SAJSM 595 (COMMENTARTY).indd
POSITION STATEMENT
1 SAJSM VOL. 33 NO. 1 2021
Creative Commons Attribution 4.0 (CC BY 4.0) International License
Recommendations for athletes and COVID-19 vaccinations: A
South African Sports Medicine Association (SASMA) position
statement – Part 3
L Pillay,1,2,3,4 MBChB, MSc; J Patricios,2 MBBCh, MMedSci; DC Janse van Rensburg,1,5 MD, MMed, MSc, MBChB;
R Saggers,2,9 MBBCh, FCPaed, MMed; D Ramagole,1 MBChB, MSc; P Viviers,6,7,8 MBBCh, MMedSc; C Thompson,6,7,8
MBChB, MPhil; S Hendricks,10,11,12 PhD
1 Section Sports Medicine & Sport, Exercise Medicine and Lifestyle Institute (SEMLI), Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
2 Wits Sport and Health (WiSH), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
3 Premier Soccer League COVID-19 Chief Medical Officer, PSL, South Africa
4 Chief Medical Officer, Gauteng Lions Cricket, South Africa
5 Medical Board Member, World Netball, Manchester, UK
6 Campus Health Service, Stellenbosch University, South Africa
7 Institute of Sport and Exercise Medicine, Division of Orthopaedic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch
University, South Africa
8 FIFA Medical Centre of Excellence, South Africa
9 Department of Paediatrics and Child Health, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
10 Division of Physiological Sciences, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, South Africa
11 Health through Physical Activity, Lifestyle and Sport (HPALS) Research Centre, Department of Human Biology, Faculty of Health Sciences, University of Cape
Town. South Africa
12 Carnegie Applied Rugby Research (CARR) centre, Institute for Sport Physical Activity and Leisure, Leeds Beckett University, Leeds, England
Corresponding author: L Pillay (drpillay@absamail.co.za)
Since the classification of COVID-19 as a pandemic
by the World Health Organization (WHO) on
March 11 2020,[1] the entire world has been
embroiled in dealing with this disease. Several
countries around the world have experienced surges in infection
numbers or “waves” of COVID-19 infections. These waves at
separate times in different countries made planning travel and
events difficult.[2] It necessitated various levels of lockdown
around the world, as determined by each country’s governmental
responses to COVID-19 activity. All levels of sporting activities,
from professional to school, have been affected for sustained
periods. At the start of the pandemic, to reduce the transmission
of COVID-19, lockdown meant that sports training and
competition had to be cancelled.
The primary non-pharmaceutical interventions against the
spread of COVID-19 infection remain: (1) hand hygiene, (2)
respiratory hygiene, (3) mask-wearing, and (4) social and physical
distancing (at gatherings in closed and open spaces). Many
countries have allowed professional sport to return with strict
infection-risk mitigating procedures in place, as approved by
their respective governments. As our understanding of COVID-
19 transmission advanced, and to reduce any further negative
effects, professional sport was gradually re-introduced under
highly controlled environments. These environments were
termed ‘bio-secure environments’ (BSE) or bio-bubbles.
Bio-secure environments (BSE)
Presently, certain sports in South Africa (such as cricket and
rugby) are competing within bio-secure environments–
commonly referred to as bio-bubbles. Bio-bubbles are possible
in these sports as they have defined competitions (for example,
the initial post-lockdown resumption of the Premier Soccer
League (PSL) and the British and Irish Lions Rugby Tour)). Bio-
bubbles cannot be achieved in a league setting in which teams
play over a protracted period of time. Other negative aspects of
bio-bubbles include the cost involved in hosting these
competitions and the mental anxiety for all those involved. [3],[4]
As an example, football in South Africa completed the
2019/2020 season in a bio-bubble. The PSL completed the
2020/2021 season outside of a BSE but with strict risk -
mitigating health protocols in place.
Vaccinations
On 31 December 2020, the World Health Organisation (WHO)
validated the first COVID-19 vaccination – an mRNA vaccine
that was subsequently approved for emergency use. [5]
Subsequently, several vaccines are now approved for
emergency use in South Africa. Since then, data have emerged
validating the efficacy of vaccinations in decreasing both
transmission and COVID-19 disease severity.[6]
The function of vaccines in the times of COVID-19 is to
achieve the following:
1. Minimise the risk of contracting COVID-19.
2. If there is a breakthrough infection, it reduces the illness
to mild symptoms and prevents progression to severe
disease which may include hospitalisation and ventilatory
support (such as High Flow Nasal Cannula Oxygen
therapy and polymasks).
