Infographic Br J Sports Med: first published as 10.1136/bjsports-2020-103751 on 17 January 2021. Downloaded from Infographic. COVID-19 RT-­PCR testing for elite athletes Alan Rankin ‍ ‍ ,1,2 Andrew Massey ‍ ‍ ,3 Éanna Cian Falvey ‍ ‍ ,4,5 Todd Ellenbecker,6 Peter Harcourt,7 Andrew Murray ‍ ‍ ,8,9 Denis Kinane,10 Bert Niesters,11 Nigel Jones,12 Rhodri Martin,13,14 Michael Roshon,15 Michael Edmund David McLarnon ‍ ‍ ,16 James Calder,17 Dionisio Izquierdo,18 Babette M Pluim ‍ ‍ ,19,20 Niall Elliott ‍ ‍ ,21 Neil Heron ‍ ‍ 22 http://bjsm.bmj.com/ on September 29, 2021 by guest. Protected copyright.

This infographic outlines evidence-based­ implementation and interpretation of COVID-19 AND RT-PCR TESTING recommendations on COVID-19 reverse testing. The current gold standard of testing is transcriptase PCR (RT-PCR)­ testing in RT-­PCR testing.4–6 The test is highly elite sport settings, aiming to protect sensitive and specific to SARS-­CoV-2 personal and population health, and PREVENTION IS BEST viral RNA in laboratory conditions.2 Test acknowledging resources and expertise Interventions to prevent COVID-19 trans- results should be interpreted on the basis that are often available in elite sport. mission should be implemented consis- of the pretest probability, previous test Public health recommendations vary by tently1 2 and should include results and clinical history. Test sensi- country and region, and protocol deci- ►► Effective hand hygiene. tivity and specificity will rely on the (1) sions should be made in consultation ►► Physical distancing: athletes should quality and location of swabbing; (2) with relevant public health authorities. minimise discretionary social contacts testing equipment and reagents, and (3) and maintain a distance of at least one laboratory expertise. 7 FORM AN EXPERT GROUP metre from others. Close contacts to a positive-testing­ An expert, multidisciplinary group with ►► Wearing a mask at all times when athlete should be isolated and proceed 3 input from clinical virology, microbi- around others, especially indoors. with daily monitoring for symptoms ology, public health, infectious diseases ►► Prioritising outdoor over indoor and temperature, and where available and sports medicine provides optimal activity where possible. testing. If the contact is asymptomatic

