By Simon Kemp, Charlotte Cowie, Mark Gillet, Richard Higgins, Jerry Hill, Zafar Iqbal, Paul Jackson, Rod Jaques, Jo Larkin, Gemma Phillips, Nick Peirce, James Calder

The SARS-CoV-2 virus (that causes COVID-19) first infected humans in December 2019. With 118,000 cases and 4000 deaths globally, the World Health Organisation (WHO) declared a global pandemic on March 11^th 2020(1). On March 20^th and 23^rd 2020, faced with a rising number of both COVID-19 cases and deaths, the United Kingdom (UK) Government imposed a range of measures in an attempt to control the pandemic in the UK. These included clear instruction for the public to stay at home with a small number of defined exceptions, a policy on essential travel only, the closure of all gyms, exercise out of the home limited to once a day (with household members only) and to follow strict 2m social distancing (SD) restrictions in public places. These instructions effectively put all sport on hold, resulting in widespread training disruption to the elite athlete population.

Collaborating to form ‘one voice’

The Chief Medical Officers (CMOs) of the major Olympic, Paralympic and Professional Sports in the United Kingdom formed a group to share thinking around how elite sport might best plan for a return, at the appropriate time. Whilst it was acknowledged that there were fundamental differences between the sports, including and not limited to: current and future competition schedules;  financial and personnel resources; potential risks of COVID-19 transmission between participants; and their ability to align with any relaxation of population SD, a collaborative approach to planning  “how” elite sport might restart was agreed to be the most effective manner to inform a single dialogue with Government and Public Health England.

Central to this approach was the development of a 5-stage model (Figure 1) that set out the discrete stages that each sport would need to progress through, to ultimately return to unrestricted competition. It was hoped that this model would help create a consistent taxonomy when in conversation with Government, Health agencies, athletes, coaches and sports administrators, and by aligning to the anticipated stages in the relaxation of SD restrictions, highlight the major changes in COVID-19 risk for athletes and support staff that in turn required the staged introduction of specific policies and procedures.

Figure 1 5 Stages for the Resumption of Elite Sport in the UK

Carmody el al(2) proposed an approach to the risk assessment of sporting events, based on WHO guidance that informs much of the planning within Stages 3, 4 and 5. Our cross sport group anticipated continued restrictions on mass gatherings in the short to medium term, leading in the first instance to a resumption of predominantly domestic UK based competition, without spectators. It is also recognised that the Stages may need to be descended, or progress paused, depending on the disease epidemiology within wider society.

Our group’s focus has been how best to plan, question, brief and influence risk management informed and government approved guidance documents.  Protecting the wellbeing of the athlete, support staff and spectators has remained a priority throughout. The guidance has also needed to accommodate our rapidly evolving understanding of the science, not adversely affect the whole population R number, nor negatively impact on key health care resources, including Personal Protective Equipment (PPE).

The guidance provides a framework for individual sports in the UK to progress, from the March 23^rd position, from Stage 0 to Stage 1 (the organised training of individual elite athletes) in hygiene optimised performance facilities whilst maintaining SD at all times. Sports can then progress to Stage 2 (close contact group and team training) where for a number of the sports involved SD or avoidance of sharing sports specific equipment/items, cannot practically be maintained or avoided at all times, and subsequently to Stage 3 (competition behind closed doors where SD often cannot be maintained at all times and opposition are included). Following discussions with UK Sport and the Department of Culture Media and Sport, minimum practice guidance for Stage 1 was published on May 13^th 2020 (3) and Stage 2 on May 25^th 2020 (4).

The Stage-specific guidance highlight the minimum standards that elite sports will need to meet, at all times. All existing current Government and Public Health England (PHE) guidance remains applicable unless otherwise specified. A summary of the key considerations for each stage are as below in Table 1.

The guidance for each Stage builds on the approach and principles set out in the guidance for the previous Stages. In Stage 2 where strict SD in some sports cannot be observed during all training activities, the risk of Covid-19 transmission between athletes and support staff is consequently increased. The Stage 2 guidance highlights the role of enhanced screening protocols for athletes and support staff, together with minimising close and face to face contact activities, consistent with effective training in mitigating this risk. The potential for significant disruptions to teams, squads and competition as a result of the isolation requirements both for athletes confirmed with COVID-19 and their close sporting and non-sporting contacts is recognised. Levels of community transmission are anticipated to be an important factor in the decision of sports with a greater risk of close and face to face contact as “when” to return to Stage 2 (and subsequently Stage 3).

