On Saturday morning, hours after playing 35 minutes against the Washington Wizards, Jayson Tatum tested positive for COVID-19. The Boston Celtics star was immediately sent into quarantine in accordance with the NBA’s health and safety protocols, a 153-page document containing the league’s guidelines for playing basketball in a pandemic. The protocols mandated contact tracing, a seven-step process required after a positive test to identify other individuals Tatum could have exposed if contagious prior to receiving his results.
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In this instance, contact tracing identified Wizards’ star Bradley Beal as having high-risk exposure to Tatum. Beal had shared the court with Tatum off and on for nearly two hours, guarding him occasionally and even fouling him once. What was identified as high risk, however, was a maskless post-game conversation Beal held with Tatum that ended with a hug. Beal was held out from his team’s game the following evening. Beal’s teammates, not identified by contact tracing, played without him.
On Monday, the league announced two games – New Orleans vs. Dallas and Chicago vs. Boston – would be postponed because teams fell short of the eight available players required to proceed. It comes in the wake of the league’s COVID-19 situation growing even more serious over the weekend, when the Celtics’ game against the Miami Heat on Sunday was postponed when Miami was unable to field the eight available players required for a game to be played. Sunday’s injury report submitted by every team scheduled to play in the next 48 hours listed 27 players from 11 teams out for health and safety protocols. At least two teams have shut down practice facilities after outbreaks.
Despite this increase in cases, Beal was the only Wizards player identified through contact tracing this past weekend because the league has come to believe there’s a low probability of on-court transmission of COVID-19, a finding it has largely based upon guidelines established by the Center for Disease Control. This belief has guided the league’s contact-tracing procedures as well as the health and safety protocols at large.
The problem, according to two infectious disease experts who spoke to The Athletic, is the league established its procedures without accounting for the extenuating circumstances of a professional basketball game.
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The Athletic has acquired a copy of the league’s health and safety protocols. The document begins its section on contract tracing by defining “close contact,” which is what contact tracing is generally looking for.
Consistent with current CDC guidance, close contacts are defined as any individual who (a) has been within six feet of an infected person for a cumulative total of 15 minutes or more over a 24-hour period (i.e., consecutively all at once or in multiple separate time blocks), starting from two days before illness onset for symptomatic individuals, and two days before specimen collection for asymptomatic individuals or (b) had direct contact with infectious secretions or excretions of the infected individual (e.g., being coughed on or bare-handed palm- to-palm handshakes or hugs).
The document then lists the CDC guidelines that helped establish this rule, which read in part as follows:
Data are limited, making it difficult to precisely define “close contact;” however, 15 cumulative minutes of exposure at a distance of 6 feet or less [over a 24-hour period] can be used as an operational definition for contact investigation. Factors to consider when defining close contact include proximity (closer distance likely increases exposure risk), the duration of exposure (longer exposure time likely increases exposure risk), whether the infected individual has symptoms (the period around onset of symptoms is associated with the highest levels of viral shedding), if the infected person was likely to generate respiratory aerosols (e.g., was coughing, singing, shouting), and other environmental factors (crowding, adequacy of ventilation, whether exposure was indoors or outdoors).
The league’s contact tracing primarily focuses on the first definition of close contact, which requires a player to spend at least 15 minutes within six feet of another individual who tests positive. The league has used Second Spectrum player tracking data to establish that players, on average, spend no more than five or six minutes within six feet of another player during any given game. It technically falls within the CDC guidelines.
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But the CDC guidelines are approximations set forth for average circumstances. Dr. Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security and infectious disease physician, is concerned the league has applied them without consideration for the extraordinary circumstances of an actual NBA game. “That guidance is probably not applicable in those situations,” he says.
“We know that when people are engaged in athletic activity they’re often breathing faster,” Adalja adds. “(It’s) more likely for more viral droplets to emanate during high intensity exercise, especially in indoor environments where people are less than six feet apart.”
Dr. Abraar Karan, a doctor of internal medicine at Brigham and Women’s Hospital and Harvard Medical School in Boston, shares Adalja’s concerns regarding physical activity.
“Transmission can happen sooner than 15 minutes,” Karan said. “The protocols here are for what an average transmission risk may be, but not if somebody is infectious and breathing extremely heavily, like they do in sports: face to face. Though you are running most of the time, there are lots of times when you’re not, like during free throws, boxing out and during a timeout.”
There have not been confirmed examples of on-court transmission between opposing teams yet, although Beal’s post-game exposure to Tatum at least indicates the league believes it could happen in some form. Frankly, if the league took a harder stance with on-court exposure, it would be difficult to continue playing games at all. Already, multiple teams have played games with the minimum required eight players.
