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Acute and post-acute COVID-19 presentations in athletes: a systematic review and meta-analysis
  1. Italo Ribeiro Lemes1,
  2. Fabiana Infante Smaira1,
  3. Willian J. D. Ribeiro1,
  4. Natalia Koenig Favero1,
  5. Luciana Diniz Nagem Janot Matos2,
  6. Ana Lúcia de Sá Pinto1,
  7. Eimear Dolan1,
  8. Bruno Gualano1
  9. Coalition SPORT-COVID-19
    1. 1 Applied Physiology & Nutrition Research Group, Laboratory of Assessment and Conditioning in Rheumatology, Universidade de Sao Paulo, Sao Paulo, Brazil
    2. 2 Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil
    1. Correspondence to Professor Bruno Gualano, Applied Physiology & Nutrition Research Group; Laboratory of Assessment and Conditioning in Rheumatology, Universidade de Sao Paulo, Sao Paulo, SP, Brazil; gualano{at}


    Objective To describe acute/postacute COVID-19 presentations in athletes.

    Design Systematic review and meta-analysis.

    Data sources The search was conducted in four databases (MEDLINE, EMBASE, SCOPUS, SPORTDiscus) and restricted to studies published from 2019 to 6 January 2022.

    Eligibility criteria for selecting studies Studies were required to (1) include professional, amateur or collegiate/university athletes with COVID-19; (2) present data on acute/postacute COVID-19 symptoms and (3) have an observational design. Risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal tools.

    Results 43 studies with 11 518 athletes were included. For acute presentation, the pooled event rates for asymptomatic and severe COVID-19 were 25.5% (95% CI: 21.1% to 30.5%) and 1.3% (95% CI: 0.7% to 2.3%), respectively. For postacute presentations, the pooled estimate of persistent symptoms was 8.3% (95% CI: 3.8% to 17.0%). Pooled estimate for myocardial involvement was 5.0% (95% CI: 2.5% to 9.8%) in athletes undergoing any cardiac testing, and 2.5% (95% CI: 1.0% to 5.8%) in athletes undergoing MRI, although clinical symptoms were not characterised. None of the studies with a control group (eg, non-infected athletes) could confirm a causal relationship between COVID-19 and myocardial involvement.

    Conclusion This broad characterisation of COVID-19 presentations in athletes indicates that ~94% exhibited mild or no acute symptoms. The available evidence did not confirm a causal relationship between COVID-19 and myocardial involvement. A small proportion of athletes experienced persistent symptoms while recovering from infection, which were mostly mild in nature, but could affect return-to-play decisions and timing.

    • Sport
    • Athletes
    • Covid-19
    • Infection
    • Meta-analysis

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    • Twitter @itolemes, @eimeardol, @Appl_Phys_Nutr

    • Correction notice This article has been corrected since it published Online First. A collaborator's name has been updated.

    • Collaborators Coalition SPORT-COVID-19: Ana Jéssica Pinto (Anschutz Health and Wellness Center, University of Colorado Anschutz Medical Campus, USA), Irineu Loturco (Nucleus of High Performance in Sport, São Paulo; Universidade Federal de São Paulo), Gilberto Szarf (Hospital Israelita Albert Einstein/Federal University of São Paulo), Marcelo Luiz Campos Vieira (Hospital Israelita Albert Einstein), Nabil Ghorayeb, Lorena Christine Araújo de Albuquerque and Bruno Bassaneze (HCor Hospital do Coração), Marcos Perillo Filho, Rodrigo Otávio Bougleux Alô and Thiago Ghorayeb Garcia (Instituto Dante Pazzanese de Cardiologia), Mateus Freitas Teixeira (Clube de Regatas Vasco da Gama/Clínica Fit Center), Danilo Prado, Fernanda Rodrigues Lima, Diego Rezende, Gisele Mendes Brito and Marina Valente Guimarães Cecchini (University of São Paulo).

    • Contributors BG, IRL and ED conceived and designed the study. IRL conducted the search. IRL, FIS, WJDR and NKF performed the screening, study selection and data extraction. IRL, BG and ED analysed and interpreted the data, and drafted the manuscript with input from FIS, WJDR, NKF, LDNJdM, ALdSP and the Coalition SPORT-COVID-19. All authors have read and approved the final version.

    • Funding This study was funded by Conselho Nacional de Desenvolvimento Científico e Tecnológico, São Paulo Research Foundation (grant nos 2017/13552-2, 2019/05616-6, 2019/14819-8, 2020/04877-8).

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.