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Invited Commentary
February 9, 2022

College Athletic Programs Thwart the Spread of SARS-CoV-2 During the COVID-19 Pandemic

Author Affiliations
  • 1Department of Medicine, Louisiana State University Health Sciences Center, Baton Rouge
  • 2Department of Epidemiology and Biostatistics, School of Public Health, Texas A&M University, College Station
  • 3Section of Tropical Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
JAMA Netw Open. 2022;5(2):e2147810. doi:10.1001/jamanetworkopen.2021.47810

The study by Schultz et al1 adds to mounting evidence suggesting the effectiveness of robust surveillance and response programs, such as those implemented for collegiate athletes, in combating the COVID-19 pandemic.1 The authors analyzed SARS-CoV-2 testing data for students from select colleges and universities in the US during the 2020 to 2021 academic year, comparing athletes with nonathletes. Despite the high-risk nature of activities in which athletes are engaged, almost all schools reported lower positivity among athletes compared with their nonathlete counterparts. Of 4 million SARS-CoV-2 tests at 12 US institutions, an overall 50% risk reduction was observed in athletic program testing, suggesting that collegiate athletics programs were associated with a protective outcome during the COVID-19 pandemic. Concern over the health of college athletes is certainly not new; it is a routine subject of health-preservation initiatives by athletic conferences, university policies, and individual athletic programs. However, in the time of COVID-19, the National Collegiate Athletic Association (NCAA) led with early and aggressive recommendations for contact tracing, isolation, and quarantine in an effort to monitor, mitigate, and manage SARS-CoV-2 infections and exposures.2 There is an ongoing and growing interest in the association of such efforts with SARS-CoV-2 infection and transmission.

Athletics activities, from training to competition, present constant challenges to the control of infectious diseases. Sports-associated events and activities can facilitate airborne, respiratory, person-to-person, and environmental transmission of viruses, bacteria, and other agents, including those with outbreak potential. Physical contact, close proximity, increased respiration, shared equipment and facilities, and travel-related experiences may aid transmission among players, athletic and event staff, and attendees and even across communities where events take place. In fact, collegiate and professional athletic programs are well versed in managing the health of their athletes, including during infectious disease outbreaks. However, the risks posed by the COVID pandemic raised acute concerns over the ability of athletic programs to remain open while operating safely and protecting the health of athletes and staff.

Schultz et al1 go on to highlight a diversity in COVID surveillance approaches at the US schools analyzed, ranging from biweekly compulsory polymerase chain reaction (PCR) testing to no testing requirement at all. While test positivity is not a true reflection of infection, it is a useful tool to help understand local transmission when considered in its local context (accounting for factors such as testing availability, awareness, knowledge, local attitudes, and adherence and uptake) and when viewed with other epidemiologic indicators. At one end of the spectrum, where testing may be infrequent, driven by clinical illness, or available on a limited basis, positivity can appear inflated given that individuals undergoing testing are often confirming infection in an apparent illness. At the other end of the spectrum, frequent or iterative testing, in which individuals undergo testing repeatedly and often at intervals, may have lower observed positivity (other factors being equal) owing to the expectation that many uninfected individuals will be tested. Active surveillance that incorporates iterative testing provides the best chance at detecting asymptomatic or subclinical infections and thus the most opportunity to interrupt transmission from those sources. This can also more accurately reflect viral prevalence and paint a better picture of the local epidemiologic situation. The results from Schulz et al1 may, in part, reflect this phenomenon, given the various campus testing strategies and range of observed positivity and given that the contextual backgrounds at schools in this analysis run the gamut. Schools with more robust testing strategies in the general student body had lower test positivity overall compared with schools without regular surveillance testing. Schools with testing frequency most similar to what was implemented for athletes had the lowest positivity, with outcomes among nonathletes more similar to what was observed in athletes across all schools.

