COVID-19: WHAT CLUBS AND ATHLETES SHOULD KNOW

The outbreak of the SARS-CoV-2 (COVID-19) virus at the end of 2019 has triggered a series of events that will presumably change many of the things we consider as normal in our everyday life. Due to the virus’ high infectivity (1), many countries have stopped their activities in order to mitigate its spreading and to avoid overloading the capacity of the health system.

Most leagues and sports competitions have been interrupted or cancelled since early March 2020. While the authorities decide how and when training and competitions will be resumed, sport health departments have been working on specific guidelines, such as the ones published in the Sports Health magazine (2). These publications intend to guide these entities for the possible different scenarios. They seek to reduce the players’ and club employees’ risk of infection, and in case they become ill, to know how to act and advise available treatments, as well as the appropriate time to get back to work after the infection.

Prevention

Although athletes have a lower risk of developing severe symptoms as a result of COVID-19, since they do not suffer from associated comorbidities, such as hypertension or obesity (3), prevention strategies are necessary for several reasons. In the first place, to prevent them from becoming a medium for the transmission of the virus, in order to reduce the risks of infecting the population which are more susceptible such as the elderly or immunosuppressed people. People with no symptoms, those who are incubating the virus and do not show symptoms, are the most difficult cases because they may spread the virus without knowing it (4). If a young athlete gets infected, as a result he may suffer mild symptoms or no symptoms at all, which may increase the risks of infecting other people. This is why it is important to follow the guidelines to mitigate the possibility of infecting other people.

On the other hand, if athletes get ill, they will interrupt their training and this will affect their fitness (2). Even though there is no high risk, some authors think the virus could have some adverse effects on organs, such as the heart, the lungs, the liver, the kidneys, the blood and the immune system (5,6), which suggest to be cautious when it comes to making decisions that minimize the possible effects of the virus. Regarding this, the following prevention measures may help reduce the infection risk:

• Hands hygiene: washing hands repeatedly with water and soap during, at least, 20 seconds or using hydroalcoholic disinfectant (at least 60% of alcohol) if there is no water or soap available (2). As the virus is able to survive several days on different surfaces, it is convenient to disinfect oneself regularly (7).
• Social distancing: it is advisable to avoid crowded areas, as well as keeping a 2-metre distance from people.
• Going out: until specific measures aren’t taken, it is advisable to stay at home and have athletes doing specific training sessions. In addition, there are temporary restrictions to travel to other countries.
• Face mask: although the WHO has not recommended the widespread use of face masks (8), different analyses (9) and reviews (10) recently published support their massive use. It seems that scientific evidence suggests its use, and that is why we should discuss its implementation in sports in the future.
• Modification of the training load: once again this point has conflicting views since, there is no conclusive evidence. Some studies suggest that prolonged and intense training is associated with temporary depression of the immune system that may last for hours or days (11). Even though the “open window” theory is not fully accepted (period in which a person is more susceptible to a possible infection) some specialists suggest a conservative approach, limiting the training sessions below 60 minutes and below 80% of the maximum capacity during this period to avoid the COVID-19 infection (2). The workout advised during the lockdown should be oriented and monitored by trainers and physiologists in order to control as much as possible the load and evolution of the athlete’s health.

A positive covid-19 test by an athlete

The virus incubation period is 14 days approximately, and the most common symptoms include fever, fatigue, dry cough and myalgia (12). Furthermore, some patients may show an alteration in biochemical parameters, such as increased lactate dehydrogenase, ferritin or interleukin-6 (12,13), which may cause a hyper-inflammatory response. However, the risk of developing severe symptoms which requires hospitalization for people between 18 and 45 years old is low (less than 10%) (14). Therefore, an athlete with no risk factors associated and infected with the virus may probably experiment an illness similar to the flu (2). Thereby, the main advisable measure is coping with the symptoms and resting (2).

This way, if the athlete is positive or is suspected to have the disease, home lockdown is advised, as long as the symptoms are not severe.

When should the lockdown come to an end?

Authorities suggest discontinuing the lockdown based on two strategies, depending on the availability of resources. In case a test can be done, the lockdown could be interrupted, as long as the following criteria are met:

• The person has no fever without taking medicine.
• The persona does not have respiratory symptoms.
• Two negative tests for COVID-19 with at least 24 hours in between.

In case there are no tests available, the following criteria should be met:

• At least 7 days should pass from manifesting the first symptoms.
• At least 72 hours should pass from the symptoms having first disappeared without taking medicine.

