CHAPEL HILL -- As expected, Florida State University beat Duke University in football on Sept. 19, 1998, but the Blue Devils got a bit of unintentional revenge. Duke players, many of whom suffered from gastroenteritis before, during and after the game, passed on the illness to their Florida rivals in a possibly unique case of disease transmission.
Everyone soon recovered, fortunately, but the event stands as strong evidence that hand washing and sanitary food preparation remain as important as they ever were, medical sleuths say. It also shows why coaches should keep athletes with stomach and intestinal problems off the field and away from teammates and others.
"To our knowledge, this is the first report of transmission of a Norwalk-like virus through a contact sport," said Dr. Christine Moe, assistant professor of epidemiology at the University of North Carolina at Chapel Hill School of Public Health. "Normally the virus is food borne or water borne."
Moe's laboratory confirmed what she and colleagues suspected - the athletes all suffered from the same Norwalk-like virus. Thirty-six Duke players came down with upset stomachs, vomiting and diarrhea on game day following a contaminated meal the day before, and then 11 Florida State players took ill hours after the game.
A report on the case appears in the Oct. 26 issue of the New England Journal of Medicine. Lead author is Dr. Karen M. Becker, who interrupted her Outer Banks honeymoon and rushed back to her Raleigh office to start investigating the outbreak. At the time she was epidemic intelligence service officer with the U.S. Centers for Disease Control and Prevention assigned to North Carolina. Now she is an epidemiologist with the U.S. Department of Health and Human Services' Office of International and Refugee Health in Rockville, Md.
Becker interviewed Duke players and some of the Florida players who became ill. She also collected stool and sera specimens and traced the outbreak to Duke athletes who ate turkey sandwiches in a Sept. 18 box lunch prepared in Durham. Moe and her staff tested the specimens with an assay known as reverse transcription-polymerase chain reaction and identified the culprit virus. They also found that two restaurant employees Becker located tested positive for serum antibodies against the same Norwalk-like virus, meaning they too suffered recent infections and were the source.
"The only contact between the two teams was on the playing field," Moe said. "The virus was passed by people touching each other's contaminated hands, uniforms and maybe even the football itself. We know Norwalk-like viruses are extremely infectious and cause 96 percent of acute nonbacterial gastroenteritis in the United States."
There's nothing the Duke players could have done to prevent getting ill since the virus was in their food, but once they were sick, coaches should not have allowed them to play, she said.
Despite the discomfort they produce, Norwalk-like viruses generally are not dangerous to otherwise healthy people, Becker said. Those most at risk of complications or even death are the very young, the very old, people who already are dehydrated for other reasons and those with impaired immune systems.
"The new molecular techniques Christine uses allowed us to go beyond basic epidemiology and nail down what happened to these young men," she said. "We soon had an exact fingerprint of the virus that made them sick. Molecular tests even showed that an outbreak of gastroenteritis at a Florida State fraternity a week later had nothing to do with the football players and was caused by a different virus."
The RT-PCR identification and amplification technique is becoming increasingly valuable as air travel promotes disease transmission across borders and across oceans, Becker said. Co-authors of the report are Drs. Karen L. Southwick of the Centers for Disease Control and Prevention and J. Newton MacCormack of the N.C. Department of Health and Human Services. "We've worked closely with Dr. MacCormack and his staff in communicable diseases to provide laboratory services in many outbreaks of gastroenteritis," Moe said. "Our collaboration, which is mutually beneficial, shows the university responds to the needs of North Carolina."
Note: Until Oct. 26, Moe can be reached in Denver at the Westin Hotel, (303) 572-9100, and afterwards at (919) 966-1420. Becker's office number is (301) 443-1774.
Contact: David Williamson, (919) 962-8596 or David_Williamson@unc.edu.
Journal
New England Journal of Medicine