COVID-19 is the name of the disease that is caused by the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2). This is a new virus recently identified in Wuhan, China. Currently there are seven types of Coronavirus that are known to infect humans, four of those commonly circulate in the community and generally result in minor illness such as the common cold. The remaining two are associated with significant illness being Middle Eastern Respiratory Syndrome Coronavirus (MERS-CoV) and Severe Acute Respiratory Virus (SARS).

COVID-19 results in a spectrum of illness ranging from possible asymptomatic carriage, common cold to severe cases requiring hospital admission. In a small minority of cases, COVID-19 can be fatal.

The early epidemiological characteristics published should be interpreted with caution. Patients with milder disease would be less likely to seek medical attention and therefore may not be included in the statistics.

Epidemiological reports from patients who received medical attention in China suggest the following breakdown of COVID-19 cases:

• 1% have no symptoms
• 81% have mild symptoms like the common cold
• 14% have severe symptoms that cause them to miss work and/or attend hospital
• 5% have severe symptoms, often requiring ICU admission (including a fatality rate of about 2.3%)

(Wu & McGoogan, 2020).

There were no reports of deaths in people aged nine years or younger and of the 1716 health care workers diagnosed who may be presumed to be younger with less co-morbidities there were five deaths reported giving a fatality rate 0.003%, which may be more representative to athletes and coaches (Wu & McGoogan, 2020).

The most common symptoms are fever, cough and shortness of breath. Atypical symptoms include loss of taste and smell, conjunctivitis and gastrointestinal upset. It is not possible to tell the difference between COVID-19 and other common respiratory illness particularly in the early stages of illness. Individuals should consult with their doctor by calling ahead. The doctor can take a thorough history, including travel history, perform a physical exam and make a recommendation regarding testing for COVID-19.

The estimated incubation period is between 1-14 days but is about five days on average. The incubation period is the time from when exposure to the virus occurs until symptoms start. Symptoms can persist for longer than three weeks, although the duration of illness will be highly variable.

The literature has demonstrated older, immune compromised and persons with cardiovascular disease are more likely to have worse outcomes from the virus, compared to fit young healthy people. However, it has been observed that even mild cases that can be managed as an outpatient have resulted in viral pneumonia observed on lung imaging, myocarditis, post viral arthritis, post viral fatigue and other non-respiratory complications. What this means for athletes is that for those athletes who contract the virus the risk of becoming critically unwell is low, however even the course of a mild infection is likely have a significant impact on your ability to train for weeks to months, re-enforcing the need to be diligent with infection prevention measures.

Analysis of the number of cases from the Diamond Princess suggests that COVID-19 is more contagious than seasonal influenza.

This can change based on the circumstances the outbreak is occurring in and it is expected this will be refined over time as more is known.

It has been established that individuals are contagious prior to the onset of symptoms, on average this is expected to be approximately 48 hours.

In the absence of dedicated control measures, it is expected that every case of diagnosed COVID-19 will generate a further 2 to 3 cases.

The virus is primarily transmitted primarily through respiratory droplets. There is mounting evidence demonstrating the relevance of aerosol spread and ongoing research to determine if there are other possible modes of transmission such as faecal.

Hand hygiene remains the single best action individuals can take to reduce their risk of acquiring any respiratory or gastrointestinal tract infection. Annual influenza vaccination remains an important infection prevention measure.

You should be vigilant with frequent hand washing using soap and water or an alcohol-based hand rub. Make sure you adhere to 'illness etiquette'. If you are coughing and sneezing, do so away from people into a tissue, your elbow or hands. If you cough or sneeze into your hands, make sure you wash your hands afterwards. Do not attend training if you are feeling unwell and seek medical review early if you have mild symptoms.

Research in respiratory infections in travelling sporting teams suggests that the most likely pattern of spread occurs from within a team, rather than from external sources. When an unwell team member joins the team, due to the regular close physical contact between team members the infections can spread readily within a team (Valtonen et al., 2019).

Unwell members of the team should not be permitted to attend training or attend work.

Social distancing is an effective measure that can contribute to the reduction of transmission of COVID-19 in the community. The current federal government provides detailed recommendations for social distancing on their web site.

