COVID-19 Recovery in Athletes The UK World Class Olympic and Paralympic Experience

COVID-19 RECOVERY IN ATHLETES:

THE UK WORLD CLASS OLYMPIC AND PARALYMPIC EXPERIENCE

FEATURE / CRAIG RANSON & JAMES HULL

Introduction

The COVID-19 pandemic has had and continues to have a devastating impact on global health. Within elite sport, there are typically three main considerations for health practitioners when assessing the athlete who has been infected with COVID-19. Firstly, the risk of illness to an athlete’s immediate health. During the early part of the pandemic, there was major concern over reports relating to a high incidence of COVID-19-related myocarditis in young athletes. Fortunately, subsequent well conducted studies provided some reassurance that this is not a common phenomenon in those with a previous diagnosis of COVID-19. Secondly, the nature of any guidance on acute management and subsequent return activity and duration recommendations. Thirdly, the identification of factors that indicate the likelihood of a prolonged recovery or ‘long COVID’ illness.

What have we learnt from the UK World Class Olympic and Paralympic Sport experience?

Practitioners from UK Home Country Sports Institutes (HCSI) in England, Scotland, Wales and Northern Ireland have closely monitored COVID-19 related illness in World Class Programme (WCP) Olympic and Paralympic Sport athletes, assessing the aforementioned factors.

Since the onset of the pandemic in 2020 to the present time, there have been 410 recorded cases of COVID-19 related illness in 357 athletes (Figure 1). This equates to approximately one quarter of the WCP population experiencing over 10,000 time-loss days (restricted or unavailable to train). The context of that time-loss was particularly pertinent given the preparatory cycle for the Tokyo summer and Beijing Winter Olympic and Paralympic games, disrupted not only by widespread illness, but also the mandatory training and travel restrictions imposed as part of the global public health strategy to manage the pandemic.

For the most part, COVID-19-related illness in the WCP cohort has been a relatively mild illness (i.e., not required hospital care or specific treatments). On balance, duration appears to be shorter lived as the pandemic progresses, with the median number days of restricted training reducing from 18 days during the first year (to end Feb 2021) to 13 days in the second year.

In late 2021 we published our experience of the impact of COVID-19 illness within the WCP1. In this analysis, we evaluated the pattern of symptoms at presentation (Box 1) and used this phenotype-based approach to provide insight regarding symptom clusters and how they might inform return to sport. The analysis found that whilst most infected athletes returned to full sport participation within two to three weeks, one quarter (23%) experienced restricted athlete training for over 28 days. Four percent of infected athletes were restricted for more than 100 days and a couple of those have been unable to return to elite sport participation.

The phenotype prevalence was different in each of the first two waves. During the first wave (Feb 2020 – July 2020), 86% of cases were from one of three respiratory phenotypes and 26% had a specific lower respiratory focus e.g., dyspnoea and chest pain. However, during the second wave (Aug 2020 – Jan 2021) only 72% of cases were from a respiratory phenotype, with just 7% of all cases having a lower respiratory focus. This means that proportionally fewer athletes presented with respiratory symptoms and more athletes presented with general viral symptoms, such as headache and fatigue. Across the board, those with a lower respiratory phenotype were approximately twice as likely to result in more than 28 days time-loss. Our finding that approximately 1 in 4 athletes diagnosed with COVID-19 did not return to

Figure 1. WCP athlete COVID-19 cases recorded per month of incidence

full training within 28 days was compared to our historical data that showed only 1 in 25 athletes diagnosed with a viral URTI had more than 28 days time-loss. Whilst

HOW COVID-19 PRESENTED: THE 5 SYMPTOM PHENOTYPES 1. Upper respiratory focus (UR);

sore throat +/- change in smell or taste or sinus problems reported +/- a cough +/- fever. 2. Lower respiratory focus (LR); presence of dyspnoea +/- chest pain +/- cough +/- fever +/- other lower respiratory tract symptoms; e.g. wheeze. 3. Cough only (CO); cough as the predominant symptom recorded and in the absence of co-existing dyspnoea and without other UR symptoms. 4. Gastrointestinal (GI); with predominant symptoms being diarrhoea +/- nausea +/- abdominal pain. 5. Non-specific (NS); main clinical feature was fever, fatigue +/- headache +/- myalgia but a lack of any prominent respiratory or GI symptoms.

symptom duration was associated with training time-loss, another factor that may have contributed to this comparatively long impact on participation was the production of a HCSI COVID-19 Return to Play Protocol2. This protocol recommended a minimum of 17 days before full training or competition participation. This might now appear conservative, however in

Figure 2. HCSI COVID-19 Graduated Return to Play Protocol (updated 2022)4

2020, it was considered appropriate given the lack of knowledge about the disease severity and concerns about the potential cardiac implications of COVID-19.3 The updated 2022 protocol recommends time-scales more closely aligned to typical post-viral return to play (Figure 2).4

New waves and vaccination - what do we know now?

