Poor Air Quality Due to Wildfire Smoke and Sports Participation: Case Study of the Special Olympics State Summer Games

Introduction The benefits of exercise for the health of individuals is well documented. Air pollution and its impact on the short- and long-term health of athletes is a growing concern (1). In addition to daily fluctuations in air pollution levels, an increase in climate related events, such as wildfires, has had an impact on scheduled athletic events (2). Smoke produced from wildfires carries numerous pollutants, many of which can have significant cardiopulmonary impact. Sports participation outdoors in the presence of wildfire smoke needs to be considered for the safety of athletes, coaches, staff, and spectators. This article will address whether or not to hold a state-wide Special Olympics event in the presence of wildfire smoke and recommendations for medical directors in mitigating risk. Case Report The annual Special Olympics Pennsylvania Summer Games occurs for 3 days in early June and brings together 1500 to 2000 athletes and 1000 volunteers in State College, Pennsylvania. In June of 2023 the air quality on the east coast of the United States was negatively impacted by wildfire smoke due to fires in Canada. Here we present a timeline of the events: June 5, 2023: Three days before Summer games. Air quality index (AQI) 51, well within the safe zone for outdoor activity. June 6, 2023: Air quality in Pennsylvania began to change and the local forecast provided warnings regarding outdoor activity. AQI 175, unsafe for outdoor activity. June 7, 2023: One day before athlete delegations were to arrive for the event, evident that the area would be facing significant air quality concerns. There was no contingency for air quality concerns in the emergency action plan (EAP). A morning meeting was held with the supervising physician, lead athletic trainer and Special Olympics Pennsylvania leadership to discuss concerns. Plans were made to monitor the forecast throughout the day and to evaluate the potential to move outdoor events to indoor venues. By the afternoon the AQI reached 189. The projected forecast was for improved air quality. Due to active construction projects on the host campus, indoor options for many sports were limited. Plans were made to move the opening ceremonies from the baseball stadium to the hockey arena. Unfortunately, dormitories for athletes were in older buildings that were not air-conditioned or well ventilated. Alternative options were not available. Because of the increased risk of cardiorespiratory complications in the Special Olympic Athlete population, the decision was made to postpone all outdoor sports if the AQI was above 150 (3,4). In addition, delegations were asked to identify athletes with respiratory issues, who would then be held out of events if the AQI was above 100. KN95 masks would be available for all to use outdoors. Indoor spaces with good ventilation were identified for athletes who were not competing. Electronic communication was distributed to volunteers including coaches and officials, with safety risks and precautions for those with cardiorespiratory disease. A plan was made to reconvene early the next morning to reassess. Athlete delegations would be leaving early the next morning for the event. A decision on proceeding with the event would need to be made early in the day. On the morning of June 8, despite forecasts, the AQI worsened and approached 200. Parts of Pennsylvania to the east had AQI exceeding 400. Contact was made with the state Department of Environmental Protection, who indicated that conditions would continue to be unpredictable and could worsen further. With unpredictable forecasts and limited indoor options, the decision was made to cancel the event. Discussion In this case report, the impact of wildfires on a statewide Special Olympics event is described. Wildfire smoke had a particular impact on this event due to the increased risk of cardiopulmonary disease in Special Olympics Athletes. Prevalence of asthma is greater in Special Olympic Athletes than in the general population (3). Many athletes also were away from their usual caregivers, which could lead to delayed recognition and treatment of respiratory distress (3,4). Wildfires are increasingly a global problem with burning that not only is more frequent but also lasting longer in duration with more intensity (5–8). This is a problem that is predicted to worsen globally into the future with the number of extreme wildfires expected to increase by 14% by 2030 and 30% by the end of 2050, according to a report by the United Nations Environment Program (9). Air quality has grown significantly worse over the past decade. While air pollution components such as lead, sulfur dioxide, nitrogen dioxide, ozone, and fine particles (from vehicles, power plants, factories, and other sources) has generally decreased over the past couple of decades, the increase in wildfires has negated much of the reductions elsewhere (10). According to the National Interagency Fire Center, as of September 2023, 43,831 fires, covering close to 3 million acres, had burned in the United States (11). Wildfire smoke is not limited to a national border. For instance, the air quality in the United States during the summer of 2023 was significantly impacted by the Canadian wildfire season. Canada registered a total of 6462 fires in the year 2023 with approximately 44 million acres burned (12). This smoke traveled throughout the United States, impacting the Northeast and Great Lakes region, areas of the country not impacted by wildfire smoke typically (13). Wildfires create high levels of air pollution by generating smoke and dust particles. Wildfire smoke is a complex mixture of particulate matter (PM), carbon dioxide, nitrogen oxide, hazardous air pollutants, water vapor, and trace amounts of thousands of other compounds (14). Suspended fine PM (< or = to 2.5 μm) is most important in terms of health (15). These fine particles are linked to inflammation and can travel deep into the respiratory tract. Additionally, there has been a proliferation of home building located in wildland-urban interfaces that are particularly at risk of wildfire (16). Wildfire smoke