Return to Sport in a COVID-19 Environment – AIS
AUSTRALIAN SPORTING ORGANISATIONS ARE ATTEMPTING TO FUNCTION UNDER WHAT ARE ARGUABLY, THE MOST DIFFICULT OPERATIONAL CONDITIONS IN HISTORY. REFLECTING ON THE ARTICLES WE HAVE WRITTEN ON THIS TOPIC OVER THE PAST SIX MONTHS, WE ARE STUNNED BY THE RAPID ACCELERATION OF CASES DIAGNOSED AROUND THE WORLD. IN MID-MARCH WHEN THE WORLD HEALTH ORGANISATION DECLARED A PANDEMIC, THERE WERE APPROXIMATELY 120,000 COVID-19 CASES AND 4000 DEATHS GLOBALLY. BY LATE APRIL THERE WERE OVER 3 MILLION CONFIRMED COVID-19 CASES AND MORE THAN 220,000 DEATHS. NOW IN MID-JULY, THERE ARE ALMOST 13 MILLION CASES AND APPROACHING 600,000 DEATHS WORLDWIDE.
The USA is now the global epicentre of COVID-19, currently exceeding 65,000 cases per day. Cases in Brazil, Russia and India are increasing at a rate that suggests the world is far from seeing the worst of this pandemic. There are many countries in Africa, South America and the Middle East where the COVID-19 journey is in its infancy.
Australia, having brought the initial COVID-19 outbreak of March/April under control, is currently experiencing a significant and worrying increase in infections. The major difference between the current outbreak and the peak of March/April is that the initial wave was overwhelmingly linked to infections imported from overseas, whereas the current cases are largely driven by community transmission. Community transmission is much more difficult to control. Most recent community transmission has occurred in Victoria with concerning evidence of community transmission spilling over into other States and Territories. The coming weeks to months will be critical in determining whether Australia can bring this outbreak under control and drive down the daily number of infections into a manageable caseload.
What is it about the SARS-CoV-2 virus (the virus which causes COVID-19) that has made this the worst pandemic since the Spanish flu of 1918? Firstly, SARS-CoV-2 has a higher basic reproductive rate (R0) than influenza or other epidemic-associated coronaviruses (Severe Acute Respiratory Syndrome [SARS] and Middle Eastern Respiratory Syndrome [MERS]), meaning that COVID-19 is much more easily transmitted through the population than these viruses. COVID-19 causes minimal or no symptoms in a high proportion of cases which allows transmission to occur through a population who can unknowingly spread the virus. In those patients who do develop symptoms, they are often maximally infective by the time the symptoms develop. This means that the virus has already been transmitted by the time the diagnosis is confirmed. The proportion of patients requiring ICU admission is much higher for COVID-19, compared to influenza. The high rate of ICU admission means that a COVID-19 outbreak places a significant strain upon healthcare resources.
clinician is that it is not possible to differentiate COVID-19 from other upper respiratory tract infections, based on history and clinical examination alone. The way that sporting organisations deal with respiratory infections therefore has profoundly changed. Every respiratory infection in an athlete must be treated as COVID-19 until proven otherwise. Any athlete with relevant symptoms should be provided with a facemask to wear and should be isolated from others. The athlete must be tested for COVID-19 and remain in strict isolation until they have been medically cleared. Even once COVID-19 has been excluded, the unwell athlete with another form of respiratory infection should be managed conservatively to avoid spreading their infection which would result in their team-mates requiring COVID-19 testing and significant disruption. Management should include hand hygiene and respiratory etiquette plus should not be returned to thegroup sporting environment until they
have been medically cleared to do so. The necessity for such aggressive standing-down of athletes with minor respiratory symptoms is new for sport, and understandably frustrating for athletes, coaches and administrators. While COVID-19 was initially viewed as a respiratory disease, there is growing evidence that it is in fact a persisting multi-organ disease causing a range of pathologies including cardiac injury, respiratory compromise, micro thrombosis, large vessel stroke, renal pathology, neurological and hepatic dysfunction.
