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Coronavirus 19

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Other Names

  • Covid 2019
  • Covid-19
  • Coronavirus 2019
  • Coronavirus Disease 2019


  • This page refers to Coronavirus 19 (Covid-19), a novel coronavirus which causes viral pneumonia and started


  • Confirmed to have originated in the city of Wuhan, Hubei province in China in December 2019[1]
  • Declared a pandemic by the World Health Organization


  • As of 5/31/20, there are 6,165,181 confirmed cases with 371,995 deaths
    • Note that this data is updated daily[2]


  • Enters the body through respiratory droplets
    • Person-to-person spread is primary vector
    • Individuals cough, sneeze or come in contact with another person's mucous membranes
    • Rate of transmission is estimated to be 1-5% (need citation)
    • Similar to other coronaviruses (including SARS, MERS)
  • Suspected etiology is animal market, specifically Bats

Risk Factors

  • Older age confers greater risk of
    • Illness
    • Death
  • Mostly surrounding chronic disease

Differential Diagnosis

Clinical Features

  • History
    • Incubation period after exposure up to 14 days
    • May patients are asymptomatic
    • Patients who are symptomatic may endorse fever (99%), dry cough (59%), myalgias, fatigue, shortness of breath
    • Fever and cough are initial symptoms
    • Shortness of breath takes an average of 9 days to present
    • Less commonly, patients may endorse headache, sore throat, nausea, vomiting, nasal congestion
    • Some patients may endorse anosmia (lack of smell), dysgeusia or ageusia (loss of taste)
  • Physical Exam
    • Careful cardiopulmonary examination
    • Close attention to vital signs, patients may be profoundly hypoxic but well appearing



  • Chest Xray
    • Portable is preferred to minimize exposure to staff
  • Sensitivity 59% (need citation)
  • Findings
    • Normal early
    • Patchy, multifocal infiltrates
    • In ill patients, may see ground glass opacities


  • Not indicated for diagnostic imaging
    • May be normal early in disease process
  • Sensitivity 86% (need citation)


  • Role of pulmonary/ lung ultrasound in Covid19 unclear


  • Test kits vary by region
  • RT-PCR (reverse transcriptase polymerase chain reaction)
    • Most commonly used for confirming tests
    • Sensitivity 75%, specificity high (need citation)
    • Turnaround hours-days
  • Real Time PCR
    • Aka "rapid test"
    • Turn around in <1 hour typically
  • Serology
    • Testing for IgG, IgM not widely available yet
    • Some test kits may not distinguish antibodies from other coronaviruses
    • Need more research, better test kits to clarify roll



  • Prevention of transmission among athletes, staff, fans and community at large is critical

Impact on Sports

  • All spring sports for college were cancelled or postponed to help reduce or prevent transmission
  • Professional leagues are currently evaluating their options to safely return to sport
    • The NBA cancelled or postponed their season on March 23, 2020[3]
    • On March 24th, The International Olympic Committee delayed the summer olympic games in Tokyo to Summer 2021[4]

Goals of Prevention

  • Reduce risk of spread to community
  • Minimize interruptions in training, competition
  • Minimize transmission or spread to opposing teams
  • Minimize risk on individual athletes ability to perform at highest level

Prevention Recommendations

  • Hand Hygiene
    • Hand sanitizer with at least 60% alcohol
    • Soap and water (superior to hand sanitizer)
  • Disinfecting common areas
    • Areas that are frequently visited or touched should be cleaned regularly
  • Social Distancing
    • Athletes should avoid high risk exposures by social distancing
    • CDC recommendation is areas where you can maintain 6 feet of distance[5]
    • Avoid mass gatherings, congregations
  • Travel
    • Travel restrictions have been implemented in various degrees around the world
    • Athletes should follow their regional guidelines
    • When traveling from high risk areas, they will need to quarantine for 14 days
  • Face Mask
    • At this time, recommendations for or against wearing a face mask in public are limited
    • If athletes choose to wear a face mask, they should not use medical equipment designated for healthcare workers.
    • N95 masks should be reserved for high risk workers only