Currently there is no specific treatment for COVID-19 in patients who are well enough to be managed outside of the hospital. The aims of outpatient medical management are to provide supportive care by identify other treatable causes of illness (such as influenza), manage any complications from COVID-19 and provide advice on how to limit the transmission from known cases.

Exercise and maintaining your level of fitness remains an important part of physical and mental health for everyone.

For those who are well, they should continue to train, within the current restrictions on public gatherings.

Athletes should discuss with their national sporting organisations and coaching staff methods for continuing to exercise and maintain their fitness through this period.

Currently there is not enough available information to provide strong, specific advice regarding any additional risks posed by COVID-19 in pregnancy. The decision for women who are pregnant or are planning to become pregnant to travel with teams to areas that have a higher risk profile is best made on an individual basis after a discussion with a medical practitioner.

NSO and coaching staff should support any decision a woman makes regarding their decision to travel or attend work in these circumstances. NSOs should offer measures to allow women to continue to contribute remotely should this be practical.

The CDC provides a summary of what is currently known regarding additional risks in pregnancy.

In planning for the post COVID-19 pandemic period, sports will need to have built in infection control measures to their daily approach. It is strongly advised the sport seek medical input when performing a risk assessment and designing infection control procedures. Teams travelling or living together represent a risk similar to that described for boarding schools and community sport. Each sport should “consider the risks versus the benefits” of staying in a team training environment, and consider the resources available to follow social isolation procedures while in that environment. For example;

Does each individual have their own bedroom?

Does each individual have their own bathroom?

Is there capacity to for individuals to prepare and consume meals away from a dining hall?

What will the team do in the event of the first and subsequently identified cases of COVID-19?

• In a team environment there will be increased proximity and duration of physical contact that can facilitate transmission of respiratory and gastrointestinal pathogens. Research in respiratory infections in travelling sporting teams suggests that the most likely pattern of spread occurs from within a team, rather than from external sources. When an unwell team member joins the team, due to the regular close physical contact between team members the infections can spread readily within a team (Valtonen et al., 2019).
• Larger group size when travelling to areas of elevated risk may increase the potential exposure to the group as a whole.

These include:

• Fear of falling ill, losing livelihood, the challenges of securing the things you need (i.e. groceries and personal care items) being socially excluded or quarantined.
• Feeling of powerless in protecting loved ones or providing appropriate care and support.
• Feelings of hopelessness, boredom, loneliness and depression due to isolation.
• Uncertainty or ambivalence towards the situation, which may include high performance objectives as well as personal circumstances.
• Some people may find they experience positive emotions such as a sense of pride about finding ways of coping, a sense of resilience or satisfaction from witnessing community altruism and cooperation.

If you are experiencing any of the above responses remember that this is completely normal under the current circumstance.

• Limit media exposure to useful and quality information sources (e.g. the AIS website & Department of Health website)
• Stay connected to your support network to foster a sense of normality, share feelings and relieve stress.
• Practice self-care by doing things that work for you and are consistent with health advisory guidelines e.g. additional physical activity, eat well, follow routine, meditate, do things you enjoy.
• Keep things in perspective by educating yourself about the facts and taking reasonable precautions as advised by reliable health information sources.

• Share useful and quality information to friends and family.
• Be aware of the social stigma and discrimination that can be associated with pandemics and seek to be inclusive.
• Psychological First Aid is a research-informed method to help people (including ourselves) which looks at the practical ways to support people by LOOKING out for people with serious distress reactions, LISTENING to needs and concerns and LINKING people with social support, information and professional help if needed.

• While most people will be able to build on existing coping resources, we can expect that a minority of people will experience a negative response that worsens or does not settle over a period of weeks to months.
• A level of anxiety over coronavirus is completely normal however if the anxiety or stress you are experiencing continues to acutely impact on everyday life, and is not responding the strategies suggested above, a trained mental health professional may be able to help.

