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Johnny Tested Positive for COVID-19, What Is Next for the Team?

2020; Lippincott Williams & Wilkins; Volume: 19; Issue: 12 Linguagem: Inglês

10.1249/jsr.0000000000000780

1537-8918

David J. Satin, Grant Simonson, William O. Roberts,

COVID-19 and Mental Health

The Case Johnny plays on the high school football team; he is not a starter but can sub in at several positions on offense and defense. His best friends since kindergarten are the starting quarterback, wide receiver, and middle linebacker. The four are inseparable, and this past week was no exception. Johnny visited his older brother at college last weekend and now is mildly symptomatic and tests positive for COVID-19. He has been practicing with the team all week, and the team is playing tonight. The Problem(s) What do I do with this information as Johnny's physician and as a team physician for the local high school? Should his close friends and teammates be in quarantine? Is there a public health prerogative to disclosure to the coaches and school administration? These questions go to the heart of confidentiality and highlight the COVID-19 conundrum of public health in the sports arena. The team physician generally reports conditions rendering athletes unable to play to the coach. COVID-19 is more complicated because it has implications for all players and staff that came into close contact with Johnny. All close contacts need to quarantine for 14 d. But what constitutes "close contact"? For our medical residents working in the hospital setting, that threshold is more than 15 min in the same room as a COVID-positive case, irrespective of symptoms, but the Centers for Disease Control and Prevention recently updated the definition of exposure to "accumulating more than 15 minutes within 6 feet of an infected individual(s)." Contact tracing for Johnny may influence decisions regarding the team — several key players have had extended contact with Johnny and their exclusion from play will severely handicap the team. The Minnesota Department of Health (MDH) among others, consider COVID-19 a mandatory reporting condition. "The MDH is requiring all mandated reporters to report any cases and deaths due to SARS-CoV-2 to MDH within one working day" (1). When all is working well, positive tests are reported by the laboratory, and the report triggers contact tracing by the Department of Health. However, we are in a public health emergency, and all is not working well. Is it up to the team physician to interview Johnny and determine who needs to be tested and who needs to be quarantined before tonight's game? Also, what about contact tracing for nonplayers who came into close contact with Johnny? What about contact tracing for his family? This quickly expands well beyond the regular scope of a team physician. Physicians are required by our medical boards and the courts to uphold the standard of care. The Federal Public Readiness and Emergency Preparedness Act (PREP Act) (2) recently passed, significantly limiting physician liability when evaluating and treating COVID-19, precisely because there is little consensus on a standard of care. Moreover, working conditions are so atypical that once-a-decade judgment calls, like the contact tracing described above, are now commonplace. In short, how the team physician ought to proceed is an open question. Personally, performing some degree of contact tracing for exposures within the team seems prudent. This duty comes with at least two complications: Health Insurance Portability and Accountability Act (HIPAA) and Family Educational Rights and Privacy Act (FERPA). More Problems HIPAA 1996 is "a federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient's consent or knowledge" (3). FERPA is "a federal law that protects the privacy of student education records" (4). The Departments of Health and Human Services and Education have released joint guidance regarding the application of HIPAA and FERPA in situations where health records and educational records might intertwine (5). FERPA applies to student health records at federally funded schools, and HIPPA applies to external health records and health records at private schools (if clinicians affiliated with those schools engage in HIPPA-qualifying activities, such as electronic billing of health insurance plans). Over and above the legal implications of HIPAA, FERPA, and the PREP Act, the moral tenets of clinician-patient confidentiality remain. On the one hand, we have an obligation to pursue limited contact tracing and to promote public health. On the other hand, we want to keep Johnny's COVID-19 status confidential. To help balance this paradox, it is worth considering why Johnny and his family may not want to share his COVID-19 status. Several reasons may exist, including simply a desire to keep all health information private. A practical concern is the stigma surrounding a COVID-19 diagnosis, an internationally recognized phenomenon that could sway a family toward nondisclosure (6,7). Stigmatization can lead to further social isolation on top of that already imposed by self-quarantine. The effect of isolation on mental health is significant, especially among adolescents (8), and only exacerbates other psychosocial aspects of the COVID-19 pandemic (9,10). Racism and stigma toward certain minority communities, such as the Chinese-American community, during the pandemic is yet another reason for some to keep positive results private (11). "COVID shaming," an emerging phenomenon, may be another concern. It involves the assumption that a person's COVID-19 diagnosis is the result of poor mitigation practices — a personal failure of social distancing, mask-wearing, sanitization, and hygiene. A COVID-19 diagnosis is, thus, seen as a moral failing worthy of shame (12). Johnny's potential for shame, stigma, and isolation is compounded by his potential impact on "Friday Night Lights." Some Clarity So how do we respect confidentiality and limit the spread of COVID-19? First, let's address the legal requirements. Parental consent is generally needed to share medical or education records with others. FERPA provides permission to disclose private information if necessary in an emergency to protect the health and safety of the student and the public, and HIPPA provides for a similar disclosure when the disclosure could prevent or lessen the risk of serious harm (5). The federal government has declared the COVID-19 pandemic to be a public health emergency (13). In these instances, clinician judgment will determine if the threat of harm is serious enough to warrant disclosure (14). Here, the moral reasoning of the clinician becomes especially important, because they must balance public health against individual confidentiality. Ideally, parental consent and student assent could be obtained prior to any disclosure of a COVID-19 result. Many parents and students would surely agree. However, if a test result must be shared despite parental or student objection, it should contain the minimum necessary protected information needed to effectively convey the risk of infection and facilitate contact tracing (5,14). Contact tracing 101 teaches to never directly disclose the source of an infection. Statements like, "It has come to our attention that you have come into close contact with someone who tested positive for COVID-19" should replace, "Johnny tested positive for COVID-19." A final twist in this case is unfortunately not too far-fetched. What if the coach and players do not follow your quarantine recommendations? After all, Johnny's close contacts are key players, asymptomatic, and have not even been tested. This situation can be addressed as a general question about what a team physician does if the coach is playing ill or injured players. It may be more akin to hiding herpes gladiatorum in wrestling matches — unproblematic for the athlete in question but a danger to others. There should be a way to report to the coach's supervisor. That is why some sports' national governing bodies under the US Olympic Committee have the medical team report to an administrator above the performance team — so the performance aspects of decision making do not create a conflict of interest with player and team safety (15). We recommend setting up the option to report to a higher administrative level when negotiating your initial role as team physician. In the absence of such an arrangement, it is the team physician's moral conviction and clinical judgment that will determine their actions. Conclusions This hypothetical case lands at the intersection of public health ethics (COVID-19 is a mandatory reportable disease without adequate contact tracing), ethics of sport (duties of a team physician), and issues of confidentiality (HIPAA, FERPA, duty to patient). It exposes the conflicting obligations of a team physician to uphold individual confidentiality, support the team, and protect the public.