With cooler temperatures and dazzling displays of red and orange foliage, fall is finally in full swing. However, as with most things in 2020, fall is going to look a little different this year due to the COVID-19 pandemic. Given the highly contagious nature of the new coronavirus, social distancing has become a key strategy for minimizing transmission. Regional, national, and international sporting events have gone silent across the globe, with most events being postponed until 2021 or canceled altogether in an effort to promote the health and safety of athletes, coaches, and the general public. Now as restrictions are being lifted and the world tries to move towards some sense of normalcy, it is important to consider how athletes can safely return to training and competition.
COVID-19 – Where are we now?
The new coronavirus disease 2019 (COVID-19) was first reported in December of 2019 and has rapidly spread across the globe. The disease is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which is known to spread through small respiratory droplets or direct contact with an infected individual. As of early October, over 34.8 million people have been infected, resulting in over 1 million deaths globally (WHO, 2020).
While many cases of COVID-19 are asymptomatic or present with mild symptoms such as headache, fever, and dry cough, some patients progress to a more severe disease which can cause acute respiratory failure, multi-organ failure, and even death. This is because COVID-19 infection is accompanied by an aggressive inflammatory response known as a “cytokine storm”, where the body releases an abnormally large amount of pro-inflammatory cytokines (Ragab et al., 2020). Cytokines are produced by immune cells to kill viral particles throughout the body and are an important part of the immune response, however, abnormally high levels of cytokines can also do damage to healthy cells, resulting in damage to most major organs.
The best strategy we currently have for minimizing transmission is social distancing and wearing face masks. The crisis imposed by COVID-19 resulted in an unprecedented global response, with researchers racing to find a solution to keep people safe and prevent viral spread. What normally takes years of research has happened in a matter of months, and there are now 11 vaccine candidates in large-scale Phase III trials, according to the New York Times, and several of these have shown promising results. Many experts believe a vaccine could become widely available by mid-2021, and high-risk populations such as healthcare workers may have access even earlier than that. This would represent the most rapid vaccine development in history. Until then, however, it is important to follow guidelines and to address potential risk factors while transitioning back into normal life. When it comes to athletes, sports medicine doctors can be a valuable resource to help with the safe return to competition.
Risk for athletes
It is now well known that comorbidities (e.g. the presence of additional medical conditions) such as obesity, hypertension, and diabetes significantly increase an individual’s risk for poorer outcomes if infected with coronavirus (Sanyaolu et al., 2020). Young athletes are generally healthy and are less likely to have these comorbidities, making them lower risk for serious illness compared to other populations (Harmon et al, 2020). On one hand, exercise has numerous physical and mental benefits and has even been suggested to play a preventative role in infection by decreasing fat tissue, increasing cardiorespiratory fitness, and suppressing inflammation (Wang et al., 2020; Yousfi et al., 2020). However, athletes are also accustomed to close-contact training and competition environments, where social distancing is close to impossible (equally so for the spectators!). It has even been suggested that high-intensity exercise may increase risk of contracting disease because of the increased aerosolization of the virus (Jang et al., 2020). The Center for Disease Control and Prevention (CDC) currently recommends that high-risk individuals at any age, including athletes, should take extra precautions and be evaluated by their physician before resuming their sport training.
A major consideration for athletes getting back in the game is the long-term effect of COVID-19 on the cardiovascular system – something which there is little data of at this point. In more serious cases, the severe cytokine storm induced by COVID-19 may disrupt normal functioning of the heart. COVID-19 can also directly infect cells of the heart, resulting in inflammation (myocarditis), reduced cardiac function, and potentially long-term scarring (Baggish et al., 2020). And while some level of myocardial injury was reported in up to 28% of severe coronavirus cases (Shi et al., 2020), its prevalence and long-term effects in mild or asymptomatic cases remains unknown. Evidence is also limited for how this affects athletes returning to training and competition. At this point, it is recommended that sports medicine doctors assess any athlete with infection for signs of inflammation of the heart (such as increased troponin levels above the 99th percentile), and abnormal changes could warrant examination by a sports cardiologist (Baggish et al., 2020).
Youth and high school sports
While social distancing has become a key step to slow transmission of the new coronavirus, this comes with several consequences for athletes of every age and competition level. Many universities and professional leagues have had to postpone or cancel sporting events altogether – even the 2020 Olympic Games have been postponed until next year. So, what does that mean for local sporting events this fall?
Pennsylvania youth athletic organizations are working towards finding alternative options for athletes following the Pennsylvania Department of Health’s recommendation to postpone all school and recreational youth sports until January of 2021. Organizations including the President’s Athletic Conference (PAC) and Inter-Academic League have canceled fall sports through the new year, and have offered preliminary models for how fall sports will be resumed in truncated formats in the spring. This has since been challenged by the Pennsylvania Interscholastic Athletic Association (PIAA), which is continuing to explore options for the safe return to competition. PIAA has permitted fall sports to begin from August 24th based on local school decisions, advocating for strong adherence to health and safety plans to help mitigate risk of coronavirus transmission. Ches-Mont and Central League high schools were among the first to accept this opportunity and develop plans to get players back in the game. In order to promote the health and safety of student-athletes and the wider community, the Pennsylvania Department of Education and PIAA have released Health and Safety Plans and Return to Competition Guidelines for student-athletes, coaches, parents and spectators to assist in the safe return to fall athletics. These recommendations include social distancing on benches and sidelines, increased disinfecting of equipment and training facilities, and wearing face masks when feasible anytime social distancing of at least 6 feet is not possible (excluding while actively engaged in workouts), in addition to general CDC guidelines. For lower-intensity sports, the CDC emphasizes wearing masks and practice social distancing.
As part of the global response to coronavirus in early Spring, all professional and collegiate sporting events in the United States were postponed or canceled. As we begin to reopen and athletes return to training and competition, professional and collegiate sport organizations have developed strategies and guidelines to prioritize the health and safety of their teams (Dove et al., 2020). These competitions will look a little different this year – players will be returning to the game without fans in the stands. Major League Soccer was the first American league to get players back on the field back in July. The NBA developed an isolated competition “bubble” in Orlando, Florida to allow teams to complete the 2019-2020 season. Similarly, the NHL has returned to play with two “hub” cities and frequent testing of players and personnel will be required. MLB teams are continuing to play, however, following an outbreak of infected players within the Miami Marlins, schedules were revised and the team was isolated to prevent to further spread of the virus. As for coronavirus and football, players within the NFL have returned to training and have agreed to follow safety protocols that include frequent testing, wearing masks, and continuing to social distance. The health and safety protocols set out by the NFL and other professional sports organizations could provide a model for other aspects of the community, such as youth athletics, schools, and businesses, to reopen safely.
COVID-19 has drastically affected every aspect of life, including the world of sports. The resumption of fall athletic programs will be a positive step towards a normal life that we are all eager to achieve, but it will require a coordinated effort by sports medicine specialists, athletes, organizations, and spectators to ensure the health and safety of athletes and the wider community. Particularly for sports medicine doctors, ongoing research, and monitoring of athletes infected with COVID-19 is essential in order to understand the long-term effects of the virus in this group. Nonetheless, youth and high school sports provide numerous physical, social, and mental benefits for athletes, and if done so safely, resumption of these activities could provide a much-needed boost to community morale. As the COVID-19 pandemic continues to evolve and new scientific evidence is brought to light, it is important to follow guidelines and remain adaptable, both on and off the field.
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