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In late December 2019, a cluster of atypical pneumonia cases in Wuhan China resulted in the identification of novel coronavirus SARS-CoV-2 and a disease known as COVID-19.1 The novel virus has spread rapidly across the globe, and continues to pose unique clinical and scientific challenges. Spread by droplets from symptomatic and asymptomatic individuals, and able to survive on surfaces for up to 72 hours,2 COVID-19 has a reproduction number, or key indicator of infectivity, ranging from one to more than four.3 Its infectivity has been shown to be influenced by a range of social distancing measures.4 The clinical presentation of COVID-19 varies from mild upper respiratory symptoms, to a terminal pneumonic process recalcitrant to current treatments. The effectiveness and sustainability of serological responses are yet to be determined and there is currently no vaccination or COVID-19 specific treatment available.5

New Zealand identified its first case of COVID-19 on 28 February, and the WHO declared a pandemic on 12 March 2020. By mid-March all international arrivals in New Zealand were required to self-isolate, New Zealanders overseas were being encouraged to return home, and on 19 March New Zealand’s borders were closed to almost everyone except New Zealanders. The Government released a four-level public health strategy for managing the pandemic on 21 March, and at midnight on 25 March, New Zealand entered a Level Four Alert. This meant that other than essential workers, New Zealanders were required to ‘stay at home’, businesses were closed and exercise was limited to the home or immediate neighbourhood.

As a consequence of these stringent but necessary measures, elite athletes have been challenged by the cessation of all domestic and international sport including the postponement of the 2020 Olympic Games. This has resulted in disruption to training and competition schedules with a concomitant impact upon the mental and physical wellbeing of athletes, coaches and other support personnel.6 Elite athletes and their coaches are not immune to mental health issues, which may be exacerbated by the inability to train and compete, as well as the broader pandemic lifestyle constraints.7,8 Known for their propensity to exertional bronchial hyperreactivity, elite athletes also demonstrate relative immune compromise associated with high training load and these factors could increase susceptibility to COVID-19.9,10 Further, following relative inactivity there are data linking resumption of training with increased risk of injury,10 thereby increasing the vulnerability of elite athletes as training resumes.6 Recognition of the unique demands of elite sport, athlete immune status and relative injury/illness risks are the genesis of guidelines to support the health and wellbeing of elite athletes. International sporting federations, sports medicine practitioners and kindred organisations have begun to develop protocols, relevant for specific countries and sport disciplines during the pandemic.6,11

Over the ensuing months New Zealand athletes will transition from the relative isolation of home-based training, to ‘new normal’ interaction with coach and support personnel. The process of transition will carry challenges and risks unique to each individual and their sport. Sport New Zealand, High Performance Sport New Zealand (HPSNZ) and other sporting bodies have established population-based guidelines for the resumption of sport and exercise at the various COVID-19 Levels, consistent with Government public health regulations, that are in turn informed by the New Zealand Ministry of Health (MOH).

This document provides evidence and consensus-based guidelines relevant to the medical support of New Zealand elite athletes during the transition to a ’new normal’ in the New Zealand environment. The following recommendations have resulted from consultation between the medical officers of New Zealand’s major sporting codes, Sports Medicine New Zealand and other health specialists. The specific foci of the consensus are the medical considerations relevant to the transition period characterised by a gradual re-opening of elite sporting facilities and a resumption of group-based training. While specific details of New Zealand COVID-19 levels may vary over time and potentially by location, this document assumes a situation whereby isolation ‘bubbles’ are no longer operating for the majority of the population.

Ethics and advocacy

Medical practitioners working in elite sport must continue to act as advocates for the wellbeing of athletes, while balancing the public health imperatives of a pandemic. During these unprecedented times in which the support of elite athletes must be contextualised on a ‘new-normal landscape’, and when difficult decisions involving conflicting needs must be made, it is critical that practitioners place medical ethics at the fore. When ethical values and principles inform decision making processes, those decisions carry a legitimacy that ultimately facilitates alignment and impact.12

To ensure the best outcomes, both how decisions are made and what decisions are made should be informed by ethics and values recognisable and shared by the broader community. This includes respecting the ethical principles of justice, non-maleficence, beneficence and autonomy. However, the ethical values that guide our decision-making should also take into account broader considerations of openness, inclusiveness, reasonableness, responsibleness and responsiveness (for a full discussion of ethical considerations during a pandemic, readers are directed to “Getting Through Together. Ethical Values for a Pandemic”).12

Healthcare facilities in the elite sporting environment

Healthcare facilities for elite athletes in New Zealand were closed during Level Three and Four, and consulting for both medicine and physiotherapy during this period was conducted by tele-health. Consistent with a graduated approach to the loosening of restrictions, at Level Two, the majority of sporting and healthcare facilities for elite athletes re-opened. Numerous public health requirements remain in place, including the need for physical distancing, public gathering restrictions, contact tracing and the need for at-risk individuals to remain at home.

Given the novel nature of the public health situation, the safe delivery of health services from training facilities and high-performance environments requires careful consideration and preparation.

Access to healthcare facilities should be regulated with a recommended single point of entry and exit, with incidental transit through healthcare facilities avoided. Access should ideally require someone inside the facility to admit individuals after ringing a ‘doorbell’ or equivalent. The triage of all patients from a car park, or equivalent area outside the healthcare facility will ensure each individual is appropriate to enter the centre. The triage may involve questions regarding the nature of the consultation, any change in their health status with respect to COVID-19 symptoms and contact with any potential COVID-19 patient since their last visit. While the use of routine temperature assessment in combination with triage questions may increase the sensitivity to detecting an early infection, its isolated use as a screening tool has been questioned.13 Notwithstanding the logistical challenges, an elevated temperature either in isolation or in combination with an affirmative response to any triage question would warrant further discussion and may influence any decision to allow the patient to enter the healthcare facility.14Waiting areas should not be utilised, with patients entering the centre only when the consultation space and respective clinician are ready. In the interests of accurate contact tracing, should this be necessary, accurate records of all clinic attendees must be documented with due respect for confidentiality.

To allow appropriate physical distancing and minimise potential infection transmission, numbers of staff and patients in any healthcare facility should be restricted. Each facility will need to determine an effective ratio concomitant with the separation of areas such as open-plan physiotherapy and massage therapy workspaces. Administrative workspaces must also allow appropriate physical distancing. To facilitate this, operating models will require flexibility that enables individuals to work from home, in rotating shifts, or to perform non-clinical duties in other workspaces.

That SARS-CoV-2 can survive on surfaces for several days2 means that cleaning of clinical and administrative areas within a healthcare facility requires particular consideration. Attention should be paid to the protocols for daily intensive cleans, between patient cleaning, and regular centre cleaning. Use of alcohol-based or equivalently evidenced cleaning products is recommended,15 with responsibility and accountability for cleaning clearly articulated and monitored.

Medical practitioners working in elite sport also have a responsibility to ensure that appropriate hygiene strategies are established across all areas of the training and sporting environment to mitigate against infection transmission. Practitioners should view the pandemic as an opportunity to enhance sport-wide hygiene practices including cleaning strategies, approaches to clinical and communal team areas, blood and respiratory pathogen transmission control, and the implementation of public health measures.

Clinical consultations

In order to minimise contact time within healthcare facilities, consultations should, when possible, be performed using telehealth. When necessary to assess in person, it is recommended that preliminary history gathering still be completed by telehealth. This could be completed while the athlete is in the carpark, prior to performing an examination within the healthcare facility. In an effort to keep in-person consultation times below 15 minutes, post-examination discussions and communication should also be completed by phone or conference calling. Investigations and prescriptions should be instigated electronically when possible.

In the elite sport environment, it is common for coaches and other support staff to be included in some athlete consultations. During this period, it is recommended that consultations are a one-on-one event only, with telehealth modalities used to include additional individuals as required.

During periods where SARS-CoV-2 continues to potentially circulate in the community, it is recommended that any individual presenting with symptoms consistent with infectious disease be managed through an established alternative clinical pathway, outside of elite sporting facilities. Symptoms consistent with a possible infection, detected through the telehealth history taking or the mandatory triage process, could be referred to the individual’s general practitioner, or other healthcare provider as determined by regional approaches to COVID-19 detection and management.

Personal protective equipment (PPE)

SARS-CoV-2 is known to be transmitted up to 48 hours before the development of symptoms and may be disseminated up to metres during coughing and sneezing.16 When treating elite athletes, close contact is routine, demanding the careful consideration of the use of PPE.

At Level Two, when elite sporting facilities and associated medical facilities reopened, there were low levels of circulating COVID-19 in the community. Based on MOH guidelines, the use of full, hospital-level PPE is unlikely to be necessary for routine consultations, particularly where potentially infectious athletes are triaged via telehealth and managed externally.

The New Zealand Government does not currently recommend the routine use of facemasks in the community unless an individual is experiencing respiratory symptoms or is diagnosed with COVID-19.17 However, in the context of the sports medicine clinic, the use of a face mask may mitigate droplet spread from a hitherto asymptomatic individual. Therefore, to allay the concerns of any patient or provider, it is recommended that at least in the early post-peak pandemic phases during consultation and treatment, patients and practitioners wear protective medical facemasks in accordance with their appropriate use and in full knowledge of their limitations. This assumes development of clear protocols for facemask use in specific elite sport settings. Given the low prevalence in New Zealand, the health checks on athletes at entry to elite sport facilities and the pragmatic realities of consulting in the elite environment, full face shields are not currently recommended.

