Back to Racing Safely – Ultrarunning Magazine

2020 has been a year of race cancellations, which have persisted longer than anyone could have anticipated. On March 15, I shook my head in disbelief as I saw the pictures of 6,200 runners lining up to race the Bath Half Marathon in the UK. I, for one, thought I would not want to be among the runners in the crowd at the start. After this, races large and small, indoors and outdoors were canceled across the planet and some replaced with virtual races. In other countries (including Spain and Israel), people were told not to even go outside. Runners were reduced to jogs in their backyards and running laps around their living rooms. Obviously, these restrictions were meant to be short-term, while the world locked down. We needed data to help us understand what was effective and what was not, in terms of mitigating the spread of COVID-19.

Over the late winter and early spring, we learned that, for the most part, COVID is being spread by respiratory droplets. This meant that almost all transmission occurred when people were within six feet of each other. The CDC has now recognized that – under optimal conditions – the disease can become truly airborne (spread by aerosols), meaning infection can occur at distances greater than six feet. However, this is felt to occur exceedingly rarely, and in conditions of indoor recirculated air. As George Rutherford, professor of epidemiology at UC San Francisco said, “I can count the number of outbreaks that likely have aerosol transmission on my fingers.” (Rutherford, 2020) We also learned over the spring that disease transmission is much less likely in outdoor than indoor settings. Specifically, the odds of transmitting the virus has been found to be over 18 times higher in indoor than outdoor settings (Nishiura, 2020). Another systematic review from London (Leclerc, 2020) found that only 2% of all so-called “super-spreading” events had occurred in an outdoor setting and all (four) of these were in (presumably crowded) construction sites in Singapore. There has been speculation that an outdoor reception held in the White House’s Rose Garden was responsible for infecting the president, among many others. First, this event did also move indoors and, as Dr. Rutherford stated about this event, “You don’t get any points for being outdoors if you’re standing within a foot of people when you’re infectious… droplets happen when you talk, and believe me, these guys talk a lot.” (Rutherford, 2020) I like how he specified standing, because these transmission events do not occur on transient flybys. In fact, the CDC only defines a “contact” as someone who has been within six feet of someone infected for over 15 minutes.

What does this mean for trail runners? Specifically, if you pass someone while trail running and spend a matter of seconds less than six feet away from them, are you at risk of catching COVID? Realistically, no. Although one can never say risk is 0%, it is very close. In order to become infected, a runner has to be exposed to a high enough dose of the virus for it to escape the defenses of the innate immune system and set up shop. The runner would need to have more prolonged contact, or the infected contact would have to be in their highly infectious window and would need to produce a massive sneeze right into the mucous membranes of the runner’s mouth or nose, in order to inoculate them with enough infectious virus to actually infect them. It’s a highly unlikely scenario. I spoke with Jennifer Kasten, MD, and ultrarunner, who is an assistant professor of pathology at the University of Cincinnati, and has a master’s degree in infectious disease epidemiology. I asked specifically about the risks of contracting COVID by running past someone during a training run or trail race. This was her take, “Passing a fellow competitor generally takes a matter of less than a minute with very transient contact. Particularly in an outdoor setting, where air currents disperse the virus, the chance of a racer inhaling the 1,000 particle infectious dose is slim to none. Therefore, during the race itself, masks are largely unnecessary due to the natural social distancing and outdoor air current dispersion of the sport. Of note, I would not say this for road races with 10,000+ participants, where runners are packed closely together throughout the duration of the race.”

The same also applies to running more than six feet behind someone. While the now infamous Belgian-Dutch “study” published on medium.com (Thoelen, 2020) showed you could get hit by a stream of respiratory droplets while running or cycling even 20 meters behind someone, getting an actual infectious droplet, one in which the virus survives being airborne, makes it to your mucous membranes in a sufficient dose (>1,000 viral particles) that infects you is incredibly improbable. And, as Dr. Kasten added, “Humans aren’t spray nozzles generating a continuous mist of droplets under steady pressure,” (as was the apparatus the scientists used in their study). And “a lot of particles are defective in human respiratory viruses and ‘fail to infect.’” In this study, “no attempt was made to simulate an appropriate infectious dose.” In other words, this study did not provide evidence that running more than six feet behind someone outdoors is actually risky in terms of transmission. When it comes to racing, we should focus our efforts on mitigating spread in the parts of the races that actually are risky. It is no way to live to go around thinking that the sky might fall on you at any second, when evidence strongly suggests the sky will not fall on you.

So, what are the potentially risky aspects of running a trail race? It is the activities where people congregate within six feet of each other for more than a few minutes. As Dr. Kasten says, “The biggest areas of concern with most trail races are at the start, finish and aid stations. That’s when both racers and volunteers are in close proximity to each other and – more importantly – are stationary for several minutes at a time. Therefore, as a fellow racer, I’d strongly advocate staggered starts (easier in chip-timed races), mandatory masking at the start, unmanned aid stations, and a lack of congregation at finish lines and podium presentations.”

As such, the activities around the race are much riskier than the actual running part of the race, and these include travel, overnight hotel stays, or dining indoors before or afterwards. This is part of the reason I am advocating for smaller trail races to open up safely all over the country, so people do not need to travel (and take unnecessary risks, both disease-related and other, or have unnecessary expenses) to run a race. Additionally, many races are held in remote areas, and a group of runners traveling to a race could easily end up becoming a major spreading event in that small community. Finally, running local is also especially important now because it supports your local running community.

