. ‍ ‍ prevalence of gladiatorum T tonsurans Terbinafine appears superior for have involved use of potassium Oral agents also have proven 125 T corporis . hydroxide examination to aid efficacious in the treatment of most Prevention of T Corporis and T Capitis Outbreaks Tdiagnosis. corporis In 1 such study, 24% of cases of . Different doses 29 wrestlers had lesions of and durations of itraconazole have P , versus 0 in a control been used in studies. Itraconazole, groupT corporis of track106 team members 100 mg, given orally once a day, Fluconazole, 100 mg per day for (‍ = .005). In another study, was superior to griseofulvin, 500 3 days, given prophylactically was detected in 10 of 19 mg, orally, once a day, when given before initiation of competitive boys (‍53%) 15 to 17 years of age for 15 days (‍87% mycological cure interscholastic high school wrestling belongingT capitis112 to a judo clubTrichophyton in Kyoto, rate versus 57%, respectively, at the and given again 6 weeks into Japan. The most common cause of end of 2 weeks after completion of 118 the season, has been reported to gladiatorum is therapy) to adolescents and adults. significantly reduce the incidence Downloaded from www.aappublications.org/news by guest on October 1, 2021 6 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Davies et al https://doi.org/10.1542/peds.2017-2477 October 2017 Infectious Diseases Associated With Organized Sports and Outbreak Control 4 140 Pediatrics 2017 ROUGH GALLEY PROOF T corporis 30 of from 67.4% to 3.5%. use in 28children older than 10 sampling of users of a swimming However, the risk-benefit analysis of years. Similarly, naftifine ointment bath in Scotland from 8.5%142 to 2.1% giving fluconazole prophylactically applied twice daily for 4 weeks and Tover mentagrophytes a 3.5-year period,​ mostly in this manner has not been sulconazole nitrate 1% cream applied attributable to the decline in rates of determined, and its use should be daily for 4 to 6 weeks have been from 5.3% to 0.5%. – in consultation with an infectious associated with significantly higher Experts believe that careful and diseases expert. mycological clearance rates (‍57% thorough drying between the toes T Pedis – 66%) compared with their vehicles after showers, daily changes of socks, T pedis ’ alone (‍13% 34% cleared) and were and periodic cleaning of athletic T rubrum– T associated with fewer relapses in footwearT Cruris can be helpful. (‍athlete s foot) presents pedis treatment of related as a fine scaly or vesiculopustular 136,137​ T cruris . However, sulconazole is eruption that is often itchy. The not approved for use in children in the (‍jock itch or crotch rot) is a lesions may involve all areas of United States. More recently, topical common pruritic fungal infection of the foot but commonly include the 133 T pedis azoles such as fenticonazole powder the groin and adjacent skin. Heat, fissures and scaling between toes. have been used in adults with up to humidity, and hyperhidrosis are Increased rates of have been 138 100% cure rates. Terbinafine 1% predisposing factors, as is wearing of well documented and common T T pedis cream applied daily for 1 week also tight-fitting or wet clothing. Similar among swimmers and runners pedis T cruris has been used effectively to treat to , obesity and diabetes are (‍especially marathon runners), 133 , with >93% mycological cure additional risk factors for T rubrum. with documented infections in up to T rubrum T mentagrophytes rate at 4 weeks, and is approved E floccosum T 22%. The predominant causes are 139 The predominant cause is 131 for children 12 years and older. mentagrophytes and . followed by and T pedis Luliconazole was recently reported as 143,144​ Spread via direct contact with the T pedis . ‍ It may be a 1% cream trial for organism, is prevalent in spread by contaminated fomites in adults, but less than 50% of warm, humid environments and (‍contaminated towels, hotel 132 the participants were cured on this affects men more than women. 