3. If there is a breakthrough infection, to reduce the length
of time of being infective and reducing the spread of the
virus.
The COVID-19 pandemic initially led to the shutdown of all
sport at a high cost to both the economy and athlete health. As
risk-mitigating protocols evolved and were implemented, the
playing of sport returned slowly to normal. The introduction of
COVID-19 vaccinations enhances the means of protection and
risk management for all. This South African Sports Medicine
Association position statement provides recommendations for
the vaccination of athletes.
Keywords: covid-19, vaccination, athletes, recommendations,
sports
S Afr J Sports Med 2021; 33:1-3. DOI: 10.17159/2078-516X/2021/v33i1a12557
mailto:drpillay@absamail.co.za
http://dx.doi.org/10.17159/2078-516X/2021/v33i1a12557
https://orcid.org/0000-0002-5341-6080
https://orcid.org/0000-0002-8353-3376
https://orcid.org/0000-0001-6593-8049
https://orcid.org/0000-0002-6829-4098
https://orcid.org/0000-0002-3416-6266
https://orcid.org/0000-0003-1058-6992
https://orcid.org/0000-0001-6682-3438
POSITION STATEMENT
SAJSM VOL. 33 NO. 1 2021 2
COVID-19 vaccinations have been shown to significantly
protect against poor disease outcomes.[7] Apart from the
primary aim of protecting athlete health, an important
advantage of an athlete-dedicated vaccine programme is the
facilitation of domestic and international travel, allowing major
tournaments and leagues to recommence without the need for
a bio-bubble. Being vaccinated may also reduce travel stress. [8]
Despite this however, challenges remain. All team members
(athletes and support staff) should be fully vaccinated. If all
team members are vaccinated, the risk of contracting and
spreading COVID-19 in the team environment and community
is significantly reduced. This limits the need for bio-bubbles.
Certain countries may still require proof of a negative COVID -
19 Polymerase Chain Reaction (PCR) test to avoid quarantining
in that country.[9]
Vaccination rollout in South Africa
The South African Vaccine Rollout Programme has been
implemented in phases. Phase One began on 17 February 2021
and involved healthcare workers as part of the Sisonke Trial.
[10],[11] The South African Health Products Regulatory Authority
(SAHPRA) approved the Johnson and Johnson COVID-19
vaccine on 31 March 2021.[12] Further vaccines have
subsequently been approved by SAHPRA (Pfizer, Sinovac) –see
Table 1. Some athletes competing in major international events,
such as the Olympic Games and the British and Irish Lions
Rugby Tour, were also enrolled in this trial. The targeted
rollout approach for the general population was then extended
to the sixty years and older age groups first, to limit severe
disease and death. Thereafter, individuals with chronic
comorbid medical conditions (e.g. diabetes and hypertension)
received the vaccination. Phase Two involved essential
workers (teachers, police members), and those in congregated
settings (for example, religious leaders). The age limit was later
expanded to those over 40 years of age. Phase Three involved
targeting the remainder of the population, in order to achieve
a national target of 67%. Most athletes fell into this latter age
group.
The nature of professional sport involves training and
competing at high-intensity levels. Team sports involve not
only interaction with team mates, but also the technical,
medical and administrative staff. Individual sports involve
athlete interaction with coaching and medical staff. Complying
with non-pharmaceutical interventions (proper mask-wearing,
hand sanitising and respiratory hygiene) as risk mitigating
measures remain vital. Vaccination of athletes further enhances
protection against contracting the COVID-19 virus and should
be strongly encouraged.
Table 1 displays the availability and approval status of
vaccinations in South Africa. It is important to note that
presently SAHPRA has approved the Pfizer and Johnson and
Johnson vaccines which are part of the nationwide rollout.
These have been approved for those eighteen years and older.
Sinovac has been approved for children twelve years and older.
Others have been approved, but not rolled out in South Africa
(Astra Zeneca) and others are in the process of being approved.
Recommendations for the vaccination of athletes
1. Allow flexible training plans for three days post-
vaccination, as one cannot predict when vaccine-related
side effects will occur. Common side effects include
headaches, myalgia, fatigue, fever and pain at the site of
injection which can typically last two to three days. [13],[14]
2. On the day of vaccination, Paracetamol (given at one gram
three times a day) can be taken to reduce side effects, if
these are experienced.