Last week, my husband and I had been hoping to run our first race since the start of the COVID pandemic: the Great Trail Race from Truckee to Tahoe City. Unfortunately, it was canceled shortly before due to COVID – specifically, permits for the race could not be obtained. As a physician with a strong interest in public health, I believe that one of our failures, not just in the United States but across the world, is being unnecessarily slow to open up events and activities that can easily be made safe. It is unrealistic and actually unhealthy to expect everyone to live endlessly in a germ-free bubble. Blanket closures that are not backed by science end up driving people to rebel and fight against all disease mitigation strategies, even the effective ones.

Trail races, in general, can be made safe. Race directors across the US and Canada have gotten creative in very similar ways.

Protocols involve:

  • Rolling start times
  • Masks at the start and finish
  • No congregating at the start or finish
  • Masks and limited staff at aid stations
  • No celebration/awards ceremony at the finish

By doing this, the activities are close to risk-free and the benefits are many:

  • The psychological well-being (and joy) that comes from racing with others
  • The motivation to get in shape and train for a race
  • The avoidance of riskier indoor activities (fitness centers, shopping, dining, indoor amusement)
  • You support the race directors and businesses of the trail and ultra community. We certainly don’t want the people who are supporting and upholding our sport to go out of business and stop doing what they do.

I spoke with Salem Stanley, the owner of Vacation Races, which put on Bryce Canyon 30K, 50K, 60K, 50-mile and 100-mile on May 29 with 436 participants, and the Zion half marathon, 50K and 100K on September 26 with 461 participants. Salem explained, “Overall attendance was about one third of normal (due to decreased runner registration). We did 60-minute rolling starts for each distance at Bryce and cut it back to 30-minute rolling starts at Zion. Participants could start anytime during that period. Feedback was so positive about the rolling start we may implement that post-COVID. We eliminated our expo and turned bib pick-up into a drive-through. [We required] masks for all staff/volunteers while interacting with anyone. We cut back on volunteers and staff. Aid stations at Bryce had zero prepared food, only grab-and-go, pre-packaged stuff. That didn’t get great reviews, so we cooked at Zion, with all cooks wearing masks, and it seemed to work okay. We cut back on crew access, allowing only one crew member at the aid stations, and expanded drop bag usage at more aid stations so people could rely more on their bags rather than food prepared by us. We asked for no congregating at the finish line. We normally have food trucks and an atmosphere to encourage people to stick around, but this time we did the opposite and asked people to celebrate on their own, away from the finish line.”

Salem added, “One funny thing, I think, is that runners showed up to Bryce in May very undertrained. Because of all the race cancellations in March through May, many runners hadn’t kept up their training.” I think that brings up an important point of how races work as motivation for so many people. Re-opening races, even with modifications and caps on participants, have been a godsend for so many people in our ultra community. Many people are just so grateful to be racing again.

At this point, I think we need to ask as a scientific question: is closing trail races expected to be an effective intervention to mitigate disease spread on a population level? With the data we now have available, I think the answer is clearly no, especially when appropriate modifications to allow social distancing are in place. Closing trail races has negative impacts on the health and well-being of the athletes in our sport, as well as on the businesses that support our athletes and arrange our races. Individuals always have the right to not participate if they feel they are at high risk.

Guidelines for holding a trail or ultra race:

  • Either a rolling start or masks at a (very brief) start line gathering
  • Participation limit allowing runners to easily space out to 6-foot distance from other runners (exact numbers will depend on how long the race is and how wide the trails are)
  • Masks and distancing of supporters at aid stations
  • Masks and no gatherings at the finish
  • Race directors and runners are also encouraged to be transparent about suspected spreading events, at or associated with a race, so other events and runners can learn from this. Knowing our ultra community, I suspect little to no disease spread has been happening at races thus far.

Many of the above rules would be extremely challenging if not impossible for large road races, and those races may need to wait or develop different protocols or setups. But knowing what we know now about how COVID spreads, smaller races that can easily be held safely should be allowed to go on.

Tracy Beth Høeg, MD, PhD, practices Sports, Spine and Regenerative Medicine in Northern California. She is affiliated with the University of California-Davis and has a passion for ultramarathon and regenerative medicine research. She is a Danish-American double citizen, married to Rasmus Høeg, MD, and they have four children. Tracy has run for the US Trail Ultramarathon Team and the Danish Long Distance Mountain Running Team.

References

Hiroshi N, et al. MHLW CVODI-10 Response Team. Motoi Suzuki. medRxiv 2020. 02.28.20029272.

Leclerc QJ, Fuller NM, Knight LE et al. What settings have been linked to SARS-CoV-2 transmission clusters? [version 2; peer review: 2 approved]. Wellcome Open Res 2020, 5:83.

Pifarré F, Zabala DD, Grazioli G, de Yzaguirre i Maura I. COVID 19 and mask in sports [published online ahead of print, 2020 Jun 6]. Apunts Sports Medicine. 2020;doi:10.1016/j.apunsm.2020.06.002

Rutherford G. “President Trump’s COVID-19 Diagnosis: Implications for Transmission, Treatment and Prognosis.” UCSF Grand Rounds. 10/6/2020. www.youtube.com

Thoelen J. Belgian-Dutch Study: Why in times of COVID-19 you should not walk/run/bike close behind each other. Medium.com 4/7/2020.




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