140 bed sheets) or autoinoculation T pedis regimen. It is only approved by the Tinea Obesity and diabetes are additional from hands or feet infected with 133 US Food and Drug Administration for Tinea unguium T pedis Tinea risk factors for . manuum from another body site Management of T Pedis Outbreaks use in adults. (‍ 133 , , or Terbinafine offers the advantage of Management). of T Cruris Infection once-daily dosing and can be given for briefer periods than skin-based T pedis Numerous treatments (‍creams T pedis treatments. Oral terbinafine, 250 mg, and oral medications) have been Similar to , terbinafine 1% given once daily for 1 week, has evaluated for treating . In cream applied daily for 1 week has similar efficacy (‍based on mycological T cruris randomized controlled trials in adults, been used effectively to treat cure rates at week 4) to 4 weeks ciclopirox olamine (‍a broad-spectrum with a mycological cure rate of T rubrum T of clotrimazole 1% cream applied hydroxypyridone antifungal with approximately 94% and is approved mentagrophytes Epidermophyton twice a day but with faster clinical 117 proven efficacy against , 141 for children 12 years and older. floccosum resolution. Oral terbinafine, 250 mg, , and Butenafine (‍a benzylamine derivative also is similar in mycological efficacy ) cream or gel (‍0.77%) of clotrimazole) applied twice daily to itraconazole, 100 mg, when given applied twice daily to the affected for 2 weeks and clotrimazole applied T pedis over a 2-week duration but may areas for 4 weeks has been shown to twice weekly for 4 weeks are also have a slightly lower rate of relapse. be effective in eradicating and over-the-counter alternatives, but Terbinafine is well tolerated in – superior to 1% clotrimazole cream butenafine is only approved in children, with the most concerning 145 148 or ciclopirox vehicle in achieving adults. ‍ Oral itraconazole ∼ potential adverse events being both clinical and mycological cure (‍100 mg daily for 2 weeks or 200 mg occasional isolated neutropenia and (‍ 60% for cyclopirox olamine cream daily for 1 week) has been shown rare liver failure, typically in people T cruris versus 6% for its vehicle only at end of to be effective in adults for treating Preventionwith preexisting of T Pedisliver disease. Outbreaks treatment, and 85% versus134,135​ 16% two and superior to oral weeks after treatment)T pedis. ‍ There griseofulvin118, 149,​(‍500150​ mg daily for are no published studies of use of 2 weeks). ‍ ‍ Several other azole151 ciclopirox to treat in children, The use of footT powder pedis after bathing topical formulations151 (‍oxiconazole,144 ​ but a dosage of topical application has been associated with a decline luliconazole,​ 152 sertaconazole,​ twice a day is recommended for in the rates of in a random eberconazole ) have been shown to Downloaded from www.aappublications.org/news by guest on October 1, 2021 PEDIATRICS Volume 140, number 4, October 2017 7

Davies et al https://doi.org/10.1542/peds.2017-2477 October 2017 Infectious Diseases Associated With Organized Sports and Outbreak Control 4 140 Pediatrics 2017 ROUGH GALLEY PROOF be effective in adults, but none have with 30% regressing within 6 months treatment of scabies can be achieved Preventionbeen studied of in T anyCruris detail Infection in children. and approximately 60% within 2 topically with permethrin 5% years. Treatment modalities are cream or oral ivermectin (‍not for usually geared toward chemical or pregnant women), but resistance T pedis 155,156​ Because of risk of spread from physical destruction of the infected has been reported to both. , covering active foot epithelium and include techniques Pregnant women and infants may be lesions with socks before wearing such as freezing with liquid nitrogen, treated with topical crotamiton or undershorts may reduce the application of salicylic acid-based precipitated sulfur ointment. Head likelihood of direct contamination. products or tretinoin (‍retinoic lice treatment requires attention Furthermore, complete drying of the acid) cream, surgical (‍paring) or not only to the live lice but also to crural folds after bathing, and use of laser removal, and use of topical34 eggs that may subsequently hatch. separate (‍clean) towels for drying immunomodulating agents. The Treatment of head lice can be the groin and other parts of the body more destructive methods may lead started with over-the-counter 1% to pain, which may inhibit athletic permethrin lotion or with pyrethrin Verrucamay help Vulgaris reduce contamination. activity. More recently, cantharidin combined with piperonyl butoxide,