Load management, mitigation and monitoring

It is well recognised that periods of relative inactivity or modified training load can have a negative impact on musculoskeletal adaptation and cardiorespiratory fitness.18 Subsequently, there is a relative increase in risk of re-injury upon the resumption of training (HPSNZ Performance Health unpublished data) related to both athlete-specific intrinsic factors, and the rate of load application. Irrespective of the cause of reduced training load, the risk of injury on return may be mitigated by the careful multi-disciplinary planning for the reintroduction of training volume and intensity, taking into consideration both individual and squad-based factors. Within the constraints of COVID-19 restrictions, maximising approaches to recovery, including physiological monitoring, nutrition, sleep and soft tissue therapies will support the optimisation of training load.

Immune function

While the immediate immunological and antibody response to SARS-CoV-2 infection is yet to be fully understood,19 it is important that an elite athlete’s immune system is not impaired when returning to the training environment.

The effectiveness of an athlete’s immune system is influenced by multiple intrinsic and extrinsic factors but compromised immune systems place individuals at greater risk of infection when exposed.20 An individual’s underlying medical status and/or routine use of certain medications may influence the efficacy of their immune function, and those individuals should be identified, with their particular circumstances carefully considered when addressing a return to training and group activities in the post-peak pandemic phase. This is particularly relevant when supporting para-athletes, in whom chronic health conditions may increase infection susceptibility and consequence. Similarly, training volume and intensity is well recognised to have an impact on immune function, and all athletes will respond uniquely to a given training situation.10 Finally, in addition to training load and volume, stress resulting from poor sleep quality, inadequate nutrition, low mood and ineffective recovery strategies may all negatively impact upon an individual’s immune function.

Healthcare providers are well positioned and have a responsibility to facilitate a multi-disciplinary approach to optimising an individual elite athlete’s immune function. This will require advanced planning and coordination within individual sporting codes.

Monitoring COVID-19 status

Polymerase chain reaction (PCR) testing is currently utilised in New Zealand for confirming the presence of SARS-CoV-2 infection in a symptomatic individual, and determining the presence of infection in the broader asymptomatic population. Despite its potentially low detection sensitivity in asymptomatic individuals, some medical bodies are advocating for the routine and regular testing of elite athletes with PCR in order to ensure athletes are not contagious.11 In the current New Zealand environment, with no or low rates of identified community transmission, the routine or regular use of PCR testing in elite athletes is not considered necessary. However, while some organisations may choose to utilise PCR testing as part of a broader strategy, this must not be at the expense of other infection control measures.

While antibody seroconversion has been observed following SARS-CoV-2 infection, it is unclear how long this is sustained, and whether it confers lasting immunity.21,22 Furthermore, at the time of writing, there is no valid means of assessing an individual’s immunity to SARS-CoV-2. Current serological tests for IgG and IgM have proven to be unreliable in many countries, and as yet no testing procedure has been approved in New Zealand. Therefore, the routine use of serology (IgG/IgM) to evaluate SARS-CoV-2 status of elite athletes is not currently indicated in New Zealand.

The potential impact of asymptomatic SARS-CoV-2 infections on the heart and other organs remains to be elucidated, but this detail may inform future decisions on the need to understand the COVID-19 status of elite athletes. Furthermore, given the high respiratory rates and close proximity often associated with elite sport, athletes may pose a high risk of virus transmission when either pre-symptomatic or asymptomatic. Subsequently, recommendations on monitoring may change as the impact of symptomatic and asymptomatic infections on the heart and other organs becomes clear, immunological knowledge expands, New Zealand infection rates change, or new technology becomes available.

Athlete psychological wellbeing

It is well recognised that athletes have a similar or slightly higher risk of mental health issues including anxiety and depression when compared to the general population.7 Periods of uncertainty, isolation and transition may exacerbate symptoms in those with known susceptibility, or elevate symptoms in those with no previous mental health issues.23

A high level of awareness is required by all support personnel interacting with athletes at this time. Atypical behaviour, lack of engagement, loss of motivation, as well as physical changes such as loss of appetite and poor sleep, may all indicate a change in mental state. In addition to maintaining a high level of vigilance for mental health issues, medical practitioners, working closely with psychologists should consider the use of brief mental health assessments (such as the ‘DASS-21’) as part of a routine post-level four health screening approach.

The use of general wellbeing data (including sleep quality, mood, energy), often collected and collated by a range of disciplines within elite sport, should be rationalised through-out the COVID-19 pandemic. In collaboration with the relevant psychologists, medical practitioners should have an established protocol for reviewing wellbeing data throughout this period.

Vaccination

While intensive research and development is underway, the development of vaccines for pre-existing coronavirus has proven difficult,24 and there is currently no effective vaccine for COVID-19. When there is a New Zealand Government approved COVID-19 vaccine and approach to public vaccination, it is recommended that elite athletes and support staff are vaccinated.

Unless contraindicated, completion of the New Zealand Immunisation Schedule and an annual influenza vaccination is recommended for elite athletes and their support personnel.

Medications and COVID-19

While concerns have been expressed that medications that alter immune function (eg, glucocorticoids) may increase susceptibility to COVID-19 infections, based on current evidence it is recommended that the ongoing management of chronic health conditions is not altered due to pandemic considerations.

Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most frequently prescribed medication to elite athletes.25 While evidence is sparse that NSAIDs may exacerbate infections, the pandemic may provide an opportunity for a more judicious approach to NSAID prescription, particularly when managing upper respiratory symptoms.26

Regardless of symptoms, when prescribing to athletes during this period, it is important that medical practitioners are cognisant of the impact of medication on the immune system.27

COVID-19 positive athletes

It is important that healthcare providers in elite sport have strategies to manage athletes who may either be infected, or who have recovered from COVID-19.

Acute COVID-19 infections should be managed in accordance with MOH guidelines, including case-reporting and quarantine. Specialist hospital support may be indicated depending on the clinical situation. Given the uncertain clinical outcomes of COVID-19 and the lack of data on the influence of exercise, elite athletes with confirmed COVID-19 should not be performing physical exercise until provided with a medical clearance from the appropriate public health authority.

Prior to returning to elite sport, but after symptoms resolution and receiving a public health clearance, an elite athlete diagnosed with COVID-19 requires review by their sport-specific medical practitioner.

SARS-CoV-2 binds to cells in the lung via receptors such as angiotensin-converting enzyme 2 (ACE2), but those same receptors are also found in many other organs including the heart.28 Acute myocarditis has been described in previous coronavirus outbreaks,29 and the clinical outcome of COVID-19 patients with cardiovascular comorbidities is poor.28 As a result, international sports medicine bodies have recommended the intensive cardiac evaluation of elite athletes prior to returning to sport training.11,30,31 In the New Zealand environment, it is recommended that any athlete diagnosed with COVID-19 has a cardiology review prior to resuming training. Upon receiving a cardiological clearance, the individual athlete’s clinical course should be considered when planning a graduated return to training, and reintegration into a training environment.

It is important that the development of any stigma associated with COVID-19 infection be avoided, by normalising and promoting the healthcare process as a standard approach, and ensuring an understanding of the COVID-19 infection by all staff and athletes.

Managing a COVID-19 related death

While it is likely that elite New Zealand athletes have been infected with COVID-19, to date there have been no reported deaths. If New Zealand is able to maintain a low rate of community transmission, it is hoped that this situation will continue. However, practitioners working within elite sporting organisations should ensure that there is an appropriate response strategy for the unexpected death of an athlete, family member or someone within the sporting organisation. That strategy should include the immediate access to counselling and psychological support.

Travel

During the immediate post-peak pandemic period, it is anticipated that international travel will be negligible and internal travel within New Zealand will be minimised. Medical practitioners must ensure that during any sport-related internal travel, appropriate hygiene strategies are established and normalised within team environments. This may include the intensified use of hand sanitiser/hand washing, regular cleaning of surfaces, cough and sneeze etiquette, and any travel-specific physical distancing or contact tracing requirements. Ensuring adequate sleep and nutrition, along with the avoidance of heavy training loads immediately prior to travel, will facilitate healthy travel outcomes.

The future and nature of international sport-related travel requires further consideration as the pandemic evolves.

Education/information sharing

Ensuring that elite athletes, coaches and support staff are well informed regarding both COVID-19, the relevant sporting considerations and the public health requirements of differing COVID-19 levels is important for optimising athlete health, wellbeing and compliance. In addition to publicly available health messages, the provision of sport-specific information and education should utilise a range of modalities, and where possible could involve the use of key athletes to deliver relevant messages.

Finally, as athletes resume squad-based training, it is recommended that in conjunction with coaching staff, sport-specific medicine, psychology and athlete life specialists provide an interactive education and information sharing session to support the athlete and coach transition from relative isolation.

Conclusion

The novel virus causing COVID-19 has already had an unprecedented impact on international health, economies and sport. With a clear COVID-19 national strategy and its early implementation, New Zealand has to date avoided the devastating levels of infection and death witnessed overseas. However, the COVID-19 pandemic is a global challenge whose course, in the absence of an effective vaccine, is difficult to predict.