818 Rankin A, et al. Br J Sports Med July 2021 Vol 55 No 14 Infographic Br J Sports Med: first published as 10.1136/bjsports-2020-103751 on 17 January 2021. Downloaded from and COVID-19 RT-­PCR tests are nega- For this reason, repeat PCR screening in Acknowledgements The authors cknowledge tive at 7 hours of follow-­up, the close asymptomatic athletes is not routinely the support and guidance provided by the UK Home contact could be considered for a return recommended for 90 days postinfection. Institute of Sport Medical and support staff, particularly from the Sport Institute of Northern Ireland. to sport, depending on discussions with Repeat testing can stratify whether viral local public health authorities. load is decreasing and may inform deci- Collaborators Science and medical support staff at the UK Home Institutes of Sport and particularly at the TESTING AND ELITE ATHLETE sions to isolate a patient beyond 10 days Sport Institute of Northern Ireland. in some cases. In the event an athlete has GATHERINGS Contributors The infographic idea was conceived by Prior to a gathering of elite athletes, for been retested within 90 days, consider AR and NH and then developed by all authors; AR and example, at a training camp or compe- their Ct value. When Ct is >35 and the NH produced the initial infographic, which was then tition, all athletes should have regular patient’s symptoms have resolved, infec- revised by all authors; all authors approved the final 6 version of the infographic. symptom checks and should undergo tivity is unlikely. RT-­PCR or other screening for the Funding The authors have not declared a specific RETURN TO SPORT FOR A COVID-19 grant for this research from any funding agency in the virus. For the first gathering, testing 6 public, commercial or not-­for-­profit sectors. and 3 days prior to the event is recom- CONFIRMED CASE Competing interests None declared. mended, as well as testing as close Following infection, there should be a to the event as logistically possible, graduated return to sport, guided by Patient consent for publication Not required. ideally within 48 hours of the meeting. professional advice which may vary based Provenance and peer review Not commissioned; Interval (eg, weekly) PCR testing for on the severity of the illness, the demands externally peer reviewed. the duration of the gathering should be of the sport and logistical factors.8–10 Addi- This article is made freely available for use in considered. tional cardiac testing should be consid- accordance with BMJ’s website terms and conditions ered based on the severity of illness.11 for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may use, download MANAGING A POSITIVE TEST 1 and print the article for any lawful, non-­commercial Positive tests should be managed Sports Medicine, SportNI Sports Institute, purpose (including text and data mining) provided Newtownabbey, UK according to national and local public 2 that all copyright notices and trade marks are Sports Medicine NI, Belfast, UK retained. health guidance, but elite sport can often 3Medical and Anti-­Doping Department, Federation provide additional medical and testing Internationale de Football Association, Zurich, Zürich, © Author(s) (or their employer(s)) 2021. No commercial support. The positive case, as well as all Switzerland re-use­ . See rights and permissions. Published by BMJ. 4 close contacts, should be isolated as soon Sport Medicine Department, World Rugby, Dublin, as possible, and contact tracing should be Ireland 5Department of Medicine, University College Cork, undertaken. Cork, Ireland To cite Rankin A, Massey A, Falvey ÉC, et al. 6 If an asymptomatic athlete tests posi- ATP Medical Services, Ponte Vedra, Florida, USA Br J Sports Med 2021;55:818–820. tive in screening, they should be isolated 7Australian Football League, Docklands, Victoria, Accepted 5 January 2021 but retested to ascertain whether the Australia 8St Andrew’s House Edinburgh, Scottish Government Published Online First 17 January 2021 result represents a true or false posi- Sport and Physical Activity Policy Team, Edinburgh, UK Br J Sports Med 2021;55:818–820. 9 tive. False positives are less likely when Sports Medicine, Scottish Institute of Sport, Stirling, UK doi:10.1136/bjsports-2020-103751 the prevalence of COVID-19 is high. 10Department of Immunology, University of Bern, Bern, Switzerland ORCID iDs http://bjsm.bmj.com/ In a symptomatic individual, a posi- 11 tive result is considered a true posi- Microbiology, University of Groningen, Groningen, The Alan Rankin http://orcid.​ ​org/0000-​ ​0001-5132-​ ​1937 Netherlands Andrew Massey http://orcid.​ ​org/0000-​ ​0002-8253-​ ​ tive. Careful attention should be paid 12Medical Department, British Cycling, Manchester, UK 932X to the PCR cycle threshold (Ct) and 13Sports Medicine, Sport Wales, Cardiff, UK Éanna Cian Falvey http://orcid.​ ​org/0000-​ ​0003-3961-​ ​ 14 the gene expression of the result, as Cwm Taf Morgannwg University Health Board, 1805 this correlates strongly with cultivable Abercynon, UK Andrew Murray http://orcid.​ ​org/0000-​ ​0003-3327-​ ​8028 15Medicine, USA Cycling, Colorado Springs, Colorado, virus.4 A test with a high Ct (>30, Michael Edmund David McLarnon http://orcid.​ ​org/​ USA 0000-0002-​ ​9478-8569​ and especially >35) may not indicate 16 School of Medicine, Dentistry and Biomedical Babette M Pluim http://orcid.​ ​org/0000-​ ​0003-0655-​ ​ on September 29, 2021 by guest. Protected copyright. 4 5 current infectivity, although the viral Sciences, Queen’s University Belfast, Belfast, UK 8980 17 load may rise in subsequent days. Trauma and Orthopaedics, Chelsea and Westminster Niall Elliott http://orcid.​ ​org/0000-​ ​0002-5394-​ ​975X Hospital, London, UK Neil Heron http://orcid.​ ​org/0000-​ ​0002-4123-​ ​9806 18Public Health/SEM, Barts Health NHS Trust, London, INTERPRETING A NEGATIVE TEST IN AN UK ATHLETE 19Faculty of Health Sciences, University of Pretoria, If an athlete has symptoms indicative Pretoria, South Africa REFERENCES 20 of coronavirus (eg, loss of taste/smell, AMC/VUmc IOC Research Center of Excellence, 1 Toresdahl BG, Asif IM. Coronavirus disease 2019 (COVID-19): considerations for the competitive athlete. dry cough or fever) but test results are Amsterdam Collaboration on Health & Safety in Sports (ACHSS), Amsterdam, The Netherlands Sports Health 2020;12:221–4. negative, repeat testing is recommended 21Sports Medicine, Sport Scotland Institute of Sport, 2 Watson J, Whiting PF, Brush JE. Interpreting a covid-19 to exclude a false negative, especially if Stirling, UK test result. BMJ 2020;369:m1808. there is a high prevalence of COVID-19 22Department of Family Practice, Queen’s University 3 Eikenberry SE, Mancuso M, Iboi E, et al. To mask or not activity. An alternative diagnosis with Belfast, Belfast, UK to mask: modeling the potential for face mask use by the general public to curtail the COVID-19 pandemic. testing for other viral aetiologies should Correspondence to Dr Neil Heron, Department of Infect Dis Model 2020;5:293–308. also be considered. Unusual test results Family Practice, Queen’s University Belfast, Belfast BT7 4 Singanayagam A, Patel M, Charlett A, et al. Duration should be discussed within the expert 1NN, UK; neilheron@​ ​yahoo.co.​ ​uk of infectiousness and correlation with RT-PCR­ group. Twitter Andrew Massey @andy_massey, Andrew cycle threshold values in cases of COVID-19, Murray @docandrewmurray, Michael Edmund David England, January to may 2020. Euro Surveill McLarnon @mmclarnon98, Dionisio Izquierdo 2020;25:2001483. RETESTING POST-COVID INFECTION @DrDionisioizq, Babette M Pluim @docpluim, 5 Group SRA. Interpretation of PCR results and Viral RNA can persist in individuals Niall Elliott @dundeesportsmed and Neil Heron infectivity, 2020. Available: https://​covid-19.​ ​sciensano.​ beyond infectivity for several months.4–6 @neilSportDoc be/sites/​ ​default/files/​ ​Covid19/30300630_​ ​Advice_​

Rankin A, et al. Br J Sports Med July 2021 Vol 55 No 14 819 Infographic Br J Sports Med: first published as 10.1136/bjsports-2020-103751 on 17 January 2021. Downloaded from

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