3. If there is a concern regarding allergies and an athlete is
prone to severe allergic reactions, it is advisable to visit a
vaccination site where medical staff are available to
attend to these allergic reactions. [15]
4. Exercise may be performed on the day of vaccination but
should be limited to low-intensity sessions. Avoid
medium- to high-intensity exercise for at least three
days.[13]
5. Should an athlete experience any vaccine-related side
effects, then exercise should be avoided until these
symptoms resolve.
6. Should an athlete experience persistent or worsening
vaccine-related side effects continuing for five days post-
vaccination, then an active COVID-19 infection must be
excluded with a PCR test. This should be reported to
SAHPRA. The athlete should consult a medical doctor. [16]
7. Should an athlete receive the Pfizer vaccine, and within 7-
14 days post-vaccination experience fever, lethargy,
shortness of breath and chest pain, myocarditis/
pericarditis these symptoms must be considered and the
athlete excluded from physical activities (usually with
haematological investigations and an electrocardiogram –
ECG). It may also warrant a referral to a cardiologist. [17]
8. If an athlete has recently been infected with COVID -19,
he/she should be vaccinated at least four weeks after de -
isolation or symptom resolution.[18]
Table 1. Available vaccines and status of approval in South Africa by South African Health Products Regulatory Authority (SAHPRA)[13]
Manufacturer Vaccine Platform Used in South Africa
Vaccines approved by SAHPRA for use in South Africa
AstraZeneca ChAdOx1 nCov-19 (AZD1222/Covishield) Viral vector No
Pfizer/BioNTech BNT-162b2 mRNA Yes
Johnson & Johnson AD26.COV2.S Viral vector Yes
Sinovac Coronavac Inactivated Not as yet
Applications submitted and awaiting approval from SAHPRA
Gamaleya Research Institute Sputnik V *rolling review by SAPHRA No
No application for approval in South Africa (but have WHO Emergency Use Listing)
Sinopharm BBIBP-CorV Inactivated N/A
Moderna mRNA-1273 mRNA N/A
Novavax NVX-CoV2373 Recombinant protein N/A
POSITION STATEMENT
3 SAJSM VOL. 33 NO. 1 2021
9. Presently, vaccine choice is limited due to SAHPRA
approval and availability. In principle, all vaccines can be
used; indeed, any vaccination is better than none. Each
vaccine’s efficacy and pitfalls should be considered if
options are available.
10. As the science evolves, booster vaccinations may become
available. This will be determined by the time of the
vaccine effect waning and the type of vaccine initially
received. There will ongoing and evolving evidence and
approvals as more research is undertaken.
Considerations for special populations
Youth: Sinovac has been recently approved by SAHPRA for
those 12 years and older.[19]
Pregnancy: Vaccinations can be administered to pregnant (at
any stage of pregnancy) and lactating mothers. [20]
Conclusion
Vaccinating the athletic population is vital for the continuation
of team and individual sport in a safe manner. Vaccinations
reduce the risk of contracting and transmitting COVID-19, and
allows for events to continue uninterrupted.
Conflicts of interest and source of funding: The authors
declare that they have no conflict of interest and no source of
funding.
Author contributions:
LP conceptualised, drafted and finalised the manuscript.
DJvR, DR, JP, CT, PV, RS and SH critically reviewed the drafts.
All involved approved the final version prior to submission.
References
1. World Health Organization. WHO Director-General’s
opening remarks at the media briefing on COVID-19 – 11
March 2020. https://www.who.int/director-
general/speeches/detail/who-director-general-s-opening-
remarks-at-the-media-briefing-on-covid-19---11-march-2020
(accessed 12 September 2021).
2. Worldometer. Coronavirus Worldwide Graphs. 2021.
https://www.worldometers.info/coronavirus/worldwide-
graphs/ (accessed 12 September 2021).
3. Supersport. Manners & Masks – Financial realities of cricket
bio-bubbles.https://supersport.com/cricket/news/
200904_Manners_Masks_Financial_realities of cricket in
biobubbles. 2020 (accessed 12 September 2021).
4. Outlook. Paddy Upton warns of mental illnesses due to
extended stay in bio-bubble. 2021.
https://www.outlookindia.com/website/story/sports-news-
paddy-upton-warns-of-mental-illnesses-due-to-extended-
stay-in-bio-bubble/372602 (accessed 12 September 2021).
