Article Text

High rates of respiratory illnesses upon arrival: lessons from Team USA at the Santiago 2023 Pan American and Parapan American Games
  1. Eric G Post1,2,
  2. Travis Anderson1,2,
  3. Olivia Samson1,2,
  4. Ashley N Triplett1,2,
  5. Alexis D Gidley1,2,
  6. Steven S Isono3,
  7. Jennifer Watters1,2,
  8. Amber T Donaldson1,2,
  9. Jonathan T Finnoff1,2,4,
  10. William M Adams1,2,5,6
  1. 1Department of Sports Medicine, United States Olympic & Paralympic Committee, Colorado Springs, Colorado, USA
  2. 2United States Coalition for the Prevention of Illness and Injury in Sport, Colorado Springs, Colorado, USA
  3. 3Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
  4. 4Department of Physical Medicine and Rehabilitation, University of Colorado, Denver, Colorado, USA
  5. 5Department of Kinesiology, University of North Carolina at Greensboro, Greensboro, North Carolina, USA
  6. 6School of Sport, Exercise and Health Sciences, National Centre for Sport and Exercise Medicine (NCSEM), Loughborough University, Loughborough, Leicestershire, UK
  1. Correspondence to Dr Eric G Post, Department of Sports Medicine, United States Olympic & Paralympic Committee, Colorado Springs, Colorado, USA; eric.post{at}usopc.org

Abstract

Objective To describe the incidence and characteristics of injuries and illnesses among Team USA athletes competing at the Santiago 2023 Pan American Games (PAG) and Parapan American Games (PPAG), with a particular focus on the incidence of respiratory illnesses and on injuries for sports new to the Olympic and Paralympic programmes.

Methods Illnesses and injuries occurring among the 870 Team USA athletes competing in the Santiago 2023 PAG or PPAG were documented within Team USA’s Injury and Illness Surveillance system. Illness and injury incidence per 1000 athlete-days (ADs) and incidence ratios (IR) were calculated, both with 95% CIs.

Results Illness (IR 2.5, 95% CI 1.6, 3.9) and injury (IR 1.8, 95% CI 1.3, 2.5) rates were greater during PPAG compared with PAG. Illness rates were higher in the pre-opening ceremony period compared with the competition period for both PAG (IR 2.7, 95% CI 1.1, 5.9) and PPAG (IR 1.9, 95% CI 0.9, 3.8). Respiratory illness was the most common illness with 3.2% and 8.9% of all Team USA athletes reporting a respiratory illness during the PAG and PPAG, respectively. Sports that are relatively new to the Olympic/Paralympic programmes exhibited the highest injury rates during the Games: breaking (250.0 (91.7, 544.2) per 1000 ADs), Para taekwondo (93.8 (19.3, 274.0) per 1000 ADs) and surfing (88.9 (24.2, 227.6) per 1000 ADs).

Conclusion Respiratory illness rates were the most common type of illness during both PAG and PPAG and were more likely to occur prior to competition starting. Our data have identified high injury risk populations (breaking, surfing, Para taekwondo) and timing (pre-opening ceremony period) for further risk factor analysis.

  • Epidemiology

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information. Data are available upon reasonable request. Request to access the data will be considered by the authors within the constraints of privacy and consent.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

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WHAT IS ALREADY KNOWN ON THIS TOPIC

  • The COVID-19 pandemic greatly affected the sports world, leading to precautions during the 2020 Tokyo Olympic and Paralympic Games, resulting in historically low respiratory illness rates. The 2023 Pan American and Parapan American Games in Santiago, Chile, were among the first major international competitions without heightened COVID-19 precautions and featured newer Olympic/Paralympic sports.

WHAT THIS STUDY ADDS

  • We observed higher rates of respiratory illness in Santiago compared with the Tokyo 2020 Games that were more aligned with respiratory illness rates from Games prior to Tokyo. We also observed higher incidence of both illness and injury during the pre-opening ceremony period as compared with the competition period, and high injury incidence in newer sports including breaking, surfing and Para taekwondo.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

  • Reinstating some illness prevention precautions from the Tokyo Games may be useful for mitigating illness risks in future international competitions. Our data highlight the need for additional travel precautions, reassessment of training protocols and increased medical preparedness for sports new to the Olympic/Paralympic programmes to reduce illness and injury risks.

