Sickel cell trait and sports: Is the NCAA a Hematologist?

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In 2006, Dale Lloyd Jr., a 19-year-old freshman at Rice University who played defensive back, died one day after collapsing during football practice. It is an event that I remember well. My son was a sophomore at Rice at that time, and he was a member of the MOB (Marching Owl Band) that played in tribute.

At post-mortem examination, it was discovered that Dale had sickle cell trait (SCT). A wrongful death lawsuit was brought against Rice University and the sports conference to which the University belonged, and as part of the settlement and the aftermath of that tragic event, the National Collegiate Athletic Association (NCAA) began, in 2010, the practice of screening all Division I athletes for SCT. In 2012, the policy was extended to include Division II athletes, and in 2013 Division III athletes were also included. Now, to participate in NCAA sanctioned athletics, a student must have a sickle cell test and report the results to his or her coach and trainer, or he or she can decline the test and sign a legal document that releases his or her respective university from liability.

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What are the facts? SCT is common. One in 12 African-Americans (~8%) has SCT. Based on this estimate, perhaps 4 million people in the United States carry the trait (with about 300 million worldwide being affected). Although exercise-associated death in individuals with SCT is extremely rare, there are epidemiologic, but not cause-effect, data that suggest a link. A landmark study showed a 37-fold greater relative risk of sudden death during basic training in army recruits with SCT.1 Confronted with this data, the U.S. Army responded, not by screening recruits for SCT, but by implementing changes in hydration and rest rules designed to protect all inductees from the adverse effects of overexertion and hyperthermia.

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A recent study surveyed newspaper reports and incident records that covered 2 million NCAA student athlete-years and identified 273 cases of sudden death.2 Only five (2%) of these were associated with SCT. All five SCT-related deaths occurred in football players, none occurred during games, and most occurred during preseason conditioning practices and thus involved less well-conditioned student athletes, akin to the less well-conditioned soldiers with SCT who died during basic military training. ASH’s statement encourages research into the effects of SCT on exercise tolerance and urges the NCAA to implement universal precautions to reduce exercise-induced injury, such as those implemented by the Army.

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