Advisory on COVID-19

Tuesday, March 3, 2020

This joint message is from the Sport Medicine Advisory Committee comprised of Chief Medical Officers from the Canadian Olympic Committee, the Canadian Paralympic Committee, and the Canadian Olympic and Paralympic Sport Institute Network (COPSIN). It is meant to guide National Sporting Organizations (NSOs) in decision-making with respect to travel to competitions within and outside Canada. Information has been obtained from the World Health Organization, Government of Canada and Australian Institute of Sports websites. Other references are listed in this document. This advisory will be updated regularly and distributed to NSOs and other high performance sport partners.

The outbreak of severe respiratory illness related to the new coronavirus (COVID-19) continues to have an expanding impact internationally. The World Health Organization (WHO) provides regular updates which guide our recommendations. The latest WHO statements can be found at WHO website on Coronavirus disease (COVID-19) outbreak.

General Information

COVID-19 is a virus in the coronavirus family. Coronaviruses in this family are responsible for illnesses that range from the common cold to more serious illnesses such as Severe Acute Respiratory Syndrome (SARS-CoV) and Middle Eastern Respiratory Syndrome (MERS-CoV). COVID-19 is a new virus and so health officials are still learning about its impact and severity. At this time, it appears to cause an illness similar to the flu with the most common signs of infection being fever, cough and shortness of breath. In severe cases patients can develop pneumonia, severe respiratory distress, kidney failure and death.

Epidemiology: The numbers
The reports from China suggest that with COVID-19:

• 1% have no symptoms
• 81% have mild symptoms
• 14% have severe symptoms that cause them to miss work or go to the hospital
• 5% have severe symptoms that lead to ICU admission, including a fatality rate of 2.3%
• The fatality rate is highest in those that are elderly and have other medical conditions
• The estimate of risk to athletes (i.e., younger and healthier) is thought to be similar to the risk of health care workers; 0.3% fatality rate
Wu and McGoogan JAMA 2020-02-24 Characteristics of and Lessons from COVID-19 in China

The number of cases in Canada is small. At this time the risk of contracting COVID-19 in Canada is very low.

Clinical Course

It appears that COVID-19 is more contagious than the typical influenza virus. The virus is transmitted primarily through respiratory droplets. Those that are experiencing symptoms are more likely to spread the illness than those that have the illness but do not have symptoms. There is ongoing research to determine if there are other possible modes of transmission such as fecal or air.

The estimated incubation period (time from initial expose to onset of symptoms) is between 1-14 days but is about five days on average. Symptoms can persist for longer than three weeks, although the duration of illness will be highly variable.

Prevention

Recommendations for protecting yourself and preventing spread of this illness include frequent hand washing and covering both your nose and mouth when coughing. Try to cough or sneeze into your arm, away from others, or into tissue paper (to be disposed in toilet). Wash your hands immediately afterwards. You should avoid close contact with anyone showing symptoms of respiratory illness.

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

What to do if you think you have COVID-19

Because the early symptoms of COVID-19 are similar to other respiratory illnesses, if you have any of the common symptoms (fever, cough and shortness of breath) you should contact your doctor’s office and arrange to have a consultation.

Treatment:

At this time, there is no specific treatment for COVID-19. The goals of medical management are to 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. There are efforts internationally to produce a vaccine and to identify if any of the currently available antiviral medications are effective and safe. An update is expected to be released in mid- 2020. A vaccine will likely take longer as it will have to go through longer clinical trials to confirm safety and efficacy.
 

Travelling to sporting events

We recommend that you check for up-to-date travel advisories from the Government of Canada at: Government of Canada COVID-19 Travel Advice.

Travel Advisories as of March 1, 2020:

China, Iran, Northern Italy: Level 3 –  Avoid non-essential travel
Do not travel to these areas at this time unless such travel is absolutely required for Olympic or Paralympic qualification. If you must go, use hyper-vigilant hand and face hygiene.

Japan, South Korea: Level 2 – Practice special precautions
In this context, with no available vaccine, this means to be hyper-vigilant about routine hygiene (see Level 1), and restrict travel to venues required for competition, training or accommodation. Avoid busy public places if possible.

Hong Kong, Singapore: Level 1 – Practice usual precautions
This includes proper hand hygiene (washing with soap for 20 seconds or use of hand disinfectants with >60% alcohol), covering coughs and sneezes with tissue that is then disposed of and hands cleaned, and avoiding contact with face, nose, or eyes with unclean hands, as well as frequent wiping of equipment and objects touched by hands.

