On December 31, 2019, Chinese public health officials notified the World Health Organization (WHO) of a mysterious pneumonia acquired by 41 people, most of whom had a connection with the Huanan Seafood Wholesale Market in Wuhan City, China. The cause of this infection, Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) was discovered on January 7, 2020, and the first death from COVID-19, the disease caused by SARS-CoV-2, was reported on January 11, 2020. The first United States (US) case of COVID-19 was diagnosed on January 20, 2020. Fifty-nine new cases of COVID-19 were diagnosed in the US over the next month, and the first US death was reported on February 29, 2020. The WHO categorized the COVID-19 outbreak as a global pandemic on March 11, 2020, and the Tokyo Olympic and Paralympic Games scheduled for that summer were indefinitely postponed on March 24, 2020.

This timeline provides contextual information related to my entry into the role of Chief Medical Officer (CMO) for the US Olympic and Paralympic Committee (USOPC), which occurred on March 2, 2020. While the Tokyo Games had not yet been postponed, the number of people, including athletes, diagnosed with COVID-19 was rapidly rising in the US and around the world, international travel restrictions were being imposed, public health authorities were closing exercise facilities, universities were switching to virtual formats, college and elite sports events were being canceled, and there was grave concern regarding the impact of COVID-19 on athlete health and the ability to safely exercise during or following an infection.

One of my first actions as CMO was to form an Infectious Disease Advisory Group (IDAG) comprised of medical and public health experts who provided invaluable advice and guidance in the development and revisions of the USOPC's policies and procedures in response to the dynamically changing environment of the COVID-19 pandemic. In collaboration with the IDAG and numerous other organizations and individuals, we created a series of documents to help guide the initial response of the sports community to the pandemic including how to create safe work, training, and competition environments. One example of these recommendations can be found in the Return to Training Considerations Post-COVID-19 document, which began with a series of ethical and societal questions such as "is it appropriate for athletes, coaches, or staff to use personal protective equipment (PPE) meant for medical personnel when there is a worldwide shortage of PPE?". This was followed by a five-phased approach to return to training based upon local public health guidelines and the development and access to COVID-19 vaccines or effective treatments. In phase 1, public health authorities required individuals to shelter in place, necessitating in-home, individual training using the athlete's own equipment and virtual coaching. As public health restrictions lessened with each phase, activities were progressed from those with a low risk of infection transmission (e.g., individual, home-based activity using your own equipment) to those with a higher risk (e.g., vigorous, large group, close contact activities using shared equipment and taking place indoors at a public facility). The information in this document was presented in such a way as to allow individual athletes, schools, and sports organizations to develop a customized approach to return to play that fit their particular situation.

It was also imperative to determine how to evaluate and treat athletes who developed COVID-19 and make informed return to sport recommendations. While there was limited data at the onset of the pandemic, the following post-COVID-19 diagnostic work-up and return to play recommendations were made by Phelan et al.¹ in 2020 based upon the available information:

• Asymptomatic infection: rest for 2 weeks followed by a gradual resumption of activity
• Mild symptoms: rest for 2 weeks following symptom resolution, evaluation by a medical professional, high sensitivity troponin blood test, 12-lead electrocardiogram, and 2-dimensional echocardiogram followed by a gradual resumption of activity if these studies were normal
• Significant symptoms: high sensitivity troponin blood test and cardiac imaging per local protocols, and if normal, 2 weeks of rest post-symptom resolution and a gradual resumption of activity

Based upon this information, and input from our sports cardiology and pulmonology consultants, we developed and implemented an algorithm at the US Olympic and Paralympic Training Centers (USOPTCs) similar to the one recommended by Phelan et al. with the additional of pulmonary function tests.² From July 2020 through October 2020, 301 athletes completed the USOPTC COVID-19 mitigation process required prior to accessing a USOPTC. Fourteen of the 301 athletes tested positive for COVID-19, none of whom had detectible abnormalities on their subsequent cardiopulmonary assessments. All 14 athletes returned to full, unrestricted activity without sequelae.