combined with podophyllotoxin- both of which36 have good safety salicylic acid has been used in profiles. Resistance to these over- Verruca vulgaris (‍common skin adults and reported to be effective the-counter agents is commonplace warts) are benign epithelial but associated with pain and in many parts of the United States, 153,154​ – proliferations of the skin and are blisteringPrevention. of‍ Verruca Vulgaris and as such, alternative Food and caused by human papillomaviruses. Infections Drug Administration approved They are typically painless, multiple treatments may be necessary. For in number, and occur on any lice resistant to over-the-counter epithelial surface, although most Precise mechanisms of preventing medications, treatment options commonly on the hands, feet,33 and common warts are unknown. include spinosad suspension, around and under the nails. They However, like most infections that benzyl alcohol lotion, malathion, may be distinguished from calluses are transmitted by contact, avoidance or ivermectin lotion. Spinosad and corns by the presence of black of contact with people known to and ivermectin lotion are ovicidal, dots (‍clotted blood vessels that have have common warts, not sharing and a single treatment may be grown into the wart) when they are equipment and towels, and wearing adequate,155, but156​ no treatment is 100% pared down as well as the associated rubber soled flip-flops or sandals in ovicidal. ‍ Suffocant treatments, loss of overlying dermatoglyphs. communal showers may minimize such as benzyl alcohol lotion or Although reports indicate that warts risk. malathion lotion, require retreatment Scabies and Lice may occur in outbreaks among approximately 1 week later to kill any athletes, there are no published data Sarcoptes scabiei new lice that hatched from nits. For on the prevalence. Reported risk lice resistant to all topical agents, oral P capitis μ factors appear to include sharing of Scabies (‍caused by ) ivermectin in a single dose of 200 equipment and exposure of unshod 34 and lice (‍ ), although not or 400 g/kg may be used in infants feet in common shower areas. In a commonly reported in sports, can weighing over 15 kg, with a second36 study of 146 adolescents who used be disqualifying if identified in dose given after 9 to 10 days. locker rooms, 27% of those who used children participating in organized, Infections Primarily Spread by communal showers on a regular basis especially contact, sports. They Airborne or Droplet Route were found to have plantar warts are transmitted primarily through Varicella-Zoster Virus versus only 1.25% of those34 who only person-to-person contact. The used the locker rooms. However, scabies parasite can survive on because the children using communal clothing35 for up to 4 days without skin showers were also members of a contact. Lice do not survive away Although varicella has been reported swim club, it is unclear whether the from the scalp more than 1 to 2 days as a cause 157of airborne sports-related communal shower or the swimming without a blood meal, and although infections,​ such reports are rare Mwasanagement the major of contributing Verruca Vulgaris factor. uncommon, can be transmitted by in the era of immunization with Infections the live attenuated vaccine against hair brushes,37 combs, hats, and hair ornaments. The transmission, the virus. The varicella-zoster risk factors, recognition, diagnosis, virus (‍VZV) manifests primarily as Most cases of common warts will treatment, and prevention are a generalized, pruritic, vesicular eventually spontaneously regress, summarized in Table 2. Successful rash consisting of 250 to 500 Downloaded from www.aappublications.org/news by guest on October 1, 2021 8 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Davies et al https://doi.org/10.1542/peds.2017-2477 October 2017 Infectious Diseases Associated With Organized Sports and Outbreak Control 4 140 Pediatrics 2017 ROUGH GALLEY PROOF Measles

