NCAA releases health and safety guidelines for college basketball

The NCAA released health and safety guidelines for college basketball on Friday afternoon.

Of note in regards to COVID-19 testing, the NCAA states the following:

Training and competing in basketball require frequent, sustained close contact among players, coaching and other essential staff, and officials in an indoor setting. Schools are encouraged to proactively define those individuals who constitute the “inner bubble” (Tier 1), which includes student-athletes and essential basketball personnel whose job function requires direct access to players on a regular basis, specifically close contact (6 feet or less) for 15 minutes or more, as per CDC guidance. Tier 1 individuals may differ from school to school (for example, some coaches maintain physical distancing at all times and therefore are not part of Tier 1). Tier 1 individuals are considered to be at higher risk of becoming infected with COVID-19 if any other individual in the group is contagious and masking/physical distancing has not been maintained. The situation is further compounded because the nature of basketball makes it challenging to train in functional units (as described in the Resocialization Standards).

A typical basketball team has 15 players, all of whom typically train on a single basketball court at the same time in an enclosed space. Generally speaking, it is expected that the total number of Tier 1 individuals within a team would approximate 25-30. If any Tier 1 individual becomes infected, schools should consider quarantining the entire team, including coaching staff and other essential personnel who are part of Tier 1, for 14 days, provided determinations around who must be quarantined are ultimately the jurisdiction of appropriate public health officials. At present, there is not a recommendation for consideration of testing out of quarantine.

The document, which is lengthy, is available in its entirety below:

As indicated below, these materials are intended as a resource for member schools to use in coordination with applicable government and related institutional policies and guidelines, and they remain subject to further revision as available data and information in this space continue to emerge and evolve. This document addresses basketball only, and future documents will address other winter sports. Unless stated otherwise (for example, testing recommendations), the guidance from Resocialization of Collegiate Sport: Developing Standards for Practice and Competition (Resocialization Standards) remains in place; athletics personnel are encouraged to review this document.

Introduction

The Resocialization Standards focused on the development of standards for practice and competition. Importantly, basketball was listed as a high contact risk sport with regard to COVID-19. Further, outdoor training was noted to be preferred over indoor training with good ventilation where feasible, and indoor training with good ventilation was noted to be preferred over indoor training with poor ventilation. This document serves as an update to the third publication, with a singular focus on basketball.

The information in this publication was developed in consultation with the NCAA COVID-19 Medical Advisory Group, which includes team physicians; infectious disease and public policy experts; representatives from the membership; and representatives from the NCAA COVID-19 Advisory Panel, National Athletic Trainers’ Association, American Medical Society for Sports Medicine, the National Medical Association, the Autonomy-5 Medical Advisory Group, and the NCAA Committee on Competitive Safeguards and Medical Aspects of Sports. While the federal government has not yet published uniform federal guidance related to certain practices like diagnostic testing protocols, contact tracing and surveillance, these groups have, through their continued review and evaluation of available research data, anecdotal evidence and related analysis and discussion, identified certain practices that should be highlighted for more focused consideration by member schools. While the materials encourage consideration of various factors and actions, they do not speak to every possible scenario, and in no event should members fall below national or appropriate public health standards set by their local or state communities.

As with prior NCAA publications, the materials are meant to be consistent with guidance published by the federal government and its health agencies. This document reflects the relevant scientific and medical information available at the time of print. These materials should not be used as a substitute for medical or legal advice. Rather, they are intended as a resource for member schools to use in coordination with applicable government and related institutional policies and guidelines, and they remain subject to further revision as available data and information in this space continue to emerge and evolve.

Behavioral Infection Risk Mitigation

Even with frequent testing for COVID-19, the most important risk mitigation strategy remains a combination of daily self-health checks, physical distancing, universal masking and hand sanitization. The Centers for Disease Control and Prevention recommendations include the following for proper wearing of face masks:

• Wash your hands before putting on your mask.
• Put it over your nose and mouth and secure it under your chin.
• Try to fit it snugly against the sides of your face.
• Make sure you can breathe easily.
• Masks with exhalation valves or vents should not be worn to help prevent the person wearing the mask from spreading COVID-19 to others (source control).