AIS Mental Health Referral Network

With this is mind, the AIS Mental Health Referral Network is opening its availability to impacted friends and family networks of our categorised athletes and staff in the high-performance sports that we service. If people would like to seek mental health support or advice from the AIS Mental Health Referral Network, they or someone on their behalf can contact on the below details. The service is covered Mon – Fri, 9am – 5pm AET. A qualified clinical psychologist is available to speak to them about their needs and connect them with one of our mental health professionals around Australia.

Mental Health Referral Network
Ph: +61 2 6214 1130
Email: mentalhealth@sportaus.gov.au

Do not travel

• Only with specific government exemption should a sporting team to travel to this location for training and competition purposes.

Reconsider your need to travel

• A concerning and elevated risk has been identified and travel in most instances should be avoided by sporting teams.
• There may be instances where appropriate risk mitigation strategies can be put in place to support travel. These can be identified using the COVID-19 Decision-Making Framework for International Travel  .
• Expect these risk mitigation strategies to include significant coordination from your Chief Medical Officer, insurance company and local health authorities.

Exercise a high degree of caution

• Use the COVID-19 Decision-Making Framework for International Travel to evaluate the need and benefits of travel, risks associated with travel and identify suitable risk mitigation strategies.
• Travel may proceed if sufficient risk mitigation strategies can be put in place. This is likely to include travelling with a team doctor, minimising team size, minimising duration of stay, confirmation of travel insurance coverage.
• Teams should have a strategy to monitor risk factors and respond to significant changes.
• An early exit plan should be agreed upon prior to departure, including the threshold required for triggering an early departure.

Exercise normal safety precautions

• Sports should still work through the COVID-19 Decision-Making Framework for International Travel in the current setting given the rapidly changing situation.
• Where possible risk mitigation strategies should be implemented, these may include travelling with a team doctor, minimising team size, minimising duration of stay, confirmation of travel insurance coverage.

The issues around COVID-19 are complex and create difficulty when planning international travel. Apart from issues of health, sporting organisations need to take in to account factors such as medical support, infection spread trends, travel restrictions to the initial destination and the possibility that spending time in the initial destination may restrict opportunities to travel to secondary destinations. Travel to some countries may result in members of the group being reclassified by health authorities into an ‘elevated risk’ category when returning to Australia.

A risk to benefit analysis when travelling to areas affected by COVID-19 should be conducted prior to departure. See the Covid-19 and international travel for sport - important safety information.

Once travel restrictions have been removed the decision for a sporting team to travel internationally should be made on a case by case basis carefully balancing the benefits, risks and risk mitigation options. A framework to help National Sporting Organisations and teams work through their options should include at least the following:

Benefits

• Why is the team travelling?
• What is the specific aim of the training camp or competition?
• Is the travel optional, important or necessary to achieve the overall objectives?
• Are there any suitable lower risk locations or events available that can provide the same or similar benefit?
• What is lost by not travelling to the intended ’elevated-risk’ location?

Risks

• How many people are in the travelling party and how long will the team be together?
• What are the current known risks and travel recommendations for the location you are going to?
• What are the current known risks and travel recommendations for adjacent locations in the region you are going to?
• What has been the recent rate of change for these locations?
• What are the key destinations and events for your team in the foreseeable future? Would the presence in an ‘elevated-risk’ location make travel to other locations more difficult, secondary to mandatory quarantine periods?
• Are there likely to be updates to the current travel recommendations? Formal recommendations from government departments will lag hours to days as they rely on indicator-based surveillance systems such as the WHO daily situation reports. One approach to monitoring this lag period include event-based surveillance tools such as MEDISYS used by the European CDC.
• How well is the destination medical system coping?
• Will you have a doctor travelling with your team?
• Are the financial resources available to pay for emergency flights back to Australia if required, noting that such flights are likely to be at first and business class rates.
• What impact will a 14 day supervised hotel quarantine have on the physical preparation for the next event?

• It is known that respiratory tract infections can spread rapidly within a sporting team once a team member has acquired an illness. Give due consideration to favouring a compact team size to limit overall team exposure.
• Can the time spent in ‘elevated-risk’ locations be minimised?
• Are there any suitable lower risk locations or events available that can provide the same benefit?
• What access to medical support and equipment will you have should an athlete become unwell or be suspected to have COVID-19? Other (non-medical) health professionals should not be expected to coordinate or provide medical care.
• Understand that actively unwell team members may have their travel interrupted by the increased screening for fevers at immigration check points.
• Confirm that current travel insurance will cover local medical treatment and evacuation if required.

