This story was updated Monday, July 19, 2021.

Editor's note: This is the first story in a series highlighting the 2021 Olympic Games with a specific emphasis on health and wellness.

July 15, 2021 -- Like all Olympic hopefuls, swimmer Michael Andrew, 22, has his eye on the gold -- and the training needed to grab that medal.

But this week, during an interview on Fox Business, Andrew laid bare the fact that these Games will not be like any other. In fact, several Olympic athletes have already tested positive for coronavirus since arriving in Japan

Andrew made news when he said he will not get a COVID-19 vaccine before heading to the Games because he didn’t want anything to possibly derail his training.

“I’m an elite athlete. Everything we take and put in our body is very calculated,” he said. “With the period going into Olympic trials, I didn’t want to risk any time out of the pool.”

It was a signal that the first Pandemic Olympic Games are near.

Andrew’s statement triggered outrage among people calling it selfish -- as well as concerns from public health experts, who say they are already worried about COVID-19 spreading at the Games. And it further shifted attention from the thousands of athletes from around the world gathering in Tokyo to the very real fact that these Olympics, already postponed from 2020, will be about the fight against coronavirus as much as it will be about the thrill of victory and the agony of defeat.

Already, COVID-19 has changed these Olympics. Gone will be the iconic moments where winning athletes bow their heads and have a medal placed around their necks. No, this year, winners will pick up their own medals off a tray.

Vaccinations Suggested, Not Required

While the International Olympic Committee (IOC) doesn't mandate vaccination, it says that 85% of athletes and officials are vaccinated or have natural immunity from a prior infection. Still, public health officials wish that percent would be closer to 100%. On Twitter and medical journals and other publications, public health experts are calling out the IOC for what they see as a failure to take the coronavirus risks seriously enough.

Their suggestions about how to reduce risks even more have largely fallen on deaf ears, says Annie Sparrow, MD, assistant professor of population health science and policy at the Icahn School of Medicine at Mount Sinai, one of a group of U.S. experts invited to submit ideas to the IOC planning meetings on reducing COVID-19 risk. "Our input really hasn't been taken seriously," she says.

In a tweet Wednesday, Sparrow lashed out at IOC President Thomas Bach, calling him "all talk, no action" for falling short on public health measures to reduce risk.

Brian McCloskey, chair of the IOC's independent expert panel and expert in global health and infectious diseases, disagrees.

He says some of their concerns have been addressed as the IOC's Olympic Playbooks have been continually updated. The third version, released in June, is a 70-page document for athletes and officials and covers recommendations for before, during, and after the Games.

"They are a key part of our risk reduction strategy for the Games and have been regularly updated as we learn from the wide range of sporting events that have successfully been staged in recent months," McCloskey says.

Other playbooks cover the workforce, marketing partners, media, families of Olympics and Paralympics participants, and international federations.

Countdown to Tokyo

An estimated 11,000 athletes from more than 200 countries are expected to gather in Tokyo for the Games of the XXXII Olympiad.

Along the way to the July 23 opening ceremonies, IOC officials have met with much resistance and concern about COVID-19, including substantial pushback from Japanese residents. In May, a survey by Asahi Shimbun, a leading daily newspaper, found that 83% of Japanese voters opposed the Olympics. More recently, however, that resistance seems to be fading. A poll in late June by Fuji Television found just 30.5% were in favor of cancellation.

Resistance may have fallen when citizens found out that the stands wouldn't be packed with people. After the government of Japan declared a state of emergency on July 8, meant to reduce the number of incoming people, the IOC and other organizing groups prohibited spectators in the Tokyo venues (but still allowing fans in some venues outside the city).

As of July 12, about 19% of the population of Japan is fully vaccinated, according to the Johns Hopkins Coronavirus Resource Center. That is low, but a sharp increase from the end of May, when other data found a fully vaccinated rate of under 3%.

As of July 12, Japan has had 824,990 COVID-19 cases and nearly 15,000 deaths.

