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Association between regular physical activity and the protective effect of vaccination against SARS-CoV-2 in a South African case–control study
  1. Shirley Collie1,
  2. Robin Terence Saggers2,3,
  3. Rossella Bandini4,
  4. Lizelle Steenkamp1,
  5. Jared Champion1,
  6. Glenda Gray5,
  7. Linda-Gail Bekker6,
  8. Ameena Goga5,7,
  9. Nigel Garrett8,9,
  10. Jon Patricios2
  1. 1Healthcare Analytics, Discovery Health, Johannesburg, South Africa
  2. 2Wits Sport and Health (WiSH), School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
  3. 3Department of Paediatrics and Child Health, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
  4. 4PRINCE: Project to Improve Neonatal Care, School of Clinical Medicine, Faculty of Health Sciences, Wits University, Johannesburg-Braamfontein, Gauteng, South Africa
  5. 5COVID-19 Research Committee, South African Medical Research Council, Tygerberg, South Africa
  6. 6Desmond Tutu HIV Centre, University of Cape Town, Observatory, South Africa
  7. 7Department of Paediatrics and Child Health, University of Pretoria, Pretoria, South Africa
  8. 8Centre for the Aids Programme of Research in South Africa, Durban, KwaZulu-Natal, South Africa
  9. 9School of Nursing and Public Health, Discipline of Public Health Medicine, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
  1. Correspondence to Professor Jon Patricios, Wits Sport and Health (WiSH), School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg-Braamfontein, South Africa; jpat{at}


Background Both vaccination and physical activity have been shown to independently decrease the likelihood of severe COVID-19 infection.

Objective To assess the association between regular physical activity and vaccination against COVID-19 among healthcare workers.

Methods A test negative case–control study design was used to estimate the risk of having an associated COVID-19-related hospital admission, among individuals who were unvaccinated compared with those who were fully vaccinated with Ad26.COV2.S (>28 days after a single dose). 196 444 participant tests were stratified into three measured physical activity subgroups with low, moderate and high activity, to test the hypothesis that physical activity is an effect modifier on the relationship between vaccination and hospitalisation.

Results Vaccine effectiveness against a COVID-19-related admission among vaccinated individuals within the low activity group was 60.0% (95% CI 39.0 to 73.8), 72.1% (95% CI 55.2 to 82.6) for the moderate activity group, and 85.8% (95% CI 74.1 to 92.2) for the high activity group. Compared with individuals with low activity levels, vaccinated individuals with moderate and high activity levels had a 1.4 (95% CI 1.36 to 1.51) and 2.8 (95% CI 2.35 to 3.35) times lower risk of COVID-19 admission, respectively (p value <0.001 for both groups).

Conclusions Regular physical activity was associated with improved vaccine effectiveness against COVID-19 hospitalisation, with higher levels of physical activity associated with greater vaccine effectiveness. Physical activity enhances vaccine effectiveness against severe COVID-19 outcomes and should be encouraged by greater public health messaging.

  • Covid-19
  • Physical activity
  • Vaccination

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  • Contributors SC conceived the format of the paper. SC, LS and JC led the actuarial and statistical analysis of the cohort data with input from RB. JP, RTS and RB conducted the literature review and drafted the initial manuscript. SC, LS, JC and RB formulated the tables. GG, L-GB, AG and NG provided input on vaccine efficacy and are the principal investigators of the Sisonke study. JP coordinated the interinstitutional collaboration, reviewed each version of the manuscript and led the subsequent iterations. All authors reviewed and edited each iteration of the manuscript and accept responsibility for the final content. SC as lead author has access to all the data while JP acts as guarantor.

  • Funding Direct funding for the Sisonke Study was provided by the National Treasury of South Africa, the National Department of Health, Solidarity Response Fund NPC, The Michael & Susan Dell Foundation, The Elma Vaccines and Immunization Foundation - grant number 21-V0001, and the Bill & Melinda Gates Foundation – grant number INV-030342. The content is solely the responsibility of the authors and does not necessarily represent the official views of Johnson and Johnson or the other Sisonke funders. The funders had an opportunity to review a preliminary version of the manuscript. The authors are solely responsible for the final content and interpretation.

  • Competing interests SC, LS and JC are employed by Discovery Health; J P is an editor of BJSM.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • 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.