The Bora-Hansgrohe team had a real dilemma the morning of stage 10.
Until then things had gone pretty well for the team. Sam Bennett had roared back into form with victories on stages two and three of the race, had worn the green jersey for several days, and was just five points behind Mads Pedersen in the competition coming out of the Vuelta’s second rest day.
Bennett was sprinting better than Pedersen in head-to-head sprints and winning the green jersey in Madrid was a distinct possibility.
And then the symptoms started. The Irishman woke up with a sore throat prior to the stage 10 time trial. Feeling unwell, he requested the team carry out an antigen test.
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To his surprise, that test was positive. So too a second test. And then, with the clock ticking until the start of his time trial, the team had another type of race on its hands.
“We needed to do a PCR test to confirm those results,” Bora-Hansgrohe head medic Christopher Edler told VeloNews. “But we really could have a big problem because of the delays in those results. Luckily we had a chance to get a quick PCR test, and the result arrived just 10 minutes before the start.”
Bennett had his fingers crossed that the viral load of the COVID-19 in his body would be low enough for him to start.
It wasn’t. He was out of the race.
At the time of writing, 27 riders have had to withdraw from the Vuelta a España with COVID-19. That’s eight more than for the whole Tour de France and shows that the virus is still rumbling around, still causing problems.
Seeking to understand how pro teams address the problems posed by the virus, VeloNews spoke at length to Edler about Bora-Hansgrohe’s protocol. It’s informed in part by the UCI’s own protocol for the race, but also incorporates the team’s approach to detecting, minimizing, and recovering from the virus.
Based on that discussion, we have broken down the team’s approach into three distinct stages.
Step one: Limit the problem.
Whether it’s at races or training camps, the primary aim of Bora-Hansgrohe’s approach is to prevent riders and staff from catching the virus. And, if someone does catch it, the goal is to limit the chances of them spreading it. Riders and staff members are encouraged to wear masks and to follow hygiene rules.
In the event there is a positive case, things change. The team will run a full screening of riders and staff members, most often using antigen tests. Any positive cases are isolated from the others in order to limit spread. For those who test negative, the usual hygiene rules are further reinforced and made compulsory.
Edler talks VeloNews through those steps. “We try to keep distances, to wear masks every time with the team, when they are in the bus, when they are doing massages,” he explained. “Of course when they eat they need to take it off, but on the way to dinner and on the way back, that’s what we recommend to try to avoid it spreading around in the team.”
However as Bennett noted in his Irish Independent diary, there are other risks outside the team bubble.
“Looking back, there is no way of knowing where I got it,” he wrote after his withdrawal from the race. “We had two flights mid-race. Two buses filled with riders. I got changed in a tent on a mountain top with 80 riders straight off their bikes with no masks.
“There were cleaners in hotels coughing and spluttering and not wearing masks. On the climbs, people were so close that you could smell their breath as they roared encouragement at us. It could have been all of these things or none of them.”
Once a rider or staff member tests positive, it is crucial for the team to do what it can to limit any further spread.
When one person at Bora-Hansgrohe catches the virus, the team identifies those they have been in contact with. Riders may have roommates, depending on the race. They have teammates they gravitate towards, friends within the squad. They may have had contact with soigneurs, physios, and doctors.
“In that situation, we are trying to track it back a little bit,” Edler says. “And for sure, we really have an eye on those people.”
Step two: remove the positive case from the race
If a rider or staff member falls ill, Bora-Hansgrohe has a clear policy in place.
“It’s actually pretty easy and straightforward,” Edler explains. “If someone is sick, he’s been taken out of the race. That also doesn’t only account for COVID, but also for any other kind of infection. If we see there’s any kind of danger, then we take them right out.
“The issue is that once someone becomes ill, they pose a risk to all the other riders that are not yet infected. If he is still traveling on the bus, if he is still riding in the peloton, if he is still at dinner with a whole group, then it’s just a matter of time until more positive cases are popping up. That is one of the reasons why we would always take someone out who really has a new COVID infection.”