Our preliminary data suggested that the USOPTC COVID-19 mitigation measures were effective, created a safe environment in which to train, and while the number of athletes assessed for post-COVID-19 cardiopulmonary complications was limited, it contributed to the mounting body of evidence indicating a relatively low prevalence of cardiopulmonary complications in athletes post-COVID-19 infection.³

As the SARS-CoV2 virus and our knowledge of the pandemic have evolved, so too has our approach to COVID-19 mitigation measures, the post-COVID-19 medical evaluation, and return to play recommendations. Guided by the 2022 ACC Expert Decision Pathway on Cardiovascular Sequelae of COVID-19 in Adults,⁴ we are now able to confidently allow athletes to resume exercise more rapidly and avoid costly and unnecessary cardiopulmonary tests. A brief comparison between the 2020 and 2022 recommendations can be found in Table 1. Team USA athletes have successfully competed in five Games over the past year including the Summer and Winter Olympic and Paralympic Games, and the Junior Pan American Games. While COVID-19 still impacts nearly every facet of our lives, our ability as a medical community to rapidly collect and disseminate scientific information related to COVID-19 in the athlete population enabled evidence-based decision-making recommendations for our athletes and the safe re-introduction of global sport.

Table 1

	2020 Recommendations	2022 Recommendations
Asymptomatic	No diagnostic evaluation. Rest x 2 weeks following positive test, then gradual return to activity.	No diagnostic evaluation if cardiopulmonary symptoms are absent.* Return to training after 3 days of rest.
Mild	Diagnostic evaluation: hsTn, 12 lead ECG, 2-D echocardiogram. Normal tests: Rest while symptomatic and for 2 weeks following symptom resolution. Gradual return to activity thereafter. Abnormal tests: follow myocarditis protocol (avoid exercise for 3-6 months)	No diagnostic evaluation if cardiopulmonary symptoms are absent.* Return to training after symptoms resolve.
Moderate	Diagnostic evaluation: hsTn, cardiac imaging per local protocol. Normal tests: Rest while symptomatic and for 2 weeks following symptom resolution.  Gradual return to activity thereafter. Abnormal tests: follow myocarditis protocol (avoid exercise for 3-6 months)	No diagnostic evaluation if cardiopulmonary symptoms are absent.* Return to training after symptoms resolve.
Severe		Diagnostic evaluation: cTn, 12 lead ECG, 2-D echocardiogram, and cardiology consultation. Abnormal tests or persistent symptoms = cardiac MRI. Normal tests: return to training after symptoms resolve. Abnormal tests: follow myocarditis protocol (avoid exercise for 3-6 months)
*Cardiopulmonary symptoms include chest pain, chest tightness, palpitations, dyspnea, and lightheadedness or syncope. If any of these symptoms are present, perform a cTn, 12 lead ECG, 2-D echocardiogram and obtain a cardiology consultation. hsTn = high-sensitivity troponin I; ECG = electrocardiogram; cTn = cardiac troponin; MRI = magnetic resonance image.

References

1. Phelan D, Kim JH, Chung EH. A game plan for the resumption of sport and exercise after coronavirus disease 2019 (COVID-19) infection. JAMA Cardiol 2020;5:1085-86.
2. Shah AB, Nabhan D, Chapman R, et al. Resumption of sport at the United States Olympic and Paralympic Training Facilities during the COVID-19 pandemic. Sports Health 2021;13:359-63.
3. Martinez MW, Tucker AM, Bloom OJ, et al. Prevalence of inflammatory heart disease among professional athletes with prior COVID-19 infection who received systematic return-to-play cardiac screening. JAMA Cardiol 2021;6:745-52.
4. Gluckman TJ, Bhave NM, Allen LA, et al. 2022 ACC expert consensus decision pathway on cardiovascular sequelae of COVID-19 in adults: myocarditis and other myocardial involvement, post-acute sequelae of SARS-CoV-2 infection and return to play. J Am Coll Cardiol 2022;79:1717-56.

Clinical Topics: Cardiovascular Care Team, COVID-19 Hub, Sports and Exercise Cardiology

Keywords: SARS-CoV-2, COVID-19, Return to Sport, COVID-19 Vaccines, Pandemics, Personal Protective Equipment, RNA, Viral, Asymptomatic Infections, Mentoring, Preliminary Data, Public Facilities, Public Health, Pulmonary Medicine, Athletes, Para-Athletes, World Health Organization, Respiratory Function Tests, Electrocardiography, Communicable Diseases, Hematologic Tests, Algorithms, Troponin, Health Policy, Policy, Clinical Trials, Phase I as Topic, Sports

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