By Dr Omar Naji and Dr Irfan Ahmed

As the U.K prepares to “unlock” for business, the return of professionalised sport and the English Premier League (EPL) is seen as a watershed moment. It marks the start of a “new normal”, both in terms of how professionalised sport will need to operate financially and how it will need to adopt new medical safety protocols. The decision to return to sport, needs to weigh up the individual risks to players and their families and be informed by the latest medical advice. We discuss some of the key ethical issues facing athletes and SEM physicians, particularly those from the Black and Minority Ethnic (BME) group, and ask whether now is the right time to return to sport?

The EPL is the most-watched sports league in the world and its return on June 17^th signals the end of a 3-month break to the competition. Where the EPL leads, other sports will follow, as they demonstrate how workplaces can ensure “bio-secure” competition and training environments for the safety of all staff. For many athletes, the decision on whether to return to sport is a sensitive one that balances the current financial, competitive and psychological pressures of professionalised sport during a pandemic. There is currently no precedent for this and given the impact of COVID-19 on communities worldwide, this remains a sensitive issue.

Data published from studies in Europe and North America have shown that ethnic minorities are at a higher risk of severe COVID-19-related illness (1–3). This has been a significant cause of anxiety amongst some footballers, with several high-profile BME players such as Troy Deeney and N’Golo Kante deciding to delay a return to training, after citing health concerns to themselves or immediate family. While the relative risk of COVID-19-related severe illness is higher in the BME populations, the absolute risk of severe infection remains low in under-40s (who are otherwise healthy). Current theories suggest that access to healthcare, housing, and socioeconomic status may increase the risk of hospitalisation due to COVID-19 in BME populations (2). Despite these concerns, it is difficult to draw any direct comparisons from the published data to professional athletes. This is due to the fact that the current data is based on non-athlete, who have a higher rate of pre-existing health conditions, are older in age and have a lower baseline level of cardiopulmonary fitness.

SEM physicians will therefore need to adopt a case-by-case approach when assessing the risk to BME athletes. This approach should include a sensitive discussion about the risks that a return to sport may pose to the athlete, and members of their “social bubble”; particularly those with pre-existing conditions. It should also reflect the latest medical advice, as we continue to understand more about the long-term outcomes of COVID-19 and how this is related to ethnicity. We can learn from the example of cardiac screening, where international standards for investigation and reporting outcomes have helped to identify ethnicity-specific risk factors for sudden cardiac death in sport (4). By engaging in early conversations with athletes and eliciting their concerns, SEM physicians can help to share the rationale behind the current medical advice. This includes discussing whether guidance is based on current data from the COVID-19 pandemic or based on studies from previous coronavirus outbreaks (e.g. SARS) and where data is still awaiting.

Early studies have reported that the risk of COVID-19 related hospitalisation is approximately 2.5 per 100,000 population (4-wk period, U.S.A) in those ages 18-49, with an even lower risk of severe or critical infection (5). Although cardiac (6,7), thromboembolic and respiratory complications (8) have been reported in patients requiring Intensive Care Unit (ICU) treatment, we do not currently have any comparable data in professional athletic populations. Whilst we estimate this risk to be low, these complications have the potential to require intensive rehabilitation and impact players’ long-term careers. Players should also be made aware that we currently do not have any prospective studies available on whether COVID-19 infection is associated with long-term immunity or impacts on athletic performance.

The return of professional sport will be regarded as a positive step towards a ‘new normal’ in society, but it will need to do so sensitively and safely. Return-to-play protocols will need to factor in the latest scientific evidence and involve the highest standards of surveillance whilst also respecting players’ autonomy. Players of all ethnicities should have the opportunity to discuss how current return-to-play protocols may impact themselves or their “social bubble” on a case-by-case basis. SEM physicians will have a key role in advocating for players best interests and delivering the latest medical guidance and clinical advice. Future research will also be needed in this area, to better understand the potential role of ethnicity as a COVID-19 risk factor in professional athletes.

This manuscript was prepared by both authors. (Equal contribution)

Dr. Omar Naji is a Foundation Year 1 doctor, working in Watford. Dr. Naji completed his undergraduate degree from Barts and the London, where he developed an interest in Sport and Exercise Medicine (SEM) and completed an intercalated degree in SEM. Although at the beginning of his medical training, he is keen to pursue a career in SEM whilst also having a keen interest in diving and hyperbaric medicine. Email: omar.naji1@nhs.net.

Dr Irfan Ahmed is an ST4 registrar in Sport & Exercise Medicine (London deanery) and General Practitioner. He has a special interest in exercise medicine, VO2 max and has published on the role of SEM clinicians during the current COVID-19 pandemic.

Email: Irfan.ahmed5@nhs.net

References 

1. Office for National Statistics. Coronavirus (COVID-19) related deaths by ethnic group, England and Wales – Office for National Statistics [Internet]. 2020 [cited 2020 Jun 5]. Available from:
2. Public Health England. Disparities in the risk and outcomes from COVID-19 [Internet]. 2020 [cited 2020 Jun 14]. Available from:
3. Kirby T. Evidence mounts on the disproportionate effect of COVID-19 on ethnic minorities. Lancet Respir Med. 2020;8(6):547–8.
4. Harmon KG, et al. Incidence, Cause, and Comparative Frequency of Sudden Cardiac Death in National Collegiate Athletic Association Athletes: A Decade in Review. Circulation. 2015 Jul;132(1):10–9.
5. Garg S, et al. Hospitalization Rates and Characteristics of Patients Hospitalized with Laboratory-Confirmed Coronavirus Disease 2019 — COVID-NET, 14 States, March 1–30, 2020. MMWR Morb Mortal Wkly Rep 2020;69:458–464. DOI: http://dx.doi.org/10.15585/mmwr.mm6915e3external icon
6. Atri D, et al. COVID-19 for the Cardiologist: Basic Virology, Epidemiology, Cardiac Manifestations, and Potential Therapeutic Strategies. JACC Basic to Transl Sci [Internet]. 2020;5(5):518–36. Available from:
7. Shi S, et al. Association of cardiac injury with mortality in hospitalized patients with COVID-19 in Wuhan, China. JAMA Cardiol. 2020;
8. Hull JH, Lloyd JK, Cooper BG. Lung function testing in the COVID-19 endemic. Lancet Respir Med. 2020;