Training Modification

  • Excessive training can stress the immune system
  • Some experts are suggesting modification of training to reduce risk of this phenomenon
  • One approach is to limit training session to less than 60 minutes at less than 80% of maximal exertion
    • No evidence to really support this approach[6]


  • As of 6/1/20 there are no vaccines available
  • Estimated end of 2020 or into 2021



  • Testing options reviewed in detail above
  • Athletes should be tested if symptomatic, immunocompromised or in close contact with someone with Covid-19


  • In general, athletes are younger age with fewer comorbidities
    • Thus lower risk for severe disease and death
  • Roughly 10% of individuals age 18-45 required hospitalization
    • Mostly due to hypoxia
    • This is likely an overestimated percentage due to limited testing availability and many asymptomatic patients who are not tested


  • If the patient is very symptomatic or ill appearing, they should be evaluated clinically
    • Patient should have puleox >93% on RA, RR under 20, HR under 110 when afebrile
    • If patient is determined to be sick, they should be directed to the nearest emergency department
  • Isolation
    • Recommended for athletes with confirmed, suspected Covid-19
    • Other members of household should be isolated away from athlete
  • Antipyretics
    • Acetaminophen, NSAIDS
    • Concern about NSAID use is theoretical, best evidence currently supports their safety
  • Corticosteroids
    • Not indicated unless other comorbidities such as Asthma
  • Other Medications
    • Symptomatic management with anti-tussive, decongestants, etc is recommended at clinician discretion

Drugs Under Investigation

  • Remdesivir
    • May shorten duration of illness
    • Currently only recommended in critically ill
    • Not recommended or available for outpatient use at this time
  • Lopinavir / Ritonavir (Kaletra)
    • Used in MERS, SARS
    • At this time, no known benefit for Covid-19[7]
  • Hydroxychloroquine
    • Not recommended for treatment or prophylaxis based upon best available evidence
  • Azithromycin
    • Recommended if suspected bacterial co-infection[8]
  • Other drugs not indicated
    • Oseltamivir
    • Baloxavir marboxil
    • Ribavirin

Team Management

  • If an athlete develops symptoms consistent with Covid-19 or confirmed case
    • Exposed teammates, coaches and other staff in the previous 14 days should begin home isolation
  • If the athlete who is symptomatic undergoes testing and it is negative
    • Exposed teammates and staff can discontinue isolation
  • Teams should be prepared to expand testing to exposed, asymptomatic athletes and staff
    • Important to have a plan in place with a testing facility
  • Consider implementing daily temperature checks (prior to exercise)

Discontinuing Isolation

  • Home isolation can be discontinued if the following conditions are met[9]
    • Absence of fever
    • Resolution of respiratory symptoms
    • Two consecutive negative Covid-19 tests collected 24 hours apart (controversial)
  • Non-testing strategy
    • 7 days since apperance of symptoms
    • 72 hours since last symptoms were present (without use of antipyretics)

Mental Health

  • Suspended and cancelled seasons can be distressing for athletes
    • Can lead to grief, stress, anxiety, frustration, and sadness for an athlete[10]
  • Sports medicine physicians and staff should anticipate this need
    • Ensure regular check in with athletes
    • Arrange for telehealth consultation with a psychiatrist or sports psychologist
    • Encourage maintaining social circle in the context of social distancing


Return to Play

  • Goal: mitigage and minimize risk to athletes, team staff, facility staff, community at large

Sick Athletes

  • Athletes must be asymptomatic prior to return to standard training or play
    • Energy levels should have returned to normal
    • Vital signs at rest should be normal
  • During the the tail end of isolation, athletes can consider light, low-intensity training at home
  • Coach, physical therapist, strength and conditioning coachs, etc will have to individualize plans with athletes