Basketball student-athletes and all athletics staff personnel who interact with the athletes should be appropriately educated about and actively participate in mitigation of COVID-19 infection through proper behavior at all times. Time away from athletics, especially social events, may be riskier than sport; therefore, all basketball athletes and staff should be vigilant at all times.

Testing Update

Two testing paradigms dominate the United States market at present. There continues to be no national testing standard, and testing availability remains problematic for certain tests and in certain parts of the country. We have attempted to highlight and summarize some of the considerations around recent advances in testing below but encourage all schools to work closely with applicable medical personnel to evaluate and discuss the benefits and limitations of each of these alternatives before deciding on a specific testing strategy. Further, schools are encouraged to proactively pursue discussions with local hospitals and/or local CLIA-certified labs. (The Clinical Laboratory Improvement Amendments regulate laboratory testing and require clinical laboratories to be certified by the Centers for Medicare and Medicaid Services before they can accept human samples for diagnostic testing.)

Nucleic Acid Amplification Tests

Nucleic acid amplification tests, including polymerase chain reaction, are considered the standard against which other tests are evaluated. This technology amplifies the RNA of the SARS-CoV-2 virus, thereby allowing detection of minimal quantities of virus particles. Samples are obtained via nasopharyngeal, oropharyngeal, or nasal swabs, or by collection of saliva. Traditionally, PCR tests were limited by the following:

• Proper collection, including personal protection equipment for those obtaining samples.
• Reagent availability for test completion.
• Laboratory and personnel capacity.
• Cost (approximately $100-$150 per test).

When access to a dedicated laboratory is not a challenge, and there are no public health contraindications to performing tests on asymptomatic or minimally symptomatic individuals, turnaround time for testing can be within 24 hours. However, due to lab access and other challenges, PCR lab-based testing in the general population will often have a turnaround time of more than 72 hours. Delayed turnaround can limit the utility of testing, especially when the individual being tested is not living within a bubble that minimizes the risk of disease transmission.

Two advances have improved PCR testing availability and turnaround time:

1. Saliva PCR testing that bypasses traditional nucleic acid extraction/reagent.

a. SalivaDirect was developed in partnership with Yale University and the National Basketball Association and was issued an emergency use authorization from the U.S. Food and Drug Administration on Aug. 15. SalivaDirect uses the collection of saliva in a container that does not require nucleic acid preservatives at sample collection, and it replaces nucleic acid extraction with a simple step that does not require reagents that may be in short supply. Therefore, use of SalivaDirect can help bypass resource risks related to sample collection and bottlenecking of reagent supply. SalivaDirect is a protocol, not a kit, and does require an authorized lab (meaning it is not point-of-care testing). This testing methodology can be performed using several common and available reagents. Any high complexity CLIA-certified lab within the Unites States may become authorized to use SalivaDirect through a submission process. Turnaround time for testing depends on the working arrangement with the lab and its dedicated personnel and lab infrastructure. The time will be highly reliant on laboratory automation. The estimated cost is $5 per test, although commercial labs may charge up to $30 per test. Researchers at the University of Illinois at Urbana-Champaign developed a similar saliva-based PCR test, which is being used for frequent testing of students, faculty and staff. The university’s dedicated lab can process 1,000-2,500 tests every four hours. The SalivaDirect test is projected to have widespread availability over the next several weeks. More information about SalivaDirect protocol and lab authorization can be found here and on the FDA website.

b. Ambry Genetics offers saliva-based PCR tests that can be self-collected as part of its broader CARE for COVID program, and results can be delivered within a fast turnaround through a portal compliant with federal privacy laws on the release of medical information. PCR tests can be further expedited through custom critical delivery services to meet the turnaround time necessary for each school or conference. More information about Ambry Genetics can be found here and on the FDA website.