The Dallas Mavericks have three players currently quarantining in Denver after one tested positive for COVID-19, while two more were identified as having close contact during a road trip. Dallas returned home without them, played a home game one day later and then was forced to shut down the team’s practice facility when a fourth player entered into the league’s self-isolation protocol. On Monday, at least five more players entered into self-isolation after another player tested positive, a team source says, causing the team to fall below the required eight available players threshold and for the evening’s game to be postponed. If the NBA’s contact tracing identified on-court exposure as a possible transmission concern, the team would likely require more players to isolate themselves, as would the two teams they’ve played since its first player recorded a positive test.
Heat guard Avery Bradley was added to the COVID health and safety protocol list shortly before Sunday’s Heat-Celtics postponement, only a few days after facing Tatum in Miami. That’s the most concerning example yet of potential on-court transmission after Bradley and Tatum spent five minutes actively guarding each other in close contact according to NBA Stats’ matchup data, which does not include downtime between possessions, free throws and other moments when they were in close proximity. It also doesn’t consider the mitigating circumstances that come with high-activity exercise.
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“If you’re face-to-face, the exposure of droplets is directly in front of you,” Karan said. “If someone is laterally next to you, you have less of an exposure than if they are facing you. But during a game, you are going to face both of those scenarios.”
Karan notes that the league’s daily testing cadence means that infectious players are being identified as early as possible, catching cases when their viral load, and therefore contagiousness, is lower than at the peak of the infectious cycle. By catching players right as they start to incubate the virus, the amount of virus particles they are breathing into the air is less than that of a highly infectious person at the peak of his infection cycle.
Playing in a large, open arena helps improve air circulation, while arenas are using bipolar ionization in their HVAC systems that emit molecules that help neutralize COVID-19 particles in the air. It’s a much different situation than, say, indoor dining. Still, this does not eliminate the potential for an infectious player to breathe the virus into the face of another player.
But there is more at stake than just controlling spread for the sake of keeping players healthy and protecting highly vulnerable people. Pretty much every athlete in the NBA is a paragon of health relative to the general population and in an age group that should mean they are highly unlikely to end up in the ICU with COVID. But when University of Florida freshman Keyontae Johnson collapsed during a Dec. 12 game and was later diagnosed with Myocarditis that may be tied to contracting COVID-19, the concern about long-term health risks amplified.
“I have myself seen viral Myocarditis in someone who was otherwise healthy before they contracted COVID,” Karan said. “I have seen heart failure develop after COVID as well. These patients were in their 40s and 50s, but they were otherwise healthy before that. It does happen, it’s concerning and it’s unclear to what frequency it happens in younger patients. It’s a risk that’s much more costly to people whose physical health is required for their livelihood.”
Though there is still much to learn about the link between Myocarditis and COVID, there has been enough time for doctors to recognize that asymptomatic patients aren’t necessarily immune to long-term health risks.
“There are patients who are completely asymptomatic and if you look at their CT scans, they do have evidence of some scarring on their lungs,” Karan said. “And so it’s hard to say the symptoms alone will tell you exactly what the future looks like.”
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It all begs the question of whether the league will hit the point of needing to suspend operations and go into quarantine. While there are currently only a few hot spots across the league, that can change quickly as people who were exposed over the past week begin to test positive. Though players and staff are supposed to follow the league’s guidelines for social distancing and limiting exposure in their daily lives, the absence of a bubble opens up the possibility for anyone to bend the rules without getting caught or simply get exposed to the virus in limited interactions with non-NBA personnel in society. The majority of the players did not want to repeat the bubble experience, either. The league still has months ahead of it to play, which leaves ample time for infections to hit some sort of critical mass. But even if that happens and the NBA decides to take two weeks off for everyone to quarantine, it may only reset the clock for a short period of time, if at all.
The league’s health and safety protocols do set broad parameters for considering a temporary shutdown:
The occurrence of independent cases (i.e., cases not spread among players or team staff) or a small or otherwise expected number of COVID-19 cases will not require a decision to suspend or cancel the 2020-21 season. The NBA and NBPA will continue to monitor public health developments affecting all teams and, based on circumstances over the course of the 2020-21 season, will discuss any modifications to these Protocols if the parties and their medical experts agree such measures are necessary to promote safety.
It will likely be months until league-wide vaccinations are possible. Until then, playing- and non-playing personnel alike must navigate an imperfect set of protocols — one Adalja is skeptical could be reformed in a way that fully guarantees safety.
“I don’t think you can come up with a one-size-fits-all (answer),” he says. “It’s really gonna depend upon each individual’s circumstances and what their risk tolerance will be, because no activity is going to have zero risk, unless you do it the way they did it before with the bubble.”
Both the league and its players understood that mitigating such risk would be a tall task, especially at the height of the pandemic. Now they could be at a crossroads. The NBA came into this season recognizing it may have to reassess its protocols when they were pushed to their limit. The past week made it clear that the inflection point is approaching — if it isn’t here already.