Elite Athletes With COVID-19: Time to Let Them Compete?

A Changing Landscape of the Pandemic

Early in the COVID-19 pandemic, the virulence and transmissibility were unknown and preliminary data suggested a high prevalence of cardiac sequelae. ¹¹ Appropriately, the resumption of sport incorporated regular COVID-19 testing, expansive prevention measures, and comprehensive cardiac testing for athletes with COVID-19.^4,10,13 This was done to prioritize athlete safety, minimize the spread of the virus in the sports setting, and identify athletes at risk for adverse cardiovascular events.

While elite athletes continue to undergo regular testing for COVID-19, the virus and associated sequelae are much better understood, and effective vaccines are now widely available in many countries.

Robust data in competitive collegiate and professional athletes collected before the availability of COVID-19 vaccinations showed that the prevalence of clinically diagnosed myocarditis was less than 1%, much lower than originally feared.^8,9 In addition, athletes diagnosed with myocarditis demonstrated typical cardiac symptoms during and/or after the acute illness. Such symptoms would prompt cardiovascular diagnostic testing regardless of any structured cardiac testing protocol, as was done before the COVID-19 pandemic when athletes developed cardiac symptoms after a viral illness.^5,6 Importantly, there have been no reported COVID-19-related cases of sudden cardiac arrest in these large cohorts of elite athletes.

Vaccines have been widely available in the United States and elsewhere since Spring/Summer 2021 and are effective at reducing the risk of transmission, the severity of illness, and the risk of “long COVID” symptoms.^3,14 Recently, the omicron strain was observed to spread quickly but caused mild or no symptoms in the majority of those who are vaccinated and otherwise healthy. ¹⁵

Respiratory Tract Infections in Athletes

Before the COVID-19 pandemic, the “neck check” was traditionally used when determining whether an athlete with a respiratory infection could train or compete.^6,7 This involves first determining whether the symptoms are from above the neck (sore throat, nasal congestion, or rhinorrhea) or below (fever, cough, or shortness of breath). For an athlete with symptoms isolated above the neck, the athlete then does a trial of low-intensity exercise. If the symptoms do not worsen with exercise, then the athlete can return to play as tolerated.

At present, state and local health departments restrict the activities of those who test positive for COVID-19. Thus, sports participation is not possible in many areas if an athlete has recently tested positive. However, health department COVID-19 protocols are being reassessed, and there has been a widespread easing of restrictions. In the absence of isolation protocols, athletic organizations and team physicians may soon need to decide whether athletes who test positive for COVID-19 can compete.

Assessing the Risks

The considerations for allowing an athlete with COVID-19 to compete are primarily twofold: the risk to the athlete and the risk to others.

Based on current data, the overall cardiovascular risk to an otherwise healthy athlete with asymptomatic or mildly symptomatic COVID-19 is low. This is reflected in the latest recommendations that no longer include routine cardiovascular testing to evaluate for inflammatory heart disease in asymptomatic or mildly symptomatic athletes. While this holds true for most elite athletes, individual risk factors must be considered. Athletes at higher risk, such as those with known cardiovascular disease and Paralympic athletes with spinal cord injuries, would benefit from individual assessment and risk stratification.

The risk to others can be assessed using the concept of close contacts for determining potential COVID-19 transmission. A common definition of a close contact is someone who was within 6 feet for 15 min during the 48 h before an individual developed symptoms or tested positive for COVID-19. ² In addition, high vaccination rates among athletes and staff further lower the risk of transmission as well as the severity of illness if a close contact were to become infected.

A Possible Path to Clearance

With widespread vaccinations and appropriate masking, asymptomatic or mildly symptomatic athletes with COVID-19 could navigate the logistics of competing in many sports without others becoming close contacts and thereby being at risk of contracting COVID-19. The most feasible scenario would be an outdoor sport where social distancing is possible, such as tennis, track and field, golf, skiing, or snowboarding. However, given reports from the National Football League (NFL) about the on-field transmission of COVID-19, ¹ allowing COVID-positive athletes to compete in other sporting environments may be justified as well. Once there is a path for COVID-positive athletes to compete safely, then routine COVID screening can begin to be phased out in sports.

Health risks are inherent to sports. As with any rule change, determining the level of risk that is acceptable requires input from various stakeholders: athletes, medical personnel, and team/league officials. Erring on the side of caution is appropriate in the absence of data, as was the case early in the COVID-19 pandemic. Now that the risks of COVID-19 in the athletic setting are better understood, these risks need to be balanced with the associated consequences of a conservative approach to managing cases of COVID-19 in elite athletes. Disqualification of an otherwise healthy athlete who tests positive for COVID-19 could have severe psychological consequences, particularly when the stakes are high and the risks to the athlete and others are low. In an emotional social media post about his disqualification, Zhou shares, “The pain of it all is pretty insane. . . I’ve already lost count of the number of times I’ve cried today.” ¹²

Assuming Zhou didn’t develop significant symptoms from COVID-19 and was healthy enough to compete, would it have been possible through masking and social distancing for him to do so without other athletes or staff becoming close contacts? It may be time for the sports medicine community to critically assess what are the real risks of letting COVID-positive athletes compete in certain scenarios.