2. Molecular-based point-of-care tests use PCR but do not require transport to a dedicated lab. Rather, the tests are performed on-site with a dedicated machine and test kits. Abbott ID NOW is another product issued an emergency use authorization and is a prototype for this type of test. Such testing requires oversight of a CLIA-certified physician (for example, a team physician who obtains the certificate), and testing can be performed by properly trained individuals who report to the CLIA-certified physician. The test kit includes a dedicated nasal swab, and tests are run individually, taking about 15 minutes per test. Each instrument costs $5,000, and test kits cost $41 per test. Given the individual nature of testing, use of this method likely would require five to seven instruments per school. Abbott ID NOW is currently not widely available and is approved for use with symptomatic individuals only (meaning testing asymptomatic individuals would be “off-label”). Production increases may lead to more widespread availability in November or December. More information about the test can be found here and on the FDA website.

Antigen Testing

Unlike nucleic acid amplification tests, antigen testing is performed by identification of an inner nucleocapsid protein of the virus using a fluorescent immunoassay. This means that the number of viral particles per sample must be substantially higher than PCR testing (thereby possibly increasing false negative tests). Although specificity in symptomatic individuals is high (thereby decreasing false positive tests), false positive test rates in asymptomatic populations is less well understood for antigen testing. Antigen testing is used with point-of-care instruments and/or test kits. Antigen testing that has been approved or is on the horizon includes the following:

1. Quidel Sofia/Sofia 2 is FDA authorized for emergency use and includes the analyzer and test kits. The most common pathway for obtaining the instruments and test kits is through a partnership with distributors who also may provide clinical services, although there are active discussions to centralize purchasing of instruments and test kits. The Department of Health and Human Services has purchased the majority of available Sofia instruments and test kits, and the next major shipment is expected in November. There may be alternative pathways before November, and we will provide additional updates as they become available. More information about Sofia/Sofia 2 can be found here and on the FDA website.

2. Abbott BinaxNOW is a newly released antigen test with emergency use authorization. The test does not require an instrument, but rather is a simple folding card test kit with nasal swab that provides a yes or no result in 15 minutes. A kit content is 40 test cards and nasal swabs. The cost is $200 for 40 cards, meaning $5 per test. This test requires CLIA physician oversight, similar to Sofia. HHS purchased 150 million test kits, and Abbott can produce 50 million per month beginning in October. Therefore, widespread availability is expected to begin around January. More information about BinaxNOW can be found here and on the FDA website.

3. Other point-of-care antigen tests are expected to enter the U.S. market in late November or December, including Quest Diagnostics, E25Bio and BD Veritor tests, as well as additional offerings through the Ambry CARE for COVID program. We will provide additional updates on emerging point-of-care antigen tests as they become available.

Testing Protocols

Training and competing in basketball require frequent, sustained close contact among players, coaching and other essential staff, and officials in an indoor setting. Schools are encouraged to proactively define those individuals who constitute the “inner bubble” (Tier 1), which includes student-athletes and essential basketball personnel whose job function requires direct access to players on a regular basis, specifically close contact (6 feet or less) for 15 minutes or more, as per CDC guidance. Tier 1 individuals may differ from school to school (for example, some coaches maintain physical distancing at all times and therefore are not part of Tier 1). Tier 1 individuals are considered to be at higher risk of becoming infected with COVID-19 if any other individual in the group is contagious and masking/physical distancing has not been maintained. The situation is further compounded because the nature of basketball makes it challenging to train in functional units (as described in the Resocialization Standards).

A typical basketball team has 15 players, all of whom typically train on a single basketball court at the same time in an enclosed space. Generally speaking, it is expected that the total number of Tier 1 individuals within a team would approximate 25-30. If any Tier 1 individual becomes infected, schools should consider quarantining the entire team, including coaching staff and other essential personnel who are part of Tier 1, for 14 days, provided determinations around who must be quarantined are ultimately the jurisdiction of appropriate public health officials. At present, there is not a recommendation for consideration of testing out of quarantine.

