After graduating from Reno's McQueen High School and enrolling at the University of Nevada, Mark Stovak envisioned a career in pro baseball. He played for the Wolf Pack from 1986-88, the bridge years when Nevada moved from off-campus Moana Stadium to on-campus Peccole Park. But then something happened.
“The fact I wasn’t fast and couldn’t throw made me realize it probably wasn’t happening,” Stovak said with a laugh.
So, Stovak quit the team after two seasons because his baseball schedule required a lot of travel and didn’t allow him to take classes after noon. Stovak was in the running for the Herz gold medal, awarded to the UNR undergrad with the highest GPA, and he wanted to graduate in four years, which he did before enrolling and graduating from Nevada’s medical school.
Stovak completed his residency in Wichita, Kan., and a sports medicine fellowship at Ball State University before serving as Wichita State athletics’ head team physician for 15 years before returning to Reno in 2015 to teach at the medical school and serve as a team physician for Wolf Pack athletics.
Last week, Stovak was added to the NCAA’s new 16-person COVID-19 Medical Advisory Group. He also serves as chair of the NCAA committee on safeguards and medical aspects of sport and is the second vice president of the American Medical Society for Sports Medicine, which he’ll become the president of in 2022. Stovak has been focused on the COVID-19 pandemic since the outbreak and wrote a soon-to-be-published chapter on infectious disease in the upcoming book, Netter's Sports Medicine.
His credentials are impeccable, which is why he was recently added to the NCAA and Mountain West COVID-19 advisory boards as college sports try to play through a pandemic. At this stage, seven of the 10 FBS conferences are playing football, with the Pac-12, MW and MAC being the only leagues not playing, although the MW said this week it is making a push to return to play as soon as safely possible.
So, what will it take for the MW to safety get back on the field? Testing. Lots of testing, Stovak said.
“You have to be able to get testing for all the schools that are going to be playing on a regular basis,” Stovak said. “How often you have to test? First, it depends on what your test is and how accurate it is and how fast you can turn it around. I don’t think every single university and every community has to test every day, but they have to test frequently enough that they’re not allowing positives to be missed several times because you get a false negative result. And they have to be able to turn around those tests fast enough that if you have somebody who is positive they don’t walk around out in the community and in the bubble for three or four days for their test to come back.”
Stovak, who said he was speaking on his behalf and not for the NCAA or MW, said how often schools must test depends in part on the prevalence of COVID-19 in their community and university. The higher the prevalence, the more testing should be done. One of the reasons the Big Ten has reversed course and will play this fall, and the Pac-12 is considering doing the same, is because it has future access to daily testing. The MW currently does not, although Stovak said daily testing is not necessarily a requirement to play this fall. The more testing the better, but a seven-day standard is hard to reach.
“Testing three times a week is a good step forward, but I don’t know that it’s going to eradicate the disease or make it perfectly safe for everybody because if we can test seven days a week that would be ideal,” Stovak said. “What is next best? Six days a week. What is next best? Five days a week. Let’s say you do three days a week, but your test doesn’t come back for three or four days. If you’re sending off a test and not getting it back before your next test that’s a worthless system.”
The importance of testing
Three types of tests are available for COVID-19, including PCR (polymerase chain reaction), antigen and antibody. The PCR and antigen tests identify if you currently have COVID-19. Antibody tests identify if you've had it in the past. PCR tests are more sensitive antigen tests, and thus more accurate, but it takes longer to deliver results. The Wolf Pack, which is practicing in multiple sports but not playing games, currently tests one day a week using PCR tests. Its results are delivered from the on-campus Nevada State Lab, although the turnaround on those results is not always speedy.
“It’s variable,” Stovak said. “It’s very variable. We don’t have control over it. It depends on the volume they have and if they have to update their equipment, but I would say for the most part the turnaround has been 24 to 48 hours, although that hasn’t happened every week. If we could get it back in 12 hours, that’d be ideal. If we could get it back in 1 hour, that'd be really ideal. But that’s not the nature of the test we’re running.”
Stovak said “Nevada is definitely at the forefront” when it comes to testing and heart evaluation post-COVID when compared to other MW schools. And it’s only testing once a week. If three tests a week might be acceptable and seven would be ideal, that shows how far the MW must come to return to playing football this fall, with the window for getting in a season closing each day. Realistically, the MW would probably need to be playing games in five weeks to have a truncated eight-game fall season, with a training camp beginning in roughly two weeks.
