In late 2019, a previously unidentified novel strain of coronavirus was identified
as the
cause of several cases of pneumonia in Wuhan, China. “Coronavirus disease 2019”
(COVID-19), declared a pandemic by the World Health Organization (WHO), has been
responsible for hundreds of thousands of cases worldwide, with sustained or widespread
transmission initially occurring in China, South Korea, Iran, Italy, and Japan, then
spreading to the majority of Europe and the United States. COVID-19 enters the body
through the same cell receptors as severe acute respiratory syndrome (SARS) and is
distantly related to Middle East respiratory syndrome (MERS).
15
Bats appear to be the primary source, given the similarity in RNA sequencing to 2
bat coronaviruses.
15
Typical features of the illness include fever, fatigue, cough, and myalgias.
Although athletes are younger and have fewer comorbidities than the general population,
and therefore are at lower risk for severe disease or death,
27
preventing the transmission of COVID-19 is necessary to protect those at high
risk of death and to slow the pandemic so that health care systems do not exceed their
capacities. Sports medicine providers involved in the care of competitive athletes
should be aware of the prevention strategies for COVID-19, common symptoms for the
disease, potential treatment options, and when it may be safe to return to athletic
participation after infection.
COVID-19 Impact on Sports
All major sports leagues and tournaments have been suspended or canceled due to
COVID-19 since early March 2020. Initially, some sporting events were to be held
without spectators to reduce transmission through close contact among
fans.
12,13
In the case of the National Basketball Association, the season
was suspended soon after a player tested positive for COVID-19.
16
Other sporting events were forced to cancel when local and state governments
restricted the sizes of gatherings.
3
On March 24, 2020, the International Olympic Committee announced that the
Olympic and Paralympic Games Tokyo 2020 would be postponed to Summer 2021.
14
Prevention of COVID-19 in Athletes
Purpose of Prevention
While the typical athlete may only experience mild symptoms as a result of
COVID-19, prevention strategies are necessary for multiple reasons. First and
foremost, preventing the transmission of COVID-19 is needed to reduce the risk
of spread to individuals within a community who are most at risk of severe
infection or death, which includes older individuals and the immunocompromised.
27
Prevention of COVID-19 is also important for the competitive athlete to
minimize interruptions in training and the adverse effects that it could have on
his or her respiratory tract and aerobic capacity in both the short and long
term.
Preventing Transmission
While the first cases of COVID-19 were associated with a seafood market in Wuhan,
the virus has since spread person-to-person primarily via respiratory
droplets.
15,26
This mode of transmission occurs when the virus, in the
form of respiratory secretions from coughing or sneezing, contacts another
person’s mucous membranes. According to Chinese data, the rate of secondary
COVID-19 infections ranges from 1% to 5%.
26
Transmission can also occur if a person touches his or her eyes, nose, or
mouth after touching a surface containing respiratory droplets with the virus,
which can remain viable for hours to days.
7
Presymptomatic/asymptomatic carriers, which comprised 48% of the 531
cases on the Diamond Princess cruise ship, are also capable of
transmitting COVID-19.
2,17,28
Currently, there is no evidence that the virus is spread
through the shipment of food or other products from overseas.
Sports medicine providers can support athletes and teams during the COVID-19
pandemic by advocating the following preventative measures:
Hand hygiene: General guidelines include washing hands
often with soap and water for at least 20 seconds or using hand
sanitizer (at least 60% alcohol) if soap and water are not available. As
the virus can survive for days on surfaces, frequently touched objects
and surfaces should be regularly cleaned and disinfected.
22
Social distancing: The Centers for Disease Control and
Prevention (CDC) describes social distancing as remaining out of
congregate settings, avoiding mass gatherings, and maintaining distance
(approximately 6 feet) from others when possible.
9
This practice is being advocated by governments and promoted by
professional athletes as well.
4,19
Travel: To slow transmission, many countries have
imposed travel restrictions. Measures have ranged from suspending
flights, to banning travelers from affected countries, to in-home
isolation for 14 days after returning from specific destinations.
Countries are also performing entry screening, including measuring body
temperature and assessing for signs and symptoms of COVID-19. Domestic
travel has become challenging as busy airports can be a common site of
person-to-person spread. However, as a result of the sweeping
suspensions and cancelations of sports leagues and tournaments, many
athletes are not needing to travel beyond returning home from where they
were training or competing.
