Opinion | Olympic Chief Medical Officer on Athletes’ GI Illness After Seine Events

In this exclusive video interview, Jeremy Faust, MD, editor-in-chief of MedPage Today, sits down with Jonathan Finnoff, DO, chief medical officer for the U.S. Olympic & Paralympic Committee, to discuss how Olympic doctors treated athletes with gastrointestinal (GI) issues after swimming in the Seine, and how they managed injuries and COVID among athletes.

You can watch part 1 of this interview — a discussion on the medical needs of Paralympic versus Olympic athletes — here.

The following is a transcript of their remarks:

Faust: Any insight on the events that were held in the Seine River, and I don’t know whether or not there are plans to have events in the Paralympic Games in the Seine. I thought the idea of doing it was kind of beautiful and amazing, but I think the execution was touch-and-go.

So I’m curious on both your reaction to how it went in the Olympic Games and if you can inform me as to whether there are plans for the Paralympic Games.

Finnoff: Yeah, so there is going to be an event in the Seine in the Paralympic Games, the triathlon. In the Olympic Games, it was triathlon and open water swimming.

They do have historical data from the IOC [International Olympic Committee] standpoint on how many people have gotten sick, specifically gastroenteritis, after various open water types of events. It’s hard to compare apples to apples because both in Rio and in Tokyo they were in saltwater, which is very different than freshwater in a river in a city, but the preliminary results from the IOC’s injury and illness surveillance data is that they have about a 10% infection rate in those who swam in the Seine, versus in the past it’s been between a 1% and 3%.

So it’s definitely higher, substantially higher, but it’s still not that high. One in 10 athletes got gastroenteritis. Some were more serious, others were not. Thankfully within Team USA, it was less than that.

Faust: So 10% had some kind of a GI illness. Were those because of the nature of the bacteria or other pathogens that might be there? Were those routinely treated with antibiotics? Versus if I as an ER [emergency room] doctor see a mild gastroenteritis in my Boston ER, I’m not giving antibiotics unless there’s some really high-risk exposure.

Finnoff: Yeah, it was variable. One of the nice things is that you can do rapid PCR tests and get an idea of what pathogen it is and then decide whether this is something that requires antibiotics or not. Also the severity of their symptoms and whether they have another competition or not comes into play.

So within Team USA, we did use antibiotics on the individuals that did have gastroenteritis-type of symptoms related to the Seine. But on some of their teams, they did sometimes and did not on others based on the pathogen.

The other thing is that there was variability between teams in terms of pre-treatment, to try to prophylactically prevent infections from happening. But as you know, if there are a lot of different pathogens, which antibiotic do you use? Is it going to be broad-spectrum enough to eliminate the risk of all of these — which it won’t — and you also have your own risks associated with antibiotic use, which can cause photosensitivity, gastrointestinal discomfort, and distress just from changing your flora. So there’s all sorts of different things.

We did not, based on infectious disease doctor’s recommendations, we did not prophylax and we had really minimal problems with gastroenteritis.

Faust: Alright. That’s a really interesting story, and a unique challenge to the games. I would love to delve into what the go-to were, but it sounds like you were driven by PCR, so you pretty much knew what you were treating there. That’s pretty interesting, and thanks for sharing that.

I want to move on to a discussion about injuries before competition. I asked some of your colleagues in Paris how do you make these decisions as to whether someone is well enough with an injury to play or recovered enough from say COVID to compete.

I would just imagine that in the case of the Paralympic games, it might be a little more up to the athlete because they might have a better read on their own unique situation. Is that a fair assessment?

Finnoff: That’s an interesting question. I would say that we always have shared decision-making.

The time that shared decision-making kind of goes out the window is if the person is impaired, so say they have a head injury, then they’re not able to make that decision for themselves. That’s why concussions are a little bit different than most other medical conditions.

But shared decision-making is a really big, important part of sports medicine where you talk about this is the risk associated with your injury, this is the recommended treatment, these are the risks if you proceed with competition. Can you participate at the level that you need to? Would it be better for you and also for the team to have a late athlete replacement moving into that position?

So there are a whole bunch of different things that go into that decision, but certainly if it puts that athlete’s health significantly at risk or those around them, then the decision would be made for them not to participate.

Faust: Yeah, and I was really interested in the Noah Lyles case, because a lot of people commented that they felt that him competing put others at risk. And as someone who studied COVID a lot, I don’t think that he put anyone at risk in the event. I mean, this is an open-air stadium. It’s very, very difficult to spread the pathogen in that situation. But the place where you might spread it was in the ready room or in the sort of infrastructure leading up to that.

How cognizant and mindful were you and your staff about those issues?

Finnoff: Very. So again, we follow CDC guidelines. And the CDC explicitly states that people should isolate when they have a fever and they have escalating symptoms. When their symptoms have improved for 24 hours and they no longer have a fever [while] off of fever-lowering medications, they no longer need to be in isolation, but they should wear a mask when they’re inside around other people.

We follow those guidelines and that’s what Noah followed.

Faust: Alright. The criticism there is that people test positive for a lot longer than that, CDC guidance notwithstanding.

Finnoff: Correct. Yeah. So we follow CDC guidelines, and the CDC guidelines are not based on when you test positive. CDC guidelines are based on when you’re symptomatic and when your symptoms are improving and your fever has resolved.

Faust: Alright. Well, I’m glad that you’re paying attention to it. I think that, obviously it wasn’t like Tokyo where everybody was getting tested every minute, so you had a different set of challenges.

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