Introduction

The global COVID-19 pandemic had an unprecedented impact on the sporting world, including within the Olympic and Paralympic movement.1 The 2020 Tokyo Olympic and Paralympic Games were ultimately delayed 1 year to the summer of 2021, and a variety of precautions were implemented to help protect the health of athletes, delegation staff and the local public during the Games.2–5 These precautions included an emphasis on personal hygiene, mandated masking and robust testing/contact tracing/isolation protocols that included both prearrival and daily screening, limited in-person interactions and encouraged vaccination for all Olympic Village residents.2 As a result, these precautions were likely (or at least partially) responsible for the reported respiratory illness rates being the lowest ever reported by the International Olympic Committee (IOC) injury and illness surveillance programme during a Games,6–11 with only 0.4% of Olympic athletes2 and 1.1% of Paralympic athletes3 reporting a respiratory illness in Tokyo. Similarly, when examining Team USA athletes specifically, only 0.9% of Olympic athletes and 1.6% of Paralympic athletes reported a respiratory illness during the Tokyo Games (unpublished data).

The 2023 Pan American Games (PAG) and Parapan American Games (PPAG), held in Santiago, Chile, were one of the largest international multisport summer competitions held since the Tokyo 2020 Summer Games. From October to November 2023, a total of 8852 athletes competed across 56 different sports in the PAG and PPAG. Due to their timing in late 2023, these Games were among the first large-scale international competitions held following the declaration in May 2023 by the WHO that the COVID-19 pandemic was no longer a public health emergency of international concern. As a result, the Santiago Games took place without the restrictions put in place for the Tokyo 2020 Summer Games or Beijing 2022 Winter Games to help prevent the spread of respiratory illness. Additionally, the Santiago Games also included sports that were either relatively new to the Olympic and Paralympic programmes (such as surfing, skateboarding, sport climbing and Para taekwondo, all introduced in Tokyo 2020 and on the schedule for Paris 2024), or completely new to the Olympic Games (such as breaking, which will debut in the Paris 2024 Olympic Games). Due to the unique timing of the Santiago 2023 PAG and PPAG relative to the COVID-19 pandemic, as well as their inclusion of sports that are relatively or completely new to the Olympic and Paralympic programmes, understanding the epidemiology of illness and injury from Santiago can help healthcare providers and national sport delegations prepare for future events, such as the 2024 Paris Olympic and Paralympic Games.

Therefore, the purpose of this study was to describe the incidence and characteristics of illnesses and injuries reported by Team USA athletes competing at the Santiago 2023 PAG and PPAG. In particular, we aimed to describe the incidence and characteristics of respiratory illnesses reported at the Santiago Games, as well as describe the incidence of injury among sports that are new to the Olympic and Paralympic programmes.

Methods

This descriptive epidemiological study assessed the findings from the US Olympic & Paralympic Committee’s (USOPC) Injury and Illness Surveillance (IIS) system during the Santiago 2023 PAG and the Santiago 2023 PPAG.

Patient and public involvement

Athletes competing in the Santiago 2023 PAG or PPAG were not directly involved in setting the research questions or outcomes of this study. However, the USOPC Research Review Committee, which consists of Olympic and Paralympic athlete representatives, sports medicine clinicians, mental health providers, sport physiologists, sport nutritionists, strength and conditioning coaches, national sport governing body representatives and legal representatives, reviewed and approved this study prior to analysis of the data.

Equity, diversity and inclusion statement

While no specific efforts were made to include participants based on their demographics, the data for this study were reported from the diverse population of elite athletes competing for Team USA at the Santiago 2023 PAG and PPAG. Athletes were provided access to required medical resources regardless of their individual backgrounds. The research team consists of a diverse, balanced group of expert clinicians and researchers (50% female; 20% physician).

Data collection

All evaluations of illnesses and injuries (including new, recurrent or exacerbation of pre-existing illnesses and injuries) reported by Team USA athletes during the Santiago 2023 PAG and PPAG were documented by Team USA credentialled healthcare providers into the USOPC IIS system. The medical encounters included in this study occurred across an 11-day pre-opening ceremony period leading up to the Opening Ceremony of each Games (PAG: 20 October 2023; PPAG: 17 November 2023), the competition period (17 days for PAG, 10 days for PPAG) and a 3-day post-closing ceremony period after the Closing Ceremony of each Games (PAG: 5 November 2023; PPAG: 26 November 2023). Medical encounters from the pre-opening ceremony and post-closing ceremony time periods were included in this study in order to capture the full time period that Team USA athletes were in Santiago for training/competition and at risk for an illness or injury.

