Q&A: DICON manual helps NFL teams reduce risk of infection

With Week 1 of the NFL season in the books, football is officially back. To help players stay healthy, the Duke Infection Control Outreach Network published an educational manual for preventing infections in locker rooms, which was distributed to all 32 teams in August. The Chronicle’s Ryan Hoerger spoke with DICON’s Dr. Deverick Anderson about how teams can best mitigate the risk of an infection spreading. Below is a condensed version of their conversation.

The Chronicle: How did this relationship with the NFL get started?

Deverick Anderson: We’ve actually had a relationship with [the NFL] for the last several years. Probably the most formal part of that relationship is that we’ve written educational newsletters for their physicians and athletic trainers about infection prevention topics over the last three or four years. About two years ago, when Tampa Bay had their issue with MRSA, they asked us to get involved. And after working with them, we negotiated with the league to develop a systematic program for all 32 teams.

TC: What makes a football locker room particularly at-risk for these types of infections?

DA: When people are in close quarters for long periods of time, that’s a good set-up for the transmission of pathogens. You can think of influenza or diarrheal illnesses, and how it seems like if one person in a household or on a team gets the flu or a diarrheal illness, then it seems pretty common that lots of other people in close proximity get it as well. Perhaps one of the best examples people think of is norovirus and diarrhea on cruise ships—that’s a perfect example of lots of people together in close quarters spending a lot of time together. And so if you couple that with what ends up being essentially occupational hazard for football players, it can be a set-up for some of these other mean bugs like MRSA. Football players, just as part of their job, have regular skin abrasions and tears and breakdowns, and the skin is one of our main defense mechanisms against pathogens that are in the environment. If you couple the breakdown of the defenses with the very frequent skin-to-skin contact, it’s a good recipe for transmission of bacteria.

TC: When you talk about guarding against infections, which types of infections are you really focusing on?

DA: The ones that are top of the list when it comes to what we try to prevent are skin infections. I would probably broaden it to skin infections—with MRSA being one of the worst types of skin infections—norovirus for diarrhea, influenza and upper respiratory infections. And then because these guys go under the knife quite a bit, we have specific recommendations for prevention of infection following surgical procedures as well.

TC: You mentioned the Tampa Bay MRSA case. Are there other well-known instances of infection breakouts in NFL locker rooms?

DA: We actually ended up doing a specific molecular analysis for two of the three players [in the Tampa Bay case]. Ultimately, three players on Tampa Bay had MRSA around the same time, so it was very suspicious that something might be going on. One of them happened before we got involved, but for the other two we were able to get our hands on their MRSA isolate and do some molecular testing that showed that they were basically completely distinct MRSA isolates, implying that they didn’t give it to each other and they didn’t get it from a single source. We actually ended up calling that a pseudo-outbreak as opposed to a true outbreak. That’s probably the one that people are going to be familiar with from the NFL most recently. There have been, over the last 5-10 years, several other instances, though. I think Cleveland had a big problem with it several years ago. If you hear about players who have an infection after a surgery, chances are more than a coin toss that it’s an MRSA infection—you just don’t often hear it described that way. Probably more commonly, we hear about these happening in college teams and high school teams.

TC: What are the most critical steps teams should be taking to prevent these infections?

DA: We’re systematically visiting each of the teams over the season and are about a quarter of the way done or so, and these are very good facilities. All of them have some areas for improvement, as every place does, but in general they do a really good job. We treat these training facilities as medical facilities. They all have some improvements they can make to really bring them up to the standard of a medical facility. There are things like access to cleaning materials, access to hand hygiene, promotion of hygiene in general, having policies for their players to shower after practice, because those types of hygienic steps, even though very basic, can really right a lot of wrongs that might happen during practice.

TC: As part of this process, have you been in contact with the Duke football team or Duke athletics as a whole?

DA: We have actually provided the same manual we gave to all the NFL teams to the Duke football team as well. [Head trainer Hap Zarzour] knows us, we talk with him frequently, we’ve even been over to the facilities to have a look around. Several years ago, we did a much more comprehensive sweep of the athletic facilities at Duke. That’s been some time ago, four or five years, and the more recent time our focus has been on the football team as we’ve developed the NFL program.... The challenge when you move from a location like the NFL to college is probably more related to volume and the number of players that are involved. College programs are just so much bigger, and there’s less ability to focus on any one specific activity like you can do as a professional team.