There is a desire from sporting organisations, athletes and the public for sport, exercise and training to resume as soon as appropriate. This includes the desire for elite athletes to return to training and ultimately competition. Health support embedded within elite sporting organisations must also consider broad public health consequence and align with Government guidelines for delivering health services. Medical practitioners will play a key role in interpreting and applying Government regulations in the various sporting codes.

Medical practitioners will undoubtedly assist in the emergence of elite sport from COVID-19 restrictions, through supporting both athlete’s health and sporting organisations readiness for the ‘new normal’. When considering those factors outlined above, practitioners should routinely support an inter-disciplinary approach to athlete care, incorporating the views of coaching staff, medicine, psychology, athlete life, physiology, nutrition and strength and conditioning expertise. This document facilitates that integrated process by providing a framework for medical practitioners and sporting organisations to consider, as elite sporting activity gradually resumes.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Bruce Hamilton, Sport and Exercise Physician, Director of Performance Health High Performance Sport NZ/NZ Olympic Committee, Medical Director Canoe Racing NZ; Lynley Anderson, Associate Professor, Bioethics Centre, Division of Health Sciences, University of Otago; Nat Anglem, Sport and Exercise Physician, Medical Director Snow Sports NZ; Stuart Armstrong, Sport and Exercise Physician, Doctor Rowing NZ, Associate Editor NZ Journal of Sports Medicine; Simon Baker, ACSEP Registrar, Medical Director Hockey (Men) NZ; Sarah Beable, Sport and Exercise Physician, High Performance Sport NZ/Snow Sports NZ Medical Practitioner; Peter Burt, Sports Doctor/General Practitioner, PhD Candidate, Bioethics Centre, Division of Health Sciences, University of Otago; Lynne Coleman, Sports Doctor/General Practitioner, Medical Director Swimming NZ; Rob Doughty, Cardiology Professor, Heart Foundation Chair, Heart Health, Auckland University; Tony Edwards, Sport and Exercise Physician, Medical Director Hockey (Women) NZ; Dan Exeter, Sport and Exercise Physician, Medical Director Athletics NZ; Mark Fulcher, Sport and Exercise Physician, Medical Director Football NZ; Stephen Kara, ACSEP Registrar, President Sports Medicine New Zealand; John Mayhew, Sports Doctor/General Practitioner, Medical Director NZ Rugby League; Sam Mayhew, Sports Doctor/General Practitioner, Medical Director Triathlon NZ/Pathway to Podium; Chris Milne, Sport and Exercise Physician, Medical Director Rowing NZ; Brendan O’Neill, Sport and Exercise Physician, Medical Director Cycling NZ; Hamish Osborne, Sport and Exercise Physician, Medical Director Basketball NZ; Melinda Parnell, Sport and Exercise Physician, Medical Director Netball NZ; Jake Pearson, Sport and Exercise Physician, Medical Director Paralympics NZ; Karen Rasmussen, New Zealand Rugby Medical Manager; Judikje Scheffer, Sports Doctor/General Practitioner, High Performance Sport NZ Cambridge; Martin Swan, Sports Doctor/General Practitioner, Medical Director NZ Cricket; Mark Thomas, Associate Professor, Faculty of Medical and Health Sciences, The University of Auckland; David Gerrard, Sport and Exercise Physician, Emeritus Professor, Department of Medicine, University of Otago.

Acknowledgements

The authors would like to thank Dr Rob Everitt for his support in the preparation of this transcript.

Correspondence

Dr Bruce Hamilton, Director of Performance Health, High Performance Sport New Zealand, AUT-Millenium Institute of Sport and Health, Mairangi Bay, Auckland.

Correspondence Email

bruce.hamilton@hpsnz.org.nz

Competing Interests

Dr Hamilton reports non-financial support from High Performance Sport NZ during the conduct of the study; Dr Gerrard is the Chair of the Therapeutic Use Exemption Committee (TUEC) Drug-Free Sport New Zealand; Chair, World Anti-Doping Agency (WADA) TUE Expert Group; Chair, TUEC, World Rugby; Vice-Chair, Sports Medicine Committee, International Swimming Federation (FINA); Dr Fulcher reports personal fees from New Zealand Football during the conduct of the study; medical director for New Zealand Football; member of the FIFA Medical Committee; Dr Exeter is a contractor to High Performance Sport NZ; Dr Coleman is a contractor for medical services.

1. Munster VJ, Koopmans M, van Doremalen N, et al. A Novel Coronavirus Emerging in China - Key Questions for Impact Assessment. New England Journal of Medicine. 2020; January 24.

2. van Doremalen N, Morris DH, Holbrook MG, et al. Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. New England Journal of Medicine. 2020; March 17:1–3.

3. Liu Y, Gayle AA, Wilder-Smith A,Rocklov J. The reproductive number of COVID-19 is higher compared to SARS coronavirus. Journal of Travel Medicine. 2020:1–4.

4. Flaxman S, Mishra S, Gandy A, et al. Estimating the nmber of infections and the impact of non-pharmaceutical interventions on COVID-19 in 11 European countries. Imperial College COVID-19 Response Team. 2020.

5. Mungroo MR, Khan NA, Siddiqui R. Novel Coronavirus: Current Understanding of Clinical Features, Diagnosis, Pathogenesis, and Treatment Options. Pathogens. 2020; 9.

6. Eirale C, Bisciotti G, Corsini A, et al. Medical recommendations for home-confined footballers’ training during the COVID-19 pademic: from evidence to practical application. Biology of Sport. 2020; 37:203–207.

7. Beable S, Fulcher M, Lee AC, Hamilton B. SHARPSports mental Health Awareness Research Project: Prevalence and risk factors of depressive symptoms and life stress in elite athletes. J Sci Med Sport. 2017.

8. Kim SSY, Hamilton B, Beable S, et al. Elite coaches have a similar prevalence of depressive symptoms to the general population and lower rates than elite athletes. BMJ Open Sport & Exercise Medicine. 2020; 6.

9. Hull J, Loosemore M, Schewellnus M. Respiratory Health in Athletes: facing the COVID-19 challenge. Lancet Respiratory Medicine. 2020; Published on-line April 8.

10. Schwellnus M, Soligard T, Alonso JM, et al. How much is too much? (Part 2) International Olympic Committee consensus statement on load in sport and risk of illness. Br J Sports Med. 2016; 50:1043–52.

11. Federation ISM, Recommendations relating to sport and Covid-19, http://www.fmsi.it/images/img/archivio/CS_Raccomandazioni_FMSI_20200404.pdf, Editor. 2020: Italy.

12. Moore A, Kirkman A, Aradagh M, et al, Getting Through Together. Ethical Values for a Pandemic, Committee NEA, Editor. 2007: Ministry of Health.

13. Quilty B, Clifford S, Group. CnW, et al. Effectiveness of airport screening at detecting travellers infected with novel coronavirus (2019-nCoV). European Communicable Diseases Bulletin. 2020.

14. Htun HL, Lim DW, Kyaw WM, et al. Responding to the COVID-19 outbreak in Singapore: Staff Protectin and Staff Temperature and Sickness Surveillance Systems. Clinical Infectious Diseases. 2020.

15. Baka A, Cenciarelli O, ECDC Technical Report: Interim guidance for environmental cleaning in non-healthcare facilities exposed to SARS-CoV-2. 2020, ECDC: http://www.ecdc.europa.eu/sites/default/files/documents/coronavirus-SARS-CoV-2-guidance-environmental-cleaning-non-healthcare-facilities.pdf

16. Bourouiba L. Turbulent Gas Clouds and Respiratory Pathogen Emissions. Potential Implications for Reducing Transmission of COVID-19. JAMA. 2020; Published online March 26, 2020.

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In late December 2019, a cluster of atypical pneumonia cases in Wuhan China resulted in the identification of novel coronavirus SARS-CoV-2 and a disease known as COVID-19.1 The novel virus has spread rapidly across the globe, and continues to pose unique clinical and scientific challenges. Spread by droplets from symptomatic and asymptomatic individuals, and able to survive on surfaces for up to 72 hours,2 COVID-19 has a reproduction number, or key indicator of infectivity, ranging from one to more than four.3 Its infectivity has been shown to be influenced by a range of social distancing measures.4 The clinical presentation of COVID-19 varies from mild upper respiratory symptoms, to a terminal pneumonic process recalcitrant to current treatments. The effectiveness and sustainability of serological responses are yet to be determined and there is currently no vaccination or COVID-19 specific treatment available.5

New Zealand identified its first case of COVID-19 on 28 February, and the WHO declared a pandemic on 12 March 2020. By mid-March all international arrivals in New Zealand were required to self-isolate, New Zealanders overseas were being encouraged to return home, and on 19 March New Zealand’s borders were closed to almost everyone except New Zealanders. The Government released a four-level public health strategy for managing the pandemic on 21 March, and at midnight on 25 March, New Zealand entered a Level Four Alert. This meant that other than essential workers, New Zealanders were required to ‘stay at home’, businesses were closed and exercise was limited to the home or immediate neighbourhood.

