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This document presents the recommendations developed by the IOC Medical and Scientific Commission and several international federations (IF) on the protection of athletes competing in the heat. It is based on a working group, meetings, field experience and a Delphi process. The first section presents recommendations for event organisers to monitor environmental conditions before and during an event; to provide sufficient ice, shading and cooling; and to work with the IF to remove regulatory and logistical limitations. The second section summarises recommendations that are directly associated with athletes’ behaviours, which include the role and methods for heat acclimation; the management of hydration; and adaptation to the warm-up and clothing. The third section explains the specific medical management of exertional heat stroke (EHS) from the field of play triage to the prehospital management in a dedicated heat deck, complementing the usual medical services. The fourth section provides an example for developing an environmental heat risk analysis for sport competitions across all IFs. In summary, while EHS is one of the leading life-threatening conditions for athletes, it is preventable and treatable with the proper risk mitigation and medical response. The protection of athletes competing in the heat involves the close cooperation of the local organising committee, the national and international federations, the athletes and their entourages and the medical team.

Introduction World-wide, endurance races, including road races, trail races, cycling events, and triathlons, attract millions of participants each year. While these events promote health, fitness, and exercise, there exists significant risk for morbidity and mortality. The World Academy of Endurance Medicine (WAEM) created the Race Emergency Medicine Course (REMC) to train and certify race organizers and medical directors regarding planning and response for medical emergencies at endurance events. The course includes asynchronous e-learning modules, in person lectures, hands-on simulation sessions, and race-day observation. Methods 599 participants from 20 courses conducted in Europe, Asia, North and South America were surveyed. A 5-point Likert scale was utilized to assess participants’ impressions regarding the format, quality and effectiveness of the course. A paired t-test was utilized to evaluate participants’ self-assessments of their confidence in managing critical siutations both before and after participating in the course. Descriptive statistics were used to evaluate responses to open-ended questions. Results Participants rated the overall REMC 4.7 out of 5. Pre-course e-learning modules were rated 4.4 out of 5 while the lectures, hands-on sessions, and race-day observation activity scored 4.6 out of 5. Overall self-confidence in managing race-related critical situations increased from a mean score of 5.0 to 6.1 on a 7-point scale ( p  < 0.01). 73% of participants indicated that they plan to modify their practice based on what they learned. Conclusion The REMC is a valuable educational tool to promote medical care and safety at endurance events. Key points Mass participation endurance events pose significant medical risks, requiring well-prepared medical teams. Emergency medical response training for endurance events is key to ensure high-quality medical services and proper athletes' care. The proposed training combines e-learning with hands-on workshops and race-day simulations, offering a structured, evidence-based curriculum to enhance emergency preparedness.

BackgroundMass gatherings at major sport events such as Olympic Games pose unique health risks because having the large number of people in a small space can aid the spread of infectious diseases. That can also pose risks for athletes’ health and can endanger their performance. Water quality testing of the fields of play (FOP) in Tokyo are showing potential environmental problems (temperature and water pollution) that could endanger the health and safety of the athletes. It is necessary to develop adequate preventive and mitigation measures that would be used in Tokyo Olympics. This research aims to provide international and local authorities with evidence-base for such an intervention.HypothesisAthletes of open water sports are more prone to gastrointestinal infections (TD) due to the exposure of polluted water on the FOP. This hypothesis has been tested by investigating data obtained from the survey and identifying the influence of contact with the water of the FOP on athletes’ health.DesignCross sectional study.SettingPre-Olympic test event Ready Steady Tokyo 2019 (17–22 August)Patients (or Participants) athletes (sailing and triathlon) and their accompanying teams on shore.Main Outcome MeasurementsSurveys among athletes in contact with the water and their accompanying teams on shore. The whole population defined in investigation was approached. Anonymous TD questionnaire was distributed in hard copy and collected on the last day of the event. The online version was available for one month after the event for participants that omitted to fulfill it on site. Data were processed using MedCalc statistical software. The incidence of diarrhea, its duration, the number of stools, impact on performance was recorded.ResultsThe study presents the epidemiology and the impact of TD to athletes participating at Pre-Olympic test event Ready Steady Tokyo 2019.ConclusionsConclusions on risk are made and compared with the data from Rio 2016 Olympics.

