By Stan Deresinski, MD, FACP, FIDSA

Clinical Professor of Medicine, Stanford University

SYNOPSIS: Aggressive implementation of mitigation procedures with continual evaluations and adjustments allowed the National Football League to complete their season with minimal COVID-19 transmission.

SOURCE: Mack CD, Wasserman EB, Perrine CG, et al. Implementation and evolution of mitigation measures, testing, and contact tracing in the National Football League, August 9-November 21, 2020. MMWR Morb Mortal Wkly Rep 2021;70:130-135.

The National Football League (NFL) consists of 32 teams in 24 states, and the decision to proceed with playing the 2020-2021 season in the midst of the COVID-19 pandemic necessitated complex and comprehensive planning and implementation of procedures designed to control SARS-CoV-2 transmission. A standard mitigation protocol was implemented in conjunction with the Players’ Association in July. The elements of this protocol included mandated masking, frequent handwashing, facility disinfection, and restricted access to facilities, together with regular and frequent polymerase chain reaction (PCR) testing of players and staff. In addition, contact tracing was performed that was supplemented with required use of wearable proximity devices while within club environments. Testing, with 24-hour turnarounds, initially was performed on players and most staff six days per week.

Initially, fewer than 10 cases of COVID-19 were detected each week, but then 41 cases were detected between Sept. 27 and Oct. 10, with 21 of these occurring at a single club resulting in the closure of their facilities. This led to league-wide implementation of a more intensive protocol, which was put in place for one week whenever a positive test was confirmed. Constant evaluation and adjustments were made. Overall, from Aug. 9 to Nov. 21, 623,000 PCR tests were performed on approximately 11,440 players and staff. During that time, 329 laboratory-confirmed cases of COVID-19 were detected, representing approximately 2.9% of the monitored population.

COMMENTARY

Despite the COVID-19 pandemic, Super Bowl LV was played on Feb. 7, 2021. The ability to accomplish this took, as indicated by the summary above, an enormous amount of effort and resource utilization at significant cost. This effort demonstrated that the mitigation efforts are effective and that intensification of the protocol was associated with decreased exposure and transmissions within the facilities and that this was accomplished at a time during which there was significantly increasing community transmission of COVID-19 throughout the United States.

In addition to once again demonstrating the benefit of various mitigation procedures in reducing transmission of SARS-CoV-2 infection, this experience developed new information that affected national policy. As an example, the observation that transmission could occur despite < 15 minutes of cumulative interaction (potential exposure) led to revision of the definition of high-risk contact that takes into account, in addition to duration and proximity of interaction, assessment of mask use and of ventilation. In the course of the activity, the importance of contact tracing was obvious, but the difficulty of characterization of individual risk also became apparent.

Nonetheless, implementation of postexposure quarantine after high-risk exposure, together with testing and enforcement of intensive mitigation protocols specific to the environment and circumstance, proved highly effective. The NFL did have its Super Bowl in the middle of a COVID-19 pandemic — to the chagrin of Kansas City and the delight of Tampa.

Figure 1: Laboratory-Confirmed* COVID-19 Cases (N = 329) and Mitigation Strategies Implemented — National Football League, United States, August 9-November 21, 2020

COVID-19 graph

Abbreviations: COVID-19 = coronavirus disease 2019; PCR = polymerase chain reaction.

* Reverse-transcription PCR tests were processed on two platforms (Roche Cobas and ThermoFisher QuantStudio) and transcription-mediated amplification on one platform (Hologic Panther Aptima)

Twenty-nine clubs spent 431 days under the intensive protocol beginning October 1; 189 high-risk contacts of 215 cases were identified and subsequently quarantined beginning October 15.

Source: Mack CD, Wasserman EB, Perrine CG, et al. Implementation and evolution of mitigation measures, testing, and contact tracing in the National Football League, August 9-November 21, 2020. MMWR Morb Mortal Wkly Rep 2021;70:130-135.