In practice, successful disease-control efforts integrate multiple strategies to detect, prevent, or mitigate infections or illness. Multipronged approaches, such as what was adopted early in athletic programs, may include iterative SARS-CoV-2 surveillance testing (eg, weekly PCR testing), quarantine and isolation protocols for individuals who have been exposed and infected, and contact tracing for exposure notifications and subsequent testing.2-4 Even asymptomatic and presymptomatic infections are unlikely to go undetected in a rigorous PCR-testing strategy, and transmission is more readily disrupted when individuals are informed about their infection statuses as early as possible. However, athletes in collegiate and professional programs are unique populations; athletes are highly managed and motivated to comply with rigorous training and other demands. The priorities and experiences of these groups are not representative of the community, in which such intensive public health activities may not be feasible or necessary. These programs have suggested a means to control and contain a pandemic in high-risk, close-contact situations, while continuing to operate.

Whatever the institutional strategy, athlete and nonathlete students at schools in this analysis appeared to have fared better than other young adults in the US during the same period. In August through December 2020, the fraction of positive SARS-CoV-2 test results among US young adults (aged 18-24 years) increased dramatically, from approximately 7% to approximately 17% in a few short months.5 Notably, US young adults consistently had the highest positivity among all age groups during that time. By stark contrast, the highest positivity among athletes and nonathletes in Schultz et al1 were 0.8% and 6.6%, respectively. This is consistent with the recent report from Dixon et al6 that 12% of football players in the Southeastern Conference (SEC) tested positive during the 2020 season. Despite the epidemic curve in football mirroring what was going on in the rest of the nation, incidence in this group did not exceed what was estimated for US young adults. Weekly incidence of SARS-CoV-2 infections tripled in the young adult population (ie, ages 18-24 years), increasing from approximately 125 to 375 infections per 100 000 individuals, while the cumulative pandemic incidence doubled to approximately 20% for individuals aged 16 to 29 years during the fall 2020 academic semester, alone.5,7

The report by Schultz et al1 suggests at least 3 takeaways. First, collegiate athletes do not appear to have borne increased risk of SARS-CoV-2 infection compared with their nonathlete peers. Second, colleges and universities may be able to create low-risk settings, even during acute infectious disease events. Athlete and nonathlete students alike (at least for the schools that made data publicly available) had lower SARS-CoV-2 incidence and testing positivity compared with their peers in the general public during the same time frame, perhaps associated with campus testing programs, with more rigorous testing associated with decreased campus incidence. Moreover, institutions that incorporated protection strategies that were more similar to guidelines for athletes (in part or full) seem to have had the lowest risk levels. Third, the findings suggest that public health tools remain useful and important in high-risk settings and dynamic situations. Robust active surveillance, aligned with guidance from the NCAA, SEC, and athletics programs across the nation, was associated with interrupted transmission and improved health monitoring and safety among athletics participants, even during high-risk activities.

The COVID-19 epidemiologic situation remains dynamic. The experiences of athletic teams at the collegiate and professional levels suggest that, with concerted effort, activities can be carried out without increased risk of infection among athletes, even during a pandemic. These lessons and strategies may be leveraged by public and private entities (eg, schools, employers, community groups, summer camps, and health care facilities) that have a need for more intensive control efforts. This study adds to the growing body of evidence suggesting that public health control measures, whether traditional or cutting edge, may be associated with effective curbing of infection, illness, and transmission. The results support evidence-based guidelines, not only for the ongoing pandemic, but also for the development of future efforts to protect public health and safety. We, the nonathlete public, are delighted to witness and eager to revere the on-field and off-field successes of athletic programs, as well as the athletes themselves and their families, during this stressful and seemingly chaotic time.

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Article Information

Published: February 9, 2022. doi:10.1001/jamanetworkopen.2021.47810

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 O’Neal CS et al. JAMA Network Open.

Corresponding Author: Rebecca S. B. Fischer, PhD, MPH, DTMH, Department of Epidemiology and Biostatistics, School of Public Health, Texas A&M University, 212 Adriance Lab Rd, Ste 211, College Station, Texas 77843 (rfischer@tamu.edu).

Conflict of Interest Disclosures: None reported.

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Crowther  M. SEC medical guidance task force requirements for COVID-19 management: fall sports. Updated December 3, 2020. Accessed January 13, 2021. http://a.espncdn.com/sec/media/2020/SEC%20Task%20Force%20Recommendations%20Fall.pdf
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