Setting Screens: The NCAA’s Universal Sickle Cell Tests

In September 2006, a Rice University football player collapsed during practice due to acute exertional rhabdomyolysis, a condition associated with the sickle cell trait (SCT). Almost four years later, in August 2010, the National Collegiate Athletic Association (NCAA) mandated that all Division I student-athletes must be screened for SCT. In an article for Health Services Research, three Robert Wood Johnson Foundation Clinical Scholars evaluated how effective the NCAA mandate was in identifying student-athletes with SCT and reducing exercise-related sudden deaths due to SCT.

The authors based their projections on publicly available data on race and ethnicity for NCAA Division I student-athletes for the years 2007-2008 – prior to the mandate. Of the 2,147 Division I student-athletes with SCT in one entering cohort, the authors estimate only 2,123 would have been identified by the screening policy, leaving 24 unidentified. Eighty-nine percent of the 2,123 would have self-identified their race and ethnicity as black, and the majority would have competed in football, track, and basketball.

Based on the model, one exercise-related sudden death would occur in a four-year period among student-athletes screened once for SCT. The authors estimate that seven student-athletes with SCT would die due to an exercise-related death—like the Rice University football player—by the 10^th year of the screening program’s implementation. To prevent one death, 144,181 student-athletes would need to undergo screening, assuming that intervention strategies were put in place and completely effective.

Using standard costs for sickle cell solubility testing, the authors estimate that screening 144,181 students to prevent a single death would cost between $1.4 million and $2.9 million. Confirmatory tests for those with positive sickle cell solubility results would be roughly $106,000.

After noting the high cost of the program and the meager results achieved from screening, the authors recommend investigating the efficacy of NCAA’s screening policy. They note that future research should investigate the efficacy of NCAA-endorsed intervention strategies “because interventions, not screening tests, save lives.” Intervention strategies include “proactive prevention” during “preseason and in-season condition.” Specifically, student-athletes with SCT should take precautions, including engaging in “a slow and gradual pre-season conditioning regiment,” staying sufficiently hydrated during practices, and being excused from “performance tests such as serial sprints or timed mile runs.” If followed, these recommendations may minimize exercise-related deaths more effectively than simple screening.

The authors argue that screening student-athletes for SCT should not be the NCAA’s one and only step toward the prevention of exercise-related deaths. The authors refer to a previous study that demonstrated the U.S. military’s success in reducing sudden deaths among recruits with SCT. Rather than implement universal screening, the military implemented universal intervention for all recruits (e.g., hydration and temperature monitoring), regardless of whether they had SCT or not. The result: the prevention of sudden death among all recruits with SCT.