IOC's Perspective

On Wednesday, the IOC’s Bach met with Japanese Prime Minister Suga Yoshihide to discuss final preparations. Bach noted that besides the 85% vaccination rate of athletes and officials in the village, nearly 100% of the IOC members and staff are vaccinated, along with 70% to 80% of media expected at the Games.

He also reported a low positivity rate so far. An estimated 8,000 people involved in the Games traveled to Japan from July 1-13; all had pre-departure tests and health checks. According to Bach, only three tested positive for COVID-19 after arrival. All were isolated right away. Close contacts were quarantined.

In the latest playbook, the IOC issues a number of guidelines. Among the highlights for athletes and officials:

  • Self-monitoring. Monitoring for symptoms should begin 14 days before departure.
  • Testing. Athletes are tested before departing for the Games, on arrival at the airport, and daily at the Games. They are also tested if any symptoms develop. If positive, they are isolated.
  • Contact tracing. Close contacts of infected people will also be tested. Contact tracing is by smartphone app.
  • Risk reduction. Masks are to be worn at all times except when eating, drinking, training, competing, or sleeping. Physical interactions are to be minimalized. Ventilation in all areas is recommended.

Public Health Experts' Response

Even with the publication of the third version of the playbook, the protocols fall short, Sparrow says. Among the strategies that she and others say should also be employed:

  • Risk stratification. Classify events as low, moderate, or high risk depending on the activity and the venue. Outdoor events in which competitors are naturally spaced out (like sailing, equestrian) may be viewed as low risk. Indoor sports, such as boxing and wrestling, are probably high risk. Protocols should vary depending on risk levels. The risk stratification can also be applied to non-competition spaces, with hotels, buses, and cafeterias viewed as higher risk than outdoor areas.
  • Testing frequency. Testing frequency is not ideal, Sparrow says. "All the athletes should be tested twice daily."
  • Ventilation. Key issues about things like ventilation are not addressed sufficiently. Hotel hallways have high density and low ventilation -- a bad combination.
  • HEPA. HEPA filters, placed widely in athletes' rooms, dining areas, and elsewhere, can reduce transmission of airborne particles.
  • Contact tracing. Contact-tracing apps are often not effective. Sparrow says very few athletes will compete as they carry a mobile phone. Better: wearable devices (rings, bracelets) with proximity sensors.

Ongoing Debates

In an opinion piece in The Hill July 6, Sparrow and Lisa Brosseau, ScD, a retired professor from the University of Illinois and an expert in infectious diseases, elaborate on the importance of stratifying sports by risk. "Wrestling is riskier than weightlifting,'' they write. "Boxing is riskier than badminton. Thomas Bach, PhD, IOC president and gold medalist in fencing, should understand that fencers have a much higher risk of spreading COVID-19 than track-and-field athletes."

Besides the playbooks about how to stay safe, McCloskey says the IOC on July 9 published the "Sports Specific Rules" that set out specific requirements for different sports. The rules focus on a course of action once an athlete or official tests positive, according to the IOC. As participants gather in Tokyo, McCloskey says, ''we can communicate directly with them in the Village and the venues, and go through the individual sports' rules and countermeasures."

But Sparrow was hoping for risk reduction strategies by sport to prevent positive tests, not information on what to do once a specific sport has a positive test.

In an earlier perspective published in The New England Journal of Medicine, Sparrow, University of Minnesota infectious disease expert Michael Osterholm, PhD, MPH, and colleagues, urged IOC organizers to heed lessons from other large sporting events, adapting measures that work, such as single hotel rooms for athletes, frequent testing, and wearable technology for contact monitoring.

Lots of Moving Parts

While much of the risk management focuses on athletes and officials, ''there are many opportunities beyond the athletic venues for the virus to spread," says William Schaffner, MD, an infectious disease specialist at Vanderbilt University Medical Center in Nashville. He's talking about all the people who make the Olympics run, ''the people in the proverbial boiler room, the local people sweeping streets, selling tickets."

