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As high school and youth sports leagues return to action -- some for the first time since 2019 -- national medical societies and committees have tinkered with existing guidelines to prevent COVID-19 spread and issued some new calls. But, given the wide variance in local situations and vaccination rates, they are largely avoiding new national guidance for what promises to be an informative fall season.

"The challenge is every jurisdiction has different rules, so putting out national guidelines is a little tricky," said Amy Powell, MD, president of the American Medical Society for Sports Medicine (AMSSM). "So that's where organizationally we have found it a little hard to weigh in."

"[The landscape] is so dynamic and there are a lot of different societies involved focusing on athletes at different age levels," said Jeffrey Hsu, MD, PhD, a sports cardiologist at UCLA Health.

Most high school teams have been practicing for a couple weeks, while many youth leagues just launched. This marks only the second season that most of these leagues have operated since the pandemic shut down play early in the 2020 spring season.

During this year's spring season, the leagues had CDC, American Academy of Pediatrics (AAP), and American College of Sports Medicine (ACSM) guidelines to follow. However, the landscape has since changed and it continues to evolve. Pandemic metrics now vary wildly even across states, leaving sports officials facing disparate climates.

What seems the same is the desire to let the kids play. While fall sports were largely canceled or postponed last year, this fall "we still want kids to participate in activities that are good for them mentally and physically with athletics," said Susannah Briskin, MD, a member of the AAP Council on Sports Medicine and Fitness Executive Committee.

"None of these guidelines are saying we should not have team sports," said Hsu, an editorial team member for the ACC.org Sports and Exercise Cardiology section. "We all realized that's going to be a tough thing to try to sell, and we realize that's also not beneficial."

But, while many are proceeding as if this were a typical fall, "we're not really back to normal," said Jon Solomon, editorial director of Aspen Institute's .

Therefore, experts have released guidance that they hope maximizes the health of everyone involved (athletes, coaches, parents, other fans, and referees), while allowing kids to play.

The AAP's Council on Sports Medicine and Fitness updated in early August. The group is asking participants to wear masks whenever possible and to get vaccinated if they are 12 and older. "Outdoors, people should be spacing out; we still don't want people sharing water bottles," Briskin noted. Spectators should also don masks, even outdoors. In addition, they are recommending that "decisions be made on a local level when considering cancellations, delays, or limitations," according to the guidance.

That same month, the AMSSM paired up with the to update their cardiopulmonary for infected high school athletes returning to play. That "timeline should be individualized and is based on numerous factors including baseline fitness, severity and duration of COVID-19 symptoms, and tolerance to progressive levels of exertion," they wrote. "These guidelines were based on expert opinion and emerging clinical experience but lacked scientific data," they noted.

There are some emerging data, however. "Eight or 10 months ago sports medicine physicians were absolutely terrified of myocarditis," said Powell, a team doctor for the University of Utah and a local high school. But evidence from new trials since then has calmed them, experts said. "In general we feel much more comfortable recognizing that cardiac abnormalities in COVID are real but rare," Powell added.

The AMSSM also worked with the National Collegiate Athletic Association (NCAA) to draft guidelines .

These are the only medical society guidelines drafted or updated since the spring, experts confirmed. ACSM supports the AAP and AMSSM guidance, said Keri Denay, MD, an ACSM fellow.

"I think they're more than appropriate," Denay said of the cardipulmonary guidelines in particular. "At least this gives us a starting point on which to start our evaluatons and return to play decisions."

The ACSM joined the AAP, AMSSM, and five other medical societies in promoting an initiative sanctioned by the Biden administration in early August, calling for providers to ask pediatric patients 12 and up about their vaccination status during sports physicals. "All athletes who do not have contraindications should be vaccinated against COVID-19 as soon as they are eligible," according to a "We encourage all youth sports and state athletic associations to ... assist with providing educational opportunities about the vaccine."

New CDC Guidance Fuels Sports Recommendations

Some of the new guidelines are based on CDC recommendations, experts said. The agency issued in early August, which featured sections on sports.