On Airplanes:

Vigilant hand and face hygiene should be practiced. Stay hydrated.

The European Centre for Disease Control (EDCD) has published research into the risk of contracting Infectious Diseases on Aircraft. While there are currently no data available on the transmission risk for COVID-19 during airline travel, we look to the risk related to similar diseases, such as influenza and SARS. The ECDC concluded that the quality of evidence to assess the risk of transmission of influenza onboard an aircraft is not adequate. SARS transmission has been documented from airline travel with transmission most likely from those who are severely ill or those experiencing rapid deterioration, usually in the second week of their illness.

On Return from Travel:

The Government of Canada advises that any travelers from the above countries should be vigilant for symptoms that may indicate a respiratory illness consistent with COVID-19 (fever, cough, shortness of breath) and report these symptoms immediately to their physician and avoid contact with others until they have been cleared to do so. What this means for sports is, if team members returning to Canada from the countries listed become unwell in the two weeks after return to Canada, they may need to be quarantined and tested for COVID-19. This should be taken into account when planning training camps and competition preparation.

Athletes and coaches who are currently unwell with fever, cough or shortness of breath should delay their flight and seek medical review. If you become unwell during your flight you should notify the flight attendants, place a P2 or N95 face mask on and seek medical review as soon as practical on arrival.

Face Masks:

Face masks are most effective in preventing transmission when worn by people who are unwell. If you are well, masks only need to be worn by those who have close contact with those who are unwell (i.e., recommended for health care workers). Correct fitting of face masks is most important to their effectiveness. A good resource is the Australian New South Wales Health web site (How to Fit a Face Mask).

Considerations for Athletes, Coaches, Sport Organizations & Event Producers:

Athletes and Coaches:

Prior to travelling overseas for training camps and competitions

• The risks associated with travel and competitions vary with multiple factors including location, age and origin of participants, indoor vs outdoor venues, and contact vs non-contact sports, among others. Check with your team physician, NSO CMO, or SMAC CMO for detailed consideration of these issues.

• Make an appointment with your team physician or 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. Vaccinations need to be administered well in advance of travel to be effective.

• Travel advisories change frequently. Check the Government of Canada Travel Health Notices regularly prior to departure as well, as the immigration department of the country you will travel to next.

• It is best to have contingency travel plans in place with the ability to change flights if needed.

• There is no need to alter your exercise or training if you are feeling well, nor do you need to wear a mask in public.

National Sporting Organizations (NSOs):

• Where travelling to places with an elevated risk, NSOs are urged to have a team doctor travel with the team. Other health professionals should not be expected to coordinate or provide medical care.

• Having appropriate travel insurance for your team that can be relied upon in the event a medical evacuation is necessary.

• When planning training camps, consider factors such as ease of access to medical resources and the prevalence of infection rates in neighbouring countries.

Sporting Events in Canada:

• There have been very few cases of COVID-19 diagnosed in Canada. There is currently no indication for event organizers to delay or postpone sporting events in Canada.

• For international athletes travelling to compete in Canada, only the Government of Canada should provide details the current travel restrictions in place. At present, the Government of Canada is asking only those that have returned from the Hubei province in the last 14 days should self-isolate for 14 days and contact your local health authority within 24 hours of arriving in Canada. There are no other recommendations. Event organizers should not impose additional restrictions on international athletes. All travelers that have symptoms of fever, cough and shortness of breath should be advised to have a physician assessment.

• Mass gathering and sporting events can pose additional infection control challenges in general. If there is concern regarding your event, please discuss with your Chief Medical Officer who can help put in place risk mitigation strategies in conjunction with your local public health unit if required.

Other Resources:

WHO travel advice
WHO emergency dashboard
WHO situation reports
USA Centers for Disease Control and Prevention
• Johns Hopkins COVID-19 dashboard

Further Questions:

Further information about COVID-19 may be obtained from your NSO Chief Medical Officer or Team Physician, or the Chief Medical Officers of the Sport Medicine Advisory Committee.

Dr. Mike Wilkinson  Canadian Olympic Committee   mwilkinson@olympic.ca
Dr. Andy Marshall   Canadian Paralympic Committee amarshall@paralympic.ca
Dr. Suzanne Lecler Institut National du Sport du Québec  sleclerc@insquebec.org
Dr. Doug Richards  Canadian Sport Institute Ontario  drichards@csiontario.ca
Dr. Brian Benson   Canadian Sport Institute Calgary  bbenson@csicalgary.ca
Dr. Paddy McCluskey Canadian Sport Institute Pacific   pmccluskey@csipacific.ca

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