Definition of illness and injury

The USOPC IIS system records illness and injury details (including onset, mechanism, setting, etc) according to the 2020 IOC Consensus Statement for recording and reporting of sport epidemiological data.12 Injuries are defined within the USOPC IIS system as ‘tissue damage or other derangement of normal physical function due to participation in sports, that requires evaluation by a healthcare provider and results in a diagnosis’. Illnesses are defined as ‘a physical health-related complaint or disorder experienced by an athlete, that requires evaluation by a healthcare provider and results in a diagnosis’. Within the USOPC IIS, each illness and injury is assigned a diagnosis using the Orchard Sports Injury and Illness Classification System v14.0.13

Calculation of athlete exposure

An individual athlete’s exposure was calculated as the number of days an athlete was in Santiago during the respective Games period, and was calculated using athlete accommodation records obtained from the USOPC. The total number of days that each athlete was in Santiago was summed to determine the total number of athlete-days (AD), both within the total athlete sample and within each subgroup of interest, which served as the measures of exposure for calculating illness and injury incidence. For PAG, a total of 5806 ADs were recorded (pre-opening ceremony: 458 ADs, competition period: 5237 ADs, post-closing ceremony: 111 ADs), and a total of 2476 ADs were recorded during PPAG (pre-opening ceremony: 381 ADs, competition period: 2006 ADs, post-closing ceremony: 89 ADs).

Statistical analysis

The number of Team USA athletes participating in the Santiago 2023 Games, total number of ADs, frequency of illnesses and injuries, sports represented, athlete ages and time loss from sport were all summarised using descriptive statistics. Incidence was calculated per 1000 ADs for both illness and injury, as well as by sex, sport, timing (pre-opening ceremony period, competition period, post-closing ceremony period), presentation (new, recurrent, exacerbation, unknown), injury mechanism, injury onset, injury setting (competition, training, peri-competition, outside of sport or unknown), injury anatomical location and illness system. Incidence ratios (IR) were calculated to compare illness and injury incidence based on Games (PAG, PPAG), sex (male, female) and timing within Games (pre-opening ceremony period, competition period, post-closing ceremony period).

For descriptive summaries, sports with <10 athletes competing were grouped based on relative similarities per regulations from the approving institution’s Institutional Review Board to maintain athlete confidentiality. However, illness and injury incidence are still presented for each sport, regardless of sport size. 95% CIs were calculated for all incidence and IR. All analyses were performed using R statistical software (V.4.3.2, R Foundation for Statistical Computing, Vienna, Austria14), and all incidence, IR and 95% CIs were calculated as described above using the epiR package, with the arguments for ctype=‘inc.rate’ and method=‘exact’.15 All statistical analysis and presentation are consistent with the CHecklist for statistical Assessment of Medical Papers (CHAMP) statement.16

Results

A total of 634 athletes (50% female) competed for Team USA at the Santiago 2023 PAG across 47 sport disciplines. For the Santiago 2023 PPAG, a total of 236 athletes (38.1% female) competed across 16 sport disciplines. Overall, both illness (IR 2.5, 95% CI 1.6, 3.9) and injury (IR 1.8, 95% CI 1.3, 2.5) rates were greater during PPAG compared with PAG.

Pan American Games

Illness rates overall, by sex and sport

Approximately 1 in 20 (5.8%) of all Team USA athletes reported at least one illness during PAG (table 1). There was no difference in illness incidence between male and female PAG athletes (IR 0.8, 95% CI 0.4, 1.5). Illness incidence was highest in archery (36.4 (9.9, 93.1) per 1000 ADs), followed by artistic swimming (36.1 (7.5, 105.6) per 1000 ADs), and then gymnastics (28.4 (10.4, 61.9) per 1000 ADs) (figure 1). Only two (4.8%) of the reported illnesses resulted in time loss from sport, with athletes who reported a time loss illness missed a median of 4 (3–5) days from sport.