lesions in different stages (‍crops)39 of mumps were common in the of development and crusting. United States, primarily in crowded Measles is characterized by a There is usually an associated low- settings including schools, prisons, prodrome of cough, coryza, and grade fever, and there may be other orphanages, and military facilities. conjunctivitis with fever followed by systemic symptoms. Disease in Although the incidence of the disease maculopapular or morbilliform rash vaccinated children is often milder has declined significantly with the that begins on the face and spreads and atypical in nature compared with introduction of the 2-dose schedule downward to the trunk and out to the wild virus infection and requires of the measles-mumps-rubella the extremities. Koplik spots, which a high index of suspicion. Diagnosis (‍MMR) vaccine, outbreaks still are considered pathognomonic, is usually made on the basis of a 40 periodically occur, primarily because also appear during the prodrome. typical clinical picture coupled with ofManagement incomplete ofvaccination. Measles and Mumps Patients are contagious 4 days before history of exposure, but vesicular Outbreaks the rash to 4 days after the rash fluid or scab scraping can be used appears. Measles outbreaks have for confirmation by using PCR, direct been reported during many different fluorescent antibody assay, or VZV- Immunization is the cornerstone types of sporting events ranging specific culture. A significant increase – of managing measles and mumps from gymnastics to skiing and in serum varicella immunoglobulin 158 163 outbreaks. All suspected cases fencing,​ ‍ ‍ highlighting the G antibody between acute and of measles or mumps should be importance of adequate vaccination convalescent serum samples can also reported immediately, and every of all athletes. Up to 5% of people assist in diagnosis. effort should be made for laboratory Management of VZV Infections who have received a single dose of confirmation of the infection either vaccine at 12 months or older have through serologic testing or detection vaccine failure. Among previously of virus from clinical specimens Isolation should be instituted for immunized people, primary vaccine (‍throat washings, nasopharyngeal those suspected to have chickenpox failure (‍inadequate response to secretions, urine, and blood for until the diagnosis is either ruled vaccine) is a more common cause of measles and buccal swabs, throat out or all the lesions are crusted failure than waning immunity. As a washings, saliva, or cerebrospinal over or in vaccinated children when result, the current recommendations fluid, if relevant, for mumps). In an there are no new lesions within a call for a 2-dose vaccine schedule for 39 40 outbreak setting, the MMR vaccine 24-hour period. Oral acyclovir children and high-risk adults. Mumps should be given to all people or valacyclovir given within 24 (‍>12 months) who lack evidence hours of rash onset results in only a of immunity. For mumps, a second modest decrease in symptoms and MMR dose should be offered to is not routinely recommended for Mumps is a systemic illness that all students (‍including those in most healthy children. It should be presents with swelling of 1 or more postsecondary school) who have considered in otherwise healthy of the salivary glands, typically the received only 1 dose of MMR vaccine. children who are at increased risk parotid glands. Up to one-third of A second MMR dose should also be of moderate to severe varicella, mumps cases do not cause salivary considered for both conditions in including people older than 12 years, gland swelling, presenting instead children 1 to 4 years of age if they people with chronic cutaneous as a respiratory tract infection. have only received 1 dose and there or pulmonary disorders, those Orchitis is a common complication is an ongoing outbreak affecting receiving long-term salicylate after puberty, but it rarely leads preschool-aged children with therapy, and those on short, to sterility. Approximately 10% of 40 Preventioncommunity-wide of Measles transmission and Mumps. intermittent, or aerosolized courses patients have an associated viral 39 Outbreaks of corticosteroids. meningitis, and numerous other Prevention of VZV Infections complications occur rarely, including permanent hearing loss, myocarditis, endocardial fibroelastosis, arthritis, The most important method to The most effective proven means thrombocytopenia, thyroiditis, prevent measles and mumps of preventing VZV is via primary mastitis, glomerulonephritis, outbreaks is routine immunization

immunization with 39the live pancreatitis, and oophoritis. The of all children with a live attenuated attenuated vaccine. Children virus has been isolated from saliva vaccine, such as MMR or MMR- exposed to VZV should have their from 7 days before through 8 varicella vaccine, at age 12 through immunity evaluated, either through days after onset of salivary gland 15 months, with a second dose at 4 vaccination records or through swelling. Before introduction to 6 years of age, and people who serologic testing. of mumps vaccine, outbreaks are not documented to have been Downloaded from www.aappublications.org/news by guest on October 1, 2021 PEDIATRICS Volume 140, number 4, October 2017 9

