Comorbid Medical Conditions in Young Athletes: Considerations for Preparticipation Guidance During the COVID-19 Pandemic

Y oung athletes, generally speaking, represent one of the healthiest and fittest groups in society. The resumption of sport and exercise will ultimately bring athletes into closer proximity than is recommended by current physical distancing practices, potentially increasing one’s risk of infection. Data are emerging that high-intensity exercise may increase aerosolization and transmissibility of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) from presymptomatic and mildly symptomatic individuals. It is in this setting that medical providers have wondered how to best counsel athletes with medical conditions that may be associated with increased risk of severe coronavirus disease (COVID-19), specifically, diabetes, asthma, sickle cell trait (SCT), hypertension, and obesity. The Centers for Disease Control and Prevention (CDC) guidance does not explicitly address young athletes returning to sport but recommends that high-risk individuals of any age take extra precautions, including those with chronic lung disease or moderate to severe asthma, chronic kidney disease being treated with dialysis, diabetes mellitus, hemoglobin disorders, liver disease, serious heart conditions, severe obesity (body mass index [BMI] ≥40 kg/m), or who are immunocompromised. There is limited epidemiologic evidence to inform guidance for such individuals, especially in the high school and college age groups; however, young people in general are at low risk for poor outcomes including death, hospitalization, and severe disease. Here, we offer our appraisal of the situation and provide information that may help frame discussions with athletes. The vast majority of deaths from coronavirus occur in those older than 25 years of age, with those aged 15 to 24 years representing only 0.1% of all deaths. Of those younger than 24 years of age who died from the virus, 4% had hypertension, 21% were obese, and 15% had diabetes. Prevalence of these conditions in the general adolescent population is similar for hypertension (4%) and obesity (20.6%) but is much lower for diabetes (0.25%). While no conclusions can be drawn based on limited data, the outcomes in this age group are consistent with the poor outcomes seen in patients with diabetes who contract COVID-19 in the general population; 1 study showed a 4-fold increased risk of severe/critical illness independent of other risk factors. Athletes with diabetes should be counseled regarding the potential for increased morbidity and mortality if infected with COVID-19 and consider delaying return until sports reintegration is confirmed safe and the risk of acquiring a new infection is better understood. Asthma affects 8.4% of the population from 0 to 17 years of age with about 5% experiencing 1 or more asthma attacks per year. CDC guidelines suggest that only those with moderate to severe asthma are in the high-risk category, while mild, well-controlled asthma is not considered a risk for poor outcomes. Moderate asthma is characterized as having daily symptoms that cause some limitation of normal activities and a forced expiratory volume (FEV) of 60% to 80%. Exerciseinduced bronchospasm is common among athletes, especially during the winter and in endurance sports, but is not known to confer a higher risk of poor outcomes with SARS-CoV-2 infection. Athletes with asthma should be evaluated prior to participation in sports to confirm their treatment regimen is optimized and they are adherent to their medications. 939079 SPHXXX10.1177/1941738120939079Harmon et alSPORTS HEALTH research-article2020