Face mask: Asymptomatic athletes should not be advised
to wear a mask to prevent becoming infected with COVID-19 in the
community setting or while traveling since it does not significantly
reduce the risk of infection.
8
Inappropriate use of masks can affect supply and demand to the
point where health care workers will have inadequate protection, as we
are currently seeing.
Training Modification
Prolonged and strenuous training has been suggested to be associated with
temporary immune system depression lasting hours to days.
21
A conservative approach would be to advise athletes to limit training
sessions to <60 minutes and to <80% of maximum ability during this time to
prevent COVID-19. However, this “open window” theory of infection susceptibility
that follows a bout of vigorous exercise has been challenged.
5
Immunization
Vaccines are in the early stages of development but are unlikely to be available
until early to mid-2021.
Symptoms of COVID-19 Infection
The incubation period is typically within 14 days from exposure, with 95% of cases
occurring within 5 days. The most common symptoms include fever (99%), fatigue
(70%), dry cough (59%), and myalgias (35%).
23
Some may also experience anosmia (loss of smell), dysgeusia (altered taste),
a sore throat, rhinorrhea, or gastrointestinal manifestations. Pneumonia is the most
common serious manifestation, with bilateral infiltrates seen on chest imaging. Of
nearly 50,000 cases in China, 81% were mild (did not require hospitalization), 14%
were severe (dyspnea, hypoxia, or >50% lung involvement on imaging within 24-48
hours), and 5% were critical (respiratory failure, shock, or organ failure).
Influenza and bacterial pneumonia should be considered when evaluating an athlete
with fever, cough, and/or shortness of breath. Testing for influenza can be done
either prior to testing for COVID-19 or simultaneously. A complete blood count to
look for leukocytosis can help determine whether the symptoms are caused by a
bacterial pneumonia. Conversely, lymphopenia and leukopenia have been seen in
COVID-19 infections, which may assist in diagnosis.
2
Testing Athletes with Suspected COVID-19
During the early course of the spread of COVID-19, availability of outpatient testing
for the virus has lagged behind clinical needs. With these limitations, testing
algorithms offered preference to patients with symptoms (fever, cough, or shortness
of breath), an immunocompromised state, or close contact with someone with COVID-19.
As more tests are developed and approved in the United States, including those with
faster turnaround times, testing criteria are expected to expand and may include
testing asymptomatic individuals, as was done in South Korea.
11
Testing is done with a nasopharyngeal swab using an RNA detection polymerase chain
reaction (PCR) test. Retesting may be needed in those with a negative initial test
and a high probability of disease. A chest computed tomography scan can also be used
to evaluate for signs of viral pneumonia as reverse transcription PCR may not detect
COVID-19 early in the course of the infection.
1
Management of an Athlete with COVID-19
The management of COVID-19 infection depends on the severity of symptoms. In New York
City, 10% of individuals age 18-45 who tested positive for COVID-19 required hospitalization.
18
However, given the limited access to testing and variable symptomatology, the
total number of individuals with COVID-19 may be much higher so the true risk of
hospitalization among this age group is likely lower. Therefore, for an otherwise
healthy athlete under age 45 who becomes infected with COVID-19, he or she would
likely experience a self-limited flu-like illness. Managing symptoms in an athlete
primarily involves symptomatic management with rest and over-the-counter
antipyretics.
In-Home Isolation
In-home isolation is recommended for athletes with confirmed or suspected
COVID-19 who do not show severe symptoms. Other members of the household should
minimize time in the same room as the affected individual, who should wear a
mask when others are present.
Antipyretics
The health minister of France recently advocated for use of acetaminophen to
treat fever associated with COVID-19 and suggested that ibuprofen could worsen
the infection.
24
This appeared to be based on a theoretical concern that the
anti-inflammatory effects of nonsteroidal anti-inflammatory drugs (NSAIDs) could
adversely affect the immune system. However, the WHO currently does not
recommend against using NSAIDs when clinically indicated in the treatment of a
COVID-19 infection.
Corticosteroids
The WHO recommends that corticosteroids not be used in patients with COVID-19
pneumonia unless there are other indications, such as the exacerbation of
chronic obstructive pulmonary disease.