Stovak said it would be wise for the MW as a conference to procure the tests rather than allow each school to formulate its own testing and procedures. That conference-down push would follow the Big Ten and Pac-12 model.
“Currently, each Mountain West institution has their own testing program, and every one of them is different,” Stovak said. “And every one of them has a different protocol (with heart examinations) they follow once they have a positive test. I really think the best way forward is if the Mountain West as a conference can facilitate every school getting adequate testing in the conference because every community is having their own different issues with testing, so if it’s left up to each individual community to obtain their own testing for their university, it’s going to be a very, very difficult way forward than if the conference can obtain it.”
Of course, it’s not easy to get this mass of testing. For the Big Ten and Pac-12, which has massive television rights contracts, spending big sums of cash to get the tests so they can fulfill those media contracts can be worth it. For the MW, whose television contract is one-tenth the size of those conferences, it might not be worth the financial lift. And even if it was, getting tests is difficult.
“It’s money and availability,” Stovak said of the hurdle to getting tests. “I don’t know if the Mountain West said, ‘Hey, we have $100 million to spend on testing’ if they could get it. It’s just if we can get the availability. That’s part of the current problem with the PCR tests being done now routinely is it requires reagents and nasal swabs and a lot of stuff on top of the machines. If any of the supply chain breaks down and you don’t have swabs or don’t have reagents or a machine breaks down that slows down your process.”
The issue of myocarditis
So why is testing important? Because the more often you test, the more likely you are to limit outbreaks. Additionally, knowing who has been COVID-19 positive is important because those who do get the infection also should have their heart tested after recovering. COVID-19 patients have been found to myocarditis, which is an inflammation of the heart muscle that can lead to heart failure.
It is that myocarditis that was cited by the Pac-12 and Big Ten as one of the biggest reasons they opted to shift football from the fall to the spring (the Big Ten has reversed course and will play next month).
“It’s always something you have to have in the back of your mind, but I don’t know that you should leverage that specific issue as the reason to play or not play,” Stovak said of myocarditis. “It’s definitely a concern, and we’ve been very, very careful with that issue with our student-athletes and evaluating them.”
Stovak said Nevada’s protocols post-COVID follow the recommendations from the American Medical Society for Sports Medicine and the American College of Cardiology. Every Wolf Pack athlete who tests positive for COVID-19 must do an EKG, cardiac enzymes with high sensitivity troponins and get an echocardiogram. If any of those are positive, they get an MRI of their heart to see if they have myocarditis. Stovak declined to say how many Wolf Pack athletes have required that MRI, but Ohio State recently did a study that showed four of its 26 positive COVID-19 students-athletes "met at least two criteria consistent with myocarditis, while a further eight showed inconclusive evidence of strain."
“They had a higher rate than you’d expect of myocarditis in those patients,” Stovak said. “The problem is we don’t know what to do with the information. Is everybody that has that at-risk? Or is the test too sensitive? Does the same percent of people who get influenza get the same amount of myocarditis if you did MRIs on every one of them? Yes, we have to consider it, and yes it’s very important because you can have sudden death with exercise if you have myocarditis. You’re at a higher risk. But we just don’t know what to do with that information, so we have to be very conservative with that.”
It is those unknowns that medical professionals must wade through to deliver recommendations on whether we should be playing sports in the pandemic. Making things more difficult is the fact myocarditis could be a result of a previous illness such as coxsackievirus virus, which causes hand, foot and mouth disease in children. Additionally, endurance sport athletes show elevated scaring in the heart. The most famous athlete death from myocarditis was Boston Celtics player Reggie Lewis in 1993.
Recently, a letter was sent from a group of physicians to multiple medical societies saying not to order cardiac MRIs on asymptomatic post-COVID patients because they didn’t know what to do with that data.
“We don’t know what all this information means,” Stovak said. “Personally, if I have information that an athlete is at a higher risk of sudden death they’re not going to be able to participate. I have absolutely no idea what other people around the country are doing with that information. You don’t want to hold people out unnecessarily, but you also don’t want to allow somebody to participate if they shouldn’t be, if they are at higher risk. Once you have the information, you’re forced to act on it.”