The latest version of the playbook does include recommendations for the workforce, such as staff, volunteers, and contractors. Many of the same recommendations are made for them as for athletes.

Many of these people may be older, and so more vulnerable to COVID-19, Schaffner says. "And if it's anything like the U.S. there will be gatherings in homes, as people get together and talk about [the Games]."

As for whether the Games have the potential to be a superspreader event, Schaffner says: "Of course it has that potential. Given everything I've heard [about prevention measures], I think that potential is reduced."

He does, however, expect some transmission.

Schaffner has sympathy for the IOC planning committee.

"The IOC has millions of issues to deal with,” he says. “Along comes coronavirus and says 'Hello, I'm in charge now.'''

Ethics and the Olympics

The lack of an IOC mandate for vaccination doesn't sit well with Arthur Caplan, PhD, professor of bioethics at New York University.

"It is ethical lunacy to have athletes coming to compete from around the world without requiring vaccination," he says. The idea ''that we have to respect choice makes zero sense when the risks are real and the danger of putting other athletes and spectators and even the community at risk are high. Tokyo is poorly vaccinated and so is Japan."

"Athletes have no fundamental right to harm others in the name of competition or getting a medal. I still don't understand why everyone [going to the Olympics] wasn't vaccinated a month ago."

Caplan calls any athlete declining vaccines ''a very poor role model for young people," unless there is a legitimate health or religious reason for passing it up.

Last week, Andrew, the Olympic swimmer, said during a news conference that he wasn’t vaccinated and didn’t plan to get a shot. He contracted COVID-19 months ago and said he was concerned about potential vaccine side effects that could affect his training schedule. He also said he felt protected by the safety protocols implemented by USA Swimming.

“I didn’t think this is what the hype and excitement around the ‘Michael Andrew’ name would be — would revolve around vaccines,” he added. “But I understand, and it’s something I’m willing to stand for.”

As the Games begin, Caplan says he hopes the media also pays attention to ethics, reporting not only on the Games but about any outbreaks, and continues to report about Japanese resistance to the Games.

Frustrations Aside, an Opportunity to Unite?

Despite debates about risk reduction, the Olympics are seen as an opportunity to unite the world at a time when it's sorely needed. Even with the frustration that Sparrow expresses about what she sees as the lack of ideal risk reduction, will she watch? "Definitely," she says. "We kind of need this to work."

In his July 14 statement, the IOC's Bach predicted that the Games ''will be followed by billions of people around the world. They will admire what the Japanese people have achieved under these difficult circumstances."

Carolyn Crist contributed to this report.

WebMD Health News

Sources

Reuters: "U.S. Olympic Swimmer Michael Andrew Won't Get Vaccinated." 

Brian McCloskey, chair, IOC Independent Expert Panel.

International Olympic Committee: "Statement after the Meeting of IOC President Thomas Bach and Japanese Prime Minister Suga Yoshihide," "Joint Statement on Spectator Capacities at the Olympic Games Tokyo 2020," Playbooks. 

Annie Sparrow, MD, MPH, assistant professor of population health science and policy, Icahn School of Medicine at Mount Sinai, New York; special advisor to the CEO, WHO Foundation.

William Schaffner, MD, professor of preventive medicine and infectious disease specialist, Vanderbilt University Medical Center, Nashville.

Arthur Caplan, PhD, Mitty Professor of Bioethics, New York University.

Asahi Shimbun: "Survey: 83% against holding Tokyo Olympic this summer."

Bloomberg: "Japan polls show more public support for Olympics."

The Hill: "Olympics: Unanswered questions about serious COVID-19 risks."

The New England Journal of Medicine: "Protecting Olympic Participants from Covid-19—The Urgent Need for a Risk-Management Approach."

Inside with Brett Hawke: "Michael Andrew."

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