Figure 1

Illness incidence by sport for Team USA athletes competing at the Santiago 2023 Pan American Games (PAG) and Parapan American Games (PPAG). Dot represents incidence value, bars indicate 95% CI values and blue dotted line indicates overall incidence. ADs, athlete-days; CP, cerebral palsy.

Table 1

Illness incidence overall and by sex for Team USA athletes competing at the Santiago 2023 Pan American Games (PAG) and Parapan American Games (PPAG)

Based on the elevated respiratory illness rates observed among Team USA athletes in Santiago, we conducted a post hoc IR calculation comparing the incidence of respiratory illness among Team USA athletes in Santiago (both PAG and PPAG) to the incidence of respiratory illness among Team USA athletes in Tokyo (online supplemental table 1). Overall, Team USA athletes in Santiago were between seven and eight times more likely to report a respiratory illness compared with Team USA athletes in Tokyo (IR 7.6, 95% CI 3.8, 17.1), and these differences were consistent when specifically examining comparisons between Pan American/Olympic athletes and Parapan American/Paralympic athletes.

Illness rates by type and timing

50% of all illnesses were respiratory in nature, making it the most common illness type during PAG (table 2). Of the 21 respiratory illnesses reported during PAG, nearly all (91%) were either respiratory system infections (n=14, 67%) or related to allergies (n=5, 24%). Illness incidence was nearly three times higher during the pre-opening ceremony period compared with the Games competition period (IR 2.7, 95% CI 1.1, 5.9) (table 3). Most (62%) illnesses reported during PAG were new in presentation, but 19% were exacerbations of ongoing medical conditions that athletes were managing prior to PAG. Most illness exacerbations (75%, 6 of 8) were related to a respiratory illness of some kind being made worse by the conditions at PAG.

Table 2

Illness incidence by medical system for Team USA athletes competing at the Santiago 2023 Pan American Games (PAG) and Parapan American Games (PPAG)

Table 3

Illness incidence by presentation and timing within Games period for Team USA athletes competing at the Santiago 2023 Pan American Games (PAG) and Parapan American Games (PPAG)

Injury rates overall, by sex and sport

Approximately 1 in 12 (8.8%) of all athletes reported at least one injury during PAG (table 4). There was no difference in injury incidence between male and female PAG athletes (IR 1.2, 95% CI 0.8, 1.9). Injury incidence was highest in breaking (250.0 (91.7, 544.2) per 1000 ADs), followed by artistic swimming (144.6 (74.7, 252.6) per 1000 ADs) and surfing (88.9 (24.2, 227.6) per 1000 ADs) (figure 2). A total of 15 (17.4%) injuries resulted in time loss, and these time loss injuries resulted in a median of 9 (1–25) days lost from sport.

Figure 2

Injury incidence by sport for Team USA athletes competing at the Santiago 2023 Pan American Games (PAG) and Parapan American Games (PPAG). Dot represents incidence value, bars indicate 95% CI values and blue dotted line indicates overall incidence. ADs, athlete-days; CP, cerebral palsy.

Table 4

Injury incidence overall and by sex for Team USA athletes competing at the Santiago 2023 Pan American Games (PAG) and Parapan American Games (PPAG)

Injury rates by location, timing and setting

Injury incidence was highest at the shoulder (2.2 (1.2, 3.8) per 1000 ADs), followed by the knee (1.7 (0.8, 3.2) per 1000 ADs) and the head and hand (both 1.6 (0.7, 2.9) per 1000 ADs) (figure 3). Injury incidence was over two times higher during the pre-opening ceremony period compared with the competition period (IR 2.4, 95% CI 1.3, 4.3) (table 5). However, the most common setting (competition, training, peri-competition or out of sport) where injuries occurred was during competitions (6.4 (4.5, 8.8) per 1000 ADs), and most injuries (60.4%) reported during PAG had a sudden onset (9.0 (6.7, 11.7) per 1000 ADs). The most common mechanism of injury was overuse, representing 38% of all injuries reported during PAG (5.7 (3.9, 8.0) per 1000 ADs).

Figure 3

Injury incidence by anatomical location for Team USA athletes competing at the Santiago 2023 Pan American Games (PAG) and Parapan American Games (PPAG). Dot represents incidence value and bars indicate 95% CI values. ADs, athlete-days.