Davies et al https://doi.org/10.1542/peds.2017-2477 October 2017 Infectious Diseases Associated With Organized Sports and Outbreak Control 4 140 Pediatrics 2017 ROUGH GALLEY PROOF Michael T. Brady, MD, FAAP – Red Book Associate William Hennrikus, MD, FAAP 40 Editor Kelsey Logan, MD, FAAP vaccinated during these periods. Mary Anne Jackson, MD, FAAP – Red Book Kody A. Moffatt, MD, FAAP People who have altered immunity Associate Editor Blaise Nemeth, MD, FAAP Sarah S. Long, MD, FAAP – Red Book Associate Brooke Pengel, MD, FAAP (‍except HIV infection, unless they Editor Andrew Peterson, MD, FAAP have severe immunosuppression) Henry H. Bernstein, DO, MHCM, FAAP – Red Book Paul Stricker, MD, FAAP should not receive MMR vaccine. Online Associate Editor Furthermore, MMR-varicella vaccine H. Cody Meissner, MD, FAAP – Visual Red Book Liaisons Associate Editor should not be given to patients with Mark Halstead, MD, FAAP – American Medical HIV (‍even if these people have little Society for Sports Medicine to no immune compromise) because Donald W. Bagnall – National Athletic Trainers Liaisons Association of a lack of safety data at the present James Stevermer, MD – American Academy of time. Family Physicians Consultant Amanda C. Cohn, MD, FAAP – Centers for Disease Neeru A. Jayanthi, MD The epidemiology and outbreak Control and Prevention control considerations for other Karen M. Farizo, MD – US Food and Drug Staff conditions primarily transmitted via Administration droplet and contaminated food and Marc Fischer, MD, FAAP – Centers for Disease Anjie Emanuel, MPH Control and Prevention water are summarized in Table 2. Lead Authors Bruce G. Gellin, MD, MPH – National Vaccine Program Office H. Dele Davies, MD, MS, MHCM, FAAP Richard L. Gorman, MD, FAAP National Institutes Mary Anne Jackson, MD, FAAP – of Health Stephen G. Rice, MD, PhD, MPH, FAAP Natasha Halasa, MD, MPH, FAAP – Pediatric Infectious Diseases Society Abbreviations Committee on Infectious Diseases, Joan L. Robinson, MD – Canadian Paediatric 2016–2017 Society β Jamie Deseda-Tous, MD – Sociedad Carrie L. Byington, MD, FAAP, Chairperson GABHS: group A -hemolytic Yvonne A. Maldonado, MD, FAAP, Vice Chairperson Latinoamericana de Infectologia Pediatrica Elizabeth D. Barnett MD, FAAP (SLIPE) streptococcus James D. Campbell, MD, FAAP Geoffrey R. Simon, MD, FAAP – Committee on HG: herpes gladiatorum H. Dele Davies, MD, MS, MHCM, FAAP Practice Ambulatory Medicine HR: herpes rugbiorum Ruth Lynfield, MD, FAAP Jeffrey R. Starke, MD, FAAP – American Thoracic Society HSV: herpes simplex virus Flor M. Munoz, MD, FAAP MMR: measles-mumps-rubella Dawn Nolt, MD, MPH, FAAP Staphylococcus aureus Ann-Christine Nyquist, MD, MSPH, FAAP Staff MRSA: methicillin-resistant Sean O’Leary, MD, MPH, FAAP Jennifer M. Frantz, MPH Mobeen H. Rathore, MD, FAAP NATA: National Athletic Trainers Mark H. Sawyer, MD, FAAP Council on Sports Medicine and Association William J. Steinbach, MD, FAAP NCAA: National Collegiate Tina Q. Tan, MD, FAAP Fitness Executive Committee, Theoklis E. Zaoutis, MD, MSCE, FAAP 2016–2017 Athletic Association Cynthia R. LaBella, MD, FAAP, Chairperson NFHS: National Federation of Margaret A. Brooks, MD, FAAP State High School Ex Officio Greg S. Canty, MD, FAAP Associations David W. Kimberlin, MD, FAAP – Red Book Editor Alex Diamond, DO, FAAP PCR: polymerase chain reaction VZV: varicella-zoster virus

DOI: https://​doi.​org/​10.​1542/​peds.​2017-​2477

Address correspondence to H. Dele Davies, MD, MS, MHCM, FAAP. E-mail: [email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2017 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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Davies et al https://doi.org/10.1542/peds.2017-2477 October 2017 Infectious Diseases Associated With Organized Sports and Outbreak Control 4 140 Pediatrics 2017 ROUGH GALLEY PROOF Infectious Diseases Associated With Organized Sports and Outbreak Control H. Dele Davies, Mary Anne Jackson, Stephen G. Rice, COMMITTEE ON INFECTIOUS DISEASES and COUNCIL ON SPORTS MEDICINE AND FITNESS Pediatrics originally published online September 25, 2017;

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