from those locations are more likely to produce smoke that differs from pure wildfire smoke with complex mixtures of biogenic and anthropogenic sources (plastics, metals, insulation, etc.) with largely unknown health impacts (17). While more research is needed to understand the longer-term impacts of wildfire smoke, short-term exposure of wildfire smoke has been associated with extensive health impacts. These impacts are striking especially in regard to respiratory and cardiovascular disease with known alterations in respiratory function (i.e., wheeze), lung function, oxidative stress, inflammation, heart rate, blood pressure, and cognition (15,18). After wildfire smoke exposure, there also is a known increase in emergency department visits and hospitalizations for respiratory illnesses, in particular for young children (younger than 5 years) (19). In June of 2023, State College, Pennsylvania was served by only one medical center emergency department. Bringing an additional 2000 athletes, many of whom have cardiopulmonary comorbidities, into town during this wildfire smoke event would have risked overwhelming local emergency resources. The impact of wildfire exposure can be magnified during physical activity (20). Physical activity results in an increase in minute ventilation, which increases the amount of air pollutants that are inhaled relative to when the athlete is at rest (21). Athletes participating in intense exercise can breathe more than 6000 L/hr when compared with 1000 L·h−1 during light exercise and 500 L·h−1 at rest (22). As the risk of wildfire smoke exposure increases throughout North America, EAP should include contingences for poor air quality (20,22). Monitoring of air quality can occur through a reputable source, such as the AQI from the US Environmental Protection Agency (EPA) (21–23). The EPA maintains a smartphone application that updates the AQI hourly. AQI reports from the EPA are regional, generally within a 50-mile radius. There are ongoing studies to evaluate local options, such as stadium monitors, which could provide more precise data (18). More research is needed to determine the accuracy of these devices. Guidelines from the National Collegiate Athletic (NCAA) and National Federation of State High School Associations (NFHSS) include modifying outdoor sports based on AQI (21,23). NCAA recommendations are listed in Table 1. Because athletes participating in Special Olympics events are more likely to have cardiopulmonary comorbidities, an AQI of 150 or higher was chosen to pause events (18,21–23). As research on AQI and physical activity expands this can be modified to maximize inclusion and minimize risk. Table 1 - NCAA guidance for sporting events occurring during poor air quality. AQI > 100: Schools should consider removing sensitive athletes from outdoor events. AQI > 150: Outdoor events should be shortened, exertion minimized, and sensitive athletes moved indoors. AQI > 200: Serious consideration for rescheduling outdoor events or moving them indoors. Prolonged and heavy exertion should be avoided. AQI > 300: Outdoor events should be moved indoors or canceled. Source: National Collegiate Athletic Association. Air Quality. [cited 2024 July 19]. Available from: www.ncaa.org/sports/2017/9/14/air-quality.aspx. Activities may be moved indoors if proper ventilation and filtration systems are present (6,7). Windows and doors must be closed to prevent outdoor pollutants entering (6–8). If adequate filtration is not present, then particulate counts can build and indoor air quality can worsen beyond outdoors, which was a concern in the case presented here, as well-ventilated options were not available. Face masks that remove ≥95% of airborne particles can be beneficial to decrease preexercise exposure (18,24). However, some athletes with intellectual and developmental disability may not be able to consistently wear or communicate through a mask, making this accommodation more challenging at a Special Olympics event (25). After the cancelation of the 2023 Summer Games, air quality planning was added to the EAP. Highlights of the EAP are presented in Table 2 and in the Figure. In October 2024, Special Olympics International published air quality guidelines for competition and training (26). Table 2 - Air quality EAP modifications for PA state summer games. 1. Indoor venue options are determined months prior to the event. 2. All athlete sleeping accommodations placed in well ventilated dormitories. 3. Face masks will be available at all events. 4. AQI is monitored by medical team daily beginning 1 wk prior to the event. If a wildfire event is occurring, monitoring is hourly and reported to the event leadership team via electronic communication. 5. All outdoor events are postponed for AQI above 150. 6. Athlete delegations identify athletes with cardiorespiratory conditions, who remain indoors for AQI above 100. 7. Volunteers with cardiopulmonary conditions are transitioned to helping with indoor activities. 8. The EAP is shared electronically a few weeks prior to the event with all delegation leadership, medical volunteers, and coaches. 9. Should the EAP need to be implemented, electronic communication via email and text messaging is shared with all volunteers, athletes, coaches, and event staff to provide updates on conditions and plans. Figure: Special Olympics PA Guidelines for AQI from the United States Environmental Protection Agency. Source: https://www.epa.gov/pmcourse/patient-exposure-and-air-quality-index. NOTE: At 151 or above, outdoor Special Olympic activities are prohibited.Conclusion Poor air quality due to wildfire smoke unfortunately led to the cancelation of the Special Olympics Pennsylvania State Summer Games. Limited options to convert outdoor activities to safe indoor spaces, poorly ventilated dormitories and a concern about overwhelming local hospital resources ultimately led to this decision. The challenges of wildfire smoke are increasingly impacting outdoor events. Preevent planning and implantation of an EAP specific to wildfire smoke will be necessary when organizing large sporting events, especially for athlete populations with higher risk of respiratory disease.

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