• football
• virus
• illness
• training
• health

In early 2020, the world is facing a global emergency called COVID-19 (coronavirus disease 2019). On 11 March 2020, the WHO has declared the ‘Pandemic state’ calling the governments to take ‘urgent and aggressive action’ to delay and mitigate the peak of infection.

The seriousness of the situation is evidenced by the extreme uncertainty of the measures taken by the governments of the various countries to stem the pandemic spread.

From 8 March 2020, the Italian Government implemented extraordinary measures to decrease the pathogen spread, targeting social distancing between individuals. The law focused on closing the commercial business, limiting the sporting activities and decreasing the opportunity for social gatherings. The most important issue has been the sharp increase in the number of people infected which is causing a significant increase in acute respiratory failure cases (severe acute respiratory syndrome coronavirus 2 (SARS-COV-2)) and acute respiratory distress syndrome requiring hospital admission and intensive care treatment. Contrary from what was thought at the beginning, young people are also affected by the disease and can develop the severe respiratory conditions mentioned above.

Initially, despite the outbreak phenomenon, professional sports were not stopped, and on 11 March 2020, the first football player belonging to Italian Serie A tested positive to coronavirus. The day after other five players and a team doctor have been declared affected.

Since 8 March 2020, the Italian Serie A has been stopped until at least 3 April 2020, but, in the meanwhile, some clubs are requesting to resume the training activities not to lose physical fitness.

There is a strong opposition to this from Serie A team doctors: recently, unanimously, they have sent a letter to Lega Serie A to strongly advise not to resume football activity before the COVID-19 emergency has clearly improved.

According to a 1995’s Italian law, team doctors are in charge of his team footballers’ health, therefore, with this letter, the whole category wanted to take a strong position about this issue.

Even though football players might have a low risk of death as a consequence of an infection by COVID-19 because of their young age, they could nevertheless develop severe respiratory failure requiring hospital admission. Furthermore, football is a contact sport and football players are often in close contact with the teammates during their daily activities and camps. These factors put the players in a high risk of disease transmission.

Moreover, a significant number of insiders participate in daily training, greatly increasing the chances of infections as well.

For these reasons, the profession of footballer does not allow compliance with the normal protection rules recommended by WHO.

Nowadays, the Italian National Health System is facing the battle of a huge unbalance between the clinical needs of the population and the overall availability of resources overstretched by the demands of COVID-19 caseloads.1 In this context, the resuming of professional football can, therefore, put at risk the health of the football players who, in case of an injury or sickness, may not be ideally treated by hospitals overwhelmed by people affected by the COVID-19 or possibly the quality of other treatment could be decreased.

Moreover, this can cause further commitment to the healthcare system: it would be right to ask whether it is ethically correct.

Despite these arguments, likely the football world will soon try to resume activities.

Another important issue is that we cannot exclude that COVID-19 infection can cause chronic health consequences.

Some authors speculate that COVID-19 might generate consequences to organs such as the heart,2 the lung,3 the liver, the kidneys and to the blood and the immune system.4

The anatomical and physiological damage is supposed to be mediated by cytokines. Indeed, a specific cytokine profile, resembling a secondary haemophagocytic lymphohistiocytosis, is associated with COVID-19 disease.5 This condition, called ‘cytokine storm syndrome’ (CSS), may cause systemic inflammation, multiorgan failure and, if untreated, often death.6 A possible complication associated with the CSS is represented by endocarditis.

Some consequences could also be expected as a result of the drugs used during the treatments, such as ACE inhibitors, ibuprofen, other non-steroidal anti-inflammatory drugs and steroids.

Given the extreme mutability and unpredictability of the situation and the variety of clinical conditions caused by COVID-19, we cannot know which subjects could be burdened by these consequences. It is therefore legitimate to ask whether it is sufficient to contract COVID-19 or whether it is necessary to have manifested serious symptomatology.

In the first case, among our athletes, we cannot detect COVID-19 positive players and therefore we cannot protect others, given the incubation period and the scarce availability of testing kits. Therefore, we could not know if the athletes, at the time of return to training, will be healthy.

Finally, it is still not clear if contracting the virus can somehow protect against reinfection or future exacerbation. Bringing our athletes back to training could eventually still expose them to a new episode, with all the consequences it implies.

In this context of uncertainty and multiple possible answers to the phenomenon, it is necessary that the football medicine community will establish uniform safe conditions to resume sports activities in the near future,7 in observance with the principle of ‘maximal caution’.

The aim of this letter is a call for action for all the football medicine community to recommend to the football governance the maximal caution on the decision when to restart sport activity. Moreover, a specific protocol to check cardiological, pulmonary and, in general, systemic sequelae of COVID-19 before resuming sporting activities should be considered.