Teams using 'herd immunity'
Another issue associated with getting COVID is an increased chance at blood clots. Jamain Stephens, a Division II football player, died earlier this month of a blood clot to the heart after testing positive for COVID-19, his family said. Stovak said getting COVID-19 puts you at a higher risk of having a heart attack, stroke or pulmonary embolism. The majority of the football rosters at LSU and Texas Tech have tested positive for COVID-19, which Stovak said is not a good thing considering the unknowns of the long-term effects.
“My advice obviously would be ‘Don’t get it’ because we don’t know all of the things that could happen to you long term, so you don’t want to get this disease,” Stovak said. “There was the theory at some schools that we’re having COVID parties so that all of the people would get the disease and once they’ve had it you would assume they’re going to be protected from it long term, so if all of your athletes all of a sudden got COVID and they got through it fine, you’d be more likely to play your season because all of your athletes have already had it and weren’t going to get held out. That was the theory."
But that "herd immunity" is short-sighted Stovak said. While athletes who recover from COVID-19 do not have to get testing again for three months, per the NCAA resocialization plans, there is proof you can get the disease twice.
“The state lab in Reno reported the first case of a patient of having two different strains of the COVID virus," Stovak said. "So now we know you can get it twice because you can get different strains, just like you can get influenza twice because you can get different strains. The standard now is once you’ve had COVID, you kind of fall out of the testing pool for three months and then we start retesting you again because to the best of our knowledge we know you’re more than likely protected from getting it for three months, or if you didn’t get it again you’ll be able to mount a pretty good response so you don’t get real sick.”
Stovak said the lack of transparency from colleges currently playing football – How many positives have they had? What tests are they using? Have they discovered myocarditis? Is there evidence of spread during games? – has been frustrating because that data could be used to help inform medical experts in their recommendations in playing during a pandemic.
“We like to make decisions based on scientific evidence and scientific data,” Stovak said. “We like to make data-driven decisions. But essentially we have no data, so we’re making what you’d call ‘expert opinions,’ consensus-driven decisions, which are great, but they’re not the ultimate standard of medical decision-making because we’ve never seen this before and have no idea what to do.”
When Stovak was asked whether he’d allow his kids to play college sports right now, he said: “It would really just depend on the testing. I would guarantee you I’d be much more comfortable having a child at Nevada right now with our testing program and our medical policies than I would at many other schools in the country who aren’t meeting the same standards we are. I would definitely feel comfortable with that.”
While testing remains the biggest hurdle the MW faces in playing sports this season – and that applies to basketball as well, which might have a season start date but still doesn’t have that robust testing, at least in the MW – there are other issues. Stovak said the recent air quality would making playing football in the MW this fall difficult and prevalence of spread in the community is also a consideration if teams are traveling. Athlete discipline to avoid potential dangers is a key, too.
“The two biggest things are the magnitude of testing and the ability to get the student-athletes to practice safe habits so you’re not going out and getting infected outside of what you’re doing in practice and your dorm room and that kind of thing,” Stovak said. “I think that many of the risks are when you’re out getting meals in the community or meeting with friends or things like that. That’s when you’re potentially taking risks outside of a very controlled environment.
Despite all of his research into this pandemic, Stovak said there’s still so much unknown about COVID-19, including the long-term effects, how prevalent spread is during competition and what the exact testing threshold is for safe play.
“For every conference, this is a major, major, major undertaking," Stovak said. "Playing sports right now is so difficult.”
Which led to this question: Should we be trying to play college athletics right now?
“That’s a tough question,” Stovak said. “So, I think college athletics are very important. It’s kind of like the Yankees game after 9/11. That was a very momentous event when the president threw out the first pitch. I think college sports are very important. I just don’t know that anybody can say if playing sports is worth the risk at this time. I think it depends on how often you’re testing and the community prevalence and everything else. But it’s not my final decision to make that decision. All we can do is make best practice recommendations as far as what we know today. And then somebody else has to actually make that decision.”
Columnist Chris Murray provides insight on Northern Nevada sports. Contact him at firstname.lastname@example.org or follow him on Twitter @ByChrisMurray.