New Normal

  • We are going to see a 'new normal' in the Covid-19 era in sports
    • Using the best information we have available, what is normal for a team will have to be different from what it was prior to Covid-19
    • Many practices might change
    • Recognize that we can not reduce risk to zero
  • Screening of athletes prior to participation/ RTP
    • Increased education to coaches, staff, families
    • Health screenings
    • Temperature check
    • Encourage self reporting of symptoms
    • Disinfect everything
  • Consider the following during games and practices
    • Avoid locker rooms when possible
    • Use proper social distancing when practical
    • Do not share water bottles
    • Elimination of team huddles
    • Elimination of handshakes, fist bumps
    • Coaches, officials should wear masks
    • Sanitize gear when possible

Facility Changes

  • Increased signage
  • Consider traffic patterns
  • Bathrooms
  • Increased cleaning of high frequency points

Changes for Players and Families

  • Increased distance for spectators
  • Fewer or no fans
  • Must wear mask


  • Critical for all stakeholders
  • Utilize
    • Phone
    • Email
    • Text
    • Increased Signage
    • Social Media

Staged Return for Teams

  • Recognition that some sports are higher risk than others
    • High risk: team sports, contact sports, collision sports
    • Lower risk: individual sports such as golf, tennis, track
  • Most teams and leagues are recommended some form of staged return
    • Each stage should last 2 weeks (or some other predetermined time) to ensure there are no outbreaks
  • USA Lacrosse has a well outlined, 5 stage RTP[11]
    • Outlines risk, goals, hygiene and social distancing, facility or venue, training and injury prevention
    • Stage 1: At home individual training
    • Stage 2: Small Group (less than 10) Modified Lacrosse Activity/Practice
    • Stage 3: Medium group (less than 50) Modified intra-squad scrimmages/practices
    • Stage 4: Medium group (less than 50) local competition/practices from teams within same locale
    • Stage 5: Larger group gatherings (more than 50) and full competition resumption


  • Death
  • Pneumonia
  • Acute respiratory distress syndrome (ARDS)
  • Myocarditis

See Also


  1. https://www.who.int/westernpacific/emergencies/covid-19
  2. https://gisanddata.maps.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6
  3. National Basketball Association . NBA to suspend season following Wednesday’s games. https://www.nba.com/article/2020/03/11/nba-suspend-season-following-wednesdays-games.
  4. nternational Olympic Committee . Joint statement from the International Olympic Committee and the Tokyo 2020 Organising Committee. https://www.olympic.org/news/joint-statement-from-the-international-olympic-committee-and-the-tokyo-2020-organising-committee.
  5. Centers for Disease Control and Prevention . Coronavirus disease 2019 (COVID-19) risk assessment and management. https://www.cdc.gov/coronavirus/2019-ncov/php/risk-assessment.html.
  6. Campbell, JP, Turner, JE. Debunking the myth of exercise-induced immune suppression: redefining the impact of exercise on immunological health across the lifespan. Front Immunol. 2018;9:648.
  7. Cao, B., Wang, Y., Wen, D., Liu, W., Wang, J., Fan, G., ... & Li, X. (2020). A trial of lopinavir–ritonavir in adults hospitalized with severe Covid-19. New England Journal of Medicine.
  8. https://www.massgeneral.org/assets/MGH/pdf/news/coronavirus/mass-general-COVID-19-treatment-guidance.pdf
  9. Centers for Disease Control and Prevention . Discontinuation of home isolation for persons with COVID-19 (interim guidance). https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-in-home-patients.html.
  10. Toresdahl, B. G., & Asif, I. M. (2020). Coronavirus Disease 2019 (COVID-19): Considerations for the Competitive Athlete. Sports Health, 12(3), 221–224.
  11. https://www.uslacrosse.org/return-to-play
Created by:
John Kiel on 1 June 2020 02:33:21
Last edited:
3 June 2020 13:10:17