There is one exception to this for Bora-Hansgrohe: if it can be shown that the positive test is due to the lingering traces of an older infection.
During the Tour de France Rafal Majka (UAE Team Emirates) tested positive for COVID-19 but was allowed to continue. Bob Jungels (Ag2r-Citroën) tested positive immediately before the race and was permitted to start.
Similarly, in the Vuelta, Juan Ayuso (UAE Team Emirates) has been given a green light by the UCI and race organizers to remain in the event, notwithstanding his positive test. Meanwhile, numerous other riders were required to leave both races. What’s the difference between them?
The answer is the level of the virus in their bodies.
“If we look at Ayuso now, a case the media is talking a lot about, the viral load and CT value are important,” Edler explains. “These are two things that are quite similar but not exactly the same. CT value means more or less this: if you put the probe into the PCR machine, how many cycles does the machine need to do until it comes out with a positive result?
“The UCI has set a threshold of 32. If you need 32 cycles or more, then you can expect you have a very, very low viral load. Or it is more probable that you have an old infection, which sometimes pops up again positively. So if this is the case, if we know someone was positive maybe four weeks ago, and we test him with a PCR test for the race, and we get a positive PCR test with a CT value of 34, then it is very, very likely that this is just an old remainder of the infection, which is already done, already over.”
Edler explains that there is a constant renewal of skin cells within the body. With COVID-19, some of the viral parts of the antigens stick in the mucosal cells of the skin inside people’s mouths. As the cells renew, old cells break off and sometimes contain dead particles of the virus, which can be picked up in tests.
“That’s why you can still get a positive PCR value after a certain time,” he says. “Therefore we need the medical history of the rider. If it is the case that they had a previous infection, then you could say this is fine, there’s no infection that is ongoing at the moment.”
Unfortunately for Bennett, this was not the case.
“With Sam, we saw that it was a new infection. He had symptoms. The CT value was low. So the decision to take him out was quite clear, and also backed up from everyone in the team. There was no discussion about it. Everyone said, ‘let’s take him out.’
“If a rider really is symptomatic, with typical COVID symptoms, that makes the decision actually quite easy. They are a risk to others, and it’s also the case where it’s dangerous to let them ride.”
Step three: Monitor the rider and protect their safety
As the race moved on, Bennett was left to isolate in his hotel room. His Vuelta was over.
So what happened after that?
Eight days have now passed since his positive test. His body has had a chance to heal and Bennett will be looking forward to returning to training and racing, but there are certain steps to take.
These steps are important to avoid possible complications in the future. Sports place high demands on the body and restarting training or racing too quickly can have adverse consequences, including lingering fatigue and myocarditis, an inflammation of the heart muscle.
Such cases are rare but have occurred. Edler and other doctors are therefore very careful about the risk.
“Myocarditis is something that is extremely serious. People can die from it,” he explained. “Luckily, it doesn’t happen often, but with COVID we saw that it happens a lot more.
“The doctors who work with the team are from a big clinic in Hamburg. My colleagues there are also taking care of teams from other sports, including footballers in the Bundesliga. If we put all our patients together, we had some myocarditis cases that were quite scary. So we really want to keep the riders safe.”
Because of that and other health risks, a thorough battery of tests was devised.
“If someone was sick, we took them out until he didn’t have any symptoms anymore, and until they were negative in a quick [antigen] test and PCR tests,” he explains. “Then we put them through the whole diagnosis process, including an ECG, echocardiography, lung function test, blood tests focussing mostly on heart enzymes. And also in the beginning we did a cardiac MRI for everyone.
“What we see now is that the risk of myocarditis is getting a little bit less with the newer variants. That meant we adapted the protocol a little bit. At the beginning of the pandemic, if there was a positive test, everyone got the full, complete diagnosis at the end. Now we look at the symptoms.”
Bora-Hansgrohe’s current protocol is this: if a rider has had severe symptoms, they do a thorough battery of tests once they test negative, including a cardiac MRI.