Serious organ damage has been documented in some young individuals who have had relatively minor COVID-19 symptoms. Therefore, any individual who has had a confirmed case of COVID-19 and who is intending to return to high intensity exercise, must be thoroughly assessed by a medical practitioner to ensure that it is safe for them to resume high intensity exercise. Anecdotally, there are high performance athletes from other nations that have had significant difficulty returning to high intensity exercise following COVID-19 infection. Currently however, there is little knowledge of the long term performance aspects of COVID-19.
The transmission of COVID-19 does not happen in a uniform fashion across a community. That is, not all of those with COVID-19 will pass on the virus to a similar number of others. There are individuals who are ‘super-spreaders’ and there are environments that are ‘super-spreading environments’. Research has indicated that between 10% and 20% of infected people are responsible for 80% of the spread of COVID-19. Several factors contribute to a particular environment having super-spreading capacity. Indoor environments are far higher risk than outdoor environments, particularly where there is poor ventilation. Confined indoor environments, where there tend to be high concentrations of individuals in a relatively small space are particularly problematic.Large clusters have been identified within nursing homes, churches, food processing plants, choirs, schools, shopping centres, worker dormitories,prisons, gymnasiums and cruise ships.
Duration of contact is important. Contact tracing has demonstrated that those that are in contact with an infected individual for greater than 10-15 minutes are far more likely to contract the virus than those who have a fleeting contact. What individuals are doing in enclosed spaces is also important. Transmission of infection occurs via respiratory droplet, aerosol generation and touching contaminated surfaces. When individuals are talking, singing, or exercising, they generate far more respiratory droplets and aerosols than they do when at rest and not talking. Indoor fitness classes have therefore been associated with clusters in several countries. Nightclubs and pubs, where individuals tend to talk loudly in close proximity for prolonged periods of time, have also been identified as high-risk environments.
How does this information translate to the sporting environment? Firstly, we have to ensure that we do not make inaccurate assumptions about transmission risk in certain sports. It is a common presumption that contact football codes would be high risk environments for transmission of COVID-19.
While transmission of COVID-19 is certainly possible in such environments, it is important to remember that contact football codes are generally played outdoors (lower risk) and contact between individuals is usually very brief(lower risk). To illustrate this point, let’s presume that I was told that I had to share an environment with a COVID-19 positive person for the next 60 minutes. I am given a choice of 4 different environments to share with the infected individual: 1. playing AFL football against them, 2. singing in a church choir with them, 3. undertaking a cycling spin class with them or 4 playing chess against them in indoors. Personally, from what I understand of this disease, I would consider the order of least risk to highest risk would be:
3. Singing in a church choir
4. Cycling spin class
Out of this list, I believe AFL would be the least risky activity because it is conducted outdoors and any contact with the infected individual would be fleeting. Chess would be higher risk because it is indoors and I am sitting in close proximity with the infected person for a prolonged period of time. That person however is probably not saying much and therefore they are not likely to be secreting large amounts of droplets or aerosols. Singing in a church choir with an infected individual has been shown to be a very highrisk activity because of the increased
secretion of respiratory droplets in an enclosed space. A cycling spin class in an indoor environment is going to result in greatly elevated secretion of respiratory droplets and aerosols in an enclosed environment with individuals inhaling deeply and therefore having a high likelihood of inhaling viral particles.
While there is no scientific literature comparing the infective potential of these activities, the next best decision making process involves a thorough understanding of the first principals and context of the virus transmission.
Across Australia, sporting organisations at both the grassroots and the high performance level have worked with governments in adopting an evidence-based approach to the resumption of sport. The AIS Framework for the reboot of sport in a COVID-19 environment (the AIS Framework) was released on 1 May 2020, as the first wave of infections decreased around Australia. The AIS Framework divides sporting activity into three levels (A, B, C). Level A is the most restrictive level of training, including;
- Exercise only individually or in pairs (thereby decreasing potential infectious contact points),
- Maintaining distance of at least 1.5 meters between a pair of individuals (thereby decreasing risk of droplet/aerosol transmission),
- No exercise with others indoors (thereby avoiding the inherent risk of indoor transmission), and no sharing of equipment (thereby decreasing the risk of transmission by touching of infected surfaces).