This framework is not intended to be an exhaustive or prescriptive decision-making tool. It is intended to highlight the specific needs and challenges for teams who are considering international travel to destinations of elevated risk of COVID-19, without formal travel restriction.

Prior to travelling overseas for training camps and competitions:

• Make an appointment with your regular doctor prior to departure to ensure that your vaccinations are up-to-date and that you will have enough of your regular medications with the appropriate documentation for your entire trip and at least an additional week.
• The current situation with travel restrictions internationally is fluid and can change rapidly. Check the Smart Traveller website regularly prior to departure as well as the immigration department of the country you will travel to next. It is best to have in place contingency travel plans with the ability to change flights if needed.
• Masks are an extra precaution to protect against COVID-19 in areas with community transmission. Check your local state and territory advice about mask recommendations and requirements. Masks can be particularly useful in situations where physical distancing is difficult such as on public transport.

• For international athletes travelling to compete in Australia, the Department of Home Affairs details the current travel restrictions in place.
• The AIS, AOC and Paralympics Australia acknowledge that there is complexity in determining an individual’s risk of transmission of COVID-19 by participating in sporting events and it is inappropriate to impose additional “health measures” which discriminate against certain ethnicities
• The AIS, AOC and Paralympics Australia strongly support the WHO guide to the prevention and addressing of social stigma
• As a member state of the WHO Australia has obligations to comply with the International Health Regulations (2005), which effectively state that any additional “health measures” such as exclusion from participation must be guided by scientific principles, available evidence of risk to human health and guidance from the WHO.
• Event organisers should not impose additional exclusion from participation of individuals without considered high level medical input.
• Dr Tedros director general of the WHO discussing stigma in the context of COVID-19

As at 22 September, the AIS has all Centre of Excellence programs training at full capacity.

As travel restrictions relax, onsite training camp activity will increase. Sports interested in arranging a training camp onsite at the AIS should make contact to discuss the current COVID-19 safety plans and for further information on athlete screenings.

If a comprehensive risk analysis is required the WHO document Public health for mass gatherings: key considerations should be referred to.

Administrative staff as well as Chief Medical Officers should be familiar with the current case definitions for COVID-19 as outlined by Communicable Disease Network Australia (CDNA). CDNA outlines what a confirmed case of COVID-19 is, what a probable case is and who should be considered a suspected case, including who should be investigated for COVID-19. This will help administrative staff understand the current risk and implications if a positive case is identified within a sport or workplace.

What is most relevant currently for Australian event organisers and hosts of international sporting teams:

• A confirmed case is a person who has had a laboratory confirmed test identifying the presence of the virus.
• Laboratory tests may not always be available, and it is useful to have other ways of identifying cases, this will include a combination of epidemiological (exposure) and clinical criteria that is identified by treating doctors. These may be referred to as a probable or suspected case.
• In the elite sport setting from a risk management point of view probable and suspected cases should be approached in the same manner as a confirmed case, even though a laboratory test may not have been conducted. Medical input is required to determine an investigation and management plan for all cases. Non doctors should not be independently referring athletes and staff for investigations.
• The epidemiological criteria will continue to change based on where areas of COVID-19 outbreak occur in and outside of Australia and what exposure individuals have had to these in the 14 days before the onset of symptoms.
• People who have been in a team sport setting or training camp with a confirmed case of COVID-19 would likely be considered a “High risk setting” by the local public health unit.
• All healthcare workers with direct patient contact automatically fill the epidemiological criteria should they become unwell with a clinically compatible illness. Clinicians should have a continuity plan should they find themselves in isolation or become unwell.
• Public spaces and flights that have had known COVID-19 exposure are listed by state health departments. Doctors and administrators should check these sites regularly.
  • ACT Health
  • Department of Human Services Victoria
  • NSW Health
  • QLD department of Health
  • SA Health
  • Department of Health WA
  • Department of Health Tas
  • NT Health