BackgroundMass gatherings at major sport events such as Olympic Games pose unique health risks because having the large number of people in a small space can aid the spread of infectious diseases. That can also pose risks for athletes’ health and can endanger their performance. Water quality testing of the fields of play (FOP) in Tokyo are showing potential environmental problems (temperature and water pollution) that could endanger the health and safety of the athletes. It is necessary to develop adequate preventive and mitigation measures that would be used in Tokyo Olympics. This research aims to provide international and local authorities with evidence-base for such an intervention.HypothesisAthletes of open water sports are more prone to gastrointestinal infections (TD) due to the exposure of polluted water on the FOP. This hypothesis has been tested by investigating data obtained from the survey and identifying the influence of contact with the water of the FOP on athletes’ health.DesignCross sectional study.SettingPre-Olympic test event Ready Steady Tokyo 2019 (17–22 August).Patients (or Participants) athletes (sailing and triathlon) and their accompanying teams on shore.Main outcome measurementsSurveys among athletes in contact with the water and their accompanying teams on shore. The whole population defined in investigation was approached. Anonymous TD questionnaire was distributed in hard copy and collected on the last day of the event. The online version was available for one month after the event for participants that omitted to fulfill it on site. Data were processed using MedCalc statistical software. The incidence of diarrhea, its duration, the number of stools, impact on performance was recorded.ResultsThe study presents the epidemiology and the impact of TD to athletes participating at Pre-Olympic test event Ready Steady Tokyo 2019.ConclusionsConclusions on risk are made and compared with the data from Rio 2016 Olympics.

Although many elite sporting events occur in climate-controlled venues, some athletes train and compete in environments that can potentially pose a risk to the athlete's health. In particular, athletes in aquatics, track and field, tennis, football and triathlon can be exposed to extreme heat during competition or while training. The International Federations responsible for these sports are aware of these health risks and have implemented measures to help protect the health of their athletes. This review paper outlines the sport-specific environmental health risks and the safety standards implemented to safeguard athlete health.

Mass participation endurance sports events are popular but a large number of participants are older and may be at risk of medical complications during events. Medical encounters (defined fully in the statement) include those traditionally considered ‘musculoskeletal’ (eg, strains) and those due to ‘illness’ (eg, cardiac, respiratory, endocrine). The rate of sudden death during mass endurance events (running, cycling and triathlon) is between 0.4 and 3.3 per 100 000 entrants. The rate of other serious medical encounters (eg, exertional heat stroke, hyponatraemia) is rarely reported; in runners it can be up to 100 times higher than that of sudden death, that is, between 16 and 155 per 100 000 race entrants. This consensus statement has two goals. It (1) defines terms for injury and illness-related medical encounters, severity and timing of medical encounters, and diagnostic categories of medical encounters, and (2) describes the methods for recording data at mass participation endurance sports events and reporting results to authorities and for publication. This unifying consensus statement will allow data from various events to be compared and aggregated. This will inform athlete/patient management, and thus make endurance events safer.

Endurance events are estimated to generate over US$3 billion/year in the USA alone.3 Taking the example of road running, 17.6 million people registered for road running events in the USA in 2019.4 Endurance sports, thanks to the competition format, allow elite and amateur athletes to compete together, attracting large crowds of participants (e.g. Henley Royal Regatta, Vasaloppet, Gran Fondos, International Triathlon Union World Championship Grand Final). [...]the cessation of endurance events represents a huge societal loss. [...]endurance events planners and stakeholders were added as an advisory working group, to provide perspective and support to the medical task force. The tool provides a macroscopic, multisport perspective taking into consideration local health and safety regulations, the individual event’s characteristics and the local community needs.

Although many elite sporting events occur in climate-controlled venues, some athletes train and compete in environments that can potentially pose a risk to the athlete's health. In particular, athletes in aquatics, track and field, tennis, football and triathlon can be exposed to extreme heat during competition or while training. The International Federations responsible for these sports are aware of these health risks and have implemented measures to help protect the health of their athletes. This review paper outlines the sport-specific environmental health risks and the safety standards implemented to safeguard athlete health.

The IOC recently published its framework on fairness, inclusion and non-discrimination based on gender identity and sex variations. This framework is drafted mainly from a human rights perspective, with less consideration for medical/scientific issues. The framework places the onus for gender eligibility and classification entirely on the International Federations (IFs), even though most will not have the capacity to implement the framework. The position of no presumption of advantage is contrary to the 2015 IOC consensus. Implementation of the 2021 framework will be a major challenge for IFs that have already recognised the inclusion of trans and women athletes with differences of sexual development (DSD) using a scientific/medical solution. The potential consequences for sports that need to prioritise fairness or safety could be one of two extremes (1) exclusion of all transgender or DSD athletes on the grounds of advantage or (2) self-identification that essentially equates to no eligibility rules. Exclusion of all transgender or DSD athletes is contrary to the Olympic charter and unlawful in many countries. While having no gender eligibility rules, sport loses its meaning and near-universal support. Athletes should not be under pressure to undergo medical procedures or treatment to meet eligibility criteria. However, if an athlete is fully informed and consents, then it is their free choice to undergo carefully considered or necessary interventions for gender classification for sport to compete fairly and safely in their chosen gender. Free choice is a fundamental human right, but so is the right to fair and safe competition.