As a consequence of these stringent but necessary measures, elite athletes have been challenged by the cessation of all domestic and international sport including the postponement of the 2020 Olympic Games. This has resulted in disruption to training and competition schedules with a concomitant impact upon the mental and physical wellbeing of athletes, coaches and other support personnel.6 Elite athletes and their coaches are not immune to mental health issues, which may be exacerbated by the inability to train and compete, as well as the broader pandemic lifestyle constraints.7,8 Known for their propensity to exertional bronchial hyperreactivity, elite athletes also demonstrate relative immune compromise associated with high training load and these factors could increase susceptibility to COVID-19.9,10 Further, following relative inactivity there are data linking resumption of training with increased risk of injury,10 thereby increasing the vulnerability of elite athletes as training resumes.6 Recognition of the unique demands of elite sport, athlete immune status and relative injury/illness risks are the genesis of guidelines to support the health and wellbeing of elite athletes. International sporting federations, sports medicine practitioners and kindred organisations have begun to develop protocols, relevant for specific countries and sport disciplines during the pandemic.6,11

Over the ensuing months New Zealand athletes will transition from the relative isolation of home-based training, to ‘new normal’ interaction with coach and support personnel. The process of transition will carry challenges and risks unique to each individual and their sport. Sport New Zealand, High Performance Sport New Zealand (HPSNZ) and other sporting bodies have established population-based guidelines for the resumption of sport and exercise at the various COVID-19 Levels, consistent with Government public health regulations, that are in turn informed by the New Zealand Ministry of Health (MOH).

This document provides evidence and consensus-based guidelines relevant to the medical support of New Zealand elite athletes during the transition to a ’new normal’ in the New Zealand environment. The following recommendations have resulted from consultation between the medical officers of New Zealand’s major sporting codes, Sports Medicine New Zealand and other health specialists. The specific foci of the consensus are the medical considerations relevant to the transition period characterised by a gradual re-opening of elite sporting facilities and a resumption of group-based training. While specific details of New Zealand COVID-19 levels may vary over time and potentially by location, this document assumes a situation whereby isolation ‘bubbles’ are no longer operating for the majority of the population.

Ethics and advocacy

Medical practitioners working in elite sport must continue to act as advocates for the wellbeing of athletes, while balancing the public health imperatives of a pandemic. During these unprecedented times in which the support of elite athletes must be contextualised on a ‘new-normal landscape’, and when difficult decisions involving conflicting needs must be made, it is critical that practitioners place medical ethics at the fore. When ethical values and principles inform decision making processes, those decisions carry a legitimacy that ultimately facilitates alignment and impact.12

To ensure the best outcomes, both how decisions are made and what decisions are made should be informed by ethics and values recognisable and shared by the broader community. This includes respecting the ethical principles of justice, non-maleficence, beneficence and autonomy. However, the ethical values that guide our decision-making should also take into account broader considerations of openness, inclusiveness, reasonableness, responsibleness and responsiveness (for a full discussion of ethical considerations during a pandemic, readers are directed to “Getting Through Together. Ethical Values for a Pandemic”).12

Healthcare facilities in the elite sporting environment

Healthcare facilities for elite athletes in New Zealand were closed during Level Three and Four, and consulting for both medicine and physiotherapy during this period was conducted by tele-health. Consistent with a graduated approach to the loosening of restrictions, at Level Two, the majority of sporting and healthcare facilities for elite athletes re-opened. Numerous public health requirements remain in place, including the need for physical distancing, public gathering restrictions, contact tracing and the need for at-risk individuals to remain at home.

Given the novel nature of the public health situation, the safe delivery of health services from training facilities and high-performance environments requires careful consideration and preparation.

Access to healthcare facilities should be regulated with a recommended single point of entry and exit, with incidental transit through healthcare facilities avoided. Access should ideally require someone inside the facility to admit individuals after ringing a ‘doorbell’ or equivalent. The triage of all patients from a car park, or equivalent area outside the healthcare facility will ensure each individual is appropriate to enter the centre. The triage may involve questions regarding the nature of the consultation, any change in their health status with respect to COVID-19 symptoms and contact with any potential COVID-19 patient since their last visit. While the use of routine temperature assessment in combination with triage questions may increase the sensitivity to detecting an early infection, its isolated use as a screening tool has been questioned.13 Notwithstanding the logistical challenges, an elevated temperature either in isolation or in combination with an affirmative response to any triage question would warrant further discussion and may influence any decision to allow the patient to enter the healthcare facility.14Waiting areas should not be utilised, with patients entering the centre only when the consultation space and respective clinician are ready. In the interests of accurate contact tracing, should this be necessary, accurate records of all clinic attendees must be documented with due respect for confidentiality.

To allow appropriate physical distancing and minimise potential infection transmission, numbers of staff and patients in any healthcare facility should be restricted. Each facility will need to determine an effective ratio concomitant with the separation of areas such as open-plan physiotherapy and massage therapy workspaces. Administrative workspaces must also allow appropriate physical distancing. To facilitate this, operating models will require flexibility that enables individuals to work from home, in rotating shifts, or to perform non-clinical duties in other workspaces.

That SARS-CoV-2 can survive on surfaces for several days2 means that cleaning of clinical and administrative areas within a healthcare facility requires particular consideration. Attention should be paid to the protocols for daily intensive cleans, between patient cleaning, and regular centre cleaning. Use of alcohol-based or equivalently evidenced cleaning products is recommended,15 with responsibility and accountability for cleaning clearly articulated and monitored.

Medical practitioners working in elite sport also have a responsibility to ensure that appropriate hygiene strategies are established across all areas of the training and sporting environment to mitigate against infection transmission. Practitioners should view the pandemic as an opportunity to enhance sport-wide hygiene practices including cleaning strategies, approaches to clinical and communal team areas, blood and respiratory pathogen transmission control, and the implementation of public health measures.

Clinical consultations

In order to minimise contact time within healthcare facilities, consultations should, when possible, be performed using telehealth. When necessary to assess in person, it is recommended that preliminary history gathering still be completed by telehealth. This could be completed while the athlete is in the carpark, prior to performing an examination within the healthcare facility. In an effort to keep in-person consultation times below 15 minutes, post-examination discussions and communication should also be completed by phone or conference calling. Investigations and prescriptions should be instigated electronically when possible.

In the elite sport environment, it is common for coaches and other support staff to be included in some athlete consultations. During this period, it is recommended that consultations are a one-on-one event only, with telehealth modalities used to include additional individuals as required.

During periods where SARS-CoV-2 continues to potentially circulate in the community, it is recommended that any individual presenting with symptoms consistent with infectious disease be managed through an established alternative clinical pathway, outside of elite sporting facilities. Symptoms consistent with a possible infection, detected through the telehealth history taking or the mandatory triage process, could be referred to the individual’s general practitioner, or other healthcare provider as determined by regional approaches to COVID-19 detection and management.

Personal protective equipment (PPE)

SARS-CoV-2 is known to be transmitted up to 48 hours before the development of symptoms and may be disseminated up to metres during coughing and sneezing.16 When treating elite athletes, close contact is routine, demanding the careful consideration of the use of PPE.

At Level Two, when elite sporting facilities and associated medical facilities reopened, there were low levels of circulating COVID-19 in the community. Based on MOH guidelines, the use of full, hospital-level PPE is unlikely to be necessary for routine consultations, particularly where potentially infectious athletes are triaged via telehealth and managed externally.

The New Zealand Government does not currently recommend the routine use of facemasks in the community unless an individual is experiencing respiratory symptoms or is diagnosed with COVID-19.17 However, in the context of the sports medicine clinic, the use of a face mask may mitigate droplet spread from a hitherto asymptomatic individual. Therefore, to allay the concerns of any patient or provider, it is recommended that at least in the early post-peak pandemic phases during consultation and treatment, patients and practitioners wear protective medical facemasks in accordance with their appropriate use and in full knowledge of their limitations. This assumes development of clear protocols for facemask use in specific elite sport settings. Given the low prevalence in New Zealand, the health checks on athletes at entry to elite sport facilities and the pragmatic realities of consulting in the elite environment, full face shields are not currently recommended.

Load management, mitigation and monitoring

It is well recognised that periods of relative inactivity or modified training load can have a negative impact on musculoskeletal adaptation and cardiorespiratory fitness.18 Subsequently, there is a relative increase in risk of re-injury upon the resumption of training (HPSNZ Performance Health unpublished data) related to both athlete-specific intrinsic factors, and the rate of load application. Irrespective of the cause of reduced training load, the risk of injury on return may be mitigated by the careful multi-disciplinary planning for the reintroduction of training volume and intensity, taking into consideration both individual and squad-based factors. Within the constraints of COVID-19 restrictions, maximising approaches to recovery, including physiological monitoring, nutrition, sleep and soft tissue therapies will support the optimisation of training load.

Immune function

While the immediate immunological and antibody response to SARS-CoV-2 infection is yet to be fully understood,19 it is important that an elite athlete’s immune system is not impaired when returning to the training environment.