Conversely, if a rider had mild symptoms during their infection, they undergo a basic screening. This comprises as a minimum an ECG, an echocardiograph, and a blood test. For someone who had zero symptoms at all, Bora-Hansgrohe carries out basic checks, even if international guidelines say they can start training three days after their last positive test without further diagnostics.
Providing the test results don’t reveal any issues, riders can return to training after about 10 days. The coaches work with the riders and will require them to step things up gradually, with the first day back never at a high intensity.
Edler explains that riders’ feedback during that time is important in determining what happens next. “If in that 10 days he has any kind of symptoms during normal training, then we would roll out more diagnoses. But otherwise, he would be fine.
Once the 10 days are passed and no symptoms are experienced, the rider can return to competition.
What about future complications?
All going well, riders will bounce back to their previous level and be able to race as before. Catching COVID-19 is at the very least an inconvenience for the competitor concerned. But the body has been under attack by a virus, and it can take a while to get back to where they were before.
Edler confirms that for a certain number of riders, their performance capacity can be suppressed in the months following an infection.
“What we see in a lot of riders is that after COVID infection, that maybe for two or three months they really have a decreased regeneration [recovery – ed.]. And also they have problems getting into their peaks.
“They are fine to train. That’s no problem. But if you ask them to do the highest intensities, they report something like muscular pain, or that they can’t really reach the top end like they are normally used to. We see that in some riders for a period of two to three months after COVID infection, but not in everyone.”
What’s interesting is that this does not correlate with the symptoms the riders initially had. Some who have lingering effects may have had only mild symptoms, such as a runny nose. And others who had stronger symptoms may not have this medium-term decrease in function.
“What we know is that this decrease is not uncommon with viral infections,” Edler explains. “Medicine knows for a long time that you can have decreased regeneration or activation for a few weeks after a viral infection. That’s nothing special. What is maybe uncommon is that it can last two to three months, something which seems to be COVID-special.”
More will become known over time. The virus may mutate again into something with fewer symptoms and after-effects. And ways may be found to further reduce the effects of COVID-19 on the body, both short and medium term.
For now, teams such as Bora-Hansgrohe will continue to work closely with their riders to limit the chances of them becoming ill and, if they do, to help them to recover as quickly and thoroughly as possible.
What future direction for testing?
During the Vuelta some riders have called for a relaxation of COVID-19 testing, or even its removal altogether.
“We might finish with 100 guys if we keep going like this,” Lotto Soudal rider Thomas De Gendt said. “As long as you are not sick then you can stay in the race. Next year I would like it that we are not tested any more, unless you are really sick.”
VeloNews asked Edler his point of view.
“I can only give my personal opinion. The way things were done at the Tour de France and the Vuelta a España is something that can work out well, because the antigen tests are quite sensitive to find cases, if you are doing them repeatedly on a few days.
“It’s compulsory to do these tests before the race and on race days. And there’s also a strong recommendation from the UCI to test your own staff nearly daily and to test the riders when they have symptoms.
“I think that definitely makes sense. Just to close your eyes and say we don’t need any tests just because we want to do our sports, I don’t think that’s logical in any kind of way.
“I don’t see any point in not testing anymore. As things are at the moment, I think it’s a good way in picking out those who are in danger, but also in identifying the riders who can continue because they have an old infection.
“At the moment, I’m actually quite satisfied with the UCL protocol requiring antigen tests. I would maybe have a different opinion if it was all about compulsory PCR tests.”
There is however one thing which could be improved. Following his positive antigen test, having access to a rapid PCR test enabled Bora-Hansgrohe to have Bennett’s results back prior to the start of his time trial. Other teams in the race have not been so fortunate, with some antigen-positive riders not having sufficient time or access to the quicker PCR test prior to the start of the next stage.
Edler points out that the Tour de France offered the facility to do rapid PCR tests at the permanence. Such tests were available for part of the Vuelta, but he believes this was not in place for the full race.
Ensuring peloton-wide access to these faster tests would, he believes, be a positive step for race organizers. It would also give riders the best possible chances to continue after a COVID-19 positive, if it is safe to do so.