Table 5

Injury incidence by setting, timing, mode of onset and mechanism for Team USA athletes competing at the Santiago 2023 Pan American Games (PAG) and Parapan American Games (PPAG)

Parapan American Games

Illness rates overall, by sex and sport

Roughly 1 in 6 (17.4%) Team USA athletes reported at least one illness during PPAG (table 1). Female Team USA athletes at PPAG were 2.7 times more likely to report an illness compared with male athletes at PPAG (IR 2.7, 95% CI 1.4, 5.2). Similar to the high illness rate in archery during PAG, the highest illness incidence for PPAG was observed in Para archery (79.4 (25.8, 185.2) per 1000 ADs) (figure 1). In total, six (13.3%) illnesses resulted in time loss from sport, with time loss illnesses resulting in a median of 3.5 (2.25–4.0) days lost from sport.

Illness rates by type and timing

Congruent with the observations from PAG, respiratory illnesses represented the most common illness type (47% of all illnesses) during PPAG, and roughly 1 in 11 (8.9%) PPAG athletes reported a respiratory illness during the Games (table 2). The 21 respiratory illnesses reported in PPAG consisted mainly of allergic conditions (n=10, 48%), COVID-19 infections (n=7, 33%) and other respiratory system infections (n=4, 19%). Again, illness incidence was nearly twice as high during the PPAG pre-opening ceremony period compared with the competition period (IR 1.9, 95% CI 0.9, 3.8) (table 3).

Injury rates overall, by sex and sport

Approximately 1 in 5 (22%) PPAG athletes reported at least one injury during the Games (table 4). There was no difference in injury incidence between male and female PPAG athletes (IR 1.0, 95% CI 0.6, 1.7). Injury incidence was highest in Para judo (187.5 (85.7, 355.9) per 1000 ADs), followed by Para taekwondo (93.8 (19.3, 274.0) per 1000 ADs) and goalball (62.9 (30.2, 115.7) per 1000 ADs) (figure 2). Of all injuries sustained by Team USA athletes during PPAG, 10 (15.4%) resulted in time loss from sport for a median of 1 (0–1.5) days lost.

Injury rates by location, timing and setting

Injury incidence was relatively similar across all anatomical locations, with the highest rates in the foot (4.4 (2.2, 8.0) per 1000 ADs), followed by the head and shoulder (both 3.6 (1.7, 6.9) per 1000 ADs) (figure 3). Similar to the PAG, injury incidence during PPAG was over two times higher during the pre-opening ceremony period compared with the competition period (IR 2.3, 95% CI 1.3, 4.0) (table 5). While the highest injury incidence was observed during training (8.5 (5.3, 13.0) per 1000 ADs), nearly a third of all injuries (30.7%) occurred outside of training or competitions. Overuse was the most common mechanism of injury (9.7 (6.2, 14.4) per 1000 ADs), closely followed by direct contact with an object (8.1 (4.9, 12.5) per 1000 ADs) and acute non-contact injuries (6.9 (4.0, 11.0) per 1000 ADs). An athlete’s impairment was reported to have directly contributed to their injury in 8 of 65 cases (12.3%), while only 2 of 65 (3.1%) injuries were directly attributable to the athletes’ adaptive equipment.

Discussion

To our knowledge, this is the first study to report the incidence and characteristics of illnesses and injuries reported by elite athletes during a PAG or PPAG. We found that (1) approximately half of all illnesses reported by Team USA athletes in Santiago were respiratory illnesses, (2) rates of illness and injury were higher during the pre-opening ceremony period compared with the competition period and (3) some of the highest reported injury rates were in sports that are relatively or completely new to the Olympic/Paralympic programmes (breaking, surfing and Para taekwondo).