The effectiveness of an athlete’s immune system is influenced by multiple intrinsic and extrinsic factors but compromised immune systems place individuals at greater risk of infection when exposed.20 An individual’s underlying medical status and/or routine use of certain medications may influence the efficacy of their immune function, and those individuals should be identified, with their particular circumstances carefully considered when addressing a return to training and group activities in the post-peak pandemic phase. This is particularly relevant when supporting para-athletes, in whom chronic health conditions may increase infection susceptibility and consequence. Similarly, training volume and intensity is well recognised to have an impact on immune function, and all athletes will respond uniquely to a given training situation.10 Finally, in addition to training load and volume, stress resulting from poor sleep quality, inadequate nutrition, low mood and ineffective recovery strategies may all negatively impact upon an individual’s immune function.

Healthcare providers are well positioned and have a responsibility to facilitate a multi-disciplinary approach to optimising an individual elite athlete’s immune function. This will require advanced planning and coordination within individual sporting codes.

Monitoring COVID-19 status

Polymerase chain reaction (PCR) testing is currently utilised in New Zealand for confirming the presence of SARS-CoV-2 infection in a symptomatic individual, and determining the presence of infection in the broader asymptomatic population. Despite its potentially low detection sensitivity in asymptomatic individuals, some medical bodies are advocating for the routine and regular testing of elite athletes with PCR in order to ensure athletes are not contagious.11 In the current New Zealand environment, with no or low rates of identified community transmission, the routine or regular use of PCR testing in elite athletes is not considered necessary. However, while some organisations may choose to utilise PCR testing as part of a broader strategy, this must not be at the expense of other infection control measures.

While antibody seroconversion has been observed following SARS-CoV-2 infection, it is unclear how long this is sustained, and whether it confers lasting immunity.21,22 Furthermore, at the time of writing, there is no valid means of assessing an individual’s immunity to SARS-CoV-2. Current serological tests for IgG and IgM have proven to be unreliable in many countries, and as yet no testing procedure has been approved in New Zealand. Therefore, the routine use of serology (IgG/IgM) to evaluate SARS-CoV-2 status of elite athletes is not currently indicated in New Zealand.

The potential impact of asymptomatic SARS-CoV-2 infections on the heart and other organs remains to be elucidated, but this detail may inform future decisions on the need to understand the COVID-19 status of elite athletes. Furthermore, given the high respiratory rates and close proximity often associated with elite sport, athletes may pose a high risk of virus transmission when either pre-symptomatic or asymptomatic. Subsequently, recommendations on monitoring may change as the impact of symptomatic and asymptomatic infections on the heart and other organs becomes clear, immunological knowledge expands, New Zealand infection rates change, or new technology becomes available.

Athlete psychological wellbeing

It is well recognised that athletes have a similar or slightly higher risk of mental health issues including anxiety and depression when compared to the general population.7 Periods of uncertainty, isolation and transition may exacerbate symptoms in those with known susceptibility, or elevate symptoms in those with no previous mental health issues.23

A high level of awareness is required by all support personnel interacting with athletes at this time. Atypical behaviour, lack of engagement, loss of motivation, as well as physical changes such as loss of appetite and poor sleep, may all indicate a change in mental state. In addition to maintaining a high level of vigilance for mental health issues, medical practitioners, working closely with psychologists should consider the use of brief mental health assessments (such as the ‘DASS-21’) as part of a routine post-level four health screening approach.

The use of general wellbeing data (including sleep quality, mood, energy), often collected and collated by a range of disciplines within elite sport, should be rationalised through-out the COVID-19 pandemic. In collaboration with the relevant psychologists, medical practitioners should have an established protocol for reviewing wellbeing data throughout this period.

Vaccination

While intensive research and development is underway, the development of vaccines for pre-existing coronavirus has proven difficult,24 and there is currently no effective vaccine for COVID-19. When there is a New Zealand Government approved COVID-19 vaccine and approach to public vaccination, it is recommended that elite athletes and support staff are vaccinated.

Unless contraindicated, completion of the New Zealand Immunisation Schedule and an annual influenza vaccination is recommended for elite athletes and their support personnel.

Medications and COVID-19

While concerns have been expressed that medications that alter immune function (eg, glucocorticoids) may increase susceptibility to COVID-19 infections, based on current evidence it is recommended that the ongoing management of chronic health conditions is not altered due to pandemic considerations.

Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most frequently prescribed medication to elite athletes.25 While evidence is sparse that NSAIDs may exacerbate infections, the pandemic may provide an opportunity for a more judicious approach to NSAID prescription, particularly when managing upper respiratory symptoms.26

Regardless of symptoms, when prescribing to athletes during this period, it is important that medical practitioners are cognisant of the impact of medication on the immune system.27

COVID-19 positive athletes

It is important that healthcare providers in elite sport have strategies to manage athletes who may either be infected, or who have recovered from COVID-19.

Acute COVID-19 infections should be managed in accordance with MOH guidelines, including case-reporting and quarantine. Specialist hospital support may be indicated depending on the clinical situation. Given the uncertain clinical outcomes of COVID-19 and the lack of data on the influence of exercise, elite athletes with confirmed COVID-19 should not be performing physical exercise until provided with a medical clearance from the appropriate public health authority.

Prior to returning to elite sport, but after symptoms resolution and receiving a public health clearance, an elite athlete diagnosed with COVID-19 requires review by their sport-specific medical practitioner.

SARS-CoV-2 binds to cells in the lung via receptors such as angiotensin-converting enzyme 2 (ACE2), but those same receptors are also found in many other organs including the heart.28 Acute myocarditis has been described in previous coronavirus outbreaks,29 and the clinical outcome of COVID-19 patients with cardiovascular comorbidities is poor.28 As a result, international sports medicine bodies have recommended the intensive cardiac evaluation of elite athletes prior to returning to sport training.11,30,31 In the New Zealand environment, it is recommended that any athlete diagnosed with COVID-19 has a cardiology review prior to resuming training. Upon receiving a cardiological clearance, the individual athlete’s clinical course should be considered when planning a graduated return to training, and reintegration into a training environment.

It is important that the development of any stigma associated with COVID-19 infection be avoided, by normalising and promoting the healthcare process as a standard approach, and ensuring an understanding of the COVID-19 infection by all staff and athletes.

Managing a COVID-19 related death

While it is likely that elite New Zealand athletes have been infected with COVID-19, to date there have been no reported deaths. If New Zealand is able to maintain a low rate of community transmission, it is hoped that this situation will continue. However, practitioners working within elite sporting organisations should ensure that there is an appropriate response strategy for the unexpected death of an athlete, family member or someone within the sporting organisation. That strategy should include the immediate access to counselling and psychological support.

Travel

During the immediate post-peak pandemic period, it is anticipated that international travel will be negligible and internal travel within New Zealand will be minimised. Medical practitioners must ensure that during any sport-related internal travel, appropriate hygiene strategies are established and normalised within team environments. This may include the intensified use of hand sanitiser/hand washing, regular cleaning of surfaces, cough and sneeze etiquette, and any travel-specific physical distancing or contact tracing requirements. Ensuring adequate sleep and nutrition, along with the avoidance of heavy training loads immediately prior to travel, will facilitate healthy travel outcomes.

The future and nature of international sport-related travel requires further consideration as the pandemic evolves.

Education/information sharing

Ensuring that elite athletes, coaches and support staff are well informed regarding both COVID-19, the relevant sporting considerations and the public health requirements of differing COVID-19 levels is important for optimising athlete health, wellbeing and compliance. In addition to publicly available health messages, the provision of sport-specific information and education should utilise a range of modalities, and where possible could involve the use of key athletes to deliver relevant messages.

Finally, as athletes resume squad-based training, it is recommended that in conjunction with coaching staff, sport-specific medicine, psychology and athlete life specialists provide an interactive education and information sharing session to support the athlete and coach transition from relative isolation.

Conclusion

The novel virus causing COVID-19 has already had an unprecedented impact on international health, economies and sport. With a clear COVID-19 national strategy and its early implementation, New Zealand has to date avoided the devastating levels of infection and death witnessed overseas. However, the COVID-19 pandemic is a global challenge whose course, in the absence of an effective vaccine, is difficult to predict.

There is a desire from sporting organisations, athletes and the public for sport, exercise and training to resume as soon as appropriate. This includes the desire for elite athletes to return to training and ultimately competition. Health support embedded within elite sporting organisations must also consider broad public health consequence and align with Government guidelines for delivering health services. Medical practitioners will play a key role in interpreting and applying Government regulations in the various sporting codes.

