TOPEKA — Fall sports have officially kicked off in Kansas, but for athletes returning from a COVID- 19 infection, the road back may be a bit longer due to added precautions over lingering effects of the virus on hearts, lungs and brains.

Gov. Laura Kelly has repeatedly said that safety should be the priority over a speedy return to sports. Health experts across the state have echoed the governor, fearing complications to internal organs often seen in COVID-19 patients could prove fatal for student-athletes.

“We have a young population of athletes who are healthy, and most will stay safe,” said Tim Beaver, a sports medicine cardiologist for the University of Kansas Health System. “However, with the propensity for this virus to affect the heart more and emerging data showing asymptomatic people having evidence of inflammation, there is a lot of concern that the baseline death rate for myocarditis will spike when people start being active.”

Many patients are impacted by myocarditis — inflammation of the heart — two to three months after, but the exact length for which inflammation may persist is not yet known, Beaver said. The question marks surrounding these effects have given some school district leaders pause.

Since the pandemic began, the Kansas Department of Health and Environment has observed 15 COVID-19 clusters related to athletics and 119 cases in those clusters. Currently, there are seven active clusters and 65 active cases.

Most school districts are going ahead as planned, but many have grappled with whether to play at all. Blue Valley school district announced Friday it would allow fall sports, despite suspending all activities only a month before. Before the announcement, several parents and student-athletes sued the district, the Kansas City Star reported.

In Dodge City, school administrators said they are glad to see student athletes back on the field but pumped the brakes for those returning to play after a COVID-19 infection.

Every sport has been modified in some way to allow for increased social distancing, said Kerri Baker, spokeswoman for Dodge City Public Schools. On top of those changes, they are following guidelines for return to play set by the Kansas State High School Activities Association.

“We are doing the best we can to not just get everyone back out on the field but keep them healthy when they are,” Baker said. “To do so, we need to follow the KSHSAA guidelines provided to us for those who had the virus previously.”

KSHSAA produced a return-to-play manual detailing best practices in anticipation of student athletes returning from an infection.

Student-athletes must first fill out a pre-participation questionnaire to help determine any symptoms or issues which may require further medical evaluation. Once cleared by a healthcare provider, students who previously suffered from COVID-19 may begin a five-stage, gradual increase in physical activity. During the first stage, which lasts for a minimum of two days, recovering athletes will participate in light activity — walking, jogging, stationary bike, etc. — for no more than 15 minutes “at an intensity no greater than 70% maximum heart rate.”

The following stages introduce movement activities, resistance training and more complex training routines. Students may return to full activity during the fifth and final stage after the minimum six days required to clear four stages of lighter intensity practice at no greater than 80% maximum heart rate.

Even after this, KDHE still recommends “athletes that have had COVID-19 be monitored closely by a physician throughout their sport’s season.”

Monitoring how much strain is being put on the heart, as KSHSAA has dictated schools do, is of the utmost importance. Many COVID-19 patients develop lung complications or myocarditis, said Dana Hawkinson, medical director of infection and control at KU Health System.

“We know that people who have no symptoms at all have changes on their CT scan in their lungs and in their heart through an MRI,” Hawkinson said.

Michael Rippee, a sports medicine concussion physician at KU Health System, said student-athletes, staff and physicians also should be monitoring brain function.

Amid the pandemic, Rippee and his colleagues noted neurocognitive changes in several COVID- 19 patients similar to those who have suffered a concussion. Symptoms include loss of attention or focus and feeling heavyheaded.

“We need to make sure we are watching very closely for these types of symptoms in athletes who have previously been diagnosed because, similarly to the heart issues, we don’t know the full circumstances,” Rippee said.

Rippee recommended standardized concussion testing, which is not required by KSHSAA to return from COVID-19, in addition to a graded return to play and frequent monitoring of the athlete’s condition.

With so many question marks surrounding how these after-effects may linger in athletes, Steve Stites, chief medical officer for the University of Kansas Medical Center, advised allowing time to recover fully from the virus rather than rush back to sports. “We’re building an airplane as we fly it. We learn more each day about youth sports,” Stites said. “The human body is a magnificent thing with amazing recuperative powers. Sometimes you just have to give it enough of a chance to fully recuperate and that takes time.”