As we learn more about SARS CoV-2 and follow the global progress of this infection, it is now apparent that there is likely to be a long-term endemic state, punctuated with further outbreaks that are driven by new variants and vaccine escape. The availability of effective vaccines has significantly modified the clinical course and transmissibility of COVID-19. In the WCP we evaluated the tolerability of COVID-19 vaccination and found it was well tolerated and associated with very few significant side effects5. The most prevalent being arm pain around the injection site (in 94% of athletes), lasting a median of 2 days (IQR 1–3). Systemic side-effects were reported in 70% of participants, with short-lived generalised fatigue in 28% after the first vaccination (median 1 day [1–2]) and 37% after the second vaccination (1 day [1–3]).

Conclusion

It may be that COVID-19 is waning as a substantial public health threat, and thankfully, severe illness or death has been extremely rare amongst elite athlete populations. However, the trend for increased incidence with each wave of the pandemic balances the reducing impact on athlete availability per case. This means that future waves may continue to be a significant threat to optimal

A COMPARISON OF COVID-19 WITH TYPICAL VIRAL URTIS

• Lower respiratory phenotype triples an athlete’s risk of prolonged symptom duration and doubles their risk of prolonged time-loss. This highlights the importance of being able to distinguish between athletes with lower respiratory symptoms as they are more likely to require a longer period of recovery • Even an athlete with relatively mild COVID-19 symptoms is likely to have greater time-loss than an athlete with an URTI

preparation for performance. Sharing data and experience with organisations and colleagues across the elite sporting landscape in the UK and overseas has proved invaluable. The benefits seen from this will hopefully lead to ongoing collaboration and resourcing that will allow collective and effective tackling of systemic athlete health challenges.

KEY MESSAGES

• In a cohort of elite athletes preparing for international competition, COVID-19 has largely resulted in a mild, self-limiting illness that does not require hospital care. • In the initial phases of the pandemic, approximately one quarter of athletes had not returned to full sport participation at day 28 after symptom onset. This is reducing as the disease and associated return to play protocols evolve. • The presence of clinical features implicating lower respiratory tract involvement (‘below the neck’ symptoms) was associated with prolonged illness and delayed return to full sport participation.

HOW MIGHT IT IMPACT ON PRACTICE

• Insight into the clinical course and time-loss following COVID-19 illness in elite athletes informs recovery management and athlete counselling. • Consideration could be given to expediting return to full sporting participation for those who present with symptoms primarily confined to the upper respiratory tract. • Further work is needed to determine the factors underpinning a delayed return to full sport participation following COVID-19 in some athletes.

Acknowledgements

We would like to acknowledge all the UK High Performance System and HCSI Athlete Health Practitioners for contributing to the WCP COVID-19 data collection and analysis. Those involved in producing the associated publications and guidance include HCSI colleagues; Dr Niall Elliott, Dr Anita Biswas, Dr Rhodri Martin, Dr Moiz Moghal, Dr Michael Loosemore, Mr Moses Wootten, and Ms Abbie Taylor.

1. Hull JH, Wootten M, Moghal M, et al. Clinical patterns, recovery time and prolonged impact of COVID-19 illness in international athletes: the UK experience. Br J Sports Med 2022; 56(1): 4-11. 2. Elliott N, Martin R, Heron N, Elliott J, Grimstead D, Biswas A. Infographic. Graduated return to play guidance following COVID-19 infection. British Journal of Sports Medicine 2020; 54(19): 1174-5. 3. Wilson MG, Hull JH, Rogers J, et al. Cardiorespiratory considerations for return-to-play in elite athletes after COVID-19 infection: a practical guide for sport and exercise medicine physicians. Br J Sports Med 2020; 54(19): 1157-61. 4. Elliott N, Biswas A, Heron N, et al. Graduated Return to Play after SARS-CoV-2 infection – what have we learned and why we’ve updated the guidance. Blog: British Journal of Sports Medicine; 2022. 5. Hull JH, Wootten M, Ranson C. Tolerability and impact of SARS-CoV-2 vaccination in elite athletes. Lancet Respir Med 2022; 10(1): e5-e6.