Medical practitioners will undoubtedly assist in the emergence of elite sport from COVID-19 restrictions, through supporting both athlete’s health and sporting organisations readiness for the ‘new normal’. When considering those factors outlined above, practitioners should routinely support an inter-disciplinary approach to athlete care, incorporating the views of coaching staff, medicine, psychology, athlete life, physiology, nutrition and strength and conditioning expertise. This document facilitates that integrated process by providing a framework for medical practitioners and sporting organisations to consider, as elite sporting activity gradually resumes.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Bruce Hamilton, Sport and Exercise Physician, Director of Performance Health High Performance Sport NZ/NZ Olympic Committee, Medical Director Canoe Racing NZ; Lynley Anderson, Associate Professor, Bioethics Centre, Division of Health Sciences, University of Otago; Nat Anglem, Sport and Exercise Physician, Medical Director Snow Sports NZ; Stuart Armstrong, Sport and Exercise Physician, Doctor Rowing NZ, Associate Editor NZ Journal of Sports Medicine; Simon Baker, ACSEP Registrar, Medical Director Hockey (Men) NZ; Sarah Beable, Sport and Exercise Physician, High Performance Sport NZ/Snow Sports NZ Medical Practitioner; Peter Burt, Sports Doctor/General Practitioner, PhD Candidate, Bioethics Centre, Division of Health Sciences, University of Otago; Lynne Coleman, Sports Doctor/General Practitioner, Medical Director Swimming NZ; Rob Doughty, Cardiology Professor, Heart Foundation Chair, Heart Health, Auckland University; Tony Edwards, Sport and Exercise Physician, Medical Director Hockey (Women) NZ; Dan Exeter, Sport and Exercise Physician, Medical Director Athletics NZ; Mark Fulcher, Sport and Exercise Physician, Medical Director Football NZ; Stephen Kara, ACSEP Registrar, President Sports Medicine New Zealand; John Mayhew, Sports Doctor/General Practitioner, Medical Director NZ Rugby League; Sam Mayhew, Sports Doctor/General Practitioner, Medical Director Triathlon NZ/Pathway to Podium; Chris Milne, Sport and Exercise Physician, Medical Director Rowing NZ; Brendan O’Neill, Sport and Exercise Physician, Medical Director Cycling NZ; Hamish Osborne, Sport and Exercise Physician, Medical Director Basketball NZ; Melinda Parnell, Sport and Exercise Physician, Medical Director Netball NZ; Jake Pearson, Sport and Exercise Physician, Medical Director Paralympics NZ; Karen Rasmussen, New Zealand Rugby Medical Manager; Judikje Scheffer, Sports Doctor/General Practitioner, High Performance Sport NZ Cambridge; Martin Swan, Sports Doctor/General Practitioner, Medical Director NZ Cricket; Mark Thomas, Associate Professor, Faculty of Medical and Health Sciences, The University of Auckland; David Gerrard, Sport and Exercise Physician, Emeritus Professor, Department of Medicine, University of Otago.

Acknowledgements

The authors would like to thank Dr Rob Everitt for his support in the preparation of this transcript.

Correspondence

Dr Bruce Hamilton, Director of Performance Health, High Performance Sport New Zealand, AUT-Millenium Institute of Sport and Health, Mairangi Bay, Auckland.

Correspondence Email

bruce.hamilton@hpsnz.org.nz

Competing Interests

Dr Hamilton reports non-financial support from High Performance Sport NZ during the conduct of the study; Dr Gerrard is the Chair of the Therapeutic Use Exemption Committee (TUEC) Drug-Free Sport New Zealand; Chair, World Anti-Doping Agency (WADA) TUE Expert Group; Chair, TUEC, World Rugby; Vice-Chair, Sports Medicine Committee, International Swimming Federation (FINA); Dr Fulcher reports personal fees from New Zealand Football during the conduct of the study; medical director for New Zealand Football; member of the FIFA Medical Committee; Dr Exeter is a contractor to High Performance Sport NZ; Dr Coleman is a contractor for medical services.

1. Munster VJ, Koopmans M, van Doremalen N, et al. A Novel Coronavirus Emerging in China - Key Questions for Impact Assessment. New England Journal of Medicine. 2020; January 24.

2. van Doremalen N, Morris DH, Holbrook MG, et al. Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. New England Journal of Medicine. 2020; March 17:1–3.

3. Liu Y, Gayle AA, Wilder-Smith A,Rocklov J. The reproductive number of COVID-19 is higher compared to SARS coronavirus. Journal of Travel Medicine. 2020:1–4.

4. Flaxman S, Mishra S, Gandy A, et al. Estimating the nmber of infections and the impact of non-pharmaceutical interventions on COVID-19 in 11 European countries. Imperial College COVID-19 Response Team. 2020.

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6. Eirale C, Bisciotti G, Corsini A, et al. Medical recommendations for home-confined footballers’ training during the COVID-19 pademic: from evidence to practical application. Biology of Sport. 2020; 37:203–207.

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8. Kim SSY, Hamilton B, Beable S, et al. Elite coaches have a similar prevalence of depressive symptoms to the general population and lower rates than elite athletes. BMJ Open Sport & Exercise Medicine. 2020; 6.

9. Hull J, Loosemore M, Schewellnus M. Respiratory Health in Athletes: facing the COVID-19 challenge. Lancet Respiratory Medicine. 2020; Published on-line April 8.

10. Schwellnus M, Soligard T, Alonso JM, et al. How much is too much? (Part 2) International Olympic Committee consensus statement on load in sport and risk of illness. Br J Sports Med. 2016; 50:1043–52.

11. Federation ISM, Recommendations relating to sport and Covid-19, http://www.fmsi.it/images/img/archivio/CS_Raccomandazioni_FMSI_20200404.pdf, Editor. 2020: Italy.

12. Moore A, Kirkman A, Aradagh M, et al, Getting Through Together. Ethical Values for a Pandemic, Committee NEA, Editor. 2007: Ministry of Health.

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Contact diana@nzma.org.nz
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In late December 2019, a cluster of atypical pneumonia cases in Wuhan China resulted in the identification of novel coronavirus SARS-CoV-2 and a disease known as COVID-19.1 The novel virus has spread rapidly across the globe, and continues to pose unique clinical and scientific challenges. Spread by droplets from symptomatic and asymptomatic individuals, and able to survive on surfaces for up to 72 hours,2 COVID-19 has a reproduction number, or key indicator of infectivity, ranging from one to more than four.3 Its infectivity has been shown to be influenced by a range of social distancing measures.4 The clinical presentation of COVID-19 varies from mild upper respiratory symptoms, to a terminal pneumonic process recalcitrant to current treatments. The effectiveness and sustainability of serological responses are yet to be determined and there is currently no vaccination or COVID-19 specific treatment available.5

New Zealand identified its first case of COVID-19 on 28 February, and the WHO declared a pandemic on 12 March 2020. By mid-March all international arrivals in New Zealand were required to self-isolate, New Zealanders overseas were being encouraged to return home, and on 19 March New Zealand’s borders were closed to almost everyone except New Zealanders. The Government released a four-level public health strategy for managing the pandemic on 21 March, and at midnight on 25 March, New Zealand entered a Level Four Alert. This meant that other than essential workers, New Zealanders were required to ‘stay at home’, businesses were closed and exercise was limited to the home or immediate neighbourhood.

As a consequence of these stringent but necessary measures, elite athletes have been challenged by the cessation of all domestic and international sport including the postponement of the 2020 Olympic Games. This has resulted in disruption to training and competition schedules with a concomitant impact upon the mental and physical wellbeing of athletes, coaches and other support personnel.6 Elite athletes and their coaches are not immune to mental health issues, which may be exacerbated by the inability to train and compete, as well as the broader pandemic lifestyle constraints.7,8 Known for their propensity to exertional bronchial hyperreactivity, elite athletes also demonstrate relative immune compromise associated with high training load and these factors could increase susceptibility to COVID-19.9,10 Further, following relative inactivity there are data linking resumption of training with increased risk of injury,10 thereby increasing the vulnerability of elite athletes as training resumes.6 Recognition of the unique demands of elite sport, athlete immune status and relative injury/illness risks are the genesis of guidelines to support the health and wellbeing of elite athletes. International sporting federations, sports medicine practitioners and kindred organisations have begun to develop protocols, relevant for specific countries and sport disciplines during the pandemic.6,11

Over the ensuing months New Zealand athletes will transition from the relative isolation of home-based training, to ‘new normal’ interaction with coach and support personnel. The process of transition will carry challenges and risks unique to each individual and their sport. Sport New Zealand, High Performance Sport New Zealand (HPSNZ) and other sporting bodies have established population-based guidelines for the resumption of sport and exercise at the various COVID-19 Levels, consistent with Government public health regulations, that are in turn informed by the New Zealand Ministry of Health (MOH).

This document provides evidence and consensus-based guidelines relevant to the medical support of New Zealand elite athletes during the transition to a ’new normal’ in the New Zealand environment. The following recommendations have resulted from consultation between the medical officers of New Zealand’s major sporting codes, Sports Medicine New Zealand and other health specialists. The specific foci of the consensus are the medical considerations relevant to the transition period characterised by a gradual re-opening of elite sporting facilities and a resumption of group-based training. While specific details of New Zealand COVID-19 levels may vary over time and potentially by location, this document assumes a situation whereby isolation ‘bubbles’ are no longer operating for the majority of the population.

Ethics and advocacy

Medical practitioners working in elite sport must continue to act as advocates for the wellbeing of athletes, while balancing the public health imperatives of a pandemic. During these unprecedented times in which the support of elite athletes must be contextualised on a ‘new-normal landscape’, and when difficult decisions involving conflicting needs must be made, it is critical that practitioners place medical ethics at the fore. When ethical values and principles inform decision making processes, those decisions carry a legitimacy that ultimately facilitates alignment and impact.12

To ensure the best outcomes, both how decisions are made and what decisions are made should be informed by ethics and values recognisable and shared by the broader community. This includes respecting the ethical principles of justice, non-maleficence, beneficence and autonomy. However, the ethical values that guide our decision-making should also take into account broader considerations of openness, inclusiveness, reasonableness, responsibleness and responsiveness (for a full discussion of ethical considerations during a pandemic, readers are directed to “Getting Through Together. Ethical Values for a Pandemic”).12

Healthcare facilities in the elite sporting environment

Healthcare facilities for elite athletes in New Zealand were closed during Level Three and Four, and consulting for both medicine and physiotherapy during this period was conducted by tele-health. Consistent with a graduated approach to the loosening of restrictions, at Level Two, the majority of sporting and healthcare facilities for elite athletes re-opened. Numerous public health requirements remain in place, including the need for physical distancing, public gathering restrictions, contact tracing and the need for at-risk individuals to remain at home.

