The American Academy of Pediatrics tackled this difficult issue in December, 1999, with a policy statement on HIV and Other Bloodborne Viral Pathogens in the Athletic Setting. In it, the Academy made clear, “Because of the low probability of transmission of their infection to other athletes, athletes infected with HIV, hepatitis B or hepatitis C should be allowed to participate in all sports.”
That participation, however, assumes all athletes and coaches will follow standard precautions to prevent and minimize exposure to bloodborne viruses. The Academy tackled each infectious disease individually:
HIV: The risk of HIV infection via skin or mucous membrane exposure to blood or other infectious bodily fluids during sports participation is very low . . . such transmission appears to require, in addition to a portal of entry, prolonged exposure to large quantities of blood. Transmission through intact skin has not been documented: no HIV infections occurred after 2,712 such exposures in 1 large prospective study. Transmission of HIV in sports has not been documented. One unsubstantiated report describes possible transmission during a collision between professional soccer players.
Hepatitis B: HBV [hepatitis B virus] is more easily transmitted via exposure to infected blood than is HIV . . . the risk of infection [is] greater if the blood [is] positive for HBV e antigen . . . transmission of infection by contamination of mucous membranes or broken skin with infected blood has been documented, but the magnitude of risk has not been quantified.
Although transmission of HBV is apparently rare in sports, 2 reports document such transmission. An asymptomatic high school sumo wrestler who had a chronic infection transmitted HBV to other members of his team. An epidemic of HBV infection occurred through unknown means among Swedish athletes participating in track finding (orienteering). The epidemiologists concluded that the most likely route of infection was the use of water contaminated with infected blood to clean wounds caused by branches and thorns.
An effective way of preventing HBV transmission in the athletic setting is through immunization of athletes. The American Academy of Pediatrics (AAP) recommends that all children and adolescents be immunized. Clinicians and the staff of athletic programs should aggressively promote immunization.
Hepatitis C: Although the transmission risks of HCV infection are not completely understood, the risk of infection from percutaneous [through the skin] exposure to infected blood is estimated to be 10 times greater than that of HIV but lower than that of HBV. Transmission via contamination of mucous membranes or broken skin also probably has a risk intermediate between that for blood infected with HIV and HBV.
“There is clearly no basis for excluding any student from sports if they are infected,” said Dr. Steven J. Anderson, who was chair of the Academy’s Committee on Sports Medicine and Fitness when it drafted the Academy’s policy, “and we should also try to protect the confidentiality of each athlete.”
Dr. Anderson, a pediatrics professor at the University of Washington and a team doctor for many high school athletic teams, ballet companies and the U.S. Olympic Diving Team, suggests students should have access to any sport, except boxing, which the Academy opposes for all youths because of its physical risks.
“I personally feel parents have no obligation to disclose the infectious status of their children to anyone,” said Dr. Anderson. Strict compliance with standard precautions is critical for this open-embrace of all athletes, regardless of their infectious status. Coaches and teachers must have a plan in place to handle blood spills, said Dr. Anderson, including latex [or non-permeable] gloves, occlusive dressings, appropriate sterilizing solutions, disposal bags and even a printed protocol for coaches, athletes and officials.
The following is an excerpt of a sample school policy, used by numerous public school districts and in compliance with ADA that addresses HIV infection:
“The privilege of participating in physical education classes, programs, competitive sports and recess is not conditional on a person’s HIV status. School authorities will make reasonable accommodations to allow students living with HIV infection to participate in school-sponsored physical activities.
“All employees must consistently adhere to infection control guidelines in locker rooms and all play and athletic settings. Rulebooks will reflect these guidelines. First aid kits and standard precautions equipment must be on hand at every athletic event.
“All physical education teachers and athletic program staff will complete an approved first aid and injury prevention course that includes implementation of infection control guidelines. Student orientation about safety on the playing field will include guidelines for avoiding HIV infection.”
In addition to the Academy, several sports and other health organizations have also weighed in on this issue. According to the NCAA, National Football League (NFL) and World Health Organization, athletes with HIV should be permitted to participate in all competitive sports at all levels.
These organizations all endorse immunization against hepatitis B for all athletes.
The National Athletic Trainers’ Association (NATA) echoes Dr. Anderson’s suggestion that coaches, trainers, athletic directors, school officials and others take the lead in educating themselves, their teams, parents and their communities about the importance of effective disease prevention.
Trainers and coaches, they suggest, should provide the following information in age-appropriate terms to all participants before or during any competition :
- The risk of transmission or infection during competition.
- The risk of transmission or infection generally.
- The availability of HIV testing (for teens and adults).
- The availability of hepatitis B vaccination and testing (for parents, teens and adults).
“Athletic trainers who have educational program responsibility should extend educational efforts to include those, such as the athletes’ families and communities, who are directly or indirectly affected by the presence of bloodborne pathogens in athletic competitions,” the NATA stated in a position paper.
See PKIDs’ Infectious Disease Workshop for more information.
Photo courtesy of Lolie Smith