25
Corticosteroids have been associated with an increased risk for mortality
in patients with influenza and delayed viral clearance in patients with MERS.
There has also been good evidence for short- and long-term harm in SARS patients
treated with corticosteroids.
20
Drugs Under Investigation
The following agents are being investigated as potential treatment options. It is
important to note that there are currently no controlled data supporting the use
of these medications and their efficacy is unknown.
Remdesivir: Randomized clinical trials are under way
assessing this investigational antiviral nucleotide analog in
hospitalized adults. It has shown promise in in vitro as well as in
animal studies.
Lopinavir-ritonavir: There have been case reports of
treatment with this protease inhibitor used in HIV treatment, which has
shown in vitro activity against MERS and SARS. However, 1 trial of
nearly 200 patients with severe COVID-19 infection showed no difference
in time to symptom resolution or mortality when compared with standard
supportive treatment.
6
Hydroxychloroquine/chloroquine: Studies are ongoing to
investigate these 2 agents, which have shown activity against COVID-19
in vitro. Hydroxychloroquine may have more potent antiviral activity.
Published clinical data are limited, and caution should be used given
potential side effects, such as QT prolongation.
Discontinuation of In-Home Isolation
The CDC recommends discontinuing home isolation using either a test-based
strategy or non–test-based strategy, depending on availability of testing resources.
10
If a test-based strategy is used, home isolation can be discontinued when
the following criteria are all met:
No fever is present without the use of fever-reducing medications
Resolution of respiratory symptoms
Two consecutive negative COVID-19 tests collected ≥24 hours apart
When a non–test based strategy is used, the following criteria must be met:
At least 7 days have passed since the appearance of symptoms
At least 72 hours (3 days) have passed since recovery of symptoms without
the use of fever-reducing medications
Mental Health Support
Suspending seasons and canceling competitions can cause significant grief,
stress, anxiety, frustration, and sadness for an athlete. The psychological
impact of COVID-19 on a competitive athlete is potentiated by the removal of his
or her social support network and normal training routine, which for some is a
critical component of managing depression or anxiety. Sports medicine providers
should anticipate the need for additional mental health support for athletes,
which could include ensuring regular check-ins with athletes, facilitating
telehealth consultation with a sports psychologist, and encouraging maintenance
of social interactions with family, friends, and teammates by phone or video
chat.
Management of a Sports Team with COVID-19
If an athlete on a sports team develops symptoms consistent with COVID-19, teammates,
coaches, and other staff who had close contact with the athlete (within 6 feet) in
the preceding 14 days should begin in-home isolation. If the athlete undergoes
testing, contacts can discontinue isolation if the test result is negative for
COVID-19. However, if the test result is positive for COVID-19 (or if testing is not
pursued and the athlete is treated presumptively), close contacts will need to
continue their in-home isolation for 14 days from the last contact with the athlete.
There will likely be requests for testing from asymptomatic teammates, coaches, and
other staff. Testing availability will likely dictate whether these individuals can
be tested. During this time, any symptoms experienced by other athletes or staff
should be reported to the team physician to determine whether they are legitimate
signs of COVID-19. Team physicians may also consider implementing daily temperature
checks.
Return to Training
For athletes with confirmed or presumed COVID-19, training can begin once symptoms
completely resolve and energy levels return to normal. Since in-home isolation is
necessary for at least 72 hours after resolution of symptoms, low-intensity indoor
training may be attempted during that time. After discontinuing in-home isolation,
an athlete can gradually return to training as tolerated. For asymptomatic athletes
who are isolated due to recent travel or close contact with an individual with
COVID-19, maintaining cardiovascular fitness may be difficult. Exercise that is
recommended during the in-home isolation period is dependent on the available
equipment, which may include a stationary bike, treadmill, and resistance training.
Guidance and monitoring by a strength and conditioning coach or exercise
physiologist can be provided remotely.
Conclusion
As of March 2020, COVID-19 has become a global pandemic, halting athletic competition
worldwide. Current focus is on the prevention of viral spread through social
distancing and other common hygiene measures. Sports medicine providers should know
the most common symptoms of COVID-19, work within their environments to learn and
develop testing protocols as indicated by local resources, and minimize spread among
teams. Treatment in the outpatient setting is mainly supportive and includes home
isolation, although several treatment drugs are under clinical investigation.