Given the novel nature of the public health situation, the safe delivery of health services from training facilities and high-performance environments requires careful consideration and preparation.

Access to healthcare facilities should be regulated with a recommended single point of entry and exit, with incidental transit through healthcare facilities avoided. Access should ideally require someone inside the facility to admit individuals after ringing a ‘doorbell’ or equivalent. The triage of all patients from a car park, or equivalent area outside the healthcare facility will ensure each individual is appropriate to enter the centre. The triage may involve questions regarding the nature of the consultation, any change in their health status with respect to COVID-19 symptoms and contact with any potential COVID-19 patient since their last visit. While the use of routine temperature assessment in combination with triage questions may increase the sensitivity to detecting an early infection, its isolated use as a screening tool has been questioned.13 Notwithstanding the logistical challenges, an elevated temperature either in isolation or in combination with an affirmative response to any triage question would warrant further discussion and may influence any decision to allow the patient to enter the healthcare facility.14Waiting areas should not be utilised, with patients entering the centre only when the consultation space and respective clinician are ready. In the interests of accurate contact tracing, should this be necessary, accurate records of all clinic attendees must be documented with due respect for confidentiality.

To allow appropriate physical distancing and minimise potential infection transmission, numbers of staff and patients in any healthcare facility should be restricted. Each facility will need to determine an effective ratio concomitant with the separation of areas such as open-plan physiotherapy and massage therapy workspaces. Administrative workspaces must also allow appropriate physical distancing. To facilitate this, operating models will require flexibility that enables individuals to work from home, in rotating shifts, or to perform non-clinical duties in other workspaces.

That SARS-CoV-2 can survive on surfaces for several days2 means that cleaning of clinical and administrative areas within a healthcare facility requires particular consideration. Attention should be paid to the protocols for daily intensive cleans, between patient cleaning, and regular centre cleaning. Use of alcohol-based or equivalently evidenced cleaning products is recommended,15 with responsibility and accountability for cleaning clearly articulated and monitored.

Medical practitioners working in elite sport also have a responsibility to ensure that appropriate hygiene strategies are established across all areas of the training and sporting environment to mitigate against infection transmission. Practitioners should view the pandemic as an opportunity to enhance sport-wide hygiene practices including cleaning strategies, approaches to clinical and communal team areas, blood and respiratory pathogen transmission control, and the implementation of public health measures.

Clinical consultations

In order to minimise contact time within healthcare facilities, consultations should, when possible, be performed using telehealth. When necessary to assess in person, it is recommended that preliminary history gathering still be completed by telehealth. This could be completed while the athlete is in the carpark, prior to performing an examination within the healthcare facility. In an effort to keep in-person consultation times below 15 minutes, post-examination discussions and communication should also be completed by phone or conference calling. Investigations and prescriptions should be instigated electronically when possible.

In the elite sport environment, it is common for coaches and other support staff to be included in some athlete consultations. During this period, it is recommended that consultations are a one-on-one event only, with telehealth modalities used to include additional individuals as required.

During periods where SARS-CoV-2 continues to potentially circulate in the community, it is recommended that any individual presenting with symptoms consistent with infectious disease be managed through an established alternative clinical pathway, outside of elite sporting facilities. Symptoms consistent with a possible infection, detected through the telehealth history taking or the mandatory triage process, could be referred to the individual’s general practitioner, or other healthcare provider as determined by regional approaches to COVID-19 detection and management.

Personal protective equipment (PPE)

SARS-CoV-2 is known to be transmitted up to 48 hours before the development of symptoms and may be disseminated up to metres during coughing and sneezing.16 When treating elite athletes, close contact is routine, demanding the careful consideration of the use of PPE.

At Level Two, when elite sporting facilities and associated medical facilities reopened, there were low levels of circulating COVID-19 in the community. Based on MOH guidelines, the use of full, hospital-level PPE is unlikely to be necessary for routine consultations, particularly where potentially infectious athletes are triaged via telehealth and managed externally.

The New Zealand Government does not currently recommend the routine use of facemasks in the community unless an individual is experiencing respiratory symptoms or is diagnosed with COVID-19.17 However, in the context of the sports medicine clinic, the use of a face mask may mitigate droplet spread from a hitherto asymptomatic individual. Therefore, to allay the concerns of any patient or provider, it is recommended that at least in the early post-peak pandemic phases during consultation and treatment, patients and practitioners wear protective medical facemasks in accordance with their appropriate use and in full knowledge of their limitations. This assumes development of clear protocols for facemask use in specific elite sport settings. Given the low prevalence in New Zealand, the health checks on athletes at entry to elite sport facilities and the pragmatic realities of consulting in the elite environment, full face shields are not currently recommended.

Load management, mitigation and monitoring

It is well recognised that periods of relative inactivity or modified training load can have a negative impact on musculoskeletal adaptation and cardiorespiratory fitness.18 Subsequently, there is a relative increase in risk of re-injury upon the resumption of training (HPSNZ Performance Health unpublished data) related to both athlete-specific intrinsic factors, and the rate of load application. Irrespective of the cause of reduced training load, the risk of injury on return may be mitigated by the careful multi-disciplinary planning for the reintroduction of training volume and intensity, taking into consideration both individual and squad-based factors. Within the constraints of COVID-19 restrictions, maximising approaches to recovery, including physiological monitoring, nutrition, sleep and soft tissue therapies will support the optimisation of training load.

Immune function

While the immediate immunological and antibody response to SARS-CoV-2 infection is yet to be fully understood,19 it is important that an elite athlete’s immune system is not impaired when returning to the training environment.

The effectiveness of an athlete’s immune system is influenced by multiple intrinsic and extrinsic factors but compromised immune systems place individuals at greater risk of infection when exposed.20 An individual’s underlying medical status and/or routine use of certain medications may influence the efficacy of their immune function, and those individuals should be identified, with their particular circumstances carefully considered when addressing a return to training and group activities in the post-peak pandemic phase. This is particularly relevant when supporting para-athletes, in whom chronic health conditions may increase infection susceptibility and consequence. Similarly, training volume and intensity is well recognised to have an impact on immune function, and all athletes will respond uniquely to a given training situation.10 Finally, in addition to training load and volume, stress resulting from poor sleep quality, inadequate nutrition, low mood and ineffective recovery strategies may all negatively impact upon an individual’s immune function.

Healthcare providers are well positioned and have a responsibility to facilitate a multi-disciplinary approach to optimising an individual elite athlete’s immune function. This will require advanced planning and coordination within individual sporting codes.

Monitoring COVID-19 status

Polymerase chain reaction (PCR) testing is currently utilised in New Zealand for confirming the presence of SARS-CoV-2 infection in a symptomatic individual, and determining the presence of infection in the broader asymptomatic population. Despite its potentially low detection sensitivity in asymptomatic individuals, some medical bodies are advocating for the routine and regular testing of elite athletes with PCR in order to ensure athletes are not contagious.11 In the current New Zealand environment, with no or low rates of identified community transmission, the routine or regular use of PCR testing in elite athletes is not considered necessary. However, while some organisations may choose to utilise PCR testing as part of a broader strategy, this must not be at the expense of other infection control measures.

While antibody seroconversion has been observed following SARS-CoV-2 infection, it is unclear how long this is sustained, and whether it confers lasting immunity.21,22 Furthermore, at the time of writing, there is no valid means of assessing an individual’s immunity to SARS-CoV-2. Current serological tests for IgG and IgM have proven to be unreliable in many countries, and as yet no testing procedure has been approved in New Zealand. Therefore, the routine use of serology (IgG/IgM) to evaluate SARS-CoV-2 status of elite athletes is not currently indicated in New Zealand.

The potential impact of asymptomatic SARS-CoV-2 infections on the heart and other organs remains to be elucidated, but this detail may inform future decisions on the need to understand the COVID-19 status of elite athletes. Furthermore, given the high respiratory rates and close proximity often associated with elite sport, athletes may pose a high risk of virus transmission when either pre-symptomatic or asymptomatic. Subsequently, recommendations on monitoring may change as the impact of symptomatic and asymptomatic infections on the heart and other organs becomes clear, immunological knowledge expands, New Zealand infection rates change, or new technology becomes available.

Athlete psychological wellbeing

It is well recognised that athletes have a similar or slightly higher risk of mental health issues including anxiety and depression when compared to the general population.7 Periods of uncertainty, isolation and transition may exacerbate symptoms in those with known susceptibility, or elevate symptoms in those with no previous mental health issues.23

A high level of awareness is required by all support personnel interacting with athletes at this time. Atypical behaviour, lack of engagement, loss of motivation, as well as physical changes such as loss of appetite and poor sleep, may all indicate a change in mental state. In addition to maintaining a high level of vigilance for mental health issues, medical practitioners, working closely with psychologists should consider the use of brief mental health assessments (such as the ‘DASS-21’) as part of a routine post-level four health screening approach.