Respiratory illness rates returned to pre-Tokyo levels

Overall, between 3.2% (PAG) and 8.9% (PPAG) of all Team USA athletes reported a respiratory illness in Santiago, in comparison to only 0.4% (Olympic) and 1.1% (Paralympic) of Team USA athletes reporting a respiratory illness in Tokyo.2 3 The rates we observed in Santiago represent a return to the typical proportion of athletes reporting respiratory illnesses in previous Games (Olympic and Paralympic: 4.8%6 and 4.9%17 in Pyeongchang 2018, 1.9%7 and 4.4%11 in Rio 2016, 4.2%8 and 5.5%18 in Sochi 2014). Every Games environment is unique, both in geographical setting and local circumstances, and therefore, we cannot definitively conclude that the absence of Tokyo-level precautions is directly responsible for the return of elevated respiratory illness rates in Santiago. For example, between a quarter and half of the respiratory illnesses reported in Santiago were related to allergies or environmental factors, likely related to seasonal changes experienced by Team USA athletes moving from the northern to the southern hemisphere, several wildfires in the greater Santiago area during the Games and ongoing construction of the Athlete Village and venues during the Games. However, based on the previously published evidence of the effectiveness of precautions in preventing respiratory illness in Tokyo,2–4 it is reasonable to state that the absence of these precautions likely played some role in the increased rates observed in Santiago.

Team USA athletes competing at the PPAG were 2.5 times more likely to sustain an illness compared with Team USA athletes competing at the PAG. In particular, female Paralympic athletes were 2.7 times more likely to report an illness compared with male Paralympic athletes. Previous research from the Tokyo 20203 and Rio 201611 Summer Paralympic Games also reported a higher risk of illness among female Paralympic compared with male Paralympic athletes, and a recent study directly comparing Olympic and Paralympic athletes suggested that Paralympic athletes may be at greater risk of illness compared with Olympic athletes.19 Therefore, national sport delegations should consider reimplementing a number of the simpler precautions that were in place for the Tokyo 2020 Games, such as emphasising personal hygiene and masking. In fact, USOPC Sports Medicine staff did implement a number of these measures, such as masking and testing/isolation protocols, when cases of respiratory illness became apparent. Despite measures being taken once illness was apparent, consideration should also be taken going forward to use these measures with the goal of primary prevention.

Illness and injury incidence were highest during the pre-opening ceremony period

Previous multinational studies have reported higher injury (Rio 201620 and Tokyo 202021) and illness (Tokyo 20203) rates during the pre-opening ceremony period compared with the competition period, but these data have only been reported within Paralympic athlete populations. We found that illness and injury rates at both PAG and PPAG were between two and three times greater in the days leading up to the Opening Ceremony compared with the actual competition period. The replication of this finding across multiple studies and Games highlights the need for further investigation of the factors responsible for this higher pre-opening ceremony period incidence of illness and injury. For example, additional travel precautions may be necessary to prevent athletes from reporting an illness during their travels that results in the onset of illness symptoms during the pre-opening ceremony period. For injury, the increased incidence may reflect challenges in maintaining proper periodisation during the travel and arrival process for a Games. Interestingly, while injury incidence was greatest during the pre-opening ceremony period compared at PAG, injury incidence was greatest during actual competitions compared with training or other settings. Therefore, it is also possible that the higher incidence observed in the pre-opening ceremony period may simply reflect increased access to medical care, in which athletes report conditions that they have been managing on their own prior to the Games as soon as they arrive.

Incidence of injury in newer sports: breaking, surfing and Para taekwondo

The newer sports of breaking, surfing and Para taekwondo all ranked within the top three in terms of injury incidence within their respective Games. Surfing and Para taekwondo were both added by the IOC and International Paralympic Committee (IPC), respectively, to the sport programme for the Tokyo 2020 Olympic and Paralympic Games, while breaking will make its Olympic debut at the Paris 2024 Olympic Games. While some retrospective and cross-sectional epidemiological studies of breaking injuries exist,22 23 this is the first study to prospectively examine illness and injury incidence within this sport among elite athletes competing at a large-scale international competition. We found breaking to have the highest injury incidence of all sports across both Games, which in part reflects the small roster size of breaking, but also reflects the nature of the sport and the extreme physical demands placed on the athlete when participating.24 For Para taekwondo, data from both the Tokyo 2020 Paralympic Games21 and our present study of the Santiago 2023 PPAG have reported a high incidence of injury within the sport, with Para taekwondo having the second highest injury incidence at both Games. On the other hand, surfing ranked third highest in injury incidence during PAG, contrasting with data from Tokyo 2020,2 where surfing fell within the middle third among all sports in terms of injury incidence. Given the elevated injury risks associated with breaking, surfing and Para taekwondo, national sport delegations with athletes participating in these sports at upcoming international events must allocate ample resources to their medical teams to deliver the care necessary to athletes in these higher risk sports. In addition, as these sports mature, it is imperative that international federations and national governing bodies consider injury risk mitigation strategies in the development of competition rules, requirements and formats.