Surveillance vs. Symptomatic Testing

If an individual has symptoms suggestive of or consistent with COVID-19, symptomatic testing performed via PCR is recommended. For asymptomatic surveillance screening during countable athletically related activities, the preseason, regular season and postseason, testing should be considered as outlined below via PCR or antigen testing.

Of note, CDC guidance provides that individuals who previously tested positive for COVID-19 do not need to quarantine or get tested again for up to three months (for example, even after a high-risk exposure) as long as they do not develop symptoms again. However, if such individuals develop symptoms consistent with COVID-19, they require reevaluation and may need to be tested again if there is no other cause identified for their symptoms.

Countable Athletically Related Activities

Based on the basketball start-of-season model adopted by the Division I Council, countable athletically related activities, also referred to as the transition period, run Sept. 21 through Oct. 13, 2020. During the period when countable athletically related activities are occurring but before the preseason begins, surveillance testing should be considered for 25%-50% of student-athletes and Tier 1 individuals every two weeks if physical distancing, masking and other protective features are not consistently maintained, plus additional testing for symptomatic and high contact risk individuals. This is consistent with the Resocialization Standards.

Preseason

Based on the basketball start-of-season model adopted by the Division I Council, the preseason period begins Oct. 14 and ends Nov. 24. During the preseason, it is anticipated that physical distancing and masking will be compromised. However, if there are no scrimmages with outside teams, student-athletes and other Tier 1 individuals will not be interacting with individuals outside the member school environment during practice. Based on this expectation, testing should be considered weekly for all Tier 1 individuals during this time. This is consistent with the Resocialization Standards. If scrimmages occur with outside schools, then the testing protocol for the regular season and postseason should be considered.

Regular-Season and Postseason Competition

Based on the basketball start-of-season model adopted by the Division I Council, the regular season begins Nov. 25. Because of the frequency of games and travel, coupled with the risk of infection in basketball, it is suggested that COVID-19 testing occur three times per week on nonconsecutive days for Tier 1 individuals during the regular season and postseason competition periods. It is suggested that the three-time-a-week testing begin one week before the first competition.

Even though some tests may be less sensitive and more prone to false negative results than others (for example, antigen vs. lab-based PCR), the frequency of testing decreases considerably the mathematical odds of the same individual obtaining a false negative test repeatedly. However, because false positive tests are more likely to occur in asymptomatic populations, schools may want to consider performing a confirmatory PCR test with any asymptomatic individual who tests positive.

As identified in the Resocialization Standards publication, game officials should be considered Tier 1 individuals during the regular season and postseason such that the same frequency of testing would be suggested for them. Schools should arrange for testing paradigms that make the most sense locally.

Membership is encouraged to work closely with school and conference medical and operations personnel to proactively identify and arrange for necessary testing paradigms that can be adequately supported through available school, local and conference resources.

Practice Without Competition

For schools that are holding basketball practice but are not competing against other schools, it is suggested that testing be performed as per the preseason recommendations.

Quarantine and Isolation Considerations

Tier 1 Individuals With High Risk Exposure

When a Tier 1 individual tests positive, it is suggested that all other Tier 1 individuals quarantine as soon as the results are known for a period of 14 days, with contact tracing beginning immediately to determine who was subject to a high-risk exposure. Ultimately, the appropriate public health officials have jurisdiction to make these determinations. Schools can consider the need for and potential benefit of training on-site personnel in contact tracing through accepted courses such as the Coursera class, as access to additional trained staff can be an invaluable contact tracing resource with respect to institutional risk-management efforts and resources.

Exercise While in Quarantine

Consistent with the Resocialization Standards, it is suggested that student-athletes who are placed in quarantine for high risk contact but who are not infected with COVID-19 be permitted to exercise individually if such exercise does not cause cardiopulmonary symptoms. If individual exercise is performed outside, schools should consider monitoring all such outdoor activities to ensure physical distancing and masking as appropriate, and such exercise should be consistent with appropriate public health official guidance. Group exercise is not recommended. It is suggested that all student-athletes placed in quarantine be monitored for the development of symptoms and undergo testing if symptoms develop.