The use of general wellbeing data (including sleep quality, mood, energy), often collected and collated by a range of disciplines within elite sport, should be rationalised through-out the COVID-19 pandemic. In collaboration with the relevant psychologists, medical practitioners should have an established protocol for reviewing wellbeing data throughout this period.

Vaccination

While intensive research and development is underway, the development of vaccines for pre-existing coronavirus has proven difficult,24 and there is currently no effective vaccine for COVID-19. When there is a New Zealand Government approved COVID-19 vaccine and approach to public vaccination, it is recommended that elite athletes and support staff are vaccinated.

Unless contraindicated, completion of the New Zealand Immunisation Schedule and an annual influenza vaccination is recommended for elite athletes and their support personnel.

Medications and COVID-19

While concerns have been expressed that medications that alter immune function (eg, glucocorticoids) may increase susceptibility to COVID-19 infections, based on current evidence it is recommended that the ongoing management of chronic health conditions is not altered due to pandemic considerations.

Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most frequently prescribed medication to elite athletes.25 While evidence is sparse that NSAIDs may exacerbate infections, the pandemic may provide an opportunity for a more judicious approach to NSAID prescription, particularly when managing upper respiratory symptoms.26

Regardless of symptoms, when prescribing to athletes during this period, it is important that medical practitioners are cognisant of the impact of medication on the immune system.27

COVID-19 positive athletes

It is important that healthcare providers in elite sport have strategies to manage athletes who may either be infected, or who have recovered from COVID-19.

Acute COVID-19 infections should be managed in accordance with MOH guidelines, including case-reporting and quarantine. Specialist hospital support may be indicated depending on the clinical situation. Given the uncertain clinical outcomes of COVID-19 and the lack of data on the influence of exercise, elite athletes with confirmed COVID-19 should not be performing physical exercise until provided with a medical clearance from the appropriate public health authority.

Prior to returning to elite sport, but after symptoms resolution and receiving a public health clearance, an elite athlete diagnosed with COVID-19 requires review by their sport-specific medical practitioner.

SARS-CoV-2 binds to cells in the lung via receptors such as angiotensin-converting enzyme 2 (ACE2), but those same receptors are also found in many other organs including the heart.28 Acute myocarditis has been described in previous coronavirus outbreaks,29 and the clinical outcome of COVID-19 patients with cardiovascular comorbidities is poor.28 As a result, international sports medicine bodies have recommended the intensive cardiac evaluation of elite athletes prior to returning to sport training.11,30,31 In the New Zealand environment, it is recommended that any athlete diagnosed with COVID-19 has a cardiology review prior to resuming training. Upon receiving a cardiological clearance, the individual athlete’s clinical course should be considered when planning a graduated return to training, and reintegration into a training environment.

It is important that the development of any stigma associated with COVID-19 infection be avoided, by normalising and promoting the healthcare process as a standard approach, and ensuring an understanding of the COVID-19 infection by all staff and athletes.

Managing a COVID-19 related death

While it is likely that elite New Zealand athletes have been infected with COVID-19, to date there have been no reported deaths. If New Zealand is able to maintain a low rate of community transmission, it is hoped that this situation will continue. However, practitioners working within elite sporting organisations should ensure that there is an appropriate response strategy for the unexpected death of an athlete, family member or someone within the sporting organisation. That strategy should include the immediate access to counselling and psychological support.

Travel

During the immediate post-peak pandemic period, it is anticipated that international travel will be negligible and internal travel within New Zealand will be minimised. Medical practitioners must ensure that during any sport-related internal travel, appropriate hygiene strategies are established and normalised within team environments. This may include the intensified use of hand sanitiser/hand washing, regular cleaning of surfaces, cough and sneeze etiquette, and any travel-specific physical distancing or contact tracing requirements. Ensuring adequate sleep and nutrition, along with the avoidance of heavy training loads immediately prior to travel, will facilitate healthy travel outcomes.

The future and nature of international sport-related travel requires further consideration as the pandemic evolves.

Education/information sharing

Ensuring that elite athletes, coaches and support staff are well informed regarding both COVID-19, the relevant sporting considerations and the public health requirements of differing COVID-19 levels is important for optimising athlete health, wellbeing and compliance. In addition to publicly available health messages, the provision of sport-specific information and education should utilise a range of modalities, and where possible could involve the use of key athletes to deliver relevant messages.

Finally, as athletes resume squad-based training, it is recommended that in conjunction with coaching staff, sport-specific medicine, psychology and athlete life specialists provide an interactive education and information sharing session to support the athlete and coach transition from relative isolation.

Conclusion

The novel virus causing COVID-19 has already had an unprecedented impact on international health, economies and sport. With a clear COVID-19 national strategy and its early implementation, New Zealand has to date avoided the devastating levels of infection and death witnessed overseas. However, the COVID-19 pandemic is a global challenge whose course, in the absence of an effective vaccine, is difficult to predict.

There is a desire from sporting organisations, athletes and the public for sport, exercise and training to resume as soon as appropriate. This includes the desire for elite athletes to return to training and ultimately competition. Health support embedded within elite sporting organisations must also consider broad public health consequence and align with Government guidelines for delivering health services. Medical practitioners will play a key role in interpreting and applying Government regulations in the various sporting codes.

Medical practitioners will undoubtedly assist in the emergence of elite sport from COVID-19 restrictions, through supporting both athlete’s health and sporting organisations readiness for the ‘new normal’. When considering those factors outlined above, practitioners should routinely support an inter-disciplinary approach to athlete care, incorporating the views of coaching staff, medicine, psychology, athlete life, physiology, nutrition and strength and conditioning expertise. This document facilitates that integrated process by providing a framework for medical practitioners and sporting organisations to consider, as elite sporting activity gradually resumes.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Bruce Hamilton, Sport and Exercise Physician, Director of Performance Health High Performance Sport NZ/NZ Olympic Committee, Medical Director Canoe Racing NZ; Lynley Anderson, Associate Professor, Bioethics Centre, Division of Health Sciences, University of Otago; Nat Anglem, Sport and Exercise Physician, Medical Director Snow Sports NZ; Stuart Armstrong, Sport and Exercise Physician, Doctor Rowing NZ, Associate Editor NZ Journal of Sports Medicine; Simon Baker, ACSEP Registrar, Medical Director Hockey (Men) NZ; Sarah Beable, Sport and Exercise Physician, High Performance Sport NZ/Snow Sports NZ Medical Practitioner; Peter Burt, Sports Doctor/General Practitioner, PhD Candidate, Bioethics Centre, Division of Health Sciences, University of Otago; Lynne Coleman, Sports Doctor/General Practitioner, Medical Director Swimming NZ; Rob Doughty, Cardiology Professor, Heart Foundation Chair, Heart Health, Auckland University; Tony Edwards, Sport and Exercise Physician, Medical Director Hockey (Women) NZ; Dan Exeter, Sport and Exercise Physician, Medical Director Athletics NZ; Mark Fulcher, Sport and Exercise Physician, Medical Director Football NZ; Stephen Kara, ACSEP Registrar, President Sports Medicine New Zealand; John Mayhew, Sports Doctor/General Practitioner, Medical Director NZ Rugby League; Sam Mayhew, Sports Doctor/General Practitioner, Medical Director Triathlon NZ/Pathway to Podium; Chris Milne, Sport and Exercise Physician, Medical Director Rowing NZ; Brendan O’Neill, Sport and Exercise Physician, Medical Director Cycling NZ; Hamish Osborne, Sport and Exercise Physician, Medical Director Basketball NZ; Melinda Parnell, Sport and Exercise Physician, Medical Director Netball NZ; Jake Pearson, Sport and Exercise Physician, Medical Director Paralympics NZ; Karen Rasmussen, New Zealand Rugby Medical Manager; Judikje Scheffer, Sports Doctor/General Practitioner, High Performance Sport NZ Cambridge; Martin Swan, Sports Doctor/General Practitioner, Medical Director NZ Cricket; Mark Thomas, Associate Professor, Faculty of Medical and Health Sciences, The University of Auckland; David Gerrard, Sport and Exercise Physician, Emeritus Professor, Department of Medicine, University of Otago.

Acknowledgements

The authors would like to thank Dr Rob Everitt for his support in the preparation of this transcript.

Correspondence

Dr Bruce Hamilton, Director of Performance Health, High Performance Sport New Zealand, AUT-Millenium Institute of Sport and Health, Mairangi Bay, Auckland.

Correspondence Email

bruce.hamilton@hpsnz.org.nz

Competing Interests

Dr Hamilton reports non-financial support from High Performance Sport NZ during the conduct of the study; Dr Gerrard is the Chair of the Therapeutic Use Exemption Committee (TUEC) Drug-Free Sport New Zealand; Chair, World Anti-Doping Agency (WADA) TUE Expert Group; Chair, TUEC, World Rugby; Vice-Chair, Sports Medicine Committee, International Swimming Federation (FINA); Dr Fulcher reports personal fees from New Zealand Football during the conduct of the study; medical director for New Zealand Football; member of the FIFA Medical Committee; Dr Exeter is a contractor to High Performance Sport NZ; Dr Coleman is a contractor for medical services.

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