5. World Health Organization. WHO issues its first emergency
use validation for a COVID-19 vaccine and emphasizes need
for equitable global access. 2020.
https://www.who.int/news/item/31-12-2020-who-issues-its-
first-emergency-use-validation-for-a-covid-19-vaccine-and-
emphasizes-need-for-equitable-global-access (accessed 12
September 2021).
6. Wise J. Covid-19: Pfizer BioNTech vaccine reduced cases by
94% in Israel, shows peer reviewed study. BMJ 2021; 372
:n567. [doi: 10.1136/bmj.n567] [PMID: 33632676].
7. Scobie HM, Johnson AG, Suthar AB, et al. Monitoring
incidence of COVID-19 cases, hospitalizations, and deaths, by
vaccination status - 13 U.S. jurisdictions, April 4–July 17, 2021.
MMWR Morb Mortal Wkly Rep 2021;70(37):1284–1290. [doi:
10.15585/mmwr.mm7037e1] [PMID: 34529637].
8. Pavli A, Maltezou HC. COVID-19 vaccine passport for safe
resumption of travel. J Travel Med 2021;28(4):taab079. [doi:
10.1093/jtm/taab079] [PMID: 34008004].
9. South Africa. National Institute for Communicable Diseases.
COVID-19 vaccine rollout strategy FAQ. 2021.
https://www.nicd.ac.za/covid-19-vaccine-rollout-strategy-
faq/#:~:text=The%20vaccines%20will%20be%20rolled,and%20pe
rsons%20over%2040%2Dyears. (accessed 12 September 2021).
10. South African Medical Research Council. Sisonke (TOGETHER)
study. 2021. http://sisonkestudy.samrc.ac.za/ (accessed 12
September 2021).
11. South African Health Product Regulatory Authority. SAHPRA
update on vaccine approvals. 21 June 2021.
https://www.sahpra.org.za/press-releases/sahpra-update-on-
vaccine-approvals/ (accessed 12 September 2021).
12. South African Health Product Regulatory Authority. SAHPRA
registers the COVID-19 vaccine Janssen. AD26.COV2-S
[Recombinant] with conditions. 2021.
https://www.sahpra.org.za/press-releases/sahpra-registers-the-
covid-19-vaccine-janssen/ (accesed 12 September 2021).
13. Hull JH, Schwellnus MP, Pyne DB, et al. COVID-19 vaccination
in athletes: ready, set, go… Lancet Respir Med 2021;9(5):455-456.
[https://doi.org/10.1016/S2213-2600(21)00082-5] [PMID:
33556316].
14. National Institute for Communicable Diseases. COVID-19
vaccine side-effects FAQ. 2021. https://www.nicd.ac.za/covid-
19-vaccine-side-effects-faq/ (accessed 12 September 2021).
15. Peter J. COVID-19 vaccination: Recommendations for
management of patients with allergy or immune-based diseases.
S Afr Med J 2021;111(4):291-294.
[doi: 10.7196/SAMJ.2021.v111i4.15576] [PMID: 33944757].
16. National Institute for Communicable Diseases. COVID-19
vaccination: Reporting adverse effects FAQ. 2021.
https://www.nicd.ac.za/covid-19-vaccination-reporting-
adverse-effects-faq/ (accessed 12 September)
17. World Health Organization. COVID-19 subcommittee of the
WHO Global Advisory Committee on Vaccine Safety (GACVS)
reviews cases of mild myocarditis reported with COVID-19
mRNA vaccines. 2021. https://www.who.int/news/item/09-07-
2021-gacvs-guidance-myocarditis -reported with covid-19-
mrna-vaccines (accessed 12 September 2021)
18. SA Coronavirus. Ministerial Advisory Committee on COVID-19
vaccines. (VMAC). 2021.
https://sacoronavirus.co.za/2021/06/24/ministerial-advisory-
committee-on-covid-19-vaccines-vmac/ (accessed 12 September).
19. South African Health Product Regulatory Authority. SAHPRA
authorises the Coronavac vaccine with conditions. 2021.
https://www.sahpra.org.za/press-releases/sahpra-authorises-
the-coronavac-vaccine-with-conditions/ (accessed 12 September
2021).