Mental health

The psychological impact this pandemic may have on athletes is still unknown. If we combine the social alarm and uncertainty with the suspension of competitions or the delay in the celebration of the Olympic Games, considering these people have set their minds on that objective for years, the result is a pile of emotions that may cause stress or anxiety. That is why, doctors and psychologists working in clubs or entities should anticipate and provide tools that help control this new reality.

Getting back to work

When the health authorities decide to ease restrictions and allow athletes to go back and practice their sports activity, sports clubs need to follow preventive protocols and monitor the risks to prevent another outbreak of the virus. If an athlete has any symptoms related to COVID-19, the teammates, trainers and workers that have interacted physically with him, should start a lockdown period until the case is confirmed. If the athlete is positive for COVID-19, the lockdown should be maintained during 14 days (2). On the contrary, if the result is negative for COVID-19, they could go back to work as usual.

On the other hand, it would be interesting to implement daily temperature control measures in the training premises gateways, as fever monitoring could reduce the occurrence of the disease (15).

Conclusion

Nowadays the goal is still to mitigate the pandemic curve and avoid making prompt decisions that take us back to the starting point. That is why sports authorities should keep focusing on preserving both the athletes’ and the overall society’s health, as well as anticipating action plans that allow getting back to work in the safest way and always taking into account the recommendations made by the health authorities.

Adrián Castillo

REFERENCES

1. Wu JT, Leung K, Leung GM. Nowcasting and forecasting the potential domestic and international spread of the 2019-nCoV outbreak originating in Wuhan, China: a modelling study. Lancet. 2020 Feb 29;395(10225):689–97. Available from: https://doi.org/10.1016/S0140-6736(20)30260-9
2. Toresdahl BG, Asif IM. Coronavirus Disease 2019 (COVID-19): Considerations for the Competitive Athlete. Sports Health. 2020 Apr 6;1941738120918876. Available from: https://doi.org/10.1177/1941738120918876
3. Dorn A van, Cooney RE, Sabin ML. COVID-19 exacerbating inequalities in the US. Lancet. 2020 Apr 18;395(10232):1243–4. Available from: https://doi.org/10.1016/S0140-6736(20)30893-X
4. Shi Y, Wang Y, Shao C, Huang J, Gan J, Huang X, et al. COVID-19 infection: the perspectives on immune responses. Cell Death Differ. 2020; Available from: https://doi.org/10.1038/s41418-020-0530-3
5. Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet. 2020 Feb 15;395(10223):507–13. Available from: https://doi.org/10.1016/S0140-6736(20)30211-7
6. Zheng Y-Y, Ma Y-T, Zhang J-Y, Xie X. COVID-19 and the cardiovascular system. Nat Rev Cardiol. 2020;17(5):259–60. Available from: https://doi.org/10.1038/s41569-020-0360-5
7. van Doremalen N, Bushmaker T, Morris DH, Holbrook MG, Gamble A, Williamson BN, et al. Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. N Engl J Med. 2020 Mar 17;382(16):1564–7. Available from: https://doi.org/10.1056/NEJMc2004973
8. Organization WH. Advice on the use of masks in the context of COVID-19: interim guidance, 6 April 2020. World Health Organization; 2020.
9. Greenhalgh T, Schmid MB, Czypionka T, Bassler D, Gruer L. Face masks for the public during the covid-19 crisis. BMJ. 2020 Apr 9;369:m1435. Available from: http://www.bmj.com/content/369/bmj.m1435.abstract
10. Howard J, Huang A, Li Z, Tufekci Z, Zdimal V, van der Westhuizen H-M, et al. Face masks against COVID-19: an evidence review. Preprints 2020; doi: 10.20944/preprints202004.0203.v1.
11. Schwellnus MP, Jeans A, Motaung S, Swart J. Exercise and infections. Olympic Textb Med Sport. 2008;344–64.
12. Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus–Infected Pneumonia in Wuhan, China. JAMA. 2020 Mar 17;323(11):1061–9. Available from: https://doi.org/10.1001/jama.2020.1585
13. del Rio C, Malani PN. COVID-19—New Insights on a Rapidly Changing Epidemic. JAMA. 2020 Apr 14;323(14):1339–40. Available from: https://doi.org/10.1001/jama.2020.3072
14. Garg S, Kim L, Whitaker M, et al. Hospitalization Rates and Characteristics of Patients Hospitalized with Laboratory-Confirmed Coronavirus Disease 2019 — COVID-NET, 14 States, March 1–30, 2020. MMWR Morb Mortal Wkly Rep 2020;69:458–464. Available from: http://dx.doi.org/10.15585/mmwr.mm6915e3.
15. Mercer JB, Ring EFJ. Fever screening and infrared thermal imaging: concerns and guidelines. Thermol Int. 2009;19(3):67–9.