Isolation and Return to Sport for Infected Individuals

It is suggested that schools continue to consider the isolation and return-to-sport guidance provided in the Resocialization Standards for individuals who test positive, including those considerations related to cardiac testing.

The Basketball Bench

The basketball bench has historically involved most Tier 1 individuals sitting or standing in close proximity to one another throughout the game. Because it is assumed that these Tier 1 individuals have tested negative and are already in close contact while on the court, it is not suggested that they must observe physical distancing and universal masking while on the bench. However, it is suggested that the basketball bench be physically separated from all other individuals who are not part of Tier 1. Logistics should be considered to address risks related to personnel who must be at the game but are not part of Tier 1. It is suggested that these Tier 2 individuals, defined as other essential basketball personnel who occasionally may need to be in close proximity to student-athletes and other Tier 1 individuals and who may need to access restricted areas periodically, observe masking and physical distancing at all times and be prevented from interacting with any of the basketball bench individuals unless physical distancing and masking are in place for all.

Similarly, other adjustments to address close contact risks within the bench area (for example, reduction/removal of unnecessary scoring, statistics and other paperwork, moving the scorers’ table to the opposite side of the court, etc.) also are encouraged where feasible, provided it is acknowledged that these types of adjustments may require further evaluation of existing rules.

Travel Considerations

Schools should continue to evaluate the current data regarding the risks and considerations identified in the Resocialization Standards related to commercial plane and other travel. These considerations include, among others, travel protocols that maximize the opportunity for physical distancing and call for universal masking for all individuals traveling; the availability of alternative travel by private car, van, chartered bus or chartered plane; proper communication of all travel rules, protocols and expectations to everyone in the travel party; prepackaged meals, room service, takeout and outdoor dining options as alternatives to inside restaurant dining; and, when feasible, traveling and playing on the same day to avoid overnight stays. In addition, schools should consider restricting the size of travel parties as much as possible, ideally requiring they are not greater than 30 individuals. Many states still have in place quarantine protocols that make travel impractical. Therefore, state and local guidelines must be considered before any anticipated travel for competition.

Considerations for Symptomatic Management During Travel

Schools should consider management strategies for student-athletes and other essential basketball personnel who travel for competition and become symptomatic after departure. Traveling teams should consider confirming, ahead of time, whether host schools have adequate on-site testing capabilities to address symptomatic athletes from either team and adequate health care resources to properly isolate and care for anyone who tests positive or is symptomatic. The traveling team also should consider, ahead of time, necessary arrangements for proper return transport of infected, isolated and quarantined student-athletes and personnel, in each case in accordance with appropriate state and local public health requirements.

Considerations Related to the Discontinuation of Athletics

Although at the time of this writing, reported data reflects that the rate of spread of COVID-19 has been decreasing or has stabilized in many regions of the country, athletics departments and member schools should continue to consider the parameters for discontinuing athletics, as per Resocialization Standards and the related NCAA Board of Governors mandate. Despite reported improvements, local circumstances and risks may still create uncertainty around safety in high contact risk sports such that schools should continue to work with appropriate public health officials and consider pausing or discontinuing athletics activities. Some examples of such local circumstances that might trigger a conversation with appropriate public health officials:

• A lack of ability to isolate new positive cases or quarantine high contact risk cases on campus.
• Unavailability or inability to perform symptomatic, surveillance and pre-competition testing when warranted and as recommended in this document.
• Campuswide or local community test rates that are considered unsafe by appropriate public health officials.
• Inability to perform adequate contact tracing consistent with governmental requirements or recommendations.
• Appropriate public health officials stating that there is an inability for the hospital infrastructure to accommodate a surge in hospitalizations related to COVID-19.

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