Context The relationships among different sports, face mask use, and COVID-19 risk among high school athletes remain unknown. Objective To evaluate the influence of sport characteristics and face mask use on the COVID-19 incidence among high school athletes. Design Descriptive epidemiology study. Setting US high school athletic departments. Patients or Other Participants Athletic directors. Main Outcome Measure(s) Surveys were completed regarding sport reinitiation, COVID-19 cases, and risk-reduction procedures in fall 2020. Separate mixed-effects Poisson regression models were developed to evaluate the associations between the reported COVID-19 incidence and (1) sport characteristics (indoor versus outdoor, individual versus team, contact versus noncontact) and (2) face mask use while playing (yes or no). Results A total of 991 schools had restarted fall sports, representing 152 484 athletes on 5854 teams. There were 2565 reported cases of COVID-19, representing a case rate of 1682 cases per 100 000 athletes and an incidence rate of 24.6 cases per 100 000 player-days. The COVID-19 incidence was lower for outdoor versus indoor sports (incidence rate ratio [IRR] = 0.54; 95% CI = 0.49, 0.60; P < .001) and noncontact versus contact sports (IRR = 0.78; 95% CI = 0.70, 0.87; P < .001), but not team versus individual sports (IRR = 0.96; 95% CI = 0.84, 1.1; P = .49). Face mask use was associated with a decreased incidence in girls' volleyball (IRR = 0.53; 95% CI = 0.37, 0.73; P < .001), boys' basketball (IRR = 0.53; 95% CI = 0.33, 0.83; P = .008), and girls' basketball (IRR = 0.36; 95% CI = 0.19, 0.63; P < .001) and approached statistical significance in football (IRR = 0.79; 95% CI = 0.59, 1.04; P = .10) and cheer or dance (IRR = 0.75; 95% CI = 0.53, 1.03; P = .081). Conclusions In this nationwide survey of high school athletes, a lower COVID-19 incidence was independently associated with participation in outdoor versus indoor and noncontact versus contact sports but not team versus individual sports. Face mask use was associated with a decreased COVID-19 incidence among indoor sports and may be protective in outdoor sports with prolonged close contact among participants
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