Context: The relationships between different sports, face mask use and COVID-19 risk among high school athletes remains unknown.

Objective: The purpose of this study was to evaluate the influence of sport characteristics and face mask use on COVID-19 incidence among high school athletes.

Design: Descriptive Epidemiology Study

Setting: United States High School Athletic Departments

Participants: Athletic Directors

Interventions: None

Main Outcome Measures: Surveys were completed regarding sport re-initiation, COVID-19 cases, and risk reduction procedures in fall 2020. Separate mixed effects Poisson regression models were developed to evaluate the associations between reported COVID-19 incidence and 1) sport characteristics (contact/non-contact, individual/team, indoor/outdoor) and 2) face mask use while playing (yes/no).

Results: 991 schools had restarted fall sports, representing 152,484 athletes on 5,854 teams. 2,565 cases of COVID-19 were reported, representing a case rate of 1,682 cases per 100,000 athletes and an incidence rate of 24.6 cases per 100,000 player-days. COVID-19 incidence was lower among outdoor versus indoor sports (incidence rate ratio [IRR]=0.54, 95% CI=0.49–0.60, p<0.001) and non-contact versus contact sports (IRR=0.78 [0.70–0.87], p<0.001), but not team versus individual sports (IRR=0.96 [0.84–1.1], p=0.49). Face mask use was associated with a decreased incidence in girls' volleyball (IRR=0.53 [0.37–0.73], p<0.001), boys' basketball (IRR=0.53 [0.33–0.83], p=0.008) and girls' basketball (IRR=0.36 [0.19–0.63], p<0.001), and approached statistical significance in football (IRR=0.79 [0.59–1.04], p=0.10) and cheer/dance (IRR=0.75 [0.53–1.03], p=0.081).

Conclusions: In this nationwide survey of high school athletes, lower COVID-19 incidence was independently associated with participation in outdoor versus indoor and non-contact versus contact sports, but not team versus individual sports. Face mask use was associated with decreased COVID-19 incidence among indoor sports, and may be protective among outdoor sports with prolonged close contact between participants.

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