"Schools should consider implementing screening testing for participants who are not fully vaccinated up to 24 hours before sporting, competition, or extracurricular events. Schools can use different screening testing strategies for lower-risk sports. High-risk sports and extracurricular activities should be virtual or canceled in areas of high community transmission unless all participants are fully vaccinated," the guidelines stated.

The agency recommended testing at least once weekly for high-risk sports -- "those that cannot be done outdoors or with masks" -- and twice weekly in hard-hit areas. An example of a high-risk sport is football, while golf is considered low risk.

"Close contact sports and indoor sports are particularly risky," the CDC noted. The agency also advised authorities to consider "specific sport-related risks" including setting, physical closeness, the number of people involved, intensity level, duration (including pre- and post-event activities), and the presence of people at increased risk of severe illness.

The national societies themselves have not avoided issuing meaningful national guidance, Hsu said -- at least when one examines the whole pandemic. Older recommendations helped athletes return to play in the first place "at almost all levels," he noted.

The recent recommendations have illustrated how to handle vaccinated versus unvaccinated athletes, Hsu added. They also lay out in detail how to bring infected athletes back to play, build on the older guidance, and cover all three amateur sports levels. "We are all just really trying to learn from each other as things progress," said Denay, who is also a family medicine practitioner and an assistant professor at the University of Michigan in Ann Arbor.

Co-creators emphasized that their guidance defers to local rule, Hsu said, because of the pandemic and vaccination variance. "Right now we are playing this game trying to balance priorities" between sharing consensus medical opinions and acknowledging disparate local policies, he noted.

Will the Public Listen?

Even the experts do not expect their guidelines to be followed to a "T." In addition to the geographical variance, many Americans have demonstrated that they will not allow COVID to prevent them from enjoying sports -- and doing so their way.

"We are kind of at the public's mercy," said Briskin.

"The question is: How much are people still following [public guidance]?" Solomon said. He advised consistently revising guidelines, and running robust marketing campaigns to promote them.

As for areas experiencing their worst COVID surges, with statistics that would have banned sports a year ago, the experts did not echo the CDC's call to stop play there.

"In high-transmission locations it would be safer to not have large crowds, even outdoors," Powell said.

"If people do make the personal decision to pack into a stadium to watch a game, there are ways to do it," Briskin noted, citing mask wearing.

"I hope school districts will acknowledge [high-risk situations]," Hsu said. "If appropriate measures are taken and adhered to strictly, there are ways they can proceed."

But Denay would not allow her own child to play contact sports such as football in hot spots, even if they were vaccinated, "because my child is still being put at increased risk." she said. "We want people playing, we really do. But ... we can't have people in situations that are increasing their risk of death."

Early return to sports has varied nationally, according to reports. High school football in COVID-ravaged Mississippi is on, while some games have been canceled in the Dallas area and central Pennsylvania because of positive COVID tests. The Massachusetts and Connecticut state athletic associations recently mandated that volleyball players wear masks during their exclusively indoor competitions.

Other jurisdictions have gone further for high school athletes: Fairfax and Loudoun counties in northern Virginia, for example, recently mandated they be vaccinated to play beginning with the winter season.

"That makes sense," Solomon said, noting that students also need to be vaccinated to attend many schools. Just in case, "let's make it safer for people."

Even if organizations follow the guidelines, the experts know they cannot completely prevent the spread of virus. "We are concerned," Powell noted.

However, "studies from outdoor contact sports, such as football and rugby, confirm low transmission risk from on-field activities. Most transmission associated with outdoor sports has been related to off-field activities," according to the AAP guidelines.

And what Powell called "a hodge podge" approach to following guidelines should at least provide researchers with organic non-control groups to compare to kids competing in masks, for example.

In addition, data from a season of football and indoor volleyball should inform guidance going forward, possibly as soon as the winter season starting in November. "The conversation will change when we get into the winter sports season," Powell said. "I hope we have more information to guide us by then; now is a little bit of a litmus test. If kids are getting sick and are hospitalized, that's going to change the landscape of winter sports. But if they don't get sick, then I think we will all feel more comfortable."

Importantly, kids under 12 still cannot get vaccinated, Powell added. "We are especially worried about those kids."

"I'm thinking about the transition from fall to winter sports, which is a little terrifying," she said. "I hope that kids don't get sick; I worry that they will."

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