- Levels B and C gradually introduce larger numbers of participants and the possibility of indoor and contact exercise. The AIS Framework is available as an open source document in the Journal of Science and Medicine in Sport.
While the AIS Framework come provided guidance to sport about the nature of activities that could be undertaken at Levels A, B and C, the pace at which sporting organisations could move towards a resumption of sporting activity was largely dictated by the Directives of the Australian State and Territory governments.
While Australia has challenges ahead with the current increase in COVID-19 infections, on the whole, we have relatively low COVID-19 case numbers and deaths, per head of population, compared to most other countries. At the time of writing, international borders are closed and individuals gaining an exemption to enter must undergo 14 days of supervised quarantine, upon arrival into Australia. Given the deteriorating situation globally, it is unlikely that international borders will be open anytime soon. This has a significant impact upon sporting organisations wishing to participate in international competition or wishing to qualify athletes for the 2021 Tokyo Paralympic/Olympics.
There have been many key learnings regarding the conduct of sport in a COVID-19 environment, over the past six months. Until an effective vaccine becomes available, sporting organisations need to adapt to a new way of operating, which incorporates fundamental safety measures to minimise the risk of COVID-19 being transmitted within the sporting environment. Individuals who are unwell should not come into the sporting environment. Any individual with symptoms of COVID-19 (fever, cough, headache, sore throat, shortness of breath) or potential symptoms not explained by another cause (fatigue, myalgia, loss of taste or smell, gastrointestinal symptoms) should isolate themselves AND should be tested for COVID-19.
High performance sport athletes are monitored via daily symptom checks for COVID-19 and daily temperature checks. Athletes and staff need to be educated about social distancing of 1.5 meters wherever possible, washing hands on entering and leaving the training environment, spending as little time as possible in communal spaces such as change rooms, showers etc. and practising appropriate respiratory hygiene. Reinforcing these personal behaviours is crucial. Individuals and sporting organisations cannot control the decisions of Federal, State or Territory governments. Every individual can however control their own behaviours and can call out any inappropriate behaviours of others within their teams/training environment.
The current increase in COVID-19 infections can be attributed at least in part, to a breakdown in protocols/procedures designed to limit the spread of COVID-19 and a complacency regarding the possibility of COVID-19 infection, by members of the public. All Australians, whether involved in sport or not, need to understand that the SARS-CoV-2 virus will remain in the Australian community for the foreseeable future. These safety measures therefore have to become and continue to be the new normal for operating in both the community and high-performance sport environments.
The AIS and Sport Australia have made a range of resources freely available to assist community and high-performance sporting organisations in their planning for the safe resumption and continuation of sporting activity in a COVID-19 environment.
These resources can be found at https://www.ais.gov.au/health-wellbeing/covid-19. Sports Medicine Australia with the AIS and Sport Australia, has recently released a guidance document on Sports Trainer Practices in a COVIDSAFE Australia.
Sports Trainers are frequently the frontline personnel overseeing the safety and wellbeing of athletes and spectators at community sporting events. Supporting Sports Trainers and other personnel at sporting events is crucial to ensuring the safety of athletes, staff and the community in this new and challenging environment.
The world of sport has changed fundamentally since the start of COVID-19 in early 2020. While there are many resources directed at the search for an effective vaccine, it remains unclear if and when such a vaccine will be available. It is crucial that all support staff working with athletes are educated and kept up to date with the latest information available about how to function in sport in a way that optimises safety. While we must all continue to listen to the experts about what is and is not permitted in various jurisdictions, the main contribution that we can all make is to ensure that our own personal behaviours and the protocols and procedures of our organisations are aligned with best practice.
Author/s: Dr David Hughes, Dr Matthew Mooney, Dr Nirmala Perera and Dr Richard Saw