20. National Institute for Communicable Diseases. Vaccination of
pregnant and breast feeding women (August update). 2021.
https://www.nicd.ac.za/vaccination-of-pregnant-and-
breastfeeding-women-august-update/ (accessed 12 September
2021)
https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020
https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020
https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020
https://www.worldometers.info/coronavirus/worldwide-graphs/
https://www.worldometers.info/coronavirus/worldwide-graphs/
https://supersport.com/cricket/news/%20200904_Manners_Masks_Financial_realities%20of%20cricket%20in%20biobubbles
https://supersport.com/cricket/news/%20200904_Manners_Masks_Financial_realities%20of%20cricket%20in%20biobubbles
https://supersport.com/cricket/news/%20200904_Manners_Masks_Financial_realities%20of%20cricket%20in%20biobubbles
https://www.outlookindia.com/website/story/sports-news-paddy-upton-warns-of-mental-illnesses-due-to-extended-stay-in-bio-bubble/372602
https://www.outlookindia.com/website/story/sports-news-paddy-upton-warns-of-mental-illnesses-due-to-extended-stay-in-bio-bubble/372602
https://www.outlookindia.com/website/story/sports-news-paddy-upton-warns-of-mental-illnesses-due-to-extended-stay-in-bio-bubble/372602
https://www.who.int/news/item/31-12-2020-who-issues-its-first-emergency-use-
https://www.who.int/news/item/31-12-2020-who-issues-its-first-emergency-use-
https://www.who.int/news/item/31-12-2020-who-issues-its-first-emergency-use-
doi:%2010.1136/bmj.n567
doi:%2010.15585/mmwr.mm7037e1
doi:%2010.15585/mmwr.mm7037e1
doi:%2010.1093/jtm/taab079
doi:%2010.1093/jtm/taab079
https://www.nicd.ac.za/covid-19-vaccine-rollout-strategy-faq/#:~:text=The%20vaccines%20will%20be%20rolled,and%20persons%20over%2040%2Dyears.
https://www.nicd.ac.za/covid-19-vaccine-rollout-strategy-faq/#:~:text=The%20vaccines%20will%20be%20rolled,and%20persons%20over%2040%2Dyears.
https://www.nicd.ac.za/covid-19-vaccine-rollout-strategy-faq/#:~:text=The%20vaccines%20will%20be%20rolled,and%20persons%20over%2040%2Dyears.
http://sisonkestudy.samrc.ac.za/
https://www.sahpra.org.za/press-releases/sahpra-update-on-vaccine-approvals/
https://www.sahpra.org.za/press-releases/sahpra-update-on-vaccine-approvals/
https://www.sahpra.org.za/press-releases/sahpra-registers-the-covid-19-vaccine-janssen/
https://www.sahpra.org.za/press-releases/sahpra-registers-the-covid-19-vaccine-janssen/
https://doi.org/10.1016/S2213-2600(21)00082-5
https://www.nicd.ac.za/covid-19-vaccine-side-effects-faq/
https://www.nicd.ac.za/covid-19-vaccine-side-effects-faq/
doi:%2010.7196/SAMJ.2021.v111i4.15576
https://www.nicd.ac.za/covid-19-vaccination-reporting-adverse-effects-faq/
https://www.nicd.ac.za/covid-19-vaccination-reporting-adverse-effects-faq/
https://www.who.int/news/item/09-07-2021-gacvs-guidance-myocarditis%20-reported%20with%20covid-19-mrna-vaccines
https://www.who.int/news/item/09-07-2021-gacvs-guidance-myocarditis%20-reported%20with%20covid-19-mrna-vaccines
https://www.who.int/news/item/09-07-2021-gacvs-guidance-myocarditis%20-reported%20with%20covid-19-mrna-vaccines
https://sacoronavirus.co.za/2021/06/24/ministerial-advisory-committee-on-covid-19-vaccines-vmac/
https://sacoronavirus.co.za/2021/06/24/ministerial-advisory-committee-on-covid-19-vaccines-vmac/
https://www.sahpra.org.za/press-releases/sahpra-authorises-the-coronavac-vaccine-with-conditions/
https://www.sahpra.org.za/press-releases/sahpra-authorises-the-coronavac-vaccine-with-conditions/
https://www.nicd.ac.za/vaccination-of-pregnant-and-breastfeeding-women-august-update/
https://www.nicd.ac.za/vaccination-of-pregnant-and-breastfeeding-women-august-update/