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Risk factors associated with acute respiratory illnesses in athletes: a systematic review by a subgroup of the IOC consensus on ‘acute respiratory illness in the athlete’
  1. Wayne Derman1,2,
  2. Marelise Badenhorst1,3,
  3. Maaike Eken1,
  4. Josu Gomez-Ezeiza1,2,
  5. Jane Fitzpatrick4,
  6. Maree Gleeson5,
  7. Lovemore Kunorozva1,
  8. Katja Mjosund6,
  9. Margo Mountjoy7,
  10. Nicola Sewry2,8,
  11. Martin Schwellnus2,8
  1. 1Institute of Sport and Exercise Medicine, Division of Orthopaedic Surgery, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
  2. 2International Olympic Committee Research Center, Pretoria, South Africa
  3. 3Sports Performance Research Institute New Zealand (SPRINZ), Auckland University of Technology, Auckland, New Zealand
  4. 4Centre for Health and Exercise Sports Medicine, Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, Victoria, Australia
  5. 5School of Biomedical Sciences and Pharmacy, Faculty of Health and Medicine, University of Newcastle, New South Wales, New South Wales, Australia
  6. 6Paavo Nurmi Centre, Sport and Exercise Medicine Unit, University of Turku, Turku, Finland
  7. 7Department of Family Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
  8. 8Sport, Exercise Medicine and Lifestyle Institute (SEMLI), Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
  1. Correspondence to Professor Wayne Derman, Institute of Sport and Exercise Medicine, Division of Orthopaedic Surgery, Department of Surgical Sciences, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, South Africa; ewderman{at}


Objective To review risk factors associated with acute respiratory illness (ARill) in athletes, including non-infectious ARill and suspected or confirmed acute respiratory infections (ARinf).

Design Systematic review.

Data sources Electronic databases: PubMed-Medline, EbscoHost and Web of Science.

Eligibility criteria Original research articles published between January 1990 and July 2020 in English were searched for prospective and retrospective full text studies that reported quantitative data on risk factors associated with ARill/ARinf in athletes, at any level of performance (elite/non-elite), aged 15–65 years.

Results 48 studies (n=19 390 athletes) were included in the study. Risk factors associated with ARill/ARinf were: increased training monotony, endurance training programmes, lack of tapering, training during winter or at altitude, international travel and vitamin D deficits. Low tear-(SIgA) and salivary-(IgA) were immune biomarkers associated with ARill/ARinf.

Conclusions Modifiable training and environmental risk factors could be considered by sports coaches and athletes to reduce the risk of ARill/ARinf. Clinicians working with athletes can consider assessing and treating specific nutritional deficiencies such as vitamin D. More research regarding the role and clinical application of measuring immune biomarkers in athletes at high risk of ARill/ARinf is warranted.

PROSPERO registration number CRD42020160928.

  • athletes
  • risk factor
  • respiratory system
  • infection

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  • Twitter @wderman, @goipergormance, @sportsdocaus, @margo.mountjoy

  • Collaborators a Subgroup of the IOC consensus on “Acute respiratory illness in the athlete”.

  • Contributors All authors contributed towards the generation of key search terms used to identify relevant articles for this systematic review. Furthermore, (LK, JG-E, KM and MG) were involved in the data extraction and secondary search for articles missed by the search strategy. KM and MG performed the clinical diagnoses of upper ARinf, ARill and URS which were verified by WD and MS. Critical appraisal and OCEBM levels of evidence were performed by LK, JG-E and MG. All authors were involved in the analysis, interpretation and writing of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • 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.