These guidance documents, read in conjunction with existing guidance around the risk assessment and minimum standards for competition (4,5), provide the major elite UK sporting organisations with a quality assured framework to plan “how” they might return. Further consideration is needed to determine “when” a return is appropriate. It is envisaged that for an individual sport, this will be based on a sport specific risk assessment, close consultation with relevant Public Health Authorities, consideration of the time needed to safely recondition its athletes(6), consultation with its stakeholder groups, and critically the ability to implement detailed policies that deliver the minimum standards set out in this guidance without compromising the wellbeing of the athletes, support staff, spectators and broader public.

References

1. World Health Organisation. WHO Director-General’s opening remarks at the media briefing on COVID-19. Available from: https://www.who.int/dg/speeches/detail/whodirector-general-s-opening-remarks-at-the-media-briefing-on-covid-19 (Accessed 11/03/2020)
2. Carmody S, Murray A, Borodina M, et al. When can professional sport recommence safely during the COVID-19 pandemic? Risk assessment and factors to consider. British Journal of Sports MedicinePublished Online First: 07 May 2020. doi: 10.1136/bjsports-2020-102539
3. Department of Culture, Media and Sport. Elite sport return to training guidance: Stage one. Available from: h https://www.gov.uk/government/publications/coronavirus-covid-19-guidance-on-phased-return-of-sport-and-recreation/elite-sport-return-to-training-guidance-step-one–2 (Accessed 13/05/2020)
4. Department of Culture, Media and Sport. Elite sport return to training guidance: Stage Two. Available from https://www.gov.uk/government/publications/coronavirus-covid-19-guidance-on-phased-return-of-sport-and-recreation/elite-sport-return-to-training-guidance-stage-two (Accessed 21/05/2020)
5. World Health Organisation. Considerations for sports federations/sports event organizers when planning mass gatherings in the context of COVID-19, 2020. Available: https://apps.who.int/iris/bitstream/handle/10665/331764/WHO-2019-nCoV-Mass_Gatherings_Sports-2020.1-eng.pdf
6. Hughes D, In the frame, road map for Australian sport on an uncertain journey through COVID-19, Journal of Science and Medicine in Sport (2020),doi: https://doi.org/10.1016/j.jsams.2020.05.003
7. Stokes K, Jones B, Bennett M et al. Returning to play after prolonged training restrictions in professional collision sports. International Journal of Sports Medicine. In Press – Manuscript ID IJSM-05-2020-8292-re.R1 – Accepted 14th May 2020

Affiliations

Simon Kemp: Rugby Football Union, Twickenham

James Calder, Fortius Clinic & Imperial College London

Charlotte Cowie: Football Association, UK

Mark Gillet: Premier League, UK

Richard Higgins: English Football League, UK

Jerry Hill: British Horse Racing, London UK

Zafar Iqbal: Crystal Palace Football Club, London UK

Paul D Jackson: English Institute of Sport, London, UK

Rod Jaques: English Institute of Sport, London, UK

Jo Larkin: LTA, London UK

Nick Peirce: England and Wales Cricket Board, Loughborough, UK

Gemma Phillips: Rugby Football League, Leeds, UK

ORCiD IDs

Simon Kemp https://orcid.org/0000-0002-3250-2713

Jo Larkin https://orcid.org/0000-0002-8350-1614

Nick Peirce https://orcid.org/0000-0002-3272-5060

Twitter

Simon Kemp @drsimonkemp

Charlotte Cowie @drccowie

Zaf Iqbal @sportsdrzaf

Paul Jackson @sportsmedteam

Jo Larkin @jolarkinlondon

Acknowledgments

We wish to acknowledge Anna Deignan, DCMS: Sally Munday and Michael Bourne, UK Sport for their assistance in the production of the guidance.

Corresponding Author

Dr Simon Kemp SimonKemp@rfu.com

Competing Interests

SK is the Medical Services Director for the Rugby Football Union

JC is a board member of the Fortius Clinic

CC is the Head of Medicine at the Football Association

MG is the Medical Advisor to the Premier League

RH is the Medical Advisor to the English Football League and a Sports Physician to the English Institute of Sport

JH is the Chief Medical Advisor to the British Horseracing Authority

ZI is Chairman of the Premier League Doctors Group and Head of Sports Medicine to Crystal Palace Football Club

PJ is the Deputy National Medical Director at the English Institute of Sport

RJ is the Director of Medical Services at the English Institute of Sport

JL is the Chief Medical Officer to the LTA

NP is the Medical Director to the England and Wales Cricket Board

GP is the Team Doctor for Hull Kingston Rovers Rugby League Club