Limitations

While this study is the first to report the incidence and characteristics of illnesses and injuries reported by elite athletes during a PAG or PPAG, particularly in a ‘post-COVID’ environment, there are several key limitations to note. As with all injury epidemiological data, our findings are reliant on the medical providers accurately documenting all illness and injury evaluations during the Santiago 2023 PAG and PPAG into the USOPC IIS system. As such, future work is needed to continue to ensure accurate documentation of injuries and illnesses, as we noted a number of instances where variables were labelled as ‘unknown’ within our data. It is important to note that our data represent the illnesses and injuries of those Team USA athletes who sought care, and not necessarily representative of all illnesses and injuries sustained during the games in Santiago. Additionally, the epidemiological data presented in this study depict the experiences of athletes from a single country’s delegation during a single Games period (Santiago 2023 PAG and PPAG). As a result, both the point estimates and CIs for certain sports may have been influenced by small numbers of athletes or cases within those sports. Subsequent research is necessary to determine whether the trends identified in this study persist across other delegations with distinct characteristics from Team USA or in future Games with disparate geographical locations and local attributes. Additionally, we did not report injury or illness incidence during PPAG based on athlete impairment type. As certain sports are limited to only athletes with specific impairments, our sport-specific incidence likely represents an interaction of both sport and impairment-specific risks. Finally, since we did not track exposures at the event-type level and rather used ADs as our measure of exposure, we were not able to statistically compare illness and injury incidence between practices and competitions. Therefore, any differences in injury incidence based on injury setting may simply reflect differences in the number of practices and competitions rather than true differences in risk based on those settings.

Clinical implications

Our findings offer valuable insights for the medical staff of national sport delegations that can be used to prepare for and mitigate illness and injury risks in upcoming Olympic and Paralympic Games and other large, multisport international competitions. First, reinstating simpler precautions from the Tokyo 2020 Games, like emphasising personal hygiene and masking, is advisable. Medical teams should also monitor local environmental conditions that may exacerbate certain pre-existing conditions, such as allergies, among competing athletes. Moreover, implementing additional travel precautions to reduce illness transmission and reassessing training protocols during travel and arrival may minimise pre-opening ceremony illness and injury risks. Medical teams must be adequately equipped and prepared to address the specific needs of sports newer to the Olympic and Paralympic programmes that have elevated injury risks, like breaking, surfing and Para taekwondo. Finally, national and international sport governing bodies for these sports should leverage these data to identify opportunities for injury risk reduction within their respective sports.

Conclusions

In conclusion, our study sheds light on the incidence and characteristics of illnesses and injuries reported by Team USA athletes during the Santiago 2023 PAG and PPAG, marking the first report of such data from these events. We observed elevated respiratory illness rates compared with the Tokyo 2020 Games and identified higher incidence of both illness and injury during the pre-opening ceremony period. Considering these findings, adopting certain precautions from the Tokyo 2020 Games, such as emphasising personal hygiene and masking, may prove beneficial for illness prevention. Moreover, we identified elevated injury risks in newer sports like breaking, surfing and Para taekwondo, highlighting the importance of further research and medical preparedness for future international competitions that include these sports.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information. Data are available upon reasonable request. Request to access the data will be considered by the authors within the constraints of privacy and consent.

Ethics statements

Patient consent for publication

Ethics approval

This study was reviewed and approved by the Institutional Review Board at the University of North Carolina at Greensboro (IRB-FY22-218).

Acknowledgments

The authors thank the medical staff for Team USA and their efforts in documenting athlete medical encounters throughout the Santiago 2023 Pan American Games and Parapan American Games.

References

Supplementary materials

  • Supplementary Data

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Footnotes

  • X @travaldinho, @william_m_adams

  • Contributors All authors contributed to the study conception and design, data collection and interpretation. EGP analysed the data. All authors drafted the paper, provided revisions and contributed to the final manuscript. WMA is the guarantor.

  • Funding This study was funded in part by a research centre grant from the International Olympic Committee.

  • Disclaimer The views and opinions in this work are the authors’ own and not that of the United States Olympic & Paralympic Committee